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Member Handbook/
Evidence of Coverage
CareMore Cal MediConnect Plan
(Medicare-Medicaid Plan)
Los Angeles County, CA
2016
This handbook was updated on 08/29/2015.
If you have questions, please call CareMore Cal MediConnect Plan
Member Services at 1-888-350-3447 (TTY 711),
Monday through Friday from 8 a.m. to 8 p.m. Pacific time.
For more information, visit
duals.caremore.com.
H6229_16_24718_U CMS Accepted 08/29/2015
eSOOV_NS_OQTNU_r Cjp Accepíed MULOVLOMNR
CareMore Cal MediConnect Plan
(Medicare-Medicaid Plan)
Member Handbook
January 1, 2016 – December 31, 2016
Your Health and Drug Coverage under CareMore Cal MediConnect
Plan
qhás handbook íells óoî aboîí óoîê coveêage îndeê Caêejoêe Cal jedáConnecí mlan
íhêoîgh aeceãbeê PNI OMNS. fí explaáns healíh caêe seêvácesI behaváoêal healíh Eãeníal
healíh and sîbsíance îse dásoêdeêF seêvácesI pêescêápíáon dêîg coveêageI and longJíeêã
seêváces and sîppoêís. iongJíeêã seêváces and sîppoêís help óoî síaó aí hoãe ánsíead of
goáng ío a nîêsáng hoãe oê hospáíal. iongJíeêã seêváces and sîppoêís consásí of CoããînáíóJ
Based Adîlí peêváces ECBApFI fnJeoãe pîppoêíáve peêváces EfeppFI jîlíápîêpose penáoê
peêváces mêogêaã EjppmFI and kîêsáng cacáláíáes EkcF.
This is an important legal document. Please keep it in a safe place.
qhás Cal jedáConnecí plan ás offeêed bó Caêejoêe eealíh mlan. then íhás Member
Handbook says "we,´ "us,´ or "our,´ it means Caêejoêe eealíh mlan. When it says "the plan´
or "our plan,´ it means Caêejoêe Cal jedáConnecí mlan.
voî can geí íhás ánfoêãaíáon foê fêee án oíheê langîages. Call jeãbeê peêváces aí NJUUUJPRM
PQQT Eqqv TNNF jondaó íhêoîgh cêádaó fêoã U a.ã. ío U p.ã. qhe call ás fêee.
Դուք կարող եք ստանալ այս ձեռնարկն անվճար է այլ լեզուներովW Call NJUUUJPRMJPQQT
երկուշաբթի J ուրբաթ `UWMM J ից UWMM J ինW qqv օգտվողները պետք է զանգահարել TNN.
Կանչի ազատ է
您可以免費取得本手冊其他語言版本。請致電NJUUUJPRMJPQQT，週一至週五，上午 UWMM 至晚
上 UWMM。qqv 使用者可撥打 TNN。此為免費電話
ً‫ *امغط امغا‬NJUUUJPRMJPQQT .ϣ‫ى امرق‬ϡ‫َل غ‬Θ‫ ا‬.َ‫ أعر‬Ζ‫غا‬ϡ‫جاناً ة‬Ϥ ‫ى وذا امكتٌب‬ϡ‫كانك امخٍَل غ‬Ϥ‫ةإ‬
‫ امساغ؍‬ϧϤٌ ‫ػ؍‬ϥ‫ امج‬Ϣًٍ ‫ مغاً؍‬ϧٌ‫ثن‬ٚ‫ ا‬Ϣًٍ ϧϤ ،)711 qqv ،‫ع أٌ امنظر‬ϥ‫ػف قي امس‬π ϣًً‫ مد‬ϧϥϤ ‫اء‬ρ‫غ‬ٚ‫ةا‬
.‫جانٌ؍‬Ϥ ‫؍‬ϥ‫كام‬ϥ‫ وذه ام‬.ً‫ساءا‬Ϥ 8:00 ‫ ٍتاحا ً مغاً؍‬8:00
ΕϋΎγ ί΍ ϭ ϪόϣΟ ΎΗ ϪΑϧηϭΩ ί΍ .Ωϳϧ̯ ΕϓΎϳέΩ Ύϫ ϥΎΑί έϳΎγ ϪΑ ϥΎ̴ϳ΍έ έϭρ ϪΑ ΍έ Ϫ̩έΗϓΩ ϥϳ΍ Ωϳϧ΍ϭΗ ̶ϣ
8:00 ΎΗ ΢Αλ 8:00 ϩέΎϣη ΎΑ Ώη 1-888-350-3447 ϥ΍έΑέΎ̯ .Ωϳέϳ̴Α αΎϣΗ TTY ϩέΎϣη ΎΑ ΩϳΎΑ 711 ϥϳ΍ .Ωϧέϳ̴Α αΎϣΗ
Εγ΍ ϥΎ̴ϳ΍έ αΎϣΗ
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If you have questionsI please call Caêejoêe Cal jedáConnecí mlan aí NJUUUJPRMJPQQT Eqqv TNNF
jondaó íhêoîgh cêádaó fêoã U a.ã. ío U p.ã. AfíeêJhoîês ãessagáng ás avaálable OQ hoîês a daóI T
N
daós a week. qhe call ás fêee. For more informationI vásáí dîals.caêeãoêe.coã.
CAobjlob CAi jbafClkkbCq miAk jbjBbo eAkaBllh
Chapíeê NW deííáng síaêíed as a ãeãbeê
លោកអ្នកអាចទទួលបានល ៀវលៅណែនាំលនេះ លោយឥតគិតថ្លៃ ជាភាសាលសេងលទៀត ។ ូមទូរ ័ព្ទមកលលខ 1-888-3503447 ព្ីថ្លៃចនទ ដល់ថ្លៃ ុក្ក ព្ីល ៉ោ ង 8:00ក្ព្ឹក ដល់ល ៉ោ ង 8:00ោច
ៃ ។ អ្នកលក្រើក្បា ់ TTY ូមលៅមកលលខ 711 ។
ការលៅទូរ ័ព្ទគឺឥតគិតថ្លៃ ។
귀하께서는 이 안내서를 다른 언어로 무료로 받아보실 수 있습니다. 주중 E월J금F 오전
UWMM시에서 오후 UWMM시 사이에 NJUUUJPRMJPQQT번으로 전화해 주십시오. qqv 사용자는
TNN로 전화해 주십시오. 통화는 무료입니다.
Этот справочник можно бесплатно получить в переводе на другие языки. Звоните по
телефону 1JUUUJPRMJ3447, линия работает с понедельника по пятницу с 8:00 до 20:00.
Если вы пользуетесь устройством TTY, звоните по телефону 711. Звонки бесплатные.
mîedes êecábáê esíe ãanîal en oíêos ádáoãas sán caêgo. ilaãa al NJUUUJPRMJPQQT de lînes a
váeênesI de U.MM a.ã. a U.MM p.ã. ios îsîaêáos de qqv deben llaãaê al TNN. ia llaãada es
gêaíîáía.
jakîkîha nánóo nang lábêe ang handbook na áío sa ábang wáka. qawagan ang
NJUUUJPRMJPQQTI iînes hanggang Báóeênes UWMM aã hanggang UWMM pã. Ang ãga
gîãagaãáí ng qqv aó dapaí íawagan ang TNN. iábêe ang pagíawag.
Quý vị có thể nhận sổ tay nây miễn phí bằng các ngôn ngữ khác. Hãy gọi số 1J888J350
3447, từ Thứ Hai đến Thứ Sáu, từ 8 giờ sáng đến 8 giờ tối. Người dûng TTY cần gọi đến số
711. Cuộc gọi được miễn phí.
voî can geí íhás ánfoêãaíáon foê fêee án oíheê foêãaísI sîch as laêge pêáníI bêaálleI oê aîdáo.
Call jeãbeê peêváces aíNJUUUJPRMJPQQT Eqqv TNNF jondaó íhêoîgh cêádaó fêoã U a.ã. ío U
p.ã. qhe call ás fêee.
Disclaimers
Caêejoêe Cal jedáConnecí mlan EjedácaêeJjedácaád mlanF ás a healíh plan íhaí coníêacís
wáíh boíh jedácaêe and jedáJCal ío pêováde benefáís of boíh pêogêaãs ío enêollees.
Caêejoêe adãánásíeês íhe coníêací on behalf of an affáláaíe of Caêejoêe. ®Caêejoêe ás a êegásíeêed íêadeãaêk of Caêejoêe eealíh pósíeã.
iáãáíaíáons and êesíêácíáons ãaó appló. coê ãoêe ánfoêãaíáonI call Caêejoêe Cal jedáConnecí
mlan jeãbeê peêváces oê êead íhe Caêejoêe Cal jedáConnecí mlan jeãbeê eandbook. qhás ãeans íhaí óoî ãaó have ío paó foê soãe seêváces and íhaí óoî need ío follow ceêíaán êîles ío have Caêejoêe Cal jedáConnecí mlan paó foê óoîê seêváces. qhe iásí of Coveêed aêîgs andLoê phaêãacó and pêovádeê neíwoêks ãaó change íhêoîghoîí íhe óeaê.
te wáll send óoî a noíáce befoêe we ãake a change íhaí affecís óoî.
Benefáís andLoê coJpaóãenís ãaó change on ganîaêó N of each óeaê.
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Chapter 1: Getting started as a member
Table of Contents
A. telcoãe ío Caêejoêe Cal jedáConnecí mlan ...............................................................................Q
B. thaí aêe jedácaêe and jedáJCal? ................................................................................................Q
jedácaêe ......................................................................................................................................Q
jedáJCal.......................................................................................................................................R
C. thaí aêe íhe advaníages of íhás plan?...........................................................................................R
D. thaí ás Caêejoêe Cal jedáConnecí mlan’s service area?.............................................................S
E. thaí ãakes óoî elágáble ío be a plan ãeãbeê?.............................................................................S
F. thaí ío expecí when óoî fáêsí âoán a healíh plan ............................................................................T
G. thaí ás a Caêe qeaã and Caêe mlan? ...........................................................................................U
Caêe qeaã ...................................................................................................................................U
Caêe mlan .....................................................................................................................................U
H. aoes Caêejoêe Cal jedáConnecí mlan have a ãoníhló plan pêeãáîã? ........................................U
I. Aboîí íhe jeãbeê eandbook ........................................................................................................V
J. thaí oíheê ánfoêãaíáon wáll óoî geí fêoã îs? .................................................................................V
voîê Caêejoêe Cal jedáConnecí mlan ãeãbeê fa caêd ..............................................................V
mêovádeê and mhaêãacó aáêecíoêó...............................................................................................NM
iásí of Coveêed aêîgs.................................................................................................................NN
qhe bxplanaíáon of Benefáís........................................................................................................NN
K. eow can óoî keep óoîê ãeãbeêsháp êecoêd îp ío daíe? .............................................................NN
ao we keep óoîê peêsonal healíh ánfoêãaíáon pêávaíe? ...............................................................NO
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A. Welcome to CareMore Cal MediConnect Plan
Caêejoêe Cal jedáConnecí mlan ás a Cal jedáConnecí plan. A Cal jedáConnecí plan ás an
oêganázaíáon ãade îp of docíoêsI hospáíalsI phaêãacáesI pêovádeês of longJíeêã seêváces and
sîppoêísI behaváoêal healíh pêovádeêsI and oíheê pêovádeês. fí also has caêe ãanageês and
caêe íeaãs ío help óoî ãanage all óoîê pêovádeês and seêváces. qheó all woêk íogeíheê ío
pêováde íhe caêe óoî need.
Caêejoêe Cal jedáConnecí mlan was appêoved bó Caláfoênáa and íhe Ceníeês foê jedácaêe C
jedácaád peêváces ECjpF ío pêováde óoî seêváces as paêí of Cal jedáConnecí.
Cal jedáConnecí ás a deãonsíêaíáon pêogêaã âoáníló ãonáíoêed bó Caláfoênáa and íhe fedeêal
goveênãení ío pêováde beííeê caêe foê people who have boíh jedácaêe and jedáJCal. rndeê
íhás deãonsíêaíáonI íhe síaíe and fedeêal goveênãení waní ío íesí new waós ío áãpêove how
óoî êeceáve óoîê jedácaêe and jedáJCal seêváces.
Caêejoêe eealíh mlan was síaêíed bó a gêoîp of docíoês án poîíheên Caláfoênáa oveê OM óeaês ago.
Caêejoêe Cal jedáConnecí mlan ás a cooêdánaíed caêe plan íhaí êedefánes how healíh caêe ás
deláveêed.

voîê Cal jedáConnecí mlan coãbánes wellnessI ãedácalI behaváoêal healíh and longJíeêã
seêváces and sîppoêís all án a sángle plan.

Caêejoêe Caêe Ceníeês pêováde óoî wáíh access ío dásease ãanageãení edîcaíáonI onJsáíe
íesíángI ãonáíoêáng and sîppoêí.

janó Caêejoêe Caêe Ceníeês ánclîde onJsáíe fáíness ceníeês íhaí offeê óoî gîáded fáíness
sîppoêí and eqîápãení íhaí ás deságned wáíh oîê ãeãbeês án ãánd.

Caêejoêe Case janageês aêe avaálable ío help cooêdánaíe íhe caêe óoî need. qheó can also
aêêange foê hoãe and coããînáíó seêváces ío help íhose wáíh coãplex caêe needs êeãaán án
íheáê hoãe.

A peêsonal caêe plan wáll be developed íogeíheê wáíh óoî and íhose ánvolved án óoîê
caêe.
B. What are Medicare and Medi-Cal?
Medicare
jedácaêe ás íhe fedeêal healíh ánsîêance pêogêaã foêW
meople SR óeaês of age oê oldeêI
poãe people îndeê age SR wáíh ceêíaán dásabáláíáesI and
meople wáíh endJsíage êenal dásease Ekádneó faálîêeF.
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Medi-Cal
jedáJCal ás the name of California’s jedácaád pêogêaã. jedáJCal ás êîn bó íhe síaíe and ás
paád foê bó íhe síaíe and íhe fedeêal goveênãení. jedáJCal helps people wáíh láãáíed áncoães
and êesoîêces paó foê longJíeêã seêváces and sîppoêís and ãedácal cosís. fí coveês exíêa
seêváces and dêîgs noí coveêed bó jedácaêe.
jedácaêe and Caláfoênáa appêoved Caêejoêe Cal jedáConnecí mlan. voî can geí jedácaêe
and jedáJCal seêváces íhêoîgh oîê plan as long asW
te choose ío offeê íhe planI and
jedácaêe and Caláfoênáa allow îs ío coníánîe ío offeê íhás plan.
bven áf oîê plan síops opeêaíáng án íhe fîíîêeI óoîê elágábáláíó foê jedácaêe and jedáJCal
seêváces woîld noí be affecíed.
C. What are the advantages of this plan?
voî wáll now geí all óoîê coveêed jedácaêe and jedáJCal seêváces fêoã Caêejoêe Cal
jedáConnecí mlanI ánclîdáng pêescêápíáon dêîgs. voî wáll noí paó exíêa ío âoán íhás healíh plan.
Caêejoêe Cal jedáConnecí mlan wáll help ãake óoîê jedácaêe and jedáJCal benefáís woêk
beííeê íogeíheê and woêk beííeê foê óoî. poãe of íhe advaníages ánclîdeW
voî wáll have a caêe íeaã íhaí óoî help pîí íogeíheê. voîê caêe íeaã ãaó ánclîde óoîêselfI
óoîê caêegáveêI docíoêsI nîêsesI coînseloêsI oê oíheê healíh pêofessáonals.
voî wáll have access ío a caêe ãanageê. qhás ás a peêson who woêks wáíh óoîI wáíh Caêejoêe
Cal jedáConnecí mlanI and wáíh óoîê caêe íeaã ío help ãake a caêe plan.
voî wáll be able ío dáêecí óoîê own caêe wáíh help fêoã óoîê caêe íeaã and caêe ãanageê.
qhe caêe íeaã and caêe ãanageê wáll woêk wáíh óoî ío coãe îp wáíh a caêe plan specáfácalló
deságned ío ãeeí óoîê healíh needs. qhe caêe íeaã wáll help cooêdánaíe íhe seêváces óoî
need. qhás ãeansI foê exaãpleW
» voîê caêe íeaã wáll ãake sîêe óoîê docíoês know aboîí all íhe ãedácánes óoî
íake so íheó can ãake sîêe óoî aêe íakáng íhe êághí ãedácánesI and so óoîê
docíoês can êedîce anó sáde effecís óoî ãaó have fêoã íhe ãedácánes.
» voîê caêe íeaã wáll ãake sîêe óoîê íesí êesîlís aêe shaêed wáíh all óoîê docíoês
and oíheê pêovádeêsI as appêopêáaíe.
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D. What is CareMore Cal MediConnect Plan’s service area?
lîê seêváce aêea ánclîdes all paêís of ios Angeles Coîníó wáíh íhe excepíáon of íhe followáng wfm
codesW
90024
90099
90272
90403
90630
91012
91301
91311
91330
91342
91355
91380
91393
91407
91436
91608
91759
93536
93584
90025
90209
90290
90404
90631
91023
91302
91313
91330
91343
91356
91381
91394
91408
91521
91609
92397
93539
93586
90035
90210
90291
90405
90639
91024
91303
91316
91331
91344
91357
91382
91395
91409
91523
91610
92821
93543
93590
90049
90211
90292
90406
90704
91025
91304
91321
91331
91345
91361
91383
91396
91410
91601
91614
92823
93544
93591
90064
90212
90293
90407
90840
91040
91305
91322
91333
91346
91362
91384
91401
91411
91602
91615
93243
93550
90067
90213
90294
90408
90846
91041
91306
91324
91334
91350
91364
91385
91402
91412
91603
91616
93510
93551
90069
90233
90295
90409
91001
91042
91307
91325
91335
91351
91365
91386
91403
91413
91604
91617
93523
93552
90073
90263
90296
90410
91003
91043
91308
91326
91337
91352
91367
91387
91404
91416
91605
91618
93532
93553
90077
90264
90401
90411
91008
91126
91309
91327
91340
91353
91372
91390
91405
91423
91606
91709
93534
93560
90095
90265
90402
90623
91011
91310
91328
91341
91354
91376
91392
91406
91426
91607
91710
93535
93563
lnló people who láve án oîê seêváce aêea can âoán Caêejoêe Cal jedáConnecí mlan.
ff óoî ãove oîísáde of oîê seêváce aêeaI óoî cannoí síaó án íhás plan. voî wáll need ío coníací
óoîê local coîníó elágábáláíó woêkeêW
jedáJCal lffáce NJUMMJRQNJRRRR Eqqv TNNF
E. What makes you eligible to be a plan member?
voî aêe elágáble foê oîê plan as long as óoîW
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
iáve án oîê seêváce aêeaI and

Aêe age ON and oldeê aí íhe íáãe of enêollãeníI and

eave boíh jedácaêe maêí A and jedácaêe maêí BI and

Aêe cîêêeníló elágáble foê jedáJCal.
S
qheêe ãaó be addáíáonal elágábáláíó êîles án óoîê coîníó. Call jeãbeê peêváces foê ãoêe
ánfoêãaíáon.
F. What to expect when you first join a health plan
then óoî fáêsí âoán íhe planI óoî wáll êeceáve a healíh êásk assessãení EeoAF wáíhán íhe fáêsí
VM daós.
te aêe êeqîáêed ío coãpleíe an eoA foê óoî. qhás eoA ás íhe basás foê developáng óoîê
ándávádîal caêe plan EfCmF. qhe eoA wáll ánclîde qîesíáons ío ádeníáfó óoîê ãedácalI longJíeêã
seêváces and sîppoêís EiqppFI and behaváoêal healíh and fîncíáonal needs.
te wáll êeach oîí ío óoî ío coãpleíe íhe eoA. qhe eoA can be coãpleíed bó an ánJpeêson
vásáíI íelephone callI oê ãaál.
te wáll send óoî ãoêe ánfoêãaíáon êegaêdáng íhás eoA.
If CareMore Cal MediConnect Plan is new for youI óoî can keep seeáng íhe docíoês óoî
go ío now foê a ceêíaán aãoîní of íáãe. voî can keep óoîê cîêêení pêovádeês and seêváce
aîíhoêázaíáons aí íhe íáãe óoî enêoll foê îp ío S ãoníhs foê jedácaêe seêváces and îp ío NO
ãoníhs foê jedáJCal seêváces áf all of íhe followáng cêáíeêáa aêe ãeíW
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
voîI óoîê êepêeseníaíáveI oê óoîê pêovádeê ãakes a dáêecí êeqîesí ío îs ío coníánîe ío
see óoîê cîêêení pêovádeê.

te aêe êeqîáêed ío appêove íhás êeqîesí áf we can esíablásh íhaí óoî had an exásíáng
êelaíáonsháp wáíh a pêáãaêó oê specáalíó caêe pêovádeêI wáíh soãe excepíáons.

te wáll deíeêãáne a pêeJexásíáng êelaíáonsháp bó êeváewáng óoîê healíh ánfoêãaíáon
avaálable ío îs. voî ãaó also gáve îs ánfoêãaíáon ío show íhás pêeJexásíáng
êelaíáonsháp wáíh a pêovádeê.

An exásíáng êelaíáonsháp ãeans óoî saw an oîíJofJneíwoêk pêáãaêó caêe pêovádeê aí
leasí once oê specáalíó caêe pêovádeê aí leasí íwáce foê a nonJeãeêgencó vásáí dîêáng
íhe NO ãoníhs pêáoê ío íhe daíe of óoîê ánáíáal enêollãení án Caêejoêe Cal
jedáConnecí mlan.

te have PM daós ío êespond ío óoîê êeqîesí. voî ãaó also ask îs ío ãake a fasíeê
decásáon and we ãîsí êespond án NR daós.

then ãakáng a êeqîesí ío coníánîe caêe wáíh óoîê cîêêení pêovádeêI óoî oê óoîê
pêovádeê ãîsí show docîãeníaíáon of an exásíáng êelaíáonsháp and agêee ío ceêíaán
íeêãs.
T

qhás êeqîesí cannot be ãade foê pêovádeês of dîêable ãedácal eqîápãení EajbFI
íêanspoêíaíáonI oíheê ancállaêó seêvácesI oê seêváces noí ánclîded îndeê Cal
jedáConnecí.
Afíeê íhe coníánîáíó of caêe peêáod endsI óoî wáll need ío see docíoês and oíheê pêovádeês án
íhe Caêejoêe Cal jedáConnecí mlan neíwoêkI înless we ãake an agêeeãení wáíh óoîê oîí
ofJneíwoêk docíoê. A neíwoêk pêovádeê ás a pêovádeê who woêks wáíh íhe healíh plan. pee
Chapíeê P foê ãoêe ánfoêãaíáon on geííáng caêe.
G. What is a Care Team and Care Plan?
Care Team
ao óoî need help geííáng íhe caêe óoî need? A caêe íeaã can help óoî. A caêe íeaã ãaó
ánclîde óoîê docíoêI a caêe ãanageêI oê oíheê healíh peêson íhaí óoî choose. A caêe
ãanageê ás a peêson who ás íêaáned ío help óoî ãanage íhe caêe óoî need. voî wáll geí a
caêe ãanageê when óoî enêoll án Caêejoêe Cal jedáConnecí mlan. qhás peêson wáll also
êefeê óoî ío coããînáíó êesoîêcesI áf Caêejoêe Cal jedáConnecí mlan does noí pêováde íhe
seêváces íhaí óoî need. voî can call îs aí NJUUUJPRMJPQQT Eqqv TNNF jondaó íhêoîgh cêádaó
fêoã U a.ã. ío U p.ã. ío ask foê a caêe íeaã.
Care Plan
voîê caêe íeaã wáll woêk wáíh óoî ío coãe îp wáíh a caêe plan. A caêe plan íells óoî and óoîê
docíoês whaí seêváces óoî needI and how óoî wáll geí íheã. fí ánclîdes óoîê ãedácalI
behaváoêal healíhI and longJíeêã sîppoêí service’s needs. voîê caêe plan wáll be ãade âîsí foê
óoî and óoîê needs.
voîê caêe plan wáll ánclîdeW

voîê healíh caêe goals.

A íáãeláne foê when óoî shoîld geí íhe seêváces óoî need.
Afíeê óoîê healíh êásk assessãeníI óoîê caêe íeaã wáll ãeeí wáíh óoî. qheó wáll íalk ío óoî
aboîí seêváces óoî need. qheó can also íell óoî aboîí seêváces óoî ãaó waní ío íhánk aboîí
geííáng. voîê caêe plan wáll be based on óoîê needs. voîê caêe íeaã wáll woêk wáíh óoî ío
îpdaíe óoîê caêe plan aí leasí eveêó óeaê.
H. Does CareMore Cal MediConnect Plan have a monthly plan
premium?
ko.
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U
I. About the Member Handbook
qhás Member Handbook ás paêí of oîê coníêací wáíh óoî. qhás ãeans íhaí we ãîsí follow all
of íhe êîles án íhás docîãení. ff óoî íhánk we have done soãeíháng íhaí goes agaánsí
íhese êîlesI óoî ãaó be able ío appealI oê challengeI oîê acíáon. coê ánfoêãaíáon aboîí
how ío appealI see Chapíeê VI oê call NJUMMJjbafCAob ENJUMMJSPPJQOOTF.
qhe coníêací ás án effecí foê íhe ãoníhs óoî aêe enêolled án Caêejoêe Cal jedáConnecí mlan
beíween ganîaêó NI OMNS and aeceãbeê NI OMNS.
J. What other information will you get from us?
voî shoîld have alêeadó êeceáved a Caêejoêe Cal jedáConnecí mlan ãeãbeê fa caêdI
ánfoêãaíáon aboîí how ío access a Provider and Pharmacy DirectoryI and a List of Covered
Drugs.
Your CareMore Cal MediConnect Plan member ID card
rndeê oîê planI óoî wáll have one caêd foê óoîê jedácaêe and jedáJCal seêvácesI ánclîdáng
longJíeêã seêváces and sîppoêísI ceêíaán behaváoêal healíh seêvácesI and pêescêápíáons. voî
must show this card when you get any services or prescriptions. Here’s a sample card to
show óoî whaí óoîês wáll look lákeW
ff óoîê Cal jedáConnecí caêd ás daãagedI losíI oê síolenI call jeãbeê peêváces êághí awaó
and we wáll send óoî a new caêd. voî can call jeãbeê peêváces aí NJUUUJPRMJPQQT
Eqqv TNNFI jondaó íhêoîgh cêádaó fêoã U a.ã. ío U p.ã.
As long as óoî aêe a ãeãbeê of oîê planI óoî do noí need ío îse óoîê êedI wháíeI and blîe
jedácaêe caêd oê óoîê jedáJCal caêd ío geí Cal jedáConnecí seêváces. heep íhose caêds án a
safe placeI án case óoî need íheã laíeê.
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 mlease êeãeãbeêI foê íhe specáalíó ãeníal healíh seêváces íhaí óoî ãaó êeceáve fêoã íhe
coîníó ãeníal healíh plan EjemFI óoî wáll need óoîê jedáJCal caêd ío access íhose
seêváces.
Provider and Pharmacy Directory
qhe Provider and Pharmacy Directory lásís íhe pêovádeês and phaêãacáes án íhe Caêejoêe
Cal jedáConnecí mlan neíwoêk. thále óoî aêe a ãeãbeê of oîê planI óoî ãîsí îse neíwoêk
pêovádeês ío geí coveêed seêváces. qheêe aêe soãe excepíáons when óoî fáêsí âoán oîê plan
Esee page TF.
 voî can êeqîesí an annîal Provider and Pharmacy Directory bó calláng jeãbeê peêváces
aí NJUUUJPRMJPQQT Eqqv TNNFI jondaó íhêoîgh cêádaó fêoã U a.ã. ío U p.ã. voî can also
see íhe Provider and Pharmacy Directory aí dîals.caêeãoêe.coãI oê download áí fêoã íhás
websáíe. Boíh jeãbeê peêváces and íhe websáíe can gáve óoî íhe ãosí îpJíoJdaíe
ánfoêãaíáon aboîí changes án oîê neíwoêk pêovádeês.
What are “network providers”?
keíwoêk pêovádeês aêe docíoêsI nîêsesI and oíheê healíh caêe pêofessáonals íhaí óoî can go
ío as a ãeãbeê of oîê plan. keíwoêk pêovádeês also ánclîde clánácsI hospáíalsI nîêsáng
facáláíáesI and oíheê places íhaí pêováde healíh seêváces án oîê plan. qheó also ánclîde long
íeêã seêváces and sîppoêísI behaváoêal healíh seêvácesI hoãe healíh agencáesI dîêable
ãedácal eqîápãení sîppláeêsI and oíheês who pêováde goods and seêváces íhaí óoî geí
íhêoîgh jedácaêe oê jedáJCal.
keíwoêk pêovádeês have agêeed ío accepí paóãení fêoã oîê plan foê coveêed seêváces as
paóãení án fîll.
fnJeoãe pîppoêíáve peêváces EfeppF pêovádeês aêe noí paêí of a neíwoêk. voî wáll alwaós be
able ío selecí anó fepp pêovádeê.
What are “network pharmacies”?
keíwoêk phaêãacáes aêe phaêãacáes Edêîg síoêesF íhaí have agêeed ío fáll pêescêápíáons foê
oîê plan ãeãbeês. rse íhe Provider and Pharmacy Directory ío fánd íhe neíwoêk phaêãacó
óoî waní ío îse.
bxcepí dîêáng an eãeêgencóI óoî must fáll óoîê pêescêápíáons aí one of oîê neíwoêk
phaêãacáes áf óoî waní oîê plan ío help óoî paó foê íheã.
Call jeãbeê peêváces aí NJUUUJPRMJPQQT Eqqv TNNFI jondaó íhêoîgh cêádaó fêoã U a.ã. ío U
p.ã. foê ãoêe ánfoêãaíáon oê ío geí a copó of íhe Provider and Pharmacy Directory. voî can
also see íhe Provider and Pharmacy Directory aí dîals.caêeãoêe.coãI oê download áí fêoã
íhás websáíe. Boíh jeãbeê peêváces and íhe websáíe can gáve óoî íhe ãosí îpJíoJdaíe
ánfoêãaíáon aboîí changes án oîê neíwoêk phaêãacáes and pêovádeês.
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NM
List of Covered Drugs
qhe plan has a List of Covered Drugs. te call áí íhe "Drug List´ for short. It tells which
pêescêápíáon dêîgs aêe coveêed bó Caêejoêe Cal jedáConnecí mlan.
qhe aêîg iásí also íells óoî áf íheêe aêe anó êîles oê êesíêácíáons on anó dêîgsI sîch as a láãáí
on íhe aãoîní óoî can geí. pee Chapíeê R foê ãoêe ánfoêãaíáon on íhese êîles and
êesíêácíáons.
bach óeaêI we wáll send óoî a copó of íhe aêîg iásíI bîí soãe changes ãaó occîê dîêáng íhe
óeaê. qo geí íhe ãosí îpJíoJdaíe ánfoêãaíáon aboîí whách dêîgs aêe coveêedI vásáí
dîals.caêeãoêe.coã oê call NJUUUJPRMJPQQT Eqqv TNNFI jondaó íhêoîgh cêádaó fêoã U a.ã.
ío U p.ã.
The Explanation of Benefits
then óoî îse óoîê maêí a pêescêápíáon dêîg benefáísI we wáll send óoî a sîããaêó êepoêí ío
help óoî îndeêsíand and keep íêack of paóãenís foê óoîê maêí a pêescêápíáon dêîgs. qhás
sîããaêó êepoêí ás called íhe Explanation of Benefits EEOBF.
qhe Explanation of Benefits íells óoî íhe íoíal aãoîní óoîI oê oíheês on óoîê behalfI have
spení on óoîê maêí a pêescêápíáon dêîgs and íhe íoíal aãoîní we have paád foê each of óoîê
maêí a pêescêápíáon dêîgs dîêáng íhe ãoníh. Chapíeê S gáves ãoêe ánfoêãaíáon aboîí íhe
Explanation of Benefits and how áí can help óoî keep íêack of óoîê dêîg coveêage.
An Explanation of Benefits sîããaêó ás also avaálable îpon êeqîesí. qo geí a copóI please
coníací jeãbeê peêváces aí NJUUUJPRMJPQQT Eqqv TNNFI jondaó íhêoîgh cêádaó fêoã U a.ã.
ío U p.ã.
K. How can you keep your membership record up to date?
voî can keep óoîê ãeãbeêsháp êecoêd îp ío daíe bó leííáng îs know when óoîê ánfoêãaíáon
changes.
The plan’s netwoêk pêovádeês and phaêãacáes need ío have íhe êághí ánfoêãaíáon aboîí óoî.
They use your membership record to know what services and drugs you get and how
much it will cost you. Becaîse of íhásI áí ás veêó áãpoêíaní íhaí óoî help îs keep óoîê
ánfoêãaíáon îpJíoJdaíe.
ieí îs know íhe followángW
ff óoî have anó changes ío óoîê naãeI óoîê addêessI oê óoîê phone nîãbeê.
ff óoî have anó changes án anó oíheê healíh ánsîêance coveêageI sîch as fêoã óoîê
employer, your spouse’s employer, or workers’ compensation.
?
NN
ff óoî have anó láabáláíó claáãsI sîch as claáãs fêoã an aîíoãobále accádení.
ff óoî aêe adãáííed ío a nîêsáng hoãe oê hospáíal.
ff óoî geí caêe án a hospáíal oê eãeêgencó êooã.
ff óoîê caêegáveê oê anóone êesponsáble foê óoî changes.
ff óoî aêe paêí of a clánácal êeseaêch síîdó.
ff anó ánfoêãaíáon changesI please leí îs know bó calláng jeãbeê peêváces aí NJUUUJPRM
PQQT Eqqv TNNFI jondaó íhêoîgh cêádaó fêoã U a.ã. ío U p.ã..
Do we keep your personal health information private?
ves. píaíe and fedeêal laws êeqîáêe íhaí we keep óoîê ãedácal êecoêds and peêsonal healíh
ánfoêãaíáon pêávaíe. te pêoíecí óoîê healíh ánfoêãaíáon. coê ãoêe deíaáls aboîí how we
pêoíecí óoîê peêsonal healíh ánfoêãaíáonI see Chapíeê UI pecíáon a.
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NO
Chapíeê OW fãpoêíaní phone nîãbeês and êesoîêces
Chapter 2: Important phone numbers and resources
Table of Contents
A. eow ío coníací Caêejoêe Cal jedáConnecí mlan jeãbeê peêváces............................................NQ
Coníací jeãbeê peêváces aboîíW ...............................................................................................NR

nîesíáons aboîí íhe plan...................................................................................................NR

nîesíáons aboîí claáãsI bálláng oê ãeãbeê caêds...............................................................NR

Coveêage decásáons aboîí óoîê healíh caêe .......................................................................NR

Appeals aboîí óoîê healíh caêe .........................................................................................NR

Coãplaánís aboîí óoîê healíh caêe ....................................................................................NR

Coveêage decásáons aboîí óoîê dêîgs................................................................................NS

Appeals aboîí óoîê dêîgs..................................................................................................NS

Coãplaánís aboîí óoîê dêîgs .............................................................................................NS

maóãení foê healíh caêe oê dêîgs óoî alêeadó paád foê.......................................................NT
B. eow ío coníací óoîê Caêe janageê .............................................................................................NU
Coníací óoîê case ãanageê aboîíW.............................................................................................NU

nîesíáons aboîí óoîê healíh caêe ......................................................................................NU

nîesíáons aboîí geííáng behaváoêal healíh Eãeníal healíh and sîbsíance îse dásoêdeêF seêváces ..............................................................................................................NV

nîesíáons aboîí íêanspoêíaíáon..........................................................................................NV

nîesíáons aboîí longJíeêã seêváces and sîppoêís EiqppF .................................................NV
C. eow ío coníací íhe kîêse Adváce Call iáne ..................................................................................OM
Coníací íhe kîêse Adváce Call iáne aboîíW .................................................................................OM

nîesíáons aboîí óoîê healíh caêe ......................................................................................OM

nîesíáons aboîí ságns oê sóãpíoãs íhaí conceên óoî. ......................................................OM
D. eow ío coníací íhe Behaváoêal eealíh Cêásás iáne.........................................................................ON
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NP
Coníací íhe Behaváoêal eealíh Cêásás iáne aboîíW........................................................................ON

nîesíáons aboîí behaváoêal healíh and sîbsíance abîse seêváces ....................................ON
E. eow ío coníací íhe eealíh fnsîêance Coînseláng and Advocacó mêogêaã EefCAmF .....................OO
Coníací efCAm aboîíW ................................................................................................................OO

nîesíáons aboîí óoîê Cal jedáConnecí plan.....................................................................OO
F. eow ío coníací íhe nîaláíó fãpêoveãení lêganázaíáon EnflF.......................................................OP
Coníací iávanía BcCCJnfl aboîíW .............................................................................................OP

nîesíáons aboîí óoîê healíh caêe ......................................................................................OP
G. eow ío coníací jedácaêe .............................................................................................................OQ
H. eow ío coníací jedáJCal eealíh Caêe lpíáons.............................................................................OR
I. eow ío coníací íhe Cal jedáConnecí lãbîds pêogêaã ..............................................................OS
J. eow ío coníací Coîníó pocáal peêváces........................................................................................OT
K. eow ío coníací óoîê Coîníó ppecáalíó jeníal eealíh mlan...........................................................OV
Coníací íhe coîníó specáalíó ãeníal healíh plan aboîíW ..............................................................OV

nîesíáons aboîí behaváoêal healíh seêváces pêováde bó íhe coîníó ....................................OV
L. eow ío coníací íhe Caláfoênáa aepaêíãení of janaged eealíh Caêe ............................................PM
M. líheê êesoîêces...........................................................................................................................PN
A. How to contact CareMore Cal MediConnect Plan Member
Services
CALL
NJUUUJPRMJPQQT qhás call ás fêee.
jondaó íhêoîgh cêádaó fêoã U a.ã. ío U p.ã. qhe call ás fêee. AfíeêJ
hoîês ãessagáng ás avaálable OQ hoîês a daóI T daós a weekI ánclîdáng
holádaós. voî can ask foê íhás handbook án oíheê foêãaísI sîch as Bêaálle
oê laêge pêání.
te have fêee áníeêpêeíeê seêváces foê people who do noí speak bnglásh.
?
NQ
TTY
TNN qhás call ás fêee.
jondaó íhêoîgh cêádaó fêoã U a.ã. ío U p.ã. AfíeêJhoîês ãessagáng ás
avaálable OQ hoîês a daóI T daós a weekI ánclîdáng holádaós.
FAX
NJUUUJQOSJRMUT
WRITE
Caêejoêe eealíh mlan
NOVMM maêk mlaza aêáveI pîáíe NRM
jpJSNRM
CeêêáíosI CA VMTMP
WEBSITE
dîals.caêeãoêe.coã
Contact Member Services about:
 Questions about the plan
 Questions about claims, billing or member cards
 Coverage decisions about your health care
A coveêage decásáon aboîí óoîê healíh caêe ás a decásáon aboîíW
» voîê benefáís and coveêed seêvácesI or
» qhe aãoîní we wáll paó foê óoîê healíh seêváces.
Call îs áf óoî have qîesíáons aboîí a coveêage decásáon aboîí óoîê healíh caêe.
 qo leaên ãoêe aboîí coveêage decásáonsI see Chapíeê VI pecíáon Q page NQV.
 Appeals about your health care
An appeal ás a foêãal waó of askáng îs ío êeváew a decásáon we ãade aboîí óoîê coveêage
and askáng îs ío change áí áf óoî íhánk we ãade a ãásíake.
 qo leaên ãoêe aboîí ãakáng an appealI see Chapíeê VI pecíáon QI page NQV.
 Complaints about your health care
voî can ãake a coãplaání aboîí îs oê anó pêovádeê Eánclîdáng a nonJneíwoêk oê neíwoêk
pêovádeêF. A neíwoêk pêovádeê ás a pêovádeê who woêks wáíh íhe healíh plan. voî can also
ãake a coãplaání aboîí íhe qîaláíó of íhe caêe óoî goí ío îs oê ío íhe nîaláíó fãpêoveãení
lêganázaíáon Esee pecíáon c belowF.
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NR
 voî can call îs and explaán óoîê coãplaání. Call jeãbeê peêváces aí NJUUUJPRMJPQQT
Eqqv TNNFI jondaó íhêoîgh cêádaó fêoã U a.ã. ío U p.ã.
 ff óoîê coãplaání ás aboîí a coveêage decásáon aboîí óoîê healíh caêeI óoî can ãake
an appeal Esee íhe secíáon aboveF.
 voî can send a coãplaání aboîí Caêejoêe Cal jedáConnecí mlan ío jedácaêe. voî
can îse an onláne foêã aí
híípsWLLwww.ãedácaêe.govLjedácaêeCoãplaánícoêãLhoãe.aspx. lê óoî can call NJUMM
jbafCAob ENJUMMJSPPJQOOTF ío ask foê help.
 voî can ãake a coãplaání aboîí Caêejoêe Cal jedáConnecí mlan ío íhe Cal
jedáConnecí lãbîds mêogêaã bó calláng NJURRJRMNJPMTT. qo leaên ãoêe aboîí
ãakáng a coãplaání aboîí óoîê healíh caêeI see Chapíeê VI pecíáon NMI page NVN.
 Coverage decisions about your drugs
A coveêage decásáon aboîí óoîê dêîgs ás a decásáon aboîíW
» voîê benefáís and coveêed dêîgsI or
» qhe aãoîní we wáll paó foê óoîê dêîgs.
qhás appláes ío óoîê maêí a dêîgsI jedáJCal pêescêápíáon dêîgsI and jedáJCal oveêJíhe
coîníeê dêîgs.
 coê ãoêe on coveêage decásáons aboîí óoîê pêescêápíáon dêîgsI see Chapíeê VI pecíáon
SI page NST.
 Appeals about your drugs
An appeal ás a waó ío ask îs ío change a coveêage decásáon.
 coê ãoêe on ãakáng an appeal aboîí óoîê pêescêápíáon dêîgsI see Chapíeê V pecíáon
S.RI page NTP.
 Complaints about your drugs
voî can ãake a coãplaání aboîí îs oê anó phaêãacó. qhás ánclîdes a coãplaání aboîí
óoîê pêescêápíáon dêîgs.
ff óoîê coãplaání ás aboîí a coveêage decásáon aboîí óoîê pêescêápíáon dêîgsI óoî can
ãake an appeal. (See the section above.)
voî can send a coãplaání aboîí Caêejoêe Cal jedáConnecí mlan ío jedácaêe. voî can
îse an onláne foêã aí híípsWLLwww.ãedácaêe.govLjedácaêeCoãplaánícoêãLhoãe.aspx. lê
óoî can call NJUMMJjbafCAob ENJUMMJSPPJQOOTF ío ask foê help.
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 coê ãoêe on ãakáng a coãplaání aboîí óoîê pêescêápíáon dêîgsI see Chapíeê VI pecíáon
NM.
 Payment for health care or drugs you already paid for
 coê ãoêe on how ío ask îs ío paó óoî backI oê ío paó a báll óoî have êeceávedI see
Chapíeê TI pecíáon AI page NOO.
 ff óoî ask îs ío paó a báll and we denó anó paêí of óoîê êeqîesíI óoî can appeal oîê
decásáon. pee Chapíeê VI pecíáon R.SI page NSR foê ãoêe on appeals.
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B. How to contact your Care Manager
A Caêe Cooêdánaíoê ás also êefeêêed ío as a Case janageê. Aí CaêejoêeI óoî wáll have íhe sîppoêí of
a Case janageê ío assásí óoî befoêeI dîêáng and afíeê a healíh evení.

then óoî becoãe a Caêejoêe Cal jedáConnecí jeãbeêI óoî wáll be asságned ío a case
ãanageê.

ff óoî have coãplex caêe needsI a case ãanageê wáll êeach oîí ío óoî ío ãake sîêe óoî
have whaí óoî need.

ff óoî eníeê íhe hospáíalI a case ãanageê can help aêêange foê seêváces íhaí ãake áí possáble
ío êecoveê aí hoãe.

ff óoî feel íhaí óoî coîld îse íhe help of a case ãanageêI óoî can coníací jeãbeê peêváces
aí NJUUUJPRMJPQQT Eqqv TNNF and ask ío speak ío a case ãanageê.

ff óoî aêe noí coãfoêíable wáíh óoîê case ãanageêI óoî can coníací jeãbeê peêváces aí NJUUUJPRMJPQQT Eqqv TNNF.
CALL
NJUUUJPRMJPQQT qhás call ás fêee.
avaálable OQ hoîês a daóI T daós a weekI ánclîdáng holádaós. voî can
ask foê íhás handbook án oíheê foêãaísI sîch as Bêaálle oê laêge pêání.
TTY
avaálable OQ hoîês a daóI T daós a weekI ánclîdáng holádaós.
FAX
NJUUUJQOSJRMUT
WRITE
NOVMM maêk mlaza aêáveI pîáíe NRM
jpJSNRM
WEBSITE
Contact your case manager about:
 Questions about your health care
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NU
 Questions about getting behavioral health (mental health and substance use
disorder) services
 Questions about transportation
 Questions about long-term services and supports (LTSS)
iqpp ánclîde fnJeoãe pîppoêíáve peêváces EfeppFI CoããînáíóJBased Adîlí peêváces
ECBApFI jîlíápîêpose penáoê peêváce mêogêaãs EjppmFI and kîêsáng cacáláíáes EkcF.
iongJíeêã seêváces and sîppoêís EiqppF aêe a vaêáeíó of seêváces and sîppoêís íhaí help
eldeêló ándávádîals and ándávádîals wáíh dásabáláíáes ãeeí íheáê daáló needs foê assásíance
and áãpêove íhe qîaláíó of íheáê láves. bxaãples ánclîde assásíance wáíh baíhángI dêessáng
and oíheê basác acíáváíáes of daáló láfe and selfJcaêeI as well as sîppoêí foê eveêódaó íasks
sîch as laîndêóI shoppángI and íêanspoêíaíáon. iqpp aêe îsîalló pêováded án hoães and
coããînáíáesI bîí also án facáláíóJbased seííáng sîch as nîêsáng facáláíáes.
Ceêíaán elágábáláíó êeqîáêeãenís ãîsí be ãeí ío qîaláfó foê íhese pêogêaãs. Call Caêejoêe
Cal jedáConnecí mlan jeãbeê peêváces aí 1-888-350-3447 (TTY 711) foê addáíáonal
ánfoêãaíáon on elágábáláíó êeqîáêeãenís.
poãeíáães óoî can geí help wáíh óoîê daáló healíh caêe and láváng needs. voî ãághí be
able ío geí íhese seêvácesW
» fnJeoãe pîppoêíáve peêváces EfeppFI
» CoããînáíóJBased Adîlí peêváces ECBApFI
» jîlíápîêpose penáoê peêváce mêogêaãs EjppmFI
» pkálled nîêsáng caêeI
» mhósácal íheêapóI
» lccîpaíáonal íheêapóI
» ppeech íheêapóI
» jedácal socáal seêvácesI and
» eoãe healíh caêe.
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C. How to contact the Nurse Advice Call Line
qhe OQJhoîê kîêse Adváce láne ás íheêe ío addêess óoîê healíh caêe qîesíáons and conceêns.
qhe nîêse adváce láne can help êeláeve óoîê woêêáes oê help óoî deíeêãáne áf óoî shoîld see
óoîê docíoê. poãeíáães óoî wáll have healíh qîesíáons laíe aí nághíI on íhe weekends oê on
holádaós. ko ãaííeê whaí daó oê íáãe áí ásI óoî can íalk ío a nîêse bó calláng íhe OQJhoîê
kîêse Adváce iáne.
CALL
NJUMMJOOQJMPPS qhás call ás fêee.
OQ hoîês a daóI T daós a weekI ánclîdáng holádaós.
TTY
NJUMMJPSUJQQOQ qhás call ás fêee.
qhás nîãbeê ás foê people who have heaêáng oê speakáng pêobleãs. voî
ãîsí have specáal íelephone eqîápãení ío call áí.
OQ hoîês a daóI T daós a weekI ánclîdáng holádaós
Contact the Nurse Advice Call Line about:
 Questions about signs or symptoms that concern you.
If you are experiencing a medical emergency, please call 911.
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D. How to contact the Behavioral Health Crisis Line
CALL
NJUUUJPORJNVRN qhás call ás fêee.
TTY
Contact the Behavioral Health Crisis Line about:
 Questions about behavioral health and substance abuse services
Cêásás ãanageãení
» Appêopêáaíe êefeêêal seêváce
» dîádance foê nexí síeps
coê qîesíáons êegaêdáng óoîê coîníó specáalíó ãeníal healíh seêvácesI go ío page OV.
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E. How to contact the Health Insurance Counseling and Advocacy
Program (HICAP)
qhe eealíh fnsîêance Coînseláng and Advocacó mêogêaã EefCAmF gáves fêee healíh
ánsîêance coînseláng ío people wáíh jedácaêe. efCAm coînseloês can answeê óoîê qîesíáons
and help óoî îndeêsíand whaí ío do ío handle óoîê pêobleã. efCAm has íêaáned coînseloês
án eveêó coîníóI and seêváces aêe fêee.
efCAm ás noí connecíed wáíh anó ánsîêance coãpanó oê healíh plan.
CALL
Ceníeê foê eealíh Caêe oághís
NJONPJPUPJQRNV oê
NJUMMJQPQJMOOO qhe call ás fêee wáíhán i.A. Coîníó
jondaóJ cêádaóI UWPM a.ã. ío QWPM p.ã..
TTY
TNN
oê
bnglásh NJUMMJTPRJOVOV
bspañol NJUMMJURRJPMMM
WRITE
ROM p. iafaóeííe maêk mlaceI pîáíe ONQI ios AngelesI CA VMMRT
WEBSITE
www.healíhcaêeêághís.oêg
Contact HICAP about:
 Questions about your Cal MediConnect plan
efCAm coînseloês canW
» eelp óoî îndeêsíand óoîê êághísI
» eelp óoî îndeêsíand óoîê plan choácesI
» Answeê óoîê qîesíáons aboîí changáng ío a new planI
» eelp óoî ãake coãplaánís aboîí óoîê healíh caêe oê íêeaíãeníI and
» eelp óoî síêaághíen oîí pêobleãs wáíh óoîê bálls.
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F. How to contact the Quality Improvement Organization (QIO)
lîê síaíe has an oêganázaíáon called a iávanía BcCCJnfl. qhás ás a gêoîp of docíoês and
oíheê healíh caêe pêofessáonals who help áãpêove íhe qîaláíó of caêe foê people wáíh
jedácaêe. iávanía BcCCJnfl ás noí connecíed wáíh oîê plan.
CALL
NJUTTJRUUJNNOP
TTY
NJURRJUUTJSSSU
WRITE
iávanía
BcCCJnfl mêogêaã
VMVM gîncíáon aêáveI pîáíe NM
Annapolás gîncíáonI ja OMTMN
WEBSITE
híípWLLbfccqáoaêeaR.coã
Contact Livanta BFCC-QIO about:
voî can ãake a coãplaání aboîí íhe caêe óoî have êeceáved áfW
» voî have a pêobleã wáíh íhe qîaláíó of caêeI
» voî íhánk óoîê hospáíal síaó ás endáng íoo soonI or
» voî íhánk óoîê hoãe healíh caêeI skálled nîêsáng facáláíó caêeI oê coãpêehensáve oîípaíáení êehabáláíaíáon facáláíó EClocF seêváces aêe endáng íoo soon.
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G. How to contact Medicare
jedácaêe ás íhe fedeêal healíh ánsîêance pêogêaã foê people SR óeaês of age oê oldeêI soãe
people îndeê age SR wáíh dásabáláíáesI and people wáíh endJsíage êenal dásease Epeêãanení
kádneó faálîêe êeqîáêáng dáalósás oê a kádneó íêansplaníF.
qhe fedeêal agencó án chaêge of jedácaêe ás íhe Ceníeês foê jedácaêe C jedácaád peêvácesI
oê Cjp.
CALL
NJUMMJjbafCAob ENJUMMJSPPJQOOTF
Calls ío íhás nîãbeê aêe fêeeI OQ hoîês a daóI T daós a week.
TTY
NJUTTJQUSJOMQU qhás call ás fêee.
qhás nîãbeê ás foê people who have heaêáng oê speakáng pêobleãs.
voî ãîsí have specáal íelephone eqîápãení ío call áí.
WEBSITE
híípWLLwww.ãedácaêe.gov
qhás ás íhe offácáal websáíe foê jedácaêe. fí gáves óoî
îpJíoJdaíe ánfoêãaíáon aboîí jedácaêe. fí also has ánfoêãaíáon aboîí
hospáíalsI nîêsáng hoãesI phósácáansI hoãe healíh agencáesI and
dáalósás facáláíáes. fí ánclîdes bookleís óoî can pêání êághí fêoã óoîê
coãpîíeê. voî can also fánd jedácaêe coníacís án óoîê síaíe bó
selecting "Forms, Help & Resources´ and then clicking on "Phone
numbers & websites.´
qhe jedácaêe websáíe has íhe followáng íool ío help óoî fánd plans án
óoîê aêeaW
Medicare Plan Finder: mêovádes peêsonalázed ánfoêãaíáon aboîí
jedácaêe pêescêápíáon dêîg plansI jedácaêe healíh plansI and
jedágap Ejedácaêe pîppleãení fnsîêanceF polácáes án óoîê aêea.
Select "Find health & drug plans.´
If you don’t have a computer, your local library or senior center may be
able ío help óoî vásáí íhás websáíe îsáng áís coãpîíeê. lêI óoî can call
jedácaêe aí íhe nîãbeê above and íell íheã whaí ánfoêãaíáon óoî aêe
lookáng foê. qheó wáll fánd íhe ánfoêãaíáon on íhe websáíeI pêání áí oîíI and
send áí ío óoî.
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H. How to contact Medi-Cal Health Care Options
jedáJCal eealíh Caêe lpíáons can help óoî áf óoî have qîesíáons aboîí selecíáng a Cal
jedáConnecí plan oê oíheê enêollãení ássîes.
CALL
NJUQQJRUMJTOTO
eealíh Caêe lpíáons êepêeseníaíáves aêe avaálable beíween íhe hoîês of
UWMM a.ã. and RWMM p.ã.I jondaó íhêoîgh cêádaó.
TTY
NJUMMJQPMJTMTT
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Caláfoênáa aepaêíãení of eealíh Caêe peêváces
eealíh Caêe lpíáons
m.l. Box VUVMMV
tesí pacêaãeníoI CA VRTVUJVURM
WEBSITE
híípWLLwww.dhcs.ca.govLseêvácesLmagesLkeweClCallJánlpíáons.aspx
OR
I. How to contact the Cal MediConnect Ombuds program
qhe Cal jedáConnecí lãbîds mêogêaã can help óoî wáíh seêváce oê bálláng pêobleãs. qheó
can answeê óoîê qîesíáons and help óoî îndeêsíand whaí ío do ío handle óoîê pêobleã. qhe
seêváces aêe fêee.
qhe Cal jedáConnecí lãbîds mêogêaã ás noí connecíed wáíh îs oê wáíh anó ánsîêance
coãpanó oê healíh plan.
CALL
NJURRJRMNJPMTT qhás call ás fêee.
jondaó íhêoîgh cêádaóI Uaã ío Rpã mpq; exclîdáng holádaós
TTY
NJURRJUQTJTVNQ
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WRITE
Cal jedáConnecí lãbîdsãan
qhe eealíh Consîãeê Ceníeê of ios Angeles
NPPOT san kîós Blvd
macoáãaI CA VNPPNJPMVV
WEBSITE
eealíhConsîãeê.oêg
OS
J. How to contact County Social Services
ff óoî need help wáíh óoîê fnJeoãe pîppoêíáve peêváces EfeppF benefáísI coníací óoîê local coîníó
socáal seêváces depaêíãení. ios Angeles Coîníó ás sîppoêíed bó eághí dásíêácí offáces. All new
pêogêaã applácanís ãîsí síaêí bó coníacíáng íhe fepp Applácaíáon eoíláne. An fepp lãbîdsãan ás
also avaálable ío pêováde assásíance wáíh ádeníáfóáng asságned casewoêkeês and appêopêáaíe dásíêácí
offáce.
CALL
General Number:
fepp Applácaíáon eoíláneW 1-888-944-4477
District Offices:
aásíêácí MN ± ChaíswoêíhW 1-888-822-9622
aásíêácí NV ± moãonaW 1-866-465-0905
aásíêácí PR ± iancasíeêW 1-866-514-9911
aásíêácí QT ± jeíêoW 1-866-512-2857
aásíêácí TP ± BîêbankW 1-866-544-9048
aásíêácí TQ ± bl joníeW 1-888-322-2204
aásíêácí TR ± oancho aoãángîezW 1-888-896-0044
aásíêácí TT ± eawíhoêneW 1-866-512-2856
qhás call ás fêee. Avaálable UWMM a.ã. ío RWMM p.ã.I jondaó íhêoîgh cêádaó.
WRITE
aásíêácí MN ± ChaíswoêíhW ONQNRJONSNR mlîããeê pí.I ChaíswoêíhI CA VNPNN
aásíêácí NV ± moãonaW PSM b. jássáon Blvd.I moãonaI CA VNTSS
aásíêácí PR J iancasíeêW PPRJC basí Ave. hJSI iancasíeêI CA VPRPR
aásíêácí QT ± jeíêoW OTMT p. dêand Ave.I ios AngelesI CA VMMMT
aásíêácí TP ± BîêbankW PPMT k. dlenoaks Blvd.I BîêbankI CA VNRMQ
aásíêácí TQ ± bl joníeW PQMM Aeêoâeí Ave.I bl joníeI CA VNTPN
aásíêácí TR ± Rancho Dominguez: 17600 "D´ Santa Fe Ave., Rancho Dominguez,
CA VMOON
aásíêácí TT ± eawíhoêneW NOMMM p. eawíhoêne Blvd.I eawíhoêneI CA VMORM
CALL
fepp Applácaíáon eoíláne NJUUUJVQQJQQTT qhás call ás fêee.
fepp lãbîdsãan NJUUUJSTUJQQTT qhás call ás fêee
jondaó íhêoîgh cêádaó UWMM aã ío RWMM pã ± exclîdáng holádaós
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OT
TTY
TNN
oê
bspañol NJUMMJURRJPMMM
qhás nîãbeê ás foê people who have heaêáng oê speakáng pêobleãs. voî ãîsí
have specáal íelephone eqîápãení ío call áí.
WEBSITE
?
híípWLLdpss.lacoîníó.govLdpssLáhssLdefaîlí.cfã
OU
K. How to contact your County Specialty Mental Health Plan
jedáJCal specáalíó ãeníal healíh seêváces aêe avaálable ío óoî íhêoîgh íhe coîníó ãeníal
healíh plan EjemF áf óoî ãeeí íhe ãedácal necessáíó cêáíeêáa.
CALL
NJUMMJURQJTTTN qhás call ás fêee.
jondaó íhêoîgh cêádaóI UWMM a.ã. ío RWMM p.ã.I exclîdáng holádaós
TNN oê
TTY
bspañol NJUMMJURRJPMMM qhás call ás fêee.
jondaó íhêoîgh cêádaóI UWMM a.ã. ío RWMM p.ã.I exclîdáng holádaós
Contact the county specialty mental health plan about:
 Questions about behavioral health services provide by the county
 jeníal healíh seêváces EassessãeníI íheêapóI êehabáláíaíáonI collaíeêalI and plan
developãeníF
jedácaíáon sîppoêí seêváces
aaó íêeaíãení áníensáve
aaó êehabáláíaíáon
Cêásás áníeêveníáon
Cêásás síabálázaíáon
Adîlí êesádeníáal íêeaíãení seêváces
Cêásás êesádeníáal íêeaíãení seêváces
msócháaíêác healíh facáláíó seêváces
msócháaíêác ánpaíáení hospáíal seêváces
qaêgeíed case ãanageãení
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L. How to contact the California Department of Managed Health
Care
qhe Caláfoênáa aepaêíãení of janaged eealíh Caêe EajeCF ás êesponsáble foê êegîlaíáng
healíh plans. qhe ajeC eelp Ceníeê can help óoî wáíh appeals and coãplaánís agaánsí óoîê
healíh plan aboîí jedáJCal seêváces.
CALL
NJUUUJQSSJOONV
ajeC êepêeseníaíáves aêe avaálable beíween íhe hoîês of UWMM a.ã.
and SWMM p.ã.I jondaó íhêoîgh cêádaó.
TTY
NJUTTJSUUJVUVN
qhás nîãbeê ás foê people who have heaêáng oê speakáng pêobleãs.
voî ãîsí have specáal íelephone eqîápãení ío call áí.
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eelp Ceníeê
Caláfoênáa aepaêíãení of janaged eealíh Caêe
VUM káníh píêeeíI pîáíe RMM
pacêaãeníoI CA VRUNQJOTOR
FAX
NJVNSJORRJROQN
WEBSITE
híípWLLwww.hãohelp.ca.gov
PM
M. Other resources
L.A. County Department of Public Health/Substance Abuse Prevention & Control
Addáíáonal sîbsíance îse dásoêdeê íêeaíãenís aêe ãade avaálable íhêoîgh i.A. Coîníó aepaêíãení of
mîblác eealíhL pîbsíance Abîse mêeveníáon C Coníêol. qhás seí of benefáís ánclîdes daó caêe
êehabáláíaíáonI oîípaíáení ándávádîal and gêoîp coînseláng and peêánaíal êesádeníáal seêváces. Coníací
oîê i.A. Caêe Cal jedáConnecí mlan Behaváoêal eealíh Cêásás iáne aí 1-877-344-2858 Eqqv 1-800735-2929F foê êefeêêal and lánkages.
How to contact the Department of Rehabilitation
qhe aepaêíãení of oehabáláíaíáon assásís ándávádîals wáíh dásabáláíáes án aêeas of eãploóãení bó
pêovádáng vocaíáonal êehabáláíaíáonI íêaánángI and âob placeãení seêváces.
CALL:
916-324-1313 Eqqv 916-558-5807F
WRITE:
aepaêíãení of oehabáláíaíáon
m.l. Box VQQOOO
pacêaãeníoI CA VQOQQJOOOM
WEBSITE:
www.dor.ca.gov
How to contact the Independent Living Centers (ILCs)
fiCs aêe oêganázaíáons whách pêováde seêváces íhaí enable ándávádîals wáíh dásabáláíáes ío láve and
woêk ándependeníló án íheáê coããînáíáes. peêváces ánclîde aííendaní êefeêêalsI advocacóI peeê
coînselángI and ánfoêãaíáon êelaíed ío hoîsáng and íêanspoêíaíáon. qhe seven fndependení iáváng
Ceníeês EfiCsF án ios Angeles Coîníó aêeW
Communities Actively Living Independent & Free (CALIF)
CALL:
213-627-0477
TTY:
213-623-9502
FAX:
213-627-0535
WRITE:
SPQ poîíh ppêáng píêeeíI Ond cl.
ios AngelesI CA VMMNQ
WEBSITE:
www.califilc.webs.com
Disabled Resource Center (DRC)
CALL:
1-562-427-1000
TTY:
1-562-427-1366
FAX:
1-562-427-2027
WRITE:
OTRM b. ppêáng píêeeíI píe. #NMM
iong BeachI CA VMUMS
WEBSITE:
www.drcinc.org
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PN
Independent Living Center of Southern California (ILCSC)
CALL:
1-877-452-4227 oê 1-818-785-6934
TTY:
1-818-785-7097
EMAIL:
álcsc@álcsc.oêg
WRITE:
NQQMT dálãoêe píêeeíI #NMN
san kîósI CA VNQMN
WEBSITE:
www.ilcsc.org
Service Center for Independent Living (SCIL)
CALL:
1-800-491-6722
Claêeãoní offáceW 909-621-6722
tesí Cována offáceW 626-337-8868
TTY:
909-445-0726
WRITE:
pCfi Claêeãoní lffáce
NMT p. ppêáng píêeeí
ClaêeãoníI CA VNTNN; oê
WEBSITE:
pCfi tesí Cována lffáce
NROM t. Caãeêon AveI píe.NSM
tesí CovánaI CA VNTVN
www.scil-ilc.org
Southern California Resource Services for Independent Living (SCRS-IL)
CALL:
562-862-6531
TTY:
562-869-0931
FAX:
562-923-5274
WRITE:
TUPM nîáll aêáveI píe. a
aowneóI CA VMOQO
WEBSITE: www.scrs-ilc.org
Westside Center for Independent Living (WCIL)
jaêsásía Ceníeê
CALL:
1-888-851-WCIL (9245)
WRITE:
NOVMN senáce Boîlevaêd
ios AngelesI CA VMMSS
WEBSITE: www.wcil.org
How to contact the Regional Centers
oegáonal Ceníeês pêováde pêogêaãs and cooêdánaíe seêváces foê ándávádîals wáíh developãeníal
dásabáláíáes and íheáê faãáláes. qhese dásabáláíáes ánclîde ceêebêal palsóI aîíásãI ãeníal êeíaêdaíáonI
and seázîêe dásoêdeês. Caláfoênáa has ON êegáonal ceníeês wáíh ãoêe íhan QM offáces locaíed
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PO
íhêoîghoîí íhe síaíe íhaí seêve ándávádîals wáíh developãeníal dásabáláíáes and íheáê faãáláes. qo
access íhás aáêecíoêó of oegáonal CeníeêsI go ío íhe websáíe lásíed below.
CALL:
TTY:
WRITE:
WEBSITE:
916-654-1690
916-654-2054
NSMM Víh píêeeí
m.l. Box VQQOMO
pacêaãeníoI CA VQOQQJOMOM
www.dds.ca.gov
How to contact the Personal Assistance Services Council (PASC)
mApC ás íhe pîblác aîíhoêáíó foê fnJeoãe pîppoêíáve peêváces EfeppF án i.A. Coîníó. mApC pêovádes
seêváces ío enhance íhe qîaláíó of láfe foê all people who êeceáve and pêováde feppI ánclîdáng
assásíance wáíh fándáng a hoãecaêe woêkeêI íeãpoêaêó hoãecaêe woêkeê assásíanceI and íêaánáng
oppoêíînáíáes foê fepp êecápáenís and hoãecaêe woêkeês.
CALL:
TTY:
FAX:
WEBSITE:
877-565-4477
818-206-7015
818-206-8000
www.pascla.org
How to contact the Area Agency on Aging (AAA)
Aêea Agencáes on Agáng EAAAsF pêováde a vaêáeíó of seêváces ío oldeê adîlís ánclîdáng êefeêêals ío ánJ
hoãe and coããînáíóJbased seêvácesI hoîsángI hoãeJdeláveêed ãealsI êespáíe caêeI jedácaêeLjedáJ
Cal coînselángI íax assásíanceI íêanspoêíaíáonI íelephone êeassîêanceI case ãanageãeníI adîlí daó
caêeI legal assásíanceI and oíheê longJíeêã caêe seêváces.
L.A. County Area Agency on Aging
CALL:
1-800-510-2020
WRITE:
PNTR tesí Síh píêeeí
ios AngelesI CA VMMOM
EMAIL:
[email protected]̂níó.gov
WEBSITE:
css.lacounty.gov/aaa.aspx
qhe i.A. Cáíó aepaêíãení of Agáng has áís own AAA foê êesádenís láváng wáíhán ios Angeles cáíó wfm
codes.
CALL:
213-482-7252 oê 1-800-510-2020
FAX:
1-213-482-7256
WRITE:
OON k. cágîeêoa pí.I píe. NUM
ios AngelesI CA VMMNO
EMAIL:
age.webánfo@lacáíó.oêg
WEBSITE:
www.aging.lacity.org
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PP
Chapter 3: Using the plan’s coverage for your health
caêe and oíheê coveêed seêváces
Chapter 3: Using the plan’s coverage for your health care
and other covered services
Table of Contents
A. About "services,´ "covered services,´ "providers,´ and "network providers´ .................................PS
B. oîles foê geííáng óoîê healíh caêeI behaváoêal healíhI and longJíeêã seêváces and sîppoêís coveêed bó íhe plan .....................................................................................................................PS
C. voîê case ãanageê .....................................................................................................................PU
D. deííáng caêe fêoã pêáãaêó caêe pêovádeêsI specáalásísI oíheê neíwoêk ãedácal pêovádeêsI and
oîíJofJneíwoêk ãedácal pêovádeês .................................................................................................PU
deííáng caêe fêoã a pêáãaêó caêe pêovádeê ..................................................................................PU
eow ío geí caêe fêoã specáalásís and oíheê neíwoêk pêovádeês ....................................................QN
thaí áf a neíwoêk pêovádeê leaves oîê plan? ...............................................................................QO
eow ío geí caêe fêoã oîíJofJneíwoêk pêovádeês ...........................................................................QP
E. eow ío geí longJíeêã seêváces and sîppoêís EiqppF ....................................................................QQ
F. eow ío geí behaváoêal healíh Eãeníal healíh C sîbsíance îse dásoêdeêF seêváces ........................QR
thaí jedáJCal behaváoêal healíh seêváces aêe pêováded oîísáde of Caêejoêe Cal
jedáConnecí mlan íhêoîgh ios Angeles Coîníó aepaêíãení of jeníal eealíh EiACajeF
and ios Angeles Coîníó aepaêíãení of mîblác eealíhLpîbsíance Abîse mêeveníáon C
Coníêol EameLpAmCF? ................................................................................................................QR
G. eow ío geí íêanspoêíaíáon seêváces...............................................................................................QS
H. eow ío geí coveêed seêváces when óoî have a ãedácal eãeêgencó oê îêgení need foê
caêeI oê dîêáng a dásasíeê .............................................................................................................QT
deííáng caêe when óoî have a ãedácal eãeêgencó ....................................................................QT
deííáng îêgeníló needed caêe .....................................................................................................QV
deííáng caêe dîêáng a dásasíeê ....................................................................................................QV
I. thaí áf óoî aêe bálled dáêecíló foê íhe fîll cosí of seêváces coveêed bó oîê plan? ...........................RM
thaí shoîld óoî do áf seêváces aêe noí coveêed bó oîê plan? .....................................................RM
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PQ
J. eow aêe óoîê healíh caêe seêváces coveêed when óoî aêe án a clánácal êeseaêch síîdó? ...............RM
thaí ás a clánácal êeseaêch síîdó? ..............................................................................................RM
then óoî aêe án a clánácal êeseaêch síîdóI who paós foê whaí? ..................................................RN
ieaênáng ãoêe ............................................................................................................................RN
K. eow aêe óoîê healíh caêe seêváces coveêed when óoî aêe án a êelágáoîs nonJãedácal healíh
caêe ánsíáíîíáon? ...........................................................................................................................RO
thaí ás a êelágáoîs nonJãedácal healíh caêe ánsíáíîíáon? .............................................................RO
thaí caêe fêoã a êelágáoîs nonJãedácal healíh caêe ánsíáíîíáon ás coveêed bó oîê plan?..............RO
L. oîles foê ownáng dîêable ãedácal eqîápãení...............................................................................RP
táll óoî own óoîê dîêable ãedácal eqîápãení?..........................................................................RP
thaí happens áf óoî swáích ío jedácaêe? ..................................................................................RP
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PR
A. About “services,” “covered services,” “providers,” and
“network providers”
Services aêe healíh caêeI longJíeêã seêváces and sîppoêísI sîppláesI behaváoêal healíh
seêvácesI pêescêápíáon and oveêJíheJcoîníeê dêîgsI eqîápãení and oíheê seêváces. Covered
services aêe anó of íhese seêváces íhaí oîê plan paós foê. Coveêed healíh caêeI behaváoêal
healíhI and longJíeêã seêváces and sîppoêís aêe lásíed án íhe Benefáís Chaêí án Chapíeê Q.
Providers aêe docíoêsI nîêsesI and oíheê people who gáve óoî seêváces and caêe. qhe íeêã
providers also ánclîdes hospáíalsI hoãe healíh agencáesI clánácsI and oíheê places íhaí gáve
óoî healíh caêe seêvácesI behaváoêal healíh seêvácesI ãedácal eqîápãeníI and ceêíaán long
íeêã seêváces and sîppoêís.
Network providers aêe pêovádeês who woêk wáíh íhe healíh plan. qhese pêovádeês have
agêeed ío accepí oîê paóãení as fîll paóãení. keíwoêk pêovádeês báll îs dáêecíló foê caêe íheó
gáve óoî. then óoî see a neíwoêk pêovádeêI óoî îsîalló paó noíháng foê coveêed seêváces.
 Please note: fnJeoãe pîppoêíáve peêváces EfeppF pêovádeês aêe noí paêí of a neíwoêk.
voî can selecí anóone ío be óoîê fepp pêovádeê.
B. Rules for getting your health care, behavioral health, and longterm services and supports covered by the plan
Caêejoêe Cal jedáConnecí mlan coveês all seêváces coveêed bó jedácaêe and jedáJCal.
qhás ánclîdes behaváoêal healíhI longJíeêã seêváces and sîppoêís EiqppFI and pêescêápíáon
dêîgs.
Caêejoêe Cal jedáConnecí mlan wáll geneêalló paó foê íhe healíh caêe seêvácesI behaváoêal
healíh seêvácesI and iqpp óoî geí áf óoî follow íhe plan êîles. qo be coveêedW
qhe caêe óoî geí ãîsí be a plan benefit. This means that it must be included in the plan’s
Benefáís Chaêí. Eqhe chaêí ás án Chapíeê Q of íhás handbookF.
qhe caêe ãîsí be determined necessary. Bó necessaêóI we ãean óoî need seêváces ío
pêeveníI dáagnoseI oê íêeaí óoîê condáíáon oê ío ãaáníaán óoîê cîêêení healíh síaíîs. qhás
ánclîdes caêe íhaí keeps óoî fêoã goáng ánío a hospáíal oê nîêsáng hoãe. fí also ãeans íhe
seêvácesI sîppláesI oê dêîgs ãeeí accepíed síandaêds of ãedácal pêacíáce.
coê ãedácal seêvácesI óoî ãîsí have a neíwoêk primary care provider (PCP) who has
oêdeêed íhe caêe oê has íold óoî ío see anoíheê docíoê. As a plan ãeãbeêI óoî ãîsí choose
a neíwoêk pêovádeê ío be óoîê mCm.
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PS
» fn ãosí casesI óoîê neíwoêk mCm or oîê plan ãîsí gáve óoî appêoval befoêe óoî
can îse oíheê pêovádeês in the plan’s network. This is called a referral. qo leaên
ãoêe aboîí êefeêêalsI see page QN.
» voî do noí need a êefeêêal fêoã óoîê mCm foê eãeêgencó caêe oê îêgeníló needed
care or to see a woman’s healíh pêovádeê. voî can geí oíheê kánds of caêe wáíhoîí
haváng a êefeêêal fêoã óoîê mCm. qo leaên ãoêe aboîí íhásI see page QN.

qo leaên ãoêe aboîí choosáng a mCmI see page QM.
You must get your care from network providers. rsîallóI íhe plan wáll noí coveê caêe fêoã
a pêovádeê who does noí woêk wáíh íhe healíh plan. eeêe aêe soãe cases when íhás êîle does
noí applóW
» qhe plan coveês eãeêgencó oê îêgeníló needed caêe fêoã an oîíJofJneíwoêk
pêovádeê. qo leaên ãoêe and ío see whaí emergency oê urgently needed care
ãeansI see page QT.
» ff óoî need caêe íhaí oîê plan coveês and oîê neíwoêk pêovádeês cannoí gáve áí ío
óoîI óoî can geí íhe caêe fêoã an oîíJofJneíwoêk pêovádeê. fn íhás sáíîaíáonI we
wáll coveê íhe caêe aí no cosí ío óoî. qo leaên aboîí geííáng appêoval ío see an
oîíJofJneíwoêk pêovádeêI see page QQ.
» The plan covers kidney dialysis services when you are outside the plan’s service
aêea foê a shoêí íáãe. voî can geí íhese seêváces aí a jedácaêeJceêíáfáed dáalósás
facáláíó.
» then óoî fáêsí âoán íhe planI óoî can ãake a êeqîesí ío îs ío coníánîe ío see
óoîê cîêêení pêovádeês. te aêe êeqîáêed ío appêove íhás êeqîesí áf we can
esíablásh íhaí óoî had an exásíáng êelaíáonsháp wáíh íhe pêovádeês wáíh soãe
excepíáons Esee Chapíeê NI page TF. ff óoîê êeqîesí ás appêovedI óoî can
coníánîe seeáng íhe pêovádeês óoî see now foê îp ío S ãoníhs foê seêváces
coveêed bó jedácaêe and îp ío NO ãoníhs foê seêváces coveêed bó jedáJCal.
aîêáng íhaí íáãeI oîê case ãanageê wáll coníací óoî ío help óoî fánd pêovádeês án
oîê neíwoêk. Afíeê íhe fáêsí S ãoníhs foê jedácaêe seêváces and NO ãoníhs foê
jedáJCal seêvácesI we wáll no longeê coveê óoîê caêe áf óoî coníánîe ío see
pêovádeês íhaí aêe noí án oîê neíwoêk. jedácaêe seêváces ánclîde ãedácalI soãe
ãeníal healíh and hospáíal caêe pêováded bó óoîê pêáãaêó caêe docíoê oê
specáalásís. jedáJCal seêváces ánclîde hoãeJ and coããînáíóJbased pêogêaãsI
sîch as iongJqeêã peêváces and pîppoêís EiqppF and caêe pêováded án long
íeêã caêe facáláíáes.
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PT
C. Your case manager
 thaí ás a case ãanageê?
» A case ãanageê ás a clánácáan oê oíheê íêaáned peêson who woêks foê oîê plan
ío pêováde case ãanageê seêváces foê óoî. Case ãanageês paêíneê wáíh
paíáenís ío geí íhe caêe íheó need ío be healíhó.
 poãe íhángs a case ãanageê helps paíáenís wáíh aêeW
o
rndeêsíand how íheáê cîêêení healíh ás doáng
»
toêk wáíh íheã on a caêe plan cêeaíed âîsí foê íheã
»
deí íhe caêe íheó need fêoã coveêed benefáís and coããînáíó êesoîêces
»
Becoãe paêí of ãanagáng íheáê own healíh
»
toêk wáíh healíh caêe woêkeês as a íeaã
»
jeeí íheáê goals of geííáng healíhó
 eow can a ãeãbeê coníací hás oê heê caêe ãanageê?
» A ãeãbeê can coníací íheáê case ãanageê bó coníacíáng jeãbeê peêváces. fn
ãanó sáíîaíáonsI íhe case ãanageê ãaó pêováde íhe ãeãbeê wáíh íheáê dáêecí
coníací ánfoêãaíáon.
 eow can a ãeãbeê change hás oê heê caêe ãanageê?
» fn sáíîaíáons wheêe íhe ãeãbeê woîld pêefeê ío be seen bó a dáffeêení case
ãanageêI íheó can coníací jeãbeê peêváces ío shaêe íheáê conceêns and
êeqîesí ío have anoíheê case ãanageê asságned ío íheã.
D. Getting care from primary care providers, specialists, other
network medical providers, and out-of-network medical providers
Getting care from a primary care provider
voî ãîsí choose a pêáãaêó caêe pêovádeê EmCmF ío pêováde and ãanage óoîê caêe.
What is a “PCP,” and what does the PCP do for you?
then óoî becoãe a ãeãbeê of oîê planI óoî ãîsí choose a plan pêovádeê ío be óoîê
Primary Care Provider (PCP). Your PCP is your main health care provider. You’ll see your
mCm foê óoîê êegîlaê checkîps. ff óoî geí sáckI óoîê mCm wáll be íhe fáêsí peêson óoî coníací.
ee oê she wáll pêescêábe ãedácánes foê óoîI and gáve óoî êefeêêals ío specáalásís and oíheê
pêovádeês áf needed. voîê mCm ãaó be an áníeênásíI faãáló oê geneêal docíoê oê lBLdvk
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PU
docíoê who ás appêoved bó íhe síaíe ío gáve óoî basác ãedácal caêe. jeãbeês can coníací
woãen healíh specáalásís foê êoîíáne and pêeveníáve healíh wáíhoîí a êefeêêal.
qo see a specáalásíI óoî îsîalló need ío get your PCP’s approval first. qhás ás called geííáng a
"referral.´ bxaãples of êefeêêals oê caêe cooêdánaíáon ánclîdeW
 Caêe fêoã docíoês who aêe specáalásís
 mhósácal and occîpaíáonal íheêapó
 eospáíal síaós
 collowJîp caêe
Aí CaêejoêeI óoî and óoîê mCm have íhe sîppoêí of íhe Caêejoêe Clánácal qeaã and Case
janageê. A case ãanageê can help óoî cooêdánaíe íhe caêe and coveêed seêváces óoî need.
"Coordinating´ your covered services means we work with other plan providers to manage
óoîê caêe and aêêange foê ánJhoãe seêváces and eqîápãení óoî ãaó need. pánce óoîê mCm
wáll pêováde and cooêdánaíe ãosí of óoîê ãedácal caêeI óoî shoîld have all of óoîê pasí
medical records sent to your PCP’s office.
qo besí seêve óoîê healíh caêe needsI we síêongló sîggesí íhaí óoî vásáí îs aí a Caêejoêe
Caêe Ceníeê foê a eealíhó píaêí appoáníãení. A eealíhó píaêí appoáníãení helps ãake sîêe
íhaí óoî coníánîe ío êeceáve íhe caêe óoî need. fí also helps îs know whách pêogêaãs oê
seêváces óoî ãaó need. lîê goal ás óoîê coãpleíe healíh. mlease call íhe jeãbeê peêváces
depaêíãení aí NJUMMJPRMJPQQT Eqqv TNNF ío schedîle óoîê eealíhó píaêí appoáníãení.
voîê mCm can also êefeê óoî ío ãanó dáffeêení pêogêaãs aí íhe Caêejoêe Caêe Ceníeê ío
help óoî síaó healíhó. Caêejoêe Caêe Ceníeê pêogêaãs ãaó ánclîdeI bîí aêe noí láãáíed íoW
 aáabeíes janageãení mêogêaã
 Chêonác lbsíêîcíáve mîlãonaêó
aásease mêogêaã EClmaF
 cooí Caêe mêogêaã
 eágh Blood mêessîêe mêogêaã
 píêengíh and cáíness qêaánáng
 And oíheês
Caêejoêe Caêe Ceníeês have ãanó specáalásís and healíh caêe expeêís ío ãeeí óoîê needsI
sîch asW
 kîêse mêacíáíáoneês
 Caêdáologásís Eheaêí docíoêF
 modáaíêásís Efooí docíoêF
 Behaváoêal eealíh ppecáalásís
 kîíêáíáonásís Ecood expeêíF
 aeêãaíologásís Eskán docíoêF
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ff óoî êeqîáêe hospáíalázaíáonI as a Caêejoêe ãeãbeê óoî and óoîê mCm have íhe sîppoêí of a
Caêejoêe bxíensávásí íhêoîgh íhe Caêejoêe Caêe Ceníeê. A Caêejoêe bxíensávásí ás a docíoê who
vásáís óoî án íhe hospáíal ío ãake sîêe óoî êeceáve íhe êághí caêe. Afíeê óoî leave íhe hospáíalI íhe
exíensávásí wáll ãanage óoîê caêe îníál óoî aêe coãpleíeló beííeê.
mlease îse íhe mêovádeê and mhaêãacó aáêecíoêó ío fánd oîí whách pêogêaãs and seêváces aêe
avaálable aí óoîê local Caêejoêe Caêe Ceníeê.
How do you choose your PCP?
voîê êelaíáonsháp wáíh óoîê mCm ás áãpoêíaní. po when óoî choose óoîê mCmI íêó ío íhánk
aboîí íhe êeasons below ío help óoî. then óoî choose a mCmI óoî shoîldW
 Choose a pêovádeê íhaí óoî îse nowI oê
 Choose a pêovádeê íhaí soãeone óoî íêîsí has sîggesíedI oê
 Choose a pêovádeê whose offáces aêe easó foê óoî ío geí ío
 Choose a pêovádeê íhaí ás close ío óoîê hoãe
then óoî enêoll wáíh Caêejoêe eealíh mlanI óoî wáll selecí a mCm bó îsáng oîê Provider
and Pharmacy Directory. mCms aêe lásíed bó cáíó and coîníóI so óoî can fánd one close ío
wheêe óoî láve oê woêk. qhe dáêecíoêó also shows óoî whaí langîages aêe spoken án íhe
PCP’s office. ff óoî need help choosáng a mCmI call jeãbeê peêváces aí NJUUUJPRMJPQQT
Eqqv TNNF.
then óoî selecí óoîê mCmI óoî aêe also choosáng íhe hospáíalEsF and specáalíó neíwoêkEsF
associated with your PCP. CareMore organizes its provider network into "neighborhoods´ to
help pêoãoíe a coããînáíóJbased appêoach ío healíh caêe. then óoî choose a mCmI óoî wáll
be êefeêêed ío íhe specáalásísI hospáíals and oíheê pêovádeês assocáaíed wáíh óoîê mCm and
neághboêhood. ff íheêe ás a paêíácîlaê plan specáalásí oê hospáíal íhaí óoî waní ío îseI check
fáêsí ío be sîêe íhaí specáalásíI oê íhaí hospáíal ás án íhe saãe neághboêhood as óoîê mCm. qhe
naãe and phone nîãbeê of óoîê mCm ás pêáníed on óoîê ãeãbeêsháp caêd. coê help án
selecíáng a mCmI óoî can also call íhe jeãbeê peêváces depaêíãení aí NJUUUJPRMJPQQT Eqqv
TNNF.
Changing your PCP
You may change your PCP for any reason, at any time. Also, it’s possible that your PCP may
leave oîê plan neíwoêk. ff óoîê mCm leaves oîê plan neíwoêkI we can help óoî fánd a new
mCm who ás wáíhán oîê plan neíwoêk.
qo change óoîê mCmI call jeãbeê peêváces aí NJUUUJPRMJPQQT Eqqv TNNF. then óoî callI be
sîêe ío íell jeãbeê peêváces áf óoî aêe seeáng specáalásís oê geííáng oíheê seêváces íhaí need
your PCP’s approval. Some of these services may be hoãe healíh seêváces and dîêable
ãedácal eqîápãení.
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voî can síaêí seeáng óoîê mCm on íhe fáêsí daó of íhe ãoníh afíeê óoîê êeqîesí. coê exaãpleI
áf óoî ask ío change óoîê mCm on pepíeãbeê NPI óoî can síaêí seeáng óoîê new pêáãaêó
docíoê on lcíobeê Nsí.
te’ll send you a new CareMore Cal MediConnect Plan ID card with your new PCP’s name
and phone nîãbeê.
Services you can get without first getting approval from your PCP
fn ãosí casesI óoî wáll need appêoval fêoã óoîê mCm befoêe seeáng oíheê pêovádeês. qhás
appêoval ás called a referral. voî can geí seêváces láke íhe ones lásíed below wáíhoîí fáêsí
geííáng appêoval fêoã óoîê mCmW
 bãeêgencó seêváces fêoã neíwoêk pêovádeês oê oîíJofJneíwoêk pêovádeês.
 rêgeníló needed caêe fêoã neíwoêk pêovádeês.
 rêgeníló needed caêe fêoã oîíJofJnetwork providers when you can’t get to network
providers (for example, when you are outside the plan’s service area).
 hádneó dáalósás seêváces íhaí óoî geí aí a jedácaêeJceêíáfáed dáalósás facáláíó when óoî
are outside the plan’s service aêea. Emlease call jeãbeê peêváces befoêe óoî leave
íhe seêváce aêea. te can help óoî geí dáalósás whále óoî aêe awaó.F
 clî shoísI hepaíáíás B vaccánaíáonsI and pneîãonáa vaccánaíáons as long as óoî geí
íheã fêoã a neíwoêk pêovádeê.
 Routine women’s health caêe and faãáló plannáng seêváces. qhás ánclîdes bêeasí
exaãsI scêeenáng ãaããogêaãs ExJêaós of íhe bêeasíFI map íesísI and pelvác exaãs
as long as óoî geí íheã fêoã a neíwoêk pêovádeê.
 AddáíáonallóI áf óoî aêe elágáble ío êeceáve seêváces fêoã fndáan healíh pêovádeêsI óoî
ãaó see íhese pêovádeês wáíhoîí a êefeêêal.
 Men’s prostate cancer screening exam, as long as you use a network provider.
 ooîíáne vásáon exaã and eóeglasses íhaí aêe noí jedácaêeJcoveêed seêváces EjedácaêeJcoveêed seêváces êeqîáêe aîíhoêázaíáonLêefeêêalF.  eealíhó píaêíLeealíhó goîêneó appoáníãení aí íhe Caêejoêe Caêe Ceníeê.
 bxeêcáse and síêengíh íêaánáng pêogêaãEsF aí planJappêoved locaíáons.
How to get care from specialists and other network providers
A specialist ás a docíoê who pêovádes healíh caêe foê a specáfác dásease oê paêí of íhe bodó.
qheêe aêe ãanó kánds of specáalásís. eeêe aêe a few exaãplesW
 Oncologists caêe foê paíáenís wáíh canceê.
 Cardiologists caêe foê paíáenís wáíh heaêí pêobleãs.
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 Orthopedists caêe foê paíáenís wáíh boneI âoáníI oê ãîscle pêobleãs.
ff óoî need specáalásí caêeI óoîê mCm wáll gáve óoî a êefeêêal ío íhe êághí docíoê oê oíheê healíh caêe
pêovádeê who can gáve óoî íhe kánd of caêe óoî need.
coê soãe seêvácesI óoî ãághí need pêáoê aîíhoêázaíáon. mêáoê aîíhoêázaíáon ãeans íhaí óoî need
appêoval fêoã îs befoêe óoî can geí a ceêíaán seêváce oê dêîg. voîê docíoê oê oíheê healíh caêe
pêovádeê wáll ask foê pêáoê aîíhoêázaíáon foê seêváces íheó feel óoî need. qo fánd oîí whách seêváces
need pêáoê aîíhoêázaíáonI see íhe Benefáís Chaêí án Chapíeê QW Benefáís Chaêí.
voîê mCm ãaó onló woêk wáíh a ceêíaán hospáíal oê gêoîp of specáalásís. qhás ás whó óoî have ío geí a
êefeêêal fêoã óoîê mCm befoêe óoî see a specáalásí. ff óoî have qîesíáons aboîí íhe specáalásís oê
hospáíals óoîê mCm woêks wáíhI coníací óoîê mCm oê jeãbeê peêváces.
fí ás veêó áãpoêíaní ío geí a êefeêêal Eappêoval án advanceF befoêe óoî see a Caêejoêe coníêacíed
specáalásí oê êeceáve specáalíó seêváces Ewáíh íhe excepíáon of íhose seêváces lásíed above îndeê
pecíáon a.F. ff óoî do noí have a êefeêêal Eappêoval án advanceF befoêe óoî êeceáve seêváces fêoã a
specáalásíI óoî ãaó have ío paó foê íhese seêváces óoîêself. mlease êefeê ío page PVI secíáon a foê
ánfoêãaíáon aboîí whách seêváces êeqîáêe êefeêêals andLoê pêáoê aîíhoêázaíáons.
ff a specáalásí wanís óoî ío coãe back foê ãoêe caêeI check fáêsí ío be sîêe íhaí íhe êefeêêal Eappêoval
án advanceF fêoã óoîê mCmI a Caêejoêe bxíensávásí oê kîêse mêacíáíáoneêI oê specáalásí íhaí óoî
êeceáved foê óoîê fáêsí vásáí coveês ãoêe vásáís ío íhaí specáalásí. líheêwáseI óoî ãîsí geí anoíheê
êefeêêal Eappêoval án advanceF foê íhe addáíáonal vásáís ío íhe specáalásí.
fn addáíáon ío oîê Caêejoêe Caêe CeníeêsI mCms have ceêíaán specáalásís and hospáíals íheó
îse foê êefeêêalsI so íhe mCm óoî selecí îsîalló deíeêãánes íhe specáalásís and hospáíals óoî
aêe êefeêêed ío. ff íheêe ás a paêíácîlaê Caêejoêe coníêacíed specáalásí oê hospáíal óoî pêefeêI
check fáêsí ío be sîêe óoîê mCm sends paíáenís ío íhaí specáalásí oê îses íhaí hospáíal.
What if a network provider leaves our plan?
A neíwoêk pêovádeê óoî aêe îsáng ãághí leave oîê plan. ff one of óoîê pêovádeês does leave
oîê planI óoî have ceêíaán êághís and pêoíecíáons íhaí aêe sîããaêázed belowW
 bven íhoîgh oîê neíwoêk of pêovádeês ãaó change dîêáng íhe óeaêI we ãîsí gáve óoî
înáníeêêîpíed access ío qîaláfáed pêovádeês.
 When possible, we will give you at least 30 days’ notice so that you have time to
selecí a new pêovádeê.
 te wáll help óoî selecí a new qîaláfáed pêovádeê ío coníánîe ãanagáng óoîê healíh caêe needs.
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 ff óoî aêe îndeêgoáng ãedácal íêeaíãeníI óoî have íhe êághí ío êeqîesíI and we wáll
woêk wáíh óoî ío ensîêeI íhaí íhe ãedácalló necessaêó íêeaíãení óoî aêe êeceáváng ás noí áníeêêîpíed.  ff óoî beláeve we have noí êeplaced óoîê pêeváoîs pêovádeê wáíh a qîaláfáed pêovádeê oê
íhaí óoîê caêe ás noí beáng appêopêáaíeló ãanagedI óoî have íhe êághí ío fále an appeal
of oîê decásáon.
ff óoî fánd oîí one of óoîê pêovádeês ás leaváng oîê planI please coníací îs so we can assásí
óoî án fándáng a new pêovádeê and ãanagáng óoîê caêe. Coníací jeãbeê peêváces aí NJUUU
PRMJPQQT Eqqv TNNF jondaó íhêoîgh cêádaó fêoã UWMM a.ã. ío UWMM p.ã. local íáãe.
ff óoî aêe cîêêeníló îndeêgoáng ãedácal íêeaíãeníI íheêe ãaó be soãe ánsíances wheêe changáng
óoîê phósácáanI ancállaêó pêovádeêI oê hospáíal woîld dásêîpí óoîê cîêêení íêeaíãení plan. iásíed below
aêe a few exaãples of ãedácal condáíáons íhaí ãaó waêêaní óoî ío êeceáve coníánîáng caêe fêoã óoîê
cîêêení pêovádeê afíeê heLshe leaves oîê neíwoêkW
 mosíJopeêaíáve vásáís followáng sîêgeêó
 Caêdáac êehabáláíaíáon
 pchedîled sîêgeêáes
 lêgan íêansplanís
 Coãpleíáon of cîêêení coîêse of cheãoíheêapó oê êadáaíáon íheêapó
 fnpaíáení caêe
líheê exaãples ãaó exásíI and appêopêáaíe aêêangeãenís wáll be ãade on a caseJbóJcase
basás dependáng on ãedácal necessáíó. ff óoî aêe cîêêeníló êeceáváng acíáve ongoáng íêeaíãení
fêoã a plan specáalásíI oê áf íheêe aêe specáal cáêcîãsíances íhaí woîld waêêaní oê êeqîáêe óoîê
ãedácal caêe ío coníánîe wáíh óoîê cîêêení pêovádeê afíeê he leaves oîê neíwoêkI please call
jeãbeê peêváces depaêíãení aí NJUUUJPRMJPQQT Eqqv TNNF.
How to get care from out-of-network providers
fn ãosí casesI we wáll noí coveê caêe óoî êeceáve fêoã an oîíJofJneíwoêk pêovádeê. qhás ãeans íhaí
your care was from a provider who is not part of our plan’s network. There are times when we will
coveê caêe fêoã an oîíJofJneíwoêk pêovádeê. eeêe aêe íhêee cases when we wáll coveê óoîê caêe fêoã
an oîíJofJneíwoêk pêovádeêW
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ff óoî need eãeêgencó oê îêgení caêe. coê ãoêe ánfoêãaíáon aboîí íhásI and ío see whaí
eãeêgencó oê îêgení caêe ãeansI see bãeêgencó caêe oê rêgeníló needed caêe án íhe jedácal
Benefáís Chaêí án Chapíeê Q.
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ff óoî need ãedácal caêe íhaí jedácaêe saós oîê plan ãîsí coveê bîí none of oîê neíwoêk
providers offer this type of care. In this case, your PCP or Specialist will need to get a "Prior
Authorization.´ This means that CareMore must approve this before you get the care. If you have
appêoval ahead of íáãe óoî wáll paó íhe saãe óoî woîld paó áf óoî goí íhe caêe fêoã a neíwoêk
pêovádeê. fí ás veêó áãpoêíaní ío geí óoîê êefeêêal fêoã óoîê mCmI ppecáalásíI oê Caêejoêe
bxíensávásí appêoved befoêe óoî see an oîíJof neíwoêk pêovádeê. ff óoî do noí have a êefeêêal
befoêe óoî êeceáve caêe fêoã an oîíJofJneíwoêk pêovádeêI óoî ãaó have ío paó foê íhese seêváces
óoîêself.
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hádneó dáalósás seêváces íhaí óoî geí aí a jedácaêeJceêíáfáed dáalósás ceníeê when óoî aêe oîísáde
the plan’s service area for a short time.
 Please note: ff óoî go ío an oîíJofJneíwoêk pêovádeêI íhe pêovádeê ãîsí be elágáble ío
paêíácápaíe án jedácaêe andLoê jedácaád. te cannoí paó a pêovádeê who ás noí elágáble ío
paêíácápaíe án jedácaêe andLoê jedácaád. ff óoî go ío a pêovádeê who ás noí elágáble ío
paêíácápaíe án jedácaêeI óoî ãîsí paó íhe fîll cosí of íhe seêváces óoî geí. mêovádeês ãîsí
íell óoî áf íheó aêe noí elágáble ío paêíácápaíe án jedácaêe.
E. How to get long-term services and supports (LTSS)
iongJíeêã seêváces and sîppoêís EiqppF consásí of Coããînáíó Based Adîlí peêváces
ECBApFI fnJeoãe pîppoêíáve peêváces EfeppFI jîlíáJmîêpose penáoê peêváces mêogêaã
EjppmFI and kîêsáng cacáláíáes EkcF. qhe seêváces ãaó occîê án óoîê hoãeI coããînáíóI oê án
a facáláíó. qhe dáffeêení íópes of iqpp aêe descêábed belowW
 Community Based Adult Services (CBAS)W lîípaíáeníI facáláíó based seêváce
pêogêaã íhaí deláveês skálled nîêsáng caêeI socáal seêvácesI íheêapáesI peêsonal caêeI
faãálóLcaêegáveê íêaánáng and sîppoêíI nîíêáíáon seêvácesI íêanspoêíaíáonI and oíheê
seêváces áf óoî ãeeí applácable elágábáláíó cêáíeêáa.
 In-Home Supportive Services (IHSS): A pêogêaã íhaí allows óoî ío selecí óoîê
pêovádeê of ánJhoãe caêe áf óoî cannoí safeló êeãaán án óoîê hoãe wáíhoîí assásíance.
qo qîaláfó foê feppI óoî ãîsí be agedI blándI oê dásabled andI án ãosí casesI have
áncoãe below íhe level ío qîaláfó foê íhe pîppleãeníal pecîêáíó fncoãeLpíaíe
pîppleãeníaêó mêogêaã.
 Multi-Purpose Senior Services Program (MSSP): A CaláfoênáaJspecáfác pêogêaã íhaí
pêovádes eoãe and CoããînáíóJBased peêváces EeCBpF ío jedáJCal elágáble
ándávádîals who aêe SR óeaês oê oldeê wáíh dásabáláíáes as an alíeênaíáve ío nîêsáng
facáláíó placeãení.
 Nursing Facility (NF): A facáláíó íhaí pêovádes caêe foê people who cannoí safeló láve
aí hoãe bîí who do noí need ío be án íhe hospáíal.
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voîê caêe ãanageê wáll help óoî îndeêsíand each pêogêaã. qo fánd oîí ãoêe aboîí anó of
íhese pêogêaãsI coníací jeãbeê peêváces aí NJUUUJPRMJPQQT Eqqv TNNF.
F. How to get behavioral health (mental health & substance use
disorder) services
voî wáll have access ío ãedácalló necessaêó behaváoêal healíh seêváces íhaí aêe coveêed bó
jedácaêe and jedáJCal. Caêejoêe Cal jedáConnecí mlan pêovádes access ío behaváoêal
healíh seêváces coveêed bó jedácaêe. jedáJCal coveêed behaváoêal healíh seêváces aêe noí
pêováded bó Caêejoêe Cal jedáConnecí mlanI bîí wáll be avaálable ío elágáble Caêejoêe Cal
jedáConnecí mlan ãeãbeês íhêoîgh ios Angeles Coîníó aepaêíãení of jeníal eealíh
EiACajeF.
What Medi-Cal behavioral health services are provided outside of CareMore Cal
MediConnect Plan through Los Angeles County Department of Mental Health
(LACDMH)?
jedáJCal specáalíó ãeníal healíh seêváces aêe avaálable ío óoî íhêoîgh íhe coîníó ãeníal
healíh plan EjemF áf óoî ãeeí jedáJCal specáalíó ãeníal healíh seêváces ãedácal necessáíó
cêáíeêáa. jedáJCal specáalíó ãeníal healíh seêváces pêováded bó ios Angeles Coîníó
aepaêíãení of jeníal eealíh EiACajeF ánclîdeW
 jeníal healíh seêváces EassessãeníI íheêapóI êehabáláíaíáonI collaíeêalI and plan
developãeníF
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jedácaíáon sîppoêí seêváces
aaó íêeaíãení áníensáve
aaó êehabáláíaíáon
Cêásás áníeêveníáon
Cêásás síabálázaíáon
Adîlí êesádeníáal íêeaíãení seêváces
Cêásás êesádeníáal íêeaíãení seêváces
msócháaíêác healíh facáláíó seêváces
msócháaíêác ánpaíáení hospáíal seêváces
qaêgeíed case ãanageãení
aêîg jedáJCal seêváces aêe avaálable ío óoî íhêoîgh ios Angeles Coîníó aepaêíãení of mîblác
eealíhLpîbsíance Abîse mêeveníáon C Coníêol EameLpAmCF áf óoî ãeeí íhe aêîg jedáJCal ãedácal
necessáíó cêáíeêáa. aêîg jedáJCal seêváces pêováded bó ios Angeles Coîníó EameLpAmCF ánclîdeW
 fníensáve oîípaíáení íêeaíãení seêváces
 oesádeníáal íêeaíãení seêváces
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 lîípaíáení dêîg fêee seêváces
 kaêcoíác íêeaíãení seêváces
 kalíêexone seêváces foê opáoád dependence
fn addáíáon ío íhe aêîg jedáJCal seêváces lásíed aboveI óoî ãaó have access ío volîníaêó
ánpaíáení deíoxáfácaíáon seêváces áf óoî ãeeí íhe ãedácal necessáíó cêáíeêáa.
Caêejoêe Cal jedáConnecí mlan has a ?ko têong aooê? appêoach ío íhe êefeêêal pêocess. ff
óoî need Behaváoêal eealíh seêvácesI êeqîesí áí fêoã íhe Caêejoêe jeãbeê peêváces
êepêeseníaíáve oê óoîê case ãanageê. CoããonlóI ãeãbeês woîld íalk ío íheáê mêáãaêó Caêe
mhósácáan oê oíheê ãedácal pêovádeê when íheó feel íheó need Behaváoêal eealíh seêváces.
jedácal mêovádeês wáll ask appêopêáaíe qîesíáons ío deíeêãáne áf a êefeêêal ío Behaváoêal
eealíh ás appêopêáaíe. then a êefeêêal ás aîíhoêázedI an ánáíáal evalîaíáon wáll be schedîled
and íhe appêopêáaíe seêváces wáll be aêêanged based on ãedácal necessáíó.
G. How to get transportation services
qwo íópes of íêanspoêíaíáon aêe coveêed îndeê íhe Caêejoêe Cal jedáConnecí mlan.
Non-emergency medical transportation

qhás benefáí allows foê íêanspoêíaíáon íhaí ás íhe ãosí cosí effecíáve and accessáble. qhás
can ánclîdeW aãbîlanceI láííeê vanI wheelchaáê van ãedácal íêanspoêíaíáon seêvácesI and
cooêdánaíáng wáíh paêaíêansáí.

qhás foêã of íêanspoêíaíáon ás aîíhoêázed whenW
» voîê ãedácal andLoê phósácal condáíáon does noí allow óoî ío íêavel bó bîsI
passengeê caêI íaxácabI oê anoíheê foêã of pîblác oê pêávaíe íêanspoêíaíáonI and
» qêanspoêíaíáon ás êeqîáêed foê íhe pîêpose of obíaánáng needed ãedácal caêe
Non-medical transportation

qhás benefáí allows foê íêanspoêíaíáon ío êeceáve ãedácal seêváces bó passengeê caêI íaxáI
oê oíheê foêãs of pîblácLpêávaíe íêanspoêíaíáon. coê an exaãpleI óoî coîld îse íhás
service if you needed a ride to your scheduled doctor’s appointment or to the CareMore
Caêe Ceníeê.
coê ãoêe ánfoêãaíáon see Chapíeê QI pecíáon a oê coníací jeãbeê peêváces.
Coveêed íêanspoêíaíáon seêváces aêe pêováded ío planJappêoved non-emergency and routine medical
care vásáís foê ãeãbeês who aêe aãbîlaíoêó oê îse síandaêdJsázed wheelchaáêsI and who do noí
have anó láãáíáng ãedácal condáíáon íhaí woîld êesíêácí íheã fêoã noêãal ãeans of pîblác
íêanspoêíaíáon.
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qo be coveêedI íêanspoêíaíáon seêváces ãîsí be pêováded bó a coníêacíed and deságnaíed
íêanspoêíaíáon seêváce caêêáeê. aáffeêení ãodes of íêanspoêíaíáon ãaó be îsed oíheê íhan vans and
íaxácabs áf planJappêoved.
How to schedule transportation




voî ãîsí cooêdánaíe óoîê íêanspoêíaíáon íhêoîgh CaêejoêeI and óoî ãîsí schedîle íêanspoêíaíáon no less than one business day pêáoê ío óoîê ãedácal appoáníãení.
bach ãeãbeê ás allowed one escoêí.
voî ãîsí ánfoêã íhe qêanspoêíaíáon aepaêíãení aí leasí one business day pêáoê ío íhe
appoáníãení áf óoî aêe íakáng an escoêí. All escoêís ãîsí be NT óeaês of age oê oldeê.
ko anáãals aêe allowed înless íheó aêe seêváce anáãals.
qo schedîle óoîê íêanspoêíaíáonI call íhe Caêejoêe qêanspoêíaíáon rnáí aí NJUTTJONNJSSUT Eqqv
TNNFI fêoã TWMM a.ã. ío SWMM p.ã. jondaó íhêoîgh cêádaó Eexclîdáng holádaósF.
Cancellation Policy
Members must notify CareMore of any cancellation one business day prior ío óoîê schedîled
êáde. ff óoîê schedîled êáde ás noí canceledI áí ãaó coîní íowaêds óoîê íêáp láãáí. Coníací jeãbeê
peêváces foê ãoêe ánfoêãaíáon.
H. How to get covered services when you have a medical
emergency or urgent need for care, or during a disaster
Getting care when you have a medical emergency
What is a medical emergency?
A medical emergency ás a ãedácal condáíáon wáíh sóãpíoãs sîch as seveêe paán oê seêáoîs
injury. The condition is so serious that, if it doesn’t get immediate medical attention, you or
anó pêîdení laópeêson wáíh an aveêage knowledge of healíh and ãedácáne coîld expecí áí ío
êesîlí ánW
 mlacing the person’s health in serious risk; or
 peêáoîs haêã ío bodáló fîncíáons; or
 peêáoîs dósfîncíáon of anó bodáló oêgan oê paêí; or
 fn íhe case of a pêegnaní woãanI an acíáve laboêI ãeanáng laboê aí a íáãe when
eáíheê of íhe followáng woîld occîêW
» qheêe ás noí enoîgh íáãe ío safeló íêansfeê íhe ãeãbeê ío anoíheê hospáíal befoêe
deláveêó.
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» qhe íêansfeê ãaó pose a íhêeaí ío íhe healíh oê safeíó of íhe ãeãbeê oê înboên
cháld.
What should you do if you have a medical emergency?
ff óoî have a ãedácal eãeêgencóW
 Get help as fast as possible. Call VNN oê go ío íhe neaêesí eãeêgencó êooã oê
hospáíal. Call foê an aãbîlance áf óoî need áí. voî do not need ío geí appêoval oê a
êefeêêal fáêsí fêoã óoîê mCm.
 As soon as possible, make sure that you tell our plan about your emergency.
te need ío follow îp on óoîê eãeêgencó caêe. voî oê soãeone else shoîld call ío
íell îs aboîí óoîê eãeêgencó caêeI îsîalló wáíhán QU hoîês. eoweveêI óoî wáll noí
have ío paó foê eãeêgencó seêváces becaîse of a delaó án íelláng îs. Coníací íhe
jeãbeê peêváces aepaêíãení aí NJUUUJPRMJPQQT Eqqv TNNFI jondaó íhêoîgh cêádaó
fêoã U a.ã. ío U p.ã. AfíeêJhoîês ãessagáng ás avaálable OQ hoîês a daóI T daós a
week.
What is covered if you have a medical emergency?
voî ãaó geí coveêed eãeêgencó caêe wheneveê óoî need áíI anówheêe án íhe rnáíed píaíes
oê áís íeêêáíoêáes. ff óoî need an aãbîlance ío geí ío íhe eãeêgencó êooãI oîê plan coveês
íhaí. qo leaên ãoêeI see íhe Benefáís Chaêí án Chapíeê Q.
Caêejoêe offeês láãáíed sîppleãeníal eãeêgencó ãedácal caêe coveêage foê occasáons when
óoî aêe oîísáde of íhe rnáíed píaíes. mlease êefeê ío íhe Medical Benefits Chart án Chapíeê Q
foê ãoêe deíaáls.
Afíeê íhe eãeêgencó ás oveêI óoî ãaó need followJîp caêe ío be sîêe óoî geí beííeê. voîê
followJîp caêe wáll be coveêed bó îs. ff óoî geí óoîê eãeêgencó caêe fêoã oîíJofJneíwoêk
pêovádeêsI we wáll íêó ío geí neíwoêk pêovádeês ío íake oveê óoîê caêe as soon as possáble.
What if it wasn’t a medical emergency after all?
poãeíáães áí can be haêd ío know áf óoî have a ãedácal eãeêgencó. voî ãághí go án foê
emergency care and have the doctor say it wasn’t really a medical emergency. As long as
óoî êeasonabló íhoîghí óoîê healíh was án seêáoîs dangeêI we wáll coveê óoîê caêe.
eoweveêI afíeê íhe docíoê saós áí was not an eãeêgencóI we wáll coveê óoîê addáíáonal caêe
only áfW
 voî go ío a neíwoêk pêovádeêI or
 The additional care you get is considered "urgently needed care´ and you follow the
êîles foê geííáng íhás caêe. Epee íhe nexí secíáon.F
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Getting urgently needed care
What is urgently needed care?
Urgently needed care is care you get for a sudden illness, injury, or condition that isn’t an
eãeêgencó bîí needs caêe êághí awaó. coê exaãpleI óoî ãághí have a flaêeJîp of an exásíáng
condáíáon and need ío have áí íêeaíed.
Getting urgently needed care when you are in the plan’s service area
fn ãosí sáíîaíáonsI we wáll coveê îêgeníló needed caêe only áfW
voî geí íhás caêe fêoã a neíwoêk pêovádeêI and
voî follow íhe oíheê êîles descêábed án íhás chapíeê.
However, if you can’t get to a neíwoêk pêovádeêI we wáll coveê îêgeníló needed caêe óoî geí
fêoã an oîíJofJneíwoêk pêovádeê.
If you have a sudden illness or injury that is not a medical emergency, and you are in
the plan’s service area, please call your PCP. If your PCP’s office is closed, please go
to any urgent care facility located within our service area. This information can be
found by using our Provider/Pharmacy Directory, or you can call Member Services at
1-888-350-3447 for additional information (TTY 711).
Getting urgently needed care when you are outside the plan’s service area
then óoî aêe oîísáde íhe seêváce aêeaI óoî ãághí noí be able ío geí caêe fêoã a neíwoêk
pêovádeê. fn íhaí caseI oîê plan wáll coveê îêgeníló needed caêe óoî geí fêoã anó pêovádeê.
 lîê plan does noí coveê îêgeníló needed caêe oê anó oíheê caêe íhaí óoî geí oîísáde íhe
rnáíed píaíes.
Getting care during a disaster
ff íhe doveênoê of óoîê síaíeI íhe r.p. pecêeíaêó of eealíh and eîãan peêvácesI oê íhe
mêesádení of íhe rnáíed píaíes declaêes a síaíe of dásasíeê oê eãeêgencó án óoîê geogêaphác
aêeaI óoî aêe síáll eníáíled ío caêe fêoã Caêejoêe Cal jedáConnecí mlan.
mlease vásáí oîê websáíe foê ánfoêãaíáon on how ío obíaán needed caêe dîêáng a declaêed
dásasíeêW dîals.caêeãoêe.coã.
aîêáng a declaêed dásasíeêI we wáll allow óoî ío geí caêe fêoã oîíJofJneíwoêk pêovádeês aí no
cosí ío óoî. ff óoî cannoí îse a neíwoêk phaêãacó dîêáng a declaêed dásasíeêI óoî wáll be
able ío fáll óoîê pêescêápíáon dêîgs aí an oîíJofJneíwoêk phaêãacó. mlease see Chapíeê R foê
ãoêe ánfoêãaíáon.
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I. What if you are billed directly for the full cost of services covered
by our plan?
ff a pêovádeê sends óoî a báll ánsíead of sendáng áí ío íhe planI óoî shoîld ask îs ío paó íhe
báll.
 voî shoîld noí paó íhe báll óoîêself. ff óoî doI íhe plan ãaó noí be able ío paó óoî back.
ff óoî have paád foê óoîê coveêed seêvácesI or ff óoî have paád ãoêe íhan óoîê shaêe foê
coveêed seêvácesI oê áf óoî have goííen a báll foê coveêed ãedácal seêvácesI see Chapíeê T
pecíáon A ío leaên whaí ío do.
What should you do if services are not covered by our plan?
Caêejoêe Cal jedáConnecí mlan coveês all seêvácesW
 qhaí aêe deíeêãáned necessaêóI and
 That are listed in the plan’s Benefits Chart (see Chapter 4F, and
 qhaí óoî geí bó followáng plan êîles.
 ff óoî geí seêváces that aren’t covered by our plan, you must pay the full cost yourself.
ff óoî waní ío know áf we wáll paó foê anó ãedácal seêváce oê caêeI óoî have íhe êághí ío ask
îs. voî also have íhe êághí ío ask foê íhás án wêáíáng. ff we saó we wáll noí paó foê óoîê
seêvácesI óoî have íhe êághí ío appeal oîê decásáon.
Chapíeê V pecíáon R explaáns whaí ío do áf óoî waní îs ío coveê a ãedácal áíeã oê seêváce. fí
also íells óoî how ío appeal oîê coveêage decásáon. voî ãaó also call jeãbeê peêváces ío
leaên ãoêe aboîí óoîê appeal êághís.
te wáll paó foê soãe seêváces îp ío a ceêíaán láãáí. ff óoî go oveê íhe láãáíI óoî wáll have ío
paó íhe fîll cosí ío geí ãoêe of íhaí íópe of seêváce. Call jeãbeê peêváces ío fánd oîí whaí íhe
láãáís aêe and how close óoî aêe ío êeacháng íheã.
J. How are your health care services covered when you are in a
clinical research study?
What is a clinical research study?
A clinical research study Ealso called a clinical trialF ás a waó docíoês íesí new íópes of healíh
caêe oê dêîgs. qheó ask foê volîníeeês ío help wáíh íhe síîdó. qhás kánd of síîdó helps docíoês
decáde wheíheê a new kánd of healíh caêe oê dêîg woêks and wheíheê áí ás safe.
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lnce jedácaêe appêoves a síîdó óoî waní ío be ánI soãeone who woêks on íhe síîdó wáll
coníací óoî. qhaí peêson wáll íell óoî aboîí íhe síîdó and see áf óoî qîaláfó ío be án áí. voî
can be án íhe síîdó as long as óoî ãeeí íhe êeqîáêed condáíáons. voî ãîsí also îndeêsíand
and accepí whaí óoî ãîsí do foê íhe síîdó.
thále óoî aêe án íhe síîdóI óoî ãaó síaó enêolled án oîê plan. qhaí waó óoî coníánîe ío geí
caêe fêoã oîê plan noí êelaíed ío íhe síîdó.
ff óoî waní ío paêíácápaíe án a jedácaêeJappêoved clánácal êeseaêch síîdóI óoî do not need ío
geí appêoval fêoã îs oê óoîê pêáãaêó caêe pêovádeê. qhe pêovádeês íhaí gáve óoî caêe as paêí
of íhe síîdó do not need ío be neíwoêk pêovádeês.
You do need to tell us before you start participating in a clinical research study.
Here’s why:
 te can íell óoî áf íhe clánácal êeseaêch síîdó ás jedácaêeJappêoved.
 te can íell óoî whaí seêváces óoî wáll geí fêoã clánácal êeseaêch síîdó pêovádeês
ánsíead of fêoã oîê plan.
ff óoî plan ío be án a clánácal êeseaêch síîdóI óoî oê óoîê caêe ãanageê shoîld coníací
jeãbeê peêváces.
When you are in a clinical research study, who pays for what?
ff óoî volîníeeê foê a clánácal êeseaêch síîdó íhaí jedácaêe appêovesI óoî wáll paó noíháng foê
íhe seêváces coveêed îndeê íhe síîdó and jedácaêe wáll paó foê seêváces coveêed îndeê íhe
síîdó as well as êoîíáne cosís assocáaíed wáíh óoîê caêe. lnce óoî âoán a jedácaêeJappêoved
clánácal êeseaêch síîdóI óoî aêe coveêed foê ãosí áíeãs and seêváces óoî geí as paêí of íhe
síîdó. qhás ánclîdesW
Room and board for a hospital stay that Medicare would pay for even if you weren’t
án a síîdó.
 An opeêaíáon oê oíheê ãedácal pêocedîêe íhaí ás paêí of íhe êeseaêch síîdó.
 qêeaíãení of anó sáde effecís and coãplácaíáons of íhe new caêe.
ff óoî aêe paêí of a síîdó íhaí jedácaêe has not appêovedI you will have to pay any costs
for being in the study.
Learning more
voî can leaên ãoêe about joining a clinical research study by reading "Medicare & Clinical
oeseaêch ptudies´ on the Medicare website
EhíípWLLwww.ãedácaêe.govLpîblácaíáonsLpîbsLpdfLMOOOS.pdfF. voî can also call
NJUMMJjbafCAob ENJUMMJSPPJQOOTFI OQ hoîês a daóI T daós a week. qqv îseês shoîld
call NJUTTJQUSJOMQU.
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K. How are your health care services covered when you are in a
religious non-medical health care institution?
What is a religious non-medical health care institution?
A religious non-medical health care institution ás a place íhaí pêovádes caêe óoî woîld
noêãalló geí án a hospáíal oê skálled nîêsáng facáláíó. ff geííáng caêe án a hospáíal oê a skálled
nîêsáng facáláíó ás agaánsí óoîê êelágáoîs beláefsI we wáll coveê caêe án a êelágáoîs nonJãedácal
healíh caêe ánsíáíîíáon. voî ãaó choose ío geí healíh caêe aí anó íáãe foê anó êeason. qhás
benefáí ás onló foê jedácaêe maêí A ánpaíáení seêváces EnonJãedácal healíh caêe seêvácesF.
jedácaêe wáll onló paó foê nonJãedácal healíh caêe seêváces pêováded bó êelágáoîs nonJãedácal
healíh caêe ánsíáíîíáons.
What care from a religious non-medical health care institution is covered by
our plan?
qo geí caêe fêoã a êelágáoîs nonJãedácal healíh caêe ánsíáíîíáonI óoî ãîsí ságn a legal
document that says you are against getting medical treatment that is "nonJexcepted.´
 "NonJexcepted´ medical treatment is any care that is voluntary and not required bó
anó fedeêalI síaíeI oê local law.
 "Excepted´ medical treatment is any care íhaí ás not volîníaêó and is required îndeê
fedeêalI síaíeI oê local law.
qo be coveêed bó oîê planI íhe caêe óoî geí fêoã a êelágáoîs nonJãedácal healíh caêe
ánsíáíîíáon ãîsí ãeeí íhe followáng condáíáonsW
 qhe facáláíó pêovádáng íhe caêe ãîsí be ceêíáfáed bó jedácaêe.
 Our plan’s coverage of services is limited to non-religious aspecís of caêe.
 lîê plan wáll coveê íhe seêváces óoî geí fêoã íhás ánsíáíîíáon án óoîê hoãeI as long as
íheó woîld be coveêed áf gáven bó hoãe healíh agencáes íhaí aêe noí êelágáoîs nonJ
ãedácal healíh caêe ánsíáíîíáons.
 ff óoî geí seêváces fêoã íhás ánsíáíîíáon íhaí aêe pêováded ío óoî án a facáláíóI íhe
followáng appláesW
» voî ãîsí have a ãedácal condáíáon íhaí woîld allow óoî ío geí coveêed seêváces
foê ánpaíáení hospáíal caêe oê skálled nîêsáng facáláíó caêe.
» voî ãîsí geí appêoval fêoã îs befoêe óoî aêe adãáííed ío íhe facáláíó oê óoîê síaó
wáll noí be coveêed.
ff óoî aêe adãáííedI óoîê ánpaíáení hospáíal caêe benefáí and coveêage ãaó appló ío seêváces
êeceáved aí êelágáoîs nonJãedácal healíh caêe ánsíáíîíáons. mlease êefeê ío óoîê ánpaíáení
hospáíal caêe benefáí explaáned án íhe jedácal Benefáís Chaêí án Chapíeê Q.
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L. Rules for owning durable medical equipment
Will you own your durable medical equipment?
Durable medical equipment ãeans ceêíaán áíeãs oêdeêed bó a pêovádeê foê îse án óoîê own
hoãe. bxaãples of íhese áíeãs aêe oxógen eqîápãení and sîppláesI wheelchaáêsI canesI
cêîíchesI walkeêsI and hospáíal beds.
voî wáll alwaós own ceêíaán áíeãsI sîch as pêosíheíács. fn íhás secíáonI we dáscîss dîêable
ãedácal eqîápãení óoî ãîsí êení.
fn jedácaêeI people who êení ceêíaán íópes of dîêable ãedácal eqîápãení own áí afíeê NP
ãoníhs. As a ãeãbeê of Caêejoêe Cal jedáConnecí mlanI howeveêI óoî îsîalló wáll noí own
íhe êeníed eqîápãeníI no ãaííeê how long óoî êení áí.
fn ceêíaán sáíîaíáonsI we wáll íêansfeê owneêsháp of íhe dîêable ãedácal eqîápãení áíeã. Call
jeãbeê peêváces ío fánd oîí aboîí íhe êeqîáêeãenís óoî ãîsí ãeeí and íhe papeês óoî need
ío pêováde.
What happens if you switch to Medicare?
voî wáll have ío ãake NP paóãenís án a êow îndeê lêágánal jedácaêe ío own íhe eqîápãení áfW
 voî dád noí becoãe íhe owneê of íhe dîêable ãedácal eqîápãení áíeã whále óoî weêe
án oîê plan and
 voî leave oîê plan and geí óoîê jedácaêe benefáís oîísáde of anó healíh plan án íhe
lêágánal jedácaêe pêogêaã.
ff óoî ãade paóãenís foê íhe dîêable ãedácal eqîápãení îndeê lêágánal jedácaêe befoêe óoî
âoáned oîê planI íhose jedácaêe paóãenís do noí coîní íowaêd íhe NP paóãenís. voî wáll
have ío ãake NP new paóãenís án a êow îndeê lêágánal jedácaêe ío own íhe áíeã.
 qheêe aêe no excepíáons ío íhás case when óoî êeíîên ío lêágánal jedácaêe.
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RP
Chapter 4: Benefits Chart
Table of Contents
A. rndeêsíandáng óoîê coveêed seêváces ..........................................................................................RR
B. lîê plan does noí allow pêovádeês ío chaêge óoî foê seêváces ......................................................RR
C. Aboîí íhe Benefáís Chaêí ..............................................................................................................RS
D. qhe Benefáís Chaêí.......................................................................................................................RT
E. Using our plan’s visitor or traveler benefits ..................................................................................VQ
F. Benefáís coveêed oîísáde of Caêejoêe Cal jedáConnecí mlan.....................................................VQ
Caláfoênáa Coããînáíó qêansáíáons ECCqF ....................................................................................VQ
jedáJCal aeníal mêogêaã ...........................................................................................................VR
eospáce Caêe .............................................................................................................................VR
G. Benefáís not coveêed bó Caêejoêe Cal jedáConnecí mlanI jedácaêeI oê jedáJCal......................VS
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jondaó íhêoîgh cêádaó fêoã U a.ã. ío U p.ã. AfíeêJhoîês ãessagáng ás avaálable OQ hoîês a daóI T daós a week. qhe call ás fêee. For more informationI vásáí dîals.caêeãoêe.coã.
RQ
Chapíeê QW Benefáís Chaêí
A. Understanding your covered services
qhás chapíeê íells óoî whaí seêváces Caêejoêe Cal jedáConnecí mlan paós foê. voî can also
leaên aboîí seêváces íhaí aêe noí coveêed. fnfoêãaíáon aboîí dêîg benefáís ás án Chapíeê RI
pecíáon B. qhás chapíeê also explaáns láãáís on soãe seêváces.
Becaîse óoî geí assásíance fêoã jedáJCalI óoî paó noíháng foê óoîê coveêed seêváces as
long as óoî follow íhe plan’s rules. See Chapter 3, Section B for details about the plan’s
êîles.
ff óoî need help îndeêsíandáng whaí seêváces aêe coveêedI call óoîê jeãbeê peêváces aí N
UUUJPRMJPQQT Eqqv TNNF.
B. Our plan does not allow providers to charge you for services
te do noí allow Caêejoêe Cal jedáConnecí mlan pêovádeês ío báll óoî foê coveêed seêváces.
te paó oîê pêovádeês dáêecílóI and we pêoíecí óoî fêoã anó chaêges. qhás ás íêîe even áf we
paó íhe pêovádeê less íhan íhe pêovádeê chaêges foê a seêváce.

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You should never get a bill from a provider for covered services. If you do, see
Chapter 7 Section A or call Member Services.
RR
C. About the Benefits Chart
qhás benefáís chaêí íells óoî whách seêváces íhe plan paós foê. fí lásís caíegoêáes of seêváces án
alphabeíácal oêdeê and explaáns íhe coveêed seêváces.
We will pay for the services listed in the Benefits Chart only when the following rules
are met. You do not pay anything for the service listed in the Benefits Chart, as long as
you meet the coverage requirements described below.
 voîê jedácaêe and jedáJCal coveêed seêváces ãîsí be pêováded accoêdáng ío íhe êîles
seí bó jedácaêe and jedáJCal.
 qhe seêváces Eánclîdáng ãedácal caêeI behaváoêal healíh and sîbsíance îse seêvácesI
long íeêã seêváces and sîppoêísI sîppláesI eqîápãeníI and dêîgsF ãîsí be ãedácalló
necessaêó. jedácalló necessaêó ãeans óoî need íhe seêváces ío pêeveníI dáagnoseI oê
íêeaí a ãedácal condáíáon. jedáJCal defánes ãedácalló necessaêó as êeasonable and
necessaêó seêváces ío pêoíecí láfeI ío pêevení ságnáfácaní állness oê ságnáfácaní dásabáláíó oê
ío alleváaíe seveêe paán íhêoîgh íhe dáagnosás oê íêeaíãení of dáseaseI állness oê ánâîêó.
 voî geí óoîê caêe fêoã a neíwoêk pêovádeê. A neíwoêk pêovádeê ás a pêovádeê who woêks
wáíh îs. fn ãosí casesI we wáll noí paó foê caêe óoî geí fêoã an oîíJofJneíwoêk pêovádeê.
Chapíeê P pecíáon a has ãoêe ánfoêãaíáon aboîí îsáng neíwoêk and oîíJofJneíwoêk
pêovádeês.
 voî have a pêáãaêó caêe pêovádeê EmCmF oê a caêe íeaã íhaí ás pêovádáng and ãanagáng
óoîê caêe. fn ãosí casesI óoîê mCm ãîsí gáve óoî appêoval befoêe óoî can see oíheê
neíwoêk pêovádeês. qhás ás called a êefeêêal. Chapíeê P pecíáon a has ãoêe ánfoêãaíáon
aboîí geííáng a êefeêêal and explaáns when óoî do noí need a êefeêêal.
 poãe of íhe seêváces lásíed án íhe Benefáís Chaêí aêe coveêed onló áf óoîê docíoê oê
oíheê neíwoêk pêovádeê geís appêoval fêoã îs fáêsí. qhás ás called prior authorization.
Coveêed seêváces íhaí need appêoval fáêsí aêe ãaêked án íhe Benefáís Chaêí án italic type.
All pêeveníáve seêváces aêe fêee. voî wáll see íhás apple
benefáís chaêí.
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nexí ío pêeveníáve seêváces án íhe
RS
D. The Benefits Chart
Services that our plan pays for
Abdominal aortic aneurysm screening
What you
must pay
AM
A oneJíáãe scêeenáng îlíêasoînd foê people aí êásk. qhe plan
onló coveês íhás scêeenáng áf óoî have ceêíaán êásk facíoês and áf
óoî geí a êefeêêal foê áí fêoã óoîê phósácáanI phósácáan assásíaníI
nîêse pêacíáíáoneêI oê clánácal nîêse specáalásí.
Alcohol misuse screening and counseling
AM
te wáll paó foê one alcoholJãásîse scêeenáng EpBfoqF foê adîlís
who ãásîse alcohol bîí aêe noí alcohol dependení. qhás
ánclîdes pêegnaní woãen.
ff óoî scêeen posáíáve foê alcohol ãásîseI óoî can geí îp ío foîê
bêáefI faceJíoJface coînseláng sessáons each óeaê Eáf óoî aêe
able and aleêí dîêáng coînselángF wáíh a qîaláfáed pêáãaêó caêe
pêovádeê oê pêacíáíáoneê án a pêáãaêó caêe seííáng.
mêáoê aîíhoêázaíáon ás noí êeqîáêed foê seêváces pêováded bó a
coníêacíed pêovádeê.
Ambulance services
AM
Coveêed aãbîlance seêváces ánclîde fáxedJwángI êoíaêóJwángI
and gêoînd aãbîlance seêváces. qhe aãbîlance wáll íake óoî ío
íhe neaêesí place íhaí can gáve óoî caêe.
voîê condáíáon ãîsí be seêáoîs enoîgh íhaí oíheê waós of
geííáng ío a place of caêe coîld êásk óoîê láfe oê healíh.
Aãbîlance seêváces foê oíheê cases ãîsí be appêoved bó îs.
fn cases íhaí aêe not eãeêgencáesI we may paó foê an
aãbîlance. voîê condáíáon ãîsí be seêáoîs enoîgh íhaí oíheê
waós of geííáng ío a place of caêe coîld êásk óoîê láfe oê healíh.
Authorization rules may apply.
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RT
Annual wellness visit
What you
must pay
AM
voî can geí an annîal checkîp. qhás ás ío ãake oê îpdaíe a
pêeveníáon plan based on óoîê cîêêení êásk facíoês. te wáll paó
foê íhás once eveêó NO ãoníhs.
Bone mass measurement
AM
te wáll paó foê ceêíaán pêocedîêes foê ãeãbeês who qîaláfó
EîsîallóI soãeone aí êásk of losáng bone ãass oê aí êásk of
osíeopoêosásF. qhese pêocedîêes ádeníáfó bone ãassI fánd bone
lossI oê fánd oîí bone qîaláíó. te wáll paó foê íhe seêváces once
eveêó OQ ãoníhsI oê ãoêe ofíen áf íheó aêe ãedácalló necessaêó.
te wáll also paó foê a docíoê ío look aí and coããení on íhe
êesîlís.
Breast cancer screening (mammograms)
AM
te wáll paó foê íhe followáng seêvácesW
 lne baseláne ãaããogêaã beíween íhe ages
of PR and PV
 lne scêeenáng ãaããogêaã eveêó NO ãoníhs
foê woãen age QM and oldeê
 Clánácal bêeasí exaãs once eveêó OQ ãoníhs
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RU
Cardiac (heart) rehabilitation services
What you
must pay
AM
te wáll paó foê caêdáac êehabáláíaíáon seêváces sîch as exeêcáseI
edîcaíáonI and coînseláng. jeãbeês ãîsí ãeeí ceêíaán
conditions with a doctor’s êefeêêal. te also coveê intensive
caêdáac êehabáláíaíáon pêogêaãsI whách aêe ãoêe áníense íhan
caêdáac êehabáláíaíáon pêogêaãs.
Cardiovascular (heart) disease risk reduction visit (therapy
for heart disease)
AM
te paó foê one vásáí a óeaê wáíh óoîê pêáãaêó caêe pêovádeê ío
help loweê óoîê êásk foê heaêí dásease. aîêáng íhás vásáíI óoîê
docíoê ãaóW
 aáscîss aspáêán îseI
 Check óoîê blood pêessîêeI andLoê
 dáve óoî íáps ío ãake sîêe óoî aêe eaíáng well.
Cardiovascular (heart) disease testing
AM
te paó foê blood íesís ío check foê caêdáovascîlaê dásease
once eveêó fáve óeaês ESM ãoníhsF. qhese blood íesís also
check foê defecís dîe ío hágh êásk of heaêí dásease.
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RV
What you
must pay
Care@Home: House call program
ff óoî hoãeboînd oê have láãáíed ãobáláíóI óoî ãaó be elágáble ío
êeceáve a vásáí aí hoãe fêoã an asságned Caêejoêe@eoãe
mêáãaêó Caêe mhósácáan. Caêejoêe pêovádes one oê ãoêe of íhe
followáng seêváces ío óoî áf ãedácalló necessaêó.
 Coãpêehensáve ãedácal hásíoêó and phósácal exaã
 mosí hospáíalázaíáon and woînd caêe assessãení
 pafeíó evalîaíáon
 jedácaíáon evalîaíáon and edîcaíáon
 Assessãení of skálled nîêsáng needs
 Assessãení of áããedáaíe caêe needs
Care@Home is subject to a medical necessity determination by
the case management department. Prior authorization rules may
apply.
Cervical and vaginal cancer screening
AM
 coê all woãenW map íesís and pelvác exaãs once eveêó OQ
ãoníhs
 coê woãen who aêe aí hágh êásk of ceêvácal canceêW one map
íesí eveêó NO ãoníhs
 coê woãen who have had an abnoêãal map íesí and aêe of
cháldbeaêáng ageW one map íesí eveêó NO ãoníhs
Chiropractic services
AM
Adâîsíãenís of íhe spáne ío coêêecí alágnãení
Authorization and/or referral rules may apply. You should talk to
your provider to get a referral.
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SM
Colorectal cancer screening
What you
must pay
AM
coê people RM and oldeêI we wáll paó foê íhe followáng seêvácesW
 clexáble ságãoádoscopó Eoê scêeenáng baêáîã eneãaF eveêó
QU ãoníhs
 cecal occîlí blood íesíI eveêó NO ãoníhs
coê people aí hágh êásk of coloêecíal canceêI we wáll paó foê one
scêeenáng colonoscopó Eoê scêeenáng baêáîã eneãaF eveêó OQ
ãoníhs
coê people noí aí hágh êásk of coloêecíal canceêI we wáll paó foê
one scêeenáng colonoscopó eveêó íen óeaês Ebîí noí wáíhán QU
ãoníhs of a scêeenáng ságãoádoscopóF.
Community Based Adult Services (CBAS)
AM
CBAp ás an oîípaíáeníI facáláíó based seêváce pêogêaã wheêe
people aííend accoêdáng ío a schedîle. fí deláveês skálled nîêsáng
caêeI socáal seêvácesI íheêapáes Eánclîdáng occîpaíáonalI phósácalI
and speechFI peêsonal caêeI faãálóLcaêegáveê íêaánáng and
sîppoêíI nîíêáíáon seêvácesI íêanspoêíaíáonI and oíheê seêváces.
te wáll paó foê CBAp áf óoî ãeeí íhe elágábáláíó cêáíeêáa.
Note: If a CBAS facility is not available, we can provide
these services separately.
Counseling to stop smoking or tobacco use
AM
ff óoî îse íobacco bîí do noí have ságns oê sóãpíoãs of
íobaccoJêelaíed dáseaseW
te wáll paó foê íwo coînseláng qîáí aííeãpís án a NOJãoníh
peêáod as a pêeveníáve seêváce. qhás seêváce ás fêee foê óoî. bach
coînseláng aííeãpí ánclîdes îp ío foîê faceJíoJface vásáís.
ff óoî îse íobacco and have been dáagnosed wáíh a íobaccoJ
êelaíed dásease oê aêe íakáng ãedácáne íhaí ãaó be affecíed bó
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SN
What you
must pay
íobaccoW
te wáll paó foê íwo coînseláng qîáí aííeãpís
wáíhán a NOJãoníh peêáod. bach coînseláng aííeãpí ánclîdes îp
ío foîê faceJíoJface vásáís.
ff óoî aêe pêegnaníI óoî ãaó êeceáve înláãáíed íobacco
cessaíáon coînseláng wáíh pêáoê aîíhoêázaíáon.
Authorization rules may apply. Contact the plan for details.
Depression screening
AM
te wáll paó foê one depêessáon scêeenáng each óeaê. qhe
scêeenáng ãîsí be done án a pêáãaêó caêe seííáng íhaí can gáve
followJîp íêeaíãení and êefeêêals.
Diabetes screening
AM
te wáll paó foê íhás scêeenáng Eánclîdes fasíáng glîcose íesísF áf
óoî have anó of íhe followáng êásk facíoêsW
eágh blood pêessîêe EhópeêíensáonF
eásíoêó of abnoêãal cholesíeêol and íêáglóceêáde levels
EdóslápádeãáaF
lbesáíó
eásíoêó of hágh blood sîgaê EglîcoseF
qesís ãaó be coveêed án soãe oíheê casesI sîch as áf óoî aêe
oveêweághí and have a faãáló hásíoêó of dáabeíes.
aependáng on íhe íesí êesîlísI óoî ãaó qîaláfó foê îp ío íwo
dáabeíes scêeenángs eveêó NO ãoníhs.
Diabetic self-management training, services, and supplies
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AM
SO
What you
must pay
te wáll paó foê íhe followáng seêváces foê all people who have
dáabeíes Ewheíheê íheó îse ánsîlán oê noíFW
pîppláes ío ãonáíoê óoîê blood glîcoseI ánclîdáng
íhe followángW
»
A blood glîcose ãonáíoê
»
Blood glîcose íesí síêáps
»
ianceí deváces and lanceís
»
dlîcoseJconíêol solîíáons foê checkáng íhe accîêacó of
íesí síêáps and ãonáíoês
coê people wáíh dáabeíes who have seveêe dáabeíác fooí
dáseaseI we wáll paó foê íhe followángW
»
lne paáê of íheêapeîíác cîsíoãJãolded shoes
Eánclîdáng ánseêísF and íwo exíêa paáês of ánseêís each
calendaê óeaêI or
»
lne paáê of depíh shoes and íhêee paáês of ánseêís
each óeaê Enoí ánclîdáng íhe nonJcîsíoãázed êeãovable
ánseêís pêováded wáíh sîch shoesF
te wáll also paó foê fáííáng íhe íheêapeîíác cîsíoãJãolded
shoes oê depíh shoes.
te wáll paó foê íêaánáng ío help óoî ãanage óoîê dáabeíesI án
soãe cases.
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SP
Durable medical equipment and related supplies
What you
must pay
AM
(For a definition of "Durable medical equipment,´ see Chapter
NO of íhás handbook.F
qhe followáng áíeãs aêe coveêedW
theelchaáês
 lxógen eqîápãení
Cêîíches
 fs ánfîsáon pîãps
eospáíal beds
 talkeês
kebîlázeês
líheê áíeãs ãaó be coveêed.
te wáll paó foê all ãedácalló necessaêó dîêable ãedácal
eqîápãení íhaí jedácaêe and jedáJCal îsîalló paó foê. ff oîê
sîppláeê án óoîê aêea does noí caêêó a paêíácîlaê bêand oê ãakeêI
óoî ãaó ask íheã áf íheó can specáalJoêdeê áí foê óoî.
If you (or your doctor) do not agree with the plan’s decision about
paóáng foê óoîê eqîápãeníI óoî oê óoîê docíoê ãaó fále an appeal.
voî can also fále an appeal if you do not agree with your doctor’s
decásáon aboîí whaí pêodîcí oê bêand ás êághí foê óoîê ãedácal
condáíáon. Ecoê ãoêe ánfoêãaíáon aboîí appealsI see Chapíeê V.F
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SQ
Emergency care
Emergency care ãeans seêváces íhaí aêeW
dáven bó a pêovádeê íêaáned ío gáve eãeêgencó seêvácesI and
keeded ío íêeaí a ãedácal eãeêgencó.
A medical emergency ás a ãedácal condáíáon wáíh seveêe paán oê
serious injury. The condition is so serious that, if it doesn’t get
áããedáaíe ãedácal aííeníáonI anóone wáíh an aveêage
knowledge of healíh and ãedácáne coîld expecí áí ío êesîlí ánW
Placing the person’s health in serious risk; or
peêáoîs haêã ío bodáló fîncíáons; or
peêáoîs dósfîncíáon of anó bodáló oêgan oê paêí; or
fn íhe case of a pêegnaní woãanI an acíáve laboêI ãeanáng
laboê aí a íáãe when eáíheê of íhe followáng woîld occîêW
»
qheêe ás noí enoîgh íáãe ío safeló íêansfeê íhe
ãeãbeê ío anoíheê hospáíal befoêe deláveêó.
»
qhe íêansfeê ãaó pose a íhêeaí ío íhe healíh oê safeíó
of íhe ãeãbeê oê înboên cháld.
Emergency services are not covered outside of the U.S. and
its territories except under limited circumstance. Contact
the plan for details.
Exercise and Strength Training
What you
must pay
AM
ff óoî geí
eãeêgencó caêe
aí an oîíJof
neíwoêk hospáíal
and need
ánpaíáení caêe
afíeê óoîê
eãeêgencó ás
síabálázedI óoî
ãîsí êeíîên ío a
foê óoîê caêe ío
coníánîe ío be
paád foê. voî can
síaó án íhe oîíJof
foê óoîê ánpaíáení
caêe onló áf íhe
plan appêoves
óoîê síaó.
AM
fs a ãedácalló sîpeêvásed exeêcáse pêogêaã ío áãpêove and
áncêease ãîscle síêengíhI balanceI ãobáláíóI flexábáláíó and oveêall
fáíness. jeãbeês aêe sîpeêvásed bó phósácal íheêapásí oê fáíness
coaches specáalló íêaáned án ãîscle developãení who develop a
peêsonaláze plan foê each ãeãbeê.
jeãbeês ãaó selfJêefeê ío íhás Caêejoêe Caêe Ceníeê based
pêogêaã. Coníací jeãbeê peêváces foê ãoêe ánfoêãaíáon.
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Fall Prevention Program
What you
must pay
AM
te paó foê an evalîaíáon íhaí ãaó ánclîde vásáonI heaêángI
cooêdánaíáon and êeváew of ãedácaíáon ío deíeêãáne áf íheêe ás a
hágh êásk of falláng.
voî ãaó selfJêefeê ío íhás pêogêaã. oîles and láãáíaíáons appló.
?
SS
Family planning services
What you
must pay
AM
qhe law leís óoî choose anó pêovádeê foê ceêíaán faãáló plannáng
seêváces. qhás ãeans anó docíoêI clánácI hospáíalI phaêãacó oê
faãáló plannáng offáce.
caãáló plannáng exaã and ãedácal íêeaíãení
caãáló plannáng lab and dáagnosíác íesís
caãáló plannáng ãeíhods Ebáêíh coníêol pállsI paíchI êángI fraI
ánâecíáonsI áãplanísF
caãáló plannáng sîppláes wáíh pêescêápíáon EcondoãI spongeI
foaãI fálãI dáaphêagãI capF
Coînseláng and dáagnosás of ánfeêíáláíóI and êelaíed seêváces
Coînseláng and íesíáng foê sexîalló íêansãáííed ánfecíáons
EpqfsFI AfapI and oíheê efsJêelaíed condáíáons
qêeaíãení foê sexîalló íêansãáííed ánfecíáons EpqfsF
solîníaêó síeêálázaíáon Evoî ãîsí be age ON oê oldeêI and óoî
ãîsí ságn a fedeêal síeêálázaíáon consení foêã. Aí leasí PM daósI
bîí noí ãoêe íhan NUM daósI ãîsí pass beíween íhe daíe íhaí
óoî ságn íhe foêã and íhe daíe of sîêgeêó.F
deneíác coînseláng
te wáll also paó foê soãe oíheê faãáló plannáng seêváces.
eoweveêI óoî ãîsí see a pêovádeê án oîê pêovádeê neíwoêk foê
íhe followáng seêvácesW
qêeaíãení foê ãedácal condáíáons of ánfeêíáláíó Eqhás seêváce
does noí ánclîde aêíáfácáal waós ío becoãe pêegnaní.F
qêeaíãení foê Afap and oíheê efsJêelaíed condáíáons
deneíác íesíáng
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ST
Health and wellness education programs
What you
must pay
AM
te offeê ãanó pêogêaãs íhaí focîs on ceêíaán healíh condáíáons.
qhese ánclîdeW





eealíh bdîcaíáon classes
kîíêáíáon bdîcaíáon classes
pãokáng and qobacco rse Cessaíáon
kîêsáng eoíláne
qeleãonáíoêáng
Members may self-refer to Healthy Start/Healthy Journey at a
CareMore Care Center. An appointment is required. Rules and
limitations apply.
Healthy Start
qhe eealíhó píaêí pêogêaã pêovádes a coãpleíe ãedácal checkîp. fí
ánclîdes blood íesís and oíheê íesís óoî ãaó need foê óoîê
condáíáon and age. fí helps îs ádeníáfó anó healíh ássîes so we can
gáve óoî íhe êághí êefeêêals and keep óoî healíhó.
aîêáng óoîê oneJhoîê eealíhó píaêí appoáníãeníI óoîê docíoê oê
nîêse pêacíáíáoneê wáll íalk wáíh óoî aboîí óoîê healíh and anó
qîesíáons óoî have. qheó wáll go oveêW
 A lásí of óoîê ãedácánesI and îêgení êefálls
 lnsáíe lab êesîlís
 oeqîesís foê needed dîêable ãedácal eqîápãení EajbF
 aáabeíes sîppláes Efoê ãeãbeês wáíh dáabeíesF
 meêsonalázed caêe plan
 bnêollãení ánío CaêejoêeDs edîcaíáon and chêonác caêe
pêogêaãs
Healthy Journey
eealíhó goîêneó ás a fêee appoáníãení once a óeaê ío go oveê anó
changes án óoîê healíh. eealíhó goîêneó does noí êeplace óoîê
êegîlaê óeaêló checkJîp. fí ás án addáíáon ío óoîê óeaêló checkJîp ío
help îs íêack óoîê healíh. qhe êesîlís of óoîê eealíhó goîêneó vásáí
aêe îsed ío cêeaíe a peêsonalázed caêe plan foê óoî. qhe êesîlís
and peêsonalázed caêe plan aêe gáven ío óoîê docíoê so he oê she
can go oveê íhe êesîlís wáíh óoî and help óoî dîêáng íhe óeaê.
koíeW ko aîíhoêázaíáon oê êefeêêal ás needed ío îse íhe kîêsáng
eoíláne.
?
SU
Hearing services
What you
must pay
AM
te paó foê heaêáng and balance íesís done bó óoîê pêovádeê.
qhese íesís íell óoî wheíheê óoî need ãedácal íêeaíãení. qheó
aêe coveêed as oîípaíáení caêe when óoî geí íheã fêoã a
phósácáanI aîdáologásíI oê oíheê qîaláfáed pêovádeê.
ff óoî aêe îndeê ON óeaês oldI pêegnaníI oê êesáde án a nîêsáng
facáláíóI we wáll also paó foê heaêáng aádsI ánclîdángW
 joldsI sîppláesI and ánseêís
 oepaáês íhaí cosí ãoêe íhan AOR peê êepaáê
 An ánáíáal seí of baííeêáes
 páx vásáís foê íêaánángI adâîsíãenísI and fáííáng wáíh íhe saãe
vendoê afíeê óoî geí íhe heaêáng aád
 qêáal peêáod êeníal of heaêáng aáds
jedáJCal eeaêáng aád allowance ás láãáíed ío ANIRNM ánclîdáng
sales íaxI peê fáscal óeaê EgîlóN ± gîne PMFI and ánclîdes ãoldsI
ãodáfácaíáon sîppláes and accessoêáes.
HIV screening
AM
te paó foê one efs scêeenáng exaã eveêó NO ãoníhs foê people
whoW
 Ask foê an efs scêeenáng íesíI oê
 Aêe aí áncêeased êásk foê efs ánfecíáon.
coê woãen who aêe pêegnaníI we paó foê îp ío íhêee efs
scêeenáng íesís dîêáng a pêegnancó.
?
SV
Home health agency care
What you
must pay
AM
Befoêe óoî can geí hoãe healíh seêvácesI a docíoê ãîsí íell îs
óoî need íheãI and íheó ãîsí be pêováded bó a hoãe healíh
agencó.
te wáll paó foê íhe followáng seêvácesI and ãaóbe oíheê seêváces
noí lásíed heêeW
 maêíJíáãe oê áníeêãáííení skálled nîêsáng and hoãe healíh
aáde seêváces.
 mhósácal íheêapóI nonJjedácaêe occîpaíáonal íheêapóI and
speech íheêapó
 jedácal and socáal seêváces
 jedácal eqîápãení and sîppláes
Hospice care
voî can geí caêe fêoã anó hospáce pêogêaã ceêíáfáed bó
jedácaêe. voî have íhe êághí ío elecí hospáce áf óoîê pêovádeê
and hospáce ãedácal dáêecíoê deíeêãáne óoî have a íeêãánal
pêognosás. qhás ãeans óoî have a íeêãánal állness and aêe
expecíed ío have sáx ãoníhs oê less ío láve. voîê hospáce docíoê
can be a neíwoêk pêovádeê oê an oîíJofJneíwoêk pêovádeê.
qhe plan wáll paó foê íhe followáng whále óoî aêe êeceáváng
hospáce seêvácesW
aêîgs ío íêeaí sóãpíoãs and paán
phoêíJíeêã êespáíe caêe
eoãe caêe
Hospice services and services covered by Medicare Part A
or B are billed to Medicare.
pee pecíáon c of íhás chapíeê foê ãoêe ánfoêãaíáon.
?
TM
What you
must pay
Hospice Care continued
For services covered by CareMore Cal MediConnect Plan
but not covered by Medicare Part A or B:
Caêejoêe Cal jedáConnecí mlan wáll coveê planJcoveêed
seêváces noí coveêed îndeê jedácaêe maêí A oê B. qhe plan wáll
coveê íhe seêváces wheíheê oê noí íheó aêe êelaíed ío óoîê
íeêãánal pêognosás. voî paó noíháng foê íhese seêváces.
For drugs that may be covered by CareMore Cal
MediConnect Plan’s Medicare Part D benefit:

aêîgs aêe neveê coveêed bó boíh hospáce and oîê plan aí
íhe saãe íáãe. coê ãoêe ánfoêãaíáonI please see Chapíeê R.
Note: ff óoî need nonJhospáce caêeI óoî shoîld call óoîê case
ãanageê aí NJUUUJPRMJPQQT Eqqv TNNF ío aêêange íhe seêváces.
konJhospáce caêe ás caêe íhaí ás noí êelaíed ío óoîê íeêãánal
pêognosás.
Immunizations
AM
mneîãonáa vaccáne
clî shoísI once a óeaêI án íhe fall oê wáníeê
eepaíáíás B vaccáne áf óoî aêe aí hágh oê áníeêãedáaíe êásk of
geííáng hepaíáíás B
líheê vaccánes áf óoî aêe aí êásk and íheó ãeeí jedácaêe maêí
B coveêage êîles
te wáll paó foê oíheê vaccánes íhaí ãeeí íhe jedácaêe maêí a
coveêage êîles. oead Chapíeê S ío leaên ãoêe.
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TN
In-Home Supportive Services (IHSS)
What you
must pay
AM
te wáll paó foê seêváces pêováded ío óoî so íhaí óoî can êeãaán
safeló án óoîê own hoãe.
qhe íópes of fepp whách can be aîíhoêázed íhêoîgh íhe Coîníó
aepaêíãení of pocáal peêváces aêeW
eoîsecleanáng
jeal pêepaêaíáon
iaîndêó
dêoceêó shoppáng
meêsonal caêe seêváces Esîch as bowel and bladdeê caêeI
baíhángI gêooãángI and paêaãedácal seêvácesF
Accoãpanáãení ío ãedácal appoáníãenís
mêoíecíáve sîpeêvásáon foê íhe ãeníalló áãpaáêed
qo qîaláfó foê feppI óoî ãîsí be agedI blándI oê dásabled andI án
ãosí casesI have áncoãe below íhe level ío qîaláfó foê íhe
pîppleãeníal pecîêáíó fncoãeLpíaíe pîppleãeníaêó mêogêaã.
ff elágábleI óoî ãaó êeceáve îp ío OUP hoîês of fepp eveêó ãoníh
áf appêoved bó óoîê coîníó socáal woêkeê.
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TO
Inpatient hospital care
peãáJpêávaíe êooã Eoê a pêávaíe êooã áf áí ás ãedácalló
necessaêóF
jealsI ánclîdáng specáal dáeís
oegîlaê nîêsáng seêváces
Cosís of specáal caêe înáísI sîch as áníensáve caêe oê
coêonaêó caêe înáís
What you
must pay
AM
voî ãîsí geí
appêoval fêoã íhe
plan ío keep
geííáng ánpaíáení
caêe aí an oîíJof
afíeê óoîê
eãeêgencó ás
îndeê coníêol.
aêîgs and ãedácaíáons
iab íesís
uJêaós and oíheê êadáologó seêváces
keeded sîêgácal and ãedácal sîppláes
AppláancesI sîch as wheelchaáês
lpeêaíáng and êecoveêó êooã seêváces
mhósácalI occîpaíáonalI and speech íheêapó
fnpaíáení sîbsíance abîse seêváces
fn soãe casesI íhe followáng íópes of íêansplanísW coênealI
kádneóI kádneóLpancêeaíácI heaêíI láveêI lîngI heaêíLlîngI bone
ãaêêowI síeã cellI and áníesíánalLãîlíávásceêal.
?
TP
What you
must pay
Inpatient hospital care
(continued)
ff óoî need a íêansplaníI a jedácaêeJappêoved íêansplaní ceníeê
wáll êeváew óoîê case and decáde wheíheê óoî aêe a candádaíe
foê a íêansplaní. qêansplaní pêovádeês ãaó be local oê oîísáde of
íhe seêváce aêea. ff local íêansplaní pêovádeês aêe wálláng ío
accepí íhe jedácaêe êaíeI íhen óoî can geí óoîê íêansplaní
seêváces localló oê aí a dásíaní locaíáon oîísáde íhe seêváce aêea.
ff Caêejoêe Cal jedáConnecí mlan pêovádes íêansplaní seêváces
aí a dásíaní locaíáon oîísáde íhe seêváce aêea and óoî choose ío
geí óoîê íêansplaní íheêeI we wáll aêêange oê paó foê lodgáng and
íêavel cosís foê óoî and one oíheê peêson.
BloodI ánclîdáng síoêage and adãánásíêaíáon
mhósácáan seêváces
qheêe ás no láãáí ío íhe nîãbeê of daós coveêed foê each hospáíal
síaó. voî ãîsí go ío neíwoêk docíoêsI specáalásís and hospáíals.
bxcepí án an eãeêgencóI óoîê docíoê ãîsí íell íhe plan íhaí óoî
aêe goáng ío be adãáííed ío íhe hospáíal.
?
TQ
Inpatient mental health care
What you
must pay
AM
te wáll paó foê ãeníal healíh caêe seêváces íhaí êeqîáêe a hospáíal
síaó.
 ff óoî need ánpaíáení seêváces án a fêeesíandáng
psócháaíêác hospáíalI we wáll paó foê íhe fáêsí NVM daós. Afíeê
íhaíI íhe local coîníó ãeníal healíh agencó wáll paó foê
ánpaíáení psócháaíêác seêváces íhaí aêe ãedácalló necessaêó.
Aîíhoêázaíáon foê caêe beóond íhe NVM daós wáll be
cooêdánaíed wáíh íhe local coîníó ãeníal healíh agencó.
o
qhe NVMJdaó láãáí does noí appló ío ánpaíáení ãeníal
healíh seêváces pêováded án a psócháaíêác înáí of a geneêal
hospáíal.

ff óoî aêe SR óeaês oê oldeêI we wáll paó foê seêváces
êeceáved án an fnsíáíîíe foê jeníal aáseases EfjaF.
bxcepí án an eãeêgencóI óoîê docíoê ãîsí íell íhe plan íhaí
óoî aêe goáng ío be adãáííed ío íhe hospáíal.
Inpatient services covered during a non-covered inpatient
stay
AM
ff óoîê ánpaíáení síaó ás noí êeasonable and neededI we wáll noí
paó foê áí.
eoweveêI án soãe cases we wáll paó foê seêváces óoî geí whále
óoî aêe án íhe hospáíal oê a nîêsáng facáláíó. te wáll paó foê íhe
followáng seêvácesI and ãaóbe oíheê seêváces noí lásíed heêeW
aocíoê seêváces
aáagnosíác íesísI láke lab íesís
uJêaóI êadáîãI and ásoíope íheêapóI ánclîdáng íechnácáan
ãaíeêáals and seêváces
pîêgácal dêessángs
pplánísI casísI and oíheê deváces îsed foê fêacíîêes and
dáslocaíáons
mêosíheíács and oêíhoíác devácesI oíheê íhan deníalI ánclîdáng
êeplaceãení oê êepaáês of sîch deváces. qhese aêe deváces íhaíW
?
TR
What you
must pay
»
oeplace all oê paêí of an áníeênal bodó oêgan
Eánclîdáng coníágîoîs íássîeFI oê
»
oeplace all oê paêí of íhe fîncíáon of an ánopeêaíáve oê
ãalfîncíáonáng áníeênal bodó oêgan.
iegI aêãI backI and neck bêacesI íêîssesI and aêíáfácáal legsI
aêãsI and eóes. qhás ánclîdes adâîsíãenísI êepaáêsI and
êeplaceãenís needed becaîse of bêeakageI weaêI lossI oê a
change in the patient’s condition
mhósácal íheêapóI speech íheêapóI and occîpaíáonal íheêapó
Kidney disease services and supplies
AM
hádneó dásease edîcaíáon seêváces ío íeach kádneó caêe and
help ãeãbeês ãake good decásáons aboîí íheáê caêe. voî ãîsí
have síage fs chêonác kádneó dáseaseI and óoîê docíoê ãîsí êefeê
óoî. te wáll coveê îp ío sáx sessáons of kádneó dásease edîcaíáon
seêváces.
lîípaíáení dáalósás íêeaíãenísI ánclîdáng dáalósás íêeaíãenís
when íeãpoêaêáló oîí of íhe seêváce aêeaI as explaáned án Chapíeê
P
fnpaíáení dáalósás íêeaíãenís áf óoî aêe adãáííed as an
ánpaíáení ío a hospáíal foê specáal caêe
pelfJdáalósás íêaánángI ánclîdáng íêaánáng foê óoî and anóone
helpáng óoî wáíh óoîê hoãe dáalósás íêeaíãenís
eoãe dáalósás eqîápãení and sîppláes
?
TS
What you
must pay
Ceêíaán hoãe sîppoêí seêvácesI sîch as necessaêó vásáís bó
íêaáned dáalósás woêkeês ío check on óoîê hoãe dáalósásI ío help
án eãeêgencáesI and ío check óoîê dáalósás eqîápãení and waíeê
sîppló.
Your Medicare Part B drug benefit pays for some drugs for
dialysis. For information, please see “Medicare Part B
prescription drugs” in this chart.
Medical nutrition therapy
AM
qhás benefáí ás foê people wáíh dáabeíes oê kádneó dásease wáíhoîí
dáalósás. fí ás also foê afíeê a kádneó íêansplaní when êefeêêed bó
óoîê docíoê.
te wáll paó foê íhêee hoîês of oneJonJone coînseláng seêváces
dîêáng óoîê fáêsí óeaê íhaí óoî êeceáve ãedácal nîíêáíáon íheêapó
seêváces îndeê jedácaêe. Eqhás ánclîdes oîê planI anó oíheê
jedácaêe Advaníage planI oê jedácaêe.F te paó foê íwo hoîês
of oneJonJone coînseláng seêváces each óeaê afíeê íhaí. ff óoîê
condáíáonI íêeaíãeníI oê dáagnosás changesI óoî ãaó be able ío
get more hours of treatment with a doctor’s êefeêêal. A docíoê
ãîsí pêescêábe íhese seêváces and êenew íhe êefeêêal each óeaê
áf óoîê íêeaíãení ás needed án íhe nexí calendaê óeaê.
Authorization from a CareMore nurse or case manager is
required.
?
TT
Medicare Part B prescription drugs
What you
must pay
AM
qhese dêîgs aêe coveêed îndeê maêí B of jedácaêe. Caêejoêe
Cal jedáConnecí mlan wáll paó foê íhe followáng dêîgsW
Drugs you don’t usually give yourself and are injected or
ánfîsed whále óoî aêe geííáng docíoêI hospáíal oîípaíáeníI oê
aãbîlaíoêó sîêgeêó ceníeê seêváces
aêîgs óoî íake îsáng dîêable ãedácal eqîápãení Esîch as
nebîlázeêsF íhaí weêe aîíhoêázed bó íhe plan
Cloííáng facíoês óoî gáve óoîêself bó ánâecíáon áf óoî have
heãopháláa
fããînosîppêessáve dêîgsI áf óoî weêe enêolled án jedácaêe
maêí A aí íhe íáãe of íhe oêgan íêansplaní
lsíeopoêosás dêîgs íhaí aêe ánâecíed. qhese dêîgs aêe paád
foê áf óoî aêe hoãeboîndI have a bone fêacíîêe íhaí a docíoê
ceêíáfáes was êelaíed ío posíJãenopaîsal osíeopoêosásI and
cannoí ánâecí íhe dêîg óoîêself
Aníágens
Ceêíaán oêal aníáJcanceê dêîgs and aníáJnaîsea dêîgs
Ceêíaán dêîgs foê hoãe dáalósásI ánclîdáng hepaêánI íhe
aníádoíe foê hepaêán Ewhen ãedácalló neededFI íopácal
anesíheíácsI and eêóíhêopoásásJsíáãîlaíáng agenís Esîch as
bpogenI mêocêáíI bpoeíán AlfaI AêanespI oê aaêbepoeíán
AlfaF
fs áããîne globîlán foê íhe hoãe íêeaíãení of pêáãaêó
áããîne defácáencó dáseases
 Chapter 5 explains the outpatient prescription
drug benefit. fí explaáns êîles óoî ãîsí follow ío have
pêescêápíáons coveêed.
 Chapter 6 explains what you pay for your
outpatient prescription drugs through our plan.
Multi-Purpose Senior Services Program (MSSP)
AM
jppm ás a case ãanageãení pêogêaã íhaí pêovádes eoãe and
?
TU
What you
must pay
CoããînáíóJBased peêváces EeCBpF ío jedáJCal elágáble
ándávádîals.
qo be elágábleI óoî ãîsí be SR óeaês of age oê oldeêI láve wáíhán a
sáíeDs seêváce aêeaI be able ío be seêved wáíhán jppmDs cosí
láãáíaíáonsI be appêopêáaíe foê caêe ãanageãení seêvácesI
cîêêeníló elágáble foê jedáJCalI and ceêíáfáed oê ceêíáfáable foê
placeãení án a nîêsáng facáláíó.
jppm seêváces ánclîdeW










Adîlí aaó Caêe L pîppoêí Ceníeê
eoîsáng Assásíance
Choêe and meêsonal Caêe Assásíance
mêoíecíáve pîpeêvásáon
Caêe janageãení
oespáíe
qêanspoêíaíáon
jeal peêváces
pocáal peêváces
Coããînácaíáons peêváces
qhás benefáí ás coveêed îp ío AQIOUR peê óeaê.
Non-emergency medical transportation
AM
qhás benefáí allows foê íêanspoêíaíáon íhaí ás íhe ãosí cosí effecíáve
and accessáble. qhás can ánclîdeW aãbîlanceI láííeê vanI
wheelchaáê van ãedácal íêanspoêíaíáon seêvácesI and cooêdánaíáng
wáíh paêa íêansáí.
qhe foêãs of íêanspoêíaíáon aêe aîíhoêázed whenW
voîê ãedácal andLoê phósácal condáíáon does noí allow óoî ío
íêavel bó bîsI passengeê caêI íaxácabI oê anoíheê foêã of pîblác
oê pêávaíe íêanspoêíaíáonI and
qêanspoêíaíáon ás êeqîáêed foê íhe pîêpose of obíaánáng needed
ãedácal caêe.
Depending on the service, prior authorization may be required.
?
TV
Non-medical transportation
What you
must pay
AM
qhás benefáí allows foê íêanspoêíaíáon ío ãedácal seêváces bó
passengeê caêI íaxáI oê oíheê foêãs of pîblácLpêávaíe
íêanspoêíaíáon.
voî wáll have access ío PM oneJwaó íêáps peê óeaê.
qhás benefáí does noí láãáí óoîê nonJeãeêgencó ãedácal
íêanspoêíaíáon benefáí.
Eligibility Requirements
fn oêdeê ío êeceáve coveêed íêanspoêíaíáon seêvácesI óoî ãîsí be
able ío îse síandaêd ãeans of íêanspoêíaíáonI sîch as bîsesI vansI
oê íaxácabs and ãîsí be able ío êáde wáíh oíheês.
then óoî schedîle óoîê appoáníãení wáíh Caêejoêe
qêanspoêíaíáon peêvácesI óoî wáll be asked ío confáêã íhaíW
voîê schedîled êáde allows íáãe foê óoî ío be íêanspoêíed ío
and fêoã óoîê appoáníãení dîêáng íhe êegîlaê íêanspoêíaíáon
bîsáness hoîêsW VWMM a.ã. ío QWMM p.ã. jondaó íhêoîgh cêádaó
Eexclîdáng holádaósF.
voî aêe able ío see íhe íêanspoêíaíáon vehácle fêoã íhe
bîáldáng.
voî aêe able ío geí fêoã íhe bîáldáng and ánío íhe
íêanspoêíaíáon vehácle înassásíed.
ff óoî îse a caneI cêîíchesI walkeêI oê aêe án a wheelchaáêI óoî
ãîsí oíheêwáse be able ío ãove ío and geí ánío íhe
íêanspoêíaíáon vehácle înassásíed.
voî do noí have anó oíheê láãáíáng ãedácal condáíáon íhaí ãaó
êesíêácí óoîê abáláíó ío îse síandaêd ãeans of íêanspoêíaíáonI
sîch as bîsesI vansI íaxácabsI oê ío êáde wáíh oíheês.
voîê schedîled escoêí ás age NT oê oldeê.
Nursing facility care
AM
A nîêsáng facáláíó EkcF ás a place íhaí pêovádes caêe foê people who
cannoí geí caêe aí hoãe bîí who do noí need ío be án a hospáíal.
?
UM
What you
must pay
Nursing facility care (cont’d.)
peêváces íhaí we wáll paó foê ánclîdeI bîí aêe noí láãáíed íoI íhe
followángW
peãápêávaíe êooã Eoê a pêávaíe êooã áf áí ás ãedácalló neededF
kîêsáng seêváces
mhósácal íheêapóI occîpaíáonal íheêapóI and speech íheêapó
 aêîgs gáven ío óoî as paêí of óoîê plan of caêe. Eqhás ánclîdes
sîbsíances íhaí aêe naíîêalló pêesení án íhe bodóI sîch as bloodJ
cloííáng facíoês.F
jedácal and sîêgácal sîppláes îsîalló gáven bó nîêsáng facáláíáes
iab íesís îsîalló gáven bó nîêsáng facáláíáes
 uJêaós and oíheê êadáologó seêváces îsîalló gáven bó nîêsáng
facáláíáes
 rse of appláancesI sîch as wheelchaáês îsîalló gáven bó nîêsáng
facáláíáes
mhósácáanLpêacíáíáoneê seêváces
aîêable ãedácal eqîápãení
aeníal seêvácesI ánclîdáng deníîêes
sásáon benefáís
eeaêáng exaãs
Cháêopêacíác caêe
modáaíêó seêváces
voî wáll îsîalló geí óoîê caêe fêoã neíwoêk facáláíáes. eoweveêI óoî
ãaó be able ío geí óoîê caêe fêoã a facáláíó noí án oîê neíwoêk. voî
can get care from the following places if they accept our plan’s
aãoînís foê paóãeníW
 A nîêsáng hoãe oê coníánîáng caêe êeíáêeãení coããînáíó wheêe
óoî weêe láváng êághí befoêe óoî wení ío íhe hospáíal Eas long as
áí pêovádes nîêsáng facáláíó caêeF.
 A nîêsáng facáláíó wheêe óoîê spoîse ás láváng aí íhe íáãe óoî
leave íhe hospáíal.
Authorization and or referral rules may apply. You should talk to
?
UN
Obesity screening and therapy to keep weight down
What you
must pay
AM
ff óoî have a bodó ãass ándex of PM oê ãoêeI we wáll paó foê
coînseláng ío help óoî lose weághí. voî ãîsí geí íhe coînseláng
án a pêáãaêó caêe seííáng. qhaí waóI áí can be ãanaged wáíh óoîê
fîll pêeveníáon plan. qalk ío óoîê pêáãaêó caêe pêovádeê ío fánd
oîí ãoêe.
Prior authorization is not required for services provided by a
contracted provider.
Outpatient diagnostic tests and therapeutic services and
supplies
AM
uJêaós
oadáaíáon Eêadáîã and ásoíopeF íheêapóI ánclîdáng íechnácáan
ãaíeêáals and sîppláes
pîêgácal sîppláesI sîch as dêessángs
pplánísI casísI and oíheê deváces îsed foê fêacíîêes and
dáslocaíáons
iab íesís
líheê oîípaíáení dáagnosíác íesís
?
UO
Outpatient hospital services
What you
must pay
AM
te paó foê ãedácalló needed seêváces óoî geí án íhe oîípaíáení
depaêíãení of a hospáíal foê dáagnosás oê íêeaíãení of an állness
oê ánâîêó.
peêváces án an eãeêgencó depaêíãení oê oîípaíáení clánácI
sîch as obseêvaíáon seêváces oê oîípaíáení sîêgeêó
iabs and dáagnosíác íesís bálled bó íhe hospáíal
jeníal healíh caêeI ánclîdáng caêe án a paêíáalJhospáíalázaíáon
pêogêaãI áf a docíoê ceêíáfáes íhaí ánpaíáení íêeaíãení woîld be
needed wáíhoîí áí
uJêaós and oíheê êadáologó seêváces bálled bó íhe hospáíal
jedácal sîppláesI sîch as splánís and casís
poãe scêeenángs and pêeveníáve seêváces
Some drugs that you can’t give yourself
?
UP
Outpatient mental health care
What you
must pay
AM
te wáll paó foê ãeníal healíh seêváces pêováded bóW
A síaíeJlácensed psócháaíêásí oê docíoê
A clánácal psóchologásí
A clánácal socáal woêkeê
A clánácal nîêse specáalásí
A nîêse pêacíáíáoneê
A phósácáan assásíaní
Anó oíheê jedácaêeJqîaláfáed ãeníal healíh caêe pêofessáonal
as allowed îndeê applácable síaíe laws
Clánác seêváces
aaó íêeaíãení
msóchosocáal êehab seêváces
maêíáal hospáíalázaíáonLfníensáve oîípaíáení pêogêaãs
fndávádîal and gêoîp ãeníal healíh evalîaíáon and íêeaíãení
msóchologácal íesíáng when clánácalló ándácaíed ío evalîaíe a
ãeníal healíh oîícoãe
lîípaíáení seêváces foê íhe pîêposes of ãonáíoêáng dêîg
íheêapó
lîípaíáení laboêaíoêóI dêîgsI sîppláes and sîppleãenís
msócháaíêác consîlíaíáon
?
UQ
Outpatient rehabilitation services
What you
must pay
AM
te wáll paó foê phósácal íheêapóI occîpaíáonal íheêapóI and
speech íheêapó.
voî can geí oîípaíáení êehabáláíaíáon seêváces fêoã hospáíal
oîípaíáení depaêíãenísI ándependení íheêapásí offácesI
coãpêehensáve oîípaíáení êehabáláíaíáon facáláíáes EClocsFI and
oíheê facáláíáes.
Outpatient substance abuse services
AM

Alcohol ãásîse scêeenáng and coînseláng

qêeaíãení of dêîg abîse

dêoîp oê ándávádîal coînseláng bó a qîaláfáed clánácáan

pîbacîíe deíoxáfácaíáon án a êesádeníáal addácíáon pêogêaã

Alcohol andLoê dêîg seêváces án an áníensáve oîípaíáení
íêeaíãení ceníeê

bxíended êelease kalíêexone EváváíêolF íêeaíãení
Outpatient surgery
AM
te wáll paó foê oîípaíáení sîêgeêó and seêváces aí hospáíal
oîípaíáení facáláíáes and aãbîlaíoêó sîêgácal ceníeês.
?
UR
Partial hospitalization services
What you
must pay
AM
Partial hospitalization ás a síêîcíîêed pêogêaã of acíáve
psócháaíêác íêeaíãení. fí ás offeêed án a hospáíal oîípaíáení seííáng
oê bó a coããînáíó ãeníal healíh ceníeê. fí ás ãoêe áníense íhan
íhe caêe óoî geí án óoîê docíoê or therapist’s office. It can help
keep óoî fêoã haváng ío síaó án íhe hospáíal.
Note: Becaîse íheêe aêe no coããînáíó ãeníal healíh ceníeês án
oîê neíwoêkI we coveê paêíáal hospáíalázaíáon onló án a hospáíal
oîípaíáení seííáng.
?
US
Physician/provider services, including doctor’s office visits
What you
must pay
AM
jedácalló necessaêó healíh caêe oê sîêgeêó seêváces gáven án
places sîch asW
»
»
»
Physician’s office
Ceêíáfáed aãbîlaíoêó sîêgácal ceníeê
eospáíal oîípaíáení depaêíãení
ConsîlíaíáonI dáagnosásI and íêeaíãení bó a specáalásí
Basác heaêáng and balance exaãs gáven bó óoîê pêáãaêó caêe
pêovádeê or specáalásí, áf óoîê docíoê oêdeês áí ío see wheíheê óoî
need íêeaíãení
poãe íelehealíh seêvácesI ánclîdáng consîlíaíáonI dáagnosásI
and íêeaíãení bó a phósácáan oê pêacíáíáoneê foê paíáenís án êîêal
aêeas oê oíheê places appêoved bó jedácaêe
pecond opánáon bó anoíheê neíwoêk pêovádeê befoêe a
ãedácal pêocedîêe
konJêoîíáne deníal caêe. Coveêed seêváces aêe láãáíed íoW
»
pîêgeêó of íhe âaw oê êelaíed síêîcíîêes
»
peííáng fêacíîêes of íhe âaw oê facáal bones
»
mîlláng íeeíh befoêe êadáaíáon íêeaíãenís of neoplasíác
canceê
»
peêváces íhaí woîld be coveêed when pêováded bó a
phósácáan
Podiatry services
AM
aáagnosás and ãedácal oê sîêgácal íêeaíãení of ánâîêáes and
dáseases of íhe fooí Esîch as haããeê íoe oê heel spîêsF
ooîíáne fooí caêe foê ãeãbeês wáíh condáíáons affecíáng íhe
legsI sîch as dáabeíes
ooîíáne fooí caêe coveêed foê îp ío NO vásáís peê óeaê
?
UT
What you
must pay
Coên êeãoval ás noí coveêed
Prostate cancer screening exams
AM
coê ãen age RM and oldeêI we wáll paó foê íhe followáng seêváces
once eveêó NO ãoníhsW
A dágáíal êecíal exaã
A pêosíaíe specáfác aníágen EmpAF íesí
Prosthetic devices and related supplies
AM
Prosthetic devices êeplace all oê paêí of a bodó paêí oê fîncíáon.
te wáll paó foê íhe followáng pêosíheíác devácesI and ãaóbe
oíheê deváces noí lásíed heêeW
Colosíoãó bags and sîppláes êelaíed ío colosíoãó caêe
maceãakeês
Bêaces
mêosíheíác shoes
Aêíáfácáal aêãs and legs
Bêeasí pêosíheses Eánclîdáng a sîêgácal bêassáeêe afíeê a
ãasíecíoãóF
fnconíánence cêeaã and dáapeês
te wáll also paó foê soãe sîppláes êelaíed ío pêosíheíác deváces.
te wáll also paó ío êepaáê oê êeplace pêosíheíác deváces.
te offeê soãe coveêage afíeê caíaêací êeãoval oê caíaêací
surgery. See "Vision Care´ later in this secíáon foê deíaáls.
te wáll noí paó foê pêosíheíác deníal deváces.
?
UU
Pulmonary rehabilitation services
What you
must pay
AM
te wáll paó foê pîlãonaêó êehabáláíaíáon pêogêaãs foê ãeãbeês
who have ãodeêaíe ío veêó seveêe chêonác obsíêîcíáve
pîlãonaêó dásease EClmaF. voî ãîsí have a êefeêêal foê
pîlãonaêó êehabáláíaíáon fêoã íhe docíoê oê pêovádeê íêeaíáng íhe
Clma.
te wáll paó foê êespáêaíoêó seêváces foê veníálaíoêJdependení
paíáenís.
Sexually transmitted infections (STIs) screening and
counseling
AM
te wáll paó foê scêeenángs foê chlaãódáaI gonoêêheaI sóphálásI
and hepaíáíás B. qhese scêeenángs aêe coveêed foê pêegnaní
woãen and foê soãe people who aêe aí áncêeased êásk foê an
pqf. A pêáãaêó caêe pêovádeê ãîsí oêdeê íhe íesís. te coveê
íhese íesís once eveêó NO ãoníhs oê aí ceêíaán íáães dîêáng
pêegnancó.
te wáll also paó foê îp ío íwo faceJíoJfaceI hághJáníensáíó
behaváoêal coînseláng sessáons each óeaê foê sexîalló acíáve
adîlís aí áncêeased êásk foê pqfs. bach sessáon can be OM ío PM
ãánîíes long. te wáll paó foê íhese coînseláng sessáons as a
pêeveníáve seêváce onló áf íheó aêe gáven bó a pêáãaêó caêe
pêovádeê. qhe sessáons ãîsí be án a pêáãaêó caêe seííángI sîch
as a doctor’s office.
mêáoê aîíhoêázaíáon ás noí êeqîáêed foê seêváces bó a coníêacíed
pêovádeê.
?
UV
Skilled nursing facility care
What you
must pay
AM
A seãáJpêávaíe êooãI oê a pêávaíe êooã áf áí ás ãedácalló
needed
kîêsáng seêváces
mhósácal íheêapóI occîpaíáonal íheêapóI and speech íheêapó
aêîgs óoî geí as paêí of óoîê plan of caêeI ánclîdáng
sîbsíances íhaí aêe naíîêalló án íhe bodóI sîch as bloodJcloííáng
facíoês
jedácal and sîêgácal sîppláes gáven bó nîêsáng facáláíáes
iab íesís gáven bó nîêsáng facáláíáes
uJêaós and oíheê êadáologó seêváces gáven bó nîêsáng facáláíáes
AppláancesI sîch as wheelchaáêsI îsîalló gáven bó nîêsáng
facáláíáes
mhósácáanLpêovádeê seêváces
voî wáll îsîalló geí óoîê caêe fêoã neíwoêk facáláíáes. eoweveêI
óoî ãaó be able ío geí óoîê caêe fêoã a facáláíó noí án oîê
neíwoêk. voî can geí caêe fêoã íhe followáng places áf íheó
accept our plan’s amounts for payment:
A nîêsáng hoãe oê coníánîáng caêe êeíáêeãení coããînáíó
wheêe óoî láved befoêe óoî wení ío íhe hospáíal Eas long as áí
pêovádes nîêsáng facáláíó caêeF
A nîêsáng facáláíó wheêe óoîê spoîse láves aí íhe íáãe óoî
leave íhe hospáíal
?
VM
Urgent care
What you
must pay
AM
Urgent care ás caêe gáven ío íêeaíW
A nonJeãeêgencóI or
A sîdden ãedácal állnessI or
An ánâîêóI or
A condáíáon íhaí needs caêe êághí awaó.
ff óoî êeqîáêe îêgení caêeI óoî shoîld fáêsí íêó ío geí áí fêoã a
neíwoêk pêovádeê. eoweveêI óoî can îse oîíJofJneíwoêk
pêovádeês when óoî cannoí geí ío a neíwoêk pêovádeê. rêgeníló
needed caêe ás noí coveêed oîísáde íhe r.p. and áís íeêêáíoêáes
excepí îndeê láãáíed cáêcîãsíances. Coníací íhe plan foê deíaáls.
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Vision care
What you
must pay
AM

One êoîíáne eóe exaã eveêó óeaê; and

rp ío ANTR allowance foê eóeglasses Efêaães and lensesF
oê îp ío ANTR allowance foê coníací lenses eveêó íwo óeaês.
te wáll paó foê oîípaíáení docíoê seêváces foê íhe dáagnosás and
íêeaíãení of dáseases and ánâîêáes of íhe eóe. qhás ánclîdes
íêeaíãení foê ageJêelaíed ãacîlaê degeneêaíáon.
coê people aí hágh êásk of glaîcoãaI we wáll paó foê one
glaîcoãa scêeenáng each óeaê. meople aí hágh êásk of glaîcoãa
ánclîdeW
meople wáíh a faãáló hásíoêó of glaîcoãa
meople wáíh dáabeíes
AfêácanJAãeêácans who aêe age RM and oldeê
te wáll paó foê one paáê of glasses oê coníací lenses afíeê each
caíaêací sîêgeêó when íhe docíoê ánseêís an áníêaocîlaê lens. Eff
óoî have íwo sepaêaíe caíaêací sîêgeêáesI óoî ãîsí geí one paáê
of glasses afíeê each sîêgeêó. voî cannoí geí íwo paáês of
glasses afíeê íhe second sîêgeêóI even áf óoî dád noí geí a paáê
of glasses afíeê íhe fáêsí sîêgeêóF.
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“Welcome to Medicare” Preventive Visit
What you
must pay
AM
te coveê íhe oneJtime "Welcome to Medicare´ preventive visit.
qhe vásáí ánclîdesW
A êeváew of óoîê healíhI
bdîcaíáon and coînseláng aboîí íhe pêeveníáve seêváces óoî
need Eánclîdáng scêeenángs and shoísFI and
oefeêêals foê oíheê caêe áf óoî need áí.
Important: We cover the "Welcome to Medicare´ preventive
vásáí onló dîêáng íhe fáêsí NO ãoníhs íhaí óoî have jedácaêe maêí
B. When you make your appointment, tell your doctor’s office
you want to schedule your "Welcome to Medicare´ preventive
vásáí.
Wound care management
Caêejoêe ãeãbeês êeceáve woînd caêe aí oîê Caêejoêe Caêe
Ceníeês bó íhe toînd Ceêíáfáed kîêse mêacíáíáoneê. poãe woînds
ãaó be slow ío heal and can be êelaíed ío cáêcîlaíoêó pêobleãsI
dáabeíesI nîíêáíáon oê oíheê condáíáons of íhe ãeãbeê. qhe Caêejoêe
kîêse mêacíáíáoneê wáll addêess íhese specáfác condáíáons íhaí ãaó
slow healáng. fn addáíáon ío êegîlaê woînd caêeI óoî wáll be pêováded
wáíh woînd caêe sîppláes ío íake hoãe and a peêsonal woînd caêe
plan.
qhás assessãení ánclîdes íhe followáng seêvácesW
 cooí caêe
 pelf ãanageãení
 bdîcaíáon classes
 cîíîêe woînd pêeveníáon
Contact Member Services for more information.
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E. Using our plan’s visitor or traveler benefits
ff you are out of the plan’s service area for more than 6 months at a time, we îsîalló ãîsí
dêop óoî fêoã oîê plan.
F. Benefits covered outside of CareMore Cal MediConnect Plan
qhe followáng seêváces aêe noí coveêed bó Caêejoêe Cal jedáConnecí mlan bîí aêe avaálable
íhêoîgh jedácaêe oê jedáJCal.
California Community Transitions (CCT)
qhe Caláfoênáa Coããînáíó qêansáíáons ECCqF pêogêaã îses local lead oêganázaíáons ío fánd
elágáble jedáJCal benefácáaêáes who have láved án an ánsíáíîíáon oê facáláíó foê VM consecîíáve
daós and waní ío íêansáíáon back ío a coããînáíó seííáng. qhe CCq pêogêaã fînds íêansáíáon
cooêdánaíáon seêváces dîêáng íhe pêeJíêansáíáon peêáod ío ãove elágáble benefácáaêáes back ío a
coããînáíó seííáng.
voî can geí pêeJíêansáíáon cooêdánaíáon seêváces fêoã anó CCq lead oêganázaíáon coníêacíed
wáíh jedáJCal íhaí seêves íhe coîníó óoî láve án. voî can fánd a lásí of CCq lead oêganázaíáons
and íhe coîníáes íhaí íheó seêve on íhe aepaêíãení of eealíh Caêe peêváces websáíe aíW
híípWLLwww.dhcs.ca.govLseêvácesLlícLaocîãenísLCCq_BOMiead_BOMlêganázaíáons.pdf.
For CCT transition coordination services:
qhe CCq lead oêganázaíáon wáll báll jedáJCal foê óoîê pêeJíêansáíáon cooêdánaíáon seêváces.
jedáJCal wáll paó foê íhe pêeJíêansáíáon cooêdánaíáon seêváces. voî paó noíháng foê íhese
seêváces.
For services that are not related to your CCT transitionW
qhe pêovádeê wáll báll Caêejoêe Cal jedáConnecí mlan foê óoîê seêváces. Caêejoêe Cal
jedáConnecí mlan wáll paó foê íhe seêváces pêováded afíeê óoîê íêansáíáon. voî paó noíháng foê
íhese seêváces.
pee íhe Benefáís Chaêí án pecíáon a of íhás chapíeê foê ãoêe ánfoêãaíáon aboîí whaí
Caêejoêe Cal jedáConnecí mlan paós foê whále óoî aêe êeceáváng CCq pêeJíêansáíáon
cooêdánaíáon seêváces.
No change in CareMore Cal MediConnect Plan drug coverage benefit:
aêîgs aêe noí coveêed bó íhe CCq pêogêaã. voî wáll coníánîe ío êeceáve óoîê noêãal dêîg
benefáí íhêoîgh Caêejoêe Cal jedáConnecí mlan. coê ãoêe ánfoêãaíáonI please see Chapíeê
R.
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Note: ff óoî need nonJCCq íêansáíáon caêeI óoî shoîld call óoîê case ãanageê ío aêêange íhe
seêváces. konJCCq íêansáíáon caêe ás caêe íhaí ás noí êelaíed ío óoîê íêansáíáon fêoã an
ánsíáíîíáonLfacáláíó.
Medi-Cal Dental Program
Ceêíaán deníal seêváces aêe avaálable íhêoîgh íhe jedáJCal aeníal mêogêaã. peêváces ánclîdeW
 fnáíáal exaãánaíáonsI êadáogêaphsLphoíogêaphác áãagesI pêophólaxásI and flîoêáde
íêeaíãenís
 Aãalgaã and coãposáíe êesíoêaíáons
 mêefabêácaíed síaánless síeelI êesánI and êesán wándow cêowns
 Aníeêáoê EfêoníF íeeíh êooí canal íheêapó
 Coãpleíe deníîêesI ánclîdáng áããedáaíe deníîêes
 Coãpleíe deníîêe adâîsíãenísI êepaáêsI and êelánes
aeníal benefáís aêe avaálable án boíh aeníáJCal feeJfoêJseêváce and íhêoîgh deníal ãanaged
caêe plans. coê ãoêe ánfoêãaíáonI oê áf óoî need help fándáng a deníásí who accepís aeníáJCalI
please coníací íhe aeníáJCal Benefácáaêó Cîsíoãeê peêváce láne aí NJUMMJPOOJSPUQ Eqqv
îseês call NJUMMJTPRJOVOOF. qhe call ás fêee. jedáJCal deníal pêogêaã êepêeseníaíáves aêe
avaálable ío assásí óoî fêoã UWMM a.ã. ío RWMM p.ã.I jondaó íhêoîgh cêádaó. voî can also vásáí
íhe aeníáJCal websáíe aí híípWLLwww.deníáJcal.ca.gov foê ãoêe ánfoêãaíáon.
NoteW aeníal ãanaged caêe plans aêe onló avaálable án ios Angeles and pacêaãenío Coîníó.
ff óoî láve án ios Angeles oê pacêaãenío Coîníó and waní ãoêe ánfoêãaíáon aboîí deníal
plansI need assásíance ádeníáfóáng óoîê deníal planI oê waní ío change deníal plansI please
coníací eealíh Caêe lpíáons aí NJUMMJQPMJQOSP Eqaa îseês call NJUMMJQPMJTMTTFI jondaó
íhêoîgh cêádaóI UWMM a.ã. ío RWMM p.ã. qhe call ás fêee.
Hospice Care
voî can geí caêe fêoã anó hospáce pêogêaã ceêíáfáed bó jedácaêe. voî have íhe êághí ío elecí
hospáce áf óoîê pêovádeê and hospáce ãedácal dáêecíoê deíeêãáne óoî have a íeêãánal
pêognosás. qhás ãeans óoî have a íeêãánal állness and aêe expecíed ío have sáx ãoníhs oê
less ío láve. voîê hospáce docíoê can be a neíwoêk pêovádeê oê an oîíJofJneíwoêk pêovádeê.
pee íhe Benefáís Chaêí án pecíáon a of íhás chapíeê foê ãoêe ánfoêãaíáon aboîí whaí
Caêejoêe Cal jedáConnecí mlan paós foê whále óoî aêe êeceáváng hospáce caêe seêváces.
For hospice services and services covered by Medicare Part A or B that relate to your
terminal prognosis:
 qhe hospáce pêovádeê wáll báll jedácaêe foê óoîê seêváces. jedácaêe wáll paó foê hospáce seêváces êelaíed ío óoîê íeêãánal pêognosás. voî paó noíháng foê íhese seêváces.
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For services covered by Medicare Part A or B that are not related to your terminal
prognosis Eexcepí foê eãeêgencó caêe oê îêgeníló needed caêeFW
 qhe pêovádeê wáll báll jedácaêe foê óoîê seêváces. jedácaêe wáll paó foê íhe seêváces coveêed bó jedácaêe maêí A oê B. voî paó noíháng foê íhese seêváces. For drugs that may be covered by CareMore Cal MediConnect Plan’s Medicare Part D
benefit:
 aêîgs aêe neveê coveêed bó boíh hospáce and oîê plan aí íhe saãe íáãe. coê ãoêe
ánfoêãaíáonI please see Chapíeê R.
Note: ff óoî need nonJhospáce caêeI óoî shoîld call óoîê case ãanageê NJUUUJPRMJPQQT
Eqqv TNNF ío aêêange íhe seêváces. konJhospáce caêe ás caêe íhaí ás noí êelaíed ío óoîê
íeêãánal pêognosás.
G. Benefits not covered by CareMore Cal MediConnect Plan,
Medicare, or Medi-Cal
qhás secíáon íells óoî whaí kánds of benefáís aêe exclîded bó íhe plan. Excluded ãeans íhaí
we do noí paó foê íhese benefáís. jedácaêe and jedáJCal wáll noí paó foê íheã eáíheê.
qhe lásí below descêábes soãe seêváces and áíeãs íhaí aêe noí coveêed bó îs îndeê anó
condáíáons and soãe íhaí aêe exclîded bó îs onló án soãe cases.
te wáll noí paó foê íhe exclîded ãedácal benefáís lásíed án íhás secíáon Eoê anówheêe else án
íhás Member HandbookF excepí îndeê íhe specáfác condáíáons lásíed. ff óoî íhánk íhaí we
shoîld paó foê a seêváce íhaí ás noí coveêedI óoî can fále an appeal. coê ánfoêãaíáon aboîí
fáláng an appealI see Chapíeê VI pecíáon Q.
fn addáíáon ío anó exclîsáons oê láãáíaíáons descêábed án íhe Benefáís ChaêíI íhe followáng áíeãs
and seêváces aêe noí coveêed bó oîê planW
 Services considered not "reasonable and
medically necessary,´ according to the
síandaêds of jedácaêe and jedáJCalI
înless íhese seêváces aêe lásíed bó oîê
plan as coveêed seêváces.
 bxpeêáãeníal ãedácal and sîêgácal
íêeaíãenísI áíeãsI and dêîgsI înless
coveêed bó jedácaêe oê îndeê a
jedácaêeJappêoved clánácal êeseaêch síîdó
oê bó oîê plan. pee page RM foê ãoêe
ánfoêãaíáon on clánácal êeseaêch síîdáes.
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bxpeêáãeníal íêeaíãení and áíeãs aêe
íhose íhaí aêe noí geneêalló accepíed bó
íhe ãedácal coããînáíó.
 pîêgácal íêeaíãení foê ãoêbád obesáíóI
excepí when áí ás ãedácalló needed and
jedácaêe paós foê áí.
 A pêávaíe êooã án a hospáíalI excepí when
áí ás ãedácalló needed.
 mêávaíe dîíó nîêses.
VS
 meêsonal áíeãs án óoîê êooã aí a hospáíal
 pîppoêíáve deváces foê íhe feeíI excepí foê
oê a nîêsáng facáláíóI sîch as a íelephone
oê a íelevásáon.
oêíhopedác oê íheêapeîíác shoes foê people
wáíh dáabeíác fooí dásease.
 cîllJíáãe nîêsáng caêe án óoîê hoãe.
 cees chaêged bó óoîê áããedáaíe êelaíáves
oê ãeãbeês of óoîê hoîsehold.
 jeals deláveêed ío óoîê hoãe înless
pêováded bó Coããînáíó Based Adîlí
peêváces ECBApF.
 blecíáve oê volîníaêó enhanceãení
pêocedîêes oê seêváces Eánclîdáng weághí
lossI haáê gêowíhI sexîal peêfoêãanceI
aíhleíác peêfoêãanceI cosãeíác pîêposesI
aníáJagáng and ãeníal peêfoêãanceFI
excepí when ãedácalló needed.
 Cosãeíác sîêgeêó oê oíheê cosãeíác woêkI
înless áí ás needed becaîse of an
accádeníal ánâîêó oê ío áãpêove a paêí of
íhe bodó íhaí ás noí shaped êághí.
eoweveêI we wáll paó foê êeconsíêîcíáon of
a bêeasí afíeê a ãasíecíoãó and foê
íêeaíáng íhe oíheê bêeasí ío ãaích áí.
 Cháêopêacíác caêeI oíheê íhan ãanîal
ãanápîlaíáon of íhe spáne consásíení wáíh
jedácaêe coveêage gîádelánes.
 oadáal keêaíoíoãóI iApfh sîêgeêóI vásáon
íheêapóI and oíheê lowJvásáon aáds.
 oeveêsal of síeêálázaíáon pêocedîêes and
nonJpêescêápíáon coníêacepíáve sîppláes.
 Acîpîncíîêe excepí foê jedáJCal coveêed
nîêsáng facáláíó êesádení seêváces.
 kaíîêopaíh seêváces Eíhe îse of naíîêal oê
alíeênaíáve íêeaíãenísF.
 peêváces pêováded ío veíeêans án seíeêans
Affaáês EsAF facáláíáes. eoweveêI when a
veíeêan geís eãeêgencó seêváces aí a sA
hospáíal and íhe sA cosíJshaêáng ás ãoêe
íhan íhe cosíJshaêáng îndeê oîê planI we
wáll êeáãbîêse íhe veíeêan foê íhe
dáffeêence. voî aêe síáll êesponsáble foê
óoîê cosíJshaêáng aãoînís.
 Behaváoêal healíh seêváces foê condáíáons
íhaí íhe aáagnosíác and síaíásíácal janîal
of jeníal aásoêdeêsI coîêíh bdáíáon
ádeníáfáes as êelaíáonal pêobleãsI sîch as
coîples coînseláng and faãáló coînseláng
foê êelaíáonal pêobleãs.
 lêíhopedác shoesI înless íhe shoes aêe
paêí of a leg bêace and aêe ánclîded án íhe
cosí of íhe bêaceI oê íhe shoes aêe foê a
peêson wáíh dáabeíác fooí dásease.
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Chapter 5: Getting your outpatient prescription drugs
through the plan
Table of Contents
fníêodîcíáon ....................................................................................................................................NMM
Rules for the plan’s outpatient drug coverage............................................................................NMM
A. deííáng óoîê pêescêápíáons fálled .................................................................................................NMN
cáll óoîê pêescêápíáon aí a neíwoêk phaêãacó..............................................................................NMN
phow óoîê plan fa caêd when óoî fáll a pêescêápíáon...................................................................NMN
thaí áf óoî waní ío change ío a dáffeêení neíwoêk phaêãacó? ...................................................NMN
thaí áf íhe phaêãacó óoî îse leaves íhe neíwoêk?...................................................................NMN
thaí áf óoî need a specáalázed phaêãacó?................................................................................NMO
Can óoî îse ãaálJoêdeê seêváces ío geí óoîê dêîgs? ..................................................................NMO
Can óoî geí a longJíeêã sîppló of dêîgs? .................................................................................NMP
Can you use a pharmacy that is not in the plan’s network? .......................................................NMQ
táll íhe plan paó óoî back áf óoî paó foê a pêescêápíáon?............................................................NMQ
B. The plan’s Drug List ..................................................................................................................NMQ
thaí ás on íhe aêîg iásí? ..........................................................................................................NMQ
eow can óoî fánd oîí áf a dêîg ás on íhe aêîg iásí? ....................................................................NMR
thaí ás not on íhe aêîg iásí? ....................................................................................................NMR
thaí aêe cosíJshaêáng íáeês?......................................................................................................NMS
C. iáãáís on coveêage foê soãe dêîgs............................................................................................NMS
thó do soãe dêîgs have láãáís?...............................................................................................NMS
thaí kánds of êîles aêe íheêe?...................................................................................................NMS
ao anó of íhese êîles appló ío óoîê dêîgs?................................................................................NMT
D. thó óoîê dêîg ãághí noí be coveêed .........................................................................................NMT
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CAobjlob CAi jbafClkkbCq miAk
jbjBbo eAkaBllh
Chapíeê RW deííáng óoîê oîípaíáení pêescêápíáon dêîgs
íhêoîgh íhe plan
voî can geí a íeãpoêaêó sîppló ................................................................................................NMU
E. Changes án coveêage foê óoîê dêîgs..........................................................................................NNM
F. aêîg coveêage án specáal cases.................................................................................................NNN
ff óoî aêe án a hospáíal oê a skálled nîêsáng facáláíó foê a síaó íhaí ás coveêed bó oîê plan ............NNN
ff óoî aêe án a longJíeêã caêe facáláíó ..........................................................................................NNN
ff óoî aêe án a longJíeêã caêe facáláíó and becoãe a new ãeãbeê of íhe plan............................NNN
ff óoî aêe án a jedácaêeJceêíáfáed hospáce pêogêaã ....................................................................NNN
G. mêogêaãs on dêîg safeíó and ãanagáng dêîgs ..........................................................................NNO
mêogêaãs ío help ãeãbeês îse dêîgs safeló.............................................................................NNO
mêogêaãs ío help ãeãbeês ãanage íheáê dêîgs ........................................................................NNO
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jbjBbo eAkaBllh
Introduction
qhás chapíeê explaáns êîles foê geííáng óoîê outpatient prescription drugs. qhese aêe dêîgs
íhaí óoîê pêovádeê oêdeês foê óoî íhaí óoî geí fêoã a phaêãacó oê bó ãaál oêdeê. qheó ánclîde
dêîgs coveêed îndeê jedácaêe maêí a and jedáJCal.
Caêejoêe Cal jedáConnecí mlan also coveês íhe followáng dêîgsI alíhoîgh íheó wáll noí be
dáscîssed án íhás chapíeêW
 aêîgs coveêed bó jedácaêe maêí A. qhese ánclîde soãe dêîgs gáven ío óoî whále óoî
aêe án a hospáíal oê nîêsáng facáláíó.
 aêîgs coveêed bó jedácaêe maêí B. qhese ánclîde soãe cheãoíheêapó dêîgsI soãe
dêîg ánâecíáons gáven ío óoî dîêáng an offáce vásáí wáíh a docíoê oê oíheê pêovádeêI and
dêîgs óoî aêe gáven aí a dáalósás clánác. qo leaên ãoêe aboîí whaí jedácaêe maêí B
dêîgs aêe coveêedI see íhe Benefáís Chaêí án Chapíeê Q pecíáon a.
Rules for the plan’s outpatient drug coverage
te wáll îsîalló coveê óoîê dêîgs as long as óoî follow íhe êîles án íhás secíáon.
N. voî ãîsí have a docíoê oê oíheê pêovádeê wêáíe óoîê pêescêápíáon. qhás peêson ofíen ás
óoîê pêáãaêó caêe pêovádeê EmCmF. fí coîld also be anoíheê pêovádeê áf óoîê pêáãaêó
caêe pêovádeê has êefeêêed óoî foê caêe.
O. voî geneêalló ãîsí îse a neíwoêk phaêãacó ío fáll óoîê pêescêápíáon.
P. Your prescribed drug must be on the plan’s List of Covered Drugs. te call áí íhe
"Drug List´ for short.

ff áí ás noí on íhe aêîg iásíI we ãaó be able ío coveê áí bó gáváng óoî an excepíáon.
pee page NNM ío leaên aboîí askáng foê an excepíáon.
Q. voîê dêîg ãîsí be îsed foê a medically accepted indication. qhás ãeans íhaí íhe îse
of íhe dêîg ás eáíheê appêoved bó íhe cood and aêîg Adãánásíêaíáon oê sîppoêíed bó
ceêíaán êefeêence books.
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A. Getting your prescriptions filled
Fill your prescription at a network pharmacy
fn ãosí casesI we wáll paó foê pêescêápíáons only áf íheó aêe fálled aí anó of oîê neíwoêk
phaêãacáes. A network pharmacy ás a dêîg síoêe íhaí has agêeed ío fáll pêescêápíáons foê oîê
plan ãeãbeês. voî ãaó go ío anó of oîê neíwoêk phaêãacáes.
qo fánd a neíwoêk phaêãacóI óoî can look án íhe Provider and Pharmacy DirectoryI vásáí oîê
websáíeI oê coníací jeãbeê peêváces aí NJUUUJPRMJPQQT Eqqv TNNF.
Show your plan ID card when you fill a prescription
qo fáll óoîê pêescêápíáonI show your plan ID card aí óoîê neíwoêk phaêãacó. qhe neíwoêk
phaêãacó wáll báll îs foê óoîê coveêed pêescêápíáon dêîg.
ff óoî do noí have óoîê plan fa caêd wáíh óoî when óoî fáll óoîê pêescêápíáonI ask íhe
phaêãacó ío call îs ío geí íhe necessaêó ánfoêãaíáon.
ff íhe phaêãacó ás noí able ío geí íhe necessaêó ánfoêãaíáonI óoî ãaó have ío paó íhe fîll
cosí of íhe pêescêápíáon when óoî páck áí îp. voî can íhen ask îs ío paó óoî back. ff óoî
cannoí paó foê íhe dêîgI coníací jeãbeê peêváces aí NJUUUJPRMJPQQT Eqqv TNNF êághí awaó.
te wáll do whaí we can ío help.
qo leaên how ío ask îs ío paó óoî backI see Chapíeê T pecíáon B.
 ff óoî need help geííáng a pêescêápíáon fálledI óoî can coníací jeãbeê peêváces aí NJUUUJPRMJPQQT
Eqqv TNNF.
What if you want to change to a different network pharmacy?
ff óoî change phaêãacáes and need a êefáll of a pêescêápíáonI óoî can ask óoîê phaêãacó ío
íêansfeê íhe pêescêápíáon ío íhe new phaêãacó.
 ff óoî need help changáng óoîê neíwoêk phaêãacóI óoî can coníací jeãbeê peêváces aí NJUUU
PRMJPQQT Eqqv TNNF
What if the pharmacy you use leaves the network?
ff íhe phaêãacó you use leaves the plan’s network, you will have to find a new network
phaêãacó.
 qo fánd a new neíwoêk phaêãacóI óoî can look án íhe Provider and Pharmacy DirectoryI vásáí oîê
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What if you need a specialized pharmacy?
poãeíáães pêescêápíáons ãîsí be fálled aí a specialized pharmacy. ppecáalázed phaêãacáes
ánclîdeW
 mhaêãacáes íhaí sîppló dêîgs foê hoãe ánfîsáon íheêapó.
 mhaêãacáes íhaí sîppló dêîgs foê êesádenís of a longJíeêã caêe facáláíóI sîch as a
nîêsáng hoãe. rsîallóI longJíeêã caêe facáláíáes have íheáê own phaêãacáes. ff óoî aêe a êesádení of a longJíeêã caêe facáláíóI we ãîsí ãake sîêe óoî can geí íhe dêîgs óoî
need at the facility’s pharmacy. If your longJterm care facility’s pharmacy ás noí án oîê
neíwoêkI oê óoî have anó dáffácîlíó accessáng óoîê dêîg benefáís án a longJíeêã caêe
facáláíóI please coníací jeãbeê peêváces aí NJUUUJPRMJPQQT Eqqv TNNF.  mhaêãacáes íhaí seêve íhe fndáan eealíh peêváceLqêábalLrêban fndáan eealíh mêogêaã.
bxcepí án eãeêgencáesI onló kaíáve Aãeêácans oê Alaska kaíáves ãaó îse íhese
phaêãacáes.
 mhaêãacáes íhaí sîppló dêîgs êeqîáêáng specáal handláng and ánsíêîcíáons on íheáê îse.
 qo fánd a specáalázed phaêãacóI óoî can look án íhe Provider and Pharmacy DirectoryI vásáí oîê
Can you use mail-order services to get your drugs?
For certain kinds of drugs, you can use the plan’s network mailJoêdeê seêváces. deneêallóI íhe
dêîgs avaálable íhêoîgh ãaálJoêdeê aêe dêîgs íhaí óoî íake on a êegîlaê basás foê a chêonác oê
longJíeêã ãedácal condáíáon. The drugs available through our plan’s mailJoêdeê seêváce aêe
ãaêked as ãaálJoêdeê dêîgs án oîê aêîg iásí.
Our plan’s mailJoêdeê seêváce allows óoî ío oêdeê a VPJdaó sîppló. A VPJdaó sîppló has íhe
saãe coJpaó as a oneJãoníh sîppló.
How do I fill my prescriptions by mail?
qo geí oêdeê foêãs and ánfoêãaíáon aboîí fálláng óoîê pêescêápíáons bó ãaálI coníací jeãbeê
peêváces aí NJUUUJPRMJPQQT Eqqv TNNF.
rsîallóI a ãaálJoêdeê pêescêápíáon wáll geí ío óoî wáíhán NQ daós. ff óoîê ãaálJoêdeê pêescêápíáon
ás delaóed foê soãe êeasonI óoî ãaó síáll obíaán óoîê ãedácaíáon fêoã óoîê local neíwoêk
phaêãacó.
How will the mail-order service process my prescription?
qhe ãaálJoêdeê seêváce has dáffeêení pêocedîêes foê new pêescêápíáons áí geís fêoã óoîI new
prescriptions it gets directly from your provider’s office, and refills on your mailJoêdeê
pêescêápíáonsW
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1. New prescriptions the pharmacy receives from you
qhe phaêãacó wáll aîíoãaíácalló fáll and deláveê new pêescêápíáons áí êeceáves fêoã óoî.
2. New prescriptions the pharmacy receives directly from your provider’s office
Afíeê íhe phaêãacó êeceáves a pêescêápíáon fêoã a healíh caêe pêovádeêI áí wáll coníací óoî
ío see áf óoî waní íhe ãedácaíáon fálled áããedáaíeló oê aí a laíeê íáãe. qhás wáll gáve óoî an
oppoêíînáíó ío ãake sîêe íhe phaêãacó ás deláveêáng íhe coêêecí dêîg Eánclîdáng síêengíhI
aãoîníI and foêãF andI áf neededI allow óoî ío síop oê delaó íhe oêdeê befoêe áí ás shápped.
fí ás áãpoêíaní íhaí óoî êespond each íáãe óoî aêe coníacíed bó íhe phaêãacóI ío leí íheã
know whaí ío do wáíh íhe new pêescêápíáon and ío pêevení anó delaós án sháppáng.
3. Refills on mail-order prescriptions
coê êefálls of óoîê dêîgsI óoî have íhe opíáon ío ságn îp foê an aîíoãaíác êefáll pêogêaã
called talgêeens Aîíofáll. rndeê íhás pêogêaã we wáll síaêí ío pêocess óoîê nexí êefáll
aîíoãaíácalló when oîê êecoêds show óoî shoîld be close ío êînnáng oîí of óoîê dêîg. qhe
phaêãacó wáll coníací óoî befoêe sháppáng each êefáll ío ãake sîêe óoî need ãoêe ãedácaíáonI and óoî can cancel schedîled êefálls áf óoî have enoîgh of óoîê ãedácaíáon oê
áf óoîê ãedácaíáon has changed. ff óoî choose noí ío îse oîê aîío êefáll pêogêaãI please
coníací óoîê phaêãacó NQ daós befoêe óoî íhánk íhe dêîgs óoî have on hand wáll êîn oîí
ío ãake sîêe óoîê nexí oêdeê ás shápped ío óoî án íáãe.
qo opí oîí of talgêeens Aîíofáll íhaí aîíoãaíácalló pêepaêes ãaál oêdeê êefállsI please
coníací îs bó calláng NJUMMJQUVJONVT Eqqv TNNF oê bó coníacíáng jeãbeê peêváces aí N
UUUJPRMJPQQT Eqqv TNNF.
po íhe phaêãacó can êeach óoî ío confáêã óoîê oêdeê befoêe sháppángI please ãake sîêe ío
leí íhe phaêãacó know íhe besí waós ío coníací óoî. Coníací jeãbeê peêváces ío îpdaíe
óoîê phone and addêess bó calláng NJUUUJPRMJPQQT Eqqv TNNF. voî can also íell jeãbeê
peêváces áf óoî pêefeê ío be êeached bó ãaál oê phone call.
Can you get a long-term supply of drugs?
voî can geí a longJíeêã sîppló of maintenance drugs on our plan’s Drug List. Maintenance
drugs aêe dêîgs íhaí óoî íake on a êegîlaê basásI foê a chêonác oê longJíeêã ãedácal condáíáon.
poãe neíwoêk phaêãacáes allow óoî ío geí a longJíeêã sîppló of ãaáníenance dêîgs. A VP
daó sîppló has íhe saãe coJpaó as a oneJãoníh sîppló. qhe Provider and Pharmacy
Directory íells óoî whách phaêãacáes can gáve óoî a longJíeêã sîppló of ãaáníenance dêîgs.
voî can also call jeãbeê peêváces aí NJUUUJPRMJPQQT Eqqv TNNF foê ãoêe ánfoêãaíáon.
For certain kinds of drugs, you can use the plan’s network mailJoêdeê seêváces ío geí a long
íeêã sîppló of ãaáníenance dêîgs. pee íhe secíáon above ío leaên aboîí ãaálJoêdeê seêváces.
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Can you use a pharmacy that is not in the plan’s network?
deneêallóI we paó foê dêîgs fálled aí an oîíJofJneíwoêk phaêãacó only when óoî aêe noí able
ío îse a neíwoêk phaêãacó. te have neíwoêk phaêãacáes oîísáde of oîê seêváce aêea wheêe
óoî can geí óoîê pêescêápíáons fálled as a ãeãbeê of oîê plan.
te wáll paó foê pêescêápíáons fálled aí an oîíJofJneíwoêk phaêãacó án íhe followáng casesW
 ff íhe pêescêápíáons aêe êelaíed ío caêe foê a ãedácal eãeêgencó oê îêgení caêe.
 ff óoî aêe înable ío obíaán a coveêed dêîg án a íáãeló ãanneê wáíhán oîê seêváce aêea
becaîse íheêe ás no neíwoêk phaêãacó wáíhán êeasonable dêáváng dásíances íhaí
pêovádes OQJhoîê seêváce.
 ff óoî aêe íêóáng ío fáll a pêescêápíáon dêîg íhaí ás noí êegîlaêló síocked aí an accessáble neíwoêk êeíaál oê ãaálJoêdeê phaêãacó Eánclîdáng hágh cosí and înáqîe dêîgsF.
 ff óoî aêe geííáng a vaccáne íhaí ás ãedácalló necessaêó bîí noí coveêed bó jedácaêe maêí B.
 fn íhese casesI please check fáêsí wáíh jeãbeê peêváces aí NJUUUJPRMJPQQT Eqqv TNNF ío see áf
íheêe ás a neíwoêk phaêãacó neaêbó.
Will the plan pay you back if you pay for a prescription?
ff óoî ãîsí îse an oîíJofJneíwoêk phaêãacóI óoî wáll geneêalló have ío paó íhe fîll cosí when
óoî geí óoîê pêescêápíáon. voî can ask îs ío paó óoî back.
qo leaên ãoêe aboîí íhásI see Chapíeê T pecíáon A.
B. The plan’s Drug List
te have a List of Covered Drugs. We call it the "Drug List´ for short.
qhe dêîgs on íhe aêîg iásí aêe selecíed bó îs wáíh íhe help of a íeaã of docíoês and
phaêãacásís. qhe aêîg iásí also íells óoî áf íheêe aêe anó êîles óoî need ío follow ío geí óoîê
dêîgs.
We will generally cover a drug on the plan’s Drug List as long as you follow the êîles
explaáned án íhás chapíeê.
What is on the Drug List?
qhe aêîg iásí ánclîdes íhe dêîgs coveêed îndeê jedácaêe maêí a and soãe pêescêápíáon and
oveêJíheJcoîníeê dêîgs and pêodîcís coveêed îndeê óoîê jedáJCal benefáís.
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qhe aêîg iásí ánclîdes boíh bêandJnaãe and generic dêîgs. deneêác dêîgs have íhe saãe
acíáve ángêedáenís as bêandJnaãe dêîgs. deneêallóI íheó woêk âîsí as well as bêandJnaãe
dêîgs and îsîalló cosí less.
We will generally cover a drug on the plan’s Drug List as long as you follow the rules
explaáned án íhás chapíeê.
lîê plan also coveês ceêíaán oveêJíheJcoîníeê dêîgs and pêodîcís. poãe oveêJíheJcoîníeê
dêîgs cosí less íhan pêescêápíáon dêîgs and woêk âîsí as well. coê ãoêe ánfoêãaíáonI call
jeãbeê peêváces aí NJUUUJPRMJPQQT Eqqv TNNF.
How can you find out if a drug is on the Drug List?
qo fánd oîí áf a dêîg óoî aêe íakáng ás on íhe aêîg iásíI óoî canW
 Check íhe ãosí êecení aêîg iásí we sení óoî án íhe ãaál.
 Visit the plan’s website at duals.caremore.com. qhe aêîg iásí on íhe websáíe ás alwaós íhe ãosí cîêêení one.
 Call jeãbeê peêváces aí NJUUUJPRMJPQQT Eqqv TNNF to find out if a drug is on the plan’s aêîg iásí oê ío ask foê a copó of íhe lásí.
What is not on the Drug List?
te do noí coveê all pêescêápíáon dêîgs. poãe dêîgs aêe noí on íhe aêîg iásí becaîse íhe law
does noí allow îs ío coveê íhose dêîgs. fn oíheê casesI we have decáded noí ío ánclîde a
dêîg on íhe aêîg iásí.
Caêejoêe Cal jedáConnecí mlan wáll not paó foê íhe dêîgs lásíed án íhás secíáon. qhese aêe
called excluded drugs. ff óoî geí a pêescêápíáon foê an exclîded dêîgI óoî ãîsí paó foê áí
óoîêself. ff óoî íhánk we shoîld paó foê an exclîded dêîg becaîse of óoîê caseI óoî can fále
an appeal. Eqo leaên how ío fále an appealI see Chapíeê V pecíáon S.R.F
eeêe aêe íhêee geneêal êîles foê exclîded dêîgsW
 Our plan’s outpatient drug coverage cannot cover a drug that would be covered under
jedácaêe maêí A oê maêí B. aêîgs íhaí woîld be coveêed îndeê jedácaêe maêí A oê maêí
B are covered under our plan’s medical benefit.
 lîê plan cannoí coveê a dêîg pîêchased oîísáde íhe rnáíed píaíes and áís íeêêáíoêáes.
 qhe îse of íhe dêîg ãîsí be eáíheê appêoved bó íhe cood and aêîg Adãánásíêaíáon oê
sîppoêíed bó ceêíaán êefeêence books as a íêeaíãení foê óoîê condáíáon. voîê docíoê
ãághí pêescêábe a ceêíaán dêîg ío íêeaí óoîê condáíáonI even íhoîgh áí was noí appêoved
ío íêeaí íhe condáíáon. qhás ás called off-label use. lîê plan îsîalló does noí coveê dêîgs
when íheó aêe pêescêábed foê offJlabel îse.
AlsoI bó lawI íhe íópes of dêîgs lásíed below aêe noí coveêed bó jedácaêe oê jedáJCal.
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 aêîgs îsed ío pêoãoíe feêíáláíó
 aêîgs îsed foê cosãeíác pîêposes oê ío pêoãoíe haáê gêowíh
 aêîgs îsed foê íhe íêeaíãení of sexîal oê eêecíále dósfîncíáonI sîch as sáagêa®I
Cáalás®I ieváíêa®I and Caveêâecí®
 lîípaíáení dêîgs when íhe coãpanó who ãakes íhe dêîgs saó íhaí óoî have ío have íesís oê seêváces done onló bó íheã
What are cost-sharing tiers?
bveêó dêîg on oîê aêîg iásí ás án one of foîê cosíJshaêáng íáeês.
 qáeê N dêîgs aêe geneêác dêîgs. qhe coJpaó foê ãedácaíáons án íhás íáeê ás AM.
 qáeê O dêîgs aêe bêandJnaãe dêîgs. qhe coJpaó foê ãedácaíáons án íhás íáeê ás AM.
 qáeê P dêîgs aêe pêescêápíáon dêîgs íhaí aêe coveêed bó jedáJCal. qhe coJpaó foê
ãedácaíáons án íhás íáeê ás AM.  qáeê Q dêîgs aêe oveêJíheJcoîníeê ElqCF dêîgs íhaí aêe coveêed bó jedáJCal. qhe co
paó foê ãedácaíáons án íhás íáeê ás AM.
qo fánd oîí whách cosíJshaêáng íáeê óoîê dêîg ás ánI look foê íhe dêîg on oîê aêîg iásí.
Chapíeê S pecíáon C íells íhe aãoîní óoî paó foê dêîgs án each íáeê.
C. Limits on coverage for some drugs
Why do some drugs have limits?
coê ceêíaán pêescêápíáon dêîgsI specáal êîles láãáí how and when íhe plan coveês íheã. fn
geneêalI oîê êîles encoîêage óoî ío geí a dêîg íhaí woêks foê óoîê ãedácal condáíáon and ás
safe and effecíáve. then a safeI loweêJcosí dêîg wáll woêk âîsí as well as a hágheêJcosí dêîgI
we expecí óoîê pêovádeê ío îse íhe loweêJcosí dêîg.
If there is a special rule for your drug, it usually means that you or your provider will
have to take extra steps for us to cover the drug. coê exaãpleI óoîê pêovádeê ãaó have ío
íell îs óoîê dáagnosás oê pêováde êesîlís of blood íesís fáêsí. ff óoî oê óoîê pêovádeê íhánks oîê
êîle shoîld noí appló ío óoîê sáíîaíáonI óoî shoîld ask îs ío ãake an excepíáon. te ãaó oê
ãaó noí agêee ío leí óoî îse íhe dêîg wáíhoîí íakáng íhe exíêa síeps.
qo leaên ãoêe aboîí askáng foê excepíáonsI see Chapíeê V pecíáon S.
What kinds of rules are there?
1. Limiting use of a brand-name drug when a generic version is available
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deneêallóI a geneêác dêîg woêks íhe saãe as a bêandJnaãe dêîg and îsîalló cosís less. fn
ãosí casesI áf íheêe ás a geneêác veêsáon of a bêandJnaãe dêîgI oîê neíwoêk phaêãacáes wáll
gáve óoî íhe geneêác veêsáon. te îsîalló wáll noí paó foê íhe bêandJnaãe dêîg when íheêe ás a
geneêác veêsáon. eoweveêI áf óoîê pêovádeê has íold îs íhe ãedácal êeason íhaí íhe geneêác
dêîg wáll noí woêk foê óoî or has íold îs íhe ãedácal êeason íhaí neáíheê íhe geneêác dêîg noê
oíheê coveêed dêîgs íhaí íêeaí íhe saãe condáíáon wáll woêk foê óoîI íhen we wáll coveê íhe
bêandJnaãe dêîg.
2. Getting plan approval in advance
coê soãe dêîgsI óoî oê óoîê docíoê ãîsí geí appêoval fêoã Caêejoêe Cal jedáConnecí mlan
before you fill your prescription. If you don’t get approval, Caêejoêe Cal jedáConnecí mlan
ãaó noí coveê íhe dêîg.
3. Quantity limits
coê soãe dêîgsI we láãáí íhe aãoîní of íhe dêîg óoî can have. coê exaãpleI we ãághí láãáí
how ãîch of a dêîg óoî can geí each íáãe óoî fáll óoîê pêescêápíáon.
Do any of these rules apply to your drugs?
qo fánd oîí áf anó of íhe êîles above appló ío a dêîg óoî íake oê waní ío íakeI check íhe
aêîg iásí. coê íhe ãosí îpJíoJdaíe ánfoêãaíáonI call jeãbeê peêváces aí NJUUUJPRMJPQQT
Eqqv TNNF oê check oîê websáíe aí dîals.caêeãoêe.coã.
D. Why your drug might not be covered
te íêó ío ãake óoîê dêîg coveêage woêk well foê óoîI bîí soãeíáães a dêîg ãághí noí be
coveêed án íhe waó íhaí óoî woîld láke áí ío be. coê exaãpleW
 The drug you want to take is not covered by our plan. qhe dêîg ãághí noí be on íhe
aêîg iásí. A geneêác veêsáon of íhe dêîg ãághí be coveêedI bîí íhe bêand naãe veêsáon
óoî waní ío íake ás noí. A dêîg ãághí be new and we have noí óeí êeváewed áí foê safeíó
and effecíáveness.
 The drug is covered, but there are special rules or limits on coverage for that
drug. As explaáned án íhe secíáon aboveI soãe of íhe dêîgs coveêed bó oîê plan have
êîles íhaí láãáí íheáê îse. fn soãe casesI óoî oê óoîê pêescêábeê ãaó waní ío ask îs foê
an excepíáon ío a êîle.
qheêe aêe íhángs óoî can do áf óoîê dêîg ás noí coveêed án íhe waó íhaí óoî woîld láke áí ío be.
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You can get a temporary supply
fn soãe casesI we can gáve óoî a íeãpoêaêó sîppló of a dêîg when íhe dêîg ás noí on íhe
aêîg iásí oê when áí ás láãáíed án soãe waó. qhás gáves óoî íáãe ío íalk wáíh óoîê pêovádeê
aboîí geííáng a dáffeêení dêîg oê ío ask îs ío coveê íhe dêîg.
To get a temporary supply of a drug, you must meet the two rules below:
The drug you have been taking:
fs no longeê on oîê aêîg iásíI or
tas neveê on oîê aêîg iásíI or
fs now láãáíed án soãe waó.
You must be in one of these situations:
You were in the plan last year and do not live in a long-term care facility.
te wáll coveê a íeãpoêaêó sîppló of óoîê dêîg during the first 90 days of the
calendar year. qhás íeãpoêaêó sîppló wáll be foê îp ío a PMJdaó sîppló. ff óoîê
pêescêápíáon ás wêáííen foê feweê daósI we wáll allow ãîlíáple fálls ío pêováde îp ío a
ãaxáãîã of a PMJdaó sîppló of ãedácaíáon. voî ãîsí fáll íhe pêescêápíáon aí a neíwoêk
phaêãacó.
You are new to our plan and do not live in a long-term care facility.
te wáll coveê a íeãpoêaêó sîppló of óoîê dêîg during the first 90 days of your
membership án íhe plan. qhás íeãpoêaêó sîppló wáll be foê îp ío a PMJdaó sîppló. ff
óoîê pêescêápíáon ás wêáííen foê feweê daósI we wáll allow ãîlíáple fálls ío pêováde îp ío a
ãaxáãîã of a PMJdaó sîppló of ãedácaíáon. voî ãîsí fáll íhe pêescêápíáon aí a neíwoêk
phaêãacó.
You were in the plan last year and live in a long-term care facility.
te wáll coveê a íeãpoêaêó sîppló of óoîê dêîg during the first 90 days of the
calendar year. qhe íoíal sîppló wáll be foê îp ío a VNJ ío VUJdaó sîppló dependáng on
íhe dáspensáng áncêeãení. ff óoîê pêescêápíáon ás wêáííen foê feweê daósI we wáll allow
ãîlíáple fálls ío pêováde îp ío a ãaxáãîã of a VUJdaó sîppló of ãedácaíáon. Emlease noíe
íhaí íhe longJíeêã caêe phaêãacó ãaó pêováde íhe dêîg án sãalleê aãoînís aí a íáãe ío
pêevení wasíe.F
You are new to the plan and live in a long-term care facility.
te wáll coveê a íeãpoêaêó sîppló of óoîê dêîg during the first 90 days of your
membership án íhe plan. qhe íoíal sîppló wáll be foê îp ío a VNJ ío VUJdaó sîppló
dependáng on íhe dáspensáng áncêeãení. ff óoîê pêescêápíáon ás wêáííen foê feweê daósI
we wáll allow ãîlíáple fálls ío pêováde îp ío a ãaxáãîã of a VUJdaó sîppló of ãedácaíáon.
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Emlease noíe íhaí íhe longJíeêã caêe phaêãacó ãaó pêováde íhe dêîg án sãalleê aãoînís aí a íáãe ío pêevení wasíe.F
 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.
te wáll coveê one PNJdaó sîpplóI oê less áf óoîê pêescêápíáon ás wêáííen foê feweê daós.
qhás ás án addáíáon ío íhe above longJíeêã caêe íêansáíáon sîppló.
 ff óoî have been án íhe plan foê ãoêe íhan VM daós and óoî expeêáence a change án óoîê level of caêe íhaí êeqîáêes óoî ío ãove fêoã one facáláíó oê íêeaíãení ceníeê ío
anoíheêI óoî ãaó be elágáble foê a oneJíáãe íeãpoêaêó fáll of íhe pêescêápíáon óoî have now. coê exaãpleI let’s say óoî weêe dáschaêged fêoã íhe hospáíal and gáven a dáschaêge lásí of ãedácaíáon based on íhe hospáíal dêîg lásí. voî ãaó be able ío geí a
oneJíáãe fáll of íhe dêîg. voî can geí íhás excepíáon no matter if you’re in your first VM
daós of pêogêaã enêollãení. eave óoîê pêescêábeê call îs foê deíaáls.

qo ask foê a íeãpoêaêó sîppló of a dêîgI call jeãbeê peêváces aí NJUUUJPRM
PQQT Eqqv TNNF.
then óoî geí a íeãpoêaêó sîppló of a dêîgI óoî shoîld íalk wáíh óoîê pêovádeê ío decáde
whaí ío do when óoîê sîppló êîns oîí. eeêe aêe óoîê choácesW
 You can change to another drug.
qheêe ãaó be a dáffeêení dêîg coveêed bó oîê plan íhaí woêks foê óoî. voî can call
jeãbeê peêváces aí NJUUUJPRMJPQQT Eqqv TNNF ío ask foê a lásí of coveêed dêîgs íhaí
íêeaí íhe saãe ãedácal condáíáon. qhe lásí can help óoîê pêovádeê fánd a coveêed dêîg
íhaí ãághí woêk foê óoî.
OR
 You can ask for an exception.
voî and óoîê pêovádeê can ask îs ío ãake an excepíáon. coê exaãpleI óoî can ask îs
ío coveê a dêîg even íhoîgh áí ás noí on íhe aêîg iásí. lê óoî can ask îs ío coveê íhe
dêîg wáíhoîí láãáís. ff óoîê pêovádeê saós óoî have a good ãedácal êeason foê an
excepíáonI he oê she can help óoî ask foê one.
ff a dêîg óoî aêe íakáng wáll be íaken off íhe aêîg iásí oê láãáíed án soãe waó foê nexí óeaêI we
wáll allow óoî ío ask foê an excepíáon befoêe nexí óeaê. te wáll íell óoî aboîí anó change án
íhe coveêage foê óoîê dêîg foê nexí óeaê. voî can íhen ask îs ío ãake an excepíáon and
coveê íhe dêîg án íhe waó óoî woîld láke áí ío be coveêed foê nexí óeaê. te wáll answeê óoîê
request for an exception within 72 hours after we receive your request (or your prescriber’s
sîppoêíáng síaíeãeníF.

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qo leaên ãoêe aboîí askáng foê an excepíáonI see Chapíeê V pecíáon S.
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
ff óoî need help askáng foê an excepíáonI óoî can coníací jeãbeê peêváces aí NJUUU
PRMJPQQT Eqqv TNNF.
E. Changes in coverage for your drugs
josí changes án dêîg coveêage happen on ganîaêó N. eoweveêI we ãághí ãake changes ío
íhe aêîg iásí dîêáng íhe óeaê. te ãághíW
 Add dêîgs becaîse new dêîgsI ánclîdáng geneêác dêîgsI becaãe avaálable oê íhe
goveênãení appêoved a new îse foê an exásíáng dêîg.
 oeãove dêîgs becaîse íheó weêe êecalled oê becaîse cheapeê dêîgs woêk âîsí as well.
 Add oê êeãove a láãáí on coveêage foê a dêîg.
 oeplace a bêandJnaãe dêîg wáíh a geneêác dêîg.
ff anó of íhe changes below affecí a dêîg óoî aêe íakángI íhe change wáll noí affecí óoî îníál
ganîaêó N of íhe nexí óeaêW
 te pîí a new láãáí on óoîê îse of íhe dêîg.
 te êeãove óoîê dêîg fêoã íhe aêîg iásíI bîí noí becaîse of a êecall oê becaîse a new
geneêác dêîg has êeplaced áí.
Befoêe ganîaêó N of íhe nexí óeaêI óoî îsîalló wáll noí have an áncêease án óoîê paóãenís oê
added láãáís ío óoîê îse of íhe dêîg. qhe changes wáll affecí óoî on ganîaêó N of íhe nexí
óeaê.
fn íhe followáng casesI óoî will be affecíed bó íhe coveêage change befoêe ganîaêó NW
 ff a bêand naãe dêîg óoî aêe íakáng ás êeplaced bó a new geneêác dêîgI we ãîsí gáve
you at least 60 days’ notice about the change.
»
»
»
te ãaó gáve óoî a SMJdaó êefáll of óoîê bêandJnaãe dêîg aí a neíwoêk phaêãacó.
voî shoîld woêk wáíh óoîê pêovádeê dîêáng íhose SM daós ío change ío íhe geneêác dêîg
oê ío a dáffeêení dêîg íhaí íhe plan coveês.
voî and óoîê pêovádeê can ask îs ío coníánîe coveêáng íhe bêandJnaãe dêîg foê óoî.
qo leaên howI see Chapíeê V pecíáon S.
 ff a dêîg ás êecalled becaîse áí ás foînd ío be însafe oê foê oíheê êeasonsI we wáll
êeãove íhe dêîg fêoã íhe aêîg iásí. te wáll íell óoî aboîí íhás change êághí awaó.
» voîê pêovádeê wáll also know aboîí íhás change. ee oê she can woêk wáíh óoî ío fánd
anoíheê dêîg foê óoîê condáíáon.
 ff íheêe ás a change ío coveêage foê a dêîg óoî aêe íakángI we will send you a notice.
koêãallóI we wáll leí óoî know aí leasí SM daós befoêe íhe change.
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F. Drug coverage in special cases
If you are in a hospital or a skilled nursing facility for a stay that is covered by
our plan
ff óoî aêe adãáííed ío a hospáíal oê skálled nîêsáng facáláíó foê a síaó coveêed bó oîê planI we
wáll geneêalló coveê íhe cosí of óoîê pêescêápíáon dêîgs dîêáng óoîê síaó. voî wáll noí have ío
paó a coJpaó. lnce óoî leave íhe hospáíal oê skálled nîêsáng facáláíóI we wáll coveê óoîê dêîgs
as long as íhe dêîgs ãeeí all of oîê êîles foê coveêage.
If you are in a long-term care facility
rsîallóI a longJíeêã caêe facáláíóI sîch as a nîêsáng hoãeI has áís own phaêãacó oê a
phaêãacó íhaí sîppláes dêîgs foê all of áís êesádenís. ff óoî aêe láváng án a longJíeêã caêe
facáláíóI óoî ãaó geí your prescription drugs through the facility’s pharmacy if it is part of our
neíwoêk.
Check óoîê Provider and Pharmacy Directory ío fánd oîí áf óoîê longJterm care facility’s
phaêãacó ás paêí of oîê neíwoêk. ff áí ás noíI oê áf óoî need ãoêe ánfoêãaíáonI please coníací
jeãbeê peêváces aí NJUUUJPRMJPQQT Eqqv TNNF.
If you are in a long-term care facility and become a new member of the plan
ff óoî need a dêîg íhaí ás noí on oîê aêîg iásí oê ás êesíêácíed án soãe waóI we wáll coveê a
íeãpoêaêó sîppló of óoîê dêîg dîêáng íhe fáêsí VM daós of óoîê ãeãbeêshápI îníál we have
gáven óoî a VNJ ío VUJdaó sîppló. qhe fáêsí sîppló wáll be foê îp ío a PNJdaó sîpplóI oê less áf
óoîê pêescêápíáon ás wêáííen foê feweê daós. ff óoî need êefállsI we wáll coveê íheã dîêáng óoîê
fáêsí VM daós án íhe plan.
ff óoî have been a ãeãbeê of oîê plan foê ãoêe íhan VM daós and óoî need a dêîg íhaí ás noí
on oîê aêîg iásíI we wáll coveê one PNJdaó sîppló. te wáll also coveê one PNJdaó sîppló áf we
have a limit on the drug’s coverage. If yoîê pêescêápíáon ás wêáííen foê feweê íhan PN daósI we
wáll paó foê íhe sãalleê aãoîní.
then óoî geí a íeãpoêaêó sîppló of a dêîgI óoî shoîld íalk wáíh óoîê pêovádeê ío decáde
whaí ío do when óoîê sîppló êîns oîí. A dáffeêení dêîg coveêed bó oîê plan ãághí woêk âîsí as
well foê óoî. lê óoî and óoîê pêovádeê can ask îs ío ãake an excepíáon and coveê íhe dêîg án
íhe waó óoî woîld láke áí ío be coveêed.
qo leaên ãoêe aboîí askáng foê excepíáonsI see Chapíeê V pecíáon S.
If you are in a Medicare-certified hospice program
aêîgs aêe neveê coveêed bó boíh hospáce and oîê plan aí íhe saãe íáãe. ff óoî aêe enêolled
án a jedácaêe hospáce and êeqîáêe a paánI aníáJnaîseaI laxaíáve oê aníáJanxáeíó dêîg noí
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coveêed bó óoîê hospáce becaîse áí ás înêelaíed ío óoîê íeêãánal pêognosás and êelaíed
condáíáonsI oîê plan ãîsí êeceáve noíáfácaíáon fêoã eáíheê íhe pêescêábeê oê óoîê hospáce
pêovádeê íhaí íhe dêîg ás înêelaíed befoêe oîê plan can coveê íhe dêîg. qo pêevení delaós án
êeceáváng anó înêelaíed dêîgs íhaí shoîld be coveêed bó oîê planI óoî can ask óoîê hospáce
pêovádeê oê pêescêábeê ío ãake sîêe we have íhe noíáfácaíáon íhaí íhe dêîg ás înêelaíed befoêe
óoî ask a phaêãacó ío fáll óoîê pêescêápíáon.
ff óoî leave hospáceI oîê plan shoîld coveê all of óoîê dêîgs. qo pêevení anó delaós aí a
phaêãacó when óoîê jedácaêe hospáce benefáí endsI óoî shoîld bêáng docîãeníaíáon ío íhe
phaêãacó ío veêáfó íhaí óoî have lefí hospáce. pee íhe pêeváoîs paêís of íhás chapíeê íhaí íell
aboîí íhe êîles foê geííáng dêîg coveêage îndeê maêí a.
qo leaên ãoêe aboîí íhe hospáce benefáíI see Chapíeê Q pecíáon C.
G. Programs on drug safety and managing drugs
Programs to help members use drugs safely
bach íáãe óoî fáll a pêescêápíáonI we look foê possáble pêobleãsI sîch asW
 aêîg eêêoês
 aêîgs íhaí ãaó noí be needed becaîse óoî aêe íakáng anoíheê dêîg íhaí does íhe
saãe íháng
 aêîgs íhaí ãaó noí be safe foê óoîê age oê gendeê
 aêîgs íhaí coîld haêã óoî áf óoî íake íheã aí íhe saãe íáãe
 aêîgs íhaí aêe ãade of íhángs óoî aêe alleêgác ío
ff we see a possáble pêobleã án óoîê îse of pêescêápíáon dêîgsI we wáll woêk wáíh óoîê pêovádeê
ío coêêecí íhe pêobleã.
Programs to help members manage their drugs
ff óoî íake ãedácaíáons foê dáffeêení ãedácal condáíáonsI óoî ãaó be elágáble ío geí seêvácesI aí
no cosí ío óoîI íhêoîgh a ãedácaíáon íheêapó ãanageãení EjqjF pêogêaã. qhás pêogêaã
helps óoî and óoîê pêovádeê ãake sîêe íhaí óoîê ãedácaíáons aêe woêkáng ío áãpêove óoîê
healíh. A phaêãacásí oê oíheê healíh pêofessáonal wáll gáve óoî a coãpêehensáve êeváew of all
óoîê ãedácaíáons and íalk wáíh óoî aboîíW
 eow ío geí íhe ãosí benefáí fêoã íhe dêîgs óoî íake
 Anó conceêns óoî haveI láke ãedácaíáon cosís and dêîg êeacíáons
 eow besí ío íake óoîê ãedácaíáons
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 Anó qîesíáons oê pêobleãs óoî have aboîí óoîê pêescêápíáon and oveêJíheJcoîníeê
ãedácaíáon
You’ll get a written summary of this discussion. The summary has a medication action plan
that recommends what you can do to make the best use of your medications. You’ll also get
a peêsonal ãedácaíáon lásí íhaí wáll ánclîde all íhe ãedácations you’re taking and why you take
íheã.
It’s a good idea to schedule your medication review before your yearly "Wellness´ visit, so
óoî can íalk ío óoîê docíoê aboîí óoîê acíáon plan and ãedácaíáon lásí. Bêáng óoîê acíáon plan
and ãedácaíáon lásí wáíh óoî ío óoîê vásáí oê anóíáãe óoî íalk wáíh óoîê docíoêsI phaêãacásísI
and oíheê healíh caêe pêovádeês. AlsoI íake óoîê ãedácaíáon lásí wáíh óoî áf óoî go ío íhe
hospáíal oê eãeêgencó êooã.
jedácaíáon íheêapó ãanageãení pêogêaãs aêe volîníaêó and fêee ío ãeãbeês íhaí qîaláfó. ff
we have a pêogêaã íhaí fáís óoîê needsI we wáll enêoll óoî án íhe pêogêaã and send óoî
ánfoêãaíáon. ff óoî do noí waní ío be án íhe pêogêaãI please leí îs knowI and we wáll íake óoî
oîí of íhe pêogêaã.
 ff óoî have anó qîesíáons aboîí íhese pêogêaãsI please coníací jeãbeê peêváces aí NJUUU
PRMJPQQT Eqqv TNNF.
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Chapíeê SW thaí óoî paó foê óoîê jedácaêe and
jedáJCal pêescêápíáon dêîgs
Chapter 6: What you pay for your Medicare and Medi-Cal
prescription drugs
Table of Contents
fníêodîcíáon ....................................................................................................................................NNR
A. qhe bxplanaíáon of Benefáís EblBF ............................................................................................NNS
B. heepáng íêack of óoîê dêîg cosís................................................................................................NNT
N. rse óoîê plan fa caêd...........................................................................................................NNT
O. jake sîêe we have íhe ánfoêãaíáon we need........................................................................NNT
P. pend îs ánfoêãaíáon aboîí íhe paóãenís oíheês have ãade foê óoî. ...................................NNT
Q. Check íhe êepoêís we send óoî. ...........................................................................................NNT
C. thaí óoî paó foê a oneJãoníh oê longJíeêã sîppló of dêîgs......................................................NNU
lîê cosíJshaêáng íáeês ...............................................................................................................NNU
voîê phaêãacó choáces............................................................................................................NNU
deííáng a longJíeêã sîppló of a dêîg ........................................................................................NNU
eow ãîch do óoî paó?............................................................................................................NNU
D. saccánaíáons ..............................................................................................................................NOM
Befoêe óoî geí a vaccánaíáon ....................................................................................................NOM
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Introduction
This chapter tells what you pay for your outpatient prescription drugs. By "drugs,´ we meanW
jedácaêe maêí a pêescêápíáon dêîgsI and
aêîgs and áíeãs coveêed îndeê jedáJCalI and
aêîgs and áíeãs coveêed bó íhe plan as addáíáonal benefáís.
Becaîse óoî aêe elágáble foê jedáJCal, you are getting "Extra Help´ from Medicare to help pay
foê óoîê jedácaêe maêí a pêescêápíáon dêîgs.
qo leaên ãoêe aboîí pêescêápíáon dêîgsI óoî can look án íhese placesW
Our List of Covered Drugs. We call this the "Drug List.´ It tells you:
» thách dêîgs we paó foê
» thách of íhe Q cosíJshaêáng íáeês each dêîg ás án
» theíheê íheêe aêe anó láãáís on íhe dêîgs ff óoî need a copó of íhe aêîg iásíI call jeãbeê peêváces aí NJUUUJPRMJPQQT Eqqv
TNNF. voî can also fánd íhe aêîg iásí on oîê websáíe aí dîals.caêeãoêe.coã. qhe aêîg
iásí on íhe websáíe ás alwaós íhe ãosí cîêêení.
Chapter 5 of this Member Handbook. Chapíeê R íells how ío geí óoîê oîípaíáení
pêescêápíáon dêîgs íhêoîgh oîê plan. fí ánclîdes êîles óoî need ío follow. fí also íells
whách íópes of pêescêápíáon dêîgs aêe not coveêed bó oîê plan.
Our Provider and Pharmacy Directory. fn ãosí casesI óoî ãîsí îse a neíwoêk
phaêãacó ío geí óoîê coveêed dêîgs. keíwoêk phaêãacáes aêe phaêãacáes íhaí have
agêeed ío woêk wáíh îs. qhe Provider and Pharmacy Directory has a lásí of neíwoêk
phaêãacáes. voî can êead ãoêe aboîí neíwoêk phaêãacáes án Chapíeê R pecíáon A.
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NNR
A. The Explanation of Benefits (EOB)
lîê plan keeps íêack of óoîê pêescêápíáon dêîgs. te keep íêack of íwo íópes of cosísW
voîê out-of-pocket costs. qhás ás íhe aãoîní of ãoneó óoîI oê oíheês on óoîê behalfI paó
foê óoîê pêescêápíáons.
voîê total drug costs. qhás ás íhe aãoîní of ãoneó óoîI oê oíheês on óoîê behalfI paó foê
óoîê pêescêápíáonsI plîs íhe aãoîní we paó.
then óoî geí pêescêápíáon dêîgs íhêoîgh oîê planI we send óoî a êepoêí called íhe
Explanation of Benefits. te call áí íhe EOB foê shoêí. qhe blB ánclîdesW
Information for the month. qhe êepoêí íells whaí pêescêápíáon dêîgs óoî goí. fí shows íhe
íoíal dêîg cosísI whaí we paádI and whaí óoî and oíheês paóáng foê óoî paád.
“Year-to-date” information. qhás ás óoîê íoíal dêîg cosís and íhe íoíal paóãenís ãade
sánce ganîaêó N.
 te offeê coveêage of dêîgs noí coveêed îndeê jedácaêe. maóãenís ãade foê íhese dêîgs
wáll noí coîní íowaêds óoîê íoíal oîíJofJpockeí cosís. qo fánd oîí whách dêîgs oîê plan
coveêsI see íhe aêîg iásí.
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NNS
B. Keeping track of your drug costs
qo keep íêack of óoîê dêîg cosís and íhe paóãenís óoî ãakeI we îse êecoêds we geí fêoã
óoî and fêoã óoîê phaêãacó. eeêe ás how óoî can help îsW
1. Use your plan ID card.
phow óoîê plan fa caêd eveêó íáãe óoî geí a pêescêápíáon fálled. qhás wáll help îs know whaí
pêescêápíáons óoî fáll and whaí óoî paó.
2. Make sure we have the information we need.
dáve îs copáes of êeceápís foê dêîgs íhaí óoî have paád foê. voî can ask îs ío paó óoî back
foê íhe dêîg.
eeêe aêe soãe íáães when óoî shoîld gáve îs copáes of óoîê êeceápísW
then óoî bîó a coveêed dêîg aí a neíwoêk phaêãacó aí a specáal pêáce oê îsáng a
discount card that is not part of our plan’s benefit
then óoî paó a coJpay for drugs that you get under a drug maker’s patient assistance
pêogêaã
then óoî bîó coveêed dêîgs aí an oîíJofJneíwoêk phaêãacó
then óoî paó íhe fîll pêáce foê a coveêed dêîg
 qo leaên how ío ask îs ío paó óoî back foê íhe dêîgI see Chapter 7 Section A.
3. Send us information about the payments others have made for you.
maóãenís ãade bó ceêíaán oíheê people and oêganázaíáons also coîní íowaêd óoîê oîíJof
pockeí cosís. coê exaãpleI paóãenís ãade bó an Afap dêîg assásíance pêogêaãI íhe fndáan
eealíh peêváceI and ãosí chaêáíáes coîní íowaêd óoîê oîíJofJpockeí cosís.
4. Check the reports we send you.
then óoî geí an bxplanaíáon of Benefáís án íhe ãaálI please ãake sîêe áí ás coãpleíe and
coêêecí. ff óoî íhánk soãeíháng ás wêong oê ãássáng fêoã íhe êepoêíI oê áf óoî have anó
qîesíáonsI please call jeãbeê peêváces aí NJUUUJPRMJPQQT Eqqv TNNF.Be sîêe ío keep íhese
êepoêís. qheó aêe an áãpoêíaní êecoêd of óoîê dêîg expenses.
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NNT
C. What you pay for a one-month or long-term supply of drugs
Our cost-sharing tiers
CosíJshaêáng íáeês aêe gêoîps of dêîgs wáíh íhe saãe coJpaó. bveêó dêîg on oîê
aêîg iásí ás án one of foîê cosíJshaêáng íáeês.
qáeê N dêîgs aêe geneêác dêîgs. qhe coJpaó foê ãedácaíáons án íhás íáeê ás AM.
qáeê O dêîgs aêe bêandJnaãe dêîgs. qhe coJpaó foê ãedácaíáons án íhás íáeê ás AM.
qáeê P dêîgs aêe pêescêápíáon dêîgs íhaí aêe coveêed bó jedáJCal. qhe coJpaó foê
ãedácaíáons án íhás íáeê ás AM.
qáeê Q dêîgs aêe oveêJíheJcoîníeê ElqCF dêîgs íhaí aêe coveêed bó jedáJCal. qhe coJpaó
foê ãedácaíáons án íhás íáeê ás AM.
Your pharmacy choices
eow ãîch óoî paó foê a dêîg depends on wheíheê óoî geí íhe dêîg fêoãW
A neíwoêk phaêãacóI or
An oîíJofJneíwoêk phaêãacó.
 fn láãáíed casesI we coveê pêescêápíáons fálled aí oîíJofJneíwoêk phaêãacáes. pee Chapíeê R
pecíáon A ío fánd oîí when we wáll do íhaí.
 qo leaên ãoêe aboîí íhese phaêãacó choácesI see Chapíeê R pecíáon A án íhás handbook
and oîê Provider and Pharmacy Directory.
Getting a long-term supply of a drug
coê soãe dêîgsI óoî can geí a longJterm supply (also called an "extended supply´) when you
fáll óoîê pêescêápíáon. A longJíeêã sîppló ás îp ío a VPJdaó sîppló. qheêe ás no cosí ío óoî foê a
longJíeêã sîppló.
 coê deíaáls on wheêe and how ío geí a longJíeêã sîppló of a dêîgI see Chapíeê R pecíáon
A oê íhe Provider and Pharmacy Directory.
How much do you pay?
 voî can coníací jeãbeê peêváces aí NJUUUJPRMJPQQT Eqqv TNNF ío fánd oîí how ãîch
óoîê coJpaó ás foê anó coveêed dêîg.
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NNU
Your share of the cost when you get a one-month or long-term supply of a covered
prescription drug from:
A network
pharmacy
A oneJãoníh
oê îp ío a VP
daó sîppló
Cost-sharing
Tier 1
The plan’s
mail-order
service
A oneJãoníh
oê îp ío a VP
daó sîppló
A network
long-term
care
pharmacy
rp ío a VP
daó sîppló
An out-ofnetwork
pharmacy
rp ío a VPJdaó
sîppló. Coveêage
ás láãáíed ío
ceêíaán cases.
pee Chapíeê R
pecíáon A foê
deíaáls.
AM
AM
AM
AM
AM
AM
AM
AM
AM
AM
AM
AM
AM
AM
AM
AM
Edeneêác dêîgsF
Cost-sharing
Tier 2
EBêandJnaãe
dêîgsF
Cost-sharing
Tier 3
Emêescêápíáon
dêîgs coveêed
bó jedáJCalF
Cost-sharing
Tier 4
ElqC dêîgs
coveêed bó
jedáJCalF
 coê ánfoêãaíáon aboîí whách phaêãacáes can gáve óoî longJterm supplies, see the plan’s
Provider and Pharmacy Directory.
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NNV
D. Vaccinations
te coveê jedácaêe maêí a vaccánes. qheêe aêe íwo paêís ío oîê coveêage of jedácaêe maêí a
vaccánaíáonsW
N. qhe fáêsí paêí of coveêage ás foê íhe cosí of the vaccine itself. qhe vaccáne ás a
pêescêápíáon dêîg.
O. qhe second paêí of coveêage ás foê íhe cosí of giving you the shot.
Before you get a vaccination
te êecoããend íhaí óoî call îs fáêsí aí jeãbeê peêváces aí NJUUUJPRMJPQQT Eqqv TNNF
wheneveê óoî aêe plannáng ío geí a vaccánaíáon.
te can íell óoî aboîí how óoîê vaccánaíáon ás coveêed bó oîê plan.
te can íell óoî how ío keep óoîê cosís down bó îsáng neíwoêk phaêãacáes and pêovádeês.
Network pharmacies aêe phaêãacáes íhaí have agêeed ío woêk wáíh oîê plan. A network
provider ás a pêovádeê who woêks wáíh íhe healíh plan. A neíwoêk pêovádeê shoîld woêk
wáíh Caêejoêe Cal jedáConnecí mlan ío ensîêe íhaí óoî do noí have anó îpfêoní cosís
foê a maêí a vaccáne.
eeêe aêe íhêee coããon waós óoî ãághí geí a jedácaêe maêí a vaccánaíáon.
N. voî geí íhe jedácaêe maêí a vaccáne aí a neíwoêk phaêãacó and geí óoîê shoí
aí íhe phaêãacó.
voî wáll paó noíháng foê íhe vaccáne.
O. You get the Medicare Part D vaccination at your doctor’s office and the doctor gives you
íhe shoí.
voî wáll paó noíháng ío íhe docíoê foê íhe vaccáne.
lîê plan wáll paó foê íhe cosí of gáváng óoî íhe shoí.
The doctor’s office should call our plan in this situation so we can make sure they know
óoî onló have ío paó noíháng foê íhe vaccáne.
P. voî geí íhe Medicare Part D vaccine itself at a pharmacy and take it to your doctor’s office
ío geí íhe shoí.
voî wáll paó noíháng foê íhe vaccáne.
lîê plan wáll paó foê íhe cosí of gáváng óoî íhe shoí.
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NOM
Chapter 7: Asking us to pay a bill you have gotten for covered services or
drugs
Table of Contents
A. then óoî can ask îs ío paó foê óoîê seêváces oê dêîgs .............................................................NON
B. eow and wheêe ío send îs óoîê êeqîesí foê paóãení ................................................................NOP
C. te wáll ãake a coveêage decásáon .............................................................................................NOP
D. voî can ãake an appeal ...........................................................................................................NOQ
A. When you can ask us to pay for your services or drugs
lîê neíwoêk pêovádeês ãîsí báll íhe plan foê óoîê coveêed seêváces and dêîgs alêeadó
êeceáved. A network provider ás a pêovádeê who woêks wáíh íhe healíh plan.
ff óoî geí a báll foê healíh caêe oê dêîgsI send íhe báll ío îs. qo send îs a bállI see page NOQ.
ff íhe seêváces oê dêîgs aêe coveêedI we wáll paó íhe pêovádeê dáêecíló.
ff íhe seêváces oê dêîgs aêe coveêed and óoî alêeadó paád íhe bállI we wáll paó óoî back. fí
ás óoîê êághí ío be paád back áf óoî paád foê íhe seêváces oê dêîgs.
ff íhe seêváces oê dêîgs aêe not coveêedI we wáll íell óoî.
 Coníací jeãbeê peêváces áf óoî have anó qîesíáons. ff óoî geí a báll and óoî do noí know
whaí ío do aboîí áíI we can help. voî can also call áf óoî waní ío íell îs ánfoêãaíáon aboîí
a êeqîesí foê paóãení óoî alêeadó sení ío îs.
eeêe aêe exaãples of íáães when óoî ãaó need ío ask îs ío paó óoî back oê ío paó a báll
óoî goíW
1. When you get emergency or urgently needed health care from an out-of-network provider
voî shoîld ask íhe pêovádeê ío báll îs.
ff óoî paó íhe fîll aãoîní when óoî geí íhe caêeI ask îs ío paó óoî back. pend îs íhe báll
and pêoof of anó paóãení óoî ãade.
voî ãaó geí a báll fêoã íhe pêovádeê askáng foê paóãení íhaí óoî íhánk óoî do noí owe. pend îs íhe báll and pêoof of anó paóãení óoî ãade.
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NON
Chapíeê TW Askáng îs ío paó a báll óoî have
goííen foê coveêed seêváces oê dêîgs
ff íhe pêovádeê shoîld be paádI we wáll paó íhe pêovádeê dáêecíló.
ff óoî have alêeadó paád foê íhe seêváceI we wáll paó óoî back.
2. When a network provider sends you a bill
keíwoêk pêovádeês ãîsí alwaós báll îs.
theneveê óoî geí a báll fêoã a neíwoêk pêovádeêI send îs íhe báll. te wáll coníací íhe
pêovádeê dáêecíló and íake caêe of íhe pêobleã.
ff óoî have alêeadó paád a báll fêoã a neíwoêk pêovádeêI send îs íhe báll and pêoof of anó
paóãení óoî ãade. te wáll paó óoî back foê óoîê coveêed seêváces.
3. When you use an out-of-network pharmacy to get a prescription filled
ff óoî go ío an oîíJofJneíwoêk phaêãacóI óoî wáll have ío paó íhe fîll cosí of óoîê
pêescêápíáon.
 fn onló a few casesI we wáll coveê pêescêápíáons fálled aí oîíJofJneíwoêk phaêãacáes.
pend îs a copó of óoîê êeceápí when óoî ask îs ío paó óoî back. mlease see Chapíeê
RI pecíáon A ío leaên ãoêe aboîí oîíJofJneíwoêk phaêãacáes.
4. When you pay the full cost for a prescription because you do not have your plan
ID card with you
ff óoî do noí have óoîê plan fa caêd wáíh óoîI óoî can ask íhe phaêãacó ío call îs oê ío
look îp óoîê plan enêollãení ánfoêãaíáon. ff íhe phaêãacó cannoí geí íhe ánfoêãaíáon íheó
need êághí awaóI óoî ãaó have ío paó íhe fîll cosí of íhe pêescêápíáon óoîêself.
pend îs a copó of óoîê êeceápí when óoî ask îs ío paó óoî back.
5. When you pay the full cost for a prescription for a drug that is not covered
voî ãaó paó íhe fîll cosí of íhe pêescêápíáon becaîse íhe dêîg ás noí coveêed.
qhe dêîg ãaó noí be on oîê List of Covered Drugs Eaêîg iásíFI oê áí coîld have a
êeqîáêeãení oê êesíêácíáon íhaí óoî dád noí know aboîí oê do noí íhánk shoîld appló ío
óoî. ff óoî decáde ío geí íhe dêîgI óoî ãaó need ío paó íhe fîll cosí foê áí.
ff óoî do noí paó foê íhe dêîg bîí íhánk áí shoîld be coveêedI óoî can ask foê a coveêage
decásáon Esee Chapíeê VI pecíáon R.OF.
ff óoî and óoîê docíoê oê oíheê pêescêábeê íhánk óoî need íhe dêîg êághí awaóI óoî can
ask foê a fasí coveêage decásáon Esee Chapíeê VI pecíáon R.OF.
pend îs a copó of óoîê êeceápí when óoî ask îs ío paó óoî back. fn soãe sáíîaíáonsI we
ãaó need ío geí ãoêe ánfoêãaíáon fêoã óoîê docíoê oê oíheê pêescêábeê án oêdeê ío paó
óoî back foê íhe dêîg.
?
NOO
then óoî send îs a êeqîesí foê paóãeníI we wáll êeváew óoîê êeqîesí and decáde wheíheê
the service or drug should be covered. This is called making a "coverage decision.´ If we
decáde áí shoîld be coveêedI we wáll paó foê íhe seêváce oê dêîg. ff we denó óoîê êeqîesí foê
paóãeníI óoî can appeal oîê decásáon.
 qo leaên how ío ãake an appealI see Chapíeê V.
B. How and where to send us your request for payment
pend îs óoîê báll and pêoof of anó paóãení óoî have ãade. mêoof of paóãení can be a copó
of íhe check óoî wêoíe oê a êeceápí fêoã íhe pêovádeê. fí ás a good ádea ío ãake a copó of óoîê
báll and êeceápís foê óoîê êecoêds.
voî can ask óoîê case ãanageê foê help. jaál oê fax óoîê êeqîesí foê paóãení íogeíheê wáíh
anó bálls oê êeceápís ío îs aí íhás addêessW
NOVMM maêk mlaza aêáveI píe. NRM
jpJSNRM
caxW NJUUUJQOSJRMUT
voî ãaó also call îs ío êeqîesí paóãení. Call jeãbeê peêváces aí NJUUUJPRMJPQQT Eqqv
TNNFI jondaó íhêoîgh cêádaó fêoã UWMM a.ã. ío UWMM p.ã.
You must submit your claim to us within 90 days of íhe daíe óoî goí íhe seêváceI áíeãI oê
dêîg.
C. We will make a coverage decision
then we geí óoîê êeqîesí foê paóãeníI we wáll ãake a coverage decision. qhás ãeans íhaí
we wáll decáde wheíheê óoîê healíh caêe oê dêîg ás coveêed bó oîê plan. te wáll also decáde
íhe aãoîní of ãoneóI áf anóI óoî have ío paó foê íhe healíh caêe oê dêîg.
te wáll leí óoî know áf we need ãoêe ánfoêãaíáon fêoã óoî.
ff we decáde íhaí íhe healíh caêe oê dêîg ás coveêed and óoî followed all íhe êîles foê
geííáng áíI we wáll paó foê áí. ff óoî have alêeadó paád foê íhe seêváce oê dêîgI we wáll ãaál
óoî a check foê whaí óoî paád. ff óoî have noí paád foê íhe seêváce oê dêîg óeíI we wáll
paó íhe pêovádeê dáêecíló.
 Chapíeê P explaáns íhe êîles foê geííáng óoîê seêváces coveêed. Chapíeê R explaáns íhe
êîles foê geííáng óoîê jedácaêe maêí a pêescêápíáon dêîgs coveêed.
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NOP
ff we decáde noí ío paó foê íhe seêváce oê dêîgI we wáll send óoî a leííeê explaánáng whó noí.
qhe leííeê wáll also explaán óoîê êághís ío ãake an appeal.
 qo leaên ãoêe aboîí coveêage decásáonsI see Chapíeê VI pecíáon Q.
D. You can make an appeal
ff óoî íhánk we ãade a ãásíake án íîênáng down óoîê êeqîesí foê paóãeníI óoî can ask îs ío
change oîê decásáon. qhás ás called making an appeal. voî can also ãake an appeal áf óoî do
noí agêee wáíh íhe aãoîní we paó.
 qhe appeals pêocess ás a foêãal pêocess wáíh deíaáled pêocedîêes and áãpoêíaní
deadlánes. qo leaên ãoêe aboîí appealsI see Chapíeê V.
ff óoî waní ío ãake an appeal aboîí geííáng paád back foê a healíh caêe seêváceI go ío
page NQV.
ff óoî waní ío ãake an appeal aboîí geííáng paád back foê a dêîgI go ío page NSS.
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NOQ
Chapter 8: Your rights and responsibilities
Table of Contents
fníêodîcíáon ....................................................................................................................................NOS
A. voî have a êághí ío geí ánfoêãaíáon án a waó íhaí ãeeís óoîê needs ..........................................NOS
B. te ãîsí íêeaí óoî wáíh êespecíI faáênessI and dágnáíó aí all íáães...............................................NPN
C. te ãîsí ensîêe íhaí óoî geí íáãeló access ío coveêed seêváces and dêîgs ...............................NPO
D. te ãîsí pêoíecí óoîê peêsonal healíh ánfoêãaíáon .....................................................................NPP
eow we pêoíecí óoîê healíh ánfoêãaíáon....................................................................................NPP
voî have a êághí ío see óoîê ãedácal êecoêds...........................................................................NPP
E. te ãîsí gáve óoî ánfoêãaíáon aboîí oîê planI oîê neíwoêk pêovádeêsI
and óoîê coveêed seêváces .........................................................................................................NPQ
F. keíwoêk pêovádeês cannoí báll óoî dáêecíló ..................................................................................NPR
G. voî have íhe êághí ío leave oîê Cal jedáConnecí plan aí anó íáãe ............................................NPR
H. voî have a êághí ío ãake decásáons aboîí óoîê healíh caêe .......................................................NPR
voî have íhe êághí ío know óoîê íêeaíãení opíáons and ãake decásáons aboîí óoîê healíh caêe..............................................................................................................NPR
voî have íhe êághí ío saó whaí óoî waní ío happen áf óoî aêe înable ío ãake healíh caêe decásáons foê óoîêself................................................................................NPS
thaí ío do áf óoîê ánsíêîcíáons aêe noí followed ........................................................................NPT
I. voî have íhe êághí ío ãake coãplaánís and ío ask îs ío êeconsádeê
decásáons we have ãade ...........................................................................................................NPT
thaí ío do áf óoî beláeve óoî aêe beáng íêeaíed înfaáêló oê óoîê êághís
aêe noí beáng êespecíed............................................................................................................NPT
eow ío geí ãoêe ánfoêãaíáon aboîí óoîê êághís .........................................................................NPT
J. voî also have êesponsábáláíáes as a ãeãbeê of íhe plan.............................................................NPU
?
NOR
Chapíeê UW voîê êághís and êesponsábáláíáes
Introduction
fn íhás chapíeêI óoî wáll fánd óoîê êághís and êesponsábáláíáes as a ãeãbeê of íhe plan. te ãîsí
honoê óoîê êághís.
A. You have a right to get information in a way that meets your
needs
te ãîsí íell óoî aboîí íhe plan’s benefits and your rights in a way that you can understand.
te ãîsí íell óoî aboîí óoîê êághís each óeaê íhaí óoî aêe án oîê plan.
 qo geí ánfoêãaíáon án a waó íhaí óoî can îndeêsíandI call jeãbeê peêváces. lîê plan has
people who can answeê qîesíáons án dáffeêení langîages.
 lîê plan can also gáve óoî ãaíeêáals án foêãaís sîch as laêge pêáníI bêaálleI oê aîdáo. voî
can call jeãbeê peêváces and ask ío have íhás ánfoêãaíáon sení ío óoî án ppanáshI
CháneseI AêãenáanI hoêeanI oîssáanI sáeínaãeseI caêsáI qagalogI hhãeê oê Aêabác. te
can also gáve óoî ánfoêãaíáon án Bêaálle oê laêge pêání.
 ff óoî aêe haváng íêoîble geííáng ánfoêãaíáon fêoã oîê plan becaîse of langîage pêobleãs
oê a dásabáláíó and óoî waní ío fále a coãplaáníI call jedácaêe aí NJUMMJjbafCAob
ENJUMMJSPPJQOOTF. voî can call OQ hoîês a daóI seven daós a week. qqv îseês shoîld call
NJUTTJQUSJOMQU. voî can ãake a coãplaání aboîí Caêejoêe Cal jedáConnecí mlan ío íhe
Cal jedáConnecí lãbîds pêogêaã bó calláng NJURRJRMNJPMTT Eqqv TNNF.
.ΎϧΗρΧ ϥϣο Ϫϳϓ ϥϭϛΗ ϡΎϋ ϝϛ ϲϓ ϙϗϭϘΣΑ ϙέΑΧϧ ϥ΃ ΏΟϳ
ϥϳΫϟ΍ ϥϳϔυϭϣϟ΍ ϥϣ ΓίϳϣΗϣ ΔϋϭϣΟϣ ΎϧΗρΧ ϥϣοΗΗ .Member Services ϡγϘΑ ϝλΗ΍ ˬΎϬϣϬϔΗ ϥ΃ ϥϛϣϳ ΔϘϳέρΑ ΕΎϣϭϠόϣ ϰϠϋ ϝϭλΣϠϟ ←
.ΔϔϠΗΧϣ Ε
˳ ΎϐϠΑ ΔϠ΋γϷ΍ ϰϠϋ ΔΑΎΟϹ΍ ϡϬϧϛϣϳ
˱ ϣ Ύο
˱ ϳ΃ ΎϧΗρΧ ϙϟ έϓϭΗ ϥ΃ ϥϛϣϳ ←
ϝλΗΗ ϥ΃ ϙϧϛϣϳ .ΔϳΗϭλ Ε
˳ ΎϔϠϣ ϭ΃ ϥϳϓϭϔϛϣϠϟ ϝϳέΑ ΔϘϳέρΑ ϭ΃ ΓέϳΑϛ ϑϭέΣΑ ΔϋΎΑρϟ΍ ϝΛϣ ΕΎϘϳγϧΗΑ ΍Ω΍ϭ
ϭ΃ Δϳέϭϛϟ΍ ϭ΃ ΔϳϧϳϣέϷ΍ ϭ΃ Δϳϧϳλϟ΍ ϭ΃ ΔϳϧΎΑγϹ΍ ϭ΃ ΔϳΑέόϟ΍ ΔϐϠϟΎΑ ΕΎϣϭϠόϣϟ΍ ϩΫϫ ϙϟ ΍ϭϠγέϳ ϥ΃ ϡϬϧϣ ΏϠρΗϭ Member Services ϡγϘΑ
ϑϭέΣΑ ΔϋΎΑρϟ΍ ϭ΃ ϥϳϓϭϔϛϣϠϟ ϝϳέΑ ΔϘϳέρΑ ΕΎϣϭϠόϣ ϙϟ έϓϭϧ ϥ΃ Ύϧϧϛϣϳ Ύϣϛ .ΔϳέϳϣΧϟ΍ ϭ΃ ΔϳϏϭϟΎϏΎΗϟ΍ ϭ΃ ΔϳγέΎϔϟ΍ ϭ΃ ΔϳϣΎϧΗϳϔϟ΍ ϭ΃ Δϳγϭέϟ΍
.ΓέϳΑϛ
MEDICARE
˰Α ϝλΗ΍ ˬϯϭϛη ϡϳΩϘΗ ΩϳέΗϭ ΔϗΎϋϹ΍ ϭ΃ ΔϐϠϟ΍ ϝϛΎηϣ ΏΑγΑ ΎϧΗρΧ ϥϣ ΕΎϣϭϠόϣϟ΍ ϰϠϋ ϝϭλΣϟ΍ ϲϓ Δ˱ Ϡϛηϣ ϪΟ΍ϭΗ Εϧϛ ΍Ϋ· ←
.(1-800-633-4227) 1-800
ϡϗέϟ΍ ϰϠϋ
ϡϳΩϘΗ ϙϧϛϣϳ .2048-486-877-1
ϡϗέϟ΍ ϰϠϋ ϝΎλΗϻ΍ TTY
ϲϣΩΧΗγϣϟ ϲϐΑϧϳ .ωϭΑγϷ΍ ϡΎϳ΃ ϝ΍ϭρ ΔϋΎγϟ΍ έ΍Ωϣ ϰϠϋ ϝΎλΗϻ΍ ϙϧϛϣϳ ←
ϰϠϋ ϝΎλΗϻ΍ ϝϼΧ ϥϣ Cal MediConnect Ombuds ΞϣΎϧέΑ ϰϟ· CareMore Cal MediConnect Plan ιϭλΧΑ ϯϭϛη
.1-855-501-3077 (TTY:711)
?
NOS
Մենք պարտավոր ենք հայտնել ձեզ պլանի նպաստների և ձեր իրավունքների մասին այն
ձևով, որն ընկալելի է ձեզ համար: Մենք պետք է պատմենք ձեզ ձեր իրավունքների մասին
յուրաքանչյուր տարի, երբ դուք գտնվում եք մեր պլանում:
 Որպեսզի ստանաք տեղեկություն ձեզ համար ընկալելի ձևով, զանգահարեք
Հաճախորդների սպասարկման բաժին: Մեր պլանում կան մարդիկ, ովքեր կարող են
պատասխանել հարցերին տարբեր լեզուներով:
 Մեր պլանը կարող է նույնպես տրամադրել այս նյութերը այլ ձևաչափերով, օրինակ,
խոշոր տառաչափ, Բրելյան տառատեսակ կամ ձայնային կրիչների վրա: Կարող եք
զանգահարել Հաճախորդների սպասարկման բաժին և խնդրել, որպեսզի այս
տեղեկատվությունը ձեզ ուղարկվի իսպաներեն, չինարեն, հայերեն, կորեերեն,
ռւոսերեն, վիեթնամերեն, պարսկերեն, թագալերեն, քմերեն կամ արաբերեն լեզվով:
Մենք նաև կարող ենք տրամադրել տեղեկություններ Բրելյան տառատեսակով և խոշոր
տառաչափով:
 Եթե դուք մեր պլանից տեղեկություն ստանալու դժվարություններ ունեք լեզվական
խնդիրների կամ հաշմանդամության պատճառով և ցանկանում եք բողոք ներկայացնել,
զանգահարեք Medicare 1-800-MEDICARE
(1-800-633-4227) հեռախոսահամարով: Կարող եք զանգահարել օրական 24 ժամ,
շաբաթական 7 օր: TTY օգտվողները պետք է զանգահարեն՝ 1-877-486-2048: Դուք կարող
եք ձեր բողոքը CareMore Cal MediConnect Plan-ի մասին ներկայացնել Cal MediConnect
Ombuds ծրագրին՝ զանգահարելով 1-855-501-3077 (TTY՝ 711):
.ϡϳϫΩ ΢ϳοϭΗ Ύϣη ϪΑ ϥΎΗϕϭϘΣ ϩέΎΑέΩ ˬΩϳΗγϫ ϭοϋ Ύϣ ϪϣΎϧέΑ έΩ Ύϣη Ϫ̯ ̶ϟΎγ έϫ
‫رح‬ς .‫اس ة̴ٌرًد‬ϥΘ jeãbeê peêváces ‫ ةا ةغش‬،‫ قاةل ػرک ةاصد‬Ϧ‫ ةه ٍ̳نها̵ که ةراًتا‬Ζ‫الغا‬ς‫ ا‬Η‫ ػرًاق‬Ηً‫ ج‬
.
‫ا جٍاب ػوند‬ϥ‫ ص‬Ζٚ‫ف ةه سؤا‬ϡ‫غت‬Ϥ ̵‫وا‬Ϧ‫ٍانند ةه زةا‬Θ‫گ‬Ϥ ‫ اقراػ̵ را ػارػ که‬،‫ا‬Ϥ
̵
‫ عط ةرًل *ةرا‬،)‫ةٌنا‬ϣ‫ *ةرا̵ اقراػ ک‬Η‫انند چاپ ػرص‬Ϥ ‫ف‬ϡ‫غت‬Ϥ ̵‫ را ػر صڪلوا‬Ζ‫الغا‬ς‫ٍاند ا‬Θ‫گ‬Ϥ ϧٌ‫ڇن‬ϥ‫ا و‬Ϥ ‫رح‬ς 
‫اس ة̴ٌرًد ٌ ةغٍاوٌد‬ϥΘ jeãbeê peêváces ‫ٍانٌد ةا ةغش‬Θ‫گ‬Ϥ .‫ا ارائه ػود‬ϥ‫ ةه ص‬Ζٍٍ ‫ ٌ ًا ػر قامب‬،)‫اقراػ ناةٌنا‬
‫ر ٌ ًا غرةگ‬ϥ‫ ع‬،‫ا̳امٍګ‬Θ ،‫ قارسگ‬،‫گ‬Ϥ‫ ًٌتنا‬،‫ رٌسگ‬،̵‫ کرها‬،‫نگ‬Ϥ‫ ار‬،‫ چٌنگ‬،‫وا̵ اسپانٌاًگ‬Ϧ‫ ةه زةا‬Ζ‫الغا‬ς‫ ا‬ϧً‫که ا‬
‫ةٌنا) ًا ةه عط ةرًل‬ϣ‫ *ةرا̵ اقراػ ک‬Η‫ را ةه صڪل چاپ ػرص‬Ζ‫الغا‬ς‫ ا‬ϣٌ‫ٍان‬Θ‫گ‬Ϥ ‫ا‬Ϥ ϧٌ‫ڇن‬ϥ‫ و‬.
‫ا ارسال صٍػ‬ϥ‫ةرا̵ ص‬
.ϣٌ‫ا ارائه ػو‬ϥ‫*ةرا̵ اقراػ ناةٌنا) ةه ص‬
‫ عٍػ‬Ηً‫گعٍاوٌد صڪا‬Ϥ ٌ ‫يڪل ػارًد‬Ϥ ‫ا‬Ϥ ‫ه‬Ϥ‫ از ةرنا‬Ζ‫الغا‬ς‫ ا‬Η‫ ػر ػرًاق‬،Ηٌ‫ٍم‬ϡ‫ػ‬Ϥ ‫ زةانگ ًا‬Ζ‫يڪال‬Ϥ ‫ ا̳ر ةه ػمٌل‬
.‫اس ة̴ٌرًد‬ϥΘ ENJUMMJSPPJQOOTF NJUMMJjbafCAob
‫اره‬ϥ‫ا ةرسانٌد ةا ص‬Ϥ ‫را ةه ٍ̳ش‬
ϩέΎϣη ΎΑ Ωϧϧ΍ϭΗ̶ϣ ̟ϳΎΗϪϠΗ ϥ΍έΑέΎ̯ .Ωϳέϳ̴Α αΎϣΗ ϩέΎϣη ϥϳ΍ ΎΑ ϪΗϔϫ ίϭέ 7
ϭ ίϭέ ΕϋΎγ 24
ϡΎϣΗ έΩ Ωϳϧ΍ϭΗ̶ϣ Ύϣη1-877-486-2048
ί΍ ΕϳΎ̰η ̵΍έΑ Ωϳϧ΍ϭΗ̶ϣ ϥϳϧ̩ϣϫ .
Ωϧέϳ̴Α αΎϣΗCareMore Cal MediConnect Plan ϪΑ Cal MediConnect Ombuds ϩέΎϣη ΎΑ
1-855-501-3077
:̟ϳΎΗϪϠΗ ϩέΎϣη)
.Ωϳέϳ̴Α αΎϣΗ 711.
យ ើងត្រវតរត្ាប់
ូ
អ្ន កអ្ំពីផលត្បយោជន៍របសតផនការយនេះ
់
និងសិទ្ធ ិរបស់អ្ន កកងរយបៀបម
នុ
ួ តែលអ្ក
ន
អាច ល់ាន ។ យ ើងត្រវតរត្ាប់
ូ
អ្ន កអ្ំពីសិទ្ធ ិរបស់អ្ន ក រាល់ឆ្ន ំនីមួ ៗតែលអ្កសិ
ន
ថ រកងតផនការរបស់
នុ
យ ើង ។
?
NOT
ិ ី ួ
ើ ី ួ
័ ៌
 យែមបទ្ទ្លានពរមានតាមវធម
តែលអ្កអាច
លាន
សមយៅទ្រសពយៅតផកយសវាកម
ន
់
ូ
ូ
ទ
ន
ម
បយត្មើសមាជិក។ តផនការរបស់យ ើងមានមនុសសតែលអាចយ្ើល សំណួ រនានាជាភាសាយផសងៗាន ។
 គយត្មាងរបស់យ
ើង ក៏អាចផល់
យផសងៗ ែចជា
អ្កសរពុមព ធំ អ្កសរ
ត ឲ្យអ្កនវឯកសារជាទ្ត្មង់
ន
ូ
ូ
សត្មាប់មនុសសខ្វក
អាចយៅទ្រសពយៅតផកយសវាសមាជិ
ក និងយសើន ឲ្យយគយផើ ញ
ា ់ ឬជាអ្ឌី
ូ
ូ ...។ អ្កក៏
ន
ូ
ទ
ន
ព័រ៌មានយនេះមកអ្ក
,
ន ជាភាសាយអ្សបញ ,ចិន ,អាយមនី ,កយរ
ូ ៉េ ,រុសស សី ,យវៀរណាម ,ហ្វសុ
ា ី ,តាហ្វឡក
ា ស
តមរម ឬ អារាប។
ការតនក
មព ជា
៉េ ់ យ ើងមំ្ ុ ក៏អាចផល់
ដ ព័រ៌មានជនអ្កជាអ្កសរជនពិ
ូ
ន
ន ឬអ្របទ្យាេះពុ
ថ
អ្កសរធំៗផងតែរ។
ា
ួ
 ត្បសិនយបើអ្ន កកំពុងមានបញ្ហជាម
ការទ្ទ្លានព័
រ៌មានពីគយត្មាងរបស់យ ង
ើ ម្ ុ ំ យោ សារតរ
ួ
បញ្ហភាសា
ឬពការភាព
យ ើ អ្កចង់
យរៀបចំបណឹត ង សមយៅទ្រសពយៅកាន
ា
ិ
ន
ូ
ូ
ទ
់ Medicare តាមរ ៈ
យលម (4227-633-800-MEDICARE (1-800-1 ។ អ្កអាចយៅទ្រសព
ន
ូ
ទ 24 យមាងកងម
នុ
ួ ថ្ងៃ ត្ាំពីរ
ថ្ងកងម
ត្ាស់ TTY សមយៅទ្រសពមកយលម2048-486-877-1
។ អ្កអាច
ៃ នុ
ួ សាត ៍ ។ អ្កយត្បើ
ន
ូ
ូ
ទ
ន
ោក់បណឹត ងអ្ំពីគយត្មាង CareMore Cal MediConnect Plan យៅកានកមវធCal
MediConnect
់
ម ិ ី
Ombudsយោ យៅទ្រសពយៅកាន់
យលម(TTY: 711) 3077-501-855-1 ។.
ូ
ទ
이 플랜의 이점과 귀하의 권리에 대해 말씀 드리겠습니다. 이 플랜에 등록할 경우, 귀하의 연간
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귀하의 모국어로 이 플랜을 설명해
드립니다.
 이 플랜은 대형 인쇄물, 점자 또는 오디오 자료로 준비되어 있습니다. 회원 전용 서비스에
문의하여 이 정보를 스페인어, 중국에, 아르메니아어, 한국어, 러시아어, 베트남어,
페르시아어, 필리핀어, 쿠메르어 또는 아랍어로 보내달라고 요청하십시오. 정보를 점자
또는 대형 인쇄물로 제공합니다.
 언어 문제 또는 장애로 인해CareMore Cal MediConnect Plan 에 따른 정보를 얻지 못할
경우, Medicare로 문의하십시오(1-800-MEDICARE(1-800-633-4227). 상기 번호는
하루에 24시간 이용할 수 있으며, 연중 무휴입니다. TTY 사용자는 1-877-486-2048을
이용하십시오. CareMore Cal MediConnect Plan 에 불만이 있는 경우, Cal MediConnect
Ombuds 프로그램에 문의하십시오(전화: 1-855-501-3077 (TTY 711).
О том, что входит в план обслуживания, и о ваших правах мы должны сообщать вам в
понятной для вас форме. Пока вы остаетесь участником нашего плана, мы должны
каждый год сообщать вам о ваших правах.
 Для того чтобы получить информацию в удобной для вас форме, позвоните в отдел
обслуживания. У нас работают люди, которые могут отвечать на вопросы
участников, говорящих на разных языках.
 Наш план также может предоставить вам материалы не только на английском, но и
на других языках, и в таких форматах как с увеличенным шрифтом, со шрифтом
Брайля или в аудиоформате. Вы можете позвонить в отдел обслуживания и
попросить нас переслать вам эту информацию в переводе на испанский, китайский,
армянский, корейский, русский, вьетнамский, фарси, тагальский, кхмерский или
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арабский язык. Кроме того, мы можем присылать вам наши материалы,
напечатанные шрифтом Брайля или крупным шрифтом.
 Если изJза недостаточного знания языка или изJза инвалидности вам трудно
получить информацию от нашего плана и вы хотите подать жалобу, позвоните в
jedácaêe по телефону 1JUMMJjbafCAob ENJUMMJSPPJ4227). Звонить можно
круглосуточно и без выходных. Пользователям qqv следует звонить по телефону 1
UTTJQUSJ2048. Жалобу на план Caêejoêe Cal jedáConnecí mlan вы можете подать
омбудсмену программы Cal jedáConnecí по телефону 1JURRJRMNJPMTT Eqqv TNNF.
aebeãos ánfoêãaêle sobêe los benefácáos del plan ó sîs deêechos de ãaneêa qîe pîeda coãpêendeêlos. aebeãos ánfoêãaêle sobêe sîs deêechos dîêaníe cada año qîe esíé en
nîesíêo plan.
 ilaãe a peêvácáos paêa ãáeãbêos paêa obíeneê ánfoêãacáón de îna ãaneêa qîe pîeda
coãpêendeê. kîesíêo plan cîenía con peêsonas qîe pîeden êespondeê pêegînías en
dáfeêeníes ádáoãas.
 kîesíêo plan íaãbáén pîede eníêegaêle ãaíeêáales en foêãaíos coão leíêa gêandeI Bêaálle
o aîdáo. mîede llaãaê a peêvácáos paêa ãáeãbêos ó solácáíaê qîe se le envíe esía
ánfoêãacáón en españolI chánoI aêãenáoI coêeanoI êîsoI váeínaãáíaI peêsaI íagaloI âeãeê o áêabe. qaãbáén podeãos daêle ánfoêãacáón en Bêaálle o leíêa gêande.
 pá íáene pêobleãas paêa obíeneê ánfoêãacáón de nîesíêo plan poê pêobleãas de ádáoãa o
îna dáscapacádad ó desea pêeseníaê îna qîeâaI llaãe a jedácaêe al NJUMMJjbafCAob EN
UMMJSPPJQOOTF. mîede llaãaê OQ hoêas al díaI los sáeíe días de la seãana. ios îsîaêáos
de qqv deben llaãaê al NJUTTJQUSJOMQU. mîede pêeseníaê îna qîeâa sobêe Caêejoêe Cal
jedáConnecí mlan al Cal jedáConnecí lãbîds mêogêaã al íeléfono NJURRJRMNJPMTT
Eqqv TNNF.
haálangan naãáng sabáhán sa ánóo ang íîngkol sa ãga benepásóo ng plano aí sa ánóong ãga
kaêapaían sa paêaang ãaîînawaan nánóo. haálangan naãáng sabáhán sa ánóo ang íîngkol sa
ánóong ãga kaêapaían sa bawaí íaon na kaóo aó nasa aãáng plano.
 rpang ãakakîha ng áãpoêãasóon sa paêaang ãaîînawaan nánóoI íîãawag sa jga
peêbásóo paêa sa hasapá. pa aãáng plano aó ãaó ãga íaong ãakakasagoí sa ãga íanong
sa ábaDí ábang wáka.
 jabábágóan êán kaóo ng aãáng plano ng ãga ãaíeêóal sa ãga foêãaí íîlad ng ãalakáng
pagkaJpêáníI bêaálleI o aîdáo. jaaaêá kaóong íîãawag sa jga peêbásóo paêa sa hasapá aí
hángán na ápadala ang áãpoêãasóong áío sa ánóo sa bspanóolI CháneseI AêãenáanI
hoêeanoI oîsoI sáeínaãeseI caêsáI qagalogI hhãeê o Aêabác. jabábágóan êán naãán kaóo
ng áãpoêãasóon sa Bêaálle o sa ãalakáng pagkaJpêání.
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 hîng nagkakapêobleãa kaóo sa pagkîha ng áãpoêãasóon sa aãáng plano dahál sa ãga
pêobleãa sa wáka o dahál sa kapansanan aí gîsío nánóong ãaghaán ng êeklaão. íîãawag
sa jedácaêe sa NJUMMJjbafCAob ENJUMMJSPPJQOOTF. jaaaêá kaóong íîãawag OQ na oêas
bawaí aêawI páíong aêaw bawaí lánggo. Ang ãga gîãagaãáí ng qqv aó dapaí íîãawag sa
NJUTTJQUSJOMQU. jaaaêá kaóong ãagêeklaão íîngkol sa Caêejoêe Cal jedáConnecí mlan
sa pêogêaãa na Cal jedáConnecí lãbîds sa paãaãagáían ng pagíawag sa NJURRJRMN
PMTT Eqqv TNNF.
Chúng íôá phảá cho qîý vị báếí về các phúc lợá của chương trînh cũng như các quyền của qîý
vị íheo cách íhức qîý vị có íhể háểu được. Chúng íôá phảá cho qîý vị báếí về các qîóền của qîý
vị ãỗi năm quý vị tham gia chương trînh của chúng íôá.
 Để nhận được íhông íán íheo cách qîý vị có íhể háểu đượcI hãó gọá jeãbeê peêváces
Eaịch sụ eội Viên). Chương trînh của chúng íôá có những ngườá có íhể íêả lờá các íhắc
ãắc bằng nháềî ngôn ngữ khác nhaî.
 Chương trînh của chúng tôi cũng có thể cîng cấp cho qîý vị íàá láệî bằng các định dạng
như bản án chữ lớnI chữ nổá Bêaálle hoặc bản âã íhanh. nîý vị có íhể gọá jeãbeê
peêváces và óýî cầî gửá íhông íán nàó cho qîý vị bằng íáếng qâó Ban khaI íáếng qêîngI
íáếng AêãenáaI íáếng eànI íáếng kgaI íáếng sáệíI íáếng Ba Tư, tiếng qagalogI íáếng hhãeê
haó íáếng ẢJêập. Chúng tôi cũng có thể cîng cấp cho qîý vị íhông íán bằng chữ nổá Bêaálle
hoặc bản án chữ lớn.
 kếî qîý vị đang gặp khó khăn khi nhận íhông íán íừ chương trînh của chúng íôá do vấn đề
ngôn ngữ hoặc khîóếí íậí và qîý vị ãîốn nộp đơn khiếî nạáI xán gọá jedácaêe íheo số N
UMMJjbafCAob ENJUMMJSPPJQOOTF. nîý vị có íhể gọi đến vào OQ gáờ íêong ngàóI bảó ngàó
íêong íîần. Ngườá dùng qqv hãó gọá số NJUTTJQUSJOMQU. nîý vị có íhể kháếî nạá về
Caêejoêe Cal jedáConnecí mlan cho chương trînh Cal MediConnect Ombuds bằng cách
gọá số NJURRJRMNJPMTT Eqqv TNNF.
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B. We must treat you with respect, fairness, and dignity at all times
te ãîsí obeó laws íhaí pêoíecí óoî fêoã dáscêáãánaíáon oê înfaáê íêeaíãení. We do not
discriminate agaánsí ãeãbeês becaîse of anó of íhe followángW
Age
jedácal hásíoêó
Appeals
jeníal abáláíó
Behaváoê
jeníal oê phósácal dásabáláíó
Claáãs expeêáence
kaíáonal oêágán
bíhnácáíó
oace
bvádence of ánsîêabáláíó
oeceápí of healíh caêe
deneíác ánfoêãaíáon
oelágáon
deogêaphác locaíáon wáíhán íhe
seêváce aêea
pex
eealíh síaíîs
pexîal oêáeníaíáon
rse of seêváces
rndeê íhe êîles of oîê planI óoî have íhe êághí ío be fêee of anó foêã of phósácal êesíêaání oê
seclîsáon íhaí woîld be îsed as a ãeans of coeêcáonI foêceI dáscápláneI convenáence oê
êeíaláaíáon.
te cannoí denó seêváces ío óoî oê pînásh óoî foê exeêcásáng óoîê êághís.
 coê ãoêe ánfoêãaíáonI oê áf óoî have conceêns aboîí dáscêáãánaíáon oê înfaáê íêeaíãeníI call
the Department of Health and Human Services’ Office for Civil Rights aí NJUMMJPSUJNMNV
Eqqv NJUMMJRPTJTSVTF. voî can also call óoîê local lffáce foê Cávál oághís. Call íhe ios
Angeles Coîníó Cávál oághís aáscêáãánaíáon Coãplaání eoíláne aí RSOJVMUJURMN.
 ff óoî have a dásabáláíó and need help accessáng caêe oê a pêovádeêI call jeãbeê peêváces.
ff óoî have a coãplaáníI sîch as a pêobleã wáíh wheelchaáê accessI jeãbeê peêváces can
help.
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C. We must ensure that you get timely access to covered services
and drugs
ff óoî cannoí geí seêváces wáíhán a êeasonable aãoîní of íáãeI we have ío paó foê oîíJof
neíwoêk caêe.
As a ãeãbeê of oîê planW
voî have íhe êághí ío choose a pêáãaêó caêe pêovádeê EmCmF án oîê neíwoêk. A network
provider ás a pêovádeê who woêks wáíh îs.
» Call jeãbeê peêváces oê look án íhe Provider and Pharmacy Directory ío leaên whách
docíoês aêe accepíáng new paíáenís.
toãen have íhe êáght to go to a gynecologist or another women’s health specialist without
geííáng a êefeêêal. A referral ás a wêáííen oêdeê fêoã óoîê pêáãaêó caêe pêovádeê.
voî have íhe êághí ío geí coveêed seêváces fêoã neíwoêk pêovádeês wáíhán a êeasonable
aãoîní of íáãe.
» qhás ánclîdes íhe êághí ío geí íáãeló seêváces fêoã specáalásís.
voî have íhe êághí ío geí eãeêgencó seêváces oê caêe íhaí ás îêgeníló needed wáíhoîí pêáoê
appêoval.
voî have íhe êághí ío geí óoîê pêescêápíáons fálled aí anó of oîê neíwoêk phaêãacáes wáíhoîí
long delaós.
voî have íhe êághí ío know when óoî can see an oîíJofJneíwoêk pêovádeê. qo leaên aboîí
oîíJofJneíwoêk pêovádeêsI see Chapíeê PI pecíáon a.
then óoî fáêsí âoán oîê planI óoî have íhe êághí ío keep óoîê cîêêení pêovádeês and seêváce
aîíhoêázaíáons foê îp ío S ãoníhs foê jedácaêe seêváces and îp ío NO ãoníhs foê jedáJ
Cal seêváces áf ceêíaán cêáíeêáa aêe ãeí. qo leaên ãoêe aboîí keepáng óoîê pêovádeês and
seêváce aîíhoêázaíáonsI see Chapíeê NI pecíáon c.
voî have íhe êághí ío háêeI fáêeI and ãanage óoîê fnJeoãe peêváces and pîppoêís EfeppF
woêkeê.
voî have íhe êághí ío selfJdáêecí caêe wáíh help fêoã óoîê caêe íeaã and caêe ãanageê.
Chapíeê V íells whaí óoî can do áf óoî íhánk óoî aêe noí geííáng óoîê seêváces oê dêîgs wáíhán
a êeasonable aãoîní of íáãe. Chapíeê VI pecíáon R also íells whaí óoî can do áf we have
denáed coveêage foê óoîê seêváces oê dêîgs and óoî do noí agêee wáíh oîê decásáon.
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D. We must protect your personal health information
te pêoíecí óoîê peêsonal healíh ánfoêãaíáon as êeqîáêed bó fedeêal and síaíe laws.
voîê peêsonal healíh ánfoêãaíáon ánclîdes íhe ánfoêãaíáon óoî gave îs when óoî enêolled
án íhás plan. fí also ánclîdes óoîê ãedácal êecoêds and oíheê ãedácal and healíh
voî have êághís ío geí ánfoêãaíáon and ío coníêol how óoîê healíh ánfoêãaíáon ás îsed. te
gáve óoî a wêáííen noíáce íhaí íells aboîí íhese êághís and also explaáns how we pêoíecí
the privacy of your health information. The notice is called the "Notice of Privacy
Practice.´
How we protect your health information
te ãake sîêe íhaí înaîíhoêázed people do noí see oê change óoîê êecoêds.
fn ãosí sáíîaíáonsI we do noí gáve óoîê healíh ánfoêãaíáon ío anóone who ás noí pêovádáng
óoîê caêe oê paóáng foê óoîê caêe. ff we doI we are required to get written permission
from you first. têáííen peêãássáon can be gáven bó óoî oê bó soãeone who has íhe
legal poweê ío ãake decásáons foê óoî.
qheêe aêe ceêíaán cases when we do noí have ío geí óoîê wêáííen peêãássáon fáêsí. qhese
excepíáons aêe allowed oê êeqîáêed bó law.
» te aêe êeqîáêed ío êelease healíh ánfoêãaíáon ío goveênãení agencáes íhaí aêe
checkáng on oîê qîaláíó of caêe.
» te aêe êeqîáêed ío êelease healíh ánfoêãaíáon bó coîêí oêdeê.
» te aêe êeqîáêed ío gáve jedácaêe óoîê healíh and dêîg ánfoêãaíáon. ff jedácaêe
êeleases óoîê ánfoêãaíáon foê êeseaêch oê oíheê îsesI áí wáll be done accoêdáng ío
fedeêal laws. ff jedáJCal êeleases óoîê ánfoêãaíáon foê êeseaêch oê oíheê îsesI áí wáll
be done accoêdáng ío fedeêal and síaíe laws.
You have a right to see your medical records
voî have íhe êághí ío look aí óoîê ãedácal êecoêds and ío geí a copó of óoîê êecoêds. te
aêe allowed ío chaêge óoî a fee foê ãakáng a copó of óoîê ãedácal êecoêds.
voî have íhe êághí ío ask îs ío îpdaíe oê coêêecí óoîê ãedácal êecoêds. ff óoî ask îs ío do
íhásI we wáll woêk wáíh óoîê healíh caêe pêovádeê ío decáde wheíheê íhe changes shoîld
be ãade.
voî have íhe êághí ío know áf and how óoîê healíh ánfoêãaíáon has been shaêed wáíh oíheês.
ff óoî have qîesíáons oê conceêns aboîí íhe pêávacó of óoîê peêsonal healíh ánfoêãaíáonI call
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E. We must give you information about our plan, our network
providers, and your covered services
As a ãeãbeê of Caêejoêe Cal jedáConnecí mlanI óoî have íhe êághí ío geí ánfoêãaíáon fêoã
îs. ff óoî do noí speak bngláshI we have áníeêpêeíeê seêváces ío answeê anó qîesíáons óoî
ãaó have aboîí oîê healíh plan. qo geí an áníeêpêeíeêI âîsí call îs aí NJUUUJPRMJPQQT Eqqv
TNNFI jondaó íhêoîgh cêádaó fêoã U a.ã. ío U p.ã. qhás ás a fêee seêváce ío óoî. voî can call
jeãbeê peêváces and ask ío have íhás ánfoêãaíáon sení ío óoî án ppanáshI CháneseI
AêãenáanI hoêeanI oîssáanI sáeínaãeseI caêsáI qagalogI hhãeê oê Aêabác. te can also gáve
óoî ánfoêãaíáon án Bêaálle oê laêge pêání.
ff óoî waní anó of íhe followángI call jeãbeê peêvácesW
Information about how to choose or change plans
Information about our plan, including:
» cánancáal ánfoêãaíáon
» eow we have been êaíed bó plan ãeãbeês
» qhe nîãbeê of appeals ãade bó ãeãbeês » eow ío leave oîê plan
Information about our network providers and our network pharmacies, including:
» eow ío choose oê change pêáãaêó caêe pêovádeês
» qhe qîaláfácaíáons of oîê neíwoêk pêovádeês and phaêãacáes
» eow we paó íhe pêovádeês án oîê neíwoêk
Information about covered services and drugs and about rules you must follow,
including:
» peêváces and dêîgs coveêed bó oîê plan
» iáãáís ío óoîê coveêage and dêîgs
» oîles óoî ãîsí follow ío geí coveêed seêváces and dêîgs
Information about why something is not covered and what you can do about it,
including:
» Askáng îs ío pîí án wêáíáng whó soãeíháng ás noí coveêed
» Askáng îs ío change a decásáon we ãade
» Askáng îs ío paó foê a báll óoî have êeceáved
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F. Network providers cannot bill you directly
aocíoêsI hospáíalsI and oíheê pêovádeês án oîê neíwoêk cannoí ãake óoî paó foê coveêed
seêváces. qheó also cannoí chaêge óoî áf we paó less íhan íhe pêovádeê chaêged. qo leaên
whaí ío do áf a neíwoêk pêovádeê íêáes ío chaêge óoî foê coveêed seêvácesI see Chapíeê T.
G. You have the right to leave our Cal MediConnect plan at any time
ko one can ãake óoî síaó án oîê plan áf óoî do noí waní ío. voî can leave oîê plan aí anó
íáãe. ff óoî leave oîê planI óoî wáll síáll be án íhe jedácaêe and jedáJCal pêogêaãs. voî have
íhe êághí ío geí ãosí of óoîê healíh caêe seêváces íhêoîgh lêágánal jedácaêe oê a jedácaêe
Advaníage plan. voî can geí óoîê jedácaêe maêí a pêescêápíáon dêîg benefáís fêoã a
pêescêápíáon dêîg plan oê fêoã a jedácaêe Advaníage plan. voîê jedáJCal benefáís wáll be
offeêed íhêoîgh a jedáJCal ãanaged caêe plan of óoîê choáce.
mlease see Chapíeê NM foê ãoêe ánfoêãaíáon on leaváng oîê plan.
H. You have a right to make decisions about your health care
You have the right to know your treatment options and make decisions about
your health care
voî have íhe êághí ío geí fîll ánfoêãaíáon fêoã óoîê docíoês and oíheê healíh caêe pêovádeês
when óoî geí seêváces. voîê pêovádeês ãîsí explaán óoîê condáíáon and óoîê íêeaíãení
choáces in a way that you can understand.
Know your choices. voî have íhe êághí ío be íold aboîí all íhe kánds of íêeaíãení.
Know the risks. voî have íhe êághí ío be íold aboîí anó êásks ánvolved. voî ãîsí be íold
án advance áf anó seêváce oê íêeaíãení ás paêí of a êeseaêch expeêáãení. voî have íhe
êághí ío êefîse expeêáãeníal íêeaíãenís.
You can get a second opinion. voî have íhe êághí ío see anoíheê docíoê befoêe decádáng
on íêeaíãení.
You can say “no.´ You have the right to refuse any treatment. This includes the right to
leave a hospáíal oê oíheê ãedácal facáláíóI even áf óoîê docíoê adváses óoî noí ío. voî
also have íhe êághí ío síop íakáng a pêescêábed dêîg. ff óoî êefîse íêeaíãení oê síop
íakáng a pêescêábed dêîgI óoî wáll noí be dêopped fêoã oîê plan. eoweveêI áf óoî êefîse
íêeaíãení oê síop íakáng a dêîgI óoî accepí fîll êesponsábáláíó foê whaí happens ío óoî.
You can ask us to explain why a provider denied care. voî have íhe êághí ío geí an
explanaíáon fêoã îs áf a pêovádeê has denáed caêe íhaí óoî beláeve óoî shoîld geí.
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You can ask us to cover a service or drug that was denied or is usually not covered.
Chapíeê V íells how ío ask íhe plan foê a coveêage decásáon.
You have the right to say what you want to happen if you are unable to make
health care decisions for yourself
poãeíáães people aêe înable ío ãake healíh caêe decásáons foê íheãselves. Befoêe íhaí
happens ío óoîI óoî canW
cáll oîí a wêáííen foêã ío give someone the right to make health care decisions for
you.
Give your doctors written instructions aboîí how óoî waní íheã ío handle óoîê healíh caêe áf óoî becoãe înable ío ãake decásáons foê óoîêself.
qhe legal docîãení íhaí óoî can îse ío gáve óoîê dáêecíáons ás called an advance directive.
qheêe aêe dáffeêení íópes of advance dáêecíáves and dáffeêení naães foê íheã. bxaãples aêe a
living will and a power of attorney for health care.
voî do noí have ío îse an advance dáêecíáveI bîí óoî can áf óoî waní ío. eeêe ás whaí ío doW
Get the form. voî can geí a foêã fêoã óoîê docíoêI a lawóeêI a legal seêváces agencóI oê
a socáal woêkeê. lêganázaíáons íhaí gáve people ánfoêãaíáon aboîí jedácaêe oê jedáJCal
sîch as íhe Cáíó of ios Angeles aepaêíãení of Agáng oê íhe Caláfoênáa aepaêíãení of
eealíh peêváces ãaó also have advance dáêecíáve foêãs. voî can also coníací jeãbeê peêváces bó calláng NJUUUJPRMJPQQT Eqqv TNNF ío ask foê íhe foêãs.
Fill it out and sign the form. qhe foêã ás a legal docîãení. voî shoîld consádeê haváng a
lawóeê help óoî pêepaêe áí.
Give copies to people who need to know about it. voî shoîld gáve a copó of íhe foêã
ío óoîê docíoê. voî shoîld also gáve a copó ío íhe peêson óoî naãe as íhe one ío
ãake decásáons foê óoî. voî ãaó also waní ío gáve copáes ío close fêáends oê faãáló
ãeãbeês. Be sîêe ío keep a copó aí hoãe.
ff óoî aêe goáng ío be hospáíalázed and óoî have ságned an advance dáêecíáveI take a copy of
it to the hospital.
qhe hospáíal wáll ask óoî wheíheê óoî have ságned an advance dáêecíáve foêã and wheíheê
óoî have áí wáíh óoî.
ff óoî have noí ságned an advance dáêecíáve foêãI íhe hospáíal has foêãs avaálable and wáll
ask áf óoî waní ío ságn one.
Remember, it is your choice to fill out an advance directive or not.
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What to do if your instructions are not followed
ff óoî have ságned an advance dáêecíáveI and óoî beláeve íhaí a docíoê oê hospáíal dád noí
follow íhe ánsíêîcíáons án áíI óoî ãaó fále a coãplaání wáíhW
jedácal Boaêd of Caláfoênáa
Ceníêal Coãplaání rnáí
OMMR bveêgêeen píêeeíI pîáíe NOMM
pacêaãeníoI CA VRUNR
qoll cêeeW NJUMMJSPPJOPOO
I. You have the right to make complaints and to ask us to
reconsider decisions we have made
Chapíeê V íells whaí óoî can do áf óoî have anó pêobleãs oê conceêns aboîí óoîê coveêed
seêváces oê caêe. coê exaãpleI óoî coîld ask îs ío ãake a coveêage decásáonI ãake an
appeal ío change a coveêage decásáonI oê ãake a coãplaání.
voî have íhe êághí ío geí ánfoêãaíáon aboîí appeals and coãplaánís íhaí oíheê ãeãbeês have
fáled agaánsí oîê plan. qo geí íhás ánfoêãaíáonI call jeãbeê peêváces.
What to do if you believe you are being treated unfairly or your rights are not
being respected
ff óoî beláeve óoî have been íêeaíed înfaáêló²and áí ás not aboîí dáscêáãánaíáon foê íhe êeasons
lásíed on page NPO²óoî can geí help án íhese waósW
voî can call Member Services.
voî can call your local Health Insurance Counseling and Advocacy Program
(HICAP) program. coê deíaáls aboîí íhás oêganázaíáon and how ío coníací áíI see
Chapíeê O.
voî can call the Cal MediConnect Ombuds Program. coê deíaáls aboîí íhás oêganázaíáon and how ío coníací áíI see Chapíeê O.
voî can call Medicare aí NJUMMJjbafCAob ENJUMMJSPPJQOOTFI OQ hoîês a daóI seven
daós a week. qqv îseês shoîld call NJUTTJQUSJOMQU.
How to get more information about your rights
qheêe aêe seveêal waós ío geí ãoêe ánfoêãaíáon aboîí óoîê êághísW
voî can call Member Services.
voî can call your local Health Insurance Counseling and Advocacy Program
(HICAP) program. coê deíaáls aboîí íhás oêganázaíáon and how ío coníací áíI see
Chapíeê O.
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voî can call the Cal MediConnect Ombuds Program. coê deíaáls aboîí íhás oêganázaíáon and how ío coníací áíI see Chapíeê O.
voî can contact Medicare.
» You can visit the Medicare website to read or download "Medicare Rights &
mêoíecíáons.´ Edo ío híípWLLwww.ãedácaêe.govLmîblácaíáonsLmîbsLpdfLNNRPQ.pdf.F
» lê óoî can call NJUMMJjbafCAob ENJUMMJSPPJQOOTFI OQ hoîês a daóI T daós a week. qqv îseês shoîld call NJUTTJQUSJOMQU.
J. You also have responsibilities as a member of the plan
As a ãeãbeê of íhe planI óoî have a êesponsábáláíó ío do íhe íhángs íhaí aêe lásíed below. ff
óoî have anó qîesíáonsI call jeãbeê peêváces.
Read the Member Handbook to learn what is covered and what rules you need to
follow to get covered services and drugs.
» coê deíaáls aboîí óoîê coveêed seêvácesI see Chapíeês P and Q.qhose chapíeês íell
óoî whaí ás coveêedI whaí ás noí coveêedI whaí êîles óoî need ío followI and whaí
óoî paó.
» coê deíaáls aboîí óoîê coveêed dêîgsI see Chapíeês R and S.
Tell us about any other health or prescription drug coverage you have. mlease call
jeãbeê peêváces ío leí îs know.
» te aêe êeqîáêed ío ãake sîêe íhaí óoî aêe îsáng all of óoîê coveêage opíáons when
óoî êeceáve healíh caêe. qhás ás called coordination of benefits.
» coê ãoêe ánfoêãaíáon aboîí cooêdánaíáon of benefáísI see Chapíeê N.
Tell your doctor and other health care providers that you are enrolled in our plan.
phow óoîê plan fa caêd wheneveê óoî geí seêváces oê dêîgs.
Help your doctors and other health care providers give you the best care.
» dáve íheã íhe ánfoêãaíáon íheó need aboîí óoî and óoîê healíh. ieaên as ãîch as
óoî can aboîí óoîê healíh pêobleãs. collow íhe íêeaíãení plans and ánsíêîcíáons
íhaí óoî and óoîê pêovádeês agêee on.
» jake sîêe óoîê docíoês and oíheê pêovádeês know aboîí all of íhe dêîgs óoî aêe
íakáng. qhás ánclîdes pêescêápíáon dêîgsI oveêJíheJcoîníeê dêîgsI váíaãánsI and
sîppleãenís.
» ff óoî have anó qîesíáonsI be sîêe ío ask. voîê docíoês and oíheê pêovádeês ãîsí
explaán íhángs án a waó óoî can îndeêsíand. ff óoî ask a qîesíáon and óoî do noí
îndeêsíand íhe answeêI ask agaán.
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Be considerate. te expecí all oîê ãeãbeês ío êespecí íhe êághís of oíheê paíáenís. te
also expect you to act with respect in your doctor’s office, hospitals, and other
providers’ offices.
Pay what you owe. As a plan ãeãbeêI óoî aêe êesponsáble foê íhese paóãenísW
» jedácaêe maêí A and jedácaêe maêí B pêeãáîãs. coê ãosí Caêejoêe Cal
jedáConnecí mlan ãeãbeêsI jedáJCal paós foê óoîê maêí A pêeãáîã and óoîê maêí
B pêeãáîã.
» ff óoî geí anó seêváces oê dêîgs íhaí aêe noí coveêed bó oîê planI óoî ãîsí paó íhe
fîll cosí.
 ff óoî dásagêee wáíh oîê decásáon ío noí coveê a seêváce oê dêîgI óoî can ãake an
appeal. mlease see Chapíeê V ío leaên how ío ãake an appeal.
Tell us if you move. ff óoî aêe goáng ío ãoveI áí ás áãpoêíaní ío íell îs êághí awaó. Call
» If you move outside of our plan service area, you cannot be a member of our
plan. Chapíeê N íells aboîí oîê seêváce aêea. te can help óoî fágîêe oîí wheíheê
óoî aêe ãováng oîísáde oîê seêváce aêea. aîêáng a specáal enêollãení peêáodI óoî
can swáích ío lêágánal jedácaêe oê enêoll án a jedácaêe healíh oê pêescêápíáon dêîg
plan án óoîê new locaíáon. te can leí óoî know áf we have a plan án óoîê new aêea.
AlsoI be sîêe ío leí jedácaêe and jedáJCal know óoîê new addêess when óoî ãove.
pee Chapíeê O foê phone nîãbeês foê jedácaêe and jedáJCal.
» If you move within our service area, we still need to know. te need ío keep óoîê ãeãbeêsháp êecoêd îp ío daíe and know how ío coníací óoî.
Call Member Services for help if you have questions or concerns.
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Chapíeê VW thaí ío do áf óoî have a pêobleã oê coãplaání
Ecoveêage decásáonsI appealsI coãplaánísF
Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)
What’s in this chapter?
qhás chapíeê has ánfoêãaíáon aboîí óoîê êághís. oead íhás chapíeê ío fánd oîí whaí ío do áfW
 voî have a pêobleã wáíh oê coãplaání aboîí óoîê plan.
 voî need a seêváceI áíeãI oê ãedácaíáon íhaí óoîê plan has saád áí wáll noí paó foê.
 voî dásagêee wáíh a decásáon íhaí óoîê plan has ãade aboîí óoîê caêe.
 voî íhánk óoîê coveêed seêváces aêe endáng íoo soon.
 voî have a pêobleã oê coãplaání wáíh óoîê longJíeêã seêváces and sîppoêísI whách
ánclîde fnJeoãe pîppoêíáve peêváces EfeppFI jîlíápîêpose penáoê peêváces mêogêaã
EjppmF. Coããînáíó Based Adîlí peêváces ECBApFI and kîêsáng cacáláíó EkcF seêváces.
ff óoî have a pêobleã oê conceênI óoî onló need ío êead íhe paêís of íhás chapíeê íhaí appló ío
óoîê sáíîaíáon. qhás chapíeê ás bêoken ánío dáffeêení secíáons ío help óoî easáló fánd whaí óoî
aêe lookáng foê.
If you are facing a problem with your health or long-term services and
supports
voî shoîld êeceáve íhe healíh caêeI dêîgsI and longJíeêã seêváces and sîppoêís íhaí óoîê
docíoê and oíheê pêovádeês deíeêãáne aêe necessaêó foê óoîê caêe as a paêí of óoîê caêe plan.
ff óoî aêe haváng a pêobleã wáíh óoîê caêeI óoî can call íhe Cal jedáConnecí lãbîds
mêogêaã aí NJURRJRMNJPMTT foê help. qhás chapíeê wáll explaán íhe dáffeêení opíáons óoî have
foê dáffeêení pêobleãs and coãplaánísI bîí óoî can alwaós call íhe Cal jedáConnecí lãbîds
mêogêaã ío help gîáde óoî íhêoîgh óoîê pêobleã.
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Table of Contents
What’s in this chapter?...................................................................................................................NQM
ff óoî aêe facáng a pêobleã wáíh óoîê healíh oê longJíeêã seêváces and sîppoêís............................NQM
pecíáon NW fníêodîcíáon ...................................................................................................................NQQ
pecíáon N.NW thaí ío do áf óoî have a pêobleã .........................................................................NQQ
pecíáon N.OW thaí aboîí íhe legal íeêãs? .................................................................................NQQ
pecíáon OW theêe ío call foê help ....................................................................................................NQR
pecíáon O.NW theêe ío geí ãoêe ánfoêãaíáon and help ...............................................................NQR
pecíáon PW mêobleãs wáíh óoîê Benefáís ..........................................................................................NQS
pecíáon P.NW phoîld óoî îse íhe pêocess foê coveêage decásáons and appeals? lê do óoî
waní ío ãake a coãplaání?.......................................................................................................NQS
pecíáon QW Coveêage decásáons and appeals...................................................................................NQU
pecíáon Q.NW lveêváew of coveêage decásáons and appeals .......................................................NQU
pecíáon Q.OW deííáng help wáíh coveêage decásáons and appeals ...............................................NQU
pecíáon Q.PW thách secíáon of íhás chapíeê wáll help óoî? ..........................................................NQV
pecíáon RW mêobleãs aboîí seêvácesI áíeãsI and dêîgs Enoí maêí a dêîgsF ......................................NRN
pecíáon R.NW then ío îse íhás secíáon.......................................................................................NRN
pecíáon R.OW Askáng foê a coveêage decásáon .............................................................................NRO
pecíáon R.PW ievel N Appeal foê seêvácesI áíeãsI and dêîgs Enoí maêí a dêîgsF..........................NRQ
pecíáon R.QW ievel O Appeal foê seêvácesI áíeãsI and dêîgs Enoí maêí a dêîgsF..........................NRT
pecíáon 5.5: Appeal a County’s decision regarding authorized hours for IHSS benefits............NSO
pecíáon R.SW maóãení pêobleãs................................................................................................NSP
pecíáon SW maêí a dêîgs ..................................................................................................................NSR
pecíáon S.NW thaí ío do áf óoî have pêobleãs geííáng a maêí a dêîg oê óoî waní îs ío paó
óoî back foê a maêí a dêîg........................................................................................................NSR
pecíáon S.OW thaí ás an excepíáon? ..........................................................................................NSS
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pecíáon S.PW fãpoêíaní íhángs ío know aboîí askáng foê excepíáons...........................................NST
pecíáon S.QW eow ío ask foê a coveêage decásáon aboîí a maêí a dêîg oê êeáãbîêseãení
foê a maêí a aêîgI ánclîdáng an excepíáon .................................................................................NSU
pecíáon S.RW ievel N Appeal foê maêí a dêîgs ............................................................................NTN
pecíáon S.SW ievel O Appeal foê maêí a dêîgs ............................................................................NTP
pecíáon TW Askáng îs ío coveê a longeê hospáíal síaó.......................................................................NTR
pecíáon T.NW ieaênáng aboîí óoîê jedácaêe êághís.....................................................................NTR
pecíáon T.OW ievel N Appeal ío change óoîê hospáíal dáschaêge daíe ........................................NTS
pecíáon T.PW ievel O Appeal ío change óoîê hospáíal dáschaêge daíe ........................................NTU
pecíáon T.QW thaí happens áf f ãáss an appeal deadláne?.........................................................NTV
pecíáon UW thaí ío do áf óoî íhánk óoîê hoãe healíh caêeI skálled nîêsáng caêeI oê
Coãpêehensáve lîípaíáení oehabáláíaíáon cacáláíó EClocF seêváces aêe endáng íoo soon ..........NUN
pecíáon U.NW te wáll íell óoî án advance when óoîê coveêage wáll be endáng.............................NUN
pecíáon U.OW ievel N Appeal ío coníánîe óoîê caêe....................................................................NUO
pecíáon U.PW ievel O Appeal ío coníánîe óoîê caêe....................................................................NUQ
pecíáon U.QW thaí áf óoî ãáss íhe deadláne foê ãakáng óoîê ievel N Appeal? ...........................NUR
pecíáon VW qakáng óoîê appeal beóond ievel O ...............................................................................NUT
pecíáon V.NW kexí síeps foê jedácaêe seêváces and áíeãs..........................................................NUT
pecíáon V.OW kexí síeps foê jedáJCal seêváces and áíeãs ..........................................................NUT
pecíáon NMW eow ío ãake a coãplaání ............................................................................................NUU
pecíáon NM.NW aeíaáls and deadlánes .........................................................................................NUV
pecíáon NM.OW voî can fále coãplaánís wáíh íhe lffáce of Cávál oághís .........................................NVM
pecíáon NM.PW voî can ãake coãplaánís aboîí qîaláíó of caêe ío íhe nîaláíó fãpêoveãení
lêganázaíáon .............................................................................................................................NVN
pecíáon NM.QW voî can íell jedácaêe aboîí óoîê coãplaání .......................................................NVN
pecíáon NM.RW voî can íell jedáJCal aboîí óoîê coãplaání ........................................................NVN
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pecíáon NM.SW voî can íell íhe Caláfoênáa aepaêíãení of janaged eealíh Caêe aboîí óoîê
coãplaání..................................................................................................................................NVN
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Section 1: Introduction
Section 1.1: What to do if you have a problem
qhás chapíeê wáll íell óoî whaí ío do áf óoî have a pêobleã wáíh óoîê plan oê wáíh óoîê seêváces
oê paóãení. qhese pêocesses have been appêoved bó jedácaêe and jedáJCal. bach pêocess
has a seí of êîlesI pêocedîêesI and deadlánes íhaí ãîsí be followed bó îs and bó óoî.
Section 1.2: What about the legal terms?
qheêe aêe dáffácîlí legal íeêãs foê soãe of íhe êîles and deadlánes án íhás chapíeê. janó of
íhese íeêãs can be haêd ío îndeêsíandI so we have îsed sáãpleê woêds án place of ceêíaán
legal íeêãs. te îse abbêeváaíáons as láííle as possáble.
coê exaãpleI we wáll saóW
 "Making a complaint´ rather than "filing a grievance´
 "Coverage decision´ rather than "organization determination´ or "coverage
deíeêãánation´
 "Fast coverage decision´ rather than "expedited determination´
hnowáng íhe pêopeê legal íeêãs ãaó help óoî coããînácaíe ãoêe cleaêlóI so we pêováde
íhose íoo.
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Section 2: Where to call for help
Section 2.1: Where to get more information and help
poãeíáães áí can be confîsáng ío síaêí oê follow íhêoîgh íhe pêocess foê dealáng wáíh a
pêobleã. qhás can be especáalló íêîe áf óoî do noí feel well oê have láãáíed eneêgó. líheê
íáãesI óoî ãaó noí have íhe knowledge óoî need ío íake íhe nexí síep.
You can get help from the Cal MediConnect Ombuds Program
ff óoî need help geííáng síaêíedI óoî can alwaós call íhe Cal jedáConnecí lãbîds mêogêaã.
qhe Cal jedáConnecí lãbîds mêogêaã can answeê óoîê qîesíáons and help óoî
îndeêsíand whaí ío do ío handle óoîê pêobleã. qhe Cal jedáConnecí lãbîds mêogêaã ás
noí connecíed wáíh îs oê wáíh anó ánsîêance coãpanó oê healíh plan. qheó can help óoî
îndeêsíand whách pêocess ío îse. qhe phone nîãbeê foê íhe Cal jedáConnecí lãbîds
mêogêaã ás NJURRJRMNJPMTT. qhe seêváces aêe fêee.
You can get help from the Health Insurance Counseling and Advocacy Program
voî can also call íhe eealíh fnsîêance Coînseláng and Advocacó mêogêaã EefCAmF. qhe
efCAm coînseloês can answeê óoîê qîesíáons and help óoî îndeêsíand whaí ío do ío handle
óoîê pêobleã. efCAm ás noí connecíed wáíh îs oê wáíh anó ánsîêance coãpanó oê healíh plan.
efCAm has íêaáned coînseloês án eveêó coîníóI and seêváces aêe fêee. qhe local efCAm phone
nîãbeê ás ONPJPUPJQRNV oê NJUMMJQPQJMOOO.
Getting help from Medicare
voî can call jedácaêe dáêecíló foê help wáíh pêobleãs. eeêe aêe íwo waós ío geí help
fêoã jedácaêeW
 Call NJUMMJjbafCAob ENJUMMJSPPJQOOTFI OQ hoîês a daóI T daós a week.
qqvW NJUTTJQUSJOMQU. qhe call ás fêee.
 sásáí íhe jedácaêe websáíe EhíípWLLwww.ãedácaêe.govF.
You can get help from the California Department of Managed Health Care
The following paragraph is a required disclosure under California Health & Safety Code
Section 1368.02(b). In this paragraph, the term “grievance” means an appeal or complaint
about Medi-Cal services.
qhe Caláfoênáa aepaêíãení of janaged eealíh Caêe ás êesponsáble foê êegîlaíáng healíh caêe
seêváce plans. ff óoî have a gêáevance agaánsí óoîê healíh planI óoî shoîld fáêsí íelephone
óoîê healíh plan aí NJUUUJPRMJPQQT Eqqv TNNF and îse óoîê healíh planDs gêáevance pêocess
befoêe coníacíáng íhe depaêíãení. ríálázáng íhás gêáevance pêocedîêe does noí pêohábáí anó
poíeníáal legal êághís oê êeãedáes íhaí ãaó be avaálable ío óoî. ff óoî need help wáíh a
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gêáevance ánvolváng an eãeêgencóI a gêáevance íhaí has noí been saíásfacíoêáló êesolved bó
óoîê healíh planI oê a gêáevance íhaí has êeãaáned înêesolved foê ãoêe íhan PM daósI óoî
ãaó call íhe depaêíãení foê assásíance. voî ãaó also be elágáble foê an fndependení jedácal
oeváew EfjoF. ff óoî aêe elágáble foê fjoI íhe fjo pêocess wáll pêováde an áãpaêíáal êeváew of
ãedácal decásáons ãade bó a healíh plan êelaíed ío íhe ãedácal necessáíó of a pêoposed
seêváce oê íêeaíãeníI coveêage decásáons foê íêeaíãenís íhaí aêe expeêáãeníal oê
ánvesíágaíáonal án naíîêe and paóãení dáspîíes foê eãeêgencó oê îêgení ãedácal seêváces.
qhe depaêíãení also has a íollJfêee íelephone nîãbeê (1-888-HMO-2219) and a qaa láne (1877-688-9891) foê íhe heaêáng and speech áãpaáêed. qhe depaêíãeníDs fníeêneí teb sáíe
http://www.hmohelp.ca.gov has coãplaání foêãsI fjo applácaíáon foêãs and ánsíêîcíáons
onláne.
You can get help from the Office of the Patient Advocate
qhe lffáce of íhe maíáení Advocaíe ElmAF can help óoî îndeêsíand óoîê êághísI leaên how ío
geí healíh ánsîêanceI and choose qîaláíó caêe.
voî can coníací lmA bó calláng VNSJPOQJSQMT oê eãaáláng coníací[email protected]. voî can
also vásáí íhe lmA websáíe aí híípWLLwww.opa.ca.gov.
You can get help from the Quality Improvement Organization
qhe nîaláíó fãpêoveãení lêganázaíáon ás a gêoîp of pêacíácáng docíoês and oíheê healíh caêe
expeêís paád bó íhe fedeêal goveênãení ío check and áãpêove íhe caêe gáven ío jedácaêe
paíáenís.
qhe phone nîãbeê foê íhe nîaláíó fãpêoveãení lêganázaíáon ás NJUTTJRUUJNNOP
EqqvW NJURRJUUTJSSSUF
Section 3: Problems with your Benefits
Section 3.1: Should you use the process for coverage decisions and appeals?
Or do you want to make a complaint?
ff óoî have a pêobleã oê conceênI óoî onló need ío êead íhe paêís of íhás chapíeê íhaí appló ío
óoîê sáíîaíáon. qhe chaêí below wáll help óoî fánd íhe êághí secíáon of íhás chapíeê foê pêobleãs
oê coãplaánís.
Is your problem or concern about your benefits or coverage?
Eqhás ánclîdes pêobleãs aboîí wheíheê paêíácîlaê ãedácal caêeI longJíeêã seêváces and
sîppoêísI oê pêescêápíáon dêîgs aêe coveêed oê noíI íhe waó án whách íheó aêe coveêedI and
pêobleãs êelaíed ío paóãení foê ãedácal caêe oê pêescêápíáon dêîgs.F
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Yes.
No.
jó pêobleã ás aboîí
benefáís oê coveêage.
jó pêobleã ás noí aboîí
benefáís oê coveêage.
do ío íhe nexí secíáon of íhás chapíeêI
Section 4, “Coverage decisions and
appeals.”
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pkáp ahead ío Section 10 aí íhe end of
íhás chapíeêW “How to make a complaint.”
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Section 4: Coverage decisions and appeals
Section 4.1: Overview of coverage decisions and appeals
qhe pêocess foê askáng foê coveêage decásáons and ãakáng appeals deals wáíh pêobleãs
êelaíed ío óoîê benefáís and coveêage. fí also ánclîdes pêobleãs wáíh paóãení. voî aêe noí
êesponsáble foê jedácaêe cosís excepí maêí a coJpaós.
What is a coverage decision?
A coverage decision ás an ánáíáal decásáon we ãake aboîí óoîê benefáís and coveêage oê aboîí
íhe aãoîní we wáll paó foê óoîê ãedácal seêvácesI áíeãsI oê dêîgs. te aêe ãakáng a coveêage
decásáon wheneveê we decáde whaí ás coveêed foê óoî and how ãîch we paó.
ff óoî oê óoîê docíoê aêe noí sîêe áf a seêváceI áíeãI oê dêîg ás coveêed bó jedácaêe oê jedáJ
CalI eáíheê of óoî can ask foê a coveêage decásáon befoêe íhe docíoê gáves íhe seêváceI áíeãI
oê dêîg.
What is an appeal?
An appeal ás a foêãal waó of askáng îs ío êeváew oîê decásáon and change áí áf óoî íhánk we
ãade a ãásíake. coê exaãpleI we ãághí decáde íhaí a seêváceI áíeãI oê dêîg íhaí óoî waní ás
noí coveêed oê ás no longeê coveêed bó jedácaêe oê jedáJCal. ff óoî oê óoîê docíoê dásagêee
wáíh oîê decásáonI óoî can appeal.
Section 4.2: Getting help with coverage decisions and appeals
Who can I call for help asking for coverage decisions or making an appeal?
voî can ask anó of íhese people foê helpW
 voî can call îs aí Member Services aí NJUUUJPRMJPQQT Eqqv TNNFI jondaó íhêoîgh
cêádaó fêoã U a.ã. ío U p.ã.
 Call íhe Cal MediConnect Ombuds Program foê fêee help. qhe Cal jedáConnecí
lãbîds mêogêaã helps people enêolled án Cal jedáConnecí wáíh seêváce oê bálláng
pêobleãs. qhe phone nîãbeê ás NJURRJRMNJPMTT.
 Call íhe Health Insurance Counseling and Advocacy Program (HICAP) foê fêee help.
efCAm ás an ándependení oêganázaíáon. fí ás noí connecíed wáíh íhás plan. qhe phone
nîãbeê ás ONPJPUPJQRNV oê NJUMMJQPQJMOOO.

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Call íhe Help Center at the Department of Managed Health Care (DMHC) foê fêee
help. qhe ajeC ás êesponsáble foê êegîlaíáng healíh plans. qhe ajeC helps people
enêolled án Cal jedáConnecí wáíh appeals aboîí jedáJCal seêváces oê bálláng
pêobleãs. qhe phone nîãbeê ás NJUUUJQSSJOONV. fndávádîals who aêe deafI haêd of
heaêángI oê speechJáãpaáêed can îse íhe íollJfêee qaa nîãbeêI NJUTTJSUUJVUVN.
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 Call óoîê local county social services office foê qîesíáons aboîí coveêage decásáons foê fnJeoãe pîppoêíáve peêváces EfeppF. qhe phone nîãbeê ás NJUUUJSTUJQQTT.
 qalk ío your doctor or other provider. voîê docíoê oê oíheê pêovádeê can ask foê a
coveêage decásáon oê appeal on óoîê behalf.
 qalk ío a friend or family member and ask háã oê heê ío ací foê óoî. voî can naãe
another person to act for you as your "representative´ to ask for a coverage decision or
ãake an appeal.
» ff óoî waní a fêáendI êelaíáveI oê oíheê peêson ío be óoîê êepêeseníaíáveI call jeãbeê
Services and ask for the "Appointment of Representative´ form. You can also get the
foêã on íhe jedácaêe websáíe aí
híípWLLwww.cãs.hhs.govLcãsfoêãsLdownloadsLcãsNSVS.pdf. qhe foêã wáll gáve íhe
peêson peêãássáon ío ací foê óoî. voî ãîsí gáve îs a copó of íhe ságned foêã.
 You also have the right to ask a lawyer ío ací foê óoî. voî ãaó call óoîê own lawóeêI
oê geí íhe naãe of a lawóeê fêoã íhe local baê assocáaíáon oê oíheê êefeêêal seêváce. poãe legal gêoîps wáll gáve óoî fêee legal seêváces áf óoî qîaláfó. ff óoî waní a lawóeê ío êepêesení óoîI óoî wáll need ío fáll oîí íhe Appoáníãení of oepêeseníaíáve foêã.
eoweveêI you do not have to have a lawyer ío ask foê anó kánd of coveêage decásáon oê ío
ãake an appeal.
Section 4.3: Which section of this chapter will help you?
qheêe aêe foîê dáffeêení íópes of sáíîaíáons íhaí ánvolve coveêage decásáons and appeals. bach
sáíîaíáon has dáffeêení êîles and deadlánes. te sepaêaíe íhás chapíeê ánío dáffeêení secíáons ío
help ío help óoî fánd íhe êîles óoî need ío follow. voî onló need ío êead íhe secíáon íhaí
appláes ío óoîê pêobleãW
 Section 5 gáves óoî ánfoêãaíáon áf óoî have pêobleãs aboîí seêvácesI áíeãsI and
dêîgs Ebîí noí maêí a dêîgsF. coê exaãpleI îse íhás secíáon áfW
o voî aêe noí geííáng ãedácal caêe óoî waníI and óoî beláeve íhaí íhás caêe ás
coveêed bó oîê plan.
o te dád noí appêove seêvácesI áíeãsI oê dêîgs íhaí óoîê docíoê wanís ío gáve
óoîI and óoî beláeve íhaí íhás caêe shoîld be coveêed.

NOTE: lnló îse pecíáon R áf íhese aêe dêîgs not coveêed bó maêí a.
aêîgs án íhe List of Covered Drugs wáíh a E*F aêe noí coveêed bó maêí
a. pee pecíáon S foê maêí a dêîg appeals.
o voî êeceáved ãedácal caêe oê seêváces íhaí óoî íhánk shoîld be coveêedI bîí
we aêe noí paóáng foê íhás caêe.
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o voî goí and paád foê ãedácal seêváces oê áíeãs óoî íhoîghí weêe coveêedI and
óoî waní ío ask îs ío paó óoî back.
o voî aêe beáng íold íhaí coveêage foê caêe óoî have been geííáng wáll be
êedîced oê síoppedI and óoî dásagêee wáíh oîê decásáon.

NOTE: If the coverage that will be stopped is for hospital care,
home health care, skilled nursing facility care, or Comprehensive
Outpatient Rehabilitation Facility (CORF) servicesI óoî need ío
êead a sepaêaíe secíáon of íhás chapíeê becaîse specáal êîles appló ío
íhese íópes of caêe. pee pecíáons T and U.
o voî aêe beáng íold óoîê fnJeoãe pîppoêíáve peêváces EfeppF hoîês wáll be
êedîced.

Section 6 gáves óoî ánfoêãaíáon aboîí maêí a dêîgs. coê exaãpleI îse íhás secíáon áfW
o voî waní ío ask îs ío ãake an excepíáon ío coveê a maêí a dêîg íhaí ás noí on
the plan’s List of Covered Drugs Eaêîg iásíF.
o voî waní ío ask îs ío waáve láãáís on íhe aãoîní of íhe dêîg óoî can geí.
o voî waní ío ask îs ío coveê a dêîg íhaí êeqîáêes pêáoê appêoval.
o te dád noí appêove óoîê êeqîesí oê excepíáonI and óoî oê óoîê docíoê oê oíheê
pêescêábeê íhánks we shoîld have.
o voî waní ío ask îs ío paó foê a pêescêápíáon dêîg óoî alêeadó boîghí. Eqhás ás
askáng foê a coveêage decásáon aboîí paóãení.F
 Section 7 gáves óoî ánfoêãaíáon on how ío ask îs ío coveê a longeê ánpaíáení hospáíal
síaó áf óoî íhánk íhe docíoê ás dáschaêgáng óoî íoo soon. rse íhás secíáon áfW
o voî aêe án íhe hospáíal and íhánk íhe docíoê asked óoî ío leave íhe hospáíal íoo
soon.
 Section 8 gáves óoî ánfoêãaíáon áf óoî íhánk óoîê hoãe healíh caêeI skálled nîêsáng
facáláíó caêeI and Coãpêehensáve lîípaíáení oehabáláíaíáon cacáláíó EClocF seêváces
aêe endáng íoo soon.
If you’re not sure which secíáon óoî shoîld be îsángI please call jeãbeê peêváces aí NJUUU
PRMJPQQT Eqqv TNNFI jondaó íhêoîgh cêádaó fêoã U a.ã. ío U p.ã. voî can also geí help oê
ánfoêãaíáon fêoã íhe Cal jedáConnecí lãbîds mêogêaã bó calláng NJURRJRMNJPMTT.
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Section 5: Problems about services, items, and drugs (not Part D drugs) Section 5.1: When to use this section
qhás secíáon ás aboîí whaí ío do áf óoî have pêobleãs wáíh óoîê benefáís foê óoîê ãedácalI
behaváoêal healíhI and longJíeêã seêváces and sîppoêís EiqppF. voî can also îse íhás secíáon
foê pêobleãs wáíh dêîgs íhaí aêe noí coveêed bó maêí a. aêîgs án íhe iásí of Coveêed aêîgs
wáíh a E*F aêe noí coveêed bó maêí a. rse pecíáon S foê maêí a dêîg Appeals.
qhás secíáon íells whaí óoî can do áf óoî aêe án anó of íhe followáng sáíîaíáonsW
1. You think the plan covers medical, behavioral health, or long term services and supports (LTSS) that you need but are not getting.
What you can do: voî can ask íhe plan ío ãake a coveêage decásáon. do ío
pecíáon R.O Epage NRQF foê ánfoêãaíáon on askáng foê a coveêage decásáon.
2. The plan did not approve care your doctor wants to give you, and you
think it should have.
What you can do: voî can appeal the plan’s decision to not approve íhe
caêe. do ío pecíáon R.P Epage NRSF foê ánfoêãaíáon on ãakáng an appeal.
3. You received services or items that you think the plan covers, but the
plan will not pay.
What you can do: voî can appeal the plan’s decision not to pay. do ío
pecíáon R.Q Epage NRVF foê ánfoêãaíáon on ãakáng an appeal.
4. You got and paid for medical services or items you thought were
covered, and you want the plan to reimburse you for the services or
items.
What you can do: voî can ask íhe plan ío paó óoî back. do ío pecíáon R.S
Epage NSRF foê ánfoêãaíáon on askáng íhe plan foê paóãení.
5. Your coverage for a certain service is being reduced or stopped,
and you disagree with our decision.
What you can do: You can appeal the plan’s decision to reduce or stop the
seêváce.
NOTE: ff íhe coveêage íhaí wáll be síopped ás foê hospáíal caêeI hoãe healíh
caêeI skálled nîêsáng facáláíó caêeI oê Coãpêehensáve lîípaíáení oehabáláíaíáon
cacáláíó EClocF seêvácesI specáal êîles appló. oead pecíáons T oê U ío fánd oîí
ãoêe.
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
fn all cases wheêe we íell óoî íhaí ãedácal caêe óoî have been geííáng wáll be
síoppedI îse íhe ánfoêãaíáon án pecíáon R.O of íhás chapíeê as óoîê gîáde foê
whaí ío do.
6. Your In-Home Supportive Services (IHSS) hours were denied or reduced,
and you disagree with the decision.
What you can do: You can appeal the county’s decision to deny or reduce
fepp hoîês bó êeqîesíáng a píaíe caáê eeaêáng.

fepp hoîês aêe deíeêãáned bó óoîê coîníó socáal woêkeêI noí oîê plan. qhe
coîníó socáal woêkeê wáll assess íhe íópes of seêváces óoî need and íhe
nîãbeê of hoîês íhe coîníó wáll aîíhoêáze foê each of íhese seêváces. ff óoî
have qîesíáons êegaêdáng óoîê fepp hoîêsI go ío pecíáon R.R of íhás chapíeê.
Section 5.2: Asking for a coverage decision
How to ask for a coverage decision to get medical, behavioral health, or certain longterm services and supports (MSSP, CBAS, or NF services)
qo ask foê a coveêage decásáonI callI wêáíeI oê fax îsI oê ask óoîê êepêeseníaíáve oê docíoê
ío ask îs foê a decásáon.
o voî can call îs aíW NJUUUJPRMJPQQT Eqqv TNNFI jondaó íhêoîgh cêádaó fêoã U a.ã. ío
U p.ã.
o voî can fax îs aíW NJUUUJQOSJRMUT
o voî can ío wêáíe îs aíW
NOVMM maêk mlaza aêáveI píe. NRM jpJSNRM CeêêáíosI CA VMTMP
How long does it take to get a coverage decision?
It usually takes up to 14 calendar days after you asked. If we don’t give you our decásáon
wáíhán NQ calendaê daósI óoî can appeal.

poãeíáães we need ãoêe íáãeI and we wáll send óoî a leííeê íelláng óoî íhaí we need ío
íake îp ío NQ calendaê ãoêe daós.
Can I get a coverage decision faster?
ves. ff óoî need a êesponse fasíeê becaîse of óoîr health, you should ask us to make a "fast
coveêage decásáon.´ ff we appêove íhe êeqîesíI we wáll noíáfó óoî of oîê decásáon within 72
hours.
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eoweveêI soãeíáães we need ãoêe íáãeI and we wáll send óoî a leííeê íelláng óoî íhaí we
need ío íake îp ío NQ ãoêe calendaê daós.
The legal term for “fast coverage decision” is “expedited determination.”
Asking for a fast coverage decision:
 ff óoî êeqîesí a fasí coveêage decásáonI síaêí bó calláng oê faxáng oîê plan ío ask îs ío
coveê íhe caêe óoî waní.
 voî can call îs aí NJUUUJPRMJPQQT Eqqv TNNFI jondaó íhêoîgh cêádaó fêoã U a.ã. ío U
p.ã. oê fax îs aí NJUUUJQOSJRMUT. coê íhe deíaáls on how ío coníací îsI go ío Chapíeê O
page NR.
 voî can also have óoîê docíoê oê óoîê êepêeseníaíáve call îs.
Here are the rules for asking for a fast coverage decision:
voî ãîsí ãeeí íhe followáng íwo êeqîáêeãenís ío geí a fasí coveêage decásáonW
o voî can geí a fasí coveêage decásáon only áf óoî aêe askáng foê coveêage foê caêe oê
an áíeã you have not yet received. Evoî cannoí geí a fasí coveêage decásáon áf óoîê
êeqîesí ás aboîí paóãení foê caêe oê an áíeã óoî have alêeadó êeceáved.F
o voî can geí a fasí coveêage decásáon only áf íhe síandaêd NQ calendaê daó deadláne
coîld 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
decáde áf óoî geí a fasí coveêage decásáon.

ff we decáde íhaí óoîê healíh does noí ãeeí íhe êeqîáêeãenís foê a fasí
coveêage decásáonI we wáll send óoî a leííeê. te wáll also îse íhe
síandaêd NQ calendaê daó deadláne ánsíead.

qhás leííeê wáll íell óoî íhaí áf óoîê docíoê asks foê íhe fasí coveêage
decásáonI we wáll aîíoãaíácalló gáve a fasí coveêage decásáon.

qhe leííeê wáll also íell how óoî can fále a "fast complaint´ about our
decásáon ío gáve óoî a síandaêd coveêage decásáon ánsíead of íhe fasí
coveêage decásáon óoî êeqîesíed. Ecoê ãoêe ánfoêãaíáon aboîí íhe
pêocess foê ãakáng coãplaánísI ánclîdáng fasí coãplaánísI see pecíáon
NM of íhás chapíeê.F
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If the coverage decision is Yes, when will I get the service or item?
voî wáll be appêoved EpêeJaîíhoêázedF ío geí íhe seêváce oê áíeã wáíhán NQ calendaê daós Efoê a
síandaêd coveêage decásáonF oê TO hoîês Efoê a fasí coveêage decásáonF of when óoî asked. ff
we exíended íhe íáãe needed ío ãake oîê coveêage decásáonI we wáll appêove íhe coveêage
bó íhe end of íhaí exíended peêáod.
If the coverage decision is No, how will I find out?
ff íhe answeê ás NoI we wáll send óoî a leííeê íelláng óoî oîê êeasons foê saóáng No.
 ff we saó noI óoî have íhe êághí ío ask îs ío êeconsádeê ± and change ± íhás decásáon bó
ãakáng an appeal. jakáng an appeal ãeans askáng îs ío êeváew oîê decásáon ío denó
coveêage.
 ff óoî decáde ío ãake an appealI áí ãeans óoî aêe goáng on ío ievel N of íhe appeals
pêocess Esee pecíáon R.P belowF.
Section 5.3: Level 1 Appeal for services, items, and drugs (not Part D drugs)
What is an Appeal?
An appeal ás a foêãal waó of askáng îs ío êeváew oîê decásáon and change áí áf óoî íhánk we
ãade a ãásíake. ff óoî oê óoîê docíoê oê oíheê pêovádeê dásagêees wáíh oîê decásáonI óoî can
appeal.
fn ãosí casesI óoî ãîsí síaêí óoîê appeal aí ievel N. However, you are not required to
start your appeal at Level 1 for Medi-Cal services. ff óoî do noí waní ío fáêsí appeal ío íhe
plan foê a jedáJCal seêváceI óoî can ask foê a píaíe caáê eeaêáng oêI án specáal casesI an
fndependení jedácal oeváew. do ío page NSM foê ãoêe ánfoêãaíáon.
What is a Level 1 Appeal?
A ievel N Appeal ás íhe fáêsí appeal ío oîê plan. te wáll êeváew oîê coveêage decásáon ío see áf
áí ás coêêecí. qhe êeváeweê wáll be soãeone who dád noí ãake íhe oêágánal coveêage decásáon.
then we coãpleíe íhe êeváewI we wáll gáve óoî oîê decásáon án wêáíáng.
ff we íell óoî afíeê oîê êeváew íhaí íhe seêváce oê áíeã ás noí coveêedI óoîê case can go ío a
ievel O Appeal.
How do I make a Level 1 Appeal?
o qo síaêí óoîê appealI óoîI óoîê docíoê oê oíheê pêovádeêI oê óoîê êepêeseníaíáve ãîsí
coníací îs. voî can call îs aí NJUUUJPRMJPQQT Eqqv TNNFI jondaó íhêoîgh cêádaó
fêoã U a.ã. ío U p.ã. coê addáíáonal deíaáls on how ío êeach îs foê appealsI see
Chapíeê OI page NR.
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o You can ask us for a "standard appeal´ or a "fast appeal.´
o ff óoî aêe askáng foê a síandaêd appeal oê fasí appealI ãake óoîê appeal án wêáíáng oê
call îs.  voî can sîbãáí a wêáííen êeqîesí ío íhe followáng addêessW
NOVMM maêk mlaza aêáveI píe. NRM jpJSNRM CeêêáíosI CA VMTMP
 voî can sîbãáí óoîê êeqîesí onláne aíW
híípWLLdîals.caêeãoêe.coãLjeãbeêsLdêáevanceJCoveêageJaeíeêãánaíáonJand
AppealsJmêocess.aspx
 voî ãaó also ask foê an appeal bó calláng îs aí NJUUUJPRMJPQQT Eqqv TNNF.
o te wáll send óoî a leííeê wáíhán R calendaê daós of êeceáváng óoîê appeal leííáng óoî
know íhaí we êeceáved áí.
The legal term for “fast appeal” is “expedited reconsideration.”
Can someone else make the appeal for me?
ves. voîê docíoê oê oíheê pêovádeê can ãake íhe appeal foê óoî. AlsoI soãeone besádes óoîê
docíoê oê oíheê pêovádeê can ãake íhe appeal foê óoîI bîí fáêsí óoî ãîsí coãpleíe an
Appoáníãení of oepêeseníaíáve foêã. qhe foêã gáves íhe oíheê peêson peêãássáon ío ací foê
óoî.
qo geí a Appoáníãení of oepêeseníaíáve foêãI call jeãbeê peêváces and ask foê oneI oê vásáí
íhe jedácaêe websáíe aí híípsWLLwww.cãs.hhs.govLcãsfoêãsLdownloadsLcãsNSVS.pdf.

ff íhe appeal coães fêoã soãeone besádes óoî oê óoîê docíoê oê oíheê pêovádeêI we ãîsí
êeceáve íhe coãpleíed Appoáníãení of oepêeseníaíáve foêã befoêe we can êeváew íhe
appeal.
How much time do I have to make an appeal?
voî ãîsí ask foê an appeal wáíhán VM calendaê daós fêoã íhe daíe on íhe leííeê we sení ío íell
óoî oîê decásáon.
ff óoî ãáss íhás deadláne and have a good êeason foê ãássáng áíI we ãaó gáve óoî ãoêe íáãe
ío ãake óoîê appeal. bxaãples of a good êeason aêeW óoî had a seêáoîs állnessI oê we gave
óoî íhe wêong ánfoêãaíáon aboîí íhe deadláne foê êeqîesíáng an appeal.
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Can I get a copy of my case file?
ves. Ask îs foê a copó.

te aêe allowed ío chaêge a fee foê copóáng and sendáng íhás ánfoêãaíáon ío óoî.
Can my doctor give you more information about my appeal?
vesI óoî and óoîê docíoê ãaó gáve îs ãoêe ánfoêãaíáon ío sîppoêí óoîê appeal.
How will the plan make the appeal decision?
te íake a caêefîl look aí all of íhe ánfoêãaíáon aboîí óoîê êeqîesí foê coveêage of
ãedácal caêe. qhenI we check ío see áf we weêe followáng all íhe êîles when we saád No
ío óoîê êeqîesí. qhe êeváeweê wáll be soãeone who dád noí ãake íhe oêágánal decásáon.
ff we need ãoêe ánfoêãaíáonI we ãaó ask óoî oê óoîê docíoê foê áí.
When will I hear about a “standard” appeal decision?
te ãîsí gáve óoî oîê answeê wáíhán PM calendaê daós afíeê we geí óoîê appeal. te wáll gáve
óoî oîê decásáon sooneê áf óoîê healíh condáíáon êeqîáêes îs ío.
 eoweveêI áf óoî ask foê ãoêe íáãeI oê áf we need ío gaíheê ãoêe ánfoêãaíáonI we can íake îp ío NQ ãoêe calendaê daós. ff we decáde ío íake exíêa daós ío ãake íhe decásáonI
we wáll íell óoî bó leííeê.
 If you believe we should not take extra days, you can file a "fast complaint´ about our
decásáon ío íake exíêa daós. then óoî fále a fasí coãplaáníI we wáll gáve óoî an answeê
ío óoîê coãplaání wáíhán OQ hoîês.
 ff we do noí gáve óoî an answeê ío óoîê appeal wáíhán PM calendaê daós oê bó íhe end of
íhe exíêa daós Eáf we íook íheãFI we wáll aîíoãaíácalló send óoîê case ío ievel O of íhe
appeals pêocess áf óoîê pêobleã ás aboîí a jedácaêe seêváce oê áíeã. voî wáll be
noíáfáed when íhás happens. ff óoîê pêobleã ás aboîí a jedáJCal seêváce oê áíeãI óoî wáll
need ío fále a ievel O Appeal óoîêself. coê ãoêe ánfoêãaíáon aboîí íhe ievel O Appeal
pêocessI go ío pecíáon R.Q of íhás chapíeê.

If our answer is Yes ío paêí oê all of whaí óoî asked foêI we ãîsí appêove oê gáve íhe
coveêage wáíhán PM calendaê daós afíeê we geí óoîê appeal.

If our answer is No ío paêí oê all of whaí óoî asked foêI we wáll send óoî a leííeê. ff óoîê
pêobleã ás aboîí a jedácaêe seêváce oê áíeãI íhe leííeê wáll íell óoî íhaí we sení óoîê case
ío íhe fndependení oeváew bníáíó foê a ievel O Appeal. ff óoîê pêobleã ás aboîí a jedáJ
Cal seêváce oê áíeãI íhe leííeê wáll íell óoî how ío fále a ievel O Appeal óoîêself. coê ãoêe
ánfoêãaíáon aboîí íhe ievel O Appeal pêocessI go ío pecíáon R.Q of íhás chapíeê.
What happens if I ask for a fast appeal?
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ff óoî ask foê a fasí appealI we wáll gáve óoî óoîê answeê wáíhán TO hoîês afíeê we geí óoîê
appeal. te wáll gáve óoî oîê answeê sooneê áf óoîê healíh êeqîáêes îs ío do so.
 eoweveêI áf óoî ask foê ãoêe íáãeI oê áf we need ío gaíheê ãoêe ánfoêãaíáonI we can íake îp ío NQ ãoêe calendaê daós. ff we decáde ío íake exíêa daós ío ãake íhe decásáonI
we wáll íell óoî bó leííeê.
 ff we do noí gáve óoî an answeê ío óoîê appeal wáíhán TO hoîês oê bó íhe end of íhe
exíêa daós Eáf we íook íheãFI we wáll aîíoãaíácalló send óoîê case ío ievel O of íhe
appeals pêocess áf óoîê pêobleã ás aboîí a jedácaêe seêváce oê áíeã. voî wáll be
noíáfáed when íhás happens. ff óoîê pêobleã ás aboîí a jedáJCal seêváce oê áíeãI óoî wáll
need ío fále a ievel O Appeal óoîêself. coê ãoêe ánfoêãaíáon aboîí íhe ievel O Appeal
pêocessI go ío pecíáon R.Q of íhás chapíeê.

If our answer is Yes ío paêí oê all of whaí óoî asked foêI we ãîsí aîíhoêáze oê pêováde
íhe coveêage wáíhán TO hoîês afíeê we geí óoîê appeal.

If our answer is No ío paêí oê all of whaí óoî asked foêI we wáll send óoî a leííeê. ff óoîê
pêobleã ás aboîí a jedácaêe seêváce oê áíeãI íhe leííeê wáll íell óoî íhaí we sení óoîê case
ío íhe fndependení oeváew bníáíó foê a ievel O Appeal. ff óoîê pêobleã ás aboîí a jedáJ
Cal seêváce oê áíeãI íhe leííeê wáll íell óoî how ío fále a ievel O Appeal óoîêself. coê ãoêe
ánfoêãaíáon aboîí íhe ievel O Appeal pêocessI go ío pecíáon R.Q of íhás chapíeê.
Will my benefits continue during Level 1 appeals?
aîêáng a ievel N AppealI óoî can keep geííáng all pêáoê appêoved nonJmaêí a benefáís íhaí we
íold óoî woîld be síopped oê changed. qhás ãeans íhaí sîch benefáís wáll coníánîe ío be
pêováded ío óoî and íhaí we ãîsí coníánîe ío paó pêovádeês foê pêovádáng sîch benefáís dîêáng
a ievel N Appeal.
Section 5.4: Level 2 Appeal for services, items, and drugs (not Part D drugs)
If the plan says No at Level 1, what happens next?
ff we saó no ío paêí oê all of óoîê ievel N AppealI we wáll send óoî a leííeê. qhás leííeê wáll íell
óoî áf íhe seêváce oê áíeã ás îsîalló coveêed bó jedácaêe oê jedáJCal.
 ff óoîê pêobleã ás aboîí a Medicare seêváce oê áíeãI we wáll aîíoãaíácalló send óoîê
case ío ievel O of íhe appeals pêocess as soon as íhe ievel N Appeal ás coãpleíe.
 ff óoîê pêobleã ás aboîí a Medi-Cal seêváce oê áíeãI óoî can fále a ievel O Appeal
óoîêself. qhe leííeê wáll íell óoî how ío do íhás. fnfoêãaíáon ás also below.
What is a Level 2 Appeal?
A ievel O Appeal ás íhe second appealI whách ás done bó an ándependení oêganázaíáon íhaí ás
noí connecíed ío íhe plan.
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My problem is about a Medi-Cal service or item. How can I make a Level 2
Appeal?
qheêe aêe íwo waós ío ãake a ievel O appeal foê jedáJCal seêváces and áíeãsW NF
fndependení jedácal oeváew EfjoF oê OF píaíe caáê eeaêáng.
1) Independent Medical Review (IMR)
voî can ask foê an fndependení jedácal oeváew EfjoF fêoã íhe eelp Ceníeê aí íhe Caláfoênáa
aepaêíãení of janaged eealíh Caêe EajeCF. An fjo ás avaálable foê anó jedáJCal coveêed
seêváce oê áíeã íhaí ás ãedácal án naíîêe. An fjo ás a êeváew of óoîê case bó docíoês who aêe
noí paêí of oîê plan. ff íhe fjo ás decáded án óoîê favoêI we ãîsí gáve óoî íhe seêváce oê áíeã
óoî êeqîesíed. voî paó no cosís foê an fjo.
voî can appló foê an fjo áf Caêejoêe Cal jedáConnecí mlanW

aenáesI changesI oê delaós a jedáJCal seêváce oê íêeaíãení Enoí ánclîdáng feppF
becaîse Caêejoêe Cal jedáConnecí mlan deíeêãánes áí ás noí ãedácalló necessaêó.

táll noí coveê an expeêáãeníal oê ánvesíágaíáonal jedáJCal íêeaíãení foê a seêáoîs ãedácal condáíáon.

táll noí paó foê eãeêgencó oê îêgení jedáJCal seêváces íhaí óoî alêeadó êeceáved.

eas noí êesolved óoîê ievel N Appeal on a jedáJCal seêváce wáíhán PM calendaê daós foê a síandaêd appeal oê TO hoîês foê a fasí appeal.
voî can ask foê an fjo áf óoî have also asked foê a píaíe caáê eeaêángI bîí noí áf óoî have
alêeadó had a píaíe caáê eeaêángI on íhe saãe ássîe.
fn ãosí casesI óoî ãîsí fále an appeal wáíh îs befoêe êeqîesíáng an fjo. pee page NRS foê
ánfoêãaíáon aboîí Caêejoêe Cal jedáConnecí mlan’s Level 1 appeal process. If you disagree
wáíh oîê decásáonI óoî can ask íhe ajeC eelp Ceníeê foê an fjo.

ff óoîê íêeaíãení was denáed becaîse áí was expeêáãeníal oê ánvesíágaíáonalI óoî do noí
have ío íake paêí án Caêejoêe Cal jedáConnecí mlan’s appeal process before you apply
foê an fjo.

ff óoîê pêobleã ás îêgení and ánvolves an áããedáaíe and seêáoîs íhêeaí ío óoîê healíhI
you may bring it immediately to the DMHC’s attention. The DMHC may waive the
êeqîáêeãení íhaí óoî fáêsí follow Caêejoêe Cal jedáConnecí mlan’s appeal process in
exíêaoêdánaêó and coãpelláng cases.
voî ãîsí appló foê an fjo wáíhán S ãoníhs afíeê we send óoî a wêáííen decásáon aboîí óoîê
appeal. qhe ajeC ãaó accepí óoîê applácaíáon afíeê S ãoníhs áf áí deíeêãánes íhaí
cáêcîãsíances kepí óoî fêoã sîbãáííáng óoîê applácaíáon án íáãe.
qo êeqîesí an fjoW
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 cáll oîí íhe fndependení jedácal oeváewLCoãplaání coêã avaálable aíW
híípWLLwww.dãhc.ca.govLcáleaCoãplaáníLfndependeníjedácaloeváewCoãplaánícoêã.aspx.
lê call íhe ajeC eelp Ceníeê aí NJUUUJQSSJOONV. qaa îseês shoîld call NJUTTJSUUJVUVN.
 ff óoî have íheãI aííach copáes of leííeês oê oíheê docîãenís aboîí íhe seêváce oê áíeã
íhaí we denáed. qhás can speed îp íhe fjo pêocess. pend copáes of docîãenísI noí
oêágánals. qhe eelp Ceníeê cannoí êeíîên anó docîãenís.
 cáll oîí íhe Aîíhoêázed Assásíaní coêã áf soãeone ás helpáng óoî wáíh óoîê fjo. voî can
geí íhe foêã aí
híípWLLwww.dãhc.ca.govLmoêíalsLMLcáleACoãplaáníLfjocoêãsLáãêAîíhoêázaíáoncoêã.pdf. lê
call íhe ajeC eelp Ceníeê aí NJUUUJQSSJOONV. qaa îseês shoîld call NJUTTJSUUJVUVN.
 jaál oê fax óoîê foêãs and anó aííachãenís íoW
eelp Ceníeê
aepaêíãení of janaged eealíh Caêe
VUM káníh píêeeíI pîáíe RMM
pacêaãeníoI CA VRUNQJOTOR
cAuW VNSJORRJROQN
coê nonJîêgení cases ánvolváng jedáJCal seêváces Enoí ánclîdáng feppFI óoî wáll êeceáve an
fjo decásáon fêoã íhe ajeC wáíhán PM daós of êeceápí of óoîê applácaíáon and sîppoêíáng
docîãenís. coê îêgení cases íhaí ánvolve an áããedáaíe oê seêáoîs êásk ío óoîê healíhI óoî wáll
êeceáve an fjo decásáon wáíhán P ío T daós.
ff óoî aêe noí saíásfáed wáíh íhe êesîlí of íhe fjoI óoî can síáll ask foê a píaíe caáê eeaêáng.
ff íhe ajeC decádes íhaí óoîê case ás noí elágáble foê fjoI íhe ajeC wáll êeváew óoîê case
íhêoîgh áís êegîlaê consîãeê coãplaání pêocess.
2) State Fair Hearing
voî can êeqîesí a píaíe caáê eeaêáng aí anó íáãe foê jedáJCal coveêed seêváces and áíeãs
Eánclîdáng feppF. ff óoîê docíoê oê oíheê pêovádeê asks foê a seêváce oê áíeã íhaí we wáll noí
appêoveI oê we wáll noí coníánîe ío paó foê a seêváce oê áíeã óoî alêeadó haveI óoî have íhe
êághí ío ask foê a píaíe caáê eeaêáng.
fn ãosí cases óoî have VM daós ío ask foê a píaíe cair Hearing after the "Your Hearing
Rights´ notice is mailed to you. You have a much shorter time to ask for a hearing if your
benefáís aêe beáng changed oê íaken awaó.
qheêe aêe íwo waós ío êeqîesí a píaíe caáê eeaêángW
N. voî ãaó coãpleíe íhe ?oeqîesí foê píaíe caáê eeaêáng? on íhe back of íhe noíáce of
acíáon. voî shoîld pêováde all êeqîesíed ánfoêãaíáon sîch as óoîê fîll naãeI addêessI
íelephone nîãbeêI íhe naãe of íhe plan oê coîníó íhaí íook íhe acíáon agaánsí óoîI
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íhe aád pêogêaãEsF ánvolvedI and a deíaáled êeason whó óoî waní a heaêáng. qhen óoî
ãaó sîbãáí óoîê êeqîesí one of íhese waósW
 qo íhe coîníó welfaêe depaêíãení aí íhe addêess shown on íhe noíáce.
 qo íhe Caláfoênáa aepaêíãení of pocáal peêvácesW
píaíe eeaêángs aávásáon
m.l. Box VQQOQPI jaál píaíáon VJNTJPT
pacêaãeníoI Caláfoênáa VQOQQJOQPM
 qo íhe píaíe eeaêángs aávásáon aí fax nîãbeê VNSJSRNJRONM oê VNSJSRNJOTUV.
O. voî ãaó ãake a íollJfêee call ío êeqîesí a píaíe caáê eeaêáng aí íhe followáng nîãbeê.
ff óoî decáde ío ãake a êeqîesí bó phoneI óoî shoîld be awaêe íhaí íhe phone lánes
aêe veêó bîsó.
Call íhe Caláfoênáa aepaêíãení of pocáal peêváces aí NJUMMJVROJRORP. qaa îseês shoîld call
NJUMMJVROJUPQV.
My problem is about a Medicare service or item. What will happen at the Level 2
Appeal?
An fndependení oeváew bníáíó wáll do a caêefîl êeváew of íhe ievel N decásáonI and decáde
wheíheê áí shoîld be changed.
 voî do noí need ío êeqîesí íhe ievel O Appeal. te wáll aîíoãaíácalló send anó denáals
Eán whole oê án paêíF ío íhe fndependení oeváew bníáíó. voî wáll be noíáfáed when íhás
happens.
 qhe fndependení oeváew bníáíó ás háêed bó jedácaêe and ás noí connecíed wáíh íhás plan.
 voî ãaó ask foê a copó of óoîê fále. te aêe allowed ío chaêge óoî a fee foê copóáng and
sendáng íhás ánfoêãaíáon ío óoî.

qhe fndependení oeváew bníáíó ãîsí gáve óoî an answeê ío óoîê ievel O Appeal wáíhán
PM calendaê daós of when áí geís óoîê appeal. qhás êîle appláes áf óoî sení óoîê appeal
befoêe geííáng ãedácal seêváces oê áíeãs.
» eoweveêI áf íhe fndependení oeváew bníáíó needs ío gaíheê ãoêe ánfoêãaíáon íhaí
ãaó benefáí óoîI áí can íake îp ío NQ ãoêe calendaê daós. ff íhe fob needs exíêa
daós ío ãake a decásáonI áí wáll íell óoî bó leííeê.

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If you had "fast appeal´ at Level 1, you will automatically have a fast appeal at Level O.
qhe êeváew oêganázaíáon ãîsí gáve óoî an answeê wáíhán TO hoîês of when áí geís óoîê
appeal.
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» eoweveêI áf íhe fndependení oeváew bníáíó needs ío gaíheê ãoêe ánfoêãaíáon íhaí
ãaó benefáí óoîI áí can íake îp ío NQ ãoêe calendaê daós. ff íhe fob needs exíêa
daós ío ãake a decásáonI áí wáll íell óoî bó leííeê.
Will my benefits continue during Level 2 appeals?
ff óoîê pêobleã ás aboîí a seêváce oê áíeã coveêed bó jedácaêeI óoîê benefáís foê íhaí seêváce
oê áíeã wáll noí coníánîe dîêáng íhe ievel O appeals pêocess wáíh íhe fndependení oeváew
bníáíó.
ff óoîê pêobleã ás aboîí a seêváce oê áíeã coveêed bó jedáJCal and óoî ask foê a píaíe caáê
eeaêángI óoîê jedáJCal benefáís foê íhaí seêváce oê áíeã wáll coníánîe îníál a heaêáng decásáon
ás ãade. voî ãîsí ask foê a heaêáng befoêe íhe daíe íhaí óoîê benefáís aêe changed oê íaken
awaó án oêdeê ío geí íhe saãe benefáís îníál óoîê heaêáng.
How will I find out about the decision?
ff óoîê ievel O Appeal was an fndependení jedácal oeváewI íhe aepaêíãení of janaged
eealíh Caêe wáll send óoî a leííeê explaánáng íhe decásáon ãade bó íhe docíoês who êeváewed
óoîê case.

ff íhe fndependení jedácal oeváew decásáon ás Yes ío paêí oê all of whaí óoî asked foêI we
ãîsí pêováde íhe seêváce oê íêeaíãení.

ff íhe fndependení jedácal oeváew decásáon ás No ío paêí oê all of whaí óoî asked foêI áí
ãeans íheó agêee wáíh íhe ievel N decásáon. voî can síáll geí a píaíe caáê eeaêáng. do ío
page NSO foê ánfoêãaíáon aboîí askáng foê a píaíe caáê eeaêáng.
ff óoîê ievel O Appeal was a píaíe caáê eeaêángI íhe Caláfoênáa aepaêíãení of pocáal peêváces
wáll send óoî a leííeê explaánáng áís decásáon.

ff íhe píaíe caáê eeaêáng decásáon ás Yes ío paêí oê all of whaí óoî asked foêI we ãîsí
coãpló wáíh íhe decásáon. te ãîsí coãpleíe íhe descêábed acíáonEsF wáíhán PM calendaê
daós of íhe daíe we êeceáved a copó of íhe decásáon.

ff íhe píaíe caáê eeaêáng decásáon ás No ío paêí oê all of whaí óoî asked foêI áí ãeans íheó
agêee wáíh íhe ievel N decásáon. te ãaó síop anó aád paád pendáng óoî aêe êeceáváng.
ff óoîê ievel O Appeal wení ío íhe jedácaêe fndependení oeváew bníáíóI áí wáll send óoî a
leííeê explaánáng áís decásáon.
?

ff íhe fndependení oeváew bníáíó saós Yes ío paêí oê all of whaí óoî asked foêI we ãîsí
aîíhoêáze íhe ãedácal caêe coveêage wáíhán TO hoîês oê gáve óoî íhe seêváce oê áíeã wáíhán
14 calendar days from the date we receive the IRE’s decision.

ff íhe fndependení oeváew bníáíó saós No ío paêí oê all of whaí óoî asked foêI áí ãeans
íheó agêee wáíh íhe ievel N decásáon. qhás ás called "upholding the decision.´ fí ás also
called "turning down your appeal.´
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If the decision is No for all or part of what I asked for, can I make another
appeal?
ff óoîê ievel O Appeal was an fndependení jedácal oeváewI óoî can êeqîesí a píaíe caáê
eeaêáng. do ío page NSO foê ánfoêãaíáon aboîí askáng foê a píaíe caáê eeaêáng.
ff óoîê ievel O Appeal was a píaíe caáê eeaêángI óoî ãaó ask foê a êeheaêáng wáíhán PM daós
afíeê óoî êeceáve íhe decásáon. voî ãaó also ask foê âîdácáal êeváew of a píaíe caáê eeaêáng
denáal bó fáláng a peíáíáon án pîpeêáoê Coîêí Eîndeê Code of Cávál mêocedîêe pecíáon NMVQ.RF
wáíhán one óeaê afíeê óoî êeceáve íhe decásáon. voî cannoí ask foê an fjo áf óoî alêeadó had
a píaíe caáê eeaêáng on íhe saãe ássîe.
ff óoîê ievel O Appeal wení ío íhe jedácaêe fndependení oeváew bníáíóI óoî can appeal
agaán onló áf íhe dollaê valîe of íhe seêváce oê áíeã óoî waní ãeeís a ceêíaán ãánáãîã
aãoîní. qhe leííeê óoî geí fêoã íhe fob wáll explaán addáíáonal appeal êághís óoî ãaó have.
pee pecíáon V of íhás chapíeê foê ãoêe ánfoêãaíáon on addáíáonal levels of appeal.
Section 5.5: Appeal a County’s decision regarding authorized hours for IHSS
benefits
fnJeoãe pîppoêíáve peêváces EfeppF benefáís aêe deíeêãáned bó óoîê coîníó socáal woêkeêI
noí oîê plan. qhe coîníó socáal woêkeê wáll assess íhe íópes of seêváces óoî need and íhe
nîãbeê of hoîês íhe coîníó wáll aîíhoêáze foê each of íhese seêváces. ff óoî waní ío appeal
the county’s decision regarding authorized hours for IHSS benefits, you must request a State
caáê eeaêáng.
voî must file a request for a State Fair Hearing within 90 days after the date of the county’s
acíáon oê ánacíáon.
qheêe aêe íwo waós ío ask foê a píaíe caáê eeaêángW
N. cáll oîí íhe back of íhe noíáce of acíáon foêã and send áí ío íhe addêess ándácaíedI oê
send a leííeê íoW
píaíe eeaêángs aávásáon
aepaêíãení of pocáal peêváces
m.l. Box VQQOQPI jaál píaíáon VJNTJPT
pacêaãeníoI Caláfoênáa VQOQQJOQPM
lo
O. Call íhe Caláfoênáa aepaêíãení of pocáal peêváces aí NJUMMJVROJRORP. qaa îseês
shoîld call NJUMMJVROJUPQV.
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Section 5.6: Payment problems
ff óoî waní ío ask îs foê paóãení foê ãedácal caêeI síaêí bó êeadáng Chapíeê T of íhás bookleíW
Asking us to pay a bill you have gotten for covered services or drugs. Chapíeê T descêábes
íhe sáíîaíáons án whách óoî ãaó need ío ask foê êeáãbîêseãení oê ío paó a báll óoî have
êeceáved fêoã a pêovádeê. fí also íells how ío send îs íhe papeêwoêk íhaí asks îs foê paóãení.
How do I ask the plan to pay me back for medical services or items I paid for?
voî aêe noí êesponsáble foê jedácaêe cosís excepí maêí a coJpaós. rndeê soãe
cáêcîãsíancesI óoî ãaó have cosí shaêáng foê jedáJCal seêvácesI sîch as fepp and nîêsáng
facáláíó síaós.
ff óoî aêe askáng ío be paád backI óoî aêe askáng foê a coveêage decásáon. te wáll see áf íhe
seêváce oê áíeã óoî paád foê ás a coveêed seêváce oê áíeãI and we wáll check ío see áf óoî
followed all íhe êîles foê îsáng óoîê coveêage.
 ff íhe ãedácal caêe óoî paád foê ás coveêed and óoî followed all íhe êîlesI we wáll send
óoî íhe paóãení foê óoîê ãedácal caêe wáíhán SM calendaê daós afíeê we geí óoîê
êeqîesí.
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 ío óoîê êeqîesí
foê a coveêage decásáon.
 ff íhe ãedácal caêe ás not coveêedI oê óoî dád not follow all íhe êîlesI we wáll send óoî a
leííeê íelláng óoî we wáll noí paó foê íhe seêváce oê áíeãI and explaánáng whó.
What if the plan says they will not pay?
ff óoî do noí agêee wáíh oîê decásáonI you can make an appeal. collow íhe appeals pêocess
descêábed án pecíáon R.P. then óoî aêe followáng íhese ánsíêîcíáonsI please noíeW
 ff óoî ãake an appeal foê êeáãbîêseãeníI we ãîsí gáve óoî oîê answeê wáíhán SM calendaê daós afíeê we geí óoîê appeal.
 ff óoî aêe askáng îs ío paó óoî back foê ãedácal caêe óoî have alêeadó êeceáved and
paád foê óoîêselfI óoî aêe noí allowed ío ask foê a fasí appeal.

If we answer "no´ to your appeal and the service or item is usually covered by Medicare,
we wáll aîíoãaíácalló send óoîê case ío íhe fndependení oeváew bníáíó. te wáll noíáfó óoî
bó leííeê áf íhás happens.
o ff íhe fob êeveêses oîê decásáon and saós we shoîld paó óoîI we ãîsí send íhe
paóãení ío óoî oê ío íhe pêovádeê wáíhán PM calendaê daós. ff íhe answeê ío óoîê
appeal ás Yes aí anó síage of íhe appeals pêocess afíeê ievel OI we ãîsí send íhe
paóãení óoî asked foê ío óoî oê ío íhe pêovádeê wáíhán SM calendaê daós.
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o ff íhe fob saós No ío óoîê appealI áí ãeans íheó agêee wáíh oîê decásáon noí ío
appêove óoîê êeqîesí. Eqhás ás called "upholding the decision.´ It is also called
"turning down your appeal.´) The letter you get will explain additional appeal rights
óoî ãaó have. voî can appeal agaán onló áf íhe dollaê valîe of íhe seêváce oê áíeã
óoî waní ãeeís a ceêíaán ãánáãîã aãoîní. pee pecíáon V of íhás chapíeê foê
ãoêe ánfoêãaíáon on addáíáonal levels of appeal.

?
If we answer "no´ to your appeal and the service or item is usually coveêed bó jedáJCalI
óoî can fále a ievel O Appeal óoîêself Esee pecíáon R.Q of íhás chapíeêF.
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Section 6: Part D drugs Section 6.1: 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
voîê benefáís as a ãeãbeê of oîê plan ánclîde coveêage foê ãanó pêescêápíáon dêîgs. josí of íhese
drugs are "Part D drugs.´ There are a few drugs that Medicare Part D does not cover but that MediJ
Cal ãaó coveê. This section only applies to Part D drug appeals.
o qhe List of Covered Drugs (Drug List)I ánclîdes soãe dêîgs wáíh a E*F. qhese dêîgs aêe not
maêí a dêîgs. Appeals oê coveêage decásáons aboîí dêîgs wáíh E*F sóãbol follow íhe pêocess
án Section 5.
Can I ask for a coverage decision or make an appeal about Part D prescription
drugs?
ves. eeêe aêe exaãples of coveêage decásáons óoî can ask îs ío ãake aboîí óoîê
maêí a dêîgsW
 voî ask îs ío ãake an excepíáon sîch asW
» Asking us to cover a Part D drug that is not on the plan’s List of Covered Drugs
Eaêîg iásíF
» Asking us to waive a restriction on the plan’s coverage for a drug (such as limits on
íhe aãoîní of íhe dêîg óoî can geíF
 You ask us if a drug is covered for you (for example, when your drug is on the plan’s
aêîg iásí bîí we êeqîáêe óoî ío geí appêoval fêoã îs befoêe we wáll coveê áí foê óoîF.
» Please note: ff óoîê phaêãacó íells óoî íhaí óoîê pêescêápíáon cannoí be fálledI óoî
wáll geí a noíáce explaánáng how ío coníací îs ío ask foê a coveêage decásáon.
 voî ask îs ío paó foê a pêescêápíáon dêîg óoî alêeadó boîghí. qhás ás askáng foê a
coveêage decásáon aboîí paóãení.
The legal term for a coverage decision about your Part D drugs is “coverage
determination.”
ff óoî dásagêee wáíh a coveêage decásáon we have ãadeI óoî can appeal oîê decásáon. qhás
secíáon íells óoî boíh how ío ask foê coveêage decásáons and how ío êeqîesí an appeal.
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rse íhe chaêí below ío help óoî deíeêãáne whách paêí has ánfoêãaíáon foê óoîê sáíîaíáonW
Which of these situations are you in?
ao óoî need a
drug that isn’t on
oîê aêîg iásí oê
need îs ío waáve
a êîle oê
êesíêácíáon on a
dêîg we coveê?
ao óoî waní îs ío
coveê a dêîg on oîê
aêîg iásí and óoî
beláeve óoî ãeeí
anó plan êîles oê
êesíêácíáons Esîch as
geííáng appêoval án
advanceF foê íhe
dêîg óoî need?
voî can ask îs ío
ãake an
excepíáon.
Eqhás ás a íópe of
coveêage
decásáon.F
voî can ask îs foê a
coveêage decásáon.
pkáp ahead ío
Section 6.4 of íhás
chapíeê.
píaêí wáíh Section
6.2 of íhás chapíeê.
Also see pecíáons
S.P and S.Q.
ao óoî
waní ío ask
îs ío paó
óoî back
foê a dêîg
óoî have
alêeadó
êeceáved
and paád
foê?
voî can ask
îs ío paó
óoî back.
Eqhás ás a
íópe of
coveêage
decásáon.F
pkáp ahead
ío Section
6.4 of íhás
chapíeê.
eave we
alêeadó
íold óoî
íhaí we wáll
noí coveê
oê paó foê a
dêîg án íhe
waó íhaí
óoî waní áí
ío be
coveêed oê
paád foê?
voî can
ãake
an appeal.
Eqhás ãeans
óoî
aêe askáng
îs ío
êeconsádeê.F
pkáp ahead
ío Section
6.5 of
íhás chapíeê.
Section 6.2: What is an exception?
An exception ás peêãássáon ío geí coveêage foê a dêîg íhaí ás noí noêãalló on oîê iásí of
Coveêed aêîgsI oê ío îse íhe dêîg wáíhoîí ceêíaán êîles and láãáíaíáons. ff a dêîg ás noí on oîê
iásí of Coveêed aêîgsI oê ás noí coveêed án íhe waó óoî woîld lákeI óoî can ask îs ío ãake
an "exception.´
then óoî ask foê an excepíáonI óoîê docíoê oê oíheê pêescêábeê wáll need ío explaán íhe
ãedácal êeasons whó óoî need íhe excepíáon.
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eeêe aêe exaãples of excepíáons íhaí óoî oê óoîê docíoê oê anoíheê pêescêábeê can ask îs ío
ãakeW
N. Coveêáng a maêí a dêîg íhaí ás noí on oîê List of Covered Drugs Eaêîg iásíF.
O. oeãováng a êesíêácíáon on oîê coveêage. qheêe aêe exíêa êîles oê êesíêácíáons íhaí appló ío ceêíaán
dêîgs on oîê aêîg iásí Efoê ãoêe ánfoêãaíáonI go ío Chapíeê RF.
 qhe exíêa êîles and êesíêácíáons on coveêage foê ceêíaán dêîgs ánclîdeW
» Beáng êeqîáêed ío îse íhe geneêác veêsáon of a dêîg ánsíead of íhe bêand naãe dêîg.
» deííáng plan appêoval befoêe we wáll agêee ío coveê íhe dêîg foê óoî. Eqhás ás
sometimes called "prior authorization.´)
» nîaníáíó láãáís. coê soãe dêîgsI íhe plan láãáís íhe aãoîní of íhe dêîg óoî can have.
The legal term for asking for removal of a restriction on coverage for a drug is
sometimes called asking for a “formulary exception.”
Section 6.3: Important things to know about asking for exceptions
Your doctor or other prescriber must tell us the medical reasons
voîê docíoê oê oíheê pêescêábeê ãîsí gáve îs a síaíeãení explaánáng íhe ãedácal êeasons foê
êeqîesíáng an excepíáon. lîê decásáon aboîí íhe excepíáon wáll be fasíeê áf óoî ánclîde íhás
ánfoêãaíáon fêoã óoîê docíoê oê oíheê pêescêábeê when óoî ask foê íhe excepíáon.
qópácallóI oîê aêîg iásí ánclîdes ãoêe íhan one dêîg foê íêeaíáng a paêíácîlaê condáíáon. qhese
different possibilities are called "alternative´ drugs. If an alternative drug would be just as
effecíáve as íhe dêîg óoî aêe askáng foêI and woîld noí caîse ãoêe sáde effecís oê oíheê
healíh pêobleãsI we wáll geneêalló not appêove óoîê êeqîesí foê an excepíáon.
We will say Yes or No to your request for an exception
 ff we saó Yes ío óoîê êeqîesí foê an excepíáonI íhe excepíáon îsîalló lasís îníál íhe end
of íhe calendaê óeaê. qhás ás íêîe as long as óoîê docíoê coníánîes ío pêescêábe íhe dêîg
foê óoî and íhaí dêîg coníánîes ío be safe and effecíáve foê íêeaíáng óoîê condáíáon.
 ff we saó No ío óoîê êeqîesí foê an excepíáonI óoî can ask foê a êeváew of oîê decásáon
bó ãakáng an appeal. pecíáon S.R íells how ío ãake an appeal áf we saó No.
qhe nexí secíáon íells óoî how ío ask foê a coveêage decásáonI ánclîdáng an excepíáon.
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Section 6.4: How to ask for a coverage decision about a Part D drug or
reimbursement for a Part D Drug, including an exception
What to do
 Ask foê íhe íópe of coveêage decásáon
óoî waní. CallI wêáíeI oê fax îs ío ãake
óoîê êeqîesí. voîI óoîê êepêeseníaíáveI
oê óoîê docíoê Eoê oíheê pêescêábeêF can
do íhás. voî can call îs aí NJUUUJPRM
PQQT Eqqv TNNFI jondaó íhêoîgh cêádaó
fêoã U a.ã. ío U p.ã.
 voî oê óoîê docíoê Eoê oíheê pêescêábeêF
oê soãeone else who ás acíáng on óoîê
behalf can ask foê a coveêage decásáon.
voî can also have a lawóeê ací on óoîê
behalf.
oead pecíáon Q ío fánd oîí how ío gáve
peêãássáon ío soãeone else ío ací as
óoîê êepêeseníaíáve.

voî do noí need ío gáve óoîê docíoê
oê oíheê pêescêábeê wêáííen peêãássáon
ío ask îs foê a coveêage decásáon on
óoîê behalf.
At a glance: How to ask for a coverage
decision about a drug or payment
CallI wêáíeI oê fax îs ío askI oê ask óoîê
êepêeseníaíáve oê docíoê oê oíheê
pêescêábeê ío ask. te wáll gáve óoî an
answeê on a síandaêd coveêage decásáon
wáíhán TO hoîês. te wáll gáve óoî an
answeê on êeáãbîêsáng óoî foê a maêí a
dêîg óoî alêeadó paád foê wáíhán NQ
calendaê daós.
 ff óoî aêe askáng foê an excepíáonI
ánclîde íhe sîppoêíáng síaíeãení fêoã
óoîê docíoê oê oíheê pêescêábeê.
 voî oê óoîê docíoê oê oíheê pêescêábeê
ãaó ask foê a fasí decásáon. Ecasí
decásáons îsîalló coãe wáíhán OQ
hoîês.F
 oead íhás chapíeê ío ãake sîêe óoî
qîaláfó foê a fasí decásáon! oead áí also
ío fánd ánfoêãaíáon aboîí decásáon
deadlánes.
 ff óoî waní ío ask îs ío paó óoî back foê
a dêîgI êead Chapíeê T pecíáon A of íhás
handbook. Chapíeê T descêábes íáães
when óoî ãaó need ío ask foê
êeáãbîêseãení. fí also íells how ío send
îs íhe papeêwoêk íhaí asks îs ío paó óoî back foê oîê shaêe of íhe cosí of a dêîg óoî
have paád foê.
 If you are requesting an exception, provide the "supporting statement.´ Your doctor or
oíheê pêescêábeê ãîsí gáve îs íhe ãedácal êeasons foê íhe dêîg excepíáon. te call íhás
the "supporting statement.´
voîê docíoê oê oíheê pêescêábeê can fax oê ãaál íhe síaíeãení ío îs. lê óoîê docíoê oê
oíheê pêescêábeê can íell îs on íhe phoneI and íhen fax oê ãaál a síaíeãení.
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.´
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 A síandaêd coveêage decásáon ãeans we wáll gáve óoî an answeê wáíhán TO hoîês afíeê
we get your doctor’s statement.
 A fasí coveêage decásáon ãeans we wáll gáve óoî an answeê wáíhán OQ hoîês afíeê we geí
your doctor’s statement.
» voî can geí a fasí coveêage decásáon only áf óoî aêe askáng foê a drug you have not
yet received. Evoî cannoí geí a fasí coveêage decásáon áf óoî aêe askáng îs ío paó
óoî back foê a dêîg óoî have alêeadó boîghí.F
» voî can geí a fasí coveêage decásáon only áf îsáng íhe síandaêd deadlánes coîld 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
leííeê wáll íell óoî íhaí.
ff óoî ask foê a fasí coveêage decision on your own (without your doctor’s or other
prescriber’s support), we will decide whether you get a fast coveêage decásáon.
ff we decáde ío gáve óoî a síandaêd decásáonI we wáll send óoî a leííeê íelláng óoî
íhaí. qhe leííeê wáll íell óoî how ío ãake a coãplaání aboîí oîê decásáon ío gáve óoî a
standard decision. You can file a "fast complaint´ and get a response to your
coãplaání wáíhán OQ hoîês.
» ff we decáde íhaí óoîê ãedácal condáíáon does noí ãeeí íhe êeqîáêeãenís foê a fasí
coveêage decásáonI we wáll send óoî a leííeê íhaí saós so Eand we wáll îse íhe
síandaêd deadlánes ánsíeadF.
The legal term for “fast coverage decision” is “expedited coverage determination.”
Deadlines for a “fast coverage decision”
 ff we aêe îsáng íhe fasí deadlánesI we ãîsí gáve óoî oîê answeê wáíhán OQ hoîês. qhás
ãeans wáíhán OQ hoîês afíeê we geí óoîê êeqîesí. lêI áf óoî aêe askáng foê an excepíáonI
24 hours after we get your doctor’s or prescriber’s statement supporting your request.
te wáll gáve óoî oîê answeê sooneê áf óoîê healíh êeqîáêes îs ío.
ff we do noí ãeeí íhás deadláneI we wáll send óoîê êeqîesí on ío ievel O of íhe appeals
pêocess. Aí ievel OI an oîísáde ándependení oêganázaíáon wáll êeváew óoîê êeqîesí.

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If our answer is Yes ío paêí oê all of whaí óoî asked foêI we ãîsí gáve óoî íhe coveêage
wáíhán OQ hoîês afíeê we geí óoîê êeqîesí or your doctor’s or prescriber’s statement
sîppoêíáng óoîê êeqîesí.
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
If our answer is No ío paêí oê all of whaí óoî asked foêI we wáll send óoî a leííeê íhaí
explaáns whó we saád No. qhe leííeê wáll also explaán how óoî can appeal oîê decásáon.
Deadlines for a “standard coverage decision” about a drug you have not
yet received
 ff we aêe îsáng íhe síandaêd deadlánesI we ãîsí gáve óoî oîê answeê wáíhán TO hoîês afíeê we geí óoîê êeqîesí oêI áf óoî aêe askáng foê an excepíáonI afíeê we geí óoîê
doctor’s or prescriber’s supporting statement. We will give you our answer sooner if
óoîê healíh êeqîáêes áí.
 ff we do noí ãeeí íhás deadláneI we wáll send óoîê êeqîesí on ío ievel O of íhe appeals pêocess. Aí ievel OI an fndependení oeváew bníáíó wáll êeváew óoîê êeqîesí.

If our answer is Yes ío paêí oê all of whaí óoî asked foêI we ãîsí appêove oê gáve íhe
coveêage wáíhán TO hoîês afíeê we geí óoîê êeqîesí oêI áf óoî aêe askáng foê
an exception, your doctor’s or prescriber’s supporting statement.

If our answer is No ío paêí oê all of whaí óoî asked foêI we wáll send óoî a leííeê
íhaí explaáns whó we saád No. qhe leííeê wáll also explaán how óoî can appeal oîê
decásáon.
Deadlines for a “standard coverage decision” about payment for a drug you
have already bought
 te ãîsí gáve óoî oîê answeê wáíhán NQ calendaê daós afíeê we geí óoîê êeqîesí.
 ff we do noí ãeeí íhás deadláneI we wáll send óoîê êeqîesí ío ievel O of íhe appeals pêocess. Aí level OI an fndependení oeváew bníáíó wáll êeváew óoîê êeqîesí.
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
If our answer is Yes ío paêí oê all of whaí óoî asked foêI we wáll ãake paóãení ío óoî
wáíhán NQ calendaê daós

explaáns whó we saád No. qhás síaíeãení wáll also explaán how óoî can appeal oîê
decásáon.
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Section 6.5: Level 1 Appeal for Part D drugs
 qo síaêí óoîê appealI óoîI óoîê
docíoê oê oíheê pêescêábeêI oê óoîê
êepêeseníaíáve ãîsí coníací îs.
 ff óoî aêe askáng foê a síandaêd
appealI óoî can ãake óoîê appeal
bó sendáng a êeqîesí án wêáíáng.
voî ãaó also ask foê an appeal bó
calláng îs aí NJUUUJPRMJPQQT Eqqv
TNNFI jondaó íhêoîgh cêádaó fêoã
U a.ã. ío U p.ã.
 ff óoî waní a fasí appealI óoî ãaó
ãake óoîê appeal án wêáíáng oê óoî
ãaó call îs.
At a glance: How to make a Level 1
Appeal
voîI óoîê docíoê oê pêescêábeêI oê óoîê
êepêeseníaíáve ãaó pîí óoîê êeqîesí án
wêáíáng and ãaál oê fax áí ío îs. voî ãaó
also ask foê an appeal bó calláng îs.
 Ask wáíhán SM calendaê daós of íhe
decásáon óoî aêe appealáng. ff óoî ãáss
íhe deadláne foê a good êeasonI óoî
ãaó síáll appeal.
 voîI óoîê docíoê oê pêescêábeêI oê óoîê
êepêeseníaíáve can call îs ío ask foê a
 jake óoîê appeal êeqîesí wáíhán
fasí appeal.
SM calendaê daós fêoã íhe daíe on
íhe noíáce we sení ío íell óoî oîê
decásáon. ff óoî ãáss íhás deadláne
and have a good êeason foê
deadlánes.
ãássáng áíI we ãaó gáve óoî ãoêe
íáãe ío ãake óoî appeal. coê
exaãpleI good êeasons foê ãássáng
íhe deadláne woîld be áf óoî have a
seêáoîs állness íhaí kepí óoî fêoã coníacíáng îs oê áf we gave óoî áncoêêecí oê
áncoãpleíe ánfoêãaíáon aboîí íhe deadláne foê êeqîesíáng an appeal.
The legal term for an appeal to the plan about a Part D drug coverage decision
is plan “redetermination.”
 voî can ask foê a copó of íhe ánfoêãaíáon án óoîê appeal and add ãoêe ánfoêãaíáon.
 voî have íhe êághí ío ask îs foê a copó of íhe ánfoêãaíáon aboîí óoîê appeal. te aêe
allowed ío chaêge a fee foê copóáng and sendáng íhás ánfoêãaíáon ío óoî.
» ff óoî wáshI óoî and óoîê docíoê oê oíheê pêescêábeê ãaó gáve îs addáíáonal
ánfoêãaíáon ío sîppoêí óoîê appeal.
If your health requires it, ask for a “fast appeal”
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 ff óoî aêe appealáng a decásáon oîê plan ãade aboîí a dêîg óoî have noí óeí êeceávedI
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´ in Section S.Q of íhás chapíeê.
The legal term for “fast appeal” is “expedited reconsideration.”
Our plan will review your appeal and give you our decision
 te íake anoíheê caêefîl look aí all of íhe ánfoêãaíáon aboîí óoîê coveêage êeqîesí. te
check ío see áf we weêe followáng all íhe êîles when we saád No ío óoîê êeqîesí. te
ãaó coníací óoî oê óoîê docíoê oê oíheê pêescêábeê ío geí ãoêe ánfoêãaíáon.
Deadlines for a “fast appeal”
 ff we aêe îsáng íhe fasí deadlánesI we wáll gáve óoî oîê answeê wáíhán TO hoîês afíeê we
geí óoîê appealI oê sooneê áf óoîê healíh êeqîáêes áí.
 ff we do noí gáve óoî an answeê wáíhán TO hoîêsI we wáll send óoîê êeqîesí on ío ievel
O of íhe appeals pêocess. Aí ievel OI an fndependení oeváew bníáíó wáll êeváew óoîê
appeal.

If our answer is Yes ío paêí oê all of whaí óoî asked foêI we ãîsí gáve íhe coveêage
wáíhán TO hoîês afíeê we geí óoîê appeal.

explaáns whó we saád No.
Deadlines for a “standard appeal”
 ff we aêe îsáng íhe síandaêd deadlánesI we ãîsí gáve óoî oîê answeê wáíhán T calendaê
daós afíeê we geí óoîê appealI oê sooneê áf óoîê healíh êeqîáêes áí. ff óoî íhánk óoîê
health requires it, you should ask for a "fast appeal.´
 ff we do noí gáve óoî a decásáon wáíhán T calendaê daósI we wáll send óoîê êeqîesí ío
ievel O of íhe appeals pêocess. Aí ievel OI an fndependení oeváew bníáíó wáll êeváew
óoîê appeal.

If our answer is Yes ío paêí oê all of whaí óoî asked foêW
» ff we appêove a êeqîesí foê coveêageI we ãîsí gáve óoî íhe coveêage as qîáckló as
óoîê healíh êeqîáêesI bîí no laíeê íhan T calendaê daós afíeê we geí óoîê appeal.
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
» ff we appêove a êeqîesí ío paó óoî back foê a dêîg óoî alêeadó boîghíI we wáll send
paóãení ío óoî wáíhán PM calendaê
daós afíeê we geí óoîê appeal
êeqîesí.
Appeal
If our answer is No ío paêí oê all of
whaí óoî asked foêI we wáll send óoî a
leííeê íhaí explaáns whó we saád No and
íells how ío appeal oîê decásáon.
Section 6.6: Level 2 Appeal for Part
D drugs
ff we saó No ío óoîê appealI óoî íhen
choose wheíheê ío accepí íhás decásáon oê
coníánîe bó ãakáng anoíheê appeal. ff óoî
decáde ío go on ío a ievel O AppealI íhe
fndependení oeváew bníáíó wáll êeváew oîê
decásáon.
 ff óoî waní íhe fndependení oeváew
bníáíó ío êeváew óoîê caseI óoîê
appeal êeqîesí ãîsí be án wêáíáng.
qhe leííeê we send aboîí oîê decásáon
án íhe ievel N Appeal wáll explaán how
ío êeqîesí íhe ievel O Appeal.
ff óoî waní íhe fndependení oeváew
lêganázaíáon ío êeváew óoîê caseI óoîê
appeal êeqîesí ãîsí be án wêáíáng.
 Ask wáíhán SM daós of íhe decásáon óoî
aêe appealáng. ff óoî ãáss íhe deadláne
foê a good êeasonI óoî ãaó síáll
appeal.
voîI óoîê docíoê oê oíheê pêescêábeêI oê
óoîê êepêeseníaíáve can êeqîesí íhe
ievel O Appeal.
deadlánes.
 then óoî ãake an appeal ío íhe fndependení oeváew bníáíóI we wáll send íheã óoîê
case fále. voî have íhe êághí ío ask îs foê a copó of óoîê case fále. te aêe allowed ío
chaêge óoî a fee foê copóáng and sendáng íhás ánfoêãaíáon ío óoî.
 voî have a êághí ío gáve íhe fndependení oeváew bníáíó oíheê ánfoêãaíáon ío sîppoêí
óoîê appeal.
 qhe fndependení oeváew bníáíó ás an ándependení oêganázaíáon íhaí ás háêed bó
jedácaêe. fí ás noí connecíed wáíh íhás plan and áí ás noí a goveênãení agencó.
 oeváeweês aí íhe fndependení oeváew bníáíó wáll íake a caêefîl look aí all of íhe
ánfoêãaíáon êelaíed ío óoîê appeal. qhe oêganázaíáon wáll send óoî a leííeê explaánáng áís
decásáon.
Deadlines for “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 óoî an answeê
ío óoîê ievel O Appeal wáíhán TO hoîês afíeê geííáng óoîê appeal êeqîesí.
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 ff íhe fndependení oeváew bníáíó saós Yes ío paêí oê all of whaí óoî asked foêI we ãîsí
aîíhoêáze oê gáve óoî íhe dêîg coveêage wáíhán OQ hoîês afíeê we geí íhe decásáon.
Deadlines for “standard appeal” at Level 2
 ff óoî have a síandaêd appeal aí ievel OI íhe fndependení oeváew bníáíó ãîsí gáve óoî
an answeê ío óoîê ievel O Appeal wáíhán T calendaê daós afíeê áí geís óoîê appeal.
» ff íhe fndependení oeváew bníáíó saós Yes ío paêí oê all of whaí óoî asked foêI we
ãîsí aîíhoêáze oê gáve óoî íhe dêîg coveêage wáíhán TO hoîês afíeê we geí íhe
decásáon.
» ff íhe fndependení oeváew bníáíó appêoves a êeqîesí ío paó óoî back foê a dêîg óoî
alêeadó boîghíI we wáll send paóãení ío óoî wáíhán PM calendaê daós afíeê we geí
íhe decásáon.
What if the Independent Review Entity says No to your Level 2 Appeal?
No ãeans íhe fndependení oeváew bníáíó agêees wáíh oîê decásáon noí ío appêove óoîê
request. This is called "upholding the decision.´ It is also called "turning down your appeal.´
ff íhe dollaê valîe of íhe dêîg coveêage óoî waní ãeeís a ceêíaán ãánáãîã aãoîníI óoî can
ãake anoíheê appeal aí ievel P. qhe leííeê óoî geí fêoã íhe fndependení oeváew bníáíó wáll
íell óoî íhe dollaê aãoîní needed ío coníánîe wáíh íhe appeals pêocess. qhe ievel P Appeal
ás handled bó an adãánásíêaíáve law âîdge.
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Section 7: Asking us to cover a longer hospital stay
then óoî aêe adãáííed ío a hospáíalI óoî have íhe êághí ío geí all hospáíal seêváces íhaí we
coveê íhaí aêe necessaêó ío dáagnose and íêeaí óoîê állness oê ánâîêó.
aîêáng óoîê coveêed hospáíal síaóI óoîê docíoê and íhe hospáíal síaff wáll be woêkáng wáíh óoî
ío pêepaêe foê íhe daó when óoî wáll leave íhe hospáíal. qheó wáll also help aêêange foê anó
caêe óoî ãaó need afíeê óoî leave.
 The day you leave the hospital is called your "discharge date.´
 voîê docíoê oê íhe hospáíal síaff wáll íell óoî whaí óoîê dáschaêge daíe ás.
ff óoî íhánk óoî aêe beáng asked ío leave íhe hospáíal íoo soonI óoî can ask foê a longeê
hospáíal síaó. qhás secíáon íells óoî how ío ask.
Section 7.1: Learning about your Medicare rights
táíhán íwo daós afíeê óoî aêe adãáííed ío íhe hospáíalI a casewoêkeê oê nîêse wáll gáve óoî a
noíáce called An Important Message from Medicare about Your Rights. ff óoî do noí geí íhás
noíáceI ask anó hospáíal eãploóee foê áí. ff óoî need helpI please call jeãbeê peêváces
Ephone nîãbeês aêe pêáníed on íhe back coveê of íhás bookleíF. voî can also call NJUMM
jbafCAob ENJUMMJSPPJQOOTFI OQ hoîês a daóI T daós a week. qqv îseês shoîld call NJUTT
QUSJOMQU.
Read this notice carefully and ask questions if you don’t understand. qhe Important Message
íells óoî aboîí óoîê êághís as a hospáíal paíáeníI ánclîdángW
 voîê êághí ío geí jedácaêeJcoveêed seêváces dîêáng and afíeê óoîê hospáíal síaó. voî
have íhe êághí ío know whaí íhese seêváces aêeI who wáll paó foê íheãI and wheêe óoî
can geí íheã.
 voîê êághí ío be a paêí of anó decásáons aboîí íhe lengíh of óoîê hospáíal síaó.
 voîê êághí ío know wheêe ío êepoêí anó conceêns óoî have aboîí íhe qîaláíó of óoîê
hospáíal caêe.
 voîê êághí ío appeal áf óoî íhánk óoî aêe beáng dáschaêged fêoã íhe hospáíal íoo soon.
voî shoîld ságn íhe jedácaêe noíáce ío show íhaí óoî goí áí and îndeêsíand óoîê êághís.
págnáng íhe noíáce does not ãean óoî agêee ío íhe dáschaêge daíe íhaí ãaó have been íold
ío óoî bó óoîê docíoê oê hospáíal síaff.
heep óoîê copó of íhe ságned noíáce so óoî wáll have íhe ánfoêãaíáon án áí áf óoî need áí.
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 qo look aí a copó of íhás noíáce án advanceI óoî can call jeãbeê peêváces aí
NJUUUJPRMJPQQT Eqqv TNNF. voî can also call NJUMM jbafCAob ENJUMMJSPPJQOOTFI OQ
hoîês a daóI T daós a week. qqv îseês shoîld call NJUTTJQUSJOMQU. qhe call ás fêee.
voî can also see íhe noíáce onláne aí híípsWLLwww.cãs.govLBkfLNO_eospáíalaáschaêgeAppealkoíáces.asp. 
ff óoî need helpI please call jeãbeê peêváces aí NJUUUJPRMJPQQT Eqqv TNNF. voî can
also call NJUMMJjbafCAob ENJUMMJSPPJQOOTFI OQ hoîês a daóI T daós a week. qqv îseês
shoîld call NJUTTJQUSJOMQU. qhe call ás fêee.
Section 7.2: Level 1 Appeal to change your hospital discharge date
ff óoî waní îs ío coveê óoîê ánpaíáení hospáíal seêváces foê a longeê íáãeI óoî ãîsí êeqîesí an
appeal. A nîaláíó fãpêoveãení lêganázaíáon wáll do íhe ievel N Appeal êeváew ío see áf óoîê
planned dáschaêge daíe ás ãedácalló appêopêáaíe foê óoî.
qo ãake an appeal ío change óoîê dáschaêge daíe call íhe nflI iávaníaI aíW 1-877-588-1123
(TTY 1-855-887-6668).
Call right away!
Call íhe nîaláíó fãpêoveãení lêganázaíáon before óoî leave íhe hospáíal and no laíeê íhan
óoîê planned dáschaêge daíe. An Important Message from Medicare about Your Rights
coníaáns ánfoêãaíáon on how ío êeach íhe nîaláíó fãpêoveãení lêganázaíáon.
 ff óoî call befoêe óoî leaveI óoî aêe allowed ío síaó án íhe hospáíal after
óoîê planned dáschaêge daíe without
paying for it whále óoî waáí ío geí íhe
decásáon on óoîê appeal fêoã íhe
nîaláíó fãpêoveãení lêganázaíáon.
 ff óoî do not call ío appealI and óoî
decáde ío síaó án íhe hospáíal afíeê
óoîê planned dáschaêge daíeI you
may have to pay all of the costs foê
hospáíal caêe óoî geí afíeê óoîê
planned dáschaêge daíe.

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At a glance: How to make
a Level 1 Appeal to change your
discharge date
Call íhe nîaláíó fãpêoveãení
lêganázaíáon foê óoîê síaíe aí 1-877588-1123 (TTY 1-855-887-6668) and
ask for a "fast review.´
Call befoêe óoî leave íhe hospáíal and
befoêe óoîê planned dáschaêge daíe.
ff óoî ãáss íhe deadláne foê coníacíáng íhe nîaláíó fãpêoveãení lêganázaíáon aboîí
óoîê appealI óoî can ãake óoîê appeal dáêecíló ío oîê plan ánsíead. coê deíaálsI see
pecíáon U.Q.
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
ff íhe nîaláíó fãpêoveãení lêganázaíáon wáll noí heaê óoîê êeqîesí ío coníánîe óoîê
hospáíal síaóI óoî ãaó also be able ío ask íhe Caláfoênáa aepaêíãení of janaged eealíh
Caêe EajeCF foê an fndependení jedácal oeváew. mlease go ío pecíáon R.Q ío leaên how
ío ask íhe ajeC foê an fndependení jedácal oeváew.
te waní ío ãake sîêe óoî îndeêsíand whaí óoî need ío do and whaí íhe deadlánes aêe.
 Ask for help if you need it. ff óoî have qîesíáons oê need help aí anó íáãeI please call
jeãbeê peêváces aí NJUUUJPRMJPQQT Eqqv TNNFI jondaó íhêoîgh cêádaó fêoã U a.ã. ío
U p.ã. voî can also call íhe eealíh fnsîêance Coînseláng and Advocacó mêogêaã
EefCAmF aí NJUMMJQPQJMOOO oê NJONPJPUPJQRNV Eqqv TNNF oê íhe Cal jedáConnecí
lãbîds mêogêaã aí NJURRJRMNJPMTT.
What is a Quality Improvement Organization?
fí ás a gêoîp of docíoês and oíheê healíh caêe pêofessáonals who aêe paád bó íhe fedeêal
goveênãení. qhese expeêís aêe noí paêí of oîê plan. qheó aêe paád bó jedácaêe ío check on
and help áãpêove íhe qîaláíó of caêe foê people wáíh jedácaêe.
Ask for a “fast review”
voî ãîsí ask íhe nîaláíó fãpêoveãení lêganázaíáon foê a “fast review” of óoîê dáschaêge.
Asking for a "fast review´ means you are asking for the organization to use the fast deadlines
foê an appeal ánsíead of îsáng íhe síandaêd deadlánes.
The legal term for “fast review” is “immediate review.”
What happens during the review?
 qhe êeváeweês aí íhe nîaláíó fãpêoveãení lêganázaíáon wáll ask óoî oê óoîê
êepêeseníaíáve whó óoî íhánk coveêage shoîld coníánîe afíeê íhe planned dáschaêge
date. You don’t have to prepare anóíháng án wêáíángI bîí óoî ãaó do so áf óoî wásh.
 qhe êeváeweês wáll look aí óoîê ãedácal êecoêdI íalk wáíh óoîê docíoêI and êeváew all of
íhe ánfoêãaíáon êelaíed ío óoîê hospáíal síaó.
 Bó noon of íhe daó afíeê íhe êeváeweês íell îs aboîí óoîê appealI óoî wáll geí a leííeê íhaí
gáves óoîê planned dáschaêge daíe. qhe leííeê explaáns íhe êeasons whó óoîê docíoêI íhe
hospáíalI and we íhánk áí ás êághí foê óoî ío be dáschaêged on íhaí daíe.
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The legal term for this written explanation is called the “Detailed Notice of
Discharge.” You can get a sample by calling Member Services at 1-888-350-3447
(TTY 711). You can also call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7
days a week. TTY users should call 1-877-486-2048 or you can see a sample notice
online at http://www.cms.hhs.gov/BNI/
What if the answer is Yes?
 ff íhe êeváew oêganázaíáon saós Yes ío óoîê appealI we ãîsí keep coveêáng óoîê hospáíal
seêváces foê as long as íheó aêe ãedácalló necessaêó.
What if the answer is No?
 ff íhe êeváew oêganázaíáon saós No ío óoîê appealI íheó aêe saóáng íhaí óoîê planned
dáschaêge daíe ás ãedácalló appêopêáaíe. ff íhás happensI oîê coveêage foê óoîê ánpaíáení
hospáíal seêváces wáll end aí noon on íhe daó after íhe nîaláíó fãpêoveãení
lêganázaíáon gáves óoî áís answeê.
 ff íhe êeváew oêganázaíáon saós No and óoî decáde ío síaó án íhe hospáíalI íhen óoî ãaó
have ío paó íhe fîll cosí of hospáíal caêe óoî geí afíeê noon on íhe daó afíeê íhe nîaláíó
fãpêoveãení lêganázaíáon gáves óoî áís answeê.
 ff íhe nîaláíó fãpêoveãení lêganázaíáon íîêns down óoîê appealI and óoî síaó án íhe
hospáíal afíeê óoîê planned dáschaêge daíeI íhen óoî can ãake a ievel O Appeal.
Section 7.3: Level 2 Appeal to change your hospital discharge date
ff íhe nîaláíó fãpêoveãení lêganázaíáon has íîêned down óoîê appealI and óoî síaó án íhe
hospáíal afíeê óoîê planned dáschaêge daíeI íhen óoî can ãake a ievel O Appeal. voî wáll
need ío coníací íhe nîaláíó fãpêoveãení lêganázaíáon agaán and ask foê anoíheê êeváew.
Ask foê íhe ievel O êeváew within 60 calendar days afíeê íhe daó when íhe nîaláíó
fãpêoveãení lêganázaíáon saád No ío óoîê ievel N Appeal. voî can ask foê íhás êeváew onló áf
óoî síaóed án íhe hospáíal afíeê íhe daíe íhaí óoîê coveêage foê íhe caêe ended.
voî can êeach íhe nflI iávaníaI aíW 1-877588-1123 (TTY 1-855-887-6668).
 oeváeweês aí íhe nîaláíó fãpêoveãení
lêganázaíáon wáll íake anoíheê caêefîl
look aí all of íhe ánfoêãaíáon êelaíed ío
óoîê appeal.
 táíhán NQ calendaê daós of êeceápí of
óoîê êeqîesí foê a second êeváewI íhe
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a Level 2 Appeal to change your
discharge date
lêganázaíáon foê óoîê síaíe and ask foê
anoíheê êeváew.
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nîaláíó fãpêoveãení lêganázaíáon êeváeweês wáll ãake a decásáon.
What happens if the answer is Yes?
 te ãîsí paó óoî back foê oîê shaêe of íhe cosís of hospáíal caêe óoî have êeceáved
sánce noon on íhe daó afíeê íhe daíe of óoîê fáêsí appeal decásáon. te ãîsí coníánîe pêovádáng coveêage foê óoîê ánpaíáení hospáíal caêe foê as long as áí ás ãedácalló
necessaêó.
 voî ãîsí coníánîe ío paó óoîê shaêe of íhe cosís and coveêage láãáíaíáons ãaó appló.
What happens if the answer is No?
fí ãeans íhe nîaláíó fãpêoveãení lêganázaíáon agêees wáíh íhe ievel N decásáon and wáll noí
change áí. qhe leííeê óoî geí wáll íell óoî whaí óoî can do áf óoî wásh ío coníánîe wáíh íhe
appeal pêocess.
ff íhe nîaláíó fãpêoveãení lêganázaíáon íîêns down óoîê ievel O AppealI óoî ãaó have ío
paó íhe fîll cosí foê óoîê síaó afíeê óoîê planned dáschaêge daíe.
voî ãaó also be able ío ask íhe ajeC foê an fndependení jedácal oeváew ío coníánîe óoîê
hospáíal síaó. mlease go ío pecíáon R.Q ío leaên how ío ask íhe ajeC foê an fndependení
jedácal oeváew.
Section 7.4: What happens if I miss an appeal deadline?
ff óoî ãáss appeal deadlánesI íheêe ás anoíheê waó ío ãake ievel N and ievel O AppealsI
called Alíeênaíe Appeals. Bîí íhe first two levels of appeal are different.
Level 1 Alternate Appeal to change your hospital discharge date
ff óoî ãáss íhe deadláne foê coníacíáng íhe nîaláíó fãpêoveãení lêganázaíáonI óoî can ãake
an appeal to us, asking for a "fast review.´ A fast review is an appeal that uses the fast
deadlánes ánsíead of íhe síandaêd deadlánes.
 aîêáng íhás êeváewI we íake a look aí all of
íhe ánfoêãaíáon aboîí óoîê hospáíal síaó.
te check ío see áf íhe decásáon aboîí
when óoî shoîld leave íhe hospáíal was
faáê and followed all íhe êîles.
At a glance: How to make a
Level 1 Alternate Appeal
 te wáll îse íhe fasí deadlánes êaíheê íhan
íhe síandaêd deadlánes foê gáváng óoî íhe
answeê ío íhás êeváew. te wáll gáve óoî oîê
decásáon wáíhán TO hoîês afíeê óoî ask foê a
"fast review.´
te wáll gáve óoî oîê decásáon
wáíhán TO hoîês.
Call oîê jeãbeê peêváces nîãbeê
and ask for a "fast review´ of your
hospáíal dáschaêge daíe.
 If we say Yes to your fast review, áí
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ãeans we agêee íhaí óoî síáll need ío be án íhe hospáíal afíeê íhe dáschaêge daíe. te
wáll keep coveêáng hospáíal seêváces foê as long as áí ás ãedácalló necessaêó.
fí also ãeans íhaí we agêee ío paó óoî back foê oîê shaêe of íhe cosís of caêe óoî have
êeceáved sánce íhe daíe when we saád óoîê coveêage woîld end.
 If we say No to your fast review, we aêe saóáng íhaí óoîê planned dáschaêge daíe was
ãedácalló appêopêáaíe. lîê coveêage foê óoîê ánpaíáení hospáíal seêváces ends on íhe
daó we saád coveêage woîld end.
» ff óoî síaóed án íhe hospáíal after óoîê planned dáschaêge daíeI íhen you may have
to pay the full cost of hospáíal caêe óoî goí afíeê íhe planned dáschaêge daíe.

qo ãake sîêe we weêe followáng all íhe êîles when we saád No ío óoîê fasí appealI we wáll
send your appeal to the "Independent Review Entity.´ When we do this, it means that
óoîê case ás automatically goáng ío ievel O of íhe appeals pêocess.
The legal term for “fast review” or “fast appeal” is “expedited appeal.”
Level 2 Alternate Appeal to change your hospital discharge date
te wáll send íhe ánfoêãaíáon foê óoîê ievel O Appeal ío íhe fndependení oeváew bníáíó wáíhán
OQ hoîês of when we gáve óoî oîê ievel N decásáon. ff óoî íhánk we aêe noí ãeeíáng íhás
deadláne oê oíheê deadlánesI óoî can ãake a coãplaání. pecíáon NM of íhás chapíeê íells how
ío ãake a coãplaání.
aîêáng íhe ievel O AppealI íhe Independent
Review Entity êeváews íhe decásáon we ãade
when we saád No to your "fast review.´ This
oêganázaíáon decádes wheíheê íhe decásáon we
ãade shoîld be changed.
 qhe fndependení oeváew bníáíó does
a "fast review´ of your appeal. The
êeváeweês îsîalló gáve óoî an answeê wáíhán TO hoîês.
At a glance: How to make a Level
2 Alternate Appeal
voî do noí have ío do anóíháng.
qhe plan wáll aîíoãaíácalló send
óoîê appeal ío íhe fndependení
oeváew bníáíó.
 qhe fndependení oeváew bníáíó ás an
ándependení oêganázaíáon íhaí ás háêed bó jedácaêe. qhás oêganázaíáon ás noí connecíed
wáíh oîê plan and áí ás noí a goveênãení agencó.
ánfoêãaíáon êelaíed ío óoîê appeal of óoîê hospáíal dáschaêge.
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 ff íhe fndependení oeváew bníáíó saós Yes ío óoîê appealI íhen we ãîsí paó óoî back
foê oîê shaêe of íhe cosís of hospáíal caêe óoî have êeceáved sánce íhe daíe of óoîê
planned discharge. We must also continue the plan’s coverage of your hospital services
foê as long as áí ás ãedácalló necessaêó.
 ff íhás oêganázaíáon saós No ío óoîê appealI áí ãeans íheó agêee wáíh îs íhaí óoîê
planned hospáíal dáschaêge daíe was ãedácalló appêopêáaíe.
qhe leííeê óoî geí fêoã íhe fndependení oeváew bníáíó wáll íell óoî whaí óoî can do áf óoî wásh ío coníánîe wáíh íhe êeváew pêocess. fí wáll gáve óoî íhe deíaáls aboîí how ío go on ío a ievel P AppealI whách ás handled bó a âîdge. voî ãaó also be able ío ask íhe ajeC foê an fndependení jedácal oeváew ío coníánîe
óoîê hospáíal síaó. mlease go ío pecíáon R.Q ío leaên how ío ask íhe ajeC foê an
fndependení jedácal oeváew.
Section 8: What to do if you think your home health care, skilled nursing
care, or Comprehensive Outpatient Rehabilitation Facility (CORF)
services are ending too soon
qhás secíáon ás aboîí íhe followáng íópes of caêe onlyW
 eoãe healíh caêe seêváces Eqhás does noí ánclîde fepp. coê fepp pêobleãs oê
coãplaánísI see pecíáon R.RF.
 pkálled nîêsáng caêe án a skálled nîêsáng facáláíó.
 oehabáláíaíáon caêe óoî aêe geííáng as an oîípaíáení aí a jedácaêeJappêoved
Coãpêehensáve lîípaíáení oehabáláíaíáon cacáláíó EClocF. rsîallóI íhás ãeans óoî aêe geííáng íêeaíãení foê an állness oê accádeníI oê óoî aêe êecoveêáng fêoã a ãaâoê
opeêaíáon.

táíh anó of íhese íhêee íópes of caêeI óoî have íhe êághí ío keep geííáng coveêed
seêváces foê as long as íhe docíoê saós óoî need áí.

then we decáde ío síop coveêáng anó of íheseI we ãîsí íell óoî befoêe óoîê
seêváces end. then óoîê coveêage foê íhaí caêe endsI we will stop paying for your
care.
ff óoî íhánk we aêe endáng íhe coveêage of óoîê caêe íoo soonI you can appeal our
decision. qhás secíáon íells óoî how ío ask foê an appeal.
Section 8.1: We will tell you in advance when your coverage will be ending
voî wáll êeceáve a noíáce aí leasí íwo daós befoêe we síop paóáng foê óoîê caêe.
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qhe wêáííen noíáce íells óoî íhe daíe when we wáll síop coveêáng óoîê caêe.
qhe wêáííen noíáce also íells óoî how ío appeal íhás decásáon.
voî oê óoîê êepêeseníaíáve shoîld ságn íhe wêáííen noíáce ío show íhaí óoî goí áí. págnáng áí
does noí ãean óoî agêee wáíh íhe plan íhaí áí ás íáãe ío síop geííáng íhe caêe.
then óoîê coveêage endsI we wáll síop paóáng foê óoîê caêe.
Section 8.2: Level 1 Appeal to continue your care
ff óoî íhánk we aêe endáng íhe coveêage of óoîê caêe íoo soonI óoî can appeal oîê decásáon.
qhás secíáon íells óoî how ío ask foê an appeal.
Befoêe óoî síaêíI îndeêsíand whaí óoî need ío do and whaí íhe deadlánes aêe.
 Meet the deadlines. qhe deadlánes aêe áãpoêíaní. Be sîêe íhaí óoî îndeêsíand and
follow íhe deadlánes íhaí appló ío íhángs óoî ãîsí do. qheêe aêe also deadlánes oîê plan
ãîsí follow. Eff óoî íhánk we aêe noí ãeeíáng oîê deadlánesI óoî can fále a coãplaání.
pecíáon NM of íhás chapíeê íells óoî how ío fále a coãplaání.F
Ask for help if you need it. ff óoî have
qîesíáons oê need help aí anó íáãeI please
call jeãbeê peêváces aí NJUUUJPRMJPQQT
Eqqv TNNFI jondaó íhêoîgh cêádaó fêoã U
a.ã. ío U p.ã. lê call óoîê píaíe eealíh
fnsîêance Assásíance mêogêaã aí NJUMM
QPQJMOOO Eqqv TNNF.
aîêáng a ievel N AppealI qhe nîaláíó
fãpêoveãení lêganázaíáon wáll êeváew óoîê
appeal and decáde wheíheê ío change íhe
decásáon we ãade. voî can fánd oîí how ío
call íheã bó êeadáng íhe Notice of Medicare
Non-Coverage.
Appeal to ask the plan to continue
your care
Call befoêe óoî leave íhe agencó oê
facáláíó íhaí ás pêovádáng óoîê caêe and
What is a Quality Improvement Organization?
fí ás a gêoîp of docíoês and oíheê healíh caêe pêofessáonals who aêe paád bó íhe fedeêal
goveênãení. qhese expeêís aêe noí paêí of oîê plan. qheó aêe paád bó jedácaêe ío check on
and help áãpêove íhe qîaláíó of caêe foê people wáíh jedácaêe.
What should you ask for?
Ask them for a "fastJtrack appeal.´ Thás ás an ándependení êeváew of wheíheê áí ás ãedácalló
appêopêáaíe foê îs ío end coveêage foê óoîê seêváces.
What is your deadline for contacting this organization?
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 voî ãîsí coníací íhe nîaláíó fãpêoveãení lêganázaíáon no later than noon of the day after you got the written notice telling you when we will stop covering your care.
 ff óoî ãáss íhe deadláne foê coníacíáng íhe nîaláíó fãpêoveãení lêganázaíáon aboîí
óoîê appealI óoî can ãake óoîê appeal dáêecíló ío îs ánsíead. coê deíaáls aboîí íhás oíheê waó ío ãake óoîê appealI see pecíáon U.Q.
 ff íhe nîaláíó fãpêoveãení lêganázaíáon wáll noí heaê óoîê êeqîesí ío coníánîe coveêage
of óoîê healíh caêe seêvácesI óoî ãaó be able ío ask íhe Caláfoênáa aepaêíãení of
janaged eealíh Caêe EajeCF foê an fndependení jedácal oeváew. mlease go ío pecíáon R.Q ío leaên how ío ask íhe ajeC foê an fndependení jedácal oeváew.
The legal term for the written notice is “Notice of Medicare Non-Coverage.”
To get a sample copy, call Member Services at 1-888-350-3447 (TTY 711) or
1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users
should call 1-877-486-2048. Or see a copy online at http://www.cms.hhs.gov/BNI/
What happens during the Quality Improvement Organization’s review?
 qhe êeváeweês aí íhe nîaláíó fãpêoveãení lêganázaíáon wáll ask óoî oê óoîê
êepêesentative why you think coverage for the services should continue. You don’t have
ío pêepaêe anóíháng án wêáíángI bîí óoî ãaó do so áf óoî wásh.
 then óoî ask foê an appealI íhe plan ãîsí wêáíe a leííeê explaánáng whó óoîê seêváces
shoîld end.
 qhe êeváeweês wáll also look aí óoîê ãedácal êecoêdsI íalk wáíh óoîê docíoêI and êeváew
ánfoêãaíáon íhaí oîê plan has gáven ío íheã.
 Within one full day after reviewers have all the information they need, they will
tell you their decision. voî wáll geí a leííeê explaánáng íhe decásáon.
The legal term for the letter explaining why your services should end is “Detailed
Explanation of Non-Coverage.”
What happens if the reviewers say Yes?
 ff íhe êeváeweês saó Yes ío óoîê appealI íhen we ãîsí keep pêovádáng óoîê coveêed
seêváces foê as long as íheó aêe ãedácalló necessaêó.
What happens if the reviewers say No?
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 ff íhe êeváeweês saó No ío óoîê appealI íhen óoîê coveêage wáll end on íhe daíe we íold óoî. te wáll síop paóáng oîê shaêe of íhe cosís of íhás caêe.
 ff óoî decáde ío keep geííáng íhe hoãe healíh caêeI skálled nîêsáng facáláíó caêeI oê
Coãpêehensáve lîípaíáení oehabáláíaíáon cacáláíó EClocF seêváces after íhe daíe óoîê
coveêage endsI íhen óoî wáll have ío paó íhe fîll cosí of íhás caêe óoîêself.
Section 8.3: Level 2 Appeal to continue your care
ff íhe nîaláíó fãpêoveãení lêganázaíáon saád No ío íhe appeal and óoî choose ío coníánîe
geííáng caêe afíeê óoîê coveêage foê íhe caêe has endedI óoî can ãake a ievel O Appeal.
voî can ask íhe nîaláíó fãpêoveãení lêganázaíáon ío íake anoíheê look aí íhe decásáon íheó
ãade aí ievel N. ff íheó saó íheó agêee wáíh íhe ievel N decásáonI óoî ãaó have ío paó íhe
fîll cosí foê óoîê hoãe healíh caêeI skálled nîêsáng facáláíó caêeI oê Coãpêehensáve lîípaíáení
oehabáláíaíáon cacáláíó EClocF seêváces after íhe daíe when we saád óoîê coveêage woîld
end. qhe nîaláíó fãpêoveãení lêganázaíáon wáll êeváew óoîê appeal and decáde wheíheê ío
change íhe decásáon we ãade. voî can fánd oîí how ío call íheã bó êeadáng íhe Notice of
Medicare Non-Coverage.
Ask foê íhe ievel O êeváew within 60
calendar days afíeê íhe daó when íhe
nîaláíó fãpêoveãení lêganázaíáon saád No
ío óoîê ievel N Appeal. voî can ask foê íhás
êeváew onló áf óoî coníánîed geííáng caêe
afíeê íhe daíe íhaí óoîê coveêage foê íhe
caêe ended.
 oeváeweês aí íhe nîaláíó fãpêoveãení
lêganázaíáon wáll íake anoíheê caêefîl
look aí all of íhe ánfoêãaíáon êelaíed ío
óoîê appeal.
Appeal to require that the plan
cover your care for longer
Call befoêe óoî leave íhe agencó oê facáláíó íhaí ás pêovádáng óoîê caêe and
 qhe nîaláíó fãpêoveãení lêganázaíáon wáll ãake áís decásáon wáíhán NQ calendaê daós of êeceápí of óoîê appeal
êeqîesí.
What happens if the review organization says Yes?
 te ãîsí paó óoî back foê oîê shaêe of íhe cosís of caêe óoî have êeceáved sánce íhe
daíe when we saád óoîê coveêage woîld end. te ãîsí coníánîe pêovádáng coveêage foê
íhe caêe foê as long as áí ás ãedácalló necessaêó.
What happens if the review organization says No?
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 fí ãeans íheó agêee wáíh íhe decásáon íheó ãade on íhe ievel N Appeal and wáll noí
change áí.
 qhe leííeê óoî geí wáll íell óoî whaí ío do áf óoî wásh ío coníánîe wáíh íhe êeváew
pêocess. fí wáll gáve óoî íhe deíaáls aboîí how ío go on ío íhe nexí level of appealI whách ás handled bó a âîdge.
 voî ãaó also be able ío ask íhe ajeC foê an fndependení jedácal oeváew ío coníánîe coveêage of óoîê healíh caêe seêváces. mlease go ío pecíáon R.Q ío leaên how ío ask íhe
ajeC foê an fndependení jedácal oeváew.
Section 8.4: What if you miss the deadline for making your Level 1 Appeal?
ff óoî ãáss appeal deadlánesI íheêe ás anoíheê waó ío ãake ievel N and ievel O AppealsI
called Alíeênaíe Appeals. Bîí íhe first two levels of appeal are different.
Level 1 Alternate Appeal to continue your care for longer
ff óoî ãáss íhe deadláne foê coníacíáng íhe nîaláíó fãpêoveãení lêganázaíáonI óoî can ãake
an appeal to us, asking for a "fast review.´ A fast review is an appeal that uses the fast
deadlánes ánsíead of íhe síandaêd deadlánes.
 aîêáng íhás êeváewI we íake a look aí all of íhe ánfoêãaíáon aboîí óoîê hospáíal síaó. te
check ío see áf íhe decásáon aboîí when
óoîê seêváces shoîld end was faáê and
followed all íhe êîles.
Alternate Appeal
 te wáll îse íhe fasí deadlánes êaíheê
Call oîê jeãbeê peêváces nîãbeê
íhan íhe síandaêd deadlánes foê gáváng
and ask for a "fast review.´
óoî íhe answeê ío íhás êeváew. te wáll
te wáll gáve óoî oîê decásáon wáíhán
gáve óoî oîê decásáon wáíhán TO hoîês
TO hoîês.
after you ask for a "fast review.´
 If we say Yes ío óoîê fasí êeváewI áí
ãeans we agêee íhaí we wáll keep coveêáng óoîê seêváces foê as long as áí ás ãedácalló necessaêó.
fí also ãeans íhaí we agêee ío paó óoî back foê oîê shaêe of íhe cosís of caêe óoî have
êeceáved sánce íhe daíe when we saád óoîê coveêage woîld end.
 If we say No ío óoîê fasí êeváewI we aêe saóáng íhaí síoppáng óoîê seêváces was ãedácalló appêopêáaíe. lîê coveêage ends as of íhe daó we saád coveêage
woîld end. » ff óoî coníánîe geííáng seêváces afíeê íhe daó we saád íheó woîld síopI you may
have to pay the full cost of íhe seêváces.
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
qo ãake sîêe we weêe followáng all íhe êîles when we saád No ío óoîê fasí appealI we wáll
send your appeal to the "Independent Review Entity.´ When we do this, it means that
óoîê case ás automatically goáng ío ievel O of íhe appeals pêocess.
The legal term for “fast review” or “fast appeal” is “expedited appeal.”
Level 2 Alternate Appeal to continue your care for longer
te wáll send íhe ánfoêãaíáon foê óoîê ievel O Appeal ío íhe fndependení oeváew bníáíó wáíhán
OQ hoîês of when we gáve óoî oîê ievel N decásáon. ff óoî íhánk we aêe noí ãeeíáng íhás
deadláne oê oíheê deadlánesI óoî can ãake a coãplaání. pecíáon NM of íhás chapíeê íells how
ío ãake a coãplaání.
aîêáng íhe ievel O AppealI íhe Independent
Review Entity êeváews íhe decásáon we ãade
when we saád No to your "fast review.´ This
oêganázaíáon decádes wheíheê íhe decásáon we
ãade shoîld be changed.
qhe fndependení oeváew bníáíó does a
"fast review´ of your appeal. The
êeváeweês îsîalló gáve óoî an answeê
wáíhán TO hoîês.
Appeal to require that the plan
continue your care
voî do noí have ío do anóíháng. qhe
plan wáll aîíoãaíácalló send óoîê
appeal ío íhe fndependení oeváew
lêganázaíáon.
 qhe fndependení oeváew bníáíó ás an
ándependení oêganázaíáon íhaí ás háêed bó
jedácaêe. qhás oêganázaíáon ás noí connecíed wáíh oîê planI and áí ás noí a goveênãení
agencó.
ánfoêãaíáon êelaíed ío óoîê appeal.
 If this organization says Yes ío óoîê appealI íhen we ãîsí paó óoî back foê oîê shaêe
of the costs of care. We must also continue the plan’s coveêage of óoîê seêváces foê as
long as áí ás ãedácalló necessaêó.
 If this organization says No ío óoîê appealI áí ãeans íheó agêee wáíh îs íhaí síoppáng
coveêage of seêváces was ãedácalló appêopêáaíe.
qhe leííeê óoî geí fêoã íhe fndependení oeváew bníáíó wáll íell óoî whaí óoî can do áf óoî
wásh ío coníánîe wáíh íhe êeváew pêocess. fí wáll gáve óoî íhe deíaáls aboîí how ío go on ío a
ievel P AppealI whách ás handled bó a âîdge. voî ãaó also be able ío ask íhe ajeC foê an
fndependení jedácal oeváew ío coníánîe coveêage of óoîê healíh caêe seêváces. mlease go ío
pecíáon R.Q ío leaên how ío ask íhe ajeC foê an fndependení jedácal oeváew.
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The formal name for “Independent Review Organization” is “Independent
Review Entity.” It is sometimes called the “IRE.”
Section 9: Taking your appeal beyond Level 2
Section 9.1: Next steps for Medicare services and items
ff óoî ãade a ievel N Appeal and a ievel O Appeal foê jedácaêe seêváces oê áíeãsI and boíh
óoîê appeals have been íîêned downI óoî ãaó have íhe êághí ío addáíáonal levels of appeal.
qhe leííeê óoî geí fêoã íhe fndependení oeváew bníáíó wáll íell óoî whaí ío do áf óoî wásh ío
coníánîe íhe appeals pêocess.
ievel P of íhe appeals pêocess ás an Adãánásíêaíáve iaw gîdge EAigF heaêáng. ff óoî waní an
Aig ío êeváew óoîê caseI íhe áíeã oê ãedácal seêváce óoî aêe êeqîesíáng wáll have ío ãeeí a
ãánáãîã dollaê aãoîní. ff íhe dollaê valîe ás less íhan íhe ãánáãîã levelI óoî cannoí appeal
anó fîêíheê. ff íhe dollaê valîe ás hágh enoîghI óoî can ask an Aig ío heaê óoîê appeal.
If you do not agree with the ALJ’s decision, you can go to the Medicare Appeals Council.
Afíeê íhaíI óoî ãaó have íhe êághí ío ask a fedeêal coîêí ío look aí óoîê appeal.
ff óoî need assásíance aí anó síage of íhe appeals pêocessI óoî can coníací íhe Cal
jedáConnecí lãbîds mêogêaã aí NJURRJRMNJPMTT.
Section 9.2: Next steps for Medi-Cal services and items
voî also have ãoêe appeal êághís áf óoîê appeal ás aboîí seêváces oê áíeãs íhaí ãághí be
coveêed bó jedáJCal. ff óoî do noí agêee wáíh íhe píaíe caáê eeaêáng decásáon and óoî waní
anoíheê âîdge ío êeváew áíI óoî ãaó êeqîesí a êeheaêáng andLoê seek âîdácáal êeváew.
qo êeqîesí a êeheaêángI ãaál a wêáííen êeqîesí Ea leííeêF íoW
qhe oeheaêáng rnáí
TQQ m píêeeíI jp NVJPT
pacêaãeníoI CA VRUNQ
qhás leííeê ãîsí be sení wáíhán PM daós afíeê óoî êeceáve óoîê decásáon. fn óoîê êeheaêáng
êeqîesíI síaíe íhe daíe óoî êeceáved óoîê decásáon and whó a êeheaêáng shoîld be gêaníed. ff
óoî waní ío pêesení addáíáonal evádenceI descêábe íhe addáíáonal evádence and explaán whó áí
was noí áníêodîced befoêe and how áí woîld change íhe decásáon. voî ãaó coníací iegal
peêváces foê assásíance.
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qo ask foê âîdácáal êeváewI óoî ãîsí fále a peíáíáon án pîpeêáoê Coîêí Eîndeê Code of Cávál
mêocedîêe pecíáonNMVQ.RF wáíhán one óeaê afíeê êeceáváng óoîê decásáon. cále óoîê peíáíáon án
íhe pîpeêáoê Coîêí foê íhe coîníó naãed án óoîê decásáon. voî ãaó fále íhás peíáíáon wáíhoîí
askáng foê a êeheaêáng. ko fáláng fees aêe êeqîáêed. voî ãaó be eníáíled ío êeasonable
attorney’s fees and costs if the Court issues a final decision in your favor.
ff a êeheaêáng was heaêd and óoî do noí agêee wáíh íhe decásáon fêoã íhe êeheaêángI óoî ãaó
seek âîdácáal êeváew bîí óoî cannoí êeqîesí anoíheê êeheaêáng.
Section 10: How to make a complaint
What kinds of problems should be complaints?
qhe coãplaání pêocess ás îsed foê ceêíaán íópes of pêobleãs only, sîch as pêobleãs êelaíed
ío qîaláíó of caêeI waáíáng íáãesI and cîsíoãeê seêváce. eeêe aêe exaãples of íhe kánds of
pêobleãs handled bó íhe coãplaání pêocess.
Complaints about quality
 voî aêe înhappó wáíh íhe qîaláíó of
caêeI sîch as íhe caêe óoî goí án íhe
hospáíal.
Complaints about privacy
 voî íhánk íhaí soãeone dád noí
êespecí óoîê êághí ío pêávacóI oê shaêed
ánfoêãaíáon aboîí óoî íhaí ás
confádeníáal.
a complaint
Call jeãbeê peêváces oê send îs a
leííeê íelláng îs aboîí óoîê coãplaání.
 ff óoîê coãplaání ás aboîí quality
of careI óoî have ãoêe choáces.
voî canW
N. jake óoîê coãplaání ío íhe nîaláíó
fãpêoveãení lêganázaíáonI
Complaints about poor customer service
 A healíh caêe pêovádeê oê síaff was
êîde oê dásêespecífîl ío óoî.
O. jake óoîê coãplaání ío jeãbeê
peêváces and ío íhe nîaláíó
fãpêoveãení lêganázaíáonI oê
 Caêejoêe Cal jedáConnecí mlan síaff
íêeaíed óoî pooêló.
P. jake óoîê coãplaání ío jedácaêe.
 voî íhánk óoî aêe beáng pîshed oîí of
íhe plan.
Complaints about physical accessibility
voî cannoí phósácalló access íhe healíh caêe seêváces and facáláíáes án a docíoê oê
provider’s office.
Complaints about waiting times
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 voî aêe haváng íêoîble geííáng an appoáníãeníI oê waáíáng íoo long ío geí áí.
 voî have been kepí waáíáng íoo long bó docíoêsI phaêãacásísI oê oíheê healíh pêofessáonals oê bó jeãbeê peêváces oê oíheê plan síaff.
Complaints about cleanliness
 voî íhánk the clinic, hospital or doctor’s office is not clean.
Complaints about language access
 voîê docíoê oê pêovádeê does noí pêováde óoî wáíh an áníeêpêeíeê dîêáng óoîê
appoáníãení.
Complaints about communications from us
 voî íhánk we faáled ío gáve óoî a noíáce oê leííeê íhaí óoî shoîld have êeceáved.
 voî íhánk íhe wêáííen ánfoêãaíáon we sení óoî ás íoo dáffácîlí ío îndeêsíand.
Complaints about the timeliness of our actions related to coverage decisions
or appeals
 voî beláeve íhaí we aêe noí ãeeíáng oîê deadlánes foê ãakáng a coveêage decásáon
oê answeêáng óoîê appeal.
 voî beláeve íhaíI afíeê geííáng a coveêage oê appeal decásáon án óoîê favoêI we aêe noí
ãeeíáng íhe deadlánes foê appêováng oê gáváng óoî íhe seêváce oê paóáng óoî back foê
ceêíaán ãedácal seêváces.
 voî beláeve we dád noí foêwaêd óoîê case ío íhe fndependení oeváew bníáíó on íáãe.
The legal term for a “complaint” is a “grievance.”
The legal term for “making a complaint” is “filing a grievance.”
Section 10.1: Details and deadlines
 Call jeãbeê peêváces aí NJUUUJPRMJPQQT Eqqv TNNFI jondaó íhêoîgh cêádaó fêoã U
a.ã. ío U p.ã.
 ff íheêe ás anóíháng else óoî need ío doI jeãbeê peêváces wáll íell óoî.
 voî can also wêáíe óoîê coãplaání and send áí ío îs. ff óoî pîí óoîê coãplaání án wêáíángI
we wáll êespond ío óoîê coãplaání án wêáíáng.
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 theíheê óoî call oê wêáíeI óoî shoîld coníací jeãbeê peêváces aí NJUUUJPRMJPQQT Eqqv TNNF êághí awaó.
 Coãplaánís êelaíed ío jedácaêe maêí a ãîsí be ãade wáíhán SM calendaê daós afíeê óoî
had íhe pêobleã óoî waní ío coãplaán aboîí. All oíheê íópes of coãplaánís ãîsí be fáled
wáíh îs oê íhe pêovádeê wáíhán NUM calendaê daós fêoã íhe daó íhe áncádení oê acíáon
occîêêed íhaí caîsed óoî ío be dássaíásfáed.
 ff we cannoí êesolve óoîê coãplaání wáíhán íhe nexí bîsáness daóI we wáll send óoî a leííeê wáíhán R calendaê daós of êeceáváng óoîê coãplaání leííáng óoî know íhaí we êeceáved áí.
 If you are making a complaint because we denied your request for a "fast coverage
decision´ or a "fast appeal,´ we will automatically give you a "fast complaint´ and êespond ío óoîê coãplaání wáíhán OQ hoîês. ff óoî have an îêgení pêobleã íhaí ánvolves
an immediate and serious risk to your health, you can request a "fast complaint´ and we
wáll êespond wáíhán TO hoîês.
The legal term for “fast complaint” is “expedited grievance.”
ff possábleI we wáll answeê óoî êághí awaó. ff óoî call îs wáíh a coãplaáníI we ãaó be able ío
gáve óoî an answeê on íhe saãe phone call. ff óoîê healíh condáíáon êeqîáêes îs ío answeê
qîácklóI we wáll do íhaí.
 josí coãplaánís aêe answeêed án PM calendaê daós. ff we need ãoêe ánfoêãaíáon
and do noí coãe ío a decásáon wáíhán PM daósI we wáll noíáfó óoî án wêáíáng and pêováde a
síaíîs îpdaíe and esíáãaíed íáãe foê óoî ío geí íhe answeê.
 If we do not agree wáíh soãe oê all of óoîê coãplaání we wáll íell óoî and gáve óoî oîê
êeasons. te wáll êespond wheíheê we agêee wáíh íhe coãplaání oê noí.
Section 10.2: You can file complaints with the Office of Civil Rights
ff óoî have a coãplaání aboîí dásabáláíó access oê aboîí langîage assásíanceI óoî can fále a
coãplaání wáíh íhe lffáce of Cávál oághís aí íhe aepaêíãení of eealíh and eîãan peêváces. 1800-368-1019 (TTY 711). voî ãaó also have êághís îndeê íhe Aãeêácans wáíh aásabáláíó AcíI
all oíheê laws íhaí appló ío oêganázaíáons íhaí geí fedeêal fîndángI and oíheê laws and êîles
íhaí appló foê anó oíheê êeason. voî can coníací íhe Cal jedáConnecí lãbîds mêogêaã foê
assásíance.
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Section 10.3: You can make complaints about quality of care to the Quality
Improvement Organization
then óoîê coãplaání ás aboîí quality of careI óoî also have íwo choácesW
 ff óoî pêefeêI óoî can ãake óoîê coãplaání aboîí íhe qîaláíó of caêe dáêecíló ío íhe
nîaláíó fãpêoveãení lêganázaíáon Ewithout ãakáng íhe coãplaání ío îsF.
 lê óoî can ãake óoîê coãplaání ío îs and also ío íhe nîaláíó fãpêoveãení
lêganázaíáon. ff óoî ãake a coãplaání ío íhás oêganázaíáonI we wáll woêk wáíh íheã ío
êesolve óoîê coãplaání.
qhe nîaláíó fãpêoveãení lêganázaíáon ás a gêoîp of pêacíácáng docíoês and oíheê healíh caêe
expeêís paád bó íhe fedeêal goveênãení ío check and áãpêove íhe caêe gáven ío jedácaêe
paíáenís.
qhe phone nîãbeê foê íhe nîaláíó fãpêoveãení lêganázaíáon ás NJUUUJPRMJPQQT Eqqv TNNFI
jondaó íhêoîgh cêádaó fêoã U a.ã. ío U p.ã.
Section 10.4: You can tell Medicare about your complaint
voî can also send óoîê coãplaání ío jedácaêe. qhe jedácaêe Coãplaání coêã ás avaálable aíW
híípsWLLwww.ãedácaêe.govLjedácaêeCoãplaánícoêãLhoãe.aspx.
jedácaêe íakes óoîê coãplaánís seêáoîsló and wáll îse íhás ánfoêãaíáon ío help áãpêove
íhe qîaláíó of íhe jedácaêe pêogêaã.
ff óoî have anó oíheê feedback oê conceênsI oê áf óoî feel íhe plan ás noí addêessáng
óoîê pêobleãI please call NJUMMJjbafCAob ENJUMMJSPPJQOOTF. qqvLqaa îseês can call
NJUTTJQUSJOMQU. qhe call ás fêee.
Section 10.5: You can tell Medi-Cal about your complaint
qhe Cal jedáConnecí lãbîds mêogêaã also helps solve pêobleãs fêoã a neîíêal síandpoání
ío ãake sîêe íhaí oîê ãeãbeês êeceáve all íhe coveêed seêváces íhaí we aêe êeqîáêed ío
pêováde. qhe Cal jedáConnecí lãbîds mêogêaã ás noí connecíed wáíh îs oê wáíh anó
ánsîêance coãpanó oê healíh plan.
qhe phone nîãbeê foê íhe Cal jedáConnecí lãbîds mêogêaã ás NJURRJRMNJPMTT. qhe
seêváces aêe fêee.
Section 10.6: You can tell the California Department of Managed Health Care
about your complaint
qhe Caláfoênáa aepaêíãení of janaged eealíh Caêe EajeCF ás êesponsáble foê êegîlaíáng
healíh plans. voî can call íhe ajeC eelp Ceníeê foê help wáíh coãplaánís aboîí jedáJCal
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seêváces. voî ãaó coníací íhe ajeC áf óoî need help wáíh a coãplaání ánvolváng an
eãeêgencóI óoî dásagêee wáíh Caêejoêe Cal jedáConnecí mlan’s decision about your
coãplaáníI oê Caêejoêe Cal jedáConnecí mlan has noí êesolved óoîê coãplaání afíeê PM
calendaê daós.
eeêe aêe íwo waós ío geí help fêoã íhe eelp CeníeêW
 Call NJUUUJejlJOONV. fndávádîals who aêe deafI haêd of heaêángI oê speechJáãpaáêed
can îse íhe íoll fêee qqv nîãbeêI NJUTTJSUUJVUVN. qhe call ás fêee.  Visit the Department of Managed Health Care’s website (http://www.hmohelp.ca.gov).
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NVO
Chapter 10: Ending your membership in our
Cal MediConnect plan
Table of Contents
fníêodîcíáon ....................................................................................................................................NVQ
A. then can óoî end óoîê ãeãbeêsháp án oîê Cal jedáConnecí plan? .........................................NVQ
B. eow do óoî end óoîê ãeãbeêsháp án oîê Cal jedáConnecí plan? .............................................NVR
C. eow do óoî âoán a dáffeêení Cal jedáConnecí plan?...................................................................NVR
D. ff óoî leave oîê plan and óoî do noí waní a dáffeêení Cal jedáConnecí planI how do óoî
geí jedácaêe and jedáJCal seêváces? ........................................................................................NVR
eow óoî wáll geí jedácaêe seêváces..........................................................................................NVR
eow óoî wáll geí jedáJCal seêváces ..........................................................................................NVT
E. rníál óoîê ãeãbeêsháp ends án oîê Cal jedáConnecí planI óoî wáll keep geííáng óoîê
ãedácal seêváces and dêîgs íhêoîgh oîê plan.............................................................................NVU
F. voîê ãeãbeêsháp án oîê Cal jedáConnecí plan wáll end án ceêíaán sáíîaíáons .............................NVU
G. te cannot ask óoî ío leave oîê Cal jedáConnecí plan foê anó êeason êelaíed ío óoîê healíh.................................................................................................................................NVV
H. voî have íhe êághí ío ãake a coãplaání áf we end óoîê ãeãbeêsháp án oîê plan ........................NVV
I. theêe can óoî geí ãoêe ánfoêãaíáon aboîí endáng óoîê plan ãeãbeêsháp? ..............................NVV
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NVP
Chapíeê NMW bndáng óoîê ãeãbeêsháp án oîê
Cal jedáConnecí plan
Introduction
qhás chapíeê íells aboîí waós óoî can end óoîê ãeãbeêsháp án oîê Cal jedáConnecí plan
and óoîê healíh coveêage opíáons afíeê óoî leave íhe plan. voî wáll síáll qîaláfó foê boíh
jedácaêe and jedáJCal benefáís áf óoî leave oîê plan.
A. When can you end your membership in our Cal MediConnect
plan?
voî can end óoîê ãeãbeêsháp án Caêejoêe Cal jedáConnecí mlan aí anó íáãe. voîê
ãeãbeêsháp wáll end on íhe lasí daó of íhe ãoníh íhaí we geí óoîê êeqîesí ío change óoîê
plan. coê exaãpleI áf we geí óoîê êeqîesí on ganîaêó NUI óoîê coveêage wáíh oîê plan wáll end
on ganîaêó PN. voîê new coveêage wáll begán íhe fáêsí daó of íhe nexí ãoníh.
then óoî end óoîê ãeãbeêsháp án oîê planI óoî wáll be enêolled án a jedáJCal ãanaged caêe
plan of óoîê choáce foê óoîê jedáJCal seêvácesI înless óoî choose a dáffeêení Cal
jedáConnecí plan. voî can also choose óoîê jedácaêe enêollãení opíáons when óoî end
óoîê ãeãbeêsháp án oîê plan.
 coê ánfoêãaíáon on jedácaêe opíáons when óoî leave oîê Cal jedáConnecí planI see íhe
íable on page NVV.
 coê ánfoêãaíáon aboîí óoîê jedáJCal seêváces when óoî leave oîê Cal jedáConnecí planI
see page OMM.
qhese aêe waós óoî can geí ãoêe ánfoêãaíáon aboîí how óoî can end óoîê ãeãbeêshápW
 Call jeãbeê peêváces aí NJUUUJPRMJPQQT Eqqv TNNFI jondaó íhêoîgh cêádaó fêoã U
?

Call eealíh Caêe lpíáons aí NJUQQJRUMJTOTOI jondaó íhêoîgh cêádaó fêoã UWMM aã ío
RWMM pã. qqv îseês shoîld call NJUMMJQPMJTMTT.

Call íhe Caláfoênáa eealíh fnsîêance Coînseláng C Advocacó mêogêaã EefCAmF aí N
UMMJUOQJMTUM Eqqv TNNF.

Call íhe Cal jedáConnecí lãbîds mêogêaã aí NJURRJRMNJPMTT.

Call jedácaêe aí NJUMMJjbafCAob ENJUMMJSPPJQOOTFI OQ hoîês a daóI seven daós a
week. qqv îseês shoîld call NJUTTJQUSJOMQU.
NVQ
B. How do you end your membership in our Cal MediConnect plan?
ff óoî decáde ío end óoîê ãeãbeêshápI íell jedáJCal oê jedácaêe íhaí óoî waní ío leave
Caêejoêe Cal jedáConnecí mlanW

RWMM pã. qqv îseês shoîld call NJUMMJQPMJTMTT; lo

week. qqv îseês Epeople who aêe deafI haêd of heaêángI oê speech dásabledF shoîld
call NJUTTJQUSJOMQU. then óoî call NJUMMJjbafCAobI óoî can also enêoll án anoíheê
jedácaêe healíh oê dêîg plan. joêe ánfoêãaíáon on geííáng óoîê jedácaêe seêváces
when óoî leave oîê plan ás án íhe chaêí on page NVV.
C. How do you join a different Cal MediConnect plan?
ff óoî waní ío keep geííáng óoîê jedácaêe and jedáJCal benefáís íogeíheê fêoã a sángle planI
óoî can âoán a dáffeêení Cal jedáConnecí plan.
qo enêoll án a dáffeêení Cal jedáConnecí planW
 Call eeaíh Caêe lpíáons aí NJUQQJRUMJTOTOI jondaó íhêoîgh cêádaó fêoã UWMM a.ã. ío
RWMM p.ã. qqv îseês shoîld call NJUMMJQPMJTMTT. qell íheã óoî waní ío leave
Caêejoêe Cal jedáConnecí mlan and âoán a dáffeêení Cal jedáConnecí plan. ff óoî aêe
noí sîêe whaí plan óoî waní ío âoánI íheó can íell óoî aboîí oíheê plans án óoîê aêea.
voîê coveêage wáíh Caêejoêe Cal jedáConnecí mlan wáll end on íhe lasí daó of íhe ãoníh íhaí
we geí óoîê êeqîesí.
D. If you leave our plan and you do not want a different Cal
MediConnect plan, how do you get Medicare and Medi-Cal
services?
ff óoî do noí waní ío enêoll án a dáffeêení Cal jedáConnecí plan afíeê óoî leave Caêejoêe Cal
jedáConnecí mlanI óoî wáll go back ío geííáng óoîê jedácaêe and jedáJCal seêváces
sepaêaíeló.
How you will get Medicare services
voî wáll have a choáce aboîí how óoî geí óoîê jedácaêe benefáís.
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NVR
voî have íhêee opíáons foê geííáng óoîê jedácaêe seêváces. Bó choosáng one of íhese opíáonsI
óoî wáll aîíoãaíácalló end óoîê ãeãbeêsháp án oîê Cal jedáConnecí plan.
1. You can change to:
A Medicare health plan, such as a
Medicare Advantage plan or
Programs of All-inclusive Care for
the Elderly (PACE)
Here is what to do:
Call jedácaêe aí NJUMMJjbafCAob ENJUMM
SPPJQOOTFI OQ hoîês a daóI seven daós a week.
qqv îseês shoîld call NJUTTJQUSJOMQU ío enêoll
án íhe new jedácaêeJonló healíh plan.
ff óoî need help oê ãoêe ánfoêãaíáonW

Call íhe Caláfoênáa eealíh fnsîêance
Coînseláng C Advocacó mêogêaã
EefCAmF aí NJUMMJUOQJMTUM Eqqv TNNF.
voî wáll aîíoãaíácalló be dásenêolled fêoã
Caêejoêe Cal jedáConnecí mlan when
your new plan’s coverage begins.
Here is what to do:
Original Medicare with a separate
Medicare prescription drug plan
Call jedácaêe aí NJUMMJjbafCAob EN
UMMJSPPJQOOTFI OQ hoîês a daóI seven
daós a week. qqv îseês shoîld call N
UTTJQUSJOMQU.

óoîê lêágánal jedácaêe coveêage begáns.
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NVS
Original Medicare without a
separate Medicare prescription
drug plan
NOTEW ff óoî swáích ío lêágánal
jedácaêe and do noí enêoll án a
sepaêaíe jedácaêe pêescêápíáon dêîg
planI jedácaêe ãaó enêoll óoî án a
dêîg planI înless óoî íell jedácaêe
you don’t want to join.
voî shoîld onló dêop pêescêápíáon
dêîg coveêage áf óoî geí dêîg
coveêage fêoã an eãploóeêI înáon oê
oíheê soîêce. ff óoî have qîesíáons
aboîí wheíheê óoî need dêîg
coveêageI call íhe Caláfoênáa eealíh
fnsîêance Coînseláng C Advocacó
mêogêaã EefCAmF aí NJUMMJUOQJMTUM
Eqqv TNNF.
Here is what to do:
Call jedácaêe aí NJUMMJjbafCAob ENJUMM
SPPJQOOTFI OQ hoîês a daóI seven daós a week.
qqv îseês shoîld call NJUTTJQUSJOMQU.

óoîê lêágánal jedácaêe coveêage begáns.
How you will get Medi-Cal services
ff óoî leave oîê Cal jedáConnecí planI óoî wáll be enêolled án a jedáJCal ãanaged caêe plan
of óoîê choáce.
voîê jedáJCal seêváces ánclîde ãosí longJíeêã seêváces and sîppoêís and behaváoêal healíh
caêe.
then óoî êeqîesí ío end óoîê ãeãbeêsháp án oîê Cal jedáConnecí planI óoî wáll need ío leí
eealíh Caêe lpíáons know whách jedáJCal ãanaged caêe plan óoî waní ío âoán.
Call eealíh Caêe lpíáons aí NJUQQJRUMJTOTOI jondaó íhêoîgh cêádaó fêoã UWMM aã ío
RWMM pã. qqv îseês shoîld call NJUMMJQPMJTMTT. qell íheã óoî waní ío leave
Caêejoêe Cal jedáConnecí mlan and âoán a jedáJCal ãanaged caêe plan. ff óoî aêe
noí sîêe whaí plan óoî waní ío âoánI íheó can íell óoî aboîí oíheê plans án óoîê aêea.
then óoî end óoîê ãeãbeêsháp wáíh oîê Cal jedáConnecí planI óoî wáll geí a new ãeãbeê
fa caêdI a new Member HandbookI and a new Provider and Pharmacy Directory foê óoîê
jedáJCal coveêage.
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NVT
E. Until your membership ends in our Cal MediConnect plan, you
will keep getting your medical services and drugs through our
plan
ff óoî leave Caêejoêe Cal jedáConnecí mlanI áí ãaó íake íáãe befoêe óoîê ãeãbeêsháp ends
and óoîê new jedácaêe and jedáJCal coveêage begáns. pee page NVT foê ãoêe ánfoêãaíáon.
aîêáng íhás íáãeI óoî wáll keep geííáng óoîê healíh caêe and dêîgs íhêoîgh oîê plan.
You should use our network pharmacies to get your prescriptions filled. rsîallóI óoîê
pêescêápíáon dêîgs aêe coveêed onló áf íheó aêe fálled aí a neíwoêk phaêãacó inclîdáng íhêoîgh
oîê ãaálJoêdeê phaêãacó seêváces.
If you are hospitalized on the day that your membership ends, your hospital stay will
usually be covered by our Cal MediConnect plan until you are discharged. qhás wáll
happen even áf óoîê new healíh coveêage begáns befoêe óoî aêe dáschaêged.
F. Your membership in our Cal MediConnect plan will end in certain
situations
qhese aêe íhe cases when Caêejoêe Cal jedáConnecí mlan ãîsí end óoîê ãeãbeêsháp án
íhe planW

ff íheêe ás a bêeak án óoîê jedácaêe maêí A and maêí B coveêage.

ff óoî no longeê qîaláfó foê jedáJCal. lîê plan ás foê people who qîaláfó foê boíh
jedácaêe and jedáJCal. qhe píaíe oê íhe Ceníeês foê jedácaêe C jedácaád peêváces
ECjpF ãaó dásenêoll óoî áf áí ás deíeêãáned íhaí óoî aêe noí elágáble foê íhe pêogêaã. áf
óoî ãove oîí of oîê seêváce aêea.

ff óoî aêe awaó fêoã oîê seêváce aêea foê ãoêe íhan sáx ãoníhs.
» ff óoî ãove oê íake a long íêápI óoî need ío call jeãbeê peêváces ío fánd oîí áf íhe
place you are moving or traveling to is in our plan’s service area.

ff óoî go ío pêáson.

ff óoî láe aboîí oê wáíhhold ánfoêãaíáon aboîí oíheê ánsîêance óoî have foê pêescêápíáon
dêîgs.
ff óoî no longeê qîaláfó foê jedáJCal oê óoîê cáêcîãsíances have changed íhaí ãake óoî no
longeê elágáble foê Cal jedáConnecíI óoî ãaó coníánîe ío geí óoîê benefáís fêoã Caêejoêe
Cal jedáConnecí mlan foê an addáíáonal oneJãoníh peêáod. qhás addáíáonal íáãe wáll allow óoî
ío coêêecí óoîê elágábáláíó ánfoêãaíáon áf óoî beláeve íhaí óoî aêe síáll elágáble. voî wáll êeceáve a
leííeê fêoã îs aboîí íhe change án óoîê elágábáláíó wáíh ánsíêîcíáons ío coêêecí óoîê elágábáláíó
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NVU

qo síaó a ãeãbeê of Caêejoêe Cal jedáConnecí mlanI óoî ãîsí qîaláfó agaán bó íhe
lasí daó of íhe oneJãoníh peêáod.
If you don’t qualify by the end of íhe oneJmonth period, you’ll be dásenêolled fêoã Caêejoêe
Cal jedáConnecí mlan.
te can ãake óoî leave oîê plan foê íhe followáng êeasons onló áf we geí peêãássáon fêoã
jedácaêe and jedáJCal fáêsíW

ff óoî áníeníáonalló gáve îs áncoêêecí ánfoêãaíáon when óoî aêe enêolláng án oîê plan and
íhaí ánfoêãaíáon affecís óoîê elágábáláíó foê oîê plan.

ff óoî coníánîoîsló behave án a waó íhaí ás dásêîpíáve and ãakes áí dáffácîlí foê îs ío
pêováde ãedácal caêe foê óoî and oíheê ãeãbeês of oîê plan.

ff óoî leí soãeone else îse óoîê fa caêd ío geí ãedácal caêe.
» ff we end óoîê ãeãbeêsháp becaîse of íhás êeasonI jedácaêe ãaó have óoîê case
ánvesíágaíed bó íhe fnspecíoê deneêal.
G. We cannot ask you to leave our Cal MediConnect plan for any
reason related to your health
ff óoî feel íhaí óoî aêe beáng asked ío leave oîê plan foê a healíhJêelaíed êeasonI óoî shoîld
call jedácaêe aí NJUMMJjbafCAob ENJUMMJSPPJQOOTF. qqv îseês shoîld call
NJUTTJQUSJOMQU. voî ãaó call OQ hoîês a daóI seven daós a week.
voî shoîld also call íhe Cal jedáConnecí lãbîds mêogêaã aí NJURRJRMNJPMTT.
H. You have the right to make a complaint if we end your
membership in our plan
ff we end óoîê ãeãbeêsháp án oîê Cal jedáConnecí planI we ãîsí íell óoî oîê êeasons án
wêáíáng foê endáng óoîê ãeãbeêsháp. te ãîsí also explaán how óoî can ãake a coãplaání
aboîí oîê decásáon ío end óoîê ãeãbeêsháp. voî can also see Chapíeê V foê ánfoêãaíáon
aboîí how ío ãake a coãplaání.
I. Where can you get more information about ending your plan
membership?
ff óoî have qîesíáons oê woîld láke ãoêe ánfoêãaíáon on when we can end óoîê ãeãbeêshápI
óoî canW
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NVV
?

Call jeãbeê peêváces aí NJUUUJPRMJPQQT Eqqv TNNFI jondaó íhêoîgh cêádaó fêoã U

RWMM pã. qqv îseês shoîld call NJUMMJQPMJTMTT.

Call íhe Caláfoênáa eealíh fnsîêance Coînseláng C Advocacó mêogêaã EefCAmF aí N
UMMJUOQJMTUM Eqqv TNNF.

Call íhe Cal jedáConnecí lãbîds mêogêaã aí NJURRJRMNJPMTT.

week. qqv îseês shoîld call NJUTTJQUSJOMQU.
OMM
Chapter 11: Legal notices
Table of Contents
A. koíáce aboîí laws ......................................................................................................................OMN
B. koíáce aboîí nondáscêáãánaíáon ..................................................................................................OMN
C. koíáce aboîí jedácaêe as a second paóeê and jedáJCal as a paóeê of lasí êesoêí .....................OMO
D. koíáce of Acíáon .........................................................................................................................OMO
A. Notice about laws
janó laws appló ío íhás Member Handbook. qhese laws ãaó affecí óoîê êághís and
êesponsábáláíáes even áf íhe laws aêe noí ánclîded oê explaáned án íhás handbook. qhe ãaán
laws íhaí appló ío íhás handbook aêe fedeêal laws aboîí íhe jedácaêe and jedáJCal
pêogêaãs. líheê fedeêal and síaíe laws ãaó appló íoo.
B. Notice about nondiscrimination
bveêó coãpanó oê agencó íhaí woêks wáíh jedácaêe and jedáJCal ãîsí obeó íhe law. voî
cannoí be íêeaíed dáffeêeníló becaîse of óoîê êaceI coloêI naíáonal oêágánI dásabáláíóI ageI
êelágáonI oê sex. voî also cannoí be íêeaíed dáffeêeníló based on óoîêI sexîal oêáeníaíáonI
ãaêáíal síaíîsI pêegnancó and coveêed veíeêan síaíîs. All oêganázaíáons láke oîê plan ãîsí
obeó cedeêal laws agaánsí dáscêáãánaíáon I ánclîdáng qáíle sf of íhe Cávál oághís Ací of NVSQI
íhe oehabáláíaíáon Ací of NVTPI íhe Age aáscêáãánaíáon Ací of NVTRI íhe Aãeêácans wáíh
aásabáláíáes AcíI all oíheê laws íhaí appló ío oêganázaíáons íhaí geí cedeêal fîndángI and anó
oíheê laws and êîles íhaí appló foê anó oíheê êeason. ff óoî íhánk íhaí óoî have noí been
íêeaíed faáêló foê anó of íhese êeasonsI call íhe aepaêíãení of eealíh and eîãan peêvácesI
lffáce foê Cávál oághís aí NJUMMJPSUJNMNV. qqv îseês shoîld call NJUMMJRPTJTSVT. voî can
also vásáí híípWLLwww.hhs.govLocê foê ãoêe ánfoêãaíáon.
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OMN
Chapíeê NNW iegal noíáces
C. Notice about Medicare as a second payer and Medi-Cal as a
payer of last resort
poãeíáães soãeone else has ío paó fáêsí foê íhe seêváces we pêováde óoî. coê exaãpleI áf
óoî aêe án a caê accádení oê áf óoî aêe ánâîêed aí woêkI ánsîêance oê toêkeês Coãpensaíáon
has ío paó fáêsí.
te have íhe êághí and êesponsábáláíó ío collecí foê coveêed jedácaêe seêváces foê whách
jedácaêe ás noí íhe fáêsí paóeê.
qhe Cal jedáConnecí pêogêaã coãpláes wáíh píaíe and cedeêal laws and êegîlaíáons êelaíáng
ío íhe legal láabáláíó of íháêd paêíáes foê healíh caêe seêváces ío benefácáaêáes. te wáll íake all
êeasonable ãeasîêes ío ensîêe íhaí íhe jedáJCal pêogêaã ás íhe paóeê of lasí êesoêí.
D. Notice of Action
te ãîsí îse íhe koíáce of Acíáon EklAF foêã ío noíáfó óoî of a denáalI íeêãánaíáonI and delaó
oê ãodáfácaíáon án benefáís. ff óoî dásagêee wáíh oîê decásáonI óoî can fále an appeal wáíh oîê
plan. coê jedáJCal seêvácesI óoî can ask foê a píaíe caáê eeaêáng aí íhe saãe íáãe. voî ãaó
have ío fále an appeal wáíh oîê plan befoêe óoî can ask foê an fndependení jedácal oeváew
EfjoFI excepí án soãe cases. voî wáll noí have ío paó foê anó of íhese pêoceedángs.
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OMO
Chapter 12: Definitions of important words
Activities of daily living (ADL): qhe íhángs people do on a noêãal daóI sîch as eaíángI
îsáng íhe íoáleíI geííáng dêessedI baíhángI oê bêîsháng íhe íeeíh.
Aid paid pending: voî can coníánîe geííáng óoîê benefáís whále óoî aêe waáíáng foê a
decásáon aboîí a ievel N Appeal oê a píaíe caáê eeaêáng Epee Chapíeê V foê ãoêe
ánfoêãaíáonF. qhás continued coverage is called "aid paid pending.´
Ambulatory surgical center: A facáláíó íhaí pêovádes oîípaíáení sîêgeêó ío paíáenís who
do noí need hospáíal caêe and who aêe noí expecíed ío need ãoêe íhan OQ hoîês of caêe.
Appeal: A waó foê óoî ío challenge oîê acíáon áf óoî íhánk we ãade a ãásíake. voî can ask
îs ío change a coveêage decásáon bó fáláng an appeal. Chapíeê V explaáns appealsI ánclîdáng
how ío ãake an appeal.
Balance billing: A sáíîaíáon when a pêovádeê Esîch as a docíoê oê hospáíalF bálls a peêson
more than the plan’s cost sharing amount for services. We do not allow providers to "balance
bill´ you. Becaîse Caêejoêe Cal jedáConnecí mlan paós íhe eníáêe cosí foê óoîê seêvácesI
óoî shoîld noí geí anó bálls fêoã pêovádeês. Call jeãbeê peêváces áf óoî geí anó bálls íhaí óoî
do noí îndeêsíand.
Behavioral Health: An allJánclîsáve íeêã êefeêêáng ío ãeníal healíh and sîbsíance îse
dásoêdeês.
Brand name drug: A pêescêápíáon dêîg íhaí ás ãade and sold bó íhe coãpanó íhaí
oêágánalló ãade íhe dêîg. Bêand naãe dêîgs have íhe saãe ángêedáenís as íhe geneêác
veêsáons of íhe dêîgs. deneêác dêîgs aêe ãade and sold bó oíheê dêîg coãpanáes.
Cal MediConnect: A pêogêaã íhaí pêovádes boíh óoîê jedácaêe and jedáJCal benefáís
íogeíheê án one healíh plan. voî have one caêd foê all óoîê benefáís.
Case manager: lne ãaán peêson who woêks wáíh óoîI wáíh íhe healíh planI and wáíh óoîê
caêe pêovádeês ío ãake sîêe óoî geí íhe caêe óoî need.
Care Plan Optional Services (CPO Services): Addáíáonal seêváces íhaí aêe opíáonal
îndeê óoîê fndávádîalázed Caêe mlan EfCmF. qhese seêváces aêe noí áníended ío êeplace long
íeêã seêváces and sîppoêís íhaí óoî aêe aîíhoêázed ío êeceáve îndeê jedáJCal.
Care plan: See "Individualized Care Plan.´
Care team: See "fníeêdáscáplánaêó Caêe Team.´
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Chapíeê NOW aefánáíáons of áãpoêíaní woêds
Centers for Medicare & Medicaid Services (CMS): qhe fedeêal agencó án chaêge of
jedácaêe. Chapíeê O explaáns how ío coníací Cjp.
Community Based Adult Services (CBAS): lîípaíáeníI facáláíó based seêváce
pêogêaã íhaí deláveês skálled nîêsáng caêeI socáal seêvácesI íheêapáesI peêsonal caêeI
faãálóLcaêegáveê íêaánáng and sîppoêíI nîíêáíáon seêvácesI íêanspoêíaíáonI and oíheê seêváces ío
elágáble bnêollees who ãeeí applácable elágábáláíó cêáíeêáa.
Complaint: A wêáííen oê spoken síaíeãení saóáng íhaí óoî have a pêobleã oê conceên
aboîí óoîê coveêed seêváces oê caêe. qhás ánclîdes anó conceêns aboîí íhe qîaláíó of óoîê
caêeI oîê neíwoêk pêovádeêsI oê oîê neíwoêk phaêãacáes. The formal name for "making a
complaint´ is "filing a grievance.´
Comprehensive outpatient rehabilitation facility (CORF): A facáláíó íhaí ãaánló
pêovádes êehabáláíaíáon seêváces afíeê an állnessI accádeníI oê ãaâoê opeêaíáon. fí pêovádes a
vaêáeíó of seêvácesI ánclîdáng phósácal íheêapóI socáal oê psóchologácal seêvácesI êespáêaíoêó
íheêapóI occîpaíáonal íheêapóI speech íheêapóI and hoãe enváêonãení evalîaíáon seêváces.
Cost sharing tier: A gêoîp of dêîgs wáíh íhe saãe coJpaó. bveêó dêîg on íhe List of
Covered Drugs ás án one of foîê cosí shaêáng íáeês. fn geneêalI íhe hágheê íhe cosí shaêáng íáeêI
íhe hágheê óoîê cosí foê íhe dêîg.
Coverage decision: A decásáon aboîí whaí benefáís we coveê. qhás ánclîdes decásáons
aboîí coveêed dêîgs and seêváces oê íhe aãoîní we wáll paó foê óoîê healíh seêváces. Chapíeê
V explaáns how ío ask îs foê a coveêage decásáon.
Covered drugs: qhe íeêã we îse ío ãean all of íhe pêescêápíáon dêîgs coveêed bó oîê
plan.
Covered services: qhe geneêal íeêã we îse ío ãean all of íhe healíh caêeI longJíeêã
seêváces and sîppoêísI sîppláesI pêescêápíáon and oveêJíheJcoîníeê dêîgsI eqîápãeníI and
oíheê seêváces coveêed bó oîê plan.
Department of Health Care Services (DHCS): qhe píaíe depaêíãení án Caláfoênáa
íhaí adãánásíeês íhe jedácaád mêogêaã Eêefeêêed ío as jedáJCal án CaláfoênáaFI geneêalló
referred to as "the State´ in this handbook.
Department of Managed Health Care (DMHC): qhe píaíe depaêíãení án Caláfoênáa
íhaí ás êesponsáble foê êegîlaíáng healíh plans. qhe ajeC helps people án Cal jedáConnecí
wáíh appeals and coãplaánís aboîí jedáJCal seêváces. qhe ajeC also condîcís
fndependení jedácal oeváews EfjoF.
Disenrollment: qhe pêocess of endáng óoîê ãeãbeêsháp án oîê plan. aásenêollãení ãaó
be volîníaêó Eóoîê own choáceF oê ánvolîníaêó Enoí óoîê own choáceF.
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Durable medical equipment (DME): Ceêíaán áíeãs óoîê docíoê oêdeês foê óoî ío îse aí
hoãe. bxaãples aêe walkeêsI wheelchaáêsI oê hospáíal beds.
Emergency: A ãedácal eãeêgencó ás when óoîI oê anó oíheê peêson wáíh an aveêage
knowledge of healíh and ãedácáneI beláeve íhaí óoî have ãedácal sóãpíoãs íhaí need
áããedáaíe ãedácal aííeníáon ío pêevení deaíhI loss of a bodó paêíI oê loss of fîncíáon of a
bodó paêí. qhe ãedácal sóãpíoãs ãaó be a seêáoîs ánâîêó oê seveêe paán.
Emergency care: Coveêed seêváces íhaí aêe gáven bó a pêovádeê íêaáned ío gáve
eãeêgencó seêváces and needed ío íêeaí a ãedácal oê behaváoêal healíh eãeêgencó.
Exception: meêãássáon ío geí coveêage foê a dêîg íhaí ás noí noêãalló coveêed oê ío îse
íhe dêîg wáíhoîí ceêíaán êîles and láãáíaíáons.
Extra Help: A jedácaêe pêogêaã íhaí helps people wáíh láãáíed áncoães and êesoîêces paó
for Medicare Part D prescription drugs. Extra help is also called the "LowJIncome Subsidy,´
or "LIS.´
Generic drug: A pêescêápíáon dêîg íhaí ás appêoved bó íhe fedeêal goveênãení ío îse án
place of a bêand naãe dêîg. A geneêác dêîg has íhe saãe ángêedáenís as a bêand naãe dêîg.
fí ás îsîalló cheapeê and woêks âîsí as well as íhe bêand naãe dêîg.
Grievance: A coãplaání óoî ãake aboîí îs oê one of oîê neíwoêk pêovádeês oê
phaêãacáes. qhás ánclîdes a coãplaání aboîí íhe qîaláíó of óoîê caêe.
Health Insurance Counseling & Advocacy Program (HICAP): A pêogêaã íhaí
pêovádes fêee and obâecíáve ánfoêãaíáon and coînseláng aboîí jedácaêe. Chapíeê O
explaáns how ío coníací efCAm.
Health plan: An oêganázaíáon ãade îp of docíoêsI hospáíalsI phaêãacáesI pêovádeês of
longJíeêã seêvácesI and oíheê pêovádeês. fí also has case ãanageês ío help óoî ãanage all
óoîê pêovádeês and seêváces. qheó all woêk íogeíheê ío pêováde íhe caêe óoî need.
Health risk assessment: A êeváew of a paíáení’s medical history and current condition. It
is used to figure out the patient’s health and how it might change in the future.
Home health aide: A peêson who pêovádes seêváces íhaí do noí need íhe skálls of a
lácensed nîêse oê íheêapásíI sîch as help wáíh peêsonal caêe Eláke baíhángI îsáng íhe íoáleíI
dêessángI oê caêêóáng oîí íhe pêescêábed exeêcásesF. eoãe healíh aádes do noí have a nîêsáng
lácense oê pêováde íheêapó. qhás ás noí óoîê fepp pêovádeê.
Hospice: A pêogêaã of caêe and sîppoêí ío help people who have a íeêãánal pêognosás láve
coãfoêíabló. A íeêãánal pêognosás ãeans íhaí a peêson has a íeêãánal állness and ás expecíed
ío have sáx ãoníhs oê less ío láve. An enêollee who has a íeêãánal pêognosás has íhe êághí ío
elecí hospáce. A specáalló íêaáned íeaã of pêofessáonals and caêegáveês pêováde caêe foê íhe
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whole peêsonI ánclîdáng phósácalI eãoíáonalI socáalI and spáêáíîal needs. Caêejoêe Cal
jedáConnecí mlan ãîsí gáve óoî a lásí of hospáce pêovádeês án óoîê geogêaphác aêea.
Independent Medical Review (IMR): ff we denó óoîê êeqîesí foê ãedácal seêváces oê
íêeaíãeníI óoî can fále an appeal wáíh îs. ff óoî dásagêee wáíh oîê decásáon and óoîê pêobleã
ás aboîí a jedáJCal seêváceI óoî can ask íhe Caláfoênáa aepaêíãení of janaged eealíh Caêe
foê an fjo. An fjo ás a êeváew of óoîê case bó docíoês who aêe noí paêí of oîê plan. ff íhe
fjo ás decáded án óoîê favoêI we ãîsí gáve óoî íhe seêváce oê íêeaíãení óoî êeqîesíed. voî
paó no cosís foê an fjo.
Individualized Care Plan (ICP or Care Plan): A plan foê whaí seêváces óoî wáll geí
and how óoî wáll geí íheã. voîê plan ãaó ánclîde ãedácal seêvácesI behaváoêal healíh
seêvácesI and longJíeêã seêváces and sîppoêís.
In-Home Supportive Services (IHSS): A Caláfoênáa pêogêaã íhaí pêovádes peêsonal
caêe seêváces foê people who cannoí safeló êeãaán án íheáê own hoães wáíhoîí assásíance.
Inpatient: A íeêã îsed when óoî have been foêãalló adãáííed ío íhe hospáíal foê skálled
ãedácal seêváces. ff óoî weêe noí foêãalló adãáííedI óoî ãághí síáll be consádeêed an
oîípaíáení ánsíead of an ánpaíáení even áf óoî síaó oveênághí.
Interdisciplinary Care Team (ICT or Care team): A caêe íeaã ãaó ánclîde docíoêsI
nîêsesI coînseloêsI oê oíheê healíh pêofessáonals who aêe íheêe ío help óoî geí íhe caêe óoî
need. voîê caêe íeaã wáll also help óoî ãake a caêe plan.
List of Covered Drugs (Drug List): A lásí of pêescêápíáon dêîgs coveêed bó íhe plan.
qhe plan chooses íhe dêîgs on íhás lásí wáíh íhe help of docíoês and phaêãacásís. qhe aêîg
iásí íells óoî áf íheêe aêe anó êîles óoî need ío follow ío geí óoîê dêîgs. qhe aêîg iásí ás
sometimes called a "formulary.´
Long-term services and supports (LTSS): iongJíeêã seêváces and sîppoêís aêe
seêváces íhaí help áãpêove a longJíeêã ãedácal condáíáon. josí of íhese seêváces help óoî
síaó án óoîê hoãe so you don’t have to go to a nursing home or hospital. LTSS include InJ
eoãe pîppoêíáve peêváces EfeppFI jîlíáJmîêpose penáoê peêváces mêogêaã EjppmFI
Coããînáíó Based Adîlí peêváces ECBApFI and kîêsáng cacáláíáesLpîbJAcîíe Caêe cacáláíáes
EkcLpCcF.
Low-income subsidy (LIS): See "Extra Help.´
Medi-Cal: This is the name of California’s Medicaid program. MediJCal ás êîn bó íhe síaíe
and ás paád foê bó íhe síaíe and íhe fedeêal goveênãení. fí helps people wáíh láãáíed áncoães
and êesoîêces paó foê longJíeêã seêváces and sîppoêís and ãedácal cosís. fí coveês exíêa
seêváces and dêîgs noí coveêed bó jedácaêe. pee Chapíeê O foê ánfoêãaíáon aboîí how ío
coníací jedáJCal.
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Medi-Cal Plans: mlans íhaí coveê onló jedáJCal benefáísI sîch as long íeêã seêváces and
sîppoêísI ãedácal eqîápãeníI and íêanspoêíaíáon. jedácaêe benefáís aêe sepaêaíe.
Medically necessary: qhás descêábes seêvácesI sîppláesI oê dêîgs óoî need ío pêeveníI
dáagnoseI oê íêeaí a ãedácal condáíáon oê ãaáníaán óoîê cîêêení healíh síaíîs. qhe seêvácesI
sîppláesI oê dêîgs ãeeí accepíed síandaêds of ãedácal pêacíáce.
Medi-Cal Medically necessary: or "medical necessity´ means reasonable and
necessaêó íópes of seêváce ío pêoíecí láfe; keep íhe paíáení fêoã geííáng seêáoîsló áll oê
dásabled; oê êedîce seveêe paán íhêoîgh íhe dáagnosás oê íêeaíãení of dáseaseI állness oê
ánâîêó.
Medicare: qhe fedeêal healíh ánsîêance pêogêaã foê people SR óeaês of age oê oldeêI soãe
people îndeê age SR wáíh ceêíaán dásabáláíáesI and people wáíh endJsíage êenal dásease
Egeneêalló íhose wáíh peêãanení kádneó faálîêe who need dáalósás oê a kádneó íêansplaníF.
meople wáíh jedácaêe can geí íheáê jedácaêe healíh coveêage íhêoîgh lêágánal jedácaêe oê a
managed care plan (see "Health plan´).
Medicare-covered services: peêváces coveêed bó jedácaêe maêí A and maêí B. All
jedácaêe healíh plansI ánclîdáng oîê planI ãîsí coveê all of íhe seêváces íhaí aêe coveêed bó
jedácaêe maêí A and maêí B.
Medicare-Medi-Cal enrollee (Dual Eligible): A peêson who qîaláfáes foê jedácaêe
and jedáJCal coveêage. A jedácaêeJjedáJCal enrollee is also called a "dual eligible
beneficiary.´
Medicare Part A: qhe jedácaêe pêogêaã íhaí coveês ãosí ãedácalló necessaêó hospáíalI
skálled nîêsáng facáláíóI hoãe healíh and hospáce caêe.
Medicare Part B: qhe jedácaêe pêogêaã íhaí coveês seêváces Eláke lab íesísI sîêgeêáesI
and docíoê vásáísF and sîppláes Eláke wheelchaáês and walkeêsF íhaí aêe ãedácalló necessaêó ío
íêeaí a dásease oê condáíáon. jedácaêe maêí B also coveês ãanó pêeveníáve and scêeenáng
seêváces.
Medicare Part C: qhe jedácaêe pêogêaã íhaí leís pêávaíe healíh ánsîêance coãpanáes
pêováde jedácaêe benefáís íhêoîgh a jedácaêe Advaníage mlan.
Medicare Part D: qhe jedácaêe pêescêápíáon dêîg benefáí pêogêaã. Ete call íhás pêogêaã
"Part D´ for short.) Part D coveês oîípaíáení pêescêápíáon dêîgsI vaccánesI and soãe sîppláes
noí coveêed bó jedácaêe maêí A oê maêí B oê jedáJCal. Caêejoêe Cal jedáConnecí mlan
ánclîdes jedácaêe maêí a.
Medicare Part D drugs: aêîgs íhaí can be coveêed îndeê jedácaêe maêí a. Congêess
specáfácalló exclîded ceêíaán caíegoêáes of dêîgs fêoã coveêage as maêí a dêîgs. jedáJCal
ãaó coveê soãe of íhese dêîgs.
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Member (member of our plan, or plan member): A peêson wáíh jedácaêe and
jedáJCal who qîaláfáes ío geí coveêed seêvácesI who has enêolled án oîê planI and whose
enêollãení has been confáêãed bó íhe Ceníeês foê jedácaêe C jedácaád peêváces ECjpF and
íhe síaíe.
Member Handbook and Disclosure Information: qhás docîãeníI along wáíh óoîê
enêollãení foêã and anó oíheê aííachãenísI êádeêsI oê oíheê opíáonal coveêage selecíed
docîãenísI whách explaáns óoîê coveêageI whaí we ãîsí doI óoîê êághísI and whaí óoî ãîsí
do as a ãeãbeê of oîê plan.
Member Services: A depaêíãení wáíhán oîê plan êesponsáble foê answeêáng óoîê
qîesíáons aboîí óoîê ãeãbeêshápI benefáísI gêáevancesI and appeals. pee Chapíeê O foê
ánfoêãaíáon aboîí how ío coníací jeãbeê peêváces.
Model of care: The coordination and road map of a patients’ care activities that are
deláveêed íhêoîgh a caêe íeaã íhaí ánclîdes íhe paíáení and all íhose ánvolved án íhe paíáenís
caêe.
Multi-Purpose Senior Services Program (MSSP): A pêogêaã íhaí pêovádes eoãe
and CoããînáíóJBased peêváces EeCBpF ío jedáJCal elágáble ándávádîals who aêe SR óeaês oê
oldeê wáíh dásabáláíáes as an alíeênaíáve ío nîêsáng facáláíó placeãení.
Network pharmacy: A phaêãacó Edêîg síoêeF íhaí has agêeed ío fáll pêescêápíáons foê oîê
plan members. We call them "network pharmacies´ because they have agreed to work with
oîê plan. fn ãosí casesI óoîê pêescêápíáons aêe coveêed onló áf íheó aêe fálled aí one of oîê
neíwoêk phaêãacáes.
Network provider: "Provider´ is the general term we use for doctors, nurses, and other
people who gáve óoî seêváces and caêe. qhe íeêã also ánclîdes hospáíalsI hoãe healíh
agencáesI clánácsI and oíheê places íhaí gáve óoî healíh caêe seêvácesI ãedácal eqîápãeníI
and longJíeêã seêváces and sîppoêís. qheó aêe lácensed oê ceêíáfáed bó jedácaêe and bó íhe
state to provide health care services. We call them "network providers´ when they agree to
woêk wáíh íhe healíh plan and accepí oîê paóãení and noí chaêge oîê ãeãbeês an exíêa
aãoîní. thále óoî aêe a ãeãbeê of oîê planI óoî ãîsí îse neíwoêk pêovádeês ío geí coveêed
services. Network providers are also called "plan providers.´
Nursing home or facility: A place íhaí pêovádes caêe foê people who cannoí geí íheáê
caêe aí hoãe bîí who do noí need ío be án íhe hospáíal.
Ombudsman: An offáce án óoîê síaíe íhaí helps óoî áf óoî aêe haváng pêobleãs wáíh oîê
plan. The ombudsman’s services are free.
Organization determination: qhe plan has ãade an oêganázaíáon deíeêãánaíáon when
áíI oê one of áís pêovádeêsI ãakes a decásáon aboîí wheíheê seêváces aêe coveêed oê how ãîch
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you have to pay for covered services. Organization determinations are called "coverage
decisions´ in íhás handbook. Chapíeê V explaáns how ío ask îs foê a coveêage decásáon.
Original Medicare (traditional Medicare or fee-for-service Medicare): lêágánal
jedácaêe ás offeêed bó íhe goveênãení. rndeê lêágánal jedácaêeI jedácaêe seêváces aêe
coveêed bó paóáng docíoêsI hospáíalsI and oíheê healíh caêe pêovádeês aãoînís íhaí aêe seí
bó Congêess. voî can see anó docíoêI hospáíalI oê oíheê healíh caêe pêovádeê íhaí accepís
jedácaêe. lêágánal jedácaêe has íwo paêísW maêí A Ehospáíal ánsîêanceF and maêí B Eãedácal
ánsîêanceF. lêágánal jedácaêe ás avaálable eveêówheêe án íhe rnáíed píaíes. ff óoî do noí waní
ío be án oîê planI óoî can choose lêágánal jedácaêe.
Out-of-network pharmacy: A phaêãacó íhaí has noí agêeed ío woêk wáíh oîê plan ío
cooêdánaíe oê pêováde coveêed dêîgs ío ãeãbeês of oîê plan. josí dêîgs óoî geí fêoã
oîíJofJneíwoêk phaêãacáes aêe noí coveêed bó oîê plan înless ceêíaán condáíáons appló.
Out-of-network provider oê Out-of-network facility: A pêovádeê oê facáláíó íhaí ás
noí eãploóedI ownedI oê opeêaíed bó oîê plan and ás noí îndeê coníêací ío pêováde coveêed
seêváces ío ãeãbeês of oîê plan. Chapíeê P explaáns oîíJofJneíwoêk pêovádeês oê facáláíáes.
Part A: See "Medicare Part A.´
Part B: See "Medicare Part B.´
Part C: See "Medicare Part C.´
Part D: See "Medicare Part D.´
Part D drugs: See "Medicare Part D drugs.´
Primary care provider (PCP): voîê pêáãaêó caêe pêovádeê ás íhe docíoê oê oíheê pêovádeê
óoî see fáêsí foê ãosí healíh pêobleãs. ee oê she ãakes sîêe óoî geí íhe caêe óoî need ío
síaó healíhó. ee oê she also ãaó íalk wáíh oíheê docíoês and healíh caêe pêovádeês aboîí óoîê
caêe and êefeê óoî ío íheã. fn ãanó jedácaêe healíh plansI óoî ãîsí see óoîê pêáãaêó caêe
pêovádeê befoêe óoî see anó oíheê healíh caêe pêovádeê. pee Chapíeê P foê ánfoêãaíáon aboîí
geííáng caêe fêoã pêáãaêó caêe pêovádeês.
Prior authorization: Appêoval needed befoêe óoî can geí ceêíaán seêváces oê dêîgs.
poãe neíwoêk ãedácal seêváces aêe coveêed onló áf óoîê docíoê oê oíheê neíwoêk pêovádeê
geís pêáoê aîíhoêázaíáon fêoã oîê plan. Coveêed seêváces íhaí need pêáoê aîíhoêázaíáon aêe
ãaêked án íhe Benefáís Chaêí án Chapíeê Q. poãe dêîgs aêe coveêed onló áf óoî geí pêáoê
aîíhoêázaíáon fêoã îs. Coveêed dêîgs íhaí need pêáoê aîíhoêázaíáon aêe ãaêked án íhe List of
Covered Drugs.
?
OMV
Program for All-Inclusive Care for the Elderly (PACE) Plans: A pêogêaã íhaí
coveês jedácaêe and jedáJCal benefáís íogeíheê foê people age RR and oldeê who need a
hágheê level of caêe ío láve aí hoãe.
Prosthetics and OrthoticsW qhese aêe ãedácal deváces oêdeêed bó óoîê docíoê oê oíheê healíh
caêe pêovádeê. Coveêed áíeãs ánclîdeI bîí aêe noí láãáíed íoI aêãI backI and neck bêaces; aêíáfácáal
láãbs; aêíáfácáal eóes; and deváces needed ío êeplace an áníeênal bodó paêí oê fîncíáonI ánclîdáng
osíoãó sîppláes and eníeêal and paêeníeêal nîíêáíáon íheêapó.
Quality improvement organization (QIO): A gêoîp of docíoês and oíheê healíh caêe
expeêís who help áãpêove íhe qîaláíó of caêe foê people wáíh jedácaêe. qheó aêe paád
bó íhe fedeêal goveênãení ío check and áãpêove íhe caêe gáven ío paíáenís. pee Chapíeê O
foê ánfoêãaíáon aboîí how ío coníací íhe nfl foê óoîê síaíe.
Quantity limits: A láãáí on íhe aãoîní of a dêîg óoî can have. iáãáís ãaó be on íhe
aãoîní of íhe dêîg íhaí we coveê peê pêescêápíáon.
Rehabilitation services: qêeaíãení óoî geí ío help óoî êecoveê fêoã an állnessI accádení
oê ãaâoê opeêaíáon. pee Chapíeê Q ío leaên ãoêe aboîí êehabáláíaíáon seêváces.
Service area: A geogêaphác aêea wheêe a healíh plan accepís ãeãbeês áf áí láãáís
ãeãbeêsháp based on wheêe people láve. coê plans íhaí láãáí whách docíoês and hospáíals óoî
ãaó îseI áí ás also geneêalló íhe aêea wheêe óoî can geí êoîíáne EnonJeãeêgencóF seêváces.
The plan may drop you if you move out of the plan’s service area.
Share of Cost: qhe poêíáon of óoîê healíh caêe cosís íhaí óoî ãaó have ío paó each
ãoníh befoêe Cal jedáConnecí benefáís becoãe effecíáve. qhe aãoîní of óoîê shaêe of cosí
vaêáes dependáng on óoîê áncoãe and êesoîêces.
Skilled nursing facility (SNF): A nîêsáng facáláíó wáíh íhe síaff and eqîápãení ío gáve
skálled nîêsáng caêe andI án ãosí casesI skálled êehabáláíaíáve seêváces and oíheê êelaíed
healíh seêváces.
Skilled nursing facility (SNF) care: pkálled nîêsáng caêe and êehabáláíaíáon seêváces
pêováded on a coníánîoîsI daáló basásI án a skálled nîêsáng facáláíó. bxaãples of skálled nîêsáng
facáláíó caêe ánclîde phósácal íheêapó oê áníêavenoîs EfsF ánâecíáons íhaí a êegásíeêed nîêse
oê a docíoê can gáve.
Specialist: A docíoê who pêovádes healíh caêe foê a specáfác dásease oê paêí of íhe bodó.
State Fair Hearing: ff óoîê docíoê oê oíheê pêovádeê asks foê a jedáJCal seêváce íhaí we
wáll noí appêoveI oê we wáll noí coníánîe ío paó foê a jedáJCal seêváce óoî alêeadó haveI óoî
can ask foê a píaíe caáê eeaêáng. ff íhe píaíe caáê eeaêáng ás decáded án óoîê favoêI we ãîsí
gáve óoî íhe seêváce óoî êeqîesíed.
?
ONM
Supplemental Security Income (SSI): A ãoníhló benefáí paád bó pocáal pecîêáíó ío
people wáíh láãáíed áncoães and êesoîêces who aêe dásabledI blándI oê age SR and oldeê.
ppf benefáís aêe noí íhe saãe as pocáal pecîêáíó benefáís.
Urgent care: Caêe óoî geí foê a sîdden állnessI ánâîêóI oê condáíáon íhaí ás
noí an eãeêgencó bîí needs caêe êághí awaó. voî can geí îêgeníló needed caêe fêoã
oîíJofJneíwoêk pêovádeês when neíwoêk pêovádeês aêe înavaálable oê óoî cannoí geí ío íheã.
?
ONN
CareMore Cal MediConnect Plan Member Services
CALL
NJUUUJPRMJPQQT
Calls ío íhás nîãbeê aêe fêee. jondaó íhêoîgh cêádaó fêoã U
jeãbeê peêváces also has fêee langîage áníeêpêeíeê
seêváces avaálable foê nonJbnglásh speakeês.
TTY
TNN
Calls ío íhás nîãbeê aêe fêee. jondaó íhêoîgh cêádaó fêoã U
FAX
NJUUUJQOSJRMUT
WRITE
NOVMM maêk mlaza aêáveI píe. NRM
jpJSNRM
WEB SITE
?
ONO
If you have questions, please call CareMore Cal MediConnect Plan Member Services at 1-888-350-3447
(TTY 711), Monday through Friday from 8 a.m. to 8 p.m. Pacific time.
For more information, visit duals.caremore.com.
Limitations and restrictions may apply. For more information, call CareMore Cal MediConnect Plan Member Services or read
the CareMore Cal MediConnect Plan Member Handbook. This means that you may have to pay for some
services and that you need to follow certain rules to have CareMore Cal MediConnect Plan pay for your services.
The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a
notice before we make a change that affects you.
Benefits and/or co-payments may change on January 1 of each year.
You can get this information for free in other formats, such as large print, braille, or audio. Call Member Services at
1-888-350-3447 (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. The call is free.
CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and
Medi-Cal to provide benefits of both programs to enrollees. CareMore administers the contract on behalf of an affiliate of
CareMore. ®CareMore is a registered trademark of CareMore Health System.
H6229_16_24718_U CMS Accepted 08/29/2015
CCADMHB-0001-15 05.15

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