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 Overview 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 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 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 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 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 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 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 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 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 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 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 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) 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 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 Rights in Medicare Health Plans * Grievance process * Coverage/payment information before service * Privacy of personal health information Medicare Part C Appeals Process 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 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 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 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 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 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 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 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 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 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 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 When Plan May Disclose PHI Examples * 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 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 Exercise * True * False Your Rights in Other Settings * A Hospital * A Skilled Nursing Facility * Home Health Care * Hospice * Comprehensive Outpatient Rehabilitation Facility (CORF) 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 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 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 Exercise * True * False 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 Medicare 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 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 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 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 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 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 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 Other Information and Resources 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 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 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 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 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/