When things go wrong with your Medicare coverage
Did you know that Congress has mandated that Medicare must provide an "Ombudsman", whose job it is to hears complaints and tries to resolve them? The Ombudsman also works with other government branches to improve Medicare service and benefit issues.Besides the Ombudsman program, there is an official procedure for filing complaints with the Medicare admisitrators.
In addition, and in some cases, you have the right to an appeal of decisions about issues that you feel are wrong, provided they fall within the regulations regarding such appeals.
(For other Medicare topics, see our home page The Medicare Project - home)
Web pages and brochures from government, education, and non-commercial sites about these subjects:
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Medicare brochure: How the Medicare Beneficiary Ombudsman Works For You source:Centers for Medicare & Medicaid Services file sie: 2 pgs; languages: English from the brochure: "An “Ombudsman” is a person who reviews issues and helps to resolve them. Congress requires that Medicare have a Beneficiary Ombudsman who helps people with Medicare. The Medicare Beneficiary Ombudsman shares information with the Secretary of Health and Human Services, Congress, and other organizations about what works well, and what doesn’t work well, to continuously improve the quality of the services and care you get through Medicare by reporting problems and making recommendations.... " more from Centers for Medicare & Medicaid Services: web page: Contact Us languages: English from the web page: "Takes you to a list of Ombudsman frequently asked questions, and offers the option to submit your own question..." |
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web page:
Solving Medicare Problems
source:Medicare Rights Center
languages: English
topics on the web page: "You have the right to appeal any health care decision made by Medicare, your doctor, hospital or a private Medicare plan–and you have a good chance of winning. In fact, most appeals turn out in favor of the person appealing..."
more from Medicare Rights Center:
brochure:
Medicare Part D Appeals: An advocate’s manual to navigating the Medicare private drug plan appeals process
file size:24 pgs; languages: English
from the web page: "The Medicare drug benefit, also known as Medicare Part D, began January 1, 2006, as the largest benefit added to Medicare coverage in 40 years. However, unlike Original Medicare, Part D drug coverage is offered exclusively through private plans that contract with Medicare. That means that all administrative complaints and problems must be addressed first through each individual private plan, rather than through Medicare..
brochure:
How to File a Complaint
source:Medicare.gov - The Official U.S. Government Site for People with Medicare
file size;2 pgs;languages: English
from the web page: "Medicare has health and safety standards to protect you. You can file a complaint against a Medicare or Medicaid provider (including hospitals, home health agencies, hospices, or nursing homes) for improper care or treatment.... CMS, the Federal agency that runs the Medicare program, the State Medicaid Agency, and the State survey agency (usually part of your state’s health department) work together to make sure providers meet Federal standards...."
more from Medicare.gov:
web page:
Notice of Privacy Practices for the Original Medicare Plan
languages: English
from the web page: "THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
By law, Medicare is required to protect the privacy of your personal medical information. Medicare is also required to give you this notice to tell you how Medicare may use and give out (“disclose”) your personal medical information held by Medicare..."
brochure:
Filing a Complaint Concerning Dialysis or Kidney Transplant Care
file size:2 pages; languages: English
from the web page: "This fact sheet provides information about filing complaints and grievances in the Medicare End-Stage Renal Disease Program by or on behalf of an individual with kidney failure..."
brochure:
Medicare Advantage Plans and Medicare Cost Plans: How to File a Complaint (Grievance or Appeal)
file size: 5 pgs; languages: English, Spanish
from the web page: "This fact sheet provides information about filing complaints in Medicare Advantage Plans and Medicare Cost Plans."
brochure:
How to File a Medicare Part A or Part B Appeal in the Original Medicare Plan
file size: 5 pgs; languages: English, Spanish
from the web page: "This fact sheet provides information about filing appeals in the Original Medicare Plan."
brochure:
What Are Your Rights When Your Medicare HMO Pulls Out?
source:Pro Seniors, Inc.
file size:4 pgs; languages: English, Spanish
from the brochure:"What does the announcement that your HMO will no longer participate in the Medicare program mean?..."
more from Pro Seniors, Inc.:
brochure:
Appealing Medicare Coverage Denials
file size: 4 pgs; languages: English
from the web page: "What To Do When You Are Turned Down For Medicare Coverage..."
web page:
Medicare Prescription Drug Coverage: Complaints, Coverage Determinations, and Appeals
source:CalMedicare.org (California)
languages: English, Spanish
from the web page: "There are many different kinds of issues or problems that you may encounter with your Medicare prescription drug plan. There are three levels of action available to you..."
web page:
Got Medicare Complaints? Here’s Your Guide!
source:California Health Advocates
languages: English
from the web page: "With so many entities and contractors involved in the Medicare program, where do you start when you have a complaint to make? Who is the most effective contractor to contact? This is a common question among beneficiaries, family members and advocates alike... "
web page:
MEDICARE COVERAGE & APPEALS
source:Center for Medicare Advocacy, Inc.
languages: English
from the web page: (topics include) "How can I appeal a Medicare denial? What are my rights and responsibilities regarding the New Prescription Drug benefit? PART A APPEALS PART B APPEALS"
web page:
Anatomy of the Medicare Appeals Process
source:Medscape Today
languages: English
from the brochure: "...Getting paid for what you do sometimes involves appealing claim denials. In the case of Medicare, the government has made significant structural and procedural changes in the existing appeals process. Here is an outline of those changes, so you will know what to expect the next time you appeal a Medicare denial...."
brochure:
Medicare Part B Premiums: What You Can Do If You Think Your Medicare Part B Income-Related Premium Is Incorrect
source:Social Security Online
file size:2 pgs; languages: English
from the brochure: "...and you disagree with the decision that you need to pay a higher premium amount, you have the right to request an appeal (also known as a reconsideration). You may request an appeal in writing..."
web page:
Medicare Advantage Appeals
source:Masspro
languages: English date:
from the web page: "...Beneficiaries enrolled in a Medicare Advantage plan (or other Medicare health plans that are not fee-for-service) have the right to appeal decisions related to their Medicare Advantage plan’s decision to end Medicare-covered skilled services in the nursing home setting or provided by a home health agency..."
Solving Medicare Problems
source:Medicare Rights Center
languages: English
topics on the web page: "You have the right to appeal any health care decision made by Medicare, your doctor, hospital or a private Medicare plan–and you have a good chance of winning. In fact, most appeals turn out in favor of the person appealing..."
more from Medicare Rights Center:
brochure:
Medicare Part D Appeals: An advocate’s manual to navigating the Medicare private drug plan appeals process
file size:24 pgs; languages: English
from the web page: "The Medicare drug benefit, also known as Medicare Part D, began January 1, 2006, as the largest benefit added to Medicare coverage in 40 years. However, unlike Original Medicare, Part D drug coverage is offered exclusively through private plans that contract with Medicare. That means that all administrative complaints and problems must be addressed first through each individual private plan, rather than through Medicare..
How to File a Complaint
source:Medicare.gov - The Official U.S. Government Site for People with Medicare
file size;2 pgs;languages: English
from the web page: "Medicare has health and safety standards to protect you. You can file a complaint against a Medicare or Medicaid provider (including hospitals, home health agencies, hospices, or nursing homes) for improper care or treatment.... CMS, the Federal agency that runs the Medicare program, the State Medicaid Agency, and the State survey agency (usually part of your state’s health department) work together to make sure providers meet Federal standards...."
more from Medicare.gov:
web page:
Notice of Privacy Practices for the Original Medicare Plan
languages: English
from the web page: "THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
By law, Medicare is required to protect the privacy of your personal medical information. Medicare is also required to give you this notice to tell you how Medicare may use and give out (“disclose”) your personal medical information held by Medicare..."
brochure:
Filing a Complaint Concerning Dialysis or Kidney Transplant Care
file size:2 pages; languages: English
from the web page: "This fact sheet provides information about filing complaints and grievances in the Medicare End-Stage Renal Disease Program by or on behalf of an individual with kidney failure..."
brochure:
Medicare Advantage Plans and Medicare Cost Plans: How to File a Complaint (Grievance or Appeal)
file size: 5 pgs; languages: English, Spanish
from the web page: "This fact sheet provides information about filing complaints in Medicare Advantage Plans and Medicare Cost Plans."
brochure:
How to File a Medicare Part A or Part B Appeal in the Original Medicare Plan
file size: 5 pgs; languages: English, Spanish
from the web page: "This fact sheet provides information about filing appeals in the Original Medicare Plan."
brochure:
What Are Your Rights When Your Medicare HMO Pulls Out?
source:Pro Seniors, Inc.
file size:4 pgs; languages: English, Spanish
from the brochure:"What does the announcement that your HMO will no longer participate in the Medicare program mean?..."
more from Pro Seniors, Inc.:
brochure:
Appealing Medicare Coverage Denials
file size: 4 pgs; languages: English
from the web page: "What To Do When You Are Turned Down For Medicare Coverage..."
Medicare Prescription Drug Coverage: Complaints, Coverage Determinations, and Appeals
source:CalMedicare.org (California)
languages: English, Spanish
from the web page: "There are many different kinds of issues or problems that you may encounter with your Medicare prescription drug plan. There are three levels of action available to you..."
Got Medicare Complaints? Here’s Your Guide!
source:California Health Advocates
languages: English
from the web page: "With so many entities and contractors involved in the Medicare program, where do you start when you have a complaint to make? Who is the most effective contractor to contact? This is a common question among beneficiaries, family members and advocates alike... "
MEDICARE COVERAGE & APPEALS
source:Center for Medicare Advocacy, Inc.
languages: English
from the web page: (topics include) "How can I appeal a Medicare denial? What are my rights and responsibilities regarding the New Prescription Drug benefit? PART A APPEALS PART B APPEALS"
Anatomy of the Medicare Appeals Process
source:Medscape Today
languages: English
from the brochure: "...Getting paid for what you do sometimes involves appealing claim denials. In the case of Medicare, the government has made significant structural and procedural changes in the existing appeals process. Here is an outline of those changes, so you will know what to expect the next time you appeal a Medicare denial...."
Medicare Part B Premiums: What You Can Do If You Think Your Medicare Part B Income-Related Premium Is Incorrect
source:Social Security Online
file size:2 pgs; languages: English
from the brochure: "...and you disagree with the decision that you need to pay a higher premium amount, you have the right to request an appeal (also known as a reconsideration). You may request an appeal in writing..."
Medicare Advantage Appeals
source:Masspro
languages: English date:
from the web page: "...Beneficiaries enrolled in a Medicare Advantage plan (or other Medicare health plans that are not fee-for-service) have the right to appeal decisions related to their Medicare Advantage plan’s decision to end Medicare-covered skilled services in the nursing home setting or provided by a home health agency..."
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