My Medicare Rights

What are my Medicare rights?

No matter how you get your Medicare, you have certain rights and protections. All people with Medicare have the right to:

• Be treated with dignity and respect at all times
• Be protected from discrimination
• Have personal and health information kept private
• Get information in a format and language they understand from Medicare, health care providers, Medicare plans, and Medicare contractors
• Have questions about Medicare answered
• Have access to doctors, other health care providers, specialists, and hospitals for medically necessary services
• Learn about their treatment choices in clear language that they can understand, and participate in treatment decisions
• Get Medicare-covered services in emergency
• Get a decision about health care payment, coverage of services, or prescription drug coverage
• Request a review (appeal) of certain decisions about health care payment, coverage of services, or prescription drug coverage
• File complaints (sometimes called "grievances"), including complaints about the quality of their care

What are my rights if my plan stops participating in Medicare?

Medicare health and prescription plans can decide not to participate in Medicare for the coming year. In this case, your coverage under the plan will end after December 31. Your plan will send you a letter explaining your options. If this happens:

• You can choose another plan between October 15-December 7. Your coverage will begin on January 1.
• You'll also have a special right to join another Medicare plan until February 29, 2020
• You may have the right to buy certain Medigap policies within 63 days after your coverage ends.

What's an appeal?

An appeal is an action you can take if you disagree with a coverage or payment decision by Medicare or your Medicare plan. For example, you can appeal if Medicare or your plan denies:

• A request for health care services, supply, item, or prescription drug that you think should be covered by Medicare.
• A request for payment of a health care service, supply, item, or prescription drug you already got.
• A request to change the amount you must pay for a health care service, supply, item, or prescription drug.

You can also appeal:

• If Medicare or your plan stops providing or paying for all or part of a health care service, supply, item, or prescription drug you think you still need it.
• An at-risk determination made under a drug management program that limits access to coverage for frequently abused drugs, like opioids and benzodiazepines.

If you decide to file an appeal, you can ask your doctor, supplier, or other health care provider for any information that may help your case. This will make your appeal stronger. You must keep a copy of everything related to your appeal, including what you send to Medicare or your plan. 

How do I file an appeal?

Filing an appeal depends on the type of Medicare coverage you have:

Original Medicare

• Get the "Medicare Summary Notice" (MSN) that shows the item or service you're appealing.
• Circle the item(s) on the MSN you disagree with, write an explanation of why you disagree with the decision. You can write on the MSN or a separate piece of paper and attach it to MSN.
• Include your name, phone number, and Medicare Number on the MSN. Keep a copy for your records.
• Send the MSN, or a copy, to the company that handles bills for Medicare listed on the MSN. You can include any other additional information you have about your appeal or you can use CMS Form 20017. Visit CMS.gov/cmsforms/downloads/cms20027.pdf
• You must file the appeal within 120 days of the date you get the MSN in the mail
• You'll generally get a decision from the Medicare Administrative Contractor within 60 days after they get your request.

Medicare Advantage or other Medicare health plan

The timeframe for filing an appeal may be different than Original Medicare. Visit Medicare.gov/appeals for more information.

Medicare Prescription Drug Plan

You have the right to do all of these:

• Get a written explanation for drug coverage decisions (Coverage Determination) from your Medicare drug plan. A Coverage Determination is the first decision your Medicare drug plan makes about your benefits.  This can be a decision about if your drug is covered if you met the plan's requirements to cover the drug, or how much you pay for the drug. You'll also get a coverage determination decision if you ask your plan to make an exception to its rules to cover your drugs.
• Ask for an exception if you or your prescriber believes you need a drug that isn't on your plan's formulary.
• Ask for an exception if you or your prescriber believes that a coverage rule should be waived.
• Ask for an exception if you think you should pay less for a higher tier drug because you or your prescriber believes you can't take any of the lower-tier drugs for the same condition.

How do I ask for a coverage determination or exception?

You or your prescriber must contact your plan to ask for a coverage determination or an exception. If your network pharmacy can't fill a prescription, the pharmacist will give you a notice that explains how to contact your Medicare drug plan so you can make a request. If the pharmacist doesn't give you this note, ask for a copy.

If you're asking for prescription drug benefits you haven't gotten yet, you or your prescriber may make a standard request by phone or in writing. If you're asking to get paid back for prescription drugs you already bought, your plan can require you or your prescriber to make the standard request in writing.

You or your prescriber can call or write your plan for an expedited request. Your request will be expedited if you haven't gotten the prescription and your plan determines, or your prescriber tells your plan, that your life or health may be at risk by waiting. 

IMPORTANT: If you're requesting an exception, your prescriber must provide a statement explaining the medical reason why your plan should approve the exception.

What are my rights if I think my services are ending too soon?

If you're getting Medicare services from a hospital, skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility, or hospice, and you think your Medicare-covered services are ending too soon, you can ask for a fast appeal. Your provider will give you a notice before the end of your service and that will tell you how to ask for a fast appeal. The notice might call it an Immediate appeal" or an "Expedited appeal".  You should read this notice carefully. if you don't get this note, ask your provider for it. With a fast appeal, an independent reviewer will decide if your covered services should continue.

How can I get help filing an appeal?

You can appoint a representative to help you. Your representative can be a family member, friend, advocate, attorney, financial advisor, doctor or someone else who will act on your behalf. You can also get help filing an appeal from your State Health Assistance Program (SHIP).

Advance Beneficiary Notice of Noncoverage (ABN)

If you have Original Medicare, your doctor, or other health care provider, or supplier may give you a notice called "Advance  Beneficiary Notice of Noncoverage (ABN) if they think they care they'll provide isn't covered by Medicare. This notice says Medicare probably (or certainly) won't pay for some services in certain situations.

What happens if I get ABN?

• You'll be asked to choose whether to get the item or services listed on the ABN.
• If you choose to get the items or services listed on the ABN, you're agreeing to pay if Medicare doesn't.
• You'll be asked to sign the ABN to say that you've read and understood it.
• Doctors, or other health care providers, and suppliers don't have to give you an ABN for services that Medicare never covers.
• An ABN isn't an official denial of coverage by Medicare. If Medicare denies payments, you can still file an appeal. However, you'll have to pay for the items or services if Medicare decides the items or services aren't covered (and no other insurer is responsible for payment).

Can I get an ABN for other reasons?

You may get a "Skilled  Nursing Facility ABN" when the facility believes Medicare will no longer cover your stay or other items and services.

What if I didn't get an ABN?

If your provider was required to give you an ABN but didn't, in most cases, your provider must give you a refund for what you paid for the item or service.

Visit Medicare.gov/appeals or Medicare.gov/publications for more information.

If you're in a Medicare plan, call your plan to find out if a service or item will be covered.