Evidence of Coverage:

Transcription

1 A nnprfit independent licensee f the Blue Crss Blue Shield Assciatin January 1 - December 31, 2018 Evidence f Cverage: Yur Medicare Health Benefits and Services and Prescriptin Drug Cverage as a Member f Medicare Blue Chice Select (HMO- POS) This bklet gives yu the details abut yur Medicare health care and prescriptin drug cverage frm January 1 December 31, It explains hw t get cverage fr the health care services and prescriptin drugs yu need. This is an imprtant legal dcument. Please keep it in a safe place. This plan, Medicare Blue Chice Select (HMO-POS), is ffered by Excellus BlueCrss BlueShield. (When this Evidence f Cverage says we, us, r ur, it means Excellus BlueCrss BlueShield. When it says plan r ur plan, it means Medicare Blue Chice Select (HMO-POS).) Excellus BlueCrss BlueShield cntracts with the Federal Gvernment and is an HMO-POS plan with a Medicare cntract. Enrllment in Excellus BlueCrss BlueShield depends n cntract renewal. This infrmatin may be available in a different frmat, including large print, audi tapes and Braille. Benefits, premium, deductible, and/r cpayments/cinsurance may change n January 1, The frmulary, pharmacy netwrk, and/r prvider netwrk may change at any time. Yu will receive ntice when necessary. H3351_4713_3 Accepted MCC-105Y18 Frm CMS ANOC/EOC OMB Apprval (Expires: May 31, 2020) (Apprved 05/2017)

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3 2018 Evidence f Cverage fr Medicare Blue Chice Select (HMO) Table f Cntents Evidence f Cverage Table f Cntents This list f chapters and page numbers is yur starting pint. Fr mre help in finding infrmatin yu need, g t the first page f a chapter. Yu will find a detailed list f tpics at the beginning f each chapter. Chapter 1. Getting started as a member... 4 Explains what it means t be in a Medicare health plan and hw t use this bklet.tells abut materials we will send yu, yur plan premium, the Part D late enrllment penalty, 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 (Medicare Blue Chice Select (HMO- POS)) and with ther rganizatins including Medicare, the State Health Insurance Assistance Prgram (SHIP), the Quality Imprvement Organizatin, Scial Security, Medicaid (the state health insurance prgram fr peple with lw incmes), prgrams that help peple pay fr their prescriptin drugs, and the Railrad Retirement Bard. Chapter 3. Using the plan s cverage fr yur medical services...36 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 rules yu need t fllw when yu get yur Part D drugs. Tells hw t use the plan s List f Cvered Drugs (Frmulary) t find ut which drugs are cvered. Tells which kinds f drugs are nt cvered. Explains several kinds f restrictins that apply t cverage fr certain drugs. Explains where t get yur prescriptins filled. Tells abut the plan s prgrams fr drug safety and managing medicatins.

4 2018 Evidence f Cverage fr Medicare Blue Chice Select (HMO) Table f Cntents 2 Chapter 6. What yu pay fr yur Part D prescriptin drugs Tells abut the fur stages f drug cverage (Deductible Stage, Initial Cverage Stage, Cverage Gap Stage, Catastrphic Cverage Stage) and hw these stages affect what yu pay fr yur drugs. Explains the five cst-sharing tiers fr yur Part D drugs and tells what yu must pay fr a drug in each cst-sharing tier. Chapter 7. Asking us t pay ur share f a bill yu have received fr cvered medical services r drugs Explains when and hw t send a bill t us when yu want t ask us t pay yu back fr ur share f the cst fr yur cvered services r drugs. Chapter 8. Yur rights and respnsibilities Explains the rights and respnsibilities yu have as a member f ur plan. Tells what yu can d if yu think yur rights are nt being respected. Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Tells yu step-by-step what t d if yu are having prblems r cncerns as a member f ur plan. Explains hw t ask fr cverage decisins and make appeals if yu are having truble getting the medical care r prescriptin drugs yu think are cvered by ur plan. This includes asking us t make exceptins t the rules r extra restrictins n yur cverage fr prescriptin drugs, and asking us t keep cvering hspital care and certain types f medical services if yu think yur cverage is ending t sn. Explains hw t make cmplaints abut quality f care, waiting times, custmer service, and ther cncerns. Chapter 10. Ending yur membership in the plan Explains when and hw yu can end yur membership in the plan. Explains situatins in which ur plan is required t end yur membership. Chapter 11. Legal ntices Includes ntices abut gverning law and abut nn-discriminatin. Chapter 12. Definitins f imprtant wrds Explains key terms used in this bklet.

5 CHAPTER 1 Getting started as a member

6 2018 Evidence f Cverage fr Medicare Blue Chice Select (HMO) Chapter 1. Getting started as a member 4 Chapter 1. Getting started as a member SECTION 1 Intrductin... 6 Sectin 1.1 Yu are enrlled in Medicare Blue Chice Select (HMO-POS), which is a Medicare HMO Pint-f-Service Plan... 6 Sectin 1.2 What is the Evidence f Cverage bklet abut?... 6 Sectin 1.3 Legal infrmatin abut the Evidence f Cverage... 6 SECTION 2 What makes yu eligible t be a plan member?...7 Sectin 2.1 Yur eligibility requirements...7 Sectin 2.2 What are Medicare Part A and Medicare Part B?... 7 Sectin 2.3 Here is the plan service area fr Medicare Blue Chice Select (HMO-POS)..7 Sectin 2.4 U.S. Citizen r Lawful Presence... 7 SECTION 3 What ther materials will yu get frm us?... 8 Sectin 3.1 Sectin 3.2 Sectin 3.3 Sectin 3.4 SECTION 4 Sectin 4.1 Yur plan membership card Use it t get all cvered care and prescriptin drugs... 8 The Prvider/Pharmacy Directry: Yur guide t all prviders and pharmacies in the plan s netwrk... 8 The plan s List f Cvered Drugs (Frmulary)...9 The Part D Explanatin f Benefits (the Part D EOB ): Reprts with a summary f payments made fr yur Part D prescriptin drugs Yur mnthly premium fr Medicare Blue Chice Select (HMO-POS) Hw much is yur plan premium?...10 SECTION 5 D yu have t pay the Part D late enrllment penalty? Sectin 5.1 What is the Part D late enrllment penalty? Sectin 5.2 Hw much is the Part D late enrllment penalty?...11 Sectin 5.3 In sme situatins, yu can enrll late and nt have t pay the penalty Sectin 5.4 What can yu d if yu disagree abut yur Part D late enrllment penalty?...12 SECTION 6 D yu have t pay an extra Part D amunt because f yur incme?...13 Sectin 6.1 Wh pays an extra Part D amunt because f incme? Sectin 6.2 Hw much is the extra Part D amunt?...13

7 2018 Evidence f Cverage fr Medicare Blue Chice Select (HMO) Chapter 1. Getting started as a member 5 Sectin 6.3 What can yu d if yu disagree abut paying an extra Part D amunt?.. 14 Sectin 6.4 What happens if yu d nt pay the extra Part D amunt?...14 SECTION 7 Sectin 7.1 Sectin 7.2 Mre infrmatin abut yur mnthly premium...14 If yu pay a Part D late enrllment penalty, there are several ways yu can pay yur penalty Can we change yur mnthly plan premium during the year?...16 SECTION 8 Please keep yur plan membership recrd up t date Sectin 8.1 Hw t help make sure that we have accurate infrmatin abut yu...17 SECTION 9 We prtect the privacy f yur persnal health infrmatin Sectin 9.1 We make sure that yur health infrmatin is prtected SECTION 10 Hw ther insurance wrks with ur plan Sectin 10.1 Which plan pays first when yu have ther insurance?...18

8 Chapter 1. Getting started as a member 6 SECTION 1 Intrductin Sectin 1.1 Yu are enrlled in Medicare Blue Chice Select (HMO-POS), which is a Medicare HMO Pint-f-Service Plan Yu are cvered by Medicare, and yu have chsen t get yur Medicare health care and yur prescriptin drug cverage thrugh ur plan, Medicare Blue Chice Select (HMO-POS). There are different types f Medicare health plans. Medicare Blue Chice Select (HMO-POS) is a Medicare Advantage HMO Plan (HMO stands fr Health Maintenance Organizatin) with a Pint-f- Service (POS) ptin apprved by Medicare and run by a private cmpany. Pint-f-Service means yu can use prviders utside the plan s netwrk fr an additinal cst. (See Chapter 3, Sectin 2.4 fr infrmatin abut using the Pint-f-Service ptin.) Sectin 1.2 What is the Evidence f Cverage bklet abut? This Evidence f Cverage bklet tells yu hw t get yur Medicare medical care and prescriptin drugs cvered thrugh ur plan. This bklet explains yur rights and respnsibilities, what is cvered, and what yu pay as a member f the plan. The wrd cverage and cvered services refers t the medical care and services and the prescriptin drugs available t yu as a member f Medicare Blue Chice Select (HMO-POS). 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 Custmer Care (phne numbers are printed n the back page 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 Medicare Blue Chice Select (HMO-POS) cvers yur care. Other parts f this cntract include yur enrllment frm, the List f Cvered Drugs (Frmulary), and any ntices yu receive frm us abut changes t yur cverage r cnditins that affect yur cverage. These ntices are smetimes called riders r amendments. The cntract is in effect fr mnths in which yu are enrlled in Medicare Blue Chice Select (HMO-POS) 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 Medicare Blue Chice Select (HMO-POS) 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 Medicare Blue Chice Select (HMO-POS) 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.

9 Chapter 1. Getting started as a member 7 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 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 POS) Here is the plan service area fr Medicare Blue Chice Select (HMO- Althugh Medicare is a Federal prgram, Medicare Blue Chice Select (HMO-POS) 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 New Yrk State: Livingstn, Mnre, Ontari, Seneca, Yates, and Wayne. If yu plan t mve ut f the service area, please cntact Custmer Care (phne numbers are printed n the back page 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 Medicare Blue Chice Select (HMO-POS) if yu are nt eligible t remain a member n this basis. Medicare Blue Chice Select (HMO-POS) must disenrll yu if yu d nt meet this requirement.

10 Chapter 1. Getting started as a member 8 SECTION 3 What ther materials will yu get frm us? Sectin 3.1 Yur plan membership card Use it t get all cvered care and prescriptin drugs While yu are a member f ur plan, yu must use yur membership card fr ur plan whenever yu get any services cvered by this plan and fr prescriptin drugs yu get at netwrk pharmacies. 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 Medicare Blue Chice Select (HMO-POS) 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 Care right away and we will send yu a new card. (Phne numbers fr Custmer Care are printed n the back page f this bklet.) Sectin 3.2 The Prvider/Pharmacy Directry: Yur guide t all prviders and pharmacies in the plan s netwrk The Prvider/Pharmacy Directry lists ur netwrk prviders and pharmacies. 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 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 may be required t use netwrk prviders t get yur

11 Chapter 1. Getting started as a member 9 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 Medicare Blue Chice Select (HMO-POS) authrizes use f ut-fnetwrk prviders. See Chapter 3 (Using the plan s cverage fr yur medical services) fr mre specific infrmatin abut emergency, ut-f-netwrk, and ut-f-area cverage. The Pint f Service (POS) (ut-f-netwrk) benefit that cmes with yur plan cvers medically necessary services yu get frm ut-f-netwrk prviders. Yu are financially respnsible fr all services rendered by an ut-f-netwrk prvider when plan rules are nt fllwed. The POS benefit des nt extend t all cvered services. Please see the Benefit Chart fr mre infrmatin. There is a POS plan cverage limit. Once this limit is reached, yu are respnsible fr 100% f the cst f ut-f-netwrk services. What are netwrk pharmacies? Netwrk pharmacies are all f the pharmacies that have agreed t fill cvered prescriptins fr ur plan members. Why d yu need t knw abut netwrk pharmacies? Yu can use the Prvider/Pharmacy Directry t find the netwrk pharmacy yu want t use. There are changes t ur netwrk f pharmacies fr next year. An updated Prvider/Pharmacy Directry is lcated n ur website at Yu may als call Custmer Care fr updated prvider infrmatin r t ask us t mail yu a Prvider/Pharmacy Directry. Please review the 2018 Prvider/Pharmacy Directry t see which pharmacies are in ur netwrk. If yu dn t have yur cpy f the Prvider/Pharmacy Directry, yu can get a cpy frm Custmer Care (phne numbers are printed n the back cver f this bklet). At any time, yu can call Custmer Care t get up-t-date infrmatin abut changes in the pharmacy netwrk. Yu can als find this infrmatin n ur website at Sectin 3.3 The plan s List f Cvered Drugs (Frmulary) The plan has a List f Cvered Drugs (Frmulary). We call it the Drug List fr shrt. It tells which Part D prescriptin drugs are cvered under the Part D benefit included in Medicare Blue Chice Select (HMO-POS). The drugs n this list are selected by the plan with the help f a team f dctrs and pharmacists. The list must meet requirements set by Medicare. Medicare has apprved the Medicare Blue Chice Select (HMO-POS) Drug List. The Drug List als tells yu if there are any rules that restrict cverage fr yur drugs. We will send yu a cpy f the Drug List. T get the mst cmplete and current infrmatin abut which drugs are cvered, yu can visit the plan s website ( r call Custmer Care (phne numbers are printed n the back page f this bklet).

12 Chapter 1. Getting started as a member 10 Sectin 3.4 The Part D Explanatin f Benefits (the Part D EOB ): Reprts with a summary f payments made fr yur Part D prescriptin drugs When yu use yur Part D prescriptin drug benefits, we will send yu a summary reprt t help yu understand and keep track f payments fr yur Part D prescriptin drugs. This summary reprt is called the Part D Explanatin f Benefits (r the Part D EOB ). The Part D Explanatin f Benefits tells yu the ttal amunt yu, r thers n yur behalf, have spent n yur Part D prescriptin drugs and the ttal amunt we have paid fr each f yur Part D prescriptin drugs during the mnth. Chapter 6 (What yu pay fr yur Part D prescriptin drugs) gives mre infrmatin abut the Part D Explanatin f Benefits and hw it can help yu keep track f yur drug cverage. A Part D Explanatin f Benefits summary is als available upn request. T get a cpy, please cntact Custmer Care (phne numbers are printed n the back page f this bklet). Yu can als view yur Part D Explanatin f Benefits electrnically. Lg-in r register at select Accunt Settings, and then Paperless Settings. Select Part D Explanatin f Benefits as part f yur paperless preferences. SECTION 4 (HMO-POS) Sectin 4.1 Yur mnthly premium fr Medicare Blue Chice Select Hw much is yur plan premium? Yu d nt pay a separate mnthly plan premium fr Medicare Blue Chice Select (HMO-POS). 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. This situatin is described belw. Sme members are required t pay a Part D late enrllment penalty because they did nt jin a Medicare drug plan when they first became eligible r because they had a cntinuus perid f 63 days r mre when they didn t have creditable prescriptin drug cverage. ( Creditable means the drug cverage is expected t pay, n average, at least as much as Medicare s standard prescriptin drug cverage.) Fr these members, the Part D late enrllment penalty is added t the plan s mnthly premium. Their premium amunt will be the mnthly plan premium plus the amunt f their Part D late enrllment penalty. If yu are required t pay the Part D late enrllment penalty, the amunt f yur penalty depends n hw lng yu waited befre yu enrlled in drug cverage r hw many mnths yu were withut drug cverage after yu became eligible. Chapter 1, Sectin 5 explains the Part D late enrllment penalty. If yu have a Part D late enrllment penalty and d nt pay it, yu culd be disenrlled frm the plan.

13 Chapter 1. Getting started as a member 11 SECTION 5 D yu have t pay the Part D late enrllment penalty? Sectin 5.1 What is the Part D late enrllment penalty? Nte: If yu receive Extra Help frm Medicare t pay fr yur prescriptin drugs, yu will nt pay a late enrllment penalty. The late enrllment penalty is an amunt that is added t yur Part D premium. Yu may we a Part D late enrllment penalty if at any time after yur initial enrllment perid is ver, there is a perid f 63 days r mre in a rw when yu did nt have Part D r ther creditable prescriptin drug cverage. Creditable prescriptin drug cverage is cverage that meets Medicare s minimum standards since it is expected t pay, n average, at least as much as Medicare s standard prescriptin drug cverage. The amunt f the penalty depends n hw lng yu waited t enrll in a creditable prescriptin drug cverage plan any time after the end f yur initial enrllment perid r hw many full calendar mnths yu went withut creditable prescriptin drug cverage. Yu will have t pay this penalty fr as lng as yu have Part D cverage. When yu first enrll in Medicare Blue Chice Select, we let yu knw the amunt f the penalty. Yur Part D late enrllment penalty is cnsidered yur plan premium. If yu d nt pay yur Part D late enrllment penalty, yu culd lse yur benefits. Sectin 5.2 Hw much is the Part D late enrllment penalty? Medicare determines the amunt f the penalty. Here is hw it wrks: First cunt the number f full mnths that yu delayed enrlling in a Medicare drug plan, after yu were eligible t enrll. Or cunt the number f full mnths in which yu did nt have creditable prescriptin drug cverage, if the break in cverage was 63 days r mre. The penalty is 1% fr every mnth that yu didn t have creditable cverage. Fr example, if yu g 14 mnths withut cverage, the penalty will be 14%. Then Medicare determines the amunt f the average mnthly premium fr Medicare drug plans in the natin frm the previus year. Fr 2017, this average premium amunt was $ This amunt may change fr T calculate yur mnthly penalty, yu multiply the penalty percentage and the average mnthly premium and then rund it t the nearest 10 cents. In the example here it wuld be 14% times $35.63, which equals $ This runds t $4.99. This amunt wuld be added t the mnthly premium fr smene with a Part D late enrllment penalty. There are three imprtant things t nte abut this mnthly Part D late enrllment penalty: First, the penalty may change each year, because the average mnthly premium can change each year. If the natinal average premium (as determined by Medicare) increases, yur penalty will increase. Secnd, yu will cntinue t pay a penalty every mnth fr as lng as yu are enrlled in a plan that has Medicare Part D drug benefits.

14 Chapter 1. Getting started as a member 12 Third, if yu are under 65 and currently receiving Medicare benefits, the Part D late enrllment penalty will reset when yu turn 65. After age 65, yur Part D late enrllment penalty will be based nly n the mnths that yu dn t have cverage after yur initial enrllment perid fr aging int Medicare. Sectin 5.3 In sme situatins, yu can enrll late and nt have t pay the penalty Even if yu have delayed enrlling in a plan ffering Medicare Part D cverage when yu were first eligible, smetimes yu d nt have t pay the Part D late enrllment penalty. Yu will nt have t pay a penalty fr late enrllment if yu are in any f these situatins: If yu already have prescriptin drug cverage that is expected t pay, n average, at least as much as Medicare s standard prescriptin drug cverage. Medicare calls this creditable drug cverage. Please nte: Creditable cverage culd include drug cverage frm a frmer emplyer r unin, TRICARE, r the Department f Veterans Affairs. Yur insurer r yur human resurces department will tell yu each year if yur drug cverage is creditable cverage. This infrmatin may be sent t yu in a letter r included in a newsletter frm the plan. Keep this infrmatin, because yu may need it if yu jin a Medicare drug plan later. Please nte: If yu receive a certificate f creditable cverage when yur health cverage ends, it may nt mean yur prescriptin drug cverage was creditable. The ntice must state that yu had creditable prescriptin drug cverage that expected t pay as much as Medicare s standard prescriptin drug plan pays. The fllwing are nt creditable prescriptin drug cverage: prescriptin drug discunt cards, free clinics, and drug discunt websites. Fr additinal infrmatin abut creditable cverage, please lk in yur Medicare & Yu 2018 Handbk r call Medicare at MEDICARE ( ). TTY users call Yu can call these numbers fr free, 24 hurs a day, 7 days a week. If yu were withut creditable cverage, but yu were withut it fr less than 63 days in a rw. If yu are receiving Extra Help frm Medicare. Sectin 5.4 What can yu d if yu disagree abut yur Part D late enrllment penalty? If yu disagree abut yur Part D late enrllment penalty, yu r yur representative can ask fr a review f the decisin abut yur late enrllment penalty. Generally, yu must request this review within 60 days frm the date n the letter yu receive stating yu have t pay a late enrllment

15 Chapter 1. Getting started as a member 13 penalty. Call Member Services t find ut mre abut hw t d this (phne numbers are printed n the back cver f this bklet). Imprtant: D nt stp paying yur Part D late enrllment penalty while yu re waiting fr a review f the decisin abut yur late enrllment penalty. If yu d, yu culd be disenrlled fr failure t pay yur plan premiums. SECTION 6 incme? D yu have t pay an extra Part D amunt because f yur Sectin 6.1 Wh pays an extra Part D amunt because f incme? Mst peple pay a standard mnthly Part D premium. Hwever, sme peple pay an extra amunt because f their yearly incme. If yur incme is $85,000 r abve fr an individual (r married individuals filing separately) r $170,000 r abve fr married cuples, yu must pay an extra amunt directly t the gvernment fr yur Medicare Part D cverage. If yu have t pay an extra amunt, Scial Security, nt yur Medicare plan, will send yu a letter telling yu what that extra amunt will be and hw t pay it. The extra amunt will be withheld frm yur Scial Security, Railrad Retirement Bard, r Office f Persnnel Management benefit check, n matter hw yu usually pay yur plan premium, unless yur mnthly benefit isn t enugh t cver the extra amunt wed. If yur benefit check isn t enugh t cver the extra amunt, yu will get a bill frm Medicare. Yu must pay the extra amunt t the gvernment. It cannt be paid with yur mnthly plan premium. Sectin 6.2 Hw much is the extra Part D amunt? If yur mdified adjusted grss incme (MAGI) as reprted n yur IRS tax return is abve a certain amunt, yu will pay an extra amunt in additin t yur mnthly plan premium. The chart belw shws the extra amunt based n yur incme. If yu filed an individual tax return and yur incme in 2016 was: If yu were married but filed a separate tax return and yur incme in 2016 was: If yu filed a jint tax return and yur incme in 2016 was: This is the mnthly cst f yur extra Part D amunt (t be paid in additin t yur plan premium) Equal t r less than $85,000 Equal t r less than $85,000 Equal t r less than $170,000 $0 Greater than $85,000 and less than r equal t $107,000 Greater than $170,000 and less than r equal t $214,000 $13.00

16 Chapter 1. Getting started as a member 14 If yu filed an individual tax return and yur incme in 2016 was: If yu were married but filed a separate tax return and yur incme in 2016 was: If yu filed a jint tax return and yur incme in 2016 was: This is the mnthly cst f yur extra Part D amunt (t be paid in additin t yur plan premium) Greater than $107,000 and less than r equal t $133,500 Greater than $214,000 and less than r equal t $267,000 $33.60 Greater than $133,500 and less than r equal t $160,000 Greater than $133,500 and less than r equal t $160,000 Greater than $267,000 and less than r equal t $320,000 $54.20 Greater than $160,000 Greater than $160,000 Greater than $320,000 $74.80 Sectin 6.3 What can yu d if yu disagree abut paying an extra Part D amunt? If yu disagree abut paying an extra amunt because f yur incme, yu can ask Scial Security t review the decisin. T find ut mre abut hw t d this, cntact Scial Security at (TTY ). Sectin 6.4 What happens if yu d nt pay the extra Part D amunt? The extra amunt is paid directly t the gvernment (nt yur Medicare plan) fr yur Medicare Part D cverage. If yu are required t pay the extra amunt and yu d nt pay it, yu will be disenrlled frm the plan and lse prescriptin drug cverage. SECTION 7 Mre infrmatin abut yur mnthly premium Many members are required t pay ther Medicare premiums Many members are required t pay ther Medicare premiums. As explained in Sectin 2 abve, in rder t be eligible fr ur plan, yu must be entitled t Medicare Part A and enrlled in Medicare Part B. Fr that reasn, sme plan members (thse wh aren t eligible fr premium-free Part A) pay a premium fr Medicare Part A and mst plan members pay a premium fr Medicare Part B. Yu must cntinue paying yur Medicare premiums t remain a member f the plan. Sme peple pay an extra amunt fr Part D because f their yearly incme. This is knwn as Incme Related Mnthly Adjustment Amunts, als knwn as IRMAA. If yur incme is greater than $85,000 fr an individual (r married individuals filing separately) r greater than $170,000

17 Chapter 1. Getting started as a member 15 fr married cuples, yu must pay an extra amunt directly t the gvernment (nt the Medicare plan) fr yur Medicare Part D cverage. If yu are required t pay the extra amunt and yu d nt pay it, yu will be disenrlled frm the plan and lse prescriptin drug cverage. If yu have t pay an extra amunt, Scial Security, nt yur Medicare plan, will send yu a letter telling yu what that extra amunt will be. Fr mre infrmatin abut Part D premiums based n incme, g t Chapter 1, Sectin 6 f this bklet. Yu can als visit n the Web r call MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call Or yu may call Scial Security at TTY users shuld call Yur cpy f Medicare & Yu 2018 gives infrmatin abut the Medicare premiums in the sectin called 2018 Medicare Csts. This explains hw the Medicare Part B and Part D premiums differ fr peple with different incmes. Everyne with Medicare receives a cpy f Medicare & Yu each year in the fall. Thse new t Medicare receive it within a mnth after first signing up. Yu can als dwnlad a cpy f Medicare & Yu 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 Sectin 7.1 If yu pay a Part D late enrllment penalty, there are several ways yu can pay yur penalty If yu pay a Part D late enrllment penalty, there are three ways yu can pay the penalty. If yu decide t change the way yu pay yur Part D late enrllment penalty, 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 Part D late enrllment penalty is paid n time. Optin 1: Yu can pay by check Yu may pay yur Part D late enrllment penalty directly t ur plan r yu can drp ff yur payment in persn by the first f each mnth at 165 Curt Street, Rchester, New Yrk Payments can be mailed t Excellus Health Plan, PO Bx 5267, Binghamtn, NY All checks must be made payable t Excellus Health Plan. Optin 2: Electrnic Funds Transfer Instead f paying by check, yu can have yur Part D late enrllment penalty autmatically withdrawn frm yur bank accunt (checking r savings) thrugh an Electrnic Funds Transfer (EFT) n a mnthly basis. If yu chse t pay yur Part D late enrllment penalty this way, yur penalty will be deducted frm yur bank accunt n apprximately the 4th day f the mnth in which the penalty applies t. Cntact Custmer Care t request a cpy f the EFT authrizatin frm t pay yur Part D late enrllment penalty this way. We will be happy t help yu set this up.

18 Chapter 1. Getting started as a member 16 Optin 3: Yu can have the Part D late enrllment penalty taken ut f yur mnthly Scial Security check Yu can have the Part D late enrllment penalty taken ut f yur mnthly Scial Security check. Cntact Custmer Care fr mre infrmatin n hw t pay yur Part D late enrllment penalty this way. We will be happy t help yu set this up. (Phne numbers fr Custmer Care are printed n the back page f this bklet.) What t d if yu are having truble paying yur Part D late enrllment penalty Yur Part D late enrllment penalty is due in ur ffice by the first f the mnth. If we have nt received yur penalty payment by the first f the mnth, we will send yu a ntice telling yu that yur plan membership will end if we d nt receive yur Part D late enrllment penalty within a 2 calendar mnth grace perid. If yu are required t pay a Part D late enrllment penalty, yu must pay the penalty t keep yur cverage. If yu are having truble paying yur Part D late enrllment penalty n time, please cntact Custmer Care t see if we can direct yu t prgrams that will help with yur penalty. (Phne numbers fr Custmer Care are printed n the back page f this bklet.) If we end yur membership because yu did nt pay yur Part D late enrllment penalty yu will have health cverage under Original Medicare. If we end yur membership with the plan because yu did nt pay yur Part D late enrllment penalty then yu may nt be able t receive Part D cverage until the fllwing year if yu enrll in a new plan during the annual enrllment perid. During the annual enrllment perid, yu may either jin a stand-alne prescriptin drug plan r a health plan that als prvides drug cverage. (If yu g withut creditable drug cverage fr mre than 63 days, yu may have t pay a Part D late enrllment penalty fr as lng as yu have Part D cverage.) At the time we end yur membership, yu may still we us fr the Part D late enrllment penalty yu have nt paid. We have the right t pursue cllectin f the Part D late enrllment penalty yu we. In the future, if yu want t enrll again in ur plan (r anther plan that we ffer), yu may need t pay the amunt yu we 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 9, Sectin 10 f this bklet tells hw t make a cmplaint. If yu had an emergency circumstance that was ut f yur cntrl and it caused yu t nt be able t pay yur premiums within ur grace perid, yu can ask us t recnsider this decisin by calling between Mnday - Friday, 8:00 a.m. - 8:00 p.m. Representatives are als available 8:00 a.m. - 8:00 p.m., Mnday - Sunday, frm Octber 1 - February 14. TTY users shuld call Yu must make yur request n later than 60 days after the date yur membership ends. Sectin 7.2 Can we change yur mnthly plan premium during the year? N. We are nt allwed t begin charging a 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.

19 Chapter 1. Getting started as a member 17 Hwever, in sme cases, yu may need t start paying r may be able t stp paying a Part D late enrllment penalty. (The Part D late enrllment penalty may apply if yu had a cntinuus perid f 63 days r mre when yu didn t have creditable prescriptin drug cverage.) This culd happen if yu becme eligible fr the Extra Help prgram r if yu lse yur eligibility fr the Extra Help prgram during the year: If yu currently pay the Part D late enrllment penalty and becme eligible fr Extra Help during the year, yu wuld be able t stp paying yur penalty. If yu ever lse yur lw-incme subsidy ( Extra Help ), yu wuld be subject t the mnthly Part D late enrllment penalty if yu have ever gne withut creditable prescriptin drug cverage fr 63 days r mre. Yu can find ut mre abut the Extra Help prgram in Chapter 2, Sectin 7 SECTION 8 Sectin 8.1 Please keep yur plan membership recrd up t date Hw t help make sure that we have accurate infrmatin abut yu Yur membership recrd has infrmatin frm yur enrllment frm, including yur address and telephne number. It shws yur specific plan cverage including yur Primary Care Prvider. The dctrs, hspitals, pharmacists, and ther prviders in the plan s netwrk need t have crrect infrmatin abut yu. These netwrk prviders use yur membership recrd t knw what services and drugs are cvered and the cst-sharing amunts fr yu. Because f this, it is very imprtant that yu help us keep yur infrmatin up t date. Let us knw abut these changes: 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 Custmer Care (phne numbers are printed n the back page 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

20 Chapter 1. Getting started as a member 18 yur benefits under ur plan. (Fr mre infrmatin abut hw ur cverage wrks when yu have ther insurance, see Sectin 10 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 Care (phne numbers are printed n the back page f this bklet). SECTION 9 Sectin 9.1 We prtect the privacy f yur persnal health infrmatin We make sure that yur health infrmatin is prtected Federal and state laws prtect the privacy f yur medical recrds and persnal health infrmatin. We prtect yur persnal health infrmatin as required by these laws. Fr mre infrmatin abut hw we prtect yur persnal health infrmatin, please g t Chapter 8, Sectin 1.4 f this bklet. SECTION 10 Sectin 10.1 Hw ther insurance wrks with ur plan Which plan pays first when yu have ther insurance? When yu have ther insurance (like emplyer grup health cverage), there are rules set by Medicare that decide whether ur plan r yur ther insurance pays first. The insurance that pays first is called the primary payer and pays up t the limits f its cverage. The ne that pays secnd, called the secndary payer, nly pays if there are csts left uncvered by the primary cverage. The secndary payer may nt pay all f the uncvered csts. These rules apply fr emplyer r unin grup health plan cverage: If yu have retiree cverage, Medicare pays first. If yur grup health plan cverage is based n yur r a family member s current emplyment, wh pays first depends n yur age, the number f peple emplyed by yur emplyer, and whether yu have Medicare based n age, disability, r End-stage Renal Disease (ESRD): If yu re under 65 and disabled and yu r yur family member is still wrking, yur grup health plan pays first if the emplyer has 100 r mre emplyees r at least ne emplyer in a multiple emplyer plan that has mre than 100 emplyees. If yu re ver 65 and yu r yur spuse is still wrking, yur grup health plan pays first if the emplyer has 20 r mre emplyees r at least ne emplyer in a multiple emplyer plan that has mre than 20 emplyees. If yu have Medicare because f ESRD, yur grup health plan will pay first fr the first 30 mnths after yu becme eligible fr Medicare. These types f cverage usually pay first fr services related t each type: N-fault insurance (including autmbile insurance) Liability (including autmbile insurance) Black lung benefits

21 Chapter 1. Getting started as a member 19 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 Care (phne numbers are printed n the back page 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.

22

23 CHAPTER 2 Imprtant phne numbers and resurces

24 Chapter 2. Imprtant phne numbers and resurces 22 Chapter 2. Imprtant phne numbers and resurces SECTION 1 SECTION 2 SECTION 3 SECTION 4 SECTION 5 SECTION 6 SECTION 7 Medicare Blue Chice Select (HMO-POS) cntacts (hw t cntact us, including hw t reach Custmer Care at the plan) Medicare (hw t get help and infrmatin directly frm the Federal Medicare prgram) State Health Insurance Assistance Prgram (free help, infrmatin, and answers t yur questins abut Medicare)...27 Quality Imprvement Organizatin (paid by Medicare t check n the quality f care fr peple with Medicare) Scial Security...28 Medicaid (a jint Federal and state prgram that helps with medical csts fr sme peple with limited incme and resurces) Infrmatin abut prgrams t help peple pay fr their prescriptin drugs...30 SECTION 8 Hw t cntact the Railrad Retirement Bard SECTION 9 D yu have grup insurance r ther health insurance frm an emplyer?... 34

25 Chapter 2. Imprtant phne numbers and resurces 23 SECTION 1 Medicare Blue Chice Select (HMO-POS) cntacts (hw t cntact us, including hw t reach Custmer Care at the plan) Hw t cntact ur plan s Custmer Care Fr assistance with claims, billing, r member card questins, please call r write t Medicare Blue Chice Select (HMO-POS) Custmer Care. We will be happy t help yu. Methd Custmer Care Cntact Infrmatin CALL Medical and Part D Prescriptin Drug: Calls t this number are free. Hurs are Mnday - Friday, 8:00 a.m. - 8:00 p.m. Representatives are als available 8:00 a.m. - 8:00 p.m., Mnday - Sunday, frm Octber 1 - February 14. Custmer Care 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. Hurs are Mnday - Friday, 8:00 a.m. - 8:00 p.m. Representatives are als available 8:00 a.m. - 8:00 p.m., Mnday - Sunday, frm Octber 1 - February 14. FAX WRITE PO Bx 546, Buffal, NY WEBSITE Hw t cntact us when yu are asking fr a cverage decisin abut yur medical care and Part D Prescriptin Drugs A cverage decisin is a decisin we make abut yur benefits and cverage r abut the amunt we will pay fr yur medical services and prescriptin drugs cvered under the Part D benefit. Fr mre infrmatin n asking fr cverage decisins abut yur medical care and Part D prescriptin drugs, see Chapter 9 (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 and Part D Prescriptin Drugs Cntact Infrmatin CALL Medical and Part D Prescriptin Drug: Calls t this number are free. Hurs are Mnday - Friday, 8:00 a.m. - 8:00 p.m. Representatives are als available 8:00 a.m. - 8:00 p.m., Mnday - Sunday, frm Octber 1 - February 14. Yu may submit a request utside f regular weekday business hurs and weekends by calling

26 Chapter 2. Imprtant phne numbers and resurces 24 Methd Cverage Decisins Fr Medical Care and Part D Prescriptin Drugs Cntact Infrmatin 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. Hurs are Mnday - Friday, 8:00 a.m. - 8:00 p.m. Representatives are als available 8:00 a.m. - 8:00 p.m., Mnday - Sunday, frm Octber 1 - February 14. FAX WRITE PO Bx 546, Buffal, NY WEBSITE Hw t cntact us when yu are making an appeal abut yur medical care and Part D Prescriptin Drugs 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 and Part D prescriptin drugs, see Chapter 9 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints)). Methd Appeals Fr Medical Care and Part D Prescriptin Drugs Cntact Infrmatin CALL Medical and Part D Prescriptin Drug: Calls t this number are free. Hurs are Mnday - Friday, 8:00 a.m. - 8:00 p.m. Representatives are als available 8:00 a.m. - 8:00 p.m., Mnday - Sunday, frm Octber 1 - February 14. Yu may submit a request utside f regular weekday business hurs and weekends by calling 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. Hurs are Mnday - Friday, 8:00 a.m. - 8:00 p.m. Representatives are als available 8:00 a.m. - 8:00 p.m., Mnday - Sunday, frm Octber 1 - February 14. FAX WRITE PO Bx 4717, Syracuse, NY WEBSITE Hw t cntact us when yu are making a cmplaint abut yur medical care and Part D Prescriptin Drugs Yu can make a cmplaint abut us r ne f ur netwrk prviders and netwrk pharmacies, 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

27 Chapter 2. Imprtant phne numbers and resurces 25 cmplaint abut yur medical care and Part D prescriptin drugs, see Chapter 9 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints)). Methd Cmplaints Abut Medical Care and Part D Prescriptin Drugs Cntact Infrmatin CALL Medical and Part D Prescriptin Drug: Calls t this number are free. Hurs are Mnday - Friday, 8:00 a.m. - 8:00 p.m. Representatives are als available 8:00 a.m. - 8:00 p.m., Mnday - Sunday, frm Octber 1 - February 14. Yu may submit a request utside f regular weekday business hurs and weekends by calling 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. Hurs are Mnday - Friday, 8:00 a.m. - 8:00 p.m. Representatives are als available 8:00 a.m. - 8:00 p.m., Mnday - Sunday, frm Octber 1 - February 14. FAX WRITE PO Bx 4717, Syracuse, NY MEDICARE WEBSITE Yu can submit a cmplaint abut Medicare Blue Chice Select (HMO-POS) directly t Medicare. T submit an nline cmplaint t Medicare g t Where t send a request asking us t pay fr ur share f the cst fr medical care r a drug 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 r drugs). Please nte: If yu send us a payment request and we deny any part f yur request, yu can appeal ur decisin. See Chapter 9 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints)) fr mre infrmatin.

28 Chapter 2. Imprtant phne numbers and resurces 26 Methd Payment Requests fr Medical Care and Part D Prescriptin Drugs Cntact Infrmatin CALL Medical and Part D Prescriptin Drug: Calls t this numbers are free. Mnday - Friday, 8:00 a.m. - 8:00 p.m. Representatives are als available 8:00 a.m. - 8:00 p.m., Mnday - Sunday, frm Octber 1 - February 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. Hurs are Mnday - Friday, 8:00 a.m. - 8:00 p.m. Representatives are als available 8:00 a.m. - 8:00 p.m., Mnday - Sunday, frm Octber 1 - February 14. FAX WRITE Medical: PO Bx 21146, Eagan, MN Part D Prescriptin Drugs: PO Bx 14711, Lexingtn, KY WEBSITE 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. 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.