Community Legal Aid

Denied by Medicare Advantage? The Odds Say Appeal.
By Attorney Alice Bers, Director, Medicare Advocacy Project
Op-Ed for The Montague Reporter

If you had a nine in ten chance of winning something, wouldn’t you go for it? Those are odds worth taking. What if it was not only something you wanted, but something you needed, like medically necessary services in a skilled nursing facility?

This is the situation many older adults and people with disabilities find themselves in if they are enrolled in a Medicare Advantage plan. These plans offer a way to receive Medicare benefits through private insurance companies, rather than directly from the federal government. Medicare Advantage plans require “prior authorization” (pre-approval) before they will cover many services. In theory, prior authorization prevents unnecessary, costly care. In practice, doctors and patients say that it has become overused and burdensome, causing delays and denials of care that patients need.

When a Medicare Advantage plan denies prior authorization, the patient has a right to appeal. It is important to understand and make use of this appeal right, because plan denials are frequently overturned. A new federal report examined nursing facility care specifically, and its findings show just how often these pre-approval denials are wrong.

The June 2026 report from the U.S. Department of Health and Human Services’ Office of Inspector General found that when patients and providers appeal Medicare Advantage denials of prior authorizations for nursing facility care, they win 95% of the time. Skilled nursing facility care, which includes physical and occupational therapy as well as nursing, helps bridge the gap between a hospital discharge and the ability to return home with as much independence as possible. Given how often denials are overturned — and how critical these services are — appealing is clearly worthwhile.

Every written denial notice from a Medicare Advantage plan must explain how to appeal, and patients can also ask their healthcare provider to support the appeal with medical documentation. Because appeals have deadlines, it is important to act promptly and ask for help if you need it. Many appeals succeed because additional information shows that the requested care meets Medicare’s coverage rules.

But most Medicare Advantage denials are not appealed. The federal analysis found that only 18% of initial denials for nursing facility care were appealed, for example. As the report notes, the “extremely high overturn rate indicates that some enrollees were initially denied medically necessary care,” and it “raises concerns about denials that were not appealed.”

Why do Medicare Advantage plans deny coverage so frequently? The federal watchdog report points to profit incentives for the plans. These plans are paid a fixed monthly amount per patient, regardless of how many services that person receives. The report flags this as “a central concern” for denials of care. Every denial that is not appealed can save money for the plan.

The result is predictable: Medicare Advantage plans deny, and many people who could receive coverage never appeal. They may not understand that they have the right to appeal, or they assume an appeal will not be successful, or they are simply overwhelmed by the bureaucratic hurdles involved. Research shows that these barriers discourage patients from pursing healthcare benefits. As a result, patients may opt for cheaper, less effective care, pay out of pocket, or go without needed care altogether. These concerns are heightened for the older adults and disabled individuals who rely on Medicare for health coverage.

The good news is that Massachusetts Medicare beneficiaries can get help with Medicare Advantage denials, and more, by reaching out to the Medicare Advocacy Project (MAP). MAP’s experienced advocates provide free legal assistance for Medicare-related issues. In central and western Massachusetts, MAP can be reached via Community Legal Aid, which provides free civil legal assistance to older adults and low-income individuals. We encourage anyone facing a Medicare denial or appeal to apply for assistance through our website (link in the comments) or by calling 855-252-5342.

Reform is needed to fix a system that gets it wrong far too often. Older adults and people with disabilities should not have to fight so hard for nursing facility services and other medical care they need and qualify for by law. U.S. taxpayers should expect Medicare Advantage plans to deliver the healthcare they pay those plans to provide.

But for now, the takeaway is simple. If a Medicare Advantage plan denies your prior authorization request, don’t assume the answer is final. Read the denial notice, pay attention to deadlines, and ask for help if you need it. Given the odds, an appeal may make all the difference.

Alice Bers is director of the Massachusetts Medicare Advocacy Project.

Worcester - we loved seeing you all at Pride Worcester this past weekend! Did you get a chance to stop at the Community Legal Aid table?

A lost job can mean losing housing. A wrongful firing can cut a person off from their health insurance. A criminal record can stand between a worker and a new opportunity. Access to benefits, education, family stability, age and disability can all shape a person's economic security.

That's why we see workers rights as everyone's work!

At Community Legal Aid, our Employment Law Unit collaborates with colleagues across our housing, elder, benefits, CORI/Re-Entry, education, and family law units to address the legal issues that affect a worker's life as a whole. We also refer clients to other services and organizations such as social service agencies and the legal advocates at the Central West Justice Center.

Massachusetts has some of the nation's strongest worker protections, from a law that protects against certain uses of criminal records in employment, to our Paid Family and Medical Leave law and our Wage Act. But rights only have meaning when people can access, understand, enforce them.

That is why Community Legal Aid is uniquely positioned to provide transformative legal services. We approach our clients' legal needs with a holistic lens and because we practice under one roof, we can step in to support each other when a client's needs cross practice areas.

For example, a client lost her job and was denied unemployment, and sought the help of our Employment Law Unit to appeal that denial. We learned that she was facing eviction due to not having her wages or unemployment benefits. Before her life could unravel further, we referred her to our housing team, to make sure she has support defending her rights as a tenant while we fight for her unemployment benefits.

Legal issues in a worker's life do not exist in silos and neither should our response. We are lucky to practice under one roof, with some of the best advocates in the state, who see how all our rights are connected.

Congratulations to Community Legal Aid Board Member and Pro Bono Volunteer Akosua Agyepong on being named one of Worcester Business Journal's 40 Under Forty honorees!🎉

40 Under Forty 2026: Akosua Agyepong Akosua Agyepong’s commitment to ensuring access to justice extends well beyond her family law practice at Turco Legal.

Happy National Paralegal Day! Learn more about the history and importance of the paralegal profession: https://bit.ly/3RPlGmm

Community Legal Aid's July 2026 Newsletter is out now! READ ALL ABOUT:

📝 How one former client is using her story to advance CLA's mission as a member of the organization's Board of Directors!

👋 How CLA is bidding farewell to beloved longtime leader Jen Dieringer, and introducing two new CLA Managing Attorneys who are taking the reins in Franklin and Hampshire Counties.

🏘️ How CLA will use new state funding for fair housing work to continue combatting discrimination and enforcing housing laws across the region

AND MORE!

You've sacrificed, you've studied, and now the day is finally here. To all those taking the Massachusetts Bar Exam this week: You've got this! We know you can do it. ⚖️ 💛