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
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...
Margaret A. O'Reilly, PC
Margaret A. O’Reilly is an estate planning and elder law attorney with over thirty-five years of legal experience. Attorney O’Reilly graduated from Duke University with a degree in psychology, and received her law degree from Northeastern University School of Law in Boston, Massachusetts. For over 15 y...
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