Medicare Part D: The Medicare prescription drug benefit program. We call this program “Part D” for short. Medicare Part D covers outpatient prescription drugs, vaccines, and some supplies not covered by Medicare Part A or Medicare Part B or Medical Assistance. Our plan includes Medicare Part D.Medicare Part A: The Medicare program that covers most medically necessary hospital, skilled nursing facility, home health, and hospice care.
Medicare Part B: The Medicare program that covers services (such as lab tests, surgeries, and doctor visits) and supplies (such as wheelchairs and walkers) that are medically necessary to treat a disease or condition. Medicare Part B also covers many preventive and screening services.Medical Assistance: This is the name of Minnesota’s Medicaid program. Medical Assistance is run by the state and is paid for by the state and the federal government. It helps people with limited incomes and resources pay for long-term services and supports and medical costs.
It covers extra services and some drugs not covered by Medicare. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

Coverage Decisions, Appeals and Complaints

This page has information about coverage decisions, member grievances (also referred to as complaints) or member appeals. Chapter 9 of the Member Handbook goes into detail on each process. Which process you could use depends on the type of problem you have.

Because you have both Medical Assistance and Medicare, we use an integrated process for handling most of the problems you have with your benefit coverage. For some benefits which are not combined, you would use either the Medicare or Medical Assistance process to resolve your problem. You don't have to worry about which process you need to use, we will help you through the entire process. There are also other resources you can work with to help with these processes.

You, your provider, or your appointed or authorized representative can ask us to make a decision about whether medical care are covered or not, the way they are covered, and how they are paid for. A coverage decision is a decision we make about your benefits, coverage or the amount we'll pay for your medical services or medicine. This decision is also called an organization determination when it is about a medical benefit. It is called a coverage determination when it relates to a Medicare Part D prescription drug.

If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision that we have made.

If you are dissatisfied with South Country, your medical provider or pharmacy, or your health plan services, you have the right to file a grievance (also referred to as a complaint). The grievance process is separate from a coverage determination or appeal process. Please refer to the drop down below for more information about a grievance.

About an authorized or appointed representative

An appointed representative is someone you appoint (designate or choose) to act on your behalf to file (request) and deal with a coverage decision, grievance (complaint), or appeal. An example of this is a relative, friend, advocate or attorney. You must have a valid representative form to give to us for this purpose. You may use the approved CMS Form 1696 or you can send us an equal or similar (equivalent) written notice. These forms are valid for one year from the date it is signed, unless revoked.

If using the CMS Form 1696, it is important to complete the form as instructed. If you send us an equivalent written notice, the notice needs to be dated and signed by both you and the person you are appointing, and it needs to also include the following information:

  • Your name, address, and telephone number
  • Your South Country ID number or your Medicare Beneficiary ID number or your HICN number (HICN stands for Health Insurance Claim Number and is a number Medicare uses for specific purposes and is based off your Social Security Number)
  • The name, address and telephone number of the person being appointed to represent you
  • The appointed person’s relationship to you or their professional status
  • A written explanation of the purpose and extent (scope) to which you want the appointed person to represent you
  • A statement that you are authorizing the representative to act on your behalf for the purpose you described, and a statement authorizing disclosure of individually identifying information to the representative
  • A statement by the person being appointed that he or she accepts the appointment

An authorized representative is someone that is authorized by law (State law or other applicable law) to act on your behalf to file (request) and deal with a coverage decision, grievance (complaint), or appeal. Some examples may include (but are not limited to) a court appointed guardian, a person with durable power of attorney, or a health care proxy.

More Information

SeniorCare Complete and AbilityCare are health plans that contract with both Medicare and the Minnesota Medical Assistance Program to provide benefits of both programs to enrollees. Enrollment in either plan depends on contract renewal.

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