About Medicare Enrollment

Welcome CarePlus Members

We want to make it easier for you to help stay in control of your health care. As one of our 166,208* members, you are the reason why we work hard to provide you with improved benefits, value, and convenience each year. We believe that good healthcare starts with prevention, which is why we focus on giving you the benefits you need to help you stay satisfied and happy.

On this page you will find the information and forms you need to help manage your healthcare decisions, and to provide us with feedback.

*The Centers for Medicare & Medicaid Services (CMS) Medicare Advantage (MA) Membership Reports October 2020.

CMS Star Ratings

The Centers for Medicare & Medicaid Services (CMS) created its Five-Star Quality Rating System to help consumers, their families, and caregivers compare Medicare health and prescription drug plans. Since 2015, CarePlus has earned a 5-star rating a total of four times, including 2019, 2020 and 2021. An overall 5 out of 5 star rating is the highest possible overall rating based on plan quality and performance.

The below information is the overall Star Rating CarePlus received for plan years 2020 and 2021. CMS makes information available about all rated Medicare health and prescription drug plans at www.medicare.gov (link opens in new window) .

Summary of the Florida Patient’s Bill of Rights and Responsibilities

Florida law requires that your healthcare provider or healthcare facility recognize your rights while you are receiving medical care and that you respect the healthcare providers’ or healthcare facility’s right to expect certain behavior on the part of patients.

PDFCarePlus Summary of the Florida Patient’s Bill of Rights and Responsibilities — English(PDF opens in new window) 

PDFCarePlus Summary of the Florida Patient’s Bill of Rights and Responsibilities — Spanish(PDF opens in new window) 

How to File a Grievance or Appeal

To file a grievance or appeal, you can contact CarePlus in one of these ways:

By phone

Please call Member Services at 1-800-794-5907 (TTY: 711). From October 1 - March 31, we are open 7 days a week, 8 a.m. to 8 p.m. From April 1 - September 30, we are open Monday - Friday, 8 a.m. to 8 p.m. You may always leave a voicemail after hours, Saturdays, Sundays, and holidays and we will return your call within one business day.

Grievance or Appeal Request Form

PDFGrievance or Appeal Request Form — English(PDF opens in new window) 

PDFGrievance or Appeal Request Form — Spanish(PDF opens in new window) 

Fax number: 1-800-956-4288

Mailing address:

CarePlus Health Plans
Grievance and Appeals
11430 NW 20th Street, Suite 300
Miami, FL 33172

You may submit feedback online directly to the Centers for Medicare & Medicaid Services. Fill out the Medicare Complaint Form (link opens in new window)  with your personal information and concern.

Contact numbers for members and physicians who have questions and need to inquire about the status of the grievance, coverage determination, and appeal processes

Members:

Please call Member Services at 1-800-794-5907 (TTY: 711). From October 1 - March 31, we are open 7 days a week, 8 a.m. to 8 p.m. From April 1 - September 30, we are open Monday - Friday, 8 a.m. to 8 p.m. You may always leave a voicemail after hours, Saturdays, Sundays, and holidays and we will return your call within one business day. Our fax number is 1-800-956-4288.

Provider/Physicians:

Please contact the CarePlus Pharmacy Coverage Determination Review Team at 1-866-315-7587. The Pharmacy Coverage Determination Review Team hours of operations are Monday - Friday, 8 a.m. - 8 p.m. TTY users should call 711. Our fax number is 1-800-310-9071.

How to obtain grievance and appeal data.

PDFHow to Obtain Grievance and Appeal Data — English(PDF opens in new window) 

PDFHow to Obtain Grievance and Appeal Data — Spanish(PDF opens in new window) 

You can find detailed information in Chapter 9 of the CarePlus Evidence of Coverage (EOC) with regard to grievances, coverage determinations (including exceptions), and the appeals process. You will find links to the EOC on the CarePlus Medicare Advantage Plan Information pages.

How to Request a Part D Coverage Determination

Certain medications require a coverage determination. CarePlus has placed this requirement on selected high-risk or high-cost medications because we want to make sure these medications do not interfere with others you take or add to your costs unnecessarily. If your medication requires this step, you, your appointed representative, or your prescribing physician or other prescriber will need to request and receive approval in order for CarePlus to cover your drug. Follow the link below for instructions about how to request a Part D Coverage Determination:

How to Request a Part D Coverage Determination

How to obtain a number of exceptions

As a member of our plan, you can request information on the aggregate number of Medicare Part D exceptions filed with the plan. To obtain this information please call our Member Services department at 1-800-794-5907. From October 1 - March 31, we are open 7 days a week, 8 a.m. to 8 p.m. From April 1 - September 30, we are open Monday - Friday, 8 a.m. to 8 p.m. You may always leave a voicemail after hours, Saturdays, Sundays, and holidays and we will return your call within one business day. TTY users should call 711.

You can find detailed information in Chapter 9 of the CarePlus Evidence of Coverage (EOC) with regard to exceptions. You will find links to the EOC on the CarePlus Medicare Advantage Plan Information pages.

How and Where to Send Us Your Request for Payment

Submit your requests for payment reimbursement, along with proof of payment (bills, receipts) and/or a copy of the medical record documentation, if available, with your request. To make sure you are giving us all the information we need to make a decision, you may download, print, and complete a copy of the below Reimbursement Request Form. If you don’t want to use the form, send us a cover letter with all the needed documentation listed above.

If you need help completing the form, or would like more information about what you need to send us, call Member Services at 1-800-794-5907 (TTY: 711). From October 1 - March 31, we are open 7 days a week, 8 a.m. to 8 p.m. From April 1 - September 30, we are open Monday - Friday, 8 a.m. to 8 p.m. You may always leave a voicemail after hours, Saturdays, Sundays, and holidays and we will return your call within one business day. You must send the Reimbursement Request Form or signed reimbursement request in writing.

PDFReimbursement Request Form — English(PDF opens in new window) 

PDFReimbursement Request Form — Spanish(PDF opens in new window) 

Mail your request for payment with any bills, receipts, and/or medical record documentation to us at:

CarePlus Health Plans
Attention: Member Services Department

11430 NW 20th Street, Suite 300
Miami, FL 33172

National Coverage Determinations

From time to time CMS makes changes to the services that are covered by Medicare. These changes are updated via National Coverage Determinations (NCD). You can access the NCD information by using the link below.

National Coverage Determinations

Quality Improvement (QI) Program

The CarePlus Quality Improvement Program includes clinical care, preventive care, and member services. See below for information about our QI Program and progress toward our goals:

PDFCarePlus Quality Improvement Program Description Overview (English) (PDF opens in new window) 

PDF CarePlus Quality Improvement Program Description Overview (Spanish) (PDF opens in new window) 

Members also can obtain a written QI Program description by calling the Quality Operations, Compliance and Accreditation Department at 1-305-626-5195, Monday - Friday, 8:30 a.m. to 5:00 p.m. TTY users should call 711. We welcome members’ input about our QI program. Members can provide feedback by writing to: CarePlus Health Plans, Quality Operations, Compliance & Accreditation Department, 3501 SW 160th Ave, Bldg. B, 1st Floor, Miramar, FL 33027.

Care Management Member Satisfaction Surveys

CarePlus conducts annual surveys to assess our members’ levels of satisfaction with the care and interventions they receive from our care management programs. With these programs, we aim to provide health education and wellness promotion services to members, with an assigned care manager serving as their advocate. We review, analyze, and incorporate results from the satisfaction surveys into quality improvement activities, in an effort to enhance our care management programs and provide our members with high-quality services. If you have questions or want a copy of these survey results, please call the CarePlus Care Management Department at 1-866-657-5625, Monday - Friday, 8 a.m. to 5 p.m., EST. TTY users should call 711.

Special Needs Plans (D-SNPs) Model of Care (MOC) Quality Improvement Evaluation (QIE)

CarePlus Health Plans conducts an annual evaluation of its MOC. If you want details related to this evaluation, please call Member Services at 1-800-794-5907 (TTY: 711). From October 1 - March 31, we are open 7 days a week, 8 a.m. to 8 p.m. From April 1 - September 30, we are open Monday - Friday, 8 a.m. to 8 p.m. You may always leave a voicemail after hours, Saturdays, Sundays, and holidays and we will return your call within one business day.

CarePlus is an HMO plan with a Medicare contract. Enrollment in CarePlus depends on contract renewal. CareNeeds (HMO D-SNP) and CareNeeds PLUS (HMO D-SNP) are sponsored by CarePlus Health Plans, Inc. and the State of Florida, Agency for Health Care Administration.

CareNeeds (HMO D-SNP) and CareNeeds PLUS (HMO D-SNP), have been approved by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (D-SNP) until December 31, 2020 based on a review of CareNeeds' and CareNeeds PLUS' Model of Care.