The Official Patient's Sourcebook on Lupus (28 page)

system. To assure that right, the Commission recommends the following:

· Consumers must not be discriminated against in the delivery of

healthcare services consistent with the benefits covered in their policy, or

as required by law, based on race, ethnicity, national origin, religion, sex,

age, mental or physical disability, sexual orientation, genetic information,

or source of payment.

· Consumers eligible for coverage under the terms and conditions of a

health plan or program, or as required by law, must not be discriminated

against in marketing and enrollment practices based on race, ethnicity,

national origin, religion, sex, age, mental or physical disability, sexual

orientation, genetic information, or source of payment.

Confidentiality of Health Information

Consumers have the right to communicate with healthcare providers in

confidence and to have the confidentiality of their individually identifiable

Your Rights and Insurance 161

healthcare information protected. Consumers also have the right to review

and copy their own medical records and request amendments to their

records.

Complaints and Appeals

Consumers have the right to a fair and efficient process for resolving

differences with their health plans, healthcare providers, and the institutions that serve them, including a rigorous system of internal review and an

independent system of external review. A free copy of the Patient’s Bill of

Rights is available from the American Hospital Association.
57

Patient Responsibilities

Treatment is a two-way street between you and your healthcare providers.

To underscore the importance of finance in modern healthcare as well as

your responsibility for the financial aspects of your care, the President’s

Advisory Commission on Consumer Protection and Quality in the

Healthcare Industry has proposed that patients understand the following

“Consumer Responsibilities.”
58
In a healthcare system that protects consumers’ rights, it is reasonable to expect and encourage consumers to

assume certain responsibilities. Greater individual involvement by the

consumer in his or her care increases the likelihood of achieving the best

outcome and helps support a quality-oriented, cost-conscious environment.

Such responsibilities include:

· Take responsibility for maximizing healthy habits such as exercising, not

smoking, and eating a healthy diet.

· Work collaboratively with healthcare providers in developing and

carrying out agreed-upon treatment plans.

· Disclose relevant information and clearly communicate wants and needs.

· Use your health insurance plan’s internal complaint and appeal processes

to address your concerns.

· Avoid knowingly spreading disease.

57 To order your free copy of the Patient’s Bill of Rights, telephone 312-422-3000 or visit the American Hospital Association’s Web site:
http://www.aha.org
. Click on “Resource Center,”

go to “Search” at bottom of page, and then type in “Patient’s Bill of Rights.” The Patient’s Bill of Rights is also available from Fax on Demand, at 312-422-2020, document number 471124.

58 Adapted from
http://www.hcqualitycommission.gov/press/cbor.html#head1
.

162 Lupus Nephritis

· Recognize the reality of risks, the limits of the medical science, and the

human fallibility of the healthcare professional.

· Be aware of a healthcare provider’s obligation to be reasonably efficient

and equitable in providing care to other patients and the community.

· Become knowledgeable about your health plan’s coverage and options

(when available) including all covered benefits, limitations, and

exclusions, rules regarding use of network providers, coverage and

referral rules, appropriate processes to secure additional information, and

the process to appeal coverage decisions.

· Show respect for other patients and health workers.

· Make a good-faith effort to meet financial obligations.

· Abide by administrative and operational procedures of health plans,

healthcare providers, and Government health benefit programs.

Choosing an Insurance Plan

There are a number of official government agencies that help consumers

understand their healthcare insurance choices.
59 The U.S.
Department of Labor, in particular, recommends ten ways to make your health benefits

choices work best for you.
60

1. Your options are important.
There are many different types of health benefit plans. Find out which one your employer offers, then check out the

plan, or plans, offered. Your employer’s human resource office, the health

plan administrator, or your union can provide information to help you

match your needs and preferences with the available plans. The more

information you have, the better your healthcare decisions will be.

2. Reviewing the benefits available.
Do the plans offered cover preventive care, well-baby care, vision or dental care? Are there deductibles? Answers

to these questions can help determine the out-of-pocket expenses you may

face. Matching your needs and those of your family members will result in

the best possible benefits. Cheapest may not always be best. Your goal is

high quality health benefits.

59 More information about quality across programs is provided at the following AHRQ Web site:

http://www.ahrq.gov/consumer/qntascii/qnthplan.htm
.

60 Adapted from the Department of Labor:

http://www.dol.gov/dol/pwba//files/03/44/56/f034456/public/pubs/health/top10-text.html
.

Your Rights and Insurance 163

3. Look for quality.
The quality of healthcare services varies, but quality can be measured. You should consider the quality of healthcare in deciding

among the healthcare plans or options available to you. Not all health plans,

doctors, hospitals and other providers give the highest quality care.

Fortunately, there is quality information you can use right now to help you

compare your healthcare choices. Find out how you can measure quality.

Consult the U.S. Department of Health and Human Services publication

“Your Guide to Choosing Quality Health Care” on the Internet at

www.ahcpr.gov/consumer
.

4. Your plan’s summary plan description (SPD) provides a wealth of

information.
Your health plan administrator can provide you with a copy of your plan’s SPD. It outlines your benefits and your legal rights under the

Employee Retirement Income Security Act (ERISA), the federal law that

protects your health benefits. It should contain information about the

coverage of dependents, what services will require a co-pay, and the

circumstances under which your employer can change or terminate a health

benefits plan. Save the SPD and all other health plan brochures and

documents, along with memos or correspondence from your employer

relating to health benefits.

5. Assess your benefit coverage as your family status changes.
Marriage, divorce, childbirth or adoption, and the death of a spouse are all life events that may signal a need to change your health benefits. You, your spouse and

dependent children may be eligible for a special enrollment period under

provisions of the Health Insurance Portability and Accountability Act

(HIPAA). Even without life-changing events, the information provided by

your employer should tell you how you can change benefits or switch plans,

if more than one plan is offered. If your spouse’s employer also offers a

health benefits package, consider coordinating both plans for maximum

coverage.

6. Changing jobs and other life events can affect your health benefits.

Under the Consolidated Omnibus Budget Reconciliation Act (COBRA), you,

your covered spouse, and your dependent children may be eligible to

purchase extended health coverage under your employer’s plan if you lose

your job, change employers, get divorced, or upon occurrence of certain

other events. Coverage can range from 18 to 36 months depending on your

situation. COBRA applies to most employers with 20 or more workers and

requires your plan to notify you of your rights. Most plans require eligible

individuals to make their COBRA election within 60 days of the plan’s

notice. Be sure to follow up with your plan sponsor if you don’t receive

notice, and make sure you respond within the allotted time.

164 Lupus Nephritis

7. HIPAA can also help if you are changing jobs, particularly if you have a
medical condition.
HIPAA generally limits pre-existing condition exclusions to a maximum of 12 months (18 months for late enrollees). HIPAA also

requires this maximum period to be reduced by the length of time you had

prior “creditable coverage.” You should receive a certificate documenting

your prior creditable coverage from your old plan when coverage ends.

8. Plan for retirement.
Before you retire, find out what health benefits, if any, extend to you and your spouse during your retirement years. Consult with

your employer’s human resources office, your union, the plan administrator,

and check your SPD. Make sure there is no conflicting information among

these sources about the benefits you will receive or the circumstances under

which they can change or be eliminated. With this information in hand, you

can make other important choices, like finding out if you are eligible for

Medicare and Medigap insurance coverage.

9. Know how to file an appeal if your health benefits claim is denied.

Understand how your plan handles grievances and where to make appeals

of the plan’s decisions. Keep records and copies of correspondence. Check

your health benefits package and your SPD to determine who is responsible

for handling problems with benefit claims. Contact PWBA for customer

service assistance if you are unable to obtain a response to your complaint.

10. You can take steps to improve the quality of the healthcare and the

health benefits you receive.
Look for and use things like Quality Reports and Accreditation Reports whenever you can. Quality reports may contain

consumer ratings -- how satisfied consumers are with the doctors in their

plan, for instance-- and clinical performance measures -- how well a

healthcare organization prevents and treats illness. Accreditation reports

provide information on how accredited organizations meet national

standards, and often include clinical performance measures. Look for these

quality measures whenever possible. Consult “Your Guide to Choosing

Quality Health Care” on the Internet at
www.ahcpr.gov/consumer
.

Medicare and Medicaid

Illness strikes both rich and poor families. For low-income families, Medicaid is available to defer the costs of treatment. The Health Care Financing

Administration (HCFA) administers Medicare, the nation’s largest health

insurance program, which covers 39 million Americans. In the following

pages, you will learn the basics about Medicare insurance as well as useful

Your Rights and Insurance 165

contact information on how to find more in-depth information about

Medicaid.
61

Who is Eligible for Medicare?

Generally, you are eligible for Medicare if you or your spouse worked for at

least 10 years in Medicare-covered employment and you are 65 years old

and a citizen or permanent resident of the United States. You might also

qualify for coverage if you are under age 65 but have a disability or End-

Stage Renal disease (permanent kidney failure requiring dialysis or

transplant). Here are some simple guidelines:

You can get Part A at age 65 without having to pay premiums if:

· You are already receiving retirement benefits from Social Security or the

Railroad Retirement Board.

· You are eligible to receive Social Security or Railroad benefits but have

not yet filed for them.

· You or your spouse had Medicare-covered government employment.

If you are under 65, you can get Part A without having to pay

premiums if:

· You have received Social Security or Railroad Retirement Board disability

benefit for 24 months.

· You are a kidney dialysis or kidney transplant patient.

Medicare has two parts:

· Part A (Hospital Insurance). Most people do not have to pay for Part A.

· Part B (Medical Insurance). Most people pay monthly for Part B.

Part A (Hospital Insurance)

Helps Pay For:
Inpatient hospital care, care in critical access hospitals (small facilities that give limited outpatient and inpatient services to people in rural areas) and skilled nursing facilities, hospice care, and some home healthcare.

61 This section has been adapted from the Official U.S. Site for Medicare Information:
http://www.medicare.gov/Basics/Overview.asp
.

166 Lupus Nephritis

Cost:
Most people get Part A automatically when they turn age 65. You do not have to pay a monthly payment called a premium for Part A because you

or a spouse paid Medicare taxes while you were working.

If you (or your spouse) did not pay Medicare taxes while you were working

and you are age 65 or older, you still may be able to buy Part A. If you are