Which Type of Medicare Do You Have?

Medicare provides coverage for most medical services. However, it divides the types of care that it covers into separate parts. Medicare beneficiaries can choose to enroll for coverage in

• Part A (mostly in-hospital care),
• Part B (mostly outpatient care),
• Part C (managed care by a private company), and/or
• Part D (most drug coverage).*

If you enroll in original Medicare (sometimes called “traditional” Medicare) instead of Part C (managed care), you can pay for private medical insurance, called a Medigap policy, for costs that Medicare does not cover.

When you disagree with a decision Medicare makes about your health care, you have the right to appeal Medicare’s decision. For example, you can appeal if Medicare refuses to pay for medical care that you think you should get or continue to receive. Also, you have the right to appeal if Medicare denies your request to change the cost of your prescription drug or refuses to cover the drug your doctor prescribes.

However, the appeal method that you must use depends upon what type of Medicare you have. Before the different appeal methods are explained below, you should be aware of the many rights and protections to which all Medicare beneficiaries are entitled, no matter which type of Medicare coverage they have.

The Rights and Protections of Medicare Beneficiaries

Besides the right to appeal certain health care decisions, all Medicare beneficiaries have the right to be respected, treated with dignity, and protected from discrimination. Medicare must give beneficiaries access to hospitals, doctors and specialists, and emergency care when and where they need it. Medicare beneficiaries also have the right to file complaints and grievances about Medicare providers and private Medicare-approved plans. Medicare provides additional protections for its beneficiaries, which are described in the Medicare & You manual.

Medicare must also give all beneficiaries a decision about its coverage of health care services. This means that beneficiaries may ask for a coverage decision before the care is provided. For example, if your doctor tells you that a certain medical procedure will not be covered by Medicare, you may ask the doctor to submit the claim to Medicare as a “demand bill.” Medicare will notify you whether it will cover the service—sometimes the doctor is mistaken. If you disagree with Medicare’s decision, you can appeal it.

All Medicare beneficiaries also have the right to have someone help them with an appeal. You may ask a family member, a friend, an attorney, a doctor, or anyone else that you choose to represent you for an appeal. You must submit an Appointment of Representative form (from the Centers for Medicare & Medicaid Services) or a letter with the same information with your appeal. You can find information about free legal assistance with a Medicare appeal at the end of this article.

Original Medicare Appeals—Part A and Part B

Redetermination. If you have received care from a Medicare provider, you will receive a Medicare Summary Notice (MSN) in the next few months. The MSN is similar to commercial insurers’ “Explanation of Benefits” statement. The MSN will show you if Medicare refused to pay for a claim and give Medicare’s reason.

If you do not agree with Medicare’s decision, within 120 days, you must send in either the MSN or a copy (make a copy of everything you send for your records) or a Medicare Redetermination Request form with your reasons for disagreeing with Medicare’s decision. You may include information from your doctor that supports your appeal. Medicare will mail its response to you in about 60 days.

Reconsideration. If you do not agree with Medicare’s redetermination of their claim decision, you may file a second level appeal, called a reconsideration. You must file this level of appeal within 180 days after receiving the redetermination decision. You will send it to the Qualified Independent Contractor (QIC), a company hired by Medicare which was not involved in the previous decisions. The QIC will notify you of their decision within 60 days.

Administrative Law Judge Hearing. If you want to appeal the QIC’s reconsideration, you must request a hearing with an administrative law judge (ALJ) within 60 days. For this third level of appeal, you must be appealing a claim in the amount of at least $120 (this minimum amount increases to $130 in 2010). The hearing will be by phone, videoconference or, rarely, in person. You should get a decision from the ALJ within 90 days.

Medicare Appeals Council (MAC). If you do not agree with the ALJ’s decision, you have 60 days to send a fourth-level appeal to the Medicare Appeals Council. The MAC is part of the U.S. Department of Health and Human Services. You should receive a decision from the MAC within 90 days.

Federal District Court. The fifth level of appeal is to the federal district court. However, the amount of the claim must be at least $1,180 (this amount increases to $1,260 in 2010). The appeal must be filed with the court within 60 days of receiving the MAC decision.

Fast Appeals

If you are receiving Medicare services from a hospital, a skilled nursing facility, a home health agency, an outpatient rehabilitation facility, or a hospice, you have the right to ask for a fast or expedited appeal if you think that your covered services are ending too soon.

At least two days before your health care services will be stopped, these types of Medicare providers must give you a written notice, usually called “Important Message from Medicare” or “Notice of Medicare Provider Non-coverage.” The notice will explain how you can appeal to Medicare’s Quality Improvement Organization (QIO), a private contractor hired by Medicare to decide this type of appeal. You can ask your doctor for medical information to help your appeal.

However, you must contact the QIO to ask for a fast appeal no later than noon of the day before your Medicare services will end. If you meet this deadline for a fast appeal and the QIO decides your services should end, Medicare will continue to pay only until the next day at noon. You will be responsible for any charges after that time. If the QIO decides your care should continue, Medicare will continue the coverage for as long as it decides the care is medically necessary.

If you did not meet the time deadline for a fast appeal, you still have standard appeal rights and should contact the QIO immediately.

Original Medicare Appeals—Part D (Drug Plan)

You or your prescriber may ask for an exception or a coverage determination from your Part D drug plan if it denies payment for your prescription. This request must usually be in writing, unless your plan will accept it by phone. In most cases, your prescriber must fax the information to your drug plan, stating the medical reasons why no similar drugs covered by your plan can be substituted for the prescribed drug.

The time limits for the drug plan’s decision are much shorter than the limits for Part A and Part B decisions. In addition, if the drug plan decides on its own or your doctor or prescriber tells the drug plan that your life or health is at risk, the drug plan must make a fast or expedited decision.

The drug plan has 72 hours (for a standard request) or 24 hours (for an expedited request) to notify you of its decision. If you disagree with your drug plan’s decision, you then have the right to several levels of appeal that are similar to the appeal levels for Part A and B determinations.

Redetermination. You, your representative, doctor, or prescriber must request a redetermination within 60 days of the drug plan’s decision. The drug plan must decide within seven calendar days for a standard request and 72 hours for an expedited request.

Reconsideration. If you disagree with your drug plan’s decision, you have 60 days to request the second level of appeal, a reconsideration from Medicare’s Independent Review Entity (IRE). The IRE must give you a decision within seven days for a standard appeal and 72 hours for an expedited request.

Administrative Law Judge. The third level of appeal is a hearing by an administrative law judge (ALJ) via telephone, teleconference or, rarely, in person. You must request the hearing within 60 days of your unfavorable reconsideration decision. The value of the drug(s) that have been denied must not be less than $120 ($130 in 2010). You may submit additional medical evidence to the ALJ no later than 10 days after you receive the hearing date notice. You should try to have your prescriber testify at the hearing with you.

Medicare Appeals Council (MAC). You have 60 days to request an appeal to the Medicare Appeals Council if you disagree with the ALJ’s decision. This is the fourth level of the Part D appeal process.

Federal District Court. The fifth level of a Part D appeal is to file a complaint in federal district court. The amount in controversy must be at least $1,180 ($1,260 in 2010).

Medicare Advantage Plan Appeals (Managed Care/Part C)

Medicare Advantage Plans are private companies that include inpatient, outpatient, and drug coverage through enrollment in a managed care plan (HMO, PPO, etc.). Medicare Advantage beneficiaries have appeal rights that are similar to Original Medicare beneficiaries’ appeal rights. They are also similar to the appeal rights that New Jersey provides for persons with non-Medicare managed care commercial policies.

Reconsideration. If you disagree with your Medicare Advantage Plan’s decision, you, your representative, or your doctor may ask for a reconsideration as the first level of appeal. If your plan decides or your doctor tells the plan that your life or health is at risk, the plan must give an expedited decision.

The Medicare Advantage Plan must give you its decision within 30 calendar days for a standard request, 60 calendar days for a payment request, and 72 hours for a fast (expedited) appeal.

Redetermination. The Independent Review Entity (IRE) will decide the second level of a Medicare Advantage appeal. The IRE’s decision will come within 30 calendar days (standard request), 60 calendar days for a payment request, and 72 hours for a fast (expedited) appeal.

Administrative Law Judge; Medicare Appeals Council; Federal District Court. These next three levels of appeal for Medicare Advantage beneficiaries are identical to the appeal rights for Medicare Part D (see above).

* Although a person may voluntarily choose not to enroll in Medicare Part A, B, and/or D when they first become eligible for Medicare, in some circumstances there are penalty fees for delayed enrollment.

This article appeared in the December 2009 edition of Looking Out for Your Legal Rights^®.

This information last reviewed 10/26/11