PARAMOUNT ADVANTAGE MEMBER HANDBOOK

Transcription

1 Dedicated to Improving Healthcare Quality for You and Your Family PARAMOUNT ADVANTAGE MEMBER HANDBOOK GETTING CARE RIGHT IN OHIO Effective January 1, 2015

2 Please let us know If you have a problem reading or understanding this information or any other Paramount Advantage information, please contact our member services at , TTY users for help at no cost to you. We can explain this information in English or in your primary language. We may have this information printed in some other languages. If you are visually or hearing-impaired, special help can be provided. Important Information from Ohio Department of Medicaid for New Members If you were on Medicaid fee-for-service the month before you became a Paramount Advantage member and have healthcare services already approved and/or scheduled, it is important that you call Member Services immediately (today or as soon as possible). In certain situations and for a specified time period after you enroll, we may allow you to receive care from a provider that is not a Paramount Advantage panel provider. Additionally, we may allow you to continue to receive services that were authorized by Medicaid fee-forservice. However, you must call Paramount Advantage before you receive the care. If you do not call us, you may not be able to receive the care and/or the claim may not be paid. For example, you need to call Member Services if you have the following services already approved and/or scheduled: Organ, bone marrow or hematopoietic stem cell transplant Third trimester prenatal (pregnancy) care, including delivery Inpatient/outpatient surgery Appointment with a specialty provider Appointment with a primary care provider Chemotherapy or radiation treatments Treatment following discharge from the hospital in the last 30 days Non-routine dental or vision services (for example, braces or surgery) Medical equipment Services you receive at home, including home health, therapies and nursing After you enroll, your MCP will tell you if any of your current medications require prior authorization that did not require authorization when they were paid by Medicaid fee-forservice. It is very important that you look at the information the MCP provides and contact your MCP s Member Services if you have any questions. You can also look on your MCP s website to find out if your medication(s) require prior authorization. You may need to follow up with the prescriber s office to submit a prior authorization request to your MCP if it is needed. If your medication(s) requires prior authorization, you cannot get the medication(s) until your provider submits a request to your MCP and it is approved. 2

3 Paramount Advantage remains committed to the members we are honored to serve. This Paramount Advantage Member Handbook was created with the guidance and support of members, who participated in our Family Advisory Councils in Allen, Cuyahoga and Muskingum County throughout I love the insurance and won t switch. I am confident with my choice in insurance provider. They listen to what you got to say. It matters to them. On behalf of everyone at Paramount Advantage, a sincerest thanks to our Family Advisory Council members for their time and talents in helping to creating our Member Handbook. We hope you find the information contained in this handbook, very helpful. Thank you! Paramount Advantage really cares about their member needs, but as well as their thoughts & opinions for improvement. It s really good to be able to talk to someone about my health care. And they can answer my questions. I believe Paramount Advantage to be very helpful to low income families. Paramount Advantage has been a wonderful plan for my children and me. I wish I had you a long time ago. Member Services Department: toll-free , TTY users

4 TABLE OF CONTENTS MEMBER SERVICES Welcome to Paramount Advantage...7 Calling the Member Services Department The Member Services Department will help you right away...8 Your Paramount Advantage Identification Card...9 If you also have another health insurance (coordination of benefits COB)...10 IN CASE OF EMERGENCY In Case of Emergency...11 Urgent Care Centers Using an Urgent Care Center...12 Going to a Participating Hospital Hour Nurse Line, the ProMedica Call Center...12 YOUR DOCTOR Your Doctor Is Your Healthcare Partner Choosing or changing a primary care provider (PCP) When should you visit your PCP?...13 Healthchek, well visits, and preventive screenings...14 WOMEN S HEALTH AND PREGNANCY Women s Health...16 Prenatal-postpartum care guidelines SERVICES COVERED Pharmacy, Filling Prescriptions, and Durable Medical Equipment...21 Restrictions on choice of providers...22 Services Covered by Paramount Advantage...23 Covered services...23 Prior Authorizations and when they are needed...24 Mental health and substance abuse services...25 Seeing a specialist...26 Dental benefit...26 Vision benefit...26 EXTRA SERVICES AND PROGRAMS 24 Hour Nurse Line, the ProMedica Call Center...27 High-risk case management services...27 Postpartum Home Healthcare Program...27 Healthcare and disease management reminders...27 Community resources guide...27 Prenatal to Cradle Pregnancy Rewards Program...27 Transportation Assistance Program...27 MyParamount is your secure member portal...28 Steps2Care Health Information Mobile App...28 Personal Call Center Rep (PCCR) go anywhere, do anything mobile website...28 Care management and outreach services...29 SERVICES NOT COVERED Services Not Covered Paramount Advantage or Ohio Medicaid...30 Grievance and appeals (complaint) form, and state hearings...31 Membership Terminations, Re-Enrolling and Conversion...35 Membership Rights and Responsibilities Your membership rights...39 Advance directives...40 INDEX Meanings of Some Words in this Handbook

5 Keep These Numbers Handy Primary Care Provider (PCP/Doctor) Name: Address: Phone: After Hours #: Urgent Care Name: Address: Phone: After Hours #: Dentist Name: Address: Phone: After Hours #: Member Services Department Answer questions and solve complaints promptly (TTY users ) Monday - Friday 7:00 a.m. - 7:00 p.m. Prenatal to Cradle Pregnancy Rewards Program (TTY users ) Monday - Friday 8:30 a.m. - 5:00 p.m. Ohio Medicaid Hotline (TTY users ) Pediatrician Name: Address: Phone: After Hours #: Pharmacy Name: Address: Phone: After Hours #: Other Name: Address: Phone: After Hours #: Paramount s 24-hour Nurse Line The ProMedica Call Center (TTY users ) 24 hours a day, 7 days a week Transportation Scheduling & Pick-up Must schedule at least 2 business days in advance (TTY users ) Monday - Friday 8:30 a.m. - 5:00 p.m. Mobile Website Member Services Department Can Take Care Of... Questions about covered benefits and services Name, address and phone number changes Changing your primary care provider (PCP) Finding a new provider, specialist, dentist, or eye doctor Questions about services not listed in the chapter What is covered? Adding your newborn and getting his/her Member ID Card Sending you a replacement Member ID Card Pre-authorization, pharmacy, and durable medical equipment questions Interpreter Services Member Services Department: toll-free , TTY users

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7 MEMBER SERVICES Welcome to Paramount Advantage MEMBER SERVICES What is Paramount Advantage? Welcome to Paramount Advantage, an affiliate of ProMedica. You are now a member of a healthcare plan also known as a managed care plan (MCP). Paramount Advantage provides health care services to Ohio residents eligible for Aged, Blind or Disabled and Covered Families and Children, including Healthy Start and Healthy Families and Adult Extension, Medicaid benefits. Paramount Advantage is pleased to provide you with access to quality healthcare services. Call our Member Services Department any time you have questions about healthcare services. You can contact Paramount Advantage to get any other information you want, including the structure and operation of Paramount Advantage and how we pay our providers. Paramount Advantage may not discriminate on the basis of race, color, religion, gender, sexual orientation, age, disability, national origin, veteran s status, ancestry, health status, or need for health services in the receipt of health services. Who can join Paramount Advantage? Aged, Blind or Disabled and Covered Families and Children Medicaid consumers in Ohio, including Healthy Start and Healthy Families and Adult Extension, can choose to join. It is important to remember that you must receive services covered by Paramount Advantage from facilities and/or providers on Paramount Advantage s panel. See page 13 for information on services covered by Paramount Advantage. The only time you can use providers that are not on Paramount Advantage s panel is for: Emergency services, Federally qualified health centers/rural health clinics, Qualified family planning providers, Ohio Department of Mental Health and Addiction Services (MHAS) certified community mental health centers and treatment centers, or An out-of-panel provider that Paramount Advantage has approved you to see What you must do to receive benefits Paramount Advantage will pay healthcare costs if you follow four guidelines: 1. You see your primary care provider (PCP). 2. You get Paramount Advantage approval to see out-of-plan providers with the exception of emergency care, federally qualified health centers/rural health clinics and qualified family planning providers in your Provider Directory. 3. You use the emergency room appropriately. (See page 11 for an explanation of emergency care.) 4. You follow the rules outlined in this Member Handbook. If you follow the guidelines above, you should not receive any bills. If you do get bills, call the Member Services Department. Member Services Department: toll-free , TTY users

8 MEMBER SERVICES New members who need ongoing care. It is important for any new members who have a health condition that requires ongoing care to call our Member Services Department as soon as possible. For example, if you need surgery, are pregnant, have asthma or diabetes, are receiving speech or physical therapy, have braces, or are receiving home health services (e.g., aides and private duty nursing), you need to call Member Services. We want to make sure that your care continues smoothly, without interruption, while you change over to Paramount Advantage. Paramount Advantage is closed on New Year s Day, Memorial Day, Independence Day (July 4), Labor Day, Thanksgiving Day, the day after Thanksgiving, and Christmas Day. If the Paramount-recognized holiday occurs on a Saturday, the Member Services Department will be closed on the preceding Friday. If the Paramount-recognized holiday occurs on a Sunday, the Member Services Department will be closed on the following Monday. If you want to tell us about things you think we should change, please call the Member Services Department at toll-free , TTY users Calling the Member Services Department The Member Services Department will help you right away. Paramount Advantage s Member Services Department can help you with any questions or issues you may have, such as what services are covered, how to access services, help finding a provider, filing a complaint about the MCP/ providers/discrimination, changing your PCP, and accessing language assistance. If your primary language is not English, are visually or hearing impaired, or have limited reading skills, please call us to arrange interpreter services. You should be satisfied with all aspects of the service you receive. If you have questions or recommendations for change, the Member Services Department is thoroughly trained and ready to help you. The Member Services Department can be reached at toll-free , TTY users The Member Services Department is available Monday Friday, 7:00 a.m. 7:00 p.m. (except on holidays). 24 Hour Nurse Line, the ProMedica Call Center. If you need medical advice, the ProMedica Call Center is a special service available 24 hours every day with general information plus a staff of nurses to assist you. The ProMedica Call Center telephone number is toll-free , or the Ohio Relay Service TTY toll-free

9 Your Paramount Advantage Identification Card You should have received a Paramount Advantage membership ID card. Each member of your family who has joined Paramount Advantage will receive his or her own card. Your ID card replaces the monthly Medicaid card. Each card is good for as long as the person is a member of Paramount Advantage. You will not receive a new card each month as you did with the Medicaid card. Call Paramount Advantage Member Services as soon as possible at toll-free , TTY users if: You have not received your card(s) yet Any of the information on the card(s) is wrong You lose your card(s) You have a new baby MEMBER SERVICES Always keep your ID card(s) with you. You will need your ID card each time you get medical services. This means that you need your Paramount Advantage ID card when you: See your primary care provider (PCP) See a specialist or other provider Go to an emergency room Go to an urgent care facility Go to a hospital for any reason Get medical supplies Get a prescription Have medical tests MEMBER NAME Jane Doe PRIMARY CARE PROVIDER John Smith (419) PROVIDERS CALL FOR PRIOR AUTH / ID NUMBER A GROUP NUMBER ADV EFF. DATE 01/01/2015 MMIS NUMBER CVS/CAREMARK RXGRP RX6407 RXBIN RXPCN MCAIDOH EMERGENCY SERVICES Call 911 or go to the nearest emergency room (ER). If you are not sure whether you need to go to the emergency room, call your primary care provider (PCP) or Paramount s 24-hour toll-free call-in-system (ProMedica Call Center) toll free at or the Ohio Relay Service TTY at SPECIALTY SERVICES Before seeing a specialist, you should always first contact your PCP as indicated in your member handbook. HOSPITAL ADMISSIONS Prior authorization must be obtained by the hospital prior to all non-emergency admissions. MEMBER SERVICES For eligibility, claims or benefit information call MEMBER SERVICES toll free at: , TTY Monday - Friday 7:00 a.m. - 7:00 p.m. If for any reason you need to change your PCP, call MEMBER SERVICES first so that you can begin using that new PCP immediately. Mailing Address: P.O. Box 928, Toledo, OH Office Address: 1901 Indian Wood Circle, Maumee, OH Provider Inquiry: Pharmacy Help Desk Transportation Scheduling: , TTY Member Portal: Member Services Department: toll-free , TTY users

10 MEMBER SERVICES How to let Paramount Advantage know if you are unhappy or do not agree with a decision we made. If you are unhappy with anything about Paramount Advantage or its providers, you should contact us as soon as possible. This includes if you do not agree with a decision we have made. You, or someone you want to speak for you, can contact us. If you want someone to speak for you, you will need to let us know this. Paramount Advantage wants you to contact us so that we can help you. To contact us you can: Call the Member Services Department at , TTY users , OR Other health insurance (coordination of benefits COB). If you or anyone in your family has health insurance with another company, it is very important that you call the Member Services Department and your county caseworker about the insurance. For example, if you work and have health insurance or if your children have health insurance through their other parent, then you need to call the Member Services Department to give us the information. It is also important to call Member Services and your county caseworker if you have lost health insurance that you had previously reported. Not giving us this information can cause problems with getting care and with bills. Fill out the form in your Member Handbook (page 24) Grievance Form, OR Call the Member Services Department to request they mail you a form, OR Visit our website at OR Write a letter telling us what you are unhappy about. Be sure to put your first and last name, the number from the front of your Paramount Advantage member ID card, and your address and telephone number in the letter so that we can contact you if needed. You should also send any information that helps explain your problem. (See address on page 33). 10

11 IN CASE OF EMERGENCY Emergency services. Emergency services are services for a medical problem that you think is so serious that it must be treated right away by a doctor. We cover care for emergencies both in and out of the county where you live. Some examples of when emergency services are needed include: problem and give you advice on what you should do. Remember, if you need emergency services: 1. Go to the nearest hospital emergency room or other appropriate setting. Be sure to tell them that you are a member of Paramount Advantage and show them your ID card. IN CASE OF EMERGENCY Broken bones Convulsions Difficult breathing Hallucinations or delusions; uncontrollable thoughts Miscarriage/pregnancy with vaginal bleeding Poisoning Severe bleeding Severe burns Severe pain in the stomach or chest areas Shock Thoughts of harming self or others; behavior dangerous to self or others Unconsciousness Vomiting blood You do not have to contact Paramount Advantage for an okay before you get emergency services. If you have an emergency, call 911 or go to the NEAREST emergency room (ER) or other appropriate setting. If you are not sure whether you need to go to the emergency room, call your primary care provider (PCP) or Paramount Advantage s 24-hour medical information service, the ProMedica Call Center, at toll-free , or the Ohio Relay Service TTY toll-free Your PCP or the ProMedica Call Center can talk to you about your medical 2. If the provider that is treating you for an emergency takes care of your emergency but thinks that you need other medical care to treat the problem that caused your emergency, the provider must call Paramount Advantage. 3. Contact your PCP or call the Member Services Department as soon as possible. Try to call within 48 hours after going to the emergency department. 4. If the hospital has you stay, please make sure that Paramount Advantage is called within 48 hours. 5. Schedule an appointment with your PCP for all follow-up services. If you are out of town. If you need non-emergency care when you are outside the county in Ohio where you live, you are covered. First, call your PCP or Paramount Advantage s 24-hour medical information service, the ProMedica Call Center at toll-free , or the Ohio Relay Service TTY toll-free If that is not possible, seek Member Services Department: toll-free , TTY users

12 treatment at the nearest medical facility or at a Paramount Advantage participating doctor s office and call the Member Services Department within 48 hours. Schedule an appointment with your PCP for all follow-up services. Participating Urgent Care Centers are listed in your Provider Directory or online at Going to the Hospital Use a participating hospital. IN CASE OF EMERGENCY Urgent Care Centers Using an Urgent Care Center. If you have a medical problem arise that you don t think is an emergency, you should call your PCP or visit a participating Urgent Care Center to prevent the injury or illness from getting worse. You can also call Paramount Advantage s 24-hour medical information service, the ProMedica Call Center, for advice and instructions on what to do to help ease the illness or injury at toll-free , or the Ohio Relay Service TTY toll-free You must use participating Paramount Advantage hospitals unless it is an emergency or you have received approval to use an out-of-state hospital for non-emergency care. Paramount Advantage offers you a choice of hospitals. Ask your PCP for names of hospitals where she/he is on staff. All elective inpatient admissions require prior authorization. If you are admitted to a hospital for an emergency when you are away from home or out of state, someone must notify your PCP or the Member Services Department within 48 hours or as soon as reasonably possible. You must see your PCP for all follow-up care. 24 Hour Nurse Line, the ProMedica Call Center. If you need medical advice, the ProMedica Call Center is a special service available 24 hours every day with general information plus a staff of nurses to assist you. The ProMedica Call Center telephone number is toll-free , or the Ohio Relay Service TTY toll-free

13 YOUR DOCTOR Your Doctor Is Your Healthcare Partner Provider panel / Provider directory. The Provider Directory lists all of our panel providers as well as other non-panel providers you can use to receive services. When you called the Medicaid Hotline to select a managed care plan (MCP), you were asked whether you wanted provider panel information given to you as a printed Provider Directory or via the Internet. If you asked for a printed directory, you should have received a Provider Directory. If you did not contact the Medicaid Hotline to enroll and were assigned to our plan, you may call Member Services to obtain a printed Provider Directory. The Provider Directory is available online and continuously updated. Visit our website at to view up-todate provider panel, pharmacy, and urgent care information. Choosing a Primary Care Provider. (PCP). Each member of Paramount Advantage must choose a primary care provider (PCP) from Paramount Advantage s Provider Directory. Your PCP is an individual physician, physician group practice, advanced practice nurse or advanced practice nurse group practice trained in family medicine (general practice), internal medicine, or pediatrics. Your PCP is your personal doctor. Your PCP will work with you to direct your health care. Your PCP will do your check-ups and shots and treat you for most of your routine healthcare needs. If needed, your PCP will send you to other doctors (specialists) or admit you to the hospital. You can reach your PCP by calling the PCP s office. Your PCP s name and telephone number are printed on your Paramount Advantage ID card. If you need non-emergency care after hours, call your PCP for instructions, or you can call Paramount Advantage s 24-hour medical information service, the ProMedica Call Center at toll-free , or the Ohio Relay Service TTY toll-free When should you visit your PCP? You should visit your primary care provider (PCP) for regular Healthchek exams, adult well exams and when you are ill. Although you do not need a PCP referral to see other providers, it is still important to contact your PCP before you see a specialist, have lab tests done or are admitted to the hospital (except in an emergency). You do not need to contact your PCP before making appointments with obstetricians, gynecologists, certified nurse-midwives, certified nurse practitioners, federally qualified health center/rural health clinic providers, family planning providers, and providers at MHAS certified community mental health centers or certified treatment centers. However, you may still want to discuss this treatment with your PCP. YOUR DOCTOR Member Services Department: toll-free , TTY users

14 YOUR DOCTOR Your PCP is responsible for managing your care, which is a feature of an MCP like Paramount Advantage. If you would like information about how Paramount providers are paid, call the Member Services Department. Changing your PCP. If for any reason you want to change your PCP, you must first call the Member Services Department to ask for the change. Members can change PCPs on a monthly basis. Paramount Advantage will send you a new ID card to let you know that your PCP has been changed and you can begin seeing your new PCP immediately. For the names of the PCPs in Paramount Advantage, you may look in your Provider Directory if you requested a printed copy, on our website at or you can call the Paramount Advantage Member Services Department at toll-free , TTY users for help. Healthchek. Healthchek is Ohio s early and periodic screening, diagnostic and treatment (EPSDT) benefit. Healthchek covers medical exams, immunizations (shots), health education, and laboratory tests for everyone eligible for Medicaid under the age of 21 years. These exams are important to make sure that children are healthy and are developing physically and mentally. Mothers should have prenatal exams, and children should have exams at birth, 3-5 days of age and at 1, 2, 4, 6, 9, 12, 15, 18, 24, and 30 months of age. After that, children should have at least one exam per year. Healthchek also covers complete medical, vision, dental, hearing, nutritional, developmental, and mental health exams, in addition to other care to treat physical, mental or other problems or conditions found by an exam. Healthchek covers tests and treatment services that may not be covered for people over age 20; some of the tests and treatment services may require prior authorization. Healthchek services are available at no cost to members and include: Preventive check-ups for newborns, infants, children, teens, and young adults under the age of 21. Healthchek screenings: Complete medical exams (with a review of physical and mental health development) Vision exams Dental exams Hearing exams Nutrition checks Developmental exams Lead testing 14

15 Laboratory tests for certain ages Immunizations Medically necessary follow-up care to treat physical, mental or other health problems or issues found during a screening. This could include, but is not limited to, services such as: Visits with a primary care provider, specialist, dentist, optometrist, and other Paramount Advantage providers to diagnose and treat problems or issues Inpatient or outpatient hospital care Clinic visits Prescription drugs Laboratory tests Health education It is very important to get preventive check-ups and screenings so your providers can find any health problems early and treat them, or make a referral to a specialist for treatment, before the problem gets more serious. Some services may require a referral from your PCP or prior authorization by Paramount Advantage. As a part of Healthchek, care management services are available to all members under the age of 21 years who have special healthcare needs. Please see page 29 to learn more about the care management services offered by Paramount Advantage. If you would like more information on the Healthchek program, please contact the Member Services Department at toll-free , TTY users Member Services can also help you with and answer questions about getting care and what services are covered, finding a provider/making an appointment, prior authorizations, or transportation assistance. You can call your PCP and dentist to make an appointment for regular check-ups and ask for a Healthchek exam when you call. YOUR DOCTOR Also, for some EPSDT items or services, your provider may request prior authorization for Paramount Advantage to cover things that have limits or are not covered for members over age 20. Please see pages to see what services require a referral and/or prior authorization. Member Services Department: toll-free , TTY users

16 WOMEN S HEALTH AND PREGNANCY WOMEN S HEALTH & PREGNANCY Women s Health and Pregnancy Care Family planning services. Family planning is available through your Primary Care Provider (PCP), Obstetrician (OB) or Gynecologist (Gyn), certified nurse-midwife, or at a qualified Medicaid family planning provider including your local health department, Federally Qualified Health Centers, Planned Parenthood, or rural clinics. You do not need a referral from your PCP. Simply pick a family planning provider from the list in the Provider Directory and make an appointment. OB or GYN care. Female Paramount Advantage members can see an in-network Primary Care Provider (PCP), Obstetrician (OB) or Gynecologist (Gyn), Certified Nurse Midwife for female health care. The OB or Gyn or certified nurse-midwife may refer you to another specialist based on your medical needs. If your health issue is not related to an OB/GYN condition, you should ask your PCP about seeing a specialist. Please call our Member Services Department for the following reasons: If you become a Paramount Advantage member in your third trimester of pregnancy You need help finding an OB/GYN or Certified Nurse Midwife, Pediatrician, or a PCP When your baby is born. Member Services will need the baby s name, date of birth, and pediatrician so we can mail a Paramount Advantage membership card for your newborn. You have questions or concerns about Paramount Advantage benefits or services * Remember to also contact Jobs & Family Services office to tell them you are pregnant and again after you deliver to have your newborn to added to your case. Prenatal care guidelines. Paramount Advantage wants you and your baby to have a healthy start. Your first OB/GYN or Certified Nurse Midwife appointment will include a health risk assessment. Your OB/GYN or Certified Nurse Midwife will talk to you about your pregnancy history and your current health. 16

17 Follow-up appointments are usually scheduled every 4 weeks for the first 28 weeks of your pregnancy, every 2 weeks through 36 weeks of your pregnancy and weekly through your last month of pregnancy. Your follow-up appointments will be scheduled based on the personal needs and health risks of your pregnancy. If your pregnancy is considered high-risk or you or your newborn have serious health complications, you may qualify for Case Management. Case Management is a program where licensed case managers work with doctors and medical providers to coordinate health care for our members. Case managers can teach you ways to play a bigger role in your health care. For more information on care management services, please call Member Services. Postpartum care guidelines. A postpartum (after delivery) appointment should be scheduled days after your delivery date. Your OB/GYN or Certified Nurse Midwife may want to see you within 7-14 days of delivery after a cesarean delivery or a complicated pregnancy but please also schedule a 3-8 weeks (21-56 days) after delivery postpartum appointment. A postpartum visit on or between 21 and 56 days after delivery should consist of: Pelvic exam Evaluation of weight, blood pressure, breasts, and abdomen Family planning and birth control discussion Paramount Advantage members get two postpartum home health visits by a nurse or home healthcare provider. Please take advantage of this member benefit as a chance to get medical care without having to leave your house so you have more time to adjust to life with your newborn. This home health visit is to help with any medical questions or concern you have after first coming home from the hospital. You will still need to schedule a postpartum appointment with your OB/GYN or Certified Nurse Midwife 3-8 weeks (21-56 days) after delivery. Postpartum Depression also known as the baby blues. 1 in 7 moms experience depression or anxiety during pregnancy or postpartum. You are not alone. A Postpartum Depression Survey is mailed to moms 2 weeks after delivery. New moms will also receive a letter explaining postpartum depression. Members are asked to: 1) complete the survey, 2) mail it back to Paramount Advantage and 3) call their OB/GYN or Certified Nurse Midwife provider for additional services if they score 11 points or higher on the survey. Breast Pumps & Lactation/ Breastfeeding Classes. Breast pumps are covered by Paramount Advantage. Breast pumps are considered Durable Medical Equipment (DME) so they require a prescription from your OB/GYN or Certified Nurse Midwife. You can order a breast pump from any network DME provider. Please contact our Member Services toll-free , TTY users to learn how to order a breast pump or for a network DME provider near you. WOMEN S HEALTH & PREGNANCY Member Services Department: toll-free , TTY users

18 For information on breastfeeding and lactation/ breastfeeding classes, please contact your local WIC office, your OB/GYN or Certified Nurse Midwife, or the hospital you will be delivering at. For information on childbirth and infant care classes, please contact the hospital you will be delivering at. Primary Care Provider (PCP) and Infant Immunizations (shots). Text4baby. Text4baby is a free text message health service for pregnant women and new moms and dads. Sign up online at to receive up to three text messages (health tips) a week, timed to your due date or your baby's birth date through the baby s first year. Text messages include helpful information on how to have a healthier pregnancy, nutrition, immunizations, and sleep safety. It is important that both you and your newborn have a Primary Care Provider (PCP). Healthchek and pro-active health services are offered to all Paramount Advantage members at no cost. For your best health, you should get regular care through their PCP before and after pregnancy. During pregnancy, you should see you OB/GYN or Certified Nurse Midwife for early and regular prenatal care and postpartum wellness. WOMEN S HEALTH & PREGNANCY Children should have well-check exams with their PCP at birth, 3-5 days of age and at 1, 2, 4, 6, 9, 12, 15, 18, 24 (2 years old), and 30 (2 ½ years old) months of age. After age 2 ½, children should have at least one well-check per year. See HealthChek Guidelines on Page 14 for full details. Prenatal to Cradle Program. Members can earn up to $125 in gift cards for completing the recommended number of prenatal/ postpartum visits. Contact Paramount Advantage Member Services Department for more information or register online at

19 Are You PREGNANT or Thinking About Having a Baby? As soon as you find out you are pregnant Get early and regular prenatal care! Important changes are happening to your baby very early in pregnancy; sometimes before a woman even knows they are pregnant. All appointments are very important to attend! OB/GYN or Certified Nurse Midwife Appointments. ASK QUESTIONS about your Growing Baby During Pregnancy. Ask what level of activity is safe for you and baby Ask about the benefits of breastfeeding Learn more about what you should expect and what you need to do during this pregnancy Ask about signs and symptoms you should report to our OB/GYN or Certified Nurse Midwife Ask about baby activity and monitoring fetal kick count Your OB/GYN or Certified Nurse Midwife may order numerous important lab tests throughout your pregnancy Talk honestly about your family health history and the health history of your baby s father Talk about ALL the over-the-counter/ prescription medicines and herbal supplements you take Prenatal-Postpartum Appointment Schedule Pregnancy First 28 weeks Weeks Last 4 weeks days after delivery Appointment Schedule Every 4 weeks Every 2 weeks Once a week Once, although may have more than one postpartum visit During your PREGNANCY & while BREASTFEEDING. DO NOT DRINK ALCOHOL No amount of alcohol is safe for the unborn baby DO NOT SMOKE OR USE ILLEGAL DRUGS if you smoke or use illegal drugs Paramount Advantage offers programs to help, please call Member Services today Avoid second hand smoke and other toxic or harmful substances Take your prenatal vitamin, folic acid, and multivitamin everyday Drink plenty of water, limit caffeine, and eat a variety of whole grains, vegetables and fruits and make sure meat, eggs, chicken/turkey and fish are fully cooked limit the amount of canned tuna and fish caught in local waters WOMEN S HEALTH & PREGNANCY These appointments may vary as your OB/GYN or Certified Nurse Midwife may want to see you more often or have you do more tests. Member Services Department: toll-free , TTY users

20 NEW MOMS Are You Trying Not to have a Baby? WOMEN S HEALTH & PREGNANCY Talk with your doctor about: Scheduling a postpartum checkup days after delivery Feelings of stress or sadness that does not go away When it s safe to go back to your regular activities Remember: Make sure baby has a safe place to sleep Alone, on their Back face up, in a Crib free of stuffed animals, blankets, pillows, bumpers, and toys Give yourself time to rest when baby is resting Ask family and friends for help Make sure your baby gets shots on time Eat a variety of vegetables, fruits, meats, and whole grains Continue taking folic acid and a multivitamin Plan to wait at least 18 months between your pregnancies Need transportation to appointments? Your newborn will have transportation benefits starting at birth. Call to schedule a ride. (See pages for full details). Being healthy will help your chance of having a healthier baby when you decide it s time More than half of all pregnancies are not planned, discuss with your PCP or OB/GYN about your birth control options Get regular wellness exams with your PCP and make sure you are up to date on your shots Have regular dental check-ups Have regular gynecological exams Learn how to protect yourself from sexually transmitted infections Drink plenty of water, avoid caffeine. Eat a variety of whole grains, vegetables and fruits, and make sure meat, eggs, chicken/turkey and fish are fully cooked Do not smoke or use illegal drugs Avoid second hand smoke and other toxic or harmful substances Get regular exercise Plan to wait at least 18 months between your pregnancies Have you joined the Prenatal to Cradle Pregnancy Rewards program? (See page 27 for full details). Other Questions? Call Member Services toll-free , TTY users