Members Guide. Toll Free: 1-(844) 320-CARE (2273) Voice/TTY: 1-(844) 510-CARE (2273) For more information visit online at:

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1 1 1 Members Guide TTY is available for those who are deaf, hard of hearing or speech impaired. For more information visit online at: Keep this member guide handy for future use.

2 Table of Contents 3 Welcome to MyCare Chicago About MyCare Chicago Who do we serve? How do I reach MyCare Chicago? Can I leave MyCare Chicago? Helpful words MyCare Chicago Team Your Medical Home What is a Medical Home? Covered Counties Why is it good to have a Medical Home?.. 11 Your Primary Care Provider What is a Primary Care Provider (PCP)?.. 12 Who can be A PCP? How to pick the best PCP for you Things to remember about your PCP Changing your PCP Visiting your PCP Your Care Coordinator What is a Care Coordinator Things to remember about your Care Coordinator (CC) What if you have a problem with your CC? Talking to your CC Making An Appointment Referrals Specialist care Non-referrals Dental services Eye specialists and services Copayments Non-emergency transportation Emergency care Emergency examples For Women Family planning/birth control services. 26 Care during pregnancy Family case management Child care resource and referral WIC (Women, Infants, and Children).. 28 Early intervention Other services Services to help you stop smoking Non-emergency transportation Alcohol and substance abuse services.. 30 Prescription drugs Mental health services Your Rights And Responsibilities Rights and responsibilities Decision-making rights Privacy and security Your responsibilities Grievances And Appeals If you have a problem or complaint Grievances Appeals Privacy and Confidentiality We Are Here To Help You Call MyCare Chicago How to Change the Information we have for you Reasons MyCare Chicago may contact you. 42 Private Health Insurance (Also Called Third Party Liability Or TPL) Important phone numbers Welcome! Notes

3 4 ABOUT JOINING MYCARE CHICAGO ABOUT JOINING MYCARE CHICAGO 5 MyCare Chicago is a healthcare plan for you and your family from the Illinois Department of Healthcare and Family Services (HFS) for residents of Cook County. When you joined MyCare Chicago, you picked or were assigned to a Primary Care Provider (PCP) as your personal doctor. Your PCP and his or her staff are your medical home. In a medical home, you and your family get quality healthcare to stay healthy. AS A MEMBER OF MYCARE CHICAGO YOU HAVE: A medical home for your entire healthcare needs. A Primary Care Provider (PCP) who gets to know you well. 24 hour, 7 day a week access to a member of your healthcare team. Tools to help you understand your health risks. A Care Coordinator who will get to know you well and be able to help you get the care and information you need. MyCare Chicago Helpline for answers to questions and other help at: In MyCare Chicago, you will continue to receive the same services you currently get with your HFS Medical Card. Your services and co-payments, if you have co-payments, will be the same. If you need to find out what services are covered for you with your medical card and whether or not you will have a co-payment for certain services, you can call MyCare Chicago at: You can also call the HFS Health Benefits Hotline at: Toll Free: 1-(866) TTY: 1-(877) MyCare Chicago is a team approach to assisting individuals with their healthcare. WHO OWNS MYCARE CHICAGO? MyCare Chicago was created by doctors, clinics and hospitals that have been treating patients just like you for a long time. Four hospitals provide hospital and emergency care to children and adults including: Ann & Robert H. Lurie Children s Hospital of Chicago Swedish Covenant Hospital Norwegian American Hospital Mercy Hospital and Medical Center Six Family Health Centers and 3 large group practices with offices all over Chicago are also owners. They joined together to create MyCare Chicago to assure you get the best care available. Your medical home will be in one of the clinics of these providers. Asian Human Services Family Health Center Erie Family Health Centers Heartland Health Centers Mercy Family Health Center Near North Health Centers PCC Wellness Lurie Childrens Uptown and Lincoln Park Clinics Swedish Medical Group MyCare Chicago is also owned by a major behavioral health provider: Community Counseling Centers of Chicago (C4) C4 provides another level of care for behavioral and mental health concerns. MyCare Chicago is based right here in Cook County covering the city from North to South and East to West to assure you have access to care without having to travel too far. We work closely with all non-profit and human service organizations in your area to help meet all of your healthcare needs.

4 6 ABOUT JOINING MYCARE CHICAGO ABOUT JOINING MYCARE CHICAGO 7 WHO DO WE SERVE? We serve Medicaid eligible children, pregnant women, parents or caretaker relatives, and adults without dependent children who became eligible under the Affordable Care Act. HOW DO I REACH MYCARE CHICAGO? The Illinois Department of Healthcare and Family Services (HFS) oversees MyCare Chicago. Information about MyCare Chicago is available in English and Spanish. You can also get interpretation services. To do this, call MyCare Chicago at: You can also visit the MyCare Chicago Web site at You can find out who your PCP is if you already have one. You can learn more about MyCare Chicago and everything the program offers you. You can switch your MyCare PCP by calling Illinois Health Connect at: Toll Free: 1-(877) TTY: 1-(866) or go online at: You can always reach customer service to help you at: CAN YOU LEAVE MYCARE CHICAGO? Once you choose MyCare Chicago, you have 90 days from that date to change plans. After those 90 days, you are locked in to MyChicago for one year. After that, you need to wait one year for your next open enrollment period to change plans. There are some exceptions. To learn more about your health plan choices, please call the Illinois Client Enrollment Broker at: Toll Free: 1-(877) TTY: 1-(866) or go online at: For answers to questions and other help By Phone MyCare Chicago Helpline By Computer Visit the Web site to get more information about MyCare Chicago or to contact us by customerservice@mycarechicago.org You Can Write to MyCare Chicago Attn: Customer Service 5145 North California Chicago, Illinois It is the job of MyCare Chicago to make sure you and your family get the information you need to make the best healthcare choices.

5 8 HELPFUL WORDS THE MY CARE CHICAGO TEAM 9 Helpful Words Care Coordination MyCare Chicago will help you understand and arrange medical care and other services you need. Care Coordinator Your MyCare Chicago contact person who will assist you to understand your health care needs and services available to you. Co-payment/Co-pay This is a small fee that you may have to pay for some services, like prescription drugs. Your co-payments depend on your age and the service you receive through your HFS Medical Card. Covered Services The services you get through the HFS Medical Card. For example, coverage for non-emergency transportation and certain dental services are provided to some persons, but not to others. Call the Helpline for more information. Open 24 hours a day, the MyCare Chicago Helpline number is:: Voice/TTY 1-(844) 510-CARE (2273) HFS (The Illinois Department of Healthcare and Family Services) The Illinois State agency that runs the HFS Medical Programs MyCare Chicago (MYCARE ) A healthcare program in which you pick a PCP and have a medical home; MyCare Chicago can help you talk to your PCP and other health and community service providers and assist you in expressing your wishes and concerns. Immunizations Shots that help prevent sicknesses like measles, mumps, the flu, and chicken pox. Lab Work Blood or urine tests for illness or physicals. Medical Home A medical home is the place you go for your healthcare needs. Your medical home is where all of your records are kept. You and your family will go to your medical home to see your Primary Care Provider (PCP) when you are sick or it is time for a checkup. Prenatal Care Care that is given to a pregnant woman the whole time she is pregnant. This careis important for the mother and to assure a healthy birth for the new baby. Primary Care Provider (PCP) Your family doctor, advanced practice nurse or other healthcare provider at your medical home who takes care of you and your family. Referral May be required when you seek services with a provider that is not your PCP. Specialist A doctor who practices a special kind of medicine, like an ear, nose and throat doctor or a foot doctor. The MyCare Chicago Team and Me Although the MyCare team includes highly trained healthcare providers, the most important member of your Care Coordination team is you (or you and your child)! We work closely with you and your PCP to develop a complete health plan. You had the chance to pick your PCP, who may be your current healthcare provider and MyCare Chicago coordinates your care with you and that PCP, so that nothing falls through the cracks. As a new member of MYCARE, we will help you in following through with your health care goals and develop a plan. It is our mission to assist you in meeting your goals and improving how you feel. And if you are healthy, we want to help you stay that way! From time to time your PCP may need to refer you to a MyCare Chicago specialist. Read this Member Guide to find out which services need a referral from your PCP or ask your PCP or your Care Coordinator.

6 10 YOUR MEDICAL HOME YOUR MEDICAL HOME 11 Your Medical Home WHAT IS A MEDICAL HOME? A medical home is the place you go for healthcare. Your medical home is where all of your records are kept. You and your family will go to your medical home to see your Primary Care Provider (PCP) when you are sick and need healthcare. Your care coordinator s office may be located in your PCP s office. You can go there to see your care coordinator or your care coordinator can come to you. COVERED COUNTIES MyCare Chicago will be coordinating care for individuals in Cook County. WHY IS IT GOOD TO HAVE A MEDICAL HOME? It is good to have a medical home because you get better healthcare. When you have a medical home, your PCP will get to know you well. You will feel more comfortable talking to your PCP about your health or any problems or questions you have. That way, you and your family get the quality healthcare you need to stay healthy. Even if you are healthy and never get sick, it is good to have a medical home. MyCare Chicago (MYCARE) will help you understand your medical home, MyCare Chicago is a team approach to assist individuals with their healthcare. Team members include Registered Nurses, a Social Worker or Mental Health Worker, and in some PCPs offices peer counselors or navigators. There is always someone that will assist in you applying for and obtaining additional assistance.

7 12 YOUR PRIMARY CARE PROVIDER 13 Who can be a PCP? Your Primary Care Provider A Primary Care Provider (PCP) is the family doctor, advanced practice nurse or other healthcare provider at your medical home who takes care of you and your family. Your PCP gets to know you well. Your CC will be in contact with your PCP as needed to coordinate your health care needs. YOUR PCP WILL: Take care of you when you are sick. Help you manage diseases and other conditions like diabetes, high blood pressure, and asthma. Refer you to specialists or other healthcare providers when you need to go. Answer questions you have about your healthcare. Give you the information you need to stay healthy. Work with you to get the healthcare you need. There are many kinds of healthcare providers who may be PCPs. A PCP is most often a doctor who treats adults or children, such as a Family Practice doctor, an Internal Medicine doctor or a Pediatrician or a Resident Physician supervised by an experienced physician. Advance trained Nurses or Midwives are also PCPs. If you have questions about who can be a PCP, or which PCPs are participating in the MYCARE program, please call MyCare Chicago at: MyCare has information about your PCP available. Can a specialist be a Primary Care Provider (PCP)? In some cases, a specialist can be a PCP. A specialist can be a PCP if they join MyCare Chicago as a PCP. This means the specialist has to agree to provide primary care services (such as checkups and immunizations) and meet other requirements of PCPs. You can pick a specialist to be your PCP if you already see them for care and they are signed up as a PCP in MYCARE. For example, a pregnant woman may want her OB/GYN to be her PCP. She can do this if her OB/GYN is a PCP in MyCare Chicago. To find out if a specialist has joined MyCare Chicago as a PCP, ask your specialist or call MyCare Chicago at: If your specialist wants to be your PCP but hasn t joined MyCare Chicago, ask the specialist to call the MyCare Chicago Helpline at: Toll Free: 1-(217) Voice/TTY: 1-(855) How to pick the best PCP for you. Think about where you get healthcare now. Do you want to stay with that doctor or clinic, or do you know another doctor or clinic that you like? Call that doctor or clinic or the MyCare Chicago Helpline to see if they are part of MyCare Chicago If your doctor or clinic is part of MyCare Chicago, you can pick them as your PCP.

8 14 YOUR PRIMARY CARE PROVIDER YOUR PRIMARY CARE PROVIDER 15 THINGS TO REMEMBER ABOUT YOUR PCP You do not have to pick your current doctor to be your PCP. If you have a special need, you can pick a PCP with that special need in mind. Whenever you have a medical need, call your MyCare Coordinator or your PCP. Depending on the medical need or question you have, it will be determined whether or not you need an appointment with your PCP. If you have a problem with your PCP, we want you to talk to your PCP first to try to work it out. If you are not able to work things out with your PCP, please call your care coordinator and they can also assist you and if you are still not satisfied, you may want to change to another PCP in the MyCare Chicago plan. To change your PCP, call the Illinois Health Connect Helpline at: Toll Free: 1-(877) TTY: 1-(866) CHANGING YOUR PCP MyCare Chicago wants you to be happy with your PCP. We also hope that you keep the same doctor for your PCP. That way, your PCP gets to know you and any health issues you have. And, you get to know your PCP. But, as a MyCare Chicago member, you have the right to change your PCP. Your PCP may ask you to change to another doctor if you don t agree to follow the PCP s treatment plan, or if your PCP feels another doctor could take better care of you. If this happens, MyCare Chicago will contact both you and your PCP to discuss the reason your PCP is asking you to change PCPs. MyCare Chicago will send you a written notice before your PCP can stop treating you. If you do not agree with the reason why your PCP is asking you to change to another PCP, you can file a complaint (see Page 36). You will not have to change your PCP until the complaint process is finished. VISITING YOUR PCP It is important that you go to see your new PCPs as soon as possible. Get to know your PCP and let him or her get to know you. This way, if you or a family member needs healthcare or gets sick, the PCP will be able to give the best care. To make an appointment with your PCP, call the PCP s office and ask for an appointment. Your CC can assist you with this during visits with you. If you need help making an appointment, please call your CC or MyCare Chicago at: TTY: 1-(844) 510-CARE (2273) MyCare Chicago will help you coordinate the healthcare you need to stay healthy. Here are some things your PCP may do when you visit: Check your blood pressure. Check your blood sugar (for diabetes). Do a breast exam and PAP smear. Give you information on family planning and sexually transmitted infections. Talk with you about substance abuse and mental health. Do screenings, such as rectal exams for older adults and referrals for mammograms. Speak with you about quitting smoking, healthy eating and other things important to your health. Of course, if you are sick or get hurt, call your PCP or your MyCare Coordinator as soon as possible. If it is an emergency, go directly to the nearest Emergency Room or call (if available in your area). If you think you may be pregnant, see your PCP or an OB/GYN right away. If you want to change your PCP for any reason, call the Illinois Health Connect Helpline at: Toll Free: 1-(877) TTY: 1-(866)

9 16 WHAT IS A CARE COORDINATOR 17 Your Care Coordinator will: Teach you about your health care conditions and how they are managed. Help you manage disease and other conditions like diabetes, high blood pressure, and asthma. Assist you to learn how to live with and manage your health conditions on a day-to-day basis. Assist you to obtain appointments with your PCP and other specialists or healthcare providers you need to see. What is a Care Coordinator? A Care Coordinator is the nurse, social worker, mental health specialist or community navigator who coordinates care for you with your medical home and other providers. Your MyCare Coordinator gets to know you well. At MyCare Chicago, there are nurses who evaluate whether you need a MyCare Coordinator or whether your PCP care coordination team will provide you what you need. If you ever have a doubt, call the MyCare Coordinator. Assist you with obtaining transportation to get to your healthcare appointments. Answer questions you have about your healthcare. Give you the information you need to stay healthy. Work with you to get the healthcare (both physical and mental health) and social service assistance you need. THINGS TO REMEMBER ABOUT YOUR MYCARE COORDINATOR: Your MyCare Coordinator wants to help you live a healthier life so call your MyCare Coordinator when you have questions or concerns about your health. And you know, your PCP or clinic have staff available to address urgent issues 24 hours aday. Whenever you have a medical need, call your PCP or MyCare Coordinator. Your MyCare Coordinator will make an appointment for you or answer your questions. Your MyCare Coordinator will assist you after a hospitalization or emergency room visit to ensure you have the services and support you need. WHAT IF YOU HAVE A PROBLEM WITH YOUR MYCARE COORDINATOR? If you have a problem with your MyCare Coordinator, we want you to talk to your MyCare Coordinator to explain the problem. If you are not able to work things out with your MyCare Coordinator, you may want to change your MyCare Coordinator. To change your MyCare Coordinator, call the MyCare Chicago Helpline at: Ask to speak to the Care Coordination Director.

10 18 WHAT IS A CARE COORDINATOR WHAT IS A CARE COORDINATOR 19 TALKING TO YOUR MYCARE COORDINATOR As soon as MyCare Chicago receives information that you have enrolled, MyCare Chicago will send you a survey and follow-up with a call to ask you a few questions about your health needs and schedule an appointment with your PCP for your annual exam. To make an appointment with your MyCare Coordinator, call MyCare Chicago s office and ask for an appointment at: MyCare Chicago assists you to obtain the healthcare you need to stay healthy. Here are some things your MyCare Coordinator might talk to you about: Taking a survey to learn more about your health. Checking your blood pressure. Assisting you in learning to check your blood sugar (for diabetes) and record the information. Assisting you to scheduled visits with providers who can provide prevention services for you (mammograms, screenings, and immunizations). Give you information on family planning and sexually transmitted infections. Talk with you about substance abuse and mental health. Speak with you about quitting smoking, healthy eating and other things important to your health. Provide you with community services in your area that may be beneficial to you. Link you with community services providers so that you get the care and support you need.

11 20 MAKING AN APPOINTMENT 21 Referrals SPECIALIST CARE Making an Appointment Call your PCP if you need medical help. Call when you first notice a problem. Your PCP will make an appointment or answer any questions you may have. Dealing with a problem early may prevent a trip to the emergency room. If you are unsure, have questions or are not sure what to do call a MyCare Coordinator at MyCare Chicago Helpline at: TTY: 1-(844) 510-CARE (2273) When you call your PCP s office for an appointment, tell the office why you need to see him or her. Your PCP office will decide if you need care right away. If you have an emergency, your PCP office will tell you to go to the nearest Emergency Room or call (if available in your area). Page 24 gives more information about Emergency Care. If you are going to be late for an appointment or cannot make it, call the PCP s office so you can set a new date and time. Some offices allow walk-in visits or urgent care visits. This means that you can go without an appointment and still be seen. Walk-ins may have to wait longer to see the PCP. If you want to know if your PCP allows walk-ins, ask the staff at your PCP s office. Your PCP may say you need special medical care. Your PCP working with a MyCare Coordinator will make a referral to the Specialist. MyCare Chicago can help you coordinate your appointments and the healthcare you get from specialists. Many MyCare Specialists will not make an appointment without a referral from your PCP. If you need help finding a specialist, ask your PCP, or call the MyCare Coordinator or the MyCare Chicago Helpline at: TTY: 1-(844) 510-CARE (2273) NO REFERRAL NEEDED In MyCare Chicago, you DO NOT NEED A REFERRAL from your PCP for: Services provided by another MyCare Chicago PCP grouped with your assigned PCP Family Planning OB/GYN Services Emergency Room Services Your PCP does not know how long it will take to see each person. Please be patient if you have to wait. Emergency and Non-Emergency Transportation Prescriptions Dental Services Eye Exams and Services Shots/Immunizations Mental Health Services

12 22 MAKING AN APPOINTMENT MAKING AN APPOINTMENT 23 Drug or Alcohol Treatment Services to treat sexually transmitted infections Services to treat tuberculosis Hospital Services Home Health Care Services provided by: Local Health Departments Mobile vans Community Health Clinic Homeless Sites and Migrant Health Centers DENTAL SERVICES You DO NOT NEED A REFERRAL from your PCP for dental services. Medicaid covers dental services for children and adults. These services include visits to prevent disease, detect problems and restore your teeth - like exams, teeth cleaning, cavity filling, root canals, and extractions. In some cases, there may be a copay for services, but there are no copays for exams. For adults, there may also be limitations on how often you can get a service. Certain services require you to get prior approval before you can receive the service. Under the dental benefit, we encourage you to go to a dentist for an oral exam. At the exam, your dentist will develop a treatment plan for you. If the treatment plan includes a covered dental service that requires prior approval, the dentist will request the approval. If approved, the dentist can perform the service. If you have any questions about finding a dentist or what is covered under your dental benefit, call the MyCare Chicago or Dental Services at Toll-Free TTY EYE SPECIALISTS AND SERVICES An eye specialist is called an ophthalmologist. To see an ophthalmologist because of eye disease or eye injury, you DO NEED A REFERRAL from your PCP. Call the MyCare Chicago Helpline at: TTY: 1-(844) 510-CARE (2273) Vision screening helps identify children who may have visual problems. Vision problems often go untreated because they are hard to notice. Without vision screening, vision problems may not be found for you. Vision problems could lead to educational or medical problems in children. You DO NOT NEED A REFERRAL from your PCP for vision services. The Medicaid services you receive include vision services. All members are eligible for eye exams. Adults are eligible for an eye exam and pair of glasses every two years. Children under the age of 21 are eligible for annual exams. You can make an appointment with any HFS vision care provider. Call either MyCare Chicago or IHC. Vision services include: Vision screenings for preschool and school age children Eye exams Eyeglasses A second pair of eyeglasses if glasses are lost, broken or medically necessary. Only certain eyeglass frames COPAYMENTS AND BALANCE BILLS Some medical services require you to pay a co-payment. It is important to know that providers cannot bill you for any services covered by HFS. Providers also cannot bill you for any unpaid balances for covered services over and above the co-payment amounts. Providers are also not allowed to send you a bill, even if HFS does not pay them, except for the co-payment amounts. The only time a provider can bill you for services provided is if they inform you before your appointment that they will not accept your medical card and you will be responsible for payment. If you get a bill for a service that you think should be covered, call the MyCare Chicago Helpline at: Toll Free: 1-(217) TTY: 1-(855) NON EMERGENCY TRANSPORTATION You DO NOT NEED A REFERRAL from your PCP for non-emergency

13 24 MAKING AN APPOINTMENT MAKING AN APPOINTMENT 25 transportation services. If it is hard for you to get to your medical appointments either because you do not have a car to use or because you cannot afford the gas, we will help you get a ride to your PCP or clinic. This is not for ambulance services. Medicaid covers non-emergency transportation to the nearest possible provider only. To see if you qualify for non-emergency transportation services, call either the MyCare Chicago Helpline or First Transit at Toll-Free TTY You can call between 8:00 a.m. and 5:00 p.m. Monday through Friday. The call is free. You must call and ask for help to get a ride at least two business days (not counting weekends or holidays) before the trip. When you call for approval for a ride, you must give: The name, address, and phone number of the person who needs the ride The recipient identification number (this is the number on the person s HFS or All Kids medical card) The name and address of the doctor or clinic the person will be seeing The date, time, and reason for the appointment The name of the transportation provider, if known EMERGENCY CARE In MyCare Chicago you DO NOT NEED A REFERRAL from your PCP for emergency services. An emergency is a health problem that is life threatening or one that will seriously affect your health if not treated right away. An emergency can be from an accident or sudden illness and puts you in danger of death or severe harm. Only go to the Emergency Room if the problem is serious. A representative of your MyCare Chicago agrees to be available 24 hours a day, 7 days a week. You should call your PCP first if you have a health problem and you are not sure if you should go to the Emergency Room. If you have an emergency, a referral is NOT needed. Call or go to the nearest emergency room right away. In an emergency you can use any hospital or other provider of emergency services. MyCare Chicago has 4 hospital Emergency Rooms in our network. Check our provider directory or call center for a list of facilities providing emergency services. SOME REASONS YOU SHOULD CALL YOUR MYCARE CHICAGO PCP FIRST There are often times you don t feel well but it might not be an emergency. Some reasons to call MyCare Chicago before going to the Emergency Room are: Fever Runny Nose Allergies/coughing/sneezing Sore Throat Rash Bruises Refill medications that are now empty Cough Stuffy nose/congestion Ear ache Cramping Strains or sprains Pain medication SOME EXAMPLES OF EMERGENCIES WHEN YOU SHOULD GO TO THE EMERGENCY ROOM: Chest pain Poisoning A serious accident Bleeding that won t stop Serious burns Damage to the eyes Broken bone(s) Throwing up blood High fever Seizures REMEMBER EMERGENCY ROOMS ARE FOR EMERGENCIES ONLY. Sudden loss of feeling or not being able to move Severe stomach pain Passing out Choking or being unable to breathe properly Severe shortness of breath Miscarriage (when a pregnant woman loses her baby) Strong feeling that you might hurt yourself or another person In MyCare Chicago, you DO NOT NEED A REFERRAL from your PCP for emergency services. Call (if available in your area) or go to the nearest Emergency Room right away. In an emergency you can use any hospital.

14 26 MAKING AN APPOINTMENT MAKING AN APPOINTMENT 27 If you are unable to reach your PCP after hours or on the weekend, MyCare Chicago can also help you decide if you have an emergency. Call the MyCare Chicago Helpline at: TTY: 1-(844) 510-CARE (2273) If you need a list of emergency providers in your area, call the MyCare Chicago Helpline at: TTY: 1-(844) 510-CARE (2273) For Women FAMILY PLANNING/BIRTH CONTROL SERVICES In MyCare Chicago you DO NOT NEED A REFERRAL from your PCP for family planning services. This includes talking to someone on how to plan for a healthy birth and about birth control. You can get this care from your PCP, an HFS family planning provider or any doctor or clinic that takes the HFS or All Kids Medical Card. If you need help finding family planning services, call the MyCare Chicago Helpline at: TTY: 1-(844) 510-CARE (2273) or family planning provider. If you are pregnant you can: Call or visit your PCP, who will help you find a prenatal care provider. Your PCP may also have information about your health that your prenatal care provider needs to know. Visit an OB/GYN or nurse midwife on your own. You do not need a referral from your PCP. Visit a health center that offers family planning services. It is best to get regular prenatal care during your whole pregnancy and use the same doctor for all your prenatal care. It is also very important to see your PCP or OB/GYN after the baby is born. MyCare Chicago can help you find an OB/GYN, nurse midwife, or family planning center that will see you. If you need help finding a doctor or making an appointment, please call MyCare Chicago at: TTY: 1-(844) 510-CARE (2273) FAMILY CASE MANAGEMENT The Family Case Management program serves pregnant women, infants and children with high-risk medical conditions. Family Case Management can help you: Find a doctor for your prenatal care to make sure you have a healthy baby. Find a PCP for your children s care. CARE DURING PREGNANCY In MyCare Chicago you DO NOT NEED A REFERRAL from your PCP for OB/GYN services. Pregnant women need special care during pregnancy called prenatal care. Prenatal care is very important. Prenatal care visits with a doctor or clinic will help pregnant women stay healthy and help their babies stay healthy too. Even if a woman has been pregnant before, prenatal care is still very important. Prenatal care should start as soon as possible. Even if you are thinking of having a baby, you should discuss this with your PCP. There are things you can do before you get pregnant that will make your pregnancy healthier and your baby too. You should get care as soon as you think you might be pregnant. If you think you are pregnant and need a pregnancy test, see your PCP Understand proper nutrition for you and your child. Understand the stages of your child s development. Get information on how to be a better parent. Understand the importance of prenatal care. Learn the signs and symptoms of 0-term labor. Understand the importance of regularly scheduled well-child visits. Understand the importance of immunizations. For more information call Family Case Management at: Toll Free: 1-(800) TTY: 1-(800)

15 28 MAKING AN APPOINTMENT MAKING AN APPOINTMENT 29 CHILD CARE RESOURCE AND REFERRAL Quality child care is an important part of helping kids to grow up healthy. The Illinois Child Care Assistance Program (CCAP) makes it possible to get help paying for child care. To find out if you qualify, or to find the Child Care Resource and Referral (CCR&R) center in your area, go to Click on the Child Care link. You can also call the DHS Helpline at: Toll Free: 1-(800) TTY: 1-(800) disabilities. If you have any questions or concerns about your child s development (physical, emotional or other), please talk with your child s PCP. It is best to take action as soon as you think your child may have a physical or emotional developmental problem. Starting care or intervention early may make a difference. Infants and toddlers will be tested to see if there is a delay in: Movement Learning Dealing with others WIC (WOMEN, INFANTS, AND CHILDREN) WIC is a free food assistance program to help pregnant women, new moms, babies, and young children eat well and stay healthy. WIC is available to: Women who are pregnant, breastfeeding or just had a baby, and infants and children under 5 years old (including foster children) who are: Low to medium income. Found to be at nutrition risk through a free health screening. It is very important that babies and young children eat right. This helps them grow up healthy and strong. WIC can teach you about good nutrition and health. With WIC you get healthy foods like milk, eggs, cheese, fruits and vegetables, juice, cereal, dried beans or peas, baby food, and whole grains (whole wheat bread and other options). WIC also covers infant formula with iron for babies who are not breast-fed. WIC can also give you information on, and help with, breastfeeding. To find out more about WIC or to find a WIC office in your area, call: Toll Free: 1-(800) TTY: 1-(866) or visit the DHS Web site at: Click on the Women, Infants and Children (WIC) link. EARLY INTERVENTION The State of Illinois has Early Intervention programs and services for infants or toddlers ages 0 to 3 that have developmental delays or Behavior Self-help skills If needed, a plan is written to set goals and identify needs. Families, with the help of Early Intervention service providers, help the infants and toddlers reach their goals. To find out more about Early Intervention or to locate an Early Intervention office in your area, call: Voice/TTY: 1-(800) Automated services: 1-(800) 323-GROW (4769) or visit the DHS Web site at: Click on the Health & Medical link. Other Services SERVICES TO HELP YOU STOP SMOKING Smoking harms you and your family. It is never too late to quit. Don t give up trying. You can call your MyCare Coordinator or the MyCare Chicago Helpline for information or to assist you to quit smoking at: You can call the Illinois Tobacco Quitline. There is no cost for using the Quitline. Quitline staff can help you if you smoke cigarettes, cigars or

16 30 MAKING AN APPOINTMENT MAKING AN APPOINTMENT 31 pipes, as well as, snuff and chew tobacco users. You can call the Illinois Tobacco Quitline at: Toll Free: 1-(866) TTY: 1-(800) Or visit the Smoke-free Illinois Web site at: or ALCOHOL AND SUBSTANCE ABUSE SERVICES Many alcohol and drug abuse services are covered by your HFS Medical Card. To find out what services are covered for you, call the HFS Health Benefits Helpline at: Toll Free: TTY: 1 (877) MyCare Chicago can help you find a provider who offers alcohol and substance abuse services. Call MyCare Chicago at: NON-EMERGENCY TRANSPORTATION In MyCare Chicago you DO NOT NEED A REFERRAL from your PCP for non-emergency transportation services. If it is hard for you to get to your medical appointments either because you do not have a car to use or because you cannot afford the gas, MyCare Chicago may be able to help you get a ride to your PCP or clinic. This is not for ambulance services. HFS covers non-emergency transportation to the nearest possible provider only. To see if you qualify for non-emergency transportation services, you should call your CC. You must call and ask CC for help to get a ride at least two business days (not counting weekends or holidays) before the trip. When you call for approval for a ride, you must give: The name, address, and phone number of the person who needs the ride. The recipient identification number (this is the number on the person s HFS or All Kids medical card). The name and address of the doctor or clinic the person will be seeing. The date, time, and reason for the appointment. The name of the transportation provider, if known. PRESCRIPTION DRUGS In MyCare Chicago you DO NOT NEED A REFERRAL from your PCP for prescription drug services. Children (under 21) are covered for all medically necessary prescription drugs. Adults who use an HFS Medical Card may or may not have their prescriptions covered. Also, some individuals must pay a co-payment on their medications. If you want to find out if your HFS Medical Card will cover your prescriptions or if you will have to pay a co-payment, call the HFS Health Benefits Hotline at: Toll Free: 1-(866) TTY: 1-(877) To get your medications you will need a prescription from your PCP or specialist. Many over-the-counter drugs may also be covered as long as you have a prescription. Pharmacists can refuse to refill a prescription for failure to pay your co-pay. If you need help finding a pharmacy or if you have any other questions call the MyCare Chicago Helpline at: MENTAL HEALTH SERVICES Every person who suffers from a behavioral health condition needs a unique set of services and care to meet their needs. The DHS Division of Mental Health (DMH) provides a variety of services for children and adults who have an HFS Medical Card. DMH partners with mental health clinics, agencies and hospitals in Illinois who can work with you and your PCP to get you the help you need. At MyCare Chicago, many of our PCPs and Medical Homes have behavioral health resources on site. If you are unsure who to call or have questions your MyCare Coordinator can help you find the services you need by calling the MyCare Chicago Helpline at: C4 for emergency and crisis assessments call: 1-(773)

17 32 YOUR RIGHTS AND RESPONSIBILITIES YOUR RIGHTS AND RESPONSIBILITIES 33 Your rights and responsibilities MyCare Chicago members will be informed of their rights and responsibilities every year. You are free to apply your rights without any action taken against you. As a Healthcare Plan, MyCARE has an obligation to protect your rights and explain these rights to you in a way you can understand before treatment begins or during the initial evaluation visit and on an ongoing basis, as needed. Your family or your guardian may exercise these rights for you in the event that you are not competent or able to exercise them for yourself. You have a right to: Have a relationship with our staff that is based on honesty and ethical standards of conduct and to have ethical issues addressed. Be free from mistreatment, neglect, verbal, mental sexual or physical abuse, including injuries of an unknown source and misappropriation of your property (exploitation).you will be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. Be treated with respect; recognition of your individuality and dignity; and to have cultural, psychosocial, spiritual and personal values, beliefs and preferences respected. You will be not discriminated based on social status political belief, sexual preference, race, color, religion, national origin, age, sex or handicap. Our staff is prohibited from accepting gifts or borrowing from you. Receive information in a manner that you can understand and have access to interpreters as indicated and necessary to ensure accurate communication. Lodge complaints and have your complaints as well as your family or your guardian s complaints heard, reviewed and, if possible, resolved regarding treatment or care that is (or fails to be) furnished or regarding the lack of respect for property by anyone who is furnishing services on behalf of the organization. You also have the right to know about the results of such complaints. The organization must document both the existence of a complaint and the resolution of complaint. Our complaint resolution process is explained in our problem solving procedure. Voice grievances/complaints regarding treatment care, lack of respect of property without fear of coercion, discrimination, reprisal or an unreasonable interruption in care, treatment or services for doing so. Decision making You have the right to: Be informed in advance of the care that is to be furnished, name(s), and responsibilities of staff members who are providing and responsible for your care, treatment or services, the planned frequency of visits proposed to be furnished, expected and unexpected outcomes, potential risks or problems and barriers to treatment. Actively participate in planning your care, treatment and services; and to participate in changing the plan whenever possible and to the extent that you are competent to do so. Be advised of any change in your plan of care before the change is made. Have family involved in decision making as appropriate concerning your care, treatment and services, when approved by you and your surrogate decision maker and when allowed by law. Participate or refuse to participate in research, investigational or experimental studies or critical trials. Your access to care, treatment and services will not be affected if you refuse or discontinue participation in research.

18 34 YOUR RIGHTS AND RESPONSIBILITIES YOUR RIGHTS AND RESPONSIBILITIES 35 Formulate advance directives and receive written information about the agency s policies and procedures on advance directives, including a description of applicable state law. You will be informed if we cannot implement an advance directive on the basis of conscience. Have your wishes concerning end of life decisions addressed and to have health care providers comply with your advance directives in accordance with state laws. You have the right to receive care without conditions or discrimination based on the execution of advance directives. Accept, refuse or discontinue care, treatment and services without fear of reprisal or discrimination after being informed of the consequences for doing so. You may refuse part or all of care/services to the extent permitted by law. However, should you refuse to comply with the plan of care and your refusal threatens to compromise our commitment to quality care, then we or your physician may be forced to discharge you from our services and refer you to another source care. Privacy and Security You have the right to: Personal privacy and security during home care visits and to have your property treated with respect. Confidentiality of written, verbal and electronic information including your medical records, information about your health, social and financial circumstances or about what takes place in your home. Access, request and receive a copy of your medical records, request changes to your medical records, and receive notification of disclosures of your medical records.. Request us to release information written about you only as required by law or with your written authorization and to be advised of our policies and procedures regarding accessing and/or disclosure of clinical records. Our Notice of Privacy Practices describes your rights in detail. Your Responsibilities You have the responsibility to: Provide complete and accurate information to the best of your knowledge about your present complaints and past illness(es), hospitalizations, medications, allergies and other matters relating to your health. Notify us at MYCARE of perceived risks or unexpected changes in your condition (e.g., hospitalization, changes in the plan of care, symptoms to be reported, pain, homebound status or change of physician). Follow the agreed on plan of care and instructions and accept responsibility for the outcomes if you do not follow the care, treatment or service plan. Ask questions when you do not understand about your care, treatment and service or other instruction about your care or cannot comply with the plan, let us know. Report and discuss pain, pain relieve options, and your questions, worries and concerns about pain medication with your PCP or appropriate medical personnel. Tell MYCARE if your visit schedule needs to be changed due to medical appointment, family emergencies, etc. Tell MYCARE if your Medicaid or other insurance coverage changes or if you decide to enroll in a Medicare or private HMO (Health Maintenance Organization) or hospice. Promptly tell MYCARE if your financial situation changes. Follow MYCARE rules and regulations. Tell MYCARE if you have an advance directive or if you change your advance directive. Tell MYCARE of any problems or dissatisfaction with the services provided. Help MYCARE maintain a safe and cooperative environment for care to be provided to you (such as no smoking and no weapons). Show respect and consideration for MYCARE staff and equipment. Carry out mutually agreed upon responsibilities with MYCARE.

19 36 GRIEVANCES AND APPEALS GRIEVANCES AND APPEALS 37 Grievances and Appeals If you have a problem or complaint MyCare Chicago (MYCARE) wants you to get the best possible service. When something goes wrong or you are not treated well, we want to know. Grievances A grievance is a complaint to MyCare Chicago about any matter involving MYCARE other than a denied, reduced or terminated service or medical item. MyCare Chicago takes member grievances very seriously. We want to know what is wrong so we can make our services better. MyCare Chicago has special procedures in place to help members who file grievances. We will do our best to answer your questions or help to resolve your problem or concern. Filing a grievance will not affect your health care services or your benefits coverage. These are examples of when you might want to file a grievance with MYCARE : Your medical provider or a MyCare Chicago staff member did not respect your rights. You had trouble getting an appointment with your provider or Care Coordinator, or talking with your provider or Care Coordinator, in an appropriate amount of time. You were unhappy with the quality of care or treatment you received. Your provider or a MyCare Chicago staff member was rude to you. Your provider or a MyCare Chicago staff member was insensitive to your cultural needs or other special needs you may have. STEP 1: HOW TO FILE A GRIEVANCE If you have a grievance about your Primary Care Provider, MyCare Chicago, or the service you have received: 1. You can call the MyCare Chicago Helpline to report it at: By Voice/TTY 1-(844) 510-CARE (2273) 2. You can put your grievance in writing and mail or fax it to: MyCare Chicago Grievance Process 5145 North California Chicago, Il, Fax Number You can also register your grievance on the MyCare website at: When you file your grievance, give us as much information as you can. For example, include the date and place the incident happened, the names of the people involved, and details about what happened. Be sure to include your name and your MyCare Chicago member ID number. STEP 2: REVIEWING YOUR GRIEVANCE We will make a record of your grievance. We will have someone not involved with the matter you are complaining about review your grievance and try to find a solution. Your satisfaction is important to us. STEP 3: TAKING ACTION ON YOUR GRIEVANCE We take action on all grievances within 30 days of receiving it. We will let you know what we decide. STEP 4: IF YOU AREN T SATISFIED WITH THE DECISION MYCARE CHICAGO MAKES, YOU MAY WRITE TO: Illinois Department of Healthcare and Family Services Bureau of Managed Care 201 South Grand Avenue East, 3rd Floor Springfield, IL Someone from HFS will review the matter and follow up with you as quickly as possible.

20 38 GRIEVANCES AND APPEALS GRIEVANCES AND APPEALS 39 Appeals You may not agree with a decision or an action made by the Illinois Department of Healthcareand Family Services (HFS) or the Illinois Department of Human Services (DHS). An appeal is a way for you to ask for a review of the Department s (HFS or DHS) actions and decisions. For example, you may not agree with a decision made or an action by the Department about your services or a medical item you requested. You may appeal within sixty (60) calendar days of the date on the letter from the Department informing you of its denial or action. If you want your services to stay the same while you appeal, you must file your appeal no later than ten (10) calendar days from the date on the Department s letter informing you of its denial or action. You can designate another person to help you file an appeal with us. We will need something in writing that authorizes that person to speak on your behalf. When you appeal, you are asking for a hearing to review the Department s action or decision that you disagree with. The person reviewing the Department s action or decision will be a hearing officer. The list below includes examples of when you might want to file an appeal. You may want to appeal if the Department: Does not approve or pay for a service or item that you or your provider asks for Stops your benefits (coverage) Says that you will start to get fewer benefits Changes your co-payments You can also appeal if you think the Department made a mistake about any action or decision. You may not get a hearing on your appeal if the Department s action or decision was because of a change in the law. HOW TO MAKE AN APPEAL When you file your appeal, tell the Department what action or decision you disagree with and want them to review. Be sure to include your name, address, phone number, , and your HFS Medical Card Identification Number (the ID# next to your name on the Medical Card). An appeal is filed either with HFS or DHS, depending on the agency that made the decision you are contesting. Generally, appeal is filed with the agency that made the decision and sent you the letter informing you of its denial or action. If you want to file an appeal related to your medical services or items, Developmental Disability(DD), or Elderly Waiver (Community Care Program (CCP)) services, send your request in writing via mail, fax, or to: Illinois Department of Healthcare and Family Services Attn: Fair Hearings Section 401 South Clinton, 6th Floor Chicago, IL Fax #: HFS.FairHearings@illinois.gov Or you may call HFS at If you use a TTY, call HFS at The call is free. If you want to file an appeal related to your Medicaid application eligibility, food stamps, TANF, Persons with Disabilities Waiver services, Traumatic Brain Injury Waiver services, HIV/AIDS Waiver services, or any Home Service Program (HSP) services, send your request in writing via mail, fax, or to: Illinois Department of Human Services Attn: Bureau of Hearings 401 South Clinton, 6th Floor Chicago, IL Fax #: DHS.BAHNewAppeal@illinois.gov Or you may call DHS at If you use a TTY, call DHS at The call is free.