Keystone 65 HMO 2021 Quick Start Guide - Hi, Neighbor! - Flexible Benefits Plans ...
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Keystone 65 HMO
2021 Quick Start Guide
Hi, Neighbor!
Welcome to Keystone 65
Dear Medicare Beneficiary:
Thank you for your interest in choosing Keystone 65 HMO
(Keystone 65) as your Medicare Advantage plan in 2021.
At Independence Blue Cross (Independence), our goal is to
provide our members rich benefits at a price they can afford.
That’s been our mission here in the Philadelphia area for more
than 80 years.
This Quick Start Guide has some easy-to-understand information
about your benefits and what you can expect as a new member.
But first, here are two important things for you to know:
• Once your membership in Keystone 65 has been approved by
the Centers for Medicare & Medicaid Services (CMS) — the
federal agency that runs the Medicare program — you’ll get
a confirmation letter. Don’t cancel any existing coverage
until you get that letter.
• Within 10 days of CMS approval, you’ll get an ID card in
the mail — as well as a Welcome Kit, which includes your
Evidence of Coverage (EOC). You can also find your EOC
online anytime at ibxmedicare.com/eoc.
At Independence, we treat our members like they’re our friends
and neighbors — because they are. And we’re always here to
help. If you ever have any questions about your plan, our Member
Help Team is ready to answer them. Simply call our Member
Help Team phone number on page 28 of this guide.
Thanks again for selecting Keystone 65!
In good health,
Dr. Heidi Syropoulos, M.D.
Medical Director, MedicareTable of contents
Your card, plan, and premium
ID card ......................................................................................................................................... 4
Digital resources .................................................................................................................... 5
Plan details ................................................................................................................................ 6
Ways to pay your premium ............................................................................................. 6
Key terms ................................................................................................................................... 8
Your benefits and coverage
Preventive care and wellness visits ........................................................................ 10
Vaccines ................................................................................................................................... 10
Care options .......................................................................................................................... 11
Benefits tailored to your needs ................................................................................. 12
Emergency services .......................................................................................................... 13
Durable medical equipment ......................................................................................... 13
Outpatient services ........................................................................................................... 14
Care and services for COVID-19 (Coronavirus) ............................................... 15
Dental ......................................................................................................................................... 16
Hearing ...................................................................................................................................... 17
Vision ........................................................................................................................................... 17
Standard and preferred pharmacies ..................................................................... 18
Mail order ................................................................................................................................. 19
Programs and services available to you
Over-the-counter benefit ............................................................................................. 22
SilverSneakers® .................................................................................................................... 23
Meal delivery ......................................................................................................................... 24
Acupuncture ......................................................................................................................... 25
Chiropractic care ............................................................................................................... 25
Specialty services .............................................................................................................. 26
One Day University .......................................................................................................... 27
Member Help Team .......................................................................................................... 28
IBX Opinions ......................................................................................................................... 28
1Your card, plan, and premium
ID card
You will receive your ID card within 10 days after CMS approves
your enrollment application. Your Keystone 65 ID card includes
all of the information your doctor and other health care providers
will need to work with us to process your health care claims.
Bring it with you anytime you seek health care. Below is an
example of the information on your card:
Keystone 65 Primary Care
ID number Physician
This is your
personal
(PCP) name
member ID PCP phone number
Pharmacy
information Lab information
Copayment
information
Important
phone numbers
Once you are enrolled in a Keystone 65 plan with Independence,
you must use your ID card to get covered services. You should
always show your ID card to receive the benefits to which you
are entitled!
Be sure to check that your PCP’s information appears on the
card. As a reminder, Keystone 65 members are required to
select a PCP. You can find a list of in-network providers at
ibxmedicare.com/providerfinder. If you have any questions
or need to change your PCP, call our Member Help Team at the
number that appears on page 28.
4Digital resources
Stay informed about important plan information, manage your
benefits, and discover healthy activities when you engage with us
online. Check out these three options for ways to get connected
with your health plan.
• ibx.com
Once you receive your confirmation letter, your health and
benefit information will be available in one place, anytime
and anywhere by logging into ibx.com. Access your ID card,
the Provider/Pharmacy Finder, recent claims, and view
important messages.
• ibxmedicare.com/connect
Sign up for email and text to stay informed about:
– I mportant plan information
–P ersonalized screening reminders
–T ips for maximizing your benefits
–A nd more
•F
acebook.com/ibxmedicare
Join the conversation on Facebook. Designed just for
Medicare members, our Facebook page offers loads of
information, including health news, wellness tips, and
seasonal recipes.
5Plan details
Monthly premiums
Below is the amount that should appear on your invoice each
month, unless you qualify for additional assistance:
Chester, Delaware, Bucks or
or Montgomery Philadelphia
Plan counties counties
Keystone 65 Basic Rx HMO $0 $0
Keystone 65 Focus Rx HMO-POS $15 $0
Keystone 65 Select Medical-Only HMO $49.50 $34.50
Keystone 65 Select Rx HMO $82.50 $56.50
Keystone 65 Preferred Medical-Only HMO $194 $178
Keystone 65 Preferred Rx HMO $258 $230
Note: “Rx” plans include Part D, or drug coverage.
Ways to pay your premium
When it comes to paying your monthly premium, you’ve got
options. Keep reading to learn more and determine which will
work best for you.
Option 1: Use Electronic Funds Transfer (EFT) to have your
plan premium withdrawn directly from your checking or savings
account each month. There are no sign-up fees or charges
per transaction, and you’ll save money on postage. If there
are insufficient funds in your bank account, no money will be
withdrawn, and you will be billed through the mail for your
monthly premium.
To sign up, download a form at ibxmedicare.com or call our
Member Help Team at the number that appears on page 28.
6Ways to pay your premium (continued)
Option 2: You can pay your premium on our website. Direct Pay
members who have registered on our website at ibx.com will be
able to view and pay their invoices directly online when they log in.
To make a payment online, click the Pay my Bill link on the home
page or via the Benefits tab to access our e-Bill system.
Option 3: Pay by check via Direct Pay. Your monthly premium bill
is sent to your home. You write the check payable to Keystone 65
(not payable to CMS or Health and Human Services (HHS)) and
send it directly to us.
Option 4: You can have the plan premium taken out of your
monthly Railroad Retirement Board (RRB) benefit check or your
monthly Social Security check. For more information on how to
pay your plan premium this way, please contact our Member Help
Team at the number that appears on page 28. We will be happy to
help you set this up.
Note: It can take up to three months for your payment method
to take effect. While we are processing your request for a new
payment method, you are responsible for making sure that your
plan premium is paid on time.
7Key terms
Explanation of Benefits
When you use your Part C and Part D benefits (Rx members only),
we’ll send you an Explanation of Benefits (EOB). EOBs can answer
a lot of questions about your coverage.
The first thing you should understand: EOBs are not bills.
They summarize the medical and hospital care you have received
(Part C) and (for Rx members) the prescriptions you have filled
through your plan (Part D).
•E
OBs show the total costs for medical and prescription claims
we have processed. They tell you what your plan has paid and
how much you have paid out of pocket (or can expect to
be billed).
•E
OBs may also show adjustments for earlier claims that were
filled in a previous month.
It’s important to look at your EOBs, so you can track your health
care expenses accurately and compare them to any statements
you receive from Independence. For more information, go to
ibx.com/eob.
Out-of-pocket costs
Under your plan, you are responsible for certain
out-of-pocket costs:
•S ome plans have a premium or monthly fee. If your plan
has a premium, you will be responsible for paying that fee
each month.
• A copayment (copay) is the fixed amount you pay each
time you receive certain medical services or covered drugs
and is due at the time of service. See your EOC for your
copay amounts.
• Coinsurance is the percentage you pay of the total cost
of certain medical services or covered drugs and is due
when you receive them. See your EOC for your plan’s
coinsurance amounts.
8Your benefits and coverage
Preventive care and wellness visits
You can receive yearly wellness visits and preventive care for more
than 20 screenings:
• If you are new to Medicare, Keystone 65 covers a one-time
Welcome to Medicare preventive visit. The visit includes a review
of your health, as well as education and counseling about the
preventive services you need.
• If you’ve had Medicare Part B for longer than 12 months,
you can get an annual wellness visit to develop or update a
personalized prevention plan based on your current health
and risk factors.
While you’re at your doctor’s office, don’t forget to ask about
completing your other preventive screenings, such as a mammogram
or colonoscopy. It’s also a good opportunity to talk to your doctor
about any medications you may be taking.
Vaccines
Vaccines (shots) are an important step in protecting your health.
Medicare covers certain vaccines under Parts B and D.
If you get a Part B vaccination as part of an office visit where you’ve
received a separate additional non-preventive evaluation and/or
service, a copayment will apply. The copayment amount depends on the
provider type or place of service. Part B vaccines are also available at
some pharmacies, but you may have to pay out of pocket and submit
for reimbursement at others. The vaccines below are available for free
under Part B:
• Pneumonia vaccine
• Flu shots, once each flu season in the fall and winter,
with additional flu shots if medically necessary
• Hepatitis B vaccine if you are at high or intermediate risk
of getting hepatitis B
If you have Medicare Part D, you’re covered for all of the above vaccines
as well as others, if they’re included in your plan’s Formulary (list of
covered drugs). Part D copays or cost-sharing will apply.
Please note: We recommend you get your Part D vaccines at a pharmacy, rather
10 than your doctor’s office, to make sure you’re charged the correct Part D cost-share.Care options
Knowing where to go for medical care may save you time and money.
Care options Costs
Your PCP’s Office
Your PCP knows your medical $0
history best.
Telemedicine
Medical doctor visits through MDLIVE® $0
focus on non-urgent medical conditions.
Behavioral health visits through MDLIVE
focus on therapy and counseling services. $
Urgent Care Center
Situations that are not an emergency
but need immediate attention like colds,
$$
sinus infections, and rashes.
Emergency Room
For serious or life-threatening symptoms.
$$$
For more information
For a list of in-network doctors and urgent care centers, use the
Find a Provider tool online at ibxmedicare.com/providerfinder.
11Benefits tailored to your needs
Special health conditions, like diabetes and congestive heart
failure (CHF), require special care – which can be costly. To help
lower costs for our members, we offer the following programs.
Vital Care
Keystone 65 Basic, Select, and Preferred members, as well as
Keystone 65 Focus members residing in Chester, Delaware,
and Montgomery counties must have both diabetes and CHF
to participate.
Benefit Cost
Cardiology Specialist Visits $10
Endocrinology Specialist Visits $10
Medicare-covered Podiatry Visits $5
Routine Podiatry Visits
$5
Up to 6 routine podiatry visits per year
Vital Care Plus
Keystone 65 Focus members residing in Philadelphia and Bucks
counties must have diabetes to participate.
Benefit Cost
Cardiology Specialist Visits $10
Endocrinology Specialist Visits $10
Pulmonology Specialist Visits $10
Medicare-covered Podiatry Visits $5
Routine Podiatry Visits
$5
Up to 6 routine podiatry visits per year
$80 allowance per quarter for over-the-counter (OTC) items
(additional $20 from base allowance)
12Emergency services
Emergency care
You are covered for medically necessary services for emergency care.
•$ 90 copay per emergency room (ER) visit in and out of network
• I f you’re admitted to the hospital, you will not pay a copay on the
day of discharge
Worldwide emergency room coverage
If you receive emergency care outside of the United States, you
will be responsible for paying for your care. But once home, you can
submit the International Claim Form. This form is available when
you log in to ibx.com via the Resources tab.
Durable medical equipment (DME)
Keystone 65 covers all medically necessary DME covered by
Original Medicare. This includes (but is not limited to) diabetic
supplies, wheelchairs, walkers, oxygen equipment, and continuous
positive airway pressure therapy (CPAP) machines.
You can use an in-network DME supplier to order your DME
equipment. Items are covered as in network only if your doctor
or other network provider gets approval (also known as “prior
authorization”) in advance. Keystone 65 Focus members may
use out-of-network DME suppliers. For the most recent list of
DME suppliers visit ibxmedicare.com and search “durable
medical equipment.”
Diabetic supplies
Diabetic supplies, test strips, and monitors must be obtained
from the preferred vendors/brands, Accu-Chek and OneTouch.
Test strips and monitors from any other vendor will not be covered.
In-network diabetic shoes and inserts, lancets, solutions, insulin
pumps, and related supplies from any brand are available to
members at no cost. 13Outpatient services
Outpatient services are tests or procedures you receive in the
outpatient department of a hospital for diagnosis or treatment
of an illness or injury.
There are two types of places where you can receive outpatient
services — ambulatory surgical centers (ASCs) and outpatient
hospital facilities (OHFs). ASCs are freestanding locations.
The cost-sharing amount for an outpatient service is determined
by two factors:
• What
kind of service you receive
• Where
the outpatient service is performed
Check your EOC for more information about the types of services
covered by your plan. Your EOC will also have more details about
options for places to receive these services.
Some doctors have the necessary equipment to conduct
some outpatient services in their offices, while others do not.
Ask your doctor if getting an outpatient service in his or her
office is possible.
Going to a nearby OHF might be convenient, but it may be
more expensive. Review your options with your physician to
determine the type of facility that best fits your needs.
14Care and services for COVID-19
(Coronavirus)
We are committed to protecting your health during the COVID-19
pandemic. And we’re making it as easy as possible for you to get
the care you need.
Testing and treatment are covered
•$ 0 copay for in-network laboratory testing of COVID-19
• $0 copay for acute, in-network, inpatient hospital stays due
to a COVID-19 diagnosis
Talk to a doctor, 24/7
If your PCP isn’t available, you can schedule an appointment with
a doctor 24/7 through MDLIVE — all for a $0 copay. If you have
symptoms of the virus, or a non-emergency medical condition,
MDLIVE doctors can assess your condition and help determine
necessary next steps, all from the comfort of your home.
Visit ibxmedicare.com/mdlive, to log in or register for MDLIVE
or call 1-888-961-4188 (TTY: 1-800-770-5531). Be sure to
have your ID card available.
15Dental
All Keystone 65 members have routine dental coverage included
in their plan.
Your in-network dental benefits include:
• Access
to a large network of dentists — no dental provider
office requirements
•$ 0 copay for exam/cleaning once every six months
•$ 0 copay for dental X-ray
– One set of dental bitewing X-rays every year
– One set of periapical, panoramic, and full-mouth X-rays
once every three years
•$ 2,000 comprehensive allowance every year for Keystone 65
Basic, Keystone 65 Focus, and Keystone 65 Select members
— services include fillings, root canals, crowns, partial
bridges, dentures, and more
•1 00% coverage for anesthesia during oral surgery
(per 60-minute session) for Keystone 65 Basic,
Keystone 65 Focus, and Keystone 65 Select members
Find a Dentist
Search for network dentists through the Find a Dentist tool at
ibxmedicare.com/findadentist.
16Hearing
Take advantage of all the routine hearing benefits your
Keystone 65 coverage offers, including:
•$ 10 copay for one routine hearing exam every year provided
by a TruHearing® provider
•$ 0 copay for up to three hearing aid fittings and evaluations
every year
• Up
to two hearing aids every year (one per ear per year),
including standard and premium digital hearing aids with a
rechargeable option, cost-sharing applies
Find a TruHearing provider
Use the Find a Provider tool at ibxmedicare.com/providerfinder
to see a list of participating providers.
Vision
Take care of your eyes with routine vision benefits through Davis
Vision providers.
Your vision coverage includes one routine eye exam every year
at a participating Davis Vision provider for a low copay.
Corrective lenses
Your plan also covers one pair of glasses and lenses, or contact
lenses, every year up to the covered allowance amount when
purchased from Visionworks® or a Davis Vision provider.
Find a vision provider
Use the Find a Provider tool at ibxmedicare.com/providerfinder
for a list of participating providers.
17Standard and preferred pharmacies
Some pharmacies contract with our plan to offer lower cost-sharing to
plan members with Part D coverage. This is known as preferred pharmacy
cost-sharing. At a preferred pharmacy, you may:
• Pay lower copays on Tier 1 and 2 prescriptions
(which include most generic drugs).
• Pick up a 90-day supply of covered generic drugs for only two copays.
90-day preferred pharmacy benefit
This money-saving benefit lets you fill up to a 90-day supply of generic
and preferred generic prescription drugs for only two copayments.
Ask your doctor for a 90-day prescription at your next visit!
Where can you get a 90-day supply?
• At a participating retail pharmacy in the preferred
pharmacy network
• Through the mail-order program
It’s easy to move prescriptions if you switch pharmacies:
• Take your prescription bottle/bag to your new pharmacy, or
• Ask your new pharmacy to contact your current pharmacy, or
• Ask your doctor to contact your new pharmacy.
Preferred pharmacies Standard pharmacies
CVS Acme
Giant Costco
ShopRite Kmart
Target Rite Aid
Walgreens Sam’s Club
Wegmans Walmart
Other independent pharmacies Other independent pharmacies
To find the preferred pharmacy near you, visit our
Find a Pharmacy tool at ibxmedicare.com/pharmacyfinder.
18Mail order
Our mail-order service, administered by FutureScripts® Secure,
delivers your prescriptions right to your door. Whether it’s a new
prescription or one you have been filling for years, mail order is an
easy way to get the medications you take regularly.
Mail order offers you:
• Cost savings — You may pay less than retail.
• Convenience — Receive up to a 90-day supply of
maintenance medications with free shipping.
• 24/7 access — Speak to a pharmacist at any time, any day.
When switching to mail order:
If you are filling a prescription at a retail pharmacy and would like
to switch to mail order:
1. C
all 1-888-678-7015 (TTY/TDD: 711) to find out if the
prescription is eligible for mail order and ask to change to
mail order.
2. P
rovide your name, address, prescription number (located on
your prescription bottle), and billing information.
If you have a new prescription:
1. Ask your doctor to send the prescription to be filled by the
FutureScripts pharmacy — OptumRx® home delivery.
2. O ptumRx home delivery will call you to confirm any details.
Pharmacies must get consent prior to shipping or delivering
any prescriptions that your prescriber sends.
Note: This section continues to the next page.
19Mail order (continued)
If you need to refill a mail-order prescription:
1. C
all 1-888-678-7015 (TTY/TDD: 711) and request a refill.
2. C
onfirm your information. Please note, FutureScripts does not
offer automatic refills.
You can also fill out and mail in the Prescription Mail-Order Form
available at ibxmedicare.com.
Your prescriptions from FutureScripts should arrive within
7 to 10 business days after we receive your complete order.
Questions? Please call FutureScripts at 1-888-678-7015
(TTY/TDD: 711), 7 days a week, 24 hours a day.
20Programs and services available to you
Over-the-counter benefit
Save with your IBX Care Card
As a member of Independence, you will receive an IBX Care
Card with funds you can use to purchase approved over-the-
counter (OTC) health and wellness items at participating
retailers, including Walmart, CVS, Walgreens, and more.
•Y
our IBX Care Card is automatically reloaded each
quarter (every three months) with your allowance.
•T
he balance remaining on the card at the end of a quarter
does not carry forward to the next quarter if it is not used.
•Y
ou must purchase OTC items at participating retailers.
•O
TC items purchased from non-participating retailers will
not be covered.
Visit ibxmedicare.com/carecard to learn more about your
IBX Care Card.
22SilverSneakers®
With your Keystone 65 plan, you are eligible for SilverSneakers
at no additional cost.
SilverSneakers is a fitness program that offers participants
specialized exercise classes, health education, and social programs
that have been shown to help seniors maintain good health,
reduce health care costs, and lead an active, independent lifestyle.
Check out some of the perks of the SilverSneakers
fitness program:
•A ccess to basic amenities at 17,000+ participating locations
•C lasses for all fitness levels with support from
trained instructors
• Fitness programs on the go or at home through
SilverSneakers GO™ or SilverSneakers On-Demand
College tuition rewards
You can earn college tuition savings for a student you know simply
by working out at a participating SilverSneakers location or by
attending live classes on silversneakers.com/live. To learn more,
please visit silversneakers.tuitionrewards.com.
To request your SilverSneakers ID card, find fitness locations,
and get additional details, visit silversneakers.com or call
1-888-423-4632 (TTY: 711), Monday through Friday,
8 a.m. to 8 p.m.
23Meal delivery
NO-COST meal delivery after discharge
Members diagnosed with diabetes and congestive heart failure
(CHF) who have been recently discharged from the hospital can
opt to receive four weeks of medically tailored meals provided by
MANNA at no cost.
•E
ach delivery includes breakfast, lunch, and dinner for each
day of the week.
•M
embers can take advantage of the four-week meal delivery
twice in a year.
24Acupuncture
Your plan covers up to six routine acupuncture visits per year for
the treatment of headaches (migraine and tension), post-operative
nausea and vomiting, chemo-induced nausea and vomiting, low
back pain, chronic neck pain, and pain from osteoarthritis of the
knee and hip.
In addition, you have up to twelve Medicare-covered visits per
year, eight additional if determined progress is made, for low back
pain only.
Chiropractic care
Your Keystone 65 plan offers six routine chiropractic
visits in addition to the Medicare-covered visits.
You must choose a provider in the Keystone 65 network.
For a list of participating providers, use the Find a Provider
tool online at ibxmedicare.com/providerfinder.
25Specialty services
•P
ersonal health visits are visits from a licensed health
professional in your home. These visits last for about an hour
and include a brief health assessment. They are a helpful and
convenient way to get personalized health advice, and they are
offered to you at no extra cost. This service is optional, and the
visits will not affect your current health insurance benefits or
premium. You will receive a call from one of our health care
partners to see if you’re interested in scheduling a visit.
ur Nursing Hotline is staffed by Registered Nurse Health
• O
Coaches and is available 24 hours a day, 7 days a week.
Health Coaches have access to your clinical history, including
conditions, prescription drugs, recent tests and therapies,
and patterns of treatment and procedures. To speak with a
Health Coach, call 1-800-ASK-BLUE (1-800-275-2583)
(TTY/TDD: 711), and when prompted, say “Health Coach.”
•E
nhanced Disease Management services are available to
members with chronic health conditions. You may be referred
to a Health Coach by your treating physician, or a Health Coach
may call you to assess your overall health and well-being.
26One Day University
Take advantage of complimentary access to One Day University,
a web-based, interactive learning experience.
•L
ive events and fascinating lectures from some of the
country’s best professors five days/week
•R
eal-time text chats with participants and speakers
•A
ccess to One Day University’s library of prerecorded
lectures and talks
Visit onedayu.com/ibx and enter code WELCOMEIBX.
There are no grades, no tests, and no homework —
just the pure joy of lifelong learning!
27Member Help Team
We understand that every member has unique needs, and
that’s why we have a dedicated Member Help Team that’s focused
on you. Have a question about copays, prescription coverage,
or a medical bill? Call our Member Help Team representatives.
Our Member Help Team is available to take your calls seven
days a week from 8 a.m. to 8 p.m. at 1-800-645-3965
(TTY/TDD: 711). Please note that on weekends and
holidays from April 1 through September 30, your call may
be sent to voicemail.
IBX Opinions
Your opinion matters to us. That’s why all Keystone 65 members
are invited to join IBX Opinions.
What is IBX Opinions?
IBX Opinions is an exclusive, online community made up of people
who live in the Philadelphia area who are interested in sharing
their opinions.
Your feedback could help improve product offerings, increase
member satisfaction, and help shape future plan benefits.
As a member of IBX Opinions, you’ll also have an opportunity
to learn about our ideas for new product offerings and tell us
what you think, give feedback on the communications we send,
and more.
Visit ibxmedicare.com/ibxopinions to learn more and see
if you qualify.
28Other Pharmacies are available in our network. Telemedicine is provided by MDLIVE, an independent company. TruHearing® is a registered trademark of TruHearing, Inc., an independent company. Vision benefits are underwritten by Keystone Health Plan East and administered by Davis Vision, an independent company. Dental benefits are underwritten by Keystone Health Plan East and administered by United Concordia Companies, Inc., an independent company. The SilverSneakers fitness program is provided by Tivity Health, Inc., an independent company. ©2021. All rights reserved. SilverSneakers is a registered trademark of Tivity Health, Inc. SilverSneakers On-Demand and SilverSneakers GO are trademarks of Tivity Health, Inc. ©2021 Tivity Health, Inc. All rights reserved. Benefits underwritten by Keystone Health Plan East, a subsidiary of Independence Blue Cross — independent licensees of the Blue Cross and Blue Shield Association. An affiliate of Independence Blue Cross has a financial interest in Visionworks, an independent company. OptumRx is an Optum® company — an independent company that provides home delivery pharmacy services. MANNA is an independent company and administers our meals program benefit. One Day University is an independent company.
Language Assistance Services
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sa wika nang walang bayad. Tumawag sa
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协助服务。致电 1-800-275-2583。
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assistência ao idioma. Ligue para 1-800-275-2583.
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.تماس بگيريد
Polish UWAGA: Jeżeli mówisz po polsku, możesz
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pod numer 1-800-275-2583. Navajo: D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go
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Italian: ATTENZIONE: Se lei parla italiano, sono H0d77lnih koj8’ 1-800-275-2583.
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.1-800-275-2583
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Y0041_HM_17_47643 Accepted 10/14/2016 Taglines as of 10/14/2016
Y0041 _ HM _ 17 _ 47643 Accepted 10/14/2016 Taglines as of 10/14/2016Discrimination is Against the Law
If you need these services, contact our Civil Rights
This Plan complies with applicable Federal civil rights Coordinator. If you believe that This Plan has failed
laws and does not discriminate on the basis of race, to provide these services or discriminated in another
color, national origin, age, disability, or sex. This Plan way on the basis of race, color, national origin, age,
does not exclude people or treat them differently disability, or sex, you can file a grievance with our Civil
because of race, color, national origin, age, disability, Rights Coordinator. You can file a grievance in the
or sex. following ways: In person or by mail: ATTN: Civil
Rights Coordinator, 1 9 0 1 M a r k e t S t r e e t ,
This Plan provides: P h i l a d e l p h i a , P A 1 9 1 0 3 , By phone: 1-888-377-
Free aids and services to people with disabilities 3933 (TTY: 711) By fax: 215-761-0245, By email:
to communicate effectively with us, such as: civilrightscoordinator@1901market.com. If you need
qualified sign language interpreters, and written help filing a grievance, our Civil Rights Coordinator is
information in other formats (large print, audio, available to help you.
accessible electronic formats, other formats).
Free language services to people whose You can also file a civil rights complaint with the U.S.
primary language is not English, such as: Department of Health and Human Services, Office for
qualified interpreters and information written in Civil Rights electronically through the Office for Civil
other languages. 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, DC 20201, 1-800-
368-1019, 800-537-7697 (TDD). Complaint forms are
available at
http://www.hhs.gov/ocr/office/file/index.html.
Y0041_HM_17_47643 Accepted 10/14/2016 Taglines as of 10/14/2016
Y0041 _ HM _ 17 _ 47643 Accepted 10/14/2016 Taglines as of 10/14/2016Keystone 65 HMO
P.O. Box 190
Dunmore, PA 18512-9978
Important Keystone 65 HMO information
19631 1100153 (09/20)
KS9886 (07/20)
Y0041 _ H3952 _ KS _ C _ 21 _ 89378You can also read
