Your Medicare Rights and Protections

Your Medicare Rights and Protections

Module 2

Session Topics Overview Rights in Original Medicare Rights in Medicare Health Plans Rights under Medicare

Prescription Drug Coverage Your Rights In Other Healthcare

Settings Medicare Privacy Practices Other Information

– Resources

06/08/2010 Your Medicare Rights and Protections 2

Overview


06/08/2010 4

Medicare Patients’ Rights

You have guaranteed rights in– Original Medicare– Medicare health plans– Medicare drug plans

These rights– Protect you when you get health care– Ensure you get medically necessary, Medicare-covered

health care services – Protect you against unethical practices– Protect your privacy


06/08/2010 5

You Have the Right to…

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


06/08/2010 6

You Have the Right to…

Learn about your treatment choices– In clear understandable language

File a complaint Appeal a denial of a treatment or payment Have personal information kept private Know your privacy rights


06/08/2010 7

Right to Emergency Care

A medical emergency (your health is in danger)– A bad injury, sudden or quickly worsening illness

No prior approval needed from a health plan Emergency care covered anywhere in the U.S.

– When and where you need it– Drug plans must cover out-of-network in emergency


06/08/2010 8

Urgently Needed Care

A sudden illness or injury – Not a serious threat to health– Medical care needed right away

In a Medicare health plan– If you are in the service area

• Generally you must use network providers– Out of the service area (less than 6 months)

• And cannot wait until you return home• Plan must pay for urgently needed care


06/08/2010 9

Right to Non-Discrimination

Cannot be treated differently because of– Race, color, national origin– Disability– Age– Religion– Sex (under certain conditions)

Call the Office for Civil Rights in your state


06/08/2010 10

Types of Beneficiary Complaints

Right to file a complaint or appeal Complaint (sometimes called a grievance)

– Quality of services– Care that is received

Appeal– Coverage or payment decision

Call Plan, SHIP, 1-800-MEDICARE (1-800-633-4227)


Rights in Original Medicare


06/08/2010 12

Rights Under Original Medicare

Rights Under Original Medicare– Access to doctors, specialists, hospitals– Timely information on Medicare payment– Fair and efficient appeals processes– Rights to buy a Medigap policy– Privacy practices notices for Original Medicare


06/08/2010 13

Appeals in Original Medicare Ask provider for information that might help your

case Instructions for filing an appeal on Medicare

Summary Notice – Why Medicare didn't pay– How to appeal– Where to file your appeal– How long you have to appeal


06/08/2010 14

Original Medicare Appeals Process

Redetermination by Medicare

Reconsideration by Qualified Independent Contractor

Hearing with Administrative Law Judge

Review by Medicare Appeals Council

Review by Federal Court


06/08/2010 15

Protection from Unexpected Bills

• When Medicare might not pay for a service– Provider gives you Advance Beneficiary Notice

• Used in Original Medicare• Only provided where the service is expected to be denied

as not reasonable & necessary• Not required for services excluded under Medicare law• Will ask you to choose whether to get the items or

services• Will ask you to confirm you read and understood the

notice



Protection from Unexpected Bills

(continued)

Advanced Beneficiary Notice of Noncoverage (ABN)

– When Medicare payment is expected to be denied

06/08/2010 17

Beneficiary Liability Notices

Four types of Advance Beneficiary Notices1. Advance Beneficiary Notice of Noncoverage2. Skilled Nursing Facility Advance Beneficiary Notice

(SNFABN)– Or denial letter

3. Home Health Advance Beneficiary Notice (HHABN)4. Hospital-Issued Notice of Non-coverage (HINN)


06/08/2010 18

Medigap Rights and Protections

Right to buy a Medigap policy (certain conditions)– Medigap open enrollment period– Guaranteed issue rights

• Can’t deny you Medigap coverage • Can’t place conditions on coverage• Must cover pre-existing conditions• Can’t charge more because of past or present health

problems


Rights in Medicare Health Plans


06/08/2010 20


Choice of health care providers Access to health care providers (treatment plan) Know how your doctors are paid Fair, efficient, and timely appeals process

– Fast appeals in certain health care settings


06/08/2010 21


Grievance process Coverage/payment information before service Privacy of personal health information



Plan Reconsideration

Independent Review Entity (IRE)

Administrative Law Judge (ALJ)

Medicare Appeals Council (MAC)

Judicial Review

Medicare Part C Appeals Process

06/08/2010 23

Rights if you File an Appeal with Your Medicare Health Plan

Right to plan’s files about you (your case file)– Call or write your plan– May charge you a reasonable fee for copying and mailing


Rights under Medicare Prescription

Drug Coverage


06/08/2010 25

Access to Covered Drugs

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– Must cover all drugs in 6 categories


Health ReformSection

3307

06/08/2010 26

Transition Supply

Plans must fill prescriptions not on plan’s 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 plan’s list– If medically necessary, request an exception


06/08/2010 27

Requesting an Exception

Can request an exception (two types)– Tiers (cost level of drug)– Formulary

• Drug not on plan’s formulary or • Access requirements

Contact the plan to find out– Exception information needed and submission process – Prescriber must submit statement supporting the

exception request


06/08/2010 28

Requesting an Exception

After receiving physician’s statement– Plan must notify you as quickly as your condition requires

• Within 24 hours (expedited) • Within 72 hours (standard)

When a request for payment involves an exception– No later than 14 calendar days after receiving a request, a

plan must• Provide notice of its decision• Make payment when appropriate


06/08/2010 29

Tier Exception

Gives access to non-preferred drug– At lower cost of drugs in the preferred tier– If plan’s preferred drug

• Would not be as effective• Would have adverse effects


06/08/2010 30

Formulary Exception

Gives access to drugs– Not on plan’s formulary– For which plan has special coverage rules

Plan establishes the level of cost sharing – For all non-formulary drugs


06/08/2010 31

Approved Exceptions

• Exception valid for refills for remainder of year if – Person remains enrolled and– Physician continues to prescribe drug and– Drug stays safe to treat person’s condition

• Plan may extend coverage into new plan year• If coverage is not extended

– Must notify enrollee in writing that coverage will not be extended


06/08/2010 32

Requesting Appeals

• Request appeal if coverage determination request denied

• The denial notice will explain – Who can request an appeal – The process for requesting the appeal

• There are five levels of appeal in the appeals process


Medicare Part D Levels of Appeal


Redetermination with the Part D plan (sponsor)

Reconsideration with the independent review entity

Hearing with an administrative law judge

Review by the Medicare Appeals Council

Review by a Federal district court

06/08/2010 34

Required Notices

At pharmacy counter– Whenever prescription is not filled as written

After every coverage determination or appeal decision

Adverse decisions – Must include information on the next appeal level– Include specific filing instructions


06/08/2010 35

Health Plans’ Disclosure of Protected Health Information (PHI)

Plan may disclose relevant PHI to people you identify – Family member or other relative– Close personal friend– Others (see examples on next slide)

May disclose PHI only under certain conditions


06/08/2010 36

When Plan May Disclose PHIExamples

To a daughter or son– To resolve claim or payment issue for parent in hospital

To human resources representative– If you are on the call or give permission by phone

To Congressional office– That faxed your request for Congressional assistance

To CMS– If information satisfies plan that you requested CMS

assistance


06/08/2010 37

ExerciseA. Medicare must disclose your personal medical

information

1. To your spouse2. To you or someone who has the legal right to act for

you (your personal representative)3. When requested by your pharmacy4. All the above


06/08/2010 38

Exercise

1. True2. False

B. Some Medicare Prescription Drug Plans pay for only brand-name drugs.


Your Rights in Other Settings A Hospital A Skilled Nursing Facility Home Health Care Hospice Comprehensive Outpatient

Rehabilitation Facility (CORF)


06/08/2010 40

Right to Hospital Care

• Right to medically-necessary, Medicare-covered hospital care– To diagnose an illness– To treat an illness or injury– To get follow-up care



Important Message from Medicare (IM)

–Given at or near admission

–Signed by you & copy provided

–Follow-up copy may be delivered before discharge

Hospital Discharge Rights

06/08/2010 42

Medicare Health Plan Fast Appeals Process

Notice of Medicare Non-Coverage– Provider must deliver at least 2 days before Medicare-

covered SNF, CORF, or HHA care will end If you think services are ending too soon

– Contact your Quality Improvement Organization (QIO) • No later than noon the day before Medicare-covered services

end to request a fast appeal• See your Notice for how to contact your QIO and for other

important information QIO must notify you of its decision

– By close of business of the day after it receives all necessary information


06/08/2010 43

Original Medicare Fast Appeal Process Notice of Medicare Provider Non-coverage

– Provider must deliver at least 2 days before Medicare-covered SNF, CORF, HHA, or Hospice care will end

If you think services are ending too soon– Contact your Quality Improvement Organization (QIO) – No later than noon the day before Medicare-covered

services end to request a fast appeal• See your Notice for how to contact your QIO and for other

important information The QIO must notify you of its decision no later than

72 hours after receipt of your appeal request


06/08/2010 44

ExerciseA. No matter how you have chosen to get your

Medicare benefits, you can get emergency care anywhere in the U.S.

1. True2. False


06/08/2010 45

ExerciseB. Your appeal rights listed on the Medicare Summary

Notice (MSN) include:

1. Information about why Medicare didn’t pay your bill2. How you can appeal3. The time limit for filing your appeal4. All of the above


Medicare Privacy Practices


06/08/2010 47

Notice of Privacy Practices Tells you how Medicare

– Must protect the privacy of your personal health information– Uses and discloses your personal medical information– Describes your rights and how you can exercise them

Published annually in Medicare & You handbook For more information

– www.medicare.gov– 1-800-MEDICARE (1-800-633-4227)

• TTY users call 1-877-486-2048


06/08/2010 48

Required Disclosures

Medicare must disclose your personal medical information

– To you– To someone with the legal right to act for you– To the Secretary of Health & Human Services– When required by law


06/08/2010 49

Permitted Disclosures Medicare may disclose personal medical

information– To pay for your health care– To operate the program– Examples:

• To Medicare contractors to process your claims• To ensure you get quality health care• To provide you with customer service• To resolve your complaints • To contact you about research studies


06/08/2010 50

Other Permitted Disclosures Medicare may disclose your personal medical

information– To state and Federal agencies– For public health activities– For government oversight– For judicial proceedings– For law enforcement purposes– To avoid a serious threat to health and safety– To contact you regarding a Medicare benefit– To create a non-traceable collection of information


06/08/2010 51

Additional Privacy Rights and Protections

Medicare needs written permission (authorization)– For any disclosures not required or permitted

You may revoke your permission at any time


06/08/2010 52

Privacy Rights Rights to

See and copy your personal medical information Correct 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 use of your medical information

• To pay your claims and run the program Get a written privacy notice


06/08/2010 53

Privacy Rights Violated

You may file a complaint– Call 1-800-MEDICARE (1-800-633-4227)

TTY users should call 1-877-486-2048 or– Contact HHS Office for Civil Rights

• Visit www.hhs.gov/ocr/office/index.html or• Call 1-866-627-7748. • TTY users should call 1-800-537-7697.

– Will not affect your Medicare benefits


http://www.hhs.gov/ocr/office/index.html

Other Informationand Resources


06/08/2010 55

Protect Yourself with an Advanced Directive

Let people know your wishes now– Should a time come when you can’t speak for yourself

Complete a “health care advance directive”– Identifies who you want to speak for you– What kind of health care you want– What kind of health care you don’t want


06/08/2010 56

Medicare Ombudsman

Works to ensure people with Medicare– Get information and help they need– Understand their Medicare options– Apply their rights and protections

May identify and track issues with– Payment policies– Coverage policies


06/08/2010 57

Medicare Ombudsman (continued)

Ensures prompt organization response if 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


06/08/2010 58

For Information and Assistance 1-800-MEDICARE (1-800-633-4227)

– TTY/TDD 1-877-486-2048 www.medicare.gov

– www.medicare.gov/basics/appeals.asp– Medicare & You handbook, CMS Pub. # 10050– Your Medicare Rights and Protections booklet, CMS Pub. #

10112 State Health Insurance Assistance Program


http://www.medicare.gov/basics/appeals.asp

06/08/2010 59

For Information and Assistance (continued)

State Quality Improvement Organization (QIO) Independent Review Entity

– www.medicareappeals.com for MA claims– www.medicarepartdappeals.com for Part D claims

Medicare Ombudsman– www.cms.hhs.gov/center/ombudsman.asp

Beneficiary Notices– http://www.cms.hhs.gov/BNI/


http://www.cms.hhs.gov/center/ombudsman.asp

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Your Medicare Rights and Protections