Other Plan Information

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

Select from the list below to view information:

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:

At any time during the grievance or appeal process, you may authorize a representative to assist you in the process. We must receive an authorization, in writing, from you to designate a representative. You may contact our customer service department for additional information about designating a representative. Download the Appointment of Representative form to act on your behalf:

You may file a grievance or complaint online using the Medicare.gov Medicare Complaint Form*.

* 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:

HIPPA Authorization Form:

To obtain information about the aggregate number of grievances, appeals and exceptions filed with Essence Healthcare or for process or status questions, please contact us.

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 www.medicare.gov. 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 is used to ensure care provided to you is objective and based on established medical evidence. Clinical criteria can help improve health and may also help you reduce what you pay for healthcare.

You can access the InterQual evidence-based clinical decision support criteria 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.

Part B Drug Criteria

Internal Policies

You can access the Plan’s coverage criteria for medical oncology medications, which is administered by Health Help.

In addition, you can access the Milliman Clinical guidelines utilized by the Plan’s behavioral health vendor here.

National Coverage Determination

From time to time, the federal agency that runs Medicare announces new information about coverage under the program. The Medicare program requires us to notify its members of this information on our website and in our member newsletter.

Member Notification of Medicare National Coverage Determination

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, 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:

You can find out if the drug you take is subject to these additional requirements or limits by looking in the Drug Formulary. If your drug is subject to one of these additional restrictions or limits, and your physician determines that you are not able to meet the additional restriction or limit for medical necessity reasons, you or your physician can request an exception (which is a type of coverage determination).

We conduct drug utilization reviews for all of our members to make sure that they are receiving safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribe their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems such as:

  • Possible medication errors
  • Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition
  • Drugs that are not safe or appropriate because of your age or gender
  • Possible harmful interactions between drugs you are taking at the same time
  • Drug allergies
  • Drug dosage errors

If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.

Learn more about the safe use of opioid pain medicines:

You may be able to get a temporary supply under certain circumstances. The plan can offer a temporary supply of a drug to you when your drug is not on the drug list or when it is restricted in some way. Doing this gives you time to talk with your doctor about the change in coverage and figure out what to do.

To be eligible for a temporary supply, you must meet the two requirements below:

  1. The change to your drug coverage must be one of the following types of changes:
    • The drug you have been taking is no longer on the plan's drug list.
    • Or — the drug you have been taking is now restricted in some way (Chapter 5, Section 4 of the EOC talks about restrictions).
  2. You must be in one of the situations described below:
    • For those members who are new or who were in the plan last year and are not in a long-term care (LTC ) facility:
      • We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you were new and during the first 90 days of the calendar year if you were in the plan last year. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication. The prescription must be filled at a network pharmacy.
    • For those members who are new or who were in the plan last year and reside in a long-term care (LTC) facility:
      • We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you are new and during the first 90 days of the calendar year if you were in the plan last year. The total supply will be for a maximum of a 31-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 31-day supply of medication. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
    • For those members who have been in the plan for more than 90 days and reside in a long-term care (LTC) facility and need a supply right away:
      • We will cover one 31-day supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
  •  

Members who have a change in level of care (setting) will be allowed up to a one-time 31-day transition supply per drug.

View our Transition Policy:

View information about our Medication Therapy Management Program.

If we leave the Medicare program or change our service area so that it no longer includes the area where you live, we'll tell you in writing. If this happens, your plan membership will end, and you'll have to change to another way of getting your Medicare benefits. All of the benefits and rules described in your Evidence of Coverage will continue until your membership ends. This means that you must continue to get your medical care 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've told you in writing that we're 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 be provided 90 days advance notice in the event that we decide not to renew our contract with CMS. The notice will supply you with Medicare alternatives within the service area.

It's also possible for CMS or Essence Healthcare to end the contract during the year. In these situations, we will try to provide you with 90 days advance notice; however, your advance notice may be as little as 30 days or fewer if CMS determines the contract must end.

Whenever a Medicare health plan leaves the Medicare program or stops serving your area, you'll 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.

Ending Your Membership in the Plan

Disenrollment from your health plan means ending your membership in our plan. Disenrollment can be voluntary or involuntary.

  • You can decide to leave your health plan 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 we leave the Medicare program. We can't ask you to leave our plan because of your health.

If you leave our plan, it can 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 can continue to get your care as usual through our health plan.

Until your membership ends, you must keep getting your Medicare services through us, or you'll have to pay for them yourself. If you get services from doctors or other medical providers who are not plan providers before your membership in our plan ends, neither we 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 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 your health plan, please call us.

Voluntary Disenrollment: If You Want to Leave Our Health Plan

You may choose to end your membership in our plan only during certain times of the year. All members have the opportunity to leave the plan during the Annual Enrollment Period and during the Medicare Advantage Open Enrollment Period. In certain situations, you may also be eligible to leave the plan at other times of the year.

  • Make sure that the type of change you want to make (and when you want to make it) fits within the rules explained in your plan's Evidence of Coverage about changing how you get Medicare. If the change does not fit within these rules, you won't be allowed to make the change.
  • Usually, to end your membership in our plan, you simply enroll in another Medicare plan. However, if you want to switch from our plan to Original Medicare but you have not selected a separate Medicare prescription drug plan, you must ask to be disenrolled from our plan. There are two ways you can ask to be disenrolled:
    • You can make a request in writing to us. Download and print a disenrollment form or contact Customer Service if you need more information.
      • Mail the completed form to P.O. Box 12487, St. Louis, MO 63132
    • You can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
Involuntary Disenrollment: We Must End Your Membership in Certain Situations

We must end your membership in the plan in certain situations. If any of the following situations occur, we will end your plan membership:

  • 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 are moving to or traveling to is in our service area. If you move permanently out of our geographic service area, or if you are away from our service area for more than six months in a row, you generally cannot remain a member of our plan.
  • If you do not stay continuously enrolled in both Medicare Part A and Part B.
  • If you give us information on your enrollment request that you know is false or deliberately misleading, and it affects whether you can enroll in our plan.
  • 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 our plan. We cannot 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 are disenrolled for this reason, CMS may refer your case to the Inspector General for additional investigation. We can't ask you to leave the plan for any reason related to your health. If you ever feel that you're being encouraged or asked to leave our plan because of a health-related reason, you should call 1-800-MEDICARE (1-800-633-4227), which is the national Medicare helpline. TTY users should call 1-877-486-2048. You can call 24 hours a day, seven days a week. 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.

Learn more about getting extra help to pay for your prescription drugs and costs.

Part D sponsors must provide access to Part D drugs at the correct LIS cost-sharing level when presented with evidence of LIS eligibility. Learn more about CMS's "Best Available Evidence" (BAE) policy.

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 www.medicare.gov.

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.

The Medicare Prescription Payment Plan is a new payment option in the prescription drug law that works with your current drug coverage to help you manage your out of-pocket Medicare Part D drug costs by spreading them across the calendar year (January-December). Starting in 2025, anyone with a Medicare drug plan or Medicare health plan with drug coverage (like a Medicare Advantage Plan with drug coverage) can use this payment option. All plans offer this payment option and participation is voluntary. If you select this payment option, each month you’ll continue to pay your plan premium (if you have one), and you’ll get a bill from your health or drug plan to pay for your prescription drugs (instead of paying the pharmacy). There’s no cost to participate in the Medicare Prescription Payment Plan.

For more information about this program and how to participate: https://www.express-scripts.com/mppp 

Other Resources: Medicare Prescription Payment Plan Fact Sheet

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