Form 107a Attachment 107a.Protocol A (Medicare)

PROTOCOL A: {BOOKLET ID}

Policyholder:

Insurance Source: Medicare

Medicare Coverage: {Medicare Advantage/Prescription Drug Part D

Medicare Advantage Plan Name (if available):

Prescription coverage included in MA Plan (if available)? {YES/NO}

PBID:

RUID:

We are requesting that you provide the current Evidence of Coverage document for your Medicare Advantage and/or Medicare Prescription Drug Part D coverage which was reported during the MEPS Interview. The Evidence of Coverage contains coverage information related to this insurance as well as other policy information and is often provided as a booklet. This information will help researchers better understand cost sharing between insurers and the insured. This task is voluntary. You will receive $30 for successful completion of this task for this plan.

There are two steps to complete this task:

1) Obtaining the current Evidence of Coverage; and

2) Sending the Evidence of Coverage to MEPS

An example of the Evidence of Coverage content and instructions for getting the document are located inside this folder.

Once you obtain the Evidence of Coverage, you have several options for sending it to MEPS. 1) Upload an electronic copy of the document to a website; 2) Place a printed copy of the document in this folder and give it to your MEPS field representative or 3) Mail the document using the prepaid envelope provided. Detailed instructions for sending the Evidence of Coverage to MEPS are inside this folder.

Your MEPS interviewer will contact you to follow up and answer any questions you may have over the next several days.

If you have questions or need help, please call XXX-XXX-XXXX or email [email protected].

Evidence of Coverage (EOC)

The Evidence of Coverage document (EOC) contains the cost sharing information that researchers are interested in. This is usually a booklet that includes information about what the plan covers and what you would pay for covered services. It will list deductibles and maximum out of pocket costs as well as services, like a visit to a specialist, and what you will pay for that service. If your Medicare includes prescription drug coverage, the EOC should contain information about the out-of-pocket costs you may pay for your medicines. EOC documents may be large; however, they should contain a section with cost-sharing information similar to the ones contained in the EOC sample images below.

The EOC must be current, meaning it must be for this plan year and the EOC coverage dates should include today’s date. There are multiple pages to this document. MEPS needs the entire document to capture all of the cost-sharing information for this study. Please submit the full document to MEPS.

PLEASE NOTE: You should search for your plan online or contact the insurance carrier that administers this Medicare-approved plan by calling the number on your insurance card. You should not contact Medicare directly for this information.

Example EOC

How to obtain the EOC:

Please use one of these options to get the EOC for your plan…

• Online from your Medicare Advantage/Medicare Part D health insurance company member portal using a desktop or laptop

  • Go to your health insurance company website (listed on your insurance card or other material) and log into your member portal.

  • Browse the menus or search for “Evidence of Coverage” or “EOC”.

  • Download the EOC to your computer and save to a location where you can locate it.

• Contact your insurance company using the phone number on your insurance card

  • Reach a customer representative and ask the following: “Can you please mail me the Evidence of Coverage document for my plan?” or ask if it is available online if you prefer to submit it online. If requested, insurance companies should be able to provide you with an EOC or tell you how to get a copy.

Many plans names sound the same. Please verify that the EOC you located matches the plan you have and includes today’s date in the coverage period.

If your first attempt is not successful, please try another option above. The EOC is the preferred document because it contains all of the information MEPS needs. However, if you request the EOC and your insurance company provides one or more documents with a different name, such as an annual notice of change, that contains the same type of cost-sharing information in the hospital/physician and prescription drug examples on the opposite page, please submit those documents to MEPS.

Your insurance company may refer to a document that contains the same information as an enrollment booklet or by another name. If you locate an enrollment booklet, please verify that the document you located matches the plan you have and includes today’s date in the coverage period. You may submit more than one document for this plan.

Receive Extra Help with Your Prescription Drug Costs?

If you receive extra help paying for your prescription drugs and you have a letter like the one below, please submit a copy of this letter along with any other documents related to your plan.

How to send the EOC to MEPS:

Please use one of the following options to send in the EOC.

1) Submit online

Go to www.XXX.com from a computer and use the login ID and password provided below to access the secure document upload site.

Login ID: XXX

Password: XXX

To send a file to MEPS after you log in, click on “Browse Files”, select the EOC file to upload from its location on your computer, or drag a file from its location to the drop area to add it to the site. Click “Upload” to add the file. To add an additional file, just click on “Browse Files” again or drag a file from its location to the drop area and add it to the site. If you need to leave the site and come back, you can return. Once you have uploaded the EOC and all cost-sharing files for this plan and do not need to return to the site, click “Done” to complete the task.

2) Return to your MEPS interviewer

Your interviewer will return on: ____________________________________

Date and Time

Place your EOC in this folder and give it to your MEPS field interviewer.

3) Return by mail

Place your EOC in this folder and mail to Westat in the provided prepaid Business Reply Envelope.

Please use this checklist to track your progress.

• Ask your MEPS interviewer to answer any questions you may have.

• Obtain your EOC using one or more of the options provided.

• If submitting paper document(s), place your EOC or any other cost-sharing documents in this folder.

• If submitting through the website, make sure you know the file location on your computer for your document(s).

• Submit your EOC to MEPS using the instructions provided inside this folder.

• Give us time to receive and process the documents and then receive a $30 check!

Thank you!

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 45 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0118) AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857.

T he Agency for Healthcare Research and Quality and

The Centers for Disease Control and Prevention of the

U.S. Department of Health and Human Services