What is denial of coverage?
Denial of coverage refers to a situation in which Original Medicare, a Medicare Advantage plan, or a Medicare Part D drug plan refuses to cover certain medical services.
What causes a Medicare denial of coverage?
A Medicare denial of coverage could be due to various factors. If you have Original Medicare, a denial of service could be due to:
- Medicare determines that the service is not medically necessary.
- You’re receiving routine dental or vision care, which are not covered by Original Medicare.
- You’ve run out of inpatient coverage days in your benefit period, or you’ve reached 100 days in a skilled nursing facility.
- You’ve entered a skilled nursing facility without a preceding inpatient hospital stay that lasted at least three days.
- You’re receiving custodial care (assistance with activities of daily living) without receiving skilled medical care at the same time.
If you have Original Medicare or a Medicare Part D plan, additional reasons for coverage denials could include:
- You’re seeking care outside your plan’s provider network.
- You’ve been prescribed a medication that isn’t on your plan’s formulary (covered drug list).
- The plan requires prior authorization and you haven’t obtained it.
One important reminder: Sometimes a service might be covered but you still have to pay for it, simply because you haven’t yet met your deductible. This is different from a denial of coverage.
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