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Eligibility and benefits

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Eligibility and benefits

Commercial
Medicare

Product & coverage information

The following is a description of all plan types offered by ConnectiCare, Inc. and its affiliates.

Plan type	Plan features
Copayment plan	Members pay a copayment cost-share for most covered health services at the time the services are rendered.
High Deductible Health Plan (Health Savings Account [HSA] Compatible)	Members must meet an in-network Plan deductible that applies to most covered health services, including prescription drug coverage, before coverage of those benefits apply. Some preventive services are covered at 100% and are exempt from the deductible requirement. After the Plan deductible is met, benefits will be covered according to the Plan. Point-of-Service High Deductible Health Plans have an additional Plan deductible requirement for services rendered by non-participating providers.
Deductible plans	Members have an in-network deductible for some covered services before coverage for the benefits will apply. After the deductible is met, benefits will be covered according to the Plan.
Coinsurance plans	Members have an in-network deductible for some covered services After the deductible has been met, coinsurance will apply to the covered benefits

PPM/10.16

Overview of plans

Overview of products

ConnectiCare offers both employer-sponsored plans and individual insurance plans. The following is a description of all product types offered by ConnectiCare, Inc. and its affiliates.

Product type	Product features	Cost share	Referral requirements
CHOICE HMO	Members are required to see participating providers, except in emergencies. No out-of-network coverage unless pre-authorized in writing by ConnectiCare.	Copayments vary by plan. Some plans may have deductible requirements. View sample member ID cards for copay and high-deductible plans for details. Note: To ensure accurate billing for plans with deductibles, bill ConnectiCare prior to taking any payment from members. Your Explanation of Payment (EOP) will specify member responsibility.
CHOICE HMO	Members are required to see participating providers, except in emergencies. No out-of-network coverage unless pre-authorized in writing by ConnectiCare.	Copayments vary by plan. Some plans may have deductible requirements. View sample member ID cards for copay and high-deductible plans for details. Note: To ensure accurate billing for plans with deductibles, bill ConnectiCare prior to taking any payment from members. Your Explanation of Payment (EOP) will specify member responsibility.	No referral requirements.
CHOICE Point-of-Service	Members receive in-network level of benefits when they see participating providers. Members receive out-of-network level of benefits when they see non-participating providers.	Copayments vary by plan. Some plans may have deductible and coinsurance requirements. View sample member ID cards for copay and high-deductible plans for details.	No referral requirements.
FlexPOS	Members receive in-network level of benefits when they see participating providers. Members receive out-of-network level of benefits when they see non-participating providers Member receive in-network level of benefits when they see PHCS Healthy Direction Providers	Copayments vary by plan. Some plans may have deductible and coinsurance requirements. View sample member ID cards for copay and high-deductible plans for details.	No referral requirements.

PPM/10.16

Overview of coverage: Connecticut only

Benefit

HMO Personal Care Plan

Point-of-Service Personal Care Plan

HMO Open Access

Point-of-Service Open Access

Allergy testing

• Limited to a maximum of $315 every two (2) calendar years for: 1.) allergenic extracts (or RAST allergen specific testing); 2.) drug, biological or venom sensitivity. Testing that exceeds this maximum is the member’s responsibility.

Ambulance

• Coverage for medical emergencies without pre-authorization.

• Land or air ambulance/medical transportation that is not due to an emergency requires pre-authorization.

• If transport is required from one facility to another on a weekend or holiday, transport must be provided by a participating service. Providers are also required to contact ConnectiCare’s Notification Line at 1-888-261-2273 to advise ConnectiCare of the transport.

Blood & blood products

• Coverage for receipt of blood and for autologous blood transfusions for the following procedures, when the procedures are covered benefits:

- Bilateral knee replacement	- Hysterectomy
- Coronary Artery Bypass Graft (CABG)	- Laminectomy/spinal fusion
- Facial reconstruction	- Prostatectomy
- Heart valve replacement	- Total hip replacement

Custodial care

• Custodial care is not a covered benefit. It includes services and supplies furnished to a member who has a medical condition that is chronic or non-acute and which, at our discretion, either:

• Are furnished primarily to assist the patient in maintaining activities of daily living, whether or not the member is disabled, including, but not limited to, bathing, dressing, walking, eating, toileting and maintaining personal hygiene or

• Can be provided safely by persons who are not medically skilled, with a reasonable amount of instruction, including, but not limited to, supervision in taking medication, homemaking, supervision of the patient who is unsafe to be left alone, and maintenance of bladder catheters, tracheotomies, colostomies/ileostomies and intravenous infusions (such as TPN) and oral or nasal suctioning. This would also include chronic ventilator care.

DME & disposable supplies

• Coverage varies by plan.

• DME, orthotics & prosthetics must be obtained from a participating commercial DME vendor unless otherwise authorized by ConnectiCare and pre-authorization must be obtained through ConnectiCare.

• HCPCS coding is required on claims.

• See the preauthorization section for a listing of DME that requires pre-authorization.

• The rental and/or purchase of CPAP and BI-PAP machines must be done through our preferred vendors.

Note: The list of covered DME and disposable supplies is reviewed periodically and subject to change at the sole discretion of ConnectiCare.

Genetic analysis & testing

All genetic testing requires preauthorization, with the exception of the following:

• Routine chromosomal analysis (e.g., peripheral blood, tissue culture, chorionic villous sampling, amniocentesis) - CPT 83890 - 83914, billed with Modifier 8A or ICD-9 diagnosis codes V77.6 or V83.81

• DNA testing for cystic fibrosis - CPT 88271 - 88275; 88291, billed with Modifier 2A - 2Z or ICD-9 codes V10.6x or V10.7x

• FISH (fluorescent in situ hybridization) for the diagnosis of lymphoma or leukemia - CPT 88230 - 88269; 88280 - 88289; 88291; 88299

Note: These procedures are covered procedures, but do not require preauthorization when performbed by in-network providers. When performed by out-of-network, these procedures do require preauthorization.

Home health care

• Home health services are coordinated by ConnectiCare's Health Services:

• To verify benefits and eligibility - (phone) 1-800-828-3407
• To inquire about an existing authorization - (phone) 1-800-562-6833
• To request a continuation of an authorization for home health care or IV therapy fax (860) 409-2437

Infertility services

• All infertility services that are subject to the mandate must be pre-authorized, including: a) injectible infertility drugs for the purpose of ovulation induction, b) intrauterine insemination with or without the use of oral or injected medications for ovulation induction, and c) all ART procedures. (A 12-month waiting period may apply for members in individual [ConnectiCare SOLO] plans.)

• Lifetime maximums apply to certain services.

• Members are no longer eligible for coverage after their 40th birthday.

Laboratory & pathology

• All routine laboratory services must be obtained from participating laboratories.

• In-office procedures are restricted to a specific list of tests that relate to the specialty of the provider. (See Other Benefit Information)

Mental health/ alcohol/substance abuse

• All requests to initiate or extend a mental health or substance abuse authorization should be directed to our Behavioral Health Program at 1-800-349-5365. Requests may be made by either the physician or the member.

New technology

• Services or supplies that are new or recently emerged uses of existing services and supplies, are not covered benefits, unless and until we determine to cover them.

• Any treatment for which there is insufficient evidence of therapeutic value for the use for which it is being prescribed is also not covered.

Oral surgery

• Pre-authorization is required.

• Coverage is provided for Temporomandibular Joint (TMJ) surgery or orthognathic procedures with pre-authorization, when medical necessity is established. Supporting evidence, which may be required includes: 1.) abnormal MRI; and 2.) abnormal arthrogram

• Postoperative physical therapy for TMJ surgery is limited to ninety (90) days from the date of surgery when pre-authorized as part of surgical procedure.

• Most plans exclude purely dental services, including oral surgery, but benefits vary by employer.

Preauthorization

• For a specific listing of services and procedures that require pre-authorization refer to the Appendices within this Manual.

• The admitting physician is responsible for pre-authorizing elective admissions five (5) working days in advance. Notify ConnectiCare within twenty-four (24) hours after an emergency admission at 1-888-261-2273.

• Without preauthorization, these services and procedures may not be covered or may be covered at a reduced rate.

• Clinical Review Prior Authorization Request Form

Radiology

• For preauthorization of the following radiological services, call 1-877-607-2363 or request online at http://www.radmd.com/.

• Bone Mineral Density exams ordered more frequently than every twenty-three (23) months
• CT scans (all diagnostic exams)
• MRI/MRA (all examinations)
• Nuclear cardiology
• PET scans
• Stress echocardiograms
• Virtual colonoscopy for diagnostic purposes only, as determined by medical necessity criteria (CPT code 0067T)

• If authorization is not obtained, payment for the service may be denied.

• In-office procedures are restricted to a specific list of tests that relate to the specialty of the physician. (See Other Benefit Information)

• Some plans may have a copayment requirement for radiology services.

Referrals

• Physicians are required to make referrals to participating specialty physicians, including chiropractic physicians.

• No specialist-to-specialist referrals permitted, except OB/Gyns may make referrals..

• Referrals must be logged in to ConnectiCare’s Provider Connection.

• Physicians may make referrals to participating specialists without entering them into the telephonic referral system.

Skilled nursing facility

• Coverage for skilled nursing facility (SNF) admissions with pre-authorization.

• If you admit a member to a SNF on a weekend or holiday, ConnectiCare will automatically authorize payment for SNF services from the day of admission through the next business day. You must call ConnectiCare’s Notification Line at 1-860-674-5870 or 1-888-261-2273 to advise ConnectiCare of the admission. This line is available twenty-four (24) hours a day, seven days a week. If you do not inform ConnectiCare according to these guidelines, the SNF may not receive payment for any additional days of the member's stay. Admission to a SNF for rehabilitation, in the absence of a hospitalization or acute episode of illness, requires preauthorization and is subject to medical necessity review.

Vision (routine) care

• For plans where coverage applies, one routine eye exam per year covered at 100% after copayment (no referral required). To determine copayment requirement, call ConnectiCare's Eligibility & Referral Line at 1-800-562-6834. See Automated and Online Features, for additional information.

• Discounts on frames, lenses, and contact lenses: 25% discount for items costing $250 or less; 30% discount for items over $250. Note: Some plans may vary.

Note: Refractions (CPT 92015) are considered part of the office visit and are not separately reimbursed.

* ConnectiCare reserves the right to use third-party vendors to administer some benefits, including utilization management services.

Note: Some plans may have different benefits/limits; refer members to Member Services for verification at 1-800-251-7722.

PPM/2.10

Overview of coverage: Massachusetts only

Benefit

HMO Personal Care Plan

Point-of-Service Personal Care Plan

HMO Open Access

Point-of-Service Open Access

Allergy testing

Ambulance

• Coverage for medical emergencies without pre-authorization.

• Land or air ambulance/medical transportation that is not due to an emergency requires pre-authorization.

Blood & blood products

• Coverage for receipt of blood and for autologous blood transfusions for the following procedures, when the procedures are covered benefits:

- Bilateral knee replacement	- Hysterectomy
- Coronary Artery Bypass Graft (CABG)	- Laminectomy/spinal fusion
- Facial reconstruction	- Prostatectomy
- Heart valve replacement	- Total hip replacement

Custodial care

• Custodial care is not a covered benefit. It includes services and supplies furnished to a member who has a medical condition that is chronic or non-acute and which, at our discretion, either:

DME & disposable supplies

• Coverage varies by plan.

• DME, orthotics & prosthetics must be obtained from a participating commercial DME vendor unless otherwise authorized by ConnectiCare and pre-authorization must be obtained through ConnectiCare.

• HCPCS coding is required on claims.

• See preauthorization list for DME that requires pre-authorization.

• The rental and/or purchase of CPAP and BI-PAP machines must be done through our preferred vendors.

Note: The list of covered DME and disposable supplies is reviewed periodically and subject to change at the sole discretion of ConnectiCare.

Genetic analysis & testing

All genetic testing requires pre-authorization, with the exception of the following:

• DNA testing for cystic fibrosis - CPT 88271 - 88275; 88291, billed with Modifier 2A - 2Z or ICD-9 codes V10.6x or V10.7x

• FISH (fluorescent in situ hybridization) for the diagnosis of lymphoma or leukemia - CPT 88230 - 88269; 88280 - 88289; 88291; 88299

Note: These procedures are covered procedures, but do not require pre-authorization in network. When performed out of network, these procedures do require pre-authorization.

Home health care

• Home health services are coordinated by ConnectiCare's Health Services:

• To verify benefits and eligibility - (phone) 1-800-828-3407

• To inquire about an existing authorization - 1-800-562-6833

• To request a continuation of authorization for home health care or IV therapy (see Forms, to obtain a copy of the applicable form) - fax (860) 409-2437

Infertility services

• Covered according to Massachusetts state mandate.

Laboratory & pathology

• All routine laboratory services must be obtained from participating laboratories.

• In-office procedures are restricted to a specific list of tests that relate to the specialty of the provider. (See Other Benefit Information)

Mental health/alcohol/substance abuse

New technology

• Services or supplies that are new or recently emerged uses of existing services and supplies, are not covered benefits, unless and until we determine to cover them.

• Any treatment for which there is insufficient evidence of therapeutic value for the use for which it is being prescribed is also not covered.

Oral surgery

• Preauthorization is required.

• Postoperative physical therapy for TMJ surgery is limited to ninety (90) days from the date of surgery when pre-authorized as part of surgical procedure.

• Most plans exclude purely dental services, including oral surgery, but benefits vary by employer

Preauthorization

• For a specific listing of services and procedures that require preauthorization please refer to the preauthorization lists found within this manual.

• Without preauthorization, these services and procedures may not be covered or may be covered at a reduced rate.

• Clinical Review Prior Authorization Request Form

Radiology

• For pre-authorization of the following radiological services, call 1-877-607-2363 or request online at http://www.radmd.com/.

• If authorization is not obtained, payment for the service may be denied.

• In-office procedures are restricted to a specific list of tests that relate to the specialty of the physician. (See Other Benefit Information)

• Some plans may have a copayment requirement for radiology services.

Referrals

• Physicians are required to make referrals to participating specialty physicians, including chiropractic physicians.

• No specialist-to-specialist referrals permitted, except OB/Gyns may make referrals.

• Referrals must be logged in ConnectiCare’s referral system via Provider Connection.

• Physicians may make referrals to participating specialists without entering them into the telephonic referral system.

Skilled nursing facility

• Coverage for skilled nursing facility (SNF) admissions with pre-authorization.

• If you admit a member to a SNF on a weekend or holiday, ConnectiCare will automatically authorize payment for SNF services from the day of admission through the next business day. You must call ConnectiCare’s Notification Line at (860) 674-5870 or 1-888-261-2273 to advise ConnectiCare of the admission. This line is available twenty-four (24) hours a day, seven days a week. If you do not inform ConnectiCare according to these guidelines, the SNF may not receive payment for any additional days of the member's stay. Admission to a SNF for rehabilitation, in the absence of a hospitalization or acute episode of illness, requires pre-authorization and is subject to medical necessity review.

Vision (routine) care

• Discounts on frames, lenses, and contact lenses: 25% discount for items costing $250 or less; 30% discount for items over $250. Note: Some plans may vary.

Note: Refractions (CPT 92015) are considered part of the office visit and are not separately reimbursed.

* ConnectiCare reserves the right to use third-party vendors to administer some benefits, including utilization management services.

Note: Some plans may have different benefits/limits; refer members to Member Services for verification at 1-800-251-7722.

Member information

Members’ rights and responsibilities

Member rights and responsibilities

ConnectiCare provides each member with a statement of member rights and responsibilities. Following is the statement in its entirety.

RIGHTS

Members are encouraged to actively participate in decision-making with regard to managing their health care. As a member of a ConnectiCare plan, each individual enjoys certain rights and benefits. Members have the right to:

Receive information about us, our services, our participating providers, and "Member’s Rights and Responsibilities."
Be treated with respect and recognition of your dignity and right to privacy.
Participate with practitioners in decision-making regarding your health care.
A candid discussion of appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage.
Refuse treatment and to receive information regarding the consequences of such action.
Voice complaints or appeals/grievances about us or the care you are provided.
Make recommendations regarding our member’s rights and responsibilities policies.

RESPONSIBILITIES

While enjoying specific rights of membership, each ConnectiCare member also assumes the following responsibilities. Members have the responsibility to:

Select a primary care provider (PCP).
Provide, to the extent possible, information providers need to render care.
Follow the plans and instructions for care that they have agreed on with practitioners.
Keep scheduled appointments or give sufficient advance notice of cancellation.
Pay applicable copayments, deductibles or coinsurance.
Follow the rules of this Plan, and assume financial responsibility for not following the rules.
Understand their health problems and participate in developing mutually agreed upon treatment goals to the degree possible.
Be considerate of our providers, and their staff and property, and respect the rights of other patients.
Read the Membership Agreement, Evidence of Coverage, or other Plan document that describes the Plan’s benefits and rules.

Members’ rights and our obligations are limited to our ability to make a good faith effort in regard to:

Delays and failures to render services due to a major disaster or epidemic affecting our facilities or personnel.
Circumstances beyond our control such as complete or partial destruction of facilities, war, or riot.

PPM/10.16

Member eligibility

Each time a member receives services, you should confirm eligibility. To verify eligibility for services, request to see the member's current ID card. New members may use a copy of the enrollment form as a temporary identification card until they receive their ID card.

If you are a primary care physician (PCP), you may also check your most recent Membership by PCP report. This report is sent to all PCPs upon request, and it lists each member who has selected or has been assigned to that PCP. (More information appears later in this section.)

Eligibility and Referral Line
You may also use the ConnectiCare Eligibility and Referral Line. This system requires that you have a touch-tone phone and know your ConnectiCare provider ID number, as well as the member's identification number, to verify eligibility. It is generally available between 7 a.m. and 9:30 p.m., Monday through Friday, and from 7 a.m. to 2 p.m. on Saturday.

If you don’t know the member's ID number, contact Provider Services during regular business hours to verify eligibility and benefits.

Medavant
Medavant, an online transaction system available to ConnectiCare participating providers, also offers a secure means for entering and verifying referrals.

For additional details on using ConnectiCare's Eligibility & Referral Line or Medavant, refer to Automated & Online Features.

First, try the Eligibility and Referral Line	Or, Medavant at www.medavant.com	If unable to verify, then call Provider Services
1-860-674-5800 or 1-800-562-6834	(you must participate with Medavant to utilize services)	1-860-674-5850 or 1-800-828-3407

PPM/2.10

Identification cards

The following are samples of each type of ID card that ConnectiCare issues to members. Product and plan details are outlined in the product and coverage section on this page. The sample ID cards are for demonstration only. Actual copayment information and other benefit information will vary.

Members can print temporary ID cards by visiting the secure portion of our member website at www.connecticare.com.

Printable ID Cards

ConnectiCare also makes available to members printable, temporary ID cards via our website. This feature is meant to assist members who need additional copies of their ID card. The temporary card is a valid form of ConnectiCare member identification.

CHOICE HMO - Copay:


Front	Back

CHOICE HMO - High-Deductible:


Front	Back

CHOICE POS - Copay:


Front	Back

CHOICE POS - High-Deductible:


Front	Back

FlexPOS - Copay:

Front

Back

FlexPOS - High-Deductible:

Front

Back

Note: PHCS is the primary network under the PPO product. ConnectiCare participating providers, who serve members covered under a PPO product but are not part of the PHCS network, are considered out-of-network. If you have questions about participation in the PHCS network, call 1-866-580-7427.

PPM/07.20

Member confidentiality

ConnectiCare distributes its privacy notice to members annually, and to new members upon enrollment in the plan. To obtain a copy of the privacy notice, visit our website at www.connecticare.com, or call Provider Services at the number below.

ConnectiCare requires all of its participating practitioners and providers to treat member medical records and other protected health information as confidential and to assure that the use, maintenance, and disclosure of such protected health informa- tion complies with all applicable state and federal laws governing the security and privacy of medical records and other protected health information.

Questions regarding the confidentiality of member information may be directed to Provider Services at 1-860-674-5850 or 1-800-828-3407.

PPM/10.16

Member complaints

ConnectiCare takes all complaints from members seriously. Occasionally, these complaints relate to the quality of care or quality of service members receive from their PCP, specialist, or the office staff. We must investigate and try to resolve all complaints. If a complaint about you or your office staff is received, ConnectiCare will contact you and request information relating to the complaint. We request your cooperation in investigating and resolving these complaints. For more information regarding complaint resolution, contact Provider Services at 1-860-674-5850 or 1-800-828-3407.

PPM/10.16

Member disenrollment

ConnectiCare reserves the right to terminate coverage for members who repeatedly fail to make the required copayments, coinsurance or deductibles, subject to the terms outlined in the applicable Member Agreement, Evidence of Coverage, or other governing contract.

Providers are responsible for seeking reimbursement from members who have terminated if the services provided occurred after the member's termination date.

PPM/2.10

Member satisfaction

Member satisfaction with ConnectiCare is very important. We conduct routine, focused surveys to monitor satisfaction using the Consumer Assessment of Health Plan Satisfaction (CAHPS) survey and implement quality improvement activities when oppor- tunities are identified. Monitoring includes member satisfaction with physicians. Member satisfaction information is updated and posted annually and is made available on our website at www.connecticare.com. If you want a paper copy of this information, you may contact Provider Services at 1-860-674-5850 or 1-800-828-3407.

PPM/10.16

Ending physician/patient relationship

Ending the physician/patient relationship

ConnectiCare requires that sufficient notice be given to all of your patients affected by a change in your practice. If you are relocating out of ConnectiCare's network or retiring, please notify your patients at least ten (10) days in advance, in writing, in addition to notifying ConnectiCare and, if applicable, your contracted PHO/IPA in writing sixty (60) days in advance. ConnectiCare will also notify members of the change thirty (30) days prior to the effective date of the change, or as soon as possible after we become aware of the change.

PCPs: Advise your patients to contact ConnectiCare s Member Services at 1-860-674-5757 or 1-800-251-7722 to designate a new PCP, even if your practice is being assumed by another physician. ConnectiCare will communicate to your patients how they may select a new PCP.

PPM/10.16

Product & coverage information

About ConnectiCare Medicare plans

About ConnectiCare Medicare Advantage plans

ConnectiCare Medicare Advantage plans include a number of Medicare Advantage Plans. These plans, sometimes called "Part C," provide all of a member's Part A (hospital coverage) and Part B (medical coverage) and may offer extra benefits too. These extra benefits include, but are not limited to, preventive services including routine annual physicals, routine vision exams and routine hearing exams. In addition, some of the ConnectiCare plans include Part D, prescription drug coverage.

The ConnectiCare Medicare Advantage network

• ConnectiCare's service area includes all counties.

• ConnectiCare, in coordination with participating providers, will maintain and monitor the network of participating providers to ensure that members have adequate access to PCPs, specialists, hospitals, and other health care providers, and that through the network of providers their care needs may be met.

Disclosure of information

• ConnectiCare will disclose to the Centers of Medicare & Medicaid Services (CMS) all information that is necessary to evaluate and administer our Medicare Advantage plans, and to establish and facilitate a process for current and prospective members to exercise choice in obtaining Medicare services. Such information includes, but is not limited to, quality and performance indicators for plan benefits regarding disenrollment rates, enrollee satisfaction, and health outcomes.

• All participating providers agree to certify that all information submitted to ConnectiCare is accurate, complete, truthful, and shall comply with applicable CMS standards. ConnectiCare will maintain such health information and make it available to CMS upon request, as necessary.

Medicare PPM/2.10

Overview of plans

Plan overview

ConnectiCare Medicare Advantage plans include a number of Medicare Advantage Plans. These plans, sometimes called "Part C," provide all of a member's Part A (hospital coverage) and Part B (optional medical coverage) coverage and offer extra benefits too. These extra benefits include, but are not limited to, vision, dental, hearing, and preventive services, like annual physicals. In addition, some of the ConnectiCare plans include Part D, prescription drug coverage.

Plan type

Plan features

Health Maintenance Organization
(Prime)

• No referrals needed for network specialists.
• Members pay a copayment as cost-share for most covered health services at the time services are rendered.

Note: Some services require preauthorization. See Medical Management.

Point-of-Service
(Option)

• No referrals needed for network specialists.
• No prior authorization requirements.
• Access to any Medicare-approved doctor or hospital in the United States.
• Members pay a copayment as cost-share for most covered health services at the time services are rendered.

Refer to the annually updated Summary of Benefits section on this page and list of Exclusions and Limitations for more details.

For benefit-related questions, call Provider Services at 1-877-224-8230.

Medicare PPM/3.11

Summary of benefits

Medicare - Product & Coverage Information

Summary of benefits

ConnectiCare Medicare Advantage plans provide all Part A and Part B benefits covered by Original Medicare. We also cover additional benefits beyond Original Medicare alone. Below are the additional benefits covered by ConnectiCare.

Skilled nursing facility (SNF)	A 3-day covered hospital stay is not required prior to being admitted.
In-area urgent care	Covered at participating urgent care providers.
Emergency care	Emergency care is covered. For emergency care received outside the U.S. there is a $100,000 limit.
Hearing services	Routine hearing tests covered up to 1 every year
Vision service	Routine eye exams covered up to 1 every year
Eye wear	Discounts are available on lenses, contacts and frames
Physical exams	Routine exams up to 1 every year
Dental services	Some plans cover preventive dental services: Up to 2 oral exams Up to 2 cleanings

In addition, the following guidelines apply:

Preventive care

The following are covered preventive care services:

Bone mass measurement
Colorectal screening exams
Flu, pneumonia and Hepatitis B vaccines
Mammograms
Pap smears and pelvic exams
Prostate cancer screening exams
Routine hearing tests
Routine eye exams
Routine physical exams

Please note there are designated frequencies and age limitations.

Podiatry services

Coverage follows Original Medicare guidelines.

Refractions

Refractions are not covered by ConnectiCare Medicare Advantage plans.

Please note: The benefit information provided is not a comprehensive list and is subject to change.

MEDICARE PPM/2.10

Access to care

ConnectiCare members are entitled to an initial assessment of their health care status within ninety (90) days of enrollment in the Plan. They should be informed of any health care needs that require follow-up, as well as self-care training.

Covered services upon self-referral

ConnectiCare members may directly access care through self-referral to a participating clinician for covered services and certain Medicare-covered services at designated frequencies and ages, including:

• Annual routine eye exam (Prime and Custom Plans only)
• Bone mass measurement
• Colorectal screening (age restrictions apply)
• Glaucoma screening
• Influenza and pneumococcal vaccinations
• Initial chiropractic assessment
• Initial mental health consultation
• Nutritionist and social worker visit
• Prostate cancer screening (age restrictions apply)
• Renal dialysis services for members temporarily outside the service area

Female members may directly access a women's health care specialist within the network for the following routine and preventive health care services provided as basic benefits:

• Annual mammography screening (age restrictions apply)
• Pelvic exam
• Screening pap test

Emergency care and urgent care

• Emergency care and out-of-area urgently needed services are covered under the Prime and Custom Plans, anytime, anywhere (worldwide). These services are covered under the Option Plan nationwide. See Glossary for definitions of emergency and urgent care.
• If you are a PCP, please discuss your provisions for after-hours care with your patients, especially for in-area, urgent care. The Evidence of Coverage (EOC) will instruct them to call their PCP. Our contract with you for participation in the ConnectiCare program requires you to provide coverage 24-hours, seven days a week, including weekends and holidays.
• When in the service area, members are expected to seek routine services, except for certain self-referred services, from their PCP. If there are unusual and extraordinary circumstances, or the enrollee’s PCP is unavailable or inaccessible, the enrollee may seek urgent care treatment at the nearest facility.

Medicare PPM/2.10

Member information

Member rights and responsibilities

ConnectiCare encourages members to actively participate in decision making with regard to managing their health care. The Members’ Rights and Responsibilities Statement, reprinted below in its entirety, summarizes ConnectiCare’s position:

Introduction to your rights and protections
Since you have Medicare, you have certain rights to help protect you. In this section, we explain your Medicare rights and protections as a member of our plan and, we explain what you can do if you think you are being treated unfairly or your rights are not being respected. If you want to receive Medicare publications on your rights, you may call and request them at 1-800- MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, or visit www.medicare.gov to view or download the publication “Your Medicare Rights & Protections.” Under “Search Tools,” select “find a Medicare Publication.” If you have any questions whether our plan will pay for a service, including inpatient hospital services, and including services obtained from providers not affiliated with our plan, you have the right under law to have a written/binding advance coverage determination made for the service. Call us and tell us you would like a decision if the service or item will be covered.

Your right to be treated with dignity, respect and fairness
You have the right to be treated with dignity, respect, and fairness at all times. Our plan must obey laws that protect you from discrimination or unfair treatment. We don’t discriminate based on a person’s race, disability, religion, sex, sexual orientation, health, ethnicity, creed, age, or national origin. If you need help with communication, such as help from a language interpreter, please call Medicare Member Services. Member Services can also help if you need to file a complaint about access (such as wheel chair access). You may also call the Office for Civil Rights at 1-800-368-1019 or TTY 1-800-537-7697, or your local Office for Civil Rights.

Your right to the privacy of your medical records and personal health information

There are federal and state laws that protect the privacy of your medical records and personal health information. We protect your personal health information under these laws. Any personal information that you give us when you enroll in this plan is protected. We will make sure that unauthorized people don’t see or change your records. Generally, we must get written permission from you (or from someone you have given legal power to make decisions for you) before we can give your health information to anyone who isn’t providing your care or paying for your care. There are exceptions allowed or required by law, such as release of health information to government agencies that are checking on quality of care.

The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. We are required to provide you with a notice that tells about these rights and explains how we protect the privacy of your health information. For example, you have the right to look at medical records held at the plan, and to get a copy of your records. You also have the right to ask us to make additions or corrections to your medical records (if you ask us to do this, we will review your request and figure out whether the changes are appropriate). You have the right to know how your health information has been given out and used for non-routine purposes. If you have questions or concerns about privacy of your personal information and medical records, please call Member Services. The plan will release your information, including your prescription drug event data, to Medicare, which may release it for research and other purposes that follow all applicable Federal statutes and regulations.

Your right to see plan providers, get covered services, and get your prescriptions filled within a reasonable period of time
You will get most or all of your care from plan providers, that is, from doctors and other health providers who are part of our plan. You have the right to choose a plan provider (we will tell you which doctors are accepting new patients). You have the right to go to a women’s health specialist (such as a gynecologist) without a referral. You have the right to timely access to your providers and to see specialists when care from a specialist is needed.

“Timely access” means that you can get appointments and services within a reasonable amount of time. You have the right to timely access to your prescriptions at any network pharmacy.

Your right to know your treatment options and participate in decisions about your health care
You have the right to get full information from your providers when you go for medical care, and the right to participate fully in decisions about your health care. Your providers must explain things in a way that you can understand. Your rights include knowing about all of the treatment options that are recommended for your condition, no matter what they cost or whether they are covered by our plan. This includes the right to know about the different Medication Management

Treatment Programs we offer and in which you may participate. You have the right to be told about any risks involved in your care. You must be told in advance if any proposed medical care or treatment is part of a research experiment, and be given the choice of refusing experimental treatments.

You have the right to receive a detailed explanation from us if you believe that a provider has denied care that you believe you were entitled to receive or care you believe you should continue to receive. In these cases, you must request an initial decision called an organization determination or a coverage determination.

You have the right to refuse treatment. This includes the right to leave a hospital or other medical facility, even if your doctor advises you not to leave. This includes the right to stop taking your medication. If you refuse treatment, you accept responsibility for what happens as a result of your refusing treatment.

Your right to use advance directives (such as a living will or a power of attorney)
You have the right to ask someone such as a family member or friend to help you with decisions about your health care. Sometimes, people become unable to make health care decisions for themselves due to accidents or serious illness. If you want to, you can use a special form to give someone the legal authority to make decisions for you if you ever become unable to make decisions for yourself. You also have the right to give your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself. The legal documents that you can use to give your directions in advance in these situations are called "advance directives." There are different types of advance directives and different names for them. Documents called "living will" and "power of attorney for health care" are examples of advance directives.

If you want to have an advance directive, you can get a form from your lawyer, from a social worker, or from some office supply stores.

You can sometimes get advance directive forms from organizations that give people information about Medicare. Regardless of where you get this form, keep in mind that it is a legal document. You should consider having a lawyer help you prepare it. It is important to sign this form and keep a copy at home. You should give a copy of the form to your doctor and to the person you name on the form as the one to make decisions for you if you can’t. You may want to give copies to close friends or family members as well.

If you know ahead of time that you are going to be hospitalized, and you have signed an advance directive, take a copy with you to the hospital. If you are admitted to the hospital, they will ask you whether you have signed an advance directive form and whether you have it with you. If you have not signed an advance directive form, the hospital has forms available and will ask if you want to sign one.

Remember, it is your choice whether you want to fill out an advance directive (including whether you want to sign one if you are in the hospital). According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive. If you have signed an advance directive, and you believe that a doctor or hospital hasn’t followed the instructions in it, you may file a complaint with:

Connecticut Department of Health
410 Capitol Avenue
P.O. Box 340308
Hartford, CT 06134-0308
1-860-509-8000, (TTY) 1-860-509-7191

Your right to get information about our plan
You have the right to get information from us about our plan. This includes information about our financial condition, and how our Plan compares to other health plans. To get any of this information, call Member Services.

Your right to get information in other formats
You have the right to get your questions answered. Our plan must have individuals and translation services available to answer questions from non-English speaking beneficiaries, and must provide information about our benefits that is accessible and appropriate for persons eligible for Medicare because of disability. If you have difficulty obtaining information from your plan based on language or a disability, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

Your right to get information about our network pharmacies and/or providers
You have the right to get information from us about our network pharmacies, providers and their qualifications and how we pay our doctors. To get this information, call Member Services.

Your right to get information about your prescription drugs, Part C medical care or services, and costs
You have the right to an explanation from us about any prescription drugs or Part C medical care or service not covered by our plan. We must tell you in writing why we will not pay for or approve a prescription drug or Part C medical care or service, and how you can file an appeal to ask us to change this decision. You also have the right to this explanation even if you obtain the prescription drug, or Part C medical care or service from a pharmacy and/or provider not affiliated with our organization. You also have the right to receive an explanation from us about any utilization-management requirements, such as step therapy or prior authorization, which may apply to your plan. Please review our formulary website or call Member Services for more information.

Your right to make complaints
You have the right to make a complaint if you have concerns or problems related to your coverage or care. A complaint can be called a grievance, an organization determination, or a coverage determination depending on the situation.

If you make a complaint, we must treat you fairly (i.e., not retaliate against you) because you made a complaint. You have the right to get a summary of information about the appeals and grievances that members have filed against our plan in the past. To get this information, call Member Services.

Your right to get information about our plan, plan providers, drugs, health care coverage, and costs

If you need more information, please call Member Services. You have the right to an explanation from us about any bills you may get for services not covered by our plan. We must tell you in writing why we will not pay for or approve a service, and how you can file an appeal to ask us to change this decision.

You also have the right to get information from us about our plan. This includes information about our financial condition, about our plan health care providers and their qualifications, about information on our network pharmacies, and how our plan compares to other health plans. You have the right to find out from us how we pay our doctors. To get any of this information, call Member Services. You have the right under law to have a written/binding advance coverage determination made for the service, even if you obtain this service from a provider not affiliated with our organization.

How to get more information about your rights
If you have questions or concerns about your rights and protections, please call Member Services. You can also get free help and information from CHOICES - your SHIP. You can also visit www.medicare.gov on the Web to view or download the publication “Your Medicare Rights & Protections.” Under “Search Tools,” select “Find a Medicare Publication.” Or, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

What to do if you think you have been treated unfairly or your rights are not being respected?
If you think you have been treated unfairly or your rights have not been respected, you may call Member Services or:

• If you think you have been treated unfairly due to your race, color, national origin, disability, age, or religion, you can call the Office for Civil Rights at 1-800-368-1019 or TTY 1-800-537-7697, or call your local Office for Civil Rights.
• If you have any other kind of concern or problem related to your Medicare rights and protections described in this section, you can also get help from CHOICES.

Your responsibilities as a member of our plan

Your responsibilities include the following:

• Getting familiar with your coverage and the rules you must follow to get care as a member. Please call Member Services if you have any questions.
• Letting us know if you have additional health insurance coverage.
• Notifying providers when seeking care (unless it is an emergency) that you are enrolled in our plan and you must present your plan enrollment card to the provider.
• Giving your doctor and other providers the information they need to care for you, and following the treatment plans and instructions that you and your doctors agree upon. Be sure to ask your doctors and other providers if you have any questions and have them explain your treatment in a way you can understand.
• Acting in a way that supports the care given to other patients and helps the smooth running of your doctor’s office, hospitals, and other offices.
• Paying your co-payments/coinsurance for your covered services. You must pay for services that aren’t covered.
• Letting us know if you have any questions, concerns, problems, or suggestions. If you do, please call Member Services.

Your right to get information about your drug coverage and costs
If you need more information, please call our Member Services. You have the right to an explanation from us about any bills you may get for drugs not covered by our Plan. We must tell you in writing why we will not pay for a drug, and how you can file an appeal to ask us to change this decision. You also have the right to receive an explanation from us of any utilization management requirements, such as step therapy or prior authorization that may apply to your plan. If you have any questions please review your formulary website or call Member Services.

Your right to get information about our plan and our network pharmacies
You have the right to get information from us about our plan. This includes information about our financial condition and about our network pharmacies. To get any of this information, call Member Services.

What can you do if you think you have been treated unfairly or your rights aren’t being respected?
For concerns or problems related to your Medicare rights and protections described in this section, you may call our Member Services. You can also get help from CHOICES - your State Health Insurance Assistance Program, or SHIP.

Medicare PPM/2.10

Member eligibility

Eligibility

Medicare members who elect to become members of ConnectiCare must meet the following qualifications:

• Members must be eligible for Medicare Part A and be enrolled in and continue to pay for Medicare Part B.
• Members must reside in the service area. The service area includes all counties in Connecticut.
• In order to maintain permanent residence, a member must not move or continuously reside outside the service area for more than 6 consecutive months.
• Members with End Stage Renal Disease (ESRD) will not qualify, except if they are currently covered by a ConnectiCare benefit plan through an employer or self pay (a commercial member).
• Members who develop ESRD after enrollment may remain with a ConnectiCare plan.
• ConnectiCare members must continue to pay the Medicare Part B premium directly to the Medicare program.

Verifying eligibility

• It is critical that the member’s eligibility be checked at each visit. Ask to see the member's ConnectiCare member identification (ID) card.
• New members may use a copy of their enrollment form.
• Members who do not have an ID card should not be denied medical services without contacting ConnectiCare first to determine the member's enrollment status.
• If a member tells you that he/she has disenrolled from ConnectiCare, ask where the bill should be sent.
• If you have any questions regarding a member's eligibility, call Provider Services at 1-877-224-8230.

Note: Presentation of a member ID card is not a guarantee of a member's eligibility.

Medicare PPM/2.10

Enrollment

Prospective members must properly complete and sign an enrollment application and submit it to ConnectiCare. Once submitted, ConnectiCare will verify the eligibility of the member with the Centers for Medicare & Medicaid Services (CMS) as they are the sole arbiter of eligibility for Medicare. ConnectiCare cannot reverse CMS' determination.

ConnectiCare enrolls individual members into the ConnectiCare plan. We may enroll “employer group” members as well. Employer group enrollment will be the result of employers electing to offer benefits to retirees through ConnectiCare. These members may have a different copayment and/or benefit package. They will be clearly distinguishable by their ID cards. As always, confirm benefits by contacting Provider Services at 1-877-224-8230.

Medicare PPM/2.10

Identification cards

ConnectiCare members will receive an identification (ID) card when they enroll in the plan. The ID card lists the following information:

• ConnectiCare member ID number
• PCP name and telephone number
• Some applicable copayments
• Pharmacy cost-share, if applicable

In addition, the ID card also includes emergency instructions and a toll-free telephone number for out-of-area and after-hours notifications, the Member Services phone number, and the claims submission address. A sample of the ConnectiCare ID cards appear below.

ConnectiCare Prime Plans:


Front	Back

ConnectiCare Option Plans:


Front	Back

Medicare PPM/2.10

Nondiscrimination

ConnectiCare eligible members shall not be discriminated against with respect to the availability or provision of health services based on an enrollee's race, sex, age, religion, place of residence, HIV status, source of payment, ConnectiCare membership, color, sexual orientation, marital status, or any factor related to an enrollee's health status. This includes, but is not limited to, an enrollee's medical condition (including mental as well as physical illness), claims experience, receipt of health care, medical history, genetic information, evidence of insurability (including conditions arising out of acts of domestic violence), disability or on any other basis otherwise prohibited by state or federal law.

All providers shall comply with Title VI of the Civil Rights Act of 1964, as implemented by regulations at 45 C.F.R. part 84; the Americans with Disabilities Act; the Age Discrimination Act of 1975, as implemented by regulations at 45 C.F.R. part 91; other laws applicable to recipients of federal funds; and all other applicable laws and rules, are required by applicable laws or regulations. Providers shall not discriminate against an enrollee based on whether or not the enrollee has executed an advance directive.

Medicare and Medicaid eligible members designated as Qualified Medicare Beneficiary

Medicare providers under their ConnectiCare contract are required to see all ConnectiCare VIP Medicare Plan members including those who are dual eligible for Medicare and Medicaid.

Providers are also reminded that dual eligible members who are designated as Qualified Medicare Beneficiaries (QMB or QMB+) cannot be billed for any Medicare cost-share. The bill of service for these members must be submitted to Medicaid for reimbursement.

For guidance in the prohibition of balance billing of QMBs, please refer to this Medicare Learning Network document.

Medicare PPM/8.16

Member confidentiality

ConnectiCare distributes its privacy notice to members annually, and to new members upon enrollment in the plan. ConnectiCare requires all of its participating practitioners and providers to treat member medical records and other protected health information as confidential and to assure that the use, maintenance, and disclosure of such protected health information complies with all applicable state and federal laws governing the security and privacy of medical records and other protected health information. Questions regarding the confidentiality of member information may be directed to Provider Services at 1-877-224-8230.

Medicare PPM/2.10

Member complaints

Medicare PPM/2.10

Advance directives

Advance directives are written instructions, such as living will, durable power of attorney for health care, health care proxy, or do not resuscitate (DNR) request, recognized under state law and relating to the provision of health care when the individual is incapacitated and unable to communicate his/her desires. ConnectiCare, in compliance with advance directives regulations, must maintain written policies and procedures concerning advance directives with respect to all adult individuals receiving medical care. ConnectiCare must provide written information to those individuals, including their rights under the law of the State to make decisions concerning their medical care, such as the right to accept or refuse medical or surgical treatment and the right to formulate advance directives.

ConnectiCare's policies must show evidence of respecting the implementation of their rights, including a clear and precise statement of limitation if ConnectiCare and its network of participating providers cannot implement an advance directive as a matter of conscience. At a minimum, this statement must:

• Clarify any differences between institution-wide conscientious objections and those that may be raised by the individual physician;
• Identify the state legal authority permitting such objection;
• Describe the range or medical conditions or procedures affected by the conscience objection;
• Document in a prominent part of the individual's current medical record whether or not the individual has executed an advance directive; and
• Not condition the provision of care or otherwise discriminate against an individual based on whether or not the individual has executed an advance directive.

The following information was provided by the Connecticut Office of Attorney General for the Department of Public Health and Addiction Services and the Department of Social Services. This information, reprinted in its entirety, is taken from the plan Evidence of Coverage.

Statement to members

Your right to use advance directives (such as a living will or a power of attorney)
You have the right to ask someone such as a family member or friend to help you with decisions about your health care. Sometimes, people become unable to make health care decisions for themselves due to accidents or serious illness. If you want to, you can use a special form to give someone the legal authority to make decisions for you if you ever become unable to make decisions for yourself. You also have the right to give your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself. The legal documents that you can use to give your directions in advance in these situations are called "advance directives." There are different types of advance directives and different names for them. Documents called a "living will" and "power of attorney for health care" are examples of advance directives.

If you want to have an advance directive, you can get a form from your lawyer, from a social worker, or from some office supply stores. You can sometimes get advance directive forms from organizations that give people information about Medicare. Regardless of where you get this form, keep in mind that it is a legal document. You should consider having a lawyer help you prepare it. It is important to sign this form and keep a copy at home. You should give a copy of the form to your doctor and to the person you name on the form as the one to make decisions for you if you can’t. You may want to give copies to close friends or family members as well.

Medicare PPM/2.10

Disenrollment

• Medicare members may disenroll from the plan when the guidelines, as set forth by the Centers for Medicare & Medicaid Services (CMS), are met.

• Refer members to the ConnectiCare Member Services at 1-800-224-2273 if they need information on disenrollment.

• We hope that our members are satisfied and decide to stay with ConnectiCare; however, should you learn that a member plans to disenroll, you may avoid payment delays by:

1. Reminding the patient to notify ConnectiCare; and
2. Asking at the time of each visit if he/she is still enrolled in a ConnectiCare plan.

ConnectiCare involuntary disenrollment
Each member’s enrollment is generally in effect as long as the member chooses to stay in ConnectiCare. The plan cannot and will not disenroll a member because of the amount or cost of services used. However, ConnectiCare must terminate members for the following:

• The member has a change of address outside the service area.
• The member loses entitlement to Medicare Parts A and/or B.
• The plan contract is terminated.

Additionally, ConnectiCare may disenroll a member if:

• Premiums are not paid on a timely basis.
• The member engages in disruptive behavior.
• The member provides fraudulent information on the application or permits abuse of an enrollment card.

Medicare PPM/2.10

Member satisfaction

Enrollee satisfaction with ConnectiCare is very important. We conduct routine, focused surveys to monitor satisfaction using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey and implement quality improvement activities when opportunities are identified. Monitoring includes member satisfaction with physicians. Enrollee satisfaction information is updated and posted each December and is made available on our website at www.connecticare.com. If you want a paper copy of this information, you may contact Provider Services at 1-877-224-8230.

Medicare PPM/2.10

Ending physician/patient relationship

Ending the physician/patient relationship

ConnectiCare requires that sufficient notice be given to all of your patients affected by a change in your practice. A voluntary termination initiated by a practitioner should be communicated to ConnectiCare verbally or in writing, in accordance with the terms set forth in the contract, but no less than sixty (60) days before the effective date. ConnectiCare will also notify members of the change thirty (30) days prior to the effective date of the change, or as soon as possible after we become aware of the change.

PCPs: Advise your patients to contact ConnectiCare's Member Services at 1-800-224-2273 to designate a new PCP, even if your practice is being assumed by another physician. ConnectiCare will communicate to your patients how they may select a new PCP.

Specialists: Provide continuity and coordination of care by sending a written report to the member's PCP regarding any treatment or consultation provided to the member.

All Practitioners: Please notify ConnectiCare in advance prior to taking any action to remove a specific member from your practice for any reason. While you may contact us by telephone, you will be asked to place your concerns in writing.

Medicare PPM/2.10

provider

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Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.