2004 REACH National Medicare Training Program Speaker Name

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

Rights and Protections for People with Medicare Module 2 2

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

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

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 5

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 6

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 7

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 8

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 9

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 10

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 11

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 12

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

Original Medicare 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 14

Original Medicare 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 15

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

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 17

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 18

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

Privacy Rights—Original Medicare 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 20

Privacy Rights—Original 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 21

Privacy Rights—Original 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 22

Privacy Rights—Original Medicare May • Disclose personal medical information – To state and Federal agencies – For public health activities – For government oversight – For judicial proceedings 23

Privacy Rights—Original 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 24

Privacy Rights—Original Medicare 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 25

Privacy Rights—Original Medicare 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 26

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

Medicare Advantage 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 28

Medicare Advantage 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 29

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

Medicare Advantage 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 31

Medicare Advantage 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 32

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

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 34

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 35

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 36

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 37

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 38

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 39

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

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

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? 42

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

More Information 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) 44

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

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

Thanks for your attention… 47