The plan's block transfer filing indicated that the termination was the result of conduct by Vantage that resulted in the inappropriate delay, denial or modification of authorizations for services and care provide to IEHP's Medi-Cal managed care enrollees. Pulmonary hypertension or cor pulmonale (high blood pressure in pulmonary arteries), determined by the measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or "P" pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or AVFL; or, If the Independent Medical Review decision is Yes to part or all of what you asked for, we must provide the service or treatment. Getting plan approval before we will agree to cover the drug for you. View Plan Details. IEHP DualChoice will honor authorizations for services already approved for you. Please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. Click here for more information on Transcatheter Edge-to-Edge Repair [TEER] for Mitral Valve Regurgitation coverage . Receive Member informing materials in alternative formats, including Braille, large print, and audio. You can also visit, You can make your complaint to the Quality Improvement Organization. Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. You must ask for an appeal within 60 calendar days from the date on the letter we sent to tell you our decision. The following medical conditions are not covered for oxygen therapy and oxygen equipment in the home setting: Other: 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. The letter will tell you how to do this. Send copies of documents, not originals. For inpatient hospital patients, the time of need is within 2 days of discharge. There may be qualifications or restrictions on the procedures below. We will give you our decision sooner if your health condition requires us to. You can file a grievance online. You will need Adobe Acrobat Reader6.0 or later to view the PDF files. You have a care team that you help put together. Have a Primary Care Provider who is responsible for coordination of your care. 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. Deadlines for standard appeal at Level 2. Be informed regarding Advance Directives, Living Wills, and Power of Attorney, and to receive information regarding changes related to existing laws. You wont pay a premium, or pay for doctor visits or other medical care if you go to a provider that works with our health plan. We call this the supporting statement.. 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. The only amount you should be asked to pay is the copay for service, item, and/or drug categories that require a copay. How do I ask the plan to pay me back for the plans share of medical services or items I paid for? We will send you your ID Card with your PCPs information. When you make an appeal to the Independent Review Entity, we will send them your case file. 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. It also includes problems with payment. Click here for more information on MRI Coverage. Rancho Cucamonga, CA 91729-1800 You can call the California Department of Social Services at (800) 952-5253. Information on this page is current as of October 01, 2022. Tier 1 drugs are: generic, brand and biosimilar drugs. 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. Here are two ways to get information directly from Medicare: By clicking on this link, you will be leaving the IEHP DualChoice website. 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. These reviews are especially important for members who have more than one provider who prescribes their drugs. This is called a referral. Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. The letter you get from the Independent Review Entity will tell you the dollar amount needed to continue with the appeals process. What is covered: 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. Important things to know about asking for exceptions. If you make an appeal for reimbursement, we must give you our answer within 60 calendar days after we get your appeal. You have a right to appeal or ask for Formulary exception if you disagree with the information provided by the pharmacist. You do not need to do anything further to get this Extra Help. Within 10 days of the mailing date of our notice to you that the adverse benefit determination (Level 1 appeal decision) has been upheld; or. What kinds of medical care and other services can you get without getting approval in advance from your Primary Care Provider (PCP) in IEHP DualChoice (HMO D-SNP)? Our plan includes doctors, hospitals, pharmacies, providers of long-term services and supports, behavioral health providers, and other providers. You can ask for a State Hearing for Medi-Cal covered services and items. To learn more about the plans benefits, cost-sharing, applicable conditions and limitations, refer to the IEHP DualChoice Member Handbook. (Implementation Date: February 27, 2023). You may choose different health plans, or providers, under Medi-Cal, like IEHP or Molina Healthcare, Blue Shield, Health Net, etc. (SeeChapter 10 oftheIEHP DualChoiceMember Handbookfor information on when your new coverage begins.) For CMS-approved studies, the protocol, including the analysis plan, must meet requirements listed in this NCD. What is covered: 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. Also, someone besides your doctor or other provider can make the appeal for you, but first you must complete an Appointment of Representative Form. Sometimes, a new and cheaper drug comes along that works as well as a drug on the Drug List now. Usually, your prescription drugs are only covered if they are filled at a network pharmacy including through our mail-order pharmacy services. What is covered: 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. 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. 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. No-cost or low-cost health care coverage for low-income adults, families with children, seniors, and people with disabilities. iii. If the service or item you paid for is covered and you followed all the rules, we will send you the payment for our share of the cost of the service or item within 60 calendar days after we get your request. 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. 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. This is not a complete list. You will be notified when this happens. If you want to change plans, call IEHP DualChoice Member Services. When possible, take along all the medication you will need. Click here for more information on Leadless Pacemakers. (Implementation Date: October 8, 2021) The List of Covered Drugs and pharmacy and provider networks may change throughout the year. The State or Medicare may disenroll you if you are determined no longer eligible to the program. If the DMHC decides that your case is not eligible for IMR, the DMHC will review your case through its regular consumer complaint process. 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. The clinical research study must meet the standards of scientific integrity and relevance to the Medicare population described in this determination. Patient must also present hypoxemia signs and symptoms such as nocturnal restlessness, insomnia, or impairment of cognitive process. Non-Covered Use: The following uses are considered non-covered: Click here for more information on Blood-Derived Products for Chronic, Non-Healing Wounds coverage. If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. Facilities must be credentialed by a CMS approved organization. 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. 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. 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. 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. How will you find out if your drugs coverage has been changed? When we add the new generic drug, we may also decide to keep the current drug on the list but change its coverage rules or limits. All other indications for colorectal cancer screening not otherwise specified in the Social Security Act, regulations, or the above remain nationally non-covered. Fecal Occult Blood Tests (gFOBT) once every 12 months, The Cologuard Multi-target Stool DNA (sDNA) Test once every 3 years, Blood-based Biomarker Tests once every 3 years, Diagnosis of bilateral moderate-to-profound sensorineural hearing impairment with limited benefit, Cognitive ability to use hearing clues and a willingness to undergo an extended program of rehabilitation, Freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to implantation, and freedom from lesions in the hearing nerve and acoustic areas of the central nervous system, No indicated risks to surgery that are determined harmful or inadvisable, The device must be used in accordance with Food and Drug Administration (FDA) approved labeling, You can complete the Member Complaint Form. If we say no, you have the right to ask us to change this decision by making an appeal. IEHP DualChoice Member Services can assist you in finding and selecting another provider. They all work together to provide the care you need. Your care team may include yourself, your caregiver, doctors, nurses, counselors, or other health professionals. Study data for CMS-approved prospective comparative studies may be collected in a registry. If we agree to make an exception and waive a restriction for you, you can still ask for an exception to the co-pay amount we require you to pay for the drug. If your Primary Care Provider changes, your IEHP DualChoice benefits and required co-payments will stay the same. Learn about your health needs and leading a healthy lifestyle. (Effective: January 1, 2022) According to IEHP, 99.4 percent of enrollees retained the same primary care physicians. 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. Also, its possible that your PCP might leave our plans network of providers and you would have to find a new PCP. Please see below for more information. Information on this page is current as of October 01, 2022. Beneficiaries receiving autologous treatment for cancer with T-cell expressing at least one least one chimeric antigen receptor CAR, when all the following requirements are met: The use of non-FDA-approved autologous T-cell expressing at least one CAR is non-covered or when the coverage requirements are not met. A care coordinator is a person who is trained to help you manage the care you need. However, your PCP can always use Language Line Services to get help from an interpreter, if needed. Are inotrope dependent OR have a Cardiac Index (CI) < 2.2 L/min/m2, while not on inotropes, and meet one of the following: Are on optimal medical management, based on current heart failure practice guidelines for at least 45 out of the last 60 days and are failing to respond; or. We will cover your prescription at an out-of-network pharmacy if at least one of the following applies: If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than paying your normal share of the cost) when you fill your prescription. 2. Follow the appeals process. 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. If there are no network pharmacies in that area, IEHP DualChoice Member Services may be able to make arrangements for you to get your prescriptions from an out-of-network pharmacy. The procedure removes a portion of the lamina in order to debulk the ligamentum flavum, essentially widening the spinal canal in the affected area. You may also ask for an appeal by calling IEHP DualChoice Member Services at 1-877-273-IEHP (4347), 8am 8pm (PST), 7 days a week, including holidays. 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. This includes: Primary Care Providers (PCPs) are usually linked to certain hospitals. IEHP DualChoice (HMO D-SNP) has a process in place to identify and reduce medication errors. You have a right to give the Independent Review Entity other information to support your appeal. Breathlessness without cor pulmonale or evidence of hypoxemia; or. (Implementation Date: July 2, 2018). See below for a brief description of each NCD. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal. What Prescription Drugs Does IEHP DualChoice Cover? 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. An annual screening for lung cancer with LDCT will be available if specific eligibility criteria are met. 1. We add a generic drug that is not new to the market and: Replace a brand name drug currently on the Drug List or. All screenings DNA tests, effective April 28, 2008, through October 8, 2014. Sacramento, CA 95899-7413. At any time, you can call IEHP DualChoice Member Services to get up-to-date information about changes in the pharmacy network. To the California Department of Social Services: To the State Hearings Division at fax number 916-651-5210 or 916-651-2789. 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 the decision is No for all or part of what I asked for, can I make another appeal? For more information on Home Use of Oxygen coverage click here. If you are hospitalized on the day that your membership ends, you will usually be covered by our plan until you are discharged (even if you are discharged after your new health coverage begins). In the instance where there is not FDA labeling specific to use in an MRI environment, coverage is only provided under specific conditions including the following: Medicare beneficiaries with an Implanted pacemaker (PM), implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), and cardiac resynchronization therapy defibrillator (CRT-D). Some changes to the Drug List will happen immediately. To learn how to submit a paper claim, please refer to the paper claims process described below. Remember, you can request to change your PCP at any time. 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. If your problem is about a Medicare service or item, we will automatically send your case to Level 2 of the appeals process as soon as the Level 1 Appeal is complete. Whether you call or write, you should contact IEHP DualChoice Member Services right away. IEHP DualChoice recognizes your dignity and right to privacy. 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. For reservations call Monday-Friday, 7am-6pm (PST). Change the coverage rules or limits for the brand name drug. 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. Will not cover an experimental or investigational Medi-Cal treatment for a serious medical condition. The form gives the other person permission to act for you. The Centers of Medicare and Medicaid Services (CMS) will cover claims for effective dates of service on or after February 15, 2018. A new generic drug becomes available. 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. 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. You, your representative, or your doctor (or other prescriber) can do this. TTY/TDD users should call 1-800-718-4347. We will give you our answer sooner if your health requires it. You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. The Office of the Ombudsmanis not connected with us or with any insurance company or health plan. If your health requires it, ask the Independent Review Entity for a fast appeal.. 3. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. The reviewer will be someone who did not make the original decision. You can also have a lawyer act on your behalf. Generally, IEHP DualChoice (HMO D-SNP) will cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. 504 Plan Defined The 504 Plan is a plan developed to ensure that a child who has a disability (Implementation Date: July 5, 2022). You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends. P.O. We will send you a notice before we make a change that affects you. The Difference Between ICD-10-CM & ICD-10-PCS. Your IEHP DualChoice Doctor cannot charge you for covered health care services, except for required co-payments. 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. You, your representative, or your provider asks us to let you keep using your current provider. The procedure is used with a mitral valve TEER system that has received premarket approval from the FDA. 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. chimeric antigen receptor (CAR) T-cell therapy coverage. Information on this page is current as of October 01, 2022. Yes. (Implementation Date: September 20, 2021). This includes: The device is used following post-cardiotomy (period following open heart surgery) to support blood circulation. Visit the Department of Managed Health Care's website: 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. 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. IEHP offers a competitive salary and stellar benefit package . For more information see Chapter 9 of your IEHP DualChoice Member Handbook. TDD users should call (800) 952-8349. You can make the complaint at any time unless it is about a Part D drug. 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. Please call or write to IEHP DualChoice Member Services. (Implementation Date: October 5, 2020). PCPs are usually linked to certain hospitals and specialists. Who is covered: Group II: After your application and supporting documents are received from your plan, the IMR decision will be made within 30 calendar days. If you disagree with our decision, you can ask the DMHC Help Center for an IMR. 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. Live in our service area (incarcerated individuals are not considered living in the geographic service area even if they are physically located in it. If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. TTY: 1-800-718-4347. H8894_DSNP_23_3879734_M Pending Accepted. CMS has updated Chapter 1, section 20.32 of the Medicare National Coverage Determinations Manual. 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 can also call if you want to give us more information about a request for payment you have already sent to us. You will usually see your PCP first for most of your routine health care needs. Copays for prescription drugs may vary based on the level of Extra Help you receive. ICDs will be covered for the following patient indications: Please refer to section 20.4 of the NCD Manual for additional coverage criteria. Make your appeal request within 60 calendar days from the date on the notice we sent to tell you our decision. 2. If IEHP DualChoice removes a covered Part D drug or makes any changes in the IEHP DualChoice Formulary, IEHP DualChoice will post the formulary changes on the IEHP DualChoice website and notify the affected Members at least thirty (30) days prior to effective date of the change made on the IEHP DualChoice Formulary. 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. 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. Or you can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. Medicare beneficiaries in need of a pacemaker who are participating in an approved clinical study. If your change request is received byIEHP by the 25th of the month, the change will be effective the first of the following month; if your change request is received byIEHP after the 25th of the month, the change will be effective the first day of the subsequent month (for some providers, you may need a referral from your PCP). When will I hear about a standard appeal decision for Part C services? Here are two ways to get help from the Help Center: You can file a complaint with the Office for Civil Rights. When you choose your PCP, you are also choosing the affiliated medical group. Who is covered? You can file a grievance. Your doctor or other provider can make the appeal for you. 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. We must give you our answer within 30 calendar days after we get your appeal. 2023 IEHP DualChoice Provider and Pharmacy Directory (PDF), http://www.dmhc.ca.gov/FileaComplaint/SubmitanIndependentMedicalReviewComplaintForm.aspx, Request for Medicare Prescription Drug Coverage Determination (PDF). 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. We will tell you in advance about these other changes to the Drug List. A care team may include your doctor, a care coordinator, or other health person that you choose. 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?
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