HMO Guide for Seniors - Office of the Patient Advocate - State of ...

58 If You Can’t Get the Care You Need
You and your Medicare HMO may not always agree about the
care you need. Your HMO may say that you do not need the
treatment or drug you want. Or your HMO may refuse to pay
for emergency care you got. If these things happen, talk to your
doctor and your HMO. If that doesn’t help, you can file an appeal
with your HMO. If your case is urgent, file an expedited appeal.
You can file an appeal if your HMO:
“My Medicare
HMO wouldn’t
pay for enough
physical therapy
after my stroke.
So I filed an
appeal with my
HMO. Now
I’m getting the
care I need.”
Refuses to give you treatment.
Delays your treatment too long.
Won’t pay for emergency or urgent care you got outside your area.
Won’t pay for medical care that you paid for yourself because you
couldn’t get the care you needed through your Medicare HMO.
Stops services you believe you still need.
Call HSAG to appeal a discharge. If your hospital, home health, or
nursing home care, or your care in a rehabilitation facility, is ending
too soon, call HSAG. The government contracts with HSAG to help
Medicare members with these problems.
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