Basics to he Enrollment of Original Medicare

Statement of Understanding

The Statement of Understanding (SOU) is part of each type of enrollment mechanism, whether paper or electronic. When the consumer signs the enrollment request form/application, they are acknowledging their understanding of the following:

  1. The requirement to keep Medicare  plans – Parts and Part B.
  2. Agrees to follow the Plan’s rules.
  3. Consents to the disclosure and exchange of information for the operation of the MA program.
  4. A member can only be enrolled in one Medicare health plan and enrollment into a MA plan will automatically disenroll him/her from any other Medicare health plan and prescription drug plan.
  5. The right to appeal service and payment denials made by the Plan.

Processing the Medicare Enrollment Request

A Medicare consumer is generally the only individual who may execute a valid enrollment or disenrollment request. However, a Power of Attorney (POA) or authorized legal representative may execute the request on the consumer’s behalf.

Non-discrimination Medigap Requirements

Plan sponsors may not discriminate based on race, ethnicity, religion, gender, sexual orientation, disability, health status, or geographic location within the service area.

Every company or agent that works with or is contracted with Medicare (see this infographic on Medicare to understand how it works) must obey the law. Consumers or members may not be treated differently because of their race, color, national origin, disability, age, religion, or sex.
All items and services of an agent must be available to all eligible consumers in the service area with the following exception:

  • Certain products and services may be made available to consumers with certain diagnosis.
  • Enrollment in the low income subsidy (LIS), as they may be additional eligibility standards.

Agents may not state or otherwise imply that plans are available to only ‘seniors’ but rather to all Medicare eligible consumers.

Examples of agent discriminatory practices include:

  • Agents who target marketing to consumers from higher income areas.
  • Agents stating or otherwise implying that plans are available only to seniors rather than to all Medicare eligible consumers.

Note: Only organizations offering Special Needs Plans may limit enrollment to dual-eligible consumers, institutionalized consumers, or consumers with severe or disabling chronic conditions and/or may target items and services to corresponding categories of consumers.

No matter what type of Medicare Coverage a member has, they have certain guaranteed rights.

What is an Appeal?
An appeal is the action members may take if they disagree with a coverage or payment decision made by Medicare. Members can appeal if Medicare or the plan denies one of the following:

  • A request for health care services, supply, or prescription that was denied.
  • A request for payment for health care services or supplies or a prescription drug that was received and then denied.
  • A request to change the amount a member pays for a prescription drug.
  • If Medicare stops providing or paying for all or part of an item or service the consumer or member believes they still need.

What is a Grievance?
A type of complaint consumers and members may make about the health plan, a health plan agent or one of its network providers or pharmacies, including a complaint concerning the quality of care. This type of complaint does not involve coverage or payment disputes. All consumers and members have the right to file a grievance with the health plan.
Note: Appeals and Grievance description and process is provided to each consumer in writing within every 2011 Enrollment kit.

Guaranteed Rights
No matter what type of advantage plan you buy with Most Medicare a member has, they have certain guaranteed rights.

These rights are to:

  • Be treated with dignity and respect at all times.
  • Be protected from discrimination.
  • Have access to doctors, specialists, and hospitals.
  • Have questions about Medicare answered.
  • Learn about all of their treatment options and participate in the treatment decision.
  • Receive information in a way the member understands from Medicare, health care providers and under certain circumstances, contractors.
  • Receive emergency care when and where a member may need it.
  • Receive a decision about health care payment or services, or prescription coverage.
  • Have the right to appeal a decision about health care payment, coverage of services or prescription drug coverage.
  • File complaints (sometimes called grievances), including complaints about the quality of health care.
  • Have their personal and health information kept private.

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