Medicare Beneficiary Rights and Protections

1. Medicare Beneficiary Rights and Protections

2. Guaranteed Rights Assures a beneficiary gets medically necessary services Protects against unethical practices Protects privacy and confidentiality

3. Protected Rights • Be treated with dignity and respect • Be protected from discrimination • Be enrolled in a MA plan without review of health status or history, disability, claims history • Excludes medical determination of ESRD • Call the Office for Civil Rights –1-800-368 1019 • TTY users call 1 800 537 7697

4. Confidentiality Rights • Have personal information kept private • Medical or health records kept accurate and confidential • Access of requested records is released timely

5. Right to Make an Informed Decision • Get information to help him/her make an informed decision • Options to get Medicare • What Medicare covers • What Medicare or Medicare Plan pays • His/her financial responsibilities • How to file a complaint or an appeal • Have questions about Medicare answered • Have information available in their native language

6. Access & Availability Rights – Medicare Advantage Reasonable access to doctors, specialists, hospitals Maintain and monitor panel of primary care providers and allow members to change their provider without interference. Provide or arrange for necessary specialist care and give female enrollees access to routine and preventative health care services

7. Protections – Medicare Advantage Emergency care, including ambulance services, and urgently-needed services in-or out-of-network Dialysis services while temporarily outside of the service area Chronic care programs Medication Therapy Management services

8. Right to a Timely Decision - MA • Timely payment of claims for received services • Get timely written decisions about denial of: • Payment (enrollee reimbursements) • Pre-service medical requests • Prescription drug coverage determinations • Request an appeal of certain denied decisions

9. Right to File a Complaint Enrollee can file a complaint (grievance) by • Calling MA Plan Customer Care • Writing a letter to MA Plan • Calling 1-800-MEDICARE • Quality of care complaints • Call the QIO, health plan, or both

10. Quality Improvement Organization (QIO)Oklahoma Oklahoma Foundation for Medical Quality 14000 Quail Springs Parkway Suite 400 Oklahoma City, OK 73134 405-840-2891 www.ofmq.com

11. Protection from Financial Liability If enrollee receives services from: Contracted network provider – no balance billing paid by the plan or the enrollee; enrollee only responsible for copayment Non-contracting, participating provider - no balance billing paid by plan or enrollee; enrollee responsible for copayment Non-contracting, non-participating provider – MA plan owes the provider the difference between the enrollee’s cost-sharing and the Original Medicare limiting charge (maximum amount that MA plans are required to pay provider) for emergency, urgently-needed care, post-stabilization care, renal dialysis, or services authorized by MA plan. Enrollee pays copayment.

12. Inpatient Discharge Rights • Inpatient Hospital & Skilled Nursing Facilities – Prior to termination of services, the provider must deliver a valid written notice (NODMR) to the enrollee of the MA Plan’s decision to end coverage no later than 2 days before their proposed discharge date. • MA Plan is financially liable for payment until 2 days after the enrollee receives valid notice. • If services are expected to be fewer than 2 days in duration, the provider must give notice upon admission. • Enrollees have the right to appeal the discharge decision with the QIO.

13. Medicare Part C Appeals Process Plan Reconsideration Independent Review Entity (IRE) Administrative Law Judge (ALJ) Medicare Appeals Council (MAC) Judicial Review

14. Part D Prescription Drugs

15. Right to Access Covered Drugs • Part D Plans must ensure enrollees have access to prescribed drugs • Formulary must include more than two drugs in each classification • Must include protected drug classes • Must include brand-name as well as generic drugs • Must have utilization management rules for managing safety, drug interaction, and dosing • Must have timely process to review requests for formulary exceptions

16. Transitional Supply • Plans must pay for prescriptions not on plan’s formulary or have UM restrictions for: • New enrollees, first 90 days for one-time, 30-day supply of current prescription • For LTC residents who enter, change level, or leave a facility, up to 14-day supply, or require an emergency supply • Transition across plan years • When Plan removes covered drugs in the next contract year • Must provide a meaningful transition period

17. Request a Coverage Determination • Enrollee or prescriber may request coverage determination for a drug when the drug: • should be on formulary but isn’t • is covered at a higher cost-sharing • requires enrollee to meet a plan coverage rule • Is not listed on the formulary • Standard timeframe: 72 hours • Expedited timeframe: 24 hours (must meet medical expediency requirements)

18. Request an “Exception” • Enrollee can request a formulary exception, but - • Prescriber must provide a completed physician’s supporting statement, indicating the medical reason for the request. • Medical records may be requested

19. Approved Exceptions • Exception valid for remainder of calendar year if: • Enrollee remains enrolled, and • Prescriber continues to prescribe drug, and • Drug remains safe to treat enrollee’s condition • Plan may extend coverage into new plan year • Plan must notify enrollee in writing if: • Coverage will not be extended with ANOC mailing • Date coverage will end • Right to request new exception

20. Medicare Part D Levels of Appeal • Redetermination from the Part D plan (sponsor) • Reconsideration by a Independent Review Entity (IRE) • Hearing before an Administrative Law Judge (ALJ) • Review by the Medicare Appeals Council (MAC) • Review by a Federal district court

21. Advanced Directives • Healthcare Power of Attorney • Appoints another to communicate health care and end of life decisions to health care providers • Durable Power of Attorney • Appoints another to handle your general and financial affairs

22. Permitted Disclosures • Medicare may disclose 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

23. Privacy Rights • 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