Medicare Advantage plans are a popular alternative to regular Medicare because the plans often offer lower out-of-pocket cost...Read more
Appealing Medicare Advantage Plan Decisions
- September 26th, 2013
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.
Local Elder Law Attorneys in Ashburn, VA
Hammond and Associates, LLC, Elder Law, Estate Planning, Wills, Trusts, Probate
For Jeffrey Hammond, the practice of Elder Law is personal. Jeff’s many years of experience in law and in business did not prepare him for the crisis he faced in 2005 and 2006 when his father suffered a stroke and both of his parents suffered from dementia and other medical problems. At that time, Jeff began an i...
Law Offices of John L. Laster
John Laster is a lawyer licensed to practice in Virginia, Maryland and the District of Columbia. He limits his practice to wealth transfer planning, trusts, wills, powers of attorney, health care decision-making issues, estate administration and related tax, elder law and disability concerns. Listed in The Best Lawyers...
Ron M. Landsman, P.A.
Ron M. Landsman has been practicing elder law since 1983, before it was known as elder law, originally with Landsman and Laster, Washington, D.C., then Landsman, Eakes and Laster, also in Arlington, VA, and since 1990 in his own practice in Montgomery County, Maryland. He has been among the most active members of the...
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.
Last Modified: 09/26/2013