Know Your Medicare Rights

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1 Appeals Hospital Discharge Appeals All Others Know Your Medicare Rights You have the right to appeal decisions that affect your health and well-being Your Medicare Rights Quality of Care Complaints Resources

2 Your Rights Under the Medicare Program As a Medicare beneficiary, you are entitled to the best possible healthcare. Specifically, you have the right to: n Receive appropriate medical care n Be fully involved in your care n Appeal a healthcare decision or report a complaint n Know what Medicare covers and what you have to pay To ensure that you receive the care you deserve, Medicare partners with Quality Improvement Organizations throughout the United States. Lumetra is Medicare s designated QIO for California. We work with Medicare beneficiaries, their caregivers, and their healthcare providers to facilitate complaints and appeals. We also work with community groups and senior advocacy organizations to build awareness about Medicare rights.

3 hour Helpline Your Medicare Rights For more than 20 years, Lumetra has offered FREE assistance with: n Hospital discharge appeals n Discharge appeals from other facilities n Quality of care complaints If you have Medicare, you have rights. Lumetra can help you exercise them. To learn more about Lumetra, visit and click on For Medicare Members. Call Medicare directly for assistance if you: n Have questions about Medicare benefits, services, and coverage n Want to discuss billing issues Order Your Medicare Rights and Protections, a detailed list of your Medicare rights, by calling MEDICARE ( ). The people at Lumetra were abolutely lovely. They checked with me every step of the way to make sure I was being represented properly.

4 Quality of Care Complaints You have the right to report a complaint If you believe you are not receiving the care you need, you can file a quality of care complaint with Lumetra. Common quality of care complaints include: n Wrong medication n Unnecessary surgery or diagnostic testing n Inadequate care or misdiagnosis by any Medicare hospital or doctor n Early discharge from a healthcare facility Any Medicare patient or a designated representative (such as a spouse or other family member, legal guardian, or caregiver) can file a complaint. Lumetra is here to help you. A team of medical experts will review your complaint and contact your provider regarding the quality of care you received. Complaints regarding ongoing care are generally addressed and resolved within five working days. Complaints about care received in the past are also reviewed. These types of complaints can take from three to six months to review.

5 hour Helpline Mediation Another Alternative Mediation is an opportunity for you to meet with your doctor or other healthcare provider and a facilitator to discuss and resolve your concerns. There is no charge for this service. Mediation is appropriate for some quality of care complaints. Lumetra will help you decide if mediation is right for you. Quality of Care Complaints Lumetra did a very good job overall. They were very professional, understanding and considerate to my needs and feelings.

6 Appeals Hospital Discharge How do I know if I should appeal an early discharge from a hospital? If you are told that you will be discharged from the hospital and feel you are not ready to go home, you have the right to appeal the discharge. If your discharge instructions are not clear (whether you re going to another healthcare facility or will continue therapy at home), you have the right to appeal. Within 48 hours of admission to the hospital, you should receive a form called An Important Message from Medicare. This form outlines steps you can take to appeal an early hospital discharge. Who can request an appeal? Any Medicare patient or a designated representative (such as a spouse or other family member, legal guardian, or caregiver) can request an appeal. How long does the appeal take? Appeals are generally resolved within two or three days, up to a week. Lumetra will notify the patient and the hospital and/or health plan of the decision. Either the discharge notice is upheld, or Lumetra disagrees with the discharge notice. In the latter case, the patient has a right to remain in the hospital until a new discharge notice is given by the hospital.

7 hour Helpline How much does it cost to appeal? There is no charge to the Medicare patient for filing an appeal. How do I file a hospital discharge appeal? To file an appeal, call Lumetra by noon of the next business day. The hospital should also provide you with a copy of An Important Message from Medicare, which outlines steps to take to appeal an early discharge. If you call Lumetra and file an appeal, you will be able to remain in the hospital while your case is being reviewed. It may take a few days, but you may remain in the hospital until the review of your case is finished. Once the appeal is completed, no matter what the decision, you will not be charged for the additional days, except for deductibles and items not normally covered by Medicare. Appeals Hospital Discharge How am I notified about the outcome of the appeal? Lumetra will contact you or your designated representative as well as the hospital and/or health plan. Do I contact Lumetra to file a hospital discharge appeal if I m hospitalized outside of California? No, you would contact the Medicare-designated Quality Improvement Organization in that state. The hospital will provide that information to you.

8 Appeals Other Discharges Discharge Appeals from other Healthcare Facilities n Skilled Nursing Facilities n Comprehensive Outpatient Rehabilitation Facilities n Home Health Agencies n Hospices Skilled nursing facilities, comprehensive outpatient rehabilitation facilities, home health agencies, and hospices are required to provide you with a notice, called a Notice of Non-coverage, at least two days before you are discharged. You can also appeal these types of discharges by contacting Lumetra. Should I appeal a healthcare decision? You should appeal a healthcare decision if you disagree with it based on your medical condition, if you feel that you are not ready to be discharged, or if you have a legitimate medical reason to continue receiving a medical service. Who can request an appeal? Any Medicare patient or a designated representative (such as a spouse or other family member, legal guardian, or caregiver) can request an appeal. How much does it cost to appeal? There is no charge to the Medicare patient for filing an appeal.

9 Appeals All Others hour Helpline It was good having an intermediary to help solve the problem, listen and be supportive.

10 Additional Sources of Information Medicare beneficiaries have these additional sources of information and assistance at their disposal. Medicare Medicare provides information about Medicare enrollment, eligibility, payment, billing, plan options, and benefits MEDICARE ( ) Long-term Care Ombudsman Program The long-term Care Ombudsman Program resolves complaints between nursing homes, residential care facilities for the elderly, and assisted living facilities and residents or their families in California Health Insurance Counseling and Advocacy Program (HICAP) HICAP offers free counseling and assistance regarding Medicare, Medigap policies, Medicare Advantage plans, or long-term care insurance

11 hour Helpline For more than 20 years, Lumetra has offered information on Medicare rights and FREE assistance with quality of care complaints and appeals for discharge notices received from hospitals, skilled nursing facilities, comprehensive outpatient rehabilitation facilities, and hospices in California. Contact Lumetra s Helpline 24 hours a day/7 days a week including holidays (Toll-free number) (TDD-hearing impaired) Note: Calls received outside of normal business hours are taken by an answering service and returned by Lumetra the next business day. Translation services are available. Resources

12 About Lumetra Lumetra, Medicare s designated Quality Improvement Organization for California, is a non-profit organization dedicated to improving the quality, safety, efficiency, and integrity of healthcare. To learn more about Lumetra, call , or visit our Web site, and click on For Medicare Members. 1 Sansome Street San Francisco, CA This material was prepared by Lumetra, the Medicare Quality Improvement Organization for California, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 8SOW-SS5-CA-07-01

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