Problems with Medicare?

Your right to appeal and other protections

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

Insurance Carriers and 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.

Your 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?

  • Medicare Parts A and B – 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 insurance plan – Review your Medicare Supplement plan materials

If you decide to file an appeal, ask your broker/agent as well as 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 Medicare Parts A and B 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 Medicare Parts A and B

If you’re enrolled in Medicare Parts A and B, 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 timeframe 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.

If you disagree with the information provided by a pharmacist, you can contact your drug plan to ask for a coverage determination. The pharmacy will give you or show you a notice that explains how to contact your drug plan.

How quickly will I receive a written explanation?

Once your drug plan receives your request for a coverage determination, the drug plan has 72 hours (for a standard request) or 24 hours (for an expedited request) to make a decision.

When should I file an appeal?

If you disagree with the health or drug plan’s written explanation, you have the right to appeal.

  • You must request the appeal within 60 calendar days from the date of the decision.
  • A standard request must be made in writing unless your plan accepts requests by phone.
  • You can call your plan or write to them for an expedited request.
  • Once your plan receives your request for an appeal, the plan has seven days (for a standard request for coverage or to pay you back) or 72 hours (for an expedited request for coverage) to make its decision.

When you enroll in a Medicare Prescription Drug Plan, the plan will send you information about the plan’s appeal procedures. Read the information carefully and call your plan if you have questions.

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

Other Medicare rights

As a Medicare member, you also have rights to

  • Receive information about coverage, benefits and costs
  • Emergency room services
  • See doctors; specialists, including women’s health specialists; and go to Medicare-certified hospitals
  • Participate in treatment decisions
  • Know your treatment choices
  • Receive information in a culturally sensitive manner (such as in languages other than English)
  • File complaints
  • Nondiscrimination
  • Privacy of your personal and health information

For more information about your rights and protections

  • Visit www.medicare.gov
  • Call 1-800-MEDICARE (1-800-633-4227) (TTY users call 1-866-653-4261) 24 hours a day, 7 days a week and say “Publications” to get a free copy of “Your Medicare Rights and Protections”

NO COST, NO OBLIGATION

Answers To Your Medicare Questions



Understanding the difference between Parts A, B, C, and D.

Medicare has four parts – A, B, C, and D. Each is designed to cover specific services, allowing you to choose the plan(s) that is the best fit for you based on your healthcare needs and budget.

When You Are Approaching Age 65, Or Eligibility Into Medicare For Any Other Reason,

You Will Notice A Stark Increase In The Amount Of “Junk Mail” You Receive!

Make Sure You Get Information From A Reputable Trusted Source Like Senior Health Advisors.

Not All Agents/Brokers Who Are Certified To Talk To YOU About Medicare Are Created Equal!!

8 things to consider when choosing or changing your coverage 
  1. Coverage: Does the plan cover the services you need?
  2. Your other coverage: If you have other types of health or prescription drug coverage, make sure you understand how that coverage works with Medicare. If you have employment-related coverage, or get your health care from an Indian Health or Tribal Health Program, talk to your benefits administrator or insurer before making any changes.
  3. Costs: How much are your premiums, deductibles, and other costs? How much do you pay for services like hospital stays or doctor visits? Is there a yearly limit on what you could pay out-of-pocket for medical services? Make sure you understand any coverage rules that may affect your costs.
  4. Doctor and hospital choice: Do your doctors accept the coverage? Are the doctors you want to see accepting new patients? Do you have to choose your hospital and health care providers from a network? Do you need to get referrals?
  5. Prescription drugs: Do you need to join a Medicare Prescription Drug Plan? Do you already have creditable prescription drug coverage? Will you pay a penalty if you join a drug plan later? What will your prescription drugs cost under each plan? Are your drugs covered under the plan’s formulary? Are there any coverage rules that apply to your prescriptions? Is the pharmacy you use in the plan’s network?
  6. Quality of care: Are you satisfied with your medical care? The quality of care and services given by plans and other health care providers can vary.
  7. Convenience: Where are the doctor’s offices? What are their hours? Which pharmacies can you use? Can you get your prescriptions by mail?
  8. Travel: Will the plan cover you if you travel to another state or outside the U.S.?

Looking back at the Medicare program

The federal Medicare program has changed the lives of millions of Americans. But the roots of Medicare go back to our nation’s early efforts to achieve health coverage for its elderly and poor citizens.

It’s hard to believe, but the gradual evolution of the plans available in Medicare today began more than a hundred years ago.

1902
The first U.S. workmen’s compensation law enacted (later declared unconstitutional)

1915
Thirty states enacted the first major legislation to require employers to insure their workers against industrial accidents – or workmen’s compensation

1935
The first federal government health insurance bill introduced in Congress

1945
President Harry S. Truman became the first sitting president to officially endorse national health insurance

1961
President John F. Kennedy sent a message to Congress recommending health insurance for the elderly under Social Security

1965
President Lyndon B. Johnson signed Medicare into law

1972
Medicare eligibility extended to people with disabilities and to people with end-stage renal disease (ESRD)

1976
HMOs began to be offered as a Medicare option effective with the HMO Act of 1976

1983
The diagnosis-related group (DRG) prospective payment system began – soon after, Medicare members could enroll in an HMO or managed care plan

1997
The Medicare+Choice program (now known as Medicare Advantage) was enacted

2003
President George W. Bush signed the “Medicare Modernization Act” into law

2006
The voluntary Part D outpatient prescription drug benefit becomes available to beneficiaries from private drug plans and Medicare Advantage Plans