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Can You Be Turned Down by a Medicare Advantage Plan?

Can You Be Turned Down by a Medicare Advantage Plan

For millions of Americans on Medicare, enrolling in a Medicare Advantage Plan seems to offer appeal. These private insurance alternatives to Original Medicare frequently charge lower monthly premiums while providing extra benefits like vision, dental, and prescription drug coverage. However, what many seniors may not realize is that Medicare Advantage Plans have the ability to reject applications or deny coverage of certain treatments in a way Original Medicare does not.

Rather than automatically accepting all Medicare beneficiaries, these private insurers maintain underwriting guidelines much like traditional health plans. This ability to turn consumers away poses serious risks seniors need to understand before signing up. In this article, we will explore the ways Medicare Advantage Plans can deny coverage, reasons behind these decisions, and tips for challenging rejections when faced with large medical bills. An informed choice between Medicare Advantage or Original Medicare relies on knowing the true limitations of each approach.

Overview of Medicare Options for Seniors

There are a few main options for healthcare coverage available to seniors enrolled in Medicare:

  1. Original Medicareconsists of Part A (hospital insurance) and Part B (medical insurance). With Original Medicare, seniors have access to a wide network of providers but generally have to pay out-of-pocket for services until meeting the deductible. This is where Medigap or Medicare Advantage Plans come in.
  2. Medigap (Medicare Supplement) plansare private insurance policies sold by companies like AARP, Mutual of Omaha, and Blue Cross Blue Shield that help cover costs like deductibles, copays, and coinsurance associated with Original Medicare. Medigap Plans have standardized benefit packages labeled Plans A through N that seniors can choose from.
  3. Medicare Advantage Plans(also called Part C) are an alternative to Original Medicare offered by private insurers that are approved by Medicare. Examples include HMOs, PPOs, and Private Fee-for-Service plans. Medicare Advantage Plans generally provide all Part A and Part B benefits, and often include prescription drug coverage and extra benefits like vision, dental, and fitness.

Medicare Advantage Plans Can Deny Coverage

Unlike Original Medicare which generally accepts anyone over 65, Medicare Advantage Plans have more leeway to deny coverage to seniors or decline to cover certain treatments. Here are some important points about denials by Medicare Advantage Plans:

Prior Authorization Required

Most Medicare Advantage Plans require seniors to get prior authorization from their plan before undergoing certain medical treatments, procedures, or seeing specialists. This is unlike Original Medicare which generally does not require pre-approval.

Frequent Denials of Authorization Requests

Many Medicare Advantage Plans deny a significant percentage of prior authorization requests from doctors, meaning seniors’ treatments would not be covered by their plan. Denials are often due to treatments being deemed not medically necessary by the private insurer.

Reasons for Denials

Primary reasons Medicare Advantage Plans deny coverage include pre-existing conditions, treatments/procedures the plan says are unnecessary, and failure by the senior or doctor to obtain the required prior authorization from the plan before care was provided.

Impact on Seniors

Receiving a denial of coverage can have serious consequences for seniors enrolled in a Medicare Advantage Plan, as they may receive large bills for care their plan refuses to pay for or be unable to access treatments recommended by their doctor. This level of risk should be carefully considered.

Enrolling in a Medicare Advantage Plan

Open Enrollment Period

Each fall, there is an Open Enrollment Period when seniors already enrolled in Medicare can switch between Original Medicare and Medicare Advantage Plans, or change plans. This is the only guaranteed enrollment period outside of certain life changes.

Role of Insurance Agents

Licensed insurance agents, who are paid a commission by the plans they enroll seniors in, play a big role in marketing Medicare Advantage Plans during Open Enrollment Fairs and one-on-one meetings. They can help compare options but aren’t unbiased.

Reasons for Enrolling

Many seniors are attracted to Medicare Advantage Plans due to lower monthly premiums than Medigap, inclusion of prescription drug coverage which Original Medicare lacks, and additional benefits. But it’s crucial to understand the risk of denied claims.

Challenging Denials of Coverage

Appeals Process

If a Medicare Advantage Plan denies coverage for a treatment, seniors have the right to appeal. There is an initial review, then multiple levels of appeal internally and ultimately an external review by Medicare. Though this process can take many months.

Appeal Success Rates Vary

Analysis has found the percentage of denied claims that are overturned on appeal differs greatly depending on the state, ranging from 11-52%. This suggests some insurers deny more legitimate claims than others.

Help from Agents

Licensed Medicare agents can assist seniors with navigating the dense appeals paperwork and process. While this help is valuable, it’s still in the agent’s financial interest to keep clients enrolled in certain Medicare Advantage Plans long-term for their commission.


In summary, while Medicare Advantage Plans offer lower costs and more benefits for some seniors, it’s critical to understand that insurers operating these plans retain the ability to deny claims or refuse coverage altogether based on pre-existing conditions or what they deem medically necessary. The risk of depleted savings or large medical bills due to denied care is real.

Those considering a Medicare Advantage Plan should carefully review the plan’s approval ratings, network of doctors/hospitals, and history of denied/overturned claims in their area. For many, Original Medicare plus a Medigap Plan remains the safer choice overall in terms of stability of coverage and lack of utilization review hurdles. Senior citizens and their families must fully educate themselves on this complex issue, understanding both pros and cons, to select the best Medicare option.

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 Senior Health Advocates a Call at (386) 222-3030. 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 I be turned down by a Medicare Advantage Plan because of pre-existing conditions?

 No, Medicare Advantage Plans cannot deny you coverage based on pre-existing conditions.

What should I do if my Medicare Advantage Plan denies coverage for necessary care?

 You have the right to file an appeal if your Medicare Advantage Plan denies coverage for necessary care. You can also seek assistance from a licensed insurance agent.

Am I eligible for Medicare Supplement insurance if I already have a Medicare Plan?

 Yes, you can purchase a Medicare Supplement insurance plan to complement your existing Medicare coverage.

Is signing up for Medicare Advantage different from signing up for Original Medicare?

 Yes, signing up for Medicare Advantage involves enrolling in a private insurance plan, while signing up for Original Medicare involves enrolling in the federal Medicare program.

Do all Medicare Advantage Plans cover prescription drugs?

 No, not every Medicare Advantage Plan includes prescription drug coverage. You may need to choose a plan that offers this coverage or consider a separate prescription drug plan.

Can seniors on Medicare living in all four states access Medicare Advantage Plans?

 Medicare Advantage Plans are available to seniors on Medicare living in all 50 states, not just four states.

What is the role of a licensed insurance agent when it comes to Medicare Plans?

 A licensed insurance agent can help seniors on Medicare understand their options, compare different plans, and choose the most suitable Medicare Plan for their needs.

Are all Medicare Advantage Plans HMOs (Health Maintenance Organizations)?

 No, while many Medicare Advantage Plans are HMOs, some plans offer different network structures, such as PPOs (Preferred Provider Organizations) or HMOPOS (HMO Point of Service).

Can individuals under the age of 65 be eligible for Medicare due to disability?

 Yes, individuals under the age of 65 can be eligible for Medicare if they have a qualifying disability and meet certain criteria.

Is it true that Medicare Advantage Plans don’t require prior approval for necessary care?

 Medicare Advantage Plans may require prior approval for certain services, treatments, or medications, so it’s essential to review the specific coverage and requirements of your plan.

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