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

<Plan name> MEMBER HANDBOOK

_Chapter 11: Legal notices

[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.]

Introduction

This chapter includes legal notices that apply to your membership in our plan. Key terms and their definitions appear in alphabetical order in the last chapter of this Member Handbook.

[Plans can include other legal notices, such as a notice of member non-liability or a notice about third-party liability, if they conform to Medicare and Medicaid laws and regulations.]

[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. Notice about laws 2

B. Notice about nondiscrimination 2

C. Notice about Medicare as a second payer and <Medicaid program name> as a payer of last resort 2

1. Notice about laws

Many laws apply to this Member Handbook. These laws may affect your rights and responsibilities even if the laws aren’t included or explained in this Member Handbook. The main laws that apply are federal laws about the Medicare and <Medicaid program name> programs. Other federal and state laws may apply too.

2. Notice about nondiscrimination

We don’t discriminate or treat you differently because of your race, ethnicity, national origin, color, religion, sex, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability, or geographic location within the service area. [Plans can add language describing additional categories covered under state human rights laws as well as the appropriate contact information below.]

If you want more information or have concerns about discrimination or unfair treatment:

• Call the Department of Health and Human Services, Office for Civil Rights at 1‑800-368-1019. TTY users can call 1-800-537-7697. You can also visit www.hhs.gov/ocr for more information.

• Call your local Office for Civil Rights. [Plans insert contact information for the local office.]

• If you have a disability and need help accessing health care services or a provider, call Member Services. If you have a complaint, such as a problem with wheelchair access, Member Services can help.

3. Notice about Medicare as a second payer and <Medicaid program name> as a payer of last resort

Sometimes someone else must pay first for the services we provide you. For example, if you’re in a car accident or if you’re injured at work, insurance or Workers Compensation must pay first.

We have the right and responsibility to collect for covered Medicare services for which Medicare isn’t the first payer.

We comply with federal and state laws and regulations relating to the legal liability of third parties for health care services to members. We take all reasonable measures to ensure that <Medicaid program name> is the payer of last resort.

[Plans can include other legal notices, such as a notice of member non-liability. These notices can only be added if they conform to Medicare and Medicaid laws and regulations. Plans can also include Medicaid-related legal notices.]

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