This publication will give you information about the rights that
you have when you are in a Medicare health plan, including a
Medicare HMO, and about some things you should consider if
you are thinking about enrolling in a Medicare Advantage plan.
Click on a section below to read the
information online.
TABLE OF CONTENTS
Introduction to Medicare and Medicare Advantage
I. You Have The Right To Stay In The Original Medicare Program
II. You Have The Right To Choose A Medicare Advantage Plan
III. You Have The Right To Disenroll From A Plan
IV. You Have The Right To Receive Information
V. You Have The Right To Receive Necessary Services
VI. You Have The Right To File A Grievance Or Appeal
VII. Conclusion
VIII. Appendix : Types of Medicare Advantage
Prepared By: SeniorLAW
230 West Wells Street, Room 800
Milwaukee, Wisconsin 53203
(414) 278-1222
INTRODUCTION
The Balanced Budget Act of 1997 created many new changes in the
Medicare program. Medicare is a health insurance program
run by the federal government. It provides some health care
coverage to people aged 65 and older, to some disabled people and
to patients with end-stage renal disease.
Until recently, people in the Medicare program all received
their benefits the same way: a person would see a provider
(doctor, therapist, etc.) of his or her choice, and if the
service is covered by Medicare, the provider would bill the
Medicare program. Medicare would pay a portion of the bill
and the patient would be responsible for a portion of the bill.
Under this "original" Medicare, patients could choose to receive
their health care from any physician, hospital, nursing home or
other provider that was Medicare-certified. This original
Medicare is still available, but now there are other options
as well.
Original Medicare is divided into 2 parts. Part A covers
hospital stays, skilled nursing facilities, and some home health
care. Part B covers physician services, outpatient
hospital care, home health care, medical equipment and some other
services. Most people who qualify for Medicare get the
Part A for free, although a small number of people have to pay a
premium. All people who enroll in Part B must pay a premium
(in 2006 the premium is $88.50 every month).
A third part has been added to the Medicare program called Part C
or Medicare Advantage. Medicare Advantage offers a variety
of different ways to receive your health care. The Medicare
Advantage health plans are run by private businesses.
The options include several different types of plans, such as:
Medicare Advantage HMOs, PPOs, PSOs, MSAs, and Private
Fee-For-Service plans. These plans are described at the end
of this booklet.
The new plans must cover the same services as original Medicare.
Some plans may cover more than original Medicare covers.
These plans also have premiums like original Medicare. Some
may charge a monthly premium that is more than original Medicare.
A person eligible for Medicare coverage may choose between
receiving original Medicare with Parts A and Parts B or may
choose one of the health care options found under Part
C.
Along with more options comes the need for more information.
With these changes it will be especially important to know what
your rights are as a person on Medicare. This booklet will
give you information about your rights under the Medicare
Advantage program.
SeniorLAW has more detailed information about Medicare Advantage
and the new options you have to choose from. SeniorLAW can
also provide you with information about specific plans available
in your area.
For questions or more information if you live in Milwaukee County,
please call your Milwaukee County Benefit Specialist at SeniorLAW,
278-1222. Outside of Milwaukee County, call the benefit specialist
for your county.
I. YOU HAVE THE RIGHT TO STAY IN THE ORIGINAL MEDICARE PROGRAM
Medicare may have changed, but you don't have to! With new
information and choices available, one of the most important
things to remember is that you do not have to make a choice at
all. You will remain in original Medicare unless you choose
and enroll in a new Medicare Advantage plan.
Original Medicare is how people on Medicare have received their
benefits since the program began in 1965. Original
Medicare pays for medical services on a "fee-for-service"
basis. This means that you may get your medical care from
the provider of your choice. After you have received the
care, the provider bills Medicare for that specific service.
Medicare pays a portion of the bill and you pay a portion of the
bill. For example, if you see a doctor because you have the flu,
Medicare will pay 80% of what it determines to be reasonable
(this is called the "approved amount") and you pay 20%.
Your responsibility to pay 20% of the Medicare approved bill is
called your "co-pay". In some circumstances, you may need
to pay more than just 20% of the "approved amount," but
usually not more than 35%. (Copayments for mental health
treatment can be higher.) You also need to meet a deductible
before Medicare will pay at all. For instance, before
Medicare starts paying its 80% of the doctor's visits costs, you
must first pay $100 a year. You may also buy a Medicare
Supplemental Insurance policy, also called "Medigap", to help
cover some of your co-pays and deductibles.
If you are currently covered by original Medicare and are happy,
you may not want to enroll in a new Medicare Advantage plan.
Keeping your current coverage and health care providers is still
an option. Remember, the choice is yours. You can
either stay with the Medicare program you have now or enroll in a
Medicare Advantage plan. You do not have tho enroll in a Medicare
Advantage plan to avoid the Part D penalty
If you choose a Medicare Advantage plan, you must give up
original Medicare. You will receive all of your benefits
through the Medicare Advantage plan rather than original Medicare.
PRACTICAL POINTERS:
-
If you are happy with original Medicare, you may stay with
original Medicare.
You do not have to switch!
-
If you are currently in original Medicare and do nothing,
you will remain in original Medicare!
II. YOU HAVE THE RIGHT TO CHOOSE A MEDICARE ADVANTAGE PLAN
Under Medicare Advantage, you have the right to choose and enroll
in a plan that will provide your Medicare benefits. The Medicare
Advantage program was designed to offer persons with Medicare more
options for how they receive their health care coverage, and to
save money for the Medicare program. Original Medicare
will still be available. However, other options may also
be available. These new options include: Health
Maintenance Organizations (HMOs); Provider Sponsored Organizations
(PSOs); Preferred Provider Organizations (PPOs); Medical Savings
Accounts (MSAs); Private Fee for Service Plans; and Religious
Fraternal Benefit Society Plans.
These new options may be available in our area in the future.
However, right now the only options available are original
Medicare or a Medicare Health Maintenance Organization (HMO).
There is presently one Medicare HMO in the Milwaukee County
are.
What is a HMO? Unlike original Medicare's "fee-for-service",
a HMO is a managed care plan. This means that you are
limited in your choice of health care providers. With a
HMO you may only use doctors, hospitals, nursing homes and home
health care agencies that are part of the HMO's network. A
network is a group of health care providers that contract with
the HMO.
In a managed care plan, each person in the plan has a primary
care physician, and that doctor manages your care. Your
primary doctor decides if you need certain tests, specialists,
hospitals or any other type of care. In addition to
your primary doctors authorization and referral for services, you
may also need prior authorization from the HMO before receiving
certain health care services. Remember that all of the
specialists that you see, as well as all of the hospitals and
nursing homes you use, must also be a part of the network.
If you go to a specialist or other care provider outside of the
network and it is not an emergency, you may have to pay for it
fully out of your own pocket.
The way that a HMO operates is that it receives a fixed amount
each month from the Medicare program for each person in its plan.
This fixed amount pays for all of your health care. It
does not matter if you use more or less than that amount.
If you use less than the fixed amount that the HMO receives,
the HMO makes a profit. If you need services that cost more
than the fixed amount than the HMO has received, it must still
provide for all of your care. You do not have to pay extra
for months that you receive more health care services as long as
you stay within the plan's network of providers and have received
all necessary referrals and prior authorizations.
Most Medicare Advantage plans will be allowed the option of
charging a premium in addition to the monthly Medicare premiums
you must continue to pay. Also, Medicare Advantage plans
may charge a co-pay for some or all services.
HMOs are designed based on a geographic service area. For
example, the service area of a HMO may be Milwaukee County.
To be eligible to enroll in a HMO, you must live in the service
area. If you travel outside of the service area you will
not be able to receive health care, except for emergency or
urgently needed care, unless you pay for it out of your own
pocket.
It is important to understand that if you enroll in a HMO or
other Medicare Advantage plan, you must give up original Medicare.
This means that if your Medicare Advantage plan refuses to
provide or pay for a service, or if you want to get a service
that is outside of the plan's network, original Medicare will
not pay for it.
Note: Because the HMO plan is currently the only plan being sold
in Wisconsin as an alternative to original Medicare, this booklet
does not go into detail on the other types of plan. For a
brief description of the alternatives that may be available in
the future, please see the appendix at the back of this booklet.
If you are interested in more details relating to the various plans,
please call SeniorLAW at 278-1222 and we will send you free
information or answer your questions over the telephone.
As long as you meet the eligibility requirements for the
particular Medicare Advantage plan you are interested in, you
will be able to choose that plan. The basic
eligibility requirements are the same for all Medicare Advantage
plans:
-
You must be eligible for the Medicare program,
-
You must enroll in the Medicare program and continue paying all
original Medicare premiums, plus any additional premiums that
the plan charges,
-
You must live in the plan's geographic service area,
-
You must enroll in the plan.
If you do not enroll in a Medicare Advantage plan, you will
remain or be placed in original Medicare.
If you wish to enroll in a Medicare Advantage Medical Savings
Account (MSA) plan, you must also meet a few additional
requirements. If you want to enroll in an MSA,
you need to live in the United States for at least 183 days a
year. In addition, you may not enroll in an MSA plan if
you are covered by Medical Assistance (also called Medicaid) or
are in a state program that pays your Medicare premiums, such
SLMB, QMB, QDWI, SLMB+, or QI. Finally, if you receive
benefits under a Federal Employee health benefit plan or
receive veteran's or military health benefits, you cannot enroll
in a Medicare Advantage MSA. Remember that currently there
are no Medicare Advantage MSAs being sold in Wisconsin.
Federal law prevents Medicare Advantage plans from discriminating
against you based on your age or health status. This means
that you may not be denied, restricted, or receive limited health
care benefits and/or limited payment for these services based on
your health status. However, individuals with End
Stage Renal Disease (ESRD) are not eligible for Medicare Advantage
plans. There are also some special rules for persons
receiving the Medicare "hospice" benefit.
Again, you may remain in original Medicare or you can choose one
of the new options available under the Medicare Advantage
program. You have the right to choose the health care
coverage that is best for you. You cannot be refused
enrollment based on your age, health status (except for those
with ESRD), or because of the amount or cost of services you need.
With all of the choices available to you, it is especially
important to carefully consider all of your options.
PRACTICAL POINTERS:
-
Remember that if you enroll in a Medicare Advantage plan, you
give up original (fee-for-service) Medicare coverage!
-
Currently, only Medicare HMOs are available in WI as an
alternative to original Medicare!
-
If you want to join a HMO, you cannot be denied based on age or
health status, except for persons with ESRD.
III. YOU HAVE THE RIGHT TO DISENROLL FROM A PLAN
Along with the right to choose the health care option that is
best for you comes the right to change your mind. Once you have
enrolled in a Medicare Advantage plan, you have the right to
disenroll from that plan if you change your mind.
"Disenroll" means to get out of your Medicare Advantage plan.
Whether you decide you want to switch to original Medicare or
choose a different Medicare Advantage plan, you are free to do
so. Except for Medicare Advantage Medical Savings
Accounts (MSA), the time during which you may is limited.
Each plan will have its own disenrollment process. If you
want to disenroll from a Medicare Advantage plan, you must first
notify your plan. You will also need to give the plan a
written, signed, and dated request for disenrollment from your
plan. Disenrollment from the Medicare Advantage plans
does not occur immediately. The disenrollment is usually
effective as of the first day of the month after you notify your
plan. For example, if you want to disenroll from your
HMO and you notify your HMO in writing on May 5, the
disenrollment will be effective as of June 1.
Special rules for disenrollment apply if you are enrolled in a
Medicare Advantage MSA. Medicare Advantage Choice MSAs
have a "lock-in" requirement, which means that if you do not
disenroll from a MSA by December 15, you will have to remain
with the MSA plan for the whole next year.
When you disenroll from a Medicare Advantage plan, you will no
longer be required to follow that plan's rules, pay that plan's
premiums (if any), or use the doctors and facilities that are
part of that plan's network. But remember, that plan will
no longer pay for your care. You will need to decide
whether you want to choose a different Medicare Advantage plan,
or to choose original Medicare. After your disenrollment,
if you don't choose a new Medicare Advantage plan, you will
automatically be put into original Medicare. If you want to go
right into a new Medicare Advantage plan after disenrollment,
you will need to make sure to coordinate the timing so that you
start in the new plan as soon as you get out of the old plan.
This
can be
tricky. If you have any questions, call SeniorLAW at
278-1222.
Even though you can disenroll from a Medicare Advantage plan,
you should still carefully evaluate each plan before you enroll.
Medical problems often arise without warning and not every plan
provides the same options. For example, if you have
enrolled in a Medicare Advantage HMO and due to unexpected
medical problems, you need to see a specialist immediately,
you may not be able to see the specialist right away unless the
specialist is part of your HMO's network or you pay to see
the specialist out of your own pocket. Just because you
can disenroll from a plan as early as the next month doesn't
mean that you do not have to seriously weigh your options before
enrolling in a plan.
Another important factor to consider is how your choice of plans
will affect your ability to buy or continue with your Medicare
Supplemental Insurance policy (also called "Medigap").
If you have a Medicare Supplemental Insurance policy that you
decide to drop because you enroll in a Medicare Advantage
plan, you might not be able to get back into your supplement if
you change your mind. Federal law only gives a 12-month
"window" where a Medigap policy is required to allow you back in,
and because of certain technicalities, we are not sure that
the "window" period protection would even apply in Wisconsin.
Further, even if you are able to buy back your supplemental
policy, you may have higher costs and/or less covered services.
You should think carefully before dropping your Medicare
Supplemental Insurance policy. We strongly urge you to
call the Medigap Helpline at 1-800-242-1060 to discuss your
situation before making any decisions. SeniorLAW also has more
detailed information about enrollment and disenrollment from
Medicare Advantage plans available free of charge.
PRACTICAL POINTERS:
-
You may want to keep your Medigap insurance for a period of time
even if you choose a Medicare Advantage plan. That way,
if you change your mind, you won't have a problem getting your
Medigap insurance back!
-
Disenrollment is not immediate. It may take as long as a
month!
IV. YOU HAVE THE RIGHT TO RECEIVE INFORMATION
A.
CMS must provide certain information to you about Medicare
Advantage.
Each year in late October or early November, CMS will send you
information about the plans available in your area.
You should receive this information before the annual
election period begins in November so that you can choose from
the plans available. This information will also tell you
how you can enroll in a Medicare Advantage plan.
CMS will send you the following information about each plan:
benefits; cost-sharing; limits on the out-of-pocket expenses to
you; monthly premium costs; cost differences between MSAs and
Private Fee-For-Service plans as compared to other Medicare
Advantage plans; your ability to receive benefits from providers
outside of the plan's network; your ability to select among
network providers and the types of participating providers;
emergency and urgent care coverage; service area; and
supplemental benefits. In addition, you will be provided
with information about when a plan can terminate its contract
with the federal government and how a termination will affect
persons in that plan.
The information that you receive from CMS will discuss the
benefits covered under original Medicare. You will also
be provided general information on the basic benefits and
rights with a Medicare Supplemental Insurance policy and Medicare
Select policies. Finally, your procedural rights, such as
the right to appeal and the right to disenroll, under both
traditional Medicare and the Medicare Advantage plans will be
included.
B.
You can request information from a Medicare Advantage plan about
how the plan works.
Before you enroll in any of the Medicare Advantage plans, you
may want to request information about the plan you are
interested in. By requesting information on the plan, you
will be able to know the specific services and doctors, hospitals,
home health care agencies and nursing homes offered by the plan.
This should help you in deciding if the plan is right for you.
You also have the right to information about the plan's service
area and whether the plan includes any coverage outside of this
area. For example, if you travel every year you may be
interested in knowing if the plan covers any services, other
than emergency and urgent care, outside of your area and if so,
how far will you have to travel. In addition, you may
request information about the specific benefits that are covered
under the plan and any costs that you may be responsible for.
You have the right to information about any mandatory or
optional supplemental benefits the plan offers. You
may obtain information about the plan's emergency service
coverage and prior authorization rules as well.
In addition to the above, you are entitled to information
about the number of doctors, hospitals, home health care agencies
and nursing homes that participate in the plan, their addresses,
and the specialties. A description of the plan's quality
assurance program should be made available to you. You
also have the right to information about the plan's grievance and
appeal rights.
Finally, you may request information about how to enroll in the
plan. Please be aware of some of the marketing techniques
for plans in your area. With some plans, if the application is
accepted, you will automatically be enrolled in the plan.
For other plans, you are not enrolled until you receive a notice
which may take a month or more.
C.
You can request certain types of additional information from the
plan or from CMS.
Anyone who is eligible to enroll in a Medicare Advantage plan
may request additional information about a plan. For
instance, you can request information from the plan about the
number of appeals and grievances that were filed and what the
results were. Further, you can ask for a description of
how the plan pays its providers, the plan's cost control
procedures, and the plan's financial condition.
You may request this information, in writing, from either your
plan or the Federal Government's CMS Regional Office V, 105
West Adams Street, 15th Floor, Chicago, Illinois 60603-6201.
D.
If you are enrolled in a Medicare Advantage plan you have the
right to receive additional information on request, and the plan
must send you certain information without you having to request
it.
If you have enrolled in a Medicare Advantage plan, you are
entitled to receive additional information. You will
receive information about the plan's service area, the
benefits included and excluded from coverage, and the plan's
providers. Your plan will also provide you with
information on coverage of emergency and urgent care services,
prior authorization rules, and out-of-area coverage.
Procedures for filing appeals and grievances with the plan must
be given to you as well. Finally, you will receive a
description of the plan's quality assurance program.
It is very important that you keep all of this information as
long as you are in the plan. You should put your policy
and other information from your Medicare Advantage plan in a
safe place where you can easily find it. This will help
if you have a question or problem with the plan's services.
If a plan changes any of its rules, it must notify its enrollees
at least 30 days before the change goes into effect.
If a plan terminates its contract with a provider, it must make
a good faith effort to provide notice to enrollees who receive
services regularly from the provider within 15 days. For
example, if a specialist that you were seeing leaves the network,
the plan must try to notify you within 15 days. If the
termination involves a primary care doctor, all patients of that
doctor must be notified.
Upon request, the plan must provide information to enrollees
demonstrating that the plan has a "fiscally sound" operation,
and about the ownership and control of the organization.
You should read all of the information you receive very
carefully before making any decisions. You may also want
to talk to someone if you have questions about any material you
receive, or if the material doesn't answer specific questions
that you have. You can call SeniorLAW at 278-1222 for
free information, or you can call the Medigap Helpline at
1-800-242-1060. The plan should also be able to answer
your questions, but remember that the plan's goal may be to get
you to enroll.
PRACTICAL POINTERS:
- Read carefully all of the information you get from
the Medicare Advantage plan before you enroll. If you have
any questions, don't make a decision until they are all answered!
-
Keep all information and papers that you receive from your
Medicare Advantage plan in a safe and easy to find place!
-
Just because you receive information from Medicare Advantage plans
does not mean that you have to switch!
V. YOU HAVE THE RIGHT TO RECEIVE NECESSARY SERVICES
A.
You have the right to receive accessible and quality services.
Regardless of which health care option you choose, you have the
right to readily available services. This means that you
must have access to medically necessary services twenty-four
hours a day, seven days a week. The right to receive
services includes access to treatment from qualified doctors,
including specialists, within the plan's service area and enough
providers to meet the needs of all of its enrollees.
This includes a sufficient number of primary care doctors,
specialists, hospitals, home health care agencies and nursing
homes. Further, special treatment provisions must be
made for women and enrollees with complex or serious medical
conditions. Finally, plans are required to monitor the
quality and performance of services.
Medicare Advantage plans must provide you with all of the
services that would be available to you under original
Medicare. Remember though that neither original Medicare
nor a Medicare Advantage plan will pay for all of your services.
For example, prescription medications are not paid for
by original Medicare and do not have to be paid for by a
Medicare Advamtage plan.
Regardless of which plan you are enrolled in, you have the right
to receive unbiased and unrestricted advice from your health care
provider. This means that plans cannot restrict your
physician from giving you advice about your condition or
treatment. Your physician must be able to advise you of
all your treatment options, without regard to whether the
services are covered by your plan and without regard to the
cost of the services.
If you are enrolled in a Medicare managed care plan, such as an
HMO, PSO, or PPO, you may not have the right to see the provider
of your choice. For instance, you may have to see your
primary care physician and obtain a referral before you can see
a specialist. Also, the Medicare Advantage plan has the
right to decide how to treat your medical problem. For
instance, you may think that a certain test is needed but the
plan has the choice of whether to provide that test or not.
If it is important to you to have complete and free choice of
providers and services, you may not want to enroll in a managed
care plan. If you remain in original Medicare, Medicare
will pay for your covered, medically necessary services from the
Medicare certified provider of your choice. In other words,
with original Medicare you can go to a specialist without a
referral and are not limited to only those doctors, hospitals or
nursing homes that are part of the network.
B.
You have the right to receive emergency services.
You have the right to coverage for emergency and urgent care
services. Emergency services include both inpatient and
outpatient services received from qualified providers that are
necessary to evaluate or stabilize an emergency medical condition.
Emergency: An emergency medical condition is a medical condition
that a reasonable, average person would consider necessary in
order to avoid: placing the individual's health in
serious jeopardy; serious impairment to bodily functions; or
serious disfunction of any bodily organ or part.
Urgently needed: Urgently needed services are services which are
provided while a person is temporarily outside of the plan's
service area. The services must be medically necessary
and immediately required as a result of an unforseen condition
and under the circumstances, it would not be reasonable to
receive the services through the person's plan. For
example, if you are on vacation and break a hip, this may be
considered urgently needed services and you would be able to
receive medical care from a doctor or hospital that is not a
part of the network.
Plans must cover emergency and urgently needed services without
requiring prior authorization and regardless of whether the
services were provided within the plan. However, you may
be responsible for either $50 or what the plan would charge if
the services were obtained through the plan, whichever is less.
C.
You have the right to a second opinion.
Whether you are enrolled in a Medicare Advantage plan or original
Medicare, you have the right to a second opinion in certain
situations. If you require a surgical procedure, you may
have a second opinion to determine whether the procedure is
medically necessary. However, in a managed care plan, you
may be required to receive the second opinion from a physician
who is also a part of the network.
Services, providers, and the right to receive needed health
care coverage are often the most important considerations in
choosing a health care plan. SeniorLAW has additional
information available regarding benefits available with
traditional Medicare and the Medicare Advantage plans.
PRACTICAL POINTERS:
-
You do not have to enroll in a Medicare Advantage plan to obtain
prescription drug coverage through Medicare Part D
-
A Medicare Advantage plan must provide at least the same basic
benefits as original Medicare, but does not have to cover all
of your medical needs.
-
A Medicare Advantage plan may provide some benefits not covered
by original Medicare. It is very important to look at
each specific plan to see what it covers.
-
Emergency services and urgently needed care should be paid by
your plan even if received from a provider that is not part of
your plan's network!
VI. YOU HAVE THE RIGHT TO FILE A GRIEVANCE OR APPEAL
When you are in a Medicare Advantage plan, you have the right
to complain or disagree with your plan. All Medicare
Advantage plans must have grievance and appeal procedures
in place for you to use if you are unhappy with something the
plan did or refused to do. It is important for you to
know the difference between a grievance and an appeal.
Appeal: you may file an appeal if payment has been
denied for services that you already received, or if you tried
to get prior authorization to receive a service and were denied.
You may also appeal if you disagree with the amount that
you must pay.
For example: if your Medicare Advantage plan is refusing
to allow or pay for a cataract surgery, you may appeal this
denial.
Grievance: if you are dissatisfied with the care or
services that you received from your plan or some other
aspect of the plan, you may file a grievance.
For example: if you had to wait a long time for an
appointment with your primary care doctor or had to wait
a long time in the waiting room, you may file a grievance.
The Medicare Advantage plan must provide all denials of
services or payment in writing. This denial notice
must provide an explanation of your rights to submit an appeal
or grievance.
Appeals: You must file an appeal within 60 days of
receiving the written denial, although you can file an
appeal as quickly as you choose. There are presently no
time limits for filing a grievance. If you file an appeal
or grievance, your plan must respond in a timely manner.
The amount of time it takes to resolve your appeal may depend
on your medical needs and whether you have already received the
service. Your plan must have a faster appeal process for
situations where your life or health may be in serious jeopardy.
The first step in an appeal takes place after you receive a
written notice as to whether the plan will allow or pay for a
service. After you have received this notice, you can
request, in writing, that the plan review its negative decision.
This step is called a reconsideration. You must request
reconsideration within 60 days of the written notice.
Then the plan has 60 days to make a decision.
However, you or a physician can request an "expedited" decision,
either orally or in writing. Where a physician requests
this, the plan must make a decision within, generally, 72 hours.
A physician does not have to be part of the plan's
network to request an expedited decision on your behalf. Where
you (not a physician) request the expedited decision, the plan
must decide your appeal within 72 hours if the plan determines
that your life or health may be in serious jeopardy.
If the plan continues to deny payment or services, it must
automatically send its decision to an independent agency, called
the Center for Health Care Dispute Resolution (CHDR).
CHDR then reviews your case and decides whether the plan's denial
was correct. CHDR must send you its decision in writing.
If CHDR upholds the plan's decision and the amount at
stake is $100 or more, you can request a hearing before an
Administrative Law Judge.
To request a hearing before an Administrative Law Judge, you must
submit a request for hearing to your local Social Security
Administration within 60 days of receiving the CHDR decision.
A hearing will be scheduled and you will have the
opportunity to speak with an Administrative Law Judge and
explain your case. You will receive a written decision
from the Judge. If you are still dissatisfied and the
amount at stake is $1,000 or more, you may go to Federal Court
for judicial review. Again, you must do this within 60
days of receiving the ALJ decision.
Grievances: The plan may set up its own procedure for
filing a grievance. The plan must tell you how to go
about filing a grievance.
While the specific procedures for filing grievances and appeals
will vary between plans, all Medicare Advantage plans must
include the procedures described above. Remember, you are
entitled to disagree with your plan but you must file an appeal
within 60 days of the denial.
A plan may encourage you to try to resolve problems informally
by meeting with the plan's representatives. This could
work for you, but remember that you also have the absolute right
to go through formal procedures, and remember that there are
time limits for those procedures! If in doubt, file an
appeal and try to work it out afterward. Remember also that
you have the right to have a representative help you on your
appeal. This could be an attorney, a benefit specialist
or a friend or relative. SeniorLAW may be able to represent you
free of charge if your case has merit!
SeniorLAW has more information about appeals and grievances
available to you free of charge. SeniorLAW can also look
at your case and give you advice or represent you in your
appeal. All SeniorLAW services are free.
PRACTICAL POINTERS:
-
If your Medicare Advantage plan or original Medicare refuses to
pay for a service you need or have received, call
SeniorLAW to talk about whether that decision was correct!
-
If you have appealed a denial of services and have not received
a decision,call SeniorLAW for free advice!
-
If in doubt about a denial of services or payment: appeal,
appeal, appeal!
VII. CONCLUSION
People with Medicare have options in the way that they receive
their health care services. There are new plans which are
part of the Medicare Advantage program. However, in
the Milwaukee area the alternatives are currently original
Medicare or a Medicare HMO.
The Medicare Advantage plans are not appropriate for everyone.
Some people will benefit greatly with a managed care plan,
others require more freedom of choice that is found in original
Medicare. This may be the most important health care
decision that you make! Do not rush into anything, talk
to your doctors and specialists and think carefully of your
needs now and in the future.
Remember, you don't have to switch to a Medicare Advantage
plan. If you choose to switch, don't be afraid to stand
up for your rights! For any questions or assistance
with original Medicare or Medicare Advantage, please call
SeniorLAW at 278-1222 if you live in Milwaukee County, or your
benefit specialist if you live outside of Milwaukee County.
VIII. APPENDIX -- TYPES OF MEDICARE ADVANTAGE PLANS
1. HEALTH MAINTENANCE ORGANIZATIONS (HMOs):
A HMO is a type of managed care plan where a beneficiary's
primary care physician coordinates and controls access to care.
The beneficiary must receive medical services from an
approved network of doctors, hospitals, skilled nursing
facilities, and other providers included in the plan.
2. PREFERRED PROVIDER ORGANIZATIONS (PPOs): A PPO is a
type of managed care plan with a network of providers.
A person in a PPO is not required to use the network providers.
There is, however, an incentive for using the network
health care providers such as lower co-pays.
3. PROVIDER SPONSORED ORGANIZATION (PSOs): A PSO is very
similar to a HMO. The main difference is that the PSO
network is developed, organized and managed by hospitals and
doctors rather than by private insurance companies.
4. MEDICARE MEDICAL SAVINGS ACCOUNTS (MSAs): Under this
type of plan, you would combine tax-free contributions from the
Medicare program to an interest-bearing savings account with a
high deductible health insurance policy. Medicare pays
the monthly premiums for the insurance policy but it will not
cover your health care costs until you meet the high
deductible. The policy would then have to pay for at least
all Medicare covered items and services. The deductible
could be as high as $6,000 per year. The money in the
savings account may be used for medical expenses, even if those
expenses would not have been covered by Medicare.
5. PRIVATE FEE-FOR-SERVICE PLANS: In a private fee-for-service
plan you choose a private insurance company that accepts persons
with Medicare. You may pay a monthly premium for the
private insurance and an amount for each health care service
you receive.
6. RELIGIOUS FRATERNAL BENEFIT SOCIETY PLANS: This is a special
plan developed which may restrict to members of that church or
affiliated group.
|
