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Medicare Complaints

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Medicare has different procedures for different kinds of problems.

For help, you can always call HICAP (the California Department of Aging's Health Insurance Counseling and Advocacy Program) at 1-800-434-0222

 

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Help for Medicare problems and complaints

Medicare can be complicated, but there are people who can help you.

  • California's HICAP program provides free help with many kinds of Medicare questions and problems. HICAP is the Health Insurance Counseling and Advocacy Program. You can make an appointment to meet with a HICAP Counselor in your area. Call 1-800-434-0222 or visit www.aging.ca.gov/hicap.
  • You can also call the federal Medicare program for general questions or help with billing problems, at 1-800-MEDICARE (1-800-633-4227). If needed, they can refer you to the Medicare Beneficiary Ombudsman for help with a complaint or appeal.
  • For more information on how to file a Medicare grievance or appeal, visit www.medicare.gov and www.hsag.com.

 

Original Medicare appeals

  • You can file an appeal if Medicare does not pay for a service you need. Ask your doctor for a letter of support.
  • Every 3 months, you should receive a Medicare Summary Notice. The back of this notice tells you how to file an appeal. To learn more, call 1-800-MEDICARE or visit www.medicare.gov/claims-and-appeals/index.html.
  • For help with an appeal, call HICAP at 1-800-434-0222.

 

Medicare Advantage appeals  

All Medicare Advantage plans have a customer service office you can call for help. Look on your plan's membership card for the phone number.

  • If your plan denies a service you need, start by filing an appeal with your plan. Your plan must reply in 7 days. If your problem is urgent, file an expedited appeal. Your plan must reply in 72 hours.
  • If your plan says it will not pay your bill, you have 60 days to file an appeal with your plan. The plan has 60 days to respond to your appeal.
  • Ask a doctor to help you tell the plan why you need the care. The doctor does not have to be a part of your plan.
  • For help with an appeal, call HICAP at 1-800-434-0222.

 

If you can't get a drug you need

If your Medicare prescription drug plan does not cover a drug you need:

  • You or your doctor can call your plan and ask it to cover the drug. Your plan must reply in 72 hours.
  • If you need the drug urgently, your doctor can ask for an expedited, or fast review. Your plan must call you with a decision in 24 hours.

 

If your hospital, home health, nursing home, or rehab care is ending

If you are receiving one of these services and it is ending too soon, call the Health Care Advisory Group (HSAG) at 1-800-841-1602. The federal government contacts with HSAG to help Medicare members in California. 

  • If you dispute a hospital discharge by calling HSAG, you will be able to remain in the hospital at no charge while your case is being reviewed. 

 

If you get poor quality care

You can call HSAG at 1-866-800-8749 about problems with the quality of your care. For example:

  • You got the wrong medicine.
  • You had unnecessary surgery or diagnostic testing.
  • You had a delay in getting a service.
  • You received poor care or treatment.

If you have Medicare Advantage, you can start by talking to your plan's customer service office before calling HSAG. Tell your plan that you want to file a grievance. You can ask them to send you a grievance form. Fill out the form and mail it back.

  • Your plan must take action within 30 days after it gets your grievance form.
  • If your plan still will not help or does not reply within the time limit, call HSAG.

 

Resources

Medicare.gov Claims and Appeals webpage

Health Plan Problems?

For HMOs  888-466-2219
For PPOs   800-927-4357

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