Base Letter

[DATE]

«MPRID»

«Title» «First_Name» «Middle_Initial» «Last_Name»

«Address»

«City», «State» «Zip»

Dear «Title» «Last_Name»:

Health Plan of Nevada, Inc. (HPN) is one of very few Health Maintenance Organizations (HMOs) in the country selected by The Centers for Medicare & Medicaid Services (CMS), the federal agency that administers the Medicare program, to participate in a multi-year Social HMO (SHMO) demonstration. The SHMO program adds expanded care coordination services to your existing Senior Dimensions Plan.

To assist us in coordinating your health care needs, a representative of HPN will be contacting you in the near future to ask some questions related to your health and other characteristics. The questions are in addition to those you answered at the time of your enrollment and are very important to the program and to ensuring that we are made aware of any special health care needs you may have.

There is no additional premium to participate in this program. Furthermore, the information you provide will not affect your status as a Senior Dimensions member. Your information will be treated confidentially and made available only to your primary care provider and his or her care coordination team.

If you prefer to call at your convenience to complete the interview, dial the toll-free number 1-888-633-8325 between 8am and 9pm Pacific time, Monday through Friday, and ask for the SHMO survey. If you have any questions, please call Member Services at 702-242-7301 or
1-800-650-6232 (for the hearing impaired, TTY 702-242-9214 or 1-800-349-3538), 8am to 5pm, Monday through Friday. Thank you in advance for your cooperation.

Sincerely,

Jonathon W. Bunker

President

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0709. The time required to complete this information collection is estimated to average 12 minutes per response, including the time to review instructions, search existing data resources, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this interview, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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