Medicare Rights

It is important to know your Medicare protections and rights

There is nothing worse than feeling like you are being abused or mistreated by the “system” or your insurance company. Therefore, it is important to understand that you have rights and protections with regard to how you get your Medicare. It is equally important to understand these rights as well as what actions you can take if you feel your rights have been violated.

The following is a list of your protections and rights through Medicare:

  • Be treated with dignity and respect at all times.
  • Be protected from discrimination.
  • Have your personal and health information kept private.
  • Get information in a way you understand from Medicare, health care providers, and Medicare contractors.
  • Have questions about Medicare answered.
  • Have access to doctors, other health care providers, specialists and hospitals.
  • Learn about your treatment choices in clear language that you can understand, and participate in treatment decisions.
  • Get emergency care when and where you need it.
  • Get a decision about health care payment, coverage of services, or prescription drug coverage.
  • Request a review (appeal) of certain decisions about health care payment, coverage of services, or prescription drug coverage.
  • File complaints (sometimes called grievances), including complaints about the quality of your care.

What is an appeal or review of a decision?

An appeal is the action you can take if you disagree with a coverage or payment decision made by Medicare or your Medicare plan (i.e., Medicare Advantage, Medicare Supplement or Prescription Drug Plan). For example, you can file an appeal if Medicare or your plan denies any of the following:

  • A request for a health care service, supply, item, or prescription drug that you think you should be able to get.
  • A request for payment of a health care service, supply, item, or prescription drug you already got.
  • A request to change the amount you must pay for a health care service, supply, item, or prescription drug.
  • You can also file an appeal if Medicare or your plan stops providing or paying for all or part of an item or service you think you still need.

If you decide to file an appeal, you can ask your doctor or other health care provider or supplier for any information that may help your case. Keep a copy of everything you send to Medicare as part of your appeal.

How do you file an appeal with Medicare?

  1. Get the “Medicare Summary Notice” (also known as “MSN”) that shows the item or service you are appealing. Your Medicare Summary Notice is the notice you get every three months that lists all the services billed to Medicare and tells you if Medicare paid for the services.
  2. Circle the item(s) you disagree with on the Medicare Summary Notice, and write an explanation of why you disagree with the decision on the Medicare Summary Notice or on a separate piece of paper and attach it to the Medicare Summary Notice.
  3. Include your name, telephone number, and your Medicare number on the Medicare Summary Notice and sign it. Keep a copy for your records.
  4. Send the Medicare Summary Notice, or a copy, to the company that handles bills for Medicare. These companies are listed on the back of the Medicare Summary Notice. You can include any other additional information you have about your appeal. You can  call 1-800-MEDICARE (1-800-633-4227) to find out if a copy can be emailed to you. TTY users should call 1-877-486-2048.

Is there a deadline to file a Medicare Appeal?

There are deadlines that you must meet when filing an appeal to a Medicare decision. Specifically, you must file the appeal within 120 days of the date you get the Medicare Summary Notice in the mail.

How long before I get a decision on my Medicare appeal?

How long does it take for the Medicare contractor to make a decision regarding your appeal? You will generally get a decision from the Medicare contractor within 60 days after they get your request. If Medicare will cover the item(s) or service(s) which were the purpose of your appeal, it will be listed on your next Medicare Summary Notice. If you have a Medicare health plan, such as Medicare Advantage or Medicare Supplement plan, learn how to file an appeal by looking at the materials your plan sends you.

How do I appeal for my  Medicare Part D Prescription Drug Plan?

There are certain special situations that allow you to file a fast, or expedited, appeal. If you have a Medicare Prescription Drug (also known as “PDP”), you have the right to do all of the following (even before you buy a certain drug):

Get a written explanation, called a “coverage determination”, from your Medicare drug plan. A coverage determination is the first decision made by your Medicare drug plan (not the pharmacy) about your benefits, including whether a certain drug is covered, whether you have met the requirements to get a requested drug, how much you pay for a drug, and whether to make an exception to a plan rule when you request it.

  • Ask for an exception if you or your physician or health care provider believes you need a drug that is not on your plan’s formulary.
  • Ask for an exception if you or your doctor believes that a coverage rule, like prior authorization, should be waived.octor
  • Ask for an exception if you think you should pay less for a higher tier, or more expensive drug because you or your doctor believes you cannot take any of the lower tier, or less expensive drugs for the same condition.

How do you ask for a Medicare coverage determination?

You or your physician or health care provider must contact your plan to ask for a coverage determination or an exception. If your network pharmacy cannot fill a prescription, the pharmacist will give you a notice that explains how to contact our Medicare drug plan so you can make your request. If the pharmacist does not give you this notice, ask for a copy.

You or your physician or healthcare provider may make a standard request by phone or in writing, if you are asking for prescription drug benefits you have not gotten yet. If you are asking to get paid back for prescription drugs you already bought, your plan can require you or your physician or health care provider to make the standard request in writing.

You or your doctor can call or write your plan for an expedited (fast) request. Your request will be expedited if you have not gotten the prescription and your plan determines, or your physician or health care provider tells your plan, that your life or health may be at risk by waiting.

If you are requesting an exception, your doctor must provide a statement explaining the medical reason why the exception should be approved.

How can you get help filing a Medicare appeal?

For more information about the different levels of appeals in a Medicare drug plan you can call 1-800-MEDICARE (1-800-633-4227)  TTY users should call 1-9977-486-2048. You can get help filing an appeal from your State Health Insurance Assistance Program (SHIP).

If you are unhappy with your Medicare health plan do not hesitate to contact a Medicare Pathways Benefit Specialist to discuss your options regarding plan availability in your area. There are certain circumstances that allow for you to change plans outside of the Annual Election Period (also known as “AEP”). Each Benefit Specialist is trained and knowledgeable regarding these special situations that create Special Enrollment Periods (also known as “SEP”) and will be able to evaluate your situation independently to determine if you are eligible to change plans. Additionally, Medicare Supplement plans can be changed at any time, not just during the Annual Election Period or a Special Enrollment Period.

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