Plan Information

Compliance & Member Protections

Troy Medicare is committed to regulatory compliance, ethical conduct, and protecting the rights of every member.

Commitment to Regulatory Compliance

Troy Medicare operates under a Medicare Advantage contract with the Centers for Medicare & Medicaid Services (CMS). We adhere to all applicable federal and state regulations governing Medicare Advantage plans, including requirements for benefits, network adequacy, quality improvement, and member protections. For a broader view of how Troy Medicare is organized and the values that guide its operations, visit the About Troy Medicare page.

Our compliance program is built on the seven elements required by CMS: written policies and procedures, a designated compliance officer, effective training and education, effective lines of communication, enforcement of well-publicized disciplinary standards, an effective system for routine monitoring and auditing, and procedures for ensuring prompt response to detected offenses.

We undergo regular internal and external audits to verify adherence to CMS guidelines, and our compliance team works closely with every department to ensure that operations, marketing, enrollment, claims processing, and member services all meet or exceed regulatory standards. Troy Medicare's care delivery approach is designed to align with these compliance standards at every level.

Member Rights & Protections

Troy Medicare members have the right to receive clear, accurate information about their coverage, benefits, and costs. This includes timely access to plan materials such as the Evidence of Coverage, Summary of Benefits, and Formulary — all written in plain language and available through the Documents & Forms page.

Members are protected by federal civil rights laws, and Troy Medicare does not discriminate on the basis of race, color, national origin, age, disability, or sex. Every member has the right to be treated with dignity and respect by plan staff and network providers, to access their medical records, and to participate in decisions about their care.

If you disagree with a coverage decision, you have the right to file an appeal. If you have a concern about the quality of care or service you received, you can use the Your Coverage Rights resources to understand the grievance process. Troy Medicare is required to respond within specific timeframes set by CMS, and expedited reviews are available for urgent situations.

Coverage Rights Non-Discrimination Notice

Fraud, Waste & Abuse Prevention

Troy Medicare maintains a comprehensive program to prevent, detect, and report fraud, waste, and abuse (FWA). Healthcare fraud — such as billing for services not provided, upcoding, or falsifying diagnoses — drives up costs for Medicare and can harm members. Waste includes overuse of services or other practices that result in unnecessary costs. Abuse involves practices that are inconsistent with accepted medical or business standards.

We educate our employees, contracted providers, and first-tier, downstream, and related entities (FDRs) on how to identify and report suspicious activity. All workforce members complete annual FWA training as required by CMS.

If you suspect fraud, waste, or abuse, you can report it confidentially by calling 1-888-494-TROY (8769), contacting our compliance hotline, or reporting directly to the HHS Office of Inspector General at 1-800-HHS-TIPS (1-800-447-8477). All reports are taken seriously, investigated promptly, and reporters are protected from retaliation.

To report suspected incidents of non-compliance and/or fraud, waste or abuse, you can contact Troy Medicare directly or anonymously:

Troy Ethics & Compliance Reporting Portal

Reporting & Contact Information

If you have concerns about compliance, fraud, potential violations of CMS rules, or your member rights, we encourage you to reach out. Troy Medicare takes every report seriously, investigates promptly, and ensures that no one faces retaliation for reporting a concern in good faith.

You may report concerns through any of the following channels: calling our member services line, submitting a written complaint, contacting our compliance officer directly, or using our confidential compliance and ethics hotline. For urgent coverage or care issues, expedited processes are available.

Brokers and agents should direct compliance-related questions through their designated broker support contacts or visit the For Brokers page. Providers may report concerns or request guidance through the For Providers page. All parties — members, providers, and brokers — can also reach Troy Medicare's compliance team by visiting the Contact Us page for additional routing options.

Phone: 1-888-494-TROY (8769) | TTY: 711

Email: compliance@troymedicare.com

Hours: Oct 1 – Mar 31: 8am – 8pm, 7 days a week | Apr 1 – Sep 30: 8am – 8pm, Mon – Fri

Governance & Oversight

Troy Medicare's compliance program is overseen by a designated Chief Compliance Officer (CCO) who reports directly to the Board of Directors and senior leadership. This reporting structure ensures that compliance matters receive the attention and authority necessary for effective resolution.

Our governance structure includes a Compliance Committee composed of cross-functional leaders who meet regularly to review audit findings, monitor corrective action plans, assess regulatory changes, and evaluate training effectiveness. The committee also reviews reports from our compliance hotline and ensures that identified issues are resolved promptly.

We participate in CMS quality improvement programs, conduct routine internal audits, and engage independent external auditors to verify that our operations, delegated entities, and provider network consistently meet or exceed the standards required of Medicare Advantage organizations.

For compliance inquiries, contact the compliance team at compliance@troymedicare.com.