(Implementation Date: January 17, 2022). If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself. 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 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. 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). 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. During this time, you must continue to get your medical care and prescription drugs through our plan. You can always contact your State Health Insurance Assistance Program (SHIP). 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. For more information on Medical Nutrition Therapy (MNT) coverage click here. In these situations, please check first with IEHP DualChoice Member Services to see if there is a network pharmacy nearby. 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. This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision. (Implementation Date: March 26, 2019). to part or all of what you asked for, we will make payment to you within 14 calendar days. You will usually see your PCP first for most of your routine health care needs. If your health condition requires us to answer quickly, we will do that. When your complaint is about quality of care. We are always available to help you. If you make an appeal for reimbursement, we must give you our answer within 60 calendar days after we get your appeal. The letter you get from the IRE will explain additional appeal rights you may have. For more information see Chapter 9 of your IEHP DualChoice Member Handbook. 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). Please see below for more information. You will be automatically enrolled in IEHP DualChoice and do not need to do anything to keep these services. 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. If you would like to switch from our plan to Original Medicare but you have not selected a separate Medicare prescription drug plan. H8894_DSNP_23_3241532_M. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal. The device must be approved by the Food and Drug Administration (FDA) for this purpose; OR. If your problem is urgent and involves an immediate and serious threat to your health, you may bring it immediately to the DMHCs attention. Ask for an exception from these changes. 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. Sign up for the free app through our secure Member portal. We will give you our answer sooner if your health requires it. IEHP DualChoice also provides information to the Centers for Medicare and Medicaid Services (CMS) regarding its quality assurance measures according to the guidelines specified by CMS. We must give you our answer within 30 calendar days after we get your appeal. You can tell Medi-Cal about your complaint. The List of Covered Drugs and pharmacy and provider networks may change throughout the year. 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. Drugs that may not be necessary because you are taking another drug to treat the same medical condition. 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 letter will also explain how you can appeal our decision. If you do not qualify by the end of the two-month period, youll de disenrolled by IEHP DualChoice. If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will use the standard deadlines instead. It tells which Part D prescription drugs are covered by IEHP DualChoice. If you would like to switch from our plan to another Medicare Advantage plan simply enroll in the new Medicare Advantage plan. The treatment is based upon efficacy from a change in surrogate endpoint such as amyloid reduction. View Plan Details. Your care team may include yourself, your caregiver, doctors, nurses, counselors, or other health professionals. In most cases you have 120 days to ask for a State Hearing after the Your Hearing Rights notice is mailed to you. For example, you can make a complaint about disability access or language assistance. Some hospitals have hospitalists who specialize in care for people during their hospital stay. Our response will include our reasons for this answer. LSS is a narrowing of the spinal canal in the lower back. For more information on Home Use of Oxygen coverage click here. Effective January 19, 2021, CMS has determined that blood-based biomarker tests are an appropriate colorectal cancer screening test, once every 3 years for Medicare beneficiaries when certain requirements are met. Beneficiaries that are at least 45 years of age or older can be screened for the following tests when all Medicare criteria found in this national coverage determination is met: Non-Covered Use: Will my benefits continue during Level 1 appeals? If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. Annapolis Junction, Maryland 20701. To stay a member of IEHP DualChoice, you must qualify again by the last day of the two-month period. If we decide to change or stop coverage for a service or item that was previously approved, we will send you a notice before taking the action. Benefits and copayments may change on January 1 of each year. 3. Patient must be evaluated for suitability for repair and must documented and made available to the Heart team members meeting the requirements of this determination. However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. (Implementation Date: July 5, 2022). This includes getting authorization to see specialists or medical services such as lab tests, x-rays, and/or hospital admittance. How will the plan make the appeal decision? You are never required to pay the balance of any bill. You, your representative, or your doctor (or other prescriber) can do this. 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. Our plans PCPs are affiliated with medical groups or Independent Physicians Associations (IPA). The Office of the Ombudsman also helps solve problems from a neutral standpoint to make sure that our members get all the covered services that we must provide. Your care team and care coordinator work with you to make a care plan designed to meet your health needs. (Implementation Date: March 24, 2023) If you need help during the appeals process, you can call the Office of the Ombudsman at 1-888-452-8609. 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). For more information on network providers refer to Chapter 1 of the IEHP DualChoice Member Handbook. 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). You should receive the IMR decision within 45 calendar days of the submission of the completed application. Whether you call or write, you should contact IEHP DualChoice Member Services right away. The leadless pacemaker eliminates the need for a device pocket and insertion of a pacing lead which are integral elements of traditional pacing systems. 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. (Effective: February 15. Our plan does not cover urgently needed care or any other care if you receive the care outside of the United States. You can call SHIP at 1-800-434-0222. The beneficiary is under pre- or post-operative care of a heart team meeting the following: Cardiac Surgeon meeting the requirements listed in the determination. Walnuts grow in U.S. Department of Agriculture plant hardiness zones 4 through 9, and hickories can be . Portable oxygen would not be covered. A care team can help you. Upon expiration, coverage will be determined by the local Medicare Administrative Contractors (MACs). 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. The clinical test must be performed at the time of need: If you are asking for a standard appeal or fast appeal, make your appeal in writing: You may also ask for an appeal by calling IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. H8894_DSNP_23_3241532_M. What is covered: We will send you a notice before we make a change that affects you. IEHP DualChoice The extra rules and restrictions on coverage for certain drugs include: Being required to use the generic version of a drug instead of the brand name drug. The Medicare Complaint Form is available at:https://www.medicare.gov/MedicareComplaintForm/home.aspx. If you wish, you and your doctor or other prescriber may give us additional information to support your appeal. You can make the complaint at any time unless it is about a Part D drug. They also have thinner, easier-to-crack shells. Who is covered? Sometimes we need more time, and we will send you a letter telling you that we need to take up to 14 calendar more days. 504 Plan Defined The 504 Plan is a plan developed to ensure that a child who has a disability 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. The benefit information is a brief summary, not a complete description of benefits. iv. CMS has updated Chapter 1, Part 1, Section 20.7 of the Medicare National Coverage Determinations Manual providing additional information regarding PTA. The following criteria must also be met as described in the NCD: Non-Covered Use: 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. Direct and oversee the process of handling difficult Providers and/or escalated cases. Oncologists care for patients with cancer. If you lose your zero share-of-cost, full scope Medi-Cal, you will be disenrolled from our plan (for your Medicare benefits) the first day of the following month andwill be covered by the Original Medicare. The NCR serves as a liaison for matters involving the contract between IEHP and both Network and Non-Network Providers. Be informed regarding Advance Directives, Living Wills, and Power of Attorney, and to receive information regarding changes related to existing laws. (Implementation Date: December 12, 2022) 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. Effective for claims with dates of service on or after February 10, 2022, CMS will cover, under Medicare Part B, a lung cancer screening counseling and shared decision-making visit. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Beneficiaries receiving treatment for Transcatheter Edge-to-Edge Repair (TEER) when either of the following are met: This determination will expire ten years after the effective date if a reconsideration is not made during this time. i. If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself. When you file a fast complaint, we will give you an answer to your appeal within 24 hours. Governing Board. For example: We may make other changes that affect the drugs you take. Heart failure cardiologist with experience treating patients with advanced heart failure. If you move out of our service area for more than six months. You can ask for an IMR if you have also asked for a State Hearing, but not if you have already had a State Hearing, on the same issue. The California Department of Managed Health Care (DMHC) is responsible for regulating health plans. Your benefits as a member of our plan include coverage for many prescription drugs. See Chapters 7 and 9 of the IEHP DualChoice Member Handbookto learn how to ask the plan to pay you back. Getting plan approval before we will agree to cover the drug for you. You can call the California Department of Social Services at (800) 952-5253. (Implementation Date: July 27, 2021) Effective on or after April 10, 2018, MRI coverage will be provided when used in accordance to the FDA labeling in an MRI environment. 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. We may not tell you before we make this change, but we will send you information about the specific change or changes we made. Capable of producing standardized plots of BP measurements for 24 hours with daytime and nighttime windows and normal BP bands demarcated; Provided to patients with oral and written instructions, and a test run in the physicians office must be performed; and. We may stop any aid paid pending you are receiving. 2) State Hearing Inland Empire Health Plan (IEHP) has over 1,234 Doctors, 3,676 Specialists, 724 Pharmacies, 74 Urgent Care, 243 OB/GYNs, 383 Behavioral Health Providers, 40 major Hospitals, and 313 Vision doctors in Riverside and San Bernardino counties. You dont have to do anything if you want to join this plan. Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. Call our transportation vendor Call the Car (CTC) at (866) 880-3654, for TTY users, call your relay service or California Relay Service at 711. 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. Medicare P4P (909) 890-2054 Monday-Friday, 8am-5pm Medicare P4P IEHP IEHP DualChoice will honor authorizations for services already approved for you. If you want to change plans, call IEHP DualChoice Member Services. 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. For other types of problems you need to use the process for making complaints. 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. You or your provider must show documentation of an existing relationship and agree to certain terms when you make the request. At Level 2, an outside independent organization will review your request and our decision. Appointment of Representatives Form (PDF), 2023 Drugs Requiring Prior Authorization (PDF). Rancho Cucamonga, CA 91729-1800 If our answer is No to part or all of what you asked for, we will send you a letter. ), 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. 5. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which IEHP DualChoice (HMO D-SNP) authorizes use of out-of-network providers. 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. Join our Team and make a difference with us! To find the name, address, and phone number of the Quality Improvement Organization in your state, lookin Chapter 2 of your. Click here for more information on Transcatheter Edge-to-Edge Repair [TEER] for Mitral Valve Regurgitation coverage . 8am - 8pm (PST), 7 days a week, including holidays, TTY: (800) 718-4347. Box 997413 IEHP DualChoice (HMO D-SNP) helps make your Medicare and Medi-Cal benefits work better together and work better for you. 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. The procedure removes a portion of the lamina in order to debulk the ligamentum flavum, essentially widening the spinal canal in the affected area. The DMHC may accept your application after 6 months if it determines that circumstances kept you from submitting your application in time. How to Enroll with IEHP DualChoice (HMO D-SNP), IEHP Texting Program Terms and Conditions. When we complete the review, we will give you our decision in writing. IEHP DualChoice Member Services can assist you in finding and selecting another provider. If your Level 2 Appeal was an Independent Medical Review, you can request a State Hearing.