Medicare denials and appeals

Medicare denials and appeals
Barry Klitsberg

Medicare is a federally run health insurance program for people who are 65 years of age or have collected Social Security Disability for 24 months.  It is also available for individuals with permanent kidney failure or Lou Gehrig’s Disease.

If you are not yet collecting Social Security, you have to apply for Medicare during the three-month period before your 65th birthday.

Upon turning 65 you are eligible for coverage and can choose a plan to cover your needs. For people already enrolled in Medicare, the ability to change their existing plan is generally limited to the Open Enrollment period, which runs from every year from Oct. 15 through Dec. 7.

As a Medicare recipient, you can appeal a denial of coverage or a payment decision by Medicare or your Medicare plan for services, supplies or drugs that you think Medicare should cover.

You can also appeal if Medicare or your plan stops providing or paying for all or part of a healthcare service or supply that you think you still need.

Any time Medicare or your health plan denies coverage or payment for a health care service you think you need, you should receive a formal denial notice which must give you your appeal rights and how to submit your request for the appeal.

It will also give you deadlines for when to file your appeal.

If you decide to file an appeal, you can ask your doctor, supplier or other healthcare provider for any information that supports your case. This will make your appeal stronger. It is also important to keep copies of everything related to your appeal including what you send or have sent to Medicare or your plan.

It is critical when choosing a first or a new plan to make sure that plan covers services, supplies and drugs that meet your specific needs. Medicare coverage can be somewhat confusing for those new to the process, as there are many options to explore. If you need help understanding or choosing a plan, Family and Children’s Association can help guide you through the process with free help available by calling the Nassau County Health Insurance Information Counseling and Assistance Program at 516-485-3754.

Barry Klitsberg is an assistant health insurance information counseling and assistance program coordinator at FCA in Garden City.



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