Dear Health First Health Plans Member:

Transcription

1 Dear Health First Health Plans Member: You are enrolled in a Medicare Advantage plan offered by Health First Health Plans. A snapshot of the 2017 plans can be found on the first page of the attached form. To make a change in the Medicare Advantage plan you have with Health First Health Plans, fill out the enclosed plan selection form to make your choice. Check off the plan you want, and sign the form. Then mail the completed form back to us by December 7th. Please be aware that you can change health plans only at certain times during the year. Between October 15th and December 7th each year, anyone can join our plan. In addition, from January 1 through February 14, anyone enrolled in a Medicare Advantage Plan (except an MSA plan) has an opportunity to disenroll from that plan and return to Original Medicare. Anyone who disenrolls from a Medicare Advantage plan during this time can join a stand-alone Medicare Prescription Drug Plan during the same period. Generally, you may not make changes at other times unless you meet certain special exceptions, such as if you move out of the plan s service area, want to join a plan in your area with a 5-star rating, or qualify for extra help paying for prescription drug coverage. If you qualify for extra help with your prescription drug costs you may enroll in, or disenroll from, a plan at any time. If you lose this extra help during the year, your opportunity to make a change continues for two months after you are notified that you no longer qualify for extra help. If you select another plan and we receive your completed selection form by December 7th, your new benefit plan will begin in January Your monthly plan premium will be $98 for Classic (HMO-POS), $33 for Value (HMO), $0 for Rewards (HMO), or $0 for Secure (HMO) and you may continue to see any Health First Health Plans primary care doctors and specialists. Complete the attached form only if you wish to change plans. To help you with your decision, we have also included a 2017 Summary of Benefits for the available options. If you have any questions, please call Health First Health Plans at TTY users should call We are open weekdays from 8 a.m. to 8 p.m. and Saturdays from 8 a.m. to noon. From October 1 to February 14, we re available seven days a week from 8 a.m. to 8 p.m. Thank you. Y0089_EL6092 Accepted

2 2017 Plan Selection Form Date: Member name: Member number: I want to transfer from my current plan to the plan I have selected below. I understand that if this form is received by the end of any month, my new plan will generally be effective the 1st of the following month. Please check the appropriate box below: Classic (HMO-POS) Monthly premium: $98 Inpatient hospital: $180 per day for days 1-7 Routine dental, hearing, vision Out of network care: 20% Out-of-pocket maximum: $3,750 in-network; $10,000 out-of-network Prescription coverage in the gap: Yes, Tiers 1, 2 & 6 Value (HMO) Monthly premium: $33 Inpatient hospital: $195 per day for days 1-7 Routine dental, vision Out-of-pocket maximum: $4,950 Prescription coverage in the gap: Yes, Tier 6 Secure (HMO) Monthly premium: $0 Inpatient hospital: $200 per day for days 1-10 Routine dental, hearing, vision Out-of-pocket maximum: $3,400 Part D drugs: None Prescription coverage in the gap: N/A Rewards (HMO) Monthly premium: $0 Inpatient hospital: $275 per day for days 1-7 Out-of-pocket maximum: $6,650 Prescription coverage in the gap: None Your Plan Premium If we determine that you owe a late enrollment penalty (or if you currently have a late enrollment penalty), we need to know how you would prefer to pay it. You can pay by mail, check, money order, or online payments from your bank account or credit card each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board check each month. You can pay your monthly plan premium (including any late enrollment penalty you have or may owe) by mail, check, money order, or online payments from your bank account or credit card each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board check each month. People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don t even know it. For more information about this extra help, contact your local Social Security office or call MEDICARE ( ), 24 hours per day, 7 days per week. TTY/TDD users should call Y0089_EL6092 Accepted

3 If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium for this benefit. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare does not cover. If you don t select a payment option, you will receive a bill each month. Please select a premium payment option: Receive monthly invoices. Automatic payments from your bank account or credit card each month. Automatic payments may be set up through our online member portal at For assistance, contact Customer Service at the phone number below. Automatic deduction from your monthly Social Security or RRB benefit check. (The Social Security or RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.) Please check one of the boxes below if you would prefer us to send you information in a language other than English or in another format: Large print Please contact Health First Health Plans at (TTY users should call ) if you need information in another format or language than what is listed above. Our office hours are weekdays from 8 a.m. to 8 p.m. and Saturdays from 8 a.m. to noon. From October 1 to February 14, we re available seven days a week from 8 a.m. to 8 p.m. Signature Today s Date If you are the authorized representative, you must sign above and provide the following information: Name: Address: Phone number: ( ) Relationship to enrollee: Please mail this form to: Health First Health Plans, Attn: Group Services, 6450 US Highway 1, Rockledge, FL Health First Health Plans is an HMO plan with a Medicare contract. Enrollment in Health First Health Plans depends on contract renewal.

4 Provides free aids and services to people with disabilities to communicate effectively with us, such as: Provides free language services to people whose primary language is not English, such as: Nondiscrimination Notice Health First Health Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health First Health Plans does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Health First Health Plans: Qualified sign language interpreters Written information in other formats (large print, accessible electronic formats) Qualified interpreters Information written in other languages If you need these services, please contact Sherri Wynn. If you believe that Health First Health Plans has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Sherri Wynn, ADA/Section 504 Coordinator, 6450 US Highway 1, Rockledge, FL 32955, , (TTY), Fax: , Sherri.Wynn@healthfirst.org. You can file a grievance in person or by mail, fax, or . If you need help filing a grievance Sherri Wynn, ADA/Section 504 Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD). Complaint forms are available at Health First Health Plans is an HMO plan with a Medicare contract. Enrollment in Health First Health Plans depends on contract renewal. Y0089_EL6075 Accepted

5 English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: ). Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: ). Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng ViỆt, có các dҷch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. GҸi số (TTY: ). Portuguese: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: ). Chinese: 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) French: ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : ). Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ). Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода; Звоните (телетайп: ). Arabic: هلحىظΕ : إذ لنΗ تتحدث ذلز ٲلغΕ قئى خدهΖΎ ٲوسΎعدΔ ٲلغىيΕ تتىقز ٲك ΎΒٲوجΎى تصٱ Βزقن *رقن هΎتف ٲصن وٲΓمن: ( Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: ). German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: ). Korean: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. Polish: UW!G!: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej; Zadzwoń pod numer (TTY: ). Gujarati: સચન : k જ તમ ગજર તj k બ લત હ, ત ન:શલ ક k ભ ષ સહ ય સવ ઓ તમ ર મ ટ ઉપલબ ધ છ. ફ ન કર (TTY: ). Thai: เรยน: ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร (TTY: ). Y0089_EL6071 Accepted