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Important plan documents

The following documents provide important information on services and benefits to help you make an informed decision about enrolling.

2021 Plan

2022 Plan

  • All-in-One Medicare Advantage Decision Guide

  • Annual Notice of Change

  • Aspire Health privacy notice

  • Benefit highlights

  • Care in an emergency or disaster

    Getting medical care & prescription drugs in disaster or emergency areas

    If the Governor of California, the U.S. Secretary of Health and Human Services, or the President of the United States declares a state of disaster or emergency in Monterey County, you can still get medical care and prescription medications from Aspire Health Plan.

    Generally, during a disaster or emergency, Aspire Health Plan will allow you to obtain medical care from out-of-network providers at in-network cost-sharing rates without prior authorization requirements. In cases where payment is required up front for the out-of-network care you may submit a request for reimbursement to the plan.

    Aspire Health Plan has a national network of pharmacies available to fill prescriptions for medications. If you cannot use a network pharmacy during a disaster, you may be able to fill your prescription drugs at an out-of-network pharmacy. In cases where payment for the cost of the drugs is required at the time the prescription is filled you may submit a request for reimbursement to the plan.

    For more information on how to obtain needed care and medications during a disaster or emergency please call the Aspire Health Plan customer service team toll free at 855-570-1600(TTY users call 711), 8 am to 8 pm PST Monday through Friday (except certain holidays) from April 1 through September 30 and 8 am to 8 pm PST seven days a week for the period of October 1 through March 31.

  • Choose to share your health Information

    We are committed to ensuring your health information is safe, while giving you the flexibility to have a family member, friend or loved one – your “representative” – help make decisions on your behalf. State and federal law requires different forms to be used depending on the actions you want your representative to take on your behalf. We’ve outlined the purpose of each of these forms below.

    Authorization for Use or Disclosure of Health Information.
    Completing the Authorization for Use or Disclosure of Health Information form will allow your designated representative to call Member Services to ask medical questions. This form is valid for as long as you are an Aspire Health Plan member. USE FOR: Medical benefit questions, claims, and bills.

    • This form doesn’t override a Power of Attorney (POA). Don’t complete this form if you have a valid POA.
    • You need to complete a separate form, if you need help filing an initial request for coverage, a grievance or appeal.
    • This form is valid as long as you are a health plan member
    • You have the right to revoke this document at any time

    Appointment of Representative form.
    Completing the Appointment of Representative allows your designated representative to call our Pharmacy Benefits Manager, MedImpact, to ask questions about your Part D prescription drug benefits, claims, or bills. For your Part C benefits, the form also allows the authorized representative to file an appeal or grievance for you, or make an initial coverage request. You will need to renew this form each year. USE FOR: Part C appeals, grievances, and coverage decisions, as well as Part D prescription drug benefits, claims, bills, appeals, or grievances.

    • This form only allows your representative to assist you with initial coverage requests, grievances or appeals.
    • Your doctor can make a coverage request and file certain appeals without being your representative.
    • This form is only valid for one year.
    • The form should be signed by both you and the individual you would like to represent you.
    • Once you have completed the form, you must submit that form via fax for mail to the applicable fax number or address listed above before we can talk to your representative.
    • You have the right to revoke this document at any time

    Already have a Power of Attorney (POA)? Make sure it’s Valid
    A valid POA must:

    • Name your agent and your relationship to the agent
    • State when it becomes effective (e.g., “immediate”) and how long it lasts
    • Include the right to revoke at any time
    • Be properly signed AND notarized or witnessed
  • Claim reimbursement request form

  • Enhanced benefits - dental, vision and hearing

    Aspire Health Plan provides comprehensive medical and pharmacy benefits, including preventive care and screenings for all our Medicare Advantage plans. If you’re looking to enhance your coverage we offer optional supplemental benefits. We have three packages to meet your needs. For an additional monthly premium, you can add dental vision, hearing, transportation and post discharge meals to any of our three plans.

    Option A – $44.90 additional premium per month (optional) for the VALUE and PLUS plans.

    Includes:

    • Preventive & Comprehensive Dental
    • Vision

    Option B – $49.90 additional premium per month (optional) for the VALUE and PLUS plans.

    Includes:

    • Preventive & Comprehensive Dental
    • Vision
    • Hearing
    • Transportation – 10 additional one-way rides
    • 14 home delivered meals, post discharge or surgery

    Option C – $43.00 additional premium per month (optional) for the ADVANTAGE plan.

    Includes:

    • Comprehensive Dental
    • Vision
    • Hearing
    • Transportation – 10 additional one-way rides
    • 14 home delivered meals, post discharge or surgery

    For a complete listing of all the benefits:

  • Enrollment instructions and forms

  • Evidence of Coverage

  • FAQ

    What does Medicare include?

    Original or traditional Medicare includes Part A and Part B.

    Medicare Part A is hospital insurance and helps cover:

    • Inpatient hospital care
    • Skilled nursing facility (SNF) care
    • Hospice care
    • Home health services

    Medicare Part B is medical insurance and helps cover:

    • Services from doctors and other healthcare providers
    • Outpatient care
    • Durable Medical Equipment (DME)
    • Preventive services

     

    How does Medicare work?

    Original Medicare beneficiaries usually don’t pay a monthly premium for Medicare Part A (hospital insurance) coverage if either they or their spouse paid Medicare taxes while working. However, those who don’t qualify for Part A at no cost can still buy Part A.

    Part B (medical insurance) does require that Medicare beneficiaries pay a monthly premium. This amount can vary, depending on income level, and is often deducted from your Social Security check.

    You can contact Social Security for more information about Part A and Part B premiums. Also, there are deductibles and co-payments for Medicare Parts A and B.

     

    What about prescription drugs?

    For prescription drug coverage, you may join a stand-alone Prescription Drug Plan (PDP) or a Medicare Advantage Part C (MAPD) plan such as Aspire Health Plan that includes Part D.

    In a stand-alone plan, participants pay a monthly premium for Part D coverage. But with Aspire Health Plan, your prescription drug coverage is included in one combined premium — it’s all-in-one.

     

    What is a Medicare Advantage plan?

    Medicare Advantage plans are referred to as Medicare Part C. They are offered by private
    companies who have a contract with the Centers for Medicare and Medicaid Services (CMS) to cover all of your Medicare Part A and Part B benefits. Medicare Advantage plans cover everything that Original Medicare covers, and they typically cover more.

     

    Why choose a Medicare Advantage plan instead of Original Medicare?

    One third of Medicare beneficiaries are on Medicare Advantage plans. Medicare Advantage plans cover everything that Original Medicare covers, plus more. Many Medicare Advantage plans, including Aspire Health plans, cover Part D prescription drugs, transportation, acupuncture, and chiropractic. What’s more, our plans do not have an annual medical or hospital deductible — so you are covered from the start. Our low co-pays and co-insurance make your healthcare costs predictable and often save you substantial amounts of money when compared to Original Medicare.

     

    What is a coordinated care plan?

    A coordinated care plan provides the right care in the right place at the right time. Aspire works directly with members and their care providers (doctors, hospitals, pharmacies, and wellness centers) to keep our members healthier. Consider people who struggle to manage their diabetes and, as a result, sometimes end up in the emergency department with high or low blood sugar. We coordinate with the member’s doctor to ensure that diabetes monitoring and education services are provided. In addition, we can assign members with high-risk diabetes to their own care manager, who can assist and guide them.

     

    Why choose our Aspire Health Plan over a Medicare supplement (Medigap) plan?

    Insurance companies offer Medicare Supplement insurance. Aspire Medicare Advantage, however, is more than that.

    1. Our plans include prescription drug coverage, making them a one-stop shop for all your healthcare needs, so you get an all-in-one plan with just one card
    2. Aspire is a coordinated care plan designed by leading local doctors and medical specialists to maintain and/or improve the health of our members. It’s a community plan just for you
    3. We don’t just fill in the gaps of what Medicare doesn’t cover, like deductibles and co-insurance. Instead, our coordinated team of healthcare providers administers all of your care including hospital, medical, and prescription drug coverage

    Finally, Medicare supplement premiums can vary widely and typically do not cover prescription drugs or other additional benefits, such as transportation, gym membership, chiropractic, and acupuncture. With a Medicare Advantage plan such as ours, premiums remain the same regardless of your age and health history.

     

    Can I continue to see my doctor?

    Aspire partners with all four hospitals and more than 700 doctors and other providers in Monterey County. Our network of primary care physicians and specialists accepts our Medicare Advantage plans. If your doctor is among the list of providers, you may continue to see him or her. If not, you may choose another doctor or stay with your current plan.

    Find out if your provider is part of our network by checking out our Provider and Pharmacy Directory.

     

    How is Aspire’s HMO-POS plan different than the two HMO plans that Aspire offers?

    All of our Medicare Advantage plans use an HMO network of doctors, specialists, hospitals, and other medical service providers. With any Aspire Health plan, you will first select a network primary care provider (PCP) here in Monterey County, who will help coordinate your care.

    All of our plans provide nationwide coverage for urgent and emergent care situations, so don’t worry about emergencies or sudden illnesses that may arise when traveling. You are covered the same way you are in-network — anywhere in the country.

    In our two HMO plans (Advantage and Value), when receiving non-urgent or non-emergent care, you must use the providers who are in our network.

    When using our HMO Point of Service (POS) Plan (Plus Plan) in Monterey County, you must access the network of providers for your healthcare services. If you use providers who are in Monterey County but not in the plan’s network, you are fully responsible for the cost of those services. When you are outside of Monterey County and anywhere in the U.S. or its territories, the plan’s Point of Service component provides coverage for you to access Medicare-eligible providers and Medicare-covered services.

     

    What is a Medicare Advantage “trial right?”

    The Medicare Advantage “trial right” is designed to take some of the pressure out of choosing between a Medigap policy and a Medicare Advantage plan.

    This trial right allows you to apply for a Medigap policy on a guaranteed issue basis if you join a Medicare Advantage plan for the first time and, within the first year of joining, decide to return to Original Medicare and purchase a Medicare supplement. You may qualify for a “trial right” under other circumstances. For more information, please visit www.medicare.gov.

     

    How do I sign up for the optional Enhanced Benefits?

    It’s easy. But please note that it will cost you an extra monthly premium. If you’re signing up for one of our health plans for the first time, you can elect the Enhanced Benefits option at the same time you choose your health plan.

    If you don’t elect coverage at that time, you will have a short grace period in which you may still add the Enhanced Benefits, but you must apply for them within 90 days of your health plan effective date. After the 90-day window has passed, you will have to wait until the next Annual Election Period (AEP) to add them.

     

    What if I sign up for the Enhanced Benefits and then decide I don’t want them?

    No problem. You may drop your Enhanced Benefits coverage at any time throughout the year, and it will not affect your health plan coverage. If you choose to drop the coverage, you must provide a written request to the plan. Your Enhanced Benefits will end effective the first of the month following the month in which you notified the plan of your intent to disenroll.

    Spanish (en español PDF)

  • Mail-order prescriptions

    If you rely on regular or long-term medications, there may be a better way to get your prescriptions filled.  MedImpact Direct is home delivery and a smart, simple way for you to get prescriptions delivered to your door. Mail order pharmacy. And, you save money on your prescription co-pays with our 3 months supply for two co-payments.

  • Medicare Star Rating

  • Member forms

  • Multi-language interpreter services

  • Provider Directory

    Provider and Pharmacy Directory PDF  |  Spanish (en español PDF)

    If you would like to request a mailed copy of the current Provider and Pharmacy Directory, or if you need help finding a network provider and/or pharmacy, please call member services toll free at (855) 570-1600 (TTY users call 711) or click on the following link for more information:

    Provider and Pharmacy Directory notice PDF |  Aviso de Directorio de Proveedores y FarmaciasSpanish (en español PDF)

  • Summary of Benefits for Monterey County

For more information, you can visit the Medicare website or call
1-800-MEDICARE 24 hours a day/7 days a week (1-800-633-4227).
TTY users should call 1-877-486-2048