Gold Coast Health Plan Total Care Advantage (HMO D-SNP) Member Resources

• Evidence of Coverage / Member Handbook (English and Spanish)
• Summary of Benefits (English and Spanish)
• Benefits Overview (English and Spanish)

You can appoint a representative to act on your behalf for Medicare-related matters. To appoint a representative, you must complete this form:

• Appointment of Representative form (English)
• Appointment of Representative form (Spanish)

• Non-Discrimination Notice (English and Spanish)
• Notice of Privacy Practices (English)
• Notice of Privacy Practices (Spanish)
• Notice of Availability of Language Assistance Services (English and Spanish)

No one can make you stay in our plan if you don’t want to.

You have the right to get most of your health care services through Original Medicare or another Medicare Advantage (MA) plan.

You can get your Medicare Part D prescription drug benefits from a prescription drug plan or from another MA plan.

Refer to Chapter 10 of the Member Handbook for more information about when you can join a new MA or prescription drug benefit plan and for information about how you’ll get your Medi-Cal benefits if you leave our plan.

About Medical Policy and Clinical Practice Guidelines

Gold Coast Health Plan (GCHP) is a County Organized Health System (COHS) that contracts with the Centers for Medicare & Medicaid Services (CMS) and the California Department of Health Care Services (DHCS) to serve Medi-Cal eligible and Dual eligible (Medicare/Medi-Cal) beneficiaries. GCHP complies with general coverage and benefit conditions included in traditional Medicare laws (unless superseded by laws applicable to Medicare Advantage plans) when making coverage decisions, including national and local coverage determinations [Medicare National Coverage Determinations (NCD) and Medicare Local Coverage Decisions (LCD)] that may include flexibility allowing for coverage in circumstances beyond the specific indications listed.

When coverage criteria are not fully established, GCHP may create internal coverage criteria. GCHP has established a formal committee structure to consult with physicians who provide services under GCHP and Gold Coast Health Plan Total Care Advantage Health Management Organization Dual Special Needs Plan (HMO D-SNP) to ensure internal coverage criteria, clinical practice guidelines, and utilization management guidelines are based on current evidence in widely used treatment guidelines or clinical literature.

To ensure the provision of high quality, culturally competent and cost-effective health care and services, GCHP applies and provides access to nationally recognized standards, evidenced based guidelines and clinical best practices in compliance with regulatory requirements. In addition, GCHP applies operational strategies and tactics to maximize implementation and compliance designed to address health disparities, promote healthy behaviors, and create supportive environments for better health while improving health outcomes, access to care, and costs effectively.

GCHP reserves the right to review, update, develop and/or withdraw polices as appropriate. GCHP medical policies describe the state of medical practices and literature at the time they were developed. Medical policies may not contain all applicable state and federal mandates, and exclusions and limitations may apply. New practices may emerge, or new medical literature may have been published.

GCHP medical policies do not fully describe or authorize benefits, and they do not guarantee coverage or payment, nor do they constitute a contract. Coverage decisions and benefits are determined by a variety of factors, including the terms and conditions of the applicable benefit plan and applicable state and/or federal law.

Medical Policy aims to:

• Function as GCHP’s primary entity responsible for the translation / interpretation and application of Medicare and Medi-Cal regulations and definition of supplemental benefits.
• Leverage industry best practices for standardizing the translation / interpretation and application of medical policies and code sets.
• Work closely with GCHP internal departments, network providers and First-Tier, Downstream and Related Entities (FDRs) to ensure that approved medical policies are implemented and compliant with Medicare and Medicaid regulations.
• Facilitate socialization and education on new medical policies and supplemental benefits for GCHP, contracted providers and FDRs.

Neither GCHP nor its delegates represent Medicare or Medi-Cal directly. Any reference to or use of the Medicare/DHCS name, CMS/DHCS logo, and products or information issued by the state or federal government, including the Medicare/Medi-Cal card image, is allowed only with authorization from CMS or DHCS.

GCHP provides access to medical policies developed to assist provider partners in administering GCHP benefits. These policies do not constitute clinical advice. Treating health care professionals are solely responsible for diagnosis, treatment, and medical advice. Members should always consult with their provider for medical advice.

Clinical Decision-Making Hierarchy

GCHP providers must adhere to the following decision-making hierarchy when considering coverage criteria for medical necessity determinations:

Centers for Medicare and Medicaid (CMS) Guidelines, including but not limited to:

Medicare National Coverage Determinations (NCDs)

Medicare Local Coverage Decisions (LCDs)

Medicare Local Coverage Articles (LCAs)

Medicare Manuals (Internet Only Manuals (IOM))

Beneficiaries that are dual eligible (Medicare and Medi-Cal) refer to the DHCS Medi-Cal Provider Manual criteria for dual eligible members. Also please refer to these guidelines for specific information on coverage criteria and coordination of benefits:

DHCS Medi-Cal Guidelines

Internal coverage criteria (in the absence of Medicare and Medi-Cal guidelines) based on current evidence in publicly available, widely used treatment guidelines or clinical literature, such as:

Nationally recognized evidence-based guidelines/criteria, in conjunction with the clinical judgement of a qualified health professional, such as:

• Utilization Management Decision-Support Guidelines (e.g., MCG^®, InterQual^®)
• National Comprehensive Cancer Network (NCCN)^®
• American Diabetes Association (ADA)^®
• American Heart Association (AHA)^®
• American Academy of Family Physicians (AAFP)^®
• American Geriatrics Society (AGS)^®
• United States Preventative Services Task Force (USPSTF)^®
• Centers for Disease Control and Prevention (CDC)^®

In coverage situations where there is no NCD, LCD, or guidance on coverage in original Medicare manuals, an MAO may adopt the coverage policies of other Medicare Advantage Organizations (MAO) in its service area. (Reference: Medicare Managed Care Manual (MMCM) Chapter 4, Section 90.5 Creating New Guidance)

NOTE: Federal and state mandates, as well as state contract language (including definitions and specific contract provisions / exclusions) may take precedence over this decision-making hierarchy and must be considered first when determining coverage.

Clinical Practice Guidelines

Clinical Practice Guidelines are an added resource for providers and beneficiaries based on current evidenced based guidelines systematically developed to guide health care decisions with the aim of improving patient care. GCHP has adopted the following Clinical Practice Guidelines.

Continuity of Care (COC) Services

Continuity of Care interventions may include coordinating care for medically necessary services authorized by an earlier health plan or provider, including but not limited to scheduled surgery, specialty appointments, durable medical equipment and medication coordination needs.

GCHP will collaborate with your current providers, as applicable, to coordinate care and services when transitioning from another county, fee-for-service Medi-Cal and/or transitioning to a new primary care provider (PCP) and/or specialist to ensure non-interrupted care and safe transition to in-network providers at such time it is medically appropriate.

Continuity of care may be requested for services such as:

• Outpatient mental health / chemical dependency treatment
• Current acute or skilled nursing facility (SNF) hospitalization
• Chemotherapy, radiation therapy or nuclear medicine
• Complex chronic condition requiring continued care and ongoing services
• Durable medical equipment (DME) (e.g. oxygen, hospital bed)
• Terminal illness requiring continued care and ongoing services
• Pending authorized surgery / procedure

Getting care during a disaster or public health emergency for Medicare Advantage and Prescription Drug Plan members

When health care is disrupted during a disaster or public health emergency in your area, Gold Coast Health Plan Total Care Advantage (HMO D-SNP) will act in your best interest and respond quickly to your needs. As a Medicare Medi-Cal Plan (MMP), we will follow the Centers for Medicare & Medicaid Services (CMS) requirements.

In a disaster or public health emergency, we will inform members about accessing health care in many ways. Following CMS requirements, these may include direct outreach through phone calls, mail, email, webpage, member portal, and more.

A disaster or public health emergency will be declared in one of these ways:

• Presidential declaration of a disaster or emergency under the Stafford Act or National Emergencies Act

• Secretarial declaration of a public health emergency under section 319 of the Public Health Service Act

• Declaration by the Governor of a State or Protectorate

When a disaster or public health emergency is declared and access to care is disrupted, Total Care Advantage will:

• Cover benefits without referral or prior authorization.

• Cover benefits provided to you by out-of-network providers with the same cost-sharing for in-network services.

• Fill prescriptions early when needed.

• Make benefit changes needed without delay, bypassing the required 30-day notice.

When the disaster or public health emergency has ended, it will be declared in one of these ways:

• All sources declaring the public health emergency or state of disaster declare an end.

• CMS declares an end.

• If the declaration has been active for 30 days with no declaration of an end date, the disaster will be considered over.

If you have any questions, please contact Total Care Advantage at 1.888.301.1228 (TTY: 711), 8 a.m. - 8 p.m., seven days a week from Oct. 1 through March 31, and 8 a.m. - 8 p.m., Monday through Friday from April 1 through Sept. 30.

What do I do if I have a problem or concern with my care or services?

If you are dissatisfied with your medical care or the service provided by Gold Coast Health Plan Total Care Advantage (HMO D-SNP) or your doctor's office, we want to address and resolve it to your satisfaction. Our grievances and appeals process allows us to do this as quickly as possible.

Expressing concerns or filing a complaint will not affect your benefits in any way. Your provider (doctor) also cannot discriminate against you because you file a complaint.

Total Care Advantage’s grievances and appeals process provides a method for members to report complaints regarding coverage determinations, or your care or services. This process ensures you get answers to your concerns or problems. The steps to filing a grievance or appeal are below. You can also find more information on our process in Chapter 9 of your Member Handbook.

What are the types of complaints I can make?

There are two types of complaints:

1. Grievance: If you are dissatisfied about the medical services or customer service you received from Total Care Advantage or a provider.
2. Appeal: If you want Total Care Advantage to reconsider a decision to deny coverage for a service or item you or your doctor requested.

Grievances

If you have concerns or problems with Total Care Advantage that are not about coverage decisions, payments or service requests, you have the right to file a grievance. Common reasons for grievances include wait time on the phone, rudeness by someone, or an incident at a network pharmacy or in the waiting room of your doctor’s office. You may file a grievance at any time.

You or your representative may file a grievance in person or by calling the Total Care Advantage Customer Service Department, at 1.888.301.1228, (TTY: 711).

You may also send your written grievance by mail. Please use the Member Grievances & Appeals Form to submit your complaint.

Mail the form to:

Total Care Advantage
Attn: Grievances and Appeals Department
P.O. Box 9176
Oxnard, CA 93031

You may also file a complaint through Medicare.gov

Call 1.800.MEDICARE (1.800.633.4227), TTY: 1.877.486.2048.

What happens after I file a grievance?

Within five (5) calendar days of getting your complaint, Total Care Advantage will send you a letter telling you we received it. Within 30 days, we will send you another letter that tells you how we resolved your problem.

Fast or expedited grievance

You have the right to request an expedited (fast / rushed) review if you disagree with Total Care Advantage’s decision to:

• Use an extension on your request for an organization determination or reconsideration, or
• Process your expedited request as a standard request.

In such cases, Total Care Advantage will notify you of the outcome within 24 hours of receipt of the request.

If you wish to have someone represent you other than your doctor, you must complete the Appointment of Representative Form and include the form with your grievance, coverage or drug exception request, or your appeal.

If you have an urgent matter involving a serious health concern, we will start an expedited (fast) review. We will give you a decision within 72 hours. To ask for an expedited review, call us at 1.888.301.1228, (TTY: 711).

Within 72 hours of getting your complaint, we will decide how we will handle your complaint and whether we will expedite it. If we find that we will not expedite your complaint, we will tell you that we will resolve your complaint within 30 days.

You can ask for help from any of the following:

• Total Care Advantage Customer Service: 1.888.301.1228, (TTY: 711)
• Medicare Medi-Cal Ombudsman Program: 1.855.501.3077.
• Health Insurance Counseling and Advocacy Program (HICAP): 1.800.434.0222.

Part C Appeals

As a member of Total Care Advantage, you, your doctor or your representative can file an appeal if Total Care Advantage makes a decision to not pay for, not approve or stop a service you think should be covered or provided to you. This could include denials for referrals to see a specialist, for durable medical equipment, or involving payment for services you received or believe you should receive under the Total Care Advantage program (including co-payments and billing issues or reimbursement).

You must file your appeal within 60 days of the date of the notice of denial. The filing timeline can be extended if you show good cause for the delay in filing your appeal. To appeal a decision, please contact the Total Care Advantage Customer Service Department by calling 1.888.301.1228, (TTY: 711). You can also send your written appeal to:

Total Care Advantage
Attn: Grievances and Appeals Department
P.O. Box 9176
Oxnard, CA 93031

Total Care Advantage will review your appeal and send you a letter telling you the review decision within 30 days of receiving your appeal. You or your representative can also provide information about your appeal by contacting our Total Care Advantage Customer Service Department.

If you think your health could be seriously harmed by waiting for a decision about a service, you can request a faster decision, which is issued within 72 hours of receiving your appeal. In both cases, you will receive a written notice of the outcome of your appeal, including any additional appeal rights which include, when necessary, an independent review entity, such as hearings before an Administrative Law Judge, review by the Medicare Appeals Council and judicial review.

For more information on our process, please see Chapter 9 of your Member Handbook, for your member rights to additional review.

Medicare Part D

As a member, you can file an appeal if Total Care Advantage’s pharmacy decides to not pay for, not approve or stop a service you think should be covered or provided to you. This could include denials for drugs or involve payment for services you received or believe you should receive under the Total Care Advantage’s pharmacy program (including co-payments and billing issues or reimbursement). You or your appointed representative must file the appeal within 65 calendar days from the date of the notice of the coverage determination.

Here are examples of coverage decisions and appeals you ask us to make about your Medicare Part D drugs:

• You ask us to make an exception, including asking us to:

» Cover a Medicare Part D drug that isn’t on our plan’s Drug List or

» Set aside a restriction on our coverage for a drug (such as limits on the amount you can get)

• You ask us if a drug is covered for you (such as when your drug is on our plan’s Drug List, but we must approve it for you before we cover it).
• You ask us to pay for a drug you already bought. This is asking for a coverage decision about payment.
• You can make an appeal to ask us to reconsider. You must ask for an appeal within 65 calendar days from the date on the letter we sent to tell you our decision.

Ask for the type of coverage decision you want by calling 1.888.301.1228, writing, or faxing us. You, your representative, or your doctor (or other prescriber) can do this. Please include your name, contact information, and information about the claim. You or your doctor (or other prescriber) or someone else acting on your behalf can ask for a coverage decision. You can also have a lawyer act on your behalf.

We use the "standard deadlines" unless we agree to use the "fast deadlines."

• A standard coverage decision means we give you an answer within 72 hours after we get your doctor’s statement.

• A fast coverage decision means we give you an answer within 24 hours after we get your doctor’s

A "fast coverage decision" is called an "expedited coverage determination."

You can get a fast coverage decision if:

• It’s for a drug you didn’t get. You can’t get a fast coverage decision if you’re asking us to pay you back for a drug you already bought.
• Your health or ability to function would be seriously harmed if we use the standard deadlines.

Medicare Part D Exceptions

If we don’t cover a drug in the way you would like, you can ask us to make an "exception." If we turn down your request for an exception, you can appeal our decision.

When you ask for an exception, your doctor or other prescriber needs to explain the medical reasons why you need the exception.

Making a Level 1 Appeal

An appeal to our plan about a Medicare Part D drug coverage decision is called a plan "redetermination."

• Start your standard or fast appeal by calling 1.888.301.1228 (TTY: 711), writing, or faxing us. You, your representative, or your doctor (or other prescriber) can do this. Please include your name, contact information, and information regarding your appeal.
• You must ask for an appeal within 65 calendar days from the date on the letter we sent to tell you our decision.
• If you miss the deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of good reasons are things like you had a serious illness or we gave you the wrong information about the deadline. Explain the reason why your appeal is late when you make your appeal.
• You have the right to ask us for a free copy of the information about your appeal. You and your doctor may also give us more information to support your appeal

To appeal a decision, you may call Total Care Advantage Customer Service Department by calling 1.888.301.1228, (TTY: 711), 24 hours a day, 7 days a week or fax the appeal to 1.805.512.8599. You can also send your appeal in writing to:

Grievance and Appeals Department
Total Care Advantage
P.O. Box 9176
Oxnard, CA 93031

To obtain an aggregate number of Total Care Advantage grievances, appeals and exceptions, please contact Member Services at 1.888.301.1228, (TTY: 711).

Prior Authorization Form (English)