Your medicare rights and protections

40 Pages·2003·2.2 MB·English

by  Centers for Medicare & Medicaid Services (U.S.)

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Your Medicare Rights
and Protections
governmen
This official
booklet has important
information about:
•_Your right to file a complaint.
Your right to get health
care services you need.
r
Where you can get
help with your questions.
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2003 CENTCKSforMEDICARE&MEDICAIDSERViaS'J-

Table of Contents
Welcome 2
Section 1: A Quick Look At Medicare 3—4
Section 2: Your Medicare Rights 5-8
Section 3: Your Rights and Protections
in the Original Medicare Plan 9-20
Section 4: Your Rights and Protections
in a Medicare Managed Care Plan 21—24
Section 5: Your Rights and Protections
in a Medicare Private Fee-for-Service Plan 25-26
Section 6: For More Information 27-30
On
Booklets Other Medicare Topics 27
Telephone Numbers You Can Call For Help 28—30
Note: At the time ofprinting, telephone numbers listed were correct.
Telephone numbers sometimes change. To get the most up-to-date
telephone numbers, look at www.medicare.gov on the web.
Select "Helpful Contacts." Or, call 1-800-MEDICARE
TTY
(1-800-633-4227). users should call 1-877-486-2048.
Section 7: Words To Know
(Where words in brown are defined) 31-33
Section 8: Index
(An alphabetical list ofwhat is in this booklet) 35—37
The information in this booklet was correct when it was printed. Changes may occur
after printing. For the most up-to-date version, look at www.medicare,gov on the web.
Select "Publications." Or, call 1-800-MEDICARE (1-800-633-4227). A Customer
TTY
Service Representative can tell you if the information has been updated. users
should call 1-877-486-2048.
YourMedicare Rights andProtections booklet isn't a legal document. The official Medicare
program provisions are contained in the relevant laws, regulations, and rulings.
Welcome
How This Booklet Can Help You
This booklet is about your Medicare rights and protections. As a
person with Medicare, you have certain guaranteed rights and
protections that
• protect you when you get health care,
• make sure you get the health care services that the law says
you can get, and
• protect you against unethical practices.
Remember, you have rights no matter ifyou are in the Original Medicare
Plan, a Medicare + Choice Plan (pronounced "Medicare plus Choice"),
or have a Medigap (Medicare Supplement Insurance) policy.
This booklet provides you with valuable information and helps you
understand
• your Medicare health plan choices,
• your rights and protections in the Original Medicare Plan,
• your rights and protections in a Medicare + Choice Plan, and
• where to get help with your questions.
"It is nice
to have ways
my
to get
Words Medicare
in
brown
questions answered."
are
defined
on pages
31-33.
A
Section Quick Look At Medicare
1:
What Medicare?
is
Medicare is a health insurance program for
• people age 65 or older,
• some people under age 65 with certain disabilities, and
• people with End-Stage Renal Disease (permanent kidney failure
requiring dialysis or a kidney tranplant).
What are my Medicare health plan choices?
Depending on where you live, you may be able to get your health care in
several ways. Your Medicare health plan choices include
• the Original Medicare Plan (see below), or
• Medicare + Choice Plans (see page 4).
What is the Original Medicare Plan?
The Original Medicare Plan is a "fee-or-service" plan. You are usually charged
a fee for each health care service or supply you get. This plan, managed by the
Federal Government, is available nationwide. You will stay in the Original
Medicare Plan unless you choose to join a Medicare + Choice Plan. Ifyou are
in the Original Medicare Plan, you use your red, white, and blue Medicare
card when you get health care.
To help cover the costs the Original Medicare Plan doesn't cover, you may want
to get a Medigap policy (see page 4).
Words
in
brown
are
defined
on pages
31-33.
A
Section 1: Quick Look At IVIedicare
What is a Medigap policy?
A
Medigap policy is a health insurance policy sold by private insurance
companies to fill the "gaps" in Original Medicare Plan coverage such as
coinsurance amounts.
Medigap policies must follow federal and state laws. These laws protect you.
There are ten standardized Medigap plans called "A" through The front of
"J."
a Medigap policy must clearly identify it as "Medicare Supplement Insurance."
A
Each plan through J has a different set ofbenefits.
For more information about Medigap policies, get a free copy ofthe Guide to
Health Insurancefor People with Medicare: Choosing a Medigap Policy (CMS
Pub. No. 02110) by looking at www.medicare.gov on the web.
Select "Pubhcations." Or, call 1-800-MEDICARE (1-800-633-4227).
TTY
users should call 1-877-486-2048.
What are Medicare + Choice Plans?
Congress created the Medicare + Choice program to provide you with more
choices and, sometimes, extra benefits by letting private companies offer you
your Medicare benefits. Ifyou join a Medicare + Choice Plan, you may have
the fDllowing choices:
• Medicare Managed Care Plans
• Medicare Private Fee-for-Service Plans
• Medicare Preferred Provider Organization Plans
• Medicare Specialty Plans
These Medicare + Choice Plans are available in many areas ofthe country.
A
company can decide, with Medicare's approval, that a plan will be available
to everyone with Medicare in a state, or be open only in certain counties or
parts ofcounties. A company may also choose to offer more than one plan in
an area, with different benefits and costs.
Medicare pays a set amount ofmoney for your care every month to these
private health plans. In turn, the Medicare + Choice Plan manages the
Medicare coverage for its members. IfMedicare + Choice Plans are available in
A
your area, and you have Medicare Part and Part B, you can join one and get
your Medicare-covered benefits through the plan. The plan may have special
rules you need to follow. You may also have to pay a monthly premium for
extra benefits.
Section Your Medicare Rights
2:
Ifyou have Medicare, you have certain guaranteed rights and protections. You have
these rights whether you have the Original Medicare Plan, a Medigap policy, or a
Medicare + Choice Plan. You have the right to:
1. Be treated with dignity and respect at all times
2. Be protected from discrimination
Discrimination is against the law. Every company or agency that works
with Medicare must follow Civil Rights laws. They can't discriminate
against you because ofyour
• race,
• color,
• national origin,
• disability,
• age, or
• religion (under certain conditions).
Ifyou think you have been discriminated against for any ofthese
reasons, call the Office for Civil Rights in your state. You can get this
number from two sources:
• www.medicare.gov on the web. Select "Helpful Contacts."
• 1-800-MEDICARE (1-800-633-4227).
TTY
users should call 1-877-486-2048.
You can have someone help you overcome a language, physical, or
communication barrier ifyou need it.
3. Get information about Medicare that you can understand to
help you make health care decisions
This information includes
Words
in • what is covered,
• what costs are paid,
• how much you have to pay, and
aeimea
• ^vvhat to do ifyou want to fde a complaint.
on pages
..
T^_TT You can h, ave someone h, el,p you mak,e d,eci•sions wh,en you need, •
it.
Section 2: Your Medicare Rights
4. Have your questions about the Medicare
program answered
To get your questions answered, you can call
• 1-800-MEDICARE (1-800-633-4227).
TTY
users should call 1-877-486-2048.
You can get help in English or Spanish, or
• your State Health Insurance Assistance Program
(see page 30).
5. Get emergency care when and where you need it
A medic—al emergency is when you think your health is in serious
danger when every second counts. Ifyou think your health is in
danger because you have a bad injury, sudden illness, or an illness
quickly getting much worse, you can get emergency care anywhere
in the United States.
Ifyou are in Medicare + Choice Plan, you don't need to get
permission from your primary care doctor before you get
emergency care. Your primary care doctor is the doctor you see
first for health problems. Ifyou get emergency care, you will have
to pay your regular share ofthe cost (copayment). Then, your plan
will pay its share. Ifyour plan doesn't pay its share for your
emergency care, you have the right to appeal (see page 7).
6. Learn about all ofyour treatment choices in clear
language that you can understand
You have the right to fully participate in all your health care
decisions. Ifyou can't fully participate, you can ask family
members, friends, or anyone you trust to help you make a decision
about what treatment is right for you. Medicare health plans can't
Words
in
have rules that stop your doctor from telling you what you need to
brown
know about your treatment choices.
are
defined
on pages
31-33.
Section Your Medicare Rights
2:
7. File a complaint
You can file a complaint about payment, services you received,
other concerns or problems you have in getting health care, and
the quality ofthe health care you received.
Your Medicare Appeals Rights
You have the right to appeal any official decision about your
Medicare services, such as billing, payment, or service issues.
You can appeal ifMedicare doesn't
• pay for a Medicare-covered item or service you have
been given,
• pay enough for an item or service you have been given,
or
• give you a Medicare-covered item or service you think
you should get.
For more information on filing an appeal, call yourState
Health Insurance Assistance Program (see page 30).
Your Medicare Quality of Care Concerns
You have a right to file a complaint ifyou think you aren't
getting quality services or you have quality ofcare issues.
This type ofcomplaint is called a "grievance" ifyou are
enrolled in aMedicare + Choice Plan. Ifyou want to file a
complaint about the quality ofhealth care you have received,
call the Quality Improvement Organization (QIO) in your
state (see page 28). Ifyou are enrolled in a Medicare + Choice
Plan, you may also call your plan.
You can also file a complaint ifyou think your privacy rights have
Words been violated. Ifyou are in the Original Medicare Plan, see the
in
brown Notice ofPrivacy Practices for the Original Medicare Plan on
pages 18-20 for more information. Ifyou are enrolled in a
are
Medicare + Choice Plan, call your health plan directly for more
defined
information.
on pages
31-33.
Section Your Medicare Rights
2:
8. Have your personal information that Medicare collects
about you kept private
Medicare may collect information about you as part ofits regular
business, such as paying your health care bills and making sure you
get quality health care. Medicare keeps the information it collects
about you private. When Medicare asks for your personal
information, they must tell you the following:
Why
• it is needed
• Whether it is required or optional
• What happens ifyou don't give the information
How
• it will be used
Ifyou want to know more about how Medicare uses your personal
information, call 1-800-MEDICARE (1-800-633-4227). TTY users
should call 1-877-486-2048.
Your state may have additional privacy laws that protect your
personal information. Ifyou want to know about the laws in your
state, call your State Health Insurance Assistance Program
(see page 30).
9. Talk with your health care providers in private and have
your personal health care information kept private
There is a new patient privacy rule that gives you more access to
your own medical records and more control over how your personal
health information is used by your health care provider or health
plan. Health plans and covered health care providers must give you a
notice that clearly explains these rights and practices. Ifyou are
Words in enrolled in the Original Medicare Plan, see the Notice ofPrivacy
brown Practices on pages 18-20. Ifyou are enrolled in a Medicare +
are Choice Plan, your plan materials describe your privacy rights.
defined
on pages
31-33.
8