Healthcare Educators


How to Appeal Medicare Decisions

by | Jun 25, 2021

More than 60 million people are enrolled in Medicare. In a program that large, some mistakes are bound to happen. You may also find yourself in an unusual situation that requires special consideration. Unfortunately, these issues could mean that your premiums are higher than they should be. It’s also possible for your claims to be denied when they should be covered, resulting in major out-of-pocket costs.

As a Medicare beneficiary, you have the right to appeal decisions that you believe are incorrect.

Late Enrollment Penalty Appeals

You age into Medicare when you turn 65.

  • You will have a seven-month Initial Enrollment Period that starts three months before your birthday month.
  • If you have qualifying group health coverage through current employment, you may be able to delay enrollment without paying a penalty, and you will be given a Special Enrollment Period to Enroll.
  • If you don’t enroll during your Initial Enrollment Period and you don’t qualify for a Special Enrollment Period, you will have to wait until the General Enrollment Period, which occurs January through March each year.

Although the General Enrollment Period gives you another chance to enroll a plan, you may end up with a gap in coverage. You may also have to pay a lifetime late enrollment penalty. CMS says that your monthly Part B premium will increase by 10% for each 12-month period you delay enrollment. You may also be charged a Medicare Part D late enrollment penalty if you go 63 days without creditable prescription drug coverage. Once again, this is a lifetime penalty.

If you believe you are being charged a late penalty when you shouldn’t be, you can appeal the decision when you receive the notice of the penalty. To appeal a Part D late enrollment penalty, fill out the reconsideration request form that you receive with your notice of penalty.

Medicare Surcharge Appeals

The standard Medicare Part B premium is $148.50 per month in 2021. However, if you earn more than $88,000, you can be charged more. People in the highest income bracket will pay $504.90 per month for Part B coverage in 2021. This surcharge is called the Income Related Monthly Adjustment Amount (IRMAA).

If you are being charged a Medicare surcharge, you will be informed of this when you receive your annual notice of Social Security benefits. If you believe the surcharge is incorrect, you can request a reconsideration of the initial determination by contacting the Social Security Administration. See the HHS page for more details on how to file an appeal and when an appeal might be warranted.

Coverage Appeals

If your Medicare plan denies coverage for a service you need or have already received, you can appeal the decision if you believe the service should be covered. This is true whether you are in Original Medicare or Medicare Advantage. You can also appeal coverage decisions involving prescription drugs.

In Original Medicare, fill out the Redetermination Request Form and send it to the address that appears in the Appeals Information section of your Medicare Summary Notice. If you have a private plan, follow the appeals process directions, which should appear in the initial denial notice and the plan materials. Contact your plan if you have questions.

It is important to appeal decisions promptly. If you miss a deadline, your appeal may not be successful. For more information on filing coverage appeals in different types of Medicare plans, see the page on filing appeals.