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

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

2015_MSA_ANOC_EOC_PRA_final

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⚠️ Notice: This form may be outdated.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

[MSA plan templates]
[2015 ANOC template]

[Insert 2015 plan name] ([insert plan type]) offered by [insert
MAO name]

Annual Notice of Changes for 2015
[Optional: insert beneficiary name]
[Optional: insert beneficiary address]
You are currently enrolled as a member of [insert 2014 plan name]. Next year, there will be
some changes to the plan’s costs and benefits. This booklet tells about the changes.
•

You have from October 15 until December 7 to make changes to your Medicare
coverage for next year.

Additional Resources
•

[Plans that meet the 5% alternative language threshold insert: This information is
available for free in other languages. Please contact our Member Services number at
[insert phone number] for additional information. (TTY users should call [insert TTY
number]). Hours are [insert days and hours of operation].] Member Services [plans that
meet the 5% threshold insert: also] has free language interpreter services available for
non-English speakers [plans that meet the 5% threshold delete the rest of this sentence]
(phone numbers are in [edit section number as needed] Section 8.1 of this booklet).

•

[Plans that meet the 5% threshold insert the paragraph above in all applicable
languages.]

•

[Plans must insert language about availability of alternate formats (e.g., Braille, large
print, audio tapes) as applicable.]

About [insert 2015 plan name]
•

[Insert Federal contracting statement.]

•

When this booklet says “we,” “us,” or “our,” it means [insert MAO name]. When it says
“plan” or “our plan,” it means [insert 2015 plan name].

[Insert as applicable: [insert Material ID] CMS Approved [MMDDYYYY] OR [insert Material
ID] File & Use [MMDDYYYY]]

[Insert 2015 plan name] Annual Notice of Changes for 2015

Think about Your Medicare Coverage for Next Year
Each fall, Medicare allows you to change your Medicare health and drug coverage during the
Annual Enrollment Period. It’s important to review your coverage now to make sure it will
meet your needs next year.

Important things to do:
 Check the changes to our benefits and costs to see if they affect you. Do the changes
affect the services you use? It is important to review benefit and cost changes to make
sure they will work for you next year. Look in Sections [insert section number] and
[insert section number] for information about benefit and cost changes for our plan.
 [Network plans insert: Check to see if your doctors and other providers will be in our
network next year. Are your doctors in our network? What about the hospitals or other
providers you use? Look in Section [insert section number] for information about our
Provider Directory.]
 Think about your overall health care costs. How much will you spend out-of-pocket
for the services and prescription drugs you use regularly? How much will you spend on
your premium? How do the total costs compare to other Medicare coverage options?
 Think about whether you are happy with our plan.

If you decide to stay with [insert 2015 plan name]:
If you want to stay with us next year, it’s easy - you don’t need to do anything. If you don’t
make a change by December 7, you will automatically stay enrolled in our plan.

If you decide to change plans:
If you decide other coverage will better meet your needs, you can switch plans between
October 15 and December 7. If you enroll in a new plan, your new coverage will begin on
January 1, 2015. Look in Section [edit section number as needed] 4.2 to learn more about
your choices.

[Insert 2015 plan name] Annual Notice of Changes for 2015

Summary of Important Costs for 2015
The table below compares the 2014 costs and 2015 costs for [insert 2015 plan name] in several
important areas. Please note this is only a summary of changes. It is important to read the
rest of this Annual Notice of Changes and review the [insert as applicable: attached OR
enclosed] Evidence of Coverage to see if other benefit or cost changes affect you.
Cost
Monthly plan premium

2014 (this year)

2015 (next year)

[insert 2014 premium
amount]

[insert 2015 premium
amount]

Yearly deposit

[insert 2014 deposit
amount]

[insert 2015 deposit
amount]

Yearly deductible

[insert 2014 deductible
amount]

[insert 2015 deductible
amount]

All Medicare-covered services

Until you meet your yearly
deductible, you pay up to
100% of the Medicareapproved amount.

After you meet your
deductible, you pay $0 for
Medicare-covered
services.

[Plans with no optional supplemental
benefits delete the following] See
Section [edit section number as
needed] 2.1 for details.

[Insert 2015 plan name] Annual Notice of Changes for 2015

Annual Notice of Changes for 2015
Table of Contents
[Update table below after completing edits]
Think about Your Medicare Coverage for Next Year .................................................. 1
Summary of Important Costs for 2015 ........................................................................ 2
SECTION 1

We Are Changing the Plan’s Name ................................................... 4

SECTION 1

Unless You Choose Another Plan, You Will Be
Automatically Enrolled in [insert 2015 plan name] in 2015............. 4

SECTION 2
Changes to Benefits and Costs for Next Year ................................. 5
Section 2.1 – Changes to the Annual Deposit........................................................................... 5
Section 2.2 – Changes to the Annual Deductible ..................................................................... 5
Section 2.3 – Changes to the Monthly Premium ...................................................................... 5
Section 2.4 – Changes to the Provider Network ....................................................................... 6
Section 2.5 – Changes to Benefits and Costs for Medical Services ......................................... 6
SECTION 3

Other Changes .................................................................................... 7

SECTION 4
Deciding Which Plan to Choose........................................................ 8
Section 4.1 – If you want to stay in [insert 2015 plan name] .................................................. 8
Section 4.2 – If you want to change plans ................................................................................ 8
SECTION 5

Deadline for Changing Plans ............................................................. 9

SECTION 6

Programs That Offer Free Counseling about Medicare .................. 9

SECTION 7

Programs That Help Pay for Prescription Drugs ........................... 10

SECTION 8
Questions?........................................................................................ 11
Section 8.1 – Getting Help from [insert 2015 plan name] ..................................................... 11
Section 8.2 – Getting Help from Medicare ............................................................................. 11

[Insert 2015 plan name] Annual Notice of Changes for 2015

[If Section 1 does not apply, plans should omit it and renumber remaining sections as needed.]

SECTION 1 We Are Changing the Plan’s Name
[Plans that are changing the plan name, as approved by CMS, include Section 1, using the
section title above and the following text:
On January 1, 2015, our plan name will change from [insert 2014 plan name] to [insert 2015
plan name].
[Insert language to inform members if they will receive new ID cards and how, as well as if the
name change will impact any other beneficiary communication.]]

SECTION 1 Unless You Choose Another Plan, You Will Be
Automatically Enrolled in [insert 2015 plan name] in 2015
[If the beneficiary is being enrolled into another plan due to a consolidation, include Section 1,
using the section title above and the text below. It is additionally expected that, as applicable
throughout the ANOC, every plan/sponsor that cross walks a member from a non-renewed plan
to a consolidated renewal plan will compare benefits and costs from that enrollee’s previous
plan to the consolidated plan.]
On January 1, 2015, [insert MAO name] will be combining [insert 2014 plan name] with one of
our plans, [insert 2015 plan name].
If you have not done anything to change your Medicare coverage by December 7, 2014, we
will automatically enroll you in our [insert 2015 plan name]. This means starting January 1,
2015, you will be getting your medical coverage through [insert 2015 plan name]. You have
choices about how to get your Medicare coverage. If you want to, you can change to a different
Medicare health plan. You can also switch to Original Medicare.
The information in this document tells you about the differences between your current benefits in
[insert 2014 plan name] and the benefits you will have on January 1, 2015 as a member of
[insert 2015 plan name].
[Plans that have previously notified members about the enrollment may insert the following
paragraph, editing as necessary: [insert MAO name] mailed you a letter called “[insert name
of letter].” This letter tells you that your membership in [insert 2014 plan name] will be
ending. It has important information about the different ways you can get your Medicare
coverage, including information about how to make a change in your coverage. If you have
any questions, or if you did not receive the letter, please call Member Services (phone
numbers are in Section [edit section number as needed] 8.1 of this booklet).]

[Insert 2015 plan name] Annual Notice of Changes for 2015

SECTION 2 Changes to Benefits and Costs for Next Year
Section 2.1 – Changes to the Annual Deposit
[If there is no change in Annual Deposit, plans may delete this section.]
Cost
Annual Deposit

2014 (this year)

2015 (next year)

[insert 2014 deposit
amount]

[insert 2015 deposit
amount]

Section 2.2 – Changes to the Annual Deductible
[If there is no change in Annual Deductible, plans may delete this section.]
Cost
Annual Deductible

2014 (this year)

2015 (next year)

[insert 2014 deductible
amount]

[insert 2015 deductible
amount]

Section 2.3 – Changes to the Monthly Premium
[Plans may add a row to this table to display changes in premiums for optional supplemental
benefits. If there is no change in premium for optional supplemental benefits, plans do not need
to insert a row.]
Cost
Monthly premium
(You must also continue to pay your
Medicare Part B premium.)

2014 (this year)

2015 (next year)

[insert 2014 premium
amount]

[insert 2015 premium
amount]

[Insert 2015 plan name] Annual Notice of Changes for 2015

Section 2.4 – Changes to the Provider Network
[Plans with no changes to their provider network delete this section.]
There are changes to our network of doctors and other providers for next year.
[Insert as applicable: We included a copy of our Provider Directory in the envelope with this
booklet. OR An updated Provider Directory is located on our website at [insert URL].] You may
also call Member Services for updated provider information or to ask us to mail you a Provider
Directory. Please review the 2015 Provider Directory to see if your providers are in our
network.
It is important that you know that we may make changes to the hospitals, doctors, and specialists
(providers) that are part of your plan during the year. There are a number of reasons why your
provider might leave your plan but if your doctor or specialist does leave your plan you have
certain rights and protections summarized below:
•

Even though our network of providers may change during the year, Medicare requires
that we furnish you with uninterrupted access to qualified doctors and specialists.

•

When possible we will provide you with at least 30 days’ notice that your provider is
leaving our plan so that you have time to select a new provider.

•

We will assist you in selecting a new qualified provider to continue managing your health
care needs.

•

If you are undergoing medical treatment you have the right to request, and we will work
with you to ensure, that the medically necessary treatment you are receiving is not
interrupted.

•

If you believe we have not furnished you with a qualified provider to replace your
previous provider or that your care is not being appropriately managed you have the right
to file an appeal of our decision.

•

If you find out your doctor or specialist is leaving your plan please contact us so we can
assist you in finding a new provider and managing your care.

Section 2.5 – Changes to Benefits and Costs for Medical Services
[If there are no changes in benefits or in cost-sharing, revise heading to “There are no changes to
your benefits or amounts you pay for medical services” and replace the rest of this section with:
Our benefits and what you pay for these covered medical services will be exactly the same in
2015 as they are in 2014.]
We are changing our coverage for certain medical services next year. The information below
describes these changes. For details about the coverage and costs for these services, see Chapter 4,
Medical Benefits Chart (what is covered and what you pay), in your 2015 Evidence of Coverage.

[Insert 2015 plan name] Annual Notice of Changes for 2015

[The table must include: (1) all new benefits that will be added or 2014 benefits that will end for
2015, including any new optional supplemental benefits (plans must indicate these optional
supplemental benefits are available for an extra premium); (2) new limitations or restrictions on
Part C benefits for CY 2015; and (3) all changes in cost-sharing for 2015 for covered medical
services, including any changes to service, category out-of-pocket maximums, and cost-sharing
for optional supplemental benefits (plans must indicate these optional supplemental benefits are
available for an extra premium).]
Cost
[Insert benefit name]

2014 (this year)
[For benefits that were not
covered in 2014 insert:
[insert benefit name] is not
covered.]
[For benefits with a copayment
insert:
You pay a $[insert 2014
copayment amount] copay
[insert language as needed to
accurately describe the benefit,
e.g., “per office visit”].]
[For benefits with a
coinsurance insert:
You pay [insert 2014
coinsurance percentage]% of
the total cost
[insert language as needed to
accurately describe the benefit,
(e.g., “for up to one visit per
year”)].]

[Insert benefit name]

[insert 2014 cost/coverage,
using format described above.]

2015 (next year)
[For benefits that are not
covered in 2015 insert: [insert
benefit name] is not covered.]
[For benefits with a copayment
insert:
You pay a $[insert 2015
copayment amount] copay
[insert language as needed to
accurately describe the benefit,
e.g., “per office visit”].]
[For benefits with a
coinsurance insert:
You pay [insert 2015
coinsurance percentage]% of
the total cost
[insert language as needed to
accurately describe the benefit,
(e.g., “for up to one visit per
year”)].]

[insert 2015 cost/coverage,
using format described above.]

SECTION 3 Other Changes
[This section is optional. Plans with administrative changes that impact members (e.g., changes
in options for paying the monthly premium, changes in prior authorization requirements, change
in contract or PBP number) may insert this section and describe the changes in the table below.
Plans that choose to omit this section should renumber the remaining sections as needed.]

[Insert 2015 plan name] Annual Notice of Changes for 2015

Process

2014 (this year)

2015 (next year)

[insert a description of the
administrative process/item
that is changing]

[insert 2014 administrative
description]

[insert 2015 administrative
description]

[insert a description of the
administrative process/item
that is changing]

[insert 2014 administrative
description]

[insert 2015 administrative
description]

SECTION 4 Deciding Which Plan to Choose
Section 4.1 – If you want to stay in [insert 2015 plan name]
To stay in our plan you don’t need to do anything. If you do not sign up for a different plan or
change to Original Medicare by December 7, you will automatically stay enrolled as a member
of our plan for 2015.

Section 4.2 – If you want to change plans
We hope to keep you as a member next year but if you want to change for 2015 follow these
steps:
Step 1: Learn about and compare your choices
•

You can join a different Medicare health plan,

•

-- OR-- You can change to Original Medicare. If you change to Original Medicare, you
will need to decide whether to join a Medicare drug plan and whether to buy a Medicare
supplement (Medigap) policy.

To learn more about Original Medicare and the different types of Medicare plans, read Medicare
& You 2015, call your State Health Insurance Assistance Program (see Section [edit section
number as needed] 6), or call Medicare (see Section [edit section number as needed] 8.2).
You can also find information about plans in your area by using the Medicare Plan Finder on the
Medicare website. Go to http://www.medicare.gov and click “Find health & drug plans.” Here,
you can find information about costs, coverage, and quality ratings for Medicare plans.
[Plans may choose to insert if applicable: As a reminder, [insert MAO name] offers other [insert
as applicable: Medicare health plans AND/OR and Medicare prescription drug plans. These other
plans may differ in coverage, monthly premiums, and cost-sharing amounts.]]

[Insert 2015 plan name] Annual Notice of Changes for 2015

Step 2: Change your coverage
•

To change to a different Medicare health plan, enroll in the new plan. You will
automatically be disenrolled from [insert 2015 plan name].

•

To change to Original Medicare with a prescription drug plan, enroll in the new drug
plan and disenroll from [insert 2015 plan name]. Enrolling in the new drug plan will not
automatically disenroll you from [insert 2015 plan name]. To disenroll from [insert 2015
plan name] you must send us a written request to disenroll. Contact Member Services if
you need more information on how to do this (phone numbers are in Section [edit section
number as needed] 8.1 of this booklet).

•

To change to Original Medicare without a prescription drug plan, you must send us a
written request to disenroll. Contact Member Services if you need more information on
how to do this (phone numbers are in Section [edit section number as needed] 8.1 of this
booklet).

SECTION 5 Deadline for Changing Plans
If you want to change to a different plan or to Original Medicare for next year, you can do it
from October 15 until December 7. The change will take effect on January 1, 2015.
Are there other times of the year to make a change?
In certain situations, changes are also allowed at other times of the year. For example, people
with Medicaid, those who get “Extra Help” paying for their drugs, and those who move out of
the service area are allowed to make a change at other times of the year. For more information,
see Chapter 8, Section 2.2 of the Evidence of Coverage.

SECTION 6 Programs That Offer Free Counseling 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.]
The State Health Insurance Assistance Program (SHIP) is a government program with trained
counselors in every state. In [insert state], the SHIP 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 plan choices and answer questions about switching plans. You can
call [insert state-specific SHIP name] at [insert SHIP phone number]. [Plans may insert the

[Insert 2015 plan name] Annual Notice of Changes for 2015

following: You can learn more about [insert state-specific SHIP name] by visiting their website
([insert SHIP website]).]

SECTION 7 Programs That Help Pay for Prescription Drugs
You may qualify for help paying for prescription drugs. [Plans in states without SPAPs, delete
the next sentence] There are two basic kinds of help:
•

“Extra Help” from Medicare. People with limited incomes may qualify for “Extra
Help” to pay for their prescription drug costs. If you qualify, Medicare could pay up to
75% or more of your drug costs including monthly prescription drug premiums, annual
deductibles, and coinsurance. Additionally, those who qualify will not have a coverage
gap or late enrollment penalty. Many people are eligible and don’t even know it. To see if
you qualify, call:
o 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24
hours a day/7 days a week;
o The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m.,
Monday through Friday. TTY users should call, 1-800-325-0778 (applications);
or
o Your State Medicaid Office (applications).

•

[Plans without an SPAP in their state(s), should delete this bullet.] [Organizations
offering plans in multiple states: Revise this bullet to use the generic name (“State
Pharmaceutical Assistance Program”) when necessary, and include a list of names for
all SPAPs in your service area.] Help from your state’s pharmaceutical assistance
program. [Insert state name] has a program called [insert state-specific SPAP name]
that helps people pay for prescription drugs based on their financial need, age, or medical
condition. To learn more about the program, check with your State Health Insurance
Assistance Program (SHIP) (the name and phone numbers for this organization are in
Section [edit section number as needed] 6 of this booklet).

•

[Plans without an ADAP in their state(s), should delete this bullet.] What if you have
coverage from an AIDS Drug Assistance Program (ADAP)? The AIDS Drug
Assistance Program (ADAP) helps ADAP-eligible individuals living with HIV/AIDS
have access to life-saving HIV medications. Medicare Part D prescription drugs that are
also covered by ADAP qualify for prescription cost-sharing assistance [insert Statespecific ADAP information]. Note: To be eligible for the ADAP operating in your State,
individuals must meet certain criteria, including proof of State residence and HIV status,
low income as defined by the State, and uninsured/under-insured status.
If you are currently enrolled in an ADAP, it can continue to provide you with Medicare
Part D prescription cost-sharing assistance for drugs on the ADAP formulary. In order to
be sure you continue receiving this assistance, please notify your local ADAP enrollment
worker of any changes in your Medicare Part D plan name or policy number. [Insert
State-specific ADAP contact information.]

[Insert 2015 plan name] Annual Notice of Changes for 2015

For information on eligibility criteria, covered drugs, or how to enroll in the program,
please call [insert State-specific ADAP contact information].

SECTION 8 Questions?
Section 8.1 – Getting Help from [insert 2015 plan name]
Questions? We’re here to help. Please call Member Services at [insert member services phone
number]. (TTY only, call [insert TTY number].) We are available for phone calls [insert days and
hours of operation]. [Insert if applicable: Calls to these numbers are free.]
Read your 2015 Evidence of Coverage (it has details about next year's benefits
and costs)
This Annual Notice of Changes gives you a summary of changes in your benefits and costs for
2015. For details, look in the 2015 Evidence of Coverage for [insert 2015 plan name]. The
Evidence of Coverage is the legal, detailed description of your plan benefits. It explains your
rights and the rules you need to follow to get covered services and prescription drugs. A copy of
the Evidence of Coverage was included in this envelope.
Visit our Website
You can also visit our website at [insert URL]. As a reminder, our website has the most up-todate information about our provider network (Provider Directory).

Section 8.2 – Getting Help from Medicare
To get information directly from Medicare:
Call 1-800-MEDICARE (1-800-633-4227)
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.
Visit the Medicare Website
You can visit the Medicare website (http://www.medicare.gov). It has information about cost,
coverage, and quality ratings to help you compare Medicare health plans. You can find
information about plans available in your area by using the Medicare Plan Finder on the
Medicare website. (To view the information about plans, go to http://www.medicare.gov and
click on “Compare Drug and Health Plans.”)

[Insert 2015 plan name] Annual Notice of Changes for 2015

Read Medicare & You 2015
You can read Medicare & You 2015 Handbook. Every year in the fall, 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), 24 hours a day, 7 days a week. TTY users should call
1-877-486-2048.

[2015 EOC template]

January 1 – December 31, 2015

Evidence of Coverage:
Your Medicare Health Benefits and Services as a Member of [insert 2015 plan
name]([insert plan type])
[Optional: insert beneficiary name]
[Optional: insert beneficiary address]
This booklet gives you the details about your Medicare health care coverage from January 1 –
December 31, 2015. It explains how to get coverage for the health care services you need.
This is an important legal document. Please keep it in a safe place.
This plan, [insert 2015 plan name], is offered by [insert MAO name]. (When this Evidence of
Coverage says “we,” “us,” or “our,” it means [insert MAO name]. When it says “plan” or “our
plan,” it means [insert 2015 plan name].)
[Insert Federal contracting statement.]
[Plans that meet the 5% alternative language threshold insert: This information is available for
free in other languages. Please contact our Member Services number at [insert phone number]
for additional information. (TTY users should call [insert TTY number].) Hours are [insert days
and hours of operation].] Member Services [plans that meet the 5% threshold insert: also] has
free language interpreter services available for non-English speakers [plans that meet the 5%
threshold delete the rest of this sentence] (phone numbers are printed on the back cover of this
booklet).
[Plans that meet the 5% threshold insert the paragraph above in all applicable languages.]
[Plans must insert language about availability of alternate formats (e.g., Braille, large print,
audio tapes) as applicable.]
[Remove terms as needed to reflect plan benefits] Benefits, premium, deductible, and/or deposit
may change on January 1, 2015.

[Insert as applicable: [insert Material ID] CMS Approved [MMDDYYYY]
OR [insert Material ID] File & Use [MMDDYYYY]]

2015 Evidence of Coverage for [insert 2015 plan name]
Table of Contents

2015 Evidence of Coverage
Table of Contents
This list of chapters and page numbers is your starting point. For more help in finding
information you need, go to the first page of a chapter. You will find a detailed list of topics at
the beginning of each chapter.
Chapter 1.

Getting started as a member ................................................................. 3
Explains 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 ........................................... 11
Tells you how to get in touch with our plan ([insert 2015 plan name]) and
with other organizations including Medicare, the State Health Insurance
Assistance Program (SHIP), 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 ........................ 24
Explains important things you need to know about getting your medical care
as a member of our plan.

Chapter 4.

Medical Benefits Chart (what is covered and what you pay) ............. 37
Gives the details about which types of medical care are covered and not
covered for you as a member of our plan. Explains how much you will pay
as your share of the cost for your covered medical care.

Chapter 5.

Asking us to pay our share of a bill you have received for
covered medical services ..................................................................... 67
Explains 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 ........................................................... 72
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.

2015 Evidence of Coverage for [insert 2015 plan name]
Table of Contents

Chapter 7.

What to do if you have a problem or complaint
(coverage decisions, appeals, complaints) ......................................... 84
Tells you step-by-step what to do if you are having problems or concerns as a
member of our plan.

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 ................................................. 125
Explains 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 ........................................................................................ 132
Includes notices about governing law and about nondiscrimination.

Chapter 10. Definitions of important words ........................................................... 134
Explains key terms used in this booklet.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 1.
Getting started as a member

Chapter 1.
SECTION 1
Section 1.1

Getting started as a member

Section 1.2
Section 1.3
Section 1.4
Section 1.5

Introduction ........................................................................................ 4
You are enrolled in [insert 2015 plan name], which is a Medicare
Medical Savings Account Plan........................................................................ 4
What is the Evidence of Coverage booklet about? .......................................... 4
What does this Chapter tell you? ..................................................................... 4
What if you are new to [insert 2015 plan name]? .......................................... 5
Legal information about the Evidence of Coverage ........................................ 5

SECTION 2
Section 2.1
Section 2.2
Section 2.3

What makes you eligible to be a plan member? .............................. 5
Your eligibility requirements .......................................................................... 5
What are Medicare Part A and Medicare Part B? ........................................... 6
Here is the plan service area for [insert 2015 plan name] .............................. 6

SECTION 3
Section 3.1
Section 3.2

What other materials will you get from us? ..................................... 7
Your plan membership card and [insert: bank or debit] card ......................... 7
The Provider Directory: Your guide to all providers in the plan’s network ... 8

SECTION 4
Section 4.1

Your monthly premium for [insert 2015 plan name] ........................ 9
How much is your plan premium? .................................................................. 9

SECTION 5
Section 5.1

Please keep your plan membership record up to date ................... 9
How to help make sure that we have accurate information about you ............ 9

SECTION 6
Section 6.1

We protect the privacy of your personal health information ........ 10
We make sure that your health information is protected ............................... 10

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 1.
Getting started as a member

SECTION 1

Introduction

Section 1.1

You are enrolled in [insert 2015 plan name], which is a
Medicare Medical Savings Account Plan

You are covered by Medicare, and you have chosen to get your Medicare health care through
our plan, [insert 2015 plan name].
There are different types of Medicare health plans. [Insert 2015 plan name] is a Medicare
Advantage Medical Savings Account (MSA) Plan. This plan does not include Part D
prescription drug coverage. Like all Medicare health plans, this Medicare MSA Plan is
approved by Medicare and run by a private company.
Section 1.2

What is the Evidence of Coverage booklet about?

This Evidence of Coverage booklet tells you how to get your Medicare medical care covered
through our plan. This booklet explains your rights and responsibilities, what is covered, and
what you pay as a member of the plan.
This plan, [insert 2015 plan name], is offered by [insert MAO name]. (When this Evidence of
Coverage says “we,” “us,” or “our,” it means [insert MAO name]. When it says “plan” or “our
plan,” it means [insert 2015 plan name].)
The word “coverage” and “covered services” refers to the medical care and services available
to you as a member of [insert 2015 plan name].
Section 1.3

What does this Chapter tell you?

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

What makes you eligible to be a plan member?

•

What is your plan’s service area?

•

What materials will you get from us?

•

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

•

How do you keep the information in your membership record up to date?

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 1.
Getting started as a member

Section 1.4

What if you are new to [insert 2015 plan name]?

If you are a new member, then it’s important for you to learn what the plan’s 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 (phone numbers are printed on the back cover of this booklet).
Section 1.5

Legal information about the 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 2015 plan name]
covers your care. Other parts of this contract include your enrollment form and any notices you
receive from us about changes to your coverage or conditions that 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 2015 plan name]
between January 1, 2015 and December 31, 2015.
Each calendar year, Medicare allows us to make changes to the plans that we offer. This means
we can change the costs and benefits of [insert 2015 plan name] after December 31, 2015. We
can also choose to stop offering the plan, or to offer it in a different service area, after December
31, 2015.
Medicare must approve our plan each year
Medicare (the Centers for Medicare & Medicaid Services) must approve [insert 2015 plan
name] each year. You can continue to get Medicare coverage as a member of our plan as long as
we choose to continue to offer the plan and Medicare renews its approval of the plan.

SECTION 2

What makes you eligible to be a plan member?

Section 2.1

Your eligibility requirements

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 have both Medicare Part A and Medicare Part B

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 1.
Getting started as a member

•

-- 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

•

– and – you are not currently getting hospice care (If you begin hospice care after you
enroll, you can remain a member of the plan.)

•

-- and – you don’t have the following types of additional health benefits:

o You don’t have other health coverage that would pay the MSA plan deductible,
including benefits under an employer or union group health plan;
o You don’t get benefits from the Department of Defense (TRICARE) or the
Department of Veterans Affairs;
o You are not a retired Federal government employee and part of the Federal
Employee Health Benefits Program (FEHBP); or
o You are not eligible for Medicaid (a joint Federal and state program that helps
with medical costs for some people with limited income and resources).
Section 2.2

What are Medicare Part A and Medicare Part B?

When you first signed up for Medicare, you received information about what services are
covered under Medicare Part A and Medicare Part B. Remember:
•

Medicare Part A generally helps cover services provided by hospitals (for inpatient
services, 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) and certain items (such as durable medical equipment and
supplies).

Section 2.3

Here is the plan service area for [insert 2015 plan name]

Although Medicare is a Federal program, [insert 2015 plan name] is available only to
individuals who live in our plan service area. To remain 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 continue to reside in the plan service area. The
service area is described [insert as appropriate: below OR in an appendix to this Evidence of
Coverage].
[Insert plan service area here or within an appendix. Plans may include references to territories
as appropriate. Use county name only if approved for entire county. For partially approved
counties, use county name plus zip code. Examples of the format for describing the service area
are provided below. If needed, plans may insert more than one row to describe their services
area:
Our service area includes all 50 states
Our service area includes these states: [insert states]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 1.
Getting started as a member

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]]
[Optional info: multi-state plans may include the following: We offer coverage in [insert as
applicable: several OR all] states [insert if applicable: and territories]. However, there may be
cost or other differences between the plans we offer in each state. If you move out of state [insert
if applicable: or territory] and into a state [insert if applicable: or territory] that is still within our
service area, you must call Member Services in order to update your information. [National
plans delete the rest of this paragraph] If you move into a state [insert if applicable: or territory]
outside of our service area, you cannot remain a member of our plan. Please call Member
Services to find out if we have a plan in your new state [insert if applicable: or territory].]
If you plan to move out of the service area, please contact Member Services (phone numbers are
printed on the back cover of this booklet). When you move, you will have a Special Enrollment
Period that will allow you to switch to Original Medicare or enroll in a Medicare health or drug
plan that is available in your new location.
It is also important that you call Social Security if you move or change your mailing address.
You can find phone numbers and contact information for Social Security in Chapter 2, Section 5.

SECTION 3

What other materials will you get from us?

Section 3.1

Your plan membership card and [insert: bank or debit] card

While you are a member of our plan, you must use your membership card for our plan whenever
you get any services covered by this plan. If you do not use your plan membership card when
receiving services, you will have to submit a claim to our plan. (For information about
submitting a claim, see Chapter 5, Asking us to pay our share of a bill you have received for
covered medical services.)
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
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 your [insert 2015 plan name] membership card while you are a
plan member, you may have to pay the full cost yourself.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 1.
Getting started as a member

You will also get a [insert: bank or debit] card to use to pay for qualified medical expenses with
money from your MSA savings account.
[Insert picture of front and back of bank/debit card. Mark it as a sample card (for example, by
superimposing the word “sample” on the image of the card.]
If your plan membership card or [insert: bank or debit] card is damaged, lost, or stolen, call
Member Services right away and we will send you a new card. (Phone numbers for Member
Services are printed on the back cover of this booklet.)
Section 3.2

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

[Note: Plans should delete or modify this section depending on whether they have network
providers.]
The Provider 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 with whom we have signed
contracts to deliver [insert if applicable: certain] covered services to members in our plan. These
providers have already agreed to see members of our plan. See Chapter 3, Section 1.2 for
information about the rules for getting your covered services under our plan.
You can still receive covered services from out-of-network providers who do not have a signed
contract with our plan, as long as the provider is in the United States and eligible to provide
services under Original Medicare.
Why do you need to know which providers are part of our network?
It is helpful to know which providers are part of our network because a network provider must
provide covered services to you while an out-of-network provider has the right to refuse to treat
you.
If you don’t have your copy of the Provider Directory, you can request a copy from Member
Services (phone numbers are printed on the back cover of this booklet). 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.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 1.
Getting started as a member

SECTION 4

Your monthly premium for [insert 2015 plan name]

Section 4.1

How much is your plan premium?

You do not pay a separate monthly plan premium for [insert 2015 plan name]. (You must
continue to pay your Medicare Part B premium.)
[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 (phone numbers are printed on the back cover of
this booklet). [If the plan describes optional supplemental benefits within Chapter 4, then the
plan must include the premium amounts for those benefits in this section.]
Many members are required to pay other Medicare premiums
Many members are required to pay other Medicare premiums. As explained in Section 2 above,
in order to be eligible for our plan, you must be entitled to Medicare Part A and enrolled in
Medicare Part B. For that reason, some plan members (those who aren’t eligible for premiumfree Part A) pay a premium for Medicare Part A. And most plan members pay a premium for
Medicare Part B. You must continue paying your Medicare Part B premium to remain a
member of the plan.
Your copy of Medicare & You 2015 gives information about these premiums in the section
called “2015 Medicare Costs.” This explains how the Medicare 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 2015 from the Medicare website
(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.

SECTION 5

Please keep your plan membership record up to date

Section 5.1

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].

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 1.
Getting started as a member

We use information in your membership record to provide your coverage. Because of this, it is
very important that you help us keep your information up to date.
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
If you receive care in an out-of-area hospital or emergency room
If your designated responsible party (such as a caregiver) changes
If you are participating in a clinical research study

If any of this information changes, please let us know by calling Member Services (phone
numbers are printed on the back cover of this booklet). [Plans that allow members to update this
information on-line may describe that option here.]
It is also important to contact Social Security if you move or change your mailing address. You
can find phone numbers and contact information for Social Security in Chapter 2, Section 5.
Read over the information we send you about any other insurance coverage you
have
[Plans collecting information by phone revise heading and section as needed to reflect process.]
Medicare requires that we collect information from you about any other medical or drug
insurance coverage that you have. That’s because other insurance coverage may make you
ineligible for 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 printed on the back cover of this booklet).

SECTION 6

We protect the privacy of your personal health
information

Section 6.1

We make sure that your health information is protected

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.
For more information about how we protect your personal health information, please go to
Chapter 6, Section 1.4 of this booklet.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

Chapter 2. Important phone numbers and resources
SECTION 1

[Insert 2015 plan name] contacts (how to contact us,
including how to reach Member Services at the plan) ........................ 12

SECTION 2

Medicare (how to get help and information directly from the
Federal Medicare program) ................................................................ 17

SECTION 3

State Health Insurance Assistance Program (free help,
information, and answers to your questions about Medicare) ............ 19

SECTION 4

Quality Improvement Organization (paid by Medicare to
check on the quality of care for people with Medicare) ....................... 20

SECTION 5

Social Security .................................................................................. 21

SECTION 6

Medicaid (a joint Federal and state program that helps with
medical costs for some people with limited income and
resources) .......................................................................................... 21

SECTION 7

How to contact the Railroad Retirement Board ............................. 23

SECTION 8

Do you have “group insurance” or other health insurance
from an employer? ........................................................................... 23

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

SECTION 1

[Insert 2015 plan name] contacts
(how to contact us, including how to reach Member
Services at the plan)

How to contact our plan’s Member Services
For assistance with claims, billing or member card questions, please call or write to [insert 2015
plan name] Member Services. We will be happy to help you.
Method

Member Services – Contact Information

CALL

[Insert phone number(s)]
Calls to this number are free. [Insert days and hours of operation,
including information on the use of alternative technologies.]
Member Services also has free language interpreter services available for
non-English speakers.

TTY

FAX

[Optional: insert fax number]

WRITE

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

WEBSITE

[Insert URL]

How to contact the [insert name of MSA trustee]
For questions about your MSA savings account and debit card, please contact [insert 2015 plan
name] Member Services and we can connect you to [insert name of MSA trustee]’s [insert name
of customer service department]. If you prefer, you may contact [insert name of trustee] directly
at the telephone number or address listed below.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

Method

[Insert name of MSA trustee] [insert name of customer service
department] – Contact Information

CALL

[Insert phone number(s)]
Calls to this number are [insert if applicable: not] free. [Insert days and
hours of operation, including information on the use of alternative
technologies.]

TTY

[Insert number]
[Insert if MSA trustee uses a direct TTY number: This number requires
special telephone equipment and is only for people who have difficulties
with hearing or speaking.]
Calls to this number are [insert if applicable: not] free. [Insert days and
hours of operation.]

FAX

[Insert fax number]

WRITE

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

WEBSITE

[Insert URL]

Note: [Insert name of MSA trustee] or the trustee that you have chosen can only assist you with
your MSA account and/or debit card, and are unable to assist you with any benefit issues. For
benefit issues, please contact our plan’s Member Services (phone numbers are printed on the
back cover of this booklet).
For more information about your MSA trustee services provided by [MSA trustee name], please
refer to your deposit agreement and disclosure statement.
[Note: If your plan uses the same contact information for the Part C issues indicated below, you
may combine the appropriate sections.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

How to contact us when you are asking for a coverage decision about your
medical care
A “coverage decision” is a decision we make about your benefits and coverage or about the
amount we will pay for your medical services. 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)).
You may call us if you have questions about our coverage decision process.
Method

Coverage Decisions for Medical Care – Contact Information

CALL

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

TTY

[Insert number]
[Insert if plan uses a direct TTY number: This number requires special
telephone equipment and is only for people who have difficulties with
hearing or speaking.]
Calls to this number are [insert if applicable: not] free. [Insert days and
hours of operation] [Note: If you have a different TTY number for
accepting expedited organization determinations, also include that
number here.]

FAX

[Optional: insert fax number] [Note: If you have a different fax number
for accepting expedited organization determinations, also include that
number here.]

WRITE

[Insert address] [Note: If you have a different address for accepting
expedited organization determinations, also include that address here.]

WEBSITE

[Optional: Insert URL]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

How to contact us when you are making an appeal about your medical care
An appeal is a formal way of asking us to review and change a coverage decision we have made.
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)).
Method

Appeals for Medical Care – Contact Information

CALL

TTY

FAX

[Optional: insert fax number] [Note: If you have a different fax number
for accepting expedited appeals, also include that number here.]

WRITE

[Insert address] [Note: If you have a different address for accepting
expedited appeals, also include that address here.]

WEBSITE

[Optional: Insert URL]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

How to contact us when you are making a complaint about your medical care
You can make a complaint about us or one of our network providers, including a complaint
about the quality of your care. This type of complaint does not involve coverage or payment
disputes. (If your problem is about the plan’s coverage or payment, you should look at the
section above about making an appeal.) 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)).
Method

Complaints about Medical Care – Contact Information

CALL

TTY

FAX

[Optional: insert fax number] [Note: If you have a different fax number
for accepting expedited grievances, also include that number here.]

WRITE

[Insert address] [Note: If you have a different address for accepting
expedited grievances, also include that address here.]

MEDICARE
WEBSITE

You can submit a complaint about [insert 2015 plan name] directly to
Medicare. To submit an online complaint to Medicare go to
www.medicare.gov/MedicareComplaintForm/home.aspx.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

Where to send a request asking 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 us for reimbursement or to pay
a bill you have received from a provider, see Chapter 5 (Asking us to pay our share of a bill you
have received for covered medical services).
Please note: If you send us a payment request and we deny any part of your request, you can
appeal our decision. See Chapter 7 (What to do if you have a problem or complaint (coverage
decisions, appeals, complaints)) for more information.
Method

Payment Requests – Contact Information

CALL

[Optional: Insert phone number and days and hours of operation]
[Note: You are required to accept payment requests in writing, and may
choose to also accept payment requests by phone.]
Calls to this number are [insert if applicable: not] free.

TTY

[Optional: Insert number]
[Insert if plan uses a direct TTY number: This number requires special
telephone equipment and is only for people who have difficulties with
hearing or speaking.]
Calls to this number are [insert if applicable: not] free. [Insert days and
hours of operation]

FAX

[Optional insert fax number]

WRITE

[Insert address]

WEBSITE

[Optional: insert URL]

SECTION 2

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 Medicare is the Centers for Medicare & Medicaid Services
(sometimes called “CMS”). This agency contracts with Medicare Advantage organizations
including us.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

Method

Medicare – Contact Information

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.
Calls to this number are free.

WEBSITE

http://www.medicare.gov
This is the official government website for Medicare. It gives you up-todate 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. You can also find Medicare contacts in your state.
The Medicare website also has detailed information about your Medicare
eligibility and enrollment options with the following tools:
•

Medicare Eligibility Tool: Provides Medicare eligibility status
information.

•

Medicare Plan Finder: Provides personalized information about
available Medicare prescription drug plans, Medicare health
plans, and Medigap (Medicare Supplement Insurance) policies in
your area. These tools provide an estimate of what your out-ofpocket costs might be in different Medicare plans.
You can also use the website to tell Medicare about any complaints you
have about [insert 2015 plan name]:
•

Tell Medicare about your complaint: You can submit a
complaint about [insert 2015 plan name] directly to Medicare. To
submit a complaint to Medicare, go to
www.medicare.gov/MedicareComplaintForm/home.aspx.
Medicare takes your complaints seriously and will use this
information to help improve the quality of the Medicare program.
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 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. (You
can call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a
day, 7 days a week. TTY users should call 1-877-486-2048.)

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

SECTION 3

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

[Organizations offering plans in multiple states: Revise the second and third paragraphs in this
section to use the generic name (“State Health Insurance Assistance Program” or “SHIP”), 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 information for 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. [Multiple-state plans inserting information in an exhibit, replace rest
of this paragraph with a sentence referencing the exhibit where members will find SHIP
information.] [Multiple-state plans inserting information in the EOC add: Here is a list of the
State Health Insurance Assistance Programs in each state we serve:] [Multiple-state plans
inserting information in the EOC use bullets for the following sentence, inserting separate
bullets for each state.] In [insert state], the SHIP 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.
Method

[Insert state-specific SHIP name] [If the SHIP’s name does not include
the name of the state, add: ([insert state name] SHIP)] –
Contact Information

CALL

[Insert phone number(s)]

TTY

[Insert number, if available. Or delete this row.]
[Insert if the SHIP uses a direct TTY number: This number requires
special telephone equipment and is only for people who have difficulties
with hearing or speaking.]

WRITE

[Insert address]

WEBSITE

[Insert URL]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

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 the second and third paragraphs of 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 for each state. [Multi-state plans inserting
information in an exhibit, replace rest of this paragraph with a sentence referencing the exhibit
where members will find QIO information.] [Multiple-state plans inserting information in the
EOC add: Here is a list of the Quality Improvement Organizations in each state we serve]
[Multi-state plans inserting information in the EOC use bullets for the following sentence,
inserting separate bullets for each state.] For [insert state], the Quality Improvement
Organization is called [insert state-specific QIO name].
[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) services are ending too soon.

Method

[Insert state-specific QIO name] [If the QIO’s name does not include
the name of the state, add: ([insert state name]’s Quality Improvement
Organization)] – Contact Information

CALL

[Insert phone number(s)]

TTY

[Insert number, if available. Or delete this row.]
[Insert if the QIO uses a direct TTY number: This number requires
special telephone equipment and is only for people who have difficulties
with hearing or speaking.]

WRITE

[Insert address]

WEBSITE

[Insert URL]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

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 meet 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. Social Security handles the enrollment
process for Medicare. To apply for Medicare, you can call Social Security or visit your local
Social Security office.
If you move or change your mailing address, it is important that you contact Social Security to
let them know.
Method

Social Security – Contact Information

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 Social Security’s 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

http://www.ssa.gov

SECTION 6

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.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

[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.]
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.
In addition, there are programs offered through Medicaid that help people with Medicare pay
their Medicare costs, such as their Medicare premiums. These “Medicare Savings Programs”
help people with limited income and resources save money each year:
•

Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B
premiums, and other cost-sharing (like deductibles, coinsurance, and copayments). (Some
people with QMB are also eligible for full Medicaid benefits (QMB+).)

•

Specified Low-Income Medicare Beneficiary (SLMB): Helps pay Part B premiums.
(Some people with SLMB are also eligible for full Medicaid benefits (SLMB+).)

•

Qualified Individual (QI): Helps pay Part B premiums.

•

Qualified Disabled & Working Individuals (QDWI): Helps pay Part A premiums.

To find out more about Medicaid and its programs, contact [insert state-specific Medicaid
agency]. (Please note that people with Medicaid coverage are not eligible for a Medicare
MSA plan.)
Method

[Insert state-specific Medicaid agency] [If the agency’s name does not
include the name of the state, add: ([insert state name]’s Medicaid
program)] – Contact Information

CALL

[Insert phone number(s)]

TTY

[Insert number, if available. Or delete this row.]
[Insert if the state Medicaid program uses a direct TTY number: This
number requires special telephone equipment and is only for people who
have difficulties with hearing or speaking.]

WRITE

[Insert address]

WEBSITE

[Insert URL]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

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.
If you receive your Medicare through the Railroad Retirement Board, it is important that you let
them know if you move or change your mailing address
Method

Railroad Retirement Board – Contact Information

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.

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

http://www.rrb.gov

SECTION 8

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

If you (or your spouse) get benefits from your (or your spouse’s) employer or retiree group as
part of this plan, you may 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. (Phone numbers for Member Services are printed
on the back cover of this booklet.) You may also call 1-800-MEDICARE (1-800-633-4227;
TTY: 1-877-486-2048) with questions related to your Medicare coverage under this plan.

2015 Evidence of Coverage for [insert 2015 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
Section 1.1
Section 1.2
Section 1.3
SECTION 2

Things to know about getting your medical care covered as
a member of our plan ....................................................................... 25
What are [insert if applicable: network] providers and covered services? ... 25
Basic rules for getting your medical care covered by the plan ..................... 25
Medical savings accounts and prescription drug coverage ........................... 26

Section 2.1

Using providers in the plan’s network to get your medical
care .................................................................................................... 26
How to get care from network providers ....................................................... 26

SECTION 3
Section 3.1
Section 3.2
Section 3.3

How to use the money in your medical savings account ............. 28
How does the medical savings account work? .............................................. 28
What types of expenses can the money in the account be used for? ............. 28
How can you keep track of your expenses? .................................................. 29

SECTION 4
Section 4.1

How to get covered services when you have an emergency ....... 30
Getting care if you have a medical emergency ............................................. 30

SECTION 5

What if you are billed directly for the full cost of your
covered services? ............................................................................ 31
You can ask us to pay our share of the cost of covered services .................. 31
If services are not covered by our plan, you must pay the full cost .............. 31

Section 5.1
Section 5.2
SECTION 6
Section 6.1
Section 6.2
SECTION 7
Section 7.1
Section 7.2

SECTION 8
Section 8.1

How are your medical services covered when you are in a
“clinical research study”? ............................................................... 32
What is a “clinical research study”? .............................................................. 32
When you participate in a clinical research study, who pays for what? ....... 33
Rules for getting care covered in a “religious non-medical
health care institution” .................................................................... 34
What is a religious non-medical health care institution? .............................. 34
What care from a religious non-medical health care institution is covered
by our plan? ................................................................................................... 34
Rules for ownership of durable medical equipment ..................... 35
Will you own the durable medical equipment after making a certain
number of payments under our plan? ............................................................ 35

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your medical services

SECTION 1

Things to know about getting your medical care
covered as a member of our plan

This chapter explains what you need to know about using the plan to get your medical care
covered. 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 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).
Section 1.1

What are [insert if applicable: 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 licensed by the state to
provide medical services and care. The term “providers” also includes hospitals and other
health care facilities.

•

[Insert if applicable: “Network providers” are the doctors and other health care
professionals, medical groups, hospitals, and other health care facilities that we have
signed contracts with to deliver covered services to members in our plan. These providers
have already agreed to see members of our plan. [Plans may delete the next sentence if it
is not applicable] 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.

Section 1.2

Basic rules for getting your medical care covered by the plan

As a Medicare health plan, [insert 2015 plan name] must cover all services covered by Original
Medicare and must follow Original Medicare’s coverage rules.
[Insert 2015 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).

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your medical services

•

The care you receive is considered medically necessary. “Medically necessary” means
that the services, supplies, or drugs are needed for the prevention, diagnosis, or treatment
of your medical condition and meet accepted standards of medical practice.

•

You receive your care from a provider in the United States who is eligible to provide
services under Original Medicare.
o You must show your plan membership card every time you visit a provider. A
provider can decide at each visit whether to accept our plan’s payment, and thus
whether to treat you.

[Insert 2015 plan name] does not require you to obtain approval in advance for medicallynecessary covered services. If you have any questions about whether we will pay for any medical
service that you are considering, you have the right to ask us whether we will cover it before you
get it.
Section 1.3

Medical savings accounts and prescription drug coverage

The law does not allow Medicare Advantage MSA plans to offer Medicare prescription drug
coverage. If you have a Medicare MSA plan, you can, however, also join a Medicare
prescription drug plan to get coverage. Any money that you use from your MSA on drug plan
deductibles or cost-sharing will not count towards your MSA plan deductible, but it will count
towards your drug plan’s out-of-pocket costs. If you are interested in enrolling in a Medicare
prescription drug plan or to see what plans are available in your area, visit
http://www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a
week. TTY users should call 1-877-486-2048. Generally, unless you are new to Medicare or
meet a special exception, you can only join during the Medicare fall open enrollment period,
which occurs from October 15 to December 7.
Note that even if you are not enrolled in a Medicare prescription drug plan, money spent from
your MSA savings account on prescription drugs are considered “qualified medical expenses”
for tax-reporting purposes and are not taxed. See the discussion on tax-reporting responsibilities
for members of MSAs in Chapter 6, Section 2.2 (Special tax-reporting responsibilities of
members of a Medicare MSA plan) for more information on qualified medical expenses.

SECTION 2

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

Section 2.1

How to get care from network providers

[Note: Plans may delete or modify this section.]
[Insert 2015 plan name] does not require you to use network providers. You can receive care
from any provider in the United States who is eligible to provide services under Original
Medicare.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your medical services

However, our plan has signed contracts with some providers to deliver covered services to
members in our plan. These providers are our network providers. [Indicate how members can get
the list of network providers.]
We have network providers for [insert as applicable: all services covered under Original
Medicare OR [indicate what category or categories of services for which network providers are
available].] You can still receive covered services from out-of-network providers (those who do
not have a signed contract with our plan), as long as the provider is in the United States and
eligible to provide services under Original Medicare.
[Plans should describe how members access network providers.]
What if a network provider leaves our plan?
[Plans should provide contact information for assistance.]
It is important that you know that we may make changes to the hospitals, doctors, and specialists
(providers) that are part of your plan during the year. There are a number of reasons why your
provider might leave your plan but if your doctor or specialist does leave your plan you have
certain rights and protections summarized below:
•

Even though our network of providers may change during the year, Medicare requires
that we furnish you with uninterrupted access to qualified doctors and specialists.

•

When possible we will provide you with at least 30 days’ notice that your provider is
leaving our plan so that you have time to select a new provider.

•

We will assist you in selecting a new qualified provider to continue managing your health
care needs.

•

If you are undergoing medical treatment you have the right to request, and we will work
with you to ensure, that the medically necessary treatment you are receiving is not
interrupted.

•

If you find out your doctor or specialist is leaving your plan please contact us so we can
assist you in finding a new provider and managing your care.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your medical services

SECTION 3

How to use the money in your medical savings
account

Section 3.1

How does the medical savings account work?

The plan makes the deposit into your medical savings account. Members receive their deposit at
the beginning of each calendar year. (Except for those who become entitled to Medicare in the
middle of the year and enroll in the plan at that time—these members receive their deposit in the
first month they are covered under the plan.) Only the plan can make deposits into your account;
you can’t deposit your own money.
You can use the money in your account to pay for medical expenses, but only Medicare Part A
and Part B covered services count toward your deductible. (For more information about what
types of expenses you can use the money for, see Section 3.2.)
•

If you use all of the money in your account and haven’t met your deductible, you must
pay for all of your medical expenses out-of-pocket until you reach your deductible.

•

If you don’t use all of the money in your account, the money left in your account at the
end of the year will remain in your account. If you stay with the plan next year, a new
deposit will be added to any leftover amount.

Once you get your initial deposit, you may move the deposit to a savings account that’s offered
through your own bank or financial institution. If you move your deposit, you will be responsible
for keeping track of your account balance.
How can I access the money in my account?
[Plans must describe how members can access the money in the account, (e.g., through
debit/credit cards, checks, etc.)]
Section 3.2

What types of expenses can the money in the account be used
for?

You can use the money in your account to pay for medical expenses, but only Medicare Part A
and Part B covered services count toward your deductible. You are responsible for handling
the money in your account. This includes deciding which types of expenses to pay with the
money in your account.
To avoid taxes and penalties, you must use the money in your account for Qualified Medical
Expenses. Qualified Medical Expenses are the same types of services and products that could be
deducted as medical expenses on your yearly income tax return. Again, only Medicare Part A
and B covered services count toward your deductible:

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your medical services

•

Some services, like doctors’ visits, lab tests, and hospital stays, are Qualified Medical
Expenses and are also covered by Medicare Part A or Part B. If you use the money in
your account for this type of expense, the money won’t be taxed and it will count to your
plan deductible.

•

Other services, like dental care, vision care, and Part D drugs, are Qualified Medical
Expenses, but aren’t covered by Medicare Part A or Part B. If you use the money in your
account for this type of expense, the money will not be taxed. However, these expenses
won’t count toward your deductible.

To avoid a tax on withdrawals from your account, you need to file Form 1040, U.S.
Individual Income Tax Return, and Form 8853 each year to report your Qualified Medical
Expenses. For a complete list of the services and products that count as Qualified Medical
Expenses and for other tax information, call the Internal Revenue Service at 1-800-TAX-FORM
(1-800-829-3676). Ask for a free copy of the IRS publication #502, “Medical and Dental
Expenses.” You can also request the IRS publication #969 to get more information about the tax
Form 8853, or visit www.irs.gov on the Web and select “Forms and Publications” to view or
print copies of the publications.
If you use the money in your account for non-qualified expenses, it will be taxed as part of
your income and will also be subject to an additional 50% tax penalty. Each year, you
should get a 1099-SA form from your MSA trustee that includes all of the withdrawals from
your account. You will need to show that you have had qualified medical expenses in at least this
amount, or you may have to pay taxes and additional penalties.
For more information about your tax reporting responsibilities, go to Chapter 6, Section 2.2.
Section 3.3

How can you keep track of your expenses?

You should keep any health care bills or receipts you get to make it easy to summarize your
account usage for tax purposes. It may be helpful to keep this information in one place.
If you keep your deposit in the trustee we have selected, you will get a monthly statement that
lists your account activity. You can also get information on whether your expenses count toward
your deductible.
If you move your deposit to a different trustee or financial institution, you are responsible for
tracking your own expenses.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your medical services

SECTION 4

How to get covered services when you have an
emergency

Section 4.1

Getting care if you have a medical emergency

What is a “medical emergency” and what should you do if you have one?
A “medical emergency” is when you believe that you have an injury or illness that requires
immediate medical attention to prevent a disability or death. 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
or hospital. Call for an ambulance if you need it. You do not need to get approval from
our plan.

•

[Plans add if applicable: 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 provide either the phone number and days and hours of operation 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 or its territories. 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.
[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. If you decide to get follow-up care from the provider treating you, then
you should tell them of your coverage as soon as possible, by showing them your plan
membership card. The plan will pay for all covered services, including non-emergency care, that

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your medical services

you get from any provider in the United States who is eligible to provide services under Original
Medicare.

SECTION 5

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

Section 5.1

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

Before you reach your deductible, you must pay the full cost of your covered services. Even
though you must pay for the services, you must submit a claim to our plan so that we can count
your expenses towards your deductible.
After you meet the deductible, we will pay for your covered services. If you receive a bill, you
should not pay it – you should submit the bill to us for payment. If you have already paid the bill,
you should submit a payment request to us so that we can pay you back.
If you have paid for your covered services, or if you have received a bill for the full cost of
covered medical services, go to Chapter 5 (Asking us to pay our share of a bill you have received
for covered medical services) for information about what to do.
Section 5.2

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

[Insert 2015 plan name] covers all medical services that are medically necessary, are listed in the
plan’s Medical Benefits Chart (this chart is in Chapter 4 of this booklet), and are obtained
consistent with plan rules. 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 7 (What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)) 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 to get
more information about how to do this (phone numbers are printed on the back cover of this
booklet).
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 Member Services when you want to know how much of your
benefit limit you have already used.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your medical services

SECTION 6

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

Section 6.1

What is a “clinical research study”?

A clinical research study (also called a “clinical trial”) 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 [plans that conduct
or cover clinical trials that are not approved by Medicare insert: or our plan] first needs to
approve the research study. If you participate in a study that Medicare [plans that conduct or
cover clinical trials that are not approved by Medicare insert: or our plan] has not approved, you
will be responsible for paying all costs for your participation in the study.
Once Medicare [plans that conduct or cover clinical trials that are not approved by Medicare
insert: or our plan] 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.
If you participate in a Medicare-approved study, Original Medicare pays most of the costs 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 us [plans that do not use PCPs may delete the rest of this sentence] or your PCP.
[Plans with no network: omit the following sentence] 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.

We can tell you what services you will get from clinical research study providers
instead of from our plan.

If you plan on participating in a clinical research study, contact Member Services (phone
numbers are printed on the back cover of this booklet).

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your medical services

Section 6.2

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

Once you join a Medicare-approved clinical research study, you are covered for routine items
and services you receive as part of the study, including:
•

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.

Original Medicare pays most of the cost of the covered services you receive as part of the study.
After Medicare has paid its share of the cost for these services, our plan will also pay for part of
the costs. We will pay the difference between the cost-sharing in Original Medicare and your
cost-sharing as a member of our plan. This means you will pay the same amount for the services
you receive as part of the study as you would if you received these services from our plan.
Therefore, if you have met your yearly deductible, you will pay nothing for the items and
services you receive as part of the study.
In order for us to pay for our share of the costs, you will need to submit a request for payment.
With your request, you will need to send us a copy of your Medicare Summary Notices or other
documentation that shows what services you received as part of the study and how much you
owe. Please see Chapter 5 for more information about submitting requests for payment.
When you are part of a clinical research study, neither Medicare nor our plan will 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 medical condition would normally require only one CT scan.

Do you want to know more?
You can get more information about joining a clinical research study by reading the publication
“Medicare and Clinical Research Studies” on the Medicare website (http://www.medicare.gov).
You can also call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY
users should call 1-877-486-2048.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your medical services

SECTION 7

Rules for getting care covered in a “religious nonmedical health care institution”

Section 7.1

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, we will instead
provide coverage for care in a religious non-medical health care institution. You may choose to
pursue medical care at any time for any reason. This benefit is provided only for Part A inpatient
services (non-medical health care services). Medicare will only pay for non-medical health care
services provided by religious non-medical health care institutions.
Section 7.2

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

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 your condition would ordinarily meet the conditions for
coverage of services 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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your medical services

[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.]

SECTION 8

Rules for ownership of durable medical equipment

Section 8.1

Will you own the durable medical equipment after making a
certain number of payments under our plan?

[Plans that furnish ownership of certain DME items must modify this section to explain the
conditions under which and, when specified, DME can be owned by the member.]
Durable medical equipment includes items such as oxygen equipment and supplies, wheelchairs,
walkers, and hospital beds ordered by a provider for use in the home. Certain items, such as
prosthetics, are always owned by the member. In this section, we discuss other types of durable
medical equipment that must be rented.
[This first sentence must be inserted even if your plan sometimes allows ownership for items
other than prosthetics] In Original Medicare, people who rent certain types of durable medical
equipment own the equipment after paying copayments for the item for 13 months. As a member
of [insert 2015 plan name], however, you [insert if the plan sometimes allows ownership:
usually] will not acquire ownership of rented durable medical equipment items no matter how
many copayments you make for the item while a member of our plan. [Insert if the plan
sometimes allows ownership for items other than prosthetics: Under certain limited
circumstances we will transfer ownership of the durable medical equipment item. Call Member
Services (phone numbers are printed on the back cover of this booklet) to find out about the
requirements you must meet and the documentation you need to provide.] [Insert if your plan
never transfers ownership (except as noted above, for example, for prosthetics): Even if you
made up to 12 consecutive payments for the durable medical equipment item under Original
Medicare before you joined our plan, you will not acquire ownership no matter how many
copayments you make for the item while a member of our plan.]
What happens to payments you have made for durable medical equipment if you
switch to Original Medicare?
If you switch to Original Medicare after being a member of our plan: If you did not acquire
ownership of the durable medical equipment item while in our plan, you will have to make 13
new consecutive payments for the item while in Original Medicare in order to acquire ownership
of the item. Your previous payments while in our plan do not count toward these 13 consecutive
payments.
If you made payments for the durable medical equipment item under Original Medicare before
you joined our plan, these previous Original Medicare payments also do not count toward the 13
consecutive payments. You will have to make 13 consecutive payments for the item under

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your medical services

Original Medicare in order to acquire ownership. There are no exceptions to this case when you
return to Original Medicare.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Chapter 4. Medical Benefits Chart (what is covered and what you
pay)
SECTION 1
Section 1.1
Section 1.2
Section 1.3
SECTION 2

Understanding your out-of-pocket costs for covered
services ............................................................................................. 38
Types of out-of-pocket costs you may pay for your covered services .......... 38
Your yearly deposit and yearly plan deductible ............................................ 38
Our plan does not allow providers to “balance bill” you .............................. 39

Section 2.1
Section 2.2

Use the Medical Benefits Chart to find out what is covered
for you and how much you will pay ................................................ 39
Your medical benefits and costs as a member of the plan ............................ 39
Extra “optional supplemental” benefits you can buy .................................... 64

SECTION 3
Section 3.1

What benefits are not covered by the plan? .................................. 64
Benefits we do not cover (exclusions) .......................................................... 64

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

SECTION 1

Understanding your out-of-pocket costs for covered
services

This chapter focuses on your covered services and what you pay for your medical benefits. It
includes a Medical Benefits Chart that lists your covered services and shows how much you will
pay for each covered service as a member of [insert 2015 plan name]. Later in this chapter, you
can find information about medical services that are not covered. [Insert if applicable: It also
explains limits on certain services.] [If applicable, you may mention other places where benefits,
limitations, and exclusions are described, such as optional additional benefits, or addenda.]
Section 1.1

Types of out-of-pocket costs you may pay for your covered
services

The only type of out-of-pocket costs you have in our plan is your yearly deductible. The
“deductible” is the amount you must pay for medical services before our plan begins to pay its
share. (Section 1.2 tells you more about your yearly deductible.)
Section 1.2

Your yearly deposit and yearly plan deductible

[Plans must disclose their deposit and deductible. If there is a network, any differential costsharing must be disclosed.]
Our plan makes a yearly deposit into your medical savings account. The plan also has a
deductible that you must meet before the plan pays for your covered services. The table below
provides more information about the deposit and deductible.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

[Plans may edit table heading as needed] Deposit and Deductible Amounts
Deposit/Deductible

Amount

Yearly Deposit

[insert 2015 deposit amount]
This is how much the plan
deposits in your medical
savings account.

This is the amount that Medicare deposits into your medical
savings account. You can use the money in your account to
pay your health care costs, including health care costs that
aren’t covered by Medicare. (But only funds used to pay for
Medicare Part A and Part B services will count toward your
yearly deductible.)
Yearly Deductible
This is the amount you have to pay out-of-pocket for
covered Medicare Part A and Part B services before the
plan will pay for your covered services.
Until you have paid the deductible amount, you must pay the
full cost of your covered services. Once you meet your
deductible, the plan will pay 100% of the costs for covered
Part A and Part B services for the rest of the calendar year.

Section 1.3

[insert 2015 deductible
amount]
This is how much you must
pay for your Part A and Part B
services before the plan will
pay for your covered services.

Our plan does not allow providers to “balance bill” you

As a member of [insert 2015 plan name], an important protection for you is that, once you meet
your deductible, we don’t allow providers to bill you for any additional charges for services
covered under our plan (called “balance billing”). This protection applies even if we pay less
than the provider charges for a service and even if there is a dispute and we don’t pay certain
provider charges.

SECTION 2

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

Section 2.1

Your medical benefits and costs as a member of the plan

The Medical Benefits Chart on the following pages lists the services [insert 2015 plan name]
covers and what you pay out-of-pocket for each service. The services listed in the Medical
Benefits Chart are covered only when the following coverage requirements are met:
•

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

•

Your services (including medical care, services, supplies, and equipment) must be
medically necessary. “Medically necessary” means that the services, supplies, or drugs

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

are needed for the prevention, diagnosis, or treatment of your medical condition and meet
accepted standards of medical practice.
•

No prior authorization, prior notification, or referral is required as a condition of
coverage when medically necessary, plan-covered services are provided to our members.

Other important things to know about our coverage:
•

Like all Medicare health plans, we cover everything that Original Medicare covers. For
some of these benefits, you pay more in our plan than you would in Original Medicare.
For others, you pay less. (If you want to know more about the coverage and costs of
Original Medicare, look in your Medicare & You 2015 Handbook. View it online at
http://www.medicare.gov or ask for a copy by calling 1-800-MEDICARE (1-800-6334227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.)

•

Sometimes, Medicare adds coverage under Original Medicare for new services during the
year. If Medicare adds coverage for any services during 2015, either Medicare or our plan
will cover those services.

You will see this apple next to the preventive services in the benefits chart.
[Instructions on completing benefits chart:
•

When preparing this Benefits Chart, please refer to the instructions for completing the
standardized/combined ANOC/EOC.

•

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.

•

Optional supplemental benefits are not permitted within the chart; plans that would like
to include information about optional supplemental benefits within the EOC may
describe these benefits within Section 2.2.

•

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 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. Additional benefits
should be placed alphabetically in the chart.

•

Plans must describe any restrictive policies, limitations, or monetary limits that might
impact a beneficiary’s access to services within the chart.

•

Plans may add references to the list of exclusions in Sec. 3.1 as appropriate.

•

Plans must make it clear for enrollees (in the sections where enrollee cost sharing is
shown) whether their hospital copays or coinsurance apply on the date of admission
and/or on the date of discharge]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Medical Benefits Chart

Services that are covered for you

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” preventive visit.
[Also list any additional benefits offered.]

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) or if
authorized by the plan.
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.

Annual wellness visit

If you’ve had Part B for longer than 12 months, you can get an annual
wellness visit to develop or update a personalized prevention plan
based on your current health and risk factors. This is covered once
every 12 months.
Note: Your first annual wellness visit can’t take place within 12
months of your “Welcome to Medicare” preventive visit. However,
you don’t need to have had a “Welcome to Medicare” visit to be
covered for annual wellness visits after you’ve had Part B for 12
months.

What you must pay
when you get these
services

There is no
coinsurance,
copayment, or
deductible for
beneficiaries eligible
for this preventive
screening.
Until you meet your
yearly deductible,
you pay up to 100%
of the Medicareapproved amount.
After you meet your
deductible, you pay
$0 for Medicarecovered services.

There is no
coinsurance,
copayment, or
deductible for the
annual wellness visit.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

What you must pay
when you get these
services

There is no
coinsurance,
For qualified individuals (generally, this means people at risk of losing copayment, or
bone mass or at risk of osteoporosis), the following services are
deductible for
covered every 24 months or more frequently if medically necessary:
Medicare-covered
procedures to identify bone mass, detect bone loss, or determine bone bone mass
quality, including a physician’s interpretation of the results.
measurement.
[Also list any additional benefits offered.]
Bone mass measurement

Breast cancer screening (mammograms)

Covered services include:
•
•
•

One baseline mammogram between the ages of 35 and 39
One screening mammogram every 12 months for women age 40
and older
Clinical breast exams once every 24 months

There is no
coinsurance,
copayment, or
deductible for
covered screening
mammograms.

[Also list any additional benefits offered.]
Cardiac rehabilitation services

Comprehensive programs of cardiac rehabilitation services that
include exercise, education, and counseling are covered for members
who meet certain conditions with a doctor’s [insert as appropriate:
referral OR order]. The plan also covers intensive cardiac
rehabilitation programs that are typically more rigorous or more
intense than cardiac rehabilitation programs.
[Also list any additional benefits offered.]

Cardiovascular disease risk reduction visit (therapy for
cardiovascular disease)

We cover 1 visit per year with your primary care doctor to help lower
your risk for cardiovascular disease. During this visit, your doctor may
discuss aspirin use (if appropriate), check your blood pressure, and
give you tips to make sure you’re eating well.
[Also list any additional benefits offered.]

Until you meet your
yearly deductible,
you pay up to 100%
of the Medicareapproved amount.
After you meet your
deductible, you pay
$0 for Medicarecovered services.
There is no
coinsurance,
copayment, or
deductible for the
intensive behavioral
therapy
cardiovascular
disease preventive
benefit.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

Cardiovascular disease testing

Blood tests for the detection of cardiovascular disease (or
abnormalities associated with an elevated risk of cardiovascular
disease) once every 5 years (60 months).
[Also list any additional benefits offered.]

Cervical and vaginal cancer screening

Covered services include:
•
•

For all women: Pap tests and pelvic 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

What you must pay
when you get these
services

There is no
coinsurance,
copayment, or
deductible for
cardiovascular
disease testing that is
covered once every 5
years..
There is no
coinsurance,
copayment, or
deductible for
Medicare-covered
preventive Pap and
pelvic exams.

[Also list any additional benefits offered.]
Chiropractic services

Covered services include:
•

We cover only manual manipulation of the spine to correct
subluxation

[Also list any additional benefits offered.]

Until you meet your
yearly deductible,
you pay up to 100%
of the Medicareapproved amount.
After you meet your
deductible, you pay
$0 for Medicarecovered services.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

Colorectal cancer 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:
•

What you must pay
when you get these
services

There is no
coinsurance,
copayment, or
deductible for a
Medicare-covered
colorectal cancer
screening exam.

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 (120 months), but not
within 48 months of a screening sigmoidoscopy

[Also list any additional benefits offered.]

Depression screening
We cover 1 screening for depression per year. The screening must be
done in a primary care setting that can provide follow-up treatment
and referrals.
[Also list any additional benefits offered.]

Diabetes screening

We cover this screening (includes fasting glucose tests) if you have
any of the following risk factors: high blood pressure (hypertension),
history of abnormal cholesterol and triglyceride levels (dyslipidemia),
obesity, or a history of high blood sugar (glucose). Tests may also be
covered if you meet other requirements, like being overweight and
having a family history of diabetes.
Based on the results of these tests, you may be eligible for up to two
diabetes screenings every 12 months.
[Also list any additional benefits offered.]

There is no
coinsurance,
copayment, or
deductible for an
annual depression
screening visit.
There is no
coinsurance,
copayment, or
deductible for the
Medicare covered
diabetes screening
tests.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

Diabetes self-management training, diabetic services and
supplies

[Plans may put items listed under a single bullet in separate bullets if
the plan charges different copays. However, all items in the bullets
must be included.] For all people who have diabetes (insulin and noninsulin users). Covered services include:
•

•

Supplies to monitor your blood glucose: Blood glucose monitor,
blood glucose test strips, lancet devices and lancets, and glucosecontrol solutions for checking the accuracy of test strips and
monitors
For people with diabetes who have severe diabetic foot disease:
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). Coverage includes fitting.
Diabetes self-management training is covered under certain
conditions

[Also list any additional benefits offered.]

What you must pay
when you get these
services

There is no
coinsurance,
copayment, or
deductible for
beneficiaries eligible
for the diabetes selfmanagement training
preventive benefit.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Durable medical equipment and related supplies

(For a definition of “durable medical equipment,” see Chapter 10 of
this booklet.)
Covered items include, but are not limited to: wheelchairs, crutches,
hospital bed, IV infusion pump, oxygen equipment, nebulizer, and
walker.
[Plans that do not limit the DME brands and manufacturers that you
will cover insert: We cover all medically necessary durable medical
equipment covered by Original Medicare. If our supplier in your area
does not carry a particular brand or manufacturer, you may ask them if
they can special order it for you.]
[Plans that limit the DME brands and manufacturers that you will
cover insert: With this Evidence of Coverage document, we sent you
[insert 2015 plan name]’s list of durable medical equipment. The list
tells you the brands and manufacturers of durable medical equipment
that we will cover. This most recent list of brands, manufacturers, and
suppliers is also available on our website at [insert URL].
Generally, [insert 2015 plan name] covers any durable medical
equipment covered by Original Medicare from the brands and
manufacturers on this list. We will not cover other brands and
manufacturers unless your doctor or other provider tells us that the
brand is appropriate for your medical needs. However, if you are new
to [insert 2015 plan name] and are using a brand of durable medical
equipment that is not on our list, we will continue to cover this brand
for you for up to 90 days. During this time, you should talk with your
doctor to decide what brand is medically appropriate for you after this
90-day period. (If you disagree with your doctor, you can ask him or
her to refer you for a second opinion.)
If you (or your provider) don’t agree with the plan’s coverage
decision, you or your provider may file an appeal. You can also file an
appeal if you don’t agree with your provider’s decision about what
product or brand is appropriate for your medical condition. (For more
information about appeals, see Chapter 7, What to do if you have a
problem or complaint (coverage decisions, appeals, complaints).)]

What you must pay
when you get these
services

Until you meet your
yearly deductible,
you pay up to 100%
of the Medicareapproved amount.
After you meet your
deductible, you pay
$0 for Medicarecovered services.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Emergency care

Emergency care refers to services that are:
•
•

Furnished by a provider qualified to furnish emergency services,
and
Needed to evaluate or stabilize an emergency medical condition.

A medical emergency is when you, or any other prudent layperson
with an average knowledge of health and medicine, believe that you
have medical symptoms that require immediate medical attention to
prevent loss of life, loss of a limb, or loss of function of a limb. The
medical symptoms may be an illness, injury, severe pain, or a medical
condition that is quickly getting worse.
Hearing services

Diagnostic hearing and balance evaluations performed by your [insert
as applicable: PCP OR provider] to determine if you need medical
treatment are covered as outpatient care when furnished by a
physician, audiologist, or other qualified provider.

HIV screening

For people who ask for an HIV screening test or who are at increased
risk for HIV infection, we cover:
•

One screening exam every 12 months

For women who are pregnant, we cover:
•

Up to three screening exams during a pregnancy

[Also list any additional benefits offered.]

What you must pay
when you get these
services

Until you meet your
yearly deductible,
you pay up to 100%
of the Medicareapproved amount.
After you meet your
deductible, you pay
$0 for Medicarecovered services.

Until you meet your
yearly deductible,
you pay up to 100%
of the Medicareapproved amount.
After you meet your
deductible, you pay
$0 for Medicarecovered services.
There is no
coinsurance,
copayment, or
deductible for
beneficiaries eligible
for Medicare-covered
preventive HIV
screening.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Home health agency care

[If needed, plans may revise language related to the doctor
certification requirement.] Prior to receiving home health services, a
doctor must certify that you need home health services and will order
home health services to be provided by a home health agency. You
must be homebound, which means leaving home is a major effort.
Covered services include, but are not limited to:
•

•
•
•

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

What you must pay
when you get these
services

Until you meet your
yearly deductible,
you pay up to 100%
of the Medicareapproved amount.
After you meet your
deductible, you pay
$0 for Medicarecovered services.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

What you must pay
when you get these
services

Hospice care

You may receive care from any Medicare-certified hospice program.
Your hospice doctor can be a network provider or an out-of-network
provider.
Covered services include:
•
•
•

Drugs for symptom control and pain relief
Short-term respite care
Home care

For hospice services and for services that are covered by Medicare
Part A or B and are related to your terminal condition: Original
Medicare (rather than our plan) will pay for your hospice services and
any Part A and Part B services related to your terminal condition.
While you are in the hospice program, your hospice provider will bill
Original Medicare for the services that Original Medicare pays for.
For services that are not related to your terminal condition: You pay
your plan cost-sharing amount for these services.
Note: If you need non-hospice care (care that is not related to your
terminal condition), you should contact us to arrange the services.
Getting your non-hospice care through our network providers will
lower your share of the costs for the services.
[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.]

Immunizations

Covered Medicare Part B 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
getting Hepatitis B
Other vaccines if you are at risk and they meet Medicare Part B
coverage rules

When you enroll in a
Medicare-certified
hospice program,
your hospice services
and your Part A and
Part B services
related to your
terminal condition
are paid for by
Original Medicare,
not [insert 2015 plan
name].
[Include information
about cost-sharing
for hospice
consultation services
if applicable.]

There is no
coinsurance,
copayment, or
deductible for the
pneumonia,
influenza, and
Hepatitis B vaccines.

[Also list any additional benefits offered.]
Inpatient hospital care

Includes inpatient acute, inpatient rehabilitation, and other types of

Until you meet your
yearly deductible,

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

inpatient hospital services. Inpatient hospital care starts the day you
are formally admitted to the hospital with a doctor’s order. The day
before you are discharged is your last inpatient day.
[List days covered and any restrictions that apply.] Covered services
include but are not limited to:
•
•
•
•
•
•
•
•
•
•
•
•
•

•

Semi-private room (or a private room if medically necessary)
Meals including special diets
Regular nursing services
Costs of special care units (such as intensive care or coronary care
units)
Drugs and medications
Lab tests
X-rays and other radiology services
Necessary surgical and medical supplies
Use of appliances, such as wheelchairs
Operating and recovery room costs
Physical, occupational, and speech language therapy
Inpatient substance abuse services
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. [Plans with a provider
network insert: Transplant providers may be local or outside of the
service area. If local transplant providers are willing to accept the
Original Medicare rate, then you can choose to obtain your
transplant services locally or at a distant location offered by the
plan. If [insert 2015 plan name] provides transplant services at a
distant location (outside of the service area) and you chose to
obtain transplants at this distant location, 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 must either pay the costs for the first 3
pints of blood you get in a calendar year or have the blood donated
by you or someone else. All other components of blood are
covered beginning with the first pint used. [Modify as necessary if

What you must pay
when you get these
services

you pay up to 100%
of the Medicareapproved amount.
After you meet your
deductible, you pay
$0 for Medicarecovered services.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

•

What you must pay
when you get these
services

the plan begins coverage with an earlier pint.]
Physician services

Note: To be an inpatient, your provider must write an order to admit
you formally as an inpatient of the hospital. Even if you stay in the
hospital overnight, you might still be considered an “outpatient.” If
you are not sure if you are an inpatient or an outpatient, you should
ask the hospital staff.
You can also find more information in a Medicare fact sheet called
“Are You a Hospital Inpatient or Outpatient? If You Have Medicare –
Ask!” This fact sheet is available on the Web at
http://www.medicare.gov/Publications/Pubs/pdf/11435.pdf or by
calling 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877486-2048. You can call these numbers for free, 24 hours a day, 7 days
a week.
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 inpatient mental health services
provided in a psychiatric unit of a general hospital.]

Until you meet your
yearly deductible,
you pay up to 100%
of the Medicareapproved amount.
After you meet your
deductible, you pay
$0 for Medicarecovered services.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Inpatient services covered during a non-covered inpatient stay

[Plans with no day limitations on a plan’s hospital or SNF coverage
may modify or delete this row as appropriate.]
If you have exhausted your inpatient benefits or if the inpatient stay is
not reasonable and necessary, we will not cover your inpatient stay.
However, in some cases, we will cover certain services you receive
while you are in the hospital or the skilled nursing facility (SNF).
Covered services include, but are not limited to:
•
•
•
•
•
•

•

Physician services
Diagnostic tests (like 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

What you must pay
when you get these
services

Until you meet your
yearly deductible,
you pay up to 100%
of the Medicareapproved amount.
After you meet your
deductible, you pay
$0 for Medicarecovered services.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

Medical nutrition therapy

This benefit is for people with diabetes, renal (kidney) disease (but not
on dialysis), or after a kidney transplant when [insert as appropriate:
referred OR ordered] by your doctor.
We cover 3 hours of one-on-one counseling services during your first
year that you receive medical nutrition therapy services under
Medicare (this includes our plan, any other Medicare Advantage plan,
or Original Medicare), and 2 hours each year after that. If your
condition, treatment, or diagnosis changes, you may be able to receive
more hours of treatment with a physician’s [insert as appropriate:
referral OR order]. A physician must prescribe these services and
renew their [insert as appropriate: referral OR order] yearly if your
treatment is needed into the next calendar year.
[Also list any additional benefits offered.]

What you must pay
when you get these
services

There is no
coinsurance,
copayment, or
deductible for
beneficiaries eligible
for Medicare-covered
medical nutrition
therapy services.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

What you must pay
when you get these
services

Medicare Part B prescription drugs

Until you meet your
These drugs are covered under Part B of Original Medicare. Members yearly deductible,
of our plan receive coverage for these drugs through our plan. Covered you pay up to 100%
drugs include:
of the Medicareapproved amount.
• Drugs that usually aren’t self-administered by the patient and are
injected or infused while you are getting physician, hospital
After you meet your
outpatient, or ambulatory surgical center services
deductible, you pay
$0 for Medicare• Drugs you take using durable medical equipment (such as
covered services.
nebulizers) that were 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
erythropoiesis-stimulating agents [plans may delete any of the
following drugs that are not covered under the plan] (such as
Epogen, Procrit, Epoetin Alfa, Aranesp, or Darbepoetin
Alfa)
• Intravenous Immune Globulin for the home treatment of primary
immune deficiency diseases

Obesity screening and therapy to promote sustained weight
loss

If you have a body mass index of 30 or more, we cover intensive
counseling to help you lose weight. This counseling is covered if you
get it in a primary care setting, where it can be coordinated with your
comprehensive prevention plan. Talk to your primary care doctor or
practitioner to find out more.
[Also list any additional benefits offered.]

There is no
coinsurance,
copayment, or
deductible for
preventive obesity
screening and
therapy.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Outpatient diagnostic tests and therapeutic services and
supplies

Covered services include, but are not limited to:
•
•

•
•
•
•

•

X-rays
Radiation (radium and isotope) therapy including technician
materials and supplies [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
Splints, casts and other devices used to reduce fractures and
dislocations
Laboratory tests
Blood. Coverage begins with the fourth pint of blood that you need
– you must either pay the costs for the first 3 pints of blood you
get in a calendar year or have the blood donated by you or
someone else. [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.]

What you must pay
when you get these
services

Until you meet your
yearly deductible,
you pay up to 100%
of the Medicareapproved amount.
After you meet your
deductible, you pay
$0 for Medicarecovered services.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Outpatient hospital services

We cover medically-necessary services you get in the outpatient
department of a hospital for diagnosis or treatment of an illness or
injury.
Covered services include, but are not limited to:
•
•
•
•
•
•
•

Services in an emergency department or outpatient clinic, such as
observation services or outpatient surgery
Laboratory and diagnostic tests billed by the hospital
Mental health care, including care in a partial-hospitalization
program, if a doctor certifies that inpatient treatment would be
required without it
X-rays and other radiology services billed by the hospital
Medical supplies such as splints and casts
Certain screenings and preventive services
Certain drugs and biologicals that you can’t give yourself

What you must pay
when you get these
services

Until you meet your
yearly deductible,
you pay up to 100%
of the Medicareapproved amount.
After you meet your
deductible, you pay
$0 for Medicarecovered services.

Note: Unless the provider has written an order to admit you as an
inpatient to the hospital, you are an outpatient. Even if you stay in the
hospital overnight, you might still be considered an “outpatient.” If
you are not sure if you are an outpatient, you should ask the hospital
staff.
You can also find more information in a Medicare fact sheet called
“Are You a Hospital Inpatient or Outpatient? If You Have Medicare –
Ask!” This fact sheet is available on the Web at
http://www.medicare.gov/Publications/Pubs/pdf/11435.pdf or by
calling 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877486-2048. You can call these numbers for free, 24 hours a day, 7 days
a week.
[Also list any additional benefits offered.]
Outpatient mental health care

Covered services include:
Mental health services provided by a state-licensed psychiatrist or
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.
[Also list any additional benefits offered.]

Until you meet your
yearly deductible,
you pay up to 100%
of the Medicareapproved amount.
After you meet your
deductible, you pay
$0 for Medicarecovered services.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Outpatient rehabilitation services

Covered services include: physical therapy, occupational therapy, and
speech language therapy.
Outpatient rehabilitation services are provided in various outpatient
settings, such as hospital outpatient departments, independent therapist
offices, and Comprehensive Outpatient Rehabilitation Facilities
(CORFs).

Outpatient substance abuse services

[Describe the plan’s benefits for outpatient substance abuse services.]

Outpatient surgery, including services provided at hospital
outpatient facilities and ambulatory surgical centers

Note: If you are having surgery in a hospital facility, you should
check with your provider about whether you will be an inpatient or
outpatient. Unless the provider writes an order to admit you as an
inpatient to the hospital, you are an outpatient. Even if you stay in the
hospital overnight, you might still be considered an “outpatient.”

What you must pay
when you get these
services

Until you meet your
yearly deductible,
you pay up to 100%
of the Medicareapproved amount.
After you meet your
deductible, you pay
$0 for Medicarecovered services.
Until you meet your
yearly deductible,
you pay up to 100%
of the Medicareapproved amount.
After you meet your
deductible, you pay
$0 for Medicarecovered services.
Until you meet your
yearly deductible,
you pay up to 100%
of the Medicareapproved amount.
After you meet your
deductible, you pay
$0 for Medicarecovered services.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Partial hospitalization services

“Partial hospitalization” is a structured program of active psychiatric
treatment provided in a hospital outpatient setting or by a community
mental health center, that is more intense than the care received in
your doctor’s or therapist’s office and is an alternative to inpatient
hospitalization.
[Network plans that do not have an in-network community mental
health center may add: Note: Because there are no community mental
health centers in our network, we cover partial hospitalization only in
a hospital outpatient setting.]
Physician/Practitioner services, including doctor’s office visits

Covered services include:
•
•
•
•

•
•

Medically-necessary medical care or surgery services furnished in
a physician’s office, certified ambulatory surgical center, hospital
outpatient department, or any other location
Consultation, diagnosis, and treatment by a specialist
Basic hearing and balance exams performed by your [insert as
applicable: PCP OR specialist], if your doctor orders it to see if
you need medical treatment
[Insert if the plan has a service area and providers/locations that
qualify for telehealth services under the Medicare requirements:
Certain telehealth services including consultation, diagnosis, and
treatment by a physician or practitioner for patients in certain rural
areas or other locations approved by Medicare]
Second opinion [Insert if appropriate: by another network
provider] prior to surgery
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 physician)

[Also list any additional benefits offered.]

What you must pay
when you get these
services

Until you meet your
yearly deductible,
you pay up to 100%
of the Medicareapproved amount.
After you meet your
deductible, you pay
$0 for Medicarecovered services.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

Podiatry services
Covered services include:
•
•

Diagnosis and the medical or surgical treatment of injuries and
diseases of the feet (such as hammer toe or heel spurs).
Routine foot care for members with certain medical conditions
affecting the lower limbs

[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:
•
•

Digital rectal exam
Prostate Specific Antigen (PSA) test

What you must pay
when you get these
services

[Also list any additional benefits offered.]
Prosthetic devices and related supplies
Devices (other than dental) that replace all or part of 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.

Until you meet your
yearly deductible,
you pay up to 100%
of the Medicareapproved amount.
After you meet your
deductible, you pay
$0 for Medicarecovered services.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Pulmonary rehabilitation services

Comprehensive programs of pulmonary rehabilitation are covered for
members who have moderate to very severe chronic obstructive
pulmonary disease (COPD) and [insert as appropriate: a referral OR
an order] for pulmonary rehabilitation from the doctor treating the
chronic respiratory disease.
[Also list any additional benefits offered.]

Screening and counseling to reduce alcohol misuse

We cover one alcohol misuse screening for adults with Medicare
(including pregnant women) who misuse alcohol, but aren’t alcohol
dependent.
If you screen positive for alcohol misuse, you can get up to 4 brief
face-to-face counseling sessions per year (if you’re competent and
alert during counseling) provided by a qualified primary care doctor or
practitioner in a primary care setting.
[Also list any additional benefits offered.]

Screening for sexually transmitted infections (STIs) and
counseling to prevent STIs

We cover sexually transmitted infection (STI) screenings for
chlamydia, gonorrhea, syphilis, and Hepatitis B. These screenings are
covered for pregnant women and for certain people who are at
increased risk for an STI when the tests are ordered by a primary care
provider. We cover these tests once every 12 months or at certain
times during pregnancy.
We also cover up to 2 individual 20 to 30 minute, face-to-face highintensity behavioral counseling sessions each year for sexually active
adults at increased risk for STIs. We will only cover these counseling
sessions as a preventive service if they are provided by a primary care
provider and take place in a primary care setting, such as a doctor’s
office.
[Also list any additional benefits offered.]

What you must pay
when you get these
services

Until you meet your
yearly deductible,
you pay up to 100%
of the Medicareapproved amount.
After you meet your
deductible, you pay
$0 for Medicarecovered services.
There is no
coinsurance,
copayment, or
deductible for the
Medicare-covered
screening and
counseling to reduce
alcohol misuse
preventive benefit.

There is no
coinsurance,
copayment, or
deductible for the
Medicare-covered
screening for STIs
and counseling to
prevent STIs
preventive benefit.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Services to treat kidney disease and conditions

Covered services include:
•

•
•
•
•
•

Kidney disease education services to teach kidney care and help
members make informed decisions about their care. For members
with stage IV chronic kidney disease when referred by their
doctor, we cover up to six sessions of kidney disease education
services per lifetime.
Outpatient dialysis treatments
Inpatient dialysis treatments (if you are admitted as an inpatient 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
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)

Certain drugs for dialysis are covered under your Medicare Part B
drug benefit. For information about coverage for Part B Drugs, please
go to the section below, “Medicare Part B prescription drugs.”

What you must pay
when you get these
services

Until you meet your
yearly deductible,
you pay up to 100%
of the Medicareapproved amount.
After you meet your
deductible, you pay
$0 for Medicarecovered services.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Skilled nursing facility (SNF) care

(For a definition of “skilled nursing facility care,” see Chapter 10 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 but are
not limited to:
•
•
•
•
•
•

•
•
•
•
•

Semiprivate room (or a private room if medically necessary)
Meals, including special diets
Skilled 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.)
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 must either pay the costs for the first 3
pints of blood you get in a calendar year or have the blood donated
by you or someone else. 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.]
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
Physician/Practitioner services

[Insert if applicable: Generally, you will get your SNF care from
network facilities. However, under certain conditions listed below,
you may be able to pay in-network cost-sharing for a facility that isn’t
a network 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.]

What you must pay
when you get these
services

Until you meet your
yearly deductible,
you pay up to 100%
of the Medicareapproved amount.
After you meet your
deductible, you pay
$0 for Medicarecovered services.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

Smoking and tobacco use cessation (counseling to stop
smoking or tobacco use)

If you use tobacco, but do not have signs or symptoms of tobaccorelated disease: We cover two counseling quit attempts within a 12month period as a preventive service with no cost to you. Each
counseling attempt includes up to four face-to-face visits.
If you use tobacco and have been diagnosed with a tobacco-related
disease or are taking medicine that may be affected by tobacco: We
cover cessation counseling services. We cover two counseling quit
attempts within a 12-month period, however, you will pay the
applicable inpatient or outpatient cost-sharing. Each counseling
attempt includes up to four face-to-face visits.
[Also list any additional benefits offered.]

What you must pay
when you get these
services

There is no
coinsurance,
copayment, or
deductible for the
Medicare-covered
smoking and tobacco
use cessation
preventive benefits.

Until you meet your
yearly deductible,
Covered services include:
you pay up to 100%
of the Medicare• Outpatient physician services for the diagnosis and treatment of
diseases and injuries of the eye, including treatment for age-related approved amount.
macular degeneration. Original Medicare doesn’t cover routine eye After you meet your
exams (eye refractions) for eyeglasses/contacts.
deductible, you pay
• For people who are at high risk of glaucoma, such as people with a $0 for Medicarecovered services.
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.
(If you have two separate cataract operations, you cannot reserve
the benefit after the first surgery and purchase two eyeglasses after
the second surgery.) Corrective lenses/frames (and replacements)
needed after a cataract removal without a lens implant.
Vision care

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

What you must pay
when you get these
services

There is no
coinsurance,
The plan covers the one-time “Welcome to Medicare” preventive visit. copayment, or
The visit includes a review of your health, as well as education and
deductible for the
counseling about the preventive services you need (including certain
“Welcome to
screenings and shots), and referrals for other care if needed.
Medicare” preventive
visit.
Important: We cover the “Welcome to Medicare” preventive visit
only within the first 12 months you have Medicare Part B. When you
make your appointment, let your doctor’s office know you would like
to schedule your “Welcome to Medicare” preventive visit.
“Welcome to Medicare” Preventive Visit

Section 2.2

Extra “optional supplemental” benefits you can buy

[Include this section if you offer optional supplemental benefits in the plan and describe benefits
below. 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
optional supplemental benefits described in [insert as applicable: this section OR the enclosed
insert] 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).]

SECTION 3

What benefits are not covered by the plan?

Section 3.1

Benefits we do not cover (exclusions)

This section tells you what kinds of benefits are “excluded.” Excluded means that the plan
doesn’t cover these benefits.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

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
excluded 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 7, 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:
[Plans may add parenthetical references to the Benefits Chart for descriptions of covered
services/items as appropriate.]
•

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

•

Experimental medical and surgical procedures, equipment and medications, unless
covered by Original Medicare or under a Medicare-approved clinical research study or by
our plan. (See Chapter 3, Section 5 for more information on clinical research studies.)
Experimental procedures and items are those items and procedures determined by our
plan and Original Medicare to not be generally accepted by the medical community.

•

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 is care provided in a nursing home, hospice, or other facility setting when
you do not require skilled medical care or skilled nursing care. Custodial care is personal
care that does not require the continuing attention of trained medical or paramedical
personnel, such as care that helps you with activities of daily living, such as bathing or
dressing.

•

Homemaker services include 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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

•

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, unless 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, fillings or dentures. However, non-routine dental
care required to treat illness or injury may be covered as inpatient or outpatient care.

•

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.

•

Routine hearing exams, hearing aids, or exams to fit hearing aids.

•

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

•

Outpatient prescription drugs.

•

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.

The plan will not cover the excluded services listed above. Even if you receive the services at an
emergency facility, the excluded services are still not covered
.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 5.
Asking us to pay our share of a bill you have received for covered medical
services

Chapter 5.

Asking us to pay our share of a bill you have received for
covered medical services

SECTION 1

Situations in which you should send us a bill you have
received for your covered services ................................................ 68
If you pay for your covered services, or if you receive a bill, you should
send the bill to us ........................................................................................... 68

Section 1.1

SECTION 2
Section 2.1
SECTION 3
Section 3.1
Section 3.2

How to ask us to pay a bill or to count your expenses
toward your deductible .................................................................... 69
How and where to send us your request ........................................................ 69
We will consider your request and say yes or no.......................... 70
We check to see whether we should cover the service and how much we
owe ................................................................................................................ 70
If we tell you that we will not pay for all or part of the medical care, you
can make an appeal........................................................................................ 70

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 5.
Asking us to pay our share of a bill you have received for covered medical
services

SECTION 1

Situations in which you should send us a bill you
have received for your covered services

Section 1.1

If you pay for your covered services, or if you receive a bill,
you should send the bill to us

[Plans may modify this section as needed] When you receive care, you should ask the provider
to bill the plan for your services. We will look at the bill and decide whether the services should
be covered and will let you know who should pay for them.
If you receive a bill for an item or services, you should send the bill to us. Here are some
situations in which you should send a bill to us:
1. When you get a bill for an item or services even though you haven’t yet met
your deductible
Before you reach your deductible, you must pay the full cost of your covered services. Even
though you are responsible for the cost, you should still send the bill to us before you pay it
so we can make sure you have been billed the correct amount. After you pay a bill, you
should send us a copy of the bill and your payment so that we can count your expenses
towards your deductible.
2. When you get a bill for an item or services after you have met your deductible
After you meet the deductible, the plan will pay for your covered services. If you receive a
bill, you should not pay it – you should submit it with a payment request to us. We will look
at the bill and decide whether the services should be covered. If we decide they should be
covered and you have not paid the bill, we will pay the provider directly. If we decide they
should be covered and you have already paid the bill, we will mail you your reimbursement.
•

After you meet your deductible, you don’t have to pay anything for services covered by
our plan. We do not allow providers to add additional separate charges, called “balance
billing.” This protection applies even if we pay the provider less than the provider
charges for a service and even if there is a dispute and we don’t pay certain provider
charges. For more information about “balance billing,” go to Chapter 4, Section 1.3.

3. If you are retroactively enrolled in our plan.
Sometimes a person’s enrollment in the plan is retroactive. (Retroactive means that the first
day of their enrollment has already passed. The enrollment date may even have occurred last
year.)

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 5.
Asking us to pay our share of a bill you have received for covered medical
services

If you were retroactively enrolled in our plan and you paid out-of-pocket for any of your
covered services after your enrollment date, you can ask us to pay you back for our share of
the costs. You will need to submit paperwork for us to handle the reimbursement.
•

Please call Member Services for additional information about how to ask us to pay you
back and deadlines for making your request. (Phone numbers for Member Services are
printed on the back cover of this booklet.)

[Plans should insert additional circumstances under which they will accept a paper claim
from an enrollee.]
When you send us a request for payment (or a request to count your expenses toward
your deductible), we are making a “coverage decision.” This means that if we deny
your request, you can appeal our decision. Chapter 7 of this booklet (What to do if you
have a problem or complaint (coverage decisions, appeals, complaints)) has
information about how to make an appeal.

SECTION 2

How to ask us to pay a bill or to count your expenses
toward your deductible

Section 2.1

How and where to send us your request

When you want us to pay a bill or to pay you back for a bill you have already paid, send us a
request for payment, along with your bill and documentation of any payment you have made.
Even if you haven’t met your deductible for the year, you should still send us your bill and
documentation of your payment so we can count your expenses toward your deductible. 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 will help us process the information faster.

•

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

Mail your request for payment together with any bills or receipts to us at this address:
[insert address]
[If the plan allows enrollees to submit oral payment requests, insert the following language:
You may also call our plan to request payment. For details, go to Chapter 2, Section 1 and look
for the section called, [plans may edit section title as necessary] Where to send a request that
asks us to pay for our share of the cost for medical care you have received.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 5.
Asking us to pay our share of a bill you have received for covered medical
services

[Insert if applicable: You must submit your claim to us within [insert timeframe] of the date
you received the service, item, or drug.]
Contact Member Services if you have any questions (phone numbers are printed on the back
cover of this booklet). If you don’t know what you should have paid, 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.

SECTION 3

We will consider your request and say yes or no

Section 3.1

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 make a coverage decision.
•

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.
o If you have met your yearly deductible and have already paid for the service, we
will mail your reimbursement to you.
o If you have met your yearly deductible and have not paid for the service yet, we
will mail the payment directly to the provider.
o If you haven’t met your deductible yet, we will tell you how much you should be
billed by the provider.

•

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 and your rights to
appeal that decision.

Section 3.2

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

If you think we have made a mistake in turning down your request or you don’t agree with the
amount we are paying, 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 or when we
turned down your request to count medical expenses you have paid (either with money from
your MSA account or out-of-pocket) toward the plan deductible. You may also appeal if you
believe that, prior to meeting the deductible, you have been required to pay more for a service
than the Medicare allowable amount.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 5.
Asking us to pay our share of a bill you have received for covered medical
services

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 formal process with detailed 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 Section
5.3 to learn how to make an appeal about getting paid back for a medical service.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 6.
Your rights and responsibilities

Chapter 6. Your rights and responsibilities
SECTION 1
Section 1.1

Section 1.2
Section 1.3
Section 1.4
Section 1.5
Section 1.6
Section 1.7
Section 1.8
Section 1.9
SECTION 2
Section 2.1
Section 2.2

Our plan must honor your rights as a member of the plan .......... 73
[Plans may edit the section heading and content to reflect the types of
alternate format materials available to plan members. Plans may not edit
references to language except as noted below.] We must provide
information in a way that works for you (in languages other than English,
in Braille, in large print, or other alternate formats, etc.) .............................. 73
We must treat you with fairness and respect at all times .............................. 73
We must ensure that you get timely access to your covered services ........... 74
We must protect the privacy of your personal health information ................ 74
We must give you information about the plan [insert if applicable: its
network of providers,] and your covered services ........................................ 75
We must support your right to make decisions about your care ................... 76
You have the right to make complaints and to ask us to reconsider
decisions we have made ................................................................................ 78
What can you do if you believe you are being treated unfairly or your
rights are not being respected? ...................................................................... 79
How to get more information about your rights ............................................ 79
You have some responsibilities as a member of the plan ............ 80
What are your responsibilities? ..................................................................... 80
Special tax-reporting responsibilities of members of a Medicare MSA
plan ................................................................................................................ 81

[Note: Plans may add to or revise this chapter as needed to reflect NCQA-required language.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 6.
Your rights and responsibilities

SECTION 1

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

Section 1.1

[Plans may edit the section heading and content to reflect the
types of alternate format materials available to plan members.
Plans may not edit references to language except as noted
below.] We must provide information in a way that works for
you (in languages other than English, in Braille, in large print,
or other alternate formats, etc.)

[Plans must insert a translation of Section 1.1 in all languages that meet the language
threshold.]
To get information from us in a way that works for you, please call Member Services (phone
numbers are printed on the back cover of this booklet).
Our plan has people and free language interpreter services available to answer questions from
non-English speaking members. [If applicable, plans may insert information about the
availability of written materials in languages other than English.] We can also give you
information in Braille, in large print, or other alternate formats if you need it. If you are eligible
for Medicare because of a 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 a disability, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours
a day, 7 days a week, and tell them that you want to file a complaint. TTY users call 1-877-4862048.
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, ethnicity, national origin, religion, gender, age, mental or
physical disability, health status, claims experience, medical history, genetic information,
evidence of insurability, or geographic location within the service area.
If you want more information or have concerns about discrimination or unfair treatment, please
call the Department of Health and Human Services’ Office for Civil Rights 1-800-368-1019
(TTY 1-800-537-7697) 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 printed on the back cover of this booklet). If you have a complaint, such as a
problem with wheelchair access, Member Services can help.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 6.
Your rights and responsibilities

Section 1.3

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

You may seek care from any provider in the United States who is eligible to provide services
under Original Medicare. You should always (except possibly in emergencies) show the provider
your MSA plan membership card.
You do not need a referral or prior approval from the plan to receive covered services.
[Insert if applicable: 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 Member Services to
learn which doctors are accepting new patients (phone numbers are printed on the back cover of
this booklet).]
[Insert if plan has a network: 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.
[Insert if applicable: 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, Section 9 of this booklet tells what you can do. (If we have denied coverage for your
medical care and you don’t agree with our decision, Chapter 7, Section 4 tells what you can do.)
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 enrolled 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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 6.
Your rights and responsibilities

•

There are certain exceptions that do not require us to get your written permission first.
These exceptions are allowed or required by law.
o For example, we are required to release health information to government
agencies that are checking on quality of care.
o Because you are a member of our plan through Medicare, we are required to give
Medicare your health information. If Medicare releases your information for
research or other uses, this will be done according to Federal statutes and
regulations.

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 work
with your health care provider to 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 printed on the back cover of this booklet).
[Note: Plans may insert custom privacy practices.]
Section 1.5

We must give you information about the plan [insert if
applicable: its network of providers,] and your covered
services

[Plans may edit the section to reflect the types of alternate format materials available to plan
members and/or language primarily spoken in the plan service area.]
As a member of [insert 2015 plan name], 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 printed on the back 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 number of appeals made by
members and the plan’s performance ratings, including how it has been rated by plan
members and how it compares to other Medicare health plans.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 6.
Your rights and responsibilities

•

[Insert if applicable: 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 [insert name of provider
directory].
o For more detailed information about our providers, you can call Member Services
(phone numbers are printed on the back cover of this booklet) or visit our website
at [insert URL].]

•

Information about your coverage and the rules you must follow when 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 printed on the back 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. [Insert if plan has a network:
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. You can ask us to change the decision by making an appeal. 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
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.

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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 6.
Your rights and responsibilities

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:
•

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 coverage for 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
[Note: Plans that would like to provide members with state-specific information about advanced
directives, including contact information for the appropriate state agency, may do so.]
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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 6.
Your rights and responsibilities

[Insert if applicable: You can also contact Member Services to ask for the forms (phone
numbers are printed on the back 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.
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 did not follow
the instructions in it, you may file a complaint with [insert appropriate state-specific agency
(such as the State Department of Health)]. [Plans also have the option to include a separate
exhibit to list the state-specific agency in all states, or in all states in which the plan is filed, and
then should revise the previous sentence to make reference to that exhibit.]
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 printed on the back cover of this booklet).

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 6.
Your rights and responsibilities

Section 1.8

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

If it is about discrimination, call the Office for Civil Rights
If you believe 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 Department of Health and Human Services’ Office for Civil Rights at 1-800-368-1019
or TTY 1-800-537-7697, or call your local Office for Civil Rights.
Is it about something else?
If you believe 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 printed on the back cover of this
booklet).

•

You can call the State Health Insurance Assistance Program. For details about this
organization and how to contact it, go to Chapter 2, Section 3.

•

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

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 call Member Services (phone numbers are printed on the back cover of this
booklet).

•

You can call the State Health Insurance Assistance Program. For details about this
organization and how to contact it, go to Chapter 2, Section 3.

•

You can contact Medicare.
o You can visit the Medicare website to read or download the publication “Your
Medicare Rights & Protections.” (The publication is available at:
http://www.medicare.gov/Pubs/pdf/11534.pdf)
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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 6.
Your rights and responsibilities

SECTION 2

You have some responsibilities as a member of the
plan

Section 2.1

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 printed on the back 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 in addition to our plan, or separate
prescription drug coverage, you are required to tell us. Please call Member Services
to let us know (phone numbers are printed on the back cover of this booklet).

•

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, learn as
much as you are able to about your health problems and 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 Make sure your doctors know all of the drugs you are taking, including over-thecounter drugs, vitamins, and supplements.
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.

•

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 In order to be eligible for our plan, you must have Medicare Part A and Medicare
Part B. For that reason, some plan members must pay a premium for Medicare
Part A and most plan members must pay a premium for Medicare Part B to
remain a member of the plan.
o Until you meet your yearly deductible, you must pay up to 100% of the Medicareapproved amount for your covered Part A and Part B services.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 6.
Your rights and responsibilities

o If you get any medical services that are not covered by our plan, you must pay the
full cost.


•

If you disagree with our decision to deny coverage for a service, you can
make an appeal. Please see Chapter 7 of this booklet for information about
how to make an appeal.

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 printed on the back cover of this booklet).
o If you move outside of our plan service area, you [if a continuation area is
offered, insert “generally” here and then explain the continuation area] 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, you will have a Special Enrollment Period when you can
join any Medicare plan available in your new 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.
o If you move, it is also important to tell Social Security (or the Railroad
Retirement Board). You can find phone numbers and contact information for
these organizations in Chapter 2.

•

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 printed on the back
cover of this booklet.
o For more information on how to reach us, including our mailing address, please
see Chapter 2.

Section 2.2

Special tax-reporting responsibilities of members of a
Medicare MSA plan

Our plan is a Medicare MSA plan. MSA enrollees must file Form 1040, U.S. Individual Income
Tax Return, along with Form 8853, “Archer MSAs and Long-Term Care (LTC) Insurance
Contracts,” to the Internal Revenue Service (IRS) for any year that distributions are made from
their Medicare MSA account to ensure that they are not taxed on their MSA account
withdrawals.
These tax forms must be filed for any year in which a MSA account withdrawal is made even if
the enrollee has no taxable income or any other reason for filing Form 1040. MSA account
withdrawals for qualified medical expenses are tax-free, while account withdrawals for nonmedical expenses are subject to both income tax and a 50% tax penalty.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 6.
Your rights and responsibilities

•

You will receive a statement (Form 1099-SA) from your MSA trustee reporting your
MSA savings account distributions by January 31 each year. The trustee is also required
to report this information to the IRS.

•

You must file tax forms 1040 and 8853 even if you are not otherwise required to file an
income tax return in order to avoid owing taxes on MSA account withdrawals.
o Form 8853, “Archer MSAs and Long-Term Care (LTC) Insurance Contracts,”
Section B, is the place to report both your Medicare MSA account withdrawals
(which the IRS calls distributions) and on your qualified medical expenses for the
year.
o Form 8853 and Form 8853 Instructions are available at http://www.irs.gov or
from 1-800-TAX-FORM (1-800-829-3676). On the Web, look up forms by
number at “Forms”. (Note: IRS tax code considers Medicare MSAs as a type of
“Archer” MSA, therefore, IRS references to “Archer” MSAs include Medicare
MSAs.)

•

You must file by April 15 of the following year, unless you request an extension on your
tax return.

Information reported to the IRS on MSA account withdrawals for qualified medical expenses is
not the same expense information that will count towards your MSA plan deductible. Only
Medicare Part A and Part B expenses will count towards your MSA plan deductible. Therefore,
you will also want to keep track of your qualified medical expenses that are also Part A and Part
B expenses and that will count towards your MSA plan deductible.
Helpful MSA-related publications related to tax-reporting requirements
The following are two IRS publications relevant to Medicare MSAs. They are available on the
Web at http://www.irs.gov or from 1-800-TAX-FORM (1-800 829-3676). On the Web, look up
publications by number at “Publications”.
•

IRS Publication 502 (“Medical and Dental Expenses”) defines what types of services
generally count as qualified medical expenses for IRS tax purposes.

•

IRS Publication 969 (“Health Savings Accounts and Other Tax-Favored Health Plans”)
includes information on medical savings accounts, including Medicare MSAs.
Publication 969 provides more items and services (in addition to those in Publication
502) that are qualified medical expenses for MSAs.

Who to call for more information or for help in preparing your tax return
You may call the IRS toll-free for live telephone assistance from Monday – Friday, 7 a.m. –
10 p.m. local time, or you may visit your local IRS office.
•
•

For individuals: 1-800-829-1040
For people with hearing impairments: 1-800-829-4059 (TDD)

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 6.
Your rights and responsibilities

Face-to-Face Assistance: In certain areas, IRS also has local offices. Find your local office at
http://www.irs.gov/localcontacts/index.html on the Web.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

Chapter 7. What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)
BACKGROUND ........................................................................................................... 86
SECTION 1
Section 1.1
Section 1.2

Introduction ...................................................................................... 86
What to do if you have a problem or concern ............................................... 86
What about the legal terms? .......................................................................... 86

SECTION 2

You can get help from government organizations that are
not connected with us...................................................................... 87
Where to get more information and personalized assistance ........................ 87

Section 2.1
SECTION 3
Section 3.1

To deal with your problem, which process should you use? ....... 87
Should you use the process for coverage decisions and appeals? Or
should you use the process for making complaints? ..................................... 87

COVERAGE DECISIONS AND APPEALS .................................................................. 88
SECTION 4
Section 4.1
Section 4.2
Section 4.3
SECTION 5
Section 5.1

Section 5.2
Section 5.3
Section 5.4
Section 5.5

A guide to the basics of coverage decisions and appeals ........... 88
Asking for coverage decisions and making appeals: the big picture ............ 88
How to get help when you are asking for a coverage decision or making
an appeal ........................................................................................................ 89
Which section of this chapter gives the details for your situation? ............... 90
Your medical care: How to ask for a coverage decision or
make an appeal ................................................................................. 90
This section tells what to do if you have problems getting coverage for
medical care or if you want us to pay you back for our share of the cost of
your care ........................................................................................................ 91
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) ........................... 92
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) .................................... 95
Step-by-step: How a Level 2 Appeal is done ................................................ 99
What if you are asking us to pay you for our share of a bill you have
received for medical care? ........................................................................... 100

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

SECTION 6
Section 6.1
Section 6.2
Section 6.3
Section 6.4
SECTION 7

How to ask us to cover a longer inpatient hospital stay if
you think the doctor is discharging you too soon ...................... 102
During your inpatient hospital stay, you will get a written notice from
Medicare that tells about your rights ........................................................... 102
Step-by-step: How to make a Level 1 Appeal to change your hospital
discharge date .............................................................................................. 103
Step-by-step: How to make a Level 2 Appeal to change your hospital
discharge date .............................................................................................. 106
What if you miss the deadline for making your Level 1 Appeal? ............... 107

Section 7.5

How to ask us to keep covering certain medical services if
you think your coverage is ending too soon ............................... 110
This section is about three services only: Home health care, skilled
nursing facility care, and Comprehensive Outpatient Rehabilitation
Facility (CORF) services ............................................................................. 110
We will tell you in advance when your coverage will be ending................ 111
Step-by-step: How to make a Level 1 Appeal to have our plan cover your
care for a longer time................................................................................... 112
Step-by-step: How to make a Level 2 Appeal to have our plan cover your
care for a longer time................................................................................... 114
What if you miss the deadline for making your Level 1 Appeal? ............... 115

SECTION 8
Section 8.1

Taking your appeal to Level 3 and beyond .................................. 118
Levels of Appeal 3, 4, and 5 for Medical Service Appeals ......................... 118

Section 7.1

Section 7.2
Section 7.3
Section 7.4

MAKING COMPLAINTS ............................................................................................. 120
SECTION 9
Section 9.1
Section 9.2
Section 9.3
Section 9.4
Section 9.5

How to make a complaint about quality of care, waiting
times, customer service, or other concerns ................................ 120
What kinds of problems are handled by the complaint process? ................ 120
The formal name for “making a complaint” is “filing a grievance” ........... 122
Step-by-step: Making a complaint .............................................................. 122
You can also make complaints about quality of care to the Quality
Improvement Organization.......................................................................... 123
You can also tell Medicare about your complaint ....................................... 123

[Plans should ensure that the text or section heading immediately preceding each “Legal
Terms” box is kept on the same page as the box.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

BACKGROUND
SECTION 1

Introduction

Section 1.1

What to do if you have a problem or concern

This chapter explains two types of processes for handling problems and concerns:
•

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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

SECTION 2

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

Section 2.1

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.
Get help from an independent government organization
We are always available to help you. But in some situations you may also want help or guidance
from someone who is not connected with us. You can always contact your State Health
Insurance Assistance Program (SHIP). This government program has trained counselors in
every state. The program is not connected with us 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.
The services of SHIP counselors are free. [Plans providing SHIP contact information in an
exhibit may revise the following sentence to direct members to it] 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

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

Section 3.1

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

If you have a problem or concern, you only need to read the parts of this chapter that apply to
your situation. The guide that follows will help.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

To figure out which part of this chapter will help with your specific problem or concern,
START HERE
Is your problem or concern about your benefits or coverage?
(This includes problems about whether particular medical care or prescription drugs are
covered or not, the way in which they are covered, and problems related to payment for
medical care or prescription drugs.)
Yes. My problem is about benefits or coverage.
Go on to the next section of this chapter, Section 4, “A guide to the basics of
coverage decisions and appeals.”

No. My problem is not about benefits or coverage.
Skip ahead to Section 9 at the end of this chapter: “How to make a complaint
about quality of care, waiting times, customer service or other concerns.”

COVERAGE DECISIONS AND APPEALS
SECTION 4

A guide to the basics of coverage decisions and
appeals

Section 4.1

Asking for coverage decisions and making appeals: the big
picture

The process for coverage decisions and 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 we make about your benefits and coverage or about the
amount we will pay for your medical services. You or your doctor can also contact us and ask for
a coverage decision if your doctor is unsure whether we will cover a particular medical service or
refuses to provide medical care you think that you need. In other words, if you want to know if
we will cover a medical service before you receive it, you can ask us to make a coverage
decision for you.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

We are making a coverage decision for you whenever we decide what is covered for you and
how much we pay. In some cases we might decide a service is not covered or is no longer
covered by Medicare for you. If you disagree with this coverage decision, you can make an
appeal.
Making an appeal
If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the
decision. An appeal is a formal way of asking us to review and change a coverage decision we
have made.
When you make an appeal, we review the coverage decision we have made to check to see if we
were following all of the rules properly. Your appeal is handled by different reviewers than those
who made the original unfavorable decision. When we have completed the review we give you
our decision.
If we say no to all or part of your Level 1 Appeal, your case will automatically go on to a Level 2
Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to
us. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue
through additional levels of appeal.
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 printed on the back cover of
this booklet).

•

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).

•

Your doctor can make a request for you. For medical care, your doctor can request a
coverage decision or a Level 1 Appeal on your behalf. If your appeal is denied at Level 1,
it will be automatically forwarded to Level 2. To request any appeal after Level 2, your
doctor must be appointed as your representative.

•

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 provider, or other person to be
your representative, call Member Services (phone numbers are printed on the

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

back cover of this booklet) and ask for the “Appointment of Representative”
form. (The form is also available on Medicare’s website at
http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf [plans may also
insert: or on our website at [insert website or link to form]].) The form gives that
person permission to act on your behalf. It must be signed by you and by the
person who you would like to act on your behalf. You must give us a copy of the
signed form.
•

You also have the right to hire a lawyer to 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.

Section 4.3

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

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:
•

Section 5 of this chapter: “Your medical care: How to ask for a coverage decision or
make an appeal”

•

Section 6 of this chapter: “How to ask us to cover a longer inpatient hospital stay if you
think the doctor is discharging you too soon”

•

Section 7 of this chapter: “How to ask us to keep covering certain medical services if you
think your coverage is ending too soon” (Applies to these services only: home health care,
skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility
(CORF) services)

If you’re not sure which section you should be using, please call Member Services (phone
numbers are printed on the back cover of this booklet). 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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

Section 5.1

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

This section is about your benefits for medical care and services. These benefits are 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 coverage for certain medical care you have been getting that we
previously approved will be reduced or stopped, and you believe that reducing or
stopping this care could harm your health.
•

NOTE: If the coverage that will be stopped is for 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 us to cover a longer inpatient hospital stay if
you think the doctor is discharging you too soon.
o Chapter 7, Section 7: How to ask us 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 CORF services.

•

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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

Which of these situations are you in?
If you are in this situation:

This is what you can do:

Do you want to find out whether we will
cover the medical care or services you
want?

You can ask us to make a coverage decision for
you.
Go to the next section of this chapter, Section 5.2.

Have we already told you that we will not
cover or pay for a medical service in the
way that you want it to be covered or
paid for?

You can make an appeal. (This means you are
asking us to reconsider.)
Skip ahead to Section 5.3 of this chapter.

Do you want to ask us to pay you back
for medical care or services you have
already received and paid for?

You can send us the bill.
Skip ahead to Section 5.5 of this chapter.

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)
Legal Terms
When a coverage decision involves your medical care, it 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 should ask us to make a
“fast coverage decision.”
Legal Terms
A “fast coverage decision” is called an “expedited
determination.”
How to request coverage for the medical care you want
•

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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

•

For the details on how to contact us, go to Chapter 2, Section 1 and look for the
section called, [plans may edit section title as necessary] How to contact us 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 coverage decision means we will give you an
answer within 14 days after we receive your request.
•

However, we can take up to 14 more calendar 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
information 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 coverage decision”
•

A fast coverage decision means we will answer within 72 hours.
o However, we can take up to 14 more calendar days if we find that some
information that may benefit you is missing, or if you need time to get
information to us for the 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 information 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 coverage decision, you must meet two requirements:
o You can get a fast coverage decision only if you are asking for coverage for
medical care you have not yet received. (You cannot get a fast coverage
decision if your request is about payment for medical care you have already
received.)
o You can get a fast coverage 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 coverage decision,” we
will automatically agree to give you a fast coverage decision.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

•

If you ask for a fast coverage decision on your own, without your doctor’s support,
we will decide whether your health requires that we give you a fast coverage
decision.
o If we decide that your medical condition does not meet the requirements for a
fast coverage 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 coverage decision,
we will automatically give a fast coverage decision.
o The letter will also tell how you can file a “fast complaint” about our decision
to give you a standard coverage decision instead of the fast coverage decision
you requested. (For more information about the process for making complaints,
including fast complaints, see Section 9 of this chapter.)

Step 2: We consider your request for medical care coverage and give you our
answer.
Deadlines for a “fast” coverage decision
•

Generally, for a fast coverage decision, we will give you our answer within 72 hours.
o As explained above, we can take up to 14 more calendar days under certain
circumstances. If we decide to take extra days to make the coverage decision,
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. When you file a fast complaint, we will
give you an answer to your complaint within 24 hours. (For more information
about the process for making complaints, including fast complaints, see Section
9 of this chapter.)
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 authorize or
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 coverage
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
detailed written explanation as to why we said no.

Deadlines for a “standard” coverage decision
•

Generally, for a standard coverage decision, we will give you our answer within 14
days of receiving your request.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

o We can take up to 14 more calendar days (“an extended time period”) under
certain circumstances. If we decide to take extra days to make the coverage
decision, 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. When you file a fast complaint, we will
give you an answer to your complaint within 24 hours. (For more information
about the process for making complaints, including fast complaints, see Section
9 of this chapter.)
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 authorize or
provide the coverage we have agreed to provide within 14 days after we received
your request. If we extended the time needed to make our coverage 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 we say 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 an appeal, it means you are going on to Level 1 of the appeals
process (see Section 5.3 below).

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)
Legal Terms
An appeal to the plan about a medical care coverage
decision is called a plan “reconsideration.”

Step 1: You contact us and make your appeal. If your health requires a quick
response, you must ask for a “fast appeal.”
What to do
•

To start an appeal you, your doctor, or your representative, must contact us.
For details on how to reach us for any purpose related to your appeal, go to

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

Chapter 2, Section 1 and look for section called, [plans may edit section title as
necessary] How to contact us when you are making an appeal about your medical
care.
•

If you are asking for a standard appeal, make your standard appeal in writing
by submitting a 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 contact us
when you are making an appeal about your medical care).]
o If you have someone appealing our decision for you other than your doctor,
your appeal must include an Appointment of Representative form authorizing
this person to represent you. (To get the form, call Member Services (phone
numbers are printed on the back cover of this booklet) and ask for the
“Appointment of Representative” form. It is also available on Medicare’s
website at http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf
[plans may also insert: or on our website at [insert website or link to form]].)
While we can accept an appeal request without the form, we cannot complete
our review until we receive it. If we do not receive the form within 44 days
after receiving your appeal request (our deadline for making a decision on
your appeal), your appeal request will be sent to the Independent Review
Organization for dismissal.

•

If you are asking for a fast appeal, make your appeal in writing or call us at
the phone number shown in Chapter 2, Section 1 titled, [plan may edit section title
as needed] How to contact us when you are making an appeal about your medical
care.

•

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. Examples of good cause for missing the
deadline may include if you had a serious illness that prevented you from
contacting us or if we provided you with incorrect or incomplete information about
the deadline for requesting an appeal.

•

You can ask for a copy of the information regarding your medical decision
and add more information to support your appeal.
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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

If your health requires it, ask for a “fast appeal” (you can make a request by calling us)
Legal Terms
A “fast appeal” is also called an
“expedited reconsideration.”
•

If you are appealing a decision we made about coverage for care you have not yet
received, you and/or 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 coverage decision.” To ask for a fast appeal, follow the instructions for
asking for a fast coverage decision. (These instructions are given earlier in this
section.)

•

If your doctor tells us that your health requires a “fast appeal,” we will give you a fast
appeal.

Step 2: We consider 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 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.

Deadlines for a “fast” appeal
•

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 calendar days. If we decide
to take extra days to make the decision, we will tell you in writing.
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 automatically 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 you 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 authorize or
provide the coverage we have agreed to provide within 72 hours after we receive your
appeal.

•

If our answer is no to part or all of what you requested, we will send you a written
denial notice informing you that we have automatically sent your appeal to the
Independent Review Organization for a Level 2 Appeal.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

Deadlines for a “standard” appeal
•

If we are using the standard deadlines, we must give you our answer within 30
calendar days after we receive your appeal if your appeal is about coverage for
services you have not yet received. 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 calendar days.
o 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. (For more information
about the process for making complaints, including fast complaints, see Section
9 of this chapter.)
o If we do not give you an answer by the deadline above (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 talk about this review
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 authorize or
provide the coverage we have agreed to provide within 30 days after we receive
your appeal.

•

Step 3: If our plan says no to part or all of your appeal, your case will
automatically be sent on to the next level of the appeals process.
•

To make sure we were following all the rules when we said no to your appeal, we are
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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

Section 5.4

Step-by-step: How a Level 2 Appeal is done

If we say 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
our decision for your first appeal. This organization decides whether the decision we made
should be changed.
Legal Terms
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 independent organization that is
hired by Medicare. This organization is not connected with us 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.]

•

You have a right to give the Independent Review Organization additional information
to support your appeal.

•

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

If you had a “fast” appeal at Level 1, you will also have a “fast” appeal at Level 2
•

If you had a fast appeal to our plan at Level 1, you will automatically receive a fast
appeal at Level 2. The review organization must give you an answer to your Level 2
Appeal within 72 hours of when it receives your appeal.

•

However, if the Independent Review Organization needs to gather more information
that may benefit you, it can take up to 14 more calendar days.

If you had a “standard” appeal at Level 1, you will also have a “standard” appeal at
Level 2
•

If you had a standard appeal to our plan at Level 1, you will automatically receive a
standard appeal at Level 2. The review organization must give you an answer to your
Level 2 Appeal within 30 calendar days of when it receives your appeal.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

•

100

However, if the Independent Review Organization needs to gather more information
that may benefit you, it can take up to 14 more calendar days.

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
authorize the medical care coverage within 72 hours or provide the service within 14
calendar days after we receive the decision from the review organization.

•

If this organization says no to part or all of your appeal, it means they agree with
us that your request (or part of 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 There is a certain dollar value that must be in dispute to continue 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. The written notice you get from the Independent Review
Organization will tell you how to find out the dollar amount to continue the
appeals process.

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. The details on how to do this are in the written notice you got
after your Level 2 Appeal.

•

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

Section 5.5

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

If you want to ask us for payment for medical care, start by reading Chapter 5 of this booklet:
Asking us to pay our share of a bill you have received for covered medical services. Chapter 5
describes the situations in which you may need to ask for reimbursement or to pay a bill you

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

101

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 us
If you send us the paperwork that asks for reimbursement, you are asking us to make a coverage
decision (for more information 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).
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 within 60 calendar days
after we receive your request. 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 in detail. (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 do not agree with our decision to turn 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, we must give you our answer within 60
calendar days after we receive your appeal. (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.)

•

If the Independent Review Organization reverses our decision to deny payment, we must
send the payment you have requested to you or to the provider within 30 calendar days. If
the answer to your appeal is yes at any stage of the appeals process after Level 2, we must
send the payment you requested to you or to the provider within 60 calendar days.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

SECTION 6

102

How to ask us to cover a longer inpatient hospital
stay if you think the doctor is discharging you 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 our 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.

•

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.

Section 6.1

During your inpatient 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 (for example, a caseworker or nurse) must
give it to you within two days after you are admitted. If you do not get the notice, ask any
hospital employee for it. If you need help, please call Member Services (phone numbers are
printed on the back cover of this booklet). You can also call 1-800-MEDICARE (1-800-6334227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
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.

•

Your right to appeal your discharge decision if you think you are being discharged
from the hospital too soon.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

103

Legal Terms
The written notice from Medicare tells you
how you can “request an immediate
review.” Requesting an immediate review
is a formal, legal way to ask for a delay in
your discharge date so that we will cover
your hospital care for a longer time.
(Section 6.2 below tells you how you can
request an immediate review.)
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.

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 two 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 (phone
numbers are printed on the back cover of this booklet) or 1-800 MEDICARE (1-800633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
You can also see it online at
http://www.cms.gov/BNI/12_HospitalDischargeAppealNotices.asp.

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 inpatient hospital services to be covered by us for a longer time,
you will need to use the appeals process to make this request. 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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

•

104

Ask for help if you need it. If you have questions or need help at any time, please
call Member Services (phone numbers are printed on the back 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.
Step 1: Contact the Quality Improvement Organization in your state and ask for a
“fast review” of your hospital discharge. You must act quickly.
Legal Terms
A “fast review” is also called an
“immediate 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 About Your
Rights) 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 6.4.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

105

Ask for a “fast review”:
•

You must ask the Quality Improvement Organization for a “fast review” of your
discharge. Asking for a “fast review” means you are asking for the organization to
use the “fast” deadlines for an appeal instead of using the standard deadlines.
Legal Terms
A “fast review” is also called an “immediate review” or
an “expedited review.”

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.

•

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

•

By noon of the day after the reviewers informed our plan of your appeal, you
will also get a written notice that gives your planned discharge date and explains
in detail the reasons why your doctor, the hospital, and we think it is right
(medically appropriate) for you to be discharged on that date.
Legal Terms
This written explanation is called the “Detailed Notice
of Discharge.” You can get a sample of this notice by
calling Member Services (phone numbers are printed on
the back cover of this booklet) or 1-800-MEDICARE (1800-633-4227, 24 hours a day, 7 days a week. TTY users
should call 1-877-486-2048. Or you can see a sample
notice online at http://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, we must keep providing your
covered inpatient hospital services for as long as these services are medically
necessary.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

•

106

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. If this happens, our coverage for your
inpatient hospital services will end at noon on the day after the Quality
Improvement Organization gives you its answer to your appeal.

•

If the review organization says no to your appeal and 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.

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. If the Quality Improvement Organization turns down your Level
2 Appeal, you may have to pay the full cost for your stay after your planned discharge date.
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 calendar 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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

107

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 calendar days, the Quality Improvement Organization reviewers
will decide on your appeal and tell you their decision.
If the review organization says yes:
•

We 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. We must continue providing coverage for your
inpatient 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 on your Level 1 Appeal and will not
change it. This is called “upholding the decision.”

•

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.

Section 6.4

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

You can appeal to us 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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

108

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 us, asking for a “fast review.” A fast review is an appeal that uses the fast deadlines
instead of the standard deadlines.
Legal Terms
A “fast review” (or “fast appeal”) is also
called an “expedited appeal”.
Step 1: Contact us and ask for a “fast review.”
•

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

•

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: We do a “fast review” of your planned discharge date, checking to see if it
was medically appropriate.
•

During this review, we take 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: We give you our decision within 72 hours after you ask for a “fast review”
(“fast appeal”).
•

If we say yes to your fast appeal, it means we have agreed with you that you still
need to be in the hospital after the discharge date, and will keep providing your
covered inpatient hospital 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 we say no to your fast appeal, we are saying that your planned discharge date was
medically appropriate. Our coverage for your inpatient hospital services ends as of the
day we said coverage would end.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

109

o 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.
Step 4: If we say 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 following all the rules when we said no to your fast appeal, we
are 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.

Step-by-Step: How to make a Level 2 Alternate Appeal
If we say 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 we made when we said no to your “fast appeal.” This organization decides whether
the decision we made should be changed.
Legal Terms
The formal name for the “Independent
Review Organization” is the “Independent
Review Entity.” It is sometimes called the
“IRE.”
Step 1: We will automatically forward your case to the Independent Review
Organization.
•

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 72 hours.
•

The Independent Review Organization is an 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.

•

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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

110

•

If this organization says yes to your appeal, then we 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 inpatient
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 us that your
planned hospital discharge date was medically appropriate.
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 a Level 3 Appeal, 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

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

Section 7.1

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 10,
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 information about this type of facility, see Chapter 10, Definitions of important
words.)

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

111

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).
When we decide 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, we will stop paying our 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 ask for an appeal.
Section 7.2

We will 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 we will stop covering the care for you.

•

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.
Legal Terms
In telling you what you can do, the written notice is telling how
you can request a “fast-track appeal.” Requesting a fast-track
appeal is a formal, legal way to request a change to our coverage
decision about when to stop your care. (Section 8.3 below tells
how you can request a fast-track appeal.)
The written notice is called the “Notice of Medicare NonCoverage.” To get a sample copy, call Member Services (phone
numbers are printed on the back cover of this booklet) or 1-800MEDICARE (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.)

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

•

112

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.

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. 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.
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.

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 us to end coverage for your medical services.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

113

Your deadline for contacting this organization.
•

You must contact the Quality Improvement Organization to start your appeal no later
than noon of the day after you receive the written notice telling you when we will stop
covering your care.

•

If you miss the deadline for contacting the Quality Improvement Organization about
your appeal, you can make your appeal directly to us instead. For details about this
other way to make your appeal, see Section 7.5.

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.

•

By the end of the day the reviewers informed us of your appeal, and you will
also get a written notice from us that explains in detail our reasons for ending
our coverage for your services.
Legal Terms
This notice explanation is called the
“Detailed Explanation of NonCoverage.”

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?
•

If the reviewers say yes to your appeal, then we 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. We will stop paying its share of the costs of this care.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

•

114

If you decide to keep getting the home health care, or skilled nursing facility care, or
Comprehensive Outpatient Rehabilitation Facility (CORF) services 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 to 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.

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. If the Quality Improvement Organization
turns down your Level 2 Appeal, you may have to pay the full cost for your home health care, or
skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF)
services after the date when we said your coverage would end.
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.

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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

115

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?
•

We must reimburse you for our share of the costs of care you have received since
the date when we said your coverage would end. We 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 we made to your Level 1 Appeal and will not
change it.

•

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 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 7.5

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

You can appeal to us instead
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 us, asking for a “fast review.” A fast review is an appeal that uses the fast deadlines
instead of the standard deadlines.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

116

Here are the steps for a Level 1 Alternate Appeal:
Legal Terms
A “fast review” (or “fast appeal”) is also
called an “expedited appeal”.
Step 1: Contact us and ask for a “fast review.”
•

•

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: We do a “fast review” of the decision we made about when to end
coverage for your services.
•

During this review, we take another look at all of the information about your case.
We check to see if we were 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: We give you our decision within 72 hours after you ask for a “fast review”
(“fast appeal”).
•

If we say yes to your fast appeal, it means we have agreed with you that you need
services longer, and will 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 we say no to your fast appeal, then your coverage will end on the date we told
you and we will not pay any share of the costs after this date.

•

If you continued to get home health care, or skilled nursing facility care, or
Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date
when we said your coverage would end, then you will have to pay the full cost of
this care yourself.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

117

Step 4: If we say no to your fast appeal, your case will automatically go on to the
next level of the appeals process.
•

Step-by-Step: How to make a Level 2 Alternate Appeal
If we say 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 we made when we said no to your “fast appeal.” This organization decides whether
the decision we made should be changed.
Legal Terms
The formal name for the “Independent Review
Organization” is the “Independent Review
Entity.” It is sometimes called the “IRE.”
Step 1: We will automatically forward your case to the Independent Review
Organization.
•

Step 2: The Independent Review Organization does a “fast review” of your
appeal. The reviewers give you an answer within 72 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 we 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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

118

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.
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 a Level 3 Appeal.

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

Taking your appeal to Level 3 and beyond

Section 8.1

Levels of Appeal 3, 4, and 5 for Medical Service Appeals

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 item 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.
Level 3 Appeal
•

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 Administrative Law Judge says yes to your appeal, the appeals process may or
may not be over - We will decide whether to appeal this decision to Level 4. Unlike a
decision at Level 2 (Independent Review Organization), we have the right to appeal a
Level 3 decision that is favorable to you.
o If we decide not to appeal the decision, we must authorize or provide you with the
service within 60 calendar days after receiving the judge’s decision.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

119

o If we decide to appeal the decision, we will send you a copy of the Level 4 Appeal
request with any accompanying documents. We may wait for the Level 4 Appeal
decision before authorizing or providing the service in dispute.
•

If the Administrative Law Judge says no to your appeal, 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 can continue to the next level of the
review process. If the administrative law judge says no to your appeal, the notice
you get will tell you what to do next if you choose to continue with your appeal.

Level 4 Appeal
•

The Appeals Council will review your appeal and give you an answer. The
Appeals Council works for the Federal government.

If the answer is yes, or if the Appeals Council denies our request to review a
favorable Level 3 Appeal decision, the appeals process may or may not be over - We
will decide whether to appeal this decision to Level 5. Unlike a decision at Level 2
(Independent Review Organization), we have the right to appeal a Level 4 decision that is
favorable to you.
o If we decide not to appeal the decision, we must authorize or provide you with the
service within 60 calendar days after receiving the Appeals Council’s decision.
o If we decide to appeal the decision, we will let you know in writing.

•

If the answer is no or if the Appeals Council denies the review request, 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. If the Appeals Council says no to your appeal, the
notice you get will tell you whether the rules allow you to go on to a Level 5
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.

Level 5 Appeal
•

A judge at the Federal District Court will review your appeal.

This is the last step of the administrative appeals process.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

120

MAKING COMPLAINTS
SECTION 9

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

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.
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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

121

If you have any of these kinds of problems, you can “make a complaint”
Complaint

Example

Quality of your
medical care

•

Are you unhappy with the quality of the care you have received
(including care in the hospital)?

Respecting your
privacy

•

Do you believe that someone did not respect your right to privacy or
shared information about you that you feel should be confidential?

Disrespect, poor
customer service,
or other negative
behaviors

•
•
•

Has someone been rude or disrespectful to you?
Are you unhappy with how our Member Services has treated you?
Do you feel you are being encouraged to leave the plan?

Waiting times

•

Are you having trouble getting an appointment, or waiting too long to
get it?
Have you been kept waiting too long by doctors or other health
professionals? Or by our Member Services or other staff at the plan?
o Examples include waiting too long on the phone, in the
waiting room, or in the exam room.

•

Cleanliness

•

Are you unhappy with the cleanliness or condition of a clinic,
hospital, or doctor’s office?

Information you
get from us

•

Do you believe we have not given you a notice that we are required
to give?
Do you think written information we have given you is hard to
understand?

•
Timeliness
(These types of
complaints are all
related to the
timeliness of our
actions related to
coverage decisions
and appeals)

The process of asking for a coverage decision and making appeals is
explained in sections 4-8 of this chapter. If you are asking for a decision
or making an appeal, you use that process, not the complaint process.
However, if you have already asked us for a coverage decision or made
an appeal, and you think that we are not responding quickly enough, you
can also make a complaint about our slowness. Here are examples:
•
•
•

•

If you have asked us to give you a “fast coverage decision” or a “fast
appeal,” and we have said we will not, you can make a complaint.
If you believe we are not meeting the deadlines for giving you a
coverage decision or an answer to an appeal you have made, you
can make a complaint.
When a coverage decision we made is reviewed and we are told
that we must cover or reimburse you for certain medical services,
there are deadlines that apply. If you think we are not meeting these
deadlines, you can make a complaint.
When we do not give you a decision on time, we are required to
forward your case to the Independent Review Organization. If we do
not do that within the required deadline, you can make a complaint.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

Section 9.2

122

The formal name for “making a complaint” is “filing a
grievance”
Legal Terms

Section 9.3

•

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

Step 1: Contact us promptly – either by phone or in writing.
•

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, and days 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 put your complaint in writing, we will
respond to your complaint in writing.

•

[Insert description of the procedures (including time frames) and instructions about what
members need to do if they want to use the 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 calendar days after you had the problem you want to
complain about.

•

If you are making a complaint because we denied your request for a “fast coverage
decision” or a “fast appeal,” we will automatically give you a “fast complaint.” If you
have a “fast complaint,” it means we will give you an answer within 24 hours.
Legal Terms
What this section calls a “fast complaint”
is also called an “expedited grievance.”

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

123

Step 2: We look into your complaint and give you our answer.
•

If possible, we will answer you right away. If you call us with a complaint, we may be
able to give you an answer on the same phone call. If your health condition requires us to
answer quickly, we will do that.

•

Most complaints are answered in 30 calendar 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
calendar days (44 calendar 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. Our response will include our
reasons for this answer. We must respond whether we agree with the complaint or not.

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 us by using the step-bystep 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 us).
o The Quality Improvement Organization is a group of practicing doctors and
other health care experts paid by the Federal government to check and improve
the care given to Medicare patients.
o To find the name, address, and phone number of the Quality Improvement
Organization for your state, look in Chapter 2, Section 4, of this booklet. If you
make a complaint to this organization, we will work 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 us and also to the Quality Improvement
Organization.

Section 9.5

You can also tell Medicare about your complaint

You can submit a complaint about [insert 2015 plan name] directly to Medicare. To submit a
complaint to Medicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx. Medicare

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

124

takes your complaints seriously and will use this information to help improve the quality of the
Medicare program.
If you have any other feedback or concerns, or if you feel the plan is not addressing your issue,
please call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 8.
Ending your membership in the plan

125

Chapter 8. Ending your membership in the plan
SECTION 1
Section 1.1

Introduction .................................................................................... 126
This chapter focuses on ending your membership in our plan .................... 126

SECTION 2
Section 2.1
Section 2.2

When can you end your membership in our plan? ..................... 126
You can end your membership during the Annual Enrollment Period ....... 126
In certain situations, you can end your membership during a Special
Enrollment Period........................................................................................ 127
Where can you get more information about when you can end your
membership? ............................................................................................... 128

Section 2.3

SECTION 3
Section 3.1

What happens if you leave our plan in the middle of the
year? ................................................................................................ 128
What happens to the money in your account if you leave our plan?........... 128

SECTION 4
Section 4.1

How do you end your membership in our plan? ......................... 129
Usually, you end your membership by enrolling in another plan ............... 129

SECTION 5

Until your membership ends, you must keep getting your
medical services through our plan ............................................... 130
Until your membership ends, you are still a member of our plan ............... 130

Section 5.1
SECTION 6
Section 6.1
Section 6.2
Section 6.3

[Insert 2015 plan name] must end your membership in the
plan in certain situations ............................................................... 130
When must we end your membership in the plan? ..................................... 130
We cannot ask you to leave our plan for any reason related to your health 131
You have the right to make a complaint if we end your membership in
our plan ........................................................................................................ 131

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 8.
Ending your membership in the plan

126

SECTION 1

Introduction

Section 1.1

This chapter focuses on ending your membership in our plan

Ending your membership in [insert 2015 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
voluntarily end your membership in the plan. Section 2 tells you when you can
end your membership in the plan.
o The process for voluntarily 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 you do not choose to leave, but 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. In certain situations, you may also be eligible to leave the plan at other times
of the year.
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 Coordinated 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.
•

When is the Annual Enrollment Period? This happens from October 15 to
December 7.

•

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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 8.
Ending your membership in the plan

127

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 Keep your Medicare Savings Account (MSA) plan and enroll in a separate
prescription drug plan (or enroll in a new prescription drug plan if you do not
currently have one);
o Another Medicare health 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.

Section 2.2

In certain situations, you can end your membership during a
Special Enrollment Period

In certain situations, members of [insert 2015 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? If any of the following situations
apply to you, you are eligible to end your membership during a Special Enrollment
Period. These are just examples, for the full list you can contact the plan, call Medicare,
or visit the Medicare website (http://www.medicare.gov):
o Usually, when you have moved.
o If we violate our contract with you.
o If you are getting care in an institution, such as a nursing home or long-term care
(LTC) hospital.
o [Plans in states with PACE, insert: If you enroll in the Program of All-inclusive
Care for the Elderly (PACE).]

•

When are Special Enrollment Periods? The enrollment periods vary depending on your
situation.

•

What can you do? To find out if you are eligible for a Special Enrollment Period, 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. 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 Keep your Medicare Savings Account (MSA) plan and enroll in a separate
prescription drug plan (or enroll in a new prescription drug plan if you do not
currently have one);

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 8.
Ending your membership in the plan

128

o Another Medicare health 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.

Section 2.3

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 printed on the back cover of this
booklet).

•

You can find the information in the Medicare & You 2015 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 the Medicare website
(http://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. TTY users should call 1-877-486-2048.

SECTION 3

What happens if you leave our plan in the middle of
the year?

Section 3.1

What happens to the money in your account if you leave our
plan?

If you leave our plan in the middle of the year, part of the current year’s deposit will be refunded
to Medicare. The amount recovered and refunded to Medicare depends on the number of months
left in the current calendar year. For example, if you get a $1,200 deposit in your account in
January and you leave the plan in March, we will recover $900 to return to Medicare.
Funds remaining in your account from any previous year belong to you. Recovery applies only to
funds deposited into your account for the current year. If you have any questions, please contact
Member Services (phone numbers are printed on the back cover of this booklet).

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 8.
Ending your membership in the plan

SECTION 4

How do you end your membership in our plan?

Section 4.1

Usually, you end your membership by enrolling in another
plan

129

Usually, to end your membership in our plan, you simply enroll in another Medicare health plan
during one of the enrollment periods (see Section 2 in this chapter for information about the
enrollment periods).
However, if you want to switch from our plan to Original Medicare, you must ask to be
disenrolled from our plan. To disenroll from [insert 2015 plan name] in this situation, you must
make a request in writing to us. Contact Member Services if you need more information on how
to do this (phone numbers are printed on the back cover of this booklet).
The table below explains how you should end your membership in our plan.
If you would like to switch from our
plan to:

This is what you should do:

•

Another Medicare health plan.

•

Enroll in the new Medicare health plan.
You will automatically be disenrolled from
[insert 2015 plan name] when your new
plan’s coverage begins.

•

Original Medicare (either with or
without a separate Medicare
prescription drug plan).

•

Send us a written request to disenroll.
Contact Member Services if you need more
information on how to do this (phone
numbers are printed on the back cover of this
booklet).
You will be disenrolled from [insert 2015
plan name] when your coverage in Original
Medicare begins.

•

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 8.
Ending your membership in the plan

130

SECTION 5

Until your membership ends, you must keep getting
your medical services through our plan

Section 5.1

Until your membership ends, you are still a member of our
plan

If you leave [insert 2015 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, your hospital stay
will usually be covered by our plan until you are discharged (even if you are
discharged after your new health coverage begins).

SECTION 6

[Insert 2015 plan name] must end your membership in
the plan in certain situations

Section 6.1

When must we end your membership in the plan?

[Insert 2015 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.

•

If you move out of our service area.

•

If you are away from our service area for more than six 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. (Phone numbers for
Member Services are printed on the back cover of this booklet.)

•

If you become incarcerated (go to prison).

•

[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. (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 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. (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. (We cannot make you leave our plan for this reason
unless we get permission from Medicare first.)

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 8.
Ending your membership in the plan

131

o If we end your membership because of this reason, Medicare may have your case
investigated by the Inspector General.
•

[Omit bullet if not applicable. Plans with one or more optional supplemental benefits
must edit this bullet as necessary to reflect their policies.] If you do not pay the
premium(s) for [describe optional benefits, such as vision, hearing or dental] we will
reduce your coverage to exclude [insert as applicable: this benefit OR these benefits].

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 printed on the
back cover of this booklet).

Section 6.2

We cannot ask you to leave our plan for any reason related to
your health

[Insert 2015 plan name] is not allowed to ask you to leave our plan for any reason related to
your health.
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
1-877-486-2048. You may call 24 hours a day, 7 days a week.
Section 6.3

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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 9.
Legal notices

132

Chapter 9. Legal notices
SECTION 1

Notice about governing law ........................................................... 133

SECTION 2

Notice about non-discrimination................................................... 133

SECTION 3

Notice about Medicare Secondary Payer subrogation rights ..... 133

[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.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 9.
Legal notices

SECTION 1

133

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 non-discrimination

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.

SECTION 3

Notice about Medicare Secondary Payer subrogation
rights

We have the right and responsibility to collect for covered Medicare services for which Medicare
is not the primary payer. According to CMS regulations at 42 CFR sections 422.108 and
423.462, [insert 2015 plan name], as a Medicare Advantage Organization, will exercise the same
rights of recovery that the Secretary exercises under CMS regulations in subparts B through D of
part 411 of 42 CFR and the rules established in this section supersede any State laws.
[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.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 10. Definitions of important words

134

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 allowable revisions to terminology (e.g., changing “Member Services” to “Customer
Service”) affect glossary terms, plans should re-label the term and alphabetize it within the
glossary.]
[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.]
Ambulatory Surgical Center – An Ambulatory Surgical Center is an entity that operates
exclusively for the purpose of furnishing outpatient surgical services to patients not requiring
hospitalization and whose expected stay in the center does not exceed 24 hours.
Annual Enrollment Period – A set time each fall when members can change their health or
drugs plans or switch to Original Medicare. The Annual Enrollment Period is from October 15
until December 7.
Appeal – An appeal is something you do if you disagree with our decision to deny a request for
coverage of health care services or payment for services you already received. You may also
make an appeal if you disagree with our decision to stop services that you are receiving. For
example, you may ask for an appeal if we don’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.
Balance Billing – When a provider (such as a doctor or hospital) bills a patient more than the
plan’s allowed cost-sharing amount. As a member of [insert 2015 plan name], you only have to
pay our plan’s cost-sharing amounts when you get services covered by our plan. We do not allow
providers to “balance bill” or otherwise charge you more than the amount of cost-sharing your
plan says you must pay.
Benefit Period – [Modify definition as needed if plan uses benefit periods for SNF stays but not
for inpatient hospital stays.] The way that [insert if applicable: both our plan and] Original
Medicare measures your use of hospital and skilled nursing facility (SNF) services. [Plans that
offer a more generous benefit period, revise the following sentences to reflect the plan’s benefit
period.] A benefit period begins the day you go into a hospital or skilled nursing facility. The
benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a
SNF) for 60 days in a row. If you go into a hospital or a skilled nursing facility after one benefit
period has ended, a new benefit period begins. [Insert if applicable: You must pay the inpatient
hospital deductible for each benefit period.] There is no limit to the number of benefit periods.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 10. Definitions of important words

135

Centers for Medicare & Medicaid Services (CMS) – The Federal agency that administers
Medicare. Chapter 2 explains how to contact CMS.
Coinsurance – An amount you may be required to pay as your share of the cost for services after
you pay any deductibles. Coinsurance is usually a percentage (for example, 20%).
Comprehensive Outpatient Rehabilitation Facility (CORF) – A facility that mainly provides
rehabilitation services after an illness or injury, and provides a variety of services including
physical therapy, social or psychological services, respiratory therapy, occupational therapy and
speech-language pathology services, and home environment evaluation services.
Copayment – An amount you may be required to pay as your share of the cost for a medical
service or supply, like a doctor’s visit, hospital outpatient visit, or a prescription. A copayment is
usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a
doctor’s visit or prescription.
Cost-sharing – Cost-sharing refers to amounts that a member has to when services are received.
Cost-sharing includes any combination of the following three types of payments: (1) any
deductible amount a plan may impose before services are covered; (2) any fixed “copayment”
amount that a plan requires when a specific service is received; or (3) any “coinsurance” amount,
a percentage of the total amount paid for a service, that a plan requires when a specific service is
received.
Covered Services – The general term we use 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 – Custodial care is personal care provided in a nursing home, hospice, or other
facility setting when you do not need skilled medical care or skilled nursing care. Custodial care
is personal care that can be provided by people who don’t have professional skills or training,
such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed
or chair, moving around, and using the bathroom. It may also include the kind of health-related
care that most people do themselves, like using eye drops. Medicare doesn’t pay for custodial
care.
Deductible – The amount you must pay for health care before our plan begins to pay.
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).

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 10. Definitions of important words

136

Durable Medical Equipment – Certain medical equipment that is ordered by your doctor for
medical reasons. Examples are walkers, wheelchairs, or hospital beds.
Emergency – A medical emergency is when you, or any other prudent layperson with an
average knowledge of health and medicine, believe that you have medical symptoms that require
immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb.
The medical symptoms may be an illness, injury, severe pain, or a medical condition that is
quickly getting worse.
Emergency Care – Covered services that are: 1) rendered by a provider qualified to furnish
emergency services; and 2) needed to treat, 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.
Extra Help – A Medicare program to help people with limited income and resources pay
Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance.
Grievance - A type of complaint you make about us or one of our network providers, 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.
Hospice - An enrollee who has 6 months or less to live has the right to elect hospice. We, your
plan, must provide you with a list of hospices in your geographic area. If you elect hospice and
continue to pay premiums you are still a member of our plan. You can still obtain all medically
necessary services as well as the supplemental benefits we offer. The hospice will provide
special treatment for your state.
Hospital Inpatient Stay – A hospital stay when you have been formally admitted to the hospital
for skilled medical services. Even if you stay in the hospital overnight, you might still be
considered an “outpatient.”
Initial Enrollment Period – When you are first eligible for Medicare, the period of time when
you can sign up for Medicare Part A and Part B. For example, if you’re eligible for Medicare
when you turn 65, your Initial Enrollment Period is the 7-month period that begins three months
before the month you turn 65, includes the month you turn 65, and ends three months after the
month you turn 65.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 10. Definitions of important words

137

Low Income Subsidy (LIS) – See “Extra Help.”
[Include if applicable: Maximum Out-of-Pocket Amount – The most that you pay out-ofpocket during the calendar year for covered [insert if applicable: Part A and Part B] services.
Amounts you pay for Medicare Part A and Part B premiums do not count toward the maximum
out-of-pocket amount. [Plans with service category MOOPs insert: In addition to the maximum
out-of-pocket amount for covered [insert if applicable: Part A and Part B] medical services, we
also have a maximum out-of-pocket amount for certain types of services.] See Chapter 4, Section
1. [insert subsection number] for information about your maximum out-of-pocket amount.]
Medicaid (or Medical Assistance) – A joint Federal and state program that helps with medical
costs for some people with low incomes and limited resources. Medicaid programs vary from
state to state, but most health care costs are covered if you qualify for both Medicare and
Medicaid. See Chapter 2, Section 6 for information about how to contact Medicaid in your state.
You cannot be a member of our Medicare Medical Savings Account (MSA) plan if you have
Medicaid.
Medically Necessary – Services, supplies, or drugs that are needed for the prevention, diagnosis,
or treatment of your medical condition and meet accepted standards of medical practice.
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). People
with Medicare can get their Medicare health coverage through Original Medicare [insert only if
there is a cost plan in your service area: a Medicare Cost Plan,] [insert only if there is a PACE
plan in your state: a PACE plan,] or a Medicare Advantage Plan.
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 and
Part B benefits. A Medicare Advantage Plan can be an HMO, PPO, a Private Fee-for-Service
(PFFS) plan, or a Medicare Medical Savings Account (MSA) plan. When you are enrolled in a
Medicare Advantage Plan, Medicare services are covered through the plan, and are not paid for
under Original Medicare. 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. [Plans may insert the following sentence: [Insert 2015 plan
name] does not offer Medicare 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 – A Medicare Cost Plan is 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.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 10. Definitions of important words

138

Medicare-Covered Services – Services covered by Medicare Part A and Part B. All Medicare
health plans, including our plan, must cover all of the services that are covered by Medicare Part
A and B.
Medicare Health Plan – A Medicare health plan is offered by a private company that contracts
with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the
plan. This term includes all Medicare Advantage Plans, Medicare Cost Plans,
Demonstration/Pilot Programs, and Programs of All-inclusive Care for the Elderly (PACE).
Medicare Medical Savings Account (MSA) Plan – A type of Medicare Advantage Plan that
combines a high-deductible health insurance plan with a medical savings account that members
can use to pay for their health care costs.
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. 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.
[Include if applicable: 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 and by the State to provide health care services. We call them “network
providers” when they [insert if appropriate: 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 plan has made an organization
determination when it makes a decision about whether items or services are covered or how
much you have to pay for covered items or services. The Medicare Advantage plan’s network

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 10. Definitions of important words

139

provider or facility has also made an organization determination when it provides you with an
item or service, or refers you to an out-of-network provider for an item or service. Organization
determinations are called “coverage decisions” in this booklet. Chapter 7 explains how to ask us
for a coverage decision.
Original Medicare (“Traditional Medicare” or “Fee-for-service” Medicare) – Original Medicare
is offered by the government, and not a private health plan like Medicare Advantage Plans and
prescription drug plans. Under Original Medicare, Medicare services are covered by paying
doctors, hospitals, and other health care providers payment amounts established by Congress.
You can see 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-Pocket Costs – See the definition for “cost-sharing” above. A member’s cost-sharing
requirement to pay for a portion of services received is also referred to as the member’s “out-ofpocket” cost requirement.
[Insert PACE plan definition only if there is a PACE plan in your state: PACE plan – A PACE
(Program of All-Inclusive Care for the Elderly) plan combines medical, social, and long-term
care (LTC) services for frail people to help people stay independent and living in their
community (instead of moving to a nursing home) as long as possible, while getting the highquality care they need. People enrolled in PACE plans receive both their Medicare and Medicaid
benefits through the plan.]
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.)
Preferred Provider Organization (PPO) Plan – A Preferred Provider Organization plan is a
Medicare Advantage 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 will generally
be higher when plan benefits are received from out-of-network providers. PPO plans have an
annual limit on your out-of-pocket costs for services received from network (preferred) providers
and a higher limit on your total combined out-of-pocket costs for services from both in-network
(preferred) and out-of-network (non-preferred) providers.
Premium – The periodic payment to Medicare, an insurance company, or a health care plan for
health or prescription drug coverage.
[Include if applicable: Primary Care [insert as appropriate: Physician OR Provider] (PCP) –
Your primary care provider is the doctor or other provider you see first for most health problems.
He or she makes sure you get the care you need to keep you healthy. He or she also may talk
with other doctors and health care providers about your care and refer you to them. In many

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 10. Definitions of important words

140

Medicare health plans, you must see your primary care provider before you see any other health
care provider. See Chapter 3, Section 2.1 for information about Primary Care [insert as
appropriate: Physicians OR Providers].]
Prior Authorization – Approval in advance to get services. As a member of a Medicare Medical
Savings Account (MSA) plan, you do not need prior authorization to obtain services. However,
you may want to check with us before obtaining services to confirm that the service is covered
by the plan.
Qualified Medical Expenses - Qualified medical expenses are those expenses that would
generally qualify for the medical and dental expenses deduction on your income tax return.
These expenses are explained in IRS Publication 502, Medical and Dental Expenses.
Quality Improvement Organization (QIO) – A group of practicing doctors and other health
care experts paid by the Federal government to check and improve the care given to Medicare
patients. See Chapter 2, Section 4 for information about how to contact the QIO for your state.
Rehabilitation Services – These services include physical therapy, speech and language
therapy, and occupational therapy.
Service Area – A geographic area where a health plan accepts members if it limits membership
based on where people live. For plans that limit which doctors and hospitals you may use, it’s
also generally the area where you can get routine (non-emergency) services. The plan may
disenroll you if you permanently move out of the plan’s service area.
Skilled Nursing Facility (SNF) Care – Skilled nursing care and rehabilitation services provided
on a continuous, daily basis, in a skilled nursing facility. Examples of skilled nursing facility care
include physical therapy or intravenous injections that can only be given by a registered nurse or
doctor.
Special Enrollment Period – A set time when members can change their health or drugs plans
or return to Original Medicare. Situations in which you may be eligible for a Special Enrollment
Period include: if you move outside the service area, if you move into a nursing home, or if we
violate our contract with you.
Special Needs Plan – A special type of Medicare Advantage Plan that provides more focused
health care for specific groups of people, such as those who have both Medicare and Medicaid,
who reside in a nursing home, or who have certain chronic medical conditions.
Supplemental Security Income (SSI) – A monthly benefit paid by Social Security 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.

[This is the back cover for the EOC. Plans may add a logo and/or photographs, as long as these
elements do not make it difficult for members to find and read the plan contact information.]
[Insert 2015 plan name] Member Services
Method

Member Services – Contact Information

CALL

TTY

FAX

[Optional: insert fax number]

WRITE

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

WEBSITE

[Insert URL]

[Insert state-specific SHIP name] [If the SHIP’s name does not include the name
of the state, add: ([insert state name] SHIP)]
[Insert state-specific SHIP name] is a state program that gets money from the Federal
government to give free local health insurance counseling to people with Medicare.
[Plans with multi-state EOCs revise heading and sentence above to use “State Health Insurance
Assistance Program,” omit table, and reference exhibit or EOC section with SHIP information.]

Method

Contact Information

CALL

[Insert phone number(s)]

TTY

WRITE

[Insert address]

WEBSITE

[Insert URL]

File Type	application/pdf
File Title	2015 Medicare Medical Savings Account (MSA) Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) Templates
Subject	Proposed revisions for 2015 Medicare Medical Savings Account (MSA) Annual Notice of Change (ANOC) and Evidence of Coverage (EOC)
Author	Centers for Medicare & Medicaid Services
File Modified	2014-01-23
File Created	2014-01-23