Our Evidence of Coverage (EOC) documents include detailed benefit information and how to get coverage. You can download a copy below.
We encourage you to read this information and hold onto it because it explains your benefits and rights. If you have questions or would like to request a hard copy, please call Member Services at 1-888-777-5536 (toll free) or TTY 711 from 8 a.m. to 8 p.m., 7 days a week.
The Annual Notice of Changes (ANOC) describes any changes to coverage, costs, or service area from the previous year, effective January 1. You can download a copy below.
We make it easy to find a doctor or pharmacy to meet your needs. All of our available doctors welcome Kaiser Permanente Medicare health plan members and you can change to another available Kaiser Permanente doctor at anytime, for any reason. You can download a provider directory below.
We operate our own pharmacies and contract with affiliated pharmacies that meet or exceed Medicare requirements for pharmacy access. You can download a pharmacy directory below.
Throughout the year, the Centers for Medicare & Medicaid Services sends out updates about additional covered services or changes to existing covered services. These notifications are called National Coverage Determinations (NCDs).
If you would like help understanding these documents, call Member Services at 1-888-777-5536 (toll-free) or TTY 711 from 8 a.m. to 8 p.m., 7 days a week.
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.
2101 East Jefferson St.
Rockville, MD 20852
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Protect your identity. Know the signs of schemes and questionable offers involving Medicare.
An identity thief could try to use your Medicare information to get paid for care you never received.
Watch out for people who ask for your Medicare claim number or plan information, or try to bribe you to see an unfamiliar doctor or use services you don’t need.
Visit the Medicare website for more information on preventing fraud. To report suspected fraud, call 1-877-7SAFERX (1-877-772-3379) (toll free).
An organization determination is a coverage decision that involves your medical care or asks us to reimburse you or pay a bill. To ask for a coverage decision on health care you want but haven’t received or to pay a bill, you can call, write, or fax Member Services.
If you need a quick answer about care or services because waiting too long could be a health risk, ask for a fast coverage decision. You, your doctor, or your representative can ask for this, and we’ll respond within 72 hours. Otherwise, we’ll respond to requests for care or services within 14 days and requests for payment within 30 days.
If we turn down your request, you can make an appeal. (See "Making an appeal" below). For more details, refer to chapter 9 in your Evidence of Coverage.
Making an appeal
If we turn down your request, you’ll get written notice of our decision. You can ask us to reconsider by making a Level 1 Appeal within 60 days of the date on that notice.
• For a standard appeal, write to Member Services. If you need a quick response for health reasons, you must ask for a fast appeal (also called an expedited reconsideration) by writing or calling Member Services. You, your doctor, or your representative can do this. If a representative is appealing our decision for you, the appeal must include an Appointment of Representative (updated 10/01/22) (PDF) form authorizing this person to represent you.
• We’ll respond to fast appeal requests within 72 hours, standard appeals for care you haven’t received within 30 days, and standard appeals about payment within 60 days.
• If we say no to all or part of your appeal, your case will be sent to Level 2 of the appeals process. To make sure our decision was fair, we will send your appeal to the Independent Review Organization, who will carefully review it and explain the decision to you in writing.
For more details, refer to chapter 9 in your Evidence of Coverage.
How do I appoint a representative?
You can appoint a representative to help you. Your representative can be a family member, friend, advocate, attorney, doctor, or someone else who will act on your behalf. Fill out an Appointment of Representative form (updated 10/01/22) (PDF) and send it in with your appeal.
Filing a grievance
If you’re unhappy with your care or services or with our processes, you can make a complaint. This is known as filing a grievance. Contact Member Services within 60 days of the incident, by phone or in writing.
We’ll look into your complaint and respond within 30 days. For more details, refer to chapter 9 in your Evidence of Coverage.
You can look at appeals and grievances other plan members have filed with Kaiser Permanente. To get this information, please contact Member Services.
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