Table of Contents

Section 1: Your Medicare Rights & Protections

Section 2: Your Rights in Original Medicare

Section 3: Your Rights in a Medicare Advantage Plan or Other Medicare Health Plan

Section 4: Your Rights if You Have Medicare Drug Coverage

Section 5: The Medicare Beneficiary Ombudsman

The information in this booklet describes the Medicare Program at the time this booklet was printed. Changes may occur after printing. Visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227) to get the most current information. TTY users can call 1-877-486-2048.

“Medicare Rights & Protections” isn’t a legal document. Official Medicare Program legal guidance is contained in the relevant statutes, regulations, and rulings.

Section 1: Your Medicare Rights & Protections

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

- Provide for your safety when you get health care.

- Ensure you get the health care services that the law says you can get.

- Protect you from unethical practices.

- Safeguard your privacy.

You have the right to:

- Be treated with courtesy, dignity, and respect at all times.

- Be 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 gender.

- Have your personal and health information kept private.

- If you have Original Medicare, you can read our detailed
privacy practices in your “Medicare & You” handbook or at
Medicare.gov/notice-of-privacy-practices-for-original-medicare.

- If you have a Medicare Advantage Plan, other Medicare health plan, or a Medicare drug plan, read your plan materials.

- Get information in a way you understand from Medicare, health care providers, and, under certain circumstances, contractors.

- Get easy to understand information about Medicare like:

- What’s covered.

- What Medicare pays for covered items and services.

- How much you’ll have to pay.

- How to file a complaint or an appeal.

- Get answers to your Medicare questions.

- Visit Medicare.gov.

- Call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

- Call your State Health Insurance Assistance Program (SHIP). Visit shiphelp.org to get your local SHIP’s contact information.

- Call your plan if you have a Medicare Advantage Plan, other Medicare health plan, or a Medicare drug plan.

- Have access to doctors, specialists, and hospitals for medically necessary services.

- Learn about your treatment choices in clear language that you can understand, and participate in treatment decisions.

You have the right to participate fully in all your health care decisions. If you can’t participate fully, ask a family member, friend, or someone you trust to help you make a decision about what treatment is right for you.

- Get Medicare information and health care services in a language you understand.

For more information, visit hhs.gov/ocr or contact your state’s Office for Civil Rights.

- Get your Medicare information in an accessible format, like braille or large print.

Go to “CMS Accessible Communications” here for more information.

- Get emergency care when and where you need it.

- If your health is in danger because you have a severe injury, sudden illness, or an illness that quickly gets much worse, call 911. You can get emergency care anywhere in the U.S.

- To learn about emergency care in Original Medicare, visit
Medicare.gov, or call 1-800-MEDICARE.

- If you have a Medicare Advantage Plan or other Medicare health plan, your plan materials describe how to get emergency care.

- You don’t need to get permission from your primary care doctor (the doctor you visit first for health problems) before you get emergency care.

- If you’re admitted to the hospital, you, a family member, or your primary care doctor should contact your plan as soon as possible.

- If you get emergency care, you’ll have to pay your regular share of the cost (called a copayment). Then, your plan will pay its share.

- If your plan doesn’t pay its share for your emergency care, you have the right to appeal.

- Get decisions about coverage and payment.

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, other Medicare health plan, or Medicare drug plan. If you disagree with the decision on your claim, you have the right to file an appeal.

- Ask for an appeal of certain decisions about health care payment, coverage of items and services, or drug coverage.

For more information on appeals:

- Visit Medicare.gov/appeals.

- Visit Medicare.gov/publications to view or print the booklet “Medicare Appeals,” or call 1-800-MEDICARE (1-800-633-4227) to find out if a copy can be mailed to you. TTY users can call 1-877-486-2048.

- If you have a Medicare Advantage Plan, other Medicare health plan, or a Medicare drug plan, read your plan materials.

- Call the SHIP in your state. Visit shiphelp.org to get your local SHIP’s contact information.

- File complaints (also called “grievances”), including complaints about the quality of care and other services you get from a Medicare provider.

- If you have Original Medicare, call your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). Call 1-800-MEDICARE to get your BFCC-QIO’s phone number.

- If you have a Medicare Advantage Plan, other Medicare health plan, or Medicare drug plan, call the BFCC-QIO, your plan, or both.

- Visit Medicare.gov/claims-appeals/how-to-file-a-complaint-grievance to learn more about filing a complaint.

If you have End-Stage Renal Disease (ESRD) and have a complaint about your care, call the ESRD Network for your state. ESRD is permanent kidney failure that requires a regular course of dialysis or a kidney transplant.

Remember to:

- File an appeal if you disagree with a decision about your claims, services, or drug coverage.

Medicare representatives don’t have the authority to change Medicare’s coverage and payment decisions.

- Pay your Medicare premiums, copayments, and deductibles on time.

- Give complete and accurate information to Medicare and your health or drug plan, if you have one.

- Review your plan materials if you have a health or drug plan.

Contact your plan if you have questions or concerns.

- Visit SSA.gov or call Social Security at 1-800-772-1213 to change your name, address, or report a death.

TTY users can call 1-800-325-0778. If you have a health or drug plan, you can also contact your plan to update your address.

- Help fight Medicare fraud and abuse.

- Visit Medicare.gov/fraud to learn how to prevent, spot, and report Medicare fraud and abuse.

- Review your “Medicare Summary Notices” (MSNs) or “Explanation of Benefits” if you have a health or drug plan.

- Guard your Medicare card like it’s a credit card. Store it in a safe place.

Section 2: Your Rights in Original Medicare

If you have Original Medicare, you have the same rights and protections as everyone with Medicare (described here). You also have the right to:

- Use any doctor or specialist (including women’s health specialists) or any Medicare-certified hospital that participates in Medicare.

- Get certain information and notices that help you understand the medical services you get and resolve issues when Medicare may not (or doesn’t) pay for health care.

- Ask for an appeal of health care coverage or payment decisions.

- Buy a Medicare Supplement Insurance (Medigap) policy.

There are certain times, including during your Medigap Open Enrollment Period, when an insurance company must sell you a Medigap policy, even if you have pre-existing health conditions.

Section 3: Your Rights in a Medicare Advantage Plan or Other Medicare Health Plan

If you have a Medicare Advantage Plan or other Medicare health plan, you have the same rights and protections as everyone with Medicare (described here). You also have the right to:

- Choose your health care providers from within the plan’s network.

For example, women have the right to go directly to a women’s health care specialist within their plan without a referral for routine and preventive health care services.

- Get a treatment plan from your doctor.

If you have a complex or serious medical condition, a treatment plan lets you use a specialist within the plan as many times as you and your doctor think you need, without a referral.

- Know how your plan pays your doctors.

When you ask your plan how it pays 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.

- Ask for an appeal to resolve differences with your plan.

You have the right to ask your plan to provide or pay for an item or service you think should be covered, provided, or continued. If your plan denies your request, you have the right to appeal that decision.

- File a complaint (also called a “grievance”) about other concerns or problems with your plan.

For example, if you believe your plan’s hours of operation should be different, or there aren’t enough specialists in the plan to meet your needs, you can file a complaint. Check your plan’s membership materials or call your plan to find out how to file a complaint.

- Get a coverage decision or coverage information from your plan before getting services.

Before you get an item or service, you can call your plan to find out if it will be covered. Your plan must tell you if you ask.

If you want to know more about your rights and protections, including rights and protections you may have in addition to those discussed in this booklet, read your plan’s membership materials, or call your plan.

Section 4: Your Rights if You Have Medicare Drug Coverage

If you have a Medicare drug plan or Medicare Advantage Plan with drug coverage, you have the same rights and protections as everyone with Medicare (described here). You also have the right to:

- Ask for a coverage determination or appeal to resolve differences with your plan.

If your pharmacist, doctor, or other prescriber tells you that your plan won’t cover a drug you think should be covered, or it will cover the drug at a higher cost than you think you’re required to pay, you can request a coverage determination from your plan.

If your plan denies your request, you have the right to appeal that decision. For more information on the appeals process, visit Medicare.gov/appeals.

- File a complaint (called a “grievance”) with the plan.

For more information on filing a complaint, visit
Medicare.gov/claims-appeals/how-to-file-a-complaint-grievance.

Note: If you have Medicare drug coverage, your plan will send you information that explains your rights. Read the information carefully, and keep it where you can find it if you need it. Call your plan if you have questions.

Section 5: The Medicare Beneficiary Ombudsman

An “ombudsman” is a person who reviews questions, concerns, and challenges with how a program is administered, and helps to resolve them when possible. They make sure information about Medicare coverage, rights, and protections is available to everyone with Medicare.

The Medicare Beneficiary Ombudsman shares feedback from people with Medicare with the Department of Health and Human Services, Congress, and other organizations. This helps improve the quality of the care and services you get through Medicare.

Does the Medicare Beneficiary Ombudsman work with organizations?

The Medicare Beneficiary Ombudsman works with organizations like State Health Insurance Assistance Programs (SHIPs) and Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) to help you resolve issues in a timely way. SHIPs and BFFC-QIOs can help you with:

- Your Medicare questions, including your benefits, coverage, premiums, deductibles, and coinsurance.

- Complaints (also called “grievances”).

- Appeals.

- Problems joining or dropping a Medicare Advantage Plan, any other Medicare health plan, or Medicare drug plan.

For more information

- Visit Medicare.gov/basics/your-medicare-rights.

- Call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

- Call your SHIP if you have questions about Medicare rights and protections, appeals, buying other insurance, choosing a Medicare health or drug plan, or buying a Medicare Supplement Insurance (Medigap) policy. To get the phone number for your state’s SHIP, visit shiphelp.org, or call 1-800-MEDICARE.

CMS Accessible Communications

Medicare provides free auxiliary aids and services, including information in accessible formats like braille, large print, data/audio files, relay services and TTY communications. If you request information in an accessible format, you won’t be disadvantaged by any additional time necessary to provide it. This means you’ll get extra time to take any action if there’s a delay in fulfilling your request.

To request Medicare or Marketplace information in an accessible format, you can:

1. Call us:
For Medicare: 1-800-MEDICARE (1-800-633-4227) TTY: 1-877-486-2048
For Marketplace: 1-800-318-2596 TTY: 1-855-889-4325

2. Email us: altformatrequest@cms.hhs.gov

3. Send us a fax: 1-844-530-3676

4. Send us a letter:
Centers for Medicare & Medicaid Services

Offices of Hearings and Inquiries (OHI)

7500 Security Boulevard, Mail Stop DO-01-20

Baltimore, MD 21244-1850

Attn: Customer Accessibility Resource Staff (CARS)

Your request should include your name, phone number, type of information you need (if known), and the mailing address where we should send the materials. We may contact you for additional information.

Note: If you’re enrolled in a Medicare Advantage Plan or Medicare drug plan, contact your plan to request its information in an accessible format. For Medicaid, contact your state or local Medicaid office.

This product was produced at U.S. taxpayer expense.

Nondiscrimination Notice

The Centers for Medicare & Medicaid Services (CMS) doesn’t exclude, deny benefits to, or otherwise discriminate against any person on the basis of race, color, national origin, disability, sex (including sexual orientation and gender identity), or age in admission to, participation in, or receipt of the services and benefits under any of its programs and activities, whether carried out by CMS directly or through a contractor or any other entity with which CMS arranges to carry out its programs and activities.

You can contact CMS in any of the ways included in this notice if you have any concerns about getting information in a format that you can use.

You may also file a complaint if you think you’ve been subjected to discrimination in a CMS program or activity, including experiencing issues with getting information in an accessible format from any Medicare Advantage Plan, Medicare drug plan, state or local Medicaid office, or Marketplace Qualified Health Plans. There are three ways to file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights:

1. Online:
hhs.gov/civil-rights/filing-a-complaint/complaint-process/index.html

2. By phone:
1-800-368-1019. TTY users can call 1-800-537-7697.

3. In writing: Send information about your complaint to:
Office for Civil Rights

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services
7500 Security Blvd.
Baltimore, MD 21244-1850

Official Business
Penalty for Private Use, $300

CMS Product No. 11534
May 2023

This booklet is available in Spanish. To get a free copy, visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Esta publicación está disponible en Español. Para obtener una copia gratis, visite Medicare.gov o llame al 1-800-MEDICARE (1-800-633-4227). Los usuarios de TTY pueden llamar al 1-877-486-2048.