There are 2 kinds of appeals with Blue Cross of Idaho Care Plus

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1 You have the right to appeal our decision You have the right to ask Blue Cross of Idaho Care Plus to review our decision by asking us for an appeal. If you lose the Medicaid services appeal with Blue Cross of Idaho Care Plus, you can ask for a State Fair Hearing. You can ask for a State Fair Hearing only after losing your appeal with Blue Cross of Idaho Care Plus. Plan Appeal: Ask Blue Cross of Idaho Care Plus for an appeal for Medicaid services within 28 days of the date of this notice. You may appeal by phone. You must follow up your phone request by writing a letter to us. See section titled How to ask for an appeal with Blue Cross of Idaho Care Plus for information on how to ask for a plan level appeal. State Fair Hearing: If you lose the Medicaid services appeal with Blue Cross of Idaho Care Plus, you can ask for a State Fair Hearing. You can ask for a State Fair Hearing only after losing your appeal with Blue Cross of Idaho Care Plus. You must ask for a State Fair Hearing within 28 days of losing the appeal with Blue Cross of Idaho Care Plus. See section titled How to ask for a Medicaid State Fair Hearing of this notice for information about how to ask for a State Fair Hearing. How to keep your services while we review your case: If we re stopping or reducing a service, you can keep getting the service while your case is being reviewed. If you want the service to continue, you must ask for an appeal within 10 days of the date of this notice or before the service is stopped or reduced, whichever is later. Your provider must agree that you should continue getting the service. If you lose your State Fair Hearing appeal, you may have to pay for these services. If you want someone else to act for you You can name a relative, friend, attorney, doctor, or someone else to act as your representative. If you want someone else to act for you, call us at: (888) to learn how to name your representative. TTY users call (800) Both you and the person you want to act for you must sign and date a statement confirming this is what you want. You ll need to mail or fax this statement to us. Keep a copy for your records. Important Information About Your Appeal Rights There are 2 kinds of appeals with Blue Cross of Idaho Care Plus Standard Appeal We ll give you a written decision on a standard appeal within 30 days after we get your appeal. Our decision might take longer if you ask for an extension, or if we need more information about your case. We ll tell you if we re taking extra time and will explain why more time is needed. If your appeal is for payment of a service you ve already received, we ll give you a written decision within 30 days. Fast Appeal We ll give you a decision on a fast appeal within 72 hours after we get your appeal. You can ask for a fast appeal if you or your doctor believe your health could be seriously harmed by waiting up to 30 days for a decision. We ll automatically give you a fast appeal if a doctor asks for one for you or if your doctor supports your request. If you ask for a fast appeal without support from a doctor, we ll decide if your request requires a fast appeal. If we don t give you a fast appeal, we ll give you a decision within 30 days.

2 How to ask for an appeal with Blue Cross of Idaho Care Plus Step 1: You, your representative, or your doctor must ask us for an appeal. Your written request must include: Your name Address Member number Reasons for appealing Whether you want a Standard or Fast Appeal (for a Fast Appeal, explain why you need one). Any evidence you want us to review, such as medical records, doctors letters (such as a doctor s supporting statement if you request a fast appeal), or other information that explains why you need the item or service. Call your doctor if you need this information. We recommend keeping a copy of everything you send us for your records. Step 2: Mail, fax, or deliver your appeal. For a Standard Appeal: Mailing: Blue Cross of Idaho Care Plus In Person: 3000 E. Pine Avenue Medicare Advantage Plans Meridian, ID PO Box 8406 Boise, ID Phone: (888) TTY Users Call: (800) Fax: (208) For a Fast Appeal: Phone: (888) TTY Users Call: (800) Fax: (208)

3 How to ask for a Medicaid State Fair Hearing Step 1: You or your representative can ask for a State Fair Hearing only after losing your appeal with Blue Cross of Idaho Care Plus. You must ask for a State Fair Hearing (in writing) within 28 days of losing your appeal with Blue Cross of Idaho Care Plus. Your written request must include: Your name Address Member number Reasons for appealing Any evidence you want us to review, such as medical records, doctors letters, or other information that explains why you need the item or service. Call your doctor if you need this information. Step 2: Send your request to: Administrative Procedures Section Idaho Department of Health and Welfare 450 West State Street 10 th floor PO Box Boise, ID Fax: APS@dhw.idaho.gov What happens next? The State will hold a hearing. You may attend the hearing in person or by phone. You ll be asked to tell the State why you disagree with our decision. You can ask a friend, relative, advocate, provider, or lawyer to help you. You ll get a written decision within 30 days. Get help & more information Blue Cross of Idaho Care Plus Toll Free: TTY users call: a.m. to 8 p.m., seven days a week or MEDICARE ( ), 24 hours, 7 days a week. TTY users call: Medicare Rights Center: HMO-9050 Elder Care Locator: or to find help in your community. Department of Health and Welfare: , TTY users call: 711 Idaho Commission on Aging:

4 Blue Cross of Idaho Care Plus is a HMO SNP health plan with a Medicare and Idaho Medicaid contract. Enrollment in Blue Cross of Idaho Care Plus depends on contract renewal. This information is available for free in other languages. Please contact our customer service number at , 8 a.m. to 8 p.m. for additional information. TTY users call Esta información está disponible sin costo alguno en otros idiomas. Para información adicional, por favor marque a nuestro número de servicio al cliente de 8 a.m. a 8 p.m. Usuarios de TTY llamar al

5 Nondiscrimination Statement: Discrimination is Against the Law Blue Cross of Idaho complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Blue Cross of Idaho does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Blue Cross of Idaho: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Blue Cross of Idaho s Customer Service Department. Call (TTY: ), or call the customer service phone number on the back of your card. If you believe that Blue Cross of Idaho has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with Blue Cross of Idaho s Grievances and Appeals Department at: Manager, Grievances and Appeals 3000 East Pine Avenue, Meridian, Idaho Telephone: (800) ext.3838, Fax: (208) grievances&appeals@bcidaho.com TTY: You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, our Grievances and Appeals team is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TTY). Complaint forms are available at Reference:

6 Language Assistance ATTENTION: If you speak Arabic, Chinese, French, German, Korean, Japanese, Persian (Farsi), Romanian, Russian, Serbo-Croatian, Spanish, Sudanic Fulfulde, Tagalog, Ukrainian, or Vietnamese, language assistance services, free of charge, are available to you. Call (TTY: ). Arabic. ملحوظة: إاذ كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم (رقم ھاتف الصم والبكم: ) Chinese 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) French ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : ). German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: ). Japanese 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: ) まで お電話にてご連絡ください Korean 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. Persian-Farsi توجھ: اگر بھ زابن فارسی گفتگو می کنید تسھیلات زیناب بصورت اراگین بریا شما فرا مھ می باشد. با ( (TTY: تماس بگیرید. Romanian ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la (TTY: ). Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). Serbo-Croation OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: ). Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). Sudanic Fulfulde MAANDO: To a waawi [Adamawa], e woodi ballooji-ma to ekkitaaki wolde caahu. Noddu (TTY: ). Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ). Ukrainian УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером (телетайп: ). Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: ). Y0010_MK17030 Accepted 08/14/2016