Plan Documents and Forms

Notice of Nondiscrimination 

Click here for the Notice of Nondiscrimination for MedStar Medicare Choice. 

 

Summary of Benefits

Please click on the links below for the Summary of Benefits for MedStar Medicare Choice plans.

2018

MedStar Medicare Choice (HMO) Summary of Benefits 

MedStar Medicare Choice Dual Advantage (HMO SNP) Summary of Benefits 

MedStar Medicare Choice Care Advantage (HMO SNP) Summary of Benefits 

2017

MedStar Medicare Choice (HMO) Summary of Benefits

MedStar Medicare Choice Dual Advantage (HMO SNP) Summary of Benefits

MedStar Medicare Choice Care Advantage (HMO SNP) Summary of Benefits


Plan Ratings Information

Please click on the link below to see plan ratings information for our MedStar Medicare Choice plans.

2018

MedStar Medicare Choice Plan Ratings Information -Coming Soon

2017

MedStar Medicare Choice Plan Ratings Information 


Provider Directory

Please click on the links below for the provider directory for MedStar Medicare Choice plan.

2018

Medstar Medicare Choice Provider Directory

2017

Medstar Medicare Choice Provider Directory


Evidence of Coverage

Please click on the links below for the Evidence of Coverage for MedStar Medicare Choice plan.

2018

If you reside in the District of Columbia 

MedStar Medicare Choice Evidence of Coverage

MedStar Medicare Choice Dual Advantage Evidence of Coverage - Coming Soon

MedStar Medicare Choice Care Advantage Evidence of Coverage

If you reside in Maryland

MedStar Medicare Choice Evidence of Coverage

MedStar Medicare Choice Dual Advantage Evidence of Coverage - Coming Soon

MedStar Medicare Choice Care Advantage Evidence of Coverage

2017

If you reside in the District of Columbia 

MedStar Medicare Choice Evidence of Coverage

MedStar Medicare Choice Dual Advantage Evidence of Coverage

MedStar Medicare Choice Care Advantage Evidence of Coverage

If you reside in Maryland

MedStar Medicare Choice Evidence of Coverage

MedStar Medicare Choice Dual Advantage Evidence of Coverage

MedStar Medicare Choice Care Advantage Evidence of Coverage

 

Multi-Language Insert

MedStar Medicare Choice offers customer support in several languages to answer any questions you may have about our plan.

Click here for 2018 information

Click here for 2017 information


Annual Notice of Change

Click the links below to view the Annual Notice of Change for MedStar Medicare Choice plans.

2018

MedStar Medicare Choice Annual Notice of Change - Maryland

MedStar Medicare Choice Annual Notice of Change - D.C. 

MedStar Medicare Choice Dual Advantage Annual Notice of Change - Maryland 

MedStar Medicare Choice Dual Advantage Annual Notice of Change - D.C. 

MedStar Medicare Choice Care Advantage Annual Notice of Change - Maryland 

MedStar Medicare Choice Care Advantage Annual Notice of Change - D.C.

2017

MedStar Medicare Choice Annual Notice of Change - Maryland

MedStar Medicare Choice Annual Notice of Change - D.C. 

MedStar Medicare Choice Dual Advantage Annual Notice of Change - Maryland 

MedStar Medicare Choice Dual Advantage Annual Notice of Change - D.C. 

MedStar Medicare Choice Care Advantage Annual Notice of Change - Maryland 

MedStar Medicare Choice Care Advantage Annual Notice of Change - D.C.

 

Disaster Policy Information 

Getting Care During a Disaster or Other Public Health Emergency Declaration         

If the President of the United States, the Governor of the State of Maryland, or the United States Secretary of Health of Human Services declares a state of emergency or disaster in your geographic area, you may obtain care from out-of-network providers and facilities that accept Medicare patients at in-network cost sharing rates.  You also won’t have to follow the prior authorization rules before you obtain that out-of-network care.  Also, if you cannot use a network pharmacy during a state of emergency or disaster in your geographic area, you may fill your prescriptions at an out-of-network pharmacy.  If there is an emergency or disaster in your geographic area, the Plan may also allow you to refill your prescriptions earlier than it otherwise normally would until the termination of a public health emergency or the end of a declared disaster or emergency.


Exclusions and Limitations Information

There are some services that are not covered and will not be paid for by MedStar Medicare Choice. The links below provide a detailed listing of these services.

2018

If you reside in the District of Columbia or Maryland

Exclusions and Limitations of MedStar Medicare Choice (HMO)

Exclusions and Limitations of MedStar Medicare Choice Dual Advantage (HMO SNP) - Coming Soon

Exclusions and Limitations of MedStar Medicare Choice Care Advantage (HMO SNP)

2017

If you reside in the District of Columbia or Maryland

Exclusions and Limitations of MedStar Medicare Choice (HMO)

Exclusions and Limitations of MedStar Medicare Choice Dual Advantage (HMO SNP)

Exclusions and Limitations of MedStar Medicare Choice Care Advantage (HMO SNP)


Service Area Map

Click the link below to see a map of the MedStar Medicare Choice service area.

2018

MedStar Medicare Choice Service Area Map 

2017

MedStar Medicare Choice Service Area Map


Authorized Representative Forms

A MedStar Medicare Choice member can appoint a person to act on his/her behalf or to view his/her protected health information (PHI). Choose the appropriate form below, complete the required fields, sign, print, and fax or mail it to us. Once we receive this completed request we will verify it, adjust our records accordingly, and speak to your appointed representative or share your PHI as needed. If you have any questions, please call our Member Services Department at 855-222-1041, from 8 a.m. to 8 p.m., seven days a week.* TTY/TDD users should call 855-250-5604.

Fax: 855-432-8762
Mail: MedStar Medicare Choice
P.O. BOX 65
Pittsburgh, PA 15230-9922

Appointment of Representative Form - Use this form to appoint a representative to make decisions for you and legally act on your behalf (e.g., make requests, present or get evidence, obtain appeals information, and receive notices regarding an appeal).

Personal Representative Designation Form - Use this form to appoint a representative to act on your behalf in discussing your health information and benefit coverage through MedStar Medicare Choice Plan.


Notice of Privacy Practices

Click the link below for the MedStar Medicare Choice Notice of Privacy Practices.

Notice of Privacy Practices


Helpful Websites About Medicare

Medicare.gov

Social Security Administration

CMS Complaint Form

Medicare Ombudsman

H9915_18_4010 - Approved

Last Updated: 10/4/2017