Appeals and Penalties

Topic 1: Original Medicare Appeals • Different types of appeals depending on the type of service beneficiaries receive and the type of coverage they have • Original Medicare appeals, which beneficiaries may file if they are denied a health care service or item and think that it should be covered • Five steps of filing a standard appeal • How to file an expedited appeal for hospital and non-hospital care Topic 2: Medicare Advantage Appeals • Medicare Advantage (MA) appeals, or appeals beneficiaries make to their Medicare Advantage Plan if the plan is denying a health care service or item that they would like to receive or have already received • Standard appeals for both pre-service and post-service denials • Standard and expedited appeals and their applicable timelines Topic 3: Part D Appeals • Medicare Part D appeals process – same for a stand-alone Part D plan (PDP) or a Medicare Advantage Plan with prescription drug coverage (MAPD) • Reasons beneficiaries might want to appeal: drug needed not covered by plan, drug covered but with coverage restrictions, drug covered but with a tiering exception request for lower copay • First pre-appeal step and five levels of appeal within both standard and expedited timeframes • Tips to help people with Medicare move effectively through the appeal process Topic 4: Medicare Late Enrollment Penalties and IRMAA • Penalties due to non-enrollment in Medicare Parts A, B, and/or D when beneficiaries are first eligible • How late enrollment penalties may be eliminated • Key IRMAA considerations: what IRMAA is, when it must be paid and who is likely to pay it, how to appeal or request a new initial determination if there is disagreement with Social Security’s IRMAA decision