AETNA BETTER HEALTH OF MISSOURI. Learn about your health care benefits. Member Handbook.

Transcription

1 AETNA BETTER HEALTH OF MISSOURI Learn about your health care benefits Member Handbook

2 Visually and hearing impaired members We have this handbook in an easy to read form for people with poor eyesight. Please call us at for help. We have a special phone number for people with poor hearing. Members who use a Telecommunications Device for the Deaf (TTY/TDD) can call 711 or Important phone numbers Transportation Transportation Fax Family Support Division Information Center Behavioral Health Hour Nurse Line TDD/TTY Access 711 or Mailing address: 10 South Broadway, Suite 1200 St. Louis MO Website: Aetna Better Health members who live in our Western Missouri region may get care through Children s Mercy Pediatric Care Network (CMPCN). If so, you can refer to the contact numbers on your member ID card. Your ID card has the CMPCN logo on the back. Personal information and contact list My member ID number: My primary care provider (PCP): My PCP s phone number:

3 Aetna Better Health of missouri Thank you for choosing Aetna Better Health of Missouri for your health care needs. Your choice of our health plan is an important one for you and your family. We re a MO HealthNet Managed Care health plan that guarantees you and your family have access to health care services or can see your doctor when you need. It s important to understand how to use your services. This Member Handbook has the information you need to learn about your Aetna Better Health services. Please take some time to read this Handbook. If you need another copy of this handbook, just call Member Services to request a copy, or you can download a copy from our website at. Thanks again for choosing Aetna Better Health of Missouri. Please contact a Member Services Representative if you have questions about your services at A representative is always able to help you Monday to Friday, 8 a.m. to 5 p.m. Sincerely, Chief Executive Officer 1

4 Table of Contents Welcome to MO HealthNet Managed Care Keeping your insurance Visually and hearing impaired members Interpreter Services Glossary Section 1: Important information about your Aetna Better Health of Missouri coverage Providing you with quality service About your coverage Extra Aetna Better Health benefits Your health benefits in MO HealthNet Managed Care Preventive Services Hospital coverage Nurse visits for you and your baby Newborn coverage Important information for members of a Federally recognized American Indian or Native Alaskan Tribe Utilization Management (UM) Inpatient pharmacy Pharmacy dispensing fees Transportation Non-Emergency Medical Transportation (NEMT) Section 2: Rights and responsibilities Your rights as a MO HealthNet Managed Care health plan member..23 Your responsibilities Regular health care appointments Advance health care directive

5 Section 3: Enrollment and eligibility Disenrollment Annual eligibility review Changes you need to report Changing to another MO HealthNet Managed Care health plan ID cards Care you get using the Red or White MO HealthNet Card Section 4: Getting help Member Services Special health care needs Advocates for Family Health Case Management services Chronic condition management programs Website information Member satisfaction survey Section 5: Using your benefits What is a primary care provider (PCP)? Your PCP If you have a new PCP Choosing and changing your primary care provider (PCP) If your PCP no longer takes Aetna Better Health Vision benefit Dental benefit Dental appointments Behavioral Health Care Behavioral Health Care appointments Second opinion and third opinion Benefit changes Family planning

6 Getting medical care Special care centers Home health care Health care away from home Fraud and Abuse Section 6: Covered services and limits Authorization process Pre-authorization Services without authorization Post-stabilization care Post-stabilization care services Provider services in the hospital Utilization process If you are billed Copayments Filing claims Explanation of Benefits Medical Technology Committee Medical Disability/MO HealthNet Fee-for-Service Insurance Health survey Section 7: General services not covered Services not covered Section 8: Emergency services and urgent care Urgent health care appointments Urgent Care and Convenience Clinics Emergency Medical Services Emergency transportation

7 Section 9: Wellness care for adults and children Wellness care for adults More benefits for children and women in a MO HealthNet category of assistance for pregnant women Immunization (shot) schedule for children Independent foster care adolescents ages 21 through Lead screening for children and pregnant women Section 10: Special programs Text4baby SM The Smiling Stork Program First Steps Consumer Advisory Committee (CAC) Hour Nurse Line Section 11: Grievances and appeals Grievances and appeals How to make a Grievance, Appeal or ask for a State Fair Hearing Copy of medical criteria Section 12: Your privacy matters Notice of Privacy Practices Notes

8 Welcome to MO HealthNet Managed Care You live in an area of the state where you get most of your benefits from a MO HealthNet Managed Care health plan. Each MO HealthNet Managed Care health plan member must have a Primary Care Provider (PCP). A PCP manages a member s health care. In non-managed care areas of the state, individuals eligible for MO HealthNet receive health care services through MO HealthNet Fee-for-Service. There are a few services that members in a MO HealthNet Managed Care health plan will receive from MO HealthNet Fee-for-Service. MO HealthNet Fee-for-Service members must go to a MO HealthNet approved provider. You can do an online search to find a MO HealthNet approved provider at or you can call for a list of MO HealthNet approved providers. Keeping your insurance It is very important you call the Family Support Division (FSD) Information Center at or visit their website at to access the FSD Program Enrollment System online to let them know when your address changes. Important letters and information will be mailed to the address you have provided. You or your children could lose your MO HealthNet coverage if you do not respond to State requests for information. Please make sure that you answer all mail from the State. Visually and hearing impaired members We have this handbook in an easy to read form for people with poor eyesight. Please call us at for help. We have a special phone number for people with poor hearing. Members who use a Telecommunications Device for the Deaf (TDD) can call Interpreter Services If you do not speak or understand English call to ask for help. We can help if you do not speak or understand English. 6

9 We will get you a translator when needed at no cost to you. We may have this book in your language. We will get a copy of the grievance and appeal rules in your language. Servicios de intérprete Si UD. no habla o no entiende inglés llame al para pedir ayuda. Nosotros podemos ayudarle si no habla o no entiende inglés. Nosotros le conseguiremos un intérprete cuando se necesite. Podemos tener este libro en su idioma. Conseguiremos una copia de las reglas de reclamaciones y quejas en su idioma. DỊCH VỤ THÔNG DỊCH Nếu quý vị không nói được tiếng Anh xin vui lòng gọi số để được giúp đỡ. Chúng tôi sẽ giúp quý vị nếu quý vị không thể nói được tiếng Anh. Chúng tôi cung cấp thông dịch viên cho quý vị khi cần đến. Chúng tôi có bản tiếng Việt của cuốn sách này. Chúng tôi cung cấp bản điều lệ về than phiền và khiếu nại bằng tiếng Việt. PREVODILAČKE USLUGE Ako ne govorite ili ne razumijete engleski jezik, nazovite Aetna Better Health na za pomoć. Mi vam možemo pomoći ako ne govorite ili ne razumijete engleski jezik. Mi ćemo vas snabdjeti sa prevodiocem po potrebi. Možda imamo ovu brošuru i na vašem jeziku. Mi ćemo vam obezbijediti formular za podnošenje tužbe kao i pravila žalbenog postupka na vašem jeziku. Mga Serbisong Pagsasalin ng Wika Kung hindi ka nagsasalita o nakakaintindi ng Ingles tumawag sa upang humingi ng tulong. Makakatulong kami kung hindi ka nagsa-salita o nakakaintindi ng Ingles. Ikukuha ka naming ng tagasalin ng wika kapag kailangan Maaaring mayroon kami ng librong ito sa iyong wika Kukuha kami ng kopya ng mga tuntunin sa karain-gan at apela sa iyong wika 7

10 Glossary Adoption subsidy Subsidy services supporting a family adopting a child. Financial, medical, and support services for the child until age 18 or in some cases until age 21. These children may choose to get their health care as a MO HealthNet Managed Care health plan member, or may choose to get health care through MO HealthNet Fee-for-Service using MO HealthNet approved providers. Advance directive An advance directive allows you to leave written directions about your medical treatment decisions and/or ask someone to decide your care for you. Approved provider A doctor, nurse, clinic, pharmacy, hospital or other providers enrolled with the MO HealthNet Division. Authorization A determination made by or for the health plan for covered services or supplies for an eligible plan member. This determination is primarily based on the medical necessity of the eligible member s condition. Capitation A predetermined monthly fee paid by the MO HealthNet Managed Care health plan to a provider to provide covered services to members who are assigned to him or her. It is based on membership rather than on services delivered. Children s Mercy Pediatric Care Network Children s Mercy Pediatric Care Network(CMPCN) is a network of health care providers in Aetna Better Health s Western Missouri region. This is where many Aetna Better Health members get their health care. If you are in the CMPCN you will see the CMPCN logo on your member ID card. It is possible that not all members in a family are in the CMPCN. Day Specific Eligibility Refers to MO HealthNet participants that could lose eligibility at anytime of the month. 8

11 DCN Departmental Client Number - also known as your MO HealthNet number. This is your identification number for MO HealthNet. Eligibility group Members who receive benefits based on age, family size, and income. Enrollment helpline Where to call to enroll in the MO HealthNet Managed Care program. An enrollment counselor can be reached at EPSDT Early Periodic Screening, Diagnosis, and Treatment, also known as HCY. Family Support Eligibility Specialist A person you can call when you have a question about MO HealthNet eligibility call the FSD Information Center at or visit their website at to access the FSD Program Enrollment System online to report changes in your address, family size or income. Grievance A way for you to report dissatisfaction about things like: the quality of care or services you received, treatment by a provider, or a disagreement you may have with a MO HealthNet Managed Care health plan policy. HCY program Healthy Children and Youth, also known as EPSDT. High Risk A medical condition you have, which may become dangerous if you get another medical problem. There are complications. Immunization (Shot) A medicine that helps the body fight disease. Medically necessary The health plan shall determine whether or not a service furnished or proposed is reasonable and medically necessary for the prevention, diagnosis or treatment of a physical or behavioral illness or injury; to achieve 9

12 age appropriate growth and development; to minimize the progression of disability; or to attain, maintain or regain functional capacity; in accordance with acceptable standards of practice in the medical community of the area in which the physical or behavioral health services are rendered; and service(s) could not have been omitted without adversely affecting the member s condition or the quality of medical care rendered; and service is furnished in the most appropriate setting. A. In reference to medically necessary care, behavioral health services shall be provided in accordance with a process of behavioral health assessment that accurately determines the clinical condition of the member and the acceptable standards of practice for such clinical conditions. The process of behavioral health assessment shall include distinct criteria for children and adolescents. B. The Omnibus Budget Reconciliation Act of 1989 (OBRA-89) mandated that Medicaid provide medically necessary services to children from birth through age 20, which are necessary to treat or ameliorate defects, physical or behavioral illness, or conditions identified by an HCY/EPSDT screen. Services must be sufficient in amount, duration, and scope to reasonably achieve their purpose and may only be limited by medical necessity. MO HealthNet approved provider A doctor, nurse, clinic, pharmacy, hospital, or other providers enrolled with the MO HealthNet Division as a MO HealthNet approved provider. MO HealthNet approved providers provide services in MO HealthNet Fee-for- Service. You will show them your red or your white MO HealthNet card. MO HealthNet approved providers are sometimes also called MO HealthNet providers. You can do an on-line search to find a MO HealthNet approved provider at or you can call for a list of MO HealthNet approved providers. 10

13 White MO HealthNet card (Effective January 2008) The card sent to you when you are eligible for MO HealthNet. Red MO HealthNet card The card sent to you before January 2008 when you are eligible for MO HealthNet. MO HealthNet Fee-for-Service A way to get some health care services that are not covered by Aetna Better Health. These services may be covered by MO HealthNet Fee-for-Service. You can go to any approved provider that takes MO HealthNet Fee-for- Service. Use only your red or white MO HealthNet card. You may call to check on how to get these services. MO HealthNet Managed Care A way to get your MO HealthNet coverage from a MO HealthNet Managed Care health plan in certain counties of the State. You must choose a MO HealthNet Managed Care health plan or one will be chosen for you. You must also choose a Primary Care Provider. Use your MO HealthNet Managed Care card and your red or white MO HealthNet card to get services. While you are waiting to get in a MO HealthNet Managed Care health plan for health care, you get services from MO HealthNet Fee-for-Service. There are a few 11

14 services that members in a MO HealthNet Managed Care health plan will receive from MO HealthNet Fee-for-Service. You may call to check on how to get services. MO HealthNet Managed Care Card The card sent to you by your MO HealthNet Managed Care health plan. Member ID Card for Aetna Better Health members whose PCP is in the Children s Mercy Pediatric Care Network Out of Home Care/Alternative Care Services (Foster Care) Alternative Care is the care of children living in a home other than their birth parents. The juvenile court removes the child from their home. The Children s Division then sets a plan of services. PCP A Primary Care Provider is a health care provider who manages a member s health care. 12

15 Prior Authorization Your MO HealthNet Managed Care health plan s method of pre-approving certain services. Referrals A process used by a PCP to let you get health care from another health care provider, usually for specialty treatment. Aetna Better Health does not require a referral to see a specialist that is in Aetna Better Health s network. 13

16 Section 1: Important information about your Aetna Better Health of Missouri coverage Providing you with quality service Aetna Better Health of Missouri serves members across 54 counties statewide. We re one of the largest managed care health plans in Missouri. Our strong partnerships with health care providers and other community organizations help to give you complete and quality care. Our commitment to the highest standards of quality health care has earned us the National Commission for Quality Assurance (NCQA) Commendable Accreditation. This means we follow the standards established for health plans to achieve quality outcomes. About your coverage If you need to contact someone about your Aetna Better Health coverage, please contact: Aetna Better Health Member Services Department 10 S Broadway, Suite 1200 St. Louis, MO (TTY: 711 or TDD: ) Please make sure you read and understand the grievance procedure in this Handbook. Below are the addresses and telephone numbers for Grievances and Appeals: Grievances Aetna Better Health of Missouri Member Services Department 10 S Broadway, Suite 1200 St. Louis, MO (TTY: 711 or TDD: ) Appeals Aetna Better Health of Missouri Appeals Coordinator 10 S Broadway, Suite 1200 St. Louis, MO (TTY: 711 or TDD: ) 14

17 Extra Aetna Better Health benefits The Non-Emergency Medical Transportation (NEMT) will take you to a pharmacy* Referrals not needed to see an in-network specialty care provider and specialist Adult dental benefit (limited) After school programs includes membership to one of the following: -- 4-H -- Discovering Options -- Girls Inc. -- Local Investment -- Boys and Girls Clubs Commission s Caring -- Girl Scouts Communities -- Boy Scouts Diabetic foot care Enhanced transportation services (for members eligible for stateapproved transportation services) *Only if you are eligible for the transportation benefit Pregnancy programs: The Smiling Stork TM Program Text4baby SM text messaging program Your health benefits in MO HealthNet Managed Care Some benefits are limited based on your eligibility group or age. The benefits that may be limited have an * next to them. Some services need prior approval before getting them. Call Aetna Better Health at for information about your health benefits. Ambulance Ambulatory surgical center, birthing center Behavioral health and substance abuse Cancer screenings Dental services related to trauma to the mouth, jaw, teeth or other contiguous sites as a result of injury. Dental services when the absence of dental treatment would adversely affect a pre-existing medical condition Durable Medical Equipment (DME)* Emergency medical, behavioral health, and substance abuse services and post-stabilization services 15

18 Family planning Home health services* Hospice, if you are in the last six months of your life. Children may receive hospice services and treatment for their illness at the same time. The hospice will provide all services for pain relief and support. Hospital, when an overnight stay is required Laboratory tests and x-rays Maternity benefits, including certified nurse midwife Optical, services include one comprehensive or one limited eye examination every two years for refractive error, services related to trauma or treatment of disease/medical condition (including eye prosthetics), and one pair eyeglasses every two years (during any 24 month period of time). Replacements within the 24 month period may be available under certain conditions. Outpatient hospital, when an overnight stay is not required Personal care Podiatry, limited medical services for your feet* Primary Care Provider (PCP) services Specialty care Transplant related services Transportation to medical appointments* You may get these services from your MO HealthNet Managed Care health plan or a local public health agency: Screening, testing, and treatment for sexually transmitted diseases Screening and testing for HIV Screening, testing, and treatment for tuberculosis Immunizations (shots) for children Screening, testing, and treatment for lead poisoning Preventive Services Aetna Better Health of Missouri must provide coverage for preventive services rated A or B by the U.S. Preventive Services Force If you have health insurance other than MO HealthNet Managed Care, your other health insurance may be responsible for the payment of these preventive services. 16

19 Direct access to Women s Health services Aetna Better Health members have direct access to in-network women s health specialists for covered routine and preventive health care services. Call Member Services at if you have questions. Hospital coverage Going to a hospital that is within our network can save you money. If you or your child goes to an in-network hospital, your costs are covered for medically necessary services. Prior-authorization rules may apply. Other costs covered under medically necessary services include: In-network hospital care Outpatient and specialist care Lab and x-ray services Medical supplies and equipment Nurse visits for you and your baby You and your Primary Care Provider (PCP) may agree for you to go home early after having a baby. If you do, you may get two nurse visits in your home. You may get the home health nurse visits if you leave the hospital less than 48 hours after having your baby, or less than 96 hours after a C-Section. The first nurse visit will be within two days of leaving the hospital. The second nurse visit is within two weeks of leaving the hospital. You may be able to get more nurse visits if you need them. At a home visit, the nurse will: Check your health and your baby Talk to you about how things are going Answer your questions Teach you how to do things such as breast feeding and Do lab tests if your PCP orders them 17

20 Newborn coverage If you have a baby, you must: Call the Family Support Division (FSD) Information Center at or visit our website at to access the FSD Program Enrollment System online as soon as possible to report the birth of your child. The State will give your baby an identification number, known as a DCN or MO HealthNet number. Call Aetna Better Health at and, Pick a PCP for your baby in Aetna Better Health of Missouri s network. Your baby will be enrolled in Aetna Better Health. Call the MO HealthNet Managed Care Enrollment Helpline at if you want a different MO HealthNet Managed Care health plan for your baby. This is the only phone number you can use to change your baby s MO HealthNet Managed Care health plan. You cannot enroll the baby before birth. You cannot change MO HealthNet Managed Care health plans for your baby until after your baby is born and has a MO HealthNet number. The Family Support Division staff cannot change your baby s MO HealthNet Managed Care health plan. To be sure your baby gets all the services he or she needs, continue to use your current MO HealthNet Managed Care health plan and PCP until the new MO HealthNet Managed Care health plan is effective. If you want to change your baby s MO HealthNet Managed Care health plan it will be, at most, 15 days before the new MO HealthNet Managed Care health plan is effective. Important information for members of a Federally recognized American Indian or Native Alaskan Tribe Is your child a member of a federally-recognized American Indian or Native Alaskan tribe? If so, you will not have to pay a premium for your child s health care coverage. To stop owing a premium, send a copy of the proof of your child s tribal membership to the Premium Collections Unit by mail, fax, or . Be sure to include your child s MO HealthNet identification card number. 18

21 Mail: MO HealthNet Division Premium Collections Unit P.O. Box 6500 Jefferson City, MO Fax: Scan your records and to Type the words Premium Collections Unit in the subject line of your . Proof of membership can be a copy of a tribal membership card or letter issued by a tribe that is recognized by the United States Department of the Interior, Bureau of Indian Affairs. Utilization Management (UM) Aetna Better Health offers a Utilization Management (UM) program. Our UM program helps make sure you get the right care when you need it. If you have questions about getting special care or a question about your doctor, call (TTY: 711 or TDD: ). This number can receive collect calls. You can reach us Monday-Friday, 8 a.m. to 5 p.m. UM is not open on holidays or weekends. If you call and we re closed, you can speak with an on-call nurse or leave a message. Someone will call you back the next business day. They ll tell you their name and let you know they re from the Aetna Better Health UM department. If you don t speak English, we can help. Our interpreters can help with any language. Inpatient pharmacy Aetna Better Health covers inpatient pharmacy costs as part of inpatient hospital costs. Pharmacy dispensing fees Children under age 19 do not have to pay a pharmacy dispensing fee. Members age 19 and older pay a pharmacy dispensing fee for each drug they get. This fee is $0.50 up to $2.00 for each drug. The amount of this fee is 19

22 based on the cost of the drug. You should never pay a fee of more than $2.00 for each drug. Remember, if you get more than one drug at the same time, you will pay these fees for each drug you get. You will not pay a dispensing fee when the medicine is for an emergency, family planning, a foster child, EPSDT/HCY services, or a pregnancy-related reason. You will be able to get your prescription even if you cannot pay. You will still owe the fee and must pay it like your other bills. Over-the-counter drugs Your MO HeathNet benefits include some over-the-counter drugs. Find out which drugs are covered through MO HealthNet Participant Services. Just call or Transportation Do you need a ride to your appointment? You may have transportation benefits offered through Aetna Better Health. We provide a ride or mileage reimbursement for health-related appointments for members who qualify. You can learn more about your transportation benefits through Member Services at Members who pay a premium to MO HealthNet are not eligible for the transportation benefit. Travel distance standards Aetna Better Health wants to make sure that you have access to providers within 30 miles of your home. We work hard to find providers in every county we serve. If you need help finding a provider call Member Services at Non-Emergency Medical Transportation (NEMT) NEMT stands for Non-Emergency Medical Transportation. NEMT can be used when you do not have a way to get to your health care appointment without charge. We may use public transportation or bus tokens, vans, taxi, or even an ambulance, if necessary, to get you to your health care appointment. 20

23 Aetna Better Health will give you a ride that meets your needs. You do not get to choose what kind of car or van or the company that will give you the ride. You may be able to get help with gas costs if you have a friend or a neighbor who can take you. This must be approved before your appointment. Who can get NEMT services? You must be a member of Aetna Better Health on the day of your appointment. Some people do not get NEMT as part of their benefits. To check, call Member Services at Children who are under age 17 must have an adult ride with them. We will only pay for one child and one parent/guardian and/or an attendant if your child is under age 21 and needs to be away from home overnight or needs someone to be with him/her. We will not pay for other children or adults. Your medical appointment requires an overnight stay. Volunteer, community, or other ancillary services are not available at no cost to you. What health care services can I get NEMT to take me to? The appointment is to a health care provider that is in the Aetna Better Health network or takes MO HealthNet Fee-for-Service. The appointment is to a service covered by Aetna Better Health or MO HealthNet Fee-for-Service. The appointment is to a health care provider near where you live. If the provider is far away, you may need to say why and get a note from your PCP. There are rules about how far you can travel to a health care appointment and get a ride. Some services already include NEMT. We will not give you a ride to these services. Examples are: some Comprehensive Substance Treatment, Abuse and Rehabilitation (CSTAR) services; hospice services; Developmental Disability (DD) Waiver services; some Community Psychiatric Rehabilitation (CPR) services; adult day health care services; and services provided in your home. School districts must supply a ride to a child s Individual Education Plan (IEP) services and IEP medical related services. The NEMT program can take you to a durable medical equipment (DME) provider only if the DME provider cannot mail or deliver your equipment to you. 21

24 How do I use the NEMT program? Call You must call at least three (3) days before the day of the appointment or you may not get NEMT. You may be able to get a ride sooner if your health care provider gives you an urgent care appointment. You can call this number If you have an emergency, dial 911, or the local emergency phone number. Public transportation We will send you bus passes at no cost to you. At least three days before your appointment, call us at You ll receive your bus passes directly to your home by mail. Benefits of riding the bus are: You are in control of your time. You don t have to wait for someone to pick you up. You can depend on bus routes and times of service. You can use the time you spent on the bus to work on hobbies, read or just relax. Mileage reimbursement On the day of your appointment, have someone at your provider s office sign the trip log. Then, send the signed log within 60 days of the appointment to: Medical Transportation Management ATTN: Mileage Reimbursement 16 Hawk Ridge Drive Lake Saint Louis, MO Or fax your trip log to Be sure to save your fax confirmation until you get your check in the mail. Or, you can take a photo of your completed mileage log and it to mileagegasreimbursementmtm-inc.net. Save the until you get your check in the mail. To receive a trip log, just call us at You can also download a trip log from our website. Just go to. Once we receive your trip log, we ll verify that the appointment has occurred. Then we ll send you your payment. 22

25 Section 2: Rights and responsibilities Your rights as a MO HealthNet Managed Care health plan member You have the right to: Be treated with respect and dignity Receive needed medical services Privacy and confidentiality (including minors) subject to state and federal laws Select your own PCP Refuse treatment Receive information about your health care and treatment options Participate in decision-making about your health care Have access to your medical records and to request changes, if necessary Have someone act on your behalf if you are unable to do so Get information on our Physician Incentive Plan, if any, by calling Be free of restraint or seclusion from a provider who wants to: -- Make you do something you should not do -- Punish you -- Get back at you; or -- Make things easier for him or her Be free to exercise these rights without retaliation Receive one copy of your medical records once a year at no cost to you Other Member rights You also have the following rights to: An open discussion with a health care professional about your health condition and treatment regardless of your benefit coverage Provide feedback about the organization s member rights and responsibilities policies Voice grievances or appeals about the organization or the care it provides Receive information about the organization, its services, its practitioners and providers and member rights and responsibilities Participate with health care providers in making decisions about your health care 23

26 Your responsibilities As a member of Aetna Better Health, you have the responsibility to: Call Aetna Better Health to order a new member ID card if yours is lost When you see your provider show your Aetna Better Health member ID card and your red or white MO HealthNet card If you have other insurance, show that card, too. When needing medical care contact your PCP first Only use the emergency room in an emergency Follow all instructions given by your health care provider Follow appointment scheduling rules - Make and keep PCP appointments - Make sure to call ahead to cancel - Make sure your child sees his or her PCP for regular checkups and shots Provide as much information as possible that the organization and its practitioners and providers need to help take care for you Understand your health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible Work with you provider to develop treatment goals Follow plans and instructions for care that you have agreed upon with your providers You ll find Rights and Responsibilities updates in the member newsletter. Just go to. Regular health care appointments Your health care providers must see you within 30 days when you call for a regular health care and dental appointment. Call if you need help. Pregnant women can see a health care provider sooner. In the first six months of pregnancy, you must be seen within seven days of asking. In the last three months of your pregnancy, you must be seen within three days of asking. You should not have to wait longer than one hour from the time of your appointment. For example, if your appointment time is 2 p.m., you should be seen by 3 p.m. Sometimes you may have to wait longer because of an emergency. 24

27 Please call Aetna Better Health at if you have problems or need help with an appointment. It is always important that you take all your health insurance cards to your appointments. Advance health care directive You have the right to accept or refuse any medical care. A time may come when you are too sick to talk to your PCP, family, or friends. You may not be able to tell anyone what health care you want. The law allows adults to do two things when this happens: An advance directive allows you to leave written directions about your medical treatment decisions An advance directive also allows you to ask someone to decide your care for you If you do not have an advance health care directive, your PCP may not know what health care you want. Talk to your PCP or call Aetna Better Health at for information on an advance health care directive. Your PCP must keep a written and signed copy of what care you want. An advance directive becomes part of your medical record. If there is a problem with things not being done the way they should with an advance directive, you may file a complaint with the Missouri Department of Health and Senior Services at or write them at P.O. Box 570, Jefferson City, Missouri You may at: info@health.mo.gov. Advance Health Care Directives are available from: The Missouri Bar P.O. Box Monroe Jefferson City, MO Or You may call them at or download forms from their website at 25

28 Disenrollment Section 3: Enrollment and eligibility You can be disenrolled from MO HealthNet Managed Care for any of the following reasons: Missing too many appointments without letting your health care provider know Repeatedly refusing to follow your PCP s lawful directions Threatening or abusing our workers You cannot be disenrolled due to the following: Grievances you made against us Health problems Annual eligibility review Each year you ll need to verify if you re eligible for MO HealthNet benefits. You ll get a letter from the Family Support Division (FSD) about your annual eligibility review. If you have questions on your annual review, call the FSD Information Center. You can reach them at It s important to follow these steps when you get your letter: Open any mail from FSD Meet any deadline in your letter Complete and return all forms Send any required information quickly You could lose your insurance if you don t follow these steps. If you re no longer eligible If you re no longer eligible, your insurance coverage from MO HealthNet ends. You ll get a letter from Family Support Division (FSD) office with a date of when your coverage ends. After this date, you won t be able to use your Aetna Better Health card or your red or white MO HealthNet card. 26

29 Changes you need to report If you move, it is important that you report your new address by calling the Family Support Division (FSD) Information Center at or visit their website at to access the FSD Program Enrollment System online and the MO HealthNet Managed Care Enrollment Helpline at Then call Aetna Better Health at Your MO HealthNet Managed Care coverage may be affected. If we do not know where you live, you will miss important information about your coverage. Changes you need to report to the FSD Information Center at include: Family size (including the birth of any babies) Income Address Phone number Availability of insurance Changing to another MO HealthNet Managed Care health plan You may change MO HealthNet Managed Care health plans for any reason during the first 90 days after you become a MO HealthNet Managed Care health plan member. You will also be able to change during your annual open enrollment time. Call the MO HealthNet Managed Care Enrollment Helpline at for help in changing MO HealthNet Managed Care health plans. You may be able to change MO HealthNet Managed Care health plans after 90 days. Some reasons for changing include but are not limited to the following: You have moved out of the MO HealthNet Managed Care area; or Your PCP or specialist is no longer with Aetna Better Health and is in another MO HealthNet Managed Care health plan. This applies to PCPs or specialists you have seen at least once in the last year or you have seen most recently except in the case of an emergency. Aetna Better Health cannot make you leave our MO HealthNet Managed Care health plan because of a health problem. 27

30 ID cards You will receive an Aetna Better Health ID card when you join our plan. Carry your ID card and your red or white MO HealthNet card with you at all times. Always show your cards when you visit your PCP or other health care provider. The PCP will know you are a member of Aetna Better Health. If you have other insurance, you ll need to show your provider that card too. Your Aetna Better Health ID card will come in the mail. If you have not received your Aetna Better Health ID card, call Member Services. If you need another ID card, please call Member Services at (TTY: 711 or TDD: ). Check glossary to see a sample of your ID card. We send new cards when: You request one Your name changed or you corrected the spelling Your card is lost or stolen You add a new member to your family You change your PCP If you call Member Services, have your Aetna Better Health ID card and MO HealthNet number with you. Care you get using the Red or White MO HealthNet Card You can get some health care that is not covered by Aetna Better Health. These services are covered by MO HealthNet Fee-for-Service using MO HealthNet approved providers. Aetna Better Health can help you find a MO HealthNet approved provider for that care. Please let your Primary Care Provider (PCP) know about the care you get. This helps your PCP take care of you. This care may include the following: Pharmacy. School based services including physical therapy (PT), occupational therapy (OT), speech therapy (ST), hearing aid, personal care, private duty nursing, or behavioral health services included in an Individualized Family Service Plan (IFSP) or Individualized Educational Program (IEP). Visits by a health worker to see if lead is in your home. 28

31 Bone marrow and organ transplants. SAFE/CARE exams for abused children. Children who are in Alternative Care or get Adoption Subsidy get behavioral health/substance abuse care through MO HealthNet Fee-for- Service using MO HealthNet approved providers. These children get their physical health care from Aetna Better Health. Community Psychiatric Rehabilitation is a special program run by the Missouri Department of Mental Health for the seriously mentally ill or seriously emotionally disturbed. Drug and alcohol treatment from a Comprehensive Substance Treatment and Rehabilitation (CSTAR) provider. Call Aetna Better Health Member Services at for a list of CSTAR providers. Targeted case management for behavioral health services. Abortion- (termination of a pregnancy resulting from rape, incest, or when needed to save the mother s life). Smoking cessation. 29

32 Member Services Section 4: Getting help Aetna Better Health Member Services is here to answer your questions. Just call We re available Monday Friday, 8 a.m. to 5 p.m., Central Time. We can explain how our health plan works. We ll help you find a provider. If you have a certain provider you ve been seeing, we can tell you if that provider is in our health plan. We can also tell you if that provider is accepting new patients or if you need a referral to see that provider. We can explain your rights and responsibilities. If you have questions about your benefits, we can answer them. Our Member Services staff can also help you with getting appointments and transportation to your appointments if you are eligible. Member Services tracks your call and will quickly respond to your questions. Special health care needs If you have a special health care need, call Aetna Better Health at Aetna Better Health will work with you to make sure you get the care you need. If you have a chronic illness and are seeing a specialist for your medical care, you may ask Aetna Better Health for a specialist to be your PCP. Advocates for Family Health Advocates for Family Health is an ombudsman service. An ombudsman is a problem solver who can advise you and help you. Advocates for Family Health can help you if: You need help understanding your rights and benefits under MO HealthNet Managed Care You feel your rights to health care are being denied You are not able to solve the problem by talking to a PCP, a nurse, or your MO HealthNet Managed Care health plan 30

33 You need to talk to someone outside of your MO HealthNet Managed Care health plan You want help when filing a grievance You need help when appealing a decision by your MO HealthNet Managed Care health plan You need help getting a State Fair Hearing You can get legal help at no cost to you by contacting the legal aid office for your county. For Clay, Jackson and Platte counties: Call Legal Aid of Western Missouri at Ask for Advocates for Family Health. For Bates, Benton, Camden, Cass, Henry, Johnson, Lafayette, Linn, Morgan, Pettis, Ray, Saline, St. Clair and Vernon counties: Call Legal Aid of Western Missouri at or Ask for Advocates for Family Health. For Franklin, Jefferson, Lincoln, Macon, Madison, Marion, Monroe, Montgomery, Perry, Pike, Ralls, Shelby, St. Charles, St. Francois, St. Louis, Ste. Genevieve, Warren, and Washington counties, and St. Louis City: Call Legal Services of Eastern Missouri at or Ask for Advocates for Family Health. For Cedar, Gasconade, Laclede, Maries, Phelps, Polk, and Pulaski counties: Call Legal Services of Southern Missouri at or Ask for the Advocates for Family Health. For Audrain, Boone, Callaway, Chariton, Cole, Cooper, Howard, Miller, Moniteau, Osage, and Randolph counties: Call Mid-Missouri Legal Services Corp. at or Ask for Advocates for Family Health. 31

34 Case Management services You may ask for an assessment for case management services at any time by calling Aetna Better Health at Aetna Better Health will offer case management services for members who are: Pregnant, or All children with elevated blood lead levels Within thirty (30) days of enrollment, Aetna Better Health will offer a case management assessment for new members with the following conditions: Cancer Individuals with special health care needs including Autism Spectrum Disorder Diabetes Sickle Cell Anemia Asthma COPD Congestive heart failure Organ failure Serious mental illness Chronic pain Hepatitis C HIV/AIDS Case management support Our case managers can help you manage your health conditions. This includes illnesses, injuries, hospitalizations, complex needs and chronic conditions. We can help with certain issues that may make it difficult for you to get healthy. Call us at Our case managers will help with: Coordinate your health care needs with your PCP and health care team Discuss benefits and services available to you Connect you to community services Get you the medicines and PCP appointments you need Provide you with health education materials specific to your needs Teach you simple every day steps to keep you well Help you set and meet goals to improve your health Talk with you or your family when you need us 32

35 Aetna Better Health may contact you about our case management services if it may be a benefit to you. Your PCP or specialist can also refer you for this program. You have the right to make choices about your health care If we contact you to join case management, you can say no. Saying no will not change your coverage in any way. If you are already in case management, you may choose to stop at any time. This will not change your coverage. To stop, call Member Services at Chronic condition management programs Aetna Better Health wants you to know everything you can to stay healthy. Our chronic condition management programs can help you manage your condition. Adults and children can use these programs. You can get health education on: Asthma Chronic Obstructive Pulmonary Disease (COPD) Depression Diabetes Heart Failure (HF) After you enroll, a Clinical Health Coordinator or Case Manager will help you. They ll teach you about your disease or condition, work with your PCP and show you ways to stay well. Aetna Better Health may contact you about our program. This is if we see that it may be a benefit to you. Your PCP or specialist can also refer you. It is your choice to be in these programs. You have the option to end the program at any time. You can call Member Services to learn more at Or visit. Website information You can get up-to-date information about your MO HealthNet Managed Care health plan on our website at. You can visit our website to get information about the services we provide, our provider network, frequently asked questions, contact phone numbers 33