What if my plan stops participating in Medicare?

Medicare health plans as well as prescriptions plans can change every year, or do away with a plan altogether. What this means to you is that your current plan may not be available next   year. If that happens, your benefits under that plan will terminate on December 31st at midnight and you will have to elect a new plan during Medicare’s open enrollment period. Open Enrollment Period commences on October 15th and ends on December 7th. Your new plan will go into effect on the 1st. day of the following year.


What’s an appeal?

An appeal is an action taken by someone who disagrees with a Medicare coverage or payment decision. It also applies to Medicare Advantage Plans. You can file an appeal if you believe that you should be able to receive a specific health care service, a drug, certain supplies and items, and Medicare or your plan denies you. Those services, drugs, supplies and items may require a certain payment, and the amount of that payment may also be appealed if you don’t agree that the amount is correct.


When filing an appeal, it is important to have good records to sustain your case. Your doctor, supplier or health care provider may be able to provide you with the information you need. Maintain a well-organized file and keep good records.


How do I file an appeal?

That depends on whether you have Original Medicare or a Medicare Advantage Plan. If you have original Medicare, you will need the Medicare Summary Notice (MSN) which displays the item or service you are appealing. You will need to circle the item you are not in agreement with and include an explanation of why you disagree. You may include the explanation on the Medicare Summary Notice or you may write it on a separate paper and attach it. Be sure to include you personal information such as name, phone number, and Medicare number. Make sure to sign the MSN and maintain a copy for your records. Once the you have completed these steps, send the MSN to the company listed on the MSN. That is the company that handles your billing for Medicare. After you file your appeal, you can expect an answer within 60 days. The Medicare Administrator Contractor should contact you.


If you have a Medicare health plan contact your plan for instructions on filing an appeal. Each plan has its own set of rules. You may also visit Medicare.gov/appeals for additional information.


If you have a Medicare Prescription Drug Plan, you will need what is referred to as a “coverage determination”. It is a written explanation of a decision made by the Medicare drug plan. It includes decisions about covered drugs, benefits, requirements, co-payments, and exceptions. These decisions are not made by the pharmacy or pharmacist. Contact your plan administrator for instructions on filing an appeal. You may also visit Medicare.gov/appeals for additional information.


Regardless of the type of appeal you are filing, you can ask for a fast appeal if you think your services are going to be ending too soon. Your doctor or health care provider can guide you and can provide you with certain paper work you will need for a fast appeal. Fast appeals are handled through an independent reviewer known as a Family Centered Care Quality Improvement Organization. A decision will be expedited.

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