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_PPO_MA_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⚠️ Notice: This form may be outdated.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

[MA-only PPO 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.
 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.

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

Cost
Monthly plan premium

2014 (this year)

2015 (next year)

[insert 2014 premium
amount]

[insert 2015 premium
amount

[Plans with no deductible may
delete this row.]
Yearly deductible

[insert 2014 deductible
amount]

[insert 2015 deductible
amount]

Maximum out-of-pocket amounts

From in-network
providers: [insert 2014 innetwork MOOP amount]

From in-network
providers: [insert 2015 innetwork MOOP amount]

From in-network and
out-of-network providers
combined: [insert 2014
combined MOOP amount]

From in-network and
out-of-network providers
combined: [insert 2015
combined MOOP amount]

Primary care visits: [insert
2014 cost-sharing for
PCPs] per visit

Primary care visits: [insert
2015 cost-sharing for
PCPs] per visit

Specialist visits: [insert
2014 cost-sharing for
specialists] per visit

Specialist visits: [insert
2015 cost-sharing for
specialists] per visit

[insert 2014 cost-sharing]

[insert 2015 cost-sharing]

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

This is the most you will pay
out-of-pocket for your covered
Part A and Part B services.
(See Section [edit section number
as needed] 2.2 for details.)

Doctor office visits

In-patient hospital stays
Includes inpatient acute, inpatient
rehabilitation, and other types of
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.

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

Annual Notice of Changes for 2015
Table of Contents
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 ................................................... 5

SECTION 1

Unless You Choose Another Plan, You Will Be
Automatically Enrolled in [insert 2015 plan name] in 2015............. 5

SECTION 2

Changes to Benefits and Costs for Next Year ................................. 6

Section 2.1 – Changes to the Monthly Premium ...................................................................... 6
Section 2.2 – Changes to Your Maximum Out-of-Pocket Amounts ........................................ 6
Section 2.3 – Changes to the Provider Network ....................................................................... 7
Section 2.4 – Changes to Benefits and Costs for Medical Services ......................................... 8
SECTION 3

Other Changes .................................................................................... 9

SECTION 4

Deciding Which Plan to Choose...................................................... 10

Section 4.1 – If you want to stay in [insert 2015 plan name] ................................................ 10
Section 4.2 – If you want to change plans .............................................................................. 10
SECTION 5

Deadline for Changing Plans ........................................................... 11

SECTION 6

Programs That Offer Free Counseling about Medicare ................ 11

SECTION 7

Programs That Help Pay for Prescription Drugs ........................... 12

SECTION 8

Questions?........................................................................................ 13

Section 8.1 – Getting Help from [insert 2015 plan name] ..................................................... 13
Section 8.2 – Getting Help from Medicare ............................................................................. 13

[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 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.]
[Plans that include a Part B premium reduction benefit may insert a row to describe the change
in the benefit.]
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]

Section 2.2 – Changes to Your Maximum Out-of-Pocket Amounts
[Plans that include the costs of supplemental benefits in the MOOP limit may revise this
information as needed.]
To protect you, Medicare requires all health plans to limit how much you pay “out-of-pocket”
during the year. These limits are called the “maximum out-of-pocket amounts.” Once you reach
the maximum out-of-pocket amounts, you generally pay nothing for covered [insert if
applicable: Part A and Part B] services for the rest of the year.

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

Cost
In-network maximum
out-of-pocket amount

2014 (this year)

2015 (next year)

[insert 2014 in-network
MOOP amount]

[insert 2015 in-network
MOOP amount]

Your costs for covered medical
services (such as copays [insert if
plan has a deductible: and
deductibles]) from in-network
providers count toward your innetwork maximum out-of-pocket
amount. [Plans with no premium
delete the following sentence] Your
plan premium does not count toward
your maximum out-of-pocket
amount.
Combined maximum
out-of-pocket amount

Once you have paid [insert
2015 in-network MOOP
amount] out-of-pocket for
covered [insert if applicable:
Part A and Part B] services
from in-network providers,
you will pay nothing for your
covered [insert if applicable:
Part A and Part B] services
from in-network providers for
the rest of the calendar year.
[insert 2014 combined
MOOP amount]

Your costs for covered medical
services (such as copays [insert if
plan has a deductible: and
deductibles]) from in-network and
out-of-network providers count
toward your combined maximum
out-of-pocket amount. [Plans with no
premium delete the following
sentence] Your plan premium does
not count toward your maximum outof-pocket amount.

[insert 2015 combined
MOOP amount]
Once you have paid [insert
2015 combined MOOP
amount] out-of-pocket for
covered [insert if applicable:
Part A and Part B] services,
you will pay nothing for your
covered [insert if applicable:
Part A and Part B] services
from in-network or out-ofnetwork providers for the rest
of the calendar year.

Section 2.3 – Changes to the Provider Network
[Plans with no changes to their provider network delete this section.]
[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

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

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 2.4 – 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.
[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).]

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

Cost
[insert benefit name]

[insert benefit name]

SECTION 3

2014 (this year)

2015 (next year)

[For benefits that were not
covered in 2014 insert:
[insert benefit name] is not
covered.]

[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 2014 copayment
amount] copay [insert
language as needed to
accurately describe the
benefit (e.g., “per office
visit”)].]

[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 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”)].]

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

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

Other Changes

[This section is optional. Plans with administrative changes that impact members (e.g., a change
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

Cost

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.

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

[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.]
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].
o To change to Original Medicare with a prescription drug plan, enroll in the
new drug plan. You will automatically be disenrolled from [insert 2015 plan
name].



To change to Original Medicare without a prescription drug plan, you must either:
o 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).
o – or – Contact Medicare, at 1-800-MEDICARE (1-800-633-4227), 24 hours a
day, 7 days a week, and ask to be disenrolled. TTY users should call 1-877-4862048.

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 2.3 of the Evidence of Coverage.
If you enrolled in a Medicare Advantage plan for January 1, 2015, and don’t like your plan
choice, you can switch to Original Medicare between January 1 and February 14, 2015. 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 2015 plan name] Annual Notice of Changes for 2015

[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
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 (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,

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

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.]
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.

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

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 “Find health & drug plans.”)
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 [insert if applicable: and
Prescription Drug Coverage] 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, formulary, pharmacy network,
premium, deductible, and/or copayments/coinsurance 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 ................................................................. 1
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 ......................................... 12
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 (the state health insurance program for people with low
incomes), 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. Topics include using the providers in the
plan’s network and how to get care when you have an emergency.

Chapter 4.

Medical Benefits Chart (what is covered and what you pay) ........... 39
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 ................................................................... 74
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 ......................................................... 79
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) ....................................... 89
Tells you step-by-step what to do if you are having problems or concerns as a
member of our plan.
•

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.

Chapter 8. Ending your membership in the plan .................................................... 130
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 ........................................................................................... 138
Includes notices about governing law and about nondiscrimination.
Chapter 10. Definitions of important words ............................................................ 140
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. Getting started as a member
SECTION 1
Section 1.1
Section 1.2
Section 1.3
Section 1.4
Section 1.5
SECTION 2
Section 2.1
Section 2.2
Section 2.3
SECTION 3
Section 3.1
Section 3.2
SECTION 4
Section 4.1
Section 4.2
Section 4.3
SECTION 5
Section 5.1
SECTION 6
Section 6.1
SECTION 7
Section 7.1

Introduction ........................................................................................ 2
You are enrolled in [insert 2015 plan name], which is a Medicare PPO ....... 2
What is the Evidence of Coverage booklet about? .......................................... 2
What does this Chapter tell you? ..................................................................... 2
What if you are new to [insert 2015 plan name]? .......................................... 2
Legal information about the Evidence of Coverage ........................................ 3
What makes you eligible to be a plan member? .............................. 3
Your eligibility requirements .......................................................................... 3
What are Medicare Part A and Medicare Part B? ........................................... 3
Here is the plan service area for [insert 2015 plan name] .............................. 4
What other materials will you get from us? ..................................... 5
Your plan membership card – Use it to get all covered care .......................... 5
The Provider Directory: Your guide to all providers in the plan’s network ... 5
Your monthly premium for [insert 2015 plan name] ........................ 6
How much is your plan premium? .................................................................. 6
There are several ways you can pay your plan premium ................................ 7
Can we change your monthly plan premium during the year?........................ 9
Please keep your plan membership record up to date ................... 9
How to help make sure that we have accurate information about you ............ 9
We protect the privacy of your personal health information ........ 10
We make sure that your health information is protected ............................... 10
How other insurance works with our plan ..................................... 10
Which plan pays first when you have other insurance? ................................ 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 PPO

You are covered by Medicare, and you have chosen to get your Medicare health care coverage
through our plan, [insert 2015 plan name].
There are different types of Medicare health plans. [Insert 2015 plan name] is a Medicare
Advantage PPO Plan (PPO stands for Preferred Provider Organization). This plan does not
include Part D prescription drug coverage. Like all Medicare health plans, this Medicare PPO
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?

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.

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

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

•

-- 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 Medicare Advantage plan that was terminated.

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:

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

•

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]
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.

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

SECTION 3

What other materials will you get from us?

Section 3.1

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

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. 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.
If your plan membership 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

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 have an agreement with us to accept our payment
and any plan cost-sharing as payment in full. We have arranged for these providers to deliver
covered services to members in our plan.
Why do you need to know which providers are part of our network?
As a member of our plan, you can choose to receive care from out-of-network providers. Our
plan will cover services from either in-network or out-of-network providers, as long as the
services are covered benefits and medically necessary. However, if you use an out-of-network
provider, your share of the costs for your covered services may be higher. See Chapter 3 (Using
the plan’s coverage for your medical services) for more specific information.

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

[Regional PPOs that CMS has granted permission to use the exception in § 422.112(a) (1) (ii) to
meet access requirements should insert: Because our Plan is a Regional Preferred Provider
Organization, if no contracted network provider is readily available you can access care at innetwork cost-sharing from an out-of-network provider. Call Member Services to let us know you
need to see an out-of-network provider, or to get help finding an out-of-network provider.]
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.]

SECTION 4

Your monthly premium for [insert 2015 plan name]

Section 4.1

How much is your plan premium?

As a member of our plan, you pay a monthly plan premium. [Select one of the following: For
2015, the monthly premium for [insert 2015 plan name] is [insert monthly premium amount].
OR The table below shows the monthly plan premium amount for each region we serve. OR The
table below shows the monthly plan premium amount for each plan we are offering in the service
area. OR The monthly premium amount for [insert 2015 plan name] is listed in [describe
attachment].] In addition, you must continue to pay your Medicare Part B premium (unless your
Part B premium is paid for you by Medicaid or another third party). [Plans may insert a list of or
table with the state/region and monthly plan premium amount for each area included within the
EOC. Plans may also include premium(s) in an attachment to the EOC.]
[Plans with no premium should replace the preceding paragraph with: You do not pay a
separate monthly plan premium for [insert 2015 plan name]. You must continue to pay your
Medicare Part B premium (unless your Part B premium is paid for you by Medicaid or another
third party).]
[Insert if applicable: Your coverage is provided through a contract with your current employer or
former employer or union. Please contact the employer’s or union’s benefits administrator for
information about your plan premium.]
In some situations, your plan premium could be more
[MA-only plans that do not offer optional supplemental benefits, may delete this section.]
[MA-only plans that offer optional supplemental benefits may replace the text below with the
following: In some situations, your plan premium could be more than the amount listed above in
Section 4.1. 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

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

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
[Plans that include a Part B premium reduction benefit may describe the benefit within this
section.]
[Plans with no monthly premium, omit: In addition to paying the monthly plan premium,] 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 premiums 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 (1800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048.
Section 4.2

There are several ways you can pay your plan premium

[Plans indicating in Section 4.1 that there is no monthly premium: Delete this section.]
There are [insert number of payment options] ways you can pay your plan premium. [Plans must
indicate how the member can inform the plan of their premium payment option choice and the
procedure for changing that choice.]
If you decide to change the way you pay your premium, it can take up to three months for your
new payment method to take effect. While we are processing your request for a new payment
method, you are responsible for making sure that your plan premium is paid on time.
Option 1: You can pay by check
[Insert plan specifics regarding premium payment intervals (e.g., monthly, quarterly- please note
that beneficiaries must have the option to pay their premiums monthly), how they can pay by
check, including an address, whether they can drop off a check in person, and by what day the
check must be received (e.g., the 5th of each month). It should be emphasized that checks should
be made payable to the Plan and not CMS nor HHS. If the Plan uses coupon books, explain

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

when they will receive it and to call Member Services for a new one if they run out or lose it. In
addition, include information if you charge for bounced checks.]
Option 2: [Insert option type]
[If applicable: Insert information about other payment options. Or delete this option.
Include information about all relevant choices (e.g., automatically withdrawn from your
checking or savings account, charged directly to your credit or debit card, or billed each month
directly by the plan). Insert information on the frequency of automatic deductions (e.g., monthly,
quarterly – please note that beneficiaries must have the option to pay their premiums monthly),
the approximate day of the month the deduction will be made, and how this can be set up. Please
note that furnishing discounts for enrollees who use direct payment electronic payment methods
is prohibited.]
Option [insert number]: You can have the plan premium taken out of your
monthly Social Security check
You can have the plan premium taken out of your monthly Social Security check. Contact
Member Services for more information on how to pay your plan premium this way. We will be
happy to help you set this up. (Phone numbers for Member Services are printed on the back
cover of this booklet.)
What to do if you are having trouble paying your plan premium
[Plans that do not disenroll members for non-payment may modify this section as needed.]
Your plan premium is due in our office by the [insert day of the month]. If we have not received
your premium payment by the [insert day of the month], we will send you a notice telling you
that your plan membership will end if we do not receive your plan premium within [insert length
of plan grace period].
If you are having trouble paying your premium on time, please contact Member Services to see if
we can direct you to programs that will help with your plan premium. (Phone numbers for
Member Services are printed on the back cover of this booklet.)
If we end your membership because you did not pay your premium, you will have health
coverage under Original Medicare.
[Insert if applicable: At the time we end your membership, you may still owe us for premiums
you have not paid. [Insert one or both statements as applicable for the plan: We have the right to
pursue collection of these premiums. AND/OR In the future, if you want to enroll again in our
plan (or another plan that we offer), you will need to pay the late premiums before you can
enroll.]]

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

If you think we have wrongfully ended your membership, you have a right to ask us to reconsider
this decision by making a complaint. Chapter 7, Section 9 of this booklet tells how to make a
complaint. If you had an emergency circumstance that was out of your control and it caused you
to not be able to pay your premiums within our grace period, you can ask Medicare to reconsider
this decision 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.
Section 4.3

Can we change your monthly plan premium during the year?

No. [Plans with no premium replace next sentence with the following: We are not allowed to
begin charging a monthly plan premium during the year.] We are not allowed to change the
amount we charge for the plan’s monthly plan premium during the year. If the monthly plan
premium changes for next year we will tell you in September and the change will take effect on
January 1.

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].
The doctors, hospitals, and other providers in the plan’s network need to have correct
information about you. These network providers use your membership record to know what
services are covered and the cost-sharing amounts for you. 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 or out-of-network hospital or emergency room

•

If your designated responsible party (such as a caregiver) changes

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

•

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 we must coordinate any other coverage you
have with your benefits under our plan. (For more information about how our coverage works
when you have other insurance, see Section 7 in this chapter.)
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.

SECTION 7

How other insurance works with our plan

Section 7.1

Which plan pays first when you have other insurance?

When you have other insurance (like employer group health coverage), there are rules set by
Medicare that decide whether our plan or your other insurance pays first. The insurance that pays
first is called the “primary payer” and pays up to the limits of its coverage. The one that pays
second, called the “secondary payer,” only pays if there are costs left uncovered by the primary
coverage. The secondary payer may not pay all of the uncovered costs.

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

These rules apply for employer or union group health plan coverage:
•

If you have retiree coverage, Medicare pays first.

•

If your group health plan coverage is based on your or a family member’s current
employment, who pays first depends on your age, the number of people employed by
your employer, and whether you have Medicare based on age, disability, or End-stage
Renal Disease (ESRD):
o If you’re under 65 and disabled and you or your family member is still working,
your plan pays first if the employer has 100 or more employees or at least one
employer in a multiple employer plan that has more than 100 employees.
o If you’re over 65 and you or your spouse is still working, the plan pays first if the
employer has 20 or more employees or at least one employer in a multiple
employer plan that has more than 20 employees.

•

If you have Medicare because of ESRD, your group health plan will pay first for the first
30 months after you become eligible for Medicare.

These types of coverage usually pay first for services related to each type:
•

No-fault insurance (including automobile insurance)

•

Liability (including automobile insurance)

•

Black lung benefits

•

Workers’ compensation

Medicaid and TRICARE never pay first for Medicare-covered services. They only pay after
Medicare, employer group health plans, and/or Medigap have paid.
If you have other insurance, tell your doctor, hospital, and pharmacy. If you have questions about
who pays first, or you need to update your other insurance information, call Member Services
(phone numbers are printed on the back cover of this booklet.) You may need to give your plan
member ID number to your other insurers (once you have confirmed their identity) so your bills
are paid correctly and on time.

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) ........................ 13

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]

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

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

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 24hour 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]

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

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

Method

Appeals For Medical Care – Contact Information

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]

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

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

Method

Complaints About Medical Care – Contact Information

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.

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] [Note: You are required to accept payment
requests in writing, and may choose to also accept payment requests
by phone.]
[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] [Note: You are required to accept
payment requests in writing, and may choose to also accept payment
requests by fax.]

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

Method

Payment Requests – Contact Information

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.
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.

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

Method

Medicare – Contact Information

WEBSITE

http://www.medicare.gov
This is the official government website for Medicare. It gives you upto-date information about Medicare and current Medicare issues. It
also has information about hospitals, nursing homes, physicians,
home health agencies, and dialysis facilities. It includes booklets you
can print directly from your computer. 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-of-pocket 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 (1-800-6334227), 24 hours a day, 7 days a week. TTY users should call 1-877486-2048.)

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)]

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)]

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 ESRD 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].
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 2
Section 2.1
Section 2.2
Section 2.3
Section 2.4
Section 2.5
SECTION 3
Section 3.1
Section 3.2
SECTION 4
Section 4.1
Section 4.2
SECTION 5
Section 5.1
Section 5.2
SECTION 6
Section 6.1
Section 6.2

Things to know about getting your medical care covered as
a member of our plan ....................................................................... 26
What are “network providers” and “covered services”? ............................... 26
Basic rules for getting your medical care covered by the plan ..................... 26
Using network and out-of-network providers to get your
medical care ...................................................................................... 27
You [insert as applicable: may OR must] choose a Primary Care
Provider (PCP) to provide and oversee your medical care ........................... 27
What kinds of medical care can you get without getting approval in
advance from your PCP? ............................................................................... 28
How to get care from specialists and other network providers ..................... 28
How to get care from out-of-network providers ........................................... 29
How to get care if you live in a non-network area ........................................ 30
How to get covered services when you have an emergency
or urgent need for care .................................................................... 31
Getting care if you have a medical emergency ............................................. 31
Getting care when you have an urgent need for care .................................... 32
What if you are billed directly for the full cost of your
covered services? ............................................................................ 33
You can ask us to pay our share of the cost of covered services .................. 33
If services are not covered by our plan, you must pay the full cost .............. 33
How are your medical services covered when you are in a
“clinical research study”? ............................................................... 33
What is a “clinical research study”? .............................................................. 33
When you participate in a clinical research study, who pays for what? ....... 34
Rules for getting care covered in a “religious non-medical
health care institution” .................................................................... 36
What is a religious non-medical health care institution? .............................. 36
What care from a religious non-medical health care institution is covered
by our plan? ................................................................................................... 36

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

SECTION 7
Section 7.1

Rules for ownership of durable medical equipment ..................... 37
Will you own the durable medical equipment after making a certain
number of payments under our plan? ............................................................ 37

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
coverage. 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 “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.

•

“Network providers” are the doctors and other health care professionals, medical
groups, hospitals, and other health care facilities that have an agreement with us to accept
our payment and your cost-sharing amount as payment in full. We have arranged for
these providers to deliver covered services to members in 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).

•

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.

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

•

You receive your care from a provider who is eligible to provide services under
Original Medicare. As a member of our plan, you can receive your care from either a
network provider or an out-of-network provider (for more about this, see Section 2 in this
chapter).
o The providers in our network are listed in the Provider Directory.
o If you use an out-of-network provider, your share of the costs for your covered
services may be higher.
o [RPPOs that CMS has granted permission to use the exception in § 422.112(a) (1)
(ii) to meet access requirements should insert: Because our plan is a Regional
Preferred Provider Organization, if there isn’t a network provider available for you
to see, you can go to an out-of-network provider but still pay the in-network
amounts.]
o Please note: While you can get your care from an out-of-network provider, the
provider must be eligible to participate in Medicare. Except for emergency care, we
cannot pay a provider who is not eligible to participate in Medicare. If you go to a
provider who is not eligible to participate in Medicare, you will be responsible for
the full cost of the services you receive. Check with your provider before receiving
services to confirm that they are eligible to participate in Medicare.

SECTION 2

Using network and out-of-network providers to get
your medical care

Section 2.1

You [insert as applicable: may OR must] choose a Primary
Care Provider (PCP) to provide and oversee your medical care

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

What is a PCP?
What types of providers may act as a PCP?
Explain the role of a PCP in your plan.
What is the role of the PCP in coordinating covered services?
What is the role of the PCP in making decisions about or obtaining prior authorization, if
applicable?]

How do you choose your PCP?
[Plans should describe how to choose a PCP.]

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

Changing your PCP
You may change your PCP for any reason, at any time. Also, it’s possible that your PCP might
leave our plan’s network of providers and you would have to find a new PCP in our plan [PPOs
with lower cost-sharing for network providers insert: or you will pay more for covered services].
[Plans should describe how to change a PCP and indicate when that change will take effect
(e.g., on the first day of the month following the date of the request, immediately upon receipt of
request, etc.).]
Section 2.2

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

[Note: Insert this section only if plans use PCPs or require referrals to network providers.]
You can get services such as those listed below without getting approval in advance from your
PCP.
•

Routine women’s health care, which includes breast exams, screening mammograms (xrays of the breast), Pap tests, and pelvic exams [insert if appropriate: as long as you get
them from a network provider].

•

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

•

Emergency services from network providers or from out-of-network providers.

•

Urgently needed care from in-network providers or from out-of-network providers when
network providers are temporarily unavailable or inaccessible, e.g., when you are
temporarily outside of the plan’s service area.

•

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

•

[Plans should add additional bullets as appropriate.]

Section 2.3

How to get care from specialists and other network providers

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

Oncologists care for patients with cancer.

•

Cardiologists care for patients with heart conditions.

•

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

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

[Plans should describe how members access specialists and other network providers, including:
• What is the role (if any) of the PCP in referring members to specialists and other
providers?
• Include an explanation of the process for obtaining Prior Authorization (PA), including
who makes the PA decision (e.g., the plan, PCP, another entity) and who is responsible
for obtaining the prior authorization (e.g., PCP, member). Refer members to Chapter 4,
Section 2.1 for information about which services require prior authorization.
• Explain if the selection of a PCP results in being limited to specific specialists or
hospitals to which that PCP refers, i.e. sub-network, referral circles.]
What if a specialist or another network provider leaves our plan?
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.

[Plans should provide contact information for assistance.]

Section 2.4

How to get care from out-of-network providers

As a member of our plan, you can choose to receive care from out-of-network providers. Our
plan will cover services from either in-network or out-of-network providers, as long as the
services are covered benefits and are medically necessary. However, if you use an out-ofnetwork provider, your share of the costs for your covered services may be higher. Here are
other important things to know about using out-of-network providers:

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

•

You can get your care from an out-of-network provider, however, in most cases that
provider must be eligible to participate in Medicare. Except for emergency care, we
cannot pay a provider who is not eligible to participate in Medicare. If you receive care
from a provider who is not eligible to participate in Medicare, you will be responsible for
the full cost of the services you receive. Check with your provider before receiving
services to confirm that they are eligible to participate in Medicare.

•

You don’t need to get a referral or prior authorization when you get care from out-ofnetwork providers. However, before getting services from out-of-network providers you
may want to ask for a pre-visit coverage decision to confirm that the services you are
getting are covered and are medically necessary. (See Chapter 7, Section 4 for
information about asking for coverage decisions.) This is important because:
o Without a pre-visit coverage decision, if we later determine that the services are
not covered or were not medically necessary, we may deny coverage and you will
be responsible for the entire cost. If we say we will not cover your services, you
have the right to appeal our decision not to cover your care. See Chapter 7 (What
to do if you have a problem or complaint) to learn how to make an appeal.

•

[RPPOs that CMS has granted permission to use the exception in § 422.112(a) (1) (ii) to
meet access requirements should insert: Because our plan is a Regional Preferred
Provider Organization, if no contracted network provider is readily available you can
access care at in-network cost-sharing from an out-of-network provider. Call Member
Services to let us know you need to see an out-of-network provider, or to get help finding
an out-of-network provider. (Phone numbers for Member Services are printed on the
back cover of this booklet.)]

•

It is best to ask an out-of-network provider to bill the plan first. But, if you have already
paid for the covered services, we will reimburse you for our share of the cost for covered
services. Or if an out-of-network provider sends you a bill that you think we should pay,
you can send it to us for payment. See Chapter 5 (Asking us to pay our share of a bill you
have received for covered medical services) for information about what to do if you
receive a bill or if you need to ask for reimbursement.

•

If you are using an out-of-network provider for emergency care, urgently needed care, or
out-of-area dialysis, you may not have to pay a higher cost-sharing amount. See Section 3
for more information about these situations.

Section 2.5

How to get care if you live in a non-network area

[RPPOs: If there are portions of your RPPO service area where you have not met Medicare
network adequacy requirements, you must insert this section and explain to your enrollees the
process they must follow to find providers who will treat them (see 422.111(b)(3)(ii)). The
expectation is that enrollees in non-network areas will receive all necessary assistance in
obtaining access to services, which may require the RPPO to pay more than the Original
Medicare payment rate to ensure access. Enrollees in non-network areas can only be charged
the in-network (i.e., preferred) cost-sharing amount for plan-covered services.]

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

SECTION 3

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

Section 3.1

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, 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.
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 or a
referral first from your PCP.
• [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. Your follow-up care will be covered by our plan. If you get your
follow-up care from out-of-network providers, you will pay the higher out-of-network costsharing.

2015 Evidence of Coverage for [insert 2015 plan name]
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What if it wasn’t a medical emergency?
Sometimes it can be hard to know if you have a medical emergency. For example, you might go
in for emergency care – thinking that your health is in serious danger – and the doctor may say
that it wasn’t a medical emergency after all. If it turns out that it was not an emergency, as long
as you reasonably thought your health was in serious danger, we will cover your care.
However, after the doctor has said that it was not an emergency, the amount of cost-sharing that
you pay will depend on whether you get the care from network providers or out-of-network
providers. If you get the care from network providers, your share of the costs will usually be
lower than if you get the care from out-of-network providers.
Section 3.2

Getting care when you have an urgent need for care

What is “urgently needed care”?
“Urgently needed care” is a non-emergency, unforeseen medical illness, injury, or condition that
requires immediate medical care. Urgently needed care may be furnished by in-network
providers or by out-of-network providers when network providers are temporarily unavailable or
inaccessible. The unforeseen condition could, for example, be an unforeseen flare-up of a known
condition that you have.
What if you are in the plan’s service area when you have an urgent need for care?
In most situations, if you are in the plan’s service area and you use an out-of-network provider,
you will pay a higher share of the costs for your care. However, if the circumstances are unusual
or extraordinary, and network providers are temporarily unavailable or inaccessible, we will
allow you to get covered services from an out-of-network provider at the lower in-network costsharing amount.
[Plans must insert instructions for how to access in-network urgently needed services (e.g., using
urgent care centers, a provider hotline, etc.)]
What if you are outside the plan’s service area when you have an urgent need for
care?
When you are outside the service area and cannot get care from a network provider, our plan will
cover urgently needed care that you get from any provider at the lower in-network cost-sharing
amount.
[Insert if applicable: Our plan does not cover urgently needed care or any other [insert if plan
covers emergency care outside of the United States: non-emergency] care if you receive the care
outside of the United States. [Modify if overseas care is covered as a supplemental benefit.]]

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

SECTION 4

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

Section 4.1

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

If you have paid more than your share for covered services, or if you have received a bill for the
full cost of covered medical services, go to Chapter 5 (Asking us to pay our share of a bill you
have received for covered medical services) for information about what to do.
Section 4.2

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, either because they are not plan covered services, or plan rules were not
followed.
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.

SECTION 5

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

Section 5.1

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

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

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.
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).
Section 5.2

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.

2015 Evidence of Coverage for [insert 2015 plan name]
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•

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.
Here’s an example of how the cost-sharing works: Let’s say that you have a lab test that
costs $100 as part of the research study. Let’s also say that your share of the costs for this
test is $20 under Original Medicare, but the test would be $10 under our plan’s benefits.
In this case, Original Medicare would pay $80 for the test and we would pay another $10.
This means that you would pay $10, which is the same amount you would pay under our
plan’s benefits.
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 6

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

Section 6.1

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 6.2

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]
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[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 7

Rules for ownership of durable medical equipment

Section 7.1

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 1.4
Section 1.5
Section 1.6
SECTION 2
Section 2.1
Section 2.2
Section 2.3
SECTION 3
Section 3.1

Understanding your out-of-pocket costs for covered
services ............................................................................................. 40
Types of out-of-pocket costs you may pay for your covered services .......... 40
What is your yearly plan deductible? ............................................................ 40
Our plan [insert if plan has an overall deductible described in Sec. 1.2:
also] has a [insert if plan has an overall deductible described in Sec. 1.2:
separate] deductible for certain types of services from in-network
providers ........................................................................................................ 41
What is the most you will pay for [insert if applicable: Medicare Part A
and Part B] covered medical services? .......................................................... 42
Our plan also limits your out-of-pocket costs for certain types of services .. 43
Our plan does not allow providers to “balance bill” you .............................. 44
Use the Medical Benefits Chart to find out what is covered
for you and how much you will pay ................................................ 45
Your medical benefits and costs as a member of the plan ............................ 45
Extra “optional supplemental” benefits you can buy .................................... 70
Getting care using our plan’s optional visitor/traveler benefit ...................... 70
What benefits are not covered by the plan? .................................. 71
Benefits we do not cover (exclusions) .......................................................... 71

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

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

The “deductible” is the amount you must pay for medical services before our plan begins
to pay its share. ([Insert if applicable: Section 1.2 tells you more about your yearly plan
deductible.] [Insert if applicable: Section 1.3 tells you more about your yearly
deductibles for certain categories of services.])

•

A “copayment” is the fixed amount you pay each time you receive certain medical
services. You pay a copayment at the time you get the medical service. (The Medical
Benefits Chart in Section 2 tells you more about your copayments.)

•

“Coinsurance” is the percentage you pay of the total cost of certain medical services.
You pay a coinsurance at the time you get the medical service. (The Medical Benefits
Chart in Section 2 tells you more about your coinsurance.)

Some people qualify for State Medicaid programs to help them pay their out-of-pocket costs for
Medicare. (These “Medicare Savings Programs” include the Qualified Medicare Beneficiary
(QMB), Specified Low-Income Medicare Beneficiary (SLMB), Qualifying Individual (QI), and
Qualified Disabled & Working Individuals (QDWI) programs.) If you are enrolled in one of
these programs, you may still have to pay a copayment for the service, depending on the rules in
your state.
Section 1.2

What is your yearly plan deductible?

[Local or regional PPO plans with no deductibles, delete this section and renumber remaining
subsections in Section 1.]

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

[Note, RPPOs and local PPO plans that choose to have a deductible are now only permitted to
have a single deductible that applies to both in-network and out-of-network services, see revised
section 422.101(d)(1).]
Your yearly deductible is [insert deductible amount]. This is the amount you have to pay out-ofpocket before we will pay our share for your covered medical services.
Until you have paid the deductible amount, you must pay the full cost for most of your covered
services. (The deductible does not apply to the services that are listed below.) Once you have
paid your deductible, we will begin to pay our share of the costs for covered medical services
and you will pay your share ([insert as applicable: your copayment OR your coinsurance amount
OR your copayment or coinsurance amount]) for the rest of the calendar year.
The deductible does not apply to some services, including certain in-network preventive services.
This means that we will pay our share of the costs for these services even if you haven’t paid
your yearly deductible yet. The deductible does not apply to the following services:
•

[Insert all services not subject to the deductible, including all Medicare-covered
preventive services and any other in-network Part A and B services the plan elects to
exempt from the deductible requirement. Plans must specify whether it is in-network
and/or out-of-network services that are exempt from the deductible.] [Note: If a PPO
has a deductible, all out-of-network Part A and B services must be subject to the
deductible with the sole exception that the PPO may elect to waive out-of-network
Medicare-covered zero cost-sharing preventive services from the deductible
requirement.]

Section 1.3

Our plan [insert if plan has an overall deductible described in
Sec. 1.2: also] has a [insert if plan has an overall deductible
described in Sec. 1.2: separate] deductible for certain types of
services from in-network providers

[Plans with service category deductibles: insert this section. If applicable, plans may revise the
text as needed to describe how the service category deductible(s) work with the overall plan
deductible.]
[Plans with a service category deductible that is not based on the calendar year – e.g., a per stay
deductible – should revise this section as needed.]
[Insert if plan has an overall deductible described in Sec. 1.2: In addition to the yearly plan
deductible that applies to all of your covered medical services, we also have a yearly deductible
for certain types of services.]
[Insert if plan does not have an overall deductible and Sec. 1.2 was therefore omitted: We have a
yearly deductible for certain types of services.]
[Insert if plan has one service category deductible: The plan has a yearly deductible amount of

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

[insert service category deductible] for [insert service category]. Until you have paid the
deductible amount, you must pay the full cost for [insert service category]. Once you have paid
your deductible, we will pay our share of the costs for these services and you will pay your share
([insert as applicable: your copayment OR your coinsurance amount OR your copayment or
coinsurance amount]) for the rest of the calendar year. [Insert if applicable: Both the yearly plan
deductible and the yearly deductible for [insert service category] apply to your covered [insert
service category]. This means that once you meet either the yearly plan deductible or the
deductible for [insert service category], we will begin to pay our share of the costs of your
covered [insert service category].]
[Insert if plan has more than one service category deductible: The plan has a yearly deductible
amount for the following types of services:
•

[Plans should insert a separate bullet for each service category deductible: Our yearly
deductible amount for [insert service category] is [insert service category deductible].
Until you have paid the deductible amount, you must pay the full cost for [insert service
category]. Once you have paid your deductible, we will pay our share of the costs for
these services and you will pay your share ([insert as applicable: your copayment OR
your coinsurance amount OR your copayment or coinsurance amount]) for the rest of the
calendar year. [Insert if applicable: Both the yearly plan deductible and the yearly
deductible for [insert service category] apply to your covered [insert service category].
This means that once you meet either the yearly plan deductible or the deductible for
[insert service category], we will begin to pay our share of the costs of your covered
[insert service category].]]

Section 1.4

What is the most you will pay for [insert if applicable: Medicare
Part A and Part B] covered medical services?

Under our plan, there are two different limits on what you have to pay out-of-pocket for covered
medical services:
•

Your in-network maximum out-of-pocket amount is [insert in-network MOOP]. This
is the most you pay during the calendar year for covered [insert as applicable: Medicare
Part A and Part B OR plan] services received from in-network providers. The amounts
you pay for [insert applicable terms: deductibles, copayments, and coinsurance] for
covered services from in-network providers count toward this in-network maximum outof-pocket amount. [Plans with no premium may modify the following sentence as needed]
(The amounts you pay for plan premiums and services from out-of-network providers do
not count toward your in-network maximum out-of-pocket amount. [Insert if applicable,
revising reference to asterisk as needed: In addition, amounts you pay for some services
do not count toward your in-network maximum out-of-pocket amount. These services are
marked with an asterisk in the Medical Benefits Chart.]) If you have paid [insert innetwork MOOP] for covered [insert if applicable: Part A and Part B] services from innetwork providers, you will not have any out-of-pocket costs for the rest of the year when
you see our network providers. However, you must continue to pay [insert if plan has a

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

premium: your plan premium and] the Medicare Part B premium (unless your Part B
premium is paid for you by Medicaid or another third party).
•

Your combined maximum out-of-pocket amount is [insert combined MOOP]. This is
the most you pay during the calendar year for covered [insert as applicable: Medicare
Part A and Part B OR plan] services received from both in-network and out-of-network
providers. The amounts you pay for [insert applicable terms: deductibles, copayments,
and coinsurance] for covered services count toward this combined maximum out-ofpocket amount. [Plans with no premium may delete the following sentence] (The
amounts you pay for your plan premiums do not count toward your combined maximum
out-of-pocket amount. [Insert if applicable, revising reference to asterisk as needed: In
addition, amounts you pay for some services do not count toward your combined
maximum out-of-pocket amount. These services are marked with an asterisk in the
Medical Benefits Chart.]) If you have paid [insert combined MOOP] for covered
services, you will have 100% coverage and will not have any out-of-pocket costs for the
rest of the year for covered [insert if applicable: Part A and Part B] services. However,
you must continue to pay [insert if plan has a premium: your plan premium and] the
Medicare Part B premium (unless your Part B premium is paid for you by Medicaid or
another third party).

Section 1.5

Our plan also limits your out-of-pocket costs for certain types
of services

[Plans with service category OOP maximums: insert this section.]
[Plans with a service category OOP maximum that is not based on the calendar year – e.g., a
per stay maximum – should revise this section as needed.]
In addition to the in-network and combined maximum out-of-pocket amounts for covered [insert
if applicable: Part A and Part B] services (see Section 1.4 above), we also have a separate
maximum out-of-pocket amount that applies only to certain types of services.
[Insert if plan has one service category MOOP: The plan has a maximum out-of-pocket amount
of [insert service category MOOP] for [insert service category]. Once you have paid [insert
service category MOOP] out-of-pocket for [insert service category], the plan will cover these
services at no cost to you for the rest of the calendar year. [Insert if service category is included
in MOOP described in Section 1.4: Both the maximum out-of-pocket amount for Part A and Part
B medical services and the maximum out-of-pocket amount for [insert service category] apply
to your covered [insert service category]. This means that once you have paid either [insert
MOOP] for Part A and Part B medical services or [insert service category OOP max] for your
[insert service category], the plan will cover your [insert service category] at no cost to you for
the rest of the year.]]
[Insert if plan has more than one service category MOOP: The plan has a maximum out-ofpocket amount for the following types of services:

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
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•

[Plans should insert a separate bullet for each service category MOOP: Our maximum
out-of-pocket amount for [insert service category] is [insert service category MOOP].
Once you have paid [insert service category MOOP] out-of-pocket for [insert service
category], the plan will cover these services at no cost to you for the rest of the calendar
year. [Insert if service category is included in MOOP described in Section 1.4: Both the
maximum out-of-pocket amount for Part A and Part B medical services and the
maximum out-of-pocket amount for [insert service category] apply to your covered
[insert service category]. This means that once you have paid either [insert MOOP] for
Part A and Part B medical services or [insert service category OOP max] for your [insert
service category], the plan will cover your [insert service category] at no cost to you for
the rest of the year.]]

Section 1.6

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 [plans with a
plan-level deductible insert: after you meet any deductibles,] you only have to pay your costsharing amount when you get services covered by our plan. We do not allow providers to add
additional separate charges, called “balance billing.” This protection (that you never pay more
than your cost-sharing amount) 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.
Here is how this protection works.
•

If your cost-sharing is a copayment (a set amount of dollars, for example, $15.00), then
you pay only that amount for any covered services from a network provider. You will
generally have higher copays when you obtain care from out-of-network providers.

•

If your cost-sharing is a coinsurance (a percentage of the total charges), then you never
pay more than that percentage. However, your cost depends on which type of provider
you see:
o If you receive the covered services from a network provider, you pay the
coinsurance percentage multiplied by the plan’s reimbursement rate (as
determined in the contract between the provider and the plan).
o If you receive the covered services from an out-of-network provider who
participates with Medicare, you pay the coinsurance percentage multiplied by the
Medicare payment rate for participating providers.
o If you receive the covered services from an out-of-network provider who does not
participate with Medicare, you pay the coinsurance percentage multiplied by the
Medicare payment rate for non-participating providers.

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

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

•

[PPO plans that use prior authorizations insert: Some of the services listed in the
Medical Benefits Chart are covered as in-network services only if your doctor or other
network provider gets approval in advance (sometimes called “prior authorization”) from
[insert 2015 plan name].
o Covered services that need approval in advance to be covered as in-network
services are marked [insert as appropriate: by an asterisk OR by a footnote OR in
bold OR in italics] in the Medical Benefits Chart. [Insert if applicable: In
addition, the following services not listed in the Benefits Chart require approval in
advance: [insert list].]
o You never need approval in advance for out-of-network services from out-ofnetwork providers.
o While you don’t need approval in advance for out-of-network services, you or
your doctor can ask us to make a coverage decision in advance.]

Other important things to know about our coverage:
•

For benefits where your cost-sharing is a coinsurance percentage, the amount you pay
depends on what type of provider you receive the services from:
o If you receive the covered services from a network provider, you pay the
coinsurance percentage multiplied by the plan’s reimbursement rate (as
determined in the contract between the provider and the plan).
o If you receive the covered services from an out-of-network provider who
participates with Medicare, you pay the coinsurance percentage multiplied by the
Medicare payment rate for participating providers.
o If you receive the covered services from an out-of-network provider who does not
participate with Medicare, you pay the coinsurance percentage multiplied by the
Medicare payment rate for non-participating providers.

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

•

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.).

•

We do not charge office visit cost-sharing if the sole purpose of the visit is to obtain
preventive services. [Insert as applicable: However, if you also are treated or monitored
for an existing medical condition during the visit when you receive the preventive
service, a copayment will apply for the care received for the existing medical condition.]

•

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 any benefits for which the plan uses Medicare amounts for member cost-sharing in
their approved bid, the plan may insert the 2014 Medicare amounts; note that these
amounts may change in 2015, and the plan will provide updated rates as soon as
Medicare releases them.
• 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 benefits.
• 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 should clearly indicate which benefits are subject to prior authorization (plans may
use asterisks or similar method).
• Plans may insert any additional benefits information based on the plan’s approved bid
that is not captured in the benefits chart or in the exclusions section. 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.]

What you must pay when
you get these services

There is no coinsurance,
copayment, or deductible for
beneficiaries eligible for this
preventive screening.

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.

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

• 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.

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

Bone mass measurement
For qualified individuals (generally, this means people at risk
of losing bone mass or at risk of osteoporosis), the following
services are covered every 24 months or more frequently if
medically necessary: procedures to identify bone mass, detect
bone loss, or determine bone quality, including a physician’s
interpretation of the results.
[Also list any additional benefits offered.]

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.
[Also list any additional benefits offered.]

What you must pay when
you get these services

There is no coinsurance,
copayment, or deductible for
Medicare-covered bone mass
measurement.

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

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 one 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.

[List copays / coinsurance /
deductible]

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

What you must pay when
you get these services

[Also list any additional benefits offered.]

Cardiovascular disease testing
Blood tests for the detection of cardiovascular disease (or
abnormalities associated with an elevated risk of
cardiovascular disease) once every five years (60 months).

There is no coinsurance,
copayment, or deductible for
cardiovascular disease
testing that is covered once
every five years.

[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.
[Also list any additional benefits offered.]

There is no coinsurance,
copayment, or deductible for
Medicare-covered preventive
Pap and pelvic exams.

Chiropractic services
Covered services include:

[List copays / coinsurance /
deductible]

•

We cover only manual manipulation of the spine to
correct subluxation.
[Also list any additional benefits offered.]

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:
•

Screening colonoscopy (or screening barium enema as

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

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

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.]
[Include row if applicable. If plan offers dental benefits as
optional supplemental benefits, they should not be included in
the chart. Plans may describe them in Section 2.2 instead.]

[List copays / coinsurance /
deductible]

Dental services
In general, preventive dental services (such as cleaning,
routine dental exams, and dental x-rays) are not covered by
Original Medicare. We cover:
[List any additional benefits offered, such as routine dental
care.]

Depression screening
We cover one screening for depression per year. The screening
must be done in a primary care setting that can provide followup treatment and referrals.

There is no coinsurance,
copayment, or deductible for
an annual depression
screening visit.

[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

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

What you must pay when
you get these services

to two diabetes screenings every 12 months.
[Also list any additional benefits offered.]

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 non-insulin users). Covered services
include:

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

•

Supplies to monitor your blood glucose: Blood glucose
monitor, blood glucose test strips, lancet devices and
lancets, and glucose-control 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.]
Durable medical equipment and related supplies
(For a definition of “durable medical equipment,” 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

[List copays / coinsurance /
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

What you must pay when
you get these services

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).)]
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

[List copays / coinsurance /
deductible. If applicable,
explain that cost-sharing is
waived if member admitted
to hospital.]
[Insert if applicable: If you
receive emergency care at an

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
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.
[Also identify whether this coverage is within the U.S. or
world-wide.]

Health and wellness education programs
[These are programs focused on health conditions such as
high blood pressure, cholesterol, asthma, and special diets.
Programs designed to enrich the health and lifestyles of
members include weight management, fitness, and stress
management. Describe the nature of the programs here.
If this benefit is not applicable, plans should delete this row.]

What you must pay when
you get these services
out-of-network hospital and
need inpatient care after your
emergency condition is
stabilized, you must move to
a network hospital in order to
pay the in-network costsharing amount for the part
of your stay after you are
stabilized. If you stay at the
out-of-network hospital, your
stay will be covered but you
will pay the out-of-network
cost-sharing amount for the
part of your stay after you
are stabilized.]

[List copays / coinsurance /
deductible]

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.

[List copays / coinsurance /
deductible]

[List any additional benefits offered, such as routine hearing
exams, hearing aids, and evaluations for fitting hearing aids.]

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

There is no coinsurance,
copayment, or deductible for
beneficiaries eligible for
Medicare-covered preventive

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
•

One screening exam every 12 months.

What you must pay when
you get these services
HIV screening.

For women who are pregnant, we cover:
•

Up to three screening exams during a pregnancy.

[Also list any additional benefits offered.]
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.

[List copays / coinsurance /
deductible]

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 8 hours per day
and 35 hours per week).
Physical therapy, occupational therapy, and speech
therapy.
Medical and social services.
Medical equipment and supplies.

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

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

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

condition: Original Medicare (rather than our plan) will pay for applicable.]
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 covered by Medicare Part A or B and are
not related to your terminal condition: If you need nonemergency, non-urgently needed services that are covered
under Medicare Part A or B and that are not related to your
terminal condition, your cost for these services depends on
whether you use a provider in our plan’s network:
•

If you obtain the covered services from a network
provider, you only pay the plan cost-sharing amount for
in-network services.

•

If you obtain the covered services from an out-ofnetwork provider, you pay the plan cost-sharing for outof-network services.

For services that are covered by [insert 2015 plan name] but
are not covered by Medicare Part A or B: [insert 2015 plan
name] will continue to cover plan-covered services that are
not covered under Part A or B whether or not they are 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.

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

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

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.

[Also list any additional benefits offered.]
Inpatient hospital care
Includes inpatient acute, inpatient rehabilitation, and other
types of 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, kidneypancreatic, 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

[List all cost-sharing
(deductible,
copayments/coinsurance)
and the period for which they
will be charged. If costsharing is based on the
original Medicare or a plandefined benefit period,
include
definition/explanation of
approved benefit period
here. Plans that use peradmission deductible
include: A per admission
deductible is applied once
during the defined benefit
period. [In addition, if
applicable, explain all other
cost-sharing that is charged
during a benefit period.]]
[If cost-sharing is not based
on the original Medicare or
plan-defined benefit period,
explain here when the costsharing will be applied. If it
is charged on a per
admission basis, include: A
deductible and/or other costsharing is charged for each
inpatient stay.]
[If inpatient cost-sharing

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

•

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 three 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.]
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 1-877-486-2048. You can call these numbers for
free, 24 hours a day, 7 days a week.

What you must pay when
you get these services
varies based on hospital tier,
enter that cost-sharing in the
data entry fields.]
If you get [insert if
applicable: authorized]
inpatient care at an out-ofnetwork hospital after your
emergency condition is
stabilized, your cost is the
[insert if applicable: highest]
cost-sharing you would pay
at a network hospital.

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 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.]

What you must pay when
you get these services
[List all cost-sharing
(deductible,
copayments/coinsurance)
and the period for which they
will be charged. If costsharing is based on the
original Medicare or a plandefined benefit period,
include
definition/explanation of
approved benefit period
here. Plans that use peradmission deductible
include: A per admission
deductible is applied once
during the defined benefit
period. [In addition, if
applicable, explain all other
cost-sharing that is charged
during a benefit period.]]
[If cost-sharing is not based
on the original Medicare or
plan-defined benefit period,
explain here when the costsharing will be applied. If it
is charged on a per
admission basis, include: A
deductible and/or other costsharing is charged for each
inpatient stay.]

Inpatient services covered during a non-covered
inpatient stay
[Plans with no day limitations on a plan’s hospital or skilled
nursing facility (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

[List copays / coinsurance /
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

What you must pay when
you get these services

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.

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.

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

[Also list any additional benefits offered.]
Medicare Part B prescription drugs
These drugs are covered under Part B of Original Medicare.
Members of our plan receive coverage for these drugs through
our plan. Covered drugs include:
•

•
•
•
•

•
•
•

•

[List copays / coinsurance /
deductible]

Drugs that usually aren’t self-administered by the patient
and are injected or infused while you are getting
physician, hospital outpatient, or ambulatory surgical
center services.
Drugs you take using durable medical equipment (such
as 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 selfadminister 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

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

What you must pay when
you get these services

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.]
Outpatient diagnostic tests and therapeutic services
and supplies
Covered services include, but are not limited to:
•
•

•
•
•
•

•

[List copays / coinsurance /
deductible]

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
three 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.]

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

[List copays / coinsurance /
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

•
•

•
•
•
•

What you must pay when
you get these services

surgery.
Laboratory and diagnostic tests billed by the hospital.
Mental health care, including care in a partialhospitalization 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.

Note: Unless the provider has written an order to admit you as
an inpatient to the hospital, you are an outpatient and pay the
cost-sharing amounts for outpatient hospital services. 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 1-877-486-2048. 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
Medicare-qualified mental health care professional as allowed
under applicable state laws.
[Also list any additional benefits offered.]
Outpatient rehabilitation services

[List copays / coinsurance /
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
Covered services include: physical therapy, occupational
therapy, and speech language therapy.

What you must pay when
you get these services
[List copays / coinsurance /
deductible]

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

[List copays / coinsurance /
deductible]

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
and pay the cost-sharing amounts for outpatient surgery. Even
if you stay in the hospital overnight, you might still be
considered an “outpatient.”
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.
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.

[List copays / coinsurance /
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

What you must pay when
you get these services

•
•

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.]
Podiatry services
Covered services include:

[List copays / coinsurance /
deductible]

•

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.
[Also list any additional benefits offered.]

There is no coinsurance,
copayment, or deductible for
an annual PSA test.

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

Prosthetic devices and related supplies
[List copays / coinsurance /
Devices (other than dental) that replace all or part of a body
deductible]
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.
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.

[List copays / coinsurance /
deductible]

[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.

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

If you screen positive for alcohol misuse, you can get up to
four 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

There is no coinsurance,
copayment, or deductible for
the Medicare-covered

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
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.

What you must pay when
you get these services
screening for STIs and
counseling to prevent STIs
preventive benefit.

We also cover up to two individual 20 to 30 minute, face-toface high-intensity 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.]
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 (including dialysis
treatments when temporarily out of the service area, as
explained in Chapter 3).
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.”

[List copays / coinsurance /
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

What you must pay when
you get these services

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 three 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.

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

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

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

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.

Smoking and tobacco use cessation (counseling
to stop smoking or tobacco use)
If you use tobacco, but do not have signs or symptoms of
tobacco-related disease: We cover two counseling quit
attempts within a 12-month period as a preventive service with
no cost to you. Each counseling attempt includes up to four
face-to-face visits.

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

If you use tobacco and have been diagnosed with a tobaccorelated 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 faceto-face visits.
[Also list any additional benefits offered.]
Urgently needed care
Urgently needed care is care provided to treat a nonemergency, unforeseen medical illness, injury, or condition
that requires immediate medical care. Urgently needed care
may be furnished by in-network providers or by out-ofnetwork providers when network providers are temporarily
unavailable or inaccessible. [Include in-network benefits. Also
identify whether this coverage is within the U.S. or worldwide.]

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

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

Vision care
Covered services include:

What you must pay when
you get these services

[List copays / coinsurance /
deductible]

•

Outpatient physician services for the diagnosis and
treatment of diseases and injuries of the eye, including
treatment for age-related macular degeneration. Original
Medicare doesn’t cover routine eye exams (eye
refractions) for eyeglasses/contacts.
• For people who are at high risk of glaucoma, such as
people with a family history of glaucoma, people with
diabetes, and African-Americans 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.
[Also list any additional benefits offered, such as
supplemental vision exams or glasses. If the additional
vision benefits are optional supplemental benefits, they
should not be included in the benefits chart; they should be
described within Section 2.2.]

“Welcome to Medicare” Preventive Visit
The plan covers the one-time “Welcome to Medicare”
preventive visit. The visit includes a review of your health, as
well as education and counseling about the preventive services
you need (including certain screenings and shots), and referrals
for other care if needed.
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.

There is no coinsurance,
copayment, or deductible for
the “Welcome to Medicare”
preventive visit.

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

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 2.3

Getting care using our plan’s optional visitor/traveler benefit

[If your plan offers a visitor/traveler program to members who are out of your service area,
insert this section, adapting and expanding the following paragraphs as needed to describe the
traveler benefits and rules related to receiving the out-of-area coverage. If you allow extended
periods of enrollment out-of-area per the exception in 42 CFR 422.74(b)(4)(iii) (for more than
six months up to 12 months) also explain that here based on the language suggested below.
When you are continuously absent from our plan’s service area for more than six months, we
usually must disenroll you from our plan. However, we offer as a supplemental benefit a
visitor/traveler program [specify areas where the visitor/traveler program is being offered],
which will allow you to remain enrolled in our plan when you are outside of our service area for
less than 12 months. This program is available to all [insert 2015 plan name] members who are
temporarily in the visitor/traveler area. Under our visitor/traveler program you may receive all
plan covered services at in-network cost-sharing. Please contact the plan for assistance in
locating a provider when using the visitor/traveler benefit.
If you are in the visitor/traveler area, you can stay enrolled in our plan for up to 12 months. If
you have not returned to the plan’s service area within 12 months, you will be disenrolled from
the plan.]

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

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.
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:
[The services listed in the remaining bullets are excluded from Original Medicare’s benefit
package. If any services below are covered supplemental benefits, delete them from this list.
When plans partially exclude services excluded by Medicare they need not delete the item
completely from the list of excluded services but may revise the text accordingly to describe the
extent of the exclusion. Plans may add parenthetical references to the Benefits Chart for
descriptions of covered services/items as appropriate. Plans may also add exclusions as
needed.]
•

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.

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

•

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.

•

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.

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

•

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
Section 1.1

Situations in which you should ask us to pay our share of
the cost of your covered services................................................... 75
If you pay our plan’s share of the cost of your covered services, or if you
receive a bill, you can ask us for payment .................................................... 75

SECTION 2

How to ask us to pay you back or to pay a bill you have
received ............................................................................................. 77

SECTION 3

We will consider your request for payment and say yes or
no ....................................................................................................... 77

Section 3.1
Section 3.2

We check to see whether we should cover the service and how much we
owe ................................................................................................................ 77
If we tell you that we will not pay for all or part of the medical care, you
can make an appeal........................................................................................ 78

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 ask us to pay our
share of the cost of your covered services

Section 1.1

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

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

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

•

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

•

Please note: While you can get your care from an out-of-network provider, the
provider must be eligible to participate in Medicare. Except for emergency care, we
cannot pay a provider who is not eligible to participate in Medicare. If the provider is
not eligible to participate in Medicare, you will be responsible for the full cost of the
services you receive.

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

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

You only have to pay your cost-sharing amount when you get services covered by our
plan. We do not allow providers to add additional separate charges, called “balance
billing.” This protection (that you never pay more than your cost-sharing amount)
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, [edit section number as needed] Section 1.6.

•

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

•

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

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.)
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.]
All of the examples above are types of coverage decisions. This means that if we deny your
request for payment, 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.

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 2

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

Section 2.1 How and where to send us your request for payment
Send us your request for payment, along with your bill and documentation of any payment you
have made. It’s a good idea to make a copy of your bill and receipts for your records.
[If the plan has developed a specific form for requesting payment, insert the following language:
To make sure you are giving us all the information we need to make a decision, you can fill out
our claim form to make your request for payment.
•

You don’t have to use the form, but it 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 or a drug you have received.]
[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 for payment 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.

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

•

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 for payment 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.
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 the
Section 5.3 in Chapter 7 that tells what to do if you want 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

Our plan must honor your rights as a member of the plan .......... 80
[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.) .............................. 80
We must treat you with fairness and respect at all times .............................. 80
We must ensure that you get timely access to your covered services ........... 81
We must protect the privacy of your personal health information ................ 81
We must give you information about the plan, its network of providers,
and your covered services ............................................................................. 82
We must support your right to make decisions about your care ................... 83
You have the right to make complaints and to ask us to reconsider
decisions we have made ................................................................................ 85
What can you do if you believe you are being treated unfairly or your
rights are not being respected? ...................................................................... 86
How to get more information about your rights ............................................ 86
You have some responsibilities as a member of the plan ............ 87
What are your responsibilities? ..................................................................... 87

[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

[If your plan does not require any referrals or prior authorization within the preferred network,
delete the next three sentences and instead state: You have the right to choose a provider for
your care.] You have the right to choose a provider in the plan’s network. Call Member Services
to learn which doctors are accepting new patients (phone numbers are printed on the back cover
of this booklet). You also have the right to go to a women’s health specialist (such as a
gynecologist) without a referral and still pay the in-network cost-sharing amount.
As a plan member, you have the right to get appointments and covered services from your
providers within a reasonable amount of time. This includes the right to get timely services from
specialists when you need that care.
[Regional PPOs: Explain how members will obtain care at in-plan rates in any areas of its
region where the plan has a limited contracted provider network.]
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.

•

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

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

o For example, we are required to release health information to government
agencies that are checking on quality of care.
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, 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

•

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. 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, 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).
o We are required to follow rules set by Medicare to make sure that you are using
all of your coverage in combination when you get your covered services from
our plan. This is called “coordination of benefits” because it involves
coordinating the health benefits you get from our plan with any other health
benefits available to you. We’ll help you coordinate your benefits. (For more
information about coordination of benefits, go to Chapter 1, Section 7.)

•

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.

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

•

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

•

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.

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 ........................................................................................................... 91
SECTION 1
Section 1.1
Section 1.2
SECTION 2
Section 2.1
SECTION 3
Section 3.1

Introduction ...................................................................................... 91
What to do if you have a problem or concern ............................................... 91
What about the legal terms? .......................................................................... 91
You can get help from government organizations that are
not connected with us...................................................................... 92
Where to get more information and personalized assistance ........................ 92
To deal with your problem, which process should you use? ....... 92
Should you use the process for coverage decisions and appeals? Or
should you use the process for making complaints? ..................................... 92

COVERAGE DECISIONS AND APPEALS .................................................................. 94
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 ........... 94
Asking for coverage decisions and making appeals: the big picture ............ 94
How to get help when you are asking for a coverage decision or making
an appeal ........................................................................................................ 95
Which section of this chapter gives the details for your situation? ............... 96
Your medical care: How to ask for a coverage decision or
make an appeal ................................................................................. 96
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 ........................................................................................................ 96
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) ........................... 98
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) .................................. 101
Step-by-step: How a Level 2 Appeal is done .............................................. 104
What if you are asking us to pay you for our share of a bill you have
received for medical care? ........................................................................... 105

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
Section 7.1

Section 7.2
Section 7.3
Section 7.4
Section 7.5
SECTION 8
Section 8.1

How to ask us to cover a longer inpatient hospital stay if
you think the doctor is discharging you too soon ...................... 107
During your inpatient hospital stay, you will get a written notice from
Medicare that tells about your rights ........................................................... 107
Step-by-step: How to make a Level 1 Appeal to change your hospital
discharge date .............................................................................................. 108
Step-by-step: How to make a Level 2 Appeal to change your hospital
discharge date .............................................................................................. 111
What if you miss the deadline for making your Level 1 Appeal? ............... 112
How to ask us to keep covering certain medical services if
you think your coverage is ending too soon ............................... 115
This section is about three services only: Home health care, skilled
nursing facility care, and Comprehensive Outpatient Rehabilitation
Facility (CORF) services ............................................................................. 115
We will tell you in advance when your coverage will be ending................ 116
Step-by-step: How to make a Level 1 Appeal to have our plan cover your
care for a longer time................................................................................... 116
Step-by-step: How to make a Level 2 Appeal to have our plan cover your
care for a longer time................................................................................... 119
What if you miss the deadline for making your Level 1 Appeal? ............... 120
Taking your appeal to Level 3 and beyond .................................. 123
Levels of Appeal 3, 4, and 5 for Medical Service Appeals ......................... 123

MAKING COMPLAINTS ............................................................................................. 125
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 ............................................................................ 125
What kinds of problems are handled by the complaint process? ................ 125
The formal name for “making a complaint” is “filing a grievance” ........... 127
Step-by-step: Making a complaint .............................................................. 127
You can also make complaints about quality of care to the Quality
Improvement Organization.......................................................................... 128
You can also tell Medicare about your complaint ....................................... 128

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

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.

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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.

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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.”

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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. For example, your plan network doctor makes a
(favorable) coverage decision for you whenever you receive medical care from him or her or if
your network doctor refers you to a medical specialist. 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.
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, you can go on to a Level 2 Appeal. The Level
2 Appeal is conducted by an independent organization that is not connected to us. (In some
situations, your case will be automatically sent to the independent organization for a Level 2

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Appeal. If this happens, we will let you know. In other situations, you will need to ask for a
Level 2 Appeal.) 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
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.

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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.
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.

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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 Comprehensive
Outpatient Rehabilitation Facility (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.

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.

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.)

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.

Go to the next section of this chapter, Section 5.2.

Skip ahead to Section 5.3 of this chapter.

Skip ahead to Section 5.5 of this chapter.

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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)

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
When a coverage decision
involves your medical care, it is
called an “organization
determination.”

How to request coverage for the medical care you want
A “fast coverage decision” is
called an “expedited
determination.”

•

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.

•

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 from out-of-network providers) 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 (such as medical records from
out-of-network providers), 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.

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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.

•

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.)

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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.
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).

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Section 5.3

101

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)

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

Legal Terms

•

To start an appeal, you, your doctor, or
An appeal to the plan about a medical
your representative, must contact us. For
care coverage decision is called a
details on how to reach us for any purpose
plan “reconsideration.”
related to your appeal, go to 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 [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.

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•

102

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.

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.

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•

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.

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.

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Section 5.4

104

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.
Step 1: The Independent Review Organization reviews your appeal.
•

Legal Terms
The Independent Review
Organization is an independent
The formal name for the “Independent
organization that is hired by
Review Organization” is the “Independent
Medicare. This organization is not
Review Entity.” It is sometimes called the
connected with us and it is not a
“IRE.”
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.

•

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

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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 amount 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
have received from a provider. It also tells how to send us the paperwork that asks us for
payment.

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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.

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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.

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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.

•

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).

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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.

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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 (1-800-633-4227, 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.

•

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).

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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.

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.

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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.

•

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.
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.

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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.
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.”

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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.

•

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

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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.)

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.

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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
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 7.3 below tells how you can request a
fast-track appeal.)
The written notice is called the “Notice of Medicare Non-Coverage.” 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 1-877486-2048.) Or see a copy online at http://www.cms.hhs.gov/BNI/
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.

2. You must sign the written notice to show that you received it.
•

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

•

Signing the notice shows only that you have received the information about when
your coverage will stop. Signing it does not mean you agree with the plan that it’s
time to stop getting the care.

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.

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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.)

•

117

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.

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.

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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 Non-Coverage.”
Step 3: Within one full day after they have all the information they need, the
reviewers will tell you their decision.
What happens if the reviewers say yes to your appeal?
•

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.

•

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.

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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.

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.

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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
Legal Terms
A “fast review” (or “fast appeal”) is also
called an “expedited 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.
Here are the steps for a Level 1 Alternate 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.

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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.

Step 4: If we say no to your fast appeal, your case will automatically go 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.

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Step-by-Step: How to make a Level 2 Alternate Appeal
Legal Terms
The formal name for the “Independent
Review Organization” is the
“Independent Review Entity.” It is
sometimes called the “IRE.”
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.
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
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.

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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.
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.

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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.

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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.

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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.

•

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

•
•
•

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.”

Section 9.3

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
Legal Terms
we denied your request for a “fast
What this section calls a “fast complaint”
coverage decision” or a “fast appeal,”
is also called an “expedited grievance.”
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.

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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

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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.

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Chapter 8. Ending your membership in the plan
SECTION 1
Section 1.1
SECTION 2
Section 2.1
Section 2.2
Section 2.3
Section 2.4

SECTION 3
Section 3.1
SECTION 4
Section 4.1
SECTION 5
Section 5.1
Section 5.2
Section 5.3

Introduction .................................................................................... 131
This chapter focuses on ending your membership in our plan .................... 131
When can you end your membership in our plan? ..................... 131
You can end your membership during the Annual Enrollment Period ....... 131
You can end your membership during the annual Medicare Advantage
Disenrollment Period, but your choices are more limited ........................... 132
In certain situations, you can end your membership during a Special
Enrollment Period........................................................................................ 132
Where can you get more information about when you can end your
membership? ............................................................................................... 133
How do you end your membership in our plan? ......................... 134
Usually, you end your membership by enrolling in another plan ............... 134
Until your membership ends, you must keep getting your
medical services through our plan ............................................... 135
Until your membership ends, you are still a member of our plan ............... 135
[Insert 2015 plan name] must end your membership in the
plan in certain situations ............................................................... 135
When must we end your membership in the plan? ..................................... 135
We cannot ask you to leave our plan for any reason related to your health 137
You have the right to make a complaint if we end your membership in
our plan ........................................................................................................ 137

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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 and during the annual Medicare Advantage Disenrollment 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 can choose to keep your current coverage or make changes to your

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coverage for the upcoming year. If you decide to change to a new plan, you can
choose any of the following types of plans:
o Another Medicare 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

You can end your membership during the annual Medicare
Advantage Disenrollment Period, but your choices are more
limited

You have the opportunity to make one change to your health coverage during the annual
Medicare Advantage Disenrollment Period.
•

When is the annual Medicare Advantage Disenrollment Period? This happens
every year from January 1 to February 14.

•

What type of plan can you switch to during the annual Medicare Advantage
Disenrollment Period? During this time, you can cancel your Medicare Advantage
Plan enrollment and switch to Original Medicare. If you choose to switch to Original
Medicare during this period, you have until February 14 to join a separate Medicare
prescription drug plan to add drug coverage.

•

When will your membership end? Your membership will end on the first day of the
month after we get your request to switch to Original Medicare. If you also choose to
enroll in a Medicare prescription drug plan, your membership in the drug plan will
begin the first day of the month after the drug plan gets your enrollment request.

Section 2.3

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 [Revise bullet to use state-specific name, if applicable] If you have Medicaid.

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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 Allinclusive 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 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 your request to change your plan is received.

Section 2.4

Where can you get more information about when you can end
your membership?

If you have any questions or would like more information on when you can end your
membership:
•

You can call Member Services (phone numbers are 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.

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SECTION 3

How do you end your membership in our plan?

Section 3.1

Usually, you end your membership by enrolling in another
plan

134

Usually, to end your membership in our plan, you simply enroll in another Medicare 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 without a Medicare
prescription drug plan, you must ask to be disenrolled from our plan. There are two ways you
can ask to be disenrolled:
•

You can 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).

•

--or--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.

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 with a
separate Medicare
prescription drug plan.

•

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

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

If you would like to switch
from our plan to:

This is what you should do:

•

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 can also contact Medicare, at 1-800-MEDICARE
(1-800-633-4227), 24 hours a day, 7 days a week, and
ask to be disenrolled. TTY users should call 1-877-4862048.

•

You will be disenrolled from [insert 2015 plan name]
when your coverage in Original Medicare begins.

Original Medicare without
a separate Medicare
prescription drug plan.

135

SECTION 4

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

Section 4.1

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 5

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

Section 5.1

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.

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

•

If you move out of our service area.

•

If you are away from our service area for more than six months. [Plans with
visitor/traveler benefits should revise this bullet to indicate when members must be
disenrolled from the plan.]

136

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.)
o [Plans with visitor/traveler benefits, insert: Go to Chapter 4, Section 2.3 for
information on getting care when you are away from the service area through our
plan’s visitor/traveler benefit.]
o [Plans with grandfathered members who were outside of area prior to January
1999, insert: If you have been a member of our plan continuously since before
January 1999 and you were living outside of our service area before January
1999, you may continue your membership. However, if you move and your move
is to another location that is outside of our service area, you will be disenrolled
from our plan.]
•

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

•

[Omit bullet and sub-bullet if not applicable. Plans with different disenrollment policies
for dual eligible members who do not pay plan premiums must edit these bullets as
necessary to reflect their policies. Plans with different disenrollment policies must be
very clear as to which population is excluded from the policy to disenroll for failure to
pay plan premiums.] If you do not pay the plan premiums for [insert length of grace
period, which cannot be less than two calendar months].

2015 Evidence of Coverage for [insert 2015 plan name]
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137

o We must notify you in writing that you have [insert length of grace period, which
cannot be less than two calendar months] to pay the plan premium before we end
your membership.
Where can you get more information?
If you have questions or would like more information on when we can end your membership:
•

You can call Member Services for more information (phone numbers are printed on the
back cover of this booklet).

Section 5.2

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 1-877486-2048. You may call 24 hours a day, 7 days a week.
Section 5.3

You have the right to make a complaint if we end your
membership in our plan

If we end your membership in our plan, we must tell you our reasons in writing for ending your
membership. We must also explain how you can make a complaint about our decision to end
your membership. You can also look in Chapter 7, Section 9 for information about how to make
a complaint.

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

138

Chapter 9. Legal notices
SECTION 1

Notice about governing law ........................................................... 139

SECTION 2

Notice about non-discrimination................................................... 139

SECTION 3

Notice about Medicare Secondary Payer subrogation rights ..... 139

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

139

[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.]

SECTION 1

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

140

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 prescription drugs or payment for services or drugs 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 a drug, 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]
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141

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
[insert if applicable: after you pay any deductibles]. Coinsurance is usually a percentage (for
example, 20%).
Combined Maximum Out-of-Pocket Amount – This is the most you will pay in a year for all
[insert if applicable: Part A and Part B] services from both network (preferred) providers and
out-of-network (non-preferred) providers. [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
combined maximum out-of-pocket amount.
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 pay when services are
received. [Insert if plan has a premium: (This is in addition to the plan’s monthly premium.)]
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 in this EOC to mean all of the health care services
and supplies that are covered by our plan.
Creditable Prescription Drug Coverage – Prescription drug coverage (for example, from an
employer or union) that is expected to pay, on average, at least as much as Medicare’s standard
prescription drug coverage. People who have this kind of coverage when they become eligible
for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll
in Medicare prescription drug coverage later.
Custodial Care – 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

2015 Evidence of Coverage for [insert 2015 plan name]
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142

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).
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.

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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 3 months
before the month you turn 65, includes the month you turn 65, and ends 3 months after the month
you turn 65.
In-Network Maximum Out-of-Pocket Amount – The most you will pay for covered [insert if
applicable: Part A and Part B] services received from network (preferred) providers. After you
have reached this limit, you will not have to pay anything when you get covered services from
network providers for the rest of the contract year. However, until you reach your combined outof-pocket amount, you must continue to pay your share of the costs when you seek care from an
out-of-network (non-preferred) provider. [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 innetwork maximum out-of-pocket amount.
Low Income Subsidy (LIS) – See “Extra Help.”
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.
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 Disenrollment Period – A set time each year when members in a
Medicare Advantage plan can cancel their plan enrollment and switch to Original Medicare. The
Medicare Advantage Disenrollment Period is from January 1 until February 14, 2015.
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

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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. 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.]
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 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.
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.”

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[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
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 such as 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-Network Provider or Out-of-Network Facility – A provider or facility with which we
have not arranged to coordinate or provide covered services to members of our plan. Out-ofnetwork providers are providers that are not employed, owned, or operated by our plan or are not
under contract to deliver covered services to you. Using out-of-network providers or facilities is
explained in this booklet in Chapter 3.
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

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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.
[Plans that do not use PCPs omit] 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 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 covered services. [Edit or delete as necessary
to make the definition applicable to your plan.] In the network portion of a PPO, some innetwork medical services are covered only if your doctor or other network provider gets “prior
authorization” from our plan. In a PPO, you do not need prior authorization to obtain out-ofnetwork services. However, you may want to check with the plan before obtaining services from
out-of-network providers to confirm that the service is covered by your plan and what your costsharing responsibility is. Covered services that need prior authorization are marked in the
Benefits Chart in Chapter 4. Some drugs are covered only if your doctor or other network
provider gets “prior authorization” from us. Covered drugs that need prior authorization are
marked in the formulary.
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.

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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.
Urgently Needed Care – Urgently needed care is care provided to treat a non-emergency,
unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently
needed care may be furnished by network providers or by out-of-network providers when
network providers are temporarily unavailable or inaccessible.

[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
CALL

TTY

FAX
WRITE

WEBSITE

Member Services – Contact Information
[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.
[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.]
[Optional: insert fax number]
[Insert address]
[Note: plans may add email addresses here.]
[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
WEBSITE

[Insert address]
[Insert URL]

File Type	application/pdf
File Title	2015 Preferred Provider Organization Medicare Advantage (PPO MA)Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) Te
Subject	Proposed revisions for 2015 Preferred Provider Organization (PPO MA) Annual Notice of Change (ANOC) and Evidence of Coverage (EO
Author	Centers for Medicare & Medicaid Services
File Modified	2014-01-23
File Created	2014-01-23