Guiding Your Clients Through a Medicare Advantage Appeal

If you have clients on Medicare Advantage plans then you are already aware that it covers all of Part A and Part B services. In addition, most Medicare Advantage plans offer prescription drug coverage (also known as Part D), along with vision, hearing, and dental coverage.

1. Part A (hospital insurance) covers inpatient hospital care, skilled nursing facility, hospice, lab tests, surgery, and home health care.
2. Part B (Medical Insurance) covers doctor appointments, outpatient services, medical equipment, home health care, and some preventative services.

While many items and services are covered under Medicare Advantage plans such as prescription drugs, diabetic test supplies, cardiovascular screenings, and hospital visits, there may be items or services not covered. How can you help your client if their Medicare Advantage plan does not cover the cost of an item or service they need? According to medicare.gov, they have the right to ask the carrier to provide or pay for items or services they believe should be covered, provided, or continued. The decision by the Medicare Advantage plan is called an “organization determination.” Filing an appeal could potentially help your client resolve these differences with their plan.

4 Tips to File an Appeal from Medicare.gov

1. Get Help: If your client needs help filing an appeal, they can contact the State Health Insurance Assistance Program (SHIP) or appoint a representative. A representative can be a family member, friend, advocate, attorney, doctor, or someone else who will act on their behalf.
2. Gather Information: Suggest they consult with their doctor, other health care providers, or supplier for any information that may help their case.
3. Keep Copies: Be sure to advise your client to keep a copy of everything they send to the carrier as part of their appeal.
4. Start the Process: Follow the directions in the carrier’s initial denial notice and plan materials. They typically have 60 days from the date of the coverage determination. If they miss the deadline, they must provide a reason for filing late. See what information to include in the written request.

Once your client starts the appeals process, they can disagree with the decision made at any level of the process and can generally go to the next level. Learn more about appeals in a Medicare Advantage Plan.

Agents

Medicare Advantage enrollment has grown rapidly over the past decade with more than one-third (36%) of all Medicare beneficiaries opting for a Medicare Advantage plan. The majority of enrollments come from nine states (HI, FL, MN, OR, WI, MI, AL, PA, CT) and Puerto Rico. We hope this information on Guiding Your Clients Through a Medicare Advantage Appeal is helpful to you.

Empower Brokerage is dedicated to helping you educate your clients on the insurance they need and staying on top of their health. Whether it’s through webinar training, one-on-one calls, seminars, or marketing plans. We want you to be successful. Give us a call if you have any questions 888-539-1633.

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