CY2024_8_PPO MA_EOC_30 day PRA CLEAN

Medicare Advantage and Prescription Drug Program: Final Marketing Provisions CFR 422.111(a)(3) and 423.128(a)(3) (CMS-10260)

CY2024_8_PPO MA_EOC_30 day PRA CLEAN

OMB: 0938-1051

Document [pdf]

Download: pdf | pdf

[2024 EOC model]

January 1 – December 31, 2024

Evidence of Coverage:
Your Medicare Health Benefits and Services [insert if applicable: and
Prescription Drug Coverage] 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) as applicable.]
[Remove terms as needed to reflect plan benefits] Benefits, premiums, deductibles, and/or
copayments/coinsurance may change on January 1, 2025.
[Remove terms as needed to reflect plan benefits] The formulary, pharmacy network, and/or
provider network may change at any time. You will receive notice when necessary. We will
notify affected enrollees about changes at least 30 days in advance.
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

2024 Evidence of Coverage
Table of Contents
CHAPTER 1: Getting started as a member................................................................. 4
SECTION 1 Introduction ........................................................................................................5
SECTION 2 What makes you eligible to be a plan member? ................................................6
SECTION 3 Important membership materials you will receive.............................................7
SECTION 4 Your monthly costs for [insert 2024 plan name] ..............................................8
SECTION 5 More information about your monthly premium .............................................10
SECTION 6 Keeping your plan membership record up to date ...........................................11
SECTION 7 How other insurance works with our plan .......................................................12
CHAPTER 2: Important phone numbers and resources ......................................... 14
SECTION 1 [Insert 2024 plan name] contacts (How to contact us, including how to
reach Member Services) ..................................................................................15
SECTION 2 Medicare (how to get help and information directly from the Federal
Medicare program)...........................................................................................18
SECTION 3 State Health Insurance Assistance Program (free help, information,
and answers to your questions about Medicare) ..............................................19
SECTION 4 Quality Improvement Organization .................................................................21
SECTION 5 Social Security .................................................................................................22
SECTION 6 Medicaid ..........................................................................................................22
SECTION 7 How to contact the Railroad Retirement Board ...............................................23
SECTION 8 Do you have group insurance or other health insurance from an
employer? .........................................................................................................24
CHAPTER 3: Using the plan for your medical services .......................................... 25
SECTION 1 Things to know about getting your medical care as a member of our
plan...................................................................................................................26
SECTION 2 Using network and out-of-network providers to get your medical care ..........27
SECTION 3 How to get services when you have an emergency or urgent need for
care or during a disaster ...................................................................................31
SECTION 4 What if you are billed directly for the full cost of your services? ...................33
SECTION 5 How are your medical services covered when you are in a clinical
research study? .................................................................................................33
SECTION 6 Rules for getting care in a religious non-medical health care institution ........35
SECTION 7 Rules for ownership of durable medical equipment ........................................36

2024 Evidence of Coverage for [insert 2024 plan name]

Table of Contents

CHAPTER 4: Medical Benefits Chart (what is covered and what you pay) ............ 39
SECTION 1 Understanding your out-of-pocket costs for covered services.........................40
SECTION 2 Use the Medical Benefits Chart to find out what is covered and how
much you will pay............................................................................................44
SECTION 3 What services are not covered by the plan? .....................................................80
CHAPTER 5: Asking us to pay our share of a bill you have received for
covered medical services .................................................................... 84
SECTION 1 Situations in which you should ask us to pay our share of the cost of
your covered services.......................................................................................85
SECTION 2 How to ask us to pay you back or to pay a bill you have received ..................86
SECTION 3 We will consider your request for payment and say yes or no ........................87
CHAPTER 6: Your rights and responsibilities ......................................................... 88
SECTION 1 Our plan must honor your rights and cultural sensitivities as a member
of the plan ........................................................................................................89
SECTION 2 You have some responsibilities as a member of the plan ................................94
CHAPTER 7: What to do if you have a problem or complaint (coverage
decisions, appeals, complaints) .......................................................... 96
SECTION 1 Introduction ......................................................................................................97
SECTION 2 Where to get more information and personalized assistance ...........................97
SECTION 3 To deal with your problem, which process should you use? ...........................98
SECTION 4 A guide to the basics of coverage decisions and appeals...............................100
SECTION 5 Your medical care: How to ask for a coverage decision or make an
appeal of a coverage decision ........................................................................103
SECTION 6 How to ask us to cover a longer inpatient hospital stay if you think the
doctor is discharging you too soon ................................................................110
SECTION 7 How to ask us to keep covering certain medical services if you think
your coverage is ending too soon...................................................................117
SECTION 8 Taking your appeal to Level 3 and beyond ....................................................123
SECTION 9 How to make a complaint about quality of care, waiting times,
customer service, or other concerns ...............................................................125
CHAPTER 8: Ending your membership in the plan ............................................... 129
SECTION 1 Introduction to ending your membership in our plan ....................................130
SECTION 2 When can you end your membership in our plan? ........................................130
SECTION 3 How do you end your membership in our plan? ............................................132
SECTION 4 Until your membership ends, you must keep getting your medical
services through our plan ...............................................................................133

2024 Evidence of Coverage for [insert 2024 plan name]

Table of Contents

SECTION 5

[Insert 2024 plan name] must end your membership in the plan in
certain situations ............................................................................................134

CHAPTER 9: Legal notices...................................................................................... 136
SECTION 1 Notice about governing law ...........................................................................137
SECTION 2 Notice about nondiscrimination .....................................................................137
SECTION 3 Notice about Medicare Secondary Payer subrogation rights .........................137
CHAPTER 10: Definitions of important words ....................................................... 138

CHAPTER 1:

Getting started as a member

OMB Approval 0938-1051 (Expires: February 29, 2024)

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 PPO

You are covered by Medicare, and you have chosen to get your Medicare health care coverage
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 PPO Plan (PPO stands for Preferred
Provider Organization). Like all Medicare health plans, this Medicare PPO is approved by
Medicare and run by a private company. This plan does not include Part D prescription drug
coverage.
Coverage under this Plan qualifies as Qualifying Health Coverage (QHC) and satisfies the
Patient Protection and Affordable Care Act’s (ACA) individual shared responsibility
requirement. Please visit the Internal Revenue Service (IRS) website at:
www.irs.gov/Affordable-Care-Act/Individuals-and-Families for more information.
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 or 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.
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.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1

Getting started as a member

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 2.2 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 are a United States citizen or are lawfully present in the United States

Section 2.2

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]]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1

Getting started as a member

[Optional info: 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.

SECTION 3

Important membership materials you will receive

Section 3.1

Your plan membership card

While you are a member of our plan, you must use your membership card whenever you get
services covered by this plan. 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.
If your plan membership card is damaged, lost, or stolen, call Member Services right away and
we will send you a new card.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1

Getting started as a member

Section 3.2

Provider Directory

The Provider Directory lists our current network providers [insert if applicable: and durable
medical equipment suppliers]. Network providers are the doctors and other health care
professionals, medical groups, [insert if applicable: durable medical equipment suppliers,]
hospitals, and other health care facilities that have an agreement with us to accept our payment
and any plan cost sharing as payment in full.
As a member of our plan, you can choose to receive care from out-of-network providers. Our
plan will cover services from either in-network or out-of-network providers, as long as the
services are covered benefits and medically necessary. However, if you use an out-of-network
provider, your share of the costs for your covered services may be higher. See Chapter 3 (Using
the plan’s coverage for your medical services) for more specific information.
[Regional PPOs that CMS has granted permission to use the exception in § 422.112(a)(1)(ii) to
meet access requirements should insert: Because our Plan is a Regional Preferred Provider
Organization, if no contracted network provider is readily available you can access care at innetwork cost sharing from an out-of-network provider. Call Member Services to let us know you
need to see an out-of-network provider, or to get help finding an out-of-network provider.]
[Insert as applicable: We included a copy of our Provider Directory in the envelope with this
document.] [Insert as applicable: We [insert as applicable: also] included a copy of our Durable
Medical Equipment Supplier Directory in the envelope with this document.] [The most recent list
of providers [insert as applicable: and suppliers] is [insert as applicable: also] available on our
website at [insert URL].]
If you don’t have your copy of the Provider Directory, you can request a copy (electronically or
in hardcopy form) from Member Services. Requests for hard copy Provider Directories will be
mailed to you within three business days.

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

Plan premium

As a member of our plan, you pay a monthly plan premium. [Select one of the following: For
2024, the monthly premium for [insert 2024 plan name] is [insert monthly premium amount].
OR The table below shows the monthly plan premium amount for each region we serve. OR The
table below shows the monthly plan premium amount for each plan we are offering in the service
area. OR The monthly premium amount for [insert 2024 plan name] is listed in [describe
attachment]. [Plans may insert a list of or table with the state/region and monthly plan premium
amount for each area included within the EOC. Plans may also include premium(s) in an
attachment to the EOC.]]
[Plans with no premium should replace the preceding paragraph with: You do not pay a
separate monthly plan premium for [insert 2024 plan name].
[Insert if applicable: Your coverage is provided through a contract with your current employer or
former employer or union. Please contact the employer’s or union’s benefits administrator for
information about your plan premium.]
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.
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.]
[Delete Chapter 1, Section 4.3 if your plan doesn't offer optional supplemental benefits.
Renumber remaining sections as appropriate.]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1

Getting started as a member

SECTION 5

More information about your monthly premium

Section 5.1

There are several ways you can pay your plan premium

[Plans indicating in Section 4.1 that there is no monthly premium: Delete this section.]
There are [insert number of payment options] ways you can pay your plan premium.
Option 1: Paying by check
[Insert plan specifics regarding premium/penalty payment intervals (e.g., monthly, quarterlyplease note that members must have the option to pay their premiums monthly), how they can
pay by check, including an address, whether they can drop off a check in person, and by what
day the check must be received (e.g., the 5th of each month). It should be emphasized that checks
should be made payable to the Plan and not CMS nor HHS. If the Plan uses coupon books,
explain when they will receive it and to call Member Services for a new one if they run out or
lose it. In addition, include information if you charge for bounced checks.]
Option 2: [Insert option type]
[If applicable: Insert information about other payment options. Or delete this option.
Include information about all relevant choices (e.g., automatically withdrawn from your
checking or savings account, charged directly to your credit or debit card, or billed each month
directly by the plan). Insert information on the frequency of automatic deductions (e.g., monthly,
quarterly – please note that members must have the option to pay their premiums monthly), the
approximate day of the month the deduction will be made, and how this can be set up. Please
note that furnishing discounts for members who use direct payment electronic payment methods
is prohibited.]
[Include the option below only if applicable. SSA only deducts plan premiums below $300.]
Option [insert number]: Having your [plans with a premium insert: plan premium]
taken out of your monthly Social Security check
Changing the way you pay your premium. If you decide to change the option by which
you pay your premium, it can take up to three months for your new payment method to take
effect. While we are processing your request for a new payment method, you are responsible for
making sure that your plan premium is paid on time. To change your payment method [Plans
must indicate how the member can inform the plan of the procedure for changing that choice.]
What to do if you are having trouble paying your premium
[Plans that do not disenroll members for non-payment may modify this section as needed.]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1

Getting started as a member

Your [plans with a premium insert: plan premium] is due in our office by the [insert day of the
month]. If we have not received your payment by the [insert day of the month], we will send you
a notice telling you that your plan membership will end if we do not receive your [plans with a
premium insert: premium] within [insert length of plan grace period].
If you are having trouble paying your [plans with a premium insert: premium] on time, please
contact Member Services to see if we can direct you to programs that will help with your costs.
If we end your membership because you did not pay your [plans with a premium insert:
premium] you will have health coverage under Original Medicare.
[Insert if applicable: At the time we end your membership, you may still owe us for [plans with
a premium insert: premiums] you have not paid. [Insert one or both statements as applicable for
the plan: We have the right to pursue collection of the amount you owe. AND/OR In the future, if
you want to enroll again in our plan (or another plan that we offer), you will need to pay the
amount you owe before you can enroll.]]
If you think we have wrongfully ended your membership, you can make a complaint (also called
a grievance); see Chapter 7 for how to file a complaint. If you had an emergency circumstance
that was out of your control and it caused you to not be able to pay your [plans with a premium
insert: plan premium] within our grace period, you can make a complaint. For complaints, we
will review our decision again. Chapter 7, Section 9 of this document tells how to make a
complaint, or you can call us at [insert phone number] between [insert hours of operation]. TTY
users should call [insert TTY number]. You must make your request no later than 60 days after
the date your membership ends.
Section 5.2

Can we change your monthly plan premium during the year?

No. We are not allowed to change the amount we charge for the plan’s monthly plan premium
during the year. If the monthly plan premium changes for next year we will tell you in September
and the change will take effect on January 1.

SECTION 6

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].
The doctors, hospitals, and other providers in the plan’s network need to have correct
information about you. These network providers use your membership record to know what
services are covered and the cost-sharing amounts for you. Because of this, it is very
important that you help us keep your information up to date.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1

Getting started as a member

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 or out-of-network 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.

SECTION 7

How other insurance works with our plan

Other insurance
[Plans collecting information by phone revise heading and section as needed to reflect process.]
Medicare requires that we collect information from you about any other medical or drug
insurance coverage that you have. That’s because we must coordinate any other coverage you
have with your benefits under our plan. This is called Coordination of Benefits.
Once each year, we will send you a letter that lists any other medical or drug insurance coverage
that we know about. Please read over this information carefully. If it is correct, you don’t need to
do anything. If the information is incorrect, or if you have other coverage that is not listed, please
call Member Services. You may need to give your plan member ID number to your other
insurers (once you have confirmed their identity) so your bills are paid correctly and on time.
When you have other insurance (like employer group health coverage), there are rules set by
Medicare that decide whether our plan or your other insurance pays first. The insurance that pays
first is called the primary payer and pays up to the limits of its coverage. The one that pays
second, called the secondary payer, only pays if there are costs left uncovered by the primary
coverage. The secondary payer may not pay all of the uncovered costs. If you have other
insurance, tell your doctor, hospital, and pharmacy.
These rules apply for employer or union group health plan coverage:

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1

Getting started as a member

•

If you have retiree coverage, Medicare pays first.

•

If your group health plan coverage is based on your or a family member’s current
employment, who pays first depends on your age, the number of people employed by
your employer, and whether you have Medicare based on age, disability, or End-Stage
Renal Disease (ESRD):

o If you’re under 65 and disabled and you or your family member is still working,
your group health plan pays first if the employer has 100 or more employees or at
least one employer in a multiple employer plan that has more than 100 employees.
o If you’re over 65 and you or your spouse or domestic partner is still working, your
group health plan pays first if the employer has 20 or more employees or at least
one employer in a multiple employer plan that has more than 20 employees.
•

If you have Medicare because of ESRD, your group health plan will pay first for the first
30 months after you become eligible for Medicare.

These types of coverage usually pay first for services related to each type:
•

No-fault insurance (including automobile insurance)

•

Liability (including automobile insurance)

•

Black lung benefits

•

Workers’ compensation

Medicaid and TRICARE never pay first for Medicare-covered services. They only pay after
Medicare, employer group health plans, and/or Medigap have paid.

CHAPTER 2:

Important phone numbers and
resources

OMB Approval 0938-1051 (Expires: February 29, 2024)

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 2 Important phone numbers and resources

SECTION 1

[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

FAX

[Optional: insert fax number]

WRITE

[Insert address]
[Note: plans may add email addresses here.]

WEBSITE

[Insert URL]

[Note: If your plan uses the same contact information for the Part C issues indicated below, you
may combine the appropriate sections.]
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)).

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 2 Important phone numbers and resources

[If the plan has different phone numbers for coverage decisions and appeals or for medical care
and prescription drugs, 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 24-hour
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]

How to contact us when you are making a complaint about your medical care
You can make a complaint about us 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 24hour lines here.] [Note: If you have a different number for accepting
expedited grievances, also include that number here.]

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Chapter 2 Important phone numbers and resources

Method

Complaints About Medical Care – Contact Information

TTY

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.
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.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 2 Important phone numbers and resources

Method

Payment Requests – Contact Information

TTY

[Optional: Insert number] [Note: You are required to accept payment
requests in writing, and may choose to also accept payment requests by
phone.]
[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] [Note: You are required to accept
payment requests in writing, and may choose to also accept payment
requests by fax.]

WRITE

[Insert address]
[Note: plans may add email addresses here.]

WEBSITE

[Optional: Insert URL]

SECTION 2

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.

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Chapter 2 Important phone numbers and resources

Method

Medicare – Contact Information

WEBSITE www.Medicare.gov
This is the official government website for Medicare. It gives you up-to-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 1800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users
should call 1-877-486-2048.)
•

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
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.]

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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 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.

Method

[Insert state-specific SHIP name] [If the SHIP’s name does not
include the name of the state, add: ([insert state name] SHIP)]
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]
[Note: plans may add email addresses here.]

WEBSITE

[Insert URL]

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Chapter 2 Important phone numbers and resources

SECTION 4

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.

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]

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Chapter 2 Important phone numbers and resources

SECTION 5

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
ESRD 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

SECTION 6

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:

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Chapter 2 Important phone numbers and resources

•

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].
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]

SECTION 7

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.

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Chapter 2 Important phone numbers and resources

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

OMB Approval 0938-1051 (Expires: February 29, 2024)

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SECTION 1

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, Part B 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 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.

•

Network providers are the doctors and other health care professionals, medical groups,
hospitals, and other health care facilities that have an agreement with us to accept our
payment and your cost-sharing amount as payment in full. We have arranged for these
providers to deliver covered services to members in our plan. The providers in our
network bill us directly for care they give you. When you see a network provider, you
pay only your share of the cost for their services.

•

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 who is eligible to provide services under
Original Medicare. As a member of our plan, you can receive your care from either a
network provider or an out-of-network provider (for more about this, see Section 2 in
this chapter).
o The providers in our network are listed in the Provider Directory.

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o If you use an out-of-network provider, your share of the costs for your covered
services may be higher.
o [RPPOs that CMS has granted permission to use the exception in § 422.112(a) (1)
(ii) to meet access requirements should insert: Because our plan is a Regional
Preferred Provider Organization, if there isn’t a network provider available for
you to see, you can go to an out-of-network provider but still pay the in-network
amounts.]
o Please note: While you can get your care from an out-of-network provider, the
provider must be eligible to participate in Medicare. Except for emergency care,
we cannot pay a provider who is not eligible to participate in Medicare. If you go
to a provider who is not eligible to participate in Medicare, you will be
responsible for the full cost of the services you receive. Check with your provider
before receiving services to confirm that they are eligible to participate in
Medicare.

SECTION 2

Using network and out-of-network providers to get
your medical care

Section 2.1

You [insert as applicable: may OR must] choose a Primary Care
Provider (PCP) to provide and oversee your medical care

[Note: Insert this section only if plan uses PCPs. Plans may edit this section to refer to a
Physician of Choice (POC) instead of PCP.]
What is a PCP and what does the PCP do for you?
[Plans should describe the following in the context of their plans:
•

What is a PCP?

•

What types of providers may act as a PCP?

•

Explain the role of a PCP in your plan.

•

What is the role of the PCP in coordinating covered services?

•

What is the role of the PCP in making decisions about or obtaining prior authorization,
(PA) if applicable?]

How do you choose your PCP?
[Plans should describe how to choose a PCP.]
Changing your PCP
You may change your PCP for any reason, at any time. Also, it’s possible that your PCP might
leave our plan’s network of providers and you would have to find a new PCP in our plan [PPOs

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with lower cost sharing for network providers insert: or you will pay more for covered services].
[Explain if the member changes their PCP this may result in being limited to specific specialists
or hospitals to which that PCP refers (i.e., sub-network, referral circles). Also noted in Section
2.3 below.]
[Plans should describe how to change a PCP and indicate when that change will take effect
(e.g., on the first day of the month following the date of the request, immediately upon receipt of
request, etc.).]
Section 2.2

What kinds of medical care can you get without a referral from
your PCP?

[Note: Insert this section only if plans use PCPs or require referrals to network providers.]
You can get the services listed below without getting approval in advance from your PCP.
•

Routine women’s health care, which includes breast exams, screening mammograms (xrays of the breast), Pap tests, and pelvic exams [insert if appropriate: as long as you get
them from a network provider]

•

Flu shots, COVID-19 vaccinations, [insert if applicable: hepatitis B vaccinations, and
pneumonia vaccinations] [insert if appropriate: as long as you get them from a network
provider]

•

Emergency services from network providers or from out-of-network providers

•

Urgently needed services are covered services that are not emergency services, provided
when the network providers are temporarily unavailable or inaccessible or when the
enrollee is out of the service area. For example, you need immediate care during the
weekend. Services must be immediately needed and medically necessary.

•

Kidney dialysis services that you get at a Medicare-certified dialysis facility when you
are temporarily outside the plan’s service area or when your provider for this service is
temporarily unavailable or inaccessible. The cost sharing you pay the plan for dialysis
can never exceed the cost sharing in Original Medicare. If you are outside the plan’s
service area and obtain the dialysis from a provider that is outside the plan’s network,
your cost sharing cannot exceed the cost sharing you pay in-network. However, if your
usual in-network provider for dialysis is temporarily unavailable and you choose to
obtain services inside the service area from a provider outside the plan’s network the
cost sharing for the dialysis may be higher. [Plans may insert requests here (e.g., If
possible, please let us know before you leave the service area so we can help arrange
for you to have maintenance dialysis while you are away.)]

•

[Plans should add additional bullets as appropriate.]

Section 2.3

How to get care from specialists and other network providers

A specialist is a doctor who provides health care services for a specific disease or part of the
body. There are many kinds of specialists. Here are a few examples:

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•

Oncologists care for patients with cancer.

•

Cardiologists care for patients with heart conditions.

•

Orthopedists care for patients with certain bone, joint, or muscle conditions.

[Plans should describe how members access specialists and other network providers, including:
•

What is the role (if any) of the PCP in referring members to specialists and other
providers?

•

Include an explanation of the process for obtaining PA, including who makes the PA
decision (e.g., the plan, PCP, another entity) and who is responsible for obtaining the
PA (e.g., PCP, member). Refer members to Chapter 4, Section 2.1 for information about
which services require PA.

•

Explain if the selection of a PCP results in being limited to specific specialists or
hospitals to which that PCP refers, i.e. sub-network, referral circles.]

What if a specialist or another network provider leaves our plan?
It is important that you know that we may make changes to the hospitals, doctors and specialists
(providers) that are part of your plan during the year. If your doctor or specialist leaves your plan
you have certain rights and protections summarized below:
•

Even though our network of providers may change during the year, Medicare requires
that we furnish you with uninterrupted access to qualified doctors and specialists.

•

We will make a good faith effort to provide you with at least 30 days’ notice that your
provider is leaving our plan so that you have time to select a new provider.

•

We will assist you in selecting a new qualified provider to continue managing your
health care needs.

•

If you are undergoing medical treatment, you have the right to request, and we will work
with you to ensure, that the medically necessary treatment you are receiving is not
interrupted.

•

If our network does not have a qualified specialist for a plan-covered service, we must
cover that service at in-network cost sharing [Plans should indicate if prior
authorization is needed.]

•

If you find out your doctor or specialist is leaving your plan, please contact us so we can
assist you in finding a new provider to manage your care.

•

If you believe we have not furnished you with a qualified provider to replace your
previous provider or that your care is not being appropriately managed, you have the
right to file a quality of care complaint to the QIO, a quality of care grievance to the
plan, or both. Please see Chapter 7.

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Section 2.4

How to get care from out-of-network providers

As a member of our plan, you can choose to receive care from out-of-network providers.
However, please note providers that do not contract with us are under no obligation to treat you,
except in emergency situations. Our plan will cover services from either in-network or out-ofnetwork providers, as long as the services are covered benefits and are medically necessary.
However, if you use an out-of-network provider, your share of the costs for your covered
services may be higher. Here are other important things to know about using out-of-network
providers:
•

You can get your care from an out-of-network provider, however, in most cases that
provider must be eligible to participate in Medicare. Except for emergency care, we
cannot pay a provider who is not eligible to participate in Medicare. If you receive care
from a provider who is not eligible to participate in Medicare, you will be responsible
for the full cost of the services you receive. Check with your provider before receiving
services to confirm that they are eligible to participate in Medicare.

•

You don’t need to get a referral or prior authorization when you get care from out-ofnetwork providers. However, before getting services from out-of-network providers you
may want to ask for a pre-visit coverage decision to confirm that the services you are
getting are covered and are medically necessary. (See Chapter 7, Section 4 for
information about asking for coverage decisions.) This is important because:
o Without a pre-visit coverage decision, if we later determine that the services are
not covered or were not medically necessary, we may deny coverage and you will
be responsible for the entire cost. If we say we will not cover your services, you
have the right to appeal our decision not to cover your care. See Chapter 7 (What
to do if you have a problem or complaint) to learn how to make an appeal.

•

[RPPOs that CMS has granted permission to use the exception in § 422.112(a) (1) (ii) to
meet access requirements should insert: Because our plan is a Regional Preferred
Provider Organization, if no contracted network provider is readily available you can
access care at in-network cost sharing from an out-of-network provider. Call Member
Services to let us know you need to see an out-of-network provider, or to get help
finding an out-of-network provider. (Phone numbers for Member Services are printed on
the back cover of this document.)]

•

It is best to ask an out-of-network provider to bill the plan first. But, if you have already
paid for the covered services, we will reimburse you for our share of the cost for covered
services. Or if an out-of-network provider sends you a bill that you think we should pay,
you can send it to us for payment. See Chapter 5 (Asking us to pay our share of a bill
you have received for covered medical services) for information about what to do if you
receive a bill or if you need to ask for reimbursement.

•

If you are using an out-of-network provider for emergency care, urgently needed
services, or out-of-area dialysis, you may not have to pay a higher cost-sharing amount.
See Section 3 for more information about these situations.

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Section 2.5

How to get care if you live in a non-network area

[RPPOs: If there are portions of your RPPO service area where you have not met Medicare
network adequacy requirements, you must insert this section and explain to your members the
process they must follow to find providers who will treat them (see 422.111(b)(3)(ii)). The
expectation is that members in non-network areas will receive all necessary assistance in
obtaining access to services, which may require the RPPO to pay more than the Original
Medicare payment rate to ensure access. Members in non-network areas can only be charged
the in-network (i.e., preferred) cost-sharing amount for plan-covered services.]

SECTION 3

How to get services when you have an emergency or
urgent need for care 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, 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 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 or a
referral first from your PCP. 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 worldwide 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 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.

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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.
What if it wasn’t a medical emergency?
Sometimes it can be hard to know if you have a medical emergency. For example, you might go
in for emergency care – thinking that your health is in serious danger – and the doctor may say
that it wasn’t a medical emergency after all. If it turns out that it was not an emergency, as long
as you reasonably thought your health was in serious danger, we will cover your care.
However, after the doctor has said that it was not an emergency, the amount of cost sharing that
you pay will depend on whether you get the care from network providers or out-of-network
providers. If you get the care from network providers, your share of the costs will usually be
lower than if you get the care from out-of-network providers.
Section 3.2

Getting care when you have an urgent need for services

What are urgently needed services?
An urgently needed service is a non-emergency situation requiring immediate medical care but
given your circumstances, it is not possible or not reasonable to obtain these services from a
network provider. The plan must cover urgently needed services provided out of network. Some
examples of urgently needed services are i) a severe sore throat that occurs over the weekend or
ii) an unforeseen flare-up of a known condition when you are temporarily outside the service
area.
[Plans must insert instructions for how to access in-network urgently needed services (e.g., using
urgent care centers, a provider hotline, etc.)]
[Insert if applicable: Plans without world-wide emergency/urgent coverage as a supplemental
benefit: Our plan does not cover emergency services, urgently needed services, nor any other
services for care outside of the United States and its territories.]
[Insert if applicable: Plans with world-wide emergency/urgent coverage as a supplemental
benefit: Our plan covers worldwide [Insert as applicable: emergency and urgent care OR
emergency OR urgent care] services outside the United States under the following circumstances
[insert details].]

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Section 3.3

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.
If you cannot use a network provider during a disaster, your plan will allow you to obtain care
from out-of-network providers at in-network cost sharing.

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

If you have paid more than your plan cost-sharing for 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, 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
whether paying for costs once a benefit limit has been reached will count toward an out-ofpocket maximum.]

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.

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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.
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

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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. 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.
Here’s an example of how the cost sharing works: Let’s say that you have a lab test that
costs $100 as part of the research study. Let’s also say that your share of the costs for this
test is $20 under Original Medicare, but the test would be $10 under our plan’s benefits.
In this case, Original Medicare would pay $80 for the test, and you would pay the $20
copay required under Original Medicare. You would then notify your plan that you
received a qualified clinical trial service and submit documentation such as a provider bill
to the plan. The plan would then directly pay you $10. Therefore, your net payment is
$10, which is the same amount you would pay under our plan’s benefits. Please note that
in order to receive payment from your plan, you must submit documentation to your plan
such as a provider bill.
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-ResearchStudies.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).

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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.]

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?

[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

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[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.
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,

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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)

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SECTION 1

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

[Describe all applicable types of cost sharing your plan uses. You may omit those that are not
applicable.]
To understand the payment information we give you in this chapter, you need to know about the
types of out-of-pocket costs you may pay for your covered services.
•

Deductible is the amount you must pay for medical services before our plan begins to
pay its share. [Insert if applicable: (Section 1.2 tells you more about your plan
deductible.)] [Insert if applicable: (Section 1.3 tells you more about your deductibles for
certain categories of services.)]

•

Copayment is a fixed amount you pay each time you receive certain medical services.
You pay a copayment at the time you get the medical service. (The Medical Benefits
Chart in Section 2 tells you more about your copayments.)

•

Coinsurance is a percentage you pay of the total cost of certain medical services. You
pay a coinsurance at the time you get the medical service. (The Medical Benefits Chart
in Section 2 tells you more about your coinsurance.)

Most people who qualify for Medicaid or for the Qualified Medicare Beneficiary (QMB)
program should never pay deductibles, copayments or coinsurance. Be sure to show your proof
of Medicaid or QMB eligibility to your provider, if applicable.
Section 1.2

What is your plan deductible?

[Local or regional PPO plans with no deductibles, delete this section and renumber remaining
subsections in Section 1.]
[Note: RPPOs and local PPO plans that choose to have a deductible are now only permitted to
have a single deductible that applies to both in-network and out-of-network services, see revised
section 422.101(d)(1).]

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Your deductible is [insert deductible amount]. Until you have paid the deductible amount, you
must pay the full cost for most of your covered services. (The deductible does not apply to the
services that are listed below.) Once you have paid your deductible, we will begin to pay our
share of the costs for covered medical services and you will pay your share [insert as applicable:
(your copayment) OR (your coinsurance amount) OR (your copayment or coinsurance amount)]
for the rest of the calendar year.
The deductible does not apply to some services, including certain in-network preventive services.
This means that we will pay our share of the costs for these services even if you haven’t paid
your deductible yet. The deductible does not apply to the following services:
•

[Insert all services not subject to the deductible, including all in-network Medicarecovered preventive services, emergency/urgency needed services, insulin furnished
through an item of durable medical equipment, and any other in-network Part A and
B services the plan elects to exempt from the deductible requirement. Plans must
specify whether it is in-network and/or out-of-network services that are exempt from
the deductible.] [Note: If a PPO has a deductible, all out-of-network Part A and B
services must be subject to the deductible with the sole exception that the PPO may
elect to waive out-of-network Medicare-covered zero cost-sharing preventive services
from the deductible requirement.]

Section 1.3

Our plan [insert if plan has an overall deductible described in
Section 1.2: also] has a [insert if plan has an overall deductible
described in Section 1.2: separate] deductible for certain types
of services from network providers

[Plans with service category deductibles: insert this section. If applicable, plans may revise the
text as needed to describe how the service category deductible(s) work with the overall plan
deductible.]
[Plans with a service category deductible that is not based on the calendar year – e.g., a per stay
deductible – should revise this section as needed.]
[Insert if plan has an overall deductible described in Section 1.2: In addition to the plan
deductible that applies to all of your covered medical services, we also have a deductible for
certain types of services.]
[Insert if plan does not have an overall deductible and Section 1.2 was therefore omitted: We
have a deductible for certain types of services.]
[Insert if plan has one service category deductible: The plan has a deductible amount for certain
services. Until you have paid the deductible amount, you must pay the full cost for [insert
service category]. Once you have paid your deductible, we will pay our share of the costs for
these services, and you will pay your share. [Insert if applicable: Both the plan deductible and
the deductible for [insert service category] apply to your covered [insert service category]. This
means that once you meet either the plan deductible or the deductible for [insert service

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category], we will begin to pay our share of the costs of your covered [insert service category].]]
The benefits chart in Section 2 shows the service category deductibles.
Section 1.4

What is the most you will pay for [insert if applicable: Medicare
Part A and Part B] covered medical services?

Under our plan, there are two different limits on what you have to pay out-of-pocket for covered
medical services:
•

Your in-network maximum out-of-pocket amount (MOOP) is [insert in-network
MOOP]. This is the most you pay during the calendar year for covered [insert as
applicable: Medicare Part A and Part B OR plan] services received from network
providers. The amounts you pay for [insert applicable terms: deductibles, copayments,
and coinsurance] for covered services from network providers count toward this innetwork maximum out-of-pocket amount. [Plans with no premium may modify the
following sentence as needed.] (The amounts you pay for plan premiums and services
from out-of-network providers do not count toward your in-network maximum out-ofpocket amount. [Insert if applicable, revising reference to asterisk as needed: In
addition, amounts you pay for some services do not count toward your in-network
maximum out-of-pocket amount. These services are marked with an asterisk in the
Medical Benefits Chart.]) If you have paid [insert in-network MOOP] for covered
[insert if applicable: Part A and Part B] services from network providers, you will not
have any out-of-pocket costs for the rest of the year when you see our network
providers. However, you must continue to pay [insert if plan has a premium: your plan
premium and] the Medicare Part B premium (unless your Part B premium is paid for
you by Medicaid or another third party).

•

Your combined maximum out-of-pocket amount is [insert combined MOOP]. This is
the most you pay during the calendar year for covered [insert as applicable: Medicare
Part A and Part B OR plan] services received from both in-network and out-of-network
providers. The amounts you pay for [insert applicable terms: deductibles, copayments,
and coinsurance] for covered services count toward this combined maximum out-ofpocket amount. [Plans with no premium may delete the following sentence.] (The
amounts you pay for your plan premiums do not count toward your combined maximum
out-of-pocket amount. [Insert if applicable, revising reference to asterisk as needed: In
addition, amounts you pay for some services do not count toward your combined
maximum out-of-pocket amount. These services are marked with an asterisk in the
Medical Benefits Chart.]) If you have paid [insert combined MOOP] for covered
services, you will have 100% coverage and will not have any out-of-pocket costs for the
rest of the year for covered [insert if applicable: Part A and Part B] services. However,
you must continue to pay [insert if plan has a premium: your plan premium and] the
Medicare Part B premium (unless your Part B premium is paid for you by Medicaid or
another third party).

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Section 1.5

Our plan also limits your out-of-pocket costs for certain types
of services

[Plans with service category OOP maximums: insert this section.
[Plans with a service category OOP maximum that is not based on the calendar year – e.g., a
per stay maximum – should revise this section as needed.]
[In addition to the in-network and combined maximum out-of-pocket amounts for covered
[insert if applicable: Part A and Part B] services (see Section 1.4 above), we also have a separate
maximum out-of-pocket amount that applies only to certain types of services.
[Insert if plan has one service category MOOP: The plan has a maximum out-of-pocket amount
of [insert service category MOOP] for [insert service category]. Once you have paid [insert
service category MOOP] out-of-pocket for [insert service category], the plan will cover these
services at no cost to you for the rest of the calendar year. [Insert if service category is included
in MOOP described in Section 1.4: Both the maximum out-of-pocket amount for Part A and Part
B medical services and the maximum out-of-pocket amount for [insert service category] apply
to your covered [insert service category]. This means that once you have paid either [insert
MOOP] for Part A and Part B medical services or [insert service category OOP max] for your
[insert service category], the plan will cover your [insert service category] at no cost to you for
the rest of the year.]] The benefits chart in Section 2 shows the service category out-of-pocket
maximums.]
Section 1.6

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 [plans with a
plan-level deductible insert: after you meet any deductibles,] you only have to pay your costsharing amount when you get services covered by our plan. Providers may not 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.
Here is how this protection works.
•

If your cost sharing is a copayment (a set amount of dollars, for example, $15.00), then
you pay only that amount for any covered services from a network provider. You will
generally have higher copays when you obtain care from out-of-network providers.

•

If your cost sharing is a coinsurance (a percentage of the total charges), then you never
pay more than that percentage. However, your cost depends on which type of provider
you see:
o If you receive the covered services from a network provider, you pay the
coinsurance percentage multiplied by the plan’s reimbursement rate (as
determined in the contract between the provider and the plan).

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o If you receive the covered services from an out-of-network provider who
participates with Medicare, you pay the coinsurance percentage multiplied by the
Medicare payment rate for participating providers.
o If you receive the covered services from an out-of-network provider who does not
participate with Medicare, you pay the coinsurance percentage multiplied by the
Medicare payment rate for non-participating providers.
•

If you believe a provider has balance billed you, call Member Services.

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
services, supplies, or drugs are needed for the prevention, diagnosis, or treatment of your
medical condition and meet accepted standards of medical practice.

•

[PPO plans that use prior authorizations insert: Some of the services listed in the
Medical Benefits Chart are covered as in-network services only if your doctor or other
network provider gets approval in advance (sometimes called prior authorization) from
[insert 2024 plan name].
o Covered services that need approval in advance to be covered as in-network
services are marked [insert as appropriate: by an asterisk OR by a footnote OR in
bold OR in italics] in the Medical Benefits Chart. [Insert if applicable: In
addition, the following services not listed in the Benefits Chart require approval in
advance: [insert list].]
o You never need approval in advance for out-of-network services from out-ofnetwork providers.
o While you don’t need approval in advance for out-of-network services, you or
your doctor can ask us to make a coverage decision in advance.]

•

[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.]

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Other important things to know about our coverage:
•

For benefits where your cost sharing is a coinsurance percentage, the amount you pay
depends on what type of provider you receive the services from:
o If you receive the covered services from a network provider, you pay the
coinsurance percentage multiplied by the plan’s reimbursement rate (as
determined in the contract between the provider and the plan).
o If you receive the covered services from an out-of-network provider who
participates with Medicare, you pay the coinsurance percentage multiplied by the
Medicare payment rate for participating providers.
o If you receive the covered services from an out-of-network provider who does not
participate with Medicare, you pay the coinsurance percentage multiplied by the
Medicare payment rate for non-participating providers.

•

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.)

•

For all preventive services that are covered at no cost under Original Medicare, we also
cover the service at no cost to you. [Insert as applicable: However, if you also are
treated or monitored for an existing medical condition during the visit when you receive
the preventive service, a copayment will apply for the care received for the existing
medical condition.]

•

If Medicare adds coverage for any new services during 2024, either Medicare or our
plan will cover those services.

[Instructions to plans offering MA Uniformity Flexibility benefits:
•

Plans must deliver to each clinically-targeted enrollee a written summary of those
benefits or information in alignment with its different strategy for communicating
information regarding MA Uniformity Flexibility Benefits so that such enrollees are
notified of the MA Uniformity Flexibility benefits for which they are eligible.

•

If applicable, plans must update the Medical Benefits Chart and include a supplemental
benefits chart including a column that details the exact targeted reduced cost-sharing
amount for each specific service, and/or the additional supplemental benefits being
offered.

[Instructions to plans offering Value-Based Insurance Design (VBID) Model benefits:
•

Plans may deliver to each clinically-targeted enrollee a written summary of those
benefits so that such enrollees are notified of VBID benefits for which they are eligible.
For VBID plans that choose to deliver a written notice, VBID plans must follow the VBID
guidance on communications for delivering a written notice when offering targeted
supplemental or VBID benefits. (See CY 2024 Value-Based Insurance Design
Communications and Marketing Guidelines).

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4

•

Medical Benefits Chart (what is covered and what you pay)

[Insert if offering VBID Model benefits:
Important Benefit Information for Enrollees with Certain Chronic Conditions
•

If you are diagnosed by a plan provider with any of the following chronic condition(s)
identified below and meet certain medical criteria, you may be eligible for targeted
supplemental benefits and/or reduced cost sharing:
o [List all applicable chronic conditions here.]

o [As applicable, plans offering benefits under VBID that require participation in a
health and wellness program or to see a high-value provider, include those
limitations and then direct the enrollee that they will be provided additional
information with how to take advantage of these additional supplemental benefits.
(See CY 2024 Value-Based Insurance Design Communications and Marketing
Guidelines).]
•

For further detail, please go to the Help with Certain Chronic Conditions row in the
Medical Benefits Chart below.]

[Insert if offering VBID benefits:
•

[Plans participating in VBID should use this section to describe the plan’s strategy for
advance care planning and any other wellness and health care planning (WHP) services
that are being offered:

Important Benefit Information for all Enrollees Participating in Wellness and Health Care
Planning (WHP) Services
•

Because [insert 2024 plan name] participates in [insert VBID program name], you
will be eligible for the following WHP services, including advance care planning
(ACP) services:
o [Include a summary of WHP services that are to reach all VBID plan enrollees
in CY 2024. The description must include language that WHP and ACP are
voluntary, and enrollees are free to decline the offers of WHP and ACP.]
o [Include information on how and when the enrollee would be able to access
WHP services.]

[Instructions to plans offering WHP benefits:
•

In addition to offering advance care planning as a covered benefit, plans
participating in the VBID Model may deliver to each VBID PBP enrollee a written
summary of WHP benefits so that such enrollees are notified of the benefits for which
they are eligible. For VBID plans that choose to deliver a written notice, VBID plans
must follow the VBID guidance on communications for delivering a written summary
when offering WHP benefits (See CY 2024 Value-Based Insurance Design
Communications and Marketing Guidelines).

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4

Medical Benefits Chart (what is covered and what you pay)

If applicable, plans should mention that enrollees may qualify for cost-sharing or copayment reductions].
[Insert if offering VBID flexibility benefits and targeted supplemental benefits to Low Income
Subsidy (LIS) enrollees, as defined in the Plan Communication User Guide (PCUG):
•

Important Benefit Information for Enrollees Who Qualify for “Extra Help”:
•

If you receive “Extra Help” to pay your Medicare prescription drug program costs, such
as premiums, deductibles, and coinsurance, you may be eligible for other targeted
supplemental benefits and/or targeted reduced cost sharing.

•

Please go to the Medical Benefits Chart in Chapter 4 for further detail.

[Instructions to plans offering VBID benefits for LIS Targeted Enrollees:
•

Plans may deliver to each LIS-targeted enrollee a written summary of those benefits so
that such enrollees are notified of VBID benefits for which they are eligible. For VBID
plans that choose to deliver a written notice, VBID plans must follow the VBID guidance
on communications for delivering such a written notice when offering targeted
supplemental or VBID benefits. (See CY 2024 Value-Based Insurance Design
Communications and Marketing Guidelines).

•

Plans who choose to reduce cost sharing for an item or service, must include a summary
of the additional supplemental benefits they would receive as well as the activities and/or
programs the member must complete in order to receive the benefit.

•

[Insert only if offering VBID mandatory supplemental benefit flexibility to Cover New and
Existing Technologies or Food and Drug Administration (FDA) approved Medical Devices:
Important Benefit Information for VBID Plan Enrollees Eligible to Receive New and Existing
Technologies or FDA Approved Medical Devices.
•

Because [insert 2024 plan name] participates in [insert VBID program name], you
may be eligible to receive new and existing technologies or FDA approved Medical
Devices:
o [Include a description of the new and existing technologies or FDA approved
medical devices specifying eligibility for the benefit and associated cost
sharing as an enrollee in the VBID plan in 2024. The description must include
language that enrollees are free to decline the benefit and how they would
notify the plan of declining this supplemental benefit.]

•
•

[Instructions to plans offering Coverage of New and Existing Technologies or FDA
approved Medical Devices as a mandatory supplemental benefit:

Plans may deliver to each VBID PBP’s enrollee a written summary of coverage of new
and existing technologies or FDA approved medical devices so that such enrollees are

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4

Medical Benefits Chart (what is covered and what you pay)

notified of the benefits for which they are eligible. For VBID plans that choose to deliver
a written notice, VBID plans must follow the VBID guidance on communications for
delivering a written summary when offering coverage of new and existing technologies or
FDA approved medical devices (See CY 2024 Value-Based Insurance Design
Communications and Marketing Guidelines).]
[Insert if offering Special Supplemental Benefits for the Chronically Ill: Important Benefit
Information for Enrollees with Chronic Conditions
•

If you are diagnosed with the following chronic condition(s) identified below and meet
certain criteria, you may be eligible for special supplemental benefits for the chronically
ill.
o [List all applicable chronic conditions here.]

o [Include information regarding the process and/or criteria for determining
eligibility for special supplemental benefits for the chronically ill]
•

Please go to the Special Supplemental Benefits for the Chronically Ill row in the below
Medical Benefits Chart for further detail.

•

Please contact us to find out exactly which benefits you may be eligible for.

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.

•

If using Medicare FFS amounts (e.g. Inpatient and SNF cost sharing) the plan must
insert the 2023 Medicare amounts and must insert: These are 2023 cost-sharing amounts
and may change for 2024. [Insert plan name] will provide updated rates as soon as they
are released. Member cost-sharing amounts may not be left blank.

•

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 benefits.

•

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 in the
network and out of network cost sharing.

•

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.).

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Medical Benefits Chart (what is covered and what you pay)

•

Plans should clearly indicate which benefits are subject to PA (plans may use asterisks
or similar method).

•

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.

•

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.]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4

Medical Benefits Chart (what is covered and what you pay)

Medical Benefits Chart

Services that are covered for you
Abdominal aortic aneurysm screening

What you must pay when
you get these services

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.]

There is no coinsurance,
copayment, or deductible for
members eligible for this
preventive screening.

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:

[List copays / coinsurance /
deductible.]

•

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,

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

What you must pay when
you get these services

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.]
•

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.
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.
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

[List copays / coinsurance /
deductible. Specify whether
cost sharing applies one-way
or for round trips.]

There is no coinsurance,
copayment, or deductible for
the annual wellness visit.

There is no coinsurance,
copayment, or deductible for
Medicare-covered bone mass
measurement.

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

What you must pay when
you get these services

interpretation of the results.
[Also list any additional benefits offered.]
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.]
•

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.]
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.]
Cardiovascular disease testing
Blood tests for the detection of cardiovascular disease (or
abnormalities associated with an elevated risk of
cardiovascular disease) once every five years (60 months).
[Also list any additional benefits offered.]
Cervical and vaginal cancer screening

There is no coinsurance,
copayment, or deductible for
covered screening
mammograms.

[List copays / coinsurance /
deductible]

There is no coinsurance,
copayment, or deductible for
the intensive behavioral
therapy cardiovascular
disease preventive benefit.

There is no coinsurance,
copayment, or deductible for
cardiovascular disease
testing that is covered once
every five years.
There is no coinsurance,

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
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.]
•

Colorectal cancer screening

•

•
•
•
•

What you must pay when
you get these services
copayment, or deductible for
Medicare-covered preventive
Pap and pelvic exams.

[List copays / coinsurance /
deductible]

There is no coinsurance,
copayment, or deductible for
Colonoscopy has no minimum or maximum age
a Medicare-covered
limitation and is covered once every 120 months (10
colorectal cancer screening
years) for patients not at high risk, or 48 months after a exam, excluding barium
previous flexible sigmoidoscopy for patients who are
enemas, for which
not at high risk for colorectal cancer, and once every
coinsurance applies. If your
24 months for high risk patients after a previous
doctor finds and removes a
screening colonoscopy or barium enema.
polyp or other tissue during
Flexible sigmoidoscopy for patients 45 years and
the colonoscopy or flexible
older. Once every 120 months for patients not at high
sigmoidoscopy, the
risk after the patient received a screening colonoscopy. screening exam becomes a
Once every 48 months for high risk patients from the
diagnostic exam and you pay
last flexible sigmoidoscopy or barium enema.
15% of the MedicareScreening fecal-occult blood tests for patients 45 years approved amount for your
and older. Once every 12 months.
doctors’ services. In a
Multitarget stool DNA for patients 45 to 85 years of
hospital outpatient setting,
age and not meeting high risk criteria. Once every 3
you also pay the hospital a
years.
15% coinsurance. The Part B
Blood-based Biomarker Tests for patients 45 to 85
deductible doesn’t apply.
years of age and not meeting high risk criteria. Once
[If applicable, list
every 3 years.
copayment and/or
Barium Enema as an alternative to colonoscopy for
patients at high risk and 24 months since the last

The following screening tests are covered:
•

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 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.

What you must pay when
you get these services
coinsurance charged for
barium enema.]

As of January 1, 2023, colorectal cancer screening tests
include a follow-on screening colonoscopy after a Medicare
covered non-invasive stool-based colorectal cancer screening
test returns a positive result.
[Also list any additional benefits offered.]
[Include row if applicable. If plan offers dental benefits as
optional supplemental benefits, they should not be included in
the chart. Plans may describe them in Section 2.2 instead.]
Dental services
In general, preventive dental services (such as cleaning,
routine dental exams, and dental x-rays) are not covered by
Original Medicare. We cover:
[List any additional benefits offered, such as routine dental
care.]
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.]
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.

[List copays / coinsurance /
deductible]

There is no coinsurance,
copayment, or deductible for
an annual depression
screening visit.

There is no coinsurance,
copayment, or deductible for
the Medicare covered
diabetes screening tests.

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

What you must pay when
you get these services

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.]
Diabetes self-management training, diabetic services
[List copays / coinsurance /
and supplies
deductible]
[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.
[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

[List copays / coinsurance /
deductible]
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]

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
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].
Our list may not limit the brands of speech generating devices
that you can purchase. We must cover all brands of speech
generating devices without limitation. Also, if you are
required to obtain diabetic supplies, our list may not
completely limit certain types of diabetic supplies. We are
required to keep on our list, diabetic monitors with big font
and diabetic monitors which the physically disabled can use.
If you don’t find what you need call our plan.

Durable medical equipment (DME) and related supplies
(continued)
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.)
If you (or your provider) don’t agree with the plan’s coverage
decision, you or your provider may file an appeal. You can

What you must pay when
you get these services
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

What you must pay when
you get these services

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.
Cost sharing for necessary emergency services furnished outof-network is the same as for such services furnished innetwork.
•

[Also

identify whether this coverage is only covered within the
U.S. as required or whether emergency care is also available
as a supplemental benefit that provides worldwide
emergency/urgent coverage.]
Health and wellness education programs
[These are programs focused on health conditions such as
high blood pressure, cholesterol, asthma, and special diets.
Programs designed to enrich the health and lifestyles of
members include weight management, fitness, and stress
management. Describe the nature of the programs here.
If this benefit is not applicable, plans should delete this row.]

[List copays / coinsurance. If
applicable, explain that cost
sharing is waived if member
admitted to hospital.]
[Insert if applicable: If you
receive emergency care at an
out-of-network hospital and
need inpatient care after your
emergency condition is
stabilized, you must move to
a network hospital in order
to pay the in-network costsharing amount for the part
of your stay after you are
stabilized. If you stay at the
out-of-network hospital,
your stay will be covered but
you will pay the out-ofnetwork cost-sharing amount
for the part of your stay after
you are stabilized.]

[List copays / coinsurance /
deductible]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4

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Services that are covered for you
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.
[List any additional benefits offered, such as routine hearing
exams, hearing aids, and evaluations for fitting hearing aids.]

What you must pay when
you get these services
[List copays / coinsurance /
deductible]

Help with Certain Chronic Conditions
[If the enrollee has been diagnosed by a plan provider with
[List copays / coinsurance /
the certain chronic condition(s) identified and meets certain
deductible]
criteria, they may be eligible for other targeted supplemental
benefits and/or targeted reduced cost sharing. The certain
chronic conditions must be listed here. The benefits listed here
must be approved in the bid. Describe the nature of the
benefits here.
If this benefit is not applicable, plans should delete this entire
row.]
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:

There is no coinsurance,
copayment, or deductible for
members eligible for
Medicare-covered preventive
HIV screening.

•
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:

[List copays / coinsurance /
deductible]

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Chapter 4

Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
•

•
•
•

What you must pay when
you get these services

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 8
hours per day and 35 hours per week)
Physical therapy, occupational therapy, and speech
therapy
Medical and social services
Medical equipment and supplies

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:

[List copays / coinsurance /
deductible]

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.]
•

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 Medicarecertified hospice programs in the plan’s service area,
including those the MA organization owns, controls, or has a
financial interest in. Your hospice doctor can be a network
provider or an out-of-network provider.

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

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Chapter 4

Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
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 covered by Medicare Part A or B and are
not related to your terminal prognosis: If you need nonemergency, non-urgently needed services that are covered
under Medicare Part A or B and that are not related to your
terminal prognosis, your cost for these services depends on
whether you use a provider in our plan’s network and follow
plan rules (such as if there is a requirement to obtain prior
authorization).
•
If you obtain the covered services from a network
provider and follow plan rules for obtaining service,
you only pay the plan cost-sharing amount for innetwork services.
•
If you obtain the covered services from an out-ofnetwork provider, you pay the plan cost sharing for
out-of-network services.
Hospice care (continued)
For services that are covered by [insert 2024 plan name] but
are not covered by Medicare Part A or B: [insert 2024 plan
name] will continue to cover plan-covered services that are
not covered under Part A or B whether or not they are related
to your terminal prognosis. You pay your plan cost-sharing
amount for these services.

What you must pay when
you get these services
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

What you must pay when
you get 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.]
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.]
•
•

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

There is no coinsurance,
copayment, or deductible for
the pneumonia, influenza,
Hepatitis B, and COVID-19
vaccines.

[List all cost sharing
(deductible, copayments/
coinsurance) and the period
for which they will be
charged. If cost sharing is
based on the Original
Medicare or a plan-defined
benefit period, include
definition/explanation of
approved benefit period
here. Plans that use peradmission deductible
include: A per admission
deductible is applied once
during the defined benefit
period. [In addition, if
applicable, explain all other
cost sharing that is charged
during a benefit period.]]
[If cost sharing is not based
on the Original Medicare or

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 substance abuse services
Under certain conditions, the following types of
transplants are covered: corneal, kidney, kidneypancreatic, 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.
[Plans with a provider network insert: Transplant
providers may be local or outside of the service area. If
our in-network transplant services are outside the
community pattern of care, you may choose to go
locally as long as the local transplant providers are
willing to accept the Original Medicare rate. 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.]

What you must pay when
you get these services
plan-defined benefit period,
explain here when the cost
sharing will be applied. If it
is charged on a per
admission basis, include: A
deductible and/or other cost
sharing is charged for each
inpatient stay.]

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/2021•

[If inpatient cost sharing
varies based on hospital tier,
enter that cost sharing in the
data entry fields.]
If you get [insert if
applicable: authorized]
inpatient care at an out-ofnetwork hospital after your
emergency condition is
stabilized, your cost is the
[insert if applicable: highest]
cost sharing you would pay
at a network hospital.

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

What you must pay when
you get these services

10/11435-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 services in a psychiatric hospital
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.]

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 skilled
nursing facility (SNF) coverage may modify or delete this row
as appropriate.]

[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

What you must pay when
you get these services

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

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.

There is no coinsurance,
copayment, or deductible for
members eligible for
Medicare-covered medical
nutrition therapy 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

What you must pay when
you get these services

[Also list any additional benefits offered.]
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
[MA plans that will be or expect to use Part B step therapy
should include the Part B drug categories below that may or
will be subject to Part B step therapy as well as a link to a list
of drugs that will be subject to Part B step therapy. The link
may be updated throughout the year and any changes need to
be added at least 30 days prior to implementation per 42 CFR
42.111(d)]
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 selfadminister the drug
Antigens

There is no coinsurance,
copayment, or deductible for
the MDPP benefit.

[List copays / coinsurance /
deductible] [If applicable
(plan has a coinsurance for
Part B drugs): Indicate that
certain rebatable drugs may
be subject to a lower
coinsurance]
[Indicate whether drugs may
be subject to step therapy]
[Indicate insulin cost
sharing is subject to a
coinsurance cap of $35 for
one-month’s supply of
insulin, and specify service
category or plan level
deductibles do not apply.]

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

What you must pay when
you get these services

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
[insert if applicable: The following link will take you to a list
of Part B Drugs that may be subject to Step Therapy: insert
link]
We also cover some vaccines under our Part B prescription
drug benefit.
•
•

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

There is no coinsurance,
copayment, or deductible for
preventive obesity screening
and therapy.

[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

What you must pay when
you get these services

•
Periodic assessments
[Plans can include other covered items and services as
appropriate (not to include meals and transportation).]
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.]

Outpatient hospital observation
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.

[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

What you must pay when
you get these services

Note: Unless the provider has written an order to admit you as
an inpatient to the hospital, you are an outpatient and pay the
cost-sharing 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/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.
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 and pay the
cost-sharing 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
•

[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

What you must pay when
you get these services

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.
[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.]
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).

[List copays / coinsurance /
deductible]

Outpatient substance abuse services
[Describe the plan’s benefits for outpatient substance abuse
services.]

[List copays / coinsurance /
deductible]

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
and pay the cost-sharing amounts for outpatient surgery. Even

[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

What you must pay when
you get these services

if you stay in the hospital overnight, you might still be
considered an outpatient.
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.
Physician/Practitioner services, including doctor’s office
visits
Covered services include:
•
Medically-necessary medical care or surgery services
furnished in a physician’s office, certified ambulatory
surgical center, hospital outpatient department, or any
other location
•
Consultation, diagnosis, and treatment by a specialist
•
Basic hearing and balance exams performed by your
[insert as applicable: PCP OR specialist], if your
doctor orders it to see if you need medical treatment
•
[Insert if providing any MA additional telehealth
benefits consistent with 42 CFR § 422.135 in the
plan’s CMS-approved Plan Benefit Package
submission: Certain telehealth services, including:
[insert general description of covered MA additional
telehealth benefits, i.e., the specific Part B service(s)
the plan has identified as clinically appropriate to
furnish through electronic exchange when the provider
is not in the same location as the enrollee. Plans may
wish to refer enrollees to their 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-ofnetwork coverage of additional telehealth
services as mandatory supplemental benefits.]
o [List the available means of electronic
exchange used for each Part B service offered

[List copays / coinsurance /
deductible]

[List copays / coinsurance /
deductible]
[If applicable, indicate
whether there are different
cost-sharing amounts for
Part B service(s) furnished
through an in-person visit
and those furnished through
electronic exchange as MA
additional telehealth
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

•

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]

Physician/Practitioner services, including doctor’s office
visits (continued)
•

•
•
•

•
•

Telehealth services for monthly end-stage renal
disease-related visits for home dialysis members in a
hospital-based 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

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
•

What you must pay when
you get these services

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

Physician/Practitioner services, including doctor’s office
visits (continued)
•
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.]
•

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.]

[List copays / coinsurance /
deductible]

There is no coinsurance,
copayment, or deductible for
an annual PSA test.

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
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.]
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
four 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

What you must pay when
you get these services
[List copays / coinsurance /
deductible]

[List copays / coinsurance /
deductible]

There is no coinsurance,
copayment, or deductible for
the Medicare-covered
screening and counseling to
reduce alcohol misuse
preventive benefit.

There is no coinsurance,
copayment, or deductible for
the Medicare covered
counseling and shared

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
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.
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 two individual 20 to 30 minute, face-toface 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.]

What you must pay when
you get these services
decision-making visit or for
the LDCT.

There is no coinsurance,
copayment, or deductible for
the Medicare-covered
screening for STIs and
counseling for STIs
preventive benefit.

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

[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

What you must pay when
you get these services

Outpatient dialysis treatments (including dialysis
treatments when temporarily out of the service area, as
explained in Chapter 3, or when your provider for this
service is temporarily unavailable or inaccessible)
•
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.
•

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.

[List copays / coinsurance /
deductible. If cost sharing is
based on benefit period,
include
definition/explanation of
BID approved benefit period
here.]

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

What you must pay when
you get these services

[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
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
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.]
Special Supplemental Benefits for the Chronically Ill
[Enrollees with chronic condition(s) that meet certain criteria
may be eligible for supplemental benefits for the chronically
ill. The chronic conditions and benefits must be listed here.

There is no coinsurance,
copayment, or deductible for
the Medicare-covered
smoking and tobacco use
cessation preventive
benefits.

[List copays / coinsurance /
deductible]

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Chapter 4

Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

What you must pay when
you get these services

The benefits listed here must be approved in the bid. Describe
the nature of the benefits and eligibility criteria here.
If this benefit is not applicable, plans should delete this row.]
Supervised Exercise Therapy (SET)
SET is covered for members who have symptomatic
peripheral artery disease (PAD) [Optional: 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:

[List copays / coinsurance /
deductible]

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.]
•

Urgently needed services
Urgently needed services are provided to treat a nonemergency, unforeseen medical illness, injury, or condition
that requires immediate medical care but, given your
circumstances, it is not possible, or it is unreasonable, to
obtain services from network providers. If it is unreasonable
given your circumstances to immediately obtain the medical
care from a network provider, then your plan will cover the
urgently needed services from a provider out-of-network.
Services must be immediately needed and medically

[List copays / coinsurance.
Plans should include
different copayments for
contracted urgent care
centers, 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

What you must pay when
you get these services

necessary. Examples of urgently needed services that the plan
must cover out of network occur if: You are temporarily
outside the service area of the plan and require medically
needed immediate services for an unforeseen condition but it
is not a medical emergency; or it is unreasonable given your
circumstances to immediately obtain the medical care from a
network provider. Cost sharing for necessary urgently needed
services furnished out-of-network is the same as for such
services furnished in-network.
[Include in-network benefits. Also identify whether this
coverage is within the U.S. or as a supplemental worldwide
emergency/urgent coverage.]
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.)
[Also list any additional benefits offered, such as
supplemental vision exams or glasses. If the additional vision
benefits are optional supplemental benefits, they should not be
•

[List copays / coinsurance /
deductible]

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Chapter 4

Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

What you must pay when
you get these services

included in the benefits chart; they should be described within
Section 2.2.]
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.
Section 2.2

There is no coinsurance,
copayment, or deductible for
the Welcome to Medicare
preventive visit.

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 2.3

Getting care using our plan’s optional visitor/traveler benefit

[If your plan offers a visitor/traveler program to members who are out of your service area,
insert this section, adapting and expanding the following paragraphs as needed to describe the
traveler benefits and rules related to receiving the out-of-area coverage. If you allow extended

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4

Medical Benefits Chart (what is covered and what you pay)

periods of enrollment out-of-area per the exception in 42 CFR 422.74(b)(4)(iii) (for more than
six months up to 12 months) also explain that here based on the language suggested below.
If you do not permanently move, but you are continuously away from our plan’s service area for
more than six months, we usually must disenroll you from our plan. However, we offer a
visitor/traveler program [specify areas where the visitor/traveler program is being offered],
which will allow you to remain enrolled when you are outside of our service area for less than 12
months. Under our visitor/traveler program you may receive all plan covered services at innetwork cost sharing. Please contact the plan for assistance in locating a provider when using the
visitor/traveler benefit.
If you are in the visitor/traveler area, you can stay enrolled in our plan for up to 12 months. If
you have not returned to the plan’s service area within 12 months, you will be disenrolled from
the plan.]

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 conditions 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.)
[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
appropriate. Plans may reorder the below excluded services alphabetically if they wish. Plans
may also add exclusions as needed.]

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Chapter 4

Medical Benefits Chart (what is covered and what you pay)

Services not covered by
Medicare
Acupuncture

Not covered under
any condition

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.

•

Cosmetic surgery or
procedures

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.)

√
√
√

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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

√

Covered only under specific
conditions

√

Orthopedic shoes or supportive
devices for the feet
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

√

Routine hearing exams,
hearing aids, or exams to fit
hearing aids.

√

Dental care required to treat illness
or injury may be covered as
inpatient or outpatient care.
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.

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
Services considered not
√
reasonable and necessary,
according to Original Medicare
standards

Covered only under specific
conditions

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

Situations in which you should ask us to pay our
share of the cost of your covered services

Sometimes when you get medical care, you may need to pay the full cost. Other times, you may
find that you have paid more than you expected under the coverage rules of the plan. Or you may
receive a bill from a provider. In these cases, you can ask our plan to pay you back (paying you
back is often called reimbursing you). It is your right to be paid back by our plan whenever
you’ve paid more than your share of the cost for medical services that are covered by our plan.
There may be deadlines that you must meet to get paid back. Please see Section 2 of this chapter.
There may also be times when you get a bill from a provider for the full cost of medical care
you have received or possibly for more than your share of cost sharing as discussed in the
document. First try to resolve the bill with the provider. If that does not work, send the bill to
us instead of paying it. We will look at the bill and decide whether the services should be
covered. If we decide they should be covered, we will pay the provider directly. If we decide
not to pay it, we will notify the provider. You should never pay more than plan-allowed costsharing. If this provider is contracted, you still have the right to treatment.
Here are examples of situations in which you may need to ask our plan to pay you back or to pay
a bill you have received:
1. When you’ve received medical care from a provider who is not in our plan’s
network
When you receive care from a provider who is not part of our network, you are only
responsible for paying your share of the cost. (Your share of the cost may be higher for an
out-of-network provider than for a network provider.) Ask the provider to bill the plan for
our share of the cost.
•

You are only responsible for paying your share of the cost for emergency or urgently
needed services. Emergency providers are legally required to provide emergency care.
If you accidentally pay the entire amount yourself at the time you receive the care, ask
us to pay you back for our share of the cost. Send us the bill, along with documentation
of any payments you have made.

•

You may get a bill from the provider asking for payment that you think you do not owe.
Send us this bill, along with documentation of any payments you have already made.
o If the provider is owed anything, we will pay the provider directly.

o If you have already paid more than your share of the cost of the service, we will
determine how much you owed and pay you back for our share of the cost.
•

Please note: While you can get your care from an out-of-network provider, the provider
must be eligible to participate in Medicare. Except for emergency care, we cannot pay a
provider who is not eligible to participate in Medicare. If the provider is not eligible to
participate in Medicare, you will be responsible for the full cost of the services you
receive.

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

2. When a network provider sends you a bill you think you should not pay
Network providers should always bill the plan directly and ask you only for your share of the
cost. But sometimes they make mistakes and ask you to pay more than your share.
•

You only have to pay your cost-sharing amount when you get covered services. We do
not allow providers to add additional separate charges, called balance billing. This
protection (that you never pay more than your cost-sharing amount) 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.

•

Whenever you get a bill from a network provider that you think is more than you
should pay, send us the bill. We will contact the provider directly and resolve the
billing problem.

•

If you have already paid a bill to a network provider, but you feel that you paid too
much, send us the bill along with documentation of any payment you have made and
ask us to pay you back the difference between the amount you paid and the amount you
owed under the plan.

3. If you are retroactively enrolled in our plan
Sometimes a person’s enrollment in the plan is retroactive. (This 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.
[Plans should insert additional circumstances under which they will accept a paper claim
from a member.]
All of the examples above are types of coverage decisions. This means that if we deny your
request for payment, 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 you back or to pay a bill you
have received

[Plans may edit this section to include a second address if they use different addresses for
processing medical and drug claims.]
You may request us to pay you back by [If the plan allows members to submit oral payment
requests, insert the following language: either calling us or] sending us a request in writing. If
you send a request in writing, send your bill and documentation of any payment you have made.

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

It’s a good idea to make a copy of your bill and receipts for your records. Insert if applicable:
You must submit your claim to us within [insert timeframe] of the date you received the
service or item.] [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]

SECTION 3

We will consider your request for payment 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, we will pay
for our share of the cost. If you have already paid for the service, we will mail your
reimbursement of our share of the cost to you. If you have not paid for the service yet,
we will mail the payment directly to 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. We will send you a letter explaining the reasons
why we are not sending the payment and your right 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 for payment or 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. The appeals process is a
formal process with detailed procedures and important deadlines. For details on how to make this
appeal, go to Chapter 7 of this document.

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

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 to 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, 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

We must ensure that you get timely access to your covered
services

[If your plan does not require any referrals or prior authorization within the preferred network,
delete the next three sentences and instead state: You have the right to choose a provider for
your care.] You have the right to choose a provider in the plan’s network. You also have the right
to go to a women’s health specialist (such as a gynecologist) without a referral and still pay the
in-network cost-sharing amount.
You have the right to get appointments and covered services from your providers within a
reasonable amount of time. This includes the right to get timely services from specialists when
you need that care.
[Regional PPOs: Explain how members will obtain care at in-plan rates in any areas of its
region where the plan has a limited contracted provider network.]
If you think that you are not getting your medical care within a reasonable amount of time,
Chapter 7, Section 9 of this document 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

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 by 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 healthcare 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, 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.

•

Information about our network providers. You have the right to get information
about the qualifications of the providers in 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 of 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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Section 1.7

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. For details, go to Chapter 2, Section 3.

•

You can contact Medicare.
o 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-Medicare-Rights-and-Protections.pdf.)
o Or you can call, 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a
week (TTY 1-877-486-2048).

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.

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•

Your rights and responsibilities

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.
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 [Insert if applicable: You must pay your plan premiums.]

o You must continue to pay your Medicare Part B premiums to remain a member of
the plan.
o For some of your medical services covered by the plan, you must pay your share
of the cost when you get the service.
•

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).

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 Part B prescription drugs are covered or
not, the way they are covered, and problems related to payment for medical care or Part B
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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100

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. For example, if your plan network doctor refers you to a
medical specialist not inside the network, this referral is considered a favorable coverage
decision unless either your network doctor can show that you received a standard denial notice
for this medical specialist, or the Evidence of Coverage makes it clear that the referred service is
never covered under any condition. 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.

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101

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. In limited circumstances a
request for a Level 1 appeal 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.

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•

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102

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 another 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/CMSForms/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 State Health Insurance
Assistance Program.

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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

103

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
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 6 and 7 of this Chapter. Special rules apply to these types of
care.

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Section 5.2

104

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,
or 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.

•

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.

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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
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.

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Section 5.3

106

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.
•

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.]

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.

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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 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, 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.
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. (For more information about the process for making complaints, including
fast complaints, see Section 9 of this chapter.)
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

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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.

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.

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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. It is also called 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.
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.

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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 coverage 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.

SECTION 6

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.

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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 also 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 or 1800-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 about:
•

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 the quality of your hospital care.

•

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.

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.

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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 1877-486-2048. You can also see the notice online at www.cms.gov/Medicare/MedicareGeneral-Information/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 who are paid by the Federal government to check on and help improve the quality
of care 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.
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.

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o 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 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. (TTY users
should call 1-877-486-2048.) Or you can see a sample notice online at
www.cms.gov/Medicare/Medicare-GeneralInformation/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.

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.

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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.

•

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.

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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
to change your hospital discharge date?
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
date. 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.

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

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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 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: 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
coverage limitations, these could limit how much we would reimburse or how long we
would continue to cover your services.

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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 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.

•

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
who are paid by the Federal government to check on and 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.

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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.

•

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.

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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.

Section 7.4

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.

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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 notice you get after your Level 2 appeal decision.

•

The Level 3 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 it is 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.

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•

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.

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.
•

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.
o 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.

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Step 3: If the independent review organization says no to your appeal, you
choose whether you want to take your appeal further.
•

•

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 an 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.

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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
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 you
get 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.

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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?

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.

•

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?

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Complaint

Example

Timeliness
(These types of
complaints are all
related to the
timeliness of our
actions related to
coverage decisions
and appeals)

If You already asked us 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 us 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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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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130

Introduction to ending your membership in our plan

Ending your membership in [insert 2024 plan name] may be voluntary (your own choice) 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 you do not choose to leave, but we are required
to end your membership. Section 5 tells you about situations when we must end your
membership.

If you are leaving our plan, our plan must continue to 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). During this time, review your health and drug coverage
and decide about coverage for the upcoming year.
•

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 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 when your new plan’s coverage begins on January 1.

Section 2.2

You can end your membership during the Medicare Advantage
Open Enrollment Period

You have the opportunity to make one change to your health coverage during the Medicare
Advantage Open Enrollment Period.

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•

The annual Medicare Advantage Open Enrollment Period is from January 1 to March
31.

•

During the annual Medicare Advantage Open Enrollment Period you can:
o Switch to another Medicare Advantage Plan with or without prescription drug
coverage.
o Disenroll from our plan and obtain coverage through Original Medicare. If you
choose to switch to Original Medicare during this period, you can also join a
separate Medicare prescription drug plan at that time.

•

Your membership will end on the first day of the month after you enroll in a different
Medicare Advantage plan or we get your request to switch to Original Medicare. If you
also choose to enroll in a Medicare prescription drug plan, your membership in the drug
plan will begin the first day of the month after the drug plan gets your enrollment
request.

Section 2.3

In certain situations, you can end your membership during a
Special Enrollment Period

In certain 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.

•

[Revise bullet to use state-specific name, if applicable.] If you have Medicaid.

•

If we violate our contract with you.

•

If you get 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).]

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 1800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877486-2048. 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

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•

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Original Medicare without a separate Medicare prescription drug plan.

When will your membership end? Your membership will usually end on the first day
of the month after your request to change your plan is received.

Section 2.4

Where can you get more information about when you can end
your membership?

If you have any questions about ending your membership you can:
•

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

How do you end your membership in our plan?

The table below explains how you should end your membership in our plan.

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If you would like to switch
from our plan to:
•

•

133

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 with
a separate Medicare
prescription drug plan.

•

Enroll in the new Medicare prescription drug plan.

•

You will automatically be disenrolled from [insert
2024 plan name] when your new plan’s coverage
begins.

Original Medicare
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 can also contact Medicare, at 1-800MEDICARE (1-800-633-4227), 24 hours a day, 7
days a week, and ask to be disenrolled. TTY users
should call 1-877-486-2048.

•

You will be disenrolled from [insert 2024 plan
name] when your coverage in Original Medicare
begins.

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 4

Until your membership ends, you must keep getting
your medical services through our plan

Until your membership ends, and your new Medicare coverage begins, you must continue to get
your medical care through our plan.
•

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).

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SECTION 5

[Insert 2024 plan name] must end your membership in
the plan in certain situations

Section 5.1

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 move out of our service area.

•

If you are away from our service area for more than six months. [Plans with
visitor/traveler benefits should revise this bullet to indicate when members must be
disenrolled from the plan.]
o 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.
o [Plans with grandfathered members who were outside of area prior to January 1999,
insert: If you have been a member of our plan continuously prior to 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. However, if you move and
your move is to another location that is outside of our service area, you will be
disenrolled from our plan.]

•

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.
(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 and sub-bullet if not applicable. Plans with different disenrollment policies
for dual eligible members who do not pay plan premiums must edit these bullets as
necessary to reflect their policies. Plans with different disenrollment policies must be
very clear as to which population is excluded from the policy to disenroll for failure to

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pay plan premiums.] If you do not pay the plan premiums for [insert length of grace
period, which cannot be less than two calendar months].
o We must notify you in writing that you have [insert length of grace period, which
cannot be less than two calendar months] to pay the plan premium before we end
your membership.
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 5.2

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, you
should call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week.
(TTY 1-877-486-2048).
Section 5.3

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 about our
decision to end your membership.

CHAPTER 9:

Legal notices

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Chapter 9 Legal notices

SECTION 1

137

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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[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 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

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Plans, in order to receive the special designation and marketing and enrollment accommodations
provided to C-SNPs.
Coinsurance – An amount you may be required to pay, expressed as a percentage (for example
20%) as your share of the cost for services [insert if applicable: after you pay any deductibles].
Combined Maximum Out-of-Pocket Amount – This is the most you will pay in a year for all
[insert if applicable: Part A and Part B] services from both network (preferred) providers and
out-of-network (non-preferred) providers. [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.] See Chapter 4, Section 1. [insert subsection number] for information about your
combined maximum out-of-pocket amount.
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. [Insert if plan has a premium: (This is in addition to the plan’s monthly premium.)]
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 in this EOC 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.

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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.
Deductible – The amount you must pay for health care before our plan pays.
Disenroll or Disenrollment – The process of ending your membership in our plan.
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.
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 or providers including a complaint
concerning the quality of your care. This type of complaint does not involve coverage or
payment disputes.

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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.
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 3 months before the month
you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.
In-Network Maximum Out-of-Pocket Amount – The most you will pay for covered [insert if
applicable: Part A and Part B] services received from network (preferred) providers. After you
have reached this limit, you will not have to pay anything when you get covered services from
network providers for the rest of the contract year. However, until you reach your combined outof-pocket amount, you must continue to pay your share of the costs when you seek care from an
out-of-network (non-preferred) provider. [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.]
Low Income Subsidy (LIS) – See “Extra Help.”
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.
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 Open Enrollment Period – The time period from January 1 until March
31 when members in a Medicare Advantage plan can cancel their plan enrollment and switch to
another Medicare Advantage plan, or obtain coverage through Original Medicare. If you choose
to switch to Original Medicare during this period, you can also join a separate Medicare

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prescription drug plan at that time. The Medicare Advantage Open Enrollment Period is also
available for a 3-month period after an individual is first eligible for Medicare.
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
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 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.
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

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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.
[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 such as 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-Network Provider or Out-of-Network Facility – A provider or facility that does not
have a contract with our plan to coordinate or provide covered services to members of our plan.
Out-of-network providers are providers that are not employed, owned, or operated by our plan.
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.

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Premium – The periodic payment to Medicare, an insurance company, or a health care plan for
health or prescription drug coverage.
[Plans that do not use PCPs omit] 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.
Prior Authorization – Approval in advance to get covered services. [Edit or delete as necessary
to make the definition applicable to your plan.] In the network portion of a PPO, some innetwork medical services are covered only if your doctor or other network provider gets prior
authorization from our plan. In a PPO, you do not need prior authorization to obtain out-ofnetwork services. However, you may want to check with the plan before obtaining services from
out-of-network providers to confirm that the service is covered by your plan and what your costsharing responsibility is. Covered services that need prior authorization are marked in the
Benefits Chart in Chapter 4.
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.
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.

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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.
Urgently Needed Services – Covered services that are not emergency services, provided when
the network providers are temporarily unavailable or inaccessible or when the enrollee is out of
the service area. For example, you need immediate care during the weekend. Services must be
immediately needed and medically necessary.

[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

TTY

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

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 Preferred Provider Organization Medicare Advantage (PPO MA) Evidence of Coverage (EOC) Templates
Subject	2023 Preferred Provider Organization (PPO MA) Evidence of Coverage (EOC) Templates
Author	Centers for Medicare & Medicaid Services
File Modified	2023-04-09
File Created	2023-04-09