PrimeWest Senior 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 go to the PrimeWest Health Member Web Portal to get more information about your services, to contact us, or to ask for print copies of your member materials.

Eligibility

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

  • You are age 65 years or over
  • 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 live in Beltrami, Big Stone, Clearwater, Douglas, Grant, Hubbard, McLeod, Meeker, Pipestone, Pope, Renville, Stevens, or Traverse County

Program Description

PrimeWest Senior Health Complete combines the health care and support services normally offered by separate programs into one seamless package. We coordinate your Medicare and Medical Assistance (Medicaid) to pay for your covered services. Our goal is to make it simpler for you to get these services. PrimeWest Senior Health Complete members work with county case managers. County case managers can help with paperwork and arrange health care and support services. PrimeWest Health care coordinators and county case managers work together to help you maintain your health.

PrimeWest Senior Health Complete is a Minnesota Senior Health Options (MSHO) program. To get the most up-to-date information about MSHO, go to the Minnesota Department of Human Services (DHS) website.

Enrollment/Disenrollment

Enrollment

If you meet the eligibility criteria above, you can enroll at certain times throughout the year. You will get a letter telling you when your enrollment is accepted. If you want to enroll in PrimeWest Senior Health Complete, please do one of the following:

3905 Dakota St
Alexandria, MN 56308

Disenrollment

Ending your membership in PrimeWest Senior Health Complete may be voluntary (your own choice) or involuntary (not your own choice).

These are the cases when PrimeWest Senior Health Complete must end your membership in the plan:

  • If there is a break in your Medicare Part A and Part B coverage
  • If you no longer qualify for Medical Assistance (Medicaid)
  • If you do not pay your medical spenddown, as applicable
  • If you move out of our service area
  • If you are away from our service area for more than 6 months
  • If you go to prison
  • If you lie about or withhold information about other insurance you have for prescription drugs
  • If you are not a United States citizen or are not lawfully present in the United States. You must be a United States citizen or be lawfully present in the United States to be a member of our plan. The Centers for Medicare & Medicaid Services will notify us if you aren’t eligible to remain a member on this basis. We must disenroll you if you don’t meet this requirement.

We can make you leave our plan for the following reasons only if we get permission from Medicare and Medical Assistance (Medicaid) first:

  • If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan
  • 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
  • If you let someone else use your member ID card to get medical care 

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 may be able to end your membership in our plan or switch to a different plan during Special Enrollment Periods. Your disenrollment will usually be effective on the first day of the month after we get 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 PrimeWest Senior Health Complete, you can do any of the following:

  • See the Member Handbook
  • Call PrimeWest Senior Health Complete Member Services.
  • Submit a signed and dated written request to disenroll from the plan.
  • Read the Medicare & You Handbook. Everyone with Medicare gets a copy of Medicare & You each fall. If you are new to Medicare, you get 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 call 1-877-486-2048. Calls to these numbers are free.

Benefits

To learn about the benefits and coverage provided by PrimeWest Senior Health Complete, read the Member Handbook. It gives details about the health care services and prescription drugs we cover. It tells how to get your health care and prescription drugs as a PrimeWest Senior Health Complete member. It also explains the rights, benefits, and responsibilities of members. Individual chapters below tell more about specific subjects. 

Chapter 1: Getting started as a member
Chapter 2: Important phone numbers and resources
Chapter 3: Using the plan’s coverage for your health care and other covered services
Chapter 4: Benefits Chart*
Chapter 5: Getting your outpatient prescription drugs through the plan
Chapter 6: What you pay for your Medicare and Medical Assistance (Medicaid) prescription drugs
Chapter 7: Asking us to pay our share of a bill you have gotten for covered 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 our plan
Chapter 11: Legal notices
Chapter 12: Definitions of important words

*Chapter 4 tells what is covered and 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 Member Handbook. Standard organization determinations are made as quickly as the member’s health condition requires and not more than 14 calendar days (10 business days) from the date we receive the request. Expedited organization determinations are made as quickly as the member’s health condition requires and not more than 72 hours from the date we receive the request. Expedited organization determinations are for cases where the provider or PrimeWest Health decides that following the standard time frame could seriously jeopardize the member’s life or health, or ability to attain, maintain, or regain maximum function. You can ask for an organization determination in either of the following ways:

  1. By Phone
    If you call us, we will need to get more information from your health care provider. Start by calling Member Services.
  2. By Mail or Fax
    You and your health care provider can print and fax or mail the Medical Service Authorization Request Form. Your provider can download the form from the Service Authorization page of our website. The form should be sent to:
     
    Mail: PrimeWest Health Service Authorization
    3905 Dakota St
    Alexandria, MN 56308
     
    Fax: 1-866-431-0804 (toll free)

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 PrimeWest Senior Health Complete before you fill your prescription. If you don’t get approval, PrimeWest Senior Health Complete 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, PrimeWest Senior Health Complete 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, PrimeWest Senior Health Complete 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: 1-858-790-7100

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 the Member Handbook
  • 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 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: 1-858-790-7100

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

PrimeWest Senior Health Complete 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 get. 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/$1.25/$3.40 (each prescription) $0/$3.80/$8.50 (each prescription)


When you reach the out-of-pocket limit of $5,100 for your prescription drugs, the Catastrophic Coverage Stage begins. You will stay in the Catastrophic Coverage Stage until the end of the calendar year. During this stage, the plan will pay all of the costs for your Medicare drugs. See the Member Handbook for more details.

Deductibles

PrimeWest Senior Health Complete 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 PrimeWest Senior Health Complete. 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 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 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 the Provider and Pharmacy Directory to see a full list of health care providers (including specialists) in the PrimeWest Senior Health Complete 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 PrimeWest Senior Health Complete 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 get routine care from out-of-network providers, neither Medicare nor PrimeWest Health will be responsible for the costs. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you.

Pharmacies

  • Read the Provider and Pharmacy Directory for a list of PrimeWest Senior Health Complete network pharmacies. We also list pharmacies that are in our network but are outside our 13-county service area. Call PrimeWest Senior Health Complete Member Services for more information.
  • Use our online search feature to see if a specific provider is in the PrimeWest Senior Health Complete 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 Member Handbook. Read the Provider and Pharmacy Directory to see a list of our network pharmacies or get more detailed information about PrimeWest Senior Health Complete prescription drug coverage. If you want a print copy of the directory, contact Member Services. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. You can call Member Services or ask for a list by mail at:

       PrimeWest Health
       3905 Dakota St
       Alexandria, MN 56308

    Read about using out-of-network pharmacies in the Member Handbook. Our network includes pharmacy availability that equals or exceeds Centers for Medicare & Medicaid Services (CMS) requirements for pharmacy access in your area. 

Appeals and Grievances (complaints)

Grievance, Appeal, and State Appeal 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. After exhausting the health plan Appeal process, you may request a State Appeal by contacting the Minnesota Department of Human Services. You have up to 120 days after PrimeWest Health's Appeal decision to ask for a State Appeal. See the Member Handbook for a complete description of the PrimeWest Health Grievance and Appeal process and the State Appeal 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 Appeal 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 Appeal to the following address:

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

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

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 get 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 need more information and the delay is in your best interest. If we decide that an extension is needed, we will make a reasonable effort to notify you promptly, both orally and in writing (within 2 calendar days), of the reasons we decided to extend the time frame. 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 process 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 tell you within 10 days that the Grievance has been received. The Grievance must be submitted within 60 days if the complaint is about 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 getting your complaint. We may extend the time frame by up to 14 days if you ask for the extension, or if we need more information and the delay is in your best interest. If we decide that an extension is needed, we will make a reasonable effort to notify you promptly, both orally and in writing (within 2 calendar days), of the reasons we decided to extend the time frame. We will tell you within 30 days that we are taking extra time and the reasons why. If we deny all or part of your Grievance, 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 Livanta. You may contact Livanta at 1-888-524-9900 (toll free) or write to:

Livanta
10820 Guilford Rd., Suite 202
Annapolis Junction, MD  20701

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 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.

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 our members. 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: 1-800-366-2906
TTY users: 1-800-627-3529
or 711
Hours are:
October 1 – March 31, 7 days a week, 8 a.m. – 8 p.m.
April 1 – 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. 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

PrimeWest Senior 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 PrimeWest Senior 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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