Your Medicare Rights and Protections

1. Your Medicare Rights and Protections Module 2

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 Your Medicare Rights and Protections

3. Overview Your Medicare Rights and Protections

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. Rights in Original Medicare Your Medicare Rights and Protections

12. 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

13. 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

14. 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

15. 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

16. Protection from Unexpected Bills (continued) • Advanced Beneficiary Notice of Noncoverage (ABN) • When Medicare payment is expected to be denied Your Medicare Rights and Protections

17. 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

18. 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

19. Rights in Medicare Health Plans Your Medicare Rights and Protections

20. 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

21. Rights in Medicare Health Plans Grievance process Coverage/payment information before service Privacy of personal health information Your Medicare Rights and Protections

22. 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

23. 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

24. Rights under Medicare Prescription Drug Coverage Your Medicare Rights and Protections

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. Exercise True False B. Some Medicare Prescription Drug Plans pay for only brand-name drugs. Your Medicare Rights and Protections

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. Medicare Privacy Practices Your Medicare Rights and Protections

47. 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

48. 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

49. 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

50. 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