Your Medicare Rights and Protections

1
Your Medicare Rights and Protections

• Module 2

2
Session Topics

• Overview
• Rights in Original Medicare
• Hospital, SNF, and home health care
• Privacy practices in Original Medicare
• Medicare Advantage
• Medicare prescription drug coverage
• More information

3
Session Topics

• Overview
• Rights in Original Medicare
• Hospital, SNF, and home health care
• Privacy practices in Original Medicare
• Medicare Advantage
• Medicare prescription drug coverage
• More information

4
Medicare Patients Rights
Overview

• You have guaranteed rights in
• Original Medicare Plan
• Medicare Advantage Plan
• Medicare Prescription Drug Plan
• These rights
• Protect you when you get health care
• Make sure you get health care services the law
  says you can get
• Protect you against unethical practices
• Protect your privacy

5
You Have the Right to
Overview

• Be treated with dignity and respect
• Be protected from discrimination
• Get information you can understand
• Get answers to your Medicare questions
• Get culturally competent services
• Get emergency care
• When you need it
• Where you need it

6
You Have the Right to
Overview

• Learn about your treatment choices
• In clear understandable language
• File a complaint
• Appeal denial of a treatment or payment
• Have personal information kept private
• Know your privacy rights

7
Right to Emergency Care
Overview

• You think your health is in serious danger
• When every second counts
• When and where you need it
• Without an OK from your health plan
• Anywhere in the United States

8
Urgently Needed Care
Overview

• For a sudden illness or injury
• Medical care needed right away
• Not a serious threat to health
• In a Medicare Advantage Plan
• In service area
• Network providers generally provide care
• Out of service area
• Plan must pay

9
Right to Non-Discrimination
Overview

• Cannot be treated unfairly because of
• Race, color, national origin
• Disability
• Age
• Religion
• Sex
• Generally limited to complaints against providers
• Call Office for Civil Rights in your state

10
Complaints
Overview

• Two kinds of complaints
• Appeals
• Grievances
• You can file an appeal if you believe
• Medicare should have paid but didnt
• Medicare didnt pay enough
• You were denied a needed service
• In a Medicare Advantage Plan

11
Grievances
Overview

• Complaints of dissatisfaction
• Plans operations
• Providers operations
• Any problems with health plan or provider
• Examples
• Problems with waiting time for appointments
• How your doctor and others behave
• Cleanliness or conditions of doctors office
• Quality of care

12
Session Topics

• Overview
• Rights in Original Medicare
• Hospital, SNF, and home health care
• Privacy practices in Original Medicare
• Medicare Advantage
• Medicare prescription drug coverage
• More information

13
Rights Under Original Medicare
Original Medicare

• Additional rights and protections
• Access to doctors, specialists, hospitals
• Timely information on Medicare payment
• Fair and efficient appeals processes
• General appeal rights
• Rights to buy a Medigap policy
• Privacy practices notices for Original Medicare

14
Appeal in Original Medicare
Original Medicare

• Ask doctor or provider for information that might
  help your case
• Appeal rights are on back of notice
• Notice will tell you
• Why Medicare didn't pay
• How to appeal
• How long you have to appeal

15
Appeal Levels in Original Medicare
Original Medicare

• Redetermination
• Reconsideration
• Administrative Law Judge
• Medicare Appeals Council
• U.S. District Court Review

16
Protection from Unexpected Bills
Original Medicare

• When Medicare might not pay for a service
• Provider gives you written notice
• Advance Beneficiary Notice
• Used in Original Medicare Plan
• Not required for non-covered services
• Excluded under Medicare law
• Will ask you to sign agreement to pay

17
Advance Beneficiary Notices
Original Medicare

• Advance Beneficiary Notice-General
• (ABN-G)
• Advance Beneficiary Notice-Laboratory
• (ABN-L)
• Skilled Nursing Facility Advance Beneficiary
  Notice (SNFABN)
• Or denial letter

18
Advance Beneficiary Notices
Original Medicare

1. Home Health Advance Beneficiary Notice (HHABN)
2. Hospital-Issued Notice of Non-coverage (HINN)

19
Medigap Rights and Protections
Original Medicare

• Right to buy a Medigap policy
• Medigap open enrollment period
• Guaranteed issue rights
• Cant deny you Medigap coverage or place
  conditions on coverage
• Must cover you for all pre-existing conditions
• Cant charge you more because of past or present
  health problems

20
Session Topics

• Overview
• Rights in Original Medicare
• Hospital, SNF, home health care
• Privacy practices in Original Medicare
• Medicare Advantage
• Medicare prescription drug coverage
• More information

21
Right to Hospital Care
Hospital, SNF, HH

• You have the right to get all the hospital care
  you need
• Your right in all Medicare health plans
• Explained in Important Message From Medicare

22
Important Message from Medicare
Hospital, SNF, HH

• Tells you
• Your right to get hospital care you need
• Your right to get follow-up care
• What to do if hospital is making you leave too
  soon
• Your appeal rights
• What you may have to pay

23
Right to Hospital Care
Hospital, SNF, HH

• Hospital Issued Notice of Non-coverage (HINN)
• Notice of Discharge Medicare Appeals Rights
  (NODMAR)
• If hospital is making you leave too soon
• Call your state QIO
• QIO reviews for all people with Medicare
• Hospital cannot force you to leave before QIO
  makes its decision

24
Rights in a Skilled Nursing Facility
Hospital, SNF, HH

• Should receive a written notice
• Facility believes Medicare wont pay
• You will be liable for remainder of stay
• Notice will inform you of rights
• Coverage ends day after you get notice

25
Denial Letters
Hospital, SNF, HH

• SNFs may use a denial letter to tell you
• Your stay is no longer covered
• Some services are no longer covered
• You will be responsible for payment after
  coverage ends
• Your right to have claims submitted to Medicare
• You can request a fast appeal

26
Home Health Rights
Hospital, SNF, HH

• Your plan of care
• Can only be changed by your doctor
• You 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 notice
• In some cases when all home care ends

27
Original Medicare Fast Appeal
Hospital, SNF, HH

• Effective July 1, 2005
• People in certain care settings have right to
  request expedited (fast) appeal
• Provider must give notice of your rights
• Explains your right to independent reviewer (QIO)

28
Original Medicare Fast Appeal
Hospital, SNF, HH

• You must get advance notice
• Usually no later than 2 days before end of
  covered services
• If you disagree
• File request with state QIO
• No later than noon of the calendar day following
  receipt of notice

29
Original Medicare Fast Appeal
Hospital, SNF, HH

• QIO must notify provider immediately
• Provider must give you detailed notice
• Usually by close of business same day QIO
  notifies the provider
• Determination by QIO
• No later than 72 hours after receipt of request
  for expedited determination

30
MA Fast-Track Appeals Process
Hospital, SNF, HH

• Your right when services are ending too soon
• Skilled nursing facility
• Home health agency
• Comprehensive outpatient rehabilitation facility
• Provider or plan must give NOMNC
• At least 2 days before services end
• Plan must give Detailed Explanation of
  Non-coverage
• Decision from QIO within 2 days

31
Session Topics

• Overview
• Original Medicare
• Hospital, SNF, and home health care
• Privacy practices in Original Medicare
• Medicare Advantage
• Medicare prescription drug coverage
• More information

32
Notice of Privacy Practices
Privacy RightsOriginal Medicare

• Rules about personal medical information
• When Medicare must disclose it
• When Medicare has the right to disclose it
• When Medicare may disclose it
• For more information
• 1-800-MEDICARE (1-800-633-4227)
• TTY users call 1-877-486-2048

33
Medicare Must
Privacy RightsOriginal Medicare

• Disclose personal medical information
• To you
• To anyone with legal right to act for you
• To the Secretary of HHS
• When required by law

34
Medicare Has the Right
Privacy RightsOriginal Medicare

• To disclose personal medical information
• To Medicare contractors to process claims
• To ensure quality health care
• To provide customer service
• To resolve your complaints

35
Medicare Has the Right
Privacy RightsOriginal Medicare

• To disclose personal medical information
• To state and Federal agencies
• For public health activities
• For government oversight
• For judicial proceedings
• For law enforcement purposes
• For research studies

36
Additional Privacy Rights
Privacy RightsOriginal Medicare

• Medicare may disclose personal medical
  information
• To avoid threat to health and safety
• To notify you about benefits
• For collection of information
• Medicare may not
• Give out your personal medical information for
  any purpose not on this list
• Without your written permission
• You may revoke your permission at any time

37
Your Privacy Rights
Privacy RightsOriginal Medicare

• Right to ask Medicare
• To see and copy your medical information
• To correct any medical information you believe is
  incorrect or incomplete
• Who your medical information was sent to
• To communicate in a different manner
• NOT to use/give out your information for reasons
  listed
• For released information in writing

38
If You Believe Your Privacy Rights Were Violated
Privacy RightsOriginal Medicare

• You may file a complaint
• Will not affect your Medicare benefits
• To file a complaint
• Call 1-800-MEDICARE (1-800-633-4227)
• Visit www.hhs.gov/ocr/hipaa to file a complaint
  with the Secretary of HHS
• Contact Office for Civil Rights
• 1-866-627-7748

39
Session Topics

• Overview
• Rights in Original Medicare
• Hospital, SNF, and home health care
• Privacy practices in Original Medicare
• Medicare Advantage
• Medicare prescription drug coverage
• More information

40
Rights in MA or Other Medicare Plan
Medicare Advantage

• Additional rights and protections
• Choice of health care providers
• Access to health care providers
• Know how your doctors are paid
• Fair, efficient, and timely appeals process
• Fast appeals in certain health care settings

41
Rights in MA or Other Medicare Plan
Medicare Advantage

• Additional rights and protections
• File a grievance
• About other concerns
• About problems
• Fast appeals
• Call your plan for information
• Privacy of your personal health information

42
Appeals in Medicare Advantage
Medicare Advantage

• Plan
• Will not pay for a service
• Does not allow a service
• Stops a service
• Can ask for fast (expedited) decision
• Plan must decide within 72 hours
• See plans membership materials

Must tell you in writing how to appeal
43
MA Appeal Process
Medicare Advantage

• Plan Reconsideration
• Independent Review Entity
• Administrative Law Judge
• Medicare Appeals Council
• Judicial Review

44
Special Rights
Medicare Advantage

• If you file an appeal
• You have right to plans files about you
• Your case file
• Plan may charge you a reasonable fee
• For copying and mailing

45
To Get Your Case File
Medicare Advantage

• Call or write your plan
• For case file sent to IRE
• Contact Center for Health Dispute Resolution
• Call 585-586-1770
• Write
• Center for Health Dispute Resolution
• One Fishers Road, Second Floor
• Pittsford, NY 14534-9597

46
Session Topics

• Overview
• Rights in Original Medicare
• Hospital, SNF, and home health care
• Privacy practices in Original Medicare
• Medicare Advantage
• Medicare prescription drug coverage
• More information

47
Drug Plan Sponsors
Medicare Prescription Drug Coverage

• Must have procedures
• For standard and expedited
• Coverage determinations
• Appeals
• Grievances

48
Drug Plan Sponsors
Medicare Prescription Drug Coverage

• Must give you written information
• Grievance procedure
• Coverage determination and appeals
• Including right to expedited review
• Quality of care complaint process

49
Access to Covered Drugs
Medicare Prescription Drug Coverage

• Plans
• May not cover all Medicare-covered drugs
• Must ensure enrollees can get drugs they need for
  their conditions
• Must include more than one drug in each
  classification
• Must pay for brand-name as well as generic drugs
• May have rules for managing access

50
All or Substantially All
Medicare Prescription Drug Coverage

• Plans must cover most drugs to treat certain
  conditions
• Cancer medications
• HIV/AIDS treatments
• Antidepressants
• Antipsychotic medications
• Anticonvulsive treatments
• For epilepsy and other conditions
• Immunosuppressants

51
Transition Supply
Medicare Prescription Drug Coverage

• Plans must fill prescriptions not on plans list
• For new enrollees
• For residents of long-term care facilities
• Immediate supply provided to new enrollee
• Fill one-time, 30-day supply of current
  prescription
• While using transition supply
• Work with doctor to switch to drug on plans list
• If medically necessary, request an exception

52
Plan Ahead
Medicare Prescription Drug Coverage

• Dont wait until transition supply is gone
• Talk with your doctor about
• Prior authorization
• Switching to covered drug
• Asking for an exception if medically necessary
• Contact the drug plan with questions

53
Requesting an Exception
Medicare Prescription Drug Coverage

• Can request an exception
• Drugs not on plans formulary
• Drug with special coverage rules
• Contact the plan
• How to submit request
• What information to submit
• Prescribing doctor
• Must submit supporting statement
• Must indicate drug is medically necessary

54
Requesting an Exception
Medicare Prescription Drug Coverage

• After receiving physicians statement
• Plan must notify you
• As quickly as your condition requires
• Within 24 hours (expedited) or
• Within 72 hours (standard)

55
Tiering Exception
Medicare Prescription Drug Coverage

• Gives access to non-preferred drug
• At lower cost of drugs in the preferred tier
• If preferred drug
• Would not be as effective
• Would have adverse effects

56
Formulary Exception
Medicare Prescription Drug Coverage

• Gives access to drugs
• Not on plans formulary
• For which plan has special coverage rules
• Plan determines level of cost sharing

57
Approved Exceptions
Medicare Prescription Drug Coverage

• Valid for remainder of plan year, as long as
• You remain enrolled in plan
• Physician continues to prescribe drug
• Drug remains safe for treating your condition
• Plan will notify of drug coverage
• For following year
• At time of approval
• At the end of plan year

58
Appeals
Medicare Prescription Drug Coverage

• 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

59
Levels of Appeal
Medicare Prescription Drug Coverage

• Appeal to the plan
• Independent review entity reconsideration
• Administrative law judge hearing
• Medicare Appeals Council
• U.S. district court review

60
Required Notices
Medicare Prescription Drug Coverage

• After every
• Adverse coverage determination
• Adverse appeal determination
• Include information on next appeal level
• Include specific instructions

61
Disclosure of PHI
Medicare Prescription Drug Coverage

• Personal Health Information (PHI)
• Plan may disclose relevant PHI
• To those you identified 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

62
When Plan May Disclose PHI
Medicare Prescription Drug Coverage

• Examples
• Daughter resolving claim of hospitalized mother
• Human resources representative
• If you are on the line or give permission by
  phone
• Congressional office
• That has faxed your request for Congressional
  assistance
• CMS
• If information satisfies plan you requested
  assistance

63
Session Topics

• Overview
• Rights in Original Medicare
• Hospital, SNF, and home health care
• Privacy practices in Original Medicare
• Medicare Advantage
• Medicare prescription drug coverage
• More information

64
Future Health Care Decisions
More Information

• Let people know your wishes
• About the health care you want
• If you cant speak for yourself
• Complete health care advance directive
• Who you want to speak for you
• What kind of health care you want
• What kind of health care you dont want

65
Medicare Ombudsman
More Information

• Works to ensure people with Medicare
• Get information and help they need
• Understand their Medicare options
• Apply their rights and protections
• May identify
• Issues and problems with payment
• Issues and problems with coverage

66
Medicare Ombudsman
More Information

• Ensures organizations respond promptly when you
• Need help filing an appeal
• Have a problem joining or leaving an MA Plan
• Have questions about Medicare premiums
• Need help understanding rights/protections

67
For Information and Assistance
More Information

• 1-800-MEDICARE (1-800-633-4227)
• TTY/TDD 1-877-486-2048
• Medicare You handbook
• Your Medicare Rights and Protections booklet
• State Health Insurance Assistance Program
• www.medicare.gov
• www.medicare.gov/basics/appeals.asp

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For Information and Assistance(continued)
More Information

• State Quality Improvement Organization (QIO)
• Independent Review Entity
• www.medicareappeals.com for MA claims
• www.medicarepartdappeals for Part D claims
• Medicare Ombudsman
• www.cms.hhs.gov/center/ombudsman.asp

69
Key Concepts

• You have certain guaranteed rights
• To get health care services you need
• To receive easy-to-understand information
• To have your medical information kept private
• To file an appeal or complaint

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