2. Rights and Protections

2.1 How Medicare’s Beneficiary Ombudsman is Working For You

Web Address

Pub Date

No. of Pages

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Appropriate

Audience

Pub Number/ Type

http://www.medicare.gov/Publications/Pubs/pdf/11173.pdf

11/05

2

CMS

Beneficiary

11173

This fact sheet provides a brief description of the goals of Medicare's Beneficiary Ombudsman.

2.2 Medicare Prescription Drug Coverage: How to File a Complaint, Coverage Determination, or Appeal

Web Address

Pub Date

No. of Pages

Published By

Appropriate

Audience

Pub Number/ Type

http://www.medicare.gov/Publications/Pubs/pdf/11112.pdf

4/06

8

CMS

Beneficiary

11112

This fact sheet explains to people with Medicare how to file a complaint, coverage determination, or appeal if they enroll in a Medicare drug plan.

Spanish

2.3 Flow Chart: Medicare Part D Appeals Process

Web Address

Pub Date

No. of Pages

Published By

Appropriate

Audience

Pub Number/ Type

http://www.cms.hhs.gov/partnerships/downloads/flowchart.pdf

2006

1

CMS

Beneficiary

Tool

This job aid, visual aid, or tool explains the appeals process for Part D. It provides information about each step of the coverage determination and appeals processes, including amount in controversy (AIC) requirements.

2.4 Medicare Beneficiaries Urged to be on the Lookout for phone scams.

Web Address

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No. of Pages

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Appropriate

Audience

Pub Number/ Type

http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1794

3/06

1

CMS

Beneficiary

Notice

This notice provides information about telephone scams and provides tips people should take to avoid being a victim of fraud.

2.5 Medicare Prescription Drug Coverage and Your Rights

Web Address

Pub Date

No. of Pages

Published By

Appropriate

Audience

Pub Number/ Type

http://www.cms.hhs.gov/partnerships/downloads/
yourrightsfactsheet.pdf

2006

1

CMS

Beneficiary

10147

This fact sheet explains to beneficiaries how plan sponsors must either post or distribute the pharmacy notice to beneficiaries about their right to request and obtain a coverage determination. A plan sponsor must arrange with its network pharmacies to post or distribute the notice.

2.6 Part D Grievances, Coverage Determinations, and Appeals

Web Address

Pub Date

No. of Pages

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Appropriate

Audience

Pub Number/ Type

http://www.cms.hhs.gov/partnerships/downloads/cda.pdf

2006

2

CMS

Beneficiary

Fact Sheet

This fact sheet provides the process for resolving grievances, coverage determinations, and appeals under the Medicare Part D program.

2.7 Quick Facts About Medicare Prescription Drug Coverage and Protecting Your Personal Information 

Web Address

Pub Date

No. of Pages

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Appropriate

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http://www.medicare.gov/Publications/Pubs/pdf/11147.pdf

2/07

2

CMS

Beneficiary

11147

This fact sheet provides information to aid in protecting a person with Medicare’s personal health information (PHI), and provides tips on identifying theft and fraud. 

Spanish

Chinese

Korean

Russian

Tagalog

Vietnamese

2.8 Prescription Drug Benefit Manual - Chapter 9: Part D Program to Control Fraud, Waste and Abuse

Web Address

Pub Date

No. of Pages

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Appropriate

Audience

Pub Number/ Type

www.cms.hhs.gov/PrescriptionDrugCovContra/Downloads/
PDBManual_Chapter9_FWA.pdf

4/06

71

CMS

Partner

Reference

This reference provides both interpretive rules and guidelines for Part D plan sponsors on how to implement the regulatory requirements under 42 C.F.R. § 423.504(b)(4)(vi)(H) to have in place a comprehensive fraud and abuse plan to detect, correct and prevent fraud, waste and abuse as an element of their compliance plan. While CMS regulations require Sponsors to implement a comprehensive fraud and abuse program, it is at the Sponsor's discretion to adopt the methods suggested within this chapter on how to implement a comprehensive fraud and abuse program. Additionally, this chapter outlines CMS’ guidelines for operational issues such as handling complaints, and coordinating with CMS and law enforcement.

2.9 Eliminating Serious, Preventable, and Costly Medical Errors – Never Events

Web Address

Pub Date

No. of Pages

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Appropriate

Audience

Pub Number/ Type

http://www.cms.hhs.gov/media/press/release.asp?Counter=1863

5/06

N/A

CMS

Partner

Fact Sheet

This fact sheet contains the announcement from Mark B. McClellan, M.D., Ph.D., that CMS is investigating ways that Medicare can help to reduce or eliminate the occurrence of “never events” – serious and costly errors in the provision of health care services that should never happen. Such action is part of the Agency's ongoing efforts to pay for better care, not just more services and higher costs. “Never events,” like surgery on the wrong body part or mismatched blood transfusion, cause serious injury or death to beneficiaries, and result in increased costs to the Medicare program to treat the consequences of the error.

2.10 Identity Theft and Your Social Security Number

Web Address

Pub Date

No. of Pages

Published By

Appropriate

Audience

Pub Number/ Type

http://www.socialsecurity.gov/pubs/10064.pdf

1/06

8

SSA

Beneficiary

05-10064

This job aid, visual aid, or tool from SSA explains the steps people can take to protect themselves from someone stealing their identity and/or social security number.

2.11 Financial Liability Notices and Expedited Determination Notices

Web Address

Pub Date

No. of Pages

Published By

Appropriate

Audience

Pub Number/ Type

http://www.cms.hhs.gov/BNI/

12/05

N/A

CMS

Partner

Sample

This is a sample or model letter, mailing, or notice.  Both Medicare beneficiaries and providers have certain rights and protections related to financial liability under the Fee-for-Service (FFS) Medicare and the Medicare Advantage (MA) Programs. Providers communicate these financial liability and appeal rights and protections to beneficiaries through notices. This library contains links and instructions for these notices. Notices include the Advance Beneficiary Notice – General, the Home Health Advance Beneficiary Notice (HHABN – CMS R-296), the Advance Beneficiary Notice – Laboratory, and the Skilled Nursing Facility Advance Beneficiary Notice used by providers for situations where Medicare payment is expected to be denied.  See also CMS R-193, a hospital admission notice given to all beneficiaries in Original Medicare and Medicare Advantage enrollees to alert them of their appeal rights at discharge from a hospital stay. 

2.12 Financial Liability Guidelines (Determining Who Is Responsible) 

Web Address

Pub Date

No. of Pages

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Audience

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http://www.cms.hhs.gov/manuals/downloads/clm104c30.pdf

Rev. 1025, 8/06

198

CMS

Partner

MCM - Chapter 30

This reference is Chapter 30 in the Medicare Claims Processing Manual: Financial Liability Protections. This chapter instructs Fee-for-Service (FFS) contractors how to determine liability.

2.13 Train-the-Trainer Module 2. Rights and Protections for People with Medicare 

Web Address

Pub Date

No. of Pages

Published By

Appropriate

Audience

Pub Number/ Type

http://www.cms.hhs.gov/NationalMedicareTrainingProgram/TL/list.asp

4/07

69

CMS

Partner

Classroom

This detailed classroom training module (zipped, PowerPoint slides with Speaker’s Notes) provides an overview of beneficiary rights, such as the right to get medically necessary health care services; the right to file a complaint; and where to get help with questions. Topics cover a variety of settings: rights and protections in the Original Medicare Plan; hospital, skilled nursing facility, and home health care rights; privacy practices in the Original Medicare Plan; rights and protections in a Medicare Health Plan; rights and appeals in a Medicare drug plan. Visit the Training Library for updates.

2.14 Your Medicare Rights & Protections 

Web Address

Pub Date

No. of Pages

Published By

Appropriate

Audience

Pub Number/ Type

http://www.medicare.gov/Publications/Pubs/pdf/10112.pdf

4/06

44

CMS

Beneficiary

10112

This booklet explains rights for people with Medicare.

2.15 Protecting Your Health Insurance Coverage

Web Address

Pub Date

No. of Pages

Published By

Appropriate

Audience

Pub Number/ Type

http://www.medicare.gov/Publications/Pubs/pdf/10199.pdf

9/00

52

CMS

Beneficiary

10199

This booklet explains the rights and protections of people with Medicare resulting from the Health Insurance Portability and Accountability Act of 1996, known as HIPAA.

2.16 Medicare's Incentive Reward Program for Fraud and Abuse

Web Address

Pub Date

No. of Pages

Published By

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Audience

Pub Number/ Type

http://www.medicare.gov/Publications/Pubs/pdf/rmf.pdf

12/98

1

CMS

Beneficiary

Tip Sheet

This tip sheet describes how to get a reward for information leading to the recovery of Medicare funds from health care providers who engage in fraud and abuse in the Medicare program.

2.17 Medicare Managed Care Appeals   

Web Address

Pub Date

No. of Pages

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Appropriate

Audience

Pub Number/ Type

http://www.medicareappeals.com/Page.asp?Script=8

N/A

N/A

CMS

Partner

Link

This site, web page, or URL provides information regarding Managed Care Appeals

2.18 Quality Improvement Organization Manual

Web Address

Pub Date

No. of Pages

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Appropriate

Audience

Pub Number/ Type

http://www.cms.hhs.gov/Manuals/IOM/itemdetail.asp?filterType=
none&filterByDID=-
99&sortByDID=1&sortOrder=ascending&itemID=CMS019035

8/05

N/A

CMS

Partner

100-10

This reference or manual provides program requirements for Quality Improvement Organizations (QIOs). See also webinar to illustrate ways that MA Plans and QIOs can increase the utilization of the information in their HOS reports, including: Review of the Medicare HOS Baseline and Performance Measurement Reports; Strategies for using more data from the HOS Baseline and Performance Measurement Reports to facilitate organizational Quality Improvement activities.  Learn more.  Update! See also official MedQIC website.  See listing of QIOs by State and their contact information.  Click here for more information on the improvement of the QIO Program.

2.19 Prescription Drug Coverage Contracting - Plan Reporting and Oversight 

Web Address

Pub Date

No. of Pages

Published By

Appropriate

Audience

Pub Number/ Type

http://www.cms.hhs.gov/PrescriptionDrugCovContra/
08_RxContracting_ReportingOversight.asp

3/07

N/A

CMS

Partner

Link

This site, web page, or URL contains information summarizing Part D plan sponsor responsibilities regarding fraud, waste, and abuse in the Prescription Drug Program and provides an overview of CMS reporting requirements.  Update!  See Changes to Part D Sponsors’ Medication Therapy Management Program (MTMP) and FAQ tool providing answers to questions (Q&A or QA) on 2006 Part D Reporting Requirements (23 pages).

2.20 Helping Patients Get the Best Care for Their Needs

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No. of Pages

Published By

Appropriate

Audience

Pub Number/ Type

http://www.cms.hhs.gov/media/press/release.asp?Counter=1872

6/06

1

CMS

Beneficiary

Fact Sheet

This fact sheet provides information to empower consumers through access to healthcare information.

2.21 Prescription Drug Benefit Manual - Chapter 18: Part D Enrollee Grievances, Coverage Determinations and Appeals

Web Address

Pub Date

No. of Pages

Published By

Appropriate

Audience

Pub Number/ Type

http://www.cms.hhs.gov/PrescriptionDrugCovContra/
Downloads/PartDManualChapter18.pdf

2/07

101

CMS

Partner

Reference

This reference provides interpretive rules and guidance for Part D plan sponsors on how to implement the regulatory requirements under 42 C.F.R. § 423, Subpart M (Part D grievances, coverage determinations and appeals).  Same as reference #4.97

2.22 Medicare Managed Care Appeals & Grievances

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Pub Date

No. of Pages

Published By

Appropriate

Audience

Pub Number/ Type

www.cms.hhs.gov/MMCAG

12/05

N/A

CMS

Partner

Link

This site, web page, or URL provides information regarding Medicare managed care notice and appeals requirements – including the right to a fast appeal for Medicare health plan enrollees receiving services from an inpatient hospital, skilled nursing facility, home health agency, or comprehensive outpatient rehabilitation facility, who think their Medicare-covered services are ending too soon.  Update! See also MAXIMUS website – the CMS Independent Review Entity (IRE).

2.23 Transmittal 594 – Instructions for Expedited Determinations in Original Medicare

Web Address

Pub Date

No. of Pages

Published By

Appropriate

Audience

Pub Number/ Type

www.cms.hhs.gov/Transmittals/downloads/R594CP.pdf

6/05

95

CMS

Partner

100-04

This reference provides preliminary instructions for Expedited Determinations//Reviews for Original Medicare and Instructions for Hospital Initiated Notices of Non-coverage.

2.24 HHS Office for Civil Rights – Privacy

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Pub Date

No. of Pages

Published By

Appropriate

Audience

Pub Number/ Type

http://www.hhs.gov/ocr/hipaa

6/06

N/A

HHS

Partner

Link

This library of resources provides legal guidance relating to prescription drug plans disclosing protected health information to those individuals assisting beneficiaries with Part D issues.

2.25 Prescription Drug Benefit Manual
Chapter 5:  Benefits and Beneficiary Protections   

Web Address

Pub Date

No. of Pages

Published By

Appropriate

Audience

Pub Number/ Type

http://www.cms.hhs.gov/PrescriptionDrugCovContra/12_PartDManuals.asp

3/07

50

CMS

Partner

Link

This reference, Chapter 5, consolidates previous guidance, questions and answers, and HPMS memoranda.  In particular, it covers information specific to the following areas: Part D benefits offered by Part D sponsors; establishment of PDP service areas; Access standards with regard to covered Part D drugs; Disclosure to beneficiaries of pricing information for generic versions of covered Part D drugs; and Privacy, confidentiality, and accuracy of PDP sponsors’ enrollee records.  Content includes: Requirements Related to Qualified Prescription Drug Coverage (what constitutes Standard Coverage, Alternative Standard, and Alternative Enhanced Coverage); Costs that count and do not count toward True-Out-Of-Pocket (TrOOP) incurred costs (p. 22); establishment of PDP service areas; Access standards for Part D covered drugs (retail pharmacy, mail order, specialty pharmacy, home infusion pharmacy, long term care - LTC pharmacy, I/T/U pharmacy, pharmacy network); Out of network access; physician office access to vaccines; Public Disclosure of Pharmaceutical Prices for Equivalent Drugs; Privacy, Confidentiality, and Accuracy of Enrollee Records.

2.26 Medicare Pay for Performance (P4P) Initiatives

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Pub Date

No. of Pages

Published By

Appropriate

Audience

Pub Number/ Type

http://www.cms.hhs.gov/apps/media/press/release.asp?counter=1343

1/05

1

CMS

Partner

Notice

This notice describes various initiatives that encourage quality of care:  Hospital Quality Initiative (MMA section 501b); Premier Hospital Quality Incentive Demonstration; Physician Group Practice Demonstration (BIPA 2000); Medicare Care Management Performance Demonstration (MMA section 649); Medicare Health Care Quality Demonstration (MMA section 646); Chronic Care Improvement Program (MMA section 721); ESRD Disease Management Demonstration (MMA section 623); Disease Management Demonstration for Severely Chronically Ill Medicare Beneficiaries (BIPA 2000); Disease Management Demonstration for Chronically Ill Dual Eligible Beneficiaries; Care Management for High Cost Beneficiaries.  See also MedPAC congressional testimony on P4P (July 2005; 12 pages). Read about a recent Medicare demonstration project aimed at physicians practicing solo, or small to medium sized group practices. Read recent notice announcing that nearly all of the nation’s eligible hospitals reported data on the quality of care they deliver, providing transparency in information for consumers on quality performance measures linked to payments hospitals receive for treating Medicare beneficiaries.

2.27   Information Partners Can Use On: Preventing Fraud 

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No. of Pages

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Audience

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http://www.cms.hhs.gov/partnerships/downloads/
PartnerTipSheetPreventingFraud100606.pdf

10/06

2

CMS

Partner

Tip Sheet

This tip sheet provides guidance to people with Medicare on how to protect all personal information.