Medicare Beneficiary Rights and Responsibilities

West Virginia Medicare Beneficiary Hotline • 1-800-MEDICARE • Available 8:15-5:00, Monday-Friday

• Medicare Rights. WVMI recognizes, respects, protects, and communicates four basic rights.
  
  
  • Medicare beneficiaries have the right to stay in the hospital until it is medically safe to leave. This right protects Medicare beneficiaries from being discharged from the hospital too soon.
  • Medicare beneficiaries have the right to be admitted to the hospital when it is medically necessary. NOTE: Admissions for Medicare Advantage beneficiaries are guided by the plan.
  • Medicare beneficiaries have the right to receive quality health care that meets established standards and guidelines.
  • Medicare beneficiaries have the right to appeal any time a provider plans to discontinue Skilled Nursing Facility (SNF), Home Health (HH), Hospice, or Comprehensive Outpatient Rehabilitation Facility (CORF) care due to lack of medical necessity. NOTE: This right excludes Hospice if a person is enrolled in a Medicare Advantage plan.
• Hospital Admission. If a doctor believes that a Medicare beneficiary needs to be admitted to a hospital, but the hospital does not believe hospitalization is required, the hospital will issue a Hospital Issued Notice of Noncoverage (HINN) letter. The steps to contact WVMI are specifically stated in the letter given by the hospital to the Medicare beneficiary. Medicare beneficiaries have the right to appeal the decision to WVMI.
  
  
  • Medicare Beneficiary Rights. Upon receipt of the HINN letter, Medicare beneficiaries have the right to ask WVMI for a free review of the medical case to determine whether or not Medicare will pay for the hospital stay. NOTE: This right does not apply if the person is enrolled in a Medicare Advantage plan such as an HMO, as appeal decisions must go through the "Plan."
  • Medicare Beneficiary Responsibilities. Upon receipt of the HINN letter, Medicare beneficiaries have the responsibility to contact WVMI using the phone numbers provided by the hospital to ask for a free review. WVMI staff will speak with the Medicare beneficiary, attending physician, and hospital to obtain the necessary information to render a decision. WVMI staff will inform Medicare beneficiaries of the review decision. If WVMI staff determines the admission is medically necessary, Medicare will pay for the hospital stay.
• Early Hospital Discharge. The length of hospital stay is based upon medical need. To protect Medicare beneficiaries from being discharged too soon, Medicare has established a free appeal process. This appeal process is updated as of July 2007.
  
  
  • Medicare Beneficiary Rights. A Medicare beneficiary can file an appeal if he/she feels he/she is being discharged too soon. This appeal is available to both Original Medicare beneficiaries and Medicare Advantage beneficiaries.
  • Medicare Beneficiary Responsibilities. It is important for the Medicare beneficiary to contact WVMI immediately after receiving the Important Message from the hospital if they feel they are being discharged too soon. The Medicare beneficiary will be contacted by WVMI staff to obtain pertinent information related to their appeal. If the Medicare beneficiary has contacted WVMI prior to midnight of the day of discharge, the Medicare beneficiary cannot be forced to leave the hospital while WVMI is conducting the review, and the Medicare beneficiary will be protected from financial liability until noon of the day following WVMI's decision.
  • Should WVMI staff determine that the continued stay is medically necessary, Medicare will continue to pay for the hospital stay. However, should WVMI staff determine the continued stay is not medically necessary and the Medicare beneficiary opts to stay, the Medicare beneficiary will be responsible for any resulting charges, beginning noon of the day following WVMI's decision.
• SNF, HH, CORF, Hospice Care. CMS has established an appeal process in the event a health care provider plans to discontinue care rendered to a FFS Medicare beneficiary in the following settings: SNF, HH, CORF, and Hospice. NOTE: A similar appeal process is available to Medicare Advantage beneficiaries in the event a health care provider plans to discontinue care in the following settings: SNF, HH, and CORF.
  
  
  • Medicare Beneficiary Rights. Upon receipt of written notification by the health care provider that services will be discontinued due to lack of medical necessity, Medicare beneficiaries have the right to appeal.
  • Medicare Responsibilities. Upon receipt of the notification from the health care provider, Medicare beneficiaries have the responsibility to contact WVMI using the phone numbers provided in the notification to ask for a free review. WVMI will obtain the necessary information from the Medicare beneficiary and health care provider in order to render an appeal decision.
• Quality of Care Complaints. Medicare wants to ensure that Medicare beneficiaries are getting the care that meets established standards and guidelines.
  
  
  • Medicare Beneficiary Rights. If the Medicare beneficiary feels he/she did not or is currently not receiving quality care, the Medicare beneficiary has the right to contact 1-800-MEDICARE, who will notify WVMI for a free review. Should the Medicare beneficiary so desire, WVMI will protect the complainant's identity, should the complainant not want the physician to know he/she has filed a complaint. However, if the Medicare beneficiary wants to know the outcome of the review, the Medicare beneficiary's identity must be revealed to the physician.
  • Medicare Beneficiary Responsibilities. Medicare beneficiaries must submit their complaint in writing to WVMI. Once the complaint is received WVMI staff will initiate the review, which can take 3 - 6 months. WVMI staff will inform the Medicare beneficiary of the outcome of the review if so desired.

To learn more, follow the links under "Medicare Rights" on the side menu.