Blue Medicare Advantage plan information

All Plan Documents

• 2024 PPO Plan Star Ratings
• 2024 HMO Plan Star Ratings
• 2024 Extra Help – Low Income Subsidy
• 2024 Drug Formulary
• 2024 Prescription Drug Formulary Search
• 2024 PPO Provider Directory
• 2024 PPO Provider and Pharmacy Directory
• 2024 HMO Provider and Pharmacy Directory
• 2024 OTC Catalog
• 2024 OTC Catalog – Spanish

The Centers for Medicare & Medicaid Services (CMS) makes changes to the services that are covered by Medicare. These changes are updated via National Coverage Determinations (NCD). When CMS updates the NCDs, the changes can be found on the Medicare Coverage Database Search.

CMS has issued the following NCDs:

An advance care plan is important as you age to ensure your health needs are managed ahead of time and for family and care providers to understand those preferences.

An Advance Directive is a legal document that outlines your expressed decisions on how you would like to be cared for when you cannot express those decisions yourself. The document only goes into effect when you cannot speak for yourself due to injury, emergency, or disease.

Blue KC Customer Service Representatives can assist members with establishing advanced directives. Call (866) 508-7140 (TTY:711)

Download your state specific Advance Directive:

• Kansas Advance Directive
• Missouri Advance Directive

Further advance directive information can be found at here.

Learn about your Blue KC Medicare Advantage plan’s rights, including:

• Initial organizational determinations
• Appeals and exceptions
• Grievances

Information about Organization & Coverage Determinations, Appeals and Grievances

Also note that each Blue Medicare Advantage plan’s Evidence of Coverage book describes our grievance, coverage determination (including exceptions) and appeals processes.

At any time during the grievance or appeal process, you may appoint a representative to assist you in the process. We must receive in writing, from you to designate a representative for an Appeal and Grievance. You can complete and submit the CMS-1696 AOR form available in the link below, or contact our Customer Service department for additional information.

Downloadable forms:

• Medicare Prescription Drug Coverage Determination Request Form
• Medicare Prescription Drug Coverage Redetermination Form
• Blue Medicare Advantage Prior Authorization Request From
• CMS-1696 Appoint a Representative for an Appeal and Grievance

To obtain information about the aggregate number of grievances, appeals and exceptions filed with Blue KC, contact us.

To file a grievance or complaint visit the Medicare.gov website.

“Disenrollment” from Blue Medicare Advantage means ending your membership in our plan. Disenrollment can be voluntary or involuntary:

• You might leave Blue Medicare Advantage 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 Blue KC 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 Blue KC, 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.

For Blue Medicare Advantage HMO members, If you get services from doctors or other medical providers who are not plan providers before your membership in our plan ends, neither Blue KC 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.

For Blue Medicare Advantage (PPO) members, Out-of-network/non-contracted providers are under no obligation to treat members, except in emergency situations. For a decision about whether Blue KC will cover an out-of-network service, we encourage you or your provider to ask Blue KC for a pre-service organization determination before the service is received. Please call Blue Medicare Advantage Customer Service or refer to the Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

If you have any questions about leaving Blue Medicare Advantage, 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 Blue Medicare Advantage 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.

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 Blue Medicare Advantage 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 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 Blue KC 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 Blue Medicare Advantage to Original Medicare, you will have the right to buy a Medigap policy regardless of your health. This is called a “guaranteed issue right” and is explained in the Evidence of Coverage.

Blue KC 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 Blue KC 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, 7 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 Blue Medicare Advantage 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, of if you are away from our service area for more than six months in a row, you generally cannot remain a member of Blue Medicare Advantage. In these situations, if you do not leave on your own, we must end your membership (“disenroll” you).

• If you do not stay continuously enrolled in both Medicare Part A and Medicare Part B.
• 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 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 Blue Medicare Advantage 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.

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.