Amendment Sheet to the Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) 2017 Evidence of Coverage/Member Handbook
November 2017
Dear Member,
This is important information on changes in your Health Net Cal MediConnect Plan coverage.
We previously sent you the Evidence of Coverage (EOC)/Member Handbook that provides information about your coverage as an enrollee in our plan. This update to the EOC/Member Handbook reflects a change in Health Net Cal MediConnect Plan’s benefits. Below you will find updated information describing the change. Please keep this information for your reference.
Changes to your EOC/Member Handbook
Where you can find Original Updated Information What does this mean for the information in Information you? your 2017 EOC/Member Handbook
In Chapter 4, on page 85, This benefit allows for This benefit allows for This change adds clarity to the under Section D, “The transportation to transportation to medical current transportation benefits. Benefits Chart”, the Non- medical services by services by passenger Additionally, some services medical transportation passenger car, taxi, or car, taxi, or other forms may require a prior benefit is listed as: other forms of of public/private authorization. public/private transportation if you transportation. confirm that other resources are not You will have access available. to unlimited one-way trips per year. You will have unlimited round-trip access. Depending on the service, prior authorization may be required.
H3237_17_MH_001Amend2_Approved_11162017 LTR017558EN00 Page 1 of 5 In Chapter 4, on page Dental benefits are Dental benefits are This change adds clarity to the 100, under Section E, available in Denti-Cal available in the fee-for- Denti-cal fee-for-service “Benefits covered fee-for-service. For service delivery system, delivery system. The change outside of Health Net Cal more information, or known as Denti-Cal. For also notifies members that MediConnect”, the if you need help more information, or if dental benefits are also Medi-Cal Dental finding a dentist who you need help finding a available through a dental Program benefit is listed accepts Denti-Cal, dentist who accepts managed care plan for as: please contact the Denti-Cal, please contact members who live in Denti-Cal Beneficiary the Denti-Cal Sacramento or Los Angeles Customer Service line Beneficiary Customer counties. at 1-800-322-6384 Service line at 1-800- (TTY users call 1- 322-6384 (TTY users 800-735-2922). The call 1-800-735-2922). call is free. Medi-Cal The call is free. Medi- dental program Cal dental program representatives are representatives are available to assist you available to assist you from 8:00 a.m. to 5:00 from 8:00 a.m. to 5:00 p.m., Monday through p.m., Monday through Friday. You can also Friday. You can also visit the Denti-Cal visit the Denti-Cal website at website at http://www.denti- http://www.denti- cal.ca.gov for more cal.ca.gov for more information. information.
In addition to Denti- If you live in Sacramento Cal fee-for-service, or Los Angeles counties, you may get dental dental benefits are also benefits through a available through a dental managed care dental managed care plan. Dental managed plan. If you want more care plans are information about dental available in Los plans, need assistance Angeles County. If identifying your dental you want more plan, or want to change information about dental plans, please dental plans, need contact Health Care assistance identifying Options at 1-800-430- your dental plan, or 4263 (TDD users call 1- want to change dental 800-430-7077), Monday plans, please contact through Friday, 8:00 a.m. Health Care Options to 5:00 p.m. The call is at 1-844-580-7272 free. (TTY users call 1-
Page 2 of 5 800-430-7077), Monday through Friday, 8:00 a.m. to 5:00 p.m. The call is free.
You are not required to take any action in response to this document, but we recommend you keep this information for future reference. If you have any questions please call us at 1-855-464-3571 (TTY: 711), Monday through Friday, 8:00 a.m. to 8:00 p.m. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day. The call is free.
Health Net Community Solutions, Inc. is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees.
You can get this information for free in other languages. Call 1-855-464-3571 (TTY: 711), Monday through Friday, 8:00 a.m. to 8:00 p.m. The call is free.
Դուք կարող եք անվճար ստանալ այս տեղեկությունն այլ լեզուներով: Զանգահարեք 1-855-464-3571 (TTY՝711) հեռախոսահամարով, երկուշաբթիից ուրբաթ օրերին, ժամը 8:00 a.m.-ից 8:00 p.m.-ը: Զանգն անվճար է:
អនកអាចទទួលបានព័ត៌មានេដាយឥតគិតៃថលកន ុងភាសាេផសងេទៀតេនះ។ េហៅទូរស័ពទ 1-855-464- 3571 (TTY: 711) ៃថងចនទដលៃថ់ ងសុរកេវលាេមា៉ ង 8:00 រពឹកដល់េមា៉ ង 8:00 លាង ចេហៅទូរស័ពទេនះគឺឥតគិតៃថល។
اين اطالعات را ميتوانيد بطور مجانی به زبانھای ديگر دريافت کنيد. به شماره (TTY: 711) 3571-464-855-1 مابين دوشنبه تا جمعه، مابين ساعات 8:00 صبح تا 8:00 عصر تلفن کنيد. اين تلفن رايگان است.
본 정보를 무료로 다른 언어로 받을 수 있습니다. 주중(월-금) 오전 8:00시에서 오후 8:00시 사이에 1-855-464-3571 (TTY: 711)번으로 전화해 주십시오. 통화는 무료입니다
Эти сведения вы можете бесплатно получить в переводе на другие языки. Позвоните по телефону 1-855-464-3571 (TTY: 711), линия работает с понедельника по пятницу с 8:00 до 20:00. Звонки бесплатные.
Page 3 of 5 Puede obtener esta información en otros idiomas en forma gratuita. Llame al 1-855-464-3571 (TTY: 711), de lunes a viernes, de 8:00 a. m. a 8:00 p. m. La llamada es gratuita.
Maaari ninyong makuha nang libre ang impormasyong ito sa iba pang mga wika. Tumawag sa 1-855-464-3571 (TTY: 711), Lunes hanggang Biyernes, 8:00 a.m. hanggang 8:00 p.m. Libre ang tawag.
Quý vị có thể nhận thông tin này miễn phí bằng các ngôn ngữ khác. Xin gọi 1- 855-464-3571 (TTY: 711), thứ Hai đến thứ Sáu, 8:00 giờ sáng đến 8:00 giờ tối. Cuộc gọi miễn phí.
Health Net Cal MediConnect complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health Net Cal MediConnect does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Health Net Cal MediConnect:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats).
• Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages.
If you need these services, contact Health Net Cal MediConnect's Customer Contact Center at 1-855-464-3571 (TTY: 711), 8:00 a.m. to 8:00 p.m Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day. The call is free.
If you believe that Health Net Cal MediConnect has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex,
Page 4 of 5 you can file a grievance by calling the number above and telling them you need help filing a grievance; Health Net Cal MediConnect's Customer Contact Center is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800–368–1019, (TDD: 1-800–537–7697).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
Page 5 of 5 Correction Sheet to the Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) 2017 Evidence of Coverage (EOC)/Member Handbook
September 2017
Dear Member,
This is important information about changes in your Health Net Cal MediConnect Plan coverage.
We previously sent you the Evidence of Coverage (EOC)/Member Handbook that provides information about your coverage as an enrollee in our plan. This update to the EOC/Member Handbook reflects a correction in Health Net Cal MediConnect Plan’s appeals and grievance process. Below you will find updated information describing the correction. Please keep this information for your reference.
Changes to your EOC/Member Handbook
Where you can find the change in your Corrected What does this mean Original Information 2017 EOC/Member Information for you? Handbook
In Chapter 9, State Fair Hearing State Hearing This change means throughout the there has been a handbook correction to the name. State Fair Hearings are now known as State Hearings. You will find this update throughout Chapter 9.
In Chapter 9 on page In most cases, you must In most cases, you must This change means that 181, under Section 5.3, start your appeal at start your appeal at you are required to start Level 1 Appeal for Level 1. However, you Level 1. If you do not your appeal at Level 1 services, items, and are not required to want to first appeal to for Medi-Cal. If you do drugs (not Part D start your appeal at the plan for a Medi-Cal not want to appeal with drugs) Level 1 for Medi-Cal service, in special cases the plan first for Medi- services. If you do not you can ask for an Cal, you may be able to want to first appeal to Independent Medical only ask for an the plan for a Medi-Cal Review. Independent Medical service, you can ask review.
H3237_17_AGAmend_ENG_Approved_10262017 LTR016912EN00
Page 1 of 5 for a State Fair Hearing or, in special cases, an Independent Medical Review.
In Chapter 9 on page How much time do I How much time do I This change means that 183, under Section 5.3, have to make an have to make an you can ask for an Level 1 Appeal for appeal? appeal? appeal within 60 services, items, and calendar days. drugs (not Part D You must ask for an You must ask for an drugs) appeal within 90 appeal within 60 calendar days from the calendar days from the date on the letter we sent date on the letter we to tell you our decision. sent to tell you our decision.
In Chapter 9 on page 2) State Fair Hearing 2) State Hearing This change means that 188, under Section 5.4, if we said no to your Level 2 Appeal for You can ask for a State You can ask for a State Level 1 appeal, you services, items, and Fair Hearing at any time Hearing for Medi-Cal have the right to ask for drugs (not Part for Medi-Cal covered covered services and a State Hearing. Also, in D drugs) services and items items (including IHSS). If most cases, you also (including IHSS). If your your doctor or other have 120 days to ask doctor or other provider provider asks for a for a State Hearing asks for a service or item service or item that we after the “Your Hearing that we will not will not approve, or we Rights” notice is mailed approve, or we will not will not continue to pay to you. continue to pay for a for a service or item you service or item you already have, and we already have, you have said no to your Level 1 the right to ask for a appeal, you have the State Fair Hearing. right to ask for a State Hearing. In most cases you have 90 days to ask for a In most cases you have State Fair Hearing after 120 days to ask for a the “Your Hearing State Hearing after the Rights” notice is mailed “Your Hearing Rights” to you. notice is mailed to you.
In Chapter 9 on page If your problem is about a If your problem is about This change means that 189, under Section 5.4, service or item covered a service or item covered you can ask for a Level 2 Appeal for by Medi-Cal and you ask by Medi-Cal and you ask hearing within 10 days services, items, and for a State Fair for a State Hearing, your of the mailing date of drugs (not Part Hearing, your Medi-Cal Medi-Cal benefits for that our Level 1 appeal D drugs) benefits for that service service or item can decision telling you that
Page 2 of 5 or item can continue until continue until a hearing our previous decision a hearing decision decision has been upheld or the is made. You must ask is made. You must ask intended effective date for a hearing on or for a hearing on or of the action. before the later of the before the later of the following in order to following in order to continue your benefits continue your benefits Within 10 days of the Within 10 days of the mailing date of our notice mailing date of our Level of action; or 1 appeal decision telling The intended effective you that our previous date of the action. decision has been upheld; or The intended effective date of the action.
In Chapter 9 on page To make an internal To make an internal This change means that 221, under Section complaint, call Member complaint, call Member the timeframe for 10.1, Internal Services at 1-855-464- Services at 1-855-464- making complaints has Complaints 3572 (TTY: 711), 3571 (TTY: 711), changed form 180 Monday through Friday, Monday through Friday, calendar days after you 8:00 a.m. to 8:00 p.m. 8:00 a.m. to 8:00 p.m. had the problem to any Complaints related to You can make the time. If the complaint is Medicare Part D must be complaint at any time about a Part D drug, you made within 60 unless it is about a Part must file it within 60 calendar days after you D drug. If the complaint calendar days after you had the problem you is about a Part D drug, had the problem you want to complain about. you must file it within 60 would like to complain All other types of calendar days after you about. complaints must be had the problem you made within 180 want to complain about. calendar days after you had the problem you want to complain about.
You are not required to take any action in response to this document, but we recommend you keep this information for future reference. If you have any questions, please call us at 1-855-464-3571 (TTY: 711), Monday through Friday, 8:00 a.m. to 8:00 p.m.. Health Net Community Solutions, Inc. is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees.
You can get this information for free in other languages. Call 1-855-464-3571. (TTY: 711), Monday through Friday, 8:00 a.m. to 8:00 p.m. The call is free.
Դուք կարող եք անվճար ստանալ այս տեղեկությունն այլ լեզուներով: Զանգահարեք
Page 3 of 5 1-855-464-3571 (TTY՝711) հեռախոսահամարով, երկուշաբթիից ուրբաթ օրերին, ժամը 8:00 a.m.-ից 8:00 p.m.-ը: Զանգն անվճար է: