Click here for more information on Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). 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. With "Extra Help," there is no plan premium for IEHP DualChoice. 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. When that happens, we may remove the current drug, but your cost for the new drug will stay the same or will be lower. PCPs are usually linked to certain hospitals and specialists. 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. 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. If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. You or your doctor (or other prescriber) or someone else who is acting on your behalf can ask for a coverage decision. If your Level 2 Appeal went to the Medicare Independent Review Entity, it will send you a letter explaining its decision. If you would like to switch from our plan to another Medicare Advantage plan simply enroll in the new Medicare Advantage plan. We may not tell you before we make this change, but we will send you information about the specific change or changes we made. My problem is about a Medi-Cal service or item. If PO2 and arterial blood gas results are conflicting, the arterial blood gas results are preferred source to determine medical need. Information on this page is current as of October 01, 2022 In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. Black walnut trees are not really cultivated on the same scale of English walnuts. For patients whose initial prescription for oxygen did not originate during an inpatient hospital stay, the time of need occurs when the treating practitioner identifies signs and symptoms of hypoxemia that can be relieved with at home oxygen therapy. For example, we might decide that a service, item, or drug that you want is not covered or is no longer covered by Medicare or Medi-Cal. NOTE: If you ask for a State Hearing because we told you that a service you currently get will be changed or stopped, you have fewer days to submit your request if you want to keep getting that service while your State Hearing is pending. You can tell Medi-Cal about your complaint. Medi-Cal is public-supported health care coverage. Can I get a coverage decision faster for Part C services? Use of autologous Platelet-Derived Growth Factor (PDGF) for treatment of chronic, non-healing, cutaneous (affecting the skin) wounds, and. If your Primary Care Provider changes, your IEHP DualChoice benefits and required co-payments will stay the same. We will send you your ID Card with your PCPs information. Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). If your health requires it, ask the Independent Review Entity for a fast appeal.. Yes. Get Help from an Independent Government Organization. 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. You can call SHIP at 1-800-434-0222. 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. To learn how to name your representative, you may call IEHP DualChoice Member Services. 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. If you disagree with a coverage decision we have made, you can appeal our decision. In most cases, you must start your appeal at Level 1. The reviewer will be someone who did not make the original coverage decision. Concurrent with Carotid Stent Placement in Patients at High Risk for Carotid Endarterectomy (CEA) ii. You pay no costs for an IMR. An ICD is an electronic device to diagnose and treat life threating Ventricular Tachyarrhythmias (VTs) that has demonstrated improvement in survival rates and reduced cardiac death for certain patients. 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. Yes. For additional information on step therapy and quantity limits, refer to Chapter5 of theIEHP DualChoice Member Handbook. If you no longer qualify for Medi-Cal or your circumstances have changed that make you no longer eligible for Dual Special Needs Plan, you may continue to get your benefits from IEHP DualChoice for an additional two-month period. You can ask for a copy of the information in your appeal and add more information. 1501 Capitol Ave., Who is covered: When you make an appeal to the Independent Review Entity, we will send them your case file. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. We are always available to help you. 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. 1. 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. 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. 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. 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. This is not a complete list. 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. 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. A clinical test providing a measurement of the partial pressure of oxygen (PO2) in arterial blood. (Implementation Date: January 17, 2022). TTY should call (800) 718-4347. Infected individuals may develop symptoms such as nausea, anorexia, fatigue, fever, and abdominal pain, or may be asymptomatic. Remember, if you get a bill that is more than your copay for covered services and items, you should not pay the bill yourself. 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: February 19, 2019) 2. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. Patients demonstrating arterial PO2 between 56-59 mm Hg, or whos arterial blood oxygen saturation is 89%, with any of the following condition: 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. Information on this page is current as of October 01, 2022. What is covered: The letter will explain why more time is needed. You have been in the plan for more than 90 days and live in a long-term care facility and need a supply right away. Make recommendations about IEHP DualChoice Members rights and responsibilities policies. When we complete the review, we will give you our decision in writing. The DMHC may waive the requirement that you first follow our appeal process in extraordinary and compelling cases. i. Arterial PO2 at or below 55 mm Hg or arterial oxygen saturation at or below 88% when tested at rest in breathing room air, or; It also includes problems with payment. You must make the request on or before the later of the following in order to continue your benefits: If you meet this deadline, you can keep getting the disputed service or item while your appeal is processing. You may change your PCP for any reason, at any time. We will answer your request for an exception within 72 hours after we get your request (or your prescribers supporting statement). Beneficiaries receiving autologous treatment for cancer with T-cell expressing at least one. With IEHP DualChoice, you will still have an IEHP DualChoice Member Service team to get help for your needs. Emergency services from network providers or from out-of-network providers. You can ask us to reimburse you for IEHP DualChoice's share of the cost. =========== TABBED SINGLE CONTENT GENERAL. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You will not have a gap in your coverage. Information on the page is current as of March 2, 2023 ii. Concurrent with Intracranial Stent Placement in FDA-Approved Category B IDE Clinical Trials For more information on Home Use of Oxygen coverage click here. To stay a member of IEHP DualChoice, you must qualify again by the last day of the two-month period. 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. when beneficiaries are suspected of having white coat hypertension or masked hypertension in addition to the coverage criteria outlined in the, Ambulatory Blood Pressure Monitoring (ABPM), for the diagnosis of hypertension when either there is suspected white coat or masked hypertension. If we tell you after our review that the service or item is not covered, your case can go to a Level 2 Appeal. A drug is taken off the market. If our answer is Yes to part or all of what you asked for, we must give the coverage within 72 hours after we get your appeal. If we say No to your appeal, you then choose whether to accept this decision or continue by making another appeal. 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. (Implementation Date: September 20, 2021). Choose a PCP that is within 10 miles or 15 minutes of your home. We may stop any aid paid pending you are receiving. For CMS-approved studies, the protocol, including the analysis plan, must meet requirements listed in this NCD. If we are using the fast deadlines, we must give you our answer within 24 hours. Possible errors in the amount (dosage) or duration of a drug you are taking. 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. What if the Independent Review Entity says No to your Level 2 Appeal? H8894_DSNP_23_3241532_M. Because you are eligible for Medi-Cal, you qualify for and are getting Extra Help from Medicare to pay for your prescription drug plan costs. 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. Be informed regarding Advance Directives, Living Wills, and Power of Attorney, and to receive information regarding changes related to existing laws. TTY should call (800) 718-4347. Coverage for future years is two hours for patients diagnosed with renal disease or diabetes. 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. (Effective: September 26, 2022) TTY users should call 1-800-718-4347. CMS-approved studies of a monoclonal antibody directed against amyloid approved by the FDA for the treatment of AD based upon evidence of efficacy from a direct measure of clinical benefit must address all of the questions included in section B.4 of this National Coverage Determination. During this time, you must continue to get your medical care and prescription drugs through our plan. You can contact Medicare. TTY users should call 1-800-718-4347. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. 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. If you are admitted to one of these hospitals, a hospitalist may serve as your caregiver as long as you remain in the hospital. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. If we uphold the denial after Redetermination, you have the right to request a Reconsideration. Make your appeal request within 60 calendar days from the date on the notice we sent to tell you our decision. 2. If the DMHC decides that your case is not eligible for IMR, the DMHC will review your case through its regular consumer complaint process. If your health requires it, ask us to give you a fast coverage decision But in some situations, you may also want help or guidance from someone who is not connected with us. Topical Application of Oxygen for Chronic Wound Care. To learn more about the plans benefits, cost-sharing, applicable conditions and limitations, refer to the IEHP DualChoice Member Handbook. 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. The FDA provides new guidance or there are new clinical guidelines about a drug. We call this the supporting statement.. Who is covered: You can appeal again only if the dollar value of the service or item you want meets a certain minimum amount. You can tell Medicare about your complaint. 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. You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends. i. 1. The Office of Ombudsman is not connected with us or with any insurance company or health plan. You, your representative, or your provider asks us to let you keep using your current provider. Who is covered: Your PCP will send a referral to your plan or medical group. Or, if you havent paid for the service or item yet, we will send the payment directly to the provider. Click here for more information on acupuncture for chronic low back pain coverage. 504 Plan Defined The 504 Plan is a plan developed to ensure that a child who has a disability In some cases, we can give you a temporary supply of a drug when the drug is not on the Drug List or when it is limited in some way. Yes. The letter you get from the IRE will explain additional appeal rights you may have. 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. If you want the Independent Review Organization to review your case, your appeal request must be in writing. Calls to this number are free. You might leave our plan because you have decided that you want to leave. The clinical study must adhere to all the standards of scientific integrity and relevance to the Medicare population. The form gives the other person permission to act for you. If the appeal comes from someone besides you or your doctor or other provider, we must receive the completed Appointment of Representative form before we can review the appeal. 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. Who is covered: Medicare beneficiaries will have their blood-based colorectal cancer screening test covered once every 3 years when ordered by a treating physician and the following conditions are met: (Effective: December 1, 2020) If you do not choose a PCP when you join IEHPDualChoice, we will choose one for you. Medicare beneficiaries with LSS who are participating in an approved clinical study. 2) State Hearing Deadlines for standard appeal at Level 2. Treatments must be discontinued if the patient is not improving or is regressing. Box 4259 After your application and supporting documents are received from your plan, the IMR decision will be made within 3 calendar days. If you put your complaint in writing, we will respond to your complaint in writing. You may also have rights under the Americans with Disability Act. How to ask for coverage decision coverage decision to get medical, behavioral health, or certain long-term services and supports (CBAS, or NF services). (Implementation Date: June 12, 2020). (Effective: February 10, 2022) If the Independent Medical Review decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. Eligible Members The population for this P4P program includes IEHP Direct DualChoice Members. How will you find out if your drugs coverage has been changed? (Implementation Date: February 19, 2019) You can also have a lawyer act on your behalf. Patient must also present hypoxemia signs and symptoms such as nocturnal restlessness, insomnia, or impairment of cognitive process. Ask for an exception from these changes. The Independent Review Entity is an independent organization that is hired by Medicare. This includes getting authorization to see specialists or medical services such as lab tests, x-rays, and/or hospital admittance. National Coverage determinations (NCDs) are made through an evidence-based process. Your PCP, along with the medical group or IPA, provides your medical care. Medicare beneficiaries may be covered with an affirmative Coverage Determination. If you lie about or withhold information about other insurance you have that provides prescription drug coverage. This is known as Exclusively Aligned Enrollment, and. Learn about your health needs and leading a healthy lifestyle. Fax: (909) 890-5877. Until your membership ends, you are still a member of our plan. Your doctor or other prescriber can fax or mail the statement to us. Flu shots as long as you get them from a network provider. IEHP DualChoice (HMO D-SNP) helps make your Medicare and Medi-Cal benefits work better together and work better for you. 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. Hepatitis B Virus (HBV) is transmitted by exposure to bodily fluids. Calls to this number are free. If the Independent Medical Review decision is Yes to part or all of what you asked for, we must provide the service or treatment. Your test results are shared with all of your doctors and other providers, as appropriate. 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. H8894_DSNP_23_3241532_M. The procedure must be performed by an interventional cardiologist or cardiac surgeon.<. For other types of problems you need to use the process for making complaints. (Implementation Date: January 3, 2023) You can get a fast coverage decision only if the standard 14 calendar day deadline could cause serious harm to your health or hurt your ability to function. TTY users should call (800) 537-7697. H8894_DSNP_23_3241532_M. Our state has an organization called Livanta Beneficiary & Family Centered Care (BFCC) Quality Improvement Organization (QIO). IEHP DualChoice will help you with the process. What is covered? TTY (800) 718-4347. You can always contact your State Health Insurance Assistance Program (SHIP). When your doctor recommends services that are not available in our network, you can receive these services by an out-of-network provider. All requests for out-of-network services must be approved by your medical group prior to receiving services. If the decision is No for all or part of what I asked for, can I make another appeal? If you need to change your PCP for any reason, your hospital and specialist may also change. 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. 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. Receive information about clinical programs, including staff qualifications, request a change of treatment choices, participate in decisions about your health care, and be informed of health care issues that require self-management. 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. 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. Be treated with respect and courtesy. Information on this page is current as of October 01, 2022, Centers for Medicare and Medicaid Services. Can my doctor give you more information about my appeal for Part C services? Mitral valve TEERs are covered for other uses not listed as an FDA-approved indication when performed in a clinical study and the following requirements are met: The procedure must be performed by an interventional cardiologist or cardiac surgeon. effort to participate in the health care programs IEHP DualChoice offers you. Click here for more information on study design and rationale requirements. If we say no to part or all of your Level 1 Appeal, we will send you a letter. You can send your complaint to Medicare. 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. 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). 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. Direct and oversee the process of handling difficult Providers and/or escalated cases. A reasonable salary expectation is between $153,670.40 and $195,936.00, based upon experience and internal equity. If your provider says you have a good medical reason for an exception, he or she can help you ask for one. We check to see if we were following all the rules when we said No to your request. Information on procedures for obtaining prior authorization of services, Quality Assurance, disenrollment, and other procedures affecting IEHP DualChoice Members. (Effective: January 27, 20) Group I: wounds affecting the skin. Click here for information on Next Generation Sequencing coverage. Send copies of documents, not originals. Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. P.O. Quantity limits. Box 997413 We will let you know of this change right away. 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. You can also have your doctor or your representative call us. If we do not give you an answer within 72 hours or by the end of the extra days (if we took them), we will automatically send your case to Level 2 of the appeals process if your problem is about a Medicare service or item. Oxygen therapy can be renewed by the MAC if deemed medically necessary. We will send you a notice with the steps you can take to ask for an exception. Medicare beneficiaries who meet either of the following criteria: Click here for more information on HBV Screenings. Removing a restriction on our coverage. Asking us to cover a Part D drug that is not on the plans List of Covered Drugs (Formulary), Asking us to waive a restriction on the plans coverage for a drug (such as limits on the amount of the drug you can get). H8894_DSNP_23_3879734_M Pending Accepted. IEHP Medi-Cal Member Services You can call the California Department of Social Services at (800) 952-5253.
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