Health Insurance: Know Your Medicare Rights

Learn How to Appeal a Medicare Decision or File a Complaint

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Note: This article about your Medicare rights is based on content accessed from Medicare & You 2010 and information available on the website.

All people with Medicare have certain guaranteed rights and protections, no matter what type of Medicare coverage you have. These rights include the following:

Be treated with dignity and respect at all times.

Be protected from discrimination.

Discrimination is against federal and state laws.

Every organization that works with Medicare must obey the law, including providers paid by Medicare on your behalf. You cannot be treated differently because of your race, color, national origin, disability, age, religion, or sex.

If you think that you have not been treated fairly for any of these reasons, visit the Office for Civil Rights (OCR) at the OCR website.

Have access to a primary care physician, medical specialists, and hospitals.

These providers can be available through Original Medicare or be part of an approved Medicare Advantage provider network.

Have access to resources to get your questions about Medicare answered.

Resources include:

If you are in a Medicare Advantage Plan or Medicare Part D Drug Plan, call your plan’s customer service number.

Get understandable information about Medicare to help you make health care decisions, including:

  • What benefits are covered
  • How much Medicare pays for a medical service or procedure
  • How much you have to pay
  • How to file a complaint or appeal a decision

Learn about all of your treatment choices in a clear explanation that you understand; and participate in the decisions made about your care.

You have the right to participate completely in all decisions about your health care. If you can’t fully participate, ask family members, friends, or anyone you trust to help you make a decision about what treatment is right for you.

This also includes your right to get health care services in a language you understand and in a culturally-sensitive way.

Get emergency care when and where you need it.

If your health is in danger because you have an injury, sudden illness, or an illness gets much worse, call 911. You can get emergency care anywhere in the United States.

Original Medicare does not pay for any medical services, including emergencies, if you are out of the country. You should purchase travel health insurance if you are planning a trip to Canada, Mexico, or overseas.

If you have a Medicare Advantage Plan, your plan materials describe how to get emergency care. You don’t need to get permission from your primary care doctor before you get emergency care. If you get emergency care, you will have to pay your share of the cost, such as a co-payment or coinsurance.

Your plan should then pay its share of the bill. If your plan does not pay its share for your emergency care, you have the right to appeal.

Have your personal and health information kept private.

To find out about your Medicare privacy rights, you can do the following:

  • For Original Medicare, see the Notice of Privacy Practices for Original Medicare. You can view this notice in the Medicare and You handbook you received in the mail. To view this information online, see Medicare and You 2010 on the Medicare website.
  • For a Medicare Advantage Plan or a Medicare Part D Drug Plan, read the benefit book sent to you by the plan.

File a complaint, including complaints about the quality of care you received.

You can file a complaint about Medicare payment issues, other concerns or problems you have in getting health care, and the quality of the your health care.

If you are concerned about the quality of the care you get from any health care provider (including your doctor), you have a right to file a complaint or grievance. If you have Original Medicare, contact the Quality Improvement Organization (QIO) in your state to file a complaint. 

A Doctor Mike Definition: A QIO is a group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to people with Medicare.

If you have a Medicare Advantage Plan, call your plan to complain or contact your state’s QIO.

Have a payment claim filed with Medicare.

Even if your doctor or another health care provider says that Medicare won’t pay for a certain item or service, you have a right to have the provider file the claim with Medicare. After the claim is filed, you will get a notice from Medicare letting you know what it will and won’t cover. This information might be different from what your provider said. You have a right to appeal the decision Medicare makes about whether or not to pay your claim, and how much you are required pay.

It is important to know your Medicare appeal rights. If you disagree with Medicare’s decision about your claims or services, you have the right to appeal. The following resources provide information about the Medicare appeal process:

If you have a Medicare Advantage Plan or a Medicare Part D Drug Plan, read your plan materials for instructions on the appeal process.

A Tip from Medicare: If you need help filing an appeal, you can appoint a representative like a family member, friend, advocate, attorney, doctor, or someone else to act on your behalf. There are two ways you can do this:

  1. Fill out an Appointment of a Representative form available on the Medicare website.
  2. Submit a letter signed and dated by you and the person helping you. Your letter must include the same information as the "Appointment of Representative" form. You must send the form or letter with your appeal request.

It is a good idea to make a copy of the form or letter before you send it.

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