File a complaint about a Medicare health or drug plan

Use an appeal for coverage or payment disputes

A grievance does not replace an appeal. If the plan refuses to cover or pay for care, an item, a service, or a prescription drug, follow the appeal instructions in the denial notice. You may file both when a coverage decision and the way the plan handled the matter create separate problems.

1. Confirm that the issue is a plan complaint

A Medicare plan grievance can address customer service, difficulty getting an appointment, long waits, disrespectful behavior, access to a specialist, confusing notices, quality of care, or a problem with how the plan handled an appeal. It generally does not decide whether a medical service or prescription drug should be covered.

2. Choose the correct complaint channel

For a Medicare Advantage plan, Medicare Cost Plan, or Medicare drug plan, follow the grievance instructions in the Evidence of Coverage or other membership materials. You may also use the official Medicare Complaint Form for a complaint about a Medicare health or drug plan. The plan contact information is usually on the membership card.

A quality-of-care concern may be filed through the plan, with the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) serving your state, or with both. Complaints about a nursing home, facility conditions, professional licensing, or another provider may use a different state or federal channel; use Medicare’s complaint directory to identify it.

3. File within the grievance deadline

CMS states that a plan grievance generally must be filed orally or in writing no later than 60 calendar days after the event or incident that caused the complaint. Do not wait for an unrelated appeal to finish if the grievance deadline is running.

4. Describe the problem clearly

Your name, Medicare number, and plan member information.
The date, location, and people or departments involved.
A concise description of what happened and why you are dissatisfied.
Copies of letters, messages, call notes, receipts, or other records that support the complaint.
The result you are requesting, such as an explanation, corrected communication, access assistance, or investigation.
Representative information and proof of authority when another person is filing for you.

Send only the information needed for the plan to identify and investigate the matter. Keep a copy of everything submitted and proof of the submission date.

5. Identify whether the 24-hour grievance rule applies

Most grievances use the standard timeframe. A Medicare Advantage plan must respond within 24 hours when the grievance challenges the plan’s decision to extend the timeframe for an organization determination or reconsideration, or its refusal to grant an expedited organization determination or reconsideration.

For Part D, the 24-hour rule applies when the grievance challenges the plan’s refusal to expedite a coverage determination or redetermination and the enrollee has not yet purchased or received the disputed drug. These narrow expedited-grievance rules are different from simply asking the plan to resolve any urgent complaint faster.

6. Track the plan’s response

The plan must resolve a standard grievance as quickly as the enrollee’s health requires and generally no later than 30 calendar days after receipt. The plan may extend the timeframe by up to 14 calendar days when the extension is in the enrollee’s best interest. Keep any extension notice and record the new response date.

7. Get help if the complaint is not resolved

If the plan does not address the grievance, contact 1-800-MEDICARE or use the complaint form. A State Health Insurance Assistance Program (SHIP) can provide free Medicare counseling. Continue any separate coverage appeal because a complaint normally does not reverse a denial by itself.