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Rights of a member under Medicare

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Rights of a member under Medicare

Rights of a member under Medicare

This section provides you with details of your rights as a member of Medicare plans or Medicare services. Know about your rights as a member and detailed information about rights such as right to appeal against any claim that is denied. Visit this page for details.

You get a number of legal rights if you are enrolled under Medicare. You can make an appeal if you have been refused service. You also have the right to appeal against a decision. You can also appeal on prescription drug coverage and the ability to get information. You can also appeal to obtain emergency services, the right to avail the services of network providers and to have a role in participating in decisions that affect your health. You also have the right to be informed about your options in treatment and to file complaints. You have a right to be treated without discrimination on any ground and the right to maintain secrecy regarding your personal information. These rules are applicable to the traditional Medicare plan and not to the Medicare Supplemental Insurance.

Perhaps the most commonly used right is that of a timely response to an appeal regarding health care ruling that do not satisfy you. You may always appeal against a Medicare ruling no matter what plan you are enrolled in. for e.g. if you come to know that covers were denied for a service that was provided to you, you may appeal against it. You may also appeal if you feel that the insurance company did not pay you enough for your claims and this increased your liabilities out of pocket. You will know about the technicalities of making these appeals from your insurance policy. Your hospital or doctor may also help you in making these appeals.

If you are availing of services from a doctor or provider who is within the network, he may be able to guide you on services which are covered and those that arenít. The can also ask for pre authorization of these services before the costs are incurred. If the plan does not cover the said procedure, you may have to sign a form assigning all costs to be paid to your account. You may also ask for an itemized statement that will help you in tracking your costs that have been billed from Medicare.

You may avail of a fast track appeal when the provider ends your coverage because benefits have run out. This may take place when you are discharged from a health care institute like a hospital, home health care or a rehab facility ad you feel that your covers have been ended prematurely.

You may also appeal against a decision made by the prescription drug plan. This may typically happen if you find that your drug is not covered by the pharmacy or that your copayment will be higher than what you expected. You may request Medicare for a detailed explanation of the decision. You may also ask the company to provide you with an exception on a particular drug with your doctorís help. This is especially helpful if your doctor opines that there are no substitutes for the said drug. I case of such an appeal, your company must reply within 72 hours. If you do not agree with the answer of the company, you can file an appeal within 60 days of filing your appeal.

Under HIPAA laws and state laws, the insurance company has to guard your privacy. Only you and a person with a legal right may be provided with the information. The department of health and human services may also avail of this information in order to verify that it is protected and your right not violated. Court cases and requirements to bring the information forward may also result in legitimizing the production of these records. Government agencies may also acquire these results under the following conditions:

  • In case state and federal agencies so require it.
  • For purposes of public health activities.
  • In case of verification by government agencies against fraud and medical claims abuses.
  • For a case or legal proceeding as required by the court.
  • To agencies of law under such circumstances as a person missing and investigations being carried out.
  • For purposes of research as long as the privacy is ensured.

For other purposes, Medicare must secure your written permission in order to release your personal information or history. Even if you do give permission for the above, you have the right to withdraw it at any time.

Medicare also gives you protection against discrimination. It is illegal for Medicare to discriminate against you on the basis of your nationality, color, age, race, religion or gender.


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