Sometimes Medicare says no. A claim may be denied, a service may not be covered, or a plan that includes Part D might refuse to pay for a prescribed drug. You may also find yourself paying a higher Medicare premium because of your income two years ago, even though your financial circumstances have changed.
The good news is that you may have options. Medicare has formal appeal processes for coverage decisions, and the Social Security Administration has a separate process for challenging certain income-related premium surcharges.
These situations are handled differently, so the first step is understanding which process applies to you.
Appealing a Claim or Coverage Denial
The process depends on whether you have Original Medicare or a Medicare Advantage plan. Both offer several levels of appeal, but the starting points and some of the procedures differ.
| Appeal level | Original Medicare |
Medicare Advantage |
| Level 1 | Redetermination by a Medicare Administrative Contractor (MAC). Generally, file within 120 days of receiving your Medicare Summary Notice. | Reconsideration by your plan. Generally, file within 65 days of the denial notice. |
| Level 2 | Reconsideration by a Qualified Independent Contractor (QIC). Generally, file within 180 days of the Level 1 decision. | If the plan upholds its denial, it generally sends your case automatically to an Independent Review Entity (IRE). |
| Level 3 | Review by an Administrative Law Judge (ALJ). Generally, request it within 60 days of the Level 2 decision. A minimum amount must be in dispute. | You can generally request an ALJ hearing within 60 days of the independent review decision, provided the amount-in-dispute requirement is met. |
| Level 4 | Review by the Medicare Appeals Council. | Review by the Medicare Appeals Council. |
| Level 5 | Judicial review in federal district court, if the applicable requirements are met. | Judicial review in federal district court, if the applicable requirements are met. |
Something to Note:
For 2026, the minimum amount in dispute is $200 for an ALJ hearing and $1,960 for federal district court review. The 2027 thresholds are $200 and $2,000, respectively. The official decision notice will explain the applicable requirements and filing deadline.
A few things worth knowing:
- The names matter. With Original Medicare, the first appeal is called a redetermination. Reconsideration comes second. With Medicare Advantage, you generally begin by asking your plan to reconsider its decision.
- Pay attention to deadlines. Your denial notice or Medicare Summary Notice should explain how to appeal. Follow the instructions carefully, including where to send your request. If you are unsure, ask for help promptly rather than risk missing a deadline.
- Many appeals are resolved early. You may not need to go through every level. If the first decision is upheld, you can consider the next step described in your decision notice.
- Urgent situations may qualify for an expedited appeal. For example, you may disagree with a decision to discharge you from a hospital or end covered skilled nursing or home health services. If waiting could jeopardize your health, ask immediately about a fast or expedited appeal. Some expedited decisions must be made within 72 hours, although the deadline depends on the type of appeal.
- Prescription drug appeals have their own procedures. For Medicare Part D, you generally begin with a coverage determination or an exception request, as appropriate. If your plan denies your request, you can seek a redetermination from the plan. Standard requests generally have a seven-day decision timeframe, while expedited requests generally have a 72-hour timeframe. Further appeals are available if the denial is upheld.
Where to start: Read the denial notice carefully. It should tell you what to do next and where to send your appeal. You can also call Medicare at 1-800-MEDICARE (1-800-633-4227) for help identifying the appropriate starting point.
You do not have to navigate the process alone. If you need help understanding your options, your State Health Insurance Assistance Program (SHIP) may also be able to assist you.
Appealing an IRMAA Surcharge
IRMAA stands for Income-Related Monthly Adjustment Amount. It is an additional charge added to your Medicare Part B and Part D premiums when your income exceeds certain thresholds.
The Social Security Administration generally bases this calculation on your federal tax return from two years earlier. That can create an uncomfortable surprise: your income may have dropped considerably, yet your Medicare premiums may still reflect a time when you were earning much more.
If your circumstances have changed, you may be able to ask Social Security to reconsider the income information used to calculate your premiums or make a new determination based on a qualifying life-changing event.
How to request an adjustment:
- Determine whether you have a qualifying life-changing event. Social Security regulations recognize eight categories, including work stoppage, a reduction in work, marriage, divorce or annulment, the death of a spouse, loss of income-producing property, loss of pension income, and receipt of an employer settlement payment. Check the current SSA-44 instructions for the precise definitions and requirements.
- Complete Form SSA-44, if appropriate. The form is titled Medicare Income-Related Monthly Adjustment Amount — Life-Changing Event. It allows you to request a new determination when a qualifying event has reduced your income. You will generally need documentation of the event and information about your more recent or estimated income.
- Submit your request to Social Security. You can start with the official SSA-44 form and instructions. You can also contact the Social Security Administration at 1-800-772-1213 or arrange an appointment with your local office for help.
- Remember that spouses may need separate requests. If both you and your spouse are affected, each person’s IRMAA determination generally needs to be addressed separately.
What if the problem is not a life-changing event?
You may believe Social Security used incorrect tax information, or you may have another reason to disagree with the determination. In that case, a formal reconsideration or a request for a new initial determination based on corrected or more recent tax information may be appropriate.
These are different procedures, and the right one depends on your circumstances. A formal reconsideration generally must be requested within 60 days of receiving the determination notice, although exceptions may be available. Do not assume that there is no deadline simply because your income has changed.
Will your premiums go down?
An adjustment is not automatic. The Social Security Administration must determine that the applicable requirements are met and that the revised income information changes your IRMAA calculation.
If your request is approved, your premiums may be reduced, and previously overpaid amounts may be corrected. The result depends on the circumstances and the period involved.
Before filing, it can help to review the current IRMAA income thresholds and gather your supporting documents. The Social Security Administration or a qualified benefits counselor can help you understand which procedure fits your situation.
A Final Word
Medicare can be complicated, and a denial or an unexpected premium increase can be discouraging. But a decision is not always the end of the story. You may have the right to ask questions, provide additional information, or request a review.
Start with the notice you received, pay attention to any deadline, and seek help if you need it. Taking that first step can make the process feel much more manageable.
Medicare decisions are personal, and the rules can change. For questions about your own situation, consult Medicare, the Social Security Administration, or a qualified benefits counselor.
Continue the series:
[Medicare Basic] · [Part A and Part B] · [Part D] · [Medigap] · [Medigap Plans: G, N, K, and L] · [Medicare Advantage Plans] · [Financial Assistance]