Medicare Resources and Forms
Use the resources and forms below to get the information you need about your healthcare coverage.
2017 Baptist Health Plan Advantage (HMO) Plan Information
Use the resources and forms below to get the information you need about the Baptist Health Plan Advantage (HMO) plan.
Includes several forms, including those linked below
Summary of Benefits
Please click on the link below for the Baptist Health Plan Advantage (HMO) Summary of Benefits to review a list of covered benefits and services.
- Baptist Health Plan Advantage (HMO) Summary of Benefits (Central Region)
- Baptist Health Plan Advantage (HMO) Summary of Benefits (Southern Region)
Annual Notice of Change (ANOC)
Please click on the link below for the Baptist Health Plan Advantage (HMO) 2017 Annual Notice of Change (ANOC) document to review annual changes made to our plans.
Evidence of Coverage
The following provides detailed plan benefits information and member rights and responsibilities.
- Baptist Health Plan Advantage (HMO) Evidence of Coverage (Central Region)
- Baptist Health Plan Advantage (HMO) Evidence of Coverage (Southern Region)
Multi-language Interpreter Services
Discrimination is Against the Law
Exclusions and Limitations
Some services are not covered and will not be paid for by Baptist Health Plan. The links below provide detailed listings of these excluded services.
Authorized Representative Forms
You can appoint a person to act on your behalf or to view your protected health information (PHI). If you would like to appoint an authorized representative to act in these capacities, choose the appropriate form below.
Complete the required fields in the form, print, sign and mail it to us. Once we receive this completed request we will verify it, adjust our records accordingly and speak to your appointed representative or share your Protected Health Information as needed. If you have any questions, please call our Member Services department at 844.405.1763. TTY users should call 844.708.1389.
Baptist Health Plan Advantage
P.O. Box 22603
Lexington, KY 40522
Appointment of Representative Form
Use the Appointment of Representative Form to appoint a representative to make decisions for you and legally act on your behalf (e.g., make requests, present or get evidence, obtain appeals information and receive notices regarding an appeal).
Notice of Privacy Practices
View the Baptist Health Plan Notice of Privacy Practices
Member Rights and Responsibilities
You have the right to file an appeal if Medicare, your Medicare Advantage Plan or Prescription Drug Plan denies your request for a healthcare service, supply item or prescription drug you feel you should be entitled to or have already received, or if you are requesting a change in the amount you are required to pay for that service, supply item or prescription drug.
Disenrollment Rights and Responsibilities
Learn about Baptist Health Plan member rights and responsibilities when disenrolling from Baptist Health Plan.
Contract Termination Information
Baptist Health Plan renews its contract with the Medicare program each year. If we plan to leave a service area, we must notify you accordingly.
If a member seeks care or pharmacy access outside the Baptist Health Plan Advantage network or service area, the member must take steps to ensure the care provided will be covered by our plan.
Learn more about out-of-network coverage:
Plan Rating Information
Learn more about information for our plans:
- Baptist Health Plan Advantage (HMO) Star ratings are not yet available.
Part D Resources
Find out how Baptist Health Plan Advantage members and prospective members can contact us.
Helpful Websites About Medicare
Looking for information about Medicare? Here are some helpful websites: