Medicare Rights

by Steve Wilson · 0 comments

Your right to appeal and other protections

Medicare plans are designed to help you receive the services you need when you need them.

The Centers for Medicare & Medicaid Services (CMS) want you to understand your rights and protections as a member of Original Medicare, Medicare Advantage, and Medicare Prescription Drug plans.

Right to appeal denied services

If you have Medicare, you have certain guaranteed rights, including the right to a fair, efficient, and timely process for appealing decisions about healthcare payment or services. No matter what kind of Medicare plan you have, you always have the right to appeal. Some reasons to appeal include:

  • A service or item you received isn’t covered, and you think it should be
  • A service or item is denied, and you think it should be paid
  • You question the amount that Medicare paid

Where can I find Information on how to file an appeal?

  • Original Medicare – Look in the Medicare Summary Notice (MSN)
  • Medicare Advantage or other Medicare health plan – Review your health plan materials
  • Medicare Prescription Drug Plan – Check your drug plan materials
  • Medicare Supplement Plan – Review your Medicare Supplement plan materials

If you decide to file an appeal, ask your doctor or provider for any information that may help your case.

How will I know my service is denied?

  • A doctor or supplier may give you a notice that says Medicare may not or will not pay for a service
  • If you still want to get the service, you will be asked to sign an agreement that you will pay for the service yourself if Medicare doesn’t pay for it. This is called an Advance Beneficiary Notice.
  • Advance Beneficiary Notices are used in the Original Medicare plan. Medicare Advantage plans, other Medicare Health plans, and Medicare Prescription Drug plans have other ways of providing this information.

How do I make sure Medicare was billed for the service?

If you aren’t sure if Medicare was billed for the services that you got:

  • Write to the healthcare provider and ask for an itemized statement. This statement will list each Medicare item or service you got from that provider. You should get it within 30 days.
  • Also, you can check your Medicare Summary Notice to see if the service was billed to Medicare. If the service was not billed to Medicare you can request a “Demand Bill.”

If you are in a Medicare Advantage plan, other Medicare health plan, or Medicare Prescription Drug plan, call your plan to find out if a service or item will be covered. The plan must tell you if you ask.

Fast-track appeals

Original Medicare

If you’re enrolled in Original Medicare, you have the right to a fast appeal when your provider services are ending. This fast-track appeal is called an expedited review.

Do I qualify for expedited review?

You can get an expedited review whenever you’re discharged (or services are stopped) from an inpatient hospital, skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility, or hospice.

When should I appeal?

  • You will get a notice from your provider that will tell you how to ask for an appeal if you believe that your services are ending too soon
  • You will be able to get an expedited review of this decision, with independent doctors looking at your case to decide if your services need to continue
  • If you decide to file an appeal, ask your doctor for any information that may help your case
  • You may have other appeal rights if you miss the time frame for filing a fast-track appeal

Medicare Advantage and other Medicare health plans

If you’re enrolled in a Medicare Advantage plan or other Medicare health plan, you have the right to a fast-track appeals process.

Do I qualify for a quick review?

You can get a quick review whenever you are discharged (or services are stopped) from a skilled nursing facility, home health agency, or comprehensive outpatient rehabilitation facility, or getting inpatient hospital care.

When should I file an appeal?

  • You will get a notice from your provider or plan that will tell you how to ask for an appeal if you believe that your services are ending too soon
  • You will be able to obtain a quick review of this decision, with independent doctors looking at your case to decide if your services need to continue
  • You may have other appeal rights if you miss the timeframe for filing a fast-track appeal

Medicare Prescription Drug Plans

Can I appeal my Medicare Prescription Drug plan’s decisions?

Yes. You have the right to get a written explanation from your Medicare Prescription Drug plan. Some reasons you might ask for a written explanation are:

  • The pharmacist tells you that your drug plan won’t cover a prescription
  • You are asked to pay more than you think you are required to pay
  • You and your doctor believe you need a drug that isn’t on your drug plan’s list of covered drugs.

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