True Blue Rx Option I (HMO)

Transcription

1 True Blue Rx Optin I (HMO) 2014 Evidence f Cverage January 1 December 31, 2014 Yur Medicare Health Benefits and Services and Prescriptin Drug Cverage as a Member f True Blue Rx Optin I (HMO) 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, True Blue Rx Optin I (HMO), is ffered by Blue Crss f Idah Health Service, Inc. (When this Evidence f Cverage says we, us, r ur, it means Blue Crss f Idah Health Service, Inc. When it says plan r ur plan, it means True Blue Rx Optin I (HMO).) True Blue Rx Optin I (HMO) is a health plan with a Medicare cntract. Enrllment in True Blue Rx Optin I (HMO) depends n cntract renewal. Custmer Service has free language interpreter services available fr nn-english speakers (phne numbers are printed n the back cver f this bklet). This dcument may be available in alternate frmats such as Braille and large print. Please call Custmer Service if yu need this in anther frmat. Benefits, frmulary, pharmacy netwrk, premium, deductible, and/r cpayments/cinsurance may change n January 1, H1350_001_CS14009 Frm N PD (09-13)

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3 Table f Cntents 2014 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... 1 Explains what it means t be in a Medicare health plan and hw t use this bklet. Tells abut materials we will send yu, yur plan premium, yur plan membership card, and keeping yur membership recrd up t date. Chapter 2. Imprtant phne numbers and resurces Tells yu hw t get in tuch with ur plan (True Blue Rx Optin Ӏ (HMO)) 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 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 Table f Cntents Chapter 6. What yu pay fr yur Part D prescriptin drugs Tells abut the three stages f drug cverage (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 cstsharing tier. Tells abut the late enrllment penalty. 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 nndiscriminatin. Chapter 12. Definitins f imprtant wrds Explains key terms used in this bklet.

5 Chapter 1: Getting started as a member 1 Chapter 1. Getting started as a member SECTION 1 Intrductin... 3 Sectin 1.1 Yu are enrlled in True Blue Rx Optin Ӏ (HMO), which is a Medicare HMO...3 Sectin 1.2 What is the Evidence f Cverage bklet abut?... 3 Sectin 1.3 What des this Chapter tell yu?...3 Sectin 1.4 What if yu are new t True Blue Rx Optin Ӏ (HMO)?...3 Sectin 1.5 Legal infrmatin abut the Evidence f Cverage...4 SECTION 2 What makes yu eligible t be a plan member?... 4 Sectin 2.1 Yur eligibility requirements...4 Sectin 2.2 What are Medicare Part A and Medicare Part B?...4 Sectin 2.3 Here is the plan service area fr True Blue Rx Optin Ӏ (HMO)...5 SECTION 3 What ther materials will yu get frm us?... 5 Sectin 3.1 Sectin 3.2 Sectin 3.3 Yur plan membership card Use it t get all cvered care and prescriptin drugs...5 The Prvider Directry: Yur guide t all prviders in the plan s netwrk...6 The Pharmacy Directry: Yur guide t pharmacies in ur netwrk...7 Sectin 3.4 The plan s List f Cvered Drugs (Frmulary)...7 Sectin 3.5 The Explanatin f Benefits (the EOB ): Reprts with a summary f payments made fr yur Part D prescriptin drugs...8 SECTION 4 Yur mnthly premium fr True Blue Rx Optin Ӏ (HMO)... 8 Sectin 4.1 Sectin 4.2 Hw much is yur plan premium?...8 There are several ways yu can pay yur plan premium...10

6 Chapter 1: Getting started as a member 2 Sectin 4.3 Can we change yur mnthly plan premium during the year? SECTION 5 Please keep yur plan membership recrd up t date Sectin 5.1 Hw t help make sure that we have accurate infrmatin abut yu SECTION 6 We prtect the privacy f yur persnal health infrmatin Sectin 6.1 We make sure that yur health infrmatin is prtected SECTION 7 Hw ther insurance wrks with ur plan Sectin 7.1 Which plan pays first when yu have ther insurance?... 13

7 Chapter 1: Getting started as a member 3 SECTION 1 Sectin 1.1 Intrductin Yu are enrlled in True Blue Rx Optin Ӏ (HMO), which is a Medicare HMO Yu are cvered by Medicare, and yu have chsen t get yur Medicare health care and yur prescriptin drug cverage thrugh ur plan, True Blue Rx Optin Ӏ (HMO). There are different types f Medicare health plans. True Blue Rx Optin I (HMO) is a Medicare Advantage HMO Plan (HMO stands fr Health Maintenance Organizatin). Like all Medicare health plans, this Medicare HMO is apprved by Medicare and run by a private cmpany. 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. This plan, True Blue Rx Optin Ӏ (HMO) is ffered by Blue Crss f Idah Health Service, Inc. (When this Evidence f Cverage says we, us, r ur, it means Blue Crss f Idah Health Service, Inc. When it says plan r ur plan, it means True Blue Rx Optin Ӏ (HMO).) The wrd cverage and cvered services refers t the medical care and services and the prescriptin drugs available t yu as a member f True Blue Rx Optin Ӏ (HMO). Sectin 1.3 What des this Chapter tell yu? Lk thrugh Chapter 1 f this Evidence f Cverage t learn: What makes yu eligible t be a plan member? What is yur plan s service area? What materials will yu get frm us? What is yur plan premium and hw can yu pay it? Hw d yu keep the infrmatin in yur membership recrd up t date? Sectin 1.4 What if yu are new t True Blue Rx Optin Ӏ (HMO)? If yu are a new member, then 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 Service (phne numbers are printed n the back cver f this bklet).

8 Chapter 1: Getting started as a member 4 Sectin 1.5 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 True Blue Rx Optin Ӏ (HMO) 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 True Blue Rx Optin Ӏ (HMO) between January 1, 2014 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 True Blue Rx Optin Ӏ (HMO) 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 True Blue Rx Optin Ӏ (HMO) 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. SECTION 2 Sectin 2.1 What makes yu eligible t be a plan member? Yur eligibility requirements Yu are eligible fr membership in ur plan as lng as: Yu live in ur gegraphic service area (sectin 2.3 belw describes ur service area) -- and -- yu have bth Medicare Part A and Medicare Part B -- 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 furnished by institutinal prviders such as hspitals (fr inpatient services), skilled nursing facilities, r hme health agencies.

9 Chapter 1: Getting started as a member 5 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 and supplies). Sectin 2.3 Here is the plan service area fr True Blue Rx Optin Ӏ (HMO) Althugh Medicare is a Federal prgram, True Blue Rx Optin Ӏ (HMO) is available nly t individuals wh live in ur plan service area. T remain a member f ur plan, yu must keep living in this service area. The service area is described belw. Our service area includes these cunties in Idah: Ada, Adams, Bannck, Benewah, Bingham, Blaine, Bise, Bnner, Bnneville, Bundary, Canyn, Caribu, Cassia, Clark, Elmre, Fremnt, Gem, Gding, Jeffersn, Jerme, Ktenai, Latah, Madisn, Minidka, Nez Perce, Oneida, Owyhee, Payette, Pwer, Shshne, Twin Falls, Valley, and Washingtn. If yu plan t mve ut f the service area, please cntact Custmer Service (phne numbers are printed n the back cver f this bklet). When yu mve, yu will have a Special Enrllment Perid that will allw yu t switch t Original Medicare r enrll in a Medicare health r drug plan that is available in yur new lcatin. It is als imprtant that yu call Scial Security if yu mve r change yur mailing address. Yu can find phne numbers and cntact infrmatin fr Scial Security in Chapter 2, Sectin 5. SECTION 3 Sectin 3.1 What ther materials will yu get frm us? 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 use yur medical card and fr prescriptin drugs yu get at netwrk pharmacies use yur prescriptin card. Here s a sample membership card t shw yu what yurs will lk like: Card fr yur medical services

10 Chapter 1: Getting started as a member 6 Card fr yur prescriptin drugs 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 True Blue Rx Optin Ӏ (HMO) 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 Service right away and we will send yu a new card. (Phne numbers fr Custmer Service are printed n the back cver f this bklet.) Sectin 3.2 The Prvider Directry: Yur guide t all prviders in the plan s netwrk The Prvider Directry lists ur netwrk prviders. What are netwrk prviders? Netwrk prviders are the dctrs and ther health care prfessinals, medical grups, hspitals, and ther health care facilities that have an agreement with us t accept ur payment and any plan cst sharing as payment in full. We have arranged fr these prviders t deliver cvered services t members in ur plan. Why d yu need t knw which prviders are part f ur netwrk? It is imprtant t knw which prviders are part f ur netwrk because, with limited exceptins, while yu are a member f ur plan yu must use netwrk prviders t get yur medical care and services. The nly exceptins are emergencies, urgently needed care when the netwrk is nt available (generally, when yu are ut f the area), ut-f-area dialysis services, and cases in which True Blue Rx Optin Ӏ (HMO) authrizes use f ut-f-netwrk prviders. See Chapter 3

11 Chapter 1: Getting started as a member 7 (Using the plan s cverage fr yur medical services) fr mre specific infrmatin abut emergency, ut-f-netwrk, and ut-f-area cverage. If yu dn t have yur cpy f the Prvider Directry, yu can request a cpy frm Custmer Service (phne numbers are printed n the back cver f this bklet). Yu may ask Custmer Service fr mre infrmatin abut ur netwrk prviders, including their qualificatins. Sectin 3.3 The Pharmacy Directry: Yur guide t pharmacies in ur netwrk What are netwrk pharmacies? Our Pharmacy Directry gives yu a cmplete list f ur netwrk pharmacies that means 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 Pharmacy Directry t find the netwrk pharmacy yu want t use. This is imprtant because, with few exceptins, yu must get yur prescriptins filled at ne f ur netwrk pharmacies if yu want ur plan t cver (help yu pay fr) them. If yu dn t have the Pharmacy Directry, yu can get a cpy frm Custmer Service (phne numbers are printed n the back cver f this bklet). At any time, yu can call Custmer Service t get up-t-date infrmatin abut changes in the pharmacy netwrk. Yu can als find this infrmatin n ur Web site at Sectin 3.4 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 by True Blue Rx Optin Ӏ (HMO). 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 True Blue Rx Optin Ӏ (HMO) 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 Web site ( r call Custmer Service (phne numbers are printed n the back cver f this bklet).

12 Chapter 1: Getting started as a member 8 Sectin 3.5 The Explanatin f Benefits (the 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 Explanatin f Benefits (r the EOB ). The Explanatin f Benefits tells yu the ttal amunt yu 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 Explanatin f Benefits and hw it can help yu keep track f yur drug cverage. An Explanatin f Benefits summary is als available upn request. T get a cpy, please cntact Custmer Service (phne numbers are printed n the back cver f this bklet). SECTION 4 Sectin 4.1 Yur mnthly premium fr True Blue Rx Optin Ӏ (HMO) Hw much is yur plan premium? As a member f ur plan, yu pay a mnthly plan premium. Fr 2014, the mnthly premium fr True Blue Rx Optin Ӏ (HMO) is $144. In additin, yu must cntinue t pay yur Medicare Part B premium (unless yur Part B premium is paid fr yu by Medicaid r anther third party). In sme situatins, yur plan premium culd be less The Extra Help prgram helps peple with limited resurces pay fr their drugs. Chapter 2, Sectin 7 tells mre abut this prgram. If yu qualify, enrlling in the prgram might lwer yur mnthly plan premium. If yu are already enrlled and getting help frm ne f these prgrams, the infrmatin abut premiums in this Evidence f Cverage may nt apply t yu. We send yu a separate insert, called the Evidence f Cverage Rider fr Peple Wh Get Extra Help Paying fr Prescriptin Drugs (als knwn as the Lw Incme Subsidy Rider r the LIS Rider ), which tells yu abut yur drug cverage. If yu dn t have this insert, please call Custmer Service and ask fr the LIS Rider. (Phne numbers fr Custmer Service are printed n the back cver f this bklet.) 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.

13 Chapter 1: Getting started as a member 9 Sme members are required t pay a 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 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 late enrllment penalty. If yu are required t pay the 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 6, Sectin 9 explains the late enrllment penalty. If yu have a late enrllment penalty and d nt pay it, yu culd be disenrlled frm the plan. Many members are required t pay ther Medicare premiums In additin t paying the mnthly plan premium, many members are required t pay ther Medicare premiums. As explained in Sectin 2 abve, in rder t be eligible fr ur plan, yu must be entitled t Medicare Part A and enrlled in Medicare Part B. Fr that reasn, sme plan members (thse wh aren t eligible fr premium-free Part A) pay a premium fr Medicare Part A. And mst plan members pay a premium fr Medicare Part B. Yu must cntinue paying yur Medicare premiums t remain a member f the plan. Sme peple pay an extra amunt fr Part D 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 (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 4, Sectin 10 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 2014 gives infrmatin abut the Medicare premiums in the sectin called 2014 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 2014 frm the Medicare Web site

14 Chapter 1: Getting started as a member 10 ( Or, yu can rder a printed cpy by phne at MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users call Sectin 4.2 There are several ways yu can pay yur plan premium There are three ways yu can pay yur plan premium. T change billing ptins cntact us at , TTY users can call We are available frm 8 a.m. t 8 p.m. seven days a week. If yu decide t change the way yu pay yur premium, it can take up t three mnths fr yur new payment methd t take effect. While we are prcessing yur request fr a new payment methd, yu are respnsible fr making sure that yur plan premium is paid n time. Optin 1: Yu can pay by check Each mnth we mail yu a statement with a payment cupn. Our premium payment is due the first f every mnth. Nt chsing a payment ptin when yu enrll means yu autmatically receive a mnthly billing statement. Yur mnthly billing statement shws the amunt due fr the upcming mnth, plus any amunt past due and yur payment due date. Make persnal checks, cashier s checks r mney rders payable t Blue Crss f Idah (nt CMS r HHS). Mail payments t Blue Crss f Idah, P.O. Bx 8406, Bise, ID 83707; r use the return envelpe we include with yur premium statement. Yu may als pay in persn; stp by ur ffice at 3000 E. Pine Avenue in Meridian, ID. Office hurs are 8 a.m. t 5 p.m. Mnday thrugh Friday. Optin 2: Autmatic Deductins The mst ppular billing ptin, this chice ffers freedm frm having t wrry abut yur payment reaching Blue Crss f Idah n time. We can autmatically deduct yur mnthly premiums frm yur checking r savings accunt. Chse this ptin when yu enrll r call Custmer Service anytime t start autmatic deductins. The back f yur mnthly billing statement includes an autmatic deductin frm as well. Chse any day between the first and the 13th f the mnth fr yur autmatic deductins. If yu dn t chse a day, we will draft yur payment n the 5th f each mnth. We need five business days frm receipt f yur request t prcess autmatic deductins. Yur first deductin will start the next billing cycle, unless yu chse a

15 Chapter 1: Getting started as a member 11 different mnth t start. Yur first deductin includes the current mnth s payment plus any previus balance due. Optin 3: Yu can have the plan premium taken ut f yur mnthly Scial Security check Yu can have the plan premium taken ut f yur mnthly Scial Security check. Cntact Custmer Service fr mre infrmatin n hw t pay yur plan premium this way. We will be happy t help yu set this up. (Phne numbers fr Custmer Service are printed n the back cver f this bklet.) What t d if yu are having truble paying yur plan premium Yur plan premium is due in ur ffice by the first. If we have nt received yur premium payment by the first, we will send yu a ntice telling yu that yur plan membership will end if we d nt receive yur premium within 90 days. If yu are having truble paying yur premium n time, please cntact Custmer Service t see if we can direct yu t prgrams that will help with yur plan premium. (Phne numbers fr Custmer Service are printed n the back cver f this bklet.) If we end yur membership with the plan because yu did nt pay yur plan premium, 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 late enrllment penalty fr as lng as yu have Part D cverage.) If we end yur membership because yu did nt pay yur premium, yu will have health cverage under Original Medicare. At the time we end yur membership, yu may still we us fr premiums yu have nt paid. In the future, if yu want t enrll again in ur plan (r anther plan that we ffer), yu will 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 Medicare t recnsider this decisin by calling MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call

16 Chapter 1: Getting started as a member 12 Sectin 4.3 Can we change yur mnthly plan premium during the year? N. We are nt allwed t change the amunt we charge fr the plan s mnthly plan premium during the year. If the mnthly plan premium changes fr next year we will tell yu in September and the change will take effect n January 1. Hwever, in sme cases the part f the premium that yu have t pay can change during the year. This happens if yu becme eligible fr the Extra Help prgram r if yu lse yur eligibility fr the Extra Help prgram during the year. If a member qualifies fr Extra Help with their prescriptin drug csts, the Extra Help prgram will pay part f the member s mnthly plan premium. S a member wh becmes eligible fr Extra Help during the year wuld begin t pay less twards their mnthly premium. And a member wh lses their eligibility during the year will need t start paying their full mnthly premium. Yu can find ut mre abut the Extra Help prgram in Chapter 2, Sectin 7. SECTION 5 Sectin 5.1 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 Service (phne numbers are printed n the back cver f this bklet).

17 Chapter 1: Getting started as a member 13 It is als imprtant t cntact Scial Security if yu mve r change yur mailing address. Yu can find phne numbers and cntact infrmatin fr Scial Security in Chapter 2, Sectin 5. Read ver the infrmatin we send yu abut any ther insurance cverage yu have Medicare requires that we cllect infrmatin frm yu abut any ther medical r drug insurance cverage that yu have. That s because we must crdinate any ther cverage yu have with yur benefits under ur plan. (Fr mre infrmatin abut hw ur cverage wrks when yu have ther insurance, see Sectin 7 in this chapter.) Once each year, we will send yu a letter that lists any ther medical r drug insurance cverage that we knw abut. Please read ver this infrmatin carefully. If it is crrect, yu dn t need t d anything. If the infrmatin is incrrect, r if yu have ther cverage that is nt listed, please call Custmer Service (phne numbers are printed n the back cver f this bklet). SECTION 6 Sectin 6.1 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 7 Sectin 7.1 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 size f the emplyer, and whether yu have Medicare based n age, disability, r End-stage Renal Disease (ESRD):

18 Chapter 1: Getting started as a member 14 If yu re under 65 and disabled and yu r yur family member is still wrking, yur plan pays first if the emplyer has 100 r mre emplyees r at least ne emplyer in a multiple emplyer plan has mre than 100 emplyees. If yu re ver 65 and yu r yur spuse is still wrking, the plan pays first if the emplyer has 20 r mre emplyees r at least ne emplyer in a multiple emplyer plan has mre than 20 emplyees. If yu have Medicare because f ESRD, yur grup health plan will pay first fr the first 30 mnths after yu becme eligible fr Medicare. These types f cverage usually pay first fr services related t each type: N-fault insurance (including autmbile insurance) Liability (including autmbile insurance) Black lung benefits Wrkers cmpensatin Medicaid and TRICARE never pay first fr Medicare-cvered services. They nly pay after Medicare, emplyer grup health plans, and/r Medigap have paid. If yu have ther insurance, tell yur dctr, hspital, and pharmacy. If yu have questins abut wh pays first, r yu need t update yur ther insurance infrmatin, call Custmer Service (phne numbers are printed n the back cver f this bklet). Yu may need t give yur plan member ID number t yur ther insurers (nce yu have cnfirmed their identity) s yur bills are paid crrectly and n time.

19 Chapter 2: Imprtant phne numbers and resurces 15 Chapter 2. Imprtant phne numbers and resurces SECTION 1 True Blue Rx Optin Ӏ (HMO) cntacts (hw t cntact us, including hw t reach Custmer Service at the plan) SECTION 2 Medicare (hw t get help and infrmatin directly frm the Federal Medicare prgram) SECTION 3 State Health Insurance Assistance Prgram (free help, infrmatin, and answers t yur questins abut Medicare) SECTION 4 Quality Imprvement Organizatin (paid by Medicare t check n the quality f care fr peple with Medicare) SECTION 5 Scial Security SECTION 6 Medicaid (a jint Federal and state prgram that helps with medical csts fr sme peple with limited incme and resurces) SECTION 7 Infrmatin abut prgrams t help peple pay fr their prescriptin drugs SECTION 8 Hw t cntact the Railrad Retirement Bard SECTION 9 D yu have grup insurance r ther health insurance frm an emplyer?... 33

20 Chapter 2: Imprtant phne numbers and resurces 16 SECTION 1 True Blue Rx Optin Ӏ (HMO) cntacts (hw t cntact us, including hw t reach Custmer Service at the plan) Hw t cntact ur plan s Custmer Service Fr assistance with claims, billing r member card questins, please call r write t True Blue Rx Optin Ӏ (HMO) Custmer Service. We will be happy t help yu. Custmer Service CALL TTY FAX WRITE P.O. Bx 8406 Bise, ID Calls t this number are free. We are available frm 8 a.m. t 8 p.m., seven days a week. After 8 p.m. please leave a message and we will return yur call the fllwing day. Custmer Service als has free language interpreter services available fr nn-english speakers. This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. We are available frm 8 a.m. t 8 p.m., seven days a week. WEB SITE

21 Chapter 2: Imprtant phne numbers and resurces 17 Hw t cntact us when yu are asking fr a cverage decisin abut yur medical care A cverage decisin is a decisin we make abut yur benefits and cverage r abut the amunt we will pay fr yur medical services. Fr mre infrmatin n asking fr cverage decisins abut yur medical care, see Chapter 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. Cverage Decisins fr Medical Care CALL TTY FAX Calls t this number are free. We are available frm 8 a.m. t 8 p.m., seven days a week. After 8 p.m. please leave a message and we will return yur call the fllwing day. This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. We are available frm 8 a.m. t 8 p.m., seven days a week. WRITE P.O. Bx 8406 Bise, ID WEB SITE

22 Chapter 2: Imprtant phne numbers and resurces 18 Hw t cntact us when yu are making an appeal abut yur medical care An appeal is a frmal way f asking us t review and change a cverage decisin we have made. Fr mre infrmatin n making an appeal abut yur medical care, see Chapter 9 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints)). Appeals fr Medical Care CALL TTY FAX Calls t this number are free. We are available frm 8 a.m. t 8 p.m., seven days a week. After 8 p.m. please leave a message and we will return yur call the fllwing day. This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. We are available frm 8 a.m. t 8 p.m., seven days a week. WRITE Blue Crss f Idah P.O. Bx 8406 Bise, ID 83707

23 Chapter 2: Imprtant phne numbers and resurces 19 Hw t cntact us when yu are making a cmplaint abut yur medical care Yu can make a cmplaint abut us r ne f ur netwrk prviders, including a cmplaint abut the quality f yur care. This type f cmplaint des nt invlve cverage r payment disputes. (If yur prblem is abut the plan s cverage r payment, yu shuld lk at the sectin abve abut making an appeal.) Fr mre infrmatin n making a cmplaint abut yur medical care, see Chapter 9 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints)). Cmplaints abut Medical Care CALL TTY FAX Calls t this number are free. We are available frm 8 a.m. t 8 p.m., seven days a week. After 8 p.m. please leave a message and we will return yur call the fllwing day. This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. We are available frm 8 a.m. t 8 p.m., seven days a week. WRITE P.O. Bx 8406 Bise, ID MEDICARE WEB SITE Yu can submit a cmplaint abut True Blue Rx Optin Ӏ (HMO) directly t Medicare. T submit an nline cmplaint t Medicare g t

24 Chapter 2: Imprtant phne numbers and resurces 20 Hw t cntact us when yu are asking fr a cverage decisin abut yur 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 Part D prescriptin drugs. Fr mre infrmatin n asking fr cverage decisins abut yur Part D prescriptin drugs, see Chapter 9 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints)). Cverage Decisins fr Part D Prescriptin Drugs CALL Calls t this number are free. Hurs f Operatin are 9 a.m. t 8 p.m. CST., Mnday thrugh Friday. TTY FAX 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 f Operatin are 9 a.m. t 8 p.m. CST., Mnday thrugh Friday. WRITE WEB SITE CVS Caremark Attentin: Prir Authrizatin Part D P.O. Bx 52000, MC109 Phenix, AZ Nt available

25 Chapter 2: Imprtant phne numbers and resurces 21 Hw t cntact us when yu are making an appeal abut yur 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 Part D prescriptin drugs, see Chapter 9 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints)). Appeals fr Part D Prescriptin Drugs CALL Calls t this number are free. Hurs f Operatin are 9 a.m. t 8 p.m. CST., Mnday thrugh Friday. 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 f Operatin are 9 a.m. t 8 p.m. CST., Mnday thrugh Friday. FAX WRITE CVS Caremark Attentin: Prir Authrizatin Part D 620 Epsiln Drive Pittsburgh, PA WEB SITE Nt available

26 Chapter 2: Imprtant phne numbers and resurces 22 Hw t cntact us when yu are making a cmplaint abut yur Part D prescriptin drugs Yu can make a cmplaint abut us r ne f ur 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 cmplaint abut yur Part D prescriptin drugs, see Chapter 9 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints)). Cmplaints abut Part D prescriptin drugs CALL TTY Calls t this number are free We are available frm 8 a.m. t 8 p.m., seven days a week. After 8 p.m. please leave a message and we will return yur call the fllwing day. This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. We are available frm 8 a.m. t 8 p.m., seven days a week. FAX WRITE P.O. Bx 8406 Bise, ID MEDICARE WEB SITE Yu can submit a cmplaint abut True Blue Rx Optin Ӏ (HMO) directly t Medicare. T submit an nline cmplaint t Medicare g t

27 Chapter 2: Imprtant phne numbers and resurces 23 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. Payment Requests CALL We are available frm 8 a.m. t 8 p.m., seven days a week. After 8 p.m. please leave a message and we will return yur call the fllwing day. Calls t this number are free. 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. We are available frm 8 a.m. t 8 p.m., seven days a week. FAX WRITE Medical Payment Requests: P.O. Bx 8406 Bise, ID Prescriptins Payment Requests: CVS Caremark Part D Services P.O. Bx Phenix, AZ WEB SITE

28 Chapter 2: Imprtant phne numbers and resurces 24 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. Medicare 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. WEB SITE Calls t this number are free. This is the fficial gvernment Web site fr Medicare. It gives yu up-t-date infrmatin abut Medicare and current Medicare issues. It als has infrmatin abut hspitals, nursing hmes, physicians, hme health agencies, and dialysis facilities. It includes bklets yu can print directly frm yur cmputer. Yu can als find Medicare cntacts in yur state. The Medicare Web site als has detailed infrmatin abut yur Medicare eligibility and enrllment ptins with the fllwing tls: Medicare Eligibility Tl: Prvides Medicare eligibility status infrmatin. Medicare Plan Finder: Prvides persnalized infrmatin abut available Medicare prescriptin drug plans, Medicare health plans, and Medigap (Medicare Supplement Insurance) plicies in yur area. These tls prvide an estimate f what

29 Chapter 2: Imprtant phne numbers and resurces 25 yur ut-f-pcket csts might be in different Medicare plans. Yu can als use the Web site t tell Medicare abut any cmplaints yu have abut True Blue Rx Optin Ӏ (HMO): Tell Medicare abut yur cmplaint: Yu can submit a cmplaint abut True Blue Rx Optin Ӏ (HMO) directly t Medicare. T submit a cmplaint t Medicare, g t Medicare takes yur cmplaints seriusly and will use this infrmatin t help imprve the quality f the Medicare prgram. If yu dn t have a cmputer, yur lcal library r senir center may be able t help yu visit this Web site using its cmputer. Or, yu can call Medicare and tell them what infrmatin yu are lking fr. They will find the infrmatin n the Web site, print it ut, and send it t yu. (Yu can call Medicare at MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call )

30 Chapter 2: Imprtant phne numbers and resurces 26 SECTION 3 State Health Insurance Assistance Prgram (free help, infrmatin, and answers t yur questins abut Medicare) The State Health Insurance Assistance Prgram (SHIP) is a gvernment prgram with trained cunselrs in every state. In Idah, the SHIP is called Senir Health Insurance Benefit Advisrs (SHIBA). SHIBA is independent (nt cnnected with any insurance cmpany r health plan). It is a state prgram that gets mney frm the Federal gvernment t give free lcal health insurance cunseling t peple with Medicare. SHIBA cunselrs can help yu with yur Medicare questins r prblems. They can help yu understand yur Medicare rights, help yu make cmplaints abut yur medical care r treatment, and help yu straighten ut prblems with yur Medicare bills. SHIBA cunselrs can als help yu understand yur Medicare plan chices and answer questins abut switching plans. Senir Health Insurance Benefit Advisrs: (Idah SHIP) CALL TTY This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. WRITE 700 West State Street, Bise, ID Irnwd Parkway, Suite 143, Ceur d Alene, ID Filmre, Suite 1104, Twin Falls, ID N. 4th Avenue, Pcatell, ID WEB SITE

31 Chapter 2: Imprtant phne numbers and resurces 27 SECTION 4 Quality Imprvement Organizatin (paid by Medicare t check n the quality f care fr peple with Medicare) There is a Quality Imprvement Organizatin fr each state. Fr Idah, the Quality Imprvement Organizatin is called Qualis Health. Qualis Health has a grup f dctrs and ther health care prfessinals wh are paid by the Federal gvernment. This rganizatin is paid by Medicare t check n and help imprve the quality f care fr peple with Medicare. Qualis Health is an independent rganizatin. It is nt cnnected with ur plan. Yu shuld cntact Qualis Health in any f these situatins: Yu have a cmplaint abut the quality f care yu have received. Yu think cverage fr yur hspital stay is ending t sn. Yu think cverage fr yur hme health care, skilled nursing facility care, r Cmprehensive Outpatient Rehabilitatin Facility (CORF) services are ending t sn. Qualis Health: (Idah s Quality Imprvement Organizatin) CALL TTY This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. WRITE WEB SITE 720 Park Bulevard, Suite 120 Bise, ID

32 Chapter 2: Imprtant phne numbers and resurces 28 SECTION 5 Scial Security Scial Security is respnsible fr determining eligibility and handling enrllment fr Medicare. U.S. citizens wh are 65 r lder, r wh have a disability r End-Stage Renal Disease and meet certain cnditins, are eligible fr Medicare. If yu are already getting Scial Security checks, enrllment int Medicare is autmatic. If yu are nt getting Scial Security checks, yu have t enrll in Medicare. Scial Security handles the enrllment prcess fr Medicare. T apply fr Medicare, yu can call Scial Security r visit yur lcal Scial Security ffice. Scial Security is als respnsible fr determining wh has t pay an extra amunt fr their Part D drug cverage because they have a higher incme. If yu gt a letter frm Scial Security telling yu that yu have t pay the extra amunt and have questins abut the amunt r if yur incme went dwn because f a life-changing event, yu can call Scial Security t ask fr a recnsideratin. If yu mve r change yur mailing address, it is imprtant that yu cntact Scial Security t let them knw. Scial Security CALL Calls t this number are free. TTY Available 7:00 am t 7:00 pm, Mnday thrugh Friday. Yu can use Scial Security s autmated telephne services t get recrded infrmatin and cnduct sme business 24 hurs a day. This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. Available 7:00 am t 7:00 pm, Mnday thrugh Friday. WEB SITE

33 Chapter 2: Imprtant phne numbers and resurces 29 SECTION 6 Medicaid (a jint Federal and state prgram that helps with medical csts fr sme peple with limited incme and resurces) Medicaid is a jint Federal and state gvernment prgram that helps with medical csts fr certain peple with limited incmes and resurces. Sme peple with Medicare are als eligible fr Medicaid. In additin, there are prgrams ffered thrugh Medicaid that help peple with Medicare pay their Medicare csts, such as their Medicare premiums. These Medicare Savings Prgrams help peple with limited incme and resurces save mney each year: Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B premiums, and ther cst sharing (like deductibles, cinsurance, and cpayments). (Sme peple with QMB are als eligible fr full Medicaid benefits (QMB+).) Specified Lw-Incme Medicare Beneficiary (SLMB): Helps pay Part B premiums. (Sme peple with SLMB are als eligible fr full Medicaid benefits (SLMB+).) Qualified Individual (QI): Helps pay Part B premiums. Qualified Disabled & Wrking Individuals (QDWI): Helps pay Part A premiums. T find ut mre abut Medicaid and its prgrams, cntact the Idah Department f Health and Welfare. Idah Department f Health and Welfare: (Idah s Medicaid prgram) CALL TTY This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. WRITE WEB SITE Idah Department f Health and Welfare P.O. Bx Bise, ID

34 Chapter 2: Imprtant phne numbers and resurces 30 SECTION 7 Infrmatin abut prgrams t help peple pay fr their prescriptin drugs Medicare s Extra Help Prgram Medicare prvides Extra Help t pay prescriptin drug csts fr peple wh have limited incme and resurces. Resurces include yur savings and stcks, but nt yur hme r car. If yu qualify, yu get help paying fr any Medicare drug plan s mnthly premium, yearly deductible, and prescriptin cpayments. This Extra Help als cunts tward yur ut-fpcket csts. Peple with limited incme and resurces may qualify fr Extra Help. Sme peple autmatically qualify fr Extra Help and dn t need t apply. Medicare mails a letter t peple wh autmatically qualify fr Extra Help. Yu may be able t get Extra Help t pay fr yur prescriptin drug premiums and csts. T see if yu qualify fr getting Extra Help, call: MEDICARE ( ). TTY users shuld call , 24 hurs a day, 7 days a week; The Scial Security Office at , between 7 am t 7 pm, Mnday thrugh Friday. TTY users shuld call ; r Yur State Medicaid Office. (See Sectin 6 f this chapter fr cntact infrmatin.) If yu believe yu have qualified fr Extra Help and yu believe that yu are paying an incrrect cst-sharing amunt when yu get yur prescriptin at a pharmacy, ur plan has established a prcess that allws yu t either request assistance in btaining evidence f yur prper cpayment level, r, if yu already have the evidence, t prvide this evidence t us. Cntact Custmer Service if yu wuld like assistance applying fr Extra Help. Yu may als have a representative, family member r pharmacists cntact us n yur behalf. Our Custmer Advcates can help btain the dcumentatin needed t update yur cst share levels. In sme cases, yu may already have the dcumentatin and we will wrk with yu t btain a cpy, in rder t update yur cst sharing infrmatin, as sn as pssible. Call (Calls t this number are free); we are available frm 8 a.m. t 8 p.m., seven days a week. TTY users call: Fax Number: Additinal Infrmatin is als available n ur Web site: