Medicare Rights and Protections
No matter how you get Medicare, whether it’s Original Medicare, Medicare Advantage, Medigap or other plans, you are guaranteed certain rights. These Medicare rights include getting health care when needed, getting medical services you’re entitled to and that your privacy is protected.
Understanding Your Medicare Rights
Medicare guarantees you a wide range of rights to health care and protections against discrimination and unethical or illegal treatment. If you believe your rights are being violated, you can contact Medicare and file an appeal or a complaint.
- Access to doctors and emergency care when you need it.
- Protection from discrimination, and the right to be treated with dignity and respect at all times.
- Protection of your right to privacy.
- The right to receive clear and accurate information about your health care options, in a way you can clearly understand it, and to have your Medicare questions answered by Medicare, health care providers and contractors.
- The right to make your own decisions about health coverage.
- You have the right to file a complaint if you think you are mistreated, discriminated against or your rights have been violated.
- You have the right to file an appeal if Medicare coverage is denied.
Your Rights in Original Medicare
In addition to the basic Medicare rights guaranteed across all types of Medicare coverage, you have additional rights if you are enrolled in Original Medicare — Parts A and B.
- Buy a Medicare supplemental insurance, or Medigap, policy.
- Go to any Medicare-certified hospital that participates in Medicare.
- Receive information, notices and appeals rights that may help you resolve issues when Medicare denies payment for your health care.
- Request an appeal of denial of health coverage.
- Request an appeal of payment decisions.
- See any doctor that participates in Medicare.
- Women may see any women’s health specialist that participates in Medicare.
Medicare appeals are one of the most detailed procedures to protect your rights. The process involves five levels, with your right to appeal to the next level each time your arguments are denied.
An appeal can be a lengthy and sometimes expensive process that may require you to seek legal advice or representation.
Rights Under Medicare Advantage
You have certain rights under all types of Medicare Advantage plans in addition to the basic Medicare rights you are already guaranteed.
For example, women have the right to see a women’s health specialist without a referral — even if their plan requires a referral for other specialists.
If you have a serious or complex health problem, you can see a specialist in your plan as often as you and your primary care doctor consider necessary.
You should familiarize yourself with your Medicare Advantage plan’s membership materials to understand more about your rights.
- Choose any doctor, hospital or other health care provider within your plan’s network.
- File a complaint or grievance over problems with your Medicare Advantage plan.
- Get a decision on or information from your Medicare Advantage plan about coverage before receiving medical service.
- Get a treatment plan from your doctor.
- Know how your doctors are paid by your Medicare Advantage plan.
- Know that your doctors’ payment methods do not interfere with getting the medical care you need.
- Request an appeal if you have a disagreement with your Medicare Advantage plan’s coverage.
Your Rights in a Medicare Part D Prescription Drug Plan
If you enroll in a Medicare Part D prescription drug plan, it is required that you are sent information explaining your rights. Read this information carefully and file it where you can refer to it in the future.
You should also call the insurance company that sold you the plan if you have questions about your rights.
Some Medicare Advantage plans also have prescription drug coverage. These plans and standalone Medicare Part D prescription drug plans are both required to guarantee you the same rights in addition to the basic rights given to all Medicare beneficiaries.
- Request an appeal or a coverage determination to resolve differences you have with your plan’s administrator.
- File a complaint, or grievance, with the company administrating your plan.
- Protection of the privacy of your health conditions.
- Protection of the privacy of your prescription drug information.
Help and Resources for Your Medicare Rights
There are multiple resources available to protect your Medicare rights. If you believe your rights have been violated, you can contact Medicare directly. There are also other organizations, agencies and services that can help address specific issues involved in protecting your rights.
- Medicare Beneficiary Ombudsman
- This service can help with complaints, grievances and getting information from Medicare. The ombudsman can provide you with information about your rights and protections and guidance on how to resolve issues. If you have called Medicare at 1-800-633-4227 and not gotten results, you can call again and ask to send your question or complaint to the Medicare Beneficiary Ombudsman.
- Beneficiary and Family Centered Care Quality Improvement Organizations (BFFCC-QIO) review quality of care for and complaints from Medicare beneficiaries. In addition to help filing complaints and appeals, they can help with reviews of medically necessary services. You can contact your local BFFCC-QIO for more information.
- Your State Health Insurance Assistance Program (SHIP) can provide information and counseling for Medicare information, complaints, appeals and how to join or leave a Medicare Advantage or other Medicare plan. You can contact your local SHIP office for more information.
- State Survey Agency
- State survey agencies inspect health care facilities and investigate complaints against them. You can contact your State Survey Agency for help with issues of abuse, neglect, mistreatment, unsafe or unsanitary conditions and related problems at facilities.
3 Cited Research Articles
- U.S. Centers for Medicare & Medicaid Services. (2018, January.). Medicare Rights & and Protections. Retrieved from https://www.medicare.gov/Pubs/pdf/11534-medicare-rights-and-protections.pdf
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Your Medicare Rights. Retrieved from https://www.medicare.gov/basics/your-medicare-rights