AETNA BETTER HEALTH SM PREMIER PLAN

Transcription

1 AETNA BETTER HEALTH SM PREMIER PLAN 2018 Member Hadbook Aeta Better Health SM Premier Pla (Medicare-Medicaid Pla) is a health pla that cotracts with Medicare ad Michiga Medicaid to provide beefits of both programs to erollees MI (7/17) 2017 Aeta Ic. H8026_18_002_MBR HNDBK ACCEPTED

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3 Aeta Better Health Premier Pla MEMBER HANDBOOK Aeta Better Health Premier Pla Member Hadbook Jauary 1, 2018 December 31, 2018 Your Health ad Drug Coverage uder the Aeta Better Health Premier Pla This hadbook tells you about your coverage uder Aeta Better Health Premier Pla through December 31, It explais health care services, behavioral health coverage, prescriptio drug coverage, ad log term supports ad services. Log term supports ad services help you stay at home istead of goig to a ursig home or hospital. This is a importat legal documet. Please keep it i a safe place. This pla is offered by Aeta Better Health of Michiga, Ic. Whe this Member Hadbook says we, us, or our, it meas Aeta Better Health of Michiga, Ic. Whe it says the pla or our pla, it meas Aeta Better Health Premier Pla. If you speak Spaish or Arabic, laguage assistace services, free of charge, are available to you. Call (TTY: 711), 24 hours a day, 7 days a week. The call is free. Si habla español o árabe, tiee a su disposició servicios de idiomas gratuitos. Llame al (TTY: 711), las 24 horas del día, los 7 días de la semaa. Esta llamada es gratuita. You ca get this documet for free i other formats, such as large prit, braille, or audio. Call (TTY: 711), 24 hours a day, 7 days a week. The call is free. If you wish to make a stadig request to receive materials i a laguage other tha Eglish or i a alterate format, you ca call Member Services at (TTY: 711), 24 hours a day, 7 days a week. Disclaimers Aeta Better Health Premier Pla is a health pla that cotracts with both Medicare ad Michiga Medicaid to provide beefits of both programs to erollees. Coverage uder Aeta Better Health Premier Pla qualifies as miimum essetial coverage (MEC). It satisfies the Patiet Protectio ad Affordable Care Act s (ACA) idividual shared resposibility requiremet. Please visit the Iteral Reveue Service (IRS) website at for more iformatio o the idividual shared resposibility requiremet for MEC. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 1

4 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 1: Gettig started as a member Limitatios, restrictios, ad patiet pay amouts may apply. This meas that you may have to pay for some services ad that you eed to follow certai rules to have Aeta Better Health Premier Pla pay for your services. For more iformatio, call Aeta Better Health Premier Pla Member Services or read the Aeta Better Health Premier Pla Member Hadbook. The List of Covered Drugs ad/or pharmacy ad provider etworks may chage throughout the year. We will sed you a otice before we make a chage that affects you. Beefits may chage o Jauary 1 of each year. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 2

5 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 1: Gettig started as a member Table of Cotets A. Welcome to Aeta Better Health Premier Pla...3 B. What are Medicare ad Michiga Medicaid?....4 C. What are the advatages of this pla?...4 D. What is Aeta Better Health Premier Pla s service area?....5 E. What makes you eligible to be a pla member?...5 F. What to expect whe you first joi our pla...6 G. What is a care pla?....6 H. Does Aeta Better Health Premier Pla have a mothly pla premium?...6 I. About the Member Hadbook....7 J. What other iformatio will you get from us?....7 Your Aeta Better Health Premier Pla Member ID Card...7 Provider ad Pharmacy Directory...8 List of Covered Drugs...9 The Explaatio of Beefits...9 K. How ca you keep your membership record up to date?...9 A. Welcome to Aeta Better Health Premier Pla Aeta Better Health Premier Pla is a Medicare-Medicaid Pla. A Medicare-Medicaid Pla is a orgaizatio made up of doctors, hospitals, pharmacies, providers of log term supports ad services, ad other providers. It also has care coordiators ad care teams to help you maage all your providers ad services. They all work together to provide the care you eed. Aeta Better Health Premier Pla was approved by the State of Michiga ad the Ceters for Medicare & Medicaid Services (CMS) to provide you services as part of the MI Health Lik program. MI Health Lik is a program joitly ru by Michiga ad the federal govermet to provide better health care for people who have both Medicare ad Michiga Medicaid. Uder this program, the state ad federal govermet wat to test ew ways to improve how you get your Medicare ad Michiga Medicaid health care services. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 3

6 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 1: Gettig started as a member B. What are Medicare ad Michiga Medicaid? Medicare Medicare is the federal health isurace program for the followig people: people 65 years of age or older, some people uder age 65 with certai disabilities, ad people with ed-stage real disease (kidey failure). Michiga Medicaid Michiga Medicaid is a program ru by the federal govermet ad the State of Michiga that helps people with limited icomes ad resources pay for log term supports ad services ad medical costs. It also covers extra services ad drugs ot covered by Medicare. Each state has its ow Medicaid program. This meas that each state decides what couts as icome ad resources ad who qualifies for Medicaid. They also decide what services are covered by Medicaid ad the cost for those services. States ca decide how to ru their ow Medicaid programs, as log as they follow the federal rules. Medicare ad the State of Michiga must approve Aeta Better Health Premier Pla each year. You ca get Medicare ad Michiga Medicaid services through our pla as log as: you are eligible to participate we choose to offer the pla, ad Medicare ad the State of Michiga approve the pla. Eve if our pla stops operatig i the future, your eligibility for Medicare ad Michiga Medicaid services will ot be affected. C. What are the advatages of this pla? You will ow get all your covered Medicare ad Michiga Medicaid services from Aeta Better Health Premier Pla, icludig prescriptio drugs. You do ot pay extra to joi this health pla. Aeta Better Health Premier Pla will help make your Medicare ad Michiga Medicaid beefits work better together ad work better for you. Some of the advatages iclude: You will ot pay a deductible or copay whe you get services from a provider or pharmacy i our health pla s provider etwork. You will have your ow Care Coordiator who will ask you about your health care eeds ad choices ad work with you to create a persoal care pla based o your goals. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 4

7 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 1: Gettig started as a member Your Care Coordiator will help you get what you eed, whe you eed it. This perso will aswer your questios ad make sure that your health care issues get the attetio they deserve. If you qualify, you will have access to home ad commuity-based supports ad services to help you live idepedetly. Aeta Better Health Premier Pla members get additioal beefits. Please see Chapter 4 for more iformatio. D. What is Aeta Better Health Premier Pla s service area? Our service area icludes these couties i Michiga: Regio 4: Barry, Berrie, Brach, Calhou, Cass, Kalamazoo, St. Joseph, ad Va Bure. Regio 7: Waye. Regio 9: Macomb. Oly people who live i our service area ca get Aeta Better Health Premier Pla. If you move outside of our service area, you caot stay i this pla. E. What makes you eligible to be a pla member? You are eligible for our pla as log as the followig are true: you live i our service area, ad you have Medicare Part A, Part B, ad Part D, ad you are eligible for full Michiga Medicaid beefits, ad you are a Uited States citize or are lawfully preset i the Uited States, ad you are ot already erolled i hospice, ad o to lear more about the hospice beefit please look at Chapter 4 of the Member Hadbook you are ot erolled i the MI Choice waiver program or the Program of All-iclusive Care for the Elderly (PACE). If you are erolled i either of these programs, you eed to diseroll before erollig i the MI Health Lik program through Aeta Better Health Premier Pla. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 5

8 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 1: Gettig started as a member F. What to expect whe you first joi our pla You will get a Level I Assessmet withi the first 45 days of joiig our pla. Oe of our Care Coordiators will cotact you withi the first 45 days of erollig with Aeta Better Health Premier Pla. The Care Coordiator will ask you a few questios to idetify your immediate ad log-term eeds. The Care Coordiator will also work with you, your providers, your family ad ayoe else you choose to develop a care pla that will help you get all the services ad care you eed. If Aeta Better Health Premier Pla is ew for you, you ca keep gettig services ad seeig the doctors ad other providers you go to ow for at least 90 days from your erollmet start date. If you get services through the Habilitatio Supports Waiver or the Specialty Services ad Supports Program through the Prepaid Ipatiet Health Pla (PIHP), you will be able to get services ad see the doctors ad providers you go to ow for up to 180 days from your erollmet start date. Your Care Coordiator will work with you to choose ew providers ad arrage services withi this time period if your curret provider is ot part of Aeta Better Health Premier Pla s provider etwork. Call Aeta Better Health Premier Pla for iformatio about ursig home services. After your first 90 days i Aeta Better Health Premier Pla (180 days if you get services through the Habilitatio Supports Waiver or the Specialty Services ad Supports Program through the PIHP), you will eed to see doctors ad other providers i the Aeta Better Health Premier Pla etwork. A etwork provider is a provider who works with the health pla. See Chapter 3 for more iformatio o gettig care. G. What is a care pla? A care pla is the pla for what supports ad services you will get ad how you will get them. After your Level I Assessmet, your care team will meet with you to talk about what health services you eed ad wat. Together, you ad your care team will make a care pla. Every year, ad whe the health services you eed ad wat chage, your care team will work with you to update your care pla. H. Does Aeta Better Health Premier Pla have a mothly pla premium? No. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 6

9 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 1: Gettig started as a member I. About the Member Hadbook This Member Hadbook is part of our cotract with you. This meas that we must follow all of the rules i this documet. If you thik we have doe somethig that goes agaist these rules, you may be able to appeal, or challege, our actio. For iformatio about how to appeal, see Chapter 9, or call MEDICARE ( ). The cotract is i effect for the moths you are erolled i Aeta Better Health Premier Pla betwee Jauary 1, 2018 ad December 31, J. What other iformatio will you get from us? You should have already gotte a Aeta Better Health Premier Pla Member ID Card, iformatio about how to access a Provider ad Pharmacy Directory ad a List of Covered Drugs. Your Aeta Better Health Premier Pla Member ID Card Uder our pla, you will have oe card for your Medicare ad Michiga Medicaid services, icludig log term supports ad services ad prescriptios. You must show this card whe you get ay services or prescriptios. Here s a sample card to show you what yours will look like : I case of emergecy, call 911 or go to the earest emergecy room. AETNA BETTER HEALTH SM PREMIER PLAN Member Name: Last Name, First Name Health Pla (80840): PCP Name: Last Name, First Name PCP Phoe: MEMBER CANNOT BE CHARGED Copays: $0 H RxBIN: RxPCN: MEDDADV RxGRP: RX8827 MEMIDUAL1 Member Services: (TTY 711) 24 Hour Nurse Advice Lie: (TTY 711) Visio Services: Detal Services: Cotact Member Services for Pharmacy beefit assistace Website: Behavioral Health Services: [1-XXX-XXX-XXXX] 24 Hr Behavioral Health Crisis Lie: [1-XXX-XXX-XXXX] Sed Claims to: Aeta Better Health of Michiga Payer ID: 128MI PO Box 66215, Phoeix, AZ Claim Iquiry: (TTY 711) MIDUAL14A If your card is damaged, lost, or stole, call Member Services right away ad we will sed you a ew card. As log as you are a member of our pla, you do ot eed to use your red, white, ad blue Medicare card or your Michiga Medicaid card to get services. Keep those cards i a safe place, i case you eed them later. If you show your Medicare card istead of your Aeta Better Health Premier Pla Member ID Card, the provider may bill Medicare istead of our pla, ad you may get a bill. See Chapter 7 to see what to do if you get a bill from a provider. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 7

10 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 1: Gettig started as a member Provider ad Pharmacy Directory The Provider ad Pharmacy Directory lists the providers ad pharmacies i the Aeta Better Health Premier Pla etwork. While you are a member of our pla, you must use etwork providers to get covered services. There are some exceptios whe you first joi our pla. (See page 29). You ca ask for a aual Provider ad Pharmacy Directory by callig Member Services at (TTY: 711), 24 hours a day, 7 days a week. You ca also see the Provider ad Pharmacy Directory at or dowload it from this website. The Provider & Pharmacy Directory has iformatio o how to get care ad lists health care professioals (such as doctors ad urse practitioers), facilities (such as hospitals or cliics), ad support providers (such as adult day health ad home health providers) that you may see as a Aeta Better Health Premier Pla member. It also lists the pharmacies that you may use to get your prescriptio drugs. What are etwork providers? Aeta Better Health Premier Pla s etwork providers iclude: o o o Doctors, urses, ad other health care professioals that you ca go to as a member of our pla; Cliics, hospitals, ursig facilities, ad other places that provide health services i our pla; ad Home health agecies, durable medical equipmet suppliers, ad others who provide goods ad services that you get through Medicare or Michiga Medicaid. Network providers have agreed to accept paymet from our pla for covered services as paymet i full. What are etwork pharmacies? Network pharmacies are pharmacies (drug stores) that have agreed to fill prescriptios for our pla members. Use the Provider ad Pharmacy Directory to fid the etwork pharmacy you wat to use. Except durig a emergecy, you must fill your prescriptios at oe of our etwork pharmacies if you wat our pla to pay for them. Call Member Services at (TTY: 711), 24 hours a day, 7 days a week for more iformatio. Both Member Services ad Aeta Better Health Premier Pla s website ca give you the most up-to-date iformatio about chages i our etwork pharmacies ad providers. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 8

11 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 1: Gettig started as a member List of Covered Drugs The pla has a List of Covered Drugs. We call it the Drug List for short. It tells which prescriptio drugs are covered by Aeta Better Health Premier Pla. The Drug List also tells you if there are ay rules or restrictios o ay drugs, such as a limit o the amout you ca get. See Chapter 5 for more iformatio o these rules ad restrictios. Each year, we will sed you iformatio about how to access a List of Covered Drugs, but some chages may occur durig the year. To get the most up-to-date iformatio about which drugs are covered, visit or call (TTY: 711), 24 hours a day, 7 days a week. The Explaatio of Beefits Whe you use your Part D prescriptio drug beefits, we will sed you a summary report to help you uderstad ad keep track of paymets for your Part D prescriptio drugs. This summary report is called the Explaatio of Beefits (or EOB). The Explaatio of Beefits tells you the total amout you or others o your behalf have spet o your Part D prescriptio drugs ad the total amout we have paid for each of your Part D prescriptio drugs durig the moth. Chapter 6 gives more iformatio about the Explaatio of Beefits ad how it ca help you keep track of your drug coverage. A Explaatio of Beefits is also available whe you ask for oe. To get a copy, please cotact Member Services. K. How ca you keep your membership record up to date? You ca keep your membership record up to date by lettig us kow whe your iformatio chages. The pla s etwork providers ad pharmacies eed to have the right iformatio about you. They use your membership record to kow what services ad drugs you get ad how much it will cost you. Because of this, it is very importat that you help us keep your iformatio up-to-date. Let us kow the followig: If you have ay chages to your ame, your address, or your phoe umber If you have ay chages i ay other health isurace coverage, such as from your employer, your spouse s employer, or workers compesatio If you have ay liability claims, such as claims from a automobile accidet If you are admitted to a ursig home or hospital If you get care i a out-of-area or out-of-etwork hospital or emergecy room If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 9

12 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 1: Gettig started as a member If your caregiver or ayoe resposible for you chages If you are part of a cliical research study If ay iformatio chages, please let us kow by callig Member Services at (TTY: 711), 24 hours a day, 7 days a week. Do we keep your persoal health iformatio private? Yes. Laws require that we keep your medical records ad persoal health iformatio private. We make sure that your health iformatio is protected. For more iformatio about how we protect your persoal health iformatio, see Chapter 8. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 10

13 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources Table of Cotets A. How to cotact Aeta Better Health Premier Pla Member Services Cotact Member Services about: Questios about the pla Questios about claims, billig or Member ID Cards Coverage decisios about your health care Appeals about your health care Complaits about your health care Coverage decisios about your drugs Appeals about your drugs Complaits about your drugs Paymet for health care or drugs you already paid for B. How to cotact your Care Coordiator Cotact your Care Coordiator about: Questios about your health care Questios about gettig behavioral health services, trasportatio, ad log term supports ad services (LTSS) Questios about ay other supports ad services you eed C. How to cotact the 24 Hour Nurse Advice Lie Cotact the 24 Hour Nurse Advice Lie about: Questios about your health care D. How to cotact the PIHP Geeral Iformatio Lie ad Behavioral Health Crisis Lie Regio 4 PIHP Geeral Iformatio Lie Regio 7 PIHP Geeral Iformatio Lie Regio 9 PIHP Geeral Iformatio Lie If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 11

14 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources Cotact the PIHP Geeral Iformatio Lie about: Questios about behavioral health services Where ad how to get a assessmet Where to go to get services A list of other commuity resources Behavioral Health Crisis Lie: Cotact the Behavioral Health Crisis Lie about: Suicidal thoughts Iformatio o metal health/illess Substace abuse/addictio To help a fried or loved oe Relatioship problems Abuse/violece Ecoomic problems causig axiety/depressio Loeliess Family problems E. How to cotact the State Health Isurace Assistace Program (SHIP) Cotact MMAP about: Questios about your Medicare ad Michiga Medicaid health isurace F. How to cotact the Quality Improvemet Orgaizatio (QIO) Cotact KEPRO about: Questios about your health care G. How to cotact Medicare H. How to cotact Michiga Medicaid I. How to cotact the MI Health Lik Ombudsma program J. How to cotact the State Log Term Care Ombudsma program K. Other resources If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 12

15 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources A. How to cotact Aeta Better Health Premier Pla Member Services CALL TTY This call is free. 24 hours a day, 7 days a week We have free iterpreter services for people who do ot speak Eglish. 711 This call is free. 24 hours a day, 7 days a week FAX WRITE WEBSITE Aeta Better Health Premier Pla 1333 Gratiot Aveue, Suite 400 Detroit, MI Cotact Member Services about: Questios about the pla Questios about claims, billig or Member ID Cards Coverage decisios about your health care A coverage decisio about your health care is a decisio about:» your beefits ad covered services, or» the amout we will pay for your health services. Call us if you have questios about a coverage decisio about health care. To lear more about coverage decisios, see Chapter 9. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 13

16 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources Appeals about your health care A appeal is a formal way of askig us to review a decisio we made about your coverage ad askig us to chage it if you thik we made a mistake. To lear more about makig a appeal, see Chapter 9. Complaits about your health care You ca make a complait about us or ay provider (icludig a o-etwork or etwork provider). A etwork provider is a provider who works with the health pla. You ca also make a complait about the quality of the care you got to us or to the Quality Improvemet Orgaizatio (see Sectio F below). If your complait is about a coverage decisio about your health care, you ca make a appeal (see the sectio above). You ca sed a complait about Aeta Better Health Premier Pla right to Medicare. You ca use a olie form at Or you ca call MEDICARE ( ) to ask for help. To lear more about makig a complait about your health care, see Chapter 9. Coverage decisios about your drugs A coverage decisio about your drugs is a decisio about:» your beefits ad covered drugs, or» the amout we will pay for your drugs. This applies to your Part D drugs, Michiga Medicaid prescriptio drugs, ad Michiga Medicaid over-the-couter drugs. For more o coverage decisios about your prescriptio drugs, see Chapter 9. Appeals about your drugs A appeal is a way to ask us to chage a coverage decisio. For more o makig a appeal about your prescriptio drugs, see Chapter 9. Complaits about your drugs You ca make a complait about us or ay pharmacy. This icludes a complait about your prescriptio drugs. If your complait is about a coverage decisio about your prescriptio drugs, you ca make a appeal. (See the sectio above.) If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 14

17 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources You ca sed a complait about Aeta Better Health Premier Pla right to Medicare. You ca use a olie form at Or you ca call MEDICARE ( ) to ask for help. For more o makig a complait about your prescriptio drugs, see Chapter 9. Paymet for health care or drugs you already paid for For more o how to ask us to pay you back, or to pay a bill you got, see Chapter 7. If you ask us to pay a bill ad we dey ay part of your request, you ca appeal our decisio. See Chapter 9 for more o appeals. B. How to cotact your Care Coordiator As a Aeta Better Health Premier Pla member, you will be assiged a Care Coordiator. This is a perso who works with you ad your care providers to make sure you get the care ad service you eed. Your Care Coordiator will give you his or her phoe umber ad address so you ca cotact him or her. It is importat that you have a good relatioship with your Care Coordiator. If you wat to chage your Care Coordiator, please call Member Services ad ask to speak to the Care Maagemet departmet. CALL TTY WRITE WEBSITE This call is free. 24 hours a day, 7 days a week We have free iterpreter services for people who do ot speak Eglish. 711 This call is free. 24 hours a day, 7 days a week Aeta Better Health Premier Pla Att: Care Maagemet Dept Gratiot Aveue, Suite 400 Detroit, MI If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 15

18 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources Cotact your Care Coordiator about: Questios about your health care Questios about gettig behavioral health services, trasportatio, ad log term supports ad services (LTSS) Questios about ay other supports ad services you eed Whe you first joi Aeta Better Health Premier Pla, oe of our Care Coordiators will meet with you to do a assessmet. The assessmet will help us lear about your health eeds. It will also help us idetify if you are eligible for LTSS. If you are eligible, we will re-evaluate you aually to idetify if your eeds or eligibility have chaged. To be eligible for LTSS, you must be at a istitutioal level of care. You may be eligible to receive some LTSS through a waiver. Sometimes you ca get help with your daily health care ad livig eeds. You might be able to get these services:» Skilled ursig care» Physical therapy» Occupatioal therapy» Speech therapy» Persoal Care Services» Home health care See Chapter 4 for additioal iformatio about Home ad Commuity Based waiver services. C. How to cotact the 24 Hour Nurse Advice Lie Aeta Better Health Premier Pla has a Nurse Advice Lie available to help aswer your medical questios. The Nurse Advice Lie does ot take the place of your primary care provider but is available as aother resource for you. This service is available 24 hours a day, 7 days a week. It is staffed by medical professioals. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 16

19 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources CALL TTY This call is free. 24 hours a day, 7 days a week We have free iterpreter services for people who do ot speak Eglish. 711 This call is free. 24 hours a day, 7 days a week Cotact the 24 Hour Nurse Advice Lie about: Questios about your health care D. How to cotact the PIHP Geeral Iformatio Lie ad Behavioral Health Crisis Lie Behavioral health services will be available to Aeta Better Health Premier Pla members through the local Prepaid Ipatiet Health Pla (PIHP) provider etwork. Members gettig services through the PIHP will cotiue to get them accordig to their pla of care. Aeta Better Health Premier Pla will provide the persoal care services previously provided by the Departmet of Health ad Huma Services (DHHS) Home Help program. Other medically ecessary behavioral health, itellectual/developmetal disability, ad substace use disorder services, icludig psychotherapy or couselig (idividual, family ad group) whe idicated, are available ad coordiated through the health pla ad PIHP. PIHP Geeral Iformatio Lie: Regio 4 PIHP Geeral Iformatio Lie Servig: Barry, Berrie, Brach, Calhou, Cass, Kalamazoo, St. Joseph, Va Bure couties CALL TTY This call is free. Moday Friday, 8 a.m. to 8 p.m. We have free iterpreter services for people who do ot speak Eglish. 711 This call is free. Moday Friday, 8 a.m. to 8 p.m. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 17

20 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources Regio 7 PIHP Geeral Iformatio Lie Servig: Waye Couty CALL TTY This call is free. 24 hours a day, 7 days a week We have free iterpreter services for people who do ot speak Eglish. 711 This call is free. 24 hours a day, 7 days a week Regio 9 PIHP Geeral Iformatio Lie Servig: Macomb Couty CALL TTY This call is free. Moday Friday, 8 a.m. to 8 p.m. We have free iterpreter services for people who do ot speak Eglish. 711 This call is free. Moday Friday, 8 a.m. to 8 p.m. Cotact the PIHP Geeral Iformatio Lie about: Questios about behavioral health services Where ad how to get a assessmet Where to go to get services A list of other commuity resources If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 18

21 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources Behavioral Health Crisis Lie: Regio 4 Barry, Berrie, Brach, Calhou, Cass, Kalamazoo, St. Joseph, Va Bure Couties CALL TTY This call is free. 24 hours a day, 7 days a week We have free iterpreter services for people who do ot speak Eglish. 711 This call is free. 24 hours a day, 7 days a week Regio 7 Behavioral Health Crisis Lie Servig: Waye Couty CALL TTY This call is free. 24 hours a day, 7 days a week We have free iterpreter services for people who do ot speak Eglish. 711 This call is free. 24 hours a day, 7 days a week Regio 9 PIHP Behavioral Health Crisis Lie Servig: Macomb Couty CALL TTY This call is free. 24 hours a day, 7 days a week We have free iterpreter services for people who do ot speak Eglish. 711 This call is free. 24 hours a day, 7 days a week If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 19

22 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources Cotact the Behavioral Health Crisis Lie about: Suicidal thoughts Iformatio o metal health/illess Substace abuse/addictio To help a fried or loved oe Relatioship problems Abuse/violece Ecoomic problems causig axiety/depressio Loeliess Family problems If you are experiecig a life or death emergecy, please call or go to the earest hospital. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 20

23 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources E. How to cotact the State Health Isurace Assistace Program (SHIP) The State Health Isurace Assistace Program (SHIP) gives free health isurace couselig to people with Medicare. I Michiga, the SHIP is called the Michiga Medicare/Medicaid Assistace Program (MMAP). MMAP is ot coected with ay isurace compay or health pla. CALL This call is free. Hours of operatio are: Moday through Friday, 8 AM to 5 PM. TRS 711 This umber is for people who have hearig or speakig problems. You must have special telephoe equipmet to call it. WRITE 6105 St Joe Hwy #204 Lasig Charter Towship, MI WEBSITE ifo@mmapic.org Cotact MMAP about: Questios about your Medicare ad Michiga Medicaid health isurace MMAP couselors ca:» help you uderstad your rights,» help you uderstad drug coverage, such as prescriptio ad over-the-couter drugs,» help you uderstad your pla choices,» aswer your questios about chagig to a ew pla,» help you make complaits about your health care or treatmet, ad» help you straighte out problems with your bills. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 21

24 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources F. How to cotact the Quality Improvemet Orgaizatio (QIO) Our state uses a orgaizatio called KEPRO for quality improvemet. This is a group of doctors ad other health care professioals who help improve the quality of care for people with Medicare. KEPRO is ot coected with our pla. CALL This call is free. Helplie hours of operatio are: Moday through Friday, 9 AM to 5 PM Saturdays, Sudays, ad Holidays, 11 AM to 3 PM TTY This umber is for people who have hearig or speakig problems. You must have special telephoe equipmet to call it. WRITE WEBSITE KEPRO 5201 W. Keedy Blvd., Suite 900 Tampa, FL KEPRO.Commuicatios@hcqis.org Cotact KEPRO about: Questios about your health care You ca make a complait about the care you got if:» You have a problem with the quality of care,» You thik your hospital stay is edig too soo, or» You thik your home health care, skilled ursig facility care, or comprehesive outpatiet rehabilitatio facility (CORF) services are edig too soo. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 22

25 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources G. How to cotact Medicare Medicare is the federal health isurace program for people 65 years of age or older, some people uder age 65 with disabilities, ad people with ed-stage real disease (permaet kidey failure requirig dialysis or a kidey trasplat). The federal agecy i charge of Medicare is the Ceters for Medicare & Medicaid Services, or CMS. CALL MEDICARE ( ) Calls to this umber are free, 24 hours a day, 7 days a week. TTY WEBSITE This call is free. This umber is for people who have hearig or speakig problems. You must have special telephoe equipmet to call it. This is the offcial website for Medicare. It gives you up-to-date iformatio about Medicare. It also has iformatio about hospitals, ursig homes, physicias, home health agecies, ad dialysis facilities. It icludes booklets you ca prit right from your computer. You ca also fid Medicare cotacts i your state by selectig Forms, Help & Resources ad the clickig o Phoe umbers & websites. The Medicare website has the followig tool to help you fid plas i your area: Medicare Pla Fider: Provides persoalized iformatio about Medicare prescriptio drug plas, Medicare health plas, ad Medigap (Medicare Supplemet Isurace) policies i your area. Select Fid health & drug plas. If you do t have a computer, your local library or seior ceter may be able to help you visit this website usig its computer. Or, you ca call Medicare at the umber above ad tell them what iformatio you are lookig for. They will fid the iformatio o the website, prit it out, ad sed it to you. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 23

26 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources H. How to cotact Michiga Medicaid Michiga Medicaid helps with medical ad log term supports ad services costs for people with limited icomes ad resources. You are erolled i Medicare ad i Michiga Medicaid. If you have questios about the help you get from Michiga Medicaid, call the Beeficiary Help Lie. CALL Beeficiary Help Lie This call is free. Offce hours are Moday through Friday, 8 AM to 7 PM. TTY This umber is for people who have hearig or speakig problems. You must have special telephoe equipmet to call it. WRITE PO Box Lasig, MI Michiga Medicaid eligibility is determied by the Michiga Departmet of Health ad Huma Services. If you have questios about your Michiga Medicaid eligibility or yearly reewal, cotact your Departmet of Health ad Huma Services Specialist. For geeral questios about Departmet of Health ad Huma Services assistace programs, call Moday through Friday, 8 AM to 5 PM. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 24

27 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources I. How to cotact the MI Health Lik Ombudsma program The MI Health Lik Ombudsma program helps people erolled i MI Health Lik with service or billig problems. They ca help you file a complait or a appeal with our pla. CALL TTY 711 This umber is for people who have hearig or speakig problems. You must have special telephoe equipmet to call it. WEBSITE help@mhlo.org J. How to cotact the State Log Term Care Ombudsma program The State Log Term Care Ombudsma program helps people lear about ursig homes ad other log term care settigs. It also helps solve problems betwee these settigs ad residets or their families. CALL WRITE WEBSITE State Log Term Care Ombudsma South US 27, Suite 73 Lasig, MI SLTCO@michiga.gov If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 25

28 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources K. Other resources LOCAL AREA AGENCY CALL WEBSITE AND AREA SERVED Detroit Area Agecy o Agig 1A Couties served: Detroit area Area Agecy O Agig 1B Couties served: Livigsto, Macomb, Moroe, Oaklad, St. Clair ad Washteaw Area Agecy O Agig 1C The Seior Alliace Couties served: Souther ad Wester Waye Area Agecy o Agig 3A Couty served: Kalamazoo Area Agecy o Agig 3B Couties served: Barry ad Calhou Area Agecy o Agig 3C Couties served: Brach ad St. Joseph Area Agecy o Agig Couties served: Berrie, Cass ad Va Bure If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 26

29 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services Table of Cotets A. About services, covered services, providers, ad etwork providers B. Rules for gettig your health care, behavioral health, ad log term supports ad services covered by the pla C. Your Care Coordiator D. Gettig care from primary care providers, specialists, other etwork providers, ad out-of-etwork providers E. How to get log term supports ad services (LTSS) F. How to get behavioral health services G. How to participate i self-determiatio arragemets H. How to get trasportatio services I. How to get covered services whe you have a medical emergecy or urget eed for care, or durig a disaster J. What if you are billed directly for services covered by our pla? K. How are your health care services covered whe you are i a cliical research study? L. How are your health care services covered whe you are i a religious o-medical health care istitutio? M. Rules for owig durable medical equipmet (DME) If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 27

30 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services A. About services, covered services, providers, ad etwork providers Services are health care, log term supports ad services, supplies, behavioral health, prescriptio ad over-the-couter drugs, equipmet ad other services. Covered services are ay of these services that our pla pays for. Covered health care ad log term supports ad services are listed i the Beefits Chart i Chapter 4. Providers are doctors, urses, ad other people who give you services ad care. The term providers also icludes hospitals, home health agecies, cliics, ad other places that give you health care services, medical equipmet, ad log term supports ad services. Network providers are providers who work with the health pla. These providers have agreed to accept our paymet as full paymet. Network providers bill us directly for care they give you. Whe you see a etwork provider, you will pay othig for covered services. B. Rules for gettig your health care, behavioral health, ad log term supports ad services covered by the pla Aeta Better Health Premier Pla covers all services covered by Medicare ad Michiga Medicaid. This icludes behavioral health services, log-term care, ad prescriptio drugs. Aeta Better Health Premier Pla will geerally pay for the health care ad other supports ad services you get if you follow the pla rules. To be covered: The care you get must be a pla beefit. This meas that it must be icluded i the pla s Beefits Chart. (The chart is i Chapter 4 of this hadbook). The care must be medically ecessary. Medically ecessary meas you eed services to prevet, diagose, or treat your medical coditio or to maitai your curret health status. This icludes care that keeps you from goig ito a hospital or ursig home. It also meas the services, supplies, or drugs meet accepted stadards of medical practice. You must have a etwork primary care provider (PCP) who has ordered the care or has told you to see aother doctor. As a pla member, you must choose a etwork provider to be your PCP.» You do ot eed a referral from your PCP for emergecy care or urgetly eeded care or to see a woma s health provider. You ca get other kids of care without havig a referral from your PCP. To lear more about this, see page 31. To lear more about choosig a PCP, see page 31. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 28

31 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services You must get your care from etwork providers. Usually, the pla will ot cover care from a provider who does ot work with the health pla. Here are some cases whe this rule does ot apply:» The pla covers emergecy or urgetly eeded care from a out-of-etwork provider. To lear more ad to see what emergecy or urgetly eeded care meas, see page 36.» If you eed care that our pla covers ad our etwork providers caot give it to you, you ca get the care from a out-of-etwork provider. The out-ofetwork provider must first get prior authorizatio from Aeta Better Health Premier Pla. I this situatio, we will cover the care as if you got it from a etwork provider. To lear about gettig approval to see a out-of-etwork provider, see page 33.» The pla covers kidey dialysis services whe you are outside the pla s service area for a short time. You ca get these services at a Medicare-certified dialysis facility.» Whe you first joi the pla, you ca keep gettig services ad seeig the doctors ad other providers you go to ow for at least 90 days from your erollmet start date. If you get services through the Habilitatio Supports Waiver or the Specialty Services ad Supports Program through the Prepaid Ipatiet Health Pla (PIHP), you will be able to get services ad see the doctors ad providers you go to ow for up to 180 days from your erollmet start date. Your Care Coordiator will work with you to choose ew providers ad arrage services withi this time period. Call Aeta Better Health Premier Pla for iformatio about ursig home services. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 29

32 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services C. Your Care Coordiator What is a Care Coordiator? A Care Coordiator is a perso who will work with you to help you get the Medicare ad Michiga Medicaid covered supports ad services you eed ad wat. How ca you cotact your Care Coordiator? Whe you first meet with your Care Coordiator, he or she will give you his or her phoe umber. You ca also reach your Care Coordiator by callig Member Services. How ca you chage your Care Coordiator? Call Member Services ad let us kow you would like to chage Care Coordiators. We will coect you to the Care Maagemet departmet to discuss your optios. D. Gettig care from primary care providers, specialists, other etwork providers, ad out-of-etwork providers Gettig care from a primary care provider You must choose a primary care provider (PCP) to provide ad maage your care. What is a PCP, ad what does the PCP do for you? What is a PCP? Your primary care provider (PCP) works with you ad your Care Coordiator to direct ad coordiate your health care. A PCP may be a doctor, a urse practitioer, or i some cases, a specialist. Your PCP does your prevetive care checkups ad treats you for most of your routie health care eeds. If eeded, your PCP will sed you to other doctors (specialists) or admit you to the hospital. Although you do ot eed approval (called a referral) from your PCP to see other providers, it is importat to cotact your PCP before you see a specialist or before seeig aother doctor for a o-emerget coditio. You should also cotact your PCP for follow-up after ay urget or emergecy departmet visit or hospital stay. This allows your PCP to maage your care for the best outcomes. What types of providers may act as a PCP? o o o o o Geeral Practice Family Practice Iteral Medicie OB/GYN Geriatrics If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 30

33 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services There are times whe doctors other tha the types above may serve as a PCP. If you have a chroic health coditio like diabetes, you may eed a specialist to take care of you as your PCP. Member Services or your Care Coordiator ca help you with this decisio. If you wat a specialist to be your PCP, the specialist must agree to do so ad must cotact us first to make arragemets. Your PCP ad your other providers are resposible for followig Aeta Better Health Premier Pla s prior authorizatio requiremets, ad for gettig a authorizatio umber. How do you choose your PCP? Whe choosig your PCP, cosider the followig: Do you have a PCP you would like to cotiue to see? Is your PCP s offce close to your home? Does your PCP practice at a hospital close to your home? Do you go to a Rural Health Cliic (RHC) or Federally Qualified Health Ceter (FQHC) for your care? Ways to fid a PCP i our etwork: Go to ad select Fid a Provider / Pharmacy. Call your Care Coordiator or Member Services. Look i your prited Provider ad Pharmacy Directory, if you requested oe. Chagig your PCP You may chage your PCP for ay reaso, at ay time. Also, it s possible that your PCP might leave our pla s etwork. We ca help you fid a ew PCP. To fid a ew PCP, use our provider search tool o our website at How to get care from specialists ad other etwork providers A specialist is a doctor who provides health care for a specific disease or part of the body. There are may kids of specialists. Here are a few examples: Ocologists care for patiets with cacer. Cardiologists care for patiets with heart problems. Orthopedists care for patiets with boe, joit, or muscle problems. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 31

34 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services You ca go to ay specialist i our etwork. Your PCP or Care Coordiator ca recommed a specialist to you. Member Services ca also help you fid a specialist ear you. You do ot eed a referral to see a etwork specialist however the specialist may have to cotact us to get approval to see you before your appoitmet. This is called prior authorizatio. Aeta Better Health Premier Pla cliicias ad Medical Directors review the services to make sure they are what you eed. Your providers must get prior authorizatio from the pla before you ca get certai services. See the Beefits Chart i Chapter 4 for iformatio about which services require prior authorizatio. The beefits that require prior authorizatio are marked with a asterisk (*) i the Beefits Chart. What if a etwork provider leaves our pla? A etwork provider you are usig might leave our pla. If oe of your providers does leave our pla, you have certai rights ad protectios that are summarized below: Eve though our etwork of providers may chage durig the year, we must give you uiterrupted access to qualified providers. We will make a good faith effort to give you at least 30 days otice so that you have time to select a ew provider. We will help you select a ew qualified provider to cotiue maagig your health care eeds. If you are udergoig medical treatmet, you have the right to ask, ad we will work with you to esure, that the medically ecessary treatmet you are gettig is ot iterrupted. If you believe we have ot replaced your previous provider with a qualified provider or that your care is ot beig appropriately maaged, you have the right to file a appeal of our decisio. If you fid out oe of your providers is leavig our pla, please cotact us so we ca assist you i fidig a ew provider ad maagig your care. Talk to your Care Coordiator or cotact Member Services for help. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 32

35 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services How to get care from out-of-etwork providers Geerally, you must see providers that are i our etwork. There are times whe you ca see a out-of-etwork provider, such as: You eed emergecy services. You eed urget care. You are out of the service area ad eed dialysis. Aeta Better Health Premier Pla has approved you to see a out-of-etwork provider durig or after your trasitio of care time period. The out-of-etwork provider must cotact us to get approval to see you before your appoitmet. A provider with a certai specialty is ot available i etwork. The provider must get prior authorizatio before your appoitmet. Out-of-etwork providers are resposible for gettig prior authorizatio. A prior authorizatio request ca be made by callig (Optio 2) or faxig the request to The prior authorizatio form is available o our website at Please ote: If you go to a out-of-etwork provider, the provider must be eligible to participate i Medicare ad/or Michiga Medicaid. We caot pay a provider who is ot eligible to participate i Medicare ad/or Michiga Medicaid. If you go to a provider who is ot eligible to participate i Medicare, you must pay the full cost of the services you get. Providers must tell you if they are ot eligible to participate i Medicare. E. How to get log term supports ad services (LTSS) As a Aeta Better Health Premier Pla member, you may qualify to receive log-term services ad supports (LTSS) i a ursig facility or at home. LTSS provides assistace to help you stay at home istead of goig to a ursig home or hospital, or may assist you to trasitio from the ursig facility to the commuity. LTSS ca provide assistace with bathig, dressig ad other basic activities of daily livig. LTSS may also iclude home modificatio, adaptive equipmet ad supplies, ad chore services. To qualify for these services, you must meet ursig facility level of care. Your Care Coordiator will meet with you ad assess your eeds. Oce you qualify for these services, we will re-assess you at least aually to see if the services are meetig your eeds. If you have questios about LTSS or to see if you qualify, call your Care Coordiator. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 33

36 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services F. How to get behavioral health services All behavioral health services are available to Aeta Better Health Premier Pla members through the local Pre-paid Ipatiet Health Pla (PIHP) provider etwork. These services are available ad coordiated through your Care Coordiator ad the PIHP. If you curretly receive services through the PIHP, you will cotiue to receive those services accordig to their pla of care. If you eed behavioral health services, talk to your Care Coordiator. To cotact the PIHP directly, see the cotact iformatio i Chapter 2. G. How to participate i self-determiatio arragemets What are arragemets that support self-determiatio? Self-determiatio is a optio available to erollees gettig services through the MI Health Lik HCBS home ad commuity based waiver program. It is a process that allows you to desig ad exercise cotrol over your ow life. This icludes maagig a fixed amout of dollars to cover your authorized supports ad services. Ofte, this is referred to as a idividual budget. If you choose to do so, you would also have cotrol over the hirig ad maagemet of providers. Who ca get arragemets that support self-determiatio? Arragemets that support self-determiatio are available for erollees who get services through the home ad commuity-based services waiver program called MI Health Lik HCBS. How to get help i employig providers? You may work with your care coordiator to get help employig providers. H. How to get trasportatio services If you eed a ride to your appoitmets, call us at (TTY: 711) ad choose the trasportatio optio. You ca also call MTM directly at (TTY: 711) Moday Friday, 8 a.m. 8 p.m. You must call at least 3 days before your appoitmet. If you eed help, call your Care Coordiator or Member Services. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 34

37 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services I. How to get covered services whe you have a medical emergecy or urget eed for care, or durig a disaster Gettig care whe you have a medical emergecy What is a medical emergecy? A medical emergecy is a medical coditio recogizable by symptoms such as severe pai or serious ijury. The coditio is so serious that, if it does t get immediate medical attetio, you or ayoe with a average kowledge of health ad medicie could expect it to result i: serious risk to your health or to that of your ubor child; or serious harm to bodily fuctios; or serious dysfuctio of ay bodily orga or part; or i the case of a pregat woma i active labor, whe:» there is ot eough time to safely trasfer you to aother hospital before delivery.» a trasfer to aother hospital may pose a threat to your health or safety or to that of your ubor child. What should you do if you have a medical emergecy? If you have a medical emergecy: Get help as fast as possible. Call 911 or go to the earest emergecy room or hospital. Call for a ambulace if you eed it. You do ot eed to get approval or a referral first from your PCP. As soo as possible, make sure that you tell our pla about your emergecy. We eed to follow up o your emergecy care. You or someoe else should call to tell us about your emergecy care, usually withi 48 hours. However, you will ot have to pay for emergecy services because of a delay i tellig us. Call your Care Coordiator or Member Services at the toll-free phoe umber o the back of your Member ID Card. What is covered if you have a medical emergecy? You may get covered emergecy care wheever you eed it, aywhere i the Uited States or its territories. If you eed a ambulace to get to the emergecy room, our pla covers that. To lear more, see the Beefits Chart i Chapter 4. If you have a emergecy, we will talk with the doctors who give you emergecy care. Those doctors will tell us whe your medical emergecy is over. After the emergecy is over, you may eed follow-up care to be sure you get better. Your follow-up care will be covered by our pla. If you get your emergecy care from out-of-etwork providers, we will try to get etwork providers to take over your care as soo as possible. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 35

38 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services What if it was t a medical emergecy after all? Sometimes it ca be hard to kow if you have a medical emergecy. You might go i for emergecy care ad have the doctor say it was t really a medical emergecy. As log as you reasoably thought your health was i serious dager, we will cover your care. However, after the doctor says it was ot a emergecy, we will cover your additioal care oly if: you go to a etwork provider, or the additioal care you get is cosidered urgetly eeded care ad you follow the rules for gettig this care. (See the ext sectio.) Gettig urgetly eeded care What is urgetly eeded care? Urgetly eeded care is care you get for a sudde illess, ijury, or coditio that is t a emergecy but eeds care right away. For example, you might have a flare-up of a existig coditio ad eed to have it treated. Gettig urgetly eeded care whe you are i the pla s service area I most situatios, we will cover urgetly eeded care oly if: you get this care from a etwork provider, ad you follow the other rules described i this chapter. However, if you ca t get to a etwork provider, we will cover urgetly eeded care you get from a out-of-etwork provider. You ca call your PCP day or ight. If you have a urget eed, your PCP or o-call provider will tell you what to do. If your PCP is ot i the offce, leave a message with the aswerig service ad your PCP will retur your call. Your PCP may tell you to go to a urget care ceter. You ca fid a urget care ceter o our website at by clickig o Locate a Provider / Pharmacy or by callig Member Services at (TTY: 711), 24 hours a day, 7 days a week. You ca also call our Nurse Advice Lie if you have medical questios. This umber is available 24 hours a day, 7 days a week. It is staffed by medical professioals. The phoe umber is Select the optio for Nurse Advice Lie. Gettig urgetly eeded care whe you are outside the pla s service area Whe you are outside the service area, you might ot be able to get care from a etwork provider. I that case, our pla will cover urgetly eeded care you get from ay provider. Our pla does ot cover urgetly eeded care or ay other care that you get outside the Uited States. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 36

39 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services Gettig care durig a disaster If the Goveror of your state, the U.S. Secretary of Health ad Huma Services, or the Presidet of the Uited States declares a state of disaster or emergecy i your geographic area, you are still etitled to care from Aeta Better Health Premier Pla. Please visit our website for iformatio o how to obtai eeded care durig a declared disaster: Durig a declared disaster, if you caot use a etwork provider, we will allow you to get care from out-of-etwork providers at o cost to you. If you caot use a etwork pharmacy durig a declared disaster, you will be able to fill your prescriptio drugs at a out-of-etwork pharmacy. Please see Chapter 5 for more iformatio. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 37

40 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services J. What if you are billed directly for services covered by our pla? If a provider seds you a bill istead of sedig it to the pla, you ca ask us to pay the bill. You should ot pay the bill yourself. If you do, the pla may ot be able to pay you back. If you have paid for your covered services or if you have gotte a bill for covered medical services, see Chapter 7 to lear what to do. What should you do if services are ot covered by our pla? Aeta Better Health Premier Pla covers all services: that are medically ecessary, ad that are listed i the pla s Beefits Chart (see Chapter 4), ad that you get by followig pla rules. If you get services that are t covered by our pla, you must pay the full cost yourself. If you wat to kow if we will pay for ay medical service or care, you have the right to ask us. You also have the right to ask for this i writig. If we say we will ot pay for your services, you have the right to appeal our decisio. Chapter 9 explais what to do if you wat the pla to cover a medical item or service. It also tells you how to appeal the pla s coverage decisio. You may also call Member Services to lear more about your appeal rights. We will pay for some services up to a certai limit. If you go over the limit, you will have to pay the full cost to get more of that type of service. Call Member Services to fid out what the limits are ad how close you are to reachig them. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 38

41 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services K. How are your health care services covered whe you are i a cliical research study? What is a cliical research study? A cliical research study (also called a cliical trial) is a way doctors test ew types of health care or drugs. They ask for voluteers to help with the study. This kid of study helps doctors decide whether a ew kid of health care or drug works ad whether it is safe. Oce Medicare approves a study you wat to be i, someoe who works o the study will cotact you. That perso will tell you about the study ad see if you qualify to be i it. You ca be i the study as log as you meet the required coditios. You must also uderstad ad accept what you must do for the study. While you are i the study, you may stay erolled i our pla. That way you cotiue to get care from our pla ot related to the study. If you wat to participate i a Medicare-approved cliical research study, you do ot eed to get approval from us or your primary care provider. The providers that give you care as part of the study do ot eed to be etwork providers. You do eed to tell us before you start participatig i a cliical research study. If you pla to be i a cliical research study, you or your Care Coordiator should cotact Member Services to let us kow you will be i a cliical trial. Whe you are i a cliical research study, who pays for what? If you voluteer for a cliical research study that Medicare approves, you will pay othig for the services covered uder the study ad Medicare will pay for services covered uder the study as well as routie costs associated with your care. Oce you joi a Medicare-approved cliical research study, you are covered for most items ad services you get as part of the study. This icludes: Room ad board for a hospital stay that Medicare would pay for eve if you were t i a study. A operatio or other medical procedure that is part of the research study. Treatmet of ay side effects ad complicatios of the ew care. If you are part of a study that Medicare has ot approved, you will have to pay ay costs for beig i the study. Learig more You ca lear more about joiig a cliical research study by readig Medicare & Cliical Research Studies o the Medicare website ( You ca also call MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 39

42 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services L. How are your health care services covered whe you are i a religious o-medical health care istitutio? What is a religious o-medical health care istitutio? A religious o-medical health care istitutio is a place that provides care you would ormally get i a hospital or skilled ursig facility. If gettig care i a hospital or a skilled ursig facility is agaist your religious beliefs, we will cover care i a religious o-medical health care istitutio. You may choose to get health care at ay time for ay reaso. This beefit is oly for Medicare Part A ipatiet services (o-medical health care services). Medicare will oly pay for o-medical health care services provided by religious o-medical health care istitutios. What care from a religious o-medical health care istitutio is covered by our pla? To get care from a religious o-medical health care istitutio, you must sig a legal documet that says you are agaist gettig medical treatmet that is o-excepted. No-excepted medical treatmet is ay care that is volutary ad ot required by ay federal, state, or local law. Excepted medical treatmet is ay care that is ot volutary ad is required uder federal, state, or local law. To be covered by our pla, the care you get from a religious o-medical health care istitutio must meet the followig coditios: The facility providig the care must be certified by Medicare. Our pla s coverage of services is limited to o-religious aspects of care. If you get services from this istitutio that are provided to you i a facility, the followig applies:» You must have a medical coditio that would allow you to get covered services for ipatiet hospital care or skilled ursig facility care.» You must get approval from our pla before you are admitted to the facility or your stay will ot be covered. Our pla will cover ulimited ipatiet hospital days i a etwork hospital whe medically ecessary with prior authorizatio. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 40

43 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services M. Rules for owig durable medical equipmet (DME) Will you ow your DME? Durable medical equipmet (DME) meas certai items ordered by a provider for use i your ow home. Examples of these items are wheelchairs, crutches, powered mattress systems, diabetic supplies, hospital beds ordered by a provider for use i the home, IV ifusio pumps, speech geeratig devices, oxyge equipmet ad supplies, ebulizers, ad walkers. You will always ow certai items, such as prosthetics. I this sectio, we discuss DME you must ret. I Medicare, people who ret certai types of DME ow it after 13 moths. As a member of Aeta Better Health Premier Pla, however, you usually will ot ow DME, o matter how log you ret it. I certai situatios, we will trasfer owership of the DME item to you. Call Member Services to fid out about the requiremets you must meet ad the papers you eed to provide. What happes if you switch to Medicare? You will have to make 13 paymets i a row uder Origial Medicare to ow the DME item if: you did ot become the ower of the DME item while you were i our pla ad you leave our pla ad get your Medicare beefits outside of ay health pla i the Origial Medicare program. If you made paymets for the DME item uder Origial Medicare before you joied our pla, those Medicare paymets do ot cout toward the 13 paymets. You will have to make 13 ew paymets i a row uder Origial Medicare to ow the DME item. There are o exceptios to this case whe you retur to Origial Medicare. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 41

44 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Table of Cotets A. Uderstadig your covered services B. Our pla does ot allow providers to charge you for services C. About the Beefits Chart D. The Beefits Chart E. Beefits covered outside of Aeta Better Health Premier Pla F. Beefits ot covered by Aeta Better Health Premier Pla, Medicare, or Michiga Medicaid...88 If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 42

45 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart A. Uderstadig your covered services This chapter tells you what services Aeta Better Health Premier Pla pays for. You ca also lear about services that are ot covered. Iformatio about drug beefits is i Chapter 5. This chapter also explais limits o some services. You pay othig for your covered services as log as you follow the pla s rules. See Chapter 3 for details about the pla s rules. The oly exceptio is if you have a Patiet Pay Amout (PPA) for ursig facility services as determied by the local Departmet of Health ad Huma Services. If you eed supports ad services related to a behavioral health coditio, itellectual or developmetal disability, or a substace use disorder, please work with your Care Coordiator to get services provided through the Prepaid Ipatiet Health Pla (PIHP). You will also get a PIHP Member Hadbook which will further explai the PIHP eligibility ad covered specialty services. Depedig o eligibility criteria, some items, supplies, supports ad services may be offered through our pla or the PIHP. To esure our pla ad PIHP are ot payig for the same items, supplies, supports or services, your Care Coordiator ca help you get what you eed from either our pla or the PIHP. Services from the PIHP have differet eligibility or medical ecessity criteria. See Sectio F i this chapter ad the PIHP hadbook for more iformatio. If you eed help uderstadig what services are covered, call your Care Coordiator ad/or Member Services at (TTY: 711), 24 hours a day, 7 days a week. B. Our pla does ot allow providers to charge you for services We do ot allow Aeta Better Health Premier Pla providers to bill you for covered services. We pay our providers directly, ad we protect you from ay charges. This is true eve if we pay the provider less tha the provider charges for a service. You should ever get a bill from a provider for covered services. If you do, see Chapter 7 or call Member Services. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 43

46 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart C. About the Beefits Chart The Beefits Chart tells you which services the pla pays for. It lists categories of services i alphabetical order ad explais the covered services. It is broke ito two sectios: Geeral Services» Offered to all erollees Home ad Commuity-Based Services (HCBS) Waiver» Offered oly to erollees who: 1) require ursig facility level of care but are ot residig i a ursig facility, ad 2) have a eed for covered waiver services We will pay for the services listed i the Beefits Chart oly whe the followig rules are met. You do ot pay aythig for the service listed i the Beefits Chart, as log as you meet the coverage requiremets described below. The oly exceptio is if you have a Patiet Pay Amout (PPA) for ursig facility services as determied by the local Departmet of Health ad Huma Services. Your Medicare ad Michiga Medicaid covered services must be provided accordig to the rules set by Medicare ad Michiga Medicaid. The services (icludig medical care, services, supplies, equipmet, ad drugs) must be medically ecessary. Medically ecessary meas you eed the services to prevet, diagose, or treat a medical coditio. This icludes care that keeps you from goig ito a hospital or ursig home. It also meas the services, supplies, or drugs meet accepted stadards of medical practice. You get your care from a etwork provider. A etwork provider is a provider who works with the health pla. I most cases, the pla will ot pay for care you get from a outof-etwork provider. Chapter 3 has more iformatio about usig etwork ad out-ofetwork providers. You have a primary care provider (PCP) that is providig your care. Some of the services listed i the Beefits Chart are covered oly if your doctor or other etwork provider gets approval from us first. This is called prior authorizatio. Covered services that eed approval first are marked i the Beefits Chart by a asterisk (*). All prevetive services are free. You will see this apple Beefits Chart. ext to prevetive services i the If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 44

47 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart D. The Beefits Chart Geeral Services that our pla covers Abdomial aortic aeurysm screeig* What you must pay $0 The pla will pay for a oe-time ultrasoud screeig for people at risk. The pla oly covers this screeig if you have certai risk factors ad if you get a referral for it from your physicia, physicia assistat, urse practitioer, or cliical urse specialist. Adaptive Medical Equipmet ad Supplies* $0 The pla covers devices, cotrols, or appliaces that eable you to icrease your ability to perform activities of daily livig or to perceive, cotrol, or commuicate with the eviromet i which you live. Services might iclude: shower chairs/beches lift chairs raised toilet seats reachers jar opeers trasfer seats bath lifts/room lifts swivel discs bath aids such as log hadle scrubbers telephoe aids This beefit is cotiued o the ext page If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 45

48 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Adaptive Medical Equipmet ad Supplies* (cotiued) What you must pay $0 automated/telephoe or watches that assist with medicatio remiders butto hooks or zipper pulls modified eatig utesils modified oral hygiee aids modified groomig tools heatig pads sharps cotaiers exercise items ad other therapy items voice output blood pressure moitor utritioal supplemets such as Esure Alcohol misuse screeig ad couselig* $0 The pla will pay for oe alcohol-misuse screeig for adults who misuse alcohol but are ot alcohol depedet. This icludes pregat wome. If you scree positive for alcohol misuse, you ca get up to four brief, face-to-face couselig sessios each year (if you are able ad alert durig couselig) with a qualified primary care provider or practitioer i a primary care settig. Ambulace services* $0 Covered ambulace services iclude fixed-wig, rotarywig, ad groud ambulace services. The ambulace will take you to the earest place that ca give you care. Your coditio must be serious eough that other ways of gettig to a place of care could risk your life or health. Ambulace services for other cases must be approved by the pla. I cases that are ot emergecies, the pla may pay for a ambulace. Your coditio must be serious eough that other ways of gettig to a place of care could risk your life or health. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 46

49 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Aual welless visit What you must pay $0 If you have bee i Medicare Part B for more tha 12 moths, you ca get a aual checkup. This is to make or update a prevetio pla based o your curret risk factors. The pla will pay for this oce every 12 moths. Note: You caot have your first aual checkup withi 12 moths of your Welcome to Medicare prevetive visit. You will be covered for aual checkups after you have had Part B for 12 moths. You do ot eed to have had a Welcome to Medicare visit first. Boe mass measuremet* $0 The pla will pay for certai procedures for members who qualify (usually, someoe at risk of losig boe mass or at risk of osteoporosis). These procedures idetify boe mass, fid boe loss, or fid out boe quality. The pla will pay for the services oce every 24 moths or more ofte if they are medically ecessary. The pla will also pay for a doctor to look at ad commet o the results. Breast cacer screeig (mammograms) $0 The pla will pay for the followig services: Oe baselie mammogram betwee the ages of 35 ad 39 Oe screeig mammogram every 12 moths for wome age 40 ad older Cliical breast exams oce every 24 moths Cardiac (heart) rehabilitatio services* $0 The pla will pay for cardiac rehabilitatio services such as exercise, educatio, ad couselig. Members must meet certai coditios with a doctor s order. The pla also covers itesive cardiac rehabilitatio programs, which are more itese tha cardiac rehabilitatio programs. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 47

50 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Cardiovascular (heart) disease risk reductio visit (therapy for heart disease) What you must pay $0 The pla pays for oe visit a year with your primary care provider to help lower your risk for heart disease. Durig this visit, your doctor may: discuss aspiri use, check your blood pressure, or give you tips to make sure you are eatig well. Cardiovascular (heart) disease testig $0 The pla pays for blood tests to check for cardiovascular disease oce every five years (60 moths). These blood tests also check for defects due to high risk of heart disease. Cell phoe beefit $0 For members who qualify for the federal cell phoe program, the pla beefit icludes free calls to preprogrammed Member Services umber (that do ot apply to mothly miute allotmet), free health-related texts, free health pla texts. Cervical ad vagial cacer screeig $0 The pla will pay for the followig services: For all wome: Pap tests ad pelvic exams oce every 24 moths For wome who are at high risk of cervical or vagial cacer: oe Pap test every 12 moths For wome who have had a abormal Pap test withi the last 3 years ad are of childbearig age: oe Pap test every 12 moths Chiropractic services* $0 The pla will pay for the followig services: Adjustmets of the spie to correct aligmet Diagostic x-rays If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 48

51 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Colorectal cacer screeig* What you must pay $0 For people 50 ad older, the pla will pay for the followig services: Flexible sigmoidoscopy (or screeig barium eema) every 48 moths Fecal occult blood test, every 12 moths Guaiac-based fecal occult blood test or fecal immuochemical test, every 12 moths DNA based colorectal screeig, every 3 years For people at high risk of colorectal cacer, the pla will pay for oe screeig colooscopy (or screeig barium eema) every 24 moths. For people ot at high risk of colorectal cacer, the pla will pay for oe screeig colooscopy every te years (but ot withi 48 moths of a screeig sigmoidoscopy). Commuity Trasitio Services* $0 The pla will pay for oe-time expeses for you to trasitio from a ursig home to aother residece where you are resposible for your ow livig arragemet. You must have a 6 moth cotiuous stay i the ursig home to get this service. Covered services may iclude: housig or security deposits utility hook-ups ad deposits (excludes televisio ad iteret) furiture (limited) appliaces (limited) movig expeses (excludes diversio or recreatioal devices) cleaig icludig pest eradicatio, allerge cotrol, ad over-all cleaig This service does ot iclude ogoig mothly retal or mortgage expese, regular utility charges, or items that are iteded for purely diversioal or recreatioal purposes. Coverage is limited to oce per year. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 49

52 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Couselig to stop smokig or tobacco use* What you must pay $0 If you use tobacco but do ot have sigs or symptoms of tobacco-related disease: The pla will pay for two couselig quit attempts i a 12 moth period as a prevetive service. This service is free for you. Each couselig attempt icludes up to four face-to-face visits. If you use tobacco ad have bee diagosed with a tobacco-related disease or are takig medicie that may be affected by tobacco: The pla will pay for two couselig quit attempts withi a 12 moth period. Each couselig attempt icludes up to four face-to-face visits. I additio, the pla offers smokig cessatio couselig sessios (up to 50 per year), icotie patches, gum ad lozeges, as well as certai pharmacy medicatios. Talk to your Care Coordiator for more iformatio. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 50

53 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Detal services* What you must pay $0 Aeta Better Health Premier Pla will pay for the followig services: Examiatios ad evaluatios are covered oce every six moths Cleaig is a covered beefit oce every six moths Silver diamie fluoride treatmet is covered with a maximum of six applicatios per lifetime X-rays» Bitewig x-rays are a covered beefit oly oce i a 12-moth period» A paoramic x-ray is a covered beefit oce every five years» A full mouth or complete series of x-rays is a covered beefit oce every five years Filligs Tooth extractios Complete or partial detures are covered oce every five years Beefits are limited to certai coditios; call Member Services for detailed beefit iformatio. Depressio screeig $0 The pla will pay for oe depressio screeig each year. The screeig must be doe i a primary care settig that ca give follow-up treatmet ad referrals, which iclude referrals to your primary care provider or the Prepaid Ipatiet Health Pla (PIHP) for further assessmet ad services. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 51

54 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Diabetes screeig* What you must pay $0 The pla will pay for this screeig (icludes fastig glucose tests) if you have ay of the followig risk factors: High blood pressure (hypertesio) History of abormal cholesterol ad triglyceride levels (dyslipidemia) Obesity History of high blood sugar (glucose) Tests may be covered i some other cases, such as if you are overweight ad have a family history of diabetes. Depedig o the test results, you may qualify for up to two diabetes screeigs every 12 moths. Diabetic self-maagemet traiig, services, ad supplies* $0 The pla will pay for the followig services for all people who have diabetes (whether they use isuli or ot): Supplies to moitor your blood glucose, icludig the followig:» A blood glucose moitor» Blood glucose test strips» Lacet devices ad lacets» Glucose-cotrol solutios for checkig the accuracy of test strips ad moitors This beefit is cotiued o the ext page If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 52

55 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Diabetic self-maagemet traiig, services, ad supplies* (cotiued) What you must pay $0 For people with diabetes who have severe diabetic foot disease, the pla will pay for the followig:» Oe pair of therapeutic custom-molded shoes (icludig iserts) ad two extra pairs of iserts each caledar year, or» Oe pair of depth shoes ad three pairs of iserts each year (ot icludig the o-customized removable iserts provided with such shoes) The pla will also pay for fittig the therapeutic custom-molded shoes or depth shoes. The pla will pay for traiig to help you maage your diabetes, i some cases. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 53

56 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Durable medical equipmet (DME) ad related supplies* What you must pay $0 (For a defiitio of Durable medical equipmet (DME), see Chapter 12 of this hadbook.) The followig items are covered: Wheelchairs Crutches Powered mattress systems Diabetic supplies Hospital beds ordered by a provider for use i the home IV ifusio pumps Speech geeratig devices Oxyge equipmet ad supplies Nebulizers Walkers The followig items are also covered: Breast Pumps Caes Commodes CPAP Device Eteral Nutritio Home Uterie Activity Moitor Icotiece Supplies Isuli Pump ad Supplies This beefit is cotiued o the ext page If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 54

57 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Durable medical equipmet (DME) ad related supplies* (cotiued) What you must pay $0 Lifts, Sligs ad Seats Lymphedema Pump Negative Pressure Woud Therapy Orthopedic Footwear Orthotics Osteogeesis Stimulator Ostomy Supplies Pareteral Nutritio Peak Flow Meter Pressure Gradiet Products Pressure Reducig Support Surfaces Prosthetics Pulse Oximeter Surgical Dressigs Tracheostomy Care Supplies Trascutaeous Electrical Nerve Stimulator Vetilators Wearable Cardioverter-Defibrillators This beefit is cotiued o the ext page If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 55

58 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Durable medical equipmet (DME) ad related supplies* (cotiued) What you must pay $0 Other items may be covered. Some DME is provided based o Michiga Medicaid policy. Requiremets for referral, physicia order ad assessmet apply alog with limitatios o replacemet ad repair. Other items may be covered, icludig evirometal aids or assistive/adaptive techology. Aeta Better Health Premier Pla may also cover you learig how to use, modify, or repair your item. Your Itegrated Care Team will work with you to decide if these other items ad services are right for you ad will be i your Pla of Care. Some items may also be covered through the Prepaid Ipatiet Health Pla (PIHP) based o eligibility criteria. These items should be paid for by either our pla or the PIHP, ot by both. We will pay for all medically ecessary DME that Medicare ad Michiga Medicaid usually pay for. If our supplier i your area does ot carry a particular brad or maker, you may ask them if they ca special-order it for you. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 56

59 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Emergecy care What you must pay $0 Emergecy care meas services that are: give by a provider traied to give emergecy services, ad eeded to treat a medical emergecy. A medical emergecy is a medical coditio with severe pai or serious ijury. The coditio is so serious that, if it does t get immediate medical attetio, ayoe with a average kowledge of health ad medicie could expect it to result i: serious risk to your health or to that of your ubor child; or serious harm to bodily fuctios; or serious dysfuctio of ay bodily orga or part; or i the case of a pregat woma i active labor, whe:» there is ot eough time to safely trasfer you to aother hospital before delivery.» a trasfer to aother hospital may pose a threat to your health or safety or that of your ubor child. If you get emergecy care at a out-of-etwork hospital ad eed ipatiet care after your emergecy is stabilized, you must retur to a etwork hospital for your care to cotiue to be paid for. You ca stay i the out-of-etwork hospital for your ipatiet care oly if the pla approves your stay. Emergecies are oly covered withi the Uited States ad its territories. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 57

60 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Family plaig services* What you must pay $0 The law lets you choose ay provider to get certai family plaig services from. This meas ay doctor, cliic, hospital, pharmacy or family plaig offce. The pla will pay for the followig services: Family plaig exam ad medical treatmet Family plaig lab ad diagostic tests Family plaig methods (birth cotrol pills, patch, rig, IUD, ijectios, implats) Family plaig supplies with prescriptio (codom, spoge, foam, film, diaphragm, cap) Couselig ad diagosis of ifertility, ad related services Couselig ad testig for sexually trasmitted ifectios (STIs), AIDS, ad other HIV-related coditios Treatmet for sexually trasmitted ifectios (STIs) Volutary sterilizatio (You must be age 21 or older, ad you must sig a federal sterilizatio coset form. At least 30 days, but ot more tha 180 days, must pass betwee the date that you sig the form ad the date of surgery.) Geetic couselig The pla will also pay for some other family plaig services. However, you must see a provider i the pla s etwork for the followig services: Treatmet for medical coditios of ifertility (This service does ot iclude artificial ways to become pregat.) Treatmet for AIDS ad other HIV-related coditios Geetic testig If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 58

61 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Health ad welless educatio programs* What you must pay $0 The pla offers a wide array of health ad utritio educatio tools ad programs available to members at o additioal cost, icludig educatioal member materials, use of educatioal tools ad support systems. Hearig services* $0 The pla pays for hearig ad balace tests doe by your provider. These tests tell you whether you eed medical treatmet. They are covered as outpatiet care whe you get them from a physicia, audiologist, or other qualified provider. I additio, the pla pays for routie hearig exams every 2 years ad gives a $1000 allowace every 3 years for hearig aids. HIV screeig $0 The pla pays for oe HIV screeig exam every 12 moths for people who: ask for a HIV screeig test, or are at icreased risk for HIV ifectio. For wome who are pregat, the pla pays for up to three HIV screeig tests durig a pregacy. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 59

62 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Home health agecy care* What you must pay $0 Before you ca get home health services, a doctor must tell us you eed them, ad they must be provided by a home health agecy. The pla will pay for the followig services, ad maybe other services ot listed here: Part-time or itermittet skilled ursig ad home health aide services (To be covered uder the home health care beefit, your skilled ursig ad home health aide services combied must total fewer tha 8 hours per day ad 35 hours per week.) Physical therapy, occupatioal therapy, ad speech therapy Medical ad social services Medical equipmet ad supplies Home health aide whe provided with a ursig service Hospice care* $0 You ca get care from ay hospice program certified by Medicare. You have the right to elect hospice if your provider ad hospice medical director determie you have a termial progosis. This meas you have a termial illess ad are expected to have six moths or less to live. Your hospice doctor ca be a etwork provider or a out-of-etwork provider. The pla will pay for the followig while you are gettig hospice services: Drugs to treat symptoms ad pai Short-term respite care Home care This beefit is cotiued o the ext page If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 60

63 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Hospice care* (cotiued) What you must pay $0 Hospice services ad services covered by Medicare Part A or B are billed to Medicare. See Sectio F of this chapter for more iformatio. For services covered by Aeta Better Health Premier Pla but ot covered by Medicare Part A or B: Aeta Better Health Premier Pla will cover pla-covered services ot covered uder Medicare Part A or B. The pla will cover the services whether or ot they are related to your termial progosis. You pay othig for these services. For drugs that may be covered by Aeta Better Health Premier Pla s Medicare Part D beefit: Drugs are ever covered by both hospice ad our pla at the same time. For more iformatio, please see Chapter 5. Note: If you eed o-hospice care, you should call your care coordiator to arrage the services. No-hospice care is care that is ot related to your termial progosis. Call your Care Coordiator at (TTY: 711). Immuizatios* $0 The pla will pay for the followig services: Peumoia vaccie Flu shots, oce a year, i the fall or witer Hepatitis B vaccie if you are at high or itermediate risk of gettig hepatitis B Other vaccies if you are at risk ad they meet Medicare Part B or Michiga Medicaid coverage rules The pla will pay for other vaccies that meet the Medicare Part D coverage rules. Read Chapter 6 to lear more. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 61

64 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Ipatiet stay: Covered services i a hospital or skill ursig facility (SNF)* The pla will pay for the followig services, ad maybe other services ot listed here: Semi-private room (or a private room if it is medically ecessary) Meals, icludig special diets What you must pay $0 You must get approval from the pla to keep gettig ipatiet care at a out-of-etwork hospital after your emergecy is uder cotrol. Regular ursig services Costs of special care uits, such as itesive care or coroary care uits Drugs ad medicatios Lab tests X-rays ad other radiology services Needed surgical ad medical supplies Appliaces, such as wheelchairs Operatig ad recovery room services Physical, occupatioal, ad speech therapy Ipatiet substace use disorder services Blood, icludig storage ad admiistratio» The pla will pay for whole blood ad packed red cells begiig with the first pit of blood you eed.» The pla will pay for all other parts of blood begiig with the first pit used. Physicia services I some cases, the followig types of trasplats: coreal, kidey, kidey/pacreatic, heart, liver, lug, heart/lug, boe marrow, stem cell, ad itestial/multivisceral. This beefit is cotiued o the ext page If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 62

65 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Ipatiet hospital care* (cotiued) If you eed a trasplat, a Medicare-approved trasplat ceter will review your case ad decide whether you are a cadidate for a trasplat. Trasplat providers may be local or outside of the service area. If local trasplat providers are willig to accept the Medicare rate, the you ca get your trasplat services locally or outside the patter of care for your commuity. If Aeta Better Health Premier Pla provides trasplat services outside the patter of care for your commuity ad you choose to get your trasplat there, we will arrage or pay for lodgig ad travel costs for you ad oe other perso. Ipatiet behavioral health care* What you must pay $0 You must get approval from the pla to keep gettig ipatiet care at a out-of-etwork hospital after your emergecy is uder cotrol. $0 The pla will refer you to the Prepaid Ipatiet Health Pla (PIHP) for this service. Refer to Sectio F i this chapter for more iformatio. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 63

66 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Kidey disease services ad supplies* What you must pay $0 The pla will pay for the followig services: Kidey disease educatio services to teach kidey care ad help members make good decisios about their care. You must have stage IV chroic kidey disease, ad your doctor must refer you. The pla will cover up to six sessios of kidey disease educatio services. Outpatiet dialysis treatmets, icludig dialysis treatmets whe temporarily out of the service area, as explaied i Chapter 3 Ipatiet dialysis treatmets if you are admitted as a ipatiet to a hospital for special care Self-dialysis traiig, icludig traiig for you ad ayoe helpig you with your home dialysis treatmets Home dialysis equipmet ad supplies Certai home support services, such as ecessary visits by traied dialysis workers to check o your home dialysis, to help i emergecies, ad to check your dialysis equipmet ad water supply Your Medicare Part B drug beefit pays for some drugs for dialysis. For iformatio, please see Medicare Part B prescriptio drugs i this chart. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 64

67 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Lug cacer screeig What you must pay $0 The pla will pay for lug cacer screeig every 12 moths if you: Are aged 55-77, ad Have a couselig ad shared decisio-makig visit with your doctor or other qualified provider, ad Have smoked at least 1 pack a day for 30 years with o sigs or symptoms of lug cacer or smoke ow or have quit withi the last 15 years. After the first screeig, the pla will pay for aother screeig each year with a writte order from your doctor or other qualified provider. Meal beefit* $0 The pla will pay for 10 home-delivered meals after ipatiet hospitalizatio or ursig home stay. Medical utritio therapy* $0 This beefit is for people with diabetes or kidey disease without dialysis. It is also for after a kidey trasplat whe ordered by your doctor. The pla will pay for three hours of oe-o-oe couselig services durig your first year that you get medical utritio therapy services uder Medicare. (This icludes our pla, ay other Medicare Advatage pla, or Medicare.) We pay for two hours of oe-o-oe couselig services each year after that. If your coditio, treatmet, or diagosis chages, you may be able to get more hours of treatmet with a doctor s order. A doctor must prescribe these services ad reew the order each year if your treatmet is eeded i the ext caledar year. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 65

68 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Medicare Part B prescriptio drugs* What you must pay $0 These drugs are covered uder Part B of Medicare. Aeta Better Health Premier Pla will pay for the followig drugs: Drugs you do t usually give yourself ad are ijected or ifused while you are gettig doctor, hospital outpatiet, or ambulatory surgery ceter services Drugs you take usig durable medical equipmet (such as ebulizers) that were authorized by the pla Clottig factors you give yourself by ijectio if you have hemophilia Immuosuppressive drugs, if you were erolled i Medicare Part A at the time of the orga trasplat Osteoporosis drugs that are ijected. These drugs are paid for if you are homeboud, have a boe fracture that a doctor certifies was related to post-meopausal osteoporosis, ad caot iject the drug yourself Atiges Certai oral ati-cacer drugs ad ati-ausea drugs Certai drugs for home dialysis, icludig hepari, the atidote for hepari (whe medically eeded), topical aesthetics, ad erythropoiesis-stimulatig agets (such as Epoge, Procrit, Epoeti Alfa, Araesp, or Darbepoeti Alfa) IV immue globuli for the home treatmet of primary immue deficiecy diseases Chapter 5 explais the outpatiet prescriptio drug beefit. It explais rules you must follow to have prescriptios covered. Chapter 6 explais what you pay for your outpatiet prescriptio drugs through our pla. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 66

69 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers No-emergecy medical trasportatio* What you must pay $0 The pla will cover trasportatio for you to travel to or from your medical appoitmets ad the pharmacy if it is a covered service. Types of o-emergecy trasportatio iclude: Wheelchair equipped va Service car Taxicab If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 67

70 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Nursig facility care* The pla will pay for the followig services, ad maybe other services ot listed here: A semi-private room, or a private room if it is medically eeded Meals, icludig special diets Nursig services Physical therapy, occupatioal therapy, ad speech therapy Drugs you get as part of your pla of care, icludig substaces that are aturally i the body, such as blood-clottig factors Medical ad surgical supplies give by ursig facilities Lab tests give by ursig facilities X-rays ad other radiology services give by ursig facilities Appliaces, such as wheelchairs, usually give by ursig facilities Physicia/provider services You will usually get your care from etwork facilities. However, you may be able to get your care from a facility ot i our etwork. You ca get care from the followig places if they accept our pla s for paymet: A ursig home or cotiuig care retiremet commuity where you lived before you wet to the hospital (as log as it provides ursig facility care) A ursig facility where your spouse or sigificat other lives at the time you leave the hospital The ursig home where you were livig whe you erolled i Aeta Better Health Premier Pla This service is iteded to be log term custodial care ad does ot overlap with skilled ursig facility care. You must meet Michiga Medicaid Nursig Facility Level of Care stadards to get this service. What you must pay Whe your icome exceeds a allowable amout, you must cotribute toward the cost of your ursig facility care. This cotributio, kow as the Patiet Pay Amout (PPA), is required if you live i a ursig facility. However, you might ot ed up havig to pay each moth. Patiet pay resposibility does ot apply to Medicare-covered days i a ursig facility. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 68

71 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Obesity screeig ad therapy to keep weight dow What you must pay $0 If you have a body mass idex of 30 or more, the pla will pay for couselig to help you lose weight. You must get the couselig i a primary care settig. That way, it ca be maaged with your full prevetio pla. Talk to your primary care provider to fid out more. Outpatiet diagostic tests ad therapeutic services ad supplies* $0 The pla will pay for the followig services, ad maybe other services ot listed here: X-rays Radiatio (radium ad isotope) therapy, icludig techicia materials ad supplies Surgical supplies, such as dressigs Splits, casts, ad other devices used for fractures ad dislocatios Lab tests Blood, begiig with the first pit of blood that you eed, icludig storage ad admiistratio. Other outpatiet diagostic tests If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 69

72 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Outpatiet hospital services* What you must pay $0 The pla pays for medically eeded services you get i the outpatiet departmet of a hospital for diagosis or treatmet of a illess or ijury. The pla will pay for the followig services, ad maybe other services ot listed here: Services i a emergecy departmet or outpatiet cliic, such as observatio services or outpatiet surgery Labs ad diagostic tests billed by the hospital Behavioral health care, icludig care i a partial-hospitalizatio program, if a doctor certifies that ipatiet treatmet would be eeded without it X-rays ad other radiology services billed by the hospital Medical supplies, such as splits ad casts Prevetive screeigs ad services listed throughout the Beefits Chart Some drugs that you ca t give yourself If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 70

73 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Outpatiet metal health care* What you must pay $0 The pla will pay for metal health services provided by a state-licesed: psychiatrist or doctor, cliical psychologist, cliical social worker, cliical urse specialist, urse practitioer, physicia assistat, or ay other Medicare or Michiga Medicaid-qualified metal health care professioal as allowed uder applicable state laws. You may cotact the PIHP, or the pla ca refer you to the PIHP for some services. The pla will pay for the followig services, ad maybe other services ot listed here: Cliic services Day treatmet Psychosocial rehab services Outpatiet rehabilitatio services* $0 The pla will pay for physical therapy, occupatioal therapy, ad speech therapy. You ca get outpatiet rehabilitatio services from hospital outpatiet departmets, idepedet therapist offces, comprehesive outpatiet rehabilitatio facilities (CORFs), ad other facilities. Outpatiet substace use disorder services* $0 The pla will refer you to the Prepaid Ipatiet Health Pla (PIHP) for these services. Refer to Sectio F i this chapter for more iformatio. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 71

74 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Outpatiet surgery* What you must pay $0 The pla will pay for outpatiet surgery ad services at hospital outpatiet facilities ad ambulatory surgical ceters. Over-the-couter supplies $0 As a added beefit, the pla offers you $20 i certai over-the-couter (OTC) supplies each moth. This beefit allows you to get OTC supplies delivered to your home (up to $20 each moth). This beefit ca be used for supplies such as*: pai relievers, digestive aids, laxatives, atacids, cough/cold/allergy relief, first aid. *This is ot a complete list. I order to use this beefit, you must order through our approved mail-order catalog. We have a order form o our website at For more iformatio, talk to your Care Coordiator or call Member Services. Partial hospitalizatio services* $0 The pla will refer you to the Prepaid Ipatiet Health Pla (PIHP) for these services. Refer to Sectio F i this chapter for more iformatio. Persoal Care Services* $0 The pla will pay for hads-o assistace to help you remai i your home for as log as possible. Services iclude assistace with activities of daily livig (ADLs), which are tasks like bathig, eatig, dressig, ad toiletig. This service ca iclude istrumetal activities of daily livig (IADLs) but oly whe there is also a eed for a ADL. IADLs iclude thigs like shoppig, laudry, meal preparatio, medicatio remiders, ad takig you to your appoitmets. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 72

75 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Persoal Emergecy Respose System* What you must pay $0 The pla covers a electroic i home device that secures help i a emergecy. You may also wear a portable help butto to allow for mobility. The system is coected to your phoe ad programmed to sigal a respose ceter oce a help butto is activated. Physicia/provider services, icludig doctor s offce visits* $0 The pla will pay for the followig services: Medically ecessary health care or surgery services give i places such as:» physicia s offce» certified ambulatory surgical ceter» hospital outpatiet departmet Cosultatio, diagosis, ad treatmet by a specialist Basic hearig ad balace exams give by your primary care provider if your doctor orders it to see whether you eed treatmet Secod opiio by aother etwork provider before a medical procedure No-routie detal care. Covered services are limited to:» surgery of the jaw or related structures,» settig fractures of the jaw or facial boes,» pullig teeth before radiatio treatmets of eoplastic cacer, or» services that would be covered whe provided by a physicia. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 73

76 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Podiatry services* What you must pay $0 The pla will pay for the followig services: Diagosis ad medical or surgical treatmet of ijuries ad diseases of the foot (such as hammer toe or heel spurs) Routie foot care for members with coditios affectig the legs, such as diabetes The pla also covers 3 routie foot care visits per year. Prostate cacer screeig exams $0 For me age 50 ad older, the pla will pay for the followig services oce every 12 moths: A digital rectal exam A prostate specific atige (PSA) test Prosthetic devices ad related supplies* $0 Prosthetic devices replace all or part of a body part or fuctio. The pla will pay for the followig prosthetic devices, ad maybe other devices ot listed here: Colostomy bags ad supplies related to colostomy care Pacemakers Braces Prosthetic shoes Artificial arms ad legs Breast prostheses (icludig a surgical brassiere after a mastectomy) The pla will also pay for some supplies related to prosthetic devices. They will also pay to repair or replace prosthetic devices. The pla offers some coverage after cataract removal or cataract surgery. See Visio Care later i this sectio for details. The pla will ot pay for prosthetic detal devices except for full ad partial detures (see Detal services ). If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 74

77 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Pulmoary rehabilitatio services* What you must pay $0 The pla will pay for pulmoary rehabilitatio programs for members who have moderate to very severe chroic obstructive pulmoary disease (COPD). The member must have a order for pulmoary rehabilitatio from the doctor or provider treatig the COPD. Respite* $0 You may get respite care services o a short-term, itermittet basis to relieve your family or other primary caregiver(s) from daily stress ad care demads durig times whe they are providig upaid care. Relief eeds of hourly or shift staff workers should be accommodated by staffg substitutios, pla adjustmets, or locatio chages ad ot by respite care. Respite is ot iteded to be provided o a cotiuous, log-term basis where it is a part of daily services that would eable a upaid caregiver to work elsewhere full time. Respite is limited to 336 hours every 365 days uless Aeta Better Health Premier Pla approves additioal time. I additio, the pla covers up to 12 hours of i-home respite care per moth. No prior authorizatio is required for the 12 hours of respite care. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 75

78 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Sexually trasmitted ifectios (STIs) screeig ad couselig What you must pay $0 The pla will pay for screeigs for chlamydia, goorrhea, syphilis, ad hepatitis B. These screeigs are covered for pregat wome ad for some people who are at icreased risk for a STI. A primary care provider must order the tests. We cover these tests oce every 12 moths or at certai times durig pregacy. The pla will also pay for up to two face-to-face, highitesity behavioral couselig sessios each year for sexually active adults at icreased risk for STIs. Each sessio ca be 20 to 30 miutes log. The pla will pay for these couselig sessios as a prevetive service oly if they are give by a primary care provider. The sessios must be i a primary care settig, such as a doctor s offce. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 76

79 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Skilled ursig facility (SNF) care* What you must pay $0 The pla will pay for the followig services, ad maybe other services ot listed here: A semi-private room, or a private room if it is medically eeded Meals, icludig special diets Nursig services Physical therapy, occupatioal therapy, ad speech therapy Drugs you get as part of your pla of care, icludig substaces that are aturally i the body, such as blood-clottig factors Blood, icludig storage ad admiistratio:» The pla will pay for whole blood ad packed red cells begiig with the first pit of blood you eed.» The pla will pay for all other parts of blood begiig with the first pit used. Medical ad surgical supplies give by ursig facilities Lab tests give by ursig facilities X-rays ad other radiology services give by ursig facilities Appliaces, such as wheelchairs, usually give by ursig facilities Physicia/provider services This beefit is cotiued o the ext page If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 77

80 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Skilled ursig facility (SNF) care* (cotiued) What you must pay $0 A hospital stay is ot required to get SNF care. You will usually get your care from etwork facilities. However, you may be able to get your care from a facility ot i our etwork. You ca get care from the followig places if they accept our pla s amouts for paymet: A ursig home or cotiuig care retiremet commuity where you lived before you wet to the hospital (as log as it provides ursig facility care) A ursig facility where your spouse lives at the time you leave the hospital Stiped for maiteace costs of a service aimal* $0 The pla will pay up to $20 per moth for maiteace costs of a service aimal if: You are receivig persoal care services, ad You are certified as disabled due to a specific coditio defied by the Americas with Disabilities Act, such as arthritis, blidess, cerebral palsy, polio, multiple sclerosis, deafess, stroke or spial cord ijury, ad The service aimal is traied to meet your specific eeds of relative to your disability. Your service pla must documet that the service aimal will be used primarily to meet your persoal care eeds. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 78

81 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Urgetly eeded care What you must pay $0 Urgetly eeded care is care give to treat: a o-emergecy, or a sudde medical illess, or a ijury, or a coditio that eeds care right away. If you require urgetly eeded care, you should first try to get it from a etwork provider. However, you ca use out-of-etwork providers whe you caot get to a etwork provider. Urgetly eeded care is oly covered withi the Uited States ad its territories. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 79

82 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Visio care* What you must pay $0 Routie eye examiatios are covered oce every year. The pla will pay for a iitial pair of eye glasses. Replacemet glasses are offered oce every year. The pla will pay for cotact leses for people with certai coditios. The pla will pay for basic ad essetial low visio aids (such as telescopes, microscopes, ad certai other low visio aids.) The pla will pay for outpatiet doctor services for the diagosis ad treatmet of diseases ad ijuries of the eye. For example, this icludes aual eye exams for diabetic retiopathy for people with diabetes ad treatmet for age-related macular degeeratio. For people at high risk of glaucoma, the pla will pay for oe glaucoma screeig each year. People at high risk of glaucoma iclude: people with a family history of glaucoma, people with diabetes, Africa-Americas who are age 50 ad older, ad Hispaic Americas who are 65 or older. The pla will pay for oe pair of glasses or cotact leses after each cataract surgery whe the doctor iserts a itraocular les. (If you have two separate cataract surgeries, you must get oe pair of glasses after each surgery. You caot get two pairs of glasses after the secod surgery, eve if you did ot get a pair of glasses after the first surgery.) I additio, the pla covers eye glasses (frames ad leses), eyeglass leses ad cotact leses accordig to MI Medicaid coverage guidelies. Call Member Services for detailed beefit iformatio. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 80

83 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Geeral Services that our pla covers Weight maagemet* (Adult) What you must pay $0 The pla offers a 12-week adult weight maagemet program with health coachig to aid i success. Please call Member Services for more details. Welcome to Medicare Prevetive Visit $0 The pla covers the oe-time Welcome to Medicare prevetive visit. The visit icludes: a review of your health, educatio ad couselig about the prevetive services you eed (icludig screeigs ad shots), ad referrals for other care if you eed it. Importat: We cover the Welcome to Medicare prevetive visit oly durig the first 12 moths that you have Medicare Part B. Whe you make your appoitmet, tell your doctor s offce you wat to schedule your Welcome to Medicare prevetive visit. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 81

84 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Home ad Commuity Based Services (HCBS) Waiver that our pla pays for Adult Day Program* What you must pay $0 The pla covers structured day activities at a program of direct care ad supervisio if you qualify. This service: provides persoal attetio, ad promotes social, physical ad emotioal well-beig Assistive Techology* $0 The pla covers techology items used to icrease, maitai, or improve fuctioig ad promote idepedece if you qualify. Some examples of services iclude: va lifts had cotrols computerized voice system commuicatio boards voice activated door locks power door mechaisms specialized alarm or itercom assistive dialig device Chore Services* $0 The pla covers services eeded to maitai your home i a clea, saitary, ad safe eviromet if you qualify. Examples of services iclude: heavy household chores (washig floors, widows, ad walls) tackig loose rugs ad tiles movig heavy items of furiture mowig, rakig, ad cleaig hazardous debris such as falle braches ad trees The pla may cover materials ad disposable supplies used to complete chore tasks. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 82

85 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Home ad Commuity Based Services (HCBS) Waiver that our pla pays for Evirometal Modificatios* What you must pay $0 The pla covers modificatios to your home if you qualify. The modificatios must be desiged to esure your health, safety ad welfare or make you more idepedet i your home. Modificatios may iclude: istallig ramps ad grab bars wideig of doorways modifyig bathroom facilities istallig specialized electric systems that are ecessary to accommodate medical equipmet ad supplies Expaded Commuity Livig Supports* $0 To get this service, you MUST have a eed for promptig, cueig, observig, guidig, teachig, ad/or remidig to help you complete activities of daily livig (ADLs) like eatig, bathig, dressig, toiletig, other persoal hygiee, etc. If you have a eed for this service, you ca also get assistace with istrumetal activities of daily livig (IADLs) like laudry, meal preparatio, trasportatio, help with fiaces, help with medicatio, shoppig, go with you to medical appoitmets, other household tasks. This may also iclude promptig, cueig, guidig, teachig, observig, remidig, ad/or other support to complete IADLs yourself. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 83

86 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Home ad Commuity Based Services (HCBS) Waiver that our pla pays for Fiscal Itermediary Services* What you must pay $0 The pla will pay for a fiscal itermediary (FI) to assist you to live idepedetly i the commuity while you cotrol your idividual budget ad choose the staff to work with you. The FI helps you to maage ad distribute fuds cotaied i the idividual budget. You use these fuds to purchase home ad commuity based services authorized i your pla of care. You have the authority to hire the caregiver of your choice. Home delivered meals* $0 The pla covers up to two prepared meals per day brought to your home if you qualify. No-medical Trasportatio* $0 The pla covers trasportatio services to eable you to access waiver ad other commuity services, activities, ad resources, if you qualify. Prevetive Nursig Services* $0 The pla covers ursig services provided by a registered urse (RN) or licesed practical urse (LPN). You must require observatio ad evaluatio of ski itegrity, blood sugar levels, prescribed rage of motio exercises, or physical status to qualify. You may get other ursig services durig the urse visit to your home. These services are ot provided o a cotiuous basis. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 84

87 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Home ad Commuity Based Services (HCBS) Waiver that our pla pays for Private Duty Nursig (PDN)* What you must pay $0 The pla covers skilled ursig services o a idividual ad cotiuous basis, up to a maximum of 16 hours per day, to meet your health eeds directly related to a physical disability. PDN icludes the provisio of ursig assessmet, treatmet ad observatio provided by licesed urse, cosistet with physicia s orders ad i accordace with your pla of care. You must meet certai medical criteria to qualify for this service. Respite Care Services* $0 You may get respite care services o a short-term, itermittet basis to relieve your family or other primary caregiver(s) from daily stress ad care demads durig times whe they are providig upaid care. Relief eeds of hourly or shift staff workers should be accommodated by staffg substitutios, pla adjustmets, or locatio chages ad ot by respite care. Respite is ot iteded to be provided o a cotiuous, log-term basis where it is a part of daily services that would eable a upaid caregiver to work elsewhere full time. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 85

88 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart E. Beefits covered outside of Aeta Better Health Premier Pla The followig services are ot covered by Aeta Better Health Premier Pla but are available through Medicare or Michiga Medicaid. Hospice care You ca get care from ay hospice program certified by Medicare. You have the right to elect hospice if your provider ad hospice medical director determie you have a termial progosis. This meas you have a termial illess ad are expected to have six moths or less to live. Your hospice doctor ca be a etwork provider or a out-of-etwork provider. See the Beefits Chart i Sectio D of this chapter for more iformatio about what Aeta Better Health Premier Pla pays for while you are gettig hospice care services. For hospice services ad services covered by Medicare Part A or B that relate to your termial progosis: The hospice provider will bill Medicare for your services. Medicare will pay for hospice services related to your termial progosis. You pay othig for these services. For services covered by Medicare Part A or B that are ot related to your termial progosis (except for emergecy care or urgetly eeded care): The provider will bill Medicare for your services. Medicare will pay for the services covered by Medicare Part A or B. You pay othig for these services. For drugs that may be covered by Aeta Better Health Premier Pla s Medicare Part D beefit: Drugs are ever covered by both hospice ad our pla at the same time. For more iformatio, please see Chapter 5. You pay othig for these drugs. For services covered by Medicaid: The provider will bill Aeta Better Health Premier Pla for your services. Aeta Better Health Premier Pla will pay for the services covered by Medicaid. You pay othig for these services. Note: If you eed o-hospice care, you should call your care coordiator to arrage the services. No-hospice care is care that is ot related to your termial progosis. Cotact your care coordiator at (TTY: 711). Services covered by the Prepaid Ipatiet Health Pla (PIHP) The followig services are covered by Aeta Better Health Premier Pla but are available through the Prepaid Ipatiet Health Pla (PIHP) ad its provider etwork. Ipatiet behavioral health care The pla will pay for behavioral health care services that require a hospital stay. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 86

89 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Outpatiet substace use disorder services We will pay for treatmet services that are provided i the outpatiet departmet of a hospital if you, for example, have bee discharged from a ipatiet stay for the treatmet of drug substace abuse or if you require treatmet but do ot require the level of services provided i the ipatiet hospital settig. Partial hospitalizatio services Partial hospitalizatio is a structured program of active psychiatric treatmet. It is offered as hospital outpatiet service or by a commuity metal health ceter. It is more itese tha the care you get i your doctor s or therapist s offce. It ca help keep you from havig to stay i the hospital. Please see the separate PIHP Member Hadbook for more iformatio ad work with your Care Coordiator to get services provided through the PIHP. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 87

90 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart F. Beefits ot covered by Aeta Better Health Premier Pla, Medicare, or Michiga Medicaid This sectio tells you what kids of beefits are excluded by the pla. Excluded meas that the pla does ot pay for these beefits. Medicare ad Michiga Medicaid will ot pay for them either. The list below describes some services ad items that are ot covered by the pla uder ay coditios ad some that are excluded by the pla oly i some cases. The pla will ot pay for the excluded medical beefits listed i this sectio (or aywhere else i this Member Hadbook) except uder the specific coditios listed. If you thik that we should pay for a service that is ot covered, you ca file a appeal. For iformatio about filig a appeal, see Chapter 9. I additio to ay exclusios or limitatios described i the Beefits Chart, the followig items ad services are ot covered by our pla, Medicare, or Michiga Medicaid: Services cosidered ot reasoable ad ecessary, accordig to the stadards of Medicare ad Michiga Medicaid, uless these services are listed by our pla as covered services. Experimetal medical ad surgical treatmets, items, ad drugs, uless covered by Medicare or uder a Medicare-approved cliical research study or by our pla. See Chapter 3, page 39, for more iformatio o cliical research studies. Experimetal treatmet ad items are those that are ot geerally accepted by the medical commuity. Surgical treatmet for morbid obesity, except whe it is medically eeded ad Medicare pays for it. A private room i a hospital or ursig facility, except whe it is medically eeded. Private duty urses except for those that qualify for this waiver service. Persoal items i your room at a hospital or a ursig facility, such as a telephoe or a televisio. Full-time ursig care i your home. Elective or volutary ehacemet procedures or services (icludig weight loss, hair growth, sexual performace, athletic performace, cosmetic purposes, ati-agig ad metal performace), except whe medically eeded. Cosmetic surgery or other cosmetic work, uless it is eeded because of a accidetal ijury or to improve a part of the body that is ot shaped right. However, the pla will pay for recostructio of a breast after a mastectomy ad for treatig the other breast to match it. Chiropractic care, other tha maual maipulatio of the spie cosistet with Medicare coverage guidelies. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 88

91 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 4: Beefits Chart Orthopedic shoes, uless the shoes are part of a leg brace ad are icluded i the cost of the brace, or the shoes are for a perso with diabetic foot disease. Supportive devices for the feet, except for orthopedic or therapeutic shoes for people with diabetic foot disease. Radial keratotomy, LASIK surgery, ad visio therapy. However, the pla will pay for glasses after cataract surgery. Reversal of sterilizatio procedures ad o-prescriptio cotraceptive supplies. Acupucture Naturopath services (the use of atural or alterative treatmets). No-emergecy services provided to veteras i Veteras Affairs (VA) facilities. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 89

92 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla Table of Cotets Itroductio If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 90 Rules for the pla s outpatiet drug coverage A. Gettig your prescriptios filled Fill your prescriptio at a etwork pharmacy Ca you get a log term supply of drugs? Ca you use a pharmacy that is ot i the pla s etwork? Will the pla pay you back if you pay for a prescriptio? B. The pla s Drug List What is o the Drug List? How ca you fid out if a drug is o the Drug List? What is ot o the Drug List? What are tiers? C. Limits o coverage for some drugs Why do some drugs have limits? What kids of rules are there? Do ay of these rules apply to your drugs? D. Why your drug might ot be covered You ca get a temporary supply E. Chages i coverage for your drugs F. Drug coverage i special cases If you are i a hospital or a skilled ursig facility for a stay that is covered by the pla If you are i a log term care facility If you are i a log term care facility ad become a ew member of the pla If you are i a Medicare-certified hospice program

93 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla G. Programs o drug safety ad maagig drugs Programs to help members use drugs safely Programs to help members maage their drugs If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 91

94 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla Itroductio This chapter explais rules for gettig your outpatiet prescriptio drugs. These are drugs that your provider orders for you that you get from a pharmacy or by mail order. They iclude drugs covered uder Medicare Part D ad Michiga Medicaid. Aeta Better Health Premier Pla also covers the followig drugs, although they will ot be discussed i this chapter: Drugs covered by Medicare Part A. These iclude some drugs give to you while you are i a hospital or ursig facility. Drugs covered by Medicare Part B. These iclude some chemotherapy drugs, some drug ijectios give to you durig a offce visit with a doctor or other provider, ad drugs you are give at a dialysis cliic. To lear more about what Medicare Part B drugs are covered, see the Beefits Chart i Chapter 4. Rules for the pla s outpatiet drug coverage The pla will usually cover your drugs as log as you follow the rules i this sectio. 1. You must have a doctor or other provider write your prescriptio. This perso ofte is your primary care provider (PCP). It could also be aother provider if your primary care provider has referred you for care. You geerally must use a etwork pharmacy to fill your prescriptio. 2. Your prescribed drug must be o the pla s List of Covered Drugs. We call it the Drug List for short. If it is ot o the Drug List, we may be able to cover it by givig you a exceptio. See page 102 to lear about askig for a exceptio. 3. Your drug must be used for a medically accepted idicatio. This meas that the use of the drug is either approved by the Food ad Drug Admiistratio or supported by certai referece books. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 92

95 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla A. Gettig your prescriptios filled Fill your prescriptio at a etwork pharmacy I most cases, the pla will pay for prescriptios oly if they are filled at the pla s etwork pharmacies. A etwork pharmacy is a drug store that has agreed to fill prescriptios for our pla members. You may go to ay of our etwork pharmacies. To fid a etwork pharmacy, you ca look i the Provider ad Pharmacy Directory, visit our website, or cotact your Care Coordiator or Member Services. Show your Member ID Card whe you fill a prescriptio To fill your prescriptio, show your Member ID Card at your etwork pharmacy. The etwork pharmacy will bill the pla for your covered prescriptio drug. You will ot be required to pay a copay. If you do ot have your Member ID Card with you whe you fill your prescriptio, ask the pharmacy to call the pla to get the ecessary iformatio. If the pharmacy is ot able to get the ecessary iformatio, you may have to pay the full cost of the prescriptio whe you pick it up. You ca the ask us to pay you back. If you caot pay for the drug, cotact Member Services right away. We will do what we ca to help. To lear how to ask us to pay you back, see Chapter 7. If you eed help gettig a prescriptio filled, you ca cotact your Care Coordiator or Member Services. What if you wat to chage to a differet etwork pharmacy? If you chage pharmacies ad eed a refill of a prescriptio, you ca ask your pharmacy to trasfer the prescriptio to the ew pharmacy. If you eed help chagig your etwork pharmacy, you ca cotact your Care Coordiator or Member Services. What if the pharmacy you use leaves the etwork? If the pharmacy you use leaves the pla s etwork, you will have to fid a ew etwork pharmacy. To fid a ew etwork pharmacy, you ca look i the Provider ad Pharmacy Directory, visit our website, or cotact your Care Coordiator or Member Services. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 93

96 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla What if you eed a specialized pharmacy? Sometimes prescriptios must be filled at a specialized pharmacy. Specialized pharmacies iclude: Pharmacies that supply drugs for home ifusio therapy. Pharmacies that supply drugs for residets of a log term care facility, such as a ursig home. Usually, log term care facilities have their ow pharmacies. If you are a residet of a log term care facility, we must make sure you ca get the drugs you eed at the facility s pharmacy. If your log term care facility s pharmacy is ot i our etwork or you have ay diffculty accessig your drug beefits i a log term care facility, please cotact Member Services. Pharmacies that serve the Idia Health Service/Tribal/Urba Idia Health Program. Except i emergecies, oly Native Americas or Alaska Natives may use these pharmacies. Pharmacies that supply drugs requirig special hadlig ad istructios o their use. To fid a specialized pharmacy, you ca look i the Provider ad Pharmacy Directory, visit our website, or cotact your Care Coordiator or Member Services. Ca you use mail-order services to get your drugs? For certai kids of drugs, you ca use the pla s etwork mail-order services. Geerally, the drugs available through mail-order are drugs that you take o a regular basis for a chroic or log term medical coditio. The drugs that are ot available through the pla s mail-order service are marked with NM i our Drug List. Our pla s mail-order service allows you to order up to a 90-day supply. A 90-day supply has o copay. How do I fill my prescriptios by mail? To get order forms ad iformatio about fillig your prescriptios by mail, go to our website at You ca also talk to your Care Coordiator or call Member Services at Usually, a mail-order prescriptio will get to you withi 10 days. If the mail-order pharmacy expects a delay of more tha 10 days, they will cotact you ad help you decide whether to wait for the medicatio, cacel the mail order, or fill the prescriptio at a local pharmacy. If you have ot received a order withi 10 caledar days of whe you set the order, call CVS Caremark at (TTY: ) ad they will begi processig a replacemet order. The order will be quickly set to you. Calls to this umber are free. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 94

97 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla How will the mail-order service process my prescriptio? The mail-order service has differet procedures for ew prescriptios it gets from you, ew prescriptios it gets directly from your provider s offce, ad refills o your mail-order prescriptios: 1. New prescriptios the pharmacy gets from you The pharmacy will automatically fill ad deliver ew prescriptios it gets from you. 2. New prescriptios the pharmacy gets directly from your provider s offce The pharmacy will automatically fill ad deliver ew prescriptios it gets from health care providers, without checkig with you first, if either: You used mail order services with this pla i the past, or You sig up for automatic delivery of all ew prescriptios you get directly from health care providers. You may ask for automatic delivery of all ew prescriptios ow or at ay time by cotactig CVS Caremark Customer Care at (TTY: ). If you used mail order i the past ad do ot wat the pharmacy to automatically fill ad ship each ew prescriptio, please cotact CVS Caremark Customer Care at (TTY: ) ad let them kow how you would like to receive your mail order prescriptios or register olie with CVS Caremark at You ca chage your mail order preferece at ay time. If you have ever used our mail order delivery ad/or decide to stop automatic fills of ew prescriptios, the pharmacy will cotact you each time it gets a ew prescriptio from a health care provider to see if you wat the medicatio filled ad shipped immediately. This will give you a opportuity to make sure that the pharmacy is deliverig the correct drug (icludig stregth, amout, ad form) ad, if ecessary, allow you to cacel or delay the order before it is shipped. It is importat that you respod each time you are cotacted by the pharmacy, to let them kow what to do with the ew prescriptio ad to prevet ay delays i shippig. To opt out of automatic deliveries of ew prescriptios you got directly from your health care provider s offce, please cotact CVS Caremark Customer Care at (TTY: ). 3. Refills o mail-order prescriptios For refills, please cotact your pharmacy 15 days before you thik the drugs you have o had will ru out to make sure your ext order is shipped to you i time. So the pharmacy ca reach you to cofirm your order before shippig, please make sure to let the pharmacy kow the best ways to cotact you. Cotact CVS Caremark Customer Care at (TTY: ) to tell them the best way to reach you. If we do t kow the best way to reach you, you might miss the chace to tell us whether you wat a refill ad you could ru out of your prescriptio drugs. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 95

98 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla Ca you get a log term supply of drugs? You ca get a log term supply of maiteace drugs o our pla s Drug List. Maiteace drugs are drugs that you take o a regular basis, for a chroic or log term medical coditio. Some etwork pharmacies allow you to get a log term supply of maiteace drugs. A 90-day supply has o copay. The Provider ad Pharmacy Directory tells you which pharmacies ca give you a log term supply of maiteace drugs. You ca also call Member Services for more iformatio. For certai kids of drugs, you ca use the pla s etwork mail-order services to get a log term supply of maiteace drugs. See the sectio above to lear about mail-order services. Ca you use a pharmacy that is ot i the pla s etwork? Geerally, we pay for drugs filled at a out-of-etwork pharmacy oly whe you are ot able to use a etwork pharmacy. We have etwork pharmacies outside of our service area where you ca get your prescriptios filled as a member of our pla. We will pay for prescriptios filled at a out-of-etwork pharmacy i the followig cases: Prescriptios you get with emergecy care. Prescriptios you get with urgetly eeded care whe etwork pharmacies are ot available. If you are uable to get a covered prescriptio drug i a timely maer withi our service area because there is o 24-hour etwork pharmacy withi a reasoable drivig distace. If you are tryig to fill a prescriptio drug that is ot regularly stocked at a available etwork retail or mail order pharmacy (these prescriptio drugs iclude orpha drugs or other specialty pharmaceuticals). If you are travelig outside your service area (withi the Uited States) ad ru out of your medicatio, lose your medicatio, or become ill ad caot get to a etwork pharmacy. If you receive a Part D prescriptio drug, filled by a out-of-etwork istitutioal-based pharmacy, while you are i the emergecy departmet, provider-based cliic, outpatiet surgery or other outpatiet settig. If you have ot received your prescriptio durig a state or federal disaster declaratio or other public health emergecy declaratio i which you are evacuated or otherwise displaced from your service area or place of residece. Out-of-etwork supply is limited to 29 days-supply. Paper claims should be submitted for reimbursemet. I these cases, please check first with Member Services to see if there is a etwork pharmacy earby. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 96

99 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla Will the pla pay you back if you pay for a prescriptio? If you must use a out-of-etwork pharmacy, you will geerally have to pay the full cost whe you get your prescriptio. You ca ask us to pay you back. To lear more about this, see Chapter 7. B. The pla s Drug List The pla has a List of Covered Drugs. We call it the Drug List for short. The drugs o the Drug List are selected by the pla with the help of a team of doctors ad pharmacists. The Drug List also tells you if there are ay rules you eed to follow to get your drugs. We will geerally cover a drug o the pla s Drug List as log as you follow the rules explaied i this chapter. What is o the Drug List? The Drug List icludes the drugs covered uder Medicare Part D ad some prescriptio ad overthe-couter drugs ad items covered uder your Michiga Medicaid beefits. The Drug List icludes both brad-ame drugs, for example PRADAXA ad geeric drugs, for example amoxicilli. Geeric drugs have the same active igrediets as brad-ame drugs. Geerally, they work just as well as brad-ame drugs ad usually cost less. We will geerally cover a drug o the pla s Drug List as log as you follow the rules explaied i this chapter. Our pla also covers certai over-the-couter drugs ad products. Some over-the-couter drugs cost less tha prescriptio drugs ad work just as well. For more iformatio, call Member Services. How ca you fid out if a drug is o the Drug List? To fid out if a drug you are takig is o the Drug List, you ca: Check the most recet Drug List we set you i the mail. Visit the pla s website at The Drug List o the website is always the most curret oe. Call Member Services to fid out if a drug is o the pla s Drug List or to ask for a copy of the list. What is ot o the Drug List? The pla does ot cover all prescriptio drugs. Some drugs are ot o the Drug List because the law does ot allow the pla to cover those drugs. I other cases, we have decided ot to iclude a drug o the Drug List. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 97

100 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla Aeta Better Health Premier Pla will ot pay for the drugs listed i this sectio. These are called excluded drugs. If you get a prescriptio for a excluded drug, you must pay for it yourself. If you thik we should pay for a excluded drug because of your case, you ca file a appeal. (To lear how to file a appeal, see Chapter 9.) Here are three geeral rules for excluded drugs: Our pla s outpatiet drug coverage (which icludes Part D ad Medicaid drugs) caot pay for a drug that would already be covered uder Medicare Part A or Part B. Drugs covered uder Medicare Part A or Part B are covered by Aeta Better Health Premier Pla for free, but they are ot cosidered part of your outpatiet prescriptio drug beefits. Our pla caot cover a drug purchased outside the Uited States ad its territories. The use of the drug must be either approved by the Food ad Drug Admiistratio or supported by certai referece books as a treatmet for your coditio. Your doctor might prescribe a certai drug to treat your coditio, eve though it was ot approved to treat the coditio. This is called off-label use. Our pla usually does ot cover drugs whe they are prescribed for off-label use. Also, by law, the types of drugs listed below are ot covered by Medicare or Michiga Medicaid. Drugs used to promote fertility Drugs used for cosmetic purposes or to promote hair growth Drugs used for the treatmet of sexual or erectile dysfuctio, such as Viagra, Cialis, Levitra, ad Caverject Drugs used for treatmet of aorexia, weight loss, or weight gai Outpatiet drugs whe the compay who makes the drugs say that you have to have tests or services doe oly by them What are tiers? Every drug o the pla s Drug List is i oe of three tiers. A tier is a group of drugs of geerally the same type (for example, brad ame, geeric, or over-the-couter drugs). Tier 1: Part D prescriptio geeric drugs Tier 2: Part D prescriptio brad ame ad geeric drugs Tier 3: No-Part D prescriptio ad over-the-couter drugs To fid out which tier your drug is i, look for the drug i the pla s Drug List. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 98

101 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla C. Limits o coverage for some drugs Why do some drugs have limits? For certai prescriptio drugs, special rules limit how ad whe the pla covers them. I geeral, our rules ecourage you to get a drug that works for your medical coditio ad is safe ad effective. Whe a safe, lower-cost drug will work just as well as a higher-cost drug, the plas expects your provider to use the lower-cost drug. If there is a special rule for your drug, it usually meas that you or your provider will have to take extra steps for us to cover the drug. For example, your provider may have to tell us your diagosis or provide results of blood tests first. If you or your provider thik our rule should ot apply to your situatio, you should ask us to make a exceptio. We may or may ot agree to let you use the drug without takig the extra steps. To lear more about askig for exceptios, see Chapter 9. What kids of rules are there? 1. Limitig use of a brad-ame drug whe a geeric versio is available Geerally, a geeric drug works the same as a brad-ame drug ad usually costs less. I most cases, there is a geeric versio of a brad-ame drug, our etwork pharmacies will give you the geeric versio. We usually will ot pay for the brad-ame drug whe there is a geeric versio. However, if your provider has told us the medical reaso that the geeric drug will ot work for you, the we will cover the brad-ame drug. 2. Gettig pla approval i advace For some drugs, you or your doctor must get approval from Aeta Better Health Premier Pla before you fill your prescriptio. If you do t get approval, Aeta Better Health Premier Pla may ot cover the drug. 3. Tryig a differet drug first I geeral, the pla wats you to try lower-cost drugs (that ofte are as effective) before the pla covers drugs that cost more. For example, if Drug A ad Drug B treat the same medical coditio, ad Drug A costs less tha Drug B, the pla may require you to try Drug A first. If Drug A does ot work for you, the pla will the cover Drug B. This is called step therapy. 4. Quatity limits For some drugs, we limit the amout of the drug you ca have. This is called a quatity limit. For example, the pla might limit how much of a drug you ca get each time you fill your prescriptio. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 99

102 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla Do ay of these rules apply to your drugs? To fid out if ay of the rules above apply to a drug you take or wat to take, check the Drug List. For the most up-to-date iformatio, call Member Services or check our website at D. Why your drug might ot be covered We try to make your drug coverage work well for you, but sometimes a drug might ot be covered i the way that you would like it to be. For example: The drug you wat to take is ot covered by the pla. The drug might ot be o the Drug List. A geeric versio of the drug might be covered, but the brad ame versio you wat to take is ot. A drug might be ew ad we have ot yet reviewed it for safety ad effectiveess. The drug is covered, but there are special rules or limits o coverage for that drug. As explaied i the sectio above, some of the drugs covered by the pla have rules that limit their use. I some cases, you or your prescriber may wat to ask us for a exceptio to a rule. There are thigs you ca do if your drug is ot covered i the way that you would like it to be. You ca get a temporary supply I some cases, the pla ca give you a temporary supply of a drug whe the drug is ot o the Drug List or whe it is limited i some way. This gives you time to talk with your provider about gettig a differet drug or to ask the pla to cover the drug. To get a temporary supply of a drug, you must meet the two rules below: 1. The drug you have bee takig: is o loger o the pla s Drug List, or was ever o the pla s Drug List, or is ow limited i some way. 2. You must be i oe of these situatios: For Medicare Part D Drugs: You were i the pla last year ad do ot live i a log term care facility. We will cover a temporary supply of your drug durig the first 90 days of the caledar year. This temporary supply will be for up to a 30-day supply. If your prescriptio is writte for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medicatio. You must fill the prescriptio at a etwork pharmacy. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 100

103 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla You are ew to the pla ad do ot live i a log term care facility. We will cover a temporary supply of your drug durig the first 90 days of your membership i the pla. This temporary supply will be for up to a 30-day supply. You are ew to the pla ad live i a log term care facility. We will cover a temporary supply of your drug durig the first 90 days of your membership i the pla. The total supply will be for up to at least a 91-day supply ad may be up to a 98-day supply depedig o the dispesig icremet). If your prescriptio is writte for fewer days, we will allow multiple fills to provide up to a maximum of a 98-day supply of medicatio. (Please ote that the log term care pharmacy may provide the drug i smaller amouts at a time to prevet waste.) You have bee i the pla for more tha 90 days ad live i a log term care facility ad eed a supply right away. We will cover oe 31-day supply, or less if your prescriptio is writte for fewer days. This is i additio to the above log term care trasitio supply. You are a curret member ad have a chage i level of care We will cover a oe-time temporary 30-day supply if you move from the hospital to a home settig ad: You eed a drug that is ot o our drug list, or Your ability to get the drug is limited We will cover a oe-time temporary 31-day supply (see the ote below for exceptios) if you move ito or out of a log-term care settig ad: You eed a drug that is ot o our drug list, or Your ability to get the drug is limited Note: Oral brad ame solid dosage form such as tablets or capsules are limited to 14 day fills with exceptios as required by Medicare Part D rules. While you are gettig a temporary supply of a drug, you should talk with your provider to decide what to do whe your temporary supply rus out. You ca either switch to a differet drug covered by the pla or ask the pla to make a exceptio for you ad cover your curret drug. For Michiga Medicaid drugs: You are ew to the pla. We will cover a supply of your Michiga Medicaid drug for up to 90 caledar days after erollmet ad will ot termiate it at the ed of the 90 caledar days without advace otice to you ad a trasitio to aother drug, if eeded. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 101

104 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla To ask for a temporary supply of a drug, call Member Services. Whe you get a temporary supply of a drug, you should talk with your provider to decide what to do whe your supply rus out. Here are your choices: You ca chage to aother drug. There may be a differet drug covered by the pla that works for you. You ca call Member Services to ask for a list of covered drugs that treat the same medical coditio. The list ca help your provider fid a covered drug that might work for you. OR You ca ask for a exceptio. You ad your provider ca ask the pla to make a exceptio. For example, you ca ask the pla to cover a drug eve though it is ot o the Drug List. Or you ca ask the pla to cover the drug without limits. If your provider says you have a good medical reaso for a exceptio, he or she ca help you ask for oe. To lear more about askig for a exceptio, see Chapter 9. If you eed help askig for a exceptio, you ca cotact your Care Coordiator or Member Services. E. Chages i coverage for your drugs Most chages i drug coverage happe o Jauary 1. However, the pla might make chages to the Drug List durig the year. The pla might: Add drugs because ew drugs, icludig geeric drugs, became available or the govermet approved a ew use for a existig drug. Remove drugs because they were recalled or because cheaper drugs work just as well. Add or remove a limit o coverage for a drug. Replace a brad-ame drug with a geeric drug. If ay of the chages below affect a drug you are takig, the chage will ot affect you util Jauary 1 of the ext year: We put a ew limit o your use of the drug. We remove your drug from the Drug List, but ot because of a recall or because a ew geeric drug has replaced it. Before Jauary 1 of the ext year, you usually will ot have added limits to your use of the drug. The chages will affect you o Jauary 1 of the ext year. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 102

105 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla I the followig cases, you will be affected by the coverage chage before Jauary 1: If a brad ame drug you are takig is replaced by a ew geeric drug, the pla must give you at least 60 days otice about the chage.» The pla may give you a 60-day refill of your brad-ame drug at a etwork pharmacy.» You should work with your provider durig those 60 days to chage to the geeric drug or to a differet drug that the pla covers.» You ad your provider ca ask the pla to cotiue coverig the brad-ame drug for you. To lear how, see Chapter 9. If a drug is recalled because it is foud to be usafe or for other reasos, the pla will remove the drug from the Drug List. We will tell you about this chage right away.» Your provider will also kow about this chage. He or she ca work with you to fid aother drug for your coditio. If there is a chage to coverage for a drug you are takig, the pla will sed you a otice. Normally, the pla will let you kow at least 60 days before the chage. F. Drug coverage i special cases If you are i a hospital or a skilled ursig facility for a stay that is covered by the pla If you are admitted to a hospital or skilled ursig facility for a stay covered by the pla, we will geerally cover the cost of your prescriptio drugs durig your stay. You will ot have to pay a copay. Oce you leave the hospital or skilled ursig facility, the pla will cover your drugs as log as the drugs meet all of our rules for coverage. If you are i a log term care facility Usually, a log term care facility, such as a ursig home, has its ow pharmacy or a pharmacy that supplies drugs for all of its residets. If you are livig i a log term care facility, you may get your prescriptio drugs through the facility s pharmacy if it is part of our etwork. Check your Provider ad Pharmacy Directory to fid out if your log term care facility s pharmacy is part of our etwork. If it is ot, or if you eed more iformatio, please cotact Member Services. If you are i a log term care facility ad become a ew member of the pla If you eed a drug that is ot o our Drug List or is restricted i some way, the pla will cover a temporary supply of your drug durig the first 90 days of your membership, util we have give you at least 91 ad may be up to 98-day supply. The first supply will be for up to a 31-day supply, or less if your prescriptio is writte for fewer days. If you eed refills, we will cover them durig your first 90 days i the pla. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 103

106 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla If you have bee a member of the pla for more tha 90 days ad you eed a drug that is ot o our Drug List, we will cover oe 31-day supply. We will also cover oe 31-day supply if the pla has a limit o the drug s coverage. If your prescriptio is writte for fewer tha 31 days, we will pay for the smaller amout. Whe you get a temporary supply of a drug, you should talk with your provider to decide what to do whe your supply rus out. A differet drug covered by the pla might work just as well for you. Or you ad your provider ca ask the pla to make a exceptio ad cover the drug i the way you would like it to be covered. To lear more about askig for exceptios, see Chapter 9. If you are i a Medicare-certified hospice program Drugs are ever covered by both hospice ad our pla at the same time. If you are erolled i a Medicare hospice ad require a pai medicatio, ati-ausea, laxative, or atiaxiety drug ot covered by your hospice because it is urelated to your termial progosis ad related coditios, our pla must get otificatio from either the prescriber or your hospice provider that the drug is urelated before our pla ca cover the drug. To prevet delays i gettig ay urelated drugs that should be covered by our pla, you ca ask your hospice provider or prescriber to make sure we have the otificatio that the drug is urelated before you ask a pharmacy to fill your prescriptio. If you leave hospice, our pla should cover all of your drugs. To prevet ay delays at a pharmacy whe your Medicare hospice beefit eds, you should brig documetatio to the pharmacy to verify that you have left hospice. See the previous parts of this chapter that tell about the rules for gettig drug coverage uder Part D. To lear more about the hospice beefit, see Chapter 4. G. Programs o drug safety ad maagig drugs Programs to help members use drugs safely Each time you fill a prescriptio, we look for possible problems, such as: Drug errors Drugs that may ot be eeded because you are takig aother drug that does the same thig Drugs that may ot be safe for your age or geder Drugs that could harm you if you take them at the same time Drugs that are made of thigs you are allergic to If we see a possible problem i your use of prescriptio drugs, we will work with your provider to correct the problem. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 104

107 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla Programs to help members maage their drugs If you take medicatios for differet medical coditios, you may be eligible to get services, at o cost to you, through a medicatio therapy maagemet (MTM) program. This program helps you ad your provider make sure that your medicatios are workig to improve your health. A pharmacist or other health professioal will give you a comprehesive review of all your medicatios ad talk with you about: How to get the most beefit from the drugs you take Ay cocers you have, like medicatio costs ad drug reactios How best to take your medicatios Ay questios or problems you have about your prescriptio ad over-the-couter medicatio You ll get a writte summary of this discussio. The summary has a medicatio actio pla that recommeds what you ca do to make the best use of your medicatios. You ll also get a persoal medicatio list that will iclude all the medicatios you re takig ad why you take them. It s a good idea to schedule your medicatio review before your yearly Welless visit, so you ca talk to your doctor about your actio pla ad medicatio list. Brig your actio pla ad medicatio list with you to your visit or aytime you talk with your doctors, pharmacists, ad other health care providers. Also, take your medicatio list with you if you go to the hospital or emergecy room. Medicatio therapy maagemet programs are volutary ad free to members that qualify. If we have a program that fits your eeds, we will eroll you i the program ad sed you iformatio. If you do ot wat to be i the program, please let us kow, ad we will take you out of the program. If you have ay questios about these programs, please cotact your Care Coordiator or Member Services. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 105

108 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 6: What you pay for your Medicare ad Michiga Medicaid prescriptio drugs Table of Cotets Itroductio A. The Explaatio of Beefits (EOB) B. Keepig track of your drug costs Use your Member ID Card Sed us iformatio about the paymets others have made for you Check the reports we sed you C. A summary of your drug coverage The pla s tiers Gettig a log-term supply of a drug D. Vacciatios Before you get a vacciatio If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 106

109 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 6: What you pay for your Medicare ad Medicaid prescriptio drugs Itroductio This chapter tells what you pay for your outpatiet prescriptio drugs. By drugs, we mea: Medicare Part D prescriptio drugs, ad drugs ad items covered uder Michiga Medicaid, ad drugs ad items covered by the pla as additioal beefits. Because you are eligible for Michiga Medicaid, you are gettig Extra Help from Medicare to help pay for your Medicare Part D prescriptio drugs. To lear more about prescriptio drugs, you ca look i these places: The pla s List of Covered Drugs. We call this the Drug List. It tells you:» Which drugs the pla pays for» Which of the 3 tiers each drug is i» Whether there are ay limits o the drugs If you eed a copy of the Drug List, call Member Services. You ca also fid the Drug List o our website at The Drug List o the website is always the most curret. Chapter 5 of this Member Hadbook. Chapter 5 tells how to get your outpatiet prescriptio drugs through the pla. It icludes rules you eed to follow. It also tells which types of prescriptio drugs are ot covered by our pla. The pla s Provider ad Pharmacy Directory. I most cases, you must use a etwork pharmacy to get your covered drugs. Network pharmacies are pharmacies that have agreed to work with our pla. The Provider ad Pharmacy Directory has a list of etwork pharmacies. You ca read more about etwork pharmacies i Chapter 5. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 107

110 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 6: What you pay for your Medicare ad Medicaid prescriptio drugs A. The Explaatio of Beefits (EOB) Our pla keeps track of your prescriptio drugs. We keep track of your total drug costs. This icludes the amout of moey the pla pays (or others o your behalf pay) for your prescriptios. Whe you get prescriptio drugs through the pla, we sed you a report called the Explaatio of Beefits. We call it the EOB for short. The EOB icludes: Iformatio for the moth. The report tells what prescriptio drugs you got. It shows the total drug costs ad what the pla paid, ad what others payig for you paid. Year-to-date iformatio. This is your total drug costs ad the total paymets made for you sice Jauary 1. We offer coverage of drugs ot covered uder Medicare. Paymets made for these drugs will ot cout towards your Part D total out-of-pocket costs. To fid out which drugs our pla covers, see the Drug List. B. Keepig track of your drug costs To keep track of drug costs, we use records we get from you ad from your pharmacy. Here is how you ca help us: 1. Use your Member ID Card. Show your Member ID Card every time you get a prescriptio filled. This will help us kow what prescriptios you fill. 2. Sed us iformatio about the paymets others have made for you. Paymets made by certai other people ad orgaizatios also cout toward your total costs. For example, paymets made by state pharmaceutical assistace program, a AIDS drug assistace program, the Idia Health Service, ad most charities cout toward your out-of-pocket costs. 3. Check the reports we sed you. Whe you get a Explaatio of Beefits i the mail, please make sure it is complete ad correct. If you thik somethig is wrog or missig from the report, or if you have ay questios, please call Member Services. Be sure to keep these reports. They are a importat record of your drug expeses. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 108

111 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 6: What you pay for your Medicare ad Medicaid prescriptio drugs C. A summary of your drug coverage As a Aeta Better Health Premier Pla member, you pay othig for covered prescriptio ad over-the-couter (OTC) drugs as log as you follow Aeta Better Health Premier Pla s rules. The pla s tiers Tiers are groups of drugs. Every drug o the pla s Drug List is i oe of three tiers. There is o cost to you for drugs o ay of the tiers. Tier 1 drugs are Part D prescriptio geeric drugs. Tier 2 drugs are Part D prescriptio brad ame ad geeric drugs. Tier 3 drugs are No-Part D prescriptio ad over-the-couter drugs. Gettig a log-term supply of a drug For some drugs, you ca get a log-term supply (also called a exteded supply ) whe you fill your prescriptio. A log-term supply is up to a 90-day supply. There is o cost to you for a logterm supply. For details o where ad how to get a log-term supply of a drug, see Chapter 5 or the Provider ad Pharmacy Directory. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 109

112 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 6: What you pay for your Medicare ad Medicaid prescriptio drugs Your coverage for a oe-moth or log-term supply of a covered prescriptio drug from: A etwork pharmacy A oe-moth or up to a 90-day supply The pla s mail-order service A oe-moth or up to a 90-day supply A etwork log-term care pharmacy Up to a 98-day supply A out-ofetwork pharmacy Up to a 29-day supply. Coverage is limited to certai cases. See Chapter 5 for details. Tier 1 (Part D prescriptio geeric drugs) Tier 2 (Part D prescriptio brad ame ad geeric drugs) $0 $0 $0 $0 $0 $0 $0 $0 Tier 3 (No-Part D prescriptio ad over-the-couter drugs) $0 Mail-order is ot available for drugs i Tier 3. $0 $0 For iformatio about which pharmacies ca give you log-term supplies, see the pla s Provider ad Pharmacy Directory. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 110

113 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 6: What you pay for your Medicare ad Medicaid prescriptio drugs D. Vacciatios Our pla covers Medicare Part D vaccies. You will ot have to pay for vaccies if you get the vaccie through a i-etwork provider. There are two parts to our coverage of Medicare Part D vacciatios: 1. The first part of coverage is for the cost of the vaccie itself. The vaccie is a prescriptio drug. 2. The secod part of coverage is for the cost of givig you the vaccie. For example, sometimes you may get the vaccie as a shot give to you by your doctor. Before you get a vacciatio We recommed that you call us first at Member Services wheever you are plaig to get a vacciatio. We ca tell you about how your vacciatio is covered by our pla. We ca tell you how to keep your costs dow by usig etwork pharmacies ad providers. Network pharmacies are pharmacies that have agreed to work with our pla. A etwork provider is a provider who works with the health pla. A etwork provider should work with Aeta Better Health Premier Pla to esure that you do ot have ay upfrot costs for a Part D vaccie. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 111

114 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 7: Askig us to pay a bill you have gotte for covered services or drugs Table of Cotets A. Whe you ca ask us to pay for your services or drugs B. How ad where to sed us your request for paymet C. We will make a coverage decisio D. You ca make a appeal A. Whe you ca ask us to pay for your services or drugs You should ot get a bill for i-etwork services or drugs. Our etwork providers must bill the pla for the services ad drugs you already got. A etwork provider is a provider who works with the health pla. If you get a bill for health care or drugs, sed the bill to us. To sed us a bill, see page 114. If the services or drugs are covered, we will pay the provider directly. If the services or drugs are covered ad you already paid the bill, it is your right to be paid back. If the services or drugs are ot covered, we will tell you. Cotact Member Services or your Care Coordiator if you have ay questios. If you get a bill ad you do ot kow what to do about it, we ca help. You ca also call if you wat to tell us iformatio about a request for paymet you already set to us. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 112

115 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 7: Askig us to pay a bill you have gotte for covered services or drugs Here are examples of times whe you may eed to ask our pla to pay you back or to pay a bill you got: 1. Whe you get emergecy or urgetly eeded health care from a out-of-etwork provider You should ask the provider to bill the pla. If you pay the full amout whe you get the care, ask us to pay you back. Sed us the bill ad proof of ay paymet you made. You may get a bill from the provider askig for paymet that you thik you do ot owe. Sed us the bill ad proof of ay paymet you made.» If the provider should be paid, we will pay the provider directly.» If you have already paid for the service, we will pay you back. 2. Whe a etwork provider seds you a bill Network providers must always bill the pla. Show your Aeta Better Health Premier Pla Member ID Card whe you get ay services or prescriptios. Improper/iappropriate billig occurs whe a provider (such as a doctor or hospital) bills you more tha the pla s cost sharig amout for services. Call Member Services if you get ay bills you do ot uderstad. Because Aeta Better Health Premier Pla pays the etire cost for your services, you do ot owe ay cost sharig. Providers should ot bill you aythig for these services. Wheever you get a bill from a etwork provider, sed us the bill. We will cotact the provider directly ad take care of the problem. If you have already paid a bill from a etwork provider, sed us the bill ad proof of ay paymet you made. We will pay you back for your covered services. 3. Whe you use a out-of-etwork pharmacy to get a prescriptio filled If you go to a out-of-etwork pharmacy, you will have to pay the full cost of your prescriptio. I oly a few cases, we will cover prescriptios filled at out-of-etwork pharmacies. Sed us a copy of your receipt whe you ask us to pay you back. Please see Chapter 5 to lear more about out-of-etwork pharmacies. 4. Whe you pay the full cost for a prescriptio because you do ot have your Member ID Card with you If you do ot have your Member ID Card with you, you ca ask the pharmacy to call the pla or to look up your pla erollmet iformatio. If the pharmacy caot get the iformatio they eed right away, you may have to pay the full cost of the prescriptio yourself. Sed us a copy of your receipt whe you ask us to pay you back. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 113

116 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 7: Askig us to pay a bill you have gotte for covered services or drugs 5. Whe you pay the full cost for a prescriptio for a drug that is ot covered You may pay the full cost of the prescriptio because the drug is ot covered. The drug may ot be o the pla s List of Covered Drugs (Drug List), or it could have a requiremet or restrictio that you did ot kow about or do ot thik should apply to you. If you decide to get the drug, you may eed to pay the full cost for it.» If you do ot pay for the drug but thik it should be covered, you ca ask for a coverage decisio (see Chapter 9).» If you ad your doctor or other prescriber thik you eed the drug right away, you ca ask for a fast coverage decisio (see Chapter 9). Sed us a copy of your receipt whe you ask us to pay you back. I some situatios, we may eed to get more iformatio from your doctor or other prescriber i order to pay you back for the drug. Whe you sed us a request for paymet, we will review your request ad decide whether the service or drug should be covered. This is called makig a coverage decisio. If we decide it should be covered, we will pay for the service or drug. If we dey your request for paymet, you ca appeal our decisio. To lear how to make a appeal, see Chapter 9. B. How ad where to sed us your request for paymet Sed us your bill ad proof of ay paymet you have made. Proof of paymet ca be a copy of the check you wrote or a receipt from the provider. It is a good idea to make a copy of your bill ad receipts for your records. You ca ask your Care Coordiator for help. Mail your request for paymet together with ay bills or receipts to us at this address: Aeta Better Health Premier Pla Att: Member Services Departmet 1333 Gratiot Aveue, Suite 400 Detroit, MI You may also call our pla to ask for paymet. Call Member services at (TTY: 711), 24 hours a day, 7 days a week. The call is free. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 114

117 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 7: Askig us to pay a bill you have gotte for covered services or drugs C. We will make a coverage decisio Whe we get your request for paymet, we will make a coverage decisio. This meas that we will decide whether your health care or drug is covered by the pla. We will also decide the amout, if ay, you have to pay for the health care or drug. We will let you kow if we eed more iformatio from you. If we decide that the health care or drug is covered ad you followed all the rules for gettig it, we will pay for it. If you have already paid for the service or drug, we will mail you a check for what you paid. If you have ot paid for the service or drug yet, we will pay the provider directly. Chapter 3 explais the rules for gettig your services covered. Chapter 5 explais the rules for gettig your Medicare Part D prescriptio drugs covered. If we decide ot to pay for the service or drug, we will sed you a letter explaiig why ot. The letter will also explai your rights to make a appeal. To lear more about coverage decisios, see Chapter 9. D. You ca make a appeal If you thik we made a mistake i turig dow your request for paymet, you ca ask us to chage our decisio. This is called makig a appeal. You ca also make a appeal if you do ot agree with the amout we pay. The appeals process is a formal process with detailed procedures ad importat deadlies. To lear more about appeals, see Chapter 9. If you wat to make a appeal about gettig paid back for a health care service, go to page 149. If you wat to make a appeal about gettig paid back for a drug, go to page 151. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 115

118 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities Table of Cotets Itroductio A. You have a right to get iformatio i a way that meets your eeds B. We must treat you with respect, fairess, ad digity at all times C. We must esure that you get timely access to covered services ad drugs D. We must protect your persoal health iformatio How we protect your health iformatio You have a right to see your medical records E. We must give you iformatio about the pla, its etwork providers, ad your covered services F. Network providers caot bill you directly G. You have the right to leave the pla at ay time H. You have a right to make decisios about your health care You have the right to kow your treatmet optios ad make decisios about your health care... You have the right to say what you wat to happe if you are uable to make health care decisios for yourself What to do if your istructios are ot followed I. You have the right to make complaits ad to ask us to recosider decisios we have made What to do if you believe you are beig treated ufairly or your rights are ot beig respected How to get more iformatio about your rights J. You also have resposibilities as a member of the pla If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 116

119 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities Itroductio I this chapter, you will fid your rights ad resposibilities as a member of the pla. We must hoor your rights. A. You have a right to get iformatio i a way that meets your eeds We must tell you about the pla s beefits ad your rights i a way that you ca uderstad. We must tell you about your rights each year that you are i our pla. To get iformatio i a way that you ca uderstad, call Member Services at (TTY: 711), 24 hours a day, 7 days a week or your Care Coordiator at (TTY: 711). Our pla has people who ca aswer questios i differet laguages. Our pla ca also give you materials i laguages other tha Eglish ad i formats such as large prit, braille, or audio. Materials are available i Spaish. If you wish to make a stadig request to receive materials i a laguage other tha Eglish or i a alterate format, you ca call Member Services at (TTY: 711), 24 hours a day, 7 days a week. If you are havig trouble gettig iformatio from our pla because of laguage problems or a disability ad you wat to file a complait, call Medicare at MEDICARE ( ). You ca call 24 hours a day, seve days a week. TTY users should call You may also file a complait with Michiga Medicaid. Please see Chapter 9 for more iformatio. Teemos la obligació de avisarle sobre los beeficios del pla, su salud, sus opcioes de tratamieto y sus derechos, de uba maera que ested pueda etederlo. Teemos la obligació de avisarle cuáles so sus derechos cada año que usted este uestro pla. Para obteer iformació e ua forma que pueda etederla, llame a Servicios al miembro, al (TTY: 711), las 24 horas del día, los 7 días de la semaa o te importa coordiador al (TTY: 711). Nuestro pla tiee persoas que puede respoder pregutas e diferetes idiomas. Nuestro pla puede proveerle los materiales e otros idiomas además de iglés y e formatos como letra grade, braille, audio o citas de video e leguaje a señas americao. Los materiales está dispoibles e español. Si usted desea hacer ua solicitud para recibir permaetemete los materiales e u idioma que o sea iglés o e u formato altero, usted puede llamar a Servicios al Miembro de Aeta Better Health Premier Pla al (TTY al 711), 24 horas al día, 7 días de la semaa. Usted puede obteer este documeto e español, o hablar co alguie sobre esta iformació e otros idiomas gratuitamete. Llame al (TTY al 711). If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 117

120 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities Si tiee problemas para obteer iformació de su pla por problemas de idioma algua discapacidad y quiere presetar ua queja, llame a Medicare al MEDICARE ( ). Puede llamar las 24 horas al día, siete días a la semaa. Los usuarios de TTY (persoas co dificultades para oír o hablar) deberá llamar al Usted tambié podrá presetar ua queja ate el estado de Michiga Medicaid. Por favor, cosulte el capítulo 9 para más iformació. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 118

121 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities B. We must treat you with respect, fairess, ad digity at all times Our pla must obey laws that protect you from discrimiatio or ufair treatmet. We do ot discrimiate agaist members because of ay of the followig : Age Medical history Appeals Metal ability Behavior Metal or physical disability Claims experiece Natioal origi Ethicity Race Evidece of isurability Receipt of health care Geetic iformatio Religio Geder idetity Sex Geographic locatio withi the service area Health status Sexual orietatio Use of services Uder the rules of the pla, you have the right to be free of ay form of physical restrait or seclusio that would be used as a meas of coercio, force, disciplie, coveiece or retaliatio. We caot dey services to you or puish you for exercisig your rights. For more iformatio, or if you have cocers about discrimiatio or ufair treatmet, call the Departmet of Health ad Huma Services Offce for Civil Rights at (TTY ). You ca also visit for more iformatio. You ca also call the Michiga Departmet of Civil Rights at If you have a disability ad eed help accessig care or a provider, call Member Services. If you have a complait, such as a problem with wheelchair access, Member Services ca help. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 119

122 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities C. We must esure that you get timely access to covered services ad drugs As a member of our pla: You have the right to choose a primary care provider (PCP) i the pla s etwork. A etwork provider is a provider who works with the health pla. You also have the right to chage the PCP withi your health pla.» Call Member Services or look i the Provider ad Pharmacy Directory to lear which doctors are acceptig ew patiets. You have the right to go to a gyecologist or aother wome s health specialist without gettig a referral. You have the right to get covered services from etwork providers withi a reasoable amout of time.» This icludes the right to get timely services from specialists.» If you caot get services withi a reasoable amout of time, we have to pay for out-of-etwork care. You have the right to get emergecy services or care that is urgetly eeded without prior approval. You have the right to get your prescriptios filled at ay of our etwork pharmacies without log delays. You have the right to kow whe you ca see a out-of-etwork provider. To lear about out-of-etwork providers, see Chapter 3. Chapter 9 tells what you ca do if you thik you are ot gettig your services or drugs withi a reasoable amout of time. Chapter 9 also tells what you ca do if we have deied coverage for your services or drugs ad you do ot agree with our decisio. D. We must protect your persoal health iformatio We protect your persoal health iformatio as required by federal ad state laws. Your persoal health iformatio icludes the iformatio you gave us whe you erolled i this pla. It also icludes your medical records ad other medical ad health iformatio. You have rights to get iformatio ad to cotrol how your health iformatio is used. We give you a writte otice that tells about these rights. The otice is called the Notice of Privacy Practice. The otice also explais how we protect the privacy of your health iformatio. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 120

123 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities How we protect your health iformatio We make sure that uauthorized people do ot see or chage your records. I most situatios, we do ot give your health iformatio to ayoe who is ot providig your care or payig for your care. If we do, we are required to get writte permissio from you first. Writte permissio ca be give by you or by someoe who has the legal power to make decisios for you. There are certai cases whe we do ot have to get your writte permissio first. These exceptios are allowed or required by law.» We are required to release health iformatio to govermet agecies that are checkig o our quality of care.» We are required to give Medicare ad Michiga Medicaid your health ad drug iformatio. If Medicare or Michiga Medicaid releases your iformatio for research or other uses, it will be doe accordig to Federal ad State laws. You have a right to see your medical records You have the right to look at your medical records ad to get a copy of your records. We are allowed to charge you a reasoable fee for makig a copy of your medical records. You have the right to amed or correct iformatio i your medical records. The correctio will become part of your record. You have the right to kow if ad how your health iformatio has bee shared with others. If you have questios or cocers about the privacy of your persoal health iformatio, call Member Services. E. We must give you iformatio about the pla, its etwork providers, ad your covered services As a member of Aeta Better Health Premier Pla, you have the right to get iformatio from us. If you do ot speak Eglish, we have free iterpreter services to aswer ay questios you may have about our health pla. To get a iterpreter, just call us at (TTY: 711). This is a free service. We have available writte materials i Spaish but ca have all of our iformatio iterpreted i ay laguage that is your primary laguage. We ca also give you iformatio i large prit, braille, or audio. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 121

124 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities If you wat ay of the followig, call Member Services: Iformatio about how to choose or chage plas Iformatio about our pla, icludig:» Fiacial iformatio» How the pla has bee rated by pla members» The umber of appeals made by members» How to leave the pla Iformatio about our etwork providers ad our etwork pharmacies, icludig:» How to choose or chage primary care providers» The qualificatios of our etwork providers ad pharmacies» How we pay the providers i our etwork For a list of providers ad pharmacies i the pla s etwork, see the Provider ad Pharmacy Directory. For more detailed iformatio about our providers or pharmacies, call Member Services, or visit our website at Iformatio about covered services ad drugs ad about rules you must follow, icludig:» Services ad drugs covered by the pla» Limits to your coverage ad drugs» Rules you must follow to get covered services ad drugs Iformatio about why somethig is ot covered ad what you ca do about it, icludig:» Askig us to put i writig why somethig is ot covered» Askig us to chage a decisio we made» Askig us to pay for a bill you got If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 122

125 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities F. Network providers caot bill you directly Doctors, hospitals, ad other providers i our etwork caot make you pay for covered services. They also caot charge you if we pay for less tha the provider charged us. To lear what to do if a etwork provider tries to charge you for covered services, see Chapter 7. G. You have the right to leave the pla at ay time No oe ca make you stay i our pla if you do ot wat to. You ca leave the pla at ay time. If you leave our pla, you will still be i the Medicare ad Michiga Medicaid programs as log as you are eligible. You have the right to get most of your health care services through Origial Medicare or a Medicare Advatage pla. You ca get your Medicare Part D prescriptio drug beefits from a prescriptio drug pla or from a Medicare Advatage pla. If there is aother MI Health Lik pla i your service area, you may also chage to a differet MI Health Lik pla ad cotiue to get coordiated Medicare ad Michiga Medicaid beefits. You ca get your Michiga Medicaid beefits through Michiga s origial (fee-for-service) Medicaid. H. You have a right to make decisios about your health care You have the right to kow your treatmet optios ad make decisios about your health care You have the right to get full iformatio from your doctors ad other health care providers whe you get services. Your providers must explai your coditio ad your treatmet choices i a way that you ca uderstad. Kow your choices. You have the right to be told about all the kids of treatmet. Kow the risks. You have the right to be told about ay risks ivolved. You must be told i advace if ay service or treatmet is part of a research experimet. You have the right to refuse experimetal treatmets. You ca get a secod opiio. You have the right to see aother doctor before decidig o treatmet. You ca say o. You have the right to refuse ay treatmet. This icludes the right to leave a hospital or other medical facility, eve if your doctor advises you ot to. You also have the right to stop takig a drug. If you refuse treatmet or stop takig a drug, you will ot be dropped from the pla. However, if you refuse treatmet or stop takig a drug, you accept full resposibility for what happes to you. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 123

126 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities You ca ask us to explai why a provider deied care. You have the right to get a explaatio from us if a provider has deied care that you believe you should get. You ca ask us to cover a service or drug that was deied or is usually ot covered. This is called a coverage decisio. Chapter 9 tells how to ask the pla for a coverage decisio. You have the right to say what you wat to happe if you are uable to make health care decisios for yourself Sometimes people are uable to make health care decisios for themselves. Before that happes to you, you ca: Fill out a writte form to give someoe the right to make health care decisios for you. Give your doctors writte istructios about how you wat them to hadle your health care if you become uable to make decisios for yourself. The legal documet that you ca use to give your directios is called a advace directive. There are differet types of advace directives ad differet ames for them. Examples are a psychiatric advace directive ad a durable power of attorey for health care. Now is a good time to write dow your advace directives because you ca make your wishes kow while you are healthy. Your doctor s offce has a advace directive you fill out to tell your doctor what you wat doe. Your advace directive ofte icludes a do-ot-resuscitate order. Some people do this after talkig to their doctor about their health status. It gives writte otice to health care workers who may be treatig you should you stop breathig or your heart stops. Your doctor ca help you with this if you are iterested. You do ot have to use a advace directive, but you ca if you wat to. Here is what to do: Get the form. You ca get a form from your doctor, a lawyer, a legal services agecy, or a social worker. Orgaizatios that give people iformatio about Medicare or Michiga Medicaid, such as the Michiga State Log Term Care Ombudsma Program, have advace directive forms. You ca also cotact Member Services to ask for the forms. Fill it out ad sig the form. The form is a legal documet. You should cosider havig a lawyer help you prepare it. Give copies to people who eed to kow about it. You should give a copy of the form to your doctor. You should also give a copy to the perso you ame as the oe to make decisios for you. You may also wat to give copies to close frieds or family members. Be sure to keep a copy at home. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 124

127 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities If you are goig to be hospitalized ad you have siged a advace directive, take a copy of it to the hospital. The hospital will ask you whether you have siged a advace directive form ad whether you have it with you. If you have ot siged a advace directive form, the hospital has forms available ad will ask if you wat to sig oe. Remember, it is your choice to fill out a advace directive or ot. What to do if your istructios are ot followed I Michiga, your advace directive has bidig effect o doctors ad hospitals. However, if you believe that a doctor or a hospital did ot follow the istructios i your advace directive, you may file a complait with the Michiga Departmet of Licesig ad Regulatory Affairs, Bureau of Health Care Services at I. You have the right to make complaits ad to ask us to recosider decisios we have made Chapter 9 tells what you ca do if you have ay problems or cocers about your covered services or care. For example, you could ask us to make a coverage decisio, make a appeal to us to chage a coverage decisio, or make a complait. You have the right to get iformatio about appeals ad complaits that other members have filed agaist our pla. To get this iformatio, call Member Services. What to do if you believe you are beig treated ufairly or your rights are ot beig respected If you believe you have bee treated ufairly ad it is ot about discrimiatio for the reasos listed o page 119 you ca get help i these ways: You ca call Member Services. You ca call the State Health Isurace Assistace Program (SHIP). I Michiga, the SHIP is called the Medicare/Medicaid Assistace Program (MMAP). For details about this orgaizatio ad how to cotact it, see Chapter 2. You ca call Medicare at MEDICARE ( ), 24 hours a day, seve days a week. TTY users should call You ca call the MI Health Lik Ombudsma program at If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 125

128 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities How to get more iformatio about your rights There are several ways to get more iformatio about your rights: You ca call Member Services. You ca call MMAP. For details about this orgaizatio ad how to cotact it, see Chapter 2. You ca cotact Medicare.» You ca visit the Medicare website to read or dowload Medicare Rights & Protectios. (Go to Or you ca call MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call You ca call the MI Health Lik Ombudsma program at J. You also have resposibilities as a member of the pla As a member of the pla, you have a resposibility to do the thigs that are listed below. If you have ay questios, call Member Services. Read the Member Hadbook to lear what is covered ad what rules you eed to follow to get covered services ad drugs.» For details about your covered services, see Chapters 3 ad 4. Those chapters tell you what is covered, what is ot covered, what rules you eed to follow, ad what you pay.» For details about your covered drugs, see Chapters 5 ad 6. Tell us about ay other health or prescriptio drug coverage you have. We are required to make sure you are usig all of your coverage optios whe you get health care. Please call Member Services if you have other coverage. Tell your doctor ad other health care providers that you are erolled i our pla. Show your Member ID Card wheever you get services or drugs. Help your doctors ad other health care providers give you the best care. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 126» Give them the iformatio they eed about you ad your health. Lear as much as you ca about your health problems. Follow the treatmet plas ad istructios that you ad your providers agree o.» Make sure your doctors ad other providers kow about all of the drugs you are takig. This icludes prescriptio drugs, over-the-couter drugs, vitamis, ad supplemets.» If you have ay questios, be sure to ask. Your doctors ad other providers must explai thigs i a way you ca uderstad. If you ask a questio ad you do ot uderstad the aswer, ask agai.

129 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities Be cosiderate. We expect all our members to respect the rights of other patiets. We also expect you to act with respect i your doctor s offce, hospitals, ad other providers offces. Pay what you owe. As a pla member, you are resposible for these paymets:» Medicare Part A ad Medicare Part B premiums. For almost all Aeta Better Health Premier Pla members, Michiga Medicaid pays for your Part A premium ad for your Part B premium.» The amout of moey you may be asked to pay for the time you stay i a ursig home is based o your icome ad set by the state. Chapter 4 provides additioal iformatio about the patiet pay amout for ursig facility services.» If you get ay services or drugs that are ot covered by our pla, you must pay the full cost. If you disagree with our decisio to ot cover a service or drug, you ca make a appeal. Please see Chapter 9 to lear how to make a appeal. Tell us if you move. If you are goig to move, it is importat to tell us right away. Call Member Services.» If you move outside of our service area, you caot stay i this pla. Oly people who live i our service area ca get Aeta Better Health Premier Pla. Chapter 1 tells about our service area. We ca help you figure out whether you are movig outside our service area.» If you move withi our service area, we still eed to kow. We eed to keep your membership record up to date ad kow how to cotact you. Call Member Services for help if you have questios or cocers. Erollees age 55 ad older who are gettig log term care services may be subject to estate recovery upo their death. For more iformatio, you may:» Cotact your Care Coordiator, or» Call the Beeficiary Helplie at , or» Visit the website at or» questios to MDHHS-EstateRecovery@michiga.gov. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 127

130 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) What s i this chapter? This chapter has iformatio about your rights. Read this chapter to fid out what to do if: You have a problem with or complait about your pla. You eed a service, item, or medicatio that your pla has said it will ot pay for. You disagree with a decisio that your pla has made about your care. You thik your covered services are edig too soo. If you have a problem or cocer, you oly eed to read the parts of this chapter that apply to your situatio. This chapter is broke ito differet sectios to help you easily fid what you are lookig for. If you are facig a problem with your health or log term supports ad services You should get the health care, drugs, ad other supports ad services that your doctor ad other providers determie are ecessary for your care as a part of your care pla. You should try to work with your providers ad Aeta Better Health Premier Pla first. If you are still havig a problem with your care or our pla, you ca call the MI Health Lik Ombudsma at This chapter explais the differet optios you have for differet problems ad complaits, but you ca always call the MI Health Lik Ombudsma to help guide you through your problem. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 128

131 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Table of Cotets What s i this chapter? If you are facig a problem with your health or log term supports ad services Sectio 1: Itroductio Sectio 1.1: What to do if you have a problem Sectio 1.2: What about the legal terms? Sectio 2: Where to call for help Sectio 2.1: Where to get more iformatio ad help Sectio 3: Which process to use to help with your problem Sectio 3.1: Should you use the process for coverage decisios ad appeals? Or do you wat to make a complait? Sectio 4: Coverage decisios ad appeals Sectio 4.1: Overview of coverage decisios ad appeals Sectio 4.2: Gettig help with coverage decisios ad appeals Sectio 4.3: Which sectio of this chapter will help you? Sectio 5: Problems about services, items, ad drugs (ot Part D drugs) Sectio 5.1: Whe to use this sectio Sectio 5.2: Askig for a coverage decisio Sectio 5.3: Iteral Appeal for services, items, ad drugs (ot Part D drugs) Sectio 5.4: Exteral Appeal for services, items, ad drugs (ot Part D drugs) Sectio 5.5: Paymet problems Sectio 6: Part D drugs Sectio 6.1: What to do if you have problems gettig a Part D drug or you wat us to pay you back for a Part D drug Sectio 6.2: What is a exceptio? Sectio 6.3: Importat thigs to kow about askig for exceptios If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 129

132 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Sectio 6.4: How to ask for a coverage decisio about a Part D drug or reimbursemet for a Part D drug, icludig a exceptio Sectio 6.5: Level 1 Appeal for Part D drugs Sectio 6.6: Level 2 Appeal for Part D drugs Sectio 7: Askig us to cover a loger hospital stay Sectio 7.1: Learig about your Medicare rights Sectio 7.2: Level 1 Appeal to chage your hospital discharge date Sectio 7.3: Level 2 Appeal to chage your hospital discharge date Sectio 7.4: What happes if I miss a appeal deadlie? Sectio 8: What to do if you thik your home health care, skilled ursig care, or Comprehesive Outpatiet Rehabilitatio Facility (CORF) services are edig too soo Sectio 8.1: We will tell you i advace whe your coverage will be edig Sectio 8.2: Level 1 Appeal to cotiue your care Sectio 8.3: Level 2 Appeal to cotiue your care Sectio 8.4: What if you miss the deadlie for makig your Level 1 Appeal? Sectio 9: Appeal optios after Level 2 or Exteral Appeals Sectio 9.1: Next steps for Medicare services ad items Sectio 9.2: Next steps for Michiga Medicaid services ad items Sectio 10: How to make a complait Sectio 10.1: Iteral complaits Sectio 10.2: Exteral complaits If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 130

133 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Sectio 1: Itroductio Sectio 1.1: What to do if you have a problem This chapter tells you what to do if you have a problem with your pla or with your services or paymet. Medicare ad Michiga Medicaid approved these processes. Each process has a set of rules, procedures, ad deadlies that must be followed by us ad by you. Sectio 1.2: What about the legal terms? There are diffcult legal terms for some of the rules ad deadlies i this chapter. May of these terms ca be hard to uderstad, so we have used simpler words i place of certai legal terms. We use abbreviatios as little as possible. For example, we will say: Makig a complait rather tha filig a grievace Coverage decisio rather tha orgaizatio determiatio, beefit determiatio, or coverage determiatio Fast coverage decisio rather tha expedited determiatio Kowig the proper legal terms may help you commuicate more clearly, so we provide those too. Sectio 2: Where to call for help Sectio 2.1: Where to get more iformatio ad help Sometimes it ca be cofusig to start or follow the process for dealig with a problem. This ca be especially true if you do ot feel well or have limited eergy. Other times, you may ot have the kowledge you eed to take the ext step. You ca get help from the MI Health Lik Ombudsma If you eed help gettig aswers to your questios or uderstadig what to do to hadle your problem, you ca call the MI Health Lik Ombudsma. The MI Health Lik Ombudsma is ot coected with us or with ay isurace compay. They ca help you uderstad which process to use. The phoe umber for the MI Health Lik Ombudsma is The services are free. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 131

134 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) You ca get help from the State Health Isurace Assistace Program (SHIP) You ca also call your State Health Isurace Assistace Program (SHIP). I Michiga the SHIP is called the Michiga Medicare/Medicaid Assistace Program (MMAP). MMAP couselors ca aswer your questios ad help you uderstad what to do to hadle your problem. MMAP is ot coected with us or with ay isurace compay or health pla. MMAP has traied couselors ad their services are free. The MMAP phoe umber is You ca also fid iformatio o MMAP s website at Gettig help from Medicare You ca call Medicare directly for help with problems. Here are two ways to get help from Medicare: Call MEDICARE ( ), 24 hours a day, 7 days a week. TTY: The call is free. Visit the Medicare website ( Gettig help from Michiga Medicaid You ca also call Michiga Medicaid for help with problems. Call the Beeficiary Help Lie Moday through Friday from 8:00 AM to 7:00 PM at (TTY: ), or if callig from a iteret based phoe service. Gettig help from KEPRO Our state uses a orgaizatio called KEPRO for quality improvemet. This is a group of doctors ad other health care professioals who help improve the quality of care for people with Medicare. KEPRO is ot coected with our pla. You ca make a complait to KEPRO about the care you have received if: You have a problem with the quality of care, You thik your hospital stay is edig too soo, or You thik your home health care, skilled ursig facility care, or comprehesive outpatiet rehabilitatio facility (CORF) services are edig too soo You ca call KEPRO at (TTY ). If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 132

135 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Sectio 3: Which process to use to help with your problem Sectio 3.1: Should you use the process for coverage decisios ad appeals? Or do you wat to make a complait? If you have a problem or cocer, you oly eed to read the parts of this chapter that apply to your situatio. The chart below will help you fid the right sectio of this chapter for problems or complaits. Is your problem or cocer about your beefits or coverage? (This icludes problems about whether particular medical care, log term supports ad services, or prescriptio drugs are covered or ot, the way i which they are covered, ad problems related to paymet for medical care, log term supports ad services, or prescriptio drugs.) Yes. My problem is about beefits or coverage. No. My problem is ot about beefits or coverage. Go to Sectio 4: Coverage decisios ad appeals o page 133. Skip ahead to Sectio 10: How to make a complait o page 174. Sectio 4: Coverage decisios ad appeals Sectio 4.1: Overview of coverage decisios ad appeals The process for askig for coverage decisios ad makig appeals deals with problems related to your beefits ad coverage. It also icludes problems with paymet. NOTE: Behavioral health services are covered by your Prepaid Ipatiet Health Pla (PIHP). This icludes metal health, itellectual/developmetal disability, ad substace use disorder services ad supports. Cotact your PIHP for iformatio about coverage decisios ad appeals o behavioral health services. See Chapter 2 for the PIHP iformatio i your regio. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 133

136 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) What is a coverage decisio? A coverage decisio is a iitial decisio we make about your beefits ad coverage or about the amout we will pay for your medical services, items, or drugs. We are makig a coverage decisio wheever we decide what is covered for you ad how much we pay. If you or your providers are ot sure if a service, item, or drug is covered by Medicare or Michiga Medicaid, either of you ca ask for a coverage decisio before you get the service, item, or drug. What is a appeal? A appeal is a formal way of askig us to review our coverage decisio ad chage it if you thik we made a mistake. For example, we might decide that a service, item, or drug that you wat is ot covered or is ot medically ecessary for you. If you or your provider disagree with our decisio, you ca appeal. Sectio 4.2: Gettig help with coverage decisios ad appeals Who ca I call for help askig for coverage decisios or makig a appeal? You ca ask ay of these people for help: Call your Care Coordiator at (TTY: 711). Call Member Services at (TTY: 711). Talk to your doctor or other provider. Your doctor or other provider ca ask for a coverage decisio or appeal o your behalf. Call the MI Health Lik Ombudsma for free help. The MI Health Lik Ombudsma ca help you with questios about or problems with MI Health Lik or our pla. The MI Health Lik Ombudsma is a idepedet program, ad is ot coected with this pla. The phoe umber is Call the Michiga Medicare/Medicaid Assistace Program (MMAP) for free help. MMAP is a idepedet orgaizatio. It is ot coected with this pla. The phoe umber is Talk to a fried or family member ad ask him or her to act for you. You ca ame aother perso to act for you as your represetative to ask for a coverage decisio or make a appeal. Your desigated represetative will have the same rights as you do i askig for a coverage decisio or makig a appeal. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 134

137 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits)» If you wat a fried, relative, or other perso to be your represetative, call Member Services ad ask for the Appoitmet of Represetative form. You ca also get the form o the Medicare website at dowloads/cms1696.pdf or o our website at The form gives the perso permissio to act for you. You must give us a copy of the siged form. You do ot eed to submit this form for your doctor or other provider to act as your represetative. You also have the right to ask a lawyer to act for you. You may call your ow lawyer, or get the ame of a lawyer from the local bar associatio or other referral service. If you choose to have a lawyer, you must pay for those legal services. However, some legal groups will give you free legal services if you qualify. If you wat a lawyer to represet you, you will eed to fill out the Appoitmet of Represetative form. However, you do ot eed a lawyer to ask for ay kid of coverage decisio or to make a appeal. Sectio 4.3: Which sectio of this chapter will help you? There are four differet types of situatios that ivolve coverage decisios ad appeals. Each situatio has differet rules ad deadlies. We separate this chapter ito differet sectios to help you fid the rules you eed to follow. You oly eed to read the sectio that applies to your problem: Sectio 5 o page 137 gives you iformatio if you have problems about services, items, ad certai drugs (ot Part D drugs). For example, use this sectio if: o o You are ot gettig medical care or other supports ad services that you wat, ad you believe our pla covers this care. We did ot approve services, items, or drugs that your doctor wats to give you, ad you believe this care should be covered ad is medically ecessary. NOTE: Oly use Sectio 5 if these are drugs ot covered by Part D. Drugs i the List of Covered Drugs with a asterisk (*) are ot covered by Part D. See Sectio 6 o page 151 for Part D drug appeals. o You got medical care or other supports ad services you thik should be covered, but we are ot payig for this care. o You got ad paid for medical care or other supports ad services you thought were covered, ad you wat to ask us to pay you back. o You are beig told that coverage for care you have bee gettig will be reduced or stopped, ad you disagree with our decisio. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 135

138 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) NOTE: If the coverage that will be stopped is for hospital care, home health care, skilled ursig facility care, or Comprehesive Outpatiet Rehabilitatio Facility (CORF) services, you eed to read a separate sectio of this chapter because special rules apply to these types of care. See Sectios 7 ad 8 o pages 161 ad 167. Sectio 6 o page 151 gives you iformatio about Part D drugs. For example, use this sectio if: o You wat to ask us to make a exceptio to cover a Part D drug that is ot o our List of Covered Drugs (Drug List). o You wat to ask us to waive limits o the amout of the drug you ca get. o You wat to ask us to cover a drug that requires prior approval. o We did ot approve your request or exceptio, ad you or your doctor or other prescriber thiks we should have. o You wat to ask us to pay for a prescriptio drug you already bought. (This is askig for a coverage decisio about paymet.) Sectio 7 o page 161 gives you iformatio o how to ask us to cover a loger ipatiet hospital stay if you thik the doctor is dischargig you too soo. Use this sectio if: o You are i the hospital ad thik the doctor asked you to leave the hospital too soo. Sectio 8 o page 167 gives you iformatio if you thik your home health care, skilled ursig facility care, ad Comprehesive Outpatiet Rehabilitatio Facility (CORF) services are edig too soo. If you re ot sure which sectio you should use, please call your Care Coordiator at (TTY: 711) or Member Services at (TTY: 711). If you eed other help or iformatio, please call the MI Health Lik Ombudsma at If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 136

139 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Sectio 5: Problems about services, items, ad drugs (ot Part D drugs) Sectio 5.1: Whe to use this sectio This sectio is about what to do if you have problems with your beefits for your medical care or other supports ad services. You ca also use this sectio for problems with drugs that are ot covered by Part D. Drugs i the List of Covered Drugs with a asterisk (*) are ot covered by Part D. Use Sectio 6 for Part D drug appeals. This sectio tells what you ca do if you are i ay of the five followig situatios: 1. You thik we cover a medical service or other supports ad services you eed but are ot gettig. What you ca do: You ca ask us to make a coverage decisio. Go to Sectio 5.2 o page 138 for iformatio o askig for a coverage decisio. 2. We did ot approve care your provider wats to give you, ad you thik we should have. What you ca do: You ca appeal our decisio to ot approve the care. Go to Sectio 5.3 o page 140 for iformatio o makig a appeal. 3. You got services or items that you thik we cover, but we will ot pay. What you ca do: You ca appeal our decisio ot to pay. Go to Sectio 5.3 o page 140 for iformatio o makig a appeal. 4. You got ad paid for services or items you thought were covered, ad you wat us to reimburse you for the services or items. What you ca do: You ca ask us to pay you back. Go to Sectio 5.5 o page 149 for iformatio o askig us for paymet. 5. We reduced or stopped your coverage for a certai service, ad you disagree with our decisio. What you ca do: You ca appeal our decisio to reduce or stop the service. Go to Sectio 5.3 o page 140 for iformatio o makig a appeal. NOTE: If the coverage that will be stopped is for hospital care, home health care, skilled ursig facility care, or Comprehesive Outpatiet Rehabilitatio Facility (CORF) services, special rules apply. Read Sectios 7 or 8 o pages 161 ad 167 to fid out more. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 137

140 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Sectio 5.2: Askig for a coverage decisio How to ask for a coverage decisio to get medical care or log term supports ad services (LTSS) To ask for a coverage decisio, call, write, or fax us, or ask your represetative or doctor to ask us for a decisio. o You ca call us at: TTY: 711. o You ca fax us at: o You ca write to us at: Aeta Better Health Premier Pla 1333 Gratiot Aveue, Suite 400 Detroit, MI NOTE: Your Prepaid Ipatiet Health Pla (PIHP) will make coverage decisios for behavioral health, itellectual/developmetal disability, ad substace use disorder services ad supports. Cotact your PIHP for more iformatio. See Chapter 2 for the PIHP cotact iformatio i your regio. How log does it take to get a coverage decisio? It usually takes up to 14 caledar days after you, your represetative, or your provider asked. If we do t give you our decisio withi 14 caledar days, you ca appeal. Sometimes we eed more time, ad we will sed you a letter tellig you that we eed to take up to 14 more caledar days. The letter will explai why more time is eeded. Ca I get a coverage decisio faster? Yes. If you eed a respose faster because of your health, ask us to make a fast coverage decisio. If we approve the request, we will otify you of our decisio withi 72 hours. However, sometimes we eed more time, ad we will sed you a letter tellig you that we eed to take up to 14 more caledar days. The letter will explai why more time is eeded. The legal term for fast coverage decisio is expedited determiatio. Askig for a fast coverage decisio: If you request a fast coverage decisio, start by callig or faxig our pla to ask us to cover the care you wat. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 138

141 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) You ca call us at (TTY: 711) or fax us at For details o how to cotact us, go to Chapter 2. You ca also have your doctor or your represetative call us. Here are the rules for askig for a fast coverage decisio: You must meet the followig two requiremets to get a fast coverage decisio: 1. You ca get a fast coverage decisio oly if you are askig about coverage for services or items you have ot yet received. (You caot get a fast coverage decisio if your request is about paymet for medical care or a item you already got.) 2. You ca get a fast coverage decisio oly if the stadard 14 caledar day deadlie could cause serious harm to your health or hurt your ability to fuctio. If your provider says that you eed a fast coverage decisio, we will automatically give you oe. If you ask for a fast coverage decisio without your provider s support, we will decide if you get a fast coverage decisio. If we decide that your coditio does ot meet the requiremets for a fast coverage decisio, we will sed you a letter. We will also use the stadard 14 caledar day deadlie istead. This letter will tell you that if your provider asks for the fast coverage decisio, we will automatically give a fast coverage decisio. The letter will also tell how you ca file a fast complait about our decisio to give you a stadard coverage decisio istead of a fast coverage decisio. For more iformatio about the process for makig complaits, icludig fast complaits, see Sectio 10 o page 174. How will I fid out the pla s aswer about my coverage decisio? We will sed you a letter tellig you whether or ot we approved coverage. If the coverage decisio is Yes, whe will I get the service or item? You will be approved (pre-authorized) to get the service or item withi 14 caledar days (for a stadard coverage decisio) or 72 hours (for a fast coverage decisio) of whe you asked. If we exteded the time eeded to make our coverage decisio, we will approve the coverage by the ed of that exteded period. If the coverage decisio is No, how will I fid out? If the aswer is No, we will sed you a letter tellig you our reasos for sayig No. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 139

142 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) If we say No, you have the right to ask us to chage this decisio by makig a appeal. Makig a appeal meas askig us to review our decisio to dey coverage. If you decide to make a appeal, it meas you are goig o to the Iteral Appeals process (read the ext sectio for more iformatio). Sectio 5.3: Iteral Appeal for services, items, ad drugs (ot Part D drugs) What is a appeal? A appeal is a formal way of askig us to review a coverage decisio (deial) or ay adverse actio that we took. If you or your provider disagree with our decisio, you ca appeal. NOTE: Your Prepaid Ipatiet Health Pla (PIHP) hadles appeals about behavioral health, itellectual/developmetal disability, ad substace use disorder services ad supports. Cotact your PIHP for more iformatio. See Chapter 2 for the PIHP cotact iformatio i your regio. If you eed help durig the appeals process, you ca call the MI Health Lik Ombudsma at The MI Health Lik Ombudsma is ot coected with us or with ay isurace compay or health pla. What is a adverse actio? A adverse actio is a actio, or lack of actio, by our pla that you ca appeal. This icludes: We deied or limited a service or item your provider requested; We reduced, suspeded, or eded coverage that was already approved; We did ot pay for a service or item that you thik is covered; We did ot resolve your authorizatio request withi the required timeframes; You could ot get a covered service or item from a provider i our etwork withi a reasoable amout of time; or We did ot act withi the timeframes for reviewig a coverage decisio ad givig you a decisio. What is a Iteral Appeal? A Iteral Appeal (also called a Level 1 Appeal) is the first appeal to our pla. We will review your coverage decisio to see if it is correct. The reviewer will be someoe who did ot make the origial coverage decisio. Whe we complete the review, we will give you our decisio i writig ad tell you what you ca do ext if you disagree with the decisio. You ca ask for a stadard appeal or a fast appeal. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 140

143 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) How do I make a Iteral Appeal? o o o To start your appeal, you, your represetative, or your provider must cotact us. You ca call us at (TTY: 711). For additioal details o how to reach us for appeals, see Chapter 2. You ca ask us for a stadard appeal or a fast appeal. If you are askig for a stadard appeal or fast appeal, make your appeal i writig or call us. You ca submit a request to the followig address: Aeta Better Health Premier Pla Att: Grievace & Appeals Departmet 1333 Gratiot Aveue, Suite 400 Detroit, MI You may also ask for a appeal by callig us at (TTY: 711). At a glace: How to make a Iteral Appeal You, your doctor, or your represetative may put your request i writig ad mail or fax it to us. You may also ask for a appeal by callig us. Ask withi 60 caledar days of the decisio you are appealig. If you miss the deadlie for a good reaso, you may still appeal. If you appeal because we told you that a service you curretly get will be chaged or stopped, you have fewer days to appeal if you wat to keep gettig that service while your appeal is processig. Keep readig this sectio to lear about what deadlie applies to your appeal. The legal term for fast appeal is expedited recosideratio. Ca someoe else make the appeal for me? Yes. Your doctor or other provider ca make the appeal for you. Also, someoe besides your doctor or other provider ca make the appeal for you, but first you must complete a Appoitmet of Represetative form. The form gives the other perso permissio to act for you. To get a Appoitmet of Represetative form, call Member Services ad ask for oe, or visit the Medicare website at cms1696.pdf or our website at If the appeal comes from someoe besides you or your doctor or other provider, we must get the completed Appoitmet of Represetative form before we ca review the appeal. How much time do I have to make a Iteral Appeal? You must ask for a Iteral Appeal withi 60 caledar days from the date o the letter we set to tell you our decisio. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 141

144 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) If you miss this deadlie ad have a good reaso for missig it, we may give you more time to make your appeal. Examples of a good reaso are: you were i the hospital, or we gave you the wrog iformatio about the deadlie for requestig a appeal. NOTE: If you appeal because we told you that a service you curretly get will be chaged or stopped, you have fewer days to appeal if you wat to keep gettig that service while your appeal is processig. Read Will my beefits cotiue durig Iteral Appeals o page 143 for more iformatio. Ca I get a copy of my case file? Yes. Ask us for a copy by callig Member Services at (TTY: 711). Ca my provider give you more iformatio about my appeal? Yes. Both you ad your provider may give us more iformatio to support your appeal. How will we make the appeal decisio? We take a careful look at all of the iformatio about your request for coverage of medical care or other supports ad services. The, we check to see if we were followig all the rules whe we said No to your request. The reviewer will be someoe who did ot make the origial decisio. If we eed more iformatio, we may ask you or your doctor for it. Whe will I hear about a stadard appeal decisio? We must give you our aswer withi 30 caledar days after we get your appeal. We will give you our decisio sooer if your coditio requires us to. However, if you ask for more time or if we eed to gather more iformatio, we ca take up to 14 more caledar days. If we decide to take extra days to make the decisio, we will sed you a letter that explais why we eed more time. If you believe we should ot take extra days, you ca file a fast complait about our decisio to take extra days. Whe you file a fast complait, we will give you a aswer to your complait withi 24 hours. For more iformatio about the process for makig complaits, icludig fast complaits, see Sectio 10 o page 174. If we do ot give you a aswer to your appeal withi 30 caledar days or by the ed of the extra days (if we took them), we will automatically sed your case for a Exteral Appeal if your problem is about coverage of a Medicare service or item. You will be otified whe this happes. If your problem is about coverage of a Michiga Medicaid service or item, you ca file a Exteral Appeal yourself. For more iformatio about the Exteral Appeal process, go to Sectio 5.4 o page 144. If our aswer is Yes to part or all of what you asked for, we must approve or give the coverage withi 30 caledar days after we get your appeal. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 142

145 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) If our aswer is No to part or all of what you asked for, we will sed you a letter. If your problem is about coverage of a Medicare service or item, the letter will tell you that we automatically set your case to the Idepedet Review Etity for a Exteral Appeal. If your problem is about coverage of a Michiga Medicaid service or item, the letter will tell you how to file a Exteral Appeal yourself. For more iformatio about the Exteral Appeal process, go to Sectio 5.4 o page 144. Whe will I hear about a fast appeal decisio? If you ask for a fast appeal, we will give you your aswer withi 72 hours after we get your appeal. We will give you our aswer sooer if your coditio requires us to do so. However, if you ask for more time or if we eed to gather more iformatio, we ca take up to 14 more caledar days. If we decide to take extra days to make the decisio, we will sed you a letter that explais why we eed more time. If you believe we should ot take extra days, you ca file a fast complait about our decisio to take extra days. Whe you file a fast complait, we will give you a aswer to your complait withi 24 hours. For more iformatio about the process for makig complaits, icludig fast complaits, see Sectio 10 o page 174. If we do ot give you a aswer to your appeal withi 72 hours or by the ed of the extra days (if we took them), we will automatically sed your case for a Exteral Appeal if your problem is about coverage of a Medicare service or item. You will be otified whe this happes. If your problem is about coverage of a Michiga Medicaid service or item, you ca file a Exteral Appeal yourself. For more iformatio about the Exteral Appeal process, go to Sectio 5.4 o page 144. If our aswer is Yes to part or all of what you asked for, we must authorize or provide the coverage withi 72 hours after we get your appeal. If our aswer is No to part or all of what you asked for, we will sed you a letter. If your problem is about coverage of a Medicare service or item, the letter will tell you that we set your case to the Idepedet Review Etity for a Exteral Appeal. If your problem is about coverage of a Michiga Medicaid service or item, the letter will tell you how to file a Exteral Appeal yourself. For more iformatio about the Exteral Appeal process, go to Sectio 5.4 o page 144. Will my beefits cotiue durig Iteral Appeals? If we decide to chage or stop coverage for a service that was previously approved, we will sed you a otice before takig the proposed actio. If you file your Iteral Appeal withi 12 caledar days of the date o our otice or prior to the iteded effective date of the actio, we will cotiue your beefits for the service while the Iteral Appeal is pedig. If you are appealig to get a ew service from our pla, the you would ot get that service uless your appeal is fiished ad the decisio is that the service is covered. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 143

146 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Sectio 5.4: Exteral Appeal for services, items, ad drugs (ot Part D drugs) If the pla says No to the Iteral Appeal, what happes ext? If we say No to part or all of your Iteral Appeal, we will sed you a appeal deial otice. This otice is called the Notice of Appeal Decisio. This otice will tell you if the service or item is usually covered by Medicare ad/or Michiga Medicaid. If your problem is about a Medicare service or item, you will automatically get a Exteral Appeal with the Idepedet Review Etity (IRE) as soo as the Iteral Appeal is complete. If your problem is about a Michiga Medicaid service or item, you ca file a Exteral Appeal yourself with the Michiga Admiistrative Hearigs System (MAHS) ad/or a request for a Exteral Review with the Michiga Departmet of Isurace ad Fiacial Services (DIFS). The Notice of Appeal Decisio will tell you how to do this. Iformatio is also o page 144. If your problem is about a service or item that could be covered by both Medicare ad Michiga Medicaid, you will automatically get a Exteral Appeal with the IRE. You ca also ask for a Exteral Appeal with MAHS ad/or Exteral Review with DIFS. What is a Exteral Appeal? A Exteral Appeal (also called a Level 2 Appeal) is the secod appeal, which is doe by a idepedet orgaizatio that is ot coected to the pla. Medicare s Exteral Appeal orgaizatio is called the Idepedet Review Etity (IRE). Michiga Medicaid s Exteral Appeal is a Fair Hearig through the Michiga Admiistrative Hearigs System (MAHS). You also have the right to request a Exteral Review of Michiga Medicaid service deials through the Michiga Departmet of Isurace ad Fiacial Services (DIFS). My problem is about a Michiga Medicaid covered service or item. How ca I make a Exteral Appeal? There are two ways to make a Exteral Appeal for Michiga Medicaid services ad items: 1) Fair Hearig ad/or 2) Exteral Review. 1) Fair Hearig You have the right to ask for a Fair Hearig from the Michiga Admiistrative Hearigs System (MAHS). A Fair Hearig is a impartial review of a decisio made by our pla. You may ask for a Fair Hearig after the Iteral Appeal with our pla. I additio, if you do ot receive a otice about your appeal, or a decisio o your appeal withi the time frame the pla has to respod o your appeal, you may ask for a Michiga Medicaid Fair Hearig. You must ask for a Fair Hearig withi 120 caledar days from the date o the Notice of Appeal Decisio. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 144

147 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) NOTE: If you ask for a Fair Hearig because we told you that a service you curretly get will be chaged or stopped, you have fewer days to file your request if you wat to keep gettig that service while your Fair Hearig is pedig. Read Will my beefits cotiue durig Exteral Appeals o page 147 for more iformatio. To ask for a Fair Hearig from MAHS, you must complete a Request for Hearig form. We will sed you a Request for Hearig form with the Notice of Appeal Decisio. You ca also get the form by callig the Michiga Medicaid Beeficiary Help Lie at (TTY: ), or if callig from a iteret based phoe service, Moday through Friday from 8:00 AM to 7:00 PM. Complete the form sed it to: Michiga Admiistrative Hearig System Departmet of Health ad Huma Services PO Box Lasig, MI FAX: You ca also ask for a expedited (fast) Fair Hearig by writig to the address or faxig to the umber listed above. After MAHS gets your Fair Hearig request, you will get a letter tellig you the date, time, ad place of your hearig. Hearigs are usually coducted over the phoe, but you ca ask that your hearig be coducted i perso. MAHS must give you a aswer i writig withi 90 caledar days of whe it gets your request for a Fair Hearig. If you qualify for a expedited Fair Hearig, MAHS must give you a aswer withi 72 hours. However, if MAHS eeds to gather more iformatio that may help you, it ca take up to 14 more caledar days. After you get the MAHS fial decisio, you have 30 caledar days from the date of the decisio to file a request for rehearig/recosideratio ad/or to file a appeal with the Circuit Court. 2) Exteral Review You also have the right to ask for a Exteral Review through the Michiga Departmet of Isurace ad Fiacial Services (DIFS). You must complete our Iteral Appeals process first before you ca ask for this type of Exteral Appeal. Your request for a Exteral Review must be submitted withi 60 caledar days of your receipt of our Iteral Appeal decisio. NOTE: If you qualified for cotiuatio of beefits durig the Iteral Appeal ad you ask for a Exteral Review withi 12 caledar days from the date of the Iteral Appeal decisio, you ca cotiue to get the disputed service durig the review. Read Will my beefits cotiue durig Exteral Appeals o page 147 for more iformatio. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 145

148 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) To ask for a Exteral Review from DIFS, you must complete the Health Care Request for Exteral Review form. We will sed you this form with our Notice of Appeal Decisio. You ca also get a copy of the form by callig DIFS at Complete the form ad sed it with all supportig documetatio to: DIFS - Offce of Geeral Cousel Health Care Appeals Sectio PO Box Lasig, MI FAX: If your request does ot ivolve reviewig medical records, the Exteral Review will be coducted by the Director of DIFS. If your request ivolves issues of medical ecessity or cliical review criteria, it will be set to a separate Idepedet Review Orgaizatio (IRO). If the review is coducted by the Director ad does ot require review by a IRO, the Director will issue a decisio withi 14 caledar days after your request is accepted. If the review is referred to a IRO, the IRO will give its recommedatio to DIFS withi 14 caledar days after it is assiged the review. The Director will the issue a decisio withi 7 busiess days after it receives the IRO s recommedatio. If the stadard timeframe for review would jeopardize your life or health, you may be able to qualify for a expedited (fast) review. A expedited review is completed withi 72 hours after your request. To qualify for a expedited review, you must have your doctor verify that the timeframe for a stadard review would jeopardize your life or health. If you disagree with the Exteral Review decisio, you have the right to appeal to Circuit Court i the couty where you live or the Michiga Court of Claims withi 60 days from the date of the decisio. My problem is about a Medicare covered service or item. What will happe at the Exteral Appeal? A Idepedet Review Etity (IRE) will carefully review the Iteral Appeal decisio ad decide whether it should be chaged. You do ot eed to ask for the Exteral Appeal. We will automatically sed ay deials (i whole or i part) to the IRE. You will be told whe this happes. The IRE is hired by Medicare ad is ot coected with this pla. You may ask for a copy of your file by callig Member Services at (TTY: 711). The IRE must give you a aswer to your Exteral Appeal withi 30 caledar days of whe it gets your appeal. This rule applies if you set your appeal before gettig medical services or items.» However, if the IRE eeds to gather more iformatio that may beefit you, it ca take up to 14 more caledar days. If the IRE eeds extra days to make a decisio, it will tell you by letter. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 146

149 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) If you had fast appeal at the Iteral Appeal, you will automatically have a fast appeal at the Exteral Appeal. The IRE must give you a aswer withi 72 hours of whe it gets your appeal.» However, if the IRE eeds to gather more iformatio that may beefit you, it ca take up to 14 more caledar days. If the IRE eeds extra days to make a decisio, it will tell you by letter. What if my service or item is covered by both Medicare ad Michiga Medicaid? If your problem is about a service or item that could be covered by both Medicare ad Michiga Medicaid, we will automatically sed your Exteral Appeal to the Idepedet Review Etity. You ca also submit a Exteral Appeal to the Michiga Admiistrative Hearigs System ad/or a Exteral Review to the Michiga Departmet of Isurace ad Fiacial Services. Follow the istructios o page 147. Will my beefits cotiue durig Exteral Appeals? If we previously approved coverage for a service but the decided to chage or stop the service before the authorizatio expired, you ca cotiue your beefits durig Exteral Appeals i some cases. If the service is covered by Medicare ad you qualified for cotiuatio of beefits durig the Iteral Appeal, your beefits for that service will automatically cotiue durig the Exteral Appeal process with the Idepedet Review Etity (IRE). If the service is covered by Michiga Medicaid, your beefits for that service will cotiue if you qualified for cotiuatio of beefits durig your Iteral Appeal ad you ask for a Fair Hearig from MAHS or a Exteral Review from the Michiga Departmet of Isurace ad Fiacial Services (DIFS) withi 12 caledar days from the date of the Notice of Appeal Decisio. If the service could be covered by both Medicare ad Michiga Medicaid ad you qualified for cotiuatio of beefits durig the Iteral Appeal, your beefits for that service will automatically cotiue durig the IRE review. You may also qualify for cotiuatio of beefits durig MAHS ad/or DIFS review if you submit your request withi the timeframes listed above. If your beefits are cotiued, you ca keep gettig the service util oe of the followig happes: 1) you withdraw the appeal; or 2) all etities that got your appeal (the IRE, MAHS, ad/or DIFS) decide o to your request. If ay of the etities decide yes to your request, your services will cotiue. How will I fid out about the decisio? If your Exteral Appeal wet to the Michiga Admiistrative Hearigs System (MAHS) for a Fair Hearig, MAHS will sed you a letter explaiig its decisio. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 147

150 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) If MAHS says Yes to part or all of what you asked for, we must approve the service for you as quickly as your coditio requires, but o later tha 72 hours from the date we receive MAHS decisio. If MAHS says No to part or all of what you asked for, it meas they agree with the Iteral Appeal decisio. This is called upholdig the decisio or turig dow your appeal. If your Exteral Appeal wet to the Michiga Departmet of Isurace ad Fiacial Services (DIFS) for a Exteral Review, DIFS will sed you a letter explaiig the Director s decisio. If DIFS says Yes to part or all of what you asked for, we must approve the service for you as quickly as your coditio requires. If DIFS says No to part or all of what you asked for, it meas they agree with the Iteral Appeal decisio. This is called upholdig the decisio or turig dow your appeal. If your Exteral Appeal wet to the Idepedet Review Etity (IRE), it will sed you a letter explaiig its decisio. If the IRE says Yes to part or all of what you asked for, we must authorize the coverage as quickly as your coditio requires, but o later tha 72 hours from the date we get the IRE s decisio. If the IRE says No to part or all of what you asked for, it meas they agree with the Iteral Appeal decisio. This is called upholdig the decisio. It is also called turig dow your appeal. What if I had differet types of Exteral Appeals ad they have differet decisios? If ay of the Exteral Appeal orgaizatios (MAHS, DIFS, ad/or the IRE) decide Yes for all or part of what you asked for, we will give you the approved service or item that is closest to what you asked for i your appeal. If the decisio is No for all or part of what I asked for, ca I make aother appeal? If your Exteral Appeal wet to the Michiga Admiistrative Hearigs System (MAHS) for a Fair Hearig, you ca appeal the decisio withi 30 days to the Circuit Court. You may also request a rehearig or recosideratio by MAHS withi 30 days. If your Exteral Appeal wet to the Michiga Departmet of Isurace ad Fiacial Services (DIFS) for a Exteral Review, you ca appeal to the Circuit Court i the couty where you live or the Michiga Court of Claims withi 60 days from the date of the decisio. If your Exteral Appeal wet to the Idepedet Review Etity (IRE), you ca appeal agai oly if the dollar value of the service or item you wat meets a certai miimum amout. The letter you get from the MAHS, DIFS, or IRE will explai additioal appeal rights you may have. See Sectio 9 o page 173 for more iformatio o additioal levels of appeal. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 148

151 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) NOTE: Your beefits for the disputed service will ot cotiue durig the additioal levels of appeal. Sectio 5.5: Paymet problems We do ot allow our etwork providers to bill you for covered services ad items. This is true eve if we pay the provider less tha the provider charges for a covered service or item. You are ever required to pay the balace of ay bill. The oly amout you should be asked to pay is ad ay required patiet pay amout for ursig home care. If you get a bill for covered services ad items, sed the bill to us. You should ot pay the bill yourself. We will cotact the provider directly ad take care of the problem. For more iformatio, start by readig Chapter 7: Askig us to pay a bill you have gotte for covered services or drugs. Chapter 7 describes the situatios i which you may eed to ask for reimbursemet or to pay a bill you got from a provider. It also tells how to sed us the paperwork that asks us for paymet. Ca I ask you to pay me back for a service or item I paid for? Remember, if you get a bill for covered services ad items, you should ot pay the bill yourself. But if you do pay the bill, you ca get a refud if you followed the rules for gettig services ad items. If you are askig to be paid back, you are askig for a coverage decisio. We will see if the service or item you paid for is a covered service or item, ad we will check to see if you followed all the rules for usig your coverage. If the service or item you paid for is covered ad you followed all the rules, we will sed you the paymet for the service or item withi 60 caledar days after we get your request. Or, if you have t paid for the service or item yet, we will sed the paymet directly to the provider. Whe we sed the paymet, it s the same as sayig Yes to your request for a coverage decisio. If the service or item is ot covered, or you did ot follow all the rules, we will sed you a letter tellig you we will ot pay for the service or item, ad explaiig why. What if we say we will ot pay? If you do ot agree with our decisio, you ca make a appeal. Follow the appeals process described i Sectio 5.3 o page 140. Whe you follow these istructios, please ote: If you make a appeal for reimbursemet, we must give you our aswer withi 60 caledar days after we get your appeal. If you are askig us to pay you back for a service or item you already got ad paid for yourself, you caot ask for a fast appeal. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 149

152 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) If we aswer No to your appeal ad the service or item is usually covered by Medicare, we will automatically sed your case to the Idepedet Review Etity (IRE). We will otify you by letter if this happes. o o If the IRE reverses our decisio ad says we should pay you, we must sed the paymet to you or to the provider withi 30 caledar days. If the aswer to your appeal is Yes at ay stage of the appeals process after review by the IRE, we must sed the paymet you asked for to you or to the provider withi 60 caledar days. If the IRE says No to your appeal, it meas they agree with our decisio ot to approve your request. (This is called upholdig the decisio. It is also called turig dow your appeal. ) The letter you get will explai additioal appeal rights you may have. You ca appeal agai oly if the dollar value of the service or item you wat meets a certai miimum amout. See Sectio 9 o page 173 for more iformatio o additioal levels of appeal. If we aswer No to your appeal ad the service or item is usually covered by Michiga Medicaid, you ca ask for a Fair Hearig from the Michiga Admiistrative Hearigs System or a Exteral Review from the Michiga Departmet of Isurace ad Fiacial Services (see Sectio 5.4 o page 144). If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 150

153 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Sectio 6: Part D drugs Sectio 6.1: What to do if you have problems gettig a Part D drug or you wat us to pay you back for a Part D drug Your beefits as a member of our pla iclude coverage for may prescriptio drugs. Most of these drugs are Part D drugs. There are a few drugs that Medicare Part D does ot cover but that Michiga Medicaid may cover. This sectio oly applies to Part D drug appeals. o The List of Covered Drugs (Drug List), icludes some drugs with a asterisk (*) These drugs are ot Part D drugs. Appeals or coverage decisios about drugs with a asterisk (*) symbol follow the process i Sectio 5 o page 137. Ca I ask for a coverage decisio or make a appeal about Part D prescriptio drugs? Yes. Here are examples of coverage decisios you ca ask us to make about your Part D drugs: You ask us to make a exceptio such as:» Askig us to cover a Part D drug that is ot o the pla s List of Covered Drugs (Drug List)» Askig us to waive a restrictio o the pla s coverage for a drug (such as limits o the amout of the drug you ca get) You ask us if a drug is covered for you (for example, whe your drug is o the pla s Drug List but we require you to get approval from us before we will cover it for you).» NOTE: If your pharmacy tells you that your prescriptio caot be filled, you will get a otice explaiig how to cotact us to ask for a coverage decisio. You ask us to pay for a prescriptio drug you already bought. This is askig for a coverage decisio about paymet. The legal term for a coverage decisio about your Part D drugs is coverage determiatio. If you disagree with a coverage decisio we have made, you ca appeal our decisio. This sectio tells you how to ask for coverage decisios ad how to request a appeal. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 151

154 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Use the chart below to help you decide which sectio has iformatio for your situatio: Which of these situatios are you i? Do you eed a drug that is t o our Drug List or eed us to waive a rule or restrictio o a drug we cover? Do you wat us to cover a drug o our Drug List ad you believe you meet ay pla rules or restrictios (such as gettig approval i advace) for the drug you eed? Do you wat to ask us to pay you back for a drug you already got ad paid for? Have we already told you that we will ot cover or pay for a drug i the way that you wat it to be covered or paid for? You ca ask us to make a exceptio. (This is a type of coverage decisio.) You ca ask us for a coverage decisio. You ca ask us to pay you back. (This is a type of coverage decisio.) You ca make a appeal. (This meas you are askig us to recosider.) Start with Sectio 6.2 o page 152. Also see Sectios 6.3 ad 6.4 o pages 153 ad 154. Skip ahead to Sectio 6.4 o page 154. Skip ahead to Sectio 6.4 o page 154. Skip ahead to Sectio 6.5 o page 157. Sectio 6.2: What is a exceptio? A exceptio is permissio to get coverage for a drug that is ot ormally o our List of Covered Drugs or to use the drug without certai rules ad limitatios. If a drug is ot o our List of Covered Drugs or is ot covered i the way you would like, you ca ask us to make a exceptio. Whe you ask for a exceptio, your doctor or other prescriber will eed to explai the medical reasos why you eed the exceptio. Here are examples of exceptios that you or your doctor or aother prescriber ca ask us to make: 1. Coverig a Part D drug that is ot o our List of Covered Drugs (Drug List). If we agree to make a exceptio ad cover a drug that is ot o the Drug List, you will ot be charged. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 152

155 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) 2. Removig a restrictio o our coverage. There are extra rules or restrictios that apply to certai drugs o our Drug List (for more iformatio, go to Chapter 5). The extra rules ad restrictios o coverage for certai drugs iclude:» Beig required to use the geeric versio of a drug istead of the brad ame drug.» Gettig pla approval before we will agree to cover the drug for you. (This is sometimes called prior authorizatio. )» Beig required to try a differet drug first before we will agree to cover the drug you are askig for. (This is sometimes called step therapy. )» Quatity limits. For some drugs, we limit the amout of the drug you ca have. The legal term for askig for removal of a restrictio o coverage for a drug is sometimes called askig for a formulary exceptio. Sectio 6.3: Importat thigs to kow about askig for exceptios Your doctor or other prescriber must tell us the medical reasos Your doctor or other prescriber must give us a statemet explaiig the medical reasos for requestig a exceptio. Our decisio about the exceptio will be faster if you iclude this iformatio from your doctor or other prescriber whe you ask for the exceptio. Typically, our Drug List icludes more tha oe drug for treatig a particular coditio. These are called alterative drugs. If a alterative drug would be just as effective as the drug you are askig for ad would ot cause more side effects or other health problems, we will geerally ot approve your request for a exceptio. We will say Yes or No to your request for a exceptio If we say Yes to your request for a exceptio, the exceptio usually lasts util the ed of the caledar year. This is true as log as your doctor cotiues to prescribe the drug for you ad that drug cotiues to be safe ad effective for treatig your coditio. If we say No to your request for a exceptio, you ca ask for a review of our decisio by makig a appeal. Sectio 6.5 o page 157 tells how to make a appeal if we say No. The ext sectio tells you how to ask for a coverage decisio, icludig a exceptio. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 153

156 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Sectio 6.4: How to ask for a coverage decisio about a Part D drug or reimbursemet for a Part D drug, icludig a exceptio What to do If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit Ask for the type of coverage decisio you wat. Call, write, or fax us to make your request. You, your represetative, or your doctor (or other prescriber) ca do this. You ca call us at (TTY: 711). You or your doctor (or other prescriber) or someoe else who is actig o your behalf ca ask for a coverage decisio. You ca also have a lawyer act o your behalf. Read Sectio 4 o page 133 to fid out how to give permissio to someoe else to act as your represetative. You do ot eed to give your doctor or other prescriber writte permissio to ask us for a coverage decisio o your behalf. If you wat to ask us to pay you back for a drug, read Chapter 7 of this hadbook. Chapter 7 describes times whe you may eed to ask for reimbursemet. It also tells how to sed us the paperwork that asks us to pay you back for our share of the cost of a drug you have paid for. At a glace: How to ask for a coverage decisio about a Part D drug or paymet Call, write, or fax us to ask, or ask your represetative or doctor or other prescriber to ask. We will give you a aswer o a stadard coverage decisio withi 72 hours. We will give you a aswer o reimbursig you for a Part D drug you already paid for withi 14 caledar days. If you are askig for a exceptio, iclude the supportig statemet from the doctor or other prescriber. You or your doctor or other prescriber may ask for a fast decisio. (Fast decisios usually come withi 24 hours.) Read this sectio to make sure you qualify for a fast decisio! Read it also to fid iformatio about decisio deadlies. If you are askig for a exceptio, provide the supportig statemet. Your doctor or other prescriber must give us the medical reasos for the drug exceptio. We call this the supportig statemet. Your doctor or other prescriber ca fax or mail the statemet to us. Or your doctor or other prescriber ca tell us o the phoe, ad the fax or mail a statemet. If your health requires it, ask us to give you a fast coverage decisio We will use the stadard deadlies uless we have agreed to use the fast deadlies. A stadard coverage decisio meas we will give you a aswer withi 72 hours after we get your doctor s statemet.

157 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) A fast coverage decisio meas we will give you a aswer withi 24 hours after we get your doctor s statemet.» You ca get a fast coverage decisio oly if you are askig for a drug you have ot yet received. (You caot get a fast coverage decisio if you are askig us to pay you back for a drug you already bought.)» You ca get a fast coverage decisio oly if usig the stadard deadlies could cause serious harm to your health or hurt your ability to fuctio.» If your doctor or other prescriber tells us that your health requires a fast coverage decisio, we will automatically agree to give you a fast coverage decisio, ad the letter will tell you that. If you ask for a fast coverage decisio o your ow (without your doctor s or other prescriber s support), we will decide whether you get a fast coverage decisio. If we decide that your medical coditio does ot meet the requiremets for a fast coverage decisio, we will use the stadard deadlies istead. We will sed you a letter tellig you that. The letter will tell you how to make a complait about our decisio to give you a stadard decisio. You ca file a fast complait ad get a respose to your complait withi 24 hours. For more iformatio about the process for makig complaits, icludig fast complaits, see Sectio 10 o page 174. The legal term for fast coverage decisio is expedited coverage determiatio. Deadlies for a fast coverage decisio If we are usig the fast deadlies, we must give you our aswer withi 24 hours. This meas withi 24 hours after we get your request. Or, if you are askig for a exceptio, 24 hours after we get your doctor s or prescriber s statemet supportig your request. We will give you our aswer sooer if your health requires it. If we do ot meet this deadlie, we will sed your request to Level 2 of the appeals process. At Level 2, a Idepedet Review Etity will review your request. If our aswer is Yes to part or all of what you asked for, we must give you the coverage withi 24 hours after we get your request or your doctor s or prescriber s statemet supportig your request. If our aswer is No to part or all of what you asked for, we will sed you a letter that explais why we said No. The letter will also explai how you ca appeal our decisio. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 155

158 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Deadlies for a stadard coverage decisio about a drug you have ot yet received If we are usig the stadard deadlies, we must give you our aswer withi 72 hours after we get your request. Or, if you are askig for a exceptio, after we get your doctor s or prescriber s supportig statemet. We will give you our aswer sooer if your health requires it. If we do ot meet this deadlie, we will sed your request o to Level 2 of the appeals process. At Level 2, a Idepedet Review Etity will review your request. If our aswer is Yes to part or all of what you asked for, we must approve or give the coverage withi 72 hours after we get your request or, if you are askig for a exceptio, your doctor s or prescriber s supportig statemet. If our aswer is No to part or all of what you asked for, we will sed you a letter that explais why we said No. The letter will also explai how you ca appeal our decisio. Deadlies for a stadard coverage decisio about paymet for a drug you already bought We must give you our aswer withi 14 caledar days after we get your request. If we do ot meet this deadlie, we will sed your request to Level 2 of the appeals process. At Level 2, a Idepedet Review Etity will review your request. If our aswer is Yes to part or all of what you asked for, we will make paymet to you withi 14 caledar days. If our aswer is No to part or all of what you asked for, we will sed you a letter that explais why we said No. The letter will also explai how you ca appeal our decisio. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 156

159 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Sectio 6.5: Level 1 Appeal for Part D drugs To start your appeal, you, your doctor or other prescriber, or your represetative must cotact us. If you are askig for a stadard appeal, you ca make your appeal by sedig a request i writig. You may also ask for a appeal by callig us at (TTY: 711). If you wat a fast appeal, you may make your appeal i writig or you may call us. Make your appeal request withi 60 caledar days from the date o the otice we set to tell you our decisio. If you miss this deadlie ad have a good reaso for missig it, we may give you more time to make you appeal. For example, good reasos for missig the deadlie would be if you have a serious illess that kept you from cotactig us or if we gave you icorrect or icomplete iformatio about the deadlie for requestig a appeal. At a glace: How to make a Level 1 Appeal You, your doctor or prescriber, or your represetative may put your request i writig ad mail or fax it to us. You may also ask for a appeal by callig us. Ask withi 60 caledar days of the decisio you are appealig. If you miss the deadlie for a good reaso, you may still appeal. You, your doctor or prescriber, or your represetative ca call us to ask for a fast appeal. Read this sectio to make sure you qualify for a fast decisio! Read it also to fid iformatio about decisio deadlies. The legal term for a appeal to the pla about a Part D drug coverage decisio is pla redetermiatio. You have the right to ask us for a copy of the iformatio about your appeal. To ask for a copy, call Member Services at (TTY: 711).» If you wish, you ad your doctor or other prescriber may give us additioal iformatio to support your appeal. If your health requires it, ask for a fast appeal If you are appealig a decisio our pla made about a drug you have ot yet received, you ad your doctor or other prescriber will eed to decide if you eed a fast appeal. The requiremets for gettig a fast appeal are the same as those for gettig a fast coverage decisio i Sectio 6.4 o page 154. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 157

160 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) The legal term for fast appeal is expedited redetermiatio. Our pla will review your appeal ad give you our decisio We take aother careful look at all of the iformatio about your coverage request. We check to see if we were followig all the rules whe we said No to your request. We may cotact you or your doctor or other prescriber to get more iformatio. The reviewer will be someoe who did ot make the origial coverage decisio. Deadlies for a fast appeal If we are usig the fast deadlies, we will give you our aswer withi 72 hours after we get your appeal, or sooer if your health requires it. If we do ot give you a aswer withi 72 hours, we will sed your request to Level 2 of the appeals process. At Level 2, a Idepedet Review Etity will review your request. If our aswer is Yes to part or all of what you asked for, we must give the coverage withi 7 2 hours after we get your appeal. If our aswer is No to part or all of what you asked for, we will sed you a letter that explais why we said No ad how to appeal our decisio. Deadlies for a stadard appeal If we are usig the stadard deadlies, we must give you our aswer withi 7 caledar days after we get your appeal, or sooer if your health requires it. If you thik your health requires it, you should ask for a fast appeal. If we do ot give you a decisio withi 7 caledar days, we will sed your request to Level 2 of the appeals process. At Level 2, a Idepedet Review Etity will review your request. If our aswer is Yes to part or all of what you asked for:» If we approve a request for coverage, we must give you the coverage as quickly as your health requires, but o later tha 7 caledar days after we get your appeal.» If we approve a request to pay you back for a drug you already bought, we will sed paymet to you withi 30 caledar days after we get your appeal request. If our aswer is No to part or all of what you asked for, we will sed you a letter that explais why we said No ad tells how to appeal our decisio. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 158

161 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Sectio 6.6: Level 2 Appeal for Part D drugs If we say No to part or all of your appeal, you ca choose whether to accept this decisio or make aother appeal. If you decide to go o to a Level 2 Appeal, the Idepedet Review Etity (IRE) will review our decisio. If you wat the IRE to review your case, your appeal request must be i writig. The letter we sed about our decisio i the Level 1 Appeal will explai how to request the Level 2 Appeal. Whe you make a appeal to the IRE, we will sed them your case file. You have the right to ask us for a copy of your case file by callig Member Services at (TTY: 711). You have a right to give the IRE other iformatio to support your appeal. The IRE is a idepedet orgaizatio that is hired by Medicare. It is ot coected with this pla ad it is ot a govermet agecy. At a glace: How to make a Level 2 Appeal If you wat the Idepedet Review Etity to review your case, your appeal request must be i writig. Reviewers at the IRE will take a careful look at all of the iformatio related to your appeal. The orgaizatio will sed you a letter explaiig its decisio. Ask withi 60 caledar days of the decisio you are appealig. If you miss the deadlie for a good reaso, you may still appeal. You, your doctor or other prescriber, or your represetative ca request the Level 2 Appeal. Read this sectio to make sure you qualify for a fast decisio! Read it also to fid iformatio about decisio deadlies. The legal term for a appeal to the IRE about a Part D drug is recosideratio. Deadlies for fast appeal at Level 2 If your health requires it, ask the Idepedet Review Etity (IRE) for a fast appeal. If the IRE agrees to give you a fast appeal, it must give you a aswer to your Level 2 Appeal withi 72 hours after gettig your appeal request. If the IRE says Yes to part or all of what you asked for, we must authorize or give you the drug coverage withi 24 hours after we get the decisio. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 159

162 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Deadlies for stadard appeal at Level 2 If you have a stadard appeal at Level 2, the Idepedet Review Etity (IRE) must give you a aswer to your Level 2 Appeal withi 7 caledar days after it gets your appeal.» If the IRE says Yes to part or all of what you asked for, we must authorize or give you the drug coverage withi 72 hours after we get the decisio.» If the IRE approves a request to pay you back for a drug you already bought, we will sed paymet to you withi 30 caledar days after we get the decisio. What if the Idepedet Review Etity says No to your Level 2 Appeal? No meas the Idepedet Review Etity (IRE) agrees with our decisio ot to approve your request. This is called upholdig the decisio. It is also called turig dow your appeal. If you wat to go to Level 3 of the appeals process, the drugs you are requestig must meet a miimum dollar value. If the dollar value is less tha the miimum, you caot appeal ay further. If the dollar value is high eough, you ca ask for a Level 3 appeal. The letter you get from the IRE will tell you the dollar value eeded to cotiue with the appeal process. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 160

163 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Sectio 7: Askig us to cover a loger hospital stay Whe you are admitted to a hospital, you have the right to get all hospital services that we cover that are ecessary to diagose ad treat your illess or ijury. Durig your covered hospital stay, your doctor ad the hospital staff will work with you to prepare for the day whe you leave the hospital. They will also help arrage for ay care you may eed after you leave. The day you leave the hospital is called your discharge date. Your doctor or the hospital staff will tell you what your discharge date is. If you thik you are beig asked to leave the hospital too soo, you ca ask for a loger hospital stay. This sectio tells you how to ask. Sectio 7.1: Learig about your Medicare rights Withi two days after you are admitted to the hospital, a caseworker or urse will give you a otice called A Importat Message from Medicare about Your Rights. If you do ot get this otice, ask ay hospital employee for it. If you eed help, please call Member Services at (TTY: 711). You ca also call MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Read this otice carefully ad ask questios if you do t uderstad. The Importat Message tells you about your rights as a hospital patiet, icludig your rights to: Get Medicare-covered services durig ad after your hospital stay. You have the right to kow what these services are, who will pay for them, ad where you ca get them. Be a part of ay decisios about the legth of your hospital stay. Kow where to report ay cocers you have about the quality of your hospital care. Appeal if you thik you are beig discharged from the hospital too soo. You should sig the Medicare otice to show that you got it ad uderstad your rights. Sigig the otice does ot mea you agree to the discharge date that may have bee told to you by your doctor or hospital staff. Keep your copy of the siged otice so you will have the iformatio i it if you eed it. To look at a copy of this otice i advace, you ca call Member Services at (TTY: 711). You ca also call MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call The call is free. You ca also see the otice olie at Iformatio/BNI/HospitalDischargeAppealNotices.html. If you eed help, please call Member Services or Medicare at the umbers listed above. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 161

164 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Sectio 7.2: Level 1 Appeal to chage your hospital discharge date If you wat us to cover your ipatiet hospital services for a loger time, you must request a appeal. A Quality Improvemet Orgaizatio will do the Level 1 Appeal review to see if your plaed discharge date is medically appropriate for you. I Michiga, the Quality Improvemet Orgaizatio is called KEPRO. To make a appeal to chage your discharge date, call KEPRO at: (TTY: ). Call right away! Call the Quality Improvemet Orgaizatio before you leave the hospital ad o later tha your plaed discharge date. A Importat Message from Medicare about Your Rights cotais iformatio o how to reach the Quality Improvemet Orgaizatio. If you call before you leave, you are allowed to stay i the hospital after your plaed discharge date without payig for it while you wait to get the decisio o your appeal from the Quality Improvemet Orgaizatio. If you do ot call to appeal, ad you decide to stay i the hospital after your plaed discharge date, you may have to pay all of the costs for hospital care you get after your plaed discharge date. At a glace: How to make a Level 1 Appeal to chage your discharge date Call the Quality Improvemet Orgaizatio for your state at ad ask for a fast review. Call before you leave the hospital ad before your plaed discharge date. If you miss the deadlie for cotactig the Quality Improvemet Orgaizatio about your appeal, you ca make your appeal directly to our pla istead. For details, see Sectio 7.4 o page 165. We wat to make sure you uderstad what you eed to do ad what the deadlies are. Ask for help if you eed it. If you have questios or eed help at ay time, please call Member Services at (TTY: 711). You ca also call the Michiga Medicare/ Medicaid Assistace Program (MMAP) at You ca also get help from the MI Health Lik Ombudsma by callig What is a Quality Improvemet Orgaizatio? It is a group of doctors ad other health care professioals who are paid by the federal govermet. These experts are ot part of our pla. They are paid by Medicare to check o ad help improve the quality of care for people with Medicare. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 162

165 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Ask for a fast review You must ask the Quality Improvemet Orgaizatio for a fast review of your discharge. Askig for a fast review meas you are askig the orgaizatio to use the fast deadlies for a appeal istead of usig the stadard deadlies. The legal term for fast review is immediate review. What happes durig the fast review? The reviewers at the Quality Improvemet Orgaizatio will ask you or your represetative why you thik coverage should cotiue after the plaed discharge date. You do t have to prepare aythig i writig, but you may do so if you wish. The reviewers will look at your medical record, talk with your doctor, ad review all of the iformatio related to your hospital stay. By oo of the day after the reviewers tell us about your appeal, you will get a letter that gives your plaed discharge date. The letter explais the reasos why your doctor, the hospital, ad we thik it is right for you to be discharged o that date. The legal term for this writte explaatio is called the Detailed Notice of Discharge. You ca get a sample by callig Member Services at You ca also call MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Or you ca see a sample otice olie at Geeral-Iformatio/BNI/HospitalDischargeAppealNotices.html What if the aswer is Yes? If the Quality Improvemet Orgaizatio says Yes to your appeal, we must keep coverig your hospital services for as log as they are medically ecessary. What if the aswer is No? If the Quality Improvemet Orgaizatio says No to your appeal, they are sayig that your plaed discharge date is medically appropriate. If this happes, our coverage for your ipatiet hospital services will ed at oo o the day after the Quality Improvemet Orgaizatio gives you its aswer. If the Quality Improvemet Orgaizatio says No ad you decide to stay i the hospital, the you may have to pay for your cotiued stay at the hospital. The cost of the hospital care that you may have to pay begis at oo o the day after the Quality Improvemet Orgaizatio gives you its aswer. If the Quality Improvemet Orgaizatio turs dow your appeal ad you stay i the hospital after your plaed discharge date, the you ca make a Level 2 Appeal. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 163

166 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Sectio 7.3: Level 2 Appeal to chage your hospital discharge date If the Quality Improvemet Orgaizatio has tured dow your appeal ad you stay i the hospital after your plaed discharge date, the you ca make a Level 2 Appeal. You will eed to cotact the Quality Improvemet Orgaizatio agai ad ask for aother review. Ask for the Level 2 review withi 60 caledar days after the day whe the Quality Improvemet Orgaizatio said No to your Level 1 Appeal. You ca ask for this review oly if you stayed i the hospital after the date that your coverage for the care eded. I Michiga, the Quality Improvemet Orgaizatio is called KEPRO. You ca reach KEPRO at: (TTY: ). Reviewers at the Quality Improvemet Orgaizatio will take aother careful look at all of the iformatio related to your appeal. Withi 14 caledar days of receipt of your request for a secod review, the Quality Improvemet Orgaizatio reviewers will make a decisio. What happes if the aswer is Yes? At a glace: How to make a Level 2 Appeal to chage your discharge date Call the Quality Improvemet Orgaizatio for your state at ad ask for aother review. We must pay you back for our share of the costs of hospital care you got sice oo o the day after the date of your first appeal decisio. We must cotiue providig coverage for your ipatiet hospital care for as log as it is medically ecessary. You must cotiue to pay your share of the costs ad coverage limitatios may apply. What happes if the aswer is No? It meas the Quality Improvemet Orgaizatio agrees with the Level 1 decisio ad will ot chage it. The letter you get will tell you what you ca do if you wish to cotiue with the appeal process. If the Quality Improvemet Orgaizatio turs dow your Level 2 Appeal, you may have to pay the full cost for your stay after your plaed discharge date. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 164

167 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Sectio 7.4: What happes if I miss a appeal deadlie? You ca appeal to us istead If you miss appeal deadlies, there is aother way to make Level 1 ad Level 2 Appeals, called Alterate Appeals. But the first two levels of appeal are differet. NOTE: Your Prepaid Ipatiet Health Pla (PIHP) hadles appeals about behavioral health, itellectual/developmetal disability, ad substace use disorder services ad supports. This icludes Alterate Appeals for ipatiet metal health care. Cotact your PIHP for more iformatio. See Chapter 2 for the PIHP cotact iformatio i your regio. Level 1 Alterate Appeal to chage your hospital discharge date If you miss the deadlie for cotactig the Quality Improvemet Orgaizatio, you ca make a appeal to us, askig for a fast review. A fast review is a appeal that uses the fast deadlies istead of the stadard deadlies. Durig this review, we take a look at all of the iformatio about your hospital stay. We check to see if the decisio about whe you should leave the hospital was fair ad followed all the rules. We will use the fast deadlies rather tha the stadard deadlies for givig you the aswer to this review. This meas we will give you our decisio withi 72 hours after you ask for a fast review. At a glace: How to make a Level 1 Alterate Appeal Call our Member Services umber ad ask for a fast review of your hospital discharge date. We will give you our decisio withi 72 hours. If we say Yes to your fast review, it meas we agree that you still eed to be i the hospital after the discharge date. We will keep coverig hospital services for as log as it is medically ecessary. It also meas that we agree to pay you back for our share of the costs of care you got sice the date whe we said your coverage would ed. If we say No to your fast review, we are sayig that your plaed discharge date was medically appropriate. Our coverage for your ipatiet hospital services eds o the day we said coverage would ed.» If you stayed i the hospital after your plaed discharge date, the you may have to pay the full cost of hospital care you got after the plaed discharge date. To make sure we were followig all the rules whe we said No to your fast appeal, we will sed your appeal to the Idepedet Review Etity. Whe we do this, it meas that your case is automatically goig to Level 2 of the appeals process. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 165

168 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) The legal term for fast review or fast appeal is expedited appeal. Level 2 Alterate Appeal to chage your hospital discharge date We will sed the iformatio for your Level 2 Appeal to the Idepedet Review Etity (IRE) withi 24 hours of whe we give you our Level 1 decisio. If you thik we are ot meetig this deadlie or other deadlies, you ca make a complait. Sectio 10 o page 174 tells how to make a complait. Durig the Level 2 Appeal, the IRE reviews the decisio we made whe we said No to your fast review. This orgaizatio decides whether the decisio we made should be chaged. The IRE does a fast review of your appeal. The reviewers usually give you a aswer withi 72 hours. The IRE is a idepedet orgaizatio that is hired by Medicare. This orgaizatio is ot coected with our pla ad it is ot a govermet agecy. Reviewers at the IRE will take a careful look at all of the iformatio related to your appeal of your hospital discharge. At a glace: How to make a Level 2 Alterate Appeal You do ot have to do aythig. The pla will automatically sed your appeal to the Idepedet Review Etity. If the IRE says Yes to your appeal, the we must pay you back for our share of the costs of hospital care you got sice the date of your plaed discharge. We must also cotiue our coverage of your hospital services for as log as it is medically ecessary. If the IRE says No to your appeal, it meas they agree with us that your plaed hospital discharge date was medically appropriate. The letter you get from the IRE will tell you what you ca do if you wish to cotiue with the review process. It will give you the details about how to go o to a Level 3 Appeal, which is hadled by a judge. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 166

169 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Sectio 8: What to do if you thik your home health care, skilled ursig care, or Comprehesive Outpatiet Rehabilitatio Facility (CORF) services are edig too soo This sectio is about the followig types of care oly: Home health care services. Skilled ursig care i a skilled ursig facility. Rehabilitatio care you are gettig as a outpatiet at a Medicare-approved Comprehesive Outpatiet Rehabilitatio Facility (CORF). Usually, this meas you are gettig treatmet for a illess or accidet, or you are recoverig from a major operatio. With ay of these three types of care, you have the right to keep gettig covered services for as log as the doctor says you eed it. Whe we decide to stop coverig ay of these, we must tell you before your services ed. Whe your coverage for that care eds, we will stop payig for your care. If you thik we are edig the coverage of your care too soo, you ca appeal our decisio. This sectio tells you how to ask for a appeal. Sectio 8.1: We will tell you i advace whe your coverage will be edig You will get a otice at least two caledar days before we stop payig for your care. This is called the Notice of Medicare No-Coverage. The writte otice tells you the date whe we will stop coverig your care. The writte otice also tells you how to appeal this decisio. You or your represetative should sig the writte otice to show that you got it. Sigig it does ot mea you agree with the pla that it is time to stop gettig the care. Whe your coverage eds, we will stop payig for your care. Sectio 8.2: Level 1 Appeal to cotiue your care If you thik we are edig coverage of your care too soo, you ca appeal our decisio. This sectio tells you how to ask for a appeal. Before you start your appeal, uderstad what you eed to do ad what the deadlies are. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 167

170 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Meet the deadlies. The deadlies are importat. Be sure that you uderstad ad follow the deadlies that apply to thigs you must do. There are also deadlies our pla must follow. (If you thik we are ot meetig our deadlies, you ca file a complait. Sectio 10 o page 174 tells you how to file a complait.) Ask for help if you eed it. If you have questios or eed help at ay time, please call Member Services at (TTY: 711). Or call the Michiga Medicare/Medicaid Assistace Program (MMAP) at Durig a Level 1 Appeal, a Quality Improvemet Orgaizatio will review your appeal ad decide whether to chage the decisio we made. I Michiga, the Quality Improvemet Orgaizatio is called KEPRO. You ca reach KEPRO at: (TTY: ). Iformatio about appealig to the Quality Improvemet Orgaizatio is also i the Notice of Medicare No-Coverage. This is the otice you got whe you were told we would stop coverig your care. What is a Quality Improvemet Orgaizatio? At a glace: How to make a Level 1 Appeal to ask the pla to cotiue your care Call the Quality Improvemet Orgaizatio for your state at ad ask a fast-track appeal. Call before you leave the agecy or facility that is providig your care ad before your plaed discharge date. It is a group of doctors ad other health care professioals who are paid by the federal govermet. These experts are ot part of our pla. They are paid by Medicare to check o ad help improve the quality of care for people with Medicare. What should you ask for? Ask them for a fast-track appeal. This is a idepedet review of whether it is medically appropriate for us to ed coverage for your services. What is your deadlie for cotactig this orgaizatio? You must cotact the Quality Improvemet Orgaizatio o later tha oo of the day after you got the writte otice tellig you whe we will stop coverig your care. If you miss the deadlie for cotactig the Quality Improvemet Orgaizatio about your appeal, you ca make your appeal directly to us istead. For details about this other way to make your appeal, see Sectio 8.4 o page 170. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 168

171 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) The legal term for this writte otice is Notice of Medicare No-Coverage. To get a sample copy, call Member Services at (TTY: 711) or MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Or see a copy olie at MAEDNotices.html What happes durig the Quality Improvemet Orgaizatio s review? The reviewers at the Quality Improvemet Orgaizatio will ask you or your represetative why you thik coverage for the services should cotiue. You do t have to prepare aythig i writig, but you may do so if you wish. Whe you ask for a appeal, the pla must write a letter to you ad the Quality Improvemet Orgaizatio explaiig why your services should ed. The reviewers will also look at your medical records, talk with your doctor, ad review iformatio that our pla has give to them. Withi oe full day after reviewers have all the iformatio they eed, they will tell you their decisio. You will get a letter explaiig the decisio. The legal term for the letter explaiig why your services should ed is Detailed Explaatio of No-Coverage. What happes if the reviewers say Yes? If the reviewers say Yes to your appeal, the we must keep providig your covered services for as log as they are medically ecessary. What happes if the reviewers say No? If the reviewers say No to your appeal, the your coverage will ed o the date we told you. We will stop payig our share of the costs of this care. If you decide to keep gettig the home health care, skilled ursig facility care, or Comprehesive Outpatiet Rehabilitatio Facility (CORF) services after the date your coverage eds, the you will have to pay the full cost of this care yourself. Sectio 8.3: Level 2 Appeal to cotiue your care If the Quality Improvemet Orgaizatio said No to the appeal ad you choose to cotiue gettig care after your coverage for the care has eded, you ca make a Level 2 Appeal. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 169

172 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Durig the Level 2 Appeal, the Quality Improvemet Orgaizatio will take aother look at the decisio they made at Level 1. If they say they agree with the Level 1 decisio, you may have to pay the full cost for your home health care, skilled ursig facility care, or Comprehesive Outpatiet Rehabilitatio Facility (CORF) services after the date whe we said your coverage would ed. I Michiga, the Quality Improvemet Orgaizatio is called KEPRO. You ca reach KEPRO at: (TTY: ). Ask for the Level 2 review withi 60 caledar days after the day whe the Quality Improvemet Orgaizatio said No to your Level 1 Appeal. You ca ask for this review oly if you cotiued gettig care after the date that your coverage for the care eded. Reviewers at the Quality Improvemet Orgaizatio will take aother careful look at all of the iformatio related to your appeal. The Quality Improvemet Orgaizatio will make its decisio withi 14 caledar days of receipt of your appeal request. What happes if the review orgaizatio says Yes? At a glace: How to make a Level 2 Appeal to require that the pla cover your care for loger Call the Quality Improvemet Orgaizatio for your state at ad ask for aother review. Call before you leave the agecy or facility that is providig your care ad before your plaed discharge date. We must pay you back for our share of the costs of care you got sice the date whe we said your coverage would ed. We must cotiue providig coverage for the care for as log as it is medically ecessary. What happes if the review orgaizatio says No? It meas they agree with the decisio they made o the Level 1 Appeal ad will ot chage it. The letter you get will tell you what to do if you wish to cotiue with the review process. It will give you the details about how to go o to the ext level of appeal, which is hadled by a judge. Sectio 8.4: What if you miss the deadlie for makig your Level 1 Appeal? You ca appeal to us istead If you miss appeal deadlies, there is aother way to make Level 1 ad Level 2 Appeals, called Alterate Appeals. But the first two levels of appeal are differet. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 170

173 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Level 1 Alterate Appeal to cotiue your care for loger If you miss the deadlie for cotactig the Quality Improvemet Orgaizatio, you ca make a appeal to us, askig for a fast review. A fast review is a appeal that uses the fast deadlies istead of the stadard deadlies. Durig this review, we take a look at all of the iformatio about your home health care, skilled ursig facility care, or care you are gettig at a Comprehesive Outpatiet Rehabilitatio Facility (CORF). We check to see if the decisio about whe your services should ed was fair ad followed all the rules. We will use the fast deadlies rather tha the stadard deadlies for givig you the aswer to this review. We will give you our decisio withi 72 hours after you ask for a fast review. At a glace: How to make a Level 1 Alterate Appeal Call our Member Services umber ad ask for a fast review. We will give you our decisio withi 72 hours. If we say Yes to your fast review, it meas we agree that we will keep coverig your services for as log as it is medically ecessary. It also meas that we agree to pay you back for our share of the costs of care you got sice the date whe we said your coverage would ed. If we say No to your fast review, we are sayig that stoppig your services was medically appropriate. Our coverage eds as of the day we said coverage would ed.» If you cotiue gettig services after the day we said they would stop, you may have to pay the full cost of the services. To make sure we were followig all the rules whe we said No to your fast appeal, we will sed your appeal to the Idepedet Review Etity. Whe we do this, it meas that your case is automatically goig to Level 2 of the appeals process. The legal term for fast review or fast appeal is expedited appeal. Level 2 Alterate Appeal to cotiue your care for loger We will sed the iformatio for your Level 2 Appeal to the Idepedet Review Etity (IRE) withi 24 hours of whe we give you our Level 1 decisio. If you thik we are ot meetig this deadlie or other deadlies, you ca make a complait. Sectio 10 o page 174 tells how to make a complait. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 171

174 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Durig the Level 2 Appeal, the IRE reviews the decisio we made whe we said No to your fast review. This orgaizatio decides whether the decisio we made should be chaged. The IRE does a fast review of your appeal. The reviewers usually give you a aswer withi 72 hours. The IRE is a idepedet orgaizatio that is hired by Medicare. This orgaizatio is ot coected with our pla, ad it is ot a govermet agecy. At a glace: How to make a Level 2 Alterate Appeal to require that the pla cotiue your care You do ot have to do aythig. The pla will automatically sed your appeal to the Idepedet Review Etity. Reviewers at the IRE will take a careful look at all of the iformatio related to your appeal. If the IRE says Yes to your appeal, the we must pay you back for our share of the costs of care. We must also cotiue our coverage of your services for as log as it is medically ecessary. If the IRE says No to your appeal, it meas they agree with us that stoppig coverage of services was medically appropriate. The letter you get from the IRE will tell you what you ca do if you wish to cotiue with the review process. It will give you details about how to go o to a Level 3 Appeal, which is hadled by a judge. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 172

175 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Sectio 9: Appeal optios after Level 2 or Exteral Appeals Sectio 9.1: Next steps for Medicare services ad items If you made a Level 1 or Iteral Appeal ad a Level 2 or Exteral Appeal for Medicare services or items, ad both your appeals have bee tured dow, you may have the right to additioal levels of appeal. The letter you get from the Idepedet Review Etity will tell you what to do if you wish to cotiue the appeals process. Level 3 of the appeals process is a Admiistrative Law Judge (ALJ) hearig. If you wat a ALJ to review your case, the item or medical service you are requestig must meet a miimum dollar amout. If the dollar value is less tha the miimum level, you caot appeal ay further. If the dollar value is high eough, you ca ask a ALJ to hear your appeal. If you do ot agree with the ALJ s decisio, you ca go to the Medicare Appeals Coucil. After that, you may have the right to ask a federal court to look at your appeal. If you eed assistace at ay stage of the appeals process, you ca cotact the MI Health Lik Ombudsma. The phoe umber is Sectio 9.2: Next steps for Michiga Medicaid services ad items You also have more appeal rights if your appeal is about services or items that might be covered by Michiga Medicaid. If your appeal wet to the Michiga Admiistrative Hearigs System (MAHS) for a Fair Hearig, MAHS will sed you a letter explaiig its decisio. If you disagree with the MAHS fial decisio, you have 30 caledar days from the date of the decisio to file a request for rehearig/ recosideratio ad/or to file a appeal with the Circuit Court. Please call MAHS at for iformatio about requiremets you must meet to qualify for a rehearig/recosideratio. If your appeal wet to the Michiga Departmet of Isurace ad Fiacial Services (DIFS) for a Exteral Review, DIFS will sed you a letter explaiig the Director s decisio. If you disagree with the decisio, you have the right to appeal to Circuit Court i the couty where you live or the Michiga Court of Claims withi 60 caledar days from the date of the decisio. If you eed help at ay stage of the appeals process, you ca cotact the MI Health Lik Ombudsma. The phoe umber is If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 173

176 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Sectio 10: How to make a complait What kids of problems should be complaits? The complait process is used for certai types of problems oly, such as problems related to quality of care, waitig times, ad customer service. Here are examples of the kids of problems hadled by the complait process. Complaits about quality You are uhappy with the quality of care, such as the care you got i the hospital. Complaits about privacy You thik that someoe did ot respect your right to privacy, or shared iformatio about you that is cofidetial. Complaits about poor customer service A health care provider or staff was rude or disrespectful to you. Aeta Better Health Premier Pla staff treated you poorly. You thik you are beig pushed out of the pla. At a glace: How to make a complait You ca make a iteral complait with our pla ad/or a exteral complait with a orgaizatio that is ot coected to our pla. To make a iteral complait, call Member Services or sed us a letter. There are differet orgaizatios that hadle exteral complaits. For more iformatio, read Sectio 10.2 o page 177. Complaits about accessibility You caot physically access the health care services ad facilities i a doctor or provider s offce. Your provider does ot give you a reasoable accommodatio you eed such as a America Sig Laguage iterpreter. Complaits about waitig times You are havig trouble gettig a appoitmet, or waitig too log to get it. You have bee kept waitig too log by doctors, pharmacists, or other health professioals or by Member Services or other pla staff. Complaits about clealiess You thik the cliic, hospital or doctor s offce is ot clea. Complaits about laguage access Your doctor or provider does ot provide you with a iterpreter durig your appoitmet. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 174

177 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Complaits about commuicatios from us You thik we failed to give you a otice or letter that you should have received. You thik the writte iformatio we set you is too diffcult to uderstad. Complaits about the timeliess of our actios related to coverage decisios or appeals You believe that we are ot meetig our deadlies for makig a coverage decisio or aswerig your appeal. You believe that, after gettig a coverage or appeal decisio i your favor, we are ot meetig the deadlies for approvig or givig you the service or payig you back for certai medical services. You believe we did ot forward your case to the Idepedet Review Etity o time. The legal term for a complait is a grievace. The legal term for makig a complait is filig a grievace. Are there differet types of complaits? Yes. You ca make a iteral complait ad/or a exteral complait. A iteral complait is filed with ad reviewed by our pla. A exteral complait is filed with ad reviewed by a orgaizatio that is ot affliated with our pla. If you eed help makig a iteral ad/or exteral complait, you ca call the MI Health Lik Ombudsma at NOTE: Behavioral health services are covered by your Prepaid Ipatiet Health Pla (PIHP). This icludes metal health, itellectual/developmetal disability, ad substace use disorder services ad supports. Cotact your PIHP for iformatio about iteral complaits o behavioral health services. See Chapter 2 for the PIHP cotact iformatio i your regio. Sectio 10.1: Iteral complaits To make a iteral complait, call Member Services at (TTY: 711). You ca make the complait at ay time uless it is about a Part D drug. If the complait is about a Part D drug, you must make it withi 60 caledar days after you had the problem you wat to complai about. If there is aythig else you eed to do, Member Services will tell you. You ca also write your complait ad sed it to us. If you put your complait i writig, we will respod to your complait i writig. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 175

178 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) If you ca show good cause i writig why you are filig later tha the 60 caledar days for Part D, Aeta Better Health Premier Pla will exted the timeframe for you to make a complait. If you set us your complait i writig we will sed you a letter withi 3 busiess days tellig you that we received it. We will review your complait withi 30 caledar days ad sed you a letter tellig you our decisio withi 2 busiess days after the decisio is made. At ay time durig the grievace process, you ca have someoe you kow represet you or act o your behalf. This perso will be your represetative. If you decide to have someoe represet you or act for you, tell Aeta Better Health Premier Pla i writig by completig the Appoitmet of Represetative (AOR) form. You or your represetative may ask Aeta Better Health Premier Pla to see ay iformatio relevat to your grievace. You may also sed us iformatio that you have about your grievace to: Aeta Better Health Premier Pla Att: Appeal ad Grievace Departmet 1333 Gratiot Aveue, Suite 400 Detroit, MI Phoe: (TTY: 711) Fax: The legal term for fast complait is expedited grievace. If possible, we will aswer you right away. If you call us with a complait, we may be able to give you a aswer o the same phoe call. If your health coditio requires us to aswer quickly, we will do that. We aswer most complaits withi 30 caledar days. If we eed more iformatio ad the delay is i your best iterest, or if you ask for more time, we ca take up to 14 more caledar days (44 caledar days total) to aswer your complait. We will tell you i writig why we eed more time. If you are makig a complait because we deied your request for a fast coverage decisio or a fast appeal, we will automatically give you a fast complait ad respod to your complait withi 24 hours. If you are makig a complait because we took extra time to make a coverage decisio or appeal, we will automatically give you a fast complait ad respod to your complait withi 24 hours. If we do ot agree with some or all of your complait, we will tell you ad give you our reasos. We will respod whether we agree with the complait or ot. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 176

179 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Sectio 10.2: Exteral complaits You ca tell Medicare about your complait You ca sed your complait to Medicare. The Medicare Complait Form is available at: Medicare takes your complaits seriously ad will use this iformatio to help improve the quality of the Medicare program. If you have ay other feedback or cocers, or if you feel the pla is ot addressig your problem, please call MEDICARE ( ). TTY/TDD users ca call The call is free. You ca tell Michiga Medicaid about your complait You ca also sed your complait to Michiga Medicaid. You ca call the Beeficiary Help Lie Moday through Friday from 8:00 AM to 7:00 PM at (TTY: ), or if callig from a iteret based phoe service. You ca file a complait with the Offce for Civil Rights You ca make a complait to the Departmet of Health ad Huma Services Offce for Civil Rights if you thik you have ot bee treated fairly. For example, you ca make a complait about disability access or laguage assistace. The phoe umber for the Offce for Civil Rights is TTY users should call You ca also visit for more iformatio. You may also cotact the local Offce for Civil Rights offce at: 233 N. Michiga Ave., Suite 240 Chicago, IL Phoe: (800) Fax: (202) You ca also cotact the Michiga Departmet of Civil Rights at: 110 W. Michiga Ave., Suite 800 Lasig, MI Phoe: Fax: TTY: You may also have rights uder the Americas with Disability Act ad uder ADA Michiga: You ca cotact the MI Health Lik Ombudsma for assistace. The phoe umber is If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 177

180 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) You ca file a complait with the Quality Improvemet Orgaizatio Whe your complait is about quality of care, you also have two choices: If you prefer, you ca make your complait about the quality of care directly to the Quality Improvemet Orgaizatio (without makig the complait to us). Or you ca make your complait to us ad to the Quality Improvemet Orgaizatio. If you make a complait to this orgaizatio, we will work with them to resolve your complait. The Quality Improvemet Orgaizatio is a group of practicig doctors ad other health care experts paid by the federal govermet to check ad improve the care give to Medicare patiets. I Michiga, the Quality Improvemet Orgaizatio is called KEPRO. The phoe umber for KEPRO is (TTY: ). You ca tell the MI Health Lik Ombudsma about your complait The MI Health Lik Ombudsma also helps solve problems from a eutral stadpoit to make sure that our members get all the covered services that we are required to provide. The MI Health Lik Ombudsma is ot coected with us or with ay isurace compay or health pla. The phoe umber is The services are free. You ca tell the State of Michiga about your complait If you have a problem with Aeta Better Health Premier Pla, you ca cotact the Michiga Departmet of Isurace ad Fiacial Services (DIFS) at , Moday through Friday from 8:00 AM to 5:00 PM. The call is free. You ca also sed a to DIFS at: difs-hicap@michiga.gov. For complaits about how your provider follows your wishes, call or write to: Michiga Departmet of Licesig ad Regulatory Affairs Bureau of Health Care Services Eforcemet Divisio P.O. Box Lasig, MI If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 178

181 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 10: Edig your membership i Aeta Better Health Premier Pla Table of Cotets A. Whe ca you ed your membership i Aeta Better Health Premier Pla? B. How do you ed your membership i our pla? C. How do you joi a differet pla? D. If you leave our pla ad you do ot wat a differet Medicare-Medicaid Pla, how do you get Medicare ad Michiga Medicaid services? E. Util your membership eds, you will keep gettig your medical services ad drugs through our pla F. Your membership will ed i certai situatios G. We caot ask you to leave our pla for ay reaso related to your health H. You have the right to make a complait if we ed your membership i our pla I. Where ca you get more iformatio about edig your pla membership? If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 179

182 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 10: Edig your membership i Aeta Better Health Premier Pla Itroductio This chapter tells about ways you ca ed your membership i our pla ad your health coverage optios after you leave the pla. If you leave our pla, you will still be i the Medicare ad Michiga Medicaid programs as log as you are eligible. A. Whe ca you ed your membership i Aeta Better Health Premier Pla? You ca ed your membership i Aeta Better Health Premier Pla at ay time. The chage will be effective the first day of the ext moth after we get your request. For iformatio o Medicare optios whe you leave our pla, see the table o page 181. For iformatio about your Michiga Medicaid services whe you leave our pla, see page 183. These are ways you ca get more iformatio about whe you ca ed your membership: Call Michiga ENROLLS at Moday through Friday, 8 AM to 7 PM. TTY users should call Call the State Health Isurace Assistace Program (SHIP). I Michiga, the SHIP is called the Michiga Medicare/Medicaid Assistace Program (MMAP). MMAP ca be reached at Call Medicare at MEDICARE ( ), 24 hours a day, seve days a week. TTY users should call B. How do you ed your membership i our pla? If you decide to ed your membership, tell Michiga Medicaid or Medicare that you wat to leave Aeta Better Health Premier Pla: Call Michiga ENROLLS at Moday through Friday, 8 AM to 7 PM. TTY users should call ; OR Call Medicare at MEDICARE ( ), 24 hours a day, seve days a week. TTY users (people who are deaf, hard of hearig, or speech disabled) should call Whe you call MEDICARE, you ca also eroll i aother Medicare health or drug pla. More iformatio o gettig your Medicare services whe you leave our pla is i the chart o page 182. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 180

183 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 10: Edig your membership i Aeta Better Health Premier Pla C. How do you joi a differet pla? If you wat to keep gettig your Medicare ad Michiga Medicaid beefits together from a sigle pla, you ca joi a differet Medicare-Medicaid Pla. To eroll i a differet Medicare-Medicaid Pla: Call Michiga ENROLLS at Moday through Friday, 8 AM to 7 PM. TTY users should call Tell them you wat to leave Aeta Better Health Premier Pla ad joi a differet Medicare-Medicaid Pla. If you are ot sure what pla you wat to joi, they ca tell you about other plas i your area. Your coverage with Aeta Better Health Premier Pla will ed o the last day of the moth that we get your request. D. If you leave our pla ad you do ot wat a differet Medicare-Medicaid Pla, how do you get Medicare ad Michiga Medicaid services? If you do ot wat to eroll i a differet Medicare-Medicaid Pla after you leave Aeta Better Health Premier Pla, you will go back to gettig your Medicare ad Michiga Medicaid services separately. How you will get Medicare services You will have a choice about how you get your Medicare beefits. You have three optios for gettig your Medicare services. By choosig oe of these optios, you will automatically ed your membership i our pla. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 181

184 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 10: Edig your membership i Aeta Better Health Premier Pla 1. You ca chage to: A Medicare health pla, such as a Medicare Advatage pla or Program of All-iclusive Care for the Elderly (PACE) Here is what to do: Call Medicare at MEDICARE ( ), 24 hours a day, seve days a week. TTY users should call to eroll i the ew Medicare-oly health pla. If you eed help or more iformatio: Call the State Health Isurace Assistace Program (SHIP) at Persos with hearig ad speech disabilities may call 711. The call is free. Offce hours are Moday through Friday, 8 AM to 5 PM. I Michiga, the SHIP is called the Michiga Medicare/Medicaid Assistace Program (MMAP). You will automatically be diserolled from Aeta Better Health Premier Pla whe your ew pla s coverage begis. 2. You ca chage to: Origial Medicare with a separate Medicare prescriptio drug pla Here is what to do: Call Medicare at MEDICARE ( ), 24 hours a day, seve days a week. TTY users should call If you eed help or more iformatio: Call the State Health Isurace Assistace Program (SHIP) at Persos with hearig ad speech disabilities may call 711. The call is free. Offce hours are Moday through Friday, 8 AM to 5 PM. I Michiga, the SHIP is called the Michiga Medicare/Medicaid Assistace Program (MMAP). You will automatically be diserolled from Aeta Better Health Premier Pla whe your Origial Medicare coverage begis. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 182

185 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 10: Edig your membership i Aeta Better Health Premier Pla 3. You ca chage to: Origial Medicare without a separate Medicare prescriptio drug pla NOTE: If you switch to Origial Medicare ad do ot eroll i a separate Medicare prescriptio drug pla, Medicare may eroll you i a drug pla, uless you tell Medicare you do t wat to joi. You should oly drop prescriptio drug coverage if you get drug coverage from a employer, uio or other source. If you have questios about whether you eed drug coverage, call your Michiga Medicare / Medicaid Assistace Program (MMAP) at Here is what to do: Call Medicare at MEDICARE ( ), 24 hours a day, seve days a week. TTY users should call If you eed help or more iformatio: Call the State Health Isurace Assistace Program (SHIP) at Persos with hearig ad speech disabilities may call 711. The call is free. Offce hours are Moday through Friday, 8 AM to 5 PM. I Michiga, the SHIP is called the Michiga Medicare/Medicaid Assistace Program (MMAP). You will automatically be diserolled from Aeta Better Health Premier Pla whe your Origial Medicare coverage begis. How you will get Michiga Medicaid services If you leave the Medicare-Medicaid Pla, you will get your Michiga Medicaid services through fee-for-service. Your Michiga Medicaid services iclude most log term supports ad services ad behavioral health care. If you leave the Medicare-Medicaid Pla, you ca see ay provider that accepts Michiga Medicaid. E. Util your membership eds, you will keep gettig your medical services ad drugs through our pla If you leave Aeta Better Health Premier Pla, it may take time before your membership eds ad your ew Medicare ad Michiga Medicaid coverage begis. See page 180 for more iformatio. Durig this time, you will keep gettig your health care ad drugs through our pla. You should use our etwork pharmacies to get your prescriptios filled. Usually, your prescriptio drugs are covered oly if they are filled at a etwork pharmacy icludig through our mail-order pharmacy services. If you are hospitalized o the day that your membership eds, your hospital stay will usually be covered by our pla util you are discharged. This will happe eve if your ew health coverage begis before you are discharged. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 183

186 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 10: Edig your membership i Aeta Better Health Premier Pla F. Your membership will ed i certai situatios These are the cases whe Aeta Better Health Premier Pla must ed your membership i the pla: If there is a break i your Medicare Part A ad Part B coverage. If you o loger qualify for Michiga Medicaid. Our pla is for people who qualify for both Medicare ad Michiga Medicaid. MI Health Lik program allows you to remai erolled i the MI Health Lik program for up to three moths after the loss of Medicaid eligibility to give you a chace to get your redetermiatio paperwork sorted out with your caseworker. This is called deemig. (See Chapter 12 for more iformatio o deemig. ). If you move out of our service area. If you are away from our service area for more tha six moths.» If you move or take a log trip, you eed to call Member Services to fid out if the place you are movig or travelig to is i our pla s service area. If you go to jail or priso for a crimial offese. If you lie about or withhold iformatio about other isurace you have for prescriptio drugs. If you are ot a Uited States citize or are ot lawfully preset i the Uited States. You must be a Uited States citize or lawfully preset i the Uited States to be a member of our pla. The Ceters for Medicare & Medicaid Services will otify us if you are t eligible to remai a member o this basis. We must diseroll you if you do t meet this requiremet. We ca make you leave our pla for the followig reasos oly if we get permissio from Medicare ad Michiga Medicaid first: If you itetioally give us icorrect iformatio whe you are erollig i our pla ad that iformatio affects your eligibility for our pla. If you cotiuously behave i a way that is disruptive ad makes it diffcult for us to provide medical care for you ad other members of our pla. If you let someoe else use your Member ID Card to get medical care.» If we ed your membership because of this reaso, Medicare may have your case ivestigated by the Ispector Geeral. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 184

187 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 10: Edig your membership i Aeta Better Health Premier Pla G. We caot ask you to leave our pla for ay reaso related to your health If you feel that you are beig asked to leave our pla for a health-related reaso, you should call Medicare at MEDICARE ( ). TTY users should call You may call 24 hours a day, seve days a week. You ca also call the Beeficiary Help Lie at (or for TTY users) Moday through Friday, 8 AM to 7 PM. You should also call the MI Health Lik Ombudsma program. You should also call the MI Health Lik Ombudsma program at , Moday through Friday, 8 a.m. to 5 p.m. H. You have the right to make a complait if we ed your membership i our pla If we ed your membership i our pla, we must tell you our reasos i writig for edig your membership. We must also explai how you ca file a grievace or make a complait about our decisio to ed your membership. You ca also see Chapter 9 for iformatio about how to make a complait. I. Where ca you get more iformatio about edig your pla membership? If you have questios or would like more iformatio o whe we ca ed your membership, you ca call Member Services at (TTY: 711), 24 hours a day, 7 days a week. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 185

188 Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 11: Legal otices Chapter 11: Legal otices Table of Cotets A. Notice about laws B. Notice about odiscrimiatio C. Notice about Medicare as a secod payer A. Notice about laws May laws apply to this Member Hadbook. These laws may affect your rights ad resposibilities eve if the laws are ot icluded or explaied i this hadbook. The mai laws that apply to this hadbook are federal laws about the Medicare ad Medicaid programs. Other federal ad state laws may apply too. B. Notice about odiscrimiatio Every compay or agecy that works with Medicare ad Michiga Medicaid must obey the law. You caot be treated differetly because of your age, claims experiece, color, creed, ethicity, evidece of isurability, geder, geetic iformatio, geographic locatio, health status, medical history, metal or physical disability, atioal origi, race, religio, or sex. If you thik that you have ot bee treated fairly for ay of these reasos, call the Departmet of Health ad Huma Services, Offce for Civil Rights at TTY users should call You ca also visit for more iformatio. You ca also call the Michiga Departmet of Civil Rights at C. Notice about Medicare as a secod payer Sometimes someoe else has to pay first for the services we provide you. For example, if you are i a car accidet or if you are ijured at work, isurace or Workers Compesatio has to pay first. We have the right ad resposibility to collect for covered Medicare services for which Medicare is ot the first payer. If you have questios, please call Aeta Better Health Premier Pla at (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit 186

189 AETNA BETTER HEALTH SM PREMIER PLAN 1333 Gratiot Aveue, Suite 400 Detroit, MI Aeta, Ic. complies with applicable Federal civil rights laws ad does ot discrimiate o the basis of race, color, atioal origi, age, disability, or sex. Aeta, Ic. does ot exclude people or treat them differetly because of race, color, atioal origi, age, disability, or sex. Aeta, Ic.: Provides free aids ad services to people with disabilities to commuicate effectively with us, such as: Qualified sig laguage iterpreters Writte iformatio i other formats (large prit, audio, accessible electroic formats, other formats) Provides free laguage services to people whose primary laguage is ot Eglish, such as: Qualified iterpreters Iformatio writte i other laguages If you eed these services, cotact Aeta Medicaid Civil Rights Coordiator If you believe that Aeta, Ic. has failed to provide these services or discrimiated i aother way o the basis of race, color, atioal origi, age, disability, or sex, you ca file a grievace with: Aeta Medicaid Civil Rights Coordiator, 4500 East Cotto Ceter Boulevard, Phoeix, AZ 85040, , TTY 711, (fax), MedicaidCRCoordiator@aeta.com. You ca file a grievace i perso or by mail, fax, or . If you eed help filig a grievace, Aeta Medicaid Civil Rights Coordiator is available to help you. You ca also file a civil rights complait with the U.S. Departmet of Health ad Huma Services, Office for Civil Rights, electroically through the Office for Civil Rights Complait Portal, available at or by mail or phoe at: U.S. Departmet of Health ad Huma Services 200 Idepedece Aveue, SW Room 509F, HHH Buildig Washigto, D.C , (TDD) Complait forms are available at MI Fed Reg 5/18/16 (Reviewed 8/17) 187