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Medicare

Your Rights

 

You have the right to be treated fairly, understand the information you get, and keep your personal information safe.

No matter how you get Medicare, you have rights and protections that:

  • Provide for your safety when you get health care.
  • Ensure you get the health care services the law says you can get.
  • Shield you against unethical practices.
  • Safeguard your privacy.

 

If you have Medicare

 

You have the right to be:

  • Treated with courtesy, dignity and respect at all times.
  • Protected from discrimination. Every company or agency that works with Medicare must obey the law. They can't treat you differently because of your race, color, national origin, disability, age, religion, or sex.

You have the right to have:

  • Your personal and health information kept private.
  • Access to doctors, specialists, and hospitals for medically necessary services.

You have the right to get:

  • Medicare-covered services in an emergency.
  • Information in a way you understand from Medicare, health care providers, and, under certain circumstances, contractors.
  • Information about your treatment choices in clear language that you can understand, and participate in treatment decisions.
  • Medicare information and health care services in a language you understand.
  • Your Medicare information in an accessible format, like braille or large print.
  • Answers to your Medicare questions.
  • A decision about health care payment, coverage of items and services, or drug coverage.

When you or your provider files a claim, you’ll get a notice letting you know what will and won’t be covered. This notice may come from:

  • Medicare
  • Your Medicare Advantage Plan (Part C) or other Medicare health plan
  • Your Medicare drug plan 

If you disagree with the decision on your claim, you have the right to file an appeal. You can ask for a review (appeal) of certain decisions about health care payment, coverage of items and services, or drug coverage. If you have concerns about the quality of care and other services you get from a Medicare provider, you can:

  • File a complaint (sometimes called a "grievance").
  • Get help from End-Stage Renal Disease (ESRD) Networks and State Survey Agencies to help you with complaints (grievances) about your dialysis or kidney transplant care.

Access to your personal health information

By law, you or your legal representative generally have the right to view and/or get copies of your personal health information from these groups:

  • Health care providers who treat you and bill Medicare for your care
  • Health plans that pay for your care, including Medicare

These types of personal health information include:

  • Claims and billing records
  • Information related to your enrollment in health plans, including Medicare
  • Medical and case management records
  • Other records that doctors or health plans use to make decisions about you

Generally, you can get your information on paper or electronically. If your providers or plans store your information electronically, they generally must give you electronic copies, if you ask for them. You have the right to get your information in a timely manner, but it may take up to 30 days to get a response. Keep in mind, if your information is electronic, you also have the right to have it sent to a third party of your choosing. A third party may be a:

  • Health care provider who treats you
  • Family member
  • Researcher

You may have to fill out a form to request copies of your information and pay a fee. This fee can’t be more than the total cost of:

  • Labor for copying the information requested
  • Supplies for creating the copy
  • Postage (if you ask your health care provider to mail you a copy)

In most cases, you won't be charged for viewing, searching, downloading, or sending your information through an electronic portal.

Get more information about your rights under HIPAA.

 

More rights based on your situation

 

When you have Medicare, there are rules that protect your right to fair treatment, access to helpful information, and the privacy of your personal and health records. If you’re a resident of a Skilled Nursing Facility (SNF) or nursing home, or if you’re getting home health or hospice services, you have additional rights under federal and state law. .

If you have Original Medicare

You can:

  • See any doctor or specialist (including women's health specialists), or go to any Medicare-certified hospital, that participates in Medicare.
  • Get certain information, notices, and appeal rights. These help you resolve issues when Medicare may not (or doesn't) pay for your health care.
  • Request an appeal of health coverage or payment decisions.
  • Buy Medicare Supplement Insurance (a Medigap policy).

If you have a Medicare Advantage Plan or other Medicare health plan

You have the same rights and protections as all people with Medicare. You also have the right to:

  • Choose health care providers within the plan.
  • Get a treatment plan from your doctor.
    • If you have a complex or serious medical condition, a treatment plan lets you directly see a specialist within the plan as many times as you and your doctor think you need.
    • Women have the right to go directly to a women's health care specialist without a referral within the plan for routine and preventive health care services.
  • Know how your doctors are paid.
    • When you ask your plan how it pays its doctors, the plan must tell you.
    • Medicare doesn't allow a plan to pay doctors in a way that could interfere with you getting the care you need.
  • Request an appeal to resolve differences with your plan.
  • File a complaint (called a "grievance") about other concerns or problems with your plan.
  • Get a coverage decision or coverage information from your plan before getting services.

To learn more about your rights and protections, read your plan’s membership materials, or call your plan.

If you have a Medicare drug plan or Medicare Advantage Plan with drug coverage

You have the same rights and protections as all people with Medicare. You also have the right to:

  • Get a written explanation for drug coverage decisions (called a “coverage determination”) from your Medicare drug plan. 
    • A coverage determination is the first decision your Medicare drug plan (not the pharmacy) makes about your benefits. This can be a decision about if your drug is covered, if you met the plan’s requirements to cover the drug, or how much you pay for the drug.
    • You’ll also get a coverage determination decision if you ask your plan to make an exception to its rules to cover your drug.
  • File a complaint (called a "grievance") with the plan. A grievance is a complaint about the way your Medicare health or drug plan is giving care.
  • Have the privacy of your Medicare health and drug information protected.

If you have Medicare drug coverage, your plan will send you information that explains your rights. Call your plan if you have questions.

If you're in a Skilled Nursing Facility (SNF)

You have certain rights and protections under federal and state law. These laws can vary by state.

The SNF must give you a written description of your legal rights. Keep the information you get about your rights, admission and transfer policies, and any other information you get from the SNF in case you need to look at them later.

If you're in a nursing home

You have certain rights and protections under federal and state law. These rights and protections help make sure you get the care and services you need. You have the right to be informed, make your own decisions, and have your personal information kept private.

The nursing home must tell you about these rights and explain them in writing in a language you understand, including:

  • How you should act while you're in the nursing home
  • What you're responsible for while you're in the nursing home

This must be done before or at the time you're admitted, as well as during your stay. You must acknowledge in writing that you got this information.

The nursing home must also: 

  • Provide you (orally and in writing) with information about how to apply for and use Medicare and Medicaid benefits.
  • Prominently display written information about Medicare and Medicaid benefits. 
  • Give you information on how to get refunds if you previously paid for a service that Medicare or Medicaid covers.

If you're getting home health services

By federal law, you have the right to:

  • Choose your home health agency. (If you have a Medicare Advantage Plan , your choice will depend on which home health agencies your plan works with.)
  • Have your property treated with respect.
  • Get a copy of your care plan and participate in decisions about your care.
  • Name a family member or guardian to act for you if you’re unable.

The home health agency must give you a written copy of your rights. For more information on your privacy rights as a home health patient, read the .

If you're getting hospice services

You have the right to:

  • Decide whether to receive services at home or in-patient
  • Participate in your own treatment plan
  • Receive effective pain management
  • Refuse treatment
  • Choose your own physician

 

Get help with your rights & protections

 

If you feel your rights have been violated, you can contact these offices and programs for help:

  • The Medicare Beneficiary Ombudsman
  • Your State Health Insurance Assistance Program (SHIP)
  • The Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO)
  • Your State Survey Agency

The Medicare Beneficiary Ombudsman

The Medicare Beneficiary Ombudsman helps you with Medicare-related complaints, grievances, and information requests. They make sure you have Medicare rights and protections information and understand how to get your concerns resolved. If you have a concern that hasn't been resolved by Medicare or your plan, ask 1-800-MEDICARE (1-800-633-4227) to submit your inquiry to the Medicare Beneficiary Ombudsman. TTY users can call 1-877-486-2048.

State Health Insurance Assistance Program (SHIP)

SHIPs are state programs that get money from the federal government to give local health insurance counseling to people with Medicare. SHIPs aren’t connected to any insurance company or health plan. They provide free, personalized counseling to you and your family to help with these and other Medicare questions:

  • Your Medicare rights
  • Billing problems
  • Complaints about your medical care or treatment
  • How Medicare works with other insurance
  • Finding help paying for your health care costs

Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO)

The BFCC-QIOs are committed to helping you get the care you need with Medicare. They review Medicare complaints and monitor your quality of care to improve the effectiveness, efficiency, economy, and quality of health care services. They can help you with:

  • Filing appeals
  • Complaints (grievances)
  • Quality of care reviews
  • Medical necessity reviews

The BFCC-QIO is administered for Medicare by Livanta or Acentra, depending on what state you live in. Check their websites to make sure you're contacting the right organization for your state. 

State Survey Agency

State Survey Agencies oversee health care facilities that participate in Medicare and Medicaid. They inspect health care facilities and investigate complaints to ensure these facilities meet health and safety standards. Contact your State Survey Agency if: 

  • You have a complaint about improper care or unsafe conditions in a hospital, home health agency, hospice, or nursing home.
  • You’re concerned about the health care, treatment, or services that you or another person got or didn’t get in a health care setting.

Your State Survey Agency can also help with things like:

  • Abuse
  • Neglect
  • Mistreatment
  • Poor care
  • Not enough staff
  • Unsafe or unsanitary conditions
  • Dietary problems

Contact your State Survey Agency for more information.

Tips for getting help:

  • If you have Original Medicare, call 1-800-MEDICARE if you have questions about your benefits or costs.
  • If you’re in a Medicare health or drug plan (like a Part D or Medicare Advantage Plan) contact your plan first if you have questions.
  • For free personalized health insurance counseling you can contact your local State Health Insurance Assistance Programs (SHIPs).
  • When you speak with a Medicare representative, a Medicare health or drug plan employee, a SHIP counselor, or a provider about an issue:
    • Give them complete and updated information for your question or concern.
    • Understand that, by law, they can’t change or approve benefits or services Medicare doesn’t cover.  
    • Remember that some issues will take longer to review and respond to. 

One Final Note...

 

Everyone deserves to be treated with respect. Any form of verbal or physical harassment, threats, or intimidation towards Medicare representatives won’t be tolerated. If these behaviors continue, Medicare representatives have the right to end their discussion with you.

 

 

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Copyright © 2000 - 2025  -  K. Kerr

Most recent revision November 19, 2025 10:55:35 AM

 

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