View important information regarding your rights and protections as an Essence Healthcare member.

Find information concerning initial organizational determinations, exceptions, appeals and grievances. Also note that each Essence Healthcare plan’s Evidence of Coverage book describes our grievance, coverage determination (including exceptions) and appeals processes. Download the Member Grievances and Appeals Booklet:
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    * 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:

    Coverage Determination:

    Coverage Redetermination:

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As a Medicare beneficiary, you have certain rights to help protect you. You can read more about your rights and responsibilities as a member of Essence Healthcare in the Evidence of Coverage. You can also contact Medicare by calling 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call 24 hours a day, seven days a week. You can also visit the Medicare website at . Following is a summary of our member’s rights and protections. All Medicare Advantage plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Advantage plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue in the program, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area. As an Essence Healthcare member, you have the right to request an initial organizational determination for medical services or a coverage determination for prescription drugs, which includes the right to request an exception. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at the pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s) or medical service, you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network providers that does not involve the coverage of services.
Coverage Criteria

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.

With few exceptions, you must pay for services you receive from providers who are not part of the Essence Healthcare network unless Essence Healthcare has approved these services in advance. The exceptions are care for a medical emergency, urgently needed care, out-of-area renal (kidney) dialysis services, and services that are found upon appeal to be services that we should have paid or covered. Essence Healthcare PPO plans include out-of-network coverage. Please refer to your Evidence of Coverage for details.
For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed the following requirements and limits for our plans to help us provide quality coverage to our members:
  • 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:
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If we leave the Medicare program or change our service area so that it no longer includes the area where you live, we will tell you in writing. If this happens, your membership in Essence Healthcare will end, and you will have to change to another way of getting your Medicare benefits. All of the benefits and rules described in the Evidence of Coverage will continue until your membership ends. This means that you must continue to get your medical care and prescription drugs in the usual way through our plan until your membership ends. Your choices for how to get your Medicare coverage will always include Original Medicare and joining a prescription drug plan to complement your Original Medicare coverage. Your choices may also include joining another Essence Healthcare plan, another Medicare Advantage plan, or a private fee-for-service plan, if these plans are available in your area and are accepting new members. Once we have told you in writing that we are leaving the Medicare program or the area where you live, you will have a chance to change to another way of getting your Medicare benefits. If you decide to change from Essence Healthcare to Original Medicare, you will have the right to buy a Medigap policy regardless of your health. This is called a “guaranteed issue right.” Essence Healthcare has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs Medicare. This contract renews each year. At the end of each year, the contract is reviewed, and either Essence Healthcare or CMS can decide to end it. You will get 90 days advance notice in this situation. It is also possible for our contract to end at some other time during the year. In these situations, we will try to tell you 90 days in advance, but your advance notice may be as little as 30 or fewer days if CMS must end our contract in the middle of the year. Whenever a Medicare health plan leaves the Medicare program or stops serving your area, you will be provided a special enrollment period to make choices about how you get Medicare coverage, including choosing a Medicare prescription drug plan and guaranteed issue rights to a Medigap policy. Generally, we cannot ask you to leave the plan because of your health. If you ever feel that you are being encouraged or asked to leave our plan because of your health, you should call 1-800-MEDICARE (1-800-633-4227), which is the national Medicare help line. TTY users should call 1-877-486-2048. You can call 24 hours a day, seven days a week. We can ask you to leave the plan under certain special conditions. If any of the following situations occur, we will end your Essence Healthcare membership:
  • 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)
You have the right to make a complaint if we ask you to leave our plan. If we ask you to leave, we will tell you our reason(s) in writing and explain how you can file a complaint against us if you so choose.

“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.
Until your membership ends, you must keep getting your Medicare services through Essence Healthcare, or you will have to pay for them yourself. If you leave our plan, it may take some time for your membership to end and your new way of getting Medicare to take effect. While you are waiting for your membership to end, you are still a member and must continue to get your care as usual through our health plan.

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.

Part D sponsors must provide access to Part D drugs at the correct LIS cost-sharing level when presented with evidence of LIS eligibility.

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 .

When an emergency or disaster disrupts access to healthcare in your service area, know that Essence makes necessary changes to ensure you have access to your health plan benefits. Until the disaster or emergency ends, we do the following:
  • 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
If we can’t resume normal operations by the end of the disaster or emergency, we’ll notify the Centers for Medicare & Medicaid Services (CMS).

Special Requirements

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.

Want to learn more about your options?

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Request FREE Information

Download your FREE Medicare Advantage Information Kit or request a copy by mail.
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