MEMBER HANDBOOK Maryland HealthChoice

Transcription

1 2015 MEMBER HANDBOOK Maryland HealthChoice

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3 Dear Member, Welcome to Kaiser Permanente! Thank you for choosing us. We want to help you stay healthy. We re also here to serve you when you are sick or injured. This Member handbook is a guide to Kaiser Permanente benefits and processes. It is written for members and/or their guardians. There are a number of ways that Kaiser Permanente is special and different from other health plans. First, most Kaiser Permanente members receive care from the doctors of the Mid-Atlantic Permanente Medical Group (MAPMG). MAPMG doctors, including primary care doctors and specialists, have their offices in our medical centers and work together. Most of our medical centers include a pharmacy, lab, and X-ray services all under the same roof. This makes getting care simple and easy. Second, our services are available 24 hours a day, seven days a week (24/7). We have urgent care available 24/7 at medical centers in Largo, South Baltimore, and Gaithersburg and have other urgent care centers as well. We have advice nurses who work with MAPMG physicians and are also available 24/7. You can access advice by calling the Appointment and Advice Call Center at whenever you need to speak with an advice nurse. Third, we have a website connected to your electronic medical record that lets you: your MAPMG doctor Make appointments at Kaiser Permanente centers Read many lab test results Order prescription refills from Kaiser Permanente pharmacies Read about medical conditions Do and learn much more! You can get these services on a computer or smartphone, day or night. We re happy you ve chosen us as your partner in health, and we look forward to helping you stay well, live well, and THRIVE. Sincerely, Kim Horn Regional President 1

4 Translation services, interpreter services, and materials for the visually impaired This information is important and is available for oral interpretation in Spanish, Mandarin, Cantonese, Korean, and Vietnamese. If you want someone to read it to you, contact Kaiser Permanente Member Services toll free at , TTY 711. You can also get this written material in Spanish. You can also get this handbook in large print and/or Braille. Interpreter services are offered at no charge. If you need an interpreter during your next doctor s visit, inform the appointment clerk when scheduling your appointment. For all other questions, call Member Services at A Member Services representative can provide an interpreter over the phone when you call Members who are deaf, hard of hearing, or speech impaired may call toll free TTY 711. Interpreter services are available at Kaiser Permanente facilities. We will provide interpretive services if a non-kaiser Permanente facility cannot provide such services. Esta información es importante. Si desea que alguien se la lea en español, chino (tradicional), cantonés, coreano o vietnamita, llame a Servicios para Miembros de Kaiser Permanente al número de llamada gratuita (855) , TTY 711. También puede recibir este material escrito en español. También puede recibir este manual en letra grande y/o en braille. Ofrecemos servicios de interpretación sin ningún costo. Si necesita un intérprete durante su próxima visita médica, informe al recepcionista a cargo de las citas cuando llame a programar la suya. Para todas las demás preguntas, llame a Servicios para Miembros al (855) Un representante de Servicios para Miembros le asignará un intérprete por teléfono cuando llame al (855) Los miembros sordos, con dificultades de audición o de lenguaje pueden llamar sin costo al número TTY 711. Nuestros servicios de interpretación se ofrecen en los centros de Kaiser Permanente. Ofrecemos los servicios de interpretación si un centro que no es de Kaiser Permanente no puede ofrecer tales servicios. 2

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6 Thông tin này quan trọng và có sẵn bằng tiếng Tây Ban Nha, Quan Thoại, Quảng Đông, Hàn, và Việt. Thông tin được cung cấp miễn phí. Nếu quý vị muốn nhờ người nào đọc cho mình, hoặc nếu quý vị muốn nhận tài liệu bằng tiếng Việt, xin gọi Ban Phục vụ Khách hàng của Kaiser Permanente số điện thoại miễn phí (855) , 711 cho máy TTY. Quý vị cũng có thể nhận cuốn cẩm nang này bằng chữ in lớn và/hoặc chữ nổi Braille. Chúng tôi cung cấp dịch vụ thông dịch miễn phí. Nếu quý vị cần một thông dịch viên trong chuyến đi bác sĩ kế tiếp, xin nói cho nhân viên phòng mạch lấy hẹn biết. Đối với tất cả các câu hỏi khác, xin gọi Ban Phục vụ Khách hàng tại số (855) Một đại diện của ban này sẽ thu xếp một thông dịch viên qua điện thoại. Khách hàng bị điếc, yếu tai hoặc gặp vấn đề về giọng nói có thể gọi số điện thoại miễn phí 711 cho máy TTY. Dịch vụ thông dịch của chúng tôi có sẵn tại các cơ sở Kaiser Permanente. Chúng tôi sẽ cung cấp dịch vụ thông dịch nếu một cơ sở không phải là Kaiser Permanente không có dịch vụ đó. 4

7 Table of contents Medicaid at Kaiser Permanente...7 Simple steps to get started...9 Quick-reference guide...10 Kaiser Permanente HealthChoice service area...12 Rights and responsibilities...13 Benefits and services...15 HealthChoice benefits...15 Optional benefits and applicable terms and conditions...19 Benefits and services not offered by Kaiser Permanente but offered by the State...20 Benefits and services not offered by Kaiser Permanente or the State...21 Self-referral services...22 Notice of stopping or changing benefits, service, or health care locations...23 Information on providers...25 What is a PCP, a specialist, and specialty care?...25 Information about your PCP and specialists...25 Selecting or changing providers...25 Special services...27 Interpreter for those who do not speak English...27 Interpreter for those who are deaf or hard of hearing...27 Transportation services...27 Services for special needs populations...27 Rare and Expensive Case Management Program (REM)...30 Getting into care...33 Identification cards...33 Making or canceling an appointment...33 Referral to a specialist or specialty care

8 After hours, urgent care, and emergency care...35 Pharmacy services...35 Out-of-service-area coverage...36 Wellness care for children (Healthy Kids EPSDT)...36 Care for women during pregnancy and two months after delivery...37 Family planning (see Self-referral services)...37 Adult dental care...38 Health education programs...38 Behavioral health services...39 Complaints, grievances, and appeals...39 Changing your MCO...43 Other important information...45 Notice of privacy practices...45 Reporting fraud and abuse...45 Coordination of benefits New medical technologies Quality care at Kaiser Permanente...46 Utilization management...46 Utilization management affirmation statement...46 What to do if you receive a bill...47 How our doctors are paid...47 Advance directives...47 Definitions

9 Medicaid at Kaiser Permanente HealthChoice is a program of the State of Maryland. As a managed care organization, Kaiser Permanente provides your medical benefits through Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (Health Plan), a participating Medicaid Managed Care Organization (MCO), and the Mid-Atlantic Permanente Medical Group, P.C. (MAPMG). We work together to give you the medical care you need. What makes Kaiser Permanente special is how we coordinate your care. Most Kaiser Permanente members receive care from the doctors of MAPMG. MAPMG is a large medical group of over 1,000 doctors dedicated to serving just Kaiser Permanente members across our entire region. MAPMG also contracts with participating providers when we do not have offices in a particular area or do not have a particular kind of specialist. Who you choose as your Kaiser Permanente primary care provider (PCP) can make a big difference in how your care is managed, because MAPMG doctors have access to very powerful tools to ensure that you get care when you need it. One of these tools is our electronic medical record system. This system allows all of our MAPMG doctors who treat you access to the same medical information about you whenever they see you. It allows them to make referrals to specialists easily and to order your medications from the pharmacy so you can pick them up before you leave a Kaiser Permanente medical center after your doctor s visit. They can also read your lab results and follow up on needed screenings. This system also gives you the power to make appointments, order medicines, and ask your doctor questions using our online member system, My Health Manager, which you can access at kp.org. There is a lot of information in this handbook about your benefits and how to get care. At the end of this handbook, we have included a Definitions section, which explains terms that may be new to you. If you have questions about any section of this handbook, please contact Member Services at , TTY

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11 Simple steps to get started Make the most of your Kaiser Permanente membership As a new member, we need to see you as soon as possible. The following Simple steps to get started will help you build a relationship with your doctor and learn ways to make full use of what Kaiser Permanente offers its members. 1. Choose your doctor You can learn about our doctors at kp.org, by reading the Provider Directory, or by calling Member Services. If you want to choose or change your PCP, call Member Services. You may contact them Monday through Friday, 7:30 a.m. to 5:30 p.m., except holidays at , TTY Schedule an appointment To schedule a routine appointment, call our Advice and Appointment Call Center, Monday through Friday, 7 a.m. to 8 p.m. at , TTY 711. If your PCP does not practice in a Kaiser Permanente medical center, call that PCP s office directly to schedule an appointment. You can get many services online. With your Kaiser Permanente ID card handy, go to kp.org/register to set up a user ID and password. Once you ve registered, you ll have around-the-clock access to the time-saving features of My Health Manager. These services are available from a computer or smartphone. If you get services at Kaiser Permanente medical centers, you can do the following through My Health Manager: your MAPMG doctor Schedule appointments with your MAPMG doctor Order most prescription refills View most lab test results performed at Kaiser Permanente medical facilities Learn about healthy living and more It s important we understand your health care needs. For your first appointment, please bring: Current medications List of allergies Past medical history Immunization records 3. Check out our website at kp.org 9

12 Quick-reference guide Action Contact What you can do Change your doctor Make an appointment Update your address or telephone 24-hour medical advice Fill a prescription Call Member Services, Monday through Friday, 7:30 a.m. to 5:30 p.m., except holidays, at: TTY 711* For MAPMG doctors, call Monday through Friday, 7 a.m. to 8 p.m., at: For hearing and speech impaired, first call the Relay Service 711 and ask to connect to Appointments and Advice at: Call Member Services, Monday through Friday, 7:30 a.m. to 5:30 p.m., except holidays, at: TTY 711* Medical advice is available 24 hours a day, seven days a week at: For hearing and speech impaired, first call the Relay Service 711 and ask to connect to Appointments and Advice at: EZ refill: , 24 hours a day, seven days a week, to refill prescriptions filled at Kaiser Permanente medical center pharmacies. Mail delivery services: Select the EZ Refill mail option to have your refillable prescription mailed anywhere in the U.S. Order online: Order your prescription refills at kp.org using My Health Manager for medications filled at Kaiser Permanente medical center pharmacies. MedImpact: Call This doctor will coordinate all of your health care needs, including making referrals. You can change your PCP or Ob/Gyn at any time, for any reason. If your doctor does not practice in a Kaiser Permanente medical center, call your doctor s office directly to make an appointment. We can help you make, cancel, and change appointments with a MAPMG doctor. You can also make, cancel, and change appointments with a MAPMG doctor online at kp.org through My Health Manager. It is important that you keep us up to date on the best place to reach you. You can get advice and/or make an appointment. In addition, if you would like to leave a non-urgent message for a medical advice nurse, you can do so at kp.org if you are registered on My Health Manager. You will receive an answer within one business day. You can also use Kaiser Permanente pharmacies to fill or refill a prescription from a doctor who does not practice in a Kaiser Permanente medical center. Bring in the prescription the same way you would at any other pharmacy. To find other participating pharmacies near you, call MedImpact. 10

13 Action Contact What you can do Emergency care Urgent care Behavioral health (Primary behavioral health services and substance use disorder services) Member Services If you think you are experiencing a medical emergency, immediately call 911 or go to the nearest emergency facility. If you are unsure about your medical problem and want medical advice, call For hearing and speech impaired, first call the Relay Service 711 and ask to connect to Appointments and Advice at: Call our 24-hour medical advice line at: For hearing and speech impaired, first call the Relay Service 711 and ask to connect to Appointments and Advice at: Talk to your PCP if you are having emotional issues or need care for substance use disorder. You can also call ValueOptions at: Call Member Services representatives, Monday through Friday, 7:30 a.m. to 5:30 p.m., except holidays, at: TTY 711* Report your emergency room visit to us as soon as possible by calling the Advice and Appointment Contact Center at: TTY 711* If you need urgent care services, call our advice nurses. Examples of instances when you might need urgent care are a sudden rash, high fever, severe vomiting, ear infection, or a sprained ankle. You can ask for outpatient treatment for emotional issues, substance use disorder and alcohol use disorder by calling ValueOptions. You do not need a referral from your PCP to receive these services. Contact Member Services if you need help with your health plan or have any other questions. CareConnect program (Complex Case Management) If you would like more information on Complex Case Management, call: If you are experiencing severe health problems or have a newly diagnosed illness that might require extensive services over time, your doctor may suggest that you enroll in our CareConnect program. *The Kaiser Permanente TTY line is available for people who are speech/hearing impaired. 11

14 Kaiser Permanente HealthChoice service area Our service area covers certain regions of the following counties: Anne Arundel Baltimore Calvert Charles Harford Howard Montgomery Prince George s St. Mary s Howard Baltimore Harford Montgomery Anne Arundel Prince George s Charles Calvert St. Mary s 12

15 Rights and responsibilities You have the right to: Be treated with respect to your dignity and privacy. Receive information, including information on treatment options and alternatives, in a manner you can understand. Participate in decisions regarding your healthcare, including the right to refuse treatment. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. Request and receive a copy of your medical records and request that they be amended or corrected as allowed. Exercise your rights and to know that the exercise of those rights will not adversely affect the way that Kaiser Permanente or our providers treat you. File appeals and grievances with us (see page 39). File appeals and grievances with the State (see more on State Fair Hearings on page 41). Request that ongoing benefits be continued during an appeal or State Fair Hearing; however, you may have to pay for the continued benefits if our decision is upheld in the appeal or hearing (see page 42). Receive a second opinion from another doctor if you don t agree with your doctor s opinion about the services that you need. Contact us at for help. Receive other information about us, such as how we are managed. You may request this information by calling You have the responsibility to: Carry your Kaiser Permanente Identification Card at all times and have your governmentissued picture ID with you at all appointments. We will need to see these when you check in for services. Please keep your appointments and be on time. Call us if you need to cancel or will be late. Treat our physicians, staff, and other Kaiser Permanente members with courtesy and respect just like you want to be treated. Privacy of all our members is important, so please observe the signs asking for privacy in member waiting areas. Tell your PCP about your symptoms and problems. Please give your doctor the information needed to address your health conditions. Ask questions if you do not understand. If your doctor gives directions that you will have trouble following, explain why. If your doctor tells you to go for a test or to take a medication, you need to do this. Before you refuse to follow your doctor s instructions, ask him/her what will happen, so you can make an informed decision. Tell your doctor who we can talk with about your health, if you want others to know. 13

16 Please contact us immediately if: Your Kaiser Permanente ID card is lost or stolen, so we can send you a new one. Your information on your Kaiser Permanente ID card is wrong or has changed because you moved or your marital status has changed. You go to an emergency room. Your doctor needs to know this so he/she can follow up with you about why you went there. You learn that you are pregnant. You get sick and need care. We can help you decide if you need to go to an emergency room if you are not sure. We can also make an appointment in urgent care if you need to be seen that day and your PCP has no open appointments. To take full advantage of being a Kaiser Permanente member: We offer many classes that relate to a particular health condition or how to improve your health. These classes are offered at no charge. You can learn about them on kp.org or at our medical centers. Use My Health Manager to make staying healthy easier. You can make appointments, order refills, see your test scores, and your doctor with any questions you may have. 14

17 Benefits and services HealthChoice benefits The table below shows the health care services and benefits that all HealthChoice enrollees can get when they need them. We may offer other services not listed here (see page 19). For a few special benefits, you have to be certain ages or have a certain kind of problem. We will never charge you for any of the health care services we provide and there is no pharmacy copay. This table lists the basic benefits that you can get through Kaiser Permanente when you need them. Prior approval Some services are only covered if we approve them first. If your PCP or specialist decides you need a service that requires prior approval, he/she will send us a request for approval. Our decision is made by a qualified health care professional. If we have questions, we will ask your doctor. Once the decision is made, we will notify you and your doctor. If you have a question or are confused about whether we offer a certain benefit, you can call the HealthChoice Enrollee Help Line at or Kaiser Permanente Member Services at for help. Benefit What it is Who can get this benefit What you don t get with this benefit Primary care services Early Periodic Screening, Diagnosis, and Treatment (EPSDT) services for children These are all of the basic health services you need to take care of your general health needs, and are usually provided by your PCP, another doctor, or advanced practice nurse. Regular well-child check-ups, immunizations (shots), and other check-ups to look for illness. Whatever is needed to take care of sick children and to keep healthy children well. All enrollees Enrollees under age 21 Pregnancyrelated services Medical care during and after pregnancy, including hospital stays and, when needed, home visits after delivery. Women who are pregnant, and for two months after the birth 15

18 Benefit What it is Who can get this benefit What you don t get with this benefit Family planning Family planning office visits, lab tests, birth control pills and devices (includes latex condoms and emergency contraceptives from the pharmacy, without a doctor s order), and permanent sterilizations. All enrollees Primary behavioral health services Primary behavioral health services are basic behavioral health services provided by your PCP or another Kaiser Permanente participating provider in the network. If more than just basic behavioral health services are needed, your PCP will refer you to, or you can call, the Public Behavioral Health System at for specialty behavioral health services. All enrollees You do not get specialty behavioral health services from Kaiser Permanente. For example, for treatment of serious emotional problems like schizophrenia, your PCP or specialist will refer you to, or you can call, the Public Behavioral Health System at Pharmacy services Prescription drugs, insulin, needles and syringes, birth control pills and devices, coated aspirin for arthritis, iron pills (ferrous sulfate), and chewable vitamins for children younger than age 12. You can get latex condoms and emergency contraceptives from the pharmacy without a doctor s order. All enrollees Non-prescription drugs except for coated aspirin, iron pills, and chewable vitamins for children younger than age 12. Specialist services Health care services provided by specially trained doctors or advanced practice nurses. You might have to get a referral from your PCP before you can see a specialist. All enrollees 16

19 Benefit What it is Who can get this benefit What you don t get with this benefit Laboratory and diagnostic services Lab tests and X-rays to help find out the cause of an illness. All enrollees Case management A case manager may be assigned to help you plan for and receive health care services. The case manager also keeps track of what services are needed and what has been provided. Special Populations: 1. Children with special health care needs 2. Pregnant and postpartum women 3. Individuals with HIV/ AIDS 4. Individuals who are homeless 5. Individuals with physical or developmental disabilities 6. Individuals in need of substance abuse care 7. Children in statesupervised care Diabetes care Special services, medical equipment, and supplies for enrollees with diabetes. Enrollees who have been diagnosed with diabetes Podiatry Foot care when medically needed. Includes special shoes, supports, and routine foot care. Available to enrollees under age 21 or individuals with diabetes and circulatory problems Vision care Eye exams Under 21: one exam every year 21 and older: one exam every two years Glasses Under 21 only Exams All enrollees Glasses and contact lenses Enrollees under age 21 More than one pair of glasses per year unless lost, stolen, broken, or new prescription is needed Contact lenses if there is a medical reason why glasses will not work 17

20 Benefit What it is Who can get this benefit What you don t get with this benefit Home health services Support services for people who are terminally ill. Those who need skilled nursing care in their home, usually after being in a hospital No personal care services (help with daily living) Hospice care In-home health care services, including nursing and home health aide care. All enrollees Rehabilitation outpatient Rehabilitation services, including physical therapy, occupational therapy, and speech therapy (without a hospital stay). All enrollees Some services for members under 21 years old are offered by the State (see page 23) Nursing home Full-time nursing care in a nursing home. All enrollees After 30 days, State pays instead of Kaiser Permanente Chronic hospital Full-time hospital care for long-term illness. All enrollees After 30 days, State pays instead of Kaiser Permanente Blood and blood products Blood used during an operation, etc. All enrollees Dialysis Treatment for kidney disease. All enrollees 18

21 Benefit What it is Who can get this benefit What you don t get with this benefit DME and DMS Durable medical equipment (DME) and disposable medical supplies (DMS) are things like crutches, walkers, wheelchairs, and finger-stick supplies (for people who do blood testing at home). All enrollees Transplants Medically necessary transplants. All enrollees No experimental transplants Clinical trials Enrollee s costs for studies to test the effectiveness of new treatments or drugs. Enrollees with lifethreatening conditions, when authorized No experimental transplants Optional benefits and applicable terms and conditions As a member of Kaiser Permanente, we offer our members several extra benefits. This section of the handbook explains those benefits and who is eligible to receive them. Dental services for adults 21 years of age or older (Except for pregnant women. See page 20 for children and pregnant women.) Kaiser Permanente offers preventive dental benefits to our adult members who are not pregnant (pregnant members already have coverage for dental services). Dental services are provided by DentaQuest. You can call DentaQuest at Dental services do not require a referral from your PCP. The preventive services we cover include: Dental exams two times per year (one every six months) Dental cleaning two times per year (one every six months) Limited X-rays once a year Limited fillings for cavities Limited non-surgical extractions Vision care for adults 21 years of age or older We offer our adult members one eye examination per year and one pair of glasses every two years. If your glasses are lost, stolen, broken, or your eyesight has changed, you may be able to get new frames or lenses sooner, as needed. 19

22 Pharmacy Kaiser Permanente charges no copay for any prescription approved by your PCP or specialist. Healthy living classes and wellness coaching Kaiser Permanente works to keep you healthy with healthy living classes and wellness coaching at no charge. These classes cover a large number of health topics, including newborn care, breastfeeding, prenatal care, weight management, stop smoking, successful living with heart failure, diabetes, asthma, and many other topics. These classes are held at Kaiser Permanente medical centers. For more information about healthy living classes and programs in your area, please visit kp.org/healthyliving or call or toll free. Please see page 38 for more on our healthy living programs. CareConnect program Case management is available for: Children with special health care needs Pregnant and postpartum women Individuals with HIV/AIDS Individuals who are homeless Individuals with physical or developmental disabilities Individuals in need of substance use disorder care Children in state-supervised care CareConnect case managers can provide the following types of help: Initial assessment, including medication review Care planning based on your needs and wishes Coordination of care across doctors Coaching and monitoring of your health status Support and education Assistance with access to Kaiser Permanente and community resources If you would like more information, call Benefits and services not offered by Kaiser Permanente but offered by the State These are benefits and services that we do not provide. People who need these services can get them through the State using their red-and-white Medical Assistance or dental card. Dental services for children under 21 and pregnant women General dentistry, including regular and emergency treatment, is offered. Dental services are provided by the Maryland Healthy Smiles Dental Program administered by DentaQuest. If you are eligible for the Dental Services Program, you will receive information and a dental card from DentaQuest. If you have not received your dental ID card or have questions about your dental benefits, call the Maryland Healthy Smiles Dental Program at Specialty behavioral health services (including substance use disorder) We offer only the basic primary behavioral health services that your PCP can provide. If these services are not enough to take care of your problem, you, your PCP, or your specialist doctor can request specialty behavioral health services through the Public Behavioral Health System by calling Intermediate Care Facilities for the Behaviorally Retarded (ICF-MR) services This is treatment in a care facility for people who have an intellectual disability and need this level of care. Skilled personal care services This is skilled help with daily living activities. Medical day care services This is help to improve daily living skills in a center licensed by the State or local health department, which includes medical and social services. 20

23 Transportation services We do not have to pay for your transportation to medical services, unless we send you to a far-away county to get treatment that you could not get in a closer county. We will help you arrange nonemergency transportation, if needed for a medical visit or treatment, through your city or county government (usually the county health department). Emergency transportation is provided by local fire companies (911 emergency service), but this is only for real emergencies. Nursing home and long-term care services Kaiser Permanente does not pay for your care in a nursing home, chronic rehabilitation hospital, or chronic hospital after the first 30 days. After that, the services are considered long-term care. After the first 30 days, you will not have to leave the nursing home or long-term hospital; you just will not be enrolled in Kaiser Permanente anymore. (This is something the State and Kaiser Permanente will take care of for you.) Once you are not a member of Kaiser Permanente, the State will pay for the medical treatment you need, including nursing home and other long-term care. Abortion services This medical procedure to end certain kinds of pregnancies is covered by the State only if: 1. The patient will probably have serious physical or behavioral health problems, or could die, if she has the baby; 2. She is pregnant because of rape or incest and reported the crime; or 3. The baby will have very serious health problems. Women eligible for HealthChoice only because of their pregnancy are not eligible for abortion services. Occupational, physical, and speech therapy, and audiology for children under the age of 21 The State pays for these services if medically needed. For help in finding a provider, you can call the State s Hotline at HIV/AIDS Certain diagnostic services for HIV/AIDS are paid for by the State (viral load testing, genotypic, and phenotypic or other HIV/AIDS resistance testing). Most HIV/AIDs drugs are also paid for by the State. Speech augmenting devices Equipment that helps people with speech impairments to communicate. Substance use disorder services Comprehensive assessments, individual and group counseling, methadone treatment, detox treatment, intensive outpatient, partial hospitalization and opioid maintenance. These services can be requested through the Public Behavioral Health System by calling Benefits and services not offered by Kaiser Permanente or the State These are benefits and services that Kaiser Permanente is not required to offer. We offer a few of them anyway (see page 20). The State will not offer any of the benefits and services on this list. Anything that you do not have a medical need for. Anything experimental unless part of an approved clinical trial. Autopsies. Shots for travel outside the continental United States or medical care outside the United States. Diet and exercise programs to help you lose weight, other than those offered by Kaiser Permanente. Fertility treatment services including services to reverse a voluntary sterilization. Cosmetic surgery to make you look better, but you do not need for any medical reason. Private hospital room without a medical reason such as having a contagious disease. Private duty nursing for people over 21 years old. 21

24 Orthodontist services braces to straighten teeth for people 21 years old and older, or children who do not have a serious problem that makes it difficult for them to speak or eat. Special (orthopedic) shoes and supports for people who do not have diabetes or circulation problems or are older than age 21. Routine foot care for people who do not have diabetes or circulation problems or are older than age 21. Non-prescription drugs except coated aspirin for arthritis, insulin, iron pills, and chewable vitamins for children younger than age 12. Hearing aids for people over age 21. Dental services for adults except for pregnant women (see page 19 for adult dental benefits offered by Kaiser Permanente). Self-referral services What are self-referral services? You will go to your Primary Care Provider (PCP) for most of your health care, or your PCP will send you to a specialist who belongs to MAPMG or is a participating provider. For some types of services, you can choose a health care provider who is not part of our network, and we will still pay for the service as long as the provider agrees to see you and accept payment from us. These are called self-referral services. We will also pay for any related lab work and medicine received at the same site that you receive the self-referral visit. The following are self-referred services: FAMILY PLANNING SERVICES If you choose to do so, you can go to a provider who is not a part of our network for any of these family planning services: Family planning office visit Pap test Special contraceptive supplies Diaphragm fitting IUD insertion and removal FDA approved contraceptives, including emergency contraceptives EMERGENCY SERVICES If you have a real medical emergency, you do not need a referral from your PCP to go to the emergency department (ED). If you re not sure if you should go to the ED, call for advice. After you are treated for an emergency condition, you may need additional services to make sure the emergency condition does not return. These are called post-stabilization services. We will work with the hospital staff to decide if you need these services. If you would like additional information about how this is decided, contact us at SCHOOL-BASED HEALTH CENTER SERVICES For children enrolled in schools that have a health center, there are a number of services that they can receive from the school health center. These are: Office visits and treatment for acute or urgent physical illness, including needed medicine Follow up to EPSDTs visits when needed Self-referred family planning services (listed earlier) PREGNANCY SERVICES If you were pregnant when you joined Kaiser Permanente and had already seen a provider who is not in Kaiser Permanente s network for at least one complete prenatal check-up, then you can choose to keep seeing that provider. You may see that provider all through your pregnancy, delivery, and for two months after the baby is born for follow-up, as long as the provider agrees to continue to see you. BABY S FIRST CHECK-UP BEFORE LEAVING HOSPITAL It is best to select your baby s doctor before you deliver. If the Kaiser Permanente MAPMG doctor you selected or another Kaiser Permanente doctor does not see your newborn baby for a check-up before the baby is ready to go home from the hospital, we will pay for the on-call doctor to do the check-up in the hospital. 22

25 CHECK-UP FOR CHILDREN ENTERING STATE CUSTODY Children entering foster care or kinship care are required to have a check-up within 30 days. The foster parent can choose a convenient provider to self-refer for this visit. CERTAIN PROVIDERS FOR CHILDREN WITH SPECIAL HEALTHCARE NEEDS Children with special healthcare needs may selfrefer to providers outside of the Kaiser Permanente network under certain conditions. Self-referral for children with special needs is intended to ensure continuity of care, and ensure that appropriate plans of care are in place. Self-referral for children with special healthcare needs will depend on whether or not the condition that is the basis for the child s special healthcare needs is diagnosed before or after the child s initial enrollment in an MCO. Medical services directly related to a special needs child s medical condition may be accessed out of network only if the following specific conditions are satisfied: New Enrollee: A child who, at the time of initial enrollment, was receiving these services as part of a current plan of care may continue to receive these specialty services if the pre-existing outof-network provider submits the plan of care to us for review and approval within 30 days of the child s effective date of enrollment in Kaiser Permanente. We must approve these services as medically necessary. Established Enrollee: A child who is already enrolled in Kaiser Permanente when diagnosed as having a special health care need requiring a plan of care that includes specific types of services may request a specific out-of-network provider. We must grant the request unless we have a local in-network specialty provider with the same professional training and expertise who is reasonably available and provides the same services. If we deny, reduce, or terminate the services, you can file an appeal. For information about appeals, see page 39 of this handbook. DIAGNOSTIC EVALUATION SERVICE (DES) One annual diagnostic and evaluation service (DES) visit for any enrollee diagnosed with HIV/AIDS, which we are responsible for facilitating on your behalf. RENAL DIALYSIS Some people with kidney disease need to have their blood cleaned. This is called renal dialysis. A person who needs renal dialysis does not have to go to a Kaiser Permanente participating provider for this treatment, but can choose any provider, either inside or outside of our MCO. People needing this service may be eligible for the Rare and Expensive Case Management Program (see page 30). BIRTHING CENTERS Services performed at a birthing center, including an out-of-state center located in a contiguous state (a state that borders Maryland), are covered as part of self-referred services. Notice of stopping or changing benefits, service, or health care locations If your medical office or provider moves or closes, Kaiser Permanente will send you a letter telling you to choose another provider near you. Once you have chosen a new provider, Kaiser Permanente will send you a new member ID card within 10 business days. If your benefits change for any reason, Kaiser Permanente will send you a letter telling you about the change before it happens. If you become ineligible for Medical Assistance, you will be automatically disenrolled. If you regain eligibility within 120 days, you will be automatically re-enrolled with Kaiser Permanente. 23

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27 Information on providers What is a PCP, a specialist, and specialty care? There are different kinds of providers who will give you certain types of care when you need it. Primary care provider (PCP) PCPs, also called family doctors, family practitioners, pediatricians, doctors of internal medicine, or nurse practitioners, are in charge of your medical care. Your PCP will give checkups, medical advice, immunizations, and referrals to specialists, when needed. Specialist A provider who has specific training beyond PCP training and can treat you for special medical conditions. Examples of specialists are obstetricians, dermatologists, and podiatrists. Specialty care Any care that is provided by a specialist. These services may or may not need a referral from your PCP. Specialty care services that do not need a referral are called self-referral services (see page 22). Information about your PCP and specialists To find out more information about your PCP and Kaiser Permanente specialists, you can: Look at their individual web pages at kp.org/doctor Review a list of doctors in the printed Physician Provider Directory Contact Member Services at for assistance For female enrollees, if your PCP is not a women s health specialist, you have the right to see a women s health specialist within Kaiser Permanente s network without a referral. Selecting or changing providers You may select your PCP. If you wish to change your assigned PCP, you may do so at any time for any reason. If your doctor is a Kaiser Permanente MAPMG doctor, the change will occur immediately. If your doctor is not a MAPMG provider and you make the change before the 15th of the month, your change will take place at the beginning of the following month. If you make a change after the 15th of the month, the change will not take place until after the end of the following month. To change your provider, simply: Visit kp.org, or Call Member Services at If your PCP leaves Kaiser Permanente or changes office location, we will send you a letter explaining the change, when the change starts, and how to choose a new PCP. A new ID card will be mailed to you within 10 business days. List of primary and specialty care providers, hospital providers, and pharmacy providers A list of our primary and specialty care providers, hospitals, and pharmacies in the Kaiser Permanente network can be found online at kp.org. The directory has the names and locations of doctors, hospitals, labs, radiology, behavioral health, and other health care providers and facilities in your area. If you want help finding a provider for any of our services or would like a paper copy of our Provider Directory, call Member Services at

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29 Special services Interpreter for those who do not speak English We offer interpreter services at no charge. If you need an interpreter during your next doctor visit, tell us when scheduling your appointment. For all other questions, call Member Services at A Member Services representative will provide an interpreter over the phone. Our interpreter services are available for medical appointments at Kaiser Permanente medical centers. Members visiting participating providers may use the Kaiser Permanente Language Line Services called Language Select at the provider site. To better assist you, please let Kaiser Permanente know if you need an interpreter before your appointment. Interpreter for those who are deaf or hard of hearing If you are deaf or hard of hearing and need a TTY/TDD line, we can arrange that. First call the relay services operation by dialing 711 and ask to connect to Kaiser Permanente Appointments and Advice Department at You can call us, 7 a.m. to 8 p.m., Monday through Friday. Please let us know that you need an interpreter before your appointment. Transportation services Emergency transportation: For transportation when you are having a medical emergency, call 911 or the emergency telephone number in your area. All other transportation: Transportation to a provider appointment is not covered by Kaiser Permanente. However, if you need a ride, your local health department may be able to help you with travel to scheduled doctor s visits. For transportation in your county call: Anne Arundel County Baltimore County Calvert County Ext. 460 Charles County Harford County Howard County Ext. 460 Montgomery County Prince George s County St. Mary s County For the local health department to help you, you must have a scheduled appointment with your doctor and call to make transportation arrangements a week before your appointment. On the day of your appointment, call to confirm your transportation an hour before your scheduled ride. Make sure you are ready 45 minutes before your scheduled ride and have your Kaiser Permanente ID card with you. Services for special needs populations The State has named certain groups as needing special support from the MCO. These groups are called special needs populations and include: Children with special health care needs Adults or children with a physical disability 27

30 Adults or children with a developmental disability Pregnant women and women who have just given birth Adults and children who are homeless Adults and children with HIV/AIDS Children in state-supervised care We have a process to let you know if you are in a special needs population. If you have a question about your special need(s), contact our Case Management Department at Services every special needs population receives If you are in one or more of these special needs populations, you are eligible to receive the services below to help you get the right amount and kind of care you need: A case manager A case manager will be a nurse, social worker, or other professional who may be assigned to your case soon after you join Kaiser Permanente. This person will help you and your Primary Care Provider (PCP) plan the treatment and services you need. The case manager will not only help plan the care, but will help keep track of the health care services you receive during the year and help those who give you treatment to work together. Specialists Having special needs requires you to see providers who have the most experience with your condition. Your PCP and your case manager will work together to be sure to send you to the right specialists. This will include specialists for supplies and equipment you might need. Follow-up when visits are missed If your PCP or specialist finds that you keep missing appointments, they will let us know and someone will try to get in touch with you by mail, telephone, or a visit to your home to remind you to call for another appointment. If you still miss appointments, you may be visited by someone from the local health department near where you live. Special needs coordinator We have a Special Needs Coordinator on staff. The Special Needs Coordinator will educate you about your condition and will suggest places in your area where you can get support from people who know about your needs. As a member of a special needs population, you will receive all of the services mentioned. Some groups will receive other special services. These are listed below: Adults and children with HIV/AIDS HIV/AIDS case management We have special case managers trained in dealing with HIV/AIDS issues and in linking persons with the services that they need. Diagnostic Evaluation Service (DES) One annual DES visit for any enrollee diagnosed with HIV/AIDS, which we are responsible for facilitating on the enrollee s behalf. Substance use disorder services Anyone with HIV/AIDS who needs treatment for substance use disorder will immediately be referred to the Behavioral Health System. Adults and children with physical and developmental disabilities Materials prepared in a way you can understand We have our materials reviewed by people with experience in the needs of people with disabilities. This means that the information will be presented using the right methods so that people with disabilities can 28

31 understand, whether in writing or by oral interpretation. Our staff is trained on the special communications needs of individuals with developmental disabilities. DDA services Enrollees who currently receive services through the Developmental Disabilities Administration (DDA) or under the DDA waiver can continue to receive those services. Medical equipment and assistive technology Our providers have the experience and training for both adults and children to provide medical equipment and assistive technology services. Case management Case managers are experienced in working with people with disabilities. Pregnant women and women who have just given birth Appointments Kaiser Permanente must schedule an appointment within 10 days of your request. If you cannot get an appointment, call us at Member Services at or the HealthChoice Enrollee Help Line at Link to a pediatric provider Every pregnant woman will be linked with a children s doctor whom she chooses before giving birth. A children s doctor may be a family practice doctor, pediatrician, or nurse practitioner. Prenatal risk evaluation Every pregnant woman should have a prenatal risk evaluation at the time of the first visit with the prenatal provider. If there is a risk that may affect the pregnancy and a healthy baby, someone from the Local Health Department or Kaiser Permanente will contact the pregnant woman and offer to visit her. Length of hospital stay The length of hospital stay after delivery is 48 hours for an uncomplicated vaginal delivery or 96 hours for an uncomplicated cesarean delivery. If you elect to be discharged earlier, a home visit must be provided within 24 hours after discharge. If you must remain in the hospital after childbirth for medical reasons, you may request that your newborn remain in the hospital while you are hospitalized. Additional hospitalization up to four (4) days is covered for your newborn. Follow-up We are required to schedule the newborn for a follow-up visit two weeks after discharge if no home visit has occurred, or within 30 days after discharge if there has been a home visit. Dental Pregnant women receive diagnostic, emergency, preventive, and therapeutic dental services for oral diseases. These services are provided by the Maryland Healthy Smiles Dental Program. Contact them at if you have questions about your dental benefits. Substance use disorder services Any pregnant or postpartum (2 months after delivery) woman who needs treatment for a substance use disorder will immediately be referred to the Specialty Behavioral Health System. HIV testing and counseling All pregnant women will be offered a test for HIV and will receive information on HIV infection and its effect on the unborn child. Nutrition counseling All pregnant women will be offered nutritional information to teach them to eat healthy. 29