Your Medical Care Services Medical Benefits with Community Health Plan of Washington

Transcription

1 Your Medical Care Services Medical Benefits with Community Health Plan of Washington Including: Your Benefits: Services covered by Community Health Plan Services covered by Health Care Authority or other programs Services covered at your local health department Services not covered by Community Health Plan, HCA, or other programs Payments for services not covered How to Get More Information UPDATED December 9, 2011

2 Contact Information Medical Care Services with Community Health Plan of Washington Community Health Plan Contacts CUSTOMER SERVICE Hours Monday Friday 8:00 am 5:00 pm Voice toll free TTY TTY Relay: Dial customercare@chpw.org OFFICE PHONE voice WEB MAILING ADDRESS Community Health Plan of Washington 720 Olive Way, Suite 300 Seattle, WA FIND PROVIDERS Visit the Provider Directory Search online: On the Community Health Plan web site ( click the Providers tab. Contact the Community Health Plan customer service team. FREE 24 HOUR NURSE ADVICE LINE Voice toll free TTY toll free Contacts Outside Community Health Plan Medical Care Services (Medicaid) Web hrsa.dshs.wa.gov/mcs/index.shtml Medicaid customer service phone Voice TTY TTY Relay: Dial WASHINGTON STATE To learn about your rights under the law, call the Washington State Office of the Insurance Commissioner: If you have a problem or concern, call the Washington State Department of Health Consumer Hotline: Your Medical Care Services Medical Benefits 2 of 16

3 Table of Contents Services Covered by Community Health Plan of Washington... 4 Medical Care Services Benefit Table... 5 Services Covered by Health Care Authority or Other Programs Services at Your Local Health Department Services Not Covered by Community Health Plan, HCA, or Other Programs For Information About Prescription Services Payments for Services Not Covered Third Party Liability HOW TO GET MORE INFORMATION Your Medical Care Services Medical Benefits Page 3 of 16

4 Services Covered by Community Health Plan of Washington This is a summary of services and treatments covered by Community Health Plan of Washington ("Community Health Plan" or "the Plan") and the Washington State Health Care Authority (HCA) for Medical Care Services. Some health care services are not covered. Services and treatments are covered only if medically necessary. You will need a referral from your PCP and often an authorization from Community Health Plan before you get a service or treatment. If you get a service before you get an authorization or referral, you might have to pay for it yourself. (See "About Prior Authorizations and Referrals." Community Health Plan covers professional services. HCA covers facility services. For information about services covered by Community Health Plan: "Medical Care Services Benefit Table" lists benefits covered by the Plan when they are medically necessary. (See "Medically Necessary.") The Details column tells more about the benefit, including whether it requires a referral or prior authorization. "Services Covered by HCA or Other Programs" lists services offered by HCA or other agencies and programs when they are medically necessary. "Services at Your Local Health Department" lists services offered by your local Washington State Department of Health office when they are medically necessary. You must show your ProviderOne ID card to get these services. For information, call "Services Not Covered by Community Health Plan, HCA, or Other Program" lists services and treatments that are not covered on your Medical Care Services program. "Payments for Services Not Covered" explains when services are not covered and how third parties may pay for services. For more information about which services are covered by the Plan: Contact your provider or other clinic staff. Phone the Community Health Plan customer service team at , Monday through Friday from 8:00 am to 5:00 pm or customercare@chpw.org. If you are hearing or speech impaired, call TTY Relay: Dial Your Medical Care Services Medical Benefits Page 4 of 16

5 Medical Care Services Benefit Table Note: If you do not find a service listed in this table, please check the lists that follow it: "Services Covered by HCA or Other Programs" "Services at Your Local Health Department" "Services Not Covered by Community Health Plan, HCA, or Other Program" Benefit Ambulance transportation for emergency medical conditions Anesthesia Antiretroviral agents Blood and blood products Cardiac rehabilitation Chemotherapy, oral and injectable or infused Circumcision only to treat underlying medical condition Diagnostic procedures and tests, including laboratory Durable medical equipment Details For non emergency conditions, appropriate transportation, including ambulance if needed, is covered if any of the following is true: You need to move to another location to get a service. You need to be carried on a stretcher. You need medical attention en route. HCA covers protease inhibitors. (See "Services Covered by HCA or Other Programs.") Requires prior authorization. Some agents require prior authorization. Check before getting the treatment. Covered by Community Health Plan, depending on the specific procedure or test. Not a covered benefit. However, in very limited cases your provider may work with Community Health Plan to get a prior authorization. Your Medical Care Services Medical Benefits Page 5 of 16

6 Benefit Emergency services, including post emergency follow up in a clinic or hospital. Eye exams Growth hormone therapy injections Health education for asthma, diabetes, and heart disease Home health services through state licensed agencies Home infusion therapy Hospital care: some outpatient surgery, including emergency room and outpatient services HPV test Immunizations, including but not limited to: Flu (For more information, see Adult Immunizations.) Menactra (meningococcal vaccine) Details Emergency service is covered when: You need immediate medical attention that won't wait for you to see your doctor. Somebody from your clinic or the Nurse Advice Line tells you to seek emergency care. An eye exam is covered once in a 24 month period. Eye care services for medical conditions are not limited. Frames are paid for by HCA. Requires prior authorization: Prescription and prior authorization if you self administer. Plan prior authorization if provider administers. Up to 6 visits per calendar year. Requires prior authorization. Requires prior authorization. Requires prior authorization. Outpatient surgery requires prior authorization Your Medical Care Services Medical Benefits Page 6 of 16

7 Benefit Injections including but not limited to: Botox (not for cosmetic) Enbrel Euflexxa Orencia Orthovisc Remicade infusion Synagis or RespiGam Synvisc or Hyalgan Tysabri (natalizumab) Xolair IV therapy, home or outpatient Laboratory diagnostic tests Lymphedema treatment Mammogram Mental health services, including: Brief mental health services from a care coordinator at the primary care clinic Six months of mental health services from a Community Mental Health Agency (by referral from a care coordinator) Unlimited management of medications provided by PCP or in conjunction with mental health treatment Neuropsychological testing Details If self administered, requires prescription and a prior authorization from Express Scripts, Inc. (ESI), the Community Health Plan pharmacy benefit manager. If the patient cannot self administer, requires Community Health Plan prior authorization. Requires prior authorization. Covered by Community Health Plan, depending on the specific test. Requires prior authorization for more than 12 visits per year. Covered by HCA or by Community Health Plan. When done in a free standing imaging center. Requires a referral from your primary care provider to the care coordinator at the primary care clinic. Requires prior authorization for more than 12 visits per year. Your Medical Care Services Medical Benefits Page 7 of 16

8 Benefit Office visits with providers such as physicians, physician assistants, registered nurses (RNs), advanced registered nurse practitioners (ARNPs), podiatrists, audiologists, and certified dietitians Orthoptic (eye training) care for eye conditions Osteopathic manipulation Pain treatment, including office visits, outpatient rehabilitation, treatment (nerve block, epidural, steroid injection) Pharmacy and prescriptions (outpatient) Physical, occupational, and speech therapy Podiatry, including diabetic foot care Preventive care, such as immunizations, screening colonoscopies, mammograms, bone density testing Radiation treatment Radiology (including PET scans, some MRI and MRA, CT head, and CT angiography), nuclear medicine, ultrasound, laboratory, other diagnostic services, including x rays and echos Rehabilitation, inpatient and outpatient. May include physical therapy, occupational therapy, speech therapy. Sexually transmitted disease treatment and follow up care Details Referrals to network providers. The Plan requires use of in network providers whenever possible. If a request is received from the member's PCP, Plan authorization is required after the first 12 visits. Referrals to out of network providers. In circumstances that require a referral to an out ofnetwork specialist, authorization from the Plan is required from the first visit. Requires prior authorization for more than 10 visits per year. Requires prior authorization for more than 12 visits per year. Only drugs on the Community Health Plan Formulary are covered. Requires prior authorization for more than 12 visits per year. Some agents require prior authorization. Check before getting the treatment. All imaging below requires a prior authorization: CT angiography PET scan MRI/MRA Inpatient requires a referral from your PCP. Outpatient requires prior authorization for more than 12 visits per year. Covered by HCA or Community Health Plan, or by both. Your Medical Care Services Medical Benefits Page 8 of 16

9 Benefit Skilled nursing facility Sleep study for obstructive sleep apnea and narcolepsy diagnosis only Smoking cessation: Prescribed drugs and some nicotine replacement Specialty care, when referred by your PCP Surgeries including, but not limited to: Adenoidectomy Ambulatory or same day outpatient surgery Arthroscopy (knee) Bladder neck suspension Blepharoplasty Breast reduction Bunionectomy Hip, knee, or shoulder replacement Hysterectomy Lasik eye surgery to correct medical condition such as glaucoma, retinal detachment, cataracts Mastectomy Rhinoplasty Sclerotherapy, leg vein Septoplasty Spontaneous miscarriage Strabismus Tonsillectomy UPPP (uvulopalatopharyngoplasty) Urgent care, including post emergency follow up. Wound care, home health agency Wound care, outpatient Details Requires referral from your PCP. All inpatient surgeries and some outpatient surgeries require prior authorization. Check before getting the treatment. Mastectomy does not require prior authorization for treatment related to breast cancer. Visits to urgent care centers require a referral from your PCP. Requires prior authorization. Requires prior authorization for more than 12 visits per year. Your Medical Care Services Medical Benefits Page 9 of 16

10 Your Medical Care Services Medical Benefits Page 10 of 16

11 Services Covered by Health Care Authority or Other Programs The services listed in this section are paid for by HCA or other programs. You must use providers who will take your ProviderOne ID card. Your provider will know how to bill for payment. These services are paid by HCA or another program, but they will be coordinated by your PCP and Community Health Plan of Washington ("Community Health Plan" or "the Plan"). Chemical dependency detoxification, inpatient treatment, outpatient counseling Convalescent or custodial care Limited dental care (not routine care) Eyeglass frames, lenses, and fitting services Hearing aid Interpreter services for medical visits Maternity care & delivery, services, or maternity support/infant case management. (Medical Care Services members who become pregnant receive their care through HCA.) Mental health services, including: 24 hour crisis intervention Emergency mental health services Inpatient psychiatric care Methadone treatment for addiction Nursing facilities through Aging and Disability Services Protease inhibitors. (Some antiretrovirals are covered by Medical Care Services.) Sterilizations when younger than 21 years old Substance abuse treatment covered by Division of Behavioral Health and Recovery Vocational rehabilitation Voluntary pregnancy termination Services at Your Local Health Department As a member of Community Health Plan of Washington, you can get the services listed in this section from Community Health Plan providers or you can go directly to a local health department or family planning clinic. You must use providers who will take your ProviderOne ID card and who will bill HCA for payment. Services you can get at your local health department: Family planning services and birth control HIV and AIDS testing Immunizations (For more information, see "Adult Immunizations.") Sexually transmitted disease treatment and follow up care TB screening and follow up care Your Medical Care Services Medical Benefits Page 11 of 16

12 Services Not Covered by Community Health Plan, HCA, or Other Programs Acupuncture Adult day health Biofeedback therapy Childbirth classes Chiropractic care for adults Cosmetic surgery and services Court ordered services Doula services Experimental and investigational treatment or services. Community Health Plan believes these health care services are not generally as effective, or have not been scientifically proven to be effective, for a particular disease or condition. They are not covered until good research shows they are more helpful than harmful. Community Health Plan looks at requests for experimental or investigational procedures on a case by case basis. Gender dysphoria or sex reassignment surgery Homeopathy Hospice care Hypnotherapy Immunizations for international travel Lasik eye surgery to correct vision Massage therapy Medical exams for Social Security Disability benefits Medical services while in jail, beginning when a law enforcement officer takes the member into custody Naturopathy Out of country (outside of the United States) care and care outside of Washington state and border cities Personal comfort items while in the hospital, such as telephone charges and TV Pharmacy: mail order prescriptions, take home drugs prescribed by hospital Physical exams needed for employment, immigration, insurance, or licensing Plastic surgery for cosmetic reasons Reversal of voluntary surgical sterilizations Services not allowed by federal or state law Sexual dysfunction treatment, including impotence treatment; penile prosthesis; diagnosis and treatment of infertility, impotence, and sexual dysfunction Sports physicals TMJ treatment, including medical and surgical treatment and appliances Zostavax (shingles) immunization Your Medical Care Services Medical Benefits Page 12 of 16

13 For Information About Prescription Services See "Prescription Drug Services" online or request a printed copy. Visit the Community Health Plan website ( Click the Plans tab, and then select Medical Care Services. Contact the Community Health Plan customer service team at , Monday through Friday from 8:00 am to 5:00 pm, or customercare@chpw.org. If you are hearing or speech impaired, please call TTY Relay: Dial Payments for Services Not Covered You do not have to pay for covered services. However, you might have to pay if you: Get treatment or services not covered by Community Health Plan of Washington, Health Care Authority, or other programs. Decide to get care outside of the Community Health Plan of Washington network of providers without prior, written Community Health Plan permission. Get non emergency services outside Washington State. Third Party Liability Community Health Plan will decide whether or how to pay for accident related medical bills. If it appears that another insurance company should pay, we will get payment from that company for any payments we made. If you get a settlement, you may need to refund Community Health Plan for any bills we have paid related to the accident. If you were hurt while at work, your medical bills will be paid by workers' compensation. You must tell your primary care provider and Community Health Plan about your injury right away. Your workers' compensation will cover all your injury related bills. If the injury is not work related, Community Health Plan will pay all related covered expenses after we get a denial letter from your workers' compensation plan. Subrogation is when there is another company that pays for health care services you get because of an injury or illness. For example, your auto insurance may pay if you are injured in a car accident, or workers' compensation may pay if you are hurt on the job. Subrogation is different than coordination of benefits because the third party will only pay for the services that are related to that injury or illness. Coordination of benefits happens when you are covered by more than one health insurance plan at the same time. If you have two insurance plans or if another company should pay for your medical bills, call the Community Health Plan customer service team at , Monday through Friday from 8:00 am to 5:00 pm, or customercare@chpw.org. If you are hearing or speech impaired, call TTY Relay: Dial Your Medical Care Services Medical Benefits Page 13 of 16

14 You should also call the Medical Assistance customer service center at to tell them you have other insurance. The other insurance plan must pay first for all the medical care it covers. Community Health Plan will then pay for the remaining covered charges. Your Medical Care Services Medical Benefits Page 14 of 16

15 HOW TO GET MORE INFORMATION You can learn more about Medical Care Services, about Community Health Plan of Washington, and about how to use your plan. We send you information: We send you printed information when you become a member, annually during the time you are a member, and at other times to make sure you get the most out of your health care. You can request printed information: This packet includes a postcard to order printed information about specific topics or a booklet that includes all of your member information. You can get this information anytime you want it. You can request information in another language or another format: You can also ask us to translate the information into the language you prefer to read. If your vision is impaired or you have difficulty reading, we can read the information to you. To get more information about your plan: The How to Find Important Information sheet enclosed in this package lists information available to you and tells you how to find the information or get a printed copy sent to you. To find a provider, pharmacy, clinic, or hospital, visit the Community Health Plan of Washington website at Click the Providers tab and select the type of search you want. To get a printed report or have someone search for you, contact our customer service team. (Contact information below.) You can also search our formulary (approved drug list) to find out if your prescription is covered. Visit our website, Click the Providers tab and select Formulary Search. To get a printed report or have someone search for you, please contact our customer service team. (Contact information below.) Contact the Community Health Plan customer service team at , Monday through Friday from 8:00 am to 5:00 pm, or customercare@chpw.org. If you are hearing or speech impaired, please call TTY Relay: Dial Your Medical Care Services Medical Benefits Page 15 of 16

16 2011 Community Health Plan of Washington MCS_06_Benefits_Dec2011