Medicare Plans Information

Friday Health Plans of Colorado’s Medicare Cost Plans are offered in 29 of the most rural and under-served counties in Colorado including:

Alamosa, Archuleta, Baca, Bent, Chaffee, Cheyenne, Conejos, Costilla, Crowley, Custer, Elbert, Fremont, Huerfano, Kiowa, Kit Carson, La Plata, Las Animas, Lincoln, Logan, Mineral, Morgan, Otero, Phillips, Prowers, Rio Grande, Saguache, Sedgwick, Washington, and Yuma Counties.

2020 Enrollment

If you are interested in applying for a plan for 2020, please download and submit the application form.

If you reside in Alamosa, Conejos, Costilla, Mineral, Rio Grande, or Saguache County:

If you reside in Archuleta, Baca, Bent, Chaffee, Cheyenne, Crowley, Custer, Elbert, Fremont, Huerfano, Kiowa, Kit Carson, La Plata, Las Animas, Lincoln, Logan, Morgan, Otero, Phillips, Prowers, Sedgwick, Washington or Yuma County:

2019 Enrollment

To apply for a plan to begin in 2019, please download and submit the application form.

If you reside in Alamosa, Conejos, Costilla, Mineral, Rio Grande, or Saguache County:

If you reside in Bent, Chaffee, Crowley, Custer, Fremont, Huerfano, Las Animas, Otero, Phillips, Prowers, or Yuma County:

To view the detailed information for contract year 2020, please view the documents and information below.

This information provides comprehensive benefit information and explains covered & non-covered benefits, what to do if you are unhappy with our services and other detailed plan information.

The following information pertains to you, if you live in Alamosa, Conejos, Costilla, Mineral, Rio Grande, and/or Saguache Counties:

Compare Benefits

2020 Medicare Plans

 

This list is not all-inclusive. For a complete list of cost-sharing, including any conditions and limitations please refer to the Evidence of Coverage.

*You must continue to pay your Medicare Part B premium. Benefits, premium and/or copayments/coinsurance may change each year on January 1. Benefits may be subject

to copayments, limitations and/or restrictions. See the Evidence of Coverage or contact Customer Service for details.

2020 Summaries

Click the Summary of Benefits link below for an overview and comparison of our plans and benefits for our service area which includes Alamosa, Conejos, Costilla, Mineral, Rio Grande, and/or Saguache Counties:

***PLAN RATINGS

Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.

Annual Notice of Change (ANOC)/Evidence of Coverage (EOC)

2020 Annual Notice of Change (ANOC)

2020 Evidences of Coverage (EOC)

The following information pertains to you, if you live in Baca, Bent, Chaffee, Cheyenne, Crowley, Custer, Elbert, Fremont, Huerfano, Kiowa, Kit Carson, La Plata, Las Animas, Lincoln Logan, Morgan, Otero, Phillips, Prowers, Sedgwick, Washington and/or Yuma Counties:

This list is not all-inclusive. For a complete list of cost-sharing, including any conditions and limitations please refer to the Evidence of Coverage.

*You must continue to pay your Medicare Part B premium. Benefits, premium and/or copayments/coinsurance may change each year on January 1. Benefits may be subject to copayments, limitations, and/or restrictions. See the Evidence of Coverage or contact Customer Service for details.

Annual Notice of Change (ANOC)/Evidence of Coverage (EOC)

2020 Annual Notice of Change (ANOC)

2020 Evidences of Coverage (EOC)

Ready to Enroll

Now that you’ve selected the plan that’s right for you, it’s easy for your to enroll!

All you have to do is download an Application at the Getting Started page, complete it, sign it, and mail it to us at:

Friday Health Plans
Attn: Enrollment – Medicare
700 Main Street, Suite 100
Alamosa, CO 81101

It’s that simple.

To view the detailed information for contract year 2019, please view the documents and information below.

This information provides comprehensive benefit information and explains covered & non-covered benefits, what to do if you are unhappy with our services and other detailed plan information.

The following information pertains to you, if you live in Alamosa, Conejos, Costilla, Mineral, Rio Grande, and/or Saguache Counties:

Compare Benefits

2019 Medicare Plans

 

This list is not all–inclusive. For a complete list of cost-sharing, including any conditions and limitations please refer to the Evidence of Coverage.

*You must continue to pay your Medicare Part B premium. Benefits, premium and/or copayments/coinsurance may change each year on January 1. Benefits may be subject

to copayments, limitations and/or restrictions. See the Evidence of Coverage or contact Customer Service for details.

2019 Summaries

Click the Summary of Benefits link below for an overview and comparison of our plans and benefits for our service area which includes Alamosa, Conejos, Costilla, Mineral, Rio Grande and/or Saguache Counties:

***PLAN RATINGS

Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.

Annual Notice of Change (ANOC)/Evidence of Coverage (EOC)

2019 Annual Notice of Change (ANOC)

2019 Evidences of Coverage (EOC)

The following information pertains to you, if you live in Bent, Chaffee, Crowley, Custer, Fremont, Huerfano, Las Animas, Otero, Prowers, and/or Yuma Counties:

 

This list is not all-inclusive. For a complete list of cost-sharing, including any conditions and limitations please refer to the Evidence of Coverage.

*You must continue to pay your Medicare Part B premium. Benefits, premium and/or copayments/coinsurance may change each year on January 1. Benefits may be subject to copayments, limitations and/or restrictions. See the Evidence of Coverage or contact Customer Service for details.

 

Annual Notice of Change (ANOC)/Evidence of Coverage (EOC)

2019 Annual Notice of Change (ANOC

2019 Evidences of Coverage (EOC)

Ready to Enroll

Now that you’ve selected the plan that’s right for you, it’s easy for your to enroll!

All you have to do is download an Application at the Getting Started page, complete it, sign it, and mail it to us at:

Friday Health Plans
Attn: Enrollment – Medicare
700 Main Street, Suite 100
Alamosa, CO 81101

It’s that simple.

As a member of our plan, you will have access to our network of physicians, hospitals and other healthcare professionals. You may see any doctor without getting a referral or preauthorization. However, some procedures, services and any in-patient admissions do require preauthorization. Please read your Evidence of Coverage (EOC) for more details.

Cost plan members may get services out-of-network even if the plan in which they are enrolled has a provider network. In such cases, members pay the cost-sharing amounts under Original Medicare. This means that you are still able to go to a doctor outside the Friday Health Plans network for Medicare-Covered services. We may not pay for the service you receive outside of or network, but Medicare will pay for its share of charges it approves. You will be responsible for paying the original Medicare deductible and coinsurance for those services.

When you become a member of Friday Health Plans of Colorado, you must choose a network provider to be your Primary Care Provider (PCP). Your PCP is a health care provider who meets state requirements and is trained to give you basic medical care. Your PCP will provide most of your and will help you arrange or coordinate the rest of the covered services you get as a Member of our plan.

We may make changes to the hospitals, doctors, and specialists (providers) that are part of your plan during the year. There are a number of reasons why your provider might leave your plan but if you doctor or specialist does leave your plan you have certain rights and protections that are summarized below:

  • Even though our network of providers may change during the year. Medicare requires that we furnish you with uninterrupted access to qualified doctors and specialists.
  • We will make a good faith effort to provide you with at least 30 days’ notice that your provider is leaving our plan so that you have time to select a new provider.
  • We will assist you in selecting a new qualified provider to continue managing your health care needs.
  • If you are undergoing medical treatment you have the right to request, and we will work with you to ensure, that the medically necessary treatment you are receiving is not interrupted.
  • If you believe we have not furnished you with a qualified provider to replace your previous provider or that your care is not being appropriately managed you have the right to file an appeal of our decision.
  • If you find out your doctor or specialist is leaving your plan please contact us so we can assist you in finding a new provider and managing your care.

Provider Directory

To view our 2020 network, please click on the link below:

This is a summary of our Grievances, Organization Determinations and Appeals processes:

For step-by-step guidance please refer to the Evidence of Coverage, Chapter 7 What to do if you have a problem or complaint (coverage decisions, appeals, complaints).

DEFINITIONS

Appeal – An appeal is something you do if you disagree with our decision to deny a request for coverage of health care services or prescription drugs or payment for services or drugs you already received. You may also make an appeal if you disagree with our decision to stop services that you are receiving. For example, you may ask for an appeal if we don’t pay for a drug, item, or service you think you should be able to receive.

As defined at 42 CFR §422.561 and §422.560, the procedures that deal with the review of adverse initial determinations made by the plan on health care services or benefits under Part C or D the enrollee believes he or she is entitled to receive, including a delay in providing, arranging for, or approving the health care services or drug coverage (when a delay would adversely affect the health of the enrollee) or on any amounts the enrollee must pay for a service or drug as defined in 42 CFR §422.566(B) and §423.566(b). These appeal procedures include a plan reconsideration or redetermination (also referred to as a level 1 appeal), a reconsideration by an independent review entity (IRE), adjudication by an Administrative Law Judge (ALJ) or attorney adjudicator, review by the Medicare Appeals Council (Council), and judicial review.

Complaint – The formal name for “making a compliant” is “filing a grievance.” The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. See also “Grievance,” in this list of definitions.

Grievance – A type of complaint you make about us, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.

An expression of dissatisfaction with any aspect of the operations, activities or behavior of a plan or its delegated entity in the provision of health care items, services, or prescription drugs, regardless of whether remedial action is requested or can be taken. A grievance does not include, and is distinct from, a dispute of the appeal of an organization determination or coverage determination or an LEP determination.

Independent Review Entity (IRE) – An independent entity contracted by CMS to review adverse level 1 appeal decisions made by the plan. Under Part C, an IRE can review plan dismissals.

Inquiry – Any verbal or written request for information to a plan or its delegated entity that does not express dissatisfaction or invoke a plan’s grievance, coverage or appeals process, such as a routine questions about a benefit.

Organization Determination – An organization determination is any determination (i.e., an approval or denial) made by an MA plan, or its delegated entity with respect to the following:

  • Payment for temporarily out of the area renal dialysis services, emergency services, post-stabilization care, or urgently needed services;
  • Payment for any other health services furnished by a provider (other than the MA plan), that the enrollee believes are covered under Medicare, or if not covered under Medicare, should have been furnished, arranged for, or reimbursed by the MA plan.
  • Refusal to authorize, provide, or pay for services, in whole or in part, including the type or level of services, which the enrollee believes should be furnished or arranged by the MA plan;
  • Reduction, or premature discontinuation, of a previously authorized ongoing course of treatment; or
  • Failure of the MA plan to approve, furnish, arrange for, or provide payment for health care services in a timely manner or to provide timely notice of an adverse determination, such that a delay would adversely affect the health of the enrollee.

The Cost plan has made an organization determination when it makes a decision about whether items or services are covered or how much you have to pay for covered items or services. Organization determinations are called “coverage decisions.”

Quality Improvement Organization (QIO) – A Group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to Medicare patients.

There is a designated Quality Improvement Organization for service Medicare beneficiaries in each State. For Colorado, the Quality Improvement Organization is called KEPRO.

You should contact KEPRO in any of these situations:

  • You have a complaint about the quality of care you have received
  • You think coverage for your hospital stay is ending too soon
  • You think coverage for your home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services are ending too soon

Quality of Care Grievance – A grievance related to whether the quality of covered services provided by a plan or provider meets professionally recognized standards of health care, including whether appropriate health care services have been provided or have been provided in appropriate settings.

Reconsideration – Under Part C, the first level in the appeals process which involves a review of an adverse organization determination by an MA plan, the evidence and findings upon which it was based, and any other evidence submitted by a party to the organization determination, the MA plan or CMS. Under Part D, the second level in the appeals process which involves a review of an adverse coverage determination by an independent review entity (IRE), the evidence and findings upon which it was based, and any other evidence the enrollee submits or the IRE obtains. As used in this guidance, the term may refer to the first level in the Part C appeals process in which the MA plan reviews an adverse Part C organization determination or the second level of appeal in both the Part C and Part D appeals process in which an independent review entity reviews an adverse plan decision

Representative – Individuals who represent enrollees may either be appointed or authorized (for purposes of this guidance, both are referred to as “representatives”) to act on behalf of the enrollee in filing a grievance, requesting an initial determination, or in dealing with any of the levels of the appeals process.

Asking for Coverage decisions

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services. For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from him or her or if your network doctor refers you to a medical specialist. You or your doctor can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think that you need. In other words, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.

We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

How to request coverage for the medical care you want

  • Start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the medical care you want. You, your doctor, or your representative can do this.

Friday Health Plans of Colorado
Attn: Appeals and Grievance Coordinator
700 Main Street, Suite 100
Alamosa, CO 81101
(719) 589-3696 phone
1-800-475-8466 (Toll-free)
1-800-659-2656 (TTY)
719-589-4901 (Fax)

Generally we use the standard deadlines for giving you our decision

When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard coverage decision means we will give you an answer within 14 calendar days after we receive your request for a medical item or service. If your request is for Medicare Part B prescription drug, we will give you an answer within 72 hours after we receive your request.

If your health requires it, ask us to give you a “fast coverage decision”

A fast coverage decision means we will answer within 72 hours if your request is for a medical item or service. If your request is for a Medicare Part B prescription drug, we will answer within 24 hours.

Making an appeal

If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

When you appeal a decision for the first time, this is called a Level 1 Appeal. In this appeal, we review the coverage decision we made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision. Under certain circumstances, which we discuss later, you can request an expedited or “fast coverage decision” or fast appeal of a coverage decision.

If we say no to all or part of your Level 1 Appeal, you can go to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to us. (In some situations, your case will be automatically sent to the independent organization for a Level 2 Appeal. If this happens, we will let you know. In other situations, you will need to ask for a Level 2 Appeal.) If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through additional levels of appeal.

How to make a Level 1 Appeal (how to ask for a review of a medical care coverage decision made by our plan)

You contact us and make your appeal. If your health requires a quick response, you must as for a “fast appeal.”

What to do

  • To start an appeal you, your doctor, or your representative, must contact us.

Friday Health Plans of Colorado
Attn: Appeals and Grievance Coordinator
700 Main Street, Suite 100
Alamosa, CO 81101
(719) 589-3696 phone
1-800-475-8466 (Toll-free)
1-800-659-2656 (TTY)
719-589-4901 (Fax)

  • If you are asking for a standard appeal, make your standard appeal in writing by submitting a request.
  • You must make your appeal request within 60 calendar days.
  • We will consider your appeal and we give you our answer within 30 calendar days for a standard appeal. If your request is for a Medicare Part B prescription drug, we will give you our answer within 7 calendar days after we receive your appeal if your appeal is about

Aggregate Information

To obtain an aggregate number of the Plans’ grievances, appeals, and exceptions filed with the plan sponsor, please call or write to Customer Service.

CALL: 719-589-3696 OR 1-800-475-8466.

TTY/TDD: 1-800-659-2656

FAX: 719-589-4901

WRITE: Friday Health Plans of Colorado, 700 Main Street, Suite 100, Alamosa, Colorado 81101.

You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal.

  • There may be someone who is already legally authorized to act as your representative under State law.
  • If you want a friend, relative, your doctor or other provider, or other person to be your representative, call Member Services and ask for the “Appointment of Representative” form. (The form is also available on Medicare’s website at https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf

The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give us a copy of the signed form.

Or you can download the form here:

You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. These are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision or appeal a decision.

*You must continue to pay your Medicare Part B premium. Benefits, premium and/or copayments/coinsurance may change each year on January 1. Benefits may be subject to copayments, limitations and/or restrictions. See the Evidence of Coverage or contact Customer Service for details.

 

H0657_2019 Website

 

Speak to a Health Plan Expert.

or give us a call at: 800-475-8466
Friday Health Plans is open Monday - Friday 8am - 5pm MST and will respond within 24 hours.