Rights & Protections

As a Medicare beneficiary, you have certain rights to help protect you. You can read more about your rights and responsibilities as a member of Essence Healthcare in the Evidence of Coverage or our Rights and Protections document located on the Documents page click Here. You can also contact Medicare by calling 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week. You can also visit the Medicare web site at www.medicare.gov. Following is a summary of our member’s rights and protections.

All Medicare Advantage plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Advantage plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue in the program, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area.

As an Essence member, you have the right to request an initial organizational determination for medical services or a coverage determination for prescription drugs, which includes the right to request an exception. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact our Customer Service team before you try to fill your prescription at the pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s) or medical service you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network providers that does not involve the coverage of services.

Y0027_18-330 - Last updated 12/20/2018