Your Medicare rights

 

No matter how you get Medicare, you have certain rights and protections designed to:

  • Protect you when you get health care.
  • Make sure you get the health care services the law says you can get.
  • Protect you against unethical practices.
  • Protect your privacy.

Details about your rights in Medicare

 

  • Be treated with dignity and respect at all times.
  • Be protected from discrimination. Every company or agency that works with Medicare must obey the law. They can’t treat you differently because of your race, color, national origin, disability, age, religion, or sex.
  • Have your personal and health information kept private.
  • Get information in a way you understand from Medicare, health care providers, and, under certain circumstances, contractors.
  • Get understandable information about Medicare to help you make health care decisions, including:
    • What’s covered.
    • What Medicare pays.
    • How much you have to pay.
    • What to do if you want to file a complaint or appeal.
  • Have your questions about Medicare answered.
  • Have access to doctors, specialists, and hospitals.
  • Learn about your treatment choices in clear language that you can understand, and participate in treatment decisions.
  • Get health care services in a language you understand and in a culturally-sensitive way.
  • Get Medicare-covered services in an emergency.
  • Get a decision about health care payment, coverage of services, or prescription drug coverage.
    • When a claim is filed, you get a notice letting you know what will and won’t be covered. The notice comes from one of these:
      • Medicare
      • Your Medicare Advantage Plan (Part C)
      • Your other Medicare health plan
      • Your Medicare Prescription Drug Plan (Part D)
    • If you disagree with the decision of your claim, you have the right to file an appeal.
  • Request a review (appeal) of certain decisions about health care payment, coverage of services, or prescription drug coverage.
  • If you disagree with a decision about your claims or services, you have the right to appeal.
  • File complaints (sometimes called “grievances”), including complaints about the quality of your care.
If you have Original Medicare, you have the same rights and protections as all people with Medicare. In addition, you have the right to:

  • See any doctor or specialist (including women’s health specialists), or go to any Medicare-certified hospital, that participates in Medicare.
  • Get certain information, notices, and appeal rights. These help you resolve issues when Medicare may not or doesn’t pay for health care. Learn about notices of noncoverage.
  • Request an appeal of health coverage or payment decisions.
  • Buy a Medicare Supplement Insurance (Medigap policy ).
If you’re in a Medicare Advantage Plan (Part C) or other Medicare health plan, in addition to the rights and protections for all people with Medicare, you have the right to:

  • Choose health care providers within the plan.
  • Get a treatment plan from your doctor.
    • If you have a complex or serious medical condition, a treatment plan lets you directly see a specialist within the plan as many times as you and your doctor think you need.
    • Women have the right to go directly to a women’s health care specialist without a referral within the plan for routine and preventive health care services.
  • Know how your doctors are paid.
    • When you ask your plan how it pays its doctors, the plan must tell you.
    • Medicare doesn’t allow a plan to pay doctors in a way that could interfere with you getting the care you need.
  • Request an appeal to resolve differences with your plan.
  • File a complaint (called a “grievance”) about other concerns or problems with your plan.
  • Get a coverage decision or coverage information from your plan before getting services.
To learn more about your rights and protections, read your plan’s membership materials, or call your plan.
You the same rights and protections as all people with Medicare. In addition, if you have a Medicare drug plan, you have the right to:

  • Request a coverage determination or appeal to resolve differences with your plan.
  • File a complaint (called a “grievance”) with the plan.
  • Have the privacy of your health and prescription drug information protected.

If you have Medicare prescription drug coverage, your plan will send you information that explains your rights. Call your plan if you have questions.
With Medicare, you have special rights and protections. There are resources available to you to make sure your rights are protected, including:

  • The Medicare Beneficiary Ombudsman
  • Your State Health Insurance Assistance Program (SHIP)
  • The Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO)
  • Your State Survey Agency
The Medicare Beneficiary Ombudsman

The Medicare Beneficiary Ombudsman helps you with complaints, grievances, and information requests about Medicare. The Medicare Beneficiary Ombudsman makes sure information is available about:

  • What you need to know to make health care decisions that are right for you
  • Your Medicare rights and protections
  • How you can get issues resolved
The Medicare Beneficiary Ombudsman also shares information with the Secretary of Health and Human Services, Congress, and other organizations about what does and doesn’t work well to improve the quality of the services and care you get through Medicare.

If you’ve called 1-800-MEDICARE (1-800-633-4227) with a question or complaint about Medicare but still need help, ask the 1-800-MEDICARE representative to send your question or complaint to the Medicare Beneficiary Ombudsman. The Ombudsman staff helps make sure that your question or complaint is resolved.

State Health Insurance Assistance Program (SHIP)

SHIPs offer local, personalized counseling to people with Medicare and their families.

SHIPs provide free information and counseling to help you with:

  • Your Medicare questions, including your benefits, coverage, premiums, deductibles, and coinsurance
  • Complaints (grievances)
  • Appeals
  • Joining or leaving a Medicare Advantage Plan (Part C) (like an HMO or PPO), any other Medicare health plan, or Medicare Prescription Drug Plan (Part D)

For more information, call your SHIP.

Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO)

The BFCC-QIOs review complaints and quality of care for people with Medicare to improve the effectiveness, efficiency, economy, and quality of services for people with Medicare.

BFCC-QIOs provide services to help you with:

  • Filing appeals in hospital and non-hospital settings if you think your coverage is ending too soon
  • Complaints (grievances)
  • Quality of care reviews
  • Medical necessity reviews

For more information or help, call your BFCC-QIO.

State Survey Agency

State Survey Agencies oversee health care facilities that participate in Medicare and/or Medicaid. The State Survey Agency inspects health care facilities and investigates complaints to ensure that health and safety standards are met. If you have a complaint about improper care or unsafe conditions in a hospital, home health agency, hospice, or nursing home, or you’re concerned about the health care, treatment, or services that you or another person got or didn’t get in a health care setting, you can contact your State Survey Agency.

You can contact the State Survey Agency if you have concerns about things like:

  • Abuse
  • Neglect
  • Mistreatment
  • Poor care
  • Not enough staff
  • Unsafe or unsanitary conditions
  • Dietary problems
By law, you or your legal representative generally have the right to view and/or get copies of your personal health information from these groups:

  • Health care providers who treat you
  • Health plans that pay for your care, including Medicare

In most cases, you also have the right to have a provider or plan send copies of your information to a third party that you choose, like these:

  • Other providers who treat you
  • A family member
  • A researcher
  • A mobile application (or “app”) you use to manage your personal health information
This information includes:

  • Claims and billing records
  • Information related to your enrollment in health plans, including Medicare
  • Medical and case management records (except psychotherapy notes)
  • Any other records that contain information that doctors or health plans use to make decisions about you

You may have to fill out a health information “request” form and pay a reasonable, cost-based fee for copies. Your providers or plans are supposed to tell you about the fee when you make the request. If they don’t, ask. The fee can only be for the labor to make the copies, copying supplies, and postage (if needed). In most cases, you won’t be charged for viewing, searching, downloading, or sending your information through an electronic portal.

Generally, you can get your information on paper or electronically. If your providers or plans store your information electronically, they generally must give you electronic copies, if that’s what you want.

You have the right to get your information in a timely manner, but it may take up to 30 days to fill the request.

Learn more about your right to access your personal health information.