C and O Employees' Hospital Association

 

 

 

Summary of Benefits for Medicare Plan Seven and Ten:

 

 

C AND O EMPLOYEES HOSPITAL ASSOCIATION ("COEHA")

MEDICARE SUPPLEMENTAL PLAN

2018 SUMMARY OF BENEFITS

PLAN SEVEN

 

COEHA Medicare Supplemental Plan Benefits

COEHA Medicare Supplemental Plan Payment

Annual Part A Deductible

Covered

Annual Part B Deductible

Covered

Ambulance

100% coinsurance when covered

Chemotherapy/Radiation Services

100% coinsurance

Chiropractic Services

100% coinsurance

Diabetic Testing Supplies

100% coinsurance for test strips, lancets, lancing devices and control solution

Durable Medical Equipment

100% coinsurance when covered

Emergency Room Services

100% coinsurance

Inpatient Hospital Care

100% coinsurance

Kidney Dialysis

100% coinsurance

Long Term Care Physician Visits and Physical Therapy

100% coinsurance

Mental Health Services

100% coinsurance

Office Visits

100% coinsurance

Ophthalmology Services

100% coinsurance

Organ Transplants

100% coinsurance

Outpatient Surgery, Diagnostic & Therapeutic Services

100% coinsurance

Physical Therapy, Occupational & Speech Therapy

100% coinsurance

Podiatry Services

100% coinsurance

Prescription Drugs effective January 1, 2018, we have contracted with Navitus MedicareRx to administer your Medicare Part D Prescription Drug Plan

2018 Medicare Part D information will be provided by Navitus MedicareRx: Summary of Benefits, Evidence of Coverage, Formulary & Pharmacy Directory

Skilled Nursing Facility

100% coinsurance

 

COEHA benefits supplement your basic Medicare benefits. Services denied by Medicare are not covered by COEHA. Also, not all services covered by Medicare are a COEHA benefit. For more details, please refer to your Medicare & You 2018 Handbook and C and O Employees Hospital Association Medicare Supplemental Handbook and Master Plan Document.

All organizations that provide Medicare Managed Care Plans, and Health Care Prepayment Plans, like COEHA, must obey federal laws against discrimination, including Title VI of the Civil Rights Act of 1964, the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities Act, all other laws that apply to organizations that receive federal funding, and any other laws and rules that apply for any other reason.

Discrimination is against the law. COEHA complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. COEHA does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

COEHA:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:
Qualified sign language interpreters
Written information in other formats (large print, audio, accessible electronic formats, and other formats)
Provides free language services to people whose primary language is not English, such as:
Qualified interpreters
Information written in other languages

If you need these services, contact Ms. Michelle Hoke, the Civil Rights Coordinator.

If you believe that COEHA has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Michelle Hoke

C and O Employees Hospital Association

511 Main Street, 2nd Floor

Clifton Forge, Virginia 24422-1166

(800) 679-9135 (toll free)

(540) 862-3552 (fax)

michellehoke@coeha.com

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Ms. Michelle Hoke, Civil Rights Coordinator, is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

 

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Spanish

ATENCIN: si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. Llame al 1-800-679-9135.

Korean

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-679-9135 번으로 전화해 주십시오.

Vietnamese

CH : Nếu bạn ni Tiếng Việt, c cc dịch vụ hỗ trợ ngn ngữ miễn ph dnh cho bạn. Gọi số 1-800-679-9135.

Chinese

注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電1-800-679-9135.

Arabic

ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم

800-679-9135-1

Tagalog

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-679-9135.

Persian (Farsi)

توجه: اگر به زبان فارسی گفتگو می کنید، تسهیلات زبانی بصورت رایگان برای شما فراهم می باشد. با 1-800-679-9135

تماس بگیرید.

Amharic

ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-800-679-9135.

Urdu

خبردار: اگر آپ اردو بولتے ہیں، تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں ۔ کال کریں1-800-679-9135

French

ATTENTION : Si vous parlez franais, des services d'aide linguistique vous sont proposs gratuitement. Appelez le 1-800-679-9135.

Russian

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-679-9135.

Hindi

ध्यान दें: यदि आप हिंदी बोलते हैं तो आपके लिए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-800-679-9135 पर कॉल करें।

German

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfgung. Rufnummer: 1-800-679-9135.

Bengali

লক্ষ্য করুনঃ যদি আপনি বাংলা, কথা বলতে পারেন, তাহলে নিঃখরচায় ভাষা সহায়তা পরিষেবা উপলব্ধ আছে ফোন করুন -1-800-679-9135

Kru (Bassa)

D ɖɛ n kɛ dyɖ gbo: Ɔ jǔ k m [Ɓsɔɔ-wɖ-po-nyɔ] jǔ n, n, wuɖu k k ɖ po-poɔ ɓɛn m gbo kpa. Ɖ 1-800-679-9135.

Ibo

Ige nti: O buru na asu Ibo asusu, enyemaka diri gi site na call 1-800-679-9135.

Yoruba

AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o. E pe ero ibanisoro yi 1-800-679-9135.

If you have any questions, please do not hesitate to give us a call at 1-800-679-9135 or locally at 862-5728. Thank you.

_____________________________________________________________________________________________________

C AND O EMPLOYEES HOSPITAL ASSOCIATION

MEDICARE SUPPLEMENTAL PLAN

2018 SUMMARY OF BENEFITS

PLAN TEN

 

COEHA Medicare Supplemental Plan Benefits

COEHA Medicare Supplemental Plan Payment

Annual Part A Deductible

Covered

Annual Part B Deductible

Covered

Ambulance

100% coinsurance when covered

Chemotherapy/Radiation Services

100% coinsurance

Chiropractic Services

100% coinsurance

Diabetic Testing Supplies

100% coinsurance for test strips, lancets, lancing devices and control solution

Durable Medical Equipment

100% coinsurance when covered

Emergency Room Services

100% coinsurance

Inpatient Hospital Care

100% coinsurance

Kidney Dialysis

100% coinsurance

Long Term Care Physician Visits and Physical Therapy

100% coinsurance

Mental Health Services

100% coinsurance

Office Visits

100% coinsurance

Ophthalmology Services

100% coinsurance

Organ Transplants

100% coinsurance

Outpatient Surgery, Diagnostic & Therapeutic Services

100% coinsurance

Physical Therapy, Occupational & Speech Therapy

100% coinsurance

Podiatry Services

100% coinsurance

Skilled Nursing Facility

100% coinsurance

COEHA benefits supplement your basic Medicare benefits. Services denied by Medicare are not covered by COEHA. Also, not all services covered by Medicare are a COEHA benefit. For more details, please refer to your Medicare & You 2018 Handbook and C and O Employees Hospital Association Medicare Supplemental Handbook and Master Plan Document.

All organizations that provide Medicare Managed Care Plans, and Health Care Prepayment Plans, like COEHA, must obey federal laws against discrimination, including Title VI of the Civil Rights Act of 1964, the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities Act, all other laws that apply to organizations that receive federal funding, and any other laws and rules that apply for any other reason.

Discrimination is against the law. COEHA complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. COEHA does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

COEHA:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:
Qualified sign language interpreters
Written information in other formats (large print, audio, accessible electronic formats, and other formats)
Provides free language services to people whose primary language is not English, such as:
Qualified interpreters
Information written in other languages

If you need these services, contact Ms. Michelle Hoke, the Civil Rights Coordinator.

If you believe that COEHA has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Michelle Hoke

C and O Employees Hospital Association

511 Main Street, 2nd Floor

Clifton Forge, Virginia 24422-1166

(800) 679-9135 (toll free)

(540) 862-3552 (fax)

michellehoke@coeha.com

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Ms. Michelle Hoke, Civil Rights Coordinator, is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

 

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Spanish

ATENCIN: si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. Llame al 1-800-679-9135.

Korean

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-679-9135 번으로 전화해 주십시오.

Vietnamese

CH : Nếu bạn ni Tiếng Việt, c cc dịch vụ hỗ trợ ngn ngữ miễn ph dnh cho bạn. Gọi số 1-800-679-9135.

Chinese

注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電1-800-679-9135.

Arabic

ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم

800-679-9135-1

Tagalog

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-679-9135.

Persian (Farsi)

توجه: اگر به زبان فارسی گفتگو می کنید، تسهیلات زبانی بصورت رایگان برای شما فراهم می باشد. با 1-800-679-9135

تماس بگیرید.

Amharic

ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-800-679-9135.

Urdu

خبردار: اگر آپ اردو بولتے ہیں، تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں ۔ کال کریں1-800-679-9135

French

ATTENTION : Si vous parlez franais, des services d'aide linguistique vous sont proposs gratuitement. Appelez le 1-800-679-9135.

Russian

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-679-9135.

Hindi

ध्यान दें: यदि आप हिंदी बोलते हैं तो आपके लिए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-800-679-9135 पर कॉल करें।

German

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfgung. Rufnummer: 1-800-679-9135.

Bengali

লক্ষ্য করুনঃ যদি আপনি বাংলা, কথা বলতে পারেন, তাহলে নিঃখরচায় ভাষা সহায়তা পরিষেবা উপলব্ধ আছে ফোন করুন -1-800-679-9135

Kru (Bassa)

D ɖɛ n kɛ dyɖ gbo: Ɔ jǔ k m [Ɓsɔɔ-wɖ-po-nyɔ] jǔ n, n, wuɖu k k ɖ po-poɔ ɓɛn m gbo kpa. Ɖ 1-800-679-9135.

Ibo

Ige nti: O buru na asu Ibo asusu, enyemaka diri gi site na call 1-800-679-9135.

Yoruba

AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o. E pe ero ibanisoro yi 1-800-679-9135.

If you have any questions, please do not hesitate to give us a call at 1-800-679-9135 or locally at 862-5728. Thank you.