When They Say No – Appealing Medicare Decisions

Aug 17, 2010  /  By: Roger Levine, Estate Planning Attorney  /  Category: Medicare

If you have Medicare, you have rights. You have the right to receive medical care, services, procedures and items that are medically necessary. Should Medicare deny coverage for anything that you or a physician feels is medically necessary, there is an appeals process. It’s a fairly quick and painless procedure, and 80%-90% of those appealing Medicare decisions end up winning on appeal.

The specific Medicare appeals process is dependent upon the type of Medicare coverage that the patient has:

Original Medicare

Your appeal rights are on the back of the Explanation of Medicare Benefits or Medicare Summary Notice that is mailed to you from a company that handles bills for Medicare. Follow the instructions and make sure to appeal immediately.

Managed Care Medicare

If you are in a Medicare managed care plan, you have the same rights to an appeal as with original Medicare. If you think your health could be seriously harmed by waiting for a decision regarding a service, ask the plan for a fast decision. The plan must answer your request within 72 hours.

The Medicare managed care plan must tell you in writing how to appeal. If the plan denies your appeal, you may have an independent organization that works for Medicare review the decision.

Going up the Ladder

If Medicare appeals are denied, and you and your physician feel that the care, procedure or item is medically necessary, there are several levels of the appeals process for denials;

  • Redetermination
  • Reconsideration
  • Administrative Law Judge Hearing
  • Medicare Appeals Council (MAC)
  • Federal District Court

Make sure to follow the instructions for the appeals process carefully and within the proper time limits. Keep copies of all documents and make notes of all telephone conversations. With a little determination and good recordkeeping, you may very well prevail in the Medicare appeals process.

Levine & Furman, LLC is a member of the American Academy of Estate Planning Attorneys.

Do you Qualify for a $250 Medicare Rebate?

Aug 11, 2010  /  By: Roger Levine, Estate Planning Attorney  /  Category: Medicare

Since the 2010 Health Care Reform legislation offered over 1,000 pages of changes to health care and coverage, we continue to highlight the portions of this legislation that affect senior citizens. In particular, Health Care Reform provided a fix to eliminate a ‘donut’ hole in the coverage of Medicare Part D, which is Medicare’s prescription drug coverage that was passed in 2006.

Under the current Medicare guidelines, over $1,500 in prescription drug costs are not covered by Medicare. Many were taken by surprise by this coverage gap. The prescription plan offered coverage until $2,830 in total drug costs were reached in a year. At that point, the full cost of prescription drugs were paid by the Medicare recipient until the out-of-pocket costs reached $4,550, when the drug plan begins to pay most of the costs of covered drugs for the remainder of the year.

For 2010, the Health Care legislation is giving a $250 rebate to Medicare beneficiaries who fall into this coverage gap. In 2011, there will be a 50% discount on prescription drugs within the ‘donut’ hole. The legislation eliminates the gap by the year 2020 when coverage within this gap will be a more palatable copay of 25% of the drug costs.

So, how do you get your rebate check? If you’re eligible, Medicare will mail it automatically to you – there are no forms required. In fact, if anyone calls or requests personal information saying it is needed for your rebate, it is a scam.

Rebate checks began to be distributed in July, 2010 and will continue monthly throughout the year as beneficiaries enter the coverage gap. If you have questions regarding your eligibility for this one-time rebate, contact Medicare at 1-800-MEDICARE.

Levine & Furman, LLC is a member of the American Academy of Estate Planning Attorneys.