First Choice VIP Care Plus (Medicare-Medicaid Plan): 2016 Summary of Benefits

Transcription

1 First Chice VIP Care Plus (Medicare-Medicaid Plan): 2016 Summary f Benefits

2 First Chice VIP Care Plus: Summary f Benefits This is a summary f health services cvered by First Chice VIP Care Plus fr This is nly a summary. Please read the Member Handbk fr the full list f benefits. First Chice VIP Care Plus is a health plan that cntracts with bth Medicare and Suth Carlina Healthy Cnnectins Medicaid t prvide benefits f bth prgrams t members. This cmbined prgram is called Healthy Cnnectins Prime. It is fr peple with bth Medicare and Healthy Cnnectins Medicaid wh are 65 r lder, have Medicare Parts A, B, and D, and are eligible fr full Healthy Cnnectins Medicaid benefits. Mre infrmatin abut wh is eligible can be fund in Chapter 1 f the Member Handbk. Under First Chice VIP Care Plus yu can get yur Medicare and Healthy Cnnectins Medicaid services in ne health plan. A First Chice VIP Care Plus care crdinatr will help manage yur health care needs. This is nt a cmplete list. The benefit infrmatin is a brief summary, nt a cmplete descriptin f benefits. Fr mre infrmatin cntact the plan r read the Member Handbk. Limitatins, cpays, and restrictins may apply. Fr mre infrmatin, call First Chice VIP Care Plus Member Services r read the First Chice VIP Care Plus Member Handbk. The List f Cvered Drugs and/r pharmacy and prvider netwrks may change thrughut the year. We will send yu a ntice befre we make a change that affects yu. Benefits and cpays may change n January 1 f each year. Yu can get this infrmatin fr free in ther frmats, such as large print, braille, r audi. Call (TTY: ), 8 a.m. 8 p.m. 7 days a week. The call is free. Yu can get this infrmatin fr free in ther languages. Please call ur custmer service number at (TTY: ), 8 a.m. 8 p.m. 7 days a week. The call is free. Esta infrmación está dispnible de frma gratuita en trs idimas. Pr favr llame a nuestr númer de servici al cliente al (TTY/TDD: ), 8:00 a.m. 8:00 p.m.- 7 días a la semana. La llamada es gratuita. H8213_001_SOB_1761 If yu have questins, please call First Chice VIP Care Plus at (TTY: ), 8 a.m. 8 p.m. 7 days a

3 First Chice VIP Care Plus: Summary f Benefits The fllwing chart lists frequently asked questins. Frequently Asked Questins (FAQ) What is a Medicare-Medicaid Plan What is a First Chice VIP Care Plus care crdinatr What are lng-term services and supprts Answers A Medicare-Medicaid Plan is an rganizatin made up f dctrs, hspitals, pharmacies, prviders f lng-term services, and ther prviders. It als has care crdinatrs t help yu manage all yur prviders and services. They all wrk tgether t prvide the care yu need. A First Chice VIP Care Plus care crdinatr is ne main persn fr yu t cntact. This persn helps manage all yur prviders and services and makes sure yu get what yu need. Lng-term services and supprts (LTSS) are a variety f services and supprts that help peple meet their daily needs fr assistance and imprve the quality f their lives. LTSS are help fr peple wh need assistance t d everyday tasks like taking a bath, getting dressed, making fd, and taking medicine. Mst f these services are prvided at yur hme r in yur cmmunity but culd be prvided in a nursing hme r hspital. If yu have questins, please call First Chice VIP Care Plus at (TTY: ), 8 a.m. 8 p.m. 7 days a

4 First Chice VIP Care Plus: Summary f Benefits Frequently Asked Questins (FAQ) Will yu get the same Medicare and Medicaid benefits in First Chice VIP Care Plus that yu get nw Answers Yu will get yur cvered Medicare and Healthy Cnnectins Medicaid benefits directly frm First Chice VIP Care Plus. Yu will wrk with a team f prviders wh will help determine what services will best meet yur needs. This means that sme f the services yu get nw may change. Yu will get almst all f yur cvered Medicare and Healthy Cnnectins Medicaid benefits directly frm First Chice VIP Care Plus, but yu may get sme benefits the same way yu d nw, utside f the plan. This plan als ffers services that are nt usually cvered by Medicare r Healthy Cnnectins Medicaid. When yu enrll in First Chice VIP Care Plus, yu and yur care team will wrk tgether t develp an Individualized Care Plan (ICP) t address yur health and supprt needs. During this time, yu can keep seeing the prviders yu see nw fr 180 days. Yu can als cntinue t receive the same services and any that were authrized prir t yur enrllment in First Chice VIP Care Plus. When yu jin ur plan, if yu are taking any Medicare Part D prescriptin drugs that First Chice VIP Care Plus des nt nrmally cver, yu can get a temprary supply. We will help yu get anther drug r get an exceptin fr First Chice VIP Care Plus t cver yur drug, if medically necessary. If yu have questins, please call First Chice VIP Care Plus at (TTY: ), 8 a.m. 8 p.m. 7 days a

5 First Chice VIP Care Plus: Summary f Benefits Frequently Asked Questins (FAQ) Can yu g t the same dctrs yu see nw What happens if yu need a service but n ne in First Chice VIP Care Plus s netwrk can prvide it Answers Often that is the case. If yur prviders (including dctrs, therapists, and pharmacies) wrk with First Chice VIP Care Plus and have a cntract with us, yu can keep ging t them. Prviders with an agreement with us are in-netwrk. Yu must use the prviders in First Chice VIP Care Plus s netwrk. If yu need urgent r emergency care r ut-f-area dialysis services, yu can use prviders utside f First Chice VIP Care Plus's plan. T find ut if yur dctrs are in the plan s netwrk, call Member Services r read First Chice VIP Care Plus s Prvider and Pharmacy Directry. If First Chice VIP Care Plus is new fr yu, yu can cntinue seeing the dctrs yu g t nw fr 180 days after yu first enrll, even if they are ut-f-netwrk. If yu need t cntinue seeing yur ut-f-netwrk prviders after yur first 180 days in ur plan, we will nly cver that care if the prvider enters a single case agreement with us. If yu are getting nging treatment frm an ut-f-netwrk prvider and think they may need a single case agreement in rder t keep treating yu, cntact Member Services at (TTY ). Mst services will be prvided by ur netwrk prviders. If yu need a service that cannt be prvided within ur netwrk, First Chice VIP Care Plus will pay fr the cst f an ut-f-netwrk prvider. If yu have questins, please call First Chice VIP Care Plus at (TTY: ), 8 a.m. 8 p.m. 7 days a

6 First Chice VIP Care Plus: Summary f Benefits Frequently Asked Questins (FAQ) Where is First Chice VIP Care Plus available Answers The service area fr this plan includes the fllwing cunties in Suth Carlina. Yu must live in ne f these areas t jin the plan. Abbeville Charlestn Fairfield Lee Pickens Allendale Cherkee Flrence Lexingtn Richland Andersn Chester Gergetwn Marin Saluda Bamberg Chesterfield Greenville Marlbr Spartanburg Barnwell Clarendn Hamptn McCrmick Unin Beaufrt Clletn Jasper Newberry Wiilliamsburg Berkeley Dilln Kershaw Ocnee Calhun Edgefield Laurens Orangeburg D yu pay a mnthly amunt (als called a premium) under First Chice VIP Care Plus What is prir authrizatin What is a referral Yu will nt pay any mnthly premiums t First Chice VIP Care Plus fr yur health cverage. Prir authrizatin means that yu must get apprval frm First Chice VIP Care Plus befre yu can get a specific service r drug r see an ut-f-netwrk prvider. First Chice VIP Care Plus may nt cver the service r drug if yu dn t get apprval. If yu need urgent r emergency care r ut-f-area dialysis services, yu dn't need t get apprval first. A referral means that yur primary care prvider must give yu apprval t see smene wh isn t yur primary care prvider. If yu dn t get apprval, First Chice VIP Care Plus may nt cver the services, and yu may be billed fr these services. Yu dn t need a referral fr sme specialists, such as wmen s health specialists. Fr mre infrmatin n when a referral is necessary, see the Member Handbk. If yu have questins, please call First Chice VIP Care Plus at (TTY: ), 8 a.m. 8 p.m. 7 days a

7 First Chice VIP Care Plus: Summary f Benefits Frequently Asked Questins (FAQ) Answers Wh shuld yu cntact if yu have questins r need help If yu have general questins r questins abut ur plan, services, service area, billing, r member cards, please call First Chice VIP Care Plus Member Services: CALL Calls t this number are free. 8 a.m. 8 p.m. 7 days a week. After regular business hurs, yu may btain plan infrmatin frm the interactive vice respnse system and may leave a message fr yur care crdinatr. Member Services als has free language interpreter services available fr peple wh d nt speak English. TTY This number is fr peple wh have hearing r speaking prblems. Yu must have special telephne equipment t call it. Calls t this number are free. 8 a.m. 8 p.m. 7 days a week. Wh shuld yu cntact if yu have questins r need help (cntinued) If yu have questins abut yur health, please call the Nurse Advice Call line: CALL Calls t this number are free. 24 hurs, 7 days a week. TTY 711 Calls t this number are free. 24 hurs, 7 days a week. If yu have questins, please call First Chice VIP Care Plus at (TTY: ), 8 a.m. 8 p.m. 7 days a

8 First Chice VIP Care Plus: Summary f Benefits The fllwing chart is a quick verview f what services yu may need, yur csts and rules abut the benefits. Yur csts fr Health need r prblem Services yu may need in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu want t see a dctr Visits t treat an injury r illness $0 Wellness visits, such as a physical $0 Specialist care $0 Referral required Care t keep yu frm getting sick, such as flu shts $0 Welcme t Medicare preventive visit (ne time nly) Yu need medical tests Lab tests, such as bld wrk $0 X-rays r ther pictures, such as CAT scans Screening tests, such as tests t check fr cancer $0 $0 Prir authrizatin required fr mst utpatient diagnstic/therapeutic radilgical and x-ray services $0 If yu have questins, please call First Chice VIP Care Plus at (TTY: ), 8 a.m. 8 p.m. 7 days a

9 First Chice VIP Care Plus: Summary f Benefits Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need drugs t treat yur illness r cnditin Generic drugs (n brand name) $0 fr a 30-day supply. There may be limitatins n the types f drugs cvered. Please see First Chice VIP Care Plus s List f Cvered Drugs (Drug List) fr mre infrmatin. Extended-day supplies are available at all netwrk retail and mail rder pharmacy lcatins. The cst- sharing amunt fr extended-day supplies is the same as fr a ne-mnth supply. Brand name drugs $0 fr a 30-day supply. There may be limitatins n the types f drugs cvered. Please see First Chice VIP Care Plus s List f Cvered Drugs (Drug List) fr mre infrmatin. Extended-day supplies are available at all netwrk retail and mail rder pharmacy lcatins. The cst- sharing amunt fr extended-day supplies is the same as fr a ne-mnth supply. Over-the-cunter drugs $0 There may be limitatins n the types f drugs cvered. Please see First Chice VIP Care Plus s List f Cvered Drugs (Drug List) fr mre infrmatin. If yu have questins, please call First Chice VIP Care Plus at (TTY: ), 8 a.m. 8 p.m. 7 days a

10 First Chice VIP Care Plus: Summary f Benefits Health need r prblem Yu need therapy after a strke r accident Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Medicare Part B prescriptin drugs $0 Part B drugs include drugs given by yur dctr in his r her ffice, sme ral cancer drugs, and sme drugs used with certain medical equipment. Read the Member Handbk fr mre infrmatin n these drugs. Occupatinal, physical, r speech therapy $0 Prir authrizatin required Chirpractic services (nly fr manual manipulatin fr certain apprved cnditins) $0 Prir authrizatin required Yu need emergency care Emergency rm services $0 Emergency rm services are prvided ut f netwrk withut prir authrizatin requirements. Ambulance services $0 Nn-emergency ambulance requests t r frm a facility d nt require a prir authrizatin. Urgent care $0 Urgent care services are prvided ut f netwrk withut prir authrizatin requirements. Yu need hspital care Hspital stay $0 Prir authrizatin required Yu need help getting better r have special health needs Dctr r surgen care $0 Referral required t see a specialist Prir authrizatin required fr Outpatient Hspital Services Rehabilitatin services $0 Prir authrizatin required fr cardiac and pulmnary rehabilitatin services If yu have questins, please call First Chice VIP Care Plus at (TTY: ), 8 a.m. 8 p.m. 7 days a

11 First Chice VIP Care Plus: Summary f Benefits Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Medical equipment fr hme care $0 All Hme and Cmmunity-Based (HCBS) Waiver Services require authrizatin frm a Cmmunity Lng Term Care (CLTC) Case Manager. Skilled nursing care $0 Referral required Available t all members as medically necessary. Yu need eye care Treatment fr eye injuries r diseases $0 Prir authrizatin required Yu need dental care Initial replacement f lens due t cataract surgery Emergency medical prcedures by ral surgens Dental prcedures related t rgan transplants, cancer, jint replacement, heart valve replacement, and trauma $0 Prir authrizatin required $0 Prir authrizatin required $0 Prir authrizatin required Yu need ft care Pdiatry services $0 Referral required Yu need hearing/auditry services Yu have a chrnic cnditin, such as diabetes r heart disease Hearing screenings $0 Cvered hearing screenings are fr medically necessary diagnstic hearing and balance exams that are cvered by Original Medicare. Services t help manage yur disease $0 Diabetes supplies and services $0 Nn-preferred brands will require an authrizatin. If yu have questins, please call First Chice VIP Care Plus at (TTY: ), 8 a.m. 8 p.m. 7 days a

12 First Chice VIP Care Plus: Summary f Benefits Health need r prblem Yu have a mental health cnditin Yu have a substance abuse prblem Yu need lng-term mental health services Services yu may need Cardiac and pulmnary rehabilitatin services Mental r behaviral health services $0 Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) $0 Prir authrizatin required Partial hspitalizatin $0 Prir authrizatin required Substance abuse services $0 Inpatient care fr peple wh need mental health care $0 Prir authrizatin required Yu need durable medical equipment (DME) Wheelchairs $0 r $3.40 The cpay is $0 fr DME medical supplies cvered by Medicare. The cpay is $3.40 fr DME medical supplies cvered nly by Suth Carlina Healthy Cnnectins Medicaid. Prir authrizatin required fr Medicarecvered DME items ver $500 fr purchase and all rental items. Referral required fr Medicaid-cvered DME. Medicaid will rent mst DME equipment fr a maximum f ten mnths and the item is cnsidered purchased thereafter. Canes $0 Same rules abut benefits fr all DME items. Crutches $0 Same rules abut benefits fr all DME items. Walkers $0 Same rules abut benefits fr all DME items. If yu have questins, please call First Chice VIP Care Plus at (TTY: ), 8 a.m. 8 p.m. 7 days a

13 First Chice VIP Care Plus: Summary f Benefits Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Oxygen $0 Same rules abut benefits fr all DME items. Yu need prsthetics Prsthetic devices $0 r $3.40 The cpay is $0 fr prsthetic devices cvered by Medicare. The cpay is $3.40 fr prsthetic devices cvered nly by Suth Carlina Healthy Cnnectins Medicaid. An authrizatin is required fr Medicarecvered prsthetics and medical supplies ver $500 fr purchase and all rental items. Yu need help living at hme A cmpleted Medicaid Certificate f Medical Necessity (MCMN) is required fr reimbursement f medical supplies cvered by Suth Carlina Healthy Cnnectins Medicaid. Meals brught t yur hme $0 Maximum f 2 meals per day. All Hme and Cmmunity-Based (HCBS) Waiver Services require authrizatin frm a Cmmunity Lng Term Care (CLTC) Case Manager. Available t all members as medically necessary. If yu have questins, please call First Chice VIP Care Plus at (TTY: ), 8 a.m. 8 p.m. 7 days a

14 First Chice VIP Care Plus: Summary f Benefits Health need r prblem Yu need help living at hme (cntinued) Services yu may need Hmemaker services, such as cleaning r husekeeping Yur csts fr in-netwrk prviders $0 Referral required. Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Authrizatin required fr residential persnal care services. All Hme and Cmmunity-Based (HCBS) Waiver Services require authrizatin frm a Cmmunity Lng Term Care (CLTC) Case Manager. Available t all members as medically necessary. Changes t yur hme, such as ramps and wheelchair access $0 Envirnmental mdificatins benefit has a $7,500 lifetime limit. All Hme and Cmmunity-Based (HCBS) Waiver Services require authrizatin frm a Cmmunity Lng Term Care (CLTC) Case Manager. Available t all members as medically necessary. If yu have questins, please call First Chice VIP Care Plus at (TTY: ), 8 a.m. 8 p.m. 7 days a

15 First Chice VIP Care Plus: Summary f Benefits Health need r prblem Services yu may need Persnal care assistant (Yu may be able t emply yur wn assistant. Call Member Services fr mre infrmatin.) Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) $0 Referral required. All Hme and Cmmunity- Based (HCBS) Waiver Services require authrizatin frm a Cmmunity Lng Term Care (CLTC) Case Manager. Available t all members as medically necessary. Hme health care services $0 r $3.30 Hme health care services cvered by Medicare have a $0 cpay. Hme health services cvered by Healthy Cnnectins Medicaid have a $3.30 cpay. Prir authrizatin required Limited t 50 visits every year Services t help yu live n yur wn Available t all members as medically necessary. $0 r $3.30 Hme health care services cvered by Medicare have a $0 cpay. Hme health services cvered by Healthy Cnnectins Medicaid have a $3.30 cpay. Hme health services include incntinence supplies, limited t 12 cases every year. Prir authrizatin required If yu have questins, please call First Chice VIP Care Plus at (TTY: ), 8 a.m. 8 p.m. 7 days a

16 First Chice VIP Care Plus: Summary f Benefits Health need r prblem Services yu may need Adult day services r ther supprt services Yur csts fr in-netwrk prviders $0 Referral required Limitatins, exceptins, & benefit infrmatin (rules abut benefits) All Hme and Cmmunity-Based (HCBS) Waiver Services require authrizatin frm a Cmmunity Lng Term Care (CLTC) Case Manager. Yu need a place t live with peple available t help yu Yur caregiver needs sme time ff Available t all members as medically necessary Nursing hme care $0 Yu must cntribute tward the cst f this service when yur incme is mre than an allwable amunt. This cntributin, knwn as the patient pay amunt, is required nly fr thse living in a nursing hme. Yu will nt need t pay if yu are in the nursing hme fr shrt-term rehabilitatin. Respite care $0 Respite care can be prvided in a cmmunity residential care facility (CRCF) r a nursing hme. Members are limited t 28 ttal days f respite care per year. Up t 14 days f respite care can be received in a nursing hme. Yu need care fr advanced illness r lifethreatening injury Referral required Prir authrizatin required Palliative care $0 Referral required Prir authrizatin required If yu have questins, please call First Chice VIP Care Plus at (TTY: ), 8 a.m. 8 p.m. 7 days a

17 First Chice VIP Care Plus: Summary f Benefits Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need family planning services Birth cntrl (cndms) $0 Family planning supplies are cvered nly with a prescriptin Family planning lab and diagnstic tests $0 Prir authrizatin required Treatment fr sexually transmitted infectins (STIs) $0 Prir authrizatin required If yu have questins, please call First Chice VIP Care Plus at (TTY: ), 8 a.m. 8 p.m. 7 days a

18 First Chice VIP Care Plus: Summary f Benefits Other services that First Chice VIP Care Plus cvers This is nt a cmplete list. Call Member Services r read the Member Handbk t find ut abut ther cvered services. If yu have questins, please call First Chice VIP Care Plus at (TTY: ), 8 a.m. 8 p.m. 7 days a

19 First Chice VIP Care Plus: Summary f Benefits Other services cvered by First Chice VIP Care Plus Yur csts fr in-netwrk prviders Adult Day Health Transprtatin $0 Bathrm Safety Devices $0 Behaviral Health Services $0 Case Management (Lng Term Care) $0 Cmpanin Services $0 Educatin and Wellness Prgrams $0 End Stage Renal Disease Services $0 Enhanced Disease Management $0 Health Educatin $0 Infusin Services $0 In-Hme Safety Assessment $0 Institutin fr Mental Disease Services fr Individuals 65 r Older $0 Nursing Hme Transitin Services $0 Nursing Htline $0 Oral Nutritinal Benefit $0 Outpatient Bld Services $0 Pst-Discharge In-Hme Medicatin Recnciliatin $0 Preventive Services $0 Private Duty Nursing Services $0 Readmissin Preventin $0 Self-Directed Persnal Assistance Services $0 If yu have questins, please call First Chice VIP Care Plus at (TTY: ), 8 a.m. 8 p.m. 7 days a

20 First Chice VIP Care Plus: Summary f Benefits Other services cvered by First Chice VIP Care Plus Yur csts fr in-netwrk prviders Services Prvided at Federally Qualified Health Centers $0 Targeted Case Management $0 Telemedicine $0 Tele-Mnitring $0 If yu have questins, please call First Chice VIP Care Plus at (TTY: ), 8 a.m. 8 p.m. 7 days a

21 First Chice VIP Care Plus: Summary f Benefits Benefits cvered utside f First Chice VIP Care Plus This is nt a cmplete list. Call Member Services t find ut abut ther services nt cvered by First Chice VIP Care Plus but available thrugh Medicare r Healthy Cnnectins Medicaid. Other services cvered by Medicare r Healthy Cnnectins Medicaid Please cntact yur care crdinatr fr mre infrmatin. Sme hspice care services: $0 cpay Dental services Diagnstics (ral evaluatin and x-rays): $3.40 cpay Preventive care (annual cleaning): $3.40 cpay Restrative care (fillings): $3.40 cpay Surgical care (extractins / remvals): $3.40 cpay Nn-emergency medical transprtatin: $0 cpay Services that First Chice VIP Care Plus, Medicare, and Healthy Cnnectins Medicaid d nt cver Services nt cvered by First Chice VIP Care Plus, Medicare, r Healthy Cnnectins Medicaid Acupuncture Chirpractic care (except manual manipulatin fr certain apprved cnditins) Csmetic surgery r csmetic wrk Dentures Elective r vluntary enhancement prcedures r services Experimental medical and surgical treatments, items and drugs Eyeglasses, regular eye exams, and certain visual prcedures such as LASIK Full-time nursing care in yur hme If yu have questins, please call First Chice VIP Care Plus at (TTY: ), 8 a.m. 8 p.m. 7 days a

22 First Chice VIP Care Plus: Summary f Benefits Services nt cvered by First Chice VIP Care Plus, Medicare, r Healthy Cnnectins Medicaid Hearing exams and hearing aids (except fr certain apprved cnditins) Naturpath services Nn-prescriptin cntraceptive supplies Orthpedic shes (unless included with brace r fr diabetic ft disease). Supprtive devices fr feet (except fr diabetic ft disease) Persnal items in yur hspital r nursing hme rm Private rm in hspital Rutine ft care (except fr certain apprved cnditins) Services nt cnsidered reasnable and necessary Services prvided t veterans in a VA facility Surgical treatment fr mrbid besity If yu have questins, please call First Chice VIP Care Plus at (TTY: ), 8 a.m. 8 p.m. 7 days a

23 First Chice VIP Care Plus: Summary f Benefits Yur rights as a member f the plan As a member f First Chice VIP Care Plus, yu have certain rights. Yu can exercise these rights withut being punished. Yu can als use these rights withut lsing yur health care services. We will tell yu abut yur rights at least nce a year. Fr mre infrmatin n yur rights, please read the Member Handbk. Yur rights include, but are nt limited t, the fllwing: Yu have a right t respect, fairness and dignity. This includes the right t: Get cvered services withut cncern abut race, ethnicity, natinal rigin, religin, gender, age, mental r physical disability, sexual rientatin, genetic infrmatin, ability t pay, r ability t speak English Get infrmatin in ther frmats (e.g., large print, braille, audi) Be free frm any frm f restraint r seclusin Nt be billed by netwrk prviders Yu have the right t get infrmatin abut yur health care. This includes infrmatin n treatment and yur treatment ptins. This infrmatin shuld be in a frmat yu can understand. These rights include getting infrmatin n: Descriptin f the services we cver Hw t get services Hw much services will cst yu Names f health care prviders and care managers Yu have the right t make decisins abut yur care, including refusing treatment. This includes the right t: Chse a Primary Care Prvider (PCP) and change yur PCP at any time See a wmen s health care prvider withut a referral Get yur cvered services and drugs quickly Knw abut all treatment ptins, n matter what they cst r whether they are cvered Refuse treatment, even if yur dctr advises against it Stp taking medicine Ask fr a secnd pinin. First Chice VIP Care Plus will pay fr the cst f yur secnd pinin visit. Yu have the right t timely access t care that des nt have any cmmunicatin r physical access barriers. This includes the right t: Get timely medical care Get in and ut f a health care prvider s ffice. This means barrier free access fr peple with disabilities, in accrdance with the Americans with Disabilities Act. Have interpreters t help with cmmunicatin with yur dctrs and yur health plan. If yu have questins, please call First Chice VIP Care Plus at (TTY: ), 8 a.m. 8 p.m. 7 days a

24 First Chice VIP Care Plus: Summary f Benefits Yu have the right t seek emergency and urgent care when yu need it. This means yu have the right t: Get emergency services withut prir apprval in an emergency See an ut f netwrk urgent r emergency care prvider, when necessary Yu have the right t make cmplaints abut yur cvered services r care. This includes the right t: File a cmplaint r grievance against us r ur prviders Ask fr a state fair hearing Get a detailed reasn fr why services were denied Yu have a right t cnfidentiality and privacy. This includes the right t: Ask fr and get a cpy f yur medical recrds in a way that yu can understand and t ask fr yur recrds t be changed r crrected. Have yur persnal health infrmatin kept private. Fr mre infrmatin abut yur rights, yu can read the First Chice VIP Care Plus Member Handbk. If yu have questins, yu can als call First Chice VIP Care Plus Member Services. If yu have questins, please call First Chice VIP Care Plus at (TTY: ), 8 a.m. 8 p.m. 7 days a

25 First Chice VIP Care Plus: Summary f Benefits If yu have a cmplaint r think we shuld cver smething we denied If yu have a cmplaint r think First Chice VIP Care Plus shuld cver smething we denied, call First Chice VIP Care Plus at Yu may be able t appeal ur decisin. Fr questins abut cmplaints and appeals, yu can read Chapter 9 f the First Chice VIP Care Plus Member Handbk. Yu can als call First Chice VIP Care Plus Member Services. If yu wuld like t write First Chice VIP Care Plus abut a cmplaint, grievance r appeal, mail us at: First Chice VIP Care Plus Attn: Appeals and Grievances P.O. Bx 337 Essingtn, PA Phne Number: ; TTY: , 8 a.m. t 8 p.m., 7 days a week There is a special mbudsman fr this prgram called the Healthy Cnnectins Prime Advcate. The Healthy Cnnectins Prime Advcate des nt wrk fr us r Healthy Cnnectins Medicaid. They can help yu understand yur rights and the appeal prcess, and they can help yu with yur appeal. Yu can reach the Healthy Cnnectins Prime Advcate at TTY users shuld call 711. If yu suspect fraud Mst health care prfessinals and rganizatins that prvide services are hnest. Unfrtunately, there may be sme wh are dishnest. If yu think a dctr, hspital r ther pharmacy is ding smething wrng, please cntact us. Call us at First Chice VIP Care Plus Member Services. Phne numbers are n the cver f this summary, r Call Medicare at MEDICARE ( ). TTY users shuld call Yu can call these numbers fr free, 24 hurs a day, 7 days a week. Call Healthy Cnnectins Medicaid at , r yu cncern t fraudres@scdhhs.gv. If yu have questins, please call First Chice VIP Care Plus at (TTY: ), 8 a.m. 8 p.m. 7 days a

26 FCVIPCPSC