Affinity Health Plan

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  • Medicare Document Center

    Find the documents, forms and directories for your plan.

     

    • Annual Notice of Change and Evidence of Coverage More

      Use the documents listed for complete program information, including benefit summaries, customer service contacts, network information, out of network coverage, if available, prescription coverage information, and grievance and appeals procedures.

      2018 Annual Notice of Change and Evidence of Coverage
      2017 Annual Notice of Change and Evidence of Coverage
    • Summary of Benefits More

      2018
      • Affinity Medicare Passport Essentials (HMO) and Affinity Medicare Passport Essentials NYC (HMO): English | Spanish | Chinese
      • Affinity Medicare Ultimate (HMO-SNP) and Affinity Medicare Solutions (HMO-SNP): English | Spanish | Chinese
      2017
      • Affinity Medicare Passport Essentials (HMO), and Affinity Medicare Passport Essentials NYC (HMO) and Affinity Medicare Passport Select (HMO): English | Spanish | Chinese
      • Affinity Medicare Ultimate (HMO-SNP) and Affinity Medicare Solutions (HMO-SNP): English | Spanish | Chinese

    • Enrollment Forms More

      2018
      2017
      • Affinity Medicare Ultimate (HMO-SNP) and Affinity Medicare Solutions (HMO-SNP): English | Spanish
      • Affinity Medicare Passport Essentials (HMO) and Affinity Medicare Passport Essentials NYC (HMO) and Affinity Medicare Passport Select (HMO): English | Spanish

    • Provider Directories More

      To find a doctor in our network select the appropriate county below, or click here to use our online tool.

    • Provider Lookup More

      To find a doctor in our network, use our online search tool.

    • Claims Forms More

      Our network providers bill the plan directly for your covered services and drugs. If you get a bill for the full cost of medical care or drugs you have received, you should send this bill to us so that we can pay it. When you send us the bill, we will look at the bill and decide whether the services should be covered. If we decide they should be covered, we will pay the provider directly.

      If you have already paid for services or drugs covered by the plan, you can ask our plan to pay you back (paying you back is often called “reimbursing” you). It is your right to be paid back by our plan whenever you’ve paid more than your share of the cost for medical services or drugs that are covered by our plan. When you send us a bill you have already paid, we will look at the bill and decide whether the services or drugs should be covered. If we decide they should be covered, we will pay you back for the services or drugs.

      Network providers should always bill the plan directly. But sometimes they make mistakes, and ask you to pay more than your share of the cost. You only have to pay your cost-sharing amount when you get services covered by our plan. We do not allow providers to add additional separate charges, called “balance billing.” This protection (that you never pay more than your cost-sharing amount) applies even if we pay the provider less than the provider charges for a service and even if there is a dispute and we don’t pay certain provider charges. For more information about “balance billing,” please refer to your plans Evidence of Coverage (EOC).

      Send us your request for payment, along with your bill and documentation of any payment you have made. It’s a good idea to make a copy of your bill and receipts for your records.

      Mail your request for payment together with any bills or receipts to us at one of these addresses:

      For Part C (medical) requests:
      Affinity Health Plan, Customer Service Department (Medicare)
      Metro Center Atrium
      1776 Eastchester Road
      Bronx, NY 10461

      For Part D (prescription drug) requests:
      Caremark Inc., Medicare Part D Claims
      P.O. Box 52066
      Phoenix, AZ 85072-2066

      You must submit your claim to us within one year of the date you received the service, item, or drug.

      Contact Customer Services at 877.234.4499, Monday to Sunday, 8:00 am to 8:00 pm; TTY 711 if you have any questions. If you don’t know what you should have paid, or you receive bills and you don’t know what to do about those bills, we can help. You can also call if you want to give us more information about a request for payment you have already sent to us.

      Pharmacy Claims Form: English | Spanish

      Pharmacy Directory: English

    • Medicare Star Ratings More

      Each year, the Centers for Medicare and Medicaid Services rates plans based on a 5-star system, in areas including customer service, drug pricing and patient safety. Star Ratings may change from one year to the next. See a summary of quality and performance for Affinity’s Medicare plans based on 19 different topics here: English | Spanish | Chinese

    • Low Income Subsidy (LIS) Table More

      For Affinity Medicare Ultimate (HMO/SNP) and Affinity Medicare Solutions (HMO/SNP) members who get extra help from Medicare to pay for their prescription drug costs, these tables show what the monthly plan premium will be within the respective year of service. 2018 | 2017

    • Appointment of a Representative More

      This form is used when someone who is not the member would like information or assistance on your behalf. Your representative can be a family member, friend, advocate, attorney, doctor or anyone else you would like to act on your behalf: English | Spanish

    • Multi Language Interpreter Services More

      Find information on free interpreter services to answer any questions you may have about our health or drug plans.

  • H5991_AffinityMedicarePlanWebsite2018 Pending Last updated 09/28/2017