1 P age Member Services toll free

Transcription

1

2 TABLE OF CONTENTS Important Phone Numbers... 5 Welcome to Health Options... 6 Alternative Formats... 6 Important Words You Should Know... 6 Getting Started... 8 Check for Your ID Card... 8 Things to Do... 8 How to Get Help... 9 Member Advocates... 9 What to Do If You Move... 9 Adding New Members or Removing Existing Members... 9 If Your Membership Stops Changing Your Health Plan Your Rights and Responsibilities Your Rights Your Responsibilities Emergency and Urgent Care How Do I Know If It is an Emergency? What Do I Do in an Emergency? What Do I Do When I Need Urgent Care? Behavioral Health Crisis Services Northern Delaware Locations and Hours Southern Delaware Locations and Hours How to Use Your Benefits Your Health Options ID Card What is a Primary Care Provider (PCP)? Making an Appointment With Your PCP When You Are Sick How to Change Your PCP P age Member Services toll free

3 Family Planning Pregnant Women and Newborns Enrolling Your Newborn Arranging Your Care Specialty Care How Can I Get a Second Opinion? Out-of-Network Care Other Medical Staff In Your Doctor s Office Wellness Programs Health Risk Assessment (HRA) Asthma Program Chronic Obstructive Pulmonary Disease Program Cardiac Program Diabetes Program EPSDT Complex Care Coordination Behavioral Health Care Coordination Transitioning Home From the Hospital Accessibility and Availability Standards Different Types of Care Routine Care Urgent Care After-hours Care Out-of-area Care Pregnancy Care Nurse Midwife or Certified Pediatric/Family Nurse Practitioner Sexually Transmitted Disease (STD) Care Specialist Care Hospital Care What We Cover P age Member Services toll free

4 Health Options Benefits Additional Benefits Special Needs Services Not When You May Have to Pay for Services Services by Fee-for-Service Medicaid Program Care Away from Home Women, Infants, and Children (WIC) Program Medicines and Prescription Drugs Health Options Drugs On Our PDL Some Drugs Need to be Approved (Prior Authorized) Generic Drugs Instead of Brand-name Drugs Over-the-counter (OTC) Drugs How Do You Get Your Medicine? Refilling Your Prescriptions Emergency Supply of Medication Quantity Limits Where to Get Your Prescriptions Filled Pharmacy Lock-in Behavioral Health Drugs Important Things to Know When You Get Your Drugs The Kinds of Drugs Health Options Covers Limits on Your Prescription Drug Benefit Preferred Diabetic Supply List (PDSL) Effective 1/1/ Dental Services Behavioral Health Services Non-Emergency Transportation (NEMT) New Technology How to File a Grievance or Appeal Grievances P age Member Services toll free

5 Appeals Expedited ( Fast ) Appeals State Fair Hearing Important Information When We Can No Longer Serve You Disenrollment Contacting our Member Services Department Advance Directives (Living Wills) Review of Member Records How to Suggest Changes in our Policies and Services Changes to the Plan Treatment of Minors You Have Other Insurance or a Third Party Liability (TPL) Claim What Do I Do With a Bill? Help In Other Languages Help for Members With Hearing, Speech, or Vision Loss Americans with Disabilities Act Fraud & Abuse Confidentiality Information About Our Plan Urgent Care Locations in Delaware P age Member Services toll free

6 IMPORTANT PHONE NUMBERS Member Services (Monday-Friday, 8am-8pm) Hour Nurse Help Line Hour Nurse Help Line TTY or Care Management (Monday-Friday, 8:00 am-5:00 pm) Behavioral Health (Monday-Friday, 8:00 am-5:00 pm) Fraud and Abuse Hotline TTY/TDD Line or Pharmacy Behavioral Health Crisis Services Northern Delaware (serving New Castle County and greater Smyrna in Northern Kent County) Southern Delaware (serving Sussex County and Kent County south of greater Smyrna) Other Important Phone Numbers Health Benefit Manager Enrollment Call this number to join in a new health plan or disenroll from your current plan. LogistiCare Transportation Services Non-Emergency Transportation Where s My Ride? Hotline State of Delaware Division of Social Services Customer Relations or Delaware Relay Service or This number allows people who have a hearing or speech loss to communicate with a trained person who can help them speak with someone who uses a regular telephone. Delaware Tobacco Quit Line to help stop smoking QUIT-NOW ( ) 5 P age Member Services toll free

7 WELCOME TO HEALTH OPTIONS Health Options is a managed health care plan. This means that we work with you and your doctor, or primary care physician (PCP), to service your total healthcare needs. Your PCP s name and phone number is on your Health Options ID card. Carry this card with you and show it whenever you seek medical attention. You must also show your Delaware Medicaid Card. Please call us right away if there are any mistakes on your ID card. This Handbook explains the benefits and services available to you. It also explains what to do if you have an emergency or urgent medical situation. Please read this handbook carefully. It will help you learn more about the healthcare services paid for by Health Options. Keep this handbook in a safe place so you can look up information later on. We urge you to use your Health Options benefits to help get the care that you need to stay healthy. Please call the Member Services Department for assistance and questions about what is covered. Member Services Representatives are available from 8am-8pm (Monday-Friday) at Your Member Services Representative can answer questions about your health care, ID card, benefits and doctors. We also invite you to visit our website, to find a variety of other useful information. ALTERNATIVE FORMATS All written materials can be provided in a language other than English or in another format (i.e. Braille) for those who are unable to see or read written materials. We also have oral interpretation services available in non-english languages free of charge. If you need these services, please call Member Services at IMPORTANT WORDS YOU SHOULD KNOW Below are some terms that you should know that we use to describe how your medical care is arranged. Benefits: The health care services covered under this plan. Co-pays or Cost Sharing: Money that you need to pay at the time of service. DHSS: Department of Health and Social Services Disenroll: To stop using the health plan because you are no longer eligible or you change your health plan. DMMA: Delaware Division of Medicaid and Medical Assistance 6 P age Member Services toll free

8 Emergency medical condition: A sudden, serious medical condition where the presenting symptoms are of sufficient severity (including severe pain) that a prudent layperson with an average knowledge of health and medicine would reasonably believe that the lack of immediate medical care could: Place your health (or the health of your unborn child) at serious risk. Impair the function of your body. Impair the function of a body part or organ. Health care provider: Any doctor, hospital, agency, or other person who has a license or is authorized to give health care services. Hospital: A place for inpatient and outpatient care from doctors and nurses. Immunization: A shot that protects you from disease. Children and adult receive different shots at different ages during regular doctor visits. Inpatient care: When you have to stay the night in the hospital or other facility for the medical care you need. Medically necessary: Items or services that have been given or will be given to a patient that are needed to treat or prevent a medical condition and are not mainly for the ease of the patient, doctor or other health care provider. Examples are to: find the cause of an illness or treatment of illness or injury; help a body part that is not normal work better; prevent illness; or help a patient meet the right growth and development levels. Member: A person approved by the state of Delaware to participate in Health Options health plan. Member Handbook: The member handbook tells you how Health Options works. If you do not understand some parts of this handbook, you can call your Member Services at the numbers below. We will mail this handbook to you upon enrollment and upon request. Outpatient care: Care you get when you do not have to stay overnight in a hospital or other place of treatment. Primary care provider (PCP): The doctor you choose for most of your health care. This person helps you get the care you need. Your PCP must OK most care ahead of time, unless it is an emergency. Prior authorization: The approval you get from us before you get a service. PROMISE: Promoting Optimal Mental Health for Individuals through Supports and Empowerment program for members with behavioral health needs overseen by the Delaware State Division of Substance Abuse and Mental Health (DSAMH). Specialist: Any doctor who has special training for a specific condition or illness. 7 P age Member Services toll free

9 Urgent medical condition: Not an emergency, but is a condition that should have medical care within 48 hours. Utilization review: A process that allows Health Options and your health care providers to work together to decide if a service you ask for is medically necessary. GETTING STARTED CHECK FOR YOUR ID CARD Your Health Options member identification (ID) card was sent to you separate from this handbook. If you did not get it, call our Member Services Department. If you have difficulty hearing or speaking, please call our Member Services TTY line. Your ID card lists your main doctor or PCP. Check that the PCP listed is the one you want. If the PCP on your ID card is not the PCP you want, call us right away so we can fix it. Every member of your family enrolled with Health Options will have his or her own ID card. Check the information on the ID card to make sure it is right. THINGS TO DO Keep your Health Options ID card and Delaware Medicaid card with you at all times. Show them every time you need health care services. Do not let anyone else use your Health Options ID card. Your Health Options ID card does not replace your Delaware Medicaid card. Keep both cards! Your Health Options ID card lists your primary care provider (PCP). A PCP is a provider who will be your main doctor. You can change your PCP for any reason. If you want to change your PCP, call our Member Services number to let us know right away. Set up an appointment for a health review with your PCP as soon as you can. If you are an adult, your first health review should be within 3 months after joining Health Options. Children should see their PCP within 2 months after joining the plan. A doctor should see your newborn within 1 month of birth. During the health review, the PCP will learn about your health care needs and teach you ways to help you stay healthy. Call your PCP when you need medical care, unless you have an emergency. Your PCP s office will help you set up an appointment for care. If you need a ride to and from your appointment, call our Member Services number. You may see a family planning provider, inside or outside of the Health Options network, without an OK from your PCP. If you have an emergency, get help right away. Call 911 or go to the nearest emergency room for health care. You do not need an OK from us for emergency care. It does not matter if you are inside or outside of our service area. We pay for emergency care even if the provider is not part of the Health Options network. If you are not sure what to do, you can call the 24-hour nurse help line. Have your Health Options ID card ready when you call. The nurse will ask for your ID card number. 8 P age Member Services toll free

10 HOW TO GET HELP For questions about Health Options or for help getting an appointment for care, call our Member Services number. You can call us toll-free 8 am until 8 pm (Monday through Friday). If you have hearing or speech loss, you may call Member Services by dialing 711. You can call our Nurse Help line at The Nurse Help Line is available 24 hours a day. You can always call your PCP for help as well. Your PCP s phone number is on your ID card For questions about enrollment, please contact the Health Benefit Manager at MEMBER ADVOCATES Health Options has Member Advocates to help you. Member Advocates: Help you get care or talk to a specific provider. Coordinate transportation and access to care and services. Help with pharmacy questions. Help our staff and providers better understand your needs. Assist you with the grievances and appeals process. To speak to our member advocates, please call (TTY: 711). WHAT TO DO IF YOU MOVE If you move or change your phone number, you must contact the DSS Change Report Center at After you contact the DSS Change Report Center, call Member Services. Member Services will help you pick a new PCP near your new home. If you move outside of Delaware or the United States, please contact the DSS Change Report Center for information you will need. ADDING NEW MEMBERS OR REMOVING EXISTING MEMBERS When you have a new baby or add a new member to your family, you must contact the DSS Change Report Center at After you contact the DSS Change Report Center, call Member Services. If you don t tell us and the DSS Change Report Center, your new family member s insurance may be delayed. If someone in your family with Health Options dies, please contact Member Services. They can assist you. You also need to let the DSS Change Report Center know about your family member s death. 9 P age Member Services toll free

11 IF YOUR MEMBERSHIP STOPS Medicaid may stop your membership with Health Options. This is called disenrollment. Your membership may end because you: Give your Medicaid ID card to someone else to use. Go to prison. Lose eligibility for Medicaid. Have a change in your Medicaid benefits that keeps you from being covered by Health Options. CHANGING YOUR HEALTH PLAN You can change your health plan during the first 90 days after you are first enrolled in Medicaid. You can also change your health plan during the Annual Open Enrollment period one a year. To change your health plan, please call the Health Benefits Manager at YOUR RIGHTS AND RESPONSIBILITIES As a Health Options Medicaid member, you have the following rights and responsibilities. YOUR RIGHTS Learn about your rights and responsibilities. Get the help you need to understand this member handbook. Learn about us, our services, doctors, and other health care providers. See your medical records as allowed by law Have your medical records kept private unless you tell us in writing that it is OK for us to share them or it is allowed by law. Complete facts from your doctor of any information relating to your medical condition, treatment plan or ability to inspect and offer corrections to your own medical records. Be part of honest talks about your health care needs and treatment options no matter the cost and whether your benefits cover them. Be part of decisions that are made by your doctors and other providers about your health care needs. Be told about other treatment choices or plans for care in a way that fits your condition. Get news about how doctors are paid. Find out how we decide if new technology or treatment should be part of a benefit. Be treated with respect, dignity and the right to privacy all the time. Know that we, your doctors, and your other health care providers cannot treat you in a different way because of your age, sex, race, national origin, language needs, or degree of illness or health condition. Talk to your doctor about private things. Have problems taken care of fast, including things you think are wrong, as well as issues about your coverage, getting an approval from us, or payment of service. Be treated the same as others. Get care that should be done for medical reasons. 10 P age Member Services toll free

12 Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. Choose your PCP from the PCPs in our Provider Directory that are taking new patients. Use providers who are in our network. Get medical care in a timely manner. Get services from providers outside our network in an emergency. Refuse care from your PCP or other caregivers. Be able to make choices about your health care. Make an Advance Directive (also called a living will). Tell us your concerns about Health Options and the health care services you get. Question a decision we make about coverage for care you got from your doctor. File a complaint or an appeal about Health Options, any care you get or if your language needs are not met. Ask how many grievances and appeals have been filed and why. Tell us what you think about your rights and responsibilities and suggest changes. Ask us about our Quality Improvement Program and tell us how you would like to see changes made. Ask us about our utilization review process and give us ideas on how to change it. Know that we only cover health care services that are part of your plan. Know that we can make changes to your health plan benefits as long as we tell you about those changes in writing. Ask for this Member Handbook and other member materials in other formats such as other languages, large print, audio CD or Braille at no charge to you. Ask for an oral interpreter and translation services at no cost to you. Use interpreters who are not your family members or friends. Know you are not liable if your health plan becomes bankrupt (insolvent). Know your provider can challenge the denial of service with your approval. Know that you can request a copy of the member handbook at any time. You will be notified annually of your right to request a member handbook. Know how you can get a list of providers in the network, including the names and education level of all Network providers, and the how you may choose providers within Health Options. TO RECEIVE THE BEST CARE YOU MUST DO YOUR PART. YOUR RESPONSIBILITIES Tell us, your doctors, and other health care providers what they need to know to treat you. Learn as much as you can about your health issue and work with your doctor to set up treatment goals you agree on with your doctor. Ask questions about any medical issue and make sure you understand what your doctor tells you. Follow the care plan and instructions that you have agreed on with your doctors or other health care professionals. Do the things that keep you from getting sick. 11 P age Member Services toll free

13 Make and keep medical appointments and tell your doctor at least 24 hours in advance when you cannot make it. Always show your member Health Options ID card and Delaware Medicaid card when you get health care services. Use the emergency room only in cases of an emergency or as your doctor tells you. If you owe a co pay to your pharmacies, pay at the time the services are received. Tell us right away if you get a bill that you should not have gotten or if you have a complaint. Treat all Health Options staff and doctors with respect and courtesy. Know and follow the rules of your health plan. Know that laws guide your health plan and the services you get. Know that we do not take the place of workers compensation insurance. Tell the DSS Change Report Center and us when you change your address, family status or other health care coverage. If a minor becomes emancipated, or legally freed from control by his or her parents (over the age of sixteen), or marries, he or she shall be responsible for following all Health Options member guidelines set forth above. EMERGENCY AND URGENT CARE HOW DO I KNOW IF IT IS AN EMERGENCY? An emergency medical condition is a condition where the symptoms are so severe that a prudent layperson with an average knowledge of health and medicine would reasonably believe that the lack of immediate medical care could: Place your health (or the health of your unborn child) at serious risk. Impair the function of your body. Impair the function of a body part or organ. There are times when it is hard to know what a real emergency is. If you call your PCP before going to the emergency room, the doctor can tell you what to do. You can also call our Nurse Help Line. Here are some examples of times when you should use the emergency room: Blackouts Car accident Chest pain or heart attack Choking Danger of losing limb or life Difficulty in breathing Heavy bleeding Criminal attack (i.e. mugging or rape) Loss of speech Overdose of medicine or drugs Paralysis (not able to move) Poisoning Possible broken bones 12 P age Member Services toll free

14 Seizures Vomiting (throwing up) blood Here are some examples of when you probably do not need to go to the emergency room. At these times, if you call your PCP, the doctor can tell you what you should do. You can also call our Nurse Help Line 24 hours a day, any day of the week. Bruises or swelling Fever or cough Cramps Small cuts or burns Earache Rash Sore throat Vomiting (throwing up) WHAT DO I DO IN AN EMERGENCY? In an emergency, get help right away. Call 911, or go to the nearest hospital emergency room or other setting you want to use for health care. You do not need an OK from us for emergency care. You do not have to go to a Health Options Medicaid provider in an emergency. It does not matter if you are inside or outside of our service area. You will be covered for emergency care even if the provider is not part of our network. After you receive emergency services, you should call your PCP to plan your follow-up care. You should do this if the emergency is at home or away. WHAT DO I DO WHEN I NEED URGENT CARE? Urgent care is for a sudden illness or injury when your PCP can t see you in the office. Your PCP can help you determine whether you need to receive urgent care. If you cannot reach your PCP, call the 24-hour nurse help line. If you need urgent care, you can go to an urgent care center in Delaware. A list of urgent care centers in Delaware is included at the end of this handbook. 13 P age Member Services toll free

15 BEHAVIORAL HEALTH CRISIS SERVICES If you are having a mental health or drug or alcohol crisis, please call Crisis Intervention Services for help: In Northern Delaware, call: In Southern Delaware, call: You can also go to: Crisis Intervention Service Centers Community Mental Health Centers Recovery Response Centers Hospital Emergency Rooms. Crisis Intervention Service staff are available 24 hours a day to help people with severe personal, family or marital problems. These problems may include depression, major life changes such as unemployment or loss of an important relationship, anxiety, feelings of hopelessness, thoughts of suicide, delusions, paranoia and abuse of drugs or alcohol. Members can call or drop-in to the crisis intervention location closest to them. Crisis Intervention Services are listed below: NORTHERN DELAWARE LOCATIONS AND HOURS Crisis Intervention Services, Northern Delaware Herman Holloway Health Campus 1901 N. DuPont Hwy., Springer Building New Castle, DE Serves all of New Castle County and greater Smyrna in Northern Kent County Staffed 24 hours a day, 7 days a week , or toll free at Crisis and Psychiatric Emergency Services (CAPES) Unit Wilmington Hospital Emergency Department Wilmington Mental Health Center Williams State Service Center 1906 Maryland Ave., Canby Park Shopping Center, Wilmington, DE Hours: 8:00 am to 4:30 pm SOUTHERN DELAWARE LOCATIONS AND HOURS Crisis Intervention Services, Southern Delaware 700 Main Street (Rear Entrance), Ellendale, DE Serves all of Sussex County and Kent County south of greater Smyrna 14 P age Member Services toll free

16 Staffed 24 hours a day, 7 days a week , or toll free at Dover Mental Health Center Williams State Service Center 805 River Road, Dover, DE Hours: 8:00 am to 4:30 pm Georgetown Mental Health Center Adams State Service Center 546 S. Bedford Street, Georgetown, DE Hours: 8:00 am to 4:30 pm HOW TO USE YOUR BENEFITS YOUR HEALTH OPTIONS HEALTH ID CARD Always carry your Health Options and Medicaid ID cards with you. Show both of these cards to your PCP, hospital or other provider when you go for health care services. Look on your Health Options ID card for the following important information: Your name Your Health Options member ID number The date your Health Options insurance began (this is the effective date ) Your PCP s name and phone number Health Options name, address and toll-free Member Services phone number The phone number for the 24-hour nurse help line What you should do in an emergency You are the only one who can get health care services with your Health Options ID card. Every Health Options member has his or her own ID card. It is important to show the right ID card for the right family member. If you let someone else use your card, you may not be able to stay on our plan. You will get a new Health Options ID card if: You change your PCP (main provider). Your PCP s phone number changes. You lose your ID card. 15 P age Member Services toll free

17 If you did not get your Health Options ID card yet, or if you need a new one, please call us at our Member Services number. If you have trouble hearing or speaking, please call our Member Services TTY line. Use your Delaware Medicaid card for Dental services for children and non-emergency transportation. If your Delaware Medicaid card is lost or stolen, call the DSS Change Report Center. WHAT IS A PRIMARY CARE PROVIDER (PCP)? A PCP is a provider who will arrange your healthcare needs. Your PCP works with you to make sure that you get the care you need. A PCP can be any of these types of providers: Pediatrician (a doctor who takes care of babies and children) Family and general practitioner (a doctor who takes care of babies, children and adults) Geriatrician (a doctor who takes care of older adults) Nurse practitioner or physician assistant (someone who works in a doctor s office and treats you, within limits) Internist (a doctor who takes care of adults) Nephrologist (if you are on dialysis) A PCP also can be a clinic such as a: Health department Federally Qualified Health Center (FQHC) Your Health Options ID card will have the name and phone number of the PCP you chose, or the PCP assigned to you if you did not choose one. You can have the same PCP for the whole family, or a different PCP for each family member. MAKING AN APPOINTMENT WITH YOUR PCP Your PCP s phone number is on your Health Options ID card. Call your PCP s office during regular business hours to schedule an appointment or get help with medical care. Have your Health Options ID card and your Medicaid ID card with you when you call. Let the office staff know you are a Health Options member. You may be asked for the member ID numbers on the ID cards. Make sure to bring your Health Options ID card and your Medicaid ID card with you whenever you visit your PCP. Be on time for your visits. Call your PCP s office as soon as you can if you know you will be late or cannot keep your appointment. This will help shorten everyone s time in the waiting room. Your PCP may not be able to see you if you are late. If you cancel your appointment, your PCP s office can help you set up a new one. 16 P age Member Services toll free

18 WHEN YOU ARE SICK Your PCP is there to see you when you are sick. If this is during office hours, call your PCP, tell the person who answers the phone that you are sick, and want to see the doctor or speak to a nurse. The person who answers your call will need your name and a phone number where you can be reached. The PCP s office staff may have to call you back. HOW TO CHANGE YOUR PCP It is best to keep the same PCP so he or she can get to know you and your health needs and history, but you can change your PCP for any reason. If you want to change your PCP, call our Member Services number. If you have trouble hearing or speaking, please call our Member Services TTY line. We want you to be happy with your PCP. If you want to change PCPs, you have to call Member Services in advance. If you change PCPs often, your health care may not be as good as it could be by staying with a PCP that knows you and your health needs. When changing PCPs, you must pick a PCP that will see new patients. A request to change your PCP may be denied if the PCP you want is not taking new patients. Please call Member Services if you need help finding a PCP that is taking new patients. If you choose a PCP who is not taking new patients, we will help you choose another one. You will get a new Health Options ID card with your new PCP s name on it. Your new PCP will help get your medical records from your old PCP. Health Options or your PCP may ask you to change your PCP if: Health Options no longer works with your PCP. You are not able to get along or agree with your PCP. You keep making appointments and not showing up for them. You have filed a law suit against your PCP. If you need a list of participating doctors, hospitals or other special providers, including what the education of your doctor is, please contact Member Services. You can also visit our website at for a list of providers. FAMILY PLANNING Family planning can help teach you how to: Be as healthy as you can before you become pregnant. Keep you or your partner from getting pregnant. Keep you from getting diseases. 17 P age Member Services toll free

19 Any member (including minors) may see a licensed family planning provider without getting an OK from us first. This includes providers who are not part of our network, such as: Clinics OB/GYNs PCPs Certified nurse-midwives You do not need to get an OK from your PCP for family planning care. Members may use any licensed family planning clinic or provider in Delaware. The provider does not have to be part of our network. If you choose to see a family planning provider, let your PCP know so you can get the best health care. Your family planning provider and your PCP will work together to make sure you get the right care. Family planning records are kept private. Doctors should keep all family planning records private, unless the law says it is OK. Your doctor is allowed to share your medical information with other doctors who take care of you, public health officials, or government agencies. PREGNANT WOMEN AND NEWBORNS Call us right away if you are pregnant. If you are in the last three months of your pregnancy and you just joined our health plan, you may be allowed to stay with your current doctor even if that doctor is not in our network. ENROLLING YOUR NEWBORN As soon as you can after your baby is born, within 30 days, call the DSS Change Report Center to make sure your baby is added for health benefits. Call Member Services to tell us what PCP you want for your baby. If you do not choose a PCP for your baby, we will choose one for you. You will get an ID card for your baby with the PCP s name and phone number on it. ARRANGING YOUR CARE There are some services that we must approve before you can get them. This is called prior authorization. You may have to pay up to the full amount of the charges when a service is provided without prior authorization. There are doctors and nurses who work for us to help your doctor choose the best way to take care of you. They make decisions about the care that is most likely to help you by using specific guidelines for medical decisions. The guidelines are based on whether the service is medically necessary. 18 P age Member Services toll free

20 Medically necessary means health care and services that will: Be directly related to the diagnosed medical condition or the effects of the condition of the member (the physical or mental functional deficits that characterize the member s condition), and be provided to the member only; Be appropriate and effective to the needs, aptitudes, abilities, and environment of the member and the member s family; Be primarily directed to treat the diagnosed medical condition or the effects of the condition of the member, in all settings for normal activities of daily living, but will not be solely for the convenience of the member, the member s family, or the member s provider; Be timely, considering the nature and current state of the member s diagnosed condition and its effects, and will be expected to achieve the intended outcomes in a reasonable time; Be the least costly, appropriate, available health service alternative, and will represent an effective and appropriate use of program funds; Be the most appropriate care or service that can be safely and effectively provided to the member, and will not duplicate other services provided to the member; Be sufficient in amount, scope and duration to reasonably achieve its purpose; Be recognized as either the treatment of choice (i.e. prevailing community or statewide standard) or common medical practice by the practitioner s peer group, or the functional equivalent of other care and services that are commonly provided; Be rendered in response to a life threatening condition or pain, or to treat an injury, illness, or other diagnosed condition, or to treat the effects of a diagnosed condition that has and will be reasonably determined to: o Diagnose, cure, correct or improve defects; physical and mental illnesses and diagnosed conditions or the effects of such conditions; or o Prevent the worsening of conditions or effects of conditions that endanger life or cause pain, or result in illness, or have caused or threaten to cause a physical or mental dysfunction, impairment, disability, or developmental delay; or o Effectively reduce the level of direct medical supervision required or reduce the level of medical care or services received in an institutional setting or other Medicaid program; or o Restore or improve physical or mental functionality, including developmental functioning, lost or delayed as the result of an illness, injury, or other diagnosed condition or the effects of the illness, injury or condition; or o Provide assistance in gaining access to needed medical, social, educational and other services required to diagnose, treat, or support a diagnosed condition or the effects of the condition, in order that the member might attain or retain independence, self-care, dignity, self-determination, personal safety, and integration into all natural family, community, and facility. Examples are: To find the cause of an illness or treatment of illness or injury. To help a part your body that is not normal work better. 19 P age Member Services toll free

21 To prevent illness. To help a member meet the right growth and development levels. If you need a service that must be approved by us before it is done, your doctor will call us to get approval. Our doctors and nurses will look at all the medical facts given by your doctor to decide if this service is the best way to take care of you. Our doctors and nurses make a decision on whether the care is medically necessary and appropriate for you. There is no extra payment given to these doctors and nurses no matter what they decide about your care. Doctors and nurses are not rewarded for reducing the amount of care approved. Some of the services that need to be approved by us before you have them are listed below: Hospital admission The use of an outpatient unit in a hospital for certain medical operations Medical equipment for your home Nurses to come to your home Physical therapy, occupational therapy or speech therapy using a doctor or other provider not in our network Hospice (care for the terminally ill or dying) Nursing home or rehabilitation admissions Surgery There may be other services that need an OK by us first. Your PCP or other doctor must contact us to get prior authorization for certain services. If you need to have tests or an operation, your doctor will call us to have the services approved. We will suggest a place for treatment. If we denied payment for a service that you already had, your doctor may ask for a retrospective review to change the decision. A retrospective review is a detailed look by us at your records and information to determine if the services were necessary to keep you healthy. If you are admitted to the hospital and your doctor feels that you may need more days of care, a concurrent review may happen. A concurrent review is a detailed review while you are still in the hospital. This is also done by us to determine if the services are necessary to get you healthy. You have the right to have any coverage denial reviewed by medical professionals with knowledge of your condition. If you have been denied coverage of a service because of medical necessity, you have the right to appeal the denial decision. 20 P age Member Services toll free

22 You may request a copy of the criteria for medical necessity on which the decision was based by sending a written request to: Health Options Member Correspondence PO Box Pittsburgh, PA SPECIALTY CARE Doctors that work with a certain area of medical care are called specialists. Some types of specialists are heart doctors, skin doctors, or someone who does surgery. Specialty services do not require a referral from your PCP. You can go to any doctors in our network for services without a referral. You can go to any doctor for family planning services, even if the doctor is not in our network. You can self-refer to a doctor for family planning services without a referral from your PCP. You do not need a referral for outpatient behavioral health services including mental health care (depression) or drug and alcohol abuse. Your behavioral health provider will contact Health Options for an authorization. Our goal is for you to be seen by the specialist that can best treat you. If we do not have a specialty doctor in our network doctors that can treat you, we will make arrangements with a specialist that is not in our network. Your PCP can help you make the request for care outside of our network doctors. If your request is denied by us, you may file an appeal. Please see the section later in this handbook for steps to follow for filing an appeal. If you have been seeing a specialist for an ongoing problem, the doctor can request to be your PCP. Please call Member Services for help in getting your specialist to be your PCP. A specialist may send you to receive special services or tests. Examples of services and tests are: Angiograms Bone Scans Chemotherapy (Hospital Setting) Endoscopies Nerve Conduction Testing Sleep studies HOW CAN I GET A SECOND OPINION? You may want to be seen by a different doctor, other than the one you have been seeing, for a second opinion. Your PCP can refer you to another doctor in our network for a second opinion. If a network doctor is not available, we will arrange for you to get a second opinion at no cost to you from an out-of-network doctor. If you have any questions, please call Member Services. 21 P age Member Services toll free

23 OUT-OF-NETWORK CARE Many doctors and hospitals participate with us. They are called the network. There may be a time when you need to use a doctor or hospital that is not a part of our network. If this happens, your PCP can call us to make this request. We will check to see if there is a doctor or hospital within our network that can give you the same care. If there is a doctor or hospital within the network, we will let your doctor know. New members have the right to keep seeing an out-of-network doctor to finish a course of treatment. The doctor must agree to our guidelines. If you have been getting ongoing care from a doctor that is not a network doctor, and you need to stay with this same doctor to finish a course of treatment, please call Member Services for help. Please keep in mind that any services received from providers not in our network must be approved by us. If a request to use a doctor or hospital outside of our network is denied, you can file an appeal by calling Member Services. If you receive services from a provider that is not in our network without approval, that provider may be allowed to bill you for the entire cost of the services. OTHER MEDICAL STAFF IN YOUR DOCTOR S OFFICE Some medical offices may have other types of staff treating you besides doctors and nurses. These types of medical staff are sometimes called physician assistants and nurse practitioners. They are specially trained to work in your doctor s office and to examine you. Your doctor will always oversee any treatment that you get. Some offices also have doctors working there who are finishing their training. These are called Medical Residents and work with your regular doctor to take care of you. WELLNESS PROGRAMS We want you to have a happy, healthy life. Below are programs that are offered to help you stay well and manage any conditions you may have. HEALTH RISK ASSESSMENT (HRA) Understanding your own health and knowing what you can do to improve it is a big first step in being happy and healthy. We want you to complete a Health Risk Assessment and return it to us. You can complete the assessment on line through the Health Options website or we will send you a form you can complete and mail back to us. We will review the assessment and send you a Personal Health Report. The Personal Health Report will give you information that can help you improve or maintain healthy habits for a healthier you. Your answers on the assessment and your Personal Health Report are private. We do not share the results with anyone. We want you to share the results with your PCP so your PCP can work on ways to help you stay healthy or make your health better. Completing a Health Risk Assessment is simple and the benefits can last a lifetime. Get started today. 22 P age Member Services toll free

24 ASTHMA PROGRAM Do asthma symptoms stop you for doing things or make things more difficult for you? If you said yes, we want you to be part of our Asthma Program. The asthma program is offered to members 2 years of age and older. A Care Coordinator will help you manage your asthma. This can help you to better control your asthma so you can do the things that you want to do. Here are a few reminders to help you stay on track: Take your controller medicine every day. This medicine helps to prevent symptoms. It controls swelling and decreases mucus in your airways. Tell your doctor if you need to use your rescue inhaler more than 2 days a week. This may mean that your asthma is out of control. You may need more medicine. Ask your doctor about an asthma action plan. This will help you know what to do when you are sick. Visit your doctor at least 2 times a year. If you need to go to the hospital, make an appointment to see your doctor within 2 weeks of leaving the hospital. Stop smoking and avoid second-hand smoke. Get help to quit smoking by calling the Delaware Quit line at QUIT-NOW ( ) If you would like more information on the Asthma Program, call our Care Management department. CHRONIC OBSTRUCTIVE PULMONARY DISEASE PROGRAM Living with chronic obstructive pulmonary disease (COPD) can be overwhelming. Health Options wants to help! If you are at least 21 years of age and are living with COPD, you may benefit from our COPD program. A Care Coordinator can help you learn how to manage your symptoms so that you can be more active and enjoy life. Here are a few reminders for managing your COPD: Take your breathing medicines as your doctor ordered. Tell your doctor if you have side effects or if you have trouble using your inhaler. Do not stop taking your medicines on your own. This may cause your COPD to flare up. Quit smoking. This is the most important change you can make. You can get help by calling the Delaware Quit line at QUIT-NOW ( ) Get a yearly flu shot. Ask your doctor about a pneumonia shot if you have not had one. Talk to your doctor about an exercise program. Daily exercise can help you to breathe better. Make sure you use your oxygen if it was ordered for you. It can help you to be more active. Avoid going outside when pollution levels are high. Air pollution can make your breathing worse. Pay attention to alerts on the radio and television. If you need to go to the hospital, get all of your medicines filled when you come home. This can help prevent your symptoms from flaring up again. Make an appointment to see your doctor within 2 weeks of leaving the hospital. If you would like more information on the COPD Program call our Care Management department. 23 P age Member Services toll free

25 CARDIAC PROGRAM If you are a member age 21 or older who has congestive heart failure, or had a heart attack, stents, or bypass surgery, you can be part of our Cardiac Program. This program helps you understand how to take care of your heart so you can live a healthy life. The Care Coordinators help you understand what has happened to your heart. They will teach you about a proper diet, exercise and how to take your medicines. They will teach you warning signs to look out for. Here are a few reminders for managing your heart problems: Take your medicine the way your doctor ordered. If you can t, call the office and tell them. Wait to hear from the office before you stop taking your pills. Some heart pills have to be stopped over several days. Do not just stop taking a pill. You can have complications if you do. Follow your doctor s directions for taking your medicine. Make sure you visit your doctor at least twice a year for a checkup. If you are admitted to the hospital make an appointment to see your doctor within 2 weeks of leaving the hospital. Ask your doctor which lab tests you need to control your heart disease. Stop smoking and avoid second-hand smoke. Get help to quit smoking by calling the Delaware Quit line at QUIT-NOW ( ) If you would like more information on the Cardiac Program call our Care Management department. DIABETES PROGRAM If you are a member with diabetes, you can be part of our Diabetes Program. Diabetes can cause problems for your heart, eyes, kidneys and circulation before you even know it. Diabetes can lead to heart failure. It is also the leading cause for amputations. Many people who are getting kidney dialysis are diabetics. We offer a diabetic program that teaches you what symptoms to look for. Care Coordinators teach you about the simple blood and urine tests you should have that warn you of some of the problems BEFORE you even know they are a problem! Here are a few reminders about managing your diabetes: Take your blood sugar readings the way your doctor ordered them. Certain tests will help to show kidney or heart problems. Make sure you get these tests at least every year and more often if the doctor tells you to: HbA1c, LDL-c, urine test, and have your blood pressure taken. Go to your eye doctor and tell them you are a diabetic. You need a dilated retinal eye exam at least every year. Your doctor can tell if diabetes is damaging your eyes during this test. Glasses cannot fix all eye problems caused by diabetes. Ask your doctor which lab tests you need to keep your diabetes under control. Stop smoking and avoid second-hand smoke. Get help to quit smoking by calling the Delaware Quit line at QUIT-NOW ( ). If you would like more information on the Diabetes Program call our Care Management department. 24 P age Member Services toll free

26 EPSDT Members under age 21 are eligible for a special program to find children s health problems early. And, once we find them, we need to keep checking to be sure children stay healthy. We call it the Growing Up Program. This program includes all of the services recommended by the state s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. These services also are called well-visits. These visits are free for enrolled members under 21 years of age. Well visits include screenings needed for your child s PCP to understand any medical needs. During these visits the PCP will complete a physical exam. He will also complete health and developmental history. Vaccines (shots) are part of these visits. Your child s PCP will check on many areas of health during EPSDT exams and screenings. The doctor will check on your child s heart, lungs, eyesight, hearing, and teeth. If your doctor finds areas of concern, he will make a referral to send your child for other tests. He can also send your child to a specialist. The doctor will recommend children age 1 and above go to a dentist as part of their regular EPSDT well child screens. For the EPSDT visit, the doctor could: Give your child shots Ask about your child s nutrition or diet Test your child s urine or blood for medical conditions Ask questions about your child s mental health and speech Ask about social actions and behavior the way your child relates to other kids their age Ask family and relatives to put together a family medical history During your child s EPSDT exam, the PCP will identify if your child is due for a dental appointment based on his or her age. This benefit is offered through your Medicaid ID card. Please remember dental health is very important even with very young children. Talk to your PCP about your child s dental health at each EPSDT visit. It is very important that you keep your EPSDT appointments with the doctor. These physical exams can sometimes be used as the exam your child needs to get into Head Start, or for school, or for a driver s license physical. The doctor may find that your child needs a medically necessary service or a piece of equipment to treat a problem found during a screening visit. If so, the doctor can call Health Options to ask for the service or equipment, and it will be reviewed for approval. If you need more information about the Growing Up program, please call Member Services. Member Services can help you set up an appointment for your child, assist you with dental appointments or help you get a ride for these appointments. COMPLEX CARE COORDINATION 25 P age Member Services toll free