NTDNSPCH3CY20244122023_CS508Cleared
Annual Notice of Change and Evidence of Coverage for Applicable Integrated Plans in States that Require Integrated Materials (CMS-10824)
NTDNSPCH3CY20244122023_CS508Cleared
OMB: 0938-1444
<Plan name> MEMBER HANDBOOK
Chapter 3: Using our plan’s coverage for your health care and other covered services
Introduction
This chapter has specific terms and rules you need to know to get health care and other covered services with our plan. It also tells you about your care coordinator, how to get care from different kinds of providers and under certain special circumstances (including from out-of-network providers or pharmacies), what to do if you are billed directly for services we cover, and the rules for owning Durable Medical Equipment (DME). Key terms and their definitions appear in alphabetical order in the last chapter of your Member Handbook.
[Plans should refer to other parts of the Member Handbook using the appropriate chapter number, section, and/or page number as appropriate. For example, "refer to Chapter 9, Section A, page 1." An instruction [insert reference, as applicable] appears with many cross references throughout the Member Handbook. Plans may always include additional references to other sections, chapters, and/or member materials when helpful to the reader.]
[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
A. Information about services and providers 4
B. Rules for getting services our plan covers 4
C1. What a care coordinator is 6
C2. How you can contact your care coordinator 6
C3. How you can change your care coordinator 6
D1. Care from a primary care provider 6
D2. Care from specialists and other network providers 8
D3. When a provider leaves our plan 9
D4. Out-of-network providers 10
E. Long-term services and supports (LTSS) 10
F. Behavioral health (mental health and substance use disorder) services 10
G. [If applicable plans should add: How to get self-directed care] 10
G1. What self-directed care is 11
G2. Who can get self-directed care (for example, if it is limited to waiver populations) 11
G3. How to get help in employing personal care providers (if applicable) 11
I. Covered services in a medical emergency, when urgently needed, or during a disaster 11
I1. Care in a medical emergency 11
J. What to do if you are billed directly for services our plan covers 14
J1. What to do if our plan does not cover services 14
K. Coverage of health care services in a clinical research study 14
K1. Definition of a clinical research study 15
K2. Payment for services when you are in a clinical research study 15
K3. More about clinical research studies 16
L. How your health care services are covered in a religious non-medical health care institution 16
L1. Definition of a religious non-medical health care institution 16
L2. Care from a religious non-medical health care institution 16
M. Durable medical equipment (DME) 17
M1. DME as a member of our plan 17
M2. DME ownership if you switch to Original Medicare 17
M3. Oxygen equipment benefits as a member of our plan 18
M4. Oxygen equipment when you switch to Original Medicare or another Medicare Advantage (MA) plan 18
Services are health care, long-term services and supports (LTSS), supplies, behavioral health services, prescription and over-the-counter drugs, equipment and other services. Covered services are any of these services that our plan pays for. Covered health care, behavioral health, and LTSS are in Chapter 4 of your Member Handbook. Your covered services for prescription and over-the-counter drugs are in Chapter 5 of your Member Handbook.
Providers are doctors, nurses, and other people who give you services and care. Providers also include hospitals, home health agencies, clinics, and other places that give you health care services, behavioral health services, medical equipment, and certain LTSS.
Network providers are providers who work with our plan. These providers agree to accept our payment [insert if plan has cost-sharing: and your cost-sharing amount] as full payment. [Plans may delete the next sentence if it is not applicable.] Network providers bill us directly for care they give you. When you use a network provider, you usually pay [insert as applicable: nothing or only your share of the cost] for covered services.
Our plan covers all services covered by Medicare and [insert name of state-specific Medicaid program]. This includes behavioral health and LTSS.
Our plan will generally pay for health care services, behavioral health services, and LTSS you get when you follow our rules. To be covered by our plan:
The care you get must be a plan benefit. This means we include it in our Benefits Chart in Chapter 4 of your Member Handbook.
The care must be medically necessary. By medically necessary, we mean you need services to prevent, diagnose, or treat your condition or to maintain your current health status. This includes care that keeps you from going into a hospital or nursing facility. It also means the services, supplies, or drugs meet accepted standards of medical practice. [Plans may revise the state-specific definition of “medically necessary” as appropriate and ensure that it is updated and used consistently throughout member material models.]
[Plans may omit or edit the PCP-related bullets as necessary, including modifying the name of the PCP.] For medical services, you must have a network primary care provider (PCP) who orders the care or tells you to use another doctor. As a plan member, you must choose a network provider to be your PCP.
In most cases, [insert as applicable: your network PCP or our plan] must give you approval before you can use a provider that is not your PCP or use other providers in our plan’s network. This is called a referral. If you don’t get approval, we may not cover the services. To learn more about referrals, refer to page <page number>.
[Insert if applicable: Our plan’s PCPs are affiliated with medical groups. When you choose your PCP, you are also choosing the affiliated medical group. This means that your PCP refers you to specialists and services that are also affiliated with their medical group. A medical group is [insert definition].]
You do not need a referral from your PCP for emergency care or urgently needed care or to use a woman’s health provider. You can get other kinds of care without having a referral from your PCP (for more information, refer to section D1 in this chapter).
You must get your care from network providers [insert if applicable: that are affiliated with your PCP’s medical group]. Usually, we won’t cover care from a provider who doesn’t work with our health plan [insert if applicable: and your PCP’s medical group]. This means that you will have to pay the provider in full for the services provided. Here are some cases when this rule does not apply:
We cover emergency or urgently needed care from an out-of-network provider (for more information, refer to Section H in this chapter).
If you need care that our plan covers and our network providers can’t give it to you, you can get care from an out-of-network provider. [Plans may specify whether authorization should be obtained before seeking care.] In this situation, we cover the care [insert as applicable: as if you got it from a network provider or at no cost to you].
We cover kidney dialysis services when you’re outside our plan’s service area for a short time or when your provider is temporarily unavailable or not accessible. You can get these services at a Medicare-certified dialysis facility. [Insert as applicable: The cost-sharing you pay for dialysis can never exceed the cost-sharing in Original Medicare. If you are outside the plan’s service area and obtain the dialysis from a provider that is outside the plan’s network, your cost-sharing cannot exceed the cost-sharing you pay in-network. However, if your usual in-network provider for dialysis is temporarily unavailable and you choose to obtain services inside the service area from an out-of-network provider the cost-sharing for the dialysis may be higher.]
[Plans add additional exceptions as appropriate including exceptions as required by the state.]
[Plans provide applicable information about the care coordinator and care coordination, as well as explanations for the following subsections. Plans should replace the terms “care coordinator” and “care team” with terms they use. If Plans use more than one type of “care coordinator,” multiple descriptions can be provided that describe each type, or additional language can be added to the care coordinator definition below.]
C1. What a care coordinator is
[Example text: A care coordinator is a trained person who works for our plan to provide care coordination services for you.]
C2. How you can contact your care coordinator
C3. How you can change your care coordinator
D1. Care from a primary care provider (PCP)
[Insert if applicable and adjust language to describe PCP requirements: You must choose a PCP to provide and manage your care. Our plan’s PCPs are affiliated with medical groups. When you choose your PCP, you are also choosing the affiliated medical group.]
Definition of a PCP and what a PCP does do for you
[Plans describe the following in the context of their plans:
What a PCP is
If applicable, what a medical group or IPA is
What types of providers may act as a PCP [If a State allows specialists to act as a PCP, plans must inform members of this and under what circumstances a specialist may be a PCP.]
The role of a PCP in
making decisions about or getting prior authorization (PA), if applicable
When a clinic can be your PCP (RHC/FQHC)]
Your choice of PCP
[Plans describe how to choose a PCP. Plans that assign members to medical groups or IPAs must include language that explains how the choice of PCP will affect member access to specialists and hospitals. For example: If there is a particular specialist or hospital that you want to use, find out if they’re affiliated with your PCP’s medical group. You can look in the Provider and Pharmacy Directory, or ask Member Services to find out if the PCP you want makes referrals to that specialist or uses that hospital.]
Option to change your PCP
You may change your PCP for any reason, at any time. Also, it’s possible that your PCP may leave our plan’s network. If your PCP leaves our network, we can help you find a new PCP in our network.
[Plans 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 the request, etc.).]
[Insert if applicable: Our plan’s PCPs are affiliated with medical groups. If you change your PCP, you may also be changing medical groups. When you ask for a change, tell Member Services if you use a specialist or get other covered services that must have PCP approval. Member Services helps you continue your specialty care and other services when you change your PCP.]
Services you can get without approval from your PCP
[Note: Insert this section only if plans require referrals to network providers.]
In most cases, you need approval from your PCP before using other providers. This approval is called a referral. You can get services like the ones listed below without getting approval from your PCP first:
emergency services from network providers or out-of-network providers
urgently needed care from network providers
urgently needed care from out-of-network providers when you can’t get to a network provider (for example, if you’re outside our plan’s service area or during the weekend)
Note: Urgently needed care must be immediately needed and medically necessary.
Kidney dialysis services that you get at a Medicare-certified dialysis facility when you’re outside our plan’s service area. Call Member Services before you leave the service area. We can help you get dialysis while you’re away.
Flu shots and COVID-19 vaccinations [insert if applicable: as well as hepatitis B vaccinations and pneumonia vaccinations] [insert if applicable: as long as you get them from a network provider].
Routine women’s health care and family planning services. This includes breast exams, screening mammograms (X-rays of the breast), Pap tests, and pelvic exams [insert if applicable: as long as you get them from a network provider].
Additionally, if eligible to get services from Indian health providers, you may use these providers without a referral.
[Plans add additional bullets consistently formatted like the rest of this section as appropriate.]
D2. Care from specialists and other network providers
A specialist is a doctor who provides health care for a specific disease or part of the body. There are many kinds of specialists, such as:
Oncologists care for patients with cancer.
Cardiologists care for patients with heart problems.
Orthopedists care for patients with bone, joint, or muscle problems.
[Plans describe how members access specialists and other network providers, including:
The role (if any) of the PCP in referring members to specialists and other providers.
A description of PA as well as the process for getting PA [Plans explain that PA means the member gets plan approval before getting a specific service or drug or using an out-of-network provider, and plans include information about who makes the PA decision (e.g., Medical Director, the PCP, or another entity).] Refer members to Chapter 4 for information about which services require PA.
If PCP selection results in being limited to specific specialists or hospitals to which that PCP refers [For example, plans include information about subnetworks.]]
[Plans with referral models, insert: A written referral may be for one visit or it may be a standing referral for more than one visit if you need ongoing services. We must give you a standing referral to a qualified specialist for any of these conditions:
a chronic (ongoing) condition;
a life-threatening mental or physical illness;
a degenerative disease or disability;
any other condition or disease that is serious or complex enough to require treatment by a specialist.
If you do not get a written referral when needed, the bill may not be paid. For more information, call Member Services at the number at the bottom of this page.]
[Plans with direct access models, insert: If we are unable to find you a qualified plan network provider, we must give you a standing service authorization for a qualified specialist for any of these conditions:
a chronic (ongoing) condition;
a life-threatening mental or physical illness;
a degenerative disease or disability;
any other condition or disease that is serious or complex enough to require treatment by a specialist.
If you do not get a service authorization from us when needed, the bill may not be paid. For more information, call Member Services at the phone number printed at the bottom of this page.]
D3. When a provider leaves our plan
[Plans may edit this section if Medicaid requires them to have a transition benefit when a provider leaves the plan.]
A network provider you use may leave our plan. If one of your providers leaves our plan, you have certain rights and protections that are summarized below:
Even if our network of providers change during the year, we must give you uninterrupted access to qualified providers.
We make a good faith effort to give you at least 30-days’ notice so that you have time to select a new provider.
We help you select a new qualified provider to continue managing your health care needs.
If you are undergoing medical treatment, you have the right to ask, and we work with you to ensure, that the medically necessary treatment you are getting is not interrupted.
If we can’t find a qualified network specialist accessible to you, we must arrange an out-of-network specialist to provide your care.
If you think we haven’t replaced your previous provider with a qualified provider or that we aren’t managing your care well, you have the right to file a quality of care complaint to the QIO, a quality of care grievance, or both. (Refer to Chapter 9 [plans may insert reference, as applicable] for more information.)
If you find out one of your providers is leaving our plan, contact us. We can assist you in finding a new provider and managing your care. [Plans include contact information for assistance.]
D4. Out-of-network providers
[Plans tell members under what circumstances they can get services from out-of-network providers (e.g., when providers of specialized services are not available in network). Include Medicaid out-of-network requirements. Describe the process for getting authorization, including who is responsible for getting it.] [Note: Members are entitled to receive services from out-of-network providers for emergency or urgently needed services. In addition, plans must cover dialysis services for ESRD members who have traveled outside the plans service area or when the provider is temporarily unavailable or not accessible and are not able to access contracted ESRD providers.]
If you use an out-of-network provider, the provider must be eligible to participate in Medicare and/or [Insert name of state-specific Medicaid program].
We cannot pay a provider who is not eligible to participate in Medicare and/or [Insert name of state-specific Medicaid program].
If you use a provider who is not eligible to participate in Medicare, you must pay the full cost of the services you get.
Providers must tell you if they are not eligible to participate in Medicare.
[Plans should provide applicable information about getting LTSS.]
[Plans should provide applicable information about getting behavioral health services.]
[Plans should provide applicable information about getting self-directed care, including the following subsections.]
G1. What self-directed care is
G2. Who can get self-directed care (for example, if it is limited to waiver populations)
G3. How to get help in employing personal care providers (if applicable)
[Plans should provide applicable information about getting transportation services.]
I1. Care in a medical emergency
A medical emergency is a medical condition with symptoms such as severe pain or serious injury. The condition is so serious that, if it doesn’t get immediate medical attention, you or anyone with an average knowledge of health and medicine could expect it to result in:
serious risk to your health [insert as applicable: or to that of your unborn child]; or
serious harm to bodily functions; or
serious dysfunction of any bodily organ or part; or
[Insert as applicable: In the case of a pregnant woman in active labor, when:
There is not enough time to safely transfer you to another hospital before delivery.
A transfer to another hospital may pose a threat to your health or safety or to that of your unborn child.]
If you have a medical emergency:
Get help as fast as possible. Call 911 or use the nearest emergency room or hospital. Call for an ambulance if you need it. You do not need approval or a referral from your PCP. You do not need to use a network provider. You may get emergency medical care whenever you need it, anywhere in the U.S. or its territories [insert as applicable: or worldwide], from any provider with an appropriate state license.
[Plans add if applicable: As soon as possible, tell our plan about your emergency. We follow up on your emergency care. You or someone else [plans may replace “someone else” with “your care coordinator” or other applicable term] should call to tell us about your emergency care, usually within 48 hours. However, you won’t pay for emergency services if you delay telling us.] [Plans must provide the contact phone number and days and hours of operation or explain where to find the information (e.g., on the back of the Member ID Card).]
Covered services in a medical emergency
[Plans that cover emergency medical care outside the United States or its territories through Medicaid may describe this coverage based on the Medicaid program coverage area. Plans must also include language emphasizing that Medicare does not provide coverage for emergency medical care outside the United States and its territories.]
If you need an ambulance to get to the emergency room, our plan covers that. We also cover medical services during the emergency. To learn more, refer to the Benefits Chart in Chapter 4 of your Member Handbook.
The providers who give you emergency care decide when your condition is stable and the medical emergency is over. They will continue to treat you and will contact us to make plans if you need follow-up care to get better.
[Plans may add to this paragraph as needed to include other information about their post-stabilization care.] Our plan covers your follow-up care. If you get your emergency care from out-of-network providers, we will try to get network providers to take over your care as soon as possible.
Getting emergency care if it wasn’t an emergency
Sometimes it can be hard to know if you have a medical or behavioral health emergency. You may go in for emergency care and the doctor says it wasn’t really an emergency. As long as you reasonably thought your health was in serious danger, we cover your care.
After the doctor says it wasn’t an emergency, we cover your additional care only if:
You use a network provider or
The additional care you get is considered “urgently needed care” and you follow the rules for getting it. Refer to the next section.
I2. Urgently needed care
Urgently needed care is care you get for a situation that isn’t an emergency but needs care right away. For example, you might have a flare-up of an existing condition or a severe sore throat that occurs over the weekend and need treatment.
Urgently needed care in our plan’s service area
In most cases, we cover urgently needed care only if:
You get this care from a network provider and
You follow the rules described in this chapter.
If it is not possible or reasonable to get to a network provider, we cover urgently needed care you get from an out-of-network provider.
[Plans must insert instructions for how to access urgently needed services (e.g., using urgent care centers, a provider hotline, etc.).]
Urgently needed care outside our plan’s service area
When you’re outside our plan’s service area, you may not be able to get care from a network provider. In that case, our plan covers urgently needed care you get from any provider.
[Plans that cover urgently needed care outside the United States or its territories through Medicaid may describe this coverage based on the Medicaid program coverage area.]
Our plan does not cover urgently needed care or any other [insert if plan covers emergency care outside of the United States and its territories: non-emergency] care that you get outside the United States.
[Insert if applicable: Plans with world-wide emergency/urgent coverage as a supplemental benefit: Our plan covers worldwide [Insert as applicable: emergency and urgently needed care OR emergency OR urgently needed care] services outside the United States under the following circumstances [insert details.]]
I3. Care during a disaster
If the governor of your state, the U.S. Secretary of Health and Human Services, or the president of the United States declares a state of disaster or emergency in your geographic area, you are still entitled to care from our plan.
Visit our website for information on how to get care you need during a declared disaster: <web address>. [In accordance with 42 CFR 422.100(m), plans must include on their web page, at a minimum, information about coverage of benefits at non-contracted facilities at network cost-sharing without required PA; terms and conditions of payment for non-contracted providers; and each declared disaster’s start and end dates.]
During a declared disaster, if you can’t use a network provider, you can get care from out-of-network providers at [insert as applicable: the in-network cost-sharing rate or no cost to you]. If you can’t use a network pharmacy during a declared disaster, you can fill your prescription drugs at an out-of-network pharmacy. Refer to Chapter 5 of your Member Handbook for more information.
[Plans with an arrangement with the state may add language to reflect that the organization is not allowed to reimburse members for Medicaid-covered benefits.]
If a provider sends you a bill instead of sending it to our plan, you should ask us to pay [plans with cost-sharing, insert: our share of] the bill.
You should not pay the bill yourself. If you do, we may not be able to pay you back.
[Insert as applicable: If you paid for your covered services or If you paid more than your plan cost-sharing for covered services] or if you got a bill for [plans with cost-sharing, insert: the full cost of] covered medical services, refer to Chapter 7 of your Member Handbook to find out what to do.
J1. What to do if our plan does not cover services
[Plans with an arrangement with the state may add language to reflect that the organization is not allowed to reimburse members for Medicaid-covered benefits.]
Our plan covers all services:
that are determined medically necessary, and
that are listed in our plan’s Benefits Chart (refer to Chapter 4 of your Member Handbook), and
that you get by following plan rules.
If you get services that our plan does not cover, you pay the full cost yourself.
If you want to know if we pay for any medical service or care, you have the right to ask us. You also have the right to ask for this in writing. If we say we will not pay for your services, you have the right to appeal our decision.
Chapter 9 of your Member Handbook explains what to do if you want us to cover a medical service or item. It also tells you how to appeal our coverage decision. Call Member Services to learn more about your appeal rights.
We pay for some services up to a certain limit. If you go over the limit, you pay the full cost to get more of that type of service. Refer to Chapter 4 for specific benefit limits. Call Member Services to find out what the benefit limits are and how much of your benefits you’ve used.
K1. Definition of a clinical research study
[If applicable, plans revise this section to describe Medicaid role in providing coverage and payment for clinical research studies.]
A clinical research study (also called a clinical trial) is a way doctors test new types of health care or drugs. A clinical research study approved by Medicare typically asks for volunteers to be in the study.
Once Medicare [plans that conduct or cover clinical trials that are not approved by Medicare, insert: or our plan] approves a study you want to be in, and you express interest, someone who works on the study contacts you. That person tells you about the study and finds out if you qualify to be in it. You can be in the study as long as you meet the required conditions. You must understand and accept what you must do in the study.
While you’re in the study, you may stay enrolled in our plan. That way, our plan continues to cover you for services and care not related to the study.
If you want to take part in any Medicare-approved clinical research study, you do not need to tell us or get approval from us [plans that do not use PCPs may delete the rest of this sentence] or your primary care provider. Providers that give you care as part of the study do not need to be network providers.
We encourage you to tell us before you take part in a clinical research study.
If you plan to be in a clinical research study, you or your care coordinator should contact Member Services to let us know you will take part in a clinical trial.
K2. Payment for services when you are in a clinical research study
If you volunteer for a clinical research study that Medicare approves, you pay nothing for the services covered under the study. Medicare pays for services covered under the study as well as routine costs associated with your care. Once you join a Medicare-approved clinical research study, you’re covered for most services and items you get as part of the study. This includes:
room and board for a hospital stay that Medicare would pay for even if you weren’t in a study
an operation or other medical procedure that is part of the research study
treatment of any side effects and complications of the new care
[Plans that conduct or cover clinical trials that are not approved by Medicare insert: If you volunteer for a clinical research study, we pay any costs that Medicare does not approve but that our plan approves.] If you’re part of 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 pay any costs for being in the study.
K3. More about clinical research studies
You can learn more about joining a clinical research study by reading “Medicare & Clinical Research Studies” on the Medicare website (www.medicare.gov/Pubs/pdf/02226-Medicare-and-Clinical-Research-Studies.pdf). 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.
L1. Definition of a religious non-medical health care institution
[If applicable, plans revise this section to describe Medicaid’s role in providing care in religious non-medical health care institutions.]
A religious non-medical health care institution is a place that provides care you would normally get in a hospital or skilled nursing facility. If getting care in a hospital or a skilled nursing facility is against your religious beliefs, we cover care in a religious non-medical health care institution.
This benefit is only for Medicare Part A inpatient services (non-medical health care services).
L2. Care from a religious non-medical health care institution
To get care from a religious non-medical health care institution, you must sign a legal document that says you are against getting medical treatment that is “non-excepted.”
“Non-excepted” medical treatment is any care that is voluntary and not required by any federal, state, or local law.
“Excepted” medical treatment is any care that is not voluntary and 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 is limited to non-religious aspects of care.
If you get services from this institution that are provided to you in a facility:
You must have a medical condition that would allow you to get covered services for inpatient hospital care or skilled nursing facility care.
[Omit this bullet if not applicable] You must get approval from us before you are admitted to the facility, or your stay will not be covered.
[Plans must explain whether Medicare Inpatient Hospital coverage limits apply (include a reference to the Benefits Chart in Chapter 4 [insert reference, as applicable]) or whether there is unlimited coverage for this benefit.]
M1. DME as a member of our plan
[Plans may modify this section as directed by the state.]
DME includes certain medically necessary items ordered by a provider, such as wheelchairs, crutches, powered mattress systems, diabetic supplies, hospital beds ordered by a provider for use in the home, intravenous (IV) infusion pumps, speech generating devices, oxygen equipment and supplies, nebulizers, and walkers.
You always own certain items, such as prosthetics.
In this section, we discuss DME you rent. As a member of our plan, you [insert if the plan sometimes allows transfer of ownership to the member: usually] will not own DME, no matter how long you rent it.
[If the plan allows transfer of ownership of certain DME items to members, the plan must modify this section to explain the conditions and when the member can own specified DME.]
[If the plan sometimes allows transfer of ownership to the member for DME items other than prosthetics, insert: In certain limited situations, we transfer ownership of the DME item to you. Call Member Services to find out about requirements you must meet and papers you need to provide.]
Even if you had DME for up to 12 months in a row under Medicare before you joined our plan, you will not own the equipment.
M2. DME ownership if you switch to Original Medicare
In the Original Medicare program, people who rent certain types of DME own it after 13 months. In a Medicare Advantage (MA) plan, the plan can set the number of months people must rent certain types of DME before they own it.
Note: You can find definitions of Original Medicare and MA Plans in Chapter 12. You can also find more information about them in the Medicare & You <Year> handbook. If you don’t have a copy of this booklet, you can get it at the Medicare website (www.medicare.gov/medicare-and-you) 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.
You will have to make 13 payments in a row under Original Medicare, or you will have to make the number of payments in a row set by the MA plan, to own the DME item if:
you did not become the owner of the DME item while you were in our plan, and
you leave our plan and get your Medicare benefits outside of any health plan in the Original Medicare program or an MA plan.
If you made payments for the DME item under Original Medicare or an MA plan before you joined our plan, those Original Medicare or MA plan payments do not count toward the payments you need to make after leaving our plan.
You will have to make 13 new payments in a row under Original Medicare or a number of new payments in a row set by the MA plan to own the DME item.
There are no exceptions to this when you return to Original Medicare or an MA plan
M3. Oxygen equipment benefits as a member of our plan
If you qualify for oxygen equipment covered by Medicare and you’re a member of our plan, we cover:
rental of oxygen equipment
delivery of oxygen and oxygen contents
tubing and related accessories for the delivery of oxygen and oxygen contents
maintenance and repairs of oxygen equipment
Oxygen equipment must be returned when it’s no longer medically necessary for you or if you leave our plan.
M4. Oxygen equipment when you switch to Original Medicare or another Medicare Advantage (MA) plan
When oxygen equipment is medically necessary and you leave our plan and switch to Original Medicare, you rent it from a supplier for 36 months. Your monthly rental payments cover the oxygen equipment and the supplies and services listed above.
If oxygen equipment is medically necessary after you rent it for 36 months, your supplier must provide:
oxygen equipment, supplies, and services for another 24 months
oxygen equipment and supplies for up to 5 years if medically necessary
If oxygen equipment is still medically necessary at the end of the 5-year period:
Your supplier no longer has to provide it, and you may choose to get replacement equipment from any supplier.
A new 5-year period begins.
You rent from a supplier for 36 months.
Your supplier then provides the oxygen equipment, supplies, and services for another 24 months.
A new cycle begins every 5 years as long as oxygen equipment is medically necessary.
When oxygen equipment is medically necessary and you leave our plan and switch to another MA plan, the plan will cover at least what Original Medicare covers. You can ask your new MA plan what oxygen equipment and supplies it covers and what your costs will be.
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 Member Handbook Chapter 3 |
| Subject | D-SNP CY 2024 Model MH Chapter 3 |
| Author | CMS/MMCO |
| File Modified | 0000-00-00 |
| File Created | 2023-08-29 |
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