394 Flares Twitter 199 Facebook 160 Email -- Email to a friend Pin It Share 0 Print this page Reddit 0 Donate 394 Flares ×

Medicare Watch

Your Weekly Medicare Consumer Advocacy Update

Medicare Rights Spotlights Medicare Advantage Denials and Appeals

October 23, 2014

New Brief Addresses Common Issues with Medicare Advantage Denials and Appeals

Last week, 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, the information that is available suggests there is significant room for improvement.

Roughly 30 percent of the 50 million people with Medicare are currently enrolled in an MA plan. While many people with MA have a positive experience with their plan, managing denials of coverage remains 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.

Click here to read Medicare Snapshot: Stories from the Helpline.

Click here for advice if you have been denied coverage for a service by your MA plan.

Medicare Rights Comments on Part D “Lock-In” Proposals

The Medicare Rights Center (Medicare Rights) President, Joe Baker, recently wrote to the Medicare Payment Advisory Commission (MedPAC) to express Medicare Rights’ concerns regarding proposals that would allow Medicare Part D plans to place restrictions on Medicare beneficiaries’ access to prescription medications when abuse or misuse is suspected. Known as “lock-in,” these proposals would grant Part D plans the ability to limit beneficiaries to a particular prescriber or pharmacy.

Mr. Baker summarizes Medicare Rights’ concerns, “proposals that would allow Part D plan sponsors to employ additional [restrictions at the pharmacy counter] on beneficiary access to medications are concerning to us, largely given our experience assisting clients denied access to prescription drugs. Additionally, as detailed by the New York Times, recent CMS audit findings and resulting sanctions illustrate that Part D plan sponsors fail to adequately manage coverage determinations, appeals, and grievances to an alarming degree.”

Medicare Rights asks that, if MedPAC does comment or recommend proposals to restrict Part D enrollees to particular pharmacies or prescribers, that MedPAC consider the following:

  • A straightforward, accessible beneficiary appeals process must be defined.
  • Efforts to strengthen data sharing, monitoring, and oversight of Medicare Part D plan sponsors must be prioritized.
  • Lock-in criteria must be developed according to clinical standards. Beneficiary advocates and providers with expertise treating addiction must be involved.
  • Provider education must be incorporated. Many parties, including prescribers and pharmacies, carry out Medicare prescription fraud and contribute to the abuse and misuse of medications.

Read Medicare Rights’ letter.

Volume 5, Issue 40

Medicare Interactive logo

Medicare Reminder

It is very important that you review your drug plan every year. Medicare private drug plans can change their costs and the list of drugs that they cover every year.  Most people can only change Medicare drug plans during Fall Open Enrollment (sometimes called the Annual Coordinated Election Period), which runs from October 15 to December 7 each year.

Even if you are satisfied with your current Medicare coverage, you should check if there is another plan in your area that offers better coverage at a lower price. Look at other Medicare options in your area and compare them with your present coverage to see which plan will best suit your needs in the upcoming year. Research shows that people with Part D plans could lower their costs by shopping among plans each year. For example, another Part D plan in your area may cover the drugs you take with fewer restrictions and charge you less.

When choosing a Medicare private drug plan, make sure to look at all the costs, not just the premium. Your costs throughout the year will depend on what drugs you take, whether your plan covers them, and whether there are any coverage restrictions. Another plan may have lower copays, cover more of your drugs, have fewer restrictions or offer some coverage during the coverage gap.

If you are considering joining a Medicare Advantage plan to get drug coverage, remember that you will get all of your Medicare benefits from that plan. Look beyond the drug coverage; make sure the plan covers you to go to the doctors, hospitals and pharmacies you prefer to use at a cost you can afford.

Click here to read more about reviewing your choice of Part D coverage.



CMS recently released a fact sheet providing an overview of the Accountable Care Organization (ACO) Investment Model, a new ACO designed for organizations that participate in the Medicare Shared Savings Program.

ACOs are groups of doctors, hospitals, and other health care providers who work together to provide coordinated care to people with Medicare. ACOs are testing ways to save money in the health care system by both streamlining care and preventing medical errors and unnecessary duplication of services.

Click here to read more about the ACO Investment Model.


Stay up-to-date on Medicare policy and advocacy developments, and learn about changes in Medicare benefits and rules with this weekly newsletter.

* * * *

Health Care Professionals:

Need to stay current on all things Medicare? Try a subscription to Medicare Rights University. This comprehensive training solution features traditional, webinar and video courses to help you train new staff and keep existing staff up to speed on Medicare changes, benefits and options.

Subscribe today at www.medicarerightsuniversity.org.

* * * *

Get answers to your Medicare questions from Medicare Interactive at www.medicareinteractive.org.

© 2014 by Medicare Rights Center. All rights reserved.

For reprint rights, please contact Mitchell Clark.