By Barbara Wilcox, SHIP Counselor
As many years as I’ve been on Medicare, and as many years as I’ve been a SHIP counselor helping others who are on Medicare, I hadn’t stopped to think about the rights of Medicare beneficiaries until I had occasion to file an appeal of a Medicare decision myself. I believe that it is important that we know our rights, and what to do if we believe our rights have been violated. So, after reviewing official Medicare documents and materials from the Medicare Quality Improvement Organization (QIO) Acentra, here is my summary of your Medicare rights. See the notes at the end of this article for places you can go for more information.
No matter how you get your Medicare, you have certain rights and protections that:
- Provide for your safety when you get health care
- Ensure you get the health care services that the law says you can get
- Protect you from unethical practices
- Safeguard your privacy
You have the right to:
- Be treated with courtesy, dignity, and respect at all times.
- Be protected from discrimination because of your race, color, national origin, disability, age, religion or sex.
- Have your personal and health information kept private.
- Get easy to understand information about Medicare (in a language you understand and in an accessible format, such as Braille or large print):
- What’s covered.
- What Medicare pays for covered items and services.
- How much you’ll have to pay.
- How to file a complaint or appeal.
- Get answers to your Medicare questions.
- Have access to providers, specialists, and hospitals for medically necessary services.
- Learn about your treatment choices in clear language that you can understand. You have the right to participate fully in all your health care decisions.
- Get emergency care when and where you need it.
- Get notice of decisions about coverage and payment when you or your provider files a claim.
- Ask for an appeal of certain decisions about payment or coverage.
- File complaints (grievances) about services and quality of care you get from a Medicare provider.[i]
If you have Original Medicare, then you receive notice directly from Medicare about claims and payments (Summary Medicare Notice), and you would follow Medicare procedures for appeals and complaints. You have the right to use any provider or specialist that participates in Medicare. If you are also enrolled in a Part D Prescription Drug Plan and/or a Medicare Supplement Plan (Medigap), then the Plan provides you with notice about claims and payments (Explanation of Benefits), and you would follow plan procedures for appeals and complaints.
If you have a Medicare Advantage Plan, then the Plan provides you with notice about claims and payments (Explanation of Benefits), and you would follow plan procedures for appeals and complaints. It is important that you read the Plan materials carefully so that you understand the plan’s network of providers, rules about pre-approval of certain treatments, rules about referrals to specialists, etc.
Help with Medicare Rights
What if you believe that your Medicare rights are being violated, or you aren’t sure how to ask for what you have a right to? There are two sources of help that are available to you, (1) SHIP and (2) Medicare Quality Improvement Organizations (QIO). I have written about the SHIP program many times over the years, and you know that you can look up your local SHIP program online or call the national tollfree number to get connected to your local SHIP office. 1-877-839-2675. This is where I would start to get basic information about your rights and to get help understanding if you are getting the health care you have a right to. SHIP can also give you instructions on filing an appeal or a complaint. SHIP offices are usually open five days a week during business hours. You may have to leave a message and wait for a return call.
What if you need help on an emergency basis, or need someone to help you through the process of an appeal or complaint? Suppose you are in the hospital, and you are being discharged too soon, when you aren’t ready to go home? In cases like these, I would turn to the Medicare QIO for your region. (See the table below for information about reaching these services.)
Acentra Health is the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for 29 states. Acentra Health provides three
services for people with Medicare (including Medicare Advantage plans): (1) Immediate Advocacy, (2) hospital discharge and skilled service termination appeals, and (3) quality of care complaints.
Immediate Advocacy helps find a quick solution to a healthcare concern. Typically, Acentra Health contacts the provider, usually by phone, to do so. Here is an example of Immediate Advocacy: A man called Acentra Health because he was concerned about his wife’s discharge from a skilled nursing facility. During a care conference with the surgeon, it was determined he could take care of her with help from home health services. However, once his wife was home, he had questions. He called Acentra Health to ask for help with understanding the plan of care and treatment options. Acentra Health scheduled a three-way conference call with the social worker at the skilled nursing facility and the patient’s husband. The plan of care was discussed further during the call, and the patient’s husband learned more about his wife’s treatment options.
Hospital discharge appeals are for Medicare patients who are not ready to leave the hospital. This service is also available for Medicare skilled services, such as physical therapy. The appeal goes to an Acentra Health doctor, who looks at the patient’s medical records to see if more treatment is needed.
Acentra Health also can review complaints about medical care. If you are unhappy with the medical care you had from a healthcare provider, such as a hospital or skilled nursing facility, you can call Acentra Health and one of our staff will talk with you about filing a quality of care complaint. If a person with Medicare believes they received the wrong care, an Acentra Health doctor can review the medical records to see if the care was appropriate. Here is an example of a quality of care complaint that can be reviewed: A Medicare patient went to the emergency department with a stroke. The time frame for the proper medication was missed, and the patient got worse. The patient felt that if treatment had not been delayed, the outcome would have been better.
For more information about assistance from Acentra Health, visit ww.acentraqio.com/bene. Consider signing up for Acentra Health’s newsletter that is written for people who have Medicare to stay updated about Medicare news. Read more about the newsletter: http://www.acentraqio.com/onthehealthcarefront Learn more about our services. [ii]
[i] Your Medicare Rights & Protections. CMS Product No. 11534
[ii] Newsletter Insert – Acentra Health’s Free Services for People with Medicare.Publication No R146810-124-07/20924, Acentra Health. Visit http://www.acentraqio.com/onthehealthcarefront