AETNA BETTER HEALTH OF OHIO a MyCare Ohio plan (Medicare Medicaid Plan)

Transcription

1 AETNA BETTER HEALTH OF OHIO a MyCare Ohio pla (Medicare Medicaid Pla) 2018 Member Hadbook Aeta Better Health of Ohio, a MyCare Ohio pla (Medicare-Medicaid Pla), is a health pla that cotracts with Medicare ad Ohio Medicaid to provide beefits of both programs to erollees OH (7/17) 2017 Aeta Ic. H7172_18_012_MBR HNDBK APPROVED

2

3 Aeta Better Health of Ohio Member Hadbook Jauary 1, 2018 December 31, 2018 Your Health ad Drug Coverage uder Aeta Better Health of Ohio (Medicare Medicaid Pla) This hadbook tells you about your coverage uder Aeta Better Health of Ohio through December 31, It explais health care services, behavioral health coverage, prescriptio drug coverage, ad home ad commuity based waiver services (also called log-term services ad supports). Log-term services ad supports 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, Aeta Better Health of Ohio, is offered by Aeta Better Health, Ic. (OH). Whe this Member Hadbook says we, us, or our, it meas Aeta Better Health, Ic. (OH). Whe it says the pla or our pla, it meas Aeta Better Health of Ohio. If you speak Spaish or Somali, laguage 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 somalí, 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. Haddii aad ku hadasho Isbaaish ama Soomaali, adeegyada lluqadda, oo bilaash ah, ayaa laguu heli karaa adiga. Wac (TTY: 711), 24 saacadood maalitii, 7 maalmood todobaadkii. Wicitaaku waa bilaash. 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 have ay problems readig or uderstadig this hadbook or ay other Aeta Better Health of Ohio iformatio, please cotact Member Services. We ca explai the iformatio or provide the iformatio i your primary laguage. We may have the iformatio prited i certai other laguages or i other ways. If you are visually or hearig impaired, special help ca be provided. If you wish to make a stadig request to receive all materials i a laguage other tha Eglish or i a alterate format, you ca call Aeta Better Health of Ohio Member Services at , (TTY: 711), 24 hours a day, 7 days a week. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 1

4 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 1: Gettig started as a member Disclaimers Aeta Better Health of Ohio is a health pla that cotracts with both Medicare ad Ohio Medicaid to provide beefits of both programs to erollees. Coverage uder Aeta Better Health of Ohio 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. 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. Limitatios ad restrictios may apply. For more iformatio, call Aeta Better Health of Ohio Member Services or read the Aeta Better Health of Ohio Member Hadbook. This meas that you may have to pay for some services ad that you eed to follow certai rules to have Aeta Better Health of Ohio pay for your services. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 2

5 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 1: Gettig started as a member Chapter 1: Gettig started as a member Table of Cotets A. Welcome to Aeta Better Health of Ohio...4 B. What are Medicare ad Medicaid?...4 Medicare...4 Medicaid...5 C. What are the advatages of this pla?...5 D. What is Aeta Better Health of Ohio s service area?...6 E. What makes you eligible to be a pla member?...6 F. What to expect whe you first joi a health pla...7 G. What is a care pla?...7 H. Does Aeta Better Health of Ohio have a mothly pla premium?...8 I. About the Member Hadbook...8 J. What other iformatio will you get from us?...8 Your Aeta Better Health of Ohio Member ID Card...8 New Member Letter...9 Provider ad Pharmacy Directory....9 List of Covered Drugs Member Hadbook Supplemet or Waiver Hadbook The Explaatio of Beefits K. How ca you keep your membership record up to date? Do we keep your persoal health iformatio private? If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 3

6 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 1: Gettig started as a member A. Welcome to Aeta Better Health of Ohio Aeta Better Health of Ohio, offered by Aeta Better Health, Ic. (OH), is a Medicare-Medicaid Pla. A Medicare-Medicaid pla is a orgaizatio made up of doctors, hospitals, pharmacies, providers of log-term services ad supports, ad other providers. It also has care maagers 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 of Ohio was approved by the Ohio Departmet of Medicaid (ODM) ad the Ceters for Medicare & Medicaid Services (CMS) to provide you services as part of the MyCare Ohio program. The MyCare Ohio program is a demostratio program joitly ru by ODM ad the federal govermet to provide better health care for people who have both Medicare ad Medicaid. Uder this demostratio, the state ad federal govermet wat to test ew ways to improve how you get your Medicare ad Medicaid health care services. Aeta Better Health of Ohio is a Medicare-Medicaid Pla (MMP) i Ohio for the MyCare Ohio program. Our paret compay, Aeta, is a leadig atioal compay that serves 52 millio people, with more tha 3 millio of those Medicaid members. Aeta has more tha 30 years of experiece maagig care for people erolled i Medicaid ad Medicare. We uderstad the eeds of our members. We work with local Ohio providers ad commuity groups to meet your eeds. B. What are Medicare ad Medicaid? You have both Medicare ad Medicaid. Aeta Better Health of Ohio will make sure these programs work together to get you the care you eed. Medicare Medicare is the federal health isurace program for: people 65 years of age or older, some people uder age 65 with certai disabilities, ad people with ed-stage real disease (kidey failure). If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 4

7 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 1: Gettig started as a member Medicaid Medicaid is a program ru by the federal govermet ad the state that helps people with limited icomes ad resources pay for log-term services ad supports ad medical costs. It covers extra services ad drugs ot covered by Medicare. Each state decides what couts as icome ad resources ad who qualifies. They also decide what services are covered ad the cost for services. States ca decide how to ru their programs, as log as they follow the federal rules. Medicare ad Ohio Medicaid must approve Aeta Better Health of Ohio each year. You ca get Medicare ad Medicaid services through our pla as log as: we choose to offer the pla, ad Medicare ad Ohio Medicaid approve the pla. Eve if our pla stops operatig i the future, your eligibility for Medicare ad Medicaid services will ot be affected. C. What are the advatages of this pla? You will ow get all your covered Medicare ad Medicaid services from Aeta Better Health of Ohio, icludig prescriptio drugs. You do ot pay extra to joi this health pla. Aeta Better Health of Ohio will help make your Medicare ad Medicaid beefits work better together ad work better for you. Some of the advatages iclude: You will have a care team that you helped put together. Your care team may iclude doctors, urses, couselors, or other health professioals who are there to help you get the care you eed. You will have a care maager. This is a perso who works with you, with Aeta Better Health of Ohio, ad with your care providers to make sure you get the care you eed. He or she will be a member of your care team. You will be able to direct your ow care with help from your care team ad care maager. The care team ad care maager will work with you to come up with a care pla specifically desiged to meet your eeds. The care team will be i charge of coordiatig the services you eed. This meas, for example:» Your care team will make sure your doctors kow about all medicies you take so they ca reduce ay side effects.» Your care team will make sure your test results are shared with all your doctors ad other providers. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 5

8 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 1: Gettig started as a member D. What is Aeta Better Health of Ohio s service area? Aeta Better Health of Ohio is available oly to people who live i our service area. To keep beig a member of our pla, you must keep livig i this service area. Our service area icludes these couties i Ohio: Butler, Clermot, Clito, Delaware, Frakli, Fulto, Hamilto, Lucas, Madiso, Ottawa, Pickaway, Uio, Warre ad Wood. If you move, you must report the move to your Couty Departmet of Job ad Family Services offce. If you move to a ew state, you will eed to apply for Medicaid i the ew state. E. What makes you eligible to be a pla member? You are eligible for membership i our pla as log as: you live i our service area; ad you have Medicare Parts A, B ad D; ad you have full Medicaid coverage; ad you are a Uited States citize or are lawfully preset i the Uited States, ad you are 18 years of age or older at time of erollmet. Eve if you meet the above criteria, you are ot eligible to eroll i Aeta Better Health of Ohio if you: have other third party creditable health care coverage; or have itellectual or other developmetal disabilities ad get services through a waiver or Itermediate Care Facility for Idividuals with Itellectual Disabilities (ICFIID); or are erolled i a Program of All-Iclusive Care for the Elderly (PACE). Additioally, you have the choice to diseroll from Aeta Better Health of Ohio if you are a member of a federally recogized Idia tribe. If you believe that you meet ay of the above criteria ad should ot be erolled, please cotact Member Services for assistace. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 6

9 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 1: Gettig started as a member F. What to expect whe you first joi a health pla Whe you first joi the pla, you will get a health care eeds assessmet withi the first 15 to 75 days of your erollmet effective date depedig o your health status. A member of our care team will cotact you ad coduct a health care eeds assessmet. He or she will ask you questios to idetify your immediate ad log term eeds. You will be assiged a care maager who is part of your care team. Your care team is made up of you, your providers, your family, your care maager ad whomever else you chose. The care team works together to develop a care pla to help you with your care ad service eeds. If Aeta Better Health of Ohio is ew for you, you ca keep seeig the doctors you go to ow for at least 90 days after you eroll. Also, if you already had previous approval to get services, our pla will hoor the approval util you get the services. This is called a trasitio period. The New Member Letter icluded with your Member Hadbook has more iformatio o the trasitio periods. If you are o the MyCare Ohio Waiver, your Member Hadbook Supplemet or Waiver Hadbook also has more iformatio o trasitio periods for waiver services. After the trasitio period, you will eed to see doctors ad other providers i the Aeta Better Health of Ohio etwork for most services. A etwork provider is a provider who works with the health pla. See Chapter 3 for more iformatio o gettig care. Member Services ca help you fid a etwork provider. If you are curretly seeig a provider that is ot a etwork provider or if you already have services approved ad/or scheduled, it is importat that you call Member Services right away so we ca arrage the services ad avoid ay billig issues. G. What is a care pla? A care pla is the pla for what health services you will get ad how you will get them. After your health care eeds 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. Your care team will cotiuously work with you to update your care pla to address the health services you eed ad wat. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 7

10 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 1: Gettig started as a member H. Does Aeta Better Health of Ohio have a mothly pla premium? No. 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, page 125. You ca also call Member Services at (TTY: 711), 24 hours a day, 7 days a week or Medicare at MEDICARE ( ). The cotract is i effect for moths i which you are erolled i Aeta Better Health of Ohio betwee Jauary 1, 2018 ad December 31, J. What other iformatio will you get from us? You will also get a Aeta Better Health of Ohio Member ID Card, a New Member Letter with importat iformatio, iformatio about how to access a Provider ad Pharmacy Directory, ad iformatio about how to access a List of Covered Drugs. Members erolled i a home ad commuity based waiver will also get a supplemet to their Member Hadbook that gives iformatio specific to waiver services. If you do ot get these items, please call Member Services for assistace. Your Aeta Better Health of Ohio Member ID Card Uder the MyCare Ohio program, you will have oe card for your Medicare ad Medicaid services, icludig log-term services ad supports ad prescriptios. You must show this card whe you get ay services or prescriptios covered by the pla. Here s a sample card to show you what yours will look like: AETNA BETTER HEALTH OF OHIO a MyCare Ohio pla Member Name Last Name, First Name MMIS Member ID# Health Pla (80840): ifo to come PCP Last Name, First Name PCP Phoe CMS - H RxBIN: RxPCN: MEDDADV RxGRP: RX8812 I a emergecy, call or go to the earest emergecy room (ER) or other appropriate settig. If you are ot sure if you eed to go to the ER, call your PCP or the 24-Hour Nurse Advice lie. Member Services: (TTY: 711) Eligibility Verificatio: Behavioral Health Crisis: , select optio 9 Care Maagemet: , select optio 5 24-hour Nurse Advice Lie: , select optio 4 Pharmacy Help Desk: Website: Sed claims to: Aeta Better Health of Ohio Claims Departmet P.O. Box 64205, Phoeix, AZ (Electroic Claims: Payer ID 50023) If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 8

11 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 1: Gettig started as a member 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, this is the oly card you eed to get services. You will o loger get a mothly Medicaid card. You also do ot eed to use your red, white, ad blue Medicare card. Keep your Medicare card i a safe place, i case you eed it later. If you show your Medicare card istead of your Aeta Better Health of Ohio 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. New Member Letter Please make sure to read the New Member Letter set with your Member Hadbook as it is a quick referece for some importat iformatio. For example, it has iformatio o thigs such as whe you may be able to get services from providers ot i our etwork, previously approved services, trasportatio services, ad who is eligible for MyCare Ohio erollmet. Provider ad Pharmacy Directory The Provider ad Pharmacy Directory lists the providers ad pharmacies i the Aeta Better Health of Ohio etwork. While you are a member of our pla, you must use etwork providers ad pharmacies to get covered services. There are some exceptios, icludig whe you first joi our pla (see page 27) ad for certai services (see Chapter 3). You ca ask for a prited Provider ad Pharmacy Directory at ay time 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 Both Member Services ad the website ca give you the most up-to-date iformatio about chages i our etwork providers. What are etwork providers? Aeta Better Health of Ohio s Network Providers iclude: o Doctors, urses, ad other health care professioals that you ca go to as a member of our pla; o Cliics, hospitals, ursig facilities, ad other places that provide health services i our pla; ad o Home health agecies, durable medical equipmet suppliers, ad others who provide goods ad services that you get through Medicare or Medicaid. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 9

12 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 1: Gettig started as a member For a full list of etwork providers, see the Provider ad Pharmacy Directory. Network providers have agreed to accept paymet from our pla for covered services as paymet i full. Network providers should ot bill you directly for services covered by the pla. For iformatio about bills from etwork providers, see Chapter 7 page 104. What are etwork pharmacies? Network pharmacies are the 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 i a emergecy, you must fill your prescriptios at oe of our etwork pharmacies if you wat our pla to pay for them. If it is ot a emergecy, you ca ask us ahead of time to use a o-etwork pharmacy. 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 of Ohio. 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 a copy of the Drug List, but some chages may occur durig the year. To get the most up-to-date iformatio about which drugs are covered, you ca visit the pla s website at or call Member Services (TTY: 711), 24 hours a day, 7 days a week. Member Hadbook Supplemet or Waiver Hadbook This supplemet provides additioal iformatio for members erolled i a home ad commuity based waiver. For example, it icludes iformatio o member rights ad resposibilities, service pla developmet, care maagemet, waiver service coordiatio, ad reportig icidets. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 10

13 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 1: Gettig started as a member 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 we or others o your behalf 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 are covered ad ay drug copay amouts for 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 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 your caregiver or ayoe resposible for you chages If you are part of a cliical research study If you have to see a provider for a ijury or illess that may have bee caused by aother perso or busiess. For example, if you are hurt i a car wreck, by a dog bite, or if you slip ad fall i a store, the aother perso or busiess may have to pay for your medical expeses. Whe you call we will eed to kow the ame of the perso or busiess at fault as well as ay isurace compaies or attoreys that are ivolved. If ay iformatio chages, please let us kow by callig Member Services at (TTY: 711), 24 hours a day, 7 days a week. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 11

14 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 1: Gettig started as a member 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 of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 12

15 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources This chapter provides you with a quick referece of cotact iformatio for Aeta Better Health of Ohio, the State of Ohio, Medicare, ad other useful resources. Table of Cotets A. How to cotact Aeta Better Health of Ohio Member Services B. How to cotact your Care Maager C. How to cotact the 24-Hour Nurse Advice Call Lie D. How to cotact the 24-Hour Behavioral Health Crisis Lie E. How to cotact the Quality Improvemet Orgaizatio (QIO) F. How to cotact Medicare G. How to cotact the Ohio Departmet of Medicaid H. How to cotact the MyCare Ohio Ombudsma I. Other resources If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 13

16 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources A. How to cotact Aeta Better Health of Ohio Member Services CALL TTY WRITE , Optio 1 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 of Ohio Att: Member Services Departmet 7400 West Campus Road, Mail Code: F494 New Albay, OH If you are sedig us a appeal or complait, you ca use the form i Chapter 9. You ca also write a letter tellig us about your questio, problem, complait, or appeal. WEBSITE Cotact Member Services about: Questios about the pla Questios about claims or billig from providers Member Idetificatio (ID) Cards Let us kow if you did t get your Member ID Card or you lost your Member ID Card. Fidig etwork providers This icludes questios about fidig or chagig your primary care provider (PCP). Gettig log term services ad supports I some cases, you ca get help with daily health care ad basic livig eeds. If it is determied ecessary by Ohio Medicaid ad Aeta Better Health of Ohio, you may be able to get assisted livig, homemaker, persoal care, meals, adaptive equipmet, emergecy respose, ad other services. Uderstadig the iformatio i your Member Hadbook Recommedatios for thigs you thik we should chage If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 14

17 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources Other iformatio about Aeta Better Health of Ohio You ca ask for more iformatio about our pla, icludig iformatio regardig the structure ad operatio of Aeta Better Health of Ohio ad ay physicia icetive plas we operate. Coverage decisios about your health care ad drugs A coverage decisio is a decisio about:» your beefits ad covered services ad drugs, or» the amout we will pay for your health services ad drugs. Call us if you have questios about a coverage decisio. To lear more about coverage decisios, see Chapter 9. Appeals about your health care ad drugs 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 ad drugs You ca make a complait about us or ay provider or pharmacy. You ca also make a complait about the quality of the care you got to us or to the Quality Improvemet Orgaizatio (see Sectio E below). If your complait is about a coverage decisio about your health care or drugs, you ca make a appeal (see the sectio above). You ca sed a complait about Aeta Better Health of Ohio right to Medicare. You ca use a olie form at Or you ca call MEDICARE ( ) to ask for help. You ca sed a complait about Aeta Better Health of Ohio directly to Ohio Medicaid. Call This call is free. See page 20 for other ways to cotact Ohio Medicaid. You ca sed a complait about Aeta Better Health of Ohio to the MyCare Ohio Ombudsma. Call This call is free. To lear more about makig a complait, see Chapter 9. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 15

18 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources Paymet for health care or drugs you already paid for For more o how to ask us to assist you with a service you paid for 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 Maager As a Aeta Better Health member, you will be assiged a care maager. This perso works with you ad your care providers to make sure you get the care ad services you eed. A care maager will be assiged to you based o where you live, so they are always close by for evets like home visits, or if you are hospitalized. Your care maager will give you his or her phoe umber ad address so you ca cotact him or her directly. You ca also cotact your care maager by callig our Care Maagemet lie at , Optio 5, 24 hours a day, 7 days a week. It is importat that you have a good relatioship with your care maager. If you wat to chage your care maager, please call the Care Maagemet lie. CALL TTY WRITE WEBSITE , Optio 5 This call is free. The care maager call lie is available 24 hours a day, 7 days a week, 365 days a year. 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 of Ohio Att: Care Maagemet 7400 West Campus Road, Mail Code: F494 New Albay, OH If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 16

19 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources C. How to cotact the 24-Hour Nurse Advice Call Lie Aeta Better Health of Ohio has a Nurse Advice Lie available to help aswer your medical questios, give advice o treatmet optios or other courses of actio ad cofirm erollmet. The Nurse Advice Lie does ot take the place of your primary care provider but is available as aother resource for you. This umber is available 24 hours a day, 7 days a week. It is staffed by medical professioals. You ca cotact the Nurse Advice Lie at , Optio 4 (TTY: 711). CALL TTY , Optio 4 This call is free. The Nurse Advice Lie is available 24 hours a day, 7 days a week, 365 days a year. 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 D. How to cotact the 24-Hour Behavioral Health Crisis Lie Aeta Better Health of Ohio offers a Behavioral Health Crisis Lie. Call this lie if you eed immediate behavioral health care ad do ot kow who to call. It is staffed by qualified health professioals experieced i behavioral health ad crisis itervetio. They ca help whe you eed immediate care for a metal health or alcohol or drug addictio crisis. This umber is available 24 hours a day, 7 days a week. Some symptoms of a behavioral health crisis are: Hopelessess, feelig like there s o way out Axiety, agitatio, sleeplessess, or mood swigs Feelig like there is o reaso to live Rage or ager Egagig i risky activities without thikig Icreasig alcohol or drug abuse Withdrawig from family ad frieds If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 17

20 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources CALL TTY , Optio 9 This call is free. The Behavioral Health Crisis Lie is available 24 hours a day, 7 days a week, 365 days a year. 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 E. How to cotact the Quality Improvemet Orgaizatio (QIO) A orgaizatio called KEPRO serves as Ohio s QIO. 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 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 West Keedy Boulevard, Suite 900 Tampa, FL 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 of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 18

21 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources F. 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 This call is free. This umber is for people who have hearig or speakig problems. You must have special telephoe equipmet to call it. WEBSITE 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 of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 19

22 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources G. How to cotact the Ohio Departmet of Medicaid Medicaid helps with medical ad log-term services ad supports costs for people with limited icomes ad resources. Ohio Medicaid pays for Medicare premiums for certai people, ad pays for Medicare deductibles, co-isurace ad copays except for prescriptios. Medicaid covers log-term care services such as home ad commuity-based waiver services ad assisted livig services ad log-term ursig home care. It also covers detal ad visio services. You are erolled i Medicare ad i Medicaid. Aeta Better Health of Ohio provides your Medicaid covered services through a provider agreemet with Ohio Medicaid. If you have questios about the help you get from Medicaid, call the Ohio Medicaid Hotlie. CALL This call is free. The Ohio Medicaid Hotlie is available Moday through Friday from 7:00 am to 8:00 pm ad Saturday from 8:00 am to 5:00 pm. TTY This call is free. This umber is for people who have hearig or speakig problems. You must have special telephoe equipmet to call it. The Ohio Medicaid TTY umber is available Moday through Friday from 7:00 am to 8:00 pm, ad Saturday from 8:00 am to 5:00 pm. WRITE WEBSITE Ohio Departmet of Medicaid Bureau of Maaged Care 50 W. Tow Street, Suite 400 Columbus, Ohio bmhc@medicaid.ohio.gov ItegratigMedicareadMedicaidBeefits.aspx You may also cotact your local Couty Departmet of Job ad Family Services if you have questios or eed to submit chages to your address, icome, or other isurace. Cotact iformatio is available olie at: If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 20

23 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources H. How to cotact the MyCare Ohio Ombudsma The MyCare Ohio Ombudsma helps with cocers about ay aspect of care. Help is available to resolve disputes with providers, protect rights, ad file complaits or appeals with our pla. The MyCare Ohio Ombudsma works together with the Offce of the State Log-term Care Ombudsma, which advocates for cosumers gettig log-term services ad supports. The MyCare Ohio Ombudsma is a idepedet program, ad the services are free. CALL This call is free. The MyCare Ohio Ombudsma is available Moday through Friday from 8:00 am to 5:00 pm. TTY Ohio Relay Service: This call is free. This umber is for people who have hearig or speakig problems. You must have special telephoe equipmet to call it. WRITE WEBSITE Ohio Departmet of Agig Att: MyCare Ohio Ombudsma 246 N. High Street, 1st Floor Columbus, Ohio You ca submit a olie complait at: If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 21

24 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources I. Other resources How to cotact the Ability Ceter of Greater Toledo The Ability Ceter of Greater Toledo assists people with disabilities to live, work ad socialize withi a fully accessible commuity. CALL TTY WRITE WEBSITE This umber is for people who have hearig or speakig problems. You must have special telephoe equipmet to call it. The Ability Ceter 5605 Moroe Street Sylvaia, OH How to cotact The Ceter for Disability Empowermet The Ceter for Disability Empowermet ca help people who live i Frakli or Delaware Couty fid resources to live, lear, worship, work ad play alogside people who do ot have disabilities. CALL WRITE WEBSITE The Ceter for Disability Empowermet 510 E. North Broadway, 4th Floor Columbus, Ohio Ifo@disabilityempowermet.et How to cotact the Ceter for Idepedet Livig Optios (CILO) The Ceter for Idepedet Livig (CILO) works to create optios ad choices for persos with disabilities. CALL WRITE WEBSITE The Ceter for Idepedet Livig 2031 Aubur Aveue Ciciati, Ohio If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 22

25 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources How to cotact the Coucil o Agig of Southwester Ohio Our state has various agecies o agig that work to help seiors live safely ad idepedetly i their ow homes for as log as possible. The Coucil o Agig of Southwester Ohio services residets i Butler, Clermot, Clito, Hamilto ad Warre couties. CALL TTY This umber is for people who have hearig or speakig problems. You must have special telephoe equipmet to call it. WRITE WEBSITE 175 Tri Couty Parkway Ciciati, OH How to cotact the Cetral Ohio Area Agecy o Agig Our state has various agecies o agig that work to help seiors live safely ad idepedetly i their ow homes for as log as possible. The Cetral Ohio Area Agecy o Agig services residets i Delaware, Lickig, Fairfield, Fayette, Frakli, Madiso, Pickaway ad Uio couties. CALL WRITE WEBSITE 3776 South High Street Columbus, OH How to cotact the Area Offce o Agig of Northwester Ohio Our state has various agecies o agig that work to help seiors live safely ad idepedetly i their ow homes for as log as possible. The Area Offce o Agig Northwester Ohio services residets i Defiace, Erie, Fulto, Hery, Lucas, Ottawa, Pauldig, Sadusky, Williams ad Wood couties. CALL WRITE WEBSITE 2155 Arligto Aveue Toledo, OH If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 23

26 Aeta Better Health of Ohio 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, etwork providers, ad etwork pharmacies B. Rules for gettig your health care, behavioral health, ad log-term services ad supports covered by the pla C. Your care team ad care maager D. Gettig care from primary care providers, specialists, other etwork providers, ad out-of-etwork providers Gettig care from a primary care provider How to get care from specialists ad other etwork providers What if a etwork provider leaves our pla? How to get care from out-of-etwork providers E. How to get log-term services ad supports (LTSS) F. How to get behavioral health services G. How to get trasportatio services H. 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 Gettig urgetly eeded care Gettig care durig a disaster I. What if you are billed directly for services covered by our pla? What should you do if services are ot covered by our pla? If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 24

27 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services J. How are your health care services covered whe you are i a cliical research study? What is a cliical research study? Whe you are i a cliical research study, who pays for what? Learig more K. 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? What care from a religious o-medical health care istitutio is covered by our pla? L. Rules for owig durable medical equipmet (DME) Will you ow your DME? What happes if you switch to Origial Medicare? If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 25

28 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services A. About services, covered services, providers, etwork providers, ad etwork pharmacies Services are health care, log-term services ad supports, 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 services ad supports are listed i the Beefits Chart i Chapter 4. Providers are doctors, urses, ad other people who deliver services ad care. The term providers also icludes hospitals, home health agecies, cliics, ad other places that deliver health care services, medical equipmet, ad log-term services ad supports. 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 pay othig for covered services. The oly exceptio is if you have a patiet liability for ursig facility or waiver services. See Chapter 4 for more iformatio. Network pharmacies are pharmacies (drug stores) that have agreed to fill prescriptios for our pla members. Network pharmacies bill us directly for prescriptios you get. Whe you use a etwork pharmacy, you pay othig for your prescriptio drugs. See Chapter 6 for more iformatio. B. Rules for gettig your health care, behavioral health, ad log-term services ad supports covered by the pla Aeta Better Health of Ohio covers health care services covered by Medicare ad Medicaid. This icludes behavioral health, log-term care, ad prescriptio drugs. Aeta Better Health of Ohio will geerally pay for the health care ad services you get if you follow the pla rules. To be covered: The care you get must be a pla beefit. See Chapter 4 for iformatio regardig covered beefits, icludig the pla s Beefits Chart. The care must be medically ecessary. Medically ecessary meas you eed services, supplies, or drugs 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. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 26

29 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services The care you get must be prior authorized by Aeta Better Health of Ohio whe required. For some services, your provider must submit iformatio to Aeta Better Health of Ohio ad ask for approval for you to get the service. This is called prior authorizatio. See the chart i Chapter 4 for more iformatio. You must choose a etwork provider to be your primary care provider (PCP) to maage your medical care. Although you do ot eed approval (called a referral) from your PCP to see other providers, it is still importat to cotact your PCP before you see a specialist or after you have a urget or emergecy departmet visit. This allows your PCP to maage your care for the best outcomes. To lear more about choosig a PCP, see page 29. You must get your care from etwork providers. Usually, the pla will ot cover care from a provider who does ot work with the pla (a out-of-etwork provider). 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 35.» If you eed care that our pla covers ad our etwork providers caot give it to you, you ca get this care from a out-of-etwork provider. The out-of-etwork provider must cotact us for approval before seeig you. I this situatio, we will cover the care at o cost to you. To lear about gettig approval to see a out-of-etwork provider, see page 31.» The pla covers services you get at out-of-etwork Federally Qualified Health Ceters, Rural Health Cliics, ad qualified family plaig providers listed i the Provider ad Pharmacy Directory.» If you are gettig assisted livig waiver services or log-term ursig facility services from a out-of-etwork provider o ad before the day you become a member, you ca cotiue to get the services from that out-of-etwork provider.» 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.» If you are ew to our pla, you may be able to cotiue to see your curret out-of-etwork providers for a period of time after you eroll. This is called a trasitio period. For more iformatio, go to Chapter 1 of this hadbook ad your New Member Letter. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 27

30 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services C. Your care team ad care maager Your care team icludes you, your family, caregivers, care maager, PCP, specialists, ay other health or service providers who you actively work with ad ayoe else you wat to iclude. How will the Care Maager ad Care Team iteract with you? Everyoe o the care team works together to make sure your care is coordiated. Your care team may ask you questios to lear more about your coditio. The you will get a persoalized care pla that is created to address your health care eeds, the way you wat. Your care team will also get a copy of your care pla to make sure you get the care ad services you eed. Your care pla will help you uderstad how to care for yourself ad how to access a rage of services, icludig local resources. Your care maager will call ad visit with you at your home to discuss your care pla ad how thigs are goig. They will cotiue to check o you with a phoe call or face to face visit while you are o our pla. Your care maager helps you maage all of your providers ad services. He or she works with your care team to make sure you get the care you eed. What is care maagemet? Care maagemet is a process to help you ad your physicia to get services that will help you reach your best health. Your care maager is your sigle cotact at Aeta Better Health of Ohio for help to get medical care ad services. How ca you cotact your care maager? Call the phoe umber o the back of your Aeta Better Health of Ohio member ID card or call your assiged care maager s cell phoe if you kow the umber. If your care maager is ot available, please follow the prompts to leave a message for your care maager. If you do ot kow the ame of your care maager, call Member Services at (TTY: 711), 24 hours a day, 7 days a week. The Member Services represetative ca advise of your care maager s ame ad trasfer you to your care maager. How ca you chage your care maager? Call the phoe umber o the back of your Aeta Better Health of Ohio member ID card ad ask the Member Services represetative to help you. You ca ask to have a ew care maager assiged at ay time, if you are ot satisfied with the services of your preset care maager. 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. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 28

31 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services What is a PCP, ad what does the PCP do for you? Your PCP is a idividual physicia or physicia group practice who works with you ad your care maager to direct ad coordiate your health care. Your PCP hadles 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 still importat to cotact your PCP before you see a specialist or after you have a urget or emergecy departmet visit. This allows your PCP to maage your care for the best outcomes. Your PCP may be a: Family practitioer Geeral practitioer Certified urse practitioer Iterist Obstetricia/Gyecologist Pediatricia Physicia assistat How do you choose your PCP? Search for a PCP o our website at Call Member Services or your care maager at (TTY: 711), 24 hours a day, 7 days a week Look i the prited Provider ad Pharmacy Directory, if you requested oe Chagig your PCP You may chage your PCP for ay reaso. You ca chage your PCP to aother etwork PCP at ay time, the chage will be effective immediately upo receipt of the request. Also, it s possible that your PCP might leave our pla s etwork. If your provider leaves the pla s etwork, we ca help you fid a ew PCP. If for ay reaso you wat to chage your PCP, you must first call Member Services at (TTY: 711) 24 hours a day, 7 days a week to ask for the chage. The chage will take effect immediately upo receipt of the request. We will issue you a ew member ID card that you will get i the mail withi 14 days. If you eed to see your PCP before you get your ew member ID card, your PCP s offce ca call us to verify your eligibility. If you are thikig about chagig your PCP, talk to your care maager. Your care maager may help with ay issues you are havig. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 29

32 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services 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. You ca go to ay specialist i our etwork. You do ot eed a referral to see a etwork specialist. Your PCP or care maager ca recommed a type of specialist to you. You ca also call Member Services at (TTY: 711), 24 hours a day, 7 days a week. We will help you fid a specialist ear you. PCPs ad specialists must cotact Aeta Better Health of Ohio to get approval for certai services ad drugs. This is called prior authorizatio. Our decisios are made based oly o appropriateess of care ad service ad beefit coverage. We do ot reward staff for issuig deials of coverage. I additio, there are o fiacial icetives for cliical decisio-makers. The provider who will be givig you the service will request prior authorizatio from Aeta Better Health of Ohio before the service is redered. Aeta Better Health of Ohio will otify your provider whe a prior authorizatio is approved, ad will otify both you ad your provider i case of disapproval withi 14 caledar days. I cases where a prior authorizatio is deied, you will receive a Notice of Deial letter that explais your appeal rights. Urget prior authorizatio requests will be reviewed withi 72 hours. If Aeta Better Health of Ohio eeds more iformatio to process a request, we may ask for a 14-day extesio. If we do ot get the requested iformatio we may dey the request. If your provider makes a urget prior authorizatio request ad it does ot meet the urget criteria, we will sed you a letter to let you kow it will be processed as a routie request. You ca make a complait, if you disagree. See the Beefits Chart i Chapter 4 ad the Drug List for iformatio about which services ad drugs require prior authorizatio. 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 have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 30

33 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services 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 complait. 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. You ca cotact Member Services at (TTY: 711), 24 hours a day, 7 days a week for assistace. 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. You ca see a out-of-etwork provider if: You eed emergecy services. You eed urget care. You are gettig services at a Federally Qualified Health Ceter (FQHC) or Rural Health Cliic (RHC). You are gettig services from a Qualified Family Plaig provider. Aeta Better Health of Ohio 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 service is ot available i etwork. You ca see a out-of-etwork provider at o cost to you for as log as we are uable to provide that service. The provider must obtai prior authorizatio before your appoitmet. Services outside of the U.S. are ot covered. Except for the out-of-etwork providers above, o-emergecy care out of the service area is ot covered. If you are out of the service area ad eed health care services, call Member Services at (TTY: 711), 24 hours a day, 7 days a week or call your PCP. Your PCP s telephoe umber is o your member ID card. Please ote: If you go to a out-of-etwork provider, the provider must be eligible to participate i Medicare ad/or Medicaid. We caot pay a provider who is ot eligible to participate i Medicare ad/or Medicaid. If you go to a provider who is ot eligible to participate i Medicare, you may have to pay the full cost of the services you get. Providers must tell you if they are ot eligible to participate i Medicare. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 31

34 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services E. How to get log-term services ad supports (LTSS) As a Aeta Better Health of Ohio member, you may be able to get ursig facility or log-term care services ad supports (LTSS) such as home health care, adult day services ad specialized medical equipmet. Log-term services ad supports give assistace to help you stay at home istead of goig to a ursig home or hospital. MyCare Ohio Waiver Services provided through Aeta Better Health of Ohio are desiged to meet the eeds of members eightee years or older who are fully eligible for both Medicaid ad Medicare, ad erolled i a MyCare Ohio Pla ad who are determied by the state of Ohio, or its desigee, to meet a itermediate or skilled level of care. These services help idividuals to live idepedetly. A request for log-term services ad supports ca be made by the member or authorized represetative. Aeta Better Health of Ohio will assig your care maager ad a team of professioals to make sure you receive the services that you eed. If you have questios about LTSS or to see if you qualify, call your care maager. F. How to get behavioral health services If you have a behavioral health crisis, call the Behavioral Health Crisis Lie at , Optio 9 (TTY: 711), 24 hours a day, 7 days a week. If you eed metal health ad/or substace abuse services, please talk to your care maager or call Member Services at , (TTY: 711), 24 hours a day, 7 days a week. You may also go directly to Ohio Departmet of Metal Health ad Addictio Services (Ohio MHAS) certified commuity metal health ceters, behavioral health professioals ad other treatmet ceters that are part of the Aeta Better Health of Ohio etwork. Please see the provider directory or call Member Services at (TTY: 711), 24 hours a day, 7 days a week for the ames ad telephoe umbers of the facilities ear you. Be sure to show your Aeta Better Health of Ohio member ID card whe you get care. You ca fid other Aeta Better Health of Ohio providers i the provider directory o our website You ca also call Member Services at (TTY: 711), 24 hours a day, 7 days a week. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 32

35 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services G. How to get trasportatio services If you must travel 30 miles or more from your home to receive covered health care services, Aeta Better Health of Ohio will provide trasportatio to ad from the provider s offce. Trasportatio by ambulette (wheelchair trasport), o-emergecy ambulace, emergecy ambulace ad waiver services are ot limited to the 30-mile requiremet. I additio, Aeta Better Health of Ohio offers 30 roud trips or 60 oe-way trips per year to Pla-approved locatios. Trasportatio for routie medical appoitmets If you eed a ride to your appoitmets, call Member Services at (TTY: 711), 24 hours a day, 7 days a week. Member Services staff is traied to assist you with your trasportatio eeds. You ca also call LogistiCare directly at (TTY: 711), Moday through Friday, 8 a.m. 5 p.m. (EST). You must call at least 3 days before your appoitmet. If you eed help, talk to your care maager or call Member Services at (TTY: 711), 24 hours a day, 7 days a week. Member Services ad LogistiCare will verify that the trasportatio request is for a covered health care service. If you have scheduled trasportatio ad your driver is late please call Where s My Ride at A represetative will work to get you to your destiatio as soo as possible. I additio to the trasportatio assistace that Aeta Better Health of Ohio provides, you ca still get help with trasportatio for certai services through the No-Emergecy Trasportatio (NET) program. Call your local Couty Departmet of Job ad Family Services for questios or assistace with NET services. Member Advisory Committee (MAC) trasportatio Aeta Better Health of Ohio also provides trasportatio services for members who serve o the pla s Member Advisory Committee (MAC). Trasportatio to ad from member advisory meetigs is provided whe a member requests it at least 3 days i advace. Members will work with pla staff to arrage this trasportatio or call Logisiticare directly. H. 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 If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 33

36 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services 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, or other appropriate settig. Call for a ambulace if you eed it. You do ot eed to get approval or a referral first from your PCP or Aeta Better Health of Ohio. Be sure to tell the provider that you are a Aeta Better Health of Ohio member. Show the provider your Aeta Better Health of Ohio Member ID Card. 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. Also, if the hospital has you stay, please make sure Aeta Better Health of Ohio is called withi 48 hours. However, you will ot have to pay for emergecy services because of a delay i tellig us. The phoe umber is o your Aeta Better Health of Ohio 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. This is called Post-stabilizatio services. 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 the provider that is treatig you for a emergecy takes care of the emergecy but thiks you eed other medical care to treat the problem that caused the emergecy, the provider must call Aeta Better Health of Ohio at (TTY: 711), 24 hours a day, 7 days a week. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 34

37 Aeta Better Health of Ohio 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 or the health of your ubor child 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. If you thik you eed urget care, call your PCP. Your PCP must give you a appoitmet by the ed of the ext workig day if you eed urget care. Do ot use a emergecy room for urget care. 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 ad click o Fid a Provider or 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 (TTY: 711). If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 35

38 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services After hours care Except i a emergecy, if you get sick after your PCP s offce is closed, or o a weeked, call the offce ayway. A aswerig service will make sure your PCP gets your message. Your PCP will call you back to tell you what to do. Be sure your phoe accepts blocked calls. Otherwise, your PCP may ot be able to reach you. You ca eve call your PCP i the middle of the ight. You might have to leave a message with the aswerig service. It may take a while, but your PCP will call you back to tell you what to do. 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 or its territories. 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 of Ohio. 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. I. What if you are billed directly for services covered by our pla? Providers should bill us for providig you covered services. You should ot get a provider bill for services covered by the pla. If a provider seds you a bill for a covered service istead of sedig it to the pla, you ca ask us to pay the bill. Call Member Services as soo as possible to give us the iformatio o the bill. You should ot pay the bill yourself. If you do, the pla may ot be able to pay you back. If a provider or pharmacy wats you to pay for covered services, you have already paid for covered services, or if you got a bill for covered services, see Chapter 7 to lear what to do. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 36

39 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services What should you do if services are ot covered by our pla? Aeta Better Health of Ohio 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 may have to 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 do ot have prior approval from Aeta Better Health of Ohio to go over the limit, you may have to pay the full cost to get more of that type of service. Call Member Services to fid out what the limits are, how close you are to reachig them, ad what your provider must do to ask to exceed the limit if they thik it is medically ecessary. J. 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. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 37

40 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services 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 maager 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 ad Cliical Research Studies o the Medicare website ( You ca also call MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call K. 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. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 38

41 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services 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: o o 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 ad with prior authorizatio. L. 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 of Ohio, 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. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 39

42 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services What happes if you switch to Origial Medicare? I Medicare, people who ret certai types of DME ow it after 13 moths. 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 of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 40

43 Aeta Better Health of Ohio 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 Prevetive Visits Prevetive Services ad Screeigs Other Services E. Accessig services whe you are away from home or outside of the service area F. Beefits covered outside of Aeta Better Health of Ohio G. Beefits ot covered by Aeta Better Health of Ohio, Medicare, or Medicaid If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 41

44 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart A. Uderstadig your covered services This chapter tells you what services Aeta Better Health of Ohio covers, how to access services, ad if there are ay limits o services. You ca also lear about services that are ot covered. Iformatio about drug beefits is i Chapter 5 ad iformatio about what you pay for drugs is i Chapter 6. Because you get assistace from Medicaid, you geerally pay othig for the covered services explaied i this chapter as log as you follow the pla s rules. See Chapter 3 for details about the pla s rules. However, you may be resposible for payig a patiet liability for ursig facility or waiver services that are covered through your Medicaid beefit. The Couty Departmet of Job ad Family Services will determie if your icome ad certai expeses require you to have a patiet liability. If you eed help uderstadig what services are covered or how to access services, please call Member Services at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week or your care maager at , Optio 5 (TTY: 711). B. Our pla does ot allow providers to charge you for services Except as idicated above, we do ot allow Aeta Better Health of Ohio 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 covered service. You should ever get a bill from a provider for a covered service. If you do, see Chapter 7 or call Member Services. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 42

45 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart C. About the Beefits Chart The followig Beefits Chart is a geeral list of services the pla covers. It lists prevetive services first ad the categories of other services i alphabetical order. It also explais the covered services, how to access the services, ad if there are ay limits or restrictios o the services. If you ca t fid the service you are lookig for, have questios, or eed additioal iformatio o covered services ad how to access services, cotact Member Services or your care maager. We will cover the services listed i the Beefits Chart oly whe the followig rules are met: Your Medicare ad Medicaid covered services must be provided accordig to the rules set by Medicare ad Ohio Medicaid. The services (icludig medical care, services, supplies, equipmet, ad drugs) must be a pla beefit ad must be medically ecessary. Medically ecessary meas you eed the services to prevet, diagose, or treat a medical coditio. If Aeta Better Health of Ohio makes a decisio that a service is ot medically ecessary or ot covered, you or someoe authorized to act o your behalf may file a appeal. For more iformatio about appeals, see Chapter 9. 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 out-of-etwork provider. Chapter 3 has more iformatio about usig etwork ad out-of-etwork providers. You have a primary care provider (PCP) or a care team that is providig ad maagig 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. Also, some of the services listed i the Beefits Chart are covered oly if your doctor or other etwork provider writes a order or a prescriptio for you to get the service. If you are ot sure whether a service requires prior authorizatio, cotact Member Services or visit our website at You do ot pay aythig for the services listed i the Beefits Chart, as log as you meet the coverage requiremets described above. The oly exceptio is if you have a patiet liability for ursig facility services or waiver services as determied by the Couty Departmet of Job ad Family Services. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 43

46 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart D. The Beefits Chart Prevetive Visits Services covered by our pla Limitatios ad exceptios Aual checkup This is a visit to make or update a prevetio pla based o your curret risk factors. Aual checkups are covered 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. Welcome to Medicare visit If you have bee i Medicare Part B for 12 moths or less, you ca get a oe-time Welcome to Medicare prevetive visit. Whe you make your appoitmet, tell your doctor s office you wat to schedule your Welcome to Medicare prevetive visit. This 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. Well child check up (also kow as Healthchek) Healthchek is Ohio s early ad periodic screeig, diagostic, ad treatmet (EPSDT) beefit for everyoe i Medicaid from birth to uder 21 years of age. Healthchek covers medical, visio, detal, hearig, utritioal, developmet, ad metal health exams. It also icludes immuizatios, health educatio, ad laboratory tests. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 44

47 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Prevetive Services ad Screeigs Services covered by our pla Limitatios ad exceptios Abdomial aortic aeurysm screeig The pla covers abdomial aortic aeurysm ultrasoud screeigs if you are at risk. Alcohol misuse screeig ad couselig Prior authorizatio is required. The pla covers alcohol-misuse screeigs for adults. This icludes pregat wome. If you scree positive for alcohol misuse, you ca get face-to-face couselig sessios with a qualified primary care provider or practitioer. Breast cacer screeig The pla covers the followig services: Prior authorizatio required for wome uder the age of 35. Oe baselie mammogram betwee the ages of 35 ad 39 Oe screeig mammogram every 12 moths for wome age 40 ad older Wome uder the age of 35 who are at high risk for developig breast cacer may also be eligible for mammograms Aual cliical breast exams Cardiovascular (heart) disease risk reductio visit (therapy for heart disease) The pla covers visits with your primary care provider to help lower your risk for heart disease. Durig this visit, your provider may: discuss aspiri use, check your blood pressure, or give you tips to make sure you are eatig well. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 45

48 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Limitatios ad exceptios Cardiovascular (heart) disease testig The pla covers blood tests to check for cardiovascular disease. These blood tests also check for defects due to high risk of heart disease. Cervical ad vagial cacer screeig The pla covers pap tests ad pelvic exams aually for all wome. Colorectal cacer screeig For people 50 ad older or at high risk of colorectal cacer, the pla covers: Flexible sigmoidoscopy (or screeig barium eema) Fecal occult blood test Screeig colooscopy Guaiac-based fecal occult blood test or fecal immuochemical test DNA based colorectal screeig 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). Couselig ad itervetios to stop smokig or tobacco use The pla covers tobacco cessatio couselig ad itervetio. Depressio screeig The pla covers depressio screeig. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 46

49 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Limitatios ad exceptios Diabetes screeig The pla covers diabetes screeig (icludes fastig glucose tests). You may wat to speak to your provider about this test if you have ay of the followig risk factors: high blood pressure (hypertesio), history of abormal cholesterol ad triglyceride levels (dyslipidemia), obesity, family history of diabetes, or history of high blood sugar (glucose). HIV screeig The pla covers HIV screeig exams for people who ask for a HIV screeig test or are at icreased risk for HIV ifectio. Immuizatios The pla covers the followig services: Vaccies for childre uder age 21 Some vaccies (other tha your aual flu shot) may require prior authorizatio. 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 Medicaid coverage rules 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 of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 47

50 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Limitatios ad exceptios Lug cacer screeig 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. Obesity screeig ad therapy to keep weight dow The pla covers couselig to help you lose weight. Prostate cacer screeig The pla covers the followig services: A digital rectal exam A prostate specific atige (PSA) test Sexually trasmitted ifectios (STIs) screeig ad couselig The pla covers screeigs for sexually trasmitted ifectios, icludig but ot limited to chlamydia, goorrhea, syphilis, ad hepatitis B. The pla also covers face-to-face, high-itesity behavioral couselig sessios for sexually active adults at icreased risk for STIs. Each sessio ca be 20 to 30 miutes log. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 48

51 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Other Services Services covered by our pla Acupucture The pla covers acupucture for pai maagemet of headaches ad lower back pai. Ambulace ad wheelchair va services Covered emergecy ambulace trasport services iclude fixed-wig, rotary-wig, 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 health or, if you are pregat, your ubor baby s life or health. I cases that are ot emergecies, ambulace or wheelchair va trasport services are covered whe medically ecessary. Cell Phoe Beefit Aeta Better Health of Ohio members who are iterested i the Lifetime, federal free cell phoe program, are provided our cotracted Lifelie vedor s phoe umber or applicatio to complete i order to determie if they qualify. Qualified members are the eligible to receive a smartphoe with talk time ad data. These Lifelie phoes provide free calls to ad from the pla s Member Services umber ad as appropriate, free health-related texts from the pla. Chiropractic services Limitatios ad exceptios Referral required. Prior authorizatio is required for treatmets more tha 30 days per year. Prior authorizatio is required for o-emergecy services. Wheelchair va trasportatio requires that you otify Aeta Better Health of Ohio of your eed to schedule va support so we ca make sure the correct vehicle is scheduled based o your idividual trasportatio eeds. For members who qualify for the federal free cell phoe program. Prior authorizatio is required. The pla covers: Diagostic x-rays Adjustmets of the spie to correct aligmet If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 49

52 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Detal services The pla covers the followig services: Limitatios ad exceptios Some services may require prior authorizatio Comprehesive oral exam (oe per provider-patiet relatioship) Periodic oral exam oce every 180 days for members uder 21 years of age, ad oce every 365 days for members age 21 ad older Prevetive services icludig prophylaxis, fluoride for members uder age 21, sealats, ad space maitaiers Routie radiographs/diagostic imagig Comprehesive detal services icludig o-routie diagostic, restorative, edodotic, periodotic, prosthodotic, orthodotic, ad surgery services If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 50

53 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Diabetic services The pla covers the followig services for all people who have diabetes (whether they use isuli or ot): Traiig to maage your diabetes, i some cases Supplies to moitor your blood glucose, icludig:» Blood glucose moitors ad test strips» Lacet devices ad lacets» Glucose-cotrol solutios for checkig the accuracy of test strips ad moitors For people with diabetes who have severe diabetic foot disease: Limitatios ad exceptios Prior authorizatio may be required for o-routie diabetic services such as those performed by a Podiatrist (foot specialist). See the Podiatry sectio below i this hadbook. Therapeutic custom molded shoes, depth shoes ad covered shoe iserts require a prescriptio from your provider. Aeta Better Health of Ohio may limit diabetic supplies ad services to specific maufacturers.» 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 also covers fittig the therapeutic custom-molded shoes or depth shoes. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 51

54 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Durable medical equipmet (DME) ad related supplies Covered DME icludes, but is ot limited to, the followig: Limitatios ad exceptios Prior authorizatio may be required. Wheelchairs Crutches Powered mattress systems Diabetic supplies Hospital beds ordered by a provider for use i the home Itraveous (IV) ifusio pumps Speech geeratig devices Oxyge equipmet ad supplies Nebulizers Walkers Other items (such as icotiece garmets, eteral utritioal products, ostomy ad urological supplies, ad surgical dressigs ad related supplies) may be covered. For additioal types of supplies that the pla covers, see the sectios o diabetic services, hearig services, ad prosthetic devices. The pla may also cover learig how to use, modify, or repair your item. Your Care Team will work with you to decide if these other items ad services are right for you ad will be i your Idividualized Care Pla. We will cover all DME that Medicare ad Medicaid usually cover. 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 of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 52

55 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Emergecy care (see also urgetly eeded care ) 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: Limitatios ad exceptios 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. 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 to that of your ubor child. I a emergecy, call 911 or go to the earest emergecy room (ER) or other appropriate settig. If you are ot sure if you eed to go to the ER, call your PCP or the 24-hour toll-free urse advice lie. Your PCP or the urse advice lie ca give you advice o what you should do. We will oly cover emergecy care withi the U.S. ad its territories. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 53

56 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Family plaig services The pla covers the followig services: Family plaig exam ad medical treatmet Limitatios ad exceptios Some diagostic tests require authorizatio. Prior authorizatio is required for geetic testig. Family plaig lab ad diagostic tests Family plaig methods (birth cotrol pills, patch, rig, IUD, ijectios, implats) Family plaig supplies (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) Treatmet for AIDS ad other HIV-related coditios 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.) Screeig, diagosis ad couselig for geetic aomalies ad/or hereditary metabolic disorders Treatmet for medical coditios of ifertility (This service does ot iclude artificial ways to become pregat.) Note: You ca get family plaig services from a etwork or out-of-etwork qualified family plaig provider (for example Plaed Parethood) listed i the Provider ad Pharmacy Directory. You ca also get family plaig services from a etwork certified urse midwife, obstetricia, gyecologist, or primary care provider. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 54

57 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Federally Qualified Health Ceters The pla covers the followig services at Federally Qualified Health Ceters: Limitatios ad exceptios Some services may require prior authorizatio. Offce visits for primary care ad specialists services Physical therapy services Speech pathology ad audiology services Detal services Podiatry services Optometric ad/or opticia services Chiropractic services Trasportatio services Metal health services Note: You ca get services from a etwork or out-ofetwork Federally Qualified Health Ceter. Health ad welless educatio programs Aeta Better Health of Ohio offers a wide array of health ad utritio educatio tools ad programs available to members at o additioal costs, icludig educatioal member materials, outreach from the itegrated Care Team, use of educatio tools ad support systems. Prior authorizatio may be required. These services will be coordiated by your care maager ad itegrated care team. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 55

58 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Hearig services ad supplies The pla covers the followig: Limitatios ad exceptios Prior authorizatio is required for hearig aids. Hearig ad balace tests to determie the eed for treatmet (covered as outpatiet care whe you get them from a physicia, audiologist, or other qualified provider) Hearig aids, batteries, ad accessories (icludig repair ad/or replacemet)» Covetioal hearig aids are covered oce every 4 years» Digital/programmable hearig aids are covered oce every 5 years If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 56

59 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Home ad commuity based waiver services The pla covers the followig home ad commuity-based waiver services: Adult day health services Alterative meals service Assisted livig services Choices home care attedat Chore services Commuity trasitio Emergecy respose services Limitatios ad exceptios These services are available oly if your eed for log-term care has bee determied by Ohio Medicaid. You may be resposible for payig a patiet liability for waiver services. The Couty Departmet of Job ad Family Services will determie if your icome ad certai expeses require you to have a patiet liability. Prior authorizatio is required. Ehaced commuity livig services Home care attedat Home delivered meals Home medical equipmet ad supplemetal adaptive ad assistive devices Home modificatio, maiteace, ad repair Homemaker services Idepedet livig assistace Nutritioal cosultatio Out of home respite services Persoal care services Pest cotrol Social work couselig Waiver ursig services Waiver trasportatio If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 57

60 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Home health services Limitatios ad exceptios Prior authorizatio is required. The pla covers the followig services provided by a home health agecy: Home health aide ad/or ursig services Physical therapy, occupatioal therapy, ad speech therapy Private duty ursig (may also be provided by a idepedet provider) Home ifusio therapy for the admiistratio of medicatios, utriets, or other solutios itraveously or eterally Medical ad social services Medical equipmet ad supplies If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 58

61 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla 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. The pla will cover the followig while you are gettig hospice services: Drugs to treat symptoms ad pai Short-term respite care Home care Limitatios ad exceptios If you wat hospice services i a ursig facility, you may be required to use a etwork ursig facility. Also, you may be resposible for payig a patiet liability for ursig facility services, after the Medicare ursig facility beefit is used. The Couty Departmet of Job ad Family Services will determie if your icome ad certai expeses require you to have a patiet liability. Prior authorizatio is required. Nursig facility care 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 of Ohio but ot covered by Medicare Part A or B: Aeta Better Health of Ohio 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. Uless you are required to pay a patiet liability for ursig facility services, you pay othig for these services. For drugs that may be covered by Aeta Better Health of Ohio 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. This beefit is cotiued o the ext page If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 59

62 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Hospice care (cotiued) Note: Except for emergecy/urget care, if you eed o-hospice care, you should call your care maager to arrage the services. No-hospice care is care that is ot related to your termial progosis. Call your care maager directly or call the Care Maagemet lie at , Optio 5 (TTY: 711). Our pla covers hospice cosultatio services (oe time oly) for a termially ill perso who has ot chose the hospice beefit. Limitatios ad exceptios If you wat hospice services i a ursig facility, you may be required to use a etwork ursig facility. Also, you may be resposible for payig a patiet liability for ursig facility services, after the Medicare ursig facility beefit is used. The Couty Departmet of Job ad Family Services will determie if your icome ad certai expeses require you to have a patiet liability. Prior authorizatio is required. Ipatiet behavioral health services Prior authorizatio is required. The pla covers the followig services: Ipatiet psychiatric care i a private or public freestadig psychiatric hospital or geeral hospital» For members years of age i a freestadig psychiatric hospital with more tha 16 beds, there is a 190-day lifetime limit Ipatiet detoxificatio care If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 60

63 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Ipatiet hospital care Limitatios ad exceptios Prior authorizatio is required. The pla covers 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 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 for use i the hospital Operatig ad recovery room services Physical, occupatioal, ad speech therapy Ipatiet substace abuse services Blood, icludig storage ad admiistratio Physicia/provider 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 of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 61

64 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Ipatiet hospital care (cotiued) Limitatios ad exceptios Prior authorizatio is required. 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 of Ohio provides trasplat services outside the patter of care for your commuity ad you choose to get your trasplat there, we will arrage or cover lodgig ad travel costs for you ad oe other perso. Kidey disease services ad supplies The pla covers the followig services: Some services may require prior authorizatio. Kidey disease educatio services to teach kidey care ad help you make good decisios about your care 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 Note: Your Medicare Part B drug beefit covers 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 of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 62

65 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Medical utritio therapy 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 covers 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 cover two hours of oe-o-oe couselig services each year after that. Limitatios ad exceptios 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 of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 63

66 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Medicare Part B prescriptio drugs Limitatios ad exceptios Prior authorizatio is required. These drugs are covered uder Part B of Medicare. Aeta Better Health of Ohio covers 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 of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 64

67 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Metal health ad substace abuse services at addictio treatmet ceters Limitatios ad exceptios Some services may require prior authorizatio. The pla covers the followig services at addictio treatmet ceters: Ambulatory detoxificatio Assessmet Case maagemet Couselig Crisis itervetio Itesive outpatiet Alcohol/drug screeig aalysis/lab urialysis Medical/somatic Methadoe admiistratio Offce admiistered medicatios for addictio icludig vivitrol ad bupreorphie iductio See Ipatiet behavioral health services ad Outpatiet metal health care for additioal iformatio. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 65

68 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Metal health ad substace abuse services at commuity metal health ceters Limitatios ad exceptios Some services may require prior authorizatio. The pla covers the followig services at certified commuity metal health ceters: Metal health assessmet/diagostic psychiatric iterview Commuity psychiatric supportive treatmet (CPST) services Couselig ad therapy Crisis itervetio Pharmacological maagemet Pre-hospital admissio screeig Certai offce admiistered ijectable atipsychotic medicatios Partial hospitalizatio» Partial hospitalizatio is a structured program of active psychiatric treatmet. It is offered as a 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. See Ipatiet behavioral health services ad Outpatiet metal health care for additioal iformatio. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 66

69 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Nursig ad skilled ursig facility (SNF) care The pla covers 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 Limitatios ad exceptios You may be resposible for payig a patiet liability for room ad board costs for ursig facility services. The Couty Departmet of Job ad Family Services will determie if your icome ad certai expeses require you to have a patiet liability. Note that patiet liability does ot apply to Medicare-covered days i a ursig facility. Prior authorizatio is required. Blood, icludig storage ad admiistratio Medical ad surgical supplies give by ursig facilities Lab tests give by ursig facilities X-rays ad other radiology services give by ursig facilities Durable Medical Equipmet, 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 Medicaid ursig facility care from the followig place if it accepts our pla s amouts for paymet: A ursig home or cotiuig care retiremet commuity where you lived o the day you became a Aeta Better Health of Ohio member This beefit is cotiued o the ext page If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 67

70 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Nursig ad skilled ursig facility (SNF) care (cotiued) You ca get Medicare ursig facility 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 Limitatios ad exceptios You may be resposible for payig a patiet liability for room ad board costs for ursig facility services. The Couty Departmet of Job ad Family Services will determie if your icome ad certai expeses require you to have a patiet liability. Note that patiet liability does ot apply to Medicare-covered days i a ursig facility. Prior authorizatio is required. Outpatiet metal health care The pla covers metal health services provided by: Some services may require prior authorizatio. a state-licesed psychiatrist or doctor, a cliical psychologist, a cliical social worker, a cliical urse specialist, a urse practitioer, a physicia assistat, or ay other qualified metal health care professioal as allowed uder applicable state laws. The pla covers the followig services, ad maybe other services ot listed here: Cliic services ad geeral hospital outpatiet psychiatric services Day treatmet Psychosocial rehab services If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 68

71 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Outpatiet services The pla covers services you get i a outpatiet settig for diagosis or treatmet of a illess or ijury. Limitatios ad exceptios Some services may require prior authorizatio except i the case of a emergecy. The followig are examples of covered services: Services i a emergecy departmet or outpatiet cliic, such as observatio services or outpatiet surgery The pla covers outpatiet surgery ad services at hospital outpatiet facilities ad ambulatory surgical ceters Chemotherapy Labs ad diagostic tests (for example urialysis) Metal health care, icludig care i a partialhospitalizatio program, if a doctor certifies that ipatiet treatmet would be eeded without it Imagig (for example x-rays, CTs, MRIs) Radiatio (radium ad isotope) therapy, icludig techicia materials ad supplies Blood, icludig storage ad admiistratio Medical supplies, such as splits ad casts Prevetive screeigs ad services listed throughout the Beefits Chart Some drugs that you ca t give yourself Over the couter products The pla provides $50 per moth for certai over-thecouter products through a mail order catalog service. There is o carryover moth-to-moth. $50 limit per moth. No carry-over moth-to-moth. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 69

72 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Physicia/provider services, icludig doctor s office visits Limitatios ad exceptios Prior authorizatio may be required. The pla covers the followig services: Health care or surgery services give i places such as a physicia s offce, certified ambulatory surgical ceter, or hospital outpatiet departmet Cosultatio, diagosis, ad treatmet by a specialist 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. Podiatry services Prior authorizatio is required. The pla covers the followig services: Diagosis ad medical or surgical treatmet of ijuries ad diseases of the foot, the muscles ad tedos of the leg goverig the foot, ad superficial lesios of the had other tha those associated with trauma Routie foot care for members with coditios affectig the legs, such as diabetes If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 70

73 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Prosthetic devices ad related supplies Limitatios ad exceptios Prior authorizatio is required. Prosthetic devices replace all or part of a body part or fuctio. The followig are examples of covered prosthetic devices: 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) Detal devices The pla also covers some supplies related to prosthetic devices ad the repair or replacemet of prosthetic devices. The pla offers some coverage after cataract removal or cataract surgery. See Visio Care later i this sectio for details. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 71

74 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Rehabilitatio services Limitatios ad exceptios Prior authorizatio is required. Outpatiet rehabilitatio services» The pla covers 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. Cardiac (heart) rehabilitatio services» The pla covers cardiac rehabilitatio services such as exercise, educatio, ad couselig for certai coditios.» The pla also covers itesive cardiac rehabilitatio programs, which are more itese tha cardiac rehabilitatio programs. Pulmoary rehabilitatio services» The pla covers pulmoary rehabilitatio programs for members who have moderate to very severe chroic obstructive pulmoary disease (COPD). If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 72

75 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Rural Health Cliics The pla covers the followig services at Rural Health Cliics: Limitatios ad exceptios Some services may require prior authorizatio. Offce visits for primary care ad specialists services Cliical psychologist Cliical social worker for the diagosis ad treatmet of metal illess Visitig urse services i certai situatios Note: You ca get services from a etwork or out-of-etwork Rural Health Cliic. SilverSeakers Commuity fitess program promotig greater health egagemet ad accoutability with o cost to Aeta Better Health of Ohio members. Provides members with regular exercise (stregth traiig, aerobics, flexibility) ad social support opportuities. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 73

76 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Specialized Recovery Services (SRS) Program If you are a adult who has bee diagosed with a severe ad persistet metal illess ad you live i the commuity, you may be eligible to get SRS specific to your recovery eeds. The pla covers the followig three services if you are erolled i the SRS program: Recovery Maagemet - Recovery maagers will work with you to: Limitatios ad exceptios If you are iterested i SRS, you will be coected with a recovery maager who will begi the assessmet for eligibility lookig at thigs such as your diagosis ad your eed for help with activities such as medical appoitmets, social iteractios ad livig skills.» develop a perso-cetered care pla which reflects your persoal goals ad desired outcomes,» regularly moitor your pla through regular meetigs, ad» provide iformatio ad referrals. Idividualized Placemet ad Support Supported Employmet (IPS SE) Supported employmet services ca:» help you fid a job if you are iterested i workig,» evaluate your iterests, skills, ad experieces as they relate to your employmet goals, ad» provide ogoig support to help you stay employed. Peer Recovery Support:» peer recovery supporters use their ow experieces with metal health ad substace use disorders to help you reach your recovery goals, ad» goals are icluded i a care pla you desig based o your prefereces ad the availability of commuity ad supports. This beefit is cotiued o the ext page If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 74

77 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Specialized Recovery Services (SRS) Program (cotiued) The peer relatioship ca help you focus o strategies ad progress towards self-determiatio, self-advocacy, well-beig ad idepedece. Trasportatio for o emergecy services (see also Ambulace ad wheelchair va services ) Limitatios ad exceptios If you are iterested i SRS, you will be coected with a recovery maager who will begi the assessmet for eligibility lookig at thigs such as your diagosis ad your eed for help with activities such as medical appoitmets, social iteractios ad livig skills. Prior authorizatio is required. If you must travel 30 miles or more from your home to get covered health care services, Aeta Better Health of Ohio will provide trasportatio to ad from the provider s office. I additio to the trasportatio assistace that Aeta Better Health of Ohio provides, you ca still get help with trasportatio for certai services through the No-Emergecy Trasportatio (NET) program. Call your local Couty Departmet of Job ad Family Services for questios or assistace with NET services. I additio to the trasportatio assistace that Aeta Better Health of Ohio provides, you ca still get help with trasportatio for certai services through the No-Emergecy Trasportatio (NET) program. Call your local Couty Departmet of Job ad Family Services for questios or assistace with NET services. For members who joi our Member Advisory Committee, we will provide trasportatio to atted committee meetigs. For more iformatio about the Member Advisory Committee, call Member Services at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week or talk to your care maager. I additio, Aeta Better Health of Ohio provides members with trasportatio for 30 roud trips or 60 oe-way trips to Pla approved locatios. Trasportatio requests must be made 3 busiess days i advace. Call Member Services at Optio 1, (TTY: 711), 24 hours a day, 7 days a week ad select the prompt for trasportatio. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 75

78 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Limitatios ad exceptios Urgetly eeded care 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. We oly cover urgetly eed care withi the U.S. ad its territories. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 76

79 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart Services covered by our pla Visio care The pla covers the followig services: Limitatios ad exceptios Prior authorizatio may be required. Oe comprehesive eye exam, complete frame, ad pair of leses (cotact leses, if medically ecessary) are covered:» per 12-moth period for members uder 21 ad over 59 years of age; or» per 24-moth period for members 21 through 59 years of age. Visio traiig Services for the diagosis ad treatmet of diseases ad ijuries of the eye, icludig but ot limited to:» Aual eye exams for diabetic retiopathy for people with diabetes ad treatmet for age-related macular degeeratio» Oe glaucoma screeig each year for members uder the age of 20 or age 50 ad older, members with a family history of glaucoma, members with diabetes, Africa-Americas who are age 50 ad older, ad Hispaic Americas who are age 65 ad older.» 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.) If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 77

80 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart E. Accessig services whe you are away from home or outside of the service area If you are away from home or outside of our service area (see Chapter 1) ad eed medical care Aeta Better Health of Ohio will cover emergecy ad urget services oly. If you are out of the service area ad you have a medical emergecy, call 911 or go to the closest emergecy room. Make sure you have your Aeta Better Health of Ohio member ID card. If you get services i the emergecy room ad you are admitted to the hospital while you are away from home, have the hospital call Member Services at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. For urget care, go to the earest urget care provider. Show the provider your Aeta Better Health of Ohio member ID card. Routie care out of the service area or out of the coutry is ot covered. If you are out of the service area ad eed health care services, call your care maager directly or your PCP. Your PCP s telephoe umber is o your member ID card. You ca also call the 24-hour Care Maagemet lie at , Optio 5 (TTY: 711) or the 24-hour Nurse Advice lie at , Optio 4 (TTY: 711), 24 hours a day, 7 days a week. F. Beefits covered outside of Aeta Better Health of Ohio The followig services are ot covered by Aeta Better Health of Ohio but are available through Medicare. Call Member Services to fid out about services ot covered by Aeta Better Health of Ohio but available through Medicare. 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 of Ohio 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. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 78

81 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart 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 of Ohio 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 maager to arrage the services. No-hospice care is care that is ot related to your termial progosis. G. Beefits ot covered by Aeta Better Health of Ohio, Medicare, or Medicaid This sectio tells you what kids of beefits are excluded by the pla. Excluded meas that the pla does ot cover these beefits. Medicare ad 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 cover 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 cover a service that is ot covered, you ca file a appeal. For iformatio about filig a appeal, see Chapter 9. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 79

82 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 4: Beefits Chart I additio to ay exclusios or limitatios described i the Beefits Chart, the followig items ad services are ot covered by our pla: Services cosidered ot reasoable ad ecessary, accordig to the stadards of Medicare ad Medicaid, uless these services are listed by our pla as covered services. Chiropractic care, other tha diagostic x-rays ad maual maipulatio (adjustmets) of the spie to correct aligmet cosistet with Medicare ad Medicaid coverage guidelies. Experimetal medical ad surgical treatmets, items, ad drugs, uless covered by Medicare or uder a Medicareapproved cliical research study or by our pla. See Chapter 3, page 37, 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 covers it. Routie foot care, except for the limited coverage provided accordig to Medicare ad Medicaid guidelies. 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. Ifertility services for males or females. A private room i a hospital, except whe it is medically eeded. Persoal items i your room at a hospital or a ursig facility, such as a telephoe or a televisio. Volutary sterilizatio if uder 21 years of age or legally icapable of cosetig to the procedure. Reversal of sterilizatio procedures ad o-prescriptio cotraceptive supplies. Ipatiet hospital custodial care. Paterity testig. 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 cover recostructio of a breast after a mastectomy ad for treatig the other breast to match it. Abortios, except i the case of a reported rape, icest, or whe medically ecessary to save the life of the mother. Naturopath services (the use of atural or alterative treatmets). Services provided to veteras i Veteras Affairs (VA) facilities. Services to fid cause of death (autopsy). If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 80

83 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla Table of Cotets Itroductio Rules for the pla s outpatiet drug coverage A. Gettig your prescriptios filled Fill your prescriptio at a etwork pharmacy Show your Member ID Card whe you fill a prescriptio What if you wat to chage a prescriptio to a differet etwork pharmacy? What if the pharmacy you use leaves the etwork? What if you eed a specialized pharmacy? Ca you use mail-order services to get your drugs? Ca you get a log-term supply of drugs? Ca you use a pharmacy that is ot i the pla s etwork? 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 If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 81

84 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla 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 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 of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 82

85 Aeta Better Health of Ohio 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 Medicaid. Aeta Better Health of Ohio 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. 2. You geerally must use a etwork pharmacy to fill your prescriptio. 3. 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 93 to lear about askig for a exceptio. 4. 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 of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 83

86 Aeta Better Health of Ohio 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 Member Services or your care maager. 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 should always show the pharmacy your Member ID Card whe you fill a prescriptio to avoid ay problems. 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 you eed help gettig a prescriptio filled, you ca cotact Member Services or your care maager. What if you wat to chage a prescriptio 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 fidig a etwork pharmacy, you ca cotact Member Services or your care maager. 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 Member Services. 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. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 84

87 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla 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 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 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 the same copay as a oe-moth supply. How do I fill my prescriptios by mail? To get order forms ad iformatio about fillig your prescriptios by mail go to our website, You ca also talk to your care maager or call Member Services at (TTY: 711), 24 hours a day, 7 days a week. 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 Customer Care at (hearig impaired oly, TTY ) ad they will begi processig a replacemet order. The order will be quickly set to you. Calls to this umber are free. 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. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 85

88 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla 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 (hearig impaired oly, 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 (hearig impaired oly, 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 get directly from your health care provider s offce, please cotact CVS Caremark Customer Care at (hearig impaired oly, TTY ). You ca also chage your prefereces by registerig olie with CVS Caremark at 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 (hearig impaired oly, 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 of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 86

89 Aeta Better Health of Ohio MEMBER HANDBOOK Ca you get a log term supply of drugs? Chapter 5: Gettig your outpatiet prescriptio drugs through the pla 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 the same copay as a oe-moth supply. 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. 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: If you get prescriptios i coectio with emergecy care. If you get prescriptios i cojuctio 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 etwork pharmacy withi a reasoable drivig distace that provides 24-hour service. If you are tryig to fill a prescriptio drug that is ot regularly stocked at a accessible 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, if you lose your medicatio, or if you become ill ad caot access a etwork pharmacy. If you receive a Part D prescriptio drug, dispesed 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. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 87

90 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla 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 use a out-of-etwork pharmacy, you may have to pay the full cost whe you get your prescriptio. If you were uable to use a etwork pharmacy ad had to pay for your prescriptio, 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 over-the-couter drugs ad items covered uder your 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. 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. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 88

91 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla 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. Aeta Better Health of Ohio 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 of Ohio 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 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 3 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 icludes Part D prescriptio geeric drugs. Tier 2 icludes Part D prescriptio brad ame ad geeric drugs. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 89

92 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla Tier 3 icludes 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. Chapter 6 tells the amout you pay for drugs i each tier. 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 pla 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, if 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 of Ohio before you fill your prescriptio. If you do t get approval, Aeta Better Health of Ohio 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. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 90

93 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla 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. 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: 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 of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 91

94 Aeta Better Health of Ohio 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. 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. You were i the pla last year ad 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. The total supply will be for 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 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 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 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, AND 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, AND Your ability to get the drug is limited If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 92

95 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla 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. 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 Member Services or your care maager 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 you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 93

96 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla 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 a icrease i your paymets or added limits to your use of the drug. The chages will affect you o Jauary 1 of the ext year. 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 have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 94

97 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla 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 a 91 day supply 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 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 have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 95

98 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla 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. 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 If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 96

99 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 5: Gettig your outpatiet prescriptio drugs through the pla 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 Member Services or your care maager. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 97

100 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 6: What you pay for your Medicare ad 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 Make sure we have the iformatio we eed Check the reports we sed you C. You pay othig for a oe-moth or log-term supply of drugs The pla s tiers Gettig a log-term supply of a drug How much do you pay? D. Vacciatios Before you get a vacciatio How much you pay for a vacciatio If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 98

101 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 6: What you pay for your Medicare ad Medicaid prescriptio drugs Itroductio This chapter tells you about your outpatiet prescriptio drugs. By drugs, we mea: Medicare Part D prescriptio drugs, ad drugs ad items covered uder Medicaid Because you are eligible for 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 of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 99

102 Aeta Better Health of Ohio 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 two types of costs: Your out-of-pocket costs. This is the amout of moey you, or others o your behalf, pay for your prescriptios. Your total drug costs. This is the amout of moey you, or others o your behalf, pay for your prescriptios, plus the amout the pla pays. 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, what the pla paid, ad what you ad others payig for you paid. Year to date iformatio. This is your total drug costs ad the total paymets made sice Jauary 1. We offer coverage of drugs ot covered uder Medicare. To fid out which drugs our pla covers, see the Drug List. B. Keepig track of your drug costs To keep track of your drug costs ad the paymets you make, ad that Medicare pays for you, 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, what you pay, ad what Medicare pays for you. 2. Make sure we have the iformatio we eed. Give us copies of receipts for drugs that you have paid for. You should give us copies of your receipts whe you buy covered drugs at a out-of-etwork pharmacy. If you were uable to use a etwork pharmacy ad had to pay for your prescriptio, see Chapter 7 for iformatio about what to do. 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 of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 100

103 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 6: What you pay for your Medicare ad Medicaid prescriptio drugs C. You pay othig for a oe-moth or log-term supply of drugs With Aeta Better Health of Ohio, you pay othig for covered drugs as log as you follow the pla s rules. The pla s tiers Tiers are groups of drugs o our Drug List. Every drug i the pla s Drug List is i oe of three tiers. You have o copays for prescriptio ad OTC drugs o Aeta Better Health of Ohio s Drug List. To fid the tiers for your drugs, you ca look i the Drug List. Tier 1 drugs are 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 of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 101

104 Aeta Better Health of Ohio MEMBER HANDBOOK How much do you pay? Chapter 6: What you pay for your Medicare ad Medicaid prescriptio drugs Your share of the cost whe you get a oe-moth or log-term supply of a covered prescriptio drug from: A etwork pharmacy A oemoth or up to a 90-day supply The pla s mail order service A oemoth or up to a 90-day supply A etwork log term care pharmacy Up to a 98-day supply A out of etwork pharmacy Up to a 29-day supply. Coverage is limited to certai cases. See Chapter 5 for details. Tier 1 $0 $0 $0 $0 (Part D prescriptio geeric drugs) Tier 2 $0 $0 $0 $0 (Part D prescriptio brad ame ad geeric drugs) 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 of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 102

105 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 6: What you pay for your Medicare ad Medicaid prescriptio drugs D. Vacciatios Our pla covers Medicare Part D vaccies. 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 of Ohio to esure that you do ot have ay upfrot costs for a Part D vaccie. How much you pay for a vacciatio As a Aeta Better Health of Ohio member you pay othig for vacciatios. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 103

106 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 7: Askig us to pay a bill you have gotte for covered services or drugs 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 to avoid paymet problems 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, call Member Services or sed the bill to us. To sed us a bill, see page 105. If you have ot paid the bill, we will pay the provider directly if the services or drugs are covered ad you followed all the rules i the Member Hadbook. If you have paid the bill, the services or drugs are covered, ad you followed all the rules i the Member Hadbook, 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 maager 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. Here are some examples of times whe you may eed to ask our pla to assist you with a paymet you made or a bill you got: 1. Whe you get emergecy or urgetly eeded health care from a out of etwork provider You should always tell the provider you are a member of Aeta Better Health of Ohio ad ask the provider to bill the pla. If you pay the full amout whe you get the care, you ca ask to have the full amout refuded. Sed us the bill ad proof of ay paymet you made. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 104

107 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 7: Askig us to pay a bill you have gotte for covered services or drugs 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 work with the provider to refud your paymet. 2. Whe a etwork provider seds you a bill Network providers must always bill the pla for covered services. Show your Aeta Better Health of Ohio 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 of Ohio 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 work with the provider to refud your paymet amout for your covered services. 3. Whe you use a out-of-etwork pharmacy to get a prescriptio filled i a emergecy situatio We will cover prescriptios filled at out-of-etwork pharmacies i emergecy situatios oly. If you get prescriptios i coectio 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 etwork pharmacy withi a reasoable drivig distace that provides 24-hour service. If you are tryig to fill a prescriptio drug that is ot regularly stocked at a accessible etwork retail or mail order pharmacy (these prescriptio drugs iclude orpha drugs or other specialty pharmaceuticals). If you are travelig outside our service area (withi the Uited States) ad ru out of your medicatio, if you lose your medicatio, or if you become ill ad caot access a etwork pharmacy. If you receive a Part D prescriptio drug, dispesed 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 questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 105

108 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 7: Askig us to pay a bill you have gotte for covered services or drugs 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. You ca always cotact Member Services at (TTY: 711), 24 hours a day, 7 days a week if you are beig asked to pay for services, get a bill, or have ay questios. You ca use the form o page 175 or ask Member Services to sed you a form if you wat to sed us the iformatio about the bill. You ca also submit the iformatio through our website at B. How to avoid paymet problems 1. Always ask the provider if the service is covered by Aeta Better Health of Ohio. Except i a emergecy or urget situatio, do ot agree to pay for a service uless you have asked Aeta Better Health of Ohio for a coverage decisio (see Chapter 9), got a fial decisio that the service is ot covered, ad decided that you still wat the service eve though the pla does ot cover it. 2. Get pla approval before seeig a out of etwork provider. A exceptio to this rule is if you eed out-of-etwork emergecy or urget care services. Aother exceptio is if you get services at Federally Qualified Health Ceters, Rural Health Cliics, ad qualified family plaig providers listed i the Provider ad Pharmacy Directory. If you get care from a out-of-etwork provider, ask the provider to bill Aeta Better Health of Ohio. If the out-of-etwork provider is approved by Aeta Better Health of Ohio, you should ot have to pay aythig. If the out-of-etwork provider will ot bill Aeta Better Health of Ohio ad you pay for the service, call Member Services as soo as possible to let us kow. Please remember that i most situatios you must get pla approval before you ca see a out-of-etwork provider. Therefore, uless you eed emergecy or urget care, are i your trasitio of care period, or the provider does ot require prior approval as idicated above, we may ot pay for services you get from a out-of-etwork provider. If you have questios about your trasitio of care period, whether you eed approval to see a certai provider, or eed help i fidig a etwork provider, call Member Services. 3. Follow the rules i the Member Hadbook whe gettig services. See Chapter 3 for the rules about gettig your health care, behavioral health, ad other services. See Chapter 5 for the rules about gettig your outpatiet prescriptio drugs. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 106

109 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 7: Askig us to pay a bill you have gotte for covered services or drugs 4. Use the Provider ad Pharmacy Directory to fid etwork providers. If you do ot have a Provider ad Pharmacy Directory, you ca call Member Services to ask for a copy or go olie at for the most up-to-date iformatio. 5. Always carry your Member ID Card ad show it to the provider or pharmacy whe gettig care. If you forgot your Member ID Card, ask the provider to call Member Services to verify eligibility. If your card is damaged, lost, or stole, call Member Services right away ad we will sed you a ew card. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 107

110 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities Table of Cotets Itroductio A. Notice about laws B. You have a right to get iformatio i a way that meets your eeds C. We must treat you with respect, fairess, ad digity at all times D. We must esure that you get timely access to covered services ad drugs E. We must protect your persoal health iformatio How we protect your health iformatio You have a right to see your medical records F. We must give you iformatio about the pla, its etwork providers, ad your covered services G. Network providers caot bill you directly H. You have the right to get your Medicare ad Part D coverage from origial Medicare or aother Medicare pla at ay time by askig for a chage I. 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 J. 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 K. Makig recommedatios about our member rights ad resposibilities policy L. You also have resposibilities as a member of the pla M.Notice about Medicare as a secod payer If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 108

111 Aeta Better Health of Ohio 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. 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 ad state laws about the Medicaid program. Other federal ad state laws may apply too. B. You have a right to get iformatio i a way that meets your eeds Each year you are i our pla, we must tell you about the pla s beefits ad your rights i a way that you ca uderstad. To get iformatio i a way that you ca uderstad, call Member Services. 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. The materials are available i Spaish ad Somali. If you wish to make a stadig request to receive all materials i a laguage other tha Eglish or i a alterate format, you ca call Aeta Better Health of Ohio 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 ca also cotact the Ohio Medicaid Hotlie at , Moday through Friday from 7:00 am to 8:00 pm ad Saturday from 8:00 am to 5:00 pm. TTY users should call Cada año que está e uestro pla, debemos iformale sobre los beeficios del pla y sus derechos de ua maera que pueda eteder. Para obteer iformació de eteder, llame a Servicios al Cliete. Nuestro pla tiee persoas que puede respoder pregutas e diferetes idiomas. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 109

112 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities Nuestro pla tambié le puede proveer a usted los materiales e otros idiomas además de iglés, y e formatos como e letra grade, braille, o audio. Los materiales está dispoibles e español y somalí. Si desea solicitar que le eviemos todos los materiales, ahora y e el futuro, e u idioma distito del iglés o e u formato alterativo, puede llamar a Servicios al Cliete de Aeta Better Health of Ohio, al o a la líea TTY 711, las 24 horas del día, los 7 días de la semaa. Si le cuesta obteer iformacio de uestro pla, Si le cuesta obteer iformacio de uestro pla, por problemas de idioma o icapacidad, y desea preseter ua queia, llame a Medicare ( ). Puede llamar las 24 horas del días de la semaa. Los usuarios de TTY debe llamar al Tambié puede llamar a la líea directa del programa Medicaid e Ohio al , de lues a vieres, de 7 a.m. a 8 p.m. y los sábados de 8 a.m. a 5 p.m. Los usuarios de la líea TTY para persoas co dificltades de audició debe llamar al 711. Saad kasta oo aad ka tirsa tahay qorshahea, waa i aa kuu sheego maaafacaadka qorshaha iyo xuquuqda aad leedahay aaga oo adeegsaa siyaabo aad fahmi kartid. Si aad macluumaadka laguugu siiyo siyaabo aad fahmi kartid, wac Adeegyada Xubita (Member Services). Qorshahea waxaa lagu heli karaa Isbaish iyo Soomaali. Waxaa kaloo macluumaadka kugu sii karaa Braille ama far waawey. Wac Adeegyada Xubita oo laga_ helo telefooka , doorasho 1 (TTY: 711) si aad u codsatid i qoraalada _ aguugu siiyo qaab kale ama luad kale, Macluumaadkaa waa lacag la aa. Qorshahayaga waxa kale oo alaabta lagugu sii karaa luqado aa Igiriisi ahay iyo qaabab kale sida far waawey, farta idhoolaha braille, ama cod ahaa. Alaabta waxa lagu heli karaa Isbaaish iyo Soomaali. Haddii aad rabto iaad samayso codsi joogto ah si aad ku hesho dhammaa alaabta hadda, iyo mustaqbalkaba, luqad aa ahay Igiriisi, ama qaab kale, waxaad ka wici kartaa Adeegyada Xubaha Ohio ee Aeta Better Health lambarka (TTY: 711), 24 saac maalitii, 7 maalmood usbuucii. Haddii aad dhibaato ku qabtid i aad macluumaad ka heshid qorshahea maxaa yeelay waxaa iira dhibatoovi la xariira luqadda ama itaal darri, waxaada rabtaa i aad soo gudbisid ashtako, wac Medicare, Medicare ( ). Waxxaad soo wici kartaa 24 saac maalitii, todobada maali halkii todobaad. Dadka isticmaala TTY waa i ay wacaa Waxaad kaloo la xariiri kartaa Telefooka Medicaid ee Ohio , Isii ilaa Jimco, laga bilaabo 7 a.m. ilaa 8 p.m. iyo Sabti laga bilaabo 8 a.m. ilaa 5 p.m. Dadka isticmaala TTY waa i ay wacaa 711. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 110

113 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities C. 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 Health status Appeals Medical history Behavior Metal ability Color Metal or physical disability Creed Natioal origi Claims experiece Race Ethicity Receipt of health care Evidece of isurability Religio Geetic iformatio Sex Geder idetity Sexual orietatio Geographic locatio withi the service area 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. You have the right to be treated with respect ad with regard for your digity ad privacy. We caot dey services to you or puish you for exercisig your rights. Exercisig your rights will ot affect the way our pla, our etwork providers, or the Ohio Departmet of Medicaid treats you. 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 Ohio Departmet of Job ad Family Services Bureau of Civil Rights at (TTY ). 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 of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 111

114 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities D. We must esure that you get timely access to covered services ad drugs As a member of our pla: You have the right to get all services that Aeta Better Health of Ohio must provide ad to choose the provider that gives you care wheever possible ad appropriate. You have the right to be sure that others caot hear or see you whe you are gettig medical care. 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.» 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 etwork gyecologist or aother etwork wome s health specialist for routie ad prevetive covered wome s health services without gettig a referral. A referral is a writte order from your primary care provider. 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. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 112

115 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities E. 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 the right to be esured of cofidetial hadlig of iformatio cocerig your diagoses, treatmets, progoses, ad medical ad social history. 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. How we protect your health iformatio You have the right to be give iformatio about your health. This iformatio may also be available to someoe who you have legally authorized to have the iformatio or who you have said should be reached i a emergecy whe it is ot i the best iterest of your health to give it to you. 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 your health ad drug iformatio. If Medicare releases your iformatio for research or other uses, it will be doe accordig to Federal ad state laws ad our govermet cotracts. 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 fee for makig a copy of your medical records if it is t to trasfer the records to a ew provider. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 113

116 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities You have the right to ask us to update or correct your medical records. If you ask us to do this, we will work with your health care provider to decide whether the chages should be made. 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. F. We must give you iformatio about the pla, its etwork providers, ad your covered services As a member of Aeta Better Health of Ohio, 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), 24 hours a day, 7 days a week. This is a free service. Writte materials are available i Spaish ad Somali upo request. We ca also give you iformatio i large prit, braille, or audio. If you wat ay of the followig, call Member Services: Iformatio about how to choose or chage plas Iformatio about our pla, icludig but ot limited to:» 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 (PCP). You ca chage your PCP to aother etwork PCP as ofte as you like. We must sed you somethig i writig that says who the ew PCP is ad the date the chage bega.» 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 If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 114

117 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities 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 G. 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. H. You have the right to get your Medicare ad Part D coverage from origial Medicare or aother Medicare pla at ay time by askig for a chage You have the right to get your Medicare 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. However, you must cotiue to get your Medicaid services from a MyCare Ohio pla. If you wat to make a chage, you ca call the Ohio Medicaid Hotlie at (TTY users should call 7-1-1), Moday through Friday from 7:00 am to 8:00 pm ad Saturday from 8:00 am to 5:00 pm. Calls to this umber are free. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 115

118 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities I. 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, provided i a way appropriate to your coditio ad ability to uderstad, regardless of cost or beefit coverage. 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 qualified etwork provider before decidig o treatmet. If a qualified etwork provider is ot able to see you, we will arrage a visit with a o-etwork provider at o cost to you. You ca say o. You have the right to refuse ay treatmet or therapy. 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 say o to treatmet, therapy or takig a drug, the doctor or Aeta Better Health of Ohio must talk to you about what could happe ad they must put a ote i your medical record. 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. 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. Kow of specific studet practitioer roles. You have the right to refuse treatmet from a studet. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 116

119 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities You have the right to say what you wat to happe if you are uable to make health care decisios for yourself Usig Advace Directives to State Your Wishes about Your Medical Care People ofte worry about the medical care they would get if they became too sick to make their wishes kow. Some people may ot wat to sped moths or years o life support. Others may wat every step take to legthe life. You ca state your medical care wishes i writig while you are healthy ad able to choose. Your health care facility must explai your right to state your wishes about medical care. It also must ask you if you have put your wishes i writig. This documet explais your rights uder Ohio law to accept or refuse medical care. The documet also explais how you ca state your wishes about the care you would wat if you could ot choose for yourself. This documet does ot cotai legal advice, but will help you uderstad your rights uder the law. What are my rights to choose my medical care? You have the right to choose your ow medical care. If you do ot wat a certai type of care, you have the right to tell your doctor you do ot wat it. What if I am too sick to decide? What if I caot make my wishes kow? Most people ca make their wishes about their medical care kow to their doctors. But some people become too sick to tell their doctors about the type of care they wat. Uder Ohio law, you have the right to fill out a form while you are able to act for yourself. The form tells your doctors what you wat doe if you ca t make your wishes kow. What kids of forms are there? Uder Ohio law, there are four differet forms, or advace directives, you ca use: a Livig Will, a Do Not Resuscitate (DNR) Order, a Health Care Power of Attorey (also kow as a Durable Power of Attorey for Health Care) ad a Declaratio for Metal Health Treatmet. You fill out a advace directive while you are able to act for yourself. The advace directive lets your doctor ad others kow your wishes about medical care. Do I have to fill out a advace directive before I get medical care? No. No oe ca make you fill out a advace directive. You decide if you wat to fill oe out. Who ca fill out a advace directive? Ayoe 18 years old or older who is of soud mid ad ca make his or her ow decisios ca fill oe out. Do I eed a lawyer? No, you do ot eed a lawyer to fill out a advace directive. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 117

120 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities Do the people givig me medical care have to follow my wishes? Yes, if your wishes follow state law. However, a perso givig you medical care may ot be able to follow your wishes because they go agaist his or her cosciece. If so, they will help you fid someoe else who will follow your wishes. Livig Will A Livig Will states how much you wat to use life-support methods to legthe your life. It takes effect oly whe you are:» i a coma that is ot expected to ed, - OR» beyod medical help with o hope of gettig better ad ca t make your wishes kow, - OR» expected to die ad are ot able to make your wishes kow. The people givig you medical care must do what you say i your Livig Will. A Livig Will gives them the right to follow your wishes. Oly you ca chage or cacel your Livig Will. You ca do so at ay time. Do Not Resuscitate Order A Do Not Resuscitate (DNR) Order is a order writte by a doctor or, uder certai circumstaces, a certified urse practitioer or cliical urse specialist, that istructs health care providers ot to do cardiopulmoary resuscitatio (CPR). I Ohio, there are two types of DNR Orders: (1) DNR Comfort Care, ad (2) DNR Comfort Care Arrest. You should talk to your doctor about DNR optios. Health Care Power of Attorey A Health Care Power of Attorey is differet from other types of powers of attorey. This documet talks oly about a Health Care Power of Attorey, ot about other types of powers of attorey. A Health Care Power of Attorey allows you to choose someoe to carry out your wishes for your medical care. The perso acts for you if you caot act for yourself. This could be for a short time period or for a log time period. Who should I choose? You ca choose ay adult relative or fried whom you trust to act for you whe you caot act for yourself. Be sure to talk with the perso about what you wat. The write dow what medical care you do or do ot wat. You should also talk to your doctor about what you wat. The perso you choose must follow your wishes. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 118

121 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities Whe does my Health Care Power of Attorey take effect? The form takes effect oly whe you ca t choose your care for yourself. The form allows your relative or fried to stop life support oly i the followig circumstaces:» if you are i a coma that is ot expected to ed, -OR» if you are expected to die. Declaratio for Metal Health Treatmet A Declaratio for Metal Health Treatmet gives more specific attetio to metal health care. It allows you, while capable, to appoit a represetative to make decisios o your behalf whe you lack the capacity to make a decisio. I additio, the declaratio ca set forth certai wishes regardig treatmet. For example, you ca idicate medicatio ad treatmet prefereces, ad prefereces cocerig admissio/retetio i a facility. What is the differece betwee a Health Care Power of Attorey ad a Livig Will? Your Livig Will explais, i writig, your wishes about the use of life-support methods if you are uable to make your wishes kow. Your Health Care Power of Attorey lets you choose someoe to carry out your wishes for medical care whe you caot act for yourself. If I have a Health Care Power of Attorey, do I eed a Livig Will, too? You may wat both. Each addresses differet parts of your medical care. Ca I chage my advace directives? Yes, you ca chage your advace directives wheever you wat. It is a good idea to look over your advace directives from time to time to make sure they still say what you wat ad that they cover all areas. If I do t have a advace directive, who chooses my medical care whe I ca t? Ohio law allows your ext-of-ki to choose your medical care if you are expected to die ad caot act for yourself. Where do I get advace directive forms? May of the people ad places that give you medical care have advace directive forms. You may also be able to get these forms from Midwest Care Alliace s website at: What do I do with my forms after fillig them out? You should give copies to your doctor ad health care facility to put ito your medical record. Give oe to a trusted family member or fried. If you have chose someoe i a Health Care Power of Attorey, give that perso a copy. Put a copy with your persoal papers. You may wat to give oe to your lawyer or clergy perso. Be sure to tell your family or frieds about what you have doe. Do ot just put these forms away ad forget about them. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 119

122 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities Orga ad Tissue Doatio Ohioas ca choose whether they would like their orgas ad tissues to be doated to others i the evet of their death. By makig their preferece kow, they ca esure that their wishes will be carried out immediately ad that their families ad loved oes will ot have the burde of makig this decisio at a already diffcult time. Some examples of orgas that ca be doated are the heart, lugs, liver, kideys ad pacreas. Some examples of tissues that ca be doated are ski, boe, ligamets, veis ad eyes. There are two ways to register to become a orga ad tissue door: (1) You ca state your wishes for orga ad/or tissue doatio whe you obtai or reew your Ohio Driver Licese or State I.D. Card, -OR (2) You may register olie for orga doatio through the Ohio Door Registry website: 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 livig will ad a power of attorey for health care. 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 Medicaid (such as the Ohio Departmet of Agig, Ohio State Bar Associatio ad AARP) may also have advace directive forms. You ca also cotact Member Services to ask for the forms. The forms are also curretly available o the followig website: 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 of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 120

123 Aeta Better Health of Ohio 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 If you have siged a advace directive, ad you believe that a doctor or hospital did ot follow the istructios i it, you may file a complait with the Ohio Departmet of Health by callig or ig HCComplaits@odh.ohio.gov. J. 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. We will also sed you a otice whe you ca make a appeal directly to the Bureau of State Hearigs withi the Ohio Departmet of Job ad Family Services. 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 You are free to exercise all of your rights kowig that Aeta Better Health of Ohio, our etwork providers, Medicare, ad the Ohio Departmet of Medicaid will ot hold it agaist you. If you believe you have bee treated ufairly ad it is ot about discrimiatio for the reasos listed o page 111 you ca get help i these ways: You ca call Member Services. You ca call the Ohio Medicaid Cosumer Hotlie at (TTY users call 7-1-1), Moday through Friday from 7:00 am to 8:00 pm ad Saturday from 8:00 am to 5:00 pm. Calls to this umber are free. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 121

124 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities You ca call Medicare at MEDICARE ( ), 24 hours a day, seve days a week. TTY users should call You ca call the MyCare Ohio Ombudsma i the Offce of the State Log-Term Care Ombudsma at , Moday through Friday from 8:00 am to 5:00 pm. See Chapter 2 for more iformatio about this orgaizatio. 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 the Ohio Medicaid Cosumer Hotlie at (TTY users call 7-1-1), Moday through Friday from 7:00 am to 8:00 pm ad Saturday from 8:00 am to 5:00 pm. 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 MyCare Ohio Ombudsma i the Offce of the State Log-Term Care Ombudsma at , Moday through Friday from 8:00 am to 5:00 pm. See Chapter 2 for more iformatio about this orgaizatio. K. Makig recommedatios about our member rights ad resposibilities policy You have the right as a member to cotact us at ay time to voice your opiios ad submit recommedatios cocerig Aeta Better Health of Ohio s Rights ad Resposibilities Policy. Call , TTY 711, 24 hours a day, 7 days a week to speak to a Member Services represetative, or cotact your care maager. L. 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. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 122

125 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities» 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.» 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. Participate with your providers developig mutually agreed upo treatmet plas, to the degree possible.» 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. 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 early all Aeta Better Health of Ohio members, Medicaid pays the Part A premium ad Part B premium. If you pay your Part A ad/or part B premium ad thik Medicaid should have paid, you ca cotact your Couty Departmet of Job ad Family Services ad ask for assistace.» If you get ay services or drugs that are ot covered by our pla, you may have to pay for the service or drug. 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. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 123

126 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 8: Your rights ad resposibilities 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 of Ohio. Chapter 1 tells about our service area. We ca help you figure out whether you are movig outside our service area. Also, be sure to let Medicare ad Medicaid kow your ew address whe you move. See Chapter 2 for phoe umbers for Medicare ad Medicaid.» 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. You must also otify your Couty Caseworker at the local Departmet of Job ad Family Services. Call Member Services for help if you have questios or cocers. M. 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 of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 124

127 Aeta Better Health of Ohio 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 to ask for a coverage decisio, a appeal or make a complait. 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 services ad supports You should get the health care, drugs, ad log-term services ad supports that your doctor ad other providers determie are ecessary for your care as a part of your care pla. However, sometimes you may ru ito a problem gettig services, or you may be uhappy with how services were provided or how you were treated. This chapter explais the differet optios you have for dealig with problems ad complaits about our pla, our pla s providers, gettig services, ad paymet of services. You ca also call the MyCare Ohio Ombudsma at to help guide you through your problem. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 125

128 Aeta Better Health of Ohio 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 services ad supports 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: Problems with your beefits 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: 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: Level 1 Appeal for services, items, ad drugs (ot Part D drugs) Sectio 5.4: Level 2 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 your paymet refuded for a Part D drug Sectio 6.2: What is a exceptio? Sectio 6.3: Importat thigs to kow about askig for exceptios 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 If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 126

129 Aeta Better Health of Ohio 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 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 Medicare 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: Takig your appeal beyod Level Sectio 9.1: Next steps for Medicare services ad items Sectio 9.2: Next steps for 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 of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 127

130 Aeta Better Health of Ohio 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 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 cotact ay of the followig resources for help. Gettig help from Aeta Better Health of Ohio s Member Services Member Services ca help you with ay problems or complaits about your health care, drugs, ad log-term services ad supports. We wat to help with problems such as: uderstadig what services are covered; how to get services; fidig a provider; beig asked to pay for a service; askig for a coverage decisio or appeal; or makig a complait (also called a grievace). To cotact us you ca: If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 128

131 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Call Member Services at (TTY: 711), 24 hours a day, 7 days a week. The call is free. Visit our website at to sed a questio, complait, or appeal. Fill out the appeal/complait form o page 178 of this chapter or call Member Services ad ask us to mail you a form. Write a letter tellig us about your questio, problem, complait, or appeal. Be sure to iclude your first ad last ame, the umber from the frot of your Aeta Better Health of Ohio Member ID Card, ad your address ad telephoe umber. You should also sed ay iformatio that helps explai your problem. Mail the form or your letter to: Aeta Better Health of Ohio Att: Member Services Departmet 7400 West Campus Road, Mail Code: F494 New Albay, OH Gettig help from the Ohio Departmet of Medicaid If you eed help, you ca always call the Ohio Medicaid Hotlie. The hotlie ca aswer your questios ad direct you to staff that will help you uderstad what to do about your problem. The hotlie is ot coected with us or with ay isurace compay or health pla. You ca call the Ohio Medicaid Hotlie at (TTY: ), Moday through Friday from 7:00 am to 8:00 pm ad Saturday from 8:00 am to 5:00 pm. The call is free. You ca also visit the Ohio Departmet of Medicaid website at Gettig help from the MyCare Ohio Ombudsma You ca also get help from the MyCare Ohio Ombudsma. The MyCare Ohio Ombudsma helps you resolve issues that you might have with our pla. They ca help you file a complait or a appeal with our pla. The MyCare Ohio Ombudsma is a idepedet advocate ad is ot coected with us or with ay isurace compay or health pla. You ca call the MyCare Ohio Ombudsma at (TTY Ohio Relay Service: ), Moday through Friday from 8:00 am to 5:00 pm. You ca also submit a olie complait at: cotact. The services are free. 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 ( If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 129

132 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Gettig help from other resources You may also wat to talk to the followig people about your problem ad ask for their help. You ca talk to your doctor or other provider. Your doctor or other provider ca ask for a coverage decisio. If you disagree with the coverage decisio, the doctor or other provider that requested the service ca submit a Level 1 appeal o your behalf.» If you wat your doctor or other provider to act o your behalf for a appeal of services covered by Medicaid oly or for a Medicaid State Hearig, you must ame him or her as your represetative i writig. You ca talk to a fried or family member. A fried or family member ca ask for a coverage decisio, a appeal, or submit a complait o your behalf if you ame them as your represetative.» If you wat someoe 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 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.» We will also accept a letter or other appropriate form to authorize your represetative. You ca talk to a lawyer. You may call your ow lawyer, or get the ame of a lawyer from the local bar associatio or other referral service. If you wat iformatio o free legal help, you ca cotact your local legal aid offce or call Ohio Legal Services toll free at (1-866-LAW-OHIO). If you wat a lawyer to represet you, you will eed to fill out the Appoitmet of Represetative form. Please ote, you do ot eed a lawyer to ask for a coverage decisio or to make a appeal or complait. Sectio 3: Problems with your beefits 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. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 130

133 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Is your problem or cocer about your beefits or coverage? (This icludes problems about whether particular medical care, prescriptio drugs, or log-term services ad supports are covered or ot, the way i which they are covered, ad problems related to the pla s deial of paymet for items ad services.) Yes. My problem is about beefits or coverage. Go to Sectio 4: Coverage decisios ad appeals o page 131. No. My problem is ot about beefits or coverage. Skip ahead to Sectio 10: How to make a complait o page 170. 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 deials. 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 doctor are ot sure if a service, item, or drug is covered by Medicare or Medicaid, either of you ca ask for a coverage decisio before the doctor gives the service, item, or drug. What is a appeal? A appeal is a formal way of askig us to review our 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 medically ecessary, ot a covered beefit, or is o loger covered by Medicare or Medicaid. If you or your doctor disagree with our decisio, you ca appeal. How ca I get help with coverage decisios ad appeals? If you eed help, you ca cotact ay of the resources listed i Sectio 2.1 o page 128. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 131

134 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Sectio 4.2: 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 133 gives you iformatio if you have problems gettig medical care or items, detal or visio services, behavioral health services, log-term services ad supports, ad prescriptio drugs (but ot Part D drugs). For example, use this sectio if: o You are ot gettig medical care you wat, ad you believe our pla covers this care. o We did ot approve services, items, or drugs that your doctor wats to give you, ad you believe this care should be covered. NOTE: Oly use Sectio 5 for problems with 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 147 for Part D drug appeals. o You got medical care or services you thik should be covered, but we are ot payig for this care. o You got ad paid for medical services or items you thought were covered, ad you wat to ask us to pay for the services so your paymet ca be refuded. o You are beig told that coverage for care you have bee gettig will be reduced or stopped, ad you disagree with our decisio. 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 158 ad 164. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit Sectio 6 o page 147 gives you iformatio if you have problems 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.

135 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) o You wat to ask us to pay for a prescriptio drug you already bought so your paymet ca be refuded. (This is askig for a coverage decisio about paymet.) Sectio 7 o page 158 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 164 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 Member Services at (TTY: 711), 24 hours a day, 7 days a week. If you eed other help or iformatio, please call the MyCare Ohio Ombudsma at (TTY Ohio Relay Service: ). 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 items, detal or visio services, behavioral health services, ad log-term services ad supports. 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 followig situatios: 1. You thik we cover a medical, behavioral health, or log term care service 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 135 for iformatio o askig for a coverage decisio. 2. You wat us to cover a beefit that requires pla approval (also called prior authorizatio) before you get the service. What you ca do: You ca ask us to make a coverage decisio. Go to Sectio 5.2 o page 135 for iformatio o askig for a coverage decisio. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 133

136 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) NOTE: See the Beefits Chart i Chapter 4 for a geeral list of covered services as well as iformatio o what services require prior authorizatio from our pla. See the List of Covered Drugs to see if ay drugs require prior authorizatio. You ca also view the lists of services ad drugs that require prior authorizatio at 3. We did ot approve care your doctor 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 138 for iformatio o makig a appeal. 4. We did ot approve your request to get waiver services from a specific etwork o agecy or participat directed provider. What you ca do: You ca appeal our decisio to ot approve the request. Go to sectio 5.3 o page 138 for iformatio o makig a appeal. 5. 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 138 for iformatio o makig a appeal. 6. You got ad paid for services or items you thought were covered, ad you wat us to work with the provider to refud your paymet. What you ca do: You ca ask us to work with the provider to refud your paymet. Go to page 138 of this sectio for iformatio o askig for paymet. 7. We reduced, suspeded, or stopped your coverage for a certai service or item, ad you disagree with our decisio. What you ca do: You ca appeal our decisio to reduce, susped, or stop the service or item. Go to Sectio 5.3 o page 138 for iformatio o makig a appeal. NOTE: If we tell you that previously approved services or items will be reduced, suspeded, or stopped before you receive all of the services or items that were approved, you may be able to cotiue to get the services ad items durig the appeal. Read Will my beefits cotiue durig Level 1 appeals o page 141. 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 158 ad 164 to fid out more. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 134

137 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) 8. We did ot make a coverage decisio withi the timeframes we should have. What you ca do: You ca file a complait or a appeal. Go to Sectio 10 o page 170 for iformatio o makig a complait. Go to Sectio 5.3 o page 138 for iformatio o makig a Level 1 Appeal. NOTE: If you eed help decidig which process to use, you ca call the MyCare Ohio Ombudsma at (TTY Ohio Relay Service: ). 9. We did ot make a appeal decisio withi the timeframes we should have. What you ca do: You ca file a complait. Go to Sectio 10 o page 170 for iformatio o makig a complait. Also, if your problem is about coverage of a Medicaid service or item, you ca ask for a State Hearig. Go to Sectio 5.4 o page 142 for iformatio o askig for a State Hearig. Note that if your problem is about coverage for a Medicare service or item, we will automatically forward your appeal to Level 2 if we do ot give you a aswer withi the required timeframe. NOTE: If you eed help decidig which process to use, you ca call the MyCare Ohio Ombudsma at (TTY Ohio Relay Service: ). Sectio 5.2: Askig for a coverage decisio How to ask for a coverage decisio to get a service, item, or Medicaid drug (go to Sectio 6 for Medicare Part D drugs) To ask for a coverage decisio, call, write, or fax us, or ask your authorized 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 of Ohio Att: Member Services Departmet 7400 West Campus Road, Mail Code: F494 New Albay, OH Remember, you must complete the Appoitmet of Represetative form to appoit someoe as your authorized represetative. We will also accept a letter or other appropriate form to authorize your represetative. For more iformatio, see Sectio 2.1 o page 128. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 135

138 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) How log does it take to get a coverage decisio? We will make a stadard coverage decisio o Medicaid drugs withi 72 hours after you asked. We will make a stadard coverage decisio o all other services ad items withi 10 caledar days after you asked. If we do t give you our decisio withi 10 caledar days, you ca appeal. You or your provider ca ask for more time, or we may eed more time to make a decisio. If we eed more time, 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 24 hours for Medicaid drugs ad withi 48 hours for all other services ad items. The legal term for fast coverage decisio is expedited determiatio. Except for fast coverage decisios for Medicaid drugs, you or your provider ca ask for more time or we may eed more time to make a decisio. If we eed more time, 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. Askig for a fast coverage decisio: o If you request a fast coverage decisio, start by callig or faxig our pla to ask us to cover the care you wat. o You ca call us at (TTY: 711) or fax us at For details o how to cotact us, go to Chapter 2. o You ca also have your doctor or your authorized 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 for coverage for medical care or a item you have ot yet received. (You caot get a fast coverage decisio if your request is about refudig your paymet for medical care or a item you already got.) 2. You ca get a fast coverage decisio oly if the stadard deadlies could cause serious harm to your health or hurt your ability to fuctio. The stadard deadlies are 72 hours for Medicaid drugs ad 10 caledar days for all other services ad items. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 136

139 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) If your doctor says that you eed a fast coverage decisio, we will automatically give you oe. If you ask for a fast coverage decisio without your doctor s support, we will decide if you get a fast coverage decisio. If we decide that your health does ot meet the requiremets for a fast coverage decisio, we will sed you a letter. We will also use the stadard deadlies istead to make our decisio. This letter will tell you that if your doctor 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 170. If the coverage decisio is Yes, whe will I get the service or item? For stadard coverage decisios, we will authorize the coverage withi 72 hours for Medicaid drugs ad 10 caledar days for all other services ad items. For fast coverage decisios, we will authorize the coverage withi 24 hours for Medicaid drugs ad 48 hours for all other services ad items. If we exteded the time eeded to make our coverage decisio, we will authorize 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. o o 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 Level 1 of the appeals process (read the ext sectio for more iformatio). If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 137

140 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Sectio 5.3: Level 1 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 our coverage decisio ad chage it if you thik we made a mistake. If you, your authorized represetative, or your doctor or other provider disagree with our decisio, you ca appeal. You ca also appeal our failure to make a coverage decisio withi the timeframes we should have. We will sed you a otice i writig wheever we take a actio or fail to take a actio that you ca appeal. NOTE: If you wat your doctor or other provider to act o your behalf for a appeal of services covered by Medicaid oly, you must ame him or her as your represetative i writig. Read Ca someoe else make the appeal for me o page 139 for more iformatio. If you eed help durig the appeals process, you ca call the MyCare Ohio Ombudsma at (TTY Ohio Relay Service: ). The MyCare Ohio Ombudsma is ot coected with us or with ay isurace compay or health pla. What is a Level 1 Appeal? 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. How do I make a Level 1 Appeal? o To start your appeal, you, your authorized represetative, or your doctor or other provider must cotact us. You ca call us at (TTY: 711) or write to us at the followig address: Aeta Better Health of Ohio Att: Member Services Departmet 7400 West Campus Road Mail Code: F494 New Albay, OH At a glace: How to make a Level 1 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. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 138

141 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) If you decide to write to us, you ca draft your ow letter or you ca use the appeal/complait form o page 178. Be sure to iclude your first ad last ame, the umber from the frot of your Aeta Better Health of Ohio Member ID Card, ad your address ad telephoe umber. You should also iclude ay iformatio that helps explai your problem. o For additioal details o how to reach us for appeals, see Chapter 2. o You ca ask us for a stadard appeal or a fast 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 else 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 or our website at We will also accept a letter or other appropriate form to authorize your represetative. If the appeal comes from someoe besides you or your doctor or other provider that requested the service, we must get your writte authorizatio before we ca review the appeal. For services covered by Medicaid oly, if you wat your doctor, other provider, or ayoe else to act o your behalf, we must get your writte authorizatio. How much time do I have to make a appeal? You must ask for a appeal withi 60 caledar days after the date o the letter 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 your appeal. Examples of a good reaso are: you had a serious illess, 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 Level 1 appeals o page 141 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). If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 139

142 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Ca my doctor give you more iformatio about my appeal? Yes, you ad your doctor 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. 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 10 caledar days after we get your appeal. We will give you our decisio sooer if your health coditio requires us to. However, if you or your provider asks for more time or if we eed to gather more iformatio, we may take up to 14 more caledar days. If we 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 170. If we do ot give you a aswer to your appeal withi 10 caledar days or by the ed of the extra days (if we took them), we will automatically sed your case to Level 2 of the appeals process if your problem is about coverage of a Medicare service or item (see Sectio 5.4 o page 142). You will be otified whe this happes. If your problem is about coverage of a Medicaid service or item, you ca ask for a State Hearig (see Sectio 5.4 o page 142). You ca also file a complait about our failure to make a appeal decisio withi the required timeframe (see Sectio 10 o page 170). If our aswer is Yes to part or all of what you asked for, we must approve the service withi 15 caledar days 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 Level 2 Appeal (see Sectio 5.4 o page 142). If your problem is about coverage of a Medicaid service or item, the letter will tell you that you ca also request a State Hearig (see Sectio 5.4 o page 142). If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 140

143 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Whe will I hear about a fast appeal decisio? If you ask for a fast appeal, we will give you your aswer withi 48 hours after we get all iformatio eeded to decide your appeal. We will give you our aswer sooer if your health requires us to do so. However, if you or your provider asks for more time or if we eed to gather more iformatio, we may take up to 14 more caledar days. If we 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 170. If we do ot give you a aswer to your appeal withi 48 hours or by the ed of the extra days (if we took them), we will automatically sed your case to Level 2 of the appeals process if your problem is about coverage of a Medicare service or item (see Sectio 5.4 o page 142). You will be otified whe this happes. If your problem is about coverage of a Medicaid service or item, you ca ask for a State Hearig (see Sectio 5.4 o page 142). You ca also file a complait about our failure to make a appeal decisio withi the required timeframe (see Sectio 10 o page 170). If our aswer is Yes to part or all of what you asked for, we must authorize 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 Level 2 Appeal (see Sectio 5.4 o page 142). If your problem is about coverage of a Medicaid service or item, the letter will tell you that you ca also request a State Hearig (see Sectio 5.4 o page 142). Will my beefits cotiue durig Level 1 appeals? Yes, if you meet certai requiremets. If we previously approved coverage for a service but the decided to chage or stop the service before the authorizatio period expired, we will sed you a otice at least 15 days i advace of takig the actio. You, your authorized represetative, or your doctor or other provider must ask for a appeal o or before the later of the followig to cotiue the service durig the appeal: Withi 15 caledar days of the mailig date of our otice of actio; or The iteded effective date of the actio. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 141

144 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) If your beefits are cotiued, you ca keep gettig the service util oe of the followig happes: 1) you withdraw the appeal; or 2) 15 caledar days pass after we otify you that we said No to your appeal. NOTE: Sometimes your beefits may cotiue eve if we say No to your appeal. If the service is covered by Medicaid ad you ask for a State Hearig, you may be able to cotiue your beefits util the Bureau of State Hearigs makes a decisio. If the service is covered by both Medicare ad Medicaid, your beefits will cotiue durig the Level 2 appeal process. For more iformatio, see Sectio 5.4 o page 142. Sectio 5.4: Level 2 Appeal for services, items, ad drugs (ot Part D drugs) If the pla says No at Level 1, what happes ext? If we say No to part or all of your Level 1 Appeal, we will sed you a letter. This letter will tell you if the service or item is primarily covered by Medicare ad/or Medicaid. If your problem is about a Medicaid service or item, the letter will tell you that you may ask for a State Hearig. See page 143 of this sectio for iformatio o State Hearigs. If your problem is about a Medicare service or item, you will automatically get a Level 2 Appeal with the Idepedet Review Etity (IRE) as soo as the Level 1 Appeal is complete. If your problem is about a service or item that could be primarily covered by both Medicare ad Medicaid, you will automatically get a Level 2 Appeal with the IRE. The letter will tell you that you may also ask for a State Hearig. See page 143 of this sectio for iformatio o State Hearigs. What is a Level 2 Appeal? A Level 2 Appeal is the secod appeal regardig a service or item. The Level 2 Appeal is reviewed by a idepedet orgaizatio that is ot coected to the pla. My problem is about a Medicaid service or item. How ca I make a Level 2 Appeal? If we say No to your Appeal at Level 1 ad the service or item is usually covered by Medicaid, you may ask for a State Hearig. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 142

145 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) What is a State Hearig? A State Hearig is a meetig with you or your authorized represetative, our pla, ad a hearig offcer from the Bureau of State Hearigs withi the Ohio Departmet of Job ad Family Services (ODJFS). You will explai why you thik our pla did ot make the right decisio ad we will explai why we made our decisio. The hearig offcer will liste ad the decide who is right based o the iformatio give ad the rules. We will sed you a otice i writig of your right to request a State Hearig. If you are o the MyCare Ohio Waiver, you may have other State Hearig rights. Please refer to your Home & Commuity-Based Services Waiver Member Hadbook for more iformatio about your rights. How do I ask for a State Hearig? To ask for a State Hearig, you or your authorized represetative must cotact the Bureau of State Hearigs withi 120 caledar days of the date that we set the otice of your State Hearig rights. The 120 caledar days begis o the day after the mailig date o the otice. If you miss the 120 caledar day deadlie ad have a good reaso for missig it, the Bureau of State Hearigs may give you more time to request a hearig. Remember, you have to ask for a Level 1 Appeal before you ca ask for a State Hearig. NOTE: If you wat someoe to act o your behalf, icludig your doctor or other provider, you must give the Bureau of State Hearigs writte otice sayig that you wat that perso to be your authorized represetative. You ca sig ad sed the State Hearig form to the address or fax umber listed o the form or submit your request by to bsh@jfs.ohio.gov. You ca also call the Bureau of State Hearigs at How log does it take to get a State Hearig decisio? State Hearig decisios are usually give o later tha 70 caledar days after the Bureau of State Hearigs gets your request. However, if the Bureau of State Hearigs agrees that this timeframe could cause serious harm to your health or hurt your ability to fuctio, the decisio will be give as quickly as eeded, but o later tha 3 workig days after the Bureau of State Hearigs gets your request. My problem is about a service or item that is covered by Medicare. What will happe at the Level 2 Appeal? If we say No to your Appeal at Level 1 ad the service or item is usually covered by Medicare, you will automatically get a Level 2 Appeal from the Idepedet Review Etity (IRE). A Idepedet Review Etity (IRE) will carefully review the Level 1 decisio ad decide whether it should be chaged. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 143

146 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) You do ot eed to request the Level 2 Appeal. We will automatically sed ay deials (i whole or i part) to the IRE. You will be otified 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). How log does it take to get a IRE decisio? The IRE must give you a aswer to your Level 2 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 had fast appeal at Level 1, you will automatically have a fast appeal at Level 2. 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 Medicaid? If your problem is about a service or item that could be covered by both Medicare ad Medicaid, we will automatically sed your Level 2 Appeal to the Idepedet Review Etity. You ca also ask for a State Hearig. To ask for a State hearig, follow the istructios i this sectio o page 143. Will my beefits cotiue durig Level 2 appeals? If we decide to chage or stop coverage for a service that was previously approved, you ca ask to cotiue your beefits durig Level 2 Appeals i some cases. If your problem is about a service primarily covered by Medicaid oly, you ca ask to cotiue your beefits durig Level 2 appeals. You or your authorized represetative must ask for a State Hearig before the later of the followig to cotiue the service durig the State Hearig: o Withi 15 caledar days of the mailig date of our letter tellig you that we deied your Level 1 appeal; or o The iteded effective date of the actio. If your problem is about a service primarily covered by Medicare oly, your beefits for that service will ot cotiue durig the Level 2 appeal process with the Idepedet Review Etity (IRE). If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 144

147 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) If your problem is about a service primarily covered by both Medicare ad Medicaid, your beefits for that service will automatically cotiue durig the Level 2 appeal process with the IRE. If you also ask for a State Hearig, you ca cotiue your beefits while the hearig is pedig 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; 2) all etities that got your Level 2 Appeal (the IRE ad/or Bureau of State Hearigs) decide No to your request. How will I fid out about the decisio? If your Level 2 Appeal was a State Hearig, the Bureau of State Hearigs will sed you a writte hearig decisio i the mail. If the hearig decisio is Yes (sustaied) to all or part of what you asked for, the decisio will clearly explai what our pla must do to address the issue. If you do ot uderstad the decisio or have a questio about gettig the service or paymet beig made, cotact Member Services for assistace. If the hearig decisio is No (overruled) to part or all of what you asked for, it meas the Bureau of State Hearigs agreed with the Level 1 decisio. The State Hearig decisio will explai the Bureau of State Hearigs reasos for sayig No ad will tell you that you have the right to request a Admiistrative Appeal. If your Level 2 Appeal wet to the Idepedet Review Etity (IRE), the Idepedet Review Etity (IRE) will sed you a letter explaiig its decisio. If the IRE says Yes to part or all of what you asked for i your stadard appeal, we must authorize the medical care coverage withi 72 hours or give you the service or item withi 14 caledar days from the date we get the IRE s decisio. If you had a fast appeal, we must authorize the medical care coverage or give you the service or item withi 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 Level 1 decisio. This is called upholdig the decisio. It is also called turig dow your appeal. I appealed to both the Idepedet Review Etity ad the Bureau of State Hearigs for services covered by both Medicare ad Medicaid. What if they have differet decisios? If either the Idepedet Review Etity or the Bureau of State Hearigs decides 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 you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 145

148 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) If the decisio is No for all or part of what I asked for, ca I make aother appeal? If your Level 2 Appeal was a State Hearig, you ca appeal agai by askig for a Admiistrative Appeal. The Bureau of State Hearigs must get your request for a Admiistrative Appeal withi 15 caledar days of the date the hearig decisio was issued. If your Level 2 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 IRE will explai additioal appeal rights you may have. See Sectio 9 o page 169 for more iformatio o 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. 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. It is possible that we will pay the provider so they ca refud your paymet or the provider will agree to stop billig you for the service. 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 us to assist you with paymet you made to a provider or to pay a bill you got from a provider. It also tells how to sed us the paperwork that asks us for paymet. Chapter 7 also gives iformatio to help you avoid paymet problems i the future. 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 work with the provider to refud your paymet. 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 you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 146

149 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) 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 138. 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 to be paid back for a service or item you already got ad paid for yourself, you caot ask for a fast appeal. 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 If the IRE reverses our decisio ad says we should make paymet, we must sed the paymet to the provider withi 30 caledar days. If the aswer to your appeal is Yes at ay stage of the appeals process after Level 2, we must sed the paymet to the provider withi 60 caledar days. o 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 169 for more iformatio o additioal levels of appeal. If we aswer No to your appeal ad the service or item is usually covered by Medicaid, you ca request a State Hearig (see Sectio 5.4 o page 142). Sectio 6: Part D drugs Sectio 6.1: What to do if you have problems gettig a Part D drug or you wat your paymet refuded 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 Medicaid may cover. This sectio oly applies to Part D drug appeals. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 147

150 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) 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 133. 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. Remember, you should ot have to pay for ay medically ecessary services covered by Medicare ad Medicaid. If you are beig asked to pay for the full cost of a drug, call Member Services for assistace. The legal term for a coverage decisio about your Part D drugs is coverage determiatio. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 148

151 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) 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. 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 get your moey 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.) Start with Sectio 6.2 o page 150. Also see Sectios 6.3 ad 6.4 o page 151. You ca ask us for a coverage decisio. Skip ahead to Sectio 6.4 o page 151. You ca ask to have your moey refuded. (This is a type of coverage decisio.) Skip ahead to Sectio 6.4 o page 151. You ca make a appeal. (This meas you are askig us to recosider.) Skip ahead to Sectio 6.5 o page 154. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 149

152 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) 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). 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. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 150

153 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) 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 154 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. 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 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 2 o page 128 to fid out how to give permissio to someoe else to act as your represetative. 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 have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 151

154 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) 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 paid for a drug that you thik should be covered, read Chapter 7 of this hadbook. Chapter 7 tells how to call Member Services or sed us the paperwork that asks us to cover the drug. 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. 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 170. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 152

155 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) 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. 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 you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 153

156 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) If our aswer is Yes to part or all of what you asked for, we will make paymet to the pharmacy withi 14 caledar days. The pharmacy will refud your moey. 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. 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 your 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 you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 154

157 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) 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 151. 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 appeal. If our aswer is Yes to part or all of what you asked for, we must give 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 that explais why we said No. 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 appeal. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 155

158 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) 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 cover a drug you already paid for, we will pay the pharmacy withi 30 caledar days after we get your appeal request. The pharmacy will refud your moey. 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. Sectio 6.6: Level 2 Appeal for Part D drugs 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. 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. 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 automatically 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. 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. The legal term for a appeal to the IRE about a Part D drug is recosideratio. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 156

159 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) 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. 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 cover a drug you already paid for, we will pay the pharmacy withi 30 caledar days after we get the decisio. The pharmacy will refud your moey. 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 with the decisio of your Level 2 appeal will tell you the dollar value eeded to cotiue with the appeal process. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 157

160 Aeta Better Health of Ohio 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), 24 hours a day, 7 days a week. You ca also call MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call The call is free. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 158

161 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) You ca also see the otice olie at Medicare-Geeral-Iformatio/BNI/HospitalDischargeAppealNotices.html. If you eed help, please call Member Services or Medicare at the umbers listed above. 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 Ohio, the Quality Improvemet Orgaizatio is called KEPRO. To make a appeal to chage your discharge date, call KEPRO at: 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 162. 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 MyCare Ohio Ombudsma at (TTY Ohio Relay Service: ). If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 159

162 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) 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 the federal govermet to check o ad help improve the quality of care for people with Medicare. 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. The legal term for this writte explaatio is called the Detailed Notice of Discharge. You ca get a sample by callig Member Services at , Optio 1 (TTY: 711). 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 Medicare-Geeral-Iformatio/BNI/HospitalDischargeAppealNotices.html 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. 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. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 160

163 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) 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. 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 Ohio, the Quality Improvemet Orgaizatio is called KEPRO. You ca reach KEPRO at: 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. 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. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 161

164 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) What happes if the aswer is Yes? 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. Sectio 7.4: What happes if I miss a appeal deadlie? 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. 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. 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. 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. 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 you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 162

165 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) 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. 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 170 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. 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. Reviewers at the IRE will take a careful look at all of the iformatio related to your appeal of your hospital discharge. 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 of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 163

166 Aeta Better Health of Ohio 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 Medicare 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 whe they are covered by Medicare: 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 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 the cost for your care. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 164

167 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) 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. 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 170 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), 24 hours a day, 7 days a week. Or call the MyCare Ohio Ombudsma at (TTY Ohio Relay Service: ). Durig a Level 1 Appeal, a Quality Improvemet Orgaizatio will review your appeal ad decide whether to chage the decisio we made. I Ohio, the Quality Improvemet Orgaizatio is called KEPRO. You ca reach KEPRO at: 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 the federal govermet 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 have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 165

168 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) 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 168. 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. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 166

169 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) 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. 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 Ohio, the Quality Improvemet Orgaizatio is called KEPRO. You ca reach KEPRO at: 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. 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. 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? 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. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 167

170 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Sectio 8.4: What if you miss the deadlie for makig your Level 1 Appeal? 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. 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 fast review or fast appeal is expedited appeal. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 168

171 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) 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 170 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. At a glace: How to make a Level 2 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. 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. Sectio 9: Takig your appeal beyod Level 2 Sectio 9.1: Next steps for Medicare services ad items If you made a Level 1 Appeal ad a Level 2 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. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 169

172 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) 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 MyCare Ohio Ombudsma. The phoe umber is (TTY Ohio Relay Service: ). Sectio 9.2: Next steps for Medicaid services ad items If you had a State Hearig for services covered by Medicaid ad your State Hearig decisio was overruled (ot i your favor), you also have the right to additioal appeals. The State Hearig decisio otice will explai how to request a Admiistrative Appeal by submittig your request to the Bureau of State Hearigs. The Bureau of State Hearigs must get your request withi 15 caledar days of the date the hearig decisio was issued. If you disagree with the Admiistrative Appeal decisio, you have the right to appeal to the court of commo pleas i the couty where you live. If you have ay questios or eed assistace with State Hearigs or Admiistrative Appeals, you ca cotact the Bureau of State Hearigs at 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, receivig a bill, 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. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 170

173 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) Complaits about poor customer service A health care provider or staff was rude or disrespectful to you. Aeta Better Health of Ohio staff treated you poorly. You thik you are beig pushed out of the pla. 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. 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 173. If you eed help makig a iteral ad/or exteral complait, you ca call the MyCare Ohio Ombudsma at (TTY Ohio Relay Service: ). 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. Complaits about receivig a bill Your doctor or provider set you a bill. 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. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 171

174 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) 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 the provider for certai medical services so they ca refud your moey. 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 MyCare Ohio Ombudsma at (TTY Ohio Relay Service: ). Sectio 10.1: Iteral complaits To make a iteral complait, call Member Services at (TTY: 711). Complaits related to Part D must be made withi 60 caledar days after you had the problem you wat to complai about. All other complaits ca be made at ay time 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. You ca also use the form o page 175 to submit the complait. 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 have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 172

175 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) 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 complaits about access to care withi 2 busiess days. We aswer all other 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. 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. If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 173

176 Aeta Better Health of Ohio MEMBER HANDBOOK Chapter 9: What to do if you have a problem or complait (coverage decisios, appeals, complaits) You ca tell Medicaid about your complait You ca call the Ohio Medicaid Hotlie at or TTY The call is free. You ca also your complait to bmhc@medicaid.ohio.gov. 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: Offce for Civil Rights Uited States Departmet of Health ad Huma Services 233 N. Michiga Ave., Suite 240 Chicago, Illiois You may also have rights uder the Americas with Disability Act. You ca cotact Member Services at (TTY: 711) or the Ohio Medicaid Hotlie at (TTY: ) for assistace. 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 Ohio, the Quality Improvemet Orgaizatio is called KEPRO. The phoe umber for KEPRO is If you have questios, please call Aeta Better Health of Ohio at , Optio 1 (TTY: 711), 24 hours a day, 7 days a week. If you eed to speak to your care maager, please call , Optio 5 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more iformatio, visit 174

177 Aeta Better Health of Ohio 7400 West Campus Road New Albay, OH Submit a Grievace To submit a grievace i writig sed us a letter tellig us the details of your complait or you may complete this form. Sed your writte request or this form by mail or fax: Address: Aeta Better Health of Ohio Grievace System Maager 7400 West Campus Road New Albay, OH Fax Number: You may also submit a grievace through our website at Grievace requests ca also be made by phoe at (TTY: 711) 24 hours a day, 7 days a week. Who May Make a Request: You, or your authorized represetative ca submit a grievace. A authorized represetative is someoe you appoit to act o your behalf, such as a fried or family member. Cotact us to lear how to ame a represetative. Erollee s Iformatio Erollee s Name Date of Birth Erollee s Address City State Zip Code Phoe Erollee s Pla ID Number Complete the followig sectio ONLY if the perso makig this request is ot the erollee: Requestor s Name Requestor s Relatioship to Erollee OH H7172_17_070 APPROVED 175

178 Aeta Better Health of Ohio 7400 West Campus Road New Albay, OH Address City State Zip Code Phoe Represetatio documetatio for grievace requests made by someoe other tha erollee (if applicable see above uder Who May Make a Request): Attach the Authorizatio of Represetatio Form CMS-1696, or writte equivalet. This documetatio shows you have the right to represet the member. If you have submitted this form withi the past year it does ot eed to be submitted agai. For more iformatio o appoitig a represetative, cotact your pla at (TTY: 711) 24 hours a day, 7 days aweek, or MEDICARE for Medicare issues. Grievace Details Date Grievace happeed Grievace Descriptio: OH H7172_17_070 APPROVED 176

179 Aeta Better Health of Ohio 7400 West Campus Road New Albay, OH Importat Note: Fast Decisios, also called Expedited Decisios You have to right to a expedited grievace decisio If you asked for a fast decisio o a service or appeal ad we decided to process it uder our regular (o-expedited) time frame. If you have a supportig statemet from your doctor, attach it to this request. If we took a extesio to decide o your request for a service or a appeal. CHECK THIS BOX IF YOU ARE REQUESTING AN EXPEDITED GRIEVANCE DECISION WITHIN 24 HOURS Sigature of perso requestig the grievace: Date: Aeta Better Health of Ohio is a health pla that cotracts with both Medicare ad Ohio Medicaid to provide beefits of both programs to erollees. Limitatios ad restrictios may apply. For more iformatio, call Aeta Better Health of Ohio Member Services or read the Aeta Better Health of Ohio Member Hadbook. Beefits may chage o Jauary 1 of each year. 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. You ca get this iformatio for free i other laguages. Call , TTY 711, 24 hours a day, 7 days a week. The call is free. Puede obteer esta iformació e otros idiomas de maera gratuita. Llame al y TTY al 711, 24 horas al día, siete días de la semaa. Esta llamada es gratuita. Waxaad macluumaadkaa oo lacag la'aa ah ku heli kartaa luqado kale. Wac (TTY: 711) 24 saac maalitii, 7 maali halkii todobaad. Wicidda waa lacag la'aa. OH H7172_17_070 APPROVED 177

180 Aeta Better Health of Ohio 7400 West Campus Road New Albay, OH Request for Appeal You have the right to ask us for a appeal whe Aeta Better Health of Ohio deies your request for coverage of, or paymet for, a item or service. To request a appeal, you have 60 days from the date of the postmark o the writte otice of a decisio that was set to you. You may fill out this form or make your request i writig with the details of what you are appealig ad why. Sed your writte request, or this form by mail or fax: Address: Aeta Better Health of Ohio Grievace System Maager 7400 West Campus Road New Albay, OH Fax Number: You may also ask us for a appeal through our website at Appeal requests ca also be made by phoe at (TTY: 711) 24 hours a day, 7 days a week. Who May Make a Request: You, or aother idividual (such as a family member or fried) that you wat to act for you ca request a appeal. If the appeal comes from someoe besides you, your primary care practitioer, or the doctor that requested the service, we must receive your writte permissio before we ca review the appeal. If you wat someoe to act for you they must be your represetative. Cotact us to lear how to ame a represetative. OH H7172_17_071 APPROVED 178

181 Aeta Better Health of Ohio 7400 West Campus Road New Albay, OH Erollee s Iformatio Erollee s Name Date of Birth Erollee s Address City State Zip Code Phoe Erollee s Pla ID Number Complete the followig sectio ONLY if the perso makig this request is ot the erollee: Requestor s Name Requestor s Relatioship to Erollee Address City State Zip Code Phoe Represetatio documetatio for appeal requests made by someoe other tha erollee (if applicable see above uder Who May Make a Request): Attach the Authorizatio of Represetatio Form CMS-1696, or writte equivalet if it was ot submitted at the coverage determiatio level. This documetatio shows you have the right to represet the member. For more iformatio o appoitig a represetative cotact your pla at (TTY: 711) 24 hours a day, 7 days a week, or MEDICARE for Medicare covered items or services. OH H7172_17_071 APPROVED 179

182 Aeta Better Health of Ohio 7400 West Campus Road New Albay, OH Item or service beig appealed Descriptio: Date of the otice of deial you received Did you receive the item pedig appeal? Yes No If Yes : Date of service: Amout paid: $ (attach copy of receipt) Importat Note: Fast Decisios, also called Expedited Decisios If you or your doctor believe that waitig 7 caledar days for Part D (drug) or 15 caledar days for all other stadard decisios could seriously harm your life or health, you ca ask for a expedited (fast) decisio. If your doctor idicates that waitig the timeframe for a stadard decisio could seriously harm your life or health, we will automatically give you a fast decisio withi 72 hours. If you do ot obtai your prescriber's support for a expedited appeal, we will decide if your case requires a fast decisio. You caot request a expedited appeal if you are askig for a appeal for medical care or a item you already received. CHECK THIS BOX IF YOU BELIEVE YOU NEED AN EXPEDITED APPEAL DECISION WITHIN 72 HOURS If you have a supportig statemet from your doctor, attach it to this request. Please explai your reasos for appealig. Attach additioal pages, if ecessary. Attach ay additioal iformatio you believe may help your case, such as a statemet from your doctor ad relevat medical records. You may wat to refer to the explaatio we provided i the deial otice. OH H7172_17_071 APPROVED 180

183 Aeta Better Health of Ohio 7400 West Campus Road New Albay, OH Sigature of perso requestig the appeal: Date: Aeta Better Health of Ohio is a health pla that cotracts with both Medicare ad Ohio Medicaid to provide beefits of both programs to erollees. Limitatios ad restrictios may apply. For more iformatio, call Aeta Better Health of Ohio Member Services or read the Aeta Better Health of Ohio Member Hadbook. Beefits may chage o Jauary 1 of each year. 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. You ca get this iformatio for free i other laguages. Call , TTY 711, 24 hours a day, 7 days a week. The call is free. Puede obteer esta iformació e otros idiomas de maera gratuita. Llame al y TTY al 711, 24 horas al día, siete días de la semaa. Esta llamada es gratuita. Waxaad macluumaadkaa oo lacag la'aa ah ku heli kartaa luqado kale. Wac (TTY: 711) 24 saac maalitii, 7 maali halkii todobaad. Wicidda waa lacag la'aa. OH H7172_17_071 APPROVED 181