Beneficiary Protections

BENEFICIARY PROTECTIONS OF MEDICARE ADVANTAGE PLANS

Medicare Advantage Plans: Beneficiary Protections

Guaranteed Issue: The plan must enroll you if you meet the requirements.
Care must be available 24 hours per day, seven days a week.
You must have access to specialists.
Doctors must be allowed to inform you of all treatment options.
The plan must have a grievance and appeal procedure.
If a layperson would think that a symptom could be an emergency, then the plan must pay for the emergency treatment.

Medicare Advantage Managed Care Plans: Beneficiary Protections

The plan cannot charge more than a $50 copayment for visits to the emergency room.
You or your doctor can appeal a denial of service and the appeal must be handled in a "timely" way. The plan must make an initial determination within 14 days. Reconsideration of a decision must be made within 30 days. Decisions regarding urgent care must be made within 72 hours.
The plan must have a process for identifying and evaluating persons with complex or serious medical conditions. A treatment plan must be developed within 90 days of your enrollment.
If your treatment plan includes specialists, you must have direct access to those specialists. You do not need a referral from your primary care physician.