QUEST MEMBER HANDBOOK

Transcription

1 QUEST MEMBER HANDBOOK

2 WELCOME TO ALOHACARE Dear Member, Aloha and welcome to AlohaCare! Our mission is to meet your health care needs so you can live life to its fullest. AlohaCare, a nonprofit health plan, was started in 1994 by Hawaii s community health centers. Your AlohaCare team includes 200 employees on Oahu and Hawaii Island, plus more than 2,600 health care providers to serve you wherever you live in our Island community. Your health matters to us. At AlohaCare, we work with you to keep you well and provide affordable, quality health care. From providing healthy living tips and vaccinations to treating serious illness and chronic disease, we are here for you. And, the eligible services are all free. Please read your Member Handbook to learn about your rights, benefits and responsibilities as an AlohaCare member. Some information, such as the appeals process and behavioral health services, has been updated since last year. If you have any questions, call us at (Oahu) or toll-free at (Neighbor Islands/Oahu). We are ready to help. Aloha, John McComas Chief Executive Officer AlohaCare Important Updates to the Member Handbook Pg. 15 See the updated processes for your QUEST eligibility renewal date. Pg. 50 See the additions to your member rights for grievances and appeals. Pg. 23 See the additions to your member responsibilities. Pg. 27 Learn more about our Care Management and Coordination Services. Pg. 31 Find out how AlohaCare makes decisions about new treatment options. Pg. 36 Learn more about our Behavioral Health services. Pg. 44 See a revised notice of our privacy practices. CS02_PUB_MQD 1

3 DO YOU NEED THIS HANDBOOK IN LARGE PRINT OR BRAILLE? CONTACT US BY PHONE OAHU: NEIGHBOR ISLAND/OAHU (TOLL-FREE): CONTACT US ONLINE CONTACT US BY MAIL ALOHACARE CUSTOMER SERVICE 1357 KAPIOLANI BLVD., SUITE 1250 HONOLULU, HI Members with hearing and/or speech difficulties may contact us through the Telecommunication Relay Service (TRS), available 24 hours a day, 365 days a year. TTY: If you need help: This document contains important information This contains important information. Call AlohaCare and ask for this document in a different language or to have it orally translated. It is free. Naglaon daytoy ti importante nga impormasyon. Umawag ti AlohaCare ken damagen daytoy nga dokumento iti nagduduma nga lengwahe wenno tapno maibaga da mismo ti panakatarus na nga sao. Daytoy ket libre. 2 TTY/TDD users (toll-free):

4 TABLE OF CONTENTS ALL ABOUT ALOHACARE... 9 Our Commitment to You... 9 Our Story... 9 Our Mission... 9 Our Core Values... 9 Our Corporate Culture... 9 YOUR ALOHACARE QUEST BENEFITS What is covered for keiki under 21 years old? What is covered for adults 21 years old and older? How do I get these services? What services are not covered benefits? What does medically necessary mean? CUSTOMER SERVICE We are here to help you How do I get help from AlohaCare? How do I contact Customer Service? What do I need to have ready when I call? What if I have questions? How can I make comments or suggestions? Getting additional information YOUR ALOHACARE ID CARD Always carry your AlohaCare ID Card When will I get my AlohaCare ID Card? How do I use my AlohaCare ID Card? How do I replace a lost or stolen AlohaCare ID Card? What if there is a change in my member status? What is the Eligibility Renewal Date on my AlohaCare ID Card? MAKING A DOCTOR S APPOINTMENT Make your appointments in advance How soon will I be seen? What should I do if I have to cancel an appointment? What do I need to take with me to my doctor s appointment? What if my PCP s office is closed? TTY/TDD users (toll-free):

5 YOUR PRIMARY CARE PROVIDER (PCP) What is a PCP? How do I choose a PCP? What will happen if I do not choose a PCP within 10 days? What if I to go to a doctor who is not my PCP? How can I change my PCP? When will my PCP change become effective? Are there reasons why my request to change my PCP may be denied? Can my PCP request that I be moved to another PCP? What happens if I move out-of-state or to another island? Your PCP helps control medical costs NURSE ADVICE LINE What is the Nurse Advice Line? MEMBER RIGHTS What are my rights as a member? MEMBER RESPONSIBILITIES What are my responsibilities as a member? EMERGENCY CARE What is emergency care? When should I go to an emergency room? Where should I go for an emergency? How soon will I be seen? What is post-stabilization? What if I get admitted to the hospital? Do I need a PCP referral to go to the emergency room? What is urgent care? How soon will I be seen? SPECIALIST SERVICES What if I need to see a specialist? What is a referral? What services need a referral? What services do not need a referral? How soon can I be seen by a specialist? How do I know which doctor I can see? TTY/TDD users (toll-free):

6 SPECIAL SERVICES AND PROGRAMS Care Management and Coordination Program What is Care Management and Coordination? When should I call Care Management and Coordination? How can Care Management and Coordination help me? How can I get Care Management and Coordination services? Disease Management Program What is Disease Management? How do I get this service? Do I still need to see my doctor? Special Health Care Needs Program What is a Special Health Care Need? How do I get this service? What if another Case Manager is already helping me? Coordination with Other Programs Transition of Care Quality Improvement Program How does this program help me? What if I am not happy with my doctor s services? How does AlohaCare make decisions about new technology, drugs or treatment options? SECOND OPINION How can I request a second opinion? HEALTH CARE FOR YOUR CHILD Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Childhood immunization (shots) schedule PHARMACY COVERAGE Are prescription drugs covered? How do I get my prescriptions filled? How do I get the list of covered drugs? How do I know if the list of covered drugs changes? Are there any limits on prescription drugs? What if my drug is not on AlohaCare s list of covered drugs? BEHAVIORAL HEALTH SERVICES Behavioral health services and treatment for drugs and alcohol use How soon will I be seen? What is covered by AlohaCare? TTY/TDD users (toll-free):

7 Behaviorial Health Plus Program services Department of Health (DOH) benefits Serious and Persistent Mental Illness (SPMI) FAMILY PLANNING How do family planning services help me? Do I need a referral from my PCP? How do I get family planning services? What is covered by AlohaCare? What is not covered by AlohaCare? MATERNITY CARE (PREGNANCY) What if I am pregnant? What maternity care services are covered by AlohaCare? NEWBORN COVERAGE Can I pick a PCP for my baby before the baby is born? How and when can I change my baby s PCP? How do I sign up my newborn baby? MEDICALLY NECESSARY TRANSPORTATION What if I need help getting a ride to a medical appointment? INTERPRETER SERVICES Can someone interpret for me when I talk with my doctor? Will I have to pay for someone to interpret? Who do I call for an interpreter? How can I get a face-to-face interpreter in the doctor s office? How far in advance do I need to call? OUT-OF-STATE AND OFF-ISLAND SERVICES What if my doctor needs to send me to another island or out-of-state for care? What if I get sick when I am out-of-state? What if I get sick when I am off-island for a long time? What if I get sick when I am out of the country? OUT-OF-NETWORK SERVICES What if I need to see a doctor who is not in the AlohaCare Provider Network? When would I have to pay? IMPORTANT INFORMATION YOU SHOULD KNOW Privacy Practices Other Ways PHI is Used Your rights TTY/TDD users (toll-free):

8 Your duties Report a problem AlohaCare keeps personal information private What if I am too sick to make a decision about my medical care? What is an Advance Directive? How can I tell my doctor about my Advance Directive? How can I get more information on Advance Directives? Are there limits on my Advance Directive? What if my doctor cannot help me? Fraud and Abuse What is fraud and abuse? Grievance and Appeals What is a grievance? What should I do if I have a grievance? How do I file a grievance in writing? Who do I call if I want to file a grievance verbally? What happens after AlohaCare gets my grievance? What if I am not happy with AlohaCare s response to my grievance? What is an appeal? When do I file an appeal? How do I file an appeal? How do I file an appeal in writing? How do I file an appeal verbally? What happens after AlohaCare gets my appeal? What happens with my medical care during the appeal process? What if I am not happy with the results of the appeal? Expedited Appeals How do I request an expedited appeal? What happens after AlohaCare gets my request for an expedited appeal? What if I am not happy with the results of my expedited appeal? Surveys No Incentives for Utilization Management Decisions APPENDIX A APPENDIX B APPENDIX C APPENDIX D TTY/TDD users (toll-free):

9 IMPORTANT HEALTH INFORMATION Your Name Your Phone Number Your QUEST ID# Your Doctor s Name Your Doctor s Phone Number Your Child s Name QUEST ID# Your Child s Name QUEST ID# Your Child s Name QUEST ID# Your Child s Name QUEST ID# Your Child s Name QUEST ID# Your Children s Doctor Information: 8 TTY/TDD users (toll-free):

10 ALL ABOUT ALOHACARE Our Commitment to You Welcome to AlohaCare! We care about your health and the health of your family. We believe that good health starts with timely, quality preventive care. AlohaCare is committed to working with you, your doctor and your other health care providers to get you the medical care that you need. Our Story AlohaCare was formed by a network of Hawaii community health centers in We are a non-profit health plan governed by a community Board of Directors that includes representatives from many of Hawaii s community health centers. AlohaCare is one of Hawaii s first QUEST health plans, and is committed to improving the health of Hawaii's communities. We offer QUEST health insurance to people living on Oahu, Kauai, Molokai, Lanai, Maui and Hawaii Island. Thank you for choosing AlohaCare as your QUEST health plan. We truly believe that at AlohaCare, "aloha is the difference." Our Mission Our passion is to serve the people of Hawaii in the true spirit of aloha. We provide a comprehensive continuum of quality health care to all, with special expertise in caring for those who are medically underserved and/or medically fragile. We emphasize prevention and primary care through community-governed health centers, and in partnership with physicians and other health care providers that share our compassion and aloha for our population. Our Core Values Fairness Honesty Loyalty Respect/Dignity Trust Our Corporate Culture Constructive Quality Results Positive Optimistic Responsible TTY/TDD users (toll-free):

11 YOUR ALOHACARE QUEST BENEFITS QUEST Keiki - What is covered for keiki under 21 years old? Below is a list of some of the QUEST plan benefits for keiki. Covered Services * Ambulance services in an emergency Diagnostic tests Durable medical equipment Emergency room and urgent care services Family planning services Immunizations (shots) Inpatient hospital services Medical Nutrition Therapy Medicines Other services, such as routine eye care, physical therapy, occupational therapy and speech therapy Outpatient behavioral health services. For some conditions, more services are available based on medical necessity. Outpatient hospital services Outpatient surgeries Physician services Pregnancy and newborn services Preventive care services Transportation, if medically necessary * Most of these services have no visit limits. See Appendix A (page 56) for a detailed list of your benefits. AlohaCare covers services you need to treat your medical condition or to help you stay healthy (such as a yearly wellness check-up). All of your covered services are free. That means you do not have to pay any cost-sharing or other fees when you see your doctor. Some services may need approval from AlohaCare before they can be provided to you. We will work with your doctor in these cases. Please call us if you have any questions about your benefits. 10 TTY/TDD users (toll-free):

12 QUEST Adult - What is covered for adults 21 years old and older? Below is a list of some of the QUEST plan benefits for adults. Covered Services * Ambulance services in an emergency Care Management Diagnostic tests Durable medical equipment Emergency room and urgent care services Family planning services Immunizations (shots) Inpatient hospital services Medical nutritional therapy Medicines Other services, such as routine eye care, physical therapy, occupational therapy and speech therapy Outpatient behavioral health services. For some conditions, more services are available based on medical necessity. Outpatient hospital services Outpatient surgeries Physician services Pregnancy and newborn services Preventive care services Transportation, if medically necessary * Most of these services have no visit limits. See Appendix A (page 56) for a detailed list of your benefits. AlohaCare covers services you need to treat your medical condition or to help you stay healthy (such as a yearly wellness check-up). All of your covered services are free. That means you do not have to pay any cost-sharing or other fees when you see your doctor and are within your benefit limits. Some services may need approval from AlohaCare before they can be provided to you. We will work with your doctor in these cases. Please call us if you have any questions about your benefits. How do I get these services? Your Primary Care Provider (PCP) will help you get the services you need. You will not always need to see your PCP for some of the services listed. Please see the section on Specialist Services on page 26. TTY/TDD users (toll-free):

13 What services are not covered benefits? Services that are not covered by QUEST will not be eligible for payment. Some of the services that are not covered by QUEST include: Acupuncture Chiropractic services Cosmetic surgery Hansen's Disease treatment after diagnosed, except to restore useful function Infertility services In-vitro fertilization Non-medical items such as books, radios, household items Personal care items for hygiene and grooming Pulmonary tuberculosis treatment, when treatment is available at no charge to the general public Reversal of voluntary sterilization Routine foot care Services by doctors who are not part of AlohaCare s provider network, unless we arrange for the services or if it is an emergency Sex-change operations Shots for travel Treatment that is experimental or for research Unapproved drugs * See Appendix B (page 66) for a detailed list of services that are not covered. What does medically necessary mean? AlohaCare covers care that is medically necessary when you are sick or hurt. This means that the service or supply meets all of the following guidelines: The reason for the service or supply is to treat your health problem. The treatment is the most appropriate choice received at the place that best fits your condition, and takes into account both how it could help or harm you. The treatment is known to help your health problem based on: Tested and well-known scientific information about how the treatment can help; or If no scientific information exists, the treatment is used by other providers as a standard of care; or If an expert on your health problem agrees that the treatment is needed for your health problem. The treatment is cost effective for your health problem, compared to other choices. Other choices can include not treating you at all and seeing if you get better on your own. Cost effective does not always mean the medical service with the lowest price. 12 TTY/TDD users (toll-free):

14 CUSTOMER SERVICE We are here to help you. AlohaCare s staff can help you arrange for health services. If you have many health problems or chronic (long-time) diseases and/or see many different doctors, AlohaCare Care Managers/Care Coordinators will help you and your Primary Care Physician (PCP) get the most out of your QUEST health plan. AlohaCare also looks at the types of services our members get. We review certain tests, surgeries and hospital stays to make sure that our members get the right health care at the right time. With your help and with the help of your health care providers and AlohaCare staff, we will work hard to get you quality, cost-effective health care. This will put you on the road to better health. How do I get help from AlohaCare? AlohaCare s Customer Service Department is here to help you with any questions or problems. Our Customer Service staff can tell you about: Membership Choosing or changing your Primary Care Provider (PCP) Specialists, hospitals and pharmacies Covered services How to file an appeal or grievance if you are not happy with AlohaCare or an AlohaCare provider We can help you get services if you have trouble hearing or seeing, are unable to read or write, or if English is not your first language. We can also help you if you are having trouble making an appointment or need a ride to the doctor. Please give us a call if you need help. How do I contact Customer Service? Call us Monday through Friday, 7:45 a.m. to 5 p.m. The telephone numbers for Customer Service are at the bottom of each page of this handbook. Our after-hours answering service is available to answer calls outside of our business hours. Calls made after-hours that need follow up will be returned the next business day. You may reach us by through our website for a response during business hours. Our website address is also on the bottom of each page of this handbook. You may also write to us at: AlohaCare Customer Service Department 1357 Kapiolani Blvd., Suite 1250 Honolulu, HI TTY/TDD users (toll-free):

15 What do I need to have ready when I call? Federal privacy laws require that we verify who you are before we can talk about your personal information. These laws do not allow us to talk to you about your adult family members unless they tell us we can. For example: We will ask you for your QUEST ID number and date of birth. If you are calling for an adult family member or friend, we will need them to write to us or tell us that we can talk to you about their personal information. We may need to take other steps to protect your privacy. Please talk to our staff if you would like to know more about how we keep your information private. What if I have questions? Please contact us if you have any questions about your QUEST benefits or how to get health care. Call our Customer Service Department at the number shown at the bottom of this page. How can I make comments or suggestions? We care about what you think. Contact us if you have comments or suggestions about AlohaCare or our policies and procedures. Getting additional information Please call us if you would like to know more about how AlohaCare does business, how we work or how we are organized. You may also contact us if you would like to get information about any provider in our network including medical school attended, residency completed and board certification status. YOUR ALOHACARE ID CARD Always carry your AlohaCare ID Card. (Temporary ID Card) (Permanent ID Card) 14 TTY/TDD users (toll-free):

16 When will I get my AlohaCare ID Card? You will get a temporary AlohaCare ID Card in your new member packet within 15 days of joining AlohaCare. You will get your permanent AlohaCare ID Card in the mail after you choose a Primary Care Provider (PCP). Call us right away if you: Do not get your card within two weeks after choosing your PCP Need to see a doctor before you have chosen a PCP How do I use my AlohaCare ID Card? Carry this card with you at all times. You will need it each time you: Have a doctor s appointment Go to the hospital or emergency room Pick up your medicine Get any other health care How do I replace a lost or stolen AlohaCare ID Card? If you lose your card or if your card is stolen, call us and we will send you a new one. What if there is a change in my member status? It is important for you to tell AlohaCare and your Med-QUEST office if there has been any change for you or your family. These changes include: Change of name Change of address or phone number Birth, death of the member or family member (spouse or dependent), marriage, divorce or adoption Pregnancy Permanent disability Transfer to a long-term care facility Admission to a state mental hospital or prison Accepting a job If you have or will be getting any other medical insurance, or if you are being treated for injuries from an automobile accident or a workers' compensation claim What is the Eligibility Renewal Date on my AlohaCare ID Card? Each year, you may need to renew your QUEST eligibility with Med-QUEST. Your Eligibility Renewal Date is printed on the front of your AlohaCare ID card. One month prior to your renewal date, you will receive your Eligibility Review (ER) form in the mail from Med-QUEST. Make sure you follow the instructions, fill out the form, and mail it back BEFORE the due date if required. If you do not return the form, you may lose your medical assistance. Make sure Med-QUEST always has your current address. If your ER form is returned to Med-QUEST as undeliverable mail, you will lose your medical assistance. If you do not receive your form, call Med- QUEST. Tell them you want to renew your medical assistance. AlohaCare will send you a letter in the mail and call you before your eligibility renewal date to remind you to renew your medical assistance. TTY/TDD users (toll-free):

17 MAKING A DOCTOR S APPOINTMENT Make your appointments in advance. When you want to see your Primary Care Provider (PCP), call your PCP s office ahead of time to make an appointment. Have your AlohaCare ID Card, paper and pen ready before you call your doctor. Be ready to tell the office: That you or your child is an AlohaCare member Your name or your child s name if you re making the appointment for your child Your (or your child s) QUEST ID number from your AlohaCare ID Card The reason you need an appointment Be on time for the visit and take your AlohaCare ID Card with you. How soon will I be seen? Your appointment time depends on how sick you are. For example: If your medical or behavioral health visit is URGENT, you will be seen within 24 hours. Your sick child should also be seen by his or her PCP within 24 hours. A PCP visit for a sick adult should be scheduled within 72 hours. If your medical or behavioral health visit is ROUTINE, you will be seen within 21 days. Appointments to see a specialist should be scheduled within 4 weeks. An inpatient stay that is not due to an emergency should be scheduled within 4 weeks. Please call us if you cannot get an appointment with your PCP or other providers within these times. We will work with your PCP or other providers to arrange an appointment for you. What should I do if I have to cancel an appointment? If you cannot keep your appointment, call your doctor s office as soon as you can to cancel or make another appointment. If you do not show up for your doctor s appointment, your doctor is not allowed to charge you a no-show fee. What do I need to take with me to my doctor s appointment? You must take your AlohaCare ID Card whenever you go to the doctor or get any health care services. You should also bring a list of all the medicines you are taking, including medicines that don t need a doctor s prescription. What if my PCP s office is closed? If your PCP's office is closed when you call, listen carefully to the recorded message. It should tell you how to get in touch with your PCP or another doctor for after-hours care. You can also call our Nurse Advice Line at any time by calling (see page 20 for more information) You do not need prior approval for emergency services. For information about emergency services see page 24, Emergency Care. 16 TTY/TDD users (toll-free):

18 YOUR PRIMARY CARE PROVIDER (PCP) Your AlohaCare QUEST health plan is a managed care health plan. A managed care health plan is a health care program that helps you get the highest quality of health care in the right care setting and at the time that you need the care. AlohaCare provides benefits that will help you stay well. It also has benefits to treat most health problems. Your plan benefits are provided by and through AlohaCare s network of health care providers (such as doctors, hospitals and pharmacies). One of the first choices you will be asked to make when you become an AlohaCare member is to choose your personal doctor. Your personal doctor is referred to as your PCP. Help manage your own health care by choosing a Primary Care Provider (PCP) from AlohaCare s network of doctors. What is a PCP? Your PCP is your personal doctor who you will see first for most of your health care needs. Your PCP may be a doctor, nurse practitioner or a clinic. You should see your PCP even when you are not sick, such as for a yearly check-up, to make sure that you stay healthy. If you need other services your PCP cannot provide, your PCP will help you arrange most of your care. Examples of these include health care services or tests that are done outside of your PCP s office, or surgery or a hospital stay. Your PCP will also refer you to a specialist and other services when you need them. Your PCP must make what is called a referral if you need the special services of another doctor, clinic or hospital. Some services, such as a planned hospital stay, surgery, some tests and rental of certain medical equipment may need prior approval (called a prior authorization) from AlohaCare before you can get them. Your doctors will work with us to get approval for these services. See Appendix C (page 68) for a detailed list of services that need prior authorization. Part of being a good health plan is helping members get care close to home. That s why AlohaCare partners with more than 2,200 providers across Hawaii care when you need it, where you need it. Provider Relations, AlohaCare TTY/TDD users (toll-free):

19 How do I choose a PCP? Choose a PCP as soon as you become an AlohaCare member, even if you do not need a doctor now. Call us within 10 days of receiving your new-member packet to choose a PCP. You can use our provider directory to find a PCP near you. You can also access our directory online at or call Customer Service for more information. In your new member packet, you will have a list of participating PCPs. Call or write to us to tell us your choice. Make sure you select a PCP for your child and tell us if your child has any special health care needs. You may want to select a PCP and, if needed, a behavioral health provider who has treated you in the past so can continue to receive care from a doctor you already know and trust. Tell us if you are already getting or have appointments to get other health care services. Call us if you need an updated PCP list. What will happen if I do not choose a PCP within 10 days? If you do not contact us within 10 days of getting your new-member packet: We will choose a PCP for you. The name of your PCP will be on your permanent AlohaCare ID card. Please call us if you would like to choose a different PCP. Call us if you need to see a doctor before you have picked a PCP. We will help you choose a PCP right away. What if I go to a doctor who is not my PCP? Once you have chosen your PCP, you will see him or her first for most of your health care needs. Regular check-ups and medical care are important, even if you are not sick, to keep you and your family healthy. You will get better health care results when your PCP gets to know you and understands your personal medical history. AlohaCare may not pay for services if you see a doctor who is not an AlohaCare provider unless it is an emergency. Please call your PCP before you: Go to a walk-in clinic See another doctor or health care provider Get any other health care that is not provided or arranged by your PCP You may go to any doctor on AlohaCare s list of doctors if you need: Emergency care (from a hospital emergency Sexually transmitted disease screening and room or clinic) treatment Family planning services and supplies Behavioral health services, such as counseling Women's health care, including yearly exams, or treatment for drug and alcohol use birth control, pap smears and breast exams Routine eye care (if you cannot see well and may need glasses) 18 TTY/TDD users (toll-free):

20 How can I change my PCP? Call us if you need to change your PCP. Reasons for changing your PCP include: Wanting to see the same PCP as your other family members Moving too far from your PCP Problems with your PCP or your PCP s office staff Let us know if you already have an appointment or are planning to make an appointment for any health care services. We can work together and share helpful information with your new PCP. When will my PCP change become effective? Your PCP change will take effect on the same day you call with your change request. Are there reasons why my request to change my PCP may be denied? Yes, your request to change your PCP may be denied. Reasons include: The PCP you want is not taking new patients The PCP you want is no longer with AlohaCare Can my PCP request that I be moved to another PCP? Yes, your PCP may request that you be moved to another PCP. Reasons include: You miss too many scheduled appointments You do not follow your PCP s advice You and your PCP do not get along What happens if I move out-of-state or to another island? If you move out-of-state or to another island, you will need to notify your Med-QUEST eligibility worker immediately. AlohaCare coverage is available on Oahu, Kauai, Molokai, Lanai, Maui and Hawaii Island You will need to call Med-QUEST before you can get regular care on your new island. After Med-QUEST updates your records, please call AlohaCare to choose your new PCP on your new island. If you need urgent medical care, call your doctor or us right away. TTY/TDD users (toll-free):

21 Your PCP helps control medical costs. Controlling medical costs means that you get the proper medical care at the right time to treat problems or keep you healthy. Your PCP helps control costs by treating a medical problem early, before it becomes more serious and harder to treat. You help control medical costs by seeing your PCP for regular checkups, even when you are not sick, and by receiving timely care when you are sick. Your good health is our first concern. Please let us know if you feel that your PCP is not giving you the care you need or is not referring you to doctors you need to see. NURSE ADVICE LINE What is the Nurse Advice Line? The Nurse Advice Line is available when you have a health concern and your PCP is not available. The Nurse Advice Line is available toll-free 24 hours a day, 7 days a week by calling When you call our Nurse Advice Line, you will talk to staff who can help answer your health questions and if needed, provide advice to guide you to the right type of care if you are sick or don t know what to do. Nurse Advice Line offers: Advice on when to seek urgent or emergency care Ways to treat your illness or your child s illness Convenient and quick access by phone to reliable health information General information about health care, preventive care and early detection of illness to help you stay healthy MEMBER RIGHTS What are my rights as a member? As an AlohaCare member, you have the right to: Respect, dignity, privacy, confidentiality and nondiscrimination. This includes the right to: Be treated with respect and dignity at all times Keep your medical information private Information on self-care Help to prepare a list of questions to ask your doctor General information about your illness, medication, tests or procedures Talk to your doctor in a place that is reasonably private. People not directly involved with your care may not be present unless you say it is okay. 20 TTY/TDD users (toll-free):

22 Appoint someone else to make health care decisions for you Expect all information and records involving your care, including information about who pays for your treatment, to be kept private and protected. No one may look at your medical information unless he or she is watching over the quality of your health care, or unless you say it is okay. Ask AlohaCare or your doctors to restrict the use and disclosure of your health information Ask for a copy of AlohaCare s notice of privacy practices Receive medically necessary services, no matter what your age, race, creed, sex, sexual preference, national origin or religion. We will not deny or allow fewer services solely because of your diagnosis, type of illness or health problem. Use your member rights and not be treated negatively by AlohaCare. No one may punish you for using your member rights. Ask questions and get answers about anything you do not understand. This includes the right to: Know the name, background and professional status of your health care providers. You have the right to know which doctor is mainly responsible for your care. Work with your doctor to make decisions about your health care Know and understand your medical problems, diagnosis and health care conditions and any known possible outcomes. No procedure or treatment will be started unless you understand the treatment, you are told about the chances of success, and you are told the risks along with available alternatives. This includes the right to: Work with your doctors and AlohaCare to set up a treatment plan A free second medical opinion from an AlohaCare provider when deciding on treatment An open discussion of appropriate or medically necessary treatment options for your health care conditions, regardless of cost or benefit coverage. Know about any experimental, research or educational activities having to do with your care. After you have been given this information, you can choose to participate or not. Please refer to page to see if the service is a covered benefit. Make comments and suggestions about anything that we do, including suggestions on our policies and procedures Get your medical information. This includes the right to: Look at and get copies of your medical records, unless your doctors or AlohaCare think sharing the information with you may be harmful to you or someone else Ask AlohaCare or your doctor to correct any medical information you feel is wrong. If your request is denied, you have the right to get the reason for denial in writing.»» Know who sees your medical records, unless the review of your records is for treatment, payment or health care operations (or some other reasons written in the law) TTY/TDD users (toll-free):

23 Make your wishes known when you are not able to make informed choices for yourself. This is known as an "Advance Directive." These are written instructions such as living wills, do not resuscitate orders, medical durable powers of attorney or health care proxy. Timely access to care that does not have any communication or physical access barriers. This includes the right to: Timely access to doctors you need to see, close to where you live (see How soon will I be seen? on page 16) Get women s routine and preventive health services without the need for a referral Get appointments with specialists if you have special health care needs Get care from a doctor who does not participate with AlohaCare until we can provide a doctor to care for you Have your doctors work together with you and AlohaCare Have written materials available in alternative formats or other languages Offer timely responses on prior approvals and referral requests To have the use of an interpreter to help you speak to AlohaCare staff or your doctor, or to be there with you when you see your doctor. Interpreter and translation services are free. Ask us to send mail and call you at the address or telephone number of your choice, to protect your privacy. If we cannot do that, we will let you know why. Refuse treatment to the extent it is allowed by law. You are responsible for your actions if you refuse medical care or if you do not follow your provider's advice. Know the details of any medical treatment for yourself and the minor children in your care Not having to pay for covered services unless co-payment or deductibles are required by Med-QUEST rules. This includes the right to: Not having to pay for covered health care services you got if AlohaCare closes Not having to pay for covered health care services you got if the Med-QUEST Program does not pay AlohaCare Not having to pay for covered health care services you got if AlohaCare does not pay your doctor Not having to pay extra for covered health care services you got even if we could have provided the service for less Not be forced to stay somewhere or be kept away from others as a way to control, punish or scare you. No one can make you stay somewhere or keep you away from others unless it is necessary for treatment or your safety. Get information about AlohaCare, our services, our health care practitioners and providers and your rights and responsibilities. Make suggestions about AlohaCare s Member Rights and Responsibilities statement. 22 TTY/TDD users (toll-free):

24 Use each available grievance and appeal process through AlohaCare and through Med-QUEST, and get a timely response to complaints, appeals and hearing. This includes the right to: File an appeal or grievance against AlohaCare or a provider. (Please see pages of this handbook.) AlohaCare respects your right to file an appeal or grievance. AlohaCare will help you with this process if you ask us. AlohaCare or your provider will not treat you differently if you file an appeal or grievance. File an appeal or grievance against AlohaCare, the care AlohaCare provides, or a doctor. (Please see pages of this handbook.) AlohaCare respects your right to file an appeal or grievance. AlohaCare will help you with this process if you ask us. AlohaCare or your provider will not treat you differently if you file an appeal or grievance. Get a timely response to complaints, appeals and a hearing. MEMBER RESPONSIBILITIES YOU ARE RESPONSIBLE TO: Share health status information that AlohaCare and your health care provider need in order to provide care. This includes the responsibility to: Tell your doctors everything you know about your current health, past illnesses, hospital stays, medicines and anything else about your health Tell AlohaCare and your doctor if you are taking part in any medical research tests Tell AlohaCare and your QUEST eligibility worker if you have a workers' compensation claim, personal injury or medical malpractice lawsuit, or if you have been in a car accident Tell AlohaCare and your QUEST eligibility worker if you have any other medical insurance. This includes any other insurance you had when you enrolled with QUEST/AlohaCare or any that you get after you become a member of AlohaCare. Tell your child s PCP about any shots your child already got. This includes immunizations or shots your child got from another clinic or doctor, or when living somewhere else. Always ask your child s doctor to fill out your child s immunization record and keep this list with your child s important papers. Work with your doctors to make decisions about your treatment options. This includes the responsibility to: Call your PCP before seeing other doctors. AlohaCare may not pay if you see a doctor who is not an AlohaCare provider unless it is an emergency. Call your PCP to get an appointment ahead of time. If you cannot make it to your appointment, call your doctor's office as soon as you can to cancel or make another appointment. Follow advice, care plans and instructions you agreed to with your doctor. Understand your health conditions. TTY/TDD users (toll-free):

25 Ask questions about your care to make sure you understand what you need to do. Tell your doctors or other providers if you do not understand what they are telling you about a medical procedure, word, diagnosis or care plan. Let them know if you do not understand what to do. Do the best you can to stay healthy Treat AlohaCare staff, your doctors and their office staff with respect and dignity, and cooperate with them Follow AlohaCare s policies and procedures. This includes the responsibility to: Be careful with your AlohaCare ID Card. Do not lend your AlohaCare ID Card or allow others to use your card. You may lose your QUEST benefits if you do. Have your AlohaCare ID Card with you when you go to see your doctor or go to the pharmacy Report if you suspect a QUEST member or a provider has committed fraud or abuse (please see page 49 of this handbook) Contact your Med-QUEST eligibility worker if you are subject to an annual review of your QUEST eligibility Report any changes in your status. Tell AlohaCare and Med-QUEST of any changes including marriage, divorce, birth of a child, adoption of a child, death of a spouse or child, a new job, getting other health insurance or change in your address or phone number. EMERGENCY CARE What is emergency care? Emergency services are covered 24 hours a day, seven days a week. Emergency services are covered in Hawaii and on the Mainland. Emergency services outside of the United States are not covered. You will need to pay for these services yourself. A medical emergency is when you suddenly become very sick or seriously injured, and not getting care right away could result in the following: Placing your life in danger Putting your health, a body function or body part in danger Harming yourself or another person Placing your life or your unborn baby s life in danger while you are pregnant 24 TTY/TDD users (toll-free):

26 When should I go to an emergency room? Emergency services and care include ambulance, medical screening, exams and evaluations by a doctor or other medical personnel. Emergency services include both physical and psychiatric emergency conditions, and active labor. Examples of emergencies include but are not limited to: Having trouble breathing Seizures (convulsions) Lots of bleeding Unconsciousness/blackouts (will not wake up) In a lot of pain (including chest pain) Swallowing of poison or medicine overdose Broken bones Head injury Eye injury Thoughts or actions about hurting yourself or someone else If you are not sure about when you should go to the emergency room, you can call the Nurse Advice Line for advice. See "Nurse Advice Line" on page 20 for more information. If you think you have a health emergency, call 911 or go to the nearest emergency room. You are not required to call your doctor before you go to the emergency room. Do not use the emergency room for routine health care. When you go to the emergency room, tell the emergency room staff that you are an AlohaCare member. Show them your AlohaCare ID Card. You can go to any emergency room. You do not need prior approval for emergency care. Where should I go for an emergency? Go to the nearest emergency room, hospital or urgent care. The emergency rooms and hospitals also provide post-stabilization services after your emergency. How soon will I be seen? As soon as possible. The emergency room staff will decide based on your condition. If you need help getting to the emergency room, call 911. What is post-stabilization? Post-stabilization is a covered service that you get following emergency medical care to keep your condition stable. To get the health care your condition needs, the emergency room or clinic must examine you and make sure you are well enough before they can: Allow you to leave the emergency room (discharge) to go home, or Admit you or transfer you to another hospital so you can get the care that you need What if I get admitted to the hospital? If you need to be admitted to the hospital from the emergency room, the hospital will let us know. We will notify your PCP. TTY/TDD users (toll-free):

27 Do I need a PCP referral to go to the emergency room? You do not need a referral from your PCP or approval from AlohaCare if you need emergency care. What is urgent care? Urgent care means you need medical care that is not an emergency, but needs to be taken care of within 24 hours to treat serious symptoms. If you think you need urgent care, call your PCP s office. If your PCP's office is closed when you call, listen carefully to the recorded message and follow the instructions. How soon will I be seen? You can be seen for urgent care within 24 hours after you ask to be seen. When you call, tell the person you are talking to that you need urgent care. SPECIALIST SERVICES What if I need to see a specialist? Your PCP will help you if you need to see a specialist or if you need a special service. Your PCP will make sure you get the special health care you need. What is a referral? A referral is an approval for you to get certain health care services. This includes when you need to see a special doctor or need a special service. Your PCP will help you get a referral. What services need a referral? You will need a referral for these services: Visits to a specialist Outpatient hospital services You may have to pay for services yourself if you get a service without a referral when you needed to get one. Please call us if you are not sure if a service needs a referral. What services do not need a referral? You do not need a referral for these services: Behavioral health services, such as counseling or treatment for drug and alcohol use Emergency services Qualified family planning services 26 TTY/TDD users (toll-free):

28 Routine eye care (if you cannot see well and may need glasses) Sexually transmitted disease screening and treatment Women's gynecological health care services, including yearly exams, birth control, pap smears and breast exams How soon can I be seen by a specialist? You will be seen within 4 weeks when you call to make an appointment with a specialist. If your medical need is urgent, you will be seen within 24 hours. How do I know which doctor I can see? Your new member packet includes a list of doctors and health care providers who provide these types of services. This list changes from time to time. Call us if you need the list of doctors or help with an appointment. SPECIAL SERVICES AND PROGRAMS Care Management and Coordination Program What is Care Management and Coordination? Care Management and Coordination is when we help make sure that you get the different medical services you need. It also may include helping you get other social services, too. If you have many health problems or need lots of health services, AlohaCare Care Management and Coordination will help you get medically necessary services. This way we can help you meet your health care needs. We do this by working with you and your family (if needed) and working with your PCP and other providers of care. This service is a covered benefit for QUEST members with special health care needs. When should I call Care Management and Coordination? If you are seeing many different doctors for your medical problems If you are taking many different medicines to treat and control your health problems If you are having trouble or getting a doctor appointment If you are having trouble getting to your doctor visits If you are homeless and would like assistance to find housing. A Care Coordinator can connect you with a community resource. If you are having money problems and cannot pay for shelter or food. A Care Coordinator can refer you to agencies in the community that can help. If you want to learn more about a medical condition you were told you have by your doctor, such as diabetes or asthma. A Care Manager/Care Coordinator can help you find classes or get information to help you understand your condition better. TTY/TDD users (toll-free):

29 How can Care Management and Coordination help me? Care Management and Coordination can: Help you make appointments with your doctors Assist you with transportation for medically necessary appointments Help your PCP or specialist get prior approvals for your health care services, when needed Tell you about community resources to help you with issues such as housing, financial assistance and legal assistance Assist you with post-discharge follow-up instructions How can I get Care Management and Coordination services? An initial Health Screening Survey will be sent to you when you become a member. Fill it out and mail it back to AlohaCare. Or, call us at the numbers below. What you tell us will help us work with you and your doctor to improve your health. You, a family member, or your doctor can call us and you will be referred to a Care Manager for further assistance. Disease Management Program What is Disease Management? AlohaCare has a program that helps members with certain medical problems. If you have any of the following conditions, you may benefit from this AlohaCare program: A high-risk pregnancy Asthma Congestive heart failure Diabetes Depression Our Disease Management program helps you manage your chronic disease or condition so you can be healthier and more active. How do I get this service? You, a family member or your doctor can call us. We will also call you if you have any of the problems listed above. When we call you, we will talk to you about your problem and ask you about your health care needs. We do this to see how we can help you and/or your doctors take care of you. If your doctor or your family recommends you for this program, it is up to you to decide if you want to participate and stay in the program. While you are in the program, we will work with you (and your family, if you wish) to talk about your health goals and how to reach them. We will work with your PCP and other health care providers to help you manage your chronic condition and give you support along the way. We will keep you (and your family, if you wish), your PCP and other health care providers informed of how you are doing while you are in the program. 28 TTY/TDD users (toll-free):