With seniors in the United States taking on average, 15-18 different medications, Medicare assistance for coverage of these medicines is often a necessity. And with a typical pricetag of greater than $11,000 annually for the most typical medicines prescribed for the elderly, it usually is devastating when Medicare abruptly denies coverage. Yet nevertheless, that’s happening a lot more frequently as Medicare plans are increasingly establishing coverage limitations on older persons – typically outside of approval from the Centers for Medicare & Medicaid Services.
Considering that the appeals process for denied coverage can be so complex, sadly, many aging adults simply accept the denial – at either an insanely high financial impact, or even at potential risk to their health if required prescription drugs are stopped due to lack of Medicare health insurance coverage. According to David Lipschutz, senior policy attorney at the Center for Medicare Advocacy, “A lot of people fall through the cracks. They simply don’t know what to do. Or they try to go through the process, and it’s complicated and time-consuming and they just give up.”
Although a variety of prescription drugs must be covered by Medicare across the board (medications for HIV/AIDS, depression, cancer, and seizures, as well as others), there’s a gray area in which prescriptions are covered for other conditions – and preapproval is usually needed, or patients are given the specifications that lower cost methods must be tried first (also known as step therapy). Denials typically occur as a result of neglecting to meet these requirements.
So, what can a senior citizen do to obtain the medication insurance coverage to which they’re entitled? There are several key steps:
- First, obtain a formal insurance coverage determination from the senior’s Medicare drug plan. Information on submitting this specific request can be found by clicking here.
- After insurance coverage is established, there are five levels in the appeals process, outlined here.
- Keep detailed documentation throughout each step of the process. For additional assistance, the Medicare Rights Center can help. It is possible to reach them at 800-333-4114.
Bear in mind it’s necessary to be persistent. Frequently, higher levels of appeals are approved even if preliminary steps generate disappointing results. Call Atlanta Home Care Partners for additional strategies for Medicare assistance and hands-on support for Atlanta seniors. We are able to provide resources to help aging adults and their family members advocate for themselves, together with expert in-home care services to make sure that prescription drugs are taken just as prescribed, that medication refills are handled, and much more. Call us at (404) 228-0103 and discover how our caregivers in Atlanta can keep your older loved one safe and thriving!