2021 EOC Premium NonAffinity LA


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Vantage
Medicare Advantage
2022 EVIDENCE OF COVERAGE
and Prescription Drug Coverage as a Member of Vantage Health Plan.

CONTACT MEMBER SERVICES
Phone: (318) 361-0900
Toll-Free: (866) 704-0109 (888) 823-1910
TTY: 711

Vantage PREMIUM (HMO-POS)

Medicare Advantage HMO
January 1, 2022 - December 31, 2022
This booklet gives the details about your Medicare healthcare and prescription drug coverage and explains how to get the care you need. This booklet is an important legal document. Please keep it in a safe place. For more information, visit www.VantageMedicare.com.

Call seven days a week 8:00 A.M. - 8:00 P.M. CST
After March 31, 2022, Monday - Friday
8:00 A.M. - 8:00 P.M. CST An answering service will operate on weekends and holidays.

H5576_1150_004r2_C_CY2022

VHP3417 071520

January 1 – December 31, 2022
Evidence of Coverage:
Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Vantage PREMIUM (HMO-POS)
This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2022. It explains how to get coverage for the health care services and prescription drugs you need. This is an important legal document. Please keep it in a safe place.
This plan, Vantage PREMIUM (HMO-POS), is offered by Vantage Health Plan, Inc. (When this Evidence of Coverage says “we,” “us,” or “our,” it means Vantage Health Plan, Inc. When it says “plan” or “our plan,” it means Vantage PREMIUM (HMO-POS).)
Please contact our Member Services number at 1-866-704-0109 for additional information. (TTY users should call 711.) Member Services will operate seven (7) days a week from 8:00 a.m.8:00 p.m. CST from October 1, 2021 – March 31, 2022. After March 31, 2022, Member Services will operate five (5) days a week, Monday – Friday, 8:00 a.m. – 8:00 p.m. CST.
Member Services has free language interpreter services available for non-English speakers (phone numbers are printed on the back cover of this booklet).
You may access your Vantage plan documents, including this Evidence of Coverage, via the Vantage website instead of traditional paper booklets. You can view Vantage plan documents at www.VantageMedicare.com, or download them from the website. You may also request copies of your documents by contacting Member Services at the phone number on the back cover of this booklet.
In addition to digital format, we can also give you this information in large print, languages other than English, and other accessible formats.
Benefits, premium, deductible, and/or copayments/coinsurance may change on January 1, 2023.
The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

H5576_1150_004r2_C_CY2022

OMB Approval 0938-1051 (Expires: February 29, 2024)

2022 Evidence of Coverage for Vantage PREMIUM (HMO-POS)

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Table of Contents

2022 Evidence of Coverage

Table of Contents

This list of chapters and page numbers is your starting point. For more help in finding information you need, go to the first page of a chapter. You will find a detailed list of topics at the beginning of each chapter.

Chapter 1.

Getting started as a member .................................................................. 5
Explains what it means to be in a Medicare health plan and how to use this booklet. Tells about materials we will send you, your plan premium, the Part D late enrollment penalty, your plan membership card, and keeping your membership record up to date.

Chapter 2.

Important phone numbers and resources ........................................... 25
Tells you how to get in touch with our plan (Vantage PREMIUM (HMO-POS)) and with other organizations including Medicare, the State Health Insurance Assistance Program (SHIP), the Quality Improvement Organization, Social Security, Medicaid (the state health insurance program for people with low incomes), programs that help people pay for their prescription drugs, and the Railroad Retirement Board.

Chapter 3.

Using the plan’s coverage for your medical services ........................ 42
Explains important things you need to know about getting your medical care as a member of our plan. Topics include using the providers in the plan’s network and how to get care when you have an emergency.

Chapter 4.

Medical Benefits Chart (what is covered and what you pay) ............. 59
Gives the details about which types of medical care are covered and not covered for you as a member of our plan. Explains how much you will pay as your share of the cost for your covered medical care.

Chapter 5.

Using the plan’s coverage for your Part D prescription drugs ........ 121
Explains rules you need to follow when you get your Part D drugs. Tells how to use the plan’s List of Covered Drugs (Formulary) to find out which drugs are covered. Tells which kinds of drugs are not covered. Explains several kinds of restrictions that apply to coverage for certain drugs. Explains where to get your prescriptions filled. Tells about the plan’s programs for drug safety and managing medications.

2022 Evidence of Coverage for Vantage PREMIUM (HMO-POS)

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Table of Contents

Chapter 6.

What you pay for your Part D prescription drugs ............................. 146
Tells about the four stages of drug coverage (Deductible Stage, Initial Coverage Stage, Coverage Gap Stage, Catastrophic Coverage Stage) and how these stages affect what you pay for your drugs. Explains the five costsharing tiers for your Part D drugs and tells what you must pay for a drug in each cost-sharing tier.

Chapter 7.

Asking us to pay our share of a bill you have received for covered medical services or drugs .................................................... 165
Explains when and how to send a bill to us when you want to ask us to pay you back for our share of the cost for your covered services or drugs.

Chapter 8.

Your rights and responsibilities ......................................................... 173
Explains the rights and responsibilities you have as a member of our plan. Tells what you can do if you think your rights are not being respected.

Chapter 9.

What to do if you have a problem or complaint (coverage decisions, appeals, complaints) ....................................... 191
Tells you step-by-step what to do if you are having problems or concerns as a member of our plan.
• Explains how to ask for coverage decisions and make appeals if you are having trouble getting the medical care or prescription drugs you think are covered by our plan. This includes asking us to make exceptions to the rules or extra restrictions on your coverage for prescription drugs, and asking us to keep covering hospital care and certain types of medical services if you think your coverage is ending too soon.
• Explains how to make complaints about quality of care, waiting times, customer service, and other concerns.

Chapter 10. Ending your membership in the plan................................................. 248
Explains when and how you can end your membership in the plan. Explains situations in which our plan is required to end your membership.

Chapter 11. Legal notices ........................................................................................ 257 Includes notices about governing law and about nondiscrimination.

Chapter 12. Definitions of important words ........................................................... 264 Explains key terms used in this booklet.

2022 Evidence of Coverage for Vantage PREMIUM (HMO-POS)

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Table of Contents

Appendices: Nondiscrimination Notice Language Assistance

CHAPTER 1
Getting started as a member

2022 Evidence of Coverage for Vantage PREMIUM (HMO-POS)

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Chapter 1. Getting started as a member

SECTION 1 Section 1.1
Section 1.2 Section 1.3
SECTION 2 Section 2.1 Section 2.2 Section 2.3 Section 2.4
SECTION 3 Section 3.1
Section 3.2 Section 3.3 Section 3.4 Section 3.5
SECTION 4 Section 4.1
SECTION 5 Section 5.1 Section 5.2 Section 5.3 Section 5.4
SECTION 6
Section 6.1 Section 6.2 Section 6.3 Section 6.4

Chapter 1. Getting started as a member
Introduction ........................................................................................ 7 You are enrolled in Vantage PREMIUM (HMO-POS), which is a Medicare HMO Point-of-Service Plan ............................................................ 7 What is the Evidence of Coverage booklet about? .......................................... 7 Legal information about the Evidence of Coverage ........................................ 8
What makes you eligible to be a plan member? .............................. 8 Your eligibility requirements .......................................................................... 8 What are Medicare Part A and Medicare Part B? ........................................... 8 Here is the plan service area for Vantage PREMIUM (HMO-POS) ............... 9 U.S. Citizen or Lawful Presence ..................................................................... 9
What other materials will you get from us? ..................................... 9 Your plan membership card – Use it to get all covered care and prescription drugs ............................................................................................ 9 The Provider Directory: Your guide to all providers in the plan’s network. 10 The Pharmacy Directory: Your guide to pharmacies in our network........... 11 The plan’s List of Covered Drugs (Formulary) ............................................ 12 The Part D Explanation of Benefits (the “Part D EOB”): Reports with a summary of payments made for your Part D prescription drugs .................. 12
Your monthly premium for Vantage PREMIUM (HMO-POS) ......... 13 How much is your plan premium? ................................................................ 13
Do you have to pay the Part D “late enrollment penalty”? ........... 14 What is the Part D “late enrollment penalty”? .............................................. 14 How much is the Part D late enrollment penalty?......................................... 14 In some situations, you can enroll late and not have to pay the penalty ....... 15 What can you do if you disagree about your Part D late enrollment penalty? ......................................................................................................... 16
Do you have to pay an extra Part D amount because of your income?............................................................................................. 16 Who pays an extra Part D amount because of income? ................................ 16 How much is the extra Part D amount?......................................................... 17 What can you do if you disagree about paying an extra Part D amount? ..... 17 What happens if you do not pay the extra Part D amount? ........................... 17

2022 Evidence of Coverage for Vantage PREMIUM (HMO-POS)

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Chapter 1. Getting started as a member

SECTION 7 Section 7.1 Section 7.2

More information about your monthly premium............................ 17 There are several ways you can pay your plan premium .............................. 18 Can we change your monthly plan premium during the year?...................... 20

SECTION 8 Section 8.1

Please keep your plan membership record up to date ................. 20 How to help make sure that we have accurate information about you.......... 20

SECTION 9 Section 9.1

We protect the privacy of your personal health information ........ 21 We make sure that your health information is protected............................... 21

SECTION 10 How other insurance works with our plan ..................................... 22 Section 10.1 Which plan pays first when you have other insurance? ................................ 22

2022 Evidence of Coverage for Vantage PREMIUM (HMO-POS)

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Chapter 1. Getting started as a member

SECTION 1 Introduction

Section 1.1

You are enrolled in Vantage PREMIUM (HMO-POS), which is a Medicare HMO Point-of-Service Plan

You are covered by Medicare, and you have chosen to get your Medicare health care and your prescription drug coverage through our plan, Vantage PREMIUM (HMO-POS).
There are different types of Medicare health plans. Vantage PREMIUM (HMO-POS) is a Medicare Advantage HMO Plan (HMO stands for Health Maintenance Organization) with a Point-of-Service (POS) option approved by Medicare and run by a private company. “Pointof-Service” means you can use providers outside the plan’s network for an additional cost. All services obtained from out-of-network providers require prior authorization (except emergency services, supplemental dental services, supplemental eyeglasses or contact lenses, supplemental hearing services, urgently needed care, and dialysis outside the plan’s service area). (See Chapter 3, Section 2.4 for information about using the Point-of-Service option.) A “network” consists of facilities, physicians, other health care professionals, pharmacies, and suppliers our plan has contracted with to provide health care services.
Coverage under this Plan qualifies as Qualifying Health Coverage (QHC) and satisfies the Patient Protection and Affordable Care Act’s (ACA) individual shared responsibility requirement. Please visit the Internal Revenue Service (IRS) website at: www.irs.gov/Affordable-Care-Act/Individuals-and-Families for more information.

Section 1.2

What is the Evidence of Coverage booklet about?

This Evidence of Coverage booklet tells you how to get your Medicare medical care and prescription 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 and services and the prescription drugs available to you as a member of Vantage PREMIUM (HMO-POS).
It is 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 Member Services (phone numbers are printed on the back cover of this booklet).

2022 Evidence of Coverage for Vantage PREMIUM (HMO-POS)

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Chapter 1. Getting started as a member

Section 1.3

Legal information about the Evidence of Coverage

It is part of our contract with you
This Evidence of Coverage is part of our contract with you about how Vantage PREMIUM (HMO-POS) 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 your coverage. These notices are sometimes called “riders” or “amendments.”
The contract is in effect for months in which you are enrolled in Vantage PREMIUM (HMOPOS) between January 1, 2022 and December 31, 2022.
Each calendar year, Medicare allows us to make changes to the plans that we offer. This means we can change the costs and benefits of Vantage PREMIUM (HMO-POS) after December 31, 2022. We can also choose to stop offering the plan, or to offer it in a different service area, after December 31, 2022.
Medicare must approve our plan each year
Medicare (the Centers for Medicare & Medicaid Services) must approve Vantage PREMIUM (HMO-POS) each year. You can continue to get Medicare coverage as a member of our plan as long as we choose to continue to offer 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 have both Medicare Part A and Medicare Part B (Section 2.2 tells you about Medicare Part A and Medicare Part B)
• -- and -- you live in our geographic service area (Section 2.3 below describes our service area)
• -- and -- you are a United States citizen or are lawfully present in the United States.

Section 2.2

What are Medicare Part A and Medicare Part B?

When you first 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 provided by hospitals (for inpatient services, skilled nursing facilities, or home health agencies).

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2021 EOC Premium NonAffinity LA