What Is the Medicare Beneficiary Ombudsman?
An ombudsman is a person who reviews how an organization operates, investigates complaints, and helps resolve those complaints. They typically work as a client advocate within an organization or business. The MBO serves this function within the Medicare program.
Learn more about the services the MBO provides and how to connect.
What is the role of a Medicare beneficiary ombudsman?
Congress formed the MBO role in 2003. The person in this role assists Medicare enrollees in various areas, including handling complaints, appeals, and requests for information.
The general duties of the MBO, as outlined in section 1808 of the Social Security Act, are to:
receive and help resolve complaints and inquiries that Medicare beneficiaries and other stakeholders make
work with representatives of health insurance counseling programs to provide information and resources to beneficiaries
report to Congress on ways to improve the administration of Medicare
In addition to addressing complaints, some of the specific issues enrollees may have to address with an MBO include:
Appeals: If you disagree with a Medicare payment or coverage determination, you can file an appeal. The MBO can assist you with this process.
Enrollment concerns: If you have issues when leaving a Medicare Advantage (Part C) plan or joining a new plan, the MBO can assist you.
Claims: If you need to file a Medicare claim, the MBO can help you through the process or troubleshoot issues that arise.
What are a beneficiary's rights under Medicare?
As a Medicare beneficiary, you have various clearly outlined rights and protections. The MBO exists to help preserve those rights and ensure fair treatment of all Medicare beneficiaries.
It can be helpful for Medicare enrollees to periodically review their rights to understand what types of treatment and services they can expect.
A Medicare beneficiary's rights include:
fair and courteous treatment
privacy of personal and health information
access to appropriate healthcare professionals for medically necessary services
clear, understandable information access regarding coverage, plan options, costs, and more
Medicare designs its protections to keep beneficiaries up to date on coverage status and prevent unexpected costs. They come into play when Medicare may not cover a service, or you reach the end of Medicare coverage.
A beneficiary's protections include:
receiving an Advance Beneficiary Notice (ABN) of Noncoverage for any services that Medicare doesn't cover
getting a Notice of Medicare Noncoverage at least 2 days before covered home health services end
acquiring a Hospital-Issued Notice of Noncoverage (HINN) for inpatient services that Medicare Part A doesn't cover
If you've experienced violations of your rights or protections or have an issue with Medicare noncoverage, you can contact the MBO for assistance.
How to contact a Medicare beneficiary ombudsman
Not all Medicare-related questions should go directly to the MBO. Other contact points may be more suitable based on your coverage and the nature of your question or concern.
If you're a Medicare Advantage or Part D enrollee, contact your insurance carrier with any questions or complaints about your plan. You can generally find contact information for the plan on the back of your insurance card.
If you have questions about Original Medicare or need help with issues that a private insurance carrier can't address, you can contact Medicare by phone at 800-633-4227.
If you have general questions or would like free, unbiased Medicare counseling, you can contact your local State Health Insurance Assistance Program (SHIP).
Finally, if you have questions that the channels above can't resolve, you can direct your query to the MBO. You can do so by contacting Medicare by phone at 800-633-4227 and requesting your case's submission to the MBO.
Summary
The MBO has a role within the Medicare program to provide customer service and advocacy.
The MBO can assist Medicare beneficiaries with resolving complaints and accessing important information. They also work to improve Medicare's administration by submitting an annual report to Congress on its operation.
If you have a concern requiring the MBO's attention, you can contact Medicare by phone and explain the situation.
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