Medical Coverage and Benefits

Troy is committed to making sure you get the medical care you need. Your experience is important to us. If you experience unhappiness or dissatisfaction with Troy, a plan provider or staff, or your coverage, you have certain rights.

Your Grievance Rights

If you are dissatisfied with something, you can file a complaint or grievance with the plan. You have three ways to file a complaint or grievance with Troy:

1. You can call us at 1-888-494-TROY (8769). We will try to resolve your dissatisfaction over the phone.
2. You also can file a grievance in writing or use our grievance form. Go to the Documents and Forms page for the Grievance/Appeal form, complete it and mail it to us.
3. You can also use the contact us page. We will call you to get additional information and try to resolve the issue over the phone.

If we can’t resolve the issue, we will work with you to resolve within 30 days. We also can take an extension of 14 days, if needed. We will let you know if we need to take an extension.

Direct link on the grievance/coverage determination webpage to the Medicare.gov complaint website at: https://www.medicare.gov/MedicareComplaintForm/home.aspx, where an enrollee can enter a complaint in lieu of calling 1-800-MEDICARE.

Your Organization Determination and Appeal Rights

There are some instances where you need to see a physician not within our network or get a service you think should be covered but not on the benefit listing, or just want to know if something is covered. In these instances, you have the right to request an Organization Determination or an Appeal if you receive a denial of a service request or claim payment. You have three ways to file a coverage determination request:

1. You can call us at 1-888-494-TROY (8769). If you request an organization determination, we will document your request and forward it to our prior authorization department for review and response to you. If you received a denial notification and request an appeal, we will document and forward your request to our Appeals Department.
2. You also can file an organization determination request in writing or use our Prior Authorization Request Form. You can file an Appeal request in writing or use our Grievance/Appeal Request form. Go to the Documents and Forms page for the Prior Authorization Request Form or the Grievance/Appeal form, complete it and mail it to us.
3. You can also use the contact us page. We will call you to get additional information and try to resolve the issue over the phone.
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Your Appointment of Representation Rights

You can appoint someone to represent you if you need someone or choose to have someone assist you with filing a grievance, organization determination, or an appeal. You will need to complete an Appointment of Representation Form (AOR) and send it to us. If you need help completing this form, please call us at 1-888-494-TROY (8769), we can help you or the person you want to help you with completing this form. AOR Form Link

Rights and Responsibilities upon Disenrollment

If you choose to end your membership or disenroll from Troy Medicare

If you choose to disenroll from Troy Medicare, there are only certain times during the year, or certain situations, when you may voluntarily end your membership in the plan. The process for voluntarily ending your membership varies depending on what type of new coverage you are choosing.

If you are leaving our plan, you must continue to get your medical care through our plan until your membership ends.

You may end your membership in our plan only during certain times of the year, known as enrollment periods. All members can leave the plan during the Annual Enrollment Period and during the Medicare Advantage Open Enrollment Period. In certain situations, members of Troy Medicare may be eligible to end their membership at other times of the year. This is known as a Special Enrollment Period.

Who is eligible for a Special Enrollment Period?

If any of the following situations apply to you, you may be eligible to end your membership during a Special Enrollment Period. These are just examples; for the full list, you can contact the plan, call Medicare, or visit the Medicare website (https://www.medicare.gov):

• Usually, when you have moved.
• If you have Medicaid.
• If you are eligible for “Extra Help” with paying for your Medicare prescriptions.
• If we violate our contract with you.
• If you are getting care in an institution, such as a nursing home or long-term care (LTC) hospital.

When are Special Enrollment Periods? The enrollment periods vary depending on your situation. To find out if you are eligible for a Special Enrollment Period, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877486-2048. If you are eligible to end your membership because of a special situation, you can choose to change both your Medicare health coverage and prescription drug coverage. This means you can choose any of the following types of plans:

• Another Medicare health plan. (You can choose a plan that covers prescription drugs or one that does not cover prescription drugs.)
• Original Medicare with a separate Medicare prescription drug plan.
• Original Medicare without a separate Medicare prescription drug plan.

If you have any questions or would like more information on when you can end your membership, you can call us, or you can find the information in the Medicare & You 2021 handbook. Your Evidence of Coverage has more information in Chapter 10, Ending your membership.