Appeals & Grievances

MD Care Health Plan [(HMO) or (HMO SNP)]

APPEALS, GRIEVANCES AND FORMULARY EXCEPTIONS

YOUR RIGHT TO MAKE COMPLAINTS

You have the right to make a complaint if you have concerns or problems related to your coverage or care. “Appeals” and “grievances” are the two different types of complaints you can make. Which one you make depends on your situation.

WHAT ARE APPEALS?

An “appeal” is the type of complaint you make when you want us to reconsider and change a decision we have made about what services or benefits are covered for you or what we will pay for a service or benefit (include Part D services and benefits). For example, if we refuse to cover or pay for services you think we should cover, you can file an appeal. If MD Care Health Plan or one of our plan providers refuses to give you a service you think should be covered, you can file an appeal. If MD Care Health Plan or one of our plan providers reduces or cuts back on services or benefits you have been receiving, you can file an appeal. If you think we are stopping your coverage of a service or benefit too soon, you can file an appeal. Except in the case of an extension of the filing time frame, you must submit your appeal within 60 calendar days from the date MD Care Health Plan denied your initial service or benefit.

HOW QUICKLY WE DECIDE ON YOUR APPEAL DEPENDS ON THE TYPE OF APPEAL:

For a decision about payment for medical care you already received
After we receive your appeal, we have 60 calendar days to make a decision.
For a standard decision about medical care that you believe should be covered by the plan
After we receive your appeal, we have 30 calendar days to make a decision, but will make it sooner if your health condition requires. However, if you ask for more time, or if we find that helpful information is missing, we can take up to 14 more days to make our decision.
For a decision about payment for Part D prescription drugs you already received
After we receive your appeal, we have up to 7 calendar days to make a decision. If we find in your favor, we have 30 days from the date of your request to issue payment.
For a standard decision about Part D prescription drugs that you believe should be covered by the plan
After we receive your appeal, we have up to 7 calendar days to make a decision, but will make it sooner if your health condition requires.

In addition, if you believe that waiting the standard timeframe could cause harm to your health, you, any doctor, or your authorized representative can ask us to give a “fast” decision (rather than a “standard” decision) about medical care or Part D prescription drug coverage that you have not already received. If we give you a “fast” decision, we must make our determination within 72 hours for a decision about medical care or Part D prescription drugs.

WHAT ARE GRIEVANCES?

A “grievance” is the type of complaint you make if you have any other type of problem with MD Care Health Plan or one of our plan providers. For example, you would file a grievance if you have a problem with things such as the quality of your care, waiting times for appointments or in the waiting room, the way your doctors others behave, being able to reach someone by phone or getting the information you need, or the cleanliness or condition of the doctor’s office. We must notify you of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. You will be notified if MD Care takes an extension.

YOU ARE ALSO ENTITLED TO A QUICK REVIEW OF YOUR GRIEVANCE IF YOU DISAGREE WITH OUR DECISION IN THE FOLLOWING SCENARIOS:

If we deny your request for an expedited review of a request for medical care
If we deny your request for an expedited review of an appeal of denied services
If we decide an extension is needed to review your request for medical care (You will be notified if MD Care takes an extension.)
If we decide an extension is needed to review your appeal of denied medical care (You will be notified if MD Care takes an extension.)

We will quickly review your request and notify you of our decision within 24 hours of receiving your complaint.

YOU HAVE THE RIGHT TO REQUEST AN EXCEPTION TO MD Care Health Plan’s FORMULARY

You can ask MD Care Health Plan to make an exception to the coverage rules. There are several types of exceptions that you can request.

You can ask MD Care Health Plan to cover your drug even though it is not on the MD Care Health Plan Drug Formulary (list of covered drugs).
You can ask MD Care Health Plan to waive coverage restrictions or limits on your drug. For example, for certain drugs, MD Care Health Plan limits the amount of the drug that is covered. If your drug has a quantity limit, you can ask to waive the limit and to have a higher quantity covered.
You can ask us to provide a higher level of coverage for your drug. This would lower the amount you must pay for your drug. For example, if your drug is contained in our specialty drug tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the generic tier instead.

You should contact us to ask for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting such exceptions you should submit a statement from your physician.

We must respond to a request for an exception (including formulary exception, an exception from utilization management rules – such as dosage or quantity limits or step therapy requirements – or a tiering exception), and make our decision no later than 72 hours after we have received your physician’s “supporting statement,” which explains why the drug you are asking for is medically necessary.

FOR COMPLETE DETAILS ON THESE PROCESSES, PLEASE REFER TO:

Advantage 1 Evidence of Coverage, Chapter 9 (H7731_090211_1027_12EOC-MAPD File & Use 09072011)
Advantage Select Evidence of Coverage, Chapter 7 (H7731_090211_1027_12EOC-MA File & Use 09072011)
Preferred Dual SNP Evidence of Coverage, Chapter 9 (H7731_090711_1027_12EOC-SNP File & Use 09122011).

MD Care Healthplan is a health plan with a Medicare contract.