VA-MHB Member Handbook. Medicaid

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1 VA-MHB Member Handbook Medicaid

2 IfYouDoNotUnderstandEnglish IfyoudonotunderstandEnglish,pleasecall andwewillprovideinformationaboutyour benefitsinyourlanguage.wecanalsohelpyoutalktoyourdoctor. Sinoentiendeelinglés,llameal ylebrindaremosinformaciónenespañolacercadesus beneficios.tambiénpodemosayudarlosinecesitahablarconsumédico. NeáuquyùvòkhoânghieåutieángAnh,xingoïisoá ,chuùngtoâiseõcungcaápthoângtinveà caùcquyeànlôïicuûaquyùvòbaèngtieángvieät.chuùngtoâicuõngcoùtheågiuùpquyùvònoùichuyeänvôùi /گر شما به 3 با 0 /نگل"سي صحبت نمي کن"د لطفا با شما" ٤٤" ٦"" "".: 6 خت"ا:تا( قر 6 : خو 6 ه"م.6.. ما هم"نطو: مي تو 6 ن"م به شما کمک کن"م که با.کترتا( صحبت کن"د. baùcsó. تما: بگ 8 ر,د 6 ما )طلاعا 2 مربو/ به مز),ا+ شما ) به فاسي <=) كنت لا تفهم )للغة )لا نجل 0 ز,ة,رجى )لاتصا ب <سوA نز<=> بمعلوما: عن مستحقاتك باللغة /لعرب+ة. كذلك %مكننا 56 ضا مساعدتك في,لتحد' مع طببك

3 Health DearMember: WelcometoINTotalHealth.Wearepleasedthatyouchoseustoarrangeforhealthcareservicesforyourfamily. ThismemberhandbooktellsyouhowINTotalHealthworksandhowtohelpkeepyourfamilyhealthy.Ittells youhowtogethealthcarewhenitisneeded,too. Ifyouhaveachild,heorshecanjoinaBoys&GirlsClub.ThisisaspecialINTotalHealthbenefitformembers ages5to18.theclubsprovidemanyfunandeducationalactivitiesforchildren.theyareagreatplacetogo afterschool.thereissomethingforeveryone YouwillgetyourINTotalHealthIDcardandmoreinformationfromusinafewdays.YourIDcardwilltellyou whenyourintotalhealthmembershipstarts.thenameofyourprimarycareproviderisonthecard,too.please checktheprovider snameshownonyouridcard.ifthisisnotright,pleasecallus. Wewanttohearfromyou.Youcancall andtalktoaMemberServicesrepresentativeabout yourbenefits.youcanalsotalktoanurseonour247hournursehelpline. Thankyouforchoosingusasyourfamily shealthplan. Sincerely, ReneeMaccannon ChiefExecutiveOfficer INTotalHealth

4 INTotalHealthTips HealthTipsThatMakeHealthHappen YouNeedToGoToYourPCPNow WhenIsItTimeforaWellnessVisit? AllINTotalHealthmembersneedtohaveregularwellnessvisits.ThiswayyourPrimaryCareProvider(PCP)can seeifyouhaveaproblembeforeitisabadproblem.whenyoubecomeanintotalhealthmember,callyour PCPandmakethefirstappointmentforyouandyourchildbeforetheendof90days. WellnessVisitsforChildren Childrenneedmorewellnessvisitsthanadults.Yourchildshouldgetwellnessvisitsattheageslistedbelow: Newborn 2monthsold 6monthsold 12monthsold 18monthsold Before6weeks 4monthsold 9monthsold 15monthsold 24monthsold Afterage2,yourchildshouldkeepgoingtothePCPeveryyear.INTotalHealthencouragesandreimbursesfor checkupseveryyearforchildrenages3through18. WhatifIBecomePregnant? Ifyouthinkyouarepregnant,callyourPCPorOB/GYNrightaway.Thiscanhelpyouhaveahealthybaby. IfyouhaveanyquestionsorneedhelpmakinganappointmentwithyourPCPorOB/GYN,pleasecallINTotal HealthMemberServicesat Alert Keeptherightcare.Donotloseyourhealthcarebenefits.Renewyoureligibilityfor Medicaidbenefitsontime. SeetheRenewYourMedicaidBenefitsonTimesectionformoredetails.

5 INTOTALHEALTH MEDICAIDMEMBERHANDBOOK 2600ParkTowerDrive,Suite600 Vienna,Virginia W855W323W5588 (TTY1W800W855W2880) WelcometoINTotalHealthYouwillgetmostofyourhealthcareservicesthroughINTotalHealth.Thismember handbookwilltellyouhowtouseyourintotalhealthbenefitstogetthehealthcareyouneed. TableofContents WELCOMETOINTOTALHEALTH...1 InformationAboutYourNewHealthPlan...1 HowtoGetHelp...1 INTotalHealthMemberServicesDepartment...1 INTotalHealth247hourNurseHelpLine...1 OtherImportantPhoneNumbers...2 YourINTotalHealthMemberHandbook...2 YourINTotalHealthIDCard...2 YOURPRIMARYCAREPROVIDER...3 ChoosingaPrimaryCareProvider...3 SecondOpinion...3 IfYouHadaDifferentPrimaryCareProviderBeforeYouJoinedINTotalHealth...3 IfYourPrimaryCareProvider'sOfficeMoves,ClosesorLeavestheINTotalHealthNetwork...3 HowtoChangeYourPrimaryCareProvider...4 IfYourProviderAsksforYoutoBeChangedtoanotherPrimaryCareProvider...4 IfYouWanttoGotoaProviderWhoIsNotYourPrimaryCareProvider...4 PickinganOB/GYN...4 Specialists...5 GOINGTOYOURPRIMARYCAREPROVIDER...5 YourFirstPrimaryCareProviderAppointment...5 HowtoMakeanAppointment...5 WaitTimesforAppointments...5 WhattoBringWhenYouGoForYourAppointment...5 HowtoCancelanAppointment...6 HowtoGettoaProviderAppointmentortotheHospital...6 IndividualswithDisabilitiesEducationAct...6 TheHeadStartProgram...6 DisabilityAccesstoINTotalHealthNetworkProvidersandHospitals...7 WHATDOESMEDICALLYNECESSARYMEAN?...7 INTOTALHEALTHCOVEREDSERVICES...7 VALUEWADDEDINTOTALHEALTHBENEFITS...11 SERVICESCOVEREDBYFEEWFORWSERVICEMEDICAID...11 SERVICESEXCLUDEDFROMTHEMANAGEDCAREPROGRAM...12 SERVICESTHATDONOTNEEDAREFERRAL...12 BENEFITSANDSERVICESNOTOFFEREDBYINTOTALHEALTHORMEDICAID...13

6 DIFFERENTTYPESOFHEALTHCARE...13 Routine,UrgentandEmergencyCare:WhatIstheDifference?...13 RoutineCare...13 UrgentCare...13 EmergencyCare...14 HowtoGetHealthCareWhenYourPrimaryCareProvider sofficeisclosed...14 HowtoGetHealthCareWhenYouAreOutOfTown...15 WELLNESSCAREFORCHILDRENANDADULTS...15 WellnessCareforChildren...15 WhyWellnessCareIsImportantForChildren...15 WhenYourChildShouldGetWellnessVisits...16 BloodLeadScreening...16 EyeExams...16 HearingExams...16 DentalCare...16 Immunizations...16 WellnessCareforAdults...20 WhenYouMissOneofYourWellnessVisits...20 SPECIALKINDSOFHEALTHCARE...20 EyeCare...20 BehavioralHealth(MentalHealth)Services...20 FamilyPlanningServices...21 SpecialCareforPregnantMembers...21 WhenYouBecomePregnant...21 WhenYouHaveaNewBaby...22 HowtoGetCareWhenYouCannotLeaveYourHome...22 Medicines...22 SPECIALINTOTALHEALTHSERVICESFORHEALTHYLIVING...23 HealthInformation...23 HealthEducationClasses...23 CommunityEvents...24 Boys&GirlsClubs...24 DiseaseManagement...24 DomesticViolence...25 Minors...25 MAKINGALIVINGWILL(ADVANCEDIRECTIVE)...26 GRIEVANCES(COMPLAINTS)ANDAPPEALS...26 ImportantInformationRegardingYourInsurance...26 Grievances(Complaints)...26 FirstLevelGrievance...27 SecondLevelGrievance...27 Appeals...28 FirstLevelAppeal...28 SecondLevelAppeal...28 ExpeditedAppeals...29 APPEALS FEEWFORWSERVICEMEDICAID...30 StateFairHearing...30

7 ContinuationofBenefits...30 OTHERINFORMATION...30 IfYouMoveorIfYourFamilySizeChanges...30 RenewYourMedicaidBenefitsonTime...31 IfYouAreNoLongerEligibleforMedicaid...31 HowtoDisenrollfromINTotalHealth...31 ReasonsWhyYouCanBeDisenrolledfromINTotalHealth(TerminationofCoverage)...32 IfYouGetABill...32 IfYouHaveOtherHealthInsurance(CoordinationofBenefits)...32 ChangestoYourINTotalHealthCoverage...32 HowtoTellINTotalHealthAboutChangesYouThinkWeShouldMake...33 HowINTotalHealthPaysProviders...33 FinancialIncentives...33 NewTechnology...34 YOURRIGHTSANDRESPONSIBILITIESASANINTOTALHEALTHMEMBER...34 HOWTOREPORTSOMEONEWHOISMISUSINGTHEMEDICAIDPROGRAM...35 NOTICEOFPRIVACYPRACTICES...36

8 WELCOME'TO'INTOTALHEALTH InformationAboutYourNewHealthPlan WelcometoINTotalHealth.INTotalHealthisamanagedcareorganizationcommittedtobringingyouandyour familyqualityhealthcarewhenyouneeditmost.weprovidemedicaidservicestointotalhealthmembers. Asamember,youandyourPrimaryCareProvider(PCP)willworktogethertohelpkeepyouhealthyandcare foryourhealthproblems.intotalhealthhelpsyougetqualityhealthcare.thismemberhandbookwillhelpyou understandyourintotalhealthhealthplan. YourmembershipwithINTotalHealthbeginsonthefirstdayofyourtermofcoverage.Yourtermofcoverageis consistentwithyourmedicaideligibility. HowtoGetHelp INTotalHealthMemberServicesDepartment IfyouhaveanyquestionsaboutyourINTotalHealthplan,youcancallourMemberServicesdepartmentat YoucancallusMondaythroughFridayfrom8:00a.m.to6:00p.m.,exceptforholidays.Ifyoucall after6:00p.m.,youcanleaveavoic message.amemberservicesrepresentativewillcallyoubackthe nextbusinessday. MemberServicescanhelpyouwith: HowINTotalHealthworks Choosingyourprimarycareprovider Whattodoinanemergencyorurgentmedicalsituation Makingappointments Healthcarebenefits Transportation Complaintsandgrievances PleasecallMemberServicesifyou: WanttorequestacopyoftheINTotalHealthNoticeofPrivacyPractices.Thisnoticedescribeshowmedical informationaboutyoumaybeusedanddisclosedandhowyoucangetaccesstothisinformation. Aremoving.Wewillneedtoknowyournewaddressandphonenumber. FormemberswhodonotspeakEnglish,weareabletohelpinmanydifferentlanguagesanddialects.This serviceisalsoavailableforvisitswithyourpcpatnocosttoyou.pleaseletusknowifyouneedaninterpreterat least24hoursbeforeyourappointment.callmemberservicesformoreinformation. Formemberswhoaredeaforhardofhearing,callthetoll7freeAT&TRelayServiceat INTotal HealthwillsetupandpayforyoutohaveapersonwhoknowssignlanguagehelpyouduringyourPCPvisits. Pleaseletusknowifyouneedaninterpreteratleast24hoursbeforeyourappointment. INTotalHealth24WhourNurseHelpLine Youcancallour247hourNurseHelpLineat ifyouneedhelpwith: Howsoonyouneedcarewhenyouaresick Whatkindofhealthcareyouneed 1 MHB7MCD707713

9 WhattodototakecareofyourselfuntilyouseeyourPCP Howyoucangetthecareyouneed WewantyoutobehappywithalltheservicesyougetfromtheINTotalHealthnetworkofprovidersand hospitals.pleasecallmemberservicesifyouhaveanyproblems.wewanttohelpyoucorrectanyproblemsyou mayhavewithyourcare. OtherImportantPhoneNumbers TheDepartmentofMedicalAssistanceServices(DMAS)ManagedCareHelplineis (tollfree). Ifyouneedroutineeyecare,pleasecallBlockVisiontollfreeat Ifyouneeddentalcareforyourchildren,calltheSmilesforChildrenDentalProgram.SmilesforChildren alsohassomeadultdentalservices.youcanreachsmilesforchildrenat Ifyouneedtransportationformedicallynecessarymedicalappointmentsandtreatments,pleasecall LogistiCaretollfreeat Ifyouneedtransportationrelatedtohome7andcommunity7basedwaiverservices,call Ifyouneedbehavioralhealthcare,pleasecallMemberServicesat YourINTotalHealthMemberHandbook ThisbookwillhelpyouunderstandyourINTotalHealthplan.Ifyouhavequestions,orneedhelpunderstanding orreadingyourmemberhandbook,callmemberservices.intotalhealthalsohasthememberhandbookina largeprintversion,anaudiotapedversionandabrailleversion.theothersideofthisbookisinspanish.intotal Healthgivesmembersamemberhandbookeachyeartokeeptheminformedofchangestobenefits,changesto policies,howtogetcare,oranyotherchangestoenrolleesrightsandresponsibilities. YourINTotalHealthIDCard IfyoudonothaveyourINTotalHealthIDcardyet,youwillgetitsoon.Pleasecarryitwithyouatalltimes.Show ittoanyproviderorhospitalyouvisit.thecardtellsprovidersandhospitalsthatyouareamemberofintotal HealthandwhoyourPCPis.ItalsotellsthemthatINTotalHealthwillpayforthemedicallyneededservices listedinthesectionintotalhealthcoveredservices. YourINTotalHealthIDcardhasthenameandphonenumberofyourPCPonit.YourMedicaididentification numberandthedateyoubecameanintotalhealthmemberarealsoshown. YourIDcardlistsourMemberServicesdepartment/NurseHelpLine,behavioralhealthservicesandpharmacy (providedbycaremark)phonenumber.italsohasthephonenumberforyoutocalltogeteyecare.ifyour INTotalHealthIDcardislostorstolen,callusrightaway.Wewillsendyouanewone. 2 MHB7MCD707713

10 AlongwithyourINTotalHealthIDcard,youmustalsocarryandpresentyourblueandwhiteplasticMedicaidID cardeachtimeyougetmedicalservices.neverthrowthiscardaway,becauseitisyourpermanentmedicaidid card.evenifyoulosemedicaideligibility,keepthecardincaseyoubecomeeligibleagaininthefuture. YOUR%PRIMARY%CARE%PROVIDER ChoosingaPrimaryCareProvider AllINTotalHealthmembersmusthaveaPrimaryCareProvider(PCP).YourPCPmustbeintheINTotalHealth network.yourpcpwillgiveyouamedicalhome.thatmeansthatheorshewillgettoknowyouandyourhealth historyandbeabletohelpyougetqualitycare.yourpcpwillgiveyouallofthebasichealthservicesyouneed. Heorshewillalsosendyoutootherprovidersorhospitalswhenyouneedspecialcare. WhenyouenrolledinINTotalHealth,youshouldhavechosenaPCP.Ifyoudidnot,wechoseoneforyou.We choseonewhoshouldbeclosetoyou.thispcp snameandphonenumberareonyourintotalhealthidcard. IfweassignedaPCPtoyou,youcanstillchooseadifferentone.JustlookintheProviderDirectorythatcame withyourenrollmentpackageandchoosethepcpyouprefer. WecanalsohelpyouchooseadifferentPCP.CallMemberServicesforhelpat Ifyoualready haveapcpyoulike,lookintheproviderdirectorytoseeifthatpcpisinournetwork.ifso,youcantellusyou wanttokeepthatpcp.familymembersdonothavetohavethesamepcp. PCPscanbeanyofthefollowingaslongastheyareintheINTotalHealthnetwork: Generalpractitioners Familypractitioners Internists Pediatricians Specialistswhoprovideprimarycare(surgeons,obstetrician/gynecologists) FederallyQualifiedHealthCenters,RuralHealthClinics,etc. SecondOpinion INTotalHealthmembershavetherighttoaskforasecondopinionabouttheuseofanyhealthcareservices. Youcangetasecondopinionfromanetworkprovideroranon7networkproviderifanetworkproviderisnot available.askyourpcptosubmitarequestforyoutohaveasecondopinion.thisisatnocosttoyou. Onceapproved,yourPCPwillletyouknowthedateandtimeoftheappointment.YourPCPwillalsosendcopies ofallrelatedrecordstotheproviderwhowillprovidethesecondopinion.yourpcpwillletyouandintotal Healthknowtheoutcomeofthesecondopinion. IfYouHadaDifferentPrimaryCareProviderBeforeYouJoinedINTotalHealth YoumayhavebeenseeingaproviderwhoisnotinournetworkforanillnessorinjurybeforeyoujoinedINTotal Health.Insomecases,youmaybeabletokeepseeingthisproviderforcarewhileyoupickanewPCP.Please callmemberservicestofindoutmoreaboutthis.intotalhealthwillmakeaplanwithyouandyourprovidersso thatweallknowwhenyouneedtostartseeingyournewintotalhealthnetworkpcp. IfYourPrimaryCareProvider'sOfficeMoves,ClosesorLeavestheINTotalHealthNetwork IfyourPCP sofficemoves,closesorleavestheintotalhealthnetwork,wewillcallorsendyoualettertotell you.insomecases,youmaybeabletokeepseeingthispcpforcarewhileyouchooseanewpcp.intotal Healthwillcoordinatewiththeout7of7networkprovider,withrespecttopaymentandensurethatthecostto 3 MHB7MCD707713

11 youisnogreaterthanitwouldbeiftheserviceswereprovidedbyanin7networkprovider. Forexample,youmaybeabletokeepseeingyourPCPifyouareinyourthirdtrimesterofpregnancyorifyou haveaterminalillness.pleasecallmemberservicesat formoreinformation. INTotalHealthwillmakeaplanwithyouandyourPCPsothatweallknowwhenyouneedtostartseeingyour newintotalhealthnetworkpcp.wecanalsohelpyouchooseanewpcp.callmemberservicesforhelpat OnceyouchooseaPCP,wewillsendyouanewINTotalHealthIDcardinth within10workingdays.Your newidcardwillhavethenameofyournewpcp. HowtoChangeYourPrimaryCareProvider IfyouneedtochangeyourPCP,youcanchooseanotherPCPfromournetwork.JustlookintheINTotalHealth ProviderDirectorythatcamewithyourenrollmentpackage.YoucanalsofindtheProviderDirectoryonlineat WecanalsohelpyouchooseaPCP.CallMemberServices.WewillhelpyouchooseanewPCP.Youcanchange yourpcpatanytime.onceyourpcphasbeenchanged,youwillgetanewintotalhealthidcardinth within10workingdays.yournewidcardwillhavethenameofyournewpcp. IfYourProviderAsksforYoutoBeChangedtoanotherPrimaryCareProvider YourPCPmayaskforyoutobechangedtoanotherPCP.YourPCPmaydothisif: Youfailtokeepyourappointments Youdonotfollowhisorhermedicaladviceoverandoveragain YourPCPagreesthatachangeisbestforyou YourPCPdoesnothavetherightexperiencetotreatyou TheassignmenttoyourPCPwasmadeinerror(forexample,anadultassignedtoachild sprovider) IfYouWanttoGotoaProviderWhoIsNotYourPrimaryCareProvider IfyouwanttogotoaproviderwhoisnotyourPCP,pleasetalktoyourPCPfirst.Pleasereadthesectionon Specialists. Youdon thavetogotothepcponyouridcardifyouwanttogotoanotherproviderintheintotalhealth network.ifyou dliketofindoutifyourpreferredpcpisinournetwork,callmemberservicesat PickinganOB/GYN Femalemembersage13andoldercanseeanINTotalHealthnetworkobstetricianand/orgynecologistfor OB/GYNhealthneeds.Theseservicesincludewellwomanvisits,prenatalcare,careforanyfemalemedical condition,andfamilyplanning.youdonotneedareferralfromyourpcptoseeyourob/gyn. IfyoudonotwanttogotoanOB/GYN,yourPCPmaybeabletotreatyouforyourOB/GYNhealthneeds.Ask yourpcpifheorshecangiveyouob/gyncare.ifnot,youwillneedtoseeanob/gyn.youwillfindalistof networkob/gynsintheintotalhealthproviderdirectorythatcamewithyourmedicaidenrollmentpackage. YoucanalsofindtheProviderDirectoryonlineatwww.intotalhealth.org. Whileyouarepregnant,yourOB/GYNcanbeyourPCP.Thenursesonour247hourNurseHelpLinecanhelpyou decideifyoushouldseeyourpcporanob/gyn.ifyouneedhelppickinganob/gyn,callmemberservices.for moreinformation,pleaseseethewomen shealthcareservicesintheintotalhealthcoveredservicessection. 4 MHB7MCD707713

12 Specialists YourPCPcantakecareofmostofyourhealthcareneeds,butyoumayalsoneedcarefromotherkindsof providers.intotalhealthoffersservicesfrommanydifferentkindsofprovidersthatprovideothermedically neededcare.theseprovidersarecalledspecialistsbecausetheyhavetraininginaspecialareaofmedicine. Someexamplesofspecialistsinclude: Allergists(allergyspecialists) Dermatologists(skinspecialists) Cardiologists(heartspecialists) Podiatrists(footspecialists) YourPCPwillreferyoutoaspecialistinournetworkifyourPCPcannotgiveyouthecareyouneed.Eventhough areferralisnotneededtoseeaspecialist,itisagoodideatogetareferralfromyourpcp.areferralformtells youandthespecialistwhatkindofhealthcareyouneed.besuretotakethereferralformwithyouwhenyougo tothespecialist. Inmostcasesareferralisnotneeded.Formoreinformation,readServicesThatDoNotNeedaReferral. GOING%TO%YOUR%PRIMARY"CARE"PROVIDER YourFirstPrimaryCareProviderAppointment YoucancallyourPrimaryCareProvider(PCP)tosetupyourfirstappointment.YoushouldseeyourPCPfora wellnessvisit(ageneralcheckup)within90daysofenrollinginintotalhealth.byfindingoutmoreaboutyour healthnow,yourpcpcantakebettercareofyouifyougetsick.wecanhelpyousetupyourfirstappointment. CallMemberServicestollfreeat ifyouwantourhelp. IfyouhavealreadybeenseeingtheproviderwhoisnowyourINTotalHealthnetworkPCP,callthePCPtoseeif itistimeforyoutogetacheckup.ifitis,makeanappointmenttoseethepcpassoonaspossible. HowtoMakeanAppointment ItiseasytomakeanappointmentwithyourPCP.JustcallthePCP soffice.thephonenumberisonyourintotal HealthIDcard.Ifyouneedhelp,callMemberServices.Wewillhelpyoumaketheappointment.Whenyoucall, letthepersonyoutalktoknowwhatyouneed(forexample,acheckuporafollow7upvisit).also,tellthepcp s officeifyouarenotfeelingwell.thiswillletthepcp sofficeknowhowsoonyouneedtobeseen.itmayalso shortenthewaitbeforeyouseeyourpcp. WaitTimesforAppointments Wewantyoutobeabletogetcareatanytime.YouwillbeabletoseethePCPasfollows: Routineprimarycarevisits Within30days MaternityCare: Routinespecialtycarevisits Within30days Firsttrimester Within14days Routinephysicalexamsforadults Within30days Secondtrimester Within7days Routinephysicalexamsforchildren Within30days Thirdtrimester Within3businessdays Emergencycare Immediately High7risk Within3businessdays Urgentcare Within24hours pregnancies WhattoBringWhenYouGoForYourAppointment WhenyougotothePCP sofficeforyourappointment,bringyourintotalhealthidcardandyourplastic MedicaidIDcard.Alsobringanymedicinesyouaretaking,alongwithanyquestionsthatyoumaywanttotalkto 5 MHB7MCD707713

13 yourpcpabout.iftheappointmentisforyourchild,bringhisorheridcards,shotrecordsandanymedicineshe orsheistaking. HowtoCancelanAppointment IfyoumakeanappointmentwithyourPCPandthencannotgo,callthePCP soffice.telltheofficetocancelthe appointment.youcanmakeanewappointmentwhenyoucall. Trytocallatleast24hoursbeforetheappointment.Thiswillletsomeoneelseseetheproviderduringthattime. Ifyouwantustocanceltheappointmentforyou,callMemberServices.IfyoudonotcalltocancelyourPCP appointments,yourpcpmayaskforyoutobechangedtoanotherpcp.ifyouhavescheduledtransportation, remembertocallandcancelthat,too. HowtoGettoaProviderAppointmentortotheHospital Youcangettransportationtoandfromyourmedicalanddentalappointments.Allyouhavetodoiscall LogistiCaretosetuptransportationtoyourmedicalanddentalappointments. Call tollfreeforservicescoveredbyMedicaid Call tollfreeforhome7andcommunity7basedwaiverservices Ifyouhavespecialtransportationneedssuchasastretchervanordoor7to7doorservices,callMemberServices at andaskforcasemanagement.acasemanagercanhelparrangethesetypesof transportation.transportationservicesareonlyprovidedtoandfrommedicalanddentalappointments. LogistiCarecandropoffandpickupfromtheselocations: Yourhome Adoctorordentaloffice Aclinicorhospital Otherplaceofmedicalservice Ifyouhaveanemergencyandneedtransportation,call911foranambulance. IndividualswithDisabilitiesEducationAct IndividualswithDisabilitiesEducationAct(IDEA)isafederallawthatgiveschildrenwithdisabilitiestherighttoa freeandappropriatepubliceducation.childrenages3 21areeligible.IDEAalsogivesthesechildrenandtheir parentsotherrights.youcangetmoreinformationaboutthisfromyourschoolsystem. Ourcasemanagerscanalsotellyoumoreaboutthisandthespecialservicesforyourchild.Childrenfrombirth uptoage3areeligibleforhealth7relatedideaservicesthroughindividualswithdisabilitieseducationactearly InterventionServices.Thisprogrampromotesthescreeningofinfantsandtoddlersfordelaysindevelopment uptoage3.yourchild sprimarycareprovidercanreferyourchildforanideaevaluation,ifappropriate. TheHeadStartProgram HeadStartisanationalprogramthatprovidesservicesforchildrenfrombirthtoage5,pregnantwomenand theirfamilies.callmemberservicestofindoutmoreaboutheadstartortofindaprograminyourarea. IfyourchildisenrolledinHeadStart,INTotalHealthwillworkwithHeadStartprogramsinyourcommunityto providetheseservicesthatwillhelpgetyourchildreadyforschool: Education Earlydevelopment 6 MHB7MCD707713

14 Medical,dentalandbehavioralhealth Nutrition Parentinvolvement DisabilityAccesstoINTotalHealthNetworkProvidersandHospitals INTotalHealthnetworkprovidersandhospitalsshouldhelpmemberswithdisabilitiesgetthecaretheyneed. Memberswhousewheelchairs,walkersorotheraidsmayneedhelpgettingintoanoffice.Ifyouneedaramp orotherhelp,makesureyourprovider sofficeknowsthisbeforeyougothere.bydoingthis,theywillbeready foryourvisit.ifyouwanthelptalkingtoyourprimarycareprovideraboutyourspecialneeds,callmember Servicesat WHAT%DOES%MEDICALLY%NECESSARY(MEAN?( Yourprimarycareproviderwillhelpyougettheservicesyouneedthataremedicallynecessaryasdefined below. Medicallynecessarybehavioralhealthservicesmeansthosebehavioralhealthserviceswhich: a) Arereasonableandnecessaryforthediagnosisortreatmentofamentalhealthdisorderortoimprove, maintainorpreventdeteriorationoffunctioningresultingfromsuchadisorder b) Areinaccordancewithprofessionallyacceptedclinicalguidelinesandstandardsofpracticeinbehavioral healthcare c) Arefurnishedinthemostappropriateandleast7restrictivesettinginwhichservicescanbesafely provided d) Arethemostappropriatelevelorsupplyofservicewhichcansafelybeprovided e) Couldnotbeomittedwithoutadverselyaffectingthemember smentaland/orphysicalhealthorthe qualityofcarerendered Medicallynecessaryhealthservicesmeanthosehealthservicesotherthanbehavioralhealthservices which: a) Arereasonableandnecessarytopreventillnessormedicalconditions,orprovideearlyscreening, interventions,and/ortreatmentsforconditionsthatcausesufferingorpain,causephysicaldeformityor limitationsinfunction,threatentocauseorworsenahandicap,causeillnessorinfirmityofamember, orendangerlife b) Areprovidedatappropriatefacilitiesandattheappropriatelevelsofcareforthetreatmentof member shealthconditions c) Areconsistentwithhealthcarepracticeguidelinesandstandardsthatareendorsedbyprofessionally recognizedhealthcareorganizationsorgovernmentalagencies d) Areconsistentwiththediagnosisoftheconditions e) Nomoreintrusiveorrestrictivethannecessarytoprovideaproperbalanceofsafety,effectivenessand efficiency INTOTAL'HEALTHCOVERED'SERVICES' ThefollowinglistshowsthehealthcareservicesandbenefitsthatmemberscangetthroughINTotalHealth. YourPrimaryCareProvider(PCP)willgiveyouthecareyouneedorreferyoutoaspecialistthatcangiveyouthe careyouneed.insomecases,yourpcpmayneedtogetpreauthorizationfromintotalhealthbeforeyoucan receivetheseservices.yourpcpcancall todothis. NocopaymentsarerequiredforanyMedicaidcoveredservice. ForafewspecialINTotalHealthbenefits,membershavetobeacertainageorhaveacertainkindofhealth problem.ifyouhaveaquestionorarenotsurewhetherwecoveracertainbenefit,youcancallmember 7 MHB7MCD707713

15 8 MHB7MCD Servicesforhelp.Ifyourbenefitschangeforanyreason,wewilltellyouaboutthechangebeforeithappens. BelowisalistoftheservicesthatarecoveredbyINTotalHealth. CertifiedNurseMidwifeServices ClinicServices INTotalHealthcoversclinicservicesthatarepreventive,diagnostic,therapeutic,rehabilitative orpalliative.renaldialysisclinicvisitsarealsocovered. ColorectalCancerScreenings CourtWorderedServices INTotalHealthcoversallMedicaidcoveredcourt7orderedservices. DentalServices INTotalHealthcoversdentalservicesthataremedicallynecessaryasaresultofanaccidental injuryforwhichtreatmentiscoveredasahealthservice.medicallynecessaryproceduresforadultsandchildren include,butarenotlimitedto,cleftpalaterepair,preparingthemouthforradiationtherapy,surgicalserviceson thehardorsofttissuewhenitisnotfortreatingtheteethorsupportingstructures,maxillaryormandibular frenectomywhennotrelatedtoadentalprocedure,orthognathicsurgerytoattainfunctionalcapacity(tmj), andanesthesiaandhospitalizationformedicallynecessarydentalservicesforchildrenundertheageof5, personswhoareseverelydisabled,andpersonswhohaveamedicalconditionthatrequiresadmissiontoa hospitaloroutpatientsurgeryfacility. Dentalservicesmustberequestedwithin60daysoftheinjury.INTotalHealthalsocoverstransportationand medicinesrelatedtodentalcare.yourchildrencangetdentalcarethroughthesmilesforchildrenprogram. SmilesforChildrendoesnotpayfordentalservicesformembers21yearsofageandolderexceptforcertain medicallynecessaryoralsurgeryservices.call seethesectionservicescoveredbyfee7for7 ServiceMedicaidformoreinformation. DigitalRectalExaminations Toscreenforprostatecancer. EarlyandPeriodicScreening,Diagnosis,andTreatment(EPSDT) INTotalHealthcoversEPSDTvisitsandany resultingmedicallynecessaryhealthcareservicesformembersunderage21.seethewellnesscareforchildren sectionformoreinformation. EmergencyandPostWstabilizationServices Emergencyandmedicallynecessarypost7stabilizationservicesdo notneedareferralorpriorauthorization.youdonothavetogetemergencyandpost7stabilizationservicesfrom anintotalhealthnetworkprovider.pleaseseethesectiononemergencycareformoreinformation. FamilyPlanningServicesandSupplies INTotalHealthcoversfamilyplanningservicesandsupplies(including allfda7approvedcontraceptives)forallmembersofchildbearingage.thisincludesservicesandsuppliesthat delayorpreventpregnancybutnotservicestotreatinfertilityorpromotefertility.youarefreetochoosethe methodoffamilyplanningtobeused,withoutbeingpressuredbyanyone.youdonothavetogetfamily planningservicesandsuppliesfromanintotalhealthnetworkprovider.youdonotneedareferraltoobtain theseservices.seethesectionfamilyplanningservicesformoreinformation. HearingAidsandSupplies Coveredonlyformembersunder21yearsofage. HIVTestingandTreatmentCounselingforpregnantmembers. HomeHealthServices INTotalHealthcoversmedicallynecessaryhomehealthservicesincludingnursing services,rehabilitationtherapiesandupto32homehealthaidevisitseachyear.

16 InpatientHospitalServices INTotalHealthcoverstheseservicesingeneralacutecareandrehabilitation hospitals.preauthorizationisrequiredexceptforemergencyhospitaladmissions. InpatientBehavioralHealthServices INTotalHealthcoversthefollowinginpatientbehavioralhealthservices: Temporarydetentionorders,includingemergencycustodyorders Staysinthepsychiatricunitofageneralacutecarehospitalforallmembers Staysinafreestandingpsychiatrichospitalformembersunderage21andmembersage65andover Inaddition,staysinafreestandingpsychiatrichospitalmaybeauthorizedbyINTotalHealthformembersofany age,ifneeded.intotalhealthdoesnotcoverinpatientbehavioralhealthservicesprovidedbystatepsychiatric hospitals.seethesectionservicescoveredbyfee7for7servicemedicaidformoreinformation. InpatientRehabilitationHospitalServices LaboratoryandXWrayServices MedicalSuppliesandEquipment INTotalHealthcoversallmedicallynecessarymedicalsuppliesand equipment.thefollowingsuppliesarenotcovered: Spaceconditioningequipment MedicalsuppliesforhospitalresidentsthathavenotbeenapprovedbytheDepartmentofMedical AssistanceServices(DMAS) Comfortandconvenienceitems ProstheticservicesthathavenotbeenpreauthorizedbyDMAS(exceptwhenmedicallynecessary;seethe sectionprosthetic/orthoticservices) Orthotics(braces,splints,supports,etc.)formembers21andover(exceptwhenpartofanapproved intensiverehabilitationprogram;seeprosthetic/orthoticservices) Homeorvehiclemodifications Itemsthatarenotusedinahomesetting Joboreducation7relatedequipment(computers,speechdevices,etc.)unlessrequiredunderEPSDT OrganTransplants INTotalHealthcoverskidneyandcorneatransplantsformembersofallages.Bone marrowtransplantsandhigh7dosechemotherapyarecoveredformembersage21orolderthatarediagnosed withbreastcancer,leukemia,lymphomaandmyeloma.intotalhealthcoversallmedicallynecessarytransplants formembersuptoage21.intotalhealthcoversheart,liverandlungtransplantsformembersover21when medicallynecessary. Experimentalorinvestigationalproceduresarenotcovered.Preauthorizationisrequiredforalltransplants exceptcorneas. OutpatientHospitalServices INTotalHealthcoversoutpatienthospitalservicesthatarepreventive, diagnostic,therapeutic,rehabilitativeorpalliative.alsoincludesobservationbedservices. OutpatientBehavioralHealthandSubstanceAbuseServices Coverageofoutpatientbehavioralhealth servicesincludesindividualtherapy,grouptherapyandfamilytherapy.intotalhealthalsocoversoutpatient substanceabuseservices,includingassessmentandevaluation. 9 MHB7MCD707713

17 PhysicalTherapy,OccupationalTherapyandSpeechWLanguagePathologyandAudiologyServices INTotal Healthcoversmedicallynecessaryservicesthatareprovidedataninpatientoroutpatienthospitalorbyahome healthservice.coverageisalsoprovidedforintensiveoutpatientphysicalrehabilitationservicesin ComprehensiveOutpatientRehabilitationFacilities.EarlyInterventionservicesprovidedtoPartCeligible children(includingtherapyservices)arecoveredbyfee7for7serviceandnotintotalhealth. ProviderServices SeetheWellnessCareforChildrenandAdultssectionformoreinformation. Podiatry INTotalHealthcoversmedicallynecessaryfoottreatment.Routineandpreventivefootcareisnot covered. PregnancyWrelatedCare INTotalHealthcoverscasemanagementservicesforhigh7riskpregnantwomenand childrenuptoage2.seethesectionspecialcareforpregnantmembersformoreinformationaboutpregnancy relatedcare. PrescriptionDrugs SeethesectionMedicinesformoreinformation. PrivateDutyNursing INTotalHealthcoversmedicallynecessaryPrivateDutyNursing(PDN)servicesfor membersunder21whenrequiredbyepsdtandprovidedoutsideofaschoolsetting.school7basedpdnservices arecoveredbyfee7for7servicemedicaid.contactthedmasmanagedcarehelplineat formoreinformation. ProstateSpecificAntigen Testinganddigitalrectalexamtoscreenforprostatecancer. Prosthetic/OrthoticServices INTotalHealthcoversmedicallynecessaryprostheticservicesanddevicesthat includeartificialarms,legs,internalbodyparts,breasts(includingreconstructivebreastsurgery)andeyes. Medicallynecessaryorthoticservicesanddevicesarecoveredforchildrenunder21.Theseservicesarealso coveredforadults21andolderwhenpartofanapprovedintensiverehabilitationprogram. TelemedicineServices Communicationtechnologythathelpsyourproviderdiagnoseandtreatanillness. Transportation INTotalHealthcoversallemergencyandnonemergencytransportationtoandfromthe provider sordentist soffice,orthehospital.seethesectionhowtogettoaprovider sappointmentortothe Hospitalformoreinformation. VisionServices INTotalHealthcoversroutineeyeexamsandrefractionsforallenrolleesonceevery24 months.formembersage20andunder,eyeglassesandcontactlensesarecoveredwhenmedicallynecessary. Asavalue7addedINTotalHealthbenefit,medicallynecessaryeyeglassesarecoveredformembersage21and over.seethesectioneyecareformoreinformation. Women shealthcareservices Forfemalemembersoverage13,INTotalHealthcoversannualexamsand routinehealthcareservices(includingpapsmears)withoutpreauthorizationfromyourpcp.seethesections PickinganOB/GYNandSpecialCareforPregnantMembersformoreinformation. Thefollowingwomen shealthcareservicesarealsocoveredbyintotalhealth: Mammogramsforwomen35andover Breastprosthesesafteramedicallyneededremovalofabreast A487hourhospitalstayafteraradicalmastectomyanda247hourstayafteratotalorpartialmastectomy Reconstructivebreastsurgery 10 MHB7MCD707713

18 Servicestopregnantwomen,including: Servicestotreatamedicalconditionthatmaycomplicatethepregnancy Smokingcessationcounseling,andprescriptionandnonprescriptionsmokingcessationdrugs Prenatalservices(patienteducation,counseling,etc.) Postpartum(after7birth)servicesuntiltheendofthesecondmonthafterthepregnancyends Lactationconsultationandbreastpumps VALUEWADDEDINTOTAL'HEALTHBENEFITS INTotalHealthcoversextrabenefitsthatmemberscannotgetfromFee7for7ServiceMedicaid.Theseextra benefitsarecalledvalue7addedservices.intotalhealthoffersthefollowing: Medicallynecessaryeyeglassesformembers21yearsofageandolder FreeBoys&GirlsClubmembershipforchildrenbetweentheagesof5and18(seethesectionBoys&Girls Clubsfordetails) Afreesportsphysicaleachyearforchildrenbetweentheagesof10and18 Starring:)Baby)and)MetheINTotalHealthprogramforallpregnantmembers.SeethesectiononSpecial CareforPregnantMembersfordetails. AddedprogramslikediseasemanagementandhealtheducationthatINTotalHealthprovidesforthebenefit ofitsmembers.seethesectionsdiseasemanagementandspecialintotalhealthservicesforhealthy Living. WegiveyouthesebenefitstohelpkeepyouhealthyandtothankyouforchoosingINTotalHealthasyourhealth careplan. SERVICES'COVERED'BY'FEEWFORWSERVICE'MEDICAID SomeservicesarecoveredbyMedicaidinsteadofINTotalHealth.Theseservicesarecalledcarved7outservices. Medicaidbenefitsinclude: Abortions(onlywhenthereisgreatdangertothehealthorlifeofthemother) CasemanagementservicesandprivatedutynursingservicesprovidedthroughHome7andCommunity7 BasedCareServiceswaivers(AIDS,IndividualandFamilyDevelopmentalDisabilitiesSupports,Mental Retardation,ElderlyorDisabledwithConsumerDirection,DaySupportorAlzheimer s)andrelated transportationtoandfromhome7andcommunity7basedwaiverservices Personalcareservices Privatedutynursingservicesprovidedinaschoolsetting TargetedCasemanagementservicesfor: Memberswithauxiliarygrants Memberswithmentalretardation Seriouslymentallyilladultsandemotionallydisturbedchildren Youthatriskofseriousemotionaldisturbance Theelderly TreatmentFosterCare Communitymentalhealthrehabilitativeservices,mentalretardationservicesandsubstanceabuse treatmentservices DentalservicesthroughSmilesforChildrenDentalProgram.SmilesforChildrenmembersarecoveredforall medicallynecessarydentalservices.adescriptionofservicesavailableforchildreniscoveredinthesmiles forchildrenhandbook.call forhelpfindingadentist. Emergencycounselingservices,intensiveoutpatientservices,opioidtreatment,daytreatmentandcase managementforsubstanceabuse 11 MHB7MCD707713

19 Leadinvestigations Testingoffluoridationlevelsinwellwater Residentialanddaysubstanceabusetreatmentservicesforpregnantwomen Schoolhealthservices,whichincludeanyservicesgivenonschoolpropertysuchasphysical,occupationalor speech7languagetherapy;psychologicalandpsychiatricservices;skillednursingservices;medical assessments;audiologyservices;personalcareservices;medicalevaluationservices;andservicesthatare partofanindividualizededucationprogram Specializedinfantformulaforchildrenunderage5throughVirginiaDepartmentofHealthWICclinics Enteralnutrition/medicalfoodsforchildrenunderage21 EarlyInterventionservicesprovidedtoPartCeligiblechildren(formoreinformationabouttheseservices, pleasecontacttheinfant&toddlerconnectionofvirginiaat orvisitwww.infantva.org) Forinformationonhowtoaccesstheseservices,pleasecalltheDMASManagedCareHelplinetollfreeat INTotalHealthsendsinformationtomemberseachyearaboutbenefits,howtogetreferrals, howtogetout7of7networkservices,oranychangesinbenefits.membersgetinformationaboutchangesto benefitsatleast30daysbeforethechangehappens. SERVICES'EXCLUDED'FROMTHEMANAGEDCAREPROGRAM ThefollowingservicesarenotcoveredbyINTotalHealth: Hospiceservices Inpatientmentalhealthservicesprovidedinastatepsychiatrichospital ServicesprovidedthroughthePlanFirstfamilyplanningwaiverprogram ServicesprovidedthroughtheTechnologyAssistedhome7andcommunity7basedwaiverprogram Servicesformembers21andunderenrolledinTreatmentFosterCareorResidentialTreatmentFacility programs,excludingthosememberswhoareenrolledfortreatmentforchildhoodobesity/weightloss Skillednursingfacilitycare Forinformationonhowtoaccesstheseservices,pleasecalltheDMASManagedCareHelplinetollfreeat SERVICES'THAT'DO'NOTNEED$A$REFERRAL$ YoucangetthefollowingserviceswithoutareferralfromyourPrimaryCareProvider(PCP): CareprovidedbyyourINTotalHealthnetworkPCP snurseorphysicianassistant RoutinedentalcarefromanyMedicaiddentist Emergencyservices EyeexamsfromanINTotalHealthnetworkeyecareprovider(optometrist) FamilyplanningfromanyINTotalHealthnetworkorstate7approvedMedicaidfamilyplanningprovider PrenatalcarefromanINTotalHealthnetworkobstetricianorcertifiednursemidwife PreventiveEPSDTcarefromanINTotalHealthnetworkprovider(thiscoverscheckupsforchildrenunderage21) ScreeningortestingforsexuallytransmitteddiseasesincludingHIVfromanINTotalHealthnetwork provider YearlyexamsfromanINTotalHealthnetworkOB/GYN 12 MHB7MCD707713

20 BENEFITS(AND(SERVICES"NOT"OFFERED"BY"INTOTAL'HEALTHORMEDICAID ThesearebenefitsandservicesthatINTotalHealthdoesnotoffer.Theseservicesarealsonotcoveredby fee7for7servicemedicaid: Anythingexperimentalsuchasanewtreatmentthatisbeingtestedorhasnotbeenshowntowork Anythingthatisnotmedicallynecessary Chiropracticservices(unlessrecommendedatanEPSDTvisit)) ChristianSciencenurses) Cosmeticsurgerythatisnotmedicallynecessary Contactlensesformembers21yearsofageorolder) Fertilitytreatmentservices Sterilizationformembersunderage21 Drugsfortreatmentoferectiledysfunction Servicesprovidedtoinmates/incarceratedrecipients FormoreinformationaboutservicesnotcoveredbyINTotalHealth,pleasecallMemberServicesat DIFFERENT(TYPES(OF(HEALTH&CARE Routine,UrgentandEmergencyCare:WhatIstheDifference? RoutineCare Inmostcaseswhenyouneedmedicalcare,youcallyourPrimaryCareProvider(PCP)tomakeanappointment. ThenyougotoseethePCP.Thiswillcovermostminorillnessesandinjuries,aswellasregularcheckups.This typeofcareisknownasroutine)care.yourpcpissomeoneyouseewhenyouarenotfeelingwell,butthatis onlypartofyourpcp sjob.yourpcpalsotakescareofyoubeforeyougetsick.thisiscalledwellnesscare. SeethesectioninthishandbookWellnessCareforChildrenandAdultsformoreinformation.Youshouldbeable toseeyourpcpwithin30daysforroutinecare. UrgentCare Thesecondtypeofcareisurgentcare.Therearesomeinjuriesandillnessesthatarenotemergenciesbutcan turnintoanemergencyiftheyarenottreatedwithin24hours. Someexamplesofurgentcareinclude: Throwingup Minorburnsorcuts Earaches Headaches Sorethroat Feverover101degrees Musclesprains/strains Forurgentcare,youshouldcallyourPCP.YourPCPwilltellyouwhattodo.YourPCPmaytellyoutogotohisor herofficerightaway.youmaybetoldtogotosomeotherofficetogetimmediatecare.youshouldfollowyour PCP sinstructions. Insomecases,yourPCPmaytellyoutogototheemergencyroomatahospitalforcare.Seethenextsection aboutemergencycareformoreinformation. 13 MHB7MCD707713

21 Youcanalsocallour247hourNurseHelpLineat foradviceabouturgentcare.Youshouldbe abletoseeyourpcpwithin24hoursforanurgentcareappointment. EmergencyCare Afterroutineandurgentcare,thethirdtypeofcareisemergencycare.Ifyouhaveanemergency,youshould call911orgotothenearesthospitalemergencyroomrightaway.ifyouwantadvice,callyourprimarycare Provider(PCP)orour247hourNurseHelpLineat Themostimportantthingistogetmedical careassoonaspossible.youshouldbeabletoseeaproviderimmediatelyforemergencycare. Whatareemergencyservices? Emergencyservicesareservicesprovidedbyanin7networkorout7of7networkproviderafterthesuddenstartof amedicalconditionwithsymptomssosevere(includingseverepain)thatsomeonewithanaverageknowledge ofhealthandmedicinecantellthat,withoutmedicalcare,theproblemcouldresultinseriousjeopardytoyour mental/physicalhealth,seriousimpairmentofbodilyfunctions,seriousdysfunctionofanybodilyorgan(or,with respecttoapregnantwoman,thehealthofthewomanorherunbornchild). EmergencyservicesintheINTotalHealthserviceareaprovidedbyanout7of7networkproviderwillbecovered whenadelayincarefromanetworkprovidercouldmakeyourconditionworse.ifyougotothehospitalfor emergencycare,aproviderwillexamineyoutodetermineifthereisanemergency.ifthereisanemergency, INTotalHealthwillcoverthescreeningandtheservicesneededtostabilizeyourcondition. Wewillalsocoverthescreeningiftheproviderdecidesthatthereisnotanemergencybutyoursymptomswere severeenoughtocallforimmediateattentionbasedonthedefinitionofanemergencyabove.ifyourpcptells youtogetemergencycare,wewillcoverthescreeningandthemedicallyneededservices. Herearesomeexamplesofproblemsthataremostlikelyemergencies: Severepain Troublebreathing Chestpains Lossofconsciousness Verybadbleedingthatdoesnotstop Verybadburns Shakescalledconvulsionsorseizures WhatispostWstabilizationcare? Post7stabilizationcareservicesarecoveredservicesthatyoureceiveafteremergencymedicalcare.Youget theseservicestohelpkeepyourconditionstable.youshouldcallyourpcpwithin24hoursafteryouvisitthe emergencyroom.ifyoucannotcall,havesomeoneelsecallforyou.yourpcpwillgiveorarrangeforanyfollow7 upcareyouneed. HowtoGetHealthCareWhenYourPrimaryCareProvider sofficeisclosed Exceptinthecaseofanemergency(seeprevioussection),orwhenyouneedcarethatdoesnotneedareferral (seethesectionservicesthatdonotneedareferral),youshouldalwayscallyourprimarycareprovider(pcp) firstbeforeyougetmedicalcare.helpfromyourpcpisavailable24hoursaday. IfyoucallyourPCP sofficewhenitisclosed,leaveamessagewithyournameandaphonenumberwhereyou canbereached.ifitisnotanemergency,someoneshouldcallyoubacksoontotellyouwhattodo.youmay alsocallournursehelpline24hoursaday,7daysaweekforhelp.ifyouthinkyouneedemergencycare(see 14 MHB7MCD707713

22 previoussection),call911orgotothenearestemergencyroomrightaway. HowtoGetHealthCareWhenYouAreOutOfTown IfyouneedemergencycarewhenyouareoutoftownoroutsideofVirginia*,gotothenearesthospital emergencyroomorcall911.ifyouneedurgentcare,callyourprimarycareprovider(pcp).*(seethesection UrgentCareformoreinformation.) IfyourPCP sofficeisclosed,leaveaphonenumberwhereyoucanbereached.yourpcporsomeoneelse shouldcallyoubacksoon.followthepcp sinstructions.youmaybetoldtogetcarewhereyouareifyouneed itveryquickly.youcanalsocallour247hournursehelplineforhelp.ifyouneedroutinecarelikeacheckupora prescriptionrefillwhenyouareoutoftown,callyourpcporour247hournursehelpline. *IfyouareoutsideoftheU.S.andgethealthcareservices,theywillnotbecoveredbyINTotalHealthor Medicaid. WELLNESS$CARE%FOR%CHILDREN%AND"ADULTS AllINTotalHealthmembersneedtohaveregularwell7carevisitswiththeirPrimaryCareProvider(PCP).Duringa well7carevisit,yourpcpcanseeifyouhaveaproblembeforeitisabadproblem.whenyoubecomeanintotal Healthmember,callyourPCPandmakeyourfirstappointmentwithin90days. WellnessCareforChildren WhyWellnessCareIsImportantForChildren Childrenneedmorewellnessvisitsthanadults.ThesewellnessvisitsforchildrenarecalledEarlyandPeriodic Screening,Diagnosis,andTreatment(EPSDT)visits.EPSDTisaprogramforanyoneinMedicaidthatisunder21 yearsold.babiesneedtoseetheirprimarycareprovideratleastseventimesbythetimetheyare12months oldandmoretimesiftheygetsick. Ifyourchildhasspecialneedsoranillnesslikeasthmaordiabetes,oneofourcarecoordinatorscanhelpyour childgethisorherwellnesscheckups,testsandshots.yourchildcangetepsdtcarefromanyintotalhealth networkprovider.youdonotneedareferralforthesevisits. Wellnessvisitswillinclude: Acomprehensivereviewofyourchild sphysicalandmentalgrowth Anunclothedphysicalexamthatincludesavisionandhearingscreening,adentalcheckandanutritional assessment Immunizations(shots)foryourchildthatwillhelpprotecthimorherfromillnesses Laboratorytests(hemoglobin/hematocrit,urinalysis,tuberculintest,bloodleadscreening) Healtheducation/helpwithpreventivecare Referralsformoremedicallyneededhealthcare UndertheEPSDTbenefitsofMedicaid,yourchildmaybeeligibletogetcertainservicesnototherwisecovered. Theseservicesmaybecoverediffoundtobemedicallynecessary.EPSDTcoversmedicallynecessaryservices whichwillcorrectorimproveanillnessorcondition,oratleastkeepitfromgettingworse. Theseservicesinclude,butarenotlimitedto: Servicesfornursingcare,includingprivatedutynursing Pharmacyservices 15 MHB7MCD707713

23 Obesitytreatment Treatmentfordevelopmentalissues Variousnoncoveredservicessuchaschiropracticcare IfyouhaveanyquestionsabouthowyourEPSDTbenefitscanbeaccessed,pleasecallMemberServices. WhenYourChildShouldGetWellnessVisits Thefirstwellnessvisitwillhappeninthehospitalrightafterthebabyisborn.Forthenextsixvisits,youmust takeyourbabytohisorherpcp soffice. YoumustsetupawellnessvisitwiththePCPwhenthebabyis: Under6weeksold 2monthsold 4monthsold 6monthsold 9monthsold 12monthsold Inyourbaby ssecondyearoflife,heorsheshouldseethepcpatleastthreemoretimesat15months,18 monthsand24months.yourchildshouldseethepcpagaineveryyearfromage3throughage18forwellness checkups.takeyourchildtohisorherpcpwhenscheduled. BloodLeadScreening Yourchild spcpwillscreenyourchildforleadpoisoningifheorsheisatriskofbeingexposedtolead.ablood leadtestwillbedoneforyourchildattheseages: Between9and12months At24months Forthebloodtest,yourchild spcpwilltakeabloodsamplebyprickingthechild sfingerortakingbloodfrom thevein.thistestwilltellifyourchildhasharmfulleadinhisorherblood. EyeExams Yourchild sprimarycareproviderwillcheckyourchild svisionateverywellnessvisit.pleaseseethesectioneye CareundertheheadingSpecialKindsofHealthCareformoreinformation. HearingExams Infantswillbegivenahearingscreeningbeforedischargefromthehospitalafterbirth.Yourchild sprimarycare providerwillcheckyourchild shearingateverywellnessvisit. DentalCare Yourchildwillhavehisorherteethandgumscheckedbyhisorherproviderasapartoftheregularwellness visits.intotalhealthwillalsoprovidecoveragefordentalfluoridevarnishasneeded. Immunizations Itisimportantforyourchildtogethisorherimmunizations(shots)ontime.Takeyourchildtothedoctorwhen hisorherpcpsaysashotisneeded.usethechartlistednexttohelpyoukeeptrackoftheshotsyourchild needs. 16 MHB7MCD707713

24 17 MHB7MCD707713

25 18 MHB7MCD707713

26 19 MHB7MCD707713

27 WellnessCareforAdults Stayinghealthymeansgoingtoseeyourprimarycareproviderforregularcheckups.Usethechartbelowto makesureyouareup7to7datewithyouryearlywellnessexams. EXAMTYPE WHONEEDSIT? HOWOFTEN? Age21 39 Every3years Wellnessvisit Age40andover Everyyear Papsmear*andpelvicexam Womenage13andover Everyyear Age20 39 Every3years Clinicalbreastexamforwomen Age40andover Everyyear BreastselfWexamforwomen Age20andover Onceamonth Mammograms(breastXWray)forwomen Age35andover Everyyear Fecalbloodocculttest Age50andover Everyyear SigmoidoscopyandDRE/PSAorColonoscopyand DRE/PSA Age50andover Every5years *CanbeperformedbyanyFDA7approvedgynecologiccytologyscreeningtechnologies WhenYouMissOneofYourWellnessVisits Ifyouoryourchilddoesnotgetawellnessvisitontime,makeanappointmentwiththePCPassoonasyoucan. Ifyouneedhelpsettinguptheappointment,callMemberServices.IfyourchildhasnotvisitedhisorherPCPon time,intotalhealthwillsendyouapostcardremindingyoutomakeyourchild swellnessappointment. SPECIAL(KINDSOFHEALTHCARE EyeCare INTotalHealthmembersdonotneedareferralfromtheirPrimaryCareProviders(PCPs)foreyecarebenefits. Allmemberscangetcoveredroutinerefractionsandroutineeyeexamsevery24months.Childrenuptotheage of21getmedicallynecessaryeyeglassesorcontactlenses. AsanextraINTotalHealthbenefit,medicallynecessaryeyeglassesarecoveredformembersage21andover. Contactlensesarenotcoveredformembers21yearsofageandolder.PleasecallBlockVisionat forhelpfindinganINTotalHealthnetworkeyecareprovider(optometrist)inyourarea. BehavioralHealth(MentalHealth)Services Sometimesthestressofhandlingthemanyresponsibilitiesofajob,homeandfamilycanleadtodepression, anxiety,marriageandfamilyproblems,parentingproblems,andalcoholanddrugabuse.ifyouorafamily memberishavingthesekindsofproblems,intotalhealthcontractswithproviderswhocanhelp. YoucanalsocallINTotalHealthMemberServicesforhelp.Youcanalsogetthenameofaproviderwhowillsee youifyouneedone.allservicesandtreatmentsarestrictlyconfidential.youdonotneedareferralfromyour PCPtogettheseservices. Mentalhealthservicesarecovered,including: Inpatientmentalhealthcare Outpatientmentalhealthcareservices,includinggroup,individualandfamilytherapy 20 MHB7MCD707713

28 Temporarydetentionorders(unlessthememberisbetweenage21and64andisadmittedtoa freestandingpsychiatricfacility) FamilyPlanningServices INTotalHealth)willarrangeforcounselingandeducationaboutplanningapregnancyorpreventingpregnancy. YoucancallyourPCPandmakeanappointmentforavisit.YoucangotoanyMedicaidproviderforfamily planningservices. SpecialCareforPregnantMembers Starring:)Baby)and)MeistheINTotalHealthprogramforallpregnantmembers.It sveryimportanttoseeyour PCPorOB/GYNforcarewhenyouarepregnant.Thiskindofcareiscalledprenatalcare.Itcanhelpyouhavea healthybaby. Prenatalcareisalwaysimportantevenifyouhavealreadyhadababy.Withourprogram,membersreceive healthinformationandbabygiftsforgettingprenatalcareandpostpartumcare.ourprogramalsohelps pregnantmemberswithcomplexhealthcareneeds.nursecasemanagersworkcloselywiththesemembersto helpteachthemabouttheseneeds.theyalsogiveemotionalsupportandhelpmemberstofollowtheir provider scareplan. Ournursesalsoworkwithproviders.Theyhelpwithotherservicesmembersmayneed.Thegoalistopromote betterhealthformembersandthebirthofhealthybabies. WhenYouBecomePregnant Ifyouthinkyouarepregnant,callyourPCPorOB/GYNproviderrightaway.Youdonotneedareferralfromyour PCPtoseeanOB/GYNprovider.YourOB/GYNshouldseeyouwithin14days.WecanhelpyoufindanOB/GYN intheintotalhealthnetwork,ifneeded. YoumustalsocallINTotalHealthMemberServiceswhenyoufindoutyouarepregnant.Thiswillhelpyoumake sureyouchooseapcpforyourbaby. IfyouareanewINTotalHealthmemberwhoispregnantandhavebeenseenbyanon7INTotalHealthprovider foratleastonecompleteprenatalcheckupbeforeyoujoinedintotalhealth,thenyoumaybeabletokeep seeingthatproviderthroughoutyourpregnancy,deliveryanduptotwomonthsafteryourbabyisborn. Whenyouarepregnant,INTotalHealthwillsendyouapregnancyeducationpackage.Itwillinclude: AletterwelcomingyoutotheStarring:)Baby)and)Me)program Aself7carebook Starring:)Baby)and)Me)rewardprogrambrochure ANurseHelpLineStarPointsfactsheet Theself7carebookgivesyouinformationaboutyourpregnancy.Youcanalsousethebooktowritedownthings thathappenduringyourpregnancy.thestarring:)baby)and)mebrochuretellsyouhowtogetyourgiftfor gettingprenatalcare. Whenyouarepregnant,youmustgotoyourPCPorOB/GYNatleast: Every4weeksforthefirst6months Every2weeksforthe7thand8thmonths Everyweekduringthelastmonth 21 MHB7MCD707713

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Healthy Michigan MEMBER HANDBOOK Healthy Michigan MEMBER HANDBOOK 2014 The new name for Healthy 1 TABLE OF CONTENTS WELCOME TO HARBOR HEALTH PLAN.... 2 Who Is Harbor Health Plan?...3 How Do I Reach Member Services?...3 Is There A Website?....

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