Plan information for Medicare Advantage members

CHPW Medicare Advantage plan information

This page has useful information about how we provide health care coverage and your rights as a CHPW Medicare Advantage member. For more details or paper copies of any of these items, contact Customer Service at 1-800-942-0247 (TTY: 711), 8 a.m. – 8 p.m., 7 days a week.

Getting started

• How to get language assistance and if you need information in a different language or format
• The availability of TTY services for members

Getting care

• How to get primary care services, including points of access*
• How to access 24/7 virtual care (telehealth) services*
• How to get care after normal office hours*
• How to get specialty care, behavioral health services, and hospital services*
• How to access emergency care and emergency rooms, including our policy if it involves or requires emergency services using 911*
• How to access care, services, covered and non-covered benefits outside the service areas*
• How to get information about in-network and out-of-network practitioners, including professional qualifications of in-network primary care and specialty care providers

Benefits and coverage

• Benefits and services included in, and excluded from, coverage*
• How we evaluate new technology to include as a covered benefit
• Premiums, Copayments and other charges for which you are responsible*
• How you may submit a claim for covered services, if applicable*
• Restrictions on benefits that apply to services obtained outside our service areas*
• Prescription Drugs benefits and Pharmaceutical Management procedures*

Special programs

• Our Quality Improvement Program, including goals, processes, and outcomes in terms of care and service
• Our Care Management Program and how you and your caregiver may self-refer to the program
• Our Health Management Programs and how you may self-refer to the programs

Utilization Management (our process of reviewing whether care is medically necessary and appropriate)

• The toll-free number to call (1-800-942-0247; TTY: 711) when you have questions about Utilization Management (UM) issues, such as authorization dates or questions about denials
• Information about how to obtain language assistance to discuss UM issues
• Our policy prohibiting financial incentives for UM decision-makers:
  • UM decision-making is based only on appropriateness of care and service and existence of coverage.
  • The organization does not specifically reward practitioners or other individuals for issuing denials of coverage.
  • Financial incentives for UM decision makers do not encourage decisions that result in underutilization.
• A description of the availability of an independent external appeals process for utilization management decisions made by Community Health Plan of Washington

Your rights and privacy

• Our Member Rights and Responsibilities statement
• How a member may complete an advance directive. An advance directive puts a member’s health care choices into writing and may name someone to speak for the member, if he or she is unable to speak. Advanced directives may include a Health Care Directive, Living Will, or a Durable Power of Attorney
• How to submit a complaint*
• How to appeal a decision that adversely affects coverage, benefits, or your relationship with us*
• Our notice of privacy practices and confidentiality policies including:
  • How we use authorizations, and your right to approve the release of personal health information (PHI)
  • How to request restrictions on the use or disclosure of PHI, amendments to PHI, access to your PHI, or an accounting of disclosures of PHI
  • Our commitment to protect your privacy
  • Our policy on sharing personal health information with Plan sponsors and employers

*Information is found in your plan’s Evidence of Coverage (EOC)

Evidence of Coverage (EOC), located on our Plan Documents page

• Dual Complete: English | Spanish
• Dual Select:  English | Spanish
• Ma Plan 2: English
• MA Plan 4:  English | Spanish
• MA Freedom: English