Medicare Advantage Plans provide the same coverage as Original Medicare and often extra benefits too. However, they are still run by private insurance companies with rules that can sometimes lead to services and treatment being denied. Understanding when Medicare Advantage Plans can turn down covering your care is important when evaluating plans.

Can Medicare Advantage Plans Deny Claims?

Medicare Advantage Plans cannot deny any services covered under Original Medicare (Part A and Part B). All enrollees have guaranteed issue rights and cannot be turned down for pre-existing conditions either.

However, Advantage Plans can deny covering:

  • Care deemed not “medically necessary” by the plan
  • Out-of-network services when an in-network provider is available
  • Treatment requiring prior authorization that was not pre-approved
  • Prescription drugs not on the plan’s formulary
  • Experimental procedures and some clinical trials

So while plans must cover all the same types of care Original Medicare does, they can impose conditions and limitations that lead to claim denials. Understanding rules is crucial to avoid surprises.

When Can Medicare Advantage Plans Deny Coverage?

There are a few common scenarios where Medicare Advantage Plans may deny covering a service, medication, or procedure:

The plan doesn’t consider it medically necessary

This is one of the most frequent reasons for claim denials. The plan determines through its clinical policy that a treatment like surgery or specialty imaging isn’t necessary for your condition when other options exist. Providers would need to appeal and demonstrate medical necessity.

No prior authorization was obtained

Many plans require pre-approval before getting certain services like inpatient hospital stays, durable medical equipment, or diagnostic imaging. Failure to get this prior authorization can lead to denial even if the care is medically necessary.

Using an out-of-network provider

Most HMOs and some PPOs limit coverage to their network of doctors and facilities. Seeing an out-of-network provider results in higher patient costs at best and outright denial at worst. Emergency care is the main exception.

The drug isn’t on the plan’s formulary

Part D prescription drug coverage through Medicare Advantage involves set formularies or lists of covered medications. Drugs not on this list are typically not covered. Exceptions can sometimes be made.

What Can’t Be Denied by Medicare Advantage Plans?

There are some protections in place over what Medicare Advantage Plans cannot reject covering. These include:

  • Care explicitly outlined as a covered benefit in the plan’s documentation
  • Treatment previously approved through the plan’s prior authorization process
  • Emergency services from any provider, even if out-of-network
  • Urgently needed care when in-network providers are temporarily unavailable
  • Any service deemed medically necessary when delivered by an in-network provider
  • Kidney dialysis received at a Medicare-certified dialysis facility
  • Claims submitted properly and on time

So while denials happen, federal regulations protect members from inappropriate denials for required Medicare coverage when plan rules are followed.

How to Appeal a Medicare Advantage Claim Denial

If a Medicare Advantage Plan does deny a claim you believe should be covered, you have the right to appeal. The appeals process involves:

  • Submitting a written request to reconsider the denial within 60 days
  • Including additional proof of medical necessity from your doctor
  • Following the plan’s specifications for necessary documentation
  • Waiting for a decision within 30 days, extended to 60 days for Medicare Advantage
  • Appealing to an independent review entity if still unsatisfied
  • Potentially continuing through additional appeal stages

Appealing requires persistence but can lead to getting denied claims overturned when appropriate. Having your provider firmly confirm necessity boosts odds for a successful appeal.

Tips for Avoiding Medicare Advantage Claim Denials

You can take proactive steps to help avoid Medicare Advantage coverage denials:

  • Review all plan requirements for prior approvals and get them in advance.
  • Stick within your plan’s provider network except for emergencies when possible.
  • Ask your doctor to justify medical necessity if a treatment seems questionable.
  • Make sure prescribed medications are on your plan’s formulary or get an exception approved.
  • Use in-network labs, imaging centers, specialists, hospitals, and pharmacies.
  • Follow all plan pre-authorization protocols for big-ticket items like surgery.

While not every denial can be avoided, understanding plan rules and taking preventive steps goes a long way towards minimizing coverage rejections.

Key Takeaways on Medicare Advantage Coverage Denials

In summary, important things to know about Medicare Advantage claim denials include:

  • Plans cannot deny any services covered under Original Medicare when rules are followed.
  • Denials commonly occur due to medical necessity disagreements, out-of-network providers, lack of prior authorization, and prescription drug formularies.
  • Members denied coverage have the right to appeal the decision by providing additional proof of necessity.
  • Following a plan’s protocols for authorizations, network providers, and formulary drugs can prevent many issues.
  • But Medicare Advantage does allow more claim rejections compared to Original Medicare in an effort to control costs.

Medicare Advantage Plans offer benefits Original Medicare doesn’t but also impose utilization checks that open the door for denials. Knowing the ins and outs of your plan coverage helps avoid surprises. With proper precautions, you can take advantage of Medicare Advantage perks while sidestepping unnecessary coverage roadblocks.

We’re Here to Help

You do not have to spend hours reading articles on the internet to get answers to your Medicare questions. Give the licensed insurance agents at Glidden Group a Call at (208) 962-0077. You will get the answers you seek in a matter of minutes, with no pressure and no sales pitch. We are truly here to help.


Can a Medicare Advantage Plan deny coverage because of pre-existing conditions?

No, Medicare Advantage Plans cannot deny coverage based on pre-existing conditions. They must accept all applicants regardless of their health status.

What is a Medicare Advantage Plan?

A Medicare Advantage Plan is an insurance plan offered by private insurers as an alternative to Original Medicare. It provides the same benefits as Original Medicare but may also offer additional health insurance coverage such as prescription drugs.

How do I sign up for Medicare Advantage Plan?

To enroll in a Medicare Advantage Plan, you can either contact the plan directly or work with a licensed insurance agent who can assist you with the enrollment process.

Can seniors on Medicare enroll in a Medicare Advantage Plan?

Yes, seniors who are eligible for Medicare can enroll in a Medicare Advantage Plan. However, it is important to compare the benefits and costs of different plans before making a decision.

What is the enrollment period for Medicare Advantage Plans?

The enrollment period for Medicare Advantage Plans is known as the Open Enrollment Period. It typically takes place from October 15th to December 7th each year.

Can Medicare Advantage Plans deny coverage?

Medicare Advantage Plans can deny coverage for services that are not considered medically necessary or that require prior authorization. However, they cannot deny coverage based on pre-existing conditions.

What are the coverage rules for Medicare Advantage Plans?

Medicare Advantage Plans must provide the same coverage as Original Medicare, but they may also offer additional benefits. These additional benefits may vary depending on the specific plan you choose.

Can I file an appeal if my Medicare Advantage Plan denies coverage?

Yes, if your Medicare Advantage Plan denies coverage for a service or treatment, you have the right to file an appeal. The plan must provide you with the necessary information on how to file an appeal.

Can Medicare Advantage Plans deny coverage for prescription drugs?

Medicare Advantage Plans that include prescription drug coverage (Medicare Part D) cannot deny coverage for prescription drugs that are prescribed by a healthcare provider and are on the plan’s formulary.

Are all insurance agents licensed to sell Medicare Advantage Plans?

No, not all insurance agents are licensed to sell Medicare Advantage Plans. It is important to work with a licensed insurance agent who specializes in Medicare to ensure you get accurate information and assistance with enrollment.