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). You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. Remember, if you get a bill that is more than your copay for covered services and items, you should not pay the bill yourself. If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply of the drug before you leave. We will tell you in advance about these other changes to the Drug List. You can always contact your State Health Insurance Assistance Program (SHIP). 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. Treatment of Atherosclerotic Obstructive Lesions It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. TDD users should call (800) 952-8349. 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. Previously, PILD for LSS was covered for beneficiaries enrolled only in a CMS-approved prospective, randomized, controlled clinical trial (RCT) under the Coverage with Evidence Development (CED) paradigm. (Implementation date: June 27, 2017). 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. Your provider will also know about this change. Dieticians and Nutritionist will determine how many units will be administered per day and must meet the requirements of this NCD as well at 42 CFR 410.130 410.134. 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. This includes: Primary Care Providers (PCPs) are usually linked to certain hospitals. Topical Application of Oxygen for Chronic Wound Care. How to obtain an aggregate number of grievances, appeals, and exceptions filed with IEHP DualChoice (HMO D-SNP)? You will get a care coordinator when you enroll in IEHP DualChoice. We will answer your request for an exception within 72 hours after we get your request (or your prescribers supporting statement). TTY users should call 1-800-718-4347. You must qualify for this benefit. Click here for more information on PILD for LSS Screenings. 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. 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. Who is covered: Information is also below. Request a second opinion about a medical condition. What is covered: Your PCP will send a referral to your plan or medical group. Related Resources. Please see below for more information. Review your Member Handbook, and call IEHP DualChoice Member Services if you do not understand something about your coverage and benefits. If you do not stay continuously enrolled in Medicare Part A and Part B. 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 will give you our decision sooner if your health condition requires us to. We will also give notice if there are any changes regarding prior authorizations, quantity limits, step therapy or moving a drug to a higher cost-sharing tier. IEHP: "Inland Empire Health Plan (IEHP) is a not-for-profit Medi-Cal and Medicare health plan headquartered in Rancho Cucamonga, California. Most complaints are answered in 30 calendar days. If you need to change your PCP for any reason, your hospital and specialist may also change. Providers from other groups including patient practitioners, nurses, research personnel, and administrators. Click here to learn more about IEHP DualChoice. You can also have a lawyer act on your behalf. The clinical research must evaluate the patients quality of life pre and post for a minimum of one year and answer at least one of the questions in this determination section. In these situations, please check first with IEHP DualChoice Member Services to see if there is a network pharmacy nearby. All Medicare covered services, doctors, hospitals, labs, and x-rays, You will have access to a Provider network that includes many of the same Providers as your current plan, Coordination of the services you get now or that you might need, Personal history of sustained VT or cardiac arrest due to Ventricular Fibrillation (VF), Prior Myocardial Infarction (MI) and measured Left Ventricular Ejection Fraction (LVEF) less than or equal to .03, Severe, ischemic, dilated cardiomyopathy without history of sustained VT or cardiac arrest due to VF, and have New York Heart Association (NYHA) Class II or III heart failure with a LVEF less than or equal to 35%, Severe, non-ischemic, dilated cardiomyopathy without history of cardiac arrest or sustained VT, NYHA Class II or II heart failure, LVEF less than or equal for 35%, and utilization of optimal medical therapy for at a minimum of three (3) months, Documented, familial or genetic disorders with a high risk of life-threating tachyarrhythmias, but not limited to long QT syndrome or hypertrophic cardiomyopathy, Existing ICD requiring replacement due to battery life, Elective Replacement Indicator (ERI), or malfunction, The procedure is performed in a Clinical Laboratory Improvement Act (CLIA)-certified laboratory. You can call the California Department of Social Services at (800) 952-5253. Arterial PO2 at or below 55 mm Hg, or arterial oxygen saturation at or below 88% when tested during sleep for patients that demonstrate an arterial PO2 at or above 56 mmHg, or You may also ask for judicial review of a State Hearing denial by filing a petition in Superior Court (under Code of Civil Procedure Section 1094.5) within one year after you receive the decision. If you dont have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself. IEHP DualChoice Medicare Team at (800) 741-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays, TTY users should call (800) 718-4347. H5355_CMC_22_2746205Accepted, (Effective: September 27, 2021) Ask for the type of coverage decision you want. 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. After the continuity of care period ends, you will need to use doctors and other providers in the IEHP DualChoice network that are affiliated with your primary care providers medical group, unless we make an agreement with your out-of-network doctor. The patient is under the care of a heart team, which consists of a cardiac surgeon, interventional cardiologist, and various Providers, nurses, and research personnel, The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the related aspects of TAVR, The hospital where the TAVR is complete must have various qualifications and implemented programs. IEHP DualChoice, a Medicare Medi-Cal Plan, allows you to get your covered Medicare and Medi-Cal benefits through our plan. (This is called upholding the decision. It is also called turning down your appeal.) The letter you get will explain additional appeal rights you may have. You should receive the IMR decision within 7 calendar days of the submission of the completed application. Emergency services from network providers or from out-of-network providers. All other indications for colorectal cancer screening not otherwise specific in the regulations or the National Coverage Determination above. 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. Make recommendations about IEHP DualChoice Members rights and responsibilities policies. You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays, TTY (800) 718-4347. Please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. 3. Eligible beneficiaries are entitled to 36 sessions over a 12-week period after meeting with the physician responsible for PAD treatment and receiving a referral. What is the Difference Between Hazelnut and Walnut Drugs that may not be necessary because you are taking another drug to treat the same medical condition. 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. For more information on Medical Nutrition Therapy (MNT) coverage click here. The program is not connected with us or with any insurance company or health plan. You may be able to get extra help to pay for your prescription drug premiums and costs. This includes denial of payment for a service after the service has been rendered (post-service) or denial of service prior to the service being rendered (pre-service). We will give you our answer sooner if your health requires us to. He or she can work with you to find another drug for your condition. A drug is taken off the market. How will the plan make the appeal decision? We will send you a letter telling you that. Click here for more information onICD Coverage. (Effective: February 19, 2019) If possible, we will answer you right away. If you want to change plans, call IEHP DualChoice Member Services. Removing a restriction on our coverage. You may choose different health plans, or providers, under Medi-Cal, like IEHP or Molina Healthcare, Blue Shield, Health Net, etc. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. You do not need to give your doctor or other prescriber written permission to ask us for a coverage determination on your behalf. Beneficiaries not meeting all the criteria for cochlear implants are deemed not eligible for Medicare coverage except for FDA-approved clinical trials as described in the NCD. If you believe we should not take extra days, you can file a fast complaint about our decision to take extra days. This is true even if we pay the provider less than the provider charges for a covered service or item. Pay rate will commensurate with experience. Click here for more information on acupuncture for chronic low back pain coverage. 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. (Implementation date: August 29, 2017 for MAC local edits; January 2, 2018 for MCS shared edits) After your coverage begins with IEHP DualChoice, you must receive medical services and prescription drug services in the IEHP DualChoice network. If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. The California Department of Managed Health Care (DMHC) is responsible for regulating health plans. Livanta is not connect with our plan. 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. 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. We will say Yes or No to your request for an exception. 5. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. How can I make a Level 2 Appeal? Send us your request for payment, along with your bill and documentation of any payment you have made. 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. The following medical conditions are not covered for oxygen therapy and oxygen equipment in the home setting: Other: These reviews are especially important for members who have more than one provider who prescribes their drugs. The time of need is indicated when the presumption of oxygen therapy within the home setting will improve the patients condition. You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function. Effective on January 1, 2023, CMS has updated section 210.3 of the NCD Manual that provides coverage for colorectal cancer (CRC) screening tests under Medicare Part B. Unless you change plans, IEHP DualChoice (HMO D-SNP) will provide your Medicare benefits. You will be automatically enrolled in a Medicare Medi-Cal Plan offered by IEHP DualChoice. This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision.