Coventry Health Care

Dear Ms [redacted] , Please see our response below to the additional concerns reported in complaint # [redacted] for [redacted] that were received by us on January 20, We have attached a copy of the automatic renewal letter that was sent to Mr [redacted] The letter was sent and was never returned to Coventry as undeliverable We are unable to offer further explanation on why he never received the letter so that he could review the offer It was confirmed that the termination request for his policy and proof of other coverage that we received on January 9, 2015, did not provide an effective date from his other insurance carrier The ID card also did not give us the effective date Additional information was received by Coventry on January 21, 2015, which allowed us to terminate his coverage back to December 31, A refund was issued for the premium payment of $that we had collected for his coverage for January The refund process was completed on Coventry’s side on January 27, 2015, but it may take 1-business days from then for his bank to credit his account We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr [redacted] ’s concerns If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Sincerely, Chris B [redacted] Executive Resolution Team

Dear [redacted] , Please see our response to complaint # [redacted] for [redacted] that was received by us on January 8, During our research, we determined that [redacted] has been receiving an Advanced Premium Tax Credit (APTC) through the Marketplace since beginning her coverage with Coventry on April 1, A letter was sent to her on October 25, advising her that her premium would increase and telling her to update her information with the Marketplace to make sure that she received the full amount of the APTC to which she was entitled The letter explained that the deadline for making any updates that would take effect January 1, 2015, was December 15, Coventry did receive notification from the Marketplace that the APTC amount has been increased beginning February 1, Unfortunately, Coventry is not able to backdate the APTC or reduce her premium prior to that date as we are required to adhere to the information we receive from the Marketplace The premium owed for January is $ Effective February 1, 2015, her premium will be lowered to $ At this time, [redacted] still owes an additional $for her premium for January In order to maintain her coverage with Coventry, she must pay that amount and her premiums for February and March by March 31, We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] ’s concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Regards, Chris B [redacted] Executive Resolution Team

Dear [redacted] , Please see our response to complaint # [redacted] for [redacted] that was received by us on February 4, Upon receiving the complaint, we noted that our Billing and Enrollment department had already begun the process of correcting the issue that led to [redacted] ’s policy not activating after the first month’s premium payment was received Unfortunately, we were not able to meet the hour deadline he had requested but the system has now been updated to show his policy active with an effective date of February 1, We have been in contact with [redacted] and advised him of this resolution We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] ’s concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] @***.com Regards, Chris B [redacted] Complaints and Appeals Consultant Executive Resolution Team

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the responseIf no reason is received your complaint will be closed Administratively Resolved] Complaint: [redacted] I am rejecting this response because: Now they say our premium rate has changedWe were never informed about this, and it is strange, that on their attempts to collect money from our old bank account, they still tried to collect the amount of $We do not want any further steps done, because we are tired of it, and are already looking for other Health Care ProvidersThank you very much, Regards, [redacted] ***

Dear [redacted] , Please see our response to complaint # [redacted] for [redacted] that was received by us on January 7, The policy in question showed [redacted] as the policyholder We reached out to [redacted] to request authorization to respond to [redacted] *** This request was granted Our research determined that [redacted] had contacted Coventry on January 2, to request termination of his policy Unfortunately, that did not allow Coventry enough time to prevent the premium draft from occurring on January 5, We withdrew $at that time A refund was issued by Coventry for that amount on January 13, Depending on the processing time his bank requires to post the refund to his account, the amount should be reflected on his balance within 1-business days from that date We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] ***’s concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Regards, Chris B [redacted] Executive Resolution Team

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the responseIf no reason is received your complaint will be closed Administratively Resolved] Complaint: [redacted] I am rejecting this response because: Regards, [redacted] It is apparent from there response is valid How do I make calls get hung up on, get the responses that I did, and then have a company ssimply respond by we have no record, so it didnt happen Obviouslu, that is how they keep getting away w their bait abd switch service (promising customer servive, than making it impossible to obtain) Then when a customer reaches out for third party intervention to encouragevthe company to honor their promoted service, this company hides behind "no record, didnt happen" This is why businesses behave in this manner, because there allowed to withiut reprucussion Shame on coventry and shame on our system

Dear *** [redacted] , Please see our response to complaint # [redacted] for [redacted] that was received by us on January 6, In reviewing [redacted] ’s complaint, we have determined that a letter was sent to him on August 27, The letter advised that his coverage would end on December 31, 2014, and could not be renewed Unfortunately, Coventry no longer offers individual policies in his area so we are not able to reinstate his coverage We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] ’s concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Sincerely, Chris B [redacted] Executive Resolution Team

Dear [redacted] , Thank you for allowing us to address the concerns reported in complaint # [redacted] for [redacted] that was received by us on December 30, 2014, regarding termination of his policy Our Executive Resolution Team researched your concerns, and we would like to share the results of the review with you We were able to locate a policy for [redacted] and called to speak with him due to the complaint not containing enough identifying information to verify which Coventry member had filed the complaint We were able to reach him and verify that we were speaking with the correct person After the complainant was verified, we were able to discuss the complaint with [redacted] We explained the role the Marketplace plays in health insurance coverage and why all requests for termination need to be made with the Marketplace when a person initially applies for a policy through them It was determined that the previous contacts that [redacted] had made with Coventry to attempt to terminate his policy were sent directly to Coventry using our online coordination of benefits questionnaire The information in those requests was reviewed to ensure we were properly coordinating the benefits between Coventry and [redacted] ’s other insurance carrier Unfortunately, those requests did not allow us to terminate his policy At this time, we are unable to refund any of the premiums paid for [redacted] ’s policy The premiums we have collected are for the months of active coverage from June 1, 2014, through December 31, [redacted] stated that the Marketplace is reviewing his case and he will attempt to request a backdated termination date with them In the event that the Marketplace allows a retroactive termination, Coventry will refund any premiums that were collected for the months of coverage after the end date for the policy, once that date is received by us We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] ’s concerns If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Regards, Chris B [redacted] Executive Resolution Team

October 10, 2014Dear Sir or Madam:Thank you for allowing us the opportunity to respond in regard to the case filed by [redacted] ***.We have been communicating with [redacted] regarding the process for policy terminationAccording to our records, [redacted] contacted us on 08/06/ to change his planWe then received a telephone call from [redacted] on 09/08/requesting that we cancel his policy effective 08/31/At that time we advised [redacted] of the termination process and the required document for him to submit in order to initiate the policy terminationOn 09/22/ [redacted] called inquiring about the termination of his policyOur representative explained that we had not received the required document to terminate his policyBecause we not yet received the documentation required to terminate [redacted] ***’s plan, the policy remained active and we attempted to draft his account for September’s premium.We have since received the required documentation to terminate [redacted] ***’s policy and his policy was terminated effective 08/31/The September premium was never received as our draft was returned to us from [redacted] ***’s bank for insufficient fundsWe originally charged a $fee for the returned draft, however, we have since waived this fee on [redacted] ***’s account[redacted] ***’s complaint has been resolved according to the desired resolution that he requested.Coventry Health Care hopes this explanation provides the Revdex.com with the necessary information to complete the investigation of this matterIf you have any further questions or concerns, please feel free to contact me at ###-###-#### and my e-mail address is [redacted] .Very truly yours,Shelly UDirector, Service Operations

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the responseIf no reason is received your complaint will be closed Administratively Resolved] Complaint: [redacted] I am rejecting this response because: As today ( Wednesday February 5th, 2014) we have not received the insurance package or ID cardsWe received an statement date January 21st, and the statement does not contain an ID numberWe received a letter last week with the ID # for the policy but without the proper ID cards we have not been able to use the coveragePrescriptions for my wife and regular visit for my son has been denied Why should we pay coverage for January if we were not covered? payment should be applied for February, but only if we receive the required docs and cards and we can have coverage for February Right now we are still the same a Jan 2014, no coverage, no ID cards Regards, [redacted]

August 20, Dear Sir of Madam:The Regulatory Compliance Department of Coventry Health Care of Kansas, Inc(“Coventry Health Care”) writes this letter in response to the consumer complaint filed by [redacted] regarding termination of her policy for non-paymentWe have researched [redacted] 's complaint and our records indicate that the member was set up on the “Paper billing” methodThis means [redacted] would have been sent a paper bill in the mail with instructions on how to send the paymentIt appears that she had not been on an automatic billing method at any point in the policyIn order to be set up on auto payment, [redacted] would have needed to sign and return an auto withdrawal form that authorized Coventry to take the payment monthlyAlso, the [redacted] could have set up automatic payment online at the member website (member.cvty.com)This is why Coventry never automatically withdrew from [redacted] ’s accountOn January 1, [redacted] was mailed an initial payment letter indicating that her payment was dueOn March 9, she was mailed a past due letter [redacted] did not respond to either letter[redacted] has a new policyThis policy is effective 07/01/for a $premium on the Silver Integrated $Copay PPC planDue to the other policy being terminated for January 31, 2014, there will be no coverage for [redacted] from February 1st to June 30thThe older policy cannot be reinstated to cover for the lapse of coverage as it was terminated for nonpaymentAfter further research it was concluded there was no error on the behalf of Coventry as the proper documentation was sent to [redacted] reminding her of the payment that was due.Coventry Health Care hopes this explanation provides the Revdex.com with the necessary information to complete the investigation of this matter, If you have any further questions or concerns, please feel free to contact me at ###-###-####My fax number is [redacted] , and my e-mail address is [redacted] .Very truly yours,Kimberly S RN, BSN, CPC Health Services Manager, Appeals

Dear Ms [redacted] , Please see our response to complaint # [redacted] for [redacted] that was received by us on March 5, During our investigation, it was determined that the information Ms [redacted] had been seeking from Coventry was the Usual and Customary (U&C) rate for a procedure that was going to be performed by a surgeon that was stating they were out of network The U&C rate is important because the benefits for the procedure are only applied on the amount up to that rate Any billed amount for a procedure that is above the U&C rate would need to be paid by the patient if the provider of services chooses to bill for it We noted that the doctor, [redacted] , is listed as an in network provider This means they have a contracted rate for the services they provide and the U&C rate does not apply We contacted the Provider Relations representative with Coventry for Dr [redacted] , Joyce W*** MsW [redacted] was not aware of any contact from the doctor’s office requesting to terminate their contract or any reports of any problems they experienced We were able to speak with Molly with Dr [redacted] ’s office on March 13, She indicated that Ms [redacted] is no longer going to have the procedure performed with Dr [redacted] We advised Molly that if Dr [redacted] wants to become out of network, their best avenue would be to contact Joyce W [redacted] to begin the process We also informed her that they are still considered in network at this time and any claims received will be processed according to their contracted rates We were able to locate additional information on the process for obtaining a U&C rate, in case it is needed by Ms [redacted] in the future All requests must be sent in writing and should include the procedure code for the service that will be performed, the zip code where the procedure will be performed, and the amount that will be billed by the provider of services The address for sending requests for U&C rates is: Coventry Health Care, [redacted] ***, London, KY 40742- We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms [redacted] ’s concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Regards, Chris B [redacted] Executive Resolution Team

October 10, Dear [redacted] : Your letter of October 1, was received in our office, and referred to my attention for review and response.In her complaint to the Revdex.com, [redacted] expressed concern that her claims for dates of service April 22, and April 23, processed at the out-of-network rate, even though she went to the provider listed on her insurance cardDuring the investigation, Coventry identified that [redacted] was assigned a Primary Care Provider (PCP) that is not a participating provider in her policy networkThis incorrect assignment occurred during [redacted] ’s enrollment with the MarketplaceCoventry continues to work with the Marketplace to remedy errors of this nature.Based on the circumstances of the complaint, Coventry will allow a one-time exception to process the April 22, and April 23, services at the in-network benefit levelPlease allow 7-business days for the adjusted Explanation of Benefits (EOBs) to be issuedCoventry will provide [redacted] with the EOBs once they are available.Our goal is to provide the opportunity and resources for [redacted] to establish care with an in-network provider [redacted] may visit the website at www.chcne.com, and choose the Carelink Powered by MIPPA link [redacted] may also call our Customer Service Department at ###-###-####, in order to find a Participating Primary Care Provider in her Open Access Point of Service (OA POS) MIPPA network.If I may be of any further assistance, please feel free to contact me at ###-###-#### or toll-free at ###-###-####, ext [redacted] Sincerely, Shawn M Complaint and Appeal Analyst

Coventry needs to find out which agent or represented spoke to me declining my original request to reinstate after we found out we were terminatedThe rep told me she could not find any such phone call made on the 29th to keep my policy active, not to terminateMy wife and I called back several times to talk to supervisors about reinstatement, only to be placed on hold for minutes both times and than to be disconnected without a call back from anyoneIt was not until I filed a complaint with insurance commissioner of GA that we finally mysteriously found that phone call that was made on the 29th of October and was reinstated Revdex.com: I have reviewed the response made by the business in reference to complaint ID 10315083, and find that this resolution is satisfactory to me Regards, [redacted]

October 6, 2014Dear Sirs:This letter is in response to the aforementioned Case Number [redacted] regarding [redacted] ’s PCP selections and assignment [redacted] also requested to be reimbursed if a PCP is not found.Please be advised that after review of your grievance, [redacted] is effective with the CATASTROPHIC $HMO plan as of April 4, [redacted] ’s plan does require PCP assignmentThis is important to the coordination of care, and members are encouraged to contact their PCP when medical care is needed[redacted] can select a PCP from one of the following specialties: Family Practice, Internal Medicine, General Practice, OB/GYN, or Pediatrics [redacted] may choose one PCP for the entire family, or each Dependent may select a different PCPTo locate the most current Directory of Health Care Providers, please visit our website at [redacted] Our online Provider directory is updated at least monthlyPlease find (enclosed) a list of General Practice and Internal Medicine PCP’s within 20miles of [redacted] zip codeIf [redacted] wishes to change her PCP, she must contact our Customer Service Department at ( [redacted] [redacted] may also visit our website at [redacted] to make this change,In regards to a refund for coverage, [redacted] must request to have her plan terminated through the MarketplaceHowever, [redacted] currently has access to many benefits of her coverage such as PCP visits, Urgent Care, Pharmacy and Emergency Room care[redacted] has no refund due at this timePlease see the termination section of the policy below:Termination by Subscriber:The Subscriber may terminate Coverage for himself/herself and any enrolled Dependents under the Contract for any reason by providing fourteen (14) days advance written notice to the Health Insurance MarketplaceFor notices received on the 1st through 15th day of the month, termination will take effect on the first day of the month in which the notice was receivedFor notices received on the 16th through 31st day of the month, termination will take effect on the first day of the month following the month in which the notice was received, unless the Health Plan agrees to an earlier terminationThe notice of termination should be sent to the Health Insurance Marketplace through which You enrolled.If you have any questions, please contact Customer Service at ###-###-####, Monday through Friday from 8:am until 5:pm or you may reach me directly at ###-###-####If you are hearing impaired please call 7-1-Telecommunications Relay Service.Sincerely,Yanique MAppeals Coordinator Grievance & Appeals Department

Dear [redacted] , Thank you for allowing us to address the concerns reported in complaint # [redacted] for [redacted] that was received by us on November 24, 2014, regarding issues she has experienced while applying for insurance through the Health Insurance Marketplace Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you Our research has determined a reason for the mismatch that displays for [redacted] when comparing the copayment summary to the Summary of Benefit Coverage (SBC) on www.Healthcare.gov When shopping for a plan on the Marketplace, a series of questions is asked to determine if the person searching is eligible for any type of assistance with paying for the premium or for healthcare If an income level is entered to the relevant question that qualifies the person for assistance, a message is displayed that provides an estimate of any premium tax credits and states, “In addition this household may also be eligible for a cost-sharing reduction on a Silver plan that reduces the out-of-pocket expenses paid for deductibles, copayments, and coinsurance.” After continuing onto the next page, a list of all available plans is displayed, with links to additional information and a brief summary of copayments and coinsurance for each plan The information displayed under the copayment/coinsurance summary section automatically includes the cost-sharing reduction mentioned in the previous message The Center for Medicare and Medicaid Services (CMS), which maintains the Marketplace website, has directed the insurance carriers offering plans to only submit the SBC for the standard plans that do not include the cost-sharing reduction Thus, the links to the SBC are only able to display the benefits that would apply for the standard plan, which do not match to the benefits that would apply for members who qualify for the assistance We were unable to locate any phone calls to Coventry representatives from [redacted] Nonetheless, all plans that are offered on the Marketplace have been fully approved by all the required organizations as well as Coventry The appropriate regulatory approvals are a CMS requirement for every plan that is offered We do apologize for any frustration [redacted] experienced with her plan selection for The information Coventry received from the Marketplace indicated that she had selected a High Performance Network (HPN) plan with a network type called Carelink It is unfortunate that her established physicians do not participate with the Carelink network When making her selection for 2015, [redacted] can use our provider search to find lists of all participating providers for the plan she chooses A link to the provider search is available through the Marketplace If she chooses a plan with FocusedCare or Carelink in the plan name, she would need to select the corresponding HPN option on the plan type selector before performing the search If FocusedCare or Carelink are not in the plan name, she would need to select the CoventryOne PPO Network We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] ’s concerns If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Regards, Chris B [redacted] Executive Resolution Team

Dear Ms [redacted] , Please see our response to complaint # [redacted] for [redacted] that was received by us on February 3, We were able to have Coventry’s system updated to show active coverage for Ms [redacted] and her daughter for The update was completed the evening of February 11, Please allow 24-hours for the policy information to be transferred over to the system that allows pharmacy claims to be processed We apologize for the delay in making the correctionWe did note that Ms [redacted] made multiple contacts with our Enrollment department to have them address the error The Enrollment department in turn made multiple requests to have the system updated but they were not handled in a timely fashion We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms [redacted] ’ concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Regards, Chris B [redacted] Executive Resolution Team

October 13, Dear [redacted] :The Member is participating in the Coventry Health and Life Insurance Company (“CHL”) HealthAmerica One individual HMO ACA health benefit plan[redacted] (the “member”) has filed a complaintThe Member states that his premium payment was drafted by the plan after the Member cancelled his coverage on 8/2/The Member is requesting reimbursement of the premium payment processed on 9/9/in the amount of $292.60.Upon review, the member called on 8/5/to term the payment for August, however the August payment had not postedTherefore, at that time, the member was not paid through AugustHe did not call back to terminate coverage until 9/11/2014, resulting in the CHL enrollment representative terming the member effective 9/30/We have now termed the policy as of 08/31/and a refund is in process for $292.60.We trust the above information is fully responsive to your requestShould you have any questions or concerns regarding this complaint, please do not hesitate to contact me.Sincerely,Emily M Complaint and Appeal Consultant

[A default letter is provided here which indicates your acceptance of the business's response If you wish, you may update it before sending it.] Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and find that this resolution is satisfactory to me Thanks! [redacted]

February 5, Dear ** [redacted] : This letter is in response to the aforementioned Case Number [redacted] regarding ** [redacted] ’s request for new member material and/or member ID number and refund of January premiums After review of this grievance, the Health Plan has confirmed, ** [redacted] paid for premiums on December 15, for a policy effective date January 1, 2014, Making a payment prior to issuance is part of the requirements for polices offered on the exchangeThere is no consideration for partial month; that is not an option the Health Plan can offer, according to Federal GuidelinesAs this is an on exchange plan and the binder payment is a requirement to hold the policy, we could not make an exception to refund** [redacted] would have to call the exchange for this or see if they were willing to move his effective date due to the circumstancesEither way the Health Plan is limited to what is fed to us by the exchange In addition, new member material can take up to 7-business days to be receivedAs of January 15, 2014, a request was made to have ** [redacted] ’s cards mailedPlease find (enclosed) ** [redacted] ’s Schedule of Benefits and Schedule of Covered ServicesOn January 24, 2014, the Health Plan has contacted ** [redacted] and informed that his policy is currently active If you have any additional questions, please contact me toll free at ###-###-####, extension [redacted] or directly at ###-###-####, Monday through Friday from 8:am until 5:pmIf you are hearing impaired please call TTY 7-1-Relay Sincerely