Medicare rights are for any individual enrolled in Medicare, whether you have Original Medicare, Medicare Advantage, or a Medigap plan.
Since Medicare Advantage plans are slightly different, they offer a few more protections.
If any rights are not being honored appropriately, there are organizations and programs that can assist beneficiaries with the appeal process, help with complaints and answer any questions one may have.
Each year Medicare beneficiaries may sit down and pick through Medicare plans. Doing so with confidence is half the battle when making these commitments. Knowing the Medicare rights and protections can essentially help enrollees with this process, and from being denied access to care and services they are legally entitled to, violating privacy, and engaging in unethical or dangerous practices. These rights and protections stand in place to assist with getting quality healthcare when needed.
What are My Medicare Rights and Protections?
Every Medicare beneficiary is entitled to the following:
- Be treated with respect each time you receive care or services from a Medicare approved provider.
- Protection from discrimination – a Medicare approved provider may not discriminate against an individual because of their race, religion, sex, disability, age, color, or national origin.
- Privacy – you have the right to keep all personal and medical information private.
- Receive information about Medicare and any Medicare-related services in a way that is easy for you to understand.
- Receive detailed, easy to understand information about Medicare that helps you make informed decisions – information you have a right to include what services and care Medicare will cover, what Medicare pays, how much you will have to pay and what to do should you wish to appeal a decision regarding your Medicare coverage or file a complaint about quality of care.
- Ask and receive answers to your Medicare questions.
- Access to hospitals, doctors, and specialists.
- Learn about all medical treatment options available to you – options must be presented in a way that is easy for you to understand.
- Take part in all medical decisions.
- Receive healthcare and any related services in a language that you understand.
- Access Medicare-covered services in the event of an emergency.
- Receive a detailed decision letter for all Medicare-covered services that outlines what is covered by Medicare, what is covered by other plans (supplemental insurance), and whether there are any services or care that isn’t covered.
Occasionally, Medicare may send out booklets or pamphlets that outline these Medicare rights and protections. Or visit the official Medicare website for a more detailed explanation.
What Do You Do if Your Medicare Rights aren’t Being Honored?
Medicare beneficiaries have access to a wide variety of resources that can help answer questions, aid with complaints, help with the appeals process and advocate on behalf of a beneficiary.
Medicare beneficiaries can receive help from the following places:
- Medicare – help with basic information regarding coverage, your rights, and how to file an appeal.
- Medicare Beneficiary Ombudsman (MBO) – makes sure you have access to information you need in a way you understand, you understand your Medicare rights and protections, and you know what your options to help resolve issues.
- State Health Insurance Assistance Program (SHIPs) – access to an individual you can speak to in person about your Medicare coverage, costs, eligibility, available plans and your rights and protections.
- Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO) – handles complaints regarding quality of care, other concerns, and grievances, filing appeals and reviews determination of “medical necessity”.
- State Health Survey Agency – monitors Medicare-covered facilities to make sure all health and safety standards are met. Also handles quality of care complaints.
Additional Rights and Protections for Individuals with Original Medicare Part A and Part B
Beneficiaries with Original Medicare – Medicare Part A and Part B have additional rights and protections. In addition to all the rights and protections listed above, Original Medicare beneficiaries are also entitled to the following:
- Choose to purchase a Medicare supplement plan or Medigap plan.
- Receive care at any Medicare-certified hospital if it is currently participating in Medicare.
- Receive information on the appeals process should Medicare deny coverage for a specific treatment or service.
- Request an official appeal if Medicare denies coverage.
- Request an appeal or review of a payment decision.
- See any doctor or specialist that participates in Medicare.
- Women may see a women’s health specialist without the need for a referral if the provider participates in Medicare.
Are There Additional Medicare Rights for Those on Medicare Advantage Plans?
Medicare beneficiaries who receive their benefits through a Medicare Advantage plan may have additional rights and protections. These rights and protections are provided by the insurance company that is providing the coverage.
Even though some Medicare Advantage rights may vary from insurance company to insurance company, there are some rights that every individual who is on Medicare Advantage is entitled to receive which include:
- Choose any doctor, hospital or provider covered by your plan’s network.
- File an official complaint or grievance about any issues you experience with your Medicare Advantage plan.
- Receive detailed information about your plan’s coverage for certain medical procedures before deciding.
- Access a treatment plan created by your doctor or healthcare team.
- Women may access women’s health providers without a need for a referral even if the plan requires a referral for services.
- Learn how your doctors are being paid by Medicare.
- Receive care without interference because a doctor or provider is having issues with payment from Medicare.
- Request an appeal if your plan denies coverage or if you feel that your plan should cover more for a certain procedure or treatment.
Understanding your Medicare rights and protections will help you make sure that you have access to quality care when you need it most.