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Can a Part D Drug Plan Deny Enrollment?

Q. I’m about to enroll in a Medicare drug plan for the first time. Could I be denied coverage for any reason or be asked to pay more because I’m not in good health?

A. You cannot be refused Medicare prescription drug coverage because of the state of your health, no matter how many medications you take or have taken in the past, or how expensive they are. Nor can you be asked to pay more than other people because of your medical history. There are no preexisting conditions in Part D.

Still, your enrollment isn’t complete until the Part D plan you’ve chosen has accepted it. In most cases, it will be accepted. But a plan can delay or reject an application in certain circumstances, such as these:

• Your eligibility for Medicare can’t be confirmed. (You must be enrolled in Part A or Part B to receive Part D drug coverage.)

• You don’t live within the plan’s service area.

• You applied outside the normal periods (either during your initial enrollment period when you first become eligible for Medicare or during the annual open enrollment season) or you don’t qualify for a special enrollment period at other times.

• You’ve applied to enroll in a Part D plan even though you have drug coverage from an employer or union, but you didn’t reply within 30 days to the plan’s letter asking for confirmation that you understand how joining Part D could affect your existing health and drug coverage.

• You applied to a Medicare Advantage (MA) plan—the kind that combines health and drug coverage—that isn’t accepting new enrollees.

• You applied to an MA plan but you already have end-stage renal disease. ESRD patients—usually defined as those undergoing dialysis or needing a kidney transplant—cannot join an MA plan. They can still get coverage under traditional Medicare and a separate stand-alone drug plan.

Within 10 days of receiving your enrollment application, a plan must send you one of three letters: a notice acknowledging your application; a request for more information needed to complete the application; or notification that your application has been denied, specifying the reason why.

If you’re asked for more information, it’s important to respond within 30 days—otherwise the plan must deny your enrollment.

There is no right of appeal against an enrollment denial. However, if you think the stated reasons are not correct, call the plan immediately at the number given on the denial notice and explain why. If that doesn’t resolve the issue, call Medicare at 1-800-633-4227 and say you wish to discuss it with someone at your Medicare regional office. You can also get free, expert advice and help from a counselor at your state health insurance assistance program.

If your enrollment is delayed beyond the time when your coverage should begin, the plan must cover your drugs while the issue is being resolved. In the meantime, you can use a copy of your enrollment form or the plan’s acknowledgment letter as proof of coverage at the pharmacy. But if the plan eventually rejects the enrollment, you must repay the plan’s share of the cost of any drugs you’ve received.

Patricia Barry is a senior editor at the AARP Bulletin.

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