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Medicare Rights, Appeals, and Complaints

October 6, 2016

As a Medicare beneficiary, you’re protected by certain rights. This article explains these rights, as well as how to file an appeal or complaint.

Your Medicare rights

Medicare guarantees certain rights and protections for everyone. They include, among others:

  • Treatment with dignity and respect
  • Protection against discrimination
  • Confidentiality of personal and health care information
  • Access to information that you can understand
  • Clear responses to your Medicare questions, in a language you can understand
  • Access to doctors and health providers
  • Emergency care anytime you need it
  • A decision from Medicare about your health-care payment, coverage of services, or prescription drug coverage

For additional information, see Medicare Rights for Everyone.

Your rights and protections in Original Medicare

If you’re enrolled in Original Medicare, Part A and Part B, you have rights and protections in addition to the ones listed above. Under Original Medicare, you have the right to:

  • Go to any doctor, specialist, or hospital that participates with Medicare.
  • Get information and notices from Medicare indicating why certain services may not be covered.
  • Get information about your right to appeal certain Medicare decisions.
  • Request an appeal about Medicare payment decisions or health-care coverage.
  • Sign up for a Medicare Supplement (Medigap) Plan.

If your doctor thinks that Original Medicare may refuse to cover a certain service, he or she may give you an Advance Beneficiary Notice of Noncoverage (ABN). An ABN lists items and services that Medicare doesn’t cover, with an explanation for the lack of coverage and an estimated cost for the service or item. Note that if a doctor or other health care provider was required to give you an ABN but didn’t, in most cases, your provider must pay you back what you paid for the item or service that he or she knows Medicare will not cover.

Your rights and protections in Medicare Advantage and other health plans

If you’re enrolled in a Medicare Advantage plan offered by a private insurance company contracted with Medicare or any other Medicare health plan offered by a private insurance company contracted with Medicare, besides your basic Medicare rights and protections, you have the right to:

  • Choose any health care provider from the Medicare Advantage plan’s network.
  • Get a treatment plan from your doctor.
  • Know how your doctor is paid.
  • Request an appeal if differences arise between you and your plan.
  • File a complaint or grievance.
  • Get coverage information prior to getting treated.

Your rights and protections in a Medicare plan providing prescription drug coverage

If you’re enrolled in a Medicare plan providing prescription drug coverage (a stand-alone Medicare Part D Prescription Drug Plan or a Medicare Advantage plan with prescription drug benefits), you have the right to privacy regarding your health and prescription drug information. You also have the right to:

  • File a complaint or grievance with the plan.
  • Appeal a plan’s decision.
  • Request information about whether Medicare will cover certain services or items.

Understanding your Medicare rights and protections

If you need further help understanding your Medicare rights, you can contact a Medicare beneficiary ombudsman. This Medicare specialist ensures that information about your Medicare rights and protections is readily available and easy to understand. A Medicare ombudsman can provide valuable help when filing appeals or complaints with Medicare. You can call the Medicare beneficiary ombudsman at 1-800-MEDICARE (1-800-633-4227; TTY users call 1-877-486-2048) 24 hours a day, seven days a week.

Filing Medicare appeals

If you disagree with a Medicare payment or coverage decision, you can file a Medicare appeal. You have the right to appeal a Medicare decision to deny coverage, in part or in full, for a health care service, supply item, or prescription drug that you either already received or that you believe you’re entitled to receive. You can also appeal a Medicare decision to change the payment amount of a health care service, supply item, or prescription drug. If you’re enrolled in a Medicare Medical Savings Account (MSA) Plan, you can appeal if you believe a certain payment should have gone toward your deductible but for some reason didn’t.

Once you decide to appeal, you should gather any information that may help your case from your doctor or other health-care provider. The appeals process includes five levels, and if you disagree with a decision made at a specific level, you can usually move to the next level.

To file an appeal, go to medicare.gov’s “How do I file an appeal? page, or call a Medicare beneficiary ombudsman (contact information listed above). You can also get help filing an appeal by contacting your State Health Insurance Program (SHIP) or Medicare health plan.

Filing Medicare complaints

While an appeal generally involves a Medicare decision not to pay for an item or service, a complaint (also called a grievance) involves the quality of care or services you received from a Medicare provider or the Medicare plan. You can file grievances about virtually any aspect of Medicare. For example, you can file a complaint about a specific doctor, hospital, or provider; a health or prescription drug plan; or the state of durable medical equipment you received.

To file a complaint, go to medicare.gov’s “How to file a complaint” page, or call a Medicare beneficiary ombudsman (contact information listed above).

For most complaints, you can contact Quality Improvement Organizations (QIOs), which are private, mostly non-profit organizations, staffed by health care professionals, and contracted by the Centers for Medicaid and Medicare Services (CMS) to help Medicare beneficiaries with grievances about the quality of their Medicare services.

To get your QIO’s phone number, go to the medicare.gov contacts page or call 1-800-MEDICARE (1-800-633-4227; TTY users call 1-877-486-2048) 24 hours a day, seven days a week.