Your Medicare Rights

If you are provided health insurance under Medicare or any Medicare health plan, you are granted many legal rights. Among these are the right to make an appeal on any denied services, the right to a fast appeal decision, appeal on prescription drug decisions, the ability to obtain information, the right for emergency medical services, the right to see certified physicians and health care providers, the right to participate in decisions made effecting your health care, the right to know all of your treatment options, the right to file complaints, the right to be treated without discrimination and the right to have your personal information kept private. These rights govern traditional Medicare and may not apply to your Medicare Supplemental Insurance.

One of the most commonly used of these rights is that of a timely response to your appeals on health care decisions that are not to your satisfaction. Regardless of the type of Medicare plan that you have, you always have the right to appeal the decisions of Medicare or your insurance company. Perhaps you find out that a service or medical treatment that you need is not covered under your plan or was denied payment after the treatment was rendered. You may also feel that Medicare or your health insurance company did not pay the correct amount toward your claim, thus increasing your out-of-pocket liability. Information on the steps you must take in order to submit an appeal are included in your insurance policy. Your physician or hospital may also be of assistance in helping you make an appeal against the insurance company.

If you doctor is part of Medicare or contracts with the insurance company that provides your Medicare coverage, they should be aware of the services that are covered and not covered under your plan. They can also request pre-authorization for these services before the medical costs are incurred. If the service is not covered by Medicare or your insurance company, the physician or hospital will probably ask you to sign a statement before the procedure that says you will be responsible for the medical expenses if the insurance company denies your claim. Requesting an itemized statement from your health care provider will also help you keep track of your expenses and what has been billed to Medicare.

A Fast-Track appeal is available when the services from a health care provider are ending because your benefits have run out. This is available whenever you are discharged from a hospital, a skilled nursing facility, a home health care agency, a hospice or a rehab facility and you believe that your services are ending before you feel they should.

You also have the right to appeal any decisions made by your prescription drug plan. Perhaps your pharmacy informs you that a particular drug is not covered under your drug plan. Or, perhaps what your co-payment is higher than you expected to pay under your drug plan. You may ask your insurance company or Medicare for a detailed explanation about this decision. You may also, with your physician's assistance, ask for a special exception on a drug that is not covered under your plan. This is usually based on your doctor's suggestion that no substitute drugs are available to treat your condition. Your drug plan company must respond to your request within 72 hours of your contacting them. If you do not agree with the decision or explanation provided by your Medicare insurance company, you may file an appeal. You have up to 60 days from the date of decision to file your appeal.

Under State and Federal HIPAA laws, your insurance company and health care providers are required to protect your privacy. Your personal information can only be given to yourself and any other person that has the expressed legal right to obtain this information. The information may also be provided to the Department of Health and Human Services so that they can make sure that your personal information is protected and this right has not been violated. There may also be legal situations, such as court orders, that could also cause legitimate release of your personal information or health history. Your medical information may be released to government agencies under the following conditions: 1) to state and Federal agencies that have the legal right to obtain this data, 2) to public health activities, 3) to government agencies that monitor fraud and medical claims abuses, 4) for a legal proceeding as ordered by the courts, 5) to law enforcement agencies under limited circumstances, such as a missing persons investigation, 6) for research studies that meet all privacy guidelines.

For any other reason, Medicare or your health care provider must have your written permission to release your personal data or health history. If you provide written permission, you have the right to cancel this authorization at any time.

You are also protected against discrimination under Medicare. It is illegal for you to be treated differently than others based on your race, color, national origin, disability, age, religion or sex.

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