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ODS Advantage PPO (2009) - a PPO with a Medicare Contract

This plan does not include prescription drug coverage.

ODS Advantage PPO has a $1500 maximum out-of-pocket limit every year for all plan services when received in-network and out of network. You can go to Medicare doctors, specialists and hospitals in or out of the network.

Enrollment Information

You must have both Medicare Part A and Part B to apply
You must reside in the state of Oregon
You must continue to pay your Part B premium (if not paid under Medicaid or third party)
You cannot enroll if you have End Stage Renal Disease (ESRD). If you are currently enrolled in an ODS medical plan, you may be able to enroll even if you are having renal dialysis or have had a recent kidney transplant. Contact member services for more information.

You can enroll in ODS Advantage PPO beginning November 15, 2008 through December 31, 2008, when you become eligible for Medicare, when you have a Special Election Period and each Annual Election Period (November 15th through December 31st of each year). Medicare Advantage eligible individuals may make one Medicare Advantage Open Enrollment Period (OEP) enrollment request from January 1st through March 31st of each year. For more information about when you can enroll or if you have questions about enrolling, please call member services.

Your coverage will generally be effective the first of the month following our receipt of a "Complete" enrollment form. If you have not completed the enrollment form we will contact you for more information. This can delay your effective date.

Warning: If you are enrolled in another Medicare Advantage plan, enrolling into ODS Advantage PPO will disenroll you from that plan and you may not be able to reapply until the next Medicare Annual Election Period November 15, 2009 through December 31, 2009.

Note: If you are already enrolled in another Medicare Advantage Prescription Drug plan, you must receive your Medicare prescription drug benefit through that plan.

Ways to Enroll

Attend a Community Meeting for more complete information about the ODS Advantage PPO plan. The Community Meeting Schedule is a list of ODS Advantage Community Meetings. A sales representative will be present with information and applications.
Print the ODS Advantage PPO Enrollment Form and Instructions and send it to the address on the form.
Call member services to request an enrollment packet

If you need help completing the ODS Advantage PPO Enrollment Form, please call ODS Advantage member services.

ODS Advantage PPO Benefits

ODS Advantage PPO plan features a number of valuable medical benefits including:

Annual out-of-pocket maximum of $1,500
No deductible
Copayments and coinsurance amounts are the same for both in and out of network services. ODS Advantage pays up to the limiting charge for Medicare covered services
$0 copayment for your Annual physical
Travel and visitor coverage for up to 12 months
Worldwide coverage for emergency medical services

The ODS Advantage PPO Summary of Benefits tells you some features of our plan. You can compare ODS Advantage PPO and Original Medicare plan using this Summary of Benefits. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of our benefits, please call ODS Advantage member services and ask for the "Evidence of coverage" which is listed below.

The ODS Advantage PPO Combined Annual Notice of Change - Evidence of Coverage describes the complete benefit and plan premium information.

Premium

The monthly premium for 2009 is $24.90. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party.

Payments may be made:

Directly to ODS Health Plan, Inc.
Through Electronic Fund Transfer from your bank
Deducted from your monthly Social Security check (Contact member services for more information on how to pay your premium this way)

If you have questions about any of these options, call member services.

ODS Advantage Provider Network

The ODS Advantage Provider Network is statewide and includes most hospitals and a broad selection of providers. ODS Advantage allows you to access services from any Medicare provider. ODS Advantage pays out of network Medicare providers up to the limiting charge for Medicare covered services.

You must use Medicare providers except in emergency care situations. ODS Advantage does not require referrals or prior authorization of services.

The ODS Advantage Network Provider Directory is a printable version of the ODS Advantage Network Provider Directory for the entire state of Oregon.

If you need help finding an ODS Advantage Network provider please call member services.

ODS Advantage PPO Grievance and Appeals Procedure

As an ODS Advantage PPO member, you have the right to file a complaint if you have concerns or problems with any part of your benefits, care and service.

There are two types of complaints:

Appeal: An appeal is a special kind of complaint you make if you disagree with a decision to deny a request for health care services payment for services you already received. You may also make a complaint if you disagree with a decision to stop services that your are receiving. For example, you may ask for an appeal if our Plan doesn’t pay for an item or services you think you should be able to receive. See Section 5 below for more information about appeals, including the process involved in making an appeal.
Grievance: A grievance is a type of complaint you make about us or one of our network providers, including a complaint concerning the quality of your care. This type of complaint does not involve payment or coverage disputes. See Section 4 below for more information about a grievance and what to do if you would like to make one.

Section 4: How to file a grievance - This section is from your Combined Annual Notice of Change - Evidence of Coverage for the ODS Advantage PPO Plan.

Section 5: Complaints and Appeals about your Part C Medical Care and Services - This section is from your Combined Annual Notice of Change - Evidence of Coverage for the ODS Advantage PPO plan.

Appointment of Representative
This form is used to name a relative, friend, advocate, doctor or anyone else to be your appointed representative. This appointed representative may request a coverage determination or file a grievance or appeal on your behalf. If you want someone to act for you, then you and that person must sign the Appointment of Representative form which will give the person legal permission to act as your appointed representative.

If you have questions or need help with your appeal or grievance, please call member services.

To obtain a report on the number of ODS Advantage PPO grievances and appeals, call member services.

Disenrollment

As a member of ODS Advantage PPO, you may want to leave our plan or there are a few situations where you would be required to leave our plan. "Disenrollment" from ODS Advantage PPO means ending your membership in ODS Advantage PPO. Disenrollment can be voluntary (your own choice) or involuntary (not your own choice):

You might leave ODS Advantage PPO because you have decided that you want to leave.
There are also limited situations where we are required to end your membership. For example, if you permanently move out of our geographic service area.

Until your membership officially ends, you should keep getting your Medicare services through ODS Advantage PPO or you will have to pay more for your services.

Whether leaving the plan is your choice or not, Section 6: Ending your Membership, from your Combined Annual Notice of Change - Evidence of Coverage explains your Medicare coverage choices after you leave and the rules that apply. A disenrollment form is located at the end of Section 6.

Administrative Information

Potential for Contract Termination

ODS Health Plan, Inc.'s contract with the Center for Medicare and Medicaid Services (CMS) may not be renewed each calendar year by CMS or by the plan. The services under the plan may change from year to year and the plan's service areas may also change. You will be notified in advance of any changes that may occur. Coverage beyond the end of the current contract year is not guaranteed.

ODS Advantage Privacy Notice

At ODS Advantage we understand that it is our responsibility to protect your private information. We will not share your private information except as allowed by law to conduct the business of providing you with your benefits, paying claims, collect premiums, and reporting to CMS, state and federal agencies as required by law.

Your Medicare Rights and Protections

ODS Health Plan, Inc. contracts with the Federal government.

ODS Advantage is a PPO with a Medicare contract.

H3813-001
H38134006PPO09A (10/2008)