Plan Selection Form

 

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(541) 471-4106 (Grants Pass)
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TTY/TDD: 1-800-735-2900

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Grants Pass
740 SE 7th St.
Grants Pass, OR 97526
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Medford
1390 Biddle Road Suite 105
Medford, OR 97504
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Updated October 2013

Dear CareSource Member,

To make a change in the Medicare Advantage plan you have with CareSource/Mid Rogue Health Plan, fill out the enclosed plan selection form to make your choice. Check off the plan you want, and sign the form. Then mail the completed form back to us by December 7th, 2013.

Please be aware that you can change health plans only at certain times during the year. Between October 15th and December 7th each year, anyone can join our plan. In addition, from January 1 through February 14, anyone enrolled in a Medicare Advantage Plan (except an MSA plan) has an opportunity to disenroll from that plan and return to Original Medicare. Anyone who disenrolls from a Medicare Advantage plan during this time can join a stand-alone Medicare Prescription Drug plan during the same period. Generally, you may not make changes at other times unless you meet certain special exceptions, such as if you move out of the plan’s service area, want to join a plan in your area with a 5-star rating, or qualify for extra help paying for prescription drug coverage.

If you qualify for extra help with your prescription drug costs you may enroll in, or disenroll from, a plan at any time. If you lose this extra help during the year, your opportunity to make a change continues for two months after you are notified that you no longer qualify for extra help.

If you select another plan and we receive your completed selection form by December 7, 2013, your new benefit plan will begin in January, 2014. Your monthly plan premium will depend on which plan you choose, and you may continue to see any CareSource primary care doctor and specialists.

Complete the attached form only if you wish to change plans.

To help you with your decision, we have also included a 2014 Summary of Benefits for the available options.

If you have any questions, please call CareSource at 541-471-4106, or 1-888-460-0185. TTY/TDD users should call 1-800-735-2900. We are open Monday–Friday, 8 a.m. to 5 p.m. Calls are answered from 8 a.m. to 8 p.m., seven days a week.

Thank you,

Freddy Sennhauser Marketing Director CareSource/Mid Rogue Health Plan

Y0048_2014PlnSel Approved

 

2014 Plan Selection Form


I want to transfer from my current plan to the plan I have selected below. I understand that if this form is received by the end of any month, my new plan will generally be effective the 1st of the following month.

Please check the appropriate box below:

CareSource Gold (HMO)

 

Josephine and Jackson Counties, and Azalea and Glendale in Douglas County

Office visit copay:$20 PCP, $30 Specialist

Durable Medical Equipment/Prosthetics: $0 copay

Urgent Care visit: $25

Part B drugs: 10% coinsurance

Emergency Room visit: $65

Outpatient Surgery: $100 Ambulatory Surgical Center, $300 Outpatient Hospital facility

Inpatient Hospital: $200/day for days 1–10

Annual Maximum Out-Of-Pocket: $2,000

Skilled Nursing Facility: $50 copay/day for days 1-20

CareSource Gold Plus Rx (HMO)

 

Josephine and Jackson Counties, and Azalea and Glendale in Douglas County

Office visit copay:$20 PCP, $30 Specialist

Durable Medical Equipment/Prosthetics: $0 copay

Urgent Care visit: $25

Part B drugs: 10% coinsurance

Emergency Room visit: $65

Outpatient Surgery: $100 Ambulatory Surgical Center, $300 Outpatient Hospital facility

Inpatient Hospital: $200/day for days 1–10

Annual Maximum Out-Of-Pocket: $2,000

Skilled Nursing Facility: $50 copay/day for days 1-20

Prescription Part D drug coverage: $0 deductible, $5 preferred generic, $0 (90 days) preferred generic from preferred mail order pharmacy, $15 non-preferred generic, $45 preferred brand, $95 non-preferred brand, 33% specialty. 60/90-day supply for two copays.

CareSource Silver (HMO)

 

Josephine and Jackson Counties, and Azalea and Glendale in Douglas County

Office visit copay:$20 PCP, $45 Specialist

Durable Medical Equipment/Prosthetics: 20% coinsurance

Urgent Care visit: $25

Part B drugs: 10% coinsurance

Emergency Room visit: $65

Outpatient Surgery: $100 Ambulatory Surgical Center, $300 Outpatient Hospital facility

Inpatient Hospital: $300/day for days 1–7

Annual Maximum Out-Of-Pocket: $3,400

Skilled Nursing Facility: $50 copay/day for days 1-40

CareSource Silver Plus Rx (HMO)

 

Josephine and Jackson Counties, and Azalea and Glendale in Douglas County

Office visit copay:$20 PCP, $45 Specialist

Durable Medical Equipment/Prosthetics: 20% coinsurance

Urgent Care visit: $25

Part B drugs: 10% coinsurance

Emergency Room visit: $65

Outpatient Surgery: $100 Ambulatory Surgical Center, $300 Outpatient Hospital facility

Inpatient Hospital: $300/day for days 1–7

Annual Maximum Out-Of-Pocket: $3,400

Skilled Nursing Facility: $50 copay/day for days 1-40

Prescription Part D drug coverage: $0 deductible, $5 preferred generic, $0 (90 days) preferred generic from preferred mail order pharmacy, $15 non-preferred generic, $45 preferred brand, $95 non-preferred brand, 33% specialty. 60/90-day supply for two copays.

CareSource Bronze Rx (HMO)

 

Josephine and Jackson Counties, and Azalea and Glendale in Douglas County

Office visit copay:$0 copay PCP, 20% Specialist

Durable Medical Equipment/Prosthetics: 20% coinsurance

Urgent Care visit: 20%

Part B drugs: 20% coinsurance

Emergency Room visit: 20% up to $65

Outpatient Surgery: $20% Ambulatory Surgical Center, 20% Outpatient Hospital facility

Inpatient Hospital: In 2013: Days 1-60: $1-184 deductible; Days 61-90: $296 per day; Days 91-150: $592 per lifetime reserve day (deductibles and copays may change for 2014)

Annual Maximum Out-Of-Pocket: $3,400

Skilled Nursing Facility: In 2013: Days 1-20: $0 per day; Days 21-100: 148 per day (copays may change in 2014)

Prescription Part D drug coverage: $310 annual deductible, 25% coinsurance until total reaches $2,850. 30/60/90 day supply available.

Your Plan Premium

You can pay your monthly plan premium (including any late enrollment penalty you have or may owe) by mail (monthly, quarterly, semi-annually or annually), or “Electronic Funds Transfer (EFT)” each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board Check each month.

People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this extra help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY/TDD users should call 1-877-486-2048.

If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium for this benefit. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare does not cover.

If you don’t select a payment option, you will receive a bill each month.

EFT (Complete the EZ-Pay form only if you want to make a CHANGE to this payment type)

The Social Security or RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.


 
 

Please contact CareSource at 541-471-4106 (TTY/TDD users should call 1-800-735-2900) if you need information in another format or language than what is listed above. The multi-language insert is located on the last page of this document. Our office hours are Monday – Friday, 8 a.m. – 5 p.m. Calls are answered from 8 a.m. to 8 p.m. seven days a week.

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