Eligibility

Medicare is health insurance for people 65 or older, people under 65 with certain disabilities, and people of any age with End-Stage Renal Disease (ESRD).

Medicare consists of four parts:

• Part A covers hospitalization, short-term nursing home care, and some home health services.
• Part B mainly covers physician fees.
• Part C includes Part A and Part B but is run by Medicare-approved private insurance companies.  It is sometimes called Medicare Advantage.
• Part D covers prescription drugs.

Any person who is at least 65 years old and is eligible for Social Security benefits is entitled to Medicare.  A spouse, widow, or widower of someone who was eligible for Social Security benefits is also entitled to Medicare Part A coverage.  Such persons must also be at least 65 years old.  A divorced spouse who has not remarried can qualify for Medicare via a former spouse’s Medicare entitlement if their marriage lasted at least 10 years.

Persons aged 65 and over who are not otherwise entitled to Medicare (because they are not eligible for social security or one of the other options listed above) may voluntarily enroll in the program and pay a monthly premium.  In 2013, people who bought Medicare Part A paid up to $441 each month.  If you choose to purchase Part A you must also obtain Part B coverage.

If you are eligible for Part A, then you are eligible for Part B.  However, unlike Part A, for Part B you will have to pay a monthly premium.  In 2013, the standard premium amount was $104.90.  If you are not eligible, a person age 65 years can obtain Part B coverage if he or she is either a U.S. citizen or a legal permanent resident.

Appealing Denial

An appeal of a claim denial is the action you can take if you disagree with a coverage or payment decision made by Medicare, your Medicare health plan, or your Medicare Prescription Drug Plan.You have the right to represent yourself in the appeals process.  A lawyer is not required.  You have the right to appeal if Medicare, your Medicare health plan, or your Medicare drug plan denies one of these:

• A request for a health care service, supply, item, or prescription drug that you think you should be able to get
• A request for payment of a health care service, supply, item, or prescription drug you already got
• A request to change the amount you must pay for a health care service, supply, item, or prescription drug

You can also appeal if Medicare or your plan stops providing or paying for all or part of a health care service, supply, item, or prescription drug you think you still need.

If you decide to appeal, ask your doctor, health care provider, or supplier for any information that may help your case. See your plan materials, or contact your plan for details about your appeal rights.

If you want to file an appeal, start by looking at your “Medicare Summary Notice” (MSN).  It shows all your services and supplies that providers and suppliers billed to Medicare during a 3-month period, what Medicare paid, and what you may owe the provider. The MSN also shows if Medicare has fully or partially denied your medical claim (this is the initial determination, which is made by the company that handles bills for Medicare). Read the MSN carefully. If you disagree with a Medicare coverage or payment decision, you can appeal the decision. The MSN contains information about your appeal rights.

You’ll get a MSN in the mail every 3 months, and you must file your appeal within 120 days of the date you get the MSN.  Follow the instructions on the back of the MSN. You must send your request for redetermination to the company that handles bills for Medicare(their address is listed in the Appeals Information section of the MSN.)

• Circle the item(s) and/or services you disagree with on the MSN.
• Explain in writing why you disagree with the decision or write it on a separate piece of paper and attach it to the MSN.
• Include your name, address, phone number, and Medicare number on the MSN and sign it.
• Include any other information you have about your appeal with the MSN. Ask your doctor, health care provider, or supplier for any information that may help your case.
• Write your Medicare number on all documents you submit with your appeal request.
• Keep a copy of everything you send to Medicare as part of your appeal.

You’ll generally get a decision from the Medicare contractor (either in a letter or an MSN) called a “Medicare Redetermination Notice” within 60 days after they get your request.

If you disagree with this decision, you have 180 days after you get the notice to request a reconsideration by a Qualified Independent Contractor (QIC).

If you disagree with the reconsideration decision in level 2, you have 60 days after you get the “Medicare Reconsideration Notice” to request a hearing by an Administrative Law Judge (ALJ).

If you disagree with the ALJ’s decision in level 3, you have 60 days after you get the ALJ’s decision to request a review by the Medicare Appeals Council (Appeals Council).

If you disagree with the Appeals Council’s decision in level 4, you have 60 days after you get the Appeals Council’s decision to request judicial review by a federal district court.  To get a judicial review in federal district court, the amount of your case must meet a minimum dollar amount. For 2014, the minimum dollar amount is $1,430. You may be able to combine claims to meet this dollar amount. Follow the directions in the MAC’s decision letter you got in level 4 to file a complaint.