How to file complaint against Medicare drug or health plan

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 they report problems with a Part D plan, ranging from the cost of drugs to difficulty in getting a specific medication their doctor prescribed.

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

You can do that by calling 1-800-MEDICARE or 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. Then we 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 near the top of the page that says “Claims & Appeals.” 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 from the date of the event that led to the complaint.

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

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

In addition, you can make a complaint if you have a concern about the quality of care or other services you get 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’s the difference between a complaint and an appeal?

A complaint is generally about the quality of care you got or are getting. For example, you may file a complaint if you have a problem contacting your plan or if you’re 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 file an appeal.

For more information on appeals, take a look at your “Medicare & You” handbook, 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 Arizona, California, Hawaii, Nevada, and the Pacific Territories. You can always get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).