What if Medicare will not pay for something?

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The Medicare Advocacy Project at Community Legal Aid, Greater Boston Legal Services, and South Coastal Counties Legal Services
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If Medicare refuses to pay for something, they send you a denial letter. The denial says they will not pay.

If you think Medicare should pay, you can challenge their decision not to pay. This is called “appealing a denial.” If you appeal a denial, Medicare may decide to pay some or all of the charge. 

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When can I appeal a denial?

You can appeal if:

  • Medicare refuses to pay for a health care service, supply, or prescription that you think you should be able to get.
  • Medicare refuses to pay the bill for health care services or supplies or a prescription drug you already got.
  • Medicare refuses to pay the amount you must pay for a drug.
  • Medicare stops paying for all or part of a service you think you still need.

Take action right away. You must appeal by the deadline. All appeals have deadlines. Different kinds of appeals have different deadlines. Your denial notice should tell you how much time you have to appeal.

How do I appeal?

Note: If you need help with an appeal, call the Medicare Advocacy Project at 1-800-323-3205 to apply for assistance.

Remember:

  1. Appeal on time,
  2. Keep copies of all your paperwork, and
  3. Try to get your doctor’s support.

It is very important to get your doctor to support your appeal. Ask your doctor for a letter that explains the medical reasons you need the service Medicare is denying.

How you appeal depends on what part of Medicare you are appealing: original A or B, Part C, or a Part D plan. You may appeal each of these plans through several administrative steps.

If you are appealing a Part C or Part D decision, contact your plan for instructions on how to appeal.

If you have Part B Original Medicare, you should get a statement every 3 months. The statement is called a Medicare Summary Notice (MSN). It shows the services that were billed to Medicare. It also shows you if Medicare will pay for these services. At the bottom of the MSN, there are instructions on how and when to appeal.

If you need a particular medication and your drug company says it is not on their covered drug list, ask your doctor to file for an “exception.” Your doctor must explain that no other drug on the list is as effective as the drug you need, or the other drugs on the list will cause negative side effects.

If Medicare approves the exception, generally the approval lasts until the end of that plan year. If Medicare does not approve the exception, you can appeal to a higher level and try to get another decision.

What happens after I appeal?

If you appeal, Medicare will send you their decision. 

  • They may “change or reverse the denial.” This means that they decide to pay some or all of the charge. 
    or
  • They may still deny your claim. The letter will include instructions for how to file the next step of the appeal.

If Medicare still denies your claim after you appeal, you can appeal to:

  1. an Administrative Law Judge, then to 
  2. the Medicare Appeals Council, then to 
  3. Federal Court.
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Get help from the Medicare Advocacy Project
Health_Medicare_Medicare Advocacy Project

The Medicare Advocacy Project (MAP) helps people who may have been unfairly denied Medicare. MAP can give you information, advise you, and sometimes represent you for free. Contact MAP via your local legal services office:

Greater Boston Legal Services (GBLS)
Serving Essex, Middlesex, Norfolk, and Suffolk counties: 617-371-1234; 800-323-3205

South Coastal County Legal Services (SCCLS)
Serving Bristol and Plymouth counties: 800-244-9023; 508-979-7150
Serving Fall River: 800-244-9023; 508-676-6265
Serving Barnstable, Dukes, Nantucket, and Plymouth counties: 800-244-9023; 508-775-7020

Community Legal Aid (CLA)
Serving Berkshire, Franklin, Hampden, Hampshire, and Worcester counties: 855-252-5342

Programs that can answer your questions
Health_Medicare_SHINE and hotlines

SHINE (Serving the Health Information Needs of Everyone): 1-800-243-4636, press 3 
The SHINE (Serving the Health Information Needs of Everyone) Program provides free health insurance counseling services to Massachusetts residents with Medicare or who are about to become eligible for Medicare, and their caregivers. SHINE counselors are trained to handle complex questions about Medicare.

MCPHS University Pharmacy Outreach Program: 1-866-633-1617
The MCPHS University Pharmacy Outreach Program can review your information to find help for your prescription costs. It can also help you understand your Medicare prescription drug plan benefit.

Health Care For All’s Helpline: 1-800-272-4232
Call or fill out the online form. The Helpline is a free service that helps enroll Massachusetts residents into health insurance coverage. In English, Spanish, Portuguese, Haitian Creole, and French.

Medicare, MassHealth, and Prescription Advantage Programs
Health_Medicare_Medicare, MassHealth, and Prescription Advantage Programs

Medicare: 1-800-MEDICARE
Medicare is a national health insurance program. It is for people who are 65 or older and adults with disabilities. 

MassHealth: 1-800-841-2900
The MassHealth program provides comprehensive health insurance — or help paying for private health insurance.

Prescription Advantage: 1-800-243-4636, press 2
Prescription Advantage is a prescription drug insurance plan for all Massachusetts residents age 65 and older, as well as younger people with disabilities who meet income and employment guidelines.

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