You have the right to be treated fairly, understand the information you get, and keep your personal information safe. To learn more about your rights and protections, please read your Evidence of Coverage and/or other relevant membership materials.
If you have Medicare Advantage
You have the right to be:
- Treated with courtesy, dignity and respect at all times.
- Protected from discrimination. Every company or agency that works with Medicare must obey the law. We cannot treat you differently because of your race, color, national origin, disability, age, religion, or sex.
You have the right to have:
- Your personal and health information kept private.
- Access to doctors, specialists, and hospitals for medically necessary services.
You have the right to get:
- Medicare-covered services in an emergency.
- Information in a way you understand.
- Information about your treatment choices in clear language that you can understand, and participate in treatment decisions.
- Medicare information and health care services in a language you understand.
- Your Medicare information in an accessible format, like braille or large print.
If you need plan information in a language other than English, or in an accessible format, contact your plan.
- Answers to your Medicare questions.
- A decision about health care payment, coverage of items and services, or drug coverage.
When you or your provider files a claim, you’ll get a notice letting you know what will and won’t be covered. This notice is called an Explanation of Benefits. You will receive this notice from:
- GlobalHealth (Part C), or
- GlobalHealth’s Pharmacy Benefits Manager (Part D)
If you disagree with the decision on your claim, you have the right to file an appeal. You may:
- Request a review (appeal) of certain decisions about health care payment, coverage of items and services, or drug coverage.
- File complaints (sometimes called “grievances"), including complaints about the quality of your care. You may decide to do this if you have concerns about the quality of care and other services you get from a Medicare provider.
Access to your personal health information
By law, you or your legal representative generally have the right to view and/or get copies of your personal health information from these groups:
- Health care providers who treat you and bill Medicare for your care.
- Health plans that pay for your care, including Medicare.
These types of personal health information include:
- Claims and billing records.
- Information related to your enrollment in health plans, including Medicare.
- Medical and case management records.
- Other records that doctors or health plans use to make decisions about you.
Generally, you can get your information on paper or electronically. We generally must give you electronic copies, if you ask for them. You have the right to get your information in a timely manner, but it may take up to 30 days to get a response. Keep in mind, if your information is electronic, you also have the right to have it sent to a third party of your choosing. A third party may be a:
- Health care provider who treats you.
- Family member.
You may have to fill out a form to request copies of your information and pay a fee. This fee can’t be more than the total cost of:
- Labor for copying the information requested.
- Supplies for creating the copy.
- Postage (if you ask your health care provider to mail you a copy).
In most cases, you won't be charged for viewing, searching, downloading, or sending your information through an electronic portal.
More rights based on your coverage
As a Medicare Advantage member, you also have the right to:
- Choose health care providers within GlobalHealth’s Provider Network.
- Get a treatment plan from your doctor.
- If you have a complex or serious medical condition, a treatment plan lets you directly see a specialist within the plan as many times as you and your doctor think you need.
- Women have the right to go directly to a women's health care specialist without a referral within the plan for routine and preventive health care services.
- Know how your doctors are paid.
- When you ask us how we pay doctors, we must tell you.
- Medicare doesn't allow us to pay doctors in a way that could interfere with you getting the care you need.
- Request an appeal to resolve differences.
- File a complaint (called a "grievance") about other concerns or problems with us.
- Get a coverage decision or coverage information from us before getting services.
- Get a written explanation for drug coverage decisions (called a “coverage determination”).
- A coverage determination is the first decision your Medicare drug plan (not the pharmacy) makes about your benefits. This can be a decision about if your drug is covered, if you met the plan’s requirements to cover the drug, or how much you pay for the drug.
- You’ll also get a coverage determination decision if you ask your plan to make an exception to its rules to cover your drug.
- File a complaint (called a "grievance") with the plan. A grievance is a complaint about the way your Medicare health or drug plan is giving care.
- Have the privacy of your Medicare health and drug information protected.
Your provider may give you a written notice if they think GlobalHealth won’t pay for the items or services you’ll get. This notice is called an “Advance Beneficiary Notice of Noncoverage” (ABN). The ABN lists the items or services that GlobalHealth isn't expected to pay for, along with an estimate of the costs for the items and services and the reasons why GlobalHealth may not pay.
What can I do if I get an Advance Beneficiary Notice of Noncoverage (ABN)?
On the ABN, you’ll be asked to choose an option box and sign the notice to say that you read and understood it. You must choose one of these options:
- Option 1: You want items or services that GlobalHealth may not pay for. Your provider or supplier may ask you to pay for these items or services now, but you also want your provider or supplier to submit a claim to GlobalHealth.
- If GlobalHealth denies payment: You’re responsible for paying. However, since a claim was submitted, you can appeal.
- If GlobalHealth does pay: Your provider or supplier will refund any payments you made (not including your copayments or deductibles).
- Option 2: You want items or services that GlobalHealth may not pay for, but you don’t want your provider or supplier to submit a claim to GlobalHealth. You may be asked to pay for the items or services now. Because you asked your provider or supplier not to submit a claim to GlobalHealth, you can’t file an appeal.
- Option 3: You don’t want the items or services that GlobalHealth may not pay for, and you aren’t responsible for any payments. A claim isn’t submitted to GlobalHealth, and you can’t file an appeal.
Remember, an ABN isn't an official denial of coverage by GlobalHealth. You have the right to file an appeal if a claim is submitted and GlobalHealth denies payment. Your ABN has clear directions for getting an official decision about payment from GlobalHealth, and for filing an appeal if GlobalHealth won’t pay.
What are the types of ABNs?
Home Health Agency Advance Beneficiary Notice:Home health agencies must give you an ABN before you get any items or services that GlobalHealth may not pay for because:
- The items or services aren’t considered medically reasonable and necessary.
- The care is only non-skilled, personal care, like help with bathing or dressing.
- You aren’t homebound.
- You don’t need skilled care on an intermittent basis.
GlobalHealth doesn’t require an ABN for items or services that GlobalHealth never covers.
“Home Health Change of Care Notice” (HHCCN): Home health agencies must give you an ABN or a HHCCN when they reduce or stop providing home health services or supplies because:
- The home health agency makes a business decision to reduce or stop giving you some or all of your home health services or supplies.
- Your doctor changed your orders, which may reduce or stop giving you certain home health services or supplies that GlobalHealth covers.
The HHCCN lists the services or supplies that will be changed, and it gives you instructions for what you can do if you disagree with the change.
The home health agency isn’t required to give you a HHCCN when it issues the “Notice of Medicare Non-coverage” (NOMNC).
“Notice of Medicare Non-Coverage” (NOMNC): Your home health agency will give you a NOMNC at least 2 days before all covered services end. If you don’t get this notice, ask for it. This written notice will tell you:
- When your covered services will end.
- How to appeal if you think the services are ending too soon.
- How to contact your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) to ask for a fast appeal.
If you decide to ask for a fast appeal, call the BFCC-QIO within the timeframe listed on the notice. After you request a fast appeal, you’ll get a second notice with more information about why your care is ending. The BFCC-QIO may ask you questions about your case. To help your case, ask your doctor for information, which you can submit to the BFCC-QIO.
“Detailed Explanation of Non-coverage” (DENC): Your home health agency will give you a DENC when the BFCC-QIO tells your home health agency that you've requested a BFCC-QIO review of your case. The DENC will explain why your home health agency believes that GlobalHealth will no longer pay for your home health care.
"Skilled Nursing Facility Advance Beneficiary Notice" (SNFABN): A Skilled Nursing Facility (SNF) will issue you a SNFABN if there's a reason to believe that Part A may not cover or continue to cover your care or stay because it isn't reasonable or necessary, or is considered custodial care.
The SNFABN lets you know that GlobalHealth will likely no longer pay for your services. If you choose to get the services that GlobalHealth may not cover, you don't have to pay for these services until a claim is submitted and GlobalHealth officially denies payment.
However, while the claim is processed, you must continue paying costs that you would normally have to pay, like the daily coinsurance and costs for services and supplies GlobalHealth generally doesn't cover.
"Hospital Issued Notice of Noncoverage" (HINN): Hospitals use a HINN when GlobalHealth may not cover all or part of your Part A inpatient hospital care. This notice will tell you why the hospital thinks GlobalHealth won't pay, and what you may have to pay if you keep getting these services.