Aetna Better Health Of Ohio Mycare Ohio Medicare Medicaid Plan

Aetna Better Health Of Ohio Mycare Ohio 2022 Copays In Hamilton County Oh

American Disabilities Act Notice

In accordance with the requirements of the federal Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973 , UnitedHealthcare Insurance Company provides full and equal access to covered services and does not discriminate against qualified individuals with disabilities on the basis of disability in its services, programs, or activities.

Notification Of Formulary Updates

We must follow CMS and state policy regarding formulary changes. Our Pharmacy Management Department may add drugs to the formulary or delete utilization management requirements at any time during the year. After March 1st of each year, our Pharmacy Management Department may only make maintenance changes to the formulary, such as replacing a brand name drug with a new generic, or modifications to quantity limits based on new drug safety information. The Centers of Medicare and Medicaid Services limits nonmaintenance formulary changes and must be approved by CMS.

If approved, enrollees currently taking the affected drugs are exempt from the change until the remainder of the calendar year. We will provide notice to affected enrollees at least sixty days prior to removing a covered drug from the formulary, or provide the enrollee with a 60day supply of the drug. If the Federal Drug Administration deems a drug unsafe or it is removed from the market by its manufacturer, we will provide a retrospective notice as soon as possible. A list of formulary changes is maintained on our website. Our Provider Services Department may notify providers of changes to the formulary via direct letter or through our website.

Federal Part D regulations require Aetna Better Health of Ohio to have a formulary that contains at least two Part D prescription drugs in each approved category, and all drugs in the six special classes listed below:

Antidepressants

Electrolytes/Replenishers

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Single Pharmacy Benefit Manager

ODM is contracting with a new, specialized managed care organization to administer Ohio Medicaids prescription drug program. This new Single Pharmacy Benefit Manager will monitor quality, transparency and accountability for CareSource.

• Ohio Medicaid Single Pharmacy Benefit Manager Find additional information about the SPBM.
• Contact ODM for questions on the SPBM.

Submitting Claims And Authorizations

ODM is implementing a fiscal intermediary to streamline claim and prior authorization submissions via the Provider Network Management portal. The FI will serve as the central point of intake for transactions and will assist in transitioning claims and authorizations to, as well as receive updates from, CareSource. Providers will be required to submit Medicaid claims and request for prior authorization to the PNM portal.

• Fiscal Intermediary View information related to the fiscal intermediary PNM portal.

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Mental Health/substance Abuse Services

In order to meet the behavioral health needs of our enrollees, Aetna Better Health of Ohio will provide a continuum of services to enrollees at risk of or suffering from mental, addictive, or other behavioral disorders. We are an experienced behavioral health care organization and have contracted with behavioral health providers who are experienced in providing behavioral health services to the Ohio population.

Is My Virtual Visit Covered By Insurance

Cleveland Clinic provides virtual visits for your convenience and health. Virtual visits are not covered by all insurance plans. In order to fully understand your benefits and potential cost, contact your insurance company and ask if virtual visits are included in your plan and if not, what it may cost you.

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Ohio Health Insurance Plans From Buckeye Health Plan

Buckeye Health Plan offers comprehensive Ohio health insurance plans that include coordinated healthcare, pharmacy, vision and transportation services.

Whether its getting insured for yourself and your loved ones or finding the right resources for your medical care, the Buckeye Health Plan team is here to help. Learn more and enroll today!

Contracted Third Party Payors

For Patients and Guests: The University of Toledo Medical Center participates in many health insurance plans and several governmental fee-for-service programs. Patients should always verify The University of Toledo Medical Center participation with their health plan benefit package prior to receiving health-care services. Access information on each underlined plan listed below by clicking on the plans name, which is hyperlinked to its respective website.

Receive a of our contracted third party payors here.

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Primary Care Provider Referral

We endorse early identification of mental health issues so that timely intervention, including treatment and patient education, can occur. To that end, providers are expected to:

Screen, evaluate, treat and/or refer , any behavioral health problem/disorder

Treat mental health and/or substance abuse disorders within the PCPs scope of practice

Inform enrollees how and where to obtain behavioral health services

Understand that enrollees may selfrefer to an Aetna Better Health of Ohio behavioral health care provider without a referral from the enrollees PCP.

Unitedhealthcare Connected Benefit Disclaimer

This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook. Limitations, copays and restrictions may apply. For more information, call UnitedHealthcare Connected® Member Services or read the UnitedHealthcare Connected® Member Handbook. Benefits, List of Covered Drugs, pharmacy and provider networks and/or copayments may change from time to time throughout the year and on January 1 of each year.

You can get this document for free in other formats, such as large print, braille, or audio. Call , TTY 711, 8 a.m. – 8 p.m., local time, Monday – Friday . The call is free.

You can call Member Services and ask us to make a note in our system that you would like materials in Spanish, large print, braille, or audio now and in the future.

Language Line is available for all in-network providers.

Puede obtener este documento de forma gratuita en otros formatos, como letra de imprenta grande, braille o audio. Llame al , TTY 711, de 08:00 a. m. a 08:00 p. m., hora local, de lunes a viernes correo de voz disponible las 24 horas del día,/los 7 días de la semana). La llamada es gratuita.

Puede llamar a Servicios para Miembros y pedirnos que registremos en nuestro sistema que le gustaría recibir documentos en español, en letra de imprenta grande, braille o audio, ahora y en el futuro.

Los servicios Language Line están disponibles para todos los proveedores dentro de la red.

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Contact Aetna Better Health Of Ohio

If you qualify for Medicare but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Advantage program on www.medicare.gov. To learn more about this plan, visit the Aetna Better Health of Ohio Medicare website.

Additional Medicare Plan Options In Hamilton County

Are you eligible for a Hamilton County, OH Medicare Special Needs Plan ? SNPs are a special type of Medicare Advantage planMedicare Advantage , also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare . designed to help people with special needs. Here are some of the SNP plans in your area:

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The Ohio Department Of Medicaid State Fair Hearing

For items/services covered by Medicaid only or by both Medicaid and Medicare, the enrollee and/or the enrollees representative acting on behalf of the enrollee may request a State Fair Hearing through the ODM within ninety calendar days from Aetna Better Healths Notice of Action Letter or the Appeal Decision Letter.

If enrollees wish services to continue receiving services while their State Fair Hearing is reviewed, they must request a State Fair Hearing within fifteen calendar days from the date of the Notice of Action Letter or the Appeal Decision Letter. At the State Fair Hearing, enrollees may represent themselves or be represented by a lawyer, their provider or other authorized representative, with the enrollees written permission. To request a State Fair Hearing, enrollees must:

Submit a request for a State Fair Hearing to the ODM, or

Fax to 16147289574

To submit a request in writing, enrollees should write to:

Ohio Department of Job and Family Services Bureau of State Hearings

P.O. Box 182825

Fax: 16147289574

The State Fair Hearing officer will render a decision about services. If the hearing decision favors the enrollee, then we will commence the services immediately.

Ohio Medicaid Selects Aetna Better Health Of Ohio For Specialized Child

Program will coordinate comprehensive care services and support for youth with complex behavioral health and multi-system needs

COLUMBUS, Ohio The Ohio Department of Medicaid selected Aetna to serve as the specialized managed care organization for the states children with the most complex behavioral health needs under the new OhioRISE program. Aetna will work with ODM and Governor DeWines Family and Children First Cabinet Council to implement a child and family-centric model featuring new targeted services and intensive care coordination delivered by community partners. Aetna also will coordinate with the states Medicaid managed care organizations and the new single pharmacy benefit manager to ensure medical and pharmaceutical services and supports are integrated in the childs comprehensive health plan.

The OhioRISE program addresses gaps in Ohios health care system that currently result in 140 Ohio kids living out of state on any given day in order to access the behavioral health services they need. Other families voluntarily relinquish custody of their children to local child welfare agencies solely to access needed behavioral health care for their children. The OhioRISE managed care plan will fill in these gaps by developing a network of care management entities and by working with Ohios behavioral health providers to offer new intensive, coordinated services for children and families statewide.

As the new OhioRISE MCO, Aetna will be responsible for:

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Unitedhealthcare Dual Complete Plans

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a contract with the State Medicaid Program. Enrollment in the plan depends on the plans contract renewal with Medicare. This plan is available to anyone who has both Medical Assistance from the State and Medicare. This information is not a complete description of benefits. Call TTY 711 for more information. Limitations, co-payments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.

Coordination Of Mental Health And Physical Health Services

We coordinate physical and mental health care services for enrollees through our Transdisciplinary Care Management Team that is led by each enrollees assigned Care Manager. Coordination and care and services includes screening, evaluations, evidence based treatment and/or referrals for physical health, behavioral health or substance use disorder, dual or multiple diagnoses, mental retardation and /or developmental disabilities. With the enrollees permission, our Care Management Staff can facilitate coordination of care management related to substance abuse screening, evaluation, and treatment.

Enrollees seen in the primary care setting may present with a behavioral health condition, which the PCP must be prepared to recognize. Primary Care Providers are encouraged to use behavioral health screening tools, treat behavioral health issues that are within their scope of practice and refer enrollees to behavioral health providers when appropriate. Enrollees seen by behavioral health providers must be screened for coexisting medical issues. Behavioral health providers must refer enrollees with known or suspected and untreated physical health problems or disorders to their PCP for examination and treatment, with the enrollees consent. Behavioral health providers may also provide physical health care services if they are licensed to do so. Mental

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Aetna Better Health Of Ohio Mycare Ohiohamilton County Oh 2022 Medicare Advantage Plan

This page contains editorial content that is not endorsed or approved by Aetna Better Health of Ohio. This is not a solicitation of insurance.

Aetna Better Health of Ohio, MyCare Ohio is a MMP Medicare Advantage plan, from Aetna Better Health of Ohio, that’s available to Medicare beneficiaries living in Hamilton County, Ohio. This is a Medicare-Medicaid plan, with prescription drug coverage, for people with both Medicare and Medicaid benefits . It gives you all of the same health insurance benefits as Original Medicare. However, the Medicare out-of-pocket costs are covered by Medicaid.

Enrollee Grievance System Overview

Aetna Better Health of Ohio takes grievances and appeals very seriously. We want to know what is wrong so we can make our services better. Enrollees can file a complaint, grievance or appeal if they are not satisfied. A network provider, acting on behalf of an enrollee and with the enrollees written consent, may file a grievance, appeal, State Fair Hearing, Medicare Appeals Council , or Judicial Review as applicable.

For Medicaid only covered items/services, an enrollee or their authorized representative may request a State Fair Hearing through the Ohio Department of Medicaid at the same time as, in lieu of, or after the appeal process.

For Medicare only covered items/services, if we uphold the coverage decision in whole or in part, we will automatically forward the case to the Independent Review Entity . If the IRE upholds the decision and the total of the item/services appealed, meets the

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Unitedhealthcare Connected For Mycare Ohio

UnitedHealthcare Connected® for MyCare Ohio is a health plan that contracts with both Medicare and Ohio Medicaid to provide benefits of both programs to enrollees. If you have any problem reading or understanding this or any other UnitedHealthcare Connected® for MyCare Ohio information, please contact our Member Services at from 7 a.m. to 8 p.m. Monday through Friday for help at no cost to you.

Si tiene problemas para leer o comprender esta o cualquier otra documentación de UnitedHealthcare Connected® de MyCare Ohio , comuníquese con nuestro Departamento de Servicio al Cliente para obtener información adicional sin costo para usted al de lunes a viernes de 7 a.m. a 8 p.m. .

Pharmacy Transition Of Care Process

New MyCare Ohio enrollees days) taking prescription drugs that are not on the formulary, or formulary drugs that are subject to certain restrictions, such as prior authorization or step therapy, will receive a temporary transitional fill of up to a thirty day supply of a nonformulary drug, or a formulary drug requiring prior authorization at a retail pharmacy. Enrollees and their prescribing physician will receive a letter instructing them to consult with their prescribing physician to decide if they should switch to an equivalent drug that is on the formulary or to request a formulary exception in order to get coverage for the drug.

We will not pay for additional fills for the drug, unless the prescriber submits a request for a coverage determination or formulary exception and we approve. If a formulary exception is approved, the approval will be valid through the remainder of the calendar year, unless prescribed for a lesser period.

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Grievance And Redetermination Overview

Enrollees can file a grievance or redetermination if they are not satisfied. A prescribing physician, acting on behalf of an enrollee, and with the enrollees written consent, may file a grievance or redetermination, QIC, Administrative Law Judge , Medicare Appeals Council , or Judicial Review as applicable.

Upon completion of the appeal process, if we do not make a decision timely, we will automatically forward the case to the QIC within twentyfour hours. If the QIC decision is unfavorable to the enrollee, the enrollee or their representative may request an ALJ, MAC, or Judicial Review in successive order.

We will inform enrollees and providers of the grievance and redetermination procedures. This information is contained in the enrollees Evidence of Coverage and within the Provider Manual including being available on our website. When requested, we give enrollees reasonable assistance in completing forms and taking other procedural steps. Our assistance includes, but is not limited to, provider interpreter services and tollfree numbers that have adequate TTY/TTD and interpreter capability.

Learn More About Mycare Ohio

Read the MyCare Ohio: What You Need to Know fact sheet to learn more about how this new managed care program might work for you or watch this MyCare Ohio Overview presentation.

For more specific information and frequently asked questions, click the link to the fact sheet that best describes your current care arrangement.

• Live in a Nursing Facility

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Where Do I Get Started

We know that it can be stressful to navigate the insurance coverage process, but we strive to make it as smooth as possible.

We accept a variety of plans from insurance companies at all of our locations. To verify if your insurance plan is accepted for services across our health system, please review our list of accepted insurance companies below.

If your insurance company is accepted by Cleveland Clinic: Please contact your insurance company to confirm what care is covered by your plan as well as information on copayments, deductibles and coinsurance amounts. See what your out-of-pocket expenses will be using our cost estimator.

If your insurance company is not accepted by Cleveland Clinic: This means your insurance plan is considered out-of-network which can lead to greater out-of-pocket expenses for your care. Please contact your insurance company for more information about what your financial responsibility may be if you choose to receive care at Cleveland Clinic. Find more information about Cleveland Clinics out-of-network insurance process.

Ohio Department Of Medicaid Mycare Ohio Waiver Program

Ohio Medicaid, in partnership with the Centers for Medicare and Medicaid , launched the MyCare Ohio Duals Demonstration in May 2014 to bring better health outcomes to dual-eligible individuals who have both Medicare and Medicaid benefits. Ohio was the third state in the nation to earn federal approval for its duals demonstration program and is a national leader in its efforts. The five MyCare Ohio managed care plans coordinate both Medicare and Medicaid benefits physical, behavioral and long-term care services. As such, formally known as the MyCare Ohio waiver, this waiver provides home- and community-based supports to MyCare members to allow them to live independently in the community with a nursing facility level of care.

The State of Ohio has worked closely with the federal government to improve the way health care services are provided by these programs. You will receive – through the MyCare Ohio health plan you choose – all of the medical, behavioral and long-term services and supports you need.

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Which Insurance Plans Are Accepted At Cleveland Clinic

Below is the list of plans that are accepted at Cleveland Clinic main campus, our family health centers and community hospitals in Northeast Ohio.

The list below is for reference purposes only and is subject to change. Not all plans within the companies listed are considered participating. Always check with your health plan to confirm that Cleveland Clinic is included.

Ohio Medicaid Selects Aetna Better Health Of Ohio As The Ohiorise Managed Care Organization

• Press Release

COLUMBUS, Ohio The Ohio Department of Medicaid selected Aetna to serve as the specialized managed care organization for the states children with the most complex behavioral health needs under the new OhioRISE program. Aetna will work with ODM and Governor DeWines Family and Children First Cabinet Council to implement a child and family-centric model featuring new targeted services and intensive care coordination delivered by community partners. Aetna also will coordinate with the states Medicaid managed care organizations and the new single pharmacy benefit manager to ensure medical and pharmaceutical services and supports are integrated in the childs comprehensive health plan.

The OhioRISE program addresses gaps in Ohios health care system that currently result in 140 Ohio kids living out of state on any given day in order to access the behavioral health services they need. Other families voluntarily relinquish custody of their children to local child welfare agencies solely to access needed behavioral health care for their children. The OhioRISE managed care plan will fill in these gaps by developing a network of care management entities and by working with Ohios behavioral health providers to offer new intensive, coordinated services for children and families statewide.

As the OhioRISE MCO, Aetna will be responsible for:

OhioRISE launches in January 2022 and is a core component of ODMs next generation managed care overhaul.

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Unitedhealthcare Senior Care Options Plan

UnitedHealthcare SCO is a Coordinated Care plan with a Medicare contract and a contract with the Commonwealth of Massachusetts Medicaid program. Enrollment in the plan depends on the plans contract renewal with Medicare. This plan is a voluntary program that is available to anyone 65 and older who qualifies for MassHealth Standard and Original Medicare. If you have MassHealth Standard, but you do not qualify for Original Medicare, you may still be eligible to enroll in our MassHealth Senior Care Option plan and receive all of your MassHealth benefits through our SCO program.

Medicare Part D Prescription Drug Coverage Determinations

Prescription drug coverage is included in the Aetna Better Health of Ohio MyCare Ohio plan. CVS Caremark is the Pharmacy Benefit Manager that Aetna Better Health of Ohio has contracted with to administer the MyCare Ohio prescription drug benefit.

Enrollees will have access to CVS Caremark participating pharmacies. CVS Caremark will review and process Medicare Part D Coverage Determinations and Exception requests initiated by our enrollees, their authorized representative and/or their prescribing provider.

While typically prescribing providers submit requests to us to make a coverage determination, enrollees have the right to request a coverage determination concerning a prescription drug they believe they are entitled to receive under their plan, including:

Basic prescription drug coverage

The amount, if any, that the enrollee is required to pay for a drug

We will process coverage determinations under the standard timeframe of seventytwo hours or receipt, unless the prescriber has indicated that the enrollee would be harmed if we apply the standard timeframe. In these cases, our CVS Caremark will process

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