Family Health Plus. Member Handbook.

Transcription

1 Family Health Plus Member Handbook

2 Family Health Plus Member Handbook Your Primary Care Professional Name Important Addresses and Telephone Numbers Address Telephone Your Nearest Hospital Emergency Room Hospital Local Pharmacy Pharmacy Address Address Telephone Telephone Other Health Care Providers Name Name Address Address Telephone Telephone Name Name Address Address Telephone Telephone Family Health Plus Member Handbook revised February 2012 D2883 MarCom CL_HHP_FHPE02 Hudson Health Plan Customer Care TTY

3 Family Health Plus Member Handbook Important Addresses and Telephone Numbers Hudson Health Plan 303 South Broadway, Suite 321 Tarrytown, NY Customer Care: Fax: Complaint Fax: New York State Department of Health (Complaints) Office of Managed Care Bureau of Certification and Surveillance Corning Tower, Room 1911 Albany, NY New York State Department of Health 145 Huguenot Street 6th Floor New Rochelle, NY Website: New York State Medicaid CHOICE Helpline New York State Department of Health Family Health Plus Information Line Westchester County Department of Social Services Managed Care Office 112 East Post Road White Plains, NY Website: socialservices.westchestergov.com 100 East 1st Street Mount Vernon, NY Court Street White Plains, NY Alexander Street Yonkers, NY Washington Street Peekskill, NY Rockland County Department of Social Services Sanatorium Road, Building L Pomona, NY Sullivan County Department of Social Services PO Box Community Lane Liberty, NY Orange County Department of Social Services Box Z 11 Quarry Road Goshen, NY Dutchess County Department of Social Services 60 Market Street Poughkeepsie, NY Ulster County Department of Social Services 1061 Development Court Kingston, NY Medical Answering Services (Non-Emergency Transportation) Orange County Rockland County Sullivan County Ulster County Westchester County MaxorPlus (Pharmacy Benefits) Healthplex (Dental Care) Beacon Health Strategies (Mental Health and Alcohol/Substance Abuse) Block Vision (Vision Care) Hudson Health Plan Customer Care TTY

4 Family Health Plus Member Handbook Important Addresses and Telephone Numbers Urgent Care Centers See page 7 for information about Urgent Care Centers. Westchester County Urgent Care of Westchester 155 White Plains Road Suite 101 Tarrytown, NY Telephone: Monday Friday Saturday Sunday 8:00 am 8:00 pm 9:00 am 3:00 pm PM Pediatrics of Mamaroneck (Patients 0-21 years old only) 620 East Boston Post Road Mamaroneck, NY Telephone: Monday Friday Saturday Sunday Rockland County 5:00 pm 12:00 midnight 12:00 noon 12:00 midnight PM Pediatrics of Rockland County (Patients 0-21 years old only) 15 Indian Rock Plaza on Route 59 Suffern, NY Telephone: Monday Friday Saturday Sunday Sullivan County 5:00 pm 12:00 midnight 5:00 pm 12:00 midnight 12:30 pm 12:00 midnight Crystal Run Healthcare Urgent Care 61 Emerald Place Rock Hill, NY Telephone: Monday Friday Saturday Sunday Ulster County 8:00 am 8:00 pm 8:00 am 8:00 pm 8:00 am 6:00 pm Emergency One 40 Hurley Avenue Kingston, NY Telephone: Monday Friday Saturday Sunday 8:00 am 8:00 pm 8:00 am 4:00 pm Orange County Crystal Run Healthcare Urgent Care 155 Crystal Run Road Middletown, NY Telephone: Monday Friday Saturday Sunday 8:00 am 8:00 pm 8:00 am 8:00 pm 8:00 am 6:00 pm Orange Urgent Care 75 Crystal Run Road Middletown, NY Telephone: Monday Friday Saturday Sunday 8:00 am 9:00 pm 9:00 am 6:00 pm Excel Urgent Care of Goshen 1 Hatfield Lane Goshen, NY Telephone: Monday Friday Saturday Sunday Dutchess County 8:00 am 8:00 pm 9:00 am 4:00 pm Emergency One 4250 Albany Post Road Hyde Park, NY Telephone: Monday Friday Saturday Sunday 8:00 am 8:00 pm 8:00 am 4:00 pm Excel Urgent Care of Fishkill 1004 Main Street Fishkill, NY Telephone: Monday Friday Saturday Sunday 8:00 am 8:00 pm 9:00 am 4:00 pm Express Pediatrics (Patients 0-21 years old only) 1989 Route 59 Hopewell Junction, NY Telephone: Monday Friday Saturday Sunday 5:00 pm 12:00 midnight 12:00 noon 12:00 midnight Hudson Health Plan Customer Care TTY

5 Family Health Plus Member Handbook Table of Contents [ Section One ] Introduction to Our Plan and Managed Care 1 [ Section Two ] Choosing Your Primary Care Professional 4 [ Section Three ] Medical Services 5 [ Section Four ] Your Benefits 8 [ Section Five ] Services Authorizations and Actions 12 [ Section Six ] Appeals and Complaints 14 [ Section Seven ] Discontinuing Your Coverage With Hudson 17 [ Section Eight ] Member Rights and Responsibilities 19 [ Section Nine ] Notice of Privacy Practices 20 Hudson Health Plan Customer Care TTY

6 Family Health Plus Member Handbook Introduction to Our Plan and Managed Care 1 [ Section One ] Introduction to Our Plan and Managed Care Welcome to the Hudson Health Plan Family Health Plus Program We are glad you have chosen Hudson Health Plan. We want to be sure you get off to a good start as a new member. In order to get to know you better, we will get in touch with you in the next two or three weeks. You can ask us any questions you have, or get help making appointments. If you need to speak with us before we call you, however, call us at (TTY ). The Plan, Our Providers, and You No doubt you have seen or heard about the change in health care. Many consumers now get their health benefits through managed care. Many counties in New York State offer their clients a choice of managed care health plans. In the counties served by Hudson Health Plan (Hudson), people with Family Health Plus must join a health care plan. Hudson has a contract with the New York State Department of Health to meet the health care needs of people with Family Health Plus. In turn, we choose a group of health care providers to help us meet your needs. These doctors and specialists, hospitals, labs, and other health care facilities make up our provider network. You will find a listing of all providers in our network in the Provider Directory and on our website at. When you join Hudson, one of our plan providers takes care of you. Most of the time that person will be your Primary Care Professional (PCP). If you need to have a test, see a specialist, or go into the hospital, your PCP will arrange it. Your PCP is available to you every day, day and night. If you need to speak to him or her after hours or on weekends, leave a message and how you can be reached. Your PCP will get back to you as soon as possible. Even though your PCP is your main source for health care, in some cases, you can selfrefer to certain doctors for some services (see Referrals for Specialty Care on page 5 for details on referrals). You may be restricted to certain Hudson providers if you have been identified as a restricted recipient. You may be a restricted member if you: get care from several doctors for the same problem get medical care more often than needed use prescription medicine in a way that may be dangerous to your health allow someone other than yourself to use your Hudson member identification card Hudson Health Plan Customer Care TTY

7 2 Introduction to Our Plan and Managed Care Family Health Plus Member Handbook Using This Handbook This handbook will tell you how your new health care system will work and how you can get the most from Hudson. This handbook is your guide to health services. It tells you the steps to take to make the plan work for you. When you have a question, check this Handbook or call our Customer Care Department. You can also call the managed care staff at your local Department of Social Services (see Important Addresses and Telephone Numbers list at the front of this Handbook) or if you live in Westchester, Orange, Ulster, Sullivan, or Dutchess counties, you can call the New York State Medicaid CHOICE Helpline at Your Hudson Member Identification Card After you enroll, we ll send you a welcome letter. Your Hudson identification card should arrive within 14 days of your enrollment date. The card has your Client Identification Number (CIN), and your PCP s name and telephone number on it. If anything is wrong on your ID card, call us right away. Carry your ID card at all times and show it each time you go for care. If you lose your Hudson member ID card and need a replacement, call Customer Care. You will also receive a Healthplex Dental ID card to receive your dental benefits (See page 9 for Dental Care information). Help and Information From Customer Care There is someone to help you at Customer Care Monday through Friday, 8:30 am 5:00 pm, at (TTY ). After regular office hours and on weekends, call this same number to reach us through our answering service. You Can Call Anytime You Have a Question or Need Help You may want to choose or change your PCP, to ask about benefits and services, to get help with referrals, to replace a lost identification card, to let us know you are pregnant and enroll in our Mommy & Me Program (see page 11 for more information about this program), report the birth of a new baby, or ask about any change that might affect you or your benefits; for example, you get a job that offers health care coverage. We offer free sessions to explain our health plan and how we can best help you. It s a great time for you to ask questions and meet other members. If you d like to come to one of the sessions, call us to find a time and place that are best for you. If You Do Not Speak English, We Can Help We want you to know how to use Hudson services no matter what language you speak. Call us and we will find a way to talk to you in your own language. We have a group of people who can help. We will also help you find a PCP who speaks your language. If You Are Disabled and Need Extra Help If you are disabled, in a wheelchair, blind, or have trouble hearing, call us if you need extra help. We can tell you if a particular provider s office is wheelchair accessible or is equipped with communications devices. Also, we offer helpful services including: relay link to TTY/TDD machine ( ) information in large print case management help in making or getting to appointments names and addresses of providers who specialize in your disability Other Information Available From Customer Care You can get the following information from Customer Care: which hospitals our health providers work with how we keep your medical records and member information private a written explanation of how we check on the quality of care to our members the guidelines we use to review a particular condition or diseases that are covered by Hudson if you request it in writing a written explanation of the qualifications needed and Hudson Health Plan Customer Care TTY

8 Family Health Plus Member Handbook Introduction to Our Plan and Managed Care 3 how health care providers can apply to be part of the Hudson provider network if our contracts or subcontracts include physician incentive plans that affect the use of referral services; and, if so, (1) the types of arrangements we use; and (2) if stoploss protection is provided for physicians and physician groups information about how our company is organized and how it works a copy of the most recent financial statements/balance sheets, summaries of income and expenses a copy of the most recent individual direct pay subscriber contract the names, addresses, and titles of Hudson s Board of Directors, Officers, Controlling Parties, Owners, and Partners consumer complaints information about Hudson from the New York State Department of Financial Services Keep Us Informed Call Customer Care whenever any of these changes happen in your life: You change your name, address, or telephone number. You have a change in circumstances that will affect your eligibility for Family Health Plus. You are pregnant or you give birth. You become covered under another health insurance program. How Our Providers Are Paid You have the right to ask us whether we have any special financial arrangement with our physicians that might affect your use of health care services. You can call Customer Care if you have specific concerns. We also want you to know that most of our providers are paid in one or more of the following ways: Salaried. If your PCP works in a clinic or health center, they probably receive a salary. The number of patients they see does not affect their salary. Monthly fee per member. Our PCPs who work from their own offices may get a set fee each month for each patient whom they are the patient s PCP. The fee stays the same whether the patient needs one visit or many or even none at all. This is called capitation. Set fee per member. Sometimes providers get a set fee for each person on their patient list, but some money (maybe 10%) can be held back for an incentive fund. At the end of the year, this fund is used to reward PCP s who have met the standards for extra pay that were set by Hudson. Fee-for-service. Providers may also be paid by fee-for-service. This means they get an agreed upon fee for each service they provide. You Can Help With Plan Policies Hudson values your opinions and suggestions. We are interested in anything you wish to tell us about Hudson. This includes your ideas, suggestions, problems, concerns, complaints, and questions. Contact Hudson Customer Care at to find out how you can help. Hudson Health Plan Customer Care TTY

9 4 Choosing Your Primary Care Professional Family Health Plus Member Handbook [ Section Two ] Choosing Your Primary Care Professional You may have already picked your Primary Care Professional (PCP) to serve as your regular doctor. This person could be a doctor or a nurse practitioner. If you have not chosen a PCP for you and your family, you should do so right away. If you do not choose a doctor within 30 days, we will choose one for you. Each family member can have a different PCP, or you can choose one PCP to take care of the whole family. A pediatrician treats children. Family practice doctors treat the whole family. Internal medicine doctors treat adults. You can get help in making a choice from Customer Care. You have received a Provider Directory. This is a list of all the doctors, clinics, hospitals, labs, and others who serve Hudson. It lists the address, telephone number, and special training of each provider. The Provider Directory will show which doctors and providers are taking new patients. You should call their office to make sure that they are taking new patients at the time you choose a PCP. You may want to find a doctor who you have seen before and understands your health problems, is taking new patients, speaks your language, and is easy for you to get to. Woman can also choose one of our OB/GYN doctors to deal with women s health issues. Women do not need a PCP referral to see a plan OB/GYN doctor. They can have routine check ups (twice a year), follow-up care if there is a problem, and regular care during pregnancy. If you are pregnant, please remember to call Customer Care to enroll in our Mommy & Me Program. Hudson also contracts with several Federally Qualified Health Centers (FQHCs). All FQHCs give primary and specialty care. Some consumers want to get their care from FQHCs because the centers have a long history in the neighborhood. Maybe you want to try them because they are easy to get to. You should know that you have a choice. You can choose any one of our private physicians listed in our directory, or you can sign up with one of the FQHCs that we work with. You will find the FQHCs listed in our Provider Directory. Call Customer Care at if you need help. In almost all cases, your doctors will be Hudson providers. There are two instances when you can still see another doctor that you had before you joined Hudson: You are more than three months pregnant when you join and you are getting prenatal care. In that case, you can keep your doctor until after your delivery and follow-up care. At the time you join, you have a life-threatening disease or condition that gets worse with time. In that case, you can keep your doctor for up to 60 days. In both cases, however, your doctor must agree to work with Hudson. If you have a long-lasting illness, like HIV/AIDS or other longterm health problems, you may be able to choose a specialist to act as your PCP. Arrangements to use a specialist as your PCP should be made through a Hudson Customer Care Representative. Changing Your PCP If you need to, you can change your PCP in the first 30 days after your first appointment with your PCP. After that, you can change once every six months without cause, or more often if you have a good reason. You can also change your OB/GYN or specialist to whom your PCP has referred you. If Your Provider Leaves the Provider Network If your provider leaves the Hudson provider network, we will tell you within 15 days from when we know about this. If you wish, you may be able to continue to see that provider if you are more than three months pregnant or if you are being treated for an ongoing condition. If you are pregnant, you may continue to see your doctor for up to 60 days after delivery. If you are seeing a doctor for an ongoing condition, you may continue your present course of treatment for up to 90 days. Your doctor must agree to work with Hudson during this time. If any of these conditions apply to you, check with your PCP or call Customer Care. Hudson Health Plan Customer Care TTY

10 Family Health Plus Member Handbook Medical Services 5 [ Section Three ] Medical Services Regular Medical Care Regular care means exams, regular check-ups, shots, or other treatments to keep you well, advice when you need it, and referral to the hospital or specialists when needed. It means you and your PCP working together to keep you well and to see that you get the care you need. Day or night, your PCP is only a telephone call away. Be sure to call him or her whenever you have a medical question or concern. If you call after hours or weekends, leave a message and say where or how you can be reached. Your PCP will call you back as quickly as possible. Remember, your PCP knows you and knows how the health plan works. Your care must be medically necessary the services you get must be needed to: prevent, or diagnose and correct what could cause more suffering deal with a danger to your life deal with a problem that could cause illness deal with something that could limit your normal activities Your PCP will take care of most of your health care needs, but you must have an appointment to see your PCP. If you can t keep an appointment, call to let your PCP know. If you can, prepare for your first appointment. As soon as you choose a PCP, call to make a first appointment. Your PCP will need to know as much about your medical history as you can tell him or her. Make a list of your medical background, any problems you have now, and the questions you want to ask your PCP. In most cases, your first visit should be within three months of becoming a Hudson member. If you need care before your first appointment, call your PCP s office to explain the problem. He or she will give you an earlier appointment, but you should still keep the first appointment. Use the following list as an appointment guide for our limits on how long you may have to wait to see your PCP: First appointment and routine physicals. Within 12 weeks of requesting an appointment. Urgent care. Within 24 hours of requesting an appointment. First pre-natal visit. Within three weeks of the first trimester, two weeks during the second trimester, one week during the third trimester. First family planning visit. Within two weeks of requesting an appointment for the first family planning visit. Non-urgent sick visit. Within three days of requesting an appointment. Routine, preventive care. Within four weeks of requesting an appointment. Follow-up visit after mental health/chemical dependence emergency room or inpatient visit. Within five days of requesting an appointment. Non-urgent mental health or chemical dependence visits. Within two weeks of requesting an appointment. Referrals for Specialty Care If you need care that your PCP cannot give, your PCP will refer you to a specialist that can provide the care you need. If your PCP or Hudson refers you to another doctor, you are not responsible for any costs except the usual co-payments (see Co-Payments on page 8). Talk with your PCP to be sure you know how referrals work. If you think the specialist does not meet your needs, talk to your PCP. Your PCP can help you if you need to see a different specialist. There are some treatments and services that your PCP must ask Hudson to approve before you can receive them. Your PCP will be able to tell you what those services are. Hudson Health Plan Customer Care TTY

11 6 Medical Services Family Health Plus Member Handbook If we do not have a specialist in our plan who can give you the care you need, we will get you the care you need from a specialist outside our provider network. If your PCP or Hudson refers you to a provider outside our network, you are not responsible for any costs except the usual co-payments. All out-of-network services must be authorized by Hudson before you receive them. If you need to see a specialist for ongoing care, your PCP may be able to refer you for a specified number of visits or length of time, which is called a standing referral. If you have a standing referral, you will not need a new referral for each time you need care. In rare cases, your PCP and our Clinical Department will agree that you need to see a non-participating provider for ongoing specialty care. Our Clinical Department will consult with the specialist and will issue a standing authorization for necessary services. If you have a long-term disease or a disabling illness that gets worse over time, your PCP may be able to arrange for your specialist to act as your PCP, refer you to a specialty care center that deals with the treatment of your problem, or arrange for hospice services if you are terminally ill. You can also call Customer Care for help if you have trouble getting a referral for care you think you need. Receiving Care From Providers Who Are Not Part of Hudson s Provider Network If you or your provider feels that your health care needs cannot be appropriately met by an in-network Hudson provider, you may submit a request for out-of-network services. All requests are evaluated and reviewed either by a Hudson Registered Nurse or the Hudson Medical Director based on your health status and the availability of an in-network provider to care for you. If your provider feels that a delay in a decision would harm you, we will make a determination as soon as possible, but no later than three business days from receipt of your request. If the matter is not urgent, we will make a decision in three business days unless we need additional information. In this case a decision will be made within three business days of receipt of the additional information, but no more than 14 days from the receipt of your request. If we determine that the requested treatment is not medically necessary or is appropriately available through an innetwork provider, the service request will be denied. You will have up to 60 business days from receipt of the denial to appeal our decision (see Action Appeals on page 14). Services That Do Not Require a Referral Hudson does not require your specialist to collect and submit any special form for referrals to in-network providers. If your PCP and Hudson agree that you need care from a non-participating provider, Hudson will give the specialist an authorization for the services required. You may be held personally financially responsible for services provided by non-participating providers without an authorization. Dental Care Covered services generally include regular and routine dental services, supplies, and devices required to alleviate health conditions. Vision Care You do not need a referral from your PCP for an eye exam or to get new glasses. You just choose from one of our participating providers. But remember that you are limited to an eye exam and new glasses once every two years. However, members diagnosed with diabetes may self-refer to any participating provider for a dilated eye (retinal) examination once in any 12-month period. If you need to see an eye specialist for care of an eye disease or defect, your PCP will refer you. Women s Services You do not need a referral from your PCP to see one of our providers IF you: are pregnant need OB/GYN services need family planning services want to see a midwife need to have a breast or pelvic exam Family Planning The family planning services you can get include advice for birth control, prescription birth control, pregnancy tests, sterilization, and abortion. During your visits for these things, you can also get tests for sexually transmitted infections, a breast cancer exam, and a pelvic exam. You do not need a referral from your PCP to get these family planning services. In fact, you can choose where to get these services. You can use your Hudson ID card to see one of our family planning providers. Check the Provider Directory or call Customer Care for help finding a provider. HIV Counseling and Testing You can get HIV testing and counseling any time you have family planning services. You do not need a referral from your PCP. Just make an appointment with one of our family planning providers. If you want HIV testing and counseling, but not as part of a family planning service, your PCP can arrange it for you. You can also visit an anonymous HIV testing and counseling site. For information, call the New York State HIV Counseling Hotline at or the New York State AIDS Hotline at AIDS ( ). If you need HIV treatment after the testing and counseling service, your PCP will help you get follow-up care. Hudson Health Plan Customer Care TTY

12 Family Health Plus Member Handbook Medical Services 7 Mental Health/Chemical Dependence (Including Alcohol and Substance Abuse) You may receive one mental health assessment and one chemical dependence (including alcohol and/or substance abuse) assessment without a referral in any 12-month period. You must use a Plan provider, but you do not need approval from your PCP. If you need more visits, your PCP will help you get a referral. Emergency Care You are always covered for emergencies. In New York State, an emergency means a medical or behavioral condition that comes on suddenly and has pain or other symptoms. This would make a person with an average knowledge of health fear that someone will suffer serious harm to body parts or functions, or serious disfigurement without immediate care. Examples of an emergency are: a heart attack or severe chest pain bleeding that won t stop or a bad burn broken bones trouble breathing, convulsions, or loss of consciousness you feel you might hurt yourself or others you are pregnant and have signs of pain, bleeding, fever, or vomiting Examples of non-emergencies are colds, sore throat, upset stomach, minor cuts and bruises, or sprained muscles. If you have an emergency, you should call 911 or go to the nearest emergency room. BUT, call your PCP as soon as you can. You do not need approval from Hudson or your PCP before getting emergency care, and you are not required to use our hospitals or doctors. If you re not sure, call your PCP or Hudson Customer Care. Tell the person you speak with what is happening. Your PCP will tell you what to do at home, tell you to come to the PCP s office, or tell you to go to the nearest emergency room. If you are out of the area when you have an emergency, go to the nearest emergency room. Call Hudson as soon as you can within 48 hours if possible. You do not need prior approval for emergency services. Use the emergency room only if you have a TRUE EMERGENCY. The emergency room should not be used for problems like the flu, sore throats, or ear infections. If you have questions, call your PCP or call Customer Care at Urgent Care You may have an injury or an illness that is not an emergency but still needs prompt care. This could be a sprained ankle, or a bad splinter you can t remove. If you cannot reach your PCP, call us at Tell the person who answers what is happening. They will tell you what to do. Urgent Care Centers You can go to an Urgent Care Center if your PCP s office is closed. Many Urgent Care Centers are open every day, and late in the evenings. You do not need an appointment to go to an Urgent Care Center. You can find a list of participating Urgent Care Centers at the front of this handbook. Care Outside of the United States Any care received outside of the United States, District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa will not be covered by Hudson. We Want to Keep You Healthy Besides the regular check-ups and shots you and your family need, some other ways we can help keep you healthy are: classes for you and your family prenatal care and nutrition breastfeeding and baby care (for more information contact our Mommy & Me Program at ) weight control diabetes counseling and self-management training asthma counseling and self-management training stop-smoking classes grief/loss support stress management cholesterol control Call Customer Care to learn more. Hudson Health Plan Customer Care TTY

13 8 Your Benefits Family Health Plus Member Handbook [ Section Four ] Your Benefits The following sections of this Handbook tell you about the covered and non-covered services, what to do if you have a complaint, and contain other information you may find useful. Keep this Handbook handy to refer to when you need it. Family Health Plus covers a comprehensive set of health care services and benefits. Hudson will provide or arrange for all of the covered services. You can get a few services, however, without going through your PCP. These include emergency care, family planning/hiv testing and counseling, and specific self referral services (see Services That Do Not Require a Referral on page 6). Co-Payments Family Health Plus members are required to make co-payments when receiving certain medical care and services. Some people are exempt and do not have to make these payments. See the following list of services that require copayments and information about who is exempt. If you have questions, call Customer Care at or the Department of Health s Family Health Plus Information Line at If you have questions about pharmacy co-payments, call MaxorPlus at or Hudson s Customer Care at for any other co-payments questions. Members will be responsible for making co-payments to providers for the following covered benefits: Brand name prescription drugs. Members pay $6 for each prescription and each refill. Generic prescription drugs. Members pay $3 for each prescription and each refill. Covered over-the-counter medications, such as stop smoking patches and gum, and insulin. Members pay 50 per medication. Clinic visits. Members pay a $5 co-pay per visit. Physician visits. Members pay a $5 co-pay per visit. Dental service visits. Members pay a $5 co-pay per visit up to a total of $25 per year. Lab tests. Members pay $0.50 per test. Radiology services, such as diagnostic x-rays, ultrasound, nuclear medicine, and oncology services. Members pay a $1 co-pay per radiology service. Inpatient hospital stays. Members pay a $25 co-pay per stay. Non-urgent emergency room visit. Members pay a $3 co-pay per visit. Covered medical supplies, such as hearing aid batteries, enteral formula, and diabetes test strips, lancets, and syringes. Members pay a $1 co-pay per supply. Certain medications may require that your PCP get prior authorization from Hudson before writing your prescription. Your PCP will work with Hudson to make sure you get the medications that you need (see Prior Authorizations and Time Frames on page 12 for more information). Hudson contracts with MaxorPlus to manage the program s prescription benefit. You can go to any pharmacy that participates with Hudson and MaxorPlus. Call Customer Care at or visit our website at org to locate a network pharmacy near you. Hudson Health Plan Customer Care TTY

14 Family Health Plus Member Handbook Your Benefits 9 You are not required to pay the co-payments if you are: under age 21 pregnant a permanent resident of a nursing home a resident of a community-based residential facility licensed by the Office of Mental Health or the Office of People with Developmental Disability not able to pay the co-payment at any time and you tell your provider that you are unable to pay Family Health Plus members who cannot afford the co-payment may not be denied a service based on their inability to pay. Your provider cannot refuse to give you care or services because you are unable to pay. However, you will still owe the unpaid co-pay amounts to the provider and the provider may ask you for payment later or send a bill. Services That Do Not Require a Co-Payment Co-payments will not apply to the following services: emergency services family planning services and supplies mental health clinics chemical dependence clinics mental illness drugs (psychotropic) tuberculosis drugs prescription drugs for a resident of an adult care facility Services Covered by Hudson You must get these services from providers who are in the Hudson provider network. All services must be medically necessary, and provided by or referred by your PCP. Regular Medical Care Regular medical care covered by Hudson includes: office visits with your PCP referrals to specialists eye exams and hearing exams Preventive Care Your preventive care benefits include: regular check-ups tests and procedures ordered by your PCP or a specialist Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services for members years of age smoking cessation counseling, limited to six sessions in a calendar year Emergency Care Emergency care services are procedures, treatments, or services needed to evaluate or stabilize an emergency. After you have received emergency care, you may need other care to make sure you remain in stable condition. Depending on the need, you may be treated in the Emergency Room, in an inpatient hospital room, or in another setting. This is called Post Stabilization Service. (For more information about emergency services, see Emergency Care on page 7.) Dental Care Hudson believes that providing you with good dental care is important to your overall health care. We offer dental care through a contract with Healthplex, an expert in providing high quality dental services, to provide dental benefits covered under our plan. Covered services include regular and routine dental services such as preventive dental check-ups, cleaning, x-rays, fillings, and other services to check for any changes or abnormalities that may require treatment and/or follow-up care. You will be able to choose your own Primary Care Dentist (PCD), who will coordinate all of your dental services. You may choose a PCD from the list of Primary Care Dentists included in the Provider Directory with your new member welcome packet. However, to make sure that you have a PCD immediately, Healthplex will assign a dentist to you and/or your family. The name, address, and telephone number of your assigned dentist will appear on your Dental ID card. You must use this dentist for any dental services you or your family require. You will receive your Dental ID card from Healthplex within your first 30 days of membership. If you need to know who your PCD is before you receive your card, or if you want to change your PCD, you may call Healthplex at You may also choose to receive dental care from a clinic operated by an academic dental center. If you have any questions about receiving dental care as a Hudson member, please call Customer Care. Vision Care Family Health Plus covers emergency vision care, and the following preventive and routine vision care provided once in any 24-month period: one eye exam either one pair of prescription eyeglass lenses and a pair of frames, or prescription contact lenses when medically necessary one pair of occupational eyeglasses (special glasses that help you perform your job duties) when medically necessary Replacement of lost, damaged, or destroyed eyeglasses is not covered. If you need help finding a vision care provider, you may call Block Vision. Hudson contracts with Block Vision to provide covered vision care services. Block Vision may be reached at Call this number if you have any questions about covered vision care services or participating vision care providers. Hudson Health Plan Customer Care TTY

15 10 Your Benefits Family Health Plus Member Handbook If you need help finding a Hudson provider, or if you want help making a choice, you can call Beacon Health Strategies. Beacon Health Strategies works with Hudson to make sure members get the mental health and chemical dependence (including alcohol and substance abuse) services they need. Your provider can also call Beacon Health Strategies any time, day or night, for help if immediate care is needed. Call Beacon Health Strategies at if you have any questions about mental health or chemical dependence services. Maternity Care Pharmacy Family Health Plus members must use their Hudson member identification card to get: prescription drugs insulin and diabetic supplies (insulin syringes, blood glucose test strips, lancets, and alcohol wipes) smoking cessation agents, including over-the-counter products hearing aid batteries enteral formulae select over-the-counter medications such as Prilosec OTC, Loratadine, Zyrtec, and vitamins emergency contraception (limited to six per calendar year) Co-payments apply for most medications. Some members are not required to pay these co-payments (see Co-Payments on page 8 for a list of co-payments). Certain medications may require that your PCP get prior authorization from Hudson before writing your prescription. Your PCP can work with Hudson to make sure you get the medications that you need. For more information about prior authorizations, see Prior Authorizations and Time Frames on page 12. Hospital Care Your hospital care benefits include inpatient and outpatient care, and lab, x-ray, and other tests. Behavioral Health Services (including alcohol and substance abuse) Hudson will cover up to 60 outpatient visits and 30 inpatient visits per year for behavioral health services. Behavioral health services include chemical dependence services, alcohol and substance abuse services, and mental health treatment services. Detoxification services (inpatient detoxification, and inpatient or outpatient withdrawal services) do not count towards the limits mentioned above. (Remember to call and enroll in our Mommy & Me Program) Most women in Family Health Plus who become pregnant will qualify for Medicaid because the financial requirements are different and the family size is changed. If you become pregnant while you are enrolled in Family Health Plus, you may want to change your coverage from Family Health Plus to Medicaid. Medicaid covers more services than Family Health Plus, which you may or may not need, depending on your medical needs. However, you may need to see a different doctor if you change to Medicaid. You should discuss this choice with your PCP and the local Department of Social Services office so that you can make the decision that best meets your needs. Your baby will be eligible for Medicaid. Children cannot be covered under Family Health Plus. In order to be sure your baby will have access to all the services covered by Medicaid, you need to let your local Department of Social Services office know when you are pregnant, and your PCP should notify Hudson. They can get started arranging for coverage for your baby before it is born. You should select your baby s doctor as soon as possible. If you stay in the Family Health Plus program, we will cover: pregnancy care doctors/midwife and hospital services postpartum care Home Health Care Hudson can arrange for some home health visits, up to 40 per year, but this is generally done only to avoid having you stay in a hospital. Your PCP must agree that your medical needs can be met at home with this help. This service includes: one medically necessary postpartum home health visit and additional visits as medically necessary for high-risk women other home health care visits as needed and ordered by your PCP or specialist Specialty Care Specialty care includes the services of these practitioners: occupational therapists, physical therapists, speech therapists, limited to 20 visits per therapy per calendar year Hudson Health Plan Customer Care TTY

16 Family Health Plus Member Handbook Your Benefits 11 midwives audiologists cardiac rehabilitation practitioners Case Management Our main goal is to assist you in being a partner in your own health care and the health care of your family. Case Management is a service that is available to all Hudson members. Registered Nurses, trained to assist you in managing your care, are part of our Case Management Department. Our Case Managers can give you information about your health condition (such as asthma, pregnancy, diabetes, lead poisoning, etc.), assist you in coordinating your care with your PCP or any specialist in our system that your PCP refers you to, and help you with other health care issues. If you would like to speak to one of Hudson s Case Managers, please call and ask for the Case Management Department. Mommy & Me Program for Pregnant Members The Mommy & Me program is a special Hudson Case Management program for pregnant members. The program s services begin as soon as we receive information about a maternity patient. We urge our pregnant members to contact us as soon as possible, so we can send important health education materials and coordinate care and services with the member s provider. We help make sure each pregnant member receives the proper prenatal health care. As an added bonus, we have gift items that are useful to new mothers and their babies. The case management program continues throughout pregnancy, the baby s birth, and the eight-week, postpartum visit. Infants are followed for 15 months to make sure they receive all recommended immunizations. This preventive health care program is designed to make sure our pregnant members and their babies receive the proper care both during and after pregnancy. Other Covered Services Other services covered by Hudson include: Emergency ambulance transportation. It is very important to Hudson that our enrollees have access to care when they need it. If you need emergency ambulance transportation, call 911. Durable medical equipment (DME). Hearing aids and supplies. Hospice services. Hudson will pay for hospice care for persons certified by a physician to be terminally ill with a life expectancy of six months or less. Hospice services include medical and supportive care provided to help lessen the pain and address the special needs that arise from physical, psychological, spiritual, social, and economic stress experienced during the final stages of a terminal illness, death, and grief. Prosthetics/orthodics. Court-ordered services, if covered by the Plan. Tuberculosis diagnosis and treatment. You can choose to go to your PCP or the county public health agency for tuberculosis diagnosis and/or treatment. You do not need a referral to go to the county public health agency. Services That Are Only Covered by Family Health Plus Non-emergency transportation, unless you are 19 or 20 years old and in the Child/Teen Health Program. If you are a year old in the Child/Teen Health Program and need non-emergency transportation, you or your provider should call Medical Answering Services (MAS), the Medicaid program s transportation manager. If possible, you or your provider should call MAS at least three days prior to your medical appointment and provide your appointment date and time. The MAS telephone numbers for each county are listed in the front of this handbook. Non-emergency transportation includes personal vehicle, bus, taxi, ambulette, and public transportation. Services That Are Not Covered by Hudson or Family Health Plus Some services are not available from Hudson. If you receive any of the following services, you may have to pay for them: Cosmetic surgery that is not medically needed. Routine foot care for members over 21 years of age. Personal and comfort items. Infertility treatments. Personal care services. Private duty nursing services. Medical supplies, such as bandages. Non-prescription drugs, such as over-the-counter medicines like aspirin. Nursing home stays that become permanent. Services of a provider who is not part of Hudson s provider network, unless Hudson and your PCP sends you to that provider. You may have to pay for any service that your PCP does not approve. Also, if before you get a service, you agree to be a private pay or self-pay patient, you will have to pay for the service. These services include: any non-covered services listed above unauthorized services services provided by providers who are not part of Hudson s provider network If you have any questions, call Customer Care. Hudson Health Plan Customer Care TTY

17 12 Service Authorizations and Actions Family Health Plus Member Handbook [ Section Five ] Service Authorizations and Actions Prior Authorizations and Time Frames There are some treatments and services that require you to get pre-approved before you receive them, or to be able to continue to receive them. This is called a prior authorization. You or someone you trust can ask for a prior authorization. The treatments or services that must be approved before you receive them include: non-emergency hospitalization ambulatory surgery home care outpatient physical therapy, occupational therapy, or speech therapy sterilization and hysterectomy durable medical equipment (DME) outpatient mental health and substance abuse treatment (except the first visit) acupuncture cardiac rehabilitation chemotherapy cosmetic procedures if medically necessary growth hormone oral surgery services of a diabetic educator podiatry FluMist laser and phototherapy treatment non-routine optometry services services provided by a health care professional who is not in the Hudson network (out of network services) some injectable medications sleep studies weight loss programs Asking for approval of a treatment or service is called a service authorization request. You must make a service authorization request prior to receiving these services. Your PCP or the specialist that your PCP refers you to must call Hudson for an authorization number. To see if you need an authorization for a service you can call Customer Care at You will also need to get prior authorization if you are getting one of these services now, but need to continue or get more of the care. This includes a request for home health care while you are in the hospital or after you have just left the hospital. This is called a concurrent review. All services provided by out of network providers require prior authorization. If you receive services from an out of network provider or if you receive services that require prior authorization without Hudson s approval, you may be responsible for the bill. What Happens After We Get Your Service Authorization Request Hudson has a review team of doctors and nurses to be sure you receive the services we cover. Their job is to make certain the treatment given is medically needed and right for the condition at hand. They do this by checking your treatment plan against medically acceptable standards. Any decision to deny a service authorization request or to approve it for an amount that is less than requested is called an action. These decisions will be made by a qualified health care professional. If we decide that the requested service is not medically necessary, the decision will be made by a clinical peer reviewer, who may be a doctor or health care professional that typically provides the care you requested. You can request the specific medical standards, called clinical review criteria, used to make the decision for actions related to medical necessity. After we get your request we will review it under a standard or fast track process. You or your doctor can ask for a fast track review if it is believed that a delay will cause serious harm to your health. If your request for a fast track review is denied, we will tell you and your case will be handled under the standard review process. If you are in the hospital or have just left the hospital and we receive a request for home health care, we will handle the request as a fast track review. In all cases, we will review your request as fast as your medical condition requires us to do so but no later than mentioned below. We will tell you and your provider both by phone and in writing if your request is approved or denied. We will also tell you the reason for the decision. We will explain what options for appeals or fair hearings you will have if you don t agree with our decision. Time Frames for Review Requests The time frames for prior authorization requests are: Standard prior authorization review. We will make a decision about your request within three workdays of when we have all the information we need, but you will hear from us no later than 14 days after we receive your request. We will tell you by the fourteenth day if we need additional information. Fast track prior authorization review. We will make a decision and you will hear from us within three workdays. We will tell you by the third workday if we need additional information. Hudson Health Plan Customer Care TTY