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The Process for Medicare Appeals

What is Medicare?

Medicare is the federal health insurance program for individuals who are 65 or older, certain younger individuals with disabilities, and people with end stage renal disease. It is administered by the Centers for Medicare and Medicaid Services (CMS), a division of the U.S. Department of Health and Human Services.

Is Medicare the Same as Medicaid?

No. Despite the similarity in terms, Medicare and Medicaid are quite different.  Both programs are designed as social insurance programs to spread the financial burden of illness among both health and sick individuals and among both affluent and indigent individuals.

While Medicare is the federal health insurance program available for all individuals older than 65 and certain individuals with disabilities and end stage renal disease, Medicaid is a program designed to provide health coverage to those lower income individuals who meet both medical and financial requirements. Many people are surprised to learn that Medicare does not cover the cost of long-term care in a personal care home, and only covers care in a nursing home under limited circumstances.

What if Medicare Refuses to Cover My Care?

Sometimes Medicare will determine that a particular treatment or service is not covered and will deny a request for a health care service or prescription drug. Other times Medicare initially determines a particular health care service or prescription drug is covered, but later determines that such health care service or prescription drug is no longer medically and reasonably necessary and discontinues coverage.  You have a right to appeal any of these determinations by Medicare.

Can Someone Appeal on My Behalf?

A Medicare recipient has the right to appoint a representative to act on their behalf with regard to a Medicare appeal. The individual appointed can be a friend, family member, advocate, attorney, physician, or other individual.    While there is a standard form for making such an appointment, any writing which contains certain required information is acceptable. Keep in mind that for each level of appeal, there are filing deadlines, some of which are very short. In addition, a decision about an appeal must be made by the determining organization within a certain timeframe after the appeal is filed.

When Can I Get an Expedited Appeal?

You have the right to an expedited appeal if you think your Medicare covered hospital stay, skilled nursing facility stay, home health agency services, or hospice services are ending too soon.

For example, when your skilled nursing facility services end, you should receive a notice called a “Notice of Medicare Non-Coverage” at least two days prior to the end of services. The Notice will explain the date the coverage of your services will end, that you may have to pay for services received after this date, and information about your right to appeal the decision.

If you choose to appeal this Notice, you must do so by calling your Beneficiary and Family Centered Care – Quality Improvement Organization (BFCC-QIO). If the BFCC-QIO determines that your services ended too soon, Medicare will continue to cover your services.  If the BFCC-QIO determines that your services should end, you will be responsible for any services received after the date on the “Notice of Medicare Non-Coverage.”

You may then appeal this decision by requesting an Expedited Reconsideration which is performed by a Qualified Independent Contractor (QIC).   If you disagree with the decision of the QIC you may appeal this decision as well to an Administrative Law Judge (ALJ), the Medicare Appeals Council (MAC), and ultimately to a federal district court.

What if I Miss the Deadline for an Expedited Appeal?

If you miss the deadline for an Expedited Appeal, you can still appeal the denial of a Medicare service by following the standard appeal track. There are five levels of appeal:

Level 1 – Redetermination – This is an examination of an initial claim determination made by a Medicare Administrative Contractor.

Level 2 – Reconsideration – If an individual is not satisfied with the redetermination decision, he or she may request reconsideration of the redetermination decision. Such request must be made in writing to a Qualified Independent Contractor (QIC).

Level 3 – Administrative Law Judge (ALJ) – If an individual is dissatisfied with a QIC decision, he or she may request a hearing before an ALJ.

Level 4 – Medicare Appeals Council (MAC) – An individual may appeal the decision of the ALJ to the MAC.

Level 5 – Federal District Court – An individual may appeal the decision of the MAC by filing an action in federal district court. For this level of appeal, the services in question must have a value of at least $1,560 for 2017.

What if I Missed the Deadline to Seek Redetermination?

Even if you missed the deadline to seek redetermination of an initial claim determination, you may still be able to appeal that decision. An individual may request that an initial determination be reopened if the request is made within one year from the date of the initial determination and can show good cause.

The Medicare system is broken. It is difficult to navigate the complex system of rules and policies.  A Reuters article from 2010 provided data from the Centers for Medicare and Medicaid Services indicating that 40% of all Part A appeals and 53% of all Part B appeals were successful.  The wrongful denial of a health care service or prescription drug coverage by Medicare can result in significant cost to an individual.  If you or your loved one have received a Medicare denial or are facing issues with regard to your Medicare coverage, contact a qualified elder law attorney to discuss your situation.