2004 REACH National Medicare Training Program

1. 2004 REACH National Medicare Training Program Speaker Name Group Name Date

2. Rights and Protections for People with Medicare Module 2

3. Session Topics • Overview • Original Medicare • Privacy practices for Original Medicare • Medicare Advantage • Hospital, SNF, and home health care • More information

4. Session Topics • Overview • Original Medicare • Privacy practices for Original Medicare • Medicare Advantage • Hospital, SNF, and home health care • More information

5. Overview Medicare Patients’ Rights • You have guaranteed rights • In the Original Medicare Plan • In a Medicare Advantage plan • These rights • Protect you when you get health care • Make sure you get the health care services the law says you can get • Protect you against unethical practices

6. Overview You Have the Right to… • Be treated with dignity and respect • Be protected from discrimination • Get information you can understand to make health care decisions • Get answers to your Medicare questions • Get emergency care when and where you need it

7. Overview You Have the Right to… • Learn about treatment choices in clear, understandable language • Know how to file a complaint • Have personal information Medicare collects kept private • Talk with health care providers in private

8. Overview Right to Emergency Care • If 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

9. Overview Urgently Needed Care • Care for a sudden illness or injury • Medical care needed right away • Not a serious threat to health • In a Medicare Managed Care plan • In service area, health plan providers generally provide care • Out of service area, plan must pay

10. Overview Right to Non-Discrimination • Cannot be treated unfairly because of • Race, color, national origin • Disability • Age • Religion • Under certain conditions • Call the Office for Civil Rights in your state

11. Overview Complaints • You can file an appeal if you believe • Medicare should have paid but didn’t • Medicare did not pay enough • You were not given a needed service (if in a Medicare Advantage Plan) • A grievance is dissatisfaction with plan’s or provider’s operations

12. Overview Medicare-Approved Drug Discount Card Complaints • You may appeal if • Denied enrollment in a card • Denied eligibility for the $600 credit • Appeal must be within 60 days of denial • Each card sponsor must have a process for handling complaints about its card

13. Session Topics • Overview • Original Medicare • Privacy practices for Original Medicare • Medicare Advantage • Hospital, SNF, and home health care • More information

14. OriginalMedicare Rights Under Original Medicare • Additional rights and protections • Culturally competent services • Access to doctors, specialists, and hospitals • Fair, efficient, and timely appeals process • Know what Medicare may not pay for • Hospital, SNF, and home health care • Medigap • Notice of privacy practices for Original Medicare

15. OriginalMedicare Appeal in 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 your bill • How to appeal • How long you have to appeal

16. OriginalMedicare Appeal in Original Medicare • Five levels • Redetermination • Fair Hearing (for Part B issues only) • Administrative Law Judge (ALJ) • Departmental Appeals Board (DAB) • Judicial Review

17. Overview Protection from Unexpected Bills • You have the right to know if Medicare won’t pay • Advance Beneficiary Notice • Used in the Original Medicare Plan • Tells you Medicare might not pay • Non-covered services are excluded

18. Overview Medigap Rights & Protections • Right to buy a Medigap policy • Medigap open enrollment period • Guaranteed 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

19. Session Topics • Overview • Original Medicare • Privacy practices in Original Medicare • Medicare Advantage • Hospital, SNF, and home health care • More information

20. PrivacyRights—OriginalMedicare Notice of Privacy Practices • New rules about personal medical information • When Medicare must disclose it • When Medicare has the right to disclose it • When Medicare may disclose it • Effective April 14, 2003 • For more information • 1-800-MEDICARE (1-800-633-4227) • TTY/TDD 1-877-486-2048

21. PrivacyRights—OriginalMedicare Medicare Must • Disclose personal medical information • To you or anyone with legal right to act for you • To the Secretary of HHS • When required by law

22. PrivacyRights—OriginalMedicare Medicare Has the Right • To disclose personal medical information to • Medicare contractors to process claims • Ensure quality health care • Provide customer service • Resolve your complaints

23. PrivacyRights—OriginalMedicare Medicare May • Disclose personal medical information • To state and Federal agencies • For public health activities • For government oversight • For judicial proceedings

24. PrivacyRights—OriginalMedicare Medicare May • Disclose personal medical information • For law enforcement purposes • For research studies • To avoid threat to health and safety • To notify you about benefits • For collection of information

25. PrivacyRights—OriginalMedicare Your Privacy Rights • 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 and give out your information for reasons listed • For released information in writing

26. PrivacyRights—OriginalMedicare If Privacy Rights Violated • Call 1-800-MEDICARE • Visit www.hhs.gov/ocr/hippa to file a complaint with the Secretary of HHS • Contact Office for Civil Rights • 1-866-627-7748

27. Session Topics • Overview • Original Medicare • Privacy practices for Original Medicare • Medicare Advantage • Hospital, SNF, and home health care • More information

28. MedicareAdvantage Rights in Medicare Advantage • Additional rights and protections • Culturally competent services • Choice of and access to health care providers • Know how your doctors are paid • Fair, efficient and timely appeals process • File a grievance about other concerns and problems • Hospital, SNF, and home health care

29. MedicareAdvantage Appeal in Medicare Advantage Plan • Plan must tell you in writing how to appeal • Appeal if • Plan will not pay for, does not allow, or stops a service that you think should be covered or provided • Can ask for fast (expedited) decision • Plan must reach a decision within 72 hours • See plan's membership materials

30. MedicareAdvantage Medicare Advantage Appeal Process • Plan Reconsideration • Independent Review Entity (IRE) Reconsideration • Administrative Law Judge (ALJ) • Departmental Appeals Board (DAB) • Judicial Review

31. MedicareAdvantage Special Rights • If you are in a Medicare Managed Care plan and file an appeal • You have a right to the plan’s files about you • Case file • The plan may charge you a fee • Reasonable amount for copying and mailing

32. MedicareAdvantage To Get Your Case File • Call or write your plan • To review case file sent to IRE • Contact CHDR • Call 585-586-1770 • Write Center for Health Dispute Resolution One Fishers Road, Second Floor Pittsford, NY 14534-9597

33. Session Topics • Overview • Original Medicare • Privacy practices for Original Medicare • Medicare Advantage • Hospital, SNF, and home health care • More information

34. Hospital, SNF, HH Right to Hospital Care • 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

35. Hospital, SNF, HH Right to Hospital Care • Hospital Issued Notice of Non-coverage (HINN) • Notice of Discharge & Medicare Appeals Rights (NODMAR) • If the 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 a decision

36. Hospital, SNF, HH Skilled Nursing Home Rights • Original Medicare Plan • Must be given Notice of Non-Coverage • Coverage ends the day after you get the notice

37. Hospital, SNF, HH Medicare Advantage Fast-Track Appeals Process • Beginning January 1, 2004 • Plan must tell you in writing when your services are expected to end • When you believe services are ending too soon in a • Skilled nursing facility • Home health agency or • Comprehensive outpatient rehabilitation facility • Will get a decision within 2 days

38. Hospital, SNF, HH Home Health Rights • Your plan of care • Can only be changed by your doctor • Cannot be changed by the agency without doctor’s approval • You must be told of changes, in writing • Home Health Advance Beneficiary Notice

39. Hospital, SNF, HH Home Health Rights • Medicare pays for home health services • As long as you are eligible AND • Your doctor says you need these services

40. Casestudy #1… Norman has Medicare and believes the hospital is discharging him too soon. Who should he contact?

41. And the answer is... He should contact his state Quality Improvement Organization (QIO).

42. Case study #2… Sophie receives her care through the Original Medicare Plan and wants to file an appeal. What is one of the first things Sophie should do?

43. Session Topics • Overview • Original Medicare • Privacy practices for Original Medicare • Medicare Advantage • Hospital, SNF, and home health care • More information

44. MoreInformation Resources • For information and assistance • 1-800-MEDICARE (1-800-633-4227) • TTY/TDD 1-877-486-2048 • Medicare & You handbook • Your Medicare Rights and Protections booklet • Your SHIP • www.medicare.gov • State Quality Improvement Organization (QIO)

45. MoreInformation If You Can’t Speak for Yourself… • Let people know your wishes about the health care you want • Complete a “health care advance directive”

46. Key Concepts • You have certain guaranteed rights • You have the right to receive easy-to-understand information • You have the right to have your personal medical information kept private • You have a right to file an appeal or complaint

47. Thanks for your attention…