Medicare Rights Center Releases Medicare Snapshot
— Highlights Beneficiary Experience with Medicare Advantage Denials of Coverage and Appeals —

New York, NY—Today, the Medicare Rights Center 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.

“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 enrollees.”

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 as possible.

Medicare Snapshot: Stories from the Helpline is available at: https://www.medicarerights.org/policy/priorities/medicare-snapshot-october-2014.

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