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Summary of Benefits for Medicare Plan Seven and Ten:
C AND O EMPLOYEES’ HOSPITAL ASSOCIATION ("COEHA")
MEDICARE SUPPLEMENTAL PLAN
2018 SUMMARY OF BENEFITS
PLAN SEVEN
COEHA Medicare Supplemental Plan Benefits |
COEHA Medicare Supplemental Plan Payment |
Annual Part A Deductible |
Covered |
Annual Part B Deductible |
Covered |
Ambulance |
100% coinsurance when covered |
Chemotherapy/Radiation Services |
100% coinsurance |
Chiropractic Services |
100% coinsurance |
Diabetic Testing Supplies |
100% coinsurance for test strips, lancets,
lancing devices and control solution |
Durable Medical Equipment |
100% coinsurance when covered |
Emergency Room Services |
100% coinsurance |
Inpatient Hospital Care |
100% coinsurance |
Kidney Dialysis |
100% coinsurance |
Long Term Care Physician Visits and Physical
Therapy |
100% coinsurance |
Mental Health Services |
100% coinsurance |
Office Visits |
100% coinsurance |
Ophthalmology Services |
100% coinsurance |
Organ Transplants |
100% coinsurance |
Outpatient Surgery, Diagnostic & Therapeutic
Services |
100% coinsurance |
Physical Therapy, Occupational & Speech
Therapy |
100% coinsurance |
Podiatry Services |
100% coinsurance |
Prescription Drugs – effective January 1,
2018, we have contracted with Navitus MedicareRx to administer your
Medicare Part D Prescription Drug Plan |
2018 Medicare Part D information will be
provided by Navitus MedicareRx: Summary of Benefits, Evidence of Coverage,
Formulary & Pharmacy Directory |
Skilled Nursing Facility |
100% coinsurance |
COEHA benefits supplement your basic Medicare
benefits. Services denied by Medicare are not covered by COEHA. Also, not all
services covered by Medicare are a COEHA benefit. For more details, please refer
to your Medicare & You 2018 Handbook and C and O Employees’
Hospital Association Medicare Supplemental Handbook and Master Plan
Document.
All organizations that provide Medicare Managed Care
Plans, and Health Care Prepayment Plans, like COEHA, must obey federal laws
against discrimination, including Title VI of the Civil Rights Act of 1964, the
Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans
with Disabilities Act, all other laws that apply to organizations that receive
federal funding, and any other laws and rules that apply for any other reason.
Discrimination is against the law. COEHA complies
with applicable Federal civil rights laws and does not discriminate on the basis
of race, color, national origin, age, disability or sex. COEHA does not exclude
people or treat them differently because of race, color, national origin, age,
disability or sex.
COEHA:
| Provides free aids and services to people with disabilities to communicate
effectively with us, such as: |
| Qualified sign language interpreters |
| Written information in other formats (large print, audio, accessible
electronic formats, and other formats) |
| Provides free language services to people whose primary language is not
English, such as: |
| Qualified interpreters |
| Information written in other languages |
If you need these services, contact Ms. Michelle Hoke,
the Civil Rights Coordinator.
If you believe that COEHA 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 file a grievance with:
Michelle Hoke
C and O Employees’ Hospital Association
511 Main Street, 2nd Floor
Clifton Forge, Virginia 24422-1166
(800) 679-9135 (toll free)
(540) 862-3552 (fax)
michellehoke@coeha.com
You can file a grievance in person or by mail, fax, or
email. If you need help filing a grievance, Ms. Michelle Hoke, Civil Rights
Coordinator, 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.
Spanish |
ATENCIÓN: si habla español, tiene a su
disposición servicios gratuitos de asistencia lingüística. Llame al
1-800-679-9135. |
Korean |
주의:
한국어를
사용하시는 경우,
언어 지원
서비스를 무료로
이용하실 수 있습니다.
1-800-679-9135 번으로
전화해 주십시오. |
Vietnamese |
CHÚ Ý: Nếu bạn nói Tiếng Việt,
có các dịch vụ hỗ trợ ngôn ngữ miễn
phí dành cho bạn. Gọi số 1-800-679-9135. |
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 1-800-679-9135. |
Arabic |
ملحوظة:
إذا كنت
تتحدث اذكر
اللغة، فإن
خدمات
المساعدة
اللغوية
تتوافر لك
بالمجان.
اتصل برقم
800-679-9135 -1 |
Tagalog |
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag
sa 1-800-679-9135. |
Persian (Farsi) |
توجه :
اگر
به
زبان
فارسی
گفتگو
می
کنید،
تسهیلات
زبانی
بصورت
رایگان
برای
شما
فراهم
می
باشد.
با
1-800-679-9135
تماس
بگیرید. |
Amharic |
ማስታወሻ :
የሚናገሩት ቋንቋ
ኣማርኛ ከሆነ
የትርጉም እርዳታ
ድርጅቶች፣ በነጻ
ሊያግዝዎት ተዘጋጀተዋል፡
ወደ ሚከተለው
ቁጥር ይደውሉ
1-800-679-9135. |
Urdu |
خبردار:
اگر آپ اردو
بولتے ہیں،
تو آپ کو زبان
کی مدد کی
خدمات مفت
میں دستیاب
ہیں ۔ کال
کریں 1-800-679-9135 |
French |
ATTENTION : Si vous parlez français, des
services d'aide linguistique vous sont proposés gratuitement. Appelez le
1-800-679-9135. |
Russian |
ВНИМАНИЕ:
Если вы
говорите на
русском
языке, то вам
доступны
бесплатные
услуги
перевода.
Звоните
1-800-679-9135. |
Hindi |
ध्यान
दें : यदि
आप हिंदी
बोलते हैं तो
आपके लिए
मुफ्त में
भाषा सहायता
सेवाएं
उपलब्ध हैं। 1-800-679-9135
पर
कॉल करें। |
German |
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen
kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer:
1-800-679-9135. |
Bengali |
লক্ষ্য
করুনঃ
যদি
আপনি
বাংলা,
কথা
বলতে
পারেন,
তাহলে
নিঃখরচায়
ভাষা
সহায়তা
পরিষেবা
উপলব্ধ
আছে।
ফোন
করুন
১-1-800-679-9135 |
Kru (Bassa) |
Dè ɖɛ nìà kɛ dyéɖé gbo:
Ɔ jǔ ké mÌ [ƁàsɔìɔÌ-wùɖù-po-nyɔÌ]
jǔ ní, nìí, à wuɖu kà kò ɖò po-poɔÌ
ɓɛììn mÌ gbo
kpáa. Ɖá 1- 800-679-9135. |
Ibo |
Ige nti: O buru na asu Ibo asusu, enyemaka diri
gi site na call 1- 800-679-9135. |
Yoruba |
AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo
lori ede wa fun yin o. E pe ero ibanisoro yi 1- 800-679-9135. |
If you have any questions, please do not hesitate to
give us a call at 1-800-679-9135 or locally at 862-5728. Thank you.
_____________________________________________________________________________________________________
C AND O EMPLOYEES’ HOSPITAL ASSOCIATION
MEDICARE SUPPLEMENTAL PLAN
2018 SUMMARY OF BENEFITS
PLAN TEN
COEHA Medicare Supplemental Plan Benefits |
COEHA Medicare Supplemental Plan Payment |
Annual Part A Deductible |
Covered |
Annual Part B Deductible |
Covered |
Ambulance |
100% coinsurance when covered |
Chemotherapy/Radiation Services |
100% coinsurance |
Chiropractic Services |
100% coinsurance |
Diabetic Testing Supplies |
100% coinsurance for test strips, lancets,
lancing devices and control solution |
Durable Medical Equipment |
100% coinsurance when covered |
Emergency Room Services |
100% coinsurance |
Inpatient Hospital Care |
100% coinsurance |
Kidney Dialysis |
100% coinsurance |
Long Term Care Physician Visits and Physical
Therapy |
100% coinsurance |
Mental Health Services |
100% coinsurance |
Office Visits |
100% coinsurance |
Ophthalmology Services |
100% coinsurance |
Organ Transplants |
100% coinsurance |
Outpatient Surgery, Diagnostic & Therapeutic
Services |
100% coinsurance |
Physical Therapy, Occupational & Speech
Therapy |
100% coinsurance |
Podiatry Services |
100% coinsurance |
Skilled Nursing Facility |
100% coinsurance |
COEHA benefits supplement your basic Medicare
benefits. Services denied by Medicare are not covered by COEHA. Also, not all
services covered by Medicare are a COEHA benefit. For more details, please refer
to your Medicare & You 2018 Handbook and C and O Employees’
Hospital Association Medicare Supplemental Handbook and Master Plan Document.
All organizations that provide Medicare Managed Care
Plans, and Health Care Prepayment Plans, like COEHA, must obey federal laws
against discrimination, including Title VI of the Civil Rights Act of 1964, the
Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans
with Disabilities Act, all other laws that apply to organizations that receive
federal funding, and any other laws and rules that apply for any other reason.
Discrimination is against the law. COEHA complies
with applicable Federal civil rights laws and does not discriminate on the basis
of race, color, national origin, age, disability or sex. COEHA does not exclude
people or treat them differently because of race, color, national origin, age,
disability or sex.
COEHA:
| Provides free aids and services to people with disabilities to communicate
effectively with us, such as: |
| Qualified sign language interpreters |
| Written information in other formats (large print, audio, accessible
electronic formats, and other formats) |
| Provides free language services to people whose primary language is not
English, such as: |
| Qualified interpreters |
| Information written in other languages |
If you need these services, contact Ms. Michelle Hoke,
the Civil Rights Coordinator.
If you believe that COEHA 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 file a grievance with:
Michelle Hoke
C and O Employees’ Hospital Association
511 Main Street, 2nd Floor
Clifton Forge, Virginia 24422-1166
(800) 679-9135 (toll free)
(540) 862-3552 (fax)
michellehoke@coeha.com
You can file a grievance in person or by mail, fax, or
email. If you need help filing a grievance, Ms. Michelle Hoke, Civil Rights
Coordinator, 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.
Spanish |
ATENCIÓN: si habla español, tiene a su
disposición servicios gratuitos de asistencia lingüística. Llame al
1-800-679-9135. |
Korean |
주의:
한국어를
사용하시는 경우,
언어 지원
서비스를 무료로
이용하실 수 있습니다.
1-800-679-9135 번으로
전화해 주십시오. |
Vietnamese |
CHÚ Ý: Nếu bạn nói Tiếng Việt,
có các dịch vụ hỗ trợ ngôn ngữ miễn
phí dành cho bạn. Gọi số 1-800-679-9135. |
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 1-800-679-9135. |
Arabic |
ملحوظة:
إذا كنت
تتحدث اذكر
اللغة، فإن
خدمات
المساعدة
اللغوية
تتوافر لك
بالمجان.
اتصل برقم
800-679-9135 -1 |
Tagalog |
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag
sa 1-800-679-9135. |
Persian (Farsi) |
توجه :
اگر
به
زبان
فارسی
گفتگو
می
کنید،
تسهیلات
زبانی
بصورت
رایگان
برای
شما
فراهم
می
باشد.
با
1-800-679-9135
تماس
بگیرید. |
Amharic |
ማስታወሻ :
የሚናገሩት ቋንቋ
ኣማርኛ ከሆነ
የትርጉም እርዳታ
ድርጅቶች፣ በነጻ
ሊያግዝዎት ተዘጋጀተዋል፡
ወደ ሚከተለው
ቁጥር ይደውሉ
1-800-679-9135. |
Urdu |
خبردار:
اگر آپ اردو
بولتے ہیں،
تو آپ کو زبان
کی مدد کی
خدمات مفت
میں دستیاب
ہیں ۔ کال
کریں 1-800-679-9135 |
French |
ATTENTION : Si vous parlez français, des
services d'aide linguistique vous sont proposés gratuitement. Appelez le
1-800-679-9135. |
Russian |
ВНИМАНИЕ:
Если вы
говорите на
русском
языке, то вам
доступны
бесплатные
услуги
перевода.
Звоните
1-800-679-9135. |
Hindi |
ध्यान
दें : यदि
आप हिंदी
बोलते हैं तो
आपके लिए
मुफ्त में
भाषा सहायता
सेवाएं
उपलब्ध हैं। 1-800-679-9135
पर
कॉल करें। |
German |
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen
kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer:
1-800-679-9135. |
Bengali |
লক্ষ্য
করুনঃ
যদি
আপনি
বাংলা,
কথা
বলতে
পারেন,
তাহলে
নিঃখরচায়
ভাষা
সহায়তা
পরিষেবা
উপলব্ধ
আছে।
ফোন
করুন
১-1-800-679-9135 |
Kru (Bassa) |
Dè ɖɛ nìà kɛ dyéɖé gbo:
Ɔ jǔ ké mÌ [ƁàsɔìɔÌ-wùɖù-po-nyɔÌ]
jǔ ní, nìí, à wuɖu kà kò ɖò po-poɔÌ
ɓɛììn mÌ gbo
kpáa. Ɖá 1- 800-679-9135. |
Ibo |
Ige nti: O buru na asu Ibo asusu, enyemaka diri
gi site na call 1- 800-679-9135. |
Yoruba |
AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo
lori ede wa fun yin o. E pe ero ibanisoro yi 1- 800-679-9135. |
If you have any questions, please do not hesitate to
give us a call at 1-800-679-9135 or locally at 862-5728. Thank you.
|