Your Rights & Protections

The Right to Appeal Coverage Decisions

If your health plan denies coverage or refuses to pay a bill, you can appeal. Federal law gives you the right to challenge the decision through multiple levels of review.

Grievances vs. Appeals

You can complain about two different things. Grievances and appeals handle different kinds of problems:

Grievance	Appeal
A complaint about the quality or delivery of your care. Example: your doctor was rude, the wait was long, or the office lost your paperwork.	A formal challenge to a coverage or payment decision. Example: your plan denied coverage for a test or refused to pay a bill.
You can file anytime while you're a member, or up to one year after you leave.	You must file within a deadline, usually 60 days from when you get the denial (expedited appeals are faster).
The plan has 30 days to respond (or 24 hours if expedited).	Standard: up to 30 days. Expedited (fast-track): 24 hours if your health is at risk.

The Appeal Ladder

Most plans have multiple appeal levels:

Level 1: Plan Reconsideration. You ask your plan to review its decision. Call, mail, or go online to request this.
Level 2: External Review. If your plan says no again, you can ask an outside reviewer (someone not connected to the plan) to look at your case.
Level 3 and Beyond. In some cases, you can appeal to Medicare or your state Medicaid office.

Each level has a deadline—usually 30 days. If your health is in danger, you can request an expedited (fast-track) appeal, which may be decided in 24 hours.

For step-by-step instructions, see How Do I Appeal a Coverage Decision?

Coverage-Decision Timelines

Your plan must give you a decision on your claim within a certain time. The time depends on the type of service:

Standard decisions (routine care like a doctor visit or blood test): usually 30 days.
Expedited decisions (urgent or life-threatening situations): 24 hours.
Concurrent review (a decision about ongoing treatment you're already getting): usually 24 hours after you request.

If your plan misses the deadline, the service is often approved automatically. Keep copies of your request and any letters from your plan.

Advance Beneficiary Notice (ABN) in Original Medicare

If you have Original Medicare (not Medicare Advantage), your provider may ask you to sign a form before giving you a service. This form is called an Advance Beneficiary Notice (ABN).

The ABN warns you that Medicare might not pay for the service. You might have to pay for it yourself. Only sign an ABN if:

You understand what service you're getting and why.
You know Medicare might not cover it.
You agree to pay yourself if Medicare says no.

You do not have to sign an ABN. If you don't want to risk paying, you can skip the service or wait for Medicare to decide first. If a provider pressures you or uses a blank ABN, report it to Medicare at CMS.gov.

Non-Discrimination & Language Access

Health plans cannot treat you unfairly because of your race, color, national origin, sex, age, disability, sexual orientation, gender identity, or other protected status. This is federal law.

You have the right to:

Free interpreter services if English is not your main language. You can request an interpreter for doctor visits, phone calls, or appeals.
Translated materials in your language—plan documents, benefits summaries, rights notices, and appeal forms.
Accessible formats if you have a disability—large print, Braille, audio recordings, or other formats.

If a plan denies these services or treats you unfairly, you can file a complaint with your state insurance commissioner or CMS.

Privacy & HIPAA Rights

Your health information is private and protected by federal law, including the Health Insurance Portability and Accountability Act (HIPAA) (the law that protects your health information). Your plan cannot share your medical records without your permission (except for treatment, payment, or plan operations).

You have the right to:

Access your medical records. You can ask your plan and doctors for copies.
Request corrections if your health information has errors.
Know who has seen your records. You can ask for a list of who accessed your information.
Restrict how your information is used. You can ask for more privacy (though your plan may say no to some requests).
Get privacy notices. Your plan must explain how it uses and protects your information.

If you think your privacy rights were violated, file a complaint with the U.S. Department of Health and Human Services (HHS).

Right to Information

Your plan must give you clear information about your coverage and costs. This includes:

Summary of Benefits and Coverage (SBC). A one-page form that explains what's covered, what you pay, and your limits.
Plan documents (handbooks with full details on benefits, exclusions, and how to file claims).
Provider directory. A list of doctors, hospitals, and other providers in your plan's network.
Drug formulary. The list of prescription drugs your plan covers and their cost level (tier).
Explanation of Benefits (EOB). After you get care, you get an EOB showing what was billed, what your plan paid, and what you owe.

You also have the right to know why your plan made a decision. If they deny a claim or charge you something unexpected, they must explain in writing.

Protection from Surprise Bills

Federal law (the No Surprises Act) protects you from unexpectedly high bills. You cannot be charged extra when:

You get emergency care at an out-of-network hospital or emergency room.
An out-of-network doctor treats you during an in-network hospital stay (like an anesthesiologist you didn't pick).
Your in-network doctor sends you to an out-of-network specialist without warning you first.

In these cases, you pay only what you would normally pay. Your provider and plan work out the rest between themselves. For more information, visit CMS.gov or ask your plan.

Know Your Deadlines. Deadlines are different depending on your program and situation. Always check your plan documents or call member services to confirm your deadline. Missing a deadline can mean you lose your right to appeal.

Fraud Protection

Fraud happens when someone steals from Medicare or Medicaid. This could be a provider billing for services they didn't give, someone using your card, or other scams. Fraud can lead to delays in your care, wrong bills, or stolen money.

Watch out for fraud:

Unexpected phone calls or emails asking for your Medicare or Medicaid number.
Charges on your bill for services you never got.
Providers offering free gifts or services for your card number.
Medical equipment showing up without your doctor's order.

Report fraud:

Medicare fraud: Call 1-800-MEDICARE (1-800-633-4227) or go to Medicare.gov.
Medicaid fraud: Contact your state Medicaid office or your state's fraud hotline (check your Medicaid card).
General fraud: Report to the HHS Office of Inspector General at OIG.hhs.gov.

The best defense is to guard your card and information. Never give your Medicare or Medicaid number to anyone except your doctor, pharmacy, or hospital.

If Your Rights Are Violated

If you think a plan or provider treated you unfairly, you can:

File a complaint with your plan.
Call your State Health Insurance Assistance Program (SHIP) for free help.
File a complaint with your state insurance commissioner.
Report to CMS if your plan is breaking federal rules.

Verify with Official Sources. Your specific rights and deadlines depend on your program (Medicare Original, Medicare Advantage, Medicaid, or CHIP), your state, and your plan. This page gives general information. Always check your official plan documents or call member services for your details. If you need help understanding your rights, contact your State Health Insurance Assistance Program (SHIP) or your state Medicaid office—these are free.