Medicare Advantage plans, commonly referred to as Part C or MA plans, are carried by insurers who have contracts with Medicare to manage and expand on Original Medicare benefits. Medicare Advantage plans must adhere to specific rules set by Medicare, but they also have the ability to make coverage determinations independently when it comes to benefits that are not a part of Original Medicare.

Common Reasons for Denial of Coverage

As with Original Medicare Part A and Part B, the medical necessity of a service can often impact coverage determinations with a Medicare Advantage plan. Cosmetic or elective procedures may be denied coverage since the procedure is not life saving or treating a specific illness.

Coverage denials can also occur when a recipient is treated by a provider that is not included in their MA plan’s network. Plan networks can change throughout the year and carriers are obligated to notify their enrollees of these changes, but enrollees may still be unaware that a provider who was previously part of their MA plan’s network may no longer be included in that network on their next scheduled appointment.

Insurers can also change their coverage area or leave a coverages area entirely, which can leave recipients vulnerable to gaps in coverage if they wait too long to switch to a new plan. Coverage denials may occur during this gap if the former plan is no longer obligated to cover the recipient once the transition period is over.

Part C plan providers can also deny coverage for services if their monthly premium is not met. Medicare Advantage plans usually allow a certain grace period for late premium payments, so coverage denials are only likely to occur if the nonpayment extends beyond this window of time.

Recipients who develop End-Stage Renal Disease (ESRD) may be referred to a Medicare Advantage Special Needs Plan due to the increase in the costs of their care. Medicare Advantage plans that are not designed to meet the special needs of these recipients may be allowed to deny enrollment.

Some types of treatment may be denied if less invasive or expensive treatments have not yet been tried. This is common with Original Medicare benefits, not just Medicare Advantage plans. Your doctor can help you determine if the treatment you need is necessary or if you are likely to respond to more conventional treatment options first.

What to Do if You’ve Been Denied Coverage

An appeal process is available to recipients who have been denied coverage by their Medicare Advantage plan. This process typically includes a few different steps and requires appropriate documentation to show why the recipient needs the care they’ve been denied and any alternatives they’ve tried. Close communication with your physician or health care team can help you prepare the proof you need that the treatment or medication is necessary.

When a Medicare Advantage plan’s network cannot offer care through an in-network provider, an appeal can help you receive coverage for treatment from an out-of-network provider. In order to protect yourself from possible out-of-pocket expenses, be sure to follow your plan’s procedures for seeing an out-of-network provider before going to the appointment. Failure to follow the required steps may result in a valid denial of coverage even when there are no in-network providers in your area.

If you need a medication that is not on your Part C provider’s prescription drug formulary and your doctor determines you cannot substitute it with a generic medication or another type of medication, an appeal may be able to unlock coverage for that medication. You may still have cost-sharing obligations like a copayment or coinsurance as you would with other medications.

Medicare Advantage plans must provide detailed justifications for any denial of coverage. If you feel your plan is not meeting its legal obligations for your care, you can contact a Medicare agency representative for more information about reporting your issues with your Medicare Advantage provider.

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