Other BayCarePlus^® Plan Information

Initial Organizational Determinations, Appeals and Grievances

An organization determination is a decision made by your Medicare health plan regarding the coverage or payment of a medical service. A coverage determination is a decision made about the coverage or payment of a Part D prescription drug. These are also referred to as “initial determinations”.

You can request several different types of coverage determinations including prior authorization and a variety of different exceptions to our Part D coverage rules.

If you receive an unfavorable determination, you may submit an appeal. If you’re dissatisfied with any aspect of your plan, you have the right to file grievance.

Go to our Prescription Drugs page to find coverage determination and appeals forms.

At any time during the appeal or grievance process, you may authorize a representative to act on your behalf. We must receive an authorization, in writing, from you to designate a representative. Complete the Appointment of Representative form (updated 9/9/2026) and mail the form to the address located on the Contact Us page. Or contact Member Services for additional details on designating a representative.

For more information about organization and coverage determinations (including exceptions) and appeals and grievances see our policies or reference your plan’s Evidence of Coverage (EOC).

You may also file a grievance online using the Medicare.gov Medicare Complaint Form.

To obtain information about the aggregate number of grievances, appeals and exceptions filed with BayCarePlus or for process or status questions, contact us. 

Member Notification of Medicare National Coverage Determination (NCD)

From time to time, the federal agency that runs Medicare announces new information about coverage under the program. The Medicare program requires to notify its members of this information on our website and in our member newsletter.

Member Notification of Medicare National Coverage Determination

Leaving or Switching Plans

“Disenrollment” from BayCarePlus means ending your membership in our plan. Disenrollment can be voluntary or involuntary:

• You might leave BayCarePlus because you’ve decided that you want to leave. You can do this for any reason; however, there are limits to when you may leave, how often you can make changes, what your other choices are for receiving Medicare services and how you can make changes.
• There are also a few situations where you would be required to leave our plan. For example, you’d have to leave if you permanently move out of our geographic service area or if BayCarePlus leaves the Medicare program. We won’t ask you to leave our plan because of your health.

Until your membership ends, you must keep getting your Medicare services through BayCarePlus, or you’ll have to pay for them yourself.

If you leave our plan, it may take some time for your membership to end and your new way of getting Medicare to take effect. While you’re waiting for your membership to end, you’re still a member and must continue to get your care as usual through our health plan.

If you get services from doctors or other medical providers who aren’t plan providers before your membership in our plan ends, neither BayCarePlus nor the Medicare program will pay for these services, with just a few exceptions. The exceptions are: urgently needed care, care for a medical emergency, out-of-area renal dialysis services and care that’s been approved by us. Another possible exception is if you happen to be hospitalized on the day your membership ends. If this happens, call us to find out if your hospital care will be covered. If you have any questions about leaving BayCarePlus, please call us.

If you want to leave our health plan:

• The first step is to be sure that the type of change you want to make (and when you want to make it) fits within the rules explained below about changing how you get Medicare. If the change doesn’t fit with these rules, you won’t be allowed to make the change.
• Then, what you must do to leave BayCarePlus depends on whether you want switch from BayCarePlus to Original Medicare or to one of your other choices.

In general, there are only certain times during the year when you can change the way you get Medicare. Your plan’s Evidence of Coverage outlines these rules. Contact us for information.

Potential for Contract Termination

If we leave the Medicare program or change our service area so that it no longer includes the area where you live, we’ll tell you in writing. If this happens, your membership in BayCarePlus will end, and you’ll have to change to another way of getting your Medicare benefits. All the benefits and rules described in the Evidence of Coverage will continue until your membership ends. This means that you must continue to get your medical care and prescription drugs in the usual way through our plan until your membership ends.

Your choices for how to get your Medicare coverage will always include Original Medicare and joining a prescription drug plan to complement your Original Medicare coverage. Your choices may also include joining another BayCarePlus plan, another Medicare Advantage plan or a private fee-for-service plan, if these plans are available in your area and are accepting new members. Once we've told you in writing that we’re leaving the Medicare program or the area where you live, you’ll have a chance to change to another way of getting your Medicare benefits. If you decide to change from BayCarePlus to Original Medicare, you’ll have the right to buy a Medigap policy regardless of your health. This is called a “guaranteed issue right.”

BayCarePlus has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs Medicare. This contract renews each year. At the end of each year, the contract is reviewed, and either BayCarePlus or CMS can decide to end it. You’ll get 90 days advance notice in this situation. It’s also possible for our contract to end at some other time during the year. In these situations we’ll try to tell you 90 days in advance, but your advance notice may be as little as 30 or fewer days if CMS must end our contract in the middle of the year.

Whenever a Medicare health plan leaves the Medicare program or stops serving your area, you’ll be provided a special enrollment period to make choices about how you get Medicare coverage, including choosing a Medicare prescription drug plan and guaranteed issue rights to a Medigap policy.

Generally, we can’t ask you to leave the plan because of your health. If you ever feel that you’re being encouraged or asked to leave our plan because of your health, you should call 1-800-MEDICARE (1-800-633-4227), which is the national Medicare help line. TTY users should call (877) 486-2048. You can call seven days a week, 24 hours a day.

We can ask you to leave the plan under certain special conditions. If any of the following situations occur, we’ll end your BayCarePlus membership:

• If you aren’t a United States citizen or lawfully present in the United States
• If you move out of the service area or are away from the service area for more than six months in a row. If you plan to move or take a long trip, please call us to find out if the place you’re moving to or traveling to is in our service area. If you move permanently out of our geographic service area, or if you’re away from our service area for more than six months in a row, you generally can’t remain a member of BayCarePlus. In these situations, if you don’t leave on your own, we must end your membership (“disenroll” you).
• If you don’t stay continuously enrolled in both Medicare Part A and Medicare Part B
• If you're required to pay the extra Part D amount because of your income and you do not pay it, Medicare will disenroll you from our plan and you'll lose prescription drug coverage
• If you give us information on your enrollment request that you know is false or deliberately misleading, and it affects whether or not you can enroll in our plan
• If you lie about or withhold information about other insurance you have that provides prescription drug coverage
• If you behave in any way that's disruptive, to the extent that your continued enrollment seriously impairs our ability to arrange or provide medical care for you or for others who are members of a BayCarePlus plan. We can’t make you leave our plan for this reason unless we get permission first from the Centers for Medicare & Medicaid Services, the government agency that runs Medicare.
• If you let someone else use your plan membership card to get medical care. If you’re disenrolled for this reason, CMS may refer your case to the Inspector General for additional investigation.
• If you become incarcerated (go to prison)

You have the right to make a complaint if we ask you to leave our plan. If we ask you to leave, we’ll tell you our reason(s) in writing and explain how you can file a complaint against us if you so choose.

Rights and Protections

As a Medicare beneficiary, you have certain rights to help protect you. You can read more about your rights and responsibilities as a member of BayCarePlus in the Evidence of Coverage. You can also contact Medicare by calling 1-800-MEDICARE (1-800-633-4227). TTY users should call (877) 486-2048. You can call seven days a week, 24 hours a day. You can go to the Medicare website at Medicare.gov. Following is a summary of our members’ rights and protections.

All Medicare Advantage plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Advantage plan leaves the program, you won’t lose Medicare coverage. If a plan decides not to continue in the program, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area.

As a BayCarePlus member, you have the right to request an initial organizational determination for medical services or a coverage determination for prescription drugs, which includes the right to request an exception. You may ask us for an exception if you believe you need a drug that isn’t on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at the pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s) or medical service, you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network providers that doesn’t involve the coverage of services.

Using Out-of-Network Providers

With few exceptions, you must pay for services you receive from providers who aren’t part of the BayCarePlus network unless BayCarePlus has approved these services in advance. The exceptions are care for a medical emergency, urgently needed care, out-of-area renal (kidney) dialysis services and services that are found upon appeal to be services that we should have paid or covered. 

Accessing Benefits During a Disaster or Emergency

What happens during a disaster or emergency?

When an emergency or disaster disrupts access to health care in your service area, know that BayCarePlus makes necessary changes to ensure you have access to your health plan benefits. Until the disaster or emergency ends, we do the following:

• Cover your BayCarePlus plan benefits (including benefits covered by Original Medicare—Parts A and B) when care is received at non-contracted facilities. Note that Part A and B services must be received at Medicare-certified facilities
• Waive referral requirements, where applicable
• Provide the same cost-sharing at non-contracted facilities as if the service or benefit were received at a plan-contracted facility
• Make changes that benefit you effective immediately without a 30-day notification requirement

Who declares a disaster or emergency?

A disaster declaration will identify the geographic area affected and may be made as one of the following:

• Presidential declaration of a disaster or emergency under either of the following:
  • Stafford Act
  • National Emergencies Act
• Secretarial declaration of a public health emergency under section 319 of the Public Health Service Act
• Declaration by the Governor of a State or Protectorate

When does the disaster or emergency end?

For the changes made above, which ensure your access to your health plan benefits, the emergency or disaster ends 30 days after the occurrence of one of the following conditions, whichever is earlier:

• When all sources that declared a disaster or emergency for the health plan’s service area declare an end to the disaster or emergency
• If no end date was identified in the disaster or emergency declaration(s), when all applicable emergencies or disasters declared for the health plan’s service area have ended, including through expiration of the declaration or any renewal of such declaration
• When there’s no longer a disruption of access to health care

If we can’t resume normal operations by the end of the disaster or emergency, we’ll notify the Centers for Medicare & Medicaid Services (CMS).

Special Requirements

In addition, we must explain the terms and conditions of payment during the emergency or disaster for non-contracted providers providing benefits to plan enrollees who live in the impacted area.