Annual Notice of Change (ANOC) and Evidence of Coverage (EOC)

<Plan name> MEMBER HANDBOOK

_{Chapter 2: Important phone numbers and resources}

Introduction

This chapter gives you contact information for important resources that can help you answer your questions about our plan and your health care benefits. You can also use this chapter to get information about how to contact your care coordinator and others to advocate on your behalf. Key terms and their definitions appear in alphabetical order in the last chapter of this Member Handbook.

[If applicable, plans should modify this chapter to include contact information for other resources.]

[Plans should refer to other parts of the Member Handbook using the appropriate chapter number and section. For example, "refer to Chapter 9, Section A." An instruction [insert reference, as applicable] appears with many cross references throughout the Member Handbook. Plans can always include additional references to other sections, chapters, and/or member materials when helpful to the reader.]

[Plans must update the Table of Contents to this document to accurately reflect where the information is found on each page after plan adds plan-customized information to this template.]

Table of Contents

A. Member Services 3

B. Your Care Coordinator 6

C. <State-specific SHIP Name> 7

D. Quality Improvement Organization (QIO) 8

E. Medicare 9

F. <Medicaid program name> 11

G. [Insert state-specific name for ombudsperson program] 12

H. [Insert State-specific Name of the Long-Term Care (LTC) Ombudsperson Program] 13

I. Programs to Help People Pay for Drugs 14

I1. Extra Help from Medicare 14

I2. State Pharmaceutical Assistance Program (SPAP) [Plans in states without an SPAP or where the SPAP excludes enrollment of dual eligible individuals should delete this section.] 15

I3. AIDS Drug Assistance Program (ADAP) 15

I4. The Medicare Prescription Payment Plan 15

J. Social Security 16

K. Railroad Retirement Board (RRB) 17

L. Group insurance or other insurance from an employer 18

M. Other resources 19

1. Member Services

Contact Type
CALL	<Phone number(s)>. This call is free. <Days and hours of operation> [Include information on the use of alternative technologies.] We have free interpreter services for people who don’t speak English.
TTY	<TTY phone number>. This call is free. [Insert if the plan uses a direct TTY number: This number is for people who have difficulty with hearing or speaking. You must have special telephone equipment to call it.] <Days and hours of operation>
FAX	[Fax number is optional.]
WRITE	<Mailing address>
EMAIL	[Email address is optional.]
WEBSITE	<URL>

Contact Member Services to get help with:

• questions about the plan

• questions about claims or billing

[If plans have different numbers for the functions listed below, plans should insert separate charts with the additional contact information.]

• coverage decisions about your health care

• A coverage decision about your health care is a decision about:

• your benefits and covered services or

• the amount we pay for your health services.

• Call us if you have questions about a coverage decision about your health care.

• To learn more about coverage decisions, refer to Chapter 9 of this Member Handbook.

• appeals about your health care

• An appeal is a formal way of asking us to review a decision we made about your coverage and asking us to change it if you think we made a mistake or disagree with the decision.

• To learn more about making an appeal, refer to Chapter 9 of this Member Handbook or contact Member Services.

• complaints about your health care

• You can make a complaint about us or any provider (including a non-network or network provider). A network provider is a provider who works with our plan. You can also make a complaint to us or to the Quality Improvement Organization (QIO) about the quality of the care you received (refer to Section F [insert reference, as applicable]).

• You can call us and explain your complaint at <phone number>.

• If your complaint is about a coverage decision about your health care, you can make an appeal (refer to the section above [insert reference, as applicable]).

• You can send a complaint about our plan to Medicare. You can use an online form at www.medicare.gov/my/medicare-complaint. Or you can call 1-800-MEDICARE (1-800-633-4227) to ask for help.

• [Insert additional instructions regarding how to make a complaint as directed by the state.]

• To learn more about making a complaint about your health care, refer to Chapter 9 of this Member Handbook.

• coverage decisions about your drugs

• A coverage decision about your drugs is a decision about:

• your benefits and covered drugs or

• the amount we pay for your drugs.

• This applies to your Medicare Part D drugs [insert if applicable, and name of Medicaid program drugs and over-the-counter drugs].

• For more on coverage decisions about your drugs, refer to Chapter 9 of this Member Handbook.

• appeals about your drugs

• An appeal is a way to ask us to change a coverage decision.

• For more on making an appeal about your drugs, refer to Chapter 9 of this Member Handbook.

• complaints about your drugs

• You can make a complaint about us or any pharmacy. This includes a complaint about your drugs.

• If your complaint is about a coverage decision about your drugs, you can make an appeal. (Refer to the section above [insert reference, as applicable].)

• You can send a complaint about our plan to Medicare. You can use an online form at www.medicare.gov/my/medicare-complaint. Or you can call 1-800-MEDICARE (1-800-633-4227) to ask for help.

• For more on making a complaint about your drugs, refer to Chapter 9 of this Member Handbook.

• payment for health care or drugs you already paid for

[Plans with an arrangement with the state can add language to reflect that the organization isn’t allowed to reimburse members for Medicaid-covered benefits.]

• For more on how to ask us to pay you back, or to pay a bill you got, refer to Chapter 7 of this Member Handbook.

• If you ask us to pay a bill and we deny any part of your request, you can appeal our decision. Refer to Chapter 9 of this Member Handbook.

2. Your Care Coordinator

[Plans should include information explaining what a care coordinator is, how members can get a care coordinator, how they can contact the care coordinator, and how they can change their care coordinator. Plans can modify this section as appropriate.]

Contact Type
CALL	<Phone number(s)>. This call is free. <Days and hours of operation> [Include information on the use of alternative technologies.] We have free interpreter services for people who don’t speak English.
TTY	<TTY phone number>. This call is [insert if applicable: not] free. [Insert if the plan uses a direct TTY number: This number is for people who have difficulty with hearing or speaking. You must have special telephone equipment to call it.] <Days and hours of operation>
FAX	[Fax number is optional.]
WRITE	<Mailing address>
EMAIL	[Email address is optional.]
WEBSITE	[URL is optional.]

Contact your care coordinator to get help with:

• questions about your health care

• questions about getting behavioral health (mental health and substance use disorder) services

• questions about transportation

• [Plans should include long-term services and supports and insert information describing LTSS coverage as applicable.]

• [Plans can insert bullets noting additional areas that care coordinators can provide assistance with.]

3. <State-specific SHIP Name>

The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors in every state that offers free help, information, and answers to your Medicare questions. In <state>, the SHIP is called <state-specific SHIP name>.

<State-specific SHIP name> is an independent state program (not connected with any insurance company or health plan) that gets money from the federal government to give free local health insurance counseling to people with Medicare.

Contact Type
CALL	<Phone number(s)> <Days and hours of operation>
TTY	[TTY phone number is optional.] [Insert if the SHIP uses a direct TTY number: This number is for people who have difficulty with hearing or speaking. You must have special telephone equipment to call it.]
WRITE	<Mailing address>
EMAIL	[Email address is optional.]
WEBSITE	<URL>

Contact <state-specific SHIP name> for help with:

• questions about Medicare

• <state-specific SHIP name> counselors can answer your questions about changing to a new plan and help you:

• understand your rights,

• understand your plan choices,

• answer questions about switching plans,

• make complaints about your health care or treatment, and

• straighten out problems with your bills.

4. Quality Improvement Organization (QIO)

Our state has an organization called <state-specific QIO name>. This is a group of doctors and other health care professionals who help improve the quality of care for people with Medicare. <state-specific QIO name> is an independent organization. It’s not connected with our plan.

Contact Type
CALL	<Phone number(s)>
TTY	[TTY phone number is optional.] [Insert if the QIO uses a direct TTY number: This number is for people who have difficulty with hearing or speaking. You must have special telephone equipment to call it.]
WRITE	<Mailing address>
EMAIL	[Email address is optional.]
WEBSITE	<URL>

Contact <state-specific QIO name> for help with:

• questions about your health care rights

• making a complaint about the care you got if you:

• have a problem with the quality of care such as getting the wrong medication, unnecessary tests or procedures, or a misdiagnosis,

• think your hospital stay is ending too soon, or

• think your home health care, skilled nursing facility care, or comprehensive outpatient rehabilitation facility (CORF) services are ending too soon.

5. Medicare

Medicare is the federal health insurance program for people 65 years of age or over, some people under age 65 with disabilities, and people with end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant).

The federal agency in charge of Medicare is the Centers for Medicare & Medicaid Services, or CMS. This agency contracts with Medicare Advantage organizations including our plan.

Contact Type
CALL	1-800-MEDICARE (1-800-633-4227) Calls to this number are free, 24 hours a day, 7 days a week.
TTY	1-877-486-2048. This call is free. This number is for people who have difficulty with hearing or speaking. You must have special telephone equipment to call it.
CHAT LIVE	Chat live at www.Medicare.gov/talk-to-someone
WRITE	Write to Medicare at PO Box 1270, Lawrence, KS 66044
WEBSITE	www.medicare.gov Get information about the Medicare health and drug plans in your area, including what they cost and what services they provide. Find Medicare-participating doctors or other health care providers and suppliers. Find out what Medicare covers, including preventive services (like screenings, shots, or vaccines, and yearly “wellness” visits). Get Medicare appeals information and forms. Get information about the quality of care provided by plans, nursing homes, hospitals, doctors, home health agencies, dialysis facilities, hospice centers, inpatient rehabilitation facilities, and long-term care hospitals. Look up helpful websites and phone numbers. To submit a complaint to Medicare, go to www.medicare.gov/my/medicare-complaint. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program.

6. <Medicaid program name>

[Plans must adapt this generic discussion of Medicaid to reflect the name or features of the Medicaid program in the plan’s state or states.]

[If there are two different agencies handling eligibility and coverage/services, the plan should include both and clarify the role of each.]

[Plans must, as appropriate, include additional telephone numbers for Medicaid program assistance.]

<Medicaid program name> helps with medical and long-term services and supports costs for people with limited incomes and resources.

You’re enrolled in Medicare and in Medicaid. If you have questions about the help you get from Medicaid, call <state-specific Medicaid agency>.

[If applicable, plans can also inform members that they can get information about Medicaid from county resource centers and indicate where members can find contact information for these centers.]

Contact Type
CALL	<state-specific Medicaid agency.> <Days and hours of operation>
TTY	[Insert number, if available. Or delete this row.] [Insert if the state Medicaid program uses a direct TTY number: This number is for people who have difficulty with hearing or speaking. You must have special telephone equipment to call it.]
WRITE	<Insert Mailing address.>
EMAIL	[Email address is optional.]
WEBSITE	<URL>

7. [Insert state-specific name for ombudsperson program]

[If there’s no general ombudsperson in the state plans can delete this section and re-letter the sections as applicable.] The <state-specific name for ombudsperson program> works as an advocate on your behalf. They can answer questions if you have a problem or complaint and can help you understand what to do. <State-specific name for ombudsperson program> also helps you with service or billing problems. They aren’t connected with our plan or with any insurance company or health plan. Their services are free.

Contact Type
CALL	<Phone number(s)> <Days and hours of operation>
TTY	[TTY phone number is optional.] [Insert if the ombudsperson program uses a direct TTY number: This number is for people who have difficulty with hearing or speaking. You must have special telephone equipment to call it.]
WRITE	<Mailing address.>
EMAIL	[Email address is optional.]
WEBSITE	<URL>

8. [Insert State-specific Name of the Long-Term Care (LTC) Ombudsperson Program]

[If there's no LTC ombudsperson in the state plans can delete this section and re-letter the sections as applicable.] The <state-specific LTC Ombudsperson name> helps people get information about nursing homes and resolve problems between nursing homes and residents or their families.

<State-specific LTC Ombudsperson name> isn’t connected with our plan or any insurance company or health plan.

Contact Type
CALL	<Phone number(s)> <Days and hours of operation>
TTY	[TTY phone number is optional.] [Insert if the LTC Ombudsperson uses a direct TTY number: This number is for people who have difficulty with hearing or speaking. You must have special telephone equipment to call it.]
WRITE	<Mailing address>
EMAIL	[Email address is optional.]
WEBSITE	<URL>

9. Programs to Help People Pay for Drugs

The Medicare website (www.medicare.gov/basics/costs/help/drug-costs) provides information on how to lower your drug costs. For people with limited incomes, there are also other programs to assist, as described below.

I1. Extra Help from Medicare

Because you’re eligible for Medicaid, you qualify for and are getting “Extra Help” from Medicare to pay for your drug plan costs. You don’t need to do anything to get this “Extra Help.”

Contact Type
CALL	1-800-MEDICARE (1-800-633-4227) Calls to this number are free, 24 hours a day, 7 days a week.
TTY	1-877-486-2048 This call is free. This number is for people who have difficulty with hearing or speaking. You must have special telephone equipment to call it.
WEBSITE	www.medicare.gov

[Plans that have no drug cost-sharing can delete this section.]

If you think you’re paying an incorrect amount for your prescription at a pharmacy, our plan has a process to help get evidence of your correct copayment amount. If you already have evidence of the right amount, we can help you share this evidence with us.

• [Plans should insert process for allowing members to ask for help to get the best available evidence, and for providing this evidence.]

• [Plans should update this description to accurately reflect the process in this bullet.] When we get the evidence showing the right copayment level, we’ll update our system so you can pay the right copayment amount when you get your next prescription. If you overpay your copayment, we’ll pay you back either by check or a future copayment credit. If the pharmacy didn’t collect your copayment and you owe them a debt, we may make the payment directly to the pharmacy. If a state paid on your behalf, we may make payment directly to the state. Call Member Services at the number at the bottom of the page if you have questions.

I2. State Pharmaceutical Assistance Program (SPAP) [Plans in states without an SPAP or where the SPAP excludes enrollment of dual eligible individuals should delete this section.]

If you’re enrolled in a SPAP, or any other program that provides coverage for Medicare Part D drugs other than “Extra Help” you still get the 70 percent discount on covered brand name drugs. Also, the plan pays five percent of the cost of brand drugs in the coverage gap. The 70 percent discount and the five percent paid by the plan are both applied to the price of the drug before any SPAP or other coverage.

I3. AIDS Drug Assistance Program (ADAP)

[Plans should delete this section if not applicable.] ADAP helps ADAP-eligible people living with HIV/AIDS have access to life-saving HIV drugs. Medicare Part D drugs that are also on the ADAP formulary qualify for prescription cost-sharing help through the <state-specific ADAP information>.

Note: To be eligible for the ADAP in your state, people must meet certain criteria, including proof of the state residence and HIV status, low income (as defined by the state), and uninsured/under-insured status. If you change plans, notify your local ADAP enrollment worker so you can continue to receive assistance for information on eligibility criteria, covered drugs, or how to enroll in the program, please call <state-specific ADAP contact information>.

I4. The Medicare Prescription Payment Plan

[Plans should delete this section if there are no copays for Part D drugs.] The Medicare Prescription Payment Plan is a payment option that works with your current drug coverage to help you manage your out-of-pocket costs for drugs covered by our plan by spreading them across the calendar year (January- December). Anyone with a Medicare drug plan or Medicare health plan with drug coverage (like a Medicare Advantage plan with drug coverage) can use this payment option. This payment option might help you manage your expenses, but it doesn’t save you money or lower your drug costs. If you’re participating in the Medicare Prescription Payment Plan and stay in the same plan, you don’t need to do anything to continue this option. “Extra Help” from Medicare and help from your SPAP and ADAP, for those who qualify, is more advantageous than participation in this payment option, no matter your income level, and plans with drug coverage must offer this payment option. To learn more about this payment option, call Member Services at the phone number at the bottom of the page or visit www.Medicare.gov.

10. Social Security

Social Security determines Medicare eligibility and handles Medicare enrollment.

If you move or change your mailing address, it’s important that you contact Social Security to let them know.

CALL	1-800-772-1213 Calls to this number are free. Available 8 a.m. to 7 p.m., Monday through Friday. You can use their automated telephone services to get recorded information and conduct some business 24 hours a day.
TTY	1-800-325-0778 This number is for people who have difficulty with hearing or speaking. You must have special telephone equipment to call it.
WEBSITE	www.ssa.gov

11. Railroad Retirement Board (RRB)

The RRB is an independent Federal agency that administers comprehensive benefit programs for the nation’s railroad workers and their families. If you get Medicare through the RRB, let them know if you move or change your mailing address. For questions about your benefits from the RRB, contact the agency.

Contact Type
CALL	1-877-772-5772 Calls to this number are free. Press “0” to speak with a RRB representative from 9 a.m. to 3:30 p.m., Monday, Tuesday, Thursday and Friday, and from 9 a.m. to 12 p.m. on Wednesday. Press “1” to access the automated RRB Help Line and get recorded information 24 hours a day, including weekends and holidays.
TTY	1-312-751-4701 This number is for people who have difficulty with hearing or speaking. You must have special telephone equipment to call it. Calls to this number aren’t free.
WEBSITE	www.rrb.gov

12. Group insurance or other insurance from an employer

[Plans should delete this section if members covered under employer groups aren’t eligible to participate in D-SNPs in the state.]

If you (or your spouse or domestic partner) get benefits from your (or your spouse’s or domestic partner’s) employer or retiree group as part of this plan, call the employer/union benefits administrator or Member Services at the phone number at the bottom of the page with any questions. You can ask about your (or your spouse’s or domestic partner’s) employer or retiree health benefits, premiums, or the enrollment period. You can also call 1-800-MEDICARE (1-800-633-4227) with questions about your Medicare coverage under this plan. TTY users call 1-877-486-2048.

If you have other drug coverage through your (or your spouse’s or domestic partner’s) employer or retiree group, contact that group’s benefits administrator. The benefits administrator can help you understand how your current drug coverage will work with our plan.

13. Other resources

[Plans can insert this section to provide additional information resources, such as county aging and disability resource centers, choice counselors, or area agencies on aging or any other sections as directed by the state. Plans should format consistently with other sections, include a brief description and information about any other resources they add, and update the Table of Contents.]

If you have questions, please call <plan name> at <toll-free phone and TTY numbers>, <days and hours of operation>. The call is free. For more information, visit <URL>. 1