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Eligibility for Independent Health’s Medicare Family Choice HMO I-SNP is available to allMedicare beneficiaries who are entitled to Medicare Part A and enrolled in Part B. Members mustqualify for an institutional level of care as defined by the state of New York and/or permanentlyreside in a participating assisted living or nursing facility and not live outside the affiliated facility formore than 30 days.Eligibility for Independent Health’s Assure Advantage HMO C-SNP:To join Independent Health’s Assure Advantage HMO C-SNP you must be entitled to MedicarePart A and enrolled in Medicare Part B. Members must also be diagnosed with a chronic heartfailure condition.A list of participating facilities can be found at the end of this introduction.What is the service area for Independent Health?Service area residency requirements: PPO Plans: Group PPO members must reside in New York state. All HMO, HMO-POS, HMO I-SNP and Individual PPO plans: Members must reside in the eightcounties of Western New York, which are Allegany, Cattaraugus, Chautauqua, Erie, Genesee,Niagara, Orleans and Wyoming. HMO C-SNP members must reside in Erie County.How do you find Independent Health providers in your area?The providers in this directory are arranged by county so you can easily find a provider close to whereyou live. This book lists Independent Health’s network providers in the eight counties of WesternNew York. Refer to the legend designations on the cover of this directory to find the abbreviation foryour plan name. Then, look for the symbol in the two columns to the right of each provider’s namewhich indicates the providers that are participating with each plan.If you have questions about Independent Health, or require assistance in selecting a PCP,please call our Member Services Department (see phone numbers on the front cover) or visitindependenthealth.com to use our “Find a Doctor” tool for the most up-to date information.6

Out-of-Area ProvidersGetting care when traveling or away from the plan’s service areaHMO and HMO-SNP plansIf you need care when you are outside the service area, your coverage is limited. We will only pay foremergency care, urgently-needed care and out-of-area dialysis.HMO-POS plansWhen you are outside of Independent Health’s service area, we will pay for emergency care,urgently-needed care, and out-of-area dialysis as an in-network benefit. For other out-of-networkcare, you must use your out-of-network benefit as stated in your Evidence of Coverage. Remember,you can get care from non-network providers. However, if you use non-network providers for carethat is not emergency care or urgently-needed care, you will have to pay more. You will have to pay allout-of-pocket costs, such as coinsurance and copayments.PPO plans (Individual PPO Plan and Employer-Sponsored PPO plans)When you are outside of Independent Health’s service area, only emergency care, urgently-neededcare and out-of-area dialysis will be covered as an in-network benefit. For all other care, you must useyour out-of-network benefit as stated in your Evidence of Coverage. Remember, you can get carefrom non-network providers. However, if you use non-network providers for care that is notemergency care or urgently-needed care, you will have to pay more. You will have to pay allout-of-pocket costs, such as coinsurance and copayments.Out-of-network/non-contracted providers are under no obligation to treat Independent Healthmembers, except in emergencies. For a decision about whether we will cover an out-of-networkservice, we encourage you or your provider to ask us for a pre-service organization determinationbefore you receive the service. Please call our Member Services Department (phone number is on theback cover of this directory). You may also refer to your Evidence of Coverage (EOC) for moreinformation, including the cost sharing that applies to out-of-network services.7

Independent Health’s Medicare Passport Advantage PPO (Individual plan only)Independent Health’s Medicare Passport Advantage PPO plan uses providers designated as“In-Network” or “Out-of-Network” for 2022. All providers listed in the Physician/ProviderDirectory participate with Independent Health, however your cost share will be different for providersdepending on whether they are “in-network” or “out-of-network” in 2022 for this plan. Note thatproviders may have changed status from 2021 to 2022.The Physician/Provider Directory contains a listing of all providers in the eight counties of WesternNew York who fully participate with Independent Health. These providers are categorized as either“In-Network” or “Out-of-Network” for Independent Health’s Medicare Passport Advantage PPOplan. While both “In-Network” and “Out-of-Network” providers listed in the directory are considered“participating” with Independent Health, you will pay less for in-network providers in this plan.If you choose a provider or facility that is marked “in-network”, you will pay a lower cost share.In-network providers for this plan are listed in this directory under the column “PPO”. The symbol “I”next to a provider’s name indicates the provider is participating in-network. The symbol “O” next to aprovider’s name indicates the provider is an out-of-network provider for the Medicare PassportAdvantage PPO individual plan only. If you choose a provider or facility that is marked“out-of-network,” you will pay a higher cost share. Refer to your Evidence of Coverage for thecopayments and coinsurance for in-network and out-of-network providers. Some providers haveadditional hospital coverage arrangements. Check with your provider prior to scheduling yourhospital admission.You can also seek care from any out-of-network provider who participates with Medicare. Theseproviders are not listed in the directory. You will pay a higher cost sharing for out-of-networkproviders. It is recommended, but not required, to get authorization from Independent Health priorto receiving out of network benefits.The most up-to-date directory is on our website under the “Find a Doctor” search /FindADoctor). You can also ask Member Servicesto assist you or send you a Provider Directory. (See phone number on back cover of Directory)8

Out-of-Network OptionsFor Independent Health’s HMO-POS plans and PPO plans only:If you get a health care service from a network provider, this is known as an “in-network service.”A health care service you get from a non-participating/non-network provider is known as an“out-of-network” service. (In the PPO Advantage plan there are also participating/network providerswho are also known as “out-of-network”. See box on previous page.)For emergency care prior to being stabilized and urgently needed care, your out-of-pocket costswill be the same both in- and out-of-network. For cost-sharing information, see your Evidence ofCoverage.You do not need to get prior authorization when you get out-of-network care from non-networkproviders. It is recommended, but not required, to contact us to see if the services you are gettingare covered by your plan and are medically necessary. This is known as a coverage determination.For more information, see your Evidence of Coverage.Referrals/Prior AuthorizationsThe “network providers” listed in this directory have agreed to provide you with your health careservices. You may go to any of our network providers listed in this directory. If you have been goingto one network provider, you are not required to continue to go to that same provider. In some cases,you may get covered services from non-network providers.Most of our plans do not require referrals. In some cases, a prior authorization may be required.When you are going to obtain services requiring prior authorization from a network provider, theprovider is responsible to obtain prior authorization from Independent Health before treatment.HMO members must use in-network plan providers except in emergency or urgent care situations,including hospital care after you are stable (“post-stabilization”), renal dialysis (kidney) and anyservices which were ordered covered through an appeals process. If you obtain routine care fromout-of-network providers neither Medicare nor Independent Health will be responsible for the costs;you will be responsible for the costs.Independent Health’s Medicare Family Choice HMO I-SNP members will be given PCP ornurse practitioner approval in advance before you use other providers in the plan’s network, suchas specialists. This is called a “referral.”9

CLAIMSIn-Network ClaimsWith Independent Health, there are no claim forms for you to file for services provided within thenetwork. Physicians and providers will send their bills directly to Independent Health.Out-of-Network Provider ClaimsIf you receive a bill for services from any health care provider whom you have been authorized to use,please do not ignore it. Simply make a copy of it for your records, put your Independent Health IDnumber on the bill, and mail it to:Independent HealthP.O. Box 9066Buffalo, NY 14231-9066The claim you submitted will be processed based on your coverage. You must submit a claim form forall Medicare-covered non-network provider services to Independent Health. The claim form must besubmitted within ninety (90) days after the date you received medically necessary health care services.HMO-POS and PPO plansIf a non-participating/non-network provider asks you to pay for covered services, contact us. Youshould never pay any provider more than what is allowed by Medicare. The non-network provider hasa right to get his/her fees, but does not have a right to get them from you.Ask the non-participating/non-network provider to bill us first. If you have already paid for thecovered services, we will reimburse you for our share of the cost. If you get a bill for the services, youcan send the bill to us for payment. We will pay your non-participating/non-network provider for ourshare of the bill and will let you know what, if anything, you must pay.If the non-participating/non-network provider issuing this bill accepts Medicare assignment (agreesto participate in the Medicare program, which you may want to verify prior to receiving services), theymust accept our payment – less any applicable copayment – as payment in full. You would have noresponsibility to pay any remaining balance. However, if a provider has chosen to “opt-out” of theMedicare program, Independent Health does not cover items or services provided or medicationsprescribed by that individual and no Medicare payment can be made to that physician, practitioner, ormember directly or on a capitated basis. If you chose to see a physician or practitioner who has optedout of the Medicare program, you must enter into a private contract with the provider. Finally, theentire balance could be your responsibility should the service provided not be a covered benefit underyour Evidence of Coverage.EMERGENCY/URGENT CARE WORLDWIDEOur plans cover emergency/urgent care services worldwide, but do not cover routine care outside ofthe United States.Emergency care can always be obtained in or out of the service area from the nearest availableprovider. In an emergency, you can get care immediately. You do not have to contact your PCP or getprior authorization. You can dial 911 for immediate help by phone, or go directly to the nearest urgentcare center or hospital.However, you or someone else should contact your PCP or doctor about your emergency as soon aspossible. This is important so that your PCP or doctor can provide follow-up care.10

HMO, HMO-POS and HMO-SNP plans: When in the service area, you must use plan providers forurgent care. When out of the service area, urgent care may be obtained at urgent care centers orwalk-in clinics. In addition, when out of the service area, you can obtain dialysis treatment from anyqualified dialysis provider that accepts Medicare. If you need to talk with your doctor or get medicalcare when the PCP or doctor’s office is closed, and it is not a medical emergency, call IndependentHealth

This directory provides a list of Independent Health's current network providers. This directory is for Erie, Niagara, Allegany, Cattaraugus, Chautauqua, Genesee, Orleans and Wyoming counties in New York state and Northwestern Pennsylvania. To access Independent Health's online provider directory, you can visit