You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends. You can also call if you want to give us more information about a request for payment you have already sent to us. Patients demonstrating arterial PO2 between 56-59 mm Hg, or whos arterial blood oxygen saturation is 89%, with any of the following condition: What is covered: Can I ask for a coverage determination or make an appeal about Part D prescription drugs? CMS has updated Chapter 1, section 30.3.3 of the Medicare National Coverage Determinations Manual. https://www.medicare.gov/MedicareComplaintForm/home.aspx. The patient is experiencing a major depressive episode, as measured by a guideline recommended depression scale assessment tool on two visits, within a 45-day span prior to implantation of the VNS device. If PO2 and arterial blood gas results are conflicting, the arterial blood gas results are preferred source to determine medical need. Some changes to the Drug List will happen immediately. 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). You must submit your claim to us within 1 year of the date you received the service, item, or drug. IEHP DualChoice For more information, call IEHP DualChoice Member Services or read the IEHP DualChoice Member Handbook. We do a review each time you fill a prescription. Be informed regarding Advance Directives, Living Wills, and Power of Attorney, and to receive information regarding changes related to existing laws. The leadless pacemaker eliminates the need for a device pocket and insertion of a pacing lead which are integral elements of traditional pacing systems. They are considered to be at high-risk for infection; or. What is covered? 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. From time to time (during the benefit year), IEHP DualChoice revises (adding or removing drugs) the Formulary based on new clinical evidence and availability of products in the market. The List of Covered Drugs and pharmacy and provider networks may change throughout the year. (Implementation Date: November 13, 2020). What if the Independent Review Entity says No to your Level 2 Appeal? IEHP DualChoice is a Cal MediConnect Plan. CAR, when all the following requirements are met: Autologous treatment is for cancer with T-cells expressing at least one chimeric antigen receptor (CAR); and, Treatment is administered at a healthcare facility enrolled in the FDAs REMS; and. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. chimeric antigen receptor (CAR) T-cell therapy coverage. It also needs to be an accepted treatment for your medical condition. 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. Prior to filling your prescription at an out-of-network pharmacy, call IEHP DualChoice Member Services to find out if there is a network pharmacy in the area where you are traveling. See Chapters 7 and 9 of the IEHP DualChoice Member Handbookto learn how to ask the plan to pay you back. Ask within 60 days of the decision you are appealing. After your coverage begins with IEHP DualChoice, you must receive medical services and prescription drug services in the IEHP DualChoice network. The FDA provides new guidance or there are new clinical guidelines about a drug. Note: You can only make this request for services of Durable Medical Equipment (DME), transportation, or other ancillary services not included in our plan. This is not a complete list. The PCP you choose can only admit you to certain hospitals. For certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for you. Mail your request for payment together with any bills or receipts to us at this address: IEHPDualChoice Its a good idea to make a copy of your bill and receipts for your records. The Office of the Ombudsman. Click here for more information on Ventricular Assist Devices (VADs) coverage. Yes. If you lie about or withhold information about other insurance you have that provides prescription drug coverage. This is called upholding the decision. It is also called turning down your appeal. 3. The phone number for the Office of the Ombudsman is 1-888-452-8609. If you are under a Doctors care for an acute condition, serious chronic condition, pregnancy, terminal illness, newborn care, or a scheduled surgery, you may ask to continue seeing your current Doctor. 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. H8894_DSNP_23_3241532_M. Click here for more information on Topical Applications of Oxygen. You will keep all of your Medicare and Medi-Cal benefits. If the answer is No, we will send you a letter telling you our reasons for saying No. How long does it take to get a coverage decision coverage decision for Part C services? Asking for a fast coverage decision coverage decision: Here are the rules for asking for a fast coverage decision coverage decision: You must meet the following two requirements to get a fast coverage decision coverage decision: If the coverage decision is Yes, when will I get the service or item? 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. 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. All other indications of VNS for the treatment of depression are nationally non-covered. IEP Defined The Individualized Educational Plan (IEP) is a plan or program developed to ensure that a child who has a disability identified under the law and is attending an elementary or secondary educational institution receives specialized instruction and related services. Box 1800 If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself. This is a person who works with you, with our plan, and with your care team to help make a care plan. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. 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. You can appeal again only if the dollar value of the service or item you want meets a certain minimum amount. If we do not give you an answer within 72 hours, we will send your request to Level 2. to part or all of what you asked for, we must give the coverage within 72 hours after we get your appeal. If you are admitted to one of these hospitals, a hospitalist may serve as your caregiver as long as you remain in the hospital. The Level 3 Appeal is handled by an administrative law judge. If we do not agree with some or all of your complaint or dont take responsibility for the problem you are complaining about, we will let you know. You may change your PCP for any reason, at any time. (This is sometimes called step therapy.). We establish that you had an existing relationship with a primary or specialty care provider, with some exceptions. Join our Team and make a difference with us! 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. ii. Oxygen therapy can be renewed by the MAC if deemed medically necessary. This is not a complete list. (800) 440-4347 We may contact you or your doctor or other prescriber to get more information. TTY users should call 1-877-486-2048. Quantity limits. The list must meet requirements set by Medicare. For more information on network providers refer to Chapter 1 of the IEHP DualChoice Member Handbook. If the State Hearing decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. The MAC may determine necessary coverage for in home oxygen therapy for patients that do not meet the criteria described above. An IMR is available for any Medi-Cal covered service or item that is medical in nature. You or your doctor (or other prescriber) or someone else who is acting on your behalf can ask for a coverage decision. 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. 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. If your Level 2 Appeal was an Independent Medical Review, you can request a State Hearing. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Group II: By clicking on this link, you will be leaving the IEHP DualChoice website. The letter you get from the Independent Review Entity will tell you the dollar amount needed to continue with the appeals process. 2023 Inland Empire Health Plan All Rights Reserved. For problems and concerns regarding eligibility determinations, assessments, and care delivered by our contracted Community Based Adult Services (CBAS) centers, or Nursing Facilities/Sub-Acute Care Facilities, you should follow the process outlined below. Suppose that you are temporarily outside our plans service area, but still in the United States. 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. CMS has updated Chapter 1, section 160.18 of the Medicare National Coverage Determinations Manual. Beneficiaries with either a renal disease or diabetes diagnosis as defined in 42 CFR 410.130. 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. Cardiologists care for patients with heart conditions. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. (800) 718-4347 (TTY), IEHP 24-Hour Nurse Advice Line (for IEHP Members only) Patients depressive illness meets a minimum criterion of four prior failed treatments of adequate dose and duration as measured by a tool designed for this purpose. See form below: Deadlines for a fast appeal at Level 2 The clinical study must adhere to all the standards of scientific integrity and relevance to the Medicare population. (Effective: January 27, 20) You can tell Medicare about your complaint. You have a right to appeal or ask for Formulary exception if you disagree with the information provided by the pharmacist. Get a 31-day supply of the drug before the change to the Drug List is made, or. 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. Decide in advance how you want to be cared for in case you have a life-threatening illness or injury. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. When we say existing relationship, it means that you saw an out-of-network provider at least once for a non-emergency visit during the 12 months before the date of your initial enrollment in our plan. MRI field strength of 1.5 Tesla using Normal Operating Mode, The Implanted pacemaker (PM), implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), and cardiac resynchronization therapy defibrillator (CRT-D) system has no fractured, epicardial, or abandoned leads, The facility has implemented a specific checklist. Denies, changes, or delays a Medi-Cal service or treatment (not including IHSS) because our plan determines it is not medically necessary. (This is sometimes called prior authorization.), Being required to try a different drug first before we will agree to cover the drug you are asking for. We must respond whether we agree with the complaint or not. The reviewer will be someone who did not make the original decision. 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. Prior to the beneficiarys first lung cancer LDCT screening, the beneficiary must receive a counseling and shared decision-making visit that meets specific criteria. We will say Yes or No to your request for an exception. Removing a restriction on our coverage. For some drugs, the plan limits the amount of the drug you can have. Be treated with respect and courtesy. The only amount you should be asked to pay is the copay for service, item, and/or drug categories that require a copay. This will give you time to talk to your doctor or other prescriber. Effective on April 7, 2022, CMS has updated section 200.3 of the National Coverage Determination (NCD) Manual to cover Food and Drug Administration (FDA) approved monoclonal antibodies directed against amyloid for treatment of Alzheimers Disease (AD) when the coverage criteria below is met. No means the Independent Review Entity agrees with our decision not to approve your request. When your PCP thinks that you need specialized treatment or supplies, your PCP will need to get prior authorization (i.e., prior approval) from your Plan and/or medical group. If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will use the standard deadlines instead. A medical group or IPA is a group of physicians, specialists, and other providers of health services that see IEHP Members. i. PO2 measurements can be obtained via the ear or by pulse oximetry. This is called prior authorization. Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. When your PCP thinks that you need specialized treatment or supplies, your PCP will need to get prior authorization (i.e., prior approval) from your Plan and/or medical group. The Medicare Complaint Form is available at:https://www.medicare.gov/MedicareComplaintForm/home.aspx. At any time, you can call IEHP DualChoice Member Services to get up-to-date information about changes in the pharmacy network. Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). The DMHC may waive the requirement that you first follow our appeal process in extraordinary and compelling cases. We may not tell you before we make this change, but we will send you information about the specific change or changes we made. How will you find out if your drugs coverage has been changed? The following criteria must also be met as described in the NCD: Non-Covered Use: There are two ways to make a Level 2 appeal for Medi-Cal services and items: 1) Independent Medical Review or 2) State Hearing. You can still get a State Hearing. When that happens, we may remove the current drug, but your cost for the new drug will stay the same or will be lower. Rancho Cucamonga, CA 91729-4259. The DMHC may accept your application after 6 months if it determines that circumstances kept you from submitting your application in time. You must choose your PCP from your Provider and Pharmacy Directory. ((Effective: December 7, 2016) TTY users should call (800) 537-7697. Your provider will also know about this change. For additional details on how to reach us for appeals, see Chapter 9 of the IEHP DualChoice Member Handbook. All requests for out-of-network services must be approved by your medical group prior to receiving services. Benefits and copayments may change on January 1 of each year. Effective for dates of service on or after January 19, 2021, CMS has updated section 20.33 of the National Coverage Determination Manual to cover Transcatheter Edge-to-Edge Repair (TEER) for Mitral Valve Regurgitation when specific requirements are met. Explore Opportunities. Note, the Member must be active with IEHP Direct on the date the services are performed. Portable oxygen would not be covered. The Centers of Medicare and Medicaid Services (CMS) will cover transcatheter aortic valve replacement (TAVR) under Coverage with Evidence Development (CED) when specific requirements are met. Have advanced heart failure for at least 14 days and are dependent on an intraaortic balloon pump (IABP) or similar temporary mechanical circulatory support for at least 7 days. They receive a left ventricular device (LVADs) if the device is FDA approved for short- or long-term use for mechanical circulatory support for beneficiaries with heart failure who meet the following requirements: Have New York Heart Association (NYHA) Class IV heart failure; and, Have a left ventricular ejection fraction (LVEF) 25%; and. If we say no, you have the right to ask us to change this decision by making an appeal. Beneficiaries with Somatic (acquired) cancer or Germline (inherited) cancer when performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all the following requirements are met: Medicare Administrative Contractors (MACs) may determine coverage of NGS as a diagnostic test when additional specific criteria are met. A PCP is your Primary Care Provider. Please see Chapter 9 (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]) of the Member Handbook for more information on exceptions. Use of autologous Platelet-Derived Growth Factor (PDGF) for treatment of chronic, non-healing, cutaneous (affecting the skin) wounds, and. All have different pros and cons. National Coverage determinations (NCDs) are made through an evidence-based process. Try to choose a PCP that can admit you to the hospital you want within 30 miles or 45 minutes of your home. (Effective: February 10, 2022) (Implementation Date: September 20, 2021). Yes. (Effective: September 26, 2022) IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test), and, average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohns Disease and ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer). In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. B. When your complaint is about quality of care. A Level 1 Appeal is the first appeal to our plan. You can ask us to make a faster decision, and we must respond in 15 days. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. Who is covered: TTY users should call (800) 718-4347. Effective July 2, 2019, CMS will cover Ambulatory Blood Pressure Monitoring (ABPM) when beneficiaries are suspected of having white coat hypertension or masked hypertension in addition to the coverage criteria outlined in the NCD Manual. It also includes problems with payment. If you are not satisfied with the result of the IMR, you can still ask for a State Hearing. Yes. To learn more about the plans benefits, cost-sharing, applicable conditions and limitations, refer to the IEHP DualChoice Member Handbook. My Choice. Click here for more information on Transcatheter Edge-to-Edge Repair [TEER] for Mitral Valve Regurgitation coverage . Click here for more information on ambulatory blood pressure monitoring coverage. Can someone else make the appeal for me for Part C services? Important things to know about asking for exceptions. In most cases, you must start your appeal at Level 1. (Effective: January 19, 2021) If we do not meet this deadline, we will send your request to Level 2 of the appeals process. Interventional echocardiographer meeting the requirements listed in the determination. After your application and supporting documents are received from your plan, the IMR decision will be made within 3 calendar days. 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. All physicians participating in the procedure must have device-specific training by the manufacturer of the device. You can tell the California Department of Managed Health Care about your complaint. If you are having a problem with your care, you can call the Office of Ombudsman at 1-888-452-8609for help. You can get a fast coverage decision coverage decision only if you are asking for coverage for care or an item you have not yet received. You are not responsible for Medicare costs except for Part D copays. The Office of Ombudsman is not connected with us or with any insurance company or health plan. (Implementation Date: December 12, 2022) You will be able to get the service or item within 14 calendar days (for a standard coverage decision) or 72 hours (for a fast coverage decision) of when you asked. This additional time will allow you to correct your eligibility information if you believe that you are still eligible. Consist of 30-60 minute sessions comprising of therapeutic exercise-training program for PAD; Be conducted in a hospital outpatient setting or physicians office; Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD; and. Angina pectoris (chest pain) in the absence of hypoxemia; or. Box 1800 For inpatient hospital patients, the time of need is within 2 days of discharge. What is a Level 1 Appeal for Part C services? =========== TABBED SINGLE CONTENT GENERAL. Click here to learn more about IEHP DualChoice. You do not need to do anything further to get this Extra Help. Patients must maintain a stable medication regimen for at least four weeks before device implantation. IEHP DualChoice recognizes your dignity and right to privacy. If we extended the time needed to make our coverage decision, we will provide the coverage by the end of that extended period. If the State Hearing decision is Yes to part or all of what you asked for, we must comply with the decision. Disrespect, poor customer service, or other negative behaviors, Timeliness of our actions related to coverage decisions or appeals, You can use our "Member Appeal and Grievance Form." Limited benefit from amplification is defined by test scores of less than or equal to 60% correct in the best-aided listening condition on recorded tests of open-set sentence recognition. If the IRE says No to your appeal, it means they agree with our decision not to approve your request. When you are discharged from the hospital, you will return to your PCP for your health care needs. Beneficiaries receiving treatment for implanting a ventricular assist device (VAD), when the following requirements are met and: All other indications for the use of VADs not otherwise listed remain non-covered, except in the context of Category B investigational device exemption clinical trials (42 CFR 405) or as a routine cost in clinical trials defined under section 310.1 of the National Coverage Determinations (NCD) Manual. You can ask us to reimburse you for IEHP DualChoice's share of the cost. We will answer your request for an exception within 72 hours after we get your request (or your prescribers supporting statement). Usually, your prescription drugs are only covered if they are filled at a network pharmacy including through our mail-order pharmacy services. We will contact the provider directly and take care of the problem. You can make a complaint to the Department of Health and Human Services Office for Civil Rights if you think you have not been treated fairly. Black Walnuts on the other hand have a bolder, earthier flavor. 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. How do I make a Level 1 Appeal for Part C services? Enrollment in IEHP DualChoice (HMO D-SNP) depends on contact renewal. 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. Remember, you can request to change your PCP at any time. Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plans service area. (Effective: May 25, 2017) Level 2 Appeal for Part D drugs. These forms are also available on the CMS website: Autologous Platelet-Rich Plasma (PRP) treatment of acute surgical wounds when applied directly to the close incision, or for splitting or open wounds. English Walnuts. Interventional Cardiologist meeting the requirements listed in the determination. CMS has updated Chapter 1, Part 2, Section 90.2 of the Medicare National Coverage Determinations Manual to include NGS testing for Germline (inherited) cancer when specific requirements are met and updated criteria for coverage of Somatic (acquired) cancer. Fill out the Authorized Assistant Form if someone is helping you with your IMR. 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. You can download a free copy by clicking here. Then, we check to see if we were following all the rules when we said No to your request. Urgently needed care from in-network providers or from out-of-network providers when network providers are temporarily unavailable or inaccessible, e.g., when you are temporarily outside of the plans service area. Most of these drugs are Part D drugs. There are a few drugs that Medicare Part D does not cover but that Medi-Cal may cover.