Medicare Resources & Forms

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.

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.


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
Medicare
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.

Learn more about Member Rights and Responsibilities for Baptist Health Plan Advantage (HMO)

Disenrollment Rights and Responsibilities

Learn about Baptist Health Plan member rights and responsibilities when disenrolling from Baptist Health Plan.

View the Baptist Health Plan Advantage (HMO) Disenrollment Rights and Responsibilities

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.

Out-of-Network Coverage

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 a network pharmacy
  • To find a drug on our formulary, click here.

Contact Us

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:

  • Medicare.gov.
  • Social Security Administration
  • Centers for Medicare & Medicaid (CMS) Complaint Form
  • Medicare Ombudsman
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Last Updated: 01/01/2018, 01:05 pm