Here is an article by David Sayen, Medicare’s regional administrator for Arizona, California, Hawaii, and Nevada.

As a person with Medicare, you have certain rights and protections. And it’s worth knowing what they are.

You have rights whether you’re enrolled in Original Medicare – in which you can choose any doctor or hospital that accepts Medicare – or Medicare Advantage, in which you get care within a network of health care providers. Such networks are run by private companies approved by Medicare.

Your rights guarantee that you get the health services the law says you can get, protect you against unethical practices, and ensure the privacy of your personal and medical information. You have the right to be treated with dignity and respect at all times, and to be protected from discrimination.

You also have the right to get information in a way you understand from Medicare, your health care providers, and, under certain circumstances, Medicare contractors. This includes information about what Medicare covers, what it pays, how much you have to pay, and how to file a complaint or appeal. Moreover, you’re entitled to learn about your treatment choices in clear language that you can understand, and to participate in treatment decisions.

One very important right is to get emergency care when and where you need it — anywhere in the United States.

If you have Medicare Advantage, your plan materials describe how to get emergency care. You don’t need permission from your primary-care doctor (the doctor you see 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, or co-payment. Then your plan will pay its share.

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

In fact, whenever a claim is filed for your care, you’ll get a notice from Medicare or your Medicare Advantage plan letting you know what will and won’t be covered. If you disagree with the decision, you have the right to appeal.

For more information on appeals, you can read our booklet “Medicare Appeals,” available at www.medicare.gov/Publications. Or call us, toll free, at 1-800-MEDICARE.

You can also file a complaint about services you got from a hospital or other provider. If you’re concerned about the quality of the care you’re getting, call the Quality Improvement Organization (QIO) in your state to file a complaint. A QIO is a group of doctors and other health care experts who check on and improve the care given to people with Medicare. You can get your QIO’s phone number at
www.medicare.gov/contacts or by calling 1-800-MEDICARE.

Many people with Original Medicare also enroll in Medicare prescription drug plans. Here, too, you have certain rights.

For example, if your pharmacist tells you that your drug 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.

If the decision isn’t in your favor, you can appeal.

You can ask for an exception if you, your doctor, or your pharmacist believe you need a drug that isn’t on your drug plan’s list of covered medications, also known as a formulary.

You don’t need a lawyer to appeal in most cases, and filing an appeal is free. You won’t be penalized in any way for challenging a decision by Medicare or your health or drug plan. And many people who file appeals wind up with a favorable outcome.

This is a brief overview of your Medicare rights. For more details, read our booklet, “Medicare Rights and Protections,” at http://www.medicare.gov/Publications/Pubs/pdf/11534.pdf.

David Sayen is Medicare’s regional administrator for Arizona, California, Hawaii, and Nevada. You can always get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).

Donna got her Medicare card in January, and it said her coverage would begin on April 1st, 2012. She enrolled in a Medicare Advantage plan, saw her doctors, and had her prescriptions filled under Part D.  On July 5th, she received a letter from her Advantage plan saying Medicare informed them that Donna does not have Medicare coverage.  What???

Donna got Social Security Disability back in March of 2010 and had to wait two years to get Medicare. That’s the rule. A person gets Medicare the 25th month after their Social Security Disability payments begin. Fortunately for Donna, she and her husband had health insurance, and they continued it until Donna got Medicare. As of April 1st, Donna dropped her health insurance and moved over to Medicare.

After getting the shocking letter from her Advantage plan, Donna called Medicare to ask what the heck was going on.  She was told something along the lines of, “Oops, we made a mistake”.

According to Medicare, Donna’s start date should not have been April 1st, so they changed her record and canceled her Medicare Advantage plan. They told her she doesn’t get Medicare until March 2013 because they found in their records that they had made a mistake calculating when her disability status began. What???

Apparently, Donna has not had any health insurance since April 1st. Apparently, her medical and drug bills may not be covered for the last four months. And apparently, Medicare doesn’t give a hoot about Donna’s dilemma.  Donna was told she can appeal this decision, but nobody could tell her how long that would take.

In fact, Donna has letters from Social Security from 2010, telling her she was awarded disability benefits as of March that year. In fact, the letters state that her disability was effective as of October 2009 and she would get back payments that were due to her from the period of October 2009 up to March 2010. In fact, she received those payments. Apparently, Medicare now wants that money back. What???

Donna is in shock – and she should be. She dropped her health insurance four months ago and cannot get it back. Given her health condition, she is probably uninsurable.  Medicare made a mistake and Donna has a big problem – and Medicare does not care that their mistake (if there was a mistake) has left Donna at risk of running up huge medical bills if she gets sick or injured and has no health insurance. How can this be???

I told Donna to contact Congressman Ron Barber’s office to ask for help. There is someone on his staff who deals with Medicare and Social Security problems all the time. That person can help Donna – but I don’t know how quickly he can get her problem resolved. In the meantime, what does she do? She can apply for health insurance and see if she gets accepted and at what cost. But how long will it take to get her application processed if the insurance company needs to review her medical records? And of course, it is highly likely that she will be denied coverage due to her pre-existing condition.

This is an amazing and shocking story. I sure hope it gets resolved quickly.