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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.

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Presentation Transcript
slide2

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

Your Medicare Rights and Protections

slide3

Overview

Your Medicare Rights and Protections

medicare patients rights
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

Your Medicare Rights and Protections

you have the right to
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-competentservices

Get emergency care

Your Medicare Rights and Protections

you have the right to1
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

Your Medicare Rights and Protections

right to emergency care
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

Your Medicare Rights and Protections

urgently needed care
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

Your Medicare Rights and Protections

right to non discrimination
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

Your Medicare Rights and Protections

types of beneficiary complaints
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)

Your Medicare Rights and Protections

slide11

Rights in Original Medicare

Your Medicare Rights and Protections

rights under original medicare
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

Your Medicare Rights and Protections

appeals in original medicare
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

Your Medicare Rights and Protections

original medicare appeals process
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

Your Medicare Rights and Protections

protection from unexpected bills
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

Your Medicare Rights and Protections

slide16

Protection from Unexpected Bills

(continued)

  • Advanced Beneficiary Notice of Noncoverage (ABN)
    • When Medicare payment is expected to be denied

Your Medicare Rights and Protections

beneficiary liability notices
Beneficiary Liability Notices

Four types of Advance Beneficiary Notices

Advance Beneficiary Notice of Noncoverage

Skilled Nursing Facility Advance Beneficiary Notice (SNFABN)

Or denial letter

Home Health Advance Beneficiary Notice (HHABN)

Hospital-Issued Notice of Non-coverage (HINN)

Your Medicare Rights and Protections

medigap rights and protections
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

Your Medicare Rights and Protections

slide19

Rights in Medicare Health Plans

Your Medicare Rights and Protections

rights in medicare health plans
Rights in Medicare Health Plans

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

Your Medicare Rights and Protections

rights in medicare health plans1
Rights in Medicare Health Plans

Grievance process

Coverage/payment information before service

Privacy of personal health information

Your Medicare Rights and Protections

medicare part c appeals process
Medicare Part C Appeals Process

Plan Reconsideration

Independent Review Entity (IRE)

Administrative Law Judge (ALJ)

Medicare Appeals Council (MAC)

Judicial Review

Your Medicare Rights and Protections

rights if you file an appeal with your medicare health plan
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

Your Medicare Rights and Protections

slide24

Rights under Medicare Prescription Drug Coverage

Your Medicare Rights and Protections

access to covered drugs
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 Reform

Section 3307

Your Medicare Rights and Protections

transition supply
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

Your Medicare Rights and Protections

requesting an exception
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

Your Medicare Rights and Protections

requesting an exception1
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

Your Medicare Rights and Protections

tier exception
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

Your Medicare Rights and Protections

formulary exception
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

Your Medicare Rights and Protections

approved exceptions
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

Your Medicare Rights and Protections

requesting appeals
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

Your Medicare Rights and Protections

medicare part d levels of appeal
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

Your Medicare Rights and Protections

required notices
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

Your Medicare Rights and Protections

health plans disclosure of protected health information phi
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

Your Medicare Rights and Protections

when plan may disclose phi examples
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

Your Medicare Rights and Protections

exercise
Exercise

To your spouse

To you or someone who has the legal right to act for you (your personal representative)

When requested by your pharmacy

All the above

A. Medicare must disclose your personal medical information

Your Medicare Rights and Protections

exercise1
Exercise

True

False

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

Your Medicare Rights and Protections

slide39

Your Rights in Other Settings

A Hospital

A Skilled Nursing Facility

Home Health Care

Hospice 

Comprehensive Outpatient Rehabilitation Facility (CORF)

Your Medicare Rights and Protections

right to hospital care
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

Your Medicare Rights and Protections

slide41

Hospital Discharge Rights

  • Important Message from Medicare (IM)
      • Given at or near admission
      • Signed by you & copy provided
    • Follow-up copy may be delivered before discharge

Your Medicare Rights and Protections

medicare health plan fast appeals process
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

Your Medicare Rights and Protections

original medicare fast appeal process
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

Your Medicare Rights and Protections

exercise2
Exercise

True

False

A. No matter how you have chosen to get your Medicare benefits, you can get emergency care anywhere in the U.S.

Your Medicare Rights and Protections

exercise3
Exercise

Information about why Medicare didn’t pay your bill

How you can appeal

The time limit for filing your appeal

All of the above

B.Your appeal rights listed on the Medicare Summary Notice (MSN) include:

Your Medicare Rights and Protections

slide46

Medicare Privacy Practices

Your Medicare Rights and Protections

notice of privacy practices
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

Your Medicare Rights and Protections

required disclosures
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

Your Medicare Rights and Protections

permitted disclosures
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

Your Medicare Rights and Protections

other permitted disclosures
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

Your Medicare Rights and Protections

additional privacy rights and protections
Additional Privacy Rights and Protections

Medicareneeds written permission (authorization)

For any disclosures not required or permitted

You may revoke your permission at any time

Your Medicare Rights and Protections

privacy rights
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

Your Medicare Rights and Protections

privacy rights violated
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

Your Medicare Rights and Protections

slide54

Other Informationand Resources

Your Medicare Rights and Protections

protect yourself with an advanced directive
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

Your Medicare Rights and Protections

medicare ombudsman
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

Your Medicare Rights and Protections

medicare ombudsman continued
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

Your Medicare Rights and Protections

for information and assistance
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

Your Medicare Rights and Protections

for information and assistance continued
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/

Your Medicare Rights and Protections