Care Blog

How to Fight Medicare Denials to Get the Coverage a Senior Needs

Medicare DenialsMedicare 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 annually for the most common drugs prescribed for the elderly, it could be debilitating when Medicare all of the sudden denies coverage. And yet, Medicare denials are happening a lot more frequently plans are increasingly establishing coverage limitations on seniors - generally outside of affirmation from the Centers for Medicare & Medicaid Services.

Considering that the appeals process for denied coverage can be so intimidating, unfortunately, many seniors simply accept the denial - at either an outrageously high financial impact, or at potential risk to their health if needed medicines are discontinued because of lack of Medicare health insurance coverage. As stated by 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.”

Although several prescription drugs must be covered by Medicare across the board (those for HIV/AIDS, depression, cancer, and seizures, to name a few), there’s a gray area in which prescription medications are covered for other conditions - and preapproval is normally required, or patients are given the specifications that less expensive measures must be tried first (also known as step therapy). Denials often come because of a consequence of neglecting to fulfill these requirements.

So, what things can a senior do to receive the medication insurance coverage to which they’re entitled? There are certain key steps:

  • First, ask for a formal coverage determination from the person's Medicare drug plan. Details on submitting this kind of request can be found by clicking here.
  • As soon as insurance coverage is determined, there will be five levels in the appeals process, specified here.
  • Keep detailed documentation throughout every step of the process. For further guidance, the Medicare Rights Center can assist. You'll be able to reach them at 800-333-4114.

Bear in mind it’s necessary to be persistent. Oftentimes, higher levels of appeals are approved even if preliminary steps generate discouraging outcomes. Contact All Care In-Home Care Solutions in Klamath, OR, for more strategies and hands-on assistance for seniors and handling Medicare denials. We are able to provide resources that can help aging adults along with their families advocate for themselves, together with expert in-home care services to make sure that medicines are taken just as prescribed, that medication refills are taken care of, and much more. Call us at (541) 857-9195 and discover how you can keep your senior loved one safe and thriving!

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