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2019EVIDENCE OFCOVERAGEThe details of your planUnitedHealthcare Dual Complete (HMO SNP)Toll-free 1-877-614-0623, TTY 7118am-8pm: 7 Days Oct-Mar; M-F Apr-Septwww.UHCCommunityPlan.comY0066 EOC H0321 002 2019 C
January 1 – December 31, 2019Evidence of Coverage:Your Medicare Health Benefits and Services and Prescription DrugCoverage as a Member of our planThis booklet gives you the details about your Medicare health care and prescription drug coveragefrom January 1 – December 31, 2019. It explains how to get coverage for the health care servicesand prescription drugs you need.This is an important legal document. Please keep it in a safe place.This plan, UnitedHealthcare Dual Complete (HMO SNP), is insured through UnitedHealthcareInsurance Company or one of its affiliates. (When this Evidence of Coverage says “we,” “us,” or“our,” it means UnitedHealthcare. When it says “plan” or “our plan,” it means UnitedHealthcareDual Complete (HMO SNP).)Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies,a Medicare Advantage organization with a Medicare contract and a contract with the StateMedicaid Program. Enrollment in the plan depends on the plan’s contract renewal with Medicare.This document is available for free in other languages.Please contact our Customer Service number at 1-877-614-0623 for additional information. (TTYusers should call 711). Hours are 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept.Esta información está disponible sin costo en otros idiomas.Para obtener más información, por favor comuníquese con Servicio al Cliente al 1-877-614-0623.(Usuarios TTY deben llamar 711). Horario es de 8 a.m. a 8 p.m., hora local, los 7 días de lasemana.El Servicio al Cliente también tiene disponible, de forma gratuita, servicios de interpretación parapersonas que no hablan inglés.This document may be available in an alternate format such as Braille, large print or audio. Pleasecontact our Customer Service number at 1-877-614-0623, TTY: 711, 8am-8pm: 7 Days Oct-Mar; MF Apr-Sept, for additional information.Benefits, premium, deductible, and/or copayments/coinsurance may change on January 1, 2020.The formulary, pharmacy network, and provider network may change at any time. You will receivenotice when necessary.Y0066 EOC H0321 002 2019 COMB Approval 0938-1051 (Expires: December 31, 2021)
2019 Evidence of Coverage for UnitedHealthcare Dual Complete (HMO SNP)Table of Contents2019 Evidence of CoverageTable of ContentsThis list of chapters and page numbers is your starting point. For more help in finding informationyou need, go to the first page of a chapter. You will find a detailed list of topics at the beginningof each chapter.Chapter 1Getting started as a member. 1-1Explains what it means to be in a Medicare health plan and how to use thisbooklet. Tells about materials we will send you, your plan premium, the Part Dlate enrollment penalty, your plan member ID card, and keeping yourmembership record up to date.Chapter 2Important phone numbers and resources. 2-1Tells you how to get in touch with our plan (UnitedHealthcare Dual Complete (HMO SNP)) and with other organizations including Medicare, the State HealthInsurance Assistance Program (SHIP), the Quality Improvement Organization,Social Security, Medicaid (the state health insurance program for people withlow incomes), programs that help people pay for their prescription drugs, andthe Railroad Retirement Board.Chapter 3Using the plan’s coverage for your medical services.3-1Explains important things you need to know about getting your medical care asa member of our plan. Topics include using the providers in the plan’s networkand how to get care when you have an emergency.Chapter 4Medical Benefits Chart (what is covered and what you pay). 4-1Gives the details about which types of medical care are covered and notcovered for you as a member of our plan. Explains how much you will pay asyour share of the cost for your covered medical care.Chapter 5Using the plan’s coverage for your Part D prescription drugs. 5-1Explains rules you need to follow when you get your Part D drugs. Tells how touse the plan’s List of Covered Drugs (Formulary) to find out which drugs arecovered. Tells which kinds of drugs are not covered. Explains several kinds ofrestrictions that apply to coverage for certain drugs. Explains where to get yourprescriptions filled. Tells about the plan’s programs for drug safety andmanaging medications.Chapter 6What you pay for your Part D prescription drugs. 6-1
2019 Evidence of Coverage for UnitedHealthcare Dual Complete (HMO SNP)Table of ContentsTells about the four stages of drug coverage (Deductible Stage, InitialCoverage Stage, Coverage Gap Stage, Catastrophic Coverage Stage) andhow these stages affect what you pay for your drugs.Chapter 7Asking us to pay our share of a bill you have received for covered medicalservices or drugs. 7-1Explains when and how to send a bill to us when you want to ask us to pay youback for our share of the cost for your covered services or drugs.Chapter 8Your rights and responsibilities. 8-1Explains the rights and responsibilities you have as a member of our plan. Tellswhat you can do if you think your rights are not being respected.Chapter 9What to do if you have a problem or complaint (coverage decisions,appeals, complaints). 9-1Tells you step-by-step what to do if you are having problems orconcerns as a member of our plan.Chapter 10· Explains how to ask for coverage decisions and make appeals if you arehaving trouble getting the medical care or prescription drugs you think arecovered by our plan. This includes asking us to make exceptions to the rulesor extra restrictions on your coverage for prescription drugs, and asking us tokeep covering hospital care and certain types of medical services if you thinkyour coverage is ending too soon.· Explains how to make complaints about quality of care, waiting times,customer service, and other concerns.Ending your membership in the plan. 10-1Explains when and how you can end your membership in the plan.Explains situations in which our plan is required to end yourmembership.Chapter 11Legal notices. 11-1Includes notices about governing law and about nondiscrimination.Chapter 12Definitions of important words. 12-1Explains key terms used in this booklet.
CHAPTER 1Getting started as a member
2019 Evidence of Coverage for UnitedHealthcare Dual Complete (HMO SNP)Chapter 1: Getting started as a member1-1Chapter 1Getting started as a memberSECTION 1Introduction. 3Section 1.1 You are enrolled in UnitedHealthcare Dual Complete (HMO SNP),which is a specialized Medicare Advantage Plan (Special Needs Plan) 3Section 1.2 What is the Evidence of Coverage booklet about?. 3Section 1.3 Legal information about the Evidence of Coverage.4SECTION 2What makes you eligible to be a plan member?. 4Section 2.1 Your eligibility requirements. 4Section 2.2 What are Medicare Part A and Medicare Part B?. 5Section 2.3 What is Medicaid?.5Section 2.4 Here is the plan service area for UnitedHealthcare Dual Complete (HMO SNP). 6Section 2.5 U.S. Citizen or Lawful Presence. 6SECTION 3What other materials will you get from us?. 6Section 3.1 Your plan member ID card – Use it to get all covered care andprescription drugs. 6Section 3.2 The Provider Directory: Your guide to all providers in the plan’snetwork. 7Section 3.3 The Pharmacy Directory: Your guide to pharmacies in our network. 8Section 3.4 The plan’s List of Covered Drugs (Formulary).8Section 3.5 The Part D Explanation of Benefits (the “Part D EOB”): Reports with asummary of payments made for your Part D prescription drugs.9SECTION 4Your monthly premium for the plan. 9Section 4.1 How much is your plan premium?. 9Section 4.2 There are several ways you can pay your plan premium. 11Section 4.3 Can we change your monthly plan premium during the year?. 12SECTION 5Please keep your plan membership record up to date.12Section 5.1 How to help make sure that we have accurate information about you 12SECTION 6We protect the privacy of your personal health information. 13
2019 Evidence of Coverage for UnitedHealthcare Dual Complete (HMO SNP)Chapter 1: Getting started as a member1-2Section 6.1 We make sure that your health information is protected. 13SECTION 7How other insurance works with our plan. 13Section 7.1 Which plan pays first when you have other insurance?. 13
2019 Evidence of Coverage for UnitedHealthcare Dual Complete (HMO SNP)Chapter 1: Getting started as a memberSECTION 1Section 1.11-3IntroductionYou are enrolled in UnitedHealthcare Dual Complete (HMO SNP),which is a specialized Medicare Advantage Plan (Special NeedsPlan)You are covered by both Medicare and Medicaid:· Medicare is the Federal health insurance program for people 65 years of age or older, somepeople under age 65 with certain disabilities, and people with end-stage renal disease (kidneyfailure).· Medicaid is a joint Federal and state government program that helps with medical costs forcertain people with limited incomes and resources. Medicaid coverage varies depending onthe state and the type of Medicaid you have. Some people with Medicaid get help paying fortheir Medicare premiums and other costs. Other people also get coverage for additionalservices and drugs that are not covered by Medicare.You have chosen to get your Medicare health care and your prescription drug coverage throughour plan, UnitedHealthcare Dual Complete (HMO SNP).There are different types of Medicare health plans. UnitedHealthcare Dual Complete (HMO SNP)is a specialized Medicare Advantage Plan (a Medicare “Special Needs Plan”), which means itsbenefits are designed for people with special health care needs. UnitedHealthcare Dual Complete (HMO SNP) is designed specifically for people who have Medicare and who are also entitled toassistance from Medicaid.Coverage under this Plan qualifies as Qualifying Health Coverage (QHC) and satisfies thePatient Protection and Affordable Care Act’s (ACA) individual shared responsibility requirement.Please visit the Internal Revenue Service (IRS) website at: s-and-Families for more information.Because you get assistance from Medicaid, you will pay less or nothing for some of your Medicarehealth care services. Medicaid may also provide other benefits to you by covering health careservices and prescription drugs that are not usually covered under Medicare. You will also receive“Extra Help” from Medicare to pay for the costs of your Medicare prescription drugs.UnitedHealthcare Dual Complete (HMO SNP) will help manage all of these benefits for you, sothat you get the health care services and payment assistance that you are entitled to.UnitedHealthcare Dual Complete (HMO SNP) is run by a private company. Like all MedicareAdvantage plans, this Medicare Special Needs Plan is approved by Medicare. The plan also has acontract with your state Medicaid program to coordinate your Medicaid benefits. We are pleasedto be providing your Medicare health care coverage, including your prescription drug coverage.Section 1.2What is the Evidence of Coverage booklet about?
2019 Evidence of Coverage for UnitedHealthcare Dual Complete (HMO SNP)Chapter 1: Getting started as a member1-4This Evidence of Coverage booklet tells you how to get your Medicare medical care andprescription 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 words “coverage” and “covered services” refer to the medical care, services and prescriptiondrugs available to you as a member of the plan.It’s important for you to learn what the plan’s rules are and what services are available to you. Weencourage 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 CustomerService (phone numbers are printed on the back cover of this booklet).Section 1.3Legal information about the Evidence of CoverageIt’s part of our contract with youThis Evidence of Coverage is part of our contract with you about how the 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 affect yourcoverage. These notices are sometimes called “riders” or “amendments.”The contract is in effect for months in which you are enrolled in the plan between January 1, 2019and December 31, 2019.Each calendar year, Medicare allows us to make changes to the plans that we offer. This meanswe can change the costs and benefits of the plan after December 31, 2019. We can also choose tostop offering the plan, or to offer it in a different service area, after December 31, 2019.Medicare must approve our plan each yearMedicare (the Centers for Medicare & Medicaid Services) must approve our plan each year. Youcan continue to get Medicare coverage as a member of our plan as long as we choose to continueto offer the plan and Medicare renews its approval of the plan.SECTION 2Section 2.1What makes you eligible to be a plan member?Your eligibility requirementsYou 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 PartA and Medicare Part B)· -- and -- you live in our geographic service area (Section 2.4 below describes our service area).· -- and -- you are a United States citizen or are lawfully present in the United States
2019 Evidence of Coverage for UnitedHealthcare Dual Complete (HMO SNP)Chapter 1: Getting started as a member1-5· -- and -- you do not have End-Stage Renal Disease (ESRD), with limited exceptions, such as ifyou develop ESRD when you are already a member of a plan that we offer, or you were amember of a different plan that was terminated.· -- and -- you meet the special eligibility requirements described below.Special eligibility requirements for our planOur plan is designed to meet the needs of people who receive certain Medicaid benefits. (Medicaidis a joint Federal and state government program that helps with medical costs for certain peoplewith limited incomes and resources.) To be eligible for our plan you must be eligible for bothMedicare and Medicaid.Please note: If you lose your Medicaid eligibility but can reasonably be expected to regain eligibilitywithin 6 month(s), then you are still eligible for membership in our plan (Chapter 4, Section 2.1 tellsyou about coverage during a period of deemed continued eligibility).Section 2.2What are Medicare Part A and Medicare Part B?When you first signed up for Medicare, you received information about what services are coveredunder 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 otheroutpatient services) and certain items (such as durable medical equipment (DME) andsupplies).Section 2.3What is Medicaid?Medicaid is a joint Federal and state government program that helps with medical costs for certainpeople who have limited incomes and resources. Each state decides what counts as income andresources, who is eligible, what services are covered, and the cost for services. States also candecide how to run their program as long as they follow the Federal guidelines.In addition, there are programs offered through Medicaid that help people with Medicare pay theirMedicare costs, such as their Medicare premiums. These “Medicare Savings Programs” helppeople with limited income and resources save money each year.You can enroll in this plan if you are in one of these Medicaid categories:·Qualified Medicare Beneficiary Plus (QMB ): You get Medicaid coverage of Medicarecost-share and are also eligible for full Medicaid benefits. Medicaid pays your Part A andPart B premiums, deductibles, coinsurance and copayment amounts. You pay nothing,except for Part D prescription drug copays.·Specified Low-Income Medicare Beneficiary (SLMB ): Medicaid pays your Part Bpremium and provides full Medicaid benefits. You are eligible for full Medicaid benefits. At
2019 Evidence of Coverage for UnitedHealthcare Dual Complete (HMO SNP)Chapter 1: Getting started as a member1-6times you may also be eligible for limited assistance from your state Medicaid agency inpaying your Medicare cost share amounts. Generally your cost share is 0% when the serviceis covered by both Medicare and Medicaid. There may be cases where you have to pay costsharing when a service or benefit is not covered by Medicaid.·Full Benefits Dual Eligible (FBDE): Medicaid may provide limited assistance with Medicarecost-sharing. Medicaid also provides full Medicaid benefits. You are eligible for full Medicaidbenefits. At times you may also be eligible for limited assistance from the State MedicaidOffice in paying your Medicare cost share amounts. Generally your cost share is 0% whenthe service is covered by both Medicare and Medicaid. There may be cases where you haveto pay cost sharing when a service or benefit is not covered by Medicaid.Section 2.4Here is the plan service area for UnitedHealthcare DualComplete (HMO SNP)Although Medicare is a Federal program, our plan is available only to individuals who live in ourplan service area. To remain a member of our plan, you must continue to reside in the plan servicearea. The service area is described below.Our service area includes these counties in Arizona: Apache, Cochise, Coconino, Graham,Greenlee, La Paz, Maricopa, Mohave, Navajo, Pima, Pinal, Santa Cruz, Yavapai, Yuma.If you plan to move out of the service area, please contact Customer Service (phone numbers areprinted on the back cover of this booklet). When you move, you will have a Special EnrollmentPeriod that will allow you to switch to Original Medicare or enroll in a Medicare health or drug planthat is available in your new location
“Extra Help” from Medicare to pay for the costs of your Medicare prescription drugs. UnitedHealthcare Dual Complete (HMO SNP) will help manage all of these benefits for you, so that you get the health care services and payment assistance that you are entitled to. UnitedHealthcare Dual Complete
