Medicare Advantage Plan Resources

Next Steps

Rights and Responsibilities Upon Disenrollment

If you decide to disenroll, this means you are ending your plan membership. Disenrollment can be voluntary (your own choice) or involuntary (not your own choice).

You can leave your plan for any reason; however, there are limits to when you can end your membership, how often you can make changes, and what type of plan you can join after you leave.

Other things to be aware of:

• If you receive "Extra Help" from Medicare to pay for your prescription drugs: If you want to switch to Original Medicare and do not enroll in a separate prescription drug plan, Medicare may enroll you in a drug plan, unless you have opted out of automatic enrollment.
• Try to avoid going without Medicare prescription drug coverage for over 63 days: You may have to pay a Part D late enrollment penalty if you join a Medicare drug plan later.
• Until your membership ends, you must keep getting your medical services and drugs through our plan: You should continue to use our network pharmacies and, if you're hospitalized on the day your membership ends, you'll usually be covered by our plan until you are discharged (even if it's after your new coverage begins).

Questions? Need more information?

For more on disenrollment, see chapter 10 in your Evidence of Coverage (EOC), which includes detailed information about:

• Ending your membership in the plan
• When you can end your membership
• How to end membership
• Situations where CareFirst BlueCross BlueShield Medicare Advantage must end your membership

Please call our Member Services team at 855-290-5744 (TTY: 711) with questions. Our Member Services hours are 8 a.m.-8 p.m., ET, 7 days a week from October 1 through March 31. From April 1 through September 30, our hours are 8 a.m.-8 p.m., ET, Monday through Friday.

How to Appoint a Representative (AOR Form)

You may appoint a personal representative who will act on your behalf in making decisions related to healthcare, which includes treatment and payment issues, as well as filing an appeal.

This individual can be:

• A family member
• A friend
• A lawyer
• An unrelated party

To appoint a representative, please complete the CMS Appointment of Representative form and send to:

Fax: 443-753-2298

Mail: CareFirst BlueCross BlueShield Medicare Advantage
P.O. Box 3626
Scranton, PA 18505

Please keep a copy of the Appointment of Representative form for your records.

Part C Medical Coverage Determination, Grievances and Appeals

Members have a right to request an organization determination. (To keep things simple, we use "coverage decision" rather than "organization determination.") If the plan denies coverage for your requested item or service, you have the right to appeal and ask us to reconsider the decision. You also have a right to file a grievance (also called a complaint) about the health plan.

COVERAGE DETERMINATION

A coverage decision is any decision made by the plan regarding:

• Receipt of, or payment for, a care item or service
• The amount you pay for an item or service
• A limit on the quantity of items or services

Any time that we make a decision about what we will cover and how much we will pay for your medical services or drugs, we are making a coverage decision.

Members have a right to request a coverage decision. If the plan denies coverage for your requested item or service, you have the right to appeal and ask us to reconsider the decision. You also have a right to file a grievance (also called a complaint) about the health plan.

You can mail your coverage determination in writing or contact our member services team for more options to submit your Part C Medical coverage determination.

To request a coverage decision regarding medical care you or your representative may:

Mail:
CareFirst BlueCross BlueShield Preservice Review Department
10455 Mill Run Circle, Room 11113-A
Owings Mills, MD 21117

To request a coverage decision regarding payment for medical care you already received you or your representative may:

Mail:
CareFirst BlueCross BlueShield Medicare Advantage Claims
P.O. Box 4495
Scranton, PA 18505

You can call Member Services to request information on a coverage determination or to request an expedited coverage determination verbally.

Concerns about the plan are important to us. For immediate attention to your grievance, you can call our Member Services to submit your grievance verbally for us to assist you in resolving your concerns.

Call:
855-290-5744

Our Member Services hours are 8 a.m.-8 p.m., ET, 7 days a week from October 1 through March 31. From April 1 through September 30, our hours are 8 a.m. - 8 p.m., ET, Monday through Friday.

Under certain circumstances you can request an expedited coverage decision which is also called a "fast coverage decision." A fast coverage decision means that we will make a decision no later than 72 hours after receiving the request.

To get a "fast coverage decision" you must meet both of the following requirements:

• You are asking for coverage for medical care you have not yet received
• Using the standard deadlines could cause serious harm to your health or hurt your ability to function. If we determine that your request does not meet the criteria above, then it will be handled as a standard coverage decision

GRIEVANCES

A grievance is any complaint or dispute expressing dissatisfaction with any aspect of our operations, including our Medicare plans, Member Services, your provider or treatment facility.

You can submit a grievance at any time. You also have the right to withdraw a grievance.

1. Standard Appeals

You have the right to file an appeal if CareFirst BlueCross BlueShield did not approve or pay for services you believe should be covered or provided. This would be a standard appeal for benefits (pre-service appeal) or payment of a claim (payment appeal).

If a standard appeal is filed, we will send you a decision within:

• 7 days if the appeal is regarding a request for a pre-service Part B drug that a member wants to receive
• 30 days if the appeal is regarding a pre-service request for coverage of a benefit or service that a member wants to receive
• 60 days for an appeal for payment for a service or Part B drug that was already received.

2. Expedited Appeals

If you believe waiting for a decision will seriously harm your health, you can ask that we process the appeal in an expedited manner. A CareFirst BlueCross BlueShield representative will contact you with a decision within 72 hours.

To file an expedited appeal, call Member Services at 855-290-5744 for assistance. You can also submit an expedited appeal in writing.

Fax for Clinical Pre-Service Expedited Appeals:
410-605-2566

Mail:
CareFirst BlueCross BlueShield Medicare Advantage
Clinical Appeals and Analysis
10455 Mill Run Circle, Room 11113-A
Owings Mills, MD 21117