The Office of the Ombudsman also helps solve problems from a neutral standpoint to make sure that our members get all the covered services that we must provide. Read your Medicare Member Drug Coverage Rights. Be prepared for important health decisions Usually, your prescription drugs are only covered if they are filled at a network pharmacy including through our mail-order pharmacy services. If we say No to your appeal, you then choose whether to accept this decision or continue by making another appeal. If you lose your zero share-of-cost, full scope Medi-Cal, you will be disenrolled from our plan (for your Medicare benefits) the first day of the following month andwill be covered by the Original Medicare. CMS has updated Section 110.24 of the Medicare National Coverage Determinations Manual to include coverage of chimeric antigen receptor (CAR) T-cell therapy when specific requirements are met. If you dont know what you should have paid, or you receive bills and you dont know what to do about those bills, we can help. This government program has trained counselors in every state. Who is covered: Your provider will also know about this change. No more than 20 acupuncture treatments may be administered annually. Information on procedures for obtaining prior authorization of services, Quality Assurance, disenrollment, and other procedures affecting IEHP DualChoice Members. (Effective: February 15, 2018) All other indications for colorectal cancer screening not otherwise specified in the Social Security Act, regulations, or the above remain nationally non-covered. You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function. If the DMHC decides that your case is not eligible for IMR, the DMHC will review your case through its regular consumer complaint process. IEHP DualChoice (HMO D-SNP) helps make your Medicare and Medi-Cal benefits work better together and work better for you. Your doctor or other provider can make the appeal for you. Please select one of the following: Primary Care Doctor Specialist Behavioral Health Hospitals We will say Yes or No to your request for an exception. IEHP DualChoice must end your membership in the plan if any of the following happen: The IEHPDualChoice Privacy Notice describes how medical information about you may be used and disclosed, and how you can get access to this information. All Medicare covered services, doctors, hospitals, labs, and x-rays, You will have access to a Provider network that includes many of the same Providers as your current plan, Coordination of the services you get now or that you might need, Personal history of sustained VT or cardiac arrest due to Ventricular Fibrillation (VF), Prior Myocardial Infarction (MI) and measured Left Ventricular Ejection Fraction (LVEF) less than or equal to .03, Severe, ischemic, dilated cardiomyopathy without history of sustained VT or cardiac arrest due to VF, and have New York Heart Association (NYHA) Class II or III heart failure with a LVEF less than or equal to 35%, Severe, non-ischemic, dilated cardiomyopathy without history of cardiac arrest or sustained VT, NYHA Class II or II heart failure, LVEF less than or equal for 35%, and utilization of optimal medical therapy for at a minimum of three (3) months, Documented, familial or genetic disorders with a high risk of life-threating tachyarrhythmias, but not limited to long QT syndrome or hypertrophic cardiomyopathy, Existing ICD requiring replacement due to battery life, Elective Replacement Indicator (ERI), or malfunction, The procedure is performed in a Clinical Laboratory Improvement Act (CLIA)-certified laboratory. CMS has updated Chapter 1, Part 1, Section 20.4 of the Medicare National Coverage Determinations Manual providing additional coverage criteria for Implantable Cardiac Defibrillators (ICD) for Ventricular Tachyarrhythmias (VTs). If patients with bipolar disorder are included, the condition must be carefully characterized. Noncoverage specifically includes the following: Click here for more information on Ambulatory Electroencephalographic Monitoring and Colorectal Cancer Screening Tests. For some drugs, the plan limits the amount of the drug you can have. If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No. You, your representative, or your provider asks us to let you keep using your current provider. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Beneficiaries participating in a CMS approved clinical study undergoing Vagus Nerve Stimulation (VNS) for treatment resistant depression and the following requirements are met: Click here for more information on Vagus Nerve Stimulation. When will I hear about a standard appeal decision for Part C services? Beneficiaries receiving autologous treatment for cancer with T-cell expressing at least one. English Walnuts. Information is also below. Get the My Life. For CMS-approved studies, the protocol, including the analysis plan, must meet requirements listed in this NCD. You can ask us to make a faster decision, and we must respond in 15 days. The services are free. We serve 1.5 million residents of Riverside and San Bernardino counties through government-sponsored programs including Medi-Cal (families, adults, seniors and people with disabilities) and Cal MediConnect. There are many kinds of specialists. (Effective: April 13, 2021) An interventional echocardiographer must perform transesophageal echocardiography during the procedure.>. If the review organization agrees to give you a fast appeal, it must give you an answer to your Level 2 Appeal within 72 hours after getting your appeal request. i. ii. Please note: If your pharmacy tells you that your prescription cannot be filled, you will get a notice explaining how to contact us to ask for a coverage determination. It also includes problems with payment. You may be able to order your prescription drugs ahead of time through our network mail order pharmacy service or through a retail network pharmacy that offers an extended supply. Arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88%, tested during functional performance of the patient or a formal exercise, You will be notified when this happens. IEHP DualChoice. to part or all of what you asked for, we must give you the coverage within 24 hours after we get your request or your doctors or prescribers statement supporting your request. CMS has added a new section, Section 20.35, to Chapter 1 entitled Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). You can tell the California Department of Managed Health Care about your complaint. Beneficiaries not meeting all the criteria for cochlear implants are deemed not eligible for Medicare coverage except for FDA-approved clinical trials as described in the NCD. For the purpose of this decision, cLBP is defined as: nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. What is covered: The DMHC may waive the requirement that you first follow our appeal process in extraordinary and compelling cases. This is true even if we pay the provider less than the provider charges for a covered service or item. LSS is a narrowing of the spinal canal in the lower back. If we answer no to your appeal and the service or item is usually covered by Medi-Cal, you can file a Level 2 Appeal yourself (see above). They have a copay of $0. Our plans Part D drug coverage cannot cover a drug that would be covered under Medicare Part A or Part B. If you call us with a complaint, we may be able to give you an answer on the same phone call. If you put your complaint in writing, we will respond to your complaint in writing. Oncologists care for patients with cancer. A Level 1 Appeal is the first appeal to our plan. Box 997413 There are two ways to make a Level 2 appeal for Medi-Cal services and items: 1) Independent Medical Review or 2) State Hearing. If the Independent Medical Review decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. (SeeChapter 10 ofthe. During these events, oxygen during sleep is the only type of unit that will be covered. For example: We may make other changes that affect the drugs you take. Here are a few examples: You will usually see your PCP first for most of your routine healthcare needs such as physical checkups, immunization, etc. P.O. If your health condition requires us to answer quickly, we will do that. If you have a fast complaint, it means we will give you an answer within 24 hours. Deadlines for standard appeal at Level 2 Off-label use is any use of the drug other than those indicated on a drugs label as approved by the Food and Drug Administration. Beneficiaries that are at least 45 years of age or older can be screened for the following tests when all Medicare criteria found in this national coverage determination is met: Non-Covered Use: In most cases you have 120 days to ask for a State Hearing after the Your Hearing Rights notice is mailed to you. Appointment of Representatives Form (PDF), 2023 Drugs Requiring Prior Authorization (PDF). 1. You may be able to get extra help to pay for your prescription drug premiums and costs. What is covered? With "Extra Help," there is no plan premium for IEHP DualChoice. If you would like to switch from our plan to another Medicare Advantage plan simply enroll in the new Medicare Advantage plan. Routine womens health care, which includes breast exams, screening mammograms (X-rays of the breast), Pap tests, and pelvic exams as long as you get them from a network provider. Click here to download a free copy of Adobe Acrobat Reader.By clicking on this link, you will be leaving the IEHP DualChoice website. H8894_DSNP_23_3241532_M. Heart failure cardiologist with experience treating patients with advanced heart failure. your medical care and prescription drugs through our plan. (Effective: January 1, 2022) If you are asking to be paid back, you are asking for a coverage decision. IEHP DualChoice (HMO D-SNP) has contracts with pharmacies that equals or exceeds CMS requirements for pharmacy access in your area. Click here for more information on PILD for LSS Screenings. effort to participate in the health care programs IEHP DualChoice offers you. What if the plan says they will not pay? What is covered? We will generally cover a drug on the plans Formulary as long as you follow the other coverage rules explained in Chapter 6 of the IEHP DualChoice Member Handbookand the drug is medically necessary, meaning reasonable and necessary for treatment of your injury or illness. To start your appeal, you, your doctor or other prescriber, or your representative must contact us. 5. For reservations call Monday-Friday, 7am-6pm (PST). Also, someone besides your doctor or other provider can make the appeal for you, but first you must complete an Appointment of Representative Form. If an alternative drug would be just as effective as the drug you are asking for, and would not cause more side effects or other health problems, we will generally not approve your request for an exception. Rancho Cucamonga, CA 91729-1800. If your Level 2 Appeal was an Independent Medical Review, the Department of Managed Health Care will send you a letter explaining its decision. Remember, you can request to change your PCP at any time. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more days (44 days total) to answer your complaint. You should receive the IMR decision within 7 calendar days of the submission of the completed application. We take another careful look at all of the information about your coverage request. A Cal MediConnect Plan is an organization made up of Doctors, Hospitals, Pharmacies, Providers of long-term services and supports, Behavioral Health Providers, and other Providers. This is not a complete list. Effective September 27, 2021, CMS has updated section 240.2 of the National Coverage Determination Manual to cover oxygen therapy and oxygen equipment for in home use of both acute and chronic conditions, short- or long- term, when a patient exhibits hypoxemia. The letter will also explain how you can appeal our decision. (Implementation Date: February 14, 2022) Interventional Cardiologist meeting the requirements listed in the determination. Which Pharmacies Does IEHP DualChoice Contract With? If you are unable to get a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24-hour service. The beneficiary is under pre- or post-operative care of a heart team meeting the following: Cardiac Surgeon meeting the requirements listed in the determination. This is called a referral. Use of autologous Platelet-Derived Growth Factor (PDGF) for treatment of chronic, non-healing, cutaneous (affecting the skin) wounds, and. Send us your request for payment, along with your bill and documentation of any payment you have made. Who is covered: Members must meet all of the following eligibility criteria: Click here for more information on LDCT coverage. Drugs that may not be necessary because you are taking another drug to treat the same medical condition. Click here for more information on Leadless Pacemakers. Effective January 21, 2020, CMS will cover acupuncture for chronic low back pain (cLBP), for up to 12 visits in 90 days and an additional 8 sessions for those beneficiaries that demonstrate improvement, in addition to the coverage criteria outlined in the. CMS has issued a National Coverage Determination (NCD) which expands coverage to include leadless pacemakers when procedures are performed in CMS-approved Coverage with Evidence Development (CED) studies. Effective for claims with dates of service on or after February 10, 2022, CMS will cover, under Medicare Part B, a lung cancer screening counseling and shared decision-making visit. Inland Empire Health Plan - Local Health Plans of California If you are asking us to pay you back for medical care you have already received and paid for yourself, you are not allowed to ask for a fast appeal. You may contact the DMHC if you need help with a complaint involving an urgent issue or one that involves an immediate and serious threat to your health, you disagree with our plans decision about your complaint, or our plan has not resolved your complaint after 30 calendar days. Your PCP should speak your language. For more information, call IEHP DualChoice Member Services or read the IEHP DualChoice Member Handbook. The following information explains who qualifies for IEHP DualChoice (HMO D-SNP). (Implementation date: June 27, 2017). You have a care team that you help put together. Utilities allowance of $40 for covered utilities. To start your appeal, you, your doctor or other provider, or your representative must contact us. For the treatment of symptomatic moderate to severe mitral regurgitation (MR) when the patient still has symptoms, despite stable doses of maximally tolerated guideline directed medical therapy (GDMT) and cardiac resynchronization therapy, when appropriate and the following are met: Treatment is a Food and Drug Administration (FDA) approved indication. (Implementation Date: December 10, 2018). B. If you make an appeal for reimbursement, we must give you our answer within 60 calendar days after we get your appeal. Medi-Cal is public-supported health care coverage. Remember, if you get a bill that is more than your copay for covered services and items, you should not pay the bill yourself. However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. TTY users should call 1-877-486-2048. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contact renewal. Patients must maintain a stable medication regimen for at least four weeks before device implantation. Unless you change plans, IEHP DualChoice (HMO D-SNP) will provide your Medicare benefits. Portable oxygen would not be covered. Because you get assistance from Medi-Cal, you can end your membership in IEHPDualChoice at any time. If you disagree with our decision, you can ask the DMHC Help Center for an IMR. 8am - 8pm (PST), 7 days a week, including holidays, TTY: (800) 718-4347. This is known as Exclusively Aligned Enrollment, and. If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. Medi-Cal provides free or low-cost health coverage to low-income individuals and their families.California has been expanding Medi-Cal to a larger and more diverse group of people. Medicare will cover both MNT and Diabetes Outpatient Self-Management Training (DSMT) during initial and subsequent years, if the physician determines treatment is medically necessary and as long as DSMT and MNT are not provided on the same date. If you wish, you and your doctor or other prescriber may give us additional information to support your appeal. TTY should call (800) 718-4347. Some hospitals have hospitalists who specialize in care for people during their hospital stay. Calls to this number are free. We must give you our answer within 14 calendar days after we get your request. Who is covered: The PTA is covered under the following conditions: TDD users should call (800) 952-8349. Your PCP will send a referral to your plan or medical group. We must give you our answer within 30 calendar days after we get your appeal. Effective for dates of service on or after August 7, 2019, CMS covers autologous treatment for cancer with T-cell expressing at least one chimeric antigen receptor (CAR) when administered at healthcare facilities enrolled in the Food and Drug Administrations (FDA) Risk Evaluation and Mitigation Strategies (REMS) and when specific requirements are met. If the answer to your appeal is Yes at any stage of the appeals process after Level 2, we must send the payment you asked for to you or to the provider within 60 calendar days. If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan. It is not connected with this plan and it is not a government agency. It attacks the liver, causing inflammation. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition. The clinical study must address whether VNS treatment improves health outcomes for treatment resistant depression compared to a control group, by answering all research questions listed in 160.18 of the National Coverage Determination Manual. If you are having a problem with your care, you can call the Office of Ombudsman at 1-888-452-8609for help. We conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care. We will contact the provider directly and take care of the problem. Click here for more information on acupuncture for chronic low back pain coverage. Sometimes a specialist, clinic, hospital or other network provider you are using might leave the plan. For additional information on step therapy and quantity limits, refer to Chapter5 of theIEHP DualChoice Member Handbook. You and your provider can ask us to make an exception. We determine an existing relationship by reviewing your available health information available or information you give us. It also has care coordinators and care teams to help you manage all your providers and services. But if you do pay the bill, you can get a refund if you followed the rules for getting services and items. Who is covered: disease); An additional 8 sessions will be covered for those patients demonstrating an improvement. The program is not connected with us or with any insurance company or health plan. CMS has updated Chapter 1, section 30.3.3 of the Medicare National Coverage Determinations Manual. The letter will tell you how to do this. Receive Member informing materials in alternative formats, including Braille, large print, and audio. If you need help to fill out the form, IEHP Member Services can assist you. If we agree to make an exception and cover a drug that is not on the Formulary, you will need to pay the cost-sharing amount that applies to drug. TTY/TDD (800) 718-4347. Dependent edema (gravity related swelling due to excess fluid) suggesting congestive heart failure; or, IEHP DualChoice IEHP DualChoice Medicare Team at (800) 741-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays, TTY users should call (800) 718-4347. With IEHP DualChoice, you will still have an IEHP DualChoice Member Service team to get help for your needs. Effective January 21, 2020, CMS will cover acupuncture for chronic low back pain (cLBP) for up to 12 visits in 90 days and an additional 8 sessions for those beneficiaries that demonstrate improvement, in addition to the coverage criteria outlined in the NCD Manual. You may choose different health plans, or providers, under Medi-Cal, like IEHP or Molina Healthcare, Blue Shield, Health Net, etc. They all work together to provide the care you need. Can I get a coverage decision faster for Part C services? Or, if you havent paid for the service or item yet, we will send the payment directly to the provider. If your doctor or other provider asks for a service or item that we will not approve, or we will not continue to pay for a service or item you already have and we said no to your Level 1 appeal, you have the right to ask for a State Hearing. If you need help during the appeals process, you can call the Office of the Ombudsman at 1-888-452-8609. Some of the advantages include: You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. We have 30 days to respond to your request. If you no longer qualify for Medi-Cal or your circumstances have changed that make you no longer eligible for Dual Special Needs Plan, you may continue to get your benefits from IEHP DualChoice for an additional two-month period. If we say Yes to your request for an exception, the exception usually lasts until the end of the calendar year. You will not have a gap in your coverage. You can give the completed form to any IEHP Provider or mail it to: Call: 1-888-452-8609(TTY 711) Monday through Friday, 9 a.m. to 5 p.m. If you miss this deadline and have a good reason for missing it, we may give you more time to make you appeal. Prescriptions written for drugs that have ingredients you are allergic to.
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