Plan Documents & Benefit Information

Below you'll find our enrollment form that you can print out, complete and mail to Memorial Hermann Advantage. Mail your completed form to:

Memorial Hermann Medicare Advantage Enrollment
PO Box 19909
Houston, Texas 77224

Enrollment Form 2023 — HMO (English) / (Spanish)

This document includes a detailed legal description of your benefits and costs as a member. All Evidence of Coverage (EOC) documents are organized by plan name.

Evidence of Coverage 2023 — HMO (English) / (Spanish)
Evidence of Coverage 2023 — Plus HMO (English) / (Spanish)
Evidence of Coverage 2023 — Golden Triangle HMO (formally Jefferson HMO) (English) / (Spanish)
Evidence of Coverage 2023 — Dual Advantage HMO (D-SNP) (English) / (Spanish)
Evidence of Coverage 2023 — Memorial Hermann Advantage Prime Value MA-only HMO (English) / (Spanish)
Evidence of Coverage 2023 Addendum — RA Cost Sharing Protections (English) / (Spanish)

The Summary of Benefits provides some of the features of our plans. These documents are organized by plan name. For a complete list of benefits, see your Evidence of Coverage (EOC).

Summary of Benefits 2023 — HMO (English) / (Spanish)
Summary of Benefits 2023 — Plus HMO (English) / (Spanish)
Summary of Benefits 2023 — Golden Triangle HMO (formally Jefferson HMO) (English) / (Spanish)
Summary of Benefits 2023 — Dual Advantage HMO (D-SNP) (English) / (Spanish)
Summary of Benefits 2023 — Memorial Hermann Advantage Prime Value MA-only HMO (English) / (Spanish)

2023 HMO Annual Notice of Changes - (English) / (Spanish)
2023 Plus HMO Annual Notice of Changes - (English) / (Spanish)
2023 Jefferson HMO (now Golden Triangle HMO) Annual Notice of Changes - (English) / (Spanish)
2023 Dual Advantage Annual Notice of Changes - (English) / (Spanish)

Here at Memorial Hermann Advantage, we strive to provide our members with the most accurate Provider Directories. If you need help finding a network provider, please call Customer Service: (855) 645-8448 (TTY 711) or click here to access our online searchable directory. If you would like a Provider Directory mailed to you, you may call the number above, or request one here.

Aquí en Memorial Hermann Advantage nos esforzamos por ofrecer a nuestros miembros los Directorios de Proveedores más precisos. Si necesitas ayuda para encontrar un proveedor dentro de la red, llama al: (855) 645-8448 (TTY 711) O visita aquí para acceder a nuestro directorio de búsqueda online. Si deseas recibir por correo un Directorio de Proveedores, puedes llamar al número indicado más arriba o solicitar uno en el sitio web aquí.

Dual Advantage (English) / (Spanish)
Golden Triangle (English) / (Spanish)
HMO (English) / (Spanish)
Plus HMO (English) / (Spanish)
Prime MA Only (English) / (Spanish)

Dental benefits under the Memorial Hermann Medicare Advantage plans are provided by Liberty Dental Plan®. Please review your plan’s Evidence of Coverage (EOC) to ensure you fully understand the dental benefits offered with your specific plan. Contact Liberty Dental Plan® directly at (888) 700-1246 for questions regarding your benefits or help finding an in-network provider. You may also register for online services or review your dental benefits at Liberty Dental Plan®.
(Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage website.)

Available for all Memorial Hermann Advantage Plans, members are provided an annual allowance of up to $400 for hearing aids and $200 for eyewear. To be reimbursed for hearing and vision equipment, please fill out the Member Reimbursement Medical Claim Form and follow the instructions to complete your submission.

Available for all Memorial Hermann Advantage Plans, Modivcare manages routine non-emergency medical transportation (NEMT) for Memorial Hermann Health Plan members. Access to Modivcare is a benefit of your health plan and is designed to help you get to your:

• Medical and dental appointments,
• Pharmacy to pick up medication, and
• Ongoing care such as dialysis.

Trip Allowance:

• Medicare Advantage HMO - Ten (10) one-way transports to a Health-related location per year.
• Medicare Advantage Plus HMO - Fifteen (15) one-way transports to a Health-related location per year.
• Golden Triangle HMO (formally Jefferson HMO) - Ten (10) one-way transports to a Health-related location per year.
• Dual Advantage HMO (D-SNP) – Fifty-eight (58) one-way transports to a Health-related location per year.
• Memorial Hermann Advantage Prime Value MA-Only HMO - Ten (10) one-way transports to a Health-related location per year.

To book your ride, visit MyModivcare.com or call (855) 330-9138.
(Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage website.)

Please be sure to have the following information available when booking your ride:

• Your Memorial Hermann Health Plan Member ID #
• Date and time of your scheduled appointment
• Name and address of your medical provider
• Pick up address or location

Please call at least 3 business days in advance, but not more than 2 weeks before your scheduled appointment.
Ride Assist Help Line: (855) 330-9138
Call the Ride Assist Help Line if your transportation is late or if you need to schedule a pick up from a facility.

Available for all Memorial Hermann Advantage Plans, Mom’s Meals® provides members with (10) meals post-discharge of an in-patient hospitalization stay. For more information about using this benefit, please call our customer service team at (855) 645-8448 (TTY 711)

Available for all Memorial Hermann Advantage Plans, the Over-The-Counter (OTC) benefit provides members with a quarterly allowance for OTC products. For more information on the OTC benefit, click here.

Our plan allows for reimbursements of certain claims. Please download the form below, complete it and follow the submission directions.

Member Reimbursement Medical Claim Form

The Medicare Program rates all health and prescription drug plans each year, based on a plan's quality and performance. Medicare Star Ratings help you know how good a job our plan is doing. You can use these Star Ratings to compare our plan's performance to other plans.

Medicare Stars Rating 2023 - HMO (English) / (Spanish)

Appointment of Representative (AOR) Form (English) / (Spanish)
This form confirms your request for a particular person to act as your representative in connection with a claim.

For information on how to Authorization to Disclose Protected Health Information, visit our Privacy Page.

Continuity of Care Form
Medical Power of Attorney
Disenrollment Information
Health Risk Assessment (HRA) Form
Multilanguage Insert — HMO
Prior Authorization Form - Part C
Privacy Forms