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National Home Members Prescription Information Part D Appeals & Grievances
 

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MEDICARE PART D APPEALS AND GRIEVANCES

Part D Appeals
If you or your physician disagrees with any coverage determination including a formulary exception, or if Care Improvement Plus fails to provide you with a timely decision on a coverage determination, you have the right to file an appeal in writing. See the Helpful Resources page for contact details. If a delay in treatment due to the denial could jeopardize your health status, you may request an expedited appeal by phone, fax or email.

The first level of a prescription drug appeal is a "redetermination" and is reviewed by the plan's pharmacists and physicians. Care Improvement Plus must gather information and make a determination within a 7-day time period for a standard appeal or within 72 hours for an expedited appeal. Redeterminations for denied claims are decided within 7 days.

If Care Improvement Plus upholds its initial denial, you will receive a written notice, including how to file an appeal at the next level. The second level of appeal is conducted by Medicare's independent review contractor, and is called a reconsideration. If the independent reviewer agrees with the health plan's denial, you have the same rights to the federal levels of appeals and judicial review as do beneficiaries in fee-for-service Medicare.

Request for Medicare Prescription Drug Redetermination Form

For appeals related to prescription drug coverage you may submit a letter or use the following: here.

For more information on how to fill out the Coverage Determination Request form here.

Grievances
If you are dissatisfied or have a complaint about any aspect of Care Improvement Plus, you may call or write our Member Services department. Complaints other than those involving coverage determinations are called grievances. (Complaints about denials and other adverse coverage determinations are handled as appeals, and are not grievances.) We will investigate the grievance and respond to you in a timely manner. Complaints about denied requests for an expedited decision or appeal, or disagreements over time extensions, will be handled as expedited grievances - they are reviewed and resolved within 24 hours.



This page was last updated on: 9/15/2011 4:09:46 PM

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Care Improvement Plus is a Medicare Advantage organization with a Medicare contract. The Care Improvement Plus contract with CMS is renewed annually and coverage availability beyond the end of the current contract year is not guaranteed. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2013.

The benefit information provided herein is a brief summary, but not a comprehensive description of available benefits. For more information contact the plan. To be eligible for a Care Improvement Plus plan you must be a Medicare beneficiary living in Arkansas, Georgia, Missouri, South Carolina, Texas and select counties in Illinois, Iowa, Indiana, Maryland, New Mexico, New York, Wisconsin and have both Medicare Part A and Part B to enroll.

To be eligible for a Care Improvement Plus Chronic Conditions Special Needs Plan, you must have diabetes and/or heart failure. To be eligible for Care Improvement Plus Dual Advantage, you must be enrolled in state Medicaid and be a dual eligible beneficiary whom the State holds harmless for Part A and Part B cost sharing.

Members may enroll in the plan only during specific times of the year. Contact Care Improvement Plus for more information. If you have diabetes, heart failure, or Medicaid/Low Income Subsidy, you may qualify to enroll in a Care Improvement Plus Special Needs Plan ANYTIME of the year by exercising a “Special Election Period.

You must continue to pay your Medicare Part B premium. If you are a full benefit dual beneficiary and your Part B premium is paid for by the State, you will not be responsible for paying your Part B premium. Premiums, copays, coinsurance and deductibles may vary based on the level of help received. Limitations, copayments and restrictions may apply.

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

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

People with limited incomes may qualify for extra help to pay their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this extra help, contact your local Social Security office, or call Social Security at 1–800–772–1213.TTY users should call 1–800–325–0778. You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp. If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a part of this premium, we will bill you for the amount that Medicare doesn’t cover.

Premiums, copays, coinsurance, and deductibles may vary based on the level of help that beneficiaries may receive. Contact the plan for further details. Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under nonroutine circumstances, and quantity and restrictions may apply. It may cost more to get care from out–of–network providers, except in an emergency. If there isn’t a network provider available for you to see, you can go to an out–of–network provider but still pay the in–network amounts except for members who live in our Maryland service areas. Those members can only use doctors, specialists, or hospitals in–network. The health providers in our network can change at any time.