Medicare Coverage Gap Options

Understanding the Appeals Process

There may be times when you do not agree with a coverage decision or payment made by your Medicare plan. If this is the case, you have the right to appeal. Before making your appeal, there is important information you should know.

Your Rights

Whether you have Original Medicare and a prescription drug plan or a Medicare Advantage Plan with or without prescription drug coverage, your rights will be the same. The way you make an appeal, however, may be different.

If you disagree with a coverage payment decision that Medicare, your Medicare health plan or your Medicare Part D plan makes, you can appeal the decision if one of these requests is denied:

  • A request for a healthcare service, supply, item or prescription drug that you think you should be able to get
  • A request for payment of a healthcare service, supply, item or prescription drug you already received
  • A request to change the amount you must pay for a healthcare service, supply, item or prescription drug

You can also appeal if Medicare or your plan stops providing or paying for all or part of a healthcare service, supply, item or prescription drug you think you still need.

Deciding to Make an Appeal

Each plan has its own rules related to appeals – you should be able to find yours in your plan materials. If you can’t find them, contact your plan to ask for the information. The contact information will generally be on your plan membership card, or it can be found online. Your plan is required to tell you, in writing, how to make an appeal.

It’s a good idea to have as much information as possible from your doctor,
healthcare provider, or supplier to support your case when making an appeal.

If you’re not comfortable making the appeal yourself, you can contact your State Health Insurance Assistance Program (SHIP) or appoint a representative, such as a family member or doctor, to file one for you.

Appeals must be made within 60 days of the initial decision by your plan to deny coverage. If you feel that your health would be put at risk by waiting on the plan’s decision, you may request a fast appeal and your plan must respond within 72 hours. 

The Appeals Process

If you have any issues with the coverage that your plan provides, talk to your doctor or your plan to see if an appeal is an option for you. In case you want to appeal the coverage for a specific medication, you might want to ask your pharmacist if there are other medications that are as effective and then talk to your doctor about switching before making an appeal.

The appeals process has five levels. Starting with the first level, redetermination, you generally have the option to move to the next level when you disagree with the decision that is made by the plan. Every time you receive a written decision letter, it will contain the instructions for how to move up to the next level of appeal.

The five levels of appeal are:

1. Redetermination by your plan
2. Review by an Independent Review Entity (IRE)
3. Hearing before an Administrative Law Judge (ALJ)
4. Review by the Medicare Appeals Council (Appeals Council)
5. Judicial review by a federal district court

Remember, if you need help filing an appeal, you can always contact your State Health Insurance Assistance Program.

Posted on: July 2, 2015
by
Vice President of Medicare Solutions

Tags:

Print Friendly

Stay Up-to-Date

Get the most out of Medicare with monthly email newsletters that give you the latest news and helpful tips for managing your healthcare and planning for the future.

> Sign Up Now