Denials of Coverage Highest For Medicare Advantage Plans

Denials of Coverage Highest For Medicare Advantage Plans

Narrow provider networks of private Medicare Advantage managed care plans can result in denials of coverage and surprise bills when care is obtained from out-of-network doctors and other healthcare providers.  A recent analysis of the 16,758 questions from the public received by the Medicare Rights Center’s National Helpline in 2016 found that, of those related to Medicare coverage and denials, 40% of the calls came from Medicare Advantage plan enrollees.

Denials of coverage are often for medically-necessary services received, but often unknowingly provided by out-of-network doctors.  The nonpartisan Kaiser Family Foundation has reported that Medicare Advantage plan networks include, on average, only 46% of physicians.  People who have Medigap supplements, on the other hand, can visit any doctor and Medicare provider.

The analysis said that people frequently used in-network facilities, such as the emergency ward of an in-network hospital, nevertheless were treated by an out-of-network physician.  The report noted “Despite protections for people with Medicare who use emergency services, plans continue to deny coverage due to out-of-network providers.”

The report went on to say the Medicare Rights Center also hears from people who are unable to access needed care in their plan’s network because the pool of network specialists is limited, and may result in long waiting periods for appointments.  While beneficiaries have the right to appeal denials of coverage, navigating through the appeals process is an onerous task, during which beneficiaries are left with bills they cannot afford to pay.

TSCL feels that Medicare Advantage plans must provide adequate provider networks in order to cover all Medicare services, something that is required by law.  TSCL believes that Medicare Advantage networks could be strengthened to ensure that all doctors, specialists and other providers are part of the same insurer networks as the hospitals and clinics they use to treat patients.

Editor’s note:  Medicare’s Open Enrollment period starts October 15th and ends December 7, 2018.  Watch for mail from your health or Part D plan and review your plan’s changes for 2019.  Take note of information about provider network changes.  If you need advice, free one-on-one counseling is available.  Get help to compare Medicare Advantage plans from a State Health Insurance Program (SHIP) counselor, and to switch plans if you find one better suited to your needs.  Find a SHIP counselor in your area at


Sources: “Medicare Trends and Recommendations: An Analysis of 2016 Call Data From The Medicare Rights Center’s National Helpline,” Medicare Rights Center, March 2018.  “Medicare Advantage:  How Robust Are Plans’ Physician Networks?” Kaiser Family Foundation, October 5, 2017.