Form CMS-10260-MAOP Annual Notice of Change & Evidence of Coverage for Medic

Medicare Advantage and Prescription Drug Program: Final Marketing Provisions CFR 422.111(a)(3) and 423.128 (a)(3)

Cover_and_EOC_Template_MA

Medicare Advantage and Prescription Drug Benefit Program: Final Marketing Provisions referenced in 42 CFR 422.111(a)(3) and 423.128(a)(3)

OMB: 0938-1051

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1051 can be found here:

Document [pdf]

Download: pdf | pdf

Annual Notice of Change & Evidence of
Coverage for Medicare Advantage Only
Plans
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 0938-1051. The time required to complete this information collection is
estimated to average
( 30min) per response, including the time to review instructions, search existing data resources, gather the
data needed, and complete and review the information collection. If you have comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500
Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850.

[Insert date]
[Plans may add a greeting (e.g., Dear Member, Dear Mrs. [insert name]).]
Here are two documents with important information for you.
1. Please start by reading the Notice of Changes for 2010. It gives you a summary of
changes to your benefits and costs for next year. These changes will take effect on January
1, 2010.
• Please take a moment very soon to look through this summary and see how the changes
might affect you.
• If you decide to stay with [insert plan name] for 2010 – you do not have to tell us or fill
out any paperwork. You will automatically remain enrolled as a member of [insert plan
name]).
• If you decide to leave [insert plan name], you can switch to a different Medicare
Advantage Plan or to Original Medicare from November 15 through December 31 each
year. The Notice of Changes tells you more.
2. We’re including a copy of next year’s Evidence of Coverage. It’s the legal, detailed
description of your benefits and costs for 2010 if you stay enrolled as a member of
[insert plan name]. It also explains your rights and rules you need to follow when using
your coverage for medical care. Please look through this document so you know what’s
in it, then keep it handy for reference.
If you have questions, we’re here to help. Please call Member Services at [insert phone
number] (TTY/TDD only, call [insert TTY/TDD number]). Hours are [insert days and hours
of operation] and calls to these numbers are [insert as applicable: free OR not free]. You can
also visit our website, ([insert URL]).
We value your membership and hope to continue to serve you next year.
[Plans may add a closing (e.g., Sincerely) and signature.]

[Insert plan name] Notice of Changes for 2010
If you remain enrolled in [insert plan name]
for 2010, there will be some changes next
year to your benefits and what you pay
[Plans may modify this introductory paragraph to tailor to its needs, as long as the paragraph is
kept brief.]

You are currently enrolled as a member of [insert plan name]. We are pleased to be
providing your Medicare health care coverage. [Plans that are consolidating, changing plan
name or rolling over membership, as approved by CMS, in 2010, insert: (1) if changing the plan
name, or consolidating other plans into the plan in which the beneficiary is enrolled —“ We also
want to let you know that we have changed our plan name from [insert previous plan name] to
[insert new plan name] for the upcoming year.” (2) if the beneficiary is being passively enrolled
into another plan due to a consolidation or termination – “As we have explained, if you do not
choose another plan, or choose to enroll in the Original Medicare Plan, you will be enrolled in the
[insert plan name]. This notice describes changes in benefits from [insert previous plan name] to
the [insert plan name] next year.”]
We’re sending you this Notice of Changes to tell you how your benefits and costs as a member
of [insert plan name] will change next year from your current benefits. The changes take effect
on January 1, 2010. Medicare has approved these changes.
What should you do?
We want you to know what’s ahead for next year, so please read this document very soon to see
how the changes in benefits and costs will affect you if you stay enrolled in [insert plan name]
for 2010.
To decide what’s best for you, compare this information we’re sending with the benefits and costs
of other Medicare Advantage plans in your area and with Original Medicare. You can see what
plans are available by visiting www.Medicare.gov. We hope to keep you as a member of [insert
plan name]. But if you want to make a change for 2010, see “When can you change” in Section
[X] for time periods when you can make a change.

We’re here to help!
We are available for phone calls [insert
days and hours of operation]. Calls to these
numbers are [insert if applicable: not] free.
[Insert phone number]
[Insert TTY/TDD number] TTY/TDD only
[Plans may insert additional numbers, e.g.,
the plan’s fax number or a number for
callers who speak Spanish.]

Website: [insert URL]
Do you need large print or another
format?
To get this material in other formats,
including large type, Braille, and
translations into other languages, call
Member Services.

[Note: If section is deleted, update table of contents to reflect this change.]
Section 1: Important things to know ............................................................. [x]
Your plan name is changing for the upcoming year ................................ [x]
This Notice of Changes is only a summary (see your Evidence
of Coverage for the details) .................................................................... [x]
Section 2: Changes to your monthly premium ............................................. [x]
Section 3: MEDICAL SERVICES:
Changes to your benefits and what you pay ............................................ [x]
Changes to your benefits ........................................................................ [x]
Changes to what you pay ....................................................................... [x]
Section [X]: What about changes to the plan’s network of providers? ....... [x]
Will your doctors and other providers you use still be in the plan’s
network next year? ................................................................................ [x]
Section [X]: What if I don’t have drug coverage that is at
least as good as Medicare’s standard prescription
drug coverage? ..................................................................................... [x]
How do I know if I have drug coverage that is at least as good as
Medicare’s standard coverage? ........................................................ [x]
What are my options for getting Medicare prescription drug coverage? . [x]
Section [X]: Do you want to stay in the plan or make a
change?.................................................................................................. [x]
Do you want to stay with [insert plan name] ......................................... [x]
Do you want to make a change? ............................................................. [x]
Section [X]: Do you need some help? Would you like more information? . [x]
We have information and answers for you ............................................. [x]
You can get help and information from your State Health Insurance
Assistance Program .............................................................................. [x]
You can get help and information from Medicare .................................. [x]

Notice of Changes in [insert plan name] for 2010

Section 1. Important things to know
[Insert first subsection if plan is changing the plan name for the upcoming year:
Your plan name is changing for the upcoming year
Plans that are consolidating, changing plan name, or rolling over membership, insert: (1) if
changing the plan name, or consolidating other plans into the plan in which the beneficiary is
enrolled—We want to let you know that we have changed our plan name from [insert previous
plan name] to [insert new plan name] for the upcoming year. Our phone numbers and address will
remain the same; (2) if the beneficiary is being passively enrolled into another plan due to a
consolidation or termination – “As we have explained, if you do not choose another plan, or
choose to enroll in the Original Medicare Plan, you will be enrolled in the [insert plan name].
This notice describes changes in benefits from [insert previous plan name] to the [insert plan
name] next year.”]
This Notice of Changes is only a summary (see your
Evidence of Coverage for the details)
This Notice of Changes gives you a summary of the changes in your benefits and what you will
pay for these services in 2010.
•

To get the details, you can look in the 2010 Evidence of Coverage for [insert plan name].
The Evidence of Coverage is the legal, detailed description of your benefits and costs for
2010. It explains your rights and the rules you need to follow to get your covered service.
(We have included a copy of the Evidence of Coverage in the same envelope with this
Notice of Changes. If you do not have this copy, call Member Services.)

•

If you have questions or need more information, you can always call Member Services
(phone numbers are on the cover of this notice).

Section 2. Changes to your monthly premium

Monthly premium

2009 (this year)

2010 (next year)

[insert 2009
premium amount]

[insert 2010
premium amount]

Notice of Changes in [insert plan name] for 2010

Section 3. Medical Services: Changes to your benefits
and what you pay
[If there are no changes in benefits or in cost-sharing, replace next two sections with: Our
benefits and what you pay for these covered services will be exactly the same in as it is in 2009.]
Changes to your benefits
[If there are no changes in benefits but changes in cost-sharing, replace text and table below with:
Our benefits will be exactly the same in 2010 as it is in 2009. However, there are some changes in
what you will pay for these covered services. See the next section for more information about the
change in what you pay for covered services.]
As shown below, [insert plan name] is [insert as appropriate: adding [a] new benefit[s] OR
ending [a] benefit[s] OR changing our covered benefits for] next year. For details, see Chapters 3
and 4 in your Evidence of Coverage.
[Plans list all new benefits that will be added or 2009 benefits that will be ended for 2010,
including any new optional supplemental benefits and the premiums for those benefits.]

[Insert benefit name]

2009 (this year)

2010 (next year)

[insert 2009 benefit,
e.g., “Not covered”]

[insert 2010
benefit, e.g.,
“Covered”]

Changes to what you payer
[If there are no changes in cost-sharing, replace text and table below with: The amount you pay
for covered services will be exactly the same in 2010 as they are in 2009.]
The chart below summarizes changes to what you will pay as your share of the cost of covered
medical services. For details, see Chapter 4, Medical benefits chart (what is covered and what
you pay), in your Evidence of Coverage.

Notice of Changes in [insert plan name] for 2010

[Plans list all changes in cost-sharing for 2010 for covered medical services.]

[Insert if applicable:] Out-ofpocket maximum for medical
services

2009 (this year)

2010 (next year)

[insert 2009 OOP
amount]

[insert 2010 OOP
amount]

[insert 2009 costsharing]

[insert 2010 costsharing]

[for coinsurance
amounts add: (you
pay xx% of the total
cost)]

[for coinsurance
amounts add:
(you pay xx% of
the total cost)]

[insert 2009 costsharing]

[insert 2010 costsharing]

[for coinsurance
amounts add: (you
pay xx% of the total
cost)]

[for coinsurance
amounts add:
(you pay xx% of
the total cost)]

[Insert description of what OOP
maximum applies to. E.g.: This
maximum applies to what you
pay as your share of the cost for
your Medicare Part A (Hospital
Insurance) and Medicare Part B
(Medical Insurance) services.]
[Insert benefit]

[Insert benefit]

Section [X]. What about changes to the plan’s network of providers?
[Plans with no provider network delete this Section.]
Will your doctors and other providers still be in the
plan’s network next year?
There are a few changes to the network of providers for 2010. In addition, it’s possible for the
network of plan providers to change at any time during the year.
•

Please check with your doctors and other providers you currently use to make sure
they will continue to be part of the provider network for [insert plan name] in 2010.

Notice of Changes in [insert plan name] for 2010

•

For the most up-to-date information on the network of providers, check our website
([insert URL]) or call Member Services (see phone numbers on the front cover).

Section [X]. What if I don’t have drug coverage that is at
least as good as Medicare’s standard prescription drug
coverage?
How do I know if I have drug coverage that is at least as
good as Medicare’s standard coverage?
Our plan does not include Medicare prescription drug coverage. If you haven’t had other
creditable prescription drug coverage, you may need to pay a late enrollment penalty if you join
a Medicare drug plan later. (“Creditable” coverage means the coverage is at least as good as
Medicare’s standard prescription drug coverage.) You will pay the penalty if you go without
creditable coverage for a continuous period of 63 days or more. The longer you wait to enroll in
a Medicare drug plan, the higher the penalty may be.
If you currently have other prescription drug coverage through your (or your spouse’s) employer
or retiree group, your employer or retiree group should send you a notice by November 15 that
tells if your prescription drug coverage is “creditable.” If you received a notice this year that you
no longer have creditable coverage, consider adding Medicare prescription drug coverage.
What are my options for getting Medicare prescription
drug coverage?
If you would like to get Medicare prescription drug coverage, you have many plan options. [MA
plans offering other plans with Part D coverage, insert: You can get Medicare prescription drug
coverage by joining another Medicare Advantage plan that includes this coverage. Our
organization offers the following plans that include Medicare drug coverage: [insert list of plans
with Part D coverage available in the service area and Member Services contact below]]
To find other plans available in your area, visit www.medicare.gov and under “Search Tools”
select either “Compare Medicare Prescription Drug Plans” or “Compare Health Plans and
Medigap Policies in Your Area.” Or, call 1-800-MEDICARE (1-800-633-4227). TTY users
should call 1-877-486-2048.
If you join another Medicare Advantage plan or a Medicare drug plan, you will be disenrolled
from our plan when your enrollment in the new plan begins.

Notice of Changes in [insert plan name] for 2010

Section [X]. Do you want to stay in the plan or make a
change?
Do you want to stay with [insert plan name]?
If you want to keep your membership in [insert plan name] for 2010, it’s easy. You don’t
need to tell us or fill out any paperwork. You will automatically remain enrolled as a
member.
Do you want to make a change?
If you decide to leave [insert plan name], you can switch to a different Medicare Advantage plan
or to Original Medicare (either with or without a separate Medicare prescription drug plan).
If you want to change to a different plan, there are many choices. [Insert if applicable: As a
reminder, [insert plan name] offers other Medicare Advantage plans in addition to the plan you
are now enrolled in. These other plans may differ in coverage, monthly premiums, and cost
sharing amounts.]

When can you change?
•

During the yearly enrollment period (called the “annual coordinated election
period”) from November 15 through December 31, 2009, you can change to any other
Medicare Advantage plan or to Original Medicare (either with or without a separate
Medicare prescription drug plan). Your new coverage will begin on January 1, 2010.

•

You also have another, more limited enrollment period from January 1 through
March 31, 2010. During this period (called the “open enrollment period), you could
switch to a different Medicare Advantage Plan without Part D prescription drug coverage
or switch to Original Medicare. (You cannot enroll in a separate prescription drug plan
during the Medicare Advantage Open Enrollment Period.) For more information about
your choices during the January 1 through March 31 open enrollment period, please see
Chapter 8, Section 2.2 of the Evidence of Coverage.

Are these the only times of year to choose a different plan?
For most people, yes. Certain individuals, such as those with Medicaid, or those who move out
of the geographic service area, can make changes at other times. For more information, see
Chapter 8, Section 2.3 of the Evidence of Coverage.
How do you make a change?
See Chapter 8 of the enclosed Evidence of Coverage document. It tells what you need to do to
make a change from [insert plan name] to another plan.

Notice of Changes in [insert plan name] for 2010

Things to check on before you make a change
• Are you a member of an employer or retiree group? If you are, please check with the
benefits administrator of your group before you switch to another way of getting medical
care.
Section [X]. Do you need some help? Would you like
more information?
We have information and answers for you
To learn more, read the information we sent in the same package with this Notice of Changes. This
includes a copy of the Evidence of Coverage.
If you have any questions, we are here to help. Please call us at [insert plan name] Member
Services. We are available for phone calls [insert days and hours of operation]. Calls to these
numbers are free: [insert phone number] (TTY/TDD only, call [insert TTY/TDD number]).
You can get help and information from your State Health
Insurance Assistance Program
[Organizations offering plans in multiple states: Revise this section to use the generic name
(“State Health Insurance Assistance Program”) when necessary, and include a list of names,
phone numbers, and addresses for all SHIPs in your service area. Plans have the option of
including a separate exhibit to list the SHIPs in all states, or in all states in which the plan is filed,
and should make reference to that exhibit below.]
The State Health Insurance Assistance Program (SHIP) is a government program with trained
counselors in every state. In [insert state name], the State Health Insurance Assistance Program is
called [insert state-specific SHIP name].
[Insert state-specific SHIP name] is independent (not connected with any insurance company
or health plan). [Insert state-specific SHIP name] counselors can help you with your Medicare
questions or problems. They can help you understand your Medicare plan choices and answer
questions about switching plans. You can call [insert state-specific SHIP name] at [insert
phone number(s), including TTY/TDD number if available].
You can get help and information from Medicare
Here are three ways to get information directly from Medicare:
•

Call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY users
should call 1-877-486-2048.

•

Visit the Medicare website (www.medicare.gov).

Notice of Changes in [insert plan name] for 2010

•

Read Medicare & You 2010. Every year in October, this booklet is mailed to people with
Medicare. It has a summary of Medicare benefits, rights and protections, and answers to
the most frequently asked questions about Medicare. If you don’t have a copy of this
booklet, you can get it at the Medicare website (http://www.medicare.gov) or by calling
1-800-MEDICARE (1-800-633-4227).

January 1 – December 31, 2010

Evidence of Coverage
This booklet is an important legal document for you to
keep and use as a reference during 2010. It explains:
The details of your Medicare health coverage
How to get the care you need

[Include plan contact information on the cover.]

2010 Evidence of Coverage for [insert plan name]
Table of Contents

Table of Contents

Chapter 1.

Getting started as a member of [insert plan name] ........................... [XX]
Tells what it means to be in a Medicare health plan and how to use this booklet.
Tells about materials we will send you, your plan premium, your plan
membership card, and keeping your membership record up to date.

Chapter 2.

Important phone numbers and resources .......................................... [XX]
Tells you how to get in touch with our plan ([insert plan name]) and with
other organizations including Medicare, the State Health Insurance Assistance
Program, the Quality Improvement Organization, Social Security, Medicaid (a
joint Federal and state program that helps with medical costs for some people
with limited income and resources), and the Railroad Retirement Board.

Chapter 3.

Using the plan’s coverage for your medical services ...................... [XX]
Explains important things you need to know about getting your medical care
as a member of our plan. Topics include using the providers in the plan’s
network and how to get care when you have an emergency.

Chapter 4.

Medical benefits chart (what is covered and what you pay) ............. [XX]
Gives the details about which types of medical care are covered and not
covered for you as a member of our plan. Tells how much you will pay as
your share of the cost for your covered medical care.

Chapter 5.

Asking the plan to pay its share of a bill you have received
for medical services ............................................................................. [XX]
Tells when and how to send a bill to us when you want to ask us to pay you
back for our share of the cost for your covered services.

Chapter 6.

Your rights and responsibilities .......................................................... [XX]
Explains the rights and responsibilities you have as a member of our plan. Tells
what you can do if you think your rights are not being respected.

Chapter 7.

What to do if you have a problem or complaint
(coverage decisions, appeals, complaints) ............................................. [XX]
Tells you step-by-step what to do if you are having problems or concerns as a
member of our plan.

2010 Evidence of Coverage for [insert plan name]
Table of Contents

Chapter 8.

•

Explains how to ask for coverage decisions and make appeals if you are
having trouble getting the medical care you think is covered by our plan.
This includes asking us to keep covering hospital care and certain types
of medical services if you think your coverage is ending too soon.

•

Explains how to make complaints about quality of care, waiting times,
customer service, and other concerns.

Ending your membership in the plan .................................................. [XX]
Tells when and how you can end your membership in the plan. Explains
situations in which our plan is required to end your membership.

Chapter 9.

Legal notices ......................................................................................... [XX]
Includes notices about governing law and about nondiscrimination.

Chapter 10. Definitions of important words ............................................................ [XX]
Explain key terms used in this booklet.

2010 Evidence of Coverage for [insert plan name]
Chapter 1: Getting started as a member of [insert plan name]

CHAPTER 1: Getting started as a member of [insert plan name]
SECTION 1. Introduction
1.1

What is this Evidence of Coverage booklet about? ................................................ [xx]

1.2

What does this Chapter tell you? ........................................................................... [xx]

1.3

What if you are new to [insert plan name]? .......................................................... [xx]

1.4

Legal information about Evidence of Coverage ..................................................... [xx]

SECTION 2. What makes you eligible to be a plan member?
2.1

Your [insert number of requirements] eligibility requirements ............................. [xx]

2.2

What are Medicare Part A and Medicare Part B? .................................................. [xx]

2.3

Here is the geographic service area for [insert plan name] .................................... [xx]

SECTION 3. What other materials will you get from us?
3.1

Your plan membership card – use it to get all covered medical care ...................... [xx]

3.2

The Provider Directory: your guide to all providers in the plan’s network ........... [xx]

SECTION 4. Your monthly premium for [insert plan name]
4.1

How much is your plan premium? ........................................................................ [xx]

4.2

There are [insert number of payment options] ways you can pay your plan
premium ............................................................................................................. [xx]

4.3

Can we change your monthly plan premium during the year? ............................... [xx]

SECTION 5. Please keep your plan membership record up to date
5.1

How to help make sure that we have accurate information about you .................... [xx]

2010 Evidence of Coverage for [insert plan name]
Chapter 1: Getting started as a member of [insert plan name]

SECTION 1

Chapter 1
Section 1.1

Introduction
What is the Evidence of Coverage
booklet about?

[SNPs with an arrangement with the State may revise this language to reflect, when
applicable, that the organization is providing both Medicaid and Medicare covered benefits.]
This Evidence of Coverage booklet tells you how to get your Medicare medical care through
our plan. This booklet explains your rights and responsibilities, what is covered, and what you
pay as a member of the plan.
•

You are covered by Medicare, and you have chosen to get your Medicare health care
coverage through our plan, [insert plan name].

•

There are different types of Medicare Advantage Plans. [Insert plan name] is a
Medicare Advantage Plan HMO (HMO stands for Health Maintenance Organization).

In this Evidence of Coverage, the terms “we,” “our,” “the plan,” “our plan,” and “your plan,” all
refer to [insert plan name].
The word “coverage” and “covered services” refers to the medical care and services available
to you as a member of [insert plan name].

Chapter 1
Section 1.2

What does this Chapter tell you?

Look through Chapter 1 of Evidence of Coverage to learn:
•

What makes you eligible to be a plan member?

•

What materials will you get from us?

•

What your plan premium is and how you can pay it?

•

How to keep the information in your membership record up to date.

2010 Evidence of Coverage for [insert plan name]
Chapter 1: Getting started as a member of [insert plan name]

Chapter 1
Section 1.3

What if you are new to [insert plan
name]?

If you are a new member, then it’s important for you to learn how the plan operates – what the
rules are and what services are available to you. We encourage you to set aside some time to
look through this Evidence of Coverage booklet.
If you are confused or concerned or just have a question, please contact our plan’s Member
Services (contact information is on the cover of this booklet).

Chapter 1
Section 1.4

Legal information about Evidence of
Coverage

It’s part of our contract with you
This Evidence of Coverage is part of our contract with you about how [insert plan name] covers
your care. Other parts of this contract include your enrollment form and any notices you receive
from [insert plan name] about changes or extra conditions that can affect your coverage. These
notices are sometimes called “riders” or “amendments.”
The contract is in effect for months in which you are enrolled in [insert plan name] between
January 1, 2010 to December 31, 2010.
Medicare must approve our plan each year
Medicare (the Centers for Medicare & Medicaid Services) must approve [insert plan name] each
year. You can continue to get Medicare coverage as a member of our plan only as long as we
choose to continue to offer the plan for the year in question and the Centers for Medicare &
Medicaid Services renews its approval of the [insert plan name] plan.

SECTION 2

Chapter 1
Section 2.1

What makes you eligible to be
plan member?

Your [insert number of requirements]
eligibility requirements

2010 Evidence of Coverage for [insert plan name]
Chapter 1: Getting started as a member of [insert plan name]

You are eligible for membership in our plan as long as:
•

You live in our geographic service area (section 2.3 below describes our service area)

•

-- and -- you are entitled to Medicare Part A

•

-- and -- you are enrolled in Medicare Part B

•

-- and -- you do not have End Stage Renal Disease (ESRD), with limited exceptions, such
as if you develop ESRD when you are already a member of a plan that we offer, or you
were a member of a different plan that was terminated.

•

[SNPs insert: -- and -- you meet the special eligibility requirements described below.]

[SNPs insert this section as applicable to your plan type:
Special eligibility requirements for our plan
Our plan is designed to meet the needs of people who [insert as appropriate: are eligible for both
Medicare and Medicaid OR live in [insert type of institution] OR have [insert chronic or
disabling condition].
[Chronic/disabling condition SNPs, insert: Here is a list of the chronic or disabling condition[s]
that meet the eligibility requirements for our plan.
[Insert list specifying the chronic or disabling condition(s), including specific lab values, if
applicable, e.g., Total Blood Cholesterol exceeding 240mg without medication.]]]

Chapter 1
Section 2.2

What are Medicare Part A and Medicare
Part B?

When you originally signed up for Medicare, you received information about how to get
Medicare Part A and Medicare Part B. Remember:
•

Medicare Part A generally covers services furnished by institutional providers such as
hospitals, skilled nursing facilities or home health agencies.

•

Medicare Part B is for most other medical services, such as physician’s services and other
outpatient services.

To learn whether you have Medicare Part A and Part B, you can look on your red, white, and
blue Medicare card. Or, call Medicare at 1-800-MEDICARE (1-800-633-4227)
24 hours a day, 7 days a week. TTY users call 1-877-486-2048.

2010 Evidence of Coverage for [insert plan name]
Chapter 1: Getting started as a member of [insert plan name]

Chapter 1
Section 2.3

Here is the geographic service area for
[insert plan name]

Although Medicare is a Federal program, [insert plan name] is available only to individuals who
live in our geographic service area. To join our plan, you must live in this service area. To stay a
member of our plan, you [if a “continuation area” is offered under 42 C.F.R. 422.54, insert
“generally” here, and add a sentence describing the continuation area] must keep living in this
service area. The service area is described [insert as appropriate: below OR in an appendix to
this Evidence of Coverage.]
[Insert plan services area here or within an appendix. Plans may include references to
territories as a appropriate. Use county name only if approved for entire county. For partially
approved counties, use county name plus zip code. Examples:
Our service area includes these states: [insert states]
Our service area includes these counties in [insert state]: [insert counties]
Our service area includes these parts of counties in [insert state]: [insert county], the following
zip codes only [insert zip codes]]
If you are not sure whether you live in the service area, or if you plan to move out of the service
area, please contact Member Services.

SECTION 3

Chapter 1
Section 3.1

What other materials will you get from
us?

Your plan membership card – Use it to get
all covered medical care

[SNPs may revise this language to reflect, when applicable, that the members will use the plan
exclusively or the plan card and a Medicaid card.]
While you are a member of our plan, you must use our membership card whenever you get any
services covered by this plan. Here’s a sample membership card to show you what yours will
look like:
[Insert picture of front and back of member ID card. Mark it as a sample card (for example, by
superimposing the word “sample” on the image of the card.]
As long as you are a member of our plan you must not use your red, white, and blue
Medicare card to get covered medical services (with the exception of routine clinical research

2010 Evidence of Coverage for [insert plan name]
Chapter 1: Getting started as a member of [insert plan name]

studies and hospice services). Keep your red, white, and blue Medicare card in a safe place in
case you need it later.
Here’s why this is so important: If you get covered services using your red, white, and blue
Medicare card instead of using our membership card while you are a plan member, you may
have to pay the full cost yourself.
If your plan membership card is damaged, lost, or stolen, call Member Services right away and
we will send you a new card.

Chapter 1
Section 3.2

The Provider Directory: your guide to all
providers in the plan’s network

Every year that you are a member of our plan, we will send you either a new Provider Directory
or an update to your Provider Directory. This directory lists our network providers.
What are “network providers”?
Network providers are the doctors and other health care professionals, medical groups,
hospitals, and other health care facilities that participate in our plan. We have arranged for these
providers to deliver covered services to members in our plan.
Why do you need to know which providers are part of our network?
It is important to know which providers are part of our network because, with limited exceptions,
you may pay more for services you receive from an out-of-network provider. The only
exceptions are emergencies, urgently needed care when the network is not available (generally,
out of the area), out-of-area dialysis services, and cases in which [insert plan name] authorizes
use of non-network providers. See Chapter 3 (Using the plan’s coverage for your medical
services) for more specific information about emergency, out-of-network, and out-of-area
coverage.
[Plans with a Point-of-Service (POS) option may briefly describe the POS option here. The
details of the POS should be addressed in Chapter 3.]
If you don’t have your copy of the Provider Directory, you can request a copy from Member
Services. You may ask Member Services for more information about our network providers,
including their qualifications. [Plans may add additional information describing the information
available in the provider directory, on the plan’s website, or from Member Services. For
example: You can also see the Provider Directory at [insert URL], or download it from this
website. Both Member Services and the website can give you the most up-to-date information
about changes in our network providers.]

2010 Evidence of Coverage for [insert plan name]
Chapter 1: Getting started as a member of [insert plan name]

[Plans with a Point-of-Service option: briefly describe POS option here. The details of the POS
should be addressed in Chapter 3.]

SECTION 4

Chapter 1
Section 4.1

Your monthly premium for [insert plan
name]

How much is your plan premium?

[Plans with a monthly premium:] As a member of our plan, you pay a monthly plan premium.
[Select one of the following: For 2010, the monthly premium for [insert plan name] is [insert
monthly premium amount]. OR The table below shows the monthly plan premium amount for
each region we serve. OR The monthly premium amount for [insert plan name is listed in
[describe attachment].] [Plans may insert a list of or table with the state/region and monthly plan
premium amount for each area included within the EOC. Plans may also include premium(s) in
an attachment to the EOC.]
[Plans with no premium should replace the preceding paragraph with: You do not pay a
separate monthly plan premium for [insert plan name].]
[Insert if applicable: If you get your benefits from your current or former employer, or from your
spouse’s current or former employer, call the employer’s benefits administrator for information
about your plan premium.]
In some situations, your plan premium could be more than [insert monthly
premium amount]
[Plans that do not offer optional supplemental benefits may omit this subsection.]
If you signed up for extra benefits, also called “optional supplemental benefits”, then you pay an
additional premium each month for these extra benefits. If you have any questions about your
plan premiums, please call Member Services.
Many members are required to pay other Medicare premiums
[Plans that include a Part B premium reduction benefit may describe the benefit within this
section.]
In addition to paying the monthly plan premium, some plan members will be paying a premium
for Medicare Part A and most plan members will be paying a premium for Medicare Part B.

2010 Evidence of Coverage for [insert plan name]
Chapter 1: Getting started as a member of [insert plan name]

•

Your copy of Medicare & You 2010 tells about these premiums in the section called
“2010 Medicare Costs.” This explains how the Part B premium differs for people with
different incomes.

•

Everyone with Medicare receives a copy of Medicare & You each year in the fall. Those
new to Medicare receive it within a month after first signing up. You can also download a
copy of Medicare & You 2010 from http://www.medicare.gov. Or, you can order a
printed copy by phone at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a
week. TTY users call 1-877-486-2048.

Chapter 1
Section 4.2

There are [insert number of payment
options] ways you can pay your plan
premium

There are [insert number of payment options] ways you can pay your plan premium. [Plans must
indicate how the member can inform the plan of their premium payment option choice and the
procedure for changing that choice.]
Option 1: You can pay by check
[Insert plan specifics regarding premium payment intervals (e.g., monthly, quarterly- please note
that beneficiaries must have the option to pay their premiums monthly), how they can pay by
check, including an address, whether they can drop off a check in person, and by what day the
check must be received (e.g., the 5th of each month). If the Plan uses coupon books, explain when
they will receive it and to call Member Services for a new one if they run out or lose it. In
addition, include information if you charge for bounced checks.]
Option 2: [Insert option type]
[If applicable: Insert information about other payment options. Or delete this section.
Include information about all relevant choices (e.g., automatically withdrawn from your bank
account, charged directly to your credit card, charged directly to your debit card). Insert
information on the frequency of automatic deductions (e.g., monthly, quarterly – please note that
beneficiaries must have the option to pay their premiums monthly), the approximate day of the
month the deduction will be made, and how this can be set up.]
Option [insert number]: You can have the plan premium
taken out of your monthly Social Security check
You can have the plan premium taken out of your monthly Social Security check. Contact
Member Services for more information on how to pay your monthly plan premium this way. We
will be happy to help you set this up.

2010 Evidence of Coverage for [insert plan name]
Chapter 1: Getting started as a member of [insert plan name]

What to do if you are having trouble paying your plan premium
Your plan premium is due in our office by the [insert day of the month]. If we have not received
your premium by the [insert day of the month], we will send you a notice telling you that your
plan membership will end if we do not receive your premium within [insert length of plan grace
period].
If you are having trouble paying your premium on time, please contact Member Services to see if
we can direct you to programs that will help with your plan premium. If we end your
membership with the plan because of non-payment of premiums, and you don’t currently have
prescription drug coverage then you will not be able to receive Part D coverage until the annual
election period. At this time, you may either join a stand-along prescription drug plan or a health
plan that also provides drug coverage.
If we end your membership due to non-payment of premiums, you will have coverage under
Original Medicare. [Insert if applicable: At the time we end your membership, you may still owe
us for premiums you have not paid. In the future, if you want to enroll again in our plan (or
another plan that we offer), you will need to pay these late premiums before you can enroll.]
Chapter 1
Section 4.3

Can we change your monthly plan
premium during the year?

[Plans without a monthly premium may delete this section.]
No. We are not allowed to change the amount we charge for the plan’s monthly plan
premium during the year. If the monthly plan premium changes for next year we will tell
you in October and the change will take effect on January 1.

SECTION 5

Chapter 1
Section 5.1

Please keep your plan membership
record up to date

How to help make sure that we have
accurate information about you

[In the heading and this section, plans should substitute the name used for this file if different
from “membership record.”]
Your membership record has information from your enrollment form, including your address and
telephone number. It shows your specific plan coverage [insert as appropriate: including your
Primary Care Provider/Medical Group/IPA].

2010 Evidence of Coverage for [insert plan name]
Chapter 1: Getting started as a member of [insert plan name]

The doctors, hospitals, and other providers in the plan’s network need to have correct
information about you. These network providers use your membership record to know what
services are covered for you. Because of this, it is very important that you help us keep your
information up to date.
Call Member Services to let us know about these changes:
•

Changes to your name, your address, or your phone number

•

Changes in any other health insurance coverage you have (such as from your employer,
your spouse’s employer, workers’ compensation, or Medicaid)

•

If you have any liability claims, such as claims from an automobile accident

•

If you have been admitted to a nursing home

Read over the information we send you about any other insurance coverage you
have
Medicare requires that we collect information from you about any other medical or drug
insurance coverage that you have. That’s because we must coordinate any other coverage you
have with your benefits under our plan.
Once each year, we will send you a letter that lists any other medical or drug insurance coverage
that we know about. Please read over this information carefully. If it is correct, you don’t need to
do anything. If the information is incorrect, or if you have other coverage that is not listed, please
call Member Services (phone numbers are on the cover of this booklet).

2010 Evidence of Coverage for [insert plan name]
Chapter 2: Important phone numbers and resources

CHAPTER 2: Important phone numbers and resources

SECTION 1. [Insert plan name] (how to contact us, including how
to reach Member Services at the plan) ................................................ [xx]
SECTION 2. Medicare (how to get help and information directly
from the Federal Medicare program) ................................................... [xx]
SECTION 3. State Health Insurance Assistance Program (free help,
information, and answers to your questions about Medicare) .............. [xx]
SECTION 4. Quality Improvement Organization (paid by Medicare to
check on the quality of care for people with Medicare) ........................ [xx]
SECTION 5. Social Security ................................................................................... [xx]
SECTION 6. Medicaid (joint Federal and state program that helps with medical
costs for some people with limited income and resources) .................. [xx]
SECTION 7. How to contact the Railroad Retirement Board .............................. [xx]
SECTION 8. Do you have “group insurance” or other health insurance
coverage from an employer? ............................................................ [xx]

2010 Evidence of Coverage for [insert plan name]
Chapter 2: Important phone numbers and resources

SECTION 1

[Insert plan name]
(how to contact us, including how to reach
Member Services at the plan)

How to contact our plan’s Member Services
For assistance with enrollment, billing, or member card questions, please call or write to [insert
plan name] Member Services. We will be happy to help you.
[Insert plan name] Member Services
CALL

[Insert phone number(s)]

TTY/TDD

Calls to this number are [insert if applicable: not] free. [Insert hours
of operation, including information on the use of alternative
technologies.]
[Insert number]
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.

FAX

Calls to this number are [insert if applicable: not] free. [Insert hours
of operation.]
[Insert fax number]

WRITE

[Insert address]

WEBSITE

[Note: plans may add email addresses here.]
[Insert URL]

2010 Evidence of Coverage for [insert plan name]
Chapter 2: Important phone numbers and resources

[Note: If your plan uses the same contact information for the Part C issues indicated below, you
may combine the appropriate sections.]
How to contact us when you are asking for a coverage
decision about your medical care
[Insert plan name] Coverage Decisions for Medical Care
CALL

[Insert phone number]

TTY/TDD

Calls to this number are [insert if applicable: not] free. [Note: You
may also include reference to 24-hour lines here.] [Note: If you have
a different number for accepting expedited organization
determinations, also include that number here.]
[Insert number]
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.

FAX

WRITE

Calls to this number are [insert if applicable: not] free. [Note: If you
have a different TTY/TDD number for accepting expedited
organization determinations, also include that number here.]
[Optional: insert fax number] [Note: If you have a different fax
number for accepting expedited organization determinations, also
include that number here.]
[Insert address] [Note: If you have a different address for accepting
expedited organization determinations, also include that number
here.]

For more information on asking for coverage decisions about your medical care, see Chapter
7 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints).
How to contact us when you making an appeal about your
medical care
[Insert plan name] Appeals for Medical Care
CALL

[Insert phone number]
Calls to this number are [insert if applicable: not] free. [Note: You
may also include reference to 24-hour lines here.] [Note: If you have
a different number for accepting expedited appeals, also include that
number here.]

2010 Evidence of Coverage for [insert plan name]
Chapter 2: Important phone numbers and resources

TTY/TDD

[Insert number]
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.

FAX

WRITE

Calls to this number are [insert if applicable: not] free. [Note: If you
have a different TTY/TDD number for accepting expedited appeals,
also include that number here.]
[Optional: insert fax number] [Note: If you have a different fax
number for accepting expedited appeals, also include that number
here.]
[Insert address] [Note: If you have a different address for accepting
expedited appeals, also include that number here.]

For more information on making an appeal about your medical care, see Chapter 7 (What to
do if you have a problem or complaint (coverage decisions, appeals, complaints).
How to contact us when you are making a complaint about
your medical care
[Insert plan name] Complaints about Medical Care
CALL

[Insert phone number]

TTY/TDD

Calls to this number are [insert if applicable: not] free. [Note: You
may also include reference to 24-hour lines here.] [Note: If you have
a different number for accepting expedited grievances, also include
that number here.]
[Insert number]
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.

FAX

WRITE

Calls to this number are [insert if applicable: not] free. [Note: If you
have a different TTY/TDD number for accepting expedited
grievances, also include that number here.]
[Optional: insert fax number] [Note: If you have a different fax
number for accepting expedited grievances, also include that number
here.]
[Insert address] [Note: If you have a different address for accepting
expedited grievances, also include that number here.]

2010 Evidence of Coverage for [insert plan name]
Chapter 2: Important phone numbers and resources

For more information on making a complaint about your medical care, see Chapter 7 (What
to do if you have a problem or complaint (coverage decisions, appeals, complaints).
Where to send a request that asks us to pay for our share of
the cost for medical care you have received
For more information on situations in which you may need to ask the plan for
reimbursement or to pay a bill you have received from a provider, see Chapter 5
(Asking the plan to pay its share of a bill you have received for medical services).
[Insert plan name] Payment Requests
CALL

[Insert phone number]

TTY/TDD

Calls to this number are [insert if applicable: not] free.
[Insert number]
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.

FAX
WRITE

SECTION 2

Calls to this number are [insert if applicable: not] free.
[Optional: Insert fax number]
[Insert address]

Medicare
(how to get help and information directly from
the Federal Medicare program)

Medicare is the Federal health insurance program for people 65 years of age or older, some
people under age 65 with disabilities, and people with End-Stage Renal Disease (permanent
kidney failure requiring dialysis or a kidney transplant).
The Federal agency in charge of the Medicare program is the Centers for Medicare &
Medicaid Services (sometimes called “CMS”). This agency contracts with and regulates
Medicare health plans including [insert plan name].

2010 Evidence of Coverage for [insert plan name]
Chapter 2: Important phone numbers and resources

Medicare
CALL

1-800-MEDICARE, or 1-800-633-4227
Calls to this number are free.
24 hours a day, 7 days a week.

TTY

1-877-486-2048
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.

WEBSITE

Calls to this number are free.
http://ww.medicare.gov
This is the official government website for Medicare. It gives you upto-date information about Medicare and current Medicare issues. It
also has information about hospitals, nursing homes, physicians,
home health agencies, and dialysis facilities. It includes booklets you
can print directly from your computer. It has tools to help you
compare Medicare Advantage Plans and Medicare drug plans in your
area. You can also find Medicare contacts in your state by selecting
“Helpful Phone Numbers and Websites.”
If you don’t have a computer, your local library or senior center may
be able to help you visit this website using its computer. Or, you can
call Medicare at the number above and tell them what information
you are looking for. They will find the information on the website,
print it out, and send it to you.

SECTION 3

State Health Insurance Assistance
Program
(free help, information, and answers to your
questions about Medicare)

[Organizations offering plans in multiple states: Revise this section to use the generic name
(“State Health Insurance Assistance Program”) when necessary, and include a list of names,
phone numbers, and addresses for all SHIPs in your service area. Plans have the option of
including a separate exhibit to list the SHIPs in all states, or in all states in which the plan is
filed, and should make reference to that exhibit below.]

2010 Evidence of Coverage for [insert plan name]
Chapter 2: Important phone numbers and resources

The State Health Insurance Assistance Program (SHIP) is a government program with trained
counselors in every state. In [insert state], the State Health Insurance Assistance Program is
called [insert state-specific SHIP name].
[Insert state-specific SHIP name] is independent (not connected with any insurance company
or health plan). It is a state program that gets money from the Federal government to give free
local health insurance counseling to people with Medicare.
[Insert state-specific SHIP name] counselors can help you with your Medicare questions or
problems. They can help you understand your Medicare rights, help you make complaints
about your medical care or treatment, and help you straighten out problems with your
Medicare bills. [Insert state-specific SHIP name] counselors can also help you understand
your Medicare plan choices and answer questions about switching plans.
[Insert state-specific SHIP name]
CALL

[Insert phone number(s)]

TTY/TDD

[Insert number, if available. Or delete this row.]

WRITE

This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.
[Insert address]

WEBSITE

[Optional: Insert URL]

SECTION 4

Quality Improvement Organization
(paid by Medicare to check on the quality of care
for people with Medicare)

[Organizations offering plans in multiple states: Revise this section to use the generic name
(“Quality Improvement Organization”) when necessary, and include a list of names, phone
numbers, and addresses for all QIOs in your service area. Plans have the option of including
a separate exhibit to list the QIOs in all states, or in all states in which the plan is filed, and
should make reference to that exhibit below.]
There is a Quality Improvement Organization in each state. In [insert state], the Quality
Improvement Organization is called [insert state-specific QIO name].

2010 Evidence of Coverage for [insert plan name]
Chapter 2: Important phone numbers and resources

[Insert state-specific QIO name] has a group of doctors and other health care professionals
who are paid by the Federal government. This organization is paid by Medicare to check on
and help improve the quality of care for people with Medicare. [Insert state-specific QIO
name] is an independent organization. It is not connected with our plan.
You should contact [insert state-specific QIO name] in any of these situations:
•

You have a complaint about the quality of care you have received.

•

You think coverage for your hospital stay is ending too soon.

•

You think coverage for your home health care, skilled nursing facility care, or
Comprehensive Outpatient Rehabilitation Facility (CORF) care is ending too soon.

[Insert state-specific QIO name]
CALL

[Insert phone number(s)]

TTY/TDD

[Insert number, if available. Or delete this row.]

WRITE

This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.
[Insert address]

WEBSITE

[Optional: Insert URL]

SECTION 5

Social Security

Social Security is responsible for determining eligibility and handling enrollment for
Medicare. U.S. citizens who are 65 or older , or who have a disability or end stage renal
disease and meets certain conditions, are eligible for Medicare. If you are already getting
Social Security checks, enrollment into Medicare is automatic. If you are not getting Social
Security checks, you have to enroll in Medicare and pay the Part A premium. Social Security
handles the enrollment process for Medicare. To apply for Medicare, you can call the Social
Security or visit your local Social Security office.

2010 Evidence of Coverage for [insert plan name]
Chapter 2: Important phone numbers and resources

Social Security Administration
CALL

1-800-772-1213
Calls to this number are free.
Available 7:00 am to 7:00 pm, Monday through Friday.
You can use our automated telephone services to get recorded
information and conduct some business 24 hours a day.

TTY

1-800-325-0778
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.
Calls to this number are free.
Available 7:00 am to 7:00 pm, Monday through Friday.

WEBSITE

SECTION 6

http://www.ssa.gov

Medicaid (a joint Federal and state program
that helps with medical costs for some people
with limited income and resources)

[Organizations offering plans in multiple states: Revise this section to include a list of agency
names, phone numbers, and addresses for all states in your service area. Plans have the
option of including a separate exhibit to list Medicaid information in all states or in all states
in which the plan is filed and should make reference to that exhibit below.]
[Plans may adapt this generic discussion of Medicaid to reflect the name or features of the
Medicaid program in the plan’s state or states.]
[SNPs may describe the Medicaid managed care program under which the organization
contracts with the state Medicaid agency.]
[SNPs must, as appropriate, include additional telephone numbers for Medicaid program
assistance, e.g., the telephone number for the state Ombudsman.]

2010 Evidence of Coverage for [insert plan name]
Chapter 2: Important phone numbers and resources

Medicaid is a joint Federal and state government program that helps with medical costs for
certain people with limited incomes and resources. Some people with Medicare are also
eligible for Medicaid. Medicaid has programs that can help pay for your Medicare premiums
and other costs, if you qualify. To find out more about Medicaid and its programs, contact
[insert state-specific Medicaid agency].
[Insert state-specific Medicaid agency]
CALL

[Insert phone number(s)]

TTY/TDD

[Insert number, if available. Or delete this row.]

WRITE

This number requires special telephone equipment and is only
for people who have difficulties with hearing or speaking.
[Insert address]

WEBSITE

[Optional: Insert URL]

SECTION 7

How to contact the Railroad Retirement
Board

The Railroad Retirement Board is an independent Federal agency that administers
comprehensive benefit programs for the nation’s railroad workers and their families. If you have
questions regarding your benefits from the Railroad Retirement Board, contact the agency.
Railroad Retirement Board
CALL

1-877-772-5772
Calls to this number are free.
Available 9:00 am to 3:30 pm, Monday through Friday
If you have a touch-tone telephone, recorded information and
automated services are available 24 hours a day, including
weekends and holidays.

2010 Evidence of Coverage for [insert plan name]
Chapter 2: Important phone numbers and resources

TTY

1-312-751-4701
This number requires special telephone equipment and is only
for people who have difficulties with hearing or speaking.
Calls to this number are not free.

WEBSITE

SECTION 8

http://www.rrb.gov

Do you have “group insurance” or other
health insurance from an employer?

[SNPs may, as appropriate, delete this section since beneficiaries covered under employer
groups are not eligible to participate in dual eligible SNPs in some states.]
If you (or your spouse) get benefits from your (or your spouse’s) employer or retiree group, call
the employer/union benefits administrator or Member Services if you have any questions. You
can ask about your (or your spouse’s) employer or retiree health benefits, premiums, or the
enrollment period.
If you have other prescription drug coverage through your (or your spouse’s) employer or
retiree group, please contact that group’s benefits administrator. The benefits administrator
can help you determine how your current prescription drug coverage will work with our plan.

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your medical services

CHAPTER 3: Using the plan’s coverage for your medical services

SECTION 1. Summary of things to know about getting your
medical care as a member of our plan
1.1

What are “network providers” and “covered services”? ........................................ [xx]

1.2

Basic rules for getting your medical care that is covered by the plan ..................... [xx]

SECTION 2. Use providers in the plan’s network to get your medical care
2.1

You must choose a Primary Care Provider (PCP) to provide and arrange for
your medical care ................................................................................................. [xx]

2.2

What kinds of medical care can you get without getting approval in advance
from your PCP? .................................................................................................... [xx]

2.3

How to get care from specialists and other network providers ............................... [xx]

2.4

How to get care from out-of-network providers .................................................... [xx]

SECTION 3. How to get covered services when you have an
emergency or urgent need for care
3.1

Getting care if you have a medical emergency ...................................................... [xx]

3.2

Getting care if you have an urgent need for care ................................................... [xx]

SECTION 4. What if you are billed directly for the full cost of your
covered services?
4.1

How to ask the plan to pay its share of the cost of your covered services .............. [xx]

4.2

If services are not covered by our plan, you must pay the full cost ........................ [xx]

SECTION 5. How are your medical services covered when you are
in a “clinical research study”?
5.1 What is a “clinical research study”? ...................................................................... [xx]
5.2

When you participate in a clinical research study, who pays for what? .................. [xx]

SECTION 6. Rules for getting care in a “religious non-medical health
care institution”
6.1

What is a religious non-medical health care institution? ........................................ [xx]

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your medical services

6.2

What care from a religious non-medical health care institution is covered by
our plan?............................................................................................................... [xx]

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your medical services

SECTION 1

Summary of things to know about getting
your medical care as a member of our
plan

This chapter tells things you need to know about using [insert plan name] to get your medical
care. It gives definitions of terms and explains the rules you will need to follow to get the
medical treatments, services, and other medical care that are covered by the plan.
For the details on what medical care is covered by our plan and how much you pay as your
share of the cost when you get this care, use the benefits chart in the next chapter, Chapter 4
(Medical benefits chart, what is covered and what you pay).

Chapter 3
Section 1.1

What are “network providers” and
“covered services”?

Here are some definitions that can help you understand how you get the care and services that
are covered for you as a member of our plan:
•

“Providers” are doctors and other health care professionals that the state licenses to
provide medical services and care. The term “providers” also includes hospitals and other
health care facilities.

•

“Network providers” are the doctors and other health care professionals, medical
groups, hospitals, and other health care facilities that participate in our plan. We have
arranged for these providers to deliver covered services to members in our plan. The
providers in our network generally bill us directly for care they give you. When you see a
network provider, you usually pay only your share of the cost for their services.

•

“Covered services” include all the medical care, health care services, supplies, and
equipment that are covered by our plan. Your covered services for medical care are listed
in the benefits chart in Chapter 4.

Chapter 3
Section 1.2

Basic rules for getting your medical care
that is covered by the plan

[Insert plan name] will generally cover your medical care as long as:
•

The care you receive is included in the plan’s Medical Benefits Chart (this chart is in
Chapter 4 of this booklet).

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your medical services

•

The care you receive is considered medically necessary. It needs to be accepted
treatment for your medical condition.

•

[Plans may omit or edit the PCP-related bullets as necessary] You have a primary care
provider (a PCP) who is providing and overseeing your care. As a member of our
plan, you must choose a PCP (for more about this, see Section 2.1 in this chapter).
o In most situations, your PCP must give you approval in advance before you can see
other providers in the plan’s network. This is called giving you a “referral.” For
more about this, see Section 2.2 of this chapter.
o Referrals from your PCP are not required for emergency care or urgently needed
care. There are also some other kinds of care you can get without having approval
in advance from your PCP (for more about this, see Section 2.3 of this chapter).

•

[Plans with a POS option may edit the network provider bullets as necessary.] You
receive your care from a network provider (for more about this, see Section 2 in this
chapter). In most cases, care you receive from a non-network provider (a provider who is
not part of our plan’s network) will not be covered. Here are two exceptions:
o Under certain circumstances, the plan covers emergency care or urgently needed
care that you get from a non-network provider. For more about this, see Section 3 in
this chapter.
o If you need medical care that Medicare requires our plan to cover and the providers
in our network cannot provide this care, you can get this care from a non-network
provider. In this situation, you will pay the same as you would pay if you got the
care from a network provider.

SECTION 2

Chapter 3
Section 2.1

Use providers in the plan’s network to get
your medical care

You must choose a Primary Care
Provider (PCP) to provide and arrange for
your medical care

[Note: Insert this section only if plan uses PCPs. Plans may edit this section to refer to a
Physician of Choice (POC) instead of PCP.]
What is a “PCP” and what does the PCP do for you?
[Plans should describe the following in the context of their plans:
•

What is a PCP?

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your medical services

•
•
•

What types of providers may act as a PCP?
Explain the role of a PCP in your plan.
What is the role of the PCP in coordinating covered services?]

How do you choose your PCP?
[Plans should describe how to choose a PCP.]
Changing your PCP
You may change your PCP for any reason, at any time. Also, it’s possible that your PCP might
leave our plan’s network of providers and you would have to find a new PCP.
[Plans should describe how to change a PCP.]
[Dual eligible SNPs that are obligated under state Medicaid programs to have a transition
benefit when a doctor leaves a plan, may discuss that benefit here.]

Chapter 3
Section 2.2

What kinds of medical care can you get
without getting approval in advance from
your PCP?

[Note: Insert this section only if plan uses PCPs.]
You can get the services listed below without getting approval in advance from your PCP.
•

Routine women’s health care, which include breast exams, mammograms (x-rays of the
breast), Pap tests, and pelvic exams, as long as you get them from a network provider.

•

Flu shots [insert if applicable: and pneumonia vaccinations] [insert if appropriate: as
long as you get them from a network provider].

•

Emergency services from network providers or from non-network providers.

•

Urgently needed care from non-network providers when network providers are
temporarily unavailable or inaccessible.

•

Kidney dialysis services that you get at a Medicare-certified dialysis facility when you
are temporarily outside the plan’s service area. [Plans may insert requests here, e.g., If
possible, please let us know before you leave the service area where you are going to be
so we can help arrange for you to have maintenance dialysis while outside the service
area.]

•

[Plans should add additional bullets as appropriate.]

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your medical services

Chapter 3
Section 2.3

How to get care from specialists and
other network providers

A specialist is a doctor who provides health care services for a specific disease or part of the
body. There are many kinds of specialists. Here are a few examples:
•

Oncologists, who care for patients with cancer.

•

Cardiologists, who care for patients with heart conditions.

•

Orthopedists, who care for patients with certain bone, joint, or muscle conditions.

[Plans should describe how members access specialists and other network providers, including:
• What is the role (if any) of the PCP in referring members to specialists and other
providers?
• For what services will the PCP need to get prior authorization from the plan?
• Explain if the selection of a PCP results in being limited to specific specialists or
hospitals to which that PCP refers, i.e. sub-network, referral circles.]
What if a specialist or another network provider leaves our plan?
Sometimes a specialist, clinic, hospital or other network provider you are using might leave the
plan. [Plans should describe what to do if their specialist or other provider leaves the network.]
[Dual eligible SNPs that are obligated under state Medicaid programs to have a transition
benefit when a doctor leaves a plan, may discuss that benefit here.]

Chapter 3
Section 2.4

How to get care from out-of-network
providers

[Plans with a POS option include Section 2.4. Describe POS option here. Tell members under
what circumstances they may obtain services from out-of-network providers and what
restrictions apply. General information (no specific dollar amounts) about cost-sharing
applicable to the use of out-of-network providers in HMO/POS plans should be inserted here,
with reference to the benefits chart where detailed information can be found.]

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your medical services

SECTION 3

Chapter 3
Section 3.1

How to get covered services when you
have an emergency or urgent need for
care

Getting care if you have a
medical emergency

What is a “medical emergency” and what should you do if you have one?
When you have a “medical emergency,” you believe that your health is in serious danger. A
medical emergency can include severe pain, a bad injury, a sudden illness, or a medical condition
that is quickly getting much worse.
If you have a medical emergency:

• Get help as quickly as possible. Call 911 for help or go to the nearest emergency room,
hospital, or urgent care center. Call for an ambulance if you need it. You do not need to
get approval or a referral first from your PCP.

• As soon as possible, make sure that our plan has been told about your emergency.
We need to follow up on your emergency care. You or someone else should call to tell us
about your emergency care, usually within 48 hours. [Plans must provider either the
number to call or explain where to find the number (e.g., on the back the plan
membership card).]
What is covered if you have a medical emergency?
You may get covered emergency medical care whenever you need it, anywhere in the United
States. (In very limited circumstances emergency services are covered in Canada. If you have an
emergency in Canada, call your plan to find out if you are eligible for coverage for emergency
services.) Our plan covers ambulance services in situations where getting to the emergency room
in any other way could endanger your health. For more information, see the medical benefits
chart in Chapter 4 of this booklet.
[Plans that offer a supplemental benefit covering emergencies or ambulance services outside of
the country, mention the benefit here and then refer members to Chapter 4 for more
information.]
If you have an emergency, we will talk with the doctors who are giving you emergency care
to help manage and follow up on your care. The doctors who are giving you emergency care
will decide when your condition is stable and the medical emergency is over.

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your medical services

[Plans may modify this paragraph as needed to address the post-stabilization care for your
plan.] After the emergency is over you are entitled to follow-up care to be sure your condition
continues to be stable. Your follow-up care will be covered by our plan. If your emergency
care is provided by non-network providers, we will try to arrange for network providers to
take over your care as soon as your medical condition and the circumstances allow.
What if it wasn’t a medical emergency?
Sometimes it can be hard to know if you have a medical emergency. For example, you might go
in for emergency care – thinking that your health is in serious danger – and the doctor may say
that it wasn’t a medical emergency after all. If it turns out that it was not an emergency, as long
as you thought your health was in serious danger, we will cover your care.
However, after the doctor has said that it was not an emergency, we will generally cover
additional care only if you get the additional care in one of these two ways:
•

You go to a network provider to get the additional care.

•

--or-- the additional care you get is considered “urgently needed care” and you
follow the rules for getting this urgent care (for more about this, see Section 3.2
below).

Chapter 3
Section 3.2

Getting care when you have an urgent
need for care

What is “urgently needed care”?
“Urgently needed care” is a non-emergency situation when:
•

You need medical care right away because of an illness, injury, or condition that you did
not expect or anticipate, but your health is not in serious danger.

•

Because of the situation, it isn’t reasonable for you to obtain medical care from a network
provider.

What if you are in the plan’s service area when you
have an urgent need for care?
Whenever possible, you must use our network providers when you are in the plan’s service area
and you have an urgent need for care. (For more about the plan’s service area, see Chapter 1,
Section 2.3 of this booklet.)
In most situations, if you are in the plan’s service area, we will cover urgently needed care only if
you get this care from a network provider and follow the other rules described earlier in this
chapter. If the circumstances are unusual or extraordinary, and network providers are temporarily

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your medical services

unavailable or inaccessible, our plan will cover urgently needed care that you get from a nonnetwork provider.
What if you are outside the plan’s service area when
you have an urgent need for care?
Suppose that you are temporarily outside our plan’s service area, but still in the United States. If
you have an urgent need for care, you probably will not be able to find or get to one of the
providers in our plan’s network. In this situation (when you are outside the service area and
cannot get care from a network provider), our plan will cover urgently needed care that you get
from any provider.
Our plan does not cover urgently needed care or any other care if you receive the care outside of
the United States.

SECTION 4

Chapter 3
Section 4.1

What if you are billed directly for the full
cost of your covered services?

You can ask the plan to pay our
share of the cost of your covered
services

Sometimes when you get medical care, you may need to pay the full cost right away. Other
times, you may find that you have paid more than you expected under the coverage rules of the
plan. In either case, you will want our plan to pay our share of the costs by reimbursing you for
payments you have already made.
There may also be times when you get a bill from a provider for the full cost of medical care
you have received. In many cases, you should send this bill to us so that we can pay our share
of the costs for your covered medical services.
If you have paid more than your share for covered services, or if you have received a bill for the
full cost of covered medical services, go to Chapter 7, Section 2.3 for information about what to
do.
Chapter 3
Section 4.2

If services are not covered by our plan,
you must pay the full cost

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your medical services

[Insert plan name] covers all medical services that are medically necessary and are covered
under Medicare. You are responsible for paying the full cost of services that aren’t covered by
our plan.
If you have any questions about whether we will pay for any medical service or care that you are
considering, you have the right to ask us whether we will cover it before you get it. If we say we
will not cover your services, you have the right to appeal our decision not to cover your care.
Chapter 9 (What to do if you have a problem or complaint) has more information about what to
do if you want a coverage decision from us or want to appeal a decision we have already made.
You may also call Member Services at the number on the front cover of this booklet to get more
information about how to do this.
For covered services that have a benefit limitation, you pay the full cost of any services you get
after you have used up your benefit for that type of covered service. [Plans should explain
whether paying for costs once a benefit limit has been reached will count toward an out-ofpocket maximum.] You can call Members Services when you want to know how much of your
benefit limit you have already used.

SECTION 5

Chapter 3
Section 5.1

How are your medical services covered
when you are in a “clinical research
study”?

What is a “clinical research study”?

A clinical research study is a way that doctors and scientists test new types of medical care, like
how well a new cancer drug works. They test new medical care procedures or drugs by asking
for volunteers to help with the study. This kind of study is one of the final stages of a research
process that helps doctors and scientists see if a new approach works and if it is safe.
Not all clinical research studies are open to members of our plan. Medicare first needs to approve
the research study. If you participate in a study that Medicare has not approved, you will be
responsible for paying all costs for your participation in the study.
Once Medicare approves the study, someone who works on the study will contact you to explain
more about the study and see if you meet the requirements set by the scientists who are running
the study. You can participate in the study as long as you meet the requirements for the study
and you have a full understanding and acceptance of what is involved if you participate in the
study.

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your medical services

If you participate in a Medicare-approved study, Original Medicare pays the doctors and other
providers for the covered services you receive as part of the study. When you are in a clinical
research study, you may stay enrolled in our plan and continue to get the rest of your care (the
care that is not related to the study) through our plan.
If you want to participate in a Medicare-approved clinical research study, you do not need to get
approval from our plan or your PCP. The providers that deliver your care as part of the clinical
research study do not need to be part of our plan’s network of providers.
Although you do not need to get our plan’s permission to be in a clinical research study, you do
need to tell us before you start participating in a clinical research study. Here is why you
need to tell us:
1. We can let you know whether the clinical research study is Medicare-approved.
2. We can tell you what services you will get from clinical research study providers instead
of from our plan.
3. We can keep track of the health care services that you receive as part of the study.
If you plan on participating in a clinical research study, contact Member Services at [insert
phone number] (TTY/TDD only, call [insert TTY/TDD number]). Hours are [insert days and
hours of operation] and calls to these numbers are [insert as applicable: free OR not free].
Chapter 3
Section 5.2

When you participate in a clinical
research study, who pays for what?

Once you join a Medicare-approved clinical research study, Medicare will pay for the covered
services you receive as part of the research study. Medicare pays for routine costs of items
and services. Examples of these items and services include the following:
•

Room and board for a hospital stay that Medicare would pay for even if you weren’t in a
study.

•

An operation or other medical procedure if it is part of the research study.

•

Treatment of side effects and complications of the new care.

When you are part of a clinical research study, Medicare will not pay for any of the following:
•

Generally, Medicare will not pay for the new item or service that the study is testing
unless Medicare would cover the item or service even if you were not in a study.

•

Items and services the study gives you or any participant for free.

•

Items or services provided only to collect data, and not used in your direct health care.
For example, Medicare would not pay for monthly CT scans done as part of the study if
your condition would usually require only one CT scan.

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your medical services

[If your plan charges the Original Medicare cost-sharing amounts for clinical trial services, use
this language: You will have to pay the same coinsurance amounts charged under Original
Medicare for the services you receive as a participant in the clinical research study. Because you
are a member of our plan, you do not have to pay the deductibles for Original Medicare Part A or
Part B.]
[If your plan will cover all or a portion of the FFS coinsurance for your members participating
in a clinical trial, say so here and/or modify the previous sentences. Also, specify the conditions
(if any) under which such additional coverage is available (e.g., if the member participants in a
clinical trial sponsored by one of your contracting providers).]
Do you want to know more?
To find out what your coinsurance would be if you joined a Medicare-approved clinical research
study, please call us at Member Services (phone numbers are on the cover of this booklet).
You can get more information about joining a clinical research study by reading the publication
“Medicare and Clinical Research Studies” at
http://www.medicare.gov/Publications/Pubs/pdf/02226.pdf. You can also call 1-800MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY users should call 1-877-4862048.

SECTION 6

Chapter 3
Section 6.1

Rules for getting care in a
“religious non-medical health care
institution”

What is a religious non-medical health
care institution?

A religious non-medical health care institution is a facility that provides care for a condition that
would ordinarily be treated in a hospital or skilled nursing facility care. If getting care in a
hospital or a skilled nursing facility is against a member’s religious beliefs, you must elect to
have your coverage for care in a religious non-medical health care institution. You may also
chose at any time if for any reason you decide to pursue medical care. This benefit provides only
for Part A inpatient services. Medicare will only pay for non-medical health care services
furnished by religious non-medical health care institution.
Chapter 3
Section 6.2

What care from a religious non-medical
health care institution is covered by our
plan?

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your medical services

To get care from a religious non-medical health care institution, you must sign a legal document
that says you are conscientiously opposed to getting medical treatment that is “non-excepted.”
• “Non-excepted” medical care or treatment is any medical care or treatment that is
voluntary and not required by any federal, state, or local law.
• (“Excepted” medical treatment is medical care or treatment that you get that is not
voluntary or is required under federal, state, or local law.)
To be covered by our plan, the care you get from a religious non-medical health care institution
must meet the following conditions:
•

The facility providing the care must be certified by Medicare.

•

Our plan’s coverage of services you receive is limited to non-religious aspects of care.

•

If you get services from this institution that are provided to you in your home, our plan
will cover these services only if they are the kind of services that would ordinarily be
given by home health agencies that are not religious non-medical health care institutions.

•

If you get services from this institution that are provided to you in a facility, the
following [insert as applicable: conditions apply OR condition applies]:
o You must have a medical condition that would allow you to receive covered
services for inpatient hospital care or skilled nursing facility care.
o [Omit this bullet if not applicable] – and – you must get approval in advance from
our plan before you are admitted to the facility or your stay will not be covered.

[Plans must explain whether Medicare Inpatient Hospital coverage limits apply (include a
reference to the benefits chart in Chapter 4) or whether there is unlimited coverage for this
benefit.]

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

CHAPTER 4: Medical benefits chart (what is covered and what you pay)

SECTION 1. Understanding your out-of-pocket costs for
covered services
1.1

What types of out-of-pocket costs do you pay for your covered services? ............. [xx]

1.2

What is the maximum amount you will pay for certain covered medical
services? ............................................................................................................... [xx]

SECTION 2. Use this Medical Benefits Chart to find out what is
covered for you and how much you will pay
2.1

Your medical benefits and costs as a member of the plan ...................................... [xx]

2.2

Extra “optional supplemental” benefit you can buy ............................................... [xx]

2.3

Getting care using our plan’s traveler benefit ........................................................ [xx]

SECTION 3. What types of benefits are not covered by the plan?
3.1

Types of benefits we do not cover ......................................................................... [xx]

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

[SNPs may add a discussion to this chapter if they cover benefits under Medicaid, as long as the
benefits are distinctly identified as Medicaid and not Medicare-covered benefits. This may
include adding new language to the benefit chart itself as well as language to the related text in
this chapter. This may be done in an additional column or additional rows or within existing
cells of the chart or group together at the end and labeled as Medicaid benefits.]

SECTION 1

Understanding your out-of-pocket costs for
covered services

This chapter focuses on your covered services and what your pay for you medical benefits. It
includes a Medical Benefits Chart that gives a list of your covered services and tells how much
you will pay for each covered service as a member of [insert plan name]. Later in this chapter,
you can find information about medical services that are not covered. [Insert if applicable: It also
tells about limitations on certain services.] [If applicable, you may mention other places where
benefits, limitations, and exclusions are described, such as optional additional benefits, or
addenda.]

Chapter 4
Section 1.1

What types of out-of-pocket costs do you
pay for your covered services?

[Describe all applicable cost-sharing types your plan uses. You may omit those that are not
applicable.]
To understand the payment information we give you in this chapter, you need to know about the
types of out-of-pocket costs you may pay for your covered services.
•

The “deductible” means the amount you must pay for medical services before our plan
begins to pay its share.

•

A “copayment” means that you pay a fixed amount each time you receive a medical
service. You pay a copayment at the time you get the medical service.

•

“Coinsurance” means that you pay a percent of the total cost of a medical service. You
pay a coinsurance at the time you get the medical service.

Some people qualify for programs to help them pay their out-of-pocket costs for Medicare. If
you are enrolled in these programs, you may still have to pay the Medicaid copayment,
depending on the rules in your state.

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

Chapter 4
Section 1.2

What is the maximum amount you will pay
for certain covered medical services?

There is a limit to how much you have to pay out-of-pocket for certain covered health care
services each year. [Plans with out-of-pocket limit should describe what services the OOP max
applies to, including dollar amounts. Plans may choose to do so using notations within the
benefits chart.]
[Section 2 should be deleted if the plan does not have an out-of-pocket limit.]

SECTION 2

Chapter 4
Section 2.1

Use this Medical Benefits Chart to find out
what is covered for you and how much
you will pay

Your medical benefits and costs as a
member of the plan

The medical benefits chart on the following pages lists the services [insert plan name] covers
and what you pay for each service. The services listed in the Medical Benefits Chart are covered
only when all coverage requirements are met:
•

Your Medicare covered services must be provided according to the coverage guidelines
established by Medicare.

•

Except in the case of preventative services and screening tests, your services (including
medical care, services, supplies, and equipment) must be medically necessary. Medically
necessary means that the services are an accepted treatment for your medical condition.

•

[Insert if applicable: You receive your care from a network provider. In most cases, care
you receive from a non-network provider will not be covered. Chapter 3 provides more
information about requirements for using network providers and the situations when we
will cover services from a non-network provider.]

• [Insert if applicable: You have a primary care provider (a PCP) who is providing and
overseeing your care. In most situations, your PCP must give you approval in advance
before you can see other providers in the plan’s network. This is called giving you a
“referral.” Chapter 3 provides more information about getting a referral and the
situations when you do not need a referral.]
•

Some of the services listed in the Medical Benefits Chart are covered only if your doctor
or other network provider gets approval in advance (sometimes called “prior
authorization”) from [insert plan name]. Covered services that need approval in advance

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

are marked in the Medical Benefits Chart [insert as appropriate: by an asterisk OR by a
footnote OR in bold OR in italics] [Insert if applicable: In addition, the following
services not listed in the Benefits Chart require prior authorization:
[insert list]]
[Instructions on completing benefits chart:
• When preparing this Benefits Chart, please refer to any instructions contained in the
cover memorandum of the standardized/combined ANOC/EOC.
• All plans with networks should clearly indicate for each service applicable the difference
in cost-sharing at network and out-of-network providers and facilities.
• Plans with a POS benefit may include POS information within the benefit chart, or may
include a section following the chart listing POS-eligible benefits and cost-sharing.
• Plans should clearly indicate which benefits are subject to prior authorization (plans may
use asterisks or similar method).
• Plans may insert any additional benefits information based on the plan’s approved bid
that is not captured in the benefits chart or in the exclusions section.]

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

Services that are covered for you

What you must
pay when you get
these services

Inpatient Care
Inpatient hospital care
[List days covered and any restrictions that apply.] Covered services
include:

•
•
•
•

Semi-private room (or a private room if medically necessary)

•
•
•
•
•
•
•
•

Drugs and medications

Meals including special diets
Regular nursing services
Costs of special care units (such as intensive or coronary care
units)
Lab tests
X-rays and other radiology services
Necessary surgical and medical supplies

[List copayments/
coinsurance. If costsharing is based on
benefit period, include
definition/
explanation of BID
approved benefit
period here. Plans
that use a peradmission deductible,
include: A per
admission deductible
is applied once during
a benefit period.]

Use of appliances, such as wheelchairs
Operating and recovery room costs
Physical, occupational, and speech language therapy
Under certain conditions, the following types of transplants are
covered: corneal, kidney, kidney-pancreatic, heart, liver, lung,
heart/lung, bone marrow, stem cell, and intestinal/multivisceral. If
you need a transplant, we will arrange to have your case reviewed
by a Medicare-approved transplant center that will decide
whether you are a candidate for a transplant. [Network plans
insert: If you are sent outside of your community for a transplant,
we will arrange or pay for appropriate lodging and transportation
costs for you and a companion.] [Plans may further define the
specifics of transplant travel coverage.]

• Blood - including storage and administration. Coverage of whole
blood and packed red cells begins only with the fourth pint of
blood that you need - you pay for the first 3 pints of unreplaced
blood. All other components of blood are covered beginning with
the first pint used. [Modify as necessary if the plan begins
coverage with an earlier pint.]

If you get [insert of
applicable:
authorized] inpatient
care at a non-plan
hospital after your
emergency condition
is stabilized, your
cost is the [Insert if
applicable: highest]
cost-sharing you
would pay at a plan
hospital.

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

Services that are covered for you

• Physician Services

What you must
pay when you get
these services

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

Services that are covered for you

What you must
pay when you get
these services

Inpatient mental health care

• Covered services include mental health care services that require a
hospital stay. [List days covered, restrictions such as 190-day
lifetime limit for inpatient services in a psychiatric hospital. The
190-day limit does not apply to Mental Health services provided in
a psychiatric unit of a general hospital.]

[List copays /
coinsurance. If costsharing is based on
benefit period,
include definition/
explanation of BID
approved benefit
period here.]

Skilled nursing facility (SNF) care
(For a definition of “skilled nursing facility,” see Chapter 12 of this
booklet. Skilled nursing facilities are sometimes called “SNFs.”)
[List days covered and any restrictions that apply, including whether any
prior hospital stay is required.] Covered services include:

•
•
•
•
•

Semiprivate room (or a private room if medically necessary)
Meals, including special diets
Regular nursing services
Physical therapy, occupational therapy, and speech therapy
Drugs administered to you as part of your plan of care (This
includes substances that are naturally present in the body, such as
blood clotting factors.)

•
•
•
•

Medical and surgical supplies ordinarily provided by SNFs
Laboratory tests ordinarily provided by SNFs
X-rays and other radiology services ordinarily provided by SNFs
Use of appliances such as wheelchairs ordinarily provided by
SNFs

[List copays/
coinsurance. If costsharing is based on
benefit period, include
definition/explanation
of BID approved
benefit period here.]

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

Services that are covered for you

What you must
pay when you get
these services

• Physician services
Generally, you will get your SNF care from plan facilities. However,
under certain conditions listed below, you may be able to pay innetwork cost-sharing for a facility that isn’t a plan provider, if the
facility accepts our plan’s amounts for payment.
•

A nursing home or continuing care retirement community where
you were living right before you went to the hospital (as long as it
provides skilled nursing facility care).

• A SNF where your spouse is living at the time you leave the
hospital.
Inpatient services covered when the hospital or SNF days
aren’t, or are no longer, covered

[List copays /
coinsurance]

Covered services include:

• Physician services
• Tests (like X-ray or lab tests)
• X-ray, radium, and isotope therapy including technician materials
and services

• Surgical dressings, splints, casts and other devices used to reduce
fractures and dislocations

• Prosthetics and orthotics devices (other than dental) that replace
all or part of an internal body organ (including contiguous tissue),
or all or part of the function of a permanently inoperative or
malfunctioning internal body organ, including replacement or
repairs of such devices

• Leg, arm, back, and neck braces; trusses, and artificial legs, arms,
and eyes including adjustments, repairs, and replacements
required because of breakage, wear, loss, or a change in the
patient’s physical condition

• Physical therapy, speech therapy, and occupational therapy
Home health agency care
Covered services include:

[List copays /

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

Services that are covered for you

• Part-time or intermittent skilled nursing and home health aide

•
•
•

What you must
pay when you get
these services
coinsurance]

services (To be covered under the home health care benefit, your
skilled nursing and home health aide services combined must
total fewer than 8 hours per day and 35 hours per week)
Physical therapy, occupational therapy, and speech therapy
Medical social services
Medical equipment and supplies

Hospice care
You may receive care from any Medicare-certified hospice program.
Original Medicare (rather than our Plan) will pay the hospice provider
for the services you receive. Your hospice doctor can be a network
provider or an out-of-network provider. You will still be a plan member
and will continue to get the rest of your care that is unrelated to your
terminal condition through our Plan. Covered services include:

• Drugs for symptom control and pain relief, short-term respite
care, and other services not otherwise covered by Original
Medicare

• Home care
[Insert if applicable, edit as appropriate: Our plan covers hospice
consultation services (one time only) for a terminally ill person who
hasn’t elected the hospice benefit.]

When you enroll in a
Medicare-certified
hospice program, your
hospice services are
paid for by Original
Medicare, not [insert
plan name].
[Include information
about cost-sharing for
hospice consultation
services if
applicable.]

Outpatient Services
Physician services, including doctor’s office visits
Covered services include:

• Office visits, including medical and surgical care in a physician’s
office or certified ambulatory surgical center

• Consultation, diagnosis, and treatment by a specialist
• Hearing and balance exams, if your doctor orders it to see if you
need medical treatment.

• Telehealth office visits including consultation, diagnosis and

[List copays /
coinsurance]

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

Services that are covered for you

What you must
pay when you get
these services

treatment by a specialist

• Second opinion [Insert in appropriate: by another network
provider] prior to surgery

• Outpatient hospital services
• Non-routine dental care (covered services are limited to surgery
of the jaw or related structures, setting fractures of the jaw or
facial bones, extraction of teeth to prepare the jaw for radiation
treatments of neoplastic cancer disease, or services that would be
covered when provided by a doctor)
[Also list any additional benefits offered.]
Chiropractic services
Covered services include:

• Manual manipulation of the spine to correct subluxation

[List copays /
coinsurance]

[Also list any additional benefits offered.]
Podiatry services
Covered services include:

• Treatment of injuries and diseases of the feet (such as hammer toe

[List copays /
coinsurance]

or heel spurs).

• Routine foot care for members with certain medical conditions
affecting the lower limbs
[Also list any additional benefits offered.]
Outpatient mental health care, including partial
hospitalization services
Covered services include:

• Mental health services provided by a doctor, clinical
psychologist, clinical social worker, clinical nurse specialist,
nurse practitioner, physician assistant, or other Medicarequalified mental health care professional as allowed under
applicable state laws.

• “Partial hospitalization” is a structured program of active

[List copays /
coinsurance]

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

Services that are covered for you

What you must
pay when you get
these services

treatment that is more intense than the care received in your
doctor’s or therapist’s office and is an alternative to inpatient
hospitalization.
[Also list any additional benefits offered.]
Outpatient substance abuse services

[List copays /
coinsurance]

Outpatient surgery, including services provided at
ambulatory surgical centers

[List copays /
coinsurance]

Ambulance services
Covered ambulance services include fixed wing, rotary wing, and ground
ambulance services, to the nearest appropriate facility that can provide
care only if they are furnished to a member whose medical condition is
such that other means of transportation are contraindicated (could
endanger the person’s health). The member’s condition must require
both the ambulance transportation itself and the level of service provided
in order for the billed service to be considered medically necessary.
Non-emergency transportation by ambulance is appropriate if it is
documented that the member’s condition is such that other means of
transportation are contraindicated (could endanger the person’s health)
and that transportation by ambulance is medically required.

[List copays /
coinsurance. Specify
whether cost-sharing
applies one-way or
for round trips.]

Emergency care
[Identify whether this coverage is limited to the U.S. or is also available
world-wide.]

[List copays /
coinsurance. If
applicable, explain
that cost-sharing is
waived if member
admitted to hospital.]
If you need inpatient
care at an out-ofnetwork hospital after
your emergency
condition is stabilized,
[Insert one or both:

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

Services that are covered for you

What you must
pay when you get
these services
you must return to a
network hospital in
order for your care to
continue to be
covered OR you must
have your inpatient
care at the out-ofnetwork hospital
authorized by the plan
and your cost is the
[Insert if applicable:
highest] cost-sharing
you would pay at a
network hospital.]

Urgently needed care
[Include in-network benefits. Also identify whether this coverage is
within the U.S. or world-wide.]

Comprehensive Outpatient Rehabilitation Facility (CORF)
service
Covered services include: Covered services include: physical therapy,
occupational therapy, speech language therapy, and cardiac
rehabilitative therapy

[List copays /
coinsurance. Plans
should include
different copayments
for contracted urgent
care centers, if
applicable.]

[List copays /
coinsurance]

Durable medical equipment and related supplies
(For a definition of “durable medical equipment,” see Chapter 12 of this
booklet.)
Covered items include, but are not limited to: wheelchairs, crutches,
hospital bed, IV infusion pump, oxygen equipment, nebulizer, and
walker.

[List copays /
coinsurance]

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

Services that are covered for you

What you must
pay when you get
these services

Prosthetic devices and related supplies
Devices (other than dental) that replace a body part or function. These
include, but are not limited to: colostomy bags and supplies directly
related to colostomy care, pacemakers, braces, prosthetic shoes, artificial
limbs, and breast prostheses (including a surgical brassiere after a
mastectomy). Includes certain supplies related to prosthetic devices, and
repair and/or replacement of prosthetic devices. Also includes some
coverage following cataract removal or cataract surgery – see “Vision
Care” later in this section for more detail.

[List copays /
coinsurance]

Diabetes self-monitoring, training, and supplies
For all people who have diabetes (insulin and non-insulin users).
Covered services include:

[List copays /
coinsurance]

• Blood glucose monitor, blood glucose test strips, lancet devices
and lancets, and glucose-control solutions for checking the
accuracy of test strips and monitors

• One pair per calendar year of therapeutic custom-molded shoes
(including inserts provided with such shoes) and two additional
pairs of inserts, or one pair of depth shoes and three pairs of
inserts (not including the non-customized removable inserts
provided with such shoes). For people with diabetes who have
severe diabetic foot disease, coverage includes fitting.

• Self-management training is covered under certain conditions
• For persons at risk of diabetes: Fasting plasma glucose tests.
[Insert frequency]
[Also list any additional benefits offered.]
Medical nutrition therapy
For people with diabetes, renal (kidney) disease (but not on dialysis),
and after a transplant when referred by your doctor.
Outpatient diagnostic tests and therapeutic services and
supplies
Covered services include:

[List copays /
coinsurance]

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

Services that are covered for you

What you must
pay when you get
these services

• X-rays
• Radiation therapy [List separately any services for which a
separate copay/coinsurance applies over and above the
outpatient radiation therapy copay/coinsurance.]

•
•
•
•

Surgical supplies, such as dressings
Supplies, such as splints and casts
Laboratory tests
Blood. Coverage begins with the fourth pint of blood that you
need – you pay for the first 3 pints of unreplaced blood. [Modify
as necessary if the plan begins coverage with an earlier pint.]
Coverage of storage and administration begins with the first pint
of blood that you need.

• Other outpatient diagnostic tests [Plans can include other
covered tests as appropriate]
Vision care
Covered services include:

• Outpatient physician services for eye care.
• For people who are at high risk of glaucoma, such as people with
a family history of glaucoma, people with diabetes, and AfricanAmericans who are age 50 and older: glaucoma screening once
per year

• [Adapt this description if the plan offers more than is covered by
Original Medicare.] One pair of eyeglasses or contact lenses after
each cataract surgery that includes insertion of an intraocular
lens. Corrective lenses/frames (and replacements) needed after a
cataract removal without a lens implant.
[Also list any additional benefits offered, such as routine vision
exams or glasses, either here or in “Vision Care” section later in
benefits chart.]

Preventive Care and Screening Tests

[List copays /
coinsurance]

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

Services that are covered for you

[For all preventive care and screening test benefit information, plans
that cover a richer benefit than Original Medicare do not need to
include given description (unless still applicable) and may instead
describe plan benefit.]

What you must
pay when you get
these services

[List copays/
coinsurance]

Abdominal aortic aneurysm screening
A one-time screening ultrasound for people at risk. The plan only
covers this screening if you get a referral for it as a result of your
“Welcome to Medicare” physical exam.
[Also list any additional benefits offered.]
“Welcome to Medicare” exam
Welcome to Medicare exam (covered during the first 12 months that the
enrollee has Medicare Part B).

[List copays/
coinsurance]

The reimbursement for this benefit does not include reimbursement for
EKGs, clinical laboratory tests, as well as screening and other
preventative services currently covered under Medicare Part B
[Also list any additional benefits offered.]
Bone mass measurement
For qualified individuals (generally, this means people at risk of
losing bone mass or at risk of osteoporosis), the following services
are covered every 2 years or more frequently if medically necessary:
procedures to identify bone mass, detect bone loss, or determine
bone quality, including a physician’s interpretation of the results.
[Also list any additional benefits offered.]

[List copays/
coinsurance]

Colorectal screening
For people 50 and older, the following are covered:

• Flexible sigmoidoscopy (or screening barium enema as an
alternative) every 48 months

• Fecal occult blood test, every 12 months
For people at high risk of colorectal cancer, we cover:

[List copays /
coinsurance]

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

Services that are covered for you

What you must
pay when you get
these services

• Screening colonoscopy (or screening barium enema as an
alternative) every 24 months
For people not at high risk of colorectal cancer, we cover:

• Screening colonoscopy every 10 years, but not within 48 months
of a screening sigmoidoscopy
[Also list any additional benefits offered.]
Immunizations
Covered services include:

• Pneumonia vaccine
• Flu shots, once a year in the fall or winter
• Hepatitis B vaccine if you are at high or intermediate risk of

[List copays /
coinsurance]

getting Hepatitis B

• Other vaccines if you are at risk
We also cover some vaccines under our outpatient prescription drug
benefit. [Also list any additional benefits offered.]
Mammography screening
Covered services include:

• One baseline exam between the ages of 35 and 39
• One screening every 12 months for women age 40 and older

[List copays /
coinsurance]

[Also list any additional benefits offered.]
Pap test, pelvic exams, and clinical breast exams
Covered services include:

• For all women, Pap tests, pelvic exams, and clinical breast exams
are covered once every 24 months

• If you are at high risk of cervical cancer or have had an abnormal
Pap test and are of childbearing age: one Pap test every 12
months

[List copays /
coinsurance]

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

Services that are covered for you

What you must
pay when you get
these services

[Also list any additional benefits offered.]
Prostate cancer screening exams
For men age 50 and older, covered services include the following - once
every 12 months:

[List copays /
coinsurance]

• Digital rectal exam
• Prostate Specific Antigen (PSA) test
[Also list any additional benefits offered.]
Cardiovascular disease testing
Blood tests for the detection of cardiovascular disease (or abnormalities
associated with an elevated risk of cardiovascular disease). [Insert
frequency.]

[List copays /
coinsurance]

Physician exams
[Plans that cover only what Original Medicare covers insert: A one-time
physical exam for members within the first 12 months that they have
Medicare Part B. Includes measurement of height, weight and blood
pressure; an electrocardiogram; education, counseling and referral with
respect to covered screening and preventive services. Doesn’t include lab
tests.]

[List copays /
coinsurance]

Other Services
Dialysis (kidney)
Covered services include:

• Outpatient dialysis treatments (including dialysis treatments when
temporarily out of the service area)

• Inpatient dialysis treatments (if you are admitted to a hospital for
special care)

• Self-dialysis training (includes training for you and anyone
helping you with your home dialysis treatments)

• Home dialysis equipment and supplies

[List copays /
coinsurance]

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

Services that are covered for you

What you must
pay when you get
these services

• Certain home support services (such as, when necessary, visits by
trained dialysis workers to check on your home dialysis, to help
in emergencies, and check your dialysis equipment and water
supply)
Medicare Part B prescription drugs
These drugs are covered under Part B of Original Medicare. Members of
our plan receive coverage for these drugs through our plan. Covered
drugs include:

• Drugs that usually aren’t self-administered by the patient and are
injected while you are getting physician services

• Drugs you take using durable medical equipment (such as
nebulizers) that was authorized by the plan

• Clotting factors you give yourself by injection if you have
hemophilia

• Immunosuppressive Drugs, if you were enrolled in Medicare Part
A at the time of the organ transplant

• Injectable osteoporosis drugs, if you are homebound, have a bone
fracture that a doctor certifies was related to post-menopausal
osteoporosis, and cannot self-administer the drug

• Antigens
• Certain oral anti-cancer drugs and anti-nausea drugs
• Certain drugs for home dialysis, including heparin, the antidote
for heparin when medically necessary, topical anesthetics, and
erythropoisis-stimulating agents (such as Epogen, Procrit,
Epoetin Alfa, Aranesp, or Darbepoetin Alfa)

• Intravenous Immune Globulin for the home treatment of primary
immune deficiency diseases
[MA only plans delete the following paragraph.] Chapter 5 explains
the Part D prescription drug benefit, including rules you must follow
to have prescriptions covered. What you pay for your Part D
prescription drugs through our plan is listed in Chapter 6.

Additional Benefits

[List copays /
coinsurance]

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

Services that are covered for you

[For all additional benefits information, plans should include only
applicable rows.]

What you must
pay when you get
these services

[List copays /
coinsurance]

Dental services
[List any additional benefits offered, such as routine dental care.]
Hearing services
[List any additional benefits offered, such as routine hearing care.]

[List copays /
coinsurance]

Vision care
[List any additional benefits offered, such as routine vision exams or
glasses, unless included in “Vision Care” section earlier in benefits
chart.]

[List copays /
coinsurance]

Health and wellness education programs
[These are programs focused on clinical health conditions such as high
blood pressure, cholesterol, asthma, and special diets. Programs
designed to enrich the health and lifestyles of members include weight
management, smoking cessation, fitness, and stress management.
Describe the nature of the programs here.]
[Include other additional benefits being offered.]

Chapter 4
Section 2.2

[List copays /
coinsurance]

Extra “optional supplemental” benefit
you can buy

[Include this section if you offer optional supplemental benefits in the Plan. (You may include
this section either in the EOC or as an insert to the EOC.)]
Our Plan offers some extra benefits that are not covered by Original Medicare and not included
in your benefits package as a plan member. These extra benefits are called “Optional
Supplemental Benefits.” If you want these optional supplemental benefits, you must sign up for
them [insert if applicable: and you may have to pay an additional premium for them]. The

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

optional supplemental benefits included in this section are subject to the same appeals process as
any other benefits.
[Insert plan specific optional benefits, premiums, deductible, copays and coinsurance and rules
using a chart like the Benefits Chart above. Insert plan specific procedures on how to elect
optional supplemental coverage, including application process and effective dates and on how to
discontinue optional supplemental coverage, including refund of premiums. Also insert any
restrictions on members’ re-applying for optional supplemental coverage (e.g., must wait until
next annual enrollment period).]

Chapter 4
Section 2.3

Getting care using our plan’s traveler
benefit

[If your plan offers traveler benefits to members who are out of your service area, adapt and
expand the following paragraphs as needed to describe the traveler benefits and rules related to
receiving the out-of-area coverage. If you allow extended periods of enrollment out-of-area per
the exception in 42 CFR 422.74(b)(4)(iii) (from 7 through 12 months) also explain that here.
Additionally, text may be modified to include a description of a visiting member program, if
offered by plan.]
You may get care when you are outside the service area. You may need to pay higher cost
sharing for routine care from non-network providers, but you won’t pay extra in a medical
emergency or if your care is urgently needed. If you have questions about your medical costs
when you travel, please call Member Services.

SECTION 3

Chapter 4
Section 3.1

What types of benefits are not covered
by the plan?

Types of benefits we do not cover

[Plans may add references to optional supplemental benefits where applicable, using the
following format: However, [insert item/items] are available under Optional Supplemental
Benefits.]
[SNPs may, as appropriate, remove or modify language regarding benefit exclusions when the
benefits are covered by the plan under the Medicaid program.]

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

This section tells you what kinds benefits are “excluded.” Excluded means that the plan doesn’t
cover these benefits.
The list below describes some services and items that aren’t covered under any conditions and
some that are excluded only under specific conditions.
If you get benefits that are excluded, you must pay for them yourself. We won’t pay for the
medical benefits listed in this section (or elsewhere in this booklet), and neither will Original
Medicare. The only exception: If a benefit on the exclusion list is found upon appeal to be a
medical benefit that we should have paid for or covered because of your specific situation. (For
information about appealing a decision we have made to not cover a medical service, go to
Chapter 9, Section 5.3 in this booklet.)
In addition to any exclusions or limitations described in the Benefits Chart, or anywhere else in
this Evidence of Coverage, [mention any other places where exclusions are given, such as
addenda,] the following items and services aren’t covered under Original Medicare or by
our plan:
[The services listed in the remaining bullets are excluded from the Original Medicare benefit
package. If any services below are covered supplemental benefits, delete them from this list.
When plans partially exclude services excluded by Medicare they need not delete the item
completely from the list of excluded services but may revise the text accordingly to describe the
extent of the exclusion. Plans may also indicate if a service may be covered as an optional
supplemental benefit.]
•

Services considered not reasonable and necessary, according to the standards of Original
Medicare, unless these services are listed by our plan as a covered services.

•

Experimental medical and surgical procedures, equipment and medications, unless
covered by Original Medicare. However, certain services may be covered under a
Medicare-approved clinical research study. See Chapter 3, Section 5 for more
information on clinical research studies.

•

Surgical treatment for morbid obesity, except when it is considered medically necessary
and covered under Original Medicare.

•

Private room in a hospital, except when it is considered medically necessary.

•

Private duty nurses.

•

Personal items in your room at a hospital or a skilled nursing facility, such as a telephone
or a television.

•

Full-time nursing care in your home.

•

Custodial care, unless it is provided with covered skilled nursing care and/or skilled
rehabilitation services. Custodial care, or non-skilled care, is care that helps you with
activities of daily living, such as bathing or dressing.

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

•

Homemaker services provide basic household assistance, including light housekeeping or
light meal preparation.

•

Fees charged by your immediate relatives or members of your household.

•

Meals delivered to your home.

•

Elective or voluntary enhancement procedures or services (including weight loss, hair
growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and
mental performance), except when medically necessary.

•

Cosmetic surgery or procedures because of an accidental injury or to improve a
malformed part of the body. However, all stages of reconstruction are covered for a
breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical
appearance.

•

Routine dental care, such as cleanings, filings or dentures. However, non-routine dental
care received at a hospital may be covered.

•

Chiropractic care, other than manual manipulation of the spine consistent with Medicare
coverage guidelines.

•

Routine foot care, except for the limited coverage provided according to Medicare
guidelines.

•

Orthopedic shoes, unless the shoes are part of a leg brace and are included in the cost of
the brace or the shoes are for a person with diabetic foot disease.

•

Supportive devices for the feet, except for orthopedic or therapeutic shoes for people with
diabetic foot disease.

•

Hearing aids and routine hearing examinations.

•

Eyeglasses, routine eye examinations, radial keratotomy, LASIK surgery, vision therapy
and other low vision aids. However, eyeglasses are covered for people after cataract
surgery.

•

Prescription drugs for treatment of sexual dysfunction, including erectile dysfunction,
impotence, and anorgasmy or hyporgasmy.

•

Reversal of sterilization procedures, sex change operations, and non-prescription
contraceptive supplies.

•

Acupuncture.

•

Naturopath services (uses natural or alternative treatments).

•

Services provided to veterans in Veterans Affairs (VA) facilities. However, when
emergency services are received at VA hospital and the VA cost-sharing is more than the
cost-sharing under our plan. We will reimburse veterans for the difference. Members are
still responsible for our cost-sharing amounts.

•

Any services listed above that aren’t covered will remain not covered even if received at
an emergency facility.

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

CHAPTER 5: Asking the plan to pay its share of a bill you have received
for medical services

SECTION 1. Situations in which you should ask our plan to pay our share of the
cost of your medical services
1.1

If you pay our plan’s share of the cost of your covered services or if you
receive a bill, you can ask us for payment ............................................................ [xx]

SECTION 2. How to ask our plan to pay you back or to pay a bill you have
received
2.1

How and where to send us your request for payment ........................................... [xx]

SECTION 3. We will consider your request for payment and say yes or no
3.1

We check to see whether we should pay you back and how much we owe........... [xx]

3.2

If we tell you that we will not pay you back, you can make an appeal.................. [xx]

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

SECTION 1

Chapter 5
Section 1.1

Situations in which you should ask our
plan to pay our share of the cost of your
covered services or drugs

If you pay our plan’s share of the cost or if
you receive a bill for your covered
services, you can ask us for payment

Sometimes when you get medical care, you may need to pay the full cost right away. Other
times, you may find that you have paid more than you expected under the coverage rules of the
plan. In either case, you can ask our plan to pay you back (paying you back is often called
“reimbursing” you). It is your right to be paid back by our plan whenever you’ve paid more than
your share of the cost for medical services or drugs that are covered by our plan.
There may also be times when you get a bill from a provider for the full cost of medical care
you have received. In many cases, you should send this bill to us instead of paying it. We will
look at the bill and decide whether the services should be covered. If we decide they should be
covered, we will pay the provider directly.
Here are examples of situations in which you may need to ask our plan to pay you back or to pay
a bill you have received:
1. When you’ve received emergency or urgently needed medical care
from a provider who is not in our plan’s network
When you receive emergency or urgently needed care from a provider who is not part of our
network, you are only responsible for paying your share of the cost, not for the entire cost.
You should ask the provider to bill the plan for our share of the cost.
•

If you pay the entire amount yourself at the time you receive the care, you need to ask
us to pay you back for our share of the cost. Send us the bill, along with documentation
of any payments you have made.

•

At times you may get a bill from the provider asking for payment that you think you do
not owe. Send us this bill, along with documentation of any payments you have already
made.
o If the provider is owed anything, we will pay the provider directly.
o If you have already paid more than your share of the cost of the service, we will
determine how much you owed and pay you back for our share of the cost.

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

2. When a network provider sends you a bill you think you should not pay
Network providers should always bill the plan directly, and ask you only for your share of
the cost. But sometimes they make mistakes, and ask you to pay more than your share.
•

Whenever you get a bill from a network provider that you think is more than you
should pay, send us the bill. We will contact the provider directly and resolve the
billing problem.

•

If you have already paid a bill to a network provider, but you feel that you paid too
much, send us the bill along with documentation of any payment you have made and
ask us to pay you back.

[Plans should insert additional circumstances under which they will accept a paper
claim from an enrollee.]

How to ask us to pay you back or to pay
a bill you have received

SECTION 2

Chapter 5
Section 2.1

How and where to send us your request
for payment

Send us your request for payment, along with your bill and documentation of any payment you
have made. It’s a good idea to make a copy of your bill and receipts for your records.
[If the plan has developed a specific form for requesting payment, insert the following language:
To make sure you are giving us all the information we need to make a decision, you can fill out
our claim form to make your request for payment.
•

You don’t have to use the form, but it’s helpful.

•

Either download a copy of the form from our website ([insert URL]) or call Member
Services and ask for the form. The phone numbers for Member Services are on the cover
of this booklet.]

Mail your request for payment together with any bills or receipts to us at this address:
[insert address]
Please be sure to contact Member Services if you have any questions. If you don’t know what
you owe, or you receive bills and you don’t know what to do about those bills, we can help. You
can also call if you want to give us more information about a request for payment you have
already sent to us.

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of a bill you have received for medical services

SECTION 3

Chapter 5
Section 3.1

We will consider your request for
payment and say yes or no

We check to see whether we should cover
the service and how much we owe

When we receive your request for payment, we will let you know if we need any additional
information from you. Otherwise, we will consider your request and decide whether to pay it and
how much we owe.
•

If we decide that the medical care is covered and you followed all the rules for getting the
care, we will pay for our share of the cost. If you have already paid for the service, we will
mail your reimbursement to you. If you have not paid for the service yet, we will mail the
payment directly to the provider. (Chapter 3 explains the rules you need to follow for
getting your medical services.)

•

If we decide that the medical care is not covered, or you did not follow all the rules, we
will not pay for our share of the cost. Instead, we will send you a letter that explains the
reasons why we are not sending the payment you have requested.

Chapter 5
Section 3.2

If we tell you that we will not pay for the
medical care, you can make an appeal

If you think we have made a mistake in turning you down, you can make an appeal. If you make
an appeal, it means you are asking us to change the decision we made when we turned down
your request for payment.
For the details on how to make this appeal, go to Chapter 7 of this booklet (What to do if you
have a problem or complaint (coverage decisions, appeals, complaints)). The appeals process is
a legal process with complicated procedures and important deadlines. If making an appeal is new
to you, you will find it helpful to start by reading Section 4 of Chapter 7. Section 4 is an
introductory section that explains the process for coverage decisions and appeals and gives
definitions of terms such as “appeal.” Then after you have read Section 4, you can go to the
Section 5.4 to learn how to make an appeal about getting paid back for a medical service.

2010 Evidence of Coverage for [insert plan name]
Chapter 6: Your rights and responsibilities

CHAPTER 6: Your rights and responsibilities

SECTION 1. Our plan must honor your rights as a member of the plan
1.1

We must provide information in a way that works for you (in languages other
than English, in large print or other alternate formats, etc.) .................................. [xx]

1.2

We must treat you with fairness and respect at all times ........................................ [xx]

1.3

We must ensure that you get timely access to your covered services .................... [xx]

1.4

We must protect the privacy of your personal health information .......................... [xx]

1.5

We must give you information about the plan, its network of providers, and
your covered services .......................................................................................... [xx]

1.6

We must support your right to make decisions about your care ............................. [xx]

1.7

You have the right to make complaints and to ask us to reconsider
decisions we have made ...................................................................................... [xx]

1.8

What can you do if you think you are being treated unfairly or your
rights are not being respected?............................................................................. [xx]

1.9

How to get more information about your rights ..................................................... [xx]

SECTION 2. You have some responsibilities as a member of the plan
2.1

What are your responsibilities? ............................................................................. [xx]

2010 Evidence of Coverage for [insert plan name]
Chapter 6: Your rights and responsibilities

SECTION 1

Chapter 6
Section 1.1

Our plan must honor your rights as a
member of the plan

We must provide information in a way
that works for you (in languages other
than English, in large print, or other
alternate formats, etc.)

To get information from us in a way that works for you, please call Member Services (phone
numbers are on the front cover).
Our plan has people and translation services available to answer questions from non-English
speaking members. We can also give you information in large print or other alternate formats if
you need it. If you are eligible for Medicare because of disability, we are required to give you
information about the plan’s benefits that is accessible and appropriate for you.
If you have any trouble getting information from our plan because of problems related to
language or disability, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a
day, 7 days a week. TTY users call 1-877-486-2048.

Chapter 6
Section 1.2

We must treat you with fairness and
respect at all times

Our plan must obey laws that protect you from discrimination or unfair treatment. We do not
discriminate based on a person’s race, disability, religion, sex, health, ethnicity, creed (beliefs),
age, or national origin.
If you want more information or have concerns about discrimination or unfair treatment, please
call the Federal government’s Office for Civil Rights 1-800-368-1019 (TTY/TDD 1-800-5377697) or your local Office for Civil Rights.
If you have a disability and need help with access to care, please call us at Member Services
(phone numbers are on the cover of this booklet). If you have a complaint, such as a problem
with wheelchair access, Member Services can help.

2010 Evidence of Coverage for [insert plan name]
Chapter 6: Your rights and responsibilities

Chapter 6
Section 1.3

We must ensure that you get timely
access to your covered services

As a member of our plan, you have the right to choose a [insert as appropriate: primary care
provider (PCP) OR provider] in the plan’s network to provide and arrange for your covered
services (Chapter 3 explains more about this). Call Members Services to learn which doctors are
accepting new patients (phone numbers are on the cover of this booklet). You also have the right
to go to a women’s health specialist (such as a gynecologist) without a referral.
As a plan member, you have the right to get appointments and covered services from the plan’s
network of providers within a reasonable amount of time. This includes the right to get timely
services from specialists when you need that care.
If you think that you are not getting your medical care within a reasonable amount of time,
Chapter 7 of this booklet tells what you can do.

Chapter 6
Section 1.4

We must protect the privacy of your
personal health information

Federal and state laws protect the privacy of your medical records and personal health
information. We protect your personal health information as required by these laws.
•

Your “personal health information” includes the personal information you gave us when
you enroll in this plan as well as your medical records and other medical and health
information.

•

The laws that protect your privacy give you rights related to getting information and
controlling how your health information is used. We give you a written notice, called a
“Notice of Privacy Practice”, that tells about these rights and explains how we protect the
privacy of your health information.

How do we protect the privacy of your health information?
•

We make sure that unauthorized people don’t see or change your records.

•

In most situations, if we give your health information to anyone who isn’t providing your
care or paying for your care, we are required to get written permission from you first.
Written permission can be given by you or by someone you have given legal power to
make decisions for you.

•

There are certain exceptions that do not require us to get your written permission first.
These exceptions are allowed or required by law.

2010 Evidence of Coverage for [insert plan name]
Chapter 6: Your rights and responsibilities

o For example, we are required to release health information to government
agencies that are checking on quality of care.
You can see the information in your records and know how it
has been shared with others
You have the right to look at your medical records held at the plan, and to get a copy of your
records. We are allowed to charge you a fee for making copies. You also have the right to ask us
to make additions or corrections to your medical records. If you ask us to do this, we will
consider your request and decide whether the changes should be made.
You have the right to know how your health information has been shared with others for any
purposes that are not routine.
If you have questions or concerns about the privacy of your personal health information, please
call Member Services (phone numbers are on the cover of this booklet).
[Note: Plans may insert custom privacy practices.]

Chapter 6
Section 1.5

We must give you information about the
plan, its network of providers, and your
covered services

As a member of our plan, you have the right to get several kinds of information from us. (As
explained above in Section 1.1, you have the right to get information from us in a way that works
for you. This includes getting the information in languages other than English and in large print
or other alternate formats.)
If you want any of the following kinds of information, please call Member Services (phone
numbers are on the cover of this booklet):
•

Information about our plan. This includes, for example, information about the plan’s
financial condition. It also includes information about the plan’s performance ratings,
including how it has been rated by plan members and how it compares to other Medicare
Advantage health plans.

•

Information about our network providers.
o For example, you have the right to get information from us about the
qualifications of the providers in our network and how we pay the providers in
our network.
o For a list of the providers in the plan’s network, see the Provider Directory.

2010 Evidence of Coverage for [insert plan name]
Chapter 6: Your rights and responsibilities

o For more detailed information about our providers, you can call Member Services
(phone numbers are on the cover of this booklet) or visit our website at [insert
URL].
•

Information about your coverage and rules you must follow in using your
coverage.
o In Chapters 3 and 4 of this booklet, we explain what medical services are covered
for you, any restrictions to your coverage, and what rules you must follow to get
your covered medical services.
o If you have questions about the rules or restrictions, please call Member Services
(phone numbers are on the cover of this booklet).

•

Information about why something is not covered and what you can do
about it.
o If a medical service is not covered for you, or if your coverage is restricted in
some way, you can ask us for a written explanation. You have the right to this
explanation even if you received the medical service from an out-of-network
provider.
o If you are not happy or if you disagree with a decision we make about what
medical care is covered for you, you have the right to ask us to change the
decision. For details on what to do if something is not covered for you in the way
you think it should be covered, see Chapter 7 of this booklet. It gives you the
details about how to ask the plan for a decision about your coverage and how to
make an appeal if you want us to change our decision. (Chapter 7 also tells about
how to make a complaint about quality of care, waiting times, and other
concerns.)
o If you want to ask our plan to pay our share of a bill you have received for
medical care, see Chapter 5 of this booklet.

Chapter 6
Section 1.6

We must support your right to make
decisions about your care

You have the right to know your treatment options and
participate in decisions about your health care
You have the right to get full information from your doctors and other health care providers
when you go for medical care. Your providers must explain your medical condition and your
treatment choices in a way that you can understand.
You also have the right to participate fully in decisions about your health care. To help you make
decisions with your doctors about what treatment is best for you, your rights include the
following:

2010 Evidence of Coverage for [insert plan name]
Chapter 6: Your rights and responsibilities

•

To know about all of your choices. This means that you have the right to be told about
all of the treatment options that are recommended for your condition, no matter what they
cost or whether they are covered by our plan.

•

To know about the risks. You have the right to be told about any risks involved in your
care. You must be told in advance if any proposed medical care or treatment is part of a
research experiment. You always have the choice to refuse any experimental treatments.

•

The right to say “no.” You have the right to refuse any recommended treatment. This
includes the right to leave a hospital or other medical facility, even if your doctor advises
you not to leave. Of course, if you refuse treatment, you accept full responsibility for
what happens to your body as a result.

•

To receive an explanation if you are denied care. You have the right to receive an
explanation from us if a provider has denied care that you believe you should receive. To
receive this explanation, you will need to ask us for a coverage decision. Chapter 7 of this
booklet tells how to ask the plan for a coverage decision.

You have the right to give instructions about what is to be done
if you are not able to make medical decisions for yourself
Sometimes people become unable to make health care decisions for themselves due to accidents
or serious illness. You have the right to say what you want to happen if you are in this situation.
This means that, if you want to, you can:
•

Fill out a written form to give someone the legal authority to make medical decisions
for you if you ever become unable to make decisions for yourself.

•

Give your doctors written instructions about how you want them to handle your
medical care if you become unable to make decisions for yourself.

The legal documents that you can use to give your directions in advance in these situations are
called “advance directives.” There are different types of advance directives and different names
for them. Documents called “living will” and “power of attorney for health care” are examples
of advance directives.
If you want to use an “advance directive” to give your instructions, here is what to do:
•

Get the form. If you want to have an advance directive, you can get a form from your
lawyer, from a social worker, or from some office supply stores. You can sometimes get
advance directive forms from organizations that give people information about Medicare.
[Insert if applicable: You can also contact Member Services to ask for the forms (phone
numbers are on the cover of this booklet).]

•

Fill it out and sign it. Regardless of where you get this form, keep in mind that it is a
legal document. You should consider having a lawyer help you prepare it.

•

Give copies to appropriate people. You should give a copy of the form to your doctor
and to the person you name on the form as the one to make decisions for you if you can’t.

2010 Evidence of Coverage for [insert plan name]
Chapter 6: Your rights and responsibilities

You may want to give copies to close friends or family members as well. Be sure to keep
a copy at home.
If you know ahead of time that you are going to be hospitalized, and you have signed an advance
directive, take a copy with you to the hospital.
•

If you are admitted to the hospital, they will ask you whether you have signed an advance
directive form and whether you have it with you.

•

If you have not signed an advance directive form, the hospital has forms available and
will ask if you want to sign one.

Remember, it is your choice whether you want to fill out an advance directive (including
whether you want to sign one if you are in the hospital). According to law, no one can deny you
care or discriminate against you based on whether or not you have signed an advance directive.
What if your instructions are not followed?
If you have signed an advance directive, and you believe that a doctor or hospital hasn’t followed
the instructions in it, you may file a complaint with [insert appropriate state-specific agency
(such as the State Department of Health)]. [Note: Plans that would like to provide members with
state specific information about advanced directives may do so.]

Chapter 6
Section 1.7

You have the right to make complaints
and to ask us to reconsider decisions we
have made

If you have any problems or concerns about your covered services or care, Chapter 7 of this
booklet tells what you can do. It gives the details about how to deal with all types of problems
and complaints.
As explained in Chapter 7, what you need to do to follow up on a problem or concern depends on
the situation. You might need to ask our plan to make a coverage decision for you, make an
appeal to us to change a coverage decision, or make a complaint. Whatever you do – ask for a
coverage decision, make an appeal, or make a complaint – we are required to treat you fairly.
You have the right to get a summary of information about the appeals and complaints that other
members have filed against our plan in the past. To get this information, please call Member
Services (phone numbers are on the cover of this booklet).

Chapter 6
Section 1.8

What can you do if you think you are
being treated unfairly or your rights are
not being respected?

2010 Evidence of Coverage for [insert plan name]
Chapter 6: Your rights and responsibilities

If it is about discrimination, call the Office for Civil Rights
If you think you have been treated unfairly or your rights have not been respected due to your
race, disability, religion, sex, health, ethnicity, creed (beliefs), age, or national origin, you should
call the Federal government’s Office for Civil Rights at 1-800-368-1019 or TTY/TDD 1-800537-7697, or call your local Office for Civil Rights.
Is it about something else?
If you think you have been treated unfairly or your rights have not been respected, and it’s not
about discrimination, you can get help dealing with the problem you are having:

• You can call Member Services (phone numbers are on the cover of this booklet).
• You can call the State Health Insurance Assistance Program. For details about this
organization and how to contact it, turn to Chapter 2 of this booklet and look for Section
3.

Chapter 6
Section 1.9

How to get more information about your
rights

There are several places where you can get more information about your rights:

• You can contact Medicare.
o You can visit http://www.medicare.gov/Publications/Pubs/pdf/10112.pdf to read
or download the publication “Your Medicare Rights & Protections.”
o Or, you can call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a
week. TTY users should call 1-877-486-2048.

2010 Evidence of Coverage for [insert plan name]
Chapter 6: Your rights and responsibilities

SECTION 2

Chapter 6
Section 2.1

Your responsibilities as a
member of the plan

What are your responsibilities?

Things you need to do as a member of the plan are listed below. If you have any questions,
please call Member Services (phone numbers are on the cover of this booklet). We’re here to
help.
•

Get familiar with your covered services and the rules you must follow to
get these covered services. Use this Evidence of Coverage booklet to learn what
is covered for you and the rules you need to follow to get your covered services.
o Chapters 3 and 4 give the details about your medical services, including what is
covered, what is not covered, rules to follow, and what you pay.

•

If you have any other health insurance coverage or prescription drug
coverage besides our plan, you are required to tell us. Please call Member
Services to let us know.
o We are required to follow rules set by Medicare to make sure that you are using
all of your coverage in combination when you get your covered services from
our plan. This is called “coordination of benefits” because it involves
coordinating the health benefits you get from our plan with any other benefits
available to you. We’ll help you with it.

•

Tell your doctor and other health care providers that you are enrolled in our
plan. Show your plan membership card whenever you get your medical care.

•

Help your doctors and other providers help you by giving them
information, asking questions, and following through on your care.
o To help your doctors and other health providers give you the best care, give them
the information they need about you and your health. Follow the treatment plans
and instructions that you and your doctors agree upon.
o If you have any questions, be sure to ask. Your doctors and other health care
providers are supposed to explain things in a way you can understand. If you ask
a question and you don’t understand the answer you are given, ask again.

2010 Evidence of Coverage for [insert plan name]
Chapter 6: Your rights and responsibilities

•

Be considerate. We expect all our members to respect the rights of other patients.
We also expect you to act in a way that helps the smooth running of your doctor’s
office, hospitals, and other offices.

•

Pay what you owe. As a plan member, you are responsible for these payments:

o [Insert if applicable: You must pay your plan premiums to continue being a
member of our plan.]
o For some of your medical services covered by the plan, you must pay your share
of the cost when you get the service. This will be a [insert as appropriate:
copayment (a fixed amount) OR coinsurance (a percentage of the total cost) OR
copayment (a fixed amount) or coinsurance (a percentage of the total cost)].
Chapter 4 of this booklet tells what you must pay for your medical services.
o If you get any medical services that are not covered by our plan or by other
insurance you may have, you must pay the full cost.
•

Tell us if you move. If you are going to move, it’s important to tell us right away.
Call Member Services (phone numbers are on the cover of this booklet).
o If you move outside of our plan service area, you cannot remain a member of
our plan. (Chapter 1 tells about our service area.) We can help you figure out
whether you are moving outside our service area. If you are leaving our service
area, we can let you know if we have a plan in your new area.
o If you move within our service area, we still need to know so we can keep your
membership record up to date and know how to contact you.

•

Call member services for help if you have questions or concerns. We also
welcome any suggestions you may have for improving our plan.
o Phone numbers and calling hours for Member Services are on the cover of this
booklet.
o For more information on how to reach us, including our mailing address, please
see Chapter 2 of this booklet.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

CHAPTER 7: What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)
Background
SECTION 1. Introduction
1.1

What to do if you have a problem or concern ...................................................... [xx]

1.2

What about the legal terms? ................................................................................ [xx]

SECTION 2. You can get help from government organizations that
are not connected with our plan
2.1

Where to get more information and personalized assistance ................................ [xx]

SECTION 3. To deal with your problem, which process should you use?
3.1

Should you use the process for coverage decisions and appeals? Or should
you use the process for making complaints? ........................................................ [xx]

Coverage decisions and appeals
SECTION 4. A guide to the basics of coverage decisions and appeals
4.1

Asking for coverage decisions and making appeals: the big picture ..................... [xx]

4.2

How to get help when you are asking for a coverage decision or making an
appeal.................................................................................................................. [xx]

4.3

Which section of this chapter gives the details for your situation? ....................... [xx]

SECTION 5. Your medical care: How to ask for a coverage decision or
make an appeal
5.1

This section tells what to if you have problems getting medical care or you
want us to pay you back for our share of the cost of your care ............................. [xx]

5.2

Step-by-step: How to ask for a coverage decision (how to ask our plan to
provide the medical care coverage you want) ...................................................... [xx]

5.3

Step-by-step: How to make a Level 1 Appeal (how to ask for a review of
a medical care coverage decision made by our plan) ............................................ [xx]

5.4

Step-by-step: How to make a Level 2 Appeal ...................................................... [xx]

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

5.5

What if you are asking our plan to pay you for our share of a bill you
have received for medical care? ........................................................................... [xx]

SECTION 6. How to ask for a longer hospital stay if you think you
are being asked to leave the hospital too soon
6.1

During your hospital stay, you will get a written notice from Medicare that
tells about your rights .......................................................................................... [xx]

6.2

Step-by-step: How to make a Level 1 Appeal to change your hospital
discharge date...................................................................................................... [xx]

6.3

Step-by-step: How to make a Level 2 Appeal to change your hospital
discharge date...................................................................................................... [xx]

6.4

What if you miss the deadline for making your Level 1 appeal? .......................... [xx]

SECTION 7. How to ask our plan to keep covering a medical service you have
been getting if you think your coverage is ending too soon
7.1

This section is about three services only: Home health care, skilled
nursing facility care, and outpatient rehabilitation care ........................................ [xx]

7.2

We will tell you in advance when your coverage will be ending .......................... [xx]

7.3

Step-by-step: How to make a Level 1 Appeal to have our plan cover
your care for a longer time................................................................................... [xx]

7.4

Step-by-step: How to make a Level 2 Appeal to have our plan cover
your care for a longer time................................................................................... [xx]

7.5

What if you miss the deadline for making your Level 1 appeal? .......................... [xx]

SECTION 8.
8.1

Taking your appeal to Level 3 and beyond

Levels of Appeal 3, 4, and 5 ................................................................................ [xx]

Making complaints
SECTION 9.

How to make complaints about quality of care, waiting
times, customer service, or other concerns

9.1

What kinds of problems are handled by the complaint process? .......................... [xx]

9.2

The formal name for “making a complaint” is “filing a grievance” ...................... [xx]

9.3

Step-by-step: Making a complaint ....................................................................... [xx]

9.4

You can also make complaints about quality of care to the Quality
Improvement Organization .................................................................................. [xx]

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

Background

SECTION 1

Chapter 7
Section 1.1

Introduction

What to do if you have a problem or
concern

Please call us first
Your health and satisfaction are important to us. When you have a problem or concern, we hope
you’ll try an informal approach first: Please call us at Member Services (phone numbers are on
the cover of this booklet). We will work with you to try to find a satisfactory solution to your
problem.
You have rights as a member of our plan and as someone who is getting Medicare. We pledge to
honor your rights, to take your problems and concerns seriously, and to treat you with respect.
Two formal processes for dealing with problems
Sometimes you might need a formal process for dealing with a problem you are having as a
member of our plan.
This chapter explains two types of formal processes for handling problems:
•

For some types of problems, you need to use the process for coverage decisions and
making appeals.

•

For other types of problems you need to use the process for making complaints.

Both of these processes have been approved by Medicare. To ensure fairness and prompt
handling of your problems, each process has a set of rules, procedures, and deadlines that must
be followed by us and by you.
Which one do you use? That depends on the type of problem you are having. The guide in
Section 3 will help you identify the right process to use.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

Chapter 7
Section 1.2

What about the legal terms?

There are technical legal terms for some of the rules, procedures, and types of deadlines
explained in this chapter. Many of these terms are unfamiliar to most people and can be hard to
understand.
To keep things simple, this chapter explains the legal rules and procedures using more common
words in place of certain legal terms. For example, this chapter generally says “making a
complaint” rather than “filing a grievance,” “coverage decision” rather than “organization
determination” and “Independent Review Organization” instead of “Independent Review
Entity.” It also uses abbreviations as little as possible.
However, it can be helpful – and sometimes quite important – for you to know the correct legal
terms for the situation you are in. Knowing which terms to use will help you communicate more
clearly and accurately when you are dealing with your problem and get the right help or
information for your situation. To help you know which terms to use, we include legal terms
when we give the details for handling specific types of situations.

SECTION 2

Chapter 7
Section 2.1

You can get help from government
organizations that are not connected with
our plan

Where to get more information and
personalized assistance

Sometimes it can be confusing to start or follow through the process for dealing with a problem.
This can be especially true if you do not feel well or have limited energy. Other times, you may
not have the knowledge you need to take the next step. Perhaps both are true for you.
Get help from an independent government organization
Our plan is always available to help you. But in some situations you may also want help or
guidance from someone who is not part of our plan. You can always contact your State
Health Insurance Assistance Program. This government program has trained counselors in
every state. The program is not connected with our plan or with any insurance company or
health plan. The counselors at this program can help you understand which process you
should use to handle a problem you are having. They can also answer your questions, give
you more information, and offer guidance on what to do.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

Their services are free. You will find phone numbers in Chapter 2, Section 3 of this booklet.
You can also get help and information from Medicare
For more information and help in handling a problem, you can also contact Medicare. Here are
two ways to get information directly from Medicare:
•

You can call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week.
TTY users should call 1-877-486-2048.

•

You can visit the Medicare website (http://www.medicare.gov).

SECTION 3

Chapter 7
Section 3.1

To deal with your problem, which process
should you use?

Should you use the process for coverage
decisions and appeals?
Or the process for making complaints?

If you have a problem or concern and you want to do something about it, you don’t need to read
this whole chapter. You just need to find and read the parts of this chapter that apply to your
situation. The guide that follows will help.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

Coverage decisions and appeals

SECTION 4

Chapter 7
Section 4.1

A guide to the basics of coverage
decisions and appeals

Asking for coverage decisions and
making appeals: the big picture

The process for coverage decisions and making appeals deals with problems related to your
benefits and coverage for medical services, including problems related to payment. This is the
process you use for issues such as whether something is covered or not and the way in which
something is covered.
Asking for coverage decisions
A coverage decision is a decision our plan makes about your benefits and coverage or about the
amount we will pay for your medical services. You ask us for a coverage decision whenever you
go to a doctor for medical care. You can also contact the plan and ask for a coverage decision.
For example, if you want to know if we will cover a medical service before you receive it.
We are making a coverage decision for you whenever we decide what is covered for you and
how much we pay:
•

Usually, there is no problem. We decide the service is covered and pay our share of the
cost.

•

But in some cases we might decide the services are not covered for you. Or we may
decide it is time to stop covering services you have been receiving. If you disagree with
this coverage decision, you can make an appeal.

Making an appeal
If our plan makes a coverage decision and you are not satisfied with this decision, you can
“appeal” the decision. An appeal is a formal way of asking our plan to review and change a
coverage decision we have made.
When you make an appeal, our plan reviews the coverage decision we have made to check to see
if our plan was being fair and following all of the rules properly. When we have completed the
review we give you our decision.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

If we say no to all or part of your Level 1 appeal, you can go on to a Level 2 appeal. The Level
2 appeal is conducted by an independent organization that is not connected to our plan. If you
are not satisfied with the decision at the Level 2 appeal, you may be able to continue through
several more levels of appeal.

Chapter 7
Section 4.2

How to get help when you are asking for
a coverage decision or making an appeal

Would you like some help? Here are resources you may wish to use if you decide to ask for any
kind of coverage decision or appeal a decision:
•

You can call us at Member Services (phone numbers are on the cover).

•

To get free help from an independent organization that is not connected with our plan,
contact your State Health Insurance Assistance Program (see Section 2 of this chapter).

•

You can, and probably need to, get your doctor involved. In most situations involving
a coverage decision or appeal, your doctor must explain the medical reasons that support
your request.

•

You can ask someone to act on your behalf. If you want to, you can name another
person to act for you as your “representative” to ask for a coverage decision or make an
appeal.
o There may be someone who is already legally authorized to act as your
representative under State law.
o If you want a friend, relative, your doctor, or other person to be your
representative, call Member Services and ask for the form to give that person
permission to act on your behalf. The form must be signed by you and by the
person who you would like to act on your behalf. You must give our plan a copy
of the signed form.



You also have the right to hire a lawyer act for you. You may contact your own
lawyer, or get the name of a lawyer from your local bar association or other referral
service. There are also groups that will give you free legal services if you qualify.
However, you are not required to hire a lawyer to ask for any kind of coverage
decision or appeal a decision.

Chapter 7
Section 4.3

Which section of this chapter gives the
details for your situation?

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

There are three different types of situations that involve coverage decisions and appeals. Since
each situation has different rules and deadlines, we give the details for each one in a separate
section:

If you’re still not sure which section you should be using, please call Member Services (phone
numbers are on the front cover). You can also get help or information from government
organizations such as your State Health Insurance Assistance Program (Chapter 2, Section 3,
of this booklet has the phone numbers for this program).

SECTION 5

Your medical care: How to ask for a
coverage decision or make an appeal

Have you read Section 4 of this chapter (A guide to “the
basics” of coverage decisions and appeals)? If not, you may
want to read it before you start this section.
Chapter 7
Section 5.1

This section tells what to if you have
problems getting medical care or if you want
us to pay you back for medical care

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

This section is about your benefits for medical care and services. These are the benefits described
in Chapter 4 of this booklet: Medical benefits chart (what is covered and what you pay). To keep
things simple, we generally refer to “medical care coverage” or “medical care” in the rest of this
section, instead of repeating “medical care or treatment or services” every time.
This section tells what you can do if you are in any of the five following situations:
1. You are not getting certain medical care you want, and you believe that this care is
covered by our plan.
2. Our plan will not approve the medical care your doctor or other medical provider wants to
give you, and you believe that this care is covered by the plan.
3. You have received medical care or services that you believe should be covered by the plan,
but we have said we will not pay for this care.
4. You have received and paid for medical care or services that you believe should be covered
by the plan, and you want to ask our plan to reimburse you for this care.
5. You are being told that certain medical care you have been getting will be reduced or
stopped, and you believe that reducing or stopping this care could harm your health.
•

NOTE: If the care that will be stopped is hospital care, home health care,
skilled nursing facility care, or Comprehensive Outpatient Rehabilitation
Facility (CORF) services, you need to read a separate section of this chapter
because special rules apply to these types of care. Here’s what to read in those
situations:
o Chapter 7, Section 6: How to ask for a longer hospital stay if you think you are
being asked to leave the hospital too soon.
o Chapter 7, Section 7: How to ask our plan to keep covering a medical service
you have been getting if you think your coverage is ending too soon. This
section is about three services only: home health care, skilled nursing facility
care, and comprehensive outpatient rehabilitation facility (CORF) care.

•

For all other situations that involve being told that medical care you have been getting
will be stopped, use this section (Section 5) as your guide for what to do.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

Chapter 7
Section 5.2

Step-by-step how to ask for a
coverage decision
(how to ask our plan to authorize or
provide the medical care coverage you
want)
A coverage decision is called an “initial
determination” or “initial decision.” When
a coverage decision involves your medical
care, the initial determination is called an
“organization determination.”

Step 1 

You ask our plan to make a coverage decision on the
medical care you are requesting. If your health requires a
quick response, you must ask us to make a “fast decision.”
A “fast decision” is called an “expedited
decision.”

How to request coverage for the medical care you want
•

Start by [insert if applicable: calling,] writing, or faxing our plan to make your
request for us to provide coverage for the medical care you want. You, or your
doctor, or your representative can do this.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

•

For the details on how to contact us, including how to reach us on evenings and
weekends, go to Chapter 2, Section 1 and look for the section called, [plans may
edit section title as necessary] How to reach our plan when you are asking for a
coverage decision about your medical care.

Generally we use the standard deadlines for giving you our decision
When we give you our decision, we will use the “standard” deadlines unless we have agreed
to use the “fast” deadlines. A standard decision means we will give you an answer within
14 days after we receive your request.
•

However, we can take up to 14 more days if you ask for more time, or if we need
information (such as medical records) that may benefit you. If we decide to take extra
days to make the decision, we will tell you in writing.

•

If you believe we should not take extra days, you can file a “fast complaint” about
our decision to take extra days. When you file a fast complaint, we will give you
an answer to your complaint within 24 hours. (The process for making a complaint
is different from the process for coverage decisions and appeals. For more about
the process for making complaints, including fast complaints, see Section 9 of this
chapter.)

If your health requires it, ask us to give you a “fast decision”
•

A fast decision means we will answer within 72 hours.
o However, we can take up to 14 more days if we find that some information
is missing that may benefit you, or if you need more time to prepare for this
review. If we decide to take extra days, we will tell you in writing.
o If you believe we should not take extra days, you can file a “fast complaint”
about our decision to take extra days. (For more about the process for making
complaints, including fast complaints, see Section 9 of this chapter.) We will
call you as soon as we make the decision.

•

To get a fast decision, you must meet two requirements:
o You can get a fast decision only if you are asking for medical care you have
not yet received. (You cannot get a fast decision if your request is about
medical care you have already received.)
o You can get a fast decision only if using the standard deadlines could cause
serious harm to your health or hurt your ability to function.

•

If your doctor tells us that your health requires a “fast decision,” we will
automatically agree to give you a fast decision.

•

If you ask for a fast decision on your own, without your doctor’s support, our plan
will decide whether your health requires that we give you a fast decision.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

o If we decide that your medical condition does not meet the requirements for a
fast decision, we will send you a letter that says so (and we will use the
standard deadlines instead).
o This letter will tell you that if your doctor asks for the fast decision, we will
automatically give a fast decision.
o The letter will also tell how you can file a “fast complaint” about our decision
to give you a standard decision instead of the fast decision you requested. (For
more about the process for making complaints, including fast complaints, see
Section 9 of this chapter.)
Step 2 

•

Our plan considers your request for medical care
coverage and we give you our answer.

Generally, for a fast decision, we will give you our answer within 72 hours.
o As explained above, we can take up to 14 more days under certain
circumstances. If we take extra days, it is called “an extended time period.”
o If we do not give you our answer within 72 hours (or if there is an extended
time period, by the end of that period), you have the right to appeal. Section 5.3
below tells how to make an appeal.

•

If our answer is yes to part or all of what you requested, we must provide the
medical care coverage we have agreed to provide within 72 hours after we received
your request. If we extended the time needed to make our decision, we will provide
the coverage by the end of that extended period.

•

If our answer is no to part or all of what you requested, we will send you a written
statement that explains why we said no.

•

Generally, for a standard decision, we will give you our answer within 14 days of
receiving your request.
o We can extend the time up to 14 more days (“an extended time period”) under
certain circumstances.
o If we do not give you our answer within 14 days (or if there is an extended time
period, by the end of that period), you have the right to appeal. Section 5.3
below tells how to make an appeal.

•

If our answer is yes to part or all of what you requested, we must provide the
coverage we have agreed to provide within 14 days. If we extended the time needed

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

to make our decision, we will provide the coverage by the end of that extended
period.
•

If our answer is no to part or all of what you requested, we will send you a written
statement that explains why we said no.

Step 3 

If we say no to your request for coverage for medical care,
you decide if you want to make an appeal

•

If our plan says no, you have the right to ask us to reconsider – and perhaps change –
this decision by making an appeal. Making an appeal means making another try to get
the medical care coverage you want.

•

If you decide to make appeal, it means you are going on to Level 1 of the appeals
process (see Section 5.3 below).

Chapter 7
Section 5.3

Step-by-step: How to make a
Level 1 Appeal
(how to ask for a review of a medical care
coverage decision made by our plan)
When you start the appeal process by
making an appeal, it is called the “first level
of appeal” or a “Level 1 Appeal.”
An appeal to the plan about a medical care
coverage decision is called a plan
“reconsideration.”

Step 1 

You contact our plan and make your appeal.
If your health requires a quick response,
you must ask for a “fast appeal.”

What to do

• To start your appeal, you (or your doctor or your representative) must
contact our plan. For details on how to reach us for any purpose related to your
appeal, go to Chapter 2, Section 1 look for section called, [plans may edit section
title as necessary]How to reach our plan when you are making an appeal about
your medical care.
•

Make your appeal in writing by submitting a signed request. [If the plan
accepts oral requests for standard appeals, insert: You may also ask for an appeal
by calling us at the phone number shown in Chapter 2, Section 1 [plans may edit
section title as necessary] (How to reach our plan when you are making an appeal
about your medical care).]

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

•

You must make your appeal request within 60 calendar days from the date on
the written notice we sent to tell you our answer to your request for a coverage
decision. If you miss this deadline and have a good reason for missing it, we may
give you more time to make your appeal.

•

You can ask for a copy of the information in your appeal and add more
information if you like.

o You have the right to ask us for a copy of the information regarding your
appeal. [If a fee is charged, insert: We are allowed to charge a fee for
copying and sending this information to you.]
o If you wish, you and your doctor may give us additional information to
support your appeal.
If your health requires it, ask for a “fast appeal”
A “fast appeal” is also called an “expedited
appeal.”
•

If you are appealing a decision our plan made about care you have not yet received,
you and your doctor will need to decide if you need a “fast appeal.”

•

The requirements and procedures for getting a “fast appeal” are the same as those for
getting a “fast decision.” To ask for a fast appeal, follow the instructions for asking
for a fast decision. (These instructions are given earlier in this section).

Step 2 

Our plan considers your appeal
and we give you our answer.

•

When our plan is reviewing your appeal, we take another careful look at all of the
information about your request for coverage of medical care. We check to see if we
were being fair and following all the rules when we said no to your request.

•

We will gather more information if we need it. We may contact you or your doctor to
get more information.

•

When we are using the fast deadlines, we must give you our answer within 72 hours
after we receive your appeal. We will give you our answer sooner if your health
requires us to do so.
o However, if you ask for more time, or if we need to gather more information
that may benefit you, we can take up to 14 more days.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

o If we do not give you an answer within 72 hours (or by the end of the extended
time period if we took extra days), we are required to send your request on to
Level 2 of the appeals process, where it will be reviewed by an independent
organization. Later in this section, we tell about this organization and explain
what happens at Level 2 of the appeals process.
•

If our answer is yes to part or all of what you requested, we must provide the
coverage we have agreed to provide within 72 hours.

•

If our answer is no to part or all of what you requested, we will send you a written
statement that explains why we said no.

•

If we are using the standard deadlines, we must give you our answer within 30
calendar days after we receive your appeal. We will give you our decision sooner if
your health condition requires us to.
o However, if you ask for more time, or if we need to gather more information
that may benefit you, we can take up to 14 more days.
o If we do not give you an answer within 30 days (or by the end of the extended
time period if we took extra days), we are required to send your request on to
Level 2 of the appeals process, where it will be reviewed by an independent
outside organization. Later in this section, we tell about this review organization
and explain what happens at Appeal Level 2 of the appeals process.

•

If our answer is yes to part or all of what you requested, we must provide the
coverage we have agreed to provide within 30 days after we receive your appeal.

•

If our answer is no to part or all of what you requested, we will send you a written
statement that explains why we said no.

Step 3 

•

If our plan says no to your appeal, your
case will automatically be sent on to the
next level of the appeals process.

To make sure we were being fair when we said no to your appeal, our plan is required
to send your appeal to the “Independent Review Organization.” When we do this, it
means that your appeal is going on to the next level of the appeals process, which is
Level 2.

If our plan says no to your level 1 appeal, your case will automatically be sent on to the next
level of the appeals process. During the level 2 appeal, the Independent Review Organization
reviews the decision our plan made when we said no to your first appeal. This organization
decides whether the decision we made should be changed.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

The formal name for the “Independent
Review Organization” is the “Independent
Review Entity.” It is sometimes called the
“IRE.”
Step 1 

The Independent Review Organization reviews
your appeal

•

The Independent Review Organization is an outside, independent organization that
is hired by Medicare. This organization is not connected with our plan and it is not a
government agency. This organization is a company chosen by Medicare to handle the
job of being the Independent Review Organization. Medicare oversees its work.

•

We will send the information about your appeal to this organization. This information is
called your “case file.” You have the right to ask us for a copy of your case file. [If a
fee is charged, insert: We are allowed to charge you a fee for copying and sending this
information to you.]

•

Reviewers at the Independent Review Organization will take a careful look at all of the
information related to your appeal.

•

If your health requires it, ask the Independent Review Organization for a “fast appeal.”

•

If the review organization agrees to give you a “fast appeal,” the review organization
must give you an answer to your Level 2 appeal within 72 hours of when it receives
your appeal.

•

If you have a standard appeal at Level 2, the review organization must give you an
answer to your Level 2 appeal within 7 calendar days of when it receives your appeal.

Step 2 

The Independent Review Organization
gives you their answer

The Independent Review Organization will tell you its decision in writing and explain the
reasons for it.
•

If the review organization says yes to part or all of what you requested, we must
provide the medical care coverage that was approved by the review organization within
72 hours after we receive the decision from the review organization.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

•

If this organization says no to your appeal, it means they agree with our plan that your
request for coverage for medical care should not be approved. (This is called “upholding
the decision.” It is also called “turning down your appeal.”)
o The notice you get from the Independent Review Organization will tell you in
writing if your case meets the requirements for continuing with the appeals
process. For example, to continue and make another appeal at Level 3, the dollar
value of the medical care coverage you are requesting must meet a certain
minimum. If the dollar value of the coverage you are requesting is too low, you
cannot make another appeal, which means that the decision at Level 2 is final.
Step 3 

If your case meets the requirements, you choose
whether you want to take your appeal further

•

There are three additional levels in the appeals process after Level 2 (for a total of five
levels of appeal).

•

If your Level 2 appeal is turned down and you meet the requirements to continue with the
appeals process, you must decide whether you want to go on to Level 3 and make a third
appeal. If you decide to make a third appeal, the details on how to do this are in the
written notice you got after your second appeal.

•

Appeal Level 3 is handled by a judge. Section 8 in this chapter tells more about Levels 3,
4, and 5 of the appeals process.

Chapter 7
Section 5.5

What if you are asking our plan to pay you
for our share of a bill you have received
for medical care?

If you want to ask our plan for payment for medical care, start by reading Chapter 7 of this
booklet: Asking the plan to pay its share of a bill you have received for medical services or
drugs. Chapter 7 describes the situations in which you may need to ask for reimbursement or to
pay a bill you have received from a provider. It also tells how to send us the paperwork that asks
us for payment.
Asking for reimbursement is asking for a coverage decision from our plan
If you send us the paperwork that asks for reimbursement, you are asking us to make a coverage
decision (for more about coverage decisions, see Section 4.1 of this chapter). To make this
coverage decision, we will check to see if the medical care you paid for is a covered service (see
Chapter 4: Medical benefits chart (what is covered and what you pay)). We will also check to
see if you followed all the rules for using your coverage for medical care (these rules are given
in Chapter 3 of this booklet: Using the plan’s coverage for your medical services).

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

We will say yes or no to your request
•

If the medical care you paid for is covered and you followed all the rules, we will send
you the payment for our share of the cost of your medical care. Or, if you haven’t paid for
the services, we will send the payment directly to the provider. When we send the
payment, it’s the same as saying yes to your request for a coverage decision.)

•

If the medical care is not covered, or you did not follow all the rules, we will not send
payment. Instead, we will send you a letter that says we will not pay for the services and
the reasons why. (When we turn down your request for payment, it’s the same as saying
no to your request for a coverage decision.)

What if you ask for payment and we say that we will not pay?
If you think we have made a mistake in turning you down, you can make an appeal. If you
make an appeal, it means you are asking us to change the coverage decision we made when we
turned down your request for payment.
To make this appeal, follow the process for appeals that we describe in part 5.3 of this
section. Go to this part for step-by-step instructions. When you are following these instructions,
please note:
•

If you make an appeal for reimbursement, the standard deadlines apply to all parts of
the appeals process. (If you are asking us to pay you back for medical care you have
already received and paid for yourself, you are not allowed to ask for a fast appeal.)

•

At any stage of the appeals process, if the answer to your appeal is yes, then our plan must
send the payment you have requested. We are required to send payment to you or to the
provider within 30 days.

SECTION 6

How to ask for a longer hospital stay if
you think you are being asked to leave
the hospital too soon

When you are admitted to a hospital, you have the right to get all of your covered hospital
services that are necessary to diagnose and treat your illness or injury. For more information
about the plan’s coverage for your hospital care, including any limitations on this coverage, see
Chapter 4 of this booklet: Medical benefits chart (what is covered and what you pay).
During your hospital stay, your doctor and the hospital staff will be working with you to prepare
for the day when you will leave the hospital. They will also help arrange for care you may need
after you leave.
•

The day you leave the hospital is called your “discharge date.” Our plan’s coverage of
your hospital stay ends on this date.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

•

When your discharge date has been decided, your doctor or the hospital staff will let you
know.

•

If you think you are being asked to leave the hospital too soon, you can ask for a longer
hospital stay and your request will be considered. This section tells you how to ask.

Chapter 7
Section 6.1

During your hospital stay, you will get a
written notice from Medicare that tells
about your rights

During your hospital stay, you will be given a written notice called An Important Message from
Medicare about Your Rights. Everyone with Medicare gets a copy of this notice whenever they
are admitted to a hospital. Someone at the hospital is supposed to give it to you within two days
after you are admitted.
1. Read this notice carefully and ask questions if you don’t understand it. It tells you
about your rights as a hospital patient, including:
•

Your right to receive Medicare-covered services during and after your hospital stay,
as ordered by your doctor. This includes the right to know what these services are,
who will pay for them, and where you can get them.

•

Your right to be involved in any decisions about your hospital stay, and know who
will pay for it.

•

Where to report any concerns you have about quality of your hospital care.

•

What to do if you think you are being discharged from the hospital too soon.
The written notice from Medicare tells you how you can
“make an appeal.” Making an appeal is a formal, legal way
to ask for a delay in your discharge date so that your hospital
care will be covered for a longer time. (Section 6.2 below
tells how to make this appeal.)

2. You must sign the written notice to show that you received it and understand your
rights.
•

You or someone who is acting on your behalf must sign the notice. (Section 4 of this
chapter tells how you can give written permission to someone else to act as your
representative.)

•

Signing the notice shows only that you have received the information about your
rights. The notice does not give your discharge date (your doctor or hospital staff will
tell you your discharge date). Signing the notice does not mean you are agreeing on
a discharge date.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

3. Keep your copy of the signed notice so you will have the information about making
an appeal (or reporting a concern about quality of care) handy if you need it.
•

If you sign the notice more than 2 days before the day you leave the hospital, you
will get another copy before you are scheduled to be discharged.

•

To look at a copy of this notice in advance, you can call Member Services or 1-800
MEDICARE (1-800-633-4227 or TTY: 1-877-486-2048). You can also see it online
at
http://www.cms.hhs.gov/BNI/12_HospitalDischargeAppealNotices.asp#TopOfPage

Chapter 7
Section 6.2

Step-by-step: How to make a Level 1 Appeal
to change your hospital discharge date

If you want to ask for your hospital services to be covered by our plan for a longer time, you
will need to use the appeals process to make this request. For general information about the
appeals process, see Section 4 of this chapter. Before you start, understand what you need to
do and what the deadlines are.
•

Follow the process. Each step in the first two levels of the appeals process is
explained below.

•

Meet the deadlines. The deadlines are important. Be sure that you understand and
follow the deadlines that apply to things you must do.

•

Ask for help if you need it. If you have questions or need help at any time, please
call Member Services (phone numbers are on the front cover of this booklet). Or call
your State Health Insurance Assistance Program, a government organization that
provides personalized assistance (see Section 2 of this chapter).

During a Level 1 appeal, the Quality Improvement Organization reviews your appeal. It
checks to see if your planned discharge date is medically appropriate for you.
When you start the appeal process by
making an appeal, it is called the “first
level of appeal” or a “Level 1 Appeal.”
Step 1 

Contact the Quality Improvement Organization in your
state and ask for a “fast review” of your hospital
discharge. You must act quickly.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

A “fast review” is also called an “immediate
review” or an “expedited review.”

What is the Quality Improvement Organization?
•

This organization is a group of doctors and other health care professionals who are
paid by the Federal government. These experts are not part of our plan. This
organization is paid by Medicare to check on and help improve the quality of care for
people with Medicare. This includes reviewing hospital discharge dates for people
with Medicare.

How can you contact this organization?
•

The written notice you received (An Important Message from Medicare) tells you
how to reach this organization. (Or find the name, address, and phone number of the
Quality Improvement Organization for your state in Chapter 2, Section 4, of this
booklet.)

Act quickly:
•

To make your appeal, you must contact the Quality Improvement Organization before
you leave the hospital and no later than your planned discharge date. (Your
“planned discharge date” is the date that has been set for you to leave the hospital.)
o If you meet this deadline, you are allowed to stay in the hospital after your
discharge date without paying for it while you wait to get the decision on your
appeal from the Quality Improvement Organization.
o If you do not meet this deadline, and you decide to stay in the hospital after
your planned discharge date, you may have to pay all of the costs for hospital
care you receive after your planned discharge date.

•

If you miss the deadline for contacting the Quality Improvement Organization about
your appeal, you can make your appeal directly to our plan instead. For details about
this other way to make your appeal, see Section 6.3.

Step 2 

The Quality Improvement Organization conducts
an independent review of your case.

What happens during this review?
•

Health professionals at the Quality Improvement Organization (we will call them “the
reviewers” for short) will ask you (or your representative) why you believe coverage
for the services should continue. You don’t have to prepare anything in writing, but
you may do so if you wish.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

•

The reviewers will also look at your medical information, talk with your doctor, and
review information that the hospital and our plan has given to them.

•

During this review process, you will also get a written notice that gives your
planned discharge date and explains the reasons why your doctor, the hospital,
and our plan think it is right (medically appropriate) for you to be discharged on
that date.
This written explanation is called the “Detailed Notice
of Discharge.” (You can get a sample of this notice by
calling Member Services or 1-800-MEDICARE (1-800633-4227, 24 hours a day, 7 days a week. TTY users
should call 1-877-486-2048.) Or, you can get see a
sample notice online at www.cms.hhs.gov/BNI/).

Step 3 

Within one full day after it has all the needed
information, the Quality Improvement Organization will
give you its answer to your appeal.

What happens if the answer is yes?
•

If the review organization says yes to your appeal, our plan must keep providing
your covered hospital services for as long as these services are medically
necessary.

•

You will have to keep paying your share of the costs (such as deductibles or
copayments, if these apply). In addition, there may be limitations on your covered
hospital services. (See Chapter 4 of this booklet).

What happens if the answer is no?
•

If the review organization says no to your appeal, they are saying that your planned
discharge date is medically appropriate. (Saying no to your appeal is also called
turning down your appeal.) If this happens, our plan’s coverage for your hospital
services will end at noon on the day after the Quality Improvement Organization
gives you its answer to your appeal.

•

If you decide to stay in the hospital, then you may have to pay the full cost of
hospital care you receive after noon on the day after the Quality Improvement
Organization gives you its answer to your appeal.

Step 4 
•

If the answer to your Level 1 appeal is no, you
decide if you want to make another appeal

If the Quality Improvement Organization has turned down your appeal, and you stay
in the hospital after your planned discharge date, then you can make another appeal.
Making another appeal means you are going on to “Level 2” of the appeals process.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

Chapter 7
Section 6.3

Step-by-step: How to make a
Level 2 Appeal to change your hospital
discharge date

If the Quality Improvement Organization has turned down your appeal, and you stay in the
hospital after your planned discharge date, then you can make a Level 2 Appeal. During a Level
2 appeal, you ask the Quality Improvement Organization to take another look at the decision they
made on your first appeal.
Here are the steps for Level 2 of the appeal process:
Step 1 
•

You must ask for this review within 60 days after the day when the Quality
Improvement Organization said no to your Level 1 appeal. You can ask for this
review only if you stayed in the hospital after the date that your coverage for the care
ended.

Step 2 
•

You contact the Quality Improvement Organization
again and ask for another review

The Quality Improvement Organization does a
second review of your situation

Reviewers at the Quality Improvement Organization will take another careful look at
all of the information related to your appeal.

Step 3 

Within 14 days, the Quality Improvement
Organization reviewers will decide on your appeal
and tell you their decision.

If the review organization says yes:
•

Our plan must reimburse you for our share of the costs of hospital care you have
received since noon on the day after the date your first appeal was turned down by the
Quality Improvement Organization. Our plan must continue providing coverage for
your hospital care for as long as it is medically necessary.

•

You must continue to pay your share of the costs and coverage limitations may
apply.

If the review organization says no:
•

It means they agree with the decision they made to your Level 1 appeal and will not
change it. This is called “upholding the decision.” It is also called “turning down your
appeal.”

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

•

The notice you get will tell you in writing what you can do if you wish to continue with
the review process. It will give you the details about how to go on to the next level of
appeal, which is handled by a judge.
Step 4 

If the answer is no, you will need to decide
whether you want to take your appeal further
by going on to Level 3

•

There are three additional levels in the appeals process after Level 2 (for a total of five
levels of appeal). If the review organization turns down your Level 2 appeal, you can
choose whether to accept that decision or whether to go on to Level 3 and make another
appeal. At Level 3, your appeal is reviewed by a judge.

•

Section 8 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.

Chapter 7
Section 6.4

What if you miss the deadline for making
your Level 1 Appeal?

You can appeal to our plan instead
As explained above in Section 6.2, you must act quickly to contact the Quality Improvement
Organization to start your first appeal of your hospital discharge. (“Quickly” means before you
leave the hospital and no later than your planned discharge date). If you miss the deadline for
contacting this organization, there is another way to make your appeal.
If you use this other way of making your appeal, the first two levels of appeal are different.
Step-by-Step: How to make a Level 1 Alternate Appeal If you miss the deadline for
contacting the Quality Improvement Organization, you can make an appeal to our plan, asking
for a “fast review.” A fast review is an appeal that uses the fast deadlines instead of the standard
deadlines.
A “fast” review (or “fast appeal”) is
also called an “expedited” review (or
“expedited appeal”).
Step 1 
•

Contact our plan and ask for a “fast review.”

For details on how to contact our plan (including how to reach us on evenings and
weekends), go to Chapter 2, Section 1 and look for the section called, [plans may
edit section title as necessary] How to reach our plan when you are making an
appeal about your medical care.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

•

Be sure to ask for a “fast review.” This means you are asking us to give you an
answer using the “fast” deadlines rather than the “standard” deadlines.

Step 2 

Our plan does a “fast” review of your planned discharge
date, checking to see if it was medically appropriate.

•

During this review, our plan takes a look at all of the information about your hospital
stay. We check to see if your planned discharge date was medically appropriate. We
will check to see if the decision about when you should leave the hospital was fair
and followed all the rules.

•

In this situation, we will use the “fast” deadlines rather than the standard deadlines for
giving you the answer to this review.

Step 3 

Our plan gives you our decision within 72 hours
after you ask for a “fast review” (“fast appeal”).

•

If our plan says yes to your fast appeal, it means we have agreed to keep providing
your covered services for as long as it is medically necessary. It also means that we have
agreed to reimburse you for our share of the costs of care you have received since the
date when we said your coverage would end. (You must pay your share of the costs and
there may be coverage limitations that apply.)

•

If our plan says no to your fast appeal, we are saying that your planned discharge date
was medically appropriate. Our coverage for your hospital services will end on that date
and our plan will stop paying its share of the costs of this care.

•

If you stayed in the hospital after your planned discharge date, then you may have to
pay the full cost of hospital care you received after the planned discharge date. You will
be responsible for the cost of care starting from noon on the day after our plan says no to
your appeal.

Step 4 

•

If our plan says no to your fast appeal, your
case will automatically be sent on to the next
level of the appeals process.

To make sure we were being fair when we said no to your fast appeal, our plan is
required to send your appeal to the “Independent Review Organization.” When we
do this, it means that you are automatically going on to Level 2 of the appeals process.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

Step-by-Step: How to make a Level 2 Alternate Appeal
If our plan says no to your level 1 appeal, your case will automatically be sent on to the next
level of the appeals process. During the level 2 appeal, the Independent Review Organization
reviews the decision our plan made when we said no to your “fast appeal.” This organization
decides whether the decision we made should be changed.
The formal name for the “Independent
Review Organization” is the “Independent
Review Entity.” It is sometimes called the
“IRE.”
Step 1 

•

Our plan asks the Independent Review Organization
to conduct a “fast review” of your case. (Our plan
asks for this review on your behalf.)

We are required to send the information for your Level 2 appeal to the Independent
Review Organization within 24 hours of when we tell you that we are saying no to your
first appeal. (If you think we are not meeting this deadline or other deadlines, you can
make a complaint. The complaint process is different from the appeal process. Section 9
of this chapter tells how to make a complaint.)
Step 2 

The Independent Review Organization does a “fast
review” of your appeal. The reviewers give you an
answer within 24 hours.

•

Reviewers at the Independent Review Organization will take a careful look at all of the
information related to your appeal of your hospital discharge.

•

If this organization says yes to your appeal, then our plan must reimburse you (pay you
back) for our share of the costs of hospital care you have received since the date of your
planned discharge. We must also continue the plan’s coverage of your hospital services
for as long as it is medically necessary. You must continue to pay your share of the costs.
If there are coverage limitations, these could limit how much we would reimburse or how
long we would continue to cover your services.

•

If this organization says no to your appeal, it means they agree with our plan that your
planned hospital discharge date was medically appropriate. (This is called “upholding the
decision.” It is also called “turning down your appeal.”)
o The notice you get from the Independent Review Organization will tell you in
writing what you can do if you wish to continue with the review process. It will

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

give you the details about how to go on to Appeal Level 3, which is handled by a
judge.
Step 3 

If the Independent Review Organization turns
down your appeal, you choose whether you want
to take your appeal further

•

There are three additional levels in the appeals process after Level 2 (for a total of five
levels of appeal). If reviewers say no to your Level 2 appeal, you decide whether to
accept their decision or go on to Level 3 and make a third appeal.

•

Section 8 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.

SECTION 7

Chapter 7
Section 7.1

How to ask our plan to keep covering
certain medical services if you think
your coverage is ending too soon

This section is about three services only:
Home health care, skilled nursing facility
care, and Comprehensive Outpatient
Rehabilitation Facility (CORF) services

This section is about the following types of care only:
•

Home health care services you are getting.

•

Skilled nursing care you are getting as a patient in a skilled nursing facility. (To learn
about requirements for being considered a “skilled nursing facility,” see Chapter 12,
Definitions of important words.)

•

Rehabilitation care you are getting as an outpatient at a Medicare-approved
Comprehensive Outpatient Rehabilitation Facility (CORF). Usually, this means you are
getting treatment for an illness or accident, or you are recovering from a major
operation. (For more about this type of facility, see Chapter 10, Definitions of important
words.)

When you are getting any of these types of care, you have the right to keep getting your covered
services for that type of care for as long as the care is needed to diagnose and treat your illness or
injury. For more information on your covered services, including your share of the cost and any
limitations to coverage that may apply, see Chapter 4 of this booklet: Medical benefits chart
(what is covered and what you pay).

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

When our plan decides it is time to stop covering any of the three types of care for you, we are
required to tell you in advance. When your coverage for that care ends, our plan will stop paying
its share of the cost for your care.
If you think we are ending the coverage of your care too soon, you can appeal our decision. This
section tells you how to appeal.
Chapter 7
Section 7.2

We tell you in advance when your coverage
will be ending

1. You receive a notice in writing. At least two days before our plan is going to stop
covering your care, the agency or facility that is providing your care will give you a
notice.
•

The written notice tells you the date when our plan will stop covering the care for
you.
In this written notice, we are telling you about a “coverage
decision” we have made about when to stop covering your care.
(For more about coverage decisions, see Section 4 in this chapter.)

•

The written notice also tells what you can do if you want to ask our plan to change
this decision about when to end your care, and keep covering it for a longer period of
time.
In telling what you can do, the written notice is telling how you
can “make an appeal.” Making an appeal is a formal, legal way
to ask our plan to change the coverage decision we have made
about when to stop your care. (Section 7.3 below tells how you
can make an appeal.)
The written notice is called the “Notice of Medicare NonCoverage.” To get a sample copy, call Member Services or 1800-MEDICARE (1-800-633-4227, 24 hours a day, 7 days a
week. TTY users should call 1-877-486-2048.). Or see a copy
online at http://www.cms.hhs.gov/BNI/.

2. You must sign the written notice to show that you received it.
•

You or someone who is acting on your behalf must sign the notice. (Section 4 tells
how you can give written permission to someone else to act as your representative.)

•

Signing the notice shows only that you have received the information about when
your coverage will stop. Signing it does not mean you agree with the plan that it’s
time to stop getting the care.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

Chapter 7
Section 7.3

Step-by-step: How to make a Level 1
Appeal to have our plan cover your
care for a longer time

If you want to ask us to cover your care for a longer period of time, you will need to use the
appeals process to make this request. For general information about the appeals process, see
Section 4 of this chapter. Before you start, understand what you need to do and what the
deadlines are.
•

Follow the process. Each step in the first two levels of the appeals process is
explained below.

•

Meet the deadlines. The deadlines are important. Be sure that you understand and
follow the deadlines that apply to things you must do. There are also deadlines our
plan must follow. (If you think we are not meeting our deadlines, you can file a
complaint. Section 9 of this chapter tells you how to file a complaint.)

•

During a Level 1 Appeal, the Quality Improvement Organization reviews your appeal and
decides whether to change the decision made by our plan.
When you start the appeal process by
making an appeal, it is called the “first
level of appeal” or “Level 1 Appeal.”

Step 1 

Make your Level 1 Appeal: contact the Quality
Improvement Organization in your state and ask
for a review. You must act quickly.

What is the Quality Improvement Organization?
•

This organization is a group of doctors and other health care experts who are paid by
the Federal government. These experts are not part of our plan. They check on the
quality of care received by people with Medicare and review plan decisions about
when it’s time to stop covering certain kinds of medical care.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints)

How can you contact this organization?
•

The written notice you received tells you how to reach this organization. (Or find the
name, address, and phone number of the Quality Improvement Organization for your
state in Chapter 2, Section 4, of this booklet.)

What should you ask for?
•

Ask this organization to do an independent review of whether it is medically
appropriate for our plan to end coverage for your medical services.

Deadline.
•

You must contact the Quality Improvement Organization to start your appeal no later
than noon of the day before the date that your coverage ends.

o If you miss the deadline for contacting the Quality Improvement Organization
about your appeal, you can make your appeal directly to our plan instead. For
details about this other way to make your appeal, see Section 7.4.
Step 2 

The Quality Improvement Organization conducts
an independent review of your case.

What happens during this review?
•

•

The review organization will also look at your medical information, talk with your
doctor, and review information that our plan has given to them.

•

During this review process, you will also get a written notice from the plan that
gives our reasons for wanting to end the plan’s coverage for your services.
This written notice is called the “Detailed
Explanation of Non-Coverage.”

Step 3 

Within one full day after they have all the
information they need, the reviewers will tell
you their decision.

What happens if the reviewers say yes to your appeal?

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints) 100

•

If the reviewers say yes to your appeal, then our plan must keep providing your
covered services for as long as it is medically necessary.

•

You will have to keep paying your share of the costs (such as deductibles or
copayments, if these apply). In addition, there may be limitations on your covered
services (see Chapter 4 of this booklet).

What happens if the reviewers say no to your appeal?
•

If the reviewers say no to your appeal, then your coverage will end on the date we
have told you. Our plan will stop paying its share of the costs of this care.

•

If you decide to keep getting the home health care, or skilled nursing facility care, or
outpatient rehabilitation care after this date when your coverage ends, then you will
have to pay the full cost of this care yourself.

Step 4 

If the answer your Level 1 appeal is no, you
decide if you want to make another appeal

•

This first appeal you make is “Level 1” of the appeals process. If reviewers say no to
your Level 1 appeal – and you choose to continue getting care after your coverage for
the care has ended – then you can make another appeal.

•

Making another appeal means you are going on to “Level 2” of the appeals process.

Chapter 7
Section 7.4

Step-by-step: How to make a Level 2
Appeal to have our plan cover your
care for a longer time

If the Quality Improvement Organization has turned down your appeal and you choose to
continue getting care after your coverage for the care has ended, then you can make a Level 2
Appeal. During a Level 2 appeal, you ask the Quality Improvement Organization to take another
look at the decision they made on your first appeal.
Here are the steps for Level 2 of the appeal process:
Step 1 
•

You contact the Quality Improvement Organization
again and ask for another review

You must ask for this review within 60 days after the day when the Quality
Improvement Organization said no to your Level 1 appeal. You can ask for this
review only if you continued getting care after the date that your coverage for the care
ended.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints) 101

Step 2 
•

The Quality Improvement Organization does
a second review of your situation

Reviewers at the Quality Improvement Organization will take another careful look at
all of the information related to your appeal.

Step 3 

Within 14 days, the Quality Improvement
Organization reviewers will decide on your
appeal and tell you their decision.

What happens if the review organization says yes to your appeal?
•

Our plan must reimburse you for our share of the costs of care you have received
since the date when we said your coverage would end. Our plan must continue
providing coverage for the care for as long as it is medically necessary.

•

You must continue to pay your share of the costs and there may be coverage
limitations that apply.

What happens if the review organization says no?
•

It means they agree with the decision they made to your Level 1 appeal and will not
change it. (This is called “upholding the decision.” It is also called “turning down
your appeal.”)

•

The notice you get will tell you in writing what you can do if you wish to continue
with the review process. It will give you the details about how to go on to the next
level of appeal, which is handled by a judge.

Step 4 

If the answer is no, you will need to decide
whether you want to take your appeal further

•

There are three additional levels of appeal after Level 2, for a total of five levels of
appeal. If reviewers turn down your Level 2 appeal, you can choose whether to accept
that decision or whether to go on to Level 3 and make another appeal. At Level 3, your
appeal is reviewed by a judge.

•

Section 8 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.

Chapter 7
Section 7.5

What if you miss the deadline for making
your Level 1 Appeal?

You can appeal to our plan instead

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints) 102

As explained above in Section 7.3, you must act quickly to contact the Quality Improvement
Organization to start your first appeal (within a day or two, at the most). If you miss the deadline
for contacting this organization, there is another way to make your appeal. If you use this other
way of making your appeal, the first two levels of appeal are different.
Step-by-Step: How to make a Level 1 Alternate Appeal
If you miss the deadline for contacting the Quality Improvement Organization, you can make an
appeal to our plan, asking for a “fast review.” A fast review is an appeal that uses the fast
deadlines instead of the standard deadlines.
Here are the steps for a Level 1 Alternate Appeal:
A “fast” review (or “fast appeal”) is
also called an “expedited” review (or
“expedited appeal”).

Step 1 
•

•

Be sure to ask for a “fast review.” This means you are asking us to give you an
answer using the “fast” deadlines rather than the “standard” deadlines.

Step 2 

Our plan does a “fast” review of the decision we made
about when to stop coverage for your services.

•

During this review, our plan takes another look at all of the information about your
case. We check to see if we were being fair and following all the rules when we set
the date for ending the plan’s coverage for services you were receiving.

•

We will use the “fast” deadlines rather than the standard deadlines for giving you the
answer to this review. (Usually, if you make an appeal to our plan and ask for a “fast
review,” we are allowed to decide whether to agree to your request and give you a
“fast review.” But in this situation, the rules require us to give you a fast response if
you ask for it.)

Step 3 
•

Contact our plan and ask for a “fast review.”

Our plan gives you our decision within 72 hours
after you ask for a “fast review” (“fast appeal”).

If our plan says yes to your fast appeal, it means we have agreed to keep providing
your covered services for as long as it is medically necessary. It also means that we have

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints) 103

agreed to reimburse you for our share of the costs of care you have received since the
date when we said your coverage would end. (You must pay your share of the costs and
there may be coverage limitations that apply.)
•

If our plan says no to your fast appeal, then your coverage will end on the date we
have told you and our plan will not pay after this date. Our plan will stop paying its share
of the costs of this care.

•

If you continued to get home health care, or skilled nursing facility care, or
comprehensive outpatient rehabilitation care (CORF) after the date when we said your
coverage would your coverage ends, then you will have to pay the full cost of this care
yourself.
Step 4 

•

If our plan says no to your fast appeal, your
case will automatically go on to the next level
of the appeals process.

•

Our plan asks the Independent Review Organization
to conduct a “fast review” of your case. (Our plan
asks for this review on your behalf.)

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints) 104

Step 2 

The Independent Review Organization does a “fast
review” of your appeal. The reviewers give you an
answer within 24 hours.

•

Reviewers at the Independent Review Organization will take a careful look at all of the
information related to your appeal.

•

If this organization says yes to your appeal, then our plan must reimburse you (pay you
back) for our share of the costs of care you have received since the date when we said
your coverage would end. We must also continue to cover the care for as long as it is
medically necessary. You must continue to pay your share of the costs. If there are
coverage limitations, these could limit how much we would reimburse or how long we
would continue to cover your services.

•

If this organization says no to your appeal, it means they agree with the decision our
plan made to your first appeal and will not change it. (This is called “upholding the
decision” It is also called “turning down your appeal.”)
o The notice you get from the Independent Review Organization will tell you in
writing what you can do if you wish to continue with the review process. It will
give you the details about how to go on to Appeal Level 3.
Step 3 

If the Independent Review Organization turns
down your appeal, you choose whether you want
to take your appeal further

•

There are three additional levels of appeal after Level 2, for a total of five levels of
appeal. If reviewers say no to your Level 2 appeal, you can choose whether to accept that
decision or whether to go on to Level 3 and make another appeal. At Level 3, your appeal
is reviewed by a judge.

•

Section 8 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.

SECTION 8

Chapter 7
Section 8.1

Taking your appeal to Level 3 and
beyond

Levels of Appeal 3, 4, and 5

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints) 105

This section may be appropriate for you if you have made a Level 1 appeal and a Level 2 appeal,
and both of your appeals have been turned down.
If the dollar value of the drug or medical service you have appealed meets certain minimum
levels, you may be able to go on to additional levels of appeal. If the dollar value is less than the
minimum level, you cannot appeal any further. If the dollar value is high enough, the written
response you receive to your Level 2 appeal will explain who to contact and what to do to ask for
a Level 3 appeal.
For most situations that involve appeals, the last three levels of appeal work in much the same
way. Here is who handles the review of your appeal at each of these levels.
A judge who works for the Federal government will
review your appeal and give you an answer. This judge is
called an “Administrative Law Judge.”

•

If the answer is yes, the appeals process is over. What you asked for in the appeal has
been approved.

•

If the answer is no, the appeals process may or may not be over.
o If you decide to accept this decision that turns down your appeal, the appeals
process is over.
o If you do not want to accept the decision, you might be able to continue to the next
level of the review process. It depends on your situation. Whenever the reviewer
says no to your appeal, the notice you get will tell you whether the rules allow you
to go on to another level of appeal. If the rules allow you to go on, the written
notice will also tell you who to contact and what to do next if you choose to
continue with your appeal.
The Medicare Appeals Council will review your appeal
and give you an answer. The Medicare Appeals Council
works for the Federal government.

•

If the answer is yes, the appeals process is over. What you asked for in the appeal has
been approved.

•

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints) 106

to go on to another level of appeal. If the rules allow you to go on, the written
notice will also tell you who to contact and what to do next if you choose to
continue with your appeal.
A judge at the Federal District Court will review
your appeal. This is the last stage of the appeals
process. The decision of the Federal Court is final.
•

This is the last stage of the appeals process. The Level 5 Appeal decision is final.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints) 107

Making complaints
[SNPs should revise the following language, as appropriate to incorporate information about the
processes available to beneficiaries to pursue grievances related to Medicaid-covered services.]
How to make a complaint about
quality of care, waiting times,
customer service, or other concerns

SECTION 9

If your problem is about decisions related to benefits,
coverage, or payment, then this section is not for you.
Instead, you need to use the process for coverage decisions
and appeals. Go to Section 4 of this chapter.

Chapter 7
Section 9.1

What kinds of problems are handled by
the complaint process?

This section explains how to use the process for making complaints. The complaint process is
used for certain types of problems only. This includes problems related to quality of care, waiting
times, and the customer service you receive. Here are examples of the kinds of problems handled
by the complaint process.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints) 108

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints) 109

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints) 110

Chapter 7
Section 9.2

Chapter 7
Section 9.3

Step 1 

The formal name for “making a
complaint” is “filing a grievance”

•

What this section calls a “complaint” is also called
a “grievance.”

•

Another term for “making a complaint” is “filing
a grievance.”

•

Another way to say “using the process for
complaints” is “using the process for filing a
grievance.”

Step-by-step: Making a complaint

•

Usually, calling Member Services is the first step. If there is anything else you need to
do, Member Services will let you know. [Insert phone number, TTY/TDD, and hours of
operation.]

•

If you do not wish to call (or you called and were not satisfied), you can put your
complaint in writing and send it to us. If you do this, it means that we will use our formal
procedure for answering grievances. Here’s how it works:
o [Insert description of the procedures (including time frames) and instructions
about what members need to do if they want to use the formal process for making
a complaint. Describe expedited grievance time frames for grievances about
decisions to not conduct expedited organization/coverage determinations or
reconsiderations/redeterminations.]

•

Whether you call or write, you should contact Member Services right away. The
complaint must be made within 60 days after you had the problem you want to complain
about.

•

If needed, you may ask for a “fast” complaint. If you ask for a “fast” complaint, and we
agree to give it to you, we will give you an answer within 24 hours. You can ask for a
“fast” complaint if you think a slower response could harm your health or hurt your ability
to function.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or concern (coverage decisions, appeals, complaints) 111

What this section calls a “fast complaint” is
also called a “fast grievance.”

Step 2 

We look into your complaint and
give you our answer

•

The longest time we can take to answer a complaint is 30 days. If we need more
information and the delay is in your best interest or if you ask for more time, we can take
up to 14 more days (44 days total) to answer your complaint.

•

If we do not agree with some or all of your complaint or don’t take responsibility for the
problem you are complaining about, we will let you know in writing. Our response will
include our reasons for this answer.

Chapter 7
Section 9.4

You can also make complaints about
quality of care to the Quality Improvement
Organization

You can make your complaint about the quality of care you received to our plan by using the
step-by-step process outlined above.
When your complaint is about quality of care, you also have two extra options:
•

You can make your complaint to the Quality Improvement Organization. If you
prefer, you can make your complaint about the quality of care you received directly to
this organization (without making the complaint to our plan). To find the name,
address, and phone number of the Quality Improvement Organization in your state,
look in Chapter 2, Section 4, of this booklet. If you make a complaint to this
organization, we will work together with them to resolve your complaint.

•

Or, you can make your complaint to both at the same time. If you wish, you can make
your complaint about quality of care to our plan and also to the Quality Improvement
Organization.

2010 Evidence of Coverage for [insert plan name]
Chapter 8: Ending your membership in the plan

114

CHAPTER 8: Ending your membership in the plan

SECTION 1. Introduction
1.1

This chapter focuses on ending your membership in our plan................................ [xx]

SECTION 2. When can you end your membership in our plan?
2.1

You can end your membership during the Annual Enrollment Period .................. [xx]

2.2

You can end your membership during the Medicare Advantage Open
Enrollment Period, but your plan choices are more limited. ................................. [xx]

2.3

In certain situations, you can end your membership during a Special
Enrollment Period .............................................................................................. [xx]

2.4

Where can you get more information about when you can end your
membership? ....................................................................................................... [xx]

SECTION 3. How do you end your membership in our plan?
3.1

Usually, you end your membership by enrolling in another plan ........................... [xx]

SECTION 4. Until your membership ends, you must keep getting your
medical services through our plan
4.1

Until your membership ends, you are still a member of our plan ........................... [xx]

SECTION 5. In certain situations, [insert plan name] can end your
membership in the plan
5.1

When will we end your membership in the plan? .................................................. [xx]

5.2

We cannot ask you to leave for any reason related to your health .......................... [xx]

5.3

What can you do if we end your membership? ...................................................... [xx]

2010 Evidence of Coverage for [insert plan name]
Chapter 8: Ending your membership in the plan

SECTION 1

Chapter 8
Section 1.1

115

Introduction

This chapter focuses on ending your
membership in our plan

Ending your membership in [insert plan name] may be voluntary (your own choice) or
involuntary (not your own choice):
•

You might leave our plan because you have decided that you want to leave.
o There are only certain times during the year, or certain situations, when you may
end your membership in the plan. Section 2 tells you when you can end your
membership in the plan.
o The process for ending your membership varies depending on what type of new
coverage you are choosing. Section 3 tells you how to end your membership in
each situation.

•

There are also limited situations where we are required to end your membership. Section
5 tells you about situations when we must end your membership.

If you are leaving our plan, you must continue to get your medical care through our plan until
your membership ends.

SECTION 2

When can you end your membership in
our plan?

You may end your membership in our plan only during certain times of the year, known as
enrollment periods. All members have the opportunity to leave the plan during the Annual
Enrollment Period and during the Medicare Advantage Open Enrollment Period. In certain
situations, you may also be eligible to leave the plan at other times of the year.

Chapter 8
Section 2.1

You can end your membership during the
Annual Enrollment Period

You can end your membership during the Annual Enrollment Period (also known as the
“Annual Election Period”). This is the time when you should review your health and drug
coverage and make a decision about your coverage for the upcoming year.

2010 Evidence of Coverage for [insert plan name]
Chapter 8: Ending your membership in the plan

116

•

When is the Annual Enrollment Period? This happens every year from November
15 to December 31.

•

What type of plan can you switch to during the Annual Enrollment Period?
During this time, you can review your health coverage and your prescription drug
coverage. You can choose to keep your current coverage or make changes to your
coverage for the upcoming year. If you decide to change to a new plan, you can
choose any of the following types of plans:
o Another Medicare Advantage plan. (You can choose a plan that covers
prescription drugs or one that does not cover prescription drugs.)
o Original Medicare with a separate Medicare prescription drug plan
o – or –Original Medicare without a separate Medicare prescription drug plan.

•

When will your membership end? Your membership will end when your new
plan’s coverage begins on January 1.

Chapter 8
Section 2.2

You can end your membership during the
Medicare Advantage Open Enrollment
Period, but your plan choices are more
limited

You have the opportunity to make one change to your health coverage during the Medicare
Advantage Open Enrollment Period.
•

When is the Medicare Advantage Open Enrollment Period? This happens every
year from January 1 to March 31.

•

What type of plan can you switch to during the Medicare Advantage Open
Enrollment Period? During this time, you can make one change to your health plan
coverage. However, you may not add or drop prescription drug coverage during this
time. Since you are currently enrolled in a Medicare Advantage plan that does not
include prescription drug coverage, this means that you can enroll in either:
o Another Medicare Advantage plan that does not include prescription drug
coverage
o – or –Original Medicare. (You cannot enroll in a separate prescription drug
plan during the Medicare Advantage Open Enrollment Period.)

•

When will your membership end? Your membership will end on the first day of the
month after we get your request to change plans.

2010 Evidence of Coverage for [insert plan name]
Chapter 8: Ending your membership in the plan

Chapter 8
Section 2.3

117

In certain situations, you can end your
membership during a Special Enrollment
Period

In certain situations, members of [insert plan name] may be eligible to end their membership at
other times of the year. This is known as a Special Enrollment Period.
•

Who is eligible for a Special Enrollment Period? These are just examples, for the
full list you can contact the plan, call 1-800-MEDICARE, or visit the Medicare
website at www.Medicare.gov:

•

If you have moved.
o If you have Medicaid.
o If you live in a facility, such as a nursing home.
These are three common examples of Special Enrollment Periods. There are
more Special Enrollment Periods for other situations. To find out more, contact
member services or 1-800-MEDICARE for more information.

•

When are Special Enrollment Periods? The enrollment periods vary depending on
your situation.

•

What can you do? If you are eligible to end your membership because of a special
situation, you can choose to change both your Medicare health coverage and
prescription drug coverage. This means you can choose any of the following types of
plans:
o Another Medicare Advantage plan. (You can choose a plan that covers
prescription drugs or one that does not cover prescription drugs.)
o Original Medicare with a separate Medicare prescription drug plan.
o – or –Original Medicare without a separate Medicare prescription drug plan.

•

When will your membership end? Your membership will usually end on the first
day of the month after we receive your request to change your plan.

Chapter 8
Section 2.4

Where can you get more information
about when you can end your
membership?

If you have any questions or would like more information on when you can end your
membership:
•

You can call Member Services (phone numbers are on the cover of this booklet).

2010 Evidence of Coverage for [insert plan name]
Chapter 8: Ending your membership in the plan

•

118

You can find the information in the Medicare & You 2010 handbook.
o Everyone with Medicare receives a copy of Medicare & You each fall. Those
new to Medicare receive it within a month after first signing up.
o You can also download a copy from www.medicare.gov. Or, you can order a
printed copy by calling Medicare at the number below.

•

You can contact Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7
days a week.

SECTION 3

Chapter 8
Section 3.1

How do you end your membership in
our plan?

You end your membership by enrolling in
another plan

Usually, to end your membership in our plan, you simply enroll in another health plan during one
of the enrollment periods (see Section 2 for information about the enrollment periods). One
exception is when you want to switch from our plan to Original Medicare without a Medicare
prescription drug plan.
In this situation, you must contact [insert plan name] Member Services and ask to be disenrolled
from our plan.
The table below explains how you should end your membership in our plan.

If you would like to switch
from our plan to:
•

Another Medicare Advantage
plan

This is what you should do:

•

Enroll in the new Medicare Advantage
plan.
You will automatically be disenrolled
from [insert plan name] when your new
plan’s coverage begins.

•

Original Medicare with a

•

Enroll in the new Medicare prescription

2010 Evidence of Coverage for [insert plan name]
Chapter 8: Ending your membership in the plan

If you would like to switch
from our plan to:

119

This is what you should do:

separate Medicare
prescription drug plan.

•

Original Medicare without a
separate Medicare
prescription drug plan

SECTION 4

Chapter 8
Section 4.1

drug plan.
You will automatically be disenrolled
from [insert plan name] when your new
plan’s coverage begins.

•

Contact Member Services and ask to
be disenrolled from the plan (phone
numbers are on the cover of this
booklet).

•

You can also contact Medicare at 1800-MEDICARE (1-800-633-4227) and
ask to be disenrolled. TTY users should
call 1-877-486-2048.

•

You will be disenrolled from [insert
plan name] when your coverage in
Original Medicare begins.

Until your membership ends, you
must keep getting your medical
services through our plan

Until your membership ends, you are still
a member of our plan

If you leave [insert plan name], it may take time before your membership ends and your new
Medicare coverage goes into effect. (See Section 2 for information on when your new coverage
begins.) During this time, you must continue to get your medical care through our plan.
•

If you are hospitalized on the day that your membership ends, you will usually be
covered by our plan until you are discharged (even if you are discharged after your
new health coverage begins).

2010 Evidence of Coverage for [insert plan name]
Chapter 8: Ending your membership in the plan

SECTION 5

Chapter 8
Section 5.1

120

[Insert plan name] can end your
membership in the plan

When will we end your membership in the
plan?

[Insert plan name] must end your membership in the plan if any of the following happen:
•

If you do not stay continuously enrolled in Medicare Part A and Part B.

•

[SNPs insert: If you no longer are [insert SNP category].]

•

If you move out of our service area for more than [Plans without visitor/traveler benefits:
six months] [Plans with visitor/traveler benefits: [insert number up to 12] months].
o If you move or take a long trip, you need to call Member Services to find out if
the place you are moving or traveling to is in our plan’s area.
o [Plans with visitor/traveler benefits, insert: Chapter 3 and Chapter 4 give more
information about getting care when you are away from the service area.]
o [Plans with grandfathered members who were outside of area prior to January
1999, insert: If you have been a member of our plan continuously since before
January 1999 and you were living outside of our service area before January
1999, you may continue your membership. However, if you move and your move
is to another location that is outside of our service area, you will be disenrolled
from our plan.]

•

[Omit if not applicable] If you intentionally give us incorrect information when you are
enrolling in our plan and that information affects your eligibility for our plan.

•

[Omit bullet and sub-bullet if not applicable] If you continuously behave in a way that is
disruptive and makes it difficult for us to provide medical care for you and other
members of our plan.
o We cannot make you leave our plan for this reason unless we get permission from
Medicare first.

•

[Omit bullet and sub-bullet if not applicable] If you let someone else use your
membership card to get medical care.
o If we end your membership because of this reason, Medicare may have your case
investigated by the Inspector General.

2010 Evidence of Coverage for [insert plan name]
Chapter 8: Ending your membership in the plan

•

121

[Omit bullet and sub-bullet if not applicable] If you do not pay the plan premiums for
[insert length of grace period].
o We must notify you in writing that you have [insert length of grace period] to pay
the plan premium before we end your membership.

Where can you get more information?
If you have questions or would like more information on when we can end your membership:
•

You can call Member Services for more information (phone numbers are on the cover of
this booklet).

Chapter 8
Section 5.2

We cannot ask you to leave our plan for
any reason related to your health

[Chronic care SNPs, delete this section.]
What should you do if this happens?
If you feel that you are being asked to leave our plan because of a health-related reason, you
should call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877486-2048. You may call 24 hours a day, 7 days a week.

Chapter 8
Section 5.3

You have the right to make a complaint
if we end your membership in our plan

If we end your membership in our plan, we must tell you our reasons in writing for ending your
membership. We must also explain how you can make a complaint about our decision to end
your membership. You can also look in Chapter 7, Section 9 for information about how to make
a complaint.

2010 Evidence of Coverage for [insert plan name]
Chapter 9: Legal notices

122

CHAPTER 9: Legal notices

SECTION 1. Notice about governing law.................................................................. [xx]
SECTION 2. Notice about nondiscrimination ............................................................ [xx]

[Note: You may include other legal notices, such as a notice of member non-liability or a notice
about third-party liability. These notices may only be added if they conform to Medicare laws
and regulations.]

2010 Evidence of Coverage for [insert plan name]
Chapter 9: Legal notices

SECTION 1

123

Notice about governing law

Many laws apply to this Evidence of Coverage and some additional provisions may apply
because they are required by law. This may affect your rights and responsibilities even if the
laws are not included or explained in this document. The principal law that applies to this
document is Title XVIII of the Social Security Act and the regulations created under the Social
Security Act by the Centers for Medicare & Medicaid Services, or CMS. In addition, other
Federal laws may apply and, under certain circumstances, the laws of the state you live in.

SECTION 2

Notice about nondiscrimination

We don’t discriminate based on a person’s race, disability, religion, sex, health, ethnicity, creed,
age, or national origin. All organizations that provide Medicare Advantage Plans, like our plan,
must obey Federal laws against discrimination, including Title VI of the Civil Rights Act of
1964, the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with
Disabilities Act, all other laws that apply to organizations that get Federal funding, and any other
laws and rules that apply for any other reason.

[Note: You may include other legal notices, such as a notice of member non-liability or a notice
about third party liability. These notices may only be added if they conform to Medicare laws
and regulations.]

2010 Evidence of Coverage for [insert plan name]
Chapter 10: Definitions of important words

124

CHAPTER 10: Definitions of important words
[Plans should insert definitions as appropriate to the plan type described in the EOC. You may
insert definitions not included in this model and exclude model definitions not applicable to your
plan, or to your contractual obligations with CMS or enrolled Medicare beneficiaries.]
[If you use any of the following terms in your EOC, you must add a definition of the term to the
first section where you use it and here in Chapter 10 with a reference from the section where you
use it: IPA, network, PHO, plan medical group, Point of Service.]
[Plans with a POS option: Provide definitions of: allowed amount, balance billing, coinsurance
and maximum charge], and prescription drug benefit manager.]
Appeal – An appeal is a special kind of complaint you make if you disagree with a decision to
deny a request for health care services or payment for services you already received. You may
also make a complaint if you disagree with a decision to stop services that you are receiving. For
example, you may ask for an appeal if our Plan doesn’t pay for an item or service you think you
should be able to receive. Chapter 7 explains appeals, including the process involved in making
an appeal.
Benefit period – For [both our Plan and] Original Medicare, a benefit period is used to
determine coverage for inpatient stays in hospitals and skilled nursing facilities. [Plans that offer
a more generous benefit period, revise the following sentences to reflect the Plan’s benefit
period.] A benefit period begins on the first day you go to a Medicare-covered inpatient hospital
or a skilled nursing facility. The benefit period ends when you haven’t been an inpatient at any
hospital or SNF for 60 days in a row. If you go to the hospital (or SNF) after one benefit period
has ended, a new benefit period begins. There is no limit to the number of benefit periods you
can have.
The type of care that is covered depends on whether you are considered an inpatient for hospital
and SNF stays. You must be admitted to the hospital as an inpatient, not just under observation.
You are an inpatient in a SNF only if your care in the SNF meets certain standards for skilled
level of care. Specifically, in order to be an inpatient in a SNF, you must need daily skillednursing or skilled-rehabilitation care, or both.
Centers for Medicare & Medicaid Services (CMS) – The Federal agency that runs the
Medicare program. Chapter 2 explains how to contact CMS.
Comprehensive Outpatient Rehabilitation Facility (CORF) – A facility that mainly provides
rehabilitation services after an illness or injury, and provides a variety of services including
physician's services, physical therapy, social or psychological services, and outpatient
rehabilitation.
Cost-sharing – Cost-sharing refers to amounts that a member has to pay when services are
received. It includes any combination of the following three types of payments: (1) any

2010 Evidence of Coverage for [insert plan name]
Chapter 10: Definitions of important words

125

deductible amount a plan may impose before services are covered; (2) any fixed “copayment”
amounts that a plan may require be paid when specific services are received; or (3) any
“coinsurance” amount that must be paid as a percentage of the total amount paid for a service.
Covered services – The general term we use in this EOC to mean all of the health care services
and supplies that are covered by our Plan.
Creditable Prescription Drug Coverage – Prescription drug coverage (for example, from an
employer or union) that is expected to pay, on average, at least as much as Medicare’s standard
prescription drug coverage. People who have this kind of coverage when they become eligible
for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll
in Medicare prescription drug coverage later.
Custodial care -- Care for personal needs rather than medically necessary needs. Custodial care
is care that can be provided by people who don’t have professional skills or training. This care
includes help with walking, dressing, bathing, eating, preparation of special diets, and taking
medication. Medicare does not cover custodial care unless it is provided as other care you are
getting in addition to daily skilled nursing care and/or skilled rehabilitation services.
Deductible – The amount you must pay for the drugs you receive before our plan begins to pay
its share of your covered drugs.
Disenroll or Disenrollment – The process of ending your membership in our plan.
Disenrollment may be voluntary (your own choice) or involuntary (not your own choice).
Durable medical equipment – Certain medical equipment that is ordered by your doctor for use
in the home. Examples are walkers, wheelchairs, or hospital beds.
Emergency care – Covered services that are: 1) rendered by a provider qualified to furnish
emergency services; and 2) needed to evaluate or stabilize an emergency medical condition.
Evidence of Coverage (EOC) and Disclosure Information – This document, along with your
enrollment form and any other attachments, riders, or other optional coverage selected, which
explains your coverage, what we must do, your rights, and what you have to do as a member of
our plan.
Grievance - A type of complaint you make about us or one of our network
[providers/pharmacies], including a complaint concerning the quality of your care. This type of
complaint does not involve coverage or payment disputes.
Home health aide – A home health aide provides services that don’t need the skills of a licensed
nurse or therapist, such as help with personal care (e.g., bathing, using the toilet, dressing, or
carrying out the prescribed exercises). Home health aides do not have a nursing license or
provide therapy.

2010 Evidence of Coverage for [insert plan name]
Chapter 10: Definitions of important words

126

Medically necessary – Drugs, services, or supplies that are proper and needed for the diagnosis
or treatment of your medical condition; are used for the diagnosis, direct care, and treatment of
your medical condition; meet the standards of good medical practice in the local community; and
are not mainly for your convenience or that of your doctor.
Medicare – The Federal health insurance program for people 65 years of age or older, some
people under age 65 with certain disabilities, and people with End-Stage Renal Disease
(generally those with permanent kidney failure who need dialysis or a kidney transplant).
Medicare Advantage (MA) Plan – Sometimes called Medicare Part C. A plan offered by a
private company that contracts with Medicare to provide you with all your Medicare Part A
(Hospital) and Part B (Medical) benefits. A MA plan offers a specific set of health benefits at the
same premium and level of cost-sharing to all people with Medicare who live in the service area
covered by the Plan. Medicare Advantage Organizations can offer one or more Medicare
Advantage plan in the same service area. A Medicare Advantage Plan can be an HMO, PPO, a
Private Fee-for-Service (PFFS) Plan, or a Medicare Medical Savings Account (MSA) plan. In
most cases, Medicare Advantage Plans also offer Medicare Part D (prescription drug coverage).
These plans are called Medicare Advantage Plans with Prescription Drug Coverage.
Everyone who has Medicare Part A and Part B is eligible to join any Medicare Health Plan that
is offered in their area, except people with End-Stage Renal Disease (unless certain exceptions
apply).
[Insert Cost plan definition only if you are a Medicare Cost plan or there is one in your service
area.] Medicare Cost Plan – Cost plan means a plan operated by a Health Maintenance
Organization (HMO) or Competitive Medical Plan (CMP) in accordance with a cost-reimbursed
contract under section 1876(h) of the Act.
Medicare Prescription Drug Coverage (Medicare Part D) – Insurance to help pay for
outpatient prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare
Part A or Part B.
“Medigap” (Medicare supplement insurance) policy – Medicare supplement insurance sold by
private insurance companies to fill “gaps” in Original Medicare coverage. Medigap policies only
work with Original Medicare. (A Medicare Advantage plan is not a Medigap policy.)
Member (member of our Plan, or “plan member”) – A person with Medicare who is eligible
to get covered services, who has enrolled in our Plan and whose enrollment has been confirmed
by the Centers for Medicare & Medicaid Services (CMS).
Member Services – A department within our plan responsible for answering your questions
about your membership, benefits, grievances, and appeals. See Chapter 2 for information about
how to contact Member Services.
Network provider – “Provider” is the general term we use for doctors, other health care
professionals, hospitals, and other health care facilities that are licensed or certified by Medicare

2010 Evidence of Coverage for [insert plan name]
Chapter 10: Definitions of important words

127

and by the State to provide health care services. We call them “network providers” when they
[have an agreement with our Plan to] accept our payment as payment in full, and in some cases
to coordinate as well as provide covered services to members of our Plan. Our Plan pays network
providers based on the agreements it has with the providers or if the providers agree to provide
you with plan-covered services. Network providers may also be referred to as “plan providers.”
[Include if applicable: Optional supplemental benefits – Non-Medicare-covered benefits that
can be purchased for an additional premium and are not included in your package of benefits. If
you choose to have optional supplemental benefits, you may have to pay an additional premium.
You must voluntarily elect Optional Supplemental Benefits in order to get them.]
Organization Determination - The Medicare Advantage organization has made an organization
determination when it, or one of its providers, makes a decision about MA services or payment
that you believe you should receive.
Original Medicare – (“Traditional Medicare” or “Fee-for-service” Medicare) Original Medicare
is the way many people get their health care coverage. It is the national pay-per-visit program
that lets you go to any doctor, hospital, or other health care provider that accepts Medicare. You
must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay
your share. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical
Insurance) and is available everywhere in the United States.
Out-of-network provider or out-of-network facility – A provider or facility with which we
have not arranged to coordinate or provide covered services to members of our Plan. Out-ofnetwork providers are providers that are not employed, owned, or operated by our Plan or are not
under contract to deliver covered services to you. Using out-of-network providers or facilities is
explained in this booklet in Chapter 3.
Part C – see “Medicare Advantage (MA) Plan”
Part D – The voluntary Medicare Prescription Drug Benefit Program. (For ease of reference, we
will refer to the prescription drug benefit program as Part D.)
Primary Care [insert as appropriate: Physician OR Provider] (PCP) – A health care
professional you select to coordinate your health care. Your PCP is responsible for providing or
authorizing covered services while you are a plan member. Chapter 3 tells more about PCPs.
Preferred Provider Organization Plan – A Preferred Provider Organization plan is an MA
plan that has a network of contracted providers that have agreed to treat plan members for a
specified payment amount. A PPO plan must cover all plan benefits whether they are received
from network or out-of-network providers. Member cost-sharing may be higher when plan
benefits are received from out-of-network providers.
Prior authorization – Approval in advance to get services or certain drugs that may or may not
be on our formulary. [Plans may delete applicable sentences if it does not require prior

2010 Evidence of Coverage for [insert plan name]
Chapter 10: Definitions of important words

128

authorization for any medical services.] Some in-network medical services are covered only if
your doctor or other network provider gets “prior authorization” from our plan. Covered services
that need prior authorization are marked in the Benefits Chart in Chapter 4.
Quality Improvement Organization (QIO) – Groups of practicing doctors and other health
care experts that are paid by the Federal government to check and improve the care given to
Medicare patients. They must review your complaints about the quality of care given by
Medicare Providers. See Chapter 2 for information about how to contact the QIO in your state
and Chapter 7 for information about making complaints to the QIO.
Rehabilitation services – These services include physical therapy, speech and language therapy,
and occupational therapy.
Service area – “Service area” is the geographic area approved by the Centers for Medicare &
Medicaid Services (CMS) within which an eligible individual may enroll in a certain plan.
Supplemental Security Income (SSI) – A monthly benefit paid by the Social Security
Administration to people with limited income and resources who are disabled, blind, or age 65
and older. SSI benefits are not the same as Social Security benefits.
Urgently needed care – Urgently needed care is a non-emergency situation when a you need
medical care right away because of an illness, injury, or condition that you did not expect or
anticipate, but your health is not in serious danger. Because of the situation, it isn’t reasonable
for you to obtain medical care from a network provider.

File Type	application/pdf
Author	CMS
File Modified	2009-06-17
File Created	2009-06-17