Medicare Advantage

How to ask for a medical coverage or request an appeal for service.

Plan ahead for peace of mind.

Sometimes a serious illness or injury can leave a patient unable to communicate and families have the burden of making difficult decisions without knowing what their loved one really wants. An advance care plan lets you make your medical wishes known ahead of time.

Start an Advance Care Plan

If you have limited resources and income, you may be eligible for a low income subsidy (also called Extra Help), which helps pay your Medicare prescription coverage (lowers your premium payment amount), and in some cases, can help lower copay costs of prescriptions. This could add up to about $4,000 per year. How much lower your premiums may be depends on what percentage of the costs Medicare will cover for you.

Learn More About Getting Extra Help

You must receive all routine care from plan providers.

How to Apply

To see if you qualify for Extra Help:

• Call the Medicare offices 24/7 - 800.Medicare (TYY/TDD users: 877.486.2048)
• Visit the Texas Medicare Office
• Call the Social Security Administration 7 AM to 7 PM weekdays - 800.772.1213 (TTY/TDD users: 800.325.0778)

Best Evidence Available for Low Income Subsidy (LIS) Beneficiaries

In accordance with the statutory requirement to provide a cost-sharing subsidy to Part D-eligible individuals who are full-benefit dual-eligible individuals or recipients of supplemental security income (SSI), Baylor Scott & White Health Plan (BSWHP) must provide access to Part D drugs at the correct LIS cost-sharing level when presented with evidence of LIS eligibility, even if the sponsor's systems and CMS's systems do not yet reflect that eligibility.

We also must update our own systems to reflect the LIS status indicated by the best available evidence and, if necessary, must submit a request to CMS so that, for the deemed population, the agency's systems can be updated as well. These requirements apply to all beneficiaries who are "deemed" subsidy-eligible including full benefit Medicare/Medicaid eligibles, partial dual-eligibles and people receiving SSI as well as those who must apply and are awarded LIS by the Social Security Administration (SSA).

For more information, and to see what forms of documentation are needed for evidence of low-income status:

• Review CMS: Best Available Evidence or
• Contact Baylor Scott & White Prescription Services Customer Call Center at 800.728.7947 from 7 AM to 8 PM CST daily (TTY/TDD users: 711)

Part D Full & Partial Subsidy — Non Full Benefit Dual

Applied or eligible for QMB/SLMB/QI or SSI, income at or below 150% FPL in 2024 for 2024 and resources ≤ $15,720 (individuals, 2024) or ≤ $31,360 (couples, 2024)

As a Medicare member, you have the right to:

• Ask for coverage of a medical service or prescription drug. In some cases, we may allow exceptions for a service or drug that is normally not covered.
• File an appeal if your request is denied. An appeal is a formal way of asking us to review and change a coverage decision we made.

You can submit your request for medical service coverage or appeal to the following:

You can submit a request for Part D drug coverage or redetermination (appeal). Visit Drug Requests - Prior Authorizations, Exceptions and Appeals for more details.

Addressing your concerns and resolving them promptly is important to us, because it's important to you. As a member of Baylor Scott & White Health Plan (BSWHP), you have the right to request an appeal and file a grievance.

Appeal

An appeal is a request for reconsideration of our determination on a service, supply or drug you have received or requested. You may file an appeal when you believe that the services or supplies should be covered or that they should be covered differently than Baylor Scott & White Health Plan approved or paid them. Your doctor can also request an appeal for you.

Grievance

A grievance is a complaint that does not involve a coverage determination. For example, grievances may be filed if you are unhappy with the quality of care or service you receive from us or from our Baylor Scott & White Health Plan network providers. You also have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug.

We encourage your input and will not discriminate against you, refuse coverage or engage in any other retaliation if you choose to file a complaint or request an appeal of a decision.

Additionally, we're prohibited from retaliating against a physician or provider who has filed a complaint against us on your behalf. You may also refer to your Evidence of Coverage for complaint examples and complete details.

For status or process questions or to obtain an aggregate number of grievances and appeals, please call Customer Service at 866.344.3141. From Oct. 1 through March 31, we're open 7 AM to 8 PM daily(closed on major holidays). From April 1 through Sept. 30, we're open weekdays, 7 AM to 8 PM (closed on major holidays). Or write:

Baylor Scott & White Health Plan
1206 W. Campus Drive
Temple, TX 76502
Fax: 800.626.3042

You can also submit an appeal and grievance to Medicare:

Voluntary Disenrollment

If you are considering disenrollment, call our Member Advocacy Department at 866.334.3141 (TTY: 711). We want to help you in any way we can. Our Member Advocates can help you resolve problems before you make the final decision to change health plans.

Medicare gives you three ways you can disenroll from a Medicare Advantage plan:

• Annual Election Period (AEP), Oct. 15-Dec. 7
• Special Election Period (SEP)
• Medicare Advantage Open Enrollment Period (MA OEP), Jan. 1-March 31

If your situation includes the following, you can enter a Special Enrollment Period:

• You move outside our service area, or have experienced another change in circumstances — as determined by the Centers for Medicare & Medicaid Services (CMS) — that causes you to no longer be enrolled in a BSW SeniorCare plan
• You're entitled to Medicare Part A and Part B and receive any type of assistance from the Title XIX (Medicaid) program
• CMS or the organization has terminated our contract in the area in which you reside, or the organization has notified you of the impending termination or discontinuation of the plan in the area you reside
• You demonstrate that we have substantially violated a material provision of our contract with CMS in relation to you, or we (or an agent) materially misrepresented the plan when marketing our plans
• You weren't adequately informed of the creditable status of drug coverage provided by an entity required to give such notice, or a loss of creditable coverage. CMS determines eligibility for this on a case by case basis
• Your enrollment or non-enrollment is erroneous due to an action, inaction or error by a federal employee
• You meet such other exceptional conditions as CMS may provide

Ways to disenroll during AEP, MA OEP or valid Special Enrollment Period:

• Call us at 866.334.3141 (TTY: 711)
• Call 800.MEDICARE
• Deliver, mail or fax a signed and dated written notice to the plan
• Enroll in another plan during a valid enrollment period, which will prompt disenrollment in your current plan. Use your current plan until disenrollment is effective

Involuntary Disenrollment

We may disenroll you if:

• Premiums are not paid on a timely basis
• You engage in disruptive behavior
• You provide fraudulent information on an enrollment request
• You permit abuse of an enrollment card

If we choose to terminate your coverage for any of these reasons, we'll send you notice of the upcoming disenrollment. This notice will:

• Advise you we plan to disenroll you, and why such action is occurring
• Provide the effective date of termination
• Include an explanation of your right to a hearing under our grievance procedures

Required Involuntary Disenrollment

We are required to disenroll you if:

• A permanent change in residence makes you ineligible to be an enrollee of our advantage plans
• You lose entitlement to Medicare
• We are notified of your passing
• Our contract is terminated, or we discontinue offering a Prescription Drug Plan in the area where it had previously been available*
• You materially misrepresent information to us regarding reimbursement for third-party coverage

*Authorized by law to refuse to renew its contract with CMS. In addition, CMS also may refuse to renew the contract, and that termination or non-renewal may result in termination of your enrollment.