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Can My Medicare Advantage Plan Deny My Coverage?

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Some people – especially those with health problems – live in fear that their health insurance companies might deny them coverage, or charge huge amounts of money. What about Medicare Advantage plans? Here’s some information about what these plans must cover, and whether Medicare Advantage plans can deny coverage.

What does Medicare Advantage cover?

For the most part, Medicare Advantage plans cover everything that Original Medicare (Part A and Part B) covers. The private insurance companies offering Medicare Advantage plans contract with Medicare to deliver Part A and Part B benefits to you, and are bound by Medicare rules.

Medicare Advantage plans don’t cover hospice benefits – but don’t worry. If you should ever need hospice benefits while you have a Medicare Advantage plan, Medicare Part A will cover them. You might pay a copayment of up to $5 for prescription medications. Most covered care must be at home, but Part A might cover limited hospice care in a facility in some situations.

Medicare Advantage plans usually cover prescription drugs (although not all plans do). Since each plan with drug coverage has its own formulary (list of covered drugs), you may want to check plan formularies before signing up for a plan. A plan can change its formulary anytime, but the plan will notify you when necessary.

There are a lot of Medicare Advantage plans that offer coverage beyond Part A and Part B. For instance, some plans offer routine vision care. This is another reason that you may want to compare the plans available in your area – see what extra benefits each one offers, if any, and whether it covers your medications. One easy way to compare plans is to click the Browse Plans button on this page.

When can’t a Medicare Advantage plan deny coverage or charge extra fees?

If you’re eligible for Medicare, and you want to enroll in a Medicare Advantage plan, here’s some good information to know. A Medicare Advantage plan can’t deny you coverage if you have a health problem (except for end-stage renal disease). That’s assuming that you live within the plan’s service area and are enrolled in Medicare Part A and Part B when you apply for the plan. If you have end-stage renal disease (permanent kidney failure that requires dialysis or a kidney transplant), you generally can’t enroll in a Medicare Advantage plan, except for a Special Needs Plan.

  • Generally, Medicare Advantage plans can’t refuse to cover your medical services once you’re enrolled, as long as you follow plan rules. For example, the plan typically can’t deny coverage of your health condition.
  • In most cases, Medicare Advantage plans can’t charge you more than Original Medicare would cost you for certain services, such as skilled nursing facility care, dialysis, or chemotherapy.
  • If a plan has agreed to treat you through an “advanced determination” (prior approval) of coverage, the plan can’t decide later to deny you coverage if it finds that your condition isn’t medically necessary.

When can a Medicare Advantage plan deny coverage?

There are some situations when a Medicare Advantage plan might not have to cover your medical services. Here are a few examples:

  • If you don’t follow plan rules
  • If the services you received were not medically necessary
  • If your plan requires you to use a provider network, and you went outside the network for services. There are exceptions, like if you received emergency care outside the network.
  • If you’re in a clinical research study, in many cases, your plan may only cover part of the costs. Original Medicare may pay the rest of the costs. Before participating in a research study, discuss it with your doctor and your Medicare Advantage plan.

What can I do if a Medicare Advantage plan denies coverage?

If your Medicare Advantage plan denies coverage of a medical service that you think it should cover, you can file an appeal.

If you’re not satisfied with how your plan treated you, you can file a complaint, called a grievance. Your state health insurance assistance program (SHIP) can help you.

  • You still need to keep paying your Medicare Part B premium, along with any premium the plan may charge.

To compare Medicare Advantage plans with the click of a button, just click the Browse Plans button on this page.

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