Plan Materials and Forms

Listed below are some documents that may be helpful at different times during your membership.

This booklet gives you a summary of costs and coverage in your plan. Please select the document for your plan and county:

Florida - Sacred Heart and St. Vincent's

Plan Name	CMS #	County	Summary of Benefits
Ascension Complete St. Vincent's Reward (HMO)	H8225 - 001	Baker, Clay, Duval & Nassau	Summary of Benefits, H8225-001 - English (PDF) Summary of Benefits, H8225-001 - Spanish (PDF)
Ascension Complete Sacred Heart Reward (HMO)	H8225 - 002	Escambia and Santa Rosa	Summary of Benefits, H8225-002 - English (PDF) Summary of Benefits, H8225-002 - Spanish (PDF)
Ascension Complete St. Vincent's Secure (HMO)	H8225 -003	Baker, Clay, Duval & Nassau	Summary of Benefits, H8225-003 - English (PDF) Summary of Benefits, H8225- 003 - Spanish (PDF)
Ascension Complete Sacred Heart Secure (HMO)	H8225 - 004	Escambia and Santa Rosa	Summary of Benefits, H8225-004 - English (PDF) Summary of Benefits, H8225-004 - Spanish (PDF)

Illinois - AMITA

Plan Name	CMS#	County	Summary of Benefits
Ascension Complete Illinois Reward (HMO)	H7399-001	Cook, DuPage, Kane and Will counties	Summary of Benefits, H7399-001 - English (PDF) Summary of Benefits, H7399-001 - Spanish (PDF)
Ascension Complete Illinois Secure (HMO)	H7399-002	Cook, DuPage, Kane and Will counties	Summary of Benefits, H7399-002 - English (PDF) Summary of Benefits, H7399-002 - Spanish (PDF)

Kansas - Via Christi

Plan Name	CMS#	County	Summary of Benefits
Ascension Complete Via Christi Reward (HMO)	H5398-001	Butler, Harvey and Sedgwick counties	Summary of Benefits, H5398-001 (PDF)
Ascension Complete Via Christi Secure (HMO)	H5398-002	Butler, Harvey and Sedgwick counties	Summary of Benefits, H5398-002 (PDF)

This booklet gives you a complete list of services, limitations and exclusions for your plan coverage.

Please select the document for your plan and county:

Florida - Sacred Heart and St. Vincent's

Plan Name	CMS #	County	Evidence of Coverage (EOC)
Ascension Complete St. Vincent's Reward (HMO)	H8225 - 001	Baker, Clay, Duval & Nassau	Evidence of Coverage, H8225-001 - English (PDF)
Ascension Complete Sacred Heart Reward (HMO)	H8225 - 002	Escambia and Santa Rosa	Evidence of Coverage, H8225-002 - English (PDF)
Ascension Complete St. Vincent's Secure (HMO)	H8225 -003	Baker, Clay, Duval & Nassau	Evidence of Coverage, H8225-003 - English (PDF)
Ascension Complete Sacred Heart Secure (HMO)	H8225 - 004	Escambia and Santa Rosa	Evidence of Coverage, H8225-004 - English (PDF)

Illinois - AMITA

Plan Name	CMS #	County	Evidence of Coverage (EOC)
Ascension Complete Illinois Reward (HMO)	H7399 - 001	Cook, DuPage, Kane and Will counties	Evidence of Coverage, H7399-001 - English (PDF)
Ascension Complete Illinois Secure (HMO)	H7399 - 002	Cook, DuPage, Kane and Will counties	Evidence of Coverage, H7399-002 - English (PDF)

Kansas - Via Christi

Plan Name	CMS #	County	Evidence of Coverage (EOC)
Ascension Complete Via Christi Reward (HMO)	H5398 - 001	Butler, Harvey and Sedgwick counties	Evidence of Coverage, H5398-001 - English (PDF)
Ascension Complete Via ChristiSecure (HMO)	H5398 - 002	Butler, Harvey and Sedgwick counties	Evidence of Coverage, H5398-002 - English (PDF)

This booklet will tell you about changes to your plan’s costs and benefits for the coming year.

Please select the document for your plan and county:

Florida - Sacred Heart and St. Vincent's

Plan Name	CMS #	County	Annual Notice of Changes (ANOC)
Ascension Complete St. Vincent's Reward (HMO)	H8225 - 001	Baker, Clay, Duval & Nassau	Annual Notice of Changes, H8225-001 - English (PDF)
Ascension Complete Sacred Heart Reward (HMO)	H8225 - 002	Escambia and Santa Rosa	Annual Notice of Changes, H8225-002 - English (PDF)
Ascension Complete St. Vincent's Secure (HMO)	H8225 -003	Baker, Clay, Duval & Nassau	Annual Notice of Changes, H8225-003 - English (PDF)
Ascension Complete Sacred Heart Secure (HMO)	H8225 - 004	Escambia and Santa Rosa	Annual Notice of Changes, H8225-004 - English (PDF)

Illinois - AMITA

Plan Name	CMS#	County	Annual Notice of Changes (ANOC)
Ascension Complete Illinois Reward (HMO)	H7399-001	Cook, DuPage, Kane and Will counties	Annual Notice of Changes, H7399-001 - English (PDF) Annual Notice of Changes, H7399-001 - Spanish (PDF)
Ascension Complete Illinois Secure (HMO)	H7399-002	Cook, DuPage, Kane and Will counties	Annual Notice of Changes, H7399-002 - English (PDF) Annual Notice of Changes, H7399-002 - Spanish (PDF)

Kansas - Via Christi

Plan Name	CMS#	County	Annual Notice of Changes (ANOC)
Ascension Complete Via Christi Reward (HMO)	H5398-001	Butler, Harvey and Sedgwick counties	Annual Notice of Changes, H5398-001 (PDF)
Ascension Complete Via Christi Secure (HMO)	H5398-002	Butler, Harvey and Sedgwick counties	Annual Notice of Changes, H5398-002 (PDF)

Plan Benefit Materials | Ascension Complete