Member Handbook

Transcription

1 Member Handbook Assistance available for those who are deaf, hard- of hearing, or speech impaired by calling the Illinois Relay DIAL 711 Monday- Friday Visit CountyCare 8am- 8pm, online at Saturday 9am- 2pm The call is free! 12/28/12 Final

2 TABLE OF CONTENTS Program... What is CountyCare?... 1 Helpful words... 1 Who is eligible for CountyCare?... 2 How can I apply?... 2 What documents are required to apply for CountyCare?... 2 What services are covered?... 5 When does coverage start?... 6 How do I find out if I am approved?... 6 Are all Medicaid doctors accepting CountyCare patients?... 6 What is a Patient Centered Medical Home?... 7 How can I change my Patient Centered Medical Home?... 7 Referrals... 7 Emergency services... 7 Mental Health, drug and alcohol services Transportation for medical services Where can I fill my prescriptions? Complaints, Rights & Responsibilities, Privacy What is a complaint? What should I do if I have a complaint? Appeals and fair hearings Your rights and responsibilities Privacy and confidentiality /28/12 Final i

3 WELCOME TO COUNTY CARE PROGRAM WHAT IS COUNTY CARE? CountyCare is a new healthcare program for adults in Cook County without health insurance. The State of Illinois and the Cook County Health and Hospitals Systems (CCHHS) operate CountyCare. It is a Medicaid program available under healthcare reform. People in CountyCare will get healthcare from CCHHS doctors. Healthcare may also be from some community clinics. HELPFUL WORDS CCHHS Cook County Health and Hospital System Covered Services The services you get through the CountyCare Program. DHS Illinois Department of Human Services Helpline The CountyCare Helpline can answer your questions about the program. You can call from 8am- 8pm Monday- Friday and 9am- 2pm Saturday. The number is or toll free (Assistance available for those who are deaf, hard- of hearing, or speech impaired by calling the Illinois Relay - Dial 711). HFS - Illinois Department of Healthcare and Family Services Medical Home A medical home is the place you go for your healthcare needs. It is where all of your records are kept. You will go to your medical home when you are sick or it is time for a checkup. Recipient Identification Number (RIN) A number assigned to you when you are approved for the CountyCare Program Referral May be required when you seek services with a provider that is not your medical home. Specialist A doctor who practices a special kind of medicine, like an ear, nose, and throat doctor. 12/28/12 Final 2

4 WHO IS ELIGIBLE FOR COUNTYCARE? To join CountyCare, you must: Live in Cook County Be years of age. Meet income limits yearly (Limits are $14,856 for an individual or $20,123 for a couple). Do not qualify for Medicaid or Medicare. This means that if you are a parent, are under 19 years old, or are over 65 you should get Medicaid instead of CountyCare. If you are a disabled person receiving disability benefits or blind, you should also get Medicaid. Be a legal immigrant for five years or more or a US citizen. Have a Social Security number or have applied for one. If you qualify for Medicaid or Medicare, you cannot join CountyCare. HOW CAN I APPLY? You can apply by phone or in person at many locations: By Phone: Call CountyCare at or toll free In person: At one of the Cook County Health and Hospitals System locations or at one of the Federally Qualified Health Centers (FQHCs). Call CountyCare at or toll free for a list of locations. We can help you find out if you eligible to apply for the CountyCare Program. You can call us at We are open Monday- Friday 8am to 8pm, and Saturday 9am to 2pm. WHAT DOCUMENTS ARE REQUIRED TO APPLY FOR COUNTYCARE? You must send in documents to verify your identity, address, citizenship or immigrant status, and income. You can use the list on the next page to find out what documents you may be able to use. You can call or toll free at to find out what you need to submit for your application. 12/28/12 Final 3

5 DOCUMENTATION CHECKLIST Identity (Only one required for each applicant) Birth Certificate Drivers license State ID Card Foreign passport/id Certificate of Citizenship Birth Certificate Certificate of Citizenship Employment Authorization Card Foreign Passport Form I- 94 Arrival- Departure Military ID card Other Identity Proof U.S. passport Work or School ID card Certificate of Naturalization Citizenship/Legal Status (Only one required for each applicant) Immigration Status Filing U.S. Passport Other citizenship/alien proof Permanent Resident Card Selected USCIS (INS) Documents Income (One document or set of documents required to verify monthly income amount for each income source) Employer Statement Most Recent Tax Return Benefits Awards Letter Support of Alimony Payment Records Retirement Benefit Records Other Benefits Records Pay Stubs/Statements Other Income Proof Unemployment Insurance Record Self- Employment Income (One document or set of documents required to verify monthly income amount for each self- employment income source) Business Record Most Recent Tax Return Other- Self- Employment Proof Receipts for goods/services Current Lease Agreement Drivers License State ID card Employment Records Letter with Address from Local Shelter, Social Services, or Religious Organization where homeless applicants can get mail from State Proof of application for a SS Number for each application who does not have a SSN Address in Cook County (Only one required) Utility bills or records Mortgage receipt Other residency proof School records Social Security Number 12/28/12 Final 4

6 WHAT SERVICES ARE COVERED? CountyCare Services Hospital emergency room visits Hospital inpatient services Hospital ambulatory services Nursing Facility Services (30 days) (covers post- hospitalization nursing home stays) Physician services Advanced Practice Nurse services Laboratory and x- ray services Prescription Drugs Family planning services and supplies Podiatric Services (for diabetics) EPSDT (for year olds) Emergency Services (includes post- stabilization services) Sub- acute alcoholism and substance use disorder services Mental Health Services (including rehabilitation and clinic option) Medical supplies, equipment, prostheses and orthoses, and respiratory equipment and supplies Home health agency visits Hospice (and palliative) Physical, Occupational, Hearing and Speech Therapy Services Transportation - to secure Covered Services Dental (for yrs only) Targeted Case Management (behavioral health) FQHCs, RHCs and other Encounter rate clinic visits

7 6 WHEN DOES COVERAGE START? 5 CountyCare expects to have its first members in February HOW DO I FIND OUT IF I AM APPROVED? You will get a letter in the mail that lets you know if you are approved for CountyCare. If you are approved, a CountyCare Medical Card will be sent. Keep this card with you at all times. If approved, you will also get a packet that explains how CountyCare works. ARE ALL MEDICAID DOCTORS ACCEPTING COUNTYCARE PATIENTS? No. Only doctors that are in the CountyCare network see CountyCare patients. When you join CountyCare, you will get to pick your Patient- Centered Medical Home, or primary care site. This is where you will go for your healthcare. Your medical home will also refer you for specialty care. You can pick the medical home that is best for you from a list of CountyCare providers (Cook County Clinics and Community Health Centers).

8 7 YOUR PATIENT CENTERED MEDICAL HOME WHAT IS A PATIENT- CENTERED MEDICAL HOME? A Patient- Centered Medical Home is the place you go for healthcare. Your medical home is where all your records are kept. You will go to you Patient- Centered Medical home to get healthcare when you are sick or just need to talk to your doctor. A Patient- Centered Medical Home is: Accessible: It is located in your community. Patient- Centered care over time: You will be connected with your primary care site for a long time. Comprehensive: Most of the healthcare services that you need will be at your primary site. Coordinated: If you need to see more than one doctor, your primary care site coordinates your care for you. Compassionate: Your primary care site and other medical providers really care about you. HOW CAN I CHANGE MY PATIENT- CENTERED MEDICAL HOME? CountyCare wants you to be happy with your Patient Centered Medical Home. If you want to change your Patient- Centered Medical Home, please call us at or toll free at and we will assist you making the change. We are open Monday - Friday 8 am- 8pm and Saturday 9am- 2pm. You can change your Patient- Centered Medical Home once per month.

9 REFERRALS Your Patient- Centered Medical Home may contact CountyCare and if they find that you need to see a different doctor or get other healthcare services. If you need a service that is not offered by Cook County Health and Hospitals Services (CCHHS), your doctor will contact CountyCare and get a referral for you to receive the service at a CountyCare network provider. EMERGENCY SERVICES You should only go to the hospital emergency room for emergency care. An emergency is a sudden start of a medical condition or severe pain that an average person with no medical training feels: 1., 2. Would result in serious harm to the body, or 3. Would result in serious harm to an organ or body part. Every situation is different. If you or your family has an emergency, go to the nearest emergency room or 24- hour care center. Dial 911 or the phone number for your local ambulance service if you need it. You can go to any hospital for emergency care. The hospital should provide appropriate medical screening to see if your condition is an emergency regardless of your ability to pay for treatment, your citizenship or the legality of your presence in the United States. Here are some examples of times when you should use the emergency room: Blackouts Car Accident Chest pain or heart attack Choking Criminal attack (i.e. mugging or rape) Danger or loosing limb or life Difficulty in breathing Heavy bleeding Loss of speech Overdose of medicine or drugs Paralysis (not able to move) Poisoning Possible broken bones Seizures Throwing up blood

10 9 8 There are times when it is hard to know what a real emergency is. If you call your Patient Centered Medical Home before going to the emergency room, they will help you decide what to do. Here are some examples of when you probably do not need to go to the emergency room. At these times, if you call your Patient Centered Medical Home, the doctor can tell you what you should do: Bruises or swelling Cold or cough Cramps Smalls cuts or burns Earache Rash Sore throat Vomiting (throwing up)

11 BENEFITS AND SPECIAL SERVICES MENTAL HEALTH, DRUG AND ALCOHOL SERVICES Services for mental health such as depression, or drug and alcohol abuse are available for you. If you need help with these services, you can call your behavioral health provider at TRANSPORTATION FOR MEDICAL SERVICES You might be eligible for a voucher to take public transportation to your medical appointments. You can talk to your Patient Centered Medical Home for information on how to get transportation vouchers. WHERE CAN I FILL MY PRESCRIPTIONS? You can continue to use the Cook County Health and Hospitals Services (CCHHS) pharmacies. If you go to a community health center, you may get to use your current pharmacy service. It might be an on- site pharmacy or relationship with a local retail pharmacy. If you do not have a pharmacy you currently use, you may go to a Cook County Health and Hospitals Services (CCHHS) pharmacy. 10

12 COMPLAINTS, RIGHTS & RESPONSIBILITES, PRIVACY WHAT IS A COMPLAINT? A complaint is when you tell us you are unhappy with the program or your Patient Centered Medical Home and do not agree with a decision. Some things you may file a complaint about: You are unhappy with the care you are getting. You cannot get the services you want. You are unhappy with your relationship with your Patient Centered Medical Home. WHAT SHOULD I DO IF I HAVE A COMPLAINT? STEP 1 CountyCare Program wants you to get the best possible service. When something goes wrong or you are not treated well, we want to know. If you are not happy with your Patient Centered Medical Home, please contact them first and explain your concern. If you still not satisfied with the outcome, contact CountyCare. If you have a problem or complaint about CountyCare or the service you have received, you can call our Helpline at Or, you can put your complaint in writing and mail it to us at: CountyCare Program ATTN: Automated Health Systems 1375 East Woodfield Road Suite 600 Schaumburg, IL You should make your complaint within 60 days of the day you are not treated well. STEP 2 We will make a record of your complaint. We will review your complaint and try to find a solution. Your satisfaction is important to us. 11

13 APPEALS AND FAIR HEARINGS An appeal is a complaint you make when you feel an action was wrong. When you appeal, you are asking for a fair hearing about it. A fair hearing is a meeting with a fair hearing officer, someone from CountyCare, and you. You can talk about your complaint during the fair hearing, and the fair hearing officer will decide what to do. You can appeal if CountyCare: Denies your application, Stops your benefits (coverage), or Says that you will start to get fewer benefits. You can also appeal if you think we made a mistake about any decision. You should make your appeal within 60 days of when the action happened. You may not get a fair hearing if the action happened because of a change in law. To make an appeal and request a fair hearing, you can call the CountyCare Program Helpline from 8am- 8pm Monday- Friday and 9am- 2pm on Saturday. Call or toll free at YOUR RIGHTS AND RESPONSIBILITIES CountyCare program will let you know your rights and responsibilities every year. You have the right to: Be treated with respect, dignity and privacy. Have your Patient Centered Medical Home explain your treatment in a way that makes sense to you. Ask questions and have them answered. do not want. Call your Patient Centered Medical Home and get help. Complain about your Patient Centered Medical Home. Be free from any means of intimidation or retaliation. 12

14 You have the responsibility to: Learn your rights as a CountyCare member. Keep your appointments and cancel in advance the ones you cannot keep. Treat your Patient Centered Medical Home with respect. Tell your Patient Centered Medical Home about your healthcare needs and about any other healthcare services you are getting. Contact your Patient Centered Medical Home first for care that is not an emergency. Share important information that your Patient Centered Medical Home needs. Follow the instructions and guidelines given by your Patient Centered Medical Home. PRIVACY AND CONFIDENTIALITY At private. Some examples of protected health information are: Your name. Your telephone number. Your address. Your recipient identification number (the number on your CountyCare ID card). Your date of birth. Your social security number. Your medical procedure and diagnosis. There are times that CountyCare will need to share your protected health information with other persons who are responsible for your care. Some examples of when we can share information are: To help you get medical care. To arrange payments for your care and services. If we are required by law. 13