Coverage & BenefitsTo learn about the benefits and coverage provided by IMCare Classic (HMO SNP), read your IMCare Classic MSHO Member Handbook (PDF) (Evidence of Coverage). It outlines how to receive care while being a part of the IMCare Classic. It reviews covered services, non-covered services, co-pays, and more. 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 an IMCare Classic (HMO SNP) member. It also explains the rights, benefits, and responsibilities of members. Benefits, formulary, pharmacy network, premium, 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 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
Organization DeterminationsAn organization determination is when IMCare makes any decision regarding
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 MSHO Member Handbook. Go to Chapter 9, Section 5, in your MSHO Member Handbook (PDF) for a more detailed explanation, or call IMCare Member services at 218-327-6188 and we can assist you.
An enrollee, the enrollee’s representative, or the enrollee’s provider can request a coverage decision. A request for a coverage decision can be made orally or in writing, and they can be standard or expedited.
- 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 IMCare Classic (HMO) 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.
Getting Care During a Declared DisasterIf you live in county included in a state of disaster or emergency declaration, you can get health care services from network or out-of-network providers at no cost to you during the disaster or emergency. You do not need a Service Authorization for covered services. You may get your prescription drugs at any pharmacy. If you are getting services through your county, contact the county for continuing coverage of those services. Services can continue this way, through the declared disaster's start date through its end date.
H2417 IMCARECLASSIC_114 CMS_Approved 04/04/2017