Your 2015/2016 Member Handbook

Transcription

1 Your 2015/2016 Member Handbook Member Services TTY Services If you have any questions or need further assistance, contact UPMC for You Member Services at Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m. TTY users should call toll-free SECTION 1 1

2 Available in large print. Call Toll-free TTY #

3 Important Telephone Numbers Important Telephone Numbers at a Glance UPMC for You Member Services TTY Line PA Enrollment HealthChoices TTY Line MA Provider Compliance Hotline (includes TTY services) UPMC Health Plan Fraud and Abuse Hotline UPMC for a New Beginning Maternity Program UPMC for You Special Needs Department Important Behavioral Health Telephone Numbers at a Glance Adams County Community Care Behavioral Health Organization TTY Line Allegheny County Community Care Behavioral Health Organization TTY Line Armstrong County Value Behavioral Health TTY Line UPMC for You Health Management Programs UPMC for You Dental Benefits UPMC for You Vision Benefits Department of Human Services Hotline TTY Line UPMC MyHealth Advice Line TTY Line If you have any questions or need further assistance, contact UPMC for You Member Services at Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m. TTY users should call toll-free

4 Beaver County Value Behavioral Health TTY Line Bedford County PerformCare TTY Line Berks County Community Care Behavioral Health Organization TTY Line Blair County Community Care Behavioral Health Organization TTY Line Butler County Value Behavioral Health TTY Line Cambria County Value Behavioral Health TTY Line Cameron County Community Care Behavioral Health Organization TTY Line Clarion County Community Care Behavioral Health Organization TTY Line Clearfield County... Community Care Behavioral Health Organization TTY Line Crawford County Value Behavioral Health TTY Line Cumberland County PerformCare TTY Line Dauphin County PerformCare TTY Line Elk County Community Care Behavioral Health Organization TTY Line Erie County Community Care Behavioral Health Organization TTY Line Fayette County Value Behavioral Health TTY Line Forest County Community Care Behavioral Health Organization TTY Line Franklin County PerformCare TTY Line Fulton County Perform Care TTY Line Greene County Value Behavioral Health TTY Line Huntingdon County Community Care Behavioral Health Organization TTY Line Indiana County Value Behavioral Health TTY Line Jefferson County Community Care Behavioral Health Organization TTY Line Lancaster County PerformCare TTY Line Lawrence County Value Behavioral Health TTY Line Lebanon County PerformCare TTY Line Lehigh County Magellan Behavioral Health TTY Line McKean County Community Care Behavioral Health Organization TTY Line Mercer County Value Behavioral Health TTY Line Northampton County Magellan Behavioral Health TTY Line

5 Perry County PerformCare TTY Line Potter County Community Care Behavioral Health Organization TTY Line Somerset County PerformCare TTY Line Venango County Value Behavioral Health TTY Line Warren County Community Care Behavioral Health Organization TTY Line Washington County Value Behavioral Health TTY Line Westmoreland County Value Behavioral Health TTY Line York County Community Care Behavioral Health Organization TTY Line Emergency Numbers Ambulance:... Emergency: 911 or your local emergency services... Fire:... PCP:... Pediatrician:... Pharmacy:... Poison Control:... Police:... If your address changes, please call your caseworker. If you have any questions or need further assistance, contact UPMC for You Member Services at Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m. TTY users should call toll-free

6 Table of Contents Section 1. Welcome to UPMC for You... 1 Facts about UPMC for You What is HealthChoices? How do I sign up? Will I get a UPMC for You ID card? You can get information 24/7! How to log in to MyHealth OnLine How do I contact UPMC for You? Section 2. Member Services Is Here to Help You... 4 Our Representatives will: Provide personal assistance. Give you information on providers. Help you select or change your PCP or schedule an appointment. Send you an ID card. Tell you what is covered or not covered and how to get services. Answer questions about your bill. Help you with other services. How do I contact UPMC for You Member Services? How can the UPMC MyHealth Advice Line help me? How can MyHealth OnLine help me? How do I ask a question through MyHealth OnLine? Section 3. When to Contact Member Services and Your DHS County Assistance Caseworker... 7 Call Member Services or your caseworker when:: You move or change your phone number. You have a new family or household member. You want to change your health plan Section 4. Understanding Special Needs... 9 What is a special need? What services does the Special Needs Department provide? Is this the department I call if I have a disability or need my member materials in a language other than English? Can the Special Needs Department help me get services that UPMC for You does not cover?

7 Who works in the Special Needs Department? Who can call the Special Needs Department? How do I contact the Special Needs Department? Section 5. Get the Most From Your Benefits These services are covered: Medical services Emergency services Hospital services Skilled nursing services Pharmacy services What services are not covered? Do some prescription drugs have to be approved by UPMC for You? What pharmacy copayments do I have as a UPMC for You member? Dental benefits What other copayments do I have? Copayment Schedule (Table) Copayment Exceptions What are the service limits for each benefit year? Are there exceptions to service limits? What is my right to appeal and to a Fair Hearing? What happens to my benefits if I have other insurance or Medicare? Section 6. Get to Know Your PCP What is a primary care practitioner (PCP)? How do I choose a PCP? How many hours per week will my PCP s office be open? How long will I have to wait in the office to see my PCP? Will my PCP s office be accessible for individuals with disabilities? Will my PCP be on call? What if my PCP takes an extended leave? When can I see my new PCP? Appointment time frames New Members PCPs and ob-gyns Specialists Will my PCP need to coordinate my care with other providers? What is a patient-centered medical home? What if I want to change my PCP? What if I need to see a specialist? Can I have a specialist as my PCP? What if I need to see an obstetriciangynecologist? Are providers free to speak openly with me about treatment options? What if I want a second opinion? When do I need a referral? Can I continue care with an out-of-network provider? What if I need emergency care? What is an emergency? What if I get admitted to the hospital because of an emergency? What is a non-emergency/routine health care problem? What if I have a non-emergency admission to the hospital? What if I need medical care while I am outside the UPMC for You service area? How do I request a printed provider directory? Section 7. Other Important Providers in Your Health Care Dentists Eye care providers Home health care providers When are services provided in my home? Home medical equipment and supplies If you have any questions or need further assistance, contact UPMC for You Member Services at Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m. TTY users should call toll-free

8 What are home medical equipment (HME) and supplies? Pharmacies Section 8. Behavioral Health Services How do I get behavioral health services? What services are provided? How do I get information about filing a Behavioral Health Complaint or Grievance? Behavioral Health Managed Care Organizations (table) Section 9. Prescriptions Section 10. Managing Your Health Preventive Services What are preventive services? Where do I go for preventive services? Physical exam Blood work and other tests For children For women For men and women Immunizations/Vaccinations Vision/Dental Services for Children Through Age 20 What is an Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) exam? Who does an EPSDT exam? What will the PCP or provider do during an EPSDT exam? How often should an EPSDT exam be done? How can I remember when to have an EPSDT exam? What dental services are covered for children and young adults under the age of 21? EPSDT Expanded Services Who can get expanded services? How do I get expanded services? Early Intervention Program How do I get Early Intervention services? Services for Women Family Planning Services Where can I go for family planning services? Care When Pregnant What do I do if I am pregnant or think I am pregnant? How often do I need to see the obstetrician? Are there any special services for pregnant women? Is there a special program for pregnant women? Direct Access to Women s Care Women s Health and Cancer Rights Act Women, Infants, and Children Program (WIC) What is WIC? How do I get WIC? Health Management Programs How can a health management program help me? How can I learn more about a health management program? Programs to help you quit smoking and stop using tobacco HIV/AIDS Services Are there special services for HIV/AIDS? How do I get AIDS Waiver services? Are there specialists who are trained to treat HIV/AIDS? Routine Transportation for Appointments I do not have my own transportation. How do I get to my appointment? Does UPMC for You cover any transportation? Is emergency transportation covered? How can I get MATP services? Section 11. Utilization Management What is utilization management? Do some services have to be approved by UPMC for You? What services must have prior authorization?

9 How does UPMC for You make prior authorization decisions? What if I disagree with a decision? How do I contact UPMC for You staff with questions about the decision-making process for my care? Will UPMC for You authorize care that involves new technology? Section 12. Rights and Responsibilities Do I have rights and responsibilities as a member of UPMC for You? What are my rights? What are my responsibilities? Do I have a self-determination right? Advance Directives Living Will Health Care Power of Attorney Important facts about Advance Directives Privacy and confidentiality Privacy statement Notice of Privacy Practices Available Documents Privacy statement Notice of Privacy Practices Words to know How UPMC for You uses and discloses your Protected Health Information Other uses and disclosures Authorized use Required disclosures Individual rights Restrictions Confidential communications Copies of your information Amending information Accounting of disclosures Copies of this notice Using your rights Filing a complaint Effective date Section 13. Complaints, Grievances, and Fair Hearings What do I do if I am unhappy about a service, how I was treated, or a decision made by UPMC for You? Complaints What is a Complaint? What should I do if I have a Complaint? First level Complaint Second level Complaint External Complaint review Grievances What is a Grievance? What should I do if I have a Grievance? First Level Grievance Second Level Grievance External Grievance Review What can I do if my health is at immediate risk? Expedited Complaints and Grievances Expedited Complaint Expedited Grievance and Expedited External Grievance What kind of help can I have with the Complaints and Grievances process? Persons whose primary language is not English Persons with disabilities If you have any questions or need further assistance, contact UPMC for You Member Services at Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m. TTY users should call toll-free

10 Department of Human Services Fair Hearings How do I ask for a Fair Hearing? What happens after I ask for a Fair Hearing? When will the Fair Hearing be decided? What to do to continue getting services Expedited Fair Hearing Fraud and Abuse Hotline MA Provider Compliance Hotline Recipient Restrictions Section 14. Additional Information Quality Improvement Program HEDIS/CAHPS Requesting Information

11 Section 1. Welcome to UPMC for You Thank you for choosing UPMC for You. We are happy to be an important part of your overall health care plan. This member handbook tells you all the ways to reach us and about services you can get. Some of these services will help keep you healthy. Others will help you when you have a health problem. Please refer to this handbook whenever you have a question. Facts About UPMC for You UPMC for You is a Managed Care Organization (MCO) licensed by the Pennsylvania Department of Health and the Pennsylvania Insurance Department. Through contracts with the Department of Human Services (DHS), UPMC for You offers coverage to eligible Medical Assistance recipients throughout 40 Pennsylvania counties. UPMC for You follows the federal and state laws that affect members, such as the Civil Rights Act of 1964, the Age Discrimination Act of 1975, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and the Americans with Disabilities Act (ADA). If you have any questions or need further assistance, contact UPMC for You Member Services at Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m. TTY users should call toll-free SECTION 1 1

12 What is HealthChoices? HealthChoices is the name of the mandatory Medical Assistance managed care program. It is for most Medical Assistance recipients who live in certain counties. Recipients must enroll in one of the Department of Human Services approved physical health managed care plans. UPMC for You is a physical health managed care plan and is available to eligible individuals who live in the following counties: How do I sign up? A DHS County Assistance Office caseworker will tell you if you are able to receive Medical Assistance. UPMC for You does not decide if you can receive Medical Assistance. UPMC for You does not decide what benefits will be covered under Medical Assistance. DHS determines whether you qualify for Medical Assistance, if you will receive coverage under the HealthChoices program, and what benefits you and/or your family members will receive. If you are eligible, your enrollment will be completed through an independent enrollment broker. The broker can explain which physical health and behavioral health plans you can join, tell you how to choose a primary care practitioner (PCP), and note whether you have any special needs. If you would like to enroll, call PA Enrollment Services at or visit TTY users should call toll-free You must continue to sign up through your DHS County Assistance Office every year and be eligible to get Medical Assistance to stay enrolled and be covered by UPMC for You. For assistance in applying for benefits, please visit the PA Compass website at or contact the Benefit Helpline at SECTION 1

13 Will I get a UPMC for You ID card? Each member of your family who has picked UPMC for You will get an identification (ID) card. Show this ID card and any other medical insurance cards to UPMC for You participating providers when you get services. You still need to keep your yellow or greenish-blue ACCESS card. Do not throw it away. You may need to use your ACCESS card for other Medical Assistance services. Your UPMC for You ID card is plastic. When you get it in the mail, remove it from the letter and keep it in your wallet with your ACCESS card. See Section 2 for more information about your card. You can get information 24 hours a day/7 days a week! Staying healthy is a 24/7 task. UPMC for You knows there are plenty of questions when it comes to health resources questions that can come up at any time of day or any day of the week. Log in to MyHealth OnLine at With online tools like a personal health record, easy to use wellness programs, and detailed ways to search for providers, you are just a click away from great health information. Health resources such as activity trackers, health coaches, WebMD, and more make MyHealth OnLine an interesting place to visit and explore. In addition, you can access your benefit information (medical, pharmacy, vision, and dental) for the current and past years, and you can see your claims information for medical and pharmacy. You will have access to documents that explain the Notice of Privacy Practices, your rights and responsibilities as a member, and how to file a Complaint or a Grievance or request a Fair Hearing. You can read member newsletters, print a temporary ID card, or even change your PCP. How to log in to MyHealth OnLine Here is how to access MyHealth OnLine: 1. Go to Have your UPMC for You ID card handy. 2. If you already have a MyHealth OnLine account, choose Log In. 3. First time users, please choose Register to create an account. How do I contact UPMC for You? Call and Member Services will help you with your questions. Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m. TTY users should call toll-free See Section 3 for more information about Member Services. If you have any questions or need further assistance, contact UPMC for You Member Services at Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m. TTY users should call toll-free SECTION 1 3

14 Section 2. Member Services Is Here to Help You We try hard to be the best at everything we do. And when it comes to Member Services, we truly succeed. Member Services includes our award-winning and dedicated customer service team.* They deliver fast, personal service, and strive to answer your question on the first call. *UPMC Health Plan s Health Care Concierge Contact Center was recognized in September 2014 by J.D. Power for providing An Outstanding Customer Service Experience for the Live Phone Channel. For J.D. Power 2014 Contact Certification Program SM information, visit Our representatives will: Provide personal assistance. Member Services will provide personal service when and where you need it, at no cost to you. A representative will provide information to help you make important decisions about your medical, vision, dental, and pharmacy benefits. Give you information about providers. Member Services can give you information about participating primary care practitioners (PCP), specialists, hospitals, and other providers. You may request a copy of the most recent provider directory or view the provider directory on the UPMC for You website at Help you select or change your PCP or schedule an appointment. If you are a new member or need a PCP, we can help you select or change your PCP or schedule an appointment. If you decide that the PCP you selected does not meet your needs after you have had an appointment with him or her, call us and we can help you select and schedule an appointment with a new PCP. 4 SECTION 2

15 Send you an ID card. Your UPMC for You ID card does not replace your ACCESS card, so you should carry both cards with you. Your UPMC for You ID card is good as long as you are a UPMC for You member. New members will receive a UPMC for You ID card shortly after their effective date. Remove the ID card from the letter and keep it in your wallet with your yellow or greenish-blue ACCESS card. Be sure that you tell your PCP or other provider s office staff about all the medical insurance you have whenever you make an appointment, go to your PCP or other provider, or use any UPMC for You medical facilities. Here is what is printed on your ID card: Your name Your UPMC for You ID number Your PCP s name Telephone number of the group in which your PCP practices Telephone number for UPMC for You Member Services If you lose your ID card, visit com to request or print a temporary card. (See Section 1 for instructions on how to log in.) You can also call Member Services to ask for a new card. If you do not have your card and need services, you can use your ACCESS card and the provider will verify that you are a member of UPMC for You. If you lose your ACCESS card, call your caseworker at your County Assistance Office. Answer questions about your bill. A participating Pennsylvania Medical Assistance provider who is in the UPMC for You network cannot charge you for services or balances that are covered by UPMC for You. You are not responsible for a bill if the network provider does not receive payment for your covered services. There are some exceptions: Based on your age and benefit category, you may receive a bill if: You did not go to a participating provider. You received services that are not a covered benefit. You have a pharmacy, medical visit, diagnostic test, or other provider copayment due. You did not provide your UPMC for You ID card or other insurance information. You did not obtain a referral from your PCP or other provider when a referral was needed. You received non-emergency services in the emergency room. The provider notified you in advance of receiving the service that it was not covered and that you may be responsible. Your request for a benefit exception to the limits was denied and the provider notified you in advance of the service that you may be responsible. You obtained services while committing identity theft when using someone else s health insurance card. You did not follow the requirements of your primary insurance, such as using a provider in their network or obtaining a prior authorization if required. Tell you what is covered or not covered and how to get services. If you have any questions about what is covered by UPMC for You, call Member Services and a representative can answer your question. If you have any questions or need further assistance, contact UPMC for You Member Services at Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m. TTY users should call toll-free SECTION 2 5

16 Remember to show your UPMC for You member ID card as well as any other medical insurance cards you have when you go for your visits. This will help us pay your claim. If you get a bill that you do not think you owe, call Member Services. You will need to have the bill available so that we can help solve your problem. Help you with other services. Our Member Services representatives can help in other ways, too. They can: Help you schedule a visit with your PCP or other provider. Explain what you can do and what to expect when filing a Complaint or Grievance. Help you arrange the medical care and services you need. Help you get copies of utilization review management and clinical practice guidelines. (See Section 11.) Explain your pharmacy coverage and how to make the most of your benefits. Help you with claims questions and contact the provider, if needed, to help resolve the issue. How do I contact UPMC for You Member Services? Call Member Services at TTY users should call toll-free Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m. For questions about dental services, call Dental Member Services at Monday through Friday from 7 a.m. to 8 p.m. TTY users should call toll-free For questions about vision services, please call Vision Member Services at Monday through Friday from 8 a.m. to 7 p.m. TTY users should call toll-free How can the UPMC MyHealth Advice Line help me? You will have immediate access to health care advice 24 hours a day/7 days a week through the MyHealth Advice Line. Whether you are seeking general health advice or information regarding a specific medical issue, experienced registered nurses are available around the clock to provide you with prompt and efficient service. Call the UPMC Health Plan MyHealth Advice Line at TTY users should call toll-free If it s an emergency, call 911 or your local ambulance service. How can MyHealth OnLine help me? MyHealth OnLine is a secure member website where you can find and store information about your personal health care coverage, send inquiries to a nurse, and chat live with a Member Services representative. See Section 1 for instructions on logging in to MyHealth OnLine. How do I ask a question through MyHealth OnLine? To access the secure Member Message Center and send an inquiry to a registered nurse, follow these steps: 1. Go to and log in as a member. 2. Click on Contact Us in the top right corner of the page. 3. Click on Send a Secure Message. 4. Click Compose. 5. Click Category and select Web Nurse from the drop-down menu. 6. Fill in the subject and your question. 7. Click Submit Message. A registered nurse will respond within 24 hours of receiving your message. The MyHealth Advice Line and the Member Message Center are not substitutes for medical care. If you need emergency care, go to the nearest emergency room or call 911 or your local ambulance service. MyHealth OnLine can also be used for claim inquiries, benefit inquiries, eligibility inquiries, PCP changes, and pharmacy and ID card inquiries. Send your message by selecting a category from the drop-down menu. 6 SECTION 2

17 Section 3: When to Contact UPMC for You Member Services and Your DHS County Assistance Office Caseworker Every Medical Assistance member is assigned a County Assistance Office and a caseworker to help you along the way. You can reach your caseworker by calling the Benefit Helpline at You can reach UPMC for You Member Services by calling the number listed on the bottom of each righthand page of this handbook. Call Member Services and your caseworker when... You move, or your phone number changes. It is very important to keep your address and telephone number up to date so that you continue to receive information from the Department of Human Services and UPMC for You. If you move or change your phone number, you need to call your DHS County Assistance Office caseworker first. Your caseworker will change your address and/or phone number so you continue to receive important information about Medical Assistance. Then call UPMC for You Member Services and give them your new phone number and/ or address. If you move out of the county or state in which you currently live or will be out of the service area for more than 30 days, you must notify your caseworker at the County Assistance Office. If you move out of the UPMC for You service area, your PCP will not be able to coordinate your care. Depending on where you move, you may need to disenroll from UPMC for You. Depending on the county you move to, you may need to enroll in another managed care plan. See Section 1 for more information on disenrollment. You have a new family or household member. If you have a baby while you are a UPMC for You member, you need to call your caseworker at the County Assistance Office to have the baby added to your case. Your baby will be covered by UPMC for You If you have any questions or need further assistance, contact UPMC for You Member Services at Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m. TTY users should call toll-free SECTION 3 7

18 from the date he or she is born if the mother is a UPMC for You member. Please call Member Services soon after you have your baby so that we can help you select a PCP for your baby. After you select a PCP for your baby, you will receive a UPMC for You ID card for him or her. See Section 1 for enrollment information. Any time you add someone to your family or household, you need to call your caseworker at the County Assistance Office. Your caseworker determines Medical Assistance eligibility for your new family or household member and adds him or her to your case. If that person is eligible, he or she can be added as a new member of UPMC for You. See Section 1 for enrollment information. You want to change your health plan. Enrollment changes are completed through an independent enrollment broker. If you want or need to make a change, visit or call TTY users should call tollfree An independent enrollment specialist will help you select a new managed care plan. You will have to disenroll from UPMC for You. You are still a UPMC for You member until the disenrollment is effective. Continue to use your UPMC for You ID card until you are enrolled in your new managed care plan. 8 SECTION 3

19 Section 4. Understanding Special Needs What is a special need? A special need is when a UPMC for You member needs some extra help. This may be because you have: Physical health problems. Trouble getting health care services. Special communication needs because you have a vision or hearing impairment or you do not speak English. A need for services in your community. Handicaps or disabilities. Behavioral health problems. (UPMC for You does not manage your behavioral health services. Your behavioral health services are managed by a Behavioral Health Managed Care Organization. See Section 8 to find the Behavioral Health Managed Care organization in the county where you live that will handle your needs. The Special Needs staff can help coordinate your physical health and behavioral health care needs.) What services does the Special Needs Department provide? The Special Needs Department helps UPMC for You members understand how to get covered services. They also help identify services in the community that may help you and your family. The Special Needs Department can: Help you access the benefits you have and the health care services you need as a UPMC for You member. Identify UPMC for You participating providers, including specialists. Tell you which UPMC for You participating providers speak languages other than English and whether a provider s office is wheelchairaccessible. If you have any questions or need further assistance, contact UPMC for You Member Services at Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m. TTY users should call toll-free SECTION 4 9

20 Direct you to your behavioral health provider if you need behavioral health services. Assist you in getting language interpreter services if needed. Help identify community agencies that can provide services that UPMC for You does not cover. Help coordinate your health care with UPMC for You participating providers and other community agencies that may be helping you. Tell you about UPMC for You programs that may help you, for example, a health management program or the maternity program if you are pregnant. Provide health management for members who have many needs. Coordinate services for children who are in the custody of the Office of Children, Youth and Families or a Juvenile Probation Office. Assist you in arranging for medical transportation. Help you file a Complaint or Grievance with UPMC for You. Teach you how to manage your health. Schedule preventive services. Is this the department I call if I have a disability or need my member materials in a language other than English? Yes. You should call the Special Needs Department for these needs. Members with hearing and/or vision impairments can obtain information in large print, Braille, or audio format at no cost by calling the Special Needs Department at TTY users should call toll-free For members who do not speak English, the Special Needs Department can use a special translation telephone service. Staff from Special Needs can contact an interpreter who speaks your language. The interpreter will talk with you and the Special Needs staff so you can tell us what we can do to help you. Providers are responsible for arranging an interpreter for members who do not speak English or who communicate through American Sign Language or other forms of visual/gestural communication. The Special Needs Department can help you and your UPMC for You participating provider find a translator who can communicate for you at your appointments. Can the Special Needs Department help me get services that UPMC for You does not cover? UPMC for You understands that you or your family may need services that are not covered by UPMC for You. The Special Needs Department knows about many services provided in your community. Staff will work with you and your family to help identify which community services will meet your needs. Some services are not covered by UPMC for You, including: Support groups. Routine transportation to your doctor appointments. (See Section 10 for more information about the Medical Assistance Transportation Program.) Homemaker services, except for members with AIDS or symptomatic HIV. (See Section 10.) Home modifications such as wheelchair ramps or wider doorways. The Special Needs Department may not be able to help you get everything that you need, but they will help find you services that may be available in your community. Who works in the Special Needs Department? The Special Needs Department has trained health coaches who can help UPMC for You members who have special needs. Health coaches are nurses and social workers who can help with care coordination, weight loss, smoking cessation, community resources, exercise advice, and healthy eating tips. UPMC for You also has health coaches in doctors offices in the community. 10 SECTION 4

21 Who can call the Special Needs Department? Anyone can call the Special Needs Department to ask for help for a UPMC for You member or for information. This includes: UPMC for You members Members family or friends Hospitals, PCPs, or other providers Community agencies Any other person helping you If someone else calls for you, the Special Needs Department will contact you to see how they can help. You will be asked to complete a form that will allow us to share information and communicate with others to coordinate your care. The Special Needs Department will keep your information confidential. (See Section 12 for more information about Privacy and Confidentiality.) How do I contact the Special Needs Department? Call TTY users should call toll-free The Special Needs staff is available Monday through Friday from 7 a.m. to 8 p.m. and Saturday from 8 a.m. to 3 p.m. If you have any questions or need further assistance, contact UPMC for You Member Services at Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m. TTY users should call toll-free SECTION 4 11

22 Section 5. Get the Most From Your Benefits As a member of UPMC for You, you receive all the health care benefits covered by ACCESS. Your benefits are based on age and benefit category, which are determined by the Department of Human Services. You must be enrolled in UPMC for You on the date that services are received for services to be covered. You do not need to submit claim forms for health care benefits. You may have a small copayment for pharmacy, non-emergent emergency room visits, medical services, or diagnostic testing. Some of your health care benefits may require a prior authorization or have certain limitations. If you or your provider feels that services are not meeting your needs, a benefit or benefit limit exception may be requested. Instructions are provided in this section. If you receive a bill for services or have questions about a bill, call Member Services. These services are covered Listed below are some of the services that are covered when determined to be medically necessary: These services keep you healthy, improve your health, or are necessary to make a diagnosis. 12 SECTION 5 Medical services Visits to your PCP Visits to a specialist s office or other provider s office with a referral from your PCP (a copayment may apply) Acute or rehab services while you are in the hospital (a copayment may apply) Outpatient hospital services, ambulatory surgical center, or short procedure unit (a copayment may apply) Yearly physical exam Required general medical exams or office visits for participation in sports and/or camps Counseling to stop smoking or using other tobacco products Well-child exams, including regular checkups and immunizations/vaccines Allergy tests and shots Laboratory tests X-rays, radiation therapy, cardiograms (EKGs), and other diagnostic tests (a copayment may apply) Physical, occupational, and speech therapy (a copayment may apply)

23 Cancer treatments Nutritional counseling Kidney dialysis Home health care intermittent skilled nursing visits to perform services such as wound care and dressing changes when ordered by your provider Home health aide personal care services provided for members under the age of 21 when ordered by your provider (requires prior authorization) Medical equipment and supplies Podiatrist services (a copayment may apply) Chiropractic services (age restriction and/or a copayment may apply) Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) medically necessary expanded services for members under the age of 21 Hearing aids for members under the age of 21 Private duty nursing-skilled nursing services for members under the age of 21 when ordered by your provider (requires prior authorization) Emergency services Care in emergency room both in and out of the service area Admission to the hospital due to an emergency condition, in and out of the service area Hospital services Hospitalization, including a semiprivate room (a private room is covered if called for by a medical condition), inpatient drugs, and physician services Outpatient surgery Inpatient and outpatient anesthesia Skilled nursing services Medically necessary services provided in a skilled nursing facility (If you need these services for more than 30 days, the Fee-for-Service (ACCESS) program will pay for these services.) Diagnostic tests and therapies Pharmacy services If you qualify for Medical Assistance from the Department of Human Services, you will receive: Prescription drugs, including birth control pills/ family planning supplies, and medications to help you stop smoking, if needed. Some over-the-counter medicines with a provider s prescription. Some over-the-counter vitamins with a provider s prescription. To ask about your pharmacy benefit package, contact Member Services. What services are not covered? Listed below are some, but not all, of the services not covered by UPMC for You: Acupuncture, medically unnecessary surgery, and other procedures that are experimental or are not in accordance with customary standards of medical practice Any service found to be medically unnecessary or inappropriate Barber, beauty, telephone, and TV service provided during an inpatient stay Cosmetic surgery, except when performed in order to improve the functioning of a malformed body part, or as post-mastectomy breast reconstruction Experimental or investigative organ transplants that are not approved by the Department of Human Services Fees charged by your provider to complete forms without a medical examination Infertility services Non-emergency care in an emergency room If you have any questions or need further assistance, contact UPMC for You Member Services at Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m. TTY users should call toll-free SECTION 5 13

24 Non-emergency inpatient and outpatient medical and surgical treatment services provided out of the service area, unless approved by UPMC for You Non-emergency routine transportation (see Section 10) Prescriptions written by providers who do not participate with UPMC for You, unless approved by UPMC for You Reversal of voluntary sterilization Services and procedures not covered on the Department of Human Services Medical Assistance fee schedule* Services and procedures not covered under the EPSDT enhanced benefits program or through waiver programs for which UPMC for You is responsible Services by providers who do not participate with UPMC for You, unless approved by UPMC for You as described in Section 6 Services obtained when committing identity theft by using someone else s health insurance cards Surgical procedures, medical care, and medication provided in connection with sexchange operations Services requiring prior authorization which were not approved or for which prior authorization was not obtained (see Section 11) Sunglasses Transfer of medical records among PCPs or other providers *Please note: Benefit limitations and most exclusions do not apply to members under the age of 21. If you or your provider feels that services are not meeting your needs, have your provider contact the Utilization Management Department to request a benefit exception. The above list may not include all services that are not covered. If you have any questions about what is covered by UPMC for You, call Member Services. UPMC for You does not manage your behavioral health benefits. These services are managed by a behavioral health managed care organization (see Section 8). 14 SECTION 5 Do some prescription drugs have to be approved by UPMC for You? Yes. Some prescription drugs have to be approved by UPMC for You. This is called prior authorization. Decisions to approve or deny a medication will be made within 24 hours of receiving the request for prior authorization. If a decision cannot be made, you may receive one of the following: A 15-day supply of medication if your prescription qualifies as an ongoing medication A 72-hour supply of medication if you have an immediate need for the medication If your PCP or other provider prescribes a drug for you, you can get it filled at any UPMC for You participating pharmacy. Take the prescription form and your UPMC for You ID card to the pharmacy. If you need help locating the nearest participating pharmacy, finding out whether your prescription requires prior authorization, or obtaining more information on pharmacy benefits, call Member Services and select the number for pharmacy services. Please see the UPMC for You booklet, Your Prescription Drug Program for more information on your prescription drug program and coverage. The booklet includes a formulary, which is a list of drugs that UPMC for You covers. It also tells you which drugs require prior authorization. If you would like a copy, contact Member Services. You can also find the booklet on our website: Go to Select Shop on the top right side of page. Select Medical Assistance. Select Pharmacy. Select UPMC for You Pharmacy Guide. What pharmacy copayments do I have as a UPMC for You member? Some drugs have a copayment. A copayment is an amount that you pay to the pharmacist when you receive your prescription or over-the-counter drugs. You cannot be denied a prescription drug if you cannot pay the copayment. Tell your pharmacist if you cannot afford to pay. Your pharmacist can still try to collect the copayment.

25 Copayments are as follows: Brand-name prescription drugs and brand-name over-the-counter drugs are $3 for each new prescription or refill. Generic prescription drugs and generic over-thecounter drugs are $1 for each new prescription or refill. Many categories of drugs do not have a copayment. These drugs include anti-hypertensives (high blood pressure drugs), anti-neoplastics (cancer drugs), anti-diabetics (diabetes drugs), anti-convulsants (epilepsy drugs), cardiovascular preparations (heart disease drugs), anti-parkinson s agents (Parkinson s disease drugs), AIDS-specific agents, anti-glaucoma agents (glaucoma drugs), antipsychotics (drugs for psychosis), and anti-depressants (drugs for depression). Drugs, including immunization (shots), given by a physician do not have copayments. Dental Benefits Dental benefits for adult members include diagnostic, preventive, and restorative services. Please note, limits do exist related to dental benefits for adults, and some services may require prior authorization. Please contact Member Services for more information about benefits. Members under the age 21 receive dental benefit described in Section 10. Two frames and four lenses per year. (Note: The second pair of glasses are available if medically necessary, for example, your prescription changes.) Exception to limits can be made if medically necessary with written documentation Replacement of eyeglasses or contact lenses if they are broken or lost, or if prescription changes, provided written documentation of the necessity of the service is submitted by the provider Eyeglasses and all other vision services deemed medically necessary, provided written documentation of the necessity of the service is submitted by the provider *If you choose standard eyeglasses or contact lenses that are within the allowance, there is no cost to you. If you exceed the allowance, you will be responsible for any cost over the $100. What other copayments do I have? You will also have a copayment for some medical services you get from your provider. Certain services will have a higher copayment than others. At the time of your visit, your provider will tell you what the copayment is and ask you to pay it. You cannot be denied service if you cannot pay the copayment at that time. But you are still responsible for the copayment, and the provider may attempt to collect the copayment by billing you for the overdue amount. Vision Services For members age 21 and older: Routine vision exams twice a year $100 allowance toward eyeglasses (one frame and two lenses) or towards one pair of contact lenses and fitting per year* Glasses or contact lenses to treat cataracts or aphakia (medical condition) Specialist eye exam with referral from PCP For members under the age of 21: Routine vision exams twice a year, or more often if medically necessary $100 allowance towards eyeglasses or toward one pair of contact lenses and fitting* If you have any questions or need further assistance, contact UPMC for You Member Services at Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m. TTY users should call toll-free SECTION 5 15

26 Copayment Schedule You will have a copayment for the following visits/services: Services Adult Medical Assistance Members Ages 18 and Older Copayment Ambulance (per trip) $0 Dental care $0 Inpatient Hospital (Acute or Rehab) Per day $3 Maximum with limits $21 Medical Centers Emergency Department (non-emergent visits) $1 minimum - $3 maximum Ambulatory Surgical Center $3 Federal Qualified Health Center/Regional Health Center $0 Independent Medical/Surgical Center $2 Convenience Care or Urgent Care Centers $0 Short Procedure Unit $3 Medical Equipment Purchase $0 Rental $0 Medical Visits Certified nurse practitioner $0 Chiropractor $1-2 Doctor (PCP, ob-gyn) $0 Optometrist $0 Podiatrist $1-2 Therapy (occupational, physical, speech) $1-2 Outpatient Hospital Per visit $2 Prescriptions Generic $1 Brand $3 Diagnostic Services (not performed in a doctor s office) Medical diagnostic testing (per service) $1 Radiology diagnostic testing (per service) $1 Nuclear medicine (per service) $1 Radiation therapy (per service) $1 16 SECTION 5