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Can you be denied Medicare coverage?

Can you be denied Medicare coverage?

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If you have pre-existing health conditions or went outside of your plan’s network to receive care, you could be wondering if you’ll be denied coverage from Medicare. While you can be denied for these reasons, you shouldn’t live in fear. 

Still, you should be aware of other reasons as to why you can be denied coverage or presented with different alternatives.

Medicare Supplement Plans

A Medicare Supplement plan won’t usually deny you coverage if you have a pre-existing health condition, such as an injury or high blood pressure, but it is possible that they can. It’s also possible that instead of denying you coverage, you will be charged more because of your pre-existing conditions.

You could also be denied coverage from a Medicare Supplement plan because you are under the age of 65. 

Medicare Advantage Plans

There are certain situations when a Medicare Advantage Plan can and can’t deny coverage for a medical service you received. For example, as long as you follow the plan’s guidelines, you should not be denied coverage once you are enrolled in the plan. If you are in a pre-approved agreement with the plan to treat you through an advanced determination of coverage, then the plan cannot deny you coverage if your condition isn’t medically necessary.

Here are a few examples of some situations where you might find yourself being denied coverage:

  • If you do not follow the plan rules or use a provider network outside your plan’s network (unless it’s for emergency purposes)
  • If you received services that were not necessary
  • If you are involved in a clinical research study
  • If you have End-Stage Renal Disease

File an Appeal

If you are denied coverage from your Medicare plan but feel as if the decision was in the wrong, you can file an appeal. Some examples of why you can file an appeal with Medicare include:

  • If your request to receive coverage for a health service, drug, or item is denied
  • If your request for payment of a health service, drug, or item that you already had is denied
  • If your request for a lower payment of a health service, drug, or item is denied

Before you begin the process of starting an appeal, read through your plan’s notices and letters to see if there is provided information as to why you are being denied coverage. 

Because there are multiple levels of an appeal, you can continue your appeal if you are not successful the first time. A tip to strengthen your appeal is to include a letter from your doctor stating they support the appeal.

Need more information?

If you are interested in learning more about the type of coverage offered through Medicare, give us a call at 877-877-5505. You can instantly get more specific information and help to enroll from a professional Medicare broker at Bobby Brock Insurance. 

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