Member Handbook FAMILY HEALTH PLAN

Transcription

1 Member Handbook FAMILY HEALTH PLAN

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3 Our Community. Our Health. CERTIFICATE OF COVERAGE This certificate of coverage represents that you are covered under the Medicaid program through IlliniCare Health, a managed care community network. IlliniCare Health shall provide to and/or arrange for you covered healthcare services in accordance with the provisions of the agreement between IlliniCare Health and the Illinois Department of HealthCare and Family Services. A description of covered healthcare services is detailed in this member handbook. This document constitutes the entire agreement between you and IlliniCare Health. Member handbooks are delivered to the address of record prior to the first effective date of coverage and annually thereafter. Members can access more information by contacting IlliniCare Health, the Illinois Department of Insurance, the U.S. Department of Labor, or the Centers for Medicare and Medicaid Services publication hotline at To learn more about your health plan choices, please contact Illinois Client Enrollment Services at or visit

4 Welcome to Dear Member, IlliniCare Health Managed Care Community Network welcomes you to your new health plan. We are happy to have you with us! As a member of IlliniCare Health, you will be able to choose your primary care provider (PCP). You will also have an active role in your healthcare. You became an IlliniCare Health member because you live in Illinois and are eligible for the Illinois Family Health Plan (FHP) program. IlliniCare Health is a health plan overseen by the Illinois Department of Healthcare and Family Services (HFS). IlliniCare Health gives you choices from establishing a medical home by choosing your primary care provider (PCP) to participating in special programs that help you stay healthy. IlliniCare Health wants you to lead a healthy lifestyle and asks you to be an active participant in your health. Your healthcare team will include your PCP, specialty providers, care coordinators, case managers, your pharmacist, and you. IlliniCare Health will give you: More choices of doctors, specialists, and hospitals A healthcare team to help you live a healthy, independent lifestyle Added services for healthy living Ways for you to share your opinion, such as through our advisory council, surveys, and other methods 4 We would like you to read everything in this packet and write down any questions you might have. IlliniCare Health staff is available Monday through Friday from 8 a.m. to 5 p.m. to answer your questions. Our main goal is to make sure you receive high-quality healthcare. Below are some advantages of becoming an IlliniCare Health member. EASY TO USE Getting benefits from IlliniCare Health is easy. We believe the best way for you to stay healthy is to develop a good relationship with your physician. That is why you selected a PCP. When you need care, all you have to do is call your PCP for an appointment. Tell them you are covered by IlliniCare Health. For mental health and substance abuse treatment, you can see any participating provider without a referral when you decide you want to start treatment. It s that simple. ACCESSIBILITY If you use a wheelchair, walker, or other aids and you need assistance getting into your doctor s offce, call the offce before you get there. This way someone will be ready to help you when you arrive. If you would like help talking with your doctor about your special needs, call IlliniCare Health at (toll-free) / (TDD/TTY). HEARING IMPAIRED MEMBERS: Call Illinois Relay at or Ask the operator to connect you to us at: (toll-free) / (TDD/TTY)

5 IlliniCare Health Toll free / (TDD/TTY) Let your doctor know if you need a sign language interpreter for a medical visit. If the doctor does not have one, call us at least seven days before your visit to make arrangements for an interpreter to be present during your appointment. TAKING GOOD CARE OF YOURSELF We encourage you to make appointments for regular checkups. Benefits with IlliniCare Health include the following services at no cost: Screenings Diagnostic x-rays Lab tests Mammograms Eye exams Routine wellness visits Annual dental cleanings and exams HOSPITAL SERVICES If you need to be in a hospital, your PCP or a specialist will admit you to a hospital where he/ she is affliated. A list of IlliniCare Health hospitals is available online at or you can call Member Services at (toll-free) / (TDD/TTY). REFERRALS TO SPECIALISTS You can access specialists on your own, but your PCP can help to coordinate referrals to specialists, hospitals, and other providers. You do not need a referral for mental health or substance abuse treatment. 5 IMMEDIATE AND EMERGENCY CARE If you have a serious illness or injury that requires immediate attention, first call your PCP. They know your medical history best. With IlliniCare Health, you have access to medical services 24 hours a day, 365 days a year. You can also call our 24-hour nurse advice line at (toll-free) / (TDD/TTY). In the event of a potentially life-threatening emergency, call 911 or go to the nearest emergency department. If you are admitted to the hospital, please call or have someone call IlliniCare Health as soon as possible. This handbook tells you how to get medical care. It explains your healthcare benefits and tells you when to call your doctor if you need medical care. You can also call our nurse advice line at (toll-free) / (TDD/ TTY) when you have questions or need help and can t reach your provider. Your rights and responsibilities are found on page 61 in this book. These are important for you to read. For additional information about IlliniCare Health, go to or call (toll-free) / (TDD/TTY). We look forward to partnering with you to meet all of your healthcare needs. IlliniCare Health

6 Contents 08 LANGUAGE HELP BUSINESS HOURS 09 HOW TO GET STARTED HOW TO REACH US 10 Benefit Summary 14 COMMUNICATION FROM ILLINICARE HEALTH 15 BASIC INFORMATION NEW ENROLLEE TRANSITION OF CARE 16 USE YOUR ILLINICARE HEALTH MEMBER ID CARD PRIMARY CARE PROVIDER (PCP) 17 CONTINUITY AND TRANSITION CARE CHANGING YOUR PCP (DOCTOR) 18 PCP CHANGE FORM 20 Medical Services 21 KEY TO DOCTOR VISITS 22 VARIOUS WAYS TO GET HEALTHCARE 24 SPECIALTY CARE URGENT CARE 25 EMERGENCY CARE 26 POST-STABILIZATION SERVICES NURSE ADVICE LINE SMOKING CESSATION 27 ADULT PREVENTIVE CARE GUIDE 28 EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) TRANSPORTATION 30 AMBULANCE CHIROPRACTOR SERVICES PHARMACY SERVICES 31 DENTAL SERVICES 32 PREGNANCY AND MATERNITY SERVICES 34 VISION BENEFITS BEHAVIORAL HEALTH AND SUBSTANCE ABUSE SERVICES LONG TERM CARE 35 LONG TERM SUPPORT SERVICES 44 SERVICES NOT COVERED 6

7 45 Program Info 46 CARE COORDINATION SERVICES 47 MEMBERCONNECTIONS CONNECTIONSPLUS CENTACCOUNT PROGRAM 49 SAFELINK 51 ACCESS TO CARE 52 ILLINICARE HEALTH WEBSITE ILLINICARE HEALTH S SECURE MEMBER PORTAL 53 QUALITY HEALTHCARE INITIATIVES SAFETY IN YOUR HOME 54 FRAUD AND ABUSE PROGRAM 55 MEMBER RIGHTS MEMBER RESPONSIBILITIES 56 CIVIL RIGHTS PROVIDER QUALIFICATIONS AND DOCTOR INCENTIVES MEDICAL DECISIONS OTHER INSURANCE MOVING 57 UPDATING YOUR ADDRESS OR PHONE NUMBER OUT OF STATE CARE OUT OF PLAN CARE ADVANCE DIRECTIVES MEMBER SATISFACTION SURVEYS 58 ENROLLEE ADVISORY COMMITTEE DENIAL OF SERVICES GRIEVANCES/APPEALS 63 RENEW YOUR HEALTH BENEFITS ANNUAL OPEN ENROLLMENT PERIOD PRIVACY NOTICE AND PRIVACY RIGHTS 64 HOW WE USE OR SHARE YOUR HEALTH RECORDS 65 WHAT ARE YOUR RIGHTS? 66 USING YOUR RIGHTS 7

8 Language Help IlliniCare Health offers language help 24 hours a day, seven days a week. This includes holidays and weekends. If your doctor does not speak your language or does not have someone who can talk to you in a way that you can understand, please contact IlliniCare Health for help. With seven days notice before your appointment, we can schedule an interpreter to go with you on your next visit. HEARING IMPAIRED MEMBERS: Call Illinois Relay at Ask the operator to connect you to us at: (toll-free) Business Hours Normal business hours of operation: 8:00 a.m. to 5:00 p.m. (Central Standard Time). Member Services TDD/TTY Member Services Fax Illinois Relay Services Behavioral Health Services (covered by FHP program) OTHER IMPORTANT PHONE NUMBERS Non-emergency Transportation Emergency Services... Call 911 ENGLISH For help translating your health coverage benefits and available services, or for assistance with any questions, please call (toll-free) / (TDD/TTY). SPANISH Para ayudar a traducir su cobertura de beneficios de salud y los servicios disponibles, o para ayudar con cualquier pregunta, llame al (toll-free) / (TDD/TTY). RUSSIAN За помощью с переводом информации о ваших страховых льготах и доступных услугах, а также с любыми вопросами. пожалуйста, звоните по телефону (toll-free) / (TDD/TTY). OTHER LANGUAGES: This member handbook is also printed in Spanish and Russian. For a hard copy, call Member Services at (toll-free) / (TDD/TTY). The handbook is also available in Braille and audio CDs free of charge. 8

9 How To Get Started TO-DO ITEMS: VERIFY YOUR PCP. You can find your doctor s (PCP) information on your member ID card. If the correct PCP is not listed on your card, or you wish to switch doctors, fill out the PCP change form that was in your welcome packet. Send it to us at the address or fax number provided below. Or call our Member Services department at (toll-free) / (TDD/TTY). You may also change your PCP online by logging on to the member portal. A current list of IlliniCare Health providers can be found at How To Reach Us SELECT A WOMEN S HEALTH PROVIDER, if needed. If you are a female, you can select an IlliniCare Health women s healthcare provider in addition to your PCP. Let us know who you have selected by using the PCP selection form included in your welcome packet. EXPECT A WELCOME CALL. An IlliniCare Health representative will call to welcome you to IlliniCare Health in your first 30 days. They will also answer any of your questions and ask you to complete a health risk screening. Please call us at (toll-free) / (TDD/ TTY). IlliniCare Health can help you 24 hours a day, seven days a week. Language assistance will also be provided through a translator if needed. You may write to us at: IlliniCare Health 999 Oakmont Plaza Drive, Suite 400 Westmont, IL Please be sure to visit our website for plan benefits, health information, and all of our current providers. You can also find a list of events on our website. This handbook can be viewed online under Member Materials. Our website is Please call us if you need help understanding this handbook or need it in a different language or format, including Spanish, Russian, large print, Braille, audio tape, or CD. AFTER HOURS & ON HOLIDAYS If you need medical advice and can t reach your doctor, you can call IlliniCare Health s nurse advice line. This is our toll-free, 24-hour, nurse-on-call phone line at: (toll-free) / (TDD/TTY). It is staffed with nurses who can assist you in any language that you may need. 9

10 BENEFIT SUMMARY 10

11 All services must be medically necessary and some services require prior authorization. Your provider will submit any needed prior authorizations. You do not need to contact us to request a prior authorization. Your provider will contact us to do this. Prior authorization is not required for approved waiver services for the following waiver recipients: persons with disability, elderly, supportive living facility, brain injury, and HIV/AIDS waiver members. COVERED SERVICES UNDER YOUR PLAN Abortion Advanced practice nurse services Ambulatory surgical treatment center services Assistive/augmentative communication devices Audiology services Blood, blood components, and the administration thereof Chiropractic services for enrollees under age 21 Dental services: Exams (1 per year for members under age 21) Dental services: Fluoride treatments (1 per year for members under age 21) Dental services: Oral surgeons for enrollees under age 21 and dental cleanings two (2) times per year Dental services: Eligible adults (age 21 and over) will be able to get limited and comprehensive exams; restorations; dentures; extractions; and sedation Dental services: Eligible pregnant women can get these additional dental services PRIOR to the birth of their babies: periodic oral examination; teeth cleaning; and periodontal work Dialysis Durable medical equipment (DME) Emergency dental services EPSDT services for enrollees under age 21 (excluding shift nursing for enrollees in the MFTD HCBS waiver for individuals who are medically fragile and technology dependent (MFTD)) Family planning services and supplies FQHCs, RHCs, and other encounter rate clinic visits Home health agency visits Hospital emergency room visits Hospital inpatient services Hospital ambulatory services Laboratory and x-ray services Medical supplies, equipment, prostheses and orthoses, and respiratory equipment and supplies Mental health services provided under the Medicaid Clinic Option, Medicaid Rehabilitation Option, and Targeted Case Management Option Nursing care for enrollees under age 21 not in the HCBS waiver for individuals who are MFTD Nursing care for the purpose of transitioning children from a hospital to home placement or other appropriate setting for enrollees under age 21 Nursing facility services Optical services and supplies; including glasses for children through the Chicago Public Schools Optometrist services Palliative and hospice services Pharmacy services (drugs used in the treatment of hepatitis C are covered only if dispensed in accordance with coverage criteria approved by the Illinois Department of Healthcare and Family Services) Physical, occupational, and speech therapy services Physician services Podiatric services Post-stabilization services Practice visits for enrollees with special needs Renal dialysis services Respiratory equipment and supplies Services to prevent illness and promote health Subacute alcoholism and substance abuse services, residential day treatment, and detox day treatment 11

12 Transplants (using transplant providers certified by the Illinois Department of Healthcare and Family Services) Transportation to secure covered services MINOR CONSENT SERVICES Minors, age 12 and older, can get certain services without their parents consent. The provider does not have to tell the parents about these services: Medical care after a sexual assault, including rape Pregnancy, family planning, and abortion services Care for the prevention and treatment of sexually transmitted diseases (STDs) Mental health and drug and alcohol abuse services that you get from your PCP that are short-term care in a primary care setting. Minors can make an appointment for these services. They do not need a referral from their PCP. For more information, call the Member Services department at (toll-free) / (TDD/TTY). PREGNANCY AND MATERNITY SERVICES We cover: Outpatient doctor services, including routine prenatal and postnatal care for problems or complications resulting from pregnancy or childbirth Inpatient hospital services in a participating hospital and out-of-network emergency labor and delivery services Care from the Comprehensive Perinatal Services Program (CPSP), including a medical/ obstetrical, nutritional, psychosocial, and health education assessment at the first prenatal visit, once each trimester thereafter, and at the postpartum visit Prenatal diagnostic procedures, including genetic testing, are covered if you have a highrisk pregnancy. The length of the hospital stay depends on the unique characteristics of each mother and her newborn child, taking into consideration the health of the mother, the health and stability of the newborn, the ability and confidence of the parent(s) to care for the newborn, the adequacy of support systems at home, and the mother and her newborn s access to appropriate follow-up care. You can stay at the hospital for at least 48 hours after a normal vaginal delivery and at least 96 hours after a cesarean section delivery. Sometimes mothers want to leave sooner. You can leave sooner if, after talking to you, your doctor approves your discharge and makes an outpatient appointment for you and the baby within 48 hours. In some cases, mothers may need to stay longer. You and your doctor will make this decision. You can choose a certified nurse midwife to deliver your baby. The midwife must work with an IlliniCare Health doctor. You can look for a certified nurse midwife in the IlliniCare Health provider directory under Allied Health Professionals. You can also see a certified nurse midwife outside of the IlliniCare Health network. You do not need IlliniCare Health s approval to see a certified nurse midwife. 12

13 GENERAL PREVENTIVE CARE SERVICES Eye exams: We cover an eye exam every two years (unless you have a medical need for more frequent exams). We cover refractions to determine a prescription for glasses. Health education programs: Including, but not limited to, diabetes education, provided by IlliniCare Health or a participating provider. Look for information on health education in your member newsletter and on our website. IlliniCare Health may also mail you information. Your PCP may tell you about other health education classes. Child and adult immunizations: Immunizations are covered according to the Advisory Committee on Immunization Practices (ACIP), Illinois adult immunization, and the United States Preventive Services Task Force recommendations. Periodic check: A complete history and physical exam every one to three years and any test recommended by IlliniCare Health and medical professionals is covered. We recommend you get a checkup according to the adult preventive care guide on page 27. VOLUNTARY FAMILY PLANNING SERVICES We cover the cost of contraceptives, including the birth control device and the fitting or insertion of the device (such as diaphragms, IUDs, Norplant). You can get services from any qualified family planning provider. S/he does not have to be a participating provider. You do not need a referral from your PCP and you do not have to get permission from IlliniCare Health to get these services. Some examples of family planning services are: Education and advice from a trained personnel to help you make choices Information about birth control Physical exams Follow-up visits Immunization services Pregnancy tests Birth control supplies Tests and treatment of STDs (sexually transmitted diseases) VOLUNTARY STERILIZATION SERVICES We cover vasectomies and tubal ligations. 13

14 ADDITIONAL COVERED SERVICES UNDER HFS WAIVERS You must qualify for the waiver services to be eligible for these services, and eligible services differ according to the waiver (see pages for specific information on what services are provided under each waiver type). Adult day care Adult day care transportation Environmental accessibility adaptations Supported employment Home health aide Intermittent nursing Nursing Extended state plan therapy services (physical, occupational, speech) Prevocational services Day habilitation Placement maintenance counseling Medically supervised day care Homemaker Home-delivered meals Personal assistant (contingent upon compliance with collective bargaining agreement and accompanying side letter between SEIU and the state) Personal emergency response systems (PERS) Respite Nurse training Family training Specialized medical equipment Cognitive behavioral therapies Assisted living Nursing facility services Communication from IlliniCare Health As a valued IlliniCare Health member, you will hear from us regularly. This will include: A copy of this handbook when you become an IlliniCare Health member A phone call from us to conduct a health risk screening A newsletter mailed to your home every four months You may also get a postcard or phone call reminding you of needed exams. OUR STAFF WILL ALWAYS IDENTIFY THEMSELVES WHEN WE CALL YOU OR RETURN YOUR CALLS. It is important to keep the state and us informed of your address and phone number so we can make sure you get the information you need. 14

15 Basic Information IlliniCare Health wants to ensure you have all the information you need about your health plan. You can contact us at any time to find out the following information: Your benefits How to receive healthcare services Authorizations needed for any healthcare services After-hours nurse advice line How to receive emergency services How to receive post-stabilization services Your rights and responsibilities as an IlliniCare Health member How to submit a grievance and an appeal Fair hearing procedures IlliniCare Health s web address and the basic information included online Our Certificate of Coverage, which explains that we are contracted by the state of Illinois Our affliated providers Most of this information can be found in this handbook. Additional information can be found online. If at any time you need assistance with finding this information, or would like to request additional information, please contact IlliniCare Health Member Services at (tollfree) / (TDD/TTY). IlliniCare Health will notify you every year of your right to receive this basic information. New Enrollee Transition of Care Are you being treated by a doctor who is not a IlliniCare Health provider? You can keep seeing that doctor for up to 90 days after joining us. We will honor all services as long as the doctor is Medicaid certified and the services are medically necessary. The doctor must also agree to accept our payment. Please let us know of any non-illinicare Health doctors you are seeing. We need to know so that we can make arrangements to pay your doctor for services and try to contract with them so you can continue to see them after your 90 days. It is important to list all of your doctors during your welcome call. You can also tell Member Services or send us the list. NEWBORN ENROLLMENT After you have your baby, contact your local caseworker at the Department of Human Services to have your baby added to your case: (toll-free) / (TTY). Also contact IlliniCare Health at (toll-free) / (TDD/TTY). 15

16 Use your IlliniCare Health Member ID Card Always carry your IlliniCare Health card with you. Show it every time you get care. You may have problems getting care or prescriptions if you do not have your ID card with you. Make sure to also bring your Illinois Medicaid card. If your Medicaid coverage was canceled during eligibility redetermination, your Medicaid coverage can be reinstated without a new application if you can produce documentation within three months of the cancellation. If you have other health coverage cards, bring them with you too. Member Name: jane doe Medicaid ID#: XXXXXXXXXXX Effective Date: xx/xx/xxxx Rx: US Script BIN: PCP Name: john doe Program: Family Health Plan PCP Number: xxx-xxx-xxxx If you have an emergency, call 911 or go to the nearest emergency room (ER). You do not have to contact IlliniCare Health for an okay before you get emergency services. If you are not sure whether you need to go to the ER, call your PCP or IlliniCare Health nurse line toll-free at (TDD/TTY ). The nurse line is open 24 hours a day. Members: Providers: Member Services line, 24/7 Nurse IVR Eligibility inquiry Prior Auth, Line, Dental/Vision: Behavioral Health: TDD/TTY: US Script Help Desk: Our address: 999 Oakmont Plaza Dr For Provider, claims and EFT/ERA Suite 400 Westmont, IL information via Web: Payer ID#: Payer ID#: Medical Claims: Mental Health Claims: IlliniCare Health Cenpatico Attn: CLAIMS Attn: CLAIMS PO Box 4020 PO Box 7300 Farmington, MO Farmington, MO Primary Care Provider (PCP) Your PCP is your primary care provider who does the following: Coaches and educates you on healthy lifestyle options Provides you with preventive and wellness care Identifies and treats you for general medical conditions Evaluates the nature of your medical condition and directs you to needed care Makes referrals to specialists when needed Primary care is usually provided outside of a hospital setting. In cases where you are admitted to the hospital, your PCP may help in or guide your care based on the nature of your medical condition. 1. See your PCP at least once a year 2. Bring a list of questions to ask your PCP 3. Bring a list of all the medications you are currently taking. Your PCP will become your medical home. As a medical home, the PCP is your primary source for healthcare. She/he will refer you to a specialist if needed. She/he will also help manage your chronic conditions. You should have an ongoing, trusting relationship with your PCP. Your PCP knows your medical history. If your primary care provider decides to no longer participate in our network, we will notify you 30 calendar days before their termination date. We can then help you choose another primary care physician that is in our network. 16

17 Continuity and Transition of Care If your provider leaves the IlliniCare Health network while you are getting covered services from them, you may be able to keep getting some services from that provider for: Acute conditions. Covered services will be provided for the duration of the condition. Serious chronic conditions. Covered services will be provided for a period of time, not to exceed 12 months from the date of the provider s termination. Pregnancy care. Covered services will be provided for the duration of the pregnancy, including immediate postpartum care. Terminal illnesses. Covered services will be provided for the duration of the illness. Care for children under age 3. Coverage limit will be the earlier of the following: 1) 12 months from the child s effective date of coverage if the child is a new member, 2) 12 months from the termination date of the terminated provider, or 3) the child s third birthday. Surgery or another procedure that is part of a course of treatment. The care must be recommended and documented by the provider to occur within 180 days of the date of the provider s termination. To learn more and to request services or a copy of our continuity of care policy, call IlliniCare Health s Member Services Department at: (toll-free) / (TDD/TTY). Changing your PCP (doctor) You may change your PCP at any time if: Your PCP is no longer in your area You are not satisfied with your PCP s services The PCP does not provide the services you seek because of religious or moral reasons You want the same or a different PCP as/from other family members You must notify us when you change your PCP. You can do this in several ways. Call Member Services at (tollfree) / (TDD/TTY). Notify us through our website by filling out a contact us form at Log in to our secure member portal to change your PCP. You can register at Complete a PCP Change form. This form is included in your new member packet and it is on our website. The next page shows an example of what this form looks like. Please note that IlliniCare Health wants you to establish a long-term medical home with your PCP. Changes in PCP are made on request and will be effective the first of the following month. One of our care coordinators will consult with you if you need to make more than three PCP changes in a year. The following page shows an example of what this PCP Change form looks like. 17

18 PCP Change Request Form MEMBER INFO First/MI/Last: Address: DOB: Member ID: City: Zip: SSN: Phone: PCP CHANGE REQUEST Requested PCP Name: Provider ID: Offce Address: City: Zip: Offce Phone: Effective Date: REASON FOR CHANGE FROM ASSIGNED PCP Already patient with requested PCP Language/communication barriers Requested PCP already sees family member Wait time in provider offce Member Preference Availability to get appointment. Member Moved Access to care PCP Hours didn t fit member s needs Association with hospital or medical group Quality of Care Established relationship w/ another Provider Location Other Signature of Member or Authorized Representative Date Printed Name of Authorized Representative DIRECTIONS: Please fax member change data forms, with a copy of the member ID card, if available, to IlliniCare Health Member Services department at , or mail it to IlliniCare Health Member Services, 999 Oakmont Plaza Drive, Suite 400, Westmont, IL IC-PCPCRF 9/14 If you have questions about how to complete this form, please call the IlliniCare Health Member Services department, Monday through Friday, 8 a.m. 5 p.m., at (toll-free) / (TDD/TTY). 18

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20 MEDICAL SERVICES 20

21 Medical Services ILLINICARE HEALTH PROVIDES THE FOLLOWING: DOCTOR CARE*: Yearly physical exams Network of specialists Wellness visits Diagnosis and treatment Immunizations (shots) Prenatal and postpartum care HOSPITAL CARE*: Inpatient services Outpatient services Laboratory x-ray Diagnostic studies Emergency care Surgeries *No prior authorization is required when services are rendered at in-plan hospitals. OTHER COVERED SERVICES*: Mental health treatment Substance abuse treatment Vision care Physical therapy Chiropractic care Pharmacy Occupational therapy Hospice Dental care MEDICAL SUPPLIES*: Durable medical equipment Disposable medical supplies Prosthetic devices MEDICALLY NECESSARY SERVICES Covered services that you get must be medically necessary. This means getting the right care, at the right place, and at the right time. IlliniCare Health uses standard guidelines to check medical necessity. IlliniCare Health does not reward its network providers or their staff to deny or delay care. Key to Doctor Visits HELPFUL TIPS TO KEEP IN MIND BEFORE, DURING, AND AFTER A VISIT TO YOUR PCP: 1. Bring a list of questions or concerns 2. Bring your IlliniCare Health ID card and photo ID 3. Bring medical and shot records 4. Bring a list of all the medications you are taking 5. Describe all of your symptoms and complaints 6. Ask the doctor any questions you have 7. Take notes during the visit 8. Talk about what will happen after the visit 9. Schedule a follow-up appointment, if needed 10. Schedule yearly checkups 11. Call to reschedule or cancel your doctor appointment if you are not able to make it 21

22 Various Ways to Get Healthcare 3 EASY STEPS TO ESTABLISH A MEDICAL HOME 1) Choose a primary care provider (PCP). If you do not choose one, IlliniCare Health will choose one for you. You can find this information on your member ID card. You will be able to change your PCP at any time by calling Member Services at (toll-free) / (TDD/TTY). 2) Make an appointment with your PCP to complete your Initial Health Assessment within 120 days of enrolling. For those under the age of 18 months, this appointment should be made within 60 days of enrolling. Remember to take your member ID card with you every time you go to the doctor s offce. If you have diffculty getting an appointment with or seeing your doctor, please call Member Services at (toll-free) / (TDD/TTY). 3) Talk to your PCP about any health problems you are experiencing. When you enroll in IlliniCare Health, you must choose a PCP. Your primary care provider, or PCP, is a doctor, nurse practitioner, certified nurse midwife, or physician assistant you see on a regular basis to take care of your medical needs. You should receive all of your basic medical care from your PCP. You can call your PCP when you are sick and do not know what to do. Seeing your doctor for regular checkups helps you find health problems early. This can help you prevent from having to go to the emergency department. If you have never seen your PCP, as soon as you join IlliniCare Health you should call your PCP, introduce yourself as a new member, and make an appointment for a preventive visit. It is best not to wait until you are sick to meet your PCP for the first time. You have many different healthcare needs. These needs will come up at different times for different reasons. There are several ways for you to get healthcare, including: Routine doctor visits Emergency care visits Urgent care visits Nurse advice line (24-hour nurse-on-call) Please see the following sections for helpful explanations and examples of when to use each place of care. You can always call us if you need additional help. In the case of an emergency, you should call PRIMARY CARE PROVIDER (PCP) When you need care, call your primary care provider (PCP) first. Your PCP will help you manage all of your health services. If you think you need to see another doctor, or a specialist, talk with your PCP. Your PCP can help you decide if you need to see another doctor. You do not need a referral from your PCP for mental health or substance abuse treatment. You can choose your PCP from those available in our network. NOTE: For women, you may also see a women s healthcare provider (for example, an OB/GYN doctor or a nurse midwife) without a referral in addition to your PCP. If needed, a specialist can also be your PCP. However, in order for a specialist to be your PCP, he/she needs to agree to provide you with that level of care. Please contact your IlliniCare Health care coordinator if you wish to proceed with your specialist as your PCP by calling (toll-free) / (TDD/TTY). 22

23 OB/GYN AND PCP Women can go to any participating doctor, family practitioner, or nurse practitioner for routine preventive OB/GYN care. You do not need approval from IlliniCare Health or a referral from your PCP. Women can also have OB/GYNs as their PCP, children can have pediatricians, and those with HIV/AIDS can have HIV/AIDS specialists, if they are available. The following are the most common services you get from an OB/GYN: Breast examination Gynecological examinations and treatments Pap test Prenatal care KNOWING YOUR DOCTOR You selected or were assigned to an IlliniCare Health PCP. Your PCP can be one of a variety of provider types: Family practice doctor General practice doctor Internal medicine doctor OB/GYN (Women can choose both a PCP and an OB/GYN) Nurse practitioner Physician s assistant Specialist YOUR DOCTOR WILL HELP YOU WITH: Checkups and immunizations Treatment of illnesses Treatment of injuries Education on conditions Prescription drugs Referrals to specialists Hospital admissions Pregnancy care VISITING YOUR DOCTOR Always call your PCP when you need care, unless it is a medical emergency. The following are cases when you should call your PCP: When you are sick To schedule checkups and tests To cancel or change appointments To get care after business hours Prior to going to the ED For help with ongoing conditions PCP RESPONSIBILITIES Your PCP will: Know your medical history Listen to your concerns Explain things to you in a way you can understand Work closely with you so you can make the best choices in care Make sure that you get all medically necessary services in a timely manner Followup on the care you get from other medical providers Take care of referrals for specialty care and services offered Provide any ongoing care you need Update your medical record, including keeping track of all the care that you get from your PCP and specialists Provide services in the same manner for all patients 23

24 Give you regular physical exams Provide preventive care Give you regular immunizations Make sure you can contact him/her or another doctor at all times Discuss what advance directives are and file the advance directives appropriately in your medical record. SECOND MEDICAL OPINION You have the right to a second opinion about your treatment choices. This means talking to a different doctor about an issue to see what he/she has to say. The second doctor is able to give you his/her point of view. This may help you decide if certain services or methods are best for you. If you want a second opinion for the following services or in the following situations, please talk to your PCP: Surgery Treatment or diagnoses of serious or lifethreatening conditions Complex cases or cases with conflicting test results Cases where the member does not respond well after an appropriate amount of time Your PCP or the IlliniCare Health Member Services staff can help you find a doctor to give you a second opinion. You may choose any IlliniCare Health network provider. If you are unable to find a doctor in network, we will help you find a doctor outside the network. If you need to see an out-of-network provider for the second opinion, it must be prior approved by IlliniCare Health. There is no cost to you for a second or third opinion if IlliniCare Health approves it first. For more information on second opinions, call the Member Services department at: (toll-free) / (TDD/TTY). Specialty Care A specialist is a doctor who works in a specific area of medicine. For example, heart, skin, or bones. Your PCP may refer you to see a specialist if needed. In some cases, a specialty provider may be assigned as your PCP due to a chronic condition that you may have. With IlliniCare Health, you do not need a referral to see a specialist, but you might want to see your PCP first. If you need mental health services, you do not need a referral as long as you see one of our providers. If you need help getting a visit, please contact Member Services at (toll-free) / (TDD/TTY). Urgent Care Urgent care is care you need sooner than a routine doctor visit. Urgent care is not emergency care. Do not go to a hospital emergency department (ED) for urgent care unless your doctor tells you to go there. If you need urgent care, call your PCP or our 24-hour nurse advice line at (tollfree) / (TDD/TTY). Your PCP or the nurse line will help you decide where to get care. You must get urgent care from in-network doctors unless you get our approval to see an out-of-plan doctor. EXAMPLES OF URGENT CARE NEEDS: Most broken bones Minor cuts Sprains Bruises Non-severe bleeding Most drug reactions Minor burns 24

25 Emergency Care WHAT IS EMERGENCY CARE? Emergency care is care needed right away. This may be caused by an injury or a sudden illness. WHAT SHOULD I DO IN AN EMERGENCY? If possible, try to see your in-plan provider (your PCP) for help. BUT you can go to the nearest hospital, doctor, or clinic to receive emergency care. You do not need a referral for emergency care. Call or your local police or fire department. WHEN SHOULD I GO TO THE EMERGENCY DEPARTMENT (ED)? If your emergency is sudden or life-threatening, you should go to the ED. If you are not sure if you have an emergency, you can call your PCP or our nurse advice line to ask if the ED is right for you. Examples of emergencies that are sudden or life-threatening: Choking Trouble breathing Suspected poisoning Serious broken bones that break the skin Suspected heart attack Suspected stroke Severe burns Sexual assault Severe or unusual bleeding Sudden loss of vision, speech, or mobility Neck or back injuries Loss of consciousness or fainting Prolonged or repeated seizures Convulsions Unconsciousness Immediate fear that you may hurt yourself or someone else When NOT to go to the ED Flu, colds, sore throats, and earaches A sprain or strain A cut or scrape not requiring stitches To get more medicine or have a prescription refilled Diaper rash 25

26 Post Stabilization Services Smoking Cessation These are services needed to keep you stabilized after emergency care. IlliniCare Health covers these services. These services may be provided in the hospital or in an offce setting. For a list of providers or facilities providing these services, please call Member Services at (toll-free) / (TDD/TTY). HELPFUL TIPS TO KEEP IN MIND: If you have a health condition that occurs often (a chronic condition), talk to your PCP about making a medical emergency plan. If you must go to an out-of-plan hospital or provider, call us as soon as you can and tell us what happened. This is important so we can help you get follow-up care. Remember, hospital emergency departments are for true emergencies only. Nurse Advice Line NURSE ADVICE LINE HERE FOR YOU 24/7 Everyone has questions about their health. If you have a question, please call our nurse advice line. Receive medical advice over the phone from registered nurses Open 24 hours a day, every day of the year Get help in deciding where to go for care NURSE LINE HEALTH TOPICS: Advice on minor injuries Questions about glucose and insulin How to address pressure sores and open wounds How to deal with asthma How much medicine to use/give What to do if you have a headache Questions about pregnancy and baby issues And more! 26 Are you ready to quit? Here s how we can help you. Tell your PCP that you want to quit. IlliniCare Health covers the following medications with a written prescription from your PCP. Nicotine patches Generic inhalers/nasal sprays Generic Zyban Here s how you can help yourself. Call the Illinois Tobacco QUITLINE at: 866-QUIT-YES ( ) Voice , TDD/TTY for hearing impaired They will help you develop a quit attempt plan, which may also include telephone counseling to assist you. Statistics show that a combination of medication along with counseling has the best success rate. PLEASE CALL YOUR PCP OR OUR NURSE ADVICE LINE: 1. If your condition is NOT an emergency hour nurse advice line at (toll-free) / (TDD/TTY)

27 Adult Preventive Care Guide THE CHART BELOW SHOWS SOME OF THE RECOMMENDED PREVENTIVE TESTS AND EXAMS. Exam Age Frequency Checkup Under Age 21 Annually Checkup Ages Every 3 years Checkup Over age 65 Annually Clinical breast exam Consult with your doctor Annual general exam Age Gender Other Preventive Service Recommended 21-29* 30-49* 50-64* Male Female Male Female Male Female Tetanus-Diphtheria Booster (should receive every 10 years) Cervical Cancer Screen, Chlamydia Screening, HPV (if under 26), Tetanus- Diphtheria Booster (should receive every 10 years) Cholesterol Testing, Tetanus-Diphtheria Booster (should receive every 10 years) Cervical Cancer Screen, Cholesterol Testing Cholesterol Testing, Prostate Exam, Tetanus-Diphtheria Booster (should receive every 10 years), Colorectal Cancer Screening, Pneumonia Vaccine, Shingles Vaccine, Flu Vaccine Cholesterol Testing, Colorectal Cancer Screening, Pneumonia Vaccine, Shingles Vaccine, Flu Vaccine *You should consult with your doctor to determine which test is right for you and the most appropriate age to receive particular tests PREVENTIVE CARE FOR WOMEN: Exam Age Frequency Pelvic exam Under age 39 Every 3 years Pelvic exam Age 40 & above Annually PAP Age 21 & above Every 3 years (Frequency depends on risk factors; ask your doctor) Mammogram Age 49 Consult with your doctor Mammogram Age Annually 27

28 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) is a preventive healthcare program for persons ages birth to 21 years old. Children and young people need to see their doctor regularly even when they are not sick. We don t want your child to miss any key steps toward good health as they grow. Doctors and nurses will examine your child or teen. They will give vaccines for diseases when necessary. Vaccines are important to keep your child healthy. They will also ask questions about your child s health problems (if any) and tell you what to do to help your child stay healthy. If there is a problem found during the checkup, your doctor can send your child to a specialist. To schedule an EPSDT visit, call your doctor. If you have problems scheduling your visit, please call Member Services at (toll-free) / (TDD/TTY). Transportation If you need a ride to or from a medical visit please call us at least two business days in advance and we will schedule a ride for you. If you need to bring a guest with you, you can. Call IlliniCare Health at (toll-free) / (TDD/TTY). When prompted, ask for transportation and a transportation specialist will assist you. Please be sure to call during normal business hours, Monday through Friday, from 8 a.m. 5 p.m. Central Time (CT). IlliniCare Health will provide transportation including: Door-to-door service Public Transportation American Disability Association (ADA) paratransit Caregiver reimbursement of personal mileage If your caregiver takes you to the doctor, they could qualify to receive reimbursement. Your caregiver would have to call Member Services at ahead of time to request a trip number and obtain required forms. We will select the best transportation method for your needs. This will be based on the distance from your home to the provider s offce, accessibility needs, and cost effectiveness. We will ask you a series of questions to determine the best transportation option for you. These questions include: Do you own and drive a working car? Do you have a friend or family member who is able to transport you? Are you able to take public transportation? Are you able to walk from your door to the vehicle with little or no assistance? Do you use any devices, such as a walker, cane, wheelchair, etc.? Are you able to step into the vehicle or do you require a lift? 28

29 Do you normally travel alone or do you require an attendant? Once your transportation is scheduled, you will receive a follow-up call the day before your appointment. We will confirm all the details of your transportation. This includes time of pickup, the name and location of your doctor, type of transportation, and the name of transport provider. Below are some common questions about transportation: What should I do if my appointment gets changed, moved or cancelled? If there are any changes to your scheduled visit, please call us at (toll-free) / (TDD/TTY). We can help you change your transportation arrangements. What should I do if my transportation doesn t arrive? Please contact us immediately at (toll-free) / (TDD/TTY). We will be able to find out where your ride is, and ensure you make it on time to your appointment. Do I need to call IlliniCare Health when I m ready for pickup after my doctor visit? It depends on your method of transportation: Door-to-door service: Your driver may wait for your visit to be done. If they do not wait for you, please contact us at (toll-free) / (TDD/TTY) after your appointment. We will contact the transportation provider to pick you up once your doctor visit is over. Taxi cab: you will need to call us at (toll-free) / (TDD/ TTY) when you are ready for pickup after your appointment. We will be able to dispatch another taxi cab to pick you up. Public transportation: your return trip will be based off of the public transportation schedule. Can I arrange transportation to the pharmacy? We are only able to provide transportation to the pharmacy on your way home from your doctor appointment. If your doctor gives you a prescription, please have the provider contact an in-network pharmacy so they can fill it right away. This way it will be ready when you pick it up. You will then tell your driver to stop at the pharmacy on your way home. If I don t have a doctor appointment but just need to go to the pharmacy, can I arrange transportation? No, we can only take you to the pharmacy if it is immediately after your doctor appointment. If for some reason you are unable to refill your prescription, please call us at (tollfree) / (TDD/TTY). We can help you. We have other options available, including receiving certain medications through the mail. Can I arrange transportation to take me to the grocery store or some other destination? No. We can only provide transportation to take you to your doctor appointments. We are unable to arrange transportation for you to go other places. Do you provide transportation on weekends? Yes, you can arrange transportation for any doctor visits over the weekend. However, we still need to be notified two business days in advance. You must call during normal business hours Monday through Friday, 8 a.m. 5 p.m. (Central Time), in order to setup transportation. Are there only certain times during the day I can receive transportation? No. We will provide you transportation no matter what time your appointment is. Please just be sure to notify us at least two business days in advance. Can I contact my provider directly for transportation? Your provider cannot set up transportation for you. You will need to call IlliniCare at (toll-free) / (TDD/ TTY) in order to schedule transportation. Is there a limit to how many times I can arrange transportation? There is no limit to the amount of transportation we provide. You are able to use transportation to go to all of your necessary doctor visits. 29

30 Ambulance Your coverage includes ambulance service for emergency care. We may also cover this service at other times. You must have prior approval from us for all non-emergency ambulance trips. Your provider can arrange this for you. If you are having a medical emergency, call 911. Chiropractor Services Your benefits include chiropractor services when it is necessary to correct the spine. Your coverage allows only manual treatment to correct the spine. If you believe that you need chiropractor services, contact Member Services at (toll-free) / (TDD/TTY). Your care coordinator can assist you in determining if you qualify for these services. Pharmacy Services IlliniCare Health provides your pharmacy coverage through our vendor US Script. We use a Preferred Drug List (PDL). A PDL is a list of the drugs that we prefer you use. You must pick up your drugs at one of the network pharmacies. The US Script open-pharmacy network contains over 62,000 retail chains and independent pharmacies. Their extensive network includes: CVS, Kmart, Kroger, Meijer, Osco, Target, Walmart, and Walgreens. If you go to a community health center, you may get to use your pharmacy or continue your relationship with a local retail pharmacy. If you need a medication that does not appear on the PDL, your doctor may ask for a review. You can find the PDL on our website. If you don t have access to the Web, please call Member Services and we will mail you a paper copy. If you are new to IlliniCare Health, you can continue any medication that you are currently using for your first 90 days with us. 30 IlliniCare Health provides another option for you to receive your medication. This is our mail order program. You can get a 90 day supply (three months supply) of the drugs you take every day. You can find a list of covered drugs in the pharmacy section of our website at www. illinicare.com. You can also call IlliniCare Health if you have any questions. If you would like to use the mail order program, there is a form in your welcome packet. Your doctor can also phone a prescription directly to our mail order pharmacy if they call RxDirect at

31 Dental Services Poor dental care can affect your physical health. A new benefit for you with IlliniCare Health is that eligible adults (age 21 and over) will be able to get the following dental care: Limited and comprehensive exams Restorations Dentures Extractions Sedation Children covered by the All Kids program will be able to get the following dental care: Exams (checkups) Fluoride treatments Cleanings Oral surgery Crowns (caps) Extractions (pulling) Fillings Root canals Sealants X-rays Also, eligible pregnant women can get these additional dental services PRIOR to the birth of their babies: Periodic oral examination Teeth cleaning Periodontal work All members are covered for emergency dental services. Please remember to make an appointment for a dental exam. We are using providers through our dental provider, DentaQuest. In order to receive dental services, you must go to an in-network provider. You can find an in-network dentist on our website or by calling IlliniCare Health Member Services at (toll-free) / (TDD/TTY). FAQ Are dentures covered as part of my benefits with IlliniCare Health? Yes, IlliniCare Health covers the cost of complete dentures if they are medically necessary. This is allowed once every five years. Partial dentures are not covered. I was told I need to get oral surgery. Is this covered? Oral surgery services, like extractions and drainage of abscesses, are covered by your dental benefits. These services may require prior authorization. Other oral surgery services may be covered by your medical benefits. Your dentist should contact IlliniCare Health or DentaQuest for authorization. Does IlliniCare cover practice visits? Yes, practice visits are covered for those members who qualify. Practice visits allow our members to feel comfortable with their dentist before receiving a cleaning or other service. Please contact us to see if you qualify for practice visits by calling (tollfree) / (TDD/TTY). If you have any questions regarding what is covered under your dental benefit, please contact us at (toll-free) / (TDD/TTY). 31

32 Pregnancy and Maternity Services WHEN YOU ARE PREGNANT Keep these points in mind if you are pregnant now or want to become pregnant: Go to the doctor as soon as you think you are pregnant. It is important for your health and your baby s health to see a doctor as early as possible. Seeing your doctor early will help your baby get off to a good start. It s even better to see your doctor before you get pregnant to get your body ready for pregnancy. Make an appointment with your dentist for a cleaning and checkup. Set a goal to live a healthier lifestyle. Healthy lifestyle habits include exercising, eating balanced healthy meals, and resting for 8-10 hours at night. Pregnancy & Maternity Services There are things you can do to have a safe pregnancy. See your doctor about any medical problems you have, such as diabetes and high blood pressure. Do not use tobacco, alcohol, or non-prescribed drugs either now or while you are pregnant. IlliniCare Health recommends that you see your doctor before becoming pregnant if you have experienced any of the following problems: You have had three or more miscarriages. You have given birth to a premature baby (this means the baby came before 37 weeks of pregnancy), a preemie. You gave birth to a stillborn baby. A note about folic acid: folic acid is a very important nutrient that can help you have a healthier baby. You should take folic acid before you become pregnant or as soon as you find out you are pregnant. Some foods that have folic acid in them include: orange juice, green vegetables, beans, peas, fortified breakfast cereals, enriched rice, and whole wheat bread. It is diffcult to get enough folic acid from food alone. Ask your doctor about taking prenatal vitamins and see your doctor as soon as you think you are pregnant. If you have questions about folic acid or your pregnancy, call Member Services at (toll-free) / (TDD/TTY). START SMART FOR YOUR BABY Start Smart for Your Baby (Start Smart) is our special program for women who are pregnant. IlliniCare Health wants to help you take care of yourself and your baby through your whole pregnancy. Information can be provided to you by mail, telephone, and through the Start Smart website, Our Start Smart staff can answer questions and give you support if you are having a problem. We can even arrange for a home visit if needed. If you are pregnant and smoke cigarettes, IlliniCare Health can help you stop smoking. We have a special smoking cessation program for pregnant women that is available at no cost to you. The program has trained healthcare clinicians who are ready to build one-to-one contacts with you. They will provide education, counseling, and the support you need to help you quit smoking. Working as a team over the telephone, you and your health coach can develop a plan to make changes in your behavior and lifestyle. These coaches will encourage and motivate you to stop smoking. We have many ways to help you have a healthy pregnancy. Before we can help, we need to know you are pregnant. We can help you contact FHP to find out if you qualify for maternity coverage. Please call Member Services at (toll-free) / (TDD/TTY) as soon as you learn you are pregnant. We will help you set up the special care that you and your baby need. 32

33 Vision Benefits IlliniCare Health works with our vision provider OptiCare to offer you a comprehensive network of vision providers. Additionally, coverage is provided for services obtained through vendors procured by Chicago Public Schools (CPS) to manufacture eyeglasses for children in CPS. We offer exams to all of our members. You also have the choice between glasses or contact lenses. You are allowed: VISION EXAM: preventive eye exam from our network of optometrists and ophthalmologists. You are allowed one vision exam every year. FRAMES: your choice from our standard selection of frames or you can opt out and use a $100 allowance toward the retail value of frames. If the value of the frames for this optout election is above $100, you are responsible for the difference in price out of pocket. You are eligible for new glasses every two (2) years. LENSES: if certain prescription requirements are met, single vision and bifocal lenses are fully covered. CONTACT LENSES: if you choose contacts instead of eye glasses, the fitting fee is fully covered and you are entitled to use an $80 retail value allowance toward the price of your contact lenses. If the value of your lenses for this opt-out election is above $80, you are responsible for the difference in price out of pocket. You must use an in-network vision provider. To find a vision provider, call IlliniCare Health Member Services at (toll-free) / (TDD/TTY) or check our directory online at Go to Find a Provider. Behavioral Health and Substance Abuse Services IlliniCare Health provides behavioral health and substance abuse services. We want you to get your needs met and to help you stay healthy. We are here 24/7 to make sure that we meet your needs. Your call is private. You can talk to a real person. Our staff will work with you to take care of your mental health, substance abuse, and physical health needs. Our staff can assist you in coordinating your care, but if you have a life-threatening emergency, please call 911 or go to the nearest hospital emergency department. We can help you with: Anxiety Bipolar disorder Depression Eating disorders (such as anorexia or bulimia) Obsessive-compulsive disorders Schizophrenia Substance abuse (such as drug and/or alcohol problems) Other mental or behavioral health conditions Behavioral health services that are covered by IlliniCare Health include but are not limited to: Hospital stays Detoxification services Stabilization services when in crisis Observation Medication monitoring and management 33

34 Mental health assessments Case management Individual, group, and family therapy Treatment plan development Community support Residential rehab Day treatment If you need these services, call us at (toll-free) / (TDD/TTY). You can also go to our website and simply select a provider you wish to see. You must see an in-network provider in order to receive services. To find a behavioral health provider, go to our website at www. illinicare.com or call us. You can find out if your provider is listed and more. You decide with your provider what services you need. Your provider may need to contact us to get approval. If this service is denied, you can file an appeal. For more information on filing an appeal, go to the Appeals/Grievances section of this handbook. You can find it on page 54. Long Term Care If you are living in a nursing home or skilled nursing facility, IlliniCare Health has supports in place to ensure you are getting the care you need. And, if you are able, we have resources to assist in transitioning you back to living independently in the community. PROVIDERS IlliniCare Health has partnered with providers to administer services for our members residing in nursing homes or skilled nursing facilities. We have a staff of doctors and nurses that will be visiting you at the facility. They will help supplement and coordinate the care you receive from your primary care provider (PCP). This is to help improve your overall health. IlliniCare Health staff will come by at regularly scheduled times. They may perform assessments of your health, treatments, or interventions. They will work with you on your needs and also communicate with your family and/or guardian. They will work closely with your PCP. YOUR PRIMARY CARE PHYSICIAN Typically, your PCP will be the physician or medical director at your facility. Depending on what you want, you can also choose to have a PCP in the community. It is your choice who your PCP is. It is important that you feel comfortable with your PCP. If you decide to change your PCP at any time, it s important to notify us. You can call us at (toll-free) / (TDD/TTY), send us a PCP change form, or change your PCP through our secure online member portal. For more information about the secure member portal, please see page 48. The PCP change form would have come with your Member Welcome Packet. A copy of what this form looks like is on page 18. TRANSPORTATION If at any time you need transportation to go to one of your medical appointments, you might be eligible for a voucher for public transportation, if appropriate. A case worker or staff member at the long-term-care facility should be able to help arrange this. We provide all the transportation to your appointments outside of your facility if you are unable to obtain a voucher for public transportation. If you or someone at the facility has questions about transportation benefits we cover, call Member Services at (toll-free) / (TDD/TTY). TRANSITIONING TO THE COMMUNITY If your PCP and long-term-care facility staff believe that you are able to transition to living in the community, it s important to contact us. We can help you with that transition by providing transportation and information on agencies that can help you in your home. If you want more information about transitioning to the community, contact your IlliniCare Health care coordinator by calling (toll-free) / (TDD/TTY). 34

35 Long Term Support Services ELIGIBILITY IlliniCare Health does not determine your eligibility into the Waiver or Nursing Home programs. Eligibility determination is under either the Department on Aging or the Department of Human Services, Division of Rehabilitative Services. If one of these Departments has decided you are eligible, you will be asked to select a health plan. A plan will be assigned for you if you did not make a choice. The following are some of the eligibility requirements of the Departments: Be a resident of the State of Illinois Be a citizen of the United States or a legally admitted alien Have a Determination of Need (DON) score of 29 points or more Needs will be met at a cost less than or equal to the cost of nursing services in an institutional setting Fully cooperate with the Medicaid application process and maintain Medicaid eligibility If you do not meet or maintain your eligibility requirements according to the Department standards, you may be disenrolled from the waiver. Your eligibility Department will send you a notice if they have found you no longer eligible, and will give you a disenrollment date. IlliniCare Health will also be informed of this action and your disenrollment date. For additional information regarding the Illinois waivers programs as alternatives to nursing homes, please visit: hfs/medicalprograms/hcbs/pages/default.aspx; CASE MANAGEMENT SERVICE IlliniCare Health Long Term Services and Supports program is for members who have been determined to be eligible for a Home and Community Based Service (HCBS) waiver program or the Nursing Facility program. You 35 will be assigned a Case Manager at the time you are enrolled. Your case manager will work with you, your authorized representative, or your guardian to help you determine your needs and services to meet those needs. If you are in the Persons who are Elderly Waiver or the Persons with Disabilities Waiver, your Case Manager will visit you at least one time every 3 months. If you are in the Persons with Brain Injury Waiver, your Case Manager will contact you at least one time every month. If you are in the Persons with HIV/AIDS Waiver, your Case Manager will contact you at least monthly by phone, and visit you at least every other month. If you live in your own home or in a Supportive Living setting, your Case Manager will complete an assessment visit and service plan with you every year. If you live in a Nursing Facility, your Case Manager will complete an assessment visit and service plan with you every 6 months. Your Case Manager can visit you more if your needs change. At each assessment visit, your Case Manager will ask questions to learn more about you. They will ask about your strengths. They will ask what you can do and what you need help with. Your Case Manager will work with you and your authorized representative, as you decide on services to meet your needs. If you live in a Nursing Facility, your Case Manager will approve your Long Term Care stay. Your Case Manager will work with you and your authorized representative to see if you can return to a community setting with services and supports. If you live in the community, your Case Manager will help get the services you need based on your waiver program. You will have case management services as long as you are an IlliniCare Health member and in a nursing facility or HCBS Waiver program.

36 NURSING FACILITY SERVICE A Nursing Facility (NF) sometimes goes by different names such as Nursing Home, Long Term Care Facility, or Skilled Nursing Facility. A Nursing Facility is a licensed facility that provides skilled nursing or long-term care services. These facilities have services that help both the medical and non-medical needs of residents who need assistance and support to care for themselves due to a chronic illness or disability. They provide care for tasks like dressing, bathing, using the bathroom, meals, laundry, and other needs. In a nursing facility, the staff will take care of your medications and order refills for you. If you live in a Nursing Facility you will need to pay a Share of Cost or Patient Credit. The Department of Human Services caseworker determines what your Patient Credit total will be based on your income and your expenses. If you have questions, your case manager will work with you to understand your Patient Credit. You will need to pay the Patient Credit to the Nursing Facility each month. HOME AND COMMUNITY BASED SERVICES AND WAIVERS Home and Community Based Services (HCBS) help you live in your own home or other type of community setting. Your Case Manager will work with you, your authorized representative, or guardian to find the right types of service. Not all services will be right for you. Once you agree to these services your Case Manager will work to arrange them for you. The HCBS Waiver programs are below. The services available are next to each program. The definitions of services are listed at the end of this list. Note These services cannot be provided to you if you have been admitted to a hospital or nursing home. WAIVER PROGRAM Elderly Waiver Also known as: Aging Waiver or Community Care Program (CCP) Persons with Disabilities Waiver Also known as: Physical Disabilities Waiver or Home Services Program (HSP) SERVICES Adult Day Service Adult Day Service Transportation Homemaker Personal Emergency Response System Adult Day Service Adult Day Service Transportation Environmental Accessibility Adaptations-Home Home Delivered Meals Home Health Aide Homemaker Nursing-Skilled Nursing-Intermittent Personal Assistant Personal Emergency Response System Physical, Occupational, and Speech Therapy Respite Specialized Medical Equipment and Supplies 36

37 WAIVER PROGRAM Persons with Brain Injury Waiver Also known as: Brain Injury Waiver; Traumatic Brain Injury (TBI) Waiver; or Home Services Program (HSP) People with HIV or AIDS Waiver Also known as: AIDS Waiver or Home Services Program (HSP) SERVICES Adult Day Service Adult Day Service Transportation Environmental Accessibility Adaptations-Home Home Delivered Meals Home Health Aide Homemaker Nursing-Skilled Nursing-Intermittent Personal Assistant Personal Emergency Response System Physical, Occupational, and Speech Therapy Respite Specialized Medical Equipment and Supplies Supported Employment Prevocational Services Day Habilitation Behavioral Services Adult Day Service Adult Day Service Transportation Environmental Accessibility Adaptations-Home Home Delivered Meals Home Health Aide Homemaker Nursing-Skilled Nursing-Intermittent Personal Assistant Personal Emergency Response System Physical, Occupational, and Speech Therapy Respite Specialized Medical Equipment and Supplies 37

38 WAIVER PROGRAM Supportive Living Program Waiver (SLP) Also known as: Supportive Living Facility Waiver (SLF) SERVICES Supportive living provides an alternative to traditional nursing home care by mixing housing with personal care and supportive services, and includes these services: Nursing Assessments Intermittent Nursing Medication Assist Personal Care Housekeeping Laundry Social & Health Promotion Activities Personal emergency response system Well-being check Maintenance 24 hour response/security Meals and snacks ADAPTIVE EQUIPMENT This service includes devices, controls, or appliances, specified in the plan of care, which enable the member to increase his or her abilities to perform activities of daily living, or to perceive, control, or communicate with the environment in which they live. ADULT DAY HEALTH ALSO KNOWN AS ADULT DAY SERVICE This is a daytime community-based program for adults not living in Supported Living Facilities. Adult Day Service provides a variety of social, recreational, health, nutrition, and related support services in a protective setting. Transportation to and from the center and lunch are included as part of this service. BEHAVIORAL SERVICES These services are behavioral therapies designed to assist members with brain injuries in managing their behavior and thinking functions, and to enhance their capacity for independent living. DAY HABILITATION ALSO KNOWN AS HABILITATION This service provides members with brain injuries training with independent living skills, such as help with gaining, maintaining, or improving self-help, socialization, and adaptive skills. This service also helps the member to gain or maintain his or her maximum functional level. PERSONAL EMERGENCY RESPONSE SYSTEM This electronic equipment allows members 24-hour access to help in an emergency. The equipment is connected to your phone line and calls the response center and/or other forms of help once the help button is pressed. ENVIRONMENTAL ACCESSIBILITY ADAPTATIONS These are physical modifications to a member s home. The modifications must be necessary to support the health, welfare, and safety of the member and to enable the member to function with greater independence in their home. Without the modification a member 38

39 would require some type of institutionalized living arrangement, such as nursing facility or assisted living. Adaptations that do not help the member s safety or independence are not included as part of this service, such as new carpeting, roof repair, central air, or home additions. HOME DELIVERED MEALS Prepared food brought to the member s home that may consist of frozen meals or a heated lunch meal and a dinner meal (or both), which can be refrigerated and eaten later. This service is designed for the member who cannot prepare his or her own meals but is able to feed him/herself. HOME HEALTH AIDE A person who works under the supervision of a medical professional, nurse, physical therapist, to assist the member with basic health services such as assistance with medication, nursing care, physical, occupational and speech therapy. HOMEMAKER In-home caregiver hired through an agency. The caregiver helps with housekeeping items such as meal preparation, shopping, light housekeeping, and laundry. The caregiver can also help with hands-on personal care such as personal hygiene, bathing, grooming and feeding. NURSING - SKILLED This service provides skilled nursing services to a member in their home for short-term acute healing needs, with the goal of restoring and maintaining a member s maximal level of function and health. These services are provided instead of a hospitalization or a nursing facility stay. A doctor s order is required for this service. NURSING - INTERMITTENT This service focuses on long term needs rather than short-term acute healing needs, such as weekly insulin syringes or medication oversight/ reminders for members unable to do this for themselves. These services are provided instead of a hospitalization or a nursing facility stay. A doctor s order is required for this service. 39 PERSONAL ASSISTANT In-home caregiver hired and managed by the member. The member must be able to manage different parts of being an employer such as hiring the caregiver, managing their time, submitting timesheets and completing other employee paperwork. The caregiver helps with housekeeping items such as meal preparation, shopping, light housekeeping, and laundry. The caregiver can also help with hands-on personal care items such as personal hygiene, bathing, grooming, and feeding. Personal Assistants can include other independent direct care givers such as RNs, LPNs, and Home Health Aides. PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY ALSO KNOWN AS REHABILITATION SERVICES Services designed to improve and or restore a person s functioning; includes physical therapy, occupational therapy, and/or speech therapy. PREVOCATIONAL SERVICES This service is for members with brain injuries and provides work experiences and training designed to assist individuals in developing skills needed for employment in the general workforce. Services include teaching concepts such as compliance, attendance, task completion, problem-solving and safety. RESPITE This service provides relief for unpaid family or primary caregivers who are meeting all the needs of the member. The respite caregiver assists the member with all daily needs when the family or primary caregiver is absent. Respite can be provided by a homemaker, personal assistant, nurse or in adult day health center. SUPPORTED EMPLOYMENT Supported employment includes activities needed to maintain paid work by individuals receiving waiver services, including supervision and training.

40 SUPPORTIVE LIVING PROGRAM ALSO KNOWN AS SUPPORTIVE LIVING FACILITY OR SERVICE An assisted living residence is a housing option that provides members with many support services to meet the member s needs to help keep the member as independent as possible. Examples of support services to meet those needs include: housekeeping, personal care, medication oversight, shopping, meals and social programs. Supportive Living does not offer complex medical services or supports. FREEDOM OF CHOICE You have the choice of nursing facility placement or home and community based services. You also have the right to choose not to receive services. You may choose which provider/agency you want to provide your Long Term Services and Supports. A list of agencies approved by the Division of Rehabilitative Services, Healthcare and Family Services, and the Department on Aging to provide services in your service area will be reviewed with you by your IlliniCare Health Case Manager. Your IlliniCare Health Case Manager will work with you to participate in your service plan development and in choosing types of services and providers to meet your needs. You will receive a copy of each service plan and any subsequent changes to the plan. The services that you receive are for needs addressed on your service plan and not for the needs of other individuals in your home. PERSONAL ASSISTANT SERVICE Depending on your Waiver, you may be able to select the Personal Assistant (PA) service. If you choose to use the Personal Assistant service you are allowed to request a criminal background check on potential employees. Home Services Program will cover the cost of the background check and it will not affect your services. You are responsible for hiring, managing and if necessary, firing your Personal Assistant. You will receive a Member (customer) packet and a PA (employee) packet. You should keep copies of paperwork in your Member packet folder. If you employ a PA, it is your responsibility to ensure the following: You need to complete and submit all necessary documentation to the local HSP offce prior to the start of employment of the PA. This includes information in both the Member and PA packets. You need to select a PA that has the physical capability to perform the tasks under your direction, and the PA will not have a medical condition which will be aggravated by the job requirements. You need to provide a copy of and review your IlliniCare Health Service Plan with your PA so they understand your needs and hours approved. You will review the Time Sheet with your PA for accuracy of all information before the Personal Assistant turns it in, and only approve hours actually worked by the PA for payment. Time Sheets will not be pre-signed or submitted prior to the last day worked in a billing period. Complete the PA s Last Day of Employment form (in your packet) and send to the HSP offce when any PA s employment ends. Notify the HSP offce within 24 hours of any incident resulting in injury to the PA at work. Complete the Report of Injury to a Provider form (in your packet) and mail or fax it to the HSP offce within 24 hours after you reported it. If you need a Personal Assistant at your place of employment or to go on vacation, you must first contact your IlliniCare Health Case Manager to request and obtain approval for paid services. 40

41 As a member of IlliniCare Health Long Term Services and Supports program you have the following rights and responsibilities. Your Rights NON-DISCRIMINATION You may not be discriminated against because of race, color, nation origin, religion, sex, ancestry, marital status, physical or mental disability, unfavorable military discharge, or age. If you feel you have been discriminated against, you have the right to file a complaint with IlliniCare Health by calling, faxing or sending us a letter: Phone: (toll-free) / (TDD/TTY) Fax: Mail: IlliniCare Health Attn: Grievance and Appeals Dept. 999 Oakmont Plaza Drive Suite 400 Westmont, IL If you are unable to call, you may have someone call for you. If you are unable to write a letter yourself, you may have someone write it for you. CONFIDENTIALITY All information about you and your case is confidential, and may be used only for purposes directly related to treatment, payment, and operation of the program including: Establishing your initial and continuing eligibility Establishing the extent of your assets, your income, and the determination of your service needs Finding and making needed services and resources available to you Assuring your health and safety TRANSFER TO OTHER PROVIDER/AGENCY You may request to transfer from one provider to another. If you want to transfer, you should contact your IlliniCare Health Case Manager to help arrange the transfer. TEMPORARY CHANGE IN RESIDENCE If you will be temporarily residing in another location in Illinois and want to continue to receive services, contact your IlliniCare Health Case Manager. Your Case Manager will assist you by arranging service transfer to your temporary location. SERVICE PLAN (DOES NOT APPLY TO SLP) Your Service Plan establishes the type of service, the number of hours of service, how often the service will be provided, and the dates the services are approved. Your Provider cannot change your Service Plan. If you need a change in services you need to call your IlliniCare Health Case Manager to review your needs and make changes to your Service Plan. If you want more services than your Service Plan allows, you may request your provider to provide more services than are listed on your Service Plan, but you may be required to pay 100% of the cost of those additional services. QUALITY OF SERVICE If you do not believe your provider/caregiver is following your Service Plan, of if your caregiver does not come to your home as scheduled, or if your caregiver is always late, you should call the caregiver agency and talk to your caregiver s supervisor. If the problem is not resolved you should call your IlliniCare Health Case Manager. If the problem is still not resolved you should call IlliniCare Health at [Insert Plan Number] to file a grievance. No information about you can be used for any other purpose, unless you have signed a Release of Information form. 41

42 Your Responsibilities NON-DISCRIMINATION OF CAREGIVERS You must not discriminate against your caregivers because of race, color, national origin, religion, sex, ancestry, marital status, physical or mental disability, unfavorable military discharge or age. To do so is a Federal offense. REPORTING CHANGES When you become enrolled in the Long Term Services and Supports program, you must report changes to your information including: Changes to your services or service needs IlliniCare Health Case Manager Change of address or phone number (even if temporary) IlliniCare Health Case Manager Enrollment Agency FINANCIAL BENEFITS Your Long Term Services and Supports program is paid by Medicaid, a Federal and State funded program monitored by Illinois Department of Healthcare and Family Services (HFS). Federal law allows HFS to recover the Medicaid assistance paid out for Long Term Services and Supports through what is known as Medicaid Estate Recovery. In order to recover the Medicaid assistance paid out for your LTSS services, HFS can file a claim against your estate, which includes real and personal property. If you are married, HFS cannot seek to recover its claim against your estate until after your spouse is deceased. Your spouse will be allowed to keep your home and other real and personal property until his/her death. HFS can seek to recover money from your estate equal to the amount of Medicaid assistance paid out for your LTSS services. For further information ask your IlliniCare Health Case Manager. HOSPITAL OR NURSING HOME ADMISSION If you are entering a hospital, nursing home, or other facility for any reason, you or your authorized representative should inform your IlliniCare Health Case Manager before or as soon as possible after you have entered such a facility. Your services cannot be provided while you are in these facilities, but can be provided as soon as you return home. Inform your IlliniCare Health Case Manager when you will be discharged home, so we can check on your service needs. If you are admitted in a hospital or facility for more than 60 calendar days, the enrollment in your home and community waiver may be terminated. (For Supportive Living Program, discharge from the waiver is automatic on the day of admission to a nursing home). If you are interested in returning home and need services, contact your IlliniCare Health Case Manager to assist you in reestablishing your in-home services and requesting reapplication to the home and community waiver. ABSENT FROM HOME LTSS Services cannot be provided if you are not at home. If you are away from your home for any reason for over 60 calendar days, your case will be referred to your Enrollment Agency for possible termination from the waiver program. You must inform your caregiver/provider if you plan to be absent from your home when your scheduled services are to be provided, such as for a doctor s appointment, a general outing, or a short vacation. Notify your caregiver/provider when you will not be home and when you plan to return so they can resume services upon your return. During your absence, give your IlliniCare Health Case Manager your temporary phone number and address, in case you need to be reached. You must Cooperate in the Delivery of Services To assist your caregivers you must: Notify your caregiver/provider at least 1 day in advance if you will be away from home on the day you are to receive service. 42

43 Allow the authorized caregiver into your home. Allow the caregiver to provide the services authorized on your Service Plan you approved. Do not require the caregiver to do more or less than what is on your Service Plan. If you want to change your Service Plan call your IlliniCare Health Case Manager. Your caregiver cannot change your Service Plan, except for SLP. You and others in your home must not harm or threaten to harm the caregiver or display any weapons. Not cooperating as noted above may result in the suspension or termination of your LTSS services. Your IlliniCare Health Case Manager will work with you and the caregiver to develop a Care Management agreement to restart your services. REPORTING ABUSE, NEGLECT, EXPLOITATION, OR UNUSUAL INCIDENTS The Health Care Worker Background Check Act applies to all unlicensed individuals employed or retained by a health care employer as home health care aides, nurse aides, personal care assistants, private duty nurse aides, day training personnel, or an individual working in any similar health-related occupation where he or she provides direct care. You can contact the Department of Public Health online or by phone at to verify status prior to employment, or the Department of Financial and Professional Regulation for information on any Licensed Practical Nurse (LPN) or Registered Nurse (RN) (nurses) that you want to employ to see if they have allegations of abuse, neglect or theft. If you are the victim of abuse, neglect or exploitation, you should report this to your IlliniCare Health Case Manager right away. You should also report the issue to one of the following agencies based on your age or placement. All reports to these agencies are kept confidential and anonymous reports are accepted. Nursing Home Hotline Illinois Department of Public Health Nursing Home Hotline is for reporting complaints 43 regarding hospitals, nursing facilities, and home health agencies and the care or lack of care of the patients. Supportive Living Program Complaint Hotline Adult Protective Services (TTY ) The Illinois Department on Aging Adult Protective Services Hotline is to report allegations of abuse, neglect, or exploitation for all adults 18 years old and over. Your IlliniCare Health Case Manager will provide you with 2 brochures on reporting Abuse, Neglect and Exploitation. You can request new copies of these brochures at any time. Illinois law defines abuse, neglect, and exploitation as: Physical abuse Inflicting physical pain or injury upon a senior or person with disabilities. Sexual abuse Touching, fondling, intercourse, or any other sexual activity with a senior or person with disabilities, when the person is unable to understand, unwilling to consent, threatened or physically forced. Emotional abuse Verbal assaults, threats of abuse, harassment, or intimidation. Confinement Restraining or isolating the person, other than for medical reasons. Passive neglect The caregiver s failure to provide a senior or person with disabilities with life s necessities, including, but not limited to, food, clothing, shelter or medical care. Willful deprivation Willfully denying a senior or person with disabilities medication, medical care, shelter, food, a therapeutic device or other physical assistance, and thereby exposing that adult to the risk of physical, mental, or emotional harm except when the person has expressed intent to forego such care. Financial exploitation The misuse or withholding of a senior or person with disabilities resources to the disadvantage of the person or the profit or advantage of someone else.

44 GRIEVANCES AND APPEALS For information on Grievances and Appeals, please look at that section of your Member Handbook. Services Not Covered Some services are not covered by the State Medicaid program provided through IlliniCare Health. These include, but are not limited to: Elective cosmetic surgery Treatment of infertility Services which are experimental in nature Services which are not medically necessary Elective abortions Certain dental services. Some examples include but are not limited to: implants, partial dentures (partial dentures are used when some natural teeth are remaining), etc. Certain transportation services. Some examples include travel to the grocery store or pharmacy. Chiropractic visits If you are unsure if a certain service is covered, please contact us at (toll-free) / (TDD/TTY). We will be able to tell you if the service is covered or not. 44

45 PROGRAM INFO 45

46 Program Information This section of the handbook tells you about the programs that IlliniCare Health offers to its members. These programs are to help you be healthy. They also help you take an active role in your healthcare. This section also discusses information about fraud and abuse and your rights and responsibilities. Care Coordination Services IlliniCare Health has several programs to improve the health of our members. We do this through education and personal help from IlliniCare Health staff. This is referred to as care coordination. The goal of this service is to add to the quality of your care and give you the support to help you improve your health. Your care coordinator will help you work toward better health through: Frequent contact with you or your caregiver and health providers An assessment and evaluation of your conditions Care planning and setting short and long-term goals Coordination of services to provide necessary and effcient care A CARE COORDINATOR is a resource person that: Answers questions about treatment Helps you meet your health needs by using their knowledge of the healthcare system Helps you consider your options and choices Helps with referrals for treatment at healthcare facilities Acts as your link to IlliniCare Health Identifies covered benefits and helps with referrals to specialists Helps plan your transition out of the hospital Helps connect you with community resources CONFIDENTIALITY: The information obtained through our care coordination process is confidential. It is shared only when needed to help plan your care and to properly pay your claims. ETHICS: IlliniCare Health provides care coordination services in an ethical manner based on Commission for Case Management (CCMC) and Case Management Society of America s (CMSA) Statement on Ethics and Standards of Practice. Information on our policies and standards for ethics for case management is available. Just check our website or ask Member Services. HEALTH PROBLEMS: If you have or are at risk for having one of the health conditions listed below, please call IlliniCare Health so we can enroll you in our care coordination program. There is no cost to you. DIABETES PROGRAM: We offer information, resources, and care management to help members take control over the condition. HEART DISEASE: We offer care management and information to address heart-related issues. ASTHMA PROGRAM: We provide care management services for asthma. We will help you develop a healthcare plan to help keep you healthy. Please contact us if you have asthma. SPECIAL HEALTHCARE NEEDS: IlliniCare Health has nurses who are trained to help our members with many other complex and/or special needs. Please call us if you would like help with your serious illness or condition. 46

47 MemberConnections MemberConnections is a program that includes a team of IlliniCare Health staff who can help you with your health coverage. This outreach program offers help to find your way through large healthcare systems and groups. The program also helps you to get the preventive care you need and refers you to resources. MemberConnections will: Help you select a doctor or PCP, if requested Assist you to schedule an appointment with your PCP Explain your health benefits and how to get care quickly Find support in your neighborhood, like food, shelter, and health programs Visit you at your home or long-term-care facility Hosts member events in your community so we can meet members face-to-face Connections Plus Connections Plus is part of the program that provides free cell phones to certain members in care coordination who do not have telephones. This program allows our members to contact physicians, case managers, and 911. To learn more about the program, please contact Member Services (toll-free) / (TDD/TTY). Or visit 47 CentAccount Program IlliniCare Health has a program to reward you for healthy behaviors. You will receive a CentAccount card with reward dollars preloaded when you complete a healthy behavior. The behaviors are listed below. New rewards will be added to your CentAccount card once you complete each additional healthy behavior. Information on the CentAccount program can be found on our website at Or call Member Services at (tollfree) / (TDD/TTY). You can earn reward dollars when each of the following occurs: $10 when you complete the Health Risk Screening (paper, online, via the phone) $20 when go to your annual PCP visit Up to $45 when you complete prenatal visits (visits while you are pregnant) $20 when you complete one postpartum visit (visit after you have the baby) $15 when you complete an annual colorectal cancer screening $15 when you complete an annual cervical cancer screening $25 when you complete an annual breast cancer screening $50 when you complete the annual Comprehensive Diabetes Management Cholesterol screening Nephropathy screening : a nephropathy screening tests you for kidney disease A1c screening: an A1c screening is a blood test that checks your blood sugar levels Eye exam $10 when you complete statin therapy. Statin therapy is diabetic medication prescribed by your doctor. $10 when you complete ACE/ARB therapy. ACE/ARB therapy is diabetic medication prescribed by your doctor.

48 USING THE CENTACCOUNT CARD The CentAccount card can be used at many stores and pharmacies such as CVS, Walgreen s, Target, Walmart, Kmart, etc. The funds on your CentAccount card can be used for many health and wellness-related items. Below are some examples of items you can purchase. For a full list of items, please visit our website at Contact lens solution Contraceptives (un-medicated condoms) Denture adhesives, repair, and cleaners (PoliGrip, Benzodent, Plate Weld, Efferdent) Diabetes testing and aids (Ascencia, One Touch, insulin syringes, glucose products) Diagnostic products (thermometers, blood pressure monitors, cholesterol tests) Ear care (Un-medicated ear drops, syringes, and ear wax removal) Elastics/athletic treatments (ACE, Futuro, elastic bandages, braces, hot/cold therapy, orthopedic supports and rib belts, etc.) Eye care (contact lens care) Family planning (pregnancy kits, ovulation kits) First aid dressings and supplies (Band Aid, 3M Nexcare, J&J First Aid, non-sport tapes) Foot care treatment (Un-medicated corn and callus treatments, devices, therapeutic insoles) Hearing aid/medical batteries Home health care (ostomy, walking aids, decubitis/pressure relief, enteral/ parenteral feeding supplies, patient lifting aids, orthopedic braces/supports, splints and casts, hydrocollators, nebulizers, electrotherapy products, catheters, unmedicated wound care, wheel chairs) Incontinence Protection and Treatment Products (Attends, Depends, GoodNites for juvenile incontinence, Prevail) Reading glasses and maintenance accessories Purchase additional cell phone minutes for your SafeLink phone at a discounted rate. For more information about SafeLink, go to page 45. Only the items on the complete list found on our website can be purchased. FREQUENTLY ASKED QUESTIONS ABOUT CENTACCOUNT Below are some common questions about CentAccount. If you have any questions or problems regarding your CentAccount card, call Member Services at (toll-free) / (TDD/TTY). What is CentAccount? CentAccount is a program that rewards members by completing easy, simple behaviors. This includes seeing your doctor once a year, or filling out a Health Risk Screening. Once you do these things, you will receive a CentAccount card in the mail. This is a pre-loaded debit card that will allow you to purchase health-related items. It is accepted at participating pharmacy locations such as Walgreen s, CVS and Target. Where can I use the CentAccount card? You can use your CentAccount card at participating pharmacy locations. This includes Walgreen s, CVS, Target, Wal-mart and many other stores. Be sure that you are using your card to purchase a health-related item. Only these types of items can be purchased with a CentAccount card. Do I need to call IlliniCare to activate the card? When you receive the card in the mail, it is already active and ready to use. Is there a pin number? You do not need a pin number when using the CentAccount card. Can I use this card to get cash from an ATM or store? No. CentAccount can only be used to purchase health-related items like hearing aid batteries, denture supplies, diabetes supplies and more. You cannot use the CentAccount card to get cash out of an ATM or at a store. 48

49 If I earn additional rewards, do I get sent another card? Any additional reward dollars you earn will be added to your same CentAccount card. How long after I complete a healthy behavior will I receive my CentAccount card? Once you complete the Health Risk Screening, you will receive your CentAccount card in about six weeks. For rewards you receive for your annual doctor s visit, these will be given to you after your provider has submitted a claim to us. This is the same for women, who receive rewards by going to necessary doctor s appointments while pregnant. If I don t use all the money on the card, do I get the remainder back in cash? Any additional money you do not use will remain on your CentAccount card. The next time you need something, you can use the remaining balance. If my card is lost, what should I do? Call Member Services at (tollfree) / (TDD/TTY), We can send you a replacement CentAccount card. Once you request a replacement card, your old card will be deactivated. How can I check my CentAccount balance? You can call to check the balance of your card. Please have your 16 digit account number available when you call. You can also check your balance online, using our Secure Member Portal. More information about the member portal can be found on page 48. When I went to use my CentAccount card, I was rejected. What s the problem? If you try to buy something that cost more than you have on your card, it will be rejected. For the purchase to go through, you need to tell the cashier how much is on the card before they swipe your card. This will let them take off the balance of your card. You will then need to pay the rest with another form of payment. If I m no longer an IlliniCare member, can I still use the rewards I earned on my CentAccount card? If you are no longer an IlliniCare Health member, your CentAccount card will be deactivated. This means you can no longer use the money on that card. If you lose coverage, but return to IlliniCare within six months, call Member Services at (toll-free) / (TDD/TTY). We will issue you a new CentAccount card with any rewards you earned before you lost coverage. SafeLink IlliniCare Health has partnered with SafeLink Wireless in order to better connect with our members. SafeLink is a federally-funded program. It provides free cell phones to people that qualify. SafeLink provides: A free cell phone 250 minutes or texts per month The ability to make and receive calls to/from your doctors, nurses, 911, family, and friends 411 directory assistance at no additional cost Voic Communication access 24 hours a day IlliniCare Health members get all the same benefits of a SafeLink phone, plus more! There is no added cost for these extras! Unlimited inbound text messages Unlimited calling to IlliniCare Health Member Services. These will not count toward your 250 minutes. The ability to take part in IlliniCare Health cell phone health programs 49

50 HOW TO ENROLL IN THE ILLINICARE HEALTH SAFELINK PROGRAM There are four ways you can enroll in the IlliniCare Health SafeLink program. 1. If you already have a SafeLink phone, call so you can begin receiving IlliniCare Health SafeLink benefits. 2. Visit to apply online. 3. Call IlliniCare Health at (tollfree) / (TDD/TTY) to request an application. 4. Call SafeLink at to apply over the phone. FAQs Below are some common questions about the SafeLink program. WHAT HAPPENS IF I RUN OUT OF MINUTES? Your phone will not be able to place outgoing calls or receive incoming calls. However, you will still be able to dial 911, 411 for directory assistance, and call IlliniCare Health Member Services. If you run out of minutes, you can purchase more at a discounted rate. You can purchase more minutes by calling SafeLink at Minutes cost $0.10 per minute. WILL I RECEIVE A BILL IF I GO OVER THE AMOUNT OF MINUTES I HAVE? You will never receive a bill for your SafeLink phone. Your phone will not be able to place outbound calls or receive incoming calls once you run out of minutes. IS THERE A CHARGE FOR SENDING TEXT MESSAGES? There is not an additional charge for sending text messages. One text message is equal to using one minute on your cell phone. So for example, if you send 10 text messages in a month, that counts as 10 used minutes. HOW CAN I PURCHASE ADDITIONAL MINUTES? You can purchase more minutes by calling SafeLink. They can be reached at Extra minutes cost $0.10 per minute. I SENT IN MY APPLICATION FOR A SAFELINK PHONE. HOW CAN I CHECK ON THE STATUS OF MY APPLICATION? You can verify the status of your eligibility and enrollment by contacting SafeLink Customer Care at WHAT HAPPENS TO MY SAFELINK PHONE IF I M NO LONGER A ILLINICARE HEALTH MEMBER? If you are no longer a IlliniCare Health member, you can continue to use your SafeLink phone. However, you will not receive the added benefits of being a IlliniCare Health member. These include unlimited calls to Member Services, unlimited inbound text messages, and receiving health information from IlliniCare Health s cell phone program. HOW CAN I CHECK ON THE NUMBER OF MINUTES I HAVE? You can check on the number of minutes you have by calling SafeLink at or by simply viewing the screen on your SafeLink phone. 50

51 Access to Care IlliniCare Health works to provide you with timely access to healthcare. We have worked with our providers to follow set quality standards. These standards set a reasonable amount of time we expect our providers to see you within. SCHEDULING/APPOINTMENT WAITING TIMES Network providers will be open at reasonable times. You will get an appointment based on your medical needs. You should be given an appointment within the following time frames: PCP APPOINTMENTS Appointment Type: Routine visit Non-urgent visit Urgent-care visit Emergency visit Initial visit pregnant women After-hours coverage Offce wait times Access Standard: Within five weeks Within three calendar days Within 24 hours Immediately, 24 hours a day, 7 days a week and without prior authorization 1st Trimester 2 weeks 2nd Trimester 1 week 3rd Trimester 3 days 24 hours per day, 7 days per week Within one hour of scheduled appointment PCP AFTER HOURS Our PCPs have 24-hour answering services. Or they have a telephone recording. This recording will instruct you on how to receive care after regular offce hours. If you have a medical problem or question and cannot reach your PCP during normal offce hours, you can call NurseWise IlliniCare Health s 24-hour, medical nurse line at (toll-free) / (TDD/TTY) to speak to a nurse. If you have an emergency, call 911 or go to the nearest emergency department (ED). NOTE: All services other than well visits, preventive services, immunizations, emergency services, urgent care services, minor consent services (sexual assault care, pregnancy care, family planning, sexually transmitted disease services), HIV testing, and abortion must be obtained through IlliniCare Health network providers or pre-approved for out of network providers. IMPORTANT: If you cannot keep an appointment, please call the doctor s offce to cancel at least 24 hours in advance. If you need to change an appointment, call the doctor s offce as soon as possible. They can make a new appointment for you. If you need help getting an appointment, call Member Services at (toll-free) / (TDD/TTY). 51

52 IlliniCare Health Website IlliniCare Health s website helps you get the answers. Our website has resources and features that make it easy for you to get quality care. IlliniCare Health s website can be found at It also gives you information on your IlliniCare Health benefits and services such as: Member handbook (evidence of coverage/ contract) Provider directory Current news and events Member self-service features Online form submission IlliniCare Health programs and services Patient health education resource at: Access to more than 5,000 topics related to health and medication IlliniCare Health s Secure Member Portal IlliniCare Health has a secure member portal where you can: Change your PCP Complete your health risk screening Print a temporary ID card Send/receive secure messages to/from IlliniCare Health through our secure messaging system In order to sign up for our secure member portal, go to At the top of the tool bar click Login. From here, you will be able to set up your portal account. All you need is your Member ID number, which is found on your IlliniCare Health member ID card. 52

53 Quality Healthcare Initiatives We want to assist you in getting quality healthcare. The quality improvement (QI) program works to ensure we are offering you the best quality of care. We do this to be sure that your safety and health needs are being met. Some of these programs include: Mailings to women over 21 a letter and brochure explains yearly Pap tests, chlamydia screenings, and mammograms. They talk about their importance and also remind members to have this done. Postcards/phone calls reminding members to receive and follow the needed care plans for various conditions: diabetes, asthma, and smoking cessation Member satisfaction surveys on the healthcare and services you have received Member access surveys on preventive dental care and routine dental visits Investigating quality of care grievances Safety in Your Home Whether you have a baby in the house, an elderly parent living with you, or a roommate who does not see well, you can make your home safer. Here are some helpful tips: Keep stairs clear and well-lit. Make sure there is a sturdy handrail. Put a rubber mat on the bathtub floor. Clean up spills right away so you won t slip on them. Put nightlights in your bedrooms and bathrooms. Install a smoke alarm and a carbon monoxide (CO) alarm in your home. Keep cleaning products in latched cabinets. We believe that having programs like these will help you. They inform you of services that can keep you healthy. Our quality department monitors these programs. We also welcome any suggestions for new programs. For more information on IlliniCare Health quality programs, please call us at (tollfree) / (TDD/TTY). 53

54 Fraud and Abuse Program Fraud means to knowingly get benefits or payments to which you are not entitled. Please let us know if you are aware of someone who is committing fraud under the Medicaid program. This could be a provider or a member. Some examples of fraud and abuse include: A lie on an application Using someone else s ID card A provider (doctor) billing for services that were not done Transportation (usage abuse) You can report any suspected areas of fraud or abuse to us by calling Member Services at (toll-free) / (TDD/ TTY). You can also use our Fraud and Abuse hotline at All information will be kept private. Eliminating fraud and abuse will provide more time and money for your healthcare needs. ABUSE AND NEGLECT IlliniCare Health knows that you rely on your doctor, caregiver, and loved ones to help with your healthcare needs. You trust that your doctor, caregiver, or loved one will take care of you. You believe they will always have your best interests in mind. Sometimes, when someone helps take care of you, they can take advantage of you. It is important to recognize the signs of neglect, abuse, and fraud. If this happens, it is important to report it. This allows you to be safe and get the care you need. WHAT IS NEGLECT? Neglect occurs when someone fails to provide or withholds the necessities of life to/from you. This includes food, clothing, shelter, or medical care. WHAT IS ABUSE? Abuse means causing any physical, sexual, or mental injury to you. This can also be taking advantage of your financial resources. 54 Physical abuse: is any inappropriate contact that causes bodily harm. For example, being slapped, scratched, or pushed. Being threatened with a weapon, such as a knife or a gun, is another example. Sexual abuse: is any sexual behavior or intimate physical contact that occurs without your permission. This can be touching your genital area, buttocks, or breasts. Mental abuse: is when you feel emotional distress resulting from the use of demeaning or threatening words. This can also include signs, gestures, and other actions. For example, controlling behavior, embarrassment, or social isolation are types of mental abuse. Financial abuse: is when someone uses your money without your consent. This includes improper use of guardianship or power of attorney. WHAT CAN I DO? If you believe that you are being taken advantage of or hurt by someone, report it. All information will be kept private. Stopping fraud and abuse will help protect you. It will also provide more time and money for your healthcare needs. There are many ways to report fraud and abuse: IlliniCare Health Member Services: (toll-free) / (TDD/ TTY) IlliniCare Health Fraud and Abuse hotline: DHS Offce of the Inspector General: IL Department on Aging: ; (TTY) Senior HelpLine: or (TTY) IL Department of Public Health:

55 Member Rights IlliniCare Health members have the rights listed below. You are free to apply your rights without any action taken against you. You have the right to receive the information provided in the Member Handbook in another language. You can also get it in another format such as audio CDs or Braille. You have the right to receive healthcare services as provided for in federal and state law. All covered services must be available and accessible to you. When medically appropriate, services must be available 24 hours a day, seven days a week. You have the right to receive information about IlliniCare Health and its services, practitioners, and providers. To get this information, visit or call (tollfree) / (TDD/TTY). You have the right to ask for an interpreter and have one provided to you during any covered service. You have the right to receive information about IlliniCare Health Member Rights and Responsibilities policy. You also have the right to make recommendations regarding this policy. You have the right to receive information about treatment options. This includes the right to request a second opinion in a way suitable to your condition and ability to understand. You have the right to make decisions about your healthcare. This includes the right to refuse treatment. You have the right to be treated with respect and with care for your dignity and privacy. You have the right to complain to IlliniCare Health on the phone or in writing about any issue. You have the right to appeal a decision made by IlliniCare Health on the phone or in writing. You also have the right to an interpreter during any complaint or appeal process. You have the right to be free from any form of restraint or seclusion used as a means of: force control ease of reprisal retaliation You have the right to request and receive a copy of your medical records. You have the right to request an amended or corrected version of your medical records. Member Responsibilities You must choose a PCP under this plan. You have the responsibility to yourself to participate in your own healthcare. This includes making and keeping appointments. If you are not able to keep an appointment, you must inform your doctor as soon as possible. You must present your IlliniCare Health ID card and state of Illinois Medicaid card when getting care or prescriptions. You have the responsibility to tell your doctor what he needs to know to treat you. You have the responsibility to follow the treatment plan agreed upon by you and your doctor. It is your responsibility to keep your information up to date. Please tell your case worker about changes in income or address. If you have other insurance, you must tell both your provider and your case worker. You must also follow the guidelines of your other insurance. 55

56 Civil Rights IlliniCare Health provides covered services to all members regardless of the below: Age Race Religion Color Disability Sex Sexual orientation National origin Marital status Arrest record Conviction record Military involvement All medically necessary covered services are offered to all members. All services are provided in the same manner to all members. All persons or organizations connected with IlliniCare Health that refer or recommend members for services must do so in the same manner for all members. Translation or interpreting services are offered for those who need them. These services are free. Provider Qualifications and Doctor Incentives PROVIDER QUALIFICATIONS You have the right to information about our providers. This includes the provider s: education board certification recertification Call IlliniCare Health for information. DOCTOR INCENTIVES You have the right to ask if we have special financial arrangements with our physicians that can affect the use of referrals and other services you might need. To get this information, call us. Medical Decisions Decisions IlliniCare Health makes about the services you receive are based on the care you need. They are also based on your coverage. We do not reward providers for reducing care or services. We do not reward anyone for issuing denials of service. We do not provide incentives for our decision makers that result in under-use of services. Other Insurance If you have insurance other than your coverage through the state, you should first contact your county case worker. Provide them with the information. You should also contact Illinois Client Enrollment Services at or TTY: Finally, you should let your doctor s offce know because they will need to submit the claim to that carrier first. Moving If you move to a different county, you must let us know. Please call us at (tollfree) / (TDD/TTY). Also contact the Department of Human Services in your new county to update your eligibility. If you move out of our service area, call Illinois Client Enrollment Services at or TTY: We will only provide emergency care if you move out of our service area. Illinois Client Enrollment Services will evaluate your situation. They will make changes in your enrollment as needed. 56

57 Updating Your Address or Phone Number It is very important to tell IlliniCare Health, your county case worker, and Illinois Client Enrollment Services your new address and phone number. If we can t reach you, we can t help you. You can contact IlliniCare Health to update your address and phone number. We can be reached at (toll-free) / (TDD/ TTY) and Illinois Client Enrollment Services can be reached at (TDD/TTY). Out of State Care Follow these rules if you need medical care but are too far away from home to go to your assigned PCP. For emergencies, go to the nearest hospital, clinic, or doctor. For urgent or routine care away from home, you must get approval from IlliniCare Health to go to a different provider. Call Member Services at (toll-free) / (TDD/ TTY) to get this approval. Out of Plan Care Information for all members: it is very important to follow the rules when you get medical care. This is so you are not billed for services. You must receive your care from in-plan providers and hospitals. You must have our approval if you do not go to one that is in-plan. The only exception is for treatment of emergency medical conditions. If you travel outside of Illinois and need emergency services, healthcare providers can treat you. They will send claims to us. You will be responsible for payment of any service you get outside Illinois if the provider will not send claims to us or will not accept our payment. Emergency services are covered only if these services are provided in the United States. Emergency services provided outside of the United States are not covered. Advance Directives Living Will or Power of Attorney for Healthcare You have a right to make decisions about your medical care. You have a right to accept or refuse medical or surgical treatment. You also have the right to plan and direct the types of healthcare you may receive in the future if you become unable to state your wishes. You can let your doctor know about your feelings by filling out a living will. You can also fill out a power of attorney for healthcare form. Contact your doctor for more information. Member Satisfaction Surveys Your satisfaction with IlliniCare Health is very important to us. You may receive a survey in the mail or by telephone asking questions about how happy or unhappy you are with the services you are getting. Please take the time to respond. We value your opinion. It will help IlliniCare Health to improve the service we provide. Thank you. 57

58 Enrollee Advisory Committee IlliniCare Health invites our members to meet face-to-face to share their opinions with us. During this meeting, members look at our materials and website and tell us what they think about our program. IlliniCare Health uses this information to make program changes based on members needs. If you want to be a part of our Enrollee Advisory Committee, call us at (toll-free) / (TDD/TTY). Or send us a note at Denial of Services A written notice will be sent to you if there is a denial, change in recommended treatment plan, and/or limitation on visits or benefits. We will not delay your care. We will not put your health at risk waiting for these decisions. All decisions are made as quickly as your health condition requires. Grievances/ Appeals We want you to be happy with services you get from IlliniCare Health and our providers. If you are not happy, you can file a grievance or appeal. GRIEVANCES A grievance is a complaint about any matter other than a denied, reduced or terminated service or item. IlliniCare Health takes member grievances very seriously. We want to know what is wrong so we can make our services better. If you have a grievance about a provider or about the quality of care or services you have received, you should let us know right away. IlliniCare Health has special procedures in place to help members who file 58 grievances. We will do our best to answer your questions or help to resolve your concern. Filing a grievance will not affect your health care services or your benefits coverage. These are examples of when you might want to file a grievance. Your provider or an IlliniCare Health staff member did not respect your rights. You had trouble getting an appointment with your provider in an appropriate amount of time. You were unhappy with the quality of care or treatment you received. Your provider or an IlliniCare Health staff member was rude to you. Your provider or an IlliniCare Health staff member was insensitive to your cultural needs or other special needs you may have. You can file your grievance on the phone by calling Member Services at or 711 TDD/TTY. You can also file your grievance in writing via mail or fax at: IlliniCare Health Attn: Grievance and Appeals Dept. 999 Oakmont Plaza Drive Suite 400 Westmont, IL Fax: In the grievance letter, give us as much information as you can. For example, include the date and place the incident happened, the names of the people involved and details about what happened. Be sure to include your name and your member ID number. You can ask us to help you file your grievance by calling Member Services at (toll-free) / (TDD/TTY). If you do not speak English, we can provide an interpreter at no cost to you. Please include this request when you file your grievance. If you are hearing impaired, call (TDD/TTY). At any time during the grievance process, you can have someone you know represent you or

59 act on your behalf. This person will be your representative. If you decide to have someone represent you or act for you, inform IlliniCare Health in writing the name of your representative and his or her contact information. We will try to resolve your grievance right away. If we cannot, we may contact you for more information. APPEALS You may not agree with a decision or an action made by IlliniCare Health about your services or an item you requested. An appeal is a way for you to ask for a review of our actions. You may appeal within sixty (60) calendar days of the date on our Notice of Action form. If you want your services to stay the same while you appeal, you must say so when you appeal, and you must file your appeal no later than ten (10) calendar days from the date on our Notice of Action form. The list below includes examples of when you might want to file an appeal. Not approving or paying for a service or item your provider asks for Stopping a service that was approved before Not giving you the service or items in a timely manner Not advising you of your right to freedom of choice of providers Not approving a service for you because it was not in our network If we decide that a requested service or item cannot be approved, or if a service is reduced or stopped, you will get a Notice of Action letter from us. This letter will tell you the following: What action was taken and the reason for it Your right to file an appeal and how to do it Your right to ask for a State Fair Hearing and how to do it Your right in some circumstances to ask for an expedited appeal and how to do it Your right to ask to have benefits continue during your appeal, how to do it and when you may have to pay for the services Here are two ways to file an appeal. 1) Call Member Services at (tollfree) / (TDD/TTY). If you file an appeal over the phone, you must follow it with a written signed appeal request. 2) Mail or fax your written appeal request to: IlliniCare Health Attn: Grievance and Appeals Dept. 999 Oakmont Plaza Drive Suite 400 Westmont, IL Fax: If you do not speak English, we can provide an interpreter at no cost to you. Please include this request when you file your appeal. If you are hearing impaired, call (TDD/TTY). Can someone help you with the appeal process? You have several options for assistance. You may: Ask someone you know to assist in representing you. This could be your Primary Care Physician or a family member, for example. Choose to be represented by a legal professional. If you are in the Disabilities Waiver, Traumatic Brain Injury Waiver, or HIV/AIDS Waiver, you may also contact CAP (Client Assistance Program) to request their assistance at (Voice) or (TTY). To appoint someone to represent you, either: 1) send us a letter informing us that you want someone else to represent you and include in the letter his or her contact information or, 2) fill out the Authorized Representative Appeals form. You may find this form on our website at: APPEAL PROCESS We will send you an acknowledgment letter within three (3) business days saying we received your appeal. We will tell you if we need more 59

60 information and how to give us such information in person or in writing. A provider with the same or similar specialty as your treating provider will review your appeal. It will not be the same provider who made the original decision to deny, reduce or stop the medical service. IlliniCare Health will send our decision in writing to you within fifteen (15) business days of the date we received your appeal request. IlliniCare Health may request an extension up to fourteen (14) more calendar days to make a decision on your case if we need to get more information before we make a decision. You can also ask us for an extension, if you need more time to obtain additional documents to support your appeal. We will call you to tell you our decision and send you and your authorized representative the Decision Notice. The Decision Notice will tell you what we will do and why. If IlliniCare Health s decision agrees with the Notice of Action, you may have to pay for the cost of the services you got during the appeal review. If IlliniCare Health s decision does not agree with the Notice of Action, we will approve the services to start right away. Things to keep in mind during the appeal process: At any time, you can provide us with more information about your appeal, if needed. You have the option to see your appeal file. You have the option to be there when IlliniCare Health reviews your appeal. How can you expedite your Appeal? If you or your provider believes our standard timeframe of fifteen (15) business days to make a decision on your appeal will seriously jeopardize your life or health, you can ask for an expedited appeal by writing or calling us. If you write to us, please include your name, member ID number, the date of your Notice of Action letter, information about your case and why you are asking for the expedited appeal. We will let 60 you know within twenty-four (24) hours if we need more information. Once all information is provided, we will call you within twenty-four (24) hours to inform you of our decision and will also send you and your authorized representative the Decision Notice. How can you withdraw an Appeal? You have the right to withdraw your appeal for any reason, at any time, during the appeal process. However, you or your authorized representative must do so in writing, using the same address as used for filing your appeal. Withdrawing your appeal will end the appeal process and no decision will be made by us on your appeal request. IlliniCare Health will acknowledge the withdrawal of your appeal by sending a notice to you or your authorized representative. If you need further information about withdrawing your appeal, call IlliniCare Health at (toll-free) / (TDD/TTY). What happens next? After you receive the IlliniCare Health appeal Decision Notice in writing, you do not have to take any action and your appeal file will be closed. However, if you disagree with the decision made on your appeal, you can take action by asking for a State Fair Hearing Appeal and/or asking for an External Review of your appeal within thirty (30) calendar days of the date on the Decision Notice. You can choose to ask for both a State Fair Hearing Appeal and an External Review or you may choose to ask for only one of them. STATE FAIR HEARING If you choose, you may ask for a State Fair Hearing Appeal within thirty (30) calendar days of the date on the Decision Notice, but you must ask for a State Fair Hearing Appeal within ten (10) calendar days of the date on the Decision Notice if you want to continue your services. If you do not win this appeal, you may be responsible for paying for these services provided to you during the appeal process. At the State Fair Hearing, just like during the IlliniCare Health Appeals process, you may ask someone to represent you, such as a lawyer or

61 have a relative or friend speak for you. To appoint someone to represent you, send us a letter informing us that you want someone else to represent you and include in the letter his or her contact information. You can ask for a State Fair Hearing in one of the following ways: Your local Family Community Resource Center can give you an appeal form to request a State Fair Hearing and will help you fill it out, if you wish. If you want to file a State Fair Hearing Appeal related to your medical services or items, or Elderly Waiver (Community Care Program (CCP)) services, send your request in writing to: Illinois Department of Healthcare and Family Services Bureau of Administrative Hearings 69 W. Washington Street, 4th Floor Chicago, IL Fax: [email protected] Or you may call , TTY: If you want to file a State Fair Hearing Appeal related to mental health services or items, substance abuse services, Persons with Disabilities Waiver services, Traumatic Brain Injury Waiver services, HIV/AIDS Waiver services, or any Home Services Program (HSP) service, send your request in writing to: Illinois Department of Human Services Bureau of Hearings 69 W. Washington Street, 4th Floor Chicago, IL Fax: [email protected] Or you may call , TTY: STATE FAIR HEARING PROCESS The hearing will be conducted by an Impartial Hearing Offcer authorized to conduct State Fair Hearings. You will receive a letter from the appropriate Hearings offce informing you of the date, time and place of the hearing. This letter will also provide information about the hearing. It is important that you read this letter carefully. At least three (3) business days before the hearing, you will receive information from IlliniCare Health. This will include all evidence we will present at the hearing. This will also be sent to the Impartial Hearing Offcer. You must provide all the evidence you will present at the hearing to IlliniCare Health and the Impartial Hearing Offcer at least three (3) business days before the hearing. This includes a list of any witnesses who will appear on your behalf, as well as all documents you will use to support your appeal. You will need to notify the appropriate Hearings Offce of any accommodation you may need. Your hearing may be conducted over the phone. Please be sure to provide the best phone number to reach you during business hours in your request for a State Fair Hearing. The hearing may be recorded. CONTINUANCE OR POSTPONEMENT You may request a continuance during the hearing, or a postponement prior to the hearing, which may be granted if good cause exists. If the Impartial Hearing Offcer agrees, you and all parties to the appeal will be notified in writing of a new date, time and place. The time limit for the appeal process to be completed will be extended by the length of the continuation or postponement. FAILURE TO APPEAR AT THE HEARING Your appeal will be dismissed if you, or your authorized representative, do not appear at the hearing at the time, date and place on the notice and you have not requested postponement in writing. If your hearing is conducted via telephone, your appeal will be dismissed if you do not answer your telephone at the scheduled appeal time. A Dismissal Notice will be sent to all parties to the appeal. Your hearing may be rescheduled, if you let us know within ten (10) calendar days from the date you received the Dismissal Notice, if the reason for your failure to appear was: 61

62 A death in the family Personal injury or illness which reasonably would prohibit your appearance A sudden and unexpected emergency If the appeal hearing is rescheduled, the Hearings Offce will send you or your authorized representative a letter rescheduling the hearing with copies to all parties to the appeal. If we deny your request to reset your hearing, you will receive a letter in the mail informing you of our denial. THE STATE FAIR HEARING DECISION A Final Administrative Decision will be sent to you and all interested parties in writing by the appropriate Hearings Offce. This Final Administrative Decision is reviewable only through the Circuit Courts of the State of Illinois. The time the Circuit Court will allow for filing of such review may be as short as thirty-five (35) days from the date of this letter. If you have questions, please call the Hearing Offce. External Review (for medical services only) Within thirty (30) calendar days after the date on the IlliniCare Health appeal Decision Notice, you may choose to ask for a review by someone outside of IlliniCare Health. This is called an external review. The outside reviewer must meet the following requirements: Board certified provider with the same or like specialty as your treating provider Currently practicing Have no financial interest in the decision Not know you and will not know your identity during the review External Review is not available for appeals related to services received through the Elderly Waiver; Persons with Disabilities Waiver; Traumatic Brain Injury Waiver; HIV/Aids Waiver; or the Home Services Program. Your letter must ask for an external review of that action and should be sent to: IlliniCare Health Attn: Grievance and Appeals Dept. 999 Oakmont Plaza Drive Suite 400 Westmont, IL Fax: What Happens Next? We will review your request to see if it meets the qualifications for external review. We have five (5) business days to do this. We will send you a letter letting you know if your request meets these requirements. If your request meets the requirements, the letter will have the name of the external reviewer. You have five (5) business days from the letter we send you to send any additional information about your request to the external reviewer. The external reviewer will send you and/or your representative and IlliniCare Health a letter with their decision within five (5) calendar days of receiving all the information they need to complete their review. EXPEDITED EXTERNAL REVIEW If the normal time frame for an external review could jeopardize your life or your health, you or your representative can ask for an expedited external review. You can do this over the phone or in writing. To ask for an expedited external review over the phone, call Member Services toll-free at or (TDD/TTY). To ask in writing, send us a letter at the address below. You can only ask one (1) time for an external review about a specific action. Your letter must ask for an external review of that action. IlliniCare Health Attn: Grievance and Appeals Dept. 999 Oakmont Plaza Drive Suite 400 Westmont, IL Fax: What happens next? Once we receive the phone call or letter 62

63 asking for an expedited external review, we will immediately review your request to see if it qualifies for an expedited external review. If it does, we will contact you or your representative to give you the name of the reviewer. We will also send the necessary information to the external reviewer so they can begin their review. As quickly as your health condition requires, but no more than two (2) business days after receiving all information needed, the external reviewer will make a decision about your request. They will let you and/or your representative and IlliniCare Health know what their decision is verbally. They will also follow up with a letter to you and/or your representative and IlliniCare Health with the decision within forty-eight (48) hours. Renew Your Health Benefits Do you know the date of your next renewal? Make sure you keep your benefits for you and your family. If you need help in renewing your coverage, we can help. Call us at (toll-free) / (TDD/TTY). If you miss your renewal date, you may lose your health plan coverage. Annual Open Enrollment Period Every year on your anniversary date, you will be given the option to change your health plan. This is called your open enrollment period. Illinois Client Enrollment Services will send you a notice before your anniversary date. Should you wish to change health plans, you will have 60 days from the date you receive the notice to do so. If you do nothing, your coverage will remain with IlliniCare Health. Below are some common questions about the open enrollment period: HOW DO I SWITCH PLANS? You can switch by contacting Illinois Client Enrollment Services at or TTY: You can also switch plans online at CAN I SWITCH HEALTH PLANS AFTER THE OPEN ENROLLMENT PERIOD? No. Enrollees are only able to switch health plans during the open enrollment period. You will receive a written notice from Illinois Client Enrollment Services before your anniversary date. You will have 60 days to switch plans. IF I DECIDE TO SWITCH, WHEN DO I START WITH THE NEW HEALTH PLAN? You will become active with your new health plan on your anniversary date. That is the day you first became active with your current health plan. To find out when your anniversary date is, contact Illinois Client Enrollment Services at or TTY: Privacy Notice and Privacy Rights This privacy notice applies to IlliniCare Health and all of its partners. Your privacy is important to us. We will do all we can to protect your health records. By law, we must protect your health records and send you this notice. This notice tells you how we use your health records. It describes when we can share your records with others. It explains your rights about the use of your health records. It also tells you how to use those rights and who can see your health records. This notice does not apply to information that does not identify you. When we talk about your health records in this notice, it includes any information about your past, present, or future physical or mental 63

64 health while you are enrolled in IlliniCare Health. This includes healthcare provided to you and payment for your healthcare while you are in our health plan. Please note: You may also receive a privacy notice from the State of Illinois outlining their rules for your health records. Other health plans and healthcare providers may have other rules when using or sharing your health records. We ask that you get a copy of their privacy notice and read it carefully. How We Use or Share Your Health Records Here are ways we may use or share your health records: To help pay your medical bills given to us by healthcare providers To help your healthcare providers give you the proper care. For example, if you are in the hospital, we may give them your records sent to us by your doctor. To help manage your healthcare. For example, we might talk to your doctor to suggest a disease or wellness program that could help improve your health. To help resolve any appeals or grievances filed by you or a healthcare provider with IlliniCare Health or the State of Illinois. To assist others who help us provide health services. We will not share your records with these outside groups unless they agree to protect your records. For public health or disaster relief efforts To remind you if you have a doctor s visit coming up To give you information about other healthcare treatments and programs, such as information on how to stop smoking or lose weight State/federal laws may require us to give your health records to others for these reasons: Required by state and federal agencies that control us, such as the Illinois Department of Insurance and the Illinois Department of Human Services For public health actions. For example, the Food and Drug Administration may need to check or track medicines and medical device problems. To public health groups if we believe there is a serious public health or safety threat To a health agency for certain activities, such as audits, inspections, licensure, and disciplinary actions Required by a court or administrative agency To law enforcement. For example, we may give your records to a law enforcement offcer to identify or locate a suspect, fugitive, material witness, or missing person. To a government representative investigating child abuse, neglect, or violence in your home To a coroner or medical examiner to identify a dead person or help find a cause of death or to a funeral director to help him/her carry out his/ her duties For the procurement, banking, or transplantation of organs If one of the above reasons does not apply, we must get your written approval to use or share your health records with others. If you change your mind, you may stop your written approval at any time. If sharing your health information is not allowed by or limited by a state law, we will obey the law that better protects your health information. 64

65 MEMBER HEALTH RECORD One of the ways IlliniCare Health uses your medical information is through our Member Health Record. This is information we share with providers through our secure online portal. This helps to keep your health records in one place, and accessible to your PCP, specialists, and hospitals. The Member Health Record helps our providers know your medical history, so they can take better care of you. The information that is included in the Member Health Record is: Recent emergency department visits Inpatient admissions Offce visits Completed assessments Top diagnoses Medication information Any gaps in your care. This could be annual exams or screenings that you need. These alerts help your doctor know if you are due for any tests. IlliniCare Health is dedicated to ensuring your health information is protected. If you do not wish your information to be included in our secure portal, please let us know. You have the option to opt out. In order to remove yourself from the Member Health Record, you need to notify Member Services at (tollfree) / (TDD/TTY). What are Your Rights? The following are your rights about your health records. If you would like to use any of these rights, please contact us. You have the right to ask us to give your records only to certain people or groups, and you have the right to say for what reasons. You also have the right to ask us to stop your records from being given to family members. You have the right to ask us to stop your records from being given to others involved in your care. While we try hard to obey your wishes, the law does not make us. You have the right to ask for a private exchange of your records. If you believe that you would be harmed if we mailed your records to your home address, you can ask us to send them by fax or mail to another address or to your doctor. You have the right to view and get a copy of all the records we keep about you. This is anything we use to make decisions about your health. It includes enrollment and payment. It also includes claims and medical management records. You do not have the right to get certain types of health records. We may decide not to give you: Records that have psychotherapy notes Records collected for use in a court case or other legal action Records subject to federal laws about biological products and clinical laboratories In some cases, we may refuse to give out copies of your records. You will be informed in writing. You may have the right to have our action reviewed. You have the right to ask us to make changes to wrong or incomplete records. These changes are known as amendments. You must ask for the change in writing. You need to give a reason for your change(s). We will get back to you in writing no later than 30 business days after we get your letter. If we make your changes, we will let you know when they were made. We will also give your changes to others who we know have your records and to other persons you name. If we choose not to make your changes, we will let you know why in writing within 30 business days after we get your letter. You will have the right to send us a letter disagreeing with us. We have the right to answer your letter. You then have the right to ask that your original request 65

66 for changes, our denial, and your second letter disagreeing with us be put with your records. You have the right to receive a list of when we have given your records to others in the past six years. By law, we do not have to give you a list of the following: Any records collected prior to 4/14/2003 Records given or used for treatment, payment, and healthcare operations purposes Records given to you or others with your written approval Records that are incidental to a use or disclosure otherwise permitted Records given to persons involved in your care or for other notification purposes Records used for national security or intelligence purposes Records given to prisons, police, or to the FBI and others who enforce laws Records given to health oversight agencies Records given or used as part of a data set for research or for public health or healthcare operations purposes Using Your Rights You have a right to get a copy of this notice at any time. We have the right to change the terms of this notice. Any changes in our privacy practices will apply to all the health records we keep. If we make changes, we will send you a new notice. If you believe your rights have been broken, you may file a complaint by writing to: Privacy Offcer IlliniCare Health 999 Oakmont Plaza Drive, Suite 400 Westmont, IL (toll-free) / (TDD/ TTY) Offce for Civil Rights Region V U.S. Department of Health and Human Services 233 N. Michigan Ave., Suite 240 Chicago, IL (TDD/TTY) (Fax) Your request for a list of disclosures has to be in writing. We will act on your request within 60 calendar days. If we need more time, we may take up to another 30 calendar days. We will give you one free list every 12 months. 66

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68 ILLINICARE HEALTH 999 Oakmont Plaza Drive Suite 400 Westmont, IL If you have questions, call the Member Services department at (toll-free) / (TDD/TTY) IC-FHP-HANDBOOK 9/14