PPO II - EmblemHealth

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2013 Evidence of Coverage for PPO II) II Chapter 1: Getting started as a member SECTION 1 INTRODUCTION Section 1.1 You are enrolled in PPO II, which is a Medicare PPO You are covered by Medicare, and you have chosen to get your Medicare health care and your prescription drug coverage through our plan, PPO II. Th ere are diff erent types of Medicare health plans. PPO II is a Medicare Advantage PPO Plan (PPO stands for Preferred Provider Organization). Like all Medicare health plans, this Medicare PPO is approved by Medicare and run by a private company. Section 1.2 What is the Evidence of Coverage booklet about? Th is Evidence of Coverage booklet tells you how to get your Medicare medical care and prescription drugs covered through our plan. Th is booklet explains your rights and responsibilities, what is covered, and what you pay as a member of the plan. Th is plan, PPO II, is off ered by Group Health Incorporated (GHI)/EmblemHealth. (When this Evidence of Coverage says “we,” “us,” or “our,” it means GHI/EmblemHealth. When it says “plan” or “our plan,” it means PPO II.) Th e word “coverage” and “covered services” refers to the medical care and services and the prescription drugs available to you as a member of our plan. Section 1.3 What does this Chapter tell you? Look through Chapter 1 of this Evidence of Coverage to learn: • What makes you eligible to be a plan member? • What is your plan’s service area? • What materials will you get from us? • What is your plan premium and how can you pay it? • How do you keep the information in your membership record up to date? Section 1.4 What if you are new to our plan? If you are a new member, then 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). 3
4 2013 Evidence Evidence of Coverage Coverage for PPO II Chapter 1: Getting started as a member Section 1.5 Legal information about the Evidence of Coverage It’s part of our contract with you Th is Evidence of Coverage is part of our contract with you about how our plan 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 aff ect your coverage. Th ese notices are sometimes called “riders” or “amendments.” Th e contract is in eff ect for months in which you are enrolled in our plan between January 1, 2013 and December 31, 2013. Medicare must approve our plan each year Medicare (the Centers for Medicare & Medicaid Services) must approve our plan each year. You can continue to get Medicare coverage as a member of our plan as long as we choose to continue to off er the plan and Medicare renews its approval of the plan. SECTION 2 WHAT MAKES YOU ELIGIBLE TO BE A PLAN MEMBER? Section 2.1 Your eligibility requirements You are eligible for membership in our plan as long as: • You live in our geographic service area (section 2.3 below describes our service area) • -- and -- you have both Medicare Part A and Medicare Part B • -- 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 off er, or you were a member of a diff erent plan that was terminated. Section 2.2 What are Medicare Part A and Medicare Part B? When you fi rst 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 furnished by institutional providers such as 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 and supplies). Section 2.3 Here is the plan service area for our plan Although Medicare is a Federal program, our plan is available only to individuals who live in our plan service area. To remain a member of our plan, you must keep living in this service area. Th e service area is described below.
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PPO II - EmblemHealth

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