Our goal is to help you stay as healthy as possible. Please call Member Services toll free at with any questions.

Transcription

1 Welcome Thank you for choosing Aetna Better Health of Illinois Family Health Plan (FHP). Our goal is to provide you and your family with: The quality care you need The respect you deserve, and Excellent service We have a long tradition of caring for Illinois citizens. As a part of Aetna Better Health of Illinois Family Health Plan, we are a proven leader in health care. Our staff is dedicated to caring for our members and our community We listen to and help those we serve We understand the needs of our members We work with local health care providers to meet your needs Please read this member handbook. It tells you about your benefits, and your rights and responsibilities. The handbook and other important information about our programs and services are a click away. Visit our website to learn more. Our goal is to help you stay as healthy as possible. Please call Member Services toll free at with any questions. Sincerely, Larry Kissner Chief Executive Officer Aetna Better Health of Illinois IL

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3 Table of Contents TABLE OF CONTENTS...3 YOUR MEMBER HANDBOOK...7 Member Services...7 Open enrollment...8 Confirmation of Enrollment...8 Open Enrollment...8 Disenrollment...8 Voluntary Disenrollment...9 Change of address...9 When you join Aetna Better Health of Illinois Family Health Plan...9 MEMBER RIGHTS & RESPONSIBILITIES All members have certain rights and responsibilities. They are listed below Website information Interpretive services Aetna Better Health of Illinois Family Health PlanMember identification cards ID Card Important ID cards for newborns Consent for the treatment of minors Fraud, waste and abuse Copays HOW TO GET SERVICES PRIMARY CARE PROVIDER OR WOMEN S HEALTHCARE PROVIDER All members need a primary care provider or Women s Healthcare Provider (PCP or WHCP). 14 How do I pick my PCP/WHCP? How do I change my PCP/WHCP? Notice of provider changes or service locations How do I set up a doctor visit? How do I cancel or change a doctor visit? SPECIALTY CARE REFERRALS What is specialty care? Prior authorization Prior Authorization Steps Prior authorization process Medical necessity definition EMERGENCY CARE SERVICES, URGENT CARE AND OUT OF SERVICE AREA CARE What care is available after hours? What if I need emergency care? What is not an emergency? What if I need urgent care? Out of service area coverage

4 COVERED BENEFIT DESCRIPTIONS Waiver Services Dental Value Added Services SERVICES THAT ARE NOT COVERED Preferred Drug List Over the Counter Drugs How to Get Your Prescriptions How to find a Network Pharmacy Mail Order Prescriptions If Your Medicines Are Not on the Preferred Drug List New technology (medical procedures) Changes in benefits COORDINATION OF HEALTH CARE BENEFITS Coordination of benefits (COB) PROVIDER INFORMATION Bills for covered medical services Provider directory How do we pay our providers? WAIVER GRIEVANCES AND APPEALS Grievances Appeals Appeal Process DECISIONS ABOUT YOUR HEALTH CARE (ADVANCE DIRECTIVES & LIVING WILLS) Living Will Health Care Power Of Attorney Mental Health Treatment Preference Declaration Do Not Resuscitate (DNR) Orders Other Information MAKING SUGGESTIONS FOR CHANGES IN POLICIES OR PROCEDURES Member Advisory Committee GENERAL HEALTH INFORMATION How can adults stay healthy? How can children stay healthy? Regular checkups Clinical guidelines Family planning services CARE FOR WOMEN DURING PREGNANCY AND AFTER BIRTH Prenatal care Prenatal care before becoming effective with Aetna Better Health of Illinois Family Health Plan

5 Prenatal risk evaluation Length of hospital stay after delivery Choosing a PCP/WHCP for your baby Baby s first check up before leaving the hospital After you give birth ADULTS AND CHILDREN WITH SPECIAL NEEDS Services for special health needs populations Disease management Asthma Congestive heart failure (CHF) Chronic obstructive pulmonary disease (COPD) Diabetes Case management HIV/AIDS case management Children with special health care needs Long term care placement BEHAVIORAL HEALTH SERVICES PRIVACY NOTICE What are your rights? THANK YOU COMMON TERMS COMMON QUESTIONS

6 Topic Contact Information Other Communication Methods Please call Member Services if you want information in other formats. We have audio CD ROM, large print, cassette tape or Braille. Behavioral Health Crisis , then press 9 24 hours a day, 7 days a week Behavioral Health Services For questions about benefits or help finding a behavioral health provider, call Member Services. Complaints, Grievances or Appeals If you have a complaint, grievance or appeal, Fax: call Member Services. Claims For questions about claims or bills call Member Services. Emergency Call 911 or go immediately to the Emergency If you have a medical condition that could Room. cause serious health problems or even death if not treated immediately. Enrollment and Disenrollment Call the Illinois Client Enrollment Broker if you have questions about eligibility or enrollment. Hearing Impaired (TDD/TTY) Illinois Relay Interpreter Services Language interpretation services, including sign language, are available free of charge. Call Member Services for help. Nurse Line Transportation Medical Transportation Management (MTM) For non emergency transportation. Vision March Vision Care Prescriptions Member Services If you have questions about prescriptions, call Member Services. CVS Caremark To sign up for mail order prescriptions (home delivery), call CVS Caremark (TTY) Dental DentaQuest (TTY) 6

7 Your member handbook This member handbook is for members who are enrolled with the Aetna Better Health of Illinois Family Health Plan and have previously qualified for Temporary Assistance for Needy Families (TANF), which is a program that provides temporary financial assistance for Affordable Care Act Enrollees, pregnant women and families with one or more dependent children. TANF provides financial assistance to help pay for food, shelter, utilities, and expenses other than medical. Please take time to read your member handbook. It tells you how to get services, and your rights and responsibilities as a member. Here is what you will find in this handbook: Benefits and services with Aetna Better Health of Illinois Family Health Plan How to get health care services The role of your primary care provider (PCP/WHCP) How to get help with appointments What to do in an emergency or urgent situation Services that are covered and not covered How to file a grievance or appeal Case management programs and more If you would like a copy of this handbook in one of the ways listed below, please call Member Services: In all other languages upon request In large print On cassette tape, CD or DVD In Braille Member Services We have a team of helpful Member Services staff available to help you. Please call us toll free at , we are here 24 hours a day, 7 days a week and can answer any questions you may have. This is some of the information Member Services can give: Your rights and responsibilities Finding a PCP/WHCP to be your medical home in your area Making an appointment with your PCP/WHCP Change you PCP/WHCPHow to get care from specialists, hospitals and other providers Making an address, telephone or address change Getting a free interpreter (language services, including sign language) Getting information in a language other than English Getting information in other ways, like audio CDs, large print, cassette tape or Braille Getting a ride to your provider appointments Getting behavioral health care Getting dental care Getting your medicines Getting medical supplies Family planning Pregnancy care Where to get help for domestic violence or elder abuse How and where to get care Your benefits and health care services What is an Advance Directive How to find Advance Directive information How to file a grievance How to get a State Fair Hearing How to get a ride to medical services If you have questions, about certain health care needs, you can talk to one of our care coordinators. For example, you may have a question about an authorization, accessing services or your health care benefits. Care coordinators are either nurses or social workers. They do not take the place of your PCP/WHCP. Care coordinators are available to answer questions about services or benefits. You can call us toll free at We are here 24 hours a day, 7 days a week. Ask to talk with a care coordinator. If you call after hours, you may leave a message with a representative. If you leave a message, a care coordinator will return your call the next business day during normal business hours. If we call you, our staff will always tell you their 7

8 name, title and that they are calling from Aetna Better Health of Illinois Family Health Plan.Open enrollment Confirmation of Enrollment You will receive a confirmation letter. It has your effective date of enrollment. It shows the name, phone number and address of the primary care provider (PCP/WHCP) that you will go to for health care. Your identification (ID) card is included with the confirmation letter. Open Enrollment If you are new to Aetna Better Health, you will have 90 days from the date of your first enrollment to try the health plan. During the first 90 days, you can change health plans one time for any reason. After the 90 days, if you are still eligible for the Family Health Program, you will stay enrolled in Aetna Better Health for the next nine months. This is called lock in. At the end of your enrollment year, you will get a letter from the Illinois Client Enrollment Broker (ICEB). The letter will say that you can change health plans if you want to. The letter will give you the dates that you can make the change. You will have 60 days to change. This 60 day period is called open enrollment. You can change health plans during your 60 day open enrollment period every year. You do not have to change health plans, but you can if you want to. If you choose to change plans during open enrollment, you will be a member in the new plan at the end of your current enrollment year. Whether you pick a new plan or stay with Aetna Better Health, you will be locked into that plan for the next 12 months. Disenrollment Disenrollment means that you are no longer a member of Aetna Better Health. If you are no longer a member, that means you cannot receive services from us. These are the only two agencies that can enroll you or disenroll you. Department of Healthcare and Family Services (HFS) Illinois Client Enrollment Broker (ICEB). Call the ICEB with questions at or TTY Under certain circumstances, Aetna Better Health can ask HFS to disenroll you from our health plan. This is called disenrollment for cause. Aetna Better Health can ask that you be disenrolled for cause for the following reasons: You misuse the member ID card. In such cases, we will also report this to the Office of the Inspector General (OIG). Your behavior is disruptive, unruly, abusive or uncooperative to the point that keeping you in our health plan seriously impairs our ability to give services to you or to other members. An involuntary disenrollment request for member behavior must include proof that Aetna Better Health did the following things. Gave the member at least one verbal warning and at least one written warning of what their actions or behavior may mean Tried to educate the member regarding rights and responsibilities Offered help through care management that would help the member to stop the behaviors Determined that the member s behavior is not related to the member s medical or behavioral health Aetna Better Health does not end your enrollment because your health gets worse, your health changes or because you use covered services. We will not have you disenrolled for diminished mental capacity. We will not have you disenrolled for uncooperative or disruptive behavior caused by special needs (unless keeping you on our health plan seriously impairs Aetna Better Health s ability to furnish covered services to you or other members). We will not have you disenrolled for exercising your appeal or grievance rights. Please note: you will be disenrolled from Aetna Better Health if you move out of the service area. Aetna Better Health serves Family Health Plans members who live in the following counties only: Boone Cook 8

9 DuPage Kane Kankakee Lake McHenry Will Winnebago Voluntary Disenrollment Members can ask to leave the health plan with an oral or written request to either HFS or Aetna Better Health. Members can ask to leave the health plan for any the reasons below: The member moves out of the covered area. The member feels that Aetna Better Health does not cover the services they are seeking because of moral or religious conflict. The member needs services to be done at the same time, but not all services are covered. The member s doctor or another doctor believes that not getting the services together would put the member s health care needs at risk. A poor quality of care. A lack of access to services covered under the contract. There are limited doctors who know how to deal with the member s health care needs. Change of address It is very important for us to have your correct address. If we do not have your correct address, you may not get important notices. If you are moving please call your DHS case worker for address changes to your Medicaid case. Then call Aetna Better Health of Illinois Family Health Plan Member Services toll free at When you join Aetna Better Health of Illinois Family Health Plan You will receive a Welcome Packet in English. This packet has: A welcome letter A welcome newsletter A member handbook in English *You will receive Member ID cards for each eligible member in your family in a separately. 9

10 Member rights & responsibilities All members have certain rights and responsibilities. They are listed below. You have the right to: Be treated with respect and dignity. Get covered benefits or services regardless of gender, race, ethnicity, age, religion, national origin, sexual orientation, physical or mental disability, type of illness or condition, ability to pay or ability to speak English. Pick a doctor who works with our provider network. Not have your medical records shown to others without your approval, unless allowed by law. Privacy when you are at an office visit, getting treatment or talking to the health plan. Get information about Aetna Better Health of Illinois Family Health Plan, the services we cover, the doctors who provide care, and the member rights and responsibilities. Have your doctor tell how he or she plans to treat you. The doctor should tell you if other treatments can be used and the risks for each one no matter how much they cost or if Aetna Better Health of Illinois Family Health Plan will pay for it. Know the cost to you if you choose to get a service that Aetna Better Health of Illinois Family Health Plan does not cover. Be involved in deciding on the type of care you want or do not want. Get a second opinion from an appropriately qualified participating health care professional at no cost to you. If an Aetna Better Health of Illinois Family Health Plan provider is not available, we will help you get a second opinion from a non participating provider at no cost to you. Find out what is in your medical records, as allowed by law, and request a copy of your records. Request and receive a copy of your medical records, and request that they be amended or corrected. You can ask for a list of people who have been given a copy of your medical records. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation, as specified in other Federal regulations on the use of restraints and seclusion. Get interpretation services if you do not speak English or have a hearing impairment to help you get the medical services you need. You may ask for materials to be presented in a manner or language that you understand at no cost to you. Voice your grievances about Aetna Better Health of Illinois Family Health Plan and the care you get from your doctor. Use the methods listed in this handbook to share questions and concerns about your health care or about Aetna Better Health of Illinois Family Health Plan. Tell us ways to improve our policies and procedures, including the member rights and responsibilities. Develop Advance Directives or a Living Will, which tell how to have medical decisions made for you if you are not able to make them for yourself. Know how Aetna Better Health of Illinois Family Health Plan pays providers, controls costs and uses services. Get emergency health care services without the approval of your primary care provider (PCP/WHCP) or Aetna Better Health of Illinois Family Health Plan when you have a true medical emergency. Say no to treatment, services, or PCP/WHCPs, and be told what may happen if you refuse the treatment. You can continue to get Medicaid and medical care even if you refuse treatment. Refuse care from a doctor you were referred to and ask for a referral to a different doctor. Be told in writing by Aetna Better Health of Illinois Family Health Plan when any of your health care services requested by your PCP/WHCP are reduced, suspended, terminated, or denied. You must follow the instructions in your notification letter. You have a responsibility to: Read this handbook. It tells you about our services and how to file a grievance or appeal. Follow Aetna Better Health of Illinois Family Health Plan rules. Know the name of your PCP/WHCP. Show your ID card to each doctor before getting health services. 10

11 Protect your member ID card. Do not lose or share it with others. Use the emergency room for true emergencies only. Make and keep appointments with your doctors. If you need to cancel an appointment, it must be done at least 24 hours before your scheduled visit. Treat the doctors, staff, and people providing services to you with respect. Give all information about your health to Aetna Better Health of Illinois Family Health Plan and your doctor. This includes immunization records for members under age 21. Tell your doctor if you do not understand what they tell you about your health so that you and your doctor can make plans together about your care. Follow what you and your doctor agree to do. Make follow up appointments. Take medicines and follow your doctor s care instructions. Schedule wellness checkups. (Members less than 21 years of age need to follow the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) schedule.) Get care as soon as you know you are pregnant. Keep all prenatal appointments. Tell Aetna Better Health of Illinois Family Health Plan and your DHS case worker for address changes to their Medicaid case when your address changes. Then call Aetna Better Health of Illinois Family Health Plan Member Services toll free at Tell them about changes in your family that might affect eligibility or enrollment. Some examples are change in family size, employment, and moving out of the state of Illinois. Tell Aetna Better Health of Illinois Family Health Plan if you have other health insurance, including Medicare. Give your doctor a copy of your Living Will and/or Advance Directive. Website information ( Aetna Better Health of Illinois Family Health Plan has an easy to use website. Our website gives you easy access to: Finding a PCP/WHCP or specialist in your area Finding out about health education programs How to contact us with questions or problems General health information Benefit information Member newsletters Member Rights and responsibilities We are dedicated to protecting your privacy and we will use our best efforts to make sure that your information is protected. We have a secure website where you can create your very own personal profile and log in. When you log in for the first time, you will need to enter your member ID number listed on your card. You will be asked to pick a user name and a password. Once you have logged in, you will be able to view: Your member eligibility Your prior authorizations And much more... If you have any questions about our website, please call Member Services. Interpretive services Please call if you need help in another language. We will get you an interpreter in your language. We can also help if you need sign language interpretation. You can also use this service at your healthcare provider s office. You must call at least three business days in advance to set up this interpretation. Specialized interpretation services, such as tactile interpretation, must be set up at least ten business days in advance. This service is available at no cost to you. You can get this member handbook interpreted in another language or assistance on available treatment options and alternatives by calling Member Services at to ask for help. Aetna Better Health of Illinois Family Health PlanMember identification cards You must show ALL ID cards whenever you receive medical care. 11

12 ID Card You will get an ID card when you join. You need this ID card to get health care. Keep your ID card in a safe place. Show it whenever you need health care services. Please call us at if: Your PCP/WHCP s name or phone number are not on your ID card You don t have an ID card You lose your ID card You move or change your telephone number We will send you a new ID card. You are the only one who can use your ID card. Do not give, loan or sell your ID card to anyone. Do not give the information on the ID card to anyone. If you give your card to someone, you could have problems getting health benefits. Your baby will receive an ID card with his or her own personal Medicaid ID number. Your baby will also receive an Aetna Better Health of Illinois Family Health Plan member ID card. The name and telephone number of the doctor you picked will be on the card. If you have not picked a PCP/WHCP for your baby, you can call Member Services toll free at to pick a doctor. Consent for the treatment of minors Doctors need permission from a parent or legal guardian for children under 18 years old (minors) to give health care. The law lets doctors provide some kinds of care to patients under 18 years old, without telling the parent or guardian. The doctor decides when to get permission before treating a minor. Aetna Better Health of Illinois Family Health Plan doctors must follow all laws on the treatment of minors. Fraud, waste and abuse You must report any member or provider fraud, waste or abuse. The Department of Healthcare and Family Services Office of the Inspector General (OIG) audits and investigates fraud and abuse. The OIG is responsible for the following activities. Investigating providers suspected of overbilling or defrauding the Illinois Department of Healthcare and Family Services Medical Program Recovering overpayments Issuing administrative sanctions Referring cases of suspected fraud for criminal investigation Important ID cards for newborns When your baby is born, call your DHS caseworker to advise of baby so they can get a RIN# and added to the case. The baby follows the mom in assignment to the MCO. Call within 30 days of your baby s birth. You can make a report over the phone. Call the: Il Department of Human Services Hotline Monday Friday (except state holidays) 8:30 a.m. 5 p.m TTY users: Call Here are examples of member fraud. Lending, selling or giving your Aetna Better Health ID card to someone else Changing the information on your ID card by any means other than calling Member Services to get a new ID card 12

13 Changing information on a prescription Billing for services that were not given Ordering services that are not medically necessary Referring members to an emergency room or other services when it is not medically necessary You do not have to give your name when you call. If you do give your name, the person you are reporting will not be told that you called. Copays Aetna Better Health members do not pay copays for standard Medicaid services, medications, or additional services offered by Aetna Better Health, such as transportation. This includes dental and vision services offered through DentaQuest and March Vision. Providers may not bill Aetna Better Health members for any services, including copays. If you do receive a bill from a provider, call Member Services toll free at A Member Services representative will help you. 13

14 How to get services Primary care provider or Women s Healthcare Provider All members need a primary care provider or Women s Healthcare Provider (PCP or WHCP) What is a PCP/WHCP? This is your primary doctor that you picked when you enrolled with us. A PCP/WHCP is a medical provider who will manage your health care. PCP/WHCP include family physicians, general practitioners, internists, or pediatricians. A PCP/WHCP will help you get all the covered services you need. It is important that you talk to your PCP/WHCP about any health problems you may have. It is important to have a good relationship with your PCP/WHCP. Your doctor will get to know you and your medical history. Always listen to your PCP/WHCP about your health care and check with your PCP/WHCP before you get medical services from other doctors. You will need to show your Aetna Better Health of Illinois Family Health Plan ID cards each time you go to a doctor. How do I pick my PCP/WHCP? When you join Aetna Better Health of Illinois Family Health Plan, you will need to pick a PCP/WHCP for yourself and your eligible family members. You must pick a PCP/WHCP in the Aetna Better Health of Illinois Family Health Plan provider network. The Provider Directory has a list of PCP/ WHCPs to pick from in your area. Each eligible family member does not have to have the same PCP/WHCP. If you do not pick a PCP/WHCP, we will pick one for you. How do I change my PCP/WHCP? Your PCP/WHCP is an important part of your health care team. We want you and your doctor to work together. If you want to choose or change your PCP/ WHCP to another doctor in the Aetna Better Health of Illinois Family Health Plan provider network, call. In most cases, the PCP/WHCP change will happen on the same day as your request. You will get a new Aetna Better Health of Illinois Family Health Plan ID card with the name of your new PCP/WHCP. You may change your PCP/WHCP up to three times each benefit year without reason. Please call Member Services to speak with a representative if you would like to change your PCP/WHCP. Notice of provider changes or service locations Sometimes we will have to change your PCP/WHCP without talking to you first. If this happens, you will be allowed to pick another PCP/WHCP by calling Member Services. An example might be if your doctor decides he/ she does not want to be a part of the Aetna Better Health of Illinois Family Health Plan provider network or they move to another location. If you are not sure if a provider is in our network, we can help. Check our website or call Member Services toll free at How do I set up a doctor visit? It is important to take charge of your health care. When you get your Aetna Better Health of Illinois Family Health Plan ID card, call your PCP/WHCP for a regular checkup. This is called an Initial Health Assessment. If you went to your doctor recently because you were sick, you still need to set up a visit with your PCP/WHCP for a checkup. You should always call and set up a time before you go to see your PCP/WHCP. This will let your PCP/WHCP spend as much time with you as you need. Your PCP/WHCP may not be able to see you if you do not call first. To see your PCP/WHCP, call the office to make an appointment. Routine care visits can be scheduled within three weeks of your call. Your PCP/WHCP and/ or nurse will help you get the care you need. Doctors 14

15 offices may be open at different times. Always tell the doctor s office that you are an Aetna Better Health of Illinois Family Health Plan member and the reason you need to see the doctor. Be sure to take all your ID cards and a list of any medications you are taking. If you are going to your child s PCP/WHCP, take your child s ID cards and your child s record of shots. Sometimes, you or your children will need to see the PCP/WHCP sooner. For example, your child might have an earache. Call the PCP/WHCP s office right away and tell him or her about the child s symptoms. Ask to bring your child in that day. Most offices keep some time open just for these problems. If you need urgent care, your PCP/ WHCP will either see you within hours, or tell you where you can go to get care. How do I cancel or change a doctor visit? When you schedule a visit with a doctor, that time is important. Doctors see lots of patients and must make time for all of them. If you need to cancel or change your visit with your doctor, let the doctor s office know at least 24 hours ahead of time. This will give the doctor more time to see other patients. A good relationship with your doctor is important. Being on time and letting your doctor s office know if you must cancel helps build a good relationship. 15

16 Specialty care referrals What is specialty care? Specialty care comes from doctors (specialists) who are trained to treat certain specific problems such as your heart. Some kinds of special health care needs will mean that you need to visit a specialist instead of your PCP/WHCP. An example of a specialist could be an ear, nose and throat doctor, a surgeon, allergist or pulmonary (lung) doctor. If you have questions, ask your PCP/WHCP or call Member Services. When your PCP/WHCP sends you to see a specialist, it is called a referral. Your PCP/WHCP will suggest a specialist. Your PCP/WHCP s office may set up the visit for you or ask you to set up a time that is best for you. If you think you need to see a specialist, talk to your PCP/WHCP about it. A referral to a specialist is not required, as long as the specialist is in the Aetna Better Health of Illinois Family Health Plan provider network. Let your PCP/WHCP know if you visit a specialist, so they can help you with your care. If you need help finding a specialist, your PCP/WHCP or Member Services can help you. If a provider you want to see is not in our network, your PCP/WHCP must request prior authorization from us in order for you to see the out of network provider. Only your PCP/WHCP can make this request. It is not something you can do yourself. Specialist services that do not require your doctor s approval are called self referral services. Some examples of self referral services are family planning services and behavioral health services. Prior authorization Prior Authorization Steps 1. Your provider contacts us by phone, fax or online to ask for prior authorization. They tell us about the service and why you need it. 2. Our medical staff looks at the information to decide if the service can be approved. They may talk more with your provider. 3. If the service is approved, we tell your provider. 4. If the service is not approved, we send a letter to you and your provider. This is called a Notice of Action letter. It explains the decision. 5. You and your provider can get a copy of the medical reasons used to make a denial decision. 6. If you disagree with the decision, you can file an appeal or ask for a State Fair Hearing. See Grievance and Appeals beginning on page 31 to learn more. We do not reward a provider for denying, limiting or delaying coverage of health care services. We do not give money to staff that make medical necessity decisions to get them to turn down services. You can call Member Services toll free at if you have questions about this process. Prior authorization process 1. Your health care provider must contact Aetna Better Health of Illinois Family Health Plan with information that can support the medical necessity for the service. 2. Aetna Better Health of Illinois Family Health Plan nurses will review the services requested and decide if it can be approved based on Aetna Better Health of Illinois Family Health Plan s clinical guidelines. If the nurse cannot approve it, an Aetna Better Health of Illinois Family Health Plan doctor will review it. Our doctor may attempt to contact the requesting provider to discuss the request. 3. If the authorization is approved, your health care provider will be notified of the approval. 4. If a denial, reduction, suspension, or termination of your services happens, we will send you a Notice of Action letter. You will receive the letter at least 10 calendar days before the change to let you know. Your doctor will also be notified of this decision. More detailed information is explained in the Grievances and Appeals section of this handbook. 16

17 5. At any time, you and your provider may ask for a copy of the clinical criteria that was used to make a denial decision for medical services. 6. If you do not agree with the decision: You may file an appeal with Aetna Better Health of Illinois Family Health Plan and/or Request a State Fair Hearing Aetna Better Health of Illinois Family Health Plan does not reward or pay extra money to health care providers, staff or other people to: Deny you care Give you less care Deny tests or treatments that are medically necessary As an Aetna Better Health of Illinois Family Health Plan member you are not responsible for paying for medically necessary covered services. You may be responsible for payment when the service provided is not covered by Aetna Better Health of Illinois Family Health Plan and your provider has told you that it is not covered before you received the service. Medical necessity definition What is Medical Necessity? When your provider asks for prior authorization, they must tell us why the service is medically necessary. A service is medically necessary if it meets the descriptions below. It is appropriate. It is considered by other health professionals to be good medical practice. It meets Aetna Better Health s guidelines, policies and procedures. It is used to diagnose or treat a covered illness or injury. It is used to prevent an illness. It is used to help you get well or stay well. This definition also applies to supplies and medicines. 17

18 Emergency care services, urgent care and Out of service area care What care is available after hours? We want you to get the care you need. If you have a question about your health or if you or your child needs to get health care at night or on a weekend, call your primary care provider (PCP/WHCP) office. We require our doctors to be available to you all the time. You may have to leave a message with an answering service. They will make sure your doctor gets your message. A doctor will call you back to tell you what to do. What if I need emergency care? If you feel like your life is in danger, call or dial and go to your nearest emergency room. Important You should only use an emergency room for real, life threatening emergencies Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following: 1. Placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, 2. Serious impairment to bodily functions or 3. Serious dysfunction of any bodily organ or part. Examples of emergencies: Sharp chest pains Choking Bleeding that will not stop Passing out Poisoning Drug overdose Severe burns Extreme shortness of breath Broken bones Severe spasms or convulsions Sudden loss of feeling or not being able to move Emergency services means covered inpatient and outpatient services that are as follows: 1. Furnished by a provider that is qualified to furnish these services. 2. Needed to evaluate or stabilize an emergency medical condition. Referrals and prior authorization is not required for emergency services. You can also utilize any hospital or other setting for Emergency Services. You should not use the emergency room instead of your PCP/ WHCP for routine care. Emergency rooms are not to be used for small problems. It is better to have your PCP/WHCP treat these problems in their office. If you have an urgent problem and your doctor cannot see you right away, you can also go to an urgent care center. Urgent care is when you need care right away but you are not in danger of lasting harm or losing your life and your doctor cannot see you right away.please refer to the provider directory on line at www. aetnabetterhealth.com or call Member Services at for a list of providers and hospitals. Post stabilization care services means covered services, related to an emergency medical condition that are provided after a member is stabilized in order to maintain the stabilized condition. Always call your PCP/WHCP for follow up after an emergency. Do not go back to the Emergency Room for follow up care or treatment unless your PCP/ WHCP refers you. What is not an emergency? Examples of medical conditions that are not usually emergencies: Flu, colds and sore throats Prescription refills or requests Health conditions that you have had for a long time Back strain 18

19 What if I need urgent care? Your doctor may tell you to go to one of the urgent care and after hours centers listed in this manual for medical care during weekends or after hours. Urgent care is when you need care right away but you are not in danger of lasting harm or losing your life and your doctor cannot see you right away. Examples of medical conditions that might need urgent care: Coughing Vomiting Diarrhea Earache Flu Sore throat Colds Pink eye Stomachache Rashes Bruises A cut that may need stitches Migraines Always call your doctor for follow up care after visiting an urgent care or after hours center. Go to our website or call Member Services toll free at for the most current list of urgent cares. Out of service area coverage There are times when you may be traveling away from home and you need care. Aetna Better Health of Illinois Family Health Plan service area is the state of Illinois. When you are out of the service area, you are only covered for emergency services. Routine care out of the service area or out of the country is not covered by Medicaid. If you are out of the service area and need health care services, call your PCP/WHCP and he or she will give you instructions on what to do. (You will find your PCP/WHCP s telephone number on your Aetna Better Health of Illinois Family Health Plan ID card.) You can call us toll free at to find out if you are out of the service area. If you are not in Illinois and you think your life is in danger, go to the closest emergency room. Make sure you or someone with you shows the hospital or facility your Aetna Better Health of Illinois Family Health Plan ID card, your Medicaid ID card, and all other insurance ID cards you may have. If you receive services in the Emergency Room and you are admitted to the hospital while you are away from home, have the hospital call us at the number listed on the back of your ID card to let us know. 19

20 Covered benefit descriptions Effective January 1, 2016 All services must be medically necessary. Some services may require prior authorization. Check with your primary care provider. This list is not all inclusive. Benefits Advanced Practice Nurse services Ambulatory Surgical Treatment Center services Assistive/Augmentative communication devices Audiology services Blood, blood components and the administration thereof Chiropractic services for Enrollees under age 21 Dental services, including oral surgeons EPSDT services for Enrollees under age 21 pursuant to 89 Ill. Admin. Code Section ; excluding shift nursing for Enrollees in the MFTD HCBS Waiver for individuals who are medically fragile and technology dependent (MFTD) Family planning services and supplies FQHCs, RHCs and other Encounter rate clinic visits Home health agency visits Hospital emergency room visits Hospital inpatient services; Hospital ambulatory services Laboratory and X ray services (Contractor shall receive and transmit electronic lab values to support clinical management and for HEDIS reporting) Medical supplies, equipment, prostheses and orthoses, and respiratory equipment and supplies Mental health services provided under the Medicaid Clinic Option, Medicaid Rehabilitation Option, and Targeted Case Management Option Benefits Nursing care for Enrollees under age 21 not in the HCBS Waiver for individuals who are MFTD, pursuant to 89 Ill. Admin. Nursing care for the purpose of transitioning children from a hospital to home placement or other appropriate setting for Enrollees under age 21, pursuant to 89 Ill Nursing Facility services Optical services and supplies Optometrist services Palliative and Hospice services Pharmacy Services Physical, Occupational and Speech Therapy services Physician services Podiatric services for Enrollees under age 21 Podiatric services for diabetic Enrollees age 21 and over, and, effective January 1, 2016, podiatric services for all Enrollees age 21 and over Post Stabilization Services Practice Visits for Enrollees with special needs Renal Dialysis services Respiratory Equipment and Supplies Services to prevent illness and promote health Subacute alcoholism and substance abuse services pursuant to 89 Ill. Transplants covered under 89 Ill. Transportation to secure Covered Services 20

21 Waiver Services Agency Waiver Program Services Elderly Waiver also known as the Aging Waiver Community Care Program Illinois Department on Aging (IDoA) Division of Rehabilitation Services within DHS (DHS DRS) The Division of Rehabilitation Services within DHS (DHS DRS) Persons with Disabilities Waiver also known as the Disabilities Waiver Persons with Brain Injury Waiver also known as the Brain Injury Waiver or TBI Waiver Adult Day Service Adult Day Service Transportation Homemaker Emergency Home Response Adult Day Service Adult Day Service Transportation Environmental Accessibility Adaptations Home Delivered Meals Home Health Aide Homemaker Nursing, Intermittent Personal Care (Personal Assistant) Personal Emergency Response System Physical, Occupational, and Speech Therapy Respite Skilled Nursing Specialized Medical Equipment and Supplies Adult Day Service Adult Day Service Transportation Behavioral Services Day Habilitation Environmental Accessibility Adaptations Home Delivered Meals Home Health Aide Homemaker Nursing, Intermittent Personal Care (Personal Assistant) Personal Emergency Response System Physical, Occupational, and Speech Therapy Prevocational Services Respite Skilled Nursing Specialized Medical Equipment and Supplies Supported Employment 21

22 Agency Waiver Program Services People with HIV or AIDS Waiver also known as the AIDS Waiver Division of Rehabilitation Services within DHS (DHS DRS) Illinois Department of Healthcare and Family Services (HFS) Supportive Living Facilities Waiver also known as the SIL Waiver Adult Day Service Adult Day Service Transportation Environmental Accessibility Adaptations Home Delivered Meals. Home Health Aide Homemaker Nursing, Intermittent Personal Care (Personal Assistant) Personal Emergency Response System Physical, Occupational, and Speech Therapy Respite Skilled Nursing Specialized Medical Equipment and Supplies Also known as Assisted Living Service Services under this package include: Nursing facility services and services provided through the Home and Community Based Services waivers, except those waivers serving individuals with developmental disabilities. Dental A new benefit for you with Aetna Better Health Family Health Plan is that you can get two yearly cleaning and exams. You also have coverage for X rays. Poor dental care can affect your physical health. Please remember to make an appointment for a dental exam. We are using providers through our dental provider, DentaQuest. You can find a covered dentist on our website illinois or call Aetna Better Health member services at Family Health Plan Dental benefits also include: Eligible adults (age 21 and over) will be able to get the following dental care: Limited and comprehensive exams Restorations Dentures Extractions Sedation Also, eligible pregnant women can get these additional dental services prior to the birth of their babies: Periodic Oral Examination Teeth Cleaning Periodontal work Vision Aetna Better Health Family Health Plan works with our vision provider March Vision to offer you a large network of vision providers. We offer exams and an enhanced frame selection to all of our members. You are allowed one routine vision exam and pair of glasses every 24 months. To find an Aetna Better Health vision provider, call Aetna Better Health member services at or check our directory online at illinois. Go to Find a Provider. 22

23 Value Added Services As an Aetna Better Health Family Health Plan member, we provide value added benefits that include: Preventive dental Preventive dental with 2 cleanings per year and one set of X rays per calendar year. Health Promotion and Education Program This program will focus on the importance of wellness visits, and reward members ages 1 21 for visiting their provider. Aetna Better Health of Illinois will also have wellness activity for enrolling and achieving milestones in maternity care program and completion of care coordination health risk assessments. Criteria for members to receive up to a $50 gift card: Obstetrics Criteria One initial pre natal visit (preferably 1st trimester) + six antepartum visits + one postpartum visit/screening ($50) Lead child Criteria One lead screening within the first two years of life ($50) Well child Visits Criteria based upon age and number of visits: Six Well child visits from age two weeks to age one year ($50) Three Well child visits from age 15 months to age two years ($50) One Well child visit each year from age two years to age five years ($50). One Well child visit for the following time frames: Between ages 6 and 8 ($50) Between ages 8 and 10 ($50) Between ages 10 and 12 ($50) Between ages 12 and 14 ($50) Between ages 14 and 16 ($50) Between ages 16 and 18 ($50) Between ages 18 and 21 ($50) Source medicalcustomers/ maternalandchildhealthpromotion/pages/wellchild. aspx For more information please contact Member Services at or visit Vision Credits $30 Credit towards eyeglass frames purchased at a contracted vendor every 2 years. Member newsletters Member Newsletter benefit members needs on relevant health topics that are mailed every 3 months include: trends that you may hear/see from members about elements of Aetna Better Health Flu/Cold immunizations information Annual reminders (for HEDIS, annual notices to members ) Free health education and information Provider education shall include information related to identifying, preventing and reporting abuse, neglect, exploitation, and critical incidents. Please see aetnabetterhealth.com/illinois for more information. Disease management programs Programs that guide members to manage health with Diabetes, Asthma, CHF and COPD with future programs which will include: Hypertension, End Stage Renal Disease (ESRD) and OB Nurse advice line Not sure if you should go to the emergency department or urgent care? The Aetna Better Health 24 hour service Nurse Line can help. For answers to your questions, call Member Services

24 Services that are not covered Services that are experimental or investigational in nature; Services that are provided by a non affiliated Provider and not authorized by Aetna Better Health of Illinois, unless this Contract specifically requires that such services be Covered Services; Services that are provided without a required Referral or prior authorization as set forth in the Provider Handbook; Medical and surgical services that are provided solely for cosmetic purposes; and Diagnostic and therapeutic procedures related to infertility or sterility. Preferred Drug List You can find out if your medicines are on the preferred drug list in one of two ways. Call Member Services toll free at Have a list of your prescriptions ready when you call. Ask the representative to look up your medicines to see if they are on the list. Go online to illinois to see the list of covered drugs. Over the Counter Drugs Aetna Better Health also covers certain over the counter drugs if they are on our list. Some of these may have rules about whether they will be covered. If the rules for that drug are met, Aetna Better Health will cover the drug. Like other drugs, over the counter drugs must have a prescription from a provider for them to be covered at no cost to you. You can find out if your over the counter medicines are on the preferred drug list in one of two ways. Call Member Services toll free at Have a list of your over the counter medicines ready when you call. Ask the representative to look up your medicines to see if they are on the list. to see the list of covered over the counter drugs How to Get Your Prescriptions Here is how to get your prescriptions as an Aetna Better Health member. 1. If you need medicine, your provider will choose a drug from our list of preferred drugs. 2. Your provider will write you a prescription. Ask your provider to make sure that the medicine is on the list. 3. Take the prescription to a network pharmacy to have it filled. 4. Show your Aetna Better Health member ID card at the pharmacy. As long as you show your member ID card and use medicines from the preferred drug list, you will not have to pay for your prescriptions. How to find a Network Pharmacy You can find a network pharmacy in one of two ways. Call Member Services toll free at Ask the representative to help you find a network pharmacy in your area. Go online to our website at Click on Find A Provider. Then click on the link to CVS Caremark Pharmacies to search for a pharmacy in your area. All prescriptions must be filled at a network pharmacy. Prescriptions filled at other pharmacies that are not in the Aetna Better Health network will not be covered. Mail Order Prescriptions If you take medicine for an ongoing health condition, you can have your medicines mailed to your home. Aetna Better Health works with a company called CVS Caremark to give you this service, which you can get at no cost to you. If you choose this option, your medicine comes right to your door. You can schedule your refills and reach pharmacists if you have questions. Here are some other features of home delivery. Pharmacists check each order for safety. 24