The short answer
You file a complaint, also called a grievance, with your plan by phone or in writing, or by using the Medicare Complaint Form. File it within 60 days of the event. The plan must generally answer within 30 days, and within 24 hours for one kind of complaint.
You have been on hold three times, nobody has called back, and the specialist you were promised is still four weeks away. None of that is a coverage decision, so there is nothing to appeal. There is still something you can file.
How do I file a complaint about a Medicare plan?
You file it with your plan, using the Medicare Complaint Form or the instructions in your plan membership materials. A complaint, also called a grievance, is about the quality of your care or how the plan is treating you. Your plan's contact details are on your membership card.
Two words for one thing is the first hurdle. Medicare's own complaints page introduces grievance in brackets straight after the word complaint. They are the same filing.
The plan is the body that answers it. That is the part people find unsatisfying, and it is also the reason the deadlines below exist: the rules that bind the plan are what turn a complaint from a letter into a process with a clock on it.
Medicare's own examples of what belongs here are worth reading before you write anything. Customer service issues. Problems with access to a specialist. A problem with an appeal, meaning the way the appeal was handled rather than how it was decided.
That last example is the one that catches people, so it is worth separating carefully. If your appeal was decided against you, that is an appeal question. If your appeal was mishandled, ignored or delayed, that is a complaint. The same event can produce both.
What is the difference between a grievance and an appeal?
A grievance is about how you were treated. An appeal is about a decision on money or coverage. You file a complaint over the quality of your care or the way your plan handles you, and an appeal over a refusal to cover something or a bill you already paid.
Medicare draws the line in two short lists. File a complaint if you have a problem with the quality of the care you got or are getting, or a problem with how you are being treated by your plan.
File an appeal if you have an issue with a plan's refusal to cover a service, supply or prescription, or if you got a bill for a claim you already submitted.
The practical test is what you want to change. If you want a decision reversed, that is an appeal. If you want conduct addressed, that is a complaint. The two routes carry separate deadlines: 60 days from the event for a plan complaint, and 65 days from the date on the denial notice for a Medicare Advantage appeal.
Nothing stops you filing both, and the two run separately. A refusal handled rudely is a coverage decision and a service failure at the same time, and each route answers only its own half.
One more distinction sits underneath. An appeal has five levels above it and can end in a federal court. A complaint does not climb. What it has instead is a set of routes that go around your plan entirely, which is the last section of this page.
What can I complain about?
Medicare's own examples for a plan complaint are customer service problems, trouble getting access to a specialist, and problems with an appeal. Quality of care is a separate category with its own route, covering things like drug errors or being sent home from hospital in severe pain.
Quality of care is the larger category and the one with the most specific list. Medicare names five examples of it.
- Not getting treatment when you got abnormal test results
- Being sent home from the hospital when you are still in severe pain
- Being sent home from the hospital without clear instructions on how to maintain your care
- Drug errors
- Unnecessary or inappropriate surgeries or treatments
Those go to an outside reviewer rather than to your plan, and the reviewer is named in the last section of this page.
Then there are subjects that belong to neither your plan nor that reviewer. Nursing home care and facility conditions, unsafe conditions in a medical facility, hospital conditions such as housekeeping or room temperature, a doctor's licensing or professional conduct, dialysis and kidney care, durable medical equipment, and home health agencies each have their own destination.
The pattern underneath all of it is simple to state and easy to miss. The subject decides the route, not the size of the problem. Each destination has its own way in, and the plan route is the one with a form and a clock attached to it.
How do I file?
You file with the plan over the phone or in writing, within 60 days from the date of the event that led to the complaint. You can use the Medicare Complaint Form instead. Complaints can be filed anonymously, and a family member or friend can act as your representative.
The 60 days runs from the event, not from the point you gave up on getting it fixed informally. That is a different starting point from most Medicare deadlines, which run from a notice, and there is no letter to remind you it is running.
The phone option matters more here than it does in appeals. A plan complaint can be made verbally, where an Original Medicare appeal must be in writing, so the barrier to filing is lower.
Anonymity is available and it depends on the route. Medicare states that you can file a complaint anonymously, and that the method for doing so depends on which type of complaint you are filing, so the answer comes from whichever body you are filing with.
If someone is helping you, they can be made formal. A trusted family member or friend can be appointed as your representative, the same mechanism that exists on the appeals side.
How long does the plan have to respond?
Generally the plan must tell you its decision no later than 30 days after it gets the complaint. One kind of complaint runs on hours instead. If it is about the plan refusing to fast track a drug decision, and you have not got the drug, the answer is due in 24 hours.
The complaint that outruns the appeal. This is our reading rather than a rule any one page states, and three government facts produce it.
Medicare says a plan complaint is generally answered within 30 days. It says separately that where the complaint is about a refusal to make a fast coverage determination or redetermination, and you have not bought or got the drug, the plan must decide within 24 hours. CMS says separately again that an expedited drug appeal itself is decided within 72 hours.
So the slow route becomes the fastest thing on the page at the exact moment its subject is a refusal to hurry. Those three facts are the government's. Reading them as one is ours.
Here is what each complaint is answered on.
| What you are complaining about | Who must answer | Their deadline |
|---|---|---|
| Your plan's service or handling | Your plan | 30 days from getting the complaint |
| A refused fast decision on a drug | Your plan | 24 hours from getting the complaint |
| Equipment from a Medicare supplier | Your supplier | 14 calendar days, plus 5 to acknowledge |
The middle row is the one worth remembering, because it is the only place a grievance is measured in hours rather than days.
The equipment route has a shape of its own. Once you file, the supplier must let you know they got your complaint and are investigating it within 5 calendar days, then send you the result and their response in writing within 14 calendar days.
Who else can I contact?
Not every complaint goes to your plan. Quality of care goes to the Beneficiary and Family Centered Care Quality Improvement Organization for your state. Facility conditions go to your State Survey Agency, hospital conditions to your state health department, and a doctor's conduct to your state medical board.
The quality of care reviewer has a long name and two jobs, and knowing that saves confusion later. The Beneficiary and Family Centered Care Quality Improvement Organization reviews Medicare complaints about quality of care in any setting except dialysis facilities. The same organization also decides fast appeals when covered services are ending too soon, which is a different job under the same name.
It is administered for Medicare by Commence Health or by Acentra, depending on which state you live in, so checking which one covers your state is the first step rather than an afterthought.
The rest divide by place and profession. Nursing home care, facility conditions and unsafe conditions in a medical facility go to your State Survey Agency, which is usually part of your state's health department. Hospital conditions go to the state health department itself. Licensing questions and unprofessional conduct go to your state medical board.
Home health has its own two step route. You call the agency and ask for the administrator, and if that does not resolve it you call your state home health hotline, a number the agency should give you when your services begin.
Free help exists for all of it. Your State Health Insurance Assistance Program gives free, personalized counseling to people with Medicare, funded by the federal government and run by your state.
What this means for you
A complaint and an appeal answer different questions, and picking the wrong one costs you time you may not have. An appeal changes a decision. A complaint addresses conduct. If your appeal was decided against you, that is an appeal; if it was mishandled, that is a complaint.
The window is shorter than it looks, because it starts earlier than you expect. You have 60 days from the date of the event, not from the day you decided the plan was not going to fix it, and nothing arrives in the post to start the count.
Most complaints are answered in 30 days. One is answered in 24 hours: the complaint that your plan refused to make a fast decision on a drug you have not yet received. That single rule is faster than the expedited appeal it is about.
And your plan is only one of six destinations. Quality of care, facility conditions, hospital conditions, a doctor's conduct, equipment and home health each go somewhere else, and the subject decides the route rather than the seriousness.
For a decision you want reversed rather than conduct you want addressed, read this publication's article on how to appeal a Medicare denial. If you have already lost a first appeal, the article on the Medicare appeal levels sets out what is above it.
FAQ
Is a grievance the same thing as a complaint?
Yes. Medicare uses the two words for the same filing, and its own complaints page introduces the word grievance in brackets after the word complaint. You can file it with the plan over the phone or in writing, or use the Medicare Complaint Form instead, and your plan's contact details are generally on your membership card.
What separates a grievance from an appeal is not the word on the form but the subject. A grievance is about the quality of care you got, or the way your plan is treating you. An appeal is about a refusal to cover something, a refusal to pay, or a change to the amount you owe.
How long do I have to file, and when does the clock start?
You must file a complaint about your plan within 60 days from the date of the event that led to the complaint. That starting point is different from most Medicare deadlines and it catches people out. An appeal deadline runs from a notice, which is a piece of paper that arrives and can be looked at again.
A complaint deadline runs from the event itself, so the count begins on the day the thing happened rather than the day anyone wrote to you about it. Medicare states the rule as 60 days from the date of the event, and names no notice that starts the count.
Which complaint gets answered in 24 hours?
One, and it is narrow. If your complaint is about your plan refusing to make a fast coverage determination or a fast redetermination, and you have not yet bought or received the drug, the plan must give you a decision no later than 24 hours after it gets the complaint.
The same 24 hour rule applies to a health plan with drug coverage that refused a fast organization determination or reconsideration on the same terms. Everything else is generally 30 days. The condition about not having got the drug is doing real work in that sentence, so it is worth reading twice.
Can I complain without giving my name?
Yes. Medicare states that you can file a complaint anonymously, and that the method for filing anonymously depends on which type of complaint you are making, so the practical answer comes from whichever body you are filing with rather than from one central rule.
That is worth knowing where the complaint is about care you are still receiving. If you would rather be named but not do the work yourself, there is a second option: a trusted family member or friend can be appointed as your representative, which is the same formal mechanism used on the appeals side of the process.
Where does a complaint about quality of care go?
Not to your plan. Complaints about the quality of care you got from any provider in any setting, except dialysis facilities, go to the Beneficiary and Family Centered Care Quality Improvement Organization.
Medicare's examples include not getting treatment after abnormal test results, being sent home from hospital while still in severe pain or without clear instructions, drug errors, and unnecessary or inappropriate surgeries.
The organization is administered for Medicare by Commence Health or by Acentra depending on your state, so check which one covers yours. It also decides fast appeals about services ending, which is a separate job under the same name.
What if my complaint is about a nursing home, a hospital building, or my doctor?
Each has its own destination and none of them is your plan. Nursing home care and facility conditions, including abuse of a resident, understaffing or unsanitary conditions, go to your State Survey Agency, which is usually part of your state's health department. Improper care or unsafe conditions in a medical facility go to the same place.
Hospital conditions, such as poor housekeeping or rooms being too hot or cold, go to your state's health department directly. Licensing questions and unprofessional conduct by a doctor or health care provider go to your state medical board. Home health is different again and runs in two steps.
You call the home health agency and ask to speak to the administrator, and if you do not believe your complaint has been resolved you call your state home health hotline, a number the agency should give you when your home health services start.
