AFFINITY MEDICARE. Passport Essentials (HMO)

Transcription

1 2018 AFFINITY MEDICARE Passport Essentials (HMO)

2 Affinity Medicare Passport Essentials (HMO) offered by Affinity Health Plan Annual Notice of Changes for 2018 You are currently enrolled as a member of Affinity Medicare Passport Essentials. Next year, there will be some changes to the plan s costs and benefits. This booklet tells about the changes. You have from October 15 until December 7 to make changes to your Medicare coverage for next year. What to do now 1. ASK: Which changes apply to you Check the changes to our benefits and costs to see if they affect you. It s important to review your coverage now to make sure it will meet your needs next year. Do the changes affect the services you use? Look in Sections 1 and 2 for information about benefit and cost changes for our plan. Check the changes in the booklet to our prescription drug coverage to see if they affect you. Will your drugs be covered? Are your drugs in a different tier, with different cost-sharing? Do any of your drugs have new restrictions, such as needing approval from us before you fill your prescription? Can you keep using the same pharmacies? Are there changes to the cost of using this pharmacy? Review the 2018 Drug List and look in Section 1.6 for information about changes to our drug coverage. Check to see if your doctors and other providers will be in our network next year. Are your doctors in our network? What about the hospitals or other providers you use? Look in Section 1.3 for information about our Provider Directory. Think about your overall health care costs. Form CMS ANOC/EOC OMB Approval (Expires May 31, 2020) (Approved 05/2017)

3 How much will you spend out-of-pocket for the services and prescription drugs you use regularly? How much will you spend on your premium and deductibles? How do your total plan costs compare to other Medicare coverage options? Think about whether you are happy with our plan. 2. COMPARE: Learn about other plan choices Check coverage and costs of plans in your area. Use the personalized search feature on the Medicare Plan Finder at website. Click Find health & drug plans. Review the list in the back of your Medicare & You handbook. Look in Section 3.2 to learn more about your choices. Once you narrow your choice to a preferred plan, confirm your costs and coverage on the plan s website. 3. CHOOSE: Decide whether you want to change your plan If you want to keep Affinity Medicare Passport Essentials, you don t need to do anything. You will stay in Affinity Medicare Passport Essentials. To change to a different plan that may better meet your needs, you can switch plans between October 15 and December ENROLL: To change plans, join a plan between October 15 and December 7, 2017 If you don t join by December 7, 2017, you will stay in Affinity Medicare Passport Essentials. If you join by December 7, 2017, your new coverage will start on January 1, 2018.

4 Additional Resources This document is available for free in Spanish. Please contact our Customer Service number at for additional information. (TTY users should call 711.) Hours are Monday to Friday, 8 am to 8 pm. This information is available in a different format, including large print, audio tape and Braille. Please call Customer Service at the number listed above if you need plan information in another format or language. Coverage under this Plan qualifies as minimum essential coverage (MEC) and satisfies the Patient Protection and Affordable Care Act s (ACA) individual shared responsibility requirement. Please visit the Internal Revenue Service (IRS) website at for more information. About Affinity Medicare Passport Essentials Affinity Health Plan is an HMO Plan with a Medicare contract. Enrollment in Affinity Health Plan depends on contract renewal. When this booklet says we, us, or our, it means Affinity Health Plan. When it says plan or our plan, it means Affinity Medicare Passport Essentials. H5991_ANOCEOCESSESSNYC18 File & Use

5 Affinity Medicare Passport Essentials Annual Notice of Changes for Summary of Important Costs for 2018 The table below compares the 2017 costs and 2018 costs for Affinity Medicare Passport Essentials in several important areas. Please note this is only a summary of changes. It is important to read the rest of this Annual Notice of Changes and review the enclosed Evidence of Coverage to see if other benefit or cost changes affect you. Cost 2017 (this year) 2018 (next year) Monthly plan premium* * Your premium may be higher or lower than this amount. See Section 1.1 for details. Maximum out-of-pocket amount This is the most you will pay out-of-pocket for your covered Part A and Part B services. (See Section 1.2 for details.) $0 $0 $6,700 $5,400 Doctor office visits Primary care visits: $0 copay per visit Specialist visits: $35 copay per visit Primary care visits: $5 copay per visit Specialist visits: $35 copay per visit Inpatient hospital stays Includes inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor s order. The day before you are discharged is your last inpatient day. $295 copay per day for days 1-6 $0 copay per day for days 7-90 $0 copay per day for days 91 and beyond $295 copay per day for days 1-6 $0 copay per day for days 7-90 $0 copay per day for days 91 and beyond

6 Affinity Medicare Passport Essentials Annual Notice of Changes for Cost 2017 (this year) 2018 (next year) Part D prescription drug coverage (See Section 1.6 for details.) Deductible: $250 Copayment/Coinsurance during the Initial Coverage Stage: Drug Tier 1: $0 copay Drug Tier 2: $10 copay Drug Tier 3: $47 copay Drug Tier 4: $100 copay Drug Tier 5: 28% of the cost Deductible: $250 Copayment/Coinsurance during the Initial Coverage Stage: Drug Tier 1: $0 copay Drug Tier 2: $10 copay Drug Tier 3: $47 copay Drug Tier 4: $100 copay Drug Tier 5: 28% of the cost

7 Affinity Medicare Passport Essentials Annual Notice of Changes for Annual Notice of Changes for 2018 Table of Contents Summary of Important Costs for SECTION 1 Changes to Benefits and Costs for Next Year... 7 Section 1.1 Changes to the Monthly Premium... 7 Section 1.2 Changes to Your Maximum Out-of-Pocket Amount... 7 Section 1.3 Changes to the Provider Network... 8 Section 1.4 Changes to the Pharmacy Network... 8 Section 1.5 Changes to Benefits and Costs for Medical Services... 9 Section 1.6 Changes to Part D Prescription Drug Coverage SECTION 2 Administrative Changes SECTION 3 Deciding Which Plan to Choose Section 3.1 If you want to stay in Affinity Medicare Passport Essentials Section 3.2 If you want to change plans SECTION 4 SECTION 5 SECTION 6 Deadline for Changing Plans Programs That Offer Free Counseling about Medicare Programs That Help Pay for Prescription Drugs SECTION 7 Questions? Section 7.1 Getting Help from Affinity Medicare Passport Essentials Section 7.2 Getting Help from Medicare... 17

8 Affinity Medicare Passport Essentials Annual Notice of Changes for SECTION 1 Changes to Benefits and Costs for Next Year Section 1.1 Changes to the Monthly Premium Cost 2017 (this year) 2018 (next year) Monthly premium (You must also continue to pay your Medicare Part B premium.) $0 $0 Your monthly plan premium will be more if you are required to pay a lifetime Part D late enrollment penalty for going without other drug coverage that is at least as good as Medicare drug coverage (also referred to as creditable coverage ) for 63 days or more. If you have a higher income, you may have to pay an additional amount each month directly to the government for your Medicare prescription drug coverage. Your monthly premium will be less if you are receiving Extra Help with your prescription drug costs. Section 1.2 Changes to Your Maximum Out-of-Pocket Amount To protect you, Medicare requires all health plans to limit how much you pay out-of-pocket during the year. This limit is called the maximum out-of-pocket amount. Once you reach this amount, you generally pay nothing for covered Part A and Part B services for the rest of the year. Cost 2017 (this year) 2018 (next year) Maximum out-of-pocket amount Your costs for covered medical services (such as copays) count toward your maximum out-ofpocket amount. Your costs for prescription drugs do not count toward your maximum out-ofpocket amount. $6,700 $5,400 Once you have paid $5,400 out-of-pocket for covered Part A and Part B services, you will pay nothing for your covered Part A and Part B services for the rest of the calendar year.

9 Affinity Medicare Passport Essentials Annual Notice of Changes for Section 1.3 Changes to the Provider Network There are changes to our network of providers for next year. An updated Provider Directory is located on our website at You may also call Customer Service for updated provider information or to ask us to mail you a Provider Directory. Please review the 2018 Provider Directory to see if your providers (primary care provider, specialists, hospitals, etc.) are in our network. It is important that you know that we may make changes to the hospitals, doctors and specialists (providers) that are part of your plan during the year. There are a number of reasons why your provider might leave your plan, but if your doctor or specialist does leave your plan you have certain rights and protections summarized below: Even though our network of providers may change during the year, Medicare requires that we furnish you with uninterrupted access to qualified doctors and specialists. We will make a good faith effort to provide you with at least 30 days notice that your provider is leaving our plan so that you have time to select a new provider. We will assist you in selecting a new qualified provider to continue managing your health care needs. If you are undergoing medical treatment you have the right to request, and we will work with you to ensure, that the medically necessary treatment you are receiving is not interrupted. If you believe we have not furnished you with a qualified provider to replace your previous provider or that your care is not being appropriately managed, you have the right to file an appeal of our decision. If you find out your doctor or specialist is leaving your plan, please contact us so we can assist you in finding a new provider and managing your care. Section 1.4 Changes to the Pharmacy Network Amounts you pay for your prescription drugs may depend on which pharmacy you use. Medicare drug plans have a network of pharmacies. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies. There are changes to our network of pharmacies for next year. An updated Pharmacy Directory is located on our website at You may also call Customer Service for updated provider information or to ask us to mail you a Pharmacy Directory. Please review the 2018 Pharmacy Directory to see which pharmacies are in our network.

10 Affinity Medicare Passport Essentials Annual Notice of Changes for Section 1.5 Changes to Benefits and Costs for Medical Services We are changing our coverage for certain medical services next year. The information below describes these changes. For details about the coverage and costs for these services, see Chapter 4, Medical Benefits Chart (what is covered and what you pay), in your 2018 Evidence of Coverage. Cost 2017 (this year) 2018 (next year) Emergency Care Hearing Services Primary Care Physician Services Skilled Nursing Facility (SNF) You pay a $75 copay for each Medicare-covered Emergency care visit. You pay a $20 copay for routine hearing exams (up to 1 every two years) Hearing aid (for up to 1 every two years) and hearing aid fitting/evaluation (for up to 1 every two years): Our plan pays up to $350 every year for hearing aids for both ears combined. You pay a $0 copay for each Medicare-covered Primary Care visit. You pay a $0 copay per day for days 1-20 $160 copay per day for days for Skilled Nursing Facility. You pay an $80 copay for each Medicare-covered Emergency care visit. You pay a $20 copay for routine hearing exams (up to 1 every year) Hearing aid (for up to 2 every year) and hearing aid fitting/evaluation (for up to 1 every year): Our plan pays up to $350 every year for hearing aids for both ears combined. You pay a $5 copay for each Medicare-covered Primary Care visit. You pay a $0 copay per day for days 1-20 $ copay per day for days for Skilled Nursing Facility.

11 Affinity Medicare Passport Essentials Annual Notice of Changes for Cost 2017 (this year) 2018 (next year) Worldwide Emergency/Urgent Coverage You pay a $75 copay for each Medicare-covered Worldwide Emergency care visit. Copay is waived if you are admitted to the hospital for the same condition. You pay a $20 copay for each Medicare-covered Worldwide Urgent care visit. Copay is waived if you are admitted to the hospital for the same condition. Worldwide emergency transportation is not covered. You pay an $80 copay for each Medicare-covered Worldwide Emergency care visit. Copay is not waived if you are admitted to the hospital for the same condition. You pay an $80 copay for each Medicare-covered Worldwide Urgent care visit. Copay is not waived if you are admitted to the hospital for the same condition. You pay an $80 copay for each Medicare-covered Worldwide emergency transportation ride. Section 1.6 Changes to Part D Prescription Drug Coverage Changes to Our Drug List Our list of covered drugs is called a Formulary or Drug List. A copy of our Drug List is in this envelope. The Drug List we included in this envelope includes many but not all of the drugs that we will cover next year. If you don t see your drug on this list, it might still be covered. You can get the complete Drug List by calling Customer Service (see the back cover) or visiting our website ( We made changes to our Drug List, including changes to the drugs we cover and changes to the restrictions that apply to our coverage for certain drugs. Review the Drug List to make sure your drugs will be covered next year and to see if there will be any restrictions. If you are affected by a change in drug coverage, you can: Work with your doctor (or other prescriber) and ask the plan to make an exception to cover the drug. We encourage current members to ask for an exception before next year.

12 Affinity Medicare Passport Essentials Annual Notice of Changes for o To learn what you must do to ask for an exception, see Chapter 9 of your Evidence of Coverage (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) or call Customer Service. Work with your doctor (or other prescriber) to find a different drug that we cover. You can call Customer Service to ask for a list of covered drugs that treat the same medical condition. In some situations, we are required to cover a one-time, temporary supply of a non-formulary drug in the first 90 days of the plan year or the first 90 days of membership to avoid a gap in therapy. (To learn more about when you can get a temporary supply and how to ask for one, see Chapter 5, Section 5.2 of the Evidence of Coverage.) During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. Current formulary exceptions will be carried over into the next year, depending on the initial time period of the exception allowance. Changes to Prescription Drug Costs Note: If you are in a program that helps pay for your drugs ( Extra Help ), the information about costs for Part D prescription drugs may not apply to you. We have included a separate insert, called the Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs (also called the Low Income Subsidy Rider or the LIS Rider ), which tells you about your drug costs. If you receive Extra Help and didn t receive this insert with this packet, please call Customer Service and ask for the LIS Rider. Phone numbers for Customer Service are in Section 7.1 of this booklet. There are four drug payment stages. How much you pay for a Part D drug depends on which drug payment stage you are in. (You can look in Chapter 6, Section 2 of your Evidence of Coverage for more information about the stages.) The information below shows the changes for next year to the first two stages the Yearly Deductible Stage and the Initial Coverage Stage. (Most members do not reach the other two stages the Coverage Gap Stage or the Catastrophic Coverage Stage. To get information about your costs in these stages, look at Chapter 6, Sections 6 and 7, in the enclosed Evidence of Coverage.)

13 Affinity Medicare Passport Essentials Annual Notice of Changes for Changes to the Deductible Stage Stage 2017 (this year) 2018 (next year) Stage 1: Yearly Deductible Stage During this stage, you pay the full cost of your Tier 3, Tier 4 and Tier 5 drugs until you have reached the yearly deductible. The deductible is $250. During this stage, you pay $0 copay costsharing for drugs on Tier 1, $10 copay cost-sharing for drugs on Tier 2, and the full cost of drugs on Tier 3, Tier 4 and Tier 5 until you have reached the yearly deductible. The deductible is $250. During this stage, you pay $0 copay cost-sharing for drugs on Tier 1, $10 copay cost-sharing for drugs on Tier 2, and the full cost of drugs on Tier 3, Tier 4 and Tier 5 until you have reached the yearly deductible. Changes to Your Cost-sharing in the Initial Coverage Stage To learn how copayments and coinsurance work, look at Chapter 6, Section 1.2, Types of out-ofpocket costs you may pay for covered drugs in your Evidence of Coverage. Stage 2017 (this year) 2018 (next year) Stage 2: Initial Coverage Stage Once you pay the yearly deductible, you move to the Initial Coverage Stage. During this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost. The costs in this row are for a one-month (30-day) supply when you fill your prescription at a network pharmacy that provides standard cost-sharing. For information about the costs for a long-term supply; or for mail-order prescriptions, look in Chapter 6, Section 5 of your Evidence of Coverage. Your cost for a one-month supply filled at a network pharmacy with standard cost-sharing: Tier 1: Preferred Generic: You pay $0 copay per prescription. Tier 2: Generic: You pay $10 copay per prescription. Tier 3: Preferred Brand: You pay $47 copay per prescription. Your cost for a one-month supply filled at a network pharmacy with standard cost-sharing: Tier 1: Preferred Generic: You pay $0 copay per prescription. Tier 2: Generic: You pay $10 copay per prescription. Tier 3: Preferred Brand: You pay $47 copay per prescription.

14 Affinity Medicare Passport Essentials Annual Notice of Changes for Stage 2017 (this year) 2018 (next year) We changed the tier for some of the drugs on our Drug List. To see if your drugs will be in a different tier, look them up on the Drug List. Tier 4: Non-Preferred Brand: You pay $100 copay per prescription. Tier 4: Non-Preferred Brand: You pay $100 copay per prescription. Tier 5: Specialty Tier: You pay 28% of the cost per prescription. Once your total drug costs have reached $3,700, you will move to the next stage (the Coverage Gap Stage). Tier 5: Specialty Tier: You pay 28% of the cost per prescription. Once your total drug costs have reached $3,750, you will move to the next stage (the Coverage Gap Stage). Changes to the Coverage Gap and Catastrophic Coverage Stages The other two drug coverage stages the Coverage Gap Stage and the Catastrophic Coverage Stage are for people with high drug costs. Most members do not reach the Coverage Gap Stage or the Catastrophic Coverage Stage. For information about your costs in these stages, look at Chapter 6, Sections 6 and 7, in your Evidence of Coverage. SECTION 2 Administrative Changes Cost 2017 (this year) 2018 (next year) Comprehensive Dental Services Outpatient Diagnostic Services Prior Authorization is not required for Comprehensive Dental Services. Prior Authorization is required for PET scans, MRI, MRA and Cardiac CT. Prior Authorization is required for Periodontic Services only. Prior Authorization is required for PET scans, MRI, MRA, Cardiac CT, ultrasounds and sleep studies.

15 Affinity Medicare Passport Essentials Annual Notice of Changes for Cost 2017 (this year) 2018 (next year) Prosthetics/Medical Supplies Prior Authorization is not required for sleep study supplies. Prior Authorization for sleep study supplies is required every three months. SECTION 3 Deciding Which Plan to Choose Section 3.1 If you want to stay in Affinity Medicare Passport Essentials To stay in our plan you don t need to do anything. If you do not sign up for a different plan or change to Original Medicare by December 7, you will automatically stay enrolled as a member of our plan for Section 3.2 If you want to change plans We hope to keep you as a member next year but if you want to change for 2018 follow these steps: Step 1: Learn about and compare your choices You can join a different Medicare health plan, OR-- You can change to Original Medicare. If you change to Original Medicare, you will need to decide whether to join a Medicare drug plan. To learn more about Original Medicare and the different types of Medicare plans, read Medicare & You 2018, call your State Health Insurance Assistance Program (see Section 5), or call Medicare (see Section 7.2). You can also find information about plans in your area by using the Medicare Plan Finder on the Medicare website. Go to and click Find health & drug plans. Here, you can find information about costs, coverage, and quality ratings for Medicare plans. Step 2: Change your coverage To change to a different Medicare health plan, enroll in the new plan. You will automatically be disenrolled from Affinity Medicare Passport Essentials. To change to Original Medicare with a prescription drug plan, enroll in the new drug plan. You will automatically be disenrolled from Affinity Medicare Passport Essentials. To change to Original Medicare without a prescription drug plan, you must either:

16 Affinity Medicare Passport Essentials Annual Notice of Changes for o Send us a written request to disenroll. Contact Customer Service if you need more information on how to do this (phone numbers are in Section 7.1 of this booklet). o or Contact Medicare, at MEDICARE ( ), 24 hours a day, 7 days a week, and ask to be disenrolled. TTY users should call SECTION 4 Deadline for Changing Plans If you want to change to a different plan or to Original Medicare for next year, you can do it from October 15 until December 7. The change will take effect on January 1, Are there other times of the year to make a change? In certain situations, changes are also allowed at other times of the year. For example, people with Medicaid, those who get Extra Help paying for their drugs, those who have or are leaving employer coverage, and those who move out of the service area are allowed to make a change at other times of the year. For more information, see Chapter 10, Section 2.3 of the Evidence of Coverage. If you enrolled in a Medicare Advantage plan for January 1, 2018, and don t like your plan choice, you can switch to Original Medicare between January 1 and February 14, For more information, see Chapter 10, Section 2.2 of the Evidence of Coverage. SECTION 5 Programs That Offer Free Counseling about Medicare The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors in every state. In New York, the SHIP is called the Health Insurance Information Counseling Assistance Program (HIICAP). The Health Insurance Information Counseling Assistance Program (HIICAP) is independent (not connected with any insurance company or health plan). It is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare. Health Insurance Information Counseling Assistance Program (HIICAP) counselors can help you with your Medicare questions or problems. They can help you understand your Medicare plan choices and answer questions about switching plans. You can call the Health Insurance Information Counseling Assistance Program (HIICAP) at You can learn more about Health Insurance Information Counseling Assistance Program (HIICAP) by visiting their website ( SECTION 6 Programs That Help Pay for Prescription Drugs You may qualify for help paying for prescription drugs. Below we list different kinds of help: Extra Help from Medicare. People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay up to

17 Affinity Medicare Passport Essentials Annual Notice of Changes for % or more of your drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not have a coverage gap or late enrollment penalty. Many people are eligible and don t even know it. To see if you qualify, call: o MEDICARE ( ). TTY users should call , 24 hours a day/7 days a week; o The Social Security Office at between 7 am and 7 p.m., Monday through Friday. TTY users should call, (applications); or o Your State Medicaid Office (applications). Help from your state s pharmaceutical assistance program. New York has a program called Elderly Pharmaceutical Insurance Coverage (EPIC) that helps people pay for prescription drugs based on their financial need, age, or medical condition. To learn more about the program, check with your State Health Insurance Assistance Program (the name and phone numbers for this organization are in Section 5 of this booklet). Prescription Cost-sharing Assistance for Persons with HIV/AIDS. The AIDS Drug Assistance Program (ADAP) helps ensure that ADAP-eligible individuals living with HIV/AIDS have access to life-saving HIV medications. Individuals must meet certain criteria, including proof of State residence and HIV status, low income as defined by the State, and uninsured/under-insured status. Medicare Part D prescription drugs that are also covered by ADAP qualify for prescription cost-sharing assistance through the NYS Department of Health s AIDS Institute. For information on eligibility criteria, covered drugs, or how to enroll in the program, please call SECTION 7 Questions? Section 7.1 Getting Help from Affinity Medicare Passport Essentials Questions? We re here to help. Please call Customer Service at (TTY only, call 711). We are available for phone calls Monday through Friday from 8 am to 8 pm. Calls to these numbers are free. Read your 2018 Evidence of Coverage (it has details about next year's benefits and costs) This Annual Notice of Changes gives you a summary of changes in your benefits and costs for For details, look in the 2018 Evidence of Coverage for Affinity Medicare Passport Essentials. The Evidence of Coverage is the legal, detailed description of your plan benefits. It explains your rights and the rules you need to follow to get covered services and prescription drugs. A copy of the Evidence of Coverage is included in this envelope.

18 Affinity Medicare Passport Essentials Annual Notice of Changes for Visit our Website You can also visit our website at As a reminder, our website has the most up-to-date information about our provider network (Provider Directory) and our list of covered drugs (Formulary/Drug List). Section 7.2 Getting Help from Medicare To get information directly from Medicare: Call MEDICARE ( ) You can call MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Visit the Medicare Website You can visit the Medicare website ( It has information about cost, coverage, and quality ratings to help you compare Medicare health plans. You can find information about plans available in your area by using the Medicare Plan Finder on the Medicare website. (To view the information about plans, go to and click on Find health & drug plans ). Read Medicare & You 2018 You can read the Medicare & You 2018 Handbook. Every year in the fall, this booklet is mailed to people with Medicare. It has a summary of Medicare benefits, rights and protections, and answers to the most frequently asked questions about Medicare. If you don t have a copy of this booklet, you can get it at the Medicare website ( or by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call

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20 January 1 December 31, 2018 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Affinity Medicare Passport Essentials/Essentials NYC (HMO) This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 December 31, It explains how to get coverage for the health care services and prescription drugs you need. This is an important legal document. Please keep it in a safe place. This plan, Affinity Medicare Passport Essentials/Essentials NYC, is offered by Affinity Health Plan. (When this Evidence of Coverage says we, us, or our, it means Affinity Health Plan. When it says plan or our plan, it means Affinity Medicare Passport Essentials/Essentials NYC.) Affinity Health Plan is an HMO Plan with a Medicare contract. Enrollment in Affinity Health Plan depends on contract renewal. This document is available for free in Spanish. Please contact our Customer Service number at for additional information. (TTY users should call 711.) Hours are 8 am to 8 pm, Monday through Friday. This information is available in a different format, including large print, audio tape and Braille. Please call Customer Service at the number listed above if you need plan information in another format or language. Benefits, premium, deductible, and/or copayments/coinsurance may change on January 1, The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. H5991_ANOCEOCESSESSNYC18 File & Use Form CMS ANOC/EOC OMB Approval (Expires: May 31, 2020) (Approved 05/2017)

21 Table of Contents Evidence of Coverage Table of Contents This list of chapters and page numbers is your starting point. For more help in finding information you need, go to the first page of a chapter. You will find a detailed list of topics at the beginning of each chapter. Chapter 1. Chapter 2. Chapter 3. Chapter 4. Chapter 5. Getting started as a member... 6 Explains what it means to be in a Medicare health plan and how to use this booklet. Tells about materials we will send you, your plan premium, the Part D late enrollment penalty, your plan membership card, and keeping your membership record up to date. Important phone numbers and resources Tells you how to get in touch with our plan (Affinity Medicare Passport Essentials/Essentials NYC) and with other organizations including Medicare, the State Health Insurance Assistance Program (SHIP), the Quality Improvement Organization, Social Security, Medicaid (the state health insurance program for people with low incomes), programs that help people pay for their prescription drugs, and the Railroad Retirement Board. Using the plan s coverage for your medical services Explains important things you need to know about getting your medical care as a member of our plan. Topics include using the providers in the plan s network and how to get care when you have an emergency. Medical Benefits Chart (what is covered and what you pay) Gives the details about which types of medical care are covered and not covered for you as a member of our plan. Explains how much you will pay as your share of the cost for your covered medical care. Using the plan s coverage for your Part D prescription drugs Explains rules you need to follow when you get your Part D drugs. Tells how to use the plan s List of Covered Drugs (Formulary) to find out which drugs are covered. Tells which kinds of drugs are not covered. Explains several kinds of restrictions that apply to coverage for certain drugs. Explains where to get your prescriptions filled. Tells about the plan s programs for drug safety and managing medications.

22 Table of Contents 3 Chapter 6. Chapter 7. Chapter 8. Chapter 9. What you pay for your Part D prescription drugs Tells about the four stages of drug coverage (Deductible Stage, Initial Coverage Stage, Coverage Gap Stage, Catastrophic Coverage Stage) and how these stages affect what you pay for your drugs. Explains the five costsharing tiers for your Part D drugs and tells what you must pay for a drug in each cost-sharing tier. Asking us to pay our share of a bill you have received for covered medical services or drugs Explains when and how to send a bill to us when you want to ask us to pay you back for our share of the cost for your covered services or drugs. Your rights and responsibilities Explains the rights and responsibilities you have as a member of our plan. Tells what you can do if you think your rights are not being respected. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Tells you step-by-step what to do if you are having problems or concerns as a member of our plan. Explains how to ask for coverage decisions and make appeals if you are having trouble getting the medical care or prescription drugs you think are covered by our plan. This includes asking us to make exceptions to the rules or extra restrictions on your coverage for prescription drugs, and asking us to keep covering hospital care and certain types of medical services if you think your coverage is ending too soon. Explains how to make complaints about quality of care, waiting times, customer service, and other concerns. Chapter 10. Ending your membership in the plan Explains when and how you can end your membership in the plan. Explains situations in which our plan is required to end your membership. Chapter 11. Legal notices Includes notices about governing law and about non-discrimination. Chapter 12. Definitions of important words Explains key terms used in this booklet

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24 CHAPTER 1 Getting started as a member

25 Chapter 1. Getting started as a member 6 Chapter 1. Getting started as a member SECTION 1 Section 1.1 Section 1.2 Section 1.3 SECTION 2 Section 2.1 Section 2.2 Section 2.3 Section 2.4 SECTION 3 Section 3.1 Section 3.2 Section 3.3 Section 3.4 Section 3.5 SECTION 4 Section 4.1 SECTION 5 Section 5.1 Section 5.2 Section 5.3 Section 5.4 SECTION 6 Section 6.1 Section 6.2 Section 6.3 Introduction... 8 You are enrolled in Affinity Medicare Passport Essentials/Essentials NYC, which is a Medicare HMO... 8 What is the Evidence of Coverage booklet about?... 8 Legal information about the Evidence of Coverage... 8 What makes you eligible to be a plan member?... 9 Your eligibility requirements... 9 What are Medicare Part A and Medicare Part B?... 9 Here is the plan service area for Affinity Medicare Passport Essentials/Essentials NYC... 9 U.S. Citizen or Lawful Presence What other materials will you get from us? Your plan membership card Use it to get all covered care and prescription drugs The Provider Directory: Your guide to all providers in the plan s network. 11 The Pharmacy Directory: Your guide to pharmacies in our network The plan s List of Covered Drugs (Formulary) The Part D Explanation of Benefits (the Part D EOB ): Reports with a summary of payments made for your Part D prescription drugs Your monthly premium for Affinity Medicare Passport Essentials/Essentials NYC How much is your plan premium? Do you have to pay the Part D late enrollment penalty? What is the Part D late enrollment penalty? How much is the Part D late enrollment penalty? In some situations, you can enroll late and not have to pay the penalty What can you do if you disagree about your Part D late enrollment penalty? Do you have to pay an extra Part D amount because of your income? Who pays an extra Part D amount because of income? How much is the extra Part D amount? What can you do if you disagree about paying an extra Part D amount?... 17

26 Chapter 1. Getting started as a member 7 Section 6.4 SECTION 7 Section 7.1 Section 7.2 SECTION 8 Section 8.1 SECTION 9 Section 9.1 SECTION 10 Section 10.1 What happens if you do not pay the extra Part D amount? More information about your monthly premium If you pay a Part D late enrollment penalty, there are several ways you can pay your penalty Can we change your monthly plan premium during the year? Please keep your plan membership record up to date How to help make sure that we have accurate information about you We protect the privacy of your personal health information We make sure that your health information is protected How other insurance works with our plan Which plan pays first when you have other insurance?... 21

27 Chapter 1. Getting started as a member 8 SECTION 1 Section 1.1 Introduction You are enrolled in Affinity Medicare Passport Essentials/Essentials NYC, which is a Medicare HMO You are covered by Medicare, and you have chosen to get your Medicare health care and your prescription drug coverage through our plan, Affinity Medicare Passport Essentials/Essentials NYC. There are different types of Medicare health plans. Affinity Medicare Passport Essentials/Essentials NYC is a Medicare Advantage HMO Plan (HMO stands for Health Maintenance Organization) approved by Medicare and run by a private company. Section 1.2 What is the Evidence of Coverage booklet about? This Evidence of Coverage booklet tells you how to get your Medicare medical care and prescription drugs covered through our plan. This booklet explains your rights and responsibilities, what is covered, and what you pay as a member of the plan. The word coverage and covered services refers to the medical care and services and the prescription drugs available to you as a member of Affinity Medicare Passport Essentials/Essentials NYC. It s important for you to learn what the plan s rules are and what services are available to you. We encourage you to set aside some time to look through this Evidence of Coverage booklet. If you are confused or concerned or just have a question, please contact our plan s Customer Service (phone numbers are printed on the back cover of this booklet). Section 1.3 Legal information about the Evidence of Coverage It s part of our contract with you This Evidence of Coverage is part of our contract with you about how Affinity Medicare Passport Essentials/Essentials NYC covers your care. Other parts of this contract include your enrollment form, the List of Covered Drugs (Formulary), and any notices you receive from us about changes to your coverage or conditions that affect your coverage. These notices are sometimes called riders or amendments. The contract is in effect for months in which you are enrolled in Affinity Medicare Passport Essentials/Essentials NYC between January 1, 2018 and December 31, Each calendar year, Medicare allows us to make changes to the plans that we offer. This means we can change the costs and benefits of Affinity Medicare Passport Essentials/Essentials NYC

28 Chapter 1. Getting started as a member 9 after December 31, We can also choose to stop offering the plan, or to offer it in a different service area, after December 31, Medicare must approve our plan each year Medicare (the Centers for Medicare & Medicaid Services) must approve Affinity Medicare Passport Essentials/Essentials NYC each year. You can continue to get Medicare coverage as a member of our plan as long as we choose to continue to offer the plan and Medicare renews its approval of the plan. SECTION 2 Section 2.1 What makes you eligible to be a plan member? Your eligibility requirements You are eligible for membership in our plan as long as: You have both Medicare Part A and Medicare Part B (section 2.2 tells you about Medicare Part A and Medicare Part B) -- and -- you live in our geographic service area (section 2.3 below describes our service area). -- and -- you are a United States citizen or are lawfully present in the United States -- and -- you do not have End-Stage Renal Disease (ESRD), with limited exceptions, such as if you develop ESRD when you are already a member of a plan that we offer, or you were a member of a different plan that was terminated. Section 2.2 What are Medicare Part A and Medicare Part B? When you first signed up for Medicare, you received information about what services are covered under Medicare Part A and Medicare Part B. Remember: Medicare Part A generally helps cover services provided by hospitals (for inpatient services, skilled nursing facilities, or home health agencies). Medicare Part B is for most other medical services (such as physician s services and other outpatient services) and certain items (such as durable medical equipment (DME) and supplies). Section 2.3 Here is the plan service area for Affinity Medicare Passport Essentials/Essentials NYC Although Medicare is a Federal program, Affinity Medicare Passport Essentials/Essentials NYC is available only to individuals who live in our plan service area. To remain a member of our plan, you must continue to reside in the plan service area. The service area is described below.

29 Chapter 1. Getting started as a member 10 Our service area includes these counties in New York: Essentials: Nassau, Orange, Rockland, and Westchester and Essentials NYC: Bronx, Kings, New York, Queens and Richmond If you plan to move out of the service area, please contact Customer Service (phone numbers are printed on the back cover of this booklet). When you move, you will have a Special Enrollment Period that will allow you to switch to Original Medicare or enroll in a Medicare health or drug plan that is available in your new location. It is also important that you call Social Security if you move or change your mailing address. You can find phone numbers and contact information for Social Security in Chapter 2, Section 5. Section 2.4 U.S. Citizen or Lawful Presence A member of a Medicare health plan must be a U.S. citizen or lawfully present in the United States. Medicare (the Centers for Medicare & Medicaid Services) will notify Affinity Medicare Passport Essentials/Essentials NYC if you are not eligible to remain a member on this basis. Affinity Medicare Passport Essentials/Essentials NYC must disenroll you if you do not meet this requirement. SECTION 3 Section 3.1 What other materials will you get from us? Your plan membership card Use it to get all covered care and prescription drugs While you are a member of our plan, you must use your membership card for our plan whenever you get any services covered by this plan and for prescription drugs you get at network pharmacies. You should also show the provider your Medicaid card, if applicable. Here s a sample membership card to show you what yours will look like: As long as you are a member of our plan you must not use your red, white, and blue Medicare card to get covered medical services (with the exception of routine clinical research studies and hospice services). Keep your red, white, and blue Medicare card in a safe place in case you need it later.

30 Chapter 1. Getting started as a member 11 Here s why this is so important: If you get covered services using your red, white, and blue Medicare card instead of using your Affinity Medicare Passport Essentials/Essentials NYC membership card while you are a plan member, you may have to pay the full cost yourself. If your plan membership card is damaged, lost, or stolen, call Customer Service right away and we will send you a new card. (Phone numbers for Customer Service are printed on the back cover of this booklet.) Section 3.2 The Provider Directory: Your guide to all providers in the plan s network The Provider Directory lists our network providers and durable medical equipment suppliers. What are network providers? Network providers are the doctors and other health care professionals, medical groups, durable medical equipment suppliers, hospitals, and other health care facilities that have an agreement with us to accept our payment and any plan cost-sharing as payment in full. We have arranged for these providers to deliver covered services to members in our plan. Why do you need to know which providers are part of our network? It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which Affinity Medicare Passport Essentials/Essentials NYC authorizes use of out-of-network providers. See Chapter 3 (Using the plan s coverage for your medical services) for more specific information about emergency, out-of-network, and out-of-area coverage. If you don t have your copy of the Provider Directory, you can request a copy from Customer Service (phone numbers are printed on the back cover of this booklet). You may ask Customer Service for more information about our network providers, including their qualifications. You can also see the Provider Directory at or download it from this website. Both Customer Service and the website can give you the most up-to-date information about changes in our network providers. Section 3.3 The Pharmacy Directory: Your guide to pharmacies in our network What are network pharmacies? Network pharmacies are all of the pharmacies that have agreed to fill covered prescriptions for our plan members.

31 Chapter 1. Getting started as a member 12 Why do you need to know about network pharmacies? You can use the Pharmacy Directory to find the network pharmacy you want to use. There are changes to our network of pharmacies for next year. An updated Pharmacy Directory is located on our website at You may also call Customer Service for updated provider information or to ask us to mail you a Pharmacy Directory. Please review the 2018 Pharmacy Directory to see which pharmacies are in our network. If you don t have the Pharmacy Directory, you can get a copy from Customer Service (phone numbers are printed on the back cover of this booklet). At any time, you can call Customer Service to get up-to-date information about changes in the pharmacy network. You can also find this information on our website at Section 3.4 The plan s List of Covered Drugs (Formulary) The plan has a List of Covered Drugs (Formulary). We call it the Drug List for short. It tells which Part D prescription drugs are covered under the Part D benefit included in Affinity Medicare Passport Essentials/Essentials NYC. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. Medicare has approved the Affinity Medicare Passport Essentials/Essentials NYC Drug List. The Drug List also tells you if there are any rules that restrict coverage for your drugs. We will send you a copy of the Drug List. The Drug List we send to you includes information for the covered drugs that are most commonly used by our members. However, we cover additional drugs that are not included in the printed Drug List. If one of your drugs is not listed in the Drug List, you should visit our website or contact Customer Service to find out if we cover it. To get the most complete and current information about which drugs are covered, you can visit the plan s website ( or call Customer Service (phone numbers are printed on the back cover of this booklet). Section 3.5 The Part D Explanation of Benefits (the Part D EOB ): Reports with a summary of payments made for your Part D prescription drugs When you use your Part D prescription drug benefits, we will send you a summary report to help you understand and keep track of payments for your Part D prescription drugs. This summary report is called the Part D Explanation of Benefits (or the Part D EOB ). The Part D Explanation of Benefits tells you the total amount you, or others on your behalf, have spent on your Part D prescription drugs and the total amount we have paid for each of your Part D prescription drugs during the month. Chapter 6 (What you pay for your Part D prescription drugs) gives more information about the Part D Explanation of Benefits and how it can help you keep track of your drug coverage.

32 Chapter 1. Getting started as a member 13 A Part D Explanation of Benefits summary is also available upon request. To get a copy, please contact Customer Service (phone numbers are printed on the back cover of this booklet). SECTION 4 Section 4.1 Your monthly premium for Affinity Medicare Passport Essentials/Essentials NYC How much is your plan premium? You do not pay a separate monthly plan premium for Affinity Medicare Passport Essentials/Essentials NYC. You must continue to pay your Medicare Part B premium (unless your Part B premium is paid for you by Medicaid or another third party). In some situations, your plan premium could be more In some situations, your plan premium could be more than the amount listed above in Section 4.1. This situation is described below. Some members are required to pay a Part D late enrollment penalty because they did not join a Medicare drug plan when they first became eligible or because they had a continuous period of 63 days or more when they didn t have creditable prescription drug coverage. ( Creditable means the drug coverage is expected to pay, on average, at least as much as Medicare s standard prescription drug coverage.) For these members, the Part D late enrollment penalty is added to the plan s monthly premium. Their premium amount will be the monthly plan premium plus the amount of their Part D late enrollment penalty. o If you are required to pay the Part D late enrollment penalty, the amount of your penalty depends on how long you waited before you enrolled in drug coverage or how many months you were without drug coverage after you became eligible. Chapter 1, Section 5 explains the Part D late enrollment penalty. o If you have a Part D late enrollment penalty and do not pay it, you could be disenrolled from the plan. SECTION 5 Section 5.1 Do you have to pay the Part D late enrollment penalty? What is the Part D late enrollment penalty? Note: If you receive Extra Help from Medicare to pay for your prescription drugs, you will not pay a late enrollment penalty. The late enrollment penalty is an amount that is added to you Part D premium. You may owe a Part D late enrollment penalty if at any time after your initial enrollment period is over, there is a