Medicare Claim Denied? How Seniors Can Get the Coverage They Need

Medicare Claim Denied?

Medicare coverage of medicines for seniors is often crucial, especially because on average, older adults take a shocking 15-18 prescription medications. And with an average price of over $11,000 yearly for the most common prescription drugs prescribed for the elderly, it usually is debilitating when a Medicare claim is suddenly denied. And yet, that’s happening more and more frequently as Medicare plans are progressively establishing coverage limits on older persons – generally outside of approval from the Centers for Medicare & Medicaid Services.

Since the appeals process for denied coverage can be so intimidating, regrettably, many seniors simply accept the denial – at frequently an insanely high financial impact, or at great risk to their health when necessary prescription drugs are stopped as a result of lack of Medicare insurance coverage. According to 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 a number of medications must be covered by Medicare across the board (medications for HIV/AIDS, depression, cancer, and seizures, among others), there’s a gray area in which medications are covered for other conditions – and preapproval is frequently needed, or patients are given the criteria that lower price options have to be tried first (also known as step therapy). Denials typically occur as a result of failing to satisfy these requirements.

So, what things can a senior citizen do to get the medication coverage to which they’re entitled? There are several key steps:

  • First, request a formal coverage determination from the senior’s Medicare drug plan. Details on submitting this request are available by clicking here.
  • When insurance coverage is determined, there will be five levels in the appeals process, detailed here.
  • Keep detailed documentation throughout each and every step of the process. To get more guidance, the Medicare Rights Center can assist. You can reach them at 800-333-4114.

Keep in mind that it’s important to be persistent. Frequently, higher levels of appeals are approved even though initial steps result in discouraging outcomes. Get in touch with Advanced Home Health Care, the top provider of Burlington home care and the surrounding areas, for more ideas and hands-on support for seniors. We can provide resources that will help aging adults along with their family members advocate for themselves, along with specialized in-home care services to ensure that medicines are taken just as prescribed, that prescription medication refills are taken care of, and much more. Call us at 800.791.7785 and learn how you can keep your senior loved one safe and flourishing!

The Care You Need. The Quality You Deserve.