Evidence of Coverage:

Transcription

1 January 1 December 31, 2017 Evidence f Cverage: Yur Medicare Health Benefits and Services and Prescriptin Drug Cverage as a Member f MedStar Medicare Chice Care Advantage (HMO SNP) This bklet gives yu the details abut yur Medicare health care and prescriptin drug cverage frm January 1 December 31, It explains hw t get cverage fr the health care services and prescriptin drugs yu need. This is an imprtant legal dcument. Please keep it in a safe place. This plan, MedStar Medicare Chice Care Advantage is ffered by MedStar Family Chice, Inc. (When this Evidence f Cverage says we, us, r ur, it means MedStar Family Chice, Inc. When it says plan r ur plan, it means MedStar Medicare Chice Care Advantage.) This plan is available t anyne with Medicare wh has been diagnsed with Chrnic Heart Failure and/r Diabetes. MedStar Medicare Chice Care Advantage (HMO SNP) has a cntract with Medicare. Enrllment in MedStar Medicare Chice Care Advantage depends n cntract renewal. Please cntact ur Member Services number at fr additinal infrmatin. (TTY users shuld call ) Hurs are Octber 1 thrugh February 14, seven days a week, frm 8 a.m. t 8 p.m., and February 15 thrugh September 30, Mnday thrugh Friday, frm 8 a.m. t 8 p.m., and n Saturday, frm 8 a.m. t 3 p.m. Member Services has free language interpreter services available fr nn-english speakers (phne numbers are printed n the back cver f this bklet). This dcument may be available in an alternative frmat such as Braille, large print, r audi. Benefits, premium, deductible, and/r cpayments/cinsurance may change n January 1, The frmulary, pharmacy netwrk, and/r prvider netwrk may change at any time. Yu will receive ntice when necessary. H9915_17_2015 Accepted Frm CMS ANOC/EOC (Apprved 03/2014) OMB Apprval

2 Nndiscriminatin Ntice MedStar Medicare Chice cmplies with applicable federal civil rights laws and des nt discriminate n the basis f race, clr, natinal rigin, age, disability, r sex. MedStar Medicare Chice des nt exclude peple r treat them differently because f race, clr, natinal rigin, age, disability, r sex. MedStar Medicare Chice: Prvides free aids and services t peple with disabilities t cmmunicate effectively with us, such as: Qualified sign language interpreters Written infrmatin in ther frmats (large print, audi, accessible electrnic frmats, ther frmats) Prvides free language services t peple whse primary language is nt English, such as: Qualified interpreters Infrmatin written in ther languages If yu need these services, cntact Catherine Kajubi, JD. If yu believe that MedStar Medicare Chice has failed t prvide these services r discriminated in anther way n the basis f race, clr, natinal rigin, age, disability, r sex, yu can file a grievance with: Catherine Kajubi, JD, Directr f Medicare Cmpliance, 5233 King Ave., Suite 400, Baltimre, MD , Telephne Number: , Fax Number: , Catherine.M.Kajubi@medstar.net. Yu can file a grievance in persn r by mail, fax, r . If yu need help filing a grievance, Catherine Kajubi, JD, Directr f Medicare Cmpliance is available t help yu. Yu can als file a civil rights cmplaint with the U.S. Department f Health and Human Services, Office fr Civil Rights electrnically thrugh the Office fr Civil Rights Cmplaint Prtal, available at r by mail r phne at: U.S. Department f Health and Human Services, 200 Independence Avenue SW., Rm 509F, HHH Building, Washingtn, DC 20201, , (TDD). Cmplaint frms are available at

3 Nndiscriminatin Statement English: MedStar Medicare Chice cmplies with applicable federal civil rights laws and des nt discriminate n the basis f race, clr, natinal rigin, age, disability, r sex. Spanish: MedStar Medicare Chice cumple cn las leyes federales de derechs civiles aplicables y n discrimina pr mtivs de raza, clr, nacinalidad, edad, discapacidad sex. French: MedStar Medicare Chice respecte les lis fédérales en vigueur relatives aux drits civiques et ne pratique aucune discriminatin basée sur la race, la culeur de peau, l'rigine natinale, l'âge, le sexe u un handicap. French Crele: MedStar Medicare Chice knfòm ak lwa su dwa sivil Federal ki aplikab y e li pa fè diskriminasyn su baz ras, kulè, peyi rijin, laj, enfimite swa sèks. Italian: MedStar Medicare Chice è cnfrme a tutte le leggi federali vigenti in materia di diritti civili e nn pne in essere discriminazini sulla base di razza, clre, rigine nazinale, età, disabilità sess. Prtuguese: MedStar Medicare Chice cumpre as leis de direits civis federais aplicáveis e nã exerce discriminaçã cm base na raça, cr, nacinalidade, idade, deficiência u sex. German: MedStar Medicare Chice erfüllt geltenden bundesstaatliche Menschenrechtsgesetze und lehnt jegliche Diskriminierung aufgrund vn Rasse, Hautfarbe, Herkunft, Alter, Behinderung der Geschlecht ab. Nrwegian: MedStar Medicare Chice verhlder gjeldende føderale lver m brgerrettigheter g diskriminerer ikke på grunnlag av etnisitet, farge, nasjnal pprinnelse, alder, funksjnshemning eller kjønn. Russian: MedStar Medicare Chice соблюдает применимое федеральное законодательство в области гражданских прав и не допускает дискриминации по признакам расы, цвета кожи, национальной принадлежности, возраста, инвалидности или пола. Persian: MedStar Medicare Chice زا نين اوق ق وقح ن دمی فردال ھطوب رم عب تيت می دن ک و ھنوگچي ھ ب تعض يی رب س اس ا داژن رنگ تس وپ تيلص ا تيل می ن س نان اوتی يا س نجيت دارف ا لي اق نمی دوش. Greek: MedStar Medicare Chice συμμορφώνεται με τους ισχύοντες ομοσπονδιακούς νόμους για τα ατομικά δικαιώματα και δεν προβαίνει σε διακρίσεις με βάση τη φυλή, το χρώμα, την εθνική καταγωγή, την ηλικία, την αναπηρία ή το φύλο.

4 Serb-Cratian: MedStar Medicare Chice pridržava se važećih saveznih zakna građanskim pravima i ne pravi diskriminaciju p snvu rase, bje kže, nacinalng prijekla, gdina starsti, invaliditeta ili pla. Urdu: MedStar Medicare Chice قب ال طا ق ق افوی رہ شی ق وقح ےک نين اوق کی ليمع ت ت رکا ےه روا يه که لس ن گ نر وقتي م رمع روذعمی يا س نج کی ين باد رپ يتم ازا نيہ ن ت رکا Hindi: MedStar Medicare Chice ल ग ह न य ग य स घ य न ग रक अ धक र क़ न न क प लन करत ह और ज त, र ग, र ट र य म ल, आय, वकल गत, य ल ग क आध र पर भ दभ व नह करत ह, Chinese: MedStar Medicare Chice 遵守適用的聯邦民權法律規定, 不因種族 膚色 民族血統 年齡 殘障或性別而歧視任何人 Japanese: MedStar Medicare Chice は適用される連邦公民権法を遵守し 人種 肌の色 出身国 年齢 障害または性別に基づく差別をいたしません Krean: MedStar Medicare Chice 은 ( 는 ) 관련연방공민권법을준수하며인종, 피부색, 출신국가, 연령, 장애또는성별을이유로차별하지않습니다. Vietnamese: MedStar Medicare Chice tuân thủ luật dân quyền hiện hành của Liên bang và không phân biệt đối xử dựa trên chủng tộc, màu da, nguồn gốc quốc gia, độ tuổi, khuyết tật, hặc giới tính. Tagalg: Sumusund ang MedStar Medicare Chice sa mga naaangkp na Pederal na batas sa karapatang sibil at hindi nandidiskrimina batay sa lahi, kulay, bansang pinagmulan, edad, kapansanan kasarian.

5 Multi-Language Interpreter Services English: ATTENTION: If yu speak English, language assistance services, free f charge, are available t yu. Call (TTY: ). Spanish: ATENCIÓN: si habla españl, tiene a su dispsición servicis gratuits de asistencia lingüística. Llame al (TTY: ). French: ATTENTION : Si vus parlez français, des services d'aide linguistique vus snt prpsés gratuitement. Appelez le (ATS: ). French Crele: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pu lang ki dispnib gratis pu u. Rele (TTY: ). Italian: ATTENZIONE: In cas la lingua parlata sia l'italian, sn dispnibili servizi di assistenza linguistica gratuiti. Chiamare il numer (TTY: ). Prtuguese: ATENÇÃO: Se fala prtuguês, encntram-se dispníveis serviçs linguístics, grátis. Ligue para (TTY: ). German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kstenls sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: ). Nrwegian: MERK: Hvis du snakker nrsk, er gratis språkassistansetjenester tilgjengelige fr deg. Ring (TTY: ). Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). Persian: ھجوت: رگ ا به ب زن ا فس رای وگتف گ می کنيد يھس ت ت ن ابزی بت روص گي ارن ا برای مشا مھارف می بدش ا. اب ( (TTY: متس ا ديريگ ب. Greek: ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε (TTY: ). Serb-Cratian: OBAVJEŠTENJE: Ak gvrite srpsk-hrvatski, usluge jezičke pmći dstupne su vam besplatn. Nazvite (TTY- Telefn za sbe sa štećenim gvrm ili sluhm: ). Urdu: رادرب خ: رگ ا پ آ ودرا ل وبتے ني ہ وت پ آ وک ب زن ا کی ددم کی خدت ام تف م من ي يتس دب ا ني ہ کال ن يرک ). (TTY:

6 Hindi: य न द : य द आप ह द ब लत ह त आपक लए म त म भ ष सह यत स व ए उपल ध ह (TTY: ) पर क ल कर Chinese: 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) Japanese: 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: ) まで お電話にてご連絡ください Krean: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành ch bạn. Gọi số (TTY: ). Tagalg: PAUNAWA: Kung nagsasalita ka ng Tagalg, maaari kang gumamit ng mga serbisy ng tulng sa wika nang walang bayad. Tumawag sa (TTY: ). <

7 Grievance Prcedure It is the plicy f MedStar Medicare Chice nt t discriminate n the basis f race, clr, natinal rigin, sex, age r disability. MedStar Medicare Chice has adpted an internal grievance prcedure prviding fr prmpt and equitable reslutin f cmplaints alleging any actin prhibited by Sectin 1557 f the Affrdable Care Act (42 U.S.C ) and its implementing regulatins at 45 CFR part 92, issued by the U.S. Department f Health and Human Services. Sectin 1557 prhibits discriminatin n the basis f race, clr, natinal rigin, sex, age r disability in certain health prgrams and activities. Sectin 1557 and its implementing regulatins may be examined in the ffice f Catherine Kajubi, JD, Directr f Medicare Cmpliance, 5233 King Ave., Suite 400, Baltimre, MD , Telephne Number: , Fax Number: , Catherine.M.Kajubi@medstar.net., wh has been designated t crdinate the effrts f MedStar Medicare Chice t cmply with Sectin Any persn wh believes smene has been subjected t discriminatin n the basis f race, clr, natinal rigin, sex, age r disability may file a grievance under this prcedure. It is against the law fr MedStar Medicare Chice t retaliate against anyne wh ppses discriminatin, files a grievance, r participates in the investigatin f a grievance. Prcedure: Grievances must be submitted t the Sectin 1557 Crdinatr within (60 days) f the date the persn filing the grievance becmes aware f the alleged discriminatry actin. A cmplaint must be in writing, cntaining the name and address f the persn filing it. The cmplaint must state the prblem r actin alleged t be discriminatry and the remedy r relief sught. The Sectin 1557 Crdinatr (r her/his designee) shall cnduct an investigatin f the cmplaint. This investigatin may be infrmal, but it will be thrugh, affrding all interested persns an pprtunity t submit evidence relevant t the cmplaint. The Sectin 1557 Crdinatr will maintain the files and recrds f MedStar Medicare Chice relating t such grievances. T the extent pssible, and in accrdance with applicable law, the Sectin 1557 Crdinatr will take apprpriate steps t preserve the cnfidentiality f files and recrds relating t grievances and will share them nly with thse wh have a need t knw. The Sectin 1557 Crdinatr will issue a written decisin n the grievance, based n a prepnderance f the evidence, n later than 30 days after its filing, including a ntice t the cmplainant f their right t pursue further administrative r legal remedies. The persn filing the grievance may appeal the decisin f the Sectin 1557 Crdinatr by writing t the (Administratr/Chief Executive Officer/Bard f Directrs/etc.) within 15 days f receiving the Sectin 1557 Crdinatr s decisin. The (Administratr/Chief Executive Officer/Bard f Directrs/etc.) shall issue a written decisin in respnse t the appeal n later than 30 days after its filing. The availability and use f this grievance prcedure des nt prevent a persn frm pursuing ther legal r administrative remedies, including filing a cmplaint f discriminatin n the basis f race, clr, natinal rigin, sex, age r disability in curt r with the U.S. Department f

8 Health and Human Services, Office fr Civil Rights. A persn can file a cmplaint f discriminatin electrnically thrugh the Office fr Civil Rights Cmplaint Prtal, which is available at: r by mail r phne at: U.S. Department f Health and Human Services, 200 Independence Avenue SW., Rm 509F, HHH Building, Washingtn, DC Cmplaint frms are available at: Such cmplaints must be filed within 180 days f the date f the alleged discriminatin. MedStar Medicare Chice will make apprpriate arrangements t ensure that individuals with disabilities and individuals with limited English prficiency are prvided auxiliary aids and services r language assistance services, respectively, if needed t participate in this grievance prcess. Such arrangements may include, but are nt limited t, prviding qualified interpreters, prviding taped cassettes f material fr individuals with lw visin, r assuring a barrier-free lcatin fr the prceedings. The Sectin 1557 Crdinatr will be respnsible fr such arrangements.

9 Table f Cntents Evidence f Cverage Table f Cntents This list f chapters and page numbers is yur starting pint. Fr mre help in finding infrmatin yu need, g t the first page f a chapter. Yu will find a detailed list f tpics at the beginning f each chapter. Chapter 1. Getting started as a member...4 Explains what it means t be in a Medicare health plan and hw t use this bklet. Tells abut materials we will send yu, yur plan premium, yur plan membership card, and keeping yur membership recrd up t date. Chapter 2. Imprtant phne numbers and resurces Tells yu hw t get in tuch with ur plan (MedStar Medicare Chice Care Advantage) and with ther rganizatins including Medicare, the State Health Insurance Assistance Prgram (SHIP), the Quality Imprvement Organizatin, Scial Security, Medicaid (the state health insurance prgram fr peple with lw incmes), prgrams that help peple pay fr their prescriptin drugs, and the Railrad Retirement Bard. Chapter 3. Using the plan s cverage fr yur medical services...40 Explains imprtant things yu need t knw abut getting yur medical care as a member f ur plan. Tpics include using the prviders in the plan s netwrk and hw t get care when yu have an emergency. Chapter 4. Medical Benefits Chart (what is cvered and what yu pay)...54 Gives the details abut which types f medical care are cvered and nt cvered fr yu as a member f ur plan. Explains hw much yu will pay as yur share f the cst fr yur cvered medical care. Chapter 5. Using the plan s cverage fr yur Part D prescriptin drugs...88 Explains rules yu need t fllw when yu get yur Part D drugs. Tells hw t use the plan s List f Cvered Drugs (Frmulary) t find ut which drugs are cvered. Tells which kinds f drugs are nt cvered. Explains several kinds f restrictins that apply t cverage fr certain drugs. Explains where t get yur prescriptins filled. Tells abut the plan s prgrams fr drug safety and managing medicatins.

10 Table f Cntents 2 Chapter 6. What yu pay fr yur Part D prescriptin drugs Tells abut the fur stages f drug cverage (Deductible Stage, Initial Cverage Stage, Cverage Gap Stage, Catastrphic Cverage Stage) and hw these stages affect what yu pay fr yur drugs. Explains the six cst-sharing tiers fr yur Part D drugs and tells what yu must pay fr a drug in each cst-sharing tier. Tells abut the late enrllment penalty. Chapter 7. Asking us t pay ur share f a bill yu have received fr cvered medical services r drugs Explains when and hw t send a bill t us when yu want t ask us t pay yu back fr ur share f the cst fr yur cvered services r drugs. Chapter 8. Yur rights and respnsibilities Explains the rights and respnsibilities yu have as a member f ur plan. Tells what yu can d if yu think yur rights are nt being respected. Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Tells yu step-by-step what t d if yu are having prblems r cncerns as a member f ur plan. Explains hw t ask fr cverage decisins and make appeals if yu are having truble getting the medical care r prescriptin drugs yu think are cvered by ur plan. This includes asking us t make exceptins t the rules r extra restrictins n yur cverage fr prescriptin drugs, and asking us t keep cvering hspital care and certain types f medical services if yu think yur cverage is ending t sn. Explains hw t make cmplaints abut quality f care, waiting times, custmer service, and ther cncerns. Chapter 10. Ending yur membership in the plan Explains when and hw yu can end yur membership in the plan. Explains situatins in which ur plan is required t end yur membership. Chapter 11. Legal ntices Includes ntices abut gverning law and abut nn-discriminatin. Chapter 12. Definitins f imprtant wrds Explains key terms used in this bklet.

11 CHAPTER 1 Getting started as a member

12 Chapter 1. Getting started as a member 5 Chapter 1. Getting started as a member SECTION 1 Intrductin...7 Sectin 1.1 Yu are currently enrlled in MedStar Medicare Chice Care Advantage, which is a specialized Medicare Advantage Plan ( Special Needs Plan )... 7 Sectin 1.2 What is the Evidence f Cverage bklet abut?... 7 Sectin 1.3 Legal infrmatin abut the Evidence f Cverage...7 SECTION 2 What makes yu eligible t be a plan member?... 8 Sectin 2.1 Yur eligibility requirements...8 Sectin 2.2 What are Medicare Part A and Medicare Part B?...8 Sectin 2.3 Here is the plan service area fr MedStar Medicare Chice Care Advantage...9 Sectin 2.4 U.S. Citizen r Lawful Presence...9 SECTION 3 What ther materials will yu get frm us?... 9 Sectin 3.1 Yur plan membership card Use it t get all cvered care and prescriptin drugs...9 Sectin 3.2 The Prvider Directry: Yur guide t all prviders and pharmacies in the plan s netwrk...10 Sectin 3.3 The plan s List f Cvered Drugs (Frmulary)...11 Sectin 3.4 The Part D Explanatin f Benefits (the Part D EOB ): Reprts with a summary f payments made fr yur Part D prescriptin drugs...11 SECTION 4 Yur mnthly premium fr MedStar Medicare Chice Care Advantage Sectin 4.1 Hw much is yur plan premium?...12 Sectin 4.2 There are several ways yu can pay yur plan premium...14 Sectin 4.3 Can we change yur mnthly plan premium during the year?...15 SECTION 5 Please keep yur plan membership recrd up t date Sectin 5.1 Hw t help make sure that we have accurate infrmatin abut yu...15 SECTION 6 We prtect the privacy f yur persnal health infrmatin Sectin 6.1 We make sure that yur health infrmatin is prtected...16

13 Chapter 1. Getting started as a member 6 SECTION 7 Hw ther insurance wrks with ur plan...17 Sectin 7.1 Which plan pays first when yu have ther insurance?...17

14 Chapter 1. Getting started as a member 7 SECTION 1 Sectin 1.1 Intrductin Yu are currently enrlled in MedStar Medicare Chice Care Advantage, which is a specialized Medicare Advantage Plan ( Special Needs Plan ) Yu are cvered by Medicare, and yu have chsen t get yur Medicare health care and yur prescriptin drug cverage thrugh ur plan, MedStar Medicare Chice Care Advantage. MedStar Medicare Chice Care Advantage is a specialized Medicare Advantage Plan (a Medicare Special Needs Plan ), which means its benefits are designed fr peple with special health care needs. MedStar Medicare Chice Care Advantage is designed t prvide additinal health benefits that specifically help peple wh have chrnic heart failure and/r diabetes. Our plan prvides access t a netwrk f prviders wh specialize in treating chrnic heart failure and/r diabetes. It als includes health prgrams designed t serve the specialized needs f peple with these cnditins. In additin, ur plan cvers prescriptin drugs t treat mst medical cnditins, including the drugs that are usually used t treat chrnic heart failure and/r diabetes. As a member f the plan, yu get benefits specially tailred t yur cnditin and have all yur care crdinated thrugh ur plan. Like all Medicare health plans, this Medicare Special Needs Plan is apprved by Medicare and run by a private cmpany. Sectin 1.2 What is the Evidence f Cverage bklet abut? This Evidence f Cverage bklet tells yu hw t get yur Medicare medical care and prescriptin drugs cvered thrugh ur plan. This bklet explains yur rights and respnsibilities, what is cvered, and what yu pay as a member f the plan. The wrd cverage and cvered services refers t the medical care and services and the prescriptin drugs available t yu as a member f MedStar Medicare Chice Care Advantage. It s imprtant fr yu t learn what the plan s rules are and what services are available t yu. We encurage yu t set aside sme time t lk thrugh this Evidence f Cverage bklet. If yu are cnfused r cncerned r just have a questin, please cntact ur plan s Member Services (phne numbers are printed n the back cver f this bklet). Sectin 1.3 Legal infrmatin abut the Evidence f Cverage It s part f ur cntract with yu This Evidence f Cverage is part f ur cntract with yu abut hw MedStar Medicare Chice Care Advantage cvers yur care. Other parts f this cntract include yur enrllment frm, the List f Cvered Drugs (Frmulary), and any ntices yu receive frm us abut changes t yur cverage r cnditins that affect yur cverage. These ntices are smetimes called riders r amendments. The cntract is in effect fr mnths in which yu are enrlled in MedStar Medicare Chice Care Advantage between January 1, 2017, and December 31, 2017.

15 Chapter 1. Getting started as a member 8 Each calendar year, Medicare allws us t make changes t the plans that we ffer. This means we can change the csts and benefits f MedStar Medicare Chice Care Advantage after December 31, We can als chse t stp ffering the plan, r t ffer it in a different service area, after December 31, Medicare must apprve ur plan each year Medicare (the Centers fr Medicare & Medicaid Services) must apprve MedStar Medicare Chice Care Advantage each year. Yu can cntinue t get Medicare cverage as a member f ur plan as lng as we chse t cntinue t ffer the plan and Medicare renews its apprval f the plan. SECTION 2 Sectin 2.1 What makes yu eligible t be aplan member? Yur eligibility requirements Yu are eligible fr membership in ur plan as lng as: Yu have bth Medicare Part A and Medicare Part B (sectin 2.2 tells yu abut Medicare Part A and Medicare Part B) -- and -- yu live in ur gegraphic service area (sectin 2.3 belw describes ur service area) -- and -- yu are a United States citizen r are lawfully present in the United States -- and -- yu d nt have End-Stage Renal Disease (ESRD), with limited exceptins, such as if yu develp ESRD when yu are already a member f a plan that we ffer, r yu were a member f a different plan that was terminated. -- and -- yu meet the special eligibility requirements described belw. Special eligibility requirements fr ur plan Our plan is designed t meet the specialized needs f peple wh have certain medical cnditins. T be eligible fr ur plan, yu must have chrnic heart failure and/r diabetes. Sectin 2.2 What are Medicare Part A and Medicare Part B? When yu first signed up fr Medicare, yu received infrmatin abut what services are cvered under Medicare Part A and Medicare Part B. Remember: Medicare Part A generally helps cver services prvided by hspitals (fr inpatient services, skilled nursing facilities, r hme health agencies). Medicare Part B is fr mst ther medical services (such as physician s services and ther utpatient services) and certain items (such as durable medical equipment and supplies).

16 Chapter 1. Getting started as a member 9 Sectin 2.3 Here is the plan service area fr MedStar Medicare Chice Care Advantage Althugh Medicare is a Federal prgram, MedStar Medicare Chice Care Advantage is available nly t individuals wh live in ur plan service area. T remain a member f ur plan, yu must cntinue t reside in the plan service area. The service area is described belw. Our service area includes the fllwing cunty in Maryland: Anne Arundel, Baltimre, Baltimre City, Calvert, Charles, Harfrd, Hward, Prince Gerge's, and St. Mary's. Our service area includes the fllwing cunty in Washingtn, D.C.: District f Clumbia. If yu plan t mve ut f the service area, please cntact Member Services (phne numbers are printed n the back cver f this bklet). When yu mve, yu will have a Special Enrllment Perid that will allw yu t switch t Original Medicare r enrll in a Medicare health r drug plan that is available in yur new lcatin. It is als imprtant that yu call Scial Security if yu mve r change yur mailing address. Yu can find phne numbers and cntact infrmatin fr Scial Security in Chapter 2, Sectin 5. Sectin 2.4 U.S. Citizen r Lawful Presence A member f a Medicare health plan must be a U.S. citizen r lawfully present in the United States. Medicare (the Centers fr Medicare & Medicaid Services) will ntify MedStar Medicare Chice Care Advantage if yu are nt eligible t remain a member n this basis. MedStar Medicare Chice Care Advantage must disenrll yu if yu d nt meet this requirement. SECTION 3 Sectin 3.1 What ther materials will yu get frm us? Yur plan membership card Use it t get all cvered care and prescriptin drugs While yu are a member f ur plan, yu must use yur membership card fr ur plan whenever yu get any services cvered by this plan and fr prescriptin drugs yu get at netwrk pharmacies. Here s a sample membership card t shw yu what yurs will lk like: As lng as yu are a member f ur plan yu must nt use yur red, white, and blue Medicare card t get cvered medical services (with the exceptin f rutine clinical research studies and hspice services). Keep yur red, white, and blue Medicare card in a safe place in case yu need it later.

17 Chapter 1. Getting started as a member 10 Here s why this is s imprtant: If yu get cvered services using yur red, white, and blue Medicare card instead f using yur MedStar Medicare Chice Care Advantage membership card while yu are a plan member, yu may have t pay the full cst yurself. If yur plan membership card is damaged, lst, r stlen, call Member Services right away and we will send yu a new card. (Phne numbers fr Member Services are printed n the back cver f this bklet.) Sectin 3.2 The Prvider Directry: Yur guide t all prviders and pharmacies in the plan s netwrk The Prvider Directry lists ur netwrk prviders, durable medical equipment suppliers, and pharmacies. What are netwrk prviders and netwrk pharmacies? Netwrk prviders are the dctrs and ther health care prfessinals, medical grups, durable medical equipment suppliers, hspitals, and ther health care facilities that have an agreement with us t accept ur payment and any plan cst-sharing as payment in full. We have arranged fr these prviders t deliver cvered services t members in ur plan. Our netwrk pharmacies are all f the pharmacies that have agreed t fill cvered prescriptins fr ur plan members. Why d yu need t knw which prviders are part f ur netwrk? It is imprtant t knw which prviders are part f ur netwrk because, with limited exceptins, while yu are a member f ur plan yu must use netwrk prviders t get yur medical care and services. The nly exceptins are emergencies, urgently needed services when the netwrk is nt available (generally, when yu are ut f the area), ut-f-area dialysis services, and cases in which MedStar Medicare Chice Care Advantage authrizes use f ut-f-netwrk prviders. See Chapter 3 (Using the plan s cverage fr yur medical services) fr mre specific infrmatin abut emergency, ut-f-netwrk, and ut-f-area cverage. If yu dn t have yur cpy f the Prvider Directry, yu can request a cpy frm Member Services (phne numbers are printed n the back cver f this bklet). Yu may ask Member Services fr mre infrmatin abut ur netwrk prviders, including their qualificatins. Yu can als see the Prvider Directry at MedStarMedicareChice.cm, r dwnlad it frm this website. Bth Member Services and the website can give yu the mst up-t-date infrmatin abut changes in ur netwrk prviders since a prvider s status in the Prvider Directry may change thrughut the year. With ur nline directry, yu can lk up dctrs by name r grup practice, lcatin, ZIP cde, specialty, r admitting hspital. We update the nline prvider search weekly with the latest changes t the MedStar Medicare Chice netwrk. The nline directry als includes the fllwing imprtant infrmatin n prviders: Dctr r grup practice s area f specialty - such as cardilgist. Gender f the prvider indicates whether the prvider is male r female. Accepting new patients indicates whether the prvider ffice is accepting new patients. Language spken - all prviders speak English. T determine whether a prvider speaks anther language r is able t cmmunicate thrugh sign language, cntact ur plan.

18 Chapter 1. Getting started as a member 11 Bard certificatin - a prvider (PCP r specialist) must pass a test n their specialty t be bard certified. Hspital admitting privileges - hspital affiliatin indicates where the prvider can admit and treat his r her patients if they need t be in a hspital. Hspital accreditatin (listed fr hspitals nly) - accreditatin helps peple t knw whether a certain facility was reviewed and met high standards. The standards are set by several grups that clsely review the facilities. Tw cmmn hspital accreditatin bards include the Jint Cmmissin n Accreditatin f Healthcare Organizatins (JCAHO) and the American Ostepathic Assciatin (AOA). Why d yu need t knw abut netwrk pharmacies? Yu can use the Prvider Directry t find the netwrk pharmacy yu want t use. There are changes t ur netwrk f pharmacies fr next year. An updated Prvider Directry is lcated n ur website at MedStarMedicareChice.cm. Yu may als call Member Services fr updated prvider infrmatin r t ask us t mail yu a Prvider Directry. Please review the 2017 Prvider Directry t see which pharmacies are in ur netwrk. If yu dn t have the Prvider Directry, yu can get a cpy frm Member Services (phne numbers are printed n the back cver f this bklet). At any time, yu can call Member Services t get up-t-date infrmatin abut changes in the pharmacy netwrk. Yu can als find this infrmatin n ur website at MedStarMedicareChice.cm. Sectin 3.3 The plan s List f Cvered Drugs (Frmulary) The plan has a List f Cvered Drugs (Frmulary). We call it the Drug List fr shrt. It tells which Part D prescriptin drugs are cvered under the Part D benefit included in MedStar Medicare Chice Care Advantage. The drugs n this list are selected by the plan with the help f a team f dctrs and pharmacists. The list must meet requirements set by Medicare. Medicare has apprved the MedStar Medicare Chice Care Advantage Drug List. The Drug List als tells yu if there are any rules that restrict cverage fr yur drugs. We will send yu a cpy f the Drug List. The Drug List we send t yu includes infrmatin fr the cvered drugs that are mst cmmnly used by ur members. Hwever, we cver additinal drugs that are nt included in the printed Drug List. If ne f yur drugs is nt listed in the Drug List, yu shuld visit ur website r cntact Member Services t find ut if we cver it. T get the mst cmplete and current infrmatin abut which drugs are cvered, yu can visit the plan s website (MedStarMedicareChice.cm) r call Member Services (phne numbers are printed n the back cver f this bklet). Sectin 3.4 The Part D Explanatin f Benefits (the Part D EOB ): Reprts with a summary f payments made fr yur Part D prescriptin drugs When yu use yur Part D prescriptin drug benefits, we will send yu a summary reprt t help yu understand and keep track f payments fr yur Part D prescriptin drugs. This summary reprt is called the Part D Explanatin f Benefits (r the Part D EOB ). The Part D Explanatin f Benefits tells yu the ttal amunt yu, r thers n yur behalf, have spent n yur Part D prescriptin drugs and the ttal amunt we have paid fr each f yur Part D prescriptin

19 Chapter 1. Getting started as a member 12 drugs during the mnth. Chapter 6 (What yu pay fr yur Part D prescriptin drugs) gives mre infrmatin abut the Part D Explanatin f Benefits and hw it can help yu keep track f yur drug cverage. A Part D Explanatin f Benefits summary is als available upn request. T get a cpy, please cntact Member Services (phne numbers are printed n the back cver f this bklet). SECTION 4 Sectin 4.1 Yur mnthly premium fr MedStar Medicare Chice Care Advantage Hw much is yur plan premium? As a member f ur plan, yu pay a mnthly plan premium. The table belw shws the mnthly plan premium amunt fr each plan we are ffering in the service area. In additin, yu must cntinue t pay yur Medicare Part B premium (unless yur Part B premium is paid fr yu by Medicaid r anther third party). Plan Name State Mnthly Premium MedStar Medicare Chice Care Advantage Washingtn, D.C. $17 MedStar Medicare Chice Care Advantage Maryland $10 In sme situatins, yur plan premium culd be less There are prgrams t help peple with limited resurces pay fr their drugs. These include Extra Help and State Pharmaceutical Assistance Prgrams. Chapter 2, Sectin 7 tells mre abut these prgrams. If yu qualify, enrlling in the prgram might lwer yur mnthly plan premium. If yu are already enrlled and getting help frm ne f these prgrams, the infrmatin abut premiums in this Evidence f Cverage des nt apply t yu. We send yu a separate insert, called the Evidence f Cverage Rider fr Peple Wh Get Extra Help Paying fr Prescriptin Drugs (als knwn as the Lw Incme Subsidy Rider r the LIS Rider ), which tells yu abut yur drug cverage. If yu dn t have this insert, please call Member Services and ask fr the LIS Rider. (Phne numbers fr Member Services are printed n the back cver f this bklet.) In sme situatins, yur plan premium culd be mre In sme situatins, yur plan premium culd be mre than the amunt listed abve in Sectin 4.1. This situatin is described belw.

20 Chapter 1. Getting started as a member 13 Sme members are required t pay a late enrllment penalty because they did nt jin a Medicare drug plan when they first became eligible r because they had a cntinuus perid f 63 days r mre when they didn t have creditable prescriptin drug cverage. ( Creditable means the drug cverage is expected t pay, n average, at least as much as Medicare s standard prescriptin drug cverage.) Fr these members, the late enrllment penalty is added t the plan s mnthly premium. Their premium amunt will be the mnthly plan premium plus the amunt f their late enrllment penalty. If yu are required t pay the late enrllment penalty, the amunt f yur penalty depends n hw lng yu waited befre yu enrlled in drug cverage r hw many mnths yu were withut drug cverage after yu became eligible. Chapter 6, Sectin 9 explains the late enrllment penalty. If yu have a late enrllment penalty and d nt pay it, yu culd be disenrlled frm the plan. Many members are required t pay ther Medicare premiums In additin t paying the mnthly plan premium, many members are required t pay ther Medicare premiums. As explained in Sectin 2 abve, in rder t be eligible fr ur plan, yu must be entitled t Medicare Part A and enrlled in Medicare Part B. Fr that reasn, sme plan members (thse wh aren t eligible fr premium-free Part A) pay a premium fr Medicare Part A. And mst plan members pay a premium fr Medicare Part B. Yu must cntinue paying yur Medicare premiums t remain a member f the plan. Sme peple pay an extra amunt fr Part D because f their yearly incme. This is knwn as Incme Related Mnthly Adjustment Amunts, als knwn as IRMAA. If yur incme is greater than ($85,000) fr an individual (r married individuals filing separately) r greater than ($170,000) fr married cuples, yu must pay an extra amunt directly t the gvernment (nt the Medicare plan) fr yur Medicare Part D cverage. If yu are required t pay the extra amunt and yu d nt pay it, yu will be disenrlled frm the plan and lse prescriptin drug cverage. If yu have t pay an extra amunt, Scial Security, nt yur Medicare plan, will send yu a letter telling yu what that extra amunt will be. Fr mre infrmatin abut Part D premiums based n incme, g t Chapter 6, Sectin 10 f this bklet. Yu can als visit n the Web r call MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call Or yu may call Scial Security at TTY users shuld call Yur cpy f Medicare & Yu 2017 gives infrmatin abut the Medicare premiums in the sectin called 2017 Medicare Csts. This explains hw the Medicare Part B and Part D premiums differ fr peple with different incmes. Everyne with Medicare receives a cpy f Medicare & Yu each year in the fall. Thse new t Medicare receive it within a mnth after first signing up. Yu can als dwnlad a cpy f Medicare & Yu 2017 frm the Medicare website ( Or, yu can rder a printed cpy by phne at MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users call

21 Chapter 1. Getting started as a member 14 Sectin 4.2 There are several ways yu can pay yur plan premium There are three ways yu can pay yur plan premium. Yur enrllment applicatin includes a sectin that allws yu t chse which ptin yu wish t use t pay yur mnthly premium. If yu select the electrnic funds transfer (EFT) r credit card ptin n yur enrllment applicatin yu will receive additinal infrmatin with yur MedStar Medicare Chice Care Advantage enrllment cnfirmatin letter regarding hw t make electrnic premium payments. If yu need t change hw yu pay yur mnthly premium after yu have enrlled, please cntact Member Services at the phne number n the back cver f this bklet. If yu decide t change the way yu pay yur premium, it can take up t three mnths fr yur new payment methd t take effect. While we are prcessing yur request fr a new payment methd, yu are respnsible fr making sure that yur yur plan premium is paid n time. Optin 1: Yu can pay by check Yu can pay yur mnthly premium by check t ur plan. Our plan typically mails premium bills (invices) t members the secnd week f the mnth fr the current mnth s plan premium. Plan premium payments are due the fifth day f the mnth fllwing the mnth in which the premium bill was issued (e.g., the February premium bill that yu received in February must be paid by March 5). Yur check shuld be made payable t MedStar Family Chice, Inc. Please d NOT make the check payable t Medicare, CMS r HHS. Yu can mail yur premium check t MedStar Family Chice, Inc, Attn: Premium Billing, P.O. Bx 75726, Baltimre, MD Optin 2: Yu can pay by electrnic funds transfer, credit card, r debit card Yu can have yur mnthly plan premium autmatically withdrawn frm yur bank accunt (e.g.,checking r savings), charged directly t yur credit card, r charged directly t yur debit card. Yu can chse a date anywhere frm the 17th f the mnth thrugh the end f the mnth r select the premium due date (the 5th f the mnth) fr yur aut-pay withdrawal. The payment will be deducted frm yur accunt regardless f whether the selected payment date is a weekend r hliday. T select an electrnic payment ptin, yu will need t cmplete a Payment Electin Frm and submit it t MedStar Medicare Chice. Please cntact Member Services t btain a payment electin frm. Optin 3: Yu can have the plan premium taken ut f yur mnthly Scial Security check Yu can have the plan premium taken ut f yur mnthly Scial Security check. Cntact Member Services fr mre infrmatin n hw t pay yur plan premium this way. We will be happy t help yu set this up. (Phne numbers fr Member Services are printed n the back cver f this bklet.) What t d if yu are having truble paying yur plan premium Yur plan premium is due in ur ffice by the 5 th day f the mnth. We may send yu a ntice telling yu that yur plan membership will end if we d nt receive yur premium within 90 days. If yu are required t pay a late enrllment penalty, yu must pay the penalty t keep yur prescriptin drug.

22 Chapter 1. Getting started as a member 15 If yu are having truble paying yur premium n time, please cntact Member Services t see if we can direct yu t prgrams that will help with yur plan premium. (Phne numbers fr Member Services are printed n the back cver f this bklet.) If we end yur membership because yu did nt pay yur premium, yu will have health cverage under Original Medicare. If we end yur membership with the plan because yu did nt pay yur plan premium, then yu may nt be able t receive Part D cverage until the fllwing year if yu enrll in a new plan during the annual enrllment perid. During the annual enrllment perid, yu may either jin a stand-alne prescriptin drug plan r a health plan that als prvides drug cverage. (If yu g withut creditable drug cverage fr mre than 63 days, yu may have t pay a late enrllment penalty fr as lng as yu have Part D cverage.) At the time we end yur membership, yu may still we us fr premiums yu have nt paid. We have the right t pursue cllectin f the premiums yu we. If yu think we have wrngfully ended yur membership, yu have a right t ask us t recnsider this decisin by making a cmplaint. Chapter 9, Sectin 10 f this bklet tells hw t make a cmplaint. If yu had an emergency circumstance that was ut f yur cntrl and it caused yu t nt be able t pay yur premiums within ur grace perid, yu can ask us t recnsider this decisin by calling between Octber 1 thrugh February 14, seven days a week, frm 8 a.m. t 8 p.m., and February 15 thrugh September 30, Mnday thrugh Friday, frm 8 a.m. t 8 p.m., and n Saturday, frm 8 a.m. t 3 p.m. TTY users shuld call Yu must make yur request n later than 60 days after the date yur membership ends. Sectin 4.3 Can we change yur mnthly plan premium during the year? N. We are nt allwed t change the amunt we charge fr the plan s mnthly plan premium during the year. If the mnthly plan premium changes fr next year we will tell yu in September and the change will take effect n January 1. Hwever, in sme cases the part f the premium that yu have t pay can change during the year. This happens if yu becme eligible fr the Extra Help prgram r if yu lse yur eligibility fr the Extra Help prgram during the year. If a member qualifies fr Extra Help with their prescriptin drug csts, the Extra Help prgram will pay all r part f the member s mnthly plan premium. If Medicare pays nly a prtin f this premium, we will bill yu fr the amunt Medicare desn t cver. A member wh lses their eligibility during the year will need t start paying their full mnthly premium. Yu can find ut mre abut the Extra Help prgram in Chapter 2, Sectin 7. SECTION 5 Sectin 5.1 Please keep yur plan membership recrd up t date Hw t help make sure that we have accurate infrmatin abut yu Yur membership recrd has infrmatin frm yur enrllment frm, including yur address and telephne number. It shws yur specific plan cverage including yur Primary Care Prvider/Medical Grup/IPA.

23 Chapter 1. Getting started as a member 16 The dctrs, hspitals, pharmacists, and ther prviders in the plan s netwrk need t have crrect infrmatin abut yu. These netwrk prviders use yur membership recrd t knw what services and drugs are cvered and the cst-sharing amunts fr yu. Because f this, it is very imprtant that yu help us keep yur infrmatin up t date. Let us knw abut these changes: l l l l l l l l Changes t yur name, yur address, r yur phne number. Changes in any ther health insurance cverage yu have (such as frm yur emplyer, yur spuse s emplyer, wrkers cmpensatin, r Medicaid). If yu have any liability claims, such as claims frm an autmbile accident. If yu have been admitted t a nursing hme. If yu receive care in an ut-f-area r ut-f-netwrk hspital r emergency rm. If yur designated respnsible party (such as a caregiver) changes. If yu are participating in a clinical research study. If any f this infrmatin changes, please let us knw by calling Member Services (phne numbers are printed n the back cver f this bklet). It is als imprtant t cntact Scial Security if yu mve r change yur mailing address. Yu can find phne numbers and cntact infrmatin fr Scial Security in Chapter 2, Sectin 5. Read ver the infrmatin we send yu abut any ther insurance cverage yu have Medicare requires that we cllect infrmatin frm yu abut any ther medical r drug insurance cverage that yu have. That s because we must crdinate any ther cverage yu have with yur benefits under ur plan. (Fr mre infrmatin abut hw ur cverage wrks when yu have ther insurance, see Sectin 7 in this chapter.) Once each year, we will send yu a letter that lists any ther medical r drug insurance cverage that we knw abut. Please read ver this infrmatin carefully. If it is crrect, yu dn t need t d anything. If the infrmatin is incrrect, r if yu have ther cverage that is nt listed, please call Member Services (phne numbers are printed n the back cver f this bklet). SECTION 6 Sectin 6.1 We prtect the privacy f yur persnal health infrmatin We make sure that yur health infrmatin is prtected Federal and state laws prtect the privacy f yur medical recrds and persnal health infrmatin. We prtect yur persnal health infrmatin as required by these laws. Fr mre infrmatin abut hw we prtect yur persnal health infrmatin, please g t Chapter 8, Sectin 1.4 f this bklet.

24 Chapter 1. Getting started as a member SECTION 7 Hw ther insurance wrks with ur plan 17 Sectin 7.1 Which plan pays first when yu have ther insurance? When yu have ther insurance (like emplyer grup health cverage), there are rules set by Medicare that decide whether ur plan r yur ther insurance pays first. The insurance that pays first is called the primary payer and pays up t the limits f its cverage. The ne that pays secnd, called the secndary payer, nly pays if there are csts left uncvered by the primary cverage. The secndary payer may nt pay all f the uncvered csts. These rules apply fr emplyer r unin grup health plan cverage: If yu have retiree cverage, Medicare pays first. If yur grup health plan cverage is based n yur r a family member s current emplyment, wh pays first depends n yur age, the number f peple emplyed by yur emplyer, and whether yu have Medicare based n age, disability, r End-stage Renal Disease (ESRD): If yu re under 65 and disabled and yu r yur family member is still wrking, yur grup health plan pays first if the emplyer has 100 r mre emplyees r at least ne emplyer in a multiple emplyer plan that has mre than 100 emplyees. If yu re ver 65 and yu r yur spuse is still wrking, yur grup health plan pays first if the emplyer has 20 r mre emplyees r at least ne emplyer in a multiple emplyer plan that has mre than 20 emplyees. If yu have Medicare because f ESRD, yur grup health plan will pay first fr the first 30 mnths after yu becme eligible fr Medicare. These types f cverage usually pay first fr services related t each type: l l l l N-fault insurance (including autmbile insurance) Liability (including autmbile insurance) Black lung benefits Wrkers cmpensatin Medicaid and TRICARE never pay first fr Medicare-cvered services. They nly pay after Medicare, emplyer grup health plans, and/r Medigap have paid. If yu have ther insurance, tell yur dctr, hspital, and pharmacy. If yu have questins abut wh pays first, r yu need t update yur ther insurance infrmatin, call Member Services (phne numbers are printed n the back cver f this bklet). Yu may need t give yur plan member ID number t yur ther insurers (nce yu have cnfirmed their identity) s yur bills are paid crrectly and n time.

25 CHAPTER 2 Imprtant phne numbers and resurces

26 Chapter 2. Imprtant phne numbers and resurces 19 Chapter 2. Imprtant phne numbers and resurces SECTION 1 MedStar Medicare Chice Care Advantage cntacts (hw t cntact us, including hw t reach Member Services at the plan) SECTION 2 Medicare (hw t get help and infrmatin directly frm the Federal Medicare prgram) SECTION 3 State Health Insurance Assistance Prgram (free help, infrmatin, and answers t yur questins abut Medicare) SECTION 4 Quality Imprvement Organizatin (paid by Medicare t check n the quality f care fr peple with Medicare) SECTION 5 Scial Security SECTION 6 Medicaid (a jint Federal and state prgram that helps with medical csts fr sme peple with limited incme and resurces) SECTION 7 Infrmatin abut prgrams t help peple pay fr their prescriptin drugs SECTION 8 Hw t cntact the Railrad Retirement Bard...38 SECTION 9 D yu have grup insurance r ther health insurance frm an emplyer?... 38

27 Chapter 2. Imprtant phne numbers and resurces 20 SECTION 1 MedStar Medicare Chice Care Advantage cntacts (hw t cntact us, including hw t reach Member Services at the plan) Hw t cntact ur plan s Member Services Fr assistance with claims, billing, r member card questins, please call r write t MedStar Medicare Chice Care Advantage Member Services. We will be happy t help yu. Methd Member Services Cntact Infrmatin CALL Calls t this number are free. We are available fr phne calls frm Octber 1 thrugh February 14, seven days a week, frm 8 a.m. t 8 p.m., and February 15 thrugh September 30, Mnday thrugh Friday, frm 8 a.m. t 8 p.m., and n Saturday, frm 8 a.m. t 3 p.m. Member Services als has free language interpreter services available fr nn-english speakers. TTY This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. We are available fr phne calls frm Octber 1 thrugh February 14, seven days a week, frm 8 a.m. t 8 p.m., and February 15 thrugh September 30, Mnday thrugh Friday, frm 8 a.m. t 8 p.m., and n Saturday, frm 8 a.m. t 3 p.m. FAX WRITE MedStar Medicare Chice Attn: Member Services P.O. Bx 240 Pittsburgh, PA WEBSITE MedStarMedicareChice.cm