Appealing Medicare Advantage Plan Decisions

If you have a Medicare Advantage plan, your plan may overrule your doctor and refuse to cover a treatment or procedure that it deems to be medically unnecessary or experimental. By one count, nearly one-third of Medicare Advantage plan enrollees say they were denied coverage for treatment by their plans. Such denials of coverage can be enraging or even life-threatening. However, there is an appeal process to resolve these conflicts.

If your plan will not pay for, does not allow, or stops a service that you think should be covered or provided, you can file an appeal. There are several steps involved in this process. After you file the appeal, the plan will reconsider its decision. If the plan does not decide in your favor, you can appeal to an independent organization, called an Independent Review Entity (IRE). If you disagree with the IRE's decision, you can request a hearing with an Administrative Law Judge (ALJ). The next step after the ALJ is the Medicare Appeals Council (MAC). Finally, if your claim is for a high enough dollar amount, you can have a court review the claim.

Medicare Advantage plans must let you know four days before they end your home health, nursing home, or certain outpatient rehabilitation care. This advance written notice must explain the following:

• Why your plan thinks that services are either not needed or are not covered
• How you can go about obtaining a fast appeal of the decision from an independent decisionmaker outside the plan if you think the services are covered
• That payment for the costs of your care will continue at least until noon of the day following the decision by the independent decisionmaker

You should check your plan's membership materials or contact the plan for details about your appeal rights.  An elder law attorney can also help.

For more about Medicare Advantage plans, click here.