Care1st Cal MediConnect Plan Medicare-Medicaid Plan offered by Care1st Health Plan

Transcription

1 H0148_18_002_MMP_SD Care1st Cal MediConnect Plan Medicare-Medicaid Plan offered by Care1st Health Plan Annual Notice of Changes for 2018 You are currently enrolled as a member of Care1st Cal MediConnect Plan. Next year, there will be some changes to the plan s benefits, coverage, rules, and costs. This Annual Notice of Changes tells you about the changes. (TTY:711), 7 days a week from 8:00 a.m. to 8:00 p.m. The call is free. For more information, visit 1

2 Table of Contents A. Think about Your Medicare and Medi-Cal Coverage for Next Year... 4 B. Changes to the network providers and pharmacies... 7 C. Changes to benefits and costs for next year... 8 Changes to benefits and costs for medical services... 8 Changes to prescription drug coverage... 9 Stage 1: Initial Coverage Stage Stage 2: Catastrophic Coverage Stage D. Deciding which plan to choose If you want to change to a different Cal MediConnect plan If you want to leave the Cal MediConnect program F. Getting help Getting help from Care1st Cal MediConnect Plan Getting help from the state enrollment broker Getting help from the Cal MediConnect Ombuds Program Getting help from the Health Insurance Counseling and Advocacy Program Getting help from Medicare Getting help from the California Department of Managed Health Care visit 2

3 A. Think about Your Medicare and Medi-Cal Coverage for Next Year It is important to review your coverage now to make sure it will still meet your needs next year. If it does not meet your needs, you can leave the plan at any time. If you choose to leave Care1st Cal MediConnect Plan, your membership will end on the last day of the month in which your request was made. If you leave our plan, you will still be in the Medicare and Medi-Cal programs as long as you are eligible. You will have a choice about how to get your Medicare benefits (go to pages to see your choices). You will continue to be enrolled in Care1st Cal MediConnect Plan for your Medi- Cal benefits, unless you choose a different Medi-Cal only plan (go to pages for more information). visit 3

4 Additional Resources If you speak a language other than English, language assistance services, free of charge, are available to you. Call (TTY/TDD users should call 711), 8:00 a.m. 8:00 p.m., seven days a week. The call is free. You can get this information for free in other formats, such as large print, braille, or audio. Call Care1st Cal MediConnect Plan Member Services at (TTY/TDD users should call 711), 8:00 a.m. 8:00 p.m., seven days a week. The call is free. Usted puede obtener este manual gratuitamente en otros idiomas. Llame al Departamento de Servicios para miembros de Care1st Cal MediConnect al (Los usuarios de TTY/TDD deben llamar al 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. Esta llamada es gratis. Quý vị có thể yêu cầu được cấp miễn phí cẩm nang này bằng những ngôn ngữ khác. Vui lòng gọi ban Dịch vụ Hội viên của Chương trình Care1st Cal MediConnect theo số (người dùng TTY/TDD vui lòng gọi 711), từ 8 giờ sáng đến 8 giờ tối, bảy ngày trong tuần. Cuộc gọi này miễn phí. Դուք կարող եք այս ձեռնարկը անվճար ստանալ այլ լեզուներով: Զանգահարեք Care1st Cal MediConnect պլանի անդամների սպասարկման ծառայությանը հեռախոսահամարով (TTY/TDD օգտագործողները պետք է զանգահարեն 711), առավոտյան ժամը 8-ից մինչև երեկոյան 8-ը, շաբաթը յոթ օր: Հեռախոսազանգը անվճար է: 您可以免费索取这本手册的其它语言版本 请致电第一健保 Care1st Cal MediConnect Plan 的会员服务部 ( 听障及语障人士请致电 711), 每周七天办公, 早上 8:00 点至晚上 8:00 点 这是一项免费服务.ی دب اش دا ش ته ی اراخت در ی گرد یزب ان ها ب ه را راهنما ک تاب چه ی نا ی دت وان یم شما خدمات مرک ز ب ا Care1st Cal MediConnect Plan Member Services ت ل فن شماره ب ه ی ری دب گ ت ماس روزه ف ته ه فت شب ٨ یال حبص ٨ ساعت ی نب ی رن دب گ ت ماس 711 شماره ب ا ی دب ا TTY/TDDیک ارب رها 이안내서는다른언어로도무료로구하실수있습니다. Care1st Cal MediConnect Plan 가입자서비스부에 (TTY/TDD 사용자는 711) 로오전 8 시에서오후 8 시사이에연중무휴연락하십시오. 통화료는무료입니다. G~kGacTTYlesovePAENnaMenH CaPasaep g@etot eday²tkit«fâ. sumturs&bæetaep~kesvasmacik«n KMerag Care1st Cal MediConnect Plan tamelx (G~ke bi TTY/TDD KYrEtehAelx 711) BIem"ag 8:00 Bwk 8:00 yb' VMBIr«f myygatit. karturs&bæmk KW²tecj«fÂeT. visit 4

5 Бесплатный перевод данного руководства на другой язык можно заказать в Отделе обслуживания участников плана Care1st Cal MediConnect Plan по номеру (линия TTY/TDD: 711) с 8:00 до 20:00 в любой день недели. Звонок бесплатный. Maaring makuha and librong ito sa ibang wika ng libre. Tawagan lamang ang Care1st Cal MediConnect Plan Member Services sa numerong (Ang mga gumagamit ng TTY/TDD ay dapat tumawag sa 711), 8:00 a.m. 8:00 p.m., pitong araw sa isang linggo. Ang tawag ay libre. يمكنك الحصول على هذا الكتيب مجان ا بلغات أخرى. اتصل بخدمات أعضاء خطة Care1st Cal MediConnect على الرقم )ينبغي على مستخدمي TTY/TDD من ضعاف السمع االتصال بالرقم 711( من الساعة 8:00 صباح ا - 8:00 مساء طوال أيام األسبوع. االتصال مجان ا You can make a standing request to get materials in a language other than English or in an alternate format now and in the future. To make a request, please contact Care1st Member Services. About Care1st Cal MediConnect Plan Care1st Health Plan is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Coverage under Care1st Cal MediConnect Plan qualifies as minimum essential coverage (MEC). It satisfies the Patient Protection and Affordable Care Act s (ACA) individual shared responsibility requirement. Please visit the Internal Revenue Service (IRS) website at for more information on the individual shared responsibility requirement for MEC. Care1st Cal MediConnect Plan is offered by Care1st Health Plan. When this Annual Notice of Changes says we, us, or our, it means Care1st Health Plan. When it says the plan or our plan, it means Care1st Cal MediConnect Plan. Disclaimers Care1st Health Plan is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Enrollment in Care1st Health Plan depends on contract renewal Limitations, copays, and restrictions may apply. For more information, call Care1st Cal MediConnect Plan Member Services or read the Care1st Cal MediConnect Plan visit 5

6 Member Handbook. This means that you may have to pay for some services and that you need to follow certain rules to have Care1st Cal MediConnect Plan pay for your services. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits and/or copays may change on January 1 of each year. Copays for prescription drugs may vary based on the level of Extra Help you get. Please contact the plan for more details. Important things to do: Check if there are any changes to our benefits and costs that may affect you. Are there any changes that affect the services you use It is important to review benefit and cost changes to make sure they will work for you next year. Look in section C for information about benefit and cost changes for our plan. Check if there are any changes to our prescription drug coverage that may affect you. Will your drugs be covered Are they in a different cost-sharing tier Can you continue to use the same pharmacies It is important to review the changes to make sure our drug coverage will work for you next year. Look in section C for information about changes to our drug coverage. Check to see if your providers and pharmacies will be in our network next year. Are your doctors in our network What about your pharmacy What about the hospitals or other providers you use Look in section B for information about our Provider and Pharmacy Directory. Think about your overall costs in the plan. How much will you spend out-ofpocket for the services and prescription drugs you use regularly How do the total costs compare to other coverage options Think about whether you are happy with our plan. visit 6

7 If you decide to stay with Care1st Cal MediConnect Plan: If you want to stay with us next year, it s easy you don t need to do anything. If you don t make a change, you will automatically stay enrolled in our plan. If you decide to change plans: If you decide other coverage will better meet your needs, you can switch plans at any time. If you enroll in a new plan, your new coverage will begin on the first day of the following month. Look in section D, pages to learn more about your choices. B. Changes to the network providers and pharmacies Our provider and pharmacy networks have changed for We strongly encourage you to review our current Provider and Pharmacy Directory to see if your providers or pharmacy are still in our network. An updated Provider and Pharmacy Directory is located on our website at You may also call Member Services at for updated provider information or to ask us to mail you a Provider and Pharmacy Directory. It is important that you know that we may also make changes to our network during the year. If your provider does leave the plan, you have certain rights and protections. For more information, see Chapter 3 of your Member Handbook. C. Changes to benefits and costs for next year Changes to benefits and costs for medical services We are changing our coverage for certain medical services and what you pay for these covered medical services next year. The following table describes these changes. visit 7

8 2017 (this year) 2018 (next year) In-Home Supportive Services (IHSS): A program that allows you to select your provider of in-home care if you cannot safely remain in your home without assistance. IHSS services may include but not be limited to: housecleaning, meal preparation, laundry, grocery shopping, personal care, accompaniment to medical appointments and other services. To qualify for IHSS, you must be over 65 years of age, blind, or disabled. In most cases, you must also have income below the level to qualify for the Supplemental Security Income/State Supplementary Program or meet all Medi-Cal income eligibility requirements. In-Home Supportive Services (IHSS): for members receiving IHSS the benefit was managed by the plan. In-Home Supportive Services (IHSS): members receiving IHSS will continue to do so, however the benefit will be managed by the county and not the plan. Changes to prescription drug coverage Changes to our Drug List An updated List of Covered Drugs is located on our website at You may also call Member Services at (TTY; 711), 8:00 a.m. to 8:00 p.m. seven days a week for updated provider information or to ask us to mail you a List of Covered Drugs. The call is free. visit 8

9 The List of Covered Drugs is also called the Drug List. We made changes to our Drug List, including changes to the drugs we cover and changes to the restrictions that apply to our coverage for certain drugs. Review the Drug List to make sure your drugs will be covered next year and to see if there will be any restrictions. If you are affected by a change in drug coverage, we encourage you to: Work with your doctor (or other prescriber) to find a different drug that we cover. You can call Member Services at (TTY: 711), 8:00 a.m.- 8:00 p.m., 7 days a week to ask for a list of covered drugs that treat the same condition. This list can help your provider find a covered drug that might work for you. For current members whose drug is no longer covered on the formulary, Care1st will cover a transitional supply of the drug for 30 days if the member has had a refill within the last 120 days. Drugs no longer on the formulary due to its generic version being available do not qualify for a transition supply. Members who are receiving drugs as a result of an approved formulary exception have been provided with a letter informing them when the exception will expire. Upon expiration of the exception, Care1st will evaluate if an extension can be granted. If granted, the member will be notified of the new expiration date. If not granted, the original expiration date will stand. To extend coverage beyond the original expiration date, you and/or your Provider will be required to submit a new exception request. Please review the formulary exception notification provided by Care1st. Changes to prescription drug costs There are two payment stages for your Medicare Part D prescription drug coverage under Care1st Cal MediConnect Plan. How much you pay depends on which stage you are in when you get a prescription filled or refilled. These are the two stages: Stage 1 Initial Coverage Stage Stage 2 Catastrophic Coverage Stage visit 9

10 Stage 1 Initial Coverage Stage During this stage, the plan pays part of the costs of your drugs, and you pay your share. Your share is called the copay. You begin this stage when you fill your first prescription of the year. Stage 2 Catastrophic Coverage Stage During this stage, the plan pays all of the costs of your drugs through December 31, You begin this stage when you have paid a certain amount of out-of-pocket costs. Stage 1: Initial Coverage Stage During the Initial Coverage Stage, the plan pays a share of the cost of your covered prescription drugs, and you pay your share. Your share is called the copay. The copay depends on what cost-sharing tier the drug is in and where you get it. You will pay a copay each time you fill a prescription. If your covered drug costs less than the copay, you will pay the lower price. We moved some of the drugs on the Drug List to a lower or higher drug tier. If your drugs move from tier to tier, this could affect your copay. To see if your drugs will be in a different tier, look them up in the Drug List. The following table shows your costs for drugs in each of our 3 drug tiers. These amounts apply only during the time when you are in the Initial Coverage Stage (this year) 2018 (next year) Drugs in Tier 1 (generic drugs) Cost for a one-month supply of a drug in Tier 1 that is filled at a network pharmacy Your copay for a onemonth (30-day) supply is $0, $1.20, or $3.30 per prescription. Your copay for a onemonth (30-day) supply is $0, $1.25, $3.35 per prescription. Drugs in Tier 2Tier (Brand Drugs) Your copay for a one- month (30-day) supply is $0, $3.70, or $8.25 per prescription. Your copay for a one-month (30-day) supply is $0, $3.70, $8.35 per prescription. visit 10

11 2017 (this year) 2018 (next year) Drugs in Tier 3 (Non-Medicare Rx/OTC drugs) Cost for a one-month supply of a drug in Tier 3 that is filled at a network pharmacy Your co pay is $0 per prescription Your co pay is $0 per prescription The Initial Coverage Stage ends when your total out-of-pocket costs reach $5,000. At that point the Catastrophic Coverage Stage begins. The plan covers all your drug costs from then until the end of the year. Stage 2: Catastrophic Coverage Stage When you reach the out-of-pocket limit for your prescription drugs, the Catastrophic Coverage Stage begins. You will stay in the Catastrophic Coverage Stage until the end of the calendar year. D. Deciding which plan to choose If you want to change to a different Cal MediConnect plan If you want to keep getting your Medicare and Medi-Cal benefits together from a single plan, you can join a different Cal MediConnect plan. To enroll in a different Cal MediConnect plan, call Heath Care Options at , Monday through Friday from 8:00 am to 5:00 pm. TTY users should call If you want to leave the Cal MediConnect program If you do not want to enroll in a different Cal MediConnect plan after you leave Care1st Cal MediConnect Plan, you will go back to getting your Medicare and Medi-Cal services separately. How you will get Medicare services visit 11

12 You will have three options for getting your Medicare services. By choosing one of these options, you will automatically end your membership in our Cal MediConnect plan: 1. You can change to: A Medicare health plan, such as a Medicare Advantage plan or, if you meet eligibility requirements, Programs of All-inclusive Care for the Elderly (PACE) Here is what to do: Call Medicare at MEDICARE ( ), 24 hours a day, seven days a week. TTY users should call to enroll in the new Medicare-only health plan. If you need help or more information: Call the California Health Insurance Counseling and Advocacy Program (HICAP) at , Monday through Friday from 8:00 a.m. to 5:00 p.m. For more information or to find a local HICAP office in your area, please visit You will automatically be disenrolled from Care1st Cal MediConnect Plan when your new plan s coverage begins. visit 12

13 2. You can change to: Original Medicare with a separate Medicare prescription drug plan Here is what to do: Here is what to do: Call Medicare at MEDICARE ( ), 24 hours a day, seven days a week. TTY users should call If you need help or more information: Call the California Health Insurance Counseling and Advocacy Program (HICAP) at , Monday through Friday from 8:00 a.m. to 5:00 p.m. For more information or to find a local HICAP office in your area, please visit You will automatically be disenrolled from Care1st Cal MediConnect Plan when your Original Medicare coverage begins. visit 13

14 3. You can change to: Original Medicare without a separate Medicare prescription drug plan NOTE: If you switch to Original Medicare and do not enroll in a separate Medicare prescription drug plan, Medicare may enroll you in a drug plan, unless you tell Medicare you don t want to join. You should only drop prescription drug coverage if you get drug coverage from an employer, union or other source. If you have questions about whether you need drug coverage, call the California Health Insurance Counseling and Advocacy Program (HICAP) at , Monday through Friday from 8:00 a.m. to 5:00 p.m. For more information or to find a local HICAP office in your area, please visit Here is what to do: Call Medicare at MEDICARE ( ), 24 hours a day, seven days a week. TTY users should call If you need help or more information: Call the California Health Insurance Counseling and Advocacy Program (HICAP) at , Monday through Friday from 8:00 a.m. to 5:00 p.m. For more information or to find a local HICAP office in your area, please visit You will automatically be disenrolled from Care1st Cal MediConnect Plan when your Original Medicare coverage begins. How you will get Medi-Cal services If you leave our Cal MediConnect plan, you will continue to get your Medi-Cal services through Care1st Health Plan unless you select a different plan for your Medi-Cal services. Your Medi-Cal services include most long-term services and supports and behavioral health care. If you want to choose a different plan for your Medi-Cal services, you need to tell Health Care Options. You can call Heath Care Options at , Monday through Friday from 8:00 am to 5:00 pm. TTY users should call visit 14

15 E. Getting help Getting help from Care1st Cal MediConnect Plan Questions We re here to help. Please call Member Services at (TTY only, call 711. We are available for phone calls 8:00 a.m. 8:00 p.m., 7 days a week. Calls to these numbers are free. Read your 2018 Member Handbook The 2018 Member Handbook is the legal, detailed description of your plan benefits. It has details about next year's benefits and costs. It explains your rights and the rules you need to follow to get covered services and prescription drugs. An up-to-date copy of the 2018 Member Handbook is always available on our website at You may also call Member Services at (TTY: 711) to ask us to mail you a 2018 Member Handbook. Visit our website You can also visit our website at As a reminder, our website has the most up-to-date information about our provider and pharmacy network (Provider and Pharmacy Directory) and our Drug List (List of Covered Drugs). Getting help from the state enrollment broker The state enrollment broker, Health Care Options, can help you sign-up for a health plan. They can also help you cancel the enrollment or disenroll from a Cal MediConnect plan if you choose. You can call Heath Care Options at , Monday through Friday from 8:00 am to 5:00 pm. TTY users should call Getting help from the Cal MediConnect Ombuds Program The Cal MediConnect Ombuds Program can help you if you are having a problem with Care1st Cal MediConnect Plan. The Cal MediConnect Ombuds Program is not connected with us or with any insurance company or health plan. The phone number for the Cal MediConnect Ombuds Program is The services are free. Getting help from the Health Insurance Counseling and Advocacy Program You can also call the Health Insurance Counseling and Advocacy Program (HICAP). The HICAP counselors can help you understand your Cal MediConnect plan choices and answer questions about switching plans. The HICAP is not connected with us or with any insurance company or health plan. The HICAP has trained counselors in every county, and services are free. The HICAP phone number is For more information or to find a local HICAP office in your area, please visit visit 15

16 Getting help from Medicare To get information directly from Medicare: Call MEDICARE ( ). You can call MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Visit the Medicare Website You can visit the Medicare website ( If you choose to disenroll from your Cal MediConnect plan and enroll in a Medicare Advantage plan, the Medicare website has information about costs, coverage, and quality ratings to help you compare Medicare Advantage plans. You can find information about Medicare Advantage plans available in your area by using the Medicare Plan Finder on the Medicare website. (To view the information about plans, go to and click on Find health & drug plans. ) Read Medicare & You 2018 You can read the Medicare & You 2018 Handbook. Every year in the fall, this booklet is mailed to people with Medicare. It has a summary of Medicare benefits, rights and protections, and answers to the most frequently asked questions about Medicare. If you don t have a copy of this booklet, you can get it at the Medicare website ( or by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Getting help from the California Department of Managed Health Care The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at (TTY: 711) and use your health plan's grievance process before contacting the Department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. visit 16

17 The Department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line ( ) for the hearing and speech impaired. The Department's Internet Web site has complaint forms, IMR application forms and instructions online. visit 17