Evidence of Coverage:

Transcription

1 January 1 December 31, 2018 Evidence f Cverage: Yur Medicare Health Benefits and Services as a Member f Keystne 65 Medical-Only HMO 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, Keystne 65 Medical-Only, is ffered by Keystne Health Plan East, Inc. (When this Evidence f Cverage says we, us, r ur, it means Keystne Health Plan East, Inc. When it says plan r ur plan, it means Keystne 65 Medical-Only.) Keystne 65 ffers HMO plans with a Medicare cntract. Enrllment in Keystne 65 Medicare Advantage plans depends n cntract renewal. T receive this dcument in an alternate frmat such as Braille, large print r audi, please cntact ur Member Help Team (phne numbers are printed n the back cver f this bklet). Benefits, premium, deductible, and/r cpayments/cinsurance may change n January 1, The prvider netwrk may change at any time. Yu will receive ntice when necessary. Benefits underwritten by Keystne Health Plan East, a subsidiary f Independence Blue Crss independent licensee f the Blue Crss and Blue Shield Assciatin. Visin benefits are underwritten by Keystne Health Plan East and administered by Davis Visin, an independent cmpany. Magellan Behaviral Health, Inc., an independent cmpany, manages mental health and substance abuse benefits fr mst Independence Blue Crss members. TruHearing is a registered trademark f TruHearing, Inc., an independent cmpany. SilverSneakers Fitness Prgram is prvided by Tivity Health Inc. 2017, an independent cmpany Y0041_H3952_KS_18_57083 accepted 8/28/2017 Frm CMS ANOC/EOC OMB Apprval (Expires: May 31, 2020) (Apprved 05/2017)

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3 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 1 Table f Cntents 2018 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 (Keystne 65 Medical-Only) 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) Chapter 5. 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. Asking us t pay ur share f a bill yu have received fr cvered medical services 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 Chapter 7. 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. 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.

4 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 2 Table f Cntents 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.

5 CHAPTER 1 Getting started as a member

6 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 4 Chapter 1. Getting started as a member Chapter 1. Getting started as a member SECTION 1 Intrductin... 5 Sectin 1.1 Yu are enrlled in Keystne 65 Medical-Only, which is a Medicare HMO.. 5 Sectin 1.2 What is the Evidence f Cverage bklet abut?... 5 Sectin 1.3 Legal infrmatin abut the Evidence f Cverage... 5 SECTION 2 What makes yu eligible t be a plan member?... 6 Sectin 2.1 Yur eligibility requirements... 6 Sectin 2.2 What are Medicare Part A and Medicare Part B?... 6 Sectin 2.3 Here is the plan service area fr Keystne 65 Medical-Only... 6 Sectin 2.4 U.S. Citizen r Lawful Presence... 6 SECTION 3 What ther materials will yu get frm us?... 7 Sectin 3.1 Yur plan membership card Use it t get all cvered care... 7 Sectin 3.2 The Prvider/Pharmacy Directry: Yur guide t all prviders in the plan s netwrk... 7 SECTION 4 Yur mnthly premium fr Keystne 65 Medical-Only... 8 Sectin 4.1 Hw much is yur plan premium?... 8 Sectin 4.2 There are several ways yu can pay yur plan premium... 9 Sectin 4.3 Can we change yur mnthly plan premium during the year?...10 SECTION 5 Please keep yur plan membership recrd up t date...11 Sectin 5.1 Hw t help make sure that we have accurate infrmatin abut yu...11 SECTION 6 We prtect the privacy f yur persnal health infrmatin...11 Sectin 6.1 We make sure that yur health infrmatin is prtected...11 SECTION 7 Hw ther insurance wrks with ur plan...12 Sectin 7.1 Which plan pays first when yu have ther insurance?...12

7 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 5 Chapter 1. Getting started as a member SECTION 1 Intrductin Sectin 1.1 Yu are enrlled in Keystne 65 Medical-Only, which is a Medicare HMO Yu are cvered by Medicare, and yu have chsen t get yur Medicare health care thrugh ur plan, Keystne 65 Medical-Only. 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: Act/Individuals-and-Families fr mre infrmatin. There are different types f Medicare health plans. Keystne 65 Medical-Only is a Medicare Advantage HMO Plan (HMO stands fr Health Maintenance Organizatin) apprved by Medicare and run by a private cmpany. Keystne 65 Medical-Only des nt include Part D prescriptin drug cverage. 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 wrds cverage and cvered services refer t the medical care and services available t yu as a member f Keystne 65 Medical-Only. 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 Help Team (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 Keystne 65 Medical-Only 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 Keystne 65 Medical-Only between January 1, 2018, 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 Keystne 65 Medical-Only 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 Keystne 65 Medical-Only 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.

8 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 6 Chapter 1. Getting started as a member SECTION 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 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 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 (DME) and supplies). Sectin 2.3 Here is the plan service area fr Keystne 65 Medical-Only Althugh Medicare is a Federal prgram, Keystne 65 Medical-Only 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 these cunties in Pennsylvania: Bucks, Chester, Delaware, Mntgmery, and Philadelphia. If yu plan t mve ut f the service area, please cntact ur Member Help Team (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 Keystne 65 Medical-Only if yu are nt eligible t remain a member n this basis. Keystne 65 Medical-Only must disenrll yu if yu d nt meet this requirement.

9 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 7 Chapter 1. Getting started as a member SECTION 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. Yu shuld als shw the prvider yur Medicaid card, if applicable. 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 Keystne 65 Medical-Only 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 ur Member Help Team right away and we will send yu a new card. (Phne numbers fr ur Member Help Team are printed n the back cver f this bklet.) Sectin 3.2 The Prvider/Pharmacy Directry: Yur guide t all prviders in the plan s netwrk The Prvider/Pharmacy 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. The mst recent list f prviders and suppliers is available n ur website at 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 Keystne 65 Medical-Only authrizes use f ut-f-netwrk prviders. See

10 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 8 Chapter 1. Getting started as a member 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 the Prvider/Pharmacy Directry, yu can request a cpy frm ur Member Help Team (phne numbers are printed n the back cver f this bklet). Yu may ask ur Member Help Team fr mre infrmatin abut ur netwrk prviders and pharmacies, including their qualificatins. Yu can als see the Prvider/Pharmacy Directry at r dwnlad it frm this website. Bth ur Member Help Team and the website can give yu the mst up-t-date infrmatin abut changes in ur netwrk prviders and pharmacies. SECTION 4 Yur mnthly premium fr Keystne 65 Medical-Only Sectin 4.1 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 Bucks r Philadelphia cunties 2018 Mnthly Premium Keystne 65 Preferred Medical-Only $178 $224 Keystne 65 Select Medical-Only $47 $66 In sme situatins, yur plan premium culd be mre Chester, Delaware, r Mntgmery cunties 2018 Mnthly Premium Keystne 65 Select Medical-Only: If yu signed up fr extra benefits, als called ptinal supplemental benefits, then yu pay an additinal premium each mnth fr these extra benefits. If yu have any questins abut yur plan premiums, please call ur Member Help Team (phne numbers are printed n the back cver f this bklet). Yur mnthly premium fr the Keystne 65 Select Medical-Only with Chice Prgram is $6 in additin t yur mnthly premium fr Keystne 65 Select Medical-Only. 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 2018 gives infrmatin abut these premiums in the sectin called 2018 Medicare Csts. This explains hw the Medicare Part B premium 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 2018 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

11 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 9 Chapter 1. Getting started as a member Sectin 4.2 There are several ways yu can pay yur plan premium There are five ways yu can pay yur plan premium. T change yur current chice f payment methd, please cntact ur Member Help Team (phne numbers are printed n the back cver f this bklet). If yu are new t yur plan, yu may indicate yur payment chice n the enrllment frm r call ur Member Help Team fr assistance. 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 Direct Pay Yur mnthly premium bill is sent t yur hme. Yu write the check payable t Keystne 65 Medical-Only (nt payable t CMS r HHS) and send it directly t us. Yu are enrlled in a plan that charges a mnthly premium and yu shuld be aware f the fllwing: Yu will receive a bill arund the 5th day f every mnth. Yur premium is due n the 15th day f every mnth, unless stated therwise n yur bill. Yur bank may apply a penalty t yur accunt if yur check is returned because f insufficient funds. Checks shuld be mailed t: Keystne 65 Medical-Only PO Bx Newark, NJ Payments can als be made in persn at: Independence Blue Crss 1919 Market Street, 2nd flr Philadelphia, PA a.m. t 5 p.m., Mnday thrugh Friday Please d nt write any ntes r crrespndence t us n yur premium bill. Optin 2: Yu can pay yur premium n ur website Direct Pay members wh have registered n ur website at will be able t view and/r pay their invices directly nline n ur member prtal. T make a payment nline, click the Pay my Bill link n the Hme page r via the Benefits tab t access ur e-bill system. In rder t schedule payments, yu must create a bank accunt prfile and then select a payment date. Please nte that payments must be scheduled n business days. They cannt be scheduled n weekends r hlidays. In additin, all payments must be scheduled at least tw business days prir t the payment due date. If a payment date is nt chsen, the calendar will default t the first available payment date. Yu can als chse t have yur payment drawn frm either a checking r savings accunt. Payments may be scheduled fr a ne-time withdrawal r n a recurring basis. The frequency f recurring withdrawals may be determined by the member (i.e., mnthly, bimnthly, quarterly, etc.) Since ur plan s members are inviced mnthly, we recmmend that yu schedule yur recurring payments fr nce each mnth.

12 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 10 Chapter 1. Getting started as a member Yu are excluded frm this ptin if yu have selected the fllwing payment ptins: Electrnic Funds Transfer (EFT) (Optin 3), direct payment deductins frm yur mnthly Railrad Retirement Bard benefit check (Optin 4), r direct payment deductins frm yur mnthly Scial Security check (Optin 5). Fr mre infrmatin regarding this payment ptin, please cntact ur Member Help Team (phne numbers are printed n the back cver f this bklet). Optin 3: Yu can have yur mnthly plan premium autmatically withdrawn frm yur bank accunt Electrnic Funds Transfer (EFT) A fully autmatic, cmputerized way t have yur mnthly premium payment deducted directly frm yur bank accunt. EFT deductins ccur mnthly n the 5th day f each mnth, unless the 5th falls n a weekend r bank hliday. At that time, the deductin ccurs n the next business day. If yu are interested in the EFT ptin, please cntact ur Member Help Team (phne numbers are printed n the back cver f this bklet). After cmpleting the EFT applicatin, please cntinue t pay yur mnthly premium directly t the plan until yu receive cnfirmatin f enrllment in the EFT prgram. Optin 4: Yu can have the plan premium taken ut f yur mnthly Railrad Retirement Bard (RRB) benefit check Yu can have the plan premium taken ut f yur mnthly Railrad Retirement Bard (RRB) benefit check. Fr mre infrmatin n hw t pay yur plan premium this way, please cntact ur Member Help Team (phne numbers are printed n the back cver f this bklet). We will be happy t help yu set this up. Optin 5: 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 ur Member Help Team fr mre infrmatin n hw t pay yur mnthly plan premium this way. We will be happy t help yu set this up. (Phne numbers fr ur Member Help Team 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 15th f the mnth. If we have nt received yur premium by the 19th f the mnth, we will send yu a ntice reminding yu that yur accunt has a balance due. If yu are having truble paying yur premium n time, please cntact ur Member Help Team t see if we can direct yu t prgrams that will help with yur plan premium. (Phne numbers fr ur Member Help Team are printed n the back cver f this bklet.) 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.

13 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 11 Chapter 1. Getting started as a member 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 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. 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 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 ur Member Help Team (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 ur Member Help Team (phne numbers are printed n the back cver f this bklet). SECTION 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.

14 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 12 Chapter 1. Getting started as a member SECTION 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 Medicare based n age, disability, r End-Stage Renal Disease (ESRD): If yu re under 65 and disabled and yu r yur family member are 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 are 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 ur Member Help Team (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.

15 CHAPTER 2 Imprtant phne numbers and resurces

16 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 14 Chapter 2. Imprtant phne numbers and resurces SECTION 1 SECTION 2 SECTION 3 SECTION 4 Chapter 2. Imprtant phne numbers and resurces Keystne 65 Medical-Only cntacts (hw t cntact us, including hw t reach ur Member Help Team at the plan)...15 Medicare (hw t get help and infrmatin directly frm the Federal Medicare prgram)...19 State Health Insurance Assistance Prgram (free help, infrmatin, and answers t yur questins abut Medicare)...21 Quality Imprvement Organizatin (paid by Medicare t check n the quality f care fr peple with Medicare)...22 SECTION 5 Scial Security...23 SECTION 6 Medicaid (a jint Federal and state prgram that helps with medical csts fr sme peple with limited incme and resurces)...24 SECTION 7 Hw t cntact the Railrad Retirement Bard...25 SECTION 8 D yu have grup insurance r ther health insurance frm an emplyer?...26

17 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 15 Chapter 2. Imprtant phne numbers and resurces SECTION 1 Keystne 65 Medical-Only cntacts (hw t cntact us, including hw t reach ur Member Help Team at the plan) Hw t cntact ur plan s Member Help Team Fr assistance with claims, billing r member card questins, please call r write t the Keystne 65 Medical-Only Member Help Team. We will be happy t help yu. Methd Member Help Team Cntact Infrmatin CALL TTY/TDD 711 FAX Calls t this number are free. 7 days a week, 8 a.m. t 8 p.m. Please nte that n weekends and hlidays frm February 15 thrugh September 30, yur call may be sent t vic . Our Member Help Team als has free language interpreter services available fr nn-english speakers. Calls t this number are free. Same hurs as the phne number abve WRITE WEBSITE Keystne 65 Medical-Only PO Bx 7799 Philadelphia, PA

18 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 16 Chapter 2. Imprtant phne numbers and resurces 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 cmplaint (cverage decisins, appeals, cmplaints)). Yu may call us if yu have questins abut ur cverage decisin prcess. Methd Cverage Decisins fr Medical Care Cntact Infrmatin CALL ASK-BLUE ( ) TTY/TDD 711 Calls t this number are free. 7 days a week, 8 a.m. t 8 p.m. Please nte that n weekends and hlidays frm February 15 thrugh September 30, yur call may be sent t vic . Calls t this number are free. Same hurs as the phne number abve. WRITE WEBSITE Keystne 65 Medical-Only Clinical Precertificatin 1901 Market Street Philadelphia, PA

19 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 17 Chapter 2. Imprtant phne numbers and resurces 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)). Methd Appeals fr Medical Care Cntact Infrmatin CALL TTY/TDD 711 FAX Calls t this number are free. 7 days a week, 8 a.m. t 8 p.m. Please nte that n weekends and hlidays frm February 15 thrugh September 30, yur call may be sent t vic . Calls t this number are free. Same hurs as the phne number abve WRITE WEBSITE Keystne 65 Medical-Only Medicare Member Appeals Unit PO Bx Philadelphia, PA

20 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 18 Chapter 2. Imprtant phne numbers and resurces 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)). Methd Cmplaints abut Medical Care Cntact Infrmatin CALL TTY/TDD 711 FAX Calls t this number are free. 7 days a week, 8 a.m. t 8 p.m. Please nte that n weekends and hlidays frm February 15 thrugh September 30, yur call may be sent t vic . Calls t this number are free. Same hurs as the phne number abve WRITE MEDICARE WEBSITE Keystne 65 Medical-Only Medicare Member Appeals Unit PO Bx Philadelphia, PA Yu can submit a cmplaint abut Keystne 65 Medical-Only directly t Medicare. T submit an nline cmplaint t Medicare g t

21 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 19 Chapter 2. Imprtant phne numbers and resurces 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 5 (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. Methd Payment Requests Cntact Infrmatin CALL Calls t this number are free. 7 days a week, 8 a.m. t 8 p.m. Please nte that n weekends and hlidays frm February 15 thrugh September 30, yur call may be sent t vic . TTY/TDD 711 Calls t this number are free. Same hurs as the phne number abve. FAX WRITE WEBSITE Independence Blue Crss Claims Receipt Center PO Bx Eagan, MN SECTION 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.

22 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 20 Chapter 2. Imprtant phne numbers and resurces Methd 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. WEBSITE This is the fficial gvernment website fr Medicare. It gives yu up-tdate 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 Keystne 65 Medical-Only: Tell Medicare abut yur cmplaint: Yu can submit a cmplaint abut Keystne 65 Medical-Only directly t Medicare. T submit a cmplaint t Medicare, g t 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 )

23 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 21 Chapter 2. Imprtant phne numbers and resurces SECTION 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 Pennsylvania, the SHIP is called APPRISE. APPRISE 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. APPRISE 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. APPRISE cunselrs can als help yu understand yur Medicare plan chices and answer questins abut switching plans. Methd APPRISE (Pennsylvania s SHIP) Cntact Infrmatin CALL WRITE WEBSITE APPRISE Cmmnwealth f Pennsylvania Department f Aging 555 Walnut Street, 5th Flr Harrisburg, PA

24 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 22 Chapter 2. Imprtant phne numbers and resurces SECTION 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 Pennsylvania, 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. Methd Livanta (Pennsylvania 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 WEBSITE Livanta BFCC-QIO Prgram 9090 Junctin Drive, Suite 10 Annaplis Junctin, MD

25 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 23 Chapter 2. Imprtant phne numbers and resurces SECTION 5 Scial Security Scial Security is respnsible fr determining eligibility and handling enrllment fr Medicare. U.S. citizens and lawful permanent residents wh are 65 r lder, r wh have a disability r End-Stage Renal Disease 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. Methd Scial Security Cntact Infrmatin CALL Calls t this number are free. TTY 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. 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

26 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 24 Chapter 2. Imprtant phne numbers and resurces SECTION 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 Pennsylvania Department f Public Welfare Office f Medical Assistance Prgrams (OMAP). Methd Pennsylvania Department f Public Welfare Office f Medical Assistance Prgrams (OMAP) Cntact Infrmatin CALL WRITE WEBSITE Pennsylvania Department f Public Welfare Office f Medical Assistance Prgrams (OMAP) Health & Welfare Building, Rm 515 PO Bx 2675 Harrisburg, PA

27 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 25 Chapter 2. Imprtant phne numbers and resurces SECTION 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 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. Methd Railrad Retirement Bard Cntact Infrmatin CALL Calls t this number are free. TTY 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. 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

28 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 26 Chapter 2. Imprtant phne numbers and resurces SECTION 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 ur Member Help Team 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 ur Member Help Team 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.

29 CHAPTER 3 Using the plan s cverage fr yur medical services

30 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 28 Chapter 3. Using the plan s cverage fr yur medical services Chapter 3. Using the plan s cverage fr yur medical services SECTION 1 Things t knw abut getting yur medical care cvered as a member f ur plan...29 Sectin 1.1 What are netwrk prviders and cvered services?...29 Sectin 1.2 Basic rules fr getting yur medical care cvered by the plan...29 SECTION 2 Use prviders in the plan s netwrk t get yur medical care...30 Sectin 2.1 Yu must chse a Primary Care Prvider (PCP) t prvide and versee yur medical care...30 Sectin 2.2 What kinds f medical care can yu get withut getting apprval in advance frm yur PCP?...31 Sectin 2.3 Hw t get care frm specialists and ther netwrk prviders...32 Sectin 2.4 Hw t get care frm ut-f-netwrk prviders...33 SECTION 3 Hw t get cvered services when yu have an emergency r urgent need fr care r during a disaster...33 Sectin 3.1 Getting care if yu have a medical emergency...33 Sectin 3.2 Getting care when yu have an urgent need fr services...34 Sectin 3.3 Getting care during a disaster...35 SECTION 4 What if yu are billed directly fr the full cst f yur cvered services?...35 Sectin 4.1 Yu can ask us t pay ur share f the cst f cvered services...35 Sectin 4.2 If services are nt cvered by ur plan, yu must pay the full cst...35 SECTION 5 Hw are yur medical services cvered when yu are in a clinical research study?...36 Sectin 5.1 What is a clinical research study?...36 Sectin 5.2 When yu participate in a clinical research study, wh pays fr what?...36 SECTION 6 Rules fr getting care cvered in a religius nn-medical health care institutin...37 Sectin 6.1 What is a religius nn-medical health care institutin?...37 Sectin 6.2 What care frm a religius nn-medical health care institutin is cvered by ur plan?...37 SECTION 7 Rules fr wnership f durable medical equipment...38 Sectin 7.1 Will yu wn the durable medical equipment after making a certain number f payments under ur plan?...38

31 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 29 Chapter 3. Using the plan s cverage fr yur medical services SECTION 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 cvered. 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 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, Keystne 65 Medical-Only must cver all services cvered by Original Medicare and must fllw Original Medicare s cverage rules. Keystne 65 Medical-Only 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 have a netwrk primary care prvider (a PCP) wh is prviding and verseeing yur care. As a member f ur plan, yu must chse a netwrk PCP (fr mre infrmatin abut this, see Sectin 2.1 in this chapter).

32 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 30 Chapter 3. Using the plan s cverage fr yur medical services Yu must receive yur care frm a netwrk prvider (fr mre infrmatin abut this, see Sectin 2 in this chapter). In mst cases, care yu receive frm an ut-f-netwrk prvider (a prvider wh is nt part f ur plan s netwrk) will nt be cvered. Here are three exceptins: The plan cvers emergency r urgently needed services that yu get frm an ut-fnetwrk prvider. Fr mre infrmatin abut this, and t see what emergency r urgently needed services means, see Sectin 3 in this chapter. If yu need medical care that Medicare requires ur plan t cver and the prviders in ur netwrk cannt prvide this care, yu can get this care frm an ut-f-netwrk prvider. Authrizatin shuld be btained frm the plan prir t seeking care. In this situatin, yu will pay the same as yu wuld pay if yu gt the care frm a netwrk prvider. Fr infrmatin abut getting apprval t see an ut-f-netwrk dctr, see Sectin 2.4 in this chapter. The plan cvers kidney dialysis services that yu get at a Medicare-certified dialysis facility when yu are temprarily utside the plan s service area. SECTION 2 Use prviders in the plan s netwrk t get yur medical care Sectin 2.1 Yu must chse a Primary Care Prvider (PCP) t prvide and versee yur medical care What is a PCP and what des the PCP d fr yu? When yu becme a member f Keystne 65 Medical-Only, yu must chse a netwrk prvider as yur primary care prvider (PCP). All PCPs meet state requirements and are trained t give yu basic medical care. A PCP is usually a family r general practitiner r an internist wh knws the plan s netwrk and can guide yu t a plan specialist when needed. Fr a list f prviders that may act as PCPs, please see the Prvider/Pharmacy Directry. Yur PCP will als crdinate any additinal cvered services yu receive as a plan member. Crdinating yur services includes checking r cnsulting with ther plan (in-netwrk) prviders abut yur care. In sme cases, fr specific cvered services, yur PCP will need t get apprval in advance frm ur plan (this is called getting prir authrizatin ). Please see Chapter 4 fr mre infrmatin n the services that require prir authrizatin. Yur PCP will prvide yu with basic medical care and help t arrange r crdinate cvered services that yu receive as a plan member. These cvered services include: X-rays; therapies; care frm dctrs wh are specialists; fllw-up care Since yur primary care prvider is respnsible fr crdinating and arranging mst f yur health care services, yur PCP has identified specific prviders fr the fllwing services: rutine X-ray, labratry, physical therapy and ccupatinal therapy.

33 2018 Evidence f Cverage fr Keystne 65 Medical-Only HMO 31 Chapter 3. Using the plan s cverage fr yur medical services Yu shuld check with yur PCP r call ur Member Help Team (phne numbers are listed n the back cver f this bklet) if yu need specific infrmatin. Hw d yu chse yur PCP? As a Keystne 65 Medical-Only member, yu must select a PCP t crdinate yur care. Yur PCP must be a part f the Keystne 65 Medical-Only netwrk. If yu d nt select a PCP at the time f enrllment, we may autmatically assign ne t yu. Yu will be prmpted t chse r change yur wn PCP when yu receive yur ID card. There are tw ways yu can chse a PCP: Yu may visit ur website ( t select a PCP nline; Or yu may call ur Member Help Team (phne numbers are printed n the back cver f this bklet). Changing yur PCP Yu may change yur PCP fr any reasn, at any time. Als, it s pssible that yur PCP might leave ur plan s netwrk f prviders and yu wuld have t find a new PCP. T change yur PCP, call ur Member Help Team (phne numbers are printed n the back cver f this bklet). When yu call, be sure t infrm ur Member Help Team representative if yu are seeing any specialists r receiving cvered services that yur PCP apprved (such as hme-health services and durable medical equipment). The change will be effective the first day f the mnth fllwing the request fr change. Our Member Help Team representative will then: help yu cntinue t receive specialty care and cvered services when yu change yur PCP; verify that yur chsen PCP is accepting new patients; change yur membership recrd t shw the name f yur new PCP; send yu a new membership card that lists the name and phne number f yur new PCP. Fr the mst up-t-date infrmatin regarding PCPs, visit Click n Find a Prvider t search fr a participating PCP. Yu may als lg n t and use ur Self-Service ptin t: change yur PCP and print a temprary ID card; rder a new ID card. If yu need assistance with accessing this infrmatin n the plan s website, yu may call ur Member Help Team (phne numbers are printed n the back cver f this bklet). Sectin 2.2 What kinds f medical care can yu get withut getting apprval in advance frm yur PCP? Yu can get the services listed belw withut getting apprval in advance frm yur PCP. Rutine wmen s health care, which includes breast exams, screening mammgrams (X-rays f the breast), Pap tests, and pelvic exams as lng as yu get them frm a netwrk prvider. Flu shts, Hepatitis B vaccinatins, and pneumnia vaccinatins as lng as yu get them frm a netwrk prvider. Emergency services frm netwrk prviders r frm ut-f-netwrk prviders.