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Medicare Appeals: How Older Adults Can Succeed in Getting the Coverage They’re Entitled to

July 19, 2017
Medicare Appeals

On average, seniors are each taking 15 – 18 different prescribed medications, so Medicare coverage of these medicines is often extremely important. And with a typical price tag of greater than $11,000 annually for the most typical medicines prescribed for the elderly, it could be debilitating when Medicare suddenly denies coverage. Nevertheless, that’s taking place ever more frequently as Medicare plans are progressively establishing coverage limits on seniors – generally outside of affirmation from the Centers for Medicare & Medicaid Services.

Because the Medicare appeals process for denied coverage can be so intimidating, unfortunately, a great many aging adults just accept the denial – at frequently an outrageously high financial impact, and also at potential risk to their health when necessary medicines are discontinued because of lack of Medicare insurance coverage. As stated by David Lipschutz, senior policy attorney at the Center for Medicare Advocacy, “A lot of people fall through the cracks. They simply don’t know what to do. Or they try to go through the process, and it’s complicated and time-consuming and they just give up.”

Even though several medications must be covered by Medicare across the board (those for HIV/AIDS, depression, cancer, and seizures, to name a few), there’s a gray area by which medications are covered for other conditions – and preapproval is oftentimes required, or patients are given the criteria that lower cost methods need to be used first (also known as step therapy). Denials usually come as a result of neglecting to satisfy these requirements.

So, exactly what can a senior try to receive the drug insurance coverage to which they’re entitled? There are particular important steps:

  • First, obtain a formal coverage determination from the senior’s Medicare drug plan. Details on submitting this specific request can be found by clicking here.
  • When coverage is determined, there are five levels in the Medicare appeals process, detailed here.
  • Keep detailed documentation throughout every step of the process. To get more guidance, the Medicare Rights Center can help.

Keep in mind that it’s important to be persistent. Frequently, higher levels of Medicare appeals are approved even though initial steps result in disheartening results. Contact Home Matters, for additional tips and hands-on assistance for seniors. We are able to provide resources that will help seniors in addition to their family members advocate for themselves, as well as specialized in-home care services to ensure that medications are taken just as prescribed, that prescription medication refills are taken care of, and much more. Call us to learn how to keep your senior loved one safe and flourishing!

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About the author

Tyler Williams

As an Area Owner and Operator of a Home Matters Caregiving franchise, I am committed to ensuring exceptional outcomes for our valued clients and caregivers. My passion for elevating our service quality is matched by my role as a blogger and social media manager for the franchise, where I share insights, updates, and foster community engagement. Prior to senior care, I used my strategic communication and brand development skills as the Marketing Director of a regional bank. My diverse experience supports my commitment to excellence and innovation in both healthcare and digital communication.
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