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A Guide to Consumer Protections for Seniors Enrolled in Medicare HMOs
Prepared by: Mark Setterfield
Acknowledgments I would like to thank, without implicating, the following for their help during the preparation of this Guide: Danny Albert, Connecticut State Insurance Department; Sarah Clark, CHOICES; Michael Katz, HCFA; Pam Meliso, Center for Medicare Advocacy; and Steve Miller, HCFA.
1. Introduction Medicare is a complicated program and can be difficult to understand. The new Medicare + Choice program, which allows you to choose new ways of receiving your Medicare benefits, makes things more complicated still. More choice can be good, of course. And the new options that Medicare + Choice provides - which include joining an HMO - may increase the range of health care services available to you. But as the number of Medicare plans grows, the program as a whole is becoming less and less standardized. It is sometimes difficult to find or understand information about different Medicare providers, which makes it hard to comparison shop, or to know which option best suits your needs. Because of this, new consumer protections have been created by the state and federal governments. These protections are there to safeguard your rights to good quality, affordable and accessible Medicare coverage. This Guide describes consumer protections for seniors enrolled in Medicare HMOs. It tells you how you are protected and what you need to do in order to take advantage of certain protections. It also calls attention to some gaps in the new protections that it is important for you to be aware of.
2. Consumer Protections at the Federal Level The federal law that created the Medicare + Choice program includes a wide variety of consumer protections. Many of these protections are general - in other words, they apply to all Medicare beneficiaries. Others have been specially designed for those who enroll in Medicare HMOs. In this section, the consumer protections that you can expect if you enroll in a Medicare HMO are described under into the following nine headings: · Enrollment and Disenrollment · Information and Education · Marketing · Benefits · Premiums and Cost Sharing · Access to Care · The Appeals Process · Quality of Care · Monitoring HMOs
i) Enrollment and Disenrollment An important feature of the Medicare + Choice program is that, beginning in 2002, your ability to leave an HMO once you have enrolled will be limited. The table below explains how your rights to disenroll from an HMO will change over the next three years.
Disenrolling from a Medicare + Choice HMO
Source: Dallek (1998) Notice that, beginning in the year 2002, you will be "locked in" to any HMO that you choose to join at the start of the year for at least the rest of that year. However, there are some important exceptions to these rules which are designed to protect you if you move away from your current home area or if your HMO behaves unfairly:
One final point. Remember that your HMO can end your enrollment if you fail to pay premiums in a timely fashion, if your behavior is disruptive, or if you commit fraud. However, you have a 90-day grace period to pay your premiums. Also, your HMO cannot terminate your membership because of disruptive behavior if this behavior is caused by diminished capacity or by your use of medical services.
CONSUMER ALERT - the Medicare + Choice program reduces your ability to leave an HMO once you have joined. Although there are some exceptions to the new, more restrictive disenrollment rules, you must be sure that you have picked the right plan before you decide to enroll in a Medicare + Choice HMO.
ii) Information and Education Making choices is difficult without good information. To make sure that you have enough information, and to protect you against information that is misleading, the Medicare program and Medicare HMOs (and other Medicare providers) must send you the following information:
Medicare + Choice HMOs are not allowed to use "gag orders" - that is, rules that stop your doctor from telling you everything that you need to know about your health and the types of care that are possible. Finally, any personal information that you give to the Medicare program - such as your name and social security number - must be kept private by the program. Medicare will require you to provide some personal information. But it may also ask for information that you don’t have to provide if you would rather not. If you are unsure about what information you must provide and what is optional, you can call 1-800-MEDICARE (1-800-633-4227).
CONSUMER ALERT - although you will receive a lot of information from organizations such as HMOs describing their plans, don’t expect this information to be completely standardized. Be aware, then, that it may not be easy for you to accurately compare the plans of different HMOs in your home area.
iii) Marketing Marketing can be informative - or misleading. Medicare + Choice HMOs must submit their marketing and application materials to the Secretary of Health and Human Services for review before they can send them to you. They must also market their plans in both high- and low-income communities and to disabled people under the age of 65 and translate their materials whenever there is a large, non-English speaking population in their service area.
CONSUMER ALERT - Medicare + Choice HMOs are allowed to use independent insurance agents to market their plans. These insurance agents may not be trained or supervised by the HMOs they work for and they may be paid commissions for each new enrollee that they recruit.
iv) Benefits All Medicare + Choice HMOs must provide at least the benefits available through the traditional Medicare fee-for-service program. In certain circumstances, HMOs will also be required to provide you with additional services - over and above those available through the traditional Medicare program - as part of their basic benefits package. Indeed, all Medicare + Choice HMOs must provide two benefits that are not part of the fee-for-service program: an initial assessment of your health care needs (within 90 days of your enrollment); and, when appropriate, instruction in self-administered care. Optional, supplementary benefits may also be made available through your HMO. Finally, you are entitled to the same benefits as any other plan member. Medicare + Choice HMOs are not allowed to offer different benefits to different members.
CONSUMER ALERT - Medicare + Choice HMOs that are required to offer additional benefits (as described above) may not offer the same additional benefits. You shouldn’t expect plans to be standardized. Once again, then, you should bear in mind that this may make it difficult to compare the plans offered by different HMOs. You should also bear in mind that the same HMO may offer different additional benefits from year to year. If you join an HMO because of, say, its prescription drug benefits, make sure that these benefits haven’t changed before you commit yourself to the HMO for another year.
v) Premiums and Cost Sharing Medicare + Choice HMOs must abide by the following rules when setting their premiums and cost-sharing arrangements:
vi) Access to Care No matter how you receive your Medicare benefits, you are covered by certain basic guarantees that ensure access to health care. First, you are entitled to care 24 hours a day, seven days a week. Second, you are entitled to see specialists for medically necessary care. And finally, you must be served in a fashion that respects language and other cultural differences. If you enroll in a Medicare + Choice HMO, you should expect to receive most of your health care from a designated network of care givers. You may be able to purchase a point-of-service option, however. This will allow you to visit care givers who are not part of your HMO’s network of providers, and without a referral. But you should expect higher out-of-pocket costs for any care you receive in this way. Your access to care is also affected by the following consumer protections:
· Access to specialists - you can choose a women’s health care specialist from your HMO’s list of providers to meet your routine and preventative women’s health care needs. Your HMO must also identify any complex or serious medical conditions that you suffer from and provide you with direct access to specialists - without referral - to meet your health care needs. · When a specialist leaves your HMO’s network - your HMO must tell you about other Medicare + Choice plans that your specialist belongs to and tell you how to return to the traditional, fee-for-service Medicare program.
vii) The Appeals Process If you are denied care that you think you are entitled to, you can appeal your HMO’s decision. Your HMO must tell you within 14 days whether or not it will provide you with a particular service (although it can seek an extension in some circumstances). If the service is denied, the HMO must write to you to explain why and to describe the following five-step appeal process:
STEP #1: Reconsideration - begin by requesting, either verbally or in writing, that your HMO reconsider its decision. It must respond to your request within 30 days (although it may be granted a 14 day extension in some circumstances). Any decision about the medical necessity of a service must be made by a physician.
STEP #2: Review by Independent, Outside Body - if step #1 fails, your request for reconsideration will automatically be forwarded to an independent, outside reviewer for further consideration.
STEP #3: Administrative Law Judge - if step #2 fails, and as long as your appeal concerns an amount of at least $100, you have 60 days to appeal, in writing, to an Administrative Law Judge.
STEP #4: Appeals Board - if step #3 fails, you can refer your appeal to a Department of Health and Human Services Appeals Board
STEP #5: Judicial Review - finally, all else failing, and as long as your appeal concerns an amount of at least $1000, you are entitled to a judicial review of your appeal.
You also have the right to an expedited review if the normal time that it would take to review your claim could harm your health. In this case, the HMO’s original decision and steps #1-2 of the appeals process described above must be completed within 72 hours (although your HMO can extend this by up to 14 days in some circumstances). You should also note that, although your HMO must grant a physician’s request for expedited review, it does not have to grant a request that comes directly from you. If you are in a hospital, you have special rights. You can appeal to a Peer Review Organization if your HMO discharges you from the hospital before you think you are ready to leave. When you enter a hospital, you should receive a notice called An Important Message From Medicare, which explains your rights to hospital care, and what to do if you think that you are being made to leave the hospital too soon. This notice will include the telephone number of the Peer Review Organization in your home area. You can call the Peer Review Organization if you have any questions about your rights to hospital care or to appeal a decision by the hospital to make you leave. You are allowed to stay in the hospital - at no charge to yourself - at least until the day after the Peer Review Organization has made a decision about your appeal.
viii) Quality of Care The quality of the care that you receive from your HMO is monitored by the federal government in a variety of ways. First, your HMO must set up its own Quality Assessment and Performance Improvement Program, to monitor member satisfaction and provide information about the quality of care that it provides to the Secretary of Health and Human Services. Your HMO must also achieve certain minimum quality standards and show how it has improved its performance over time in one targeted clinical area (such as the treatment of a particular disease) and one targeted non-clinical area (such as members’ access to health care services). Second, your HMO will be periodically reviewed by an external agency. And finally, your HMO is prohibited from making any payments to physicians that encourage them to reduce the amount of care that you receive.
ix) Monitoring HMOs The rules and regulations described above will only help you if they are properly enforced. A number of efforts are being made by the federal government to monitor Medicare + Choice HMOs, to make sure that they meet the proper standards of health care provision. For example:
3. Consumer Protections at the State Level Most of the consumer protections that will affect you if you enroll in a Medicare + Choice HMO are administered by the federal government. But the Connecticut state government has made one important addition to these federal protections, which fits in with federal efforts to regulate information as discussed in section 2.(ii) above. A law passed last year requires the Connecticut Department of Social Services - through its CHOICES program - to create and distribute a Connecticut Medicare consumers guide. This guide, which will be available to anyone who requests a copy, will include the following:
All HMOs - and any other organizations - that provide care to Connecticut Medicare beneficiaries must supply the State Insurance Commissioner with the information needed for this guide. HMOs can be fined if they fail to provide the information in a timely fashion. Until the Connecticut Medicare consumer guide becomes available - and even after it is available - remember that you can contact the Connecticut CHOICES program for free information and assistance when you are trying to decide which Medicare + Choice plan is best for you. It is even possible to arrange for a member of the CHOICES staff to visit you or your family in your home. You can reach CHOICES by phoning your regional Area Agency on Aging, or by dialing a statewide hotline. Here are the phone numbers that you will need to contact CHOICES:
4. And Finally If, for any reason, you think that your rights as a Medicare beneficiary have been violated, you can always call the State Health Insurance Assistance Program. In Connecticut, the State Health Insurance Assistance Program can be reached by phone at the following numbers: TOLL FREE (in-state only): 1-800-994-9422 OR: 1-860-424-5245 1-860-842-5424 ( TTY)
References The following sources were referred to in the preparation of this Guide. Section 1 of the Guide draws extensively on Dallek (1998).
HCFA, "Medicare patient’s rights," Publication No. HCFA-10112
HCFA, "Medicare and You 2000"
Public Act 99-177, An Act Creating a Medicare Consumer’s Guide |