Medicare 411 – Need to File A Complaint?

Medicare 411 – Need to File A Complaint?

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Ways to File Complaints Against Your Medicare Drug or Health Plan

Greg Dill
Courtesy: Medicare

Having practiced pharmacy for many years, I often find myself talking to people about their Medicare prescription drug, or Part D, plans.

People with Part D usually share their thoughts about a favorite pharmacy or pharmacist, or how their plan offers medicines at affordable prices. Sometimes, however, they report problems with a Part D plan, ranging from the cost of the drugs to the difficulty in getting a specific medication their doctor prescribed.

A first step in correcting problems is always to contact your drug plan (contact information is on the back of your drug card). A call to the plan will usually resolve your issue. If that doesn’t work, you can file a complaint.

You can do that by calling 1-800-MEDICARE or by going online at www.Medicare.gov. Complaints can be made against Part D drug plans as well as Part C health plans, also known as Medicare Advantage plans.

The online Medicare Complaint Form is easy to use. Medicare takes the information you send and directs it to your plan. We then follow up and monitor how well the plan resolves your complaint.

To find the complaint form, go to
www.Medicare.gov and locate the blue box titled “Claims & Appeals” near the top of the page. Place your cursor over that box until a dropdown menu appears and click on “file a complaint.” When the next page comes up, click on “Your health or drug plan.”

You can also lodge a complaint by calling or writing to your plan. Your complaint could involve a problem with customer service, difficulty in getting access to a specialist, being given the wrong drug or being given drugs that interact in a negative way.

If you file a complaint about your Part D drug plan, certain requirements apply:

• You must file your complaint within 60 days of the date of the event that led to your complaint.

• You must be notified of the decision generally no later than 30 days after the plan receives your complaint.

• If your complaint relates to a plan’s refusal to make a fast coverage determination or redetermination and you have not purchased or gotten the drug, the plan must give you a decision no later than 24 hours after it receives the complaint.

In addition, you can make a complaint if you have a concern about the quality of care or other services you receive from a Medicare provider. This includes doctors, hospitals or other medical providers; your dialysis or kidney transplant care; or a Medicare-certified supplier of durable medical equipment such as wheelchairs, walkers and oxygen equipment.

How you file a complaint depends on what your complaint is about. For more information, go to www.medicare.gov/claims-and-appeals/file-a-complaint/complaint.html.

As a Medicare beneficiary, you also have certain appeal rights. What is the difference between a complaint and an appeal?

A complaint is generally about the quality of care you received or are receiving. For example, you may file a complaint if you have a problem contacting your plan or if you are unhappy with how a staff person at the plan treated you. However, if you have an issue with a plan’s refusal to pay for a service, supply or prescription, you should file an appeal.

For more information on appeals, review your “Medicare & You” handbook, which is mailed each fall to every Medicare household in the country, or go online at www.medicare.gov/claims-and-appeals/file-an-appeal/appeals.html.

Greg Dill is Medicare’s regional administrator for Hawai‘i, California, Nevada, Arizona and the Pacific Territories. You can always get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).

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