Member Forms & Other Resources

Member Forms
Here are some commonly used Member Forms:

• Appointment of Representative Form.
  By filling out this form and returning to us, Members may appoint any of the following to act as his/her representative: a relative, friend, advocate, attorney, and physician; employee of a pharmacy, charity, or state pharmaceutical assistance program.
  
  
• Member Coverage Determination Request Form.
  
  
• Provider Coverage Determination Request Form.
  
  
• Request For Prescription Information or Change.

• An Appeal is a complaint you make if you disagree with a coverage or payment decision. You can appeal if you request a health care service, supply, or prescription that you think you should be able to get, or if you request payment for health care you already got, and Medicare or your plan denies the request.
  
  
• A Grievance is a complaint about the way your Medicare health plan is giving care. For example, you may file a grievance if you have a problem calling the plan or if you are unhappy with the way a staff person at the plan has behaved toward you.

Second, ask yourself if this is a Part D (Prescription Drug) Grievance, Appeal, or Coverage Determination?

• An Part D Appeal is any of the procedures that deal with the review of an unfavorable coverage determination or exception request.
  
  
• A Part D Grievance is any other type complaint regarding Part D benefits or services.
  
  
• A Part D Coverage Determination is the first decision (made by Freedom Health not the pharmacy) about your drug benefits, including whether to provide or pay for a drug or to grant an exception request.

To learn more about our Grievance and Appeal Process or to learn how to make an Appeal, Grievance, or Coverage Determination, read more.

Member Rights and Responsibilities Upon Disenrollment
Disenrollment from Freedom Health ends your membership with the Freedom Medicare Advantage Plans.  If you leave the Freedom Medicare Advantage Plans, it takes some time for your membership to end and your new way of getting Medicare to take effect.  Until your membership officially ends, you must keep receiving your Medicare services through the Freedom Medicare Advantage Plans or you will have to pay for these services yourself--with a few exceptions.  These exceptions are urgently needed care, care for a medical emergency, out-of-area renal (kidney) dialysis services, and care that has been approved by Freedom Health.  One other possible exception is if you happen to be hospitalized on the day your membership ends.  If this occurs, you should contact Member Services to find out if your hospital care will be covered by the Freedom Medicare Advantage Plans.

You may contact our Grievance and Appeals Department from 8:00 a.m. to 6:00 p.m. Monday to Friday. TTY users may call 1-800-955-8771

Our Contract with CMS
Freedom Health may terminate or refuse to renew its contract with the Centers for Medicare and Medicaid Services (CMS), or reduce the service area included in its current contract.  More information on your Medicare coverage may be found in the “Medicare & You Handbook” published each year by CMS or at the CMS web site at http://www.medicare.gov.