MINNESOTA. Coverage Details Medica AccessAbility Solution. Special Needs BasicCare (SNBC) MEDICAL ASSISTANCE (MEDICAID) PLAN

MINNESOTA

2021 Medica

AccessAbility Solution ^®

Special Needs BasicCare (SNBC)

Coverage Details

MEDICAL ASSISTANCE (MEDICAID) PLAN

THAT’S MEDICA ACCESSABILITY

High-quality coverage you can trust, delivered with a personal

touch — SOLUTION

Talk with a Medica AccessAbility Solution Sales Consultant

1 (800) 266-2157 (TTY: 711)

Go online for plan and benefit details 24/7

Medica.com/SNBC

You want reliable health coverage that helps you stay healthy and independent. That gives you a great variety of valuable health benefits. That’s simple to use. And meets your needs.

Medica AccessAbility Solution delivers all this – and so much more – at no cost to you!*

Medica AccessAbility Solution is our Special Needs BasicCare (SNBC) plan. SNBC plans were designed by the State of Minnesota with and for adults with certified mental health, physical and developmental disabilities.

There’s $0 premium. $0 medical and hospital costs. $0 copays and deductibles. No cost to enroll. Benefits such as a Medica Care Coordinator and no-cost rides to medical appointments.

And it’s offered to you by Medica, the Minnesota- based plan you know and trust. When you carry our card, you can rest assured we’ve got you covered.

ONE PLAN.

SIMPLE. EASY.

ALL FOR YOU.

Medica AccessAbility Solution offers high-quality coverage you can trust

This plan includes benefits covering hospital and emergency room care, home health services, lab and X-rays, prescription drugs, nursing home care and many more important

health services.

Medica AccessAbility Solution goes even further for you. It gives you several extra health and wellness benefits to help you be and stay well. Compare many of these benefits with those of Minnesota’s Families and Children Medical Assistance coverage on page 6 of this booklet.

All this, and more, means you’ll enjoy top-notch health coverage delivered with a smile.

Can You Join?

Medica AccessAbility Solution members:

» Are 18-64 years old

» Have a certified disability

» Are eligible for Medical Assistance*

» Live in the plan’s 14-county service area of Anoka, Carver, Dakota, Hennepin, Kandiyohi, Morrison, Ramsey, Rice, Scott, Sherburne, Todd, Wadena,

Washington and Wright counties. ^Rice

Scott Dakota Carver Hennepin Ramsey

Washington

Kandiyohi

Anoka Wright

Sherburne Morrison Todd

Wadena

Are you an SNBC member with

Medicare? Then look at AccessAbility Solution Enhanced.

If you’re enrolled in Medica AccessAbility Solution or SNBC through another health plan and also have Medicare, you may be eligible for Medica AccessAbility Solution®

Enhanced if you live in the plan's service area.

Medica AccessAbility Solution Enhanced offers you many more benefits and services than you get with SNBC – and at no cost to you.

Call our Sales Consultants at 1 (800) 266-2157 (TTY: 711) to learn more!

* Medical Assistance (MA) is Minnesota's Medicaid program for people with low income. Visit mn.gov/dhs/ for program and eligibility information.

COUNT ON MEDICA

ACCESSABILITY SOLUTION FOR QUALITY CARE & SERVICE

Enjoy Choice Without Referrals in Our Broad Provider Network

You’ll receive high-quality health, dental, mental health and specialty care from specialists and clinics of your choice and at major hospitals with disability care experience across the Medica AccessAbility Solution service area. No referrals are needed.

Experience Medica's Personalized Care Coordination Service

We know how important it is to have your health care needs heard and understood.

That’s why your AccessAbility Solution Care Coordinator is a supportive partner who’s always on your side.

Medica Care Coordinators are registered nurses, social workers and other professionals.

They help you in many ways so you and others involved in your life and care have peace of mind.

Together you’ll create a personalized care plan that includes many resources to support your best health. This individual attention means your services are tailored to your medical, social and daily needs.

"Thank you for calling Medica. How may I help you?"

Our Member Services team is a point of great pride at Medica. Well-trained staff are ready to:

» Answer your health plan questions.

» Arrange for no-cost interpreter services in 150 different languages to help communicate with Care Coordinators and your health care providers.

» Respond to provider and pharmacy network questions.

» Fill requests for plan materials and documents.

» Connect you with Medica staff and partners who support your care.

YOUR TRUSTED

PARTNER IN HEALTH

You Can Always Depend on Your Medica Care Coordinator

Your Care Coordinator helps you in many ways.

Puts you and your health first

» Visits you in your home or location of your choice at least once a year and more often if your health changes

» Helps you make appointments and schedule rides to see health care providers

» Explains plan benefits and covered services.

» Works closely with you to create, follow and update your personal care plan

» Helps you learn about your health conditions and other topics such as nutrition, exercise and how to prevent falls

» Assists with your health care paperwork.

Helps meet your social and everyday needs

» Explores and provides information on community resources for you

» Works collaboratively with your county case manager

Visit Medica.com/SNBC 24/7

- Conduct provider searches for network physicians, clinics, hospitals or pharmacies - View a PDF of the Provider and Pharmacy

Directory

- View the List of Covered Drugs (Formulary)

Call us at 1 (800) 266-2157 (TTY: 711)

Ask us any questions! We’re here to help you learn if Medica AccessAbility Solution is the right plan for you.

Take comfort in knowing high-quality resources are ready for you

Wondering if your doctor is in the Medica AccessAbility Solution network? Are your medications in the plan's drug list? What pharmacies, hospitals or clinics you can use? Here are easy ways to get answers to your provider and medication questions.

OUR EXTRAS HELP YOU ACCESS CARE WHEN AND WHERE YOU NEED IT

You get so much more than just great health coverage with Medica AccessAbility Solution.

Here’s a look at many of the included and extra benefits we’ve added to support your needs and boost your well-being year ‘round. And they’re all offered at no cost to you.*

GREAT BENEFITS SUPPORT YOUR HEALTH ACCESSABILITY SOLUTION FAMILIES AND CHILDREN (Minnesota

Medical Assistance)

One new pair of eyeglasses when medically necessary ü ü

Medica Care Coordinator who’s a registered nurse or social worker, knows about disability services and is committed to

helping you achieve your health goals ü

Dental education from Delta Dental® about your dental

benefits, oral health and help to find and schedule a dental visit ü

No-cost rides to medical, dental, pharmacy, medical

equipment or substance use disorder services ü ü

24/7 NurseLine^TM by Health Advocate^SM to consult about

treatment options and get support for non-urgent illnesses ü 24/7 phone access to care through a contracted service Healthy Savings® program offering instant savings on

healthy foods. ü

Services by phone for smoking cessation, mental health and

substance use care ü ü

Healthy Pregnancy Program with Ovia Health^TM apps for health, fertility, pregnancy and parenting support; 1:1 coaching

and guidance; home-delivered vitamins and supplements ü

Access mymedica.com online tools about plan benefits and

medical resources ü

Health Advocate^SM Personal Health Advocates to help you find providers and medical services, manage health care

resources and schedule visits ü

virtuwell® online care for 24/7 treatment of 50+ health concerns ü

Prescription drug services through Express Scripts®

Medica’s Formulary of 1,000+ covered drugs

Minnesota fee-for­

service Medicaid Preferred Drug List

*If you’re an SNBC member who also has Medicare, you must get most of your prescription drugs through a Medicare prescription drug (Medicare Part D) plan. You may have a Part D plan premium. You may also have a copay with no monthly limit for some of these services.

ENROLL TODAY IN MEDICA

Eligible members are 18-64 years old, have a certified disability, are eligible for Minnesota Medical Assistance and live in the plan’s 14-county service area of Anoka, Carver, Dakota, Hennepin, Kandiyohi, Morrison, Ramsey, Rice, Scott, Sherburne, Todd, Wadena, Washington and Wright counties.

Choose From Three Easy Ways

Call 1 (800) 266-2157 (TTY: 711) for fast and easy enrollment over the phone.

Go to Medica.com/SNBC to complete your enrollment online.

Complete and sign a paper application and submit via mail or fax. You can request a paper application by calling 1 (800) 266-2157 (TTY: 711).

Submit your completed paper forms via mail or fax.

Mail to: Medica AccessAbility Solution Mail Route CW140

PO Box 9310

Minneapolis, MN 55440-9310 Or fax to: (952) 992-2682

AFTER YOU ENROLL

Following your enrollment in Medica Accessability Solution, you'll receive:

A letter from Medica that tells you we’ve received your enrollment information.

Your Medica AccessAbility Solution member identification card one or two weeks after the first day of the next month. It’s sent separately from your Member Packet.

Your Member Packet, which includes your Quick Member Reference Guide to keep and review.

A welcome letter within two weeks. It will include your Medica Care Coordinator’s name.

A call from your Care Coordinator in your first month of membership to discuss your needs and outline your plans.

Attention. If you need free help interpreting this document, call the above number.

Attention. Si vous avez besoin d’une aide gratuite pour interpréter le présent document, veuillez appeler au numéro ci-dessus.

Thov ua twb zoo nyeem. Yog hais tias koj xav tau kev pab txhais lus rau tsab ntaub ntawv no pub dawb, ces hu rau tus najnpawb xov tooj saum toj no.

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vDwJpdeD>*H>vXx;tHRM.wuh>I

알려드립니다. 이 문서에 대한 이해를 돕기 위해 무료로 제공되는 도움을 받으시려면 위의 전화번호로 연락하십시오.

ໂປຣດຊາບ. ຖ້້າຫາກ ທ່່ານຕ້້ອງການການຊ່ວຍເຫືອໃນການແປເອກະສານນ້້ຟຣ້, ຈົ່ ່່ງ ໂທ່ຣໄປທ່້່ໝາຍເລກຂ້້າງເທ່້ງນ້້.

Hubachiisa. Dokumentiin kun tola akka siif hiikamu gargaarsa hoo feete, lakkoobsa gubbatti kenname bilbili.

Внимание: если вам нужна бесплатная помощь в устном переводе данного документа, позвоните по указанному выше телефону.

Digniin. Haddii aad u baahantahay caawimaad lacag-la’aan ah ee tarjumaadda (afcelinta) qoraalkan, lambarka kore wac.

Atención. Si desea recibir asistencia gratuita para interpretar este documento, llame al número indicado arriba.

Chú ý. Nếu quý vị cần được giúp đỡ dịch tài liệu này miễn phí, xin gọi số bên

trên.

Attention. If you need free help interpreting this document, call the above number.

ያስተውሉ፡ ካለምንም ክፍያ ይህንን ዶኩመንት የሚተረጉምሎ አስተርጓሚ ከፈለጉ ከላይ ወደተጻፈው የስልክ ቁጥር ይደውሉ።

.هلاعأ مقرلا ىلع لصتا ،ةقيثولا هذه ةمجرتل ةيناجم ةدعاسم تدرأ اذإ :ةظحلام သတိိ။ ဤစာာရ က္္စာာတိမ္း္ အားာ အားခမ္း့ဘာာသာပန္ေ္ ပ ခင္း္ အားက္ူအားညီီလုုိိိိအားပ္ပါက္၊

အားထက္္ပါဖုုိိန္ေ္ န္ေံပါတိ္က္ိိိ ခၚဆုုိိိိပါ။

kMNt’sMKal’ . ebIG~k¨tUvkarCMnYyk~¬gkarbkE¨bäksarenHeday²tKit«f sUmehATUrs&BÍtamelxxagelI .

請注意，如果您需要免費協助傳譯這份文件，請撥打上面的電話號碼。

Attention. Si vous avez besoin d’une aide gratuite pour interpréter le présent document, veuillez appeler au numéro ci-dessus.

Thov ua twb zoo nyeem. Yog hais tias koj xav tau kev pab txhais lus rau tsab ntaub ntawv no pub dawb, ces hu rau tus najnpawb xov tooj saum toj no.

Hubachiisa. Dokumentiin kun tola akka siif hiikamu gargaarsa hoo feete, lakkoobsa gubbatti kenname bilbili.

Внимание: если вам нужна бесплатная помощь в устном переводе данного документа, позвоните по указанному выше телефону.

Digniin. Haddii aad u baahantahay caawimaad lacag-la’aan ah ee tarjumaadda (afcelinta) qoraalkan, lambarka kore wac.

Atención. Si desea recibir asistencia gratuita para interpretar este documento, llame al número indicado arriba.

Chú ý. Nếu quý vị cần được giúp đỡ dịch tài liệu này miễn phí, xin gọi số bên

trên.

Medica Member Services 1 (888) 347-3630 (toll free) TTY: 711

Attention. If you need free help interpreting this document, call the above number.

SPP-0321-C

Digniin. Haddii aad u baahantahay caawimaad lacag-la’aan ah ee tarjumaadda (afcelinta) qoraalkan, lambarka kore wac.

Atención. Si desea recibir asistencia gratuita para interpretar este documento, llame al número indicado arriba.

Chú ý. Nếu quý vị cần được giúp đỡ dịch tài liệu này miễn phí, xin gọi số bên trên.

Hubachiisa. Dokumentiin kun tola akka siif hiikamu gargaarsa hoo feete, lakkoobsa gubbatti kenname bilbili.

Thov ua twb zoo nyeem. Yog hais tias koj xav tau kev pab txhais lus rau tsab ntaub ntawv no pub dawb, ces hu rau tus najnpawb xov tooj saum toj no.

Attention. Si vous avez besoin d’une aide gratuite pour interpréter le présent document, veuillex appeler au numéro ci-dessus.

Внимание: если вам нужна бесплатная помощь в устном переводе данного документа, позвоните по указанному выше телефону.

ያስተውሉ፡ ካለምንም ክፍያ ይህንን ዶኩመንት የሚተረጉምሎ አስተርጓሚ ከፈለጉ ከላይ ወደተጻፈው የስልክ ቁጥር ይደውሉ።

.هلاعأ مقرلا ىلع لصتا ،ةقيثولا هذه ةمجرتل ةيناجم ةدعاسم تدرأ اذإ :ةظحلام သတိိ။ ဤစာာရ က္္စာာတိမ္း္ အားာ အားခမ္း့ဘာာသာပန္ေ္ ပ ခင္း္ အားက္ူအားညီီလုုိိိိအားပ္ပါက္၊

အားထက္္ပါဖုုိိန္ေ္ န္ေံပါတိ္က္ိိိ ခၚဆုုိိိိပါ။

kMNt’sMKal’ . ebIG~k¨tUvkarCMnYyk~¬gkarbkE¨bäksarenHeday²tKit«f sUmehATUrs&BÍtamelxxagelI .

請注意，如果您需要免費協助傳譯這份文件，請撥打上面的電話號碼。

ymol.ymo;b.wuh>I zJerh>vd.b.w>rRpXRuvDvXw>uusd;xH0J'.vHm wDvHmrDwcgtHRM.<ud;b.

vDwJpdeD>*H>vXx;tHRM.wuh>I

알려드립니다. 이 문서에 대한 이해를 돕기 위해 무료로 제공되는 도움을 받으시려면 위의 전화번호로 연락하십시오.

ໂປຣດຊາບ. ຖ້້າຫາກ ທ່່ານຕ້້ອງການການຊ່ວຍເຫືອໃນການແປເອກະສານນ້້ຟຣ້, ຈົ່ ່່ງ ໂທ່ຣໄປທ່້່ ໝາຍເລກຂ້້າງເທ່້ງນ້້.

LB2 (10-20)

CB5 (MCOs) (5-2020)

Civil Rights Notice

Discrimination is against the law. Medica does not discriminate on the basis of any of the following:

• race • age • political beliefs

• color • disability (including physical • medical condition

• national origin or mental impairment) • health status

• creed • sex (including sex • receipt of health care services

• religion stereotypes and gender • claims experience

• sexual orientation identity) • medical history

• public assistance status • marital status • genetic information

Auxiliary Aids and Services: Medica provides auxiliary aids and services, like qualified interpreters or information in accessible formats, free of charge and in a timely manner to ensure an equal opportunity to participate in our health care programs. Contact Medica at 1-888-347-3630 (toll free); TTY: 711 or at

medica.com/contactmedicaid.

Language Assistance Services: Medica provides translated documents and

spoken language interpreting, free of charge and in a timely manner, when language assistance services are necessary to ensure limited English speakers have meaningful access to our information and services. Contact Medica at 1-888-347-3630 (toll free);

TTY: 711 or at medica.com/contactmedicaid.

Civil Rights Complaints

You have the right to file a discrimination complaint if you believe you were treated in a discriminatory way by Medica. You may contact any of the following four agencies directly to file a discrimination complaint.

U.S. Department of Health and Human Services’ Office for Civil Rights (OCR)

You have the right to file a complaint with the OCR, a federal agency, if you believe you have been discriminated against because of any of the following:

• race • disability

• color • sex

• national origin • religion (in some cases)

• age

Contact the OCR directly to file a complaint:

Director

U.S. Department of Health and Human Services’ Office for Civil Rights 200 Independence Avenue SW

Room 515F HHH Building

Washington, DC 20201

Customer Response Center: Toll-free: 800-368-1019 TDD: 800-537-7697

Email: [email protected]

Minnesota Department of Human Rights (MDHR)

In Minnesota, you have the right to file a complaint with the MDHR if you believe you have been discriminated against because of any of the following:

• race • creed • public assistance status

• color • sex • disability

• national origin • sexual orientation

• religion • marital status

Contact the MDHR directly to file a complaint:

Minnesota Department of Human Rights 540 Fairview Avenue North

Suite 201

St. Paul, MN 55104 651-539-1100 (voice) 800-657-3704 (toll free)

711 or 800-627-3529 (MN Relay) 651-296-9042 (fax)

[email protected] (email)

Minnesota Department of Human Services (DHS)

You have the right to file a complaint with DHS if you believe you have been discriminated against in our health care programs because of any of the following:

• race • age • political beliefs

• color • disability (including physical • medical condition

• national origin or mental impairment) • health status

• creed • sex (including sex • receipt of health care services

• religion stereotypes and gender • claims experience

• sexual orientation identity) • medical history

• public assistance status • marital status • genetic information

Complaints must be in writing and filed within 180 days of the date you discovered the alleged discrimination.

The complaint must contain your name and address and describe the discrimination you are complaining about. After we get your complaint, we will review it and notify you in writing about whether we have authority to investigate. If we do, we will investigate the complaint.

DHS will notify you in writing of the investigation’s outcome. You have the right to appeal the outcome if you disagree with the decision. To appeal, you must send a written request to have DHS review the investigation outcome. Be brief and state why you disagree with the decision. Include additional information you think is important.

If you file a complaint in this way, the people who work for the agency named in the complaint cannot retaliate against you. This means they cannot punish you in any way for filing a complaint. Filing a complaint in this way does not stop you from seeking out other legal or administrative actions.

Contact DHS directly to file a discrimination complaint:

Civil Rights Coordinator

Minnesota Department of Human Services Equal Opportunity and Access Division P.O. Box 64997

St. Paul, MN 55164-0997

651-431-3040 (voice) or use your preferred relay service Medica Complaint Notice

You have the right to file a complaint with Medica if you believe you have been discriminated against because of any of the following:

• medical condition

• health status

• receipt of health care services

• claims experience

• medical history

• genetic information

• disability (including mental or physical impairment)

• marital status

• age

• sex (including sex stereotypes and gender identity)

• sexual orientation

• national origin

• race

• color

• religion

• creed

• public assistance status

• political beliefs

You can file a complaint and ask for help in filing a complaint in person or by mail, phone, fax, or email at:

Medica Civil Rights Coordinator Medica Health Plans

PO Box 9310, Mail Route CP250 Minneapolis, MN 55443-9310

952-992-3422 (voice and fax) TTY: 711 Email: [email protected]

American Indians can continue or begin to use tribal and Indian Health Services (IHS) clinics.

We will not require prior approval or impose any conditions for you to get services at these clinics. For elders age 65 years and older this includes Elderly Waiver (EW) services accessed through the tribe. If a doctor or other provider in a tribal or IHS clinic refers you to a provider in our network, we will not require you to see your primary care provider prior to the referral.

MINNESOTA.

WE’VE GOT

YOU COVERED.

Call toll free

1 (800) 266-2157 (TTY: 711)

8 a.m. to 5 p.m., Monday-Friday Email us

[email protected] Visit us online

Medica.com/SNBC

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© 2021 Medica. Medica®, Medica AccessAbility Solution® and Medica AccessAbility Solution® Enhanced are registered service marks of Medica Health Plans. "Medica" refers to the family of health services companies that includes Medica Health Plans, Medica Community Health Plan, Medica Insurance Company, Medica Self-Insured, MMSI, Inc. d/b/a Medica Health Plan Solutions, Medica Health Management, LLC and the Medica Foundation.

All other trademarks are the property of their respective owners.