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pdf[2024 EOC model]
January 1 – December 31, 2024
Evidence of Coverage:
Your Medicare Health Benefits and Services as a Member of [insert 2024 plan
name] [insert plan type]
[Optional: insert member name]
[Optional: insert member address]
This document gives you the details about your Medicare health care coverage from January 1 –
December 31, 2024. This is an important legal document. Please keep it in a safe place.
For questions about this document, please contact Member Services at [insert phone
number]. (TTY users should call [insert TTY number]). Hours are [insert days and hours of
operation]. This call is free.
This plan, [insert 2024 plan name], is offered by [insert MAO name] [insert DBA names in
parentheses, as applicable, after listing required MAO names throughout this document]. (When
this Evidence of Coverage says “we,” “us,” or “our,” it means [insert MAO name] [insert DBA
names in parentheses, as applicable, after listing required MAO names]. When it says “plan” or
“our plan,” it means [insert 2024 plan name].)
[Plans that meet the 5% alternative language threshold insert: This document is available for
free in [insert languages that meet the 5% threshold]. [Plans must insert language about
availability of alternate formats (e.g., braille, large print, audio tapes) as applicable.]
[Remove terms as needed to reflect plan benefits] Benefits, premiums, deductibles, and/or
deposit may change on January 1, 2025.
This document explains your benefits and rights. Use this document to understand about:
• Your plan premium and cost sharing;
• Your medical benefits;
• How to file a complaint if you are not satisfied with a service or treatment;
• How to contact us if you need further assistance; and,
• Other protections required by Medicare law.
[Insert as applicable: [insert Material ID] CMS Approved [MMDDYYYY]
OR [insert Material ID]]
OMB Approval 0938-1051 (Expires: February 29, 2024)
2024 Evidence of Coverage for [insert 2024 plan name]
Table of Contents
1
2024 Evidence of Coverage
Table of Contents
CHAPTER 1: Getting started as a member................................................................. 4
SECTION 1
SECTION 2
SECTION 3
SECTION 4
SECTION 5
Introduction ........................................................................................................5
What makes you eligible to be a plan member? ................................................6
Your plan membership card – Use it to get all covered care .............................8
Your monthly costs for [insert 2024 plan name] ..............................................8
Keeping your plan membership record up to date ...........................................10
CHAPTER 2: Important phone numbers and resources ......................................... 11
SECTION 1
SECTION 2
SECTION 3
SECTION 4
SECTION 5
SECTION 6
SECTION 7
SECTION 8
[Insert 2024 plan name] contacts (how to contact us, including how to
reach Member Services) ..................................................................................12
Medicare (how to get help and information directly from the Federal
Medicare program)...........................................................................................16
State Health Insurance Assistance Program (free help, information,
and answers to your questions about Medicare) ..............................................17
Quality Improvement Organization .................................................................19
Social Security .................................................................................................20
Medicaid ..........................................................................................................21
How to contact the Railroad Retirement Board ...............................................22
Do you have group insurance or other health insurance from an
employer? .........................................................................................................22
CHAPTER 3: Using the plan for your medical services .......................................... 23
SECTION 1
SECTION 2
SECTION 3
SECTION 4
SECTION 5
SECTION 6
SECTION 7
Things to know about getting your medical care as a member of our
plan...................................................................................................................24
How to use the money in your medical savings account .................................25
How to get services when you have an emergency or during a disaster..........27
What if you are billed directly for the full cost of your services? ...................28
How are your medical services covered when you are in a clinical
research study? .................................................................................................29
Rules for getting care in a religious non-medical health care institution ........31
Rules for ownership of durable medical equipment ........................................32
CHAPTER 4: Medical Benefits Chart (what is covered and what you pay) ............ 34
SECTION 1
Understanding your out-of-pocket costs for covered services.........................35
2024 Evidence of Coverage for [insert 2024 plan name]
Table of Contents
SECTION 2
SECTION 3
2
Use the Medical Benefits Chart to find out what is covered and how
much you will pay............................................................................................36
What services are not covered by the plan? .....................................................72
CHAPTER 5: Asking us to pay our share of a bill you have received for
covered medical services .................................................................... 76
SECTION 1
SECTION 2
SECTION 3
Situations in which you should send us a bill you have received for
your covered services.......................................................................................77
How to ask us to pay a bill or to count your expenses toward your
deductible .........................................................................................................78
We will consider your request and say yes or no.............................................79
CHAPTER 6: Your rights and responsibilities ......................................................... 80
SECTION 1
SECTION 2
Our plan must honor your rights and cultural sensitivities as a member
of the plan ........................................................................................................81
You have some responsibilities as a member of the plan ................................86
CHAPTER 7: What to do if you have a problem or complaint (coverage
decisions, appeals, complaints) .......................................................... 90
SECTION 1
SECTION 2
SECTION 3
SECTION 4
SECTION 5
SECTION 6
SECTION 7
SECTION 8
SECTION 9
Introduction ......................................................................................................91
Where to get more information and personalized assistance ...........................91
To deal with your problem, which process should you use? ...........................92
A guide to the basics of coverage decisions and appeals.................................93
Your medical care: How to ask for a coverage decision or make an
appeal of a coverage decision ..........................................................................95
How to ask us to cover a longer inpatient hospital stay if you think the
doctor is discharging you too soon ................................................................103
How to ask us to keep covering certain medical services if you think
your coverage is ending too soon...................................................................109
Taking your appeal to Level 3 and beyond ....................................................115
How to make a complaint about quality of care, waiting times,
customer service, or other concerns ...............................................................116
CHAPTER 8: Ending your membership in the plan ............................................... 120
SECTION 1
SECTION 2
SECTION 3
SECTION 4
SECTION 5
Introduction to ending your membership in our plan ....................................121
When can you end your membership in our plan? ........................................121
What happens if you leave our plan in the middle of the year? .....................123
How do you end your membership in our plan? ............................................123
Until your membership ends, you must keep getting your medical
services and drugs through our plan ..............................................................124
2024 Evidence of Coverage for [insert 2024 plan name]
Table of Contents
SECTION 6
3
[Insert 2024 plan name] must end your membership in the plan in
certain situations ............................................................................................124
CHAPTER 9: Legal notices...................................................................................... 126
SECTION 1
SECTION 2
SECTION 3
Notice about governing law ...........................................................................127
Notice about nondiscrimination .....................................................................127
Notice about Medicare Secondary Payer subrogation rights .........................127
CHAPTER 10: Definitions of important words ....................................................... 128
CHAPTER 1:
Getting started as a member
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 1 Getting started as a member
SECTION 1
Introduction
Section 1.1
You are enrolled in [insert 2024 plan name], which is a
Medicare Medical Savings Account Plan
5
You are covered by Medicare, and you have chosen to get your Medicare health care through our
plan, [insert 2024 plan name]. We are required to cover all Part A and Part B services. However,
cost sharing and provider access in this plan differ from Original Medicare.
[Insert 2024 plan name] is a Medicare Advantage Medical Savings Account (MSA) Plan. This
plan does not include Part D prescription drug coverage. Like all Medicare health plans, this
Medicare MSA Plan is approved by Medicare and run by a private company. If you are
interested in enrolling in a Medicare prescription drug plan or to see what plans are available in
your area, visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day,
7 days a week. TTY users should call 1-877-486-2048. Generally, unless you are new to
Medicare or meet a special exception, you can only join during the Medicare fall open
enrollment period, which occurs from October 15 to December 7. If this is your first time
enrolling in an MSA plan, you may cancel this enrollment by December 15, 2023.
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/affordablecare-act/individuals-and-families for more information.
Section 1.2
What is the Evidence of Coverage document about?
This Evidence of Coverage document tells you how to get your medical care. It explains your
rights and responsibilities, what is covered, what you pay as a member of the plan, and how to
file a complaint if you are not satisfied with a decision or treatment.
The words coverage and covered services refer to the medical care and services available to
you as a member of [insert 2024 plan name].
It’s important for you to learn what the plan’s rules are and what services are available to you.
We encourage you to set aside some time to look through this Evidence of Coverage document.
If you are confused, concerned or just have a question, please contact Member Services.
Section 1.3
Legal information about the Evidence of Coverage
This Evidence of Coverage is part of our contract with you about how [insert 2024 plan name]
covers your care. Other parts of this contract include your enrollment form and any notices you
receive from us about changes to your coverage or conditions that affect your coverage. These
notices are sometimes called riders or amendments.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 1 Getting started as a member
6
The contract is in effect for months in which you are enrolled in [insert 2024 plan name]
between January 1, 2024, and December 31, 2024.
Each calendar year, Medicare allows us to make changes to the plans that we offer. This means
we can change the costs and benefits of [insert 2024 plan name] after December 31, 2024. We
can also choose to stop offering the plan in your service area, after December 31, 2024.
Medicare (the Centers for Medicare & Medicaid Services) must approve [insert 2024 plan
name] each year. You can continue each year to get Medicare coverage as a member of our plan
as long as we choose to continue to offer the plan and Medicare renews its approval of the plan.
SECTION 2
What makes you eligible to be a plan member?
Section 2.1
Your eligibility requirements
You are eligible for membership in our plan as long as:
•
You have both Medicare Part A and Medicare Part B
•
-- and -- you live in our geographic service area (Section 2.3 below describes our service
area). [Plans with grandfathered members who were outside of area prior to January
1999, insert: If you have been a member of our plan continuously since before January
1999 and you were living outside of our service area before January 1999, you are still
eligible as long as you have not moved since before January 1999.] Incarcerated
individuals are not considered living in the geographic service area even if they are
physically located in it.
•
-- and -- you must reside in the United States for 183 or more days during the year in
which the enrollment becomes effective
•
-- and -- you are a United States citizen or are lawfully present in the United States
•
-- and -- you are not currently getting hospice care (If you begin hospice care after you
enroll, you can remain a member of the plan.)
•
-- and -- you don’t have the following types of additional health benefits:
o You don’t have other health coverage that would pay the MSA plan deductible,
including benefits under an employer or union group health plan;
o You don’t get benefits from the Department of Defense (TRICARE) or the
Department of Veterans Affairs;
o You are not a retired Federal government employee and part of the Federal
Employee Health Benefits Program (FEHBP); or
o You are not eligible for Medicaid (a joint Federal and state program that helps
with medical costs for some people with limited income and resources).
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 1 Getting started as a member
Section 2.2
7
Here is the plan service area for [insert 2024 plan name]
[Insert 2024 plan name] is available only to individuals who live in our plan service area. To
remain a member of our plan, you [if a continuation area is offered under 42 CFR 422.54,
insert: generally, here and add a sentence describing the continuation area] must continue to
reside in the plan service area. The service area is described [insert as appropriate: below OR in
an appendix to this Evidence of Coverage].
[Insert plan service area here or within an appendix. Plans may include references to territories,
as appropriate. Use the county name only if approved for the entire county. For an approved
partial county, use the county name plus the approved zip code(s). Examples of the format for
describing the service area are provided below. If needed, plans may insert more than one row
to describe their service area.
Our service area includes all 50 states
Our service area includes these states: [insert states]
Our service area includes these counties in [insert state]: [insert counties]
Our service area includes these parts of counties in [insert state]: [insert county], the following
zip codes only [insert zip codes]]
[Optional information: multi-state plans may include the following: We offer coverage in [insert
as applicable: several OR all] states [insert if applicable: and territories]. However, there may be
cost or other differences between the plans we offer in each state. If you move out of state [insert
if applicable: or territory] and into a state [insert if applicable: or territory] that is still within our
service area, you must call Member Services in order to update your information. [National
plans delete this paragraph.]
If you plan to move out of the service area, you cannot remain a member of this plan. Please
contact Member Services to see if we have a plan in your new area. When you move, you will
have a Special Enrollment Period that will allow you to switch to Original Medicare or enroll in
a Medicare health or drug plan that is available in your new location.
It is also important that you call Social Security if you move or change your mailing address.
You can find phone numbers and contact information for Social Security in Chapter 2, Section 5.
Section 2.3
U.S. Citizen or Lawful Presence
A member of a Medicare health plan must be a U.S. citizen or lawfully present in the United
States. Medicare (the Centers for Medicare & Medicaid Services) will notify [insert 2024 plan
name] if you are not eligible to remain a member on this basis. [Insert 2024 plan name] must
disenroll you if you do not meet this requirement.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 1 Getting started as a member
SECTION 3
8
Your plan membership card – Use it to get all covered
care
While you are a member of our plan, you must use your membership card whenever you get
services covered by this plan. If you do not use your plan membership card when receiving
services, you will have to submit a claim to our plan. (For information about submitting a claim,
see Chapter 5, Asking us to pay our share of a bill you have received for covered medical
services.) You should also show the provider your Medicaid card, if applicable. Here’s a sample
membership card to show you what yours will look like:
[Insert picture of front and back of member ID card. Mark it as a sample card (for example, by
superimposing the word sample on the image of the card).]
Do NOT use your red, white, and blue Medicare card for covered medical services while you are
a member of this plan. If you use your Medicare card instead of your [insert 2024 plan name]
membership card, you may have to pay the full cost of medical services yourself. Keep your
Medicare card in a safe place. You may be asked to show it if you need hospital services, hospice
services, or participate in Medicare approved clinical research studies also called clinical trials.
You will also get a [insert: bank or debit] card to use to pay for qualified medical expenses with
money from your MSA savings account.
[Insert picture of front and back of bank/debit card. Mark it as a sample card (for example, by
superimposing the word sample on the image of the card.]
If your plan membership card or [insert: bank or debit] card is damaged, lost, or stolen, call
Member Services right away and we will send you a new card.
SECTION 4
Your monthly costs for [insert 2024 plan name]
[Delete Optional Supplemental Benefit Premium bullet if your plan doesn't offer optional
supplemental benefits. Renumber remaining sections as appropriate.]
Your costs may include the following:
• Plan Premium (Section 4.1)
• Monthly Medicare Part B Premium (Section 4.2)
• Optional Supplemental Benefit Premium (Section 4.3)
Medicare Part B premiums differ for people with different incomes. If you have questions about
these premiums review your copy of Medicare & You 2024 handbook, the section called 2024
Medicare Costs. If you need a copy, you can download it from the Medicare website
(www.medicare.gov). Or, you can order a printed copy by phone at 1-800-MEDICARE (1-800633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 1 Getting started as a member
Section 4.1
9
Plan premium
You do not pay a separate monthly plan premium for [insert 2024 plan name]. (You must
continue to pay your Medicare Part B premium).
[Plans that do not offer optional supplemental benefits may omit this subsection.]
If you signed up for extra benefits, also called optional supplemental benefits, then you pay an
additional premium each month for these extra benefits. If you have any questions about your
plan premiums, please call Member Services. [If the plan describes optional supplemental
benefits within Chapter 4, then the plan must include the premium amounts for those benefits in
this section.]
Section 4.2
Monthly Medicare Part B Premium
Many members are required to pay other Medicare premiums
[Plans that include a Part B premium reduction benefit may describe the benefit within this
section.]
[Plans with no monthly premium, omit: In addition to paying the monthly plan premium,] you
must continue paying your Medicare premiums to remain a member of the plan. This
includes your premium for Part B. It may also include a premium for Part A which affects
members who aren’t eligible for premium free Part A.
Many members are required to pay other Medicare premiums. As explained in Section 2 above,
in order to be eligible for our plan, you must have both Medicare Part A and Medicare Part B.
Some plan members (those who aren’t eligible for premium-free Part A) pay a premium for
Medicare Part A. Most plan members pay a premium for Medicare Part B. You must continue
paying your Medicare Part B premium to remain a member of the plan.
Your copy of the Medicare & You 2024 handbook gives information about these premiums in
the section called 2024 Medicare Costs. This explains how the Medicare Part B premium differs
for people with different incomes. Everyone with Medicare receives a copy of the Medicare &
You 2024 handbook each year in the fall. Those new to Medicare receive it within a month after
first signing up. You can also download a copy of the Medicare & You 2024 handbook from the
Medicare website (www.medicare.gov). Or, you can order a printed copy by phone at 1-800MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048.
Section 4.3
Optional Supplemental Benefit Premium
If you signed up for extra benefits, also called optional supplemental benefits, then you pay an
additional premium each month for these extra benefits. See Chapter 4, Section 2.2 for details.
[If the plan describes optional supplemental benefits within Chapter 4, then the plan must
include the premium amounts for those benefits in this section.]
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 1 Getting started as a member
10
[Delete Chapter 1, Section 4.3 if your plan doesn't offer optional supplemental benefits.
Renumber remaining sections as appropriate.]
SECTION 5
Keeping your plan membership record up to date
[In the heading and this section, plans should substitute the name used for this file if different
from membership record.]
Your membership record has information from your enrollment form, including your address and
telephone number. It shows your specific plan coverage [insert as appropriate: including your
Primary Care Provider/Medical Group/IPA].
We use information in your membership record to provide your coverage. Because of this, it is
very important that you help us keep your information up to date.
Let us know about these changes:
•
Changes to your name, your address, or your phone number
•
Changes in any other health insurance coverage you have (such as from your employer,
your spouse or domestic partner’s employer, workers’ compensation, or Medicaid)
•
If you have any liability claims, such as claims from an automobile accident
•
If you have been admitted to a nursing home
•
If you receive care in an out-of-area hospital or emergency room
•
If your designated responsible party (such as a caregiver) changes
•
If you are participating in a clinical research study (Note: You are not required to tell
your plan about the clinical research studies you intend to participate in, but we
encourage you to do so).
If any of this information changes, please let us know by calling Member Services. [Plans that
allow members to update this information on-line may describe that option here.]
It is also important to contact Social Security if you move or change your mailing address. You
can find phone numbers and contact information for Social Security in Chapter 2, Section 5.
CHAPTER 2:
Important phone numbers and
resources
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 2 Important phone numbers and resources
SECTION 1
12
[Insert 2024 plan name] contacts
(how to contact us, including how to reach Member
Services)
How to contact our plan’s Member Services
For assistance with claims, billing or member card questions, please call or write to [insert 2024
plan name] Member Services. We will be happy to help you.
Method
Member Services – Contact Information
CALL
[Insert phone number(s)]
Calls to this number are free. [Insert days and hours of operation,
including information on the use of alternative technologies.]
Member Services also has free language interpreter services available
for non-English speakers.
TTY
[Insert number]
[Insert if plan uses a direct TTY number: This number requires special
telephone equipment and is only for people who have difficulties with
hearing or speaking.]
Calls to this number are free. [Insert days and hours of operation.]
FAX
[Optional: insert fax number]
WRITE
[Insert address]
[Note: plans may add email addresses here.]
WEBSITE
[Insert URL]
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 2 Important phone numbers and resources
13
How to contact the [insert name of MSA trustee]
For questions about your MSA savings account and debit card, please contact [insert 2024 plan
name] Member Services and we can connect you to [insert name of MSA trustee]’s [insert name
of customer service department]. If you prefer, you may contact [insert name of trustee] directly
at the telephone number or address listed below.
Method
[Insert name of MSA trustee] [insert name of customer service
department] – Contact Information
CALL
[Insert phone number(s)]
Calls to this number are [insert if applicable: not] free. [Insert days
and hours of operation, including information on the use of alternative
technologies.]
TTY
[Insert number]
[Insert if MSA trustee uses a direct TTY number: This number requires
special telephone equipment and is only for people who have
difficulties with hearing or speaking.]
Calls to this number are [insert if applicable: not] free. [Insert days
and hours of operation.]
FAX
[Insert fax number]
WRITE
[Insert address]
[Note: plans may add email addresses here.]
WEBSITE
[Insert URL]
Note: [Insert name of MSA trustee] or the trustee that you have chosen can only assist you with
your MSA account and/or debit card, and are unable to assist you with any benefit issues. For
benefit issues, please contact our plan’s Member Services.
For more information about your MSA trustee services provided by [MSA trustee name], please
refer to your deposit agreement and disclosure statement.
[Note: If your plan uses the same contact information for the Part C issues indicated below, you
may combine the appropriate sections.]
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 2 Important phone numbers and resources
14
How to contact us when you are asking for a coverage decision or appeal about
your medical care
A coverage decision is a decision we make about your benefits and coverage or about the
amount we will pay for your medical services. An appeal is a formal way of asking us to review
and change a coverage decision we have made. For more information on asking for coverage
decisions or appeals about your medical care, see Chapter 7 (What to do if you have a problem or
complaint (coverage decisions, appeals, complaints)).
[If the plan has different phone numbers for coverage decisions and appeals or for medical care,
the plan should duplicate the chart as necessary, labeling appropriately.]
Method
Coverage Decisions and Appeals for Medical Care – Contact
Information
CALL
[Insert phone number]
Calls to this number are [insert if applicable: not] free. [Insert days
and hours of operation] [Note: You may also include reference to 24hour lines here.] [Note: If you have a different number for accepting
expedited organization determinations, also include that number here.]
TTY
[Insert number]
[Insert if plan uses a direct TTY number: This number requires special
telephone equipment and is only for people who have difficulties with
hearing or speaking.]
Calls to this number are free. [Insert days and hours of operation]
[Note: If you have a different TTY number for accepting expedited
organization determinations, also include that number here.]
FAX
[Optional: insert fax number] [Note: If you have a different fax
number for accepting expedited organization determinations, also
include that number here.]
WRITE
[Insert address] [Note: If you have a different address for accepting
expedited organization determinations, also include that address
here.]
[Note: plans may add email addresses here.]
WEBSITE
[Optional: Insert URL]
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 2 Important phone numbers and resources
15
How to contact us when you are making a complaint about your medical care
You can make a complaint about us [Plans with network providers insert: or one of our network
providers] including a complaint about the quality of your care. This type of complaint does not
involve coverage or payment disputes. For more information on making a complaint about your
medical care, see Chapter 7 (What to do if you have a problem or complaint (coverage decisions,
appeals, complaints)).
Method
Complaints about Medical Care – Contact Information
CALL
[Insert phone number]
Calls to this number are [insert if applicable: not] free. [Insert days and
hours of operation] [Note: You may also include reference to 24-hour
lines here.] [Note: If you have a different number for accepting
expedited grievances, also include that number here.]
TTY
[Insert number]
[Insert if plan uses a direct TTY number: This number requires special
telephone equipment and is only for people who have difficulties with
hearing or speaking.]
Calls to this number are free. [Insert days and hours of operation]
[Note: If you have a different TTY number for accepting expedited
grievances, also include that number here.]
FAX
[Optional: insert fax number] [Note: If you have a different fax number
for accepting expedited grievances, also include that number here.]
WRITE
[Insert address] [Note: If you have a different address for accepting
expedited grievances, also include that address here.]
[Note: plans may add email addresses here.]
MEDICARE
WEBSITE
You can submit a complaint about [insert 2024 plan name] directly to
Medicare. To submit an online complaint to Medicare, go to
www.medicare.gov/MedicareComplaintForm/home.aspx.
Where to send a request asking us to pay for our share of the cost for medical
care you have received
If you have received a bill or paid for services (such as a provider bill) that you think we should
pay for, you may need to ask us for reimbursement or to pay the provider bill. See Chapter 5
(Asking us to pay our share of a bill you have received for covered medical services).
Please note: If you send us a payment request and we deny any part of your request, you can
appeal our decision. See Chapter 7 (What to do if you have a problem or complaint (coverage
decisions, appeals, complaints)) for more information.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 2 Important phone numbers and resources
Method
Payment Requests – Contact Information
CALL
[Optional: Insert phone number and days and hours of operation]
[Note: You are required to accept payment requests in writing, and
may choose to also accept payment requests by phone.]
Calls to this number are [insert if applicable: not] free.
TTY
[Optional: Insert number]
[Insert if plan uses a direct TTY number: This number requires special
telephone equipment and is only for people who have difficulties with
hearing or speaking.]
Calls to this number are free. [Insert days and hours of operation]
FAX
[Optional: Insert fax number]
WRITE
[Insert address]
[Note: plans may add email addresses here.]
WEBSITE
[Optional: Insert URL]
SECTION 2
16
Medicare
(how to get help and information directly from the Federal
Medicare program)
Medicare is the Federal health insurance program for people 65 years of age or older, some
people under age 65 with disabilities, and people with End-Stage Renal Disease (permanent
kidney failure requiring dialysis or a kidney transplant).
The Federal agency in charge of Medicare is the Centers for Medicare & Medicaid Services
(sometimes called CMS). This agency contracts with Medicare Advantage organizations
including us.
Method
Medicare – Contact Information
CALL
1-800-MEDICARE, or 1-800-633-4227
Calls to this number are free.
24 hours a day, 7 days a week.
TTY
1-877-486-2048
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.
Calls to this number are free.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 2 Important phone numbers and resources
17
Method
Medicare – Contact Information
WEBSITE
www.Medicare.gov
This is the official government website for Medicare. It gives you upto-date information about Medicare and current Medicare issues. It
also has information about hospitals, nursing homes, physicians, home
health agencies, and dialysis facilities. It includes documents you can
print directly from your computer. You can also find Medicare
contacts in your state.
The Medicare website also has detailed information about your
Medicare eligibility and enrollment options with the following tools:
•
Medicare Eligibility Tool: Provides Medicare eligibility status
information.
Medicare Plan Finder: Provides personalized information
about available Medicare prescription drug plans, Medicare
health plans, and Medigap (Medicare Supplement Insurance)
policies in your area. These tools provide an estimate of what
your out-of-pocket costs might be in different Medicare plans.
You can also use the website to tell Medicare about any complaints
you have about [insert 2024 plan name]:
•
Tell Medicare about your complaint: You can submit a
complaint about [insert 2024 plan name] directly to Medicare.
To submit a complaint to Medicare, go to
www.medicare.gov/MedicareComplaintForm/home.aspx.
Medicare takes your complaints seriously and will use this
information to help improve the quality of the Medicare
program.
If you don’t have a computer, your local library or senior center may
be able to help you visit this website using its computer. Or, you can
call Medicare and tell them what information you are looking for. They
will find the information on the website and review the information
with you. (You can call Medicare at 1-800-MEDICARE (1-800-6334227), 24 hours a day, 7 days a week. TTY users should call 1-877486-2048.)
•
SECTION 3
State Health Insurance Assistance Program
(free help, information, and answers to your questions
about Medicare)
[Organizations offering plans in multiple states: Revise the second and third paragraphs in this
section to use the generic name (State Health Insurance Assistance Program or SHIP), and
include a list of names, phone numbers, and addresses for all SHIPs in your service area. Plans
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 2 Important phone numbers and resources
18
have the option of including a separate exhibit to list information for all states in which the plan
is filed and should refer to that exhibit below.]
The State Health Insurance Assistance Program (SHIP) is a government program with trained
counselors in every state. [Multiple-state plans inserting information in an exhibit, replace the
rest of this paragraph with a sentence referencing the exhibit where members will find SHIP
information.] [Multiple-state plans inserting information in the EOC add: Here is a list of the
State Health Insurance Assistance Programs in each state we serve:] [Multiple-state plans
inserting information in the EOC use bullets for the following sentence, inserting separate
bullets for each state.] In [insert state], the SHIP is called [insert state-specific SHIP name].
[Insert state-specific SHIP name] is an independent (not connected with any insurance company
or health plan) 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 understand your Medicare rights, help
you make complaints about your medical care or treatment, and help you straighten out problems
with your Medicare bills. [Insert state-specific SHIP name] counselors can also help you with
Medicare questions or problems and help you understand your Medicare plan choices and
answer questions about switching plans.
METHOD TO ACCESS SHIP and OTHER RESOURCES:
•
•
•
Visit https://www.shiphelp.org (Click on SHIP LOCATOR in middle of
page)
Click on Talk to Someone in the middle of the homepage
You now have the following options:
o Option #1: You can have a live chat with a 1-800-MEDICARE
representative
o Option #2: You can select your STATE from the dropdown
menu and click GO. This will take you to a page with phone
numbers and resources specific to your state.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 2 Important phone numbers and resources
Method
[Insert state-specific SHIP name] [If the SHIP’s name does not
include the name of the state, add: ([insert state name] SHIP)]
CALL
[Insert phone number(s)]
TTY
[Insert number, if available. Or delete this row.]
[Insert if the SHIP uses a direct TTY number: This number requires
special telephone equipment and is only for people who have
difficulties with hearing or speaking.]
WRITE
[Insert address]
[Note: plans may add email addresses here.]
WEBSITE
[Insert URL]
SECTION 4
19
Quality Improvement Organization
[Organizations offering plans in multiple states: Revise the second and third paragraphs of this
section to use the generic name (Quality Improvement Organization) when necessary, and
include a list of names, phone numbers, and addresses for all QIOs in your service area. Plans
have the option of including a separate exhibit to list the QIOs in all states, or in all states in
which the plan is filed and should refer to that exhibit below.]
There is a designated Quality Improvement Organization for serving Medicare beneficiaries in
each state. [Multi-state plans inserting information in an exhibit, replace the rest of this
paragraph with a sentence referencing the exhibit where members will find QIO information.]
[Multiple-state plans inserting information in the EOC add: Here is a list of the Quality
Improvement Organizations in each state we serve:] [Multi-state plans inserting information in
the EOC use bullets for the following sentence, inserting separate bullets for each state.] For
[insert state], the Quality Improvement Organization is called [insert state-specific QIO name].
[Insert state-specific QIO name] has a group of doctors and other health care professionals who
are paid by Medicare to check on and help improve the quality of care for people with Medicare.
[Insert state-specific QIO name] is an independent organization. It is not connected with our
plan.
You should contact [insert state-specific QIO name] in any of these situations:
•
You have a complaint about the quality of care you have received.
•
You think coverage for your hospital stay is ending too soon.
•
You think coverage for your home health care, skilled nursing facility care, or
Comprehensive Outpatient Rehabilitation Facility (CORF) services are ending too soon.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 2 Important phone numbers and resources
Method
[Insert state-specific QIO name] [If the QIO’s name does not include
the name of the state, add: ([insert state name]’s Quality
Improvement Organization)] – Contact Information
CALL
[Insert phone number(s) and days and hours of operation]
TTY
[Insert number, if available. Or delete this row.]
[Insert if the QIO uses a direct TTY number: This number requires
special telephone equipment and is only for people who have
difficulties with hearing or speaking.]
WRITE
[Insert address]
[Note: plans may add email addresses here.]
WEBSITE
[Insert URL]
SECTION 5
20
Social Security
Social Security is responsible for determining eligibility and handling enrollment for Medicare.
U.S. citizens and lawful permanent residents who are 65 or older, or who have a disability or
End-Stage Renal Disease and meet certain conditions, are eligible for Medicare. If you are
already getting Social Security checks, enrollment into Medicare is automatic. If you are not
getting Social Security checks, you have to enroll in Medicare. To apply for Medicare, you can
call Social Security or visit your local Social Security office.
If you move or change your mailing address, it is important that you contact Social Security to
let them know.
Method
Social Security – Contact Information
CALL
1-800-772-1213
Calls to this number are free.
Available 8:00 am to 7:00 pm, Monday through Friday.
You can use Social Security’s automated telephone services to get
recorded information and conduct some business 24 hours a day.
TTY
1-800-325-0778
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.
Calls to this number are free.
Available 8:00 am to 7:00 pm, Monday through Friday.
WEBSITE
www.ssa.gov
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 2 Important phone numbers and resources
SECTION 6
21
Medicaid
[Organizations offering plans in multiple states: Revise this section to include a list of agency
names, phone numbers, days and hours of operation, and addresses for all states in your service
area. Plans have the option of including a separate exhibit to list Medicaid information in all
states or in all states in which the plan is filed and should refer to that exhibit below.]
[Plans may adapt this generic discussion of Medicaid to reflect the name or features of the
Medicaid program in the plan’s state or states.]
Medicaid is a joint Federal and state government program that helps with medical costs for
certain people with limited incomes and resources. Some people with Medicare are also eligible
for Medicaid.
The programs offered through Medicaid help people with Medicare pay their Medicare costs,
such as their Medicare premiums. These Medicare Savings Programs include:
•
Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B
premiums, and other cost sharing (like deductibles, coinsurance, and copayments). (Some
people with QMB are also eligible for full Medicaid benefits (QMB+).)
•
Specified Low-Income Medicare Beneficiary (SLMB): Helps pay Part B premiums.
(Some people with SLMB are also eligible for full Medicaid benefits (SLMB+).)
•
Qualifying Individual (QI): Helps pay Part B premiums.
•
Qualified Disabled & Working Individuals (QDWI): Helps pay Part A premiums.
To find out more about Medicaid and its programs, contact [insert state-specific Medicaid
agency]. (Please note that people with Medicaid coverage are not eligible for a Medicare MSA
plan.)
Method
[Insert state-specific Medicaid agency] [If the agency’s name does not
include the name of the state, add: ([insert state name]’s Medicaid
program)] – Contact Information
CALL
[Insert phone number(s) and days and hours of operation]
TTY
[Insert number, if available. Or delete this row.]
[Insert if the state Medicaid program uses a direct TTY number: This
number requires special telephone equipment and is only for people
who have difficulties with hearing or speaking.]
WRITE
[Insert address]
[Note: plans may add email addresses here.]
WEBSITE
[Insert URL]
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 2 Important phone numbers and resources
SECTION 7
22
How to contact the Railroad Retirement Board
The Railroad Retirement Board is an independent Federal agency that administers
comprehensive benefit programs for the nation’s railroad workers and their families. If you
receive your Medicare through the Railroad Retirement Board, it is important that you let them
know if you move or change your mailing address. If you have questions regarding your benefits
from the Railroad Retirement Board, contact the agency.
Method
Railroad Retirement Board – Contact Information
CALL
1-877-772-5772
Calls to this number are free.
If you press “0”, you may speak with an RRB representative from 9:00
am to 3:30 pm, Monday, Tuesday, Thursday, and Friday, and from
9:00 am to 12:00 pm on Wednesday.
If you press “1”, you may access the automated RRB HelpLine and
recorded information 24 hours a day, including weekends and
holidays.
TTY
1-312-751-4701
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.
Calls to this number are not free.
WEBSITE
rrb.gov/
SECTION 8
Do you have group insurance or other health
insurance from an employer?
If you (or your spouse or domestic partner) get benefits from your (or your spouse or domestic
partner’s) employer or retiree group as part of this plan, you may call the employer/union
benefits administrator or Member Services if you have any questions. You can ask about your (or
your spouse or domestic partner’s) employer or retiree health benefits, premiums, or the
enrollment period. (Phone numbers for Member Services are printed on the back cover of this
document.) You may also call 1-800-MEDICARE (1-800-633-4227; TTY: 1-877-486-2048)
with questions related to your Medicare coverage under this plan.
CHAPTER 3:
Using the plan for your medical
services
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 3 Using the plan for your medical services
SECTION 1
24
Things to know about getting your medical care as a
member of our plan
This chapter explains what you need to know about using the plan to get your medical care
covered. It gives definitions of terms and explains the rules you will need to follow to get the
medical treatments, services, equipment, prescription drugs, and other medical care that are
covered by the plan.
For the details on what medical care is covered by our plan and how much you pay when you get
this care, use the benefits chart in the next chapter, Chapter 4 (Medical Benefits Chart, what is
covered and what you pay).
Section 1.1
What are [insert if applicable: network] providers and covered
services?
•
Providers are doctors and other health care professionals licensed by the state to provide
medical services and care. The term providers also includes hospitals and other health
care facilities.
•
Covered services include all the medical care, health care services, supplies, and
equipment that are covered by our plan. Your covered services for medical care are listed
in the benefits chart in Chapter 4.
Section 1.2
Basic rules for getting your medical care covered by the plan
As a Medicare health plan, [insert 2024 plan name] must cover all services covered by Original
Medicare and must follow Original Medicare’s coverage rules.
[Insert 2024 plan name] will generally cover your medical care as long as:
•
The care you receive is included in the plan’s Medical Benefits Chart (this chart is in
Chapter 4 of this document).
•
The care you receive is considered medically necessary. Medically necessary means
that the services, supplies, equipment, or drugs are needed for the prevention, diagnosis,
or treatment of your medical condition and meet accepted standards of medical practice.
•
You receive your care from a provider in the United States who is eligible to provide
services under Original Medicare.
o You must show your plan membership card every time you visit a provider. A
provider can decide at each visit whether to accept the payment amount, and thus
whether to treat you. You may obtain plan services and equipment from any
licensed provider in the United States. [Plans with network providers insert:
However, the lowest cost sharing you will pay will be from the providers listed in
the directory.]
[Insert 2024 plan name] does not require you to obtain approval in advance for medically-
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 3 Using the plan for your medical services
25
necessary covered services. If you have any questions about whether we will pay for any medical
service that you are considering, you have the right to ask us whether we will cover it before you
get it.
Section 1.3
Medical savings accounts and prescription drug coverage
The law does not allow Medicare Advantage MSA plans to offer Medicare prescription drug
coverage. If you have a Medicare MSA plan, you can, however, also join a Medicare
prescription drug plan to get coverage. Any money that you use from your MSA savings account
on drug plan deductibles or cost sharing will not count towards your MSA plan deductible, but it
will count towards your drug plan’s out-of-pocket costs. If you are interested in enrolling in a
Medicare prescription drug plan or to see what plans are available in your area, visit
www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week.
TTY users should call 1-877-486-2048. Generally, unless you are new to Medicare or meet a
special exception, you can only join during the Medicare fall open enrollment period, which
occurs from October 15 to December 7.
Note that even if you are not enrolled in a Medicare prescription drug plan, money spent from
your MSA savings account on prescription drugs are considered “qualified medical expenses”
for tax-reporting purposes and are not taxed. See the discussion on tax-reporting responsibilities
for members of MSAs in Chapter 6, Section 2.2 (Special tax-reporting responsibilities of
members of a Medicare MSA plan) for more information on qualified medical expenses.
SECTION 2
How to use the money in your medical savings
account
Section 2.1
How does the medical savings account work?
The plan makes the deposit into your medical savings account at the beginning of each calendar
year. (Except for those who become entitled to Medicare in the middle of the year and enroll in
the plan at that time—these members receive their deposit in the first month they are covered
under the plan.) Only the plan can make deposits into your account; you can’t deposit your own
money. The deposit amount will be less than your deductible amount.
You can use the money in your account to pay for medical expenses, but only Medicare Part A
and Part B covered services count toward your deductible. (For more information about what
types of expenses you can use the money for, see Section 2.2.)
•
If you use all of the money in your account and haven’t met your deductible, you must
pay for all of your medical expenses out-of-pocket until you reach your deductible.
•
If you don’t use all of the money in your account, the money left in your account at the
end of the year will remain in your account. If you stay with the plan next year, a new
deposit will be added to any leftover amount.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 3 Using the plan for your medical services
26
Once you get your initial deposit, you may move the deposit to a savings account that’s offered
through your own bank or financial institution. If you move your deposit, you will be responsible
for keeping track of your account balance.
How can I access the money in my account?
[Plans must describe how members can access the money in the account (e.g., through
debit/credit cards, checks, etc.).]
Section 2.2
What types of expenses can the money in the account be used
for?
You can use the money in your account to pay for medical expenses, but only Medicare Part A
and Part B covered services count toward your deductible. You are responsible for handling
the money in your account. This includes deciding which types of expenses to pay with the
money in your account.
To avoid taxes and penalties, you must use the money in your account for Qualified Medical
Expenses. Qualified Medical Expenses are the same types of services and products that could be
deducted as medical expenses on your yearly income tax return. Again, only Medicare Part A
and B covered services count toward your deductible:
•
Some services, like doctors’ visits, lab tests, and hospital stays, are Qualified Medical
Expenses and are also covered by Medicare Part A or Part B. If you use the money in
your account for this type of expense, the money won’t be taxed, and it will count toward
your plan deductible.
•
Other services, like dental care, vision care, and Part D drugs, are Qualified Medical
Expenses, but aren’t covered by Medicare Part A or Part B. If you use the money in your
account for this type of expense, the money will not be taxed. However, these expenses
won’t count toward your deductible.
To avoid a tax on withdrawals from your account, you need to file Form 1040, U.S.
Individual Income Tax Return, and Form 8853 each year to report your Qualified Medical
Expenses. For a complete list of the services and products that count as Qualified Medical
Expenses and for other tax information, call the Internal Revenue Service at 1-800-TAX-FORM
(1-800-829-3676). Ask for a free copy of the IRS publication #502, Medical and Dental
Expenses. You can also request the IRS publication #969 to get more information about the tax
Form 8853, or visit www.irs.gov on the Web and select Forms and Publications to view or print
copies of the publications.
If you use the money in your account for non-qualified expenses, it will be taxed as part of
your income and will also be subject to an additional 50% tax penalty. Each year, you
should get a 1099-SA form from your MSA trustee that includes all of the withdrawals from
your account. You will need to show that you have had qualified medical expenses in at least this
amount, or you may have to pay taxes and additional penalties.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 3 Using the plan for your medical services
27
For more information about your tax reporting responsibilities, go to Chapter 6, Section 2.2.
Section 2.3
How can you keep track of your expenses?
You should keep any health care bills or receipts you get to make it easy to summarize your
account usage for tax purposes. It may be helpful to keep this information in one place.
If you keep your deposit in the trustee we have selected, you will get a monthly statement that
lists your account activity. You can also get information on whether your expenses count toward
your deductible.
If you move your deposit to a different trustee or financial institution, you are responsible for
tracking your own expenses.
SECTION 3
How to get services when you have an emergency or
during a disaster
Section 3.1
Getting care if you have a medical emergency
What is a medical emergency and what should you do if you have one?
A medical emergency is when you believe that you have medical symptoms that require
immediate medical attention to prevent your loss of life (and, if you are a pregnant woman, loss
of an unborn child), loss of a limb or function of a limb, or loss of or serious impairment to a
bodily function. The medical symptoms may be an illness, injury, severe pain, or a medical
condition that is quickly getting worse.
If you have a medical emergency:
•
Get help as quickly as possible. Call 911 for help or go to the nearest emergency room
or hospital. Call for an ambulance if you need it. You do not need to get approval from
our plan. You do not need to use a network doctor. You may get covered emergency
medical care whenever you need it, anywhere in the United States or its territories, and
from any provider with an appropriate state license even if they are not part of our
network [plans may modify this sentence to identify whether this coverage is within the
U.S. or world-wide emergency/urgent coverage].
•
[Plans add if applicable: As soon as possible, make sure that our plan has been told
about your emergency. We need to follow up on your emergency care. You or someone
else should call to tell us about your emergency care, usually within 48 hours. [Plans
must provide either the phone number and days and hours of operation or explain where
to find the number (e.g., on the back of the plan membership card).]]
What is covered if you have a medical emergency?
Our plan covers ambulance services in situations where getting to the emergency room in any
other way could endanger your health. We also cover medical services during the emergency.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 3 Using the plan for your medical services
28
The doctors who are giving you emergency care will decide when your condition is stable, and
the medical emergency is over.
[Plans may modify this paragraph as needed to address the post-stabilization care for your
plan.] After the emergency is over, you are entitled to follow-up care to be sure your condition
continues to be stable. Your doctors will continue to treat you until your doctors contact us and
make plans for additional care. Your follow-up care will be covered by our plan.
Section 3.2
Getting 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 your plan.
Please visit the following website: [insert website] for information on how to obtain needed care
during a disaster.
SECTION 4
What if you are billed directly for the full cost of your
services?
Section 4.1
You can ask us to pay our share of the cost of covered
services
Before you reach your deductible, you must pay the full cost of your covered services. Even
though you must pay for the services, you must submit a claim to our plan so that we can count
your expenses towards your deductible.
After you meet the deductible, we will pay for your covered services. If you receive a bill, you
should not pay it – you should submit the bill to us for payment. If you have already paid the bill,
you should submit a payment request to us so that we can pay you back.
If you have paid for your covered services, or if you have received a bill for the full cost of
covered medical services, go to Chapter 5 (Asking us to pay our share of a bill you have received
for covered medical services) for information about what to do.
Section 4.2
If services are not covered by our plan, you must pay the full
cost
[Insert 2024 plan name] covers all medically necessary services as listed in the Medical Benefits
Chart in Chapter 4 of this document. If you receive services not covered by our plan or services
obtained out-of-network and were not authorized, you are responsible for paying the full cost of
services.
For covered services that have a benefit limitation, you also pay the full cost of any services you
get after you have used up your benefit for that type of covered service. [Plans should explain
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 3 Using the plan for your medical services
29
whether paying for costs once a benefit limit has been reached will count toward an out-ofpocket maximum.]
If you have any questions about whether we will pay for any medical service or care that you are
considering, you have the right to ask us whether we will cover it before you get it. You also
have the right to ask for this in writing. If we say we will not cover your services, you have the
right to appeal our decision not to cover your care.
Chapter 7 (What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)) has more information about what to do if you want a coverage decision from us or
want to appeal a decision we have already made.
SECTION 5
How are your medical services covered when you are
in a clinical research study?
Section 5.1
What is a clinical research study?
A clinical research study (also called a clinical trial) is a way that doctors and scientists test new
types of medical care, like how well a new cancer drug works. Certain clinical research studies
are approved by Medicare. Clinical research studies approved by Medicare typically request
volunteers to participate in the study.
Once Medicare approves the study, and you express interest, someone who works on the study
will contact you to explain more about the study and see if you meet the requirements set by the
scientists who are running the study. You can participate in the study as long as you meet the
requirements for the study, and you have a full understanding and acceptance of what is involved
if you participate in the study.
If you participate in a Medicare-approved study, Original Medicare pays most of the costs for the
covered services you receive as part of the study. If you tell us that you are in a qualified clinical
trial, then you are only responsible for the in-network cost sharing for the services in that trial. If
you paid more, for example, if you already paid the Original Medicare cost-sharing amount, we
will reimburse the difference between what you paid and the in-network cost sharing. However,
you will need to provide documentation to show us how much you paid. When you are in a
clinical research study, you may stay enrolled in our plan and continue to get the rest of your
care (the care that is not related to the study) through our plan.
If you want to participate in any Medicare-approved clinical research study, you do not need to
tell us or to get approval from us [plans that do not use PCPs may delete the rest of this
sentence] or your PCP. The providers that deliver your care as part of the clinical research study
do not need to be part of our plan’s network of providers. Please note that this does not include
benefits for which our plan is responsible that include, as a component, a clinical trial or registry
to assess the benefit. These include certain benefits specified under national coverage
determinations (NCDs) and investigational device trials (IDE) and may be subject to prior
authorization and other plan rules.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 3 Using the plan for your medical services
30
Although you do not need to get our plan’s permission to be in a clinical research study, covered
for Medicare Advantage enrollees by Original Medicare, we encourage you to notify us in
advance when you choose to participate in Medicare-qualified clinical trials.
[For plans that offer their own studies insert the paragraph: Our plan also covers some clinical
research studies. For these studies, we will have to approve your participation. Participation in
the clinical research study is also voluntary.]
If you participate in a study that Medicare [plans that conduct or cover clinical trials that are not
approved by Medicare insert: or our plan] has not approved, you will be responsible for paying
all costs for your participation in the study.
Section 5.2
When you participate in a clinical research study, who pays for
what?
Once you join a Medicare-approved clinical research study, Original Medicare covers the routine
items and services you receive as part of the study, including:
•
Room and board for a hospital stay that Medicare would pay for even if you weren’t in a
study.
•
An operation or other medical procedure if it is part of the research study.
•
Treatment of side effects and complications of the new care.
After Medicare has paid its share of the cost for these services, our plan will pay the difference
between the cost sharing in Original Medicare and your in-network cost sharing as a member of
our plan. This means you will pay the same amount for the services you receive as part of the
study as you would if you received these services from our plan. Therefore, if you have met your
yearly deductible, you will pay nothing for the items and services you receive as part of the
study. However, you are required to submit documentation showing how much cost sharing you
paid. Please see Chapter 5 for more information for submitting requests for payments.
When you are part of a clinical research study, neither Medicare nor our plan will pay for any
of the following:
•
Generally, Medicare will not pay for the new item or service that the study is testing
unless Medicare would cover the item or service even if you were not in a study.
•
Items or services provided only to collect data, and not used in your direct health care.
For example, Medicare would not pay for monthly CT scans done as part of the study if
your medical condition would normally require only one CT scan.
Do you want to know more?
You can get more information about joining a clinical research study by visiting the Medicare
website to read or download the publication Medicare and Clinical Research Studies. (The
publication is available at: www.medicare.gov/Pubs/pdf/02226-Medicare-and-Clinical-Research-
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 3 Using the plan for your medical services
31
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.
SECTION 6
Rules for getting care in a religious non-medical
health care institution
Section 6.1
What is a religious non-medical health care institution?
A religious non-medical health care institution is a facility that provides care for a condition that
would ordinarily be treated in a hospital or skilled nursing facility. If getting care in a hospital or
a skilled nursing facility is against a member’s religious beliefs, we will instead provide
coverage for care in a religious non-medical health care institution. This benefit is provided only
for Part A inpatient services (non-medical health care services).
Section 6.2
Receiving 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 conscientiously opposed to getting medical treatment that is non-excepted.
•
Non-excepted medical care or treatment is any medical care or treatment that is
voluntary and not required by any federal, state, or local law.
•
Excepted medical treatment is medical care or treatment that you get that is not voluntary
or is required under federal, state, or local law.
To be covered by our plan, the care you get from a religious non-medical health care institution
must meet the following conditions:
•
The facility providing the care must be certified by Medicare.
•
Our plan’s coverage of services you receive is limited to non-religious aspects of care.
•
If you get services from this institution that are provided to you in a facility, the
following [insert as applicable: conditions apply OR condition applies]:
o You must have a medical condition that would allow you to receive covered
services for inpatient hospital care or skilled nursing facility care.
o [Omit this bullet if not applicable] – and – you must get approval in advance from
our plan before you are admitted to the facility, or your stay will not be covered.
[Plans must explain whether Medicare Inpatient Hospital coverage limits apply (include a
reference to the benefits chart in Chapter 4) or whether there is unlimited coverage for this
benefit.]
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 3 Using the plan for your medical services
SECTION 7
Rules for ownership of durable medical equipment
Section 7.1
Will you own the durable medical equipment after making a
certain number of payments under our plan?
32
[Plans that allow transfer of ownership of certain DME items to members must modify this
section to explain the conditions under which and, when the member can own specified, DME.]
Durable medical equipment (DME) includes items such as oxygen equipment and supplies,
wheelchairs, walkers, powered mattress systems, crutches, diabetic supplies, speech generating
devices, IV infusion pumps, nebulizers, and hospital beds ordered by a provider for use in the
home. The member always owns certain items, such as prosthetics. In this section, we discuss
other types of (DME) that you must rent.
In Original Medicare, people who rent certain types of DME own the equipment after paying
copayments for the item for 13 months. As a member of [insert 2024 plan name], however, you
[insert if the plan sometimes allows ownership: usually] will not acquire ownership of rented
DME items no matter how many copayments you make for the item while a member of our plan,
even if you made up to 12 consecutive payments for the DME item under Original Medicare
before you joined our plan. [Insert if your plan sometimes allows transfer of ownership for items
other than prosthetics: Under certain limited circumstances we will transfer ownership of the
DME item to you. Call member services for more information.]
What happens to payments you made for durable medical equipment if you
switch to Original Medicare?
If you did not acquire ownership of the DME item while in our plan, you will have to make 13
new consecutive payments after you switch to Original Medicare in order to own the item. The
payments made while enrolled in your plan do not count.
Example 1: You made 12 or fewer consecutive payments for the item in Original Medicare and
then joined our plan. The payments you made in Original Medicare do not count. [If your plan
allows ownership insert: You will have to make 13 payments to our plan before owning the
item] [Plans who wish to honor former payments should state so].
Example 2: You made 12 or fewer consecutive payments for the item in Original Medicare and
then joined our plan. You were in our plan but did not obtain ownership while in our plan. You
then go back to Original Medicare. You will have to make 13 consecutive new payments to own
the item once you join Original Medicare again. All previous payments (whether to our plan or
to Original Medicare) do not count.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 3 Using the plan for your medical services
33
Section 7.2 Rules for oxygen equipment, supplies, and maintenance
What oxygen benefits are you entitled to?
If you qualify for Medicare oxygen equipment coverage [insert 2024 plan name] will cover:
•
Rental of oxygen equipment
•
Delivery of oxygen and oxygen contents
•
Tubing and related oxygen accessories for the delivery of oxygen and oxygen contents
•
Maintenance and repairs of oxygen equipment
If you leave [insert 2024 plan name] or no longer medically require oxygen equipment, then the
oxygen equipment must be returned.
What happens if you leave your plan and return to Original Medicare?
Original Medicare requires an oxygen supplier to provide you services for five years. During the
first 36 months you rent the equipment. The remaining 24 months the supplier provides the
equipment and maintenance (you are still responsible for the copayment for oxygen). After five
years, you may choose to stay with the same company or go to another company. At this point,
the five-year cycle begins again, even if you remain with the same company, requiring you to
pay copayments for the first 36 months. If you join or leave our plan, the five-year cycle starts
over.
CHAPTER 4:
Medical Benefits Chart (what is
covered and what you pay)
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
SECTION 1
35
Understanding your out-of-pocket costs for covered
services
This chapter provides a Medical Benefits Chart that lists your covered services and shows how
much you will pay for each covered service as a member of [insert 2024 plan name]. Later in this
chapter, you can find information about medical services that are not covered. [Insert if
applicable: It also explains limits on certain services.] [If applicable, you may mention other
places where benefits, limitations, and exclusions are described, such as optional additional
benefits, or addenda.]
Section 1.1
Types of out-of-pocket costs you may pay for your covered
services
The only type of out-of-pocket costs you have in our plan is your yearly deductible. The
deductible is the amount you must pay for medical services before our plan begins to pay its
share. (Section 1.2 tells you more about your yearly deductible.)
Section 1.2
Your yearly deposit and yearly plan deductible
[Plans must disclose their deposit and deductible. If there is a network, any differential cost
sharing must be disclosed.]
Our plan makes a yearly deposit into your medical savings account. The plan also has a
deductible that you must meet before the plan pays for your covered services. The table below
provides more information about the deposit and deductible.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
36
[Plans may edit table heading as needed] Deposit and Deductible Amounts
Deposit/Deductible
Amount
Yearly Deposit
[Insert 2024 deposit amount]
This is the amount that Medicare deposits into your medical
savings account. You can use the money in your account to
pay your health care costs, including health care costs that
aren’t covered by Medicare. (But only funds used to pay for
Medicare Part A and Part B services will count toward your
yearly deductible.)
This is how much the plan
deposits in your medical
savings account.
Yearly Deductible
[Insert 2024 deductible
amount]
This is the amount you have to pay out-of-pocket for
covered Medicare Part A and Part B services before the plan
will pay for your covered services.
Until you have paid the deductible amount, you must pay the
full cost of your covered services. Once you meet your
deductible, the plan will pay 100% of the costs for covered
Part A and Part B services for the rest of the calendar year.
Section 1.3
This is how much you must
pay for your Part A and Part B
services before the plan will
pay for your covered services.
Our plan does not allow providers to balance bill you
As a member of [insert 2024 plan name], an important protection for you is that, once you meet
your deductible, we don’t allow providers to bill you for any additional charges for services
covered under our plan (called balance billing). This protection applies even if we pay less than
the provider charges for a service and even if there is a dispute and we don’t pay certain provider
charges.
SECTION 2
Use the Medical Benefits Chart to find out what is
covered and how much you will pay
Section 2.1
Your medical benefits and costs as a member of the plan
The Medical Benefits Chart on the following pages lists the services [insert 2024 plan name]
covers and what you pay out-of-pocket for each service. The services listed in the Medical
Benefits Chart are covered only when the following coverage requirements are met:
•
Your Medicare covered services must be provided according to the coverage guidelines
established by Medicare.
•
Your services (including medical care, services, supplies, equipment, and Part B
prescription drugs) must be medically necessary. Medically necessary means that the
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
37
services, supplies, or drugs are needed for the prevention, diagnosis, or treatment of your
medical condition and meet accepted standards of medical practice.
•
No prior authorization, prior notification, or referral is required as a condition of
coverage when medically necessary, plan-covered services are provided to our members.
•
[Insert as applicable: We may also charge you administrative fees for missed
appointments or for not paying your required cost sharing at the time of service. Call
Member Services if you have questions regarding these administrative fees.]
Other important things to know about our coverage:
•
Like all Medicare health plans, we cover everything that Original Medicare covers. For
some of these benefits, you pay more in our plan than you would in Original Medicare.
For others, you pay less. (If you want to know more about the coverage and costs of
Original Medicare, look in your Medicare & You 2024 handbook. View it online at
www.medicare.gov or ask for a copy 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.)
•
If Medicare adds coverage for any new services during 2024, either Medicare or our plan
will cover those services.
You will see this apple next to the preventive services in the benefits chart.
[Instructions on completing benefits chart:
•
When preparing this Benefits Chart, please refer to the instructions for completing the
standardized ANOC and EOC.
•
For all preventive care and screening test benefit information, plans that cover a richer
benefit than Original Medicare do not need to include given description (unless still
applicable) and may instead describe plan benefit.
•
Optional supplemental benefits are not permitted within the chart; plans may describe
these benefits within Section 2.2.
•
Plans with out of network services must clearly indicate for each service, both the in
network and out of network cost.
•
Plans that have tiered cost sharing of medical benefits based on contracted providers
should clearly indicate for each service the cost sharing for each tier, in addition to
defining what each tier means and how it corresponds to the special characters and/or
footnotes indicating such in the provider directory (When one reads the provider
directory, it is clear what the special character and/or footnote means when reading this
section of the EOC. Refer to the current Medicare Advantage and Section 1876 Cost Plan
Provider Directory Model for more information.).
•
Plans may insert any additional benefits information based on the plan’s approved bid
that is not captured in the benefits chart or in the exclusions section. Additional benefits
should be placed alphabetically in the chart.
•
Plans must describe any restrictive policies, limitations, or monetary limits that might
impact a member’s access to services within the chart.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
•
Plans may add references to the list of exclusions in Section 3.1 as appropriate.
•
Plans must make it clear for members (in the sections where member cost sharing is
shown) whether their hospital copays or coinsurance apply on the date of admission
and/or on the date of discharge.]
38
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
39
Medical Benefits Chart
Services that are covered for you
Abdominal aortic aneurysm screening
A one-time screening ultrasound for people at risk. The plan only
covers this screening if you have certain risk factors and if you
get a referral for it from your physician, physician assistant,
nurse practitioner, or clinical nurse specialist. [Also list any
additional benefits offered.]
What you must pay
when you get these
services
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
Acupuncture for chronic low back pain
Covered services include:
Up to 12 visits in 90 days are covered for Medicare beneficiaries
under the following circumstances:
For the purpose of this benefit, chronic low back pain is defined
as:
•
Lasting 12 weeks or longer;
•
nonspecific, in that it has no identifiable systemic cause
(i.e., not associated with metastatic, inflammatory,
infectious disease, etc.);
•
not associated with surgery; and
• not associated with pregnancy.
An additional eight sessions will be covered for those patients
demonstrating an improvement. No more than 20 acupuncture
treatments may be administered annually.
Treatment must be discontinued if the patient is not improving or
is regressing.
Provider Requirements:
Physicians (as defined in 1861(r)(1) of the Social Security Act
(the Act)) may furnish acupuncture in accordance with
applicable state requirements.
Physician assistants (PAs), nurse practitioners (NPs)/clinical
nurse specialists (CNSs) (as identified in 1861(aa) (5) of the
Act), and auxiliary personnel may furnish acupuncture if they
meet all applicable state requirements and have:
•
a masters or doctoral level degree in acupuncture or
Oriental Medicine from a school accredited by the
Accreditation Commission on Acupuncture and Oriental
Medicine (ACAOM); and,
a current, full, active, and unrestricted license to practice
acupuncture in a State, Territory, or Commonwealth (i.e.
Puerto Rico) of the United States, or District of
Columbia.
Auxiliary personnel furnishing acupuncture must be under the
appropriate level of supervision of a physician, PA, or NP/CNS
required by our regulations at 42 CFR §§ 410.26 and 410.27.
[Also list any additional benefits offered.]
•
40
What you must pay
when you get these
services
[List copays / coinsurance
/ deductible.]
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
Ambulance services
•
•
Covered ambulance services include fixed wing, rotary
wing, and ground ambulance services, to the nearest
appropriate facility that can provide care only if they are
furnished to a member whose medical condition is such
that other means of transportation could endanger the
person’s health or if authorized by the plan
Non-emergency transportation by ambulance is
appropriate if it is documented that the member’s
condition is such that other means of transportation could
endanger the person’s health and that transportation by
ambulance is medically required
41
What you must pay
when you get these
services
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
Annual wellness visit
If you’ve had Part B for longer than 12 months, you can get an
annual wellness visit to develop or update a personalized
prevention plan based on your current health and risk factors.
This is covered once every 12 months.
Note: Your first annual wellness visit can’t take place within 12
months of your Welcome to Medicare preventive visit. However,
you don’t need to have had a Welcome to Medicare visit to be
covered for annual wellness visits after you’ve had Part B for 12
months.
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
Bone mass measurement
For qualified individuals (generally, this means people at risk of
losing bone mass or at risk of osteoporosis), the following
services are covered every 24 months or more frequently if
medically necessary: procedures to identify bone mass, detect
bone loss, or determine bone quality, including a physician’s
interpretation of the results.
[Also list any additional benefits offered.]
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
Breast cancer screening (mammograms)
Covered services include:
One baseline mammogram between the ages of 35 and 39
One screening mammogram every 12 months for women
aged 40 and older
• Clinical breast exams once every 24 months
[Also list any additional benefits offered.]
•
•
42
What you must pay
when you get these
services
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
Cardiac rehabilitation services
Comprehensive programs of cardiac rehabilitation services that
include exercise, education, and counseling are covered for
members who meet certain conditions with a doctor’s [insert as
appropriate: referral OR order]. The plan also covers intensive
cardiac rehabilitation programs that are typically more rigorous
or more intense than cardiac rehabilitation programs.
[Also list any additional benefits offered.]
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
Cardiovascular disease risk reduction visit (therapy for
cardiovascular disease)
We cover one visit per year with your primary care doctor to
help lower your risk for cardiovascular disease. During this visit,
your doctor may discuss aspirin use (if appropriate), check your
blood pressure, and give you tips to make sure you’re eating
healthy.
[Also list any additional benefits offered.]
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
Cardiovascular disease testing
Blood tests for the detection of cardiovascular disease (or
abnormalities associated with an elevated risk of cardiovascular
disease) once every 5 years (60 months).
[Also list any additional benefits offered.]
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
Cervical and vaginal cancer screening
Covered services include:
For all women: Pap tests and pelvic exams are covered
once every 24 months
• If you are at high risk of cervical or vaginal cancer or you
are of childbearing age and have had an abnormal Pap
test within the past 3 years: one Pap test every 12 months
[Also list any additional benefits offered.]
•
Chiropractic services
Covered services include:
[If the plan only covers manual manipulation, insert: We
cover only] Manual manipulation of the spine to correct
subluxation
[Also list any additional benefits offered.]
•
43
What you must pay
when you get these
services
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
Colorectal cancer screening
The following screening tests are covered:
•
•
•
•
•
•
•
Colonoscopy has no minimum or maximum age
limitation and is covered once every 120 months (10
years) for patients not at high risk, or 48 months after a
previous flexible sigmoidoscopy for patients who are not
at high risk for colorectal cancer, and once every 24
months for high risk patients after a previous screening
colonoscopy or barium enema.
Flexible sigmoidoscopy for patients 45 years and older.
Once every 120 months for patients not at high risk after
the patient received a screening colonoscopy. Once every
48 months for high risk patients from the last flexible
sigmoidoscopy or barium enema.
Screening fecal-occult blood tests for patients 45 years
and older. Once every 12 months.
Multitarget stool DNA for patients 45 to 85 years of age
and not meeting high risk criteria. Once every 3 years.
Blood-based Biomarker Tests for patients 45 to 85 years
of age and not meeting high risk criteria. Once every 3
years.
Barium Enema as an alternative to colonoscopy for
patients at high risk and 24 months since the last
screening barium enema or the last screening
colonoscopy.
Barium Enema as an alternative to flexible
sigmoidoscopy for patient not at high risk and 45 years or
older. Once at least 48 months following the last
screening barium enema or screening flexible
sigmoidoscopy.
As of January 1, 2023, colorectal cancer screening tests include a
follow-on screening colonoscopy after a Medicare covered noninvasive stool-based colorectal cancer screening test returns a
positive result.
[Also list any additional benefits offered.]
44
What you must pay
when you get these
services
There is no coinsurance,
copayment, or deductible
for a Medicare-covered
colorectal cancer
screening exam,
excluding barium enemas,
for which coinsurance
applies. If your doctor
finds and removes a polyp
or other tissue during the
colonoscopy or flexible
sigmoidoscopy, the
screening exam becomes
a diagnostic exam and
you pay 15% of the
Medicare-approved
amount for your doctors’
services. In a hospital
outpatient setting, you
also pay the hospital a
15% coinsurance. The
Part B deductible doesn’t
apply.
[If applicable, list
copayment and/or
coinsurance charged for
barium enema.]
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
45
What you must pay
when you get these
services
Depression screening
We cover one screening for depression per year. The screening
must be done in a primary care setting that can provide follow-up
treatment and/or referrals.
[Also list any additional benefits offered.]
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
Diabetes screening
We cover this screening (includes fasting glucose tests) if you
have any of the following risk factors: high blood pressure
(hypertension), history of abnormal cholesterol and triglyceride
levels (dyslipidemia), obesity, or a history of high blood sugar
(glucose). Tests may also be covered if you meet other
requirements, like being overweight and having a family history
of diabetes.
Based on the results of these tests, you may be eligible for up to
two diabetes screenings every 12 months.
[Also list any additional benefits offered.]
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
Diabetes self-management training, diabetic services and
supplies
[Plans may put items listed under a single bullet in separate
bullets if the plan charges different copays. However, all items in
the bullets must be included.] For all people who have diabetes
(insulin and non-insulin users). Covered services include:
Supplies to monitor your blood glucose: Blood glucose
monitor, blood glucose test strips, lancet devices and
lancets, and glucose-control solutions for checking the
accuracy of test strips and monitors.
• For people with diabetes who have severe diabetic foot
disease: One pair per calendar year of therapeutic
custom-molded shoes (including inserts provided with
such shoes) and two additional pairs of inserts, or one
pair of depth shoes and three pairs of inserts (not
including the non-customized removable inserts provided
with such shoes). Coverage includes fitting.
• Diabetes self-management training is covered under
certain conditions.
[Also list any additional benefits offered.]
•
Durable medical equipment (DME) and related supplies
(For a definition of durable medical equipment, see Chapter 10
of this document as well as Chapter 3, Section 7.)
Covered items include, but are not limited to: wheelchairs,
crutches, powered mattress systems, diabetic supplies, hospital
beds ordered by a provider for use in the home, IV infusion
pumps, speech generating devices, oxygen equipment,
nebulizers, and walkers.
46
What you must pay
when you get these
services
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
Durable medical equipment (DME) and related supplies
(continued)
[Plans that do not limit the DME brands and manufacturers that
you will cover insert: We cover all medically necessary DME
covered by Original Medicare. If our supplier in your area does
not carry a particular brand or manufacturer, you may ask them if
they can special order it for you. [Insert as applicable: We
included a copy of our DME supplier directory in the envelope
with this document.] The most recent list of suppliers is [insert
as applicable: also] available on our website at [insert URL].]
[Plans that limit the DME brands and manufacturers that you
will cover insert: With this Evidence of Coverage document, we
sent you [insert 2024 plan name]’s list of DME. The list tells
you the brands and manufacturers of DME that we will cover.
[Insert as applicable: We included a copy of our DME
supplier directory in the envelope with this document]. This most
recent list of brands, manufacturers, and suppliers is also
available on our website at [insert URL].]
[Generally, [insert 2024 plan name] covers any DME covered by
Original Medicare from the brands and manufacturers on this
list. We will not cover other brands and manufacturers unless
your doctor or other provider tells us that the brand is appropriate
for your medical needs. However, if you are new to [insert 2024
plan name] and are using a brand of DME that is not on our list,
we will continue to cover this brand for you for up to 90 days.
During this time, you should talk with your doctor to decide what
brand is medically appropriate for you after this 90-day period.
(If you disagree with your doctor, you can ask him or her to refer
you for a second opinion.)
47
What you must pay
when you get these
services
[Plans should insert cost
sharing] Your cost
sharing for Medicare
oxygen equipment
coverage is [Insert copay
amount or coinsurance
percentage], every [Insert
required frequency of
payment].
[Plans that use a constant
cost-sharing structure for
oxygen equipment insert]
Your cost sharing will not
change after being
enrolled for 36 months.
[Plans that wish to vary
cost sharing for oxygen
equipment after 36
months insert details
including whether
original cost sharing
resumes after 5 years and
you are still in the plan.]
[If cost sharing is
different for members who
made 36 months of rental
payments prior to joining
the plan insert:]
If prior to enrolling in
[insert 2024 plan name]
you had made 36 months
of rental payment for
oxygen equipment
coverage, your cost
sharing in [insert 2024
plan name] is [Plans
should insert cost
sharing].
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
48
What you must pay
when you get these
services
Durable medical equipment (DME) and related supplies
(continued)
If you (or your provider) don’t agree with the plan’s coverage
decision, you or your provider may file an appeal. You can also
file an appeal if you don’t agree with your provider’s decision
about what product or brand is appropriate for your medical
condition. (For more information about appeals, see Chapter 7,
What to do if you have a problem or complaint (coverage
decisions, appeals, complaints).)]
Emergency care
Emergency care refers to services that are:
Furnished by a provider qualified to furnish emergency
services, and
• Needed to evaluate or stabilize an emergency medical
condition.
A medical emergency is when you, or any other prudent
layperson with an average knowledge of health and medicine,
believe that you have medical symptoms that require immediate
medical attention to prevent loss of life (and, if you are a
pregnant woman, loss of an unborn child), loss of a limb, or loss
of function of a limb. The medical symptoms may be an illness,
injury, severe pain, or a medical condition that is quickly getting
worse.
[Plans with a network insert: Cost sharing for necessary
emergency services furnished out-of-network is the same as for
such services furnished in-network.]
[Also identify whether this plan would only provide coverage as
required in the U.S. or whether it provides world-wide
emergency/urgent coverage as a supplemental benefit.]
•
Hearing services
Diagnostic hearing and balance evaluations performed by your
[insert as applicable: PCP OR provider] to determine if you need
medical treatment are covered as outpatient care when furnished
by a physician, audiologist, or other qualified provider.
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
HIV screening
For people who ask for an HIV screening test or who are at
increased risk for HIV infection, we cover:
• One screening exam every 12 months
For women who are pregnant, we cover:
• Up to three screening exams during a pregnancy
[Also list any additional benefits offered.]
Home health agency care
[If needed, plans may revise language related to the doctor
certification requirement.] Prior to receiving home health
services, a doctor must certify that you need home health
services and will order home health services to be provided by a
home health agency. You must be homebound, which means
leaving home is a major effort.
Covered services include, but are not limited to:
•
•
•
•
Part-time or intermittent skilled nursing and home health
aide services (To be covered under the home health care
benefit, your skilled nursing and home health aide
services combined must total fewer than eight hours per
day and 35 hours per week)
Physical therapy, occupational therapy, and speech
therapy
Medical and social services
Medical equipment and supplies
49
What you must pay
when you get these
services
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
Home infusion therapy
Home infusion therapy involves the intravenous or subcutaneous
administration of drugs or biologicals to an individual at home.
The components needed to perform home infusion include the
drug (for example, antivirals, immune globulin), equipment (for
example, a pump), and supplies (for example, tubing and
catheters).
Covered services include, but are not limited to:
Professional services, including nursing services,
furnished in accordance with the plan of care
• Patient training and education not otherwise covered
under the durable medical equipment benefit
• Remote monitoring
• Monitoring services for the provision of home infusion
therapy and home infusion drugs furnished by a qualified
home infusion therapy supplier
[Also list any additional benefits offered.]
•
50
What you must pay
when you get these
services
[List copays / coinsurance
/ deductible]
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
Hospice care
You are eligible for the hospice benefit when your doctor and the
hospice medical director have given you a terminal prognosis
certifying that you’re terminally ill and have 6 months or less to
live if your illness runs its normal course. You may receive care
from any Medicare-certified hospice program. Your plan is
obligated to help you find Medicare-certified hospice programs
in the plan’s service area, including those the MA organization
owns, controls, or has a financial interest in.
Covered services include:
• Drugs for symptom control and pain relief
• Short-term respite care
• Home care
When you are admitted to a hospice you have the right to remain
in your plan; if you chose to remain in your plan, you must
continue to pay plan premiums.
For hospice services and for services that are covered by
Medicare Part A or B and are related to your terminal prognosis:
Original Medicare (rather than our plan) will pay your hospice
provider for your hospice services and any Part A and Part B
services related to your terminal prognosis. While you are in the
hospice program, your hospice provider will bill Original
Medicare for the services that Original Medicare pays for. You
will be billed Original Medicare cost sharing.
For services that are not related to your terminal prognosis: You
pay your plan cost-sharing amount for these services.
Note: If you need non-hospice care (care that is not related to
your terminal prognosis), you should contact us to arrange the
services.
•
[Insert if applicable, edit as appropriate: Our plan covers
hospice consultation services (one time only) for a
terminally ill person who hasn’t elected the hospice
benefit.]
51
What you must pay
when you get these
services
When you enroll in a
Medicare-certified
hospice program, your
hospice services and your
Part A and Part B services
related to your terminal
prognosis are paid for by
Original Medicare, not
[insert 2024 plan name].
[Include information
about cost sharing for
hospice consultation
services if applicable.]
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
Immunizations
Covered Medicare Part B services include:
Pneumonia vaccine
Flu shots, once each flu season in the fall and winter, with
additional flu shots if medically necessary
• Hepatitis B vaccine if you are at high or intermediate risk of
getting Hepatitis B
• COVID-19 vaccine
• Other vaccines if you are at risk and they meet Medicare Part
B coverage rules
[Also list any additional benefits offered.]
•
•
52
What you must pay
when you get these
services
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
Inpatient hospital care
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.
[List days covered and any restrictions that apply.] Covered
services include but are not limited to:
Semi-private room (or a private room if medically
necessary)
• Meals including special diets
• Regular nursing services
• Costs of special care units (such as intensive care or
coronary care units)
• Drugs and medications
• Lab tests
• X-rays and other radiology services
• Necessary surgical and medical supplies
• Use of appliances, such as wheelchairs
• Operating and recovery room costs
• Physical, occupational, and speech language therapy
• Inpatient substance abuse services
Under certain conditions, the following types of transplants are
covered: corneal, kidney, kidney-pancreatic, heart, liver, lung,
heart/lung, bone marrow, stem cell, and intestinal/multivisceral.
If you need a transplant, we will arrange to have your case
reviewed by a Medicare-approved transplant center that will
decide whether you are a candidate for a transplant. [If [insert
2024 plan name] provides transplant services at a location
outside the pattern of care for transplants in your community and
you choose to obtain transplants at this distant location, we will
arrange or pay for appropriate lodging and transportation costs
for you and a companion.] [Plans may further define the
specifics of transplant travel coverage.]
•
53
What you must pay
when you get these
services
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
54
What you must pay
when you get these
services
Inpatient hospital care (continued)
Blood - including storage and administration. Coverage
of whole blood and packed red cells begins only with the
fourth pint of blood that you need - you must either pay
the costs for the first three pints of blood you get in a
calendar year or have the blood donated by you or
someone else. All other components of blood are covered
beginning with the first pint used [Modify as necessary if
the plan begins coverage with an earlier pint.]
• Physician services
Note: To be an inpatient, your provider must write an order to
admit you formally as an inpatient of the hospital. Even if you
stay in the hospital overnight, you might still be considered an
outpatient. If you are not sure if you are an inpatient or an
outpatient, you should ask the hospital staff.
You can also find more information in a Medicare fact sheet
called Are You a Hospital Inpatient or Outpatient? If You
Have Medicare – Ask! This fact sheet is available on the Web
at https://www.medicare.gov/sites/default/files/202110/11435-Inpatient-or-Outpatient.pdf or by calling 1-800MEDICARE (1-800-633-4227). TTY users call 1-877-4862048. You can call these numbers for free, 24 hours a day, 7
days a week
•
Inpatient mental health care
Covered services include mental health care services that require
a hospital stay. [List days covered, restrictions such as 190-day
lifetime limit for inpatient services in a psychiatric hospital. The
190-day limit does not apply to inpatient mental health services
provided in a psychiatric unit of a general hospital.]
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
Inpatient stay: Covered services received in a hospital or
SNF during a non-covered inpatient stay
[Plans with no day limitations on a plan’s hospital or SNF
coverage may modify or delete this row as appropriate.]
If you have exhausted your inpatient benefits or if the inpatient
stay is not reasonable and necessary, we will not cover your
inpatient stay. However, in some cases, we will cover certain
services you receive while you are in the hospital or the skilled
nursing facility (SNF). Covered services include, but are not
limited to:
•
•
•
•
•
•
•
•
Physician services
Diagnostic tests (like lab tests)
X-ray, radium, and isotope therapy including technician
materials and services
Surgical dressings
Splints, casts and other devices used to reduce fractures
and dislocations
Prosthetics and orthotics devices (other than dental) that
replace all or part of an internal body organ (including
contiguous tissue), or all or part of the function of a
permanently inoperative or malfunctioning internal body
organ, including replacement or repairs of such devices
Leg, arm, back, and neck braces; trusses, and artificial
legs, arms, and eyes including adjustments, repairs, and
replacements required because of breakage, wear, loss, or
a change in the patient’s physical condition
Physical therapy, speech therapy, and occupational
therapy
55
What you must pay
when you get these
services
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
Medical nutrition therapy
This benefit is for people with diabetes, renal (kidney) disease
(but not on dialysis), or after a kidney transplant when [insert as
appropriate: referred OR ordered] by your doctor.
We cover 3 hours of one-on-one counseling services during your
first year that you receive medical nutrition therapy services
under Medicare (this includes our plan, any other Medicare
Advantage plan, or Original Medicare), and 2 hours each year
after that. If your condition, treatment, or diagnosis changes, you
may be able to receive more hours of treatment with a
physician’s [insert as appropriate: referral OR order]. A
physician must prescribe these services and renew their [insert as
appropriate: referral OR order] yearly if your treatment is
needed into the next calendar year.
•
[Also list any additional benefits offered.]
56
What you must pay
when you get these
services
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
Medicare Diabetes Prevention Program (MDPP)
MDPP services will be covered for eligible Medicare
beneficiaries under all Medicare health plans.
MDPP is a structured health behavior change intervention that
provides practical training in long-term dietary change, increased
physical activity, and problem-solving strategies for overcoming
challenges to sustaining weight loss and a healthy lifestyle.
Medicare Part B prescription drugs
These drugs are covered under Part B of Original Medicare.
Members of our plan receive coverage for these drugs through
our plan. Covered drugs include:
•
•
•
•
•
•
•
•
•
•
Drugs that usually aren’t self-administered by the patient
and are injected or infused while you are getting
physician, hospital outpatient, or ambulatory surgical
center services
Insulin furnished through an item of durable medical
equipment (such as a medically necessary insulin pump)
Other drugs you take using durable medical equipment
(such as nebulizers) that were authorized by the plan
Clotting factors you give yourself by injection if you
have hemophilia
Immunosuppressive drugs, if you were enrolled in
Medicare Part A at the time of the organ transplant
Injectable osteoporosis drugs, if you are homebound,
have a bone fracture that a doctor certifies was related to
post-menopausal osteoporosis, and cannot self-administer
the drug
Antigens
Certain oral anti-cancer drugs and anti-nausea drugs
Certain drugs for home dialysis, including heparin, the
antidote for heparin when medically necessary, topical
anesthetics, and erythropoiesis-stimulating agents [plans
may delete any of the following drugs that are not
covered under the plan] (such as Epogen, Procrit,
Epoetin Alfa, Aranesp, or Darbepoetin Alfa)
Intravenous Immune Globulin for the home treatment of
primary immune deficiency diseases
57
What you must pay
when you get these
services
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
[List copays / coinsurance
/ deductible]
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
Obesity screening and therapy to promote sustained weight
loss
If you have a body mass index of 30 or more, we cover intensive
counseling to help you lose weight. This counseling is covered if
you get it in a primary care setting, where it can be coordinated
with your comprehensive prevention plan. Talk to your primary
care doctor or practitioner to find out more.
•
[Also list any additional benefits offered.]
Opioid treatment program services
Members of our plan with opioid use disorder (OUD) can
receive coverage of services to treat OUD through an Opioid
Treatment Program (OTP) which includes the following
services:
U.S. Food and Drug Administration (FDA)-approved
opioid agonist and antagonist medication-assisted
treatment (MAT) medications.
• Dispensing and administration of MAT medications (if
applicable)
• Substance use counseling
• Individual and group therapy
• Toxicology testing
• Intake activities
• Periodic assessments
[Plans can include other covered items and services as
appropriate (not to include meals and transportation).]
•
58
What you must pay
when you get these
services
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
Outpatient diagnostic tests and therapeutic services and
supplies
Covered services include, but are not limited to:
X-rays
Radiation (radium and isotope) therapy including
technician materials and supplies [List separately any
services for which a separate copay/coinsurance applies
over and above the outpatient radiation therapy
copay/coinsurance.]
• Surgical supplies, such as dressings
• Splints, casts and other devices used to reduce fractures
and dislocations
• Laboratory tests
• Blood - including storage and administration. Coverage
of whole blood and packed red cells begins only with the
fourth pint of blood that you need - you must either pay
the costs for the first three pints of blood you get in a
calendar year or have the blood donated by you or
someone else. All other components of blood are covered
beginning with the first pint used [Modify as necessary if
the plan begins coverage with an earlier pint.]
Other outpatient diagnostic tests [Plans can include other
covered tests as appropriate.]
•
•
59
What you must pay
when you get these
services
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
60
What you must pay
when you get these
services
Outpatient hospital observation
[List copays / coinsurance
/ deductible]
Observation services are hospital outpatient services given to
determine if you need to be admitted as an inpatient or can be
discharged.
For outpatient hospital observation services to be covered, they
must meet the Medicare criteria and be considered reasonable
and necessary. Observation services are covered only when
provided by the order of a physician or another individual
authorized by state licensure law and hospital staff bylaws to
admit patients to the hospital or order outpatient tests.
Note: Unless the provider has written an order to admit you as an
inpatient to the hospital, you are an outpatient and pay the costsharing amounts for outpatient hospital services. Even if you stay
in the hospital overnight, you might still be considered an
outpatient. If you are not sure if you are an outpatient, you
should ask the hospital staff.
You can also find more information in a Medicare fact sheet
called Are You a Hospital Inpatient or Outpatient? If You Have
Medicare – Ask! This fact sheet is available on the Web at
https://www.medicare.gov/sites/default/files/2021-10/11435Inpatient-or-Outpatient.pdf or by calling 1-800-MEDICARE (1800-633-4227). TTY users call 1-877-486-2048. You can call
these numbers for free, 24 hours a day, 7 days a week.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
Outpatient hospital services
We cover medically-necessary services you get in the outpatient
department of a hospital for diagnosis or treatment of an illness
or injury.
Covered services include, but are not limited to:
Services in an emergency department or outpatient clinic,
such as observation services or outpatient surgery
• Laboratory and diagnostic tests billed by the hospital
• Mental health care, including care in a partialhospitalization program, if a doctor certifies that inpatient
treatment would be required without it
• X-rays and other radiology services billed by the hospital
• Medical supplies such as splints and casts
• Certain drugs and biologicals that you can’t give yourself
Note: Unless the provider has written an order to admit you as an
inpatient to the hospital, you are an outpatient. Even if you stay
in the hospital overnight, you might still be considered an
outpatient. If you are not sure if you are an outpatient, you
should ask the hospital staff.
You can also find more information in a Medicare fact sheet
called Are You a Hospital Inpatient or Outpatient? If You Have
Medicare – Ask! This fact sheet is available on the Web at
https://www.medicare.gov/sites/default/files/2021-10/11435Inpatient-or-Outpatient.pdf or by calling 1-800-MEDICARE (1800-633-4227). TTY users call 1-877-486-2048. You can call
these numbers for free, 24 hours a day, 7 days a week.
[Also list any additional benefits offered.]
•
Outpatient mental health care
Covered services include:
Mental health services provided by a state-licensed psychiatrist
or doctor, clinical psychologist, clinical social worker, clinical
nurse specialist, licensed professional counselor (LPC), licensed
marriage and family therapist (LMFT), nurse practitioner (NP),
physician assistant (PA), or other Medicare-qualified mental
health care professional as allowed under applicable state laws.
[Also list any additional benefits offered.]
61
What you must pay
when you get these
services
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
Outpatient rehabilitation services
Covered services include: physical therapy, occupational
therapy, and speech language therapy.
Outpatient rehabilitation services are provided in various
outpatient settings, such as hospital outpatient departments,
independent therapist offices, and Comprehensive Outpatient
Rehabilitation Facilities (CORFs).
Outpatient substance abuse services
[Describe the plan’s benefits for outpatient substance abuse
services.]
Outpatient surgery, including services provided at hospital
outpatient facilities and ambulatory surgical centers
Note: If you are having surgery in a hospital facility, you should
check with your provider about whether you will be an inpatient
or outpatient. Unless the provider writes an order to admit you as
an inpatient to the hospital, you are an outpatient. Even if you
stay in the hospital overnight, you might still be considered an
outpatient.
62
What you must pay
when you get these
services
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
63
Services that are covered for you
What you must pay
when you get these
services
Partial hospitalization services
Partial hospitalization is a structured program of active
psychiatric treatment provided as a hospital outpatient service or
by a community mental health center, that is more intense than
the care received in your doctor’s or therapist’s office and is an
alternative to inpatient hospitalization.
[Network plans that do not have an in-network community
mental health center may add: Note: Because there are no
community mental health centers in our network, we cover
partial hospitalization only as a hospital outpatient service.]
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
Physician/Practitioner services, including doctor’s office
visits
Covered services include:
•
•
•
•
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
Medically-necessary medical care or surgery services
amount.
furnished in a physician’s office, certified ambulatory
After you meet your
surgical center, hospital outpatient department, or any
deductible, you pay $0 for
other location
Medicare-covered
Consultation, diagnosis, and treatment by a specialist
services.
Basic hearing and balance exams performed by your
[insert as applicable: PCP OR specialist], if your doctor
[If applicable, indicate
orders it to see if you need medical treatment
whether there are
[Insert if providing any MA additional telehealth benefits different cost-sharing
consistent with 42 CFR § 422.135 in the plan’s CMSamounts for Part B
approved Plan Benefit Package submission: Certain
service(s) furnished
telehealth services, including: [insert general description through an in-person visit
of covered MA additional telehealth benefits, i.e., the
and those furnished
specific Part B service(s) the plan has identified as
through electronic
clinically appropriate to furnish through electronic
exchange as MA
exchange when the provider is not in the same location as additional telehealth
the enrollee. Plans may wish to refer enrollees to their
benefits.]
medical coverage policy here]
o You have the option of getting these services
through an in-person visit or by telehealth. If you
choose to get one of these services by telehealth,
you must use a network provider who offers the
service by telehealth. [Modify as necessary if plan
benefits include out-of-network coverage of
additional telehealth services as mandatory
supplemental benefits.]
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
Physician/Practitioner services, including doctor’s office
visits (continued)
o [List the available means of electronic exchange
used for each Part B service offered as an MA
additional telehealth benefit along with any other
access instructions that may apply.]]
• [Insert if the plan’s service area and providers/locations
qualify for telehealth services under original Medicare
requirements in section 1834(m) of the Act: Some
telehealth services including consultation, diagnosis, and
treatment by a physician or practitioner, for patients in
certain rural areas or other places approved by Medicare]
• Telehealth services for monthly end-stage renal diseaserelated visits for home dialysis members in a hospitalbased or critical access hospital-based renal dialysis
center, renal dialysis facility, or the member’s home
• Telehealth services to diagnose, evaluate, or treat
symptoms of a stroke regardless of your location
• Telehealth services for members with a substance use
disorder or co-occurring mental health disorder,
regardless of their location
• Telehealth services for diagnosis, evaluation, and
treatment of mental health disorders if:
o You have an in-person visit within 6 months prior
to your first telehealth visit
o You have an in-person visit every 12 months
while receiving these telehealth services
o Exceptions can be made to the above for certain
circumstances
• Telehealth services for mental health visits provided by
Rural Health Clinics and Federally Qualified Health
Centers
• Virtual check-ins (for example, by phone or video chat)
with your doctor for 5-10 minutes if:
o You’re not a new patient and
o The check-in isn’t related to an office visit in the
past 7 days and
o The check-in doesn’t lead to an office visit within
24 hours or the soonest available appointment
What you must pay
when you get these
services
64
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
65
What you must pay
when you get these
services
Physician/Practitioner services, including doctor’s office
visits (continued)
•
•
•
•
•
Evaluation of video and/or images you send to your
doctor, and interpretation and follow-up by your doctor
within 24 hours if:
o You’re not a new patient and
o The evaluation isn’t related to an office visit in
the past 7 days and
o The evaluation doesn’t lead to an office visit
within 24 hours or the soonest available
appointment
Consultation your doctor has with other doctors by
phone, internet, or electronic health record
Second opinion [insert if appropriate: by another
network provider] prior to surgery
Non-routine dental care (covered services are limited to
surgery of the jaw or related structures, setting fractures
of the jaw or facial bones, extraction of teeth to prepare
the jaw for radiation treatments of neoplastic cancer
disease, or services that would be covered when provided
by a physician)
[Also list any additional benefits offered.]
Podiatry services
Covered services include:
Diagnosis and the medical or surgical treatment of
injuries and diseases of the feet (such as hammer toe or
heel spurs)
• Routine foot care for members with certain medical
conditions affecting the lower limbs
[Also list any additional benefits offered.]
•
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
Prostate cancer screening exams
For men aged 50 and older, covered services include the
following - once every 12 months:
• Digital rectal exam
• Prostate Specific Antigen (PSA) test
[Also list any additional benefits offered.]
Prosthetic devices and related supplies
Devices (other than dental) that replace all or part of a body part
or function. These include, but are not limited to: colostomy bags
and supplies directly related to colostomy care, pacemakers,
braces, prosthetic shoes, artificial limbs, and breast prostheses
(including a surgical brassiere after a mastectomy). Includes
certain supplies related to prosthetic devices, and repair and/or
replacement of prosthetic devices. Also includes some coverage
following cataract removal or cataract surgery – see Vision Care
later in this section for more detail.
Pulmonary rehabilitation services
Comprehensive programs of pulmonary rehabilitation are
covered for members who have moderate to very severe chronic
obstructive pulmonary disease (COPD) and [insert as
appropriate: a referral OR an order] for pulmonary rehabilitation
from the doctor treating the chronic respiratory disease.
[Also list any additional benefits offered.]
66
What you must pay
when you get these
services
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
Screening and counseling to reduce alcohol misuse
We cover one alcohol misuse screening for adults with Medicare
(including pregnant women) who misuse alcohol, but aren’t
alcohol dependent.
If you screen positive for alcohol misuse, you can get up to 4
brief face-to-face counseling sessions per year (if you’re
competent and alert during counseling) provided by a qualified
primary care doctor or practitioner in a primary care setting.
[Also list any additional benefits offered.]
Screening for lung cancer with low dose computed
tomography (LDCT)
For qualified individuals, a LDCT is covered every 12 months.
Eligible members are: people aged 50 – 77 years who have no
signs or symptoms of lung cancer, but who have a history of
tobacco smoking of at least 20 pack-years and who currently
smoke or have quit smoking within the last 15 years, who receive
a written order for LDCT during a lung cancer screening
counseling and shared decision making visit that meets the
Medicare criteria for such visits and be furnished by a physician
or qualified non-physician practitioner.
For LDCT lung cancer screenings after the initial LDCT
screening: the member must receive a written order for LDCT
lung cancer screening, which may be furnished during any
appropriate visit with a physician or qualified non-physician
practitioner. If a physician or qualified non-physician practitioner
elects to provide a lung cancer screening counseling and shared
decision-making visit for subsequent lung cancer screenings with
LDCT, the visit must meet the Medicare criteria for such visits.
67
What you must pay
when you get these
services
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
Screening for sexually transmitted infections (STIs) and
counseling to prevent STIs
We cover sexually transmitted infection (STI) screenings for
chlamydia, gonorrhea, syphilis, and Hepatitis B. These
screenings are covered for pregnant women and for certain
people who are at increased risk for an STI when the tests are
ordered by a primary care provider. We cover these tests once
every 12 months or at certain times during pregnancy.
We also cover up to 2 individual 20 to 30 minute, face-to-face
high-intensity behavioral counseling sessions each year for
sexually active adults at increased risk for STIs. We will only
cover these counseling sessions as a preventive service if they
are provided by a primary care provider and take place in a
primary care setting, such as a doctor’s office.
[Also list any additional benefits offered.]
Services to treat kidney disease
Covered services include:
Kidney disease education services to teach kidney care
and help members make informed decisions about their
care. For members with stage IV chronic kidney disease
when referred by their doctor, we cover up to six sessions
of kidney disease education services per lifetime
• Outpatient dialysis treatments
• Inpatient dialysis treatments (if you are admitted as an
inpatient to a hospital for special care)
• Self-dialysis training (includes training for you and
anyone helping you with your home dialysis treatments)
• Home dialysis equipment and supplies
• Certain home support services (such as, when necessary,
visits by trained dialysis workers to check on your home
dialysis, to help in emergencies, and check your dialysis
equipment and water supply)
Certain drugs for dialysis are covered under your Medicare Part
B drug benefit. For information about coverage for Part B Drugs,
please go to the section, Medicare Part B prescription drugs.
•
68
What you must pay
when you get these
services
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
Skilled nursing facility (SNF) care
(For a definition of skilled nursing facility care, see Chapter 10
of this document. Skilled nursing facilities are sometimes called
SNFs.)
[List days covered and any restrictions that apply, including
whether any prior hospital stay is required.] Covered services
include but are not limited to:
• Semiprivate room (or a private room if medically
necessary)
• Meals, including special diets
• Skilled nursing services
• Physical therapy, occupational therapy, and speech
therapy
• Drugs administered to you as part of your plan of care
(This includes substances that are naturally present in the
body, such as blood clotting factors.)
• Blood - including storage and administration. Coverage
of whole blood and packed red cells begins only with the
fourth pint of blood that you need - you must either pay
the costs for the first three pints of blood you get in a
calendar year or have the blood donated by you or
someone else. All other components of blood are covered
beginning with the first pint used [Modify as necessary if
the plan begins coverage with an earlier pint.]
• Medical and surgical supplies ordinarily provided by
SNFs
• Laboratory tests ordinarily provided by SNFs
• X-rays and other radiology services ordinarily provided
by SNFs
• Use of appliances such as wheelchairs ordinarily
provided by SNFs
• Physician/Practitioner services
[Insert if applicable: Generally, you will get your SNF care from
network facilities. However, under certain conditions listed
below, you may be able to pay in-network cost sharing for a
facility that isn’t a network provider, if the facility accepts our
plan’s amounts for payment.
• A nursing home or continuing care retirement community
where you were living right before you went to the
hospital (as long as it provides skilled nursing facility
care).
• A SNF where your spouse or domestic partner is living at
the time you leave the hospital.]
69
What you must pay
when you get these
services
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
Smoking and tobacco use cessation (counseling to stop
smoking or tobacco use)
If you use tobacco, but do not have signs or symptoms of
tobacco-related disease: We cover two counseling quit attempts
within a 12-month period as a preventive service with no cost to
you. Each counseling attempt includes up to four face-to-face
visits.
If you use tobacco and have been diagnosed with a tobaccorelated disease or are taking medicine that may be affected by
tobacco: We cover cessation counseling services. We cover two
counseling quit attempts within a 12-month period, however, you
will pay the applicable cost sharing. Each counseling attempt
includes up to four face-to-face visits.
[Also list any additional benefits offered.]
Supervised Exercise Therapy (SET)
SET is covered for members who have symptomatic peripheral
artery disease (PAD) and a referral for PAD from the physician
responsible for PAD treatment.
Up to 36 sessions over a 12-week period are covered if the SET
program requirements are met.
The SET program must:
Consist of sessions lasting 30-60 minutes, comprising a
therapeutic exercise-training program for PAD in patients
with claudication
• Be conducted in a hospital outpatient setting or a
physician’s office
• Be delivered by qualified auxiliary personnel necessary
to ensure benefits exceed harms, and who are trained in
exercise therapy for PAD
• Be under the direct supervision of a physician, physician
assistant, or nurse practitioner/clinical nurse specialist
who must be trained in both basic and advanced life
support techniques
SET may be covered beyond 36 sessions over 12 weeks for an
additional 36 sessions over an extended period of time if deemed
medically necessary by a health care provider.
[Also list any additional benefits offered.]
•
70
What you must pay
when you get these
services
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
[List copays / coinsurance
/ deductible]
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services that are covered for you
Vision care
Covered services include:
•
•
•
•
Outpatient physician services for the diagnosis and
treatment of diseases and injuries of the eye, including
treatment for age-related macular degeneration. Original
Medicare doesn’t cover routine eye exams (eye
refractions) for eyeglasses/contacts
For people who are at high risk of glaucoma, we will
cover one glaucoma screening each year. People at high
risk of glaucoma include: people with a family history of
glaucoma, people with diabetes, African-Americans who
are age 50 and older, and Hispanic Americans who are 65
or older
For people with diabetes, screening for diabetic
retinopathy is covered once per year
[Adapt this description if the plan offers more than is
covered by Original Medicare.] One pair of eyeglasses or
contact lenses after each cataract surgery that includes
insertion of an intraocular lens. (If you have two separate
cataract operations, you cannot reserve the benefit after
the first surgery and purchase two eyeglasses after the
second surgery.)
Welcome to Medicare preventive visit
The plan covers the one-time Welcome to Medicare preventive
visit. The visit includes a review of your health, as well as
education and counseling about the preventive services you need
(including certain screenings and shots), and referrals for other
care if needed.
•
Important: We cover the Welcome to Medicare
preventive visit only within the first 12 months you have
Medicare Part B. When you make your appointment, let
your doctor’s office know you would like to schedule
your Welcome to Medicare preventive visit
71
What you must pay
when you get these
services
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
Until you meet your
yearly deductible, you
pay up to 100% of the
Medicare-approved
amount.
After you meet your
deductible, you pay $0 for
Medicare-covered
services.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Section 2.2
72
Extra optional supplemental benefits you can buy
[Include this section if you offer optional supplemental benefits in the plan and describe benefits
below. You may include this section either in the EOC or as an insert to the EOC.]
Our plan offers some extra benefits that are not covered by Original Medicare and not included
in your benefits package. These extra benefits are called Optional Supplemental Benefits. If
you want these optional supplemental benefits, you must sign up for them [insert if applicable:
and you may have to pay an additional premium for them]. The optional supplemental benefits
described in [insert as applicable: this section OR the enclosed insert] are subject to the same
appeals process as any other benefits.
[Insert plan specific optional benefits, premiums, deductible, copays and coinsurance and rules
using a chart like the Benefits Chart above. Insert plan specific procedures on how to elect
optional supplemental coverage, including application process and effective dates and on how to
discontinue optional supplemental coverage, including refund of premiums. Also insert any
restrictions on members’ re-applying for optional supplemental coverage (e.g., must wait until
next annual enrollment period).]
SECTION 3
What services are not covered by the plan?
Section 3.1
Services we do not cover (exclusions)
This section tells you what services are excluded from Medicare coverage and therefore, are not
covered by this plan.
The chart below lists services and items that either are not covered under any condition or are
covered only under specific conditions.
If you get services that are excluded (not covered), you must pay for them yourself except under
the specific condition listed below. Even if you receive the excluded services at an emergency
facility, the excluded services are still not covered, and our plan will not pay for them. The only
exception is if the service is appealed and decided upon appeal to be a medical service that we
should have paid for or covered because of your specific situation. (For information about
appealing a decision we have made to not cover a medical service, go to Chapter 7, Section 5.3
in this document.)
[Plans may add parenthetical references to the Benefits Chart for descriptions of covered
services/items as appropriate.]
[The services listed in the chart below are excluded from Original Medicare’s benefit package. If
any services below are covered supplemental benefits, delete them from this list. When plans
partially exclude services excluded by Medicare, they do not need to delete the item completely
but may revise the text accordingly to describe the extent of the exclusion. Plans may add
parenthetical references to the Benefits Chart for descriptions of covered services/items as
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
73
appropriate. Plans may reorder the below excluded services alphabetically if they wish. Plans
may also add exclusions as needed.]
Services not covered by
Medicare
Acupuncture
Not covered under
any condition
Cosmetic surgery or
procedures
Custodial care
√
Custodial care is personal care
that does not require the
continuing attention of trained
medical or paramedical
personnel, such as care that
helps you with activities of
daily living, such as bathing or
dressing.
Experimental medical and
surgical procedures, equipment
and medications.
Experimental procedures and
items are those items and
procedures determined by
Original Medicare to not be
generally accepted by the
medical community.
Fees charged for care by your
immediate relatives or
members of your household.
Full-time nursing care in your
home.
Home-delivered meals
Covered only under specific
conditions
• Available for people with
chronic low back pain under
certain circumstances.
• Covered in cases of an
accidental injury or for
improvement of the functioning
of a malformed body member.
• Covered for all stages of
reconstruction for a breast after a
mastectomy, as well as for the
unaffected breast to produce a
symmetrical appearance.
May be covered by Original
Medicare under a Medicareapproved clinical research study or
by our plan.
(See Chapter 3, Section 5 for more
information on clinical research
studies.)
√
√
√
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services not covered by
Medicare
Homemaker services include
basic household assistance,
including light housekeeping
or light meal preparation.
Naturopath services (uses
natural or alternative
treatments).
Non-routine dental care
Not covered under
any condition
√
74
Covered only under specific
conditions
√
Dental care required to treat illness
or injury may be covered as
inpatient or outpatient care.
Orthopedic shoes or supportive
devices for the feet
Shoes that are part of a leg brace and
are included in the cost of the brace.
Orthopedic or therapeutic shoes for
people with diabetic foot disease.
Personal items in your room at
a hospital or a skilled nursing
facility, such as a telephone or
a television.
Private room in a hospital.
√
Reversal of sterilization
procedures and/or nonprescription contraceptive
supplies.
Routine chiropractic care
√
Routine dental care, such as
cleanings, fillings or dentures.
Routine eye examinations,
eyeglasses, radial keratotomy,
LASIK surgery, and other low
vision aids.
Routine foot care
√
Covered only when medically
necessary.
Manual manipulation of the spine to
correct a subluxation is covered.
Eye exam and one pair of eyeglasses
(or contact lenses) are covered for
people after cataract surgery.
Some limited coverage provided
according to Medicare guidelines
(e.g., if you have diabetes).
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 4 Medical Benefits Chart (what is covered and what you pay)
Services not covered by
Not covered under
Medicare
any condition
Routine hearing exams,
√
hearing aids, or exams to fit
hearing aids.
Services considered not
√
reasonable and necessary,
according to Original Medicare
standards
Covered only under specific
conditions
75
CHAPTER 5:
Asking us to pay our share of a bill
you have received for covered
medical services
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 5 Asking us to pay our share of a bill you have received for covered
medical services
SECTION 1
77
Situations in which you should send us a bill you
have received for your covered services
[Plans may modify this section as needed.] When you receive care, you should ask the provider
to bill the plan for your services. We will look at the bill and decide whether the services should
be covered and will let you know who should pay for them.
If you receive a bill for an item or services, you should send the bill to us. Here are some
situations in which you should send a bill to us:
1. When you get a bill for an item or services even though you haven’t yet met
your deductible
Before you reach your deductible, you must pay the full cost of your covered services. Even
though you are responsible for the cost, you should still send the bill to us before you pay it
so we can make sure you have been billed the correct amount. After you pay a bill, you
should send us a copy of the bill and your payment so that we can count your expenses
towards your deductible.
2. When you get a bill for an item or services after you have met your deductible
After you meet the deductible, the plan will pay for your covered services. If you receive a
bill, you should not pay it – you should submit it with a payment request to us. We will look
at the bill and decide whether the services should be covered. If we decide they should be
covered and you have not paid the bill, we will pay the provider directly. If we decide they
should be covered and you have already paid the bill, we will mail you your reimbursement.
•
After you meet your deductible, you don’t have to pay anything for services covered by
our plan. We do not allow providers to add additional separate charges, called balance
billing. This protection applies even if we pay the provider less than the provider charges
for a service and even if there is a dispute and we don’t pay certain provider charges. For
more information about balance billing, go to Chapter 4, Section 1.3.
3. If you are retroactively enrolled in our plan
Sometimes a person’s enrollment in the plan is retroactive. (Retroactive means that the first
day of their enrollment has already passed. The enrollment date may even have occurred last
year.)
If you were retroactively enrolled in our plan and you paid out-of-pocket for any of your
covered services after your enrollment date, you can ask us to pay you back for our share of
the costs. You will need to submit paperwork such as receipts and bills for us to handle the
reimbursement.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 5 Asking us to pay our share of a bill you have received for covered
medical services
78
Please call Member Services for additional information about how to ask us to pay you back
and deadlines for making your request. (Phone numbers for Member Services are printed on
the back cover of this document.)
[Plans should insert additional circumstances under which they will accept a paper claim
from a member.]
When you send us a request for payment (or a request to count your expenses toward your
deductible), we are making a coverage decision. This means that if we deny your request, you
can appeal our decision. Chapter 7 of this document (What to do if you have a problem or
complaint (coverage decisions, appeals, complaints)) has information about how to make an
appeal.
SECTION 2
How to ask us to pay a bill or to count your expenses
toward your deductible
When you want us to pay a bill or to pay you back for a bill you have already paid, send us a
request for payment, along with your bill and documentation of any payment you have made.
Even if you haven’t met your deductible for the year, you should still send us your bill and
documentation of your payment so we can count your expenses toward your deductible. It’s a
good idea to make a copy of your bill and receipts for your records.
[If the plan has developed a specific form for requesting payment, insert the following language:
To make sure you are giving us all the information we need to make a decision, you can fill out
our claim form to make your request for payment.
•
You don’t have to use the form, but it will help us process the information faster. [Insert
the required data needed to make a decision (e.g., name, date of services, item, etc.)]
•
Either download a copy of the form from our website ([insert URL]) or call Member
Services and ask for the form.]
Mail your request for payment together with any bills or paid receipts to us at this address:
[Insert address]
[If the plan allows members to submit oral payment requests, insert the following language:
You may also call our plan to request payment. For details, go to Chapter 2, Section 1 and look
for the section called, [plans may edit section title as necessary] Where to send a request asking
us to pay for our share of the cost for medical care you have received.]
[Insert if applicable: You must submit your claim to us within [insert timeframe] of the date
you received the service or item.]
Contact Member Services if you have any questions. If you don’t know what you should have
paid, or you receive bills and you don’t know what to do about those bills, we can help. You can
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 5 Asking us to pay our share of a bill you have received for covered
medical services
79
also call if you want to give us more information about a request for payment you have already
sent to us.
SECTION 3
We will consider your request and say yes or no
Section 3.1
We check to see whether we should cover the service and how
much we owe
When we receive your request for payment, we will let you know if we need any additional
information from you. Otherwise, we will consider your request and make a coverage decision.
•
If we decide that the medical care is covered and you followed all the rules for getting the
care, we will pay for our share of the cost.
o If you have met your yearly deductible and have already paid for the service, we
will mail your reimbursement to you.
o If you have met your yearly deductible and have not paid for the service yet, we
will mail the payment directly to the provider.
o If you haven’t met your deductible yet, we will tell you how much you should be
billed by the provider.
•
If we decide that the medical care is not covered, or you did not follow all the rules, we
will not pay for our share of the cost. Instead, we will send you a letter that explains the
reasons why we are not sending the payment you have requested and your rights to
appeal that decision.
Section 3.2
If we tell you that we will not pay for all or part of the medical
care, you can make an appeal
If you think we have made a mistake in turning down your request or you don’t agree with the
amount we are paying, you can make an appeal. If you make an appeal, it means you are asking
us to change the decision we made when we turned down your request for payment or when we
turned down your request to count medical expenses you have paid (either with money from
your MSA account or out-of-pocket) toward the plan deductible. You may also appeal if you
believe that, prior to meeting the deductible, you have been required to pay more for a service
than the Medicare allowable amount.
For the details on how to make this appeal, go to Chapter 7 of this document (What to do if you
have a problem or complaint (coverage decisions, appeals, complaints)). The appeals process is
a formal process with detailed procedures and important deadlines. If making an appeal is new to
you, you will find it helpful to start by reading Section 4 of Chapter 7. Section 4 is an
introductory section that explains the process for coverage decisions and appeals and gives
definitions of terms such as “appeal.” Then after you have read Section 4, you can go to
Section 5.3 to learn how to make an appeal about getting paid back for a medical service.
CHAPTER 6:
Your rights and responsibilities
[Note: Plans may add to or revise this chapter as needed to reflect NCQA-required language.]
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 6 Your rights and responsibilities
81
SECTION 1
Our plan must honor your rights and cultural
sensitivities as a member of the plan
Section 1.1
[Plans may edit the section heading and content to reflect the types
of alternate format materials available to plan members. Plans may
not edit references to language except as noted below.] We must
provide information in a way that works for you and consistent
with your cultural sensitivities (in languages other than
English, in braille, in large print, or other alternate formats,
etc.)
[Plans must insert a translation of Section 1.1 in all languages that meet the language
threshold.]
Your plan is required to ensure that all services, both clinical and non-clinical, are provided in a
culturally competent manner and are accessible to all enrollees, including those with limited
English proficiency, limited reading skills, hearing incapacity, or those with diverse cultural and
ethnic backgrounds. Examples of how a plan may meet these accessibility requirements include,
but are not limited to provision of translator services, interpreter services, teletypewriters, or
TTY (text telephone or teletypewriter phone) connection.
Our plan has free interpreter services available to answer questions from non-English speaking
members. [If applicable, plans may insert information about the availability of written materials
in languages other than English.] We can also give you information in braille, in large print, or
other alternate formats at no cost if you need it. We are required to give you information about
the plan’s benefits in a format that is accessible and appropriate for you. To get information from
us in a way that works for you, please call Member Services.
Our plan is required give female enrollees the option of direct access to a women’s health
specialist within the network for women’s routine and preventive health care services.
If providers in the plan’s network for a specialty are not available, it is the plan’s responsibility
to locate specialty providers outside the network who will provide you with the necessary care.
In this case, you will only pay in-network cost sharing. If you find yourself in a situation where
there are no specialists in the plan’s network that cover a service you need, call the plan for
information on where to go to obtain this service at in-network cost sharing.
If you have any trouble getting information from our plan in a format that is accessible and
appropriate for you, seeing a women’s health specialists or finding a network specialist, please
call to file a grievance with [insert plan contact information]. You may also file a complaint
with Medicare by calling 1-800-MEDICARE (1-800-633-4227) or directly with the Office for
Civil Rights 1-800-368-1019 or TTY 1-800-537-7697.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 6 Your rights and responsibilities
Section 1.2
82
We must ensure that you get timely access to your covered
services
You may seek care from any provider in the United States who is eligible to provide services
under Original Medicare. You should always (except possibly in emergencies) show the provider
your MSA plan membership card.
You do not need a referral or prior approval from the plan to receive covered services.
[Insert if applicable: You have the right to choose a [insert as appropriate: primary care
provider (PCP) OR provider] in the plan’s network to provide and arrange for your covered
services.]
[Insert if plan has a network: You have the right to get appointments and covered services from
the plan’s network of providers within a reasonable amount of time. [Insert if applicable: This
includes the right to get timely services from specialists when you need that care.]]
If you think that you are not getting your medical care within a reasonable amount of time,
Chapter 7 tells what you can do.
Section 1.3
We must protect the privacy of your personal health
information
Federal and state laws protect the privacy of your medical records and personal health
information. We protect your personal health information as required by these laws.
•
Your personal health information includes the personal information you gave us when
you enrolled in this plan as well as your medical records and other medical and health
information.
•
You have rights related to your information and controlling how your health information
is used. We give you a written notice, called a Notice of Privacy Practice, that tells about
these rights and explains how we protect the privacy of your health information.
How do we protect the privacy of your health information?
•
We make sure that unauthorized people don’t see or change your records.
•
Except for the circumstances noted below, if we intend to give your health information to
anyone who isn’t providing your care or paying for your care, we are required to get
written permission from you or someone you have given legal power to make decisions
for you first.
•
There are certain exceptions that do not require us to get your written permission first.
These exceptions are allowed or required by law.
o We are required to release health information to government agencies that are
checking on quality of care.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 6 Your rights and responsibilities
83
o Because you are a member of our plan through Medicare, we are required to give
Medicare your health information. If Medicare releases your information for
research or other uses, this will be done according to Federal statutes and
regulations; typically, this requires that information that uniquely identifies you
not be shared.
You can see the information in your records and know how it has been shared
with others
You have the right to look at your medical records held at the plan, and to get a copy of your
records. We are allowed to charge you a fee for making copies. You also have the right to ask us
to make additions or corrections to your medical records. If you ask us to do this, we will work
with your health care provider to decide whether the changes should be made.
You have the right to know how your health information has been shared with others for any
purposes that are not routine.
If you have questions or concerns about the privacy of your personal health information, please
call Member Services.
[Note: Plans may insert custom privacy practices.]
Section 1.4
We must give you information about the plan [insert if
applicable: its network of providers,] and your covered services
[Plans may edit the section to reflect the types of alternate format materials available to plan
members and/or language primarily spoken in the plan service area.]
As a member of [insert 2024 plan name], you have the right to get several kinds of information
from us.
If you want any of the following kinds of information, please call Member Services:
•
Information about our plan. This includes, for example, information about the plan’s
financial condition.
•
[Insert if applicable: Information about our network providers. You have the right to
get information about the qualifications of the providers our network and how we pay the
providers in our network.]
•
Information about your coverage and the rules you must follow when using your
coverage. Chapters 3 and 4 provide information regarding medical services.
•
Information about why something is not covered and what you can do about it.
Chapter 7 provides information on asking for a written explanation on why a medical
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service is not covered or if your coverage is restricted. Chapter 7 also provides
information on asking us to change a decision, also called an appeal.
Section 1.5
We must support your right to make decisions about your care
You have the right to know your treatment options and participate in decisions
about your health care
You have the right to get full information from your doctors and other health care providers.
Your providers must explain your medical condition and your treatment choices in a way that
you can understand.
You also have the right to participate fully in decisions about your health care. To help you make
decisions with your doctors about what treatment is best for you, your rights include the
following:
•
To know about all of your choices. You have the right to be told about all of the
treatment options that are recommended for your condition, no matter what they cost or
whether they are covered by our plan.
•
To know about the risks. You have the right to be told about any risks involved in your
care. You must be told in advance if any proposed medical care or treatment is part of a
research experiment. You always have the choice to refuse any experimental treatments.
•
The right to say “no.” You have the right to refuse any recommended treatment. This
includes the right to leave a hospital or other medical facility, even if your doctor advises
you not to leave. Of course, if you refuse treatment, you accept full responsibility for
what happens to your body as a result.
You have the right to give instructions about what is to be done if you are not
able to make medical decisions for yourself
[Note: Plans that would like to provide members with state-specific information about advanced
directives, including contact information for the appropriate state agency, may do so.]
Sometimes people become unable to make health care decisions for themselves due to accidents
or serious illness. You have the right to say what you want to happen if you are in this situation.
This means that, if you want to, you can:
•
Fill out a written form to give someone the legal authority to make medical decisions
for you if you ever become unable to make decisions for yourself.
•
Give your doctors written instructions about how you want them to handle your
medical care if you become unable to make decisions for yourself.
The legal documents that you can use to give your directions in advance in these situations are
called advance directives. There are different types of advance directives and different names
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for them. Documents called living will and power of attorney for health care are examples of
advance directives.
If you want to use an advance directive to give your instructions, here is what to do:
•
Get the form. You can get an advance directive form from your lawyer, from a social
worker, or from some office supply stores. You can sometimes get advance directive
forms from organizations that give people information about Medicare. [Insert if
applicable: You can also contact Member Services to ask for the forms.]
•
Fill it out and sign it. Regardless of where you get this form, keep in mind that it is a
legal document. You should consider having a lawyer help you prepare it.
•
Give copies to appropriate people. You should give a copy of the form to your doctor
and to the person you name on the form who can make decisions for you if you can’t.
You may want to give copies to close friends or family members. Keep a copy at home.
If you know ahead of time that you are going to be hospitalized, and you have signed an advance
directive, take a copy with you to the hospital.
•
The hospital will ask you whether you have signed an advance directive form and
whether you have it with you.
•
If you have not signed an advance directive form, the hospital has forms available and
will ask if you want to sign one.
Remember, it is your choice whether you want to fill out an advance directive (including
whether you want to sign one if you are in the hospital). According to law, no one can deny you
care or discriminate against you based on whether or not you have signed an advance directive.
What if your instructions are not followed?
If you have signed an advance directive, and you believe that a doctor or hospital did not follow
the instructions in it, you may file a complaint with [insert appropriate state-specific agency
(such as the State Department of Health)]. [Plans also have the option to include a separate
exhibit to list the state-specific agency in all states, or in all states in which the plan is filed, and
then should revise the previous sentence to refer to that exhibit.]
Section 1.6
You have the right to make complaints and to ask us to
reconsider decisions we have made
If you have any problems, concerns, or complaints and need to request coverage, or make an
appeal, Chapter 7 of this document tells what you can do. Whatever you do – ask for a coverage
decision, make an appeal, or make a complaint – we are required to treat you fairly.
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What can you do if you believe you are being treated unfairly
or your rights are not being respected?
If it is about discrimination, call the Office for Civil Rights
If you believe you have been treated unfairly or your rights have not been respected due to your
race, disability, religion, sex, health, ethnicity, creed (beliefs), age, sexual orientation, or national
origin, you should call the Department of Health and Human Services’ Office for Civil Rights at
1-800-368-1019 or TTY 1-800-537-7697, or call your local Office for Civil Rights.
Is it about something else?
If you believe you have been treated unfairly or your rights have not been respected, and it’s not
about discrimination, you can get help dealing with the problem you are having:
•
You can call Member Services.
•
You can call the SHIP. For details, go to Chapter 2, Section 3.
•
Or, you can call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day,
7 days a week (TTY 1-877-486-2048).
Section 1.8
How to get more information about your rights
There are several places where you can get more information about your rights:
•
You can call Member Services.
•
You can call the SHIP, go to Chapter 2, Section 3.
•
You can contact Medicare.
You can visit the Medicare website to read or download the publication Medicare Rights &
Protections. (The publication is available at: www.medicare.gov/Pubs/pdf/11534-MedicareRights-and-Protections.pdf.)
Or, you can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week (TTY 1877-486-2048).
SECTION 2
You have some responsibilities as a member of the
plan
Things you need to do as a member of the plan are listed below. If you have any questions,
please call Member Services.
•
Get familiar with your covered services and the rules you must follow to get these
covered services. Use this Evidence of Coverage to learn what is covered for you and the
rules you need to follow to get your covered services.
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o Chapters 3 and 4 give the details about your medical services.
•
If you have any other health insurance coverage in addition to our plan, or separate
prescription drug coverage, you are required to tell us. Chapter 1 tells you about
coordinating these benefits.
•
Tell your doctor and other health care providers that you are enrolled in our plan.
Show your plan membership card whenever you get your medical care.
•
Help your doctors and other providers help you by giving them information, asking
questions, and following through on your care.
o To help get the best care, tell your doctors and other health providers about your
health problems. Follow the treatment plans and instructions that you and your
doctors agree upon.
o Make sure your doctors know all of the drugs you are taking, including over-thecounter drugs, vitamins, and supplements.
o If you have any questions, be sure to ask and get an answer you can understand.
•
Be considerate. We expect all our members to respect the rights of other patients. We
also expect you to act in a way that helps the smooth running of your doctor’s office,
hospitals, and other offices.
•
Pay what you owe. As a plan member, you are responsible for these payments:
o You must continue to pay a premium for your Medicare Part B to remain a
member of the plan.
o Until you meet your yearly deductible, you must pay up to 100% of the Medicareapproved amount for your covered Part A and Part B services.
•
If you move within our service area, we need to know so we can keep your
membership record up to date and know how to contact you.
•
If you move outside of our plan service area, you [if a continuation area is offered,
insert generally here and then explain the continuation area] cannot remain a member
of our plan.
•
If you move, it is also important to tell Social Security (or the Railroad Retirement
Board).
Section 2.1
Special tax-reporting responsibilities of members of a
Medicare MSA plan
Our plan is a Medicare MSA plan. MSA members must file Form 1040, U.S. Individual Income
Tax Return, along with Form 8853, Archer MSAs and Long-Term Care (LTC) Insurance
Contracts, to the Internal Revenue Service (IRS) for any year that distributions are made from
their Medicare MSA account to ensure that they are not taxed on their MSA account
withdrawals.
These tax forms must be filed for any year in which a MSA account withdrawal is made even if
the member has no taxable income or any other reason for filing Form 1040. MSA account
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withdrawals for qualified medical expenses are tax-free, while account withdrawals for nonmedical expenses are subject to both income tax and a 50% tax penalty.
•
You will receive a statement (Form 1099-SA) from your MSA trustee reporting your
MSA savings account distributions by January 31 each year. The trustee is also required
to report this information to the IRS.
o You must file tax forms 1040 and 8853 even if you are not otherwise required to
file an income tax return in order to avoid owing taxes on MSA account
withdrawals.
o Form 8853, Archer MSAs and Long-Term Care (LTC) Insurance Contracts,
Section B, is the place to report both your Medicare MSA account withdrawals
(which the IRS calls distributions) and on your qualified medical expenses for the
year.
o Form 8853 and Form 8853 Instructions are available at www.irs.gov or from 1800-TAX-FORM (1-800-829-3676). On the Web, look up forms by number at
Forms. (Note: IRS tax code considers Medicare MSAs as a type of Archer MSA,
therefore, IRS references to Archer MSAs include Medicare MSAs.)
•
You must file by April 15 of the following year unless you request an extension on your
tax return.
Information reported to the IRS on MSA account withdrawals for qualified medical expenses is
not the same expense information that will count towards your MSA plan deductible. Only
Medicare Part A and Part B expenses will count towards your MSA plan deductible. Therefore,
you will also want to keep track of your qualified medical expenses that are also Part A and
Part B expenses and that will count towards your MSA plan deductible.
Helpful MSA-related publications related to tax-reporting requirements
The following are two IRS publications relevant to Medicare MSAs. They are available on the
Web at www.irs.gov or from 1-800-TAX-FORM (1-800 829-3676). On the Web, look up
publications by number at Publications.
•
IRS Publication 502 (Medical and Dental Expenses) defines what types of services
generally count as qualified medical expenses for IRS tax purposes.
•
IRS Publication 969 (Health Savings Accounts and Other Tax-Favored Health Plans)
includes information on medical savings accounts, including Medicare MSAs.
Publication 969 provides more items and services (in addition to those in Publication
502) that are qualified medical expenses for MSAs.
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Who to call for more information or for help in preparing your tax return
You may call the IRS toll-free for live telephone assistance from Monday – Friday, 7 am –
10 pm local time, or you may visit your local IRS office.
•
For individuals: 1-800-829-1040
•
For people with hearing impairments: 1-800-829-4059 (TDD)
Face-to-Face Assistance: In certain areas, IRS also has local offices. Find your local office at
www.irs.gov/help/contact-your-local-irs-office on the Web.
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CHAPTER 7:
What to do if you have a problem or
complaint (coverage decisions,
appeals, complaints)
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[Plans should ensure that the text or section heading immediately preceding each “Legal
Terms” box is kept on the same page as the box.]
SECTION 1
Introduction
Section 1.1
What to do if you have a problem or concern
This chapter explains two types of processes for handling problems and concerns:
•
For some problems, you need to use the process for coverage decisions and appeals.
•
For other problems, you need to use the process for making complaints; also called
grievances.
Both of these processes have been approved by Medicare. Each process has a set of rules,
procedures, and deadlines that must be followed by us and by you.
The guide in Section 3 will help you identify the right process to use and what you should do.
Section 1.2
What about the legal terms?
There are legal terms for some of the rules, procedures, and types of deadlines explained in this
chapter. Many of these terms are unfamiliar to most people and can be hard to understand. To
make things easier, this chapter:
•
•
Uses simpler words in place of certain legal terms. For example, this chapter generally
says, making a complaint rather than filing a grievance, coverage decision rather than
organization determination, and independent review organization instead of Independent
Review Entity.
It also uses abbreviations as little as possible.
However, it can be helpful – and sometimes quite important – for you to know the correct legal
terms. Knowing which terms to use will help you communicate more accurately to get the right
help or information for your situation. To help you know which terms to use, we include legal
terms when we give the details for handling specific types of situations.
SECTION 2
Where to get more information and personalized
assistance
We are always available to help you. Even if you have a complaint about our treatment of you,
we are obligated to honor your right to complain. Therefore, you should always reach out to
customer service for help. But in some situations, you may also want help or guidance from
someone who is not connected with us. Below are two entities that can assist you.
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State Health Insurance Assistance Program (SHIP).
Each state has a government program with trained counselors. The program is not connected
with us or with any insurance company or health plan. The counselors at this program can help
you understand which process you should use to handle a problem you are having. They can also
answer your questions, give you more information, and offer guidance on what to do.
The services of SHIP counselors are free. [Plans providing SHIP contact information in an
exhibit may revise the following sentence to direct members to it.] You will find phone numbers
and website URLs in Chapter 2, Section 3 of this document.
Medicare
You can also contact Medicare to get help. To contact Medicare:
•
You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week.
TTY users should call 1-877-486-2048.
•
You can also visit the Medicare website (www.medicare.gov).
SECTION 3
To deal with your problem, which process should you
use?
If you have a problem or concern, you only need to read the parts of this chapter that apply to
your situation. The guide that follows will help.
Is your problem or concern about your benefits or coverage?
This includes problems about whether medical care or prescription drugs are covered or not,
the way they are covered, and problems related to payment for medical care or prescription
drugs.
Yes.
Go on to the next section of this chapter, Section 4, A guide to the basics of
coverage decisions and appeals.
No.
Skip ahead to Section 9 at the end of this chapter: How to make a complaint
about quality of care, waiting times, customer service or other concerns.
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COVERAGE DECISIONS AND APPEALS
SECTION 4
A guide to the basics of coverage decisions and
appeals
Section 4.1
Asking for coverage decisions and making appeals: the big
picture
Coverage decisions and appeals deal with problems related to your benefits and coverage for
medical services, including payment. This is the process you use for issues such as whether
something is covered or not and the way in which something is covered.
Asking for coverage decisions prior to receiving benefits
A coverage decision is a decision we make about your benefits and coverage or about the amount
we will pay for your medical services or drugs. For example, your plan network doctor makes a
(favorable) coverage decision for you whenever you receive medical care from him or her or if
your network doctor refers you to a medical specialist. You or your doctor can also contact us
and ask for a coverage decision if your doctor is unsure whether we will cover a particular
medical service or refuses to provide medical care you think that you need. In other words, if you
want to know if we will cover a medical service before you receive it, you can ask us to make a
coverage decision for you. In limited circumstances a request for a coverage decision will be
dismissed, which means we won’t review the request. Examples of when a request will be
dismissed include if the request is incomplete, if someone makes the request on your behalf but
isn’t legally authorized to do so or if you ask for your request to be withdrawn. If we dismiss a
request for a coverage decision, we will send a notice explaining why the request was dismissed
and how to ask for a review of the dismissal.
We are making a coverage decision for you whenever we decide what is covered for you and
how much we pay. In some cases, we might decide a service is not covered or is no longer
covered by Medicare for you. If you disagree with this coverage decision, you can make an
appeal.
Making an appeal
If we make a coverage decision, whether before or after a benefit is received, and you are not
satisfied, you can appeal the decision. An appeal is a formal way of asking us to review and
change a coverage decision we have made. Under certain circumstances, which we discuss later,
you can request an expedited or fast appeal of a coverage decision. Your appeal is handled by
different reviewers than those who made the original decision.
When you appeal a decision for the first time, this is called a Level 1 appeal. In this appeal, we
review the coverage decision we made to check to see if we were properly following the rules.
When we have completed the review, we give you our decision.
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In limited circumstances an appeal request will be dismissed, which means we won’t review the
request. Examples of when a request will be dismissed include if the request is incomplete if
someone makes the request on your behalf but isn’t legally authorized to do so or if you ask for
your request to be withdrawn. If we dismiss a request for a Level 1 appeal, we will send a notice
explaining why the request was dismissed and how to ask for a review of the dismissal.
If we say no to all or part of your Level 1 appeal for medical services and Part B drugs, your
appeal will automatically go on to a Level 2 appeal conducted by an independent review
organization that is not connected to us.
•
You do not need to do anything to start a Level 2 appeal. Medicare rules require we
automatically send your appeal for medical services and Part B drugs to Level 2 if we do
not fully agree with your Level 1 appeal.
•
See Section 6.4 of this chapter for more information about Level 2 appeals.
•
For Part D drug appeals, if we say no to all or part of your appeal, you will need to ask
for a Level 2 appeal. Part D appeals are discussed further in Section 7 of this chapter.
If you are not satisfied with the decision at the Level 2 appeal, you may be able to continue
through additional levels of appeal (Section 8 in this chapter explains the Level 3, 4, and 5
appeals processes).
Section 4.2
How to get help when you are asking for a coverage decision
or making an appeal
Here are resources if you decide to ask for any kind of coverage decision or appeal a decision:
•
You can call us at Member Services.
•
You can get free help from your State Health Insurance Assistance Program.
•
Your doctor can make a request for you. If your doctor helps with an appeal past Level
2, they will need to be appointed as your representative. Please call Member Services and
ask for the Appointment of Representative form. (The form is also available on
Medicare’s website at www.cms.gov/Medicare/CMS-Forms/CMSForms/downloads/cms1696.pdf [plans may also insert: or on our website at [insert
website or link to form]].)
o For medical care or Part B prescription drugs, your doctor can request a coverage
decision or a Level 1 appeal on your behalf. If your appeal is denied at Level 1, it
will be automatically forwarded to Level 2.
•
You can ask someone to act on your behalf. If you want to, you can name another
person to act for you as your representative to ask for a coverage decision or make an
appeal.
o If you want a friend, relative, or other person to be your representative, call
Member Services and ask for the Appointment of Representative form. (The form
is also available on Medicare’s website at www.cms.gov/Medicare/CMS-
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Forms/CMS-Forms/downloads/cms1696.pdf [plans may also insert: or on our
website at [insert website or link to form]].) The form gives that person
permission to act on your behalf. It must be signed by you and by the person who
you would like to act on your behalf. You must give us a copy of the signed form.
o While we can accept an appeal request without the form, we cannot begin or
complete our review until we receive it. If we do not receive the form within 44
calendar days after receiving your appeal request (our deadline for making a
decision on your appeal), your appeal request will be dismissed. If this happens,
we will send you a written notice explaining your right to ask the independent
review organization to review our decision to dismiss your appeal.
•
You also have the right to hire a lawyer. You may contact your own lawyer, or get the
name of a lawyer from your local bar association or other referral service. There are also
groups that will give you free legal services if you qualify. However, you are not
required to hire a lawyer to ask for any kind of coverage decision or appeal a decision.
Section 4.3
Which section of this chapter gives the details for your
situation?
There are three different situations that involve coverage decisions and appeals. Since each
situation has different rules and deadlines, we give the details for each one in a separate section:
•
Section 5 of this chapter: Your medical care: How to ask for a coverage decision or make
an appeal
•
Section 6 of this chapter: How to ask us to cover a longer inpatient hospital stay if you
think the doctor is discharging you too soon
•
Section 7 of this chapter: How to ask us to keep covering certain medical services if you
think your coverage is ending too soon (Applies only to these services: home health care,
skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility
(CORF) services)
If you’re not sure which section you should be using, please call Member Services. You can also
get help or information from government organizations such as your SHIP.
SECTION 5
Your medical care: How to ask for a coverage
decision or make an appeal of a coverage decision
Section 5.1
This section tells what to do if you have problems getting
coverage for medical care or if you want us to pay you back
for our share of the cost of your care
This section is about your benefits for medical care and services. These benefits are described in
Chapter 4 of this document: Medical Benefits Chart (what is covered and what you pay). To
keep things simple, we generally refer to medical care coverage or medical care which includes
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medical items and services as well as Medicare Part B prescription drugs. In some cases,
different rules apply to a request for a Part B prescription drug. In those cases, we will explain
how the rules for Part B prescription drugs are different from the rules for medical items and
services.
This section tells what you can do if you are in any of the five following situations:
1. You are not getting certain medical care you want, and you believe that this care is covered
by our plan. Ask for a coverage decision. Section 5.2.
2. Our plan will not approve the medical care your doctor or other medical provider wants to
give you, and you believe that this care is covered by the plan. Ask for a coverage decision.
Section 5.2.
3. You have received medical care that you believe should be covered by the plan, but we have
said we will not pay for this care. Make an appeal. Section 5.3.
4. You have received and paid for medical care that you believe should be covered by the plan,
and you want to ask our plan to reimburse you for this care. Send us the bill. Section 5.5
5. You are being told that coverage for certain medical care you have been getting that we
previously approved will be reduced or stopped, and you believe that reducing or stopping
this care could harm your health. Make an appeal. Section 5.3
Note: If the coverage that will be stopped is for hospital care, home health care, skilled
nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF)
services, you need to read Sections 7 and 8 of this Chapter. Special rules apply to these types of
care.
Section 5.2
Step-by-step: How to ask for a coverage decision
Legal Terms
When a coverage decision involves your medical care, it is called an organization
determination.
A fast coverage decision is called an expedited determination.
Step 1: Decide if you need a standard coverage decision or a fast coverage
decision.
A standard coverage decision is usually made within 14 days or 72 hours for Part B
drugs. A fast coverage decision is generally made within 72 hours, for medical services,
24 hours for Part B drugs. In order to get a fast coverage decision, you must meet two
requirements:
•
You may only ask for coverage for medical care you have not yet received.
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•
You can get a fast coverage decision only if using the standard deadlines could
cause serious harm to your health or hurt your ability to function.
•
If your doctor tells us that your health requires a fast coverage decision, we
will automatically agree to give you a fast coverage decision.
•
If you ask for a fast coverage decision on your own, without your doctor’s
support, we will decide whether your health requires that we give you a fast
coverage decision. If we do not approve a fast coverage decision, we will send you a
letter that:
o Explains that we will use the standard deadlines.
o Explains if your doctor asks for the fast coverage decision, we will
automatically give you a fast coverage decision.
o Explains that you can file a fast complaint about our decision to give you a
standard coverage decision instead of the fast coverage decision you
requested.
Step 2: Ask our plan to make a coverage decision or fast coverage decision
•
Start by calling, writing, or faxing our plan to make your request for us to
authorize or provide coverage for the medical care you want. You, your doctor, or
your representative can do this. Chapter 2 has contact information.
Step 3: We consider your request for medical care coverage and give you our
answer.
For standard coverage decisions we use the standard deadlines.
This means we will give you an answer within 14 calendar days after we receive your request
for a medical item or service. If your request is for a Medicare Part B prescription drug, we
will give you an answer within 72 hours after we receive your request.
•
However, if you ask for more time, or if we need more information that may benefit
you we can take up to 14 more days if your request is for a medical item or service.
If we take extra days, we will tell you in writing. We can’t take extra time to make a
decision if your request is for a Medicare Part B prescription drug.
•
If you believe we should not take extra days, you can file a fast complaint. We will
give you an answer to your complaint as soon as we make the decision. (The
process for making a complaint is different from the process for coverage
decisions and appeals. See Section 9 of this chapter for information on
complaints.)
For Fast Coverage decisions we use an expedited timeframe
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A fast coverage decision means we will answer within 72 hours if your request is for a
medical item or service. If your request is for a Medicare Part B prescription drug, we will
answer within 24 hours.
•
However, if you ask for more time, or if we need more that may benefit you we can
take up to 14 more days. If we take extra days, we will tell you in writing. We can’t
take extra time to make a decision if your request is for a Medicare Part B
prescription drug.
•
If you believe we should not take extra days, you can file a fast complaint. (See
Section 9 of this chapter for information on complaints.) We will call you as soon
as we make the decision.
•
If our answer is no to part or all of what you requested, we will send you a written
statement that explains why we said no.
Step 4: If we say no to your request for coverage for medical care, you can
appeal.
•
If we say no, you have the right to ask us to reconsider this decision by making an
appeal. This means asking again to get the medical care coverage you want. If you
make an appeal, it means you are going on to Level 1 of the appeals process.
Section 5.3
Step-by-step: How to make a Level 1 appeal
Legal Terms
An appeal to the plan about a medical care coverage decision is called a plan reconsideration.
A fast appeal is also called an expedited reconsideration.
Step 1: Decide if you need a standard appeal or a fast appeal.
A standard appeal is usually made within 30 days or 7 days for Part B drugs. A fast
appeal is generally made within 72 hours.
•
If you are appealing a decision, we made about coverage for care that you have not
yet received, you and/or your doctor will need to decide if you need a fast appeal. If
your doctor tells us that your health requires a fast appeal, we will give you a fast
appeal.
•
The requirements for getting a fast appeal are the same as those for getting a fast
coverage decision in Section 5.2 of this chapter.
Step 2: Ask our plan for an appeal or a fast appeal
•
If you are asking for a standard appeal, submit your standard appeal in
writing. [If the plan accepts oral requests for standard appeals, insert: You may
also ask for an appeal by calling us.] Chapter 2 has contact information.
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If you are asking for a fast appeal, make your appeal in writing or call us.
Chapter 2 has contact information.
•
You must make your appeal request within 60 calendar days from the date on
the written notice we sent to tell you our answer on the coverage decision. If you
miss this deadline and have a good reason for missing it, explain the reason your
appeal is late when you make your appeal. We may give you more time to make
your appeal. Examples of good cause may include a serious illness that prevented
you from contacting us or if we provided you with incorrect or incomplete
information about the deadline for requesting an appeal.
•
You can ask for a copy of the information regarding your medical decision.
You and your doctor may add more information to support your appeal. [If a
fee is charged, insert: We are allowed to charge a fee for copying and sending this
information to you.]
99
Step 3: We consider your appeal and we give you our answer.
•
When our plan is reviewing your appeal, we take a careful look at all of the
information. We check to see if we were following all the rules when we said no to
your request.
•
We will gather more information if needed, possibly contacting you or your doctor.
Deadlines for a fast appeal
For fast appeals, we must give you our answer within 72 hours after we receive your
appeal. We will give you our answer sooner if your health requires us to.
o However, if you ask for more time, or if we need more information that may
benefit you, we can take up to 14 more calendar days if your request is for a
medical item or service. If we take extra days, we will tell you in writing. We
can’t take extra time if your request is for a Medicare Part B prescription drug.
o If we do not give you an answer within 72 hours (or by the end of the extended
time period if we took extra days), we are required to automatically send your
request on to Level 2 of the appeals process, where it will be reviewed by an
independent review organization. Section 5.4 explains the Level 2 appeal process.
•
If our answer is yes to part or all of what you requested, we must authorize or
provide the coverage we have agreed to provide within 72 hours after we receive your
appeal.
•
If our answer is no to part or all of what you requested, we will send you our
decision in writing and automatically forward your appeal to the independent review
organization for a Level 2 appeal. The independent review organization will notify
you in writing when it receives your appeal.
Deadlines for a standard appeal
•
For standard appeals, we must give you our answer within 30 calendar days after we
receive your appeal. If your request is for a Medicare Part B prescription drug you
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have not yet received, we will give you our answer within 7 calendar days after we
receive your appeal. We will give you our decision sooner if your health condition
requires us to.
o However, if you ask for more time, or if we need more information that may
benefit you, we can take up to 14 more calendar days if your request is for a
medical item or service. If we take extra days to make the decision, we will tell
you in writing. We can’t take extra time if your request is for a Medicare Part B
prescription drug.
o If you believe we should not take extra days, you can file a fast complaint. When
you file a fast complaint, we will give you an answer to your complaint within 24
hours. (Section 9 of this chapter for information on complaints.)
o If we do not give you an answer by the deadline (or by the end of the extended
time period), we will send your request to a Level 2 appeal, where an independent
review organization will review the appeal. Section 5.4 explains the Level 2
appeal process.
•
If our answer is yes to part or all of what you requested, we must authorize or
provide the coverage within 30 calendar days if your request is for a medical item
or service, or within 7 calendar days if your request is for a Medicare Part B
prescription drug.
•
If our plan says no to part or all of your appeal, we will automatically send your
appeal to the independent review organization for a Level 2 appeal.
Section 5.4
Step-by-step: How a Level 2 appeal is done
Legal Term
The formal name for the Independent Review Organization is the Independent Review
Entity. It is sometimes called the IRE.
The independent review organization is an independent organization hired by Medicare. It
is not connected with us and is not a government agency. This organization decides whether the
decision we made is correct or if it should be changed. Medicare oversees its work.
Step 1: The independent review organization reviews your appeal.
•
We will send the information about your appeal to this organization. This information is
called your case file. You have the right to ask us for a copy of your case file. [If a fee
is charged, insert: We are allowed to charge you a fee for copying and sending this
information to you.]
•
You have a right to give the independent review organization additional information to
support your appeal.
•
Reviewers at the independent review organization will take a careful look at all of the
information related to your appeal.
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If you had a fast appeal at Level 1, you will also have a fast appeal at Level 2
•
For the fast appeal the review organization must give you an answer to your Level 2
appeal within 72 hours of when it receives your appeal.
•
However, if your request is for a medical item or service and the independent review
organization needs to gather more information that may benefit you, it can take up to 14
more calendar days. The independent review organization can’t take extra time to make
a decision if your request is for a Medicare Part B prescription drug.
If you had a standard appeal at Level 1, you will also have a standard appeal at Level 2
•
For the standard appeal if your request is for a medical item or service, the review
organization must give you an answer to your Level 2 appeal within 30 calendar days of
when it receives your appeal. If your request is for a Medicare Part B prescription drug,
the review organization must give you an answer to your Level 2 appeal within 7
calendar days of when it receives your appeal.
•
However, if your request is for a medical item or service and the independent review
organization needs to gather more information that may benefit you, it can take up to 14
more calendar days. The independent review organization can’t take extra time to make
a decision if your request is for a Medicare Part B prescription drug.
Step 2: The independent review organization gives you their answer.
The independent review organization will tell you its decision in writing and explain the
reasons for it.
•
If the review organization says yes to part or all of a request for a medical item or
service, we must authorize the medical care coverage within 72 hours or provide the
service within 14 calendar days after we receive the decision from the review
organization for standard requests. For expedited requests, we have 72 hours from the
date we receive the decision from the review organization.
•
If the review organization says yes to part or all of a request for a Medicare Part B
prescription drug, we must authorize or provide the Part B prescription drug within 72
hours after we receive the decision from the review organization for standard requests.
For expedited requests, we have 24 hours from the date we receive the decision from
the review organization.
•
If this organization says no to part or all of your appeal, it means they agree with us
that your request (or part of your request) for coverage for medical care should not be
approved. (This is called upholding the decision or turning down your appeal.). In this
case, the independent review organization will send you a letter:
o Explaining its decision.
o Notifying you of the right to a Level 3 appeal if the dollar value of the medical
care coverage meets a certain minimum. The written notice you get from the
independent review organization will tell you the dollar amount you must meet to
continue the appeals process.
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o Telling you how to file a Level 3 appeal.
Step 3: If your case meets the requirements, you choose whether you want to
take your appeal further.
•
There are three additional levels in the appeals process after Level 2 (for a total of five
levels of appeal). If you want to go to a Level 3 appeal, the details on how to do this are
in the written notice you get after your Level 2 appeal.
•
The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator.
Section 8 in this chapter explains the Level 3, 4, and 5 appeals processes.
Section 5.5
What if you are asking us to pay you for our share of a bill you
have received for medical care?
Chapter 5 describes when you may need to ask for reimbursement or to pay a bill you have
received from a provider. It also tells how to send us the paperwork that asks us for payment.
Asking for reimbursement is asking for a coverage decision from us
If you send us the paperwork asking for reimbursement, you are asking for a coverage decision.
To make this decision, we will check to see if the medical care you paid for is a covered service.
We will also check to see if you followed all the rules for using your coverage for medical care.
•
If we say yes to your request: If the medical care is covered and you followed all the
rules, we will send you the payment for our share of the cost within 60 calendar days
after we receive your request. If you haven’t paid for the services, we will send the
payment directly to the provider.
•
If we say no to your request: If the medical care is not covered, or you did not follow all
the rules, we will not send payment. Instead, we will send you a letter that says we will
not pay for the services and the reasons why
If you do not agree with our decision to turn you down, you can make an appeal. If you make
an appeal, it means you are asking us to change the coverage decision we made when we turned
down your request for payment.
To make this appeal, follow the process for appeals that we describe in Section 5.3. For
appeals concerning reimbursement, please note:
•
We must give you our answer within 60 calendar days after we receive your appeal. If
you are asking us to pay you back for medical care you have already received and paid
for, you are not allowed to ask for a fast appeal.
•
If the independent review organization decides we should pay, we must send you or the
provider the payment within 30 calendar days. If the answer to your appeal is yes at any
stage of the appeals process after Level 2, we must send the payment you requested to
you or to the provider within 60 calendar days.
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How to ask us to cover a longer inpatient hospital
stay if you think the doctor is discharging you too
soon
When you are admitted to a hospital, you have the right to get all of your covered hospital
services that are necessary to diagnose and treat your illness or injury.
During your covered hospital stay, your doctor and the hospital staff will be working with you to
prepare for the day when you will leave the hospital. They will help arrange for care you may
need after you leave.
•
The day you leave the hospital is called your discharge date.
•
When your discharge date is decided, your doctor or the hospital staff will tell you.
•
If you think you are being asked to leave the hospital too soon, you can ask for a longer
hospital stay, and your request will be considered.
Section 6.1
During your inpatient hospital stay, you will get a written
notice from Medicare that tells about your rights
Within two days of being admitted to the hospital, you will be given a written notice called An
Important Message from Medicare about Your Rights. Everyone with Medicare gets a copy of
this notice. If you do not get the notice from someone at the hospital (for example, a caseworker
or nurse), ask any hospital employee for it. If you need help, please call Member Services or1800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week (TTY 1-877-486-2048).
1. Read this notice carefully and ask questions if you don’t understand it. It tells you:
•
Your right to receive Medicare-covered services during and after your hospital stay,
as ordered by your doctor. This includes the right to know what these services are,
who will pay for them, and where you can get them.
•
Your right to be involved in any decisions about your hospital stay.
•
Where to report any concerns, you have about quality of your hospital care.
o Your right to request an immediate review of the decision to discharge you if
you think you are being discharged from the hospital too soon. This is a formal,
legal way to ask for a delay in your discharge date so that we will cover your
hospital care for a longer time.
2. You will be asked to sign the written notice to show that you received it and
understand your rights.
•
You or someone who is acting on your behalf will be asked to sign the notice.
•
Signing the notice shows only that you have received the information about your
rights. The notice does not give your discharge date. Signing the notice does not
mean you are agreeing on a discharge date.
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3. Keep your copy of the notice handy so you will have the information about making an
appeal (or reporting a concern about quality of care) if you need it.
•
If you sign the notice more than two days before your discharge date, you will get
another copy before you are scheduled to be discharged.
•
To look at a copy of this notice in advance, you can call Member Services or 1-800
MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should
call 1-877-486-2048. You can also see the notice online at
www.cms.gov/Medicare/Medicare-GeneralInformation/BNI/HospitalDischargeappealNotices.
Section 6.2
Step-by-step: How to make a Level 1 appeal to change your
hospital discharge date
If you want to ask for your inpatient hospital services to be covered by us for a longer time,
you will need to use the appeals process to make this request. Before you start, understand
what you need to do and what the deadlines are.
•
Follow the process.
•
Meet the deadlines.
•
Ask for help if you need it. If you have questions or need help at any time, please
call Member Services. Or call your State Health Insurance Assistance Program, a
government organization that provides personalized assistance.
During a Level 1 appeal, the Quality Improvement Organization reviews your appeal. It
checks to see if your planned discharge date is medically appropriate for you.
The Quality Improvement Organization is a group of doctors and other health care
professionals paid by the Federal government to check on and help improve the quality of care
for people with Medicare. This includes reviewing hospital discharge dates for people with
Medicare. These experts are not part of our plan.
Step 1: Contact the Quality Improvement Organization for your state and ask for
an immediate review of your hospital discharge. You must act quickly. How can
you contact this organization?
•
The written notice you received (An Important Message from Medicare About Your
Rights) tells you how to reach this organization. Or find the name, address, and phone
number of the Quality Improvement Organization for your state in Chapter 2.
Act quickly:
•
To make your appeal, you must contact the Quality Improvement Organization before
you leave the hospital and no later than midnight the day of your discharge.
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o If you meet this deadline, you may stay in the hospital after your discharge
date without paying for it while you wait to get the decision from the Quality
Improvement Organization.
o If you do not meet this deadline, and you decide to stay in the hospital after
your planned discharge date, you may have to pay all of the costs for hospital
care you receive after your planned discharge date.
•
If you miss the deadline for contacting the Quality Improvement Organization, and
you still wish to appeal, you must make an appeal directly to our plan instead. For
details about this other way to make your appeal, see Section 6.4.
Once you request an immediate review of your hospital discharge the Quality Improvement
Organization will contact us. By noon of the day after we are contacted, we will give you a
Detailed Notice of Discharge. This notice gives your planned discharge date and explains in
detail the reasons why your doctor, the hospital, and we think it is right (medically appropriate)
for you to be discharged on that date.
You can get a sample of the Detailed Notice of Discharge by calling Member Services or 1800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. (TTY users should call 1877-486-2048.) Or you can see a sample notice online at www.cms.gov/Medicare/MedicareGeneral-Information/BNI/HospitalDischargeappealNotices.
Step 2: The Quality Improvement Organization conducts an independent review
of your case.
•
Health professionals at the Quality Improvement Organization (the reviewers) will
ask you (or your representative) why you believe coverage for the services should
continue. You don’t have to prepare anything in writing, but you may do so if you
wish.
•
The reviewers will also look at your medical information, talk with your doctor, and
review information that the hospital and we have given to them.
•
By noon of the day after the reviewers told us of your appeal, you will get a
written notice from us that gives your planned discharge date. This notice also
explains in detail the reasons why your doctor, the hospital, and we think it is
right (medically appropriate) for you to be discharged on that date.
Step 3: Within one full day after it has all the needed information, the Quality
Improvement Organization will give you its answer to your appeal.
What happens if the answer is yes?
•
If the review organization says yes, we must keep providing your covered inpatient
hospital services for as long as these services are medically necessary.
•
You will have to keep paying your share of the costs (such as deductibles or
copayments if these apply). In addition, there may be limitations on your covered
hospital services.
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What happens if the answer is no?
•
If the review organization says no, they are saying that your planned discharge date is
medically appropriate. If this happens, our coverage for your inpatient hospital
services will end at noon on the day after the Quality Improvement Organization
gives you its answer to your appeal.
•
If the review organization says no to your appeal and you decide to stay in the
hospital, then you may have to pay the full cost of hospital care you receive after
noon on the day after the Quality Improvement Organization gives you its answer to
your appeal.
Step 4: If the answer to your Level 1 appeal is no, you decide if you want to make
another appeal
•
If the Quality Improvement Organization has said no to your appeal, and you stay in
the hospital after your planned discharge date, then you can make another appeal.
Making another appeal means you are going on to Level 2 of the appeals process.
Section 6.3
Step-by-step: How to make a Level 2 appeal to change your
hospital discharge date
During a Level 2 appeal, you ask the Quality Improvement Organization to take another look at
their decision on your first appeal. If the Quality Improvement Organization turns down your
Level 2 appeal, you may have to pay the full cost for your stay after your planned discharge date.
Step 1: Contact the Quality Improvement Organization again and ask for another
review
•
You must ask for this review within 60 calendar days after the day the Quality
Improvement Organization said no to your Level 1 appeal. You can ask for this
review only if you stay in the hospital after the date that your coverage for the care
ended.
Step 2: The Quality Improvement Organization does a second review of your
situation
•
Reviewers at the Quality Improvement Organization will take another careful look at
all of the information related to your appeal.
Step 3: Within 14 calendar days of receipt of your request for a Level 2 appeal, the
reviewers will decide on your appeal and tell you their decision.
If the review organization says yes:
•
We must reimburse you for our share of the costs of hospital care you have received
since noon on the day after the date your first appeal was turned down by the Quality
Improvement Organization. We must continue providing coverage for your inpatient
hospital care for as long as it is medically necessary.
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You must continue to pay your share of the costs and coverage limitations may
apply.
If the review organization says no:
•
It means they agree with the decision they made on your Level 1 appeal. This is called
upholding the decision.
•
The notice you get will tell you in writing what you can do if you wish to continue with
the review process.
Step 4: If the answer is no, you will need to decide whether you want to take your
appeal further by going on to Level 3
•
There are three additional levels in the appeals process after Level 2 (for a total of five
levels of appeal). If you want to go to a Level 3 appeal, the details on how to do this are in
the written notice you get after your Level 2 appeal decision.
•
The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator.
Section 8 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.
Section 6.4
What if you miss the deadline for making your Level 1 appeal?
Legal Term
A fast review (or fast appeal) is also called an expedited appeal.
You can appeal to us instead
As explained above, you must act quickly to start your Level 1 appeal of your hospital discharge.
If you miss the deadline for contacting the Quality Improvement Organization, there is another
way to make your appeal.
If you use this other way of making your appeal, the first two levels of appeal are different.
Step-by-Step: How to make a Level 1 Alternate appeal
Step 1: Contact us and ask for a fast review.
•
Ask for a fast review. This means you are asking us to give you an answer using the fast
deadlines rather than the standard deadlines. Chapter 2 has contact information.
Step 2: We do a fast review of your planned discharge date, checking to see if it
was medically appropriate.
•
During this review, we take a look at all of the information about your hospital stay.
We check to see if your planned discharge date was medically appropriate. We see if
the decision about when you should leave the hospital was fair and followed all the
rules.
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Step 3: We give you our decision within 72 hours after you ask for a fast review.
•
If we say yes to your appeal, it means we have agreed with you that you still need to be
in the hospital after the discharge date. We will keep providing your covered inpatient
hospital services for as long as they are medically necessary. It also means that we have
agreed to reimburse you for our share of the costs of care you have received since the
date when we said your coverage would end. (You must pay your share of the costs and
there may be coverage limitations that apply.)
•
If we say no to your appeal, we are saying that your planned discharge date was
medically appropriate. Our coverage for your inpatient hospital services ends as of the day
we said coverage would end.
o If you stayed in the hospital after your planned discharge date, then you may
have to pay the full cost of hospital care you received after the planned discharge
date.
Step 4: If we say no to your appeal, your case will automatically be sent on to the
next level of the appeals process.
Step-by-Step: Level 2 Alternate appeal Process
Legal Term
The formal name for the independent review organization is the Independent Review Entity.
It is sometimes called the IRE.
The independent review organization is an independent organization hired by Medicare. It
is not connected with our plan and is not a government agency. This organization decides
whether the decision we made is correct or if it should be changed. Medicare oversees its work.
Step 1: We will automatically forward your case to the independent review
organization.
•
We are required to send the information for your Level 2 appeal to the independent
review organization within 24 hours of when we tell you that we are saying no to your
first appeal. (If you think we are not meeting this deadline or other deadlines, you can
make a complaint. Section 9 of this chapter tells how to make a complaint.)
Step 2: The independent review organization does a fast review of your appeal.
The reviewers give you an answer within 72 hours.
•
Reviewers at the independent review organization will take a careful look at all of the
information related to your appeal of your hospital discharge.
•
If this organization says yes to your appeal, then we must pay you back for our share of
the costs of hospital care you received since the date of your planned discharge. We must
also continue the plan’s coverage of your inpatient hospital services for as long as it is
medically necessary. You must continue to pay your share of the costs. If there are
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coverage limitations, these could limit how much we would reimburse or how long we
would continue to cover your services.
•
If this organization says no to your appeal, it means they agree that your planned
hospital discharge date was medically appropriate.
o The written notice you get from the Independent Review Organization will tell
how to start a Level 3 appeal with the review process, which is handled by an
Administrative Law Judge or attorney adjudicator.
Step 3: If the Independent Review Organization turns down your appeal, you
choose whether you want to take your appeal further
•
There are three additional levels in the appeals process after Level 2 (for a total of five
levels of appeal). If reviewers say no to your Level 2 appeal, you decide whether to
accept their decision or go on to Level 3 appeal.
•
Section 8 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.
SECTION 7
How to ask us to keep covering certain medical
services if you think your coverage is ending too
soon
Section 7.1
This section is only about three services: Home health care,
skilled nursing facility care, and Comprehensive Outpatient
Rehabilitation Facility (CORF) services
When you are getting home health services, skilled nursing care, or rehabilitation care
(Comprehensive Outpatient Rehabilitation Facility), you have the right to keep getting your
covered services for that type of care for as long as the care is needed to diagnose and treat your
illness or injury.
When we decide it is time to stop covering any of the three types of care for you, we are required
to tell you in advance. When your coverage for that care ends, we will stop paying our share of
the cost for your care.
If you think we are ending the coverage of your care too soon, you can appeal our decision. This
section tells you how to ask for an appeal.
Section 7.2
We will tell you in advance when your coverage will be ending
Legal Term
Notice of Medicare Non-Coverage. It tells you how you can request a fast-track appeal.
Requesting a fast-track appeal is a formal, legal way to request a change to our coverage
decision about when to stop your care.
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1. You receive a notice in writing at least two days before our plan is going to stop
covering your care. The notice tells you:
•
The date when we will stop covering the care for you.
•
How to request a fast track appeal to request us to keep covering your care for a
longer period of time.
2. You, or someone who is acting on your behalf, will be asked to sign the written
notice to show that you received it. Signing the notice shows only that you have
received the information about when your coverage will stop. Signing it does not mean
you agree with the plan’s decision to stop care.
Section 7.3
Step-by-step: How to make a Level 1 appeal to have our plan
cover your care for a longer time
If you want to ask us to cover your care for a longer period of time, you will need to use the
appeals process to make this request. Before you start, understand what you need to do and
what the deadlines are:
•
Follow the process.
•
Meet the deadlines.
•
Ask for help if you need it. If you have questions or need help at any time, please
call Member Services. Or call your State Health Insurance Assistance Program, a
government organization that provides personalized assistance.
During a Level 1 appeal, the Quality Improvement Organization reviews your appeal. It
decides if the end date for your care is medically appropriate.
The Quality Improvement Organization is a group of doctors and other health care experts
paid by the Federal government to check on and help improve the quality of care for people with
Medicare. This includes reviewing plan decisions about when it’s time to stop covering certain
kinds of medical care. These experts are not part of our plan.
Step 1: Make your Level 1 appeal: contact the Quality Improvement Organization
and ask for a fast-track appeal. You must act quickly.
How can you contact this organization?
•
The written notice you received (Notice of Medicare Non-Coverage) tells you how to
reach this organization. Or find the name, address, and phone number of the Quality
Improvement Organization for your state in Chapter 2.
Act quickly:
•
You must contact the Quality Improvement Organization to start your appeal by noon
of the day before the effective date on the Notice of Medicare Non-Coverage.
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If you miss the deadline for contacting the Quality Improvement Organization, and
you still wish to file an appeal, you must make an appeal directly to us instead. For
details about this other way to make your appeal, see Section 7.5.
Step 2: The Quality Improvement Organization conducts an independent review
of your case.
Legal Term
Detailed Explanation of Non-Coverage. Notice that provides details on reasons for ending
coverage.
What happens during this review?
•
Health professionals at the Quality Improvement Organization (the reviewers) will
ask you, or your representative why you believe coverage for the services should
continue. You don’t have to prepare anything in writing, but you may do so if you
wish.
•
The review organization will also look at your medical information, talk with your
doctor, and review information that our plan has given to them.
•
By the end of the day the reviewers tell us of your appeal, you will get the
Detailed Explanation of Non-Coverage from us that explains in detail our
reasons for ending our coverage for your services.
Step 3: Within one full day after they have all the information they need, the
reviewers will tell you their decision.
What happens if the reviewers say yes?
•
If the reviewers say yes to your appeal, then we must keep providing your covered
services for as long as it is medically necessary.
•
You will have to keep paying your share of the costs (such as deductibles or
copayments, if these apply). There may be limitations on your covered services.
What happens if the reviewers say no?
•
If the reviewers say no, then your coverage will end on the date we have told you.
•
If you decide to keep getting the home health care, or skilled nursing facility care, or
Comprehensive Outpatient Rehabilitation Facility (CORF) services after this date
when your coverage ends, then you will have to pay the full cost of this care
yourself.
Step 4: If the answer to your Level 1 appeal is no, you decide if you want to make
another appeal.
•
If reviewers say no to your Level 1 appeal – and you choose to continue getting care
after your coverage for the care has ended – then you can make a Level 2 appeal.
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Step-by-step: How to make a Level 2 appeal to have our plan
cover your care for a longer time
During a Level 2 appeal, you ask the Quality Improvement Organization to take another look at
the decision on your first appeal. If the Quality Improvement Organization turns down your
Level 2 appeal, you may have to pay the full cost for your home health care, or skilled nursing
facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date
when we said your coverage would end.
Step 1: Contact the Quality Improvement Organization again and ask for another
review.
•
You must ask for this review within 60 days after the day when the Quality
Improvement Organization said no to your Level 1 appeal. You can ask for this
review only if you continued getting care after the date that your coverage for the care
ended.
Step 2: The Quality Improvement Organization does a second review of your
situation.
•
Reviewers at the Quality Improvement Organization will take another careful look at
all of the information related to your appeal.
Step 3: Within 14 days of receipt of your appeal request, reviewers will decide on
your appeal and tell you their decision.
What happens if the review organization says yes?
•
We must reimburse you for our share of the costs of care you have received since the
date when we said your coverage would end. We must continue providing coverage for
the care for as long as it is medically necessary.
•
You must continue to pay your share of the costs and there may be coverage limitations
that apply.
What happens if the review organization says no?
•
It means they agree with the decision made to your Level 1 appeal.
•
The notice you get will tell you in writing what you can do if you wish to continue
with the review process. It will give you the details about how to go on to the next
level of appeal, which is handled by an Administrative Law Judge or attorney
adjudicator.
Step 4: If the answer is no, you will need to decide whether you want to take your
appeal further.
•
There are three additional levels of appeal after Level 2, for a total of five levels of appeal.
If you want to go on to a Level 3 appeal, the details on how to do this are in the written
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notice you get after your Level 2 appeal decision. The Level 3 appeal is handled by an
Administrative Law Judge or attorney adjudicator. Section 8 in this chapter tells more
about Levels 3, 4, and 5 of the appeals process.
Section 7.5
What if you miss the deadline for making your Level 1 appeal?
You can appeal to us instead
As explained above, you must act quickly to contact the Quality Improvement Organization to
start your first appeal (within a day or two, at the most). If you miss the deadline for contacting
this organization, there is another way to make your appeal. If you use this other way of making
your appeal, the first two levels of appeal are different.
Step-by-Step: How to make a Level 1 Alternate appeal
Legal Term
A fast review (or fast appeal) is also called an expedited appeal.
Step 1: Contact us and ask for a fast review.
•
Ask for a fast review. This means you are asking us to give you an answer using the fast
deadlines rather than the standard deadlines. Chapter 2 has contact information.
Step 2: We do a fast review of the decision we made about when to end coverage
for your services.
•
During this review, we take another look at all of the information about your case. We
check to see if we were following all the rules when we set the date for ending the plan’s
coverage for services you were receiving.
Step 3: We give you our decision within 72 hours after you ask for a fast review.
•
If we say yes to your appeal, it means we have agreed with you that you need services
longer and will keep providing your covered services for as long as they are medically
necessary. It also means that we have agreed to reimburse you for our share of the costs
of care you have received since the date when we said your coverage would end. (You
must pay your share of the costs and there may be coverage limitations that apply.)
•
If we say no to your appeal, then your coverage will end on the date we told you and we
will not pay any share of the costs after this date.
•
If you continued to get home health care, or skilled nursing facility care, or
Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date when
we said your coverage would end, then you will have to pay the full cost of this care.
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Step 4: If we say no to your fast appeal, your case will automatically go on to the
next level of the appeals process.
Legal Term
The formal name for the Independent Review Organization is the Independent Review
Entity. It is sometimes called the IRE.
Step-by-Step: Level 2 Alternate appeal Process
During the Level 2 appeal, the Independent Review Organization reviews the decision we
made to your fast appeal. This organization decides whether the decision should be changed.
The Independent Review Organization is an independent organization that is hired by
Medicare. This organization is not connected with our plan, and it is not a government agency.
This organization is a company chosen by Medicare to handle the job of being the Independent
Review Organization. Medicare oversees its work.
Step 1: We automatically forward your case to the Independent Review
Organization.
•
We are required to send the information for your Level 2 appeal to the Independent
Review Organization within 24 hours of when we tell you that we are saying no to your
first appeal. (If you think we are not meeting this deadline or other deadlines, you can
make a complaint. Section 9 of this chapter tells how to make a complaint.)
Step 2: The Independent Review Organization does a fast review of your appeal.
The reviewers give you an answer within 72 hours.
•
Reviewers at the Independent Review Organization will take a careful look at all of the
information related to your appeal.
•
If this organization says yes to your appeal, then we must pay you back for our share of
the costs of care you have received since the date when we said your coverage would
end. We must also continue to cover the care for as long as it is medically necessary. You
must continue to pay your share of the costs. If there are coverage limitations, these could
limit how much we would reimburse or how long we would continue to cover services.
•
If this organization says no to your appeal, it means they agree with the decision our
plan made to your first appeal and will not change it.
•
The notice you get from the Independent Review Organization will tell you in writing
what you can do if you wish to go on to a Level 3 appeal.
Step 3: If the Independent Review Organization say no your appeal, you choose
whether you want to take your appeal further.
•
There are three additional levels of appeal after Level 2, for a total of five levels of
appeal. If you want to go on to a Level 3 appeal, the details on how to do this are in the
written notice you get after your Level 2 appeal decision.
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115
A Level 3 appeal is reviewed by an Administrative Law Judge or attorney adjudicator.
Section 8 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.
SECTION 8
Taking your appeal to Level 3 and beyond
Section 8.1
Appeal Levels 3, 4 and 5 for Medical Service Requests
This section may be appropriate for you if you have made a Level 1 appeal and a Level 2 appeal,
and both of your appeals have been turned down.
If the dollar value of the item or medical service you have appealed meets certain minimum
levels, you may be able to go on to additional levels of appeal. If the dollar value is less than the
minimum level, you cannot appeal any further. The written response you receive to your Level 2
appeal will explain how to make a Level 3 appeal.
For most situations that involve appeals, the last three levels of appeal work in much the same
way. Here is who handles the review of your appeal at each of these levels.
Level 3 appeal
•
An Administrative Law Judge or attorney adjudicator who works for the
Federal government will review your appeal and give you an answer.
If the Administrative Law Judge or attorney adjudicator says yes to your appeal,
the appeals process may or may not be over. Unlike a decision at a Level 2 appeal, we
have the right to appeal a Level 3 decision that is favorable to you. If we decide to appeal
it will go to a Level 4 appeal.
o If we decide not to appeal, we must authorize or provide you with the service within
60 calendar days after receiving the Administrative Law Judge’s or attorney
adjudicator’s decision.
o If we decide to appeal the decision, we will send you a copy of the Level 4 appeal
request with any accompanying documents. We may wait for the Level 4 appeal
decision before authorizing or providing the service in dispute.
•
If the Administrative Law Judge or attorney adjudicator says no to your appeal, the
appeals process may or may not be over.
o If you decide to accept this decision that turns down your appeal, the appeals
process is over.
o If you do not want to accept the decision, you can continue to the next level of the
review process. The notice you get will tell you what to do for a Level 4 appeal.
Level 4 appeal
•
The Medicare Appeals Council (Council) will review your appeal and give
you an answer. The Council is part of the Federal government.
If the answer is yes, or if the Council denies our request to review a favorable Level
3 appeal decision, the appeals process may or may not be over. Unlike a decision at
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Level 2, we have the right to appeal a Level 4 decision that is favorable to you. We will
decide whether to appeal this decision to Level 5.
o If we decide not to appeal the decision, we must authorize or provide you with the
service within 60 calendar days after receiving the Council’s decision.
o If we decide to appeal the decision, we will let you know in writing.
•
If the answer is no or if the Council denies the review request, the appeals process
may or may not be over.
o If you decide to accept this decision that turns down your appeal, the appeals
process is over.
o If you do not want to accept the decision, you may be able to continue to the next
level of the review process. If the Council says no to your appeal, the notice will tell
you whether the rules allow you to go on to a Level 5 appeal and how to continue
with a Level 5 appeal.
Level 5 appeal
•
A judge at the Federal District Court will review your appeal.
A judge will review all of the information and decide yes or no to your request. This is a
final answer. There are no more appeal levels after the Federal District Court.
MAKING COMPLAINTS
SECTION 9
How to make a complaint about quality of care,
waiting times, customer service, or other concerns
Section 9.1
What kinds of problems are handled by the complaint
process?
The complaint process is only used for certain types of problems. This includes problems related
to quality of care, waiting times, and the customer service. Here are examples of the kinds of
problems handled by the complaint process:
Complaint
Example
Quality of your
medical care
•
Are you unhappy with the quality of the care you have received
(including care in the hospital)?
Respecting your
privacy
•
Did someone not respect your right to privacy or share
confidential information?
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Chapter 7 What to do if you have a problem or complaint (coverage decisions,
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Complaint
Example
Disrespect, poor
customer service,
or other negative
behaviors
•
•
•
Has someone been rude or disrespectful to you?
Are you unhappy with our Member Services?
Do you feel you are being encouraged to leave the plan?
Waiting times
•
Are you having trouble getting an appointment, or waiting too
long to get it?
Have you been kept waiting too long by doctors or other health
professionals? Or by our Member Services or other staff at the
plan?
o Examples include waiting too long on the phone, in the
waiting or exam room.
•
117
Cleanliness
•
Are you unhappy with the cleanliness or condition of a clinic,
hospital, or doctor’s office?
Information you
get from us
•
•
Did we fail to give you a required notice?
Is our written information hard to understand?
Timeliness
(These types of
complaints are all
related to the
timeliness of our
actions related to
coverage decisions
and appeals)
If you have asked for a coverage decision or made an appeal, and you
think that we are not responding quickly enough, you can make a
complaint about our slowness. Here are examples:
•
•
•
•
You asked for a fast coverage decision or a fast appeal, and we
have said no; you can make a complaint.
You believe we are not meeting the deadlines for coverage
decisions or appeals; you can make a complaint.
You believe we are not meeting deadlines for covering or
reimbursing you for certain medical services, that were
approved; you can make a complaint.
You believe we failed to meet required deadlines for forwarding
your case to the Independent Review Organization; you can
make a complaint.
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Section 9.2
118
How to make a complaint
Legal Terms
•
A Complaint is also called a grievance.
•
Making a complaint is also called filing a grievance.
•
Using the process for complaints is also called using the process for filing a grievance.
•
A fast complaint is also called an expedited grievance.
Section 9.3
Step-by-step: Making a complaint
Step 1: Contact us promptly – either by phone or in writing.
•
Usually, calling Member Services is the first step. If there is anything else you need to
do, Member Services will let you know.
•
If you do not wish to call (or you called and were not satisfied), you can put your
complaint in writing and send it to us. If you put your complaint in writing, we will
respond to your complaint in writing.
•
[Insert description of the procedures (including time frames) and instructions about what
members need to do if they want to use the process for making a complaint. Describe
expedited grievance time frames for grievances about decisions to not conduct expedited
organization/coverage determinations or reconsiderations/redeterminations.]
•
The deadline for making a complaint is 60 calendar days from the time you had the
problem you want to complain about.
Step 2: We look into your complaint and give you our answer.
•
If possible, we will answer you right away. If you call us with a complaint, we may be
able to give you an answer on the same phone call.
•
Most complaints are answered within 30 calendar days. If we need more information
and the delay is in your best interest or if you ask for more time, we can take up to 14
more calendar days (44 calendar days total) to answer your complaint. If we decide to
take extra days, we will tell you in writing.
•
If you are making a complaint because we denied your request for a fast coverage
decision or a fast appeal, we will automatically give you a fast complaint. If you have a
fast complaint, it means we will give you an answer within 24 hours.
•
If we do not agree with some or all of your complaint or don’t take responsibility for the
problem you are complaining about, we will include our reasons in our response to you.
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You can also make complaints about quality of care to the
Quality Improvement Organization
When your complaint is about quality of care, you also have two extra options:
•
You can make your complaint directly to the Quality Improvement Organization.
o The Quality Improvement Organization is a group of practicing doctors and other
health care experts paid by the Federal government to check and improve the care
given to Medicare patients. Chapter 2 has contact information.
OR
•
You can make your complaint to both the Quality Improvement Organization and
us at the same time.
Section 9.5
You can also tell Medicare about your complaint
You can submit a complaint about [insert 2024 plan name] directly to Medicare. To submit a
complaint to Medicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx. You may
also call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048.
CHAPTER 8:
Ending your membership in the plan
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SECTION 1
121
Introduction to ending your membership in our plan
Ending your membership in [insert 2024 plan name] may be voluntary (your own choice under
permitted situations) or involuntary (not your own choice):
•
You might leave our plan because you have decided that you want to leave. Sections 2
and 3 provide information on ending your membership voluntarily.
•
There are also limited situations where we are required to end your membership. Section
6 tells you about situations when we must end your membership.
If you are leaving our plan, our plan must continue provide your medical care and you will
continue to pay your cost share until your membership ends.
SECTION 2
When can you end your membership in our plan?
Section 2.1
You can end your membership during the Annual Enrollment
Period
You can end your membership in our plan during the Annual Enrollment Period (also known
as the Annual Open Enrollment Period). In certain situations, you may also be eligible to leave
the plan at other times of the year. If this is your first time enrolling in an MSA plan, you may
cancel this enrollment by December 15, 2023.
•
The Annual Enrollment Period is from October 15 to December 7.
•
Choose to keep your current coverage or make changes to your coverage for the
upcoming year. If you decide to change to a new plan, you can choose any of the
following types of plans:
o Keep your Medicare Savings Account (MSA) plan and enroll in a separate
prescription drug plan (or enroll in a new prescription drug plan if you do not
currently have one);
o Another Medicare health plan, with or without prescription drug coverage;
o Original Medicare with a separate Medicare prescription drug plan;
OR
o Original Medicare without a separate Medicare prescription drug plan.
•
Your membership will end in our plan when your new plan’s coverage begins on
January 1.
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Section 2.2
122
In certain limited situations, you can end your membership
during a Special Enrollment Period
In certain limited situations, members of [insert 2024 plan name] may be eligible to end their
membership at other times of the year. This is known as a Special Enrollment Period.
You may be eligible to end your membership during a Special Enrollment Period if any of
the following situations apply to you. These are just examples, for the full list you can contact
the plan, call Medicare, or visit the Medicare website (www.medicare.gov):
•
Usually, when you have moved.
•
If we violate our contract with you.
•
If you are getting care in an institution, such as a nursing home or long-term care (LTC)
hospital.
•
[Plans in states with PACE, insert: If you enroll in the Program of All-inclusive Care for
the Elderly (PACE).]
•
If you have a change in your Medicaid status. (Please note that people with Medicaid
coverage are not eligible to enroll in a Medicare MSA plan.)
The enrollment time periods vary depending on your situation.
To find out if you are eligible for a Special Enrollment Period, please call Medicare at
1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1877-486-2048. If you are eligible to end your membership because of a special situation,
you can choose to change both your Medicare health coverage and prescription drug
coverage you can choose:
•
Another Medicare health plan with or without prescription drug coverage.
•
Original Medicare with a separate Medicare prescription drug plan (or enroll in a new
prescription drug plan if you do not currently have one).
OR
•
Original Medicare without a separate Medicare prescription drug plan.
Your membership will usually end on the first day of the month after we receive your request
to change your plan.
If you receive “Extra Help” from Medicare to pay for your prescription drugs: 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 have opted out of automatic enrollment.
Section 2.3
Where can you get more information about when you can end
your membership?
If you have any questions about ending your membership you can:
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Chapter 8 Ending your membership in the plan
•
Call Member Services.
•
You can find the information in the Medicare & You 2024 handbook.
•
Contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a
week (TTY 1-877-486-2048).
SECTION 3
What happens if you leave our plan in the middle of
the year?
Section 3.1
What happens to the money in your account if you leave our
plan?
If you leave our plan in the middle of the year, part of the current year’s deposit will be refunded
to Medicare. The amount recovered and refunded to Medicare depends on the number of months
left in the current calendar year. For example, if you get a $1,200 deposit in your account in
January and you leave the plan in March, we will recover $900 to return to Medicare.
Funds remaining in your account from any previous year belong to you. Recovery applies only to
funds deposited into your account for the current year. If you have any questions, please contact
Member Services.
SECTION 4
How do you end your membership in our plan?
The table below explains how you should end your membership in our plan during permitted
timeframes:
If you would like to switch from our
plan to:
This is what you should do:
•
Another Medicare health plan.
•
Enroll in the new Medicare health plan.
You will automatically be disenrolled
from [insert 2024 plan name] when your
new plan’s coverage begins.
•
Original Medicare (either with or
without a separate Medicare
prescription drug plan).
•
Send us a written request to disenroll
[insert if organization has complied with
CMS guidelines for online disenrollment
or visit our website to disenroll online].
Contact Member Services if you need
more information on how to do this.
•
You will be disenrolled from [insert 2024
plan name] when your coverage in
Original Medicare begins.
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Note: If you also have creditable prescription drug coverage (e.g., standalone PDP) and disenroll
from that coverage, you may have to pay a Part D late enrollment penalty if you join a Medicare
drug plan later after going without creditable prescription drug coverage for 63 days or more in a
row.
SECTION 5
Until your membership ends, you must keep getting
your medical services and drugs through our plan
Until your membership ends, and your new Medicare coverage begins, you must continue to get
your medical care through our plan.
•
[Non-network plans can eliminate] Continue to use our network providers to receive
medical care.
•
If you are hospitalized on the day that your membership ends, your hospital stay
will be covered by our plan until you are discharged (even if you are discharged after
your new health coverage begins).
SECTION 6
[Insert 2024 plan name] must end your membership in
the plan in certain situations
Section 6.1
When must we end your membership in the plan?
[Insert 2024 plan name] must end your membership in the plan if any of the following
happen:
•
If you no longer have Medicare Part A and Part B.
•
If you obtain other insurance (to include supplemental policies) that covers all or part of
the annual Medicare MSA deductible such as through insurance primary to Medicare, or
retirement health benefits.
•
If you move out of our service area.
•
If you are away from our service area for more than six months.
•
If you move or take a long trip, call Member Services to find out if the place you are
moving or traveling to is in our plan’s area.
•
If you become incarcerated (go to prison).
•
If you are no longer a United States citizen or lawfully present in the United States.
•
[Omit if not applicable] If you intentionally give us incorrect information when you are
enrolling in our plan and that information affects your eligibility for our plan. (We cannot
make you leave our plan for this reason unless we get permission from Medicare first.)
•
[Omit bullet if not applicable] If you continuously behave in a way that is disruptive and
makes it difficult for us to provide medical care for you and other members of our plan.
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(We cannot make you leave our plan for this reason unless we get permission from
Medicare first.)
•
[Omit bullet and sub-bullet if not applicable] If you let someone else use your
membership card to get medical care. (We cannot make you leave our plan for this reason
unless we get permission from Medicare first.)
o If we end your membership because of this reason, Medicare may have your case
investigated by the Inspector General.
•
[Omit bullet if not applicable. Plans with one or more optional supplemental benefits
must edit this bullet as necessary to reflect their policies.] If you do not pay the
premium(s) for [describe optional benefits, such as vision, hearing or dental] we will
reduce your coverage to exclude [insert as applicable: this benefit OR these benefits].
Where can you get more information?
If you have questions or would like more information on when we can end your membership,
call Member Services.
Section 6.2
We cannot ask you to leave our plan for any health-related
reason
[Insert 2024 plan name] is not allowed to ask you to leave our plan for any health-related reason.
What should you do if this happens?
If you feel that you are being asked to leave our plan because of a health-related reason, call
Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. (TTY
1-877-486-2048).
Section 6.3
You have the right to make a complaint if we end your
membership in our plan
If we end your membership in our plan, we must tell you our reasons in writing for ending your
membership. We must also explain how you can file a grievance or make a complaint (also
called a grievance) about our decision to end your membership; see Chapter 7 for how to file a
complaint.
CHAPTER 9:
Legal notices
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 9 Legal notices
SECTION 1
127
Notice about governing law
The principal law that applies to this Evidence of Coverage document is Title XVIII of the Social
Security Act and the regulations created under the Social Security Act by the Centers for
Medicare & Medicaid Services, or CMS. In addition, other Federal laws may apply and, under
certain circumstances, the laws of the state you live in. This may affect your rights and
responsibilities even if the laws are not included or explained in this document.
SECTION 2
Notice about nondiscrimination
[Plans may add language describing additional categories covered under state human rights
laws.] We don’t discriminate based on race, ethnicity, national origin, color, religion, sex,
gender, age, sexual orientation, mental or physical disability, health status, claims experience,
medical history, genetic information, evidence of insurability, or geographic location within the
service area. All organizations that provide Medicare Advantage plans, like our plan, must obey
Federal laws against discrimination, including Title VI of the Civil Rights Act of 1964, the
Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities
Act, Section 1557 of the Affordable Care Act, all other laws that apply to organizations that get
Federal funding, and any other laws and rules that apply for any other reason.
If you want more information or have concerns about discrimination or unfair treatment, please
call the Department of Health and Human Services’ Office for Civil Rights at 1-800-368-1019
(TTY 1-800-537-7697) or your local Office for Civil Rights. You can also review information
from the Department of Health and Human Services’ Office for Civil Rights at
https://www.hhs.gov/ocr/index.html.
If you have a disability and need help with access to care, please call us at Member Services. If
you have a complaint, such as a problem with wheelchair access, Member Services can help.
SECTION 3
Notice about Medicare Secondary Payer subrogation
rights
We have the right and responsibility to collect for covered Medicare services for which Medicare
is not the primary payer. According to CMS regulations at 42 CFR sections 422.108 and
423.462, [insert 2024 plan name], as a Medicare Advantage Organization, will exercise the same
rights of recovery that the Secretary exercises under CMS regulations in subparts B through D of
part 411 of 42 CFR and the rules established in this section supersede any State laws.
[Note: You may include other legal notices, such as a notice of member non-liability or a notice
about third-party liability or a nondiscrimination notice under Section 1557 of the Affordable
Care Act. These notices may only be added if they conform to Medicare laws and regulations.
Plans may also include Medicaid-related legal notices.]
CHAPTER 10:
Definitions of important words
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Chapter 10 Definitions of important words
129
[Plans should insert definitions as appropriate to the plan type described in the EOC. You may
insert definitions not included in this model and exclude model definitions not applicable to your
plan, or to your contractual obligations with CMS or enrolled Medicare beneficiaries.]
[If allowable revisions to terminology (e.g., changing Member Services to Customer Service)
affect glossary terms, plans should re-label the term and alphabetize it within the glossary.]
[If you use any of the following terms in your EOC, you must add a definition of the term to the
first section where you use it and here in Chapter 10 with a reference from the section where you
use it: IPA, network, PHO, plan medical group, Point of Service.]
Ambulatory Surgical Center – An Ambulatory Surgical Center is an entity that operates
exclusively for the purpose of furnishing outpatient surgical services to patients not requiring
hospitalization and whose expected stay in the center does not exceed 24 hours.
Annual Enrollment Period – The time period of October 15 until December 7 of each year
when members can change their health or drug plans or switch to Original Medicare.
Appeal – An appeal is something you do if you disagree with our decision to deny a request for
coverage of health care services or payment for services you already received. You may also
make an appeal if you disagree with our decision to stop services that you are receiving.
Balance Billing – When a provider (such as a doctor or hospital) bills a patient more than the
plan’s allowed cost-sharing amount. As a member of [insert 2024 plan name], you only have to
pay our plan’s cost-sharing amounts when you get services covered by our plan. We do not allow
providers to balance bill or otherwise charge you more than the amount of cost sharing your plan
says you must pay.
Benefit Period – [Modify definition as needed if plan uses benefit periods for SNF stays but not
for inpatient hospital stays.] The way that [insert if applicable: both our plan and] Original
Medicare measures your use of hospital and skilled nursing facility (SNF) services. [Plans that
offer a more generous benefit period, revise the following sentences to reflect the plan’s benefit
period.] A benefit period begins the day you go into a hospital or skilled nursing facility. The
benefit period ends when you have not received any inpatient hospital care (or skilled care in a
SNF) for 60 days in a row. If you go into a hospital or a skilled nursing facility after one benefit
period has ended, a new benefit period begins. [Insert if applicable: You must pay the inpatient
hospital deductible for each benefit period.] There is no limit to the number of benefit periods.
Centers for Medicare & Medicaid Services (CMS) – The Federal agency that administers
Medicare.
Chronic-Care Special Needs Plan – C-SNPs are SNPs that restrict enrollment to special needs
individuals with specific severe or disabling chronic conditions, defined in 42 CFR 422.2. A C-A
SNP must have specific attributes that go beyond the provision of basic Medicare Parts A and B
services and care coordination that is required of all Medicare Advantage Coordinated Care
Plans, in order to receive the special designation and marketing and enrollment accommodations
provided to C-SNPs.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 10 Definitions of important words
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Coinsurance – An amount you may be required to pay, expressed as a percentage (for example
20%) as your share of the cost for services after you pay any deductibles.
Complaint – The formal name for making a complaint is filing a grievance. The complaint
process is used only for certain types of problems. This includes problems related to quality of
care, waiting times, and the customer service you receive. It also includes complaints if your plan
does not follow the time periods in the appeal process.
Comprehensive Outpatient Rehabilitation Facility (CORF) – A facility that mainly provides
rehabilitation services after an illness or injury, including physical therapy, social or
psychological services, respiratory therapy, occupational therapy and speech-language pathology
services, and home environment evaluation services.
Copayment (or copay) – An amount you may be required to pay as your share of the cost for a
medical service or supply, like a doctor’s visit, hospital outpatient visit, or a prescription. A
copayment is a set amount (for example $10), rather than a percentage.
Cost Sharing – Cost sharing refers to amounts that a member has to pay when services are
received. Cost sharing includes any combination of the following three types of payments: (1)
any deductible amount a plan may impose before services are covered; (2) any fixed copayment
amount that a plan requires when a specific service is received; or (3) any coinsurance amount, a
percentage of the total amount paid for a service, that a plan requires when a specific service is
received.
Covered Services – The term we use to mean all of the health care services and supplies that are
covered by our plan.
Creditable Prescription Drug Coverage – Prescription drug coverage (for example, from an
employer or union) that is expected to pay, on average, at least as much as Medicare’s standard
prescription drug coverage. People who have this kind of coverage when they become eligible
for Medicare can generally keep that coverage without paying a penalty if they decide to enroll
in Medicare prescription drug coverage later.
Chronic-Care Special Needs Plan - C-SNPs are SNPs that restrict enrollment to special needs
individuals with specific severe or disabling chronic conditions, defined in 42 CFR 422.2. A CSNP must have specific attributes that go beyond the provision of basic Medicare Parts A and B
services and care coordination that is required of all Medicare Advantage Coordinated Care
Plans, in order to receive the special designation and marketing and enrollment accommodations
provided to C-SNPs.
Custodial Care – Custodial care is personal care provided in a nursing home, hospice, or other
facility setting when you do not need skilled medical care or skilled nursing care. Custodial care
provided by people who do not have professional skills or training, includes help with activities
of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around,
and using the bathroom. It may also include the kind of health-related care that most people do
themselves, like using eye drops. Medicare doesn’t pay for custodial care.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 10 Definitions of important words
131
Deductible – The amount you must pay for health care before our plan pays.
Dual Eligible Special Needs Plans (D-SNP) – D-SNPs enroll individuals who are entitled to
both Medicare (title XVIII of the Social Security Act) and medical assistance from a state plan
under Medicaid (title XIX). States cover some Medicare costs, depending on the state and the
individual’s eligibility.
Disenroll or Disenrollment – The process of ending your membership in our plan.
Durable Medical Equipment (DME) – Certain medical equipment that is ordered by your
doctor for medical reasons. Examples include walkers, wheelchairs, crutches, powered mattress
systems, diabetic supplies, IV infusion pumps, speech generating devices, oxygen equipment,
nebulizers, or hospital beds ordered by a provider for use in the home.
Emergency – A medical emergency is when you, or any other prudent layperson with an
average knowledge of health and medicine, believe that you have medical symptoms that require
immediate medical attention to prevent loss of life (and, if you are a pregnant woman, loss of an
unborn child), loss of a limb, or loss of function of a limb, or loss of or serious impairment to a
bodily function. The medical symptoms may be an illness, injury, severe pain, or a medical
condition that is quickly getting worse.
Emergency Care – Covered services that are: 1) provided by a provider qualified to furnish
emergency services; and 2) needed to treat, evaluate, or stabilize an emergency medical
condition.
Evidence of Coverage (EOC) and Disclosure Information – This document, along with your
enrollment form and any other attachments, riders, or other optional coverage selected, which
explains your coverage, what we must do, your rights, and what you have to do as a member of
our plan.
Extra Help – A Medicare or a State program to help people with limited income and resources
pay Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance.
Grievance - A type of complaint you make about our plan, providers, including a complaint
concerning the quality of your care. This does not involve coverage or payment disputes.
Home Health Aide – A person who provides services that do not need the skills of a licensed
nurse or therapist, such as help with personal care (e.g., bathing, using the toilet, dressing, or
carrying out the prescribed exercises).
Hospice - A benefit that provides special treatment for a member who has been medically
certified as terminally ill, meaning having a life expectancy of 6 months or less. We, your plan,
must provide you with a list of hospices in your geographic area. If you elect hospice and
continue to pay premiums you are still a member of our plan. You can still obtain all medically
necessary services as well as the supplemental benefits we offer.
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 10 Definitions of important words
132
Hospital Inpatient Stay – A hospital stay when you have been formally admitted to the hospital
for skilled medical services. Even if you stay in the hospital overnight, you might still be
considered an outpatient.
Initial Enrollment Period – When you are first eligible for Medicare, the period of time when
you can sign up for Medicare Part A and Part B. If you’re eligible for Medicare when you turn
65, your Initial Enrollment Period is the 7-month period that begins three months before the
month you turn 65, includes the month you turn 65, and ends three months after the month you
turn 65.
Institutional Special Needs Plan (SNP) – A plan that enrolls eligible individuals who
continuously reside or are expected to continuously reside for 90 days or longer in a long-term
care (LTC) facility. These facilities may include a skilled nursing facility (SNF), nursing facility
(NF), (SNF/NF), an Intermediate Care Facility for Individuals with Intellectual Disabilities
(ICF/IID), an inpatient psychiatric facility, and/or facilities approved by CMS that furnishes
similar long-term, healthcare services that are covered under Medicare Part A, Medicare Part B,
or Medicaid; and whose residents have similar needs and healthcare status to the other named
facility types. An institutional Special Needs Plan must have a contractual arrangement with (or
own and operate) the specific LTC facility(ies).
Low Income Subsidy (LIS) – See “Extra Help.”
[Include if applicable: Maximum Out-of-Pocket Amount (MOOP) – The most that you pay
out-of-pocket during the calendar year for covered [insert if applicable: Part A and Part B]
services. Amounts you pay for Medicare Part A and Part B premiums do not count toward the
maximum out-of-pocket amount. [Plans with service category MOOPs insert: In addition to the
maximum out-of-pocket amount for covered [insert if applicable: Part A and Part B] medical
services, we also have a maximum out-of-pocket amount for certain types of services.]]
Medicaid (or Medical Assistance) – A joint Federal and state program that helps with medical
costs for some people with low incomes and limited resources. State Medicaid programs vary,
but most health care costs are covered if you qualify for both Medicare and Medicaid. You
cannot be a member of our Medicare Medical Savings Account (MSA) plan if you have
Medicaid.
Medically Necessary – Services, supplies, or drugs that are needed for the prevention, diagnosis,
or treatment of your medical condition and meet accepted standards of medical practice.
Medicare – The Federal health insurance program for people 65 years of age or older, some
people under age 65 with certain disabilities, and people with End-Stage Renal Disease
(generally those with permanent kidney failure who need dialysis or a kidney transplant).
Medicare Advantage (MA) Plan – Sometimes called Medicare Part C. A plan offered by a
private company that contracts with Medicare to provide you with all your Medicare Part A and
Part B benefits. A Medicare Advantage Plan can be an i) HMO, ii) PPO, a iii) Private Fee-forService (PFFS) plan, or a iv) Medicare Medical Savings Account (MSA) plan. Besides choosing
from these types of plans, a Medicare Advantage HMO or PPO plan can also be a Special Needs
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 10 Definitions of important words
133
Plan (SNP) In most cases, Medicare Advantage Plans also offer Medicare Part D (prescription
drug coverage). These plans are called Medicare Advantage Plans with Prescription Drug
Coverage.
[Insert Cost Plan definition only if you are a Medicare Cost Plan or there is one in your service
area: Medicare Cost Plan – A Medicare Cost Plan is a plan operated by a Health Maintenance
Organization (HMO) or Competitive Medical Plan (CMP) in accordance with a cost-reimbursed
contract under section 1876(h) of the Act.]
Medicare-Covered Services – Services covered by Medicare Part A and Part B. All Medicare
health plans must cover all of the services that are covered by Medicare Part A and B. The term
Medicare Covered services does not include the extra benefits, such as vision, dental or hearing,
that a Medicare Advantage plan may offer.
Medicare Health Plan – A Medicare health plan is offered by a private company that contracts
with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the
plan. This term includes all Medicare Advantage Plans, Medicare Cost Plans, Special Needs
Plans, Demonstration/Pilot Programs, and Programs of All-inclusive Care for the Elderly
(PACE).
Medicare Medical Savings Account (MSA) Plan – A type of Medicare Advantage Plan that
combines a high-deductible health insurance plan with a medical savings account that members
can use to pay for their health care costs.
Medicare Prescription Drug Coverage (Medicare Part D) – Insurance to help pay for
outpatient prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare
Part A or Part B.
Medigap (Medicare Supplement Insurance) Policy – Medicare supplement insurance sold by
private insurance companies to fill gaps in Original Medicare. Medigap policies only work with
Original Medicare. (A Medicare Advantage Plan is not a Medigap policy.)
Member (Member of our Plan, or Plan Member) – A person with Medicare who is eligible to
get covered services, who has enrolled in our plan and whose enrollment has been confirmed by
the Centers for Medicare & Medicaid Services (CMS).
Member Services – A department within our plan responsible for answering your questions
about your membership, benefits, grievances, and appeals.
[Include if applicable: Network Provider – Provider is the general term for doctors, other
health care professionals, hospitals, and other health care facilities that are licensed or certified
by Medicare and by the State to provide health care services. Network providers have an
agreement with our plan to accept our payment as payment in full, and in some cases to
coordinate as well as provide covered services to members of our plan. Network providers are
also called plan providers.]
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 10 Definitions of important words
134
[Include if applicable: Optional Supplemental Benefits – Non-Medicare-covered benefits that
can be purchased for an additional premium and are not included in your package of benefits.
You must voluntarily elect Optional Supplemental Benefits in order to get them.]
Organization Determination – A decision our plan makes about whether items or services are
covered or how much you have to pay for covered items or services. Organization
determinations are called coverage decisions in this document.
Original Medicare (Traditional Medicare or Fee-for-service Medicare) – Original Medicare is
offered by the government, and not a private health plan like Medicare Advantage Plans and
prescription drug plans. Under Original Medicare, Medicare services are covered by paying
doctors, hospitals, and other health care providers payment amounts established by Congress.
You can see any doctor, hospital, or other health care provider that accepts Medicare. You must
pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your
share. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical
Insurance) and is available everywhere in the United States.
Out-of-Pocket Costs – See the definition for cost sharing above. A member’s cost-sharing
requirement to pay for a portion of services received is also referred to as the member’s out-ofpocket cost requirement.
[Insert PACE plan definition only if there is a PACE plan in your state: PACE plan – A PACE
(Program of All-Inclusive Care for the Elderly) plan combines medical, social, and long-term
services and supports (LTSS) for frail people to help people stay independent and living in their
community (instead of moving to a nursing home) as long as possible. People enrolled in PACE
plans receive both their Medicare and Medicaid benefits through the plan.]
Part C – see Medicare Advantage (MA) Plan.
Part D – The voluntary Medicare Prescription Drug Benefit Program.
Preferred Provider Organization (PPO) Plan – A Preferred Provider Organization plan is a
Medicare Advantage Plan that has a network of contracted providers that have agreed to treat
plan members for a specified payment amount. A PPO plan must cover all plan benefits whether
they are received from network or out-of-network providers. Member cost sharing will generally
be higher when plan benefits are received from out-of-network providers. PPO plans have an
annual limit on your out-of-pocket costs for services received from network (preferred) providers
and a higher limit on your total combined out-of-pocket costs for services from both in-network
(preferred) and out-of-network (non-preferred) providers.
Premium – The periodic payment to Medicare, an insurance company, or a health care plan for
health or prescription drug coverage.
[Include if applicable: Primary Care [insert as appropriate: Physician OR Provider] (PCP) –
The doctor or other provider you see first for most health problems. In many Medicare health
plans, you must see your primary care provider before you see any other health care provider.]
2024 Evidence of Coverage for [insert 2024 plan name]
Chapter 10 Definitions of important words
135
Prior Authorization – Approval in advance to get services. As a member of a Medicare Medical
Savings Account (MSA) plan, you do not need prior authorization to obtain services. However,
you may want to check with us before obtaining services to confirm that the service is covered
by the plan.
Prosthetics and Orthotics – Medical devices including, but are not limited to, arm, back and
neck braces; artificial limbs; artificial eyes; and devices needed to replace an internal body part
or function, including ostomy supplies and enteral and parenteral nutrition therapy.
Qualified Medical Expenses - Qualified medical expenses are those expenses that would
generally qualify for the medical and dental expenses deduction on your income tax return.
These expenses are explained in IRS Publication 502, Medical and Dental Expenses.
Quality Improvement Organization (QIO) – A group of practicing doctors and other health
care experts paid by the Federal government to check and improve the care given to Medicare
patients.
Rehabilitation Services – These services include physical therapy, speech and language
therapy, and occupational therapy.
Service Area – A geographic area where you must live to join a particular health plan. For plans
that limit which doctors and hospitals you may use, it’s also generally the area where you can get
routine (non-emergency) services. The plan must disenroll you if you permanently move out of
the plan’s service area.
Skilled Nursing Facility (SNF) Care – Skilled nursing care and rehabilitation services provided
on a continuous, daily basis, in a skilled nursing facility. Examples of care include physical
therapy or intravenous injections that can only be given by a registered nurse or doctor.
Special Enrollment Period – A set time when members can change their health or drug plans or
return to Original Medicare. Situations in which you may be eligible for a Special Enrollment
Period include: if you move outside the service area, if you move into a nursing home, or if we
violate our contract with you.
Special Needs Plan – A special type of Medicare Advantage Plan that provides more focused
health care for specific groups of people, such as those who have both Medicare and Medicaid,
who reside in a nursing home, or who have certain chronic medical conditions.
Supplemental Security Income (SSI) – A monthly benefit paid by Social Security to people
with limited income and resources who are disabled, blind, or age 65 and older. SSI benefits are
not the same as Social Security benefits.
[This is the back cover for the EOC. Plans may add a logo and/or photographs, as long as these
elements do not make it difficult for members to find and read the plan contact information.]
[Insert 2024 plan name] Member Services
Method
Member Services – Contact Information
CALL
[Insert phone number(s)]
Calls to this number are free. [Insert days and hours of operation,
including information on the use of alternative technologies.]
Member Services also has free language interpreter services available
for non-English speakers.
TTY
[Insert number]
[Insert if plan uses a direct TTY number: This number requires special
telephone equipment and is only for people who have difficulties with
hearing or speaking.]
Calls to this number are free. [Insert days and hours of operation.]
FAX
[Optional: insert fax number]
WRITE
[Insert address]
[Note: plans may add email addresses here.]
WEBSITE
[Insert URL]
[Insert state-specific SHIP name] [If the SHIP’s name does not include the name of
the state, add: ([insert state name] SHIP)]
[Insert state-specific SHIP name] is a state program that gets money from the Federal
government to give free local health insurance counseling to people with Medicare.
[Plans with multi-state EOCs revise heading and sentence above to use State Health Insurance
Assistance Program, omit table, and reference exhibit or EOC section with SHIP information.]
Method
Contact Information
CALL
[Insert phone number(s)]
TTY
[Insert number, if available. Or delete this row.]
[Insert if the SHIP uses a direct TTY number: This number requires
special telephone equipment and is only for people who have
difficulties with hearing or speaking.]
WRITE
[Insert address]
WEBSITE
[Insert URL]
PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are
required to respond to a collection of information unless it displays a valid OMB control number.
The valid OMB control number for this information collection is 0938-1051. If you have
comments or suggestions for improving this form, please write to: CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850.
| File Type | application/pdf |
| File Title | 2023 Medicare Medical Savings Account (MSA) Evidence of Coverage (EOC) Templates |
| Subject | 2023 Medicare Medical Savings Account (MSA) Evidence of Coverage (EOC) Templates |
| Author | Centers for Medicare & Medicaid Services |
| File Modified | 2023-04-08 |
| File Created | 2023-04-08 |