National Member Information

blue and white line

Advance Directives

State your health care preferences.

Decisions about end of life medical care can be much easier when
advance directives are used. An Advance directive is a written
instruction, such as a living will or durable power of attorney for
health care, made while you are competent, about the medical treatment you want when you consciously cannot make decisions. By stating your health care preferences in writing about end of life care, your decisions are legally valid and will be respected by medical professionals, the health care decision-makers designated by you, and your family.

A Health Care Power of Attorney is a document that allows you to name
a person who will act on your behalf to make health care decisions for
you if you become unable to make them for yourself.

A Living Will is a document that allows you to establish, in advance,
the type of medical care you would want to receive if you become
permanently unconscious or terminally ill and unable to tell your
physician or family what kind of life-sustaining treatments you want to

If you want to use an advance directive, we recommend that you:

• Get the form. If you want an advance directive, you can get the form that complies with state law from your lawyer, from a social worker, from some office supply stores and from organizations that provide information about Medicare. You can also contact Member Services to ask for the forms (phone numbers are listed on the back of your member ID card).

• Complete the form and sign as directed. Regardless of where you get the advance directive form, keep in mind that it is a legal document.
Consider asking a lawyer help you prepare it.

• Give copies of the signed forms to appropriate people. We recommend
that you give a copy of the form to your physician, your lawyer, and to
the person you name on the form to make decisions for you. You may also give copies to close friends or family members. Be sure to keep a copy at home.

If you know ahead of time that you are going to be hospitalized, and
you have an advance directive, take a copy with you to the hospital.

• If you are admitted to the hospital, a hospital staff member will ask whether you have an advance directive and whether you have it with you.

• If you have not signed an advance directive, the hospital has forms
available and a staff member will ask if you want to sign one.

Remember, it is your choice of whether you want to complete an
advance directive (including whether you want to sign one if you are in
hospital). Under the law, no one can deny you care or discriminate
against you based on whether or not you signed an advance directive.

Advance directives should be reviewed on a periodic basis so they can be updated as necessary.

Federal Disasters

Getting Medical Care and Prescription Drugs in a Disaster or Emergency Area

If the Governor of your state, the U.S. Secretary of Health and Human
Services, or the President of the United States declares a state of
disaster or emergency in your geographic area, you are still entitled to care from us. PrimeTime Health Plan will temporarily change our rules for affected member’s medical care and prescription drugs during an emergency or disaster as described below:

Medical Care

• Allow members to see certain doctors or go to certain hospitals that
accept Medicare patients, even if the doctor or hospital isn’t in our
network and your health care isn’t an emergency.

• Waive referral rules for out-of-network services.

• Reduce plan-approved out-of-network cost-sharing to in-network cost-sharing amounts.

Pharmacy Access (Plans with Part D coverage)

• Lift the “refill-too-soon” edits on your prescriptions if you had to
leave your home without them or they were lost or damaged due to the
emergency or disaster.

• Allow you to obtain the maximum extended-day supply of your
medication, if requested and available at the time of refill, at one of our extended-day supply pharmacies.

• Allow access to covered Part D drugs dispensed at out-of-network
pharmacies when you cannot obtain your covered drugs at a network
pharmacy. You may have to pay more at an out-of-network pharmacy. If you pay full cost for your medications at an out-of-network pharmacy, you may submit your receipt for reimbursement consideration.

Replacing lost or damaged durable medical equipment or supplies (wheelchair, walker, diabetic supplies, etc.)

• Equipment and supplies normally covered under the plan will be
replaced at the network level of benefits if they are lost or damaged
due to the disaster.

Replacing a lost plan member identification card

• Contact our Service Center at the phone numbers listed below to replace a lost or damaged member identification card.

Paying your plan premium

• If your plan has a monthly plan premium and you pay us directly, you
can sign up for premium withholding from your Social Security check or
pay by electronic funds transfer through your bank. Contact our Service Center at the phone numbers listed below for additional information.

Contact information
To get more information about getting care from doctors or other
providers and prescription drugs during an emergency or disaster, please contact us:

Call:  330-363-7407 or 1-800-577-5084

TTY users:  711

Call Center Hours:  Monday through Friday 8:00 a.m. to 8:00 p.m. (October 1st – March 31st, we are available 7 days a week, 8:00 a.m. to 8:00 p.m.)


National Coverage Determinations

Throughout the year, the Centers for Medicare & Medicaid Services
(CMS) may issue notifications of new coverage rules for additional services covered by the Medicare program or clarifications of existing covered services. These notifications are called National Coverage Determinations (NCDs). NCDs expand coverage for a specific service or set of services to Medicare beneficiaries. Services addressed by NCDs may be covered by PrimeTime Health Plan. The CMS requires PrimeTime Health Plan to notify members when NCDs are issued.

What does this mean to me?

This is an announcement of new coverage rules. The new rules may not affect allmembers. See below for a list of NCDs for the current plan year. 

What are the new coverage rules?

The Centers for Medicare & Medicaid Services (CMS) will cover acupuncture for chronic low back pain under section 1862(a)(1)(A) of the Social Security Act. Up to 12 visits in 90 days are covered for Medicare beneficiaries under the following circumstances: (effective January 21, 2020)

· For the purpose of this decision, chronic low back pain (cLBP) is defined as:

     o Lasting 12 weeks or longer;

     o Nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease);

     o Not associated with surgery; and

     o Not associated with pregnancy.

· An additional eight sessions will be covered for those patients demonstrating an improvement.

     o No more than 20 acupuncture treatments many be administered annually.

     o Treatment must be discontinued if the patient is not improving or is regressing.   

NCD for Acupuncture for Chronic Low Back Pain (cLBP) released 05.13.2020  

The Centers for Medicare & Medicaid Service (CMS) has determined that the evidence is sufficient to cover ambulatory blood pressure monitoring (ABPM) for the diagnosis of hypertension in Medicare beneficiaries under certain circumstances.

ABPM devices must be:
- Capable of recording and plotting blood pressure measurements for 24 hours.
-Provided to patients with oral and written instructions and a test run in the physician's office must be performed; and
- Interpreted by the treating physician or treating non-physician practitioner.

For eligible patients, ABPM is covered once per year.

NCD for Ambulatory Blood Pressure Monitoring (ABPM) released 07.02.19

Medicare covers leadless pacemakers through Coverage with Evidence Development(CED) when procedures are performed in CMS-approved CED studies effective January 18, 2017.

NCD for Screening for Leadless Pacemakers_released 07.28.2017

Medicare has concluded that implanted permanent cardiac pacemakers, single chamber or dual chamber, are reasonable and necessary for the treatment of non-reversible symptomatic bradycardia due to sinus node dysfunction and secondand/or third degree atrioventricular block.

NCD for Single Chamber and Dual Chamber Permanent Cardiac pacemakers_update released 10.26.2015

Medicare will cover a lung cancer screening with Low Dose Computed Tomography (LDCT) once per year for Medicare beneficiaries who meet specific criteria.

NCD for Lung Cancer Screening with Low Dose Computed Tomography (LDCT)_released 02.05.2015

What should I do if I have questions?

If you would like help understanding these new rules, call PrimeTime
Health Plan at (330) 363-7407 or 1-800-577-5084. (TTY only call 711) We are available for phone calls Monday
through Friday 8:00 a.m. to 8:00 p.m. From October 1st - March 31st
the Service Center is open 7 days a week from 8:00 a.m. to 8:00 p.m.

PrimeTime Health Plan is an HMO-POS plan with a Medicare contract.
Enrollment in PrimeTime Health Plan depends on contract renewal.

Last updated: 06/10/2020
Reviewed: 9/16/2021