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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.
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.
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.
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.
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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eHealth's Medicare website is operated by eHealthInsurance Services, Inc., a licensed health insurance agency doing business as eHealth. The purpose of this site is the solicitation of insurance. Contact may be made by an insurance agent/producer or insurance company. eHealth and Medicare supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. We offer plans from a number of insurance companies.