Medicare Rights & Protections - Everything You Need to Know | Health Insurance Basics
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Health Insurance Basics

What are your Rights & Protections Under Medicare?

Medicare is a federal program that provides health coverage for those aged 65 and older or have certain disabilities, no matter your age.

 

If you’re enrolled in Medicare, you likely know that there are four different types of coverage:

 

  • Part A (Hospital Insurance)
  • Part B (Medical Insurance)
  • Part C (Medicare Advantage Plans with extra benefits)
  • Part D (Prescription Drug Coverage)

 

Medicare Open Enrollment Dates

 

Medicare Open Enrollment runs from October 15 to December 7 each year, with coverage effective beginning January 1. During this period, you can make changes to your coverage:

  • Switch from Original Medicare (Parts A & B) to Medicare Advantage
  • Switch from one Medicare Advantage Plan to another or from one Medicare Part D (prescription drug) plan to another
  • Enroll in Medicare Part D if you didn’t elect to do so when you were first eligible

 

If you didn’t enroll in Medicare when you were first eligible, you may do so from January 1 to February 14 each year, with coverage effective beginning July 1. However, you may be subject to an enrollment penalty.

 

No matter which Medicare plans you have, you are entitled to certain rights and protections. These are designed to ensure you’re getting the services outlined by law, protect against unethical practices and respect your privacy.

 

In general, you have the following rights:

  • You should be treated with dignity and respect.
  • You are to be protected from discrimination.
  • Your personal health information needs to be kept private.
  • You should receive information in a way you understand from your healthcare provider and Medicare representatives and have your questions answered.
  • You should have access to doctors and hospitals, as well as urgently needed care whenever you need it.
  • You have the ability to file complaints about your care and also appeal certain decisions about coverage or payment.

 

If you have Medicare Parts A and B, you are also entitled to these rights:

  • You are able to see any doctor or specialist that participates in Medicare and also go to any Medicare-certified hospital.
  • You should receive certain notices, information and appeal rights to help you resolve issues when Medicare doesn’t pay for your care.
  • You can request an appeal of healthcare coverage and payment decisions relating to your hospital stays and medical care.
  • You also have the opportunity to buy a Medicare Supplement Insurance (Medigap) during your open enrollment period.

 

If you have Medicare Part C coverage, take note of these rights:

  • You have the right to choose your healthcare providers within the plan.
  • You should receive a treatment plan from your doctor.
  • You have the right to know how your doctors are paid.
  • You’re able to request an appeal in order to resolve differences in what you think should be covered in your plan versus what is covered. If denied, you also have the right to appeal the decision.
  • You can file a complaint or grievance about your plan.
  • You’re allowed to get coverage decision and coverage information from your plan before getting services.

 

Finally, if you have Part D coverage, you’re also entitled to these rights:

  • You can request a coverage determination or appeal to resolve differences you think are in your plan.
  • You can file a complaint or grievance about your plan.
  • You have the right to have your health and prescription drug information protected.

 

If you think any of your rights and protections have been violated, there are certain resources available to you:

  • The Medicare Beneficiary Ombudsman: This person can help you with complaints, grievances and requests for information about Medicare. He or she provides information about what you need to know when making healthcare decisions, rights and protections and how issues can be resolved.
  • The Competitive Acquisition Ombudsman (CAO): This person reviews and resolves complaints that have to do with durable medical equipment in areas where there is a competitive bidding program for these medical devices and supplies.
  • Your State Health Insurance Assistance Program (SHIP): Representatives from this program offer local, personalized counseling regarding Medicare. They can help with questions about benefits, coverage, premiums, deductibles, etc., as well as help with complaints and appeals.
  • The Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO): This group reviews complaints and quality of care for people with Medicaid. The goal is to help improve effectiveness, efficiency, economy and quality of services within the program.
  • Your State Survey Agency: These agencies oversee the facilities that provide healthcare associated with Medicare and makes sure that health and safety standards are met.

 

If you’re enrolled in a Gateway Health Medicare plan, you can use the below contact numbers to learn more about your rights and protections under the program.

 

MEDICARE ASSURED MEMBER CONTACT INFORMATION

Toll Free Numbers

Pennsylvania 1-800-685-5209

Ohio: 1-888-447-4505

North Carolina: 1-855-847-6430

TDD/TTY: 711

 

8:00 AM – 8:00 PM Eastern Time

7 Days a week from October 1 through March 31.

* From April 1 through September 30 our business hours are 8 a.m. – 8 p.m., Monday through Friday.

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  1. https://www.medicare.gov/Pubs/pdf/11534-Medicare-Rights-and-Protections.pdf
  2. https://www.medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman.html

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