Medicare Best Available Evidence and Additional Information

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HOW TO END YOUR MEMBERSHIP / BENEFICIARIES AND PLAN RIGHTS AND RESPONSIBILITY UPON DISENROLLMENT

‍Ending your membership in our Plan may be voluntary (your own choice) or involuntary (not your own choice):

• You might leave our plan because you have decided that you want to leave.

     ○ There are only certain times during the year, or certain situations, when you may voluntarily end your membership in the plan. Section 1(below) tells you when you can end your membership in the plan.
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     ○ The process for voluntarily ending your membership varies depending on what type of new coverage you are choosing. Section 2 tells you how to end your membership in each situation.

• There are also limited situations where you do not choose to leave, but we are required to end your membership. Section 4 tells you about situations when we must end your membership.

If you are leaving our plan, you must continue to get your medical care through our plan until your membership ends.
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SECTION 1 When can you end your membership in our plan?
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You may end your membership in our plan only during certain times of the year, known as enrollment periods. All members have the opportunity to leave the plan during the Annual Enrollment Period and during the annual Medicare Advantage Disenrollment Period. In certain situations, you may also be eligible to leave the plan at other times of the year.

Section 1.1 You can end your membership during the Annual Enrollment Period

You can end your membership during the Annual Enrollment Period (also known as the “Annual Open Enrollment Period”). This is the time when you should review your health and drug coverage and make a decision about your coverage for the upcoming year.

When is the Annual Enrollment Period? This happens from October 15 to December 7.

What type of plan can you switch to during the Annual Enrollment Period?

During this time, you can review your health coverage and your prescription drug coverage. You can choose to keep your current coverage or make changes to your coverage for the upcoming year. If you decide to change to a new plan, you can choose any of the following types of plans:

○ Another Medicare health plan. (You can choose a plan that covers prescription drugs or one that does not cover prescription drugs.)
○ Original Medicare with a separate Medicare Prescription Drug Plan.
○ – or – Original Medicare without a separate Medicare Prescription Drug Plan.

If you receive “Extra Help” from Medicare to pay for your prescription drugs:

If you switch to Original Medicare and do not enroll in a separate Medicare Prescription Drug Plan, Medicare may enroll you in a drug plan, unless you have opted out of automatic enrollment.

Note: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug coverage, you may need to pay a late enrollment penalty if you join a Medicare drug plan later. (“Creditable” coverage means the coverage is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.)

When will your membership end? Your membership will end when your new plan’s coverage begins on January 1.

Section 1.2 You can end your membership during the Medicare Advantage Open Enrollment Period

You have the opportunity to make one change to your health coverage during the annual Medicare Advantage Open Enrollment Period.

When is the annual Medicare Advantage Open Erollment Period?

This happens every year from January 1st to March 31st.

What type of plan can you switch to during the annual Medicare Advantage Open Enrollment Period?

o  Switch to another Medicare Advantage Plan. (You can choose a plan that covers prescription drugs or one that does not cover prescription drugs.)

o  Disenroll from our plan and obtain coverage through Original Medicare. If you choose to switch to Original Medicare during this period, you have until March 31 to join a separate Medicare prescription drug plan to add drug coverage.

When will your membership end?

Your membership will end on the first day of the month after you enroll in a different Medicare Advantage plan or we get your request to switch to Original Medicare. If you also choose to enroll in a Medicare prescription drug plan, your membership in the drug plan will begin the first day of the month after the drug plan gets your enrollment request.

Section 1.3 In certain situations, you can end your membership during a Special Enrollment Period

In certain situations, members of PrimeTime Health Plan (HMO-POS) may be eligible to end their membership at other times of the year. This is known as a Special Enrollment Period.

Who is eligible for a Special Enrollment Period?

If any of the following situations apply to you, you are eligible to end your membership during a Special Enrollment Period. These are just examples, for the full list you can contact PrimeTime Health Plan (HMO-POS) Customer Service, call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048, or visit the Medicare website at (http://www.medicare.gov):

○ Usually, when you have moved.
○ If you have Medicaid.
○ If you are eligible for “Extra Help” with paying for your Medicare prescriptions.
○ If we violate our contract with you.
○ If you are getting care in an institution, such as a nursing home or long-term care (LTC) hospital.
○ If you enroll in the Program of All-inclusive Care for the Elderly (PACE).]

When are Special Enrollment Periods?

The enrollment periods vary depending on your situation.

What can you do?

To find out if you are eligible for a Special Enrollment Period, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048. If you are eligible to end your membership because of a special situation, you can choose to change both your Medicare health coverage and prescription drug coverage. This means you can choose any of the following types of plans:

○ Another Medicare health plan. (You can choose a plan that covers prescription drugs or one that does not cover prescription drugs.)
○ Original Medicare with a separate Medicare Prescription Drug Plan.
○ – or – Original Medicare without a separate Medicare Prescription Drug Plan.
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• If you receive “Extra Help” from Medicare to pay for your prescription drugs: If you switch to Original Medicare and do not enroll in a separate Medicare Prescription Drug Plan, Medicare may enroll you in a drug plan, unless you have opted out of automatic enrollment.

Note: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug coverage for a continuous period of 63 days or more, you may have to pay a Part D late enrollment penalty if you join a Medicare drug plan later. (“Creditable”coverage means the coverage is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.)

When will your membership end?

Your membership will usually end on the first day of the month after your request to change your plan is received.

Section 1.4 Where can you get more information about when you can end your membership?

If you have any questions or would like more information on when you can end your membership:

• You can call PrimeTime Health Plan (HMO-POS) Customer Service at 330-363-7407 or 1-800-577-5084. TTY users should call 711. We are open Monday through Friday 8:00 a.m. to 8:00 p.m. (October 1st – March 31st, we are available 7 days a weeks, 8 a.m. to 8 p.m.).

• You can find the information in the Medicare & You Handbook.

     ○ Everyone with Medicare receives a copy of Medicare & You each fall. Those new to Medicare receive it within a month after first signing up.
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     ○ You can also download a copy from the Medicare website (http://www.medicare.gov). Or, you can order a printed copy by calling Medicare at the number below.
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• You can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

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SECTION 2 How do you end your membership in our plan?
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Usually, to end your membership in our plan, you simply enroll in another Medicare plan during one of the enrollment periods (see Section 1 above for information about the enrollment periods). However, if you want to switch from our plan to Original Medicare without a Medicare Prescription Drug Plan, you must ask to be disenrolled from our plan. There are two ways you can ask to be disenrolled:

• You can make a request in writing to us. If you need more information on how to do this, contact PrimeTime Health Plan (HMO-POS) Customer Service.

• --or--You can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Note: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug coverage for a continuous period of 63 days or more, you may have to pay a Part D late enrollment penalty if you join a Medicare drug plan later. (“Creditable”coverage means the coverage is expected to pay, on average, at least as much as Medicare’s standard prescription drug

The text below explains how you should end your membership in our plan.
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If you would like to switch from our plan to:

‍• Another Medicare health plan.
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   This is what you should do:
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• Enroll in the new Medicare health plan.
You will automatically be disenrolled from PrimeTime Health Plan (HMO-POS) when your new plan’s coverage begins.
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If you would like to switch from our plan to:

• Original Medicare with a separate Medicare Prescription Drug Plan.
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This is what you should do:
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• Enroll in the new Medicare Prescription Drug Plan.
You will automatically be disenrolled from PrimeTime Health Plan (HMO-POS) when your new plan’s coverage begins.
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If you would like to switch from our plan to:

‍• Original Medicare without a separate Medicare prescription drug plan.
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○ Note: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug coverage for a continuous period of 63 days or more, you may have to pay a Part D late enrollment penalty if you join a Medicare drug plan later. (“Creditable”coverage means the coverage is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.)

This is what you should do:

‍• Send us a written request to disenroll.
Contact PrimeTime Health Plan (HMO-POS) Customer Service, if you need more information on how to do this.

• You can also contact Medicare, at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, and ask to be disenrolled. TTY users should call 1-877-486-2048.

You will be disenrolled from PrimeTime Health Plan (HMO-POS) when your coverage in Original Medicare begins.
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SECTION 3 Until your membership ends, you must keep getting your medical services and drugs through PrimeTime Health Plan (HMO-POS).
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If you leave our plan, it may take time before your membership ends and your new Medicare coverage goes into effect. During this time, you must continue to get your medical care and prescription drugs through our plan.

• While you are waiting for your membership to end, you are still a member of our plan and should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends. In most cases, your prescriptions are covered only if they are filled at a network pharmacy (including our mail-order pharmacy service).

• If you are hospitalized on the day that your membership ends, your hospital stay will usually be covered by our plan until you are discharged (even if you are discharged after your new health coverage begins).


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SECTION 4 In certain situations, PrimeTime Health Plan (HMO-POS) must end your membership in the plan.
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‍Section 4.1 When must we end your membership in the plan?

PrimeTime Health Plan (HMO-POS) must end your membership in the plan if any of the following happen:

• If you do not stay continuously enrolled in Medicare Part A and Part B

• If you travel away from our service area for more than six months.

• If you move out of our service area.

    ○ If you move, call PrimeTime Health Plan (HMO-POS) Customer Service, to find out if the place you are moving to is in our plan’s service area.

• If you become incarcerated (go to prison).

• If you lie about or withhold information about other insurance you have that provides prescription drug coverage.If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)

• If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other members of our plan. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)

• If you let someone else use your membership card to get medical care. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)
    ○ If we end your membership because of this reason, Medicare may have your case investigated by the Inspector General.

• If you do not pay the plan premiums for 2 calendar months.
    ○ We must notify you in writing that you have 2 calendar months to pay the plan premium before we end your membership.

• If you are required to pay the extra Part D amount because of your income and you do not pay it, Medicare will disenroll you from our plan and you will lose prescription drug coverage.

Section 4.2 We cannot ask you to leave our plan for any reason related to your health

PrimeTime Health Plan (HMO-POS) is not allowed to ask you to leave our plan for any reason related to your health.

What should you do if this happens?

If you feel that you are being asked to leave our plan because of a health-related reason, you should call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may call 24 hours a day, 7 days a week.

Section 4.3 You have the right to make a complaint if we end your membership in our plan

If we end your membership in our plan, we must tell you our reasons in writing for ending your membership. We must also explain how you can make a complaint about our decision to end your membership.

Where can you get more information?

If you have questions or would like more information on when we can end your membership:

You can call PrimeTime Health Plan (HMO-POS) Customer Service at 330-363-7407 or 1-800-577-5084. TTY users should call 711. We are open Monday through Friday 8:00 a.m. to 8:00 p.m. (October 1st -March 31st, we are available 7 days a week, 8 am -8 pm).

Quality health care and benefits are responsibilities you share with your doctors and your plan. We want you to know your responsibilities and rights. They are based on common sense, courtesy, and honest communication. Please read your Evidence of Coverage for a full description. If you have a question, concern, or a recommendation on
improving PrimeTime Health Plan policies for promoting enrollee responsibilities and rights, contact us through our website at www.primetimehealthplan.com or call the Service Center at 330-363-7407 or toll free at
1-800-577-5084 or TTY/TDD 711. Monday through Friday, 8:00 a.m. to 8:00 p.m. From October 1st through March 31st, we are open 8:00 a.m. to 8:00 p.m., 7 days a week.

You have a Right to:

• Receive information about the organization, its services, its practitioners and providers, and member rights and responsibilities.

• Receive information about your coverage (see your Evidence of Coverage book).

• A list of doctors, hospitals, and other PrimeTime Health Plan network providers. Visit our Find a Doctor Tool here

• Be treated with dignity and respect.

• A frank discussion with your doctor about your medical condition, including appropriate and medically necessary treatment options, regardless of cost or benefit coverage and to participate in making decisions about your health care. Your doctors are independent. They are not restricted or prohibited from discussing treatment options with
you, including those that are not covered.

• Privacy of your health care and claims information. Your Protected Health Information will be used to pay claims, as permitted by HIPAA and as described in your Notice of Privacy Practices. Protected Health Information will not be disclosed to others without your authorization.

• Ask questions, raise concerns, make complaints, and appeal denials, as explained in your Evidence of Coverage book.

• To make recommendations about PrimeTime Health Plan’s Enrollee Rights and Responsibilities Policy.


You have a Responsibility to:

• Bring your PrimeTime Health Plan ID card when you go to the doctor, hospital, drug store, or health care provider. It contains important information. Having your card may help save time and prevent mistakes.

• Tell the doctor or nurse about your condition. Tell your doctor what medications you are taking. Answer any questions the doctor or nurse may ask you completely and truthfully. This information may help your
doctor form treatment goals and alternatives. Understand your health problems and participate in developing mutually agreed upon goals.

• Ask questions if you do not understand something about your medical condition and the treatment alternatives (including medications) the doctor is recommending.

• Follow your doctor’s medical advice and instructions. Take medications as directed. Let the doctor know if you have a bad reaction. Let your doctor know if your symptoms do not get better, or if they get worse. Schedule recommended follow-up appointments.

• Live a healthy lifestyle.

• Check your benefit chart (schedule of benefits).

• Get all required pre-approvals (pre-certification) and second opinions.

• Call PrimeTime Health Plan if you have questions about your coverage or responsibilities.‍

What is Fraud, Waste, and Abuse?

Fraud, as defined by the Centers for Medicare and Medicaid Services, CMS, is an intentional deception or
misrepresentation that someone makes, knowing it is false, that could result in the payment of unauthorized benefits.

Waste involves the intentional and unintentional, thoughtless or careless utilization, consumption, mismanagement,
uses or squandering of health care benefits.

Abuse involves actions that are inconsistent with sound medical, business, or fiscal practices. Abuse, directly
or indirectly, results in higher costs to the health care program through improper payments that are not medically necessary.

The primary difference between fraud and abuse is a person's intent. That is, did they know they were committing a
crime?

PrimeTime Health Plan’s Fraud, Waste, and Abuse Protection Mission

The mission of PrimeTime Health Plan's (PTHP) Fraud, Waste, and Abuse Unit is to protect our customers, including companies, enrollees and employees against fraud, waste, and abuse by investigating all unlawful and wasteful activity directed at the corporation's assets and to seek remedies for the benefit of the company's policyholders.

How PTHP Works to Protect You

PTHP maintains a committed Anti-Fraud Unit. Our unit works closely with National Benefit Integrity Medicare Drug Integrity Contractor (NBI MEDIC), National Health Care Anti-Fraud Association (NHCAA), the Department of Health
and Human Services Office of Inspector General (HHS-OIG), the Federal Bureau of Investigation (FBI), the United States Attorney's Offices, and other partners to identify fraud, waste, and abuse. We develop cases for referral to
NBI MEDIC, local and federal law enforcement authorities, support civil and/or criminal prosecutions, recover lost
money, and pursue the exclusion of bad providers from the PTHP system.

What to Look For

Fraud, waste, and abuse can take many forms. Some common forms may include, but are not limited to:

• Billing for services or supplies never provided.
• Misrepresenting the services rendered.
• Misrepresenting the diagnosis to justify payment for services.
• Altering claim forms to obtain higher payment amount.
• Soliciting, offering or receiving a kickback, bribe or rebate
• Deliberately applying for more than one payment for the same service.
• Unlawfully completing a Certificate of Medical Necessity.
• Falsifying documents.
• Misrepresenting the place of service.
• Secret, unlawful agreements between a supplier, beneficiary, and/or other healthcare provider that results in higher costs or charges to PTHP.

For more information, please visit this Medicare Resource page.

What Happens After Suspected Fraud is Reported?

The PTHP SIU Department will begin an investigation. At that point, an investigator may request relevant medical
documentation from the parties involved. All materials are then analyzed before a final determination is made.

In order for us to provide you with this service, you will need to supply the requested information. See our Privacy Statement for more information about our policies.

Please notify PTHP if you suspect healthcare fraud, waste, and abuse

CALL OUR HOTLINE: 1-866-307-3528 or

ONLINE - https://aultcare.ethicspoint.com

MAIL OR FAX - Submit your suspicions to the SIU Department by mailing or faxing to:
FAX - (330) 363-3066

MAIL - AultCare/ PTHP
SIU Department
P. O. Box 6910
Canton, Ohio 44706-0910

PTHP encourages anyone with knowledge of suspected instances of fraud, waste, and abuse to report this information to the SIU. Please know this information can be reported anonymously and without fear of retaliation. Every effort is made to maintain confidentiality.

To promote an environment of open communication and reporting PTHP has and enforces a policy of non retaliation and non retribution toward any party reporting suspected fraud, waste, and abuse.

PrimeTime Health Plan is committed to providing each member timely resolution for all questions, complaints, or concerns. If you ever have any issues with PrimeTime Health Plan, your benefits, or our providers, please let us know so we can help.

Our representatives are available to assist you at 1-800-577-5084 (TTY: 711) Monday through Friday, 8:00 a.m. to 8:00 p.m. (October 1st – March 31, we are available 7 days a week, 8:00 a.m. to 8:00 p.m.)

If you would like to meet with a customer service representative in person, you can visit us during our office hours, Monday through Friday, 8:00 a.m. to 4:30 p.m.

Complaints/Grievances

You have the right to file a grievance orally or in writing.

‍Submit a Written Grievance to:
PrimeTime Health Plan
P.O. Box 6029
Canton, Ohio 44706
Fax: 330-363-3066
Or email us at: PGrievance@aultcare.com


‍Submit a Verbal Grievance to:
PrimeTime Health Plan
Customer Service
Local:330-363-7407 or
Toll-Free: 800-577-5084
TTY: 711
PrimeTime Health Plan will not treat you differently for filing a complaint. Your health care benefits will not be affected.

PrimeTime Health Plan maintains information on the number of Grievances and Appeals that are made against us. This information can be obtained by writing to PrimeTime Health Plan at P.O. Box 6029, Canton, OH 44706.

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For more information on coverage determinations, including exceptions, grievances, and appeals, please select one of the links below. This information is also available in Chapter 9 of your plan’s Evidence of Coverage.

Medical Determinations, Grievances, or Appeals Information

This section provides a brief summary of your rights to request coverage for care, services, or payments made for medical services and your right to file a grievance or appeal.


Prescription Drug Coverage Determinations, Grievances, or Appeals Information

This section provides a brief summary of your right to request coverage for prescription drugs and your right to file a grievance or appeal.

Medicare Prescription Drug Coverage Determination

Complete the Medicare Prescription Drug Coverage Determination Form to request a coverage decision for a Part D prescription drug. This form may be completed by a member or a provider. To initiate requests by phone, please contact our service center or send us an email to PTHPPharmacy@aultcare.com

Request for Redetermination of Medicare Prescription Drug Coverage Denial

Complete the Request for Redetermination of Medicare Prescription Drug Coverage Form to request a redetermination (appeal) of a coverage determination decision. To initiate requests by phone, please contact our service center or send us an email to PTHPAppeals@aultcare.com

Appointment of Representative

If you choose a friend, relative, provider, or other person to be your representative, please complete and return this form. It must be signed by you and the representative acting on your behalf. You must give us a copy of the signed form.

Other Resources

PrimeTime cares about our member satisfaction. Please contact us (link to contact info above) so we can help. You can also submit a complaint directly to Medicare if you’d like by completing the Medicare Complaint Form.   You can also call 1-800- MEDICARE. The office of the Medicare Ombudsman (OMO) helps you with complaints, grievances, and information requests. Visit their site here.

2023 LIS Premium Summary Table

As a member of our Plan, you pay a monthly premium. If you qualify for Extra Help from Medicare, called the Low Income Subsidy, or LIS you may not have to pay for all or part of the monthly premium. The PrimeTime Health Plan premiums that are listed are for both medical and prescription coverage.

The premiums that are listed on this website do not reflect additional premiums you may have to pay as a member of Medicare. The Part B premium is in addition to the PrimeTime Health Plan premium that is listed. You may have to pay a late enrollment penalty (LEP) if you did not meet the requirements. Please refer to any of our Evidence of Coverage's to review this information in Chapter 1, Sections 4-7.

There is also a Medicare Part A premium that may have to be paid. (Generally, most people do not have to pay this premium.)

The Low Income Subsidy Chart will tell you by plan what your premium will generally be if you qualify for Extra Help from Medicare.

To inquire with the Social Security Administration on the status or level of your LIS benefits, you may contact them calling 1-800-772-1213 (TTY users should call 1-800-325-0778).

Language Services - Updated 7/19/2022

Language Services

English: ATTENTION:
If you speak English, language assistance services, free of charge, are available to you. Call 1-800-577-5084 (TTY 711).

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注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致 電1-800-577-5084 (TTY 711).

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ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-577-5084 (TTY 711).

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Wann du [Deitsch (Pennsylvania German / Dutch)]:
schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 1-800-577-5084 (TTY: 711).

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Français (French):
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Tiếng Việt (Vietnamese):
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Oroomiffa (Chushite-Oromo):
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Italiano (Italian):
ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-577-5084 (TTY: 711).

日本語 (Japanese):
注意事項：日本語を話される場合、無料の言語支援をご利用いただ けます。1-800-577-5084 (TTY 711).まで、お電話にてご連絡ください。

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Română (Romanian):
ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-800-577-5084 (TTY: 711).

Non-discrimination Notice

PrimeTime Health Plan complies with applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, or sex. PrimeTime Health
Plan does not exclude people or treat them differently because of race, color, national origin, age,
disability, or sex. PrimeTime Health Plan provides free aids and services to people with
disabilities to communicate effectively with us, such as: Qualified sign language interpreters and
written information in other formats (large print, audio, accessible electronic formats, other
formats). PrimeTime Health Plan provides free language services to people whose primary
language is not English, such as: Qualified interpreters and information written in other
languages.

If you need these services, or if you believe that PrimeTime Health Plan has failed to provide
these services or discriminated in another way on the basis of race, color, national origin, age,
disability, or sex, you can contact or file a grievance with the: PrimeTime Health Plan Civil
Rights Coordinator, 2600 6th St. S.W. Canton, OH 44710, 330-363-7456,
CivilRightsCoordinator@aultcare.com You can file a grievance in person or by mail, fax, or
email. If you need help filing a grievance, our Civil Rights staff is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human
Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint
Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S.
Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH
Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html

PRIMETIME HEALTH PLANS—NOTICE OF PRIVACY PRACTICES YOUR INFORMATION. YOUR RIGHTS. OUR RESPONSIBILITIES.

This Notice of Privacy Practices (NPP) describes how medical and claims information about you may be used and disclosed, how you can get access to your information, and your rights under HIPAA. Please review this NPP carefully. Feel free to share it with your family or personal representative.

Introduction
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AultCare Insurance Company (dba AultCare HMO), which is part of an Organized Health Care Arrangement with AultCare Corporation, AultCare Health Insuring Corporation dba PrimeTime Health Plan, and Aultra Administrative Group (AultCare or We) is a Group Health Plan Covered Entity under HIPAA.

We’re committed to safeguarding the Privacy and Security of Protected Health Information of its enrollees and their eligible dependents (you) in paper (PHI) or electronic form (ePHI).

This NPP describes our HIPAA-compliant policies and procedures for the Use and Disclosure of your PHI/ePHI, including the use of PHI/ePHI for eligibility, enrollment, underwriting, claims processing, coordination of benefits, and payment of treatment under your group health plan in compliance with HIPAA’s Privacy and Security Rules (updated by the Omnibus Rule of 2013), the HITECH Act, and the Genetic Information Nondiscrimination Act (GINA).

You may access this NPP on our website www.primetimehealthplan.com. If you do not have a computer or internet access, or if you want a paper copy of this NPP, please call our Service Center at 330-363-7407 or 1-800-577-5084.

Not every use or disclosure of PHI, with or without a signed Authorization, is listed in this NPP. Uses or disclosures not specified in this NPP often require an Authorization. Please contact our Privacy Officer if you have a question, concern, or need further guidance.

Terms

Accounting: An Accounting is a list of disclosures of your PHI/ePHI we have made.

Authorization: An Authorization is a document signed and dated by the individual who authorizes the use or disclosure of PHI/ePHI for purposes other than treatment, payment, or healthcare operations.

Business Associates: We contract with outside business associates that may access, use, or disclose PHI/ePHI to perform covered services for us. Examples include auditing, accounting, accreditation, actuarial services, and legal services. Business associates must protect the privacy and security of your PHI/ePHI to the same extent we do. If a business associate delegates services to a subcontractor or agent, that subcontractor or agent also is a business associate that must comply with HIPAA.

Covered Entities: Covered entities include health care providers ( e.g . hospitals, doctors, nurses, nursing homes, home health agencies, durable medical equipment suppliers, other health care professionals and suppliers), and group health plans. AultCare is a group health plan covered entity.

Designated Record Set: A designated record set is a group of records containing PHI in paper or electronic form that we created and store. A designated record set include medical, healthcare and service records, billing, claims and payment information, eligibility and enrollment information, and other information we use to make decisions regarding the coverage and payment of medical care under your plan. Records created by others are not part of a designated record set.

Disclose: Disclose means our releasing, transferring, providing access to, or divulging PHI/ePHI to a third party, including covered entities and their business associates: (1) for treatment, payment, and health care operations; or (2) when you permit us by your signed authorization; or (3) as required by law.

Genetic Information: Genetic information includes genetic testing of the individual or family members.

Health Plan: Health plan means an individual or group health plan that provides, or pays the cost of, medical care and includes a health insurance issuer, HMO, Part A or B of Medicare, Medicaid, voluntary prescription drug benefit program, issuer of Medicare supplemental policy, issuer or a long-term care policy, employee welfare benefit plan, plan for uniformed services, veterans health care program, CHAMPUS, Indian health service program, federal employee health benefit program, Medicare Advantage plan, approved state child health plan, high risk pool, and any other individual or group health plans or combination that provides or pays for the cost of medical care. AultCare is a group health plan.

Health Care Operations: Health care operations include quality assurance, performance improvement, utilization review, accreditation, licensing, legal compliance, provider/supplier credentialing, peer review, business management, auditing, enrollment, underwriting, stop-loss/reinsurance, and other functions related to your health plan, as well as offering and providing preventive, wellness, case management, and related services.

Individual: Individual means the enrollee or eligible dependent (including minors) to whom PHI belongs. It also applies to your family member or personal representative acting on your behalf.

Minimum Necessary: We will limit the use or disclosure of your PHI/ePHI to the minimum needed to accomplish the intended purpose of the use, disclosure, or request.

Payment: Payment means the activities by a group health plan to obtain premiums or to determine or fulfill its responsibility for coverage and the provisions of benefits under your plan and includes eligibility or coverage determination, coordination of benefits, adjudication and subrogation of health benefit claims, billing, claims management, EOBs, health care data processing, reinsurance (including stop-loss and excess), determination of medical necessity, utilization review (including pre-certification and retrospective review), and related activities.

Personal Representative: Personal Representative means a person acting on behalf of the individual, including family, spouse, guardian, attorney-in-fact under a durable or general power of attorney, or friend assisting the individual with healthcare and payment decisions.

Protected Health Information (PHI/ePHI): PHI/ePHI means individually identifiable medical and health information regarding your medical condition, treatment of your medical condition, and payment of your medical condition, and includes oral, written, and electronically generated and stored information. PHI/ePHI excludes de-identified information or health information regarding a person who has been deceased for more than 50 years.

Treatment : Treatment means the provision, coordination, and management of health care and services by one or more health care providers, including referrals and consultations between providers or suppliers.

Use: Use means our accessing, sharing, employing, applying, utilizing, examining, or analyzing your PHI/ePHI within the AultCare organization for payment and health care operation purposes. Your PHI/ePHI is accessible only to members of AultCare’s workforce who have been trained in HIPAA Privacy and have signed a confidentiality agreement that limits their access and use of PHI/ePHI, according to the minimum necessary standard, to perform the authorized purpose.

Wellness Program: Wellness Program means a program that an employer has adopted to promote health and disease prevention, which is offered to employees as part of an employer-sponsored group health plan or separately as a benefit of employment.

Your Rights

When it comes to your health information, you have certain rights. This section explains some of your rights and our responsibilities.

You may get a copy or summary of your health and claims records:

• You may ask to see or get a copy of your health and claims records and PHI kept in a designated record set. Please call the Service Center to ask how to do this. There are some restrictions.

• We will get you a paper copy or electronic version of your health and claims records, or give you a summary, usually within 30 days of your request. We may charge reasonable, cost-based fees.

You may ask us to correct your health and claims records:

• You may ask us in writing to correct your health and claims records in a designated records set if you believe they are incorrect, inaccurate, or incomplete. Please call the Service Center or visit our website to get an amendment request form.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

• You will have an opportunity to appeal.

You may request confidential communications of communications by alternative means:

• You may ask us to contact you about claims, premiums, EOBs, or other matters about your health plan and coverage in a specific way, such as home phone, office phone, or cell phone, or by alternate means, such as an address different from your home or usual email address.

• Let us know if you do not want us to leave any voice mail message.

•Contact the Service Center to request. We will consider all reasonable requests.

You may ask us to limit (restrict) what we use or disclose:

• You may ask us in writing not to use or disclose certain health information for treatment, payment, or operations. We may honor your request if you pay for treatment in full out-of-pocket.

• Please call the Service Center for a restriction request form or visit our website.

• While we will consider reasonable requests, we are not required to agree to your request. We may say “no” if restricting information could affect your care or if disclosure is required by law.

You may request a list (“Accounting”) of those to whom we’ve disclosed PHI/ePHI:

• You may ask in writing for a list of disclosures of your PHI/ePHI (Accounting) for the six years prior to your request.

• We will include all disclosures except for those about treatment, payment, and health care operations, and disclosures made to you or you authorized us to make. We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

You may get a copy of this NPP:

• You may ask for a paper copy of this NPP at any time, even if you have agreed to receive this NPP electronically. We will provide you with a paper copy promptly.

• You may access electronic copy of this NPP on our website at any time.

You may choose someone to act for you:

• You may choose a family member or personal representative to receive PHI/ePHI from us, exercise your rights, and make choices for you.
• We will use reasonable efforts to confirm that the person is authorized to act on your behalf before we take any action.

You may file a complaint if you believe your rights have been violated:

• If you believe your privacy or your HIPAA rights have been violated, we urge you to contact our privacy officer, either by calling the Service Center or filing a written complaint at AultCare, P.O. Box 6029, Canton, OH 44706.

• We take all complaints very seriously. We will investigate and take appropriate action if needed.You also may file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting https://www.hhs.gov/hipaa/filing-a-complaint/index.html

• We will never retaliate against you for filing a complaint, asking a question, or expressing a concern.

Communicating with You

This section describes how we may communicate with you, family members, or your personal representative.

Communicating with You:

We may communicate with you about claims, premiums, or other things regarding your health plan.

Communicating with Family or Others Involved In Your Care:  

• We may disclose your PHI/ePHI to designated family, friends, guardians, persons named in a durable or general power of attorney, personal representatives, or others assisting in your care or payment of claims.

Minors and Emancipated Minors:

• We may disclose a minor’s PHI/ePHI to the minor’s parent(s) or guardian, unless there are legal or policy reasons not to.
• We will not disclose PHI/ePHI to the parent(s) or guardian of an emancipated minor. A minor is emancipated if he/she: (1) does not live with his/her parent(s); (2) is not covered by parental health insurance; (3) is financially independent of parent(s); (4) is married; (5) has children; or (6) is in the military.

Deceased Enrollees:  

• If you die, we may disclose your PHI to the executor or administrator of your estate.

• We may disclose PHI/ePHI to your spouse, family, personal representative, or others who were involved in your care or management of your affairs, unless doing so would be inconsistent with your wishes made known to us.

Uses and Disclosures

This section describes how we typically use or disclose your PHI/ePHI with and without an Authorization.

No Authorization Needed:  

• We will create, receive, or access your PHI/ePHI, which we may use or disclose to other covered entities for treatment, payment, and health care operations, without the need for you to sign an Authorization.

• We will disclose PHI/ePHI needed to treat or authorize treatment. For example, a doctor or health facility involved in your care may request your PHI/ePHI to make treatment decisions covered by the plan.

• We will use or disclose your PHI needed for payment. For example, we will use information about your medical procedures and treatment to process and pay claims, to determine whether services are medically necessary, and to pre-authorize or certify services covered by your health plan.

• We may disclose PHI/ePHI to governmental or commercial health plans that may be obligated under coordination of benefit rules to process and pay your claims.

• We will use and disclose your PHI/ePHI as necessary or required by law to administer your plan and for our health care operations. For example, we may use or disclose PHI/ePHI for underwriting purposes.

• We will not use or disclose genetic information for underwriting purposes.

• We may disclose PHI/ePHI to business associates to perform covered services. It is not necessary for you to sign an Authorization for us to share PHI/ePHI with our business associates for covered services.

Authorization Needed:
We will not use or disclose your PHI/ePHI for any purpose other than treatment, payment, or healthcare operations without your signed HIPAA-compliant Authorization, unless required by law.

• We will not disclose psychotherapy notes without a signed Authorization unless required by law.We will not disclose your PHI/ePHI to your employer without your signed Authorization.

• We may disclose PHI/ePHI to the plan sponsor of your health benefit plan on condition that the plan sponsor certifies that it will maintain the confidentiality of PHI/ePHI and will not use PHI to make employment-related decisions or employee benefit determinations.

• We will not release medical records if subpoenaed, unless you sign an Authorization, or the lawyers sign a qualified protective order, or if we receive a valid court or administrative order.

You may choose to receive information about health-related products or services or fundraising:

• We may use your PHI/ePHI if we believe you may be interested in, or benefit from, treatment alternatives, wellness, preventive, disease management, or health-related programs, products or services that may be available to you as an enrollee or eligible beneficiary under your health plan. For example, we may use your PHI/ePHI to identify whether you have a particular illness, and contact you to let you know about a disease management program is available to help manage your illness.

• Let us know if you do not want to be contacted or receive information about these services and programs. Opting out will not affect coverage or services.

• We will not sell or disclose your PHI/ePHI to third-parties for marketing without your Authorization, which will indicate whether we are paid for selling PHI.

• We may contact you about charitable fundraising. If you do not want to be contacted or receive fundraising materials, let our Service Center know. Opting out will not affect coverage or services.

Wellness Programs:

• If you voluntarily choose to participate in a Wellness Program, you may be asked to answer questions on a health risk assessment (HRA) and/or undergo biometric screenings for risk factors.

• Wellness Programs may also provide educational health-related information or services that may include nutrition classes, weight loss and smoking cessation programs, onsite exercise facilities, and/or health coaching to help employees meet their health goals.

• If your employer has entered or may enter into a contract with us to perform services, as well as receive, collect, use, disclose, and store data in connection with a Wellness Program. We will protect the privacy of your PHI.

Use and Disclosure of Health Information Permitted or Required by Law  

We may use or disclose PHI/ePHI, without your Authorization, as required by law, including, but not limited to:

• Workers’ Compensation
• Public health agencies
• FDA and OSHA
• Ohio Department of Insurance and other regulatory and licensing agencies
• Armed Forces to assist in notifying family members of your location, general condition, or death
• Law Enforcement
• Homeland security
• Emergency and disaster
• Prevent threat of serious harm
• Proof of immunization

Breach Notification

• You have the right to notification if a breach of your PHI/ePHI occurs. We will promptly notify you by first-class mail, at your last known address, or by email (if you prefer) if we discover a breach of unsecured PHI/ePHI, which includes the unauthorized acquisition, access, use, or disclosure of your PHI/ePHI, unless we determine through a risk analysis that a low probability exists that the compromise of your PHI would cause you financial, reputational, or other harm.
• We will include in the breach notification a brief description of what happened, a description of the types of unsecured PHI involved, steps you should take to protect yourself from potential harm, a brief description of what we are doing to investigate the breach and mitigate any potential harm, as well as contact information for you to ask questions and learn additional information.

Changes to this NPP

This section describes how and when we may changes NPP and how we will inform you of any material changes.

• We reserve the right to change this NPP at any time, which we may make effective for PHI/ePHI we already used or disclosed, and for any PHI/ePHI we may create, receive, use, or disclose in the future.

• We will make material amendments based on changes in the HIPAA laws.

• The revised NPP will be posted on our website www.pthp.com. Copies of revised NPPs will be mailed to all enrollees covered by the plan, and copies may be obtained by mailing a request to: Privacy Coordinator, P.O. Box 6029, Canton, Ohio 44706.

If you have questions or need further assistance regarding this Notice, you may contact the Service Center at 330-363-7407 or 1-800-577-5084. For people who are hearing impaired, please call our TTY line at 711. Interpreter services are provided free of charge to you. A customer service representative is available to assist you Monday through Friday from 8 a.m. to 8 p.m. (October 1st-March 31st, we are available 7 days a week, 8 a.m. to 8 p.m.). If you would like to meet with a customer service representative in person, you can visit us during our office hours Monday through Friday from 8:00 a.m. to 4:30 p.m. As a member you retain the right to obtain a paper copy of this Notice of Privacy Practices, even if you have requested such copy by e-mail or other electronic means.

‍EFFECTIVE DATE

This Notice of Privacy Practices became effective on April 14, 2003.

Last Approved Date: 8/21/2020

Reviewed: 07/31/06, 09/25/06, 04/06/07, 02/15/12, 6/15/12 (name change),9/18/13, 9/3/14, 9/10/15; 5/24/16, 7/31/16
Revised: 07/31/06, 09/25/06, 04/06/07, 02/15/12, 6/15/12 (name change), 7/17/13; 5/24/16, 8/1/16, 1/13/2017

Approved 9/3/14; 7/31/16 in Privacy Committee. MK, KKT

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2024 Medication Therapy Management MTM

2024 Part D Prescription Drug Coverage Information

Please send PTHP an itemized statement and proof of payment for possible reimbursement.  You can mail it to PO Box 6905, Canton, Ohio 44706, fax it to 330-363-7714, or drop it off in the lock box in front of the Morrow House.  You have 12 months from the date of service to submit for possible reimbursement.