Photo by Jakub Żerdzicki on Unsplash
One of the most essential things a new Medicare beneficiary can do — besides reading the handbook — is to brush up on the program’s rights and protections, according to Francine Chuchanis, Direction Home Akron Canton’s director of entitlement rights.
“They need to know their rights so that they can obtain the covered benefits they have under the law and the benefits that they need to maintain their health,” Chuchanis says.
Direction Home, a nonprofit that assists older adults and those with disabilities in Portage, Stark, Summit and Wayne counties, makes teaching the Medicare community about those rights and protections part of its mission. Each year, the organization provides a free seminar on enrollment, coverage selection, legislative initiatives, protections and rights. This year’s event is set for Oct. 21, during Medicare open enrollment — Oct. 15 to Dec. 7.
Before you can understand your rights and protections, however, you must understand the differences between Medicare plans — chiefly original Medicare (which includes Part A, hospital insurance, and Part B, medical insurance) and Medicare Advantage (also known as Part C, a Medicare-approved private plan). You are first eligible to enroll in Medicare parts A and B three months before you turn 65 through three months after this birthday. Once you obtain this coverage, you may be eligible to switch to Medicare Part C. The protections and rights a beneficiary is afforded can depend on which route they’ve chosen.
“Traditional Medicare is where you use your red, white and blue card,” says Chuchanis. “Under traditional Medicare, you can go to any Medicare provider in the United States, but there aren’t a lot of extra benefits that you might have when you join a Medicare Advantage plan, like dental coverage, vision coverage, going to a gym.”
Medicare Advantage plans do offer those additional benefits — but can require prior authorizations for some services.
“Under traditional Medicare, that is not the case. … You don’t have to go through that process,” she explains. “The biggest difference is the provider network. Typically, in a Medicare Advantage plan, you may have to only use their in-network providers or pay a little bit more if they allow you to go out of network.”
Those with original Medicare may need to supplement with a Medicare Part D plan, which helps with the cost of prescription drugs. (Medicare Advantage usually includes drug coverage.)
“Every year, they should look at their coverage. They should make a list of the medications that they take and the dosages,” Chuchanis says. “If they start there, they can go online, and they could compare what they would spend for traditional Medicare with a Part D plan and what they would spend under a Medicare Advantage plan.”
Only original Medicare users can add supplemental private insurance — also known as Medigap — to help pay extra costs. The open enrollment period for Medigap begins the first month a beneficiary 65 or older has Medicare Part B.
“Supplemental insurance is private insurance people buy to cover the cost gaps in traditional Medicare,” Chuchanis explains. “Supplemental plans will cover the out-of-pocket expenses incurred under traditional Medicare.”
Additionally, emergency care in the United States is generally covered by both original Medicare and Medicare Advantage plans.
Once a plan type has been selected, it’s important to make sure you know what is entitled to you — that knowledge could be key to your well-being.
All Medicare Plans
There are some rights and protections afforded to all Medicare recipients, regardless of the plan they choose. One right is to be treated with courtesy and respect.
“Every Medicare beneficiary has the right to be spoken to by plan representatives and all Medicare providers in a courteous manner and to have their questions answered honestly regarding coverage,” Chuchanis explains. “I have had individuals call me who feel they’ve called Medicare and not gotten … an appropriate response. It is a right — they can call Medicare back and file a grievance.”
The ability to file a grievance — a complaint about a plan or the quality of care or services obtained from a Medicare provider, including (but not limited to) a doctor or hospital — is another broad right. You can get a Medicare Beneficiary Ombudsman to assist in the filing process, which shifts depending on the complaint type.
All people receiving Medicare are protected from discrimination.
“Medicare recipients should receive the same equitable treatment by all Medicare providers and be able to receive all medically necessary covered services,” says Chuchanis. “This includes receiving information in a language that is understandable. That could even include receiving information in Braille, larger print or sign language.”
Beneficiaries have the right to receive easy-to-understand information about Medicare, including what is covered, how much they have to pay, what Medicare pays for covered elements and how to file a complaint or appeal. They’re also entitled to get Medicare-related questions answered — by calling the Medicare ombudsman program, Medicare itself or trained Medicare counselors through the Ohio Senior Health Insurance Information Program. They should be participating fully in decisions regarding their health care.
“When somebody loses capacity, or assigns another person to act on their behalf, or if a person has a guardian or other legal authority — that’s the only time when another individual should be making a decision for a Medicare beneficiary,” she explains.
It’s important to note that all beneficiaries have a right to their personal and health information’s privacy. This information should only be available to the beneficiary or their legal representative. Any records used in decision-making fall under the right to privacy, including enrollment information, billing information and medical and case management records. Those on Medicare can receive a copy of their medical record from any Medicare provider, but they must be prepared to pay a fee.
Original Medicare
As mentioned previously, those on original Medicare may go to any provider participating in Medicare in the country. If a service, supply, drug or item is not covered by Medicare, those on the original plan should first receive an Advance Beneficiary Notice of Non-coverage. This notifies the person that Medicare won’t cover the service, supply, item or drug.
If someone on original Medicare is denied coverage, there are five steps to the appeals process: First, a redetermination by a Medicare Administrative Contractor; second, in Ohio, a reconsideration by a Quality Improvement Organization; third, an appeal to the Office of Medicare Hearings and Appeals; fourth, a Medicare Appeals Council review; and, finally, a judicial review.
“Most appeals don’t go past the Office of Medicare Hearings and Appeals,” says Chuchanis. “Regular appeals will take 30 days for services, 60 days for billing. … They can request what’s called an expedited appeal, and those will be responded to within 72 hours.”
Those on original Medicare should also receive quarterly statements about their coverage and payment, called a Medicare Summary Notice. (Those with Part D plans should also expect monthly statements.)
Medicare Advantage
Since those with Medicare Advantage have the right to choose a provider within the plan’s network, it’s key to understand your plan type. If the plan is a Health Maintenance Organization, the beneficiary should generally use the providers in network. Under a Preferred Provider Organization plan, recipients may be able to go out of the network but will likely pay more.
“If you’re in a Medicare Advantage plan that only allows you to go to the in-network providers and you go to an out-of-network provider,” Chuchanis warns, “you will be responsible for the bill.”
Those on Medicare Advantage also have the right to obtain a treatment plan from a doctor and may receive statements about what is covered.
If coverage is denied, beneficiaries can appeal the decision. Under Medicare Advantage, someone can first ask for a reconsideration by the plan.
“If the plan still denies it, then it goes to, again, the Quality Improvement Organization. So somebody outside the plan is reviewing it, and they will give a response,” Chuchanis says.
The final three phases of the appeals process are the same as the steps for beneficiaries with original Medicare.
Medicare can be confusing — doubly so when considering the differences between plans. Your rights and protections, however, are worth the time it takes to understand them. Make sure you read your handbook and evidence of coverage notice to see a full listing of your rights and protections under Medicare.
Clarifying Care
Learn how a Medicare Beneficiary Ombudsman can help you.
If you have questions about your plan, you may be pointed to a Medicare Beneficiary Ombudsman. This is a person hired by Medicare to assist beneficiaries with questions, complaints and the understanding of their rights and protections.
“It’s a helpline through Medicare itself,” Chuchanis says.
An ombudsman can assist with the filing of grievances and appeals. So, who might benefit from calling a Medicare ombudsman?
“Anybody who has questions about their coverage or any denials that they might have received. … Or if they have complaints against Medicare,” she says. “Sometimes denials from Medicare can be incorrect. An outside, independent authority might be needed to review that decision.”
Though Chuchanis is an ombudsman through MyCare Ohio, she does not work for Medicare. Depending on the information the beneficiary would like to discuss, speaking to someone outside of Medicare is another option.
“We consider ourselves to be independent advocates,” Chuchanis says. “We’re not a government agency. We do receive state and federal funds, but I’m not paid by the government, so I tell people the truth.”
For more info, contact Direction Home Akron Canton, 1949 Town Park Blvd., Uniontown, 800-421-7277, dhad.org
