What if the plan says they will not pay? Level 2 Appeal for Part D drugs. For the benefit year of 2023 here is what youll get and what you will pay: With IEHP DualChoice, you pay nothing for covered drugs as long as you follow the plans rules. Heart failure cardiologist with experience treating patients with advanced heart failure. 2023 IEHP DualChoice Member Handbook (PDF), Click here to download a free copy of Adobe Acrobat Reader. Are a United States citizen or are lawfully present in the United States. 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. Call IEHP DualChoice Member Services if you need help in choosing a PCP or changing your PCP. IEHP: "Inland Empire Health Plan (IEHP) is a not-for-profit Medi-Cal and Medicare health plan headquartered in Rancho Cucamonga, California. Medicare Prescription Drug Coverage and Your Rights Notice- Posting of Member Drug Coverage Rights: Medicare requires pharmacies to provide notice to enrollees each time a member is denied coverage or disagrees with cost-sharing information. Unless you change plans, IEHP DualChoice (HMO D-SNP) will provide your Medicare benefits. They are considered to be at high-risk for infection; or. The letter you get from the IRE will explain additional appeal rights you may have. See plan Providers, get covered services, and get your prescription filled timely. TTY users should call 1-800-718-4347. During these reviews, we look for potential problems such as: If we see a possible problem in your use of medications, we will work with your Doctor to correct the problem. If we say No to your request for an exception, you can ask for a review of our decision by making an appeal. You ask us to pay for a prescription drug you already bought. For more information on Member Rights and Responsibilities refer to Chapter 8 of your. The list can help your provider find a covered drug that might work for you. Black walnut trees are not really cultivated on the same scale of English walnuts. It attacks the liver, causing inflammation. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drugs manufacturer takes a drug off the market, we will take it off the Drug List. If you do not get this approval, your drug might not be covered by the plan. There may be qualifications or restrictions on the procedures below. This section is about asking for coverage decisions and making appeals with problems related to your benefits and coverage. Angina pectoris (chest pain) in the absence of hypoxemia; or. TTY users should call (800) 718-4347 or fax us at (909) 890-5877. 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. We will give you our answer sooner if your health requires us to do so. We will send you a letter within 5 calendar days of receiving your appeal letting you know that we received it. When your doctor recommends services that are not available in our network, you can receive these services by an out-of-network provider. Governing Board. Effective on January 1, 2023, CMS has updated section 210.3 of the NCD Manual that provides coverage for colorectal cancer (CRC) screening tests under Medicare Part B. The procedure removes a portion of the lamina in order to debulk the ligamentum flavum, essentially widening the spinal canal in the affected area. If you need help during the appeals process, you can call the Office of the Ombudsman at 1-888-452-8609. Can I ask for a coverage determination or make an appeal about Part D prescription drugs? If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. At any time, you can call IEHP DualChoice Member Services to get up-to-date information about changes in the pharmacy network. The Centers of Medicare and Medicaid Services (CMS) will cover acupuncture for chronic low back pain (cLBP) when specific requirements are met. Covering a Part D drug that is not on our List of Covered Drugs (Formulary). Receive emergency care whenever and wherever you need it. You can also visit https://www.hhs.gov/ocr/index.html for more information. You may be able to get extra help to pay for your prescription drug premiums and costs. The USPTF has found that screening for HBV allows for early intervention which can help decrease disease acquisition, transmission and, through treatment, improve intermediate outcomes for those infected. Receive information about clinical programs, including staff qualifications, request a change of treatment choices, participate in decisions about your health care, and be informed of health care issues that require self-management. i. (Implementation date: August 29, 2017 for MAC local edits; January 2, 2018 for MCS shared edits) (800) 718-4347 (TTY), IEHP DualChoice Member Services Review your Member Handbook, and call IEHP DualChoice Member Services if you do not understand something about your coverage and benefits. Medicare beneficiaries who meet either of the following criteria: Click here for more information on HBV Screenings. TTY/TDD users should call 1-800-718-4347. Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). If you want the Independent Review Organization to review your case, your appeal request must be in writing. The program is not connected with us or with any insurance company or health plan. After your application and supporting documents are received from your plan, the IMR decision will be made within 30 calendar days. If your health condition requires us to answer quickly, we will do that. If you do not stay continuously enrolled in Medicare Part A and Part B. Ask within 60 days of the decision you are appealing. The phone number is (888) 452-8609. If you would like to switch from our plan to another Medicare Advantage plan simply enroll in the new Medicare Advantage plan. TTY/TDD (800) 718-4347. Request and receive appeal data from IEHP DualChoice; Receive notice when an appeal is forwarded to the Independent Review Entity (IRE); Automatic reconsideration by the IRE when IEHP DualChoice upholds its original adverse determination in whole or in part; Administrative Law Judge (ALJ) hearing if the independent review entity upholds the original adverse determination in whole or in part and the remaining amount in controversy is $100 or more; Request Departmental Appeals Board (DAB) review if the ALJ hearing is unfavorable to the Member in whole or in part; Judicial review of the hearing decision if the ALJ hearing and/or DAB review is unfavorable to the Member in whole or in part and the amount remaining in controversy is $1,000 or more; Make a quality of care complaint under the QIO process; Request QIO review of a determination of noncoverage of inpatient hospital care; Request QIO review of a determination of noncoverage in skilled nursing facilities, home health agencies and comprehensive outpatient rehabilitation facilities; Request a timely copy of your case file, subject to federal and state law regarding confidentiality of patient information; Challenge local and national Medicare coverage determination. Which Pharmacies Does IEHP DualChoice Contract With? What if the Independent Review Entity says No to your Level 2 Appeal? The Social Security Office at (800) 772-1213 between 7 a.m. and 7 p.m., Monday through Friday, TTY users should call (800) 325-0778; or. For example, this means that your care team makes sure: Your doctors know about all the medicines you take so they can make sure youre taking the right medicines and can reduce any side effects you may have from the medicines. Make necessary appointments for routine and sick care, and inform your Doctor when you are unable to make a scheduled appointment. After cracking, the nutmeat is easy to remove from the English walnut shell, while the nutmeat from the black walnut is much more difficult to remove after it has been cracked . If our answer is Yes to part or all of what you asked for, we must give the coverage within 72 hours after we get your appeal. H8894_DSNP_23_3241532_M. If you are admitted to one of these hospitals, a hospitalist may serve as your caregiver as long as you remain in the hospital. A Level 2 Appeal is the second appeal, which is done by an independent organization that is not connected to the plan. Current or lifetime history of psychotic features in any MDE; Current or lifetime history of schizophrenia or schizoaffective disorder; Current or lifetime history of any other psychotic disorder; Current or lifetime history of rapid cycling bipolar disorder; Current secondary diagnosis of delirium, dementia, amnesia, or other cognitive disorder; Treatment with another investigational device or investigational drugs. Our state has an organization called Livanta Beneficiary & Family Centered Care (BFCC) Quality Improvement Organization (QIO). We have 30 days to respond to your request. You will keep all of your Medicare and Medi-Cal benefits. If you are trying to fill a covered prescription drug that is not regularly stocked at an eligible network retail or mail order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals). If patients with bipolar disorder are included, the condition must be carefully characterized. Effective February 15, 2020, CMS will cover FDA approved Vagus Nerve Stimulation (VNS) devices for treatment-resistant depression through Coverage with Evidence Development (CED) in a CMS approved clinical trial in addition to the coverage criteria outlined in the National Coverage Determination Manual. Mail or fax your forms and any attachments to: You may complete the "Request for State Hearing" on the back of the notice of action. Who is covered: If you ask for a fast appeal, we will give you your answer within 72 hours after we get your appeal. Click here for more information on PILD for LSS Screenings. Generally, you must receive all routine care from plan providers and network pharmacies to access their prescription drug benefits, except in non-routine circumstances, quantity limitations and restrictions may apply. This is called a referral. CMS has updated Chapter 1, section 20.19 of the Medicare National Coverage Determinations Manual. You will get a letter from us about the change in your eligibility with instructions to correct your eligibility information. Yes. A clinical test providing a measurement of the partial pressure of oxygen (PO2) in arterial blood. Transportation: $0. Try to choose a PCP that can admit you to the hospital you want within 30 miles or 45 minutes of your home. TAVR under CED when the procedure is related to the treatment of symptomatic aortic stenosis and according to the Food and Drug Administration (FDA) approved indication for use with an approved device, or in clinical studies when criteria are met, in addition to the coverage criteria outlined in the NCD Manual. 2023 Plan Benefits. Live in our service area (incarcerated individuals are not considered living in the geographic service area even if they are physically located in it. We check to see if we were following all the rules when we said No to your request. Reviewers at the Independent Review Entity will take a careful look at all of the information related to your appeal. We will also use the standard 14 calendar day deadline instead. b. 711 (TTY), To Enroll with IEHP Effective for dates of service on or after January 1, 2022, CMS has updated section 180.1 of the National Coverage Determination Manual to cover three hours of administration during one year of Medical Nutrition Therapy (MNT) in patients with a diagnosis of renal disease or diabetes, as defined in 42 CFR 410.130. If the plan says No at Level 1, what happens next? Your care team and care coordinator work with you to make a care plan designed to meet your health needs. How do I make a Level 1 Appeal for Part C services? Your benefits as a member of our plan include coverage for many prescription drugs. Who is covered? If your PCP leaves our Plan, we will let you know and help you choose another PCP so that you can keep getting covered services. c. The Medicare Administrative Contractors (MACs) will review the arterial PO2 levels above and also take into consideration various oxygen measurements that can results from factors such as patients age, patients skin pigmentation, altitude level and the patients decreased oxygen carrying capacity. when beneficiaries are suspected of having white coat hypertension or masked hypertension in addition to the coverage criteria outlined in the, Ambulatory Blood Pressure Monitoring (ABPM), for the diagnosis of hypertension when either there is suspected white coat or masked hypertension. Arterial oxygen saturation at or above 89% when awake;or greater than normal decrease in oxygen level while sleeping represented by a decrease in arterial PO2 more than 10 mmHg or a decrease in arterial oxygen saturation more than 5%. If we are using the fast deadlines, we will give you our answer within 72 hours after we get your appeal, or sooner if your health requires it. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures, and deadlines that must be followed by us and by you. Vision Care: $350 limit every year for contact lenses and eyeglasses (frames and lenses). ii. 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. If you are not satisfied with the result of the IMR, you can still ask for a State Hearing. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. Yes. Bringing focus and accountability to our work. If our answer is Yes to part or all of what you asked for, we must authorize or provide the coverage within 72 hours after we get your appeal. If the State Hearing decision is Yes to part or all of what you asked for, we must comply with the decision. See Chapters 7 and 9 of the IEHP DualChoice Member Handbookto learn how to ask the plan to pay you back. The diagnostic laboratory test using NGS must have: Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic and; FDA-approved or cleared indication for use in that patients cancer and; results provided to the treating physician for management of the patient using a report template to specify treatment options. You can ask us to make a faster decision, and we must respond in 15 days. This means that your PCP will be referring you to specialists and services that are affiliated with their medical group. How to ask for coverage decision coverage decision to get medical, behavioral health, or certain long-term services and supports (CBAS, or NF services). Fax: (909) 890-5877. It has been concluded that high-quality research illustrates the effectiveness of SET over more invasive treatment options and beneficiaries who are suffering from Intermittent Claudication (a common symptom of PAD) are now entitled to an initial treatment. A specialist is a doctor who provides health care services for a specific disease or part of the body. With this app, you or a designated person with Power of Attorney can access your advance health care directives at any time from a home computer or smartphone. When we send the payment, its the same as saying Yes to your request for a coverage decision. Click here to learn more about IEHP DualChoice. . If our answer is Yes 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. 2023 Inland Empire Health Plan All Rights Reserved. What to do if you have a problem or concern with IEHP DualChoice (HMO D-SNP): You can call IEHP Member Services at (877) 273-IEHP (4347) and ask for a Member Complaint Form. The letter will explain why more time is needed. The Independent Review Entity is an independent organization that is hired by Medicare. The services of SHIP counselors are free. If the dollar value of the drug coverage you want meets a certain minimum amount, you can make another appeal at Level 3. We add a generic drug that is not new to the market and: Replace a brand name drug currently on the Drug List or. Complain about IEHP DualChoice, its Providers, or your care. We will give you our answer sooner if your health requires it. Click here for more information on Transcatheter Edge-to-Edge Repair [TEER] for Mitral Valve Regurgitation coverage . Here are two ways to get information directly from Medicare: By clicking on this link, you will be leaving the IEHP DualChoice website. For a patient demonstrating arterial PO2 at or above 56 mm Hg, or an arterial oxygen saturation at or above 89%, at rest and during the day. TTY users should call (800) 718-4347. If your health requires it, ask the Independent Review Entity for a fast appeal.. We will look into your complaint and give you our answer. It stores all your advance care planning documents in one place online. An interventional echocardiographer must perform transesophageal echocardiography during the procedure.>. (Effective: February 19, 2019) When possible, take along all the medication you will need. ), and, Are age 21 and older at the time of enrollment, and, Have both Medicare Part A and Medicare Part B, and, Are a full-benefit dual eligible beneficiary and enroll in IEHP DualChoice for your Medicare benefits and Inland Empire Health Plan (IEHP) for your Medi-Cal benefits. To make this request, or if you have any concerns about your continuity of care, please call IEHP DualChoice Member Services at 1-877-273-IEHP (4347). This includes getting authorization to see specialists or medical services such as lab tests, x-rays, and/or hospital admittance. Be prepared for important health decisions Utilities allowance of $40 for covered utilities. If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize or give you the drug coverage within 72 hours after we get the decision. You can change your Doctor by calling IEHP DualChoice Member Services. You should provide all requested information such as your full name, address, telephone number, the name of the plan or county that took the action against you, the aid program(s) involved, and a detailed reason why you want a hearing. 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). Most recently, as of May 1, 2016, Medi-Cal now covers all low income children under the age of 19, regardless of immigration status. If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other members of our plan. Emergency services from network providers or from out-of-network providers. To see if you qualify for getting extra help, you can contact: Do you need help getting the care you need? You can always contact your State Health Insurance Assistance Program (SHIP). If you are requesting an exception, provide the supporting statement. Your doctor or other prescriber must give us the medical reasons for the drug exception. a. For additional details on how to reach us for appeals, see Chapter 9 of the IEHP DualChoice Member Handbook. Our plan does not cover urgently needed care or any other care if you receive the care outside of the United States. What is covered: In order to receive out-of-network services, your Primary Care Provider (PCP) or Specialist must submit a referral request to your plan or medical group. You, your doctor or other prescriber, or your representative can request the Level 2 Appeal. Use of autologous Platelet-Derived Growth Factor (PDGF) for treatment of chronic, non-healing, cutaneous (affecting the skin) wounds, and. If you make an appeal for reimbursement, we must give you our answer within 60 calendar days after we get your appeal. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You have a right to give the Independent Review Entity other information to support your appeal. 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. Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. Has not resolved your Level 1 Appeal on a Medi-Cal service within 30 calendar days for a standard appeal or 72 hours for a fast appeal. We call this the supporting statement.. The counselors at this program can help you understand which process you should use to handle a problem you are having. There are two ways to ask for a State Hearing: If you meet this deadline, you can keep getting the disputed service or item until the hearing decision is made. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. You can file a grievance. PCPs are usually linked to certain hospitals and specialists. according to the FDA-approved indications and the following conditions are met: The procedure and implantation system received FDA premarket approval (PMA) for that system's FDA approved indication. Asymptomatic (no signs or symptoms of lung cancer); Tobacco smoking history of at least 20 pack-years (one pack-year = smoking one pack per day for one year; 1 pack =20 cigarettes); Current smoker or one who has quit smoking within the last 15 years; Receive an order for lung cancer screening with LDCT. If our answer is Yes to part or all of what you asked for, we must approve or give the coverage within 30 calendar days after we get your appeal. After the continuity of care period ends, you will need to use doctors and other providers in the IEHP DualChoice network that are affiliated with your primary care providers medical group, unless we make an agreement with your out-of-network doctor. A fast coverage decision means we will give you an answer within 24 hours after we get your doctors statement. (Implementation Date: October 8, 2021) Remember, you can request to change your PCP at any time. A new generic drug becomes available. Both of these processes have been approved by Medicare. (Effective: June 21, 2019) Make your appeal request within 60 calendar days from the date on the notice we sent to tell you our decision. If you are traveling within the US, but outside of the Plans service area, and you become ill, lose or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy if you follow all other coverage rules identified within this document and a network pharmacy is not available. If you ask for a fast coverage decision on your own (without your doctors or other prescribers support), we will decide whether you get a fast coverage decision. This can speed up the IMR process.

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