The Office of the Ombudsmanis not connected with us or with any insurance company or health plan. 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. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. There are two ways you can asked to be disenrolled: To disenroll, please call Health Care Options (HCO) at 1-844-580-7272, 8am - 6pm (PST), Monday - Friday. You can tell Medi-Cal about your complaint. You can switch yourDoctor (and hospital) for any reason (once per month). 3. 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. (Effective: September 26, 2022) Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program. Your care team may include yourself, your caregiver, doctors, nurses, counselors, or other health professionals. The reviewer will be someone who did not make the original coverage decision. Please call or write to IEHP DualChoice Member Services. You or your doctor (or other prescriber) or someone else who is acting on your behalf can ask for a coverage decision. Yes. If you have Medi-Cal with IEHP and would like information on how to pursue appeals and grievances related to Medi-Cal covered services, please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), TTY (800) 718-4347, 8am - 8pm (PST), 7 days a week, including holidays. When you are outside the service area and cannot get care from a network provider, our plan will cover urgently needed care that you get from any provider. IEHP DualChoice will honor authorizations for services already approved for you. You can send your complaint to Medicare. This is called upholding the decision. It is also called turning down your appeal. (Implementation Date: October 8, 2021) IEHP DualChoice will give notice to IEHPDualChoice Members prior to removing Part D drug from the Part D formulary. If your Level 2 Appeal went to the Medicare Independent Review Entity, you can appeal again only if the dollar value of the service or item you want meets a certain minimum amount. The person you name would be your representative. You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. 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. If your doctor or other prescriber tells us that your health requires a fast coverage decision, we will automatically agree to give you a fast coverage decision, and the letter will tell you that. Noncoverage specifically includes the following: Click here for more information on Ambulatory Electroencephalographic Monitoring and Colorectal Cancer Screening Tests. LSS is a narrowing of the spinal canal in the lower back. Utilities allowance of $40 for covered utilities. For more information visit the. You are not responsible for Medicare costs except for Part D copays. The clinical research must evaluate the required twelve questions in this determination. When you are following these instructions, please note: If we answer no to your appeal and the service or item is usually covered by Medicare, we will automatically send your case to the Independent Review Entity. 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. Drugs that may not be necessary because you are taking another drug to treat the same medical condition. TTY users should call 1-800-718-4347. Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. If we extended the time needed to make our coverage decision, we will provide the coverage by the end of that extended period. CMS has revised Chapter 1, Section 20.29, Subsection C Topical Application of Oxygen to remove the exclusion of this treatment. (Effective: February 15, 2018) 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. IEHP DualChoice will help you with the process. Becaplermin, a non-autologous growth factor for chronic, non-healing, subcutaneous (beneath the skin) wounds, and. Its a good idea to make a copy of your bill and receipts for your records. Or you can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. The procedure is used with a mitral valve TEER system that has received premarket approval from the FDA. (Implementation Date: October 3, 2022) 2. Ask for the type of coverage decision you want. What if the Independent Review Entity says No to your Level 2 Appeal? For additional details on how to reach us for appeals, see Chapter 9 of the IEHP DualChoice Member Handbook. If your health requires it, ask us to give you a fast coverage decision 2) State Hearing You have a right to give the Independent Review Entity other information to support your appeal. Who is covered? You must submit your claim to us within 1 year of the date you received the service, item, or drug. Denies, changes, or delays a Medi-Cal service or treatment (not including IHSS) because our plan determines it is not medically necessary. Rights and Responsibilities Upon Disenrollment, Ending your membership in IEHP DualChoice (HMO D-SNP) may be voluntary (your own choice) or involuntary (not your own choice). When a provider leaves a network, we will mail you a letter informing you about your new provider. 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. You will not have a gap in your coverage. H8894_DSNP_23_3241532_M. IEHP DualChoice will cover many of the Medicare and Medi-Cal benefits you get now, including: You will have access to a Provider network that includes many of the same Providers as your current plan. Concurrent with Carotid Stent Placement in Patients at High Risk for Carotid Endarterectomy (CEA) 1. 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. 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. Sign up for the free app through our secure Member portal. Hazelnuts are the round brown hard-shelled nuts of the trees of genus Corylus while walnuts are the wrinkled edible nuts of the trees of genus Juglans. You may change your PCP for any reason, at any time. Who is covered: Important things to know about asking for exceptions. We are also one of the largest employers in the region, designated as "Great Place to Work.". This is not a complete list. Your PCP will send a referral to your plan or medical group. The organization will send you a letter explaining its decision. Click here to learn more about IEHP DualChoice. You can also have your doctor or your representative call us. In this situation (when you are outside the service area and cannot get care from a network provider), our plan will cover urgently needed care that you get from any provider. At Level 2, an Independent Review Entity will review the decision. You can file a grievance. Complain about IEHP DualChoice, its Providers, or your care. (Implementation Date: July 27, 2021) You can call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. The State or Medicare may disenroll you if you are determined no longer eligible to the program. The time of need is indicated when the presumption of oxygen therapy within the home setting will improve the patients condition. If patients with bipolar disorder are included, the condition must be carefully characterized. (Implementation date: August 29, 2017 for MAC local edits; January 2, 2018 for MCS shared edits) This statement will also explain how you can appeal our decision. This number requires special telephone equipment. If a drug you are taking will be taken off the Drug List or limited in some way for next year, we will allow you to ask for an exception before next year. These different possibilities are called alternative drugs. Yes, you and your doctor may give us more information to support your appeal. We take a careful look at all of the information about your request for coverage of medical care. See plan Providers, get covered services, and get your prescription filled timely. If you have questions, you can contact IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. 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. This is called upholding the decision. It is also called turning down your appeal.. These changes might happen if: When these changes happen, we will tell you at least 30 days before we make the change to the Drug List or when you ask for a refill. TTY users should call 1-800-718-4347. Review, request changes to, and receive a copy of your medical records in a timely fashion. The following information explains who qualifies for IEHP DualChoice (HMO D-SNP). If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. Level 2 Appeal for Part D drugs. As an IEHP DualChoice (HMO D-SNP) Member, you have the right to: As an IEHP DualChoice Member, you have the responsibility to: For more information on Member Rights and Responsibilities refer to Chapter 8 of your IEHP DualChoice Member Handbook. and hickory trees (Carya spp.) My Choice. Effective on September 26, 2022, CMS has updated section 50.3 of the National Coverage Determination (NCD) Manual that expands coverage on cochlear implants for the treatment of bilateral pre- or post- linguistic, sensorineural, moderate-to-profound hearing loss when the individual demonstrates limited benefit from amplification under Medicare Part B. Deadlines for a standard coverage decision about payment for a drug you have already bought, If our answer is Yes to part or all of what you asked for, we will make payment to you within 14 calendar days. If the service or item is not covered, or you did not follow all the rules, we will send you a letter telling you we will not pay for the service or item and explaining why. An IMR is available for any Medi-Cal covered service or item that is medical in nature. IEHP DualChoice Formulary consists of medications that are considered as first line therapies (drugs that should be used first for the indicated conditions). The Centers of Medicare and Medicaid Services (CMS) will cover Vagus Nerve Stimulation (VNS) for treatment-resistant depression when specific requirements are met. (888) 244-4347 CMS has expanded the PILD for LSS National Coverage Determination (NCD) to now cover beneficiaries that are enrolled in a CMS-approved prospective longitudinal study. Removing a restriction on our coverage. Concurrent with Carotid Stent Placement in FDA-Approved Post-Approvals Studies Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plans service area. Also, its possible that your PCP might leave our plans network of providers and you would have to find a new PCP. Our plan includes doctors, hospitals, pharmacies, providers of long-term services and supports, behavioral health providers, and other providers. Heart failure cardiologist with experience treating patients with advanced heart failure. What is covered? You dont have to do anything if you want to join this plan. It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. Study data for CMS-approved prospective comparative studies may be collected in a registry. If IEHP DualChoice removes a Covered Part D drug or makes any changes in the IEHP DualChoice Formulary, we will post the formulary changes on IEHPDualChoice website and notify the affected Members at least thirty (30) days prior to effective date of the change made on the IEHP DualChoice Formulary. If you put your complaint in writing, we will respond to your complaint in writing. 1. (Effective: February 19, 2019) 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. You may also contact the local Office for Civil Rights office at: U.S. Department of Health and Human Services. Click here to learn more about IEHP DualChoice. https://www.medicare.gov/MedicareComplaintForm/home.aspx. If you do not qualify by the end of the two-month period, youll de disenrolled by IEHP DualChoice. If your Level 2 Appeal went to the Medicare Independent Review Entity, it will send you a letter explaining its decision. If the IRE reverses our decision and says we should pay you, we must send the payment to you or to the provider within 30 calendar days. You will usually see your PCP first for most of your routine health care needs. 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. Livanta is not connect with our plan. We will review our coverage decision to see if it is correct. You can then ask us to make an exception and cover the drug in the way you would like it to be covered for next year. Again, if a drug is suddenly recalled because its been found to be unsafe or for other reasons, the plan will immediately remove the drug from the Formulary. You may use the following form to submit an appeal: Can someone else make the appeal for me? Direct and oversee the process of handling difficult Providers and/or escalated cases. If the IRE says No to your appeal, it means they agree with our decision not to approve your request. If you are admitted to one of these hospitals, a hospitalist may serve as your caregiver as long as you remain in the hospital. Beneficiaries receiving autologous treatment for cancer with T-cell expressing at least one. If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize the medical care coverage within 72 hours or give you the service or item within 14 calendar days from the date we receive the IREs decision. We are also one of the largest employers in the region, designated as "Great Place to Work.". You or your provider can ask for an exception from these changes. TTY users should call (800) 718-4347. How to ask for coverage decision coverage decision to get medical, behavioral health, or certain long-term services and supports (CBAS, or NF services). Department of Health Care Services What if you are outside the plans service area when you have an urgent need for care? Information is also below. See below for a brief description of each NCD. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. The call is free. Your benefits as a member of our plan include coverage for many prescription drugs. 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. Additional hours of treatment are considered medically necessary if a physician determines there has been a shift in the patients medical condition, diagnosis or treatment regimen that requires an adjustment in MNT order or additional hours of care. TDD users should call (800) 952-8349. We must give you our answer within 30 calendar days after we get your appeal. Your PCP should speak your language. You can call the California Department of Social Services at (800) 952-5253. When possible, take along all the medication you will need. Learn about your health needs and leading a healthy lifestyle. 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. We must respond whether we agree with the complaint or not. Follow the appeals process. You can ask for a copy of the information in your appeal and add more information. Change the coverage rules or limits for the brand name drug. If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan. Angina pectoris (chest pain) in the absence of hypoxemia; or. You must apply for an IMR within 6 months after we send you a written decision about your appeal. Use the IEHP Medicare Prescription Drug Coverage Determination Form for a prior authorization. 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. IEHP DualChoice is a Cal MediConnect Plan. 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. How much time do I have to make an appeal for Part C services? The MAC may also approve the use of portable oxygen systems to beneficiaries who are mobile in home and benefit from of this unit alone, or in conjunction to a stationary oxygen system. Note, the Member must be active with IEHP Direct on the date the services are performed. (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already bought.). Never wavering in our commitment to our Members, Providers, Partners, and each other. Information on this page is current as of October 01, 2022 Until your membership ends, you are still a member of our plan. 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. What Prescription Drugs Does IEHP DualChoice Cover? If you do not choose a PCP when you join IEHPDualChoice, we will choose one for you. This is called a referral. We do the right thing by: Placing our Members at the center of our universe. It also includes problems with payment. 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 24 hours after we get the decision. A care coordinator is a person who is trained to help you manage the care you need. If your provider says you have a good medical reason for an exception, he or she can help you ask for one. We may contact you or your doctor or other prescriber to get more information. If your case is urgent and you qualify for an IMR, the DMHC will review your case and send you a letter within 2 calendar days telling you that you qualify for an IMR. Make recommendations about IEHP DualChoice Members rights and responsibilities policies. Notify IEHP if your language needs are not met. We will let you know of this change right away. IEHP DualChoice (HMO D-SNP) has contracts with pharmacies that equals or exceeds CMS requirements for pharmacy access in your area. 2023 Inland Empire Health Plan All Rights Reserved. In most cases, you must file an appeal with us before requesting an IMR. It also has care coordinators and care teams to help you manage all your providers and services. Who is covered: IEHP DualChoice, a Medicare Medi-Cal Plan, allows you to get your covered Medicare and Medi-Cal benefits through our plan. You will be automatically enrolled in a Medicare Medi-Cal Plan offered by IEHP DualChoice. If we say No to your request for an exception, you can ask for a review of our decision by making an appeal. If the answer is No, we will send you a letter telling you our reasons for saying No. According to the FDA labeling in an MRI environment, MRI coverage will be provided for beneficiaries under certain conditions. This is a group of doctors and other health care professionals who help improve the quality of care for people with Medicare. You can call SHIP at 1-800-434-0222. If the coverage decision is No, how will I find out? Send copies of documents, not originals. See form below: Deadlines for a fast appeal at Level 2 The treatment is based upon efficacy from a direct measure of clinical benefit in CMS-approved prospective comparative studies. Typically, our Formulary includes more than one drug for treating a particular condition. If the IMR is decided in your favor, we must give you the service or item you requested. Use of other PET radiopharmaceutical tracers for cancer may be covered at the discretion of local Medicare Administrative Contractors (MACs), when used in accordance to their Food and Drug Administration (FDA) approval indications. chimeric antigen receptor (CAR) T-cell therapy coverage. (Implementation Date: October 4, 2021). Click here for more information on Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). Box 1800 A specialist is a doctor who provides health care services for a specific disease or part of the body. The procedure removes a portion of the lamina in order to debulk the ligamentum flavum, essentially widening the spinal canal in the affected area. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. For more detailed information on each of the NCDs including restrictions and qualifications click on the link after each NCD or call IEHP DualChoice Member Services at (877) 273-IEHP (4347) 8am-8pm (PST), 7 days a week, including holidays, or. CMS has added a new section, Section 220.2, to Chapter 1, Part 4 of the Medicare National Coverage Determinations Manual entitled Magnetic Resonance Imaging (MRI). You may choose different health plans, or providers, under Medi-Cal, like IEHP or Molina Healthcare, Blue Shield, Health Net, etc. (Effective: February 10, 2022) How will I find out about the decision? You can tell Medicare about your complaint. H8894_DSNP_23_3241532_M. If you have a standard appeal at Level 2, the Independent Review Entity must give you an answer to your Level 2 Appeal within 7 calendar days after it gets your appeal. These forms are also available on the CMS website: The treatment is based upon efficacy from a change in surrogate endpoint such as amyloid reduction. Effective for dates of service on or after December 1, 2020, CMS has updated section 20.9.1 of the National Coverage Determination Manual to cover ventricular assist devices (VADs) when received at facilities credentialed by a CMS approved organization and when specific requirements are met. iv. At IEHP, you will find opportunities to take initiative, expand your knowledge and advance your career while working a position that's both challenging and rewarding. You can also visit https://www.hhs.gov/ocr/index.html for more information. If your doctor says that you need a fast coverage decision, we will automatically give you one. A standard coverage decision means we will give you an answer within 72 hours after we get your doctors statement. At Level 2, an Independent Review Entity will review your appeal. If we need more information, we may ask you or your doctor for it. The reviewer will be someone who did not make the original decision. If you believe we should not take extra days, you can file a fast complaint about our decision to take extra days. If you want to change plans, call IEHP DualChoice Member Services. These different possibilities are called alternative drugs. Coverage for future years is two hours for patients diagnosed with renal disease or diabetes. If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself. What is covered? Benefits and copayments may change on January 1 of each year. (Effective: April 7, 2022) In most cases you have 120 days to ask for a State Hearing after the Your Hearing Rights notice is mailed to you. You can ask us to reimburse you for our share of the cost by submitting a claim form. 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). C. Beneficiarys diagnosis meets one of the following defined groups below: a. (Implementation Date: February 14, 2022) However, if the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drugs manufacturer removes the drug from the market we will immediately remove the drug from our formulary. Flu shots as long as you get them from a network provider. An acute HBV infection could progress and lead to life-threatening complications. Previous Next ===== TABBED SINGLE CONTENT GENERAL. If your problem is about a Medicare service or item, the letter will tell you that we sent your case to the Independent Review Entity for a Level 2 Appeal. The Centers of Medicare and Medicaid Services (CMS) will cover acupuncture for chronic low back pain (cLBP) when specific requirements are met. Beneficiaries that demonstrate limited benefit from amplification. You will be notified when this happens. All other indications for colorectal cancer screening not otherwise specified in the Social Security Act, regulations, or the above remain nationally non-covered. TTY/TDD (800) 718-4347. TTY/TDD users should call 1-800-718-4347. Our plan usually cannot cover off-label use. When you choose your PCP, remember the following: You will usually see your Primary Care Provider (PCP) first for most of your routine healthcare needs such as physical check-ups, immunization, etc. When can you end your membership in our plan? For some drugs, the plan limits the amount of the drug you can have. Mail your request for payment together with any bills or receipts to us at this address: IEHPDualChoice Concurrent with Intracranial Stent Placement in FDA-Approved Category B IDE Clinical Trials 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. We will notify you by letter if this happens. Treatment is furnished as part of a CMS approved trial through Coverage with Evidence Development (CED).Detailed clinical trial criteria can be found in section 160.18 of the National Coverage Determination Manual. New to IEHP DualChoice. To stay a member of IEHP DualChoice, you must qualify again by the last day of the two-month period.

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