Many seniors choose Medicare Advantage plans, believing they offer the same coverage as Original Medicare with added benefits. But what happens when unexpected denials happen when you need it most?
Denials of medically necessary care are becoming a major issue with Medicare Advantage plans. Insurance companies have the power to approve or deny treatments, often leaving patients with massive out-of-pocket costs.
In this article, we’ll share real-life stories of Medicare Advantage denials, how they impact beneficiaries, and what you need to know before choosing your healthcare plan.
What Is a Medicare Advantage Denial?
A denial of coverage happens when your insurance company refuses to pay for a medical service, claiming it isn’t “medically necessary” according to their internal guidelines.
With Medicare Advantage plans, the insurance company—not Medicare—decides what’s covered. Even if your doctor says a procedure is necessary, your plan can still deny it.
At The Benefit Link, we hear these stories every week—and they’re heartbreaking.
Real Stories of Medicare Advantage Denials
A $90,000 Medical Bill at 77 Years Old
One of our team members’ grandfather, age 77, was rushed to the hospital in October after suffering a double-saddle pulmonary embolism—a life-threatening condition causing blood clots in the lungs.
- He was transferred to another hospital for urgent treatment, racking up a $90,000 medical bill.
- His Medicare Advantage plan only covered $36,000, leaving him with a $54,000 bill to pay out of pocket.
- Even after being transferred to an in-network hospital, he still faced unexpected costs.
For a senior on a fixed retirement income, this kind of expense can be devastating.
From Medicare Supplement to Medicare Advantage—Then Cancer
Another client had been on a Medicare Supplement for years but decided to switch to a Medicare Advantage plan to save money. Shortly after switching, she was diagnosed with cancer.
- She soon found out her chemotherapy and radiation treatments would require 20% out-of-pocket costs under her Advantage plan.
- She called us, hoping to switch back to her Medicare Supplement, but she was no longer eligible due to her new health condition.
- Over time, she ended up paying $500,000 in medical expenses that her plan wouldn’t cover.
This is one of the biggest risks with Medicare Advantage—once your health declines, you may not be able to return to a Medicare Supplement plan. Many insurance companies require a waiting period of 2-10 years for pre-existing conditions like cancer.
What You Need to Consider Before Choosing a Medicare Advantage Plan
Medicare Advantage may seem appealing because of its low or $0 premiums, but the true cost of these plans is often hidden.
Before enrolling, ask yourself:
- Will my doctor and hospital accept this plan? Many hospitals are dropping Medicare Advantage plans due to payment issues.
- What happens if I need extensive medical care? Advantage plans often have high deductibles, co-pays, and out-of-pocket maximums.
- Can I switch back to a Medicare Supplement if my health changes? Many people don’t realize they could be locked out of a better plan if they develop a serious condition.
- How often does this plan deny claims? Medicare Advantage plans routinely deny treatments that Original Medicare would cover.
Protect Yourself from Unexpected Denials
When it comes to your health, the last thing you want is a surprise bill or a denial of coverage when you need care the most.
If you have questions about your Medicare options, call us today at (817) 945-6409. We’ll help you understand your choices and find a plan that truly protects you.
🔗 thebenefitlink.com
Your health is too important to leave to chance. Know your Medicare options before it’s too late!
