C and O Employees' Hospital Association
C AND O EMPLOYEES’ HOSPITAL ASSOCIATION
TABLE OF CONTENTS
MEMBER’S RESPONSIBILITIES 4
Plan Name 5
Employer Identification and Plan Numbers 5
Administrator of Plan 5
Type of Plan 5
Plan Year 5
Contributions and Funding 5
Agent for Service of Legal Process 6
Plan Eligibility 6
Plan Purpose 6
Board of Directors 7
COEHA MEDICARE MEMBERS 9
Medicare Members 9
COORDINATION OF BENEFITS 10
COEHA MEDICARE PLANS 12
Plan Seven 12
Plan Ten 12
COEHA Health Care Prepayment Plan for Medicare Members 12
ENROLLMENT PERIOD 12
COEHA DISENROLLMENT FORM 14
COEHA NETWORK 15
Identification Cards (COEHA & Medicare) 16
Time Limit for Filing All Claims 16
How to File Medicare Supplemental Claims 17
How to File COEHA HCPP Claims 17
Chemo/Radiation Services 17
Chiropractic Services 17
Diabetic Supplies & Home Blood Glucose Monitors 18
Durable Medical Equipment 18
Emergency Room Benefits 18
Gastric Bypass/Stomach Stapling/Lap Belt 19
Kidney Dialysis 19
Mental Health 19
Organ Transplants 20
Orthotic Devices 20
Outpatient Office Visits, Consultations & Diagnostic Testing 20
Physical, Occupational and Speech Therapy 20
Prescription Drugs 20
Prosthetic Devices 21
Reconstructive Surgery Following Mastectomy 21
Removal of Excess Skin After Gastric Bypass or Extreme
Weight Loss/Tummy Tuck 21
Skilled Nursing Facility Care 21
Exceptional Cases 22
ADVANCE DIRECTIVE 23
SUBROGATION AND REIMBURSEMENT 26
INTERNAL GRIEVANCE PROCESS 31
YOU CAN ALSO FILE A COMPLAINT ABOUT QUALITY OF CARE 32
TO THE QUALITY IMPROVEMENT ORGANIZATION ("QIO")
TWO TYPES OF APPEAL PROCEDURES 34
Outline of Appeal Procedures for COEHA Medicare HCPP Enrollees 34
Appeal Rights and Procedures for COEHA Medicare HCPP Enrollees 36
Outline of Appeal Procedures for Supplemental Medicare Coverage 39
Claims and Appeals Procedure for Supplemental Medicare Coverage 40
Representative Filing on Behalf of the Member 42
NOTICE ABOUT NON-DISCRIMINATION 43
IF YOU HAVE ANY QUESTIONS REGARDING BENEFITS, CLAIMS OR ELIGIBILITY, CONTACT THE C AND O EMPLOYEES’ HOSPITAL ASSOCIATION AT:
C and O Employees’ Hospital Association
511 Main Street, 2nd Floor
Clifton Forge, Virginia 24422-1166
(800) 679-9135 (toll free)
(540) 862-5728 (bell)
(8) 443-1463 (RR)
(540) 862-3552 (claims)
(540) 862-4958 (membership eligibility)
Web site: www.coeha.com
Hours of Operation:
Monday through Friday, 8:30am to 5:00 pm
The members who support the C and O Employees’ Hospital Association and the dedicated staff of professionals who administer the benefits keep this Organization operating efficiently.
C and O Employees’ Hospital Association (COEHA)
Employer Identification and Plan Numbers:
Employer Identification Number is 23-7082348
Plan Number is 501
Administration of Plan:
The Plan is administered by the C and O Employees’ Hospital Association, 511 Main Street, 2nd Floor, Clifton Forge, Virginia 24422-1166
Type of Plan:
COEHA is a Medicare Supplemental Plan
January 1 through December 31
Contributions and Funding:
The Plan is funded by membership contributions through a monthly dues assessment.
Agent for Service of Legal Process:
Kenneth R. Farley
C and O Employees Hospital Association
511 Main Street, 2nd Floor
Clifton Forge, Virginia 24422-1166
Former employees on the former C and O Railway territory and other individuals, which the Board of Directors may from time to time decide to admit to the C and O Employees’ Hospital Association, are eligible for membership.
Any member of the C and O Employees’ Hospital Association who fails to submit current membership premiums shall be notified of the delinquency and given thirty (90) days to bring membership status up to date. Failure to comply with this notice will result in forfeiture of membership.
As a cost containment measure, COEHA has instituted an automatic dues deduction program for monthly membership premiums from your checking account. You will be required to participate in the automatic dues deduction program or you may remit your dues directly to COEHA either quarterly, semi-annually, or annually. Your check should be made payable to the C and O Employees’ Hospital Association and we must receive it by the 5th of each month. If you choose to participate in the automatic dues deduction program, your premiums will be deducted on the fifth (5th) day of each month unless the 5th of the month is on a weekend or holiday.
The C and O Employees’ Hospital Association was established in 1897 as a joint effort between the Chesapeake and Ohio Railway Company and its employees to provide certain healthcare benefits for the employees and retirees of the Chesapeake and Ohio Railway Company.
Healthcare benefits will be furnished in accordance with such rules and regulations as may from time to time be approved by the Board of Directors of the C and O Employees’ Hospital Association, provided, that at all times the C and O Employees’ Hospital Association shall conduct itself strictly as a non-profit organization pursuant to Section 501(c)(9) of the Internal Revenue Code of 1986 as same may be amended, or the comparable section of any future Revenue Act.
All benefits are subject to the limitations and exclusions in this Medicare Supplemental Handbook and are payable when determined by the Plan to be medically necessary. No oral statement of any person shall modify or otherwise affect the benefits, limitations, and exclusions of this Medicare Supplemental Handbook, convey or void any coverage, increase or reduce any benefits under this Plan, or be used in the prosecution or defense of a claim under this Plan.
Your C and O Employees’ Hospital Association, hereafter referred to in this Medicare Supplemental Handbook as "COEHA," is governed by a Board of Directors. The current members of the Board of Directors are:
Director Union Affiliation
Kenneth Farley Local Chairman, E Craft
President, COEHA United Transportation Union
271 Township Road 1167
Proctorville, Ohio 45669
Norman V. Smith Brother of Locomotive
Vice President, COEHA Engineers
1707 Jones Street
Flatwoods, KY 41139
Jonathan Barron Local Chairman
Secretary-Treasurer, COEHA United Transportation Union
17295 Shiloh Church Road
Montpelier, VA 23192
Tim Braden Junior Vice General Chairman
Director, COEHA Brotherhood of Locomotive
P. O. Box 274 Engineers
Russell, KY 41169
Glenn W. Hazelwood Yardmaster Director, COEHA United Transportation Union
2423 Old Geneva Road
Henderson, KY 42420
Howard Knight At Large Director
100 Bells Island Drive
Hampton, VA 23664
Matt Thornton General Chairman
Director, COEHA Brotherhood of Locomotive
P. O. Box 49 Engineers
Etowah, TN 37331-0049
Jim Townsend General Chairman
Director, COEHA United Transportation Union
1319 Chestnut Street
Kenova, WV 25530
COEHA MEDICARE MEMBERS
Please refer to the COEHA Plan Section of this Medicare Supplemental Handbook for a summary of your benefits. The Benefits Section provides coverage information regarding specific healthcare services.
Active employees age 65 or older and eligible for Medicare coverage will still be covered by COEHA as their primary insurer and coverage for active employees is outlined in the COEHA Rules and Regulations.
When a pensioned member becomes eligible for Medicare by virtue of attaining age (65), or by meeting the disability requirements established by the Railroad Retirement Board/Social Security Administration, COEHA membership may be converted to one of our Medicare Supplemental Plans, at which time you will pay the appropriate premium for a Medicare member. The Original Medicare Plan consists of Part A, which pays for hospital services, and Part B, which pays for physician and other medical services. As a Medicare member of COEHA, you are required to carry the Original Medicare Plan, both Parts A & B. If you are enrolled in a Medicare Advantage Plan, you do not have the Original Medicare Plan. (You are covered under COEHA’s Plans Seven or Ten.)
We have also extended our Medicare supplemental plans to the following people:
COEHA does not exclude or limit membership based on your health condition.
Anyone who wishes to participate in one of the Medicare Supplemental Plans must submit an application on COEHA’s Medicare Supplemental Enrollment Form. By signing the Medicare Supplemental Enrollment Form, all applicants authorize the Centers for Medicare and Medicaid Services ("CMS") to provide COEHA with information concerning their entitlement to Medicare and their Part B claims history.
The Coordination of Benefits provision is intended to prevent the payment of benefits where other duplicative coverage exists. It applies when the covered member is also covered by other insurance or another plan. In no circumstance will COEHA provide duplication of benefits.
The Coordination of Benefits provision applies whether or not a claim is filed under the other insurance or plan. If needed, authorization must be given COEHA to obtain information as to benefits or services available from the other plan or plans, or to recover overpayment.
The term "plan" as used herein will mean any plan providing benefits or services for or by reason of medical, vision, or dental treatment, and such benefits or services are provided by:
The term "plan" will be construed separately with respect to each policy, contract, or other arrangement for benefits or services, and separately with respect to that portion of any such policy, contract, or other arrangement which reserves the right to take the benefits or services of other plans into consideration in determining its benefits and that portion which does not.
Order Of Benefit Determination
If a covered member is covered under one or more Medicare supplemental plans or policies, whether through a spouse or otherwise, the COEHA Plan will always be secondary to that other policy or plan. Under no circumstances will the COEHA Plan pay duplicate benefits.
If a covered member is covered under one or more other plans including, but not limited to, automobile or health insurance, the benefits under this Plan incurred in a calendar year will be reduced by the amount of any benefits payable by such other plan so that the total benefits paid will not exceed 100% of the expenses incurred. COEHA will determine which plan is the primary plan that will pay its benefits first according to the following rules: (1) When only one of the plans has a coordination of benefits provision, then the plan without such a provision will be the primary plan. (2) If both plans have such a provision, the plan under which the covered member is covered as an active employee will be the primary plan. (3) If both of the foregoing rules do not establish which plan is the primary plan, then the plan that has covered the person for the longer period of time will be the primary plan.
If you are a Medicare member and you are also a covered beneficiary under your spouse’s Medicare supplemental insurance policy or plan, COEHA would be tertiary coverage to your spouse’s coverage and Medicare Parts A and B coverage. Your spouse’s insurance or health plan is primary to this coverage.
COEHA MEDICARE PLANS
Plan benefits are highlighted below. For specific benefits, please refer to the Benefits Section.
Plan Seven (Medicare)—includes Hospital, Medical and Prescription Drug Coverage
Plan Ten (Medicare)—Hospital and Medical Coverage Only
COEHA Health Care Prepayment Plan
COEHA is contracted as a Health Care Prepayment Plan ("HCPP") with the Center for Medicare and Medicaid Services ("CMS"), the Federal Agency that administers Medicare. This contract authorizes COEHA to pay your Medicare Part B claims to participating providers for office visits and related office services, consultations, hospital visits, x-rays and surgical procedures. When COEHA HCPP receives a participating provider’s claim for your services, payments for Medicare Part B benefits and your COEHA Medicare Supplemental Plan benefits are made in one check directly to the provider, which eliminates billing Medicare and you. As a COEHA Medicare Supplemental Plan member, you are automatically enrolled in the COEHA Medicare Health Care Prepayment Plan.
The COEHA HCPP contract with CMS renews annually on January 1. Either CMS or COEHA may terminate the contract by providing advance notice to each other and to you. If the contract ends, your COEHA Supplemental Plan benefits will continue to be in force. COEHA Medicare members do not change or temporarily lose their access to Medicare Parts A and B. COEHA HCPP members continue to access Medicare Parts A and B whether or not the provider is participating with COEHA. COEHA HCPP does not change Medicare Part B benefits—congressional law creates and defines those benefits. The COEHA Board of Directors determines only the premium amounts and the benefits that are paid as a supplement to your Medicare coverage under the COEHA Medicare Supplemental Plan.
You may choose to go out-of-network anywhere and at anytime using your Medicare benefits. COEHA HCPP cannot pay the Medicare Part B payments for these nonparticipating providers. Medicare processes these out-of-network claims. However, your COEHA Medicare Supplemental Plan will pay the deductible and/or coinsurance for these providers.
We do not have an open enrollment period. You may enroll in Plan Seven or Plan Ten at any time.
Disenrollment from the COEHA Medicare Supplemental and Medicare HCPP Plans means ending your membership.
Voluntary Disenrollment: You may choose to end your membership in the COEHA Medicare Supplemental and HCPP Plans at any time and for any reason.
Involuntary Disenrollment: Disenrollment from the COEHA Medicare Supplemental and HCPP Plans does not affect your enrollment in original Medicare Part A and B. Following are the only reasons that members may be involuntarily disenrolled by COEHA:
Disenrollment from the COEHA Medicare Supplemental and HCPP plans will be effective on the first day of the month following the month COEHA receives the disenrollment form (unless a later date of disenrollment is requested).
C AND O EMPLOYEES’ HOSPITAL ASSOCIATION DISENROLLMENT FORM
If you wish to discontinue your membership in the C and O Employees’ Hospital Association, please COMPLETE AND RETURN this form to:
C and O Employees’ Hospital Association
511 Main Street, 2nd Floor
Clifton Forge, Virginia 24422
ATTN: MEMBERSHIP DUES DEPT.
(name of member)
wish to discontinue my membership in the C and O Employees’ Hospital Association, effective the first day of
I understand that by discontinuing my membership in the C and O Employees’ Hospital Association, I am also disenrolling from your COEHA Health Care Prepayment Plan (HCPP).
(Social Security Number) (HPIN)
This form is for disenrollment in the C and O Employees Hospital Association. Your Medicare coverage is intact. If you would like assistance in obtaining other health care insurance, you may contact your State Health Insurance Assistance Program, State Insurance Department and State Medical Assistance Office.
To give you the highest quality medical care available, we have created an extensive network of healthcare providers. We have an open network, which means you can use the services of providers who belong to our network without first getting a referral from another physician. All of our providers are participating with Medicare, which means the provider has agreed to accept Medicare’s approved charge and they cannot bill the patient for the amount not approved by Medicare.
The existence of an open network does not mean that every service and specialty will automatically be covered. The Benefits Section provides coverage information regarding specific healthcare services.
You may also seek treatment out-of-network with a provider of your choice, and we will be responsible for the deductible and/or coinsurance not covered by Medicare. If the provider does not accept an assignment with Medicare, COEHA will be responsible for only the deductible and/or coinsurance, and not the amount which Medicare does not approve. In most instances, the nonparticipating provider is allowed to bill the patient for 15% over Medicare’s approved charge—this is called the "limiting charge." Always ask your provider whether they accept assignment with Medicare because it could save you money.
IDENTIFICATION CARDS (COEHA & MEDICARE)
Your COEHA identification card identifies you as a member of COEHA. It contains a unique member identification number which helps COEHA protect you against possible identity theft. You must present this card when you receive medical services. You should make sure the provider copies the front and back of the card. Please have this number available when you call COEHA. Also, please list this number on any correspondence or premium payments sent to COEHA.
Your COEHA membership card does not guarantee coverage of all services or current eligibility. You or your provider can verify your eligibility by contacting COEHA. Should your membership card become lost, stolen or damaged, you can call COEHA with a replacement request at 1-800-679-9135 or locally 1-540-862-5728.
You should also present your red, white and blue Medicare Card when you receive medical services.
TIME LIMIT FOR FILING ALL CLAIMS
All claims for services provided our members must be received within one year from the date the services were rendered to be eligible for payment by COEHA. Also, all corrected rebills should be received within one year from the original denial date to be eligible for payment by COEHA.
HOW TO FILE MEDICARE SUPPLEMENTAL CLAIMS
We can process Medicare Parts A and B from the remittance notices we receive during the crossover from GHI (Medicare COB contractor). We no longer require a paper claim.
If a paper claim is filed, it should be on a UB-04 or CMS-1500 Form, with the appropriate Medicare Remittance Notice and/or other insurance payment record attached, to the following address:
C and O Employees’ Hospital Association
511 Main Street, 2nd Floor
Clifton Forge, VA 24422
HOW TO FILE COEHA HCPP CLAIMS
Providers may file claims on a CMS-1500 Form by mail to the following address:
C and O Employees’ Hospital Association
511 Main Street, 2nd Floor
Clifton Forge, VA 24422
Claims may also be filed electronically. COEHA is contracted with WebMD to
accept medical claims through WebMD Transaction Division/ENVOY as a Blanket
Your COEHA benefits supplement your basic Medicare benefits. COEHA covers full payment of the Medicare deductible and/or coinsurance amounts for covered services. Services denied by Medicare are not covered by COEHA.
COEHA will provide medically necessary ambulance service to the nearest treatment facility under emergency circumstances when other transportation would endanger your health. In the event necessary specialty service is not available at this facility, COEHA will provide medically necessary ambulance service to the nearest facility where specialty service is available.
Effective January 1, 2008, we will now cover the deductible and/or coinsurance after Medicare for covered chiropractic services. Medicare Part B covers limited chiropractic services to help correct a subluxation using manipulation of the spine.
Medicare does not cover any other services or tests ordered by a chiropractor (including x-rays or massage therapy).
DIABETIC SUPPLIES & HOME BLOOD GLUCOSE MONITORS
You are only eligible for diabetic supplies (test strips, lancets, lancing devices and control solution) through our diabetic supply program with Neighborhood Diabetes. These supplies are a Medicare Part B expense. Neighborhood Diabetes is a fully accredited organization with more than a decade of success in helping people with diabetes. These supplies may be ordered by telephone and for your convenience, they will be shipped directly to your home. Neighborhood Diabetes will file the expense for these supplies with Medicare and COEHA. There will be no payment due by you on these testing supplies if they are ordered through Neighborhood Diabetes.
EXCEPTION: IF YOU LIVE IN A MEDICARE DURABLE MEDICAL EQUIPMENT COMPETITIVE BIDDING AREA, YOU MUST USE SPECIFIC SUPPLIERS CALLED "CONTRACT SUPPLIERS" IN ORDER FOR MEDICARE AND COEHA TO COVER YOUR DIABETIC TESTING SUPPLIES AND YOU WILL NOT BE ABLE TO UTILIZE NEIGHBORHOOD DIABETES.
Your diabetic medications, such as Insulin, syringes and alcohol wipes/swabs are a Medicare Part D expense, and are handled through our prescription drug program. Navitus Health Solutions is our Pharmacy Benefits Manager. There will be a copayment on your Part D diabetic medications and supplies.
Home blood glucose monitors are only covered when they are provided by Neighborhood Diabetes.
You may contact Neighborhood Diabetes at 1-866-784-5647.
Diabetic shoes and inserts are not covered.
DURABLE MEDICAL EQUIPMENT
This is equipment needed for medical reasons, which is sturdy enough to be used many times without wearing out. COEHA covers certain durable equipment items such as oxygen, oxygen equipment, wheelchairs, hospital beds, etc. COEHA does not cover maintenance, repair, or replacement of such items. Only one of each article is covered.
Not all durable medical equipment is covered. This benefit is administered on a case by case basis.
(See Section on Diabetic Supplies & Home Blood Glucose Monitors for coverage of a glucose monitor.)
EMERGENCY ROOM BENEFITS
Payment for services rendered in hospital emergency rooms is limited to treatment of emergency problems only. A medical emergency is when you believe that your health is in serious danger—when every second counts. Treatment of non-emergency problems that can be handled in a physician’s office will be denied.
GASTRIC BYPASS /STOMACH STAPLING/LAP BELT
There is a one time limit of $25,000 per lifetime. COEHA will cover the deductible and/or coinsurance after Medicare for this procedure. Surgery must be due to a medical necessity and preauthorization by COEHA is required.
A benefit period begins on the first day you go into the hospital and ends when you have not received any hospital care for 60 consecutive days. If you go to the hospital after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefits periods you can have.
For periods of hospitalization up to 60 days, COEHA will cover the deductible. For the 61st through the 90th day, COEHA will cover the coinsurance not covered by Medicare. For the 91st through the 150th day, (which are your 60 lifetime reserve days), COEHA will pay the balance of covered charges which Medicare does not cover. Services in excess of 150 days (your lifetime reserve days) are not covered by Medicare or COEHA.
Private rooms are covered when it has been determined by the attending physician that it is medically necessary.
COEHA will cover the cost of the first three pints of blood, if used and not replaced, which is your blood deductible.
Private duty nursing is not covered.
COEHA will cover the deductible and/or coinsurance for services associated with the treatment of mental health only to the limit of Medicare coverage, subject to Medicare guidelines.
For mental health care (outpatient), Medicare covers mental health care services to help with conditions such as depression or anxiety. Coverage includes services generally provided in an outpatient setting, including visits with a psychiatrist or other doctor, clinical psychologist, nurse practitioner, physician’s assistant, clinical nurse specialist, or clinical social worker, certain treatment for substance, and lab tests. Certain limits and conditions apply.
For mental health care (inpatient), Medicare covers semi-private rooms, meals, general nursing, and drugs as part of your inpatient treatment, and other hospital services and supplies. This includes mental health care.
Routine eye examinations and refractions for the purpose of prescribing glasses or other visual aids which may be required are not covered by COEHA.
Coverage for services other than routine eye examination and refractions is provided. Refractions are not covered under any circumstances, since Medicare does not participate in the cost of this expense.
There is a one-time limit of $100,000 per lifetime for human kidney, cornea, bone marrow, liver or heart transplants. Transplant services must be preauthorized by COEHA. COEHA does not cover transplant cases which are considered experimental. The $100,000 limit includes the actual hospital stay for the organ transplant and all services incident to the hospital stay, including charge for procurement of the organ from a living donor.
Bone marrow harvesting which may be done as an outpatient prior to the hospital stay for the actual transplant of the marrow, will also count towards the $100,000 limit.
Immunosuppressive drugs (anti-rejection drugs) are covered. However, they are not available through your prescription drug program because Medicare will pay for these drugs. They should be purchased through a provider who will file the expense with Medicare and file the deductible and/or coinsurance with COEHA.
These are items serving to protect, restore or improve function. COEHA covers certain orthotic devices such as braces and supports. Repair, replacement or maintenance of such item is not covered. Only one of each article is covered.
Not all orthotic devices are covered. This benefit is administered on a case by case basis.
OUTPATIENT OFFICE VISITS, CONSULTATIONS & DIAGNOSTIC TESTING
PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPY
COEHA will cover services by a Podiatrist when such services cannot be provided by an orthopedic specialist.
General foot care is not covered because Medicare does not participate in the cost of this expense.
Arch supports and foot orthotics, such as inserts, are not covered.
We are contracted with the Federal Government to provide our members with an enhanced Medicare Part D Prescription Drug Plan. Please refer to our Handbook entitled, Evidence of Coverage for COEHA Medicare Part D Prescription Drug Plan.
This includes artificial substitutes that replace missing body parts. COEHA covers certain prosthetic devices such as artificial limbs, eyes, etc. COEHA does not cover maintenance, repair, or replacement of such items. Only one of each article is covered. Breast prosthetics are excluded from the "Only one of each article" regulation.
Prosthetic devices also include items used to replace an internal body part or function such as ostomy supplies and parenteral/enteral nutrition therapy. (We do cover the balance after Medicare on ostomy supplies; however, parenteral/enteral nutrition therapy is not covered.)
Not all prosthetic devices are covered. This benefit is administered on a case by case basis.
(See Section on Reconstructive Surgery Following Mastectomy for coverage on breast prosthetics)
RECONSTRUCTIVE SURGERY FOLLOWING MASTECTOMY
COEHA provides coverage, in the case of a member who is receiving benefits in connection with a mastectomy and who elects breast reconstruction in connection with such mastectomy, (i) all stages of reconstruction of the breast on which the mastectomy has been performed; (ii) surgery and reconstruction of the other breast to produce a symmetrical appearance; and (iii) prostheses and physical complications of mastectomy, including lymphedemas in a manner determined in consultation with the attending physician and the patient. Such coverage is subject to annual deductibles and coinsurance provisions as may be deemed appropriate and as are consistent with those established for other benefits under the Plan.
REMOVAL OF EXCESS SKIN AFTER GASTRIC BYPASS OR EXTREME WEIGHT LOSS/TUMMY TUCK
There is a one time limit of $7500 per lifetime. COEHA will cover the deductible and/or coinsurance after Medicare for this procedure. Surgery must be due to a medical necessity and preauthorization by COEHA is required.
SKILLED NURSING FACILITY CARE
Medicare defines "Skilled Nursing Facility (SNF) Care" as "skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a skilled nursing facility. Examples of skilled nursing facility care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor."
Medicare covers semi-private rooms, meals, skilled nursing and rehabilitative services, and other services and supplies that are medically necessary after a three-day minimum medically-necessary inpatient hospital stay for a related illness or injury. An inpatient hospital stay begins the day you are formally admitted with a doctor’s order and does not include the day you are discharged. To qualify for care in a skilled nursing facility, your doctor must certify that you need daily skilled care like intravenous injections or physical therapy. Medicare does not cover long-term care or custodial care.
COEHA will cover the balance after Medicare for SNF. COEHA will not cover skilled care if you do not meet Medicare’s requirements. COEHA will not cover skilled care once your Medicare coverage is exhausted.
COEHA does not cover custodial care. Custodial care is care that helps you with usual daily activities like walking, eating, or bathing.
COEHA does not cover long-term care facility charges. Long-term care is a variety of services that help people with health or personal needs and activities of daily living over a period of time. Most long-term care is custodial care.
Effective January 1, 2008, COEHA will cover the deductible and/or coinsurance after Medicare for certain medical services provided a member while a resident in a long-term facility, such as physician visits and physical therapy.
Cases may arise involving medical care that is not specified in this Medicare Supplemental Handbook. In these cases, contact COEHA for instructions.
You can decide in advance what medical treatment you want to receive if you become physically or mentally unable to communicate your wishes. You can do this by preparing an Advance Directive.
An Advance Directive is a written document which states your choice about medical treatment. It can also designate someone else to make medical decisions for you, if you are unable to make these choices yourself. This document is called an Advance Directive because it is signed in advance to let your doctor know your wishes concerning medical treatment. You do not have to have an Advance Directive if you do not want one.
The laws for Advance Directives differ from state to state. There are different types of advance directives and different names for them depending on your state or local area. For example, documents called "living will" and "power of attorney for health care" are examples of advance directives. If you are interested in obtaining Advance Directive information for the state in which you reside, please contact us. We will send you the appropriate information.
It is your choice whether you want to fill out an advance directive. The law forbids any discrimination against you in your medical care based on whether you have an advance directive or not.
The following services are not covered by C and O Employees’ Hospital Association—this does not mean that Medicare does not cover all of these services.
Appliances used in birth control
Arch supports and foot orthotics
Blood pressure monitor
Charge for completion of insurance papers, reports, etc.
Cosmetic/Reconstructive surgery, except for repair or alleviation of damage to the member caused solely by bodily injury while the member is covered and except for breast reconstruction following a mastectomy covered by the Plan.
Custodial or long-term care (except as defined in the Skilled Nursing Facility Section of this Handbook
Dependent child’s pregnancy or the resulting childbirth, abortion or miscarriage
Evaluation and studies performed in connection with litigation
Fertility procedures and tests
General foot care
Glasses or other visual aids
Hearing aids and batteries for such
Home Health nursing visits
Hospital admissions for diagnostic testing only
Instructional booklets or videos
In vitro fertilization, embryo transfer procedures, artificial insemination, immunotherapy for treatment of infertility
Medical services or testing provided a member incident to treatment of a spouse and/or dependent
Membership to YMCA or other fitness organizations
On-duty injuries that occur while working and receiving compensation from a person, firm, company, or organization other than the CSXT and/or subsidiaries and affiliated companies
Outpatient self-administered drugs
Personal convenience items (television, radios, telephone calls, guest trays, private room differential, etc.)
Physician certification and re-certification for home health and hospice services
Physician visits to the domiciliary/home
Prescribed drugs and/or items which can be purchased over-the-counter (with the exception of Prilosec OTC, Zyrtec OTC and Claritin OTC)
Preventative healthcare services, such as routine physicals
Radial Keratotomy/Lasik Surgery
Reversal of sterilization
Sales tax; shipping and handling for medical supplies
Services that are not reasonable and customary under the Original Medicare program standards
Sex change surgery
Special lift chairs, or separate chair lift for patient owned furniture, geriatric chairs
Special shoes, unless they are attached to braces
Supplemental feeding (parenteral/enteral nutrition therapy) and feeding supply kit
Transfer bench/shower chair
Treatment outside of the United States (unless your circumstances fall under the Medicare exceptions’ category for travel)
Treatment rendered by a family member (spouse, mother, father, children, sister, brother, in-laws, grandparents, grandchildren, etc.)
Vaccines (except for tetanus when medically necessary—some vaccines may be covered under the COEHA Medicare Part D Prescription Drug Plan)
SUBROGATION AND REIMBURSEMENT
Benefits Subject to this Provision
This provision shall apply to all benefits provided under any section of the C and O Employees’ Hospital Association Plan.
Statement of Purpose
Subrogation and reimbursement represent significant C and O Employees’ Hospital Association Plan assets and are vital to the financial stability of the Plan. Subrogation and reimbursement recoveries are used to pay future claims for other C and O Employees’ Hospital Association members. Anyone in possession of these assets holds them as a fiduciary and constructive trustee for the benefit of C and O Employees’ Hospital Association. The Plan Administrator has a fiduciary obligation under ERISA to pursue and recover these Plan assets to the fullest extent possible.
"Another party" shall mean any individual or entity, other than C and O Employees’ Hospital Association, who is liable or legally responsible to pay expenses, compensation or damages in connection with a covered member’s injuries or illness.
"Another party" shall include the party or parties who caused the injuries or illness; the liability insurer, guarantor or other indemnifier of the party or parties who caused the injuries or illness; a covered member’s own insurance coverage, such as uninsured, underinsured, medical payments, no-fault, homeowner’s, renter’s or any other insurer; a workers’ compensation insurer; governmental entity or any other individual, corporation, association or entity that is liable or legally responsible for payment in connection with the injuries or illness.
A "Covered Member" shall mean any person, dependents or representatives, other than C and O Employees’ Hospital Association, who is bound by the terms of the Subrogation and Reimbursement Provision herein.
A "Covered Member" shall include but is not limited to any beneficiary, dependent, spouse or person who has or will receive benefits under the C and O Employees’ Hospital Association Plan, and any legal or personal representatives of that person, including parents, guardians, attorneys, trustees, administrators or executors of an estate of a covered member, and heirs of the estate.
"Recovery" shall mean any and all monies identified or paid to the covered member through or from another party by way of judgment, award, settlement, covenant, release or otherwise (no matter how those monies may be characterized, designated or allocated) to compensate for any losses caused by, or in connection with, the injuries or illness. A recovery exists as soon as any fund is identified as compensation for a covered member from another party. Any recovery shall be deemed to apply, first, for reimbursement of C and O Employees’ Hospital Association’s lien.
"Subrogation" shall mean C and O Employees’ Hospital Association’s right to pursue the covered member’s claims for medical or other charges paid by the Plan against another party.
"Reimbursement" shall mean repayment to C and O Employees’ Hospital Association of recovered medical or other benefits that it has paid toward care and treatment of the injury or illness for which there has been a recovery.
Plan Administrator Discretion
The Plan Administrator has maximum discretion to interpret the terms of this provision and to make changes as it deems necessary.
When this Provision Applies
A covered member may incur medical or other charges related to injuries or illness caused in part or in whole by the act or omission of the covered member of another person; or another party may be liable or legally responsible for payment of charges incurred in connection with the injuries or illness. If so, the covered member may have a claim against that other person or another party for payment of the medical or other charges. In that event, the C and O Employees’ Hospital Association Plan will be secondary, not primary. The covered member agrees, if charges are paid by C and O Employees’ Hospital Association, to transfer all rights to recover damages in full to C and O Employees’ Hospital Association.
Duties of the Covered Member
When a right of recovery exists, and as a condition to any payment by C and O Employees’ Hospital Association (including payment of future benefits for other illnesses or injuries), the covered member will execute and deliver all required instruments and papers, including a subrogation and reimbursement agreement provided by C and O Employees’ Hospital Association as well as doing and providing whatever else is needed, to secure C and O Employees’ Hospital Association’s rights of subrogation and reimbursement, before any medical or other benefits will be paid by C and O Employees’ Hospital Association for the injuries or illness. The Plan Administrator may determine, in its sole discretion, that it is in C and O Employees’ Hospital Association’s best interests to pay medical or other benefits for the injuries or illness before these papers are signed (for example, to obtain a prompt payment discount); however, in that event, C and O Employees’ Hospital Association still will be entitled to subrogation and reimbursement. In addition, the covered member will do nothing to prejudice C and O Employees’ Hospital Association’s right to subrogation and reimbursement and acknowledges that the Plan precludes operation of the made-whole and common-fund doctrines. A covered member who receives any recovery (whether by judgment, settlement, compromise, or otherwise) has an absolute obligation to immediately tender the portion of the recovery subject to the Plan’s lien to C and O Employees’ Hospital Association under the terms of this provision. A covered member who receives any such recovery and does not immediately tender the recovery to C and O Employees’ Hospital Association will be deemed to hold the recovery in constructive trust for C and O Employees’ Hospital Association, because the covered member is not the rightful owner of the recovery and should not be in possession of the recovery until C and O Employees’ Hospital Association has been fully reimbursed.
The covered member must:
First Priority Right of Subrogation and/or Reimbursement
Any amounts recovered will be subject to subrogation or reimbursement. In no case will the amount subject to subrogation or reimbursement exceed the amount of medical or other benefits paid for the injuries or illness under the Plan and the expenses incurred by C and O Employees’ Hospital Association in collecting this amount. The Plan will be subrogated to all rights the covered member may have against that other person or another party and will be entitled to first priority reimbursement out of any recovery to the extent of the Plan’s payments. In addition,
C and O Employees’ Hospital Association shall have the first priority lien against any recovery to the extent of benefits paid and to be payable in the future. C and O Employees’ Hospital Association’s first priority lien supersedes any right that the covered member may have to be "made whole." In other words, C and O Employees’ Hospital Association is entitled to the right of first reimbursement out of any recovery the covered member procures or may be entitled to procure regardless of whether the covered member has received full compensation for any of his or her damages or expenses, including attorneys’ fees or costs; and regardless of whether or not the recovery is designated as payment for medical expenses or otherwise. Additionally, C and O Employees’ Hospital Association’s right of first reimbursement will not be reduced for any reason, including attorneys’ fees, costs, comparative or contributory negligence, limits of collectability or responsibility, characterization of recovery as pain and suffering or otherwise. As a condition to receiving benefits under the Plan, the covered member agrees that acceptance of benefits is constructive notice of this provision.
If the covered member retains an attorney, the Plan Administrator may require that attorney to sign the subrogation and reimbursement agreement as a condition to any payment of benefits and as a condition to any payment of future benefits for other illnesses or injuries. Additionally, the covered member’s attorney must recognize and consent to the fact that this provision precludes the operation of the "made-whole" and "common fund" doctrines, and the attorney must agree not to assert either doctrine against C and O Employees’ Hospital Association in his pursuit of recovery. The Plan will not pay the covered member’s attorneys’ fees and costs associated with the recovery of funds, nor will it reduce its reimbursement pro rata for the payment of the covered member’s attorneys’ fees and costs.
An attorney who receives any recovery (whether by judgment, settlement, compromise, or otherwise) has an absolute obligation to immediately tender the recovery to C and O Employees’ Hospital Association under the terms of this provision. As a possessor of a portion of the recovery, the covered member’s attorney holds the recovery as a constructive trustee and fiduciary and is obligated to tender the recovery immediately over to the Plan. A covered member’s attorney who receives any such recovery and does not immediately tender the recovery to C and O Employees’ Hospital Association will be deemed to hold the recovery in constructive trust for C and O Employees’ Hospital Association, because neither the covered member nor his attorney is the rightful owner of the portion of the recovery subject to C and O Employees’ Hospital Association’s lien.
When the Covered Member is a Minor or is Deceased or Incapacitated
The provisions of this subrogation and reimbursement provision apply with equal force to the parents, trustees, guardians, administrators, or other representatives of a minor covered member and to the heirs or personal and legal representatives of the estate of a deceased or incapacitated covered member, regardless of applicable law and whether or not the representatives have access or control of the recovery. No representative of a covered member listed here may allow proceeds from a recovery to be allocated in a way that reduces or minimizes the C and O Employees’ Hospital Association’s claim by arranging for others to receive proceeds of any judgment, award, settlement, covenant, release or other payment; or releasing any claim in whole or in part without full compensation therefore.
When a covered member does not comply with the provisions of this section, the Plan Administrator shall have the authority, in its sole discretion, to deny payment of any claims for benefits by the covered member and to deny or reduce future benefits payable (including payment of future benefits for other injuries or illnesses) under the C and O Employees’ Hospital Association Plan by the amount due as a dollar for dollar satisfaction for the reimbursement to the Plan. The Plan Administrator may also, in its sole discretion, deny or reduce future benefits (including future benefits for other injuries or illnesses) under any other group benefits plan maintained by C and O Employees’ Hospital Association. The reductions will equal the amount of the required reimbursement. If C and O Employees’ Hospital Association must bring an action against a covered member to enforce the provisions of this section, then that covered member agrees to pay C and O Employees’ Hospital Association’s attorneys’ fees and costs, regardless of the action’s outcome.
Recovery of Future Benefits
In certain circumstances, a covered member may receive a recovery that exceeds the amount of C and O Employees’ Hospital Association’s payments for past and/or present expenses for treatment of the illness or injury that is the subject of the recovery. In other situations, a covered member may have received a prior recovery that was intended, in part or in whole, to be compensation for future expenses for treatment of the illness or injury that is the subject of a current claim for benefits under the Plan. In these situations, the Plan will not cover any present or future expenses related to the illness or injury for which compensation was provided through a current or previous recovery. The covered member is required to submit full and complete documentation of any such recovery in order for C and O Employees’ Hospital Association to consider eligible expenses that exceed the recovery. To the extent a covered member’s recovery exceeds the amount of the C and O Employees’ Hospital Association’s lien, the Plan is entitled to a credit or cushion in that amount against any claims for future benefits relating to the illness or injury. In those situations following any recovery that exceeds the amount of C and O Employees’ Hospital Association’s lien, the covered member will be solely responsible for payment of medical bills related to the illness or injury out of the remaining recovery. The Plan also precludes operation of the made-whole and common-fund doctrines in applying this provision.
The Plan Administrator has sole discretion to determine whether expenses are related to the illness or injury to the extent this provision applies. Acceptance of benefits under the C and O Employees’ Hospital Association Plan for an illness or injury which the covered member has already received a recovery may be considered fraud, and the covered member will be subject to any sanctions determined by the Plan Administrator, in its sole discretion, to be appropriate, including denial of present or future benefits under the Plan.
INTERNAL GRIEVANCE PROCESS
COEHA maintains an internal grievance process through which members may seek resolution of grievances other than claims denials or adverse organization determinations. Grievances involving other than claims denials or adverse organization determinations may be resolved only through COEHA’s internal grievance process. Examples of such grievances include:
If you have a complaint, we encourage you to first call our Customer Service Department at 1-800-679-9135. We will try to resolve any complaint that you might have over the phone. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints listed below under "Procedures".
Whether you call or write, you should contact COEHA Customer Service right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about.
YOU CAN ALSO FILE A COMPLAINT ABOUT QUALITY OF CARE TO THE QUALITY IMPROVEMENT ORGANIZATION ("QIO")
TWO TYPES OF APPEAL PROCEDURES
There are two types of appeal procedures for our Medicare members. The first appeal procedure listed under the heading, "Appeal Rights and Procedures for COEHA Medicare HCPP Enrollees," deals with your appeal procedure for the amount Medicare denied when services were rendered by COEHA network physicians and COEHA processed this Medicare Part B claim. In this instance, you would utilize the first appeal procedure. A copy of this appeal procedure will be attached to your written notice of denial.
The second appeal procedure listed under the heading, "Claims and Appeals Procedure for Supplemental Medicare Coverage," deals with your appeal procedure for the coinsurance and/or deductible amounts. For example, Medicare covers physician services provided in a nursing home; however, COEHA does not unless you are receiving skilled nursing facility care as defined in this Handbook. If you wish to appeal COEHA’s denial of the coinsurance and/or deductible amounts, you would utilize the second appeal procedure. A copy of this appeal procedure will be attached to your written notice of denial.
OUTLINE OF APPEAL PROCEDURE FOR COEHA MEDICARE HCPP ENROLLEES:
For your convenience, we are listing below step by step directions on how to file a reconsideration request for service or payment of the Medicare Part B portion of your claim for HCPP members. There are six possible steps for requesting care or payment for care you can take to request the care or payment you want from COEHA. At each step, your request is considered and a decision is made. If you are unhappy with the decision, there may be another step you can take if you want to continue requesting the care or payment. These six steps are summarized below. These same six steps are covered in more detail under Appeal Rights and Procedures for COEHA Medicare HCPP Enrollees.
In Steps 1 and 2, you make your request directly to COEHA. We review it and give you our decision.
In Steps 3 through 6, people in organizations that are not connected to COEHA make the decisions about your request. To keep the review independent and impartial, those who conduct the review and make the decision in Steps 3 through 6 are part of (or in some way connected to) the Medicare program, the Social Security Administration, or the federal court system.
The six possible steps are summarized below:
Step 1: The initial decision by COEHA
The starting point is when COEHA makes an "initial decision" (also called an "organizational decision") about your medical care or about paying for care you have already received. When we make an "initial decision," we are giving our interpretation of how the benefits and services that are covered for members of COEHA apply to your specific situation.
Step 2: Appealing the initial decision by COEHA
If you disagree with the decision we make in Step 1, you may ask us to reconsider our decision. This is called an "appeal" or a "request for reconsideration." After reviewing your appeal, we will decide whether to stay with our original decision, or change this decision and give you some or all of the care or payment you want.
Step 3: Review of your request by an Independent Review Organization
If we turn down part or all of your request in Step 2, we are required to send your request to an independent review organization that has a contract with the federal government and is not part of COEHA. This organization will review your request and make a decision about whether we must give you the care or payment you want.
Step 4: Review by an Administrative Law Judge
If you are unhappy with the decision made by the organization that reviews your case in Step 3, you may ask for an Administrative Law Judge to consider your case and make a decision. The Administrative Law Judge works for the federal government. The dollar value of your medical care must be at least $130 to be considered in Step 4.
Step 5: Review by the Medicare Appeals Council ("MAC")
If you or COEHA are unhappy with the decision made in step 4, you or COEHA may ask for the Medicare Appeals Council to review your case. This Board is part of the federal department that runs Medicare.
Step 6: Judicial Review
If you or COEHA are unhappy with the decision made by the Medicare Appeals Council in Step 5, either you or COEHA may be able to file a civil action in a district court of the United States. The dollar value of your medical care must be at least $1,350 to go to a district court.
APPEAL RIGHTS AND PROCEDURES FOR COEHA MEDICARE HCPP ENROLLEES
COEHA HCPP is responsible for your appeal if we paid your original Medicare Part B claim for benefits. COEHA HCPP appeals involve your Medicare Part B claims for services that you have already received and you are disputing the payment amount or denial of payment. Remember, we only pay Medicare Part B claims for COEHA participating physician office visits and office services, consultations, hospital visits, x-rays and surgical procedures if the claim is sent to us.
You, your representative, or a participating physician may appeal the payment amount or denial of payment made by COEHA HCPP within 60 days of the time the original claim was processed. The appeal must be made in writing. We recommend that any additional information that may help your appeal be submitted to us at the time of the written request. COEHA will never perform this type of appeal for Medicare Part A services, or nonparticipating provider (out-of-network) services because COEHA HCPP would not have processed the original Medicare claim.
You have a right to appeal
You can appeal if you do not agree with COEHA HCPP decisions about payment of your Medicare Part B claims that were originally paid by us. You have a right to appeal if you think that COEHA HCPP has not paid a bill or has not paid a bill in full. Your appeal will apply to payment of claims for services that have already been received by you.
60-day appeal process
If you want to file an appeal request that will be processed within 60 days, do the following:
File your request within 60 days of the date of the notice of our initial decision. Mail or deliver your written appeal request to the following address:
You may send your written appeal to your local Railroad Retirement Board office or your local Social Security Administration office if you are a Social Security retiree.
Fax your written request to COEHA HCPP at (540) 862-3552 or (540) 862-4958.
For additional information on filing your appeal, read the topics entitled Support for Your Appeal and Who May File an Appeal?
If you file your appeal with the Railroad Retirement Board or Social Security Administration
If you file your appeal request with the Railroad Retirement Board office or Social Security office, they will transfer it to COEHA HCPP. This could cause some delay for you because we are responsible for processing your appeal request within 60 days from the date we receive it from them.
If We Do Not Rule Fully In Your Favor
If we do not rule fully in your favor, and you could have any financial responsibility on the claim(s) that were appealed, we will forward your appeal to MAXIMUS Federal Services, the independent review organization for the Center for Medicare and Medicaid Services, for a decision.
Review by an Administrative Law Judge
If you are unhappy with the decision made by the organization that reviews your case, you may ask for an Administrative Law Judge to consider your case and make a decision. The Administrative Law Judge works for the federal government. The dollar value of your medical care must be at least $130 to be considered.
Review by a Medicare Appeals Council
If you or we are unhappy with the decision made by the Administrative Law Judge, either of us may be able to ask the Medicare Appeals Council to review your case.
If you or we are unhappy with the decision made by the Medicare Appeals Council, you may be able to file a civil action in a district count of the United States. The dollar value of your contested medical care must be at least $1,350 to go to a district court.
You are not required to submit additional information to support your appeal. However, if you include additional information to clarify or support your position it may help your appeal. You may want to include supportive information such as medical records or physician opinions. To obtain medical records, send a written request to your physician. If you have seen other specialist physicians, you may need to make a separate written request for your medical records to each of the specialist physicians who provided medical services for you.
You, the COEHA participating physician who provided your services, a court appointed guardian or an agent under a health care proxy (to the extent provided under state law) can file an appeal request.
If you appoint a representative to file the appeal request for you. Please refer to the section entitled Representative Filing On Behalf Of The Member. A signed representative form must be included with each appeal.
This type of appeal applies only if the service has not yet been provided, and not to services that have already been provided or claims that have been processed. If the services have already been performed, one of the previously described appeals process applies.
COEHA HCPP pre-service organization determinations only affect approval of original Medicare Part B payment for services we normally process. If the claim is not sent to the COEHA HCPP for processing after approval is given, the claim could be denied.
COEHA HCPP approval does not guarantee Medicare payment from Railroad Medicare (Palmetto GBA) or Medicare Part A intermediaries, or that the service is a covered benefit under the COEHA Medicare Secondary Plan.
If we or an HCPP COEHA physician denies a service to you and you believe it
is a medically necessary covered benefit under original Medicare Part B, COEHA
HCPP will make a standard
Certain stipulations must be met in order to qualify for a COEHA HCPP standard pre-service 30-day organization determination. The service must be:
COEHA does not perform pre-service organization determinations for those services that would not be processed by COEHA HCPP.
COEHA HCPP Expedited Pre-Service Organization Determination
Expedited decisions may not be requested for cases in which the only issue involved a claim for payment for services that you have already received.
You or any physician may request that we expedite a reconsideration of an organization determination in situations where applying the standard procedure could seriously jeopardize your life, health, or ability to regain maximum function.
If COEHA decides that it is a time-sensitive situation, or if any physician states that it is one, we will make a decision on your request for a service on a fast (expedited) 72-hour basis. Fast decisions only apply to a service that has been denied to you by us, a COEHA HCPP physician or a COEHA HCPP physician wants to discontinue a service that you are receiving and you believe it is medically necessary and a covered benefit under original Medicare Part B.
We may extend this time frame by up to 14 calendar days if you request the extension or if we need additional information, and the extension of time benefits you; for example, if we need additional medical records from medical providers that could change a denial decision. We must make a decision as expeditiously as your health requires, but no later than the end of any extension period. If such an extension is necessary, we will notify you in writing of the delay.
If we deny your request for reconsideration of an expedited organization determination, we will automatically transfer the request to the standard time frame and make a determination within 30 calendar days.
You have the right to file an expedited grievance if you disagree with our determination not to expedite the appeal.
Where to submit your pre-service appeal request
To request a COEHA HCPP standard or expedited pre-service appeal, you or your authorized representative may call, write, fax, email, or visit COEHA. If you want an expedited determination, you must specifically state this at the time of your request.
Mail or deliver your pre-service appeal to the following address:
511 Main Street, 2nd Floor
Clifton Forge, VA 24422
Fax your written pre-service appeal to COEHA at 1-540-862-3552 or 1-540-862-4958.
Telephone your pre-service appeal request to COEHA Customer Service at 1-800-679-9135 or if you are local at 862-5728, Monday through Friday from 8:30 am to 5:00 pm (EST).
Forwarding Your Case to the Independent Review Contractor
If we make an adverse organization determination, we will forward your case to the Center for Medicare and Medicaid Services independent review contractor, MAXIMUS Federal Services, for a decision. We will notify you that we have forwarded your case to the independent review contractor.
OUTLINE OF APPEAL PROCEDURE FOR SUPPLEMENTAL MEDICARE COVERAGE:
For your convenience, we are listing below step by step directions on how to file an appeal for the coinsurance and/or deductible portion of your claim. For more detail, please refer to the procedure listed under Claims and Appeals Procedure for Supplemental Medicare Coverage.
CLAIMS AND APPEALS PROCEDURE FOR SUPPLEMENTAL MEDICARE COVERAGE
The claims procedures described below are effective January 1, 2003 and supercede any conflicting language in these Rules and Regulations.
If a member’s claim under the Plan is wholly or partially denied, he or she will be notified of the decision, after the Plan’s receipt of the claim, within:
A determination regarding a request for the Plan to approve an on-going course of treatment will be made in sufficient advance of the proposed reduction or termination of treatment to allow the member to appeal before the benefit is reduced or terminated.
Under special circumstances, the notice period may be extended for an additional:
If an extension is required, the member will be notified of the special circumstances involved and the date by which the Plan Administrator expects to render a final decision.
If the member’s claim is denied, the Plan Administrator will provide the member with a written or electronic notification of an adverse benefit determination. The notice will:
In the case of an adverse benefit determination involving a claim for urgent care, the information described above may be provided to the member orally within the permitted time frame provided that written or electronic notification is furnished to the member no later than three days after such oral notification.
Appeal of Denied Claims. If the member’s claim is denied, the member will be provided:
Further, the review must provide that the consulted health care provider was not consulted upon for the adverse determination which is subject to the appeal (nor his or her subordinate) and provide, in the case of an urgent care claim, an expedited review process, to which the member’s request may be submitted orally or in writing. All necessary information may be transmitted between the Plan and the member by telephone, facsimile, or other available method.
The Plan Administrator will notify the member of the Plan’s benefit determination upon review of a denied claim within:
(i) for an urgent care claim, within 72 hours;
The Plan’s decision on review may be either a written or electronic notification. The notification will set forth for the member:
(i) the specific reason for the adverse determination,
REPRESENTATIVE FILING ON BEHALF OF THE MEMBER
Individuals who represent members may either be appointed or authorized to act on behalf of the member in filing a grievance, requesting an organization determination or in dealing with any of the levels of the appeals process. A member may appoint any individual (such as a relative, friend, advocate, an attorney, or any physician) to act as his or her representative. Alternatively, a representative may be authorized by the court or act in accordance with State law to act on behalf of a member.
To be appointed by a member, both the member making the appointment and the representative accepting the appointment (including attorneys) must sign, date, and complete a representative form. You can obtain a representative form by calling COEHA Customer Service and requesting a form called "Appointment of Representative". This form is also available on Medicare’s website at http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf.
The signed representative form for a representative appointed by a member, or other appropriate legal papers supporting an authorized representative’s status, must be included with each request for a grievance, an organization determination, or an appeal. When a request for a grievance, organization determination, or appeal is filed by a person claiming to be a representative, but the representative does not provide appropriate documentation, we cannot undertake a review until or unless such documentation is obtained.
NOTICE ABOUT NON-DISCRIMINATION
When we make decisions about employment of staff, we do not discriminate based on a person’s race, disability, religion, sex, sexual orientation, health, ethnicity, creed, age, or national origin. 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.
EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 (ERISA) RIGHTS
As a COEHA member, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to:
Receive Information About Your Plan and Benefits
Examine, without charge, at the Plan Administrator's office and at other specified locations, such as worksites and union halls, all documents governing the Plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Pension and Welfare Benefit Administration.
Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may make a reasonable charge for the copies.
Receive a summary of the Plan's annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report.
Continue Group Health Plan Coverage
Continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the Plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the Plan on the rules governing your COBRA continuation coverage rights.
Reduction or elimination of exclusionary periods of coverage for preexisting conditions under your group health plan, if you have creditable coverage from another plan. You should be provided a certificate of creditable coverage, free of charge, from your group health plan or health insurance issuer when you lose coverage under the plan, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a preexisting condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your coverage.
Prudent Actions by Plan Fiduciaries
In addition to creating rights for Plan participants ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan, called "fiduciaries" of the Plan, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a (pension, welfare) benefit or exercising your rights under ERISA.
Enforce Your Rights
If your claim for a (pension, welfare) benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Plan documents or the latest annual report from the Plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the plan administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with the Plan's decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in Federal court. If it should happen that Plan fiduciaries misuse the Plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.
Assistance with Your Questions
If you have any questions about your Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Pension and Welfare Benefits Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Pension and Welfare Benefits Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Pension and Welfare Benefits Administration.