3. ENROLLMENT AND ASSIGNMENT. A. IEHP Service Area APPLIES TO:

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1 A. IEHP Service Area APPLIES TO: A. This policy applies to all IEHP DualChoice Cal MediConnect Plan (Medicare Medicaid Plan) Members. POLICY: A. IEHP provides health care coverage to eligible Members in those areas of San Bernardino and Riverside Counties for which it is licensed as an HMO. PROCEDURES: A. Geographic Service Area IEHP is licensed to serve eligible Members in the zip codes within Riverside and San Bernardino Counties listed below: 1. Riverside County Zip Codes Mira Loma Indio Indio Indio Indian Wells Palm Desert Banning Beaumont Cabazon Cathedral City Cathedral City Coachella Desert Hot Springs Desert Hot Springs La Quinta La Quinta La Quinta Mecca Palm Desert North Palm Springs Palm Desert Palm Desert Palm Desert Palm Desert Palm Desert Rancho Mirage Thermal Thousand Palms White Water Palm Springs Calimesa Riverside IEHP Provider Policy and Procedure Manual 01/18 MA_03A Medicare DualChoice Page 1 of 5

2 A. IEHP Service Area Riverside Riverside Riverside Riverside Riverside Riverside Riverside Riverside Riverside Riverside Riverside Riverside Riverside Riverside Riverside Riverside Riverside Lake Elsinore Lake Elsinore Lake Elsinore Aguanga Anza Hemet Hemet Hemet Hemet Homeland Idyllwild Moreno Valley Moreno Valley Moreno Valley Moreno Valley Moreno Valley Moreno Valley Moreno Valley Mountain Center Murrieta Murrieta Murrieta Nuevo Perris Perris Perris San Jacinto San Jacinto San Jacinto Menifee Sun City Sun City Sun City Temecula Temecula Temecula Temecula Temecula Wildomar Winchester Perris Norco Corona IEHP Provider Policy and Procedure Manual 01/18 MA_03A Medicare DualChoice Page 2 of 5

3 A. IEHP Service Area Corona Corona Corona Corona Corona Corona 2. San Bernardino County Zip Codes Rancho Cucamonga Chino Chino Hills Chino Rancho Cucamonga Rancho Cucamonga Rancho Cucamonga Rancho Cucamonga Guasti Ontario Mt. Baldy Ontario Ontario Montclair Ontario Chino Upland Upland Upland Ontario Joshua Tree Morongo Valley Pioneertown Twentynine Palms Twentynine Palms Yucca Valley Landers Yucca Valley Adelanto Amboy Angelus Oaks Apple Valley Apple Valley Baker Fort Irwin Barstow Barstow Grand Terrace Big Bear City Big Bear City Bloomington Blue Jay Bryn Mawr Cedar Glen Cedarpines Park Colton Crestline Crest Park IEHP Provider Policy and Procedure Manual 01/18 MA_03A Medicare DualChoice Page 3 of 5

4 A. IEHP Service Area Daggett Phelan Fontana Fawnskin Fontana Fontana Fontana Fontana Ludlow Forest Falls Hesperia Green Valley Lake Helendale Hesperia Hesperia Highland Hinkley Loma Linda Lake Arrowhead Loma Linda Lucerne Valley Loma Linda Lytle Creek Mentone Newberry Springs Oro Grande Patton Phelan Pinon Hills Redlands Redlands Redlands Rialto Rialto Rimforest Running Springs Skyforest Sugarloaf Twin Peaks Victorville Victorville Victorville Victorville Wrightwood Yermo Yucaipa San Bernardino San Bernardino San Bernardino San Bernardino San Bernardino San Bernardino San Bernardino San Bernardino San Bernardino San Bernardino San Bernardino San Bernardino San Bernardino San Bernardino IEHP Provider Policy and Procedure Manual 01/18 MA_03A Medicare DualChoice Page 4 of 5

5 A. IEHP Service Area San Bernardino San Bernardino San Bernardino B. Exclusions San Bernardino San Bernardino The following listed zip codes are comprised of remote rural and/or mountainous areas where IEHP is not licensed to provide health care service(s) in these areas. 1. Riverside County Excluded Zip Codes Blythe Blythe Desert Center/Eagle Mountain 2. San Bernardino County Excluded Zip Codes Big River/Earp Nipton/Baker Parker Dam Mountain Pass Vidal/Blythe Red Mountain Cima Trona/Argus Essex Trona Needles C. To be eligible to enroll in IEHP Programs, Members must reside within the covered zip codes for Riverside or San Bernardino Counties. INLAND EMPIRE HEALTH PLAN Chief Approval: Signature on file Original Effective Date: July 1, 2013 Chief Title: Chief Network Officer Revision Date: January 1, 2017 IEHP Provider Policy and Procedure Manual 01/18 MA_03A Medicare DualChoice Page 5 of 5

6 B Primary Care Physician (PCP) Assignment APPLIES TO: A. This policy applies to all IEHP DualChoice Cal MediConnect Plan (Medicare MedicaidPlan) Members. POLICY: A. IEHP DualChoice Cal MediConnect Plan (Medicare Medicaid Plan) Members will have the opportunity to select their PCP upon enrolling with IEHP. If they do not select a PCP, they will be auto assigned a PCP. B. Each Member has the right to choose any PCP who has a panel that is open to Member assignment and is contracted to provide services for IEHP DualChoice Cal MediConnect Plan (Medicare Medicaid Plan) Members. C. In rural areas where PCP coverage is limited, Members may be assigned to a Nurse Practitioner (NP). NP in a rural area approved to act as a PCP. PCP selection is based on Member choice, family relationships or random assignment utilizing an auto-assignment algorithm. 1 EHP will also use FFS data to assign based on established relationship. D. IEHP allows Members to select a specialist as their PCP as long as the specialist agrees to abide by PCP requirements. E. A Member may request to transfer to another PCP by calling an IEHP Member Services Representative (MSR) at IEHP (4347) or online via the IEHP Member web portal, in accordance to Policy 17A1, Primary Care Physician (PCP) Transfers - Voluntary. F. IEHP allows Members with an established relationship with their in-network Provider to remain with this Provider to avoid care disruption. G. IEHP allows the choice of traditional and safety-net Providers for Member s PCP selection and has procedures in place for proportionate assignment. PROCEDURES: A. IEHP receives eligibility and enrollment data files directly from the Centers for Medicare and Medicaid Services (CMS) containing enrollments, disenrollments and updated IEHP DualChoice Cal MediConnect Plan (Medicare Medicaid Plan) Member information. B. IEHP processes this information and assigns a PCP to each Member based on the following: 1. Health Care Options (HCO) IEHP receives a weekly HCO file from the state which includes the PCP that is chosen by the Member. If a Member does not IEHP Provider Policy and Procedure Manual 01/18 MA_03B Medicare DualChoice Page 1 of 2

7 B Primary Care Physician (PCP) Assignment make a PCP or Medical Group selection during the enrollment process, but the Member was previously associated with IEHP and assigned to a currently active IEHP Medicare contracted PCP, IEHP will continue the assignment. 2. Member Choice/IEHP Contact IEHP assigns Members to those PCPs that they have requested through contact with an IEHP representative. 3. FFS Utilization Data - IEHP assigns Members to those PCPs who are currently active IEHP DualChoice contracted PCPs. 4. Auto Assignment - Members who have not been assigned a PCP through either of the above processes are assigned a PCP using the IEHP Auto Assignment Process. The Auto Assignment process is a computer generated program that assigns Members to PCPs by comparing PCP and member demographics: residence/geography a. age b. gender c. language d. enrollment limits C. Members are allowed to change PCPs each month. IEHP Members can call IEHP Member Services to facilitate a PCP change. See Section 17, Member Transfers and Disenrollment for more information. INLAND EMPIRE HEALTH PLAN Chief Approval: Signature on file Original Effective Date: July 1, 2013 Chief Title: Chief Network Officer Revision Date: January 1, 2017 IEHP Provider Policy and Procedure Manual 01/18 MA_03B Medicare DualChoice Page 2 of 2

8 C. Member Identification Cards APPLIES TO: A. This policy applies to all IEHP DualChoice Cal MediConnect Plan (Medicare Medicaid Plan) Members. POLICY: A. All Members will be mailed an IEHP Identification Card or Evidence of Coverage document, no later than the Member s effective date of IEHP DualChoice Cal MediConnect Plan (Medicare Medicaid Plan) coverage. When an enrollment request is received less than ten (10) days from the end of the month, and the beneficiary is effective the 1 st of the next month, ID cards will be sent within ten (10) calendar days after the receipt of Centers for Medicare and Medicaid Services (CMS) Confirmation of enrollment. PROCEDURES: A. IEHP ID Card: 1. Each Member will be mailed an IEHP Identification (ID) Card no later than the Member s effective date of IEHP DualChoice Cal MediConnect Plan (Medicare Medicaid Plan) coverage. The card contains the PCP name, office telephone number, after hours telephone number, and general co-payment information (See Attachment, IEHP ID Card Cal MediConnect in Section 3). 2. If IEHP is unable to mail the Member Card prior to the effective date, it will be mailed within ten (10) calendar days of receiving the CMS confirmation of enrollment. An evidence of insurance coverage document will be provided to the Member within thirty (30) calendar days of receiving the completed enrollment request so that he/she may begin using services as of the effective date. a. Voluntary Enrollment IEHP will mail the ID Card no later than ten (10) calendar days from receipt of CMS confirmation of enrollment or by the last calendar day of the month prior to the effective date, whichever occurs later. b. Passive Enrollment IEHP will mail the ID Card to the Member no later than by the last calendar day of the month prior to the effective date. 3. Temporary IEHP ID Card: a. A temporary IEHP ID Card is available for Providers to print through the IEHP website at b. Temporary ID Cards are printed with an expiration date of the last day of the current month. IEHP Provider Policy and Procedure Manual 01/18 MA_03C Medicare DualChoice Page 1 of 2

9 C. Member Identification Cards c. The IEHP ID card does not guarantee eligibility; therefore it is important that Providers verify eligibility as outlined in Policy MA_4A, Eligibility Verification. d. Members are able to access the temporary ID card via the secure Member Portal at If the Member presents the temporary ID card via a mobile device such as a tablet or phone, IEHP requests that the temporary ID card viewed through the mobile device be acknowledged as valid in compliance with the specifications listed above. B. Evidence of Coverage: 1. IEHP is required to provide the Member with a form of evidence of coverage within ten (10) calendar days of the completed enrollment. The Provider should verify the eligibility as outlined in Policy 4B, Eligibility Verification Methods. C. Medicare Card: 1. In addition to the IEHP ID Card, Medicare Members continue to receive their Medicare card issued by the Social Security Administration. The Medicare card only contains beneficiary identification information and does not guarantee eligibility. D. Medi-Cal BIC Card: 1. In addition to the IEHP ID Card, Dual Eligible Special Needs Plan Medi-Cal eligible Members will continue to receive a Benefit Identification Card (BIC) from the State. The BIC only contains beneficiary identification information and does not guarantee eligibility (See Attachment, BIC Card in Section 3). E. Providers are encouraged to verify Member s identification through a secondary means, such as a Driver License or state identification card with both a picture and signature, when presented with an IEHP ID Card. This should be used as a precautionary measure to protect against fraud and abuse of the Member s ID card. INLAND EMPIRE HEALTH PLAN Chief Approval: Signature on file Original Effective Date: July 1, 2013 Chief Title: Chief Network Officer Revision Date: January 1, 2017 IEHP Provider Policy and Procedure Manual 01/18 MA_03C Medicare DualChoice Page 2 of 2

10 D. Identifying IPA and Hospital Affiliation APPLIES TO: A. This policy applies to all IEHP DualChoice Cal MediConnect Plan (Medicare Medicaid Plan) Members. POLICY: A. In order for Providers to easily recognize a Member s PCP, IPA and Hospital affiliation, IEHP has developed unique IEHP assigned PCP numbers. PROCEDURES: A. A PCP s IPA and Hospital affiliation is identified by a nine (9) character number assigned to that PCP by IEHP. B. Each character in the PCP s assigned identification number is coded to represent the following: characters identifies the IPA that the PCP is affiliated with; characters identify the assigned Hospital that the PCP is affiliated with; characters are unique to the PCP. C. If a PCP has two (2) different IPA affiliations or two (2) Hospital affiliations, the last four (4) characters of the PCP s assigned identification number are identical per location. D. It is very important for all Providers to train contracted PCPs and staff so they understand this coding mechanism to ensure referrals are made for the right Member to the correct Hospital. E. Attachment, Contracted IEHP Providers in Section 3 is a list of contracted IEHP IPAs and Hospitals with the code assigned to each. Provider staff should be aware of this system; IEHP uses these codes in correspondence with Providers. INLAND EMPIRE HEALTH PLAN Chief Approval: Signature on file Original Effective Date: July 1, 2013 Chief Title: Chief Network Officer Revision Date: January 1, 2017 IEHP Provider Policy and Procedure Manual 01/18 MA_03D Medicare DualChoice Page 1 of 1

11 E. Post Enrollment Kit APPLIES TO: A. This policy applies to all IEHP DualChoice Cal MediConnect Plan (Medicare Medicaid Plan) Members. POLICY: A. All IEHP DualChoice Members receive a Post Enrollment Kit (i.e., Welcome Kit). PROCEDURES: A. An IEHP Post Enrollment Kit is sent to all IEHP DualChoice Members upon Centers for Medicare and Medicaid Services (CMS)-California Department of Health Care Services (DHCS s) approval of their enrollment with IEHP. The table below lists the materials for the Post Enrollment Kit, based on how the Member is enrolled into the Plan. Enrollment Type/Timing of Beneficiary receipt Required Materials for New Members Choice Enrollment Passive Enrollment (as necessary) For Members who voluntarily choose to enroll into IEHP DualChoice, these materials will be provided no later than ten (10) calendar days from receipt of CMS confirmation of enrollment or by the last day of the month prior to the effective date, whichever occurs later For Members who are passively enrolled the following materials will be provided no later than twenty (20) calendar days prior to the effective date of enrollment Welcome letter Model of Care (MOC) Letter Formulary Provider & Pharmacy Directory ID Card EOC (Member handbook) Privacy Notice Welcome letter Summary of Benefits Formulary Provider & Pharmacy Directory ID Card EOC (Member Handbook) Privacy Notice B. The IEHP Post Enrollment Kit may include, but is not limited to the following materials: 1. IEHP Wellness Program information; 2. Relevant information regarding their program eligibility; 3. IEHP DualChoice Quick Guide; and IEHP Provider Policy and Procedure Manual 01/18 MA_03E Medicare DualChoice Page 1 of 2

12 E. Post Enrollment Kit 4. Nurse Advice Line brochure and magnet. INLAND EMPIRE HEALTH PLAN Chief Approval: Signature on file Original Effective Date: July 1, 2013 Chief Title: Chief Network Officer Revision Date: January 1, 2017 IEHP Provider Policy and Procedure Manual 01/18 MA_03E Medicare DualChoice Page 2 of 2

13 F. Enrollment and Eligibility APPLIES TO: A. This policy applies to all IEHP DualChoice Cal MediConnect Plan (Medicare Medicaid Plan) Members. POLICY: A. Department of Health Care Services (DHCS) Health Care Options (HCO) Unit is responsible for enrolling and disenrolling IEHP DualChoice Cal MediConnect Plan (Medicare Medicaid Plan) Members into IEHP. PROCEDURES: A. IEHP DualChoice Cal MediConnect Plan (Medicare Medicaid Plan) Members Only: 1. An IEHP DualChoice Cal MediConnect Plan (Medicare Medicaid Plan) recipient is enrolled with IEHP by calling HCO directly or if the recipient calls IEHP to enroll.. 2. HCO is the only entity that determines the enrollment and disenrollment of IEHP DualChoice Cal MediConnect Plan (Medicare Medicaid Plan) recipients under the Two-Plan model. INLAND EMPIRE HEALTH PLAN Chief Approval: Signature on file Original Effective Date: July 1, 2013 Chief Title: Chief Network Officer Revision Date: January 1, 2018 IEHP Provider Policy and Procedure Manual 01/18 MA_03F Medicare DualChoice Page 1 of 1

14 G. Eligible Members APPLIES TO: A. This policy applies to all IEHP DualChoice Cal MediConnect Plan (Medicare Medicaid Plan) Members. POLICY: A. Department of Health Care Services (DHCS) and Centers for Medicare and Medicaid Services (CMS) determine Member eligibility based on select criteria. B. DHCS determines Medi-Cal Aid Codes for IEHP DualChoice Cal MediConnect Plan (Medicare Medicaid Plan) Members. PROCEDURES: A. IEHP currently serves the following Aid Categories and Aid Codes under its IEHP DualChoice Cal MediConnect Plan (Medicare Medicaid Plan) contract with the State: Medi-Cal The following Aid Codes are covered by IEHP MEDI-CAL AID CODES Mandatory A A 3C 3E 3F Voluntary Family Adult Disabled Aged LTC Disabled/ BCCTP** Adult Family 3G 3H 3L 3M 3N 3P 3R 3U 3W A 7J 7S 7W 7X 82 8P 8R E2 E5 K1 M3 M7 P5 P7 P9 L1 M1 7U * 2E 2H * 6A 6C 6E 6G 6H 6J 6N 6P 6V 6W* 6X* 6Y* * 1E 1H 1X* 1Y* IEHP Provider Policy and Procedure Manual 01/18 MA_03G Medicare DualChoice Page 1 of N 0P 0W A 4F 4G 4H 4K 4L 4M 4N 4S 4T 4W 5K 2P 2R 2S 2T 2U 4U

15 G. Eligible Members *These Aid Codes will only be for Dual-Eligible Members. **BCCTP: Breast and Cervical Cancer Treatment Program Medicare The following Aid Codes are covered by IEHP MD MF MN MT Cal MediConnect Medicare DualChoice (Medicare Medicaid Plan) IEHP Medicare DualChoice and IEHP Medi-Cal IEHP Medicare DualChoice and Fee For Service Medi-Cal IEHP Medicare DualChoice and No Medi-Cal Opt-out/Medicare FFS Medi-Cal only with IEHP B. Under the Coordinated Care Initiative (CCI) Duals program, Medi-Cal beneficiaries may be eligible for Long Term Services and Supports (LTSS) benefits, such as: 1. Community-Based Adult Services (CBAS) eligibility to this benefit is determined by IEHP; 2. Multipurpose Senior Services Program (MSSP) eligibility to this benefit is determined by the county; 3. In-Home Supportive Services (IHSS) eligibility to this benefit is determined by the county; 4. Long Term Care (LTC)/Skilled Nursing Facility (SNF) eligibility to the benefit is determined by the county. C. Recipients assigned an Aid Code or Aid Category not listed above remain under the State s fee-for-service system and cannot select IEHP as their health plan. INLAND EMPIRE HEALTH PLAN Chief Approval: Signature on file Original Effective Date: July 1, 2013 Chief Title: Chief Network Officer Revision Date: January 1, 2017 IEHP Provider Policy and Procedure Manual 01/18 MA_03G Medicare DualChoice Page 2 of 2

16 Attachments DESCRIPTION BIC Card Contracted IEHP Providers IEHP ID Card IEHP DualChoice POLICY CROSS REFERENCE 3C 3D 3C IEHP Provider Policy and Procedure Manual 01/18 MA_03 Medicare DualChoice Page 1 of 1

17 Attachment 03 - Contracted IEHP Providers IPA NAME IPA CODE IPA NAME IPA CODE Alpha Care Medical Group 00A Alliance Desert Physicians, Inc. * 06U Dignity Health Medical Foundation 00B Chaffey Medical Group * 07U Vantage Medical Group 00C FENIX Medical Group* 08U LaSalle Medical Associates 00E Heritage Medical * 01H Inland Faculty Medical Group 00F Regal Medical Group * 02H Inland Valleys IPA * 01I Desert Oasis Healthcare * 03H IEHP Direct JJJ Heritage Victor Valley Medical Group * 04H Physicians Health Network 00N Pomona Valley Medical Group, Inc. * 01G/02G Allied Pacific IPA 01P Dignity Health Physician Network-IE * 01W Kaiser Fontana & Riverside 00X Horizon Valley Medical Group 01T PrimeCare Medical Network * 01S PrimeCare of Sun City * 02S PrimeCare Medical of Chino Valley * 03S PrimeCare of Corona * 04S PrimeCare of Inland Valley * 06S PrimeCare of San Bernardino * 07S PrimeCare of Moreno Valley * 08S PrimeCare of Riverside * 09S PrimeCare of Hemet Valley * 10S Valley Physicians Network* 11S PrimeCare of Citrus Valley * 12S PrimeCare of Redlands * 13S PrimeCare of Temecula * 14S CPN Horizon Valley Medical Group * 01Y Riverside Medical Clinic * 02R San Bernardino Medical Group * 0SB EPIC Health Plan * 01U Beaver Medical Group * 02U Redlands-Yucaipa Medical Group * 03U TriValley Medical Group * 04U Pinnacle Medical Group * 05U Revised Date: 01/01/2017 * IPAs with Medicare link Department: Provider Services

18 Attachment 03 - Contracted IEHP Providers HOSPITAL NAME HOSP CODE HOSPITAL NAME Chino Valley Medical Center 01 Network Access as Directed by Your Doctor 88 HOSP CODE Community Hospital of San Bernardino 02 Children s Hospital of Orange County 1953 Corona Regional Medical Center 03 Children s Hospital at Mission 6475 Desert Regional Medical Center 04 Bear Valley Hospital 7791 Desert Valley Hospital 05 USC Norris Cancer Hospital Hemet Valley Medical Center 06 Keck Hospital of USC John F. Kennedy Memorial Hospital 07 Loma Linda University Medical Center - Murrieta Loma Linda University Medical Center 08 Temecula Valley Hospital Menifee Valley Medical Center 09 Redlands Community Hospital 11 Riverside University Health Care System 12 San Antonio Community Hospital 13 Arrowhead Regional Medical Center 14 San Gorgonio Memorial Hospital 15 Rancho Springs Medical Center 16 St. Bernardine Medical Center 17 St. Mary Medical Center 18 Victor Valley Global Medical Center 20 Kaiser Fontana/Riverside 22 Pomona Valley Hospital Medical Center 23 Parkview Community Hospital Med. Center 24 Riverside Community Hospital 25 Montclair Hospital Medical Center 26 Barstow Community Hospital 27 Inland Valley Regional Medical Center 28 Mountains Community Hospital 29 Eisenhower Medical Center 31 Hi Desert Medical Center 32 CHSB (IEHP-Direct)/LaSalle) 33 Kaiser Foundation Hospital MVH 39 Loma Linda University Children Hospital Revised Date: 01/01/2017 * IPAs with Medicare link Department: Provider Services

19 Attachment 03 IEHP ID Card IEHP DualChoice Cal MediConnect Plan (Medicare Medicaid Plan)

20 Plastic Benefits Identification Card (BIC) Attachment 03 - BIC Card