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 outofnetwork
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