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. IEHP DualChoice 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. When you choose a PCP, it also determines what hospital and specialist you can use. In most cases you have 120 days to ask for a State Hearing after the Your Hearing Rights notice is mailed to you. However, sometimes we need more time, and we will send you a letter telling you that we need to take up to 14 more calendar days. A standard coverage decision means we will give you an answer within 72 hours after we get your doctors statement. We will also use the standard 14 calendar day deadline instead. Receive Member informing materials in alternative formats, including Braille, large print, and audio. You can file a grievance online. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. If your Primary Care Provider changes, your IEHP DualChoice benefits and required co-payments will stay the same. View Plan Details. Positron Emission Tomography NaF-18 (NaF-18 PET) services to identify bone metastases of cancer provided on or after December 15, 2017, are nationally non-covered. The Help Center cannot return any documents. When will I hear about a standard appeal decision for Part C services? The following link will take you to the Centers for Medicaid and Medicare Services website, where you can look through the CMS Best Available Evidence Policy using the following link: CMS Best Available Evidence Policy. No-cost or low-cost health care coverage for low-income adults, families with children, seniors, and people with disabilities. 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. Tier 1 drugs are: generic, brand and biosimilar drugs. If you want a fast appeal, you may make your appeal in writing or you may call us. Decide in advance how you want to be cared for in case you have a life-threatening illness or injury. 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. Can I get a coverage decision faster for Part C services? 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. 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)? If you have an urgent need for care, you probably will not be able to find or get to one of the providers in our plans network. 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. Including bus pass. (Implementation Date: February 19, 2019) 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). If you have been receiving care from a health care provider, you may have a right to keep your provider for a designated time period. Typically, our Formulary includes more than one drug for treating a particular condition. The Social Security Office at (800) 772-1213 between 7 a.m. and 7 p.m., Monday through Friday, TTY users should call (800) 325-0778; or. A Level 1 Appeal is the first appeal to our plan. The screen test must have all the following: Food and Drug Administration (FDA) market authorization with an indication for colorectal cancer screening; and. Click here for more information on acupuncture for chronic low back pain coverage. You can tell Medi-Cal about your complaint. 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 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 can download a free copy here. Learn about your health needs and leading a healthy lifestyle. If your health condition requires us to answer quickly, we will do that. How will I find out about the decision? (Implementation Date: October 3, 2022) You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. We will see if the service or item you paid for is a covered service or item, and we will check to see if you followed all the rules for using your coverage. Sometimes a specialist, clinic, hospital or other network provider you are using might leave the plan. CMS has updated section 240.2 of the National Coverage Determination Manual to amend the period of initial coverage for patients in section D of NCD 240.2 from 120 days to 90 days, to align with the 90-day statutory time period. All requests for out-of-network services must be approved by your medical group prior to receiving services. 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. All of our plan participating providers also contract us to provide covered Medi-Cal benefits. After your application and supporting documents are received from your plan, the IMR decision will be made within 3 calendar days. Beneficiaries with Alzheimers Disease (AD) may be covered for treatment when the following conditions (A or B) are met: Click here for more information on Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimers Disease (AD). This is asking for a coverage determination about payment. a. Beneficiaries participating in a CMS approved clinical study undergoing Vagus Nerve Stimulation (VNS) for treatment resistant depression and the following requirements are met: Click here for more information on Vagus Nerve Stimulation. 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. If our answer is Yes to part or all of what you asked for, we must approve or give the coverage within 30 calendar days after we get your appeal. How will the plan make the appeal decision? To learn more about asking for exceptions, see Chapter 9 (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]). If PO2 and arterial blood gas results are conflicting, the arterial blood gas results are preferred source to determine medical need. It attacks the liver, causing inflammation. If you are under a Doctors care for an acute condition, serious chronic condition, pregnancy, terminal illness, newborn care, or a scheduled surgery, you may ask to continue seeing your current Doctor. No more than 20 acupuncture treatments may be administered annually. National Coverage determinations (NCDs) are made through an evidence-based process. Medicare Prescription Drug Coverage and Your Rights Notice- Posting of Member Drug Coverage Rights: Medicare requires pharmacies to provide notice to enrollees each time a member is denied coverage or disagrees with cost-sharing information. Effective July 2, 2019, CMS will cover Ambulatory Blood Pressure Monitoring (ABPM) when beneficiaries are suspected of having white coat hypertension or masked hypertension in addition to the coverage criteria outlined in the NCD Manual. We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency. For some types of problems, you need to use the process for coverage decisions and making appeals. Effective on or after April 10, 2018, MRI coverage will be provided when used in accordance to the FDA labeling in an MRI environment. Try to choose a PCP that can admit you to the hospital you want within 30 miles or 45 minutes of your home. You can work with us for all of your health care needs. Vision Care: $350 limit every year for contact lenses and eyeglasses (frames and lenses). The Level 3 Appeal is handled by an administrative law judge. The form gives the other person permission to act for 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. Our plans Part D drug coverage cannot cover a drug that would be covered under Medicare Part A or Part B. 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; For certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for you. (Implementation Date: July 22, 2020). What is covered: Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. Your care team and care coordinator work with you to make a care plan designed to meet your health needs. If your provider says you have a good medical reason for an exception, he or she can help you ask for one. Get a 31-day supply of the drug before the change to the Drug List is made, or. IEHP DualChoice will help you with the process. The therapy is used for a medically accepted indication, which is defined as used for either and FDA approved indication according to the label of that product, or the use is supported in one or more CMS approved compendia. We must complete the described action(s) within 30 calendar days of the date we received a copy of the decision. If patients with bipolar disorder are included, the condition must be carefully characterized. You can also have your doctor or your representative call us. The clinical test must be performed at the time of need: 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. 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. If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize or give you the drug coverage within 72 hours after we get the decision. Or your doctor or other prescriber can tell us on the phone, and then fax or mail a statement. We take a careful look at all of the information about your request for coverage of medical care. When you make an appeal to the Independent Review Entity, we will send them your case file. For more information on network providers refer to Chapter 1 of the IEHP DualChoice Member Handbook. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. TTY users should call (800) 537-7697. TDD users should call (800) 952-8349. 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. Typically, our Formulary includes more than one drug for treating a particular condition. If you do not choose a PCP when you join IEHPDualChoice, we will choose one for you. You will get a care coordinator when you enroll in IEHP DualChoice. Here are examples of coverage determination you can ask us to make about your Part D drugs. When a provider leaves a network, we will mail you a letter informing you about your new provider. IEHP DualChoice will give notice to IEHPDualChoice Members prior to removing Part D drug from the Part D formulary. 2023 IEHP DualChoice Provider and Pharmacy Directory (PDF), http://www.dmhc.ca.gov/FileaComplaint/SubmitanIndependentMedicalReviewComplaintForm.aspx, Request for Medicare Prescription Drug Coverage Determination (PDF). You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. IEHP DualChoice (HMO D-SNP) has a process in place to identify and reduce medication errors. Consist of 30-60 minute sessions comprising of therapeutic exercise-training program for PAD; Be conducted in a hospital outpatient setting or physicians office; Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD; and. 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. With "Extra Help," there is no plan premium for IEHP DualChoice. When you choose your PCP, you are also choosing the affiliated medical group. A specialist is a doctor who provides health care services for a specific disease or part of the body. Will not pay for emergency or urgent Medi-Cal services that you already received. If we are using the fast deadlines, we must give you our answer within 24 hours. The procedure must be performed by an interventional cardiologist or cardiac surgeon.<. This is not a complete list. TTY (800) 718-4347. (Effective: August 7, 2019) (Implementation Date: March 26, 2019). 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. (Implementation date: October 2, 2017 for design and coding; January 1, 2018 for testing and implementation) Read Will my benefits continue during Level 2 appeals in Chapter 9 of the Member Handbook for more information. 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. IEHP DualChoice Yes. You can get the form at. 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 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. 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. Note, the Member must be active with IEHP Direct on the date the services are performed. Limitations, copays, and restrictions may apply. Sprint from Voice Telephone: (800) 877-5379, Visit: 10801 Sixth Street, Suite 120, Rancho Cucamonga, CA 91730. The list can help your provider find a covered drug that might work for you. Click here for more information on Positron Emission Tomography NaF-18 (NaF-18 PET) to Identify Bone Metastasis of Cancer coverage. You ask us to pay for a prescription drug you already bought. Our service area includes all of Riverside and San Bernardino counties. (Implementation Date: February 14, 2022) P.O. Mail your request for payment together with any bills or receipts to us at this address: IEHPDualChoice IEHP DualChoice, a Medicare Medi-Cal Plan, allows you to get your covered Medicare and Medi-Cal benefits through our plan. There are two ways to make a Level 2 appeal for Medi-Cal services and items: 1) Independent Medical Review or 2) State Hearing. Your IEHP DualChoice Doctor cannot charge you for covered health care services, except for required co-payments. Upon expiration, coverage will be determined by the local Medicare Administrative Contractors (MACs). TTY/TDD (877) 486-2048. The following medical conditions are not covered for oxygen therapy and oxygen equipment in the home setting: Other: (Implementation Date: June 16, 2020). Hazelnuts have more carbohydrates and dietary fibres than walnuts while walnuts have more calories, proteins, and fats than hazelnuts. What is covered: We will give you our answer sooner if your health requires us to do so. If our answer is No to part or all of what you asked for, we will send you a letter. Effective for claims with dates of service on or after 12/07/16, Medicare will cover PILD under CED for beneficiaries with LSS when provided in an approved clinical study. 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. (866) 294-4347 If your Level 2 Appeal was a State Hearing, the California Department of Social Services will send you a letter explaining its decision. "Coordinating" your services includes checking or consulting with other Plan providers about your care and how it is going. Box 1800 CMS has updated Chapter 1, Part 1, Section 20.4 of the Medicare National Coverage Determinations Manual providing additional coverage criteria for Implantable Cardiac Defibrillators (ICD) for Ventricular Tachyarrhythmias (VTs). . There is no deductible for IEHP DualChoice. 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. Treatments must be discontinued if the patient is not improving or is regressing. What is a Level 1 Appeal for Part C services? If we are using the standard deadlines, we must give you our answer within 7 calendar days after we get your appeal, or sooner if your health requires it. 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. TTY users should call 1-800-718-4347. Review, request changes to, and receive a copy of your medical records in a timely fashion. (Effective: February 10, 2022) ii. (Effective: May 25, 2017) Welcome to Inland Empire Health Plan \. 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) To learn how to name your representative, you may call IEHP DualChoice Member Services. If you miss this deadline and have a good reason for missing it, we may give you more time to make you appeal. Beneficiaries receiving treatment for implanting a ventricular assist device (VAD), when the following requirements are met and: All other indications for the use of VADs not otherwise listed remain non-covered, except in the context of Category B investigational device exemption clinical trials (42 CFR 405) or as a routine cost in clinical trials defined under section 310.1 of the National Coverage Determinations (NCD) Manual. We will give you our decision sooner if your health condition requires us to. More . 2. If your Level 2 Appeal was an Independent Medical Review, you can request a 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. We may contact you or your doctor or other prescriber to get more information. b. You or your provider can ask for an exception from these changes. Beneficiaries who meet the coverage criteria, if determined eligible. The following information explains who qualifies for IEHP DualChoice (HMO D-SNP). You can call the California Department of Social Services at (800) 952-5253. TTY users should call (800) 537-7697. You, your doctor or other prescriber, or your representative can request the Level 2 Appeal. Beneficiaries who exhibit hypoxemia (low oxygen in your blood) when ALL (A, B, and C) of the following are met: A. Hypoxemia is based on results of a clinical test ordered and evaluated by a patients treating practitioner meeting either of the following: Information on this page is current as of October 01, 2022 Related Resources. We determine an existing relationship by reviewing your available health information available or information you give us. 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 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.

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