IEHP DualChoice (HMO D-SNP) 

What is IEHP DualChoice (HMO D-SNP)?

IEHP DualChoice, a Medicare Medi-Cal Plan, allows you to get your covered Medicare and Medi-Cal benefits through our plan.  Our plan includes doctors, hospitals, pharmacies, providers of long-term services and supports, behavioral health providers, and other providers. It also has care coordinators and care teams to help you manage all your providers and services. They all work together to provide the care you need.

• You can work with us for all of your health care needs.
• You have a care team that you help put together. Your care team may include yourself, your caregiver, doctors, nurses, counselors, or other health professionals.
• You have access to a care coordinator. This is a person who works with you, with our plan, and with your care team to help make a care plan.
• Your care team and care coordinator work with you to make a care plan designed to meet your health needs. The care team helps coordinate the services you need. For example, this means that your care team makes sure:
  • Your doctors know about all the medicines you take so they can make sure you’re taking the right medicines and can reduce any side effects you may have from the medicines.
  • Your test results are shared with all of your doctors and other providers, as appropriate. 

Who is eligible for IEHP DualChoice?

IEHP DualChoice is for people with both Medicare (Part A and B) and Medi-Cal. The following information explains who qualifies for IEHP DualChoice (HMO D-SNP).

You are eligible for our plan as long as you:        

• Live in our service area (incarcerated individuals are not considered living in the geographic service area even if they are physically located in it.), and
• Are age 21 and older at the time of enrollment, and
• Have both Medicare Part A and Medicare Part B, and
• Are currently eligible for Medi-Cal, and
• Are a full-benefit dual eligible beneficiary and enroll in IEHP DualChoice for your Medicare benefits and Inland Empire Health Plan (IEHP) for your Medi-Cal benefits. This is known as “Exclusively Aligned Enrollment”, and
• Are a United States citizen or are lawfully present in the United States.

Service Area 

Only people who live in our service area can join IEHP DualChoice. Our service area includes all of Riverside and San Bernardino counties. 

How to Enroll

To enroll, please call the:

IEHP DualChoice Medicare Team at (800) 741-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays, TTY users should call (800) 718-4347

• Visit our enrollment page to learn more. 

IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. This is not a complete list. 

Information on this page is current as of October 01, 2022.
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2023 Plan Benefits and Cost Sharing

For the benefit year of 2023 here is what you’ll get and what you will pay:

Benefits

• Doctor Visit: $0
• Vision Care: $350 limit every year for contact lenses and eyeglasses (frames and lenses)
• Inpatient Hospital Care: $0
• Home Health Agency Care: $0
• Ambulance Services: $0
• Transportation: $0. Including bus pass. Call our transportation vendor Call the Car (CTC) at (866) 880-3654, for TTY users, call your relay service or California Relay Service at 711. For reservations call Monday-Friday, 7am-6pm (PST). Call at least 5 days before your appointment.
• Diagnostic Tests, X-Rays & Lab Services: $0
• Durable Medical Equipment: $0
• Home and Community Based Services (HCBS): $0
• Community Based Adult Services (CBAS): $0
• Long Term Care that includes custodial care and facility: $0
• Utilities allowance of $40 for covered utilities. You must qualify for this benefit.

You pay nothing for a one-month or long term-supply of drugs

With IEHP DualChoice, you pay nothing for covered drugs as long as you follow the plan’s rules.

• Tier 1 drugs are: generic, brand and biosimilar drugs. They have a copay of $0.

After your coverage begins with IEHP DualChoice, you must receive medical services and prescription drug services in the IEHP DualChoice network.

To learn more about the plan’s benefits, cost-sharing, applicable conditions and limitations, refer to the IEHP DualChoice Member Handbook.

• 2023 Summary of Benefits (PDF)
• 2023 Annual Notice of Changes (PDF)
• 2023 IEHP DualChoice Member Handbook (PDF)

You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Click here to download a free copy of Adobe Acrobat Reader.By clicking on this link, you will be leaving the IEHP DualChoice website. 

Plan Premium

With "Extra Help," there is no plan premium for IEHP DualChoice.

Plan Deductible

There is no deductible for IEHP DualChoice.

Because you are eligible for Medi-Cal, you qualify for and are getting “Extra Help” from Medicare to pay for your prescription drug plan costs. You do not need to do anything further to get this Extra Help. 

You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, you can contact:

• 1-800-MEDICARE (1-800-633-4227). , TTY users should call (877) 486-2048, 24 hours a day/7days a week
• The Social Security Office at (800) 772-1213 between 7 a.m. and 7 p.m., Monday through Friday, TTY users should call (800) 325-0778; or
• Your State Medicaid Office

How to get care coordination

Do you need help getting the care you need? A care team can help you. A care team may include your doctor, a care coordinator, or other health person that you choose. A care coordinator is a person who is trained to help you manage the care you need. You will get a care coordinator when you enroll in IEHP DualChoice. This person will also refer you to community resources, if IEHP DualChoice does not provide the services that you need.

To speak with a care coordinator, please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY users should call 1-800-718-4347.

Prior Authorization and Out of Network Coverage 

What kinds of medical care and other services can you get without getting approval in advance from your Primary Care Provider (PCP) in IEHP DualChoice (HMO D-SNP)? You can get services such as those listed below without getting approval in advance from your Primary Care Provider (PCP).

• Routine women’s health care, which includes breast exams, screening mammograms (X-rays of the breast), Pap tests, and pelvic exams as long as you get them from a network provider.
• Flu shots as long as you get them from a network provider.
• Emergency services from network providers or from out-of-network providers.
• Urgently needed care from in-network providers or from out-of-network providers when network providers are temporarily unavailable or inaccessible, e.g., when you are temporarily outside of the plan’s service area.
• Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area. (If possible, please call IEHP DualChoice Member Services before you leave the service area so we can help arrange for you to have maintenance dialysis while you are away.)

How to get care from specialists and other network providers

A specialist is a doctor who provides health care services for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples:

• Oncologists care for patients with cancer.
• Cardiologists care for patients with heart conditions.
• Orthopedists care for patients with certain bone, joint, or muscle conditions.

You will usually see your PCP first for most of your routine healthcare needs such as physical checkups, immunization, etc. When your PCP thinks that you need specialized treatment or supplies, your PCP will need to get prior authorization (i.e., prior approval) from your Plan and/or medical group. This is called a referral. Your PCP will send a referral to your plan or medical group. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. If you don’t have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself. PCPs are usually linked to certain hospitals and specialists. When you choose a PCP, it also determines what hospital and specialist you can use. 

What if a specialist or another network provider leaves our plan?

Sometimes a specialist, clinic, hospital or other network provider you are using might leave the plan. When a provider leaves a network, we will mail you a letter informing you about your new provider. If you prefer a different one, please call IEHP DualChoice Member Services and we can assist you in finding and selecting another provider.

How to get care from out-of-network providers

When your doctor recommends services that are not available in our network, you can receive these services by an out-of-network provider. In order to receive out-of-network services, your Primary Care Provider (PCP) or Specialist must submit a referral request to your plan or medical group. All requests for out-of-network services must be approved by your medical group prior to receiving services.

IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. This is not a complete list. 

Information on this page is current as of October 1, 2022.
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What to expect when you first join IEHP DualChoice

Look at your IEHP DualChoice Member Card to locate important phone numbers including your Doctor, IEHP DualChoice Member Services, and IEHP’s 24-Hour Nurse Advice Line.

Be sure to complete your health risk assessment (HRA).

When you first join our plan, you get a health risk assessment (HRA) within 90 days before or after your effective enrollment date. 

We must complete an HRA for you. This HRA is the basis for developing your care plan. The HRA include questions to identify your medical, LTSS, and behavioral health and functional needs. 

We reach out to you to complete the HRA. We can complete the HRA by an in-person visit, telephone call, or mail. We’ll send you more information about this HRA upon your enrollment with the plan. 

If our plan is new for you, you can keep using the doctors you use now for a certain amount of time, if they are not in our network. We call this continuity of care. If they are not in our network, you can keep your current providers and service authorizations at the time you enroll for up to 12 months if all of the following conditions are met: 

• You, your representative, or your provider asks us to let you keep using your current provider. 
• We establish that you had an existing relationship with a primary or specialty care provider, with some exceptions. When we say “existing relationship,” it means that you saw an out-of-network provider at least once for a non-emergency visit during the 12 months before the date of your initial enrollment in our plan.
  • We determine an existing relationship by reviewing your available health information available or information you give us.
  • We have 30 days to respond to your request. You can ask us to make a faster decision, and we must respond in 15 days.
  • You or your provider must show documentation of an existing relationship and agree to certain terms when you make the request.

Note: You can only make this request for services of Durable Medical Equipment (DME), transportation, or other ancillary services not included in our plan. You cannot make this request for providers of DME, transportation or other ancillary providers.

After the continuity of care period ends, you will need to use doctors and other providers in the IEHP DualChoice network that are affiliated with your primary care provider’s medical group, unless we make an agreement with your out-of-network doctor. A network provider is a provider who works with the health plan. Our plan’s PCPs are affiliated with medical groups or Independent Physicians Associations (IPA). When you choose your PCP, you are also choosing the affiliated medical group. This means that your PCP will be referring you to specialists and services that are affiliated with their medical group. A medical group or IPA is a group of physicians, specialists, and other providers of health services that see IEHP Members. Your PCP, along with the medical group or IPA, provides your medical care. This includes getting authorization to see specialists or medical services such as lab tests, x-rays, and/or hospital admittance. In some cases, IEHP is your medical group or IPA. Refer to Chapter 3 of your Member Handbook for more information on getting care.

Be prepared for important health decisions

Get the My Life. My Choice. app today. It stores all your advance care planning documents in one place online. Advance care planning (ACP) involves shared decision making to write down-in an advance care directive-a person’s wishes about their future medical care. ACP and the advance health care directive can bridge the gap between the care someone wants and the care they receive if they lose the capacity to make their own decisions. With this app, you or a designated person with Power of Attorney can access your advance health care directives at any time from a home computer or smartphone.

Sign up for the free app through our secure Member portal.

IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. This is not a complete list.

Information on this page is current as of October 01, 2022.
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IEHP DualChoice (HMO D-SNP)

IEHP DualChoice Cal MediConnect (Medicare-Medicaid Plan) is changing to IEHP DualChoice (HMO D-SNP) on January 1, 2023. Unless you change plans, IEHP DualChoice (HMO D-SNP) will provide your Medicare benefits. You will keep all of your Medicare and Medi-Cal benefits. You will not have a gap in your coverage.

You will be automatically enrolled in IEHP DualChoice and do not need to do anything to keep these services. IEHP DualChoice is very similar to your current Cal MediConnect plan. With IEHP DualChoice, you will still have an IEHP DualChoice Member Service team to get help for your needs. You won’t pay a premium, or pay for doctor visits or other medical care if you go to a provider that works with our health plan. To learn more about your prescription drug costs, call IEHP DualChoice Member Services. To ask if your PCP or other providers are in our network in 2023, call IEHP DualChoice Member Services.

Click here to learn more about IEHP DualChoice.

What services will my Medicare Medi-Cal Plan cover?

IEHP DualChoice will cover many of the Medicare and Medi-Cal benefits you get now, including:

• All Medicare covered services, doctors, hospitals, labs, and x-rays
• You will have access to a Provider network that includes many of the same Providers as your current plan
• Prescription drugs covered by Medicare
• Coordination of the services you get now or that you might need
• Transportation to medical services
• Medical supplies
• Durable Medical Equipment (DME)
• Nursing home care
• Community-Based Adult Services (CBAS)

You will have access to a Provider network that includes many of the same Providers as your current plan. You will not have a gap in your coverage. You will be automatically enrolled in a Medicare Medi-Cal Plan offered by IEHP DualChoice. You don’t have to do anything if you want to join this plan. If you want to change plans, call IEHP DualChoice Member Services. 

If you have questions, you can contact IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY: 1-800-718-4347.

National Coverage Determination

The Centers for Medicare and Medical Services (CMS) has determined the following services to be necessary for the treatment of an illness or injury. National Coverage determinations (NCDs) are made through an evidence-based process. See below for a brief description of each NCD. There may be qualifications or restrictions on the procedures below.

For more detailed information on each of the NCDs including restrictions and qualifications click on the link after each NCD or call IEHP DualChoice Member Services at (877) 273-IEHP (4347) 8am-8pm (PST), 7 days a week, including holidays, or. TTY/TDD (800) 718-4347

1. Screening for Hepatitis B Virus (HBV) Infection

(Effective: September 28, 2016) 
(Implementation date: October 2, 2017 – for design and coding; January 1, 2018 – for testing and implementation)

Per the recommendation of the United States Preventive Services Task Force (USPSTF), CMS has issued a National Coverage Determination (NCD) which expands coverage to include screening for HBV infection. Previously, HBV screening and re-screening was only covered for pregnant women. 

Hepatitis B Virus (HBV) is transmitted by exposure to bodily fluids. It attacks the liver, causing inflammation. Infected individuals may develop symptoms such as nausea, anorexia, fatigue, fever, and abdominal pain, or may be asymptomatic. An acute HBV infection could progress and lead to life-threatening complications.

The USPTF has found that screening for HBV allows for early intervention which can help decrease disease acquisition, transmission and, through treatment, improve intermediate outcomes for those infected.

What is covered?
Effective for claims with dates of service on or after 09/28/2016, CMS covers screening for HBV infection.

Who is covered?
Medicare beneficiaries who meet either of the following criteria:

• They are considered to be at high-risk for infection; or
• They are pregnant.

Click here for more information on HBV Screenings.

2. Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS)

((Effective: December 7, 2016) 
(Implementation date: June 27, 2017)

CMS has expanded the PILD for LSS National Coverage Determination (NCD) to now cover beneficiaries that are enrolled in a CMS-approved prospective longitudinal study. Previously, PILD for LSS was covered for beneficiaries enrolled only in a CMS-approved prospective, randomized, controlled clinical trial (RCT) under the Coverage with Evidence Development (CED) paradigm. Now, the NCD will cover PILD for LSS under both RCT and longitudinal studies.

LSS is a narrowing of the spinal canal in the lower back. PILD is a posterior decompression of the lumbar spine performed under indirect image guidance without any direct visualization of the surgical area. The procedure removes a portion of the lamina in order to debulk the ligamentum flavum, essentially widening the spinal canal in the affected area.

What is covered?
Effective for claims with dates of service on or after 12/07/16, Medicare will cover PILD under CED for beneficiaries with LSS when provided in an approved clinical study.

Who is covered?
Medicare beneficiaries with LSS who are participating in an approved clinical study.

Click here for more information on PILD for LSS Screenings.

3. Leadless Pacemakers  

(Effective: January 18, 2017) 
(Implementation date: August 29, 2017 – for MAC local edits; January 2, 2018 – for MCS shared edits)

CMS has issued a National Coverage Determination (NCD) which expands coverage to include leadless pacemakers when procedures are performed in CMS-approved Coverage with Evidence Development (CED) studies. 

Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. The leadless pacemaker eliminates the need for a device pocket and insertion of a pacing lead which are integral elements of traditional pacing systems. The removal of these elements eliminates an important source of complications associated with traditional pacing systems while providing similar benefits. Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. Prior to January 18, 2017, there was no national coverage determination (NCD) in effect.

What is covered?
Effective for claims with dates of service on or after 01/18/17, Medicare will cover leadless pacemakers under CED when procedures are performed in CMS-approved studies.

Who is covered?
Medicare beneficiaries in need of a pacemaker who are participating in an approved clinical study.

Click here for more information on Leadless Pacemakers.

4. Hyperbaric Oxygen (HBO) Therapy (Section C, Topical Application of Oxygen) 

(Effective: April 3, 2017) 
(Implementation date: December 18, 2017)

CMS has revised Chapter 1, Section 20.29, Subsection C Topical Application of Oxygen to remove the exclusion of this treatment.  It has been updated that coverage determinations for providing Topical Application of Oxygen for the treatment of chronic wounds can be made by the local Contractors.    

What is covered?
Topical Application of Oxygen for Chronic Wound Care.

Who is covered?
Medicare beneficiaries may be covered with an affirmative Coverage Determination.

Click here for more information on Topical Applications of Oxygen.

5. Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD)

(Effective: May 25, 2017)
(Implementation Date: July 2, 2018)

CMS has added a new section, Section 20.35, to Chapter 1 entitled Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD).  It has been concluded that high-quality research illustrates the effectiveness of SET over more invasive treatment options and beneficiaries who are suffering from Intermittent Claudication (a common symptom of PAD) are now entitled to an initial treatment.

What is covered?

Eligible beneficiaries are entitled to 36 sessions over a 12-week period after meeting with the physician responsible for PAD treatment and receiving a referral. 

The SET program must:

• Consist of 30-60 minute sessions comprising of therapeutic exercise-training program for PAD;
• Be conducted in a hospital outpatient setting or physician’s office;
• Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD; and,
• Be under the direct supervision of a physician.

Who is covered?

Medicare beneficiaries who are diagnosed with Symptomatic Peripheral Artery Disease who would benefit from this therapy.

Click here for more information on Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD).

6. Magnetic Resonance Imaging (MRI)

(Effective: April 10, 2017)
(Implementation Date: December 10, 2018)

CMS has added a new section, Section 220.2, to Chapter 1, Part 4 of the Medicare National Coverage Determinations Manual entitled Magnetic Resonance Imaging (MRI). According to the FDA labeling in an MRI environment, MRI coverage will be provided for beneficiaries under certain conditions.

What is covered?

Effective on or after April 10, 2018, MRI coverage will be provided when used in accordance to the FDA labeling in an MRI environment.

In the instance where there is not FDA labeling specific to use in an MRI environment, coverage is only provided under specific conditions including the following:

• MRI field strength of 1.5 Tesla using Normal Operating Mode
• The Implanted pacemaker (PM), implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), and cardiac resynchronization therapy defibrillator (CRT-D) system has no fractured, epicardial, or abandoned leads
• The facility has implemented a specific checklist

Who is covered?

Medicare beneficiaries with an Implanted pacemaker (PM), implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), and cardiac resynchronization therapy defibrillator (CRT-D).

Click here for more information on MRI Coverage.

7. Implantable Cardiac Defibrillators (ICDs)

(Effective: February 15, 2018)
(Implementation Date: March 26, 2019)

CMS has updated Chapter 1, Part 1, Section 20.4 of the Medicare National Coverage Determinations Manual providing additional coverage criteria for Implantable Cardiac Defibrillators (ICD) for Ventricular Tachyarrhythmias (VTs).

What is covered?

An ICD is an electronic device to diagnose and treat life threating Ventricular Tachyarrhythmias (VTs) that has demonstrated improvement in survival rates and reduced cardiac death for certain patients. The Centers of Medicare and Medicaid Services (CMS) will cover claims for effective dates of service on or after February 15, 2018.

Who is covered:

Beneficiaries who meet the coverage criteria, if determined eligible.

ICDs will be covered for the following patient indications:

• Personal history of sustained VT or cardiac arrest due to Ventricular Fibrillation (VF)
• Prior Myocardial Infarction (MI) and measured Left Ventricular Ejection Fraction (LVEF) less than or equal to .03
• Severe, ischemic, dilated cardiomyopathy without history of sustained VT or cardiac arrest due to VF, and have New York Heart Association (NYHA) Class II or III heart failure with a LVEF less than or equal to 35%
• Severe, non-ischemic, dilated cardiomyopathy without history of cardiac arrest or sustained VT, NYHA Class II or II heart failure, LVEF less than or equal for 35%, and utilization of optimal medical therapy for at a minimum of three (3) months
• Documented, familial or genetic disorders with a high risk of life-threating tachyarrhythmias, but not limited to long QT syndrome or hypertrophic cardiomyopathy
• Existing ICD requiring replacement due to battery life, Elective Replacement Indicator (ERI), or malfunction

Please refer to section 20.4 of the NCD Manual for additional coverage criteria.

Click here for more information on ICD Coverage.

8. Next Generation Sequencing (NGS) for Medicare Beneficiaries with Germline (Inherited) Cancer

(Effective: January 27, 20) 
(Implementation Date: November 13, 2020)

CMS has updated Chapter 1, Part 2, Section 90.2 of the Medicare National Coverage Determinations Manual to include NGS testing for Germline (inherited) cancer when specific requirements are met and updated criteria for coverage of Somatic (acquired) cancer.

What is covered:

Effective for dates of service on or after January 27, 2020, CMS has determined that NGS, as a diagnostic laboratory test, is reasonable and necessary and covered nationally for patients with germline (inherited) cancer when performed in a CLIA-certified laboratory, when ordered by a treating physician and when specific requirements are met.

Who is covered:

Beneficiaries with Somatic (acquired) cancer or Germline (inherited) cancer when performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all the following requirements are met:

For Somatic (acquired) cancer:

• Beneficiary has:
  • either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer and;
  • has not been previously tested with the same test using NGS for the same cancer genetic content and;
  • has decided to seek further cancer treatment (e.g., therapeutic chemotherapy).
• The diagnostic laboratory test using NGS must have:
  • Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic and;
  • FDA-approved or cleared indication for use in that patient’s cancer and;
  • results provided to the treating physician for management of the patient using a report template to specify treatment options.

For Germline (inherited) Cancer

• Beneficiary has:
  • -ovarian or breast cancer and;
  • a clinical indication for germline (inherited) testing for hereditary breast or ovarian cancer and;
  • a risk factor for germline (inherited) breast or ovarian cancer and;
  • -not been previously tested with the same germline test using NGS for the same germline genetic content.
• The diagnostic laboratory test using NGS must have:
  • FDA-approval or clearance; and,
  • results provided to the treating physician for management of the patient using a report template to specify treatment options.

Medicare Administrative Contractors (MACs) may determine coverage of NGS as a diagnostic test when additional specific criteria are met.

Click here for information on Next Generation Sequencing coverage.

9. Percutaneous Transluminal Angioplasty (PTA)   

(Effective: February 19, 2019) 
(Implementation Date: February 19, 2019) 

CMS has updated Chapter 1, Part 1, Section 20.7 of the Medicare National Coverage Determinations Manual providing additional information regarding PTA. 

What is covered:

Percutaneous Transluminal Angioplasty (PTA) is covered in the below instances in order to improve blood flow through the diseased segment of a vessel in order to dilate lesions of peripheral, renal and coronary arteries. 

Who is covered:

The PTA is covered under the following conditions: 
1. Treatment of Atherosclerotic Obstructive Lesions 
2. Concurrent with Carotid Stent Placement in Food and Drug Administration (FDA) – Approved Category B Investigational Device Exemption (IDE) Clinical Trials 
3. Concurrent with Carotid Stent Placement in FDA-Approved Post-Approvals Studies 
4. Concurrent with Carotid Stent Placement in Patients at High Risk for Carotid Endarterectomy (CEA)
5. Concurrent with Intracranial Stent Placement in FDA-Approved Category B IDE Clinical Trials

Click here for more detailed information on PTA coverage.

10. Transcatheter Aortic Valve Replacement (TAVR)

(Effective: June 21, 2019)
(Implementation Date: June 12, 2020)

CMS has updated Chapter 1, section 20.32 of the Medicare National Coverage Determinations Manual. The Centers of Medicare and Medicaid Services (CMS) will cover transcatheter aortic valve replacement (TAVR) under Coverage with Evidence Development (CED) when specific requirements are met.

What is covered:

Effective June 21, 2019, CMS will cover TAVR under CED when the procedure is related to the treatment of symptomatic aortic stenosis and according to the Food and Drug Administration (FDA) approved indication for use with an approved device, or in clinical studies when criteria are met, in addition to the coverage criteria outlined in the NCD Manual.

Who is covered:

This service will be covered when the TAVR is used for the treatment of symptomatic aortic valve stenosis according to the FDA-approved indications and the following conditions are met:

• The procedure and implantation system received FDA premarket approval (PMA) for that system's FDA approved indication
• The patient is under the care of a heart team, which consists of a cardiac surgeon, interventional cardiologist, and various Providers, nurses, and research personnel
• The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the related aspects of TAVR
• The hospital where the TAVR is complete must have various qualifications and implemented programs
• The registry shall collect necessary data and have a written analysis plan to address various questions.

This service will be covered when the TAVR is not expressly listed as an FDA-approved indication, but when performed within a clinical study and the following conditions are met:

• The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the related aspects of TAVR
• The clinical research study must critically evaluate each patient's quality of life pre- and post-TAVR for a minimum of 1 year, but must also address other various questions
• The clinical study must adhere to all the standards of scientific integrity and relevance to the Medicare population.

Click here for more information on NGS coverage.

11. Ambulatory Blood Pressure Monitoring (ABPM)

(Effective: July 2, 2019)
(Implementation Date: June 16, 2020)

CMS has updated Chapter 1, section 20.19 of the Medicare National Coverage Determinations Manual. The Centers of Medicare and Medicaid Services (CMS) will cover Ambulatory Blood Pressure Monitoring (ABPM) when specific requirements are met.

What is covered:

Effective July 2, 2019, CMS will cover Ambulatory Blood Pressure Monitoring (ABPM) when beneficiaries are suspected of having white coat hypertension or masked hypertension in addition to the coverage criteria outlined in the NCD Manual.

Who is covered:

This service will be covered when the Ambulatory Blood Pressure Monitoring (ABPM) is used for the diagnosis of hypertension when either there is suspected white coat or masked hypertension and the following conditions are met:

The ABPM device must be:

• Capable of producing standardized plots of BP measurements for 24 hours with daytime and nighttime windows and normal BP bands demarcated;
• Provided to patients with oral and written instructions, and a test run in the physician’s office must be performed; and,
• Interpreted by the treating physician or treating non-physician practitioner.

Coverage of other indications for ABPM is at the discretion of the Medicare Administrative Contractors.

Click here for more information on ambulatory blood pressure monitoring coverage.

12. Acupuncture for Chronic Low Back Pain (cLBP)

(Effective: January 21, 2020)
(Implementation Date: October 5, 2020)

CMS has updated Chapter 1, section 30.3.3 of the Medicare National Coverage Determinations Manual. The Centers of Medicare and Medicaid Services (CMS) will cover acupuncture for chronic low back pain (cLBP) when specific requirements are met.

What is covered:

Effective January 21, 2020, CMS will cover acupuncture for chronic low back pain (cLBP) for up to 12 visits in 90 days and an additional 8 sessions for those beneficiaries that demonstrate improvement, in addition to the coverage criteria outlined in the NCD Manual.

Who is covered:

This service will be covered only for beneficiaries diagnosed with chronic Lower Back Pain (cLBP) when the following conditions are met:

• For the purpose of this decision, cLBP is defined as:
  • Lasting 12 weeks or longer;
  • nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease);
  • not associated with surgery; and,
  • not associated with pregnancy.
• An additional 8 sessions will be covered for those patients demonstrating an improvement.
• No more than 20 acupuncture treatments may be administered annually.
• Treatments must be discontinued if the patient is not improving or is regressing.

All types of acupuncture including dry needling for any condition other than cLBP are non-covered by Medicare.

Click here for more information on acupuncture for chronic low back pain coverage.

13. Vagus Nerve Stimulation (VNS)

(Effective: February 15. 2020)
(Implementation Date: July 22, 2020)

CMS has updated Chapter 1, section 160.18 of the Medicare National Coverage Determinations Manual. The Centers of Medicare and Medicaid Services (CMS) will cover Vagus Nerve Stimulation (VNS) for treatment-resistant depression when specific requirements are met.

What is covered: 

Effective February 15, 2020, CMS will cover FDA approved Vagus Nerve Stimulation (VNS) devices for treatment-resistant depression through Coverage with Evidence Development (CED) in a CMS approved clinical trial in addition to the coverage criteria outlined in the National Coverage Determination Manual.

Who is covered:

Beneficiaries participating in a CMS approved clinical study undergoing Vagus Nerve Stimulation (VNS) for treatment resistant depression and the following requirements are met:

• Treatment is furnished as part of a CMS approved trial through Coverage with Evidence Development (CED).Detailed clinical trial criteria can be found in section 160.18 of the National Coverage Determination Manual.
• The clinical study must address whether VNS treatment improves health outcomes for treatment resistant depression compared to a control group, by answering all research questions listed in 160.18 of the National Coverage Determination Manual.

Patient Criteria:     

• The following criteria must be used to identify a beneficiary demonstrating treatment resistant depression:
  • Beneficiary must be in a major depressive disorder episode for at least two years or have had at least four episodes, including the current episode.
  • Patient’s depressive illness meets a minimum criterion of four prior failed treatments of adequate dose and duration as measured by a tool designed for this purpose.
  • The patient is experiencing a major depressive episode, as measured by a guideline recommended depression scale assessment tool on two visits, within a 45-day span prior to implantation of the VNS device.
• Patients must maintain a stable medication regimen for at least four weeks before device implantation.
• If patients with bipolar disorder are included, the condition must be carefully characterized.
• Patients must not have:
  • Current or lifetime history of psychotic features in any MDE;
  • Current or lifetime history of schizophrenia or schizoaffective disorder;
  • Current or lifetime history of any other psychotic disorder;
  • Current or lifetime history of rapid cycling bipolar disorder;
  • Current secondary diagnosis of delirium, dementia, amnesia, or other cognitive disorder;
  • Current suicidal intent; or,
  • Treatment with another investigational device or investigational drugs.
• CMS reviews studies to determine if they meet the criteria listed in Section 160.18 of the National Coverage Determination Manual.
• Nationally Non-Covered Indications
  • VNS is non-covered for the treatment of TRD when furnished outside of a CMS-approved CED study.
  • All other indications of VNS for the treatment of depression are nationally non-covered.
• Patients implanted with a VNS device for TRD may receive a VNS device replacement if it is required due to the end of battery life, or any other device-related malfunction.

Click here for more information on Vagus Nerve Stimulation. 

14. Chimeric Antigen Receptor (CAR) T-cell Therapy

(Effective: August 7, 2019)
(Implementation Date: September 20, 2021)

CMS has updated Section 110.24 of the Medicare National Coverage Determinations Manual to include coverage of chimeric antigen receptor (CAR) T-cell therapy when specific requirements are met.

What is covered:

Effective for dates of service on or after August 7, 2019, CMS covers autologous treatment for cancer with T-cell expressing at least one chimeric antigen receptor (CAR) when administered at healthcare facilities enrolled in the Food and Drug Administration’s (FDA) Risk Evaluation and Mitigation Strategies (REMS) and when specific requirements are met.

Who is covered:

Beneficiaries receiving autologous treatment for cancer with T-cell expressing at least one least one chimeric antigen receptor CAR, when all the following requirements are met:

• Autologous treatment is for cancer with T-cells expressing at least one chimeric antigen receptor (CAR); and
• Treatment is administered at a healthcare facility enrolled in the FDA’s REMS; and
• The therapy is used for a medically accepted indication, which is defined as used for either and FDA approved indication according to the label of that product, or the use is supported in one or more CMS approved compendia.

Non-Covered Use:

The use of non-FDA-approved autologous T-cell expressing at least one CAR is non-covered or when the coverage requirements are not met.

Click here for more information on chimeric antigen receptor (CAR) T-cell therapy coverage. 

15. Screening for Colorectal Cancer (CRC)-Blood-Based Biomarker Tests

(Effective: January 19, 2021) 
(Implementation Date: October 4, 2021) 

What is covered:

Effective January 19, 2021, CMS has determined that blood-based biomarker tests are an appropriate colorectal cancer screening test, once every 3 years for Medicare beneficiaries when certain requirements are met. 

Who is covered:

Medicare beneficiaries will have their blood-based colorectal cancer screening test covered once every 3 years when ordered by a treating physician and the following conditions are met:

• The procedure is performed in a Clinical Laboratory Improvement Act (CLIA)-certified laboratory
• The Patient is: 
  • age 50-85 years, and,
  • asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test), and,
  • average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer)
• The screen test must have all the following:
  • Food and Drug Administration (FDA) market authorization with an indication for colorectal cancer screening; and
  • Proven test performance characteristics for a blood-based screening test with both sensitivity greater than or equal to 74% and specificity greater than or equal to 90% in the detection of colorectal cancer compared to the recognized standard (accepted as colonoscopy at this time), based on the pivotal studies included in the FDA labeling.

What is not covered:

• All other indications for colorectal cancer screening not otherwise specific in the regulations or the National Coverage Determination above. This includes:
  • All screenings DNA tests, effective April 28, 2008, through October 8, 2014. Effective for dates of service on or after October 9, 2014, all other screening sDNA tests not otherwise specified above remain nationally non-covered.
  • Screening computed tomographic colonography (CTC), effective May 12, 2009.

Click here for more information on NGS coverage.

16. Ventricular Assist Devices (VADs)

(Effective: December 1, 2020)
(Implementation Date: July 27, 2021)

What is covered:

Effective for dates of service on or after December 1, 2020, CMS has updated section 20.9.1 of the National Coverage Determination Manual to cover ventricular assist devices (VADs) when received at facilities credentialed by a CMS approved organization and when specific requirements are met.

Who is covered:

Beneficiaries receiving treatment for implanting a ventricular assist device (VAD), when the following requirements are met and:

• The device is used following post-cardiotomy (period following open heart surgery) to support blood circulation.
  • The device must be approved by the Food and Drug Administration (FDA) for this purpose; OR
• They receive a left ventricular device (LVADs) if the device is FDA approved for short- or long-term use for mechanical circulatory support for beneficiaries with heart failure who meet the following requirements:
  • Have New York Heart Association (NYHA) Class IV heart failure; and
  • Have a left ventricular ejection fraction (LVEF) ≤ 25%; and
  • Are inotrope dependent OR have a Cardiac Index (CI) < 2.2 L/min/m2, while not on inotropes, and meet one of the following:
    • Are on optimal medical management, based on current heart failure practice guidelines for at least 45 out of the last 60 days and are failing to respond; or
    • Have advanced heart failure for at least 14 days and are dependent on an intra‐aortic balloon pump (IABP) or similar temporary mechanical circulatory support for at least 7 days.
• Beneficiaries must be managed by a team of medical professionals meeting the minimum requirements in the National Coverage Determination Manual.
• Facilities must be credentialed by a CMS approved organization.

Non-Covered Use:

All other indications for the use of VADs not otherwise listed remain non-covered, except in the context of Category B investigational device exemption clinical trials (42 CFR 405) or as a routine cost in clinical trials defined under section 310.1 of the National Coverage Determinations (NCD) Manual.

Click here for more information on Ventricular Assist Devices (VADs) coverage.

17. Blood-Derived Products for Chronic, Non-Healing Wounds

(Effective: April 13, 2021)
(Implementation Date: February 14, 2022)

What is covered:

Effective for dates of service on or after April 13, 2021, CMS has updated section 270.3 of the National Coverage Determination Manual to cover Autologous (obtained from the same person) Platelet-Rich Plasma (PRP) when specific requirements are met.

Who is covered:

Beneficiaries receiving treatment for chronic non-healing diabetic wounds for a duration of 20 weeks, when prepared by a device cleared by the Food and Drug Administration (FDA) for the management of exuding (bleeding, oozing, seeping, etc.) wounds affecting the skin.

Non-Covered Use:

The following uses are considered non-covered:

• Use of autologous Platelet-Derived Growth Factor (PDGF) for treatment of chronic, non-healing, cutaneous (affecting the skin) wounds, and,
• Becaplermin, a non-autologous growth factor for chronic, non-healing, subcutaneous (beneath the skin) wounds, and,
• Autologous Platelet-Rich Plasma (PRP) treatment of acute surgical wounds when applied directly to the close incision, or for splitting or open wounds.

Other:

Coverage for the treatment beyond 20 weeks, or for all other chronic non-healing wounds will be determined by the local Medicare Administrative Contractors (

Click here for more information on Blood-Derived Products for Chronic, Non-Healing Wounds coverage.

18. Transcatheter Edge-to-Edge Repair [TEER] for Mitral Valve Regurgitation

(Effective: January 19, 2021)
(Implementation Date: October 8, 2021)

What is covered:

Effective for dates of service on or after January 19, 2021, CMS has updated section 20.33 of the National Coverage Determination Manual to cover Transcatheter Edge-to-Edge Repair (TEER) for Mitral Valve Regurgitation when specific requirements are met.

Who is covered:

Beneficiaries receiving treatment for Transcatheter Edge-to-Edge Repair (TEER) when either of the following are met:

1. For the treatment of symptomatic moderate to severe mitral regurgitation (MR) when the patient still has symptoms, despite stable doses of maximally tolerated guideline directed medical therapy (GDMT) and cardiac resynchronization therapy, when appropriate and the following are met:
   1. Treatment is a Food and Drug Administration (FDA) approved indication,
   2. The procedure is used with a mitral valve TEER system that has received premarket approval from the FDA.
   3. The beneficiary is under pre- or post-operative care of a heart team meeting the following:
      1. Cardiac Surgeon meeting the requirements listed in the determination.
      2. Interventional Cardiologist meeting the requirements listed in the determination.
      3. Interventional echocardiographer meeting the requirements listed in the determination.
      4. Heart failure cardiologist with experience treating patients with advanced heart failure.
      5. Providers from other groups including patient practitioners, nurses, research personnel, and administrators.
   4. Patient must be evaluated for suitability for repair and must documented and made available to the Heart team members meeting the requirements of this determination.
   5. The procedure must be performed by an interventional cardiologist or cardiac surgeon.<
   6. An interventional echocardiographer must perform transesophageal echocardiography during the procedure.
   7. All physicians participating in the procedure must have device-specific training by the manufacturer of the device.
   8. The procedure must be performed in a hospital with infrastructure and experience meeting the requirements in this determination.
   9. The Heart team must participate in the national registry and track outcomes according to the requirements in this determination.>
2. Mitral valve TEERs are covered for other uses not listed as an FDA-approved indication when performed in a clinical study and the following requirements are met:
   1. The procedure must be performed by an interventional cardiologist or cardiac surgeon.
   2. An interventional echocardiographer must perform transesophageal echocardiography during the procedure.>
   3. All physicians participating in the procedure must have device-specific training by the manufacturer of the device.
   4. The clinical research must evaluate the required twelve questions in this determination.
   5. The clinical research must evaluate the patient’s quality of life pre and post for a minimum of one year and answer at least one of the questions in this determination section.
   6. The clinical research study must meet the standards of scientific integrity and relevance to the Medicare population described in this determination.
   7. Submit the required study information to CMS for approval.

Non-Covered Use:

The following uses are considered non-covered:

• Treatment for patients with existing co-morbidities that would preclude the benefit from the procedure.
• Treatment for patients with untreated severe aortic stenosis.

Other:

This determination will expire ten years after the effective date if a reconsideration is not made during this time.  Upon expiration, coverage will be determined by the local Medicare Administrative Contractors (MACs).

Click here for more information on Transcatheter Edge-to-Edge Repair [TEER] for Mitral Valve Regurgitation coverage .

19. Positron Emission Tomography NaF-18 (NaF-18 PET) to Identify Bone Metastasis of Cancer- Manual Update Only 

(Effective: December 15, 2017)
(Implementation Date: January 17, 2022) 

Effective for dates of service on or after December 15, 2017, CMS has updated section 220.6.19 of the National Coverage Determination Manual clarifying there are no nationally covered indications for Positron Emission Tomography NaF-18 (NaF-18 PET).

Non-Covered Use:

Positron Emission Tomography NaF-18 (NaF-18 PET) services to identify bone metastases of cancer provided on or after December 15, 2017, are nationally non-covered.

Other

Use of other PET radiopharmaceutical tracers for cancer may be covered at the discretion of local Medicare Administrative Contractors (MACs), when used in accordance to their Food and Drug Administration (FDA) approval indications.

Click here for more information on Positron Emission Tomography NaF-18 (NaF-18 PET) to Identify Bone Metastasis of Cancer coverage.

Information on the page is current as of December 28, 2021
H5355_CMC_22_2746205 Accepted

20. Home Use of Oxygen 

(Effective: September 27, 2021)
(Implementation Date: January 3, 2023)

What is covered:
Effective September 27, 2021, CMS has updated section 240.2 of the National Coverage Determination Manual to cover oxygen therapy and oxygen equipment for in home use of both acute and chronic conditions, short- or long- term, when a patient exhibits hypoxemia. CMS has updated section 240.2 of the National Coverage Determination Manual to amend the period of initial coverage for patients in section D of NCD 240.2 from 120 days to 90 days, to align with the 90-day statutory time period

Who is covered:
Beneficiaries who exhibit hypoxemia (low oxygen in your blood) when ALL (A, B, and C) of the following are met:

  A. Hypoxemia is based on results of a clinical test ordered and evaluated by a patient’s treating practitioner meeting either of the following:
a. A clinical test providing a measurement of the partial pressure of oxygen (PO2) in arterial blood.
i. PO2 measurements can be obtained via the ear or by pulse oximetry.
ii. PO2 may be performed by the treating practitioner or by a qualified provider or supplier of laboratory services.
b. A clinical test providing the measurement of arterial blood gas.
i. If PO2 and arterial blood gas results are conflicting, the arterial blood gas results are preferred source to determine medical need.

B. The clinical test must be performed at the time of need:
a. The time of need is indicated when the presumption of oxygen therapy within the home setting will improve the patient’s condition.
i. For inpatient hospital patient’s, the time of need is within 2 days of discharge.
ii. For patient’s whose initial prescription for oxygen did not originate during an inpatient hospital stay, the time of need occurs when the treating practitioner identifies signs and symptoms of hypoxemia that can be relieved with at home oxygen therapy.

C. Beneficiary’s diagnosis meets one of the following defined groups below:
a. Group I:
i. Arterial PO2 at or below 55 mm Hg or arterial oxygen saturation at or below 88% when tested at rest in breathing room air, or;
ii. Arterial PO2 at or below 55 mm Hg, or arterial oxygen saturation at or below 88% when tested during sleep for patients that demonstrate an arterial PO2 at or above 56 mmHg, or
iii. Arterial oxygen saturation at or above 89% when awake;or greater than normal decrease in oxygen level while sleeping represented by a decrease in arterial PO2 more than 10 mmHg or a decrease in arterial oxygen saturation more than 5%.

a. Patient must also present hypoxemia signs and symptoms such as nocturnal restlessness, insomnia, or impairment of cognitive process.
2. During these events, oxygen during sleep is the only type of unit that will be covered.
3. Portable oxygen would not be covered.
iv. Arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88%, tested during functional performance of the patient or a formal exercise,
1. For a patient demonstrating arterial PO2 at or above 56 mm Hg, or an arterial oxygen saturation at or above 89%, at rest and during the day.
2. During these events, supplemental oxygen is provided during exercise, if the use of oxygen improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air.
b. Group II:
i. Patients demonstrating arterial PO2 between 56-59 mm Hg, or who’s arterial blood oxygen saturation is 89%, with any of the following condition:
1. Dependent edema (gravity related swelling due to excess fluid) suggesting congestive heart failure; or,
2. Pulmonary hypertension or cor pulmonale (high blood pressure in pulmonary arteries), determined by the measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or "P" pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or AVFL; or,
3. Erythrocythemia (increased red blood cells) with a hematocrit greater than 56%.
c. The Medicare Administrative Contractors (MACs) will review the arterial PO2 levels above and also take into consideration various oxygen measurements that can results from factors such as patient’s age, patients skin pigmentation, altitude level and the patients decreased oxygen carrying capacity.

Non-Covered Use:
The following medical conditions are not covered for oxygen therapy and oxygen equipment in the home setting:

• Angina pectoris (chest pain) in the absence of hypoxemia; or,
• Breathlessness without cor pulmonale or evidence of hypoxemia; or,
• Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities; or,
• Terminal illnesses, unless it affects the patient’s ability to breathe.

Other:
The MAC may determine necessary coverage for in home oxygen therapy for patient’s that do not meet the criteria described above. Initial coverage for patient’s experiencing conditions not described above can be limited to a prescription shorter than 90 days, or less than the numbers of days indicated on the practitioner’s prescription. Oxygen therapy can be renewed by the MAC if deemed medically necessary.

The MAC may also approve the use of portable oxygen systems to beneficiaries who are mobile in home and benefit from of this unit alone, or in conjunction to a stationary oxygen system.

For more information on Home Use of Oxygen coverage click here.

21. 180.1 - Medical Nutrition Therapy (MNT)

(Effective: January 1, 2022)
(Implementation Date: July 5, 2022)

What is covered:

Effective for dates of service on or after January 1, 2022, CMS has updated section 180.1 of the National Coverage Determination Manual to cover three hours of administration during one year of Medical Nutrition Therapy (MNT) in patients with a diagnosis of renal disease or diabetes, as defined in 42 CFR 410.130. Coverage for future years is two hours for patients diagnosed with renal disease or diabetes.

Medicare will cover both MNT and Diabetes Outpatient Self-Management Training (DSMT) during initial and subsequent years, if the physician determines treatment is medically necessary and as long as DSMT and MNT are not provided on the same date.

Dieticians and Nutritionist will determine how many units will be administered per day and must meet the requirements of this NCD as well at 42 CFR 410.130 – 410.134. Additional hours of treatment are considered medically necessary if a physician determines there has been a shift in the patients’ medical condition, diagnosis or treatment regimen that requires an adjustment in MNT order or additional hours of care.

Who is covered:

Beneficiaries with either a renal disease or diabetes diagnosis as defined in 42 CFR 410.130.

For more information on Medical Nutrition Therapy (MNT) coverage click here.

22.  Reconsideration – Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)

(Effective: February 10, 2022)
(Implementation Date: October 3, 2022) 

What is covered:

Effective for claims with dates of service on or after February 10, 2022, CMS will cover, under Medicare Part B, a lung cancer screening counseling and shared decision-making visit. An annual screening for lung cancer with LDCT will be available if specific eligibility criteria are met. 

Prior to the beneficiary’s first lung cancer LDCT screening, the beneficiary must receive a counseling and shared decision-making visit that meets specific criteria.

Who is covered:

Members must meet all of the following eligibility criteria: 

• 50– 77 years old;
• Asymptomatic (no signs or symptoms of lung cancer);
• Tobacco smoking history of at least 20 pack-years (one pack-year = smoking one pack per day for one year; 1 pack =20 cigarettes);
• Current smoker or one who has quit smoking within the last 15 years;
• Receive an order for lung cancer screening with LDCT.

Click here for more information on LDCT coverage. 

23. (Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease (AD)) 

(Effective: April 7, 2022)
(Implementation Date: December 12, 2022) 

What is covered:

Effective on April 7, 2022, CMS has updated section 200.3 of the National Coverage Determination (NCD) Manual to cover Food and Drug Administration (FDA) approved monoclonal antibodies directed against amyloid for treatment of Alzheimer’s Disease (AD) when the coverage criteria below is met. 

Who is covered:

Beneficiaries with Alzheimer’s Disease (AD) may be covered for treatment when the following conditions (A or B) are met: 

How to Access Care

It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which IEHP DualChoice (HMO D-SNP) authorizes use of out-of-network providers.

What are Network providers?

Network providers are the doctors and other health care professionals, medical groups, hospitals, and other health care facilities that have an agreement with us to accept our payment as payment in full. We have arranged for these providers to deliver covered services to members in our plan.

All of our plan participating providers also contract us to provide covered Medi-Cal benefits.

Find a Doctor

Use the IEHP DualChoice Provider and Pharmacy Directory below to find a network provider:

• 2023 IEHP DualChoice Provider and Pharmacy Directory (PDF)

What is a Primary Care Provider (PCP) and their role in your Plan?

A PCP is your Primary Care Provider. You will usually see your PCP first for most of your routine health care needs. Your PCP will also help you arrange or coordinate the rest of the covered services you get as a member of our Plan. "Coordinating" your services includes checking or consulting with other Plan providers about your care and how it is going. This includes:

• your X-rays
• laboratory tests, therapies
• care from doctors who are specialists
• hospital admissions, and follow-up care

Primary Care Providers (PCPs) are usually linked to certain hospitals. When you choose your PCP, remember the following:

• You must choose your PCP from your Provider and Pharmacy Directory. Call IEHP DualChoice Member Services if you need help in choosing a PCP or changing your PCP.
• Choose a PCP that is within 10 miles or 15 minutes of your home.
• The PCP you choose can only admit you to certain hospitals. Try to choose a PCP that can admit you to the hospital you want within 30 miles or 45 minutes of your home.
• Some hospitals have “hospitalists” who specialize in care for people during their hospital stay. If you are admitted to one of these hospitals, a “hospitalist” may serve as your caregiver as long as you remain in the hospital. When you are discharged from the hospital, you will return to your PCP for your health care needs.
• If you need to change your PCP for any reason, your hospital and specialist may also change. Your PCP should speak your language. However, your PCP can always use Language Line Services to get help from an interpreter, if needed.
• If you do not choose a PCP when you join IEHP DualChoice, we will choose one for you. We will send you your ID Card with your PCP’s information. Remember, you can request to change your PCP at any time.
• You can switch your Doctor (and hospital) for any reason (once per month). If your change request is received by IEHP by the 25th of the month, the change will be effective the first of the following month; if your change request is received by IEHP after the 25th of the month, the change will be effective the first day of the subsequent month (for some providers, you may need a referral from your PCP). 

How to Get Care from a Specialist

You will usually see your Primary Care Provider (PCP) first for most of your routine healthcare needs such as physical check-ups, immunization, etc. When your PCP thinks that you need specialized treatment or supplies, your PCP will need to get prior authorization (i.e., prior approval) from your Plan and/or medical group. This is called a referral. Your PCP will send a referral to your plan or medical group.  It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. If you don't have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself.

What if you are outside the plan’s service area when you have an urgent need for care?

Suppose that you are temporarily outside our plan’s service area, but still in the United States. If you have an urgent need for care, you probably will not be able to find or get to one of the providers in our plan’s network. In this situation (when you are outside the service area and cannot get care from a network provider), our plan will cover urgently needed care that you get from any provider.

Our plan does not cover urgently needed care or any other care if you receive the care outside of the United States.

Changing your Primary Care Provider (PCP)

You may change your PCP for any reason, at any time. Also, it’s possible that your PCP might leave our plan’s network of providers and you would have to find a new PCP. If this happens, you will have to switch to another provider who is part of our Plan. If your PCP leaves our Plan, we will let you know and help you choose another PCP so that you can keep getting covered services. IEHP DualChoice Member Services can assist you in finding and selecting another provider. You can change your Doctor by calling IEHP DualChoice Member Services. Please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY users should call (800) 718-4347.

For more information on network providers refer to Chapter 1 of the IEHP DualChoice Member Handbook.

IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. This is not a complete list. 

You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Click here to download a free copy by clicking Adobe Acrobat Reader. 

Information on this page is current as of October 01, 2022
H8894_DSNP_23_3241532_M

What to do if you have a problem or concern with IEHP DualChoice (HMO D-SNP):

• You can call IEHP Member Services at (877) 273-IEHP (4347) and ask for a Member Complaint Form. If you need help to fill out the form, IEHP Member Services can assist you.
• You can complete the Member Complaint Form online.
• You can give the completed form to any IEHP Provider or mail it to:
  P.O Box 1800,
  Rancho Cucamonga, CA 91729-1800
• You can fax the completed form to (909) 890-5877. You can file a grievance online. This form is for IEHP DualChoice as well as other IEHP programs. 
• For some types of problems, you need to use the process for coverage decisions and making appeals.

For other types of problems you need to use the process for making complaints. Both of these processes have been approved by Medicare. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures, and deadlines that must be followed by us and by you.

Long-Term Services and Supports:

• If you are having a problem with your care, you can call the Office of Ombudsman at 1-888-452-8609 for help.
• For problems and concerns regarding eligibility determinations, assessments, and care delivered by our contracted Community Based Adult Services (CBAS) centers,  or Nursing Facilities/Sub-Acute Care Facilities, you should follow the process outlined below.

Community Based Adult Services (CBAS)

• You can call IEHP Member Services at (877) 273-IEHP (4347) and ask for a Member Complaint Form. If you need help to fill out the form, IEHP Member Services can assist you.
• You can give the completed form to any IEHP Provider or mail it to:
  P.O Box 1800
  Rancho Cucamonga, CA 91729-1800
• You can fax the completed form to (909) 890-5877. You can file a grievance online. This form is for IEHP DualChoice as well as other IEHP programs.

Help in Handling a Problem

You can contact Medicare. Here are two ways to get information directly from Medicare:

• You can call (800) MEDICARE (800) 633-4227, 24 hours a day, 7 days a week, TTY (877) 486-2048.
• You can visit the Medicare website

By clicking on this link, you will be leaving the IEHP DualChoice website.

Get Help from an Independent Government Organization

We are always available to help you. But in some situations, you may also want help or guidance from someone who is not connected with us. You can always contact your State Health Insurance Assistance Program (SHIP). This government program has trained counselors in every state. The program is not connected with us or with any insurance company or health plan. The counselors at this program can help you understand which process you should use to handle a problem you are having. They can also answer your questions, give you more information, and offer guidance on what to do. The services of SHIP counselors are free. You can call SHIP at 1-800-434-0222.

Get Help and Information from DHCS

• Call: (916) 445-4171
• MCI from TDD at (800) 735-2929
• MCI from Voice Telephone: (800) 735-2922
• Sprint from TDD at (800) 877-5378
• Sprint from Voice Telephone: (800) 877-5379
• Write to:

  Department of Health Care Services
  1501 Capitol Ave.,
  P.O. Box 997413
  Sacramento, CA 95899-7413

• Website:www.dhcs.ca.gov

By clicking on this link, you will be leaving the IEHP DualChoice website.

Get Help and Information from Medi-Cal

The Office of the Ombudsman Program can answer your questions and help you understand what to do to handle your problem. The Office of the Ombudsman is not connected with us or with any insurance company or health plan. They can help you understand which process to use.

• Call: 1-888-452-8609 (TTY 711) Monday through Friday, 9 a.m. to 5 p.m.
• Visit their website at: www.healthconsumer.org/

By clicking on this link, you will be leaving the IEHP DualChoice website.

Get Help and Information from Livanta

Our state has an organization called Livanta Beneficiary & Family Centered Care (BFCC) Quality Improvement Organization (QIO). This is a group of doctors and other health care professionals who help improve the quality of care for people with Medicare. Livanta is not connect with our plan.

• Call: (877) 588-1123, TTY (855) 887-6668
• For appeals: (855) 694-2929
• For all other reviews: (844) 420-6672
• Write to:

  Livanta BFCC-QIO Program
  10820 Guilford Road, Suite 202
  Annapolis Junction, Maryland 20701

• Website: www.livanta.com

By clicking on this link, you will be leaving the IEHP DualChoice website.

How to obtain an aggregate number of grievances, appeals, and exceptions filed with IEHP DualChoice (HMO D-SNP)?

Please call or write to IEHP DualChoice Member Services.

• Call: (877) 273-IEHP (4347). Calls to this number are free. 8am - 8pm (PST), 7 days a week, including holidays, TTY: (800) 718-4347. This number requires special telephone equipment. Calls to this number are free.
• Fax: (909) 890-5877
• Write:
  IEHP DualChoice,
  P.O. Box 1800
  Rancho Cucamonga, CA 91729-1800
• Email: memberservices@iehp.org
• Visit: 10801 Sixth Street, Suite 120, Rancho Cucamonga, CA 91730

IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. This is not a complete list. 

Information on this page is current as of October 01, 2022.
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Part C: Coverage Decision and Appeals 

This section is about asking for coverage decisions and making appeals with problems related to your benefits and coverage. It also includes problems with payment. You are not responsible for Medicare costs except for Part D copays.

How to ask for coverage decision coverage decision to get medical, behavioral health, or certain long-term services and supports (CBAS, or NF services) 

To ask for a coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for an coverage decision. 

• You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays, TTY (800) 718-4347. 
• You can fax us at: (909) 890-5877 
• You can to write us at:

IEHP DualChoice

P.O. Box 1800

Rancho Cucamonga, CA 91729-1800.

How long does it take to get a coverage decision coverage decision for Part C services?

It usually takes up to 14 calendar days after you asked. If we don’t give you our decision within 14 calendar days, you can appeal.

Sometimes we need more time, and we will send you a letter telling you that we need to take up to 14 calendar more days. The letter will explain why more time is needed.

Can I get a coverage decision faster for Part C services?

Yes. If you need a response faster because of your health, you should ask us to make a “fast coverage decision.”  If we approve the request, we will notify you of our coverage decision coverage decision within 72 hours. However, sometimes we need more time, and we will send you a letter telling you that we need to take up to 14 more calendar days.

Asking for a fast coverage decision coverage decision:

• If you request a fast coverage decision coverage decision, start by calling or faxing our plan to ask us to cover the care you want. 
• You can call IEHP DualChoice at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY users should call (800) 718-4347 or fax us at (909) 890-5877.
• You can also have your doctor or your representative call us.

Here are the rules for asking for a fast coverage decision coverage decision: 

You must meet the following two requirements to get a fast coverage decision coverage decision: 

1. You can get a fast coverage decision coverage decision only if you are asking for coverage for care or an item you have not yet received. (You cannot get a fast coverage decision coverage decision if your request is about payment for care or an item you have already received.)
2. You can get a fast coverage decision only if the standard 14 calendar day deadline could cause serious harm to your health or hurt your ability to function. 
• If your doctor says that you need a fast coverage decision, we will automatically give you one.
• If you ask for a fast coverage decision, without your doctor’s support, we will decide if you get a fast coverage decision. 
  • If we decide that your health does not meet the requirements for a fast coverage decision, we will send you a letter. We will also use the standard 14 calendar day deadline instead.
  • This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision.
  • The letter will also tell how you can file a “fast appeal” about our decision to give you a fast coverage decision instead of the fast coverage decision you requested.

If the coverage decision is Yes, when will I get the service or item?

You will be able to get the service or item within 14 calendar days (for a standard coverage decision) or 72 hours (for a fast coverage decision) of when you asked. If we extended the time needed to make our coverage decision, we will provide the coverage by the end of that extended period.

If the coverage decision is No, how will I find out? 

If the answer is No, we will send you a letter telling you our reasons for saying No.

• If we say no, you have the right to ask us to change this decision by making an appeal. Making an appeal means asking us to review our decision to deny coverage.
• If you decide to make an appeal, it means you are going on to Level 1 of the appeals process.

Appeals

What is an Appeal?

An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. For example, we might decide that a service, item, or drug that you want is not covered or is no longer covered by Medicare or Medi-Cal. If you or your doctor disagree with our decision, you can appeal.

In most cases, you must start your appeal at Level 1. If you do not want to first appeal to the plan for a Medi-Cal service, in special cases you can ask for an Independent Medical Review. If you need help during the appeals process, you can call the Office of the Ombudsman at 1-888-452-8609. The Office of Ombudsman is not connected with us or with any insurance company or health plan.

What is a Level 1 Appeal for Part C services?

A Level 1 Appeal is the first appeal to our plan. We will review our coverage decision to see if it is correct. The reviewer will be someone who did not make the original coverage decision. When we complete the review, we will give you our decision in writing. If we tell you after our review that the service or item is not covered, your case can go to a Level 2 Appeal. 

Can someone else make the appeal for me for Part C services?

Yes. Your doctor or other provider can make the appeal for you. Also, someone besides your doctor or other provider can make the appeal for you, but first you must complete an Appointment of Representative Form. The form gives the other person permission to act for you.

• If the appeal comes from someone besides you or your doctor or other provider, we must receive the completed Appointment of Representative form before we can review the appeal.

How do I make a Level 1 Appeal for Part C services?

To start your appeal, you, your doctor or other provider, or your representative must contact us. You can call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY should call (800) 718-4347. For additional details on how to reach us for appeals, see Chapter 9 of the IEHP DualChoice Member Handbook.

• You can ask us for a “standard appeal” or a “fast appeal.”
• If you are asking for a standard appeal or fast appeal, make your appeal in writing:

IEHP DualChoice
P.O. Box 1800
Rancho Cucamonga, CA 91729-1800

Fax: (909) 890-5748

• You may also ask for an appeal by calling IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY should call (800) 718-4347.

We will send you a letter within 5 calendar days of receiving your appeal letting you know that we received it.

How much time do I have to make an appeal for Part C services?

You must ask for an appeal within 60 calendar days from the date on the letter we sent to tell you our decision.

If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of a good reason are: you had a serious illness, or we gave you the wrong information about the deadline for requesting an appeal.

Can I get a copy of my case file?

Yes. Ask us for a copy by calling Member Services at (877) 273-IEHP (4347). TTY (800) 718-4347.

Can my doctor give you more information about my appeal for Part C services?

Yes, you and your doctor may give us more information to support your appeal.

How will the plan make the appeal decision? 

We take a careful look at all of the information about your request for coverage of medical care. Then, we check to see if we were following all the rules when we said No to your request. The reviewer will be someone who did not make the original decision. If we need more information, we may ask you or your doctor for it. 

When will I hear about a “standard” appeal decision for Part C services?

We must give you our answer within 30 calendar days after we get your appeal. We will give you our decision sooner if your health condition requires us to.

• However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will tell you by letter.
• If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we will give you an answer to your appeal within 24 hours.
• If we do not give you an answer within 30 calendar days or by the end of the extra days (if we took them), we will automatically send your case to Level 2 of the appeals process if your problem is about a Medicare service or item. You will be notified when this happens. If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself. Please see below for more information. 

If our answer is Yes to part or all of what you asked for, we must approve or give the coverage within 30 calendar days after we get your appeal.

If our answer is No to part or all of what you asked for, we will send you a letter. If your problem is about a Medicare service or item, the letter will tell you that we sent your case to the Independent Review Entity for a Level 2 Appeal. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. Please see below for more information.

What happens if I ask for a fast appeal?

If you ask for a fast appeal, we will give you your answer within 72 hours after we get your appeal. We will give you our answer sooner if your health requires us to do so.

• However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will tell you by letter.
• If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we will give you an answer to your appeal within 24 hours.
• If we do not give you an answer within 72 hours or by the end of the extra days (if we took them), we will automatically send your case to Level 2 of the appeals process if your problem is about a Medicare service or item. You will be notified when this happens. If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself. Please see below for more information.

If our answer is Yes to part or all of what you asked for, we must authorize or provide the coverage within 72 hours after we get your appeal. 

If our answer is No to part or all of what you asked for, we will send you a letter. If your problem is about a Medicare service or item, the letter will tell you that we sent your case to the Independent Review Entity for a Level 2 Appeal. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. Please see below for more information.

Will my benefits continue during Level 1 appeals?
If we decide to change or stop coverage for a service or item that was previously approved, we will send you a notice before taking the action. If you disagree with the action, you can file a Level 1 Appeal and ask that we continue your benefits for the service or item. You must make the request on or before the later of the following in order to continue your benefits:

• Within 10 days of the mailing date of our notice of action; or
• The intended effective date of the action.

If you meet this deadline, you can keep getting the disputed service or item while your appeal is processing.

Level 2 Appeal

If the plan says No at Level 1, what happens next?
If we say no to part or all of your Level 1 Appeal, we will send you a letter. This letter will tell you if the service or item is usually covered by Medicare or Medi-Cal.

• If your problem is about a Medicare service or item, we will automatically send your case to Level 2 of the appeals process as soon as the Level 1 Appeal is complete.
• If your problem is about a Medi-Cal service or item, you can file a Level 2 Appeal yourself. The letter will tell you how to do this. Information is also below.

What is a Level 2 Appeal?
A Level 2 Appeal is the second appeal, which is done by an independent organization that is not connected to the plan.  

My problem is about a Medi-Cal service or item. How can I make a Level 2 Appeal?
There are two ways to make a Level 2 appeal for Medi-Cal services and items: 1) Independent Medical Review or 2) State Hearing.

1)    Independent Medical Review

You can ask for an Independent Medical Review (IMR) from the Help Center at the California Department of Managed Health Care (DMHC). An IMR is available for any Medi-Cal covered service or item that is medical in nature. An IMR is a review of your case by doctors who are not part of our plan. If the IMR is decided in your favor, we must give you the service or item you requested. You pay no costs for an IMR.

You can apply for an IMR if our plan:

• Denies, changes, or delays a Medi-Cal service or treatment (not including IHSS) because our plan determines it is not medically necessary.
• Will not cover an experimental or investigational Medi-Cal treatment for a serious medical condition.
• Will not pay for emergency or urgent Medi-Cal services that you already received.
• Has not resolved your Level 1 Appeal on a Medi-Cal service within 30 calendar days for a standard appeal or 72 hours for a fast appeal.

You can ask for an IMR if you have also asked for a State Hearing, but not if you have already had a State Hearing, on the same issue.

In most cases, you must file an appeal with us before requesting an IMR. If you disagree with our decision, you can ask the DMHC Help Center for an IMR.

• If your treatment was denied because it was experimental or investigational, you do not have to take part in our appeal process before you apply for an IMR.
• If your problem is urgent and involves an immediate and serious threat to your health, you may bring it immediately to the DMHC’s attention. The DMHC may waive the requirement that you first follow our appeal process in extraordinary and compelling cases.

You must apply for an IMR within 6 months after we send you a written decision about your appeal. The DMHC may accept your application after 6 months if it determines that circumstances kept you from submitting your application in time.

To ask for an IMR:

• Fill out the Independent Medical Review/Complaint Form available at: http://www.dmhc.ca.gov/FileaComplaint/SubmitanIndependentMedicalReviewComplaintForm.aspx or call the DMHC Help Center at (888) 466-2219. TDD users should call (877) 688-9891.
• If you have them, attach copies of letters or other documents about the service or item that we denied. This can speed up the IMR process. Send copies of documents, not originals. The Help Center cannot return any documents.
• Fill out the Authorized Assistant Form if someone is helping you with your IMR. You can get the form at http://www.dmhc.ca.gov/FileaComplaint/SubmitanIndependentMedicalReviewComplaintForm.aspx Or call the DMHC Help Center at (888) 466-2219. TDD users should call (877) 688-9891.
• Mail or fax your forms and any attachments to: 

Help Center

Department of Managed Health Care

980 Ninth Street, Suite 500

Sacramento, CA 95814-2725

FAX: 916-255-5241

If you qualify for an IMR, the DMHC will review your case and send you a letter within 7 calendar days telling you that you qualify for an IMR. After your application and supporting documents are received from your plan, the IMR decision will be made within 30 calendar days. You should receive the IMR decision within 45 calendar days of the submission of the completed application.

If your case is urgent and you qualify for an IMR, the DMHC will review your case and send you a letter within 2 calendar days telling you that you qualify for an IMR. After your application and supporting documents are received from your plan, the IMR decision will be made within 3 calendar days. You should receive the IMR decision within 7 calendar days of the submission of the completed application.

If you are not satisfied with the result of the IMR, you can still ask for a State Hearing. 

If the DMHC decides that your case is not eligible for IMR, the DMHC will review your case through its regular consumer complaint process.

2)    State Hearing
You can ask for a State Hearing for Medi-Cal covered services and items. If your doctor or other provider asks for a service or item that we will not approve, or we will not continue to pay for a service or item you already have and we said no to your Level 1 appeal, you have the right to ask for a State Hearing.

In most cases you have 120 days to ask for a State Hearing after the “Your Hearing Rights” notice is mailed to you. 

NOTE: If you ask for a State Hearing because we told you that a service you currently get will be changed or stopped, you have fewer days to submit your request if you want to keep getting that service while your State Hearing is pending. Read “Will my benefits continue during Level 2 appeals” in Chapter 9 of the Member Handbook for more information.

There are two ways to ask for a State Hearing:

1. You may complete the "Request for State Hearing" on the back of the notice of action. You should provide all requested information such as your full name, address, telephone number, the name of the plan or county that took the action against you, the aid program(s) involved, and a detailed reason why you want a hearing. Then you may submit your request one of these ways:

• To the county welfare department at the address shown on the notice.
• To the California Department of Social Services:

State Hearings Division

P.O. Box 944243, Mail Station 9-17-37

Sacramento, California 94244-2430

• To the State Hearings Division at fax number 916-651-5210 or 916-651-2789.

2. You can call the California Department of Social Services at (800) 952-5253. TDD users should call (800) 952-8349. If you decide to ask for a State Hearing by phone, you should be aware that the phone lines are very busy.

Will my benefits continue during Level 2 appeals?
If your problem is about a service or item covered by Medicare, your benefits for that service or item will not continue during the Level 2 appeals process with the Independent Review Entity.

If your problem is about a service or item covered by Medi-Cal and you ask for a State Fair Hearing, your Medi-Cal benefits for that service or item will continue until a hearing decision is made. You must ask for a hearing on or before the later of the following in order to continue your benefits:

• Within 10 days of the mailing date of our notice to you that the adverse benefit determination (Level 1 appeal decision) has been upheld; or
• The intended effective date of the action.

If you meet this deadline, you can keep getting the disputed service or item until the hearing decision is made.

How will I find out about the decision?
If your Level 2 Appeal was a State Hearing, the California Department of Social Services will send you a letter explaining its decision. 

• If the State Hearing decision is Yes to part or all of what you asked for, we must comply with the decision. We must complete the described action(s) within 30 calendar days of the date we received a copy of the decision.
• If the State Hearing decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. We may stop any aid paid pending you are receiving. 

If your Level 2 Appeal was an Independent Medical Review, the Department of Managed Health Care will send you a letter explaining its decision. 

• If the Independent Medical Review decision is Yes to part or all of what you asked for, we must provide the service or treatment.
• If the Independent Medical Review decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. You can still get a State Hearing.

If your Level 2 Appeal went to the Medicare Independent Review Entity, it will send you a letter explaining its decision.

• If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize the medical care coverage within 72 hours or give you the service or item within 14 calendar days from the date we receive the IRE’s decision. 
• If the Independent Review Entity says No to part or all of what you asked for, it means they agree with the Level 1 decision. This is called “upholding the decision.” It is also called “turning down your appeal.”

If the decision is No for all or part of what I asked for, can I make another appeal?
If your Level 2 Appeal was a State Hearing, you may ask for a rehearing within 30 days after you receive the decision. You may also ask for judicial review of a State Hearing denial by filing a petition in Superior Court (under Code of Civil Procedure Section 1094.5) within one year after you receive the decision. 

If your Level 2 Appeal was an Independent Medical Review, you can request a State Hearing. 

If your Level 2 Appeal went to the Medicare Independent Review Entity, you can appeal again only if the dollar value of the service or item you want meets a certain minimum amount. The letter you get from the IRE will explain additional appeal rights you may have.

Payment Problems

We do not allow our network providers to bill you for covered services and items. This is true even if we pay the provider less than the provider charges for a covered service or item. You are never required to pay the balance of any bill. The only amount you should be asked to pay is the copay for service, item, and/or drug categories that require a copay. If you get a bill that is more than your copay for covered services and items, send the bill to us. You should not pay the bill yourself. We will contact the provider directly and take care of the problem.

How do I ask the plan to pay me back for the plan’s share of medical services or items I paid for?
Remember, if you get a bill that is more than your copay for covered services and items, you should not pay the bill yourself. But if you do pay the bill, you can get a refund if you followed the rules for getting services and items. 

If you are asking to be paid back, you are asking for a coverage decision. We will see if the service or item you paid for is a covered service or item, and we will check to see if you followed all the rules for using your coverage.

• If the service or item you paid for is covered and you followed all the rules, we will send you the payment for our share of the cost of the service or item within 60 calendar days after we get your request.

Or, if you haven’t paid for the service or item yet, we will send the payment directly to the provider. When we send the payment, it’s the same as saying Yes to your request for a coverage decision.

• If the service or item is not covered, or you did not follow all the rules, we will send you a letter telling you we will not pay for the service or item and explaining why.

What if the plan says they will not pay?
If you do not agree with our decision, you can make an appeal. Follow the appeals process. When you are following these instructions, please note:

• If you make an appeal for reimbursement, we must give you our answer within 60 calendar days after we get your appeal.
• If you are asking us to pay you back for medical care you have already received and paid for yourself, you are not allowed to ask for a fast appeal. 

If we answer “no” to your appeal and the service or item is usually covered by Medicare, we will automatically send your case to the Independent Review Entity. We will notify you by letter if this happens.

• If the IRE reverses our decision and says we should pay you, we must send the payment to you or to the provider within 30 calendar days. If the answer to your appeal is Yes at any stage of the appeals process after Level 2, we must send the payment you asked for to you or to the provider within 60 calendar days.
• If the IRE says No to your appeal, it means they agree with our decision not to approve your request. (This is called “upholding the decision.” It is also called “turning down your appeal.”) The letter you get will explain additional appeal rights you may have. You can appeal again only if the dollar value of the service or item you want meets a certain minimum amount.

If we answer “no” to your appeal and the service or item is usually covered by Medi-Cal, you can file a Level 2 Appeal yourself (see above).

IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal.

Information on this page is current as of October 01, 2022.
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Part D: Coverage Determination and Appeals

This page provides you information on what to do if you have problems getting a Part D drug or you want us to pay you back for a Part D drug.

Your benefits as a member of our plan include coverage for many prescription drugs. Most of these drugs are “Part D drugs.” There are a few drugs that Medicare Part D does not cover but that Medi-Cal may cover.

Can I ask for a coverage determination or make an appeal about Part D prescription drugs?

Yes. Here are examples of coverage determination you can ask us to make about your Part D drugs. 

• You ask us to make an exception such as:
• Asking us to cover a Part D drug that is not on the plan’s List of Covered Drugs (Formulary)
• Asking us to waive a restriction on the plan’s coverage for a drug (such as limits on the amount of the drug you can get)
• You ask us if a drug is covered for you (for example, when your drug is on the plan’s Formulary but we require you to get approval from us before we will cover it for you).
• Please note: If your pharmacy tells you that your prescription cannot be filled, you will get a notice explaining how to contact us to ask for a coverage determination.
• You ask us to pay for a prescription drug you already bought. This is asking for a coverage determination about payment.

If you disagree with a coverage decision we have made, you can appeal our decision.

What is an exception?

An exception is permission to get coverage for a drug that is not normally on our List of Covered Drugs, or to use the drug without certain rules and limitations. If a drug is not on our List of Covered Drugs, or is not covered in the way you would like, you can ask us to make an “exception.”

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception.

Here are examples of exceptions that you or your doctor or another prescriber can ask us to make: 

1. Covering a Part D drug that is not on our List of Covered Drugs (Formulary).
   • If we agree to make an exception and cover a drug that is not on the Formulary, you will need to pay the cost-sharing amount that applies to drug.
   • You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug.
2. Removing a restriction on our coverage. There are extra rules or restrictions that apply to certain drugs on our Formulary.
   • The extra rules and restrictions on coverage for certain drugs include:
     • Being required to use the generic version of a drug instead of the brand name drug.
     • Getting plan approval before we will agree to cover the drug for you. (This is sometimes called “prior authorization.”)
     • Being required to try a different drug first before we will agree to cover the drug you are asking for. (This is sometimes called “step therapy.”)
     • Quantity limits. For some drugs, the plan limits the amount of the drug you can have.
   • If we agree to make an exception and waive a restriction for you, you can still ask for an exception to the co-pay amount we require you to pay for the drug.

Important things to know about asking for exceptions

Your doctor or other prescriber must give us a statement explaining the medical reasons for requesting an exception. Our decision about the exception will be faster if you include this information from your doctor or other prescriber when you ask for the exception.

Typically, our Formulary includes more than one drug for treating a particular condition. These different possibilities are called “alternative” drugs. If an alternative drug would be just as effective as the drug you are asking for, and would not cause more side effects or other health problems, we will generally not approve your request for an exception.

We will say Yes or No to your request for an exception.

• If we say Yes to your request for an exception, the exception usually lasts until the end of the calendar year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.
• If we say No to your request for an exception, you can ask for a review of our decision by making an appeal.

Coverage Decision

What to do

• Ask for the type of coverage decision you want. Call, write, or fax us to make your request. You, your representative, or your doctor (or other prescriber) can do this.  
  • You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY users should call 1-800-718-4347.
  • You can fax us at: (909) 890-5877 
  • You can to write us at:
    IEHP DualChoice
    P.O. Box 1800
    Rancho Cucamonga, CA 91729-1800
• You or your doctor (or other prescriber) or someone else who is acting on your behalf can ask for a coverage decision. You can also have a lawyer act on your behalf.
• You do not need to give your doctor or other prescriber written permission to ask us for a coverage determination on your behalf.
• If you are requesting an exception, provide the “supporting statement.” Your doctor or other prescriber must give us the medical reasons for the drug exception. We call this the “supporting statement.” 

Your doctor or other prescriber can fax or mail the statement to us. Or your doctor or other prescriber can tell us on the phone, and then fax or mail a statement.

• Request for Medicare Prescription Drug Coverage Determination (PDF)

These forms are also available on the CMS website:

Medicare Prescription Drug Determination Request Form (for use by enrollees and providers)

By clicking on this link, you will be leaving the IEHP DualChoice website.

Deadlines for a “standard coverage decision” about a drug you have not yet received

• If we are using the standard deadlines, we must give you our answer within 72 hours after we get your request or, if you are asking for an exception, after we get your doctor’s or prescriber’s supporting statement. We will give you our answer sooner if your health requires it.
• If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. At Level 2, an Independent Review Entity will review the decision.

If our answer is Yes to part or all of what you asked for, we must approve or give the coverage within 72 hours after we get your request or, if you are asking for an exception, your doctor’s or prescriber’s supporting statement. 

If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No. The letter will also explain how you can appeal our decision.

Deadlines for a “standard coverage decision” about payment for a drug you have already bought

• We must give you our answer within 14 calendar days after we get your request.
• If we do not meet this deadline, we will send your request to Level 2 of the appeals process. At level 2, an Independent Review Entity will review the decision.

If our answer is Yes to part or all of what you asked for, we will make payment to you within 14 calendar days.

If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No. This statement will also explain how you can appeal our decision.

If your health requires it, ask us to give you a “fast coverage decision”
We will use the “standard deadlines” unless we have agreed to use the “fast deadlines.”

• A standard coverage decision means we will give you an answer within 72 hours after we get your doctor’s statement.
• A fast coverage decision means we will give you an answer within 24 hours after we get your doctor’s statement.

You can get a fast coverage decision only if you are asking for a drug you have not yet received. (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already bought.)

You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.

• If your doctor or other prescriber tells us that your health requires a “fast coverage decision,” we will automatically agree to give you a fast coverage decision, and the letter will tell you that.
• If you ask for a fast coverage decision on your own (without your doctor’s or other prescriber’s support), we will decide whether you get a fast coverage decision.
• If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will use the standard deadlines instead.
  • We will send you a letter telling you that. The letter will tell you how to make a complaint about our decision to give you a standard decision.
  • You can file a “fast complaint” and get a response to your complaint within 24 hours.

Deadlines for a “fast coverage decision”

• If we are using the fast deadlines, we must give you our answer within 24 hours. This means within 24 hours after we get your request. Or, if you are asking for an exception, 24 hours after we get your doctor’s or prescriber’s statement supporting your request. We will give you our answer sooner if your health requires us to.
• If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. At Level 2, an outside independent organization will review your request and our decision.

If our answer is Yes to part or all of what you asked for, we must give you the coverage within 24 hours after we get your request or your doctor’s or prescriber’s statement supporting your request.

If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No. The letter will also explain how you can appeal our decision.

Level 1 Appeal for Part D drugs

To start your appeal, you, your doctor or other prescriber, or your representative must contact us.

• If you are asking for a standard appeal, you can make your appeal by sending a request in writing. You may also ask for an appeal by calling IEHP DualChoice Member Services at 1-877-273-IEHP (4347), 8am – 8pm (PST), 7 days a week, including holidays. TTY/TDD users should call 1-800-718-4347.
• If you want a fast appeal, you may make your appeal in writing or you may call us.
• Make your appeal request within 60 calendar days from the date on the notice we sent to tell you our decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make you appeal.  For example, good reasons for missing the deadline would be if you have a serious illness that kept you from contacting us or if we gave you incorrect or incomplete information about the deadline for requesting an appeal.
• You can ask for a copy of the information in your appeal and add more information.
• You have the right to ask us for a copy of the information about your appeal. 
• If you wish, you and your doctor or other prescriber may give us additional information to support your appeal.

You may use the following form to submit an appeal:

• Coverage Determination Form (PDF)

Can someone else make the appeal for me?
Yes. Your doctor or other provider can make the appeal for you. Also, someone besides your doctor or other provider can make the appeal for you, but first you must complete an Appointment of Representative Form. The form gives the other person permission to act for you.

• If the appeal comes from someone besides you or your doctor or other provider, we must receive the completed Appointment of Representative form before we can review the appeal. 

Deadlines for a “standard appeal”

• If we are using the standard deadlines, we must give you our answer within 7 calendar days after we get your appeal, or sooner if your health requires it. If you think your health requires it, you should ask for a “fast appeal.” If you are asking us to pay you back for a drug you already bought, we must give you our answer within 14 calendar days after we get your appeal.

• If we do not give you a decision within 7 calendar days, or 14 days if you asked us to pay you back for a drug you already bought, we will send your request to Level 2 of the appeals process. At Level 2, an Independent Review Entity will review our decision.

If your health requires it, ask for a “fast appeal”

• If you are appealing a decision our plan made about a drug you have not yet received, you and your doctor or other prescriber will need to decide if you need a “fast appeal.”
• The requirements for getting a “fast appeal” are the same as those for getting a “fast coverage decision.” 

Our plan will review your appeal and give you our decision

• We take another careful look at all of the information about your coverage request. We check to see if we were following all the rules when we said No to your request. We may contact you or your doctor or other prescriber to get more information.

Deadlines for a “fast appeal”

• If we are using the fast deadlines, we will give you our answer within 72 hours after we get your appeal, or sooner if your health requires it.

• If we do not give you an answer within 72 hours, we will send your request to Level 2

of the appeals process. At Level 2, an Independent Review Entity will review your appeal.

If our answer is Yes to part or all of what you asked for, we must give the coverage within 72 hours after we get your appeal.

If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No.

Level 2 Appeal for Part D drugs

If we say No to your appeal, you then choose whether to accept this decision or continue by making another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Entity (IRE) will review our decision.

If you want the Independent Review Organization to review your case, your appeal request must be in writing.  

• Ask within 60 days of the decision you are appealing. If you miss the deadline for a good reason, you may still appeal.
• You, your doctor or other prescriber, or your representative can request the Level 2 Appeal.

When you make an appeal to the Independent Review Entity, we will send them your case file. You have the right to ask us for a copy of your case file. You have a right to give the Independent Review Entity other information to support your appeal. The Independent Review Entity is an independent organization that is hired by Medicare. It is not connected with this plan and it is not a government agency. Reviewers at the Independent Review Entity will take a careful look at all of the information related to your appeal. The organization will send you a letter explaining its decision.

If we uphold the denial after Redetermination, you have the right to request a Reconsideration. See form below:

• Reconsideration Form (PDF)

Deadlines for a “fast appeal” at Level 2
If your health requires it, ask the Independent Review Entity for a “fast appeal.”

• If the review organization agrees to give you a “fast appeal,” it must give you an answer to your Level 2 Appeal within 72 hours after getting your appeal request.
• If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize or give you the drug coverage within 24 hours after we get the decision.

Deadlines for “standard appeal” at Level 2
If you have a standard appeal at Level 2, the Independent Review Entity must give you an answer to your Level 2 Appeal within 7 calendar days after it gets your appeal.

• If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize or give you the drug coverage within 72 hours after we get the decision.  
• If the Independent Review Entity approves a request to pay you back for a drug you already bought, we will send payment to you within 30 calendar days after we get the decision.

What if the Independent Review Entity says No to your Level 2 Appeal?
No means the Independent Review Entity agrees with our decision not to approve your request. This is called “upholding the decision.” It is also called “turning down your appeal.”

If the dollar value of the drug coverage you want meets a certain minimum amount, you can make another appeal at Level 3. The letter you get from the Independent Review Entity will tell you the dollar amount needed to continue with the appeals process. The Level 3 Appeal is handled by an administrative law judge.

For more information see Chapter 9 of your IEHP DualChoice Member Handbook.

IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal.

Information on this page is current as of October 01, 2022.
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Making Complaints

The formal name for “making a complaint” is “filing a grievance.” A grievance is the kinds of problems related to:

• Quality of your medical care
• Respecting your privacy
• Disrespect, poor customer service, or other negative behaviors
• Physical accessibility
• Waiting times
• Cleanliness
• Information you get from our plan
• Language access
• Communication from us
• Timeliness of our actions related to coverage decisions or appeals

How to file a Grievance with IEHP DualChoice (HMO D-SNP)

1. Contact us promptly – call IEHP DualChoice at (877) 273-IEHP (4347), 8am - 8pm, 7 days a week, including holidays.TTY users should call 1-800-718-4347. You can make the complaint at any time unless it is about a Part D drug. If the complaint is about a Part D drug, you must file it within 60 calendar days after you had the problem you want to complain about.

If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing. 

• You can use our "Member Appeal and Grievance Form." All of our Doctor’s offices and service providers have the form or we can mail one to you. You can file a grievance online. You can give a completed form to our Plan provider or send it to us at the address listed below or fax the completed form to the fax number listed below. This form is for IEHP DualChoice as well as other IEHP programs.

IEHP DualChoice 
P.O. Box 1800
Rancho Cucamonga, CA 91729-1800
Fax: (909) 890-5877

Whether you call or write, you should contact IEHP DualChoice Member Services right away.

2. We will look into your complaint and give you our answer

• If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that.
• Most complaints are answered in 30 calendar days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more days (44 days total) to answer your complaint.
• If we do not agree with some or all of your complaint or don’t take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.

Fast Grievances

If you are making a complaint because we denied your request for a “fast coverage determination” or fast appeal, we will automatically give you a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours.

Who may file a grievance?

You or someone you name may file a grievance. The person you name would be your “representative.”  You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. To learn how to name your representative, you may call IEHP DualChoice Member Services.

External Complaints

You can tell Medicare about your complaint

You can send your complaint to Medicare. The Medicare Complaint Form is available at: https://www.medicare.gov/MedicareComplaintForm/home.aspx.

Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program.

If you have any other feedback or concerns, or if you feel the plan is not addressing your problem, please call (800) MEDICARE (800) 633-4227). TTY/TDD (877) 486-2048. The call is free.

You can tell Medi-Cal about your complaint

The Office of the Ombudsman also helps solve problems from a neutral standpoint to make sure that our members get all the covered services that we must provide. The Office of the Ombudsman is not connected with us or with any insurance company or health plan.

The phone number for the Office of the Ombudsman is 1-888-452-8609. The services are free.

You can tell the California Department of Managed Health Care about your complaint

The California Department of Managed Health Care (DMHC) is responsible for regulating health plans. You can call the DMHC Help Center for help with complaints about Medi-Cal services. You may contact the DMHC if you need help with a complaint involving an urgent issue or one that involves an immediate and serious threat to your health, you disagree with our plan’s decision about your complaint, or our plan has not resolved your complaint after 30 calendar days.

Here are two ways to get help from the Help Center:

• Call (888) 466-2219, TTY (877) 688-9891. The call is free.
• Visit the Department of Managed Health Care's website: http://www.dmhc.ca.gov/

You can file a complaint with the Office for Civil Rights

You can make a complaint to the Department of Health and Human Services’ Office for Civil Rights if you think you have not been treated fairly. For example, you can make a complaint about disability access or language assistance. The phone number for the Office for Civil Rights is (800) 368-1019. TTY users should call (800) 537-7697. You can also visit https://www.hhs.gov/ocr/index.html for more information.

You may also contact the local Office for Civil Rights office at:

U.S. Department of Health and Human Services

90 7th Street, Suite 4-100

San Francisco, CA 94103

Telephone: (800) 368-1019

TDD: (800) 537-7697

Fax: (415) 437-8329

You may also have rights under the Americans with Disability Act. You can contact the Office of the Ombudsman for assistance. The phone number is (888) 452-8609.

When your complaint is about quality of care

You have two extra options:

• You can make your complaint to the Quality Improvement Organization. If you prefer, you can make your complaint about the quality of care you received directly to this organization (without making the complaint to our plan). To find the name, address, and phone number of the Quality Improvement Organization in your state, look in Chapter 2 of your IEHP DualChoice Member Handbook. If you make a complaint to this organization, we will work with them to resolve your complaint.
• Or you can make your complaint to both at the same time. If you wish, you can make your complaint about quality of care to our plan and also to the Quality Improvement Organization.

For more information on Grievances see Chapter 9 of your IEHP DualChoice Member Handbook.

Handling problems about your Medi-Cal benefits

If you have Medi-Cal with IEHP and would like information on how to pursue appeals and grievances related to Medi-Cal covered services, please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), TTY (800) 718-4347, 8am - 8pm (PST), 7 days a week, including holidays.

IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal.

Information on this page is current as of October 01, 2022.
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Rights and Responsibilities as a Member of IEHP DualChoice

As an IEHP DualChoice (HMO D-SNP) Member, you have the right to:

1. Receive information about your rights and responsibilities as an IEHP DualChoice Member.
2. Be treated with respect and courtesy. IEHP DualChoice recognizes your dignity and right   to privacy.
3. Receive services without regard to race, ethnicity, national origin, religion, sex, age, mental or physical disability or medical condition, sexual orientation, claims experience, medical history, evidence of insurability (including conditions arising out of acts of domestic violence), disability, genetic information, or source of payment. 
4. Receive information about IEHP DualChoice, its programs and services, its Doctors, Providers, health care facilities, and your drug coverage and costs, which you can understand.
5. Have a Primary Care Provider who is responsible for coordination of your care.
6. If your Primary Care Provider changes, your IEHP DualChoice benefits and required co-payments will stay the same.
7. Your IEHP DualChoice Doctor cannot charge you for covered health care services, except for required co-payments.
8. Request a second opinion about a medical condition.
9. Receive emergency care whenever and wherever you need it.
10. See plan Providers, get covered services, and get your prescription filled timely.
11. Receive information about clinical programs, including staff qualifications, request a change of treatment choices, participate in decisions about your health care, and be informed of health care issues that require self-management.
12. If you have been receiving care from a health care provider, you may have a right to keep your provider for a designated time period.
13. If you are under a Doctor’s care for an acute condition, serious chronic condition, pregnancy, terminal illness, newborn care, or a scheduled surgery, you may ask to continue seeing your current Doctor. To make this request, or if you have any concerns about your continuity of care, please call IEHP DualChoice Member Services at 1-877-273-IEHP (4347).
14. Receive Member informing materials in alternative formats, including Braille, large print, and audio.
15. Information on procedures for obtaining prior authorization of services, Quality Assurance, disenrollment, and other procedures affecting IEHP DualChoice Members.
16. IEHP DualChoice will honor authorizations for services already approved for you. If you have any authorizations pending approval, if you are in them idle of treatment, or if specialty care has been scheduled for you by your current Doctor, contact IEHP to help you coordinate your care during this transition time. Call IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY users should call 1-800-718-4347.
17. Review, request changes to, and receive a copy of your medical records in a timely fashion.
18. Receive interpreter services at no cost.
19. Notify IEHP if your language needs are not met.
20. Make recommendations about IEHP DualChoice Members’ rights and responsibilities policies.
21. Be informed regarding Advance Directives, Living Wills, and Power of Attorney, and to receive information regarding changes related to existing laws.
22. Decide in advance how you want to be cared for in case you have a life-threatening illness or injury.
23. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation
24. Complain about IEHP DualChoice, its Providers, or your care. IEHP DualChoice will help you with the process. You have the right to choose someone to represent you during your appeal or grievance process and for your grievances and appeals to be reviewed as quickly as possible and be told how long it will take.
• Have grievances heard and resolved in accordance with Medicare guidelines;
• Request quality of care grievances data from IEHP DualChoice.
25. Appeal any decision IEHP DualChoice makes regarding, but not limited to, a denial, termination, payment, or reduction of services. This includes denial of payment for a service after the service has been rendered (post-service) or denial of service prior to the service being rendered (pre-service).
• Request fast reconsideration;
• Request and receive appeal data from IEHP DualChoice;
• Receive notice when an appeal is forwarded to the Independent Review Entity (IRE);
• Automatic reconsideration by the IRE when IEHP DualChoice upholds its original adverse determination in whole or in part;
• Administrative Law Judge (ALJ) hearing if the independent review entity upholds the original adverse determination in whole or in part and the remaining amount in controversy is $100 or more;
• Request Departmental Appeals Board (DAB) review if the ALJ hearing is unfavorable to the Member in whole or in part;
• Judicial review of the hearing decision if the ALJ hearing and/or DAB review is unfavorable to the Member in whole or in part and the amount remaining in controversy is $1,000 or more;
• Make a quality of care complaint under the QIO process;
• Request QIO review of a determination of noncoverage of inpatient hospital care;
• Request QIO review of a determination of noncoverage in skilled nursing facilities, home health agencies and comprehensive outpatient rehabilitation facilities;
• Request a timely copy of your case file, subject to federal and state law regarding confidentiality of patient information;
• Challenge local and national Medicare coverage determination.

As an IEHP DualChoice Member, you have the responsibility to:

1. Review your Member Handbook, and call IEHP DualChoice Member Services if you do not understand something about your coverage and benefits
2. Inform your Doctor about your medical condition, and concerns.
3. Follow the plan of treatment your Doctor feels is necessary
4. Make necessary appointments for routine and sick care, and inform your Doctor when you are unable to make a scheduled appointment.
5. Learn about your health needs and leading a healthy lifestyle.
6. Make every effort to participate in the health care programs IEHP DualChoice offers you.

For more information on Member Rights and Responsibilities refer to Chapter 8 of your IEHP DualChoice Member Handbook.

Rights and Responsibilities Upon Disenrollment

Ending your membership in IEHP DualChoice (HMO D-SNP) may be voluntary (your own choice) or involuntary (not your own choice)

• You might leave our plan because you have decided that you want to leave.
• There are also limited situations where you do not choose to leave, but we are required to end your membership.Chapter 10 of your IEHP DualChoice Member Handbook tells you about situations when we must end your membership.

When can you end your membership in our plan?

• Because you get assistance from Medi-Cal, you can end your membership in IEHP DualChoice at any time.
• Your membership will usually end on the first day of the month after we receive your request to change plans. Your enrollment in your new plan will also begin on this day.

How to voluntarily end your membership in our plan?

1. If you would like to switch from our plan to another Medicare Advantage plan simply enroll in the new Medicare Advantage plan. You will be automatically disenrolled from IEHP DualChoice, when your new plan’s coverage begins.
2. If you would like to switch from our plan to Original Medicare but you have not selected a separate Medicare prescription drug plan. You must ask to be disenrolled from IEHP DualChoice. There are two ways you can asked to be disenrolled:

• To disenroll, please call Health Care Options (HCO) at 1-844-580-7272, 8am - 6pm (PST), Monday - Friday. TTY/TDD users should call 1-800-430-7077. For more information visit the DHCS website. By clicking on this link, you will be leaving the IEHP DualChoice website.
• Or you can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Until your membership ends, you are still a member of our plan.

If you leave IEHP DualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. (See Chapter 10 of the IEHP DualChoice Member Handbook for information on when your new coverage begins.) During this time, you must continue to get your medical care and prescription drugs through our plan.

• You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends. Usually, your prescription drugs are only covered if they are filled at a network pharmacy including through our mail-order pharmacy services.
• If you are hospitalized on the day that your membership ends, you will usually be covered by our plan until you are discharged (even if you are discharged after your new health coverage begins).
• If you no longer qualify for Medi-Cal or your circumstances have changed that make you no longer eligible for Dual Special Needs Plan, you may continue to get your benefits from IEHP DualChoice for an additional two-month period. This additional time will allow you to correct your eligibility information if you believe that you are still eligible. You will get a letter from us about the change in your eligibility with instructions to correct your eligibility information.
• To stay a member of IEHP DualChoice, you must qualify again by the last day of the two-month period.
• If you do not qualify by the end of the two-month period, you’ll de disenrolled by IEHP DualChoice.

Involuntarily ending your membership

IEHP DualChoice must end your membership in the plan if any of the following happen:

• If you do not stay continuously enrolled in Medicare Part A and Part B.
• If you move out of our service area for more than six months.       
• If you become incarcerated.
• If you lie about or withhold information about other insurance you have that provides prescription drug coverage.
• If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan.
• If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other members of our plan.
• If you let someone else use your membership card to get medical care.
• To be a Member of IEHP DualChoice, you must keep your eligibility with Medi-Cal and Medicare. If you lose your zero share-of-cost, full scope Medi-Cal, you will be disenrolled from our plan (for your Medicare benefits) the first day of the following month and will be covered by the Original Medicare.
• The State or Medicare may disenroll you if you are determined no longer eligible to the program.

IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal.

Information on this page is current as of October 01, 2022.
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Resources

• 2023 IEHP DualChoice Member Handbook (PDF)
  
• Appointment of Representatives Form (PDF)
• Medicare Complaint Form (by clicking this link, you will be leaving the IEHP DualChoice website)

The IEHP DualChoice Privacy Notice describes how medical information about you may be used and disclosed, and how you can get access to this information.

• IEHP DualChoice Privacy Notice (PDF)

Centers for Medicare and Medicaid Services

The following link will take you to the Centers for Medicaid and Medicare Services website, where you can look through the CMS Best Available Evidence Policy using the following link: CMS Best Available Evidence Policy. By clicking on this link, you will be leaving the IEHP DualChoice website.

You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here. By clicking on this link, you will be leaving the IEHP DualChoice website.

IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contact renewal.

Information on this page is current as of October 01, 2022.
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Prescription Drugs

IEHP DualChoice (HMO D-SNP) has contracts with pharmacies that equals or exceeds CMS requirements for pharmacy access in your area. There are over 700 pharmacies in the IEHP DualChoice network. IEHP DualChoice network providers are required to comply with minimum standards for pharmacy practices as established by the State of California.

What Prescription Drugs Does IEHP DualChoice Cover?

IEHP DualChoice (HMO D-SNP) has a list of Covered Drugs called a Formulary. It tells which Part D prescription drugs are covered by IEHP DualChoice. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. Medicare has approved the IEHP DualChoice Formulary. 

Find a covered drug below:

• 2023 Formulary (PDF)
• Formulary Change (PDF)
• 2023 Step Therapy (PDF)
• 2023 Drugs Requiring Prior Authorization (PDF)

Which Pharmacies Does IEHP DualChoice Contract With?

Our IEHP DualChoice (HMO D-SNP) Provider and Pharmacy Directory gives you a complete list of our network pharmacies – that means all of the pharmacies that have agreed to fill covered prescriptions for our plan members.

Generally, you must receive all routine care from plan providers and network pharmacies to access their prescription drug benefits, except in non-routine circumstances, quantity limitations and restrictions may apply. 

This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. Limitations, copays, and restrictions may apply. Copays for prescription drugs may vary based on the level of Extra Help you receive. Benefits and copayments may change on January 1 of each year. The List of Covered Drugs and pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. For more information, call IEHP DualChoice Member Services or read the IEHP DualChoice Member Handbook. 

• 2023 IEHP DualChoice Provider and Pharmacy Directory (PDF)

You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy here. By clicking on this link, you will be leaving the IEHP DualChoice website. 

If you don’t have the IEHP DualChoice Provider and Pharmacy Directory, you can get a copy from IEHP DualChoice Member Services. At any time, you can call IEHP DualChoice Member Services to get up-to-date information about changes in the pharmacy network. Call IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY users should call 1-800-718-4347.

Out of Network Coverage

Generally, IEHP DualChoice (HMO D-SNP) will cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

• What if I need a prescription because of a medical emergency?

  We will cover prescriptions that are filled at an out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgently needed care. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. To learn how to submit a paper claim, please refer to the paper claims process described below.



• Getting coverage when you travel or are away from the Plan’s service area

  If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply of the drug before you leave. When possible, take along all the medication you will need. You may be able to order your prescription drugs ahead of time through our network mail order pharmacy service or through a retail network pharmacy that offers an extended supply.

  If you are traveling within the US, but outside of the Plan’s service area, and you become ill, lose or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy if you follow all other coverage rules identified within this document and a network pharmacy is not available. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form. To learn how to submit a paper claim, please refer to the paper claims process described below.

  Prior to filling your prescription at an out-of-network pharmacy, call IEHP DualChoice Member Services to find out if there is a network pharmacy in the area where you are traveling. If there are no network pharmacies in that area, IEHP DualChoice Member Services may be able to make arrangements for you to get your prescriptions from an out-of-network pharmacy.

  We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency.



• What if you are outside the plan’s service area when you have an urgent need for care?

  When you are outside the service area and cannot get care from a network provider, our plan will cover urgently needed care that you get from any provider. Our plan does not cover urgently needed care or any other care if you receive the care outside of the United States.



• Other times you can get your prescription covered if you go to an out-of-network pharmacy

  We will cover your prescription at an out-of-network pharmacy if at least one of the following applies:

  • If you are unable to get a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24-hour service.
  • If you are trying to fill a covered prescription drug that is not regularly stocked at an eligible network retail or mail order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals). In these situations, please check first with IEHP DualChoice Member Services to see if there is a network pharmacy nearby. 


• How do you ask for reimbursement from the plan? 

  If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than paying your normal share of the cost) when you fill your prescription. You can ask us to reimburse you for IEHP DualChoice's share of the cost. Send us your request for payment, along with your bill and documentation of any payment you have made. It’s a good idea to make a copy of your bill and receipts for your records. Mail your request for payment together with any bills or receipts to us at this address: 

  IEHP DualChoice
  P.O. Box 4259
  Rancho Cucamonga, CA 91729-4259 

  You must submit your claim to us within 1 year of the date you received the service, item, or drug. Please be sure to contact IEHP DualChoice Member Services if you have any questions. If you don’t know what you should have paid, or you receive bills and you don’t know what to do about those bills, we can help. You can also call if you want to give us more information about a request for payment you have already sent to us. See Chapters 7 and 9 of the IEHP DualChoice Member Handbook to learn how to ask the plan to pay you back.

Changes to the IEHP DualChoice Formulary

IEHP DualChoice Formulary consists of medications that are considered as first line therapies (drugs that should be used first for the indicated conditions). IEHP DualChoice develops and maintains the Formulary continuously by reviewing the efficacy (how effective) and safety (how safe) of new drugs, compare new versus existing drugs, and develops clinical practice guidelines based on clinical evidence.

From time to time (during the benefit year), IEHP DualChoice revises (adding or removing drugs) the Formulary based on new clinical evidence and availability of products in the market.  All the changes are reviewed and approved by a selected group of Providers and Pharmacists that are currently in practice.

IEHP DualChoice will give notice to IEHP DualChoice Members prior to removing Part D drug from the Part D formulary. We will also give notice if there are any changes regarding prior authorizations, quantity limits, step therapy or moving a drug to a higher cost-sharing tier.

If IEHP DualChoice removes a Covered Part D drug or makes any changes in the IEHP DualChoice Formulary, we will post the formulary changes on IEHP DualChoice website and notify the affected Members at least thirty (30) days prior to effective date of the change made on the IEHP DualChoice Formulary. However, if the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market we will immediately remove the drug from our formulary.

Some changes to the Drug List will happen immediately. For example:

• A new generic drug becomes available. Sometimes, a new and cheaper drug comes along that works as well as a drug on the Drug List now. When that happens, we may remove the current drug, but your cost for the new drug will stay the same or will be lower. When we add the new generic drug, we may also decide to keep the current drug on the list but change its coverage rules or limits.
  • We may not tell you before we make this change, but we will send you information about the specific change or changes we made.
  • You or your provider can ask for an “exception” from these changes. We will send you a notice with the steps you can take to ask for an exception. Please see Chapter 9 (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]) of the Member Handbook for more information on exceptions.
• A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drug’s manufacturer takes a drug off the market, we will take it off the Drug List. If you are taking the drug, we will let you know. Your provider will also know about this change. He or she can work with you to find another drug for your condition.

We may make other changes that affect the drugs you take.

We will tell you in advance about these other changes to the Drug List. These changes might happen if:

• The FDA provides new guidance or there are new clinical guidelines about a drug.
• We add a generic drug that is not new to the market and:
  • Replace a brand name drug currently on the Drug List or
  • Change the coverage rules or limits for the brand name drug.

When these changes happen, we will tell you at least 30 days before we make the change to the Drug List or when you ask for a refill. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Then you can:

• Get a 31-day supply of the drug before the change to the Drug List is made, or
• Ask for an exception from these changes. To learn more about asking for exceptions, see Chapter 9 (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]).

Again, if a drug is suddenly recalled because it’s been found to be unsafe or for other reasons, the plan will immediately remove the drug from the Formulary. We will let you know of this change right away.

Your doctor will also know about this change and can work with you to find another drug for your condition.

How will you find out if your drugs coverage has been changed?

If IEHP DualChoice removes a covered Part D drug or makes any changes in the IEHP DualChoice Formulary, IEHP DualChoice will post the formulary changes on the IEHP DualChoice website and notify the affected Members at least thirty (30) days prior to effective date of the change made on the IEHP DualChoice Formulary. However, if the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market we will immediately remove the drug from our formulary.

Getting Plan Approval

For certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for you. This is called “prior authorization.” Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan. For additional information on step therapy and quantity limits, refer to Chapter 5 of the IEHP DualChoice Member Handbook. Use the IEHP Medicare Prescription Drug Coverage Determination Form for a prior authorization.

• Request for Medicare Prescription Drug Coverage Determination (PDF)
• Model Form Instructions
  

These forms are also available on the CMS website: 
Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). 

By clicking on this link, you will be leaving the IEHP DualChoice website.

Applicable Conditions and limitations

We will generally cover a drug on the plan’s Formulary as long as you follow the other coverage rules explained in Chapter 6 of the IEHP DualChoice Member Handbook and the drug is medically necessary, meaning reasonable and necessary for treatment of your injury or illness. It also needs to be an accepted treatment for your medical condition.

Here are three general rules about drugs that Medicare drug plans will not cover under Part D:

• Our plan’s Part D drug coverage cannot cover a drug that would be covered under Medicare Part A or Part B.
• Our plan cannot cover a drug purchased outside the United States and its territories.
• Our plan usually cannot cover off-label use. “Off-label use” is any use of the drug other than those indicated on a drug’s label as approved by the Food and Drug Administration.

For more information refer to Chapter 6 of your IEHP DualChoice Member Handbook.

Getting a temporary supply

In some cases, we can give you a temporary supply of a drug when the drug is not on the Drug List or when it is limited in some way. This gives you time to talk with your provider about getting a different drug or to ask us to cover the drug.

To get a temporary supply of a drug, you must meet the two rules below:

1. The drug you have been taking:
   • is no longer on our Drug List, or
   • was never on our Drug List, or
   • is now limited in some way.
2. You must be in one of these situations:
• You were in the plan last year.
• You are new to our plan.
• You have been in the plan for more than 90 days and live in a long-term care facility and need a supply right away.

When you get a temporary supply of a drug, you should talk with your provider to decide what to do when your supply runs out. Here are your choices:

• You can change to another drug.

  There may be a different drug covered by our plan that works for you. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. The list can help your provider find a covered drug that might work for you.

OR

• You can ask for an exception.

  You and your provider can ask us to make an exception. For example, you can ask us to cover a drug even though it is not on the Drug List. Or you can ask us to cover the drug without limits. If your provider says you have a good medical reason for an exception, he or she can help you ask for one.

If a drug you are taking will be taken off the Drug List or limited in some way for next year, we will allow you to ask for an exception before next year.

• We will tell you about any change in the coverage for your drug for next year. You can then ask us to make an exception and cover the drug in the way you would like it to be covered for next year.
• We will answer your request for an exception within 72 hours after we get your request (or your prescriber’s supporting statement).

Medicare Prescription Drug Coverage and Your Rights Notice- Posting of Member Drug Coverage Rights:

Medicare requires pharmacies to provide notice to enrollees each time a member is denied coverage or disagrees with cost-sharing information.

You have a right to appeal or ask for Formulary exception if you disagree with the information provided by the pharmacist.  Read your Medicare Member Drug Coverage Rights.  

Drug Utilization Management

We conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one provider who prescribes their drugs.

IEHP DualChoice (HMO D-SNP) has a process in place to identify and reduce medication errors. We do a review each time you fill a prescription. We also review our records on a regular basis. During these reviews, we look for potential problems such as:

• Possible medication errors.
• Drugs that may not be necessary because you are taking another drug to treat the same medical condition.
• Drugs that may not be safe or appropriate because of your age or gender.
• Certain combinations of drugs that could harm you if taken at the same time.
• Prescriptions written for drugs that have ingredients you are allergic to.
• Possible errors in the amount (dosage) or duration of a drug you are taking.
• Over-utilization and under-utilization
• Clinical abuse/misuse

If we see a possible problem in your use of medications, we will work with your Doctor to correct the problem. IEHP DualChoice also provides information to the Centers for Medicare and Medicaid Services (CMS) regarding its quality assurance measures according to the guidelines specified by CMS.

Information on this page is current as of October 01, 2022
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