It pays to know your Medicare rights
July 24, 2012
If you’re a person who receives Medicare, you have certain rights and protections. And it’s worth knowing what they are.
You have rights whether you’re enrolled in original Medicare, in which you can choose any doctor or hospital that accepts Medicare; or Medicare Advantage, in which you get care within a network of health-care providers. Such networks are run by private companies approved by Medicare.
Your rights guarantee that you get the health services the law says you can get, protect you against unethical practices, and ensure the privacy of your personal and medical information. You have the right to be treated with dignity and respect at all times, and to be protected from discrimination.
You also have the right to get information in a way you understand from Medicare, your health care providers, and, under certain circumstances, Medicare contractors. This includes information about what Medicare covers, what it pays, how much you have to pay, and how to file a complaint or appeal. Moreover, you’re entitled to learn about your treatment choices in clear language that you can understand, and to participate in treatment decisions.
One very important right is to get emergency care when and where you need it, anywhere in the United States.
If you have Medicare Advantage, your plan materials describe how to get emergency care. You don’t need permission from your primary-care doctor (the doctor you see first for health problems) before you get emergency care. If you’re admitted to the hospital, you, a family member, or your primary-care doctor should contact your plan as soon as possible. If you get emergency care, you’ll have to pay your regular share of the cost, or copayment. Then your plan will pay its share.
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If your plan doesn’t pay its share, you have the right to appeal.
In fact, whenever a claim is filed for your care, you’ll get a notice from Medicare or your Medicare Advantage plan letting you know what will and won’t be covered. If you disagree with the decision, you have the right to appeal.
For more information on appeals, you can read our booklet “Medicare Appeals,” available at http://www.medicare.gov/Publications. Or call 1-800-MEDICARE.
You can also file a complaint about services you got from a hospital or other provider. If you’re concerned about the quality of the care you’re getting, call the Quality Improvement Organization (QIO) in your state to file a complaint. A QIO is a group of doctors and other health care experts who check on and improve the care given to people with Medicare. You can get your QIO’s phone number at http://www.medicare.gov/contacts or by calling 1-800-MEDICARE.
Many people with Original Medicare also enroll in Medicare prescription drug plans. Here, too, you have certain rights.
For example, if your pharmacist tells you that your drug plan won’t cover a drug you think should be covered, or it will cover the drug at a higher cost than you think you’re required to pay, you can request a coverage determination.
If the decision isn’t in your favor, you can appeal.
You can ask for an exception if you, your doctor, or your pharmacist believe you need a drug that isn’t on your drug plan’s list of covered medications, also known as a formulary.
You don’t need a lawyer to appeal in most cases, and filing an appeal is free. You won’t be penalized in any way for challenging a decision by Medicare or your health or drug plan. And many people who file appeals wind up with a favorable outcome.
This is a brief overview of your Medicare rights. For more details, read our booklet, “Medicare Rights and Protections,” at http://www.medicare.gov/Publications/Pubs/pdf/11534.pdf.
• David Sayen is Medicare’s regional administrator for Arizona, California, Hawaii, and Nevada. You can always get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).