Medicare Advantage Plan - Understanding your
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2021
Understanding your
Medicare Advantage Plan
Get a
free gift!
Review your plan documents in this packet then complete a short online survey
to receive a free gift. Complete the survey at www.securityhealth.org/yourthoughts.
Verifiable retail value: $2. Prizes awarded upon survey completion.
Use this Member Handbook as Use this Member Handbook as
a quick-start guide to help you a quick-start guide to help you
find the information you need. find the information you need.
Table of Contents
2 Welcome to Security Health Plan
3 Getting started
5 Finding a provider
6 Preventive care
Inside front cover -
7 Using your ID card
blank
8 Your Personal Health Statement
10 Services to help you maintain
your health
11 Receiving care after hours
12 Over-the-counter $30 credit (OTC)
13 SilverSneakers® fitness program
14 Hearing services
15 Vision exams and eyeglasses
16 Set up advance directives
on your terms Promises kept,
plain and simple.®
INTERPRETER SERVICES: If you need help interpreting
any information in this booklet, please call Customer
Service at 1-877-998-0998 (TTY 711).
Getting Started
This Member Handbook is designed to be a quick-start guide for you – to help you find the
information you need. We’ve outlined a few basic steps to follow to help you get the most from
your Security Health Plan coverage.
STEP 1: Register for My Security Health Plan
It’s an easy, free and secure way to manage your
health care online. You can register for My Security Health Plan
at www.securityhealth.org/registration.
Some of the things you can do with My Security Health Plan include:
• view or request ID cards
Welcome to Security Health Plan • check your deductible, claims and prior authorizations
• pay your monthly premium, if applicable
• find an in-network provider with your plan
• find a pharmacy
We want to make sure you understand how your health • request a call from a nurse
plan works and can make the most of your health coverage. • access Care My Way® virtual visits
We encourage you to go online to view important plan documents, find a • quick access to plan documents
network provider or pharmacy and look up your prescription drugs. You can • complete a WebMD health assessment
view your plan documents within your My Security Health Plan account. See • enroll in wellness support programs
page 3 for more information about this members-only website and mobile • view prescription drug information
app that gives you access to your health insurance information - anytime, and pharmacy benefit details
anywhere. You can also read or download your plan documents at • place your quarterly Over-the-Counter (OTC) supply order
www.securityhealth.org/medicaredocuments: If you have questions,
• view your personal health statements There’s an
please call Security Health
•E
vidence of Coverage (EOC) • live chat with Customer Service app for that!
Plan Customer Service at
This is your main guidebook to gain a thorough understanding of the Register for your My Security
1-877-998-0998.
benefits and other provisions of your Medicare Advantage plan. Health Plan account. Next,
•P
rovider Directory download our app from Google
If you are hearing- or Play or find it in the App Store.
Find nearby doctors, other health professionals and facilities available in
speech-impaired, please You'll then be able to access your
your network at www.securityhealth.org/directory.
call TTY 711. electronic ID cards and manage
•P
harmacy Directory and Formulary (prescription drug list)
your health plan on the go.
Find convenient pharmacies and make sure your medications are covered
We are open 7 days a
at www.securityhealth.org/prescriptiontools.
week, 8 a.m. to 8 p.m.,
Oct. 1-March 31; and
If you prefer to have a printed copy of an Evidence of Coverage, Provider Monday through Friday,
Directory, Pharmacy Directory or Abridged Formulary mailed to you, you 8 a.m. to 8 p.m., Watch a short video about many of the
have two options:
s
April 1-Sept. 30. features of My Security Health Plan at
www.securityhealth.org/MyAccount
• Visit www.securityhealth.org/paper and place your order online.
• Call Customer Service (number at right) and select the prompt to order
your paper copy. We look forward to helping you have the best health plan
experience possible.
2 3
Getting Started (continued) Finding a provider
You may receive services from any provider or facility listed in your Provider Directory, and for most
STEP 2: Read your plan documents services you are able to use any Medicare-certified provider in the United States that has not opted
Once you are registered for My Security Health Plan, you should read your plan documents. out of Medicare. You pay the same costs when using in-network and out-of-network providers for
Medicare-covered services. For some services as noted in your Evidence of Coverage, you may be
Your Evidence of Coverage explains what services are covered and excluded from your plan. required to get prior authorization when using out-of-network providers. Emergency and urgent care
It also explains: are covered anywhere in the world.
• terms you should know
• how to file a grievance Establishing a primary care provider
• how to obtain a prior authorization* We encourage you to establish a relationship with a primary care provider. A primary care provider is
• notice of privacy practices and member rights and responsibilities someone you see on a regular basis who coordinates your health care, including referrals to other health
care providers within your plan’s network. Primary care providers are physicians, physician assistants or
nurse practitioners. They are preventive care specialists who can help you reduce your health risks and
help you create lifelong healthy habits. They get to know you and partner with you for the best health-
related choices for you.
The Notice of Privacy Practices is available within your Evidence of Coverage. You may also Some primary care providers work in the following areas:
view the Notice of Privacy Practices and Members' Rights and Responsibilities • Internal Medicine: usually treats patients over the age of 18
at www.securityhealth.org/privacy. To request a paper copy, • Family Practice/Family Medicine: treats patients of all ages
please call 1-877-998-0998 (TTY 711). • General Practice: treats patients of all ages
Choose a primary care provider today
to get more health care and less worry.
STEP 3: Questions and Concerns 1. Go to www.securityhealth.org/lets-talk
We know insurance and health care can be confusing.
2. Complete the online form
If you have questions or concerns after you’ve read
3. U
nder “What can we help you with?”
your plan documents you can:
choose: “Add or change Primary Care Provider.”
4. Include the name of your PCP in the “Message” field.
Chat live with a customer service agent,
online. You must be a current member Receiving care from specialists
and be logged into your My Security Health If you need to see a specialist, including
Plan account. This feature is available behavioral health and inpatient hospital care,
Monday-Friday, 8 a.m. - 4:30 p.m. you may see any provider listed in the Provider
Directory for your benefit plan. It is a good You have access
You may also call Customer Service at idea to discuss your care with your primary to top-notch providers
1-877-998-0998 (TTY 711). care provider first so it can be better as a member of Security
coordinated, and to determine if prior Health Plan. Visit
Or email Customer Service at authorization is necessary. www.securityhealth.org/
shpcsweb@securityhealth.org. directory to get
to know your provider
network.
4 5
Preventive care Using your ID card
You receive preventive health services at no extra cost Show your Security Health Plan ID card when you visit your health care
Even if you feel healthy it’s important to receive regular preventive screenings. Visiting your primary care provider or pharmacy. As long as you are a member of our plan, use the
provider for routine preventive care can lower your risk for illness, disease and other health problems. Security Health Plan ID card and not the red, white and blue Medicare
card to get covered medical services. You may be asked to show your Need medical
We are committed to enriching our members’ lives so our members can reach their best health. Preventive
care can help preserve and may improve your health. In the long run that contributes to lower health care
Medicare card if you need hospital services. Keep your red, white and care, but don't
costs. Preventive care is a benefit for you both medically and financially.
blue Medicare card in a safe place in case you need it later. have your ID card?
Remember, acceptance of your Security Health Plan ID card does not
You will have coverage for all Medicare-covered preventive services including bone mass measurement, Download the My Security
guarantee your provider is an in-network provider nor ensure the
colonoscopies and mammograms, as well as vaccines, diabetes testing supplies and more. Health plan app for access
medical or pharmacy services will be covered under your benefits.
to your ID card on the go.
Welcome to Medicare While you are a member of our plan, you must use your Security Health
Your plan covers the one-time “Welcome to Medicare” preventive visit. The visit includes a review of your
Plan ID card whenever you get services covered by this plan.
health, as well as education and counseling about the preventive services you need (including certain
screenings and shots), and referrals for other care if needed. If your plan ID card is damaged, lost or stolen, call Customer Service
right away and we will send you a new card.
If you have 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.
This is covered once every 12 months.
Member must obtain prior approval for some services. Cost sharing is
the same in and out of network for Medicare-covered services. Please
Important: We cover the “Welcome to Medicare” call Customer Service for prior authorization and benefit information.
Emergency and urgent care is covered worldwide. If you receive
emergency services from a nonaffiliated provider, please call us within
preventive visit only within the first 12 months Essence
Essence Rx
Rx (HMO-POS)
(HMO-POS) 48 hours or as soon as reasonably possible.
Subscriber
Subscriber #:
#: 12001234560000
12001234560000
you have Medicare Part B. When you make your Member:
Member: John
John LL Doe
Doe
Present this card, NOT your Medicare card, at the time of service.
DOB: 1/2/1934 Security Health Plan Send paper claims to:
appointment, let your doctor’s office know you DOB: 1/2/1934
01/01/2021
Effective Date: 1/1/2020
Effective Date: 1/1/2020
Provider Line Attn: Claims Department
Providers may call: Security Health Plan
would like to schedule your “Welcome to Medicare” Here is Member Customer Service: 1-877-998-0998
Member Customer Service: 1-877-998-0998
For Hearing Impaired: TTY 711
For Hearing Impaired: TTY 711
1.800.548.1224 PO Box 8000
Marshfield, WI 54449-8000
preventive visit. Your first annual wellness visit can’t a sample 24-hour Nurse Line: 1-800-549-3174
24-hour Nurse Line: 1-800-549-3174
Date issued: 01/01/2021
01/01/2020
Date issued: 01/01/2020
www.securityhealth.org/members
take place within 12 months of your “Welcome to Security Pharmacy Information
Medicare” preventive visit. Health Plan Present this ID card to a participating pharmacy to access your drug
benefit or discount.
ID card. Only the person named on this card may use this card to obtain
Vaccines Name:
Name: John
RxBIN:
John LL Doe
Doe
015574
drug benefits; however, this card does NOT guarantee coverage.
Please call Customer Service for prior authorization, claim and
benefit information.
RxBIN: 015574
Your Security Health Plan coverage includes RxPCN:
RxPCN:
ASPROD1
ASPROD1 Security Health Plan Send paper claims to:
RxGrp: SEC01
RxGrp: SEC01
vaccinations covered with Medicare Part B, including: Issuer:
Issuer:
ID #:
80840
80840
12001234560000 CMS-H5211 003
Pharmacy Services
Pharmacies may call:
Attn: Pharmacy Claims
Security Health Plan
ID #: 12001234560000 CMS-H5211 003
1.877.873.5611 PO Box 8000
• Pneumonia vaccine Date Issued: 01/01/2020
Date Issued: 01/01/2021
01/01/2020 Marshfield, WI 54449-8000
©2020 Offered by Security Health Plan of Wisconsin, Inc.
•F lu shots - once each flu season, with additional flu
shots if medically necessary (Front of card) (Back of card)
99-0453-01 (08/20)
•H epatitis B vaccine - if you are at high or 24016-001
intermediate risk of getting Hepatitis B
•O ther vaccines if you are at risk and they meet To learn how Security Health Plan stays on top of medical advances,
Medicare Part B coverage rules please visit www.securityhealth.org/quality.
Other vaccines such as shingles vaccines and routine
tetanus shots are covered only if you have our Part Security Health Plan makes utilization management decisions based solely on appropriateness
D prescription drug coverage. We cover all Part D of care and existence of coverage. Security Health Plan does not reward practitioners or other individuals
vaccines under our Part D prescription drug benefit. for issuing denials of coverage. There are no financial incentives that encourage underutilization.
6 7
Your Personal Health Statement
Health insurance terms to know Part D EOB – what is it?
You might not be familiar with many terms commonly used in health insurance. Many of these terms Each month you fill a prescription, Medicare requires Security Health Plan to mail
appear on your Personal Health Statement, which Security Health Plan sends you after every claim we you a Part D Explanation of Benefits, or EOB. This notice gives you a summary of your
receive for your health care services. Your Personal Health Statement explains the services you received, prescription drug claims and costs. Like your Personal Health Statement, it is important
what they cost, payments Security Health Plan made to the provider on your behalf and additional that you also review your Part D EOB for mistakes. Contact us if you have any questions.
payments you might owe the provider. When you receive your Personal Health Statement, compare it to
your provider’s bill. By reporting any errors you may find, you will help control rising insurance premiums.
venue
Joseph A
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1 Health benefits at a glance - a summary of all your health care benefits for the current year.
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Date prin
ted: 7/23
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2 Summary of claims - the total amount billed, how much you saved, how much was paid and how
Sample
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5 Health professional - health care provider who provided the service(s) listed.
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Total for this practice: $0.00 $0.00 $0.00 $0.00 $0.00
Notes
service you received.
• A description of your diagnosis and/or treatment and the corresponding codes are available upon request for each claim.
Y0117_49
57_0 4-19_C Member name: JOHN L
Member ID: 1234560
DOE • Negative dollar amounts may represent a correction to a previous charge. Common corrections result from changing people covered under
the policy, provider claim corrections, benefit changes, etc.
10 Other insurance payments - what costs are covered by other insurance you may have.
Policy number: 997000
• Your provider is not allowed to bill you for the amount in “Your savings.” Security Health Plan has applied industry-standard claim edits or
11 Personinalplace
Practice: PATIENT PAID
CHIROPRACTIC
12 13
fee reductions, or has a contract
14
Hea lthprevents
that
15
Stateme yournt
provider from billing you for the amount listed.
16 a bill.
This is not
11 Non-covered service amount - amount that applies to services not covered by Security Health Plan.
Reason code explanation
Date of YOU
1 RDeductible Amount
RESPONSIBILI
service
Service description
[billing code]
Non-covered
service amount
Copay
[set dollar
Deductible
[set dollar
TY
Coinsurance
[percentage of
Reason code Amount
12 Copay - a specific dollar amount you pay a provider for certain services.
amount for amount for you owe
charges]
Go green!
Claim number: 17555E1 specific service]
01/01/2020
0970
DESCRIPTION OF
$0.00
benefit year]
Practice patient account
number: 19411700 13 Deductible - the amount applied to your yearly deductible, the portion you need to pay each year
SERVICE $0.00 Y0117_4957_04-19_C Page 3 of 8
[G3030]
$0.00 $0.00 1 $0.00
You can opt to receive before health plan benefits start.
DESCRIPTION OF
01/01/2020 $0.00 $0.00
SERVICE
[G3030]
$0.00 $0.00
$0.00
your personal health 14 Coinsurance - a percentage of your medical costs that you pay to a health care provider.
Claim total:
$0.00 $0.00
statement electronically
Total for this practice $0.00 $0.00
Notes
$0.00 $0.00 $0.00 $0.00
1 $0.00
$0.00
in your My Security 15 Reason code - additional information about why a specific amount was not covered.
• A description of your
diagn osis and/or treatment and
Health Plan account.
16 Amount you owe - what you must pay the provider after your plan benefits are paid.
• Negative dollar amo the corresponding code
unts may represent a corre s are available upon requ
ction to a previous char est for each claim.
the policy, provider claim ge. Common correction
corrections, benefit chan s result from changing peop
• Your provider is not ges, etc. le covered under
allowed to bill you for the
fee reductions, or has a amount in “Your savings.”
contract in place that prev Security Health Plan has
ents your provider from appli ed indu stry-standard claim edits
billing you for the amount or
Reason code explanatio listed.
n
1 Deductible Amount
8 Y0117_4957_04-19_C 9
These services can help you
maintain your health After hours care
You try your best to stay healthy, but sometimes you need extra help. Security Health Plan’s team of
professionals can help improve your health through support, guidance and motivation. Receiving help
is easy. Security Health Plan offers wellness and care management services at no extra cost to you.
24-hour Nurse Line
Our Health Coaches can help you with: You have a 103˚ fever. If you need to talk to a provider
• losing weight • increasing physical activity • managing stress and more
after hours, you may call the
• healthy eating • quitting nicotine provider’s office. You may also call
You have a 103 fever. Security Health Plan’s 24-hour
Our Nurse Navigators offer information about providers, hospitals, services, and insurance benefits.
They identify in-network providers and specialists and assist with requests for prior authorization. Nurse Line at 1-800-549-3174,
seven days a week, including
Our Care Managers are registered nurses and social workers. They assist in managing complex health holidays, to connect with a
situations, behavioral health and chronic health conditions. They listen to you, help you identify and registered nurse who can help
understand your health care needs, and give you one-on-one support, encouragement and resources to answer your health care questions.
? ? ?
make sure you get the right care for your health care goals. They can also help you: Is your Should you The registered nurse will provide
condition make a doctor’s
• schedule and coordinate medical appointments serious enough appointment
What steps
can you
advice for seeking care or
to go to the for the next
• manage chronic medical conditions and medications emergency day?
take? instructions for care at home.
room?
• better understand your medical and behavioral needs To access these
services call Care My Way®
• explore choices for your health care
Customer Service Symptoms of certain minor
•
•
gain confidence in making health care decisions
recover from acute health episodes and avoid hospitalization 1-877-998-0998 Start by calling our illnesses can be all too familiar,
24-hour Nurse Line.
but a trip to the doctor’s office can
• connect with health resources in your community (TTY 711)
take time and energy you don’t
www.securityhealth.org/ Call 1-800-549-3174 (TTY 711)
Nicotine and substance-use disorder services members
have. Call Care My Way instead. For
many common health conditions,
Security Health Plan coverage includes unlimited counseling sessions for
you can talk to one of our nurse
tobacco/nicotine cessation and up to a 6-month supply of over–the-counter
practitioners by phone, or try a
nicotine replacement therapy at no charge to members who participate in A registered nurse will ask
our free Nicotine-Free program. We also cover treatment for substance-use disorders
you about your health problem. virtual visit by downloading the
and opioid management. Please see your Evidence of Coverage for details.
The nurse will advise you based app. The nurse can verify your
on your responses. The nurse may:
symptoms and, if needed, call
Achieve your health goals online a prescription into the network
We work with WebMD, a respected name in online health education, to offer members timely, objective pharmacy of your choice – saving
and easy-to-understand health information. Complete your WebMD health assessment and receive: you time and hassle. Care My
provide refer you to a urge you to urge you to Way has no copay, no deductible
• a complete picture of your health instructions Care My Way visit your visit urgent
for care at nurse physician care or the charge and unlimited visits.
• a personalized wellness plan home practitioner if emergency
you describe department For a complete list of conditions
• access to WebMD’s health improvement resources symptoms
related to a Care My Way can treat, and more
common health
information about the service,
Download the WebMD Wellness at Your Side app! condition
go to: www.securityhealth.org/
Make positive lifestyle changes and form healthier habits from your smartphone or tablet! This handy app
CareMyWay.
is fully integrated with your My Security Health Plan account, so you can easily set lifestyle goals, track
your progress, and get personalized well-being recommendations. Download Wellness at Your Side today
Our 24-hour Nurse Line is available seven days a week, including holidays. Care My Way services are available in
at the Google Play or Apple App store. After downloading and opening the app, enter your Connection Wisconsin, Minnesota and Michigan.
Code: Security. Sign in using your My Security Health Plan username and password.
10 11
Your coverage includes additional benefits
Security Health Plan offers coverage like no other health plan in Wisconsin. SilverSneakers®, preventive dental, NEW Enjoy SilverSneakers® fitness programs near you
vision and hearing benefits as well as a quarterly credit for over-the-counter supplies are built right into our Our Medicare Advantage plans offer this popular benefit at no cost to you. You receive access to
Medicare Advantage HMO plans. This overview highlights each benefit and explains how to access the benefits.
SilverSneakers’ network of national and local fitness centers.1 SilverSneakers offers the convenient
More information about benefit specifics are in your plan’s Summary of Benefits and Evidence of Coverage.
SilverSneakers GOTM mobile fitness app and SilverSneakers On-DemandTM with 200+ online workout
videos. You also can access full-length live classes and workshops with SilverSneakers LIVE.
Over-the-Counter credit
To get started with your SilverSneakers® membership -
Security Health Plan understands over-the-counter (OTC) drugs and supplies can be expensive. That’s why
you need to get your SilverSneakers ID number. You will need information from your Security Health
we offer you a way to save money on these items – and have them conveniently delivered to your home.
Plan ID card during this process. Here are three ways to get your SilverSneakers ID number:
How the service works 1. Go to www.silversneakers.com/starthere
• Each plan subscriber is eligible for a $30 quarterly credit to purchase select OTC health and wellness products 2. Use the SilverSneakers GO mobile app, or
available through our mail order catalog. 3. Call 1-888-423-4632
• Subscribers can place one OTC order per quarter (quarters start January, April, July and October). Once you have your SilverSneakers ID number you can find a participating location near you using the
• If your order exceeds $30, include payment information (debit or credit card) with your order. interactive map at www.silversneakers.com/locations.1
You should allow about 30 minutes on your initial visit at any participating location to enroll for the
first time. It is recommended that you call the participating fitness center in advance. Staff at the fitness
center location can give you a tour of the facility and demonstrate how to use the equipment.
You can view the OTC catalog and order form online.
Visit www.securityhealth.org/OTC for more information or call our Pharmacy Benefits Department Your membership includes basic access to fitness
at 1-877-216-8533 (TTY 711) , Monday-Friday 8 a.m. to 5 p.m. centers. There could be extra costs if you sign up for Download the SilverSneakers GO app
s
for custom workout programs and tips.
additional services, like personal training.
If you already use a fitness center that is not a
OTC product and delivery information Two ways to order: participating SilverSneakers location, you can switch
• When
placing an order, you will receive to a SilverSneakers location. You can enroll at multiple
the generic equivalent of the name-brand Log in to your My Security Health Plan SilverSneakers fitness center locations at any time.
account at www.securityhealth.org
drug or a similar product.
to place your order. If you don’t have an It is always recommended that you
• If
you choose a product that is unavailable
account, register at www.securityhealth. talk with your doctor before you
or not in stock, a similar product may be start an exercise program. Need
org/registration.
substituted at no additional charge. additional help?
• Similar
products are used for the same Contact SilverSneakers
If you are unable to place your order at 1-888-423-4632, TTY
purpose but may have different ingredients, strength, 711, Monday through
online, please call us at 1-877-216-8533
dosage form or package size. Friday, 7 a.m. to 7 p.m.
or 715-221-9208. We can place your
• Orders
will be shipped to your home by order for you over the phone, Monday-
the US Postal Service at no extra cost to you. Friday, 8 a.m. to 5 p.m. SilverSneakers and the SilverSneakers shoe logotype are
registered trademarks of Tivity Health, Inc. SilverSneakers GO
Please allow 14 business days upon and SilverSneakers On-Demand are trademarks of Tivity Health, Inc.
©2020 Tivity Health, Inc. All rights reserved.
receipt of order to receive shipment.
1. Participating locations (“PL”) are not owned or operated by Tivity Health,
• There
may be order quantity limits on certain OTC items. Inc. or its affiliates. Use of PL facilities and amenities are limited to terms and
conditions of PL basic membership. Facilities and amenities vary by PL.
12 13
Additional benefits (continued)
Additional hearing benefits* Vision exams and eyeglass allowance
Your Security Health Plan Medicare Advantage plan goes beyond Original Medicare, covering routine and
diagnostic hearing services and hearing aids.
Free Eye Exam*
Your coverage includes one free preventive eye exam and an allowance for purchasing eyeglasses.
Routine and diagnostic services You are covered for one free eye exam including refraction per calendar year.
For a Medicare-covered diagnostic exam or a routine exam, you pay only a copayment. To find an in-network To find an in-network optometrist or ophthalmologist, go to www.securityhealth.org/directory.
audiologist, search Security Health Plan’s online provider directory at www.securityhealth.org/directory. • Select your plan, then enter your location information.
• Select your plan, then enter your location information. • Select Optometry or Ophthalmology as the Doctor Type in the Filter menu.
• Select Audiology as the Doctor Type in the Filter menu. • Select a provider and schedule an appointment.
• Select an audiologist and call to schedule an appointment.
* This benefit does not apply to the Ally Rx D-SNP plan.
Hearing Aids
Security Health Plan covers hearing aid fittings and evaluations in conjunction with plan-covered hearing aid Eyeglasses
dispensing. We also cover up to two hearing aids per calendar year. Hearing aids can cost thousands of dollars, Security Health Plan provides an allowance each calendar year toward the purchase of eyeglasses
of your choosing.
but with Security Health Plan you pay only $500 for each aid.
You must use an in-network hearing aid provider and you are limited to the selected hearing aid brands/types Your order for new eyeglasses must be placed through an in-network optometrist or ophthalmologist.
specified by the provider. What you pay does not count toward your out-of-pocket maximum. You must pay any amount above the allowance. Any amount you pay for eyeglasses does not count toward your
out-of-pocket maximum.
To find an in-network hearing aid provider, go to www.securityhealth.org/directory.
If you purchase eyeglasses that cost more than the allowance, you will receive a denial notice from Security
• Click on Find Clinics, Hospitals or Medical Equipment. Health Plan. But don’t worry! This is a Medicare requirement and applies only to the amount above the allowance.
• Select your plan. It just means Security Health Plan will not pay the amount above the allowance and it must be paid by you.
• From the drop down menu choose Hearing Aid Provider.
• Enter your location information.
• Select a provider and schedule an appointment.
* This benefit does not apply to the Ally Rx D-SNP plan.
Free preventive dental
You are covered for preventive dental services with your Medicare Advantage plan. Get one free
preventive dental exam per calendar year, which includes a standard preventive cleaning or
periodontal maintenance cleaning and one set of X-rays: full mouth series, bitewing X-rays or
panoramic X-ray. Be sure to use your Delta Dental ID card for these dental services.
Please note you must use a Delta Dental Medicare Advantage network dentist for all preventive
dental services.
We also offer an optional supplemental dental services benefit. If you have purchased that
supplemental benefit please refer to your Delta Dental certificate of coverage for an explanation of For help finding in-network providers for these additional benefits, or for more information,
your additional dental coverage. call Customer Service at 1-877-998-0998 (TTY 711). We are open 7 days a week, 8 a.m. to 8 p.m.,
Oct. 1-March 31; and Monday through Friday, 8 a.m. to 8 p.m., April 1-Sept. 30.
14 15
Making your health care 3. Do Not Resuscitate (DNR) Order and Bracelet - a DNR order is a request not to have cardiopulmonary
and other decisions on your terms
resuscitation (CPR) if your heart stops or if you stop breathing. If you qualify, you can tell your doctor you do
not want to be resuscitated. To qualify, you must be terminally ill or have a medical condition so severe that
resuscitation would be unsuccessful or harm you. There are two types of DNR orders: pre-hospital or hospital.
The pre-hospital DNR order is for a bracelet that you would wear at all times and that would alert emergency
medical personnel that you do not wish to be resuscitated. The hospital DNR order applies to the in-hospital
Advance Care Planning refers to the information you need to let your doctors, family members and
setting and lets your health care providers know that you do not want to be resuscitated while in the hospital.
friends know your wishes should you ever become unable to make medical or other decisions.
Both types of orders are put in your medical chart by your doctor.
It’s important and is easy to set up an advance directive. An advance directive is a legal document that 4. Power of Attorney for Finances and Property - this document lets you designate someone to make
expresses your health care or other wishes and desires. It allows you to plan ahead before you become financial decisions for you. You can choose when this document becomes active, either when you sign it or
disabled by an accident, illness or debilitating condition and become unable to make decisions. It will when you become incapacitated. It does not authorize anyone to make medical decisions for you. It provides
provide you a way to communicate your wishes to family, friends and health care providers. It is also a options about bill payments, banking, insurance and other financial matters.
way to spare your loved ones the stress of making decisions about your care or payment for care when
you are sick or injured. Medicare Advantage members are not required to complete an advance directive,
but we encourage you to do so. Discrimination is against the law
Security Health Plan of Wisconsin, Inc., complies with applicable Federal civil rights laws and does
You may want to consider having a lawyer help you prepare your advance directive. Information and
not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual
assistance on advance directives may also be available at your county Department of Aging, community
orientation or health status in the administration of the plan, including enrollment and benefit
resource center, local clinic or hospital.
determinations. Security Health Plan does not exclude people or treat them differently because of
race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status.
There are four kinds of advance directives
available in Wisconsin: Security Health Plan:
• Provides free aids and services to people with disabilities to communicate effectively with
1. Power of Attorney for Health Care - this allows you us, such as:
to designate one or more people to make health care Qualified sign language interpreters
–
decisions for you if you become unable to do so. This – Written information in other formats (large print, audio, accessible electronic formats,
person would become your health care agent. Your agent other formats)
would make decisions based on the wishes you have
• Provides free language services to people whose primary language is not English, such as:
expressed within the document or specifically to your
– Qualified interpreters
agent. Their authority would take affect only when you
– Information written in other languages
are certified as being unable to make the decisions for
yourself. This document does not authorize anyone to If you need these services, contact Customer Service at 1-877-998-0998 (TTY 711). If you believe that
make financial decisions for you. It provides options about Security Health Plan has failed to provide these services or discriminated in another way on the basis
nursing or group homes, feeding tubes and treatment of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status,
during pregnancy. It also allows you to state any specific you can file a grievance with:
instructions for your health care like resuscitation, pain
Security Health Plan
control, organ donation or religious preferences about
Attn: Grievances, 1515 North Saint Joseph Avenue, Marshfield, WI 54449-8000
treatment, such as blood transfusions.
Phone: 715-221-9596 (TTY 711) Fax: 715-221-9424
2. Living Will (Declaration to Physicians) - Email: shp.appeals.grievance@securityhealth.org
this document allows you to make choices about
You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, Security
feeding tubes and life-sustaining procedures
You can get our Advance Health Plan can help you. You can also file a civil rights complaint with the U.S. Department of Health
that would be used if you enter a terminal or
Directives brochure and and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint
persistent vegetative state. You can accept or the Wisconsin forms from
refuse care and it allows you to express these Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
Security Health Plan. For more
specific choices to physicians. It does not let you information, call Customer U.S. Department of Health and Human Services
choose someone to make decisions for you. Service at 1-877-998-0998 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201
(TTY 711). Phone: 1–800–368–1019 or 800–537–7697 (TDD)
Continued on next page.
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
16 17Fraud, waste and abuse
We do all we can to detect and prevent health care fraud, waste and abuse. We ask you to help too,
because you know best what health care services you have received.
Here are some examples:
• Fraud – Your doctor bills for a health care service you didn’t receive
• Waste – You get charged twice for a health service because the provider’s office doesn’t keep
accurate records
• Abuse – You receive a health care service you didn’t need
We ask you to report fraud, waste or abuse if you see it happen. Call our Customer Service Department
at 1-877-998-0998 (TTY 711) or our Fraud & Abuse Hotline at 715-221-9570.
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
Limited English proficiency language services
ATTENTION: If you speak a language other than English, language assistance services,
free of charge, are available to you. Call 1-877-998-0998 (TTY 711).
ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia
lingüística. Llame al 1-877-998-0998 (TTY 711).
LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau
koj. Hu rau 1-877-998-0998 (TTY 711).
If you require materials in large print, please call
1-877-998-0998 (TTY 711).
1515 North Saint Joseph Avenue
PO Box 8000
Marshfield, WI 54449-8000
1-877-998-0998
715-221-9897
TTY: 711
Fax 715-221-9500
www.securityhealth.org
©2020 Security Health Plan of Wisconsin, Inc. All rights reserved. Written
permission to reproduce or transmit this document in any form or by any
means must be obtained from Security Health Plan of Wisconsin, Inc.
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