Dual Options Ohio _ MyCare Ohio

Dual Options Ohio _ MyCare Ohio. please call Member Services at (855) 665-4623, Monday -

Friday, 8 a.m. to 8 p.m., local time. The call is free. TTY/TDD: 711.With the Molina Dual options plan in Ohio known as My care Ohio you are getting

all the benefits of a health plan that will help coordinate your Medicare and Medicaid benefits together. So that means you will have

One ID card for both Medicare and Medicaid

You will have your own Molina care manger that will make sure that everyone is following your individual plan of care which we create for you and your needs and you are very active in planning your care.

MyCare ohio is a health plan that contracts with both medicare and ohio medicaid to provide benifits of both programs to our members enrolled in the plan

You are the center of your own care-

Medicaid helps with medical and long-term services and supports costs for people with

limited incomes and resources. Ohio Medicaid pays for Medicare premiums for certain

people, and pays for Medicare deductibles, co-insurance and co-payments except for

prescriptions.Medicaid covers long-term care services such as home and community-based

waiver services and assisted living services and long-term nursing home care. It also

covers dental and vision services

MyCare Ohio Ombudsman

The MyCare Ohio Ombudsman helps with concerns about any aspect of care. Help is

available to resolve disputes with providers, protect rights, and file complaints or appeals with

our plan. 1-800-282-1206 This call is free.

The MyCare Ohio Ombudsman is available Monday through Friday from

8:00 am to 5:00 pm

Molina Dual Options MyCare Ohio covers services covered by Medicare and Medicaid. This

includes behavioral health, long term care, and prescription drugs.

You must choose a net work provider to be your pcp

You must get care from network providers unless its emergency or urgently need care

If you need care from specialist that is out of network My care ohio requries prior authoriation . In this case we will cover the care at no cost to the member If you are new to our plan, you may be able to continue to see your current out-ofnetwork

providers for a period of time after you enroll. This is called a transition

period

Your Molina Dual Options MyCare Ohio Care Manager will make sure your care

team is connected and will be your single point of contact for all of your Care

Management needs

Your care team will help you to figure out what services you need to get, how to

access services (including local resources), and which providers can help provide

the best care for you

Your care team makes sure your care is coordinated. Coordinated care means that

your care team will:

o Hold care team conferences scheduled by your Care Manager. This means

that you can meet regularly with members of your care team to update your

care plan.

o Make sure medical tests and lab tests are done, and that the results are

shared with your providers as needed.

o Work together with your doctors to make sure they know all medicines you

take so they can help to prevent any negative drug interactions and to reduce

side effects.

o Remind you of important doctor appointments.

Please note: If you go to an out-of-network provider, the provider must be eligible to

participate in Medicare and/or Medicaid. We cannot pay a provider who is not eligible to

participate in Medicare and/or Medicaid. If you go to a provider who is not eligible to

participate in Medicare, you may have to pay the full cost of the services you get.

Providers must tell you if they are not eligible to participate in Medicare.

We will pay for some services up to a certain limit. If you do not have prior approval from

Molina Dual Options MyCare Ohio to go over the limit, you may have to pay the full cost to

get more of that type of service.

Medicare Inpatient Hospital coverage has a 100

Because you get assistance from Medicaid, you generally pay nothing for the covered

services explained in this chapter as long as you follow the plans rules. See Chapter 3 for

details about the plans rules. However, you may be responsible for paying a patient liability

for nursing facility or waiver services that are covered through your Medicaid benefit. The

County Department of Job and Family Services will determine if your income and certain

expenses require you to have a patient liability.

Except as indicated above, we do not allow Molina Dual Options MyCare Ohio providers to

bill you for covered services. We pay our providers directly, and we protect you from any

charges. This is true even if we pay the provider less than the provider charges for a covered

service.

Drugs covered by Medicare Part A. These include some drugs given to you while you

are in a hospital or nursing facility.

Drugs covered by Medicare Part B. These include some chemotherapy drugs, some

drug injections given to you during an office visit with a doctor or other provider, and

drugs you are given at a dialysis clinic

There are certain drugs that are excluded by Medicare that are covered by Medicaid. For

example, certain over-the-counter (OTC) products

What are tiers?

Every drug on the plans Drug List is in one of five (5) tiers.

Tier 2 drugs are brand name drugs. The copay will be from $0 to $6.35, depending on

your level of Medicaid eligibility.

Tier 3, tier 4, and tier 5 drugs have a copay of $0.

of rules are there? for pharmacy drugs

Prior authorization (PA) certain criteria must be met before a drug is covered. For example,

diagnosis, lab values, or previous treatments tried and failed.

Step therapy (ST) first-line therapy must be used before certain drugs are covered. For

example, certain brand-name medications will only be covered if a generic alternative has

been tried first.

Quantity limit (QL) Certain drugs have a maximum quantity that will be covered. For

example, certain drugs that are approved by the FDA to be taken once daily may have a

quantity limit of #30 per 30 days.

drug tiers is on page 103