With "Extra Help," there is no plan premium for IEHP DualChoice. TTY users should call (800) 718-4347 or fax us at (909) 890-5877. We will review our coverage decision to see if it is correct. You can always contact your State Health Insurance Assistance Program (SHIP). This service will be covered when the TAVR is used, for the treatment of symptomatic aortic valve stenosis. H8894_DSNP_23_3241532_M. Your PCP will also help you arrange or coordinate the rest of the covered services you get as a member of our Plan. Here are examples of coverage determination you can ask us to make about your Part D drugs. Interpreted by the treating physician or treating non-physician practitioner. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Please see below for more information. The Centers of Medicare and Medicaid Services (CMS) will cover Vagus Nerve Stimulation (VNS) for treatment-resistant depression when specific requirements are met. We must complete the described action(s) within 30 calendar days of the date we received a copy of the decision. If you want to change plans, call IEHP DualChoice Member Services. How will I find out about the decision? It is not connected with this plan and it is not a government agency. If you decide to ask for a State Hearing by phone, you should be aware that the phone lines are very busy. Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. Submit the required study information to CMS for approval. Sprint from Voice Telephone: (800) 877-5379, Visit: 10801 Sixth Street, Suite 120, Rancho Cucamonga, CA 91730. This is called prior authorization. Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. Denies, changes, or delays a Medi-Cal service or treatment (not including IHSS) because our plan determines it is not medically necessary. If you have a fast complaint, it means we will give you an answer within 24 hours. (Implementation Date: December 12, 2022) 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. Coverage for future years is two hours for patients diagnosed with renal disease or diabetes. Sacramento, CA 95899-7413. (This is sometimes called step therapy.). (Implementation date: October 2, 2017 for design and coding; January 1, 2018 for testing and implementation) Click here to download a free copy by clicking Adobe Acrobat Reader. Treatments must be discontinued if the patient is not improving or is regressing. Per the recommendation of the United States Preventive Services Task Force (USPSTF), CMS has issued a National Coverage Determination (NCD) which expands coverage to include screening for HBV infection. IEHP DualChoice. Complex Care Management; Medi-Cal Demographic Updates . In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. Effective for dates of service on or after October 9, 2014, all other screening sDNA tests not otherwise specified above remain nationally non-covered. Rancho Cucamonga, CA 91729-1800. Receive information about your rights and responsibilities as an IEHP DualChoice Member. Explore Opportunities. Quantity limits. The Centers for Medicare and Medical Services (CMS) has determined the following services to be necessary for the treatment of an illness or injury. We must respond whether we agree with the complaint or not. When can you end your membership in our plan? If we decide that your health does not meet the requirements for a fast coverage decision, we will send you a letter. H8894_DSNP_23_3241532_M. If the dollar value of the drug coverage you want meets a certain minimum amount, you can make another appeal at Level 3. (Effective: February 15, 2018) You can call (800) MEDICARE (800) 633-4227, 24 hours a day, 7 days a week, TTY (877) 486-2048. Concurrent with Carotid Stent Placement in Patients at High Risk for Carotid Endarterectomy (CEA) If we do not give you a decision within 7 calendar days, or 14 days if you asked us to pay you back for a drug you already bought, we will send your request to Level 2 of the appeals process. 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. Utilities allowance of $40 for covered utilities. We will say Yes or No to your request for an exception. Upon expiration, coverage will be determined by the local Medicare Administrative Contractors (MACs). Interventional Cardiologist meeting the requirements listed in the determination. Our plan cannot cover a drug purchased outside the United States and its territories. Information on this page is current as of October 01, 2022. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Prior to the beneficiarys first lung cancer LDCT screening, the beneficiary must receive a counseling and shared decision-making visit that meets specific criteria. We will send you a letter telling you that. You can call IEHP DualChoice at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. The letter will explain why more time is needed. ii. (Effective: January 19, 2021) (Implementation Date: July 5, 2022). Our plans PCPs are affiliated with medical groups or Independent Physicians Associations (IPA). 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. i. Erythrocythemia (increased red blood cells) with a hematocrit greater than 56%. IEHP DualChoice (HMO D-SNP) helps make your Medicare and Medi-Cal benefits work better together and work better for you. chimeric antigen receptor (CAR) T-cell therapy coverage. Its a good idea to make a copy of your bill and receipts for your records. 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. 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. Send copies of documents, not originals. Effective on or after April 10, 2018, MRI coverage will be provided when used in accordance to the FDA labeling in an MRI environment. Yes, you and your doctor may give us more information to support your appeal. Tier 1 drugs are: generic, brand and biosimilar drugs. Drugs that may not be safe or appropriate because of your age or gender. Please select one of the following: Primary Care Doctor Specialist Behavioral Health Hospitals No means the Independent Review Entity agrees with our decision not to approve your request. TTY should call (800) 718-4347. If the decision is No for all or part of what I asked for, can I make another appeal? 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 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. Receive information about IEHP DualChoice, its programs and services, its Doctors, Providers, health care facilities, and your drug coverage and costs, which you can understand. IEHP DualChoice is a Cal MediConnect Plan. See form below: Deadlines for a fast appeal at Level 2 Complain about IEHP DualChoice, its Providers, or your care. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. VNS is non-covered for the treatment of TRD when furnished outside of a CMS-approved CED study. If your Level 2 Appeal went to the Medicare Independent Review Entity, it will send you a letter explaining its decision. You are not responsible for Medicare costs except for Part D copays. =========== TABBED SINGLE CONTENT GENERAL. You ask us to pay for a prescription drug you already bought. Can my doctor give you more information about my appeal for Part C services? (Implementation Date: December 10, 2018). If you need help during the appeals process, you can call the Office of the Ombudsman at 1-888-452-8609. Our state has an organization called Livanta Beneficiary & Family Centered Care (BFCC) Quality Improvement Organization (QIO). Request and receive appeal data from IEHP DualChoice; Receive notice when an appeal is forwarded to the Independent Review Entity (IRE); Automatic reconsideration by the IRE when IEHP DualChoice upholds its original adverse determination in whole or in part; Administrative Law Judge (ALJ) hearing if the independent review entity upholds the original adverse determination in whole or in part and the remaining amount in controversy is $100 or more; Request Departmental Appeals Board (DAB) review if the ALJ hearing is unfavorable to the Member in whole or in part; Judicial review of the hearing decision if the ALJ hearing and/or DAB review is unfavorable to the Member in whole or in part and the amount remaining in controversy is $1,000 or more; Make a quality of care complaint under the QIO process; Request QIO review of a determination of noncoverage of inpatient hospital care; Request QIO review of a determination of noncoverage in skilled nursing facilities, home health agencies and comprehensive outpatient rehabilitation facilities; Request a timely copy of your case file, subject to federal and state law regarding confidentiality of patient information; Challenge local and national Medicare coverage determination. Other persons may already be authorized by the Court or in accordance with State law to act for you. This is not a complete list. Who is covered: Members must meet all of the following eligibility criteria: Click here for more information on LDCT coverage. Yes. You will usually see your PCP first for most of your routine health care needs. The following criteria must also be met as described in the NCD: Non-Covered Use: We have arranged for these providers to deliver covered services to members in our plan. You can tell Medicare about your complaint. You should receive the IMR decision within 7 calendar days of the submission of the completed application. The FDA provides new guidance or there are new clinical guidelines about a drug. 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. This is a person who works with you, with our plan, and with your care team to help make a care plan. 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. Your doctor will also know about this change and can work with you to find another drug for your condition. TTY users should call 1-800-718-4347. All the changes are reviewed and approved by a selected group of Providers and Pharmacists that are currently in practice. 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 only amount you should be asked to pay is the copay for service, item, and/or drug categories that require a copay. Prior to January 18, 2017, there was no national coverage determination (NCD) in effect. Your care team may include yourself, your caregiver, doctors, nurses, counselors, or other health professionals. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. 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. The phone number for the Office of the Ombudsman is 1-888-452-8609. If you move out of our service area for more than six months. Screening computed tomographic colonography (CTC), effective May 12, 2009. The Heart team must participate in the national registry and track outcomes according to the requirements in this determination.>. For more information, call IEHP DualChoice Member Services or read the IEHP DualChoice Member Handbook. Effective June 21, 2019, CMS will cover TAVR under CED when the procedure is related to the treatment of symptomatic aortic stenosis and according to the Food and Drug Administration (FDA) approved indication for use with an approved device, or in clinical studies when criteria are met, in addition to the coverage criteria outlined in the NCD Manual. We take a careful look at all of the information about your request for coverage of medical care. effort to participate in the health care programs IEHP DualChoice offers you. b. Ask within 60 days of the decision you are appealing. 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. The letter will also explain how you can appeal our decision. (Implementation Date: October 5, 2020). PO2 may be performed by the treating practitioner or by a qualified provider or supplier of laboratory services. IEHP DualChoice develops and maintains the Formulary continuously by reviewing the efficacy (how effective) and safety (how safe) of new drugs, compare new versus existing drugs, and develops clinical practice guidelines based on clinical evidence. There are over 700 pharmacies in the IEHP DualChoice network. 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. The time of need is indicated when the presumption of oxygen therapy within the home setting will improve the patients condition. These forms are also available on the CMS website: You may change your PCP for any reason, at any time. The treatment is considered reasonably likely to predict a clinical benefit and is administrated in a randomized controlled trial under an investigational new drug application. You should receive the IMR decision within 45 calendar days of the submission of the completed application. Effective for claims with dates of service on or after 09/28/2016, CMS covers screening for HBV infection. If you would like to switch from our plan to another Medicare Advantage plan simply enroll in the new Medicare Advantage plan. You can get a fast coverage decision coverage decision only if you are asking for coverage for care or an item you have not yet received. (Effective: January 1, 2022) Yes. You have a care team that you help put together. Walnut trees (Juglans spp.) (This is sometimes called prior authorization.), Being required to try a different drug first before we will agree to cover the drug you are asking for. i. Make your appeal request within 60 calendar days from the date on the notice we sent to tell you our decision. Autologous Platelet-Rich Plasma (PRP) treatment of acute surgical wounds when applied directly to the close incision, or for splitting or open wounds. (888) 244-4347 By clicking on this link, you will be leaving the IEHP DualChoice website. The screen test must have all the following: Food and Drug Administration (FDA) market authorization with an indication for colorectal cancer screening; and. 2. This is known as Exclusively Aligned Enrollment, and. a. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. Click here for more information on Transcatheter Edge-to-Edge Repair [TEER] for Mitral Valve Regurgitation coverage . (Effective: April 7, 2022) "Coordinating" your services includes checking or consulting with other Plan providers about your care and how it is going. (Effective: April 13, 2021) When your complaint is about quality of care. For example, you can ask us to cover a drug even though it is not on the Drug List. They also have thinner, easier-to-crack shells. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal. (Effective: February 15. All of our Doctors offices and service providers have the form or we can mail one to you. The diagnostic laboratory test using NGS must have: Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic and; FDA-approved or cleared indication for use in that patients cancer and; results provided to the treating physician for management of the patient using a report template to specify treatment options. Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). 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. During these events, supplemental oxygen is provided during exercise, if the use of oxygen improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air. If you are admitted to one of these hospitals, a hospitalist may serve as your caregiver as long as you remain in the hospital. This statement will also explain how you can appeal our decision. Breathlessness without cor pulmonale or evidence of hypoxemia; or. This is asking for a coverage determination about payment. Transportation: $0. The Medicare Complaint Form is available at:https://www.medicare.gov/MedicareComplaintForm/home.aspx. Treatment for patients with existing co-morbidities that would preclude the benefit from the procedure. We will look into your complaint and give you our answer. The Level 3 Appeal is handled by an administrative law judge. 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.