Plan Documents

At Nascentia Health Plus, we make it easy to find the information you need. The list below includes links to a variety of materials pertinent to your membership in the plan. You may also request printed copies of any these materials by calling 1.888.477.HOME (4663) (TTY/TDD: 711).

Hours of Operation 8am – 8pm, 7 days* a week
*October 1st – March 31st / Mon- Fri rest of the year

Nascentia Health Plus Dual Eligible Plan (D-SNP)

Individuals enrolled in Nascentia Health Dual Eligible Plan receive tailored care management designed to improve care coordination, provider interventions, and partnerships with community-based organizations. Through this approach, Medicare and Medicaid benefits are better integrated and aligned to meeting the specialized needs of dual eligible beneficiaries.

To join our Nascentia Health Dual Plan (HMO SNP) you:

  • Must be enrolled in Medicare Part A and Part B
  • Must be enrolled for full Medicaid benefits and/or assistance with Medicare premiums or cost sharing
  • Must continue to pay your Medicare Part B premium if it’s not paid for by Medicaid or another third party
  • Must live in the Nascentia Health Plus service area.
  • Must not have End-Stage Renal Disease (ESRD), with limited exceptions 

Nascentia Health Plus Institutional Plan (I-SNP)

Individuals enrolled in Nascentia Health Institutional Plan can benefit from enhanced clinical coordination and care focused on the specialized needs of individuals requiring services provided in a long-term care skilled nursing facility for 90 days or more.

To join our Nascentia Health Institutional Plan (HMO SNP) you:

  • Must be enrolled in Medicare Part A and Part B
  • Must for 90 days or longer, require or are expected to need the level of services provided in a long-term care (LTC) skilled nursing facility (SNF)
  • Must continue to pay your Medicare Part B premium if it’s not paid for by Medicaid or another third party
  • Must live in the Nascentia Health Plus service area
  • Must not have End-Stage Renal Disease (ESRD), with limited exceptions

Documents and Links

Appointment of Representative Form (pdf)
Appointment of Representative Instructions (pdf)
Coverage Determination Request Form (pdf)
Drug Formulary
Drug Formulary (pdf)
Enrollment Form (pdf)
Evidence of Coverage (EOC)
FAQs (pdf)
Grievance and Appeals Form (pdf)
HIPAA Release of Information Form (pdf)
MTM Letter and Personal Medication List (pdf)
MTM Program Requirements
Medicare Complaint Form
Medicare Enrollment Help
Medicare Plan Finder
Member Rights & Responsibilities
Pharmacy Directory
Pharmacy Transition Process (pdf)
Privacy Practices (pdf)
Provider Directory (pdf)
Nondiscrimination Notice (pdf)
Redetermination Request Form (pdf)
Summary of Benefits – Nascentia Health Dual Eligible Special Needs Plan (HMO D-SNP) (pdf)
Summary of Benefits Nascentia Health Institutional Special Needs Plan (HMO I-SNP) (pdf)

 

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