introduction to the reassignment notice: plan … to the reassignment notice: plan termination...

Introduction to the Reassignment Notice: Plan Termination Version

What’s the purpose of this notice? This notice informs people who qualify for Extra Help and whose Medicare Drug Plan is leaving the Medicare Program that they’ll be reassigned to a new Medicare drug plan if they don’t join a plan on their own by December 31. The notice includes two pages. The first page is a notice printed on the front and back of blue paper. The second page includes a list of plans for each region that have premiums at or below the low-income premium subsidy amount. Who gets this notice? Medicare will reassign all people who qualify for Extra Help whose Medicare Drug Plan is terminating on December 31. When do people get this notice? The notice will be mailed by late October. What should people do next? People should consider their options carefully. People who want more information about Medicare prescription drug coverage can:

• Visit Medicare.gov and get personalized drug plan information. • Call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. • Call their State Health Insurance Assistance Program (SHIP) for free, personalized health

insurance counseling. People should visit Medicare.gov/contacts, read the “Medicare & You” handbook, or call 1-800-MEDICARE for the phone number for their state.

People can reference CMS Product No. 11208 when calling Medicare or their SHIP with questions about this notice.

CMS Product No. 11208 - BLUE October 2017

<BENEFICIARY FULL NAME> <file creation date> <ADDRESS> <CITY STATE ZIP>

Medicare is moving you to a new drug plan for 2018 You’re getting this notice because <Old Organization Marketing Name>’s <Old Plan Name> (<old contract>/<old PBP>) is leaving the Medicare Program on December 31, 2017, and will no longer provide your prescription drug coverage. Because your plan is leaving, Medicare is moving you to a new drug plan to make sure you have drug coverage in 2018. You have 2 options: Option 1: If you do nothing, Medicare will enroll you in <New Organization’s Name>’s <New Name of Plan> (<new contract>/<new PBP>). Your coverage starts on January 1, 2018. With this new Medicare drug plan, you’ll pay:

• <subsidy % or $0> of the monthly drug plan premium • <$0 or up to $83> of the yearly drug plan deductible • <insert LIS copayment amounts or % of the cost of each prescription> for each

prescription covered by the plan filled at one of the plan’s pharmacies Visit <Plan Website>, or call <New Plan Name> at <New Plan Phone> for more information about this Medicare drug plan. In December, Medicare will send you another blue letter letting you know which of the drugs you take will be covered in this plan. This plan serves <States>. If this isn’t where you live, call <New Plan Name> to make sure it serves where you live now. If it doesn’t, call 1-800-MEDICARE (1-800-633-4227) to choose and join a plan that serves the state where you live. TTY users can call 1-877-486-2048.

Option 2: You qualify for Extra Help, so you can join a different Medicare drug plan anytime. If you don’t want Medicare to enroll you in this plan, you should join a different plan before December 31, 2017. A different Medicare drug plan may cover more of your drugs. To switch to a different Medicare drug plan, see the list of plans included with this notice. You can join any plan in this list and pay <subsidy % or $0> premium and <insert LIS copayment amounts > for each prescription. Since you qualify for Extra Help, you can switch Medicare drug plans anytime. Your new coverage would start the next month.

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, MD 21244-1850


If you want to join a different Medicare drug plan If you join a new plan, it’s a good idea to do it as early as possible before December 31, 2017. Enrolling early in the month gives your new Medicare drug plan time to mail your membership materials before your new coverage becomes effective. This way, even if you go to the pharmacy on January 1, you can get your prescriptions filled without any problems. If you want to join a new Medicare drug plan, call the new plan to find out how to join. Joining a new plan will automatically disenroll you from your current plan. You don’t need to call your current plan to disenroll. Get help & more information Consider your options carefully. For help understanding this notice, show it to a family member, case manager, or someone else you trust. You can also call your local Office on Aging or your <Local SHIP Name> at <SHIP Phone Number> for free, personalized health insurance counseling, or call 1-800-MEDICARE (1-800-633-4227) for help. TTY users can call 1-877-486-2048. For free help in another language, say “Agent” at any time to talk to a customer service representative.


Nondiscrimination Notice - The Centers for Medicare & Medicaid Services (CMS) doesn’t exclude, deny benefits to, or otherwise discriminate against any person on the basis of race, color, national origin, disability, sex, or age. If you think you’ve been discriminated against or treated unfairly for any of these reasons, you can file a complaint with the Department of Health and Human Services, Office for Civil Rights by:

• Calling 1-800-368-1019. TTY users can call 1-800-537-7697. • Visiting hhs.gov/ocr/civilrights/complaints. • Writing: Office for Civil Rights, U.S. Department of Health and Human Services, 200

Independence Avenue SW, Room 509F, HHH Building, Washington, D.C. 20201 Notice of Availability of Auxiliary Aids & Services - We’re committed to making our programs, benefits, services, facilities, information, and technology accessible in accordance with Sections 504 and 508 of the Rehabilitation Act of 1973. We’ll take appropriate steps to make sure that people with disabilities, including people who are deaf, hard of hearing or blind, or who have low vision or other sensory limitations, have an equal opportunity to participate in our services, activities, programs, and other benefits. We provide various auxiliary aids and services to communicate with people with disabilities, including:

• Relay service — TTY users can call 1-877-486-2048. • Alternate formats — This notice is available in alternate formats, including large print,

Braille, data CD and audio CD. To request your notice in an alternate format, call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Aviso sobre la discriminación - Los Centros de Servicios de Medicare y Medicaid (CMS) no excluye, niega beneficios o discrimina contra ninguna persona por motivos de raza, color, origen nacional, incapacidad, género o edad. Si cree que ha sido discriminado o tratado injustamente por cualquiera de estos motivos, puede presentar una queja ante el Departamento de Salud y Servicios Humanos, Oficina de Derechos Civiles:

• Llamando al 1-800-368-1019. Los usuarios de TTY pueden llamar al 1-800-537-7697. • Visitando hhs.gov/ocr/civilrights/complaints. • Escribiendo a la: Oficina de Derechos Civiles del Departamento de Salud y Servicios

Humanos 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

Ayuda y servicios auxiliares para personas con incapacidades - Medicare está dedicado a ofrecerles a todos sus beneficiarios los programas, beneficios, servicios, dependencias, información y su tecnología, en cumplimiento con las Secciones 504 y 508 de la Ley de Rehabilitación del 1973. Medicare tomará las medidas necesarias para asegurarse de que las personas incapacitadas, entre los que se incluyen los que tiene problemas auditivos, son sordos, ciegos, tienen problemas visuales u otro tipo de limitaciones, tengan las mismas oportunidades de participar y aprovechar los programas y beneficios disponibles. Medicare ofrece varios servicios y ayuda para facilitar la comunicación con las personas incapacitadas incluyendo:

• Servicios de retransmisión de mensajes — Los usuarios de TTY pueden llamar al 1-877-486-2048.

• Formatos alternativos — Los productos de Medicare, incluyendo este documento, están disponible en letra grande, versión digital, Braille y audio. Para ordenar su aviso en un formato alternativo, llame al 1-800-MEDICARE (1-800-633-4227). Los usuarios de TTY


pueden llamar al 1-877-486-2048. _____________________________________________________________________________________________ ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-800-MEDICARE (TTY: 1-877-486-2048).

(Arabic) ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل ةيبرعلا ).1-2048-486-877(رقم ھاتف الصم والبكم: MEDICARE-800-1برق

հայերեն (Armenian) ՈՒՇԱԴՐՈՒԹՅՈՒՆ՝ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք 1-800-MEDICARE (TTY (հեռատիպ)՝ 1-877-486-2048) 繁體中文 (Chinese) 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-MEDICARE（TTY： 1 -877-486-2048）。

شما فراھم می باشد. با : اگر بھ زبان فارسی گفتگو می کنید، تسھیالت زبانی بصورت رایگان برایتوجھ (Farsi) فارسی1-800-MEDICARE (TTY: 1-877-486-2048) .تماس بگیرید

Français (French) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-MEDICARE (ATS : 1-877-486-2048). Kreyòl Ayisyen (French Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-MEDICARE (TTY: 1-877-486-2048). Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-MEDICARE (TTY: 1-877-486-2048). Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-MEDICARE (TTY: 1-877-486-2048). 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-MEDICARE（TTY:1-877-486-2048）まで、お電話にてご連絡ください。 한국어(Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-MEDICARE (TTY: 1-877-486-2048) 번으로 전화해 주십시오. Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-MEDICARE (TTY: 1-877-486-2048). Português (Portuguese) ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-MEDICARE (TTY: 1-877-486-2048). Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-MEDICARE (телетайп: 1-877-486-2048).


Español (Spanish) ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-MEDICARE (TTY: 1-877-486-2048). Tagalog (Tagalog) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-MEDICARE (TTY: 1-877-486-2048). Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-MEDICARE (TTY: 1-877-486-2048).

CMS Product No. 11208 October 2017

Medicare drug plans in Maine & New Hampshire You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:

• If the plan covers the drugs you take. • What special drug coverage rules may affect your prescriptions (like prior

authorization, which means the plan won’t cover a specific drug unless the plan approves it first).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. For free help in another language, say “Agent” at any time to talk to a customer service representative. You can also call your «Local SHIP Name» for free, personalized health insurance counseling at 1-877-353-3771 (Maine) or 1-866-634-9412 (New Hampshire). If you join a Medicare drug plan that isn’t listed above, you may have to pay a higher monthly premium. Be sure to ask about the premium when you’re comparing plans.

http://www.medicare.gov/


Medicare drug plans in Connecticut, Massachusetts, Rhode Island & Vermont You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:




Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. For free help in another language, say “Agent” at any time to talk to a customer service representative. You can also call your «Local SHIP Name» for free, personalized health insurance counseling at the number listed on the other side of this page. If you join a Medicare drug plan that isn’t listed above, you may have to pay a higher monthly premium. Be sure to ask about the premium when you’re comparing plans.



Medicare drug plans in New York You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:




Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. For free help in another language, say “Agent” at any time to talk to a customer service representative. You can also call your «Local SHIP Name» for free, personalized health insurance counseling at 1-800-701-0501. If you join a Medicare drug plan that isn’t listed above, you may have to pay a higher monthly premium. Be sure to ask about the premium when you’re comparing plans.



Medicare drug plans in New Jersey You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:







Medicare drug plans in Delaware, District of Columbia & Maryland You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:







Medicare drug plans in Pennsylvania & West Virginia You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:




Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. For free help in another language, say “Agent” at any time to talk to a customer service representative. You can also call your «Local SHIP Name» for free, personalized health insurance counseling at 1-800-783-7067 (Pennsylvania) or 1-877-987-4463 (West Virginia). If you join a Medicare drug plan that isn’t listed above, you may have to pay a higher monthly premium. Be sure to ask about the premium when you’re comparing plans.



Medicare drug plans in Virginia You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:







Medicare drug plans in North Carolina You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:







Medicare drug plans in South Carolina You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:







Medicare drug plans in Georgia You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:







Medicare drug plans in Florida You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:







Medicare drug plans in Alabama & Tennessee You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:




Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. For free help in another language, say “Agent” at any time to talk to a customer service representative. You can also call your «Local SHIP Name» for free, personalized health insurance counseling at 1-800-243-5463 (Alabama) or 1-877-801-0044 (Tennessee). If you join a Medicare drug plan that isn’t listed above, you may have to pay a higher monthly premium. Be sure to ask about the premium when you’re comparing plans.



Medicare drug plans in Michigan You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:







Medicare drug plans in Ohio You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:







Medicare drug plans in Indiana & Kentucky You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:




Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. For free help in another language, say “Agent” at any time to talk to a customer service representative. You can also call your «Local SHIP Name» for free, personalized health insurance counseling at 1-800-452-4800 (Indiana) or 1-877-293-7447 (Kentucky). If you join a Medicare drug plan that isn’t listed above, you may have to pay a higher monthly premium. Be sure to ask about the premium when you’re comparing plans.



Medicare drug plans in Wisconsin You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:







Medicare drug plans in Illinois You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:







Medicare drug plans in Missouri You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:







Medicare drug plans in Arkansas You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:







Medicare drug plans in Mississippi You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:







Medicare drug plans in Louisiana You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:







Medicare drug plans in Texas You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:







Medicare drug plans in Oklahoma You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:







Medicare drug plans in Kansas You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:







Medicare drug plans in Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota & Wyoming You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:







Medicare drug plans in New Mexico You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:







Medicare drug plans in Colorado You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:







Medicare drug plans in Arizona You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:







Medicare drug plans in Nevada You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:







Medicare drug plans in Oregon & Washington You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:




Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. For free help in another language, say “Agent” at any time to talk to a customer service representative. You can also call your «Local SHIP Name» for free, personalized health insurance counseling at 1-800-722-4134 (Oregon) or 1-800-562-6900 (Washington). If you join a Medicare drug plan that isn’t listed above, you may have to pay a higher monthly premium. Be sure to ask about the premium when you’re comparing plans.



Medicare drug plans in Idaho & Utah You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:




Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. For free help in another language, say “Agent” at any time to talk to a customer service representative. You can also call your «Local SHIP Name» for free, personalized health insurance counseling at 1-800-247-4422 (Idaho) or 1-800-541-7735 (Utah). If you join a Medicare drug plan that isn’t listed above, you may have to pay a higher monthly premium. Be sure to ask about the premium when you’re comparing plans.



Medicare drug plans in California You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:







Medicare drug plans in Hawaii You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:







Medicare drug plans in Alaska You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. If you don’t want Medicare to enroll you in a plan, join one of these other plans by December 31. Compare the plans and join one that works for you. You should ask:






introduction to the reassignment notice: plan … to the reassignment notice: plan termination...

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