David Sayen
Courtesy: Medicare
As a person with Medicare, do you have any rights and protections? You certainly do!
You have rights whether you are enrolled in Original Medicare, which allows you to choose any doctor or hospital that accepts Medicare — or Medicare Advantage, in which you receive care from a network of health care providers.
Your rights guarantee that you receive the health services the law entitles you to, 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 obtain 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 are 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 access 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 do not 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 receive emergency care, you will have to pay your regular share of the cost, or co-payment. Your plan will then pay its share.
If your plan does not pay its share, you have the right to appeal.
In fact, whenever a claim is filed for your care, you will receive a notice from Medicare or your Medicare Advantage plan, informing you of what will and will not be covered. If you disagree with the decision, you have the right to appeal.
You will not need a lawyer to appeal in most cases, and filing an appeal is free. You will not be penalized in any way for challenging a decision by Medicare or your health or drug plan. Many people who file appeals end up with a favorable outcome.
For more information on appeals, read our booklet, “Medicare Appeals,” which is available at www.medicare.gov/Publications. Or, call us, toll free, at 1-800-MEDICARE.
You can also file a complaint about services you received at a hospital or from another provider. If you are concerned about the quality of the care you are receiving, call the Quality Improvement Organization 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 www.medicare.gov/contacts or by calling 1-800-MEDICARE.
Many people with Original Medicare also enroll in Medicare Part D prescription drug plans. Here, too, you have certain rights.
For example, if your pharmacist tells you that your plan will not cover a drug that you think should be covered, or that it will cover the drug at a higher cost than you think you’re required to pay, you can request a coverage determination.
If that decision isn’t in your favor, request an exception.
You can request an exception if you, your doctor or your pharmacist believes you need a drug that is not on your drug plan’s list of covered medications, also known as a formulary.
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 Hawai‘i, California, Nevada, Arizona and the Pacific Territories. You can always get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).
