Prime Health Complete (HMO SNP)

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Question mark in a bubbleQuestions? Need help? Call Member Services! All calls during business hours are answered by a person, not a machine. We're here to help you. You can also access the PrimeWest Health Member Web Portal to get more information about your services, to contact us, or to request print copies of your member materials.

Eligibility

You are eligible to join Prime Health Complete (HMO SNP) if you meet the following criteria:

  • You are at least 18 years of age and under age 65
  • You qualify for Medical Assistance (Medicaid). To learn more about Medical Assistance (Medicaid) and how you qualify, go to the Minnesota Department of Human Services (DHS) website.
  • You have Medicare Parts A and B
  • You have a certified disability through the Social Security Administration or the State Medical Review Team; or you have been determined by the county to have a developmental disability (DD) for purposes of the DD waiver
  • You live in Beltrami, Big Stone, Clearwater, Douglas, Grant, Hubbard, McLeod, Meeker, Pipestone, Pope, Renville, Stevens, or Traverse County 

Note: If you meet these eligibility criteria but do not have Medicare, read about our Special Needs BasicCare (SNBC) program, which provides Medical Assistance (Medicaid) coverage only.

Program Description

Prime Health Complete (HMO SNP) members have the same benefits covered under fee-for-service. We coordinate your Medicare and Medical Assistance (Medicaid) to pay for your covered services. PrimeWest Health care coordinators work with county case managers to help you maintain your health, whether you live in your own home or in a care facility. PrimeWest Health's goal is to support members and keep them healthy.

Prime Health Complete is a Special Needs BasicCare (SNBC) program. To get the most up-to-date information about SNBC, go to the Minnesota Department of Human Services (DHS) website.

Enrollment/Disenrollment

Enrollment
If you meet the eligibility criteria above, you can enroll at any time. You will get a letter telling you when your enrollment is accepted. If you would like to enroll in Prime Health Complete (HMO SNP), please do one of the following:

Disenrollment
Ending your membership in Prime Health Complete (HMO SNP) may be voluntary (your own choice) or involuntary (not your own choice).

Prime Health Complete must end your membership in the plan if any of the following happen:

  • If you do not stay continuously enrolled in Medicare Part A and Part B
  • If you are no longer eligible for Medical Assistance (Medicaid)
  • If you turn 65
  • If you do not pay your medical spenddown, if applicable
  • If you move out of our service area
  • If you are away from our service area for more than 6 months
  • If you become incarcerated (go to prison)
  • If you are not a United States citizen or lawfully present in the United States
  • If you lie about or withhold information about other insurance you have that provides prescription drug coverage
  • If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)
  • If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other members of our plan (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)
  • If you let someone else use your identification card to get medical care (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)

If you are leaving our plan, you must continue to get your medical care through our plan until your membership ends. Because you are eligible for Medical Assistance (Medicaid) you can end your membership in Prime Health Complete (HMO SNP) at any time. Your disenrollment will usually be effective on the first day of the month after we receive your request to change plans. Your enrollment in your new plan will also begin on this day. If you decide to change to a new plan, you can choose another Medicare health plan or Original Medicare.

For more complete information about disenrolling from Prime Health Complete (HMO SNP), you can do any of the following:

  • See Chapter 10 (Ending your membership in the plan) of your Evidence of Coverage
  • Call Prime Health Complete (HMO SNP) Member Services.
  • Submit a signed and dated written request to disenroll from the plan.
  • Read the Medicare & You Handbook. Everyone with Medicare receives a copy of Medicare & You each fall. Those new to Medicare receive it within a month after first signing up. You can also download a copy from the Medicare website (www.medicare.gov). Or, you can order a printed copy by calling Medicare at the number below.
  • Contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Calls to these numbers are free.

Benefits

To learn about the benefits and coverage provided by Prime Health Complete (HMO SNP), read your Evidence of Coverage. It gives details about the health care services and prescription drugs we will cover. It tells how to get your health care and prescription drugs as a Prime Health Complete (HMO SNP) member. It also explains the rights, benefits, and responsibilities of members. Individual chapters below tell more about specific subjects. Benefits and/or copays may change on January 1 of each year.

Chapter 1: Getting started as a member
Chapter 2: Important phone numbers and resources
Chapter 3: Using the plan's coverage for your medical and other covered services
Chapter 4: Benefits chart (what is covered)*
Chapter 5: Using the plan's coverage for your Part D prescription drugs
Chapter 6: What you pay for your Part D prescription drugs
Chapter 7: Asking us to pay our share of a bill you have received for covered medical services or drugs
Chapter 8: Your rights and responsibilities
Chapter 9: What to do if you have a problem or complaint (coverage decisions, Appeals, complaints)
Chapter 10: Ending your membership in the plan
Chapter 11: Legal notices
Chapter 12: Definitions of important words

*Chapter 4 also tells what is not covered

Organization Determinations
PrimeWest Health has made an organization determination when it makes a decision about whether items or services are covered or how much you have to pay for covered items or services. Organization determinations are also called “coverage decisions” in the Evidence of Coverage. Chapter 9 explains how to ask for a coverage decision. Standard organization determinations are made as expeditiously as the member’s health condition requires, not to exceed 14 calendar days (10 business days) from the date the request was received. Expedited organization determinations are made as expeditiously as the member’s health condition requires, not to exceed 72 hours from the date the request was received. Expedited organization determinations are for cases where the provider indicates or PrimeWest Health determines that following the standard time frame could seriously jeopardize the member’s life or health, or ability to attain, maintain, or regain maximum function.

Prescription Drug Benefits

Drug coverage

Restrictions on covered drugs
Some drugs have restrictions on coverage. In some cases, you or your health care provider must do something before you can get the drug. Specific restrictions are as follows:

  • Getting plan approval in advance

For some drugs, you or your health care provider must get approval from Prime Health Complete (HMO SNP) before you fill your prescription. If you don’t get approval, Prime Health Complete (HMO SNP) may not cover the drug. This is called Prior Authorization. Prior Authorization criteria are used to make decisions about whether to cover the drug. Your provider will need to fill out a Prior Authorization form to ask for coverage.

  • Trying a different drug first

In general, Prime Health Complete (HMO SNP) wants you to try lower-cost drugs (that often are as effective) before we cover drugs that cost more. For example, if Drug A and Drug B treat the same medical condition, and Drug A costs less than Drug B, we may require you to try Drug A first. If Drug A does not work for you, we will then cover Drug B. This is called Step Therapy. Step Therapy criteria are used to make decisions about whether to cover the drug. Your provider will need to fill out a Step Therapy form to ask for coverage.

  • Quantity limits

For some drugs, Prime Health Complete (HMO SNP) limits the amount of the drug you can have. For example, we might limit how much of a drug you can get each time you fill your prescription. These limits are usually to ensure safe use of the drug. The Quantity Limits for drugs are listed in your List of Covered Drugs. Your provider will need to fill out a Quantity Limits form to ask for an exception to these limits.

Exceptions/Coverage Determinations
You may ask for an exception to the drug coverage and restriction rules by doing any of the following:

  • Fill out the Formulary Exception Form. Note: this form must be completed by a health care provider. Completed forms can be mailed or faxed:
     
    Mail: MedImpact HealthCare Systems
    Attention: Prior Authorization
    10181 Scripps Gateway Court
    San Diego, CA 92131
    Fax: 1-858-549-1569 (toll free)

Transition period drug benefits
Read our Transition Period Drug Benefit Policy to learn about your benefits during a transition period.

Questions/complaints about prescription drug coverage
If you have a complaint about your prescription drug coverage (e.g., if your drug will not be covered, has restrictions that you don't agree with, or if you think your copay is too high), you can do any of the following:

  • Read about “coverage decisions” and “Appeals” in Chapter 9, Section 6, of your Evidence of Coverage
  • Contact PrimeWest Health Member Services
  • Tell Medicare about your complaint by visiting the Centers for Medicare & Medicaid Services (CMS) website. You may also call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TTD users can call 1-877-486-2048. Calls to these numbers are free.
  • Ask someone to help you file a complaint. Someone you choose may file a complaint (Grievance) or Appeal for you. The person you name would be your “appointed representative.” You may name a relative, friend, lawyer, advocate, health care provider, or anyone else to act for you. Other people may already be authorized by the Court or under State law to act for you. If you want someone to act for you who is not already authorized by the Court or State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. You may call Member Services to learn how to name your appointed representative. You may also fill out the Appointment of Representative form. Once you have filled out the form, you should print it and mail or fax it to MedImpact:
     
    Mail: MedImpact HealthCare Systems
    Attention: Prior Authorization
    10181 Scripps Gateway Court
    San Diego, CA 92131
    Fax: 1-858-549-1569

Reimbursement
We cannot pay you back for most medical bills that you pay. State and Federal laws prevent us from paying you directly. The exception is if you pay for Part D prescription drugs. If you paid for a drug that you think we should have covered, call Member Services. Or, you can print a Medicare Prescription Drug Claim Form and follow the instructions to complete and submit it to us for review.

Cost Sharing (copays/deductibles/premiums)

Copays
Prime Health Complete (HMO SNP) members do not have copays for medical services. The chart below shows copays for prescription drugs during the Initial Coverage Stage. Copays may vary based on the level of Extra Help you receive. Please contact the plan for further details.

Your copay amount for generic
(Tier 1 Generic) drugs is no more than
Your copay for all other drugs
(Tier 1 Brand) is no more than
$0/$1.20/$3.30 (each prescription) $0/$3.70/$8.25 (each prescription)


You qualify for the Catastrophic Coverage Stage when your out-of-pocket costs have reached the $4,950 limit for the calendar year. Once you are in the Catastrophic Coverage Stage, you will stay in this payment stage until the end of the calendar year. During this stage, the plan will pay all of the costs for your drugs. See your Evidence of Coverage for more details.


Deductibles
Prime Health Complete (HMO SNP) members do not pay a deductible for Medicare-covered health care services or prescription drugs.

Premiums
You do not pay a separate monthly plan premium for Prime Health Complete (HMO SNP). If you have Medical Assistance (Medicaid), you qualify for and are getting Extra Help to pay for your prescription drug premiums and costs. If you have questions about Extra Help, call one of the following:

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

Read the LIS Premium Summary Chart to see the premium for your plan.

Some plan members may be paying a premium for Medicare Part A and/or Medicare Part B. Many members do not pay premiums for Medicare Part A and/or Medicare Part B due to Medical Assistance (Medicaid) eligibility. If you are paying for your Medicare Part B, you must continue to pay your Medicare Part B premium. For full information about PrimeWest Health benefits, call Member Services.

Providers and Pharmacies

Providers

  • Read your Provider and Pharmacy Directory to see a full list of health care providers (including specialists) in the Prime Health Complete (HMO SNP) network. If you want a print copy of the directory, contact Member Services.
  • Use our online search feature to see if a specific provider is in the Prime Health Complete (HMO SNP) network.
  • You must use network providers except in emergency or urgent care situations, or for open access services, out-of-network dialysis services, or any other services previously authorized. If you obtain routine care from out-of-network providers neither Medicare nor PrimeWest Health will be responsible for the costs. The provider network may change at any time. You will receive notice when neccessary.

Pharmacies

  • Read your Provider and Pharmacy Directory for a list of Prime Health Complete (HMO SNP) network pharmacies. We also list pharmacies that are in our network but are outside our 13-county service area. Call Prime Health Complete (HMO SNP) Member Services for additional information.
  • Use our online search feature to see if a specific provider is in the Prime Health Complete (HMO SNP) network.
  • You must use network pharmacies to access your prescription drug benefit, except under non-routine circumstances. Limitations, copays, and restrictions may apply. For more information, call Member Services or read the Evidence of Coverage. Read your Provider and Pharmacy Directory to see a list of our network pharmacies or get more detailed information about Prime Health Complete (HMO SNP) prescription drug coverage. If you want a print copy of the directory contact Member Services. The pharmacy network may change at any time. You will receive notice when necessary. You can also call Member Services or request a list by mail at:

             PrimeWest Health
             3905 Dakota St
             Alexandria, MN 56308

Read about using out-of-network pharmacies in your Evidence of Coverage. Our network includes pharmacy availability that equals or exceeds Centers for Medicare & Medicaid Services (CMS) requirements for pharmacy access in your area. Nationally, more than 65,000 pharmacies participate in our network. More than 1,000 of these are in Minnesota.

Appeals and Grievances (complaints)

Grievance, Appeals, and Beneficiary and Family Centered Care State Fair Hearing process
You can contact Member Services to file a Grievance (complaint) or Appeal if you disagree with a decision or have a complaint about your medical benefits or the services you received. You can also contact the Minnesota Department of Human Services to request a State Fair Hearing. You may request a State Fair Hearing at any time during the PrimeWest Health Grievance or Appeal process. You do not have to file a Grievance or Appeal with PrimeWest Health before you request a State Fair Hearing. See your Evidence of Coverage for a complete description of the PrimeWest Health Grievance, Appeals, and State Fair Hearing process.

You may call Member Services about your Grievance or Appeal. You may also send a fax to 1-877-600-4912 (toll free).

You may send a letter about your Grievance or Appeal to PrimeWest Health at the following address:

        PrimeWest Health Appeals & Grievances
        3905 Dakota St
        Alexandria, MN 56308

You may use the online PrimeWest Health Member Appeal and Grievance Form to submit your Grievance or Appeal.

You may call the Ombudsman for Public Managed Health Care Programs at the Minnesota Department of Human Services about your Grievance or Appeal or to request a State Fair Hearing at 1-800-657-3729 (toll free) or 1-651-431-2660. TTY users call 1-800-627-3529 or 711 (toll free).

You may send a written request for a State Fair Hearing to the following address:

        Minnesota Department of Human Services
        Appeals Office
        PO Box 64941
        Saint Paul, MN 55164-0941

Call: 1-651-431-3600 or 1-800-657-3510 (toll free); TTY 1-800-627-3529 or 711

You can also file online at: https://edocs.dhs.state.mn.us/lfserver/Public/DHS-0033-ENG

To file an Appeal about your Medicare Part D benefits, you may call Member Services about your Grievance or Appeal. You may also send a fax to 1-858-790-6060 (toll free).

Grievances
A Grievance is any complaint, other than one that involves a request for an initial determination or an Appeal. Grievances do not involve problems related to approving or paying for medical care, services, Part D or non-Part D drugs, problems about having to leave the hospital too soon, and problems about having Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF) services ending too soon.

Problems that may lead to a Grievance

  • Problems with the service you receive from Member Services
  • You feel that you are being encouraged to leave (disenroll from) the Plan
  • We don't give you required notices
  • You believe our notices and other written materials are hard to understand
  • Waiting too long for prescriptions to be filled
  • Waiting too long on the phone, in the waiting room, or in the exam room
  • Problems getting appointments when you need them or waiting too long for them
  • Rude behavior by network pharmacists or other staff
  • Cleanliness or condition of network pharmacies
  • We fail to respect your rights
  • You disagree with our decision not to give you a “fast” decision or a “fast” Appeal
  • We don't give you a decision within the required time frame

If you have one of these types of problems and want to make a complaint, it is called “filing a Grievance.”

Filing a Grievance with our Plan
If you have a complaint, you or your representative may call Member Services. We will try to resolve your complaint over the phone. We will give you a decision within 10 days. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. If you ask for a written response, file a written Grievance, or your complaint is related to quality of care, we will respond in writing to you.

If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this the written Grievance process. You can mail or fax a letter about your Grievance to the following:

Mail: PrimeWest Health Appeals & Grievances
3905 Dakota St
Alexandria, MN 56308
 
Fax: 1-877-600-4912 (toll free)


We will notify you within 10 days that the Grievance has been received. The Grievance must be submitted within 60 days if the complaint is regarding Part D drugs. We must address your Grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. We will tell you within 30 days that we are taking extra time and the reasons why. If we deny your Grievance in whole or in part, our written decision will explain why we denied it and will tell you about any dispute resolution options you may have.

Fast Grievances
You have the right to ask for a “fast” or “expedited” Grievance. You may file a fast or expedited Grievance orally or in writing. We will respond to your oral or written Grievance within 24 hours.

Filing a Grievance through the Quality Improvement Organization (QIO)
You may complain about the quality of care received under Medicare, including care during a hospital stay. You may complain to us using the Grievance process, the QIO, or both. In Minnesota, the QIO is called KEPRO. You may contact KEPRO at 1-855-408-8557 (toll free) or write to:

KEPRO
5201 W Kennedy Blvd, Ste 900
Tampa, FL 33609

Filing a Grievance with the Centers for Medicare & Medicaid Services (CMS)
We encourage you to contact PrimeWest Health Member Services first if you have a Grievance. However, you can also tell Medicare about your Grievance directly by visiting the Centers for Medicare & Medicaid Services (CMS) website. You may also call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TTD users can call 1-877-486-2048. Calls to these numbers are free.

Who may file a Grievance
You or someone you name may file a complaint (Grievance) or Appeal for you. The person you name would be your “appointed representative.” You may name a relative, friend, lawyer, advocate, health care provider, or anyone else to act for you. Other people may already be authorized by the Court or under State law to act for you. If you want someone to act for you who is not already authorized by the Court or State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. You may call Member Services to learn how to name your appointed representative. You may also fill out the Appointment of Representative form. Once you have filled out the form, you may print and mail or fax the form to:

Mail: PrimeWest Health Appeals & Grievances
3905 Dakota St
Alexandria, MN 56308
 
Fax: 1-877-600-4912 (toll free)


Total number of complaints filed to the plan
To find out about the total number of Grievances, Appeals, and exceptions received by this plan, call Member Services.

Quality Programs

PrimeWest Health is here to meet the needs of our members and health care partners. We strive to meet the highest quality and safety standards. We follow standards developed by the National Committee for Quality Assurance (NCQA) to reach this goal.

Quality Objectives

  • To improve the health status of PrimeWest Health members
  • To ensure access to high quality and safe health care services in the PrimeWest Health service area

For more information on the PrimeWest Health Quality program, call Member Services at 1-866-431-0801 (toll free), Monday – Friday, 8 a.m. – 5 p.m. TTY users call 1-800-627-3529 or 711 (toll free).

Star Ratings
Each year, Medicare rates how well health plans perform. They rate plans on different measures, such as detecting and preventing illness, member satisfaction, patient safety, customer service, and more. Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.

Member Outreach

PrimeWest Health hosts stakeholder meetings for members of our MSC+, SNBC, PrimeWest Senior Health Complete (HMO SNP), and Prime Health Complete (HMO SNP) programs. These meetings give members, their advocates, and providers a chance to learn about their benefits and how to navigate the health care system. Members, advocates, and providers share their ideas, opinions, concerns, and suggestions about the services offered by PrimeWest Health. This stakeholders’ group has helped PrimeWest Health identify and put in place changes to provide better service to our members. If you want to see a copy of the minutes from the stakeholders’ meetings, call Member Services.

Contact Us

Call:

Member Services: 1-877-600-4913
TTY users: 1-800-627-3529
or 711
Hours are:
October 1 – February 14, 7 days a week, 8 a.m. – 8 p.m.
February 15 – September 30, Monday – Friday, 8 a.m. – 8 p.m.

Utilization Management: 1-866-431-0803
Questions about where to get services, getting authorization for services, or restrictions on prescription drugs

Hours are Monday – Friday, 8 a.m. – 4:30 p.m.

Calls to all of these numbers are free.

Email:

To contact Member Services through secure email, sign in to the Member Web Portal.

Write: PrimeWest Health
3905 Dakota St
Alexandria, MN 56308

Member Web Portal

Log in to the PrimeWest Health Member Web Portal to view your benefits and member information. Once logged in, you can do the following:

  • Ask for a new member ID card
  • Update your member information
  • Choose or change a primary care provider or clinic
  • Complete a Health Risk Assessment and access online tools to keep you healthy
  • Ask to have disease management or care management services
  • Ask questions
  • Request materials
  • View services requiring authorization
  • View eligibility and claims status

Centers for Medicare & Medicaid Services (CMS) Forms and Information

Prime Health Complete (HMO SNP) is a health plan that contracts with both Medicare and the Minnesota Medical Assistance (Medicaid) program to provide benefits of both programs to enrollees. Enrollment in Prime Health Complete (HMO SNP) depends on contract renewal.

 

How does our website work for you? If you have comments, questions, or feedback about our website, please call Member Services. We look forward to hearing from you!

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