Kathleen G. Kane - Pennsylvania Office of Attorney General - Protecting Pennsylvanians

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Your Rights Under Medicare  

Q.- What are my rights as a Medicare patient?

A. - If you have Medicare, you have certain guaranteed rights.  You have them whether you are in the Original Medicare Plan or a Medicare managed care plan.

You have the right to get emergency care when and where you need it, without prior approval.  If you think your health is in serious danger because you have severe pain, a bad injury, sudden illness, or an illness quickly getting much worse, you can get emergency care anywhere in the United States.

  • You have the right to appeal if Medicare does not pay for a covered service you have been given, or if your doctor of hospital does not give you a service that you believe should be covered.
  • You have the right to know all your treatment options from your health care provider in language that is clear to you.  Medicare must give you information about what is covered and how much you have to pay.  Medicare managed care plans cannot have rules that stop a doctor from telling you everything you need to know about your health care, including treatment options.

Q.- How do I question or appeal a Medicare managed care plan coverage decision?

A.-  You have a right to appeal many decisions about your Medicare-covered services.  You have this right if you are enrolled in a Medicare managed care plan.  Your health plan must provide you with written instructions on how to appeal.  You may file an appeal if your health plan denies a service, or terminates or refuses to pay for services that you believe should be covered.  After you file an appeal, the health plan reviews its decision.  Then, if your health plan does not decide in your favor, the appeal automatically goes to an independent review organization that contracts with Medicare.  You may be eligible for a fast decision (within 72 hours) if your health or ability to function could be seriously harmed by waiting the amount of time needed for a standard decision.  See the healthy plan's membership materials or call your health plan for details about your Medicare appeal rights.

Q.-  How do I appeal a Medicare payment or coverage decision under the Original Medicare Plan?

A.-  If you are dissatisfied, you have a right to appeal any decision concerning your Medicare-covered services in the Original Medicare Plan.  You can file an appeal if you believe Medicare did not pay enough for services or should have paid for health care services you received.  Your appeal rights are written on the back of the Medicare Summary Notice or Explanation of Medicare Benefits that is mailed to you.

Q.-  What can I do if I think I'm being discharged from the hospital too soon?

A.-  If you believe you are being discharged too soon from a hospital, you have a right to immediate review by the Peer Review Organization (PRO).  You can stay in the hospital at no charge and cannot be discharged before the PRO makes a decision.  In Pennsylvania the PRO service is done by KePRO.  You can contact KePro at 1-800-322-1914 or www.kepro.org.

You can contact the Health Care Section at 1-717-705-6938 on weekdays from 8:30 AM until 5:00 PM.  The Section also has a toll-free line, 1-877-888-4877, which operates within Pennsylvania on weekdays between the hours of 8:30 AM and 9:00 PM.