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Last Modified: 6/10/2018 Location: FL, PR, USVI Business: Part A, Part B

Plan Coverage FAQ

Q: Will Medicare supplement insurance (i.e., Medigap) policy information be returned in the ‘Plan Coverage’ section under ‘Check Eligibility’? If a beneficiary has a Medicare advantage (MA) plan, why would some or all of the information about the plan not be displayed in Plan Coverage?
A: No. Information about Medicare supplement insurance (i.e., Medigap) is not included in the ‘Plan Coverage’ section because the information is not returned by the HIPAA Eligibility Transaction System (HETS).
The SPOT only displays information contained within HETS, which is the source for all benefits and eligibility information accessible through the portal.

Plan Coverage data

The ‘Plan Coverage’ submenu option displays data regarding the beneficiary’s enrollment -- as applicable -- in one or more of the following plans:
Medicare advantage (MA)
Part D contracts
MA managed care plans (i.e., Part C contracts) that provide Part A and B benefits for beneficiaries enrolled under a contract.
Note: If no active data is available, the ‘Plan Coverage’ option will be displayed as a grayed-out tab.

Data field descriptions

Plan coverage data
Description
Plan type
A full plan description followed by plan type code:
Health Maintenance Organization Medicare Non Risk – HM
Health Maintenance Organization Medicare Risk – HN
Indemnity – IN
Preferred provider organization – PR
Point of Service – PS
Pharmacy – Part D
Enrollment date
The date that indicates the start of enrollment to the coverage plan
Disenrollment date
The date that indicates the termination of enrollment to the coverage. No date in this field means the plan enrollment has not terminated
Contract number/Plan benefit package Id
The contract number followed by the plan number (if on file)
MCO bill option code
The bill option code of the plan type. This field only applies to plan types HM, HN, IN, PR, and PS. This field will not be displayed for Part D plan type.
Contract website address
Contract’s website address that will provide information on the beneficiary’s insurance
Plan name
A descriptive name of the beneficiary’s insurance coverage organization
Address line 1
Coverage plan’s address line 1
Phone number
Coverage plan’s contract telephone number (if on file) displayed as XXX-XXX-XXXX
Address Line 2
Coverage plan’s address line 2
City
Coverage plan’s city address
State
Coverage plan’s state address
ZIP code
Coverage plan’s ZIP code

Display and accessibility of plan coverage data

However, the display and accessibility of information in Plan Coverage are contingent upon the availability of active data directly associated with the beneficiary. If the Centers for Medicare & Medicaid Services (CMS) has not been informed by the Social Security Administration (SSA) of the plan, the ‘Plan Coverage’ option will display as a grayed-out screen tab.
It is the responsibility of the insurer to notify the SSA of the plan and of any information associated with the plan (e.g., policy number, name of insurer). Once the SSA has been notified, the information will be shared with CMS’ systems, including its HIPAA Eligibility Transaction System (HETS).
Since HETS is the source for all eligibility data accessed from the SPOT, the portal will display only data that is contained within the system.
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First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.