Annual Notice of Change (ANOC) and Evidence of Coverage (EOC)

[MA-only HMO (and HMO-POS) models]
[2021 ANOC model]

[Insert 2021 plan name] ([insert plan type]) offered by [insert MAO name] [insert DBA names in parentheses, as applicable, after listing required MAO names throughout this document]

Annual Notice of Changes for 2021

[Optional: insert member name]
[Optional: insert member address]

You are currently enrolled as a member of [insert 2020 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.

What to do now

1. ASK: Which changes apply to you

• Check the changes to our benefits and costs to see if they affect you.

• It’s important to review your coverage now to make sure it will meet your needs next year.

• Do the changes affect the services you use?

• 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, including specialists you see regularly, 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 and deductibles?

• How do your total plan costs compare to other Medicare coverage options?

• Think about whether you are happy with our plan.

2. COMPARE: Learn about other plan choices

• Check coverage and costs of plans in your area.

• Use the personalized search feature on the Medicare Plan Finder at www.medicare.gov/plan-compare website.

• Review the list in the back of your Medicare & You handbook.

• Look in Section [edit section number as needed] 4.2 to learn more about your choices.

• Once you narrow your choice to a preferred plan, confirm your costs and coverage on the plan’s website.

3. CHOOSE: Decide whether you want to change your plan

• If you want to keep [insert plan name], you don’t need to do anything. You will stay in [insert plan name].

• To change to a different plan that may better meet your needs, you can switch plans between October 15 and December 7.

4. ENROLL: To change plans, join a plan between October 15 and December 7, 2020

• If you don’t join another plan by December 7, 2020, you will stay in [insert 2020 plan name]. [If the plan is being crosswalked, replace previous sentence with: If you don’t join another plan by December 7, 2020, you will be enrolled in [insert 2021 plan name].]

• If you join another plan by December 7, 2020, your new coverage will start on January 1, 2021. You will be automatically disenrolled from your current plan.

Additional Resources

• [Plans that meet the 5% alternative language threshold insert: This document is available for free in [insert languages that meet the 5% threshold].

• Please contact our Member Services number at [insert member services phone number] for additional information. (TTY users should call [insert TTY number].) Hours are [insert days and hours of operation].

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

• Coverage under this Plan qualifies as Qualifying Health Coverage (QHC) and satisfies the Patient Protection and Affordable Care Act’s (ACA) individual shared responsibility requirement. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/Affordable-Care-Act/Individuals-and-Families for more information.

About [insert 2021 plan name]

• [Insert Federal contracting statement.]

• When this booklet says “we,” “us,” or “our,” it means [insert MAO name] [insert DBA names in parentheses, as applicable, after listing required MAO names throughout this document]. When it says “plan” or “our plan,” it means [insert 2021 plan name].

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

Summary of Important Costs for 2021

The table below compares the 2020 costs and 2021 costs for [insert 2021 plan name] in several important areas. Please note this is only a summary of changes. A copy of the Evidence of Coverage is located on our website at [insert URL]. [Insert as applicable: You can also review the attached OR enclosed OR separately mailed Evidence of Coverage to see if other benefit or cost changes affect you.] You may also call Member Services to ask us to mail you an Evidence of Coverage.

[If using Medicare FFS amounts (e.g. Inpatient and SNF cost sharing) the plan must insert the 2020 Medicare amounts and must insert: “These are 2020 cost-sharing amounts and may change for 2021. [insert plan name] will provide updated rates as soon as they are released.” Member cost-sharing amounts may not be left blank.]

Cost	2020 (this year)	2021 (next year)
Monthly plan premium [Plans with no optional supplemental benefits delete the following.] (See Section [edit section number as needed] 2.1 for details.)	[Insert 2020 premium amount]	[Insert 2021 premium amount]
[Plans with no deductible may delete this row.] Deductible	[Insert 2020 deductible amount]	[Insert 2021 deductible amount]
Maximum out-of-pocket amount This is the most you will pay out-of-pocket for your covered [insert if applicable: Part A and Part B] services. (See Section [edit section number as needed] 2.2 for details.)	[Insert 2020 MOOP amount]	[Insert 2021 MOOP amount]
Doctor office visits	Primary care visits: [insert 2020 cost-sharing for PCPs] per visit Specialist visits: [insert 2020 cost-sharing for specialists] per visit	Primary care visits: [insert 2021 cost-sharing for PCPs] per visit Specialist visits: [insert 2021 cost-sharing for specialists] per visit
Inpatient hospital stays Includes inpatient acute, inpatient rehabilitation, long-term care hospitals 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 2020 cost-sharing]	[Insert 2021 cost-sharing]

Annual Notice of Changes for 2021
Table of Contents

Summary of Important Costs for 2021 1

SECTION 1 We Are Changing the Plan’s Name 4

SECTION 1 Unless You Choose Another Plan, You Will Be Automatically Enrolled in [insert 2021 plan name] in 2021 4

SECTION 2 Changes to Benefits and Costs for Next Year 5

Section 2.1 – Changes to the Monthly Premium 5

Section 2.2 – Changes to Your Maximum Out-of-Pocket Amount 6

Section 2.3 – Changes to the Provider Network 7

Section 2.4 – Changes to Benefits and Costs for Medical Services 8

SECTION 3 Administrative Changes 9

SECTION 4 Deciding Which Plan to Choose 9

Section 4.1 – If you want to stay in [insert 2021 plan name] 9

Section 4.2 – If you want to change plans 9

SECTION 5 Deadline for Changing Plans 10

SECTION 6 Programs That Offer Free Counseling about Medicare 11

SECTION 7 Programs That Help Pay for Prescription Drugs 11

SECTION 8 Questions? 12

Section 8.1 – Getting Help from [insert 2021 plan name] 12

Section 8.2 – Getting Help from Medicare 13

[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, 2021, our plan name will change from [insert 2020 plan name] to [insert 2021 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 member communication.]]

SECTION 1 Unless You Choose Another Plan, You Will Be Automatically Enrolled in [insert 2021 plan name] in 2021

[If the member 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 member’s previous plan to the consolidated plan.

On January 1, 2021, [insert MAO name] [insert DBA names in parentheses, as applicable, after listing required MAO names throughout this document] will be combining [insert 2020 plan name] with one of our plans, [insert 2021 plan name].

If you do nothing to change your Medicare coverage by December 7, 2020, we will automatically enroll you in our [insert 2021 plan name]. This means starting January 1, 2021, you will be getting your medical coverage through [insert 2021 plan name]. If you want to, you can change to a different Medicare health plan. You can also switch to Original Medicare. If you want to change plans, you can do so between October 15 and December 7. If you are eligible for Extra Help, you may be able to change plans during other times.

The information in this document tells you about the differences between your current benefits in [insert 2020 plan name] and the benefits you will have on January 1, 2021 as a member of [insert 2021 plan name].]

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.]

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

Cost	2020 (this year)	2021 (next year)
Monthly premium [Plans that include a Part B premium reduction benefit may modify this row to describe the change in the benefit. If there are no changes from year to year, plans may indicate in the column that there is no change for the upcoming benefit year.] (You must also continue to pay your Medicare Part B premium.)	[Insert 2020 premium amount]	[Insert 2021 premium amount]

Section 2.2 – Changes to Your Maximum Out-of-Pocket Amount

[Plans that include the costs of supplemental benefits (e.g., POS 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. This limit is called the “maximum out-of-pocket amount.” Once you reach this amount, you generally pay nothing for covered [insert if applicable: Part A and Part B] services for the rest of the year.

Cost	2020 (this year)	2021 (next year)
Maximum out-of-pocket amount Your costs for covered medical services (such as copays [insert if plan has a deductible: and deductibles]) count toward your maximum out-of-pocket amount. [Plans with no premium may delete the following sentence.] Your plan premium does not count toward your maximum out-of-pocket amount. [If there are no changes from year to year, plans may indicate in the column that there is no change for the upcoming benefit year.]	[Insert 2020 MOOP amount]	[Insert 2021 MOOP amount] Once you have paid [insert 2021 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 for the rest of the calendar year.

Section 2.3 – Changes to the Provider Network

[Insert applicable section: For a plan that has changes in its provider network] There are changes to our network of providers for next year. [Insert if applicable: We included a copy of our Provider Directory in the envelope with this booklet.] 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 2021 Provider Directory to see if your providers (primary care provider, specialists, hospitals, etc.) are in our network.

OR

[For a plan that will have a higher than normal number of providers either leaving and/or joining its network] Our network has changed more than usual for 2021. [Insert if applicable: We included a copy of our Provider Directory in the envelope with this booklet.] 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. We strongly suggest that you review our current Provider Directory to see if your providers (primary care provider, specialists, hospitals, etc.) are still in our network.

It is important that you know that we may make changes to the hospitals, doctors, and specialists (providers) that are part of your plan during the year. There are a number of reasons why your provider might leave your plan but if your doctor or specialist does leave your plan you have certain rights and protections summarized below:

• Even though our network of providers may change during the year, we must furnish you with uninterrupted access to qualified doctors and specialists

• We will make a good faith effort to 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 to manage 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 2021 as they are in 2020.]

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 2021 Evidence of Coverage.

[The table must include: (1) all new benefits that will be added or 2020 benefits that will end for 2021, including any new optional supplemental benefits (plans must indicate these optional supplemental benefits are available for an extra premium); (2) new/changing limitations or restrictions, including prior authorization for CY2021 Part C benefits; and (3) all changes in cost-sharing for 2021 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).]

[If using Medicare FFS amounts (e.g. Inpatient and SNF cost sharing) the plan must insert the 2020 Medicare amounts and must insert: These are 2020 cost-sharing amounts and may change for 2021. [Insert plan name] will provide updated rates as soon as they are released. Member cost-sharing amounts may not be left blank.]

Cost	2020 (this year)	2021 (next year)
[Insert benefit name]	[For benefits that were not covered in 2020 insert: [insert benefit name] is not covered.] [For benefits with a copayment insert: You pay a $[insert 2020 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 2020 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 that are not covered in 2021 insert: [insert benefit name] is not covered.] [For benefits with a copayment insert: You pay a $[insert 2021 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 2021 coinsurance percentage]% of the total cost [insert language as needed to accurately describe the benefit (e.g., “for up to one visit per year”)].]
[Insert benefit name]	[Insert 2020 cost/coverage, using format described above]	[Insert 2021 cost/coverage, using format described above]

SECTION 3 Administrative Changes

[This section is optional. Plans with administrative changes that impact members (e.g., changes in options for paying the monthly premium, change in contract or PBP number) may insert this section and include an introductory sentence that explains the general nature of the administrative changes. Plans that choose to omit this section should renumber the remaining sections as needed.]

Cost	2020 (this year)	2021 (next year)
[Insert a description of the administrative process/item that is changing]	[Insert 2020 administrative description]	[Insert 2021 administrative description]
[Insert a description of the administrative process/item that is changing]	[Insert 2020 administrative description]	[Insert 2021 administrative description]

SECTION 4 Deciding Which Plan to Choose

Section 4.1 – If you want to stay in [insert 2021 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 2021.

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 2021 follow these steps:

Step 1: Learn about and compare your choices

• You can join a different Medicare health plan timely,

• -- 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. If you do not enroll in a Medicare drug plan, there may be a potential Part D late enrollment penalty.

To learn more about Original Medicare and the different types of Medicare plans, read Medicare & You 2021, call your State Health Insurance Assistance Program (SHIP) (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 www.medicare.gov/plan-compare. Here, you can find information about costs, coverage, and quality ratings for Medicare plans.

[Plans may choose to insert if applicable: As a reminder, [insert MAO name] [insert DBA names in parentheses, as applicable, after listing required MAO names throughout this document] offers other [insert as applicable: Medicare health plans AND/OR 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 2021 plan name].

• To change to Original Medicare with a prescription drug plan, enroll in the new drug plan. You will automatically be disenrolled from [insert 2021 plan name].

• To change to Original Medicare without a prescription drug plan, you must either:

• 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).

• – 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 1-877-486-2048.

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, 2021.

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, those who have or are leaving employer coverage, and those who move out of the service area may be 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, 2021, and don’t like your plan choice, you can switch to another Medicare health plan (either with or without Medicare prescription drug coverage) or switch to Original Medicare (either with or without Medicare prescription drug coverage) between January 1 and March 31, 2021. For more information, see Chapter 8, Section 2.2 of the Evidence of Coverage.

SECTION 6 Programs That Offer Free Counseling about Medicare

[Organizations offering plans in multiple states: Revise this section to use the generic name (“State Health Insurance Assistance Program”) when necessary, and include a list of names, phone numbers, and addresses for all SHIPs in your service area.]

The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors in every state. In [insert state], the SHIP is called [insert state-specific SHIP name].

[Insert state-specific SHIP name] is independent (not connected with any insurance company or health plan). It is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare. [Insert state-specific SHIP name] counselors can help you with your Medicare questions or problems. They can help you understand your Medicare plan choices and answer questions about switching plans. You can call [insert state-specific SHIP name] at [insert SHIP phone number]. [Plans may insert the 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.] Below we list different 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:

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

• The Social Security Office at 1-800-772-1213 between 7 am and 7 pm, Monday through Friday. TTY users should call, 1-800-325-0778 (applications); or

• 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 State-specific ADAP information]. Note: To be eligible for the ADAP operating in your State, individuals must meet certain criteria, including proof of State residence and HIV status, low income as defined by the State, and uninsured/under-insured status.

If you are currently enrolled in an ADAP, it can continue to provide you with Medicare Part D prescription cost-sharing assistance for drugs on the ADAP formulary. In order to be sure you continue receiving this assistance, please notify your local ADAP enrollment worker of any changes in your Medicare Part D plan name or policy number. [Insert State-specific ADAP contact information.]

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 2021 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 2021 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 2021. For details, look in the 2021 Evidence of Coverage for [insert 2021 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 is located on our website at [insert URL]. [Insert as applicable: You can also review the attached OR enclosed OR separately mailed Evidence of Coverage to see if other benefit or cost changes affect you.] You may also call Member Services to ask us to mail you an Evidence of Coverage.

Visit Our Website

You can also visit our website at [insert URL]. As a reminder, our website has the most up-to-date information about our provider network (Provider Directory).

Section 8.2 – Getting Help from Medicare

To get information directly from Medicare:

Call 1-800-MEDICARE (1-800-633-4227)

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

Visit the Medicare Website

You can visit the Medicare website (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 www.medicare.gov/plan-compare).

Read Medicare & You 2021

You can read Medicare & You 2021 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 (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.

OMB Approval 0938-1051 (Expires: December 31, 2021)