Secure Blue (PPO) 2016 Evidence of Coverage. January 1 December 31, 2016

Transcription

1 Secure Blue (PPO) 2016 Evidence f Cverage January 1 December 31, 2016 Yur Medicare Health Benefits and Services Cverage as a Member f Secure Blue (PPO) This bklet gives yu the details abut yur Medicare health care cverage frm January 1 December 31, It explains hw t get cverage fr the health care services yu need. This is an imprtant legal dcument. Please keep it in a safe place. This plan, Secure Blue (PPO), is ffered by Blue Crss f Idah Care Plus, Inc. (When this Evidence f Cverage says we, us, r ur, it means Blue Crss f Idah Care Plus, Inc. When it says plan r ur plan, it means Secure Blue (PPO).) Secure Blue (PPO) is a health plan with a Medicare cntract. Enrllment in Secure Blue (PPO) depends n cntract renewal. Custmer Service 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 alternate frmats such as audi and large print. Please call Custmer Service if yu need this in anther frmat. Benefits, premium, and/r cpayments/cinsurance may change n January 1, H1302_004_OP16061 Accepted 08/20/ (09-15)

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3 Chapter 1: Getting started as a member 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... 2 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 (Secure Blue (PPO)) 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), and the Railrad Retirement Bard. Chapter 3 Using the plan s cverage fr yur medical services 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) 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 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. Chapter 6 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 7 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 yu think is cvered by ur plan. This includes 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 8 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 9 Legal ntices Includes ntices abut gverning law and abut nndiscriminatin. Chapter 10 Definitins f imprtant wrds Explains key terms used in this bklet.

4 Chapter 1: Getting started as a member 2 CHAPTER 1 Getting started as a member

5 Chapter 1: Getting started as a member 3 Chapter 1 Getting started as a member Sectin 1 Intrductin... 3 Sectin 1.1 Yu are enrlled in Secure Blue (PPO), which is a Medicare PPO... 3 Sectin 1.2 What is the Evidence f Cverage bklet abut?... 3 Sectin 1.3 Legal infrmatin abut the Evidence f Cverage... 4 Sectin 2 What makes yu eligible t be a plan member?... 4 Sectin 2.1 Yur eligibility requirements... 4 Sectin 2.2 What are Medicare Part A and Medicare Part B?... 4 Sectin 2.3 Here is the plan service area fr Secure Blue (PPO)... 4 Sectin 3 What ther materials will yu get frm us?... 5 Sectin 3.1 Yur plan membership card Use it t get all cvered care... 5 Sectin 3.2 The Prvider Directry: Yur guide t all prviders in the plan s netwrk... 6 Sectin 4 Yur mnthly premium fr Secure Blue (PPO)... 6 Sectin 4.1 Hw much is yur plan premium?... 6 Sectin 4.2 There are several ways yu can pay yur plan premium... 7 Sectin 4.3 Can we change yur mnthly plan premium during the year?... 8 Sectin 5 Please keep yur plan membership recrd up t date... 8 Sectin 5.1 Hw t help make sure that we have accurate infrmatin abut yu... 8 Sectin 6 We prtect the privacy f yur persnal health infrmatin... 9 Sectin 6.1 We make sure that yur health infrmatin is prtected... 9 Sectin 7 Hw ther insurance wrks with ur plan... 9 Sectin 7.1 Which plan pays first when yu have ther insurance?... 9 Sectin 1 Intrductin Sectin 1.1 Yu are enrlled in Secure Blue (PPO), which is a Medicare PPO Yu are cvered by Medicare, and yu have chsen t get yur Medicare health care cverage thrugh ur plan, Secure Blue (PPO). There are different types f Medicare health plans. Secure Blue (PPO) is a Medicare Advantage PPO Plan (PPO stands fr Preferred Prvider Organizatin). This plan des nt include Part D prescriptin drug cverage. Like all Medicare health plans, this Medicare PPO 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 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 available t yu as a member f Secure Blue (PPO). 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

6 Chapter 1: Getting started as a member 4 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 Custmer Service (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 Secure Blue (PPO) cvers yur care. Other parts f this cntract include yur enrllment frm 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 Secure Blue (PPO) between January 1, 2016 and December 31, 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 Secure Blue (PPO) 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 Secure Blue (PPO) 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. Sectin 2 What makes yu eligible t be a plan member? Sectin 2.1 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 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 Medicare Advantage plan that was terminated. 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). Sectin 2.3 Here is the plan service area fr Secure Blue (PPO) Althugh Medicare is a Federal prgram, Secure Blue (PPO) is available nly t individuals wh live in ur plan service area. T remain a member f ur plan, yu must

7 Chapter 1: Getting started as a member 5 cntinue t reside in the plan service area. The service area is described belw. Card fr yur medical services Our service area includes these cunties in Idah: Ada, Adams, Bannck, Bear Lake, Benewah, Bingham, Blaine, Bise, Bnner, Bnneville, Bundary, Butte, Camas, Canyn, Caribu, Cassia, Clark, Clearwater, Custer, Elmre, Fremnt, Gem, Gding, Idah, Jeffersn, Jerme, Ktenai, Latah, Lewis, Lincln, Madisn, Minidka, Nez Perce, Oneida, Owyhee, Payette, Pwer, Shshne, Tetn, Twin Falls, Valley and Washingtn. If yu plan t mve ut f the service area, please cntact Custmer Service (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 3 What ther materials will yu get frm us? Sectin 3.1 Yur plan membership card Use it t get all cvered care 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. 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. Here s why this is s imprtant: If yu get cvered services using yur red, white, and blue Medicare card instead f using yur Secure Blue (PPO) 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 Custmer Service right away and we will send yu a new card. (Phne numbers fr Custmer Service are printed n the back cver f this bklet.)

8 Chapter 1: Getting started as a member 6 Sectin 3.2 The Prvider Directry: Yur guide t all prviders in the plan s netwrk The Prvider Directry lists ur netwrk prviders and durable medical equipment suppliers. What are netwrk prviders? 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. Why d yu need t knw which prviders are part f ur netwrk? As a member f ur plan, yu can chse t receive care frm ut-f-netwrk prviders. Our plan will cver services frm either innetwrk r ut-f-netwrk prviders, as lng as the services are cvered benefits and medically necessary. Hwever, if yu use an ut-f-netwrk prvider, yur share f the csts fr yur cvered services may be higher. See Chapter 3 (Using the plan s cverage fr yur medical services) fr mre specific infrmatin. If yu dn t have yur cpy f the Prvider Directry, yu can request a cpy frm Custmer Service (phne numbers are printed n the back cver f this bklet). Yu may ask Custmer Service fr mre infrmatin abut ur netwrk prviders, including their qualificatins. Yu can als search fr a Secure Blue prvider n ur website at Sectin 4 Yur mnthly premium fr Secure Blue (PPO) Sectin 4.1 Hw much is yur plan premium? As a member f ur plan, yu pay a mnthly plan premium. Fr 2016, the mnthly premium fr Secure Blue (PPO) is $42. 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). 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. If yu signed up fr extra benefits, als called ptinal supplemental benefits, then yu pay an additinal premium each mnth fr these extra benefits. The supplemental dental benefits ffered are an additinal $29.90 each mnth. If yu have any questins abut yur plan premiums, please call Custmer Service (phne numbers are printed n the back cver f this bklet). 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. Yur cpy f Medicare & Yu 2016 gives infrmatin abut these premiums in the sectin called 2016 Medicare Csts. This explains hw the Medicare Part B premium

9 Chapter 1: Getting started as a member 7 differs 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 2016 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 Sectin 4.2 There are several ways yu can pay yur plan premium There are 4 ways yu can pay yur plan premium. T change billing ptins cntact us at , TTY users can call We are available frm 8 a.m. t 8 p.m. seven days a week. 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 plan premium is paid n time. Optin 1: Yu can pay by check Each mnth we mail yu a statement with a payment cupn. Our premium payment is due the 1 st f every mnth. Nt chsing a payment ptin when yu enrll means yu autmatically receive a mnthly billing statement. Yur mnthly billing statement shws the amunt due fr the upcming mnth, plus any amunt past-due and yur payment due date. Make persnal checks, cashier s checks r mney rders payable t Blue Crss f Idah (nt CMS r HHS). Mail payments t Blue Crss f Idah, P.O. Bx 8406, Bise, ID 83707; r use the return envelpe we include wit yur premium statement. Yu may als pay in persn. Stp by ur ffice at 3000 E. Pine Avenue in Meridian, ID. Office hurs are 8 a.m. t 5 p.m. Mnday thrugh Friday. Optin 2: Autmatic Deductins Autmatically deducting yur mnthly premium frm yur checking r savings accunt is the mst ppular billing ptin fr members. Aut deductins give yu freedm frm having t wrry abut yur payment reaching Blue Crss f Idah n time. If yu did nt chse this ptin when yu enrlled, call Custmer Service t start autmatic deductins tday. r An autmatic deductin enrllment frm is printed n the back f yur mnthly billing statement r Sign up n ur website with a few easy steps. G t sign in, click n Save time with aut pay! and enter yur bank accunt infrmatin. Yu can chse any day between the 1st and the 24th f the mnth fr yur autmatic deductin. If yu dn t chse a day, we will draft yur payment n the 5th f each mnth. We need 5 business days frm receipt f yur request t prcess autmatic deductins. Yur first deductin starts during the next billing cycle, unless yu chse a different mnth t start. Yur first deductin includes the current mnth s payment, plus any previus balance due. Optin 3: Pay by echeck r debit card T make a single payment, yu have the ptin t pay nline r by phne G t ur website, sign in, click Make a Payment, chse either Pay by Debit Card r Pay by Electrnic Check Call us at and fllw the prmpts fr payment by phne.

10 Chapter 1: Getting started as a member 8 Optin 4: 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 Custmer Service 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 Custmer Service 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 1st. If we have nt received yur premium payment by the 1st, we will send yu a ntice telling yu that yur plan membership will end if we d nt receive yur plan premium within 90 days. If yu are having truble paying yur premium n time, please cntact Custmer Service t see if we can direct yu t prgrams that will help with yur plan premium. (Phne numbers fr Custmer Service 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. At the time we end yur membership, yu may still we us fr premiums yu have nt paid. In the future, if yu want t enrll again in ur plan (r anther plan that we ffer), yu will need t pay the late premiums befre yu can enrll. 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 7, Sectin 9 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 Medicare t recnsider this decisin by calling MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call 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. Sectin 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 Yur membership recrd has infrmatin frm yur enrllment frm, including yur address and telephne number. It shws yur specific plan cverage. The dctrs, hspitals, 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 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: 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

11 Chapter 1: Getting started as a member 9 If yu receive care in an ut-f-area r utf-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 Custmer Service (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 Custmer Service (phne numbers are printed n the back cver f this bklet). Sectin 6 We prtect the privacy f yur persnal health infrmatin Sectin 6.1 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 6, Sectin 1.4 f this bklet. Sectin 7 Hw ther insurance wrks with ur plan 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

12 Chapter 1: Getting started as a member 10 Medicare based n age, disability, r Endstage 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: 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 Custmer Service (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.

13 Chapter 2. Imprtant phne numbers and resurces 11 CHAPTER 2 Imprtant phne numbers and resurces

14 Chapter 2. Imprtant phne numbers and resurces 12 Chapter 2 Imprtant phne numbers and resurces Sectin 1 Secure Blue (PPO) cntacts (hw t cntact us, including hw t reach Custmer Service at the plan) Sectin 2 Medicare (hw t get help and infrmatin directly frm the Federal Medicare prgram) Sectin 3 State Health Insurance Assistance Prgram (free help, infrmatin, and answers t yur questins abut Medicare) Sectin 4 Quality Imprvement Organizatin (paid by Medicare t check n the quality f care fr peple with Medicare) Sectin 5 Scial Security Sectin 6 Medicaid (a jint Federal and state prgram that helps with medical csts fr sme peple with limited incme and resurces) Sectin 7 Hw t cntact the Railrad Retirement Bard Sectin 8 D yu have grup insurance r ther health insurance frm an emplyer? Sectin 1 Secure Blue (PPO) cntacts (hw t cntact us, including hw t reach Custmer Service at the plan) Hw t cntact ur plan s Custmer Service Fr assistance with claims, billing r member card questins, please call r write t Secure Blue (PPO) Custmer Service. We will be happy t help yu. Custmer Service Cntact Infrmatin CALL Calls t this number are free. We are available frm 8 a.m. t 8 p.m., seven days a week. After 8 p.m. please leave a message and we will return yur call the fllwing day. Custmer Service 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 frm 8 a.m. t 8 p.m., seven days a week. FAX WRITE Blue Crss f Idah P.O. Bx 8406 Bise, ID MACS@bcidah.cm WEBSITE Hw t cntact us when yu are asking fr a cverage decisin abut yur medical care A cverage decisin is a decisin we make abut yur benefits and cverage r abut the amunt we will pay fr yur medical services. Fr mre infrmatin n asking fr cverage decisins abut yur medical care, see Chapter 7 (What t d if yu have a prblem r

15 Chapter 2. Imprtant phne numbers and resurces 13 cmplaint (cverage decisins, appeals, cmplaints)). Yu may call us if yu have questins abut ur cverage decisin prcess. Cverage Decisins fr Medical Care Cntact Infrmatin CALL Calls t this number are free. We are available frm 8 a.m. t 8 p.m., seven days a week. After 8 p.m. please leave a message and we will return yur call the fllwing day. 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 frm 8 a.m. t 8 p.m., seven days a week. WRITE Blue Crss f Idah P.O. Bx 8406 Bise, ID WEBSITE Hw t cntact us when yu are making an appeal abut yur medical care An appeal is a frmal way f asking us t review and change a cverage decisin we have made. Fr mre infrmatin n making an appeal abut yur medical care, see Chapter 7 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints)). Appeals fr Medical Care Cntact Infrmatin CALL Calls t this number are free. We are available frm 8 a.m. t 8 p.m., seven days a week. After 8 p.m. please leave a message and we will return yur call the fllwing day. 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 frm 8 a.m. t 8 p.m., seven days a week. FAX WRITE Blue Crss f Idah P.O. Bx 8406 Bise, ID Hw t cntact us when yu are making a cmplaint abut yur medical care Yu can make a cmplaint abut us r ne f ur netwrk prviders, including a cmplaint abut the quality f yur care. This type f cmplaint des nt invlve cverage r payment disputes. (If yur prblem is abut the plan s cverage r payment, yu shuld lk at the sectin abve abut making an appeal.) Fr mre infrmatin n making a cmplaint abut yur medical care, see Chapter 7 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints)). Cmplaints abut Medical Care Cntact Infrmatin CALL Calls t this number are free. We are available frm 8 a.m. t 8 p.m., seven days a week. After 8 p.m. please leave a message and we will return yur call the fllwing day.

16 Chapter 2. Imprtant phne numbers and resurces 14 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 frm 8 a.m. t 8 p.m., seven days a week. FAX WRITE Blue Crss f Idah P.O. Bx 8406 Bise, ID MEDICARE WEBSITE Yu can submit a cmplaint abut Secure Blue (PPO) directly t Medicare. T submit an nline cmplaint t Medicare g t m/hme.aspx. Where t send a request asking us t pay fr ur share f the cst fr medical care yu have received Fr mre infrmatin n situatins in which yu may need t ask us fr reimbursement r t pay a bill yu have received frm a prvider, see Chapter 7 (Asking us t pay ur share f a bill yu have received fr cvered medical services). Please nte: If yu send us a payment request and we deny any part f yur request, yu can appeal ur decisin. See Chapter 7 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints)) fr mre infrmatin. Payment Requests Cntact Infrmatin CALL Calls t this number are free. We are available frm 8 a.m. t 8 p.m., seven days a week. After 8 p.m. please leave a message and we will return yur call the fllwing day. 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 frm 8 a.m. t 8 p.m., seven days a week. FAX WRITE Medical Payment Requests: Blue Crss f Idah P.O. Bx 8406 Bise, ID WEBSITE Sectin 2 Medicare (hw t get help and infrmatin directly frm the Federal Medicare prgram) Medicare is the Federal health insurance prgram fr peple 65 years f age r lder, sme peple under age 65 with disabilities, and peple with End-Stage Renal Disease (permanent kidney failure requiring dialysis r a kidney transplant). The Federal agency in charge f Medicare is the Centers fr Medicare & Medicaid Services (smetimes called CMS ). This agency cntracts with Medicare Advantage rganizatins including us. Medicare Cntact Infrmatin CALL MEDICARE, r Calls t this number are free. 24 hurs a day, 7 days a week. 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.

17 Chapter 2. Imprtant phne numbers and resurces 15 WEBSITE This is the fficial gvernment website fr Medicare. It gives yu up-t-date infrmatin abut Medicare and current Medicare issues. It als has infrmatin abut hspitals, nursing hmes, physicians, hme health agencies, and dialysis facilities. It includes bklets yu can print directly frm yur cmputer. Yu can als find Medicare cntacts in yur state. The Medicare website als has detailed infrmatin abut yur Medicare eligibility and enrllment ptins with the fllwing tls: Medicare Eligibility Tl: Prvides Medicare eligibility status infrmatin. Medicare Plan Finder: Prvides persnalized infrmatin abut available Medicare prescriptin drug plans, Medicare health plans, and Medigap (Medicare Supplement Insurance) plicies in yur area. These tls prvide an estimate f what yur ut-f-pcket csts might be in different Medicare plans. Yu can als use the website t tell Medicare abut any cmplaints yu have abut Secure Blue (PPO): Tell Medicare abut yur cmplaint: Yu can submit a cmplaint abut Secure Blue (PPO) directly t Medicare. T submit a cmplaint t Medicare, g t rm/hme.aspx. Medicare takes yur cmplaints seriusly and will use this infrmatin t help imprve the quality f the Medicare prgram. If yu dn t have a cmputer, yur lcal library r senir center may be able t help yu visit this website using its cmputer. Or, yu can call Medicare and tell them what infrmatin yu are lking fr. They will find the infrmatin n the website, print it ut, and send it t yu. (Yu can call Medicare at MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call ) Minimum essential cverage (MEC): Cverage under this Plan qualifies as minimum essential cverage (MEC) and satisfies the Patient Prtectin and Affrdable Care Act s (ACA) individual shared respnsibility requirement. Please visit the Internal Revenue Service (IRS) website at Answers-n-the-Individual-Shared- Respnsibility-Prvisin fr mre infrmatin n the individual requirement fr MEC. Sectin 3 State Health Insurance Assistance Prgram (free help, infrmatin, and answers t yur questins abut Medicare) The State Health Insurance Assistance Prgram (SHIP) is a gvernment prgram with trained cunselrs in every state. In Idah, the SHIP is called Senir Health Insurance Benefit Advisrs (SHIBA). SHIBA is independent (nt cnnected with any insurance cmpany r health plan). It is a state prgram that gets mney frm the Federal gvernment t give free lcal health insurance cunseling t peple with Medicare. SHIBA cunselrs can help yu with yur Medicare questins r prblems. They can help yu understand yur Medicare rights, help yu make cmplaints abut yur medical care r treatment, and help yu straighten ut prblems with yur Medicare bills. SHIBA cunselrs can als help yu understand yur Medicare plan chices and answer questins abut switching plans.

18 Chapter 2. Imprtant phne numbers and resurces 16 Senir Health Insurance Benefit Advisrs: (Idah SHIP) Cntact Infrmatin CALL TTY 711 This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. WRITE SHIBA 700 West State Street, Bise, ID Irnwd Parkway, Suite 143, Ceur d Alene, ID N. 4th Avenue, Pcatell, ID WEBSITE Sectin 4 Quality Imprvement Organizatin (paid by Medicare t check n the quality f care fr peple with Medicare) There is a designated Quality Imprvement Organizatin fr serving Medicare beneficiaries in each state. Fr Idah, the Quality Imprvement Organizatin is called Livanta. Livanta has a grup f dctrs and ther health care prfessinals wh are paid by the Federal gvernment. This rganizatin is paid by Medicare t check n and help imprve the quality f care fr peple with Medicare. Livanta is an independent rganizatin. It is nt cnnected with ur plan. Yu shuld cntact Livanta in any f these situatins: Yu have a cmplaint abut the quality f care yu have received. Yu think cverage fr yur hspital stay is ending t sn. Yu think cverage fr yur hme health care, skilled nursing facility care, r Cmprehensive Outpatient Rehabilitatin Facility (CORF) services are ending t sn. Livanta: (Idah s Quality Imprvement Organizatin) Cntact Infrmatin CALL TTY This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. WRITE Livanta LLC BFCC-QIO Prgram 9090 Junctin Drive, Suite 10 Annaplis Junctin, MD WEBSITE Sectin 5 Scial Security Scial Security is respnsible fr determining eligibility and handling enrllment fr Medicare. U.S. citizens wh are 65 r lder, r wh have a disability r ESRD and meet certain cnditins, are eligible fr Medicare. If yu are already getting Scial Security checks, enrllment int Medicare is autmatic. If yu are nt getting Scial Security checks, yu have t enrll in Medicare. Scial Security handles the enrllment prcess fr Medicare. T apply fr Medicare, yu can call Scial Security r visit yur lcal Scial Security ffice. If yu mve r change yur mailing address, it is imprtant that yu cntact Scial Security t let them knw.

19 Chapter 2. Imprtant phne numbers and resurces 17 Scial Security Cntact Infrmatin CALL Calls t this number are free. Available 7:00 am t 7:00 pm, Mnday thrugh Friday. Yu can use Scial Security s autmated telephne services t get recrded infrmatin and cnduct sme business 24 hurs a day. 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. Available 7:00 am t 7:00 pm, Mnday thrugh Friday. WEBSITE Sectin 6 Medicaid (a jint Federal and state prgram that helps with medical csts fr sme peple with limited incme and resurces) Medicaid is a jint Federal and state gvernment prgram that helps with medical csts fr certain peple with limited incmes and resurces. Sme peple with Medicare are als eligible fr Medicaid. In additin, there are prgrams ffered thrugh Medicaid that help peple with Medicare pay their Medicare csts, such as their Medicare premiums. These Medicare Savings Prgrams help peple with limited incme and resurces save mney each year: Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B premiums, and ther cst-sharing (like deductibles, cinsurance, and cpayments). (Sme peple with QMB are als eligible fr full Medicaid benefits (QMB+).) Specified Lw-Incme Medicare Beneficiary (SLMB): Helps pay Part B premiums. (Sme peple with SLMB are als eligible fr full Medicaid benefits (SLMB+).) Qualified Individual (QI): Helps pay Part B premiums. Qualified Disabled & Wrking Individuals (QDWI): Helps pay Part A premiums. T find ut mre abut Medicaid and its prgrams, cntact the Idah Department f Health and Welfare. Idah Department f Health and Welfare: (Idah s Medicaid prgram) Cntact Infrmatin CALL TTY 711 This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. WRITE Idah Department f Health and Welfare P.O. Bx Bise, ID WEBSITE Sectin 7 Hw t cntact the Railrad Retirement Bard The Railrad Retirement Bard is an independent Federal agency that administers cmprehensive benefit prgrams fr the natin s railrad wrkers and their families. If yu have questins regarding yur benefits

20 Chapter 2. Imprtant phne numbers and resurces 18 frm the Railrad Retirement Bard, cntact the agency. If yu receive yur Medicare thrugh the Railrad Retirement Bard, it is imprtant that yu let them knw if yu mve r change yur mailing address. Railrad Retirement Bard Cntact Infrmatin CALL Calls t this number are free. Available 9:00 am t 3:30 pm, Mnday thrugh Friday If yu have a tuch-tne telephne, recrded infrmatin and autmated services are available 24 hurs a day, including weekends and hlidays. TTY This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are nt free. WEBSITE Sectin 8 D yu have grup insurance r ther health insurance frm an emplyer? If yu (r yur spuse) get benefits frm yur (r yur spuse s) emplyer r retiree grup as part f this plan, yu may call the emplyer/unin benefits administratr r Custmer Service if yu have any questins. Yu can ask abut yur (r yur spuse s) emplyer r retiree health benefits, premiums, r the enrllment perid. (Phne numbers fr Custmer Service are printed n the back cver f this bklet.) Yu may als call MEDICARE ( ; TTY: ) with questins related t yur Medicare cverage under this plan.

21 Chapter 3: Using the plan s cverage fr yur medical services 19 CHAPTER 3 Using the plan s cverage fr yur medical services

22 Chapter 3: Using the plan s cverage fr yur medical services 20 Chapter 3 Using the plan s cverage fr yur medical services Sectin 1 Things t knw abut getting yur medical care cvered as a member f ur plan Sectin 1.1 What are netwrk prviders and cvered services? Sectin 1.2 Basic rules fr getting yur medical care cvered by the plan Sectin 2 Using netwrk and ut-f-netwrk prviders t get yur medical care Sectin 2.1 Hw t get care frm specialists and ther netwrk prviders Sectin 2.2 Hw t get care frm ut-f-netwrk prviders Sectin 3 Hw t get cvered services when yu have an emergency r urgent need fr care r during a disaster Sectin 3.1 Getting care if yu have a medical emergency Sectin 3.2 Getting care when yu have an urgent need fr services Sectin 3.3 Getting care during a disaster Sectin 4 What if yu are billed directly fr the full cst f yur cvered services?.. 25 Sectin 4.1 Yu can ask us t pay ur share f the cst f cvered services Sectin 4.2 If services are nt cvered by ur plan, yu must pay the full cst Sectin 5 Hw are yur medical services cvered when yu are in a clinical research study? Sectin 5.1 What is a clinical research study? Sectin 5.2 When yu participate in a clinical research study, wh pays fr what? Sectin 6 Rules fr getting care cvered in a religius nn-medical health care institutin Sectin 6.1 What is a religius nn-medical health care institutin? Sectin 6.2 What care frm a religius nn-medical health care institutin is cvered by ur plan? Sectin 7 Rules fr wnership f durable medical equipment Sectin 7.1 Will yu wn the durable medical equipment after making a certain number f payments under ur plan? Sectin 1 Things t knw abut getting yur medical care cvered as a member f ur plan This chapter explains what yu need t knw abut using the plan t get yur medical care cverage. It gives definitins f terms and explains the rules yu will need t fllw t get the medical treatments, services, and ther medical care that are cvered by the plan. Fr the details n what medical care is cvered by ur plan and hw much yu pay when yu get this care, use the benefits chart in the next chapter, Chapter 4 (Medical Benefits Chart, what is cvered and what yu pay). Sectin 1.1 What are netwrk prviders and cvered services? Here are sme definitins that can help yu understand hw yu get the care and services

23 Chapter 3: Using the plan s cverage fr yur medical services 21 that are cvered fr yu as a member f ur plan: Prviders are dctrs and ther health care prfessinals licensed by the state t prvide medical services and care. The term prviders als includes hspitals and ther health care facilities. Netwrk prviders are the dctrs and ther health care prfessinals, medical grups, hspitals, and ther health care facilities that have an agreement with us t accept ur payment and yur cst-sharing amunt as payment in full. We have arranged fr these prviders t deliver cvered services t members in ur plan. The prviders in ur netwrk bill us directly fr care they give yu. When yu see a netwrk prvider, yu pay nly yur share f the cst fr their services. Cvered services include all the medical care, health care services, supplies, and equipment that are cvered by ur plan. Yur cvered services fr medical care are listed in the benefits chart in Chapter 4. Sectin 1.2 Basic rules fr getting yur medical care cvered by the plan As a Medicare health plan, Secure Blue (PPO) must cver all services cvered by Original Medicare and must fllw Original Medicare s cverage rules. Secure Blue (PPO) will generally cver yur medical care as lng as: The care yu receive is included in the plan s Medical Benefits Chart (this chart is in Chapter 4 f this bklet). The care yu receive is cnsidered medically necessary. Medically necessary means that the services, supplies, r drugs are needed fr the preventin, diagnsis, r treatment f yur medical cnditin and meet accepted standards f medical practice. Yu receive yur care frm a prvider wh is eligible t prvide services under Original Medicare. As a member f ur plan, yu can receive yur care frm either a netwrk prvider r an ut-f-netwrk prvider (fr mre abut this, see Sectin 2 in this chapter). The prviders in ur netwrk are listed in the Prvider Directry. If yu use an ut-f-netwrk prvider, yur share f the csts fr yur cvered services may be higher. Please nte: While yu can get yur care frm an ut-f-netwrk prvider, the prvider must be eligible t participate in Medicare. Except fr emergency care, we cannt pay a prvider wh is nt eligible t participate in Medicare. If yu g t a prvider wh is nt eligible t participate in Medicare, yu will be respnsible fr the full cst f the services yu receive. Check with yur prvider befre receiving services t cnfirm that they are eligible t participate in Medicare. Sectin 2 Using netwrk and ut-f-netwrk prviders t get yur medical care Sectin 2.1 Hw t get care frm specialists and ther netwrk prviders A specialist is a dctr wh prvides health care services fr a specific disease r part f the bdy. There are many kinds f specialists. Here are a few examples: Onclgists care fr patients with cancer. Cardilgists care fr patients with heart cnditins. Orthpedists care fr patients with certain bne, jint, r muscle cnditins.

24 Chapter 3: Using the plan s cverage fr yur medical services 22 Our in-netwrk prviders understand hw ur plan wrks and knw it is their respnsibility t get any required authrizatins fr services they may perfrm r request n yur behalf. Althugh requesting apprval t see an innetwrk prvider is nt yur respnsibility, yu can call Custmer Service if yu wuld like cnfirmatin that we cver a service. See Chapter 4, Sectin 2.1 fr infrmatin abut which services require prir authrizatin. Other netwrk prviders Secure Blue in-netwrk prviders include Blue Crss Blue Shield dctrs and hspitals in select states and/r cunties. Yu pay innetwrk csts when visiting these prviders. Yu can call Custmer Service fr assistance (phne numbers are printed n the back cver f this bklet). Other netwrk prviders include select cunties in 34 states and 1 territry: Alabama, Arkansas, Califrnia, Clrad, Cnnecticut, Flrida, Gergia, Hawaii, Illinis, Indiana, Kentucky, Maine, Massachusetts, Michigan, Missuri, Mntana, Nevada, New Hampshire, New Jersey, New Mexic, New Yrk, Nrth Carlina, Ohi, Oklahma, Oregn, Pennsylvania, Puert Ric, Suth Carlina, Tennessee, Texas, Utah, Virginia, Washingtn, West Virginia and Wiscnsin. What if a specialist r anther netwrk prvider leaves ur plan? We may make changes t the hspitals, dctrs and specialists (prviders) that are part f yur plan during the year. There are a number f reasns why yur prvider might leave yur plan but if yur dctr r specialist des leave yur plan yu have certain rights and prtectins that are summarized belw: Even thugh ur netwrk f prviders may change during the year, Medicare requires that we furnish yu with uninterrupted access t qualified dctrs and specialists. When pssible we will prvide yu with at least 30 days ntice that yur prvider is leaving ur plan s that yu have time t select a new prvider. We will assist yu in selecting a new qualified prvider t cntinue managing yur health care needs. If yu are underging medical treatment yu have the right t request, and we will wrk with yu t ensure, that the medically necessary treatment yu are receiving is nt interrupted. If yu believe we have nt furnished yu with a qualified prvider t replace yur previus prvider r that yur care is nt being apprpriately managed yu have the right t file an appeal f ur decisin. If yu find ut yur dctr r specialist is leaving yur plan please cntact us s we can assist yu in finding a new prvider and managing yur care. Yu can call Custmer Service fr assistance (phne numbers are printed n the back cver f this bklet). Sectin 2.2 Hw t get care frm ut-f-netwrk prviders As a member f ur plan, yu can chse t receive care frm ut-f-netwrk prviders. Our plan will cver services frm either netwrk r ut-f-netwrk prviders, as lng as the services are cvered benefits and are medically necessary. Hwever, if yu use an ut-f-netwrk prvider, yur share f the csts fr yur cvered services may be higher. Here are ther imprtant things t knw abut using ut-f-netwrk prviders: Yu can get yur care frm an ut-fnetwrk prvider; hwever, in mst cases that prvider must be eligible t participate in Medicare. Except fr emergency care, we cannt pay a prvider wh is nt eligible t participate in Medicare. If yu receive care frm a prvider wh is nt eligible t participate in Medicare, yu will

25 Chapter 3: Using the plan s cverage fr yur medical services 23 be respnsible fr the full cst f the services yu receive. Check with yur prvider befre receiving services t cnfirm that they are eligible t participate in Medicare. Yu dn t need t get a referral r prir authrizatin when yu get care frm utf-netwrk prviders. Hwever, befre getting services frm ut-f-netwrk prviders yu may want t ask fr a previsit cverage decisin t cnfirm that the services yu are getting are cvered and are medically necessary. (See Chapter 7, Sectin 4 fr infrmatin abut asking fr cverage decisins.) This is imprtant because: Withut a pre-visit cverage decisin, if we later determine that the services are nt cvered r were nt medically necessary, we may deny cverage and yu will be respnsible fr the entire cst. If we say we will nt cver yur services, yu have the right t appeal ur decisin nt t cver yur care. See Chapter 7 (What t d if yu have a prblem r cmplaint) t learn hw t make an appeal. It is best t ask an ut-f-netwrk prvider t bill the plan first. But, if yu have already paid fr the cvered services, we will reimburse yu fr ur share f the cst fr cvered services. Or if an ut-f-netwrk prvider sends yu a bill that yu think we shuld pay, yu can send it t us fr payment. See Chapter 5 (Asking us t pay ur share f a bill yu have received fr cvered medical services) fr infrmatin abut what t d if yu receive a bill r if yu need t ask fr reimbursement. If yu are using an ut-f-netwrk prvider fr emergency care, urgently needed services, r ut-f-area dialysis, yu may nt have t pay a higher cst-sharing amunt. See Sectin 3 fr mre infrmatin abut these situatins. Sectin 3 Hw t get cvered services when yu have an emergency r urgent need fr care r during a disaster Sectin 3.1 Getting care if yu have a medical emergency What is a medical emergency and what shuld yu d if yu have ne? A medical emergency is when yu, r any ther prudent laypersn with an average knwledge f health and medicine, believe that yu have medical symptms that require immediate medical attentin t prevent lss f life, lss f a limb, r lss f functin f a limb. The medical symptms may be an illness, injury, severe pain, r a medical cnditin that is quickly getting wrse. If yu have a medical emergency: Get help as quickly as pssible. Call 911 fr help r g t the nearest emergency rm r hspital. Call fr an ambulance if yu need it. Yu d nt need t get apprval r a referral first frm yur prvider. As sn as pssible, make sure that ur plan has been tld abut yur emergency. We need t fllw up n yur emergency care. Yu r smene else shuld call t tell us abut yur emergency care, usually within 48 hurs. Please call the number n the back f yur membership card. What is cvered if yu have a medical emergency?