MEMBER HANDBOOK FOR 2017

Transcription

1 Ble Cross Commnity MMAI SM MEMBER HANDBOOK FOR Effective Janary 2017 H0927_BEN_IL_MHB17a Accepted

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3 H0927_BEN_IL_MHB17a Ble Cross Commnity MMAI SM Member Handbook 1

4 Chapter 1: Getting started as a member Janary 1, December 31, 2017 Yor Health and Drg Coverage nder the Ble Cross Commnity MMAI Medicare-Medicaid Plan This handbook tells yo abot yor coverage for the time yo are enrolled with Ble Cross Commnity MMAI throgh December 31, It explains health care services, behavioral health coverage, prescription drg coverage, and long-term services and spports. Long-term services and spports inclde long term care and home and commnity based waivers (HCBS). HCBS waivers can offer services that will help yo stay in yor home and commnity. This is an important legal docment. Please keep it in a safe place. Ble Cross Commnity MMAI plan is offered by Health Care Service Corporation. When this Member Handbook says we, s, or or, it means Health Care Service Corporation. When it says the plan or or plan, it means Ble Cross Commnity MMAI. Yo can get this handbook for free in Spanish or speak with someone abot this information in other langages or free. Call (TTY/TDD: 711). We are available seven (7) days a week. Or call center is open Monday-Friday 8:00 a.m.-8:00 p.m. Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day. The call is free. Usted pede obtener este docmento en Espanol, o hablar con algien acerca de esta información en otros idiomas, de forma gratita. Llame al (TTY/TDD: 711). Atendemos los siete (7) días de la semana. Nestro horario de atención es de lnes a viernes, de 8:00 a. m. a 8:00 p. m., Hora Centro. Servicio de bzón de voz disponible drante los fines de semana y días feriados federales. Si nos deja n mensaje, n Especialista en Servicio al Cliente regresará s llamada al sigiente día hábil. Llamada gratita. Yo can get this handbook for free in other formats, sch as large print, braille, or adio. Call (TTY/TDD: 711). We are available seven (7) days a week. Or call center is open Monday-Friday 8:00 a.m.-8:00 p.m. Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day. The call is free. Yo can ask to always get yor materials free in langages other than English or in alternate formats sch as Braille, adio or large print. Call (TTY/TDD: 711), We are available seven (7) days a week. Or call center is open Monday-Friday 8:00 a.m.- 8:00 p.m. Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day. The call is free. 2

5 Disclaimers Ble Cross Commnity MMAI MEMBER HANDBOOK Chapter 1: Getting started as a member Ble Cross Commnity MMAI is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to enrollees. Limitations and restrictions may apply. For more information, call Ble Cross Commnity MMAI Member Services or read the Ble Cross Commnity MMAI Member Handbook. This means that yo may have to pay for some services and that yo need to follow certain rles to have Ble Cross Commnity MMAI pay for yor services. The List of Covered Drgs and/or pharmacy and provider networks may change throghot the year. We will send yo a notice before we make a change that affects yo. Benefits may change on Janary 1 of each year. The SilverSneakers Fitness Program is a wellness program owned and operated by Healthways, Inc., an independent company. Healthways and SilverSneakers are registered trademarks of Healthways, Inc. and/or its sbsidiaries. Benefits, List of Covered Drgs, pharmacy and provider networks and/or copayments may change from time to time throghot the year and on Janary 1 of each year. Medicare-Medicaid Plan provided by Ble Cross and Ble Shield of Illinois, a Division of Health Care Service Corporation, a Mtal Legal Reserve Company (HCSC), an Independent Licensee of the Ble Cross and Ble Shield Association. HCSC is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to enrollees. Enrollment in HCSC s plan depends on contract renewal. Ble Cross, Ble Shield and the Cross and Shield Symbols are registered service marks of the Ble Cross and Ble Shield Association, an association of independent Ble Cross and Ble Shield Plans. 3

6 Chapter 1: Getting started as a member Table of Contents A. Welcome to Ble Cross Commnity MMAI...5 B. What are Medicare and Medicaid?...5 Medicare...5 Medicaid...5 C. What are the advantages of this plan?...6 D. What is Ble Cross Commnity MMAI s service area?...6 E. What makes yo eligible to be a plan member?...6 F. What to expect when yo first join a health plan...7 G. What is a care plan?...8 H. Does Ble Cross Commnity MMAI have a monthly plan premim?...8 I. Abot the Member Handbook...8 J. What other information will yo get from s?...8 Yor Ble Cross Commnity MMAI Member ID Card...9 Provider and Pharmacy Directory...9 List of Drable Medical Eqipment...10 List of Covered Drgs...10 The Explanation of Benefits...11 K. How can yo keep yor Enrollee Profile p to date? Do we keep yor personal health information private?

7 Chapter 1: Getting started as a member A. Welcome to Ble Cross Commnity MMAI Ble Cross Commnity MMAI is a Medicare-Medicaid Plan. A Medicare-Medicaid plan is an organization made p of doctors, hospitals, pharmacies, providers of long-term services and spports, and other providers. It also has care coordinators and care teams to help yo manage all yor providers and services. They all work together to provide the care yo need. Ble Cross Commnity MMAI was approved by the State and the Centers for Medicare & Medicaid Services (CMS) to provide yo services as part of the Medicare-Medicaid Alignment Initiative. The Medicare-Medicaid Alignment Initiative is a demonstration program jointly rn by Illinois and the federal government to provide better health care for people who have both Medicare and Medicaid. Under this demonstration, the state and federal government want to test new ways to improve how yo get yor Medicare and Medicaid health care services. B. What are Medicare and Medicaid? Medicare Medicare is the federal health insrance program for: People 65 years of age or older, Some people nder age 65 with certain disabilities, and People with end-stage renal disease (kidney failre). Medicaid Medicaid is a program rn by the federal government and the state that helps people with limited incomes and resorces pay for long-term services and spports and medical costs. It covers extra services and drgs not covered by Medicare. Each state decides what conts as income and resorces and who qalifies. They also decide what services are covered and the cost for services. States can decide how to rn their programs, as long as they follow the federal rles. Medicare and Illinois mst approve Ble Cross Commnity MMAI each year. Yo can get Medicare and Medicaid services throgh or plan as long as: We choose to offer the plan, and Medicare and the State approve the plan. Even if or plan stops operating in the ftre, yor eligibility for Medicare and Medicaid services will not be affected. 5

8 Chapter 1: Getting started as a member C. What are the advantages of this plan? Yo will now get all yor covered Medicare and Medicaid services from Ble Cross Commnity MMAI, inclding prescription drgs. Yo do not pay extra to join this health plan. Ble Cross Commnity MMAI will help make yor Medicare and Medicaid benefits work better together and work better for yo. Some of the advantages inclde: Yo will have a care team that yo helped pt together. Yor care team may inclde doctors, nrses, conselors, or other health professionals who are there to help yo get the care yo need. Yo will have a care coordinator. This is a person who works with yo, with Ble Cross Commnity MMAI, and with yor care providers to make sre yo get the care yo need. Yo will be able to direct yor own care with help from yor care team and care coordinator. The care team and care coordinator will work with yo to come p with a care plan specifically designed to meet yor health needs. The care team will be in charge of coordinating the services yo need. This means, for example: Yor care team will make sre yor doctors know abot all medicines yo take so they can redce any side effects. Yor care team will make sre yor test reslts are shared with all yor doctors and other providers. D. What is the Ble Cross Commnity MMAI service area? Or service area incldes these conties in Illinois: Cook, DPage, Kane, Kankakee, Lake and Will conties. Only people who live in or service area can get Ble Cross Commnity MMAI. If yo move otside of or service area, yo cannot stay in this plan. E. What makes yo eligible to be a plan member? Yo are eligible for or plan as long as: yo live in or service area, and yo have both Medicare Part A and Medicare Part B, and yo are eligible for Medicaid, and yo are a United States citizen or are lawflly present in the United States, and yo are age 21 and older at the time of enrollment, and yo are enrolled in the Medicaid Aid to the Aged, Blind and Disabled category of assistance, and 6

9 Chapter 1: Getting started as a member if yo meet all other Demonstration criteria and are in one of the following Medicaid 1915(c) waivers: Persons who are Elderly; Persons with Disabilities; Persons with HIV/AIDS; Persons with Brain Injry; or Persons residing in Spportive Living Facilities. Yo do not have End-Stage Renal Disease (ESRD), with limited exceptions, sch as if yo develop ESRD when yo are already a member of a plan that we offer, or yo were a member of a different plan that was terminated. F. What to expect when yo first join a health plan When yo first join the plan, yo will get a health risk assessment within the first 90 days. The Health Risk Assessment (HRA) is completed annally with a health expert from the plan. It is done in person or on the phone. Dring the HRA, the interviewer will: Review yor personal information. Tell yo how to find a PCP or specialist. Tell yo how to contact yor care coordinator. Let yo know if yo will have a homeor long-term care facility visit. Give yo a more detailed health assessment if needed If this is yor first time in a Medicare-Medicaid Plan, yo can keep seeing the doctors yo go to now for 180 days. If yo changed to Ble Cross Commnity MMAI from a different Medicare- Medicaid Plan, yo can keep seeing the doctors yo go to now for 90 days. The State of Illinois says that yor health plan mst let yo keep seeing yor doctor for at least 90 days after joining the plan if yor doctor is not part of the health plan s network. Ble Cross Commnity MMAI gives yo 180 days to keep seeing yor doctor. After the first 180 days, yo will need to see doctors and other providers in the Ble Cross Commnity MMAI network. A network provider is a provider who works with the health plan. See Chapter 3 for more information on getting care. 7

10 Chapter 1: Getting started as a member G. What is a care plan? A care plan is the plan for what medical, behavioral, long-term spports, social and fnctional services yo will get and how yo will get them. After yor health risk assessment, yor care team will meet with yo to talk abot what services yo need and want. Together, yo and yor care team will make a care plan. Every year, yor care team will work with yo to pdate yor care plan when the services yo need and want change. If yo are getting Home and Commnity Based Waiver services, yo will also have a service plan. The service plan lists the services yo will get and how often yo will get them. This service plan will become part of yor overall care plan. H. Does Ble Cross Commnity MMAI have a monthly plan premim? No. I. Abot the Member Handbook This Member Handbook is part of or contract with yo. This means that we mst follow all of the rles in this docment. If yo think we have done something that goes against these rles, yo may be able to appeal, or challenge, or action. For information abot how to appeal, see Chapter 9, Section 4, or call MEDICARE ( ). The contract is in effect for the months yo are enrolled in Ble Cross Commnity MMAI between Janary 1, 2017 and December 31, J. What other information will yo get from s? Yo shold have already gotten a Ble Cross Commnity MMAI Member ID Card, information abot how to access a Provider and Pharmacy Directory, and a List of Covered Drgs. 8

11 Yor Ble Cross Commnity MMAI Member ID Card Under or plan, yo will have one card for yor Medicare and Medicaid services, inclding long term services and spports and prescriptions. Yo mst show this card when yo get any services or prescriptions. Here s a sample card to show yo what yors will look like: If yor card is damaged, lost, or stolen, call Member Services right away and we will send yo a new card. Ble Cross Commnity MMAI MEMBER HANDBOOK Chapter 1: Getting started as a member Grop Name:<XXXX> Enrollment Effective Date: <MM,DD,YYYY> PCP:<PCP NAME> MEMBERS: <PCP PHONE NUMBER> Member Services: < > TDD/TTY: /7 Nrse Line: < > PROVIDERS: < > PHARMACISTS ONLY: < > Ble Cross and Ble Shield of Illinois, a Division of Health Care Service Corporation, a Mtal Legal Reserve Company (HCSC), an independent Member Name: <John A Doe> Medical & Behavioral Health Claims: Ble Cross Commnity ICP Attn: Claims PO Box Chicago, IL SAMPLE For all other claims (inclding dental, vision, and transportation) call < > for paper claim address. licensee of the Ble Cross and Ble Shield Association. Ble Cross Commnity ICP SM Medicaid ID: < > Member ID: < > SAMPLE RxBIN: <011552> RxPCN: <XXXX> As long as yo are a member of or plan, yo do not need to se yor red, white, and ble Medicare card or yor Medicaid card to get services. Keep those cards in a safe place, in case yo need them later. Provider and Pharmacy Directory The Provider and Pharmacy Directory lists the providers and pharmacies in the Ble Cross Commnity MMAI network. While yo are a member of or plan, yo mst se network providers to get covered services. There are some exceptions when yo first join or plan (see page 34). Yo can ask for an annal Provider and Pharmacy Directory by calling Member Services at (TTY/TDD: 711), We are available seven (7) days a week. Or call center is open Monday-Friday 8:00 a.m.-8:00 p.m. Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day. The call is free. Yo can also see the Provider and Pharmacy Directory at or download it from this website. The directory incldes hospitals, physicians and other providers participating in the Ble Cross Commnity MMAI. The table of contents describes each section inclded in the Provider and Pharmacy Directory, and each section is organized alphabetically by conty. Within each conty, the city and/or physician names are listed in alphabetical order along with the address and phone nmber. For the most pdated provider information, please visit or Provider Finder at 9

12 Chapter 1: Getting started as a member What are network providers? Network providers are doctors, nrses, and other health care professionals that yo can go to as a member of or plan. Network providers also inclde clinics, hospitals, nrsing facilities, and other places that provide health services in or plan. They also inclde home health agencies, drable medical eqipment sppliers, and others who provide goods and services that yo get throgh Medicare or Medicaid. Long-term spport and services are also inclded, sch as: Home services. Day habilitation services. Home health care or personal care attendant services. Network providers have agreed to accept payment from or plan for covered services as payment in fll. Adlt day health services. Nrsing home care. Respite care and home modifications. What are network pharmacies? Network pharmacies are pharmacies (drg stores) that have agreed to fill prescriptions for or plan members. Use the Provider and Pharmacy Directory to find the network pharmacy yo want to se. Except dring an emergency, yo mst fill yor prescriptions at one of or network pharmacies if yo want or plan to help yo pay for them. Call Member Services at (TTY/TDD: 711). We are available seven (7) days a week. Or call center is open Monday-Friday 8:00 a.m.-8:00 p.m. Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day for more information. The call is free. Yo can also see the Provider and Pharmacy Directory at or download it from this website. Both Member Services and Ble Cross Commnity MMAI s website can give yo the most p-to-date information abot changes in or network pharmacies and providers. List of Drable Medical Eqipment With this Member Handbook, we sent yo Ble Cross Commnity MMAI s List of Drable Medical Eqipment. This list tells yo the brands and makers of drable medical eqipment that we cover. The most recent list of brands, makers, and sppliers is also available on or website at List of Covered Drgs The plan has a List of Covered Drgs. We call it the Drg List for short. It tells which prescription drgs are covered by Ble Cross Commnity MMAI. The Drg List also tells yo if there are any rles or restrictions on any drgs, sch as a limit on the amont yo can get. See Chapter 5 section C for more information on these rles and restrictions. 10

13 Chapter 1: Getting started as a member Each year, we will send yo a copy of the Drg List, bt some changes may occr dring the year. To get the most p-to-date information abot which drgs are covered, visit or call Member Services at (TTY/TDD: 711). We are available seven (7) days a week. Or call center is open Monday-Friday 8:00 a.m.-8:00 p.m. Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day. The call is free. The Explanation of Benefits When yo se yor Part D prescription drg benefits, we will send yo a smmary report to help yo nderstand and keep track of payments for yor Part D prescription drgs. This smmary report is called the Explanation of Benefits (or EOB). The Explanation of Benefits tells yo the total amont yo or others on yor behalf have spent on yor Part D prescription drgs and the total amont we have paid for each of yor Part D prescription drgs dring the month. Chapter 6 gives more information abot the Explanation of Benefits and how it can help yo keep track of yor drg coverage. An Explanation of Benefits is also available when yo ask for one. To get a copy, please contact Member Services. K. How can yo keep yor Enrollee Profile p to date? Yo can keep yor enrollee profile p to date by letting s know when yor information changes. The plan s network providers and pharmacies need to have the right information abot yo. They se yor enrollee profile to know what services and drgs yo get and how mch it will cost yo. Becase of this, it is very important that yo help s keep yor information p-to-date. Let s know the following: If yo have any changes to yor name, yor address, or yor phone nmber If yo have any changes in any other health insrance coverage, sch as from yor employer, yor spose s employer, or workers compensation If yo have any liability claims, sch as claims from an atomobile accident If yo are admitted to a nrsing home or hospital If yo get care in an ot-of-area or ot-of-network hospital or emergency room If yor caregiver or anyone responsible for yo changes If yo are part of a clinical research stdy 11

14 Chapter 1: Getting started as a member If any information changes, please let s know by calling Member Services at (TTY/TDD: 711). We are available seven (7) days a week. Or call center is open Monday-Friday 8:00 a.m.-8:00 p.m. Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day. The call is free. Do we keep yor personal health information private? Yes. Laws reqire that we keep yor medical records and personal health information private. We make sre that yor health information is protected. For more information abot how we protect yor personal health information, see the HIPAA Notice of Privacy Practices located on the website 12

15 Chapter 2: Important phone nmbers and resorces 13

16 Chapter 2: Important phone nmbers and resorces Table of Contents A. How to contact Ble Cross Commnity MMAI Member Services...16 Contact Member Services abot:...16 Qestions abot the plan Qestions abot claims, billing or Member ID Cards Coverage decisions abot yor health care Appeals abot yor health care Complaints abot yor health care Coverage decisions abot yor drgs Appeals abot yor drgs Complaints abot yor drgs Payment for health care or drgs yo already paid for B. How to contact yor Care Coordinator...19 Contact yor care coordinator abot:...20 Qestions abot yor health care Qestions abot getting behavioral health services, transportation, and long-term services and spports (LTSS) C. How to contact the Nrse Advice Call Line...21 Contact the Nrse Advice Call Line abot:...21 Qestions abot yor health care D. How to contact the Behavioral Health Crisis Line...22 Contact the Behavioral Health Crisis Line abot:...22 E. How to contact the Senior Health Insrance Program (SHIP)...23 Contact SHIP abot:...23 Qestions abot yor Medicare health insrance

17 Chapter 2: Important phone nmbers and resorces F. How to contact the Qality Improvement Organization (QIO)...24 Contact Telligen QIO abot:...24 Qestions abot yor health care G. How to contact Medicare...25 H. How to contact Medicaid...26 I. How to contact the Illinois Health Benefits Hotline...26 J. How to contact the Illinois Long Term Care Ombdsman Program...27 K. Other resorces

18 Chapter 2: Important phone nmbers and resorces A. How to contact Ble Cross Commnity MMAI Member Services CALL TTY This call is free. We are available seven (7) days a week. Or call center is open Monday-Friday 8:00 a.m.-8:00 p.m. Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day. We have free interpreter services for people who do not speak English. 711 This call is free. This nmber is for people who have hearing or speaking problems. Yo mst have special telephone eqipment to call it. We are available seven (7) days a week. Or call center is open Monday-Friday 8:00 a.m.-8:00 p.m. Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day. FAX WRITE PO Box 3836 Scranton, PA WEBSITE Contact Member Services abot: Qestions abot the plan Qestions abot claims, billing or Ble Cross Commnity MMAI Member ID Cards Coverage decisions abot yor health care A coverage decision abot yor health care is a decision abot: yor benefits and covered services, or the amont we will pay for yor health services. Call s if yo have qestions abot a coverage decision abot health care. To learn more abot coverage decisions, see Chapter 9. 16

19 Chapter 2: Important phone nmbers and resorces Appeals abot yor health care An appeal is a formal way of asking s to review a decision we made abot yor coverage and asking s to change it if yo think we made a mistake. To learn more abot making an appeal, see Chapter 9, Section 4. Complaints abot yor health care Yo can make a complaint abot s or any provider inclding a non-network or network provider. A network provider is a provider who works with the health plan. Yo can also make a complaint abot the qality of the care yo got to s or to the Qality Improvement Organization (see Section F below). If yor complaint is abot a coverage decision abot yor health care, yo can make an appeal. (See the section above.) Yo can send a complaint abot Ble Cross Commnity MMAI right to Medicare. Yo can se an online form at Or yo can call MEDICARE ( ) to ask for help. To learn more abot making a complaint abot yor health care, see Chapter 9. Coverage decisions abot yor drgs A coverage decision abot yor drgs is a decision abot: yor benefits and covered drgs, or the amont we will pay for yor drgs. This applies to yor Part D drgs, Medicaid prescription drgs, and Medicaid over-the-conter drgs. For more on coverage decisions abot yor prescription drgs, see Chapter 9, Section 6. Appeals abot yor drgs An appeal is a way to ask s to change a coverage decision. For more on making an appeal abot yor prescription drgs, see Chapter 9, Section 6.5 or call Member Services at (TTY/TDD: 711). Complaints abot yor drgs Yo can make a complaint abot s or a pharmacy. This incldes a complaint abot yor prescription drgs. 17

20 Chapter 2: Important phone nmbers and resorces If yor complaint is abot a coverage decision abot yor prescription drgs, yo can make an appeal. (See the section above.) Yo can send a complaint abot Ble Cross Commnity MMAI right to Medicare. Yo can se an online form at Or yo can call MEDICARE ( ) to ask for help. For more on making a complaint abot yor prescription drgs, see Chapter 9, Section 10. Payment for health care or drgs yo already paid for For more on how to ask s to pay yo back, or to pay a bill yo got, see Chapter 7, Section B. If yo ask s to pay a bill and we deny any part of yor reqest, yo can appeal or decision. See Chapter 9, Section 5 for more on appeals. 18

21 Chapter 2: Important phone nmbers and resorces B. How to contact yor Care Coordinator As a member of Ble Cross Commnity MMAI, yo will be assigned a care coordinator. Yor care coordinator will help yo manage all yor doctors and health services. He or she will make sre yo get all the tests, labs and other care yo need. They also make sre that yor test reslts are shared with yor health care team. To reach yor care coordinator, or for qestions abot changing yor care coordinator: This call is free. CALL We are available seven (7) days a week. Or call center is open Monday-Friday 8:00 a.m.-8:00 p.m. Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day. We have free interpreter services for people who do not speak English. 711 This call is free. This nmber is for people who have hearing or speaking problems. Yo mst have special telephone eqipment to call it. TTY We are available seven (7) days a week. Or call center is open Monday-Friday 8:00 a.m.-8:00 p.m. Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day. FAX WRITE P.O. Box 3836 Scranton, PA WEBSITE 19

22 Chapter 2: Important phone nmbers and resorces Contact yor care coordinator abot: Qestions abot yor health care Qestions abot getting behavioral health services, transportation, and long-term services and spports (LTSS) If yor provider or Care Coordinator thinks yo may be eligible for Long Term Care or additional spports and services to keep yo in yor home, they will refer yo to an agency that will decide if yo are eligible for those services. Sometimes yo can get help with yor daily health care and living needs. Yo might be able to get these services: Skilled nrsing care Home Delivered Meals Personal Assistant Home health care Homemaker Intermittent Nrsing Adlt Day Care Occpational therapy Emergency Home Response System Personal Aide Travel to Adlt Day Care Physical therapy Behavioral Services Prevocational Services Day Habilitation to help regain Specialized Medical Eqipment and Spplies independence in yor home Speech therapy Emergency Home Response System (devices Spported Employment that call for help by pshing a btton) Respite for family and friend caregiver Home Accessibility Improvements like wheelchair ramps or bathroom railings 20

23 Chapter 2: Important phone nmbers and resorces C. How to contact the Nrse Advice Call Line Or free 24/7 Nrse Advice Call Line will connect yo with a nrse who can answer yor health qestions. The nrse can help yo decide if yo need to go to the ER or rgent care center, or if yo shold wait to see yor PCP. If yo think yo have an rgent problem and yor doctor cannot see yo right away, call the Nrse Advice Call Line for help This call is free. CALL 24 hors a day, 7 days a week We have free interpreter services for people who do not speak English. 711 This call is free. TTY This nmber is for people who have hearing or speaking problems. Yo mst have special telephone eqipment to call it. 24 hors a day, 7 days a week Contact the Nrse Advice Call Line abot: Qestions abot yor health care Or free 24/7 Nrse Advice Call Line will connect yo with a nrse who can answer yor health qestions. The nrse can help yo decide if yo need to go to the ER or rgent care center, or if yo shold wait to see yor PCP. If yo think yo have an rgent problem and yor doctor cannot see yo right away, call the Nrse Advice Call Line for help. 21

24 Chapter 2: Important phone nmbers and resorces D. How to contact the Behavioral Health Crisis Line CALL TTY This call is free. 24 hors a day, 7 days a week Or call center is open Monday-Friday 8:00 a.m.- 8:00 p.m. Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day. We have free interpreter services for people who do not speak English. 711 This call is free. This nmber is for people who have hearing or speaking problems. Yo mst have special telephone eqipment to call it. We are available seven (7) days a week. Or call center is open Monday-Friday 8:00 a.m.-8:00 p.m. Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day. Contact the Behavioral Health Crisis Line abot: Feelings of hrting yorself or others Wanting to give p Feeling confsed or pset Feeling ot of control If yo are experiencing a medical emergency, please call 911. If yo have qestions, please call Ble Cross Commnity MMAI at (TTY/TDD: 711), 8:00 a.m. ntil 8:00 p.m. Central time, seven (7) days a week. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a cstomer service representative will retrn yor call no later than the next bsiness day. For more information, visit 22

25 Chapter 2: Important phone nmbers and resorces E. How to contact the Senior Health Insrance Program (SHIP) The Senior Health Insrance Program (SHIP) gives free health insrance conseling to people with Medicare. SHIP is not connected with any insrance company or health plan. CALL TTY WRITE WEBSITE Monday-Friday 8:30 a.m. - 5 p.m. The call is free Monday-Friday 8:30 a.m. 5 p.m. The call is free. Senior Health Insrance Program Illinois Department on Aging One Natral Resorces Way, Site 100 Springfield, IL AGING.SHIP@illinois.gov Contact SHIP abot: Qestions abot yor Medicare health insrance SHIP conselors can: help yo nderstand yor rights, help yo nderstand yor plan choices, answer yor qestions abot changing to a new plan, help yo make complaints abot yor health care or treatment, and help yo straighten ot problems with yor bills. 23

26 Chapter 2: Important phone nmbers and resorces F. How to contact the Qality Improvement Organization (QIO) Or state has an organization called a Telligen QIO. This is a grop of doctors and other health care professionals who help improve the qality of care for people with Medicare. Telligen QIO is not connected with or plan. CALL (TTY/TDD 711) TTY WRITE WEBSITE This nmber is for people who have hearing or speaking problems. Yo mst have special telephone eqipment to call it. Telligen Attn: BFCC 1776 West Lakes Parkway West Des Moines, IA Contact Telligen QIO abot: Qestions abot yor health care Yo can make a complaint abot the care yo got if: Yo have a problem with the qality of care, Yo think yor hospital stay is ending too soon, or Yo think yor home health care, skilled nrsing facility care, or comprehensive otpatient rehabilitation facility (CORF) services are ending too soon. 24

27 Chapter 2: Important phone nmbers and resorces G. How to contact Medicare Medicare is the federal health insrance program for people 65 years of age or older, some people nder age 65 with disabilities, and people with end-stage renal disease (permanent kidney failre reqiring dialysis or a kidney transplant). The federal agency in charge of Medicare is the Centers for Medicare & Medicaid Services, or CMS. CALL MEDICARE ( ) Calls to this nmber are free, 24 hors a day, 7 days a week This call is free. TTY This nmber is for people who have hearing or speaking problems. Yo mst have special telephone eqipment to call it. This is the official website for Medicare. It gives yo p-to-date information abot Medicare. It also has information abot hospitals, nrsing homes, physicians, home health agencies, and dialysis facilities. It incldes booklets yo can print right from yor compter. Yo can also find Medicare contacts in yor state by selecting Forms, Help & Resorces and then clicking on Phone nmbers & websites. The Medicare website has the following tool to help yo find plans in yor area: Medicare Plan Finder: Provides personalized information abot Medicare prescription drg plans, Medicare health plans, and Medigap (Medicare Spplement Insrance) policies in yor area. Select Find health & drg plans. WEBSITE If yo don t have a compter, yor local library or senior center may be able to help yo visit this website sing its compter. Or, yo can call Medicare at the nmber above and tell them what information yo are looking for. They will find the information on the website, print it ot, and send it to yo. 25

28 Chapter 2: Important phone nmbers and resorces H. How to contact Medicaid Medicaid helps with medical and long-term services and spports costs for people with limited incomes and resorces. Yo are enrolled in Medicare and in Medicaid. If yo have qestions abot yor Medicaid eligibility, call the Illinois Department of Hman Services Cstomer Help Line. CALL TTY WEBSITE Monday-Friday 8 a.m. 5 p.m. The call is free Monday-Friday 8 a.m. 5 p.m. The call is free. DHS.WebBits@illinois.gov I. How to contact the Illinois Health Benefits Hotline The Illinois Department of Healthcare and Family Services Health Benefits Helpline helps people enrolled in Medicaid with service or billing problems. They can help yo file a complaint or an appeal with or plan. CALL TTY Monday-Friday 8 a.m. - 4:45 p.m. The call is free Monday-Friday 8 a.m. - 4:45 p.m. The call is free. WEBSITE This is the official website for Medicaid. It gives yo p-to-date information abot Medicaid. 26

29 Chapter 2: Important phone nmbers and resorces J. How to contact the Illinois Long Term Care Ombdsman Program The Illinois Long Term Care Ombdsman Program helps protect and promote the rights of people who live in nrsing homes and other long-term care settings. It also helps solve problems between these settings and residents or their families. CALL TTY WRITE WEBSITE Monday-Friday 8:30 a.m. 5 p.m. The call is free Monday-Friday 8:30 a.m. 5 p.m. The call is free. Long Term Care Ombdsman Program Illinois Department on Aging One Natral Resorces Way, Site 100 Springfield, IL aging.ilsenior@illinois.gov defalt.aspx K. Other resorces Illinois Client Enrollment Services Illinois Client Enrollment Services is available to assist yo with plan comparisons, find a provider and enroll in a health plan. CALL Monday to Friday 8 a.m. to 7 p.m. and Satrday 9 a.m. to 3 p.m. TTY Hfs.webmaster@illinois.gov WEBSITE Central West Senior Center - Chicago Department on Aging 2102 W. Ogden Ave Phone: TTY: Fax: aging@cityofchicago.org URL: The Central West Regional Center serves a diverse area that incldes the 1st, 22nd, 24th, 25th, 26th, 27th, 28th, 29th, 31st, 32nd, 37th, and 42nd wards. There are an estimated 100 senior clbs and grops that participate in programs at the Central West Senior Center. Major social activities inclde classes, trips, parties, and recreational activities. The center also serves a hot lnch daily, as part of the department s Golden Diners Program. A comprehensive fitness and wellness program is also offered. Services also inclde a commnity-based Information & Assistance Unit that can link senior citizens to benefits and services. 27

30 Chapter 2: Important phone nmbers and resorces Coalition of Limited English Speaking Elderly (CLESE) 53 West Jackson, Site 1340 Chicago, IL / (fax) / info@clese.org CLESE promotes nderstanding, sensitivity, and insight into cltrally diverse commnities. CLESE is a resorce to ethnic agencies by providing assistance and information. Fifty for commnity-based ethnic organizations can be reached by contacting CLESE, inclding: AgeOptions Chicago Department of Family and Spport Services Illinois Department on Aging Illinois Department of Pblic Health Illinois Department of Hman Services Jewish Federation of Metropolitan Chicago ORR Refgee Agricltral Partnership Program Retirement Research Fondation Northeastern Illinois Area Agency on Aging Main Office P.O. Box 809 Kankakee, IL (800) toll free in Illinois (815) phone (815) fax info@agegide.org Serves DPage, Grndy, Kane, Kankakee, Kendall, Lake, McHenry, and Will Conties The Agency on Aging is a resorce that connects local, state and national aging programs and services, provides at-risk elders the opportnity to stay in their own homes with dignity and safety and the agency also advocates and collaborates with commnities to prepare seniors and families for aging. 28

31 Chapter 3: Using the plan s coverage for yor health care and other covered services 29

32 Chapter 3: Using the plan s coverage for yor health care and other covered services Table of Contents A. Abot services, covered services, providers, and network providers...31 B. Rles for getting yor health care, behavioral health, and long-term services and spports covered by the plan...31 C. Yor care coordinator...33 D. Getting care from primary care providers, specialists, other network providers, and ot-of-network providers...33 E. How to get long-term services and spports (LTSS)...37 F. How to get behavioral health services...37 G. How to get self-directed care...38 H. How to get transportation services...38 I. How to get covered services when yo have a medical emergency or rgent need for care, or dring a disaster...39 J. What if yo are billed directly for the fll cost of services covered by or plan?...42 K. How are yor health care services covered when yo are in a clinical research stdy?...42 L. How are yor health care services covered when yo are in a religios non-medical health care instittion?...44 M. Rles for owning drable medical eqipment

33 Chapter 3: Using the plan s coverage for yor health care and other covered services A. Abot services, covered services, providers, and network providers Services are health care, long-term services and spports, spplies, behavioral health, prescription and over-the-conter drgs, eqipment and other services. Covered services are any of these services that or plan pays for. Covered health care and long-term services and spports are listed in the Benefits Chart in Chapter 4, Section C. Providers are doctors, nrses, specialists and other people who give yo services and care. The term providers also incldes hospitals, home health agencies, clinics, and other places that give yo health care services, medical eqipment, and long-term services and spports. Network providers are providers who work with the health plan. These providers have agreed to accept or payment as fll payment. Network providers bill s directly for care they give yo. When yo see a network provider, yo sally pay nothing for covered services. B. Rles for getting yor health care, behavioral health, and long-term services and spports covered by the plan Ble Cross Commnity MMAI covers all services covered by Medicare and Medicaid. This incldes medical, behavioral health, long term services and spports, and prescription drgs. Ble Cross Commnity MMAI will generally pay for the health care and services yo get if yo follow the plan rles. To be covered: The care yo get mst be a plan benefit. This means that it mst be inclded in the plan s Benefits Chart. (The chart is in Chapter 4, Section C of this handbook). The care mst be medically necessary. Medically necessary means yo need services to prevent, diagnose, or treat yor medical condition or to maintain yor crrent health stats. This incldes care that keeps yo from going into a hospital or nrsing home. It also means the services, spplies, or drgs meet accepted standards of medical practice or are otherwise necessary nder crrent Medicare or Illinois Medicaid coverage rles. Yo mst have a network primary care provider (PCP) who has ordered the care or has told yo to see another doctor. As a plan member, yo mst choose a network provider to be yor PCP. Yo do not need a referral from yor PCP for emergency care or rgently needed care or to see a woman s health provider. Yo can get other kinds of care withot having a referral from yor PCP. To learn more abot this, see page 34. To learn more abot choosing a PCP, see page

34 Chapter 3: Using the plan s coverage for yor health care and other covered services Please note: If this is yor first time in a Medicare-Medicaid Plan, yo may contine to see yor crrent providers for the first 180 days with or plan, at no cost, if they are not a part of or network. If yo changed to Ble Cross Commnity MMAI from a different Medicare-Medicaid Plan, yo may contine to see yor crrent providers for the first 90 days with or plan, at no cost, if they are not a part of or network. Dring the transition time, or care coordinator will contact yo to help yo find providers in or network. After that time, we will no longer cover yor care if yo contine to see ot-ofnetwork providers. Yo mst get yor care from network providers. Usally, the plan will not cover care from a provider who does not work with the health plan. Here are some cases when this rle does not apply: The plan covers emergency or rgently needed care from an ot-of-network provider. To learn more and to see what emergency or rgently needed care means, see page 39. If yo need care that or plan covers and or network providers cannot give it to yo, yo can get the care from an ot-of-network provider. Or plan reqires athorization for yo to get the care from an ot-of-network provider, please work with yor PCP and contact Member Services to start this process. Yo or yor PCP can start this. In this sitation, we will cover the care as if yo got it from a network provider. To learn abot getting approval to see an ot-of-network provider, see page 37. The plan covers kidney dialysis services when yo are otside the plan s service area for a short time. Yo can get these services at a Medicare-certified dialysis facility. When yo first join the plan, yo can contine seeing the providers yo see now for 180 days. 32

35 Chapter 3: Using the plan s coverage for yor health care and other covered services C. Yor care coordinator Everyone on yor health care team works together to make sre yo get the health care yo need. Yo have a care coordinator who directs yor care and an Interdisciplinary Care Team that works closely with yor main caregiver to make sre that needed social and behavioral health services are inclded in yor care plan. What is a care coordinator? Yor care coordinator is in charge of arranging yor care and helping yo manage yor health providers and services. He or she will: make sre yo get all the tests, labs and other care that yo need make sre that yor test reslts are shared with yor Care Team and the right providers always get yor permission before sharing medical information with other providers. How can yo contact yor care coordinator? Yo may call Member Services at (TTY/TDD: 711). We are available seven (7) days a week. Or call center is open Monday-Friday 8:00 a.m.-8:00 p.m. Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day. The call is free. We have free translation for people who do not speak English. How can yo change yor care coordinator? Call Member Services at (TTY/TDD: 711) dring the hors above. This call is free. Ask for a translator if yo do not speak English. D. Getting care from primary care providers, specialists, other network providers, and ot-of-network providers Getting care from a primary care provider Yo mst choose a primary care provider (PCP) to provide and manage yor care. What is a PCP, and what does the PCP do for yo? A PCP is a doctor who gives yo rotine health care. Yor PCP: Will keep yor medical records and get to know yor health needs over time. Will give yo a referral if yo need to see an ot-of-network provider. Has signed a special Medical Service agreement with Ble Cross and Ble Shield of Illinois. What types of providers may act as a PCP? Yor PCP cold be a doctor specializing in Internal Medicine, Family Practice or Geriatrics. If yo are a woman, yo may select a Woman s Health Care Provider, sch as a Gynecologist or Obstetrician/Gynecologist (OB/GYN), as yor PCP. 33

36 Chapter 3: Using the plan s coverage for yor health care and other covered services What is the role of a PCP? Yor PCP is the most important person to help yo with yor health care needs. This is who yo will go to first when yo are sick or need a checkp. Yo and yor PCP shold work as a team to take care of yor health. Yo shold be able to talk to yor PCP abot all of yor health care needs. What is the role of a PCP in coordinating covered services? Yor PCP is responsible for handling all of yor health care needs. He or she will provide most of yor care and will help yo arrange the rest of the covered services yo get as a member of the Ble Cross Commnity MMAI Plan. What is the role of a PCP in making decisions abot or getting prior athorization? Certain services reqire prior athorization. This means yo get approval in advance. If yor PCP finds that a referral is needed, he or she will handle the process. Can a clinic be yor primary care provider? Yes. A clinic is sometimes known as a Primary Care Medical Home. This is a health care setting that teams p with a patient, his or her personal doctor and, when sitable, the patient s family. Patients get care when and where they need and want it in a manner that respects their cltre and langage. How do yo choose yor PCP? Yo can choose yor PCP when yo enroll in Ble Cross Commnity MMAI. If yo want to see a certain specialist or go to a specific hospital, check first to be sre the specialist or hospital is in network. If not, yor PCP will need to reqest prior athorization. To choose a PCP, go to the list of doctors in yor Ble Cross Commnity MMAI 2016 Provider and Pharmacy Directory and: Choose a doctor that yo se now, or Choose a doctor who has been spported by someone yo trst, or Choose a doctor whose offices are easy for yo to get to. How do yo change yor PCP? Yo may change yor PCP for any reason, at any time. Also, it s possible that yor PCP might leave or plan s network. We can help yo find a new PCP. To change yor PCP, jst call Member Services at (TTY/TDD: 711). We are available seven (7) days a week. Or call center is open Monday-Friday 8:00 a.m.-8:00 p.m. Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day. The call is free. We have free translation for people who do not speak English. We will let yo know the date the change will happen and send yo a new ID card showing the change. 34

37 Chapter 3: Using the plan s coverage for yor health care and other covered services If yo ask s to change yor PCP anytime dring the month, yo may see yor new PCP the first calendar day of the next month. For example: If yo call on April 13, yo may see yor new PCP on or after May 1. Please get care from yor crrent PCP ntil the change takes place. If yor PCP or another provider that yo see often leaves or network, we will send yo a letter at least 30 days before the PCP leaves to let yo know. To choose a new provider, look in the Provider and Pharmacy Directory, call Member Services or go to the online provider directory at What services can yo get withot first getting approval from yor PCP? In most cases, yo will need approval from yor PCP before seeing other providers. This approval is called a referral. Yo can get services like the ones listed below withot first getting approval from yor PCP: Emergency services from network providers or ot-of-network providers. Urgently needed care from network providers. Urgently needed care from ot-of-network providers when yo can t get to network providers (for example, when yo are otside the plan s service area). Kidney dialysis services that yo get at a Medicare-certified dialysis facility when yo are otside the plan s service area. (Please call Member Services before yo leave the service area. We can help yo get dialysis while yo are away.) Fl shots, hepatitis B vaccinations, and pnemonia vaccinations as long as yo get them from a network provider. Rotine women s health care and family planning services. This incldes breast exams, screening mammograms (x-rays of the breast), Pap tests, and pelvic exams as long as yo get them from a network provider. Additionally, if yo are eligible to get services from Indian health providers, yo may see these providers withot a referral. Getting care from specialists and other network providers A specialist is a doctor who provides health care for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples: Oncologists care for patients with cancer. Cardiologists care for patients with heart problems. Orthopedists care for patients with bone, joint, or mscle problems. 35

38 Chapter 3: Using the plan s coverage for yor health care and other covered services What is the role of the PCP in referring members to specialists and other providers? If yor PCP thinks yo need to see a specialist or other provider, he or she will refer yo. Yor PCP will sally refer yo to a provider that he or she has worked with before. Yo may also go see a specialist that is in or network withot a PCP referral. Keep in mind that services or spplies not listed as covered (see Chapter 4) will not be covered even if they are ordered by yor PCP. What is the process for getting prior athorization? Prior Athorization is the steps in which yo or yor provider get or plan s approval for specific services or drgs. Yo or yor provider can start this by contacting Member Services. Please see the Benefits Chart in Chapter 4 for information abot which services reqire Prior athorization. Yor PCP will handle the prior athorization process. What if a network provider leaves or plan? A network provider yo are sing might leave or plan. If a network provider yo are sing leaves or plan, we will notify yo in writing by mail. We will also call yo to see if yo need help selecting a new PCP. If yor provider leaves the plan s network, we will allow a transition period of 90 days from date of notice if yo have an ongoing corse of treatment or are in yor third trimester of pregnancy, inclding postpartm care. If one of yor providers does leave or plan, yo have certain rights and protections that are smmarized below: Even thogh or network of providers may change dring the year, we mst give yo ninterrpted access to qalified providers. We will help yo select a new qalified provider to contine managing yor health care needs. If yo are ndergoing medical treatment, yo have the right to ask that the medically necessary treatment yo are getting is not interrpted. We will work with yo to ensre yo contine getting the treatment yo need. If yo believe we have not replaced yor previos provider with a qalified provider or that yor care is not being appropriately managed, yo have the right to file an appeal of or decision. If yo find ot one of yor providers is leaving or plan, please contact s so we can assist yo in finding a new provider and managing yor care. If yo have qestions, please call Ble Cross Commnity MMAI at (TTY/TDD 711), We are available seven (7) days a week. Or call center is open Monday-Friday 8:00am-8:00pm Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day. The call is free. For more information, visit 36

39 Chapter 3: Using the plan s coverage for yor health care and other covered services Getting care from ot-of-network providers If yo choose to go to a doctor otside of or network, withot an approval from or plan yo mst pay for these services yorself. Neither the plan nor Original Medicare will pay for these services except for emergency care. The exceptions to this rle are when yo need rgent or emergency care or dialysis and cannot get to a provider in the plan, like when yo are away from home. Yo can also go otside the plan for other non-emergency services if Ble Cross Commnity MMAI gives yo athorization first What if an ot-of-network provider is not eligible to participate in Medicare and/or Medicaid? If yo go to an ot-of-network provider, the provider mst be eligible to participate in Medicare and/or Medicaid. We cannot pay a provider who is not eligible to participate in Medicare and/ or Medicaid. If yo go to a provider who is not eligible to participate in Medicare, yo mst pay the fll cost of the services yo get. Providers mst tell yo if they are not eligible to participate in Medicare. Also, a provider mst be enrolled as an Illinois Medicaid Provider to get paid for any Medicaid services they provide to yo. E. How to get long-term services and spports (LTSS) Long-term services and spports (LTSS) are for people who need help to do everyday tasks. Most of these services are provided at yor home or in yor commnity, bt cold be provided in a nrsing home or hospital. For more information abot LTSS services, please see the Long Term Services and Spport (LTSS) Handbook. F. How to get behavioral health services Behavioral health services spport mental health and sbstance abse treatment needs yo may have. This can inclde emotional, social, edcational, and recovery care, as well as more common psychiatric or medical care. This care may be given in a commnity setting, sch as a day program, or in another place that is easier for yo, like yor home. Please see the Benefits Chart in Chapter 4, Section D for more information, as well as the list of what yo will need to get pre-approval for covered behavioral health care. How do yo get behavioral health services? Yo can talk abot the many services available with yor care coordinator and other members of yor Care Team. The care coordinator will spport yo in finding help in the area and help yo schedle appointments or screenings. Yor Care Team may also inclde health otreach workers (commnity health workers) or other mental health experts that will be working with yor care coordinator to 37

40 Chapter 3: Using the plan s coverage for yor health care and other covered services make sre that yo have all the spport yo need to stay well while staying in the commnity. Most otpatient mental health care does not call for pre-approval, bt some do. Yor Care Team will help yo with any needed pre-approval. If yo need any help, please call Member Services at (TTY/TDD: 711). We are open 8:00 a.m. ntil 8:00 p.m. Central time, seven (7) days a week. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a cstomer service representative will retrn yor call no later than the next bsiness day. All members who reqest and need mental health spport can get behavioral health services. Please see the Benefits Chart in Chapter 4, Section D for more information on behavioral services and prior athorization reqirements. G. How to get self directed care Self-directed care gives members and/or their families the right to design service and spport plans that reflect their wishes. As a Member of Ble Cross Commnity MMAI yo may be able to self-direct some of yor services. How to get help in employing personal care providers? For example, yo and yor Interdisciplinary Care Team may decide yo need a Personal Assistant (PA). The Self-Directed Care Program lets yo hire and manage yor PA. This incldes overseeing yor PA s dties and signing his or her time sheet. Yo will have an active part in writing and revising yor plan of care. Here is how it works: Yo will receive a call for a health risk assessment. Yo will then be given a care coordinator. Based on yor assessment, yo and yor care coordinator will design yor care plan to meet yor needs (sch as a PA, meal delivery, eqipment). H. How to get transportation services Yo may be able to get transportation to and from yor doctors office or health care facility. Trips mst be for medical reasons only. What services are covered? The plan offers rides when yo have no other way to get to: A doctor s visit. A visit with other health care providers. A dental visit. A pharmacy after a provider visit. 38

41 Chapter 3: Using the plan s coverage for yor health care and other covered services What s not covered? The plan does not cover rides: For non-medical reasons. To see a provider who is more than 65 miles from where yo live (withot special approval). To see a provider who is otside of or network (withot special approval). If yo need a ride to the doctor, please call Member Services at (TTY/TDD: 711) at least 24 hors before yor appointment. Call 911 if yo need emergency transportation. Yo do not need prior approval in an emergency. I. How to get covered services when yo have a medical emergency or rgent need for care, or dring a disaster Getting care when yo have a medical emergency What is a medical emergency? A medical emergency is a medical condition recognizable by symptoms sch as severe pain or serios injry. The condition is so serios that, if it doesn t get immediate medical attention, yo or any prdent layperson (meaning a person with an average knowledge of health and medicine) cold expect it to reslt in: serios risk to yor health; or serios harm to bodily fnctions; or serios dysfnction of any bodily organ or part; or in the case of a pregnant woman in active labor, meaning labor at a time when either of the following wold occr: There is not enogh time to safely transfer yo to another hospital before delivery. The transfer may pose a threat to yor health or safety or to that of yor nborn child. What shold yo do if yo have a medical emergency? If yo have a medical emergency: Get help as fast as possible. Call 911 or go to the nearest emergency room or hospital. Call for an amblance if yo need it. Yo do not need to get approval or a referral first from yor PCP. As soon as possible, make sre that yo tell or plan abot yor emergency. We need to follow p on yor emergency care. Yo or yor care coordinator shold call to tell s abot yor emergency care, sally within 48 hors. However, yo will not have to pay for emergency services becase of a delay in telling s. 39

42 Chapter 3: Using the plan s coverage for yor health care and other covered services Please call (TTY/TDD 711, We are available seven (7) days a week. Or call center is open Monday to Friday 8:00 am to 8:00 pm Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day. The call is free.. What is covered if yo have a medical emergency? Medicare and Medicaid do not provide coverage for emergency medical care otside the United States and its territories. Yo may get covered emergency care whenever yo need it, anywhere in the United States or its territories. If yo need an amblance to get to the emergency room, or plan covers that. To learn more, see the Benefits Chart in Chapter 4, Section D. Emergency care otside the U.S. and its territories is not covered, except when: The emergency arose in the U.S. and the foreign hospital is closer than the nearest U.S. hospital that can treat yor health problem. Yo are traveling throgh Canada by the most direct rote between Alaska and some other state, when a medical emergency occrs and the Canadian hospital is closer than the nearest U.S. hospital that can treat the emergency. Yo live in the U.S. and the foreign hospital is closer to yor home than the nearest U.S. hospital that can treat yor medical condition, whether or not it is an emergency. If yo have an emergency, we will talk with the doctors who give yo emergency care. Those doctors will tell s when yor medical emergency is over. After the emergency is over, yo may need follow-p care to be sre yo get better. Yor follow-p care will reqire a referral from yor PCP in order to be covered by or plan. If yo get yor emergency care from ot-of-network providers, we will try to get network providers to take over yor care as soon as possible. What if it wasn t a medical emergency after all? Sometimes it can be hard to know if yo have a medical emergency. Yo might go in for emergency care and have the doctor say it wasn t really a medical emergency. As long as yo reasonably thoght yor health was in serios danger, we will cover yor care. However, after the doctor says it was not an emergency, we will cover yor additional care only if: yo go to a network provider, or the additional care yo get is considered rgently needed care and yo follow the rles for getting this care. (See the next section.) 40

43 Chapter 3: Using the plan s coverage for yor health care and other covered services Getting rgently needed care What is rgently needed care? Urgently needed care is care yo get for a sdden illness, injry, or condition that isn t an emergency bt needs care right away. For example, yo might have a flare-p of an existing condition and need to have it treated. Getting rgently needed care when yo are in the plan s service area In most sitations, we will cover rgently needed care only if: yo get this care from a network provider, and yo follow the other rles described in this chapter. However, if yo can t get to a network provider, we will cover rgently needed care yo get from an ot of network provider. Yo may go to any rgent care center if yo believe yo need rgent care. If yo are within the plan s service area, call yor PCP s Medical Grop at the nmber on yor member ID card for help on how to get rgent care. If yo don t have an ID card, call Member Services at (TTY/TDD: 711) for help. Getting rgently needed care when yo are otside the plan s service area When yo are otside the service area, yo might not be able to get care from a network provider. In that case, or plan will cover rgently needed care yo get from any provider. Or plan does not cover rgently needed care or any other care that yo get otside the United States. Getting care dring a disaster If the Governor of yor state, the U.S. Secretary of Health and Hman Services, or the President of the United States declares a state of disaster or emergency in yor geographic area, yo are still entitled to care from Ble Cross Commnity MMAI. Please visit or website for information on how to obtain needed care dring a declared disaster: www. bcbsil.com/mmai. Dring a declared disaster, if yo cannot se a network provider, we will allow yo to get care from otof-network providers at no cost to yo. If yo cannot se a network pharmacy dring a declared disaster, yo will be able to fill yor prescription drgs at an ot-of-network pharmacy. Please see Chapter 5 for more information. 41

44 Chapter 3: Using the plan s coverage for yor health care and other covered services J. What if yo are billed directly for the fll cost of services covered by or plan? If a provider sends yo a bill instead of sending it to the plan, yo can ask s to pay the bill. Yo shold not pay the bill yorself. If yo do, the plan may not be able to pay yo back. If yo have paid for yor covered services or if yo have gotten a bill for covered medical services, see Chapter 7, Sections A and B to learn what to do. What shold yo do if services are not covered by or plan? Ble Cross Commnity MMAI covers all services: that are medically necessary, and that are listed in the plan s Benefits Chart (see Chapter 4, Section C), and that yo get by following plan rles. If yo get services that aren t covered by or plan, yo mst pay the fll cost yorself. If yo want to know if we will pay for any medical service or care, yo have the right to ask s. If we say we will not pay for yor services, yo have the right to appeal or decision. Chapter 9 explains what to do if yo want the plan to cover a medical item or service. It also tells yo how to appeal the plan s coverage decision. Yo may also call Member Services to learn more abot yor appeal rights. We will pay for some services p to a certain limit. If yo go over the limit, yo will have to pay the fll cost to get more of that type of service. Call Member Services to find ot what the limits are and how close yo are to reaching them. K. How are yor health care services covered when yo are in a clinical research stdy? What is a clinical research stdy? A clinical research stdy (also called a clinical trial) is a way doctors test new types of health care or drgs. They ask for volnteers to help with the stdy. This kind of stdy helps doctors decide whether a new kind of health care or drg works and whether it is safe. 42

45 Chapter 3: Using the plan s coverage for yor health care and other covered services Once Medicare approves a stdy yo want to be in, someone who works on the stdy will contact yo. That person will tell yo abot the stdy and see if yo qalify to be in it. Yo can be in the stdy as long as yo meet the reqired conditions. Yo mst also nderstand and accept what yo mst do for the stdy. While yo are in the stdy, yo may stay enrolled in or plan. That way yo contine to get care from or plan not related to the stdy. If yo want to participate in a Medicare-approved clinical research stdy, yo do not need to get approval from s or yor primary care provider. The providers that give yo care as part of the stdy do not need to be network providers. Yo do need to tell s before yo start participating in a clinical research stdy. Here s why: We can tell yo if the clinical research stdy is Medicare-approved. We can tell yo what services yo will get from clinical research stdy providers instead of from or plan. If yo plan to be in a clinical research stdy, yo or yor care coordinator shold contact Member Services. When yo are in a clinical research stdy, who pays for what? If yo volnteer for a clinical research stdy that Medicare approves, yo will pay nothing for the services covered nder the stdy and Medicare will pay for services covered nder the stdy as well as rotine costs associated with yor care. Once yo join a Medicare-approved clinical research stdy, yo are covered for most items and services yo get as part of the stdy. This incldes: Room and board for a hospital stay that Medicare wold pay for even if yo weren t in a stdy. An operation or other medical procedre that is part of the research stdy. Treatment of any side effects and complications of the new care. If yo are part of a stdy that Medicare has not approved, yo will have to pay any costs for being in the stdy. Learning more Yo can learn more abot joining a clinical research stdy by reading Medicare & Clinical Research Stdies on the Medicare website ( Yo can also call MEDICARE ( ), 24 hors a day, 7 days a week. TTY sers shold call

46 Chapter 3: Using the plan s coverage for yor health care and other covered services L. How are yor health care services covered when yo are in a religios non-medical health care instittion? What is a religios non-medical health care instittion? A religios non-medical health care instittion is a place that provides care yo wold normally get in a hospital or skilled nrsing facility. If getting care in a hospital or a skilled nrsing facility is against yor religios beliefs, we will cover care in a religios non-medical health care instittion. Yo may choose to get health care at any time for any reason. This benefit is only for Medicare Part A inpatient services (non-medical health care services). Medicare will only pay for non-medical health care services provided by religios non-medical health care instittions. What care from a religios non-medical health care instittion is covered by or plan? To get care from a religios non-medical health care instittion, yo mst sign a legal docment that says yo are against getting medical treatment that is non-excepted. Non-excepted medical treatment is any care that is volntary and not reqired by any federal, state, or local law. Excepted medical treatment is any care that is not volntary and is reqired nder federal, state, or local law. To be covered by or plan, the care yo get from a religios non-medical health care instittion mst meet the following conditions: The facility providing the care mst be certified by Medicare. Or plan s coverage of services is limited to non-religios aspects of care. If yo get services from this instittion that are provided to yo in a facility, the following applies: Yo mst have a medical condition that wold allow yo to get covered services for inpatient hospital care or skilled nrsing facility care. Medicare Inpatient Hospital coverage limits apply. Please see the plan s Benefits Chart (Chapter 4, Section D). 44

47 Chapter 3: Using the plan s coverage for yor health care and other covered services M. Rles for owning drable medical eqipment Drable medical eqipment means certain items ordered by a provider for se in yor own home. Examples of these items are oxygen eqipment and spplies, wheelchairs, canes, crtches, walkers, and hospital beds. Will yo own yor drable medical eqipment? Yo will always own certain items, sch as prosthetics. In this section, we discss drable medical eqipment yo mst rent. In Medicare, people who rent certain types of drable medical eqipment own it after 13 months. As a member of Ble Cross Commnity MMAI, however, yo sally will not own the rented eqipment, no matter how long yo rent it. In certain sitations, we will transfer ownership of the drable medical eqipment item. Call Member Services to find ot abot the reqirements yo mst meet and the papers yo need to provide. What happens if yo switch to Medicare? Yo will have to make 13 payments in a row nder Original Medicare to own the eqipment if: yo did not become the owner of the drable medical eqipment item while yo were in or plan and yo leave or plan and get yor Medicare benefits throgh Original Medicare instead of a health plan. If yo made payments for the drable medical eqipment nder Original Medicare before yo joined or plan, those Medicare payments do not cont toward the 13 payments. Yo will have to make 13 new payments in a row nder Original Medicare to own the item. There are no exceptions to this case when yo retrn to Original Medicare. 45

48 Chapter 4: Benefits Chart 46

49 Table of Contents Ble Cross Commnity MMAI MEMBER HANDBOOK Chapter 4: Benefits Chart A. Understanding yor covered services...48 B. Or plan does not allow providers to charge yo for services...48 C. Abot the Benefits Chart...49 D. The Benefits Chart...50 E. Using or plan s visitor or traveler benefits...89 F. Benefits covered otside of Ble Cross Commnity MMAI...90 G. Benefits not covered by Ble Cross Commnity MMAI, Medicare, or Medicaid

50 Chapter 4: Benefits Chart A. Understanding yor covered services This chapter tells yo what services Ble Cross Commnity MMAI covers. Yo can also learn abot services that are not covered. Information abot drg benefits is in Chapter 5. Becase yo get assistance from Medicaid, yo pay nothing for yor covered services as long as yo follow the plan s rles. See Chapter 3 for details abot the plan s rles. If yo need help nderstanding what services are covered, call yor Member Services at We are available seven (7) days a week. Or call center is open Monday-Friday 8:00 a.m.-8:00 p.m. Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day. TTY sers shold call TTY/TDD: 711. B. Or plan does not allow providers to charge yo for services We do not allow Ble Cross Commnity MMAI providers to bill yo for covered services. We pay or providers directly, and we protect yo from any charges. This is tre even if we pay the provider less than the provider charges for a service. Yo shold never get a bill from a provider for covered services. If yo do, see Chapter 7 or call Member Services. 48

51 C. Abot the Benefits Chart Ble Cross Commnity MMAI MEMBER HANDBOOK Chapter 4: Benefits Chart This benefits chart tells yo which services the plan pays for. It lists categories of services in alphabetical order and explains the covered services. It is broken into two sections, General Services offered to all enrollees, and Home and Commnity-based Services offered to enrollees who qalify throgh a home and commnity-based services waiver program. We will pay for the services listed in the Benefits Chart only when the following rles are met. Yo do not pay anything for the service listed in the Benefits Chart, as long as yo meet the coverage reqirements described below. Yor Medicare and Medicaid covered services mst be provided according to the rles set by Medicare and Medicaid. The services (inclding medical care, services, spplies, eqipment, and drgs) mst be medically necessary. Medically necessary means yo need services to prevent, diagnose, or treat yor medical condition or to maintain yor crrent health stats. This incldes care that keeps yo from going into a hospital or nrsing home. It also means the services, spplies, or drgs meet accepted standards of medical practice or are otherwise necessary nder crrent Medicare or Illinois Medicaid coverage rles. Yo get yor care from a network provider. A network provider is a provider who works with the health plan. In most cases, the plan will not pay for care yo get from an ot-of-network provider. Chapter 3 has more information abot sing network and ot-of-network providers. Yo have a primary care provider (PCP) or a care team that is providing and managing yor care. Some of the services listed in the Benefits Chart are covered only if yor doctor or other network provider gets approval from s first. This is called prior athorization. Covered services that need approval first are marked in the Benefits Chart by an asterisk (*). All preventive services are free. Yo will see this apple benefits chart. next to preventive services in the 49

52 Chapter 4: Benefits Chart D. The Benefits Chart General services that or plan covers Abdominal aortic anerysm screening The plan will cover a one-time ltrasond screening for people at risk. The plan only covers this screening if yo have certain risk factors and if yo get a referral for it from yor physician, physician assistant, nrse practitioner, or clinical nrse specialist. Alcohol misse screening and conseling The plan covers one alcohol-misse screening for adlts who misse alcohol bt are not alcohol dependent. This incldes pregnant women. If yo screen positive for alcohol misse, the plan covers p to for brief, face-to-face conseling sessions each year (if yo are able and alert dring conseling) with a qalified primary care provider or practitioner in a primary care setting. Amblance services * Covered amblance services inclde fixed-wing, rotary-wing, and grond amblance services. The amblance will take yo to the nearest place that can give yo care. Yor condition mst be serios enogh that other ways of getting to a place of care cold risk yor life or health. Amblance services for other cases mst be approved by the plan. In cases that are not emergencies, the plan may pay for an amblance. Yor condition mst be serios enogh that other ways of getting to a place of care cold risk yor life or health. What yo mst pay $0 $0 $0 50

53 Chapter 4: Benefits Chart General services that or plan covers Annal wellness visit If yo have been in Medicare Part B for more than 12 months, yo can get an annal checkp. This is to make or pdate a prevention plan based on yor crrent risk factors. The plan will cover this once every 12 months. Note: Yo cannot have yor first annal checkp within 12 months of yor Welcome to Medicare preventive visit. Yo will be covered for annal checkps after yo have had Part B for 12 months. Yo do not need to have had a Welcome to Medicare visit first. Bone mass measrement The plan covers certain procedres for members who qalify (sally, someone at risk of losing bone mass or at risk of osteoporosis). These procedres identify bone mass, find bone loss, or find ot bone qality. The plan will cover the services once every 24 months, or more often if they are medically necessary. The plan will also pay for a doctor to look at and comment on the reslts. Breast cancer screening (mammograms) The plan will cover the following services: One baseline mammogram between the ages of 35 and 39 One screening mammogram every 12 months for women age 40 and older Clinical breast exams once every 24 months Cardiac (heart) rehabilitation services * The plan covers cardiac rehabilitation services sch as exercise, edcation, and conseling. Members mst meet certain conditions with a doctor s order. The plan also covers intensive cardiac rehabilitation programs, which are more intense than cardiac rehabilitation programs. What yo mst pay $0 $0 $0 $0 51

54 Chapter 4: Benefits Chart General services that or plan covers Cardiovasclar (heart) disease risk redction visit (therapy for heart disease) What yo mst pay $0 The plan covers one visit a year with yor primary care provider to help lower yor risk for heart disease. Dring this visit, yor doctor may: discss aspirin se, check yor blood pressre, or give yo tips to make sre yo are eating well. Cardiovasclar (heart) disease testing The plan covers blood tests to check for cardiovasclar disease once every five years (60 months). These blood tests also check for defects de to high risk of heart disease. Additional testing may be covered if deemed medically necessary by yor primary care provider. Cell phone * The plan covers a cell phone for members with certain health conditions who do not have reglar access to a phone. Yor care coordinator mst approve that yo need a phone in yor care plan. Cervical and vaginal cancer screening The plan covers the following services: For all women: Pap tests and pelvic exams once every 12 months Chiropractic services The plan covers adjstments of the spine to correct alignment. $0 $0 $0 $0 52

55 Chapter 4: Benefits Chart General services that or plan covers Colorectal cancer screening The plan covers the following services: Flexible sigmoidoscopy (or screening barim enema) every 48 months Fecal occlt blood test, every 12 months Gaiac-based fecal occlt blood test or fecal immnochemical test DNA based colorectal screening, every 3 years Screening colonoscopy What yo mst pay $0 For people at high risk of colorectal cancer, the plan will cover one screening colonoscopy (or screening barim enema) every 24 months. For people not at high risk of colorectal cancer, the plan will cover one screening colonoscopy every ten years (bt not within 48 months of a screening sigmoidoscopy). Additional screenings may be covered if deemed medically necessary by yor primary care provider. 53

56 Chapter 4: Benefits Chart General services that or plan covers Conseling to stop smoking or tobacco se If yo se tobacco bt do not have signs or symptoms of tobacco related disease: The plan will cover two conseling qit attempts in a 12 month period as a preventive service. This service is free for yo. Each conseling attempt incldes p to for face-to-face visits. What yo mst pay $0 If yo se tobacco and have been diagnosed with a tobacco related disease or are taking medicine that may be affected by tobacco: The plan will cover two conseling qit attempts within a 12 month period. Each conseling attempt incldes p to for face-to-face visits. If yo se tobacco and are pregnant: The plan will cover three conseling qit attempts within a 12 month period. This service is free for yo. Each conseling attempt incldes p to for face-to-face visits. Cstodial Nrsing Facility Care The plan will cover skilled nrsing facilities (SNF) and intermediate care facilities (ICF). The nrsing facilities provide the following services: All staff, rotine eqipment and spplies inclding oxygen (if less than one tank has been frnished to the resident for the month in qestion). Room and board, spervision and oversight, and all landry services. Food sbstittes and ntritional spplements. Medications which are reglarly available withot prescription at a commercial pharmacy and which may be stocked by the facility nder Department of Pblic Health reglations. Certain over-the-conter drgs or items ordered by a physician. Additional reqired services. Care in skilled nrsing facilities reqires prior athorization. $0 54

57 Chapter 4: Benefits Chart General services that or plan covers Dental services The plan covers the following dental services: Limited and comprehensive exams Restorations Dentres Extractions Sedation Dental emergencies Dental services necessary for the health of a pregnant woman prior to delivery of her baby What yo mst pay $0 In addition to the above dental services, Ble Cross Commnity MMAI also covers the following preventive services: Two oral exams each year. Two preventative cleanings each year. One floride treatment each year. Dental, comprehensive services The plan offers a $500 allowance as a spplemental benefit each year to help pay for dental services that wold NOT otherwise be covered by Medicare or Medicaid. Depression screening The plan will cover one depression screening each year. The screening mst be done in a primary care setting that can give follow-p treatment and referrals. Member wold be responsible for any charges for services that exceed the annal $ 500 spplemental benefit allowance. $0 55

58 Chapter 4: Benefits Chart General services that or plan covers Diabetes screening The plan will cover this screening (incldes fasting glcose tests) if yo have any of the following risk factors: High blood pressre (hypertension) History of abnormal cholesterol and triglyceride levels (dyslipidemia) Obesity History of high blood sgar (glcose) What yo mst pay $0 Tests may be covered in some other cases, sch as if yo are overweight and have a family history of diabetes. Depending on the test reslts, yo may qalify for p to two diabetes screenings every 12 months 56

59 Chapter 4: Benefits Chart General services that or plan covers Diabetic self-management training, services, and spplies * The plan will cover the following services for all people who have diabetes (whether they se inslin or not): Spplies to monitor yor blood glcose, inclding the following: A blood glcose monitor Blood glcose test strips Lancet devices and lancets Glcose-control soltions for checking the accracy of test strips and monitors For people with diabetes who have severe diabetic foot disease, the plan will cover the following: One pair of therapetic cstom-molded shoes (inclding inserts) and two extra pairs of inserts each calendar year, or One pair of depth shoes and three pairs of inserts each year (not inclding the non-cstomized removable inserts provided with sch shoes) What yo mst pay $0 The plan will also cover fitting the therapetic cstom-molded shoes or depth shoes. The plan will cover training to help yo manage yor diabetes, in some cases. 57

60 Chapter 4: Benefits Chart General services that or plan covers Emergency care Emergency care means services that are: given by a provider trained to give emergency services, and needed to treat a medical emergency. A medical emergency is a medical condition with severe pain or serios injry. The condition is so serios that, if it doesn t get immediate medical attention, anyone with an average knowledge of health and medicine cold expect it to reslt in: serios risk to yor health; or serios harm to bodily fnctions; or serios dysfnction of any bodily organ or part; or in the case of a pregnant woman, in active labor, meaning labor at a time when either of the following wold occr: There is not enogh time to safely transfer yo to another hospital before delivery. The transfer may pose a threat to yor health or safety or to that of yor nborn child. What yo mst pay $0 If yo get emergency care at an ot-ofnetwork hospital and need inpatient care after yor emergency is stabilized, yo mst retrn to a network hospital for yor care to contine to be paid for. Yo can stay in the ot-of-network hospital for yor inpatient care only if the plan approves yor stay. Emergency care is not covered otside the U.S. and its territories except in certain cases. Call for details. 58

61 Chapter 4: Benefits Chart General services that or plan covers Family planning services The law lets yo choose any provider to get certain family planning services from. This means any doctor, clinic, hospital, pharmacy or family planning office. The plan will cover the following services: Family planning exam and medical treatment Family planning lab and diagnostic tests Family planning methods (birth control pills, patch, ring, IUD, injections, implants) Family planning spplies with prescription (condom, sponge, foam, film, diaphragm, cap) Conseling and diagnosis of infertility, and related services Conseling and testing for sexally transmitted infections (STIs), AIDS, and other HIV-related conditions Treatment for sexally transmitted infections (STIs) Volntary sterilization (Yo mst be age 21 or older, and yo mst sign a federal sterilization consent form. At least 30 days, bt not more than 180 days, mst pass between the date that yo sign the form and the date of srgery.) Genetic conseling Folic acid spplements and prenatal vitamins ordered by prescription and dispensed by a pharmacy What yo mst pay $0 The plan will also cover some other family planning services. However, yo mst see a provider in the plan s network for the following services: Treatment for medical conditions of infertility (This service does not inclde artificial ways to become pregnant.) Treatment for AIDS and other HIV-related conditions Genetic testing 59

62 Chapter 4: Benefits Chart General services that or plan covers Fitness programs The plan covers membership in the SilverSneakers Fitness Program. What yo mst pay $0 This is a program exclsively designed with low impact classes. Health and wellness edcation programs * Covered Services inclde: Training to manage yor diabetes Training on kidney disease Conseling to stop smoking Conseling on food and diet Hearing services * The plan covers hearing and balance tests done by yor provider. These tests tell yo whether yo need medical treatment. They are covered as otpatient care when yo get them from a physician, adiologist, or other qalified provider. The plan also covers the following: Basic and advanced hearing tests Hearing aid conseling Fitting/evalation for a hearing aid $0 $0 Hearing aids once every three years * Hearing aid batteries and accessories Hearing aid repair and replacement of parts 60

63 Chapter 4: Benefits Chart General services that or plan covers HIV screening The plan pays for one HIV screening exam every 12 months for people who: ask for an HIV screening test, or are at increased risk for HIV infection. What yo mst pay $0 For women who are pregnant, the plan pays for p to three HIV screening tests dring a pregnancy. Home health agency care * Before yo can get home health services, a doctor mst tell s yo need them, and they mst be provided by a home health agency. The plan will cover the following services, and maybe other services not listed here: Part-time or intermittent skilled nrsing and home health aide services (To be covered nder the home health care benefit, yor skilled nrsing and home health aide services combined mst total fewer than 8 hors per day and 35 hors per week) Physical therapy, occpational therapy, and speech therapy Medical and social services Medical eqipment and spplies $0 61

64 Chapter 4: Benefits Chart General services that or plan covers Hospice care * Yo can get care from any hospice program certified by Medicare. Yo have the right to elect hospice if yor provider and hospice medical director determine yo have a terminal prognosis. This means yo have a terminal illness and are expected to have six months or less to live. Yor hospice doctor can be a network provider or an ot-of-network provider. The plan will cover the following while yo are getting hospice services: Drgs to treat symptoms and pain Short-term respite care Home care, inclding home health aide services Occpational, physical and speech-langage therapy services to control symptoms Conseling services What yo mst pay $0 Hospice services and services covered by Medicare Part A or B are billed to Medicare: See Section F of this chapter for more information. For services covered by Ble Cross Commnity MMAI bt not covered by Medicare Part A or B: Ble Cross Commnity MMAI will cover plan-covered services not covered nder Medicare Part A or B. The plan will cover the services whether or not they are related to yor terminal prognosis. Yo pay nothing for these services. For drgs that may be covered by Ble Cross Commnity MMAI s Medicare Part D benefit: Drgs are never covered by both hospice and or plan at the same time. For more information, please see Chapter 5. This benefit is contined on the next page 62

65 Chapter 4: Benefits Chart General services that or plan covers What yo mst pay Hospice care (contined) Note: If yo need non-hospice care, yo shold call yor care coordinator to arrange the services. Non-hospice care is care that is not related to yor terminal prognosis. Yo can reach yor care coordinator by calling (TTY/TDD: 711). Or plan covers hospice consltation services (one time only) for a terminally ill person who has not chosen the hospice benefit. Immnizations The plan will cover the following services: Pnemonia vaccine Fl shots, once a year, in the fall or winter Hepatitis B vaccine if yo are at high or intermediate risk of getting hepatitis B Other vaccines if yo are at risk and they meet Medicare Part B coverage rles $0 The plan will cover other vaccines that meet the Medicare Part D coverage rles. Read Chapter 6 to learn more. 63

66 Chapter 4: Benefits Chart General services that or plan covers Inpatient hospital care * The plan will cover the following services, and maybe other services not listed here: Semi-private room (or a private room if it is medically necessary) Meals, inclding special diets Reglar nrsing services Costs of special care nits, sch as intensive care or coronary care nits Drgs and medications Lab tests X-rays and other radiology services Needed srgical and medical spplies Appliances, sch as wheelchairs Operating and recovery room services Physical, occpational, and speech therapy Inpatient sbstance abse services Blood, inclding storage, blood components and administration thereof Physician services What yo mst pay $0 Yo mst get approval from the plan to keep getting inpatient care at an ot of network hospital after yor emergency is nder control. This benefit is contined on the next page 64

67 Chapter 4: Benefits Chart General services that or plan covers What yo mst pay Inpatient hospital care * (contined) In some cases, the following types of transplants: corneal, kidney, kidney/pancreatic, heart, liver, lng, heart/lng, bone marrow, stem cell, and intestinal/mltivisceral. If yo need a transplant, a Medicare-approved transplant center will review yor case and decide whether yo are a candidate for a transplant. A Medicare-approved transplant center will review yor case and decide whether yo are a candidate for a transplant. Transplant providers may be local or otside of the service area. If local transplant providers are willing to accept the Medicare rate, then yo can get yor transplant services locally or at a distant location otside the service area. If Ble Cross Commnity MMAI provides transplant services at a distant location otside the service area and yo choose to get yor transplant there, we will arrange or pay for lodging and travel costs for yo and one other person. Inpatient mental health care The plan will cover medically necessary psychiatric inpatient care at approved instittions. $0 65

68 Chapter 4: Benefits Chart General services that or plan covers Inpatient services covered dring a non-covered inpatient stay What yo mst pay $0 If yor inpatient stay is not reasonable and needed, the plan will not cover it. However, in some cases the plan will cover services yo get while yo are in the hospital or a nrsing facility. The plan will cover the following services, and maybe other services not listed here: Doctor services Diagnostic tests, like lab tests X-ray, radim, and isotope therapy, inclding technician materials and services Srgical dressings Splints, casts, and other devices sed for fractres and dislocations Prosthetics and orthotic devices, other than dental, inclding replacement or repairs of sch devices. These are devices that: replace all or part of an internal body organ (inclding contigos tisse), or replace all or part of the fnction of an inoperative or malfnctioning internal body organ. Leg, arm, back, and neck braces, trsses, and artificial legs, arms, and eyes. This incldes adjstments, repairs, and replacements needed becase of breakage, wear, loss, or a change in the patient s condition Physical therapy, speech therapy, and occpational therapy 66

69 Chapter 4: Benefits Chart General services that or plan covers Kidney disease services and spplies * The plan will cover the following services: Kidney disease edcation services to teach kidney care and help members make good decisions abot their care. Yo mst have stage IV chronic kidney disease, and yor doctor mst refer yo. The plan will cover p to six sessions of kidney disease edcation services. Otpatient dialysis treatments, inclding dialysis treatments when temporarily ot of the service area, as explained in Chapter 3 Inpatient dialysis treatments if yo are admitted as an inpatient to a hospital for special care Self-dialysis training, inclding training for yo and anyone helping yo with yor home dialysis treatments Home dialysis eqipment and spplies Certain home spport services, sch as necessary visits by trained dialysis workers to check on yor home dialysis, to help in emergencies, and to check yor dialysis eqipment and water spply What yo mst pay $0 Yor Medicare Part B drg benefit pays for some drgs for dialysis. For information, please see Medicare Part B prescription drgs in this chart. 67

70 Chapter 4: Benefits Chart General services that or plan covers Lng cancer screening The plan will pay for lng cancer screening every 12 months if yo: Are aged 55-77, and Have a conseling and shared decision-making visit with yor doctor or other qalified provider, and Have smoked at least 1 pack a day for 30 years with no signs or symptoms of lng cancer or smoke now or have qit within the last 15 years. What yo mst pay $0 After the first screening, the plan will pay for another screening each year with a written order from yor doctor or other qalified provider. 68

71 Chapter 4: Benefits Chart General services that or plan covers Medical eqipment and related spplies * The following general types of services and items are covered: Nondrable medical spplies, sch as srgical dressings, bandages, disposable syringes, incontinence spplies, ostomy spplies and enteral ntrition therapy Drable medical eqipment, sch as wheelchairs, crtches, walkers, hospital beds, IV infsion pmps and spplies, hmidifiers, and speech generating devices (for a definition of Drable medical eqipment, see Chapter 12 of this handbook) Prosthetic and orthotic devices, compression stockings, shoe orthotics, arch spports, foot inserts Respiratory eqipment and spplies, sch as oxygen eqipment, CPAP and BIPAP eqipment Repair of drable medical eqipment, prosthetic devices and orthotic devices Rental of medical eqipment nder circmstances where patient s needs are temporary What yo mst pay $0 To be eligible for reimbrsement some services may be sbject to prior approval and/or medical criteria. We will pay for all medically necessary drable medical eqipment that Medicare and Medicaid sally pay for. If or spplier in yor area does not carry a particlar brand or maker, yo may ask them if they can special-order it for yo. This benefit is contined on the next page 69

72 Chapter 4: Benefits Chart General services that or plan covers What yo mst pay Medical eqipment and related spplies (contined) With this Member Handbook, we sent yo Ble Cross Commnity MMAI s list of drable medical eqipment. The list tells yo the brands and makers of drable medical eqipment that we will pay for. This most recent list of brands, makers, and sppliers is also available on or website at Generally, Ble Cross Commnity MMAI covers any drable medical eqipment covered by Medicare and Medicaid from the brands and makers on this list. We will not cover other brands and makers nless yor doctor or other provider tells s that yo need the brand. However, if yo are new to Ble Cross Commnity MMAI and are sing a brand of drable medical eqipment that is not on or list, we will contine to pay for this brand for yo for p to 90 days. Dring this time, yo shold talk with yor doctor to decide what brand is medically right for yo after this 90-day period. (If yo disagree with yor doctor, yo can ask him or her to refer yo for a second opinion.) If yo (or yor doctor) do not agree with Ble Cross Commnity MMAI s decision abot paying for yor eqipment, yo or yor doctor may file an appeal. Yo can also file an appeal if yo do not agree with yor doctor s decision abot what prodct or brand is right for yor medical condition. (For more information abot appeals, see Chapter 9.) 70

73 Chapter 4: Benefits Chart General services that or plan covers Medical ntrition therapy This benefit is for people with diabetes or kidney disease withot dialysis. It is also for after a kidney transplant when ordered by yor doctor. The plan will cover three hors of one-on-one conseling services dring yor first year that yo get medical ntrition therapy services nder Medicare. (This incldes or plan, any other Medicare Advantage plan, or Medicare.) We cover two hors of one-onone conseling services each year after that. If yor condition, treatment, or diagnosis changes, yo may be able to get more hors of treatment with a doctor s order. A doctor mst prescribe these services and renew the order each year if yor treatment is needed in the next calendar year. What yo mst pay $0 71

74 Chapter 4: Benefits Chart General services that or plan covers Medicare Part B prescription drgs * These drgs are covered nder Part B of Medicare. Ble Cross Commnity MMAI will cover the following drgs: Drgs yo don t sally give yorself and are injected or infsed while yo are getting doctor, hospital otpatient, or amblatory srgery center services Drgs yo take sing drable medical eqipment (sch as neblizers) that were athorized by the plan Clotting factors yo give yorself by injection if yo have hemophilia Immnosppressive drgs, if yo were enrolled in Medicare Part A at the time of the organ transplant Osteoporosis drgs that are injected. These drgs are paid for if yo are homebond, have a bone fractre that a doctor certifies was related to post-menopasal osteoporosis, and cannot inject the drg yorself Antigens Certain oral anti-cancer drgs and anti-nasea drgs Certain drgs for home dialysis, inclding heparin, the antidote for heparin (when medically needed), topical anesthetics, and erythropoiesis-stimlating agents (sch as Epogen and Procrit ) IV immne globlin for the home treatment of primary immne deficiency diseases Chapter 5, Section A explains the otpatient prescription drg benefit. It explains rles yo mst follow to have prescriptions covered. Chapter 6, Section A explains what yo pay for yor otpatient prescription drgs throgh or plan. What yo mst pay $0 72

75 Chapter 4: Benefits Chart General services that or plan covers Non-emergency transportation * The plan will cover transportation for yo to travel to or from yor medical appointments if it is a covered service. Types of nonemergency transportation inclde: Medicar Service car Taxicab What yo mst pay $0 The plan will also cover the cost of getting to a pharmacy after a visit to the doctor. 73

76 Chapter 4: Benefits Chart General services that or plan covers Nrsing facility care and skilled nrsing facility care * The plan will cover skilled nrsing facilities (SNF) and intermediate care facilities (ICF). The plan will pay for the following services and maybe other services not listed here: A semi-private room, or a private room if it is medically needed, maintenance and cleaning Meals, inclding special meals, food sbstittes, and ntritional spplements Nrsing services and resident spervision/oversight Physician services Physical therapy, occpational therapy, and speech therapy Drgs, and other medications available throgh a pharmacy withot a prescription, ordered by yor doctor as part of yor plan of care, inclding over-theconter medications and their administration Non-cstom drable medical eqipment (sch as wheelchairs and walkers) Medical and srgical spply items (sch as bandages, oxygen administration spplies, oral care spplies and eqipment, one tank of oxygen per resident per month) Additional services provided by a nrsing facility in compliance with state and federal reqirements Care received in an Acte SNF* What yo mst pay When yor income exceeds an allowable amont, yo mst contribte toward the cost of services. This is known as the patient pay amont and is reqired if yo live in a nrsing facility. However, yo may not end p having to pay an amont each month. Patient pay responsibility does not apply to Medicarecovered days in a nrsing facility. This benefit is contined on the next page 74

77 Chapter 4: Benefits Chart General services that or plan covers Nrsing facility care and skilled nrsing facility care * Contined Yo will sally get yor care from network facilities. However, yo may be able to get yor care from a facility not in or network. Yo can get care from the following places if they accept or plan s amonts for payment: A nrsing home or contining care retirement commnity where yo lived before yo went to the hospital (as long as it provides nrsing facility care) A nrsing facility where yor spose lives at the time yo leave the hospital. Obesity screening and therapy to keep weight down If yo have a body mass index of 30 or more, the plan will cover conseling to help yo lose weight. Yo mst get the conseling in a primary care setting. That way, it can be managed with yor fll prevention plan. Talk to yor primary care provider to find ot more. Otpatient diagnostic tests and therapetic services * The plan will cover the following services, and maybe other services not listed here: X-rays Radiation (radim and isotope) therapy, inclding technician materials and spplies Lab tests Blood, blood components and administration thereof Other otpatient diagnostic tests What yo mst pay When yor income exceeds an allowable amont, yo mst contribte toward the cost of services. This is known as the patient pay amont and is reqired if yo live in a nrsing facility. However, yo may not end p having to pay an amont each month. Patient pay responsibility does not apply to Medicarecovered days in a nrsing facility. $0 $0 75

78 Chapter 4: Benefits Chart General services that or plan covers Otpatient hospital services * The plan pays for medically needed services yo get in the otpatient department of a hospital for diagnosis or treatment of an illness or injry. The plan will cover the following services, and maybe other services not listed here: Services in an emergency department or otpatient clinic, sch as observation services or otpatient srgery Labs and diagnostic tests billed by the hospital Mental health care, inclding care in a partialhospitalization program, if a doctor certifies that inpatient treatment wold be needed withot it X-rays and other radiology services billed by the hospital Medical spplies, sch as splints and casts Some screenings and preventive services Some drgs that yo can t give yorself What yo mst pay $0 76

79 Chapter 4: Benefits Chart General services that or plan covers Otpatient mental health care The plan will cover mental health services provided by: a state-licensed psychiatrist or doctor, a clinical psychologist, a clinical social worker, a clinical nrse specialist, a nrse practitioner, a physician assistant, Commnity Mental Health Centers (CMHCs), Hospitals, Enconter rate clinics sch as Federally Qalified Health Centers (FQHCs), DASA licensed sbstance abse providers, or any other Medicare-qalified mental health care professional as allowed nder applicable state laws. What yo mst pay $0 This benefit is contined on the next page 77

80 Chapter 4: Benefits Chart General services that or plan covers Otpatient mental health care Contined The plan will cover the following types of otpatient mental health services: Clinic services provided nder the direction of a physician Rehabilitation services recommended by a physician or Licensed Practitioner of the Healing Arts, sch as mental health assessment, treatment planning, crisis intervention, therapy, and case management Day treatment services Otpatient hospital services, sch as Clinic Option Type A and Type B services Sbstance abse treatment What yo mst pay $0 The specific services each provider type listed above can deliver and any tilization controls on sch services shall be determined by the plan consistent with federal and state laws and all applicable policies and/or agreements. Otpatient rehabilitation services * The plan will cover physical therapy, occpational therapy, and speech therapy. Yo can get otpatient rehabilitation services from hospital otpatient departments, independent therapist offices, comprehensive otpatient rehabilitation facilities (CORFs), and other facilities. Otpatient sbstance abse services The plan covers the following services: Otpatient services (grop or individal) Intensive otpatient services (grop or individal) Detoxification services Residential services Diagnostic Psychiatric Evalation $0 $0 78

81 Chapter 4: Benefits Chart General services that or plan covers Otpatient srgery * The plan will cover otpatient srgery and services at hospital otpatient facilities and amblatory srgical centers. Certain otpatient and srgical procedres reqire a prior athorization: Cochlear Implants Dental Anesthesia Dental Trama Experimental or Investigational Procedres Transplants (solid organ and tisse) Uvlopapatopharyngoplaysty (UPPP) Weight Loss Procedres, Services and Srgeries What yo mst pay $0 79

82 Chapter 4: Benefits Chart General services that or plan covers What yo mst pay Over-the-Conter Drgs & Spplies - Spplemental personal health related items The plan covers certain over-the-conter drgs and spplies. The plan will pay p to a $30 benefit, pls a $5 shipping fee per qarter. Yo may make one (1) order each qarter. Benefits or coverage do not carry over. The benefit incldes, bt is not limited to, prodcts from the following categories: Minerals and Vitamins In home testing and monitoring Fiber spplements First aid spplies Incontinence spplies Medicines, ointments and sprays with active medical ingredients that alleviate symptoms Spportive items for comfort Oral Care Call Member Services at (TTY/TDD: 711) for more information. We are available seven (7) days a week. Or call center is open Monday-Friday 8:00 a.m.- 8:00 p.m. Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day. The call is free. Partial hospitalization services Partial hospitalization is a strctred program of active psychiatric treatment. It is offered in a hospital otpatient setting or by a commnity mental health center. It is more intense than the care yo get in yor doctor s or therapist s office. It can help keep yo from having to stay in the hospital. $0 80

83 Chapter 4: Benefits Chart General services that or plan covers Physician/provider services, inclding doctor s office visits The plan will cover the following services: Medically necessary health care or srgery services given in places sch as: physician s office certified amblatory srgical center hospital otpatient department Consltation, diagnosis, and treatment by a specialist Basic hearing and balance exams given by yor primary care provider, if yor doctor orders it to see whether yo need treatment Some telehealth services, inclding consltation, diagnosis, and treatment by a physician or practitioner for patients in rral areas or other places approved by Medicare. Second opinion by another network provider before a medical procedre Non-rotine dental care. Covered services are limited to: srgery of the jaw or related strctres, setting fractres of the jaw or facial bones, plling teeth before radiation treatments of neoplastic cancer, or services that wold be covered when provided by a physician. Podiatry services * The plan will cover the following services: Diagnosis and medical or srgical treatment of injries and diseases of the foot (sch as hammer toe or heel sprs) Rotine foot care for members with conditions affecting the legs, sch as diabetes What yo mst pay $0 $0 81

84 Chapter 4: Benefits Chart General services that or plan covers Prostate cancer screening exams The plan will cover a digital rectal exam and a prostate specific antigen (PSA) test once every 12 months for: Men age 50 and older African American men age 40 and older Men age 40 and older with a family history of prostate cancer Prosthetic devices and related spplies * Prosthetic devices replace all or part of a body part or fnction. The plan will cover the following prosthetic devices, and maybe other devices not listed here: Colostomy bags and spplies related to colostomy care Pacemakers Braces Prosthetic shoes Artificial arms and legs Breast prostheses (inclding a srgical brassiere after a mastectomy) What yo mst pay $0 $0 Prosthetic devices that cost more than $2500 * The plan will also cover some spplies related to prosthetic devices. They will also pay to repair or replace prosthetic devices. The plan offers some coverage after cataract removal or cataract srgery. See Vision Care later in this section for details. Plmonary rehabilitation services * The plan will cover plmonary rehabilitation programs for members who have moderate to very severe chronic obstrctive plmonary disease (COPD). The member mst have an order for plmonary rehabilitation from the doctor or provider treating the COPD. $0 82

85 Chapter 4: Benefits Chart General services that or plan covers Sexally transmitted infections (STIs) screening and conseling What yo mst pay $0 The plan will cover screenings for chlamydia, gonorrhea, syphilis, and hepatitis B. These screenings are covered for pregnant women and for some people who are at increased risk for an STI. A primary care provider mst order the tests. We cover these tests once every 12 months or at certain times dring pregnancy. The plan will also cover p to two face-to-face, high-intensity behavioral conseling sessions each year for sexally active adlts at increased risk for STIs. Each session can be 20 to 30 mintes long. The plan will cover these conseling sessions as a preventive service only if they are given by a primary care provider. The sessions mst be in a primary care setting, sch as a doctor s office. Sbstance abse services The plan will cover sbstance abse services provided by: A state-licensed sbstance abse facility or Hospitals. $0 The plan will cover the following types of medically necessary sbstance abse services: Otpatient services (grop or individal), sch as assessment, therapy, medication monitoring, and psychiatric evalation, Medication Assisted Treatment (MAT) for opioid dependency, sch as ordering and administering methadone, managing the care plan, and coordinating other sbstance se disorder services, Intensive otpatient services (grop or individal), Detoxification services, and Some residential services, sch as short term Rehabilitation Services. 83

86 Chapter 4: Benefits Chart General services that or plan covers Urgently needed care Urgently needed care is care given to treat: a non-emergency, or a sdden medical illness, or an injry, or a condition that needs care right away. What yo mst pay $0 If yo reqire rgently needed care, yo shold first try to get it from a network provider. However, yo can se ot-of-network providers when yo cannot get to a network provider. Urgent care is NOT covered otside of the.s. and its territories. 84

87 Chapter 4: Benefits Chart General services that or plan covers Vision care The plan covers the following: Annal rotine eye exams Eye glasses (lenses and frames) Frames limited to one pair in a 24 month period An added $130 pgrade toward non standard frames every two years. Lenses limited to one pair in a 24 month period, bt yo may get more when medically necessary, with prior approval Cstom-made artificial eye Low vision devices Contacts and special lenses when medically necessary, with prior approval What yo mst pay $0 To be eligible for reimbrsement, some services may be sbject to prior approval and/or medical criteria. The plan covers otpatient doctor services for the diagnosis and treatment of diseases and injries of the eye. For example, this incldes annal eye exams for diabetic retinopathy for people with diabetes and treatment for age-related maclar degeneration. This benefit is contined on the next page 85

88 Chapter 4: Benefits Chart General services that or plan covers What yo mst pay Vision care (contined) For people at high risk of glacoma, the plan covers one glacoma screening each year. People at high risk of glacoma inclde: people with a family history of glacoma, people with diabetes, African-Americans who are age 50 and older, and Hispanic Americans who are 65 or older. The plan covers one pair of glasses or contact lenses after each cataract srgery when the doctor inserts an intraoclar lens. (If yo have two separate cataract srgeries, yo mst get one pair of glasses after each srgery. Yo cannot get two pairs of glasses after the second srgery, even if yo did not get a pair of glasses after the first srgery.) Welcome to Medicare Preventive Visit The plan covers the one-time Welcome to Medicare preventive visit. The visit incldes: a review of yor health, edcation and conseling abot the preventive services yo need (inclding screenings and shots), and referrals for other care if yo need it. $0 Important: We cover the Welcome to Medicare preventive visit only dring the first 12 months that yo have Medicare Part B. When yo make yor appointment, tell yor doctor s office yo want to schedle yor Welcome to Medicare preventive visit. 86

89 Chapter 4: Benefits Chart Home and commnity-based services that or plan covers Adlt day service The plan covers strctred day activities at a program of direct care and spervision if yo qalify. This service: Provides personal attention Promotes social, physical and emotional well-being Assisted living If yo qalify, the Spportive Living Facility provides an alternative to Nrsing Facility placement. Some of the services inclde the following: Assistance with activities of daily living Nrsing services Personal care Medication administration Hosekeeping 24 hor response/secrity staff Habilitation day The plan covers day habilitation, which assists with the retention or improvement in self help, socialization and adaptive skills otside the home if yo qalify. Home delivered meals The plan covers prepared meals broght to yor home if yo qalify. Home health aide The plan covers services from a home health aide, nder the spervision of a registered nrse (RN) or other professional, if yo qalify. Services may inclde the following: Simple dressing changes Assistance with medications Activities to spport skilled therapies Rotine care of prosthetic and orthotic devices What yo mst pay $0 $0 $0 $0 $0 87

90 Chapter 4: Benefits Chart Home and commnity-based services that or plan covers Home modifications * The plan covers modifications to yor home if yo qalify. The modifications mst be designed to ensre yor health, safety and welfare or make yo more independent in yor home. Modifications may inclde: Ramps Grab-bars Doorway widening Homemaker services The plan covers home care services provided in yor home or commnity if yo qalify. These services may inclde the following: A worker to help yo with landry A worker to help yo with cleaning Training to improve yor commnity living skills Nrsing services The plan covers shift and intermittent nrsing services by a registered nrse (RN) or licensed practical nrse (LPN) if yo qalify. Personal assistant The plan covers a personal assistant to help yo with activities of daily living if yo qalify. These inclde, for example: Bathing Feeding Dressing Landry Personal emergency response system The plan covers an electronic in home device that secres help in an emergency if yo qalify. Respite care The plan covers respite services to provide relief for an npaid family member or primary caregiver who meet all of yor service needs if yo qalify. Certain limitations apply. What yo mst pay $0 $0 $0 $0 $0 $0 88

91 Chapter 4: Benefits Chart Home and commnity-based services that or plan covers Specialized drable medical eqipment and spplies * If yo qalify, the plan covers devices, controls, or appliances that enable yo to increase yor ability to perform activities of daily living or to perceive, control, or commnicate with the environment in which yo live. Services might inclde: Hoyer lift Shower benches/chairs Stair lift Bed rails Therapies The plan covers occpational, physical, and speech therapy if yo qalify. These therapies focs on long term habilitative needs rather than short term acte restorative needs. Training The plan covers training to help yo get paid or npaid jobs. What yo mst pay $0 $0 $0 E. Using or plan s visitor or traveler benefits If yo are in a visitor/traveler area, yo can stay enrolled in the plan for 6 months.. If yo have not retrned to the plan s service area by the last day of the sixth month after yor departre, yo will be dropped from the plan. 89

92 Chapter 4: Benefits Chart F. Benefits covered otside of Ble Cross Commnity MMAI The following services are not covered by Ble Cross Commnity MMAI bt are available throgh Medicare. Hospice Care Yo can get care from any hospice program certified by Medicare. Yo have the right to elect hospice if yor provider and hospice medical director determine yo have a terminal prognosis. This means yo have a terminal illness and are expected to have six months or less to live. Yor hospice doctor can be a network provider or an ot-of-network provider. See the Benefits Chart in Section C of this chapter for more information abot what Ble Cross Commnity MMAI pays for while yo are getting hospice care services. For hospice services and services covered by Medicare Part A or B that relate to yor terminal prognosis: The hospice provider will bill Medicare for yor services. Medicare will pay for hospice services related to yor terminal prognosis. Yo pay nothing for these services. For services covered by Medicare Part A or B that are not related to yor terminal prognosis (except for emergency care or rgently needed care): The provider will bill Medicare for yor services. Medicare will pay for the services covered by Medicare Part A or B. Yo pay nothing for these services. For drgs that may be covered by Ble Cross Commnity MMAI s Medicare Part D benefit: Drgs are never covered by both hospice and or plan at the same time. For more information, please see Chapter 5. Note: If yo need non-hospice care, yo shold call yor care coordinator to arrange the services. Non hospice care is care that is not related to yor terminal prognosis. Yo can reach yor care coordinator by calling (TTY/TDD: 711). 90

93 Chapter 4: Benefits Chart G. Benefits not covered by Ble Cross Commnity MMAI, Medicare, or Medicaid This section tells yo what kinds of benefits are exclded by the plan. Exclded means that the plan does not cover these benefits. Medicare and Medicaid will not pay for them either. The list below describes some services and items that are not covered by the plan nder any conditions and some that are exclded by the plan only in some cases. The plan will not cover the exclded medical benefits listed in this section (or anywhere else in this Member Handbook) except nder the specific conditions listed. If yo think that we shold cover a service that is not covered, yo can file an appeal. For information abot filing an appeal, see Chapter 9. In addition to any exclsions or limitations described in the Benefits Chart, the following items and services are not covered by or plan: The services listed in the remaining bllets are exclded from Medicare s and Medicaid s benefit packages. Services considered not reasonable and necessary, according to the standards of Medicare and Medicaid, nless these services are listed by or plan as covered services. Services that are provided withot a reqired referral or approval Experimental medical and srgical treatments, items, and drgs, nless covered by Medicare or nder a Medicare-approved clinical research stdy or by or plan. See page 42 for more information on clinical research stdies. Experimental treatment and items are those that are not generally accepted by the medical commnity. Srgical treatment for morbid obesity, except when it is medically needed and Medicare pays for it. A private room in a hospital, except when it is medically needed. Private dty nrses. Personal items in yor room at a hospital or a nrsing facility, sch as a telephone or a television. Fll-time nrsing care in yor home. Fees charged by yor immediate relatives or members of yor hosehold. Elective or volntary enhancement procedres or services (inclding weight loss, hair growth, sexal performance, athletic performance, cosmetic prposes, anti aging and mental performance), except when medically needed. Cosmetic srgery or other cosmetic work, nless it is needed becase of an accidental injry or to improve a part of the body that is not shaped right. However, the plan will cover reconstrction of a breast after a mastectomy and for treating the other breast to match it. Chiropractic care, other than manal maniplation of the spine consistent with Medicare coverage gidelines. 91

94 Chapter 4: Benefits Chart Radial keratotomy, LASIK srgery, and vision therapy. Reversal of sterilization procedres. Acpnctre. Natropath services (the se of natral or alternative treatments). Services provided to veterans in Veterans Affairs (VA) facilities. However, when a veteran gets emergency services at a VA hospital and the VA cost sharing is more than the cost sharing nder or plan, we will reimbrse the veteran for the difference. Members are still responsible for their cost sharing amonts. 92

95 Chapter 5: Getting yor otpatient prescription drgs throgh the plan 93

96 Chapter 5: Getting yor otpatient prescription drgs throgh the plan Table of Contents Introdction...96 Rles for the plan s otpatient drg coverage A. Getting yor prescriptions filled...97 Fill yor prescription at a network pharmacy...97 Show yor Member ID Card when yo fill a prescription...97 What if yo want to change to a different network pharmacy?...97 What if the pharmacy yo se leaves the network?...97 What if yo need a specialized pharmacy? Can yo se mail-order services to get yor drgs? Can yo get a long-term spply of drgs? Can yo se a pharmacy that is not in the plan s network? Will the plan pay yo back if yo pay for a prescription? B. The plan s Drg List What is on the Drg List? How can yo find ot if a drg is on the Drg List? What is not on the Drg List? What are tiers? C. Limits on coverage for some drgs Why do some drgs have limits? What kinds of rles are there? Do any of these rles apply to yor drgs? D. Why yor drg might not be covered Yo can get a temporary spply E. Changes in coverage for yor drgs

97 Chapter 5: Getting yor otpatient prescription drgs throgh the plan F. Drg coverage in special cases If yo are in a hospital or a skilled nrsing facility for a stay that is covered by the plan If yo are in a long-term care facility If yo are in a long-term care facility and become a new member of the plan If yo are in a Medicare-certified hospice program G. Programs on drg safety and managing drgs Programs to help members se drgs safely Programs to help members manage their drgs

98 Chapter 5: Getting yor otpatient prescription drgs throgh the plan Introdction This chapter explains rles for getting yor otpatient prescription drgs. These are drgs that yor provider orders for yo that yo get from a pharmacy or by mail order. They inclde drgs covered nder Medicare Part D and Medicaid. Ble Cross Commnity MMAI also covers the following drgs, althogh they will not be discssed in this chapter: Drgs covered by Medicare Part A. These inclde some drgs given to yo while yo are in a hospital or nrsing facility. Drgs covered by Medicare Part B. These inclde some chemotherapy drgs, some drg injections given to yo dring an office visit with a doctor or other provider, and drgs yo are given at a dialysis clinic. To learn more abot what Medicare Part B drgs are covered, see the Benefits Chart in Chapter 4, section D. Rles for the plan s otpatient drg coverage The plan will sally cover yor drgs as long as yo follow the rles in this section. 1. Yo mst have a doctor or other provider write yor prescription. This person often is yor primary care provider (PCP). It cold also be another provider if yor primary care provider has referred yo for care. 2. Yo generally mst se a network pharmacy to fill yor prescription. 3. Yor prescribed drg mst be on the plan s List of Covered Drgs. We call it the Drg List for short. If it is not on the Drg List, we may be able to cover it by giving yo an exception. See page 161, Chapter 9, Section 6.2 to learn abot asking for an exception. 4. Yor drg mst be sed for a medically accepted indication. This means that the se of the drg is either approved by the Food and Drg Administration or spported by certain reference books. 96

99 A. Getting yor prescriptions filled Fill yor prescription at a network pharmacy Ble Cross Commnity MMAI MEMBER HANDBOOK Chapter 5: Getting yor otpatient prescription drgs throgh the plan In most cases, the plan will pay for prescriptions only if they are filled at the plan s network pharmacies. A network pharmacy is a drg store that has agreed to fill prescriptions for or plan members. Yo may go to any of or network pharmacies. To find a network pharmacy, yo can look in the Provider and Pharmacy Directory, visit or website, or contact Member Services. Show yor Member ID Card when yo fill a prescription To fill yor prescription, show yor Ble Cross Commnity MMAI Member ID Card at yor network pharmacy. The network pharmacy will bill Ble Cross Commnity MMAI for yor covered prescription drg. If yo do not have yor Member ID Card with yo when yo fill yor prescription, ask the pharmacy to call the plan to get the necessary information. If the pharmacy is not able to get the necessary information, yo may have to pay the fll cost of the prescription when yo pick it p. Yo can then ask s to pay yo back. If yo cannot pay for the drg, contact Member Services right away. We will do what we can to help. To learn how to ask s to pay yo back, see Chapter 7, section B. If yo need help getting a prescription filled, yo can contact Member Services or yor care coordinator. What if yo want to change to a different network pharmacy? If yo change pharmacies and need a refill of a prescription, yo can either ask to have a new prescription written by a provider or ask yor pharmacy to transfer the prescription to the new pharmacy. If yo need help changing yor network pharmacy, yo can contact Member Services or yor care coordinator. What if the pharmacy yo se leaves the network? If the pharmacy yo se leaves the plan s network, yo will have to find a new network pharmacy. We will send yo a letter if the pharmacy yo are sing leaves the network. 97

100 Chapter 5: Getting yor otpatient prescription drgs throgh the plan To find a new network pharmacy, yo can look in the Provider and Pharmacy Directory, visit or website, or contact Member Services or yor care coordinator. What if yo need a specialized pharmacy? Sometimes prescriptions mst be filled at a specialized pharmacy. Specialized pharmacies inclde: Pharmacies that spply drgs for home infsion therapy. Pharmacies that spply drgs for residents of a long-term care facility, sch as a nrsing home. Usally, long-term care facilities have their own pharmacies. If yo are a resident of a long-term care facility, we mst make sre yo can get the drgs yo need at the facility s pharmacy. If yor long-term care facility s pharmacy is not in or network, or yo have any difficlty accessing yor drg benefits in a long-term care facility, please contact Member Services. Pharmacies that serve the Indian Health Service/Tribal/Urban Indian Health Program. Except in emergencies, only Native Americans or Alaska Natives may se these pharmacies. Pharmacies that spply drgs reqiring special handling and instrctions on their se. To find a specialized pharmacy, yo can look in the Provider and Pharmacy Directory, visit or website, or contact Member Services or yor care coordinator. Can yo se mail-order services to get yor drgs? For certain kinds of drgs, yo can se the plan s network mail-order services. Generally, the drgs available throgh mail-order are drgs that yo take on a reglar basis for a chronic or long-term medical condition. Or plan s mail-order service allows yo to order p to a 90 day spply. A 90-day spply has the same copay as a one-month spply. To get order forms and information abot filling yor prescriptions by mail, or to ask for a refill of prescriptions on file, yo may: Mail yor prescriptions to Prim or Have yor prescriber call in, fax or a new prescription. For refills, yo may call Prim and speak with a trained Member Services Agent or se or atomated voice system. Visit MyPrime.com or call for more information. 98

101 Chapter 5: Getting yor otpatient prescription drgs throgh the plan How do I fill my prescriptions by mail? Usally, a mail-order prescription will get to yo within 14 days. If yor order is delayed and yo are at risk of rnning ot of yor drgs, please call Member Services to get approval. Once approval is given, we can send yor prescription to the pharmacy of yor choice. We can also have yor prescriber call in a shorter spply to the pharmacy. To reach Prim Cstomer Service, call , 24 hors a day, 7 days a week. TTY/TDD sers shold call 711. How will the mail-order service process my prescription? The mail-order service has different procedres for new prescriptions it gets from yo, new prescriptions it gets directly from yor provider s office, and refills on yor mail-order prescriptions: 1. New prescriptions the pharmacy gets from yo The pharmacy will atomatically fill and deliver new prescriptions it gets from yo. 2. New prescriptions the pharmacy gets directly from yor provider s office After the pharmacy gets a prescription from a health care provider, it will contact yo to see if yo want the medication filled immediately or at a later time. This will give yo an opportnity to make sre the pharmacy is delivering the correct drg (inclding strength, amont, and form) and, if needed, allow yo to stop or delay the order before it is shipped. It is important that yo respond each time yo are contacted by the pharmacy, to let them know what to do with the new prescription and to prevent any delays in shipping. 3. Refills on mail-order prescriptions For refills, please contact yor pharmacy 14 days before yo think the drgs yo have on hand will rn ot to make sre yor next order is shipped to yo in time. So the pharmacy can reach yo to confirm yor order before shipping, please make sre to let the pharmacy know the best ways to contact yo. Log in to yor acont at MyPrime.com or call to provide yor commnication preferences. Can yo get a long-term spply of drgs? Yo can get a long-term spply of maintenance drgs on or plan s Drg List. Maintenance drgs are drgs that yo take on a reglar basis, for a chronic or long-term medical condition. Some network pharmacies allow yo to get a long-term spply of maintenance drgs. A 90-day spply has the same copay as a one-month spply. The Provider and Pharmacy Directory tells yo which pharmacies can give yo a long-term spply of maintenance drgs. Yo can also call Member Services for more information. Yo can se the plan s network mail-order services to get a long-term spply of maintenance drgs. See the section above Chapter 5, Section A to learn abot mail-order services. 99

102 Chapter 5: Getting yor otpatient prescription drgs throgh the plan Can yo se a pharmacy that is not in the plan s network? Generally, we pay for drgs filled at an ot-of-network pharmacy only when yo are not able to se a network pharmacy. We have network pharmacies otside of or service area where yo can get yor prescriptions filled as a member of or plan. We will pay for prescriptions filled at an ot-of-network pharmacy in the following cases: Yo are traveling otside yor Plan s service area and yo: Rn ot of or lose yor covered drgs; or Become ill and need a covered drg; or Cannot reach a network pharmacy. Yo are nable to get a covered drg in a timely manner in yor service area becase, for example, there is no network pharmacy in a reasonable driving distance that provides 24/7 service; Yo are filling a prescription for a covered drg and that drg (sch as an orphan drg or other specialty drg) is not stocked at a nearby network retail or mail-order pharmacy; Yo are given covered drgs from a pharmacy in an emergency room, provider-based clinic, or other otpatient setting. Any federal disaster or other pblic health emergency has been declared in which yo are displaced from yor residence and cannot be expected to get yor covered drgs at a network pharmacy. Access to yor sal pharmacy is not available. In these cases, please check first with Member Services to see if there is a network pharmacy nearby. Will the plan pay yo back if yo pay for a prescription? If yo mst se an ot-of-network pharmacy, yo will generally have to pay the fll cost when yo get yor prescription. Yo can ask s to pay yo back. To learn more abot this, see Chapter 7, Section A. 100

103 Chapter 5: Getting yor otpatient prescription drgs throgh the plan B. The plan s Drg List The plan has a List of Covered Drgs. We call it the Drg List for short. The drgs on the Drg List are selected by the plan with the help of a team of doctors and pharmacists. The Drg List also tells yo if there are any rles yo need to follow to get yor drgs. We will generally cover a drg on the plan s Drg List as long as yo follow the rles explained in this chapter. What is on the Drg List? The Drg List incldes the drgs covered nder Medicare Part D and some prescription and over the conter drgs and items covered nder yor Medicaid benefits. The Drg List incldes both brand-name and generic drgs. Generic drgs have the same active ingredients as brand-name drgs. Generally, they work jst as well as brand-name drgs and sally cost less. We will generally cover a drg on the plan s Drg List as long as yo follow the rles explained in this chapter. Or plan also covers certain over-the-conter drgs and prodcts. Some over-the-conter drgs cost less than prescription drgs and work jst as well. For more information, call Member Services. How can yo find ot if a drg is on the Drg List? To find ot if a drg yo are taking is on the Drg List, yo can: Check the most recent Drg List we sent yo in the mail. Visit the plan s website at The Drg List on the website is always the most crrent one. Call Member Services to find ot if a drg is on the plan s Drg List or to ask for a copy of the list. What is not on the Drg List? The plan does not cover all prescription drgs. Some drgs are not on the Drg List becase the law does not allow the plan to cover those drgs. In other cases, we have decided not to inclde a drg on the Drg List. Ble Cross Commnity MMAI will not pay for the drgs listed in this section except for certain drgs covered nder or enhanced drg coverage. These are called exclded drgs. If yo get a prescription for an exclded drg, yo mst pay for it yorself. If yo think we shold pay for an exclded drg becase of yor case, yo can file an appeal. (To learn how to file an appeal, see Chapter 9, Section 5.) 101

104 Chapter 5: Getting yor otpatient prescription drgs throgh the plan Here are three general rles for exclded drgs: Or plan s otpatient drg coverage (which incldes Part D and Medicaid drgs) cannot pay for a drg that wold already be covered nder Medicare Part A or Part B. Drgs covered nder Medicare Part A or Part B are covered nder or plan s medical benefit by Ble Cross Commnity MMAI for free, bt they are not considered part of yor otpatient prescription drg benefits. Or plan cannot cover a drg prchased otside the United States and its territories. The se of the drg mst be either approved by the Food and Drg Administration or spported by certain reference books as a treatment for yor condition. Yor doctor might prescribe a certain drg to treat yor condition, even thogh it was not approved to treat the condition. This is called off-label se. Or plan sally does not cover drgs when they are prescribed for off-label se. Also, by law, the types of drgs listed below are not covered by Medicare or Medicaid. Drgs sed to promote fertility Drgs sed for the relief of cogh or cold symptoms Drgs sed for cosmetic prposes or to promote hair growth Prescription vitamins and mineral prodcts, except prenatal vitamins and floride preparations Drgs sed for the treatment of sexal or erectile dysfnction, sch as Viagra, Cialis, Levitra, and Caverject Drgs sed for treatment of anorexia, weight loss, or weight gain Otpatient drgs when the company who makes the drgs say that yo have to have tests or services done only by them What are tiers? Every drg on the plan s Drg List is in one of three tiers. A tier is a grop of drgs of generally the same type (for example, brand name, generic, or over-the-conter drgs). Tier 1 - Generic drgs Tier 2 - Brand drgs Tier 3 - Over the conter drgs To find ot which tier yor drg is in, look for the drg in the plan s Drg List. 102

105 C. Limits on coverage for some drgs Why do some drgs have limits? Ble Cross Commnity MMAI MEMBER HANDBOOK Chapter 5: Getting yor otpatient prescription drgs throgh the plan For certain prescription drgs, special rles limit how and when the plan covers them. In general, or rles encorage yo to get a drg that works for yor medical condition and is safe and effective. When a safe, lower-cost drg will work jst as well as a higher-cost drg, the plans expects yor provider to se the lower-cost drg. If there is a special rle for yor drg, it sally means that yo or yor provider will have to take extra steps for s to cover the drg. For example, yor provider may have to tell s yor diagnosis or provide reslts of blood tests first. If yo or yor provider think or rle shold not apply to yor sitation, yo shold ask s to make an exception. We may or may not agree to let yo se the drg withot taking the extra steps. To learn more abot asking for exceptions, see Chapter 9. What kinds of rles are there? 1. Limiting se of a brand-name drg when a generic version is available Generally, a generic drg works the same as a brand-name drg and sally costs less. If there is a generic version of a brand-name drg, or network pharmacies will give yo the generic version. We sally will not pay for the brand-name drg when there is a generic version. However, if yor provider has told s the medical reason that the generic drg will not work for yo or has written No sbstittions on yor prescription for a brand-name drg or has told s the medical reason that neither the generic drg nor other covered drgs that treat the same condition will work for yo, then we will cover the brand-name drg. 2. Getting plan approval in advance For some drgs, yo or yor doctor mst get approval from Ble Cross Commnity MMAI before yo fill yor prescription. If yo don t get approval, Ble Cross Commnity MMAI may not cover the drg. 3. Trying a different drg first In general, the plan wants yo to try lower-cost drgs (that often are as effective) before the plan covers drgs that cost more. For example, if Drg A and Drg B treat the same medical condition, and Drg A costs less than Drg B, the plan may reqire yo to try Drg A first. If Drg A does not work for yo, the plan will then cover Drg B. This is called step therapy. 4. Qantity limits For some drgs, we limit the amont of the drg yo can have. This is called a qantity limit. For example, the plan might limit how mch of a drg yo can get each time yo fill yor prescription. 103

106 Chapter 5: Getting yor otpatient prescription drgs throgh the plan Do any of these rles apply to yor drgs? To find ot if any of the rles above apply to a drg yo take or want to take, check the Drg List. For the most p-to-date information, call Member Services or check or website at D. Why yor drg might not be covered We try to make yor drg coverage work well for yo, bt sometimes a drg might not be covered in the way that yo wold like it to be. For example: The drg yo want to take is not covered by the plan. The drg might not be on the Drg List. A generic version of the drg might be covered, bt the brand name version yo want to take is not. A drg might be new and we have not yet reviewed it for safety and effectiveness. The drg is covered, bt there are special rles or limits on coverage for that drg. As explained in the section above, some of the drgs covered by the plan have rles that limit their se. In some cases, yo or yor prescriber may want to ask s for an exception to a rle. There are things yo can do if yor drg is not covered in the way that yo wold like it to be. Yo can get a temporary spply In some cases, the plan can give yo a temporary spply of a drg when the drg is not on the Drg List or when it is limited in some way. This gives yo time to talk with yor provider abot getting a different drg or to ask the plan to cover the drg. To get a temporary spply of a drg, yo mst meet the two rles below: 1. The drg yo have been taking: is no longer on the plan s Drg List, or was never on the plan s Drg List, or is now limited in some way. 2. Yo mst be in one of these sitations: Yo were in the plan last year and do not live in a long-term care facility. We will cover a temporary spply of yor drg dring the first 90 days of the calendar year. This temporary spply will be for p to a 30-day spply. If yor prescription is written for fewer days, we will allow mltiple fills to provide p to a maximm of a 30-day spply of medication. Yo mst fill the prescription at a network pharmacy. Yo are new to the plan and do not live in a long-term care facility. 104

107 Chapter 5: Getting yor otpatient prescription drgs throgh the plan We will cover a temporary spply of yor drg dring the first 90 days of yor membership in the plan. This temporary spply will be for p to a 30-day spply. If yor prescription is written for fewer days, we will allow mltiple fills to provide p to a maximm of a 30-day spply of medication. Yo mst fill the prescription at a network pharmacy. Yo were in the plan last year and live in a long-term care facility. We will cover a temporary spply of yor drg dring the first 90 days of the calendar year. The total spply will be for p to 98-days. If yor prescription is written for fewer days, we will allow mltiple fills to provide p to a maximm of 98-days of medication. (Please note that the long-term care pharmacy may provide the drg in smaller amonts at a time to prevent waste.) Yo are new to the plan and live in a long-term care facility. We will cover a temporary spply of yor drg dring the first 90 days of yor membership in the plan. The total spply will be for p to a 98-day spply. If yor prescription is written for fewer days, we will allow mltiple fills to provide p to a maximm of a 98-day spply of medication. (Please note that the long-term care pharmacy may provide the drg in smaller amonts at a time to prevent waste.) Yo have been in the plan for more than 90 days and live in a long term care facility and need a spply right away. We will cover one 31-day spply, or less if yor prescription is written for fewer days. This is in addition to the above long-term care transition spply. Yo have been in the plan and are entering or leaving a long-term care facility. Sometimes a prescribed drg may not be on the Drg List. This can happen when yo re moving from one treatment setting to another. In sch a case, yo mst se or exceptions and appeals process. We will handle yor case as qickly as yor health condition reqires. In these cases, a limited spply can be given to yo by the facility when yo go home. To prevent a gap in care, yo are also permitted to have a fll spply to se at home to contine treatment. This benefit is available before discharge from a Part A stay. When yo are entering or leaving a long-term care facility, and do not have access to yor remaining drgs, we will make sre yo have a refill. We can do this one time for each drg needed. Early refills will not limit access to yor benefit, so yo can still get a refill. To ask for a temporary spply of a drg, call Member Services. When yo get a temporary spply of a drg, yo shold talk with yor provider to decide what to do when yor spply rns ot. Here are yor choices: 105

108 Chapter 5: Getting yor otpatient prescription drgs throgh the plan Yo can change to another drg. There may be a different drg covered by the plan that works for yo. Yo can call Member Services to ask for a list of covered drgs that treat the same medical condition. The list can help yor provider find a covered drg that might work for yo. OR Yo can ask for an exception. Yo and yor provider can ask the plan to make an exception. For example, yo can ask the plan to cover a drg even thogh it is not on the Drg List. Or yo can ask the plan to cover the drg withot limits. If yor provider says yo have a good medical reason for an exception, he or she can help yo ask for one. To learn more abot asking for an exception, see Chapter 9. If yo need help asking for an exception, yo can contact Member Services or yor care coordinator. E. Changes in coverage for yor drgs Most changes in drg coverage happen on Janary 1. However, the plan might make changes to the Drg List dring the year. The plan might: Add drgs becase new drgs, inclding generic drgs, became available or the government approved a new se for an existing drg. Remove drgs becase they were recalled or becase cheaper drgs work jst as well. Add or remove a limit on coverage for a drg. Replace a brand-name drg with a generic drg. If any of the changes below affect a drg yo are taking, the change will not affect yo ntil Janary 1 of the next year: We pt a new limit on yor se of the drg. We remove yor drg from the Drg List, bt not becase of a recall or becase a new generic drg has replaced it. Before Janary 1 of the next year, yo sally will not have an increase in yor payments or added limits to yor se of the drg. The changes will affect yo on Janary 1 of the next year. In the following cases, yo will be affected by the coverage change before Janary 1: 106

109 Chapter 5: Getting yor otpatient prescription drgs throgh the plan If a brand name drg yo are taking is replaced by a new generic drg, the plan mst give yo at least 60 days notice abot the change. The plan may give yo a 60-day refill of yor brand-name drg at a network pharmacy. Yo shold work with yor provider dring those 60 days to change to the generic drg or to a different drg that the plan covers. Yo and yor provider can ask the plan to contine covering the brandname drg for yo. To learn how, see Chapter 9. If a drg is recalled becase it is fond to be nsafe or for other reasons, the plan will remove the drg from the Drg List. We will tell yo abot this change right away. Yor provider will also know abot this change. He or she can work with yo to find another drg for yor condition. If there is a change to coverage for a drg yo are taking, the plan will send yo a notice. Normally, the plan will let yo know at least 60 days before the change. F. Drg coverage in special cases If yo are in a hospital or a skilled nrsing facility for a stay that is covered by the plan If yo are admitted to a hospital or skilled nrsing facility for a stay covered by the plan, we will generally cover the cost of yor prescription drgs dring yor stay. Yo will not have to pay a copay. Once yo leave the hospital or skilled nrsing facility, the plan will cover yor drgs as long as the drgs meet all of or rles for coverage. If yo are in a long-term care facility Usally, a long-term care facility, sch as a nrsing home, has its own pharmacy or a pharmacy that spplies drgs for all of its residents. If yo are living in a long-term care facility, yo may get yor prescription drgs throgh the facility s pharmacy if it is part of or network. Check yor Provider and Pharmacy Directory to find ot if yor long-term care facility s pharmacy is part of or network. If it is not, or if yo need more information, please contact Member Services. If yo are in a long-term care facility and become a new member of the plan If yo need a drg that is not on or Drg List or is restricted in some way, the plan will cover a temporary spply of yor drg dring the first 90 days of yor membership, ntil we have given yo a 98 day spply. The first spply will be for p to a 31-day spply, or less if yor prescription is written for fewer days. If yo need refills, we will cover them dring yor first 90 days in the plan. 107

110 Chapter 5: Getting yor otpatient prescription drgs throgh the plan If yo have been a member of the plan for more than 90 days and yo need a drg that is not on or Drg List, we will cover one 31 day spply. We will also cover one 31-day spply if the plan has a limit on the drg s coverage. If yor prescription is written for fewer than 31 days, we will pay for the smaller amont. When yo get a temporary spply of a drg, yo shold talk with yor provider to decide what to do when yor spply rns ot. A different drg covered by the plan might work jst as well for yo. Or yo and yor provider can ask the plan to make an exception and cover the drg in the way yo wold like it to be covered. To learn more abot asking for exceptions, see Chapter 9. If yo are in a Medicare-certified hospice program Drgs are never covered by both hospice and or plan at the same time. If yo are enrolled in a Medicare hospice and reqire a pain medication, anti-nasea, laxative, or antianxiety drg not covered by yor hospice becase it is nrelated to yor terminal prognosis and related conditions, or plan mst get notification from either the prescriber or yor hospice provider that the drg is nrelated before or plan can cover the drg. To prevent delays in getting any nrelated drgs that shold be covered by or plan, yo can ask yor hospice provider or prescriber to make sre we have the notification that the drg is nrelated before yo ask a pharmacy to fill yor prescription. If yo leave hospice, or plan shold cover all of yor drgs. To prevent any delays at a pharmacy when yor Medicare hospice benefit ends, yo shold bring docmentation to the pharmacy to verify that yo have left hospice. See the previos parts of this chapter that tell abot the rles for getting drg coverage nder Part D. To learn more abot the hospice benefit, see Chapter

111 Chapter 5: Getting yor otpatient prescription drgs throgh the plan G. Programs on drg safety and managing drgs Programs to help members se drgs safely Each time yo fill a prescription, we look for possible problems, sch as: Drg errors Drgs that may not be needed becase yo are taking another drg that does the same thing Drgs that may not be safe for yor age or gender Drgs that cold harm yo if yo take them at the same time Drgs that are made of things yo are allergic to If we see a possible problem in yor se of prescription drgs, we will work with yor provider to correct the problem. Programs to help members manage their drgs If yo take medications for different medical conditions, yo may be eligible to get services, at no cost to yo, throgh a medication therapy management (MTM) program. This program helps yo and yor provider make sre that yor medications are working to improve yor health. A pharmacist or other health professional will give yo a comprehensive review of all yor medications and talk with yo abot: How to get the most benefit from the drgs yo take Any concerns yo have, like medication costs and drg reactions How best to take yor medications Any qestions or problems yo have abot yor prescription and over-the-conter medication Yo ll get a written smmary of this discssion. The smmary has a medication action plan that recommends what yo can do to make the best se of yor medications. Yo ll also get a personal medication list that will inclde all the medications yo re taking and why yo take them. It s a good idea to schedle yor medication review before yor yearly Wellness visit, so yo can talk to yor doctor abot yor action plan and medication list. Bring yor action plan and medication list with yo to yor visit or anytime yo talk with yor doctors, pharmacists, and other health care providers. Also, take yor medication list with yo if yo go to the hospital or emergency room. Medication therapy management programs are volntary and free to members that qalify. If we have a program that fits yor needs, we will enroll yo in the program and send yo information. If yo do not want to be in the program, please let s know, and we will take yo ot of the program. If yo have any qestions abot these programs, please contact Member Services or yor care coordinator. 109

112 Chapter 6: What yo pay for yor Medicare and Medicaid prescription drgs 110

113 Chapter 6: What yo pay for yor Medicare and Medicaid prescription drgs Table of Contents Introdction A. The Explanation of Benefits (EOB) B. Keeping track of yor drg costs Use yor Member ID Card Make sre we have the information we need Send s information abot the payments others have made for yo Check the reports we send yo C. Yo pay nothing for a one-month or long-term spply of drgs The plan s tiers Yor pharmacy choices Getting a long-term spply of a drg D. Vaccinations Before yo get a vaccination

114 Chapter 6: What yo pay for yor Medicare and Medicaid prescription drgs Introdction This chapter tells what yo pay for yor otpatient prescription drgs. By drgs, we mean: Medicare Part D prescription drgs, and drgs and items covered nder Medicaid, and drgs and items covered by the plan as additional benefits. Becase yo are eligible for Medicaid, yo are getting Extra Help from Medicare to help pay for yor Medicare Part D prescription drgs. To learn more abot prescription drgs, yo can look in these places: The plan s List of Covered Drgs. We call this the Drg List. It tells yo: Which drgs the plan pays for Which of the three (3) tiers each drg is in Whether there are any limits on the drgs If yo need a copy of the Drg List, call Member Services. Yo can also find the Drg List on or website at The Drg List on the website is always the most crrent. Chapter 5 of this Member Handbook. Chapter 5 section A tells how to get yor otpatient prescription drgs throgh the plan. It incldes rles yo need to follow. It also tells which types of prescription drgs are not covered by or plan. The plan s Provider and Pharmacy Directory. In most cases, yo mst se a network pharmacy to get yor covered drgs. Network pharmacies are pharmacies that have agreed to work with or plan. The Provider and Pharmacy Directory has a list of network pharmacies. Yo can read more abot network pharmacies in Chapter 5 section A. 112

115 Chapter 6: What yo pay for yor Medicare and Medicaid prescription drgs A. The Explanation of Benefits (EOB) Or plan keeps track of yor prescription drgs. We keep track of two types of costs: Yor ot-of-pocket costs. This is the amont of money yo or others on yor behalf pay for yor prescriptions. Yor total drg costs. This is the amont of money yo or others on yor behalf pay for yor prescriptions, pls the amont the plan pays. When yo get prescription drgs throgh the plan, we send yo a report called the Explanation of Benefits. We call it the EOB for short. The EOB incldes: Information for the month. The report tells what prescription drgs yo got. It shows the total drg costs, what the plan paid, and what yo and others paying for yo paid. Year-to-date information. This is yor total drg costs and the total payments made since Janary 1. We offer coverage of drgs not covered nder Medicare. Payments made for these drgs will not cont towards yor total ot-of-pocket costs. We also pay for some over-the-conter drgs. Yo do not have to pay anything for these drgs. To find ot which drgs or plan covers, see the Drg List. 113

116 Chapter 6: What yo pay for yor Medicare and Medicaid prescription drgs B. Keeping track of yor drg costs To keep track of yor drg costs and the payments yo make, we se records we get from yo and from yor pharmacy. Here is how yo can help s: 1. Use yor Member ID Card. Show yor Member ID Card every time yo get a prescription filled. This will help s know what prescriptions yo fill and what yo pay. 2. Make sre we have the information we need. Give s copies of receipts for drgs that yo have paid for. Yo can ask s to pay yo back for the drg. Here are some times when yo shold give s copies of yor receipts: When yo by a covered drg at a network pharmacy at a special price or sing a discont card that is not part of or plan s benefit When yo pay a copay for drgs that yo get nder a drg maker s patient assistance program When yo by covered drgs at an ot-of-network pharmacy When yo pay the fll price for a covered drg To learn how to ask s to pay yo back for the drg, see Chapter 7, Section B. 3. Send s information abot the payments others have made for yo. Payments made by certain other people and organizations also cont toward yor ot-of-pocket costs. For example, payments made by an AIDS drg assistance program, the Indian Health Service, and most charities cont toward yor ot-of-pocket costs. 4. Check the reports we send yo. When yo get an Explanation of Benefits in the mail, please make sre it is complete and correct. If yo think something is wrong or missing from the report, or if yo have any qestions, please call Member Services. Be sre to keep these reports. They are an important record of yor drg expenses. 114

117 Chapter 6: What yo pay for yor Medicare and Medicaid prescription drgs C. Yo pay nothing for a one-month or long term spply of drgs With Ble Cross Commnity MMAI, yo pay nothing for covered drgs as long as yo follow the plan s rles. The plan s tiers Tiers are grops of drgs on or Drg List. Every drg in the plan s Drg List is in one of three tiers. Yo have no copays for prescription and OTC drgs on Ble Cross Commnity MMAI s Drg List. To find the tiers for yor drgs, yo can look in the Drg List. Tier 1 Generic drgs Tier 2 Brand name drgs Tier 3 Over the conter (OTC) drgs Yor pharmacy choices How mch yo pay for a drg depends on whether yo get the drg from: a network pharmacy, or an ot-of-network pharmacy. In limited cases, we cover prescriptions filled at ot-of-network pharmacies. See Chapter 5, Section A to find ot when we will do that. To learn more abot these pharmacy choices, see Chapter 5, Section A in this handbook and the plan s Provider and Pharmacy Directory. Getting a long-term spply of a drg For some drgs, yo can get a long-term spply (also called an extended spply ) when yo fill yor prescription. A long-term spply is a 90 day spply. There is no cost to yo for a long-term spply. For details on where and how to get a long-term spply of a drg, see Chapter 5, Section A or the Provider and Pharmacy Directory. 115

118 Chapter 6: What yo pay for yor Medicare and Medicaid prescription drgs D. Vaccinations Or plan covers Medicare Part D vaccines. There are two parts to or coverage of Medicare Part D vaccinations: 1. The first part of coverage is for the cost of the vaccine itself. The vaccine is a prescription drg. 2. The second part of coverage is for the cost of giving yo the vaccine. For example, sometimes yo may get the vaccine as a shot given to yo by yor doctor. Before yo get a vaccination We recommend that yo call s first at Member Services whenever yo are planning to get a vaccination. We can tell yo abot how yor vaccination is covered by or plan. We can tell yo how to keep yor costs down by sing network pharmacies and providers. Network pharmacies are pharmacies that have agreed to work with or plan. A network provider is a provider who works with the health plan. A network provider shold work with Ble Cross Commnity MMAI to ensre that yo do not have any pfront costs for a Part D vaccine. Here are three common ways yo might get a Medicare Part D vaccination. 1. Yo get the Medicare Part D vaccine at a network pharmacy and get yor shot at the pharmacy. Yo will pay nothing for the vaccine. Some states do not allow pharmacies to give shots. 2. Yo get the Medicare Part D vaccine at yor doctor s office and the doctor gives yo the shot. Yo will pay nothing to the doctor for the vaccine. Or plan will pay for the cost of giving yo the shot. The doctor s office shold call or plan in this sitation so we can make sre they know yo only have to pay nothing for the vaccine. 3. Yo get the Medicare Part D vaccine itself at a pharmacy and take it to yor doctor s office to get the shot. Yo will pay nothing for the vaccine. Or plan will pay for the cost of giving yo the shot. 116

119 Chapter 7: Asking s to pay a bill yo have gotten for covered services or drgs 117

120 Chapter 7: Asking s to pay a bill yo have gotten for covered services or drgs Table of Contents A. When yo can ask s to pay for yor covered services or drgs B. How and where to send s yor reqest for payment C. We will make a coverage decision D. Yo can make an appeal

121 Chapter 7: Asking s to pay a bill yo have gotten for covered services or drgs A. When yo can ask s to pay for yor services or drgs Yo shold not get a bill for in-network services or drgs. Or network providers mst bill the plan for the services and drgs yo already got. A network provider is a provider who works with the health plan. If yo get a bill for health care or drgs, send the bill to s. To send s a bill, see page 212-Ble Cross Commnity MMAI Member Services. If the services or drgs are covered, we will pay the provider directly. If the services or drgs are covered and yo already paid the bill, it is yor right to be paid back. If the services or drgs are not covered, we will tell yo. Contact Member Services or yor care coordinator if yo have any qestions. If yo get a bill and yo do not know what to do abot it, we can help. Yo can also call if yo want to tell s information abot a reqest for payment yo already sent to s. Here are examples of times when yo may need to ask or plan to pay yo back or to pay a bill yo got: 1. When yo get emergency or rgently needed health care from an ot-of-network provider Yo shold ask the provider to bill the plan. If yo pay the fll amont when yo get the care, ask s to pay yo back. Send s the bill and proof of any payment yo made. Yo may get a bill from the provider asking for payment that yo think yo do not owe. Send s the bill and proof of any payment yo made. If the provider shold be paid, we will pay the provider directly. If yo have already paid for the service, we will pay yo back. 2. When a network provider sends yo a bill Network providers mst always bill the plan. Whenever yo get a bill from a network provider, send s the bill. We will contact the provider directly and take care of the problem. If yo have already paid a bill from a network provider, send s the bill and proof of any payment yo made. We will pay yo back for yor covered services. 3. When yo se an ot-of-network pharmacy to get a prescription filled If yo go to an ot-of-network pharmacy, yo will have to pay the fll cost of yor prescription. 119

122 Chapter 7: Asking s to pay a bill yo have gotten for covered services or drgs In only a few cases, we will cover prescriptions filled at ot-of-network pharmacies. Send s a copy of yor receipt when yo ask s to pay yo back. Please see Chapter 5 to learn more abot ot of network pharmacies. 4. When yo pay the fll cost for a prescription becase yo do not have yor Member ID Card with yo If yo do not have yor Ble Cross Commnity MMAI Member ID Card with yo, yo can ask the pharmacy to call the plan or to look p yor plan enrollment information. If the pharmacy cannot get the information they need right away, yo may have to pay the fll cost of the prescription yorself. Send s a copy of yor receipt when yo ask s to pay yo back. 5. When yo pay the fll cost for a prescription for a drg that is not covered Yo may pay the fll cost of the prescription becase the drg is not covered. The drg may not be on the plan s List of Covered Drgs (Drg List), or it cold have a reqirement or restriction that yo did not know abot or do not think shold apply to yo. If yo decide to get the drg, yo may need to pay the fll cost for it. If yo do not pay for the drg bt think it shold be covered, yo can ask for a coverage decision (see Chapter 9). If yo and yor doctor or other prescriber think yo need the drg right away, yo can ask for a fast coverage decision (see Chapter 9). Send s a copy of yor receipt when yo ask s to pay yo back. In some sitations, we may need to get more information from yor doctor or other prescriber in order to pay yo back for the drg. When yo send s a reqest for payment, we will review yor reqest and decide whether the service or drg shold be covered. This is called making a coverage decision. If we decide it shold be covered, we will pay for the service or drg. If we deny yor reqest for payment, yo can appeal or decision. To learn how to make an appeal, see Chapter 9. B. How and where to send s yor reqest for payment Send s yor bill and proof of any payment yo have made. Proof of payment can be a copy of the check yo wrote or a receipt from the provider. It is a good idea to make a copy of yor bill and receipts for yor records. Yo can ask yor care coordinator for help. 120

123 Chapter 7: Asking s to pay a bill yo have gotten for covered services or drgs To make sre yo are giving s all the information we need to make a decision, yo can fill ot or claim form to make yor reqest for payment. Yo do not have to se the form, bt it will help s process the information faster. Yo can get a copy of the form on or website or yo can call Member Services and ask for the form. Mail yor reqest for payment together with any bills or receipts to s at this address: For medical claims, mail yor reqest for payment together with any bills or receipts to s at this address: Ble Cross Commnity MMAI P.O. Box Chicago, IL For prescription Drg claims, mail yor reqest for payment together with any bills or receipts to s at this address: Ble Cross Commnity MMAI P.O. Box Lexington, KY Yo may also call or plan to reqest payment at (TTY/TDD: 711). We are open 8:00 a.m. ntil 8:00 p.m. Central time, seven (7) days a week. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a cstomer service representative will retrn yor call no later than the next bsiness day. Yo mst sbmit yor claim to s within 180 days of the date yo got the service, item, or drg. 121

124 Chapter 7: Asking s to pay a bill yo have gotten for covered services or drgs C. We will make a coverage decision When we get yor reqest for payment, we will make a coverage decision. This means that we will decide whether yor health care or drg is covered by the plan. We will also decide the amont, if any, yo have to pay for the health care or drg. We will let yo know if we need more information from yo. If we decide that the health care or drg is covered and yo followed all the rles for getting it, we will pay for it. If yo have already paid for the service or drg, we will mail yo a check for what yo paid. If yo have not paid for the service or drg yet, we will pay the provider directly. Chapter 3 explains the rles for getting yor services covered. Chapter 5 explains the rles for getting yor Medicare Part D prescription drgs covered. If we decide not to pay for the service or drg, we will send yo a letter explaining why not. The letter will also explain yor rights to make an appeal. To learn more abot coverage decisions, see Chapter 9. D. Yo can make an appeal If yo think we made a mistake in trning down yor reqest for payment, yo can ask s to change or decision. This is called making an appeal. Yo can also make an appeal if yo do not agree with the amont we pay. The appeals process is a formal process with detailed procedres and important deadlines. To learn more abot appeals, see Chapter 9. If yo want to make an appeal abot getting paid back for a health care service, go to page 158. If yo want to make an appeal abot getting paid back for a drg, go to page

125 Chapter 8: Yor rights and responsibilities 123

126 Chapter 8: Yor rights and responsibilities Table of Contents Introdction A. Yo have a right to get information in a way that meets yor needs B. We mst treat yo with respect, fairness, and dignity at all times C. We mst ensre that yo get timely access to covered services and drgs D. We mst protect yor personal health information How we protect yor health information Yo have a right to see yor medical records E. We mst give yo information abot the plan, its network providers, and yor covered services F. Network providers cannot bill yo directly G. Yo have the right to leave the plan at any time H. Yo have a right to make decisions abot yor health care Yo have the right to know yor treatment options and make decisions abot yor health care Yo have the right to say what yo want to happen if yo are nable to make health care decisions for yorself What to do if yor instrctions are not followed I. Yo have the right to make complaints and to ask s to reconsider decisions we have made What to do if yo believe yo are being treated nfairly or yor rights are not being respected How to get more information abot yor rights J. Yo also have responsibilities as a member of the plan

127 Introdction Ble Cross Commnity MMAI MEMBER HANDBOOK Chapter 8: Yor rights and responsibilities In this chapter, yo will find yor rights and responsibilities as a member of the plan. We mst honor yor rights. A. Yo have a right to get information in a way that meets yor needs We mst tell yo abot the plan s benefits and yor rights in a way that yo can nderstand. We mst tell yo abot yor rights each year that yo are in or plan. To get information in a way that yo can nderstand, call Member Services. Or plan has people who can answer qestions in different langages. The call is free. Or plan can also give yo materials in langages other than English and in formats sch as large print, braille, or adio. Or plan can also give yo materials in langages other than English and in formats sch as large print,braille, or adio. Materials are available in Spanish,Cantonese,Hind,Korean, Mandarin, Polish,Rssian, and Thai. If yo wish to make a standing reqest to receive all materials now, and in the ftre, in a langage other than English, or in an alternate format, yo can call Member Services at (TTY/TDD 711). To get information in a way that yo can nderstand, call Member Services. Or plan has people who can answer qestions in different langages. If yo are having troble getting information from or plan becase of langage problems or a disability and yo want to file a complaint, call Medicare at MEDICARE ( ). Yo can call 24 hors a day, seven days a week. TTY sers shold call Yo can also file a complaint with Medicaid by calling the Illinois Health Benefits Hotline at TTY sers shold call

128 Chapter 8: Yor rights and responsibilities B. We mst treat yo with respect, fairness, and dignity at all times Or plan mst obey laws that protect yo from discrimination or nfair treatment. We do not discriminate against members becase of any of the following: Age Medical history Appeals Behavior Claims experience Ethnicity Evidence of insrability Genetic information Gender Identity Geographic location within the service area Health stats Mental ability Mental or physical disability National origin Race Receipt of health care Religion Sex Sexal orientation Use of services Under the rles of the plan, yo have the right to be free of any form of physical restraint or seclsion that wold be sed as a means of coercion, force, discipline, convenience or retaliation. We cannot deny services to yo or pnish yo for exercising yor rights. For more information, or if yo have concerns abot discrimination or nfair treatment, call the Department of Health and Hman Services Office for Civil Rights at (TTY ). Yo can also call yor local Office for Civil Rights. Yo can also call yor local Office for Civil Rights at the Illinois Department of Hman Rights If yo have a disability and need help accessing care or a provider, call Member Services. If yo have a complaint, sch as a problem with wheelchair access, Member Services can help. 126

129 Chapter 8: Yor rights and responsibilities C. We mst ensre that yo get timely access to covered services and drgs If yo cannot get services within a reasonable amont of time, we have to pay for ot-of-network care. As a member of or plan: Yo have the right to choose a primary care provider (PCP) in the plan s network. A network provider is a provider who works with the health plan. Call Member Services or look in the Provider and Pharmacy Directory to learn which doctors are accepting new patients. Yo have the right to go to a gynecologist or another women s health specialist withot getting a referral. A referral is a written order from yor primary care provider. Yo have the right to get covered services from network providers within a reasonable amont of time. This incldes the right to get timely services from specialists. Yo have the right to get emergency services or care that is rgently needed withot prior approval. Yo have the right to get yor prescriptions filled at any of or network pharmacies withot long delays. Yo have the right to know when yo can see an ot-of-network provider. To learn abot ot-of-network providers, see Chapter 3. Chapter 9 tells what yo can do if yo think yo are not getting yor services or drgs within a reasonable amont of time. Chapter 9 also tells what yo can do if we have denied coverage for yor services or drgs and yo do not agree with or decision. 127

130 Chapter 8: Yor rights and responsibilities D. We mst protect yor personal health information We protect yor personal health information as reqired by federal and state laws. Yor personal health information incldes the information yo gave s when yo enrolled in this plan. It also incldes yor medical records and other medical and health information. Yo have rights to get information and to control how yor health information is sed. We give yo a written notice that tells abot these rights. The notice is called the Notice of Privacy Practice. The notice also explains how we protect the privacy of yor health information. How we protect yor health information We make sre that nathorized people do not see or change yor records. In most sitations, we do not give yor health information to anyone who is not providing yor care or paying for yor care. If we do, we are reqired to get written permission from yo first. Written permission can be given by yo or by someone who has the legal power to make decisions for yo. There are certain cases when we do not have to get yor written permission first. These exceptions are allowed or reqired by law. We are reqired to release health information to government agencies that are checking on or qality of care. We are reqired to give Medicare yor health and drg information. If Medicare releases yor information for research or other ses, it will be done according to Federal laws. Yo have a right to see yor medical records Yo have the right to look at yor medical records and to get a copy of yor records. We are allowed to charge yo a fee for making a copy of yor medical records. Yo have the right to ask s to pdate or correct yor medical records. If yo ask s to do this, we will work with yor health care provider to decide whether the changes shold be made. Yo have the right to know if and how yor health information has been shared with others. If yo have qestions or concerns abot the privacy of yor personal health information, call Member Services. 128

131 Chapter 8: Yor rights and responsibilities E. We mst give yo information abot the plan, its network providers, and yor covered services As a member of Ble Cross Commnity MMAI, yo have the right to get information from s. If yo do not speak English, we have free interpreter services to answer any qestions yo may have abot or health plan. To get an interpreter, jst call s at (TTY/TDD: 711). This is a free service. Written materials are available in these langages: Cantonese, Haitian Creole, Hindi, Korean, Mandarin, Polish, Rssian, Spanish. Member Services also has free langage interpreter services available for non English speakers and the hearing impaired. We can also give yo information in braille, large print or adio. We can also give yo information in large print, braille, or adio. If yo want any of the following, call Member Services: Information abot how to choose or change plans Information abot or plan, inclding: Financial information How the plan has been rated by plan members The nmber of appeals made by members How to leave the plan Information abot or network providers and or network pharmacies, inclding: How to choose or change primary care providers The qalifications of or network providers and pharmacies How we pay the providers in or network For a list of providers and pharmacies in the plan s network, see the Provider and Pharmacy Directory. For more detailed information abot or providers or pharmacies, call Member Services at (TTY/TDD: 711), we are available seven (7) days a week. Or call center is open Monday-Friday 8:00 a.m.-8:00p.m. Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day. The call is free. Or visit or website at Information abot covered services and drgs and abot rles yo mst follow, inclding: Services and drgs covered by the plan Limits to yor coverage and drgs Rles yo mst follow to get covered services and drgs Information abot why something is not covered and what yo can do abot it, inclding: Asking s to pt in writing why something is not covered Asking s to change a decision we made Asking s to pay for a bill yo have received 129

132 Chapter 8: Yor rights and responsibilities F. Network providers cannot bill yo directly Doctors, hospitals, and other providers in or network cannot make yo pay for covered services. They also cannot charge yo if we pay for less than the provider charged s. To learn what to do if a network provider tries to charge yo for covered services, see Chapter 7, Section A. G. Yo have the right to leave the plan at any time No one can make yo stay in or plan if yo do not want to. Yo can leave the plan at any time. If yo leave or plan, yo will still be in the Medicare and Medicaid programs as long as yo are eligible. Yo have the right to get yor Medicare benefits throgh: A different Medicare-Medicaid plan Original Medicare A Medicare Advantage plan Yo can get yor Medicare Part D prescription drg benefits from: A different Medicare-Medicaid plan A prescription drg plan A Medicare Advantage plan Yo can get yor Medicaid benefits throgh: A different Medicare-Medicaid plan Medicaid fee-for-service or a Medicaid Managed Long-Term Services and Spports plan Important Note: If yo are getting long-term care or home and commnity based waiver services, yo mst either stay with or plan or choose another plan to get yor long-term spports and services. To choose a Medicaid Managed Long Term Services and Spports plan, yo can call Illinois Client Enrollment Services at from 8 a.m. to 7 p.m. Monday throgh Friday. TTY sers shold call Tell them yo want to leave Ble Cross Commnity MMAI and join a Medicaid Managed Long Term Services and Spports health plan. If yo don t pick a health plan, yo will be assigned to or company s Medicaid Managed Long Term Services and Spports health plan. See chapter 10 for more information. 130

133 Chapter 8: Yor rights and responsibilities H. Yo have a right to make decisions abot yor health care Yo have the right to know yor treatment options and make decisions abot yor health care Yo have the right to get fll information from yor doctors and other health care providers when yo get services. Yor providers mst explain yor condition and yor treatment choices in a way that yo can nderstand. Know yor choices. Yo have the right to be told abot all the kinds of treatment. Know the risks. Yo have the right to be told abot any risks involved. Yo mst be told in advance if any service or treatment is part of a research experiment. Yo have the right to refse experimental treatments. Yo can get a second opinion. Yo have the right to see another doctor before deciding on treatment. Yo can say no. Yo have the right to refse any treatment. This incldes the right to leave a hospital or other medical facility, even if yor doctor advises yo not to. Yo also have the right to stop taking a drg. If yo refse treatment or stop taking a drg, yo will not be dropped from the plan. However, if yo refse treatment or stop taking a drg, yo accept fll responsibility for what happens to yo. Yo can ask s to explain why a provider denied care. Yo have the right to get an explanation from s if a provider has denied care that yo believe yo shold get. Yo can ask s to cover a service or drg that was denied or is sally not covered. This is called a coverage decision. Chapter 9, Section 4 tells how to ask the plan for a coverage decision. Yo have the right to say what yo want to happen if yo are nable to make health care decisions for yorself Sometimes people are nable to make health care decisions for themselves. Before that happens to yo, yo can: Fill ot a written form to give someone the right to make health care decisions for yo. Give yor doctors written instrctions abot how yo want them to handle yor health care if yo become nable to make decisions for yorself. The legal docment that yo can se to give yor directions is called an advance directive. There are different types of advance directives and different names for them. Examples are a living will and a power of attorney for health care. To learn more abot advance directives in Illinois, go to the Illinois Department of Pblic Health s website at: 131

134 Chapter 8: Yor rights and responsibilities Yo do not have to se an advance directive, bt yo can if yo want to. Here is what to do: Get the form. Yo can get a form from yor doctor, a lawyer, a legal services agency, or a social worker. Organizations that give people information abot Medicare or Medicaid sch as the Illinois Department of Aging Senior Helpline ( or aging.ilsenior@illinois.gov) may also have advance directive forms. Fill it ot and sign the form. The form is a legal docment. Yo shold consider having a lawyer help yo prepare it. Give copies to people who need to know abot it. Yo shold give a copy of the form to yor doctor. Yo shold also give a copy to the person yo name as the one to make decisions for yo. Yo may also want to give copies to close friends or family members. Be sre to keep a copy at home. Ble Cross Commnity MMAI will make yor completed form part of yor medical record. Ble Cross Commnity MMAI cannot, as a condition of treatment, reqire yo to fill ot or waive an advance directive. If yo are going to be hospitalized and yo have signed an advance directive, take a copy of it to the hospital. The hospital will ask yo whether yo have signed an advance directive form and whether yo have it with yo. If yo have not signed an advance directive form, the hospital has forms available and will ask if yo want to sign one. Remember, it is yor choice to fill ot an advance directive or not. What to do if yor instrctions are not followed If yo have signed an advance directive, and yo believe that a doctor or hospital did not follow the instrctions in it, yo may file a complaint by calling the Senior Helpline at TTY sers shold call The call is free. 132

135 Chapter 8: Yor rights and responsibilities I. Yo have the right to make complaints and to ask s to reconsider decisions we have made Chapter 9, Section 3 tells what yo can do if yo have any problems or concerns abot yor covered services or care. For example, yo cold ask s to make a coverage decision, make an appeal to s to change a coverage decision, or make a complaint. Yo have the right to get information abot appeals and complaints that other members have filed against or plan. To get this information, call Member Services at (TTY/TDD 711), We are available seven (7) days a week. Or call center is open Monday-Friday 8:00am-8:00pm Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day. The call is free. What to do if yo believe yo are being treated nfairly or yor rights are not being respected If yo believe yo have been treated nfairly and it is not abot discrimination for the reasons listed on page 198 yo can get help in these ways: Yo can call Member Services at (TTY/TDD: 711), we are available seven (7) days a week. Or call center is open Monday-Friday 8:00 a.m.-8:00p.m. Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day. The call is free. Yo can call the Senior Health Insrance Program at from 8:30 a.m. to 5 p.m. Monday throgh Friday. TTY sers shold call The call is free. For details abot this organization, see Chapter 2, Section E. Yo can call Medicare at MEDICARE ( ), 24 hors a day, seven days a week. TTY sers shold call Yo can call the Senior Helpline at from 8:30 a.m. to 5 p.m. Monday throgh Friday. TTY sers shold call The call is free. 133

136 Chapter 8: Yor rights and responsibilities How to get more information abot yor rights There are several ways to get more information abot yor rights: Yo can call Member Services at (TTY/TDD: 711), we are available seven (7) days a week. Or call center is open Monday-Friday 8:00 a.m.-8:00p.m. Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day. The call is free. Yo can call the Senior Health Insrance Program at from 8:30 a.m. to 5 p.m. Monday throgh Friday. TTY sers shold call The call is free. For details abot this organization, see Chapter 2. Yo can contact Medicare. Yo can visit the Medicare website to read or download Medicare Rights & Protections. (Go to Or yo can call MEDICARE ( ), 24 hors a day, 7 days a week. TTY sers shold call Yo can call the Senior Helpline at from 8:30 a.m. to 5 p.m. Monday throgh Friday. TTY sers shold call The call is free. 134

137 J. Yo also have responsibilities as a member of the plan Ble Cross Commnity MMAI MEMBER HANDBOOK Chapter 8: Yor rights and responsibilities As a member of the plan, yo have a responsibility to do the things that are listed below. If yo have any qestions, call Member Services. Read the Member Handbook to learn what is covered and what rles yo need to follow to get covered services and drgs. For details abot yor covered services, see Chapters 3 and 4. Those chapters tell yo what is covered, what is not covered, what rles yo need to follow, and what yo pay. For details abot yor covered drgs, see Chapters 5 and 6. Tell s abot any other health or prescription drg coverage yo have. We are reqired to make sre yo are sing all of yor coverage options when yo get health care. Please call Member Services if yo have other coverage. Tell yor doctor and other health care providers that yo are enrolled in or plan. Show yor plan ID card whenever yo get services or drgs. Help yor doctors and other health care providers give yo the best care. Give them the information they need abot yo and yor health. Learn as mch as yo can abot yor health problems. Follow the treatment plans and instrctions that yo and yor providers agree on. Make sre yor doctors and other providers know abot all of the drgs yo are taking. This incldes prescription drgs, over-the-conter drgs, vitamins, and spplements. If yo have any qestions, be sre to ask. Yor doctors and other providers mst explain things in a way yo can nderstand. If yo ask a qestion and yo do not nderstand the answer, ask again. Be considerate. We expect all or members to respect the rights of other patients. We also expect yo to act with respect in yor doctor s office, hospitals, and other providers offices. Pay what yo owe. As a plan member, yo are responsible for these payments: Medicare Part A and Medicare Part B premims. For most Ble Cross Commnity MMAI members, Medicaid pays for yor Part A premim and for yor Part B premim. If yo get any services or drgs that are not covered by or plan, yo mst pay the fll cost. If yo disagree with or decision to not cover a service or drg, yo can make an appeal. Please see Chapter 9, Section 4 to learn how to make an appeal. Tell s if yo move. If yo are going to move, it is important to tell s right away. Call Member Services. 135

138 Chapter 8: Yor rights and responsibilities If yo move otside of or plan service area, yo cannot be a member of or plan. Chapter 1, Section D tells abot or service area. We can help yo figre ot whether yo are moving otside or service area. We can let yo know if we have a plan in yor new area. Also, be sre to let Medicare and Medicaid know yor new address when yo move. See Chapter 2, Sections G and H for phone nmbers for Medicare and Medicaid. If yo move within or service area, we still need to know. We need to keep yor membership record p to date and know how to contact yo. Call Member Services at (TTY/TDD 711), We are available seven (7) days a week. Or call center is open Monday-Friday 8:00am-8:00pm Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day. The call is free. 136

139 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) 137

140 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) What s in this chapter? This chapter has information abot yor rights. Read this chapter to find ot what to do if: Yo have a problem with or complaint abot yor plan. Yo need a service, item, or medication that yor plan has said it will not pay for. Yo disagree with a decision that yor plan has made abot yor care. Yo think yor covered services are ending too soon. If yo have a problem or concern, yo only need to read the parts of this chapter that apply to yor sitation. This chapter is broken into different sections to help yo easily find what yo are looking for. If yo are facing a problem with yor health or long-term services and spports Yo shold get the health care, drgs, and long-term services and spports that yor doctor and other providers determine are necessary for yor care as a part of yor care plan. If yo are having a problem with yor care, yo can call the Senior HelpLine at , TTY/TDD: This chapter explains the options yo have for different problems and complaints, bt yo can always call the Senior HelpLine to help gide yo throgh yor problem. The Senior Helpline will help anyone at any age enrolled in this plan. 138

141 Table of Contents Ble Cross Commnity MMAI MEMBER HANDBOOK Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) What s in this chapter? If yo are facing a problem with yor health or long-term services and spports Section 1: Section 2: Section 3: Section 4: Section 5: Introdction Section 1.1: Section 1.2: What to do if yo have a problem What abot the legal terms? Where to call for help Section 2.1: Where to get more information and help Problems with yor benefits Section 3.1: Shold yo se the process for coverage decisions and appeals? Or do yo want to make a complaint? Coverage decisions and appeals Section 4.1: Overview of coverage decisions and appeals Section 4.2: Section 4.3: Getting help with coverage decisions and appeals Which section of this chapter will help yo? Problems abot services, items, and drgs (not Part D drgs) Section 5.1: When to se this section Section 5.2: Section 5.3: Section 5.4: Section 5.5: Asking for a coverage decision Level 1 Appeal for services, items, and drgs (not Part D drgs) Level 2 Appeal for services, items, and drgs (not Part D drgs) Payment problems

142 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Section 6: Part D drgs Section 6.1: What to do if yo have problems getting a Part D drg or yo want s to pay yo back for a Part D drg Section 6.2: Section 6.3: Section 6.4: Section 6.5: Section 6.6: What is an exception? Important things to know abot asking for exceptions How to ask for a coverage decision abot a Part D drg or reimbrsement for a Part D drg, inclding an exception Level 1 Appeal for Part D drgs Level 2 Appeal for Part D drgs Section 7: Section 8: Asking s to cover a longer hospital stay Section 7.1: Learning abot yor Medicare rights Section 7.2: Section 7.3: Section 7.4: Level 1 Appeal to change yor hospital discharge date Level 2 Appeal to change yor hospital discharge date What happens if I miss an appeal deadline? What to do if yo think yor home health care, skilled nrsing care, or Comprehensive Otpatient Rehabilitation Facility (CORF) services are ending too soon Section 8.1: We will tell yo in advance when yor coverage will be ending Section 8.2: Section 8.3: Section 8.4: Level 1 Appeal to contine yor care Level 2 Appeal to contine yor care What if yo miss the deadline for making yor Level 1 Appeal? Section 9: Taking yor appeal beyond Level Section 9.1: Next steps for Medicare services and items Section 9.2: Next steps for Medicaid services and items

143 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Section 10: How to make a complaint Section 10.1: Internal complaints Section 10.2: External complaints

144 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Section 1: Introdction Section 1.1: What to do if yo have a problem This chapter tells yo what to do if yo have a problem with yor plan or with yor services or payment. Medicare and Medicaid approved these processes. Each process has a set of rles, procedres, and deadlines that mst be followed by s and by yo. Section 1.2: What abot the legal terms? There are difficlt legal terms for some of the rles and deadlines in this chapter. Many of these terms can be hard to nderstand, so we have sed simpler words in place of certain legal terms. We se abbreviations as little as possible. For example, we will say: Making a complaint rather than filing a grievance Coverage decision rather than organization determination or coverage determination Fast coverage decision rather than expedited determination Knowing the proper legal terms may help yo commnicate more clearly, so we provide those too. 142

145 Section 2: Where to call for help Section 2.1: Where to get more information and help Ble Cross Commnity MMAI MEMBER HANDBOOK Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Sometimes it can be confsing to start or follow the process for dealing with a problem. This can be especially tre if yo do not feel well or have limited energy. Other times, yo may not have the knowledge yo need to take the next step. Yo can get help from the Senior HelpLine If yo need help, yo can always call the Senior HelpLine. The Senior HelpLine can answer yor qestions and help yo nderstand what to do to handle yor problem. The Senior HelpLine is not connected with s or with any insrance company or health plan. They can help yo nderstand which process to se. The phone nmber for the Senior HelpLine is , TTY: Yo can call the Senior Help Line Monday throgh Friday from 8:30 a.m. to 5:00 p.m. The call and help are free and are available to yo no matter how old yo are. Yo can get help from the Senior Health Insrance Program (SHIP) Yo can also call the Senior Health Insrance Program (SHIP). SHIP conselors can answer yor qestions and help yo nderstand what to do to handle yor problem. SHIP conselors can help yo no matter how old yo are. The SHIP is not connected with s or with any insrance company or health plan. The SHIP phone nmber is , TTY: The call and help are free. Getting help from Medicare Yo can call Medicare directly for help with problems. Here are two ways to get help from Medicare: Call MEDICARE ( ), 24 hors a day, 7 days a week. TTY: The call is free. Visit the Medicare website ( Getting help from Medicaid Yo can call the State of Illinois directly for help with problems. Call the Illinois Department of Healthcare and Family Services Health Benefits Hotline at , TTY Monday throgh Friday from 8:00 a.m. to 4:45 p.m. The call is free. Yo can also call the Qality Improvement Organization (QIO). In Illinois, this is Telligen QIO, at , TTY/TDD: 711. This is a grop of doctors and other health care providers who help improve the qality of care for people with Medicare. It is not connected with or plan. 143

146 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Section 3: Problems with yor benefits Section 3.1: Shold yo se the process for coverage decisions and appeals? Or do yo want to make a complaint? If yo have a problem or concern, yo only need to read the parts of this chapter that apply to yor sitation. The chart below will help yo find the right section of this chapter for problems or complaints. Is yor problem or concern abot yor benefits or coverage? (This incldes problems abot whether particlar medical care or prescription drgs are covered or not, the way in which they are covered, and problems related to payment for medical care or prescription drgs.) Yes. My problem is abot benefits or coverage. Go to Section 4: Coverage decisions and appeals on page 145. No. My problem is not abot benefits or coverage. Skip ahead to Section 10: How to make a complaint on page

147 Section 4: Coverage decisions and appeals Section 4.1: Overview of coverage decisions and appeals Ble Cross Commnity MMAI MEMBER HANDBOOK Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) The process for asking for coverage decisions and making appeals deals with problems related to yor benefits and coverage. It also incldes problems with payment. What is a coverage decision? A coverage decision is an initial decision we make abot yor benefits and coverage or abot the amont we will pay for yor medical services, items, or drgs. We are making a coverage decision whenever we decide what is covered for yo and how mch we pay. If yo or yor doctor are not sre if a service, item, or drg is covered by Medicare or Medicaid, either of yo can ask for a coverage decision before the doctor gives the service, item, or drg. What is an appeal? An appeal is a formal way of asking s to review or decision and change it if yo think we made a mistake. For example, we might decide that a service, item, or drg that yo want is not covered or is no longer covered by Medicare or Medicaid. If yo or yor doctor disagree with or decision, yo can appeal. Section 4.2: Getting help with coverage decisions and appeals Who can I call for help asking for coverage decisions or making an appeal? Yo can ask any of these people for help: Call Member Services at Call the Illinois Health Benefits Hotline for free help Monday throgh Friday from 8:00 a.m. to 4:45 p.m. The Illinois Health Benefits Hotline helps people enrolled in Medicaid with problems. The phone nmber is , TTY: Call the Senior HelpLine for free help Monday throgh Friday from 8:30 a.m. to 5:00 p.m. The Senior Helpline will help anyone at any age enrolled in this plan. The Senior HelpLine is an independent organization. It is not connected with this plan. The phone nmber is , TTY: Talk to yor doctor or other provider. Yor doctor or other provider can ask for a coverage decision or appeal on yor behalf. If yo want yor doctor or other provider to be yor representative, call Member Services and ask for the Appointment of Representative form. Yo can also get the form on the Medicare Website at The form gives the person permission to act for yo. Yo mst give s a copy of the signed form. 145

148 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Note that nder the Medicare program, yor doctor or other provider can file an appeal withot the Appointment of Representative form. Talk to a friend or family member and ask him or her to act for yo. Yo can name another person to act for yo as yor representative to ask for a coverage decision or make an appeal. If yo want a friend, relative, or other person to be yor representative, call Member Services and ask for the Appointment of Representative form. Yo can also get the form on the Medicare website at The form gives the person permission to act for yo. Yo mst give s a copy of the signed form. Yo also have the right to ask a lawyer to act for yo. Yo may call yor own lawyer, or get the name of a lawyer from the local bar association or other referral service. Some legal grops will give yo free legal services if yo qalify. If yo want a lawyer to represent yo, yo will need to fill ot the Appointment of Representative form. However, yo do not have to have a lawyer to ask for any kind of coverage decision or to make an appeal. Section 4.3: Which section of this chapter will help yo? There are for different types of sitations that involve coverage decisions and appeals. Each sitation has different rles and deadlines. We separate this chapter into different sections to help yo find the rles yo need to follow. Yo only need to read the section that applies to yor problem: Section 5 on page 148 gives yo information if yo have problems abot services, items, and drgs (bt not Part D drgs). For example, se this section if: Yo are not getting medical care yo want, and yo believe or plan covers this care. We did not approve services, items, or drgs that yor doctor wants to give yo, and yo believe this care shold be covered. NOTE: Only se Section 5 if these are drgs not covered by Part D. Drgs in the List of Covered Drgs with a MC are not covered by Part D. See Section 6 on page 160 for Part D drg appeals. Yo got medical care or services yo think shold be covered, bt we are not paying for this care. Yo got and paid for medical services or items yo thoght were covered, and yo want to ask s to pay yo back. Yo are being told that coverage for care yo have been getting will be redced or stopped, and yo disagree with or decision. 146

149 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) NOTE: If the coverage that will be stopped is for hospital care, home health care, skilled nrsing facility care, or Comprehensive Otpatient Rehabilitation Facility (CORF) services, yo need to read a separate section of this chapter becase special rles apply to these types of care. See Sections 7 and 8 on pages 170 and 176. Section 6 on page 160 gives yo information abot Part D drgs. For example, se this section if: Yo want to ask s to make an exception to cover a Part D drg that is not on or List of Covered Drgs (Drg List). Yo want to ask s to waive limits on the amont of the drg yo can get. Yo want to ask s to cover a drg that reqires prior approval. We did not approve yor reqest or exception, and yo or yor doctor or other prescriber thinks we shold have. Yo want to ask s to pay for a prescription drg yo already boght. (This is asking for a coverage decision abot payment.) Section 7 on page 170 gives yo information on how to ask s to cover a longer inpatient hospital stay if yo think the doctor is discharging yo too soon. Use this section if: Yo are in the hospital and think the doctor asked yo to leave the hospital too soon. Section 8 on page 176 gives yo information if yo think yor home health care, skilled nrsing facility care, and Comprehensive Otpatient Rehabilitation Facility (CORF) services are ending too soon. If yo re not sre which section yo shold se, please call Member Services at If yo need other help or information, please call the Senior HelpLine at (TTY: ), Monday throgh Friday from 8:30 a.m. to 5:00 p.m. The call and help are free. 147

150 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Section 5: Problems abot services, items, and drgs (not Part D drgs) Section 5.1: When to se this section This section is abot what to do if yo have problems with yor benefits for yor medical, behavioral health, and long term care services. Yo can also se this section for problems with drgs that are not covered by Part D. Drgs in the List of Covered Drgs with an MC are not covered by Part D. Use Section 6 for Part D drg appeals. This section tells what yo can do if yo are in any of the five following sitations: 1. Yo think we cover a medical, behavioral health or long term care service yo need bt are not getting. What yo can do: Yo can ask s to make a coverage decision. Go to Section 5.2 on page 149 for information on asking for a coverage decision. 2. We did not approve care yor doctor wants to give yo, and yo think we shold have. What yo can do: Yo can appeal or decision to not approve the care. Go to Section 5.3 on page 150 for information on making an appeal. 3. Yo got services or items that yo think we cover, bt we will not pay. What yo can do: Yo can appeal or decision not to pay. Go to Section 5.3 on page 150 for information on making an appeal. 4. Yo got and paid for services or items yo thoght were covered, and yo want s to reimbrse yo for the services or items. What yo can do: Yo can ask s to pay yo back. Go to Section 5.5 on page 158 for information on asking s for payment. 5. We redced or stopped yor coverage for a certain service, and yo disagree with or decision. What yo can do: Yo can appeal or decision to redce or stop the service. Go to Section 5.3 on page 150 for information on making an appeal. NOTE: If the coverage that will be stopped is for hospital care, home health care, skilled nrsing facility care, or Comprehensive Otpatient Rehabilitation Facility (CORF) services, special rles apply. Read Sections 7 and 8 on pages 170 and 176 to find ot more. 148

151 Section 5.2: Asking for a coverage decision Ble Cross Commnity MMAI MEMBER HANDBOOK Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) How to ask for a coverage decision to get a medical, behavioral health or long-term care service To ask for a coverage decision, call, write, or fax s, or ask yor representative or doctor to ask s for a decision. Yo can call s at: TTY: 711. Yo can fax s at: Yo can write to s at: PO Box , Chicago, IL How long does it take to get a coverage decision? It sally takes p to 14 calendar days after yo asked. If we don t give yo or decision within 14 calendar days, yo can appeal. Sometimes we need more time, and we will send yo a letter telling yo that we need to take p to 14 more calendar days. The letter will explain why more time is needed. Can I get a coverage decision faster? Yes. If yo need a response faster becase of yor health, ask s to make a fast coverage decision. If we approve the reqest, we will notify yo of or decision within 72 hors. However, sometimes we need more time, and we will send yo a letter telling yo that we need to take p to 14 more calendar days. The letter will explain why more time is needed. The legal term for fast coverage decision is expedited determination. Asking for a fast coverage decision: If yo reqest a fast coverage decision, start by calling or faxing or plan to ask s to cover the care yo want. Yo can call s at or fax s at For details on how to contact s, go to Chapter 2 on page 13. Yo can also have yor doctor or yor representative call s. Here are the rles for asking for a fast coverage decision: Yo mst meet the following two reqirements to get a fast coverage decision: 1. Yo can get a fast coverage decision only if yo are asking for coverage for medical care or an item yo have not yet received. (Yo cannot get a fast coverage decision if yor reqest is abot payment for medical care or an item yo already got.) 149

152 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) 2. Yo can get a fast coverage decision only if the standard 14 calendar day deadline cold case serios harm to yor health or hrt yor ability to fnction. If yor doctor says that yo need a fast coverage decision, we will atomatically give yo one. If yo ask for a fast coverage decision withot yor doctor s spport, we will decide if yo get a fast coverage decision. If we decide that yor health does not meet the reqirements for a fast coverage decision, we will send yo a letter. We will also se the standard 14 calendar day deadline instead. This letter will tell yo that if yor doctor asks for the fast coverage decision, we will atomatically give a fast coverage decision. The letter will also tell how yo can file a fast complaint abot or decision to give yo a standard coverage decision instead of a fast coverage decision. For more information abot the process for making complaints, inclding fast complaints, see Section 10 on page 183. If the coverage decision is Yes, when will I get the service or item? Yo will be approved (pre-athorized) to get the service or item within 14 calendar days (for a standard coverage decision) or 72 hors (for a fast coverage decision) of when yo asked. If we extended the time needed to make or coverage decision, we will approve the coverage by the end of that extended period. If the coverage decision is No, how will I find ot? If the answer is No, we will send yo a letter telling yo or reasons for saying No. If we say No, yo have the right to ask s to change this decision by making an appeal. Making an appeal means asking s to review or decision to deny coverage. If yo decide to make an appeal, it means yo are going on to Level 1 of the appeals process (read the next section for more information). Section 5.3: Level 1 Appeal for services, items, and drgs (not Part D drgs) What is an appeal? An appeal is a formal way of asking s to review or decision and change it if yo think we made a mistake. If yo or yor doctor or other provider disagrees with or decision, yo can appeal. In all cases, yo mst start yor appeal at Level

153 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) If yo need help dring the appeals process, yo can call the Senior HelpLine at (TTY: ), Monday throgh Friday from 8:30 a.m. to 5:00 p.m. The Senior HelpLine is not connected with s or with any insrance company or health plan. The call and help are free. What is a Level 1 Appeal? A Level 1 Appeal is the first appeal to or plan. We will review yor coverage decision to see if it is correct. The reviewer will be someone who did not make the original coverage decision. When we complete the review, we will give yo or decision in writing. If we tell yo after or review that the service or item is not covered, yor case can go to a Level 2 Appeal. How do I make a Level 1 Appeal? To start yor appeal, yo, yor doctor or other provider, or yor representative mst contact s. Yo can call s at For additional details on how to reach s for appeals, see Chapter 2 on page 13. Yo can ask s for a standard appeal or a fast appeal. If yo are asking for a standard appeal or fast appeal, make yor appeal in writing or call s. Yo can sbmit a reqest to the following address: P.O. Box 27838, Albqerqe, NM The legal term for fast appeal is expedited reconsideration. At a glance: How to make a Level 1 Appeal Yo, yor doctor, or yor representative may pt yor reqest in writing and mail or fax it to s. Yo may also ask for an appeal by calling s. Ask within 60 calendar days of the decision yo are appealing. If yo miss the deadline for a good reason, yo may still appeal. If yo appeal becase we told yo that a Medicaid service yo crrently get will be changed or stopped, yo have 10 calendar days to appeal if yo want to keep getting that Medicaid service while yor appeal is processing. Keep reading this section to learn abot what deadline applies to yor appeal. Can someone else make the appeal for me? Yes. Yor doctor, other provider, or someone else can make the appeal for yo, bt first yo mst complete an Appointment of Representative form. The form gives the other person permission to act for yo. 151

154 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) To get an Appointment of Representative form, call Member Services and ask for one, or visit the Medicare website at cms1696.pdf If the appeal comes from someone besides yo, we sally mst get the completed Appointment of Representative form before we can review the appeal. Note that nder the Medicare program, yor doctor or other provider can file an appeal withot the Appointment of Representative form. How mch time do I have to make an appeal? Yo mst ask for an appeal within 60 calendar days from the date on the letter we sent to tell yo or decision. If yo miss this deadline and have a good reason for missing it, we may give yo more time to make yor appeal. Examples of a good reason are: yo had a serios illness, or we gave yo the wrong information abot the deadline for reqesting an appeal. NOTE: If yo appeal becase we told yo that a Medicaid service yo crrently get will be changed or stopped, yo have 10 calendar days to appeal if yo want to keep getting that Medicaid service while yor appeal is processing. Read Will my benefits contine dring Level 1 Appeals on page 154 for more information. Can I get a copy of my case file? Yes. Ask s for a copy by calling Member Services at Can my doctor give yo more information abot my appeal? Yes, yo and yor doctor may give s more information to spport yor appeal. How will we make the appeal decision? We take a carefl look at all of the information abot yor reqest for coverage of medical care. Then, we check to see if we were following all the rles when we said No to yor reqest. The reviewer will be someone who did not make the original decision. If we need more information, we may ask yo or yor doctor for it. When will I hear abot a standard appeal decision? We mst give yo or answer within 15 bsiness days after we get yor appeal. We will give yo or decision sooner if yor health condition reqires s to. 152

155 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) However, if yo ask for more time or if we need to gather more information, we can take p to 14 more calendar days. If we decide to take extra days to make the decision, we will send yo a letter that explains why we need more time. If yo believe we shold not take extra days, yo can file a fast complaint abot or decision to take extra days. When yo file a fast complaint, we will give yo an answer to yor complaint within 24 hors. For more information abot the process for making complaints, inclding fast complaints, see Section 10 on page 183. If we do not give yo an answer to yor appeal within 15 bsiness days or by the end of the extra days (if we took them), we will atomatically send yor case to Level 2 of the appeals process if yor problem is abot a service or item covered by Medicare or both Medicare and Medicaid. Yo will be notified when this happens. If yor problem is abot a service or item covered only by Medicaid, yo can file a Level 2 Appeal yorself. For more information abot the Level 2 Appeal process, go to Section 5.4 on page 154. If or answer is Yes to part or all of what yo asked for, we mst approve or give the coverage within 72 hors after we give yo or answer. If or answer is No to part or all of what yo asked for, we will send yo a letter. If yor problem is abot a service or item covered by Medicare or both Medicare and Medicaid, the letter will tell yo that we sent yor case to the Independent Review Entity for a Level 2 Appeal. If yor problem is abot a service or item covered only by Medicaid, the letter will tell yo how to file a Level 2 Appeal yorself. For more information abot the Level 2 Appeal process, go to Section 5.4 on page 154. When will I hear abot a fast appeal decision? If yo ask for a fast appeal, we will let yo know within 24 hors after we get yor reqest if we need more information to decide yor appeal. We will make a decision on yor fast appeal within 24 hors after receiving all of the reqired information from yo. However, if yo ask for more time or if we need to gather more information, we can take p to 14 more calendar days. If we decide to take extra days to make the decision, we will send yo a letter that explains why we need more time. If yo believe we shold not take extra days, yo can file a fast complaint abot or decision to take extra days. When yo file a fast complaint, we will give yo an answer to yor complaint within 24 hors. For more information abot the process for making complaints, inclding fast complaints, see Section 10 on page

156 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) If we do not give yo an answer to yor appeal within 24 hors after receiving all reqired information or by the end of the extra days (if we took them), we will atomatically send yor case to Level 2 of the appeals process if yor problem is abot a service or item covered by Medicare or both Medicare and Medicaid. Yo will be notified when this happens. If yor problem is abot a service or item covered only by Medicaid, yo can file a Level 2 Appeal yorself. For more information abot the Level 2 Appeal process, go to Section 5.4 on page 154. If or answer is Yes to part or all of what yo asked for, we mst athorize or provide the coverage within 72 hors after we make or decision. If or answer is No to part or all of what yo asked for, we will send yo a letter. If yor problem is abot a service or item covered by Medicare or both Medicare and Medicaid, the letter will tell yo that we sent yor case to the Independent Review Entity for a Level 2 Appeal. If yor problem is abot a service or item covered only by Medicaid, the letter will tell yo how to file a Level 2 Appeal yorself. For more information abot the Level 2 Appeal process, go to Section 5.4 on page 154. Will my benefits contine dring Level 1 Appeals? If yor problem is abot a service covered by Medicare or both Medicare and Medicaid, yor benefits for that service will contine dring the Level 1 Appeal process. If yor problem is abot a service covered only by Medicaid, yor benefits for that service will not contine nless yo ask the plan to contine yor benefits when yo appeal. Yo mst sbmit yor appeal and asks to contine benefits within 10 calendar days after yo receive the Notice of Denial of Medical Coverage. If yo lose the appeal, yo may have to pay for the service. Section 5.4: Level 2 Appeal for services, items, and drgs (not Part D drgs) If the plan says No at Level 1, what happens next? If we say No to part or all of yor Level 1 Appeal, we will send yo a letter. This letter will tell yo if the service or item is sally covered by Medicare and/or Medicaid. If yor problem is abot a Medicare service or item, yo will atomatically get a Level 2 Appeal with the Independent Review Entity (IRE) as soon as the Level 1 Appeal is complete. If yor problem is abot a Medicaid service or item, yo can file a Level 2 Appeal yorself with the State Fair Hearings office. The letter will tell yo how to do this. Information is also below. If yor problem is abot a service or item that cold be covered by both Medicare and Medicaid, yo will atomatically get a Level 2 Appeal with the IRE. If they also say No to yor appeal, yo can ask for another Level 2 Appeal with the State Fair Hearings office. 154

157 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) What is a Level 2 Appeal? A Level 2 Appeal is the second appeal, which is done by an independent organization that is not connected to the plan. It is either an Independent Review Entity (IRE) or it is a Medicaid State Fair Hearings office. My problem is abot a Medicaid service or item. How can I make a Level 2 Appeal? Level 2 of the appeals process for Medicaid services is a State Fair Hearing. Yo mst ask for a State Fair Hearing in writing or over the phone within 30 calendar days of receiving or decision letter on yor Level 1 Appeal. The letter yo get from s will tell yo where to sbmit yor hearing reqest. If yo want to ask for a State Fair Hearing abot a standard Medicaid item or service, the Aging Waiver (Commnity Care Program, or CCP), or the Spportive Living Facilities Waiver, sbmit yor appeal in writing or over the phone to: MAIL Illinois Healthcare and Family Services Brea of Administrative Hearings Fair Hearings Section 69 West Washington, 4th Floor Chicago, Illinois CALL (toll free) TTY FAX HFS.FairHearings@illinois.gov If yo want to ask for a State Fair Hearing abot the Persons with Disabilities Waiver, Tramatic Brain Injry Waiver, or the HIV/AIDS Waiver (Home Services Program, or HSP), sbmit yor appeal in writing or over the phone to: MAIL Department of Hman Services Brea of Hearings 69 West Washington, 4th Floor Chicago, Illinois CALL (toll free) TTY FAX DHS.BAHNewAppeal@illinois.gov The hearing will be handled by an Impartial Hearing Officer athorized to oversee State Fair Hearings. Yo will get a letter from the Hearings office telling yo the date, time, and place of the hearing. This letter will also provide detailed information abot the hearing. It is important that yo read this letter 155

158 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) careflly. At least three bsiness days before the hearing, yo will get a packet of information from or plan. This packet will inclde all the evidence we will present at the hearing. This packet will also be sent to the Impartial Hearing Officer. Yo will need to tell the Hearings office of any reasonable accommodations yo may need. If becase of yor disability yo cannot participate in person at the local office, yo may ask to participate by phone. Please provide the Hearings staff with the phone nmber to best reach yo. Yo mst provide all the evidence yo will present at the hearing to the Impartial Hearing Officer at least three days before the hearing. This incldes a list of any witnesses who will appear, as well as all docments yo will se. The hearing will be recorded. My problem is abot a service or item that is covered by Medicare or both Medicare and Medicaid. What will happen at the Level 2 Appeal? If we say No to yor Appeal at Level 1 and the service or item is sally covered by Medicare or both Medicare and Medicaid, yo will atomatically get a Level 2 Appeal from the Independent Review Entity (IRE). The IRE will careflly review the Level 1 decision and decide whether it shold be changed. Yo do not need to reqest the Level 2 Appeal. We will atomatically send any denials (in whole or in part) to the IRE. Yo will be notified when this happens. The IRE is hired by Medicare and is not connected with this plan. Yo may ask for a copy of yor file by calling Member Services at (TTY/TDD: 711), we are available seven (7) days a week. Or call center is open Monday-Friday 8:00 a.m.-8:00 p.m. Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day. The IRE mst give yo an answer to yor Level 2 Appeal within 30 calendar days of when it gets yor appeal. This rle applies if yo sent yor appeal before getting medical services or items. If However, if the IRE needs to gather more information that may benefit yo, it can take p to 14 more calendar days. If the IRE needs extra days to make a decision, it will tell yo by letter. yo had fast appeal at Level 1, yo will atomatically have a fast appeal at Level 2. The IRE mst give yo an answer within 72 hors of when it gets yor appeal. However, if the IRE needs to gather more information that may benefit yo, it can take p to 14 more calendar days. If the IRE needs extra days to make a decision, it will tell yo by letter. 156

159 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) How will I find ot abot the decision? If yor Level 2 Appeal was a State Fair Hearing, the State Fair Hearings office will send yo a letter explaining its decision. This letter is called a Final Administrative Decision. If the State Fair Hearings office says Yes to part or all of what yo asked for, we mst athorize or provide the medical care coverage as soon as yor health reqires. If the State Fair Hearings office says No to part or all of what yo asked for, it means they agree with the Level 1 decision. This is called pholding the decision. It is also called trning down yor appeal. If yor Level 2 Appeal went to the Independent Review Entity (IRE), it will send yo a letter explaining its decision. If the IRE says Yes to part or all of what yo asked for in yor standard appeal, we mst athorize the medical care coverage within 72 hors or give yo the service or item within 14 calendar days from the date we get the IRE s decision. If yo had a fast appeal, we mst athorize the medical care coverage or give yo the service or item within 72 hors from the date we get the IRE s decision. If the IRE says No to part or all of what yo asked for, it means they agree with the Level 1 decision. This is called pholding the decision. It is also called trning down yor appeal. If the decision is No for all or part of what I asked for, can I make another appeal? If yor Level 2 Appeal went to the State Fair Hearings office, and yo disagree with the decision, yo cannot make another appeal on the same isse to the State Fair Hearings office. The decision is reviewable only throgh the Circit corts of the State of Illinois. If yor Level 2 Appeal went to the Independent Review Entity (IRE), yo may be able to appeal again in certain sitations: If yor problem is abot a service or item that is covered by both Medicare and Medicaid, yo can ask for another Level 2 Appeal with the State Fair Hearings office. After the IRE makes its decision, we will send yo a letter telling yo abot yor right to ask for a State Fair Hearing. Go to page 155 for information on the State Fair Hearing process. If yor problem is abot a service or item that is covered by Medicare or both Medicare and Medicaid, yo can appeal after Level 2 only if the dollar vale of the service or item yo want meets a certain minimm amont. The letter yo get from the IRE will explain additional appeal rights yo may have. 157

160 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) See Section 9 on page 182 for more information on yor appeal rights after Level 2. Will my benefits contine dring Level 2 appeals? Maybe. If yor problem is abot a service covered by Medicare only, yor benefits for that service will not contine dring the Level 2 appeals process with the IRE. If yor problem is abot a service covered by Medicaid only, yor benefits for that service will contine if yo sbmit a Level 2 Appeal within 10 calendar days after receiving the plan s decision letter. If yor problem is abot a service covered by both Medicare and Medicaid, yor benefits for that service will contine dring the Level 2 appeal process with the IRE. If yo sbmit the appeal to the State Fair Hearings office after the IRE makes its decision, yor benefits will contine if yo file yor appeal within 10 calendar days of the notice from the IRE. Section 5.5: Payment problems We do not allow or network providers to bill yo for covered services and items. This is tre even if we pay the provider less than the provider charges for a covered service or item. If a provider bills yo for any charges that we did not pay, that is called balance billing. Yo are never reqired to pay the balance of any bill. If yo get a bill for covered services and items, send the bill to s. Yo shold not pay the bill yorself. We will contact the provider directly and take care of the problem. For more information, start by reading Chapter 7: Asking s to pay a bill yo have gotten for covered services or drgs. Chapter 7 describes the sitations in which yo may need to ask for reimbrsement or to pay a bill yo got from a provider. It also tells how to send s the paperwork that asks s for payment. Can I ask yo to pay me back for a service or item I paid for? Remember, if yo get a bill for covered services and items, yo shold not pay the bill yorself. Bt if yo do pay the bill, yo can get a refnd if yo followed the rles for getting services and items. If yo are asking to be paid back, yo are asking for a coverage decision. We will see if the service or item yo paid for is a covered service or item, and we will check to see if yo followed all the rles for sing yor coverage. If the service or item yo paid for is covered and yo followed all the rles, we will send yo the payment for the service or item within 60 calendar days after we get yor reqest. Or, if yo haven t paid for the service or item yet, we will send the payment directly to the provider. When we send the payment, it s the same as saying Yes to yor reqest for a coverage decision. If the service or item is not covered, or yo did not follow all the rles, we will send yo a letter telling yo we will not pay for the service or item, and explaining why. 158

161 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) What if we say we will not pay? If yo do not agree with or decision, yo can make an appeal. Follow the appeals process described in Section 5.3 on page 150. When yo are following these instrctions, please note: If yo make an appeal for reimbrsement, we mst give yo or answer within 60 calendar days after we get yor appeal. If yo are asking s to pay yo back for a service or item yo already got and paid for yorself, yo cannot ask for a fast appeal. If we answer No to yor appeal and the service or item is sally covered by Medicare or both Medicare and Medicaid, we will atomatically send yor case to the Independent Review Entity (IRE). We will notify yo by letter if this happens. If the IRE reverses or decision and says we shold pay yo, we mst send the payment to yo or to the provider within 30 calendar days. If the answer to yor appeal is Yes at any stage of the appeals process after Level 2, we mst send the payment yo asked for to yo or to the provider within 60 calendar days. If the IRE says No to yor appeal, it means they agree with or decision not to approve yor reqest. (This is called pholding the decision. It is also called trning down yor appeal. ) The letter yo get will explain additional appeal rights yo may have. If we answer No to yor appeal and the service or item is sally covered by Medicaid only, yo can file a Level 2 Appeal yorself (see Section 5.4 on page 154). 159

162 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Section 6: Part D drgs Section 6.1: What to do if yo have problems getting a Part D drg or yo want s to pay yo back for a Part D drg Yor benefits as a member of or plan inclde coverage for many prescription drgs. Most of these drgs are Part D drgs. There are a few drgs that Medicare Part D does not cover bt that Medicaid may cover. This section only applies to Part D drg appeals. The List of Covered Drgs (Drg List), incldes some drgs with an MC. These drgs are not Part D drgs. Appeals or coverage decisions abot drgs with MC symbol follow the process in Section 5 on page 148. Can I ask for a coverage decision or make an appeal abot Part D prescription drgs? Yes. Here are examples of coverage decisions yo can ask s to make abot yor Part D drgs: Yo ask s to make an exception sch as: Asking s to cover a Part D drg that is not on the plan s List of Covered Drgs (Drg List) Asking s to waive a restriction on the plan s coverage for a drg (sch as limits on the amont of the drg yo can get). Yo ask s if a drg is covered for yo (for example, when yor drg is on the plan s Drg List bt we reqire yo to get approval from s before we will cover it for yo). Note: If yor pharmacy tells yo that yor prescription cannot be filled, yo will get a notice explaining how to contact s to ask for a coverage decision. Yo ask s to pay for a prescription drg yo already boght. This is asking for a coverage decision abot payment. The legal term for a coverage decision abot yor Part D drgs is coverage determination. If yo disagree with a coverage decision we have made, yo can appeal or decision. This section tells yo how to ask for coverage decisions and how to reqest an appeal. Use the chart below to help yo decide which section has information for yor sitation: 160

163 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Which of these sitations are yo in? Do yo need a drg that isn t on or Drg List or need s to waive a rle or restriction on a drg we cover? Yo can ask s to make an exception. (This is a type of coverage decision.) Start with Section 6.2 on page 161. Also see Sections 6.3 and 6.4 on pages 162 and 163. Do yo want s to cover a drg on or Drg List and yo believe yo meet any plan rles or restrictions (sch as getting approval in advance) for the drg yo need? Yo can ask s for a coverage decision. Skip ahead to Section 6.4 on page 163. Do yo want to ask s to pay yo back for a drg yo already got and paid for? Yo can ask s to pay yo back. (This is a type of coverage decision.) Skip ahead to Section 6.4 on page 163. Have we already told yo that we will not cover or pay for a drg in the way that yo want it to be covered or paid for? Yo can make an appeal. (This means yo are asking s to reconsider.) Skip ahead to Section 6.5 on page 166. Section 6.2: What is an exception? An exception is permission to get coverage for a drg that is not normally on or List of Covered Drgs or to se the drg withot certain rles and limitations. If a drg is not on or List of Covered Drgs or is not covered in the way yo wold like, yo can ask s to make an exception. When yo ask for an exception, yor doctor or other prescriber will need to explain the medical reasons why yo need the exception. Here are examples of exceptions that yo or yor doctor or another prescriber can ask s to make: 1. Covering a Part D drg that is not on or List of Covered Drgs (Drg List). 2. Removing a restriction on or coverage. There are extra rles or restrictions that apply to certain drgs on or Drg List (for more information, go to Chapter 5, Section C. The extra rles and restrictions on coverage for certain drgs inclde: Being reqired to se the generic version of a drg instead of the brand name drg. Getting plan approval before we will agree to cover the drg for yo. (This is sometimes called prior athorization. ) Being reqired to try a different drg first before we will agree to cover the drg yo are asking for. (This is sometimes called step therapy. ) 161

164 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Qantity limits. For some drgs, we limit the amont of the drg yo can have. The legal term for asking for removal of a restriction on coverage for a drg is sometimes called asking for a formlary exception. Section 6.3: Important things to know abot asking for exceptions Yor doctor or other prescriber mst tell s the medical reasons Yor doctor or other prescriber mst give s a statement explaining the medical reasons for reqesting an exception. Or decision abot the exception will be faster if yo inclde this information from yor doctor or other prescriber when yo ask for the exception. Typically, or Drg List incldes more than one drg for treating a particlar condition. These are called alternative drgs. If an alternative drg wold be jst as effective as the drg yo are asking for and wold not case more side effects or other health problems, we will generally not approve yor reqest for an exception. We will say Yes or No to yor reqest for an exception If we say Yes to yor reqest for an exception, the exception sally lasts ntil the end of the calendar year. This is tre as long as yor doctor contines to prescribe the drg for yo and that drg contines to be safe and effective for treating yor condition. If we say No to yor reqest for an exception, yo can ask for a review of or decision by making an appeal. Section 6.5 (page 166) tells how to make an appeal if we say No. The next section tells yo how to ask for a coverage decision, inclding an exception. 162

165 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) SECTION 6.4: HOW TO ASK FOR A COVERAGE DECISION ABOUT A PART D DRUG OR REIMBURSEMENT FOR A PART D DRUG, INCLUDING AN EXCEPTION What to do Ask for the type of coverage decision yo want. Call, write, or fax s to make yor reqest. Yo, yor representative, or yor doctor (or other prescriber) can do this. Yo can call s at Yo or yor doctor (or other prescriber) or someone else who is acting on yor behalf can ask for a coverage decision. Yo can also have a lawyer act on yor behalf. Read Section 4 on page 145 to find ot how to give permission to someone else to act as yor representative. Yo do not need to give yor doctor or other prescriber written permission to ask s for a coverage decision on yor behalf. If yo want to ask s to pay yo back for a drg, read Chapter 7 of this handbook. Chapter 7 describes times when yo may need to ask for reimbrsement. It also tells how to send s the paperwork that asks s to pay yo back for or share of the cost of a drg yo have paid for. At a glance: How to ask for a coverage decision abot a drg or payment Call, write, or fax s to ask, or ask yor representative or doctor or other prescriber to ask. We will give yo an answer on a standard coverage decision within 72 hors. We will give yo an answer on reimbrsing yo for a Part D drg yo already paid for within 14 calendar days. If yo are asking for an exception, inclde the spporting statement from yor doctor or other prescriber. Yo or yor doctor or other prescriber may ask for a fast decision. (Fast decisions sally come within 24 hors.) Read this section to make sre yo qalify for a fast decision! Read it also to find information abot decision deadlines. If yo are asking for an exception, provide the spporting statement. Yor doctor or other prescriber mst give s the medical reasons for the drg exception. We call this the spporting statement. Yor doctor or other prescriber can fax or mail the statement to s. Or yor doctor or other prescriber can tell s on the phone, and then fax or mail a statement. If yor health reqires it, ask s to give yo a fast coverage decision We will se the standard deadlines nless we have agreed to se the fast deadlines. A standard coverage decision means we will give yo an answer within 72 hors after we get yor doctor s statement. 163

166 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) A fast coverage decision means we will give yo an answer within 24 hors after we get yor doctor s statement. Yo can get a fast coverage decision only if yo are asking for a drg yo have not yet received. (Yo cannot get a fast coverage decision if yo are asking s to pay yo back for a drg yo already boght.) Yo can get a fast coverage decision only if sing the standard deadlines cold case serios harm to yor health or hrt yor ability to fnction. If yor doctor or other prescriber tells s that yor health reqires a fast coverage decision, we will atomatically agree to give yo a fast coverage decision, and the letter will tell yo that. If yo ask for a fast coverage decision on yor own (withot yor doctor s or other prescriber s spport), we will decide whether yo get a fast coverage decision. If we decide that yor medical condition does not meet the reqirements for a fast coverage decision, we will se the standard deadlines instead. We will send yo a letter telling yo that. The letter will tell yo how to make a complaint abot or decision to give yo a standard decision. Yo can file a fast complaint and get a response to yor complaint within 24 hors. For more information abot the process for making complaints, inclding fast complaints, see Section 10 on page 183. The legal term for fast coverage decision is expedited coverage determination. Deadlines for a fast coverage decision If we are sing the fast deadlines, we mst give yo or answer within 24 hors. This means within 24 hors after we get yor reqest. Or, if yo are asking for an exception, 24 hors after we get yor doctor s or prescriber s statement spporting yor reqest. We will give yo or answer sooner if yor health reqires it. If we do not meet this deadline, we will send yor reqest to Level 2 of the appeals process. At Level 2, an Independent Review Entity will review yor reqest. If or answer is Yes to part or all of what yo asked for, we mst give yo the coverage within 24 hors after we get yor reqest or yor doctor s or prescriber s statement spporting yor reqest. If or answer is No to part or all of what yo asked for, we will send yo a letter that explains why we said No. The letter will also explain how yo can appeal or decision. 164

167 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Deadlines for a standard coverage decision abot a drg yo have not yet received If we are sing the standard deadlines, we mst give yo or answer within 72 hors after we get yor reqest. Or, if yo are asking for an exception, after we get yor doctor s or prescriber s spporting statement. We will give yo or answer sooner if yor health reqires it. If we do not meet this deadline, we will send yor reqest on to Level 2 of the appeals process. At Level 2, an Independent Review Entity will review yor reqest. If or answer is Yes to part or all of what yo asked for, we mst approve or give the coverage within 72 hors after we get yor reqest or, if yo are asking for an exception, yor doctor s or prescriber s spporting statement. If or answer is No to part or all of what yo asked for, we will send yo a letter that explains why we said No. The letter will also explain how yo can appeal or decision. Deadlines for a standard coverage decision abot payment for a drg yo already boght We mst give yo or answer within 14 calendar days after we get yor reqest. If we do not meet this deadline, we will send yor reqest to Level 2 of the appeals process. At level 2, an Independent Review Entity will review yor reqest. If or answer is Yes to part or all of what yo asked for, we will make payment to yo within 14 calendar days. If or answer is No to part or all of what yo asked for, we will send yo a letter that explains why we said No. The letter will also explain how yo can appeal or decision. 165

168 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Section 6.5: Level 1 Appeal for Part D drgs To start yor appeal, yo, yor doctor or other prescriber, or yor representative mst contact s. If yo are asking for a standard appeal, yo can make yor appeal by sending a reqest in writing. Yo may also ask for an appeal by calling s at If yo want a fast appeal, yo may make yor appeal in writing or yo may call s. Make yor appeal reqest within 60 calendar days from the date on the notice we sent to tell yo or decision. If yo miss this deadline and have a good reason for missing it, we may give yo more time to make yo appeal. For example, good reasons for missing the deadline wold be if yo have a serios illness that kept yo from contacting s or if we gave yo incorrect or incomplete information abot the deadline for reqesting an appeal. The legal term for an appeal to the plan abot a Part D drg coverage decision is plan redetermination. Yo have the right to ask s for a copy of the information abot yor appeal. To ask for a copy, call Member Services at If yo wish, yo and yor doctor or other prescriber may give s additional information to spport yor appeal. If yor health reqires it, ask for a fast appeal If yo are appealing a decision or plan made abot a drg yo have not yet received, yo and yor doctor or other prescriber will need to decide if yo need a fast appeal. The reqirements for getting a fast appeal are the same as those for getting a fast coverage decision in Section 6.4 on page 163. The legal term for fast appeal is expedited redetermination. At a glance: How to make a Level 1 Appeal Yo, yor doctor or prescriber, or yor representative may pt yor reqest in writing and mail or fax it to s. Yo may also ask for an appeal by calling s. Ask within 60 calendar days of the decision yo are appealing. If yo miss the deadline for a good reason, yo may still appeal. Yo, yor doctor or prescriber, or yor representative can call s to ask for a fast appeal. Read this chapter section to make sre yo qalify for a fast decision! Read it also to find information abot decision deadlines. 166

169 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Or plan will review yor appeal and give yo or decision We take another carefl look at all of the information abot yor coverage reqest. We check to see if we were following all the rles when we said No to yor reqest. We may contact yo or yor doctor or other prescriber to get more information. The reviewer will be someone who did not make the original coverage decision. Deadlines for a fast appeal If we are sing the fast deadlines, we will give yo or answer within 72 hors after we get yor appeal, or sooner if yor health reqires it. If we do not give yo an answer within 72 hors, we will send yor reqest to Level 2 of the appeals process. At Level 2, an Independent Review Entity will review yor appeal. If or answer is Yes to part or all of what yo asked for, we mst give the coverage within 72 hors after we get yor appeal. If or answer is No to part or all of what yo asked for, we will send yo a letter that explains why we said No. Deadlines for a standard appeal If we are sing the standard deadlines, we mst give yo or answer within 7 calendar days after we get yor appeal, or sooner if yor health reqires it. If yo think yor health reqires it, yo shold ask for a fast appeal. If we do not give yo a decision within 7 calendar days, we will send yor reqest to Level 2 of the appeals process. At Level 2, an Independent Review Entity will review yor appeal. If or answer is Yes to part or all of what yo asked for: If we approve a reqest for coverage, we mst give yo the coverage as qickly as yor health reqires, bt no later than 7 calendar days after we get yor appeal. If we approve a reqest to pay yo back for a drg yo already boght, we will send payment to yo within 30 calendar days after we get yor appeal reqest. If or answer is No to part or all of what yo asked for, we will send yo a letter that explains why we said No and tells how to appeal or decision. 167

170 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Section 6.6: Level 2 Appeal for Part D drgs If we say No to part or all of yor appeal, yo can choose whether to accept this decision or make another appeal. If yo decide to go on to a Level 2 Appeal, the Independent Review Entity (IRE) will review or decision. If yo want the IRE to review yor case, yor appeal reqest mst be in writing. The letter we send abot or decision in the Level 1 Appeal will explain how to reqest the Level 2 Appeal. When yo make an appeal to the IRE, we will send them yor case file. Yo have the right to ask s for a copy of yor case file by calling Member Services at (TTY/TDD 711). Yo have a right to give the IRE other information to spport yor appeal. The IRE is an independent organization that is hired by Medicare. It is not connected with this plan and it is not a government agency. Reviewers at the IRE will take a carefl look at all of the information related to yor appeal. The organization will send yo a letter explaining its decision. The legal term for an appeal to the IRE abot a Part D drg is reconsideration. Deadlines for fast appeal at Level 2 If yor health reqires it, ask the Independent Review Entity (IRE) for a fast appeal. If the IRE agrees to give yo a fast appeal, it mst give yo an answer to yor Level 2 Appeal within 72 hors after getting yor appeal reqest. At a glance: How to make a Level 2 Appeal If yo want the Independent Review Entity to review yor case, yor appeal reqest mst be in writing. Ask within 60 calendar days of the decision yo are appealing. If yo miss the deadline for a good reason, yo may still appeal. If the IRE says Yes to part or all of what yo asked for, we mst athorize or give yo the drg coverage within 24 hors after we get the decision. Yo, yor doctor or other prescriber, or yor representative can reqest the Level 2 Appeal. Read this section to make sre yo qalify for a fast decision! Read it also to find information abot decision deadlines. Deadlines for standard appeal at Level 2 If yo have a standard appeal at Level 2, the Independent Review Entity (IRE) mst give yo an answer to yor Level 2 Appeal within 7 calendar days after it gets yor appeal. If the IRE says Yes to part or all of what yo asked for, we mst athorize or give yo the drg coverage within 72 hors after we get the decision. 168

171 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) If the IRE approves a reqest to pay yo back for a drg yo already boght, we will send payment to yo within 30 calendar days after we get the decision. What if the Independent Review Entity says No to yor Level 2 Appeal? No means the Independent Review Entity (IRE) agrees with or decision not to approve yor reqest. This is called pholding the decision. It is also called trning down yor appeal. If yo want to go to Level 3 of the appeals process, the drgs yo are reqesting mst meet a minimm dollar vale. If the dollar vale is less than the minimm, yo cannot appeal any frther. If the dollar vale is high enogh, yo can ask for a Level 3 appeal. The letter yo get from the IRE will tell yo the dollar vale needed to contine with the appeal process. 169

172 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Section 7: Asking s to cover a longer hospital stay When yo are admitted to a hospital, yo have the right to get all hospital services that we cover that are necessary to diagnose and treat yor illness or injry. Dring yor covered hospital stay, yor doctor and the hospital staff will work with yo to prepare for the day when yo leave the hospital. They will also help arrange for any care yo may need after yo leave. The day yo leave the hospital is called yor discharge date. Yor doctor or the hospital staff will tell yo what yor discharge date is. If yo think yo are being asked to leave the hospital too soon, yo can ask for a longer hospital stay. This section tells yo how to ask. Section 7.1: Learning abot yor Medicare rights Within two days after yo are admitted to the hospital, a caseworker or nrse will give yo a notice called An Important Message from Medicare abot Yor Rights. If yo do not get this notice, ask any hospital employee for it. If yo need help, please call Member Services at Yo can also call MEDICARE ( ), 24 hors a day, 7 days a week. TTY sers shold call Read this notice careflly and ask qestions if yo don t nderstand. The Important Message tells yo abot yor rights as a hospital patient, inclding yor rights to: Get Medicare-covered services dring and after yor hospital stay. Yo have the right to know what these services are, who will pay for them, and where yo can get them. Be a part of any decisions abot the length of yor hospital stay. Know where to report any concerns yo have abot the qality of yor hospital care. Appeal if yo think yo are being discharged from the hospital too soon. Yo shold sign the Medicare notice to show that yo got it and nderstand yor rights. Signing the notice does not mean yo agree to the discharge date that may have been told to yo by yor doctor or hospital staff. Keep yor copy of the signed notice so yo will have the information in it if yo need it. To look at a copy of this notice in advance, yo can call Member Services at Yo can also call MEDICARE ( ), 24 hors a day, 7 days a week. TTY sers shold call The call is free. Yo can also see the notice online at BNI/12_HospitalDischargeAppealNotices.html. If yo need help, please call Member Services or Medicare at the nmbers listed above. 170

173 Section 7.2: Level 1 Appeal to change yor hospital discharge date Ble Cross Commnity MMAI MEMBER HANDBOOK Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) If yo want s to cover yor inpatient hospital services for a longer time, yo mst reqest an appeal. A Qality Improvement Organization will do the Level 1 Appeal review to see if yor planned discharge date is medically appropriate for yo.in Illinois, the Qality Improvement Organization is called Telligen. To make an appeal to change yor discharge date call Telligen at Call right away! Call the Qality Improvement Organization before yo leave the hospital and no later than yor planned discharge date. An Important Message from Medicare abot Yor Rights contains information on how to reach the Qality Improvement Organization. If yo call before yo leave, yo are allowed to stay in the hospital after yor planned discharge date withot paying for it while yo wait to get the decision on yor appeal from the Qality Improvement Organization. If yo do not call to appeal, and yo decide to stay in the hospital after yor planned discharge date, yo may have to pay all of the costs for hospital care yo get after yor planned discharge date. At a glance: How to make a Level 1 Appeal to change yor discharge date Call the Qality Improvement Organization for yor state at and ask for a fast review. Call before yo leave the hospital and before yor planned discharge date. If yo miss the deadline for contacting the Qality Improvement Organization abot yor appeal, yo can make yor appeal directly to or plan instead. For details, see Section 8.4 on page 180. We want to make sre yo nderstand what yo need to do and what the deadlines are. Ask for help if yo need it. If yo have qestions or need help at any time, please call Member Services at (TTY/TDD: 711). Yo can also call the Senior HelpLine Monday throgh Friday from 8:30 a.m. to 5:00 p.m. The phone nmber is , TTY/TDD: The call and help are free. What is a Qality Improvement Organization? It is a grop of doctors and other health care professionals who are paid by the federal government. These experts are not part of or plan. They are paid by Medicare to check on and help improve the qality of care for people with Medicare. 171

174 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Ask for a fast review Yo mst ask the Qality Improvement Organization for a fast review of yor discharge. Asking for a fast review means yo are asking the organization to se the fast deadlines for an appeal instead of sing the standard deadlines. The legal term for fast review is immediate review. What happens dring the fast review? The reviewers at the Qality Improvement Organization will ask yo or yor representative why yo think coverage shold contine after the planned discharge date. Yo don t have to prepare anything in writing, bt yo may do so if yo wish. The reviewers will look at yor medical record, talk with yor doctor, and review all of the information related to yor hospital stay. By noon of the day after the reviewers tell s abot yor appeal, yo will get a letter that gives yor planned discharge date. The letter explains the reasons why yor doctor, the hospital, and we think it is right for yo to be discharged on that date. The legal term for this written explanation is called the Detailed Notice of Discharge. Yo can get a sample by calling Member Services at (TTY/TDD: 711). Yo can also call MEDICARE ( ), 24 hors a day, 7 days a week. TTY sers shold call Or yo can see a sample notice online at Medicare-General-Information/BNI/HospitalDischargeAppealNotices.html What if the answer is Yes? If the Qality Improvement Organization says Yes to yor appeal, we mst keep covering yor hospital services for as long as they are medically necessary. What if the answer is No? If the Qality Improvement Organization says No to yor appeal, they are saying that yor planned discharge date is medically appropriate. If this happens, or coverage for yor inpatient hospital services will end at noon on the day after the Qality Improvement Organization gives yo its answer. If the Qality Improvement Organization says No and yo decide to stay in the hospital, then yo may have to pay for yor contined stay at the hospital. The cost of the hospital care that yo may have to pay begins at noon on the day after the Qality Improvement Organization gives yo its answer. If the Qality Improvement Organization trns down yor appeal and yo stay in the hospital after yor planned discharge date, then yo can make a Level 2 Appeal. 172

175 Section 7.3: Level 2 Appeal to change yor hospital discharge date Ble Cross Commnity MMAI MEMBER HANDBOOK Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) If the Qality Improvement Organization has trned down yor appeal and yo stay in the hospital after yor planned discharge date, then yo can make a Level 2 Appeal. Yo will need to contact the Qality Improvement Organization again and ask for another review. Ask for the Level 2 review within 60 calendar days after the day when the Qality Improvement Organization said No to yor Level 1 Appeal. Yo can ask for this review only if yo stayed in the hospital after the date that yor coverage for the care ended. In Illinois, the Qality Improvement Organization is called Telligen QIO. Yo can reach Telligen QIO at: Reviewers at the Qality Improvement Organization will take another carefl look at all of the information related to yor appeal. Within 14 calendar days of receipt of yor reqest for a second review, the Qality Improvement Organization reviewers will make a decision. At a glance: How to make a Level 2 Appeal to change yor discharge date Call the Qality Improvement Organization for yor state at and ask for another review. What happens if the answer is Yes? We mst pay yo back for or share of the costs of hospital care yo got since noon on the day after the date of yor first appeal decision. We mst contine providing coverage for yor inpatient hospital care for as long as it is medically necessary. Yo mst contine to pay yor share of the costs and coverage limitations may apply. What happens if the answer is No? It means the Qality Improvement Organization agrees with the Level 1 decision and will not change it. The letter yo get will tell yo what yo can do if yo wish to contine with the appeal process. If the Qality Improvement Organization trns down yor Level 2 Appeal, yo may have to pay the fll cost for yor stay after yor planned discharge date. 173

176 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Section 7.4: What happens if I miss an appeal deadline? If yo miss appeal deadlines, there is another way to make Level 1 and Level 2 Appeals, called Alternate Appeals. Bt the first two levels of appeal are different. Level 1 Alternate Appeal to change yor hospital discharge date If yo miss the deadline for contacting the Qality Improvement Organization, yo can make an appeal to s, asking for a fast review. A fast review is an appeal that ses the fast deadlines instead of the standard deadlines. Dring this review, we take a look at all of the information abot yor hospital stay. We check to see if the decision abot when yo shold leave the hospital was fair and followed all the rles. We will se the fast deadlines rather We will give yo or decision within 72 hors. than the standard deadlines for giving yo the answer to this review. This means we will give yo or decision within 72 hors after yo ask for a fast review. If we say Yes to yor fast review, it means we agree that yo still need to be in the hospital after the discharge date. We will keep covering hospital services for as long as it is medically necessary. It also means that we agree to pay yo back for or share of the costs of care yo got since the date when we said yor coverage wold end. If we say No to yor fast review, we are saying that yor planned discharge date was medically appropriate. Or coverage for yor inpatient hospital services ends on the day we said coverage wold end. At a glance: How to make a Level 1 Alternate Appeal Call or Member Services nmber and ask for a fast review of yor hospital discharge date. If yo stayed in the hospital after yor planned discharge date, then yo may have to pay the fll cost of hospital care yo got after the planned discharge date. To make sre we were following all the rles when we said No to yor fast appeal, we will send yor appeal to the Independent Review Entity. When we do this, it means that yor case is atomatically going to Level 2 of the appeals process. The legal term for fast review or fast appeal is expedited appeal. 174

177 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Level 2 Alternate Appeal to change yor hospital discharge date We will send the information for yor Level 2 Appeal to the Independent Review Entity (IRE) within 24 hors of when we give yo or Level 1 decision. If yo think we are not meeting this deadline or other deadlines, yo can make a complaint. Section 10 on page 184 tells how to make a complaint. Dring the Level 2 Appeal, the IRE reviews the decision we made when we said No to yor fast review. This organization decides whether the decision we made shold be changed. The IRE does a fast review of yor appeal. The reviewers sally give yo an answer within 72 hors. The IRE is an independent organization that is hired by Medicare. This organization is not connected with or plan, and it is not a government agency. Reviewers at the IRE will take a carefl look at all of the information related to yor appeal of yor hospital discharge. At a glance: How to make a Level 2 Alternate Appeal Yo do not have to do anything. The plan will atomatically send yor appeal to the Independent Review Entity. If the IRE says Yes to yor appeal, then we mst pay yo back for or share of the costs of hospital care yo got since the date of yor planned discharge. We mst also contine or coverage of yor hospital services for as long as it is medically necessary. If the IRE says No to yor appeal, it means they agree with s that yor planned hospital discharge date was medically appropriate. The letter yo get from the IRE will tell yo what yo can do if yo wish to contine with the review process. It will give yo the details abot how to go on to a Level 3 Appeal, which is handled by a jdge. 175

178 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Section 8: What to do if yo think yor home health care, skilled nrsing care, or Comprehensive Otpatient Rehabilitation Facility (CORF) services are ending too soon This section is abot the following types of care only: Home health care services. Skilled nrsing care in a skilled nrsing facility. Rehabilitation care yo are getting as an otpatient at a Medicare-approved Comprehensive Otpatient Rehabilitation Facility (CORF). Usally, this means yo are getting treatment for an illness or accident, or yo are recovering from a major operation. With any of these three types of care, yo have the right to keep getting covered services for as long as the doctor says yo need it. When we decide to stop covering any of these, we mst tell yo before yor services end. When yor coverage for that care ends, we will stop paying for yor care. If yo think we are ending the coverage of yor care too soon, yo can appeal or decision. This section tells yo how to ask for an appeal. Section 8.1: We will tell yo in advance when yor coverage will be ending Yo will get a notice at least two days before we stop paying for yor care. This is called the Notice of Medicare Non-Coverage. The written notice tells yo the date when we will stop covering yor care. The written notice also tells yo how to appeal this decision. Yo or yor representative shold sign the written notice to show that yo got it. Signing it does not mean yo agree with the plan that it is time to stop getting the care. When yor coverage ends, we will stop paying. Section 8.2: Level 1 Appeal to contine yor care If yo think we are ending coverage of yor care too soon, yo can appeal or decision. This section tells yo how to ask for an appeal. Before yo start yor appeal, nderstand what yo need to do and what the deadlines are. 176

179 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Meet the deadlines. The deadlines are important. Be sre that yo nderstand and follow the deadlines that apply to things yo mst do. There are also deadlines or plan mst follow. (If yo think we are not meeting or deadlines, yo can file a complaint. Section 10 on page 184 tells yo how to file a complaint.) Ask for help if yo need it. If yo have qestions or need help at any time, please call Member Services at (TTY/TDD: 711). Or call the Senior HelpLine at (TTY: ), Monday throgh Friday from 8:30 a.m. to 5:00 p.m. The call and help are free. Dring a Level 1 Appeal, a Qality Improvement Organization will review yor appeal and decide whether to change the decision we made. In Illinois, the Qality Improvement Organization is called Telligen. Yo can reach Telligen at: Information abot appealing to the Qality Improvement Organization is also in the Notice of Medicare Non-Coverage. This is the notice yo got when yo were told we wold stop covering yor care. At a glance: How to make a Level 1 Appeal to ask the plan to contine yor care Call the Qality Improvement Organization for yor state at and ask for a fast track appeal. Call before yo leave the agency or facility that is providing yor care and before yor planned discharge date. What is a Qality Improvement Organization? It is a grop of doctors and other health care professionals who are paid by the federal government. These experts are not part of or plan. They are paid by Medicare to check on and help improve the qality of care for people with Medicare. What shold yo ask for? Ask them for a fast-track appeal. This is an independent review of whether it is medically appropriate for s to end coverage for yor services. What is yor deadline for contacting this organization? Yo mst contact the Qality Improvement Organization no later than noon of the day after yo got the written notice telling yo when we will stop covering yor care. If yo miss the deadline for contacting the Qality Improvement Organization abot yor appeal, yo can make yor appeal directly to s instead. For details abot this other way to make yor appeal, see Section 8.4 on page

180 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) The legal term for the written notice is Notice of Medicare Non-Coverage. To get a sample copy, call Member Services at (TTY/TDD: 711) or MEDICARE ( ), 24 hors a day, 7 days a week. TTY sers shold call Or see a copy online at MAEDNotices.html What happens dring the Qality Improvement Organization s review? The reviewers at the Qality Improvement Organization will ask yo or yor representative why yo think coverage for the services shold contine. Yo don t have to prepare anything in writing, bt yo may do so if yo wish. When yo ask for an appeal, the plan mst write a letter to yo and the Qality Improvement Organization explaining why yor services shold end. The reviewers will also look at yor medical records, talk with yor doctor, and review information that or plan has given to them. Within one fll day after reviewers have all the information they need, they will tell yo their decision. Yo will get a letter explaining the decision. The legal term for the letter explaining why yor services shold end is Detailed Explanation of Non-Coverage. What happens if the reviewers say Yes? If the reviewers say Yes to yor appeal, then we mst keep providing yor covered services for as long as they are medically necessary. What happens if the reviewers say No? If the reviewers say No to yor appeal, then yor coverage will end on the date we told yo. We will stop paying or share of the costs of this care. If yo decide to keep getting the home health care, skilled nrsing facility care, or Comprehensive Otpatient Rehabilitation Facility (CORF) services after the date yor coverage ends, then yo will have to pay the fll cost of this care yorself. 178

181 Section 8.3: Level 2 Appeal to contine yor care Ble Cross Commnity MMAI MEMBER HANDBOOK Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) If the Qality Improvement Organization said No to the appeal and yo choose to contine getting care after yor coverage for the care has ended, yo can make a Level 2 Appeal. Dring the Level 2 Appeal, the Qality Improvement Organization will take another look at the decision they made at Level 1. If they say they agree with the Level 1 decision, yo may have to pay the fll cost for yor home health care, skilled nrsing facility care, or Comprehensive Otpatient Rehabilitation Facility (CORF) services after the date when we said yor coverage wold end. In Illinois, the Qality Improvement Organization is called QIO Telligen. Yo can reach QIO Telligen at: Ask for the Level 2 review within 60 calendar days after the day when the Qality Improvement Organization said No to yor Level 1 Appeal. Yo can ask for this review only if yo contined getting care after the date that yor coverage for the care ended. Reviewers at the Qality Improvement Organization will take another carefl look at all of the information related to yor appeal. The Qality Improvement Organization will make its decision within 14 calendar days of receipt of yor appeal reqest. What happens if the review organization says Yes? We mst pay yo back for or share of the costs of care yo got since the date when we said yor coverage wold end. We mst contine providing coverage for the care for as long as it is medically necessary. At a glance: How to make a Level 2 Appeal to reqire that the plan cover yor care for longer Call the Qality Improvement Organization for yor state at and ask for another review. Call before yo leave the agency or facility that is providing yor care and before yor planned discharge date. What happens if the review organization says No? It means they agree with the decision they made on the Level 1 Appeal and will not change it. The letter yo get will tell yo what to do if yo wish to contine with the review process. It will give yo the details abot how to go on to the next level of appeal, which is handled by a jdge. 179

182 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Section 8.4: What if yo miss the deadline for making yor Level 1 Appeal? If yo miss appeal deadlines, there is another way to make Level 1 and Level 2 Appeals, called Alternate Appeals. Bt the first two levels of appeal are different. Level 1 Alternate Appeal to contine yor care for longer If yo miss the deadline for contacting the Qality Improvement Organization, yo can make an appeal to s, asking for a fast review. A fast review is an appeal that ses the fast deadlines instead of the standard deadlines. Dring this review, we take a look at all of the information abot yor home health care, skilled nrsing facility care, or care yo are getting at a Comprehensive Otpatient Rehabilitation Facility (CORF). We check to see if the decision abot when yor services shold end was fair and followed all the rles. We will se the fast deadlines rather than the standard deadlines for giving yo the answer to this review. We will give yo or decision within 72 hors after yo ask for a fast review. If we say Yes to yor fast review, it means we agree that we will keep covering yor services for as long as it is medically necessary. At a glance: How to make a Level 1 Alternate Appeal Call or Member Services nmber and ask for a fast review. We will give yo or decision within 72 hors. It also means that we agree to pay yo back for or share of the costs of care yo got since the date when we said yor coverage wold end. If we say No to yor fast review, we are saying that stopping yor services was medically appropriate. Or coverage ends as of the day we said coverage wold end. If yo contine getting services after the day we said they wold stop, yo may have to pay the fll cost of the services. To make sre we were following all the rles when we said No to yor fast appeal, we will send yor appeal to the Independent Review Entity. When we do this, it means that yor case is atomatically going to Level 2 of the appeals process. The legal term for fast review or fast appeal is expedited appeal. 180

183 Level 2 Alternate Appeal to contine yor care for longer We will send the information for yor Level 2 Appeal to the Independent Review Entity (IRE) within 24 hors of when we give yo or Level 1 decision. If yo think we are not meeting this deadline or other deadlines, yo can make a complaint. Section 10 on page 183 tells how to make a complaint. Ble Cross Commnity MMAI MEMBER HANDBOOK Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Dring the Level 2 Appeal, the IRE reviews the decision we made when we said No to yor fast review. This organization decides whether the decision we made shold be changed. The IRE does a fast review of yor appeal. The reviewers sally give yo an answer within 72 hors. The IRE is an independent organization that is hired by Medicare. This organization is not connected with or plan, and it is not a government agency. Reviewers at the IRE will take a carefl look at all of the information related to yor appeal. If the IRE says Yes to yor appeal, then we mst pay yo back for or share of the costs of care. We mst also contine or coverage of yor services for as long as it is medically necessary. If the IRE says No to yor appeal, it means they agree with s that stopping coverage of services was medically appropriate. At a glance: How to make a Level 2 Appeal to reqire that the plan contine yor care Yo do not have to do anything. The plan will atomatically send yor appeal to the Independent Review Entity. The letter yo get from the IRE will tell yo what yo can do if yo wish to contine with the review process. It will give yo details abot how to go on to a Level 3 Appeal, which is handled by a jdge. 181

184 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Section 9: Taking yor appeal beyond Level 2 Section 9.1: Next steps for Medicare services and items If yo made a Level 1 Appeal and a Level 2 Appeal for Medicare services or items, and both yor appeals have been trned down, yo may have the right to additional levels of appeal. The letter yo get from the Independent Review Entity will tell yo what to do if yo wish to contine the appeals process. Level 3 of the appeals process is an Administrative Law Jdge (ALJ) hearing. If yo want an ALJ to review yor case, the item or medical service yo are reqesting mst meet a minimm dollar amont. If the dollar vale is less than the minimm level, yo cannot appeal any frther. If the dollar vale is high enogh, yo can ask an ALJ to hear yor appeal. If yo do not agree with the ALJ s decision, yo can go to the Medicare Appeals Concil. After that, yo may have the right to ask a federal cort to look at yor appeal. If yo need assistance at any stage of the appeals process, yo can contact the Senior HelpLine Monday throgh Friday from 8:30 a.m. to 5:00 p.m. The phone nmber is (TTY: ). The call and help are free. Section 9.2: Next steps for Medicaid services and items Yo also have more appeal rights if yor appeal is abot services or items that might be covered by Medicaid. After yor Level 2 Appeal in the State Fair Hearings office has conclded, yo will get a written decision called a Final Administrative Decision. This decision is made by the Director of the Agency based on recommendations from the Impartial Hearing Officer. The decision will be sent to yo and all interested parties in writing by the Hearings office. This decision is reviewable only throgh the Circit corts of the State of Illinois. The time the Circit Cort will allow for filing for sch review may be as short as 35 days from the date of yor Final Administrative Decision. 182

185 Section 10: How to make a complaint Ble Cross Commnity MMAI MEMBER HANDBOOK Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) What kinds of problems shold be complaints? The complaint process is sed for certain types of problems only, sch as problems related to qality of care, waiting times, and cstomer service. Here are examples of the kinds of problems handled by the complaint process. Complaints abot qality Yo are nhappy with the qality of care, sch as the care yo got in the hospital. Complaints abot privacy Yo think that someone did not respect yor right to privacy, or shared information abot yo that is confidential. Complaints abot poor cstomer service A health care provider or staff was rde or disrespectfl to yo. Ble Cross Commnity MMAI staff treated yo poorly. Yo think yo are being pshed ot of the plan. At a glance: How to make a complaint Yo can make an internal complaint with or plan and/or an external complaint with an organization that is not connected to or plan. To make an internal complaint, call Member Services or send s a letter. There are different organizations that handle external complaints. For more information, read Section 10.2 on page 186. Complaints abot accessibility Yo cannot physically access the health care services and facilities in a doctor or provider s office. Yor provider does not give yo a reasonable accommodation yo need sch as an American Sign Langage interpreter. Complaints abot waiting times Yo are having troble getting an appointment, or waiting too long to get it. Yo have been kept waiting too long by doctors, pharmacists, or other health professionals or by Member Services or other plan staff. Complaints abot cleanliness Yo think the clinic, hospital or doctor s office is not clean. Complaints abot langage access Yor doctor or provider does not provide yo with an interpreter dring yor appointment. 183

186 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Complaints abot commnications from s Yo think we failed to give yo a notice or letter that yo shold have received. Yo think the written information we sent yo is too difficlt to nderstand. Complaints abot the timeliness of or actions related to coverage decisions or appeals Yo believe that we are not meeting or deadlines for making a coverage decision or answering yor appeal. Yo believe that, after getting a coverage or appeal decision in yor favor, we are not meeting the deadlines for approving or giving yo the service or paying yo back for certain medical services. Yo believe we did not forward yor case to the Independent Review Entity on time. The legal term for a complaint is a grievance. The legal term for making a complaint is filing a grievance. Are there different types of complaints? Yes. Yo can make an internal complaint and/or an external complaint. An internal complaint is filed with and reviewed by or plan. An external complaint is filed with and reviewed by an organization that is not affiliated with or plan. If yo need help making an internal and/or external complaint, yo can call the Senior HelpLine at (TTY: ), Monday throgh Friday from 8:30 a.m. to 5:00 p.m. The call and help are free. Section 10.1: Internal complaints To make an internal complaint, call Member Services at (TTY/TDD: 711). Complaints related to Part D mst be made within 60 calendar days after yo had the problem yo want to complain abot. If yo are reqesting action on any other Medicare isse, the complaint mst also be made within 60 calendar days after yo had the problem yo want to complain abot. All other types of complaints can be made at any time. If there is anything else yo need to do, Member Services will tell yo. Yo can also write yor complaint and send it to s. If yo pt yor complaint in writing, we will respond to yor complaint in writing. If yo send s the complaint in writing, please inclde the date and place the incident happened, the names of people involved and details abot what happened. Be sre to inclde yor name and member ID nmber. 184

187 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Dring the complaint process, yo may have someone yo know act on yor behalf. This person will be yor representative. If yo decide to have someone act for yo, please let or Member Services know and they will help yo. We will let yo know we received yor formal complaint within three (3) bsiness days after we receive it. We will look into yor complaint as qickly as possible and give yo an answer in no later than 30 calendar days. If we need more information and the delay is in yor best interest, or if yo ask for more time, we can take p to 14 more calendar days to answer yor complaint. After yo get or answer abot yor complaint, if yo are still not satisfied yo may ask to have yor concerns heard at a grievance committee. Yo mst ask for this within 10 calendar days after yo receive or answer. We will let yo know we received yor reqest within three (3) bsiness days after we get it, and will let yo know the date of the next committee hearing. The committee will review yor complaint and we will send yo a decision within 30 calendar days. The decision of the committee is final. Some complaints, by their natre, cannot be resolved (for example: food at Adlt Day Health was served cold). Or plan tracks and logs these complaints and looks to identify any repeated problems and ses this information to tell the proper department (for example: the Provider Network Management Department or the Clinical Department) abot inferior care. If yo are concerned abot the qality of care yo received, inclding care dring a hospital stay, yo may complain to Telligen, the Qality Improvement Organization for Illinois, by calling If yo are making a complaint becase we denied yor reqest for a fast coverage decision or a fast appeal, we will atomatically give yo a fast complaint and respond to yor complaint within 24 hors. The legal term for fast complaint is expedited grievance. If possible, we will answer yo right away. If yo call s with a complaint, we may be able to give yo an answer on the same phone call. If yor health condition reqires s to answer qickly, we will do that. We answer most complaints within 30 calendar days. If we need more information and the delay is in yor best interest, or if yo ask for more time, we can take p to 14 more calendar days (44 calendar days total) to answer yor complaint. We will tell yo in writing why we need more time. If yo are making a complaint becase we denied yor reqest for a fast coverage decision or a fast appeal, we will atomatically give yo a fast complaint and respond to yor complaint within 24 hors. 185

188 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) If yo are making a complaint becase we took extra time to make a coverage decision or appeal, we will atomatically give yo a fast complaint and respond to yor complaint within 24 hors. If we do not agree with some or all of yor complaint, we will tell yo and give yo or reasons. We will respond whether we agree with the complaint or not. Section 10.2: External complaints Yo can tell Medicare abot yor complaint Yo can send yor complaint to Medicare. The Medicare Complaint Form is available at: Medicare takes yor complaints seriosly and will se this information to help improve the qality of the Medicare program. If yo have any other feedback or concerns, or if yo feel the plan is not addressing yor problem, please call MEDICARE ( ). TTY/TDD sers can call The call is free. Yo can tell the Illinois Department of Healthcare and Family Services abot yor complaint To file a complaint with the Illinois Department of Healthcare and Family Services, send an to HFS.CareCoord@illinois.gov. Yo can file a complaint with the Office for Civil Rights Yo can make a complaint to the Department of Health and Hman Services Office for Civil Rights if yo think yo have not been treated fairly. For example, yo can make a complaint abot disability access or langage assistance. The phone nmber for the Office for Civil Rights is TTY sers shold call Yo can also visit for more information. Yo may also contact the local Office for Civil Rights office at: Office for Civil Rights U.S. Department of Health and Hman Services 233 N. Michigan Ave., Site 240 Chicago, IL Voice Phone (800) FAX (312) TDD (800) Yo may also have rights nder the Americans with Disability Act. Yo can contact the Senior HelpLine for assistance Monday throgh Friday from 8:30 a.m. to 5:00 p.m. The phone nmber is , TTY: The call and help are free. 186

189 Chapter 9: What to do if yo have a problem or complaint (coverage decisions, appeals, complaints) Yo can file a complaint with the Qality Improvement Organization When yor complaint is abot qality of care, yo also have two choices: If yo prefer, yo can make yor complaint abot the qality of care directly to the Qality Improvement Organization (withot making the complaint to s). Or yo can make yor complaint to s and to the Qality Improvement Organization. If yo make a complaint to this organization, we will work with them to resolve yor complaint. The Qality Improvement Organization is a grop of practicing doctors and other health care experts paid by the federal government to check and improve the care given to Medicare patients. In Illinois, the Qality Improvement Organization is called Telligen. The phone nmber for Qality Improvement is

190 Chapter 10: Ending yor membership in or Medicare-Medicaid Plan 188

191 Table of Contents Ble Cross Commnity MMAI MEMBER HANDBOOK Chapter 10: Ending yor membership in or Medicare-Medicaid Plan A. When can yo end yor membership in or Medicare-Medicaid plan? B. How do yo end yor membership in or plan? C. How do yo join a different Medicare-Medicaid plan? D. If yo leave or plan and yo do not want a different Medicare Medicaid plan, how do yo get Medicare and Medicaid services? E. Until yor membership ends, yo will keep getting yor medical services and drgs throgh or plan F. Yor membership will end in certain sitations G. We cannot ask yo to leave or plan for any reason related to yor health H. Yo have the right to make a complaint if we end yor membership in or plan I. Where can yo get more information abot ending yor plan membership?

192 Chapter 10: Ending yor membership in or Medicare-Medicaid Plan Introdction This chapter tells abot ways yo can end yor membership in or plan and yor health coverage options after yo leave the plan. Yo will still qalify for both Medicare and Medicaid benefits if yo leave or plan. A. When can yo end yor membership in or Medicare-Medicaid plan? Yo can ask to end yor membership in Ble Cross Commnity MMAI Medicare-Medicaid Plan at any time. If yo want to go back to getting yor Medicare and Medicaid services separately: Yor membership will end on the last day of the month that Illinois Client Enrollment Services or Medicare gets yor reqest to change yor plan. Yor new coverage will begin the first day of the next month. For example, if Illinois Client Enrollment Services or Medicare gets yor reqest on Janary 18th, yor new coverage will begin Febrary 1st. If yo want to switch to a different Medicare-Medicaid Plan: If yo ask to change plans before the 18th of the month, yor membership will end on the last day of that same month. Yor new coverage will begin the first day of the next month. For example, if Illinois Client Enrollment Services gets yor reqest on Agst 6th, yor coverage in the new plan will begin September 1st. If yo ask to change plans after the 18th of the month, yor membership will end on the last day of the following month. Yor new coverage will begin the first day of the month after that. For example, if Illinois Client Enrollment Services gets yor reqest on Agst 24th, yor coverage in the new plan will begin October 1st. For information on Medicare options when yo leave or plan, see the table on page 191. For information abot yor Medicaid services when yo leave or plan, see page 192. These are ways yo can get more information abot when yo can end yor membership: Call Illinois Client Enrollment Services at , from 8 a.m. to 7 p.m. Monday throgh Friday and 9 a.m. to 3 p.m. on Satrday. TTY sers shold call Call the Senior Health Insrance Program (SHIP) at TTY sers shold call Call Medicare at MEDICARE ( ), 24 hors a day, seven days a week. TTY sers shold call , 24 hors a day, seven days a week. 190

193 Chapter 10: Ending yor membership in or Medicare-Medicaid Plan B. How do yo end yor membership in or plan? If yo decide to end yor membership, tell Medicaid or Medicare that yo want to leave Ble Cross Commnity MMAI: Call Illinois Client Enrollment Services at , from 8 a.m. to 7 p.m. Monday throgh Friday. TTY sers shold call ; OR Call Medicare at MEDICARE ( ), 24 hors a day, seven days a week. TTY sers (people who are deaf, hard of hearing, or speech disabled) shold call When yo call MEDICARE, yo can also enroll in another Medicare health or drg plan. More information on getting yor Medicare services when yo leave or plan is in the chart on page 192. C. How do yo join a different Medicare-Medicaid plan? If yo want to keep getting yor Medicare and Medicaid benefits together from a single plan, yo can join a different Medicare-Medicaid plan. To enroll in a different Medicare-Medicaid plan: Call Illinois Client Enrollment Services at , from 8 a.m. to 7 p.m. Monday throgh Friday. TTY sers shold call Tell them yo want to leave Ble Cross Commnity MMAI and join a different Medicare-Medicaid plan. If yo are not sre what plan yo want to join, they can tell yo abot other plans in yor area. If Illinois Client Enrollment Services gets yor reqest before the 18th of the month, yor coverage with Ble Cross Commnity MMAI will end on the last day of that same month. If Illinois Client Enrollment Services gets yor reqest after the 18th of the month, yor coverage with Ble Cross Commnity MMAI will end on the last day of the following month. See Section A above for more information abot when yo can end yor membership. D. If yo leave or plan and yo do not want a different Medicare-Medicaid plan, how do yo get Medicare and Medicaid services? If yo do not want to enroll in a different Medicare-Medicaid plan after yo leave Ble Cross Commnity MMAI, yo will go back to getting yor Medicare and Medicaid services separately. How yo will get Medicare services Yo will have a choice abot how yo get yor Medicare benefits. Yo have three options for getting yor Medicare services. By choosing one of these options, yo will atomatically end yor membership in or plan. 191

194 Chapter 10: Ending yor membership in or Medicare-Medicaid Plan 1. Yo can change to: A Medicare health plan, sch as a Medicare Advantage plan or Programs of All-inclsive Care for the Elderly (PACE) Here is what to do: Call Medicare at MEDICARE ( ), 24 hors a day, seven days a week. TTY sers shold call to enroll in the new Medicare-only health plan. If yo need help or more information: Call the Senior Health Insrance Program (SHIP) at Yo will atomatically be disenrolled from Ble Cross Commnity MMAI when yor new plan s coverage begins. 2. Yo can change to: Original Medicare with a separate Medicare prescription drg plan Here is what to do: Call Medicare at MEDICARE ( ), 24 hors a day, seven days a week. TTY sers shold call If yo need help or more information: Call the Senior Health Insrance Program (SHIP) at Yo will atomatically be disenrolled from Ble Cross Commnity MMAI when yor Original Medicare coverage begins. 192

195 Chapter 10: Ending yor membership in or Medicare-Medicaid Plan 3. Yo can change to: Original Medicare withot a separate Medicare prescription drg plan NOTE: If yo switch to Original Medicare and do not enroll in a separate Medicare prescription drg plan, Medicare may enroll yo in a drg plan, nless yo tell Medicare yo don t want to join. Yo shold only drop prescription drg coverage if yo get drg coverage from an employer, nion or other sorce. If yo have qestions abot whether yo need drg coverage, call yor Senior Health Insrance Program at Here is what to do: Call Medicare at MEDICARE ( ), 24 hors a day, seven days a week. TTY sers shold call If yo need help or more information: Call the Senior Health Insrance Program (SHIP) at Yo will atomatically be disenrolled from Ble Cross Commnity MMAIwhen yor Original Medicare coverage begins. How yo will get Medicaid services If yo leave or Medicare-Medicaid Plan, yo will either get yor Medicaid services throgh fee for service or be reqired to enroll in the Medicaid Managed Long Term Services and Spports program to get yor Medicaid services. If yo are not in a nrsing facility or enrolled in a HCBS waiver, yo will be in Medicaid fee-for-service. Yo can see any provider that accepts Medicaid and new patients. If yo are in a nrsing facility or are enrolled in a Home and Commnity Based Service (HCBS) waiver, yo will be reqired to enroll in the Medicaid Managed Long Term Services and Spports program to get yor Medicaid services. To choose a Medicaid Managed Long Term Services and Spports health plan, yo can call Illinois Client Enrollment Services at from 8 a.m. to 7 p.m. Monday throgh Friday. TTY sers shold call Tell them yo want to leave Ble Cross Commnity MMAI and join a Managed Long Term Services and Spports health plan. If yo don t pick a Medicaid Managed Long Term Services and Spports health plan, yo will be assigned to or company s Managed Long Term Services and Spports health plan. After yo are enrolled in Medicaid Managed Long Term Services and Spports health plan, yo will have 90 days to switch to another Medicaid Managed Long Term Services and Spports health plan. Yo will get a new Member ID Card, a new Member Handbook, and a new Provider Directory from yor Medicaid Managed Long Term Services and Spports health plan. 193

196 Chapter 10: Ending yor membership in or Medicare-Medicaid Plan E. Until yor membership ends, yo will keep getting yor medical services and drgs throgh or plan If yo leave Ble Cross Commnity MMAI, it may take time before yor membership ends and yor new Medicare and Medicaid coverage begins. See page 48 Section A for more information. Dring this time, yo will keep getting yor health care and drgs throgh or plan. Yo shold se or network pharmacies to get yor prescriptions filled. Usally, yor prescription drgs are covered only if they are filled at a network pharmacy inclding throgh or mail-order pharmacy services. If yo are hospitalized on the day that yor membership ends, yor hospital stay will sally be covered by or plan ntil yo are discharged. This will happen even if yor new health coverage begins before yo are discharged. F. Yor membership will end in certain sitations These are the cases when Ble Cross Commnity MMAI mst end yor membership in the plan: If there is a break in yor Medicare Part A and Part B coverage. If yo no longer qalify for Medicaid. Or plan is for people who qalify for both Medicare and Medicaid. If yo move ot of or service area. If yo are away from or service area for more than six months. If yo move or take a long trip, yo need to call Member Services to find ot if the place yo are moving or traveling to is in or plan s service area. If yo go to prison. If yo lie abot or withhold information abot other insrance yo have for prescription drgs. If yo are not a United States citizen or are not lawflly present in the United States. Yo mst be a United States citizen or lawflly present in the United States to be a member of or plan. The Centers for Medicare & Medicaid Services will notify s if yo aren t eligible to remain a member on this basis. We mst disenroll yo if yo don t meet this reqirement. We can make yo leave or plan for the following reasons only if we get permission from Medicare and Medicaid first: If yo intentionally give s incorrect information when yo are enrolling in or plan and that information affects yor eligibility for or plan. If yo continosly behave in a way that is disrptive and makes it difficlt for s to provide medical care for yo and other members of or plan. 194

197 Chapter 10: Ending yor membership in or Medicare-Medicaid Plan If yo let someone else se yor ID card to get medical care. If we end yor membership becase of this reason, Medicare may have yor case investigated by the Inspector General. G. We cannot ask yo to leave or plan for any reason related to yor health If yo feel that yo are being asked to leave or plan for a health-related reason, yo shold call Medicare at MEDICARE ( ). TTY sers shold call Yo may call 24 hors a day, seven days a week. Yo shold also call Medicaid s Health Benefits Hotline at TTY sers shold call H. Yo have the right to make a complaint if we end yor membership in or plan If we end yor membership in or plan, we mst tell yo or reasons in writing for ending yor membership. We mst also explain how yo can make a complaint abot or decision to end yor membership. Yo can also see Chapter 9, Section 10 for information abot how to make a complaint. I. Where can yo get more information abot ending yor plan membership? If yo have qestions or wold like more information on when we can end yor membership, yo can call Member Services at (TTY/TDD 711). 195

198 Chapter 11: Legal notices 196

199 Table of Contents Ble Cross Commnity MMAI MEMBER HANDBOOK Chapter 11: Legal notices A. Notice abot laws B. Notice abot nondiscrimination C. Notice abot Ble Cross Commnity MMAI as a Second Payer D. Patient Confidentiality and Notice Abot Privacy Practices

200 Chapter 11: Legal notices A. Notice abot laws Many laws apply to this Member Handbook. These laws may affect yor rights and responsibilities even if the laws are not inclded or explained in this handbook. The main laws that apply to this handbook are federal laws abot the Medicare and Medicaid programs. Other federal and state laws may apply too. B. Notice abot nondiscrimination Every company or agency that works with Medicare mst obey the law. Yo cannot be treated differently becase of yor age, claims experience, color, creed, ethnicity, evidence of insrability, gender, genetic information, geographic location, health stats, medical history, mental or physical disability, national origin, race, religion, or sex. If yo think that yo have not been treated fairly for any of these reasons, call the Department of Health and Hman Services, Office for Civil Rights at TTY sers shold call Yo can also visit for more information. 198

201 Chapter 11: Legal notices Ble Cross and Ble Shield of Illinois complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Ble Cross and Ble Shield of Illinois does not exclde people or treat them differently becase of race, color, national origin, age, disability, or sex. Ble Cross and Ble Shield of Illinois: Provides free aids and services to people with disabilities to commnicate effectively with s, sch as: Qalified sign langage interpreters Written information in other formats (large print, adio, accessible electronic formats, other formats) Provides free langage services to people whose primary langage is not English, sch as: Qalified interpreters Information written in other langages If yo need these services, contact Civil Rights Coordinator If yo believe that Ble Cross and Ble Shield of Illinois has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, yo can file a grievance with: Civil Rights Coordinator, Office of Civil Rights Coordinator, 300 E. Randolph St., 35th floor, Chicago, Illinois 60601, , TTY/TDD: , Fax: , Civilrightscoordinator@hcsc.net. Yo can file a grievance in person or by mail, fax, or . If yo need help filing a grievance, Civil Rights Coordinator is available to help yo. Yo can also file a civil rights complaint with the U.S. Department of Health and Hman Services, Office for Civil Rights, electronically throgh the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Hman Services 200 Independence Avene, SW Room 509F, HHH Bilding Washington, D.C , (TDD) Complaint forms are available at 199

202 Chapter 11: Legal notices English: ATTENTION: If yo speak a langage other than English, langage assistance services, free of charge, are available to yo. Call (TTY/TDD: 711). Español (Spanish): ATENCIÓN: si habla español, tiene a s disposición servicios gratitos de asistencia lingüística. Llame al (TTY/TDD: 711). 繁體中文 (Chinese): 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY/TDD: 711). Tagalog (Tagalog Filipino): PAUNAWA: Kng nagsasalita ka ng Tagalog, maaari kang gmamit ng mga serbisyo ng tlong sa wika nang walang bayad. Tmawag sa (TTY/TDD: 711). Français (French): ATTENTION : Si vos parlez français, des services d'aide lingistiqe vos sont proposés gratitement. Appelez le (ATS : 711). Tiếng Việt (Vietnamese): CHÚ Ý: Nế bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY/TDD: 711). Detsch (German): ACHTUNG: Wenn Sie Detsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistngen zr Verfügng. Rfnmmer: (TTY/TDD: 711). 한국어 (Korean): 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY/TDD: 711) 번으로전화해주십시오. Русский (Rssian): ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). (Arabic): العربیة ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم (رقم ھاتف الصم والبكم: 117).!ह द% (Hindi):!य न द': य)द आप )ह द. ब लत ह4 त आपक 6लए म :त म' भ ष सह यत स व ए उपल@ध ह (TTY/TDD: 711) पर क ल कर' 200

203 Chapter 11: Legal notices Italiano (Italian): ATTENZIONE: In caso la linga parlata sia l'italiano, sono disponibili servizi di assistenza lingistica gratiti. Chiamare il nmero (TTY/TDD: 711). ગજર ત (Gjarati):!ચન : % ત' ગજર ત બ લત હ, ત ન:શ3ક ભ ષ સહ ય 9વ ઓ તમ ર મ = ઉપલ@ધ B. ફ ન કર (TTY/TDD: 711) کریں کال ہیں دستیاب میں مفت خدمات کی مدد کی زبان کو آپ تو ہیں بولتے اردو آپ اگر :خبردار (Urd): ا رد و (TTY/TDD: 711). Polski (Polish): UWAGA: Jeżeli mówisz po polsk, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod nmer (TTY/TDD: 711). λληνικά (Greek): ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθε σή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε (TTY/TDD: 711). 201

204 Chapter 11: Legal notices C. Notice abot Ble Cross Commnity MMAI as a Second Payer Sometimes someone else has to pay first for the services we provide yo. For example, if yo are in a car accident or if yo are injred at work, insrance or Workers Compensation has to pay first. Ble Cross Commnity MMAI has the right and the responsibility to collect payment for covered services when someone else has to pay first. Ble Cross Commnity MMAI s Right of Sbrogation Sbrogation is the process by which Ble Cross Commnity MMAI gets back some or all of the costs of yor health care from another insrer. Examples of other insrers inclde: Yor motor vehicle or homeowner s insrance The motor vehicle or homeowner s insrance of an individal who cased yor illness or injry Workers Compensation If an insrer other than Ble Cross Commnity MMAI shold pay for services related to an illness or injry, Ble Cross Commnity MMAI has the right to ask that insrer to repay s. Unless otherwise reqired by law, coverage nder this policy by Ble Cross Commnity MMAI will be secondary when another plan, inclding another insrance plan, provides yo with coverage for health care services. Ble Cross Commnity MMAI s Right of Reimbrsement If yo get money from a lawsit or settlement for an illness or injry, Ble Cross Commnity MMAI has a right to ask yo to repay the cost of covered services that we paid for. We cannot make yo repay s more than the amont of money yo got from the lawsit or settlement. Yor Responsibilities As a member of Ble Cross Commnity MMAI, yo agree to: Let s know of any events that may affect Ble Cross Commnity MMAI s rights of Sbrogation or Reimbrsement. Cooperate with Ble Cross Commnity MMAI when we ask for information and assistance with Coordination of Benefits, Sbrogation, or Reimbrsement. Sign docments to help Ble Cross Commnity MMAI with its rights to Sbrogation and Reimbrsement. Athorize Ble Cross Commnity MMAI to investigate, reqest and release information which is necessary to carry ot Coordination of Benefits, Sbrogation, and Reimbrsement to the extent allowed by law. Pay all sch amonts to Ble Cross Commnity MMAI recovered by lawsit, settlement or otherwise from any third person or his or her insrer to the extent of the benefits provided nder the coverage, p to the vale of the benefits provided. 202

205 Chapter 11: Legal notices If yo are not willing to help s, yo may have to pay s back for or costs, inclding reasonable attorneys fees, in enforcing or rights nder this plan. D. Patient Confidentiality and Notice Abot Privacy Practices We will ensre that all information, records, data and data elements related to yo, sed by or organization, employees, sbcontractors and bsiness associates, shall be protected from nathorized disclosre prsant to 305 ILCS 5/11-9, 11-10, and 11-12; 42 USC 654(26); 42 CFR Part 431, Sbpart F; and 45 CFR Part 160 and 45 CFR Part 164, Sbparts A and E. We are reqired by law to provide yo with a Notice that describes how health information abot yo may be sed and disclosed, and how yo can get this information. Please review this Notice of Privacy Practices careflly. If yo have qestions, please call Ble Cross Commnity MMAI at (TTY/TDD 711), We are available seven (7) days a week. Or call center is open Monday-Friday 8:00am- 8:00pm Central time. On weekends and Federal holidays, voice messaging is available. If yo leave a voice message, a Member Services representative will retrn yor call no later than the next bsiness day. The call is free. To obtain a copy of the Notice of Privacy Practices, please call Member Services or visit the website at 203

206 Chapter 12: Definitions of important words 204