CHIP Member Handbook N U E C E S S E R V I C E A R E A toll free TTY DriscollHealthPlan.com M E M B E R S E R V I C E S

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1 N U E C E S S E R V I C E A R E A SEPTEMBER 2015 CHIP-MHB M E M B E R S E R V I C E S toll free TTY DriscollHealthPlan.com An affiliate of Driscoll Health System

2 Your CHIP Benefits Include: Doctor visits. Prescription drugs. Hospital care at local hospitals. Shots (immunizations). Eye exams and glasses. Hearing and dental exams. Interpretation services. Get help with transportation to your doctor. Mental health benefits. Offers You These Services* Asthma Services One $20 gift card for Members who refill six months of asthma medicines. Refills must be continuous. One time sponsorship to summer camp for Members with asthma ages 7 to 14. Access to Fitness Programs Boys & Girls Club memberships at select locations. Space is limited. Memberships offered on first come first serve basis. $50 gift card for Members who join a health and wellness or sports program. Eyeglasses $100 for frames and lenses every two years ages 2 to 18. Cell Phone Minutes and Texting 250 extra minutes and health education text messages per month for certain members First Aid Kit One first-aid kit per family for new Members five years of age and younger. Gifts for Completing Checkups One $20 gift card for Pregnant Members who get a prenatal checkup on time. Visit must take place within 42 days of joining DHP or first trimester. One $20 gift card for Pregnant Members who get a postpartum checkup on time. Visit must take place 21 to 56 days after delivery. One $20 gift card for Members who get four on-time newborn Well Child checkups. One $20 gift card for getting two of three Well Child checkups (12 month, 15 month or 18 month) on time for CHIP Members. One $20 gift card after receiving a Well Child checkup on time each year for Members ages 2 to 19. Prenatal Education for Moms Prenatal Education Sessions - Cadena de Madres hosts three baby showers for new moms. Each shower teaches about each pregnancy trimester. New moms can learn what to expect and how to stay healthy. Car Seat Pregnant members can get a car seat after attending all three baby showers. Gift Cards Get up to $40 in gift cards for going to two of three baby showers. Members can get help to learn about breast-feeding. Members get help to learn about nutrition. Birthing classes for Pregnant Members at certain sites. Parenting class for CHIP Members who just had a baby. One $20 gift card for Members who just had a baby and go to a parenting class. For a listing of locations for Baby Showers, Parenting and Birthing classes please go to our website. Smoking Cessation Benefits $50 repayment for products to stop smoking. One time limit for CHIP Members. Sports/School Physicals One each year for CHIP Members ages 5 to 18. Transportation Services Help with getting a ride to doctor visits or certain health classes. *This is not an all-inclusive list of extra services. Restrictions and/or limitations apply. These extra services are valid through August DriscollHealthPlan.com toll free TTY

3 Page 1 Introduction Introduction to By picking the (DHP), your child will get all the CHIP benefits plus more. Your own doctor Friendly and confidential staff Use of Driscoll Children s Hospital and many other hospitals Free health education for children of any age Getting care regardless of nationality, race, religion, origin and gender If you have any questions or concerns about getting care, and feel that you were not allowed to get care because of nationality, race, religion, origin, or gender, please contact DHP Member Services at as soon as possible. Your concern will be investigated and fixed quickly. The doctor you picked when you joined DHP CHIP will be your child's Primary Care Provider and will help take care of all your child s health care needs. First things first. These are a few important things about your child's health care. You will receive a DHP ID card, if you have not already received one. Your Primary Care Provider s name will be on the DHP ID card. Please check the ID card to make sure the names on it are correct. Get to know your child s doctor. Make an appointment with your Primary Care Provider as soon as possible. Call your Primary Care Provider for appointments. Tell them your child is a DHP CHIP member. Call your Primary Care Provider whenever your child needs health care. Follow your Primary Care Provider s advice. Carry your child's DHP ID card with you at all times. Use the hospital emergency room only for emergencies. This Member Handbook answers many questions about DHP. References to you, my, or I apply if you are a CHIP Member. References to my child or my daughter apply if your child is a CHIP or CHIP Perinate Newborn Member. We hope you read it soon. Keep it in a place where you can find it easily. Please feel free to call or write us if you have any questions. At DHP we are ready to help you any time during the day or night. We have special services for people who have trouble reading, hearing, seeing, or speak a language other than English or Spanish. If you need this handbook on tape (audio), in larger print, in Braille, or another language than Spanish, tell Member Services at as soon as possible. DHP will give these materials to you at no cost. Again, Welcome!

4 Page 2 Important Phone Numbers Call us: Se Habla Español Write us: Regular Business Hours: Before 8 a.m. or after 5 p.m. 24 Hour/7 Days A Week Behavioral Health Hotline Member Services (toll-free) (English or Spanish) Other interpretive services exist. If there is an emergency or crisis, go to the ER or call For those with hearing loss: (TTY) toll-free Interpreter Services also exists. 615 N Upper Broadway, Suite1621 Corpus Christi, T a.m. to 5 p.m. CST, Monday through Friday except for state approved holidays Call and leave a message. We will return your call the next working day (English or Spanish) with facts on services. Other interpretive services exist. If there is an emergency or crisis, go to the ER or call Vision and Eye Care Number Dental Care Number Pharmacist Help Line CHIP Help Line for questions regarding eye exams and glasses DentaQuest MCNA Dental Call (toll-free) if you need help getting a prescription filled.

5 Page 3 Table of Contents Page Introduction.. 1 Important Phone Numbers... 2 Table of Contents... 3 and CHIP 6 Your CHIP ID Card... 6 DHP CHIP Identification Card (ID Card) 6 Reading the DHP CHIP ID Card. 6 Using the DHP CHIP ID Card.. 7 If you lose your ID Card or move. 7 All About Primary Care Providers What do I need to bring to my / my child s Doctor s appointment? 7 What is a Primary Care Provider?.. 7 Can I have a Specialist doctor be my child s Primary Care Provider?. 7 Can a Clinic be my / my child s Primary Care Provider? 7 How can I change my / my child s Primary Care Provider? 7 How many times can I change my / my child s Primary Care Provider? 8 When will a Primary Care Provider change become effective?.. 8 Are there any reasons why my request to change my Primary Care Provider may be denied? 8 Can a Primary Care Provider move me / my child to another Primary Care Provider for non-compliance? 8 What if my Primary Care Provider leaves the health plan?.. 8 What if I choose to go to another doctor who is not my / my child s Primary Care Provider?. 9 How do I get medical care after my / my child s Primary Care Provider office is closed?... 9 Physician Incentive Plan 9 Changing Health Plans.. 9 What if I want to change health plans?.. 9 Who do I call?. 9 How many times can I change health plans? 9 When will my health plan change become effective?.. 9 Can DHP ask that I get dropped from their health plan for non-compliance, etc.?. 10 Health Care and Other Services. 10 What is routine medical care?. 10 What is urgent medical care?.. 10 What is a limited provider network? 11 Emergency Care 11 What is Emergency, an Emergency Medical Condition and an Emergency Behavioral Health Condition? 11 What is Emergency Services and/or Emergency Care?. 11 Are Emergency Dental Services Covered? 11 What do I do if I need Emergency Dental Care? 12 How soon can I expect to be seen / how soon can I expect my child to be seen?.. 12 Getting care at night or on weekends.. 12 What is post stabilization?. 12 What if I get sick when I am out of town or traveling / what if my child gets sick when he or she is out of town or traveling? What if I am / my child is out of the state? 12 What if I am / my child is out of the country?.. 13 ATTENTION FEMALE MEMBERS What if I need / my daughter needs OB/GYN care?.. 13 Do I have the right to choose an OB/GYN? 13 How do I choose an OB/GYN?. 13 If I don t choose an OB/GYN, do I have direct access? 14 Will I need a referral?. 14 How soon can I / can my daughter be seen after contacting the OB/GYN for an appointment?.. 14

6 Page 4 Can I / my daughter stay with an OB/GYN who is not with?. 14 What if I am pregnant / my daughter is pregnant? Who do I call?.. 14 What other services / activities / education does offer pregnant women? CHIP Benefits 14 What are my CHIP Benefits?. 14 How do I get these services / how do I get these services for my child? 14 What services are not covered?. 15 Medicaid Versus CHIP Coverage for CHIP Perinatal Program Newborns.. 15 What are the CHIP Perinatal benefits?. 15 Concurrent Enrollment of Family Members in CHIP and CHIP Perinatal 15 What are my prescription drug benefits?.. 15 Behavioral (Mental) Health Services 15 How do I get help if I have/my child has behavioral (mental) health or drug problems?.. 15 Do I need a referral for this?.. 16 Prescription coverage How do I get my / my child s medications?. 16 How do I find a network drug store?. 16 What if I go to a drug store not in network?. 16 What do I bring with me to the drug store?.. 16 What if I need my / my child s medications delivered to me? 16 Who do I call if I have problems getting my / my child s medications?.. 16 What if I can t get the medication my / my child s doctor ordered approved? 16 What if I lose my / my child s medication? 16 What if I need / my child needs an over the counter medication for CHIP? 17 What if I need / my child needs more than 34 days of a prescribed medication?. 17 What if I need / my child needs birth control pills?. 17 Other Health Coverage and Services. 17 What health education classes does DHP offer? 17 How do I get eye care services / how do I get eye care services for my child?. 17 How do I get dental services / how do I get dental services for my child?.. 17 Interpreter 17 Can someone interpret for me when I talk with my / my child s doctor?. 17 Who do I call for an interpreter?. 17 How far in advance do I need to call? 18 How can I get a face-to-face interpreter in the provider s office?.. 18 Costs of Your DHP CHIP Insurance What are Co-payments? How much are they and when do I have to pay them?.. 18 What Extra Benefits does a member of get? How can I get these benefits / how can I get these benefits for my child?.. 19 CHIP Cost-Sharing Caps. 19 What If I get a bill from my Doctor? 20 Who do I call? 20 What information will they need?.. 20 What do I have to do if I move?. 20 What if I have an accident and pays the bill?.. 20 Other costs for CHIP Members. 20 Referrals to Specialists.. 20 What is a referral? 20 What services do not need a referral?.. 20 What if I / my child needs to see a special doctor (specialist)?. 21 How soon can I expect to be seen by a specialist / how soon can I expect my child to be seen by a specialist? 21

7 Page 5 Who do I call if I have / my child has special health care needs and I need someone to help me?.. 21 How can I ask for a second opinion? 21 Services that require prior authorization.. 21 How to Appeal a Denied Service. 21 What can I do if my doctor asks for a service for me that s covered but denies or limits it?.. 22 How will I find out if services are denied? 22 What are the timeframes for the appeal process?. 22 When do I have the right to ask for an appeal?. 22 Does my request have to be in writing?.. 22 Can someone from DHP help me file an appeal?.. 22 Expedited Appeal 23 What is an Expedited Appeal?. 23 How do I ask for an Expedited Appeal?.. 23 Does my request have to be in writing?.. 23 What are the timeframes for an Expedited Appeal? What happens if DHP denies your request for an Expedited Appeal? 23 Who can help me in filing an Expedited Appeal? 23 Independent Review Organization (IRO) Process.. 23 What is an Independent Review Organization?. 23 How do I ask for a review by an Independent Review Organization?. 23 What are the timeframes for this process?.. 24 What if I need an appeal decision quickly?. 24 Complaints. 24 What should I do if I have a complaint? 24 Who do I call? 24 Can someone from DHP help me file a complaint? How long will it take to process my complaint? 24 What are the requirements and timeframes for filing a complaint?.. 25 If I am not satisfied with the outcome, who else can I contact? 25 Do I have the right to meet with a Complaint Appeal Panel? 25 Fraud and Abuse of the CHIP Program.. 25 Do you want to report CHIP Waste, Abuse or Fraud? 25 Reporting Waste, Abuse or Fraud in CHIP by a Provider or Client.. 26 Member Rights and Responsibilities.. 26 Members Have a Right To 26 Member Responsibilities DHP CHIP Scope of Benefits.. 28 What does Medically Necessary mean? 29 Description of Benefits.. 29 Value Added Services 42 Exclusions 44 DME/Supplies.. 45

8 Page Page 6 6 and and CHIP Laws Laws passed by by the the U.S. U.S. Congress and and the the Texas Legislature started the the Health Insurance Program (CHIP) in in Texas. CHIP CHIP helps helps children of of families that that have have incomes too too high high to to qualify for for Medicaid but but too too low low to to easily afford private family coverage. By By picking the the Plan (DHP), we we can can give give CHIP CHIP benefits to to your your children from from birth birth through age age Health care care through DHP DHP CHIP CHIP exists in in these these south south Texas counties: Aransas Bee Bee Brooks Calhoun Jim Jim Wells Wells Karnes Kenedy Kleberg Nueces Refugio San San Patricio Victoria Goliad Live Live Oak Oak DHP DHP is a is a not-for-profit Health Maintenance Organization (HMO) licensed by by the the Texas Department of of Insurance. DHP DHP has has a a contract with with a third a third party party administrator. This This company is is Valence Health. They They process and and pay pay your your doctor and and hospital bills bills for for us. us. Your CHIP ID ID Card You You will will get get a a CHIP Identification (ID) (ID) card card after after you you join join DHP. A A copy copy of of the the DHP DHP ID ID card card is is shown below. Facts Facts about about your your child child Primary Care Care Provider name and and phone number CHIP Member Name: DCCHIPNC A SAMPLE Member ID#: G Effective Date: 05/01/2013 PCP: PHYSICIAN NAME PCP Phone #: (555) Effective Date of PCP: 05/01/2013 Co-payment Amounts/Co-pagos: OV: $0 *ER: $0 IP: $0 R Brand: $0 R Generic: $0 No Co-payment for CHIP Perinate Newborn No hay Co-pago para los recien Nacidos Perinatal *ER co-pays apply only for non-emergent ER visits. Member Service Phone #: Important Information/Información Importante 24/7 Member Services/Departamento de Servicios para Miembros (gratis) TTY for hearing impaired/tty para personas con problemas del oído /7 Behavioral Health Hotline/Linea de Servicios de Salud Mental Vision Services/Servicios para la vista Directions for what to do in an emergency In case of emergency call 911 or go to the closest emergency room. After treatment, call your PCP within 24 hours or as soon as possible. Instrucciones en caso de emergencia En caso de emergencia, llame al 911 o vaya a la sala de emergencias más cercana. Después de recibir tratamiento, llame al PCP dentro de 24 horas o tan pronto como sea posible. NOTICE TO PROVIDER: The member whose name appears on the face of this card is covered by for CHIP services. For provider billing or UM questions, The toll free UM FA number is Submit Claims to: DHP, P.O. Box 3668, Corpus Christi, Texas NAVITUS HEALTH SOLUTIONS is the pharmacy benefits provider for DHP. NAVITUS HEALTH SOLUTIONS es el proveedor de beneficios de farmacia de DHP. Pharmacist (Only) Help Desk: BIN: PCN: MCD Rx GRP: DCH REV 6/14 Each Each of of your your children will will have have a a different card. card. You You will will not not get get a new a new DHP DHP CHIP CHIP card card every every month. You You will will get get a new a new one one if you if you lose lose your your ID ID card, card, or or if you if you call call us us to to change your your Primary Care Care Provider. Reading the the DHP DHP CHIP CHIP ID ID Card Card The The front front of of the the DHP DHP CHIP CHIP ID ID card card shows important facts facts about about your your child, child, the the Primary Care Care Provider s name and and Primary Care Care Provider s phone number. It also It also shows the the a a mounts (co-payments) you you might might have have to to pay pay for for your your doctor visits, hospital visits, visits, or or for for prescriptions. The The back back of of the the card card shows important phone numbers for for emergencies or or other other help help from from DHP DHP Member Services. Plan Form CHIP

9 Page 7 Using the DHP CHIP ID Card Carry your child s DHP CHIP ID Card with you when your child gets any health care services. You must show your CHIP ID Card each time for any health service. If you lose an ID Card or Move If you lose the DHP CHIP ID Card, call us right away at to get a new one. If you move or change phone numbers, call us so we can send you another ID card. We always need to have your correct address and phone number. What do I need to bring to my / my child s Doctor s appointments? All About Primary Care Providers Always take your / your child s DHP ID card with you when you go to the doctor. If your child is going to get vaccines, don t forget your child s vaccine records. What is a Primary Care Provider? The Primary Care Provider you chose is considered your child s medical home. He or she will help you with all medical care. Your Primary Care Provider will get to know you and your child. He or she will do regular checkups and treat your children when they are sick. Your Primary Care Provider will prescribe medicines and medical supplies for your children and send them to a specialist if needed. It is important to follow the Primary Care Provider s advice. Take part in decisions about your child s health care. Your Primary Care Provider might ask us to assign you to another Primary Care Provider if you do not follow his or her advice. It might also happen if you and the Primary Care Provider do not get along. The Primary Care Provider must tell us if this happens. We will contact you and ask that you pick another Primary Care Provider. Call your Primary Care Provider during office hours when you can. If possible, do not wait until evening to call to take care of a medical problem. Most illnesses tend to get worse as the day goes on. Call early. You must only see the Primary Care Provider listed on your ID Card. If you see another Primary Care Provider, you will have to pay the bill. Can I have a Specialist doctor be my child s Primary Care Provider? There might be times when DHP might allow a Specialist to be your child s Primary Care Provider. This is for Children with Special Health Care Needs (CSHCN). You must sign the Agreement for Specialist to function as a Primary Care Provider form. The Specialist must also sign the form agreeing to be the Primary Care Provider. Our Medical Director will review and will make a decision about approval within thirty (30) days of receiving the request. You will receive this decision in a letter that we will send to you. If your request is denied, you do have the right to appeal the decision. (See page 21 about how to file a complaint and appeal.) The effective date of this change will be the first of the month when the request was made. Call DHP Member Services at to learn more. Can a Clinic be my / my child s Primary Care Provider? You can pick a clinic as the Primary Care Provider for your child. This can be a Federally Qualified Health Center (FQHC), or a Rural Health Clinic (RHC). If you have questions call Member Services at How can I change my / my child s Primary Care Provider? You might want to change to another Primary Care Provider if:

10 Page 8 You are not happy with your Primary Care Provider s care. You need a different kind of doctor to take care of your child. You move farther away from your Primary Care Provider. Your Primary Care Provider is no longer a part of DHP s network. You can change your Primary Care Provider by calling toll-free at The DHP Provider Directory lists all Primary Care Providers. You will get a new ID card that shows the date your new Primary Care Provider can begin to care for your child. The new card will show the new Primary Care Provider s name and phone number. Changing your Primary Care Provider will not stop you from getting care. If you need care before the date your new Primary Care Provider can start caring for your child, call the Primary Care Provider on your current card. To give you the best care possible, your Primary Care Provider needs to know your child s medical history. Your medical records are private and confidential. Only you, your Primary Care Provider, and other approved providers have a right to see them. If you change doctors, be sure to give your new Primary Care Provider any facts needed about your medical history. How many times can I change my / my child s Primary Care Provider? There is no limit on how many times you can change your or your child s primary care provider. You can change primary care providers by calling us toll free at or writing to, 615 N Upper Broadway Suite 1621, Corpus Christi, Texas When will a Primary Care Provider change become effective? You can change your Primary Care Provider at anytime. If you call BEFORE the 5 th of the month, the change will become effective immediately. If you call AFTER the 5 th of the month, the Primary Care Provider will not change until the first of the next month. If you see the new Primary Care Provider before the change, you will have to pay the bill. Are there any reasons why my request to change my Primary Care Provider may be denied? You might not be able to have the Primary Care Provider you chose if: The Primary Care Provider you picked is not seeing new patients. The Primary Care Provider you picked is no longer a part of DHP. Can a Primary Care Provider move me or my child to another Primary Care Provider for noncompliance? It is important to follow the Primary Care Provider s advice. Take part in decisions about your child s health care. Your Primary Care Provider might ask us to assign your child to another Primary Care Provider if you do not follow his or her advice. It might also happen if you and the Primary Care Provider do not get along or you miss visits without calling to tell the Primary Care Provider why you weren t there. The Primary Care Provider must tell us if this happens. We will contact you and ask that you pick another Primary Care Provider. What if my Primary Care Provider leaves the health plan? If your Primary Care Provider decides to no longer be a provider for DHP and your child has special needs, we will continue to pay for services to this Primary care Provider up to 90 days after the effective date when the provider left. Your Primary Care Provider will need to send us a request to continue to provide service and to explain the special needs of your child. If we terminate your Primary Care Provider, except for medical competence or professional behavior, we will notify you right away. We will continue to pay for services if your child is special needs up to 90 days after the effective termination date. If we terminate your Primary Care Provider for medical competence or professional behavior, we

11 Page 9 will notify you right away. You will need to pick right away another Primary Care Provider that is a network provider for DHP. What if I choose to go to another doctor who is not my / my child s Primary Care Provider? You can go to any provider, if you need 24-hour emergency care from an emergency room. You can go to any DHP OB/GYN provider. You do not need a referral from your Primary Care Provider. If you need mental health or substance abuse services you should call the Behavioral Health Hotline at Behavioral Health Services are very private so your Primary Care Provider does not need to agree for you to get these services. If you need a routine vision exam, your Primary Care Provider does not need to agree for you to get these services. But if you have an eye problem you will need a referral from your Primary Care Provider. For questions about vision services, call For all other care, you must only see the Primary Care Provider listed on your ID Card. If you see another Primary Care Provider, you might have to pay the bill. How do I get medical care after my / my child s Primary Care Provider s office is closed? Except in an emergency, if your child gets sick at night or on a weekend and cannot wait to get medical care, call your Primary Care Provider for advice. Your Primary Care Provider or another doctor exists by phone 24 hours a day, 7 days a week. If your child has a fever or a sore throat and you are not sure what to do, call your Primary Care Provider s office. Physician Incentive Plan A physician incentive plan rewards doctors for treatments that reduce or limit services for people covered by CHIP. Right now, does not have a physician incentive plan. Changing Health Plans What if I want to change health plans? You are allowed to make health plan changes: For any reason within 90 days of enrollment in CHIP; For cause at any time; During the annual CHIP re-enrollment period. Who do I call? For more information, call CHIP toll-free at How many times can I change health plans? A CHIP member may change health plan at anytime for these reasons: For any reason within 90 days of enrollment in CHIP; For cause at any time; During the annual CHIP re-enrollment period. When will my health plan change become effective? The health plan change will become effective the following month after you requested the change.

12 Page 10 Can DHP ask that I get dropped from their health plan for non-compliance, etc.? DHP may request that you be taken out of our health plan for good cause. Good Cause could be: 1. Fraud or abuse by a member 2. Threats of physical acts leading to harming of DHP staff or providers 3. Theft 4. Refusal to go by DHP policies and procedures, like: a. Let someone use your CHIP ID card b. Miss appointments to your provider over and over c. Rude or act out against a provider or a DHP staff member d. Keep using a doctor that is not a DHP provider DHP will not ask you to leave the health plan without trying to work with you. If you have questions about this process, call Member Services at The Texas Health and Human Services Commission will decide if a Member can be told to leave the program. What is routine medical care? Health Care and Other Services Routine medical care might be when your child is seeing the Primary Care Provider for a well-child visit. Routine medical care might also be your first visit with the Primary Care Provider. o How soon can I expect to be seen / how soon can I expect my child to be seen? You should expect the Primary Care Provider to give you an appointment within 14 days for your first visit or for any other routine care. If your Primary Care Provider refers your child to a Specialist, you should be seen within three (3) weeks. What is urgent medical care? Urgent medical care is when your child is sick or hurt and needs treatment as soon as possible to keep your child from getting worse. These are situations when you need to call your child s Primary Care Provider first: Earache Toothache or baby teething Rash Colds, cough, sore throat, flu or sinus problems Minor sun burn Minor cooking burn Chronic back pain Minor headache Broken cast Stitches needing to be removed Medication refills o How soon can I expect to be seen / how soon can I expect my child to be seen? You can expect to be seen for urgent medical care within 24 hours.

13 Page 11 What is a limited provider network? A limited provider network is a list of providers who only refer members to other providers within our network. DHP does not have any limited provider networks. A list of all our providers can be found on our website at Emergency Care What is an Emergency, an Emergency Medical Condition and an Emergency Behavioral Health Condition? Emergency care is a covered service. Emergency care is provided for Emergency Medical Conditions and Emergency Behavioral Health Conditions. Emergency Medical Condition means a medical condition of recent onset and severity, including, but not limited to, severe pain that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that the child s condition, sickness, or injury is of such a nature that failure to get immediate care could result in: placing the child s health in serious jeopardy; serious impairment to bodily functions; serious dysfunction of any bodily organ or part; serious disfigurement; or in the case of a pregnant child, serious jeopardy to the health of the fetus. Emergency Behavioral Health Condition means any condition, without regard to the nature or cause of the condition, that in the opinion of a prudent layperson, possessing average knowledge of medicine and health: requires immediate intervention and/or medical attention without which the child would present an immediate danger to himself or others; or that renders the child incapable of controlling, knowing or understanding the consequences of his actions. What is Emergency Services and/or Emergency Care? Emergency services and/or emergency care means health care services provided in an in-network or out-of-network hospital emergency department, free-standing emergency medical facility, or other comparable facility by in-network or out-of-network physicians, providers, or facility staff to evaluate and stabilize Emergency Medical Conditions and/or Emergency Behavioral Health Conditions. Emergency services also include, but are not limited to, any medical screening examination or other evaluation required by state or federal law that is necessary to determine whether an Emergency Medical Condition and/or an Emergency Behavioral Health Condition exists. Are Emergency Dental Services Covered? DHP will pay for some emergency dental services provided in a hospital, urgent care center, or ambulatory surgical center setting, such as services for: Treatment of a dislocated jaw Treatment of traumatic damage to teeth and supporting structures Removal of cysts Treatment of oral abscess of tooth or gum origin Treatment for craniofacial anomalies Drugs for any of the above conditions

14 Page 12 DHP also covers other dental services your child gets in a hospital, urgent care, or ambulatory surgical center setting. This includes services from the doctor and other services your child might need, like anesthesia. What do I do if I need Emergency Dental Care? During normal business hours, call your child s Main Dentist to find out how to get emergency services. If your child needs emergency dental services after the Main Dentist s office has closed, call us toll-free at If your child has an emergency, go to the closest Emergency Room right away or call Examples of when to go to the emergency room are: Someone might die. Someone has bad chest pains. Someone cannot breathe or is choking Someone has passed out or is having a seizure. Someone is sick from poison or a drug overdose Someone has a broken bone. Someone is bleeding a lot. Someone has been attacked (raped, stabbed, shot, beaten). Someone is about to deliver a baby. Someone has a serious injury to the arm, leg, hand, foot, or head. Someone has a severe burn. Someone has a severe allergic reaction or has an animal bite. Someone has trouble controlling behavior and without treatment is dangerous to self or others. Go to the nearest hospital if you think you have any of these problems. You can call for help in getting to the hospital emergency room. A cold, cough, rash, small cuts, minor burns or bruises are not good reasons to go to the Emergency Room. How soon can I expect to be seen / how soon can I expect my child to be seen? Emergency medical care is ready through the closest hospital 24 hours a day, 7 days a week. If you go to the ER, be sure to call your Primary Care Provider within 24 hours, or as soon as your child is medically stable. Getting care at night or on weekends If your child gets sick at night or on a weekend and cannot wait to get medical care, call your child s Primary Care Provider for advice. The Primary Care Provider or another doctor is ready by phone 24 hours a day, 7 days a week. If your child has a fever or a sore throat and you are not sure what to do, call the Primary Care Provider s office.

15 Page 13 What is post stabilization? Post-stabilization care services are services covered by CHIP that keep your condition stable following emergency medical care. What if I get sick when I am out of town or traveling / what if my child gets sick when he or she is out of town or traveling? What if I am / my child is out of the state? If you/your child needs medical care when traveling, call us toll-free at and we will help you find a doctor. If you/your child needs emergency services while traveling, go to a nearby hospital, then call us toll free at Keep your / your child s DHP ID card with you at all times. When you / your child will be temporarily away from home, you should contact your Primary Care Provider ahead of time to schedule appointments or obtain prescriptions to last for the duration of your child s stay. If your child gets sick while he or she is out of town and it is not an emergency he or she will still remain under the care of your Primary Care Provider. With the exception of emergency care, if you / your child sees an out-of-town doctor you might have to pay. What if I am / my child is out of the country?. Medical services performed out of the country are not covered by CHIP. ATTENTION FEMALE MEMBERS What if I need / my daughter needs OB/GYN care? If you need help picking an OB/GYN doctor you can call Member Services at If you or your child is pregnant you should choose an OB/GYN for care. ATTENTION MEMBERS You have the right to pick an OB/GYN for yourself / your daughter without a referral from your / your daughter s Primary Care Provider. An OB/GYN can give you: One well-woman checkup each year. Care related to pregnancy. Care for any female medical condition. Referral to special doctor (specialist) within the network. allows you / your daughter to pick any OB/GYN, but this doctor must be in the same network as your / your daughter s Primary Care Provider. If you have questions about OB/GYN services, call DHP Member Services at Do I have the right to choose an OB/GYN? You do have the right to choose any provider who provides OB/GYN services. How do I choose an OB/GYN? Pick an OB/GYN provider from your DHP Provider Directory. If you pick an OB/GYN who is not on the DHP Provider Directory list, you might have to pay.

16 Page 14 If I don t choose an OB/GYN, do I have direct access? Yes, you may go directly to an OB/GYN Provider. Will I need a referral? No, you will not need a referral from your Primary Care Provider. How soon can I / can my daughter be seen after contacting the OB/GYN for an appointment? You / your daughter should be able to get an appointment within 2 weeks of calling for an appointment. If you / your daughter are 7 months pregnant or more and a new member, you / your daughter should be able to get an appointment within 5 days, or immediately if there is an emergency. Can I / my daughter stay with an OB/GYN who is not with? If you / your daughter is close to the end of the pregnancy, you may stay with the OB/GYN doctor you or your daughter has been seeing. Otherwise, you need to contact DHP Member Services at Ask for a Case Manager who can help you with finding an OB/GYN doctor who is with. What if I am pregnant / what if my daughter is pregnant? Who do I need to call? It is very important that you call to tell us you / your daughter is pregnant and what doctors you or she is seeing. Call Member Services at It is very important for you / her to start prenatal care immediately. You also need to call the CHIP hotline at so that you or your daughter may be moved to the CHIP Perinatal Program. What other services / activities / education does offer pregnant women? Pregnant women will receive case management and health education. A nurse case manager will: Contact you by phone. Contact you by mail. Tell you about your / your daughter s pregnancy. Help you find an OB/GYN doctor for you / your daughter. There are other value added services that you can have if you / your daughter are pregnant. See page 46 for the list of value added services. What are my CHIP Benefits? For a full list of benefits see pages How do I get these services / how do I get these services for my child? CHIP Benefits Call Member Services at We will be happy to explain how you or your child can get these benefits. Are there any limits to any covered services? For any limits to any services, see the list of covered services starting on page 29.

17 Page 15 What services are not covered? A list of services not covered by CHIP are on page 43 of this Member Handbook. Medicaid Versus CHIP Coverage for CHIP Perinatal Program Newborns At birth, the CHIP Perinate Newborn will be moved to Medicaid for twelve (12) months continuous coverage, if the newborn lives in a family with an income at or below 185% of the Federal Poverty Level (FPL). If the family income is 186% to 200% FPL, the CHIP Perinate Newborn will continue to be in the CHIP Program. What are the CHIP Perinatal benefits? For the CHIP Perinatal Newborn, the benefits are the same as for CHIP members. For the mother of the CHIP Perinatal Newborn, see the CHIP Perinate Program Member Handbook. o How do I get these services for my child? The CHIP Perinatal Newborn will begin CHIP services at birth o What benefits does my baby receive at birth? The benefits for the newborn baby, that qualifies as a CHIP member, are the same as for CHIP members. Concurrent Enrollment of Family Members in CHIP and CHIP Perinatal For members in the CHIP Perinatal Program, the health plan that is chosen will also be the health plan for other CHIP Members in the family. So if another health plan is chosen by the CHIP Perinatal member, the children on CHIP will be moved to the same health plan. Co-payments are still applicable for the CHIP Members. CHIP Perinatal Program Members have no copayments. What are my prescription drug benefits? covers most drugs your doctor orders. To learn more call Member Services at Behavioral (Mental) Health Services How do I get help if I have / my child has behavioral (mental) health or alcohol or drug problems? You can get help for behavioral (mental) health problems and/or alcohol and/or substance (drug) abuse. You can go to a mental health provider without a referral from your Primary Care Provider. The provider you pick must be a provider with s Behavioral Health network. Call the Behavioral Health Hotline on your ID card for help. The phone number is You can call anytime 24 hours a day, seven (7) days a week. If your child has an emergency related to mental health problems or drug or alcohol abuse, go to the nearest hospital emergency room or call 911.

18 Page 16 Do I need a referral for this? Behavioral health services are very private so your Primary Care Provider does not have to agree for you to get these services. You do not need a referral from your Primary Care Provider. How Do I Get My / My Child s Medications? Prescription Coverage CHIP covers most of the medicine your/your child s doctor says you need. Your/your child s doctor will write a prescription so you can take it to the drug store, or may be able to send the prescription for you. Exclusions include: contraceptive medications prescribed only for the purpose to prevent pregnancy and medications for weight loss or gain. You might have to pay a co-payment for the prescription filled depending on your income. How do I find a network drug store? Call Member Services at They will be able to help you find a drug store. You may also visit the DHP website to find a drug store. The website is What if I go to a drug store not in network? The pharmacy can call the Pharmacy Help Desk number on the back of your ID card. They will help in obtaining a medication for you. What do I bring with me to the drug store? You will need to bring your CHIP ID card with you to the drug store. What if I need my / my child s medications delivered to me at my home? Call Member Services at and they will help you find a drug store that delivers medications. There is no charge for this home delivery, Who do I call if I have problems getting my / my child s medications? Call Member Services at What if I can t get the medication my / my child s doctor ordered approved? If your / your child s doctor cannot be reached to approve a prescription, your child may be able to get a three-day emergency supply of your/your child s medication. Call at for help with your medications and refills. What if I lose my/my child s medication? Lost medication is not a covered benefit. You may contact your pharmacy for an early refill and pay the cost of the medication.

19 Page 17 What if I need/my child needs an over the counter medication for CHIP? The pharmacy cannot give you an over the counter medication as part of your/your child s CHIP benefit. If you need/your child needs an over the counter medication, you will have to pay for it. What if I need/my child needs more than 34 days of a prescribed medication? The pharmacy can only give you an amount of a medication that you need/your child needs for the next 34 days. For any other questions, please call at What if I need/my child needs birth control pills? The pharmacy cannot give you/your child birth control pills to prevent pregnancy. You/your child can only get birth control pills if they are needed to treat a medical condition. What health education classes does DHP offer? Other Health Coverage and Services DHP has education for members on many different health subjects. There is no charge for DHP s health education. Health education might include facts on: Immunizations Special diets for diabetes Asthma care Wellness programs and health fairs If you need health education materials in another language, or in another format, call Member Services at How do I get eye care services / how do I get eye care services for my child? Eye care services include one examination by an eye doctor per year. You or your child may get one pair of eyeglasses each year. To learn more about eye exams or glasses, call our eye care vendor at How do I get dental services/how do I get dental services for my child? Your child s CHIP dental plan provides dental services including services that help prevent tooth decay and services that fix dental problems. Call your child s CHIP dental plan to learn more about the dental services they offer.. covers emergency dental services your child gets in a hospital. services the doctor provides and other services your child might need like anesthesia. This includes Interpreter Can someone interpret for me when I talk with my / my child s doctor? Yes. This can be Spanish, or other language. You or your doctor may call to arrange for an interpreter. Who do I call for an interpreter? Call Member Services at We will arrange for an interpreter to help you during your visit.

20 Page 18 How far in advance do I need to call? You will need to call at least 48 hours in advance of your appointment. How can I get a face-to-face interpreter in the provider s office? The interpreter we arrange for you can be someone that comes to the office. This interpreter will be in the doctor s office with you. Let us know if this is what you want. Se Habla Espanol DHP has people to help you who speak both Spanish and English. We also have member brochures in Spanish. Costs of Your DHP CHIP Insurance What are co-payments? How much are they and when do I have to pay them? Co-payments are part of the doctor s bill or prescription costs that you will have to pay. The following table lists the CHIP co-payment schedule according to family income. Co-payments for medical services or prescription drugs are paid to the doctor s office or drug store at the time of service. You do not need to pay a co-payment for preventive care such as well-child or well-baby visits or immunizations. You do not need to pay a co-payment for pregnancy related help. Your child s health plan ID card lists the co-payments that apply to your family. Present your ID card when you receive office visit or emergency room services or have a prescription filled. Co-pay facts You do not have to pay a co-pay if: You are a Native American You are a CHIP Perinate Member, or You have a CHIP Perinate Newborn, You do not have to pay a co-pay for: Well-baby checkup Well-child checkup Preventive checkup, or Pregnancy related services Federal Poverty Levels Native Americans At or Below 100% Office Visits Non- Emergency Room Visits Inpatient Hospitalizations Prescription Generic Drugs Prescription Brand Drugs $0 $0 $0 $0 $0 $0 $3 $3 $15 $0 $3 101%-150% $5 $5 $35 $0 $5 151%-185% $20 $75 $75 $10 $35 186%-200% $25 $75 $125 $10 $35 What extra benefits does a Member of get? Once a Year Reporting Caps 5% cap of family yearly income 5% cap of family yearly income 5% cap of family yearly net income 5% cap of family yearly net income All members might be able to receive the following Extra Benefits (Value Added services): Eyeglasses with a retail value up to $100 every 24 months. Transportation services for members who have special health care needs, and do not have transportation to their doctor or health education classes.

21 Page 19 Federal lifeline application assistance for all Members and 250 extra minutes and health education text messages for certain Members in the Federal Lifeline Program Temporary cell phone for Members with medical need who are not in the Federal Lifeline Program One Sport/school physical per year for members 5-18 years of age. Smoking cessation benefits one time $50 reimbursement for over-the-counter product. Home study for members with asthma, and free pillow covers and bed covers once the review is done. One time Summer Camp program for certain members with asthma ages 7 to 14, Free pregnancy and food counseling classes at certain places for pregnant CHIP and CHIP Perinate Members living in Bee, Jim Wells, Kleberg, Nueces, San Patricio, and Victoria counties Breast feeding counseling for Pregnant Members Nutrition counseling for Pregnant Members Pregnancy birthing classes at certain locations for Pregnant Members Free family membership to Boys and Girls Clubs available in Corpus Christi and Victoria area or one Sports Scholarship of $25 per member per year,. Access to Going Non-Stop Program Up to $25 in gifts each year for CHIP Members participating in Going Non Stop Program Free gifts and $5 gift card for health related items for pregnant CHIP and CHIP Perinatal Members participating in educational baby showers 1 Emergency Preparedness Kit for each CHIP and CHIP Perinate family each year upon enrollment Up to 6 gift certificates for diapers for Members who complete a required post-partum visit and 4 on-time newborn Well Child exams. One $20 gift card after receiving all Well Child exams on time each year for Members age 19 and under. How can I get these benefits / how can I get these benefits for my child? For eyeglasses, contact our vision vendor at If you need transportation services to your doctor, call Member Services at to arrange these services. You will need to call 48 hours in advance of your doctor s appointment to arrange these services. Services might exist in the evenings or on weekends. Extra time might be needed to arrange for these services. Operation hours are 8 a.m. to 5 p.m. For temporary cell phones or questions about any of the extra benefits, contact Member Services at For prenatal education or nutritional counseling contact Member Services at CHIP Cost-Sharing Caps When you joined CHIP you received a form that you should use to track your CHIP expenses. To ensure that you do not exceed your cost-sharing limit, please keep track of your CHIP-related expenses on this form. The CHIP welcome letter tells you exactly what your cost-sharing cap is based on your family s income. If you have lost this letter, please call CHIP hotline at and they will tell you what your yearly limit is. When you reach your yearly cap, please send the form to the HHSC Administrative Services Contractor. This contractor will notify us that you have reached your yearly cap. Once we are notified we will issue a new member ID card within five (5) days from the day we were notified. This new card will indicate that no co-payments are due when your child receives services. If you must go to the doctor or emergency room before you get your new ID card, have the doctor or emergency room contact us to verify co-pay amounts. We will inform them that there is no co-pay required. Call member services at

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