Other Plan Information
View important information regarding your rights and protections as an Essence Healthcare member.
* Clicking the above link will take you to the secure online complaint form on the Medicare.gov website.
You may also print, complete and mail the Medicare Complaint Form to the address on our Contact Us page.
Prescription Drug Coverage Determination and Redetermination Forms:
Along with using internally created policies based on Medicare documents and other medical industry research, Essence Healthcare utilizes InterQual® clinical criteria, to determine the necessity and appropriateness of healthcare services.Clinical criteria are not used to deny care, but rather, to ensure care is objective and based on sound medical evidence. Clinical criteria can help improve health and may also help you reduce what you pay for healthcare. You can access the used by hospitals, providers, and health plans (including Essence Healthcare) to make objective, evidence-based decisions for quality, efficient care. The following policies and procedures are used to guide medical decisions regarding diagnosis, management, and treatment of specific areas of healthcare.
- Prior Authorization: We require you to get prior authorization for certain drugs. This means that your doctor will need to get approval from us before you fill your prescription. If they don’t get approval, we may not cover the drug. View our prior authorization criteria:
- If you are not a United States citizen or lawfully present in the United States
- If you move out of the service area or are away from the service area for more than six months in a row. If you plan to move or take a long trip, please call us to find out if the place you’re moving to or traveling to is in our service area. If you move permanently out of our geographic service area, or if you’re away from our service area for more than six months in a row, you generally can’t remain a member of Essence Healthcare. In these situations, if you don’t leave on your own, we must end your membership (“disenroll” you)
- If you don’t stay continuously enrolled in both Medicare Part A and Medicare Part B
- If you are required to pay the extra Part D amount because of your income and you do not pay it, Medicare will disenroll you from our plan and you will lose prescription drug coverage
- If you give us information on your enrollment request that you know is false or deliberately misleading, and it affects whether or not you can enroll in our plan.
- If you lie about or withhold information about other insurance you have that provides prescription drug coverage
- If you behave in any way that is disruptive, to the extent that your continued enrollment seriously impairs our ability to arrange or provide medical care for you or for others who are members of a Essence Healthcare plan. We can’t make you leave our plan for this reason unless we get permission first from the Centers for Medicare & Medicaid Services, the government agency that runs Medicare
- If you let someone else use your plan membership card to get medical care. If you’re disenrolled for this reason, CMS may refer your case to the Inspector General for additional investigation
- If you become incarcerated (go to prison)
“Disenrollment” from Essence Healthcare means ending your membership in our plan. Disenrollment can be voluntary or involuntary:
- You might leave Essence Healthcare because you have decided that you want to leave. You can do this for any reason; however, there are limits to when you may leave, how often you can make changes, what your other choices are for receiving Medicare services and how you can make changes.
- There are also a few situations where you would be required to leave our plan. For example, you would have to leave if you permanently move out of our geographic service area or if Essence Healthcare leaves the Medicare program. We will not ask you to leave our plan because of your health.
If you get services from doctors or other medical providers who are not plan providers before your membership in our plan ends, neither Essence Healthcare nor the Medicare program will pay for these services, with just a few exceptions. The exceptions are: urgently needed care, care for a medical emergency, out-of-area renal dialysis services and care that has been approved by us. Another possible exception is if you happen to be hospitalized on the day your membership ends. If this happens to you, call us to find out if your hospital care will be covered. If you have any questions about leaving Essence Healthcare, please call us.If you want to leave our health plan: The first step is to be sure that the type of change you want to make (and when you want to make it) fits within the rules explained below about changing how you get Medicare. If the change does not fit with these rules, you won’t be allowed to make the change. Then, what you must do to leave Essence Healthcare depends on whether you want to switch to Original Medicare or to one of your other choices. In general, there are only certain times during the year when you can change the way you get Medicare. Your plan’s Evidence of Coverage outlines these rules. Contact us for information.
Please consult the Summary of Benefits and the Evidence of Coverage for other important enrollment and membership information. Medicare beneficiaries may also enroll in Essence Healthcare through the CMS Medicare Online Enrollment Center located at .
- Cover your Essence plan benefits (including benefits covered by Original Medicare—Parts A and B) when care is received at non-contracted facilities. Note that Part A and B services must be received at Medicare-certified facilities.
- Waive referral requirements, where applicable.
- Provide the same cost-sharing at non-contracted facilities as if the service or benefit were received at a plan-contracted facility.
- Make changes that benefit you effective immediately without a 30-day notification requirement.
Who declares a disaster or emergency?A disaster declaration will identify the geographic area affected and may be made as one of the following:
- Presidential declaration of a disaster or emergency under either of the following:
- Stafford Act
- National Emergencies Act
- Secretarial declaration of a public health emergency under section 319 of the Public Health Service Act
- Declaration by the Governor of a State or Protectorate
When does the disaster or emergency end?For the changes made above, which ensure your access to your health plan benefits, the emergency or disaster ends 30 days after the occurrence of one of the following conditions, whichever is earlier:
- When all sources that declared a disaster or emergency for the health plan’s service area declare an end to the disaster or emergency
- If no end date was identified in the disaster or emergency declaration(s), when all applicable emergencies or disasters declared for the health plan’s service area have ended, including through expiration of the declaration or any renewal of such declaration
- When there’s no longer a disruption of access to healthcare
In addition, we must explain the terms and conditions of payment during the emergency or disaster for non-contracted providers providing benefits to plan enrollees who live in the impacted area.