NTDSNPANOCCY20244122023_CS508Cleared
Annual Notice of Change and Evidence of Coverage for Applicable Integrated Plans in States that Require Integrated Materials (CMS-10824)
NTDSNPANOCCY20244122023_CS508Cleared
OMB: 0938-1444
<Material ID>
Instructions to Health Plans
[Plans may include the ANOC in the 2024 Member Handbook (Evidence of Coverage) or provide it to members separately.]
[Plans may modify the language in the ANOC, as applicable, to address Medicaid benefits and cost-sharing for its dual eligible population.]
[Plans must use the state-specific name for Medicaid in references to “Medicaid” in any plan-customized language throughout the ANOC.]
[Throughout the document update language based on how the integrated program is described in the state as instructed by the state (i.e. one name for the plan or matching Medicare and Medicaid plans, etc.).]
[Where the ANOC uses “medical care,” “medical services,” or “health care services” to explain services provided, plans may revise and/or add references to long-term services and supports and/or home and community-based services as applicable.]
[Plans may change references to terms such as “member,” “customer,” “beneficiary,” “enrollee,” “member services,” “care coordinator,” “primary care provider,” “prior authorization (PA)” as instructed by the state or based on plan preference and update them consistently throughout the ANOC.]
[Where the model material instructs inclusion of a plan phone number, plans must ensure it is a toll-free number and include a toll-free TTY number and days and hours of operation.]
[Throughout the ANOC, plans must follow the applicable style rules of the state, if any. For instance, where the model material instructs inclusion of a date or time, plans must use the specific format requested by the state Medicaid program. Other items covered by a state-specific style guide or similar document should also be updated accordingly.]
[Plans should refer to the Member Handbook as needed using the appropriate chapter number, section, and/or page number. For example, "refer to Chapter 9, Section A, page 1." An instruction [insert reference, as applicable] appears with many cross references throughout the ANOC and Member Handbook. Plans may always include additional references to other sections, chapters, and/or member materials when helpful to the reader.]
[Wherever possible, plans are encouraged to adopt good formatting practices that make information easier for English-speaking and non-English-speaking enrollees to read and understand. The following are based on input from beneficiary interviews:
Format a section, chart, table, or block of text to fit onto a single page. In instances where plan-customized information causes an item or text to continue on the following page, enter a blank return before right aligning with clear indication that the item continues (for example, similar to the Benefits Chart in Chapter 4 of the Member Handbook, insert: This section is continued on the next page).
Ensure plan-customized text is in plain language and complies with reading level requirements established in the three-way contract.
Break up large blocks of plan-customized text into short paragraphs or bulleted lists and give a couple of plan-specific examples as applicable.
Spell out an acronym or abbreviation before its first use in a document or on a page (for example, Long-term services and supports (LTSS) or low-income subsidy (LIS)). Plans may choose to spell out terms each time they are used.
Include the meaning of any plan-specific acronym, abbreviation, or key term with its first use.
Avoid separating a heading or subheading from the text that follows when paginating the model.
Use universal symbols or commonly understood pictorials.
Draft and format plan-customized text and terminology in translated models to be culturally and linguistically appropriate for non-English speakers.
Consider using regionally appropriate terms or common dialects in translated models.
Include instructions and navigational aids in translated models in the translated language rather than in English.]
<Plan name> [insert plan type] offered by [insert sponsor name]
Annual Notice of Changes for 2024
[Optional: insert member name]
[Optional: insert member address]
Introduction
[If there are any changes to the plan for 2024, insert: You are currently enrolled as a member of our plan. Next year, there will be some changes to our [insert as applicable: benefits, coverage, rules, [and] costs]. This [insert as applicable: section or Annual Notice of Changes] tells you about the changes and where to find more information about them. To get more information about costs, benefits, or rules please review the Member Handbook, which is located on our website at [insert URL]. Key terms and their definitions appear in alphabetical order in the last chapter of your Member Handbook.]
[If there are no changes whatsoever for 2024 (e.g., no changes to benefits, coverage, rules, costs, networks), insert: You are currently enrolled as a member of our plan. Next year, there are no changes to our benefits, coverage, [and] rules [insert if applicable: and costs]. However, you should still read this [insert as applicable: section or Annual Notice of Changes] to learn about your coverage choices. To get more information about costs, benefits, or rules please review the Member Handbook, which is located on our website at [insert URL]. Key terms and their definitions appear in alphabetical order in the last chapter of your Member Handbook.]
Additional resources
[Plans that meet the 5% alternative language or Medicaid required language threshold insert: This document is available for free in [insert the languages that meet the threshold].]
You can get this Annual Notice of Changes for free in other formats, such as large print, braille, or audio. Call [insert Member Services toll-free phone and TTY numbers, and days and hours of operation]. The call is free.
[Plans also simply describe:
how they request a member’s preferred language other than English and/or alternate format,
how they keep the member’s information as a standing request for future mailings and communications so the member does not need to make a separate request each time, and
how a member can change a standing request for preferred language and/or format.]
We have free interpreter services to answer any questions that you may have about our health or drug plan. To get an interpreter just call us at [insert phone number]. Someone that speaks [insert language] can help you. This is a free service. [This information must be included in the following languages: Spanish, Chinese, Tagalog, French, Vietnamese, German, Korean, Russian, Arabic, Italian, Portuguese, French Creole, Polish, Hindi, Japanese, and any additional languages required by the state.]
[Any plan that does not include a particular section (e.g., Section C, Section F) deletes the section, orders all remaining sections and subsections sequentially, and updates the Table of Contents accordingly. Plans must update the Table of Contents to this document to accurately reflect where the information is found on each page after plan adds plan-customized information to this template.]
Table of Contents
B1. Information about <plan name> 7
D. Changes to our network providers and pharmacies 9
E. Changes to benefits [insert if applicable: and costs] for next year 9
E1. Changes to benefits [insert if applicable: and costs] for medical services 9
E2. Changes to prescription drug coverage 11
E3. Stage 1: “Initial Coverage Stage” 14
E4. Stage 2: “Catastrophic Coverage Stage” 15
H2. [Insert name of the State Health Insurance Assistance Program (SHIP)] 21
H3. [Insert State-specific name for Ombudsperson Program] 21
H5. [Insert State-specific name of Medicaid program] 22
H6. [Insert additional resources if applicable] 22
[Plans must include all applicable disclaimers as required in federal regulations (42 CFR Part 422, Subpart V, and Part 423, Subpart V), the Medicare Communications and Marketing Guidance and included in any state-specific guidance provided by <insert state>.] [Consistent with the formatting in this section, plans may insert additional bulleted disclaimers or state-required statements, including state-required disclaimer language, here.]
Reviewing your Medicare and [Insert state-specific name of Medicaid program] (Medicaid) coverage for next year
It is important to review your coverage now to make sure it will still meet your needs next year. If it doesn’t meet your needs, you may be able to leave our plan. Refer to Section E for more information on changes to your benefits for next year.
If you choose to leave our plan, your Medicare [delete Medicare if the end date is the same for Medicare and Medicaid] membership will end on the last day of the month in which your request was made. [If there is a different end date for Medicaid coverage enter a description here.] You will still be in the Medicare and [Insert name of Medicaid program] programs as long as you are eligible.
If you leave our plan, you can get information about your:
Medicare options in the table in Section G2 [insert reference, as applicable].
[Insert name of Medicaid program and insert either: options and services or options] in Section G2 [insert reference, as applicable].
B1. Information about <plan name>
|
B2. Important things to do
|
If you decide to stay with <2024 plan name>: |
If you decide to change plans: |
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, you automatically stay enrolled in <2024 plan name>. |
[Plans should revise this paragraph as necessary] If you decide other coverage will better meet your needs, you may be able to switch plans (refer to Section G2 for more information). If you enroll in a new plan, or change to Original Medicare, your new coverage will begin on the first day of the following month. |
[Plans that are not changing the plan name, delete this section. Plans with an anticipated name change at a time other than January 1 may modify the date below as necessary.]
On January 1, 2024, our plan name changes from <2023 plan name> to <2024 plan name>.
[Insert language to inform members whether they will get new plan ID cards and how, as well as how the name change affects any other member communication.]
[Plans with no changes to network providers and pharmacies insert: We have not made any changes to our network of providers and pharmacies for next year.
However, it’s important that you know that we may make changes to our network during the year. If your provider leaves our plan, you have certain rights and protections. For more information, refer to Chapter 3 of your Member Handbook.]
[Plans with changes to provider and/or pharmacy networks, insert: Our [insert if applicable: provider] [and] [insert if applicable: pharmacy] network[s] [insert as applicable: has or have] changed for 2024.
Please review the 2024 Provider and Pharmacy Directory to find out if your providers or pharmacy are in our network. An updated Provider and Pharmacy Directory is located on our website at <web address>. You may also call Member Services at the numbers at the bottom of the page for updated provider information or to ask us to mail you a Provider and Pharmacy Directory.
It’s important that you know that we may also make changes to our network during the year. If your provider leaves our plan, you have certain rights and protections. For more information, refer to Chapter 3 of your Member Handbook.]
E1. Changes to benefits [insert if applicable: and costs] for medical services
[If there are no changes in benefits or in cost-sharing, replace the rest of the section with: There are no changes to your benefits [insert if applicable: or amounts you pay] for medical services. Our benefits [insert if applicable: and what you pay for these covered medical services] will be exactly the same in 2024 as they are in 2023.]
We’re changing our coverage for certain medical services [insert if applicable: and what you pay for these covered medical services] next year. The table below describes these changes.
[The table must include:
all new benefits that will be added or 2023 benefits that will end for 2024;
new or changing limitations or restrictions, including prior authorizations (PA), on benefits for 2024; and
all changes in cost-sharing for 2024 for covered medical services, including any changes to service category out-of-pocket maximums.]
[Instructions to plans offering Value-Based Insurance Design (VBID) Model benefits: VBID Model participating plans should update this section to reflect coverage for any new VBID Model benefits that will be added for CY 2024 benefits, and/or for previous CY 2023 VBID Model benefits that will end for CY 2024. Specific to the VBID Model benefits, the table must include: (1) all new VBID Model benefits that will be added for 2024, except for the hospice benefit component (which has separate ANOC instructions to VBID participating plans and Part D cost-sharing reduction or elimination which should be listed in Section 2.5), including mandatory supplemental benefits such as the flexibility to cover new and existing technologies or Food and Drug Administration (FDA) approved medical devices or 2023 benefits that will end for 2024 such as cash or monetary rebates; and (2) all changes in cost-sharing for all VBID Model benefits for 2024.
Note that for CY 2024, plans wishing to communicate the removal of cash or monetary rebates and its replacement with different supplemental benefits may do so but must use the following language: CMS removed the Cash Benefits for 2024. Instead, you’ll get [please identify and insert in these brackets supplemental benefits that your organization is offering in lieu of cash or monetary rebates] in place of the Cash Benefit you got in 2023. Review your Member Handbook for more information about available supplemental benefits].]
|
2023 (this year) |
2024 (next year) |
[Insert benefit name] |
[For benefits that were not covered in 2023, insert: [insert benefit name] is not covered.] [For benefits with a copay insert: You pay a $<2023 copay amount> copay [insert language as needed to accurately describe the benefit, e.g., “per office visit”].] |
[For benefits that will not be covered in 2024, insert: [insert benefit name] is not covered.] [For benefits with a copay insert: You pay a $<2024 copay amount> copay [insert language as needed to accurately describe the benefit, e.g., “per office visit”].] |
[Insert benefit name] |
[Insert 2023 cost or coverage, using format described above.] |
[Insert 2024 cost or coverage, using format described above.] |
E2. Changes to prescription drug coverage
[Plans that did not include a List of Covered Drugs in the envelope, insert: You will get a 2024 List of Covered Drugs in a separate mailing.]
[Plans that did not include a List of Covered Drugs in the envelope and will not mail it separately unless requested, insert: An updated List of Covered Drugs is located on our website at <web address>. You may also call Member Services at the numbers at the bottom of the page for updated drug information or to ask us to mail you a List of Covered Drugs.]
[Plans that included a List of Covered Drugs in the envelope, insert: We sent you a copy of our 2024 List of Covered Drugs in this envelope.] The List of Covered Drugs is also called the “Drug List.”
[Plans with no changes to covered drugs, tier assignment, or restrictions may replace the rest of this section with: We have not made any changes to our Drug List for next year. However, we are allowed to make changes to the Drug List from time to time throughout the year, with approval from Medicare and/or the state. Refer to the 2024 Drug List for more information.]
We made changes to our Drug List, including changes to the drugs we cover and changes to the restrictions that apply to our coverage for certain drugs.
Review the Drug List to make sure your drugs will be covered next year and to find out if there are any restrictions.
If you are affected by a change in drug coverage, we encourage you to:
Work with your doctor (or other prescriber) to find a different drug that we cover.
You can call Member Services at the numbers at the bottom of the page [insert if applicable: or contact your care coordinator] to ask for a list of covered drugs that treat the same condition.
This list can help your provider find a covered drug that might work for you.
[Plans should include the following language if they have an advance transition process for current members:] Work with your doctor (or other prescriber) and ask us to make an exception to cover the drug.
You can ask for an exception before next year, and we’ll give you an answer within 72 hours after we get your request (or your prescriber’s supporting statement).
To learn what you must do to ask for an exception, refer to Chapter 9 of your Member Handbook or call Member Services at the numbers at the bottom of the page.
If you need help asking for an exception, contact Member Services [insert if applicable: or your care coordinator]. Refer to Chapters 2 and 3 of your Member Handbook to learn more about how to contact your care coordinator.
[Plans should include the following language if all current members will not be transitioned in advance for the following year:] Ask us to cover a temporary supply of the drug.
In some situations, we cover a temporary supply of the drug during the first [must be at least 90] days of the calendar year.
This temporary supply is for up to [insert supply limit (must be the number of days in plan’s one-month supply)] days. (To learn more about when you can get a temporary supply and how to ask for one, refer to Chapter 5 of your Member Handbook.)
When you get a temporary supply of a drug, talk with your doctor about what to do when your temporary supply runs out. You can either switch to a different drug our plan covers or ask us to make an exception for you and cover your current drug.
[Plans may include additional information about processes for transitioning current enrollees to formulary drugs when your formulary changes relative to the previous plan year.]
[Include language to explain whether current formulary exceptions will still be covered next year or a new one needs to be submitted.]
Changes to prescription drug costs [option for plans with two drug payment stages]
[VBID Model participating plans approved to offer Part D reduced or eliminated cost-sharing should update this section to reflect coverage for any new VBID Model Part D cost-sharing reduction or elimination for all VBID Model benefits for 2024.][Plans with two payment stages (i.e., those charging LIS cost-sharing in the initial coverage stage), should include the following information in the ANOC.]
[Only plans with two payment stages (i.e., those charging LIS cost-sharing in the initial coverage stage, etc.), include the following information in this section of the ANOC. Plans with one payment stage do not include the information in this section.]
[If there are no changes in prescription drug costs, insert: There are no changes to the amount you pay for prescription drugs in 2024. Read below for more information about your prescription drug coverage.]
There are two payment stages for your Medicare Part D prescription drug coverage under our plan. How much you pay depends on which stage you are in when you get a prescription filled or refilled. These are the two stages:
Stage 1 Initial Coverage Stage |
Stage 2 Catastrophic Coverage Stage |
During this stage, our plan pays part of the costs of your drugs, and you pay your share. Your share is called the copay. You begin this stage when you fill your first prescription of the year. |
During this stage, the plan pays all of the costs of your drugs through December 31, 2024. You begin this stage after you pay a certain amount of out-of-pocket costs. |
The Initial Coverage Stage ends when your total out-of-pocket costs for prescription drugs reaches [insert as applicable: $<TrOOP amount>]. At that point, the Catastrophic Coverage Stage begins. Our plan covers all of your drug costs from then until the end of the year. Refer to Chapter 6 of your Member Handbook for more information on how much you will pay for prescription drugs.
E3. Stage 1: “Initial Coverage Stage”
During the Initial Coverage Stage, our plan pays a share of the cost of your covered prescription drugs, and you pay your share. Your share is called the copay. The copay depends on what cost-sharing tier the drug is in and where you get it. You pay a copay each time you fill a prescription. If your covered drug costs less than the copay, you pay the lower price.
[Insert if applicable: We moved some of the drugs on our Drug List to a lower or higher drug tier. If your drugs move from tier to tier, this could affect your copay. To find out if your drugs are in a different tier, look them up in our Drug List.]
The following table shows your costs for drugs in each of our [insert number of tiers] drug tiers. These amounts apply only during the time when you’re in the Initial Coverage Stage.
[Plans must list all drug tiers in the following table.]
|
2023 (this year) |
2024 (next year) |
Drugs in Tier <Tier number> ([Insert short description of tier (e.g., generic drugs)]) Cost for a one-month supply of a drug in Tier <Tier number> that is filled at a network pharmacy |
[Insert 2023 cost-sharing: Your copay for a one-month ([insert number of days in a one-month supply]-day) supply is $<XX> per prescription.] |
[Insert 2024 cost-sharing: Your copay for a one-month ([insert number of days in a one-month supply]-day) supply is $<XX> per prescription.] |
Drugs in Tier <Tier number> ([Insert short description of tier (e.g., generic drugs)]) Cost for a one-month supply of a drug in Tier <Tier number> that is filled at a network pharmacy |
[Insert 2023 cost-sharing: Your copay for a one-month ([insert number of days in a one-month supply]-day) supply is $<XX> per prescription.] |
[Insert 2024 [cost-sharing: Your copay for a one-month ([insert number of days in a one-month supply]-day) supply is $<XX> per prescription.] |
The Initial Coverage Stage ends when your total out-of-pocket costs reach [insert as applicable: $<TrOOP amount>]. At that point the Catastrophic Coverage Stage begins. [Insert as applicable: The plan covers all of your drug costs from then until the end of the year. If the plan covers excluded drugs under an enhanced benefit or Medicaid drugs with cost-sharing in this stage insert: The plan covers all of your Part D drugs until the end of the year. You may have cost-sharing for excluded drugs that are covered under <insert as applicable: our enhanced benefit/Medicaid>]. Refer to Chapter 6 of your Member Handbook for more information about how much you pay for prescription drugs.
E4. Stage 2: “Catastrophic Coverage Stage”
When you reach the out-of-pocket limit [insert as applicable: $<TrOOP amount>] for your prescription drugs, the Catastrophic Coverage Stage begins. You stay in the Catastrophic Coverage Stage until the end of the calendar year.
[Plans that do not reduce the copays for Medicaid covered drugs or excluded drugs under an enhanced benefit in the catastrophic coverage stage should insert the following language: To locate more information about your prescriptions that Medicare and [insert name of the Medicaid program] cover, refer to the List of Covered Drugs, [insert reference, as applicable].]
Changes to prescription drug costs [option for plans with a single payment stage]
[Plans with one payment stage (i.e., those with no cost-sharing for all Medicare Part D drugs), include the following information.]
[If there are no changes in prescription drug costs, insert: There are no changes to the amount you pay for prescription drugs in 2024. Read below for more information about your prescription drug coverage.]
[Insert if applicable: We moved some of the drugs on the Drug List to a lower or higher drug tier. [Insert if applicable: If your drugs move from tier to tier, this could affect your copay.] To find out if your drugs are in a different tier, look them up in the Drug List.]
The following table shows your costs for drugs in each of our [insert number of tiers] drug tiers.
[Plans must list all drug tiers in the following table.]
|
2023 (this year) |
2024 (next year) |
|---|---|---|
Drugs in Tier <Tier number> ([Insert short description of tier (e.g., generic drugs)]) Cost for a one-month supply of a drug in Tier <Tier number> that is filled at a network pharmacy |
[Insert 2023 cost-sharing: Your copay for a one-month ([insert number of days in a one-month supply]-day) supply is $<XX> per prescription.] |
[Insert 2024 cost-sharing: Your copay for a one-month ([insert number of days in a one-month supply]-day) supply is $<XX> per prescription.] |
Drugs in Tier <Tier number> ([Insert short description of tier (e.g., generic drugs)]) Cost for a one-month supply of a drug in Tier <Tier number> that is filled at a network pharmacy |
[Insert 2023 cost-sharing: Your copay for a one-month ([insert number of days in a one-month supply]-day) supply is $<XX> per prescription.] |
[Insert 2024 cost-sharing: Your copay for a one-month ([insert number of days in a one-month supply]-day) supply is $<XX> per prescription.] |
[Insert this section if applicable. Plans with administrative changes that impact members (e.g., change in contract or PBP number) may insert this section, include an introductory sentence that explains the general nature of administrative changes, and describe the specific changes in the table below. Plans that choose to omit this section should renumber the remaining sections as needed.]
|
2023 (this year) |
2024 (next year) |
[Insert a description of the administrative process/item that is changing] |
[Insert 2023 administrative description] |
[Insert 2024 administrative description] |
[Insert a description of the administrative process/item that is changing] |
[Insert 2023 administrative description] |
[Insert 2024 administrative description] |
G1. Staying in our plan
We hope to keep you as a plan member. You do not have to do anything to stay in our plan. If you do not change to another Medicare plan or change to Original Medicare, you automatically stay enrolled as a member of our plan for 2024.
G2. Changing plans
[Plans should add any additional Medicaid information as directed by the state.] Most people with Medicare can end their membership during certain times of the year. Because you have [Insert name of Medicaid program], you may be able to end your membership in our plan or switch to a different plan one time during each of the following Special Enrollment Periods:
In addition to these three Special Enrollment periods, you may end your membership in our plan during the following periods:
The Annual Enrollment Period, which lasts from October 15 to December 7. If you choose a new plan during this period, your membership in our plan ends on December 31 and your membership in the new plan starts on January 1.
The Medicare Advantage (MA) Open Enrollment Period, which lasts from January 1 to March 31. If you choose a new plan during this period, your membership in the new plan starts the first day of the next month.
There may be other situations when you are eligible to make a change to your enrollment. For example, when:
your eligibility for [Insert name of Medicaid Program] or Extra Help changed, or
if you recently moved into, currently are getting care in, or just moved out of a nursing facility or a long-term care hospital.
Your Medicare services
You have three options for getting your Medicare services. By choosing one of these options, you automatically end your membership in our plan. [Insert additional option to change to another integrated program as directed by the state.]
1. You can change to: Another Medicare health plan [Insert additional instructions regarding Medicaid as directed by the state.] |
Here is what to do: 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. For Program of All-inclusive Care for the Elderly (PACE) inquiries, call 1-855-921-PACE (7223). If you need help or more information:
OR Enroll in a new Medicare plan. You will automatically be disenrolled from our plan when your new plan’s coverage begins. [Insert impact on Medicaid enrollment as directed by the state.] |
2. You can change to: Original Medicare with a separate Medicare prescription drug plan [Insert additional instructions regarding Medicaid as directed by the state.] |
Here is what to do: 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. If you need help or more information:
OR Enroll in a new Medicare prescription drug plan. You will automatically be disenrolled from our plan when your Original Medicare coverage begins. [Insert impact on Medicaid enrollment as directed by the state.] |
3. You can change to: Original Medicare without a separate Medicare prescription drug plan [Insert additional instructions regarding Medicaid as directed by the state.] NOTE: If you switch to Original Medicare and do not enroll in a separate Medicare prescription drug plan, Medicare may enroll you in a drug plan, unless you tell Medicare you don’t want to join. You should only drop prescription drug coverage if you have drug coverage from another source, such as an employer or union. If you have questions about whether you need drug coverage, call [Insert contact information regarding state SHIP program including name of program, phone number, days and hours of operation, TTY number and website address.]
|
Here is what to do: 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. If you need help or more information:
You will automatically be disenrolled from our plan when your Original Medicare coverage begins. [Insert impact on Medicaid enrollment as directed by the state.] |
Your [insert name of state Medicaid program] services
For questions about how to get your [insert name of Medicaid program] services after you leave our plan, contact [insert name of program as directed by the state, phone number, days and hours of operation, and TTY number and website if applicable]. Ask how joining another plan or returning to Original Medicare affects how you get your [insert name of Medicaid program] coverage.
H1. Our plan
We’re here to help if you have any questions. Call Member Services at the numbers at the bottom of the page during the days and hours of operation listed. These calls are toll-free.
Read your Member Handbook
Your Member Handbook is a legal, detailed description of our plan’s benefits. It has details about benefits [insert if applicable: and costs] for 2024. It explains your rights and the rules to follow to get services and prescription drugs we cover.
[If the ANOC is sent or provided separately from the Member Handbook, include the following: The Member Handbook for 2024 will be available by October 15.] [Insert if applicable: You can also review the <attached or enclosed or separately mailed> Member Handbook to find out if other benefit [insert if applicable: or cost] changes affect you.] An up-to-date copy of the Member Handbook is available on our website at <web address>. You may also call Member Services at the numbers at the bottom of the page to ask us to mail you a Member Handbook for 2024.
Our website
You can visit our website at <web address>. As a reminder, our website has the most up-to-date information about our provider and pharmacy network (Provider and Pharmacy Directory) and our Drug List (List of Covered Drugs).
H2. [Insert name of the State Health Insurance Assistance Program (SHIP)]
You can also call the SHIP. In [Insert name of state] the SHIP is called the [Insert name of program]. [Insert name of program] can help you understand your plan choices and answer questions about switching plans. [Insert name of program] is not connected with us or with any insurance company or health plan. [Insert name of program] has trained counselors [insert in every county or locations] and services are free. [Insert name of program] phone number is [TTY phone number is optional.] For more information or to find a local [Insert name of program] office in your area, please visit [insert website address].
H3. [Insert State-specific name for Ombudsperson Program]
[Insert this section if there is an ombudsperson program in the state. Include a description of what the program can do, whether the services are free, and phone number. Please refer to an example of language below.]
[Optional language example: The Ombudsperson Program can help you if you have a problem with our plan. The ombudsperson’s services are free and available in all languages. The Ombudsperson Program:
works as an advocate on your behalf. They can answer questions if you have a problem or complaint and can help you understand what to do.
makes sure you have information related to your rights and protections and how you can get your concerns resolved.
is not connected with us or with any insurance company or health plan. The phone number for the Ombudsperson Program is [insert phone number].]
H4. Medicare
To get information directly from Medicare, call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
Medicare’s Website
You can visit the Medicare website (www.medicare.gov). If you choose to disenroll from our plan and enroll in another Medicare plan, the Medicare website has information about costs, coverage, and quality ratings to help you compare plans.
You can find information about Medicare plans available in your area by using Medicare Plan Finder on Medicare’s website. (For information about plans, refer to www.medicare.gov and click on “Find plans.”)
Medicare & You 2024
You can read the Medicare & You 2024 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. This handbook is also available in Spanish, Chinese, and Vietnamese.
If you don’t have a copy of this booklet, you can get it at the Medicare website (www.medicare.gov/Pubs/pdf/10050-medicare-and-you.pdf) 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.
[Insert any additional sections as required by the state, such as the QIO or additional resources that might be available.]
H5. [Insert state-specific name of Medicaid program]
[Insert a description of the state Medicaid program’s role and how to receive assistance from the state.]
H6. [Insert additional resources if applicable]
[If applicable, insert a new section for each additional resource, including contact information and a description of their role.]
If
you have questions, please call <plan name> at <toll-free
phone and TTY numbers>, <days and hours of operation>. The
call is free. For more information, visit <web address>.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Contract Year 2024 Dual Eligible Special Needs Plans Model Annual Notice of Changes |
| Subject | D-SNP CY 2024 Model ANOC |
| Author | CMS/MMCO |
| File Modified | 0000-00-00 |
| File Created | 2023-08-29 |
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