evidence of coverage - molina healthcare...evidence of coverage california imperial, los angeles,...

Evidenceof Coverage

California

Imperial, Los Angeles, Riverside (partial), San Bernardino (partial),and San Diego

2017

Molina Medicare Options Plus HMOSNP(800) 665-0898 7 days a week, 8 a.m. - 8 p.m. local time

4722556MED0916H5810_17_1127_0001_CASoCalAE

Discrimination is Against the LawMolina Medicare Options Plus HMO SNP complies with applicable Federal civil rights laws anddoes not discriminate on the basis of race, color, national origin, age, disability, or sex. MolinaMedicare Options Plus HMO SNP does not exclude people or treat them differently because ofrace, color, national origin, age, disability, or sex.

Molina Medicare Options Plus HMO SNP:

• Provides free aids and services to people with disabilities to communicate effectively with us,such as:

◦ Qualified sign language interpreters◦ Written information in other formats (large print, audio, accessible electronic formats,

other formats)

• Provides free language services to people whose primary language is not English, such as:◦ Qualified interpreters◦ Information written in other languages◦ If you need these services, contact the Civil Rights Grievance Coordinator

If you believe that Molina Medicare Options Plus HMO SNP has failed to provide these services ordiscriminated in another way on the basis of race, color, national origin, age, disability, or sex, youcan file a grievance with: Molina Medicare Options Plus HMO SNP, Attn: Civil Rights GrievanceCoordinator, P.O. Box 22816, Long Beach, CA 90801, or by calling (800) 665-0898 , TTY/TDD:711, Monday - Friday, 8 a.m. to 8 p.m., local time, by fax: (562) 499-0610, email:[email protected]. You can file a grievance in person or bymail, fax, or email. If you need help filing a grievance, the Civil Rights Grievance Coordinator isavailable to help you. You can also file a civil rights complaint with the U.S. Department of Healthand Human Services, Office for Civil Rights, electronically through the Office for Civil RightsComplaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services200 Independence Avenue SW Room 509F, HHH BuildingWashington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

http://www.hhs.gov/ocr/office/file/index.html

January 1 - December 31, 2017

Evidence of Coverage:Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Memberof Molina Medicare Options Plus HMO SNP

This booklet gives you the details about your Medicare health care and prescription drug coveragefrom January 1 - December 31, 2017. It explains how to get coverage for the health care servicesand prescription drugs you need. This is an important legal document. Please keep it in a safeplace.

This plan, Molina Medicare Options Plus HMO SNP, is offered by Molina Healthcare ofCalifornia. (When this Evidence of Coverage says "we," "us," or "our," it means MolinaHealthcare of California. When it says "plan" or "our plan," it means Molina Medicare OptionsPlus HMO SNP.)

Molina Medicare Options Plus HMO SNP is a Health Plan with a Medicare Contract and acontract with the state Medi-Cal (Medicaid) program. Enrollment in Molina Medicare OptionsPlus depends on contract renewal.

Member Services also has free language interpreter services available for non-English speakers.

This information is available for free in other languages.

Please contact our Member Services number at (800) 665-0898 for additional information. (TTYusers should call 711.) Hours are 7 days a week, 8 a.m. - 8 p.m., local time.

Esta información está disponible gratuitamente en otros idiomas. Por favor, comuníquese anuestro número de teléfono para servicio al cliente al (800) 665-0898 TTY 711, los 7 días de lasemana, de 8:00 a.m. a 8:00 p.m., hora local. El Departamento de Servicios para Miembrostambién cuenta con servicios de interpretación disponibles para las personas que no hablan inglés.

You can also ask for this information in other formats such as: audio, Braille, or large print.

Benefits, premium, and/or copayments/coinsurance may change on January 1, 2018.

The formulary, pharmacy network, and/or provider network may change at any time. You willreceive notice when necessary.

4722556MED0916

OMB Approval 0938-1051

H5810_17_1127_0001_CASoCalAE Accepted 9/9/2016

Form CMS 10260-ANOC/EOC (Approved 03/2014)

2017 Evidence of Coverage

Table of Contents

This list of chapters and page numbers is your starting point. For more help in finding informationyou need, go to the first page of a chapter. You will find a detailed list of topics at the beginningof each chapter.

52017 Evidence of Coverage for Molina Medicare Options Plus HMO SNPTable of Contents

Chapter 1. Getting started as a member. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Explains what it means to be in a Medicare health plan and how to use this booklet.Tells about materials we will send you, your plan premium, your plan membershipcard, and keeping your membership record up to date.

Chapter 2. Important phone numbers and resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Tells you how to get in touch with our plan (Molina Medicare Options Plus HMOSNP) and with other organizations including Medicare, the State Health InsuranceAssistance Program (SHIP), the Quality Improvement Organization, Social Security,Medicaid (the state health insurance program for people with low incomes), programsthat help people pay for their prescription drugs, and the Railroad Retirement Board.

Chapter 3. Using the plan’s coverage for your medical and other covered services . . . . . 44Explains important things you need to know about getting your medical care as amember of our plan. Topics include using the providers in the plan's network and howto get care when you have an emergency.

Chapter 4. Benefits Chart (what is covered). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62Gives the details about which types of medical care are covered and not covered foryou as a member of our plan.

Chapter 5. Using the plan’s coverage for your Part D prescription drugs. . . . . . . . . . . . . . . 91Explains rules you need to follow when you get your Part D drugs. Tells how to usethe plan's List of Covered Drugs (Formulary) to find out which drugs are covered.Tells which kinds of drugs are not covered. Explains several kinds of restrictions thatapply to coverage for certain drugs. Explains where to get your prescriptions filled.Tells about the plan's programs for drug safety and managing medications.

Chapter 6. What you pay for your Part D prescription drugs. . . . . . . . . . . . . . . . . . . . . . . . 115Tells about the (3) stages of drug coverage (Initial Coverage Stage, Coverage GapStage, Catastrophic Coverage Stage) and how these stages affect what you pay foryour drugs. Explains the (5) cost-sharing tiers for your Part D drugs and tells what

Chapter 7. Asking us to pay our share of a bill you have received for covered medicalservices or drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139Explains when and how to send a bill to us when you want to ask us to pay you backfor our share of the cost for your covered services or drugs.

Chapter 8. Your rights and responsibilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147Explains the rights and responsibilities you have as a member of our plan. Tells whatyou can do if you think your rights are not being respected.

Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals,complaints). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168Tells you step-by-step what to do if you are having problems or concerns as a memberof our plan.• Explains how to ask for coverage decisions and make appeals if you are having

trouble getting the medical care or prescription drugs you think are covered by ourplan. This includes asking us to make exceptions to the rules or extra restrictions onyour coverage for prescription drugs, and asking us to keep covering hospital careand certain types of medical services if you think your coverage is ending too soon.

• Explains how to make complaints about quality of care, waiting times, customerservice, and other concerns.

Chapter 10. Ending your membership in the plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228Explains when and how you can end your membership in the plan. Explains

situations in which our plan is required to end your membership.

Chapter 11. Legal notices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236Includes notices about governing law and about nondiscrimination.

Chapter 12. Definitions of important words. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239Explains key terms used in this booklet.

you must pay for a drug in each cost-sharing tier. Tells about the late enrollmentpenalty.

62017 Evidence of Coverage for Molina Medicare Options Plus HMO SNPTable of Contents

CHAPTER 1Getting started as a member

SECTION 1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Section 1.1 You are enrolled in Molina Medicare Options Plus HMO SNP, which is a

specialized Medicare Advantage Plan (Special Needs Plan). . . . . . . . . . . . . . . . . 10Section 1.2 What is the Evidence of Coverage booklet about?. . . . . . . . . . . . . . . . . . . . . . . . . 11Section 1.3 Legal information about the Evidence of Coverage . . . . . . . . . . . . . . . . . . . . . . . 11

SECTION 2 What makes you eligible to be a plan member?. . . . . . . . . . . . . . . . . . . . . . . . 12Section 2.1 Your eligibility requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Section 2.2 What are Medicare Part A and Medicare Part B? . . . . . . . . . . . . . . . . . . . . . . . . . 12Section 2.3 What is Medi-Cal (Medicaid)?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Section 2.4 Here is the plan service area for Molina Medicare Options Plus HMO SNP . . . . 13Section 2.5 U.S. Citizen or Lawful Presence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

SECTION 3 What other materials will you get from us?. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Section 3.1 Your plan membership card - Use it to get all covered care and prescription drugs. .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Section 3.2 The Provider/Pharmacy Directory: Your guide to all providers in the plan's

network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Section 3.3 The Provider/Pharmacy Directory: Your guide to pharmacies in our network . . 16Section 3.4 The plan's List of Covered Drugs (Formulary) . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Section 3.5 The Part D Explanation of Benefits (the "Part D EOB"): Reports with a summary

of payments made for your Part D prescription drugs. . . . . . . . . . . . . . . . . . . . . . 17

SECTION 4 Your monthly premium for Molina Medicare Options Plus HMO SNP . . . . . . 18Section 4.1 How much is your plan premium?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Section 4.2 If you pay a Part D late enrollment penalty, there are several ways you can pay your

plan premium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Section 4.3 Can we change your monthly plan premium during the year? . . . . . . . . . . . . . . . 21

SECTION 5 Please keep your plan membership record up to date. . . . . . . . . . . . . . . . . . . 21Section 5.1 How to help make sure that we have accurate information about you. . . . . . . . . . 21

SECTION 6 We protect the privacy of your personal health information. . . . . . . . . . . . . . 22Section 6.1 We make sure that your health information is protected. . . . . . . . . . . . . . . . . . . . 23

Chapter 1. Getting started as a member

2017 Evidence of Coverage forMolina Medicare Options Plus HMO SNPChapter 1. Getting started as a member

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SECTION 7 How other insurance works with our plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Section 7.1 Which plan pays first when you have other insurance?. . . . . . . . . . . . . . . . . . . . . 23


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SECTION 1 Introduction

Section 1.1 You are enrolled in Molina Medicare Options Plus HMOSNP , which is a specialized Medicare Advantage Plan(Special Needs Plan)

You are covered by both Medicare and Medicaid:

• Medicare is the Federal health insurance program for people 65 years of age or older, somepeople under age 65 with certain disabilities, and people with end-stage renal disease (kidneyfailure).

• Medi-Cal (Medicaid) is a joint Federal and state government program that helps with medicalcosts for certain people with limited incomes and resources. Medi-Cal (Medicaid) coveragevaries depending on the state and the type of Medi-Cal (Medicaid) you have. Some peoplewith Medi-Cal (Medicaid) get help paying for their Medicare premiums and other costs. Otherpeople also get coverage for additional services and drugs that are not covered by Medicare.

You have chosen to get your Medicare health care and your prescription drug coverage throughour plan, Molina Medicare Options Plus HMO SNP .

There are different types of Medicare health plans. Molina Medicare Options Plus HMO SNP is aspecialized Medicare Advantage Plan (a Medicare "Special Needs Plan"), which means itsbenefits are designed for people with special health care needs. Molina Medicare Options PlusHMO SNP is designed specifically for people who have Medicare and who are also entitled toassistance from Medi-Cal (Medicaid).

Because you get assistance from Medi-Cal (Medicaid), you will pay less for some of yourMedicare health care services. Medi-Cal (Medicaid) may also provide other benefits to you bycovering health care services that are not usually covered under Medicare. You will also receive"Extra Help" from Medicare to pay for the costs of your Medicare prescription drugs. MolinaMedicare Options Plus HMO SNP will help manage all of these benefits for you, so that you getthe health care services and payment assistance that you are entitled to.

Molina Medicare Options Plus HMO SNP is run by a private company. Like all MedicareAdvantage Plans, this Medicare Special Needs Plan is approved by Medicare. The plan also has acontract with the California Medi-Cal (Medicaid) program to coordinate your Medi-Cal(Medicaid) benefits. We are pleased to be providing your Medicare health care coverage,including your prescription drug coverage.


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Section 1.2 What is the Evidence of Coverage booklet about?

This Evidence of Coverage booklet tells you how to get your Medicare medical care andprescription drugs covered through our plan. This booklet explains your rights and responsibilities,what is covered, and what you pay as a member of the plan.

The word "coverage" and "covered services" refers to the medical care and services and theprescription drugs available to you as a member of Molina Medicare Options Plus HMO SNP.

It's important for you to learn what the plan's rules are and what services are available to you. Weencourage you to set aside some time to look through this Evidence of Coverage booklet.

If you are confused or concerned or just have a question, please contact our plan's MemberServices (phone numbers are printed on the back cover of this booklet).

Section 1.3 Legal information about the Evidence of Coverage

It's part of our contract with you

This Evidence of Coverage is part of our contract with you about how Molina Medicare OptionsPlus HMO SNP covers your care. Other parts of this contract include your enrollment form, theList of Covered Drugs (Formulary), and any notices you receive from us about changes to yourcoverage or conditions that affect your coverage. These notices are sometimes called "riders" or"amendments."

The contract is in effect for months in which you are enrolled in Molina Medicare Options PlusHMO SNP between January 1, 2017 and December 31, 2017.

Each calendar year, Medicare allows us to make changes to the plans that we offer. This means wecan change the costs and benefits of Molina Medicare Options Plus HMO SNP after December 31,2017. We can also choose to stop offering the plan, or to offer it in a different service area, afterDecember 31, 2017.

Medicare must approve our plan each year

Medicare (the Centers for Medicare & Medicaid Services) must approve Molina MedicareOptions Plus HMO SNP each year. You can continue to get Medicare coverage as a member ofour plan as long as we choose to continue to offer the plan and Medicare renews its approval ofthe plan.


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SECTION 2 What makes you eligible to be a plan member?

Section 2.1 Your eligibility requirements

You are eligible for membership in our plan as long as:

• You have both Medicare Part A and Medicare Part B (section 2.2 tells you about MedicarePart A and Medicare Part B)

• -- and -- You live in our geographic service area (section 2.3 below describes our service area)

• -- and -- You are a United States citizen or are lawfully present in the United States

• -- and -- You do not have End-Stage Renal Disease (ESRD), with limited exceptions, such asif you develop ESRD when you are already a member of a plan that we offer, or you were amember of a different plan that was terminated.

• -- and -- You meet the special eligibility requirements described below.

Special eligibility requirements for our plan

Our plan is designed to meet the needs of people who receive certain Medi-Cal (Medicaid)benefits. (Medi-Cal (Medicaid) is a joint Federal and state government program that helps withmedical costs for certain people with limited incomes and resources.) To be eligible for our planyou must be eligible for Medicare cost-sharing assistance under Medi-Cal (Medicaid).

Please note: If you lose your Medi-Cal (Medicaid) eligibility but can reasonably be expected toregain eligibility within 6 month(s), then you are still eligible for membership in our plan (chapter4, section 2.1 tells you about coverage during a period of deemed continued eligibility).

Section 2.2 What are Medicare Part A and Medicare Part B?

When you first signed up for Medicare, you received information about what services are coveredunder Medicare Part A and Medicare Part B. Remember:

• Medicare Part A generally helps cover services provided by hospitals (for inpatient services,skilled nursing facilities, or home health agencies).

• Medicare Part B is for most other medical services (such as physician's services and otheroutpatient services) and certain items (such as durable medical equipment and supplies).


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Section 2.3 What is Medi-Cal (Medicaid)?

Medi-Cal (Medicaid) is a joint Federal and state government program that helps with medicalcosts for certain people who have limited incomes and resources. Each state decides what countsas income and resources, who is eligible, what services are covered, and the cost for services.States also can decide how to run their program as long as they follow the Federal guidelines.

In addition, there are programs offered through Medi-Cal (Medicaid) that help people withMedicare pay their Medicare costs, such as their Medicare premiums. These “Medicare SavingsPrograms” help people with limited income and resources save money each year:

Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B premiums, andother cost sharing (like deductibles, coinsurance, and copayments). (Some people with QMB arealso eligible for full Medi-Cal (Medicaid) benefits (QMB+).)

Specified Low-Income Medicare Beneficiary (SLMB+): Helps pay Part B premiums and areeligible for full Medicaid benefits.

Section 2.4 Here is the plan service area for Molina MedicareOptions Plus HMO SNP

Although Medicare is a Federal program, Molina Medicare Options Plus HMO SNP is availableonly to individuals who live in our plan service area. To remain a member of our plan, you mustcontinue to reside in the plan service area. The service area is described below.

Our service area includes these counties in California: Imperial, Los Angeles, Riverside (partial),San Bernardino (partial), and San Diego.

Our service area includes these parts of counties in California. Riverside, the following zip codesonly:

91718; 91719; 91720; 91752; 91760; 92201; 92202; 92203; 92210; 92211; 92220; 92223; 92230;92234; 92235; 92236; 92240; 92241; 92247; 92248; 92253; 92254; 92255; 92258; 92260; 92261;92262; 92263; 92264; 92270; 92274; 92276; 92282; 92292; 92320; 92501; 92502; 92503; 92504;92505; 92506; 92507; 92508; 92509; 92513; 92514; 92515; 92516; 92517; 92518; 92519; 92521;92522; 92530; 92531; 92532; 92536; 92539; 92543; 92544; 92545; 92546; 92548; 92549; 92551;92552; 92553; 92554; 92555; 92556; 92557; 92561; 92562; 92563; 92564; 92567; 92570; 92571;92572; 92581; 92582; 92583; 92584; 92585; 92586; 92587; 92589; 92590; 92591; 92592; 92593;92595; 92596; 92599; 92860; 92877; 92878; 92879; 92880; 92881; 92882; 92883;


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San Bernardino County, the following zip codes only:

91701; 91708; 91709; 91710; 91729; 91730; 91737; 91739; 91743; 91758; 91759; 91761; 91762;91763; 91764; 91784; 91785; 91786; 91798; 92301; 92307; 92308; 92313; 92316; 92318; 92322;92324; 92326; 92329; 92331; 92334; 92335; 92336; 92337; 92340; 92341; 92344; 92345; 92346;92350; 92354; 92357; 92358; 92359; 92368; 92369; 92371; 92372; 92373; 92374; 92375; 92376;92377; 92392; 92393; 92394; 92395; 92397; 92399; 92401; 92402; 92403; 92404; 92405; 92406;92407; 92408; 92410; 92411; 92412; 92413; 92414; 92415; 92418; 92423; 92424; 92427;

We offer coverage in several states. However, there may be cost or other difference between theplans we offer in each state. If you move out of state and into a state that is still within our servicearea, you must call Member Services in order to update your information. If you move into a stateoutside of our service area, you cannot remain a member of our plan. Please call Member Servicesto find out if we have a plan in your new state.

If you plan to move to a new state, you should also contact your state's Medi-Cal (Medicaid)office and ask how this move will affect your Medi-Cal (Medicaid) benefits. Phone numbers forMedi-Cal (Medicaid) are in Chapter 2, Section 6 of this booklet

If you plan to move out of the service area, please contact Member Services (phone numbers areprinted on the back cover of this booklet). When you move, you will have a Special EnrollmentPeriod that will allow you to switch to Original Medicare or enroll in a Medicare health or drugplan that is available in your new location.

It is also important that you call Social Security if you move or change your mailing address. Youcan find phone numbers and contact information for Social Security in Chapter 2, Section 5.

Section 2.5 U.S. Citizen of Lawful Presence

A member of a Medicare health plan must be a U.S. citizen or lawfully present in the UnitedStates. Medicare (the Centers for Medicare & Medicaid Services) will notify Molina MedicareOptions Plus HMO SNP if you are not eligible to remain a member on this basis. Molina MedicareOptions Plus HMO SNP must disenroll you if you do not meet this requirement.


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SECTION 3 What other materials will you get from us?

Section 3.1 Your plan membership card - Use it to get all coveredcare and prescription drugs

While you are a member of our plan, you must use your membership card for our plan wheneveryou get any services covered by this plan and for prescription drugs you get at networkpharmacies. Always remember to show both your Molina Medicare Options Plus HMO SNP IDcard and Medi-Cal (Medicaid) ID card each time you present for care. Here’s a samplemembership card to show you what yours will look like:

As long as you are a member of our plan you must not use your red, white, and blue Medicarecard to get covered medical services (with the exception of routine clinical research studies andhospice services). Keep your red, white, and blue Medicare card in a safe place in case you need itlater.

Here's why this is so important: If you get covered services using your red, white, and blueMedicare card instead of using your Molina Medicare Options Plus HMO SNP membership cardwhile you are a plan member, you may have to pay the full cost yourself.

If your plan membership card is damaged, lost, or stolen, call Member Services right away and wewill send you a new card. (Phone numbers for Member Services are printed on the back cover ofthis booklet.)

Section 3.2 The Provider/Pharmacy Directory: Your guide to allproviders in the plan's network

The Provider/Pharmacy Directory lists our network providers, and durable medical equipmentsuppliers. The directory also denotes those providers accepting Medi-Cal (Medicaid) with a Medi-Cal (Medicaid) indicator.


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What are "network providers"?

Network providers are the doctors and other health care professionals, medical groups, durablemedical equipment suppliers, hospitals, and other health care facilities that have an agreementwith us to accept our payment and any plan cost-sharing as payment in full. We have arranged forthese providers to deliver covered services to members in our plan.

Why do you need to know which providers are part of our network?

It is important to know which providers are part of our network because, with limited exceptions,while you are a member of our plan you must use network providers to get your medical care andservices. If you choose a PCP who is part of an IPA, you must only see the specialists andproviders that are also participating with this same IPA. The only exceptions are emergencies,urgently needed services when the network is not available (generally, when you are out of thearea), out-of-area dialysis services, and cases in which Molina Medicare Options Plus HMO SNPauthorizes use of out-of-network providers. See Chapter 3 (Using the plan's coverage for yourmedical services) for more specific information about emergency, out-of-network, and out-of-areacoverage.

It is important that you know who the Medi-Cal (Medicaid) providers are in our network. Youshould go to these providers because they have an agreement with us to accept our payment foryour medical care. When you see a network provider, you usually pay nothing for coveredservices.

If you don't have your copy of the Provider/Pharmacy Directory, you can request a copy fromMember Services (phone numbers are printed on the back cover of this booklet). You may askMember Services for more information about our network providers, including theirqualifications. You can also see the Provider/Pharmacy Directory at http://www.molinahealthcare.com/medicare , or download it from this website. Both Member Servicesand the website can give you the most up-to-date information about changes in our networkproviders.

Section 3.3 The Provider/Pharmacy Directory: Your guide topharmacies in our network

What are "network pharmacies"?

Network pharmacies are all of the pharmacies that have agreed to fill covered prescriptions for ourplan members.


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http://www.molinahealthcare.com/medicare

Why do you need to know about network pharmacies?

You can use the Provider/Pharmacy Directory to find the network pharmacy you want to use.There are changes to our network of pharmacies for next year. An updated Provider/PharmacyDirectory is located on our website at http://www.molinahealthcare.com/medicare . You may alsocall Member Services for updated provider information or to ask us to mail you a Provider/Pharmacy Directory. Please review the 2017 Pharmacy Directory to see which pharmacies arein our network.

If you don't have the Provider/Pharmacy Directory, you can get a copy from Member Services(phone numbers are printed on the back cover of this booklet). At any time, you can call MemberServices to get up-to-date information about changes in the pharmacy network. You can also findthis information on our website at http://www.molinahealthcare.com/medicare .

Section 3.4 The plan's List of Covered Drugs (Formulary)

The plan has a List of Covered Drugs (Formulary). We call it the "Drug List" for short. It tellswhich prescription drugs are covered by Molina Medicare Options Plus HMO SNP. The drugs onthis list are selected by the plan with the help of a team of doctors and pharmacists. The list mustmeet requirements set by Medicare and Medi-Cal (Medicaid). Medicare and Medi-Cal (Medicaid)have approved the Molina Medicare Options Plus HMO SNP Drug List.

The Drug List also tells you if there are any rules that restrict coverage for your drugs.

We will send you a copy of the Drug List. To get the most complete and current information aboutwhich drugs are covered, you can visit the plan's website ( http://www.molinahealthcare.com/medicare ) or call Member Services (phone numbers are printed on the back cover of this booklet).

Section 3.5 The Part D Explanation of Benefits (the "Part D EOB"):Reports with a summary of payments made for yourPart D prescription drugs

When you use your Part D prescription drug benefits, we will send you a summary report to helpyou understand and keep track of payments for your Part D prescription drugs. This summaryreport is called the Part D Explanation of Benefits (or the "Part D EOB").The Part D Explanation of Benefits tells you the total amount you, or others on your behalf, havespent on your Part D prescription drugs and the total amount we have paid for each of your Part Dprescription drugs during the month. Chapter 6 (What you pay for your Part D prescription drugs)


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http://www.molinahealthcare.com/medicarehttp://www.molinahealthcare.com/medicarehttp://www.molinahealthcare.com/medicare

gives more information about the Explanation of Benefits and how it can help you keep track ofyour drug coverage.

A Part D Explanation of Benefits summary is also available upon request. To get a copy, pleasecontact Member Services (phone numbers are printed on the back cover of this booklet).

SECTION 4 Your monthly premium for Molina Medicare OptionsPlus HMO SNP

Section 4.1 How much is your plan premium?

You do not pay a separate monthly plan premium for Molina Medicare Options Plus HMO SNP.You must continue to pay your Medicare Part B premium (unless your Part B premium is paid foryou by Medi-Cal (Medicaid) or another third party).

In some situations, your plan premium could be more

In some situations, your plan premium could be more than the amount listed above in Section 4.1.This situation is described below.

• Some members are required to pay a late enrollment penalty because they did not join aMedicare drug plan when they first became eligible or because they had a continuous periodof 63 days or more when they didn't have "creditable" prescription drug coverage.("Creditable" means the drug coverage is expected to pay, on average, at least as much asMedicare's standard prescription drug coverage.) For these members, the late enrollmentpenalty is added to the plan's monthly premium. Their premium amount will be the monthlyplan premium plus the amount of their late enrollment penalty.

◦ If you receive "Extra Help" from Medicare to pay for your prescription drugs, you willnot pay a late enrollment penalty.

◦ If you ever lose your low income subsidy ("Extra Help"), you must maintain your PartD coverage or you could be subject to a late enrollment penalty if you ever chose toenroll in Part D in the future

◦ If you are required to pay the late enrollment penalty, the amount of your penaltydepends on how many months you were without drug coverage after you becameeligible. Chapter 6, Section 10 explains the late enrollment penalty.


18

Some members are required to pay other Medicare premiums

As explained in Section 2 above, in order to be eligible for our plan, you must maintain youreligibility for Medi-Cal (Medicaid) as well as be entitled to Medicare Part A and enrolled inMedicare Part B. For most Molina Medicare Options Plus HMO SNP members, Medi-Cal(Medicaid) pays for your Part A premium (if you don’t qualify for it automatically) and for yourPart B premium. If Medi-Cal (Medicaid) is not paying your Medicare premiums for you, you mustcontinue to pay your Medicare premiums to remain a member of the plan.

Some people pay an extra amount for Part D because of their yearly income; this is known asIncome Related Monthly Adjustment Amounts, also known as IRMAA. If your income is greaterthan $84,999 for an individual (or married individuals filing separately) or greater than $169,999for married couples, you must pay an extra amount directly to the government (not theMedicare plan) for your Medicare Part D coverage.

• If you have to pay an extra amount, Social Security, not your Medicare plan, will send you aletter telling you what that extra amount will be. If you had a life-changing event that causedyour income to go down, you can ask Social Security to reconsider their decision.

• If you are required to pay the extra amount and you do not pay it, you will be disenrolledfrom the plan.

• For more information about Part D premiums based on income, go to Chapter 6, Section 11 ofthis booklet. You can also visit http://www.medicare.gov on the Web or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call1-877-486-2048. Or you may call Social Security at 1-800-772-1213. TTY users should call1-800-325-0778.

Your copy of Medicare & You 2017 gives information about these premiums in the section called"2017 Medicare Costs." Everyone with Medicare receives a copy of Medicare & You each year inthe fall. Those new to Medicare receive it within a month after first signing up. You can alsodownload a copy of Medicare & You 2017 from the Medicare website (http://www.medicare.gov).Or, you can order a printed copy by phone at 1-800-MEDICARE (1-800-633-4227), 24 hours aday, 7 days a week. TTY users call 1-877-486-2048.

Section 4.2 If you pay a Part D late enrollment penalty, there areseveral ways you can pay your penalty

If you pay a Part D late enrollment penalty, there are 3 ways you can pay the penalty.

If you decide to change the way you pay your late enrollment penalty, it can take up to threemonths for your new payment method to take effect. While we are processing your request for a


19

http://www.medicare.govhttp://www.medicare.gov

new payment method, you are responsible for making sure that your late enrollment penalty ispaid on time.

Option 1: You can pay by check

You can pay your late enrollment penalty by check with our coupon book. Upon signing up to payby check we will mail out a coupon book that will be effective your entire enrollment period ofone year. The book will have a coupon that you will submit with your check each month. Thecheck should be made payable to your plan name, Molina Medicare Options Plus HMO SNP andmailed to: (Checks should NOT be made out to CMS or HHS).

Molina Medicare P.O.Box 515189 Los Angeles, CA 90051-5189

If you lose your coupon book, need to change your payment options or have any questions pleasecontact Member Services (phone numbers are on the back cover of this booklet).

Option 2: Electronic Funds Transfer

You can pay by EFT which means the late enrollment penalty will be automatically withdrawnfrom your checking or savings account, directly by the plan. On the enrollment form included inyour enrollment package, please complete the bank information section to begin your EFTpayments. Automatic deductions will occur between the 20th - 25th day of each month. If youneed to change your payment option or have any questions please contact Member Services(phone numbers are on the back cover of this booklet.).

Option 3: You can have the late enrollment penalty taken out of your monthly SocialSecurity check

You can have the late enrollment penalty taken out of your monthly Social Security check.Contact Member Services for more information on how to pay your late enrollment penalty thisway. We will be happy to help you set this up. (Phone numbers for Member Services are printedon the back cover of this booklet.)

What to do if you are having trouble paying your late enrollment penalty

If you are having trouble paying your late enrollment penalty on time, please contact MemberServices to see if we can direct you to programs that will help with your penalty. (Phone numbersfor Member Services are printed on the back cover of this booklet.)

If you think we have wrongfully ended your membership, you have a right to ask us to reconsiderthis decision by making a complaint. Chapter 9, Section 11 of this booklet tells how to make acomplaint. If you had an emergency circumstance that was out of your control and it caused you to


20

not be able to pay your premiums within our grace period, you can ask us to reconsider thisdecision by calling (800) 665-0898 between 8 a.m. - 8 p.m., local time 7 days a week. TTY usersshould call 711. You must make your request no later than 60 days after the date your membershipends.

Section 4.3 Can we change your monthly plan premium during theyear?

No. We are not allowed to begin charging a monthly plan premium during the year. If the monthlyplan premium changes for next year we will tell you in September and the change will take effecton January 1.

However, in some cases, you may need to start paying or may be able to stop paying a lateenrollment penalty. (The late enrollment penalty may apply if you had a continuous period of 63days or more when you didn’t have "creditable" prescription drug coverage.) This could happen ifyou become eligible for the "Extra Help" program or if you lose your eligibility for the "ExtraHelp" program during the year:

If you currently pay the late enrollment penalty and become eligible for "Extra Help" during theyear, you would be able to stop paying your penalty.

If you ever lose "Extra Help", you must maintain your Part D coverage or you could be subject to alate enrollment penalty.

You can find out more about the "Extra Help" program in Chapter 2, Section 7.

SECTION 5 Please keep your plan membership record up to date

Section 5.1 How to help make sure that we have accurateinformation about you

Your membership record has information from your enrollment form, including your address andtelephone number. It shows your specific plan coverage including your Primary Care Provider/Medical Group/IPA.

The doctors, hospitals, pharmacists, and other providers in the plan's network need to have correctinformation about you. These network providers use your membership record to know whatservices and drugs are covered and the cost-sharing amounts for you. Because of this, it isvery important that you help us keep your information up to date.


21

Let us know about these changes:

• Changes to your name, your address, or your phone number

• Changes in any other health insurance coverage you have (such as from your employer, yourspouse's employer, workers' compensation, or Medi-Cal (Medicaid))

• If you have any liability claims, such as claims from an automobile accident

• If you have been admitted to a nursing home

• If you receive care in an out-of-area or out-of-network hospital or emergency room

• If your designated responsible party (such as a caregiver) changes

• If you are participating in a clinical research study

If any of this information changes, please let us know by calling Member Services (phonenumbers are printed on the back cover of this booklet). Members can create an online My Molinaaccount to change their doctor, update their contact information, request a new ID card, get healthreminders on services they need, or view their service history. Visit http://www.molinahealthcare.com/medicare to create or access your My Molina account.

It is also important to contact Social Security if you move or change your mailing address. Youcan find phone numbers and contact information for Social Security in Chapter 2, Section 5.

Read over the information we send you about any other insurance coverage youhave

Medicare requires that we collect information from you about any other medical or drug insurancecoverage that you have. That's because we must coordinate any other coverage you have with yourbenefits under our plan. (For more information about how our coverage works when you haveother insurance, see Section 7 in this chapter.)

Once each year, we will send you a letter that lists any other medical or drug insurance coveragethat we know about. Please read over this information carefully. If it is correct, you don't need todo anything. If the information is incorrect, or if you have other coverage that is not listed, pleasecall Member Services (phone numbers are printed on the back cover of this booklet).


22

SECTION 6 We protect the privacy of your personal healthinformation


Section 6.1 We make sure that your health information isprotected

Federal and state laws protect the privacy of your medical records and personal healthinformation. We protect your personal health information as required by these laws.For more information about how we protect your personal health information, please go toChapter 8, Section 1.4 of this booklet.

SECTION 7 How other insurance works with our plan

Section 7.1 Which plan pays first when you have other insurance?

When you have other insurance (like employer group health coverage), there are rules set byMedicare that decide whether our plan or your other insurance pays first. The insurance that paysfirst is called the "primary payer" and pays up to the limits of its coverage. The one that payssecond, called the "secondary payer," only pays if there are costs left uncovered by the primarycoverage. The secondary payer may not pay all of the uncovered costs.These rules apply for employer or union group health plan coverage:

• If you have retiree coverage, Medicare pays first.

• If your group health plan coverage is based on your or a family member's current employment,who pays first depends on your age, the number of people employed by your employer, andwhether you have Medicare based on age, disability, or End-stage Renal Disease (ESRD):

◦ If you're under 65 and disabled and you or your family member is still working, yourgroup health plan pays first if the employer has 100 or more employees or at least oneemployer in a multiple employer plan that has more than 100 employees.

◦ If you're over 65 and you or your spouse is still working, your group health plan paysfirst if the employer has 20 or more employees or at least one employer in a multipleemployer plan that has more than 20 employees.

• If you have Medicare because of ESRD, your group health plan will pay first for the first 30months after you become eligible for Medicare.

These types of coverage usually pay first for services related to each type:

• No-fault insurance (including automobile insurance)

• Liability (including automobile insurance)


23

• Black lung benefits

• Workers' compensation

Medi-Cal (Medicaid) and TRICARE never pay first for Medicare-covered services. They only payafter Medicare and/or employer group health plans have paid.

If you have other insurance, tell your doctor, hospital, and pharmacy. If you have questions aboutwho pays first, or you need to update your other insurance information, call Member Services(phone numbers are printed on the back cover of this booklet). You may need to give your planmember ID number to your other insurers (once you have confirmed their identity) so your billsare paid correctly and on time.


24

CHAPTER 2Important phone numbers and resources

Chapter 2. Important phone numbers and resources

2017 Evidence of Coverage forMolina Medicare Options Plus HMO SNPChapter 2. Important phone numbers and resources

26

SECTION 1 Molina Medicare Options Plus HMO SNP contacts (how to contact us,including how to reach Member Services at the plan). . . . . . . . . . . . . . . . . . . 27

SECTION 2 Medicare (how to get help and information directly from the Federal Medicareprogram). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

SECTION 3 State Health Insurance Assistance Program (free help, information, andanswers to your questions about Medicare). . . . . . . . . . . . . . . . . . . . . . . . . . . 34

SECTION 4 Quality Improvement Organization (paid by Medicare to check on the qualityof care for people with Medicare). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

SECTION 5 Social Security. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

SECTION 6 Medicaid (a joint Federal and state program that helps with medical costs forsome people with limited income and resources). . . . . . . . . . . . . . . . . . . . . . 37

SECTION 7 Information about programs to help people pay for their prescription drugs 39

SECTION 8 How to contact the Railroad Retirement Board. . . . . . . . . . . . . . . . . . . . . . . . . 42

SECTION 9 Do you have "group insurance" or other health insurance from an employer?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

SECTION 1 Molina Medicare Options Plus HMO SNP contacts (howto contact us, including how to reach Member Servicesat the plan)

How to contact our plan's Member Services

For assistance with claims, billing or member card questions, please call or write to MolinaMedicare Options Plus HMO SNP Member Services. We will be happy to help you.

Method Member Services - Contact Information

(800) 665-0898Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m., local time.Member Services also has free language interpreter services available fornon-English speakers.

711This number requires special telephone equipment and is only for peoplewho have difficulties with hearing or speaking.Calls to this number are free. The National Relay is available 24 hours aday, 7 days a week.

(801) 858-0409

Molina Healthcare

7050 Union Park Center, Suite 200Midvale, UT 84047

CALL

TTY

FAX

WRITE

WEBSITE http://www.molinahealthcare.com/medicare

How to contact us when you are asking for a coverage decision about your medical care

A coverage decision is a decision we make about your benefits and coverage or about the amountwe will pay for your medical services. For more information on asking for coverage decisionsabout your medical care, see Chapter 9 (What to do if you have a problem or complaint (coveragedecisions, appeals, complaints)).


27


You may call us if you have questions about our coverage decision process.

Method Coverage Decisions for Medical Care - Contact Information

CALL (800) 526-8196 Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m., local time.

TTY 711This number requires special telephone equipment and is only for peoplewho have difficulties with hearing or speaking.Calls to this number are free. The National Relay is available 24 hours aday, 7 days a week.

FAX (866) 472-0596

WRITEMolina Healthcare 200 Oceangate, Suite 100Long Beach, CA 90802


How to contact us when you are making an appeal about your medical care

An appeal is a formal way of asking us to review and change a coverage decision we have made.For more information on making an appeal about your medical care, see Chapter 9 (What to do ifyou have a problem or complaint (coverage decisions, appeals, complaints)).

Method Appeals for Medical Care - Contact Information

CALL (800) 665-0898Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m., local time.


FAX (562) 499-0610


28


WRITEMolina Healthcare ATTN: Grievance and AppealsP.O. Box 22816Long Beach, CA 90801-9977


How to contact us when you are making a complaint about your medical care

You can make a complaint about us or one of our network providers, including a complaint aboutthe quality of your care. This type of complaint does not involve coverage or payment disputes. (Ifyour problem is about the plan's coverage or payment, you should look at the section above aboutmaking an appeal.) For more information on making a complaint about your medical care, seeChapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals,complaints)).

Method Complaints about Medical Care - Contact Information

CALL (800) 665-0898Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m., localtime.

TTY 711This number requires special telephone equipment and is only forpeople who have difficulties with hearing or speaking.Calls to this number are free. The National Relay is available 24 hoursa day, 7 days a week.

FAX (562) 499-0610

WRITE

MEDICARE WEBSITE

Molina Healthcare ATTN: Grievance and AppealsP.O. Box 22816Long Beach, CA 90801-9977

You can submit a complaint about Molina Medicare Options Plus HMOSNP directly to Medicare. To submit an online complaint to Medicarego to www.medicare.gov/MedicareComplaintForm/home.aspx.


29

How to contact us when you are asking for a coverage decision about your Part Dprescription drugs

A coverage decision is a decision we make about your benefits and coverage or about the amountwe will pay for your prescription drugs covered under the Part D benefit included in your plan.For more information on asking for coverage decisions about your Part D prescription drugs, seeChapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals,complaints).

Method Coverage Decisions for Part D Prescription Drugs - ContactInformation



FAX (866) 290-1309

WRITEMolina Healthcare ATTN: Pharmacy Department7050 Union Park Center, Suite 200Midvale, UT 84047


How to contact us when you are making an appeal about your Part D prescription drugs

An appeal is a formal way of asking us to review and change a coverage decision we have made.For more information on making an appeal about your Part D prescription drugs, see Chapter 9(What to do if you have a problem or complaint (coverage decisions, appeals, complaints)).

Method Appeals for Part D Prescription Drugs - Contact Information

CALL (888) 665-1328


30


Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m., local time.


FAX (866) 290-1309

WRITEMolina Healthcare ATTN: Pharmacy Department7050 Union Park Center, Suite 200Midvale, UT 84047


How to contact us when you are making a complaint about your Part D prescription drugs

You can make a complaint about us or one of our network pharmacies, including a complaintabout the quality of your care. This type of complaint does not involve coverage or paymentdisputes. (If your problem is about the plan's coverage or payment, you should look at the sectionabove about making an appeal.) For more information on making a complaint about your Part Dprescription drugs, see Chapter 9 (What to do if you have a problem or complaint (coveragedecisions, appeals, complaints).

Method Complaints about Part D prescription drugs - Contact Information

CALL (888) 665-1328Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m., localtime.

TTY 711This number requires special telephone equipment and is only forpeople who have difficulties with hearing or speaking.Calls to this number are free. The National Relay is available 24 hoursa day, 7 days a week.

FAX (562) 499-0610


31


WRITE Molina Healthcare

ATTN: Grievance and AppealsP.O. Box 22816Long Beach, CA 90801-9977

You can file a grievance via our complaint form located at:http://www.molinahealthcare.com/medicare

MEDICAREWEBSITE

You can submit a complaint about Molina Medicare Options Plus HMOSNP directly to Medicare. To submit an online complaint to Medicarego to www.medicare.gov/MedicareComplaintForm/home.aspx.

Where to send a request asking us to pay for our share of the cost for medical care or adrug you have received

For more information on situations in which you may need to ask us for reimbursement or to pay abill you have received from a provider, see Chapter 7 (Asking us to pay a bill you have receivedfor covered medical services or drugs).

Please note: If you send us a payment request and we deny any part of your request, you canappeal our decision. See Chapter 9 (What to do if you have a problem or complaint (coveragedecisions, appeals, complaints)) for more information.

Method Payment Request - Contact Information



FAX Part C (Medical Services): (801) 858-0409Part D (Pharmacy): (866) 771-0117

WRITEMolina Healthcare ATTN: Member Services


32

SECTION 2 Medicare (how to get help and information directlyfrom the Federal Medicare program)

Medicare is the Federal health insurance program for people 65 years of age or older, some peopleunder age 65 with disabilities, and people with End-Stage Renal Disease (permanent kidneyfailure requiring dialysis or a kidney transplant).

The Federal agency in charge of Medicare is the Centers for Medicare & Medicaid Services(sometimes called "CMS"). This agency contracts with Medicare Advantage organizationsincluding us.

P.O. Box 8542Midvale, UT 84047


Method Medicare - Contact Information

CALL 1-800-MEDICARE, or 1-800-633-4227Calls to this number are free.24 hours a day, 7 days a week.

TTY 1-877-486-2048This number requires special telephone equipment and is only forpeople who have difficulties with hearing or speaking.Calls to this number are free.

WEBSITE http://www.medicare.govThis is the official government website for Medicare. It gives you up-to-date information about Medicare and current Medicare issues. It alsohas information about hospitals, nursing homes, physicians, homehealth agencies, and dialysis facilities. It includes booklets you can printdirectly from your computer. You can also find Medicare contacts inyour state.The Medicare website also has detailed information about your Medicareeligibility and enrollment options with the following tools:

• Medicare Eligibility Tool: Provides Medicare eligibility statusinformation.

• Medicare Plan Finder: Provides personalized information aboutavailable Medicare prescription drug plans, Medicare health plans,


33

http://www.molinahealthcare.com/medicarehttp://www.medicare.gov

SECTION 3 State Health Insurance Assistance Program (free help,information, and answers to your questions aboutMedicare)

and Medigap (Medicare Supplement Insurance) policies in yourarea. These tools provide an estimate of what your out-of-pocketcosts might be in different Medicare plans.

WEBSITE(continued)

You can also use the website to tell Medicare about any complaints youhave about Molina Medicare Options Plus HMO SNP:

• Tell Medicare about your complaint: You can submit a complaintabout Molina Medicare Options Plus HMO SNP directly toMedicare. To submit a complaint to Medicare, go towww.medicare.gov/MedicareComplaintForm/home.aspx. Medicaretakes your complaints seriously and will use this information tohelp improve the quality of the Medicare program.

If you don't have a computer, your local library or senior center may beable to help you visit this website using its computer. Or, you can callMedicare and tell them what information you are looking for. They willfind the information on the website, print it out, and send it to you. (Youcan call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours aday, 7 days a week. TTY users should call 1-877-486-2048.)

• Minimum essential coverage (MEC): Coverage under this Planqualifies as minimum essential coverage (MEC) and satisfies thePatient Protection and Affordable Care Act's (ACA) individualshared responsibility requirement. Please visit the Internal RevenueService (IRS) website at https://www.irs.gov/Affordable-Care-Act/Individuals-and-Families for more information on the individualrequirement for MEC.

The State Health Insurance Assistance Program (SHIP) is a government program with trainedcounselors in every state. In California, the SHIP is called HICAP .

HICAP is independent (not connected with any insurance company or health plan). It is a stateprogram that gets money from the Federal government to give free local health insurancecounseling to people with Medicare.

HICAP counselors can help you with your Medicare questions or problems. They can help youunderstand your Medicare rights, help you make complaints about your medical care or treatment,


34

and help you straighten out problems with your Medicare bills. HICAP counselors can also helpyou understand your Medicare plan choices and answer questions about switching plans.

Method HICAP (California's SHIP) - Contact Information

CALL (800) 434-0222

TTY 711This number requires special telephone equipment and is only for peoplewho have difficulties with hearing or speaking.

WRITEHICAP Los Angeles County: Center For Health Care Rights 520 S. Lafayette Park Place, Suite 214 Los Angeles, CA 90057

Riverside and San Bernardino Counties: Inland Agency HICAP 9121 Haven Ave Suite 120 Rancho Cucamonga, CA 91739

San Diego and Imperial Counties: Elder Law & Advocacy 5151 Murphy Canyon Road, Suite 100 San Diego, CA 92123

WEBSITE http://www.cahealthadvocates.org/HICAP/


35

SECTION 4 Quality Improvement Organization (paid by Medicare tocheck on the quality of care for people with Medicare)

There is a designated Quality Improvement Organization for serving Medicare beneficiaries ineach state. For California, the Quality Improvement Organization is called Livanta.

Livanta has a group of doctors and other health care professionals who are paid by the Federalgovernment. This organization is paid by Medicare to check on and help improve the quality ofcare for people with Medicare. Livanta is an independent organization. It is not connected withour plan.

You should contact Livanta in any of these situations:

SECTION 5 Social Security

Social Security is responsible for determining eligibility and handling enrollment for Medicare.U.S. citizens who are 65 or older, or who have a disability or End-Stage Renal Disease and meetcertain conditions, are eligible for Medicare. If you are already getting Social Security checks,enrollment into Medicare is automatic. If you are not getting Social Security checks, you have toenroll in Medicare. Social Security handles the enrollment process for Medicare. To apply forMedicare, you can call Social Security or visit your local Social Security office.

Social Security is also responsible for determining who has to pay an extra amount for their Part Ddrug coverage because they have a higher income. If you got a letter from Social Security tellingyou that you have to pay the extra amount and have questions about the amount or if your incomewent down because of a life-changing event, you can call Social Security to ask forreconsideration.

If you move or change your mailing address, it is important that you contact Social Security to letthem know.

• You have a complaint about the quality of care you have received.

• You think coverage for your hospital stay is ending too soon.

• You think coverage for your home health care, skilled nursing facility care, or ComprehensiveOutpatient Rehabilitation Facility (CORF) services are ending too soon.

Method Livanta (California's Quality Improvement Organization) -Contact Information

CALL (877) 588-1123

TTY (855) 887-6668This number requires special telephone equipment and is only for peoplewho have difficulties with hearing or speaking.

WRITELivanta BFCC-QIO Program 9090 Junction Drive, Suite 10 Annapolis Junction, MD 20701

WEBSITE http://bfccqioarea5.com/


36

SECTION 6 Medi-Cal (Medicaid) (a joint Federal and state programthat helps with medical costs for some people withlimited income and resources)

Medi-Cal (Medicaid) is a joint Federal and state government program that helps with medicalcosts for certain people with limited incomes and resources.

In addition, there are programs offered through Medi-Cal (Medicaid) that help people withMedicare pay their Medicare costs, such as their Medicare premiums. These "Medicare SavingsPrograms" help people with limited income and resources save money each year:

Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B premiums, andother cost sharing (like deductibles, coinsurance, and copayments). (Some people with QMB arealso eligible for full Medi-Cal (Medicaid) benefits (QMB+).)

Specified Low-Income Medicare Beneficiary (SLMB+): Helps pay Part B premiums and areeligible for full Medicaid benefits.

Members of this Plan are dually enrolled in both Medicare and Medi-Cal (Medicaid). If you havequestions about the assistance you get from Medi-Cal (Medicaid), contact California Departmentof Health Care Services.

Method Social Security - Contact Information

CALL 1-800-772-1213Calls to this number are free.Available 7:00 am to 7:00 pm, Monday through Friday.You can use Social Security's automated telephone services to getrecorded information and conduct some business 24 hours a day.

TTY 1-800-325-0778This number requires special telephone equipment and is only for peoplewho have difficulties with hearing or speaking.Calls to this number are free.Available 7:00 am to 7:00 pm, Monday through Friday.

WEBSITE http://www.ssa.gov


37

http://www.ssa.gov

Method California Department of Health Care Services (California'sMedicaid program) - Contact Information

CALL (916) 449-5000


WRITEMedi-Cal Managed Care P.O. Box 997413, MS 4400 Sacramento, CA 95899-7413 Physical Address: 1501 Capitol Ave., MS 4400 Sacramento, CA 95814

WEBSITE http://www.dhcs.ca.gov/Pages/default.aspx

The Medi-Cal Managed Care Office of the Ombudsman helps people enrolled in Medi-Cal(Medicaid) with service or billing problems. They can help you file a grievance or appeal with ourplan.

Method Medi-Cal Managed Care Office of the Ombudsman- ContactInformation

CALL (888) 452-8609


WRITEMedi-Cal Managed Care Office of the Ombudsman P.O. Box 997413, MS 4400 Sacramento, CA 95899-7413

WEBSITE http://www.dhcs.ca.gov/services/medi-cal/Pages/MMCDOfficeoftheOmbudsman.aspx


38

The California Department of Aging Long-Term Care Ombudsman Program helps people getinformation about nursing homes and resolve problems between nursing homes and residents ortheir families.

Method California Department of Aging Long-Term Care OmbudsmanProgram - Contact Information

CALL (800) 231-4024


WRITECalifornia Department of Aging Office of the State Long Term CareOmbudsman 1300 National Dr., Suite 200Sacramento, CA 95834

WEBSITE http://www.aging.ca.gov/ProgramsProviders/LTCOP/

SECTION 7 Information about programs to help people pay fortheir prescription drugs

Medicare's "Extra Help" Program

Because you are eligible for Medi-Cal (Medicaid), you qualify for and are getting "Extra Help"from Medicare to pay for your prescription drug plan costs. You do not need to do anythingfurther to get this "Extra Help."

If you have questions about "Extra Help," call:

• 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048 (applications),24 hours a day, 7 days a week;

• The Social Security Office at 1-800-772-1213, between 7 am to 7 pm, Monday throughFriday. TTY users should call 1-800-325-0778; or

• Your State Medicaid Office (applications) (See Section 6 of this chapter for contactinformation).


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If you believe that you are paying an incorrect cost-sharing amount when you get yourprescription at a pharmacy, our plan has established a process that allows you to either requestassistance in obtaining evidence of your proper copayment level, or, if you already have theevidence, to provide this evidence to us.

• The Best Available Evidence (BAE) located on the web at http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Best_Available_Evidence_Policy.html. BAE is used to determine a member’s Low IncomeSubsidy. Our Member Services department and Pharmacy department identify cases where theBAE policy applies. Members may send BAE documentation to establish eligibility to theMember Services address listed in Chapter 2. Additionally you may contact Member Servicesif you have questions (phone numbers are printed on the back cover of this booklet).Acceptable forms of evidence are:

◦ SSA Award Letter◦ Notice of Award◦ Supplemental Security Income

• When we receive the evidence showing your copayment level, we will update our system sothat you can pay the correct copayment when you get your next prescription at the pharmacy.If you overpay your copayment, we will reimburse you. Either we will forward a check to youin the amount of your overpayment or we will offset future copayments. If the pharmacyhasn’t collected a copayment from you and is carrying your copayment as a debt owed by you,we may make the payment directly to the pharmacy. If a state paid on your behalf, we maymake payment directly to the state. Please contact Member Services if you have questions(phone numbers are printed on the back cover of this booklet).

Medicare Coverage Gap Discount Program

The Medicare Coverage Gap Discount Program provides manufacturer discounts on brand namedrugs to Part D enrollees who have reached the coverage gap and are not receiving "Extra Help."For branded drugs, the 50% discount provided by manufacturers excludes any dispensing fee forcosts in the gap. The enrollee would pay the dispensing fee on the portion of the cost, which ispaid by the plan (10% in 2017).

If you reach the coverage gap, we will automatically apply the discount when your pharmacy billsyou for your prescription and your Part D Explanation of Benefits (Part D EOB) will show anydiscount provided. Both the amount you pay and the amount discounted by the manufacturercount toward your out-of-pocket costs as if you had paid them and move you through the coveragegap. The amount paid by the plan (10%) does not count toward your out-of-pocket costs.

You also receive some coverage for generic drugs. If you reach the coverage gap, the plan pays49% of the price for generic drugs and you pay the remaining 51% of the price. For generic drugs,the amount paid by the plan (49%) does not count toward your out-of-pocket costs. Only the


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amount you pay counts and moves you through the coverage gap. Also, the dispensing fee isincluded as part of the cost of the drug.

Because you get "Extra Help" from Medicare to pay for your prescription drug plan costs, theMedicare Coverage Gap Discount Program does not apply to you. You already have coverage foryour prescription drugs during the coverage gap through the "Extra Help" program.

For people who don’t get "Extra Help," the Medicare Coverage Gap Discount Program providesmanufacturer discounts on brand name drugs to Part D enrollees who have reached the coveragegap. These enrollees also receive some coverage for generic drugs. If you have any questionsabout the Medicare Coverage Gap Discount Program, please contact Member Services (phonenumbers are printed on the back cover of this booklet).

If you have any questions about the availability of discounts for the drugs you are taking or aboutthe Medicare Coverage Gap Discount Program in general, please contact Member Services (phonenumbers are printed on the back cover of this booklet).

What if you have coverage from an AIDS Drug Assistance Program (ADAP)? What is theAIDS Drug Assistance Program (ADAP)?

The AIDS Drug Assistance Program (ADAP) helps ADAP-eligible individuals living with HIV/AIDS have access to life-saving HIV medications. Medicare Part D prescription drugs that arealso covered by ADAP qualify for prescription cost-sharing assistance. Note: To be eligible for theADAP operating in your State, individuals must meet certain criteria, including proof of Stateresidence and HIV status, low income as defined by the State, and uninsured/under-insured status.

If you are currently enrolled in an ADAP, it can continue to provide you with Medicare Part Dprescription cost-sharing assistance for drugs on the ADAP formulary. In order to be sure youcontinue receiving this assistance, please notify your local ADAP enrollment worker of anychanges in your Medicare Part D plan name or policy number. Office of AIDS, Phone: (916)449-5900 .

For information on eligibility criteria, covered drugs, or how to enroll in the program, please callOffice of AIDS, Phone: (916) 449-5900 .

What if you get "Extra Help" from Medicare to help pay your prescription drug costs? Canyou get the discounts?

Most of our members get "Extra Help" from Medicare to pay for their prescription drug plancosts. If you get "Extra Help," the Medicare Coverage Gap Discount Program does not apply toyou. If you get "Extra Help," you already have coverage for your prescription drug costs duringthe coverage gap.


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What if you don't get a discount, and you think you should have?

If you think that you have reached the coverage gap and did not get a discount when you paid foryour brand name drug, you should review your next Part D Explanation of Benefits (Part D EOB)notice. If the discount doesn't appear on your Part D Explanation of Benefits, you should contactus to make sure that your prescription records are correct and up-to-date. If we don't agree thatyou are owed a discount, you can appeal. You can get help filing an appeal from your State HealthInsurance Assistance Program (SHIP) (telephone numbers are in Section 3 of this Chapter) or bycalling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users shouldcall 1-877-486-2048.

SECTION 8 How to contact the Railroad Retirement Board

The Railroad Retirement Board is an independent Federal agency that administers comprehensivebenefit programs for the nation's railroad workers and their families. If you have questionsregarding your benefits from the Railroad Retirement Board, contact the agency.If you receive your Medicare through the Railroad Retirement Board, it is important that you letthem know if you move or change your mailing address

Method Railroad Retirement Board - Contact Information

CALL 1-877-772-5772Calls to this number are free.Available 9:00 am to 3:30 pm, Monday through FridayIf you have a touch-tone telephone, recorded information and automatedservices are available 24 hours a day, including weekends and holidays.

TTY 1-312-751-4701This number requires special telephone equipment and is only for peoplewho have difficulties with hearing or speaking.Calls to this number are not free.

WEBSITE http://www.rrb.gov

SECTION 9 Do you have "group insurance" or other healthinsurance from an employer?

If you (or your spouse) get benefits from your (or your spouse's) employer or retiree group as partof this plan, you may call the employer/union benefits administrator or Member Services if you


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http://www.rrb.gov

have any questions. You can ask about your (or your spouse's) employer or retiree health benefits,premiums, or the enrollment period. (Phone numbers for Member Services are printed on the backcover of this booklet.) You may also call 1-800-MEDICARE (1-800-633-4227; TTY:1-877-486-2048) with questions related to your Medicare coverage under this plan.

If you have other prescription drug coverage through your (or your spouse's) employer or retireegroup, please contact that group's benefits administrator. The benefits administrator can helpyou determine how your current prescription drug coverage will work with our plan.


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CHAPTER 3Using the plan's coverage for your medical and other

covered services

Chapter 3. Using the plan's coverage for your medical and othercovered services

2017 Evidence of Coverage forMolina Medicare Options Plus HMO SNPChapter 3. Using the plan's coverage for your medical and other covered services

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SECTION 1 Things to know about getting your medical care and other services coveredas a member of our plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Section 1.1 What are "network providers" and "covered services"?. . . . . . . . . . . . . . . . . . . . . 47Section 1.2 Basic rules for getting your medical care and other services covered by the plan. 47

SECTION 2 Use providers in the plan's network to get your medical care and otherservices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Section 2.1 You must choose a Primary Care Provider (PCP) to provide and oversee your care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Section 2.2 What kinds of medical care and other services can you get without getting approvalin advance from your PCP?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Section 2.3 How to get care from specialists and other network providers. . . . . . . . . . . . . . . 51Section 2.4 How to get care from out-of-network providers. . . . . . . . . . . . . . . . . . . . . . . . . . 53

SECTION 3 How to get covered services when you have an emergency or urgent need forcare or during a disaster. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Section 3.1 Getting care if you have a medical emergency. . . . . . . . . . . . . . . . . . . . . . . . . . . 53Section 3.2 Getting care when you have an urgent need for services. . . . . . . . . . . . . . . . . . . . 54Section 3.3 Getting care during a disaster. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

SECTION 4 What if you are billed directly for the full cost of your covered services?. . . 55Section 4.1 You can ask us to pay for covered services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Section 4.2 What should you do if services are not covered by our plan?. . . . . . . . . . . . . . . . 56

SECTION 5 How are your medical services covered when you are in a "clinical researchstudy"?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Section 5.1 What is a "clinical research study"?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Section 5.2 When you participate in a clinical research study, who pays for what?. . . . . . . . . 58

SECTION 6 Rules for getting care covered in a "religious non-medical health careinstitution". . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Section 6.1 What is a religious non-medical health care institution?. . . . . . . . . . . . . . . . . . . . 59Section 6.2 What care from a religious non-medical health care institution is covered by our

plan?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

SECTION 7 Rules for ownership of durable medical equipment. . . . . . . . . . . . . . . . . . . . . 60Section 7.1 Will you own the durable medical equipment after making a certain number of

payments under our plan?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60


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SECTION 1 Things to know about getting your medical care andother services covered as a member of our plan

This chapter explains what you need to know about using the plan to get your medical care andother services covered. It gives definitions of terms and explains the rules you will need to followto get the medical treatments, services, and other medical care that are covered by the plan.

For the details on what medical care and other services are covered by our plan, use the benefitschart in the next chapter, Chapter 4 (Benefits Chart, what is covered).

Section 1.1 What are "network providers" and "covered services"?

Here are some definitions that can help you understand how you get the care and services that arecovered for you as a member of our plan:

• "Providers" are doctors and other health care professionals licensed by the state to providemedical services and care. The term "providers" also includes hospitals and other health carefacilities.

• "Network providers" are the doctors and other health care professionals, medical groups,hospitals, and other health care facilities that have an agreement with us to accept our paymentas payment in full. We have arranged for these providers to deliver covered services tomembers in our plan. The providers in our network bill us directly for care they give you.When you see a network provider, you pay nothing for covered services.

• "Covered services" include all the medical care, health care services, supplies, andequipment that are covered by our plan. Your covered services for medical care are listed inthe benefits chart in Chapter 4.

Section 1.2 Basic rules for getting your medical care and otherservices covered by the plan

As a Medicare and Medi-Cal (Medicaid) health plan, Molina Medicare Options Plus HMO SNPmust cover all services covered by Original Medicare and other services and must follow OriginalMedicare's coverage rules for these services.

Molina Medicare Options Plus HMO SNP will generally cover your medical care as long as:

• The care you receive is included in the plan's Benefits Chart (this chart is in Chapter 4 ofthis booklet).


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• The care you receive is considered medically necessary. "Medically necessary" means thatthe services, supplies, or drugs are needed for the prevention, diagnosis, or treatment of yourmedical condition and meet accepted standards of medical practice.

• You have a network primary care provider (a PCP) who is providing and overseeingyour care. As a member of our plan, you must choose a network PCP (for more informationabout this, see Section 2.1 in this chapter).

◦ In most situations, your network PCP must give you approval in advance before youcan use other providers in the plan's network, such as specialists, hospitals, skillednursing facilities, or home health care agencies. This is called giving you a "referral."For more information about this, see Section 2.3 of this chapter.

◦ Referrals from your PCP are not required for emergency care or urgently neededservices. There are also some other kinds of care you can get without having approvalin advance from your PCP (for more information about this, see Section 2.2 of thischapter).

• You must receive your care from a network provider (for more information about this, seeSection 2 in this chapter). In most cases, care you receive from an out-of-network provider (aprovider who is not part of our pl

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