Medicaid Managed Care. Member Handbook

Transcription

1 Medicaid Managed Care Member Handbook

2 Medicaid Managed Care Member Handbook Your Primary Care Professional Name Important Addresses and Telephone Numbers Address Telephone Your Nearest Hospital Emergency Room Hospital Local Pharmacy Pharmacy Address Address Telephone Telephone Other Health Care Providers Name Name Address Address Telephone Telephone Name Name Address Address Telephone Telephone Medicaid Managed Care Member Handbook revised January 2012 D2883 MarCom CL_HHP_MDCE

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

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

5 Medicaid Managed Care Member Handbook Table of Contents [ Section One ] Introduction to Our Plan and Managed Care 1 [ Section Two ] Choosing Your Primary Care Professional 4 [ Section Three ] Medical Services 5 [ Section Four ] Your Benefits 8 [ Section Five ] Service Authorizations and Actions 13 [ Section Six ] Appeals and Complaints 15 [ Section Seven ] Discontinuing Your Coverage With Hudson 19 [ Section Eight ] Member Rights and Responsibilities 20 [ Section Nine ] Notice of Privacy Practices 21

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

7 2 Introduction to Our Plan and Managed Care Medicaid Managed Care Member Handbook Using This Handbook This handbook will tell you how your new health care system will work and how you can get the most from Hudson. This handbook is your guide to health services. It tells you the steps to take to make the plan work for you. When you have a question, check this Handbook or call our Customer Care Department. You can also call the managed care staff at your local Department of Social Services (see Important Addresses and Telephone Numbers list at the front of this Handbook) or if you live in Westchester, Orange, Ulster, Sullivan, or Dutchess counties, you can call the New York State Medicaid CHOICE Helpline at Your Hudson Member Identification Card After you enroll, we ll send you a welcome letter. Your Hudson member identification card should arrive within 14 days of your enrollment date. The card has your Client Identification Number (CIN), and your PCP s name and telephone number on it. If anything is wrong on your ID card, call us right away. Carry your ID card at all times and show it each time you go for care. You should keep your Medicaid benefit card. You will need the Medicaid benefit card to get services that Hudson does not cover. These services include outpatient chemical dependency benefits. If you lose your Hudson member ID card and need a replacement, call Customer Care. You will also receive a Healthplex Dental ID card to receive your dental benefits (See page 9 for Dental Benefit information). Help and Information From Customer Care There is someone to help you at Customer Care Monday through Friday, 8:30 am 5:00 pm, at (TTY ). After regular office hours and on weekends, call this same number to reach us through our answering service. You Can Call Anytime You Have a Question or Need Help You may want to choose or change your PCP, to ask about benefits and services, to get help with referrals, to replace a lost identification card, to let us know you are pregnant and enroll in our Mommy & Me Program (see page 11 for more information about this program), report the birth of a new baby, or ask about any change that might affect you or your family s benefits. If you become pregnant while a member of our Plan, your child will become part of Hudson on the day he or she is born. This will happen unless your newborn child is in a group that cannot join managed care. A newborn child may not be able to join managed care if the child weighs less than 1200 grams (2 lbs. 10 oz.) at birth, is Medicaid eligible but lives with an incarcerated mother, or has access to full and cost-effective private health care coverage. You should call us and your local Department of Social Services right away if you become pregnant and let us help you choose a doctor for your newborn baby before he or she is born. We offer free sessions to explain our health plan and how we can best help you. It s a great time for you to ask questions and meet other members. If you d like to come to one of the sessions, call us to find a time and place that are best for you. If You Do Not Speak English, We Can Help We want you to know how to use Hudson services no matter what language you speak. Call us and we will find a way to talk to you in your own language. We have a group of people who can help. We will also help you find a PCP who speaks your language. If You Are Disabled and Need Extra Help If you are disabled, in a wheelchair, blind, or have trouble hearing, call us if you need extra help. We can tell you if a particular provider s office is wheelchair accessible or is equipped with communications devices. Also, we offer helpful services including: relay link to TTY/TDD machine ( ) information in large print case management help in making or getting to appointments names and addresses of providers who specialize in your disability

8 Medicaid Managed Care Member Handbook Introduction to Our Plan and Managed Care 3 Other Information Available From Customer Care You can get the following information from Customer Care: which hospitals our health providers work with the guidelines we use to review a particular condition or diseases that are covered by Hudson if you request it in writing how we keep your medical records and member information private a written explanation of how we check on the quality of care to our members a written explanation of the qualifications needed and how health care providers can apply to be part of Hudson s provider network if our contracts or subcontracts include physician incentive plans that affect the use of referral services; and, if so, (1) the types of arrangements we use; and (2) if stoploss protection is provided for physicians and physician groups information about how our company is organized and how it works a copy of the most recent financial statements/balance sheets, summaries of income and expenses a copy of the most recent individual direct pay subscriber contract the names, addresses, and titles of Hudson s Board of Directors, Officers, Controlling Parties, Owners, and Partners consumer complaints information about Hudson from the New York State Department of Financial Services Keep Us Informed Call Customer Care whenever any of these changes happen in your life: You change your name, address, or telephone number. You have a change in Medicaid eligibility. You are pregnant or you give birth. There is a change in insurance for you or your children. If at some time you are no longer eligible for Medicaid, you may be able to enroll your children in Child Health Plus, even if you lose Medicaid benefits. Adults age may be able to get Family Health Plus coverage. Check with your local Department of Social Services or call Customer Care. How Our Providers Are Paid You have the right to ask us whether we have any special financial arrangement with our physicians that might affect your use of health care services. You can call Customer Care if you have specific concerns. We also want you to know that most of our providers are paid in one or more of the following ways: Salaried. If your PCP works in a clinic or health center, they probably receive a salary. The number of patients they see does not affect their salary. Monthly fee per member. Our PCPs who work from their own offices may get a set fee each month for each patient whom they are the patient s PCP. The fee stays the same whether the patient needs one visit or many or even none at all. This is called capitation. Set fee per member. Sometimes providers get a set fee for each person on their patient list, but some money (maybe 10%) can be held back for an incentive fund. At the end of the year, this fund is used to reward PCP s who have met the standards for extra pay that were set by Hudson. Fee-for-service. Providers may also be paid by fee-for-service. This means they get an agreed upon fee for each service they provide. You Can Help With Plan Policies Hudson values your opinions and suggestions. We are interested in anything you wish to tell us about Hudson. This includes your ideas, suggestions, problems, concerns, complaints, and questions. To find out how you can help, contact the Hudson Customer Care Department at

9 4 Choosing Your Primary Care Professional Medicaid Managed Care Member Handbook [ Section Two ] Choosing Your Primary Care Professional You may have already picked your PCP to serve as your regular doctor. This person could be a doctor or a nurse practitioner. If you have not chosen a PCP for you and your family, you should do so right away. If you do not choose a doctor within 30 days, we will choose one for you. Each family member can have a different PCP, or you can choose one PCP to take care of the whole family. A pediatrician treats children. Family practice doctors treat the whole family. Internal medicine doctors treat adults. You can get help in making a choice from Customer Care. You have received a Provider Directory. This is a list of all the doctors, clinics, hospitals, labs, and others who serve Hudson. It lists the address, telephone number, and special training of each provider. The Provider Directory will show which doctors and providers are taking new patients. You should call their office to make sure that they are taking new patients at the time you choose a PCP. You may want to find a doctor who you have seen before and understands your health problems, is taking new patients, speaks your language, and is easy for you to get to. Woman can also choose one of our OB/GYN doctors to deal with women s health issues. Women do not need a PCP referral to see a plan OB/GYN doctor. They can have routine check ups (twice a year), follow-up care if there is a problem, and regular care during pregnancy. If you are pregnant, please remember to call Customer Care to enroll in our Mommy & Me Program. If a woman has a serious problem, such as a lump in her breast or a positive pap smear, she can see an OB/GYN specialist with no referral. Hudson also contracts with several Federally Qualified Health Centers (FQHCs). All FQHCs give primary and specialty care. Some consumers want to get their care from FQHCs because the centers have a long history in the neighborhood. Maybe you want to try them because they are easy to get to. You should know that you have a choice. You can choose any one of our private physicians listed in our directory, or you can sign up with one of the FQHCs that we work with. You will find the FQHCs listed in our Provider Directory. Call Customer Care at if you need help. In almost all cases, your doctors will be Hudson providers. There are two instances when you can still see another doctor that you had before you joined Hudson: You are more than three months pregnant when you join and you are getting prenatal care. In that case, you can keep your doctor until after your delivery and through postpartum care. At the time you join, you have a life-threatening disease or condition that gets worse with time. In that case, you can keep your doctor for up to 60 days. In both cases, however, your doctor must agree to work with our Plan. If you have a long-lasting illness, like HIV/AIDS or other longterm health problems, you may be able to choose a specialist to act as your PCP. Arrangements to use a specialist as your PCP should be made through your Hudson Customer Care Representative. Changing Your PCP If you need to, you can change your PCP in the first 30 days after your first appointment with your PCP. After that, you can change once every six months without cause, or more often if you have a good reason. You can also change your OB/GYN or specialist to whom your PCP has referred you. If Your Provider Leaves the Provider Network If your provider leaves the Hudson provider network, we will tell you within 15 days from when we know about this. If you wish, you may be able to continue to see that provider if you are more than three months pregnant or if you are being treated for an ongoing condition. If you are pregnant, you may continue to see your doctor for up to 60 days after delivery. If you are seeing a doctor for an ongoing condition, you may continue your present course of treatment for up to 90 days. Your doctor must agree to work with the Plan during this time. If any of these conditions apply to you, check with your PCP or call Customer Care.

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

11 6 Medical Services Medicaid Managed Care Member Handbook be able to refer you for a specified number of visits or length of time, a standing referral. If you have a standing referral, you will not need a new referral for each time you need care. If you have a long-term disease or a disabling illness that gets worse over time, your PCP may be able to arrange for your specialist to act as your PCP or refer you to a specialty care center that deals with the treatment of your problem. You can also call Customer Care for help if you have trouble getting a referral for care you think you need. Receiving Care From Providers Who Are Not Part of Hudson s Provider Network If you or your provider feels that your health care needs cannot be appropriately met by an in-network Hudson provider, you may submit a request for out-of-network services. All requests are evaluated and reviewed either by a Hudson Registered Nurse or the Hudson Medical Director based on your health status and the availability of an in-network provider to care for you. If your provider feels that a delay in a decision would harm you, we will make a determination as soon as possible, but no later than three business days from receipt of your request. If the matter is not urgent, we will make a decision in three business days unless we need additional information. In this case a decision will be made within three business days of receipt of the additional information, but no more than 14 days from the receipt of your request. If we determine that the requested treatment is not medically necessary or is appropriately available through an innetwork provider, the service request will be denied. You will have up to 60 business days from receipt of the denial to appeal our decision (see Action Appeals on page 15). Services That Do Not Require a Referral Hudson does not require your specialist to collect and submit any special form for referrals to in-network providers. If your PCP and Hudson agree that you need care from a non-participating provider, Hudson will give the specialist an authorization for the services required. You may be held personally financially responsible for services provided by non-participating providers without an authorization. Dental Care Covered services generally include regular and routine dental services, supplies, and devices required to alleviate health conditions. Members may self-refer to a Hudson provider or to a dental clinic that is operated by an academic dental center. Vision Care The covered benefits include the needed services of an ophthalmologist, optometrist, and an ophthalmic dispenser, and include an eye exam and pair of eyeglasses, if needed. Generally, you can get these once every two years, or more often if medically needed. You just choose one of our participating providers. New eyeglasses, with Medicaid approved frames, are provided once every two years. New lenses may be ordered more often if, for example, your vision changes more than one-half diopter. If you break your glasses, they can be repaired. Lost or broken eyeglasses that can t be fixed, will be replaced with the same prescription and style of frames. If you need to see an eye specialist for care of an eye disease or defect, your PCP will refer you. Women s Services You do not need a referral from your PCP to see one of our providers IF you: are pregnant need OB/GYN services need family planning services want to see a midwife need to have a breast or pelvic exam Family Planning The family planning services you can get include advice for birth control, pregnancy tests, sterilization, and abortion. During your visits for these things, you can also get tests for sexually transmitted infections, a breast cancer exam, and a pelvic exam. You do not need a referral from your PCP to get these family planning services. In fact, you can choose where to get these services. You can use your Hudson ID card to see one of our family planning providers. Check the Provider Directory or call Customer Care for help finding a provider. Or, you can use your Medicaid benefit card if you want to go to a doctor or clinic outside our Plan. Ask your PCP or Customer Care for a list of places to go to get these services. You can also call the New York State Growing Up Healthy Hotline at for the names of family planning providers near you. HIV Counseling and Testing You can get HIV testing and counseling any time you have family planning services. You do not need a referral from your PCP. Just make an appointment with one of our family planning providers. If you d rather not see one of our Plan s providers, you can use your Medicaid benefit card to see a family planning provider outside the Plan. For help in finding either a Plan provider or a Medicaid provider for family services, call Customer Care. If you want HIV testing and counseling, but not as part of a family planning service, your PCP can arrange it for you. You can also visit an anonymous HIV testing and counseling site. For information, call the New York State HIV Counseling Hotline at or the New York State AIDS Hotline at AIDS ( ). If you need HIV treatment after the testing and counseling service, your PCP will help you get follow-up care.

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

13 8 Your Benefits Medicaid Managed Care Member Handbook [ Section Four ] Your Benefits The following sections of this Handbook tell you about the covered and non-covered services, what to do if you have a complaint, and contain other information you may find useful. Keep this Handbook handy to refer to when you need it. Medicaid Managed Care provides a number of services you get in addition to those you get with regular Medicaid. We will provide or arrange for most services that you will need. You can get a few services, however, without going through your PCP. These include emergency care, family planning, HIV testing and counseling, and specific self-referral services, including those you can get with Hudson and some that you can choose to receive from any Medicaid provider of the service. Please call Customer Care at if you have any questions or need help getting any of the following services. Services Covered by Hudson You must get these services from providers who are in the Hudson provider network. All services must be medically necessary, and provided by or referred by your PCP. Regular Medical Care Regular medical care covered by Hudson includes office visits with your PCP, referrals to specialists, eye exams, and hearing exams. Preventive Care Your preventive care benefits include: well-baby and well-child care regular check-ups shots for children from birth through childhood access to Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services from birth through age 21 smoking cessation counseling, limited to six sessions in a calendar year Emergency Care Emergency care services are procedures, treatments, or services needed to evaluate or stabilize an emergency. After you have received emergency care, you may need other care to make sure you remain in stable condition. Depending on the need, you may be treated in the Emergency Room, in an inpatient hospital room, or in another setting. This is called Post Stabilization Service. (For more information about emergency services, see Emergency Care on page 7.) Maternity Care (Remember to call and enroll in our Mommy & Me Program) Covered maternity care services include: pregnancy care doctors/midwife and hospital services newborn nursery care

14 Medicaid Managed Care Member Handbook Your Benefits 9 smoking cessation counseling for pregnant women, limited to six sessions during pregnancy and six sessions during postpartum care in a calendar year Dental Care Hudson believes that providing you with good dental care is important to your overall health care. We offer dental care through a contract with Healthplex, an expert in providing high quality dental services, to provide dental benefits covered under our plan. Covered services include regular and routine dental services such as preventive dental check-ups, cleaning, x-rays, fillings, and other services to check for any changes or abnormalities that may require treatment and/or follow-up care. You will be able to choose your own Primary Care Dentist (PCD), who will coordinate all of your dental services. You may choose a PCD from the list of Primary Care Dentists enclosed with your enrollment packet. However, to make sure that you have a PCD immediately, Healthplex will assign a dentist to you and/or your family. The name, address, and telephone number of your assigned dentist will appear on your Dental ID card. You must use this dentist for any dental services you or your family require. You will receive your Dental ID card from Healthplex within your first 30 days of membership. If you need to know who your PCD is before you receive your card, or if you want to change your PCD, you may call Healthplex at You may also go to a dental clinic operated by an academic dental center without a referral. If you have any questions about receiving dental care as a Hudson member, please call Customer Care. Vision Care Your vision care benefits include: services of an ophthalmologist, ophthalmic dispenser, and optometrist; and coverage for contact lenses, polycarbonate lenses, artificial eyes, and/or replacement of lost or destroyed glasses, including repairs, when medically necessary; artificial eyes are covered as ordered by a Hudson provider eye exams, generally every two years, unless medically needed more often glasses (new pair of Medicaid approved frames every two years, or more often if medically needed) low vision exam and vision aids ordered by your PCP specialist referrals for eye diseases or defects If you need help finding a vision care provider, you may call Block Vision. Hudson contracts with Block Vision to provide covered vision care services. Block Vision may be reached at Call this number if you have any questions about covered vision care services or participating vision care providers. Pharmacy Your pharmacy benefit includes: prescription drugs and over-the-counter medicines insulin and diabetic supplies smoking cessation agents, including over-the-counter products hearing aid batteries enteral formula emergency contraception (6 per calendar year) medical and surgical supplies Some members are required to make a co-payment when receiving certain medications and pharmacy items. Some members are exempt and do not have to make these payments. If you have questions about covered pharmacy benefits, please call Customer Care or the Medicaid Help Line at Members who are required to make co-payments are responsible to make co-payments for the following medications and pharmacy items: Brand name prescription drugs. Members pay a $3 or $1 co-pay, depending on the drug, for each new prescription and each refill. For more information on brand name prescription drugs co-pays, call MaxorPlus at or go to our website, org, and select Find a Pharmacy. Generic prescription drugs. Members pay a $1 co-pay for each new prescription and each refill. Over-the-counter medications. Members pay a $0.50 co-pay for each over-the-counter item, such as smoking cessation and diabetes medications. A co-payment is required for each new prescription and each refill.

15 10 Your Benefits Medicaid Managed Care Member Handbook You are not required to pay the pharmacy co-payments if you are: under the age of 21 pregnant, including the two months after the month in which the pregnancy ends in a Comprehensive Medicaid Case Management (CMCM) program or a service coordination program in an OMH (Office of Mental Health) or OPWDD (Office for People With Developmental Disabilities) Home and Community Based Services (HCBS) Waiver program in a Department of Health HCBS Waiver program for persons with Traumatic Brain Injury (TBI) You are not required to pay the pharmacy co-payments for the following medications and pharmacy items: family planning drugs and supplies such as birth control pills and condoms drugs to treat mental illness (psychotropic) drugs to treat tuberculosis If you are required to pay a co-pay, you are responsible for a maximum of $200 per calendar year. If you transferred to Hudson from another Medicaid Managed Care plan during the calendar year, keep the receipts for the above items while you were a member of the other plan. You will need to provide these to Hudson as proof of your co-payments. You may also request proof of paid co-payments from your pharmacy. Certain medications may require that your PCP get prior authorization from Hudson before writing your prescription. Your PCP will work with Hudson to make sure you get the medications that you need. See Prior Authorizations and Time Frames on page 13 for more information. Hudson contracts with MaxorPlus to manage the program s prescription benefit. You can go to any pharmacy that participates with Hudson and MaxorPlus. Call Customer Care at or visit our website at org to locate a network pharmacy near you. Hospital Care Your hospital care benefits include inpatient and outpatient care, and lab, x-ray, and other tests. Mental Health/Chemical Dependence (including alcohol and substance abuse) Services for mental health/chemical dependence include: all inpatient mental health and chemical dependence, including alcohol and substance abuse most outpatient mental health services (contact us for specific covered services) Medicaid recipients who receive Supplemental Security Income (SSI), or who are certified blind or disabled can use their Medicaid benefit card to get mental health and chemical dependence (including alcohol and substance abuse) services from any Medicaid provider. Detoxification services, however, are covered by Hudson as a benefit. If you need help finding a Plan provider, or if you want help making a choice, you can call Beacon Health Strategies. Beacon Health Strategies works with Hudson to make sure members get the mental health and chemical dependence (including alcohol and substance abuse) services they need. Your provider can also call Beacon Health Strategies any time, day or night, for help if immediate care is needed. Beacon Health Strategies may be reached at Call this number if you have any questions about mental health or chemical dependence services. Specialty Care Specialty care includes the services of these practitioners: medical and nursing staffs occupational therapists, physical therapists, and speech therapists, limited to 20 visits per therapy per calender year, except for children under 21 years of age, members who have been determined to be developmentally disabled by the Office for People with Development Disabilities, or members who have a traumatic brain injury audiologists midwives cardiac rehabilitation practitioners Home Health Care Home health care must be medically needed and arranged by Hudson, and includes: at least two visits to high-risk infants (newborns) visit to women who stay in the hospital less than 48 hours after birth visit to women who stay in hospital less than 96 hours after a cesarean birth other home health care visits as needed and ordered by your PCP or specialist Personal Care/Home Health Attendant Personal care/home health attendant care must be medically necessary and arranged by Hudson. This service provides some or total assistance with personal hygiene, dressing and feeding, preparing meals, and housekeeping. Personal Emergency Response System (PERS). To qualify for and receive this service, you must be receiving personal care/home health attendant services. Residential Health Care Facility (Nursing Home) Services covered when ordered by your physician and authorized by Hudson and when the stay in the nursing home is not determined permanent by your local Department of Social Services.

16 Medicaid Managed Care Member Handbook Your Benefits 11 Covered nursing home services include: medical supervision and 24-hour nursing care assistance with activities of daily living, physical therapy, occupational therapy, and speech-language pathology HIV Treatment Services for the treatment of HIV include case management, care from an HIV specialist, and treatment at a designated AIDS center. Case Management Our main goal is to assist you in being a partner in your own health care and the health care of your family. Case Management is a service that is available to all Hudson enrollees. Registered Nurses, trained to assist you in managing your care, are part of our Case Management Department. Our Case Managers can give you information about your health condition (such as asthma, pregnancy, diabetes, lead poisoning, etc.), assist you in coordinating your care with your PCP or any specialist in our system that your PCP refers you to, and help you with other health care issues. If you would like to speak to one of Hudson s Case Managers, please call and ask for the Case Management Department. Mommy & Me Program for Pregnant Members The Mommy & Me program is a special Hudson Case Management program for pregnant members. The program s services begin as soon as we receive information about a maternity patient. We urge our pregnant members to contact us as soon as possible so we can send important health education materials and coordinate care and services with the member s provider to make sure each pregnant member receives the proper prenatal health care. As an added bonus, we have attractive gift items for all pregnant members that are useful to new mothers and their babies. The Mommy & Me program continues throughout pregnancy, the baby s birth, and the eight-week, postpartum visit. Infants are followed for 15 months to make sure they receive all recommended immunizations. This preventive health care program is designed to make sure our pregnant members and their babies receive the proper care both during and after pregnancy. Other Covered Services Other services covered by Hudson include: Emergency ambulance transportation for members living in Dutchess County. For information about emergency transportation for members living in other counties, see Services Only Available With Your Medicaid Benefit Card on this page. Durable medical equipment (DME)/hearing aids/ prosthetics/orthotics. Court ordered services. Help getting social support services. Federally Qualified Health Centers or similar services. Family planning. For information about family planning services, see Family Planning below. Podiatry services for children and persons with special problems (e.g., diabetes, etc.). Services You Can Get From Hudson or With Your Medicaid Benefit Card For some services, you can choose where to get the care. You can get these services by using your Hudson member identification card. You can also go to providers who will take your Medicaid benefit card. You do not need a referral from your PCP to get these services. Call Customer Care at if you have questions. Family Planning You can go to any doctor or clinic that accepts Medicaid and offers family planning services, or you can visit one of our family planning providers as well. You do not need a referral from your PCP. HIV Testing and Counseling You can get these services from Hudson doctors, or from doctors and clinics that accept Medicaid. You do not need a referral when you get this service as a part of a family planning visit. You can also get HIV testing services any time from Plan providers, if you talk to your PCP first. You can also go to anonymous counseling and testing clinics offered by the State and local health departments. To get more information about these sites, call the New York State HIV Counseling Hotline at or the New York State AIDS Hotline at AIDS ( ). Tuberculosis Diagnosis and Treatment You can choose to go to either to your PCP or to the county public health agency for diagnosis and/or treatment. You do not need a referral to go to the county public health agency. Services Only Available With Your Medicaid Benefit Card There are some services Hudson does not provide. You can get these services from any provider who accepts Medicaid by using your Medicaid benefit card. Transportation Emergency ambulance transportation for members living in Orange, Rockland, Sullivan, Ulster, and Westchester Counties. It is very important to Hudson that our enrollees have access to care when they need it. If you need emergency transportation, call 911.

17 12 Your Benefits Medicaid Managed Care Member Handbook Non-emergency transportation. If you live in Orange, Rockland, Sullivan, Ulster, or Westchester county and need assistance arranging transportation for non-emergencies, you should call Medical Answering Services (MAS), the Medicaid Program s transportation manager. If possible, you or your provider should call MAS at least three days prior to your medical appointment. Non-emergency medical transportation includes personal vehicle, bus, taxi, ambulette, and public transportation. The MAS telephone numbers for each county are listed in the front of this handbook. If you live in Dutchess County, call your local Department of Social Services at for assistance arranging nonemergency transportation. Mental Health Mental health services that are only available with your Medicaid benefit card are: intensive psychiatric rehabilitation treatment day treatment and continuing day treatment intensive case management partial hospital care rehabilitation services to those in community homes or in family-based treatment clinic services for children with Serious Emotional Disturbance (SED) at mental health clinics certified by the State Office of Mental Health All covered mental health services for people who receive Supplemental Security Income (SSI) or who are certified blind or disabled are available by using the Medicaid benefit card. Outpatient Chemical Dependency You can go to any Medicaid provider or clinic that provides outpatient chemical dependency treatment. Mental Retardation and Developmental Disabilities Members who need services for mental retardation and developmental disabilities can use their Medicaid benefit card for: long-term therapies day treatment housing services Medicaid Service Coordination (MSC) program Medical Model (Care-at-Home) Waiver Services services received under the Home and Community Based Services Waiver outpatient alcohol clinic services and rehabilitation outpatient chemical dependence programs for youths chemical dependence (including alcohol and substance abuse) services ordered by the local Department of Social Services All covered alcohol and substance abuse services, with the exception of detoxification, are available for people who receive Supplemental Security Income (SSI) or who are certified blind or disabled by using their Medicaid benefit card. Detoxification services are available using your Hudson Member Identification card. Other Medicaid Services Other services you can only get using your Medicaid card: pre-school and school services programs (early intervention) early start programs Comprehensive Medicaid Case Management program tuberculosis therapy/directly Observed Therapy (DOT) adult day treatment for persons with HIV hospice services Services That Are Not Covered by Hudson or Medicaid Managed Care Some services are not available from Hudson or Medicaid. If you receive any of the following services, you may be required to pay for them. cosmetic surgery if not medically needed routine foot care for those 21 years and older personal and comfort items infertility treatments services of a provider who is not part of Hudson s provider network (unless Hudson and your PCP sends you to that provider) services for which you need a referral (approval) in advance and did not get one from your PCP and Hudson You may have to pay for any service that your PCP does not approve. Also, if before you get a service, you agree to be a private pay or self-pay patient, you will have to pay for the service. These services include: any non-covered services listed above unauthorized services services provided by providers who are not part of Hudson s provider network Alcohol and Substance Abuse Services Members can use their Medicaid benefit card for these alcohol and substance abuse services: methadone treatment outpatient substance abuse treatment

18 Medicaid Managed Care Member Handbook Service Authorizations and Actions 13 [ Section Five ] Service Authorizations and Actions Prior Authorizations and Time Frames There are some treatments and services that require you to get pre-approved before you receive them, or to be able to continue to receive them. This is called a prior authorization. You or someone you trust can ask for a prior authorization. The following treatments or services must be approved before you receive them: non-emergency hospitalization ambulatory surgery home care outpatient physical therapy, occupational therapy, or speech therapy sterilization and hysterectomy durable medical equipment (DME) outpatient mental health and substance abuse treatment (except the first visit) acupuncture cardiac rehabilitation chemotherapy cosmetic procedures if medically necessary growth hormone oral surgery services of a diabetic educator podiatry FluMist laser and phototherapy treatment non-routine optometry services services provided by a health care professional who is not in the Hudson network (out of network services) some injectable medications sleep studies weight loss programs Asking for approval of a treatment or service is called a service authorization request. You must make a service authorization request prior to receiving these services. Your PCP or the specialist that your PCP refers you to must call Hudson for an authorization number. To see if you need an authorization for a service you can call Customer Care at You will also need to get prior authorization if you are getting one of these services now, but need to continue or get more of the care. This includes a request for home health care while you are in the hospital or after you have just left the hospital. This is called a concurrent review. All services provided by out of network providers require authorization. If you receive services from an out of network provider or if you receive services that require prior authorization without calling Hudson, you may be responsible for the bill. What Happens After We Get Your Service Authorization Request Hudson has a review team of doctors and nurses to be sure you receive the services we cover. Their job is to make certain the treatment given is medically needed and right for the condition at hand. They do this by checking your treatment plan against medically acceptable standards. Any decision to deny a service authorization request or to approve it for an amount that is less than requested is called an action. These decisions will be made by a qualified health care professional. If we decide that the requested service is not medically necessary, the decision will be made by a clinical peer reviewer, who may be a doctor or health care professional that typically provides the care you requested. You can request the specific medical standards, called clinical review criteria, used to make the decision for actions related to medical necessity. After we get your request we will review it under a standard or fast track process. You or your doctor can ask for a fast track review if it is believed that a delay will cause serious harm to your health. If your request for a fast track review is denied, we will tell you and your case will be handled under the standard review process. If you are in the hospital or have just left the hospital and we receive a request for home health care, we will handle the request as a fast track review. In all cases, we will review your request as fast as your medical condition requires us to do so but no later than mentioned below. We will tell you and your provider both by phone and in writing if your request is approved or denied. We will also tell you the reason for the decision. We will explain what options for appeals or fair hearings you will have if you don t agree with our decision. Time Frames for Review Requests The time frames for prior authorization requests are: Standard prior authorization review. We will make a decision about your request within three workdays of when we have all the information we need, but you will hear from us no later than 14 days after we receive your request. We will tell you by the fourteenth day if we need additional information. Fast track prior authorization review. We will make a decision and you will hear from us within three workdays. We will tell you by the third workday if we need additional information.

19 14 Service Authorizations and Actions Medicaid Managed Care Member Handbook The time frames for concurrent review requests are: Standard concurrent review. We will make a decision within one workday of when we have all the information we need, but you will hear from us no later than 14 days after we receive your request We will tell you by the fourteenth day if we need additional information. Fast track concurrent review. We will make a decision within one workday of when we have all the information we need. However, if you are in the hospital or have just left the hospital and you ask for home health care on a Friday or the day before a holiday, we will make a decision no later than 72 hours of when we have all of the information we need. In all cases, you will hear from us no later than three workdays after we have received your request. We will tell you by the third workday if we need more information. If we need additional information to make either a standard or fast track decision about your service request, we will: write and tell you what information is needed. If your request is in a fast track review, we will call you right away and send a written notice later tell you why the delay is in your best interest make a decision no later than 14 days from the day we asked for additional information You, your provider, or someone you trust may also ask us to take more time to make a decision. This may be because you have more information to give the Plan to help decide your case. This can be done by calling or writing to Customer Care (see Important Addresses and Telephone Numbers at the front of this Handbook). You or someone you trust can file a complaint with the Plan if you don t agree with our decision to take more time to review your request. You or someone you trust can also file a complaint about the review time with the New York State Department of Health at We will notify you by the date our time for review has expired. But if for some reason you do not hear from us by that date, it is the same as if we denied your service authorization request. If you are not satisfied with this answer, you have the right to file an action appeal with us (for more information, see Action Appeals on page 15). In most cases, if we make a decision to reduce, suspend, or terminate a service we have already approved and you are now getting, we must tell you at least ten days before we change the service. If we are checking care that has been given in the past. We will make a decision about paying for it within 30 days of receiving necessary information for that retrospective review. If we deny payment for a service we will send a notice to you and your provider the day the payment is denied. You will not have to pay for any care you received that was covered by Hudson or Medicaid even if we later deny payment to the provider. Other Decisions About Your Care Sometimes we will do a concurrent review on the care you are receiving to see if you still need the care. We may also do a retrospective review of other treatments and services you have already received. We will tell you if we take these other actions. The time frames for notice of other actions are: If we are checking a service already approved or one you are now getting.

20 Medicaid Managed Care Member Handbook Appeals and Complaints 15 [ Section Six ] Appeals and Complaints There are some treatments and services that require approval before you receive them or to be able to continue receiving them. This is called a prior authorization (see Prior Authorizations on page 13). Asking for approval of a treatment or service is called a service authorization request. Any decision to deny a service authorization request or to approve it for an amount that is less than requested is called an action. If you are not satisfied with our decision about your care, there are steps you can take. Your Provider can ask for reconsideration if we made a decision that your service authorization request was not medically necessary, experimental, or investigational without talking to your doctor about it, your doctor may ask to speak to the Plan s Medical Director. The Medical Director will talk to your doctor within one workday. Action Appeals You can file an action appeal yourself, or ask someone you trust to file the appeal for you if you are not satisfied with an action we took or what we decided about your service authorization request. You have at least 60 business days, but no more than 90 calendar days, after hearing from us to file an action appeal. Call Customer Care at if you need help filing an action appeal. We will not treat you any differently or act badly toward you because you file an action appeal. The action appeal can be made by telephone or in writing. If you make an action appeal by phone it must be followed up in writing. Action Appeals Fast Track Process Your action appeal will be reviewed under the fast track process if: You or your doctor asks to have your action appeal reviewed this way. Your doctor would have to explain how a delay will cause harm to your health. If your request for fast track review is denied, we will tell you and your action appeal will be reviewed under the standard review process; or Your request was denied when you asked to continue receiving care that you are now getting or need to extend a service that has been provided; or Your request was denied when you asked for home health care after you were in the hospital. Fast track action appeals can be made by telephone and do not have to be followed up in writing. What Happens After We Get Your Action Appeal Once we get your action appeal, we will send you a letter within 15 days after we receive it to let you know we are working on it. Action appeals of clinical matters will be decided by qualified health care professionals who did not make the first decision, at least one of whom will be a clinical peer reviewer. Non-clinical decisions will be handled by persons who work at a higher level than the people who worked on your first decision. Before and during the action appeal process you or your designee can see your case file, including medical records and any other documents and records being used to make a decision on your case. You can provide information, in person or in writing, to be used in making the decision. Call Customer Care at if you are not sure what information to give us. If you are appealing our decision that an out-of-network service you asked for was not different from a service that is available in our network, ask your doctor to send us: a written statement that the service you asked for is different from the service we have in our network two pieces of medical evidence, such as published articles or scientific studies, that show the service you asked for is better for you and will not cause you more harm than the service we have in our network You will be given the reasons for our decision and our clinical rationale, if it applies. If you are still not satisfied, any further appeal rights you have will be explained, or you or someone you trust can file a complaint with the New York State Department of Health at Time Frames for Action Appeals The time frames for action appeals are: Standard action appeals. If we have all the information we need, we will tell you our decision within 30 days from your action appeal. A written notice of our decision will be sent within two workdays from when we make the decision. Fast track action appeals. If we have all the information we need, fast track action appeal decisions will be made within two workdays from your action appeal. We will tell you if we need more information within three workdays after giving us your action appeal. We will tell you our decision by phone and send you a written notice later. If we need more information to make either a standard or fast track decision about your action appeal, we will write you and tell you what information is needed. If your request