2013 SecureBlue(SM) (HMO SNP) health care benefits in one easy plan

Plan overview

SecureBlue is a Coordinated Care plan with a Medicare contract and a contract with the Minnesota Medical Assistance (Medicaid) program. This is a voluntary program. This program is offered in conjunction with the Minnesota Senior Health Options (MSHO) program.

SecureBlue, from Blue Plus, is a plan that combines your Medicare and Medical Assistance health care benefits in one plan. It includes Part D prescription drug coverage. If you are eligible for both Medicare and Medicaid (dual eligible), you may join or leave this plan at any time.

Am I eligible?
You can enroll in this plan if you:

• are at least 65 years old
  
• have Medical Assistance
  
• have Medicare Part A and Part B
  
• live in the service area
  
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• Why choose SecureBlue?
  SecureBlue is designed to make your life easier and help you stay your healthiest — at no additional cost to join. Coverage includes:

• A care coordinator — a professional nurse or social worker who works with your doctors and clinics to get you the health care you need. Your care coordinator will take the time to get to know you and your health and safety concerns. He or she can help with your medications, answer health plan questions, support your health care decisions, and arrange home meal delivery (and other services) for you.
  
• No referrals for specialty care — you can see any specialist in our large provider network. Note: some medical services need a special review between your doctor and health plan. This “prior authorization” helps make sure certain medical services are needed and covered by your plan.
  
• Health support to help improve your health and wellness
  
• SecureBlue includes Part D prescription drug coverage
• Rides to and from covered health care appointments at no charge using the BlueRide transportation service
  
• For information about our service area, benefits, cost-sharing, premiums and coverage limitations, refer to the 2013 Summary of Benefits (PDF).  
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• Call us for more information and help enrolling
  We’re available to make enrolling fast and easy. We’ll help you find out if you qualify, fill out your enrollment form and answer your questions.

1-866-477-1584 (toll-free)
8 a.m. to 8 p.m. Central Time, daily
TTY users call 711
Send mail to:
Blue Plus
P.O. Box 64560
St. Paul, MN 55164-0179

Enrolling in this plan is voluntary. For additional information about your rights and responsibilities, the service area, premiums and cost-sharing, out of network coverage and information about filing a grievance, coverage determination or appeal, review the Summary of Benefits and Evidence of Coverage documents below.

This information may be available in other forms to people with disabilities by calling Blue Plus member services toll free at 1-888-740-6013 or 711, or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY, voice, ASCII, hearing carryover), or 1-877-627-3848 (speech-to-speech).

Forms and coverage information2013 SecureBlue brochure (PDF) 2013 pre-enrollment disclosure 2013 Summary of benefits (PDF) 2013 Evidence of Coverage (PDF)

(see Chapter 8 for rights and responsibilities; see Chapter 9 for grievance, coverage determination and appeals information)

2013 Enrollment form (PDF) 2013 LIS premium summary table (PDF) Privacy notice (PDF) Plan ratings (PDF) Best Available Evidence policy Visit the official Medicare site Medicare complaint form Contact the Medicare Ombudsman Get Acrobat Reader

Health support

SecureBlue members have access to these programs and services to help improve your health and keep you well.

• Dental services — basic dental care services, including X-rays, fillings, checkups and teeth cleaning, are provided by Delta Dental of Minnesota using the CivicSmiles network
  
• Fall prevention and safety — your care coordinator can look for ways to make your home safer. You may be eligible for a risk assessment, follow-up support services and up to $750 per year toward home safety items that promote safety, injury prevention and encourage maximal function
  
• Language services — available for members who need help during a health care visit
  
• Mental health, drug and alcohol services — access to care for mental health, drug and alcohol abuse through the Behavioral Health network
  
• Specialty care — access to services like chiropractic care, ob/gyn, vision care and more
  
• Transportation — rides to and from covered health care appointments at no charge through BlueRide
  
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• Other programs
• SecureBlue members receive discounts on some programs or services that help you reach your healthy living goals.
  
• 24-Hour Nurse Advice Line — if you or someone in your family is sick, you can call a nurse 24 hours a day, seven days a week
  
• Dedicated Clinician — if you’re living with an ongoing health condition or you have had a major illness or injury, a Dedicated Clinician can help you make the best choices for your care and help you follow your treatment plan
  
• Online health and wellness resources — get information, news and tools on almost any health topic, with special sections on cancer, pain, heart health, mental health and alternative medicine
  
• Weight Watchers discounts — members do not pay a registration fee when ordering pre-paid meeting vouchers. If you prefer to use a Weight Watchers At Home kit, you can get a $10 discount.
  
• Stop-Smoking Support — one-on-one phone counseling and tools to help you quit tobacco, at no cost to you
  
  
• Delta Dental of Minnesota is independent from Blue Cross and Blue Shield of Minnesota and Blue Plus. Delta Dental provides administrative services for dental benefits, including access to the CivicSmiles network.

Drug coverage and pharmacy information

What’s included?
SecureBlue includes Part D prescription drug coverage that helps you pay for brand-name and generic drugs. Minnesota Senior Health Options plans like SecureBlue have no copays for prescription drugs covered by Medical Assistance. You will still pay Part D drug copays.

Pharmacies
You can get prescriptions filled by going to a pharmacy or drug store, among the 63,000 in the SecureBlue network. For more on pharmacy locations and to see a list of drugs that are covered by this plan, visit the Prime Therapeutics website.  

More information
For information on Part D prescription drug coverage for SecureBlue, call us at 1-866-477-1584, daily 8 a.m. to 8 p.m. Central Time. TTY users call 711.

Or, visit  Medicare.gov or call 1-800-MEDICARE (1-800-633-4227), TTY users should call 1-877-486-2048, 24 hours a day, seven days a week.

Send mail to:
Blue Plus
P.O. Box 64179
St. Paul, MN 55164

Utilization management, prior authorization, and coverage determinations
A formulary is a list of brand and generic drugs preferred by your plan. To view the formulary, visit the Prime Therapeutics website.  

Some Part D drugs are covered only if your doctor or other network provider gets approval in advance. This is called "prior authorization." Covered drugs that need prior authorization are marked in the formulary. If you have any questions about whether Blue Plus will pay for a drug prescribed for you, you have the right to have a coverage determination made. You may call member services and tell us you would like a decision on whether the drug will be covered and the amount, if any, you are required to pay for the prescription.

For more information about utilization management, prior authorization, or coverage determination (including exceptions) related to Part D drug coverage see the 2013 Evidence of Coverage (PDF).  

Forms related to Part D drug coverage, including utilization management, prior authorization, or coverage determination (including exceptions), are available on the  Prime Therapeutics website.  

If you or your provider have questions about the prior authorization process or the status of a request, call member services toll free at 1-888-740-6013, 8 a.m. to 8 p.m. Central Time, seven days a week. TTY/TDD users call 711, or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY, voice, ASCII, hearing carryover), or 1-877-627-3848 (speech-to-speech).

Complaints
If you have a complaint or grievance about your Medicare Part D prescription drug coverage, call member services toll free at 1-888-740-6013, 8 a.m. to 8 p.m. Central Time, seven days a week. TTY/TDD users call 711, or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY, voice, ASCII, hearing carryover), or 1-877-627-3848 (speech-to-speech).

See information about filing a complaint related to your Medicare Part D prescription drug benefits. For a complete description of the complaint, coverage determination (including exceptions) and appeals processes, see Chapters 8 and 9 of the 2013 Evidence of Coverage (PDF).  

Send a letter about your complaint to:
Blue Plus
Consumer Service Center
P.O. Box 64560
St. Paul, MN 55164

Appeals
If you want to appeal your Part D prescription drug benefit coverage determination call member services toll free at 1-888-740-6013, 8 a.m. to 8 p.m. Central Time, seven days a week. TTY users call 711, or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY, voice, ASCII, hearing carryover), or 1-877-627-3848 (speech-to-speech).

Quality assurance, medication therapy management and drug utilization
For information related to quality assurance, medication therapy management and drug utilization, visit the  Prime Therapeutics website.  

Transition process
For more information about the transition process for SecureBlue, refer to Chapter 5 of the 2013 Evidence of Coverage (PDF) or on the Prime Therapeutics website.  

Forms and coverage information

2013 pre-enrollment disclosure 2013 Summary of Benefits (PDF) 2013 Evidence of Coverage (PDF)  
(see Chapter 8 for rights and responsibilities; see Chapter 9 for grievance, coverage determination and appeals information)

2013 Enrollment form (PDF) Medicare Prescription Drug Determination Request form (PDF) 2013 LIS premium summary table (PDF) Plan ratings (PDF) Best available evidence of LIS eligibility Visit the official Medicare site Get Acrobat Reader

Related information

Service area (counties in Minnesota)
Aitkin, Anoka, Becker, Benton, Carlton, Carver, Cass, Chippewa, Chisago, Clay, Cook, Cottonwood, Crow Wing, Dakota, Faribault, Fillmore, Houston, Isanti, Jackson, Kandiyohi, Kittson, Koochiching, Lac qui Parle, Lake, Lake of the Woods, LeSueur, Lincoln, Lyon, Mahnomen, Marshall, Martin, Mille Lacs, Morrison, Mower, Murray, Nicollet, Nobles, Norman, Olmsted, Otter Tail, Pennington, Pine, Polk, Ramsey, Red Lake, Redwood, Rice, Rock, Roseau, St. Louis, Scott, Sherburne, Stearns, Swift, Todd, Wadena, Washington, Watonwan, Wilkin, Wright, Winona, Yellow Medicine

Providers
See if your health care provider is in our network. You must use network providers except in emergency or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers, neither Medicare nor Blue Plus will be responsible for those costs.

American Indians can continue or begin to use tribal and Indian Health Services (IHS) clinics. We will not require prior approval or impose any conditions for you to get services at these clinics. For enrollees age 65 years and older this includes Elderly Waiver (EW) services accessed through the tribe. If a doctor or other provider in a tribal or IHS clinic refers you to a provider in our network, we will not require you to see your health plan primary care provider prior to the referral.

Prior authorization and coverage decisions
Some medical services require a special review between your doctor and your health plan. This is called prior authorization. Prior authorization helps make sure that certain medical services and procedures are necessary and covered by your plan. 

If you have any questions about whether Blue Plus will pay for a service or item, including inpatient hospital services, you have the right to have a coverage decision made for the service. You may call member services and tell us you would like a decision on whether the service will be covered. For more information about prior authorization or coverage decisions related to medical services see the 2013 Evidence of Coverage (PDF).  

Forms for prior authorization

• Forms related to medical services, including prior authorization and coverage decisions (including exceptions) are available in Provider Forms & Publications. Select “forms: pre admission/prior authorization” from the drop-down menu to see the forms. You will need to work with your doctor to fill out these forms.
  
• Forms related to Part D drug coverage, including prior authorization, utilization management, or coverage determinations (including exceptions), are available on the  Prime Therapeutics website.
•  
• If you have questions about the prior authorization process or the status of a request, call member services at 1-888-740-6013 (toll free), 8 a.m. to 8 p.m. Central Time, seven days a week. TTY/TDD users call 711, or through the Minnesota Relay Service at 1-877-627-3848 (speech to speech relay service). Or your provider can call provider services at 1-800-262-0820. 

Reconsiderations
You may ask for a reconsideration if you disagree with a prior authorization or coverage decision. Your provider will need to fill out the “Provider Claim Adjustment / Status Check / Appeal Form” available in Provider Forms & Publications. Select "forms: clinical operations" from the drop down menu. 

How to appoint a representative
You may name a relative, friend, advocate, doctor or anyone else to act for you. The person you name would be your "appointed representative." Other persons may already be authorized under State law to act for you. If you want someone to act for you who is not already authorized under State law, then you and that person must complete Medicare’s Appointment of Representative form located in the Medicare Prescription Drug Appeals & Grievances section on the CMS website.

Be sure to sign and date the form and then mail or fax it to:
Blue Cross and Blue Shield of Minnesota and Blue Plus
P. O. Box 64179
St. Paul, MN 55164
Fax: (651) 662-6860

If you have questions about how to name your appointed representative, you may call member services at 1-888-740-6013 (toll free), 8 a.m. to 8 p.m. Central Time, seven days a week. TTY/TDD users call 711, or through the Minnesota Relay Service at 1-877-627-3848 (speech to speech relay service).

Complaints, Appeals and State Fair Hearing process
If you disagree with a decision or have a complaint regarding medical benefits, you can write to or call member services to file a grievance or appeal.

To call member services, dial 1-888-740-6013 (toll free), 8 a.m. to 8 p.m. Central Time, seven days a week. TTY/TDD users call  1-888-878-0137 (toll free). You may also fax to (651) 662-2138.

Send a letter about your complaint or appeal to:
Blue Plus
Consumer Service Center
P.O. Box 64560
St. Paul, MN 55164

If you disagree with a decision made by our plan, you can also write to the Minnesota Department of Human Services to request a State Fair Hearing. You must request a State Fair Hearing in writing.

Send a written request for a State Fair Hearing to:
Minnesota Department of Human Services
Appeals Office
P.O. Box 64249
St. Paul, MN 55164

For a complete description of the complaint, appeal and State Fair Hearing process for medical services, please see Chapters 8 and 9 of the 2013 Evidence of Coverage (PDF).

Total number of complaints, appeals and exceptions
If you would like to find out about the total number of complaints, appeals and exceptions received by this plan, call 1-888-740-6013 (toll free), 8 a.m. to 8 p.m., seven days a week. TTY/TDD users call 711.

Disenrollment
You may end your membership in our plan at any time. Ending your membership in our plan may be voluntary (your own choice) or involuntary (not your own choice). Please refer to Chapter 10 of the 2013 Evidence of Coverage (PDF).  

Potential for contract terminations
All health plans in the Medicare program agree to stay with the program for a full year at a time. Each year the plans decide whether to continue for another year. Even if a Medicare health plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for health care coverage in your area and give you information about your rights to other Medicare coverage. You can choose another health plan if one is available.
 

This information may be available in other forms to people with disabilities by calling Blue Plus member services at 1-888-740-6013 (toll free), or 711, or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY, voice, ASCII, hearing carryover), or 1-877- 627-3848 (speech-to-speech).
Blue Cross® and Blue Shield® of Minnesota and Blue Plus® is a nonprofit independent licensee of the Blue Cross and Blue Shield Association.

More information

2013 Evidence of Coverage (PDF)  
(see Chapter 8 for rights and responsibilities; see Chapter 9 for grievance, coverage determination and appeals information)

Visit the official Medicare site Medicare complaint form Office of the Medicare Ombudsman (OMO) Get Acrobat Reader