2019 Preferred Provider Organization Medicare Advantage (PPO
MA)Annual Notice of Change (ANOC) and Evidence of Coverage (EOC)
Templates2019 1 1 12 31
[insert 2019 plan name] [insert plan type] Medicare [insert if
applicable: ]
[Optional: insert beneficiary name] [Optional: insert beneficiary
address]
2019 1 1 12 31 Medicare
[insert 2019 plan name] [insert MAO name] [insert MAO name] [insert
2019 plan name]
[Insert Federal contracting statement.]
[Plans that meet the 5% alternative language threshold insert:
[insert languages that meet the 5% threshold]
[insert phone number] [insert TTY number][insert days and hours of
operation]]
[Plans must insert language about availability of alternate formats
(e.g., Braille, large print, audio tapes) as applicable.]
[Remove terms as needed to reflect plan benefits] 2020 1 1 //
[Remove terms as needed to reflect plan benefits] /
[Insert as applicable: [insert Material ID] CMS Approved [MMDDYYYY]
OR [insert Material ID] File & Use [MMDDYYYY]]
OMB Approval 0938-1051Pending OMB Approval
2019
Medicare
2 14
([insert 2019 plan name]) Medicare (SHIP)Medicaid
3 27
5 80
·
·
1 3
1.1 [insert 2019 plan name] Medicare PPO 3
1.2 3
1.3 3
2 4
2.1 4
2.2 Medicare A Medicare B 4
2.3 [insert 2019 plan name] 5
2.4 5
3 6
3.1 6
3.2 6
4 [insert 2019 plan name] 7
4.1 7
4.2 8
4.3 10
5 10
5.1 10
6 11
6.1 11
7 11
7.1 11
1
1.1 [insert 2019 plan name] Medicare PPO
Medicare [insert 2019 plan name] Medicare
Qualifying Health Coverage (QHC) (ACA) (IRS)
https://www.irs.gov/Affordable-Care-Act/Individuals-and-Families
Medicare [Insert 2019 plan name] Medicare Advantage PPO PPO
Preferred Provider Organization D Medicare Medicare PPO
Medicare
1.2
[insert 2019 plan name]
[insert 2019 plan name]
2019 1 1 12 31 [insert 2019 plan name]
Medicare 2019 12 31 [insert 2019 plan name] 2019 12 31
Medicare
MedicareMedicare Medicaid [insert 2019 plan name] Medicare
Medicare
2
2.1
Medicare A Medicare B 2.2 Medicare A Medicare B
2.3 [Plans with grandfathered members who were outside of area
prior to January 1999, insert: 1999 1 1999 1 1999 1 ]
2.2 Medicare A Medicare B
Medicare Medicare A B
Medicare A
2.3 [insert 2019 plan name]
Medicare [insert 2019 plan name] [if a “continuation area” is
offered under 42 CFR 422.54, insert here, and add a sentence
describing the continuation area] [insert as appropriate: OR
]
[Insert plan service area here or within an appendix. Plans may
include references to territories as appropriate. Use county name
only if approved for entire county. For partially approved
counties, use county name plus zip code. Examples of the format for
describing the service area are provided below.If needed, plans may
insert more than one row to describe their service area:
50
[insert states]
[insert state] [insert county][insert zip codes]]
[Optional info: multi-state plans may include the following:
[insert as applicable: OR ] [insert if applicable: ] [insert if
applicable: ] [insert if applicable: ][National plans delete the
rest of this paragraph.] [insert if applicable: ] [insert if
applicable: ] ]
Original Medicare Medicare
2 5
2.4
3
Medicaid
[Insert picture of front and back of member ID card. Mark it as a
sample card (for example, by superimposing the word “sample” on the
image of the card.]
Medicare Medicare Medicare
Medicare [insert 2019 plan name]
3.2
[insert if applicable: ]
[Regional PPOs that CMS has granted permission to use the exception
in § 422.112(a)(1)(ii) to meet access requirements should insert:
]
[Plans may add additional information describing the information
available in the provider directory, on the plan’s website, or from
Member Services. For example: [insert URL] ]
4 [insert 2019 plan name]
4.1
[Select one of the following: 2019 [insert 2019 plan name] [insert
monthly premium amount]OR OR OR [insert 2019 plan name] [describe
attachment][Plans may insert a list of or table with the
state/region and monthly plan premium amount for each area included
within the EOC. Plans may also include premium(s) in an attachment
to the EOC.]] Medicare B B Medicaid
[Plans with no premium should replace the preceding paragraph with:
[insert 2019 plan name] Medicare B B Medicaid ]
[Insert if applicable: ]
[MA-only plans that do not offer optional supplemental benefits,
may delete this section.]
[MA-only plans that offer optional supplemental benefits may
replace the text below with the following: 4.1 [If the plan
describes optional supplemental benefits within Chapter 4, then the
plan must include the premium amounts for those benefits in this
section.]]
Medicare
[Plans that include a Part B premium reduction benefit may describe
the benefit within this section.]
[Plans with no monthly premium, omit: ] Medicare 2 Medicare A
Medicare B A Medicare A Medicare B Medicare
2019 Medicare 2019 Medicare Medicare B Medicare Medicare Medicare
Medicare ( https://www.medicare.gov ) 2019 Medicare 7 24
1-800-MEDICARE (1-800-633-4227) 1-877-486-2048
4.2
[Plans indicating in Section 4.1 that there is no monthly premium:
Delete this section.]
[insert number of payment options] [Plans must indicate how the
member can inform the plan of their premium payment option choice
and the procedure for changing that choice.]
1
[Insert plan specifics regarding premium payment intervals (e.g.,
monthly, quarterly- please note that beneficiaries must have the
option to pay their premiums monthly), how they can pay by check,
including an address, whether they can drop off a check in person,
and by what day the check must be received (e.g., the 5th of each
month). It should be emphasized that checks should be made payable
to the Plan and not CMS nor HHS. If the Plan uses coupon books,
explain when they will receive it and to call Member Services for a
new one if they run out or lose it. In addition, include
information if you charge for bounced checks.]
2[Insert option type]
[If applicable: Insert information about other payment options. Or
delete this option.
Include information about all relevant choices (e.g., automatically
withdrawn from your checking or savings account, charged directly
to your credit or debit card, or billed each month directly by the
plan). Insert information on the frequency of automatic deductions
(e.g., monthly, quarterly – please note that beneficiaries must
have the option to pay their premiums monthly), the approximate day
of the month the deduction will be made, and how this can be set
up. Please note that furnishing discounts for members who use
direct payment electronic payment methods is prohibited.]
[Include the option below only if applicable. SSA only deducts plan
premiums below $300.]
[insert number]
[Plans that do not disenroll members for non-payment may modify
this section as needed.]
[insert day of the month] [insert day of the month] [insert length
of plan grace period]
[Insert if applicable: [Insert one or both statements as applicable
for the plan: AND/OR ]]
7 9 [insert hours of operation] [insert phone number] [insert TTY
number] 60
4.3
[Plans with no premium replace next sentence with the following: ]
1 1
5
5.1
[In the heading and this section, plans should substitute the name
used for this file if different from “membership record.”]
[insert as appropriate: //IPA]
[Plans that allow members to update this information on-line may
describe that option here.]
2 5
6
6.1
7
Medicare
65 100 100
65 20 20
ESRD Medicare Medicare 30
Medicare Medicaid TRICARE Medicare/ Medigap
ID
2019 [insert 2019 plan name] 90
2
2
1 [Insert 2019 plan name] 15
2 Medicare Medicare 19
3 Medicare 20
4 Medicare Medicare 21
5 22
6 Medicaid 23
7 24
8 25
1 [Insert 2019 plan name]
[Insert phone number(s)]
[Insert days and hours of operation, including information on the
use of alternative technologies.]
/
[Insert if plan uses a direct TTY number: ]
[insert if applicable:] [Insert days and hours of operation.]
[Insert URL]
[Note: If your plan uses the same contact information for the Part
C issues indicated below, you may combine the appropriate
sections.]
[Insert phone number]
[insert if applicable:] [Insert days and hours of operation] [Note:
You may also include reference to 24-hour lines here.] [Note: If
you have a different number for accepting expedited organization
determinations, also include that number here.]
/
[Insert if plan uses a direct TTY number: ]
[insert if applicable: ] [Insert days and hours of operation]
[Note: If you have a different TTY number for accepting expedited
organization determinations, also include that number here.]
[Optional: insert fax number] [Note: If you have a different fax
number for accepting expedited organization determinations, also
include that number here.]
[Insert address] [Note: If you have a different address for
accepting expedited organization determinations, also include that
address here.]
[Note: plans may add email addresses here.]
[Insert phone number]
[insert if applicable: ] [Insert days and hours of operation]
[Note: You may also include reference to 24-hour lines here.]
[Note: If you have a different number for accepting expedited
appeals, also include that number here.]
/
[Insert if plan uses a direct TTY number: ]
[insert if applicable: ] [Insert days and hours of operation]
[Note: If you have a different TTY number for accepting expedited
appeals, also include that number here.]
[Optional: insert fax number] [Note: If you have a different fax
number for accepting expedited appeals, also include that number
here.]
[Insert address] [Note: If you have a different address for
accepting expedited appeals, also include that address here.]
[Note: plans may add email addresses here.]
[Insert phone number]
[insert if applicable: ] [Insert days and hours of operation]
[Note: You may also include reference to 24-hour lines here.]
[Note: If you have a different number for accepting expedited
grievances, also include that number here.]
/
[Insert if plan uses a direct TTY number: ]
[insert if applicable: ] [Insert days and hours of operation]
[Note: If you have a different TTY number for accepting expedited
grievances, also include that number here.]
[Optional: insert fax number] [Note: If you have a different fax
number for accepting expedited grievances, also include that number
here.]
[Insert address] [Note: If you have a different address for
accepting expedited grievances, also include that address
here.]
[Note: plans may add email addresses here.]
MEDICARE
Medicare [insert 2019 plan name] Medicare
https://www.medicare.gov/MedicareComplaintForm/home.aspx
5
7
[Optional: Insert phone number and days and hours of operation]
[Note: You are required to accept payment requests in writing, and
may choose to also accept payment requests by phone.]
[insert if applicable: ]
/
[Optional: Insert number] [Note: You are required to accept payment
requests in writing, and may choose to also accept payment requests
by phone.]
[Insert if plan uses a direct TTY number: ]
[insert if applicable: ] [Insert days and hours of operation]
[Optional: Insert fax number] [Note: You are required to accept
payment requests in writing, and may choose to also accept payment
requests by fax.]
Medicare 65 65
Medicare Medicare Medicaid CMS Medicare Advantage
Medicare Medicare Medicare Medicare
Medicare Medicare
· Medicare Eligibility Tool Medicare
· Medicare Plan Finder Medicare Medicare MedigapMedicare
Medicare
[insert 2019 plan name] Medicare
· Medicare Medicare [insert 2019 plan name] Medicare
https://www.medicare.gov/MedicareComplaintForm/home.aspx Medicare
Medicare
Medicare 1-800-MEDICARE (1-800-633-4227) Medicare
1-877-486-2048
3 Medicare
[Organizations offering plans in multiple states: Revise the second
and third paragraphs in this section to use the generic name
(“State Health Insurance Assistance Program” or “SHIP”), and
include a list of names, phone numbers, and addresses for all SHIPs
in your service area. Plans have the option of including a separate
exhibit to list information for all states in which the plan is
filed, and should make reference to that exhibit below.]
(SHIP) [Multiple-state plans inserting information in an exhibit,
replace rest of this paragraph with a sentence referencing the
exhibit where members will find SHIP information.] [Multiple-state
plans inserting information in the EOC add: ] [Multiple-state plans
inserting information in the EOC use bullets for the following
sentence, inserting separate bullets for each state.] [insert
state]SHIP [insert state-specific SHIP name]
[Insert state-specific SHIP name] Medicare
[Insert state-specific SHIP name] Medicare Medicare Medicare
[Insert state-specific SHIP name] Medicare
[Insert state-specific SHIP name] [If the SHIP’s name does not
include the name of the state, add: ([insert state name]
SHIP)]
[Insert number, if available. Or delete this row.]
[Insert if the SHIP uses a direct TTY number: ]
4 Medicare Medicare
[Organizations offering plans in multiple states: Revise the second
and third paragraphs of this section to use the generic name
(“Quality Improvement Organization”) when necessary, and include a
list of names, phone numbers, and addresses for all QIOs in your
service area. Plans have the option of including a separate exhibit
to list the QIOs in all states, or in all states in which the plan
is filed, and should make reference to that exhibit below.]
Medicare [Multi-state plans inserting information in an exhibit,
replace rest of this paragraph with a sentence referencing the
exhibit where members will find QIO information.] [Multiple-state
plans inserting information in the EOC add: ] [Multiple-state plans
inserting information in the EOC use bullets for the following
sentence, inserting separate bullets for each state.] [insert
state] [insert state-specific QIO name]
[Insert state-specific QIO name] Medicare Medicare [Insert
state-specific QIO name]
[insert state-specific QIO name]
[Insert state-specific QIO name] [If the QIO’s name does not
include the name of the state, add:[insert state name] ]
/
[Insert number, if available. Or delete this row.]
[Insert if the QIO uses a direct TTY number: ]
/
1-800-325-0778
6 Medicaid
[Organizations offering plans in multiple states: Revise this
section to include a list of agency names, phone numbers, days and
hours of operation, and addresses for all states in your service
area. Plans have the option of including a separate exhibit to list
Medicaid information in all states or in all states in which the
plan is filed and should make reference to that exhibit
below.]
[Plans may adapt this generic discussion of Medicaid to reflect the
name or features of the Medicaid program in the plan’s state or
states.]
Medicaid Medicare Medicaid
Medicaid Medicare Medicare Medicare Medicare
Medicare (QMB) Medicare A B QMB Medicaid (QMB+)
Medicare (SLMB) B SLMB Medicaid (SLMB+)
(QI) B
(QDWI) A
Medicaid [insert state-specific Medicaid agency]
[Insert state-specific Medicaid agency] [If the agency’s name does
not include the name of the state, add:[insert state name] Medicaid
]
/
[Insert number, if available. Or delete this row.]
[Insert if the state Medicaid program uses a direct TTY number:
]
/ 1-800-MEDICARE1-800-633-4227/ 1-877-486-2048 Medicare
3
1.1 28
1.2 28
2 29
2.1 [insert as applicable: OR ] (PCP) 29
2.2 PCP 30
2.3 30
2.4 31
2.5 32
3 33
3.1 33
3.2 34
3.3 34
4 35
4.1 35
4.2 35
5 35
5.1 35
5.2 36
6 37
6.1 37
6.2 37
7 38
7.1 38
1
4
1.1
4
1.2
Medicare [insert 2019 plan name] Original Medicare Original
Medicare
[Insert 2019 plan name]
4
Original Medicare 2
[RPPOs that CMS has granted permission to use the exception in §
422.112(a) (1) (ii) to meet access requirements should insert:
]
Medicare Medicare Medicare Medicare
2
2.1 [insert as applicable: OR ] (PCP)
[Note: Insert this section only if plan uses PCPs.Plans may edit
this section to refer to a Physician of Choice (POC) instead of
PCP.]
PCPPCP
[Plans should describe the following in the context of their
plans:
PCP
PCP
PCP
PCP PCP PCP [PPOs with lower cost-sharing for network providers
insert: ][Explain if the member changes their PCP this may result
in being limited to specific specialists or hospitals to which that
PCP refers (i.e., sub-network, referral circles). Also noted in
Section 2.3 below.]
[Plans should describe how to change a PCP and indicate when that
change will take effect (e.g., on the first day of the month
following the date of the request, immediately upon receipt of
request, etc.).]
2.2 PCP
[Note: Insert this section only if plans use PCPs or require
referrals to network providers.]
PCP
X [insert if appropriate: ]
[insert if applicable: B ] [insert if appropriate: ]
Medicare [Plans may insert requests here (e.g., )]
· [Plans should add additional bullets as appropriate.]
2.3
[Plans should describe how members access specialists and other
network providers, including:
· PCP
· Include an explanation of the process for obtaining Prior
Authorization (PA), including who makes the PA decision (e.g., the
plan, PCP, another entity) and who is responsible for obtaining the
prior authorization (e.g., PCP, member). Refer members to Chapter
4, Section 2.1 for information about which services require prior
authorization.
· Explain if the selection of a PCP results in being limited to
specific specialists or hospitals to which that PCP refers, i.e.
sub-network, referral circles.]
Medicare
30
2.4
Medicare Medicare Medicare Medicare
7 4
7
[RPPOs that CMS has granted permission to use the exception in §
422.112(a) (1) (ii) to meet access requirements should insert:
]
5
3
2.5
[RPPOs: If there are portions of your RPPO service area where you
have not met Medicare network adequacy requirements, you must
insert this section and explain to your members the process they
must follow to find providers who will treat them (see
422.111(b)(3)(ii)). The expectation is that members in non-network
areas will receive all necessary assistance in obtaining access to
services, which may require the RPPO to pay more than the Original
Medicare payment rate to ensure access. Members in non-network
areas can only be charged the in-network (i.e., preferred)
cost-sharing amount for plan-covered services.]
3
3.1
911 PCP PCP
[Plans add if applicable: 48 [Plans must provide either the phone
number and days and hours of operation or explain where to find the
number (e.g., on the back the plan membership card).]]
[plans may modify this sentence to identify whether this coverage
is within the U.S. or worldwide emergency/urgent coverage.] 4
[Plans that offer a supplemental benefit covering worldwide
emergency/urgent coverage or ambulance services outside of the U.S.
and its territories, mention the benefit here and then refer
members to Chapter 4 for more information.]
[Plans may modify this paragraph as needed to address the
post-stabilization care for your plan.]
3.2
[Plans must insert instructions for how to access in-network
urgently needed services (e.g., using urgent care centers, a
provider hotline, etc.)]
[Insert if applicable: [insert if plan covers emergency care
outside of the United States: ] [Modify if worldwide
emergency/urgent coverage is covered as a supplemental
benefit.]]
3.3
4.1
4.2
[Insert 2019 plan name] 4
7
[Plans should explain whether paying for costs once a benefit limit
has been reached will count toward an out-of-pocket maximum.]
5
5.1
Medicare [plans that conduct or cover clinical trials that are not
approved by Medicare insert: ] Medicare [plans that conduct or
cover clinical trials that are not approved by Medicare insert:
]
Medicare [plans that conduct or cover clinical trials that are not
approved by Medicare insert:]
Medicare Original Medicare
Medicare [plans that do not use PCPs may delete the rest of this
sentence] PCP
Medicare
$100 Original Medicare $20 $10Original Medicare $80 $10 $10
Medicare 5
Medicare
6
6.1
A Medicare
6.2
[Omit this bullet if not applicable]
[Plans must explain whether Medicare Inpatient Hospital coverage
limits apply (include a reference to the benefits chart in Chapter
4) or whether there is unlimited coverage for this benefit.]
7
7.1
[Plans that allow transfer of ownership of certain DME items to
members must modify this section to explain the conditions under
which and when the member can own specified DME.]
(DME) DME
Original Medicare DME 13 [insert 2019 plan name] [insert if the
plan sometimes allows ownership: ] DME [Insert if your plan
sometimes allows transfer of ownership for items other than
prosthetics: DME ] [Insert if your plan never transfers ownership
(except as noted above, for example, for prosthetics): Original
Medicare DME 12 ]
Original Medicare
DME Original Medicare 13 13
Original Medicare DME 13 13 Original Medicare 13 Original
Medicare
4
4
1 42
1.1 42
1.2 42
1.3 [insert if plan has an overall deductible described in Section
1.2: ] [insert if plan has an overall deductible described in
Section 1.2: ] 43
1.4 [insert if applicable: Medicare A B ] 44
1.5 45
1.6 46
2 47
2.1 47
2.2 75
2.3 / 75
3 76
3.1 76
1
1.1
[Describe all applicable types of cost-sharing your plan uses. You
may omit those that are not applicable.]
2
2
Medicaid Qualified Medicare Beneficiary (QMB) Medicaid QMB
1.2
[Local or regional PPO plans with no deductibles, delete this
section and renumber remaining subsections in Section 1.]
[Note: deductibles cannot be applied to $0.00 Medicare preventive
services, emergency services or urgently needed services]
[Note: RPPOs and local PPO plans that choose to have a deductible
are now only permitted to have a single deductible that applies to
both in-network and out-of-network services, see revised section
422.101(d)(1).]
[insert deductible amount] [insert as applicable:OROR]
[Insert all services not subject to the deductible, including all
Medicare-covered preventive services and any other in-network Part
A and B services the plan elects to exempt from the deductible
requirement.Plans must specify whether it is in-network and/or
out-of-network services that are exempt from the deductible.][Note:
If a PPO has a deductible, all out-of-network Part A and B services
must be subject to the deductible with the sole exception that the
PPO may elect to waive out-of-network Medicare-covered zero
cost-sharing preventive services from the deductible
requirement.]
1.3 [insert if plan has an overall deductible described in Section
1.2: ] [insert if plan has an overall deductible described in
Section 1.2: ]
[Plans with service category deductibles: insert this section. If
applicable, plans may revise the text as needed to describe how the
service category deductible(s) work with the overall plan
deductible.]
[Plans with a service category deductible that is not based on the
calendar year – e.g., a per stay deductible – should revise this
section as needed.]
[Insert if plan has an overall deductible described in Section 1.2:
]
[Insert if plan does not have an overall deductible and Section 1.2
was therefore omitted: ]
[Insert if plan has one service category deductible: [insert
service category] [insert service category deductible] [insert
service category] [insert as applicable:OROR][Insert if applicable:
[insert service category] [insert service category] [insert service
category] [insert service category] ]]
[Insert if plan has more than one service category
deductible:
[Plans should insert a separate bullet for each service category
deductible: [insert service category] [insert service category
deductible] [insert service category] [insert as
applicable:OROR][Insert if applicable: [insert service category]
[insert service category] [insert service category] [insert service
category] ]]]
1.4 [insert if applicable: Medicare A B ]
[insert combined MOOP] [insert as applicable: Medicare A B OR ]
[insert applicable terms: ] [Plans with no premium may delete the
following sentence.][Insert if applicable, revising reference to
asterisk as needed: ] [insert combined MOOP] 100% [insert if
applicable: A B ] [insert if plan has a premium: ] Medicare B B
Medicaid
1.5
[Plans with service category OOP maximums: insert this
section.
[Plans with a service category OOP maximum that is not based on the
calendar year – e.g., a per stay maximum – should revise this
section as needed.]
[insert if applicable: A B ] 1.4
[Insert if plan has one service category MOOP: [insert service
category] [insert service category MOOP] [insert service category]
[insert service category MOOP] [Insert if service category is
included in MOOP described in Section 1.4: A B [insert service
category] [insert service category] A B [insert MOOP] [insert
service category] [insert service category OOP max] [insert service
category]]]
[Insert if plan has more than one service category MOOP:
Plans should insert a separate bullet for each service category
MOOP: [insert service category] [insert service category MOOP]
[insert service category] [insert service category MOOP] [Insert if
service category is included in MOOP described in Section 1.4: A B
[insert service category] [insert service category] A B [insert
MOOP] [insert service category] [insert service category OOP max]
[insert service category]]]
1.6
[insert 2019 plan name] [plans with a plan-level deductible insert:
]
2
2.1
Medicare Medicare
[PPO plans that use prior authorizations insert: [insert 2019 plan
name]
[insert as appropriate: OR OR OR ] [Insert if applicable: [insert
list]]
Medicare Original Medicare Original Medicare Original Medicare 2019
Medicare https://www.medicare.gov 1-800-MEDICARE (1-800-633-4227)
1-877-486-2048)
Original Medicare [Insert as applicable: ]
Medicare Original Medicare Medicare 2019 Medicare
[Insert if offering MA Uniformity Flexibility benefits and/or
targeted supplemental benefits, or Value Based Insurance Design
Model Test (VBID) benefits:
· /
· [List all applicable chronic conditions here.]
· [If applicable, plans offering benefits under VBID that require
participation in a health and wellness program, direct the enrollee
to see the “Notice of VBID Benefits.” (See Medicare Advantage
Value-Based Insurance Design Model CY2019 Communications
Guidelines).]
·
[Instructions to plans offering MA Uniformity Flexibility benefits
or VBID benefits:
· Plans must deliver to each clinically-targeted enrollee a written
summary of those benefits so that such enrollees are notified of
the MA Uniformity Flexibility or VBID benefits for which they are
eligible. VBID plans should follow the VBID guidance on
communications for delivering such notice when offering targeted
supplemental or VBID benefits. (See Medicare Advantage Value-Based
Insurance Design Model CY 2019 Communications Guidelines).
· If applicable, plans must update the Medical Benefits Chart and
include a supplemental benefits chart including a column that
details the exact targeted reduced cost sharing amount for each
specific service, and/or the additional supplemental benefits being
offered. Specific services should include details as it relates to
Part D benefits and VBID.
· If applicable, plans with VBID should mention that beneficiaries
may qualify for a reduction or elimination of their cost sharing
for Part D drugs.]
[Instructions on completing benefits chart:
· When preparing this Benefits Chart, please refer to the
instructions for completing the standardized ANOC and EOC.
· If using Medicare FFS amounts (e.g. Inpatient and SNF cost
sharing) the plan must insert the 2018 Medicare amounts and must
insert: 2018 2019 [Insert plan name] Member cost-sharing amounts
may not be left blank.
· For all preventive care and screening test benefit information,
plans that cover a richer benefit than Original Medicare do not
need to include given description (unless still applicable) and may
instead describe plan benefits.
· Optional supplemental benefits are not permitted within the
chart; plans that would like to include information about optional
supplemental benefits within the EOC may describe these benefits
within Section 2.2.
· All plans with networks should clearly indicate for each service
applicable the difference in cost-sharing at network and
out-of-network providers and facilities.
· Plans that have tiered cost-sharing of medical benefits based on
contracted providers should clearly indicate for each service the
cost-sharing for each tier, in addition to defining what each tier
means and how it corresponds to the characters or footnotes
indicating such in the provider directory (when one reads the
provider directory, it is clear what the symbol or footnote means
when reading this section of the EOC).
· Plans should clearly indicate which benefits are subject to prior
authorization (plans may use asterisks or similar method).
· Plans may insert any additional benefits information based on the
plan’s approved bid that is not captured in the benefits chart or
in the exclusions section. Additional benefits should be placed
alphabetically in the chart.
· Plans must describe any restrictive policies, limitations, or
monetary limits that might impact a beneficiary’s access to
services within the chart.
· Plans may add references to the list of exclusions in Section 3.1
as appropriate.
· Plans must make it clear for members (in the sections where
member cost sharing is shown) whether their hospital copays or
coinsurance apply on the date of admission and / or on the date of
discharge.]
[List copays / coinsurance / deductible. Specify whether
cost-sharing applies one-way or for round trips.]
B 12 12
Medicare 12 B 12 Medicare
[Also list any additional benefits offered.]
Medicare
40 12
24
[Also list any additional benefits offered.]
[List copays / coinsurance / deductible]
[Also list any additional benefits offered.]
[Also list any additional benefits offered.]
Medicare
[If the plan only covers manual manipulation, insert: ]
[Also list any additional benefits offered.]
[List copays / coinsurance / deductible]
[Also list any additional benefits offered.]
Medicare
[If applicable, list copayment and / or coinsurance charged for
barium enema.]
[Include row if applicable. If plan offers dental benefits as
optional supplemental benefits, they should not be included in the
chart. Plans may describe them in Section 2.2 instead.]
[List any additional benefits offered, such as routine dental
care.]
[List copays / coinsurance / deductible]
12
Medicare
[Plans may put items listed under a single bullet in separate
bullets if the plan charges different copays. However, all items in
the bullets must be included.]
[List copays / coinsurance / deductible]
(DME)
10
[Plans that do not limit the DME brands and manufacturers that you
will cover insert: Original Medicare DME[Insert as applicable: DME
] [insert URL] [insert as applicable: ] ]
[Plans that limit the DME brands and manufacturers that you will
cover insert: [insert 2019 plan name] DME DME [Insert as
applicable: DME ] [insert URL]
[List copays / coinsurance / deductible]
(DME)
[insert 2019 plan name] Original Medicare DME [insert 2019 plan
name] DME 90 90 /
7 []]
[Also identify whether this coverage is only covered within the
U.S. as required or whether emergency care is also available as a
supplemental benefit that provides worldwide emergency/urgent
coverage.]
[List copays / coinsurance. If applicable, explain that
cost-sharing is waived if member admitted to hospital.]
[Insert if applicable: ]
[These are programs focused on health conditions such as high blood
pressure, cholesterol, asthma, and special diets. Programs designed
to enrich the health and lifestyles of members include weight
management, fitness, and stress management. Describe the nature of
the programs here.
If this benefit is not applicable, plans should delete this
row.]
[List copays / coinsurance / deductible]
[insert as applicable: PCP OR ]
[List any additional benefits offered, such as routine hearing
exams, hearing aids, and evaluations for fitting hearing
aids.]
[List copays / coinsurance / deductible]
[If the enrollee has been diagnosed by a plan provider with the
certain chronic condition(s) identified and meets certain criteria,
they may be eligible for other targeted supplemental benefits
and/or targeted reduced cost sharing. The certain chronic
conditions must be listed here. The benefits listed here must be
approved in the bid.Describe the nature of the benefits here.
If this benefit is not applicable, plans should delete this entire
row.]
[List copays / coinsurance / deductible]
12
Medicare A B Original Medicare A B Original Medicare
Medicare A B Medicare A B
[insert 2019 plan name] Medicare A B [insert 2019 plan name] A
B
Medicare A B Original Medicare [insert 2019 plan name]
[Include information about cost-sharing for hospice consultation
services if applicable.]
Medicare B
[Also list any additional benefits offered.]
B
[List days covered and any restrictions that apply.]
[List all cost-sharing (deductible, copayments/ coinsurance) and
the period for which they will be charged. If cost-sharing is based
on the Original Medicare or a plan-defined benefit period, include
definition/explanation of approved benefit period here.Plans that
use per-admission deductible include: [In addition, if applicable,
explain all other cost-sharing that is charged during a benefit
period.]]
[If cost-sharing is not based on the Original Medicare or
plan-defined benefit period, explain here when the cost-sharing
will be applied. If it is charged on a per admission basis,
include: / ]
Are You a Hospital Inpatient or Outpatient? If You Have Medicare -
Ask! Medicare Medicare https://www.medicare.gov/Pubs/pdf/11435.pdf
1-800-MEDICARE (1-800-633-4227) 1-877-486-2048
[If inpatient cost-sharing varies based on hospital tier, enter
that cost-sharing in the data entry fields.]
[insert if applicable: ] [insert if applicable: ]
[List days covered, restrictions such as 190-day lifetime limit for
inpatient services in a psychiatric hospital. 190 ]
[List all cost-sharing (deductible, copayments/ coinsurance) and
the period for which they will be charged. If cost-sharing is based
on the Original Medicare or a plan-defined benefit period, include
definition/explanation of approved benefit period here. Plans that
use per-admission deductible include: [In addition, if applicable,
explain all other cost-sharing that is charged during a benefit
period.]]
[If cost-sharing is not based on the Original Medicare or
plan-defined benefit period, explain here when the cost-sharing
will be applied. If it is charged on a per admission basis,
include: / ]
SNF
[Plans with no day limitations on a plan’s hospital or skilled
nursing facility (SNF) coverage may modify or delete this row as
appropriate.]
(SNF)
[insert as appropriate: OR ]
Medicare Medicare Advantage Original Medicare 3 2 [insert as
appropriate: OR ] [insert as appropriate: OR ]
[Also list any additional benefits offered.]
Medicare
MDPP
MDPP
Medicare B
[plans may delete any of the following drugs that are not covered
under the plan] Epogen []Procrit []Epoetin Alfa []Aranesp []
Darbepoetin Alfa []
[Also list any additional benefits offered.]
X
[List separately any services for which a separate copay /
coinsurance applies over and above the outpatient radiation therapy
copay / coinsurance.]
[Plans can include other covered tests as appropriate.]
[List copays / coinsurance / deductible]
Are You a Hospital Inpatient or Outpatient? If You Have Medicare -
Ask! Medicare Medicare https://www.medicare.gov/Pubs/pdf/11435.pdf
1-800-MEDICARE (1-800-633-4227) 1-877-486-2048
[Also list any additional benefits offered.]
[List copays / coinsurance / deductible]
[Also list any additional benefits offered.]
[List copays / coinsurance / deductible]
[List copays / coinsurance / deductible]
[Describe the plan’s benefits for outpatient substance abuse
services.]
[List copays / coinsurance / deductible]
[List copays / coinsurance / deductible]
[insert as applicable: PCP OR ]
[Insert if the plan has a service area and providers / locations
that qualify for telehealth services under the Medicare
requirements: Medicare ]
[Insert if appropriate: ]
[Also list any additional benefits offered.]
[List copays / coinsurance / deductible]
[List copays / coinsurance / deductible]
PSA
[List copays / coinsurance / deductible]
[Also list any additional benefits offered.]
[List copays / coinsurance / deductible]
Medicare
12 LDCT
55 77 30 15 Medicare LDCT
LDCT LDCT LDCT LDCT Medicare
Medicare LDCT
(STI) STI
B (STI) STI 12
STI 20-30
[Also list any additional benefits offered.]
Medicare STI STI
Medicare B B Medicare B
[List copays / coinsurance / deductible]
10 SNF
[List days covered and any restrictions that apply, including
whether any prior hospital stay is required.]
SNF
SNF
/
[List copays / coinsurance / deductible. If cost-sharing is based
on benefit period, include definition / explanation of BID approved
benefit period here.]
12
[Also list any additional benefits offered.]
Medicare
(SET)
SET 12 36
SET
·
· /
[Also list any additional benefits offered.]
[List copays / coinsurance / deductible]
[Include in-network benefits. Also identify whether this coverage
is within the U.S. or as a supplemental worldwide emergency /
urgent coverage.]
[List copays / coinsurance. Plans should include different
copayments for contracted urgent care centers, if
applicable.]
50 65
[Adapt this description if the plan offers more than is covered by
Original Medicare.]
[Also list any additional benefits offered, such as supplemental
vision exams or glasses. If the additional vision benefits are
optional supplemental benefits, they should not be included in the
benefits chart; they should be described within Section 2.2.]
[List copays / coinsurance / deductible]
Medicare
Medicare B 12 Medicare Medicare
Medicare
2.2
[Include this section if you offer optional supplemental benefits
in the plan and describe benefits below. You may include this
section either in the EOC or as an insert to the EOC.]
Original Medicare [insert if applicable: ][insert as applicable:
OR]
[Insert plan specific optional benefits, premiums, deductible,
copays and coinsurance and rules using a chart like the Benefits
Chart above.Insert plan specific procedures on how to elect
optional supplemental coverage, including application process and
effective dates and on how to discontinue optional supplemental
coverage, including refund of premiums.Also insert any restrictions
on members’ re-applying for optional supplemental coverage (e.g.,
must wait until next annual enrollment period).]
2.3 /
[If your plan offers a visitor/traveler program to members who are
out of your service area, insert this section, adapting and
expanding the following paragraphs as needed to describe the
traveler benefits and rules related to receiving the out-of-area
coverage. If you allow extended periods of enrollment out-of-area
per the exception in 42 CFR 422.74(b)(4)(iii) (for more than six
months up to 12 months) also explain that here based on the
language suggested below.
/ [specify areas where the visitor/traveler program is being
offered] 12 / [insert 2019 plan name] //
/ 12 12 ]
3
Medicare
[The services listed in the chart below are excluded from Original
Medicare’s benefit package. If any services below are covered
supplemental benefits, delete them from this list. When plans
partially exclude services excluded by Medicare, they need not
delete the item completely from the list of excluded services but
may revise the text accordingly to describe the extent of the
exclusion.Plans may add parenthetical references to the Benefits
Chart for descriptions of covered services / items as
appropriate.Plans may reorder the below excluded services
alphabetically, if they wish. Plans may also add exclusions as
needed.]
Medicare
Medicare Original Medicare
3 5
1.1 81
2 82
3 83
3.1 83
3.2 84
1
1.1
1.
2.
· 4 [edit section number as needed] 1.6
·
·
[Plans should insert additional circumstances under which they will
accept a paper claim from a member.]
7
2
2.1
[If the plan has developed a specific form for requesting payment,
insert the following language:
[Insert address]
[If the plan allows members to submit oral payment requests, insert
the following language:
2 1 [plans may edit section title as necessary] ]
[Insert if applicable: [insert timeframe] ]
3
3.1
3
3.2
7 7 4 4 4 7 5.3
6
1 87
1.1 [Plans may edit the section heading and content to reflect the
types of alternate format materials available to plan members.
Plans may not edit references to language except as noted below.]
87
1.2 87
1.3 88
1.4 88
1.5 89
1.6 90
1.7 92
1.8 92
1.9 93
2 93
2.1 93
[Note: Plans may add to or revise this chapter as needed to reflect
NCQA-required language.]
1
1.1 [Plans may edit the section heading and content to reflect the
types of alternate format materials available to plan members.
Plans may not edit references to language except as noted
below.]
[Plans must insert a translation of Section 1.1 in all languages
that meet the language threshold.]
[insert plan contact information] 1-800-MEDICARE (1-800-633-4227)
Medicare [plan customer service]
1.2
1-800-368-1019 1-800-537-7697
1.3
[If your plan does not require any referrals or prior authorization
within the preferred network, delete the next three sentences and
instead state: ]
[Regional PPOs: Explain how members will obtain care at in-plan
rates in any areas of its region where the plan has a limited
contracted provider network.]
7 9 7 4
1.4
1.5
[Plans may edit the section to reflect the types of alternate
format materials available to plan members and / or language
primarily spoken in the plan service area.]
[insert 2019 plan name] 1.1
[insert URL]
7 7
5
1.6
7
[Note: Plans that would like to provide members with state-specific
information about advanced directives, including contact
information for the appropriate state agency, may do so.]
[insert appropriate state-specific agency (such as the State
Department of Health)] [Plans also have the option to include a
separate exhibit to list the state-specific agency in all states,
or in all states in which the plan is filed, and then should revise
the previous sentence to make reference to that exhibit.]
1.7
1-800-368-1019 1-800-537-7697
1-800-MEDICARE (1-800-633-4227) Medicare 1-877-486-2048
1.9
Medicare
Medicare Your Medicare Rights & Protections Medicare
https://www.medicare.gov/Pubs/pdf/11534.pdf
1-800-MEDICARE (1-800-633-4227) 1-877-486-2048
2
2.1
Medicare 1 7
[Insert if applicable: ]
Medicare A B Medicare A Medicare B
[insert if applicable: ] [insert as appropriate: OR OR OR ] 4
[if a continuation area is offered, insert here and then explain
the continuation area] 1 Medicare
7
99
3 100
3.1 100
102
4.1 102
4.2 103
4.3 103
5 104
5.1 104
5.2 105
5.3 1 108
5.4 2 110
5.5 112
6 113
6.1 Medicare 113
6.2 1 114
6.3 2 117
6.4 1 118
7 120
7.1 (CORF) 120
7.2 121
7.3 1 121
7.4 2 123
7.5 1 124
8 3 126
8.1 34 5 126
128
9.1 128
9.2 130
9.3 130
9.4 131
9.5 Medicare 131
[Plans should ensure that the text or section heading immediately
preceding each “Legal Terms” box is kept on the same page as the
box.]
3
1.2
2
2.1
(SHIP)
SHIP [Plans providing SHIP contact information in an exhibit may
revise the following sentence to direct members to it.] 2 3
Medicare
Medicare ( https://www.medicare.gov )
1
1 2 2 2 2 2
4.2
2
1 1 2 2
4.3
7 [CORF]
2 3
5
4
5.1
4
1.
2.
7 6
7 7 (CORF)
5
2 1 [plans may edit section title as necessary]
14
14
24 [] 9
72
9
2
24 9
72 5.3
72
24 9
14 5.3
14
1 5.3
5.3 1
1
2 1 [plans may edit section title as necessary]
[If the plan accepts oral requests for standard appeals, insert: 2
1 [plans may edit section title as necessary]]
Medicare
https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf
[plans may also insert: [insert website or link to form]] 44
2 1 [plan may edit section title as needed]
60
14
72 2 2
72
2
14
24 9
2 2
30
2
2
5.4 2
1 2
1
Medicare Medicare Medicare
[If a fee is charged, insert: ]
1 2
1 2 2 72
14
1 2
1 2 2 30
14
2
3 3 2
3
2
2 3 2
3 8 34 5
5.5
5 5
60
30 2 60
6
4
Medicare (An Important Message from Medicare about Your Rights)
Medicare 1-800-MEDICARE (1-800-633-4227) 1-877-486-2048
1.
Medicare
2.
6.2 1
1
Medicare 2 4
2
3
2 2 2
2
1 60
2
4 3
2 2 3 3
8 34 5
6.4 1
1
2 1 [plans may edit section title as necessary]
2
2
2
1 2
1
2 72
Medicare Medicare Medicare
3
2 2 3
8 34 5
7
7.1 (CORF)
Medicare (CORF) 10
4
Medicare 1-800-MEDICARE (1-800-633-4227) 1-877-486-2048
https://www.cms.gov/Medicare/Medicare-General-Information/BNI/MAEDNotices.html
1.
2
1
1 1
2
4 1
1 1
2
2 2 2 (CORF)
2
1 60
2
4
2 2 3 3
8 34 5
7.5 1
1
1
1
2 1 [plans may edit section title as necessary]
2
2
2
1 2
1
2 72
Medicare Medicare Medicare
3
3
2 2 3 3
8 34 5
8 3
8.1 34 5
1 2
2 3
4 2 3
60
4 4
4 Medicare
3 5 2 4
60
5
4
9.1
·
·
·
1
[Insert phone number, TTY, and days and hours of operation.]
[Insert description of the procedures (including time frames) and
instructions about what members need to do if they want to use the
process for making a complaint. Describe expedited grievance time
frames for grievances about decisions to not conduct expedited
organization/coverage determinations or
reconsiderations/redeterminations.]
60
24
2
30 14 44
9.4
2 4
Medicare [insert 2019 plan name] Medicare
https://www.medicare.gov/MedicareComplaintForm/home.aspx Medicare
Medicare
1-800-MEDICARE (1-800-633-4227) 1-877-486-2048
66
2.2 Medicare Advantage 135
2.3 135
2.4 136
3 136
3.1 136
4 137
4.1 137
5 [Insert 2019 plan name] 138
5.1 138
5.2 139
5.3 139
1
1.1
3
2.1
10 15 12 7
Medicare
— — Medicare Original Medicare
1 1
2.2 Medicare Advantage
Medicare Advantage
Medicare Advantage 1 1 3 31
Medicare Advantage
Medicare Advantage
Original Medicare Original Medicare 3 31 Medicare
Medicare Advantage Original Medicare Medicare
2.3
[insert 2019 plan name]
Medicare ( https://www.medicare.gov )
[Revise bullet to use state-specific name, if applicable.]
Medicaid
Medicare
Medicare Original Medicare
— — Medicare Original Medicare
Medicare Medicare Medicare
Medicare ( https://www.medicare.gov ) Medicare
1-800-MEDICARE (1-800-633-4227) Medicare 1-877-486-2048
3
3.1
Medicare 2 Medicare Original Medicare
Medicare Original Medicare
Medicare
Medicare Original Medicare
1-800-MEDICARE (1-800-633-4227) Medicare 1-877-486-2048
Original Medicare [insert 2019 plan name]
4
4.1
[insert 2019 plan name] Medicare 2
5 [Insert 2019 plan name]
5.1
[Plans with visitor / traveler benefits should revise this bullet
to indicate when members must be disenrolled from the plan.]
[Plans with visitor / traveler benefits, insert: / 4 2.3 ]
[Plans with grandfathered members who were outside of area prior to
January 1999, insert: 1999 1 1999 1 1999 1 ] ]
[Omit bullet if not applicable] Medicare
[Omit bullet and sub-bullet if not applicable] Medicare
Medicare
[Omit bullet and sub-bullet if not applicable. Plans with different
disenrollment policies for dual eligible members who do not pay
plan premiums must edit these bullets as necessary to reflect their
policies. Plans with different disenrollment policies must be very
clear as to which population is excluded from the policy to
disenroll for failure to pay plan premiums.] [insert length of
grace period, which cannot be less than two calendar months]
[insert length of grace period, which cannot be less than two
calendar months]
5.3
7 9
66
3 Medicare 142
[Note: You may include other legal notices, such as a notice of
member non-liability, a notice about third-party liability or a
nondiscrimination notice under Section 1557 of the Affordable Care
Act. These notices may only be added if they conform to Medicare
laws and regulations.]
1
2
[Plans may add language describing additional categories covered
under state human rights laws.] Medicare Advantage 1964 1973 1975
1557
3 Medicare
Medicare Medicare CMS 42 CFR 422.108 423.462 [insert 2019 plan
name] Medicare Advantage 42 CFR 411 B D CMS
[Note: You may include other legal notices, such as a notice of
member non-liability, a notice about third-party liability or a
nondiscrimination notice under Section 1557 of the Affordable Care
Act. These notices may only be added if they conform to Medicare
laws and regulations.]
66
10
[Plans should insert definitions as appropriate to the plan type
described in the EOC.You may insert definitions not included in
this model and exclude model definitions not applicable to your
plan, or to your contractual obligations with CMS or enrolled
Medicare beneficiaries.]
[If allowable revisions to terminology (e.g., changing “Member
Services” to “Customer Service”) affect glossary terms, plans
should re-label the term and alphabetize it within the
glossary.]
[If you use any of the following terms in your EOC, you must add a
definition of the term to the first section where you use it and
here in Chapter 10 with a reference from the section where you use
it: IPA, network, PHO, plan medical group, Point of Service.]
[Include if applicable: Medicare ]
[Insert cost plan definition only if you are a Medicare Cost Plan
or there is one in your service areaMedicare Cost Plan (HMO) (CMP)
1876(h) ]
[Insert PACE plan definition only if there is a PACE plan in your
state: PACE PACE (LTC) PACE Medicare Medicaid ]
[Plans that do not use PCPs, omit] [insert as appropriate: OR ]
(PCP) Medicare 3 2.1 [insert as appropriate: OR ]
MedigapMedicare Original Medicare Medicare Medigap Original
MedicareMedicare Advantage Medigap
C Medicare Advantage (MA)
D Medicare D
Medicaid Medicaid Medicare Medicaid Medicaid 2 6
Medicare 65 65 Medicare Original Medicare [insert only if there is
a cost plan in your service area: Medicare Cost Plan,] [insert only
if there is a PACE plan in your state: PACE ] Medicare Advantage
Medicare
Medicare Advantage (MA) Medicare C Medicare Medicare A B Medicare
Advantage HMOPPO (PFFS) Medicare (MSA) Medicare Advantage Medicare
Original Medicare Medicare Advantage Medicare D Medicare Advantage
Medicare A B Medicare
Medicare Advantage Medicare Advantage Original Medicare D 2019 1 1
3 31
Medicare Medicare A B Medicare Medicare A B
Medicare Medicare Medicare Medicare A B Medicare Advantage
Medicare / (PACE)
Medicare Medicare D Medicare A B
Medicare Medicaid (CMS) Medicare 2 CMS
Original Medicare Medicare Medicare Original Medicare Medicare
Advantage Original Medicare Medicare Medicare Medicare Medicare
Original Medicare A B
7
[Insert if plan has a premium:](1) (2) (3)
[insert if applicable:] 20%
[insert if applicable: A B ] [Plans with service category MOOPs
insert: [insert if applicable: A B ] ] 4 1.[insert subsection
number]
Original Medicare 10 15 12 7
Medicare Medicare Medicare
(LIS)
[Edit or delete as necessary to make the definition applicable to
your plan.] PPO PPO 4
[Modify definition as needed if plan uses benefit periods for SNF
stays but not for inpatient hospital stays.] [insert if applicable:
] Original Medicare (SNF) [Plans that offer a more generous benefit
period, revise the following sentences to reflect the plan’s
benefit period.] 60 SNF [Insert if applicable: ]
10 20
EOC
(SSI) 65 SSI
24
Medicare
/Medicare
(DME)
Medicare Medicare A B 65 Medicare 7 65 3 65 65 3
(PPO) Medicare Advantage PPO PPO
[insert 2019 plan name]
Original Medicare
Medicare Advantage Medicare Medicaid
(SNF)
6
Medicare Medicare Medicaid (CMS)
2
(CORF)
Medicare [insert if appropriate: ]
[insert if applicable: A B ] [Plans with service category MOOPs
insert: [insert if applicable: A B ] ] 4 1.[insert subsection
number]
3
1) 2)
Medicare Advantage 7
Medicare Medicare
[This is the back cover for the EOC.Plans may add a logo and / or
photographs, as long as these elements do not make it difficult for
members to find and read the plan contact information.]
[Insert 2019 plan name]
[Insert phone number(s)]
[Insert days and hours of operation, including information on the
use of alternative technologies.]
/
[Insert if plan uses a direct TTY number: ]
[insert if applicable: ] [Insert days and hours of
operation.]
[Insert URL]
[Insert state-specific SHIP name] [If the SHIP’s name does not
include the name of the state, add: ([insert state name]
SHIP)]
[Insert state-specific SHIP name] Medicare
[Plans with multi-state EOCs revise heading and sentence above to
use “State Health Insurance Assistance Program,” omit table, and
reference exhibit or EOC section with SHIP information.]
[Insert number, if available. Or delete this row.]
[Insert if the SHIP uses a direct TTY number: ]
[Insert URL]