You are eligible to join Prime Health Complete (HMO SNP) if you meet the following criteria:
- You are at least 18 years of age and under age 65
- You qualify for Medical Assistance (MA). To learn more about Medical Assistance and how you qualify, go to the Minnesota Department of Human Services (DHS) website.
- You have Medicare Parts A and B
- You have a certified disability through the Social Security Administration or the State Medical Review Team; or you have been determined by the county to have a developmental disability (DD) for purposes of the DD waiver
- You live in Beltrami, Big Stone, Clearwater, Douglas, Grant, Hubbard, McLeod, Meeker, Pipestone, Pope, Renville, Stevens, or Traverse County
Note: If you meet these eligibility criteria but do not have Medicare, read about our Prime Health Complete (SNBC)/Special Needs BasicCare (SNBC) program for members with Medicaid only.
Prime Health Complete (HMO SNP) members have the same benefits covered under fee-for-service. We coordinate with Medicare and Medical Assistance to pay for your covered services. PrimeWest Health care coordinators work with county case managers to help you maintain your health, whether you live in your own home or in a care facility. PrimeWest Health's goal is to support members and keep them healthy.
Prime Health Complete is a Special Needs BasicCare (SNBC) program. To get the most up-to-date information about SNBC, go to the Minnesota Department of Human Services (DHS) website.
A Coordinated Care plan with a Medicare Advantage contract and a contract with the Minnesota Medicaid programFrequently Asked Questions (click to expand/collapse)
- Call Member Services at 1-877-600-4913. TTY users can call 1-800-627-3529 or 711. Calls to these numbers are free. Hours are 7 days a week, 8 a.m. – 8 p.m.
- Fill out the Prime Health Complete (HMO SNP) Enrollment Form and return it to us at the address provided.
Chapter 1: Getting started as a member of Prime Health Complete
Chapter 2: Important phone numbers and resources
Chapter 3: Using the plan's coverage for your covered services
Chapter 4: Benefits chart (what is covered)*
Chapter 5: Using the plan's coverage for your Part D prescription drugs
Chapter 6: What you pay for your Part D prescription drugs
Chapter 7: Asking the plan to pay its share of a bill you have received for covered services or drugs
Chapter 8: Your rights and responsibilities
Chapter 9: What to do if you have a problem or complaint (coverage decisions, Appeals, and complaints)
Chapter 10: Ending your membership in the plan
Chapter 11: Legal notices
Chapter 12: Definitions of important words
*Chapter 4 also tells what is not covered
- 1-800-MEDICARE (1-800-633-4227, toll free). TTY users should call 1-877-486-2048 (toll free), 24 hours a day, 7 days a week.
- The Social Security Office at 1-800-772-1213 (toll free), 7 a.m. – 7 p.m., Monday – Friday. TTY users should call 1-800-325-0778 (toll free).
- Your State Medicaid Office
Read the LIS Premium Summary Chart to see the premium for your plan.
Some plan members may be paying a premium for Medicare Part A and/or Medicare Part B. Many members do not pay premiums for Medicare Part A and/or Medicare Part B due to Medical Assistance eligibility. If you are paying for your Medicare Part B, you must continue paying your Medicare Part B premium to remain a member of the plan. For full information on PrimeWest Health benefits, call Member Services at 1-877-600-4913. TTY users call 1-800-627-3529 or 711. Calls to these numbers are free. Hours are 7 days a week, 8 a.m. – 8 p.m.
| Your copay amount for generic (tier 1) drugs is no more than |
Your copay for all other drugs (tiers 2 or 3) is no more than |
|---|---|
$0/$1.10/$2.60 (each prescription) |
$0/$3.30/$6.50 (each prescription) |
- Our online search feature lets you see if specific specific Part D drugs are covered by Prime Health Complete (HMO SNP).
- Our Formulary lists the Part D drugs covered by Prime Health Complete (HMO SNP).
- The list of Medicaid-covered, Part D-excluded drugs tells you which drugs are covered under your Medical Assistance benefit.
- Our Over-the-Counter drug list tells you which of these drugs are covered by Prime Health Complete (HMO SNP). The items on the list are covered when you have a prescription from your health care provider or pharmacist.
- Read about "coverage decisions" and "Appeals" in Chapter 9, Section 6 of your Evidence of Coverage.
- You may use the Secure Online Submission Process to ask for a coverage decision or appeal.
- We encourage you to contact PrimeWest Health Member Services first if you have a Grievance. However, you can also tell Medicare about your Grievance directly by visiting the Centers for Medicare & Medicaid Services (CMS) website.
Prime Therapeutics LLC
Clinical Review Dept
1305 Corporate Center Drive
Eagan, Minnesota 55121
- Use the Formulary Exception Form. Note: This form must be completed by a health care provider. Completed forms can be mailed or faxed to:
Mail: Prime Therapeutics LLC
Attn: Medicare Appeals Dept
1305 Corporate Center Dr, Bldg EC
Eagan, MN 55121
Fax: 1-800-693-6703 (toll free)
- You may also contact Member Services at 1-877-600-4913 (toll free) 7 days a week, 8 a.m. – 8 p.m. TTY users should call 1-800-627-3529 or 711 (toll free). If you contact us, we may need to get more information from your prescribing health care provider. If you need help or have questions, call Member Services.
- You may also use the Secure Online Submission Process to ask for an exception.
- Read your Provider/Pharmacy Directory for a list of Minnesota pharmacies in the Prime Health Complete (HMO SNP) network.
- Use our online search feature to see if a specific pharmacy is in the Prime Health Complete (HMO SNP) network.
You must use network pharmacies to access your prescription drug benefit, except under non-routine circumstances. Quantity limits and restrictions may apply. Read your Provider/Pharmacy Directory to see a list of our network pharmacies or get more detailed information about Prime Health Complete (HMO SNP) prescription drug coverage. You can also call us at 1-877-600-4913 (toll free) or 1-800-627-3529 or 711 (toll free TTY), 7 days a week, 8 a.m. – 8 p.m. Or, request a list by mail at:
PrimeWest Health
2209 Jefferson St, Ste 101
Alexandria, MN 56308
- Read your Primary Care Network Listing to see a list of primary care clinics in the Prime Health Complete (HMO SNP) network.
- Read your Provider/Pharmacy Directory to see a full list of health care providers (including specialists) in the Prime Health Complete (HMO SNP) network.
- Use our online search feature to see if a specific provider is in the Prime Health Complete (HMO SNP) network.
You must use network providers except in emergency or urgent care situations, or for open access services, out-of-network dialysis services, or any other services previously authorized. If you obtain routine care from out-of-network providers neither Medicare nor PrimeWest Health will be responsible for the costs.
You may call Member Services about your Grievance or Appeal at 1-877-600-4913 (toll free), 7 days a week, 8 a.m. – 8 p.m. TTY users call 1-800-627-3529 or 711 (toll free). You may also send a fax to 1-877-600-4912 (toll free).
You may send a letter about your Grievance or Appeal to PrimeWest Health at the following address:
PrimeWest Health Appeals & Grievances
2209 Jefferson St, Ste 101
Alexandria, MN 56308
You may call the Ombudsman for State Managed Care Programs at the Minnesota Department of Human Services about your Grievance or Appeal or to request a State Fair Hearing at 1-800-657-3729 (toll free) or 1-651-431-2660.
You may send a written request for a State Fair Hearing to the following address:
Minnesota Department of Human Services
Appeals Office
PO Box 64941
Saint Paul, MN 55164-0941
To file an Appeal about your Medicare Part D benefits, you may call Member Services about your Grievance or Appeal at 1-877-600-4913 (toll free), 7 days a week, 8 a.m. – 8 p.m. TTY users call 1-800-627-3529 or 711 (toll free). You may also send a fax to 1-800-693-6703 (toll free).
What is a Grievance?
A Grievance is any complaint, other than one that involves a request for an initial determination or an Appeal. Grievances do not involve problems related to approving or paying for medical care, services, Part D or non-Part D drugs, problems about having to leave the hospital too soon, and problems about having Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF) services ending too soon.
What types of problems might lead you to file a Grievance?
- Problems with the service you receive from Member Services
- You feel that you are being encouraged to leave (disenroll from) the Plan
- We don't give you required notices
- You believe our notices and other written materials are hard to understand
- Waiting too long for prescriptions to be filled
- Waiting too long on the phone, in the waiting room, or in the exam room
- Problems getting appointments when you need them or waiting too long for them
- Rude behavior by network pharmacists or other staff
- Cleanliness or condition of network pharmacies
- We fail to respect your rights
- You disagree with our decision not to give you a "fast" decision or a "fast" Appeal
- We don't give you a decision within the required time frame
If you have one of these types of problems and want to make a complaint, it is called "filing a Grievance."
Who may file a Grievance
You or someone you name may file a Grievance. The person you name would be your "appointed representative." You may name a relative, friend, lawyer, advocate, health care provider, or anyone else to act for you. Other people may already be authorized by the Court or in accordance with State law to act for you. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. To learn how to name a representative, you may call Member Services at 1-877-600-4913 (toll free).
Filing a Grievance with our Plan
If you have a complaint, you or your representative may call Member Services at
1-877-600-4913 (toll free). We will try to resolve your complaint over the phone. We will give you a decision within 10 days. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. If you ask for a written response, file a written Grievance, or your complaint is related to quality of care, we will respond in writing to you.
If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this the written Grievance process. You can send us a letter about your Grievance. Write to:
PrimeWest Health Appeals & Grievances
2209 Jefferson St, Ste 101
Alexandria, MN 56308
We will notify you within 10 days that the Grievance has been received. The Grievance must be submitted within 60 days if the complaint is regarding Part D drugs. We must address your Grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. We will tell you within 30 days that we are taking extra time and the reasons why. If we deny your Grievance in whole or in part, our written decision will explain why we denied it and will tell you about any dispute resolution options you may have.
For quality of care problems, if you have Medicare, you may also complain to the Quality Improvement Organization (QIO)
You may complain about the quality of care received under Medicare, including care during a hospital stay. You may complain to us using the Grievance process, the Quality Improvement Organization (QIO), or both. In Minnesota, the QIO is called Stratis Health. You may contact Stratis Health at 1-800-444-3423 (toll free) or 1-952-854-3306 (Twin Cities Metro) or write to:
Stratis Health
2901 Metro Dr, Ste 400
Bloomington, MN 55425
Fast Grievances
You have the right to ask for a "fast" or "expedited" Grievance. You may file a fast or expedited Grievance orally or in writing. We will respond to your oral or written Grievance within 24 hours.
Filing a complaint with the Centers for Medicare & Medicaid Services (CMS)
We encourage you to contact PrimeWest Health Member Services first if you have a Grievance. However, you can also tell Medicare about your Grievance directly by visiting the Centers for Medicare & Medicaid Services (CMS) website.
PrimeWest Health Appeals & Grievances
2209 Jefferson St, Ste 101
Alexandria, MN 56308
Quality Objectives
- To improve the health status of PrimeWest Health members
- To ensure access to high quality and safe health care services in the PrimeWest Health service area
For more information on the PrimeWest Health Quality program, call Member Services at 1-866-431-0801 (toll free), Monday – Friday, 8 a.m. – 5 p.m. TTY users call
1-800-627-3529 or 711 (toll free).
Plan Ratings
Each year, the Centers for Medicare & Medicaid Services (CMS) rates how well health plans perform. They rate plans on different measures, such as detecting and preventing illness, member satisfaction, patient safety, customer service, and more. Plan performance summary star ratings are assessed each year and may change from one year to the next.
Request for Redetermination of Medicare Prescription Drug Denial
Best Available Evidence (BAE) – Centers for Medicare & Medicaid Services
Medicare Complaint Form – Centers for Medicare & Medicaid Services