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Can My Medicare Advantage Plan Deny My Coverage?

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Medicare Advantage plans must provide members the same coverage as Original Medicare, in most cases. If your Medicare Advantage plan denies coverage to you, you may be able to file an appeal.

Medicare Advantage plans: what do they have to cover?

Every Medicare Advantage plan must provide Medicare Part A (hospital insurance) and Part B (medical insurance) to its members. Medicare Advantage plans are available through private insurance companies that contract with Medicare. The exception is hospice care, which is covered directly under Medicare Part A instead of through the Medicare Advantage plan.

Can my Medicare Advantage plan deny my coverage for medical services or supplies?

Medicare Advantage plans have to abide by certain coverage rules, according to the Centers for Medicare & Medicaid Services. Here are just a few examples of when a Medicare Advantage plan can’t typically deny you coverage.

  • Generally, if you’re eligible for Original Medicare (Part A and Part B), you can’t be denied enrollment into a Medicare Advantage plan. An exception would be if you have end-stage renal disease (ESRD), which is kidney failure requiring dialysis or a kidney transplant. If you have ESRD, you might not be eligible for Medicare Advantage plans except for certain Special Needs Plans.
  • If a Medicare Advantage plan gave you prior approval for a medical service, it can’t deny you coverage later due to lack of medical necessity.
  • Your Medicare Advantage plan isn’t allowed to make statements such as “It is our policy to deny coverage for this service” without providing justification.
  • If you require care that’s considered medically necessary, and your Medicare Advantage plan doesn’t have providers in its network that provide that care, the plan can’t deny you coverage. The plan has to arrange your care from a qualified out-of-network provider.

What should I do if my Medicare Advantage plan denies my coverage?

If your Medicare Advantage plan denies coverage of a medical service or item that you think it should cover, you can file an appeal. An appeal can be a multi-stage process, unless your plan agrees to cover the service or item in question right away. Contact your plan for instructions, or go to your plan’s website and look for information about appeals.

Can my Medicare Advantage plan deny coverage of a prescription drug I need?

If your Medicare Advantage plan includes prescription drug coverage, and doesn’t cover a medication your doctor prescribed for you, you can file an appeal for that, too. Your first step might be to ask your doctor if there’s a different medication you could take instead, one that your plan does cover. But if you or your doctor says you need a particular medication to treat your condition and your plan doesn’t cover it, there is an appeals process. Contact your plan for instructions and forms. Read more about how to file an appeal if your plan doesn’t cover a prescription drug you need.

If your Medicare Advantage plan denies you coverage and you need help with your appeal, you can call Medicare at the number listed at the bottom of this page. You can ask the representative to forward your question or concern to the Medicare Beneficiary Ombudsman.

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