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Your Medicare Rights and Protections
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Your Medicare Rights and Protections
03-27-08 2
Session Topics
OverviewRights in Original MedicareHospital, SNF, and home health carePrivacy practices in Original MedicareMedicare AdvantageMedicare prescription drug coverageMore information
03-27-08 3
Session Topics
OverviewRights in Original MedicareHospital, Skilled Nursing Facility (SNF),
and home health carePrivacy practices in Original MedicareMedicare AdvantageMedicare prescription drug coverageMore information
03-27-08 4
Medicare Patients’ Rights
You have guaranteed rights inOriginal MedicareMedicare AdvantageMedicare Prescription Drug
These rightsProtect you when you get health careMake sure you get health care services the law
says you can getProtect you against unethical practicesProtect your privacy
Overview
03-27-08 5
You Have the Right to …
Be treated with dignity and respectBe protected from discriminationGet information you can understand Get answers to your Medicare questionsGet culturally competent services Get emergency care
When you need itWhere you need it
Overview
03-27-08 6
You Have the Right to …
Learn about your treatment choicesIn clear understandable language
File a complaintAppeal denial of a treatment or paymentHave personal information kept privateKnow your privacy rights
Overview
03-27-08 7
Right to Emergency Care
You think your health is in serious dangerWhen every second counts
When and where you need itWithout an OK from your health planAnywhere in the United States
Overview
03-27-08 8
Urgently Needed Care
For a sudden illness or injuryMedical care needed right awayNot a serious threat to health
In a Medicare Advantage PlanIn service area
• Network providers generally provide careOut of service area
• Plan must pay
Overview
03-27-08 9
Right to Non-Discrimination
Cannot be treated unfairly because ofRace, color, national originDisabilityAgeReligionSex
• Generally limited to complaints against providers
Call Office for Civil Rights in your state
Overview
03-27-08 10
Complaints
Two kinds of complaintsAppealsGrievances
You can file an appeal if you believeMedicare should have paid but didn’tMedicare didn’t pay enoughYou were denied a needed service
• In a Medicare Advantage Plan
Overview
03-27-08 11
Grievances
Complaints of dissatisfactionPlan’s operationsProvider’s operations
Any problems with health plan or provider Examples
Problems with waiting time for appointmentsHow your doctor and others behaveCleanliness or conditions of doctor’s officeQuality of care
Overview
03-27-08 12
Session Topics
OverviewRights in Original MedicareHospital, SNF, and home health carePrivacy practices in Original MedicareMedicare AdvantageMedicare prescription drug coverageMore information
03-27-08 13
Rights Under Original MedicareAdditional rights and protections
Access to doctors, specialists, hospitalsTimely information on Medicare paymentFair and efficient appeals processesGeneral appeal rightsRights to buy a Medigap policyPrivacy practices notices for Original Medicare
Original Medicare
03-27-08 14
Appeal in Original MedicareAsk doctor or provider for information that
might help your caseAppeal rights are on back of Medicare
Summary NoticeNotice will tell you
• Why Medicare didn't pay
• How to appeal
• How long you have to appeal
Original Medicare
03-27-08 15
Appeal Levels in Original Medicare
RedeterminationReconsiderationAdministrative Law JudgeMedicare Appeals CouncilU.S. District Court Review
Original Medicare
03-27-08 16
Protection from Unexpected BillsWhen Medicare might not pay for a service
Provider gives you written notice • Advance Beneficiary Notice
• Used in Original Medicare
• Not required for non-covered services – Excluded under Medicare law
• Will ask you to sign agreement to pay
Original Medicare
03-27-08 17
Advance Beneficiary Notices1) Advance Beneficiary Notice-General
(ABN-G)
2) Advance Beneficiary Notice-Laboratory
(ABN-L)
3) Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) Or denial letter
Original Medicare
03-27-08 18
Advance Beneficiary Notices4) Home Health Advance Beneficiary Notice
(HHABN)
5) Hospital-Issued Notice of Non-coverage (HINN)
Original Medicare
03-27-08 19
Medigap Rights and Protections
Right to buy a Medigap policyMedigap open enrollment periodGuaranteed issue rights
• Can’t deny you Medigap coverage or place conditions on coverage
• Must cover you for all pre-existing conditions
• Can’t charge you more because of past or present health problems
Original Medicare
03-27-08 20
Session Topics
OverviewRights in Original MedicareHospital, SNF, home health carePrivacy practices in Original MedicareMedicare AdvantageMedicare prescription drug coverageMore information
03-27-08 21
Right to Hospital Care
You have the right to get all the hospital care you need
Your right in all Medicare health plansExplained in Important Message From
Medicare
Hospital, SNF, HH
03-27-08 22
Important Message from Medicare
Tells youYour right to get hospital care you needYour right to get follow-up careWhat to do if hospital is making you leave too
soonYour appeal rightsWhat you may have to pay
Hospital, SNF, HH
03-27-08 23
Right to Hospital CareImportant Message from Medicare (IM)Follow-up copy of IM delivered If hospital is making you leave too soon
Call your state Quality Improvement Organization (QIO)
QIO reviews for all people with MedicareHospital cannot force you to leave before
QIO makes its decision
Hospital, SNF, HH
03-27-08 24
Rights in a Skilled Nursing Facility
Should receive a written noticeFacility believes Medicare won’t payYou will be liable for remainder of stayNotice will inform you of rightsCoverage ends day after you get notice
Hospital, SNF, HH
03-27-08 25
Home Health RightsYour plan of care
Can only be changed by your doctorYou must be told of changes in writing
Agency must provide Home Health Advance Beneficiary Notice When it denies or reduces care
You may receive a fast appeal noticeIn some cases when all home care ends
Hospital, SNF, HH
03-27-08 26
Original Medicare Fast AppealEffective July 1, 2005People in certain care settings have right to
request expedited (fast) appealsProvider must give notice of your rights
Explains your right to independent reviewer (QIO)
Hospital, SNF, HH
03-27-08 27
Original Medicare Fast AppealYou must get advance notice
Usually no later than 2 days before end of covered services
If you disagreeFile request with state QIO
• No later than noon of the calendar day following receipt of notice
Hospital, SNF, HH
03-27-08 28
Original Medicare Fast AppealQIO must notify provider immediately Provider must give you detailed notice
Usually by close of business same day QIO notifies the provider
Determination by QIONo later than 72 hours after receipt of request
for expedited determination
Hospital, SNF, HH
03-27-08 29
MA Fast-Track Appeals Process Your right when services are ending too soon
Skilled nursing facilityHome health agencyComprehensive outpatient rehabilitation facility
Provider or plan must give Notice of Medicare Non-coverage (NOMNC)At least 2 days before services end
Plan must give Detailed Explanation of Non-coverage Decision from QIO within 2 days
Hospital, SNF, HH
03-27-08
Exercise
30
1. No matter how you have chosen to get your Medicare benefits you can get emergency care anywhere in the
United StatesA. True
B. False
03-27-08
Exercise
31
2. Your appeal rights listed on the back of the Medicare Summary Notice (MSN) include:
A. Information about why Medicare didn’t pay your bill
B. How you can appeal
C. The time limit for filing your appeal
D. All of the above
03-27-08
Exercise
32
3. An insurance company can refuse to issue you a Medigap policy when you are in your Open Enrollment Period
A. True
B. False
03-27-08
Exercise
33
4. If you think you are being made to leave the hospital too soon, you should call the Quality Improvement Organization for your state
A. True
B. False
03-27-08 34
Session Topics
OverviewOriginal MedicareHospital, SNF, and home health carePrivacy practices in Original MedicareMedicare AdvantageMedicare prescription drug coverageMore information
03-27-08 35
Notice of Privacy Practices Tells you
That Medicare is required to protect the privacy of your personal medical information
How Medicare uses and discloses your personal medical information
Your rights and how to exercise them Published annually in Medicare & You handbook For more information
www.medicare.gov1-800-MEDICARE (1-800-633-4227)
• TTY users call 1-877-486-2048
Privacy Rights—Original Medicare
03-27-08 36
Required DisclosuresMedicare must disclose your personal
medical informationTo youTo someone with the legal right to act for youTo the Secretary of Health & Human ServicesWhen required by law
Privacy Rights—Original Medicare
03-27-08 37
Permitted Disclosures Medicare discloses your personal medical
informationTo pay for your health care andTo operate the program
ExamplesTo Medicare contractors to process your claimsTo ensure you get quality health careTo provide you with customer serviceTo resolve your complaints
Privacy Rights—Original Medicare
03-27-08 38
Other Permitted DisclosuresMedicare may disclose your personal
medical informationTo state and Federal agenciesFor public health activitiesFor government oversightFor judicial proceedingsFor law enforcement purposesFor research studiesTo avoid a serious threat to health and safety
Privacy Rights—Original Medicare
03-27-08 39
Additional Privacy Rights and Protections
Medicare needs your written permission (authorization)For any disclosures not required or permitted
You may take back (revoke) your permission at any time
Privacy Rights—Original Medicare
03-27-08 40
You Have the Right to … See and copy your personal medical information Correct any medical information you believe is
wrong or incomplete Know who your medical information was sent to Communicate in a different manner Ask Medicare to limit the use of your medical
information to pay your claims and run the program Get a written privacy notice
Privacy Rights—Original Medicare
03-27-08 41
If You Believe Your Privacy Rights Were Violated
You may file a complaintCall 1-800-MEDICARE (1-800-633-4227)
TTY users should call 1-877-486-2048 orContact HHS Office for Civil Rights
• Visit www.hhs.gov/ocr/hipaa or• Call 1-866-627-7748. TTY users should call
1-800-537-7697.
Will not affect your Medicare benefits
Privacy Rights—Original Medicare
03-27-08 42
Session Topics
OverviewRights in Original MedicareHospital, SNF, and home health carePrivacy practices in Original MedicareMedicare AdvantageMedicare prescription drug coverageMore information
03-27-08 43
Rights in MA or Other Medicare Plan
Additional rights and protectionsChoice of health care providersAccess to health care providersKnow how your doctors are paidFair, efficient, and timely appeals processFast appeals in certain health care settings
Medicare Advantage
03-27-08 44
Rights in MA or Other Medicare Plan
Additional rights and protectionsFile a grievance about other concerns and
problemsFast appeals Call your plan for informationPrivacy of your personal health informationFor PACE rights and Protections visit
cms.hhs.gov/pace/downloads/prtemp.pdf
Medicare Advantage
03-27-08 45
Appeals in Medicare Advantage
PlanWill not pay for a serviceDoes not allow a serviceStops a service
Can ask for fast (expedited) decisionPlan must decide within 72 hours
See plan’s membership materials
Medicare Advantage
Must tell you in writing how to appeal
03-27-08 46
MA Appeal Process
Plan ReconsiderationIndependent Review Entity Administrative Law JudgeMedicare Appeals CouncilJudicial Review
Medicare Advantage
03-27-08 47
Special Rights
If you file an appealYou have right to plan’s files about you
• Your case file
Plan may charge you a reasonable fee• For copying and mailing
Medicare Advantage
03-27-08 48
To Get Your Case File
Call or write your planFor case file sent to Independent Review
Entity (IRE)Contact MAXIMUS Federal Services, Inc.
• Call 585-425-5210• Write
MAXIMUS Federal Services, Inc. Medicare Managed Care & PACE Reconsideration Project
Victor, NY 14564-1099
Medicare Advantage
03-27-08 49
Session Topics
OverviewRights in Original MedicareHospital, SNF, and home health carePrivacy practices in Original MedicareMedicare AdvantageMedicare prescription drug coverageMore information
03-27-08 50
Drug Plan Sponsors
Must have proceduresFor standard and expedited
• Coverage determinations
• Appeals
• Grievances
Medicare Prescription Drug Coverage
03-27-08 51
Drug Plan Sponsors
Must give you written informationGrievance procedureCoverage determination and appeals
• Including right to expedited reviewQuality of care complaint process
Medicare Prescription Drug Coverage
03-27-08 52
Access to Covered Drugs
Plans May not cover all Medicare-covered drugsMust ensure enrollees can get drugs they need
for their conditionsMust include more than one drug in each
classificationMust pay for brand-name as well as generic
drugsMay have rules for managing access
Medicare Prescription Drug Coverage
03-27-08 53
“All or Substantially All”
Plans must cover most drugs to treat certain conditionsCancer medicationsHIV/AIDS treatmentsAntidepressantsAntipsychotic medicationsAnticonvulsive treatments
• For epilepsy and other conditionsImmunosuppressants
Medicare Prescription Drug Coverage
03-27-08 54
Transition Supply
Plans must fill prescriptions not on plan’s list For new enrolleesFor residents of long-term care facilities
Immediate supply provided to new enrolleeFill one-time, 30-day supply of current prescription
While using transition supplyWork with doctor to switch to drug on plan’s listIf medically necessary, request an exception
Medicare Prescription Drug Coverage
03-27-08 55
Plan Ahead
Don’t wait until transition supply is goneTalk with your doctor about
Prior authorizationSwitching to covered drugAsking for an exception if medically necessary
Contact the drug plan with questions
Medicare Prescription Drug Coverage
03-27-08 56
Requesting an Exception
Can request an exceptionDrugs not on plan’s formularyDrug with special coverage rules
Contact the planHow to submit requestWhat information to submit Prescribing doctor
• Must submit supporting statement • Must indicate drug is “medically necessary”
Medicare Prescription Drug Coverage
03-27-08 57
Requesting an Exception
After receiving physician’s statementPlan must notify you
• As quickly as your condition requires
• Within 24 hours (expedited) or
• Within 72 hours (standard)
Medicare Prescription Drug Coverage
03-27-08 58
Tiering Exception
Gives access to non-preferred drugAt lower cost of drugs in the preferred tierIf preferred drug
• Would not be as effective
• Would have adverse effects
Medicare Prescription Drug Coverage
03-27-08 59
Formulary Exception
Gives access to drugsNot on plan’s formularyFor which plan has special coverage rules
Plan determines level of cost sharing
Medicare Prescription Drug Coverage
03-27-08 60
Approved Exceptions
Valid for remainder of plan year, as long asYou remain enrolled in planPhysician continues to prescribe drugDrug remains safe for treating your condition
Plan will notify of drug coverageFor following yearAt time of approvalAt the end of plan year
Medicare Prescription Drug Coverage
03-27-08 61
Appeals
Can appeal unfavorable exception decision Five levels of appeal
First level is appeal to the plan
Will receive information upon enrollment Expedited appeals take only a few days An appointed representative may appeal Generally must be made in writing
Medicare Prescription Drug Coverage
03-27-08 62
Levels of Appeal
Appeal to the planIndependent review entity reconsiderationAdministrative law judge hearingMedicare Appeals CouncilU.S. district court review
Medicare Prescription Drug Coverage
03-27-08 63
Required Notices
After every Adverse coverage determinationAdverse appeal determination
Include information on next appeal levelInclude specific instructions
Medicare Prescription Drug Coverage
03-27-08 64
Health Plans’ Disclosure of Protected Health Information (PHI)Plan may disclose relevant PHI
To people you identify as being involved in your care or payment • Family member or other relative
• Close personal friend
• Others (see examples on next slide)
Only under certain conditions
Medicare Prescription Drug Coverage
03-27-08 65
When Plan May Disclose PHIExamples
To a daughterResolving claim or payment issue of hospitalized mother
To human resources representativeIf you are on the line or give permission by phone
To Congressional officeThat has faxed your request for Congressional
assistance To CMS
If information satisfies plan that you requested CMS assistance
Medicare Prescription Drug Coverage
03-27-08 66
Session Topics
OverviewRights in Original MedicareHospital, SNF, and home health carePrivacy practices in Original MedicareMedicare AdvantageMedicare prescription drug coverageMore information
03-27-08 67
Future Health Care DecisionsLet people know your wishes
About the health care you want If you can’t speak for yourself
Complete “health care advance directive”Who you want to speak for youWhat kind of health care you wantWhat kind of health care you don’t want
More Information
03-27-08 68
Medicare OmbudsmanWorks to ensure people with Medicare
Get information and help they needUnderstand their Medicare optionsApply their rights and protections
May identifyIssues and problems with paymentIssues and problems with coverage
More Information
03-27-08 69
Medicare OmbudsmanEnsures organizations respond promptly
when youNeed help filing an appealHave a problem joining or leaving an MA PlanHave questions about Medicare premiumsNeed help understanding rights/protections
More Information
03-27-08 70
For Information and Assistance1-800-MEDICARE (1-800-633-4227)
TTY/TDD 1-877-486-2048
Medicare & You handbookYour Medicare Rights and Protections bookletState Health Insurance Assistance Programwww.medicare.gov
www.medicare.gov/basics/appeals.asp
More Information
03-27-08 71
For Information and Assistance(continued)
State Quality Improvement Organization (QIO)
Independent Review Entitywww.medicareappeals.com for MA claimswww.medicarepartdappeals for Part D
claims
Medicare Ombudsmanwww.cms.hhs.gov/center/ombudsman.asp
More Information
03-27-08 72
Key Concepts
You have certain guaranteed rightsTo get health care services you needTo receive easy-to-understand informationTo have your medical information kept privateTo file an appeal or complaint
03-27-08
Exercise
73
1. Medicare must disclose your personal medical information
A. To your spouse
B. To you
C. When requested by your pharmacy
D. All the above
03-27-08
Exercise
74
2. If you are in a Medicare Advantage plan, you have a right to know how your plan
is paid
A. True
B. False
03-27-08
Exercise
75
A. True
B. False
3. Some Medicare Prescription Drug Plans pay for only brand-name drugs
03-27-08
Exercise
76
4. In an advance directive you give directions about
A. Who you want to speak for you
B. What kind of health care you want
C. What kind of health care you don’t want
D. All of the above
This training module provided by the
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