Medicare HMO
What if your Medicare HMO does not approve care you need?
1. Ask the Medicare HMO for a letter explaining why your request was not approved.
Tip: You do not need a reason to get this information in writing. You have a right to it. If anyone at your Medicare HMO asks you why you want the information in writing, tell them Medicare says you have a right to it.
2. If you disagree with a Medicare HMO's decision to deny you care, you have a right to ask the HMO to reconsider it.
Tip: Even if the HMO does not give you a letter in writing saying why they denied you care, you still have a right to ask them to reconsider their decision.
If you receive a letter from the HMO saying why they denied you care, you have 60 days to request a reconsideration. If the HMO fails to give you something in writing, there is no time limit.
3. Make your request for reconsideration in writing and keep a copy of it for your records.
Tip: When you ask the HMO to reconsider its decision, this is called an appeal. Don't let this word appeal put you off or stop you from taking care of yourself. If you appeal you are not questioning your doctor. You are appealing the denial by the HMO. (Remember, the HMO is like an insurance company and it tries to keep costs low.) Asking for a reconsideration should in no way harm your HMO coverage or your relationship with you doctor.
NOTE: HMOs also have "grievance procedures," which are different from an "appeal." You can use grievance procedures for internal HMO matters, such as problems with HMO staff or appointment waiting time.