Problems Seniors Have with Medicare Advantage Plans
Medicare Rights Center highlights Advantage Plan
denials of coverage and appeals
21, 2014 -The Medicare Rights Center has released its first
Medicare Snapshot: Stories from the Helpline, spotlighting Medicare
Advantage (MA) plan denials of coverage and appeals issues as
experienced by a typical caller to Medicare Rights’ national helpline.
Over one-third of all callers to the helpline express difficulty
managing coverage denials and appeals.
While there is limited public data on how well MA
plans address appeals and grievances, what information is available
suggests there is significant room for improvement, according to the
Medicare Rights Center.
“Roughly 30 percent of the 50 million people with
Medicare are currently enrolled in a Medicare Advantage plan,” said Joe
Baker, President of the Medicare Rights Center. “Many people with MA
plans have a positive experience with their plan; yet, we find that
managing denials of coverage remain a consistent concern for many MA
To address common issues with denials of coverage
and appeals, Medicare Snapshot outlines key improvements to
Medicare private health plans, including:
● Requiring plans to better assist
beneficiaries through the appeals process.
● Continuing to release plan-level data on
appeals and grievances.
● Providing better consumer education on how
plans work, particularly with respect to coverage and access rules.
● Requiring plans to send copies of all
materials used to arrive at a denial decision to the beneficiary and to
the independent review entity evaluating the appeal.
For those denied coverage for a service by their MA
plan, Medicare Snapshot offers this advice:
● Carefully read all materials that your plan
sends you, and call your plan with any questions, or to confirm that you
understand the rules that apply to your situation.
● Keep good records of all of your
conversations with your plan, including the time you called, the person
you spoke to, and what you were told.
● Appeal, appeal, appeal: if a service is
denied or you disagree with your plan’s coverage determination, you
should appeal the plan’s decision. Be sure to get the reason for the
denial in writing from the plan.
● When putting together materials to support
your appeal, try to:
>> Get help from your doctor—have your
doctor write a letter in support of your appeal.
>> Respond as directly as possible to the
reason listed in the plan’s denial letter. If the reason is unclear,
state that the denial letter is unclear, and provide as much information
Medicare Rights Center
is a national, nonprofit consumer service organization that works to
ensure access to affordable health care for older adults and people with
disabilities through counseling and advocacy, educational programs, and
public policy initiatives. Located at 520 Eighth Avenue, North Wing, 3rd
Floor ∙ New York, New York 10018 with an office at 1825 K Street NW,
Suite 400 ∙ Washington, DC 20006 ∙ www.medicarerights.org,
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