by David Sayen
As a person with Medicare, you have certain rights and protections. You have rights whether you’re enrolled in Original Medicare – in which you can choose any doctor or hospital that accepts Medicare – or Medicare Advantage, in which you get care within a network of health care providers. Such networks are run by private companies approved by Medicare.
Your rights guarantee that you get the health services the law says you can get, protect you against unethical practices, and ensure the privacy of your medical information. You have the right to be treated with dignity and respect, and to be protected from discrimination.
You also have the right to get information in a way you understand from Medicare and your health care providers. This includes information about what Medicare covers, what it pays, how much you have to pay, and how to file an appeal.
One very important right is to get emergency care when and where you need it — anywhere in the United States. If you have Medicare Advantage, your plan materials describe how to get emergency care. You don’t need permission from your primary-care doctor before you get emergency care. If you’re admitted to the hospital, you or your primary-care doctor should contact your plan as soon as possible. If you get emergency care, you must pay your regular copayment. Then your plan will pay its share.
If your plan doesn’t pay its share, you have the right to appeal. In fact, whenever a claim is filed for your care, you’ll get a notice from Medicare or your Medicare Advantage plan letting you know what will and won’t be covered. If you disagree with the decision, you have the right to appeal.
You don’t need a lawyer to appeal in most cases, and filing an appeal is free. You won’t be penalized in any way for challenging a decision by Medicare or your health or drug plan. And many people who appeal often wind up with a favorable outcome.
Many people with Original Medicare also enroll in Medicare prescription drug plans. Here, too, you have rights. For example, if your plan won’t cover a drug you think should be covered, or it will cover the drug at a higher cost than you think you’re required to pay, you can request a coverage determination. If the decision isn’t in your favor, you can appeal.
You can ask for an exception if you, your doctor, or your pharmacist believe you need a drug that isn’t on your plan’s list of covered medications.
For more information, read our booklet “Medicare Appeals,” available at www.medicare.gov/Publications. Or call us, toll free, at 1-800-MEDICARE.
David Sayen is Medicare’s regional administrator for California.