Molina Medicare Complete Care
ina Medicare Complete Care HMO SNP
2021 | Evidence of Coverage
California H5810-013 Serving Imperial county
January 1 December 31, 2021
Evidence of Coverage:
Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Molina Medicare Complete Care (HMO SNP) This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 December 31, 2021. It explains how to get coverage for the health care services and prescription drugs you need. This is an important legal document. Please keep it in a safe place. This plan, Molina Medicare Complete Care (HMO SNP), is offered by Molina Healthcare of California (When this Evidence of Coverage says "we," "us," or "our," it means Molina Healthcare of California. When it says "plan" or "our plan," it means Molina Medicare Complete Care (HMO SNP).) This document is available for free in Spanish. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (800) 665-0898 (TTY: 711). Please contact our Member Services number at (800) 665-0898 for additional information. (TTY users should call 711.) Hours are 7 days a week, 8:00 a.m. to 8:00 p.m., local time. You can also ask for this information in other formats such as: audio, Braille, or large print. Benefits, and/or copayments/coinsurance may change on January 1, 2021. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (800) 665-0898 (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (800) 665-0898 (TTY: 711). Molina Healthcare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, ethnicity, national origin, religion, gender, sex, age, mental or physical disability, health status, receipt of healthcare, claims experience, medical history, genetic information, evidence of insurability, geographic location. H5810_21_1150_013_CAEOC_C Accepted CAM13ECEN0920
OMB Approval 0938-1051 (Expires: December 31, 2021)
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Table of Contents
2021 Evidence of Coverage Table of Contents
This list of chapters and page numbers is your starting point. For more help in finding information you need, go to the first page of a chapter. You will find a detailed list of topics at the beginning of each chapter.
Chapter 1.
Getting started as a member ......................................................................................3
Explains what it means to be in a Medicare health plan and how to use this booklet. Tells about materials we will send you, your plan premium, your plan membership card, and keeping your membership record up to date.
Chapter 2.
Important phone numbers and resources .............................................................. 18
Tells you how to get in touch with our plan (Molina Medicare Complete Care (HMO SNP)) and with other organizations including Medicare, the State Health Insurance Assistance Program (SHIP), the Quality Improvement Organization, Social Security, Medicaid (the state health insurance program for people with low incomes), programs that help people pay for their prescription drugs, and the Railroad Retirement Board.
Chapter 3.
Using the plan's coverage for your medical and other covered services ........... 34
Explains important things you need to know about getting your medical care as a member of our plan. Topics include using the providers in the plan's network and how to get care when you have an emergency.
Chapter 4.
Benefits Chart (what is covered ) ............................................................................ 49
Gives the details about which types of medical care are covered and not covered for you as a member of our plan.
Chapter 5.
Using the plan's coverage for your Part D prescription drugs ............................. 96
Explains rules you need to follow when you get your Part D drugs. Tells how to use the plan's List of Covered Drugs (Formulary) to find out which drugs are covered. Tells which kinds of drugs are not covered. Explains several kinds of restrictions that apply to coverage for certain drugs. Explains where to get your prescriptions filled. Tells about the plan's programs for drug safety and managing medications.
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Chapter 6.
What you pay for your Part D prescription drugs ................................................ 117
Tells about the (3) stages of drug coverage (Initial Coverage Stage, Coverage Gap Stage, Catastrophic Coverage Stage) and how these stages affect what you pay for your drugs. Explains the five (5) cost sharing tiers for your Part D drugs and tells what you must pay for a drug in each cost sharing tier.
Chapter 7.
Asking us to pay our share of a bill you have received for covered medical services or drugs ....................................................................................................................134
Explains when and how to send a bill to us when you want to ask us to pay you back for our share of the cost for your covered services or drugs.
Chapter 8.
Your rights and responsibilities ............................................................................ 141
Explains the rights and responsibilities you have as a member of our plan. Tells what you can do if you think your rights are not being respected.
Chapter 9.
What to do if you have a problem or complaint (coverage decisions, appeals, complaints) .......................................................... 158
Tells you step-by-step what to do if you are having problems or concerns as a member of our plan.
1 Explains how to ask for coverage decisions and make appeals if you are having trouble getting the medical care or prescription drugs you think are covered by our plan. This includes asking us to make exceptions to the rules or extra restrictions on your coverage for prescription drugs, and asking us to keep covering hospital care and certain types of medical services if you think your coverage is ending too soon.
1 Explains how to make complaints about quality of care, waiting times, customer service, and other concerns.
Chapter 10. Ending your membership in the plan .................................................................... 210
Explains when and how you can end your membership in the plan. Explains situations in which our plan is required to end your membership.
Chapter 11. Legal notices ...........................................................................................................219 Includes notices about governing law and about nondiscrimination.
Chapter 12. Definitions of important words .............................................................................. 222 Explains key terms used in this booklet.
CHAPTER 1
Getting started as a member
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Chapter 1. Getting started as a member
SECTION 1 Introduction .................................................................................................................6 Section 1.1 You are enrolled in Molina Medicare Complete Care (HMO SNP), which is a specialized Medicare Advantage Plan (Special Needs Plan) ..................................................................... 6 Section 1.2 What is the Evidence of Coverage booklet about? .................................................................. 6 Section 1.3 Legal information about the Evidence of Coverage ................................................................ 7
SECTION 2 What makes you eligible to be a plan member? ...................................................... 7 Section 2.1 Your eligibility requirements .................................................................................................. 7 Section 2.2 What are Medicare Part A and Medicare Part B? ................................................................... 8 Section 2.3 What is Medi-cal (Medicaid)? ................................................................................................ 8 Section 2.4 Here is the plan service area for Molina Medicare Complete Care (HMO SNP) ................... 8 Section 2.5 U.S. Citizen or Lawful Presence ............................................................................................. 9
SECTION 3 What other materials will you get from us? ............................................................ 10 Section 3.1 Your plan membership card Use it to get all covered care and prescription drugs ........... 10 Section 3.2 The Provider Directory: Your guide to all providers in the plan's network ........................ 10 Section 3.3 The Pharmacy Directory: Your guide to pharmacies in our network .................................. 11 Section 3.4 The plan's List of Covered Drugs (Formulary) .................................................................... 11 Section 3.5 The Part D Explanation of Benefits (the "Part D EOB"): Reports with a summary of payments made for your Part D prescription drugs .............................................................. 12
SECTION 4 Your monthly premium for Molina Medicare Complete Care (HMO SNP) ........... 12 Section 4.1 How much is your plan premium? ........................................................................................ 12 Section 4.2 If you pay a Part D late enrollment penalty, there are several ways you can pay your penalty ................................................................................................................................... 13 Section 4.3 Can we change your monthly plan premium during the year? ............................................. 15
SECTION 5 Please keep your plan membership record up to date .......................................... 15 Section 5.1 How to help make sure that we have accurate information about you ................................. 15
SECTION 6 We protect the privacy of your personal health information ................................ 16 Section 6.1 We make sure that your health information is protected ...................................................... 16
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SECTION 7 How other insurance works with our plan .............................................................. 16 Section 7.1 Which plan pays first when you have other insurance? ........................................................ 16
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SECTION 1 Introduction
Section 1.1
You are enrolled in Molina Medicare Complete Care (HMO SNP), which is a specialized Medicare Advantage Plan (Special Needs Plan)
You are covered by both Medicare and Medicaid:
1 Medicare is the Federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with end-stage renal disease (kidney failure).
1 Medicaid is a joint Federal and state government program that helps with medical costs for certain people with limited incomes and resources. Medicaid coverage varies depending on the state and the type of Medicaid you have. Some people with Medicaid get help paying for their Medicare premiums and other costs. Other people also get coverage for additional services and drugs that are not covered by Medicare.
You have chosen to get your Medicare health care and your prescription drug coverage through our plan, Molina Medicare Complete Care (HMO SNP).
There are different types of Medicare health plans. Molina Medicare Complete Care (HMO SNP) is a specialized Medicare Advantage Plan (a Medicare "Special Needs Plan"), which means its benefits are designed for people with special health care needs. Molina Medicare Complete Care (HMO SNP) is designed specifically for people who have Medicare and who are also entitled to assistance from Medicaid.
Because you get assistance from Medi-cal (Medicaid) with your Medicare Part A and B cost sharing (deductibles, copayments, and coinsurance) you may pay nothing for your Medicare health care services. Medi-cal (Medicaid) also provides other benefits to you by covering health care services that are not usually covered under Medicare. You will also receive "Extra Help" from Medicare to pay for the costs of your Medicare prescription drugs. Molina Medicare Complete Care (HMO SNP) will help manage all of these benefits for you, so that you get the health care services and payment assistance that you are entitled to.
Molina Medicare Complete Care (HMO SNP) is run by a private company. Like all Medicare Advantage Plans, this Medicare Special Needs Plan is approved by Medicare. The plan also has a contract with the California Medi-cal (Medicaid) program to coordinate your Medi-cal (Medicaid) benefits. We are pleased to be providing your Medicare health care coverage, including your prescription drug coverage.
Coverage under this Plan qualifies as Qualifying Health Coverage (QHC) and satisfies the Patient Protection and Affordable Care Act's (ACA) individual shared responsibility requirement. Please visit the Internal Revenue Service (IRS) website at: https://www.irs.gov/Affordable-Care- Act/Individuals-and-Families for more information.
Section 1.2 What is the Evidence of Coverage booklet about?
This Evidence of Coverage booklet tells you how to get your Medicare medical care and prescription drugs covered through our plan. This booklet explains your rights and responsibilities, what is covered, and what you pay as a member of the plan.
The word "coverage" and "covered services" refers to the medical care and services and the prescription drugs available to you as a member of Molina Medicare Complete Care (HMO SNP).
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It's important for you to learn what the plan's rules are and what services are available to you. We encourage you to set aside some time to look through this Evidence of Coverage booklet. If you are confused or concerned or just have a question, please contact our plan's Member Services (phone numbers are printed on the back cover of this booklet).
Section 1.3 Legal information about the Evidence of Coverage
It's part of our contract with you This Evidence of Coverage is part of our contract with you about how Molina Medicare Complete Care (HMO SNP) covers your care. Other parts of this contract include your enrollment form, the List of Covered Drugs (Formulary), and any notices you receive from us about changes to your coverage or conditions that affect your coverage. These notices are sometimes called "riders" or "amendments." The contract is in effect for months in which you are enrolled in Molina Medicare Complete Care (HMO SNP) between January 1, 2021, and December 31, 2021. Each calendar year, Medicare allows us to make changes to the plans that we offer. This means we can change the costs and benefits of Molina Medicare Complete Care (HMO SNP) after December 31, 2021. We can also choose to stop offering the plan, or to offer it in a different service area, after December 31, 2021.
Medicare must approve our plan each year Medicare (the Centers for Medicare & Medicaid Services) must approve Molina Medicare Complete Care (HMO SNP) each year. You can continue to get Medicare coverage as a member of our plan as long as we choose to continue to offer the plan and Medicare renews its approval of the plan.
SECTION 2 What makes you eligible to be a plan member?
Section 2.1 Your eligibility requirements
You are eligible for membership in our plan as long as: 1 You have both Medicare Part A and Medicare Part B (Section 2.2 tells you about Medicare Part A and Medicare Part B) 1 -- and -- You live in our geographic service area (Section 2.4 below describes our service area). 1 -- and -- you are a United States citizen or are lawfully present in the United States 1 -- and -- You meet the special eligibility requirements described below.
Special eligibility requirements for our plan Our plan is designed to meet the needs of people who receive certain Medicaid benefits. (Medicaid is a joint Federal and state government program that helps with medical costs for certain people with limited incomes and resources.) To be eligible for our plan you must be eligible for Medicare cost sharing assistance under Medicaid.
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Please note: If you lose your eligibility but can reasonably be expected to regain eligibility within 6-month(s), then you are still eligible for membership in our plan (Chapter 4, Section 2.1 tells you about coverage and cost sharing during a period of deemed continued eligibility).
Section 2.2 What are Medicare Part A and Medicare Part B?
When you first signed up for Medicare, you received information about what services are covered under Medicare Part A and Medicare Part B. Remember:
1 Medicare Part A generally helps cover services provided by hospitals (for inpatient services, skilled nursing facilities, or home health agencies).
1 Medicare Part B is for most other medical services (such as physician's services, home infusion therapy, and other outpatient services) and certain items (such as durable medical equipment (DME) and supplies).
Section 2.3 What is Medi-cal (Medicaid)?
Medicaid is a joint Federal and state government program that helps with medical costs for certain people who have limited incomes and resources. Each state decides what counts as income and resources, who is eligible, what services are covered, and the cost for services. States also can decide how to run their program as long as they follow the Federal guidelines. In addition, there are programs offered through Medi-cal (Medicaid) that help people with Medicare pay their Medicare costs, such as their Medicare premiums. These "Medicare Savings Programs" help people with limited income and resources save money each year:
1 Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B premiums, and other cost sharing (like deductibles, coinsurance, and copayments). (Some people with QMB are also eligible for full Medi-cal (Medicaid) benefits (QMB+).)
1 Qualified Medicare Beneficiary-Plus QMB+: Medicaid pays your Medicare Part A and Part B premiums, deductibles, coinsurance, and copayment amounts. You receive Medicaid coverage of Medicare cost share and are eligible for full Medi-cal (Medicaid) benefits.
1 Specified Low-Income Medicare Beneficiary-Plus (SLMB+): Helps pay Part B premiums and is also eligible for full Medi-cal (Medicaid) benefits.
1 Full-Benefit Dual Eligible (FBDE): At times, individuals may qualify for both limited coverage of Medicare cost sharing as well as full Medi-cal (Medicaid) benefits.
Section 2.4 Here is the plan service area for Molina Medicare Complete Care (HMO SNP)
Although Medicare is a Federal program, Molina Medicare Complete Care (HMO SNP) is available only to individuals who live in our plan service area. To remain a member of our plan, you must continue to reside in the plan service area. The service area is described below. Our service area includes these parts of counties in California:
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Riverside, the following zip codes only:
91718; 91719; 91720; 91752; 91760; 92201; 92202; 92203; 92210; 92211; 92220; 92223; 92230; 92234;92235; 92236; 92240; 92241; 92247; 92248; 92253; 92254; 92255; 92258; 92260; 92261; 92262; 92263; 92264; 92270; 92274; 92276; 92282; 92292; 92320; 92501; 92502; 92503; 92504; 92505; 92506; 92507; 92508; 92509; 92513; 92514; 92515; 92516; 92517; 92518; 92519; 92521; 92522; 92530; 92531; 92532; 92536; 92539; 92543; 92544; 92545; 92546; 92548; 92549; 92551; 92552; 92553; 92554; 92555; 92556; 92557; 92561; 92562; 92563; 92564; 92567; 92570; 92571; 92572; 92581; 92582; 92583; 92584; 92585; 92586; 92587; 92589; 92590; 92591; 92592; 92593; 92595; 92596; 92599; 92860; 92877; 92878; 92879; 92880; 92881; 92882; 92883;
San Bernardino County, the following zip codes only:
91701; 91708; 91709; 91710; 91729; 91730; 91737; 91739; 91743; 91758; 91759; 91761; 91762; 91763; 91764; 91784; 91785; 91786; 91798; 92301; 92307; 92308; 92313; 92316; 92318; 92322; 92324; 92326; 92329; 92331; 92334; 92335; 92336; 92337; 92340; 92341; 92344; 92345; 92346; 92350; 92354; 92357; 92358; 92359; 92368; 92369; 92371; 92372; 92373; 92374; 92375; 92376; 92377; 92392; 92393; 92394; 92395; 92397; 92399; 92401; 92402; 92403; 92404; 92405; 92406; 92407; 92408; 92410; 92411; 92412; 92413; 92414; 92415; 92418; 92423; 92424; 92427;
We offer coverage in several states. However, there may be cost or other difference between the plans we offer in each state. If you move out of state and into a state that is still within our service area, you must call Member Services in order to update your information. If you move into a state outside of our service area, you cannot remain a member of our plan. Please call Member Services to find out if we have a plan in your new state.
If you plan to move to a new state, you should also contact your state's Medi-cal (Medicaid) office and ask how this move will affect your Medi-cal (Medicaid) benefits. Phone numbers for Medi-cal (Medicaid) are in Chapter 2, Section 6 of this booklet.
If you plan to move out of the service area, please contact Member Services (phone numbers are printed on the back cover of this booklet). When you move, you will have a Special Enrollment Period that will allow you to switch to Original Medicare or enroll in a Medicare health or drug plan that is available in your new location.
It is also important that you call Social Security if you move or change your mailing address. You can find phone numbers and contact information for Social Security in Chapter 2, Section 5.
Section 2.5 U.S. Citizen or Lawful Presence
A member of a Medicare health plan must be a U.S. citizen or lawfully present in the United States. Medicare (the Centers for Medicare & Medicaid Services) will notify Molina Medicare Complete Care (HMO SNP) if you are not eligible to remain a member on this basis. Molina Medicare Complete Care (HMO SNP) must disenroll you if you do not meet this requirement.
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SECTION 3 What other materials will you get from us?
Section 3.1
Your plan membership card Use it to get all covered care and prescription drugs
While you are a member of our plan, you must use your membership card for our plan whenever you get any services covered by this plan and for prescription drugs you get at network pharmacies. Always remember to show both your Molina Medicare Complete Care (HMO SNP) ID card and California Department of Health Care Services Medicaid ID card each time you present for care. You should also show the provider your Medicaid card. Here's a sample membership card to show you what yours will look like:
Do NOT use your red, white, and blue Medicare card for covered medical services while you are a member of this plan. If you use your Medicare card instead of you Molina Medicare Complete Care membership card, you may have to pay the full cost of medical services yourself. Keep your Medicare card in a safe place. You may be asked to show it if you need hospital services, hospice services, or participate in routine research studies.
Here's why this is so important: If you get covered services using your red, white, and blue Medicare card instead of using your Molina Medicare Complete Care (HMO SNP) membership card while you are a plan member, you may have to pay the full cost yourself.
If your plan membership card is damaged, lost, or stolen, call Member Services right away and we will send you a new card. (Phone numbers for Member Services are printed on the back cover of this booklet.)
Section 3.2
The Provider/Pharmacy Directory: Your guide to all providers in the plan's network
The Provider/Pharmacy Directory lists our network providers, and durable medical equipment suppliers. The directory also denotes those providers accepting Medicaid with a Medicaid indicator.
What are "network providers"?
Network providers are the doctors and other health care professionals, medical groups, durable medical equipment suppliers, hospitals and other health care facilities that have an agreement with us to accept our payment and any plan cost sharing as payment in full. We have arranged for these providers to deliver covered services to members
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in our plan. The most recent list of providers and suppliers is available on our website at MolinaHealthcare.com/ Medicare.
Why do you need to know which providers are part of our network?
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 only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which Molina Medicare Complete Care (HMO SNP) authorizes use of out-of-network providers. See Chapter 3 (Using the plan's coverage for your medical services) for more specific information about emergency, out-of-network, and out-of-area coverage.
It is important that you know who the Medicaid providers are in our network. You should go to these providers because they have an agreement with us to accept our payment for your medical care. When you see a network provider, you usually pay nothing for covered services.
If you don't have your copy of the Provider/Pharmacy Directory, you can request a copy from Member Services (phone numbers are printed on the back cover of this booklet). You may ask Member Services for more information about our network providers, including their qualifications. You can also see the Provider/Pharmacy Directory at MolinaHealthcare.com/Medicare, or download it from this website. Both Member Services and the website can give you the most up-to-date information about changes in our network providers.
Section 3.3 The Provider/Pharmacy Directory: Your guide to pharmacies in our network
What are "network pharmacies"?
Network pharmacies are all of the pharmacies that have agreed to fill covered prescriptions for our plan members.
Why do you need to know about network pharmacies?
You can use the Provider/Pharmacy Directory to find the network pharmacy you want to use. There are changes to our network of pharmacies for next year. An updated Provider/Pharmacy Directory is located on our website at MolinaHealthcare.com/Medicare. You may also call Member Services for updated provider information or to ask us to mail you a Provider/Pharmacy Directory. Please review the 2021 Provider/Pharmacy Directory to see which pharmacies are in our network.
If you don't have the Provider/Pharmacy Directory, you can get a copy from Member Services (phone numbers are printed on the back cover of this booklet). At any time, you can call Member Services to get up-to-date information about changes in the pharmacy network. You can also find this information on our website at MolinaHealthcare.com/Medicare.
Section 3.4 The plan's List of Covered Drugs (Formulary)
The plan has a List of Covered Drugs (Formulary). We call it the "Drug List" for short. It tells which Part D prescription drugs are covered under the Part D benefit included in Molina Medicare Complete Care (HMO SNP). In addition to the drugs covered by Part D, some prescription drugs are covered for you under your Medicaid benefits. The Drug List tells you how to find out which drugs are covered under Medicaid.
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The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. Medicare has approved the Molina Medicare Complete Care (HMO SNP) Drug List.
The Drug List also tells you if there are any rules that restrict coverage for your drugs.
We will provide you a copy of the Drug List. To get the most complete and current information about which drugs are covered, you can visit the plan's website (MolinaHealthcare.com/Medicare) or call Member Services (phone numbers are printed on the back cover of this booklet).
Section 3.5
The Part D Explanation of Benefits (the "Part D EOB"): Reports with a summary of payments made for your Part D prescription drugs
When you use your Part D prescription drug benefits, we will send you a summary report to help you understand and keep track of payments for your Part D prescription drugs. This summary report is called the Part D Explanation of Benefits (or the "Part D EOB").
The Part D Explanation of Benefits tells you the total amount you, or others on your behalf, have spent on your Part D prescription drugs and the total amount we have paid for each of your Part D prescription drugs during the month. The Part D EOB provides more information about the drugs you take, such as increases in price and other drugs with lower cost sharing that may be available. You should consult with your prescriber about these lower cost options. Chapter 6 (What you pay for your Part D prescription drugs) gives more information about the Explanation of Benefits and how it can help you keep track of your drug coverage.
A Part D Explanation of Benefits summary is also available upon request. To get a copy, please contact Member Services (phone numbers are printed on the back cover of this booklet).
SECTION 4 Your monthly premium for Molina Medicare Complete Care (HMO SNP)
Section 4.1 How much is your plan premium?
You do not pay a separate monthly plan premium for Molina Medicare Complete Care (HMO SNP).
In some situations, your plan premium could be more In some situations, your plan premium could be more than the amount listed above in Section 4.1. This situation is described below.
1 Some members are required to pay a Part D late enrollment penalty because they did not join a Medicare drug plan when they first became eligible or because they had a continuous period of 63 days or more when they didn't have "creditable" prescription drug coverage. ("Creditable" means the drug coverage is expected to pay, on average, at least as much as Medicare's standard prescription drug coverage.) For these members, the Part D late enrollment penalty is added to the plan's monthly premium. Their premium amount will be the monthly plan premium plus the amount of their Part D late enrollment penalty.
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4 If you receive "Extra Help" from Medicare to pay for your prescription drugs, you will not pay a late enrollment penalty.
4 If you lose Extra Help, you may be subject to the late enrollment penalty if you go 63 days or more in a row without Part D or other creditable prescription drug coverage.
4 If you are required to pay the Part D late enrollment penalty, the cost of the late enrollment penalty depends on how long you went without Part D or other creditable prescription drug coverage.
1 Some members may be required to pay an extra charge, known as the Part D Income Related Monthly Adjustment Amount, also known as IRMAA, because, 2 years ago, they had a modified adjusted gross income, above a certain amount, on their IRS tax return. Members subject to an IRMAA will have to pay the standard premium amount and this extra charge, which will be added to their premium.
Some members are required to pay other Medicare premiums
In addition to paying the monthly plan premium, some members are required to pay other Medicare premiums. As explained in Section 2 above, in order to be eligible for our plan, you must maintain your eligibility for Medicaid as well as have both Medicare Part A and Medicare Part B. For most Molina Medicare Complete Care (HMO SNP) members, Medicaid pays for your Part A premium (if you don't qualify for it automatically) and for your Part B premium. If Medicaid is not paying your Medicare premiums for you, you must continue to pay your Medicare premiums to remain a member of the plan.
If your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you'll pay the standard premium amount and an Income Related Monthly Adjustment Amount, also known as IRMAA. IRMAA is an extra charge added to your premium.
1 If you have to pay an extra amount, Social Security, not your Medicare plan, will send you a letter telling you what that extra amount will be. If you had a life-changing event that caused your income to go down, you can ask Social Security to reconsider their decision.
1 If you are required to pay the extra amount and you do not pay it, you will be disenrolled from the plan.
1 You can also visit www.medicare.gov on the Web or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or you may call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
Your copy of Medicare & You 2021 gives information about these premiums in the section called "2021 Medicare Costs." Everyone with Medicare receives a copy of Medicare & You each year in the fall. Those new to Medicare receive it within a month after first signing up. You can also download a copy of Medicare & You 2021 from the Medicare website (www.medicare.gov). Or, you can order a printed copy by phone at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048.
Section 4.2
If you pay a Part D late enrollment penalty, there are several ways you can pay your penalty
If you are required to pay a Part D late enrollment penalty, there are 3 ways you can pay the penalty.
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If you decide to change the way you pay your Part D late enrollment penalty, it can take up to three months for your new payment method to take effect. While we are processing your request for a new payment method, you are responsible for making sure that your Part D late enrollment penalty is paid on time.
Option 1: You can pay by check
You can pay your late enrollment penalty by check with our coupon book. Upon signing up to pay by check we will mail out a coupon book that will be effective your entire enrollment period of one year. The book will have a coupon that you will submit with your check each month. The check should be made payable to your plan name, Molina Medicare Complete Care (HMO SNP), and mailed to: (Checks should NOT be made out to CMS or HHS)
Molina Healthcare P.O.Box 515189 Los Angeles, CA 90051-5189
If you lose your coupon book, need to change your payment options or have any questions please contact Member Services (phone numbers are on the back cover of this booklet).
Option 2: Electronic Funds Transfer
You can pay by EFT which means the monthly premium will be automatically withdrawn from your checking or savings account, directly by the plan. On the enrollment form included in your enrollment package, please complete the bank information section to begin your EFT payments. Automatic deductions will occur between the 23rd 30th day of each month. If you need to change your payment option or have any questions please contact Member Services (phone numbers are on the back cover of this booklet.)
Option 3: You can have the Part D late enrollment penalty taken out of your monthly Social Security check
You can have the Part D late enrollment penalty taken out of your monthly Social Security check. Contact Member Services for more information on how to pay your monthly penalty this way. We will be happy to help you set this up. (Phone numbers for Member Services are printed on the back cover of this booklet.)
What to do if you are having trouble paying your Part D late enrollment penalty
If you are having trouble paying your late enrollment penalty on time, please contact Member Services to see if we can direct you to programs that will help with your late enrollment penalty. (Phone numbers for Member Services are printed on the back cover of this booklet.)
If you think we have wrongfully ended your membership, you have a right to ask us to reconsider this decision by making a complaint. Chapter 9, Section 11 of this booklet tells how to make a complaint. If you had an emergency circumstance that was out of your control and it caused you to not be able to pay your plan premium within our grace period, you can ask us to reconsider this decision by calling (800) 665-0898 between 8 a.m. - 8 p.m., local time 7 days a week. TTY users should call 711. You must make your request no later than 60 days after the date your membership ends.
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Section 4.3 Can we change your monthly plan premium during the year?
No. We are not allowed to begin charging a monthly plan premium during the year.
SECTION 5 Please keep your plan membership record up to date
Section 5.1 How to help make sure that we have accurate information about you
Your membership record has information from your enrollment form, including your address and telephone number. It shows your specific plan coverage including your Primary Care Provider/Medical Group/IPA. The doctors, hospitals, pharmacists, and other providers in the plan's network need to have correct information about you. These network providers use your membership record to know what services and drugs are covered and the cost sharing amounts for you. Because of this, it is very important that you help us keep your information up to date.
Let us know about these changes: 1 Changes to your name, your address, or your phone number 1 Changes in any other health insurance coverage you have (such as from your employer, your spouse's employer, workers' compensation, or Medicaid) 1 If you have any liability claims, such as claims from an automobile accident 1 If you have been admitted to a nursing home 1 If you receive care in an out-of-area or out-of-network hospital or emergency room 1 If your designated responsible party (such as a caregiver) changes 1 If you are participating in a clinical research study
If any of this information changes, please let us know by calling Member Services (phone numbers are printed on the back cover of this booklet). Members can create an online My Molina account to change their doctor, update their contact information, request a new ID card, get health reminders on services they need, or view their service history. Visit http://www.MolinaHealthcare.com/Medicare to create or access your My Molina account. It is also important to contact Social Security if you move or change your mailing address. You can find phone numbers and contact information for Social Security in Chapter 2, Section 5.
Read over the information we send you about any other insurance coverage you have Medicare requires that we collect information from you about any other medical or drug insurance coverage that you have. That's because we must coordinate any other coverage you have with your benefits under our plan. (For more information about how our coverage works when you have other insurance, see Section 7 in this chapter.) Once each year, we will send you a letter that lists any other medical or drug insurance coverage that we know about. Please read over this information carefully. If it is correct, you don't need to do anything. If the information
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is incorrect, or if you have other coverage that is not listed, please call Member Services (phone numbers are printed on the back cover of this booklet).
SECTION 6 We protect the privacy of your personal health information
Section 6.1 We make sure that your health information is protected
Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws. For more information about how we protect your personal health information, please go to Chapter 8, Section 1.3 of this booklet.
SECTION 7 How other insurance works with our plan
Section 7.1 Which plan pays first when you have other insurance?
When you have other insurance (like employer group health coverage), there are rules set by Medicare that decide whether our plan or your other insurance pays first. The insurance that pays first is called the "primary payer" and pays up to the limits of its coverage. The one that pays second, called the "secondary payer," only pays if there are costs left uncovered by the primary coverage. The secondary payer may not pay all of the uncovered costs. These rules apply for employer or union group health plan coverage:
1 If you have retiree coverage, Medicare pays first. 1 If your group health plan coverage is based on your or a family member's current employment, who pays
first depends on your age, the number of people employed by your employer, and whether you have Medicare based on age, disability, or End-Stage Renal Disease (ESRD): 4 If you're under 65 and disabled and you or your family member is still working, your group health plan
pays first if the employer has 100 or more employees or at least one employer in a multiple employer plan that has more than 100 employees. 4 If you're over 65 and you or your spouse is still working, your group health plan pays first if the employer has 20 or more employees or at least one employer in a multiple employer plan that has more than 20 employees. 1 If you have Medicare because of ESRD, your group health plan will pay first for the first 30 months after you become eligible for Medicare. These types of coverage usually pay first for services related to each type: 1 No-fault insurance (including automobile insurance) 1 Liability (including automobile insurance) 1 Black lung benefits
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1 Workers' compensation
Medicaid and TRICARE never pay first for Medicare-covered services. They only pay after Medicare and/or employer group health plans have paid.
If you have other insurance, tell your doctor, hospital, and pharmacy. If you have questions about who pays first, or you need to update your other insurance information, call Member Services (phone numbers are printed on the back cover of this booklet). You may need to give your plan member ID number to your other insurers (once you have confirmed their identity) so your bills are paid correctly and on time.
CHAPTER 2
Important phone numbers and resources
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Chapter 2. Important phone numbers and resources
SECTION 1 Molina Medicare Complete Care (HMO SNP) contacts (how to contact us, including how to reach Member Services at the plan) ................................................................ 20
SECTION 2 Medicare (how to get help and information directly from the Federal Medicare program) ......................................................................................................................25
SECTION 3 State Health Insurance Assistance Program (free help, information, and answers to your questions about Medicare) .............................................................................. 26
SECTION 4 Quality Improvement Organization (paid by Medicare to check on the quality of care for people with Medicare) ....................................................................................27
SECTION 5 Social Security ...........................................................................................................28
SECTION 6 Medi-cal (Medicaid) (a joint Federal and state program that helps with medical costs for some people with limited income and resources) ......................................... 28
SECTION 7 Information about programs to help people pay for their prescription drugs ..........................................................................................................................30
SECTION 8 How to contact the Railroad Retirement Board ..................................................... 32
SECTION 9 Do you have "group insurance" or other health insurance from an employer? ..................................................................................................................32
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SECTION 1 Molina Medicare Complete Care (HMO SNP) contacts (how to contact us, including how to reach Member Services at the plan)
How to contact our plan's Member Services
For assistance with claims, billing, or member card questions, please call or write to Molina Medicare Complete Care (HMO SNP) Member Services. We will be happy to help you.
Method CALL
TTY
FAX WRITE WEBSITE
Member Services Contact Information
(800) 665-0898 Calls to this number are free. 7 days a week, 8:00 a.m. to 8:00 p.m., local time Member Services also has free language interpreter services available for non-English speakers.
711 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. The National Relay is available 24 hours a day, 7 days a week.
(801) 858-0409
Molina Healthcare 7050 Union Park Center, Suite 200 Midvale, UT 84047
MolinaHealthcare.com/Medicare
How to contact us when you are asking for a coverage decision about your medical care
A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services. For more information on asking for coverage decisions about your medical care, see Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)).
You may call us if you have questions about our coverage decision process.
Method CALL
TTY
Coverage Decisions for Medical Care Contact Information (800) 665-0898 Calls to this number are free. 7 days a week, 8:00 a.m. to 8:00 p.m., local time 711 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free.
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Method FAX WRITE
WEBSITE
Coverage Decisions for Medical Care Contact Information
The National Relay is available 24 hours a day, 7 days a week.
(844) 251-1450
Molina Healthcare 200 Oceangate, Suite 100 Long Beach, CA 90802
MolinaHealthcare.com/Medicare
How to contact us when you are making an appeal about your medical care
An appeal is a formal way of asking us to review and change a coverage decision we have made. For more information on making an appeal about your medical care, see Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)).
Method CALL TTY
FAX WRITE
WEBSITE
Appeals for Medical Care Contact Information
(800) 665-0898 Calls to this number are free. 7 days a week, 8:00 a.m. to 8:00 p.m., local time
711 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. The National Relay is available 24 hours a day, 7 days a week.
(562) 499-0610
Molina Healthcare Attn: Appeals and Grievance P.O. Box 22816 Long Beach, CA 90801-9977
MolinaHealthcare.com/Medicare
How to contact us when you are making a complaint about your medical care
You can make a complaint about us or one of our network providers, including a complaint about the quality of your care. This type of complaint does not involve coverage or payment disputes. (If your problem is about the plan's coverage or payment, you should look at the section above about making an appeal.) For more information on making a complaint about your medical care, see Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)).
Method CALL
Complaints about Medical Care Contact Information (800) 665-0898
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Method TTY
FAX WRITE
MEDICARE WEBSITE
Complaints about Medical Care Contact Information
Calls to this number are free. 7 days a week, 8:00 a.m. to 8:00 p.m., local time
711
This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
Calls to this number are free.
The National Relay is available 24 hours a day, 7 days a week.
(562) 499-0610
Molina Healthcare Attn: Grievance & Appeals P.O. Box 22816 Long Beach, CA 90801-9977
You can submit a complaint about Molina Medicare Complete Care (HMO SNP) directly to Medicare. To submit an online complaint to Medicare go to www.medicare. gov/MedicareComplaintForm/home.aspx.
How to contact us when you are asking for a coverage decision about your Part D prescription drugs
A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs covered under the Part D benefit included in your plan. For more information on asking for coverage decisions about your Part D prescription drugs, see Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints).
Method CALL TTY
FAX WRITE
Coverage Decisions for Part D Prescription Drugs Contact Information
(888) 665-1328 Calls to this number are free. 7 days a week, 8:00 a.m. to 8:00 p.m., local time
711 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. The National Relay is available 24 hours a day, 7 days a week.
(866) 290-1309
Molina Healthcare Attn: Pharmacy Department 7050 Union Park Center, Suite 200 Midvale, UT 84047
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Method WEBSITE
Coverage Decisions for Part D Prescription Drugs Contact Information MolinaHealthcare.com/Medicare
How to contact us when you are making an appeal about your Part D prescription drugs
An appeal is a formal way of asking us to review and change a coverage decision we have made. For more information on making an appeal about your Part D prescription drugs, see Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)).
Method CALL TTY
FAX WRITE
WEBSITE
Appeals for Part D Prescription Drugs Contact Information
(888) 665-1328 Calls to this number are free. 7 days a week, 8:00 a.m. to 8:00 p.m., local time
711 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. The National Relay is available 24 hours a day, 7 days a week.
(866) 290-1309
Molina Healthcare Attn: Pharmacy Department 7050 Union Park Center, Suite 200 Midvale, UT 84047
MolinaHealthcare.com/Medicare
How to contact us when you are making a complaint about your Part D prescription drugs
You can make a complaint about us or one of our network pharmacies, including a complaint about the quality of your care. This type of complaint does not involve coverage or payment disputes. (If your problem is about the plan's coverage or payment, you should look at the section above about making an appeal.) For more information on making a complaint about your Part D prescription drugs, see Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints).
Method CALL
TTY
Complaints about Part D prescription drugs Contact Information (888) 665-1328 Calls to this number are free. 7 days a week, 8:00 a.m. to 8:00 p.m., local time 711 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
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Method
FAX WRITE
MEDICARE WEBSITE
Complaints about Part D prescription drugs Contact Information
Calls to this number are free.
The National Relay is available 24 hours a day, 7 days a week.
(562) 499-0610
Molina Healthcare Attn: Grievance & Appeals P.O. Box 22816 Long Beach, CA 90801-9977
You can file a grievance via our complaint form located at: http:// www.molinahealthcare.com/medicare
You can submit a complaint about Molina Medicare Complete Care (HMO SNP) directly to Medicare. To submit an online complaint to Medicare go to www.medicare. gov/MedicareComplaintForm/home.aspx.
Where to send a request asking us to pay our share of the cost for medical care or a drug you have received
For more information on situations in which you may need to ask us for reimbursement or to pay a bill you have received from a provider, see Chapter 7 (Asking us to pay our share of a bill you have received for covered medical services or drugs).
Please note: If you send us a payment request and we deny any part of your request, you can appeal our decision. See Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) for more information.
Method CALL TTY
FAX
Payment Request Contact Information (800) 665-0898 Calls to this number are free. 7 days a week, 8:00 a.m. to 8:00 p.m., local time 711 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. The National Relay is available 24 hours a day, 7 days a week. Part C: (801) 858-0409 Part D: (866) 290-1309
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Method WRITE
WEBSITE
Payment Request Contact Information
Molina Healthcare Attn: Medicare Member Services 200 Oceangate, Suite 100 Long Beach, CA 90802
MolinaHealthcare.com/Medicare
SECTION 2 Medicare (how to get help and information directly from the Federal Medicare program)
Medicare is the Federal health insurance program for people 65 years of age or older, some people under age 65 with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
The Federal agency in charge of Medicare is the Centers for Medicare & Medicaid Services (sometimes called "CMS"). This agency contracts with Medicare Advantage organizations including us.
Method CALL TTY
WEBSITE
Medicare Contact Information
1-800-MEDICARE, or 1-800-633-4227 Calls to this number are free. 24 hours a day, 7 days a week.
1-877-486-2048 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free.
www.medicare.gov This is the official government website for Medicare. It gives you up-to-date information about Medicare and current Medicare issues. It also has information about hospitals, nursing homes, physicians, home health agencies, and dialysis facilities. It includes booklets you can print directly from your computer. You can also find Medicare contacts in your state. The Medicare website also has detailed information about your Medicare eligibility and enrollment options with the following tools:
1 Medicare Eligibility Tool: Provides Medicare eligibility status information.
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Method
Medicare Contact Information
1 Medicare Plan Finder: Provides personalized information about available Medicare prescription drug plans, Medicare health plans, and Medigap (Medicare Supplement Insurance) policies in your area. These tools provide an estimate of what your out-of-pocket costs might be in different Medicare plans.
You can also use the website to tell Medicare about any complaints you have about Molina Medicare Complete Care (HMO SNP):
1 Tell Medicare about your complaint: You can submit a complaint about Molina Medicare Complete Care (HMO SNP) directly to Medicare. To submit a complaint to Medicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program.
If you don't have a computer, your local library or senior center may be able to help you visit this website using its computer. Or, you can call Medicare and tell them what information you are looking for. They will find the information on the website, print it out, and send it to you. (You can call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.)
SECTION 3 State Health Insurance Assistance Program (free help, information, and answers to your questions about Medicare)
The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors in every state. In California, the SHIP is called Health Insurance Counseling & Advocacy Program (HICAP).
Health Insurance Counseling & Advocacy Program (HICAP) is independent (not connected with any insurance company or health plan). It is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare.
Health Insurance Counseling & Advocacy Program (HICAP) counselors can help you with your Medicare questions or problems. They can help you understand your Medicare rights, help you make complaints about your medical care or treatment, and help you straighten out problems with your Medicare bills. Health Insurance Counseling & Advocacy Program (HICAP) counselors can also help you understand your Medicare plan choices and answer questions about switching plans.
Method CALL TTY
Health Insurance Counseling & Advocacy Program (HICAP) (California's SHIP) Contact Information
(760) 353-0223 , Los Angeles: Monday - Friday 8:30 a.m. to 4:30 p.m., local time. San Diego and Imperial: Monday - Friday 8:00 a.m. to 5:00 .p.m., local time. Riverside and San Bernardino: Monday - Friday 9:00 a.m.-4:00 p.m., local time.
711
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Method WRITE WEBSITE
Health Insurance Counseling & Advocacy Program (HICAP) (California's SHIP) Contact Information
This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
Imperial County: Elder Law & Advocacy 5151 Murphy Canyon Road, Suite110 San Diego, CA 92123
http://www.cahealthadvocates.org/HICAP/
SECTION 4 Quality Improvement Organization (paid by Medicare to check on the quality of care for people with Medicare)
There is a designated Quality Improvement Organization for serving Medicare beneficiaries in each state. For California, the Quality Improvement Organization is called Livanta.
Livanta has a group of doctors and other health care professionals who are paid by the Federal government. This organization is paid by Medicare to check on and help improve the quality of care for people with Medicare. Livanta is an independent organization. It is not connected with our plan.
You should contact Livanta in any of these situations:
1 You have a complaint about the quality of care you have received.
1 You think coverage for your hospital stay is ending too soon.
1 You think coverage for your home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services are ending too soon.
Method CALL TTY
WRITE
WEBSITE
Livanta (California's Quality Improvement Organization) Contact Information
(877) 588-1123, Monday-Friday: 9:00 a.m. - 5:00 p.m. (local time), 24 hour voicemail is available
(855) 887-6668
This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
Livanta BFCC-QIO Program 10820 Guilford Road, Suite 202 Annapolis Junction, MD 20701
https://www.livantaqio.com/
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SECTION 5 Social Security
Social Security is responsible for determining eligibility and handling enrollment for Medicare. U.S. citizens and lawful permanent residents who are 65 or older, or who have a disability or End-Stage Renal Disease and meet certain conditions, are eligible for Medicare. If you are already getting Social Security checks, enrollment into Medicare is automatic. If you are not getting Social Security checks, you have to enroll in Medicare. Social Security handles the enrollment process for Medicare. To apply for Medicare, you can call Social Security or visit your local Social Security office.
Social Security is also responsible for determining who has to pay an extra amount for their Part D drug coverage because they have a higher income. If you got a letter from Social Security telling you that you have to pay the extra amount and have questions about the amount or if your income went down because of a life-changing event, you can call Social Security to ask for reconsideration.
If you move or change your mailing address, it is important that you contact Social Security to let them know.
Method CALL
TTY
WEBSITE
Social Security Contact Information 1-800-772-1213 Calls to this number are free. Available 7:00 am to 7:00 pm, Monday through Friday. You can use Social Security's automated telephone services to get recorded information and conduct some business 24 hours a day. 1-800-325-0778 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. Available 7:00 am to 7:00 pm, Monday through Friday. www.ssa.gov
SECTION 6 Medi-cal (Medicaid) (a joint Federal and state program that helps with medical costs for some people with limited income and resources)
Medi-cal (Medicaid) is a joint Federal and state government program that helps with medical costs for certain people with limited incomes and resources.
In addition, there are programs offered through Medi-cal (Medicaid) that help people with Medicare pay their Medicare costs, such as their Medicare premiums. These "Medicare Savings Programs" help people with limited income and resources save money each year:
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1 Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B premiums, and other cost sharing (like deductibles, coinsurance, and copayments). (Some people with QMB are also eligible for full Medi-cal (Medicaid) benefits (QMB+).)
1 Qualified Medicare Beneficiary-Plus QMB+: Medicaid pays your Medicare Part A and Part B premiums, deductibles, coinsurance, and copayment amounts. You receive Medicaid coverage of Medicare cost share and are eligible for full Medi-cal (Medicaid) benefits.
1 Specified Low-Income Medicare Beneficiary-Plus (SLMB+): Helps pay Part B premiums and is also eligible for full Medi-cal (Medicaid) benefits.
1 Full-Benefit Dual Eligible (FBDE): At times, individuals may qualify for both limited coverage of Medicare cost sharing as well as full Medi-cal (Medicaid) benefits.
Members of this Plan are dually enrolled in both Medicare and Medi-cal (Medicaid). If you have questions about the assistance you get from Medi-cal (Medicaid), contact California Department of Health Care Services.
Method CALL TTY WRITE
WEBSITE
California Department of Health Care Services, (California's Medicaid program) Contact Information
(916) 449-5000, Monday - Friday 8:00 a.m. - 5:00 p.m., local time
711
This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
Medi-Cal Managed Care P.O. Box 997413, MS 4400 Sacramento, CA 95899-7413 Physical Address: 1501 Capitol Ave., MS 4400 Sacramento, CA 95814
http://www.dhcs.ca.gov/Pages/default.aspx
The Medi-Cal Managed Care Office of the Ombudsman (California's Ombudsman Program) helps people enrolled in Medicaid with service or billing problems. They can help you file a grievance or appeal with our plan.
Method CALL TTY
WRITE
Medi-Cal Managed Care Office of the Ombudsman Contact Information (888) 452-8609, Monday - Friday 8:00 a.m. - 5:00 p.m. local time, excluding holidays
This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Office of the Ombudsman MS-4412 1501 Capitol Avenue P.O. Box 997413 Sacramento, Ca 95899-7413
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Method WEBSITE
Medi-Cal Managed Care Office of the Ombudsman Contact Information
http://www.dhcs.ca.gov/services/medi-cal/Pages/ MMCDOfficeoftheOmbudsman. aspx
The California Department of Aging Long-Term Care Ombudsman Program helps people get information about nursing homes and resolve problems between nursing homes and residents or their families.
Method CALL TTY
WRITE
WEBSITE
California Department of Aging Long-Term Care Ombudsman Program Contact Information
(800) 231-4024, Monday - Friday, 8:00 a.m. - 5:00 p.m. local time, excluding holidays
(800) 231-4024
This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
California Department of Aging 1300 National Dr., Suite 200 Sacramento, CA 95834
http://www.aging.ca.gov/ProgramsProviders/LTCOP/
SECTION 7 Information about programs to help people pay for their prescription drugs
Medicare's "Extra Help" Program
Because you are eligible for Medicaid, you qualify for and are getting "Extra Help" from Medicare to pay for your prescription drug plan costs. You do not need to do anything further to get this "Extra Help."
If you have questions about "Extra Help," call:
1 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048 , 24 hours a day, 7 days a week;
1 The Social Security Office at 1-800-772-1213, between 7 am to 7 pm, Monday through Friday. TTY users should call 1-800-325-0778; or
1 Your State Medicaid Office (See Section 6 of this chapter for contact information).
If you believe you have qualified for "Extra Help" and you believe that you are paying an incorrect cost sharing amount when you get your prescription at a pharmacy, our plan has established a process that allows you to either request assistance in obtaining evidence of your proper copayment level, or, if you already have the evidence, to provide this evidence to us.
1 The Best Available Evidence (BAE) located on the web at http://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovContra/Best_Available_Evidence_Policy.html. BAE is used to determine a member's Low Income Subsidy. Our Member Services department and Pharmacy department identify cases
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Chapter 2. Important phone numbers and resources
where the BAE policy applies. Members may send BAE documentation to establish eligibility to the Member Services address listed in Chapter 2. Additionally you may contact Member Services if you have questions (phone numbers are printed on the back cover of this booklet). Acceptable forms of evidence are:
4 SSA Award Letter
4 Notice of Award
4 Supplemental Security Income
1 When we receive the evidence showing your copayment level, we will update our system so that you can pay the correct copayment when you get your next prescription at the pharmacy. If you overpay your copayment, we will reimburse you. Either we will forward a check to you in the amount of your overpayment or we will offset future copayments. If the pharmacy hasn't collected a copayment from you and is carrying your copayment as a debt owed by you, we may make the payment directly to the pharmacy. If a state paid on your behalf, we may make payment directly to the state. Please contact Member Services if you have questions (phone numbers are printed on the back cover of this booklet).
What if you have coverage from an AIDS Drug Assistance Program (ADAP)? What is the AIDS Drug Assistance Program (ADAP)?
The AIDS Drug Assistance Program (ADAP) helps ADAP-eligible individuals living with HIV/AIDS have access to life-saving HIV medications. Medicare Part D prescription drugs that are also covered by ADAP qualify for prescription cost sharing assistance from the Office of AIDS, Phone: (916) 449-5900. Note: To be eligible for the ADAP operating in your State, individuals must meet certain criteria, including proof of State residence and HIV status, low income as defined by the State, and uninsured/under-insured status.
If you are currently enrolled in an ADAP, it can continue to provide you with Medicare Part D prescription cost sharing assistance for drugs on the ADAP formulary. In order to be sure you continue receiving this assistance, please notify your local ADAP enrollment worker of any changes in your Medicare Part D plan name or policy number. Office of AIDS, Phone: (916) 449-5900.
For information on eligibility criteria, covered drugs, or how to enroll in the program, please call the Office of AIDS, Phone: (916) 449-5900.
What if you get "Extra Help" from Medicare to help pay your prescription drug costs? Can you get the discounts?
Most of our members get "Extra Help" from Medicare to pay for their prescription drug plan costs. If you get "Extra Help," the Medicare Coverage Gap Discount Program does not apply to you. If you get "Extra Help," you already have coverage for your prescription drug costs during the coverage gap.
What if you don't get a discount, and you think you should have?
If you think that you have reached the coverage gap and did not get a discount when you paid for your brand name drug, you should review your next Part D Explanation of Benefits (Part D EOB) notice. If the discount doesn't appear on your Part D Explanation of Benefits, you should contact us to make sure that your prescription records are correct and up-to-date. If we don't agree that you are owed a discount, you can appeal. You can get help filing an appeal from your State Health Insurance Assistance Program (SHIP) (telephone numbers are in Section 3 of
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this Chapter) or by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
SECTION 8 How to contact the Railroad Retirement Board
The Railroad Retirement Board is an independent Federal agency that administers comprehensive benefit programs for the nation's railroad workers and their families. If you have questions regarding your benefits from the Railroad Retirement Board, contact the agency.
If you receive your Medicare through the Railroad Retirement Board, it is important that you let them know if you move or change your mailing address.
Method CALL
TTY WEBSITE
Railroad Retirement Board Contact Information
1-877-772-5772
Calls to this number are free.
If you press "0," you may speak with an RRB representative from 9:00 am to 3:30 pm, Monday through , Tuesday, Thursday, and Friday, and from 9:00 am to 12:00 pm on Wednesday.
If you have a touch-tone telephone, If you press "1", you may access the automated RRB HelpLine and recorded information and automated services are available 24 hours a day, including weekends and holidays.
1-312-751-4701
This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
Calls to this number are not free.
rrb.gov/
SECTION 9 Do you have "group insurance" or other health insurance from an employer?
If you (or your spouse) get benefits from your (or your spouse's) employer or retiree group as part of this plan, you may call the employer/union benefits administrator or Member Services if you have any questions. You can ask about your (or your spouse's) employer or retiree health benefits or premiums. (Phone numbers for Member Services are printed on the back cover of this booklet.) You may also call 1-800-MEDICARE (1-800-633-4227; TTY: 1-877-486-2048) with questions related to your Medicare coverage under this plan or enrollment periods to make a change.
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If you have other prescription drug coverage through your (or your spouse's) employer or retiree group, please contact that group's benefits administrator. The benefits administrator can help you determine how your current prescription drug coverage will work with our plan.
CHAPTER 3
Using the plan's coverage for your medical and other covered services
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Chapter 3. Using the plan's coverage for your medical and other covered services
SECTION 1 Things to know about getting your medical care and other services covered as a member of our plan ...........................................................................................37
Section 1.1 What are "network providers" and "covered services"? ....................................................... 37 Section 1.2 Basic rules for getting your medical care and other services covered by the plan ............... 37
SECTION 2 Use providers in the plan's network to get your medical care and other services ......................................................................................................................38
Section 2.1 You must choose a Primary Care Provider (PCP) to provide and oversee your care ........... 38 Section 2.2 What kinds of medical care and other services can you get without getting approval in
advance from your PCP? ....................................................................................................... 40 Section 2.3 How to get care from specialists and other network providers ............................................. 41 Section 2.4 How to get care from out-of-network providers ................................................................... 42
SECTION 3 How to get covered services when you have an emergency or urgent need for care or during a disaster ..........................................................................................42
Section 3.1 Getting care if you have a medical emergency ..................................................................... 42 Section 3.2 Getting care when you have an urgent need for services ...................................................... 43 Section 3.3 Getting care during a disaster ................................................................................................ 43
SECTION 4 What if you are billed directly for the full cost of your covered services? .......... 44 Section 4.1 You can ask us to pay for covered services .......................................................................... 44 Section 4.2 What should you do if services are not covered by our plan? .............................................. 44
SECTION 5 How are your medical services covered when you are in a "clinical research study"? .......................................................................................................................45
Section 5.1 What is a "clinical research study"? ...................................................................................... 45 Section 5.2 When you participate in a clinical research study, who pays for what? ............................... 45
SECTION 6 Rules for getting care covered in a "religious non-medical health care institution" .................................................................................................................46
Section 6.1 What is a religious non-medical health care institution? ...................................................... 46 Section 6.2 Receiving Care From a Religious Non-Medical Health Care Institution ............................. 46
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SECTION 7 Rules for ownership of durable medical equipment .............................................. 47 Section 7.1 Will you own the durable medical equipment after making a certain number of payments under our plan? ...................................................................................................................... 47
SECTION 8 Rules for Oxygen Equipment, Supplies, and Maintenance ................................... 48 Section 8.1 What oxygen benefits are you entitled to? ............................................................................ 48 Section 8.2 What is your cost sharing? Will it change after 36 months? ................................................. 48 Section 8.3 What happens if you leave your plan and return to Original Medicare? .............................. 48
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SECTION 1 Things to know about getting your medical care and other services covered as a member of our plan
This chapter explains what you need to know about using the plan to get your medical care and other services covered. It gives definitions of terms and explains the rules you will need to follow to get the medical treatments, services, and other medical care that are covered by the plan. For the details on what medical care and other services are covered by our plan, use the benefits chart in the next chapter, Chapter 4 (Benefits Chart, what is covered).
Section 1.1 What are "network providers" and "covered services"?
Here are some definitions that can help you understand how you get the care and services that are covered for you as a member of our plan:
1 "Providers" are doctors and other health care professionals licensed by the state to provide medical services and care. The term "providers" also includes hospitals and other health care facilities.
1 "Network providers" are the doctors and other health care professionals, medical groups, hospitals, and other health care facilities that have an agreement with us to accept our payment as payment in full. We have arranged for these providers to deliver covered services to members in our plan. The providers in our network bill us directly for care they give you. When you see a network provider, you pay nothing for covered services.
1 "Covered services" include all the medical care, health care services, supplies, and equipment that are covered by our plan. Your covered services for medical care are listed in the benefits chart in Chapter 4.
Section 1.2 Basic rules for getting your medical care and other services covered by the plan
As a Medicare Medi-cal (Medicaid) health plan, Molina Medicare Complete Care (HMO SNP) must cover all services covered by Original Medicare and other services and must follow Original Medicare's coverage rules for these services. Molina Medicare Complete Care (HMO SNP) will generally cover your medical care as long as:
1 The care you receive is included in the plan's Benefits Chart (this chart is in Chapter 4 of this booklet). 1 The care you receive is considered medically necessary. "Medically necessary" means that the services,
supplies, or drugs are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice. 1 You have a network primary care provider (a PCP) who is providing and overseeing your care. As a member of our plan, you must choose a network PCP (for more information about this, see Section 2.1 in this chapter).
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4 In most situations, your network PCP must give you approval in advance before you can use other providers in the plan's network, such as specialists, hospitals, skilled nursing facilities, or home health care agencies. This is called giving you a "referral." For more information about this, see Section 2.3 of this chapter.
4 Referrals from your PCP are not required for emergency care or urgently needed services. There are also some other kinds of care you can get without having approval in advance from your PCP (for more information about this, see Section 2.2 of this chapter).
1 You must receive your care from a network provider (for more information about this, see Section 2 in this chapter). In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered. Here are three exceptions:
4 The plan covers emergency care or urgently needed services that you get from an out-of-network provider. For more information about this, and to see what emergency or urgently needed services means, see Section 3 in this chapter.
4 If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. In this case prior authorization is required. Please contact Member Services for assistance (the contact information is located on the back of this booklet). If you obtain routine care from out of network providers without prior authorization, neither Medicare nor the plan will be responsible for the costs. In this situation, we will cover these services as if you got the care from a network provider. For information about getting approval to see an out-of-network doctor, see Section 2.4 in this chapter.
4 The plan covers kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan's service area.
SECTION 2 Use providers in the plan's network to get your medical care and other services
Section 2.1
You must choose a Primary Care Provider (PCP) to provide and oversee your care
What is a "PCP" and what does the PCP do for you?
When you become a member of our Plan, you must choose a network provider to be your Primary Care Provider (PCP). Your PCP can be a physician, nurse practitioner, or other health care professional who meets state requirements and is trained to give you basic medical care. Health professionals are eligible to provide services as PCPs in our Plan when they practice in the areas of family medicine, general practice, geriatrics, internal medicine or obstetrics/gynecology. As we explain below, you will get your routine or basic care from your PCP. Your PCP will also coordinate the rest of the covered services you get as a member of our Plan. For example, in order for you to see a specialist, you usually need to get your PCP's approval first (this is called getting a "referral" to a specialist). Your PCP will provide most of your care and will help you arrange or coordinate the rest of the covered services you get as a member of our Plan. This includes:
1 Your X-rays
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1 Laboratory tests
1 Therapies
1 Care from doctors who are specialists
1 Hospital admissions
1 Follow-up care
"Coordinating" your services includes checking or consulting with other network providers about your care and how it is going. If you need certain types of covered services or supplies, you must get approval in advance from your PCP (such as giving you a referral to see a specialist). In some cases, your PCP will need to get prior authorization (prior approval) from us. Since your PCP will provide and coordinate your medical care, you should have all of your past medical records sent to your PCP's office. Section 3 tells you how we will protect the privacy of your medical records and personal health information.
How do you choose your PCP?
Your relationship with your PCP is an important one. We strongly recommend that you choose a PCP close to home. Having your PCP nearby makes receiving medical care and developing a trusting and open relationship easier. For a copy of the most current Provider/Pharmacy Directory, or to seek additional assistance in choosing a PCP, please contact Member Services. If there is a particular specialist or hospital that you want to use, check first to be sure your PCP makes referrals to that specialist, or uses that hospital. Once you have chosen your PCP, we recommend that you have all your medical records transferred to his or her office. This will provide your PCP access to your medical history and make him or her aware of any existing health care conditions you may have. Your PCP is now responsible for all your routine health care services, so he or she should be the first one you call with any health concerns. The name and office telephone number of your PCP is printed on your membership card.
Changing your PCP
You may change your PCP for any reason, at any time. Also, it's possible that your PCP might leave our plan's network of providers and you would have to find a new PCP.
Molina Medicare has a Continuity-of-Care (COC) Policy that allows you continued access to non-contracted practitioners in the following situations:
If you are a new member, you may continue treatment for up to 90 days:
1 If you are in an active course of treatment with a non-contracted practitioner/s at the time of enrollment.
1 If you have current DME equipment- Molina will ensure continued access to needed DME and repairs from non-contracted providers.
1 If you are pregnant you will receive continuity of care until postpartum services are completed or for a longer period if necessary for safe transfer to another provider.
If you are an existing member you may receive continuity of care for up to a year for ongoing services upon discontinuation of a contract between Molina and your practitioner or facility, provided the following caveats:
1 Services are part of your benefits.
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1 The provider was not discontinued due to quality of care issues.
1 The provider has to agree to continue seeing you.
1 The provider has agreed to accept the regulatory required rates.
Molina Medicare staff will work with your non-contracted practitioner to bring them into the Molina Medicare network as a contracted provider or work with you and the provider to transition your care to a practitioner within the Molina Medicare network during the 90 day continuity-of-care time period. Continuity of care will be provided within the limits of your benefits.
Exceptions to Policy:
1. Molina Medicare staff may extend the 90 day period as long as necessary to meet any unusual needs you may have.
2. Molina will not approve continued care by a non-participating provider if:
4 You only require monitoring of a chronic condition.
4 The discontinued contract with the practitioner is based on a professional review action for incompetence or inappropriate conduct, and your welfare might be in jeopardy.
4 The practitioner is unwilling to continue providing care for you.
4 Care with the non-participating provider was initiated after you enrolled with Molina
3. The provider who would do the ongoing care either did not meet Molina's Credentialing policies/ criteria in the past or attempts to become credentialed while providing ongoing care.
Section 2.2
What kinds of medical care and other services can you get without getting approval in advance from your PCP?
You can get the services listed below without getting approval in advance from your PCP.
1 Routine women's health care, which includes breast exams, screening mammograms (x-rays of the breast), Pap tests, and pelvic exams.
1 Flu shots, Hepatitis B vaccinations, and pneumonia vaccinations.
1 Emergency services from network providers or from out-of-network providers
1 Urgently needed services from 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 plan's service area.
1 Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan's service area. (If possible, please call Member Services before you leave the service area so we can help arrange for you to have maintenance dialysis while you are away. Phone numbers for Member Services are printed on the back cover of this booklet.)
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Section 2.3 How to get care from specialists and other network providers
A specialist is a doctor who provides health care services for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples:
1 Oncologists care for patients with cancer.
1 Cardiologists care for patients with heart conditions.
1 Orthopedists care for patients with certain bone, joint, or muscle conditions.
For some types of referrals, your PCP may need to get approval in advance from our plan (this is called getting "prior authorization"). Please refer to Chapter 4, Section 2.1 for information about which services require prior authorization.
It is very important to get a referral (approval in advance) from your PCP before you see a Network specialist or certain other providers (there are a few exceptions, including routine women's health care, or dialysis). If you don't have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself. If the specialist wants you to come back for more care, check first to be sure that the referral (approval in advance) you got from your PCP for the first visit covers more visits to the specialist.
If there are specific specialists you want to use, find out whether your PCP sends patients to these specialists. Each plan PCP has certain network specialists they use for referrals. This means the PCP you select may determine the specialists you may see. You may generally change your PCP at any time if you want to see a network specialist that your current PCP can't refer you to. If there are specific hospitals you want to use, you must first find out whether your PCP uses these hospitals.
What if a specialist or another network provider leaves our plan?
We may make changes to the hospitals, doctors, and specialists (providers) that are part of your plan during the year. There are a number of reasons why your provider might leave your plan, but if your doctor or specialist does leave your plan you have certain rights and protections that are summarized below:
1 Even though our network of providers may change during the year, Medicare requires that we furnish you with uninterrupted access to qualified doctors and specialists.
1 We will make a good faith effort to provide you with at least 30 days' notice that your provider is leaving our plan so that you have time to select a new provider.
1 We will assist you in selecting a new qualified provider to continue managing your health care needs.
1 If you are undergoing medical treatment you have the right to request, and we will work with you to ensure, that the medically necessary treatment you are receiving is not interrupted.
1 If you believe we have not furnished you with a qualified provider to replace your previous provider or that your care is not being appropriately managed, you have the right to file an appeal of our decision.
1 If you find out your doctor or specialist is leaving your plan, please contact us so we can assist you in finding a new provider to manage your care.
Please contact Member Services for assistance (contact information is located on the back of this booklet).
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Section 2.4 How to get care from out-of-network providers
If you need medical care that Medicare requires our plan to cover and the providers in our Network cannot provide this care; you can get this care from an out-of-network provider. In this case a prior authorization is required. Please contact Member Services for assistance (contact information is located on the back of this booklet). If you obtain routine care from out-of-network providers without prior authorization, neither Medicare nor the Plan will be responsible for the costs.
SECTION 3 How to get covered services when you have an emergency or urgent need for care or during a disaster
Section 3.1 Getting care if you have a medical emergency
What is a "medical emergency" and what should you do if you have one? A "medical emergency" is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.
If you have a medical emergency: 1 Get help as quickly as possible. Call 911 for help or go to the nearest emergency room or hospital. Call for an ambulance if you need it. You do not need to get approval or a referral first from your PCP. 1 As soon as possible, make sure that our plan has been told about your emergency. We need to follow up on your emergency care. You or someone else should call to tell us about your emergency care, usually within 48 hours. Please call Member Services at the number on the back of the plan membership card.
What is covered if you have a medical emergency? You may get covered emergency medical care whenever you need it, anywhere in the United States or its territories. Our plan covers ambulance services in situations where getting to the emergency room in any other way could endanger your health. For more information, see the Benefits Chart in Chapter 4 of this booklet.
We offer up to $10,000 of worldwide emergency coverage each calendar year for emergency transportation, urgent care, emergency care, and post-stabilization care.
If you have an emergency, we will talk with the doctors who are giving you emergency care to help manage and follow up on your care. The doctors who are giving you emergency care will decide when your condition is stable and the medical emergency is over.
After the emergency is over you are entitled to follow-up care to be sure your condition continues to be stable. Your follow-up care will be covered by our plan. If your emergency care is provided by out-of-network providers, we will try to arrange for network providers to take over your care as soon as your medical condition and the circumstances allow.
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What if it wasn't a medical emergency? Sometimes it can be hard to know if you have a medical emergency. For example, you might go in for emergency care thinking that your health is in serious danger and the doctor may say that it wasn't a medical emergency after all. If it turns out that it was not an emergency, as long as you reasonably thought your health was in serious danger, we will cover your care. However, after the doctor has said that it was not an emergency, we will cover additional care only if you get the additional care in one of these two ways:
1 You go to a network provider to get the additional care. 1 or The additional care you get is considered "urgently needed services" and you follow the rules for
getting this urgent care (for more information about this, see Section 3.2 below).
Section 3.2 Getting care when you have an urgent need for services
What are "urgently needed services"? "Urgently needed services" are non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed services may be furnished by network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible. The unforeseen condition could, for example, be an unforeseen flare-up of a known condition that you have.
What if you are in the plan's service area when you have an urgent need for care? You should always try to obtain urgently needed services from network providers. However, if providers are temporarily unavailable or inaccessible and it is not reasonable to wait to obtain care from your network provider when the network becomes available, we will cover urgently needed services that you get from an out-of-network provider. When network providers are temporarily unavailable or inaccessible, urgent care can be accessed using any available urgent care center. You may also call the Nurse Advice Line at (888) 275-8750 for English and Spanish users. TTY users should call 711.
What if you are outside the plan's service area when you have an urgent need for care? When you are outside the service area and cannot get care from a network provider, our plan will cover urgently needed services that you get from any provider. We offer up to $10,000 of worldwide emergency coverage each calendar year for emergency transportation, urgent care, emergency care, and post-stabilization care.
Section 3.3 Getting care during a disaster
If the Governor of your state, the U.S. Secretary of Health and Human Services, or the President of the United States declares a state of disaster or emergency in your geographic area, you are still entitled to care from your plan.
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Please visit the following website: MolinaHealthcare.com/Medicare for information on how to obtain needed care during a disaster. Generally, if you cannot use a network provider during a disaster, your plan will allow you to obtain care from out-of-network providers at in-network cost sharing. If you cannot use a network pharmacy during a disaster, you may be able to fill your prescription drugs at an out-of-network pharmacy. Please see Chapter 5, Section 2.5 for more information.
SECTION 4 What if you are billed directly for the full cost of your covered services?
Section 4.1 You can ask us to pay for covered services
If you have paid for your covered services, or if you have received a bill for covered medical services, go to Chapter 7 (Asking us to pay a bill you have received for covered medical services or drugs) for information about what to do.
Section 4.2 What should you do if services are not covered by our plan?
Molina Medicare Complete Care (HMO SNP) covers all medical services that are medically necessary, these services are listed in the plan's Benefits Chart (this chart is in Chapter 4 of this booklet), and are obtained consistent with plan rules. You are responsible for paying the full cost of services that aren't covered by our plan, either because they are not plan covered services, or they were obtained out-of-network and were not authorized. If you have any questions about whether we will pay for any medical service or care that you are considering, you have the right to ask us whether we will cover it before you get it. You also have the right to ask for this in writing. If we say we will not cover your services, you have the right to appeal our decision not to cover your care. Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) has more information about what to do if you want a coverage decision from us or want to appeal a decision we have already made. You may also call Member Services to get more information (phone numbers are printed on the back cover of this booklet). For covered services that have a benefit limitation, you pay the full cost of any services you get after you have used up your benefit for that type of covered service. If you pay for costs once a benefit limit has been reached, these costs will not count towards your out-of-pocket maximum. You can call Member Services when you want to know how much of your benefit limit you have already used.
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SECTION 5 How are your medical services covered when you are in a "clinical research study"?
Section 5.1 What is a "clinical research study"?
A clinical research study (also called a "clinical trial") is a way that doctors and scientists test new types of medical care, like how well a new cancer drug works. They test new medical care procedures or drugs by asking for volunteers to help with the study. This kind of study is one of the final stages of a research process that helps doctors and scientists see if a new approach works and if it is safe.
Not all clinical research studies are open to members of our plan. Medicare or our plan first needs to approve the research study. If you participate in a study that Medicare or our plan has not approved, you will be responsible for paying all costs for your participation in the study.
Once Medicare or our plan approves the study, someone who works on the study will contact you to explain more about the study and see if you meet the requirements set by the scientists who are running the study. You can participate in the study as long as you meet the requirements for the study and you have a full understanding and acceptance of what is involved if you participate in the study.
If you participate in a Medicare-approved study, Original Medicare pays most of the costs for the covered services you receive as part of the study. When you are in a clinical research study, you may stay enrolled in our plan and continue to get the rest of your care (the care that is not related to the study) through our plan.
If you want to participate in a Medicare-approved clinical research study, you do not need to get approval from us or your PCP. The providers that deliver your care as part of the clinical research study do not need to be part of our plan's network of providers.
Although you do not need to get our plan's permission to be in a clinical research study, you do need to tell us before you start participating in a clinical research study.
If you plan on participating in a clinical research study, contact Member Services (phone numbers are printed on the back cover of this booklet) to let them know that you will be participating in a clinical trial and to find out more specific details about what your plan will pay.
Section 5.2 When you participate in a clinical research study, who pays for what?
Once you join a Medicare-approved clinical research study, you are covered for routine items and services you receive as part of the study, including:
1 Room and board for a hospital stay that Medicare would pay for even if you weren't in a study 1 An operation or other medical procedure if it is part of the research study 1 Treatment of side effects and complications of the new care
Original Medicare pays most of the cost of the covered services you receive as part of the study. After Medicare has paid its share of the cost for these services, our plan will pay the rest. Like for all covered services, you will pay nothing for the covered services you get in the clinical research study.
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When you are part of a clinical research study, neither Medicare nor our plan will pay for any of the following: 1 Generally, Medicare will not pay for the new item or service that the study is testing unless Medicare would cover the item or service even if you were not in a study. 1 Items and services the study gives you or any participant for free 1 Items or services provided only to collect data, and not used in your direct health care. For example, Medicare would not pay for monthly CT scans done as part of the study if your medical condition would normally require only one CT scan.
Do you want to know more? You can get more information about joining a clinical research study by reading the publication "Medicare and Clinical Research Studies" on the Medicare website (www.medicare.gov). You can also call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
SECTION 6 Rules for getting care covered in a "religious non-medical health care institution"
Section 6.1 What is a religious non-medical health care institution?
A religious non-medical health care institution is a facility that provides care for a condition that would ordinarily be treated in a hospital or skilled nursing facility. If getting care in a hospital or a skilled nursing facility is against a member's religious beliefs, we will instead provide coverage for care in a religious non-medical health care institution. You may choose to pursue medical care at any time for any reason. This benefit is provided only for Part A inpatient services (non-medical health care services). Medicare will only pay for non-medical health care services provided by religious non-medical health care institutions.
Section 6.2 Receiving Care From a Religious Non-Medical Health Care Institution
To get care from a religious non-medical health care institution, you must sign a legal document that says you are conscientiously opposed to getting medical treatment that is "non-excepted."
1 "Non-excepted" medical care or treatment is any medical care or treatment that is voluntary and not required by any federal, state, or local law.
1 "Excepted" medical treatment is medical care or treatment that you get that is not voluntary or is required under federal, state, or local law.
To be covered by our plan, the care you get from a religious non-medical health care institution must meet the following conditions:
1 The facility providing the care must be certified by Medicare. 1 Our plan's coverage of services you receive is limited to non-religious aspects of care. 1 If you get services from this institution that are provided to you in a facility, the following conditions apply:
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4 You must have a medical condition that would allow you to receive covered services for inpatient hospital care or skilled nursing facility care.
4 and You must get approval in advance from our plan before you are admitted to the facility or your stay will not be covered.
4 and Medicare Inpatient Hospital coverage limits may apply (refer to the benefit in Chapter 4).
Additionally, you should contact Member Services (the contact information is located on the back cover of this booklet) or your State Medicaid office (the contact information is listed in Chapter 2, Section 6) for more information on Medicaid-covered services to understand all your coverage options.
SECTION 7 Rules for ownership of durable medical equipment
Section 7.1
Will you own the durable medical equipment after making a certain number of payments under our plan?
Durable medical equipment (DME) includes items such as oxygen equipment and supplies, wheelchairs, walkers, powered mattress systems, crutches, diabetic supplies, speech generating devices, IV infusion pumps, nebulizers, and hospital beds ordered by a provider for use in the home. The member always owns certain items, such as prosthetics. In this section, we discuss other types of DME that you must rent.
In Original Medicare, people who rent certain types of DME own the equipment after paying copayments for the item for 13 months. As a member of Molina Medicare Complete Care (HMO SNP), however, you will not acquire ownership of rented DME items no matter how many copayments you make for the item while a member of our plan. Under certain limited circumstances we will transfer ownership of the DME item to you. Call Member Services (phone numbers are printed on the back cover of this booklet) to find out about the requirements you must meet and the documentation you need to provide.
What happens to payments you made for durable medical equipment if you switch to Original Medicare?
If you did not acquire ownership of the DME item while in our plan, you will have to make 13 new consecutive payments after you switch to Original Medicare in order to own the item. Payments you made while in our plan do not count toward these 13 consecutive payments.
If you made fewer than 13 payments for the DME item under Original Medicare before you joined our plan, your previous payments also do not count toward the 13 consecutive payments. You will have to make 13 new consecutive payments after you return to Original Medicare in order to own the item. There are no exceptions to this case when you return to Original Medicare.
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Chapter 3. Using the plan's coverage for your medical and other covered services
SECTION 8 Rules for Oxygen Equipment, Supplies, and Maintenance
Section 8.1 What oxygen benefits are you entitled to?
If you qualify for Medicare oxygen equipment coverage, then for as long as you are enrolled, Molina Medicare Complete Care (HMO SNP) will cover:
1 Rental of oxygen equipment 1 Delivery of oxygen and oxygen contents 1 Tubing and related oxygen accessories for the delivery of oxygen and oxygen contents 1 Maintenance and repairs of oxygen equipment If you leave Molina Medicare Complete Care (HMO SNP) or no longer medically require oxygen equipment, then the oxygen equipment must be returned to the owner.
Section 8.2 What is your cost sharing? Will it change after 36 months?
Your cost sharing for Medicare oxygen equipment coverage is $0 for Medicare-covered DME and related supplies. Your cost sharing will not change after being enrolled for 36 months in Molina Medicare Complete Care (HMO SNP).
Section 8.3 What happens if you leave your plan and return to Original Medicare?
If you return to Original Medicare, then you start a new 36-month cycle which renews every five years. For example, if you had paid rentals for oxygen equipment for 36 months prior to joining Molina Medicare Complete Care (HMO SNP), join Molina Medicare Complete Care (HMO SNP) for 12 months, and then return to Original Medicare, you will pay full cost sharing for oxygen equipment coverage. Similarly, if you made payments for 36 months while enrolled in Molina Medicare Complete Care (HMO SNP) and then return to Original Medicare, you will pay full cost sharing for oxygen equipment coverage.
CHAPTER 4
Benefits Chart (what is covered )
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Chapter 4. Benefits Chart (what is covered )
Chapter 4. Benefits Chart (what is covered )
SECTION 1 Understanding covered services ............................................................................. 51 Section 1.1 You pay nothing for your covered services .......................................................................... 51 Section 1.2 What is the most you will pay for Medicare Part A and Part B covered medical services? ................................................................................................................................ 51
SECTION 2 Use the Benefits Chart to find out what is covered for you .................................. 51 Section 2.1 Your medical benefits as a member of the plan .................................................................... 51
SECTION 3 What services are covered outside of Molina Medicare Complete Care (HMO SNP)? ..........................................................................................................................92
Section 3.1 Services not covered by Molina Medicare Complete Care (HMO SNP) ............................. 92
SECTION 4 What services are not covered by the plan? .......................................................... 93 Section 4.1 Services not covered by the plan (exclusions) OR Medicaid ................................................ 93
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Chapter 4. Benefits Chart (what is covered )
SECTION 1 Understanding covered services
This chapter focuses on what services are covered. It includes a Benefits Chart that lists your covered services as a member of Molina Medicare Complete Care (HMO SNP). Later in this chapter, you can find information about medical services that are not covered. It also explains limits on certain services.
Section 1.1 You pay nothing for your covered services
Because you get assistance from Medicaid, you pay nothing for your covered services as long as you follow the plans' rules for getting your care. (See Chapter 3 for more information about the plans' rules for getting your care.) If you receive Medicare cost sharing assistance under Medicaid, you pay nothing for your covered services as long as you follow the plan's rules for getting your care because you receive assistance from Medicaid with Medicare Part A and B cost sharing.
Section 1.2
What is the most you will pay for Medicare Part A and Part B covered medical services?
Note: Because our members also get assistance from Medicaid, very few members ever reach this out-of-pocket maximum. If you are eligible for Medicare cost sharing assistance under Medicaid, you are not responsible for paying any out-of-pocket costs toward the maximum out-of-pocket amount for covered Part A and Part B services.
Because you are enrolled in a Medicare Advantage Plan, there is a limit to how much you have to pay out-of-pocket each year for medical services that are covered under Medicare Part A and Part B (see the Medical Benefits Chart in Section 2, below). This limit is called the maximum out-of-pocket amount for medical services.
As a member of Molina Medicare Complete Care (HMO SNP), the most you will have to pay out-of-pocket for Part A and Part B services in 2021 is $4,500. The amounts you pay for covered services count toward this maximum out-of-pocket amount. (The amounts you pay for Part D prescription drugs do not count toward your maximum out-of-pocket amount. In addition, amounts you pay for some services do not count toward your maximum out-of-pocket amount. These services are marked with an asterisk (*) in the Medical Benefits Chart.) If you reach the maximum out-of-pocket amount of $4,500, you will not have to pay any out-of-pocket costs for the rest of the year for covered Part A and Part B services. However, you must continue to pay the Medicare Part B premium (unless your Part B premium is paid for you by Medicaid or another third party).
SECTION 2 Use the Benefits Chart to find out what is covered for you
Section 2.1 Your medical benefits as a member of the plan
The Benefits Chart on the following pages lists the services Molina Medicare Complete Care (HMO SNP) covers and what you pay out-of-pocket for each service. The services listed in the Benefits Chart are covered only when the following coverage requirements are met:
1 Your Medicare covered services must be provided according to the coverage guidelines established by Medicare.
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Chapter 4. Benefits Chart (what is covered )
1 Your services (including medical care, services, supplies, and equipment) must be medically necessary. "Medically necessary" means that the services, supplies, or drugs are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice.
1 You receive your care from a network provider. In most cases, care you receive from an out-of-network provider will not be covered. Chapter 3 provides more information about requirements for using network providers and the situations when we will cover services from an out-of-network provider.
1 You have a primary care provider (a PCP) who is providing and overseeing your care. In most situations, your PCP must give you approval in advance before you can see other providers in the plan's network. This is called giving you a "referral." Chapter 3 provides more information about getting a referral and the situations when you do not need a referral.
1 Some of the services listed in the Benefits Chart are covered only if your doctor or other network provider gets approval in advance (sometimes called "prior authorization") from us. Covered services that need approval in advance are marked in the Benefits Chart by a + sign.
Other important things to know about our coverage:
1 You are covered by both Medicare and Medicaid. Medicare covers health care and prescription drugs. Medicaid covers your cost sharing for Medicare services, including inpatient hospital services and outpatient hospital services. Medicaid also covers services Medicare does not cover, like family planning services.
1 Like all Medicare health plans, we cover everything that Original Medicare covers. (If you want to know more about the coverage and costs of Original Medicare, look in your Medicare & You 2021 Handbook. View it online at www.medicare.gov or ask for a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.)
1 For all preventive services that are covered at no cost under Original Medicare, we also cover the service at no cost to you.
1 Sometimes, Medicare adds coverage under Original Medicare for new services during the year. If Medicare adds coverage for any services during 2021, either Medicare or our plan will cover those services.
1 If you are within our plan's six (6)-month period of deemed continued eligibility, we will continue to provide all appropriate Medicare Advantage plan covered benefits. However, during this period, Molina Medicare offers a six (6) month Loss of Medicaid (LOM) grace period allowing Members adequate time to reapply for Medicaid and become reinstated if they still qualify. During the LOM grace period the Member is kept whole and their Part C cost share and Part D low-income cost share (LICS)/Low-income premium subsidy (LIPS) remain as though they had no change. Medicare cost sharing amounts for Medicare basic and supplemental benefits do not change during this period.
You do not pay anything for the services listed in the Benefits Chart, as long as you meet the coverage requirements described above.
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Chapter 4. Benefits Chart (what is covered )
You will see this apple next to the preventive services in the benefits chart.
Benefits Chart
Services that are covered for you
What you must pay when you get these services
Abdominal aortic aneurysm screening *
There is no coinsurance,
A one-time screening ultrasound for people at risk. The plan only covers this copayment, or deductible for
screening if you have certain risk factors and if you get a referral for it from members eligible for this
your physician, physician assistant, nurse practitioner, or clinical nurse preventive screening.
specialist.
Acupuncture for chronic low back pain
Covered services include: Up to 12 visits in 90 days are covered for Medicare beneficiaries under the following circumstances: For the purpose of this benefit, chronic low back pain is defined as:
You pay $0 for each Medicare-covered treatment.
1 Lasting 12 weeks or longer;
1 nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease);
1 not associated with surgery; and
1 not associated with pregnancy.
An additional eight sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually.
Treatment must be discontinued if the patient is not improving or is regressing.
Ambulance services +
1 Covered ambulance services include fixed wing, rotary wing, and ground You pay $0 for each
ambulance services, to the nearest appropriate facility that can provide Medicare-covered one-way
care if they are furnished to a member whose medical condition is such ambulance trip.
that other means of transportation could endanger the person's health or Prior authorization is only
if authorized by the plan.
required for non-emergent
1 Non-emergency transportation by ambulance is appropriate if it is
ambulance transport.
documented that the member's condition is such that other means of If you need emergency care, dial transportation could endanger the person's health and that transportation 911 and request an ambulance. by ambulance is medically required.
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Chapter 4. Benefits Chart (what is covered )
Services that are covered for you
What you must pay when you get these services
Refer to "Worldwide emergency/ urgent coverage" in this chart if you need emergency ambulance transport outside the U.S.
Annual physical exam (Supplemental) *
You pay $0 for these services.
The annual routine physical exam provides coverage for additional physical If additional services are required,
examination services that can only be rendered by a physician, nurse
your provider will refer you to a
practitioner, or physician assistant. This is a great opportunity to focus
specialist or submit a prior
attention on prevention and screening. During a routine physical examination, authorization if needed.
the clinician will examine you to identify problems through visual inspection,
palpation, auscultation, and percussion. The last three of these involve direct
physical contact and are necessary to identify the presence (or absence) of
a physical condition.
Annual wellness visit *
There is no coinsurance,
If you've had Part B for longer than 12 months, you can get an annual
copayment, or deductible for the
wellness visit to develop or update a personalized prevention plan based on annual wellness visit.
your current health and risk factors. This is covered once every 12 months.
Note: Your first annual wellness visit can't take place within 12 months of your "Welcome to Medicare" preventive visit. However, you don't need to have had a "Welcome to Medicare" visit to be covered for annual wellness visits after you've had Part B for 12 months.
Bone mass measurement *
There is no coinsurance,
For qualified individuals (generally, this means people at risk of losing bone copayment, or deductible for
mass or at risk of osteoporosis), the following services are covered every 24 Medicare-covered bone mass
months or more frequently if medically necessary: procedures to identify measurement.
bone mass, detect bone loss, or determine bone quality, including a
physician's interpretation of the results.
Breast cancer screening (mammograms) * Covered services include: 1 One baseline mammogram between the ages of 35 and 39
There is no coinsurance, copayment, or deductible for covered screening mammograms.
1 One screening mammogram every 12 months for women age 40 and older
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Chapter 4. Benefits Chart (what is covered )
Services that are covered for you
What you must pay when you get these services
1 Clinical breast exams once every 24 months
A screening mammography is used for the early detection of breast cancer. Once a history of breast cancer has been established, and until there are no longer any signs or symptoms of breast cancer, ongoing mammograms are considered diagnostic and are covered under "Outpatient diagnostic tests and therapeutic services and supplies" in this chart. The screening mammography annual benefit is not available for members who have signs or symptoms of breast cancer.
Cardiac rehabilitation services +
Comprehensive programs of cardiac rehabilitation services that include exercise, education, and counseling are covered for members who meet certain conditions with a doctor's order. The plan also covers intensive cardiac rehabilitation programs that are typically more rigorous or more intense than cardiac rehabilitation programs.
You pay $0 per visit for Medicare-covered cardiac (heart) rehab services in a primary care setting like your doctor's office.
Your outpatient hospital cost share applies if these programs are provided in a hospital outpatient setting. Refer to "Outpatient hospital services" in the chart to learn more.
Plan maximum applies:
1 Up to 36 sessions over 36 weeks.
1 No more than 2 one-hour sessions per day.
Cardiovascular disease risk reduction visit (therapy for cardiovascular disease) *
There is no coinsurance, copayment, or deductible for the
We cover one visit per year with your primary care doctor to help lower your intensive behavioral therapy
risk for cardiovascular disease. During this visit, your doctor may discuss cardiovascular disease preventive
aspirin use (if appropriate), check your blood pressure, and give you tips to benefit.
make sure you're eating healthy.
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Chapter 4. Benefits Chart (what is covered )
Services that are covered for you
What you must pay when you get these services
Cardiovascular disease testing *
There is no coinsurance,
Blood tests for the detection of cardiovascular disease (or abnormalities copayment, or deductible for
associated with an elevated risk of cardiovascular disease) once every 5 years cardiovascular disease testing that
(60 months).
is covered once every 5 years.
Cervical and vaginal cancer screening *
Covered services include:
1 For all women: Pap tests and pelvic exams are covered once every 24 months
1 If you are at high risk of cervical or vaginal cancer or you are of childbearing age and have had an abnormal Pap test within the past 3 years: one Pap test every 12 months
There is no coinsurance, copayment, or deductible for Medicare-covered preventive Pap and pelvic exams.
Chiropractic services (Medicare-covered)
Covered services include:
You pay $0 per visit for these
1 We only cover manual manipulation of the spine to correct subluxation. Medicare-covered services.
Colorectal cancer screening * For people 50 and older, the following are covered: 1 Flexible sigmoidoscopy (or screening barium enema as an alternative)
every 48 months One of the following every 12 months: 1 Guaiac-based fecal occult blood test (gFOBT) 1 Fecal immunochemical test (FIT) DNA based colorectal screening every 3 years For people at high risk of colorectal cancer, we cover: 1 Screening colonoscopy (or screening barium enema as an alternative)
every 24 months For people not at high risk of colorectal cancer, we cover: 1 Screening colonoscopy every 10 years (120 months), but not within 48
months of a screening sigmoidoscopy
There is no coinsurance, copayment, or deductible for a Medicare-covered colorectal cancer screening exam.
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Chapter 4. Benefits Chart (what is covered )
Services that are covered for you
What you must pay when you get these services
Dental services (Medicare-covered) +
You pay $0 for these
In general, preventive dental services (such as cleaning, routine dental exams, Medicare-covered dental services.
and dental x-rays) are not covered by Original Medicare.
We cover:
Additional dental benefits that Original Medicare does not cover. These benefits are detailed separately below under the Dental services (Supplemental) category.
Dental services (Supplemental) * +
You pay $0 for these services.
We offer additional dental benefits that include dental services such as
Not all dental procedures
cleanings, fillings, and dentures.
recommended by a dentist may
You have a $2,000 maximum allowance each calendar year for all supplemental comprehensive dental services, including dentures.
be covered. Have the dentist tell you what the plan will pay and what you will have to pay out-of-
The annual maximum allowance does not apply towards your supplemental pocket.
preventive dental services.
You may be responsible for costs
Only the services listed below are covered and each service has a specific if a service is not covered or if
limit (e.g., maximum allowance, number of procedures, and/or frequency of you exceed your maximum
services).
allowance.
1 Oral Exams
Services are only available when
4 Up to 2 every calendar year; either D0120, D0150 or D0180. D0150 provided by contracted
and D0180 allowed once per provider per lifetime.
in-network dentists. If you receive
care from an out-of-network
1 Dental X-Rays
dental provider you must pay for
4 Up to 4 sets every calendar year; either D0272 or D0274.
your own care.
4 Up to 6 periapicals every calendar year (D0220, D0230). 4 D0330 is allowed once every 5 calendar years. If you get a full
mouth x-ray (D0330) you cannot get bitewing x-rays (D0272 or D0274) within the same calendar year. 1 Prophylaxis (Cleanings) 4 Up to 2 every calendar year (D1110). 1 Fluoride Treatment 4 Up to 2 every calendar year (D1206, D1208). 1 Periodontics (Deep Scaling)
To find an in-network dental provider close to you:
1 Call our Member Services Department, or
1 Search online using our supplemental dental provider online search tool at MolinaHealthcare.com/ Medicare
A referral from your Primary Care Physician (PCP) is not required for this benefit.
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Chapter 4. Benefits Chart (what is covered )
Services that are covered for you
What you must pay when you get these services
4 Up to 4 quadrants every 2 calendar years. Coverage includes any combination of D4341 or D4342.
1 Periodontics (Debridement)
4 Up to 1 every calendar year (D4355).
4 Up to 2 every calendar year (D4910).
1 Restorative Services (Fillings)
4 Up to 6 restorations or 12 surfaces every calendar year from any of the covered amalgam or resin-based restorative ADA codes (D2140-D2161, D2330-D2335, and D2391-D2394).
1 Extractions (Simple)
4 Up to 8 every calendar year (D7140).
1 Extractions (Surgical)
4 Up to 3 every calendar year (D7210-D7241).
1 Incision and Drainage
4 Up to 1 per tooth per lifetime; either D7510, D7511 or D7520, D7521.
1 Crowns and Crown Repair
4 Up to 2 every calendar year; once every 5 years per tooth (D2510-D2540, D2542-D2544, D2620, D2630, D2642-D2644, D2650-D2652, D2662-D2664, D2710-D2722, D2740, D2751, D2752, D2781-D2783, D2790-D2794, D2799, D2951-D2954, D2980).
1 Endodontics / Root Canals
4 Up to 1 per tooth, every calendar year (D3220, D3310-D3330, D3410, D3421, D3425, D3426).
1 Dentures
4 Up to 1 set of dentures (either full or partial) every 3 calendar years; up to the plan annual maximum coverage amount (D5110-D5140, D5211-D5214, D5225, D5226).
1 Denture Repairs and Adjustments
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Chapter 4. Benefits Chart (what is covered )
Services that are covered for you
What you must pay when you get these services
4 Up to 4 every calendar year (D5511, D5512, D5520, D5611, D5612, D5621, D5622, D5630, D5640, D5650, D5660, D5670, D5671, D5710, D5711, D5720, D5721, D5730, D5731, D5740, D5741, D5750, D5751, D5760, D5761).
1 Palliative Emergency Treatment
4 Up to 4 every calendar year (D9110).
1 Anesthesia (Deep Sedation and Intravenous)
4 Covered with oral surgery (D9222, D9223, D9239, D9243).
These codes may be updated by the American Dental Association (ADA) during the year. If you have a question about a dental ADA code, please call Member Services. Their phone number can be found on the back page of this booklet and on the back of your plan member ID card.
Some dental services require prior authorization. Your provider will handle any plan-required authorizations for you.
Depression screening *
There is no coinsurance,
We cover one screening for depression per year. The screening must be done copayment, or deductible for an
in a primary care setting that can provide follow-up treatment and/or referrals. annual depression screening visit.
Diabetes screening *
There is no coinsurance,
We cover this screening (includes fasting glucose tests) if you have any of copayment, or deductible for the
the following risk factors: high blood pressure (hypertension), history of Medicare-covered diabetes
abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a screening tests.
history of high blood sugar (glucose). Tests may also be covered if you meet
other requirements, like being overweight and having a family history of
diabetes.
Based on the results of these tests, you may be eligible for up to two diabetes screenings every 12 months.
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Chapter 4. Benefits Chart (what is covered )
Services that are covered for you
What you must pay when you get these services
Diabetes self-management training, diabetic services
and supplies * For all people who have diabetes (insulin and non-insulin users). Covered services include:
You pay $0 if you qualify for Medicare-covered:
1 Diabetic therapeutic shoes or inserts.
1 Supplies to monitor your blood glucose: Blood glucose monitor, blood 1 Diabetes self-management
glucose test strips, lancet devices and lancets, and glucose-control
training.
solutions for checking the accuracy of test strips and monitors. +
You pay $0 for covered diabetic
4 Blood glucose (sugar) monitors
supplies.
- Covered when your doctor prescribes for use in your home. Supplies are covered when you
- Preferred brand blood glucose monitors do not require prior have a prescription and fill it at a
authorization.
network retail pharmacy or
4 Blood glucose (sugar) test strips
through the Mail Service Pharmacy program.
- Preferred brand blood glucose test strips do not require prior Your Medicare Part D deductible
authorization.
and cost share may apply for
- May be limited to a 30-day supply per fill.
diabetic supplies covered under
4 Insulin
your Medicare Part D coverage. See "Medicare Part D" in this
- Not covered under Medicare Part B. May be covered under booklet.
Medicare Part D.
Cost-share may apply to an
- If you use an external insulin pump, insulin and the pump may insulin pump under your durable
be covered as durable medical equipment (DME). However, medical equipment benefit. See
suppliers of insulin pumps might not provide insulin.
"Durable medical equipment
4 Glucose control solutions for checking the accuracy of test strips (DME) and related supplies" in
and monitors.
this chart.
1 For people with diabetes who have severe diabetic foot disease: One See "Vision care" in this chart for pair per calendar year of therapeutic custom-molded shoes (including doctor's services if you need an inserts provided with such shoes) and two additional pairs of inserts, eye exam for diabetic retinopathy or one pair of depth shoes and three pairs of inserts (not including the or a glaucoma screening.
non-customized removable inserts provided with such shoes). Coverage See "Podiatry services" in this
includes fitting. +
chart if you are diabetic and need
1 Diabetes self-management training is covered under certain
to see a doctor for a foot exam.
conditions.+
See "Medical nutrition therapy"
1 Medicare-covered diabetic services include: 4 Yearly eye exam and glaucoma tests
in this chart if you are diabetic and need medical nutrition therapy services (MNT).
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Chapter 4. Benefits Chart (what is covered )
Services that are covered for you
What you must pay when you get these services
4 Foot exams
4 Medical nutrition therapy services (MNT) +
We cover diabetic supplies from a preferred manufacturer without a prior authorization. We will cover other brands if you get a prior authorization from us.
Durable medical equipment (DME) and related supplies +
(For a definition of "durable medical equipment," see Chapter 12 of this You pay $0 for Medicare-covered
booklet.)
DME and related supplies.
Covered items include, but are not limited to: wheelchairs, crutches, powered Your cost share may be less if mattress systems, diabetic supplies, hospital beds ordered by a provider for you go to a preferred provider. use in the home, IV infusion pumps, speech generating devices, oxygen equipment, nebulizers, and walkers.
We cover all medically necessary DME covered by Original Medicare. If our supplier in your area does not carry a particular brand or manufacturer, you may ask them if they can special order it for you. The most recent list of suppliers is available on our website at MolinaHealthcare.com/Medicare.
Emergency care
Emergency care refers to services that are:
You pay $0 for each
1 Furnished by a provider qualified to furnish emergency services, and
Medicare-covered emergency room visit.
1 Needed to evaluate or stabilize an emergency medical condition.
If you are admitted to a hospital,
A medical emergency is when you, or any other prudent layperson with an you will pay cost sharing as
average knowledge of health and medicine, believe that you have medical described in "Inpatient hospital
symptoms that require immediate medical attention to prevent loss of life, care" in this chart.
loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.
Your cost share is the same for in-network or out-of-network emergency services.
Cost sharing for necessary emergency services furnished out-of-network is the same as for such services furnished in-network.
If you receive emergency care at an out-of-network hospital and
As an added benefit, we offer up to $10,000 of worldwide emergency
need inpatient care after your
coverage each calendar year for emergency transportation, urgent care, emergency condition is stabilized,
emergency care, and post-stabilization care.
you must return to a network
hospital in order for your care to
continue to be covered OR you
must have your inpatient care at
the out-of-network hospital
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Chapter 4. Benefits Chart (what is covered )
Services that are covered for you
What you must pay when you get these services
authorized by the plan. Your out-of-pocket cost is the highest cost sharing you would pay at a network hospital.
Emergency care outside of the United States (U.S.) may be considered an emergency and covered under the worldwide emergency/urgent coverage benefit. See "Worldwide emergency/urgent care coverage" in this chart to learn more.
Fitness benefit (Supplemental) *
We provide a membership in participating fitness centers, and the home fitness program for members who are unable to visit a fitness center or prefer to work out from home, through the Silver&Fit® Healthy Aging and Exercise program.
If you choose to workout at a participating fitness center, you can register through the SilverandFit.com website or at the participating fitness center.
If you choose to workout at a participating fitness center and you have a caregiver, you can bring them with you to help you use the fitness center's services and equipment.
You pay $0 for these services.
No referral or prior authorization is required to use this benefit.
Always talk to your doctor before starting or changing your exercise routine.
If you choose to workout using the Home Fitness program, you can pick up to 2 Home Fitness Kits and 1 Stay Fit Kit from a selection of kits each calendar year to keep active in the comfort of your home.
No matter your choice, as a Silver&Fit member you will also have access to 1,500+ digital workout videos on the Silver&Fit website and the Silver&Fit ASHConnectTM mobile app. Enjoy daily workout classes on Facebook Live and the Silver&Fit YouTube channel. Additional digital resources, such as Healthy Aging classes, a quarterly newsletter, and rewards for reaching new milestones. You may also have access to telephonic coaching.
Participating fitness centers may also offer low-impact classes focused on improving and increasing muscular strength and endurance, mobility, flexibility, range of motion, balance, agility, and coordination.
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Chapter 4. Benefits Chart (what is covered )
Services that are covered for you
What you must pay when you get these services
Enrollment Options:
1 Go to SilverandFit.com and register to use the website. After registering, you can browse the library of online fitness classes, locate a nearby fitness center, or enroll into the Home Fitness program.
1 You can also call toll-free (877) 427-4711 (TTY/TDD: 711), Monday to Friday, 5 a.m. to 6 p.m. (Pacific Time) excluding holidays to find a participating fitness center or to enroll in the Home Fitness program.
*Non-standard services that call for an added fee are not part of the Silver&Fit program and will not be reimbursed. The Silver&Fit program is provided by American Specialty Health Fitness, Inc., a subsidiary of American Specialty Health Incorporated (ASH). Silver&Fit and ASHConnect are trademarks of ASH and used with permission herein. Kits are subject to change. Other names or logos may be trademarks of their respective owners. Participating fitness centers and fitness chains may vary by location and are subject to change.
Health and wellness education programs * Health Management Programs
You pay $0 for these services.
We have programs available to help you manage a diagnosed health condition. Programs include:
1 Asthma management.
1 Depression management.
1 Diabetes management.
1 High blood pressure management.
1 Cardiovascular Disease (CVD) management.
1 Chronic Obstructive Pulmonary Disease (COPD) management.
1 Pregnancy program.
Learning materials and care tips are available. We can also help you work with your provider.
Enrollment in Health Management Programs:
1 You are automatically enrolled into the program(s) that best meets your needs based on medical or pharmacy claims data.
1 You can also enroll through your provider or self-refer.
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Services that are covered for you
What you must pay when you get these services
There are certain requirements that you must meet to enroll.
Disenrollment from Health Management Programs:
1 These programs are voluntary, and you can choose to be removed from a program at any time.
You can learn more or enroll in any of the programs above by calling our Health Management Department at (866) 891-2320 (TTY: 711), Monday to Friday, 6 a.m. to 6 p.m. (Pacific Standard Time).
Health Promotion Programs
Other programs designed to enrich your health and lifestyle are also available, such as:
1 A smoking cessation program.
1 A weight control program.
For information and/or materials for smoking cessation or weight control call (866) 472-9483 (TTY/TDD: 711), Monday to Friday, 6 a.m. to 6 p.m. (Pacific Standard Time).
Nutritional / Dietary Counseling
See the "Nutrition counseling (Supplemental)" benefit in this chart.
Nurse Advice Line
Whether you have an immediate health concern, questions about a medical condition, or would like general information about available health resources the nurse advice line is available 24 hours a day, 7 days a week.
The toll-free Nurse Advice Line phone number is:
(888) 275-8750, (TTY/TDD: 711)
A registered nurse will help you determine if you can manage your care at home or need the attention of a medical professional.
Call anytime, day or night, to speak with a registered nurse about illnesses or injuries.
1 No referral or prior authorization is needed
This service isn't intended for emergencies. In case of an emergency, dial 911 immediately.
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Chapter 4. Benefits Chart (what is covered )
Services that are covered for you
What you must pay when you get these services
Hearing services (Medicare-covered)
Diagnostic hearing and balance evaluations performed by your provider to You pay $0 for Medicare-covered determine if you need medical treatment are covered as outpatient care when hearing services. furnished by a physician, audiologist, or other qualified provider.
Medicare-covered diagnostic hearing and balance exams help determine whether or not you need medical treatment.
The exam is based on a medical need only, such as a loss of hearing due to illness, disease, injury, or surgery.
Hearing services (Supplemental) *
In addition to the Medicare-covered hearing services, you can get a routine You pay $0 for a routine hearing
hearing test once every calendar year.
test.
After the routine hearing test, you may be fitted for a hearing aid.
If you need a hearing aid, You
1 fitting / evaluation for hearing aids can be done once every 2 calendar pay $0 for a fitting / evaluation
years.
for hearing aids and $0 for
preselected hearing aids from a
If you are told you need hearing aids, you can get up to 2 pre-selected hearing plan approved provider.
aids from a plan-approved provider every 2 calendar years for both ears
combined. +
HIV screening * For people who ask for an HIV screening test or who are at increased risk for HIV infection, we cover: 1 One screening exam every 12 months For women who are pregnant, we cover: 1 Up to three screening exams during a pregnancy
There is no coinsurance, copayment, or deductible for members eligible for Medicare-covered preventive HIV screening.
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What you must pay when you get these services
Home health agency care +
Prior to receiving home health services, a doctor must certify that you need You pay $0 for these services.
home health services and will order home health services to be provided by See "Durable medical equipment
a home health agency. You must be homebound, which means leaving home and related supplies" in this chart
is a major effort.
for cost share related to
Covered services include, but are not limited to:
medically-necessary medical
1 Part-time or intermittent skilled nursing and home health aide services equipment and supplies covered (To be covered under the home health care benefit, your skilled nursing by Original Medicare.
and home health aide services combined must total fewer than 8 hours
per day and 35 hours per week)
1 Physical therapy, occupational therapy, and speech therapy
1 Medical and social services
1 Medical equipment and supplies
Home infusion therapy
Home infusion therapy involves the intravenous or subcutaneous
You pay $0 for Medicare-covered
administration of drugs or biologicals to an individual at home. The
Home infusion therapy.
components needed to perform home infusion include the drug (for example,
antivirals, immune globulin), equipment (for example, a pump), and supplies
(for example, tubing and catheters). Covered services include, but are not
limited to:
1 Professional services, including nursing services, furnished in accordance with the plan of care
1 Patient training and education not otherwise covered under the durable medical equipment benefit
1 Remote monitoring
1 Monitoring services for the provision of home infusion therapy and home infusion drugs furnished by a qualified home infusion therapy supplier
Hospice care *
You may receive care from any Medicare-certified hospice program. You When you enroll in a are eligible for the hospice benefit when your doctor and the hospice medical Medicare-certified hospice director have given you a terminal prognosis certifying that you're terminally program, your hospice services ill and have 6 months or less to live if your illness runs its normal course. and your Part A and Part B
services related to your terminal
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What you must pay when you get these services
Your hospice doctor can be a network provider or an out-of-network provider. prognosis are paid for by Original
Covered services include:
Medicare, not Molina Medicare
1 Drugs for symptom control and pain relief
Complete Care (HMO SNP).
1 Short-term respite care
1 Home care
For hospice services and for services that are covered by Medicare Part A or B and are related to your terminal prognosis: Original Medicare (rather than our plan) will pay for your hospice services related to your terminal prognosis. While you are in the hospice program, your hospice provider will bill Original Medicare for the services that Original Medicare pays for.
For services that are covered by Medicare Part A or B and are not related to your terminal prognosis: If you need non-emergency, non-urgently needed services that are covered under Medicare Part A or B and that are not related to your terminal prognosis, your cost for these services depends on whether you use a provider in our plan's network:
1 If you obtain the covered services from a network provider, you only pay the plan cost sharing amount for in-network services
1 If you obtain the covered services from an out-of-network provider, you pay the cost sharing under Fee-for-Service Medicare (Original Medicare)
For services that are covered by Molina Medicare Complete Care (HMO SNP) but are not covered by Medicare Part A or B: Molina Medicare Complete Care (HMO SNP) will continue to cover plan-covered services that are not covered under Part A or B whether or not they are related to your terminal prognosis. You pay your plan cost sharing amount for these services.
For drugs that may be covered by the plan's Part D benefit: Drugs are never covered by both hospice and our plan at the same time. For more information, please see Chapter 5, Section 9.4 (What if you're in Medicare-certified hospice).
Note: If you need non-hospice care (care that is not related to your terminal prognosis), you should contact us to arrange the services.
Our plan covers hospice consultation services (one time only) for a terminally ill member who hasn't elected the hospice benefit.
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Chapter 4. Benefits Chart (what is covered )
Services that are covered for you
What you must pay when you get these services
Immunizations *
There is no coinsurance,
Covered Medicare Part B services include:
copayment, or deductible for the
1 Pneumonia vaccine
pneumonia, influenza, and Hepatitis B vaccines.
1 Flu shots, once each flu season in the fall and winter, with additional flu
shots if medically necessary
1 Hepatitis B vaccine if you are at high or intermediate risk of getting Hepatitis B
1 Other vaccines if you are at risk and they meet Medicare Part B coverage rules
We also cover some vaccines under our Part D prescription drug benefit. See Chapter 6 for more information about coverage and applicable cost sharing.
Inpatient hospital care +
Includes inpatient acute, inpatient rehabilitation, long-term care hospitals Each benefit period you pay:
and other types of inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor's order. The day before you are discharged is your last inpatient day.
1 $0 for days 1 to 90 and for each lifetime reserve day you elect to use after 90
Covered services include but are not limited to:
days
1 Semi-private room (or a private room if medically necessary) 1 Meals including special diets 1 Regular nursing services
1 All costs beyond your Medicare lifetime reserve days (up to 60 days over your lifetime)
1 Costs of special care units (such as intensive care or coronary care units) Medicare benefit periods apply.
1 Drugs and medications 1 Lab tests
A benefit period begins on the first day that you are admitted to a Medicare-covered inpatient
1 X-rays and other radiology services 1 Necessary surgical and medical supplies
hospital or SNF. The benefit period ends when you haven't received any inpatient hospital
1 Use of appliances, such as wheelchairs 1 Operating and recovery room costs
care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one
1 Physical, occupational, and speech language therapy
benefit period has ended, a new
1 Inpatient substance abuse services
benefit period begins. There is no limit to the number of benefit
periods you can have.
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What you must pay when you get these services
1 Under certain conditions, the following types of transplants are covered: If you are admitted at the end of
corneal, kidney, kidney-pancreatic, heart, liver, lung, heart/lung, bone the year but not discharged until
marrow, stem cell, and intestinal/multivisceral. If you need a transplant, the following year, your benefit
we will arrange to have your case reviewed by a Medicare-approved and cost share is based on the
transplant center that will decide whether you are a candidate for a
year that you were admitted.
transplant. Transplant providers may be local or outside of the service If you get authorized inpatient area. If our in-network transplant services are outside the community care at an out-of-network hospital pattern of care, you may choose to go locally as long as the local transplant after your emergency condition providers are willing to accept the Original Medicare rate. If Molina is stabilized, your cost is the Medicare Complete Care (HMO SNP) provides transplant services at a highest cost sharing you would location outside the pattern of care for transplants in your community and pay at a network hospital. you choose to obtain transplants at this distant location, we will arrange
or pay for appropriate lodging and transportation costs for you and a
companion.
1 Blood - Coverage of storage and administration begins with the first pint of blood that you need
1 Physician services
Note: To be an inpatient, your provider must write an order to admit you formally as an inpatient of the hospital. Even if you stay in the hospital overnight, you might still be considered an "outpatient." If you are not sure if you are an inpatient or an outpatient, you should ask the hospital staff.
You can also find more information in a Medicare fact sheet called "Are You a Hospital Inpatient or Outpatient? If You Have Medicare Ask!" This fact sheet is available on the Web at www.medicare.gov/sites/default/files/ 2018-09/11435-Are-You-an-Inpatient-or-Outpatient.pdf or by calling 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week.
Inpatient mental health care +
Covered services include mental health care services that require a hospital Each benefit period you pay:
stay.
1 $0 for days 1 to 90 and for
1 You can get these services either in a general hospital or a psychiatric
each lifetime reserve day
hospital that only cares for people with mental health conditions.
you elect to use after 90
1 If you're in a psychiatric hospital (instead of a general hospital),
days
Medicare only pays for up to 190 days of inpatient psychiatric hospital 1 All costs beyond your
services during your lifetime.
Medicare lifetime reserve
days (up to 60 days over
your lifetime)
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What you must pay when you get these services
1 If you used part of your 190-day lifetime limit prior to enrolling in Medicare benefit periods apply.
our plan, then the number of covered lifetime hospital days is reduced A benefit period begins on the
by the number of inpatient days for mental health care treatment
first day that you are admitted to
previously covered by Medicare in a psychiatric hospital.
a Medicare-covered inpatient
1 The 190-day limit does not apply to mental health services provided hospital or SNF. The benefit
in a psychiatric unit of a general hospital.
period ends when you haven't
1 There's no limit to the number of benefit periods you can have when received any inpatient hospital
you get mental health care in a general hospital. You can also have care (or skilled care in a SNF) for
multiple benefit periods when you get care in a psychiatric hospital, 60 days in a row. If you go into a
but there's a lifetime limit of 190 days.
hospital or a SNF after one
benefit period has ended, a new
Medicare doesn't cover:
benefit period begins. There is no
1 Private duty nursing 1 A phone or television in your room 1 A private room (unless medically necessary)
limit to the number of benefit periods you can have.
If you are admitted at the end of the year but not discharged until
the following year, your benefit
and cost share is based on the
year that you were admitted.
If you get authorized inpatient care at an out-of-network hospital after your emergency condition is stabilized, your cost is the highest cost sharing you would pay at a network hospital.
Inpatient stay: Covered services received in a hospital or SNF during a See the benefit in this chart to
non-covered inpatient stay +
understand your cost share for:
If you have exhausted your inpatient benefits or if the inpatient stay is not reasonable and necessary, we will not cover your inpatient stay. However, in some cases, we will cover certain services you receive while you are in the hospital or the skilled nursing facility (SNF). Covered services include but are not limited to:
1 Physician services
1 "Physician/Practitioner services, including doctor's office visits"
1 "Outpatient diagnostic tests and therapeutic services and supplies"
1 Diagnostic tests (like lab tests)
1 X-ray, radium, and isotope therapy including technician materials and services
1 Surgical dressings
1 "Prosthetic devices and related supplies"
1 "Outpatient rehabilitation services"
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What you must pay when you get these services
1 Splints, casts and other devices used to reduce fractures and dislocations
1 Prosthetics and orthotics devices (other than dental) that replace all or part of an internal body organ (including contiguous tissue), or all or part of the function of a permanently inoperative or malfunctioning internal body organ, including replacement or repairs of such devices
1 Leg, arm, back, and neck braces, trusses, and artificial legs, arms, and eyes including adjustments, repairs, and replacements required because of breakage, wear, loss, or a change in the patient's physical condition
1 Physical therapy, speech therapy, and occupational therapy
Meal benefit (Supplemental) * +
This benefit is meant to keep you healthy and strong after an Inpatient
You pay $0 for these services.
Hospital or Skilled Nursing Facility (SNF) stay, or for a medical condition Plan maximum coverage of 4 or potential medical condition that requires you to remain at home for a weeks, and up to 56 meals every period of time. Your Case Manager or your doctor will decide if you are in calendar year applies. need of this benefit. Your doctor can request this benefit for you if you have
certain chronic conditions.
This benefit provides 2 meals a day for 14 days with a total of 28 meals delivered. Meal types will be based on any dietary needs you may have. You may also qualify for an additional 28 meals over 14 days with approval.
Your Case Manager will order your meals for you and they will be delivered to your home. The first delivery usually arrives within 72 hours (3 business days) of order processing. You will be contacted in advance of the delivery date(s).
Medical nutrition therapy *
There is no coinsurance,
This benefit is for people with diabetes, renal (kidney) disease (but not on copayment, or deductible for
dialysis), or after a kidney transplant when ordered by your doctor.
members eligible for
We cover 3 hours of one-on-one counseling services during your first year that you receive medical nutrition therapy services under Medicare (this
Medicare-covered medical nutrition therapy services.
includes our plan, any other Medicare Advantage plan, or Original Medicare),
and 2 hours each year after that. If your condition, treatment, or diagnosis
changes, you may be able to receive more hours of treatment with a
physician's order. A physician must prescribe these services and renew their
order yearly if your treatment is needed into the next calendar year.
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Services that are covered for you
What you must pay when you get these services
Medicare Diabetes Prevention Program (MDPP) *
There is no coinsurance,
MDPP services will be covered for eligible Medicare beneficiaries under all copayment, or deductible for the
Medicare health plans.
MDPP benefit.
MDPP is a structured health behavior change intervention that provides practical training in long-term dietary change, increased physical activity, and problem-solving strategies for overcoming challenges to sustaining weight loss and a healthy lifestyle.
Medicare Part B prescription drugs +
You pay $0 for each Medicare
These drugs are covered under Part B of Original Medicare. Members of our Part B prescription drug.
plan receive coverage for these drugs through our plan. Covered
You may pay cost sharing for the
drugs include:
administration of that drug
1 Drugs that usually aren't self-administered by the patient and are injected depending on where you receive
or infused while you are getting physician, hospital outpatient, or
drug administration or infusion
ambulatory surgical center services
services. Refer to the appropriate
benefit in this chart:
1 Drugs you take using durable medical equipment (such as nebulizers) that were authorized by the plan
1 "Physician/Practitioner services, including doctor's
1 Clotting factors you give yourself by injection if you have hemophilia
office visits"
1 Immunosuppressive drugs, if you were enrolled in Medicare Part A at the time of the organ transplant
1 "Outpatient hospital services"
1 Injectable osteoporosis drugs, if you are homebound, have a bone fracture that a doctor certifies was related to post-menopausal osteoporosis, and cannot self-administer the drug
1 Antigens
1 Certain oral anti-cancer drugs and anti-nausea drugs
1 Certain drugs for home dialysis, including heparin, the antidote for heparin when medically necessary, topical anesthetics, and erythropoiesis-stimulating agents (such as Procrit® and Epoetin Alfa)
1 Intravenous Immune Globulin for the home treatment of primary immune deficiency diseases
We also cover some vaccines under our Part B and Part D prescription drug benefit.
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Chapter 4. Benefits Chart (what is covered )
Services that are covered for you
What you must pay when you get these services
Chapter 5 explains the Part D prescription drug benefit, including rules you must follow to have prescriptions covered. What you pay for your Part D prescription drugs through our plan is explained in Chapter 6.
Nutrition counseling (Supplemental) *
You can get individual telephonic nutrition counseling upon request.
You pay $0 for these services.
Your provider will need to complete and sign a Health Education Referral Form so we have a clear understanding of your needs before we call you.
1 Telephonic intervention is 30 to 60 minutes in length.
1 You will be given contact information for further information and/or follow-up as needed or desired.
You also can get up to 12 individual in-person or group sessions every calendar year. Your provider will refer you to an in-network dietitian for these services.
If you also qualify for the Medicare-covered Medical Nutrition Therapy (MNT) benefit, your individual or group coverage under this benefit can be combined with your MNT coverage.
Obesity screening and therapy to promote sustained weight loss * There is no coinsurance, If you have a body mass index of 30 or more, we cover intensive counseling copayment, or deductible for to help you lose weight. This counseling is covered if you get it in a primary preventive obesity screening and care setting, where it can be coordinated with your comprehensive prevention therapy. plan. Talk to your primary care doctor or practitioner to find out more.
Opioid treatment program services +
Opioid use disorder treatment services are covered under Part B of Original You pay $0 for Medicare-covered
Medicare. Members of our plan receive coverage for these services through outpatient opioid treatment
our plan. Covered services include:
program services.
1 FDA-approved opioid agonist and antagonist treatment medications You may pay cost sharing for
and the dispensing and administration of such medications, if applicable opioid treatment medications and
1 Substance use counseling 1 Individual and group therapy
the dispensing and administration of such medications.
Prior authorization is not required
1 Toxicology testing
for Medicare-covered outpatient
opioid treatment program services
but may be needed if you require
opioid treatment medications.
Outpatient diagnostic tests and therapeutic services and supplies +
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Chapter 4. Benefits Chart (what is covered )
Services that are covered for you
What you must pay when you get these services
Covered services include, but are not limited to:
You pay $0 for Medicare-covered
1 X-rays
outpatient:
1 Radiation (radium and isotope) therapy including technician materials 1 X-ray services.
and supplies
1 Therapeutic radiological
1 Surgical supplies, such as dressings
services such as radiation (radium and isotope)
1 Splints, casts and other devices used to reduce fractures and
treatment for cancer
dislocations
including technical
Note: There is no separate charge for medical supplies routinely used in the
materials and supplies.
course of an office visit and included in the provider's charges for that visit (such as bandages, cotton swabs, and other routine supplies).
1 Medical and surgical supplies, splints, casts, and
However, supplies for which an appropriate separate charge is made by providers (such as, chemical agents used in certain diagnostic procedures) are subject to cost sharing as shown.
other devices used to reduce fractures and dislocations.
1 Laboratory tests
1 Blood - including storage and administration. Coverage begins with the first pint of blood that you need
1 Outpatient non-radiological diagnostic tests (such as EKGs, EEGs, and sleep studies).
1 Other outpatient diagnostic tests non-radiological diagnostic services such as EKGs, EEGs, pulmonary function tests, sleep studies, and treadmill stress tests.
1 Diagnostic radiological services both non-complex (ultrasound and x-rays with
1 Diagnostic radiological services (both complex and non-complex)
contrast) and complex (CT,
such as specialized scans, CT, SPECT, PET, MRI, MRA, nuclear
MRI, and PET scans).
studies, ultrasounds, diagnostic mammograms and interventional
1 Lab services.
radiological procedures (myelogram, cystogram, angiogram, and
barium studies).
1 Blood (including storage
and administration).
No authorization is required for outpatient lab services and outpatient X-ray
services.
Refer to "Outpatient hospital
services" in this chart if you need
these services in the outpatient
department of a hospital.
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Chapter 4. Benefits Chart (what is covered )
Services that are covered for you
What you must pay when you get these services
Outpatient hospital observation
Observation services are hospital outpatient services given to determine if You pay $0 for each day of
you need to be admitted as an inpatient or can be discharged.
outpatient hospital observation
For outpatient hospital observation services to be covered, they must meet services.
the Medicare criteria and be considered reasonable and necessary.
Unless your provider writes an
Observation services are covered only when provided by the order of a order to admit you as inpatient to
physician or another individual authorized by state licensure law and hospital the hospital you pay the cost
staff bylaws to admit patients to the hospital or order outpatient tests.
sharing amounts for outpatient
Note: Unless the provider has written an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost sharing amounts for outpatient hospital services. Even if you stay in the hospital overnight, you might still be considered an "outpatient." If you are not sure if you are an
hospital services or outpatient surgery. See these and other benefits in this chart for more information:
outpatient, you should ask the hospital staff.
1 "Outpatient hospital
You can also find more information in a Medicare fact sheet called "Are
services"
You a Hospital Inpatient or Outpatient? If You Have Medicare Ask!" This 1 "Outpatient surgery
fact sheet is available on the Web at www.medicare.gov/sites/default/files/
including services provided
2018-09/11435-Are-You-an-Inpatient-or-Outpatient.pdf or by calling
at hospital facilities and
1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. You
ambulatory surgical
can call these numbers for free, 24 hours a day, 7 days a week.
centers"
1 "Inpatient hospital care"
Outpatient hospital services +
We cover medically-necessary services you get in the outpatient department You pay $0 per event for
of a hospital for diagnosis or treatment of an illness or injury.
outpatient hospital services.
Covered services include, but are not limited to:
1 Services in an emergency department or outpatient clinic, such as observation services or outpatient surgery
1 Laboratory and diagnostic tests billed by the hospital
Outpatient hospital services are covered under other benefits in this chart. See these and other benefits when care is provided in an outpatient hospital setting:
1 Mental health care, including care in a partial-hospitalization program, if a doctor certifies that inpatient treatment would be required without it
1 X-rays and other radiology services billed by the hospital
1 "Emergency care"
1 "Worldwide emergency/ urgent coverage"
1 Medical supplies such as splints and casts 1 Certain drugs and biologicals that you can't give yourself
Note: Unless the provider has written an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost sharing amounts for
1 "Outpatient diagnostic tests and therapeutic services and supplies"
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Chapter 4. Benefits Chart (what is covered )
Services that are covered for you
What you must pay when you get these services
outpatient hospital services. Even if you stay in the hospital overnight, you might still be considered an "outpatient." If you are not sure if you are an outpatient, you should ask the hospital staff.
You can also find more information in a Medicare fact sheet called "Are You a Hospital Inpatient or Outpatient? If You Have Medicare Ask!" This fact sheet is available on the Web at www.medicare.gov/sites/default/files/ 2018-09/11435-Are-You-an-Inpatient-or-Outpatient.pdf or by calling 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week.
No authorization is required for outpatient lab services or outpatient x-ray services.
1 "Outpatient surgery provided at hospital outpatient facilities and ambulatory surgical centers"
1 "Partial hospitalization"
Outpatient mental health care
Covered services include:
You pay $0 per event for
Mental health services provided by a state-licensed psychiatrist or doctor, clinical psychologist, clinical social worker, clinical nurse specialist, nurse practitioner, physician assistant, or other Medicare-qualified mental health care professional as allowed under applicable state laws.
Your Medicare outpatient mental health care coverage includes:
1 One depression screening every calendar year. The screening must be done in a primary care doctor's office or primary care clinic that can provide follow-up treatment and referrals.
1 Individual and group psychotherapy with doctors or certain licensed professionals allowed by the state where you get these services.
non-physician outpatient mental health care and psychiatric services including monitoring drug therapy and individual or group therapy visits.
See "Depression screening" in this chart for your yearly depression screening.
See "Partial hospitalization" in this chart if you need this Medicare-covered outpatient
1 Family counseling, if the main purpose is to help with your treatment. mental health care treatment.
1 Testing to find out if you're getting the services you need and if your current treatment is helping you.
1 Psychiatric evaluation.
1 Medication management.
Outpatient rehabilitation services +
Covered services include: physical therapy, occupational therapy, and
You pay $0 for each
speech-language therapy.
medically-necessary outpatient
Outpatient rehabilitation services are provided in various outpatient settings, physical therapy (PT),
such as hospital outpatient departments, independent therapist offices, and occupational therapy (OT), and/
Comprehensive Outpatient Rehabilitation Facilities (CORFs).
or speech-language (SP) visit.
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Chapter 4. Benefits Chart (what is covered )
Services that are covered for you
What you must pay when you get these services
Outpatient substance abuse services
We cover outpatient care for the treatment of drug or alcohol dependence, without the use of pharmaceutical drugs.
Services may include intensive outpatient services as well as traditional counseling.
You pay $0 for:
1 Each Medicare-covered individual or group outpatient therapy visit.
1 Each Medicare-covered intensive outpatient service.
Outpatient surgery, including services provided at hospital outpatient
facilities and ambulatory surgical centers +
You pay $0 for each covered
Note: If you are having surgery in a hospital facility, you should check with outpatient surgery or for each day
your provider about whether you will be an inpatient or outpatient. Unless of observation including, but not
the provider writes an order to admit you as an inpatient to the hospital, you limited to, hospital or other
are an outpatient and pay the cost sharing amounts for outpatient surgery. facility charges and physician or
Even if you stay in the hospital overnight, you might still be considered an surgical charges.
"outpatient."
Additional cost-sharing applies
for Medicare Part B prescription
drugs (such as chemotherapy),
diagnostic tests, laboratory tests,
and / or x-rays you receiving
during an outpatient hospital or
ambulatory surgical center visit.
See "Medicare Part B prescription
drugs" and "Outpatient diagnostic
tests and therapeutic services and
supplies" in this chart.
Over-the-counter (OTC) items (Supplemental) *
Your coverage includes non-prescription OTC health and wellness items like vitamins, sunscreen, pain relievers, cough and cold medicine, and bandages.
You can order:
You pay $0 for these services.
You have $125 every quarter (3 months) to spend on plan-approved OTC items.
1. Online visit MolinaHealthcareOTC.com
Quarterly OTC benefit periods
2. By Phone call an OTC Advocate toll-free at (866) 420-4010 (TTY/ are January-March, April-June,
TDD: 711), Monday to Friday, 8 a.m. to 11 p.m. (Eastern Standard July-September, and
Time), excluding holidays
October-December.
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What you must pay when you get these services
3. By Mail fill out and return the OTC Order Form in the OTC Product If you don't use all of your
Catalog
quarterly OTC benefit amount
4. By Mobile Application (Mobile App) download our new
when you order, the remaining
OTC-Anywhere mobile app and access the app from your smartphone balance will rollover to the next
or tablet to place your order. There is no charge to download or use OTC benefit period, giving you
the app. This new app works on mobile devices using Apple or
more to spend the next time you
Android operating systems.
order.
5. By Debit Card/Retail call an OTC Advocate at the toll-free number Be sure to spend any unused OTC listed above to request for an OTC Debit Card. Your OTC Debit Card, benefit amount by the end of the along with activation instructions, will be mailed to you. You may year as it will expire on December use your OTC Debit Card to purchase approved OTC products at any 31 of the benefit year.
Walmart store. If your card is lost or stolen, please call OTC customer
service to request for a replacement card.
When you order online, by phone, by mail, or by mobile application, your order will be shipped to the address you give when ordering. Shipping will not cost you anything.
Refer to your 2021 OTC Product Catalog for a complete list of plan-approved OTC items or call an OTC Advocate for more information. You will find important information you should keep in mind (order guidelines) in the 2021 OTC Product Catalog.
Partial hospitalization services +
"Partial hospitalization" is a structured program of active psychiatric treatment You pay $0 each day you qualify
provided as a hospital outpatient service or by a community mental health for Medicare-covered partial
center, that is more intense than the care received in your doctor's or
hospitalization services. You must
therapist's office and is an alternative to inpatient hospitalization.
meet certain requirements to
qualify for coverage and your
doctor must certify that you
would otherwise need inpatient
treatment.
This treatment is given during the day in a hospital outpatient department or community mental health center and doesn't require an overnight stay.
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Services that are covered for you
What you must pay when you get these services
Personal emergency response system (PERS) (Supplemental) * +
You pay $0 for these services.
PERS is an in-home medical alarm system that can get you help in an emergency. If you qualify, you will be given a mobile, cellular, or landline device and a small pendant that should be worn at all times. The pendant can be worn on the neck, wrist, or belt. With the press of a button you will be connected to a Caring Center Representative at the monitoring company.
Operators are available 24 hours a day, 7 days a week, and will stay on the line with you in the event of an emergency. Whether you need urgent medical service or a family member to assist you, the Caring Center Representative will get you the help you need.
Your Case Manager will decide if you qualify for this benefit. Prior authorization is required.
As an added benefit to the standard 24/7 monitoring of emergent needs, qualified members will also receive PERSPlus service levels. Using your mobile or in-home PERS device you can activate your button for non-emergent needs. If you are feeling lonely or want to talk to someone, need help scheduling your doctor's appointment, arranging transportation, or in need of any other assistance, the Caring Center Representative will assist you and may connect you to Molina Member Services or your Case Manager to help you get the assistance you need.
Physician/Practitioner services, including doctor's office visits
Covered services include:
Office visits:
1 Medically-necessary medical care or surgery services furnished in a physician's office, certified ambulatory surgical center, hospital outpatient department, or any other location+
1 Consultation, diagnosis, and treatment by a specialist
1 You pay $0 for primary care physician visits.
1 You pay $0 for specialist's visits.
1 Basic hearing and balance exams performed by your PCP, if your Additional telehealth services:
doctor orders it to see if you need medical treatment
1 Virtual medical visits
1 Certain telehealth services, including: primary care services
provided by a network
4 You have the option of getting these services through an in-person visit or by telehealth. If you choose to get one of these services by telehealth, you must use a network provider who offers the service
provider that currently offers the services via telehealth:
by telehealth
You pay $0.
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Services that are covered for you
What you must pay when you get these services
4 Virtual medical visits are medical visits delivered to you outside of medical facilities by virtual providers that use online technology and live audio/video capabilities. To find a participating Teladoc physician, call (800) 835-2362, (TTY: 711), or visit www.Teladoc.com/Molina to access virtual visits 24 hours a day, 7 days a week
4 Note: Not all medical conditions can be treated through virtual visits. The virtual visit doctor will identify if you need to see an in-person doctor for treatment
1 Some telehealth services including consultation, diagnosis, and treatment by a physician or practitioner, for patients in certain rural areas or other places approved by Medicare
1 Telehealth services for monthly end-stage renal disease-related visits for home dialysis members in a hospital-based or critical access hospital-based renal dialysis center, renal dialysis facility, or the member's home
1 Telehealth services to diagnose, evaluate, or treat symptoms of a stroke
1 Virtual check-ins (for example, by phone or video chat) with your doctor for 5-10 minutes if:
4 You're not a new patient and
4 The check-in isn't related to an office visit in the past 7 days and
4 The check-in doesn't lead to an office visit within 24 hours or the soonest available appointment
1 Evaluation of video and/or images you send to your doctor, and interpretation and follow-up by your doctor within 24 hours if:
4 You're not a new patient and
4 The evaluation isn't related to an office visit in the past 7 days and
4 The evaluation doesn't lead to an office visit within 24 hours or the soonest available appointment
1 Consultation your doctor has with other doctors by phone, internet, or electronic health record if you're not a new patient
1 Second opinion by another network provider prior to surgery
1 Virtual medical visits provided by Teladoc:
You pay $0.
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Services that are covered for you
What you must pay when you get these services
1 Non-routine dental care (covered services are limited to surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician) +
1 Monitoring services in a physician's office or outpatient hospital setting if you are taking anti-coagulation medications, such as Coumadin, Heparin, or Warfarin.
Podiatry services (Medicare-covered)
Covered services include:
You pay $0 for each
1 Diagnosis and the medical or surgical treatment of injuries and diseases Medicare-covered podiatry visit.
of the feet (such as hammer toe or heel spurs).
1 Routine foot care for members with certain medical conditions affecting the lower limbs.
Podiatry services (Supplemental) *
You don't need an underlying condition to take advantage of this benefit. You pay $0 for these services.
Coverage includes general foot care such as corn and callous removal, cutting Plan maximum of up to
of toenails, treatment of cracked skin, and other foot problems.
12 supplemental routine foot care
visits every calendar year.
Prostate cancer screening exams * For men age 50 and older, covered services include the following - once every 12 months: 1 Digital rectal exam 1 Prostate Specific Antigen (PSA) test
There is no coinsurance, copayment, or deductible for an annual PSA test.
Diagnostic PSA exams are subject to cost-sharing as described under "Outpatient diagnostic tests and therapeutic services and supplies" in this chart.
Prosthetic devices and related supplies +
Devices (other than dental) that replace all or part of a body part or function. You pay $0 copay for each
These include, but are not limited to: colostomy bags and supplies directly Medicare-covered prosthetic or
related to colostomy care, pacemakers, braces, prosthetic shoes, artificial orthotic device, including
limbs, and breast prostheses (including a surgical brassiere after a
replacement or repairs of such
mastectomy). Includes certain supplies related to prosthetic devices, and devices, and related supplies.
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What you must pay when you get these services
repair and/or replacement of prosthetic devices. Also includes some coverage following cataract removal or cataract surgery see "Vision care" later in this section for more detail.
Pulmonary rehabilitation services +
Comprehensive programs of pulmonary rehabilitation are covered for
You pay $0 copay for each
members who have moderate to very severe chronic obstructive pulmonary Medicare-covered pulmonary
disease (COPD) and an order for pulmonary rehabilitation from the doctor rehabilitative visit.
treating the chronic respiratory disease.
Screening and counseling to reduce alcohol misuse *
There is no coinsurance,
We cover one alcohol misuse screening for adults with Medicare (including copayment, or deductible for the
pregnant women) who misuse alcohol, but aren't alcohol dependent.
Medicare-covered screening and
If you screen positive for alcohol misuse, you can get up to 4 brief face-to-face counseling sessions per year (if you're competent and alert
counseling to reduce alcohol misuse preventive benefit.
during counseling) provided by a qualified primary care doctor or practitioner
in a primary care setting.
Screening for lung cancer with low dose computed tomography (LDCT) *
There is no coinsurance, copayment, or deductible for the
For qualified individuals, a LDCT is covered every 12 months.
Medicare covered counseling and
Eligible members are: people aged 55 77 years who have no signs or symptoms of lung cancer, but who have a history of tobacco smoking of at
shared decision making visit or for the LDCT.
least 30 pack-years and who currently smoke or have quit smoking within
the last 15 years, who receive a written order for LDCT during a lung cancer
screening counseling and shared decision making visit that meets the
Medicare criteria for such visits and be furnished by a physician or qualified
non-physician practitioner.
For LDCT lung cancer screenings after the initial LDCT screening: the member must receive a written order for LDCT lung cancer screening, which may be furnished during any appropriate visit with a physician or qualified non-physician practitioner. If a physician or qualified non-physician practitioner elects to provide a lung cancer screening counseling and shared decision making visit for subsequent lung cancer screenings with LDCT, the visit must meet the Medicare criteria for such visits.
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Services that are covered for you
What you must pay when you get these services
Screening for sexually transmitted infections (STIs) and counseling There is no coinsurance,
to prevent STIs *
copayment, or deductible for the
We cover sexually transmitted infection (STI) screenings for chlamydia, Medicare-covered screening for
gonorrhea, syphilis, and Hepatitis B. These screenings are covered for
STIs and counseling for STIs
pregnant women and for certain people who are at increased risk for an STI preventive benefit.
when the tests are ordered by a primary care provider. We cover these tests
once every 12 months or at certain times during pregnancy.
We also cover up to 2 individual 20 to 30 minute, face-to-face high-intensity behavioral counseling sessions each year for sexually active adults at increased risk for STIs. We will only cover these counseling sessions as a preventive service if they are provided by a primary care provider and take place in a primary care setting, such as a doctor's office.
Services to treat kidney disease
Covered services include:
Kidney Disease Education
1 Kidney disease education services to teach kidney care and help members Services
make informed decisions about their care. For members with stage IV
1 You pay $0 for these
chronic kidney disease when referred by their doctor, we cover up to six
services. Medicare covers
sessions of kidney disease education services per lifetime.
up to 6 sessions per
1 Outpatient dialysis treatments (including dialysis treatments when
lifetime.
temporarily out of the service area, as explained in Chapter 3)
Outpatient Dialysis Treatments
1 Inpatient dialysis treatments (if you are admitted as an inpatient to a
1 You pay $0 copay for
hospital for special care)
Medicare-covered
1 Self-dialysis training (includes training for you and anyone helping you with your home dialysis treatments)
outpatient renal dialysis services.
1 Home dialysis equipment and supplies
Inpatient Dialysis Treatments
1 Certain home support services (such as, when necessary, visits by trained dialysis workers to check on your home dialysis, to help in emergencies,
1 See "Inpatient hospital care" in this chart.
and check your dialysis equipment and water supply)
Self-Dialysis Training
Certain drugs for dialysis are covered under your Medicare Part B drug benefit. For information about coverage for Part B Drugs, please go to the section, "Medicare Part B prescription drugs."
1 You pay $0 for these services.
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Chapter 4. Benefits Chart (what is covered )
Services that are covered for you
What you must pay when you get these services
Home Dialysis Equipment and Supplies
1 See "Durable medical equipment and related supplies" in this chart.
Home Support Services
1 See "Home health agency care" in this chart.
Medicare Part B Dialysis Drugs
1 See "Medicare Part B prescription drugs" in this chart.
Skilled nursing facility (SNF) care +
(For a definition of "skilled nursing facility care," see Chapter 12 of this Each benefit period you pay:
booklet. Skilled nursing facilities are sometimes called "SNFs.")
1 $0 for days 1 to 100
Covered services include but are not limited to:
1 All costs after 100 days
1 Semiprivate room (or a private room if medically necessary)
Medicare benefit periods apply.
1 Meals, including special diets
A benefit period begins on the
1 Skilled nursing services 1 Physical therapy, occupational therapy, and speech therapy
first day that you are admitted to a Medicare-covered inpatient hospital or SNF. The benefit
1 Drugs administered to you as part of your plan of care (This includes substances that are naturally present in the body, such as blood clotting factors.)
1 Blood - including storage and administration. Coverage begins with the first pint of blood that you need.
period ends when you haven't received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new
1 Medical and surgical supplies ordinarily provided by SNFs 1 Laboratory tests ordinarily provided by SNFs
benefit period begins. There is no limit to the number of benefit periods you can have.
1 X-rays and other radiology services ordinarily provided by SNFs
In accordance with Medicare
1 Use of appliances such as wheelchairs ordinarily provided by SNFs
guidelines, you are covered for
1 Physician/Practitioner services
up to 100 days each benefit period for inpatient services in a SNF.
Generally, you will get your SNF care from network facilities. However, Lifetime reserve days cannot be
under certain conditions listed below, you may be able to get your care from
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Services that are covered for you
What you must pay when you get these services
a facility that isn't a network provider, if the facility accepts our plan's amounts for payment.
1 A nursing home or continuing care retirement community where you were living right before you went to the hospital (as long as it provides skilled nursing facility care)
1 A SNF where your spouse is living at the time you leave the hospital
used to pay down your share of cost after this time.
A 3-day prior hospital stay is not required.
If you are admitted at the end of the year but not discharged until the following year, your benefit and cost-share is based on the year that you were admitted.
Smoking and tobacco use cessation (counseling to stop smoking or There is no coinsurance,
tobacco use) *
copayment, or deductible for the
If you use tobacco, but do not have signs or symptoms of tobacco-related Medicare-covered smoking and
disease: We cover two counseling quit attempts within a 12-month period tobacco use cessation preventive
as a preventive service with no cost to you. Each counseling attempt includes benefits.
up to four face-to-face visits.
If you use tobacco and have been diagnosed with a tobacco-related disease or are taking medicine that may be affected by tobacco: We cover cessation counseling services. We cover two counseling quit attempts within a 12-month period; however, you will pay the applicable cost sharing. Each counseling attempt includes up to four face-to-face visits.
Supervised Exercise Therapy (SET) +
SET is covered for members who have symptomatic peripheral artery disease You pay $0 for Medicare-covered
(PAD).
Supervised Exercise Therapy
Up to 36 sessions over a 12-week period are covered if the SET program (SET) visits.
requirements are met.
The SET program must:
1 Consist of sessions lasting 30-60 minutes, comprising a therapeutic exercise-training program for PAD in patients with claudication
1 Be conducted in a hospital outpatient setting or a physician's office
1 Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD
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1 Be under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist who must be trained in both basic and advanced life support techniques
SET may be covered beyond 36 sessions over 12 weeks for an additional 36 sessions over an extended period of time if deemed medically necessary by a health care provider.
Transportation non-emergency (Supplemental) + *
You can use this benefit when you need to get to and from plan-approved You pay $0 for these services.
locations. Plan-approved locations are places where you get care and services Your coverage includes up to we cover. For example, your doctor's office, dentist's office, and pharmacy 12 one-way trips every calendar are all plan-approved locations. Rides to non-medical destinations such as year to plan-approved locations grocery stores, fitness centers (gyms), and senior centers are not covered. for non-emergency transportation.
How one-way trips work
If you need emergency care, dial
Transportation trips are counted as one-way trips. A pick-up from one location 911 and request an ambulance.
and drop-off to another location is a one-way trip. For example, if you go to Refer to "Ambulance services" in
your doctor's office, then to the dentist before going back home, you would this chart to learn more about
use 3 one-way trips.
emergency transportation.
1 1st one-way trip: Your home to your doctor's office.
1 2nd one-way trip: Your doctor's office to your dentist's office.
1 3rd one-way trip: Your dentist's office to your home.
A stop at the pharmacy following a medical appointment will not be counted as a one-way trip but our transportation vendor will have to be made aware of the pharmacy stop in advance.
Trips to and from the pharmacy when the trip is not following a medical appointment will be counted as 2 one-way trips.
You will need prior authorization if you travel over 150 miles for a one-way trip. Call our transportation vendor or our Member Services Department for help with the authorization.
If you need to travel to the same location often, and we authorize, you will not have to get a new authorization each time.
How to schedule For appointments that you make in advance, like doctor visits or eye exams:
1 Have your plan member ID number and the information about your appointment on hand when you call.
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What you must pay when you get these services
1 You must call the reservation line at least 3 business days before your appointment to book your trip.
1 Reservations can be made up to 30 days in advance.
1 Reservations for repeat appointments for services like chemotherapy, radiation, physical therapy, or dialysis can be scheduled for a period of 90 days at a time.
1 If you are going to need help getting to and from the vehicle, let our transportation vendor know when you call to schedule your ride.
1 You can also schedule and manage transportation services with the Access2Care mobile app. Visit the iPhone App Store or Google Play and search "A2C" to download.
For routine, urgent care appointments, hospital discharges, or to find out where your ride is, you can call our transportation vendor 24 hours a day, 7 days a week.
Trips to the emergency room or between emergency rooms are not covered under this non-emergency transportation benefit. However, a trip from the emergency room following discharge back to your home is covered.
If you need a wheelchair or a cane, you must bring your own. If you do not have a wheelchair when you are discharged from the hospital, let our transportation vendor know. If they have a driver who has a collapsible wheelchair, they will do their best to help you. If not, they will let you know and provide instructions for next steps.
What to expect
1 The driver may arrive up to 15 minutes before or after your scheduled pickup time.
1 You should be ready to leave when the driver arrives.
1 If you call for a ride after your appointment, the driver should pick you up within 60 minutes.
1 If the driver is more than 15 minutes late call our transportation vendor for Ride Assist. Do not call the driver who dropped you off.
Should you need to cancel
1 If you no longer need a ride you must cancel your reservation at least 24-hours in advance. If a ride is not cancelled before the driver has been dispatched, the ride will be applied to and deducted from your annual trip limit.
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Chapter 4. Benefits Chart (what is covered )
Services that are covered for you
What you must pay when you get these services
Types of transportation Types of vehicles that may be used:
1 A sedan, van, taxi, or rideshare services if you are able to walk.
1 A vehicle with a wheelchair lift, if you have limited mobility.
The type of vehicle used to transport you will be based on your mobility and physical needs.
You cannot pick the type of vehicle. If needed, our transportation vendor may call your doctor to make sure that the right type of vehicle is sent to pick you up.
If you can walk and want to use the bus, tell our transportation vendor and they will send you a bus voucher to get to your appointment.
Mileage reimbursement
Mileage reimbursement is available if you have someone who will drive you to and from your appointment. Mileage reimbursement is when we have our transportation vendor pay your driver back for the miles they drove you to plan-approved locations.
To use mileage reimbursement instead of our transportation vendor:
1 Call the reservation line before your appointment and tell them you want to use mileage reimbursement.
1 Our transportation vendor will calculate the mileage for you and send your driver(s) a check within thirty (30) calendar days of your completed trip.
Once this supplemental benefit is exhausted
Once this benefit is exhausted, if you have Medicaid medical coverage, you may have access to a Medicaid non-emergency transportation benefit which will cover trips to your PCP and other providers. Contact your Medicaid insurance carrier to learn more.
Urgently needed services
Urgently needed services are provided to treat a non-emergency, unforeseen You pay $0 for each medical illness, injury, or condition that requires immediate medical care. Medicare-covered urgently Urgently needed services may be furnished by network providers or by needed care visit. out-of-network providers when network providers are temporarily unavailable or inaccessible.
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Services that are covered for you
What you must pay when you get these services
Cost sharing for necessary urgently needed services furnished out-of-network is the same as for such services furnished in-network.
Urgently needed care outside of the United States (U.S.) may be covered under the worldwide emergency/urgent coverage benefit. See "Worldwide emergency/urgent coverage" in this chart to learn more.
Vision care (Medicare-covered)
You pay $0 for:
Covered services include:
1 Medicare-covered vision
1 Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration. Original Medicare doesn't cover routine eye exams (eye
care such as exams to diagnose and treat diseases and conditions of the eye.
refractions) for eyeglasses/contacts.
1 One Medicare-covered
1 For people who are at high risk of glaucoma, we will cover one glaucoma screening each year. People at high risk of glaucoma include: people with a family history of glaucoma, people with diabetes, African-Americans
glaucoma screening each calendar year if you are at high risk of glaucoma.
who are age 50 and older and Hispanic Americans who are 65 or older.
1 One Medicare-covered
1 For people with diabetes, screening for diabetic retinopathy is covered once per year.
1 One pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery.)
diabetic retinopathy screening each calendar year if you have diabetes.
1 One pair of Medicare-covered eyeglasses or contact lenses after each cataract surgery
that includes insertion of
an intraocular lens.
1 Medicare-covered corrective lenses / frames (and replacement(s) needed after a cataract removal without a lens implant. Note Medicare-covered eyewear following cataract surgery is a limited benefit and only includes basic frames, lenses, or contact lenses.
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Services that are covered for you
What you must pay when you get these services
For cataract surgery that meets medical necessity, including the removal of a cataract and insertions of a Medicare-covered intraocular lens see the following sections in this chart for your cost share:
1 Cataract surgery: see "Outpatient surgery."
1 Intraocular lens: see "Prosthetic devices and related supplies."
If the eyewear you purchase after cataract surgery costs more than what Medicare covers, you pay the difference. If you haven't used all of your supplemental vision allowance, any remaining credit may be used to pay the difference.
Vision care (Supplemental) *
Coverage includes: 1 One routine eye exam every calendar year 1 An eyewear allowance
You can use your eyewear allowance to purchase:
You pay $0 for up to one routine eye exam and refraction for eyeglasses every calendar year.
You have an eyewear allowance of $550 every 2 calendar years.
1 Contact lenses*
1 Eyeglasses (lenses and frames)
1 Eyeglass lenses and / or frames
1 Upgrades (such as, tinted, U-V, polarized or photochromatic lenses).
*If you choose contact lenses, your eyewear allowance can also be used to pay down all or a portion of your contact lens fitting fee.
You are responsible for paying for any corrective eyewear over the limit of the plan's eyewear allowance.
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Chapter 4. Benefits Chart (what is covered )
Services that are covered for you
What you must pay when you get these services
"Welcome to Medicare" preventive visit *
There is no coinsurance,
The plan covers the one-time "Welcome to Medicare" preventive visit. The copayment, or deductible for the
visit includes a review of your health, as well as education and counseling "Welcome to Medicare"
about the preventive services you need (including certain screenings and preventive visit.
shots), and referrals for other care if needed.
Important: We cover the "Welcome to Medicare" preventive visit only within the first 12 months you have Medicare Part B. When you make your appointment, let your doctor's office know you would like to schedule your "Welcome to Medicare" preventive visit.
Worldwide emergency/urgent coverage (Supplemental) *
As an added benefit, your coverage includes up to $10,000 every calendar You pay $0 for these services.
year for worldwide emergent/urgent care outside of the United States (U.S.) If you receive emergency care
This benefit is limited to services that would be classified as emergency or outside the U.S. and need
urgent care had the care been provided in the U.S.
inpatient care after your
Worldwide coverage includes emergency or urgently needed care, emergency emergency condition is stabilized,
ambulance transportation from the scene of an emergency to the nearest you must return to a network
medical treatment facility and post-stabilization care.
hospital in order for your care to
continue to be covered OR you
Ambulance services are covered in situations where getting to the emergency must have your inpatient care at
room in any other way could endanger your health.
the out-of-network hospital
When these situations happen, we ask that you or someone caring for you authorized by the plan. Your cost
call us. We will try to arrange for network providers to take over your care is the highest cost sharing you
as soon as your medical condition and circumstances allow.
would pay at a network hospital.
Plan maximum applies.
Transportation back to the U.S. from another country is not covered. Routine
care and pre-scheduled or elective procedures are not covered.
You may need to file a claim for
reimbursement of emergency/
Foreign taxes and fees (including but not limited to, currency conversion or urgent care received outside the
transaction fees) are not covered.
U.S.
U.S. means 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Island, and American Samoa.
Plan maximum of $10,000 every calendar year applies for this
benefit.
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Chapter 4. Benefits Chart (what is covered )
SECTION 3 What services are covered outside of Molina Medicare Complete Care (HMO SNP)?
Section 3.1 Services not covered by Molina Medicare Complete Care (HMO SNP)
The following services are not covered by Molina Medicare Complete Care (HMO SNP) but are available through Medicaid:
1 AIDS Waiver Program 1 Blood and Blood Derivatives 1 Chronic Dialysis Services 1 Community-Based Adult Services (CBAS) 1 Community-Supported Living Arrangements (waiver only) 1 Comprehensive Perinatal Services Program (Preventive services) 1 Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) 1 Enteral Formula 1 Family Nurse Practitioner 1 Family Planning Services and Supplies 1 Federally Qualified Health Center Services (FQHC) 1 Home and Community Care for functionally disabled elderly (waiver only) 1 Intermediate Care Facility 1 Licensed Midwife Services 1 Local Educational Agency (LEA) Services 1 Nurse Anesthetist Services 1 Nurse Midwife 1 Personal Care Services 1 Psychology Services 1 Rehabilitation Facilities 1 Respiratory Care for Ventilator-Dependent Patients 1 Rural Health Clinic Services (RHC) 1 Special Duty Nursing Services 1 Sign Language Interpreter Services 1 Targeted Case Management
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1 TB-Related Services 1 Transplants
SECTION 4 What services are not covered by the plan?
Section 4.1 Services not covered by the plan (exclusions) OR Medicaid
This section tells you what services are "excluded". Excluded means that the plan doesn't cover these services. The chart below describes some services and items that aren't covered by the plan under any conditions or are covered by Medicaid only under specific conditions. We won't pay for the excluded medical services listed in the chart below except under the specific conditions listed. The only exception: we will pay if a service in the chart below is found upon appeal to be a medical service that we should have paid for or covered because of your specific situation. (For information about appealing a decision we have made to not cover a medical service, go to Chapter 9, Section 6.3 in this booklet.) All exclusions or limitations on services are described in the Benefits Chart or in the chart below.
Services not covered by Medicare
Services considered not reasonable and necessary, according to the standards of Original Medicare
Not covered under any condition
Experimental medical and surgical procedures, equipment and medications.
Experimental procedures and items are those items and procedures determined by our plan and Original Medicare to not be generally accepted by the medical community.
Private room in a hospital.
Personal items in your room at a
hospital or a skilled nursing facility,
such as a telephone or a television.
Full-time nursing care in your home.
*Custodial care is care provided in a
nursing home, hospice, or other
Covered only under specific conditions
May be covered by Original Medicare under a Medicare-approved clinical research study or by our plan. (See Chapter 3, Section 5 for more information on clinical research studies.)
Covered only when medically necessary.
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Chapter 4. Benefits Chart (what is covered )
Services not covered by Medicare Not covered under any condition
facility setting when you do not require skilled medical care or skilled nursing care.
Homemaker services include basic household assistance, including light housekeeping or light meal preparation.
Fees charged for care by your
immediate relatives or members of
your household.
Cosmetic surgery or procedures
Routine chiropractic care Orthopedic shoes
Supportive devices for the feet
Radial keratotomy, LASIK surgery, and other low vision aids
Reversal of sterilization procedures
and or non-prescription contraceptive
supplies.
Covered only under specific conditions
Covered under Medicaid.
1 Covered in cases of an accidental injury
or for improvement of the functioning of a malformed body member. 1 Covered for all stages of reconstruction for a breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical appearance.
Manual manipulation of the spine to correct a subluxation is covered.
If shoes are part of a leg brace and are included in the cost of the brace, or the shoes are for a person with diabetic foot disease.
Orthopedic or therapeutic shoes for people with diabetic foot disease.
This plan offers additional coverage. See the Benefits Chart in section 2.1 of this Chapter for more information.
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Services not covered by Medicare
Acupuncture Naturopath services (uses natural or alternative treatments)
Not covered under any condition
Covered only under specific conditions
*Custodial care is personal care that does not require the continuing attention of trained medical or paramedical personnel, such as care that helps you with activities of daily living, such as bathing or dressing.
CHAPTER 5
Using the plan's coverage for your Part D prescription drugs
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Chapter 5. Using the plan's coverage for your Part D prescription drugs
SECTION 1 Introduction ...............................................................................................................99 Section 1.1 This chapter describes your coverage for Part D drugs ........................................................ 99 Section 1.2 Basic rules for the plan's Part D drug coverage .................................................................... 99
SECTION 2 Fill your prescription at a network pharmacy or through the plan's mail-order service ......................................................................................................................100
Section 2.1 To have your prescription covered, use a network pharmacy ............................................. 100 Section 2.2 Finding network pharmacies ............................................................................................... 100 Section 2.3 Using the plan's mail-order services ................................................................................... 101 Section 2.4 How can you get a long-term supply of drugs? .................................................................. 102 Section 2.5 When can you use a pharmacy that is not in the plan's network? ...................................... 102
SECTION 3 Your drugs need to be on the plan's "Drug List" ................................................ 103 Section 3.1 The "Drug List" tells which Part D drugs are covered ....................................................... 103 Section 3.2 There are five (5) "cost sharing tiers" for drugs on the Drug List ...................................... 104 Section 3.3 How can you find out if a specific drug is on the Drug List? ............................................. 104
SECTION 4 There are restrictions on coverage for some drugs ............................................ 104 Section 4.1 Why do some drugs have restrictions? ................................................................................ 104 Section 4.2 What kinds of restrictions? ................................................................................................. 105 Section 4.3 Do any of these restrictions apply to your drugs? ............................................................... 106
SECTION 5 What if one of your drugs is not covered in the way you'd like it to be covered? ..................................................................................................................106
Section 5.1 There are things you can do if your drug is not covered in the way you'd like it to be covered ................................................................................................................................ 106
Section 5.2 What can you do if your drug is not on the Drug List or if the drug is restricted in some way? .................................................................................................................................... 107
Section 5.3 What can you do if your drug is in a cost sharing tier you think is too high? .................... 108
SECTION 6 What if your coverage changes for one of your drugs? ..................................... 109 Section 6.1 The Drug List can change during the year .......................................................................... 109 Section 6.2 What happens if coverage changes for a drug you are taking? ........................................... 109
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SECTION 7 What types of drugs are not covered by the plan? .............................................. 111 Section 7.1 Types of drugs we do not cover .......................................................................................... 111
SECTION 8 Show your plan membership card when you fill a prescription ......................... 112 Section 8.1 Show your membership card ............................................................................................... 112 Section 8.2 What if you don't have your membership card with you? .................................................. 112
SECTION 9 Part D drug coverage in special situations .......................................................... 113 Section 9.1 What if you're in a hospital or a skilled nursing facility for a stay that is covered by the plan? .................................................................................................................................... 113 Section 9.2 What if you're a resident in a long-term care (LTC) facility? ............................................ 113 Section 9.3 What if you're also getting drug coverage from an employer or retiree group plan? ......... 114 Section 9.4 What if you're in Medicare-certified hospice? ................................................................... 114
SECTION 10 Programs on drug safety and managing medications ........................................ 114 Section 10.1 Programs to help members use drugs safely ....................................................................... 114 Section 10.2 Drug Management Program (DMP) to help members safely use their opioid medications ......................................................................................................................... 115 Section 10.3 Medication Therapy Management (MTM) program to help members manage their medications ......................................................................................................................... 116
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How can you get information about your drug costs
Because you are eligible for Medicaid, you qualify for and are getting "Extra Help" from Medicare to pay for your prescription drug plan costs. Because you are in the "Extra Help" program, some information in this Evidence of Coverage about the costs for Part D prescription drugs may not apply to you. We sent you a separate insert, called the "Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs" (also known as the "Low Income Subsidy Rider" or the "LIS Rider"), which tells you about your drug coverage. If you don't have this insert, please call Member Services and ask for the "LIS Rider." (Phone numbers for Member Services are printed on the back cover of this booklet.)
SECTION 1 Introduction
Section 1.1 This chapter describes your coverage for Part D drugs
This chapter explains rules for using your coverage for Part D drugs. The next chapter tells what you pay for Part D drugs (Chapter 6, What you pay for your Part D prescription drugs).
In addition to your coverage for Part D drugs, Molina Medicare Complete Care (HMO SNP) also covers some drugs under the plan's medical benefits. Through its coverage of Medicare Part A benefits, our plan generally covers drugs you are given during covered stays in the hospital or in a skilled nursing facility. Through its coverage of Medicare Part B benefits, our plan covers drugs including certain chemotherapy drugs, certain drug injections you are given during an office visit, and drugs you are given at a dialysis facility. Chapter 4 (Medical Benefits Chart, what is covered) tells about the benefits and costs for drugs during a covered hospital or skilled nursing facility stay, as well as your benefits and costs for Part B drugs.
Your drugs may be covered by Original Medicare if you are in Medicare hospice. Our plan only covers Medicare Parts A, B, and D services and drugs that are unrelated to your terminal prognosis and related conditions and therefore not covered under the Medicare hospice benefit. For more information, please see Section 9.4 (What if you're in Medicare-certified hospice). For information on hospice coverage, see the hospice section of Chapter 4 (Medical Benefits Chart, what is covered).
The following sections discuss coverage of your drugs under the plan's Part D benefit rules. Section 9, Part D drug coverage in special situations includes more information on your Part D coverage and Original Medicare.
In addition to the drugs covered by Medicare, some prescription drugs are covered for you under your Medicaid benefits.
For more information on Medicaid drug coverage, you should contact Member Services (Phone numbers for Member Services are printed on the back cover of this booklet) or your State Medicaid office (the contact information is listed in Chapter 2, Section 6).
Section 1.2 Basic rules for the plan's Part D drug coverage
The plan will generally cover your drugs as long as you follow these basic rules:
1 You must have a provider (a doctor, dentist or other prescriber) write your prescription.
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1 Your prescriber must either accept Medicare or file documentation with CMS showing that he or she is qualified to write prescriptions, or your Part D claim will be denied. You should ask your prescribers the next time you call or visit if they meet this condition. If not, please be aware it takes time for your prescriber to submit the necessary paperwork to be processed.
1 You generally must use a network pharmacy to fill your prescription. (See Section 2, Fill your prescriptions at a network pharmacy or through the plan's mail-order service.)
1 Your drug must be on the plan's List of Covered Drugs (Formulary) (we call it the "Drug List" for short). (See Section 3, Your drugs need to be on the plan's "Drug List.")
1 Your drug must be used for a medically accepted indication. A "medically accepted indication" is a use of the drug that is either approved by the Food and Drug Administration or supported by certain reference books. (See Section 3 for more information about a medically accepted indication.)
SECTION 2 Fill your prescription at a network pharmacy or through the plan's mail-order service
Section 2.1 To have your prescription covered, use a network pharmacy
In most cases, your prescriptions are covered only if they are filled at the plan's network pharmacies. (See Section 2.5 for information about when we would cover prescriptions filled at out-of-network pharmacies.) A network pharmacy is a pharmacy that has a contract with the plan to provide your covered prescription drugs. The term "covered drugs" means all of the Part D prescription drugs that are covered on the plan's Drug List.
Section 2.2 Finding network pharmacies
How do you find a network pharmacy in your area? To find a network pharmacy, you can look in your Provider/Pharmacy Directory, visit our website (MolinaHealthcare.com/Medicare), or call Member Services (phone numbers are printed on the back cover of this booklet). You may go to any of our network pharmacies. If you switch from one network pharmacy to another, and you need a refill of a drug you have been taking, you can ask either to have a new prescription written by a provider or to have your prescription transferred to your new network pharmacy.
What if the pharmacy you have been using leaves the network? If the pharmacy you have been using leaves the plan's network, you will have to find a new pharmacy that is in the network. To find another network pharmacy in your area, you can get help from Member Services (phone numbers are printed on the back cover of this booklet) or use the Provider/Pharmacy Directory. You can also find information on our website at MolinaHealthcare.com/Medicare.
What if you need a specialized pharmacy? Sometimes prescriptions must be filled at a specialized pharmacy. Specialized pharmacies include:
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1 Pharmacies that supply drugs for home infusion therapy.
1 Pharmacies that supply drugs for residents of a long-term care (LTC) facility. Usually, a long-term care facility (such as a nursing home) has its own pharmacy. If you are in an LTC facility, we must ensure that you are able to routinely receive your Part D benefits through our network of LTC pharmacies, which is typically the pharmacy that the LTC facility uses. If you have any difficulty accessing your Part D benefits in an LTC facility, please contact Member Services.
1 Pharmacies that serve the Indian Health Service / Tribal / Urban Indian Health Program (not available in Puerto Rico). Except in emergencies, only Native Americans or Alaska Natives have access to these pharmacies in our network.
1 Pharmacies that dispense drugs that are restricted by the FDA to certain locations or that require special handling, provider coordination, or education on their use. (Note: This scenario should happen rarely.)
To locate a specialized pharmacy, look in your Provider/Pharmacy Directory or call Member Services (phone numbers are printed on the back cover of this booklet).
Section 2.3 Using the plan's mail-order services
For certain kinds of drugs, you can use the plan's network mail-order services. Generally, the drugs provided through mail order are drugs that you take on a regular basis, for a chronic or long term medical condition. The drugs that are not available through the plan's mail-order service are marked as "NM" for No Mail Order in our Drug List.
Our plan's mail-order service allows you to order up to a 90-day supply.
To get order forms and information about filling your prescriptions by mail please call Member Services (phone numbers for Member Services are printed on the back cover of this booklet) or visit our website at http://www. MolinaHealthcare.com/Medicare
Usually a mail-order pharmacy order will get to you in no more than 14 days. If there is an urgent need or this timing is delayed, please call Member Services (phone numbers for Member Services are printed on the back cover of this booklet) for help in receiving a temporary supply of your prescription.
New prescriptions the pharmacy receives directly from your doctor's office. After the pharmacy receives a prescription from a health care provider, it will contact you to see if you want the medication filled immediately or at a later time. This will give you an opportunity to make sure that the pharmacy is delivering the correct drug (including strength, amount, and form) and, if needed, allow you to stop or delay the order before you are billed and it is shipped. It is important that you respond each time you are contacted by the pharmacy, to let them know what to do with the new prescription and to prevent any delays in shipping.
Refills on mail order prescriptions. For refills of your drugs, you have the option to sign up for an automatic refill program. Under this program we will start to process your next refill automatically when our records show you should be close to running out of your drug. The pharmacy will contact you prior to shipping each refill to make sure you are in need of more medication, and you can cancel scheduled refills if you have enough of your medication or if your medication has changed. If you choose not to use our auto refill
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program, please contact your pharmacy 14 days before you think the drugs you have on hand will run out to make sure your next order is shipped to you in time.
To opt out of our program that automatically prepares mail order refills, please call Member Services (phone numbers for Member Services are printed on the back cover of this booklet) or visit our website at MolinaHealthcare.com/Medicare.
So the pharmacy can reach you to confirm your order before shipping, please make sure to let the pharmacy know the best ways to contact you. To provide communication preferences, please call Member Services (phone numbers for Member Services are printed on the back cover of this booklet) or visit our website at MolinaHealthcare.com/ Medicare.
Section 2.4 How can you get a long-term supply of drugs?
When you get a long-term supply of drugs, your cost sharing may be lower. The plan offers two ways to get a long-term supply (also called an "extended supply") of "maintenance" drugs on our plan's Drug List. (Maintenance drugs are drugs that you take on a regular basis, for a chronic or long-term medical condition.) You may order this supply through mail order (see Section 2.3) or you may go to a retail pharmacy.
1. Some retail pharmacies in our network allow you to get a long-term supply of maintenance drugs. Your Provider/Pharmacy Directory tells you which pharmacies in our network can give you a long-term supply of maintenance drugs. You can also call Member Services for more information (phone numbers are printed on the back cover of this booklet).
2. For certain kinds of drugs, you can use the plan's network mail-order services. The drugs that are not available through the plan's mail-order service are marked with an "NM" indicating no mail order in our Drug List. Our plan's mail-order service requires you to order up to a 90-day supply. See Section 2.3 for more information about using our mail-order services.
Section 2.5 When can you use a pharmacy that is not in the plan's network?
Your prescription may be covered in certain situations
Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. To help you, we have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. If you cannot use a network pharmacy, here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:
1 If the prescription is related to urgently needed care
1 If these prescriptions are related to care for a medical emergency
1 Coverage will be limited to a 30-day supply unless the prescription is written for less.
In these situations, please check first with Member Services to see if there is a network pharmacy nearby. (Phone numbers for Member Services are printed on the back cover of this booklet.) You may be required to pay the difference between what you pay for the drug at the out-of-network pharmacy and the cost that we would cover at an in-network pharmacy.
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How do you ask for reimbursement from the plan? If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal share of the cost) at the time you fill your prescription. You can ask us to reimburse you for our share of the cost. (Chapter 7, Section 2.1 explains how to ask the plan to pay you back.)
SECTION 3 Your drugs need to be on the plan's "Drug List"
Section 3.1 The "Drug List" tells which Part D drugs are covered
The plan has a "List of Covered Drugs (Formulary)." In this Evidence of Coverage, we call it the "Drug List" for short. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. Medicare has approved the plan's Drug List. The Drug List includes the drugs covered under Medicare Part D (earlier in this chapter, Section 1.1 explains about Part D drugs). In addition to the drugs covered by Medicare, some prescription drugs are covered for you under your Medicaid benefits. For more information on Medicaid drug coverage, you should contact Member Services (Phone numbers for Member Services are printed on the back cover of this booklet) or your State Medicaid office (the contact information is listed in Chapter 2, Section 6). We will generally cover a drug on the plan's Drug List as long as you follow the other coverage rules explained in this chapter and the use of the drug is a medically accepted indication. A "medically accepted indication" is a use of the drug that is either:
1 Approved by the Food and Drug Administration. (That is, the Food and Drug Administration has approved the drug for the diagnosis or condition for which it is being prescribed.)
1 -- or -- Supported by certain references, such as the American Hospital Formulary Service Drug Information and the DRUGDEX Information System.
The Drug List includes both brand name and generic drugs A generic drug is a prescription drug that has the same active ingredients as the brand name drug. Generally, it works just as well as the brand name drug and usually costs less. There are generic drug substitutes available for many brand name drugs.
What is not on the Drug List? The plan does not cover all prescription drugs.
1 In some cases, the law does not allow any Medicare plan to cover certain types of drugs (for more information about this, see Section 7.1 in this chapter).
1 In other cases, we have decided not to include a particular drug on our Drug List.
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1 Additionally, Medicaid may cover additional prescription drugs. For more information on Medicaid drug coverage, you should contact Member Services (Phone numbers for Member Services are printed on the back cover of this booklet) or your State Medicaid office (the contact information is listed in Chapter 2, Section 6).
Section 3.2 There are five (5) "cost sharing tiers" for drugs on the Drug List
Every drug on the plan's Drug List is in one of five (5) cost sharing tiers. In general, the higher the cost sharing tier, the higher your cost for the drug:
1 Tier 1 - Preferred Generic (lowest cost share) 1 Tier 2 - Generic 1 Tier 3 - Preferred Brand 1 Tier 4 - Non-Preferred Drug 1 Tier 5 - Specialty Tier (highest cost share) To find out which cost sharing tier your drug is in, look it up in the plan's Drug List. The amount you pay for drugs in each cost sharing tier is shown in Chapter 6 (What you pay for your Part D prescription drugs).
Section 3.3 How can you find out if a specific drug is on the Drug List?
You have 3 ways to find out: 1. Check the most recent Drug List we provided electronically. 2. Visit the plan's website (MolinaHealthcare.com/Medicare). The Drug List on the website is always the most current. 3. Call Member Services to find out if a particular drug is on the plan's Drug List or to ask for a copy of the list. (Phone numbers for Member Services are printed on the back cover of this booklet.)
SECTION 4 There are restrictions on coverage for some drugs
Section 4.1 Why do some drugs have restrictions?
For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable. In general, our rules encourage you to get a drug that works for your medical condition and is safe and effective. Whenever a safe, lower-cost drug will work just as well medically as a higher-cost drug, the plan's rules are
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designed to encourage you and your provider to use that lower-cost option. We also need to comply with Medicare's rules and regulations for drug coverage and cost sharing.
If there is a restriction for your drug, it usually means that you or your provider will have to take extra steps in order for us to cover the drug. If you want us to waive the restriction for you, you will need to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you. (See Chapter 9, Section 7.2 for information about asking for exceptions.)
Please note that sometimes a drug may appear more than once in our drug list. This is because different restrictions or cost sharing may apply based on factors such as the strength, amount, or form of the drug prescribed by your health care provider (for instance, 10 mg versus 100 mg; one per day versus two per day; tablet versus liquid).
Section 4.2 What kinds of restrictions?
Our plan uses different types of restrictions to help our members use drugs in the most effective ways. The sections below tell you more about the types of restrictions we use for certain drugs.
1 Quantity limits - We may restrict the quantity of the prescription based on safety and efficiency.
1 Prior authorization - These pre-approval requirements may be used by the plan to ensure the drug is being used appropriately to treat your health needs.
1 Step therapy - We may require you to try other medications before you will receive the requested medication.
1 B vs. D Some drugs may be covered under Medicare part D or B, depending on the circumstances.
Restricting brand name drugs when a generic version is available
Generally, a "generic" drug works the same as a brand name drug and usually costs less. In most cases, when a generic version of a brand name drug is available, our network pharmacies will provide you the generic version. We usually will not cover the brand name drug when a generic version is available. However, if your provider has told us the medical reason that neither the generic drug nor other covered drugs that treat the same condition will work for you, then we will cover the brand name drug. (Your share of the cost may be greater for the brand name drug than for the generic drug.)
Getting plan approval in advance
For certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for you. This is called "prior authorization." Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan.
Trying a different drug first
This requirement encourages you to try less costly but just as effective drugs before the plan covers another drug. For example, if Drug A and Drug B treat the same medical condition and Drug A is less costly, the plan may require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. This requirement to try a different drug first is called "step therapy."
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Quantity limits
For certain drugs, we limit the amount of the drug that you can have by limiting how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day.
Section 4.3 Do any of these restrictions apply to your drugs?
The plan's Drug List includes information about the restrictions described above. To find out if any of these restrictions apply to a drug you take or want to take, check the Drug List. For the most up-to-date information, call Member Services (phone numbers are printed on the back cover of this booklet) or check our website (MolinaHealthcare.com/Medicare).
If there is a restriction for your drug, it usually means that you or your provider will have to take extra steps in order for us to cover the drug. If there is a restriction on the drug you want to take, you should contact Member Services to learn what you or your provider would need to do to get coverage for the drug. If you want us to waive the restriction for you, you will need to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you. (See Chapter 9, Section 7.2 for information about asking for exceptions.)
SECTION 5 What if one of your drugs is not covered in the way you'd like it to be covered?
Section 5.1
There are things you can do if your drug is not covered in the way you'd like it to be covered
We hope that your drug coverage will work well for you. But it's possible that there could be a prescription drug you are currently taking, or one that you and your provider think you should be taking, that is not on our formulary or is on our formulary with restrictions. For example:
1 The drug might not be covered at all. Or maybe a generic version of the drug is covered but the brand name version you want to take is not covered.
1 The drug is covered, but there are extra rules or restrictions on coverage for that drug. As explained in Section 4, some of the drugs covered by the plan have extra rules to restrict their use. For example, you might be required to try a different drug first, to see if it will work, before the drug you want to take will be covered for you. Or there might be limits on what amount of the drug (number of pills, etc.) is covered during a particular time period. In some cases, you may want us to waive the restriction for you.
1 The drug is covered, but it is in a cost sharing tier that makes your cost sharing more expensive than you think it should be. The plan puts each covered drug into one of five (5) different cost sharing tiers. How much you pay for your prescription depends in part on which cost sharing tier your drug is in.
There are things you can do if your drug is not covered in the way that you'd like it to be covered. Your options depend on what type of problem you have:
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1 If your drug is not on the Drug List or if your drug is restricted, go to Section 5.2 to learn what you can do.
1 If your drug is in a cost sharing tier that makes your cost more expensive than you think it should be, go to Section 5.3 to learn what you can do.
Section 5.2
What can you do if your drug is not on the Drug List or if the drug is restricted in some way?
If your drug is not on the Drug List or is restricted, here are things you can do:
1 You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply). This will give you and your provider time to change to another drug or to file a request to have the drug covered.
1 You can change to another drug.
1 You can request an exception and ask the plan to cover the drug or remove restrictions from the drug.
You may be able to get a temporary supply
Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.
To be eligible for a temporary supply, you must meet the two requirements below:
1. The change to your drug coverage must be one of the following types of changes:
1 The drug you have been taking is no longer on the plan's Drug List.
1 -- or -- the drug you have been taking is now restricted in some way (Section 4 in this chapter tells about restrictions).
2. You must be in one of the situations described below:
1 For those members who are new or who were in the plan last year:
We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you are new and during the first 90 days of the calendar year if you were in the plan last year. The total supply will be for a maximum of a 31-day supply depending on the dispensing increment. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 31-day supply of medication. The prescription must be filled at a network pharmacy. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
1 For those members who have been in the plan for more than 90 days and reside in a long- term care (LTC) facility and need a supply right away:
We will cover one 31-day supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above temporary supply situation.
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1 If you are a new resident of an LTC facility and have been enrolled in our plan for more than 90 days and need a drug that isn't on our formulary or is subject to other restrictions, such as step therapy or quantity limits (dosage limits), we will cover a temporary 31-day emergency supply of that drug (unless the prescription is for fewer days) while the member pursues a formulary exception. Exceptions are available in situations where you experience a change in the level of care you are receiving that also requires you to transition from one facility or treatment center to another. In such circumstances, you would be eligible for a temporary, onetime fill exception even if you are outside the first 90 days as a member of the plan. Please note that our transition policy applies only to those drugs that are "Part D" and bought at a network pharmacy. The transition policy cannot be used to buy a non-Part D drug or a drug out-of-network, unless you qualify for out-of-network access.
To ask for a temporary supply, call Member Services (phone numbers are printed on the back cover of this booklet).
During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. The sections below tell you more about these options.
You can change to another drug
Start by talking with your provider. Perhaps there is a different drug covered by the plan that might work just as well for you. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. This list can help your provider find a covered drug that might work for you. (Phone numbers for Member Services are printed on the back cover of this booklet.)
You can ask for an exception
You and your provider can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the rule. For example, you can ask the plan to cover a drug even though it is not on the plan's Drug List. Or you can ask the plan to make an exception and cover the drug without restrictions.
If you are a current member and a drug you are taking will be removed from the formulary or restricted in some way for next year, we will allow you to request a formulary exception in advance for next year. We will tell you about any change in the coverage for your drug for next year. You can ask for an exception before next year and we will give you an answer within 72 hours after we receive your request (or your prescriber's supporting statement). If we approve your request, we will authorize the coverage before the change takes effect.
If you and your provider want to ask for an exception, Chapter 9, Section 7.4 tells what to do. It explains the procedures and deadlines that have been set by Medicare to make sure your request is handled promptly and fairly.
Section 5.3 What can you do if your drug is in a cost sharing tier you think is too high?
If your drug is in a cost sharing tier you think is too high, here are things you can do:
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You can change to another drug
If your drug is in a cost sharing tier you think is too high, start by talking with your provider. Perhaps there is a different drug in a lower cost sharing tier that might work just as well for you. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. This list can help your provider find a covered drug that might work for you. (Phone numbers for Member Services are printed on the back cover of this booklet.)
You can ask for an exception
You and your provider can ask the plan to make an exception in the cost sharing tier for the drug so that you pay less for it. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the rule.
If you and your provider want to ask for an exception, Chapter 9, Section 7.4 tells what to do. It explains the procedures and deadlines that have been set by Medicare to make sure your request is handled promptly and fairly.
Drugs in our five (5) - Specialty Tier are not eligible for this type of exception. We do not lower the cost sharing amount for drugs in this tier.
SECTION 6 What if your coverage changes for one of your drugs?
Section 6.1 The Drug List can change during the year
Most of the changes in drug coverage happen at the beginning of each year (January 1). However, during the year, the plan might make changes to the Drug List. For example, the plan might:
1 Add or remove drugs from the Drug List. New drugs become available, including new generic drugs. Perhaps the government has given approval to a new use for an existing drug. Sometimes, a drug gets recalled and we decide not to cover it. Or we might remove a drug from the list because it has been found to be ineffective.
1 Move a drug to a higher or lower cost sharing tier. 1 Add or remove a restriction on coverage for a drug (for more information about restrictions to coverage,
see Section 4 in this chapter). 1 Replace a brand name drug with a generic drug. We must follow Medicare requirements before we change the plan's Drug List.
Section 6.2 What happens if coverage changes for a drug you are taking?
Information on changes to drug coverage When changes to the Drug List occur during the year, we post information on our website about those changes. We will update our online Drug List on a regularly scheduled basis to include any changes that have occurred after the last update. Below we point out the times that you would get direct notice if changes are made to a drug that you are then taking. You can also call Member Services for more information (phone numbers are printed on the back cover of this booklet).
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Do changes to your drug coverage affect you right away?
Changes that can affect you this year: In the below cases, you will be affected by the coverage changes during the current year:
1 A new generic drug replaces a brand name drug on the Drug List (or we change the cost sharing tier or add new restrictions to the brand name drug or both)
4 We may immediately remove a brand name drug on our Drug List if we are replacing it with a newly approved generic version of the same drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a higher cost sharing tier or add new restrictions or both.
4 We may not tell you in advance before we make that change--even if you are currently taking the brand name drug.
4 You or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. For information on how to ask for an exception, see Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)).
4 If you are taking the brand name drug at the time we make the change, we will provide you with information about the specific change(s) we made. This will also include information on the steps you may take to request an exception to cover the brand name drug. You may not get this notice before we make the change.
1 A generic drug replaces a brand name drug on the Drug List (or we change the cost sharing tier or add new restrictions to the brand name drug or both)
4 If a brand name drug you are taking is replaced by a generic drug, the plan must give you at least 30 days' advance notice of the change or give you notice of the change and a 31-day refill of your brand name drug at a network pharmacy.
4 After you receive notice of the change you should be working with your provider to switch to the generic or to a different drug that we cover.
4 Or you or your prescriber can ask the plan to make an exception and continue to cover the brand name drug for you. For information on how to ask for an exception, see Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints).
1 Unsafe drugs and other drugs on the Drug List that are withdrawn from the market
4 Once in a while, a drug may be suddenly withdrawn because it has been found to be unsafe or removed from the market for another reason. If this happens, we will immediately remove the drug from the Drug List. If you are taking that drug, we will let you know of this change right away.
4 Your prescriber will also know about this change, and can work with you to find another drug for your condition.
1 Other changes to drugs on the Drug List
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4 We may make other changes once the year has started that affect drugs you are taking. For instance, we might add a generic drug that is not new to the market to replace a brand name drug or change the cost sharing tier or add new restrictions to the brand name drug or both. We also might make changes based on FDA boxed warnings or new clinical guidelines recognized by Medicare. We must give you at least 30 days' advance notice of the change or give you notice of the change and a 31-day refill of the drug you are taking at a network pharmacy.
4 After you receive notice of the change you should be working with your prescriber to switch to a different drug that we cover.
4 Or you or your prescriber can ask us to make an exception and continue to cover the drug for you. For information on how to ask for an exception, see Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints).
Changes to drugs on the Drug List that will not affect people currently taking the drug: For changes to the Drug List that are not described above, if you are currently taking the drug the following types of changes will not affect you until January 1 of the next year if you stay in the plan:
1 If we move your drug into a higher cost sharing tier
1 If we put a new restriction on your use of the drug
1 If we remove your drug from the Drug List
If any of these changes happen for a drug you are taking (but not because of a market withdrawal, a generic drug replacing a brand name drug, or other change noted in the sections above), then the change won't affect your use or what you pay as your share of the cost until January 1 of the next year. Until that date, you probably won't see any increase in your payments or any added restriction to your use of the drug. You will not get direct notice this year about changes that do not affect you. However, on January 1 of the next year, the changes will affect you, and it is important to check the Drug List in the new benefit year for any changes to drugs.
SECTION 7 What types of drugs are not covered by the plan?
Section 7.1 Types of drugs we do not cover
This section tells you what kinds of prescription drugs are "excluded." This means Medicare does not pay for these drugs.
We won't pay for the drugs that are listed in this section. The only exception: If the requested drug is found upon appeal to be a drug that is not excluded under Part D and we should have paid for or covered it because of your specific situation. (For information about appealing a decision we have made to not cover a drug, go to Chapter 9, Section 7.5 in this booklet.) If the drug excluded by our plan is also excluded by Medicaid, you must pay for it yourself.
Here are three general rules about drugs that Medicare drug plans will not cover under Part D:
1 Our plan's Part D drug coverage cannot cover a drug that would be covered under Medicare Part A or Part B.
1 Our plan cannot cover a drug purchased outside the United States and its territories.
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1 Our plan usually cannot cover off-label use. "Off-label use" is any use of the drug other than those indicated on a drug's label as approved by the Food and Drug Administration.
4 Generally, coverage for "off-label use" is allowed only when the use is supported by certain references, such as the American Hospital Formulary Service Drug Information and the DRUGDEX Information System. If the use is not supported by any of these references, then our plan cannot cover its "off-label use."
Also, by law, the categories of drugs listed below are not covered by Medicare. However, some of these drugs, such as Over-the-Counter drugs are covered under your Molina Medicare Complete Care (HMO SNP) Plan supplemental benefit (see Chapter 4, Section 2 Benefit Chart) and/or your Medicaid drug coverage.
For more information on Medicaid drug coverage, you should contact Member Services (Phone numbers for Member Services are printed on the back cover of this booklet) or your State Medicaid office (the contact information is listed in Chapter 2, Section 6).
1 Non-prescription drugs (also called over-the-counter drugs)
1 Drugs when used to promote fertility
1 Drugs when used for the relief of cough or cold symptoms
1 Drugs when used for cosmetic purposes or to promote hair growth
1 Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
1 Drugs when used for the treatment of sexual or erectile dysfunction
1 Drugs when used for treatment of anorexia, weight loss, or weight gain
1 Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale
SECTION 8 Show your plan membership card when you fill a prescription
Section 8.1 Show your membership card
To fill your prescription, show your plan membership card at the network pharmacy you choose. When you show your plan membership card, the network pharmacy will automatically bill the plan for our share of the costs of your covered prescription drug. You will need to pay the pharmacy your share of the cost when you pick up your prescription.
Section 8.2 What if you don't have your membership card with you?
If you don't have your plan membership card with you when you fill your prescription, ask the pharmacy to call the plan to get the necessary information.
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If the pharmacy is not able to get the necessary information, you may have to pay the full cost of the prescription when you pick it up. (You can then ask us to reimburse you for our share. See Chapter 7, Section 2.1 for information about how to ask the plan for reimbursement.)
SECTION 9 Part D drug coverage in special situations
Section 9.1
What if you're in a hospital or a skilled nursing facility for a stay that is covered by the plan?
If you are admitted to a hospital or to a skilled nursing facility for a stay covered by the plan, we will generally cover the cost of your prescription drugs during your stay. Once you leave the hospital or skilled nursing facility, the plan will cover your drugs as long as the drugs meet all of our rules for coverage. See the previous parts of this section that tell about the rules for getting drug coverage. Chapter 6 (What you pay for your Part D prescription drugs) gives more information about drug coverage and what you pay.
Section 9.2 What if you're a resident in a long-term care (LTC) facility?
Usually, a long-term care (LTC) facility (such as a nursing home) has its own pharmacy, or a pharmacy that supplies drugs for all of its residents. If you are a resident of a long-term care facility, you may get your prescription drugs through the facility's pharmacy as long as it is part of our network.
Check your Provider/Pharmacy Directory to find out if your long-term care facility's pharmacy is part of our network. If it isn't, or if you need more information, please contact Member Services (phone numbers are printed on the back cover of this booklet).
What if you're a resident in a long-term care (LTC) facility and become a new member of the plan?
If you need a drug that is not on our Drug List or is restricted in some way, the plan will cover a temporary supply of your drug during the first 90 days of your membership. The total supply will be for a maximum of 31 days, or less if your prescription is written for fewer days. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.) If you have been a member of the plan for more than 90 days and need a drug that is not on our Drug List or if the plan has any restriction on the drug's coverage, we will cover one 31-day supply, or less if your prescription is written for fewer days.
During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. Perhaps there is a different drug covered by the plan that might work just as well for you. Or you and your provider can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If you and your provider want to ask for an exception, Chapter 9, Section 7.4 tells what to do.
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Section 9.3
What if you're also getting drug coverage from an employer or retiree group plan?
Do you currently have other prescription drug coverage through your (or your spouse's) employer or retiree group? If so, please contact that group's benefits administrator. He or she can help you determine how your current prescription drug coverage will work with our plan.
In general, if you are currently employed, the prescription drug coverage you get from us will be secondary to your employer or retiree group coverage. That means your group coverage would pay first.
Special note about `creditable coverage':
Each year your employer or retiree group should send you a notice that tells if your prescription drug coverage for the next calendar year is "creditable" and the choices you have for drug coverage.
If the coverage from the group plan is "creditable," it means that the plan has drug coverage that is expected to pay, on average, at least as much as Medicare's standard prescription drug coverage.
Keep these notices about creditable coverage, because you may need them later. If you enroll in a Medicare plan that includes Part D drug coverage, you may need these notices to show that you have maintained creditable coverage. If you didn't get a notice about creditable coverage from your employer or retiree group plan, you can get a copy from your employer or retiree plan's benefits administrator or the employer or union.
Section 9.4 What if you're in Medicare-certified hospice?
Drugs are never covered by both hospice and our plan at the same time. If you are enrolled in Medicare hospice and require an anti-nausea, laxative, pain medication or antianxiety drug that is not covered by your hospice because it is unrelated to your terminal illness and related conditions, our plan must receive notification from either the prescriber or your hospice provider that the drug is unrelated before our plan can cover the drug. To prevent delays in receiving any unrelated drugs that should be covered by our plan, you can ask your hospice provider or prescriber to make sure we have the notification that the drug is unrelated before you ask a pharmacy to fill your prescription.
In the event you either revoke your hospice election or are discharged from hospice, our plan should cover all your drugs. To prevent any delays at a pharmacy when your Medicare hospice benefit ends, you should bring documentation to the pharmacy to verify your revocation or discharge. See the previous parts of this section that tell about the rules for getting drug coverage under Part D Chapter 6 (What you pay for your Part D prescription drugs) gives more information about drug coverage and what you pay.
SECTION 10 Programs on drug safety and managing medications
Section 10.1 Programs to help members use drugs safely We conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one provider who prescribes their drugs.
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We do a review each time you fill a prescription. We also review our records on a regular basis. During these reviews, we look for potential problems such as:
1 Possible medication errors
1 Drugs that may not be necessary because you are taking another drug to treat the same medical condition
1 Drugs that may not be safe or appropriate because of your age or gender
1 Certain combinations of drugs that could harm you if taken at the same time
1 Prescriptions written for drugs that have ingredients you are allergic to
1 Possible errors in the amount (dosage) of a drug you are taking.
1 Unsafe amounts of opioid pain medications
If we see a possible problem in your use of medications, we will work with your provider to correct the problem.
Section 10.2 Drug Management Program (DMP) to help members safely use their opioid medications
We have a program that can help make sure our members safely use their prescription opioid medications, and other medications that are frequently abused. This program is called a Drug Management Program (DMP). If you use opioid medications that you get from several doctors or pharmacies, we may talk to your doctors to make sure your use of opioid medications is appropriate and medically necessary. Working with your doctors, if we decide your use of prescription opioid or benzodiazpine medications is not safe, we may limit how you can get those medications. The limitations may be:
1 Requiring you to get all your prescriptions for opioid or benzodiazpine medications from a certain pharmacy(ies)
1 Requiring you to get all your prescriptions for opioid or benzodiazpine medications from a certain doctor(s)
1 Limiting the amount of opioid or benzodiazpine medications we will cover for you
If we think that one or more of these limitations should apply to you, we will send you a letter in advance. The letter will have information explaining the limitations we think should apply to you. You will also have an opportunity to tell us which doctors or pharmacies you prefer to use, and about any other information you think is important for us to know. After you've had the opportunity to respond, if we decide to limit your coverage for these medications, we will send you another letter confirming the limitation. If you think we made a mistake or you disagree with our determination that you are at-risk for prescription drug misuse or with the limitation, you and your prescriber have the right to ask us for an appeal. If you choose to appeal, we will review your case and give you a decision. If we continue to deny any part of your request related to the limitations that apply to your access to medications, we will automatically send your case to an independent reviewer outside of our plan. See Chapter 9 for information about how to ask for an appeal.
The DMP may not apply to you if you have certain medical conditions, such as cancer, you are receiving hospice, palliative, or end-of-life care, or live in a long-term care facility.
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Section 10.3 Medication Therapy Management (MTM) program to help members manage their medications
We have a program that can help our members with complex health needs.
This program is voluntary and free to members. A team of pharmacists and doctors developed the program for us. This program can help make sure that our members get the most benefit from the drugs they take. Our program is called a Medication Therapy Management (MTM) program.
Some members who take medications for different medical conditions and have high drug costs may be able to get services through an MTM program. A pharmacist or other health professional will give you a comprehensive review of all your medications. You can talk about how best to take your medications, your costs, and any problems or questions you have about your prescription and over-the-counter medications. You'll get a written summary of this discussion. The summary has a medication action plan that recommends what you can do to make the best use of your medications, with space for you to take notes or write down any follow-up questions. You'll also get a personal medication list that will include all the medications you're taking and why you take them.
It's a good idea to have your medication review before your yearly "Wellness" visit, so you can talk to your doctor about your action plan and medication list. Bring your action plan and medication list with you to your visit or anytime you talk with your doctors, pharmacists, and other health care providers. Also, keep your medication list with you (for example, with your ID) in case you go to the hospital or emergency room.
If we have a program that fits your needs, we will automatically enroll you in the program and send you information. If you decide not to participate, please notify us and we will withdraw you from the program. If you have any questions about these programs, please contact Member Services (phone numbers are printed on the back cover of this booklet).
CHAPTER 6
What you pay for your Part D prescription drugs
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Chapter 6. What you pay for your Part D prescription drugs
SECTION 1 Introduction .............................................................................................................120 Section 1.1 Use this chapter together with other materials that explain your drug coverage ................ 120 Section 1.2 Types of out-of-pocket costs you may pay for covered drugs ............................................ 120
SECTION 2 What you pay for a drug depends on which "drug payment stage" you are in when you get the drug ............................................................................................121
Section 2.1 What are the drug payment stages for Molina Medicare Complete Care (HMO SNP) members? ............................................................................................................................ 121
SECTION 3 We send you reports that explain payments for your drugs and which payment stage you are in .......................................................................................................122
Section 3.1 We send you a monthly report called the "Part D Explanation of Benefits" (the "Part D EOB") .................................................................................................................................. 122
Section 3.2 Help us keep our information about your drug payments up to date .................................. 122
SECTION 4 There is no deductible for Molina Medicare Complete Care (HMO SNP) ........... 123 Section 4.1 You do not pay a deductible for your Part D drugs ............................................................ 123
SECTION 5 During the Initial Coverage Stage, the plan pays its share of your drug costs and you pay your share ..........................................................................................123
Section 5.1 What you pay for a drug depends on the drug and where you fill your prescription .......... 123 Section 5.2 A table that shows your costs for a one-month supply of a drug ........................................ 124 Section 5.3 If your doctor prescribes less than a full month's supply, you may not have to pay the
cost of the entire month's supply ........................................................................................ 126 Section 5.4 A table that shows your costs for a long-term (up to a 90-day) supply of a drug ............... 127 Section 5.5 You stay in the Initial Coverage Stage until your total drug costs for the year reach
$4,130 .................................................................................................................................. 128
SECTION 6 During the Coverage Gap Stage, you receive a discount on brand name drugs and pay no more than 25% of the costs of generic drugs .................................. 129
Section 6.1 You stay in the Coverage Gap Stage until your out-of-pocket costs reach $6,550 ............ 129 Section 6.2 How Medicare calculates your out-of-pocket costs for prescription drugs ........................ 129
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SECTION 7 During the Catastrophic Coverage Stage, the plan pays all of the costs for your drugs ................................................................................................................131
Section 7.1 Once you are in the Catastrophic Coverage Stage, you will stay in this stage for the rest of the year ............................................................................................................................ 131
SECTION 8 What you pay for vaccinations covered by Part D depends on how and where you get them ............................................................................................................131
Section 8.1 Our plan may have separate coverage for the Part D vaccine medication itself and for the cost of giving you the vaccine ............................................................................................. 131
Section 8.2 You may want to call us at Member Services before you get a vaccination ...................... 132
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How can you get information about your drug costs
Because you are eligible for Medicaid, you qualify for and are getting "Extra Help" from Medicare to pay for your prescription drug plan costs. Because you are in the "Extra Help" program, some information in this Evidence of Coverage about the costs for Part D prescription drugs may not apply to you. We sent you a separate insert, called the "Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs" (also known as the "Low Income Subsidy Rider" or the "LIS Rider"), which tells you about your drug coverage. If you don't have this insert, please call Member Services and ask for the "LIS Rider." (Phone numbers for Member Services are printed on the back cover of this booklet.)
SECTION 1 Introduction
Section 1.1 Use this chapter together with other materials that explain your drug coverage
This chapter focuses on what you pay for your Part D prescription drugs. To keep things simple, we use "drug" in this chapter to mean a Part D prescription drug. As explained in Chapter 5, not all drugs are Part D drugs some drugs are excluded from Part D coverage by law. Some of the drugs excluded from Part D coverage are covered under Medicare Part A or Part B or under Medicaid.
To understand the payment information we give you in this chapter, you need to know the basics of what drugs are covered, where to fill your prescriptions, and what rules to follow when you get your covered drugs. Here are materials that explain these basics:
1 The plan's List of Covered Drugs (Formulary). To keep things simple, we call this the "Drug List." 4 This Drug List tells which drugs are covered for you.
4 It also tells which of the five (5) "cost sharing tiers" the drug is in and whether there are any restrictions on your coverage for the drug.
4 If you need a copy of the Drug List, call Member Services (phone numbers are printed on the back cover of this booklet). You can also find the Drug List on our website at MolinaHealthcare.com/Medicare. The Drug List on the website is always the most current.
1 Chapter 5 of this booklet. Chapter 5 gives the details about your prescription drug coverage, including rules you need to follow when you get your covered drugs. Chapter 5 also tells which types of prescription drugs are not covered by our plan.
1 The plan's Provider/Pharmacy Directory. In most situations you must use a network pharmacy to get your covered drugs (see Chapter 5 for the details). The Provider/Pharmacy Directory has a list of pharmacies in the plan's network. It also tells you which pharmacies in our network can give you a long-term supply of a drug (such as filling a prescription for a three-month's supply).
Section 1.2 Types of out-of-pocket costs you may pay for covered drugs
To understand the payment information we give you in this chapter, you need to know about the types of out-of-pocket costs you may pay for your covered services. The amount that you pay for a drug is called "cost sharing," and there are three ways you may be asked to pay.
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1 The "deductible" is the amount you must pay for drugs before our plan begins to pay its share. 1 "Copayment" means that you pay a fixed amount each time you fill a prescription. 1 "Coinsurance" means that you pay a percent of the total cost of the drug each time you fill a prescription.
SECTION 2 What you pay for a drug depends on which "drug payment stage" you are in when you get the drug
Section 2.1
What are the drug payment stages for Molina Medicare Complete Care (HMO SNP) members?
As shown in the table below, there are "drug payment stages" for your Medicare Part D prescription drug coverage under Molina Medicare Complete Care (HMO SNP). How much you pay for a drug depends on which of these stages you are in at the time you get a prescription filled or refilled.
Stage 1 Yearly Deductible
Stage
Stage 2 Initial Coverage
Stage
Stage 3 Coverage Gap
Stage
Stage 4 Catastrophic Coverage Stage
Because there is no deductible for the You begin in this stage During this stage, you pay During this stage,
plan, this payment stage does not when you fill your first 25% of the price for
the plan will pay
apply to you.
prescription of the year. brand name drugs plus a all of the costs of
If you receive "Extra Help" to pay During this stage, the portion of the dispensing your drugs for the
your prescription drugs, this payment plan pays its share of the fee) and 25% of the price rest of the calendar
stage does not apply to you.
cost of your drugs and for generic drugs.
year. (through
(Details are in Section 4 of this chapter.)
you pay your share of the cost.
You stay in this stage until your year-to-date
December 31, 2021).
You stay in this stage "out-of-pocket costs" (Details are in
until your year-to-date (your payments) reach a Section 7 of this
"total drug costs" (your total of $6,550. This
chapter.)
payments plus any
amount and rules for
Part D plan's payments) counting costs toward this
total $4,130.
amount have been set by
(Details are in Section 5 Medicare.
of this chapter.)
(Details are in Section 6
of this chapter.)
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SECTION 3 We send you reports that explain payments for your drugs and which payment stage you are in
Section 3.1
We send you a monthly report called the "Part D Explanation of Benefits" (the "Part D EOB")
Our plan keeps track of the costs of your prescription drugs and the payments you have made when you get your prescriptions filled or refilled at the pharmacy. This way, we can tell you when you have moved from one drug payment stage to the next. In particular, there are two types of costs we keep track of:
1 We keep track of how much you have paid. This is called your "out-of-pocket" cost.
1 We keep track of your "total drug costs." This is the amount you pay out-of-pocket or others pay on your behalf plus the amount paid by the plan.
Our plan will prepare a written report called the Part D Explanation of Benefits (it is sometimes called the "Part D EOB") when you have had one or more prescriptions filled through the plan during the previous month. The Part D EOB provides more information about the drugs you take, such as increases in price and other drugs with lower cost sharing that may be available. You should consult with your prescriber about these lower cost options. It includes:
1 Information for that month. This report gives the payment details about the prescriptions you have filled during the previous month. It shows the total drug costs, what the plan paid, and what you and others on your behalf paid.
1 Totals for the year since January 1. This is called "year-to-date" information. It shows you the total drug costs and total payments for your drugs since the year began.
1 Drug price information. This information will display cumulative percentage increases for each prescription claim.
1 Available lower cost alternative prescriptions. This will include information about other drugs with lower cost sharing for each prescription claim that may be available.
Section 3.2 Help us keep our information about your drug payments up to date
To keep track of your drug costs and the payments you make for drugs, we use records we get from pharmacies. Here is how you can help us keep your information correct and up to date:
1 Show your membership card when you get a prescription filled. To make sure we know about the prescriptions you are filling and what you are paying, show your plan membership card every time you get a prescription filled.
1 Make sure we have the information we need. There are times you may pay for prescription drugs when we will not automatically get the information we need to keep track of your out-of-pocket costs. To help us keep track of your out-of-pocket costs, you may give us copies of receipts for drugs that you have purchased. (If you are billed for a covered drug, you can ask our plan to pay our share of the cost for the drug. For instructions on how to do this, go to Chapter 7, Section 2 of this booklet.) Here are some types of situations
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when you may want to give us copies of your drug receipts to be sure we have a complete record of what you have spent for your drugs: 4 When you purchase a covered drug at a network pharmacy at a special price or using a discount card that
is not part of our plan's benefit 4 When you made a copayment for drugs that are provided under a drug manufacturer patient assistance
program. 4 Any time you have purchased covered drugs at out-of-network pharmacies or other times you have paid
the full price for a covered drug under special circumstances. 1 Send us information about the payments others have made for you. Payments made by certain other
individuals and organizations also count toward your out-of-pocket costs and help qualify you for catastrophic coverage. For example, payments made by an AIDS drug assistance program (ADAP), the Indian Health Service, and most charities count toward your out-of-pocket costs. You should keep a record of these payments and send them to us so we can track your costs. 1 Check the written report we send you. When you receive a Part D Explanation of Benefits (a Part D EOB) in the mail, please look it over to be sure the information is complete and correct. If you think something is missing from the report, or you have any questions, please call us at Member Services (phone numbers are printed on the back cover of this booklet). Be sure to keep these reports. They are an important record of your drug expenses.
SECTION 4 There is no deductible for Molina Medicare Complete Care (HMO SNP)
Section 4.1 You do not pay a deductible for your Part D drugs
There is no deductible for Molina Medicare Complete Care (HMO SNP). You begin in the Initial Coverage Stage when you fill your first prescription of the year. See Section 5 for information about your coverage in the Initial Coverage Stage
SECTION 5 During the Initial Coverage Stage, the plan pays its share of your drug costs and you pay your share
Section 5.1 What you pay for a drug depends on the drug and where you fill your prescription
During the Initial Coverage Stage, the plan pays its share of the cost of your covered prescription drugs, and you pay your share (your copayment or coinsurance amount). Your share of the cost will vary depending on the drug and where you fill your prescription.
The plan has five (5) cost sharing tiers Every drug on the plan's Drug List is in one of five (5) cost sharing tiers. In general, the higher the cost sharing tier number, the higher your cost for the drug:
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1 Tier 1 - Preferred Generic (lowest cost share) 1 Tier 2 - Generic 1 Tier 3 - Preferred Brand 1 Tier 4 - Non-Preferred Drug 1 Tier 5 - Specialty Tier (highest cost share) To find out which cost sharing tier your drug is in, look it up in the plan's Drug List.
Your pharmacy choices How much you pay for a drug depends on whether you get the drug from:
1 A retail pharmacy that is in our plan's network 1 A pharmacy that is not in the plan's network 1 The plan's mail-order pharmacy For more information about these pharmacy choices and filling your prescriptions, see Chapter 5 in this booklet and the plan's Provider/Pharmacy Directory.
Section 5.2 A table that shows your costs for a one-month supply of a drug
During the Initial Coverage Stage, your share of the cost of a covered drug will be either a copayment or coinsurance. 1 "Copayment" means that you pay a fixed amount each time you fill a prescription. 1 "Coinsurance" means that you pay a percent of the total cost of the drug each time you fill a prescription.
As shown in the table below, the amount of the copayment or coinsurance depends on which cost sharing tier your drug is in. Please note:
1 If your covered drug costs less than the copayment amount listed in the chart, you will pay that lower price for the drug. You pay either the full price of the drug or the copayment amount, whichever is lower.
1 We cover prescriptions filled at out-of-network pharmacies in only limited situations. Please see Chapter 5, Section 2.5 for information about when we will cover a prescription filled at an out-of-network pharmacy.
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Your share of the cost when you get a one-month supply of a covered Part D prescription drug:
Tier
Standard retail cost Mail-order cost Long-term care Out-of-network cost
sharing (in-net- sharing
(LTC) cost sharing sharing
work)
(up to a 31-day sup- (up to a 31-day sup- (Coverage is limited
(up to a 31-day sup- ply)
ply)
to certain situa-
ply)
tions; see Chapter 5
for details.) (up to a
31-day supply)
Cost Sharing Tier 1 $0 copay (Preferred Generic)
$0 copay
$0 copay
$0 copay
Cost Sharing Tier 2 $0, $1.30, or $3.70
(Generic)
copay for generic drugs (including
brand drugs treated
as generic)
$0, $1.30, or $3.70 copay for generic drugs (including brand drugs treated as generic)
$0, $1.30, or $3.70 copay for generic drugs (including brand drugs treated as generic)
$0, $1.30, or $3.70 copay for generic drugs (including brand drugs treated as generic)
$0, $4.00, or $9.20 copay for all other drugs per prescription.
$0, $4.00, or $9.20 copay for all other drugs per prescription.
$0, $4.00, or $9.20 copay for all other drugs per prescription.
$0, $4.00, or $9.20 copay for all other drugs per prescription.
Cost Sharing Tier 3 $0, $1.30, or $3.70 (Preferred Brand) copay for generic
drugs (including brand drugs treated as generic)
$0, $1.30, or $3.70 copay for generic drugs (including brand drugs treated as generic)
$0, $1.30, or $3.70 copay for generic drugs (including brand drugs treated as generic)
$0, $1.30, or $3.70 copay for generic drugs (including brand drugs treated as generic)
$0, $4.00, or $9.20 copay for all other drugs per prescription.
$0, $4.00, or $9.20 copay for all other drugs per prescription.
$0, $4.00, or $9.20 copay for all other drugs per prescription.
$0, $4.00, or $9.20 copay for all other drugs per prescription.
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Tier
Standard retail cost Mail-order cost Long-term care Out-of-network cost
sharing (in-net- sharing
(LTC) cost sharing sharing
work)
(up to a 31-day sup- (up to a 31-day sup- (Coverage is limited
(up to a 31-day sup- ply)
ply)
to certain situa-
ply)
tions; see Chapter 5
for details.) (up to a
31-day supply)
Cost Sharing Tier 4 $0, $1.30, or $3.70 (Non-Preferred Drug) copay for generic
drugs (including brand drugs treated as generic)
$0, $1.30, or $3.70 copay for generic drugs (including brand drugs treated as generic)
$0, $1.30, or $3.70 copay for generic drugs (including brand drugs treated as generic)
$0, $1.30, or $3.70 copay for generic drugs (including brand drugs treated as generic)
$0, $4.00, or $9.20 copay for all other drugs per prescription.
$0, $4.00, or $9.20 copay for all other drugs per prescription.
$0, $4.00, or $9.20 copay for all other drugs per prescription.
$0, $4.00, or $9.20 copay for all other drugs per prescription.
Cost Sharing Tier 5 $0, $1.30, or $3.70
(Specialty Tier)
copay for generic drugs (including
brand drugs treated
as generic)
$0, $1.30, or $3.70 copay for generic drugs (including brand drugs treated as generic)
$0, $1.30, or $3.70 copay for generic drugs (including brand drugs treated as generic)
$0, $1.30, or $3.70 copay for generic drugs (including brand drugs treated as generic)
$0, $4.00, or $9.20 copay for all other drugs per prescription.
$0, $4.00, or $9.20 copay for all other drugs per prescription.
$0, $4.00, or $9.20 copay for all other drugs per prescription.
$0, $4.00, or $9.20 copay for all other drugs per prescription.
Section 5.3
If your doctor prescribes less than a full month's supply, you may not have to pay the cost of the entire month's supply
Typically, the amount you pay for a prescription drug covers a full month's supply of a covered drug. However, your doctor can prescribe less than a month's supply of drugs. There may be times when you want to ask your doctor about prescribing less than a month's supply of a drug (for example, when you are trying a medication for the first time that is known to have serious side effects). If your doctor prescribes less than a full month's supply, you will not have to pay for the full month's supply for certain drugs.
The amount you pay when you get less than a full month's supply will depend on whether you are responsible for paying coinsurance (a percentage of the total cost) or a copayment (a flat dollar amount).
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1 If you are responsible for coinsurance, you pay a percentage of the total cost of the drug. You pay the same percentage regardless of whether the prescription is for a full month's supply or for fewer days. However, because the entire drug cost will be lower if you get less than a full month's supply, the amount you pay will be less.
1 If you are responsible for a copayment for the drug, your copay will be based on the number of days of the drug that you receive. We will calculate the amount you pay per day for your drug (the "daily cost sharing rate") and multiply it by the number of days of the drug you receive.
4 Here's an example: Let's say the copay for your drug for a full month's supply (a 30-day supply) is $30. This means that the amount you pay per day for your drug is $1. If you receive a 7 days' supply of the drug, your payment will be $1 per day multiplied by 7 days, for a total payment of $7.
Daily cost sharing allows you to make sure a drug works for you before you have to pay for an entire month's supply. You can also ask your doctor to prescribe, and your pharmacist to dispense, less than a full month's supply of a drug or drugs, if this will help you better plan refill dates for different prescriptions so that you can take fewer trips to the pharmacy. The amount you pay will depend upon the days' supply you receive.
Section 5.4 A table that shows your costs for a long-term (up to a 90-day) supply of a drug
For some drugs, you can get a long-term supply (also called an "extended supply") when you fill your prescription. A long-term supply is up to a 90-day supply. (For details on where and how to get a long-term supply of a drug, see Chapter 5, Section 2.4.)
The table below shows what you pay when you get a long-term (up to a 90-day) supply of a drug.
Your share of the cost when you get a long-term supply of a covered Part D prescription drug:
Tier
Cost Sharing Tier 1 (Preferred Generic) Cost Sharing Tier 2 (Generic)
Standard retail cost sharing (innetwork)
(90-day supply)
Mail-order cost sharing (90-day supply)
$0 copay
$0 copay
$0, $1.30, or $3.70 copay for generic $0, $1.30, or $3.70 copay for generic
drugs (including brand drugs treated drugs (including brand drugs treated
as generic)
as generic)
$0, $4.00, or $9.20 copay for all other drugs per prescription.
$0, $4.00, or $9.20 copay for all other drugs per prescription.
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Tier
Cost Sharing Tier 3 (Preferred Brand)
Cost Sharing Tier 4 (Non-Preferred Drug)
Cost Sharing Tier 5 (Specialty Tier)
Standard retail cost sharing (innetwork)
(90-day supply)
Mail-order cost sharing (90-day supply)
$0, $1.30, or $3.70 copay for generic $0, $1.30, or $3.70 copay for generic
drugs (including brand drugs treated drugs (including brand drugs treated
as generic)
as generic)
$0, $4.00, or $9.20 copay for all other drugs per prescription.
$0, $4.00, or $9.20 copay for all other drugs per prescription.
$0, $1.30, or $3.70 copay for generic $0, $1.30, or $3.70 copay for generic
drugs (including brand drugs treated drugs (including brand drugs treated
as generic)
as generic)
$0, $4.00, or $9.20 copay for all other drugs per prescription.
$0, $4.00, or $9.20 copay for all other drugs per prescription.
A long-term supply is not available Mail order is not available for drugs
for drugs in tier five (5).
in tier five (5).
Section 5.5
You stay in the Initial Coverage Stage until your total drug costs for the year reach $4,130
You stay in the Initial Coverage Stage until the total amount for the prescription drugs you have filled and refilled reaches the $4,130 limit for the Initial Coverage Stage.
Your total drug cost is based on adding together what you have paid and what any Part D plan has paid:
1 What you have paid for all the covered drugs you have gotten since you started with your first drug purchase of the year. (See Section 6.2 for more information about how Medicare calculates your out-of-pocket costs.) This includes:
4 The total you paid as your share of the cost for your drugs during the Initial Coverage Stage.
1 What the plan has paid as its share of the cost for your drugs during the Initial Coverage Stage. (If you were enrolled in a different Part D plan at any time during 2021, the amount that plan paid during the Initial Coverage Stage also counts toward your total drug costs.)
The Part D Explanation of Benefits (Part D EOB) that we send to you will help you keep track of how much you and the plan, as well as any third parties, have spent on your behalf during the year. Many people do not reach the $4,130 limit in a year.
We will let you know if you reach this $4,130 amount. If you do reach this amount, you will leave the Initial Coverage Stage and move on to the Coverage Gap Stage.
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SECTION 6 During the Coverage Gap Stage, you receive a discount on brand name drugs and pay no more than 25% of the costs of generic drugs
Section 6.1 You stay in the Coverage Gap Stage until your out-of-pocket costs reach $6,550
When you are in the Coverage Gap Stage, the Medicare Coverage Gap Discount Program provides manufacturer discounts on brand name drugs. You pay 25% of the negotiated price and a portion of the dispensing fee for brand name drugs. Both the amount you pay and the amount discounted by the manufacturer count toward your out-of-pocket costs as if you had paid them and move you through the coverage gap. You also receive some coverage for generic drugs. You pay no more than 25% of the cost for generic drugs and the plan pays the rest. For generic drugs, the amount paid by the plan (75%) does not count toward your out-of-pocket costs. Only the amount you pay counts and moves you through the coverage gap. You continue paying the discounted price for brand name drugs and no more than 25% of the costs of generic drugs until your yearly out-of-pocket payments reach a maximum amount that Medicare has set. In 2021, that amount is $6,550. Medicare has rules about what counts and what does not count as your out-of-pocket costs. When you reach an out-of-pocket limit of $6,550, you leave the Coverage Gap Stage and move on to the Catastrophic Coverage Stage.
Section 6.2 How Medicare calculates your out-of-pocket costs for prescription drugs
Here are Medicare's rules that we must follow when we keep track of your out-of-pocket costs for your drugs.
These payments are included in your out-of-pocket costs
When you add up your out-of-pocket costs, you can include the payments listed below (as long as they are for Part D covered drugs and you followed the rules for drug coverage that are explained in Chapter 5 of this booklet):
1 The amount you pay for drugs when you are in any of the following drug payment stages: 4 The Initial Coverage Stage
4 The Coverage Gap Stage
1 Any payments you made during this calendar year as a member of a different Medicare prescription drug plan before you joined our plan.
It matters who pays:
1 If you make these payments yourself, they are included in your out-of-pocket costs.
1 These payments are also included if they are made on your behalf by certain other individuals or organizations. This includes payments for your drugs made by a friend or relative, by most charities, by AIDS drug assistance programs, or by the Indian Health Service. Payments made by Medicare's "Extra Help" Program are also included.
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1 Some of the payments made by the Medicare Coverage Gap Discount Program are included. The amount the manufacturer pays for your brand name drugs is included. But the amount the plan pays for your generic drugs is not included.
Moving on to the Catastrophic Coverage Stage:
When you (or those paying on your behalf) have spent a total of $6,550 in out-of-pocket costs within the calendar year, you will move from the Coverage Gap Stage to the Catastrophic Coverage Stage.
These payments are not included in your out-of-pocket costs When you add up your out-of-pocket costs, you are not allowed to include any of these types of payments for prescription drugs: 1 Drugs you buy outside the United States and its territories. 1 Drugs that are not covered by our plan. 1 Drugs you get at an out-of-network pharmacy that do not meet the plan's requirements for out-of-network
coverage. 1 Non-Part D drugs, including prescription drugs covered by Part A or Part B and other drugs excluded from
coverage by Medicare. 1 Payments you make toward prescription drugs not normally covered in a Medicare Prescription Drug Plan. 1 Payments made by the plan for your brand or generic drugs while in the Coverage Gap. 1 Payments for your drugs that are made by group health plans including employer health plans. 1 Payments for your drugs that are made by certain insurance plans and government-funded health programs
such as TRICARE and Veterans Affairs. 1 Payments for your drugs made by a third-party with a legal obligation to pay for prescription costs (for
example, workers compensation). Reminder: If any other organization such as the ones listed above pays part or all of your out-of-pocket costs for drugs, you are required to tell our plan. Call Member Services to let us know (phone numbers are printed on the back cover of this booklet).
How can you keep track of your out-of-pocket total? 1 We will help you. The Part D Explanation of Benefits (Part D EOB) report we send to you includes the current amount of your out-of-pocket costs (Section 3 in this chapter tells about this report). When you reach a total of $6,550 in out-of-pocket costs for the year, this report will tell you that you have left the Coverage Gap Stage and have moved on to the Catastrophic Coverage Stage.
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1 Make sure we have the information we need. Section 3.2 tells what you can do to help make sure that our records of what you have spent are complete and up to date.
SECTION 7 During the Catastrophic Coverage Stage, the plan pays all of the costs for your drugs
Section 7.1
Once you are in the Catastrophic Coverage Stage, you will stay in this stage for the rest of the year
You qualify for the Catastrophic Coverage Stage when your out-of-pocket costs have reached the $6,550 limit for the calendar year. Once you are in the Catastrophic Coverage Stage, you will stay in this payment stage until the end of the calendar year.
During this stage, the plan will pay all of the costs for your drugs.
SECTION 8 What you pay for vaccinations covered by Part D depends on how and where you get them
Section 8.1
Our plan may have separate coverage for the Part D vaccine medication itself and for the cost of giving you the vaccine
Our plan provides coverage of a number of Part D vaccines. We also cover vaccines that are considered medical benefits. You can find out about coverage of these vaccines by going to the Benefits Chart in Chapter 4, Section 2.1.
There are two parts to our coverage of Part D vaccinations: 1 The first part of coverage is the cost of the vaccine medication itself. The vaccine is a prescription medication. 1 The second part of coverage is for the cost of giving you the vaccine. (This is sometimes called the "administration" of the vaccine.)
What do you pay for a Part D vaccination? What you pay for a Part D vaccination depends on three things: 1. The type of vaccine (what you are being vaccinated for).
4 Some vaccines are considered medical benefits. You can find out about your coverage of these vaccines by going to Chapter 4, Benefits Chart (what is covered).
4 Other vaccines are considered Part D drugs. You can find these vaccines listed in the plan's List of Covered Drugs (Formulary).
2. Where you get the vaccine medication.
3. Who gives you the vaccine.
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What you pay at the time you get the Part D vaccination can vary depending on the circumstances. For example:
1 Sometimes when you get your vaccine, you will have to pay the entire cost for both the vaccine medication and for getting the vaccine. You can ask our plan to pay you back for our share of the cost.
1 Other times, when you get the vaccine medication or the vaccine, you will pay only your share of the cost.
To show how this works, here are three common ways you might get a Part D vaccine. Remember you are responsible for all of the costs associated with vaccines (including their administration) during the Deductible and Coverage Gap Stage of your benefit.
Situation 1:
You buy the Part D vaccine at the pharmacy and you get your vaccine at the network pharmacy. (Whether you have this choice depends on where you live. Some states do not allow pharmacies to administer a vaccination.)
1 You will have to pay the pharmacy the amount of your copayment for the vaccine and the cost of giving you the vaccine.
1 Our plan will pay the remainder of the costs.
Situation 2: You get the Part D vaccination at your doctor's office. 1 When you get the vaccination, you will pay for the entire cost of the vaccine and its administration.
1 You can then ask our plan to pay you back for our share of the cost by using the procedures that are described in Chapter 7 of this booklet (Asking us to pay our share of a bill you have received for covered medical services or drugs).
1 You will be reimbursed the amount you paid less your normal copayment for the vaccine (including administration) less any difference between the amount the doctor charges and what we normally pay. (If you get "Extra Help," we will reimburse you for this difference.)
Situation 3: You buy the Part D vaccine at your pharmacy, and then take it to your doctor's office where they give you the vaccine. 1 You will have to pay the pharmacy the amount of your copayment for the vaccine itself.
1 When your doctor gives you the vaccine, you will pay the entire cost for this service. You can then ask our plan to pay you back for our share of the cost by using the procedures described in Chapter 7 of this booklet.
1 You will be reimbursed the amount charged by the doctor for administering the vaccine.
1 Additionally, based upon your level of Medicaid eligibility, some or all cost sharing may be covered.
Section 8.2 You may want to call us at Member Services before you get a vaccination
The rules for coverage of vaccinations are complicated. We are here to help. We recommend that you call us first at Member Services whenever you are planning to get a vaccination. (Phone numbers for Member Services are printed on the back cover of this booklet.)
1 We can tell you about how your vaccination is covered by our plan and explain your share of the cost.
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1 We can tell you how to keep your own cost down by using providers and pharmacies in our network.
1 If you are not able to use a network provider and pharmacy, we can tell you what you need to do to ask us to pay you back for our share of the cost.
1 Additionally, based upon your level of Medicaid eligibility, some or all cost sharing may be covered.
CHAPTER 7
Asking us to pay our share of a bill you have received for covered medical services or drugs
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Chapter 7. Asking us to pay our share of a bill you have received for covered medical services or drugs
SECTION 1 Situations in which you should ask us to pay for your covered services or drugs ........................................................................................................................136
Section 1.1 If you pay for your covered services or drugs, or if you receive a bill, you can ask us for payment ............................................................................................................................... 136
SECTION 2 How to ask us to pay you back or to pay a bill you have received .................... 138 Section 2.1 How and where to send us your request for payment ......................................................... 138
SECTION 3 We will consider your request for payment and say yes or no .......................... 138 Section 3.1 We check to see whether we should cover the service or drug and how much we owe ..... 138 Section 3.2 If we tell you that we will not pay for all or part of the medical care or drug, you can make an appeal ............................................................................................................................. 139
SECTION 4 Other situations in which you should save your receipts and send copies to us ..............................................................................................................................139
Section 4.1 In some cases, you should send copies of your receipts to us to help us track your out-of-pocket drug costs ...................................................................................................... 139
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SECTION 1 Situations in which you should ask us to pay for your covered services or drugs
Section 1.1
If you pay for your covered services or drugs, or if you receive a bill, you can ask us for payment
Our network providers bill the plan directly for your covered services and drugs. If you get a bill for the full cost of medical care or drugs you have received, you should send this bill to us so that we can pay it. When you send us the bill, we will look at the bill and decide whether the services should be covered. If we decide they should be covered, we will pay the provider directly.
We can't reimburse you directly for a Medicaid service or item. If you get a bill that is more than your copay for Medicaid-covered services and items, send the bill to us. You should not pay the bill yourself. We will contact the provider directly and take care of the problem. But if you do pay the bill, you can get a refund from that health care provider if you followed the rules for getting the service or item.
If you have already paid for a Medicare service or item covered by the plan, you can ask our plan to pay you back (paying you back is often called "reimbursing" you). It is your right to be paid back by our plan whenever you've paid more than your share of the cost for medical services or drugs that are covered by our plan. When you send us a bill you have already paid, we will look at the bill and decide whether the services or drugs should be covered. If we decide they should be covered, we will pay you back for the services or drugs.
Here are examples of situations in which you may need to ask our plan to pay you back or to pay a bill you have received.
1. When you've received emergency or urgently needed medical care from a provider who is not in our plan's network
You can receive emergency services from any provider, whether or not the provider is a part of our network. When you receive emergency or urgently needed services from a provider who is not part of our network, you should ask the provider to bill the plan.
1 If you pay the entire amount yourself at the time you receive the care, you need to ask us to pay you back. Send us the bill, along with documentation of any payments you have made.
1 At times you may get a bill from the provider asking for payment that you think you do not owe. Send us this bill, along with documentation of any payments you have already made.
4 If the provider is owed anything, we will pay the provider directly.
4 If you have already paid for the service, we will pay you back.
2. When a network provider sends you a bill you think you should not pay
Network providers should always bill the plan directly. But sometimes they make mistakes, and ask you to pay for your services.
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1 You only have to pay your cost sharing amount when you get services covered by our plan. We do not allow providers to add additional separate charges, called "balance billing." This protection (that you never pay more than your cost sharing amount) applies even if we pay the provider less than the provider charges for a service and even if there is a dispute and we don't pay certain provider charges. We do not allow providers to bill you for covered services. We pay our providers directly, and we protect you from any charges. This is true even if we pay the provider less than the provider charges for a service. For more information about "balance billing," go to Chapter 4, Section 1.5.
1 Whenever you get a bill from a network provider, send us the bill. We will contact the provider directly and resolve the billing problem.
1 If you have already paid a bill to a network provider, send us the bill along with documentation of any payment you have made. You should ask us to pay you back for your covered services.
3. If you are retroactively enrolled in our plan
Sometimes a person's enrollment in the plan is retroactive. (Retroactive means that the first day of their enrollment has already passed. The enrollment date may even have occurred last year.)
If you were retroactively enrolled in our plan and you paid out-of-pocket for any of your covered services or drugs after your enrollment date, you can ask us to pay you back for our share of the costs. You will need to submit paperwork for us to handle the reimbursement. Please contact Member Services for additional information about how to ask us to pay you back and deadlines for making your request. (Phone numbers for Member Services are printed on the back cover of this booklet.)
4. When you use an out-of-network pharmacy to get a prescription filled
If you go to an out-of-network pharmacy and try to use your membership card to fill a prescription, the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the full cost of your prescription. (We cover prescriptions filled at out-of-network pharmacies only in a few special situations. Please go to Chapter 5, Section 2.5 to learn more.) Save your receipt and send a copy to us when you ask us to pay you back for our share of the cost.
5. When you pay the full cost for a prescription because you don't have your plan membership card with you
If you do not have your plan membership card with you, you can ask the pharmacy to call the plan or to look up your plan enrollment information. However, if the pharmacy cannot get the enrollment information they need right away, you may need to pay the full cost of the prescription yourself. Save your receipt and send a copy to us when you ask us to pay you back for our share of the cost.
6. When you pay the full cost for a prescription in other situations
You may pay the full cost of the prescription because you find that the drug is not covered for some reason.
1 For example, the drug may not be on the plan's List of Covered Drugs (Formulary); or it could have a requirement or restriction that you didn't know about or don't think should apply to you. If you decide to get the drug immediately, you may need to pay the full cost for it.
1 Save your receipt and send a copy to us when you ask us to pay you back. In some situations, we may need to get more information from your doctor in order to pay you back for our share of the cost of the drug.
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1 A billing error at the Pharmacy in reference to a formulary medication.
When you send us a request for payment, we will review your request and decide whether the service or drug should be covered. This is called making a "coverage decision." If we decide it should be covered, we will pay for our share of the cost for the service or drug. If we deny your request for payment, you can appeal our decision. Chapter 9 of this booklet (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) has information about how to make an appeal.
SECTION 2 How to ask us to pay you back or to pay a bill you have received
Section 2.1 How and where to send us your request for payment
Send us your request for payment, along with your bill and documentation of any payment you have made. It's a good idea to make a copy of your bill and receipts for your records.
Mail your request for payment together with any bills or receipts to us at this address:
Medical Services reimbursements:
Molina Healthcare Attn: Medicare Member Services 200 Oceangate, Suite 100 Long Beach, CA 90802
Or fax to (310) 507-6186
Part D reimbursements:
Molina Healthcare Attn: Medicare Pharmacy Department 7050 Union Park Center, Suite 200 Midvale, UT 84047
You must submit your claim to us within one (1) calendar year of the date you received the service, item, or drug.
Contact Member Services if you have any questions (phone numbers are printed on the back cover of this booklet). If you receive bills and you don't know what to do about those bills, we can help. You can also call if you want to give us more information about a request for payment you have already sent to us.
SECTION 3 We will consider your request for payment and say yes or no
Section 3.1
We check to see whether we should cover the service or drug and how much we owe
When we receive your request for payment, we will let you know if we need any additional information from you. Otherwise, we will consider your request and make a coverage decision.
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1 If we decide that the medical care or drug is covered and you followed all the rules for getting the care or drug, we will pay for our share of the cost for the service. If you have already paid for the service or drug, we will mail your reimbursement of our share of the cost to you. If you have not paid for the service or drug yet, we will mail the payment directly to the provider. (Chapter 3 explains the rules you need to follow for getting your medical services covered. Chapter 5 explains the rules you need to follow for getting your Part D prescription drugs covered.)
1 If we decide that the medical care or drug is not covered, or you did not follow all the rules, we will not pay for our share of the cost of the care or drug. Instead, we will send you a letter that explains the reasons why we are not sending the payment you have requested and your rights to appeal that decision.
Section 3.2
If we tell you that we will not pay for all or part of the medical care or drug, you can make an appeal
If you think we have made a mistake in turning down your request for payment or you don't agree with the amount we are paying, you can make an appeal. If you make an appeal, it means you are asking us to change the decision we made when we turned down your request for payment.
For the details on how to make this appeal, go to Chapter 9 of this booklet (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)). The appeals process is a formal process with detailed procedures and important deadlines. If making an appeal is new to you, you will find it helpful to start by reading Section 5 of Chapter 9. Section 5 is an introductory section that explains the process for coverage decisions and appeals and gives definitions of terms such as "appeal." Then after you have read Section 5, you can go to the section in Chapter 9 that tells what to do for your situation:
1 If you want to make an appeal about getting paid back for a medical service, go to Section 6.3 in Chapter 9.
1 If you want to make an appeal about getting paid back for a drug, go to Section 7.5 of Chapter 9.
SECTION 4 Other situations in which you should save your receipts and send copies to us
Section 4.1
In some cases, you should send copies of your receipts to us to help us track your out-of-pocket drug costs
There are some situations when you should let us know about payments you have made for your drugs. In these cases, you are not asking us for payment. Instead, you are telling us about your payments so that we can calculate your out-of-pocket costs correctly. This may help you to qualify for the Catastrophic Coverage Stage more quickly.
Below is an example of a situation when you should send us copies of receipts to let us know about payments you have made for your drugs:
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When you get a drug through a patient assistance program offered by a drug manufacturer
Some members are enrolled in a patient assistance program offered by a drug manufacturer that is outside the plan benefits. If you get any drugs through a program offered by a drug manufacturer, you may pay a copayment to the patient assistance program.
1 Save your receipt and send a copy to us so that we can have your out-of-pocket expenses count toward qualifying you for the Catastrophic Coverage Stage.
1 Please note: Because you are getting your drug through the patient assistance program and not through the plan's benefits, we will not pay for any share of these drug costs. But sending a copy of the receipt allows us to calculate your out-of-pocket costs correctly and may help you qualify for the Catastrophic Coverage Stage more quickly.
Since you are not asking for payment in the case described above, this situation is not considered a coverage decision. Therefore, you cannot make an appeal if you disagree with our decision.
CHAPTER 8
Your rights and responsibilities
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Chapter 8. Your rights and responsibilities
SECTION 1 Our plan must honor your rights as a member of the plan ................................. 143
Section 1.1
We must provide information in a way that works for you (in languages other than English, in braille, in large print, or other alternate formats, etc.) Debemos proporcionar información de una manera que sea útil para usted (en otros idiomas además del inglés, en sistema braille, en letra grande, u otros formatos alternativos, etc.) .............................. 143
Section 1.2 We must ensure that you get timely access to your covered services and drugs ................ 143
Section 1.3 We must protect the privacy of your personal health information ...................................... 144
Section 1.4 We must give you information about the plan, its network of providers, and your covered services ................................................................................................................................ 150
Section 1.5 We must support your right to make decisions about your care ......................................... 151
Section 1.6 You have the right to make complaints and to ask us to reconsider decisions we have made .................................................................................................................................... 154
Section 1.7 What can you do if you believe you are being treated unfairly or your rights are not being respected? ............................................................................................................................ 155
Section 1.8 How to get more information about your rights .................................................................. 155
SECTION 2 You have some responsibilities as a member of the plan .................................. 155 Section 2.1 What are your responsibilities? ........................................................................................... 155
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SECTION 1 Our plan must honor your rights as a member of the plan
Section 1.1
We must provide information in a way that works for you (in languages other than English, in braille, in large print, or other alternate formats, etc.) Debemos proporcionar información de una manera que sea útil para usted (en otros idiomas además del inglés, en sistema braille, en letra grande, u otros formatos alternativos, etc.)
To get information from us in a way that works for you, please call Member Services (phone numbers are printed on the back cover of this booklet).
Our plan has people and free interpreter services available to answer questions from disabled and non-English speaking members. We can also give you information in braille, in large print, or other alternate formats at no cost if you need it. We are required to give you information about the plan's benefits in a format that is accessible and appropriate for you. To get information from us in a way that works for you, please call Member Services (phone numbers are printed on the back cover of this booklet).
If you have any trouble getting information from our plan in a format that is accessible and appropriate for you, please call to file a grievance with Member Services Department by calling, (800) 665-0898, 7 days a week, 8:00 a.m. to 8:00 p.m., local time. TTY users, please call 711. You may also file a complaint with Medicare by calling 1-800-MEDICARE (1-800-633-4227) or directly with the Office for Civil Rights. Contact information is included in this Evidence of Coverage or with this mailing, or you may contact Member Services (phone numbers are printed on the back cover of this booklet) for additional information.
Para obtener informacion de nosotros de una manera que sea util, favor de llamar al Departamento de Servicios para Miembros (los numeros telefonicos estan impresos en la contraportada de este folleto).
Nuestro plan tiene a personas que brindan servicios gratuitos de interprete de idiomas, los cuales estan disponibles a contester las preguntas de los miembros que no hablan el idioma ingles. Si usted necesita, tambien le podemos proporcionar la informacion en el Sistema Braille, en letra grande, u otros formatos alternativos, sin ningun costo a usted. Para obtener informacion de nosotros de una manera que sea util, favor de llamar al Departamento de Servicios para Miembros (los numeros telefonicos estan impresos en la contraportada de este folleto) o puede contactar civil.rights@molinahealthcare.com.
Si usted tiene cualquier problema para obtener la informacion de nuestro plan a causa de problemas relacionados con el idioma o por una descapacidad, favor de presentar su queja con el Departamento de Servicios para Miembros llamando al, (800) 665-0898, 7 dias a la semana, 8:00 a.m a 8:00 p.m., hora local. Usuarios de TTY, favor de llamar al 711. Tambien puede presenter su queja llamando a Medicare al 1-800- MEDICARE (1-800-633-4227) o directamente con la Oficina de Los Derechos Civiles. Esta infomacion puede ser encontrada en este document de Evidencia de Cobertura o con este envio, o puede comunicarse con el Departamento de Servicios para Miembros (los numeros telefonicos estan impresos en la contraportada de este folleto) para obtener información adicional.
Section 1.2 We must ensure that you get timely access to your covered services and drugs
As a member of our plan, you have the right to choose a primary care provider (PCP) in the plan's network to provide and arrange for your covered services (Chapter 3 explains more about this). Call Member Services to learn
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which doctors are accepting new patients (phone numbers are printed on the back cover of this booklet). You also have the right to go to a women's health specialist (such as a gynecologist) without a referral.
As a plan member, you have the right to get appointments and covered services from the plan's network of providers within a reasonable amount of time. This includes the right to get timely services from specialists when you need that care. You also have the right to get your prescriptions filled or refilled at any of our network pharmacies without long delays.
If you think that you are not getting your medical care or Part D drugs within a reasonable amount of time, Chapter 9, Section 11 of this booklet tells what you can do. (If we have denied coverage for your medical care or drugs and you don't agree with our decision, Chapter 9, Section 5 tells what you can do.)
Section 1.3 We must protect the privacy of your personal health information
Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws.
1 Your "personal health information" includes the personal information you gave us when you enrolled in this plan as well as your medical records and other medical and health information.
1 The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. We give you a written notice, called a "Notice of Privacy Practice," that tells about these rights and explains how we protect the privacy of your health information.
How do we protect the privacy of your health information?
1 We make sure that unauthorized people don't see or change your records.
1 In most situations, if we give your health information to anyone who isn't providing your care or paying for your care, we are required to get written permission from you first. Written permission can be given by you or by someone you have given legal power to make decisions for you.
1 There are certain exceptions that do not require us to get your written permission first. These exceptions are allowed or required by law.
4 For example, we are required to release health information to government agencies that are checking on quality of care.
4 Because you are a member of our plan through Medicare, we are required to give Medicare your health information including information about your Part D prescription drugs. If Medicare releases your information for research or other uses, this will be done according to Federal statutes and regulations.
You can see the information in your records and know how it has been shared with others
You have the right to look at your medical records held at the plan, and to get a copy of your records. We are allowed to charge you a fee for making copies. You also have the right to ask us to make additions or corrections to your medical records. If you ask us to do this, we will work with your health care provider to decide whether the changes should be made.
You have the right to know how your health information has been shared with others for any purposes that are not routine.
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If you have questions or concerns about the privacy of your personal health information, please call Member Services (phone numbers are printed on the back cover of this booklet). Your Privacy Dear Molina Medicare Member: Your privacy is important to us. We respect and protect your privacy. Molina uses and shares your information to provide you with health benefits. Molina wants to let you know how your information is used or shared. PHI means protected health information. PHI is health information that includes your name, member number or other identifiers, and is used or shared by Molina. Why does Molina use or share our Members' PHI?
1 To provide for your treatment 1 To pay for your health care 1 To review the quality of the care you get 1 To tell you about your choices for care 1 To run our health plan 1 To use or share PHI for other purposes as required or permitted by law. When does Molina need your written authorization (approval) to use or share your PHI? Molina needs your written approval to use or share your PHI for purposes not listed above. What are your privacy rights? 1 To look at your PHI 1 To get a copy of your PHI 1 To amend your PHI 1 To ask us to not use or share your PHI in certain ways 1 To get a list of certain people or places we have shared your PHI with How does Molina protect your PHI? Molina uses many ways to protect PHI across our health plan. This includes PHI in written word, spoken word, or in a computer. Below are some ways Molina protects PHI: 1 Molina has policies and rules to protect PHI. 1 Molina limits who may see PHI. Only Molina staff with a need to know PHI may use it. 1 Molina staff is trained on how to protect and secure PHI. 1 Molina staff must agree in writing to follow the rules and policies that protect and secure PHI 1 Molina secures PHI in our computers. PHI in our computers is kept private by using firewalls and passwords. What must Molina do by law?
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1 Keep your PHI private.
1 Give you written information, such as this on our duties and privacy practices about your PHI.
1 Follow the terms of our Notice of Privacy Practices.
What can you do if you feel your privacy rights have not been protected?
1 Call or write Molina and complain.
1 Complain to the Department of Health and Human Services.
We will not hold anything against you. Your action would not change your care in any way.
The above is only a summary. Our Notice of Privacy Practices has more information about how we use and share our Members' PHI. Our Notice of Privacy Practices is in the following section of this document. It is on our website at http://www.MolinaHealthcare.com/Medicare. You may also get a copy of our Notice of Privacy Practices by calling our Member Services Department at, (800) 665-0898 7 days a week, 8:00 a.m. to 8:00 p.m., local time. TTY/TDD users, please call 711.
NOTICE OF PRIVACY PRACTICES MOLINA MEDICARE
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Molina Healthcare of California ("Molina", "we" or "our") uses and shares protected health information about you to provide your health benefits as a Molina Medicare member. We use and share your information to carry out treatment, payment and health care operations. We also use and share your information for other reasons as allowed and required by law. We have the duty to keep your health information private and to follow the terms of this Notice. The effective date of this Notice is September 23, 2013.
PHI means protected health information. PHI is health information that includes your name, member number or other identifiers, and is used or shared by Molina.
Why does Molina use or share your PHI?
We use or share your PHI to provide you with health care benefits. Your PHI is used or shared for treatment, payment, and health care operations.
For Treatment
Molina may use or share your PHI to give you, or arrange for, your medical care. This treatment also includes referrals between your doctors or other health care providers. For example, we may share information about your health condition with a specialist. This helps the specialist talk about your treatment with your doctor.
For Payment
Molina may use or share PHI to make decisions on payment. This may include claims, approvals for treatment, and decisions about medical need. Your name, your condition, your treatment, and supplies given may be written on the bill. For example, we may let a doctor know that you have our benefits. We would also tell the doctor the amount of the bill that we would pay.
For Health Care Operations
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Molina may use or share PHI about you to run our health plan. For example, we may use information from your claim to let you know about a health program that could help you. We may also use or share your PHI to solve member concerns. Your PHI may also be used to see that claims are paid right. Health care operations involve many daily business needs. It includes but is not limited to the following:
1 Improving quality; 1 Actions in health programs to help members with certain conditions (such as asthma); 1 Conducting or arranging for medical review; 1 Legal services, including fraud and abuse detection and prosecution programs; 1 Actions to help us obey laws; 1 Address member needs, including solving complaints and grievances. We will share your PHI with other companies ("business associates") that perform different kinds of activities for our health plan. We may also use your PHI to give you reminders about your appointments. We may use your PHI to give you information about other treatment, or other health-related benefits and services. When can Molina use or share your PHI without getting written authorization (approval) from you? In addition to treatment, payment and health care operations, the law allows or requires Molina to use and share your PHI for several other purposes, including the following: Required by law We will use or share information about you as required by law. We will share your PHI when required by the Secretary of the Department of Health and Human Services (HHS). This may be for a court case, other legal review, or when required for law enforcement purposes. Public Health Your PHI may be used or shared for public health activities. This may include helping public health agencies to prevent or control disease. Health Care Oversight Your PHI may be used or shared with government agencies. They may need your PHI for audits. Research Your PHI may be used or shared for research in certain cases, such as when approved by a privacy or institutional review board. Legal or Administrative Proceedings Your PHI may be used or shared for legal proceedings, such as in response to a court order. Law Enforcement Your PHI may be used or shared with police for law enforcement purposes, such as to help find a suspect, witness or missing person. Health and Safety
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PHI may be shared to prevent a serious threat to public health or safety.
Government Functions
Your PHI may be shared with the government for special functions, such as national security activities.
Victims of Abuse, Neglect or Domestic Violence
Your PHI may be shared with legal authorities if we believe that a person is a victim of abuse or neglect.
Workers Compensation
Your PHI may be used or shared to obey Workers Compensation laws.
Other Disclosures
PHI may be shared with funeral directors or coroners to help them to do their jobs.
When does Molina need your written authorization (approval) to use or share your PHI?
Molina needs your written approval to use or share your PHI for a purpose other than those listed in this Notice. Molina needs your authorization before we disclose your PHI for the following: (1) most uses and disclosures of psychotherapy notes; (2) uses and disclosures for marketing purposes; and (3) uses and disclosures that involve the sale of PHI. You may cancel a written approval that you have given us. Your cancellation will not apply to actions already taken by us because of the approval you already gave to us.
What are your health information rights?
You have the right to:
1 Request Restrictions on PHI Uses or Disclosures (Sharing of Your PHI) You may ask us not to share your PHI to carry out treatment, payment or health care operations. You may also ask us to not to share your PHI with family, friends or other persons you name who are involved in your health care. However, we are not required to agree to your request. You will need to make your request in writing. You may use Molina's form to make your request.
1 Request Confidential Communications of PHI You may ask Molina to give you your PHI in a certain way or at a certain place to help keep your PHI private. We will follow reasonable requests, if you tell us how sharing all or a part of that PHI could put your life at risk. You will need to make your request in writing. You may use Molina's form to make your request.
1 Review and Copy Your PHI You have a right to review and get a copy of your PHI held by us. This may include records used in making coverage, claims and other decisions as a Molina member. You will need to make your request in writing. You may use Molina's form to make your request. We may charge you a reasonable fee for copying and mailing the records. In certain cases, we may deny the request. Important Note: We do not have complete copies of your medical records. If you want to look at, get a copy of, or change your medical records, please contact your doctor or clinic.
1 Amend Your PHI You may ask that we amend (change) your PHI. This involves only those records kept by us about you as a member. You will need to make your request in writing. You may use Molina's form to make your request. You may file a letter disagreeing with us if we deny the request.
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1 Receive an Accounting of PHI Disclosures (Sharing of your PHI) You may ask that we give you a list of certain parties that we shared your PHI with during the six years prior to the date of your request. The list will not include PHI shared as follows:
4 for treatment, payment or health care operations;
4 to persons about their own PHI;
4 sharing done with your authorization;
4 incident to a use or disclosure otherwise permitted or required under applicable law;
4 as part of a limited data set in accordance with applicable law; or
4 PHI released in the interest of national security or for intelligence purposes.
We will charge a reasonable fee for each list if you ask for this list more than once in a 12-month period. You will need to make your request in writing. You may use Molina's form to request.
You may make any of the requests listed above, or may get a paper copy of this Notice. Please call Molina Member Services at (800) 665-0898, 7 days a week, 8:00 a.m. to 8:00 p.m., local time. TTY/ TDD users, please call 711.
What can you do if your rights have not been protected?
You may complain to Molina and to the Department of Health and Human Services if you believe your privacy rights have been violated. We will not do anything against you for filing a complaint. Your care and benefits will not change in any way.
You may complain to us at the following:
By Phone:
Molina Member Services (800) 665-0898 7 days a week, 8:00 a.m. to 8:00 p.m., local time. TTY/TDD users, please call 711.
In Writing:
Molina Healthcare of California Attention: Manager of Member Services 7050 Union Park Center, Suite 200 Midvale, UT 84047
You may file a complaint with the Secretary of the U.S. Department of Health and Human Services at:
Office for Civil Rights U.S. Department of Health & Human Services 90 7th Street, Suite 4-100 San Francisco, CA 94103 Phone: (800) 368-1019; TDD: (800) 537-7697; Fax (415) 437-8329
What are the duties of Molina?
Molina is required to:
1 Keep your PHI private;
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1 Give you written information such as this on our duties and privacy practices about your PHI;
1 Provide you with a notice in the event of any breach of your unsecured PHI:
1 Not use or disclose your genetic information for underwriting purposes;
1 Follow the terms of this Notice
This Notice is Subject to Change Molina reserves the right to change its information practices and terms of this Notice at any time. If we do, the new terms and practices will then apply to all PHI we keep. If we make any material changes, Molina will post the revised Notice on our web site and send the revised Notice, or information about the material change and how to obtain the revised Notice, in our next annual mailing to our members then covered by Molina.
Contact Information
If you have any questions, please contact the following office:
By Phone:
Molina Member Services (800) 665-0898 7 days a week, 8:00 a.m. to 8:00 p.m., local time. TTY/TDD users, please call 711.
In Writing:
Molina Healthcare of California Attention: Manager of Member Services 7050 Union Park Center, Suite 200 Midvale, UT 84047
Section 1.4
We must give you information about the plan, its network of providers, and your covered services
As a member of Molina Medicare Complete Care (HMO SNP), you have the right to get several kinds of information from us. (As explained above in Section 1.1, you have the right to get information from us in a way that works for you. This includes getting the information in languages other than English and in large print or other alternate formats.)
If you want any of the following kinds of information, please call Member Services (phone numbers are printed on the back cover of this booklet):
1 Information about our plan. This includes, for example, information about the plan's financial condition. It also includes information about the number of appeals made by members and the plan's performance ratings, including how it has been rated by plan members and how it compares to other Medicare health plans.
1 Information about our network providers including our network pharmacies.
4 For example, you have the right to get information from us about the qualifications of the providers and pharmacies in our network and how we pay the providers in our network.
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4 For a list of the providers and pharmacies in the plan's network, see the Provider/Pharmacy Directory.
4 For more detailed information about our providers or pharmacies, you can call Member Services (phone numbers are printed on the back cover of this booklet) or visit our website at MolinaHealthcare.com/Medicare.
1 Information about your coverage and the rules you must follow when using your coverage.
4 In Chapters 3 and 4 of this booklet, we explain what medical services are covered for you, any restrictions to your coverage, and what rules you must follow to get your covered medical services.
4 To get the details on your Part D prescription drug coverage, see Chapters 5 and 6 of this booklet plus the plan's List of Covered Drugs (Formulary). These chapters, together with the List of Covered Drugs (Formulary), tell you what drugs are covered and explain the rules you must follow and the restrictions to your coverage for certain drugs.
4 If you have questions about the rules or restrictions, please call Member Services (phone numbers are printed on the back cover of this booklet).
1 Information about why something is not covered and what you can do about it.
4 If a medical service or Part D drug is not covered for you, or if your coverage is restricted in some way, you can ask us for a written explanation. You have the right to this explanation even if you received the medical service or drug from an out-of-network provider or pharmacy.
4 If you are not happy or if you disagree with a decision we make about what medical care or Part D drug is covered for you, you have the right to ask us to change the decision. You can ask us to change the decision by making an appeal. For details on what to do if something is not covered for you in the way you think it should be covered, see Chapter 9 of this booklet. It gives you the details about how to make an appeal if you want us to change our decision. (Chapter 9 also tells about how to make a complaint about quality of care, waiting times, and other concerns.)
4 If you want to ask our plan to pay our share of a bill you have received for medical care or a Part D prescription drug, see Chapter 7 of this booklet.
Section 1.5 We must support your right to make decisions about your care
You have the right to know your treatment options and participate in decisions about your health care
You have the right to get full information from your doctors and other health care providers when you go for medical care. Your providers must explain your medical condition and your treatment choices in a way that you can understand.
You also have the right to participate fully in decisions about your health care. To help you make decisions with your doctors about what treatment is best for you, your rights include the following:
1 To know about all of your choices. This means that you have the right to be told about all of the treatment options that are recommended for your condition, no matter what they cost or whether they are covered by our plan. It also includes being told about programs our plan offers to help members manage their medications and use drugs safely.
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1 To know about the risks. You have the right to be told about any risks involved in your care. You must be told in advance if any proposed medical care or treatment is part of a research experiment. You always have the choice to refuse any experimental treatments.
1 The right to say "no." You have the right to refuse any recommended treatment. This includes the right to leave a hospital or other medical facility, even if your doctor advises you not to leave. You also have the right to stop taking your medication. Of course, if you refuse treatment or stop taking medication, you accept full responsibility for what happens to your body as a result.
1 To receive an explanation if you are denied coverage for care. You have the right to receive an explanation from us if a provider has denied care that you believe you should receive. To receive this explanation, you will need to ask us for a coverage decision. Chapter 9 of this booklet tells how to ask the plan for a coverage decision.
You have the right to give instructions about what is to be done if you are not able to make medical decisions for yourself
Sometimes people become unable to make health care decisions for themselves due to accidents or serious illness. You have the right to say what you want to happen if you are in this situation. This means that, if you want to, you can:
1 Fill out a written form to give someone the legal authority to make medical decisions for you if you ever become unable to make decisions for yourself.
1 Give your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself.
The legal documents that you can use to give your directions in advance in these situations are called "advance directives." There are different types of advance directives and different names for them. Documents called "living will" and "power of attorney for health care" are examples of advance directives.
If you want to use an "advance directive" to give your instructions, here is what to do:
1 Get the form. If you want to have an advance directive, you can get a form from your lawyer, from a social worker, or from some office supply stores. You can sometimes get advance directive forms from organizations that give people information about Medicare. You can also contact Member Services to ask for the forms (phone numbers are printed on the back cover of this booklet).
1 The forms are also available through a link to Caring Connections on the Molina Medicare website or at http://www.caringinfo.org/i4a/pages/index.cfm?pageid=3289
1 Fill it out and sign it. Regardless of where you get this form, keep in mind that it is a legal document. You should consider having a lawyer help you prepare it.
1 Give copies to appropriate people. You should give a copy of the form to your doctor and to the person you name on the form as the one to make decisions for you if you can't. You may want to give copies to close friends or family members as well. Be sure to keep a copy at home.
If you know ahead of time that you are going to be hospitalized, and you have signed an advance directive, take a copy with you to the hospital.
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1 If you are admitted to the hospital, they will ask you whether you have signed an advance directive form and whether you have it with you.
1 If you have not signed an advance directive form, the hospital has forms available and will ask if you want to sign one.
Remember, it is your choice whether you want to fill out an advance directive (including whether you want to sign one if you are in the hospital). According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive.
What if your instructions are not followed? If you have signed an advance directive, and you believe that a doctor or hospital did not follow the instructions in it, you may file a complaint with
For complaints regarding healthcare professionals: Medical Board of California Central Complaint Unit 2005 Evergreen Street, Suite 1200 Sacramento, CA 95815 Phone: (800) 633-2322, TTY: (916) 263-0935 Fax: (916) 263-2435
For complaints regarding healthcare facilities and Hospitals:
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Los Angeles District Office Health Facilities Inspection Division Administration 12440 E. Imperial Highway, Room 522 Norwalk, CA 90650 Phone: (850) 245-4339 Fax: (562) 406-8801
Riverside District Office 625 E. Carnegie Drive, Suite 280 San Bernardino, CA 92408 Phone: (888) 354-9203 Fax: (909) 388-7174
San Bernardino District Office 464 West Fourth Street, Suite 529 San Bernardino, CA 92401 Phone: (800) 344-2896 Fax: (909) 888-2315
San Diego North District Office 7575 Metropolitan Drive, Suite 104 San Diego, CA 92108-4402 Phone: (800) 824-0613 Fax: (619) 278-3725
San Diego South District Office 7575 Metropolitan Drive, Suite 211 San Diego, CA 92108-4402 Phone: (866) 706-0759 Fax: (619) 688-6444
Section 1.6
You have the right to make complaints and to ask us to reconsider decisions we have made
If you have any problems or concerns about your covered services or care, Chapter 9 of this booklet tells what you can do. It gives the details about how to deal with all types of problems and complaints. What you need to do to follow up on a problem or concern depends on the situation. You might need to ask our plan to make a coverage decision for you, make an appeal to us to change a coverage decision, or make a complaint. Whatever you do ask for a coverage decision, make an appeal, or make a complaint we are required to treat you fairly.
You have the right to get a summary of information about the appeals and complaints that other members have filed against our plan in the past. To get this information, please call Member Services (phone numbers are printed on the back cover of this booklet).
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Section 1.7
What can you do if you believe you are being treated unfairly or your rights are not being respected?
If it is about discrimination, call the Office for Civil Rights
If you believe you have been treated unfairly or your rights have not been respected due to your race, disability, religion, sex, health, ethnicity, creed (beliefs), age, or national origin, you should call the Department of Health and Human Services' Office for Civil Rights at 1-800-368-1019 or TTY 1-800-537-7697, or call your local Office for Civil Rights.
Is it about something else?
If you believe you have been treated unfairly or your rights have not been respected, and it's not about discrimination, you can get help dealing with the problem you are having:
1 You can call Member Services (phone numbers are printed on the back cover of this booklet).
1 You can call the State Health Insurance Assistance Program. For details about this organization and how to contact it, go to Chapter 2, Section 3.
1 Or, you can call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
Section 1.8 How to get more information about your rights
There are several places where you can get more information about your rights: 1 You can call Member Services (phone numbers are printed on the back cover of this booklet). 1 You can call the State Health Insurance Assistance Program. For details about this organization and how to contact it, go to Chapter 2, Section 3. 1 You can contact Medicare. 4 You can visit the Medicare website to read or download the publication "Medicare Rights & Protections." (The publication is available at: www.medicare.gov/Pubs/pdf/11534-Medicare-Rights-and-Protections. pdf.) 4 Or, you can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
SECTION 2 You have some responsibilities as a member of the plan
Section 2.1 What are your responsibilities? Things you need to do as a member of the plan are listed below. If you have any questions, please call Member Services (phone numbers are printed on the back cover of this booklet). We're here to help.
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1 Get familiar with your covered services and the rules you must follow to get these covered services. Use this Evidence of Coverage booklet to learn what is covered for you and the rules you need to follow to get your covered services.
4 Chapters 3 and 4 give the details about your medical services, including what is covered, what is not covered, rules to follow, and what you pay.
4 Chapters 5 and 6 give the details about your coverage for Part D prescription drugs.
1 If you have any other health insurance coverage or prescription drug coverage in addition to our plan, you are required to tell us. Please call Member Services to let us know (phone numbers are printed on the back cover of this booklet).
4 We are required to follow rules set by Medicare and Medicaid to make sure that you are using all of your coverage in combination when you get your covered services from our plan. This is called "coordination of benefits" because it involves coordinating the health and drug benefits you get from our plan with any other health and drug benefits available to you. We'll help you coordinate your benefits. (For more information about coordination of benefits, go to Chapter 1, Section 7.)
1 Tell your doctor and other health care providers that you are enrolled in our plan. Show your plan membership card and your medicaid card whenever you get your medical care or Part D prescription drugs.
1 Help your doctors and other providers help you by giving them information, asking questions, and following through on your care.
4 To help your doctors and other health providers give you the best care, learn as much as you are able to about your health problems and give them the information they need about you and your health. Follow the treatment plans and instructions that you and your doctors agree upon.
4 Make sure your doctors know all of the drugs you are taking, including over-the-counter drugs, vitamins, and supplements.
4 If you have any questions, be sure to ask. Your doctors and other health care providers are supposed to explain things in a way you can understand. If you ask a question and you don't understand the answer you are given, ask again.
1 Be considerate. We expect all our members to respect the rights of other patients. We also expect you to act in a way that helps the smooth running of your doctor's office, hospitals, and other offices.
1 Pay what you owe. As a plan member, you are responsible for these payments:
4 In order to be eligible for our plan, you must have Medicare Part A and Medicare Part B. For most Molina Medicare Complete Care (HMO SNP) members, Medicaid pays for your Part A premium (if you don't qualify for it automatically) and for your Part B premium. If Medicaid is not paying your Medicare premiums for you, you must continue to pay your Medicare premiums to remain a member of the plan.
4 For most of your medical services or drugs covered by the plan, you must pay your share of the cost when you get the service or drug. This will be a copayment (a fixed amount) or coinsurance (a percentage of the total cost). Chapter 6 tells what you must pay for your Part D prescription drugs.
4 If you get any medical services or drugs that are not covered by our plan or by other insurance you may have, you must pay the full cost.
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- If you disagree with our decision to deny coverage for a service or drug, you can make an appeal. Please see Chapter 9 of this booklet for information about how to make an appeal.
4 If you are required to pay the extra amount for Part D because of your higher income (as reported on your last tax return), you must pay the extra amount directly to the government to remain a member of the plan.
1 Tell us if you move. If you are going to move, it's important to tell us right away. Call Member Services (phone numbers are printed on the back cover of this booklet).
4 If you move outside of our plan service area, you cannot remain a member of our plan. (Chapter 1 tells about our service area.) We can help you figure out whether you are moving outside our service area. If you are leaving our service area, you will have a Special Enrollment Period when you can join any Medicare plan available in your new area. We can let you know if we have a plan in your new area.
4 If you move within our service area, we still need to know so we can keep your membership record up to date and know how to contact you.
4 If you move, it is also important to tell Social Security (or the Railroad Retirement Board). You can find phone numbers and contact information for these organizations in Chapter 2.
1 Call Member Services for help if you have questions or concerns. We also welcome any suggestions you may have for improving our plan.
4 Phone numbers and calling hours for Member Services are printed on the back cover of this booklet.
4 For more information on how to reach us, including our mailing address, please see Chapter 2.
CHAPTER 9
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)
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Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)
SECTION 1 Introduction .............................................................................................................162 Section 1.1 What to do if you have a problem or concern ..................................................................... 162 Section 1.2 What about the legal terms? ................................................................................................ 162
SECTION 2 You can get help from government organizations that are not connected with us ..............................................................................................................................162
Section 2.1 Where to get more information and personalized assistance .............................................. 162
SECTION 3 To deal with your problem, which process should you use? ............................. 165 Section 3.1 Should you use the process for Medicare benefits or Medicaid benefits? .......................... 165
PROBLEMS ABOUT YOUR MEDICARE BENEFITS ...................................................................... 166
SECTION 4 Handling problems about your Medicare benefits ............................................... 166 Section 4.1 Should you use the process for coverage decisions and appeals? Or should you use the process for making complaints? .......................................................................................... 166
SECTION 5 A guide to the basics of coverage decisions and appeals ................................. 166 Section 5.1 Asking for coverage decisions and making appeals: the big picture .................................. 166 Section 5.2 How to get help when you are asking for a coverage decision or making an appeal ......... 167 Section 5.3 Which section of this chapter gives the details for your situation? ..................................... 168
SECTION 6 Your medical care: How to ask for a coverage decision or make an appeal .... 168 Section 6.1 This section tells what to do if you have problems getting coverage for medical care or if you want us to pay you back for your care ...................................................................... 169 Section 6.2 Step-by-step: How to ask for a coverage decision (how to ask our plan to authorize or provide the medical care coverage you want) ..................................................................... 170 Section 6.3 Step-by-step: How to make a Level 1 Appeal (How to ask for a review of a medical care coverage decision made by our plan) .................................................................................. 173 Section 6.4 Step-by-step: How a Level 2 Appeal is done ...................................................................... 175 Section 6.5 What if you are asking us to pay you back for a bill you have received for medical care? .................................................................................................................................... 177
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SECTION 7 Your Part D prescription drugs: How to ask for a coverage decision or make an appeal ..................................................................................................................178
Section 7.1 This section tells you what to do if you have problems getting a Part D drug or you want us to pay you back for a Part D drug ................................................................................... 178
Section 7.2 What is an exception? ......................................................................................................... 180 Section 7.3 Important things to know about asking for exceptions ....................................................... 181 Section 7.4 Step-by-step: How to ask for a coverage decision, including an exception ........................ 182 Section 7.5 Step-by-step: How to make a Level 1 Appeal (how to ask for a review of a coverage
decision made by our plan) ................................................................................................. 185 Section 7.6 Step-by-step: How to make a Level 2 Appeal .................................................................... 187
SECTION 8 How to ask us to cover a longer inpatient hospital stay if you think the doctor is discharging you too soon ..................................................................................189
Section 8.1 During your inpatient hospital stay, you will get a written notice from Medicare that tells about your rights ................................................................................................................. 189
Section 8.2 Step-by-step: How to make a Level 1 Appeal to change your hospital discharge date ...... 190 Section 8.3 Step-by-step: How to make a Level 2 Appeal to change your hospital discharge date ...... 193 Section 8.4 What if you miss the deadline for making your Level 1 Appeal? ...................................... 194
SECTION 9 How to ask us to keep covering certain medical services if you think your coverage is ending too soon .................................................................................196
Section 9.1 This section is about three services only: Home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services .......................... 196
Section 9.2 We will tell you in advance when your coverage will be ending ....................................... 197 Section 9.3 Step-by-step: How to make a Level 1 Appeal to have our plan cover your care for a longer
time ...................................................................................................................................... 197 Section 9.4 Step-by-step: How to make a Level 2 Appeal to have our plan cover your care for a longer
time ...................................................................................................................................... 199 Section 9.5 What if you miss the deadline for making your Level 1 Appeal? ...................................... 200
SECTION 10 Taking your appeal to Level 3 and beyond ........................................................... 202 Section 10.1 Appeal Levels 3, 4 and 5 for Medical Service Requests ..................................................... 202 Section 10.2 Appeal Levels 3, 4 and 5 for Part D Drug Requests ........................................................... 204
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SECTION 11 How to make a complaint about quality of care, waiting times, customer service, or other concerns ....................................................................................................205
Section 11.1 What kinds of problems are handled by the complaint process? ........................................ 205 Section 11.2 The formal name for "making a complaint" is "filing a grievance" ................................... 207 Section 11.3 Step-by-step: Making a complaint ...................................................................................... 207 Section 11.4 You can also make complaints about quality of care to the Quality Improvement
Organization ........................................................................................................................ 208 Section 11.5 You can also tell Medicare about your complaint .............................................................. 209 PROBLEMS ABOUT YOUR MEDICAID BENEFITS ....................................................................... 209
SECTION 12 Handling problems about your Medicaid benefits ............................................... 209
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SECTION 1 Introduction
Section 1.1 What to do if you have a problem or concern
This chapter explains the processes for handling problems and concerns. The process you use to handle your problem depends on two things:
1. Whether your problem is about benefits covered by Medicare or Medicaid. If you would like help deciding whether to use the Medicare process or the Medicaid process, or both, please contact Member Services (phone numbers are printed on the back cover of this booklet).
2. The type of problem you are having: 4 For some types of problems, you need to use the process for coverage decisions and appeals. 4 For other types of problems, you need to use the process for making complaints.
These processes have been approved by Medicare. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures, and deadlines that must be followed by us and by you. Which one do you use? The guide in Section 3 will help you identify the right process to use.
Section 1.2 What about the legal terms?
There are technical legal terms for some of the rules, procedures, and types of deadlines explained in this chapter. Many of these terms are unfamiliar to most people and can be hard to understand. To keep things simple, this chapter explains the legal rules and procedures using simpler words in place of certain legal terms. For example, this chapter generally says "making a complaint" rather than "filing a grievance," "coverage decision" rather than "organization determination" or "coverage determination" or "at-risk determination," and "Independent Review Organization" instead of "Independent Review Entity." It also uses abbreviations as little as possible. However, it can be helpful and sometimes quite important for you to know the correct legal terms for the situation you are in. Knowing which terms to use will help you communicate more clearly and accurately when you are dealing with your problem and get the right help or information for your situation. To help you know which terms to use, we include legal terms when we give the details for handling specific types of situations.
SECTION 2 You can get help from government organizations that are not connected with us
Section 2.1 Where to get more information and personalized assistance
Sometimes it can be confusing to start or follow through the process for dealing with a problem. This can be especially true if you do not feel well or have limited energy. Other times, you may not have the knowledge you need to take the next step.
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Get help from an independent government organization
We are always available to help you. But in some situations you may also want help or guidance from someone who is not connected with us. You can always contact your State Health Insurance Assistance Program (SHIP). This government program has trained counselors in every state. The program is not connected with us or with any insurance company or health plan. The counselors at this program can help you understand which process you should use to handle a problem you are having. They can also answer your questions, give you more information, and offer guidance on what to do.
The services of SHIP counselors are free. You will find phone numbers in Chapter 2, Section 3 of this booklet.
You can also get help and information from Medicare
For more information and help in handling a problem, you can also contact Medicare. Here are two ways to get information directly from Medicare:
1 You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
1 You can visit the Medicare website (www.medicare.gov).
You can get help and information from Medicaid
Method CALL TTY
WRITE
California Department of Health Care Services (California's Medicaid Program) Contact Information
(916) 449-5000, Monday - Friday 8:00 a.m. - 5:00 p.m., local time
711
This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
Medi-Cal Managed Care P.O. Box 997413, MS 4400 Sacramento, CA 95899-7413 Physical Address: 1501 Capitol Ave., MS 4400 Sacramento, CA 95814
WEBSITE
http://www.dhcs.ca.gov/Pages/default.aspx
Method
CALL TTY
Medi-Cal Managed Care Office of the Ombudsman (California's Ombudsman Program) Contact Information
(888) 452-8609, Monday - Friday 8:00 a.m. - 5:00 p.m. local time, excluding holidays
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Method WRITE WEBSITE
Medi-Cal Managed Care Office of the Ombudsman (California's Ombudsman Program) Contact Information
This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
Office of the Ombudsman MS-4412 1501 Capitol Avenue P.O. Box 997413 Sacramento, Ca 95899-7413
http://www.dhcs.ca.gov/services/medi-cal/Pages/ MMCDOfficeoftheOmbudsman. aspx
Method CALL TTY
WRITE
WEBSITE
California Department of Aging Long-Term Care Ombudsman Program Contact Information
(800) 231-4024, Monday - Friday, 8:00 a.m. - 5:00 p.m. local time, excluding holidays
(800) 231-4024 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
California Department of Aging 1300 National Dr., Suite 200 Sacramento, CA 95834
http://www.aging.ca.gov/ProgramsProviders/LTCOP/
Method CALL TTY
WRITE
Livanta (California's Quality Improvement Organization) - Contact Information
(877) 588-1123, Monday-Friday: 9:00 a.m. - 5:00 p.m. (local time), 24 hour voicemail is available
(855) 887-6668
This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
Livanta BFCC-QIO Program 10820 Guilford Road, Suite 202 Annapolis Junction, MD 20701
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Method WEBSITE
Livanta (California's Quality Improvement Organization) - Contact Information https://www.livantaqio.com/
SECTION 3 To deal with your problem, which process should you use?
Section 3.1 Should you use the process for Medicare benefits or Medicaid benefits?
Because you have Medicare and get assistance from Medicaid, you have different processes that you can use to handle your problem or complaint. Which process you use depends on whether the problem is about Medicare benefits or Medicaid benefits. If your problem is about a benefit covered by Medicare, then you should use the Medicare process. If your problem is about a benefit covered by Medicaid, then you should use the Medicaid process. If you would like help deciding whether to use the Medicare process or the Medicaid process, please contact Member Services (phone numbers are printed on the back cover of this booklet). The Medicare process and Medicaid process are described in different parts of this chapter. To find out which part you should read, use the chart below.
To figure out which part of this chapter will help with your specific problem or concern, START HERE
Is your problem about Medicare benefits or Medicaid benefits? (If you would like help deciding whether your problem is about Medicare benefits or Medicaid benefits, please contact Member Services. Phone numbers for Member Services are printed on the back cover of this booklet.)
My problem is about Medicare benefits. Go to the next section of this chapter, Section 4, "Handling problems about your Medicare your benefits."
My problem is about Medicaid coverage. Skip ahead to Section 12 of this chapter, "Handling problems about your Medicaid benefits."
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PROBLEMS ABOUT YOUR MEDICARE BENEFITS
SECTION 4 Handling problems about your Medicare benefits
Section 4.1
Should you use the process for coverage decisions and appeals? Or should you use the process for making complaints?
If you have a problem or concern, you only need to read the parts of this chapter that apply to your situation. The chart below will help you find the right section of this chapter for problems or complaints about benefits covered by Medicare.
To figure out which part of this chapter will help with your problem or concern about your Medicare benefits, use this chart:
Is your problem or concern about your benefits or coverage? (This includes problems about whether particular medical care or prescription drugs are covered or not, the way in which they are covered, and problems related to payment for medical care or prescription drugs.)
Yes. My problem is about benefits or coverage.
Go on to the next section of this chapter, Section 5, "A guide to the basics of coverage decisions and appeals."
No. My problem is not about benefits or coverage.
Skip ahead to Section 11 at the end of this chapter: "How to make a complaint about quality of care, waiting times, customer service or other concerns."
SECTION 5 A guide to the basics of coverage decisions and appeals
Section 5.1 Asking for coverage decisions and making appeals: the big picture
The process for asking for coverage decisions and appeals deals with problems related to your benefits and coverage, including problems related to payment. This is the process you use for issues such as whether something is covered or not and the way in which something is covered.
Asking for coverage decisions A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. We are making a coverage decision whenever we decide what is covered for you and how much we pay. For example, your plan network doctor makes a (favorable) coverage decision for you
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whenever you receive medical care from him or her or if your network doctor refers you to a medical specialist. You or your doctor can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think that you need. In other words, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.
In some cases, we might decide a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.
Making an appeal
If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.
When you appeal a decision for the first time, this is called a Level 1 Appeal. In this appeal, we review the coverage decision we made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision. Under certain circumstances, which we discuss later, you can request an expedited or "fast coverage decision" or fast appeal of a coverage decision.
If we say no to all or part of your Level 1 Appeal, you can go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an Independent Review Organization that is not connected to us.
1 In some situations, your case will be automatically sent to the Independent Review Organization for a Level 2 Appeal.
1 In other situations, you will need to ask for a Level 2 Appeal.
1 See Section 6.4 of this chapter for more information about Level 2 Appeals.
If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through additional levels of appeal.
Section 5.2 How to get help when you are asking for a coverage decision or making an appeal
Would you like some help? Here are resources you may wish to use if you decide to ask for any kind of coverage decision or appeal a decision:
1 You can call us at Member Services (phone numbers are printed on the back cover of this booklet).
1 You can get free help from your State Health Insurance Assistance Program (see Section 2 of this chapter).
1 Your doctor can make a request for you.
4 For medical care, your doctor can request a coverage decision or a Level 1 Appeal on your behalf. If your appeal is denied at Level 1, it will be automatically forwarded to Level 2. To request any appeal after Level 2, your doctor must be appointed as your representative.
4 For Part D prescription drugs, your doctor or other prescriber can request a coverage decision or a Level 1 or Level 2 Appeal on your behalf. To request any appeal after Level 2, your doctor or other prescriber must be appointed as your representative.
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1 You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your "representative" to ask for a coverage decision or make an appeal.
4 There may be someone who is already legally authorized to act as your representative under State law.
4 If you want a friend, relative, your doctor or other provider, or other person to be your representative, call Member Services (phone numbers are printed on the back cover of this booklet) and ask for the "Appointment of Representative" form. (The form is also available on Medicare's website at www.cms. gov/Medicare/CMSForms/CMS-Forms/downloads/cms1696.pdf.)The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give us a copy of the signed form.
1 You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision or appeal a decision.
Section 5.3 Which section of this chapter gives the details for your situation?
There are four different types of situations that involve coverage decisions and appeals. Since each situation has different rules and deadlines, we give the details for each one in a separate section:
1 Section 6 of this chapter: "Your medical care: How to ask for a coverage decision or make an appeal"
1 Section 7 of this chapter: "Your Part D prescription drugs: How to ask for a coverage decision or make an appeal"
1 Section 8 of this chapter: "How to ask us to cover a longer inpatient hospital stay if you think the doctor is discharging you too soon"
1 Section 9 of this chapter: "How to ask us to keep covering certain medical services if you think your coverage is ending too soon" (Applies to these services only: home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services)
If you're not sure which section you should be using, please call Member Services (phone numbers are printed on the back cover of this booklet). You can also get help or information from government organizations such as your State Health Insurance Assistance Program (Chapter 2, Section 3, of this booklet has the phone numbers for this program).
SECTION 6 Your medical care: How to ask for a coverage decision or make an appeal
Have you read Section 5 of this chapter (A guide to "the basics" of coverage decisions and appeals)? If not, you may want to read it before you start this section.
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Section 6.1
This section tells what to do if you have problems getting coverage for medical care or if you want us to pay you back for your care
This section is about your benefits for medical care and services. These benefits are described in Chapter 4 of this booklet: Benefits Chart (what is covered). To keep things simple, we generally refer to "medical care coverage" or "medical care" in the rest of this section, instead of repeating "medical care or treatment or services" every time. The term "medical care" includes medical items and services as well as Medicare Part B prescription drugs. In some cases, different rules apply to a request for a Part B prescription drug. In those cases, we will explain how the rules for Part B prescription drugs are different from the rules for medical items and services.
This section tells what you can do if you are in any of the five following situations:
1. You are not getting certain medical care you want, and you believe that this care is covered by our plan.
2. Our plan will not approve the medical care your doctor or other medical provider wants to give you, and you believe that this care is covered by the plan.
3. You have received medical care that you believe should be covered by the plan, but we have said we will not pay for this care.
4. You have received and paid for medical care that you believe should be covered by the plan, and you want to ask our plan to reimburse you for this care.
5. You are being told that coverage for certain medical care you have been getting that we previously approved will be reduced or stopped, and you believe that reducing or stopping this care could harm your health.
1 NOTE: If the coverage that will be stopped is for hospital care, home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services, you need to read a separate section of this chapter because special rules apply to these types of care. Here's what to read in those situations:
4 Section 8 of this chapter: How to ask us to cover a longer inpatient hospital stay if you think the doctor is discharging you too soon.
4 Section 9 of this chapter: How to ask us to keep covering certain medical services if you think your coverage is ending too soon. This section is about three services only: home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services.
1 For all other situations that involve being told that medical care you have been getting will be stopped, use this section (Section 6) as your guide for what to do.
Which of these situations are you in?
If you are in this situation:
This is what you can do:
To find out whether we will cover the medical care You can ask us to make a coverage decision for you.
or services you want?
Go to the next section of this chapter, Section 6.2.
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If you are in this situation:
This is what you can do:
If we already told you that we will not cover or pay You can make an appeal. (This means you are asking us to
for a medical service in the way that you want it reconsider.)
to be covered or paid for?
Skip ahead to Section 6.3 of this chapter.
If you want to ask us to pay you back for medical You can send us the bill.
care you have already received and paid for.
Skip ahead to Section 6.5 of this chapter.
Section 6.2
Step-by-step: How to ask for a coverage decision (how to ask our plan to authorize or provide the medical care coverage you want)
Legal Terms
When a coverage decision involves your medical care, it is called an "organization determination."
Step 1: You ask our plan to make a coverage decision on the medical care you are requesting. If your health requires a quick response, you should ask us to make a "fast coverage decision."
Legal Terms
A "fast coverage decision" is called an "expedited determination."
How to request coverage for the medical care you want 1 Start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the medical care you want. You, your doctor, or your representative can do this. 1 For the details on how to contact us, go to Chapter 2, Section 1 and look for the section called How to contact us when you are asking for a coverage decision about your medical care.
Generally, we use the standard deadlines for giving you our decision
When we give you our decision, we will use the "standard" deadlines unless we have agreed to use the "fast" deadlines. A standard coverage decision means we will give you an answer within 14 calendar days after we receive your request for a medical item or service. If your request is for a Medicare Part B prescription drug, we will give you an answer within 72 hours after we receive your request. 1 For a request for a medical item or service we can take up to 14 more calendar days if you ask for
more time, or if we need information (such as medical records from out-of-network providers) that may benefit you. If we decide to take extra days to make the decision, we will tell you in writing. We can't take extra time to make a decision if your request is for a Medicare Part B prescription drug.
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1 If you believe we should not take extra days, you can file a "fast complaint" about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours. (The process for making a complaint is different from the process for coverage decisions and appeals. For more information about the process for making complaints, including fast complaints, see Section 11 of this chapter.)
If your health requires it, ask us to give you a "fast coverage decision"
1 A fast coverage decision means we will answer within 72 hours if your request is for a medical item or service. If your request is for a Medicare Part B prescription drug, we will answer within 24 hours.
4 For a request for a medical item or service we can take up to 14 more calendar days if we find that some information that may benefit you is missing (such as medical records from out-of-network providers), or if you need time to get information to us for the review. If we decide to take extra days, we will tell you in writing. We can't take extra time to make a decision if your request is for a Medicare Part B prescription drug.
4 If you believe we should not take extra days, you can file a "fast complaint" about our decision to take extra days. (For more information about the process for making complaints, including fast complaints, see Section 11 of this chapter.) We will call you as soon as we make the decision.
1 To get a fast coverage decision, you must meet two requirements:
4 You can get a fast coverage decision only if you are asking for coverage for medical care you have not yet received. (You cannot ask for a fast coverage decision if your request is about payment for medical care you have already received.)
4 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.
1 If your doctor tells us that your health requires a "fast coverage decision," we will automatically agree to give you a fast coverage decision.
1 If you ask for a fast coverage decision on your own, without your doctor's support, we will decide whether your health requires that we give you a fast coverage decision.
4 If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will send you a letter that says so (and we will use the standard deadlines instead).
4 This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision.
4 The letter will also tell how you can file a "fast complaint" about our decision to give you a standard coverage decision instead of the fast coverage decision you requested. (For more information about the process for making complaints, including fast complaints, see Section 11 of this chapter.)
Step 2: We consider your request for medical care coverage and give you our answer.
Deadlines for a "fast" coverage decision
1 Generally, for a fast coverage decision on a request for a medical item or service, we will give you our answer within 72 hours. If your request is for a Medicare Part B prescription drug, we will answer within 24 hours.
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4 As explained above, we can take up to 14 more calendar days under certain circumstances. If we decide to take extra days to make the coverage decision, we will tell you in writing. We can't take extra time to make a decision if your request is for a Medicare Part B prescription drug.
4 If you believe we should not take extra days, you can file a "fast complaint" about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours. (For more information about the process for making complaints, including fast complaints, see Section 11 of this chapter.)
4 If we do not give you our answer within 72 hours (or if there is an extended time period, by the end of that period), or 24 hours if your request is for a Part B prescription drug, you have the right to appeal. Section 6.3 below tells how to make an appeal.
1 If our answer is no to part or all of what you requested, we will send you a detailed written explanation as to why we said no.
Deadlines for a "standard" coverage decision
1 Generally, for a standard coverage decision on a request for a medical item or service, we will give you our answer within 14 calendar days of receiving your request. If your request is for a Medicare Part B prescription drug, we will give you an answer within 72 hours after we receive your request.
4 For a request for a medical item or service, we can take up to 14 more calendar days ("an extended time period") under certain circumstances. If we decide to take extra days to make the coverage decision, we will tell you in writing. We can't take extra time to make a decision if your request is for a Medicare Part B prescription drug.
4 If you believe we should not take extra days, you can file a "fast complaint" about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours. (For more information about the process for making complaints, including fast complaints, see Section 11 of this chapter.)
4 If we do not give you our answer within 14 calendar days (or if there is an extended time period, by the end of that period), or 72 hours if your request is for a Part B prescription drug, you have the right to appeal. Section 6.3 below tells how to make an appeal.
1 If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.
Step 3: If we say no to your request for coverage for medical care, you decide if you want to make an appeal.
1 If we say no, you have the right to ask us to reconsider and perhaps change this decision by making an appeal. Making an appeal means making another try to get the medical care coverage you want.
1 If you decide to make an appeal, it means you are going on to Level 1 of the appeals process (see Section 6.3 below).
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Section 6.3
Step-by-step: How to make a Level 1 Appeal (How to ask for a review of a medical care coverage decision made by our plan)
Legal Terms
An appeal to the plan about a medical care coverage decision is called a plan "reconsideration."
Step 1: You contact us and make your appeal. If your health requires a quick response, you must ask for a "fast appeal."
What to do
1 To start an appeal you, your doctor, or your representative, must contact us. For details on how to reach us for any purpose related to your appeal, go to Chapter 2, Section 1 and look for the section called How to contact us when you are making an appeal about your medical care.
1 If you are asking for a standard appeal, make your standard appeal in writing by submitting a request.
4 If you have someone appealing our decision for you other than your doctor, your appeal must include an Appointment of Representative form authorizing this person to represent you. (To get the form, call Member Services (phone numbers are printed on the back cover of this booklet) and ask for the "Appointment of Representative" form. It is also available on Medicare's website at www.cms.hhs.gov/ cmsforms/downloads/cms1696.pdf.) While we can accept an appeal request without the form, we cannot begin or complete our review until we receive it. If we do not receive the form within 44 calendar days after receiving your appeal request (our deadline for making a decision on your appeal), your appeal request will be dismissed. If this happens, we will send you a written notice explaining your right to ask the Independent Review Organization to review our decision to dismiss your appeal.
1 If you are asking for a fast appeal, make your appeal in writing or call us at the phone number shown in Chapter 2, Section 1 (How to contact us when you are making an appeal about your medical care).
1 You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, explain the reason your appeal is late when you make your appeal. We may give you more time to make your appeal. Examples of good cause for missing the deadline may include if you had a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.
1 You can ask for a copy of the information regarding your medical decision and add more information to support your appeal.
4 You have the right to ask us for a copy of the information regarding your appeal.
4 If you wish, you and your doctor may give us additional information to support your appeal.
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If your health requires it, ask for a "fast appeal" (you can make a request by calling us)
Legal Terms
A "fast appeal" is also called an "expedited reconsideration."
1 If you are appealing a decision we made about coverage for care that you have not yet received, you and/or your doctor will need to decide if you need a "fast appeal."
1 The requirements and procedures for getting a "fast appeal" are the same as those for getting a "fast coverage decision." To ask for a fast appeal, follow the instructions for asking for a fast coverage decision. (These instructions are given earlier in this section.)
1 If your doctor tells us that your health requires a "fast appeal," we will give you a fast appeal.
Step 2: We consider your appeal and we give you our answer.
1 When we are reviewing your appeal, we take another careful look at all of the information about your request for coverage of medical care. We check to see if we were following all the rules when we said no to your request.
1 We will gather more information if we need it. We may contact you or your doctor to get more information.
Deadlines for a "fast" appeal
1 When we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires us to do so.
4 If you ask for more time, or if we need to gather more information that may benefit you, we can take up to 14 more calendar days if your request is for a medical item or service. If we decide to take extra days to make the decision, we will tell you in writing. We can't take extra time to make a decision if your request is for a Medicare Part B prescription drug.
4 If we do not give you an answer within 72 hours (or by the end of the extended time period if we took extra days), we are required to automatically send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization. Later in this section, we tell you about this organization and explain what happens at Level 2 of the appeals process.
1 If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 72 hours after we receive your appeal.
1 If our answer is no to part or all of what you requested, we will automatically send your appeal to the Independent Review Organization for a Level 2 Appeal.
Deadlines for a "standard" appeal
1 If we are using the standard deadlines, we must give you our answer on a request for a medical item or service within 30 calendar days after we receive your appeal if your appeal is about coverage for services you have not yet received. If your request is for a Medicare Part B prescription drug, we will give you an answer within 7 calendar days after we receive your appeal if your appeal is about coverage for a Part B
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prescription drug you have not yet received. We will give you our decision sooner if your health condition requires us to.
4 However, if you ask for more time, or if we need to gather more information that may benefit you, we can take up to 14 more calendar days if your request is for a medical item or service. If we decide we need to take extra days to make the decision, we will tell you in writing. We can't take extra time to make a decision if your request is for a Medicare Part B prescription drug.
4 If you believe we should not take extra days, you can file a "fast complaint" about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours. (For more information about the process for making complaints, including fast complaints, see Section 11 of this chapter.)
4 If we do not give you an answer by the applicable deadline above (or by the end of the extended time period if we took extra days on your request for a medical item or service), we are required to send your request on to Level 2 of the appeals process. Then an Independent Review Organization will review it. Later in this section, we talk about this review organization and explain what happens at Level 2 of the appeals process.
1 If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 30 calendar days, or within 7 calendar days if your request is for a Medicare Part B prescription drug if your request is for a medical item or service, or within 7 calendar days if your request is for a Medicare Part B prescription drug.
1 If our answer is no to part or all of what you requested, we will automatically send your appeal to the Independent Review Organization for a Level 2 Appeal.
Step 3: If our plan says no to part or all of your appeal, your case will automatically be sent on to the next level of the appeals process.
1 To make sure we were following all the rules when we said no to your appeal, we are required to send your appeal to the "Independent Review Organization." When we do this, it means that your appeal is going on to the next level of the appeals process, which is Level 2.
Section 6.4 Step-by-step: How a Level 2 Appeal is done
If we say NO to your Level 1 Appeal, your case will automatically be sent on to the next level of the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews our decision for your first appeal. This organization decides whether the decision we made should be changed.
Legal Terms
The formal name for the "Independent Review Organization" is the "Independent Review Entity." It is sometimes called the "IRE."
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Step 1: The Independent Review Organization reviews your appeal.
1 The Independent Review Organization is an independent organization that is hired by Medicare. This organization is not connected with us and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the Independent Review Organization. Medicare oversees its work.
1 We will send the information about your appeal to this organization. This information is called your "case file." You have the right to ask us for a copy of your case file.
1 You have a right to give the Independent Review Organization additional information to support your appeal.
1 Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal.
If you had a "fast" appeal at Level 1, you will also have a "fast" appeal at Level 2
1 If you had a fast appeal to our plan at Level 1, you will automatically receive a fast appeal at Level 2. The review organization must give you an answer to your Level 2 Appeal within 72 hours of when it receives your appeal.
1 If your request is for a medical item or service and your request is for a medical item or service and the Independent Review Organization needs to gather more information that may benefit you, it can take up to 14 more calendar days. The Independent Review Organization can't take extra time to make a decision if your request is for a Medicare Part B prescription drug.
If you had a "standard" appeal at Level 1, you will also have a "standard" appeal at Level 2
1 If you had a standard appeal to our plan at Level 1, you will automatically receive a standard appeal at Level 2.
1 If your request is for a medical item or service, the review organization must give you an answer to your Level 2 Appeal within 30 calendar days of when it receives your appeal.
1 If your request is for a Medicare Part B prescription drug, the review organization must give you an answer to your Level 2 Appeal within 7 calendar days of when it receives your appeal.
1 If your request is for a medical item or service and your request is for a medical item or service and the Independent Review Organization needs to gather more information that may benefit you, it can take up to 14 more calendar days. The Independent Review Organization can't take extra time to make a decision if your request is for a Medicare Part B prescription drug.
Step 2: The Independent Review Organization gives you their answer.
The Independent Review Organization will tell you its decision in writing and explain the reasons for it.
1 If the review organization says yes to part or all of a request for a medical item or service, we must:
4 authorize the medical care coverage within 72 hours or
4 provide the service within 14 calendar days after we receive the decision from the review organization for standard requests or
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4 provide the service within 72 hours from the date we receive the decision from the review organization for expedited requests.
1 If the review organization says yes to part or all of a request for a Medicare Part B prescription drug, we must:
4 authorize or provide the Part B prescription drug under dispute within 72 hours after we receive the decision from the review organization for standard requests or
4 within 24 hours from the date we receive the decision from the review organization for expedited requests.
1 If this organization says no to part or all of your appeal, it means they agree with our plan that your request (or part of your request) for coverage for medical care should not be approved. (This is called "upholding the decision." It is also called "turning down your appeal.")
4 If the Independent Review Organization "upholds the decision" you have the right to a Level 3 Appeal. However, to make another appeal at Level 3, the dollar value of the medical care coverage you are requesting must meet a certain minimum. If the dollar value of the coverage you are requesting is too low, you cannot make another appeal, which means that the decision at Level 2 is final. The written notice you get from the Independent Review Organization will tell you how to find out the dollar amount to continue the appeals process.
Step 3: If your case meets the requirements, you choose whether you want to take your appeal further.
1 There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). See Section 10 of this chapter for more information.
1 If your Level 2 Appeal is turned down and you meet the requirements to continue with the appeals process, you must decide whether you want to go on to Level 3 and make a third appeal. The details on how to do this are in the written notice you get after your Level 2 Appeal.
1 The Level 3 Appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 10 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.
Section 6.5
What if you are asking us to pay you back for a bill you have received for medical care?
If you want to ask us for payment for medical care, start by reading Chapter 7 of this booklet: Asking us to pay our share of a bill you have received for covered medical services or drugs. Chapter 7 describes the situations in which you may need to ask for reimbursement or to pay a bill you have received from a provider. It also tells how to send us the paperwork that asks us for payment.
Asking for reimbursement is asking for a coverage decision from us
If you send us the paperwork that asks for reimbursement, you are asking us to make a coverage decision (for more information about coverage decisions, see Section 5.1 of this chapter). To make this coverage decision, we will check to see if the medical care you paid for is a covered service (see Chapter 4: Benefits Chart (what is
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covered)). We will also check to see if you followed all the rules for using your coverage for medical care (these rules are given in Chapter 3 of this booklet: Using the plan's coverage for your medical services).
We will say yes or no to your request
1 If the medical care you paid for is covered and you followed all the rules, we will send you the payment for your medical care within 60 calendar days after we receive your request. Or, if you haven't paid for the services, we will send the payment directly to the provider. When we send the payment, it's the same as saying yes to your request for a coverage decision.)
1 If the medical care is not covered, or you did not follow all the rules, we will not send payment. Instead, we will send you a letter that says we will not pay for the services and the reasons why in detail. (When we turn down your request for payment, it's the same as saying no to your request for a coverage decision.)
What if you ask for payment and we say that we will not pay?
If you do not agree with our decision to turn you down, you can make an appeal. If you make an appeal, it means you are asking us to change the coverage decision we made when we turned down your request for payment.
To make this appeal, follow the process for appeals that we describe in Section 5.3. Go to this section for step-by-step instructions. When you are following these instructions, please note:
1 If you make an appeal for reimbursement, we must give you our answer within 60 calendar days after we receive your appeal. (If you are asking us to pay you back for medical care you have already received and paid for yourself, you are not allowed to ask for a fast appeal.)
1 If the Independent Review Organization reverses our decision to deny payment, we must send the payment you have requested to you or to the provider within 30 calendar days. If the answer to your appeal is yes at any stage of the appeals process after Level 2, we must send the payment you requested to you or to the provider within 60 calendar days.
SECTION 7 Your Part D prescription drugs: How to ask for a coverage decision or make an appeal
Have you read Section 5 of this chapter (A guide to "the basics" of coverage decisions and appeals)? If not, you may want to read it before you start this section.
Section 7.1
This section tells you what to do if you have problems getting a Part D drug or you want us to pay you back for a Part D drug
Your benefits as a member of our plan include coverage for many prescription drugs. Please refer to our plan's List of Covered Drugs (Formulary). To be covered, the drug must be used for a medically accepted indication. (A "medically accepted indication" is a use of the drug that is either approved by the Food and Drug Administration or supported by certain reference books. See Chapter 5, Section 3 for more information about a medically accepted indication.)
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1 This section is about your Part D drugs only. To keep things simple, we generally say "drug" in the rest of this section, instead of repeating "covered outpatient prescription drug" or "Part D drug" every time.
1 For details about what we mean by Part D drugs, the List of Covered Drugs (Formulary), rules and restrictions on coverage, and cost information, see Chapter 5 (Using our plan's coverage for your Part D prescription drugs) and Chapter 6 (What you pay for your Part D prescription drugs).
Part D coverage decisions and appeals As discussed in Section 5 of this chapter, a coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your drugs.
Legal Terms
An initial coverage decision about your Part D drugs is called a "coverage determination."
Here are examples of coverage decisions you ask us to make about your Part D drugs:
1 You ask us to make an exception, including:
4 Asking us to cover a Part D drug that is not on the plan's List of Covered Drugs (Formulary)
4 Asking us to waive a restriction on the plan's coverage for a drug (such as limits on the amount of the drug you can get)
4 Asking to pay a lower cost sharing amount for a covered drug on a higher cost sharing tier
1 You ask us whether a drug is covered for you and whether you meet the requirements for coverage. (For example, when your drug is on the plan's List of Covered Drugs (Formulary) but we require you to get approval from us before we will cover it for you.)
4 Please note: If your pharmacy tells you that your prescription cannot be filled as written, the pharmacy will give you a written notice explaining how to contact us to ask for a coverage decision.
1 You ask us to pay for a prescription drug you already bought. This is a request for a coverage decision about payment.
If you disagree with a coverage decision we have made, you can appeal our decision.
This section tells you both how to ask for coverage decisions and how to request an appeal. Use the chart below to help you determine which part has information for your situation:
Which of these situations are you in?
If you are in this situation:
This is what you can do:
If you need a drug that isn't on our Drug List or You can ask us to make an exception. (This is a type of
need us to waive a rule or restriction on a drug we coverage decision.)
cover?
Start with Section 7.2 of this chapter.
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If you are in this situation:
This is what you can do:
If you want us to cover a drug on our Drug List and You can ask us for a coverage decision. you believe you meet any plan rules or restrictions Skip ahead to Section 7.4 of this chapter. (such as getting approval in advance) for the drug you need?
If you want to ask us to pay you back for a drug You can ask us to pay you back. (This is a type of coverage
you have already received and paid for?
decision.)
Skip ahead to Section 7.4 of this chapter.
If we already told you that we will not cover or pay You can make an appeal. (This means you are asking us to
for a drug in the way that you want it to be covered reconsider.)
or paid for.
Skip ahead to Section 7.5 of this chapter.
Section 7.2 What is an exception?
If a drug is not covered in the way you would like it to be covered, you can ask us to make an "exception." An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision. When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request. Here are three examples of exceptions that you or your doctor or other prescriber can ask us to make: 1. Covering a Part D drug for you that is not on our List of Covered Drugs (Formulary). (We call it the "Drug
List" for short.)
Legal Terms
Asking for coverage of a drug that is not on the Drug List is sometimes called asking for a "formulary exception."
1 If we agree to make an exception and cover a drug that is not on the Drug List, you will need to pay the cost sharing amount that applies to drugs in tier five (5). You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug.
2. Removing a restriction on our coverage for a covered drug. There are extra rules or restrictions that apply to certain drugs on our List of Covered Drugs (Formulary) (for more information, go to Chapter 5, Section 4).
Legal Terms
Asking for removal of a restriction on coverage for a drug is sometimes called asking for a "formulary exception."
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1 The extra rules and restrictions on coverage for certain drugs include: 4 Being required to use the generic version of a drug instead of the brand name drug. 4 Getting plan approval in advance before we will agree to cover the drug for you. (This is sometimes called "prior authorization.") 4 Being required to try a different drug first before we will agree to cover the drug you are asking for. (This is sometimes called "step therapy.") 4 Quantity limits. For some drugs, there are restrictions on the amount of the drug you can have. 4 B vs. D - Some drugs may be covered under Medicare part D or B, depending on the circumstances
1 If we agree to make an exception and waive a restriction for you, you can ask for an exception to the copayment or coinsurance amount we require you to pay for the drug.
3. Changing coverage of a drug to a lower cost sharing tier. Every drug on our Drug List is in one of five (5) cost sharing tiers. In general, the lower the cost sharing tier number, the less you will pay as your share of the cost of the drug.
Legal Terms
Asking to pay a lower price for a covered non-preferred drug is sometimes called asking for a "tiering exception."
1 If our drug list contains alternative drug(s) for treating your medical condition that are in a lower cost sharing tier than your drug, you can ask us to cover your drug at the cost sharing amount that applies to the alternative drug(s). This would lower your share of the cost for the drug. 0 If the drug you're taking is a brand name drug you can ask us to cover your drug at the cost sharing amount that applies to the lowest tier that contains brand name alternatives for treating your condition. 0 If the drug you're taking is a generic drug you can ask us to cover your drug at the cost sharing amount that applies to the lowest tier that contains either brand or generic alternatives for treating your condition. 1 You cannot ask us to change the cost sharing tier for any drug in tier five (5) Specialty. 1 If we approve your request for a tiering exception and there is more than one lower cost sharing tier with alternative drugs you can't take, you will usually pay the lowest amount.
Section 7.3 Important things to know about asking for exceptions
Your doctor must tell us the medical reasons Your doctor or other prescriber must give us a statement that explains the medical reasons for requesting an exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception.
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Typically, our Drug List includes more than one drug for treating a particular condition. These different possibilities are called "alternative" drugs. If an alternative drug would be just as effective as the drug you are requesting and would not cause more side effects or other health problems, we will generally not approve your request for an exception. If you ask us for a tiering exception, we will generally not approve your request for an exception unless all the alternative drugs in the lower cost sharing tier(s) won't work as well for you.
We can say yes or no to your request
1 If we approve your request for an exception, our approval usually is valid until the end of the plan year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.
1 If we say no to your request for an exception, you can ask for a review of our decision by making an appeal. Section 7.5 of this chapter tells how to make an appeal if we say no.
The next section tells you how to ask for a coverage decision, including an exception.
Section 7.4 Step-by-step: How to ask for a coverage decision, including an exception
Step 1: You ask us to make a coverage decision about the drug(s) or payment you need. If your health requires a quick response, you must ask us to make a "fast coverage decision." You cannot ask for a fast coverage decision if you are asking us to pay you back for a drug you already bought.
What to do
1 Request the type of coverage decision you want. Start by calling, writing, or faxing us to make your request. You, your representative, or your doctor (or other prescriber) can do this. You can also access the coverage decision process through our website. For the details, go to Chapter 2, Section 1 and look for the section called How to contact us when you are asking for a coverage decision about your Part D prescription drugs. Or if you are asking us to pay you back for a drug, go to the section called Where to send a request that asks us to pay for our share of the cost for medical care or a drug you have received.
1 You or your doctor or someone else who is acting on your behalf can ask for a coverage decision. Section 5 of this chapter tells how you can give written permission to someone else to act as your representative. You can also have a lawyer act on your behalf.
1 If you want to ask us to pay you back for a drug, start by reading Chapter 7 of this booklet: Asking us to pay our share of a bill you have received for covered medical services or drugs. Chapter 7 describes the situations in which you may need to ask for reimbursement. It also tells how to send us the paperwork that asks us to pay you back for our share of the cost of a drug you have paid for.
1 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 you are requesting. (We call this the "supporting statement.") Your doctor or other prescriber can fax or mail the statement to us. Or your doctor or other prescriber can tell us on the phone and follow up by faxing or mailing a written statement if necessary. See Sections 6.2 and 6.3 of this chapter for more information about exception requests.
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1 We must accept any written request, including a request submitted on the CMS Model Coverage Determination Request Form, which available on our website.
If your health requires it, ask us to give you a "fast coverage decision"
Legal Terms
A "fast coverage decision" is called an "expedited coverage determination."
1 When we give you our decision, we will use the "standard" deadlines unless we have agreed to use the "fast" deadlines. A standard coverage decision means we will give you an answer within 72 hours after we receive your doctor's statement. A fast coverage decision means we will answer within 24 hours after we receive your doctor's statement.
1 To get a fast coverage decision, you must meet two requirements:
4 You can get a fast coverage decision only if you are asking for a drug you have not yet received. (You cannot ask for fast coverage decision if you are asking us to pay you back for a drug you have already bought.)
4 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.
1 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.
1 If you ask for a fast coverage decision on your own (without your doctor's or other prescriber's support), we will decide whether your health requires that we give you a fast coverage decision.
4 If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will send you a letter that says so (and we will use the standard deadlines instead).
4 This letter will tell you that if your doctor or other prescriber asks for the fast coverage decision, we will automatically give a fast coverage decision.
4 The letter will also tell how you can file a complaint about our decision to give you a standard coverage decision instead of the fast coverage decision you requested. It tells how to file a "fast" complaint, which means you would get our answer to your complaint within 24 hours of receiving the complaint. (The process for making a complaint is different from the process for coverage decisions and appeals. For more information about the process for making complaints, see Section 11 of this chapter.)
Step 2: We consider your request and we give you our answer.
Deadlines for a "fast" coverage decision
1 If we are using the fast deadlines, we must give you our answer within 24 hours.
4 Generally, this means within 24 hours after we receive your request. If you are requesting an exception, we will give you our answer within 24 hours after we receive your doctor's statement supporting your request. We will give you our answer sooner if your health requires us to.
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4 If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization. In section 7.6 of this chapter, we talk about this review organization and explain what happens at Appeal Level 2.
1 If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 24 hours after we receive your request or doctor's statement supporting your request.
1 If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how you can appeal.
Deadlines for a "standard" coverage decision about a drug you have not yet received
1 If we are using the standard deadlines, we must give you our answer within 72 hours.
4 Generally, this means within 72 hours after we receive your request. If you are requesting an exception, we will give you our answer within 72 hours after we receive your doctor's statement supporting your request. We will give you our answer sooner if your health requires us to.
4 If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization. In Section 7.6 of this chapter, we talk about this review organization and explain what happens at Appeal Level 2.
1 If our answer is yes to part or all of what you requested
4 If we approve your request for coverage, we must provide the coverage we have agreed to provide within 72 hours after we receive your request or doctor's statement supporting your request.
1 If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how you can appeal.
Deadlines for a "standard" coverage decision about payment for a drug you have already bought
1 We must give you our answer within 14 calendar days after we receive your request.
1 If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization. In Section 7.6 of this chapter, we talk about this review organization and explain what happens at Appeal Level 2.
1 If our answer is yes to part or all of what you requested, we are also required to make payment to you within 14 calendar days after we receive your request.
1 If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how you can appeal.
Step 3: If we say no to your coverage request, you decide if you want to make an appeal.
1 If we say no, you have the right to request an appeal. Requesting an appeal means asking us to reconsider and possibly change the decision we made.
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Section 7.5
Step-by-step: How to make a Level 1 Appeal (how to ask for a review of a coverage decision made by our plan)
Legal Terms
An appeal to the plan about a Part D drug coverage decision is called a plan "redetermination."
Step 1: You contact us and make your Level 1 Appeal. If your health requires a quick response, you must ask for a "fast appeal."
What to do
1 To start your appeal, you (or your representative or your doctor or other prescriber) must contact us.
4 For details on how to reach us by phone, fax, or mail, or on our website for any purpose related to your appeal, go to Chapter 2, Section 1, and look for the section called How to contact us when you are making an appeal about your Part D prescription drugs.
1 If you are asking for a standard appeal, make your appeal by submitting a written request.
1 If you are asking for a fast appeal, you may make your appeal in writing or you may call us at the phone number shown in Chapter 2, Section 1 (How to contact us when you are making an appeal about your Part D prescription drugs).
1 We must accept any written request, including a request submitted on the CMS Model Coverage Determination Request Form, which is available on our website.
1 You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of good cause for missing the deadline may include if you had a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.
1 You can ask for a copy of the information in your appeal and add more information.
4 You have the right to ask us for a copy of the information regarding your appeal.
4 If you wish, you and your doctor or other prescriber may give us additional information to support your appeal.
If your health requires it, ask for a "fast appeal"
Legal Terms
A "fast appeal" is also called an "expedited redetermination."
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1 If you are appealing a decision we made about a drug you have not yet received, you and your doctor or other prescriber will need to decide if you need a "fast appeal."
1 The requirements for getting a "fast appeal" are the same as those for getting a "fast coverage decision" in Section 7.4 of this chapter.
Step 2: We consider your appeal and we give you our answer.
1 When we are reviewing your appeal, we take another careful look at all of the information about your coverage request. We check to see if we were following all the rules when we said no to your request. We may contact you or your doctor or other prescriber to get more information.
Deadlines for a "fast" appeal
1 If we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires it.
4 If we do not give you an answer within 72 hours, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization. In Section 7.6 of this chapter, we talk about this review organization and explain what happens at Level 2 of the appeals process.
1 If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 72 hours after we receive your appeal.
1 If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no and how you can appeal our decision.
Deadlines for a "standard" appeal
1 If we are using the standard deadlines, we must give you our answer within 7 calendar days after we receive your appeal for a drug you have not received yet. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so. If you believe your health requires it, you should ask for "fast" appeal.
4 If we do not give you a decision within 7 calendar days, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization. In Section 7.6 of this chapter, we talk about this review organization and explain what happens at Level 2 of the appeals process.
1 If our answer is yes to part or all of what you requested
4 If we approve a request for coverage, we must provide the coverage we have agreed to provide as quickly as your health requires, but no later than 7 calendar days after we receive your appeal.
4 If we approve a request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive your appeal request.
1 If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no and how you can appeal our decision.
1 If you are requesting that we pay you back for a drug you have already bought, we must give you our answer within 14 calendar days after we receive your request.
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4 If we do not give you a decision within 14 calendar days, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization. Later in this section, we talk about this review organization and explain what happens at Appeal Level 2.
1 If our answer is yes to part or all of what you requested, we are also required to make payment to you within 30 calendar days after we receive your request.
1 If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how you can appeal our decision.
Step 3: If we say no to your appeal, you decide if you want to continue with the appeals process and make another appeal.
1 If we say no to your appeal, you then choose whether to accept this decision or continue by making another appeal.
1 If you decide to make another appeal, it means your appeal is going on to Level 2 of the appeals process (see below).
Section 7.6 Step-by-step: How to make a Level 2 Appeal
If we say no to your appeal, you then choose whether to accept this decision or continue by making another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Organization reviews the decision we made when we said no to your first appeal. This organization decides whether the decision we made should be changed.
Legal Terms
The formal name for the "Independent Review Organization" is the "Independent Review Entity." It is sometimes called the "IRE."
Step 1: To make a Level 2 Appeal, you (or your representative or your doctor or other prescriber) must contact the Independent Review Organization and ask for a review of your case.
1 If we say no to your Level 1 Appeal, the written notice we send you will include instructions on how to make a Level 2 Appeal with the Independent Review Organization. These instructions will tell who can make this Level 2 Appeal, what deadlines you must follow, and how to reach the review organization.
1 When you make an appeal to the Independent Review Organization, we will send the information we have about your appeal to this organization. This information is called your "case file." You have the right to ask us for a copy of your case file.
1 You have a right to give the Independent Review Organization additional information to support your appeal.
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Step 2: The Independent Review Organization does a review of your appeal and gives you an answer.
1 The Independent Review Organization is an independent organization that is hired by Medicare. This organization is not connected with us and it is not a government agency. This organization is a company chosen by Medicare to review our decisions about your Part D benefits with us.
1 Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal. The organization will tell you its decision in writing and explain the reasons for it.
Deadlines for "fast" appeal at Level 2
1 If your health requires it, ask the Independent Review Organization for a "fast appeal."
1 If the review organization agrees to give you a "fast appeal," the review organization must give you an answer to your Level 2 Appeal within 72 hours after it receives your appeal request.
1 If the Independent Review Organization says yes to part or all of what you requested, we must provide the drug coverage that was approved by the review organization within 24 hours after we receive the decision from the review organization.
Deadlines for "standard" appeal at Level 2
1 If you have a standard appeal at Level 2, the review organization must give you an answer to your Level 2 Appeal within 7 calendar days after it receives your appeal if it is for a drug you have not received yet. If you are requesting that we pay you back for a drug you have already bought, the review organization must give you an answer to your level 2 appeal within 14 calendar days after it receives your request.
1 If the Independent Review Organization says yes to part or all of what you requested
4 If the Independent Review Organization approves a request for coverage, we must provide the drug coverage that was approved by the review organization within 72 hours after we receive the decision from the review organization.
4 If the Independent Review Organization approves a request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive the decision from the review organization.
What if the review organization says no to your appeal?
If this organization says no to your appeal, it means the organization agrees with our decision not to approve your request. (This is called "upholding the decision." It is also called "turning down your appeal.")
If the Independent Review Organization "upholds the decision" you have the right to a Level 3 appeal. However, to make another appeal at Level 3, the dollar value of the drug coverage you are requesting must meet a minimum amount. If the dollar value of the drug coverage you are requesting is too low, you cannot make another appeal and the decision at Level 2 is final. The notice you get from the Independent Review Organization will tell you the dollar value that must be in dispute to continue with the appeals process.
Step 3: If the dollar value of the coverage you are requesting meets the requirement, you choose whether you want to take your appeal further.
1 There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal).
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1 If your Level 2 Appeal is turned down and you meet the requirements to continue with the appeals process, you must decide whether you want to go on to Level 3 and make a third appeal. If you decide to make a third appeal, the details on how to do this are in the written notice you got after your second appeal.
1 The Level 3 Appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 10 of this chapter tells more about Levels 3, 4, and 5 of the appeals process.
SECTION 8 How to ask us to cover a longer inpatient hospital stay if you think the doctor is discharging you too soon
When you are admitted to a hospital, you have the right to get all of your covered hospital services that are necessary to diagnose and treat your illness or injury. For more information about our coverage for your hospital care, including any limitations on this coverage, see Chapter 4 of this booklet: Benefits Chart (what is covered and what you pay).
During your covered hospital stay, your doctor and the hospital staff will be working with you to prepare for the day when you will leave the hospital. They will also help arrange for care you may need after you leave.
1 The day you leave the hospital is called your "discharge date."
1 When your discharge date has been decided, your doctor or the hospital staff will let you know.
1 If you think you are being asked to leave the hospital too soon, you can ask for a longer hospital stay and your request will be considered. This section tells you how to ask.
Section 8.1
During your inpatient hospital stay, you will get a written notice from Medicare that tells about your rights
During your covered hospital stay, you will be given a written notice called An Important Message from Medicare about Your Rights. Everyone with Medicare gets a copy of this notice whenever they are admitted to a hospital. Someone at the hospital (for example, a caseworker or nurse) must give it to you within two days after you are admitted. If you do not get the notice, ask any hospital employee for it. If you need help, please call Member Services (phone numbers are printed on the back cover of this booklet). You can also call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
1. Read this notice carefully and ask questions if you don't understand it. It tells you about your rights as a hospital patient, including:
1 Your right to receive Medicare-covered services during and after your hospital stay, as ordered by your doctor. This includes the right to know what these services are, who will pay for them, and where you can get them.
1 Your right to be involved in any decisions about your hospital stay, and your right to know who will pay for it.
1 Where to report any concerns you have about quality of your hospital care.
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1 Your right to appeal your discharge decision if you think you are being discharged from the hospital too soon.
Legal Terms
The written notice from Medicare tells you how you can "request an immediate review." Requesting an immediate review is a formal, legal way to ask for a delay in your discharge date so that we will cover your hospital care for a longer time. (Section 8.2 below tells you how you can request an immediate review.)
2. You will be asked to sign the written notice to show that you received it and understand your rights.
1 You or someone who is acting on your behalf will be asked to sign the notice. (Section 5.2 of this chapter tells how you can give written permission to someone else to act as your representative.)
1 Signing the notice shows only that you have received the information about your rights. The notice does not give your discharge date (your doctor or hospital staff will tell you your discharge date). Signing the notice does not mean you are agreeing on a discharge date.
3. Keep your copy of the notice so you will have the information about making an appeal (or reporting a concern about quality of care) handy if you need it.
1 If you sign the notice more than two days before the day you leave the hospital, you will get another copy before you are scheduled to be discharged.
1 To look at a copy of this notice in advance, you can call Member Services (phone numbers are printed on the back cover of this booklet) or 1-800 MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. You can also see the notice online at www.cms.gov/ Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices.html
Section 8.2
Step-by-step: How to make a Level 1 Appeal to change your hospital discharge date
If you want to ask for your inpatient hospital services to be covered by us for a longer time, you will need to use the appeals process to make this request. Before you start, understand what you need to do and what the deadlines are.
1 Follow the process. Each step in the first two levels of the appeals process is explained below.
1 Meet the deadlines. The deadlines are important. Be sure that you understand and follow the deadlines that apply to things you must do.
1 Ask for help if you need it. If you have questions or need help at any time, please call Member Services (phone numbers are printed on the back cover of this booklet). Or call your State Health Insurance Assistance Program, a government organization that provides personalized assistance (see Section 2 of this chapter).
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During a Level 1 Appeal, the Quality Improvement Organization reviews your appeal. It checks to see if your planned discharge date is medically appropriate for you.
Step 1: Contact the Quality Improvement Organization for your state and ask for a "fast review" of your hospital discharge. You must act quickly.
A "fast review" is also called an "immediate review." What is the Quality Improvement Organization?
1 This organization is a group of doctors and other health care professionals who are paid by the Federal government. These experts are not part of our plan. This organization is paid by Medicare to check on and help improve the quality of care for people with Medicare. This includes reviewing hospital discharge dates for people with Medicare.
How can you contact this organization? 1 The written notice you received (An Important Message from Medicare About Your Rights) tells you how to reach this organization. (Or find the name, address, and phone number of the Quality Improvement Organization for your state in Chapter 2, Section 4, of this booklet.)
Act quickly: 1 To make your appeal, you must contact the Quality Improvement Organization before you leave the hospital and no later than midnight the day of your discharge. (Your "planned discharge date" is the date that has been set for you to leave the hospital.) 4 If you meet this deadline, you are allowed to stay in the hospital after your discharge date without paying for it while you wait to get the decision on your appeal from the Quality Improvement Organization. 4 If you do not meet this deadline, and you decide to stay in the hospital after your planned discharge date, you may have to pay all of the costs for hospital care you receive after your planned discharge date. 1 If you miss the deadline for contacting the Quality Improvement Organization, and you still wish to appeal, you must make an appeal directly to our plan instead. For details about this other way to make your appeal, see Section 8.4 of this chapter.
Ask for a "fast review": 1 You must ask the Quality Improvement Organization for a "fast review" of your discharge. Asking for a "fast review" means you are asking for the organization to use the "fast" deadlines for an appeal instead of using the standard deadlines.
Legal Terms
A "fast review" is also called an "immediate review" or an "expedited review."
Step 2: The Quality Improvement Organization conducts an independent review of your case. What happens during this review?
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1 Health professionals at the Quality Improvement Organization (we will call them "the reviewers" for short) will ask you (or your representative) why you believe coverage for the services should continue. You don't have to prepare anything in writing, but you may do so if you wish.
1 The reviewers will also look at your medical information, talk with your doctor, and review information that the hospital and we have given to them.
1 By noon of the day after the reviewers informed our plan of your appeal, you will also get a written notice that gives your planned discharge date and explains in detail the reasons why your doctor, the hospital, and we think it is right (medically appropriate) for you to be discharged on that date.
Legal Terms
This written explanation is called the "Detailed Notice of Discharge." You can get a sample of this notice by calling Member Services (phone numbers are printed on the back cover of this booklet) or 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. (TTY users should call 1-877-486-2048.) Or you can see a sample notice online at www. cms.gov/Medicare/Medicare-GeneralInformation/BNI/ HospitalDischargeAppealNotices.html
Step 3: Within one full day after it has all the needed information, the Quality Improvement Organization will give you its answer to your appeal.
What happens if the answer is yes?
1 If the review organization says yes to your appeal, we must keep providing your covered inpatient hospital services for as long as these services are medically necessary.
1 You will have to keep paying your share of the costs (such as deductibles or copayments, if these apply). In addition, there may be limitations on your covered hospital services. (See Chapter 4 of this booklet.)
What happens if the answer is no?
1 If the review organization says no to your appeal, they are saying that your planned discharge date is medically appropriate. If this happens, our coverage for your inpatient hospital services will end at noon on the day after the Quality Improvement Organization gives you its answer to your appeal.
1 If the review organization says no to your appeal and you decide to stay in the hospital, then you may have to pay the full cost of hospital care you receive after noon on the day after the Quality Improvement Organization gives you its answer to your appeal.
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Step 4: If the answer to your Level 1 Appeal is no, you decide if you want to make another appeal.
1 If the Quality Improvement Organization has turned down your appeal, and you stay in the hospital after your planned discharge date, then you can make another appeal. Making another appeal means you are going on to "Level 2" of the appeals process.
Section 8.3
Step-by-step: How to make a Level 2 Appeal to change your hospital discharge date
If the Quality Improvement Organization has turned down your appeal, and you stay in the hospital after your planned discharge date, then you can make a Level 2 Appeal. During a Level 2 Appeal, you ask the Quality Improvement Organization to take another look at the decision they made on your first appeal. If the Quality Improvement Organization turns down your Level 2 Appeal, you may have to pay the full cost for your stay after your planned discharge date.
Here are the steps for Level 2 of the appeal process:
Step 1: You contact the Quality Improvement Organization again and ask for another review.
1 You must ask for this review within 60 calendar days after the day the Quality Improvement Organization said no to your Level 1 Appeal. You can ask for this review only if you stay in the hospital after the date that your coverage for the care ended.
Step 2: The Quality Improvement Organization does a second review of your situation.
1 Reviewers at the Quality Improvement Organization will take another careful look at all of the information related to your appeal.
Step 3: Within 14 calendar days of receipt of your request for a second review, the Quality Improvement Organization reviewers will decide on your appeal and tell you their decision.
If the review organization says yes:
1 We must reimburse you for our share of the costs of hospital care you have received since noon on the day after the date your first appeal was turned down by the Quality Improvement Organization. We must continue providing coverage for your inpatient hospital care for as long as it is medically necessary.
1 You must continue to pay your share of the costs and coverage limitations may apply.
If the review organization says no:
1 It means they agree with the decision they made on your Level 1 Appeal and will not change it.
1 The notice you get will tell you in writing what you can do if you wish to continue with the review process. It will give you the details about how to go on to the next level of appeal, which is handled by an Administrative Law Judge or attorney adjudicator.
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Step 4: If the answer is no, you will need to decide whether you want to take your appeal further by going on to Level 3.
1 There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If the review organization turns down your Level 2 Appeal, you can choose whether to accept that decision or whether to go on to Level 3 and make another appeal. At Level 3, your appeal is reviewed by an Administrative Law Judge or attorney adjudicator.
1 Section 10 of this chapter tells more about Levels 3, 4, and 5 of the appeals process.
Section 8.4 What if you miss the deadline for making your Level 1 Appeal?
You can appeal to us instead As explained above in Section 8.2, you must act quickly to contact the Quality Improvement Organization to start your first appeal of your hospital discharge. ("Quickly" means before you leave the hospital and no later than your planned discharge date, whichever comes first.) If you miss the deadline for contacting this organization, there is another way to make your appeal. If you use this other way of making your appeal, the first two levels of appeal are different.
Step-by-Step: How to make a Level 1 Alternate Appeal If you miss the deadline for contacting the Quality Improvement Organization, you can make an appeal to us, asking for a "fast review." A fast review is an appeal that uses the fast deadlines instead of the standard deadlines.
Legal Terms
A "fast" review (or "fast appeal") is also called an "expedited appeal."
Step 1: Contact us and ask for a "fast review." 1 For details on how to contact us, go to Chapter 2, Section 1 and look for the section called, How to contact us when you are making an appeal about your medical care. 1 Be sure to ask for a "fast review." This means you are asking us to give you an answer using the "fast" deadlines rather than the "standard" deadlines.
Step 2: We do a "fast" review of your planned discharge date, checking to see if it was medically appropriate.
1 During this review, we take a look at all of the information about your hospital stay. We check to see if your planned discharge date was medically appropriate. We will check to see if the decision about when you should leave the hospital was fair and followed all the rules.
1 In this situation, we will use the "fast" deadlines rather than the standard deadlines for giving you the answer to this review.
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Step 3: We give you our decision within 72 hours after you ask for a "fast review" ("fast appeal").
1 If we say yes to your fast appeal, it means we have agreed with you that you still need to be in the hospital after the discharge date, and will keep providing your covered inpatient hospital services for as long as it is medically necessary. It also means that we have agreed to reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. (You must pay your share of the costs and there may be coverage limitations that apply.)
1 If we say no to your fast appeal, we are saying that your planned discharge date was medically appropriate. Our coverage for your inpatient hospital services ends as of the day we said coverage would end.
4 If you stayed in the hospital after your planned discharge date, then you may have to pay the full cost of hospital care you received after the planned discharge date.
Step 4: If we say no to your fast appeal, your case will automatically be sent on to the next level of the appeals process.
1 To make sure we were following all the rules when we said no to your fast appeal, we are required to send your appeal to the "Independent Review Organization." When we do this, it means that you are automatically going on to Level 2 of the appeals process.
Step-by-Step: Level 2 Alternate Appeal Process
During the Level 2 Appeal, an Independent Review Organization reviews the decision we made when we said no to your "fast appeal." This organization decides whether the decision we made should be changed.
Legal Terms
The formal name for the "Independent Review Organization" is the "Independent Review Entity." It is sometimes called the "IRE."
Step 1: We will automatically forward your case to the Independent Review Organization.
1 We are required to send the information for your Level 2 Appeal to the Independent Review Organization within 24 hours of when we tell you that we are saying no to your first appeal. (If you think we are not meeting this deadline or other deadlines, you can make a complaint. The complaint process is different from the appeal process. Section 11 of this chapter tells how to make a complaint.)
Step 2: The Independent Review Organization does a "fast review" of your appeal. The reviewers give you an answer within 72 hours.
1 The Independent Review Organization is an independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the Independent Review Organization. Medicare oversees its work.
1 Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal of your hospital discharge.
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1 If this organization says yes to your appeal, then we must reimburse you (pay you back) for our share of the costs of hospital care you have received since the date of your planned discharge. We must also continue the plan's coverage of your inpatient hospital services for as long as it is medically necessary. You must continue to pay your share of the costs. If there are coverage limitations, these could limit how much we would reimburse or how long we would continue to cover your services.
1 If this organization says no to your appeal, it means they agree with us that your planned hospital discharge date was medically appropriate.
4 The notice you get from the Independent Review Organization will tell you in writing what you can do if you wish to continue with the review process. It will give you the details about how to go on to a Level 3 Appeal, which is handled by an Administrative Law Judge or attorney adjudicator.
Step 3: If the Independent Review Organization turns down your appeal, you choose whether you want to take your appeal further.
1 There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If reviewers say no to your Level 2 Appeal, you decide whether to accept their decision or go on to Level 3 and make a third appeal.
1 Section 10 of this chapter tells more about Levels 3, 4, and 5 of the appeals process.
SECTION 9 How to ask us to keep covering certain medical services if you think your coverage is ending too soon
Section 9.1
This section is about three services only: Home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services
This section is about the following types of care only:
1 Home health care services you are getting
1 Skilled nursing care you are getting as a patient in a skilled nursing facility. (To learn about requirements for being considered a "skilled nursing facility," see Chapter 12, Definitions of important words.)
1 Rehabilitation care you are getting as an outpatient at a Medicare-approved Comprehensive Outpatient Rehabilitation Facility (CORF). Usually, this means you are getting treatment for an illness or accident, or you are recovering from a major operation. (For more information about this type of facility, see Chapter 12, Definitions of important words.)
When you are getting any of these types of care, you have the right to keep getting your covered services for that type of care for as long as the care is needed to diagnose and treat your illness or injury. For more information on your covered services, including your share of the cost and any limitations to coverage that may apply, see Chapter 4 of this booklet: Benefits Chart (what is covered).
When we decide it is time to stop covering any of the three types of care for you, we are required to tell you in advance. When your coverage for that care ends, we will stop paying for your care.
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If you think we are ending the coverage of your care too soon, you can appeal our decision. This section tells you how to ask for an appeal.
Section 9.2 We will tell you in advance when your coverage will be ending
1. You receive a notice in writing. At least two days before our plan is going to stop covering your care, you will receive a notice.
1 The written notice tells you the date when we will stop covering the care for you.
1 The written notice also tells what you can do if you want to ask our plan to change this decision about when to end your care, and keep covering it for a longer period of time.
Legal Terms
In telling you what you can do, the written notice is telling how you can request a "fast-track appeal." Requesting a fast-track appeal is a formal, legal way to request a change to our coverage decision about when to stop your care. (Section 9.3 below tells how you can request a fast-track appeal.)
The written notice is called the "Notice of Medicare Non-Coverage."
2. You will be asked to sign the written notice to show that you received it.
1 You or someone who is acting on your behalf will be asked to sign the notice. (Section 5.2 tells how you can give written permission to someone else to act as your representative.)
1 Signing the notice shows only that you have received the information about when your coverage will stop. Signing it does not mean you agree with the plan that it's time to stop getting the care.
Section 9.3
Step-by-step: How to make a Level 1 Appeal to have our plan cover your care for a longer time
If you want to ask us to cover your care for a longer period of time, you will need to use the appeals process to make this request. Before you start, understand what you need to do and what the deadlines are.
1 Follow the process. Each step in the first two levels of the appeals process is explained below.
1 Meet the deadlines. The deadlines are important. Be sure that you understand and follow the deadlines that apply to things you must do. There are also deadlines our plan must follow. (If you think we are not meeting our deadlines, you can file a complaint. Section 11 of this chapter tells you how to file a complaint.)
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1 Ask for help if you need it. If you have questions or need help at any time, please call Member Services (phone numbers are printed on the back cover of this booklet). Or call your State Health Insurance Assistance Program, a government organization that provides personalized assistance (see Section 2 of this chapter).
During a Level 1 Appeal, the Quality Improvement Organization reviews your appeal and decides whether to change the decision made by our plan.
Step 1: Make your Level 1 Appeal: contact the Quality Improvement Organization for your state and ask for a review. You must act quickly.
What is the Quality Improvement Organization?
1 This organization is a group of doctors and other health care experts who are paid by the Federal government. These experts are not part of our plan. They check on the quality of care received by people with Medicare and review plan decisions about when it's time to stop covering certain kinds of medical care.
How can you contact this organization?
1 The written notice you received tells you how to reach this organization. (Or find the name, address, and phone number of the Quality Improvement Organization for your state in Chapter 2, Section 4 of this booklet.)
What should you ask for?
1 Ask this organization for a "fast-track appeal" (to do an independent review) of whether it is medically appropriate for us to end coverage for your medical services.
Your deadline for contacting this organization.
1 You must contact the Quality Improvement Organization to start your appeal by noon of the day before the effective date on the Notice of Medicare Non-Coverage.
1 If you miss the deadline for contacting the Quality Improvement Organization, and you still wish to file an appeal, you must make an appeal directly to us instead. For details about this other way to make your appeal, see Section 9.5 of this chapter.
Step 2: The Quality Improvement Organization conducts an independent review of your case.
What happens during this review?
1 Health professionals at the Quality Improvement Organization (we will call them "the reviewers" for short) will ask you (or your representative) why you believe coverage for the services should continue. You don't have to prepare anything in writing, but you may do so if you wish.
1 The review organization will also look at your medical information, talk with your doctor, and review information that our plan has given to them.
1 By the end of the day the reviewers informed us of your appeal, and you will also get a written notice from us that explains in detail our reasons for ending our coverage for your services.
Legal Terms
This notice explanation is called the "Detailed Explanation of Non-Coverage."
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Step 3: Within one full day after they have all the information they need, the reviewers will tell you their decision.
What happens if the reviewers say yes to your appeal?
1 If the reviewers say yes to your appeal, then we must keep providing your covered services for as long as it is medically necessary.
1 You will have to keep paying your share of the costs (such as deductibles or copayments, if these apply). In addition, there may be limitations on your covered services (see Chapter 4 of this booklet).
What happens if the reviewers say no to your appeal?
1 If the reviewers say no to your appeal, then your coverage will end on the date we have told you. We will stop paying our share of the costs of this care on the date listed on the notice.
1 If you decide to keep getting the home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after this date when your coverage ends, then you will have to pay the full cost of this care yourself.
Step 4: If the answer to your Level 1 Appeal is no, you decide if you want to make another appeal.
1 This first appeal you make is "Level 1" of the appeals process. If reviewers say no to your Level 1 Appeal and you choose to continue getting care after your coverage for the care has ended then you can make another appeal.
1 Making another appeal means you are going on to "Level 2" of the appeals process.
Section 9.4
Step-by-step: How to make a Level 2 Appeal to have our plan cover your care for a longer time
If the Quality Improvement Organization has turned down your appeal and you choose to continue getting care after your coverage for the care has ended, then you can make a Level 2 Appeal. During a Level 2 Appeal, you ask the Quality Improvement Organization to take another look at the decision they made on your first appeal. If the Quality Improvement Organization turns down your Level 2 Appeal, you may have to pay the full cost for your home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date when we said your coverage would end.
Here are the steps for Level 2 of the appeal process:
Step 1: You contact the Quality Improvement Organization again and ask for another review.
1 You must ask for this review within 60 days after the day when the Quality Improvement Organization said no to your Level 1 Appeal. You can ask for this review only if you continued getting care after the date that your coverage for the care ended.
Step 2: The Quality Improvement Organization does a second review of your situation.
1 Reviewers at the Quality Improvement Organization will take another careful look at all of the information related to your appeal.
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Step 3: Within 14 days of receipt of your appeal request, reviewers will decide on your appeal and tell you their decision. What happens if the review organization says yes to your appeal?
1 We must reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. We must continue providing coverage for the care for as long as it is medically necessary.
1 You must continue to pay your share of the costs and there may be coverage limitations that apply. What happens if the review organization says no?
1 It means they agree with the decision we made to your Level 1 Appeal and will not change it. 1 The notice you get will tell you in writing what you can do if you wish to continue with the review process.
It will give you the details about how to go on to the next level of appeal, which is handled by an Administrative Law Judge or attorney adjudicator.
Step 4: If the answer is no, you will need to decide whether you want to take your appeal further. 1 There are three additional levels of appeal after Level 2, for a total of five levels of appeal. If reviewers turn down your Level 2 Appeal, you can choose whether to accept that decision or to go on to Level 3 and make another appeal. At Level 3, your appeal is reviewed by an Administrative Law Judge or attorney adjudicator. 1 Section 10 of this chapter tells more about Levels 3, 4, and 5 of the appeals process.
Section 9.5 What if you miss the deadline for making your Level 1 Appeal?
You can appeal to us instead As explained above in Section 9.3, you must act quickly to contact the Quality Improvement Organization to start your first appeal (within a day or two, at the most). If you miss the deadline for contacting this organization, there is another way to make your appeal. If you use this other way of making your appeal, the first two levels of appeal are different.
Step-by-Step: How to make a Level 1 Alternate Appeal If you miss the deadline for contacting the Quality Improvement Organization, you can make an appeal to us, asking for a "fast review." A fast review is an appeal that uses the fast deadlines instead of the standard deadlines. Here are the steps for a Level 1 Alternate Appeal:
Legal Terms
A "fast" review (or "fast appeal") is also called an "expedited appeal."
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Step 1: Contact us and ask for a "fast review."
1 For details on how to contact us, go to Chapter 2, Section 1 and look for the section called How to contact us when you are making an appeal about your medical care.
1 Be sure to ask for a "fast review." This means you are asking us to give you an answer using the "fast" deadlines rather than the "standard" deadlines.
Step 2: We do a "fast" review of the decision we made about when to end coverage for your services.
1 During this review, we take another look at all of the information about your case. We check to see if we were following all the rules when we set the date for ending the plan's coverage for services you were receiving.
1 We will use the "fast" deadlines rather than the standard deadlines for giving you the answer to this review.
Step 3: We give you our decision within 72 hours after you ask for a "fast review" ("fast appeal").
1 If we say yes to your fast appeal, it means we have agreed with you that you need services longer, and will keep providing your covered services for as long as it is medically necessary. It also means that we have agreed to reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. (You must pay your share of the costs and there may be coverage limitations that apply.)
1 If we say no to your fast appeal, then your coverage will end on the date we told you and we will not pay any share of the costs after this date.
1 If you continued to get home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date when we said your coverage would end, then you will have to pay the full cost of this care yourself.
Step 4: If we say no to your fast appeal, your case will automatically go on to the next level of the appeals process.
1 To make sure we were following all the rules when we said no to your fast appeal, we are required to send your appeal to the "Independent Review Organization." When we do this, it means that you are automatically going on to Level 2 of the appeals process.
Step-by-Step: Level 2 Alternate Appeal Process
During the Level 2 Appeal, the Independent Review Organization reviews the decision we made when we said no to your "fast appeal." This organization decides whether the decision we made should be changed.
Legal Terms
The formal name for the "Independent Review Organization" is the "Independent Review Entity." It is sometimes called the "IRE."
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Step 1: We will automatically forward your case to the Independent Review Organization.
1 We are required to send the information for your Level 2 Appeal to the Independent Review Organization within 24 hours of when we tell you that we are saying no to your first appeal. (If you think we are not meeting this deadline or other deadlines, you can make a complaint. The complaint process is different from the appeal process. Section 11 of this chapter tells how to make a complaint.)
Step 2: The Independent Review Organization does a "fast review" of your appeal. The reviewers give you an answer within 72 hours.
1 The Independent Review Organization is an independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the Independent Review Organization. Medicare oversees its work.
1 Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal.
1 If this organization says yes to your appeal, then we must reimburse you (pay you back) for our share of the costs of care you have received since the date when we said your coverage would end. We must also continue to cover the care for as long as it is medically necessary. You must continue to pay your share of the costs. If there are coverage limitations, these could limit how much we would reimburse or how long we would continue to cover your services.
1 If this organization says no to your appeal, it means they agree with the decision our plan made to your first appeal and will not change it.
4 The notice you get from the Independent Review Organization will tell you in writing what you can do if you wish to continue with the review process. It will give you the details about how to go on to a Level 3 Appeal.
Step 3: If the Independent Review Organization turns down your appeal, you choose whether you want to take your appeal further.
1 There are three additional levels of appeal after Level 2, for a total of five levels of appeal. If reviewers say no to your Level 2 Appeal, you can choose whether to accept that decision or whether to go on to Level 3 and make another appeal. At Level 3, your appeal is reviewed by an Administrative Law Judge or attorney adjudicator.
1 Section 10 of this chapter tells more about Levels 3, 4, and 5 of the appeals process.
SECTION 10 Taking your appeal to Level 3 and beyond
Section 10.1 Appeal Levels 3, 4 and 5 for Medical Service Requests This section may be appropriate for you if you have made a Level 1 Appeal and a Level 2 Appeal, and both of your appeals have been turned down.
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If the dollar value of the item or medical service you have appealed meets certain minimum levels, you may be able to go on to additional levels of appeal. If the dollar value is less than the minimum level, you cannot appeal any further. If the dollar value is high enough, the written response you receive to your Level 2 Appeal will explain who to contact and what to do to ask for a Level 3 Appeal.
For most situations that involve appeals, the last three levels of appeal work in much the same way. Here is who handles the review of your appeal at each of these levels.
Level 3 Appeal A judge (called an Administrative Law Judge) or an attorney adjudicator who works for the Federal government will review your appeal and give you an answer.
1 If the Administrative Law Judge or attorney adjudicator says yes to your appeal, the appeals process may or may not be over - We will decide whether to appeal this decision to Level 4. Unlike a decision at Level 2 (Independent Review Organization), we have the right to appeal a Level 3 decision that is favorable to you.
4 If we decide not to appeal the decision, we must authorize or provide you with the service within 60 calendar days after receiving the Administrative Law Judge's or attorney adjudicator's decision.
4 If we decide to appeal the decision, we will send you a copy of the Level 4 Appeal request with any accompanying documents. We may wait for the Level 4 Appeal decision before authorizing or providing the service in dispute.
1 If the Administrative Law Judge or attorney adjudicator says no to your appeal, the appeals process may or may not be over.
4 If you decide to accept this decision that turns down your appeal, the appeals process is over.
4 If you do not want to accept the decision, you can continue to the next level of the review process. If the Administrative Law Judge or attorney adjudicator says no to your appeal, the notice you get will tell you what to do next if you choose to continue with your appeal.
Level 4 Appeal The Medicare Appeals Council (Council) will review your appeal and give you an answer. The Council is part of the Federal government.
1 If the answer is yes, or if the Council denies our request to review a favorable Level 3 Appeal decision, the appeals process may or may not be over - We will decide whether to appeal this decision to Level 5. Unlike a decision at Level 2 (Independent Review Organization), we have the right to appeal a Level 4 decision that is favorable to you if the value of the item or medical service meets the required dollar value.
4 If we decide not to appeal the decision, we must authorize or provide you with the service within 60 calendar days after receiving the Council's decision.
4 If we decide to appeal the decision, we will let you know in writing.
1 If the answer is no or if the Council denies the review request, the appeals process may or may not be over.
4 If you decide to accept this decision that turns down your appeal, the appeals process is over.
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4 If you do not want to accept the decision, you might be able to continue to the next level of the review process. If the Council says no to your appeal, the notice you get will tell you whether the rules allow you to go on to a Level 5 Appeal. If the rules allow you to go on, the written notice will also tell you who to contact and what to do next if you choose to continue with your appeal.
Level 5 Appeal A judge at the Federal District Court will review your appeal.
1 This is the last step of the appeals process.
Section 10.2 Appeal Levels 3, 4 and 5 for Part D Drug Requests
This section may be appropriate for you if you have made a Level 1 Appeal and a Level 2 Appeal, and both of your appeals have been turned down. If the value of the drug you have appealed meets a certain dollar amount, you may be able to go on to additional levels of appeal. If the dollar amount is less, you cannot appeal any further. The written response you receive to your Level 2 Appeal will explain who to contact and what to do to ask for a Level 3 Appeal. For most situations that involve appeals, the last three levels of appeal work in much the same way. Here is who handles the review of your appeal at each of these levels.
Level 3 Appeal A judge (called an Administrative Law Judge) or attorney adjudicator who works for the Federal government will review your appeal and give you an answer.
1 If the answer is yes, the appeals process is over. What you asked for in the appeal has been approved. We must authorize or provide the drug coverage that was approved by the Administrative Law Judge or attorney adjudicator within 72 hours (24 hours for expedited appeals) or make payment no later than 30 calendar days after we receive the decision.
1 If the answer is no, the appeals process may or may not be over. 4 If you decide to accept this decision that turns down your appeal, the appeals process is over. 4 If you do not want to accept the decision, you can continue to the next level of the review process. If the Administrative Law Judge or attorney adjudicator says no to your appeal, the notice you get will tell you what to do next if you choose to continue with your appeal.
Level 4 Appeal The Medicare Appeals Council (Council) will review your appeal and give you an answer. The Council is part of the Federal government.
1 If the answer is yes, the appeals process is over. What you asked for in the appeal has been approved. We must authorize or provide the drug coverage that was approved by the Council within 72 hours (24 hours for expedited appeals) or make payment no later than 30 calendar days after we receive the decision.
1 If the answer is no, the appeals process may or may not be over. 4 If you decide to accept this decision that turns down your appeal, the appeals process is over.
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4 If you do not want to accept the decision, you might be able to continue to the next level of the review process. If the Council says no to your appeal or denies your request to review the appeal, the notice you get will tell you whether the rules allow you to go on to a Level 5 Appeal. If the rules allow you to go on, the written notice will also tell you who to contact and what to do next if you choose to continue with your appeal.
Level 5 Appeal A judge at the Federal District Court will review your appeal.
1 This is the last step of the appeals process.
SECTION 11 How to make a complaint about quality of care, waiting times, customer service, or other concerns
If your problem is about decisions related to benefits, coverage, or payment, then this section is not for you. Instead, you need to use the process for coverage decisions and appeals. Go to Section 5 of this chapter.
Section 11.1 What kinds of problems are handled by the complaint process?
This section explains how to use the process for making complaints. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Here are examples of the kinds of problems handled by the complaint process.
If you have any of these kinds of problems, you can "make a complaint"
Complaint
Example
Quality of your medical care
1 Are you unhappy with the quality of the care you have received (including care in the hospital)?
Respecting your privacy
1 Do you believe that someone did not respect your right to privacy or shared information about you that you feel should be confidential?
Disrespect, poor customer service, or 1 Has someone been rude or disrespectful to you?
other negative behaviors
1 Are you unhappy with how our Member Services has treated you?
1 Do you feel you are being encouraged to leave the plan?
Waiting times
1 Are you having trouble getting an appointment, or waiting too long to get it?
1 Have you been kept waiting too long by doctors, pharmacists, or other health professionals? Or by our Member Services or other staff at the plan?
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Complaint
Example
4 Examples include waiting too long on the phone, in the waiting room, when getting a prescription, or in the exam room.
Cleanliness
1 Are you unhappy with the cleanliness or condition of a clinic, hospital, or doctor's office?
Information you get from us
1 Do you believe we have not given you a notice that we are required to give?
1 Do you think written information we have given you is hard to understand?
Timeliness
The process of asking for a coverage decision and making appeals is
(These types of complaints are all related explained in sections 4-10 of this chapter. If you are asking for a
to the timeliness of our actions related to coverage decision or making an appeal, you use that process, not the
coverage decisions and appeals)
complaint process.
However, if you have already asked us for a coverage decision or made an appeal, and you think that we are not responding quickly enough, you can also make a complaint about our slowness. Here are examples:
1 If you have asked us to give you a "fast coverage decision" or a "fast appeal," and we have said we will not, you can make a complaint.
1 If you believe we are not meeting the deadlines for giving you a coverage decision or an answer to an appeal you have made, you can make a complaint.
1 When a coverage decision we made is reviewed and we are told that we must cover or reimburse you for certain medical services or drugs, there are deadlines that apply. If you think we are not meeting these deadlines, you can make a complaint.
1 When we do not give you a decision on time, we are required to forward your case to the Independent Review Organization. If we do not do that within the required deadline, you can make a complaint.
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Section 11.2 The formal name for "making a complaint" is "filing a grievance"
Legal Terms
1 What this section calls a "complaint" is also called a "grievance."
1 Another term for "making a complaint" is "filing a grievance."
1 Another way to say "using the process for complaints" is "using the process for filing a grievance."
Section 11.3 Step-by-step: Making a complaint
Step 1: Contact us promptly either by phone or in writing.
1 Usually, calling Member Services is the first step. If there is anything else you need to do, Member Services will let you know. (800) 665-0898, TTY users please call 711, 7 days a week, 8:00 a.m. to 8:00 p.m., local time.
1 If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing.
1 We will try to resolve your complaint over the phone. If you ask for a written response, file a written grievance, or your complaint is related to quality of care, we will respond in writing to you. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this our Member Grievance Process. We will respond to all quality of care grievances in writing, regardless of how the grievance was filed no later than (30) days, unless additional information is needed.
You, or your representative, are entitled to file an expedited grievance whenever Molina asks for an extension relating to an organization's determination reconsideration, or when we refuse to expedite a request for an organization determination or reconsideration. Molina will respond to these grievances within (24) hours after receipt.
The grievance must be submitted within 60 days of the event or incident. We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. When we resolve your grievance in whole or in part, our written decision will explain the details, and will tell you about any dispute resolution options you may have.
1 Whether you call or write, you should contact Member Services right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about.
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1 If you are making a complaint because we denied your request for a "fast coverage decision" or a "fast appeal," we will automatically give you a "fast" complaint. If you have a "fast" complaint, it means we will give you an answer within 24 hours.
Legal Terms
What this section calls a "fast complaint" is also called an "expedited grievance."
Step 2: We look into your complaint and give you our answer. 1 If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that. 1 Most complaints are answered within 30 calendar days. 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 calendar days (44 calendar days total) to answer your complaint. If we decide to take extra days, we will tell you in writing. 1 If we do not agree with some or all of your complaint or don't take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.
Section 11.4 You can also make complaints about quality of care to the Quality Improvement Organization
You can make your complaint about the quality of care you received by using the step-by-step process outlined above. When your complaint is about quality of care, you also have two extra options:
1 You can make your complaint to the Quality Improvement Organization. If you prefer, you can make your complaint about the quality of care you received directly to this organization (without making the complaint to us). 4 The Quality Improvement Organization is a group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to Medicare patients. 4 To find the name, address, and phone number of the Quality Improvement Organization for your state, look in Chapter 2, Section 4 of this booklet. If you make a complaint to this organization, we will work with them to resolve your complaint.
1 Or you can make your complaint to both at the same time. If you wish, you can make your complaint about quality of care to us and also to the Quality Improvement Organization.
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Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)
Section 11.5 You can also tell Medicare about your complaint
You can submit a complaint about Molina Medicare Complete Care (HMO SNP) directly to Medicare. To submit a complaint to Medicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program. If you have any other feedback or concerns or if you feel the plan is not addressing your issue, call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048.
PROBLEMS ABOUT YOUR MEDICAID BENEFITS
SECTION 12 Handling problems about your Medicaid benefits
For more information on Medicaid-covered benefits and/or processes, you should contact Member Services (phone numbers are printed on the back cover of this booklet) or your State Medicaid Office (the contact information is listed in Chapter 2, Section 6).
CHAPTER 10
Ending your membership in the plan
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Chapter 10. Ending your membership in the plan
SECTION 1 Introduction .............................................................................................................212 Section 1.1 This chapter focuses on ending your membership in our plan ............................................ 212
SECTION 2 When can you end your membership in our plan? .............................................. 212 Section 2.1 You may be able to end your membership because you have Medicare and Medicaid ..... 212 Section 2.2 You can end your membership during the Annual Enrollment Period ............................... 213 Section 2.3 You can end your membership during the Medicare Advantage Open Enrollment Period .................................................................................................................................. 214 Section 2.4 In certain situations, you can end your membership during a Special Enrollment Period .................................................................................................................................. 214 Section 2.5 Where can you get more information about when you can end your membership? ........... 215
SECTION 3 How do you end your membership in our plan? .................................................. 216 Section 3.1 Usually, you end your membership by enrolling in another plan ....................................... 216
SECTION 4 Until your membership ends, you must keep getting your medical services and drugs through our plan ...................................................................................217
Section 4.1 Until your membership ends, you are still a member of our plan ....................................... 217
SECTION 5 Molina Medicare Complete Care (HMO SNP) must end your membership in the plan in certain situations .................................................................................217
Section 5.1 When must we end your membership in the plan? ............................................................. 217 Section 5.2 We cannot ask you to leave our plan for any reason related to your health ....................... 218 Section 5.3 You have the right to make a complaint if we end your membership in our plan .............. 218
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SECTION 1 Introduction
Section 1.1 This chapter focuses on ending your membership in our plan
Ending your membership in Molina Medicare Complete Care (HMO SNP) may be voluntary (your own choice) or involuntary (not your own choice):
1 You might leave our plan because you have decided that you want to leave. 4 There are only certain times during the year, or certain situations, when you may voluntarily end your membership in the plan. Section 2 tells you when you can end your membership in the plan. Section 2 tells you about the types of plans you can enroll in and when your enrollment in your new coverage will begin. 4 The process for voluntarily ending your membership varies depending on what type of new coverage you are choosing. Section 3 tells you how to end your membership in each situation.
1 There are also limited situations where you do not choose to leave, but we are required to end your membership. Section 5 tells you about situations when we must end your membership.
If you are leaving our plan, you must continue to get your medical care through our plan until your membership ends.
SECTION 2 When can you end your membership in our plan?
You may end your membership in our plan only during certain times of the year, known as enrollment periods. All members have the opportunity to leave the plan during the Annual Enrollment Period and during the Medicare Advantage Open Enrollment Period. In certain situations, you may also be eligible to leave the plan at other times of the year.
Section 2.1
You may be able to end your membership because you have Medicare and Medicaid
Most people with Medicare can end their membership only during certain times of the year. Because you have Medicaid, you may be able to end your membership in our plan or switch to a different plan one time during each of the following Special Enrollment Periods:
1 January to March
1 April to June
1 July to September
If you joined our plan during one of these periods, you'll have to wait for the next period to end your membership or switch to a different plan. You can't use this Special Enrollment Period to end your membership in our plan between October and December. However, all people with Medicare can make changes from October 15 December 7 during the Annual Enrollment Period. Section 2.2 tells you more about the Annual Enrollment Period.
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1 What type of plan can you switch to? If you decide to change to a new plan, you can choose any of the following types of Medicare plans:
4 Another Medicare health plan. (You can choose a plan that covers prescription drugs or one that does not cover prescription drugs.)
4 Original Medicare with a separate Medicare prescription drug plan
- If you switch to Original Medicare and do not enroll in a separate Medicare prescription drug plan, Medicare may enroll you in a drug plan, unless you have opted out of automatic enrollment.
Note: If you disenroll from Medicare prescription drug coverage and go without "creditable" prescription drug coverage for a continuous period of 63 days or more, you may have to pay a Part D late enrollment penalty if you join a Medicare drug plan later. ("Creditable" coverage means the coverage is expected to pay, on average, at least as much as Medicare's standard prescription drug coverage.)
Contact your State Medicaid Office to learn about your Medicaid plan options (telephone numbers are in Chapter 2, Section 6 of this booklet).
1 When will your membership end? Your membership will usually end on the first day of the month after we receive your request to change your plans. Your enrollment in your new plan will also begin on this day.
Section 2.2 You can end your membership during the Annual Enrollment Period
You can end your membership during the Annual Enrollment Period (also known as the "Annual Open Enrollment Period"). This is the time when you should review your health and drug coverage and make a decision about your coverage for the upcoming year.
1 When is the Annual Enrollment Period? This happens from October 15 to December 7.
1 What type of plan can you switch to during the Annual Enrollment Period? You can choose to keep your current coverage or make changes to your coverage for the upcoming year. If you decide to change to a new plan, you can choose any of the following types of plans:
4 Another Medicare health plan. (You can choose a plan that covers prescription drugs or one that does not cover prescription drugs.)
4 Original Medicare with a separate Medicare prescription drug plan
4 or Original Medicare without a separate Medicare prescription drug plan.
If you receive "Extra Help" from Medicare to pay for your prescription drugs: If you switch to Original Medicare and do not enroll in a separate Medicare prescription drug plan, Medicare may enroll you in a drug plan, unless you have opted out of automatic enrollment.
Note: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug coverage for 63 days or more in a row, you may have to pay a Part D late enrollment penalty if you join a Medicare drug plan later. ("Creditable" coverage means the coverage is expected to pay, on average, at least as much as Medicare's standard prescription drug coverage.) See Chapter 1, Section 5 for more information about the late enrollment penalty.
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1 When will your membership end? Your membership will end when your new plan's coverage begins on January 1.
Section 2.3
You can end your membership during the Medicare Advantage Open Enrollment Period
You have the opportunity to make one change to your health coverage during the Medicare Advantage Open Enrollment Period.
1 When is the annual Medicare Advantage Open Enrollment Period? This happens every year from January 1 to March 31.
1 What type of plan can you switch to during the annual Medicare Advantage Open Enrollment Period? During this time, you can:
4 Switch to another Medicare Advantage Plan. (You can choose a plan that covers prescription drugs or one that does not cover prescription drugs.)
4 Disenroll from our plan and obtain coverage through Original Medicare. If you choose to switch to Original Medicare during this period, you can also join a separate Medicare prescription drug plan at that time.
1 When will your membership end? Your membership will end on the first day of the month after you enroll in a different Medicare Advantage plan or we get your request to switch to Original Medicare. If you also choose to enroll in a Medicare prescription drug plan, your membership in the drug plan will begin the first day of the month after the drug plan gets your enrollment request.
Section 2.4
In certain situations, you can end your membership during a Special Enrollment Period
In certain situations, you may be eligible to end your membership at other times of the year. This is known as a Special Enrollment Period.
1 Who is eligible for a Special Enrollment Period? If any of the following situations apply to you, you may be eligible to end your membership during a Special Enrollment Period. These are just examples, for the full list you can contact the plan, call Medicare, or visit the Medicare website (www.medicare.gov):
4 Usually, when you have moved
4 If you have Medicaid
4 If you are eligible for "Extra Help" with paying for your Medicare prescriptions
4 If we violate our contract with you
4 If you are getting care in an institution, such as a nursing home or long-term care (LTC) hospital
4 If you enroll in the Program of All-inclusive Care for the Elderly (PACE)
4 Note: If you're in a drug management program, you may not be able to change plans. Chapter 5, Section 10 tells you more about drug management programs.
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Note: Section 2.1 tells you more about the special enrollment period for people with Medicaid.
1 When are Special Enrollment Periods? The enrollment periods vary depending on your situation.
1 What can you do? To find out if you are eligible for a Special Enrollment Period, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048. If you are eligible to end your membership because of a special situation, you can choose to change both your Medicare health coverage and prescription drug coverage. This means you can choose any of the following types of plans:
4 Another Medicare health plan. (You can choose a plan that covers prescription drugs or one that does not cover prescription drugs.)
4 Original Medicare with a separate Medicare prescription drug plan
4 or Original Medicare without a separate Medicare prescription drug plan.
If you receive "Extra Help" from Medicare to pay for your prescription drugs: If you switch to Original Medicare and do not enroll in a separate Medicare prescription drug plan, Medicare may enroll you in a drug plan, unless you have opted out of automatic enrollment.
Note: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug coverage for a continuous period of 63 days or more, you may have to pay a Part D late enrollment penalty if you join a Medicare drug plan later. ("Creditable" coverage means the coverage is expected to pay, on average, at least as much as Medicare's standard prescription drug coverage.) See Chapter 1, Section 4 for more information about the late enrollment penalty.
1 When will your membership end? Your membership will usually end on the first day of the month after your request to change your plan is received.
Note: Sections 2.1 and 2.2 tell you more about the special enrollment period for people with Medicaid and Extra Help.
Section 2.5 Where can you get more information about when you can end your membership?
If you have any questions or would like more information on when you can end your membership:
1 You can call Member Services (phone numbers are printed on the back cover of this booklet).
1 You can find the information in the Medicare & You 2021 Handbook. 4 Everyone with Medicare receives a copy of Medicare & You each fall. Those new to Medicare receive it within a month after first signing up.
4 You can also download a copy from the Medicare website (www.medicare.gov). Or, you can order a printed copy by calling Medicare at the number below.
1 You can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
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SECTION 3 How do you end your membership in our plan?
Section 3.1 Usually, you end your membership by enrolling in another plan
Usually, to end your membership in our plan, you simply enroll in another Medicare plan. However, if you want to switch from our plan to Original Medicare but you have not selected a separate Medicare prescription drug plan, you must ask to be disenrolled from our plan. There are two ways you can ask to be disenrolled:
1 You can make a request in writing to us. Contact Member Services if you need more information on how to do this (phone numbers are printed on the back cover of this booklet).
1 --or--You can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
The table below explains how you should end your membership in our plan.
If you would like to switch from our plan to: This is what you should do:
1 Another Medicare health plan.
1 Enroll in the new Medicare health plan. Your new coverage will begin on the first day of the following month. You will automatically be disenrolled from Molina Medicare Complete Care (HMO SNP) when your new plan's coverage begins.
1 Original Medicare with a separate Medicare prescription drug plan.
1 Enroll in the new Medicare prescription drug plan. Your new coverage will begin on the first day of the following month. You will automatically be disenrolled from Molina Medicare Complete Care (HMO SNP) when your new plan's coverage begins.
1 Original Medicare without a separate Medicare 1 Send us a written request to disenroll. Contact Member
prescription drug plan.
Services if you need more information on how to do this
4 If you switch to Original Medicare and do not enroll in a separate Medicare
(phone numbers are printed on the back cover of this booklet).
prescription drug plan, Medicare may 1 You can also contact Medicare, at 1-800-MEDICARE
enroll you in a drug plan, unless you have (1-800-633-4227), 24 hours a day, 7 days a week, and
opted out of automatic enrollment.
ask to be disenrolled. TTY users should call
4 If you disenroll from Medicare
1-877-486-2048.
prescription drug coverage and go 63 days 1 You will be disenrolled from Molina Medicare Complete
or more in a row without creditable
Care (HMO SNP) when your coverage in Original
prescription drug coverage, you may have Medicare begins.
to pay a late enrollment penalty if you join
a Medicare drug plan later.
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For questions about your California Department of Health Care Services benefits, contact California Department of Health Care Services, (916) 449-5000, TTY: 711, Monday - Friday 8:00 a.m. - 5:00 p.m., local time. Ask how joining another plan or returning to Original Medicare affects how you get your Medicaid coverage.
SECTION 4 Until your membership ends, you must keep getting your medical services and drugs through our plan
Section 4.1 Until your membership ends, you are still a member of our plan
If you leave Molina Medicare Complete Care (HMO SNP), it may take time before your membership ends and your new Medicare coverage goes into effect. (See Section 2 for information on when your new coverage begins.) During this time, you must continue to get your medical care and prescription drugs through our plan.
1 You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends. Usually, your prescription drugs are only covered if they are filled at a network pharmacy including through our mail-order pharmacy services.
1 If you are hospitalized on the day that your membership ends, your hospital stay will usually be covered by our plan until you are discharged (even if you are discharged after your new health coverage begins).
SECTION 5 Molina Medicare Complete Care (HMO SNP) must end your membership in the plan in certain situations
Section 5.1 When must we end your membership in the plan?
Molina Medicare Complete Care (HMO SNP) must end your membership in the plan if any of the following happen:
1 If you no longer have Medicare Part A and Part B. 1 If you are no longer eligible for Medicaid. As stated in Chapter 1, Section 2.1, our plan is for people who
are eligible for both Medicare and Medicaid. 1 When Molina Medicare determines you no longer meet the eligibility requirements you will receive a
notification letter stating the reason for the possible disenrollment. You will then have six (6) months from the date of the letter to respond for reconsideration of your membership eligibility in the Plan. 1 If you move out of our service area. 1 If you are away from our service area for more than six months. 4 If you move or take a long trip, you need to call Member Services to find out if the place you are moving
or traveling to is in our plan's area. (Phone numbers for Member Services are printed on the back cover of this booklet.)
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1 If you become incarcerated (go to prison). 1 If you are not a United States citizen or lawfully present in the United States. 1 If you lie about or withhold information about other insurance you have that provides prescription drug
coverage. 1 If you intentionally give us incorrect information when you are enrolling in our plan and that information
affects your eligibility for our plan. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.) 1 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. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.) 1 If you let someone else use your membership card to get medical care. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.) 4 If we end your membership because of this reason, Medicare may have your case investigated by the
Inspector General. 1 If you are required to pay the extra Part D amount because of your income and you do not pay it, Medicare
will disenroll you from our plan.
Where can you get more information? If you have questions or would like more information on when we can end your membership:
1 You can call Member Services for more information (phone numbers are printed on the back cover of this booklet).
Section 5.2 We cannot ask you to leave our plan for any reason related to your health
Molina Medicare Complete Care (HMO SNP) is not allowed to ask you to leave our plan for any reason related to your health.
What should you do if this happens? If you feel that you are being asked to leave our plan because of a health-related reason, you should call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may call 24 hours a day, 7 days a week.
Section 5.3 You have the right to make a complaint if we end your membership in our plan
If we end your membership in our plan, we must tell you our reasons in writing for ending your membership. We must also explain how you can file a grievance or make a complaint about our decision to end your membership. You can also look in Chapter 9, Section 11 for information about how to make a complaint.
CHAPTER 11
Legal notices
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Chapter 11. Legal notices
SECTION 1 Notice about governing law ...................................................................................221 SECTION 2 Notice about nondiscrimination ............................................................................ 221 SECTION 3 Notice about Medicare Secondary Payer subrogation rights ............................. 221
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SECTION 1 Notice about governing law
Many laws apply to this Evidence of Coverage and some additional provisions may apply because they are required by law. This may affect your rights and responsibilities even if the laws are not included or explained in this document. The principal law that applies to this document is Title XVIII of the Social Security Act and the regulations created under the Social Security Act by the Centers for Medicare & Medicaid Services, or CMS. In addition, other Federal laws may apply and, under certain circumstances, the laws of the state you live in.
SECTION 2 Notice about nondiscrimination
Our plan must obey laws that protect you from discrimination or unfair treatment. We don't discriminate based on race, ethnicity, national origin, color, religion, sex, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability, or geographic location within the service area. All organizations that provide Medicare Advantage plans, like our plan, must obey Federal laws against discrimination, including Title VI of the Civil Rights Act of 1964, the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities Act, Section 1557 of the Affordable Care Act, all other laws that apply to organizations that get Federal funding, and any other laws and rules that apply for any other reason. If you want more information or have concerns about discrimination or unfair treatment, please call the Department of Health and Human Services' Office for Civil Rights at 1-800-368-1019 (TTY 1-800-537-7697) or your local Office for Civil Rights. If you have a disability and need help with access to care, please call us at Member Services (phone numbers are printed on the back cover of this booklet). If you have a complaint, such as a problem with wheelchair access, Member Services can help.
SECTION 3 Notice about Medicare Secondary Payer subrogation rights
We have the right and responsibility to collect for covered Medicare services for which Medicare is not the primary payer. According to CMS regulations at 42 CFR sections 422.108 and 423.462, Molina Medicare Complete Care (HMO SNP), as a Medicare Advantage Organization, will exercise the same rights of recovery that the Secretary exercises under CMS regulations in subparts B through D of part 411 of 42 CFR and the rules established in this section supersede any State laws.
CHAPTER 12
Definitions of important words
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Chapter 12. Definitions of important words
Ambulatory Surgical Center An Ambulatory Surgical Center is an entity that operates exclusively for the purpose of furnishing outpatient surgical services to patients not requiring hospitalization and whose expected stay in the center does not exceed 24 hours.
Appeal An appeal is something you do if you disagree with our decision to deny a request for coverage of health care services or prescription drugs or payment for services or drugs you already received. You may also make an appeal if you disagree with our decision to stop services that you are receiving. For example, you may ask for an appeal if we don't pay for a drug, item, or service you think you should be able to receive. Chapter 9 explains appeals, including the process involved in making an appeal.
Benefit Period The way that both our plan and Original Medicare measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven't received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods.
Brand Name Drug A prescription drug that is manufactured and sold by the pharmaceutical company that originally researched and developed the drug. Brand name drugs have the same active-ingredient formula as the generic version of the drug. However, generic drugs are manufactured and sold by other drug manufacturers and are generally not available until after the patent on the brand name drug has expired.
Catastrophic Coverage Stage The stage in the Part D Drug Benefit where you pay no copayment or coinsurance for your drugs after you or other qualified parties on your behalf have spent $6,550 in covered drugs during the covered year.
Centers for Medicare & Medicaid Services (CMS) The Federal agency that administers Medicare. Chapter 2 explains how to contact CMS.
Coinsurance An amount you may be required to pay as your share of the cost for services or prescription drugs after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%).
Complaint -- The formal name for "making a complaint" is "filing a grievance." The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. See also "Grievance," in this list of definitions.
Comprehensive Outpatient Rehabilitation Facility (CORF) A facility that mainly provides rehabilitation services after an illness or injury, and provides a variety of services including physical therapy, social or psychological services, respiratory therapy, occupational therapy and speech-language pathology services, and home environment evaluation services.
Copayment (or "copay") An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor's visit, hospital outpatient visit, or a prescription drug. A copayment is a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor's visit or prescription drug.
Cost sharing Cost sharing refers to amounts that a member has to pay when services or drugs are received. Cost sharing includes any combination of the following three types of payments: (1) any deductible amount a plan may impose before services or drugs are covered; (2) any fixed "copayment" amount that a plan requires when a specific service or drug is received; or (3) any "coinsurance" amount, a percentage of the total amount paid for a service
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or drug that a plan requires when a specific service or drug is received. A "daily cost sharing rate" may apply when your doctor prescribes less than a full month's supply of certain drugs for you and you are required to pay a copayment.
Cost Sharing Tier Every drug on the list of covered drugs is in one of five (5) cost sharing tiers. In general, the higher the cost sharing tier, the higher your cost for the drug.
Coverage Determination A decision about whether a drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn't covered under your plan, that isn't a coverage determination. You need to call or write to your plan to ask for a formal decision about the coverage. Coverage determinations are called "coverage decisions" in this booklet. Chapter 9 explains how to ask us for a coverage decision.
Covered Drugs The term we use to mean all of the prescription drugs covered by our plan.
Covered Services The general term we use to mean all of the health care services and supplies that are covered by our plan.
Creditable Prescription Drug Coverage Prescription drug coverage (for example, from an employer or union) that is expected to pay, on average, at least as much as Medicare's standard prescription drug coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll in Medicare prescription drug coverage later.
Custodial Care Custodial care is personal care provided in a nursing home, hospice, or other facility setting when you do not need skilled medical care or skilled nursing care. Custodial care is personal care that can be provided by people who don't have professional skills or training, such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. It may also include the kind of health-related care that most people do themselves, like using eye drops. Medicare doesn't pay for custodial care.
Daily cost sharing rate A "daily cost sharing rate" may apply when your doctor prescribes less than a full month's supply of certain drugs for you and you are required to pay a copayment. A daily cost sharing rate is the copayment divided by the number of days in a month's supply. Here is an example: If your copayment for a one-month supply of a drug is $30, and a one-month's supply in your plan is 30 days, then your "daily cost sharing rate" is $1 per day. This means you pay $1 for each day's supply when you fill your prescription.
Deductible The amount you must pay for health care or prescriptions before our plan begins to pay.
Disenroll or Disenrollment The process of ending your membership in our plan. Disenrollment may be voluntary (your own choice) or involuntary (not your own choice).
Dispensing Fee A fee charged each time a covered drug is dispensed to pay for the cost of filling a prescription. The dispensing fee covers costs such as the pharmacist's time to prepare and package the prescription.
Dual Eligible Individual A person who qualifies for Medicare and Medicaid coverage.
Durable Medical Equipment (DME) Certain medical equipment that is ordered by your doctor for medical reasons. Examples include walkers, wheelchairs, crutches, powered mattress systems, diabetic supplies, IV infusion pumps, speech generating devices, oxygen equipment, nebulizers, or hospital beds ordered by a provider for use in the home.
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Emergency A medical emergency is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.
Emergency Care Covered services that are: (1) rendered by a provider qualified to furnish emergency services; and (2) needed to treat, evaluate, or stabilize an emergency medical condition.
Evidence of Coverage (EOC) and Disclosure Information This document, along with your enrollment form and any other attachments, riders, or other optional coverage selected, which explains your coverage, what we must do, your rights, and what you have to do as a member of our plan.
Exception A type of coverage decision that, if approved, allows you to get a drug that is not on your plan sponsor's formulary (a formulary exception), or get a non-preferred drug at a lower cost sharing level (a tiering exception). You may also request an exception if your plan sponsor requires you to try another drug before receiving the drug you are requesting, or the plan limits the quantity or dosage of the drug you are requesting (a formulary exception).
Extra Help A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance.
Generic Drug A prescription drug that is approved by the Food and Drug Administration (FDA) as having the same active ingredient(s) as the brand name drug. Generally, a "generic" drug works the same as a brand name drug and usually costs less.
Grievance A type of complaint you make about us or pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.
Home Health Aide A home health aide provides services that don't need the skills of a licensed nurse or therapist, such as help with personal care (e.g., bathing, using the toilet, dressing, or carrying out the prescribed exercises). Home health aides do not have a nursing license or provide therapy.
Hospice A member who has 6 months or less to live has the right to elect hospice. We, your plan, must provide you with a list of hospices in your geographic area. If you elect hospice and continue to pay premiums you are still a member of our plan. You can still obtain all medically necessary services as well as the supplemental benefits we offer. The hospice will provide special treatment for your state.
Hospital Inpatient Stay A hospital stay when you have been formally admitted to the hospital for skilled medical services. Even if you stay in the hospital overnight, you might still be considered an "outpatient."
Income Related Monthly Adjustment Amount (IRMAA) If your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you'll pay the standard premium amount and an Income Related Monthly Adjustment Amount, also known as IRMAA. IRMAA is an extra charge added to your premium. Less than 5% of people with Medicare are affected, so most people will not pay a higher premium.
Initial Coverage Limit The maximum limit of coverage under the Initial Coverage Stage.
Initial Coverage Stage This is the stage before your total drug costs including amounts you have paid and what your plan has paid on your behalf for the year have reached $6,550.
Initial Enrollment Period When you are first eligible for Medicare, the period of time when you can sign up for Medicare Part A and Part B. For example, if you're eligible for Medicare when you turn 65, your Initial
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Enrollment Period is the 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.
Institutional Special Needs Plan (SNP) A Special Needs Plan that enrolls eligible individuals who continuously reside or are expected to continuously reside for 90 days or longer in a long-term care (LTC) facility. These LTC facilities may include a skilled nursing facility (SNF); nursing facility (NF); (SNF/NF); an intermediate care facility for the mentally retarded (ICF/MR); and/or an inpatient psychiatric facility. An institutional Special Needs Plan to serve Medicare residents of LTC facilities must have a contractual arrangement with (or own and operate) the specific LTC facility(ies).
Institutional Equivalent Special Needs Plan (SNP) An institutional Special Needs Plan that enrolls eligible individuals living in the community but requiring an institutional level of care based on the State assessment. The assessment must be performed using the same respective State level of care assessment tool and administered by an entity other than the organization offering the plan. This type of Special Needs Plan may restrict enrollment to individuals that reside in a contracted assisted living facility (ALF) if necessary to ensure uniform delivery of specialized care.
List of Covered Drugs (Formulary or "Drug List") A list of prescription drugs covered by the plan. The drugs on this list are selected by the plan with the help of doctors and pharmacists. The list includes both brand name and generic drugs.
Low Income Subsidy (LIS) See "Extra Help."
Maximum Out-of-Pocket Amount The most that you pay out-of-pocket during the calendar year for covered Part A and Part B services. Amounts you pay for your plan premiums, Medicare Part A and Part B premiums, and prescription drugs do not count toward the maximum out-of-pocket amount. (Note: Because our members also get assistance from Medicaid, very few members ever reach this out-of-pocket maximum.) See Chapter 4, Section 1, for information about your maximum out-of-pocket amount.
Medicaid (or Medical Assistance) A joint Federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid. See Chapter 2, Section 6 for information about how to contact Medicaid in your state.
Medically Accepted Indication A use of a drug that is either approved by the Food and Drug Administration or supported by certain reference books. See Chapter 5, Section 3 for more information about a medically accepted indication.
Medically Necessary Services, supplies, or drugs that are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice.
Medicare The Federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with End-Stage Renal Disease (generally those with permanent kidney failure who need dialysis or a kidney transplant). People with Medicare can get their Medicare health coverage through Original Medicare , a PACE plan, or a Medicare Advantage Plan.
Medicare Advantage Open Enrollment Period A set time each year when members in a Medicare Advantage plan can cancel their plan enrollment and switch to another Medicare Advantage plan, or obtain coverage through Original Medicare. If you choose to switch to Original Medicare during this period, you can also join a separate
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Medicare prescription drug plan at that time. The Medicare Advantage Open Enrollment Period is from January 1 until March 31, and is also available for a 3-month period after an individual is first eligible for Medicare.
Medicare Advantage (MA) Plan Sometimes called Medicare Part C. A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. A Medicare Advantage Plan can be an HMO, PPO, a Private Fee-for-Service (PFFS) plan, or a Medicare Medical Savings Account (MSA) plan. When you are enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan, and are not paid for under Original Medicare. In most cases, Medicare Advantage Plans also offer Medicare Part D (prescription drug coverage). These plans are called Medicare Advantage Plans with Prescription Drug Coverage. Everyone who has Medicare Part A and Part B is eligible to join any Medicare Advantage health plan that is offered in their area.
Medicare Coverage Gap Discount Program A program that provides discounts on most covered Part D brand name drugs to Part D members who have reached the Coverage Gap Stage and who are not already receiving "Extra Help." Discounts are based on agreements between the Federal government and certain drug manufacturers. For this reason, most, but not all, brand name drugs are discounted.
Medicare-Covered Services Services covered by Medicare Part A and Part B. All Medicare health plans, including our plan, must cover all of the services that are covered by Medicare Part A and B.
Medicare Health Plan A Medicare health plan is offered by a private company that contracts with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan. This term includes all Medicare Advantage Plans, Medicare Cost Plans, Demonstration/Pilot Programs, and Programs of All-inclusive Care for the Elderly (PACE).
Medicare Prescription Drug Coverage (Medicare Part D) Insurance to help pay for outpatient prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare Part A or Part B.
"Medigap" (Medicare Supplement Insurance) Policy Medicare supplement insurance sold by private insurance companies to fill "gaps" in Original Medicare. Medigap policies only work with Original Medicare. (A Medicare Advantage Plan is not a Medigap policy.)
Member (Member of our Plan, or "Plan Member") A person with Medicare who is eligible to get covered services, who has enrolled in our plan and whose enrollment has been confirmed by the Centers for Medicare & Medicaid Services (CMS).
Member Services A department within our plan responsible for answering your questions about your membership, benefits, grievances, and appeals. See Chapter 2 for information about how to contact Member Services.
Network Pharmacy A network pharmacy is a pharmacy where members of our plan can get their prescription drug benefits. We call them "network pharmacies" because they contract with our plan. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies.
Network Provider "Provider" is the general term we use for doctors, other health care professionals, hospitals, and other health care facilities that are licensed or certified by Medicare and by the State to provide health care services. We call them "network providers" when they have an agreement with our plan to accept our payment as payment in full, and in some cases to coordinate as well as provide covered services to members of our plan. Our plan pays network providers based on the agreements it has with the providers or if the providers agree to provide you with plan-covered services. Network providers may also be referred to as "plan providers."
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Organization Determination The Medicare Advantage plan has made an organization determination when it makes a decision about whether items or services are covered or how much you have to pay for covered items or services. Organization determinations are called "coverage decisions" in this booklet. Chapter 9 explains how to ask us for a coverage decision.
Original Medicare ("Traditional Medicare" or "Fee-for-service" Medicare) Original Medicare is offered by the government, and not a private health plan like Medicare Advantage Plans and prescription drug plans. Under Original Medicare, Medicare services are covered by paying doctors, hospitals, and other health care providers payment amounts established by Congress. You can see any doctor, hospital, or other health care provider that accepts Medicare. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance) and is available everywhere in the United States.
Out-of-Network Pharmacy A pharmacy that doesn't have a contract with our plan to coordinate or provide covered drugs to members of our plan. As explained in this Evidence of Coverage, most drugs you get from out-of-network pharmacies are not covered by our plan unless certain conditions apply.
Out-of-Network Provider or Out-of-Network Facility A provider or facility with which we have not arranged to coordinate or provide covered services to members of our plan. Out-of-network providers are providers that are not employed, owned, or operated by our plan or are not under contract to deliver covered services to you. Using out-of-network providers or facilities is explained in this booklet in Chapter 3.
Out-of-Pocket Costs See the definition for "cost sharing" above. A member's cost sharing requirement to pay for a portion of services or drugs received is also referred to as the member's "out-of-pocket" cost requirement.
PACE plan A PACE (Program of All-Inclusive Care for the Elderly) plan combines medical, social, and long-term care (LTC) services for frail people to help people stay independent and living in their community (instead of moving to a nursing home) as long as possible, while getting the high-quality care they need. People enrolled in PACE plans receive both their Medicare and Medicaid benefits through the plan.
Part C see "Medicare Advantage (MA) Plan."
Part D The voluntary Medicare Prescription Drug Benefit Program. (For ease of reference, we will refer to the prescription drug benefit program as Part D.)
Part D Drugs Drugs that can be covered under Part D. We may or may not offer all Part D drugs. (See your formulary for a specific list of covered drugs.) Certain categories of drugs were specifically excluded by Congress from being covered as Part D drugs.
Part D Late Enrollment Penalty An amount added to your monthly premium for Medicare drug coverage if you go without creditable coverage (coverage that is expected to pay, on average, at least as much as standard Medicare prescription drug coverage) for a continuous period of 63 days or more after you are a first eligible to join a Part D plan. You pay this higher amount as long as you have a Medicare drug plan. There are some exceptions. For example, if you receive "Extra Help" from Medicare to pay your prescription drug plan costs, you will not pay a late enrollment penalty. If you lose Extra Help, you may be subject to the late enrollment penalty if you go 63 days or more in a row without Part D or other creditable prescription drug coverage.
If you ever lose your low income subsidy ("Extra Help"), you would be subject to the monthly Part D late enrollment penalty if you have ever gone without creditable prescription drug coverage for 63 days or more.
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Preferred Provider Organization (PPO) Plan A Preferred Provider Organization plan is a Medicare Advantage Plan that has a network of contracted providers that have agreed to treat plan members for a specified payment amount. A PPO plan must cover all plan benefits whether they are received from network or out-of-network providers. Member cost sharing will generally be higher when plan benefits are received from out-of-network providers. PPO plans have an annual limit on your out-of-pocket costs for services received from network (preferred) providers and a higher limit on your total combined out-of-pocket costs for services from both network (preferred) and out-of-network (non-preferred) providers.
Premium The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.
Primary Care Provider (PCP) Your primary care provider is the doctor or other provider you see first for most health problems. He or she makes sure you get the care you need to keep you healthy. He or she also may talk with other doctors and health care providers about your care and refer you to them. In many Medicare health plans, you must see your primary care provider before you see any other health care provider. See Chapter 3, Section 2.1 for information about Primary Care Providers.
Prior Authorization Approval in advance to get services or certain drugs that may or may not be on our formulary. Some in-network medical services are covered only if your doctor or other network provider gets "prior authorization" from our plan. Covered services that need prior authorization are marked in the Benefits Chart in Chapter 4. Some drugs are covered only if your doctor or other network provider gets "prior authorization" from us. Covered drugs that need prior authorization are marked in the formulary.
Prosthetics and Orthotics These are medical devices ordered by your doctor or other health care provider. Covered items include, but are not limited to, arm, back, and neck braces; artificial limbs; artificial eyes; and devices needed to replace an internal body part or function, including ostomy supplies and enteral and parenteral nutrition therapy.
Quality Improvement Organization (QIO) A group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to Medicare patients. See Chapter 2, Section 4 for information about how to contact the QIO for your state.
Quantity Limits A management tool that is designed to limit the use of selected drugs for quality, safety, or utilization reasons. Limits may be on the amount of the drug that we cover per prescription or for a defined period of time.
Rehabilitation Services These services include physical therapy, speech and language therapy, and occupational therapy.
Service Area A geographic area where a health plan accepts members if it limits membership based on where people live. For plans that limit which doctors and hospitals you may use, it's also generally the area where you can get routine (non-emergency) services. The plan may disenroll you if you permanently move out of the plan's service area.
Skilled Nursing Facility (SNF) Care Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a skilled nursing facility. Examples of skilled nursing facility care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor.
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Special Needs Plan A special type of Medicare Advantage Plan that provides more focused health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or who have certain chronic medical conditions.
Step Therapy A utilization tool that requires you to first try another drug to treat your medical condition before we will cover the drug your physician may have initially prescribed.
Supplemental Security Income (SSI) A monthly benefit paid by Social Security to people with limited income and resources who are disabled, blind, or age 65 and older. SSI benefits are not the same as Social Security benefits.
Urgently Needed Services Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed services may be furnished by network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible.
Molina Medicare Complete Care (HMO SNP) Member Services
Method CALL
TTY
FAX WRITE WEBSITE
Member Services Contact Information
(800) 665-0898 Calls to this number are free. 7 days a week, 8:00 a.m. to 8:00 p.m., local time Member Services also has free language interpreter services available for non-English speakers.
711 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. The National Relay is available 24 hours a day, 7 days a week.
(801) 858-0409
Molina Healthcare 7050 Union Park Center, Suite 200 Midvale, UT 84047
MolinaHealthcare.com/Medicare
Health Insurance Counseling & Advocacy Program (HICAP) (California 's SHIP) is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare.
Method CALL TTY
WRITE
WEBSITE
Contact Information
(760) 353-0223
711 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
Imperial County: Elder Law & Advocacy 5151 Murphy Canyon Road, Suite110 San Diego, CA 92123
http://www.cahealthadvocates.org/HICAP/
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