Quick Read – Medicare Advantage denies 54% of inpatient rehab requests, and those rejected services never count toward the plan’s advertised out-of-pocket maximum. – About 80% of appealed Medicare Advantage denials get overturned, yet only 4% of denied claims are ever…
allenged. – Returning to a Medigap plan after the six-month enrollment window closes lets insurers in most states reject applicants based on medical history. – A 72-year-old with a Medicare Advantage plan undergoes a scheduled hip replacement expecting a short rehabilitation stay in a skilled nursing facility, then supervised outpatient therapy. Her plan approved the surgery
Two days after admission, the insurer denies prior authorization for the rehab stay, citing medical necessity criteria she has never seen. She can go home with a walker, or pay the facility out of pocket while her appeal moves through the plan. The surgery was approved.
The recovery was not. That is the Medicare Advantage risk most enrollees never model before signing up, and it can make the choice much harder to reverse than the marketing brochure suggests. The Denial Rate No One Quotes at Sign-Up In a June 2024 snapshot covering 19 of the largest Medicare Advantage organizations, the Department of Health and Human Services Office of Inspector General uncovered the reality.