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2 TABLE OF CONTENTS Important Phone Numbers... 5 Welcome to Health Options... 6 Alternative Formats... 6 Important Words You Should Know... 6 Getting Started... 8 Check for Your ID Card... 8 Things to Do... 8 How to Get Help... 9 Member Advocates... 9 What to Do If You Move... 9 Adding New Members or Removing Existing Members... 9 If Your Membership Stops Changing Your Health Plan Your Rights and Responsibilities Your Rights Your Responsibilities Emergency and Urgent Care How Do I Know If It is an Emergency? What Do I Do in an Emergency? What Do I Do When I Need Urgent Care? Behavioral Health Crisis Services Northern Delaware Locations and Hours Southern Delaware Locations and Hours How to Use Your Benefits Your Health Options ID Card What is a Primary Care Provider (PCP)? Making an Appointment With Your PCP When You Are Sick How to Change Your PCP P age Member Services toll free

3 Family Planning Pregnant Women and Newborns Enrolling Your Newborn Arranging Your Care Specialty Care How Can I Get a Second Opinion? Out-of-Network Care Other Medical Staff In Your Doctor s Office Wellness Programs Health Risk Assessment (HRA) Asthma Program Chronic Obstructive Pulmonary Disease Program Cardiac Program Diabetes Program EPSDT Complex Care Coordination Behavioral Health Care Coordination Transitioning Home From the Hospital Accessibility and Availability Standards Different Types of Care Routine Care Urgent Care After-hours Care Out-of-area Care Pregnancy Care Nurse Midwife or Certified Pediatric/Family Nurse Practitioner Sexually Transmitted Disease (STD) Care Specialist Care Hospital Care What We Cover P age Member Services toll free

4 Health Options Benefits Additional Benefits Special Needs Services Not When You May Have to Pay for Services Services by Fee-for-Service Medicaid Program Care Away from Home Women, Infants, and Children (WIC) Program Medicines and Prescription Drugs Health Options Drugs On Our PDL Some Drugs Need to be Approved (Prior Authorized) Generic Drugs Instead of Brand-name Drugs Over-the-counter (OTC) Drugs How Do You Get Your Medicine? Refilling Your Prescriptions Emergency Supply of Medication Quantity Limits Where to Get Your Prescriptions Filled Pharmacy Lock-in Behavioral Health Drugs Important Things to Know When You Get Your Drugs The Kinds of Drugs Health Options Covers Limits on Your Prescription Drug Benefit Preferred Diabetic Supply List (PDSL) Effective 1/1/ Dental Services Behavioral Health Services Non-Emergency Transportation (NEMT) New Technology How to File a Grievance or Appeal Grievances P age Member Services toll free

5 Appeals Expedited ( Fast ) Appeals State Fair Hearing Important Information When We Can No Longer Serve You Disenrollment Contacting our Member Services Department Advance Directives (Living Wills) Review of Member Records How to Suggest Changes in our Policies and Services Changes to the Plan Treatment of Minors You Have Other Insurance or a Third Party Liability (TPL) Claim What Do I Do With a Bill? Help In Other Languages Help for Members With Hearing, Speech, or Vision Loss Americans with Disabilities Act Fraud & Abuse Confidentiality Information About Our Plan Urgent Care Locations in Delaware P age Member Services toll free

6 IMPORTANT PHONE NUMBERS Member Services (Monday-Friday, 8am-8pm) Hour Nurse Help Line Hour Nurse Help Line TTY or Care Management (Monday-Friday, 8:00 am-5:00 pm) Behavioral Health (Monday-Friday, 8:00 am-5:00 pm) Fraud and Abuse Hotline TTY/TDD Line or Pharmacy Behavioral Health Crisis Services Northern Delaware (serving New Castle County and greater Smyrna in Northern Kent County) Southern Delaware (serving Sussex County and Kent County south of greater Smyrna) Other Important Phone Numbers Health Benefit Manager Enrollment Call this number to join in a new health plan or disenroll from your current plan. LogistiCare Transportation Services Non-Emergency Transportation Where s My Ride? Hotline State of Delaware Division of Social Services Customer Relations or Delaware Relay Service or This number allows people who have a hearing or speech loss to communicate with a trained person who can help them speak with someone who uses a regular telephone. Delaware Tobacco Quit Line to help stop smoking QUIT-NOW ( ) 5 P age Member Services toll free

7 WELCOME TO HEALTH OPTIONS Health Options is a managed health care plan. This means that we work with you and your doctor, or primary care physician (PCP), to service your total healthcare needs. Your PCP s name and phone number is on your Health Options ID card. Carry this card with you and show it whenever you seek medical attention. You must also show your Delaware Medicaid Card. Please call us right away if there are any mistakes on your ID card. This Handbook explains the benefits and services available to you. It also explains what to do if you have an emergency or urgent medical situation. Please read this handbook carefully. It will help you learn more about the healthcare services paid for by Health Options. Keep this handbook in a safe place so you can look up information later on. We urge you to use your Health Options benefits to help get the care that you need to stay healthy. Please call the Member Services Department for assistance and questions about what is covered. Member Services Representatives are available from 8am-8pm (Monday-Friday) at Your Member Services Representative can answer questions about your health care, ID card, benefits and doctors. We also invite you to visit our website, to find a variety of other useful information. ALTERNATIVE FORMATS All written materials can be provided in a language other than English or in another format (i.e. Braille) for those who are unable to see or read written materials. We also have oral interpretation services available in non-english languages free of charge. If you need these services, please call Member Services at IMPORTANT WORDS YOU SHOULD KNOW Below are some terms that you should know that we use to describe how your medical care is arranged. Benefits: The health care services covered under this plan. Co-pays or Cost Sharing: Money that you need to pay at the time of service. DHSS: Department of Health and Social Services Disenroll: To stop using the health plan because you are no longer eligible or you change your health plan. DMMA: Delaware Division of Medicaid and Medical Assistance 6 P age Member Services toll free

8 Emergency medical condition: A sudden, serious medical condition where the presenting symptoms are of sufficient severity (including severe pain) that a prudent layperson with an average knowledge of health and medicine would reasonably believe that the lack of immediate medical care could: Place your health (or the health of your unborn child) at serious risk. Impair the function of your body. Impair the function of a body part or organ. Health care provider: Any doctor, hospital, agency, or other person who has a license or is authorized to give health care services. Hospital: A place for inpatient and outpatient care from doctors and nurses. Immunization: A shot that protects you from disease. Children and adult receive different shots at different ages during regular doctor visits. Inpatient care: When you have to stay the night in the hospital or other facility for the medical care you need. Medically necessary: Items or services that have been given or will be given to a patient that are needed to treat or prevent a medical condition and are not mainly for the ease of the patient, doctor or other health care provider. Examples are to: find the cause of an illness or treatment of illness or injury; help a body part that is not normal work better; prevent illness; or help a patient meet the right growth and development levels. Member: A person approved by the state of Delaware to participate in Health Options health plan. Member Handbook: The member handbook tells you how Health Options works. If you do not understand some parts of this handbook, you can call your Member Services at the numbers below. We will mail this handbook to you upon enrollment and upon request. Outpatient care: Care you get when you do not have to stay overnight in a hospital or other place of treatment. Primary care provider (PCP): The doctor you choose for most of your health care. This person helps you get the care you need. Your PCP must OK most care ahead of time, unless it is an emergency. Prior authorization: The approval you get from us before you get a service. PROMISE: Promoting Optimal Mental Health for Individuals through Supports and Empowerment program for members with behavioral health needs overseen by the Delaware State Division of Substance Abuse and Mental Health (DSAMH). Specialist: Any doctor who has special training for a specific condition or illness. 7 P age Member Services toll free

9 Urgent medical condition: Not an emergency, but is a condition that should have medical care within 48 hours. Utilization review: A process that allows Health Options and your health care providers to work together to decide if a service you ask for is medically necessary. GETTING STARTED CHECK FOR YOUR ID CARD Your Health Options member identification (ID) card was sent to you separate from this handbook. If you did not get it, call our Member Services Department. If you have difficulty hearing or speaking, please call our Member Services TTY line. Your ID card lists your main doctor or PCP. Check that the PCP listed is the one you want. If the PCP on your ID card is not the PCP you want, call us right away so we can fix it. Every member of your family enrolled with Health Options will have his or her own ID card. Check the information on the ID card to make sure it is right. THINGS TO DO Keep your Health Options ID card and Delaware Medicaid card with you at all times. Show them every time you need health care services. Do not let anyone else use your Health Options ID card. Your Health Options ID card does not replace your Delaware Medicaid card. Keep both cards! Your Health Options ID card lists your primary care provider (PCP). A PCP is a provider who will be your main doctor. You can change your PCP for any reason. If you want to change your PCP, call our Member Services number to let us know right away. Set up an appointment for a health review with your PCP as soon as you can. If you are an adult, your first health review should be within 3 months after joining Health Options. Children should see their PCP within 2 months after joining the plan. A doctor should see your newborn within 1 month of birth. During the health review, the PCP will learn about your health care needs and teach you ways to help you stay healthy. Call your PCP when you need medical care, unless you have an emergency. Your PCP s office will help you set up an appointment for care. If you need a ride to and from your appointment, call our Member Services number. You may see a family planning provider, inside or outside of the Health Options network, without an OK from your PCP. If you have an emergency, get help right away. Call 911 or go to the nearest emergency room for health care. You do not need an OK from us for emergency care. It does not matter if you are inside or outside of our service area. We pay for emergency care even if the provider is not part of the Health Options network. If you are not sure what to do, you can call the 24-hour nurse help line. Have your Health Options ID card ready when you call. The nurse will ask for your ID card number. 8 P age Member Services toll free

10 HOW TO GET HELP For questions about Health Options or for help getting an appointment for care, call our Member Services number. You can call us toll-free 8 am until 8 pm (Monday through Friday). If you have hearing or speech loss, you may call Member Services by dialing 711. You can call our Nurse Help line at The Nurse Help Line is available 24 hours a day. You can always call your PCP for help as well. Your PCP s phone number is on your ID card For questions about enrollment, please contact the Health Benefit Manager at MEMBER ADVOCATES Health Options has Member Advocates to help you. Member Advocates: Help you get care or talk to a specific provider. Coordinate transportation and access to care and services. Help with pharmacy questions. Help our staff and providers better understand your needs. Assist you with the grievances and appeals process. To speak to our member advocates, please call (TTY: 711). WHAT TO DO IF YOU MOVE If you move or change your phone number, you must contact the DSS Change Report Center at After you contact the DSS Change Report Center, call Member Services. Member Services will help you pick a new PCP near your new home. If you move outside of Delaware or the United States, please contact the DSS Change Report Center for information you will need. ADDING NEW MEMBERS OR REMOVING EXISTING MEMBERS When you have a new baby or add a new member to your family, you must contact the DSS Change Report Center at After you contact the DSS Change Report Center, call Member Services. If you don t tell us and the DSS Change Report Center, your new family member s insurance may be delayed. If someone in your family with Health Options dies, please contact Member Services. They can assist you. You also need to let the DSS Change Report Center know about your family member s death. 9 P age Member Services toll free

11 IF YOUR MEMBERSHIP STOPS Medicaid may stop your membership with Health Options. This is called disenrollment. Your membership may end because you: Give your Medicaid ID card to someone else to use. Go to prison. Lose eligibility for Medicaid. Have a change in your Medicaid benefits that keeps you from being covered by Health Options. CHANGING YOUR HEALTH PLAN You can change your health plan during the first 90 days after you are first enrolled in Medicaid. You can also change your health plan during the Annual Open Enrollment period one a year. To change your health plan, please call the Health Benefits Manager at YOUR RIGHTS AND RESPONSIBILITIES As a Health Options Medicaid member, you have the following rights and responsibilities. YOUR RIGHTS Learn about your rights and responsibilities. Get the help you need to understand this member handbook. Learn about us, our services, doctors, and other health care providers. See your medical records as allowed by law Have your medical records kept private unless you tell us in writing that it is OK for us to share them or it is allowed by law. Complete facts from your doctor of any information relating to your medical condition, treatment plan or ability to inspect and offer corrections to your own medical records. Be part of honest talks about your health care needs and treatment options no matter the cost and whether your benefits cover them. Be part of decisions that are made by your doctors and other providers about your health care needs. Be told about other treatment choices or plans for care in a way that fits your condition. Get news about how doctors are paid. Find out how we decide if new technology or treatment should be part of a benefit. Be treated with respect, dignity and the right to privacy all the time. Know that we, your doctors, and your other health care providers cannot treat you in a different way because of your age, sex, race, national origin, language needs, or degree of illness or health condition. Talk to your doctor about private things. Have problems taken care of fast, including things you think are wrong, as well as issues about your coverage, getting an approval from us, or payment of service. Be treated the same as others. Get care that should be done for medical reasons. 10 P age Member Services toll free

12 Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. Choose your PCP from the PCPs in our Provider Directory that are taking new patients. Use providers who are in our network. Get medical care in a timely manner. Get services from providers outside our network in an emergency. Refuse care from your PCP or other caregivers. Be able to make choices about your health care. Make an Advance Directive (also called a living will). Tell us your concerns about Health Options and the health care services you get. Question a decision we make about coverage for care you got from your doctor. File a complaint or an appeal about Health Options, any care you get or if your language needs are not met. Ask how many grievances and appeals have been filed and why. Tell us what you think about your rights and responsibilities and suggest changes. Ask us about our Quality Improvement Program and tell us how you would like to see changes made. Ask us about our utilization review process and give us ideas on how to change it. Know that we only cover health care services that are part of your plan. Know that we can make changes to your health plan benefits as long as we tell you about those changes in writing. Ask for this Member Handbook and other member materials in other formats such as other languages, large print, audio CD or Braille at no charge to you. Ask for an oral interpreter and translation services at no cost to you. Use interpreters who are not your family members or friends. Know you are not liable if your health plan becomes bankrupt (insolvent). Know your provider can challenge the denial of service with your approval. Know that you can request a copy of the member handbook at any time. You will be notified annually of your right to request a member handbook. Know how you can get a list of providers in the network, including the names and education level of all Network providers, and the how you may choose providers within Health Options. TO RECEIVE THE BEST CARE YOU MUST DO YOUR PART. YOUR RESPONSIBILITIES Tell us, your doctors, and other health care providers what they need to know to treat you. Learn as much as you can about your health issue and work with your doctor to set up treatment goals you agree on with your doctor. Ask questions about any medical issue and make sure you understand what your doctor tells you. Follow the care plan and instructions that you have agreed on with your doctors or other health care professionals. Do the things that keep you from getting sick. 11 P age Member Services toll free

13 Make and keep medical appointments and tell your doctor at least 24 hours in advance when you cannot make it. Always show your member Health Options ID card and Delaware Medicaid card when you get health care services. Use the emergency room only in cases of an emergency or as your doctor tells you. If you owe a co pay to your pharmacies, pay at the time the services are received. Tell us right away if you get a bill that you should not have gotten or if you have a complaint. Treat all Health Options staff and doctors with respect and courtesy. Know and follow the rules of your health plan. Know that laws guide your health plan and the services you get. Know that we do not take the place of workers compensation insurance. Tell the DSS Change Report Center and us when you change your address, family status or other health care coverage. If a minor becomes emancipated, or legally freed from control by his or her parents (over the age of sixteen), or marries, he or she shall be responsible for following all Health Options member guidelines set forth above. EMERGENCY AND URGENT CARE HOW DO I KNOW IF IT IS AN EMERGENCY? An emergency medical condition is a condition where the symptoms are so severe that a prudent layperson with an average knowledge of health and medicine would reasonably believe that the lack of immediate medical care could: Place your health (or the health of your unborn child) at serious risk. Impair the function of your body. Impair the function of a body part or organ. There are times when it is hard to know what a real emergency is. If you call your PCP before going to the emergency room, the doctor can tell you what to do. You can also call our Nurse Help Line. Here are some examples of times when you should use the emergency room: Blackouts Car accident Chest pain or heart attack Choking Danger of losing limb or life Difficulty in breathing Heavy bleeding Criminal attack (i.e. mugging or rape) Loss of speech Overdose of medicine or drugs Paralysis (not able to move) Poisoning Possible broken bones 12 P age Member Services toll free

14 Seizures Vomiting (throwing up) blood Here are some examples of when you probably do not need to go to the emergency room. At these times, if you call your PCP, the doctor can tell you what you should do. You can also call our Nurse Help Line 24 hours a day, any day of the week. Bruises or swelling Fever or cough Cramps Small cuts or burns Earache Rash Sore throat Vomiting (throwing up) WHAT DO I DO IN AN EMERGENCY? In an emergency, get help right away. Call 911, or go to the nearest hospital emergency room or other setting you want to use for health care. You do not need an OK from us for emergency care. You do not have to go to a Health Options Medicaid provider in an emergency. It does not matter if you are inside or outside of our service area. You will be covered for emergency care even if the provider is not part of our network. After you receive emergency services, you should call your PCP to plan your follow-up care. You should do this if the emergency is at home or away. WHAT DO I DO WHEN I NEED URGENT CARE? Urgent care is for a sudden illness or injury when your PCP can t see you in the office. Your PCP can help you determine whether you need to receive urgent care. If you cannot reach your PCP, call the 24-hour nurse help line. If you need urgent care, you can go to an urgent care center in Delaware. A list of urgent care centers in Delaware is included at the end of this handbook. 13 P age Member Services toll free

15 BEHAVIORAL HEALTH CRISIS SERVICES If you are having a mental health or drug or alcohol crisis, please call Crisis Intervention Services for help: In Northern Delaware, call: In Southern Delaware, call: You can also go to: Crisis Intervention Service Centers Community Mental Health Centers Recovery Response Centers Hospital Emergency Rooms. Crisis Intervention Service staff are available 24 hours a day to help people with severe personal, family or marital problems. These problems may include depression, major life changes such as unemployment or loss of an important relationship, anxiety, feelings of hopelessness, thoughts of suicide, delusions, paranoia and abuse of drugs or alcohol. Members can call or drop-in to the crisis intervention location closest to them. Crisis Intervention Services are listed below: NORTHERN DELAWARE LOCATIONS AND HOURS Crisis Intervention Services, Northern Delaware Herman Holloway Health Campus 1901 N. DuPont Hwy., Springer Building New Castle, DE Serves all of New Castle County and greater Smyrna in Northern Kent County Staffed 24 hours a day, 7 days a week , or toll free at Crisis and Psychiatric Emergency Services (CAPES) Unit Wilmington Hospital Emergency Department Wilmington Mental Health Center Williams State Service Center 1906 Maryland Ave., Canby Park Shopping Center, Wilmington, DE Hours: 8:00 am to 4:30 pm SOUTHERN DELAWARE LOCATIONS AND HOURS Crisis Intervention Services, Southern Delaware 700 Main Street (Rear Entrance), Ellendale, DE Serves all of Sussex County and Kent County south of greater Smyrna 14 P age Member Services toll free

16 Staffed 24 hours a day, 7 days a week , or toll free at Dover Mental Health Center Williams State Service Center 805 River Road, Dover, DE Hours: 8:00 am to 4:30 pm Georgetown Mental Health Center Adams State Service Center 546 S. Bedford Street, Georgetown, DE Hours: 8:00 am to 4:30 pm HOW TO USE YOUR BENEFITS YOUR HEALTH OPTIONS HEALTH ID CARD Always carry your Health Options and Medicaid ID cards with you. Show both of these cards to your PCP, hospital or other provider when you go for health care services. Look on your Health Options ID card for the following important information: Your name Your Health Options member ID number The date your Health Options insurance began (this is the effective date ) Your PCP s name and phone number Health Options name, address and toll-free Member Services phone number The phone number for the 24-hour nurse help line What you should do in an emergency You are the only one who can get health care services with your Health Options ID card. Every Health Options member has his or her own ID card. It is important to show the right ID card for the right family member. If you let someone else use your card, you may not be able to stay on our plan. You will get a new Health Options ID card if: You change your PCP (main provider). Your PCP s phone number changes. You lose your ID card. 15 P age Member Services toll free

17 If you did not get your Health Options ID card yet, or if you need a new one, please call us at our Member Services number. If you have trouble hearing or speaking, please call our Member Services TTY line. Use your Delaware Medicaid card for Dental services for children and non-emergency transportation. If your Delaware Medicaid card is lost or stolen, call the DSS Change Report Center. WHAT IS A PRIMARY CARE PROVIDER (PCP)? A PCP is a provider who will arrange your healthcare needs. Your PCP works with you to make sure that you get the care you need. A PCP can be any of these types of providers: Pediatrician (a doctor who takes care of babies and children) Family and general practitioner (a doctor who takes care of babies, children and adults) Geriatrician (a doctor who takes care of older adults) Nurse practitioner or physician assistant (someone who works in a doctor s office and treats you, within limits) Internist (a doctor who takes care of adults) Nephrologist (if you are on dialysis) A PCP also can be a clinic such as a: Health department Federally Qualified Health Center (FQHC) Your Health Options ID card will have the name and phone number of the PCP you chose, or the PCP assigned to you if you did not choose one. You can have the same PCP for the whole family, or a different PCP for each family member. MAKING AN APPOINTMENT WITH YOUR PCP Your PCP s phone number is on your Health Options ID card. Call your PCP s office during regular business hours to schedule an appointment or get help with medical care. Have your Health Options ID card and your Medicaid ID card with you when you call. Let the office staff know you are a Health Options member. You may be asked for the member ID numbers on the ID cards. Make sure to bring your Health Options ID card and your Medicaid ID card with you whenever you visit your PCP. Be on time for your visits. Call your PCP s office as soon as you can if you know you will be late or cannot keep your appointment. This will help shorten everyone s time in the waiting room. Your PCP may not be able to see you if you are late. If you cancel your appointment, your PCP s office can help you set up a new one. 16 P age Member Services toll free

18 WHEN YOU ARE SICK Your PCP is there to see you when you are sick. If this is during office hours, call your PCP, tell the person who answers the phone that you are sick, and want to see the doctor or speak to a nurse. The person who answers your call will need your name and a phone number where you can be reached. The PCP s office staff may have to call you back. HOW TO CHANGE YOUR PCP It is best to keep the same PCP so he or she can get to know you and your health needs and history, but you can change your PCP for any reason. If you want to change your PCP, call our Member Services number. If you have trouble hearing or speaking, please call our Member Services TTY line. We want you to be happy with your PCP. If you want to change PCPs, you have to call Member Services in advance. If you change PCPs often, your health care may not be as good as it could be by staying with a PCP that knows you and your health needs. When changing PCPs, you must pick a PCP that will see new patients. A request to change your PCP may be denied if the PCP you want is not taking new patients. Please call Member Services if you need help finding a PCP that is taking new patients. If you choose a PCP who is not taking new patients, we will help you choose another one. You will get a new Health Options ID card with your new PCP s name on it. Your new PCP will help get your medical records from your old PCP. Health Options or your PCP may ask you to change your PCP if: Health Options no longer works with your PCP. You are not able to get along or agree with your PCP. You keep making appointments and not showing up for them. You have filed a law suit against your PCP. If you need a list of participating doctors, hospitals or other special providers, including what the education of your doctor is, please contact Member Services. You can also visit our website at for a list of providers. FAMILY PLANNING Family planning can help teach you how to: Be as healthy as you can before you become pregnant. Keep you or your partner from getting pregnant. Keep you from getting diseases. 17 P age Member Services toll free

19 Any member (including minors) may see a licensed family planning provider without getting an OK from us first. This includes providers who are not part of our network, such as: Clinics OB/GYNs PCPs Certified nurse-midwives You do not need to get an OK from your PCP for family planning care. Members may use any licensed family planning clinic or provider in Delaware. The provider does not have to be part of our network. If you choose to see a family planning provider, let your PCP know so you can get the best health care. Your family planning provider and your PCP will work together to make sure you get the right care. Family planning records are kept private. Doctors should keep all family planning records private, unless the law says it is OK. Your doctor is allowed to share your medical information with other doctors who take care of you, public health officials, or government agencies. PREGNANT WOMEN AND NEWBORNS Call us right away if you are pregnant. If you are in the last three months of your pregnancy and you just joined our health plan, you may be allowed to stay with your current doctor even if that doctor is not in our network. ENROLLING YOUR NEWBORN As soon as you can after your baby is born, within 30 days, call the DSS Change Report Center to make sure your baby is added for health benefits. Call Member Services to tell us what PCP you want for your baby. If you do not choose a PCP for your baby, we will choose one for you. You will get an ID card for your baby with the PCP s name and phone number on it. ARRANGING YOUR CARE There are some services that we must approve before you can get them. This is called prior authorization. You may have to pay up to the full amount of the charges when a service is provided without prior authorization. There are doctors and nurses who work for us to help your doctor choose the best way to take care of you. They make decisions about the care that is most likely to help you by using specific guidelines for medical decisions. The guidelines are based on whether the service is medically necessary. 18 P age Member Services toll free

20 Medically necessary means health care and services that will: Be directly related to the diagnosed medical condition or the effects of the condition of the member (the physical or mental functional deficits that characterize the member s condition), and be provided to the member only; Be appropriate and effective to the needs, aptitudes, abilities, and environment of the member and the member s family; Be primarily directed to treat the diagnosed medical condition or the effects of the condition of the member, in all settings for normal activities of daily living, but will not be solely for the convenience of the member, the member s family, or the member s provider; Be timely, considering the nature and current state of the member s diagnosed condition and its effects, and will be expected to achieve the intended outcomes in a reasonable time; Be the least costly, appropriate, available health service alternative, and will represent an effective and appropriate use of program funds; Be the most appropriate care or service that can be safely and effectively provided to the member, and will not duplicate other services provided to the member; Be sufficient in amount, scope and duration to reasonably achieve its purpose; Be recognized as either the treatment of choice (i.e. prevailing community or statewide standard) or common medical practice by the practitioner s peer group, or the functional equivalent of other care and services that are commonly provided; Be rendered in response to a life threatening condition or pain, or to treat an injury, illness, or other diagnosed condition, or to treat the effects of a diagnosed condition that has and will be reasonably determined to: o Diagnose, cure, correct or improve defects; physical and mental illnesses and diagnosed conditions or the effects of such conditions; or o Prevent the worsening of conditions or effects of conditions that endanger life or cause pain, or result in illness, or have caused or threaten to cause a physical or mental dysfunction, impairment, disability, or developmental delay; or o Effectively reduce the level of direct medical supervision required or reduce the level of medical care or services received in an institutional setting or other Medicaid program; or o Restore or improve physical or mental functionality, including developmental functioning, lost or delayed as the result of an illness, injury, or other diagnosed condition or the effects of the illness, injury or condition; or o Provide assistance in gaining access to needed medical, social, educational and other services required to diagnose, treat, or support a diagnosed condition or the effects of the condition, in order that the member might attain or retain independence, self-care, dignity, self-determination, personal safety, and integration into all natural family, community, and facility. Examples are: To find the cause of an illness or treatment of illness or injury. To help a part your body that is not normal work better. 19 P age Member Services toll free

21 To prevent illness. To help a member meet the right growth and development levels. If you need a service that must be approved by us before it is done, your doctor will call us to get approval. Our doctors and nurses will look at all the medical facts given by your doctor to decide if this service is the best way to take care of you. Our doctors and nurses make a decision on whether the care is medically necessary and appropriate for you. There is no extra payment given to these doctors and nurses no matter what they decide about your care. Doctors and nurses are not rewarded for reducing the amount of care approved. Some of the services that need to be approved by us before you have them are listed below: Hospital admission The use of an outpatient unit in a hospital for certain medical operations Medical equipment for your home Nurses to come to your home Physical therapy, occupational therapy or speech therapy using a doctor or other provider not in our network Hospice (care for the terminally ill or dying) Nursing home or rehabilitation admissions Surgery There may be other services that need an OK by us first. Your PCP or other doctor must contact us to get prior authorization for certain services. If you need to have tests or an operation, your doctor will call us to have the services approved. We will suggest a place for treatment. If we denied payment for a service that you already had, your doctor may ask for a retrospective review to change the decision. A retrospective review is a detailed look by us at your records and information to determine if the services were necessary to keep you healthy. If you are admitted to the hospital and your doctor feels that you may need more days of care, a concurrent review may happen. A concurrent review is a detailed review while you are still in the hospital. This is also done by us to determine if the services are necessary to get you healthy. You have the right to have any coverage denial reviewed by medical professionals with knowledge of your condition. If you have been denied coverage of a service because of medical necessity, you have the right to appeal the denial decision. 20 P age Member Services toll free

22 You may request a copy of the criteria for medical necessity on which the decision was based by sending a written request to: Health Options Member Correspondence PO Box Pittsburgh, PA SPECIALTY CARE Doctors that work with a certain area of medical care are called specialists. Some types of specialists are heart doctors, skin doctors, or someone who does surgery. Specialty services do not require a referral from your PCP. You can go to any doctors in our network for services without a referral. You can go to any doctor for family planning services, even if the doctor is not in our network. You can self-refer to a doctor for family planning services without a referral from your PCP. You do not need a referral for outpatient behavioral health services including mental health care (depression) or drug and alcohol abuse. Your behavioral health provider will contact Health Options for an authorization. Our goal is for you to be seen by the specialist that can best treat you. If we do not have a specialty doctor in our network doctors that can treat you, we will make arrangements with a specialist that is not in our network. Your PCP can help you make the request for care outside of our network doctors. If your request is denied by us, you may file an appeal. Please see the section later in this handbook for steps to follow for filing an appeal. If you have been seeing a specialist for an ongoing problem, the doctor can request to be your PCP. Please call Member Services for help in getting your specialist to be your PCP. A specialist may send you to receive special services or tests. Examples of services and tests are: Angiograms Bone Scans Chemotherapy (Hospital Setting) Endoscopies Nerve Conduction Testing Sleep studies HOW CAN I GET A SECOND OPINION? You may want to be seen by a different doctor, other than the one you have been seeing, for a second opinion. Your PCP can refer you to another doctor in our network for a second opinion. If a network doctor is not available, we will arrange for you to get a second opinion at no cost to you from an out-of-network doctor. If you have any questions, please call Member Services. 21 P age Member Services toll free

23 OUT-OF-NETWORK CARE Many doctors and hospitals participate with us. They are called the network. There may be a time when you need to use a doctor or hospital that is not a part of our network. If this happens, your PCP can call us to make this request. We will check to see if there is a doctor or hospital within our network that can give you the same care. If there is a doctor or hospital within the network, we will let your doctor know. New members have the right to keep seeing an out-of-network doctor to finish a course of treatment. The doctor must agree to our guidelines. If you have been getting ongoing care from a doctor that is not a network doctor, and you need to stay with this same doctor to finish a course of treatment, please call Member Services for help. Please keep in mind that any services received from providers not in our network must be approved by us. If a request to use a doctor or hospital outside of our network is denied, you can file an appeal by calling Member Services. If you receive services from a provider that is not in our network without approval, that provider may be allowed to bill you for the entire cost of the services. OTHER MEDICAL STAFF IN YOUR DOCTOR S OFFICE Some medical offices may have other types of staff treating you besides doctors and nurses. These types of medical staff are sometimes called physician assistants and nurse practitioners. They are specially trained to work in your doctor s office and to examine you. Your doctor will always oversee any treatment that you get. Some offices also have doctors working there who are finishing their training. These are called Medical Residents and work with your regular doctor to take care of you. WELLNESS PROGRAMS We want you to have a happy, healthy life. Below are programs that are offered to help you stay well and manage any conditions you may have. HEALTH RISK ASSESSMENT (HRA) Understanding your own health and knowing what you can do to improve it is a big first step in being happy and healthy. We want you to complete a Health Risk Assessment and return it to us. You can complete the assessment on line through the Health Options website or we will send you a form you can complete and mail back to us. We will review the assessment and send you a Personal Health Report. The Personal Health Report will give you information that can help you improve or maintain healthy habits for a healthier you. Your answers on the assessment and your Personal Health Report are private. We do not share the results with anyone. We want you to share the results with your PCP so your PCP can work on ways to help you stay healthy or make your health better. Completing a Health Risk Assessment is simple and the benefits can last a lifetime. Get started today. 22 P age Member Services toll free

24 ASTHMA PROGRAM Do asthma symptoms stop you for doing things or make things more difficult for you? If you said yes, we want you to be part of our Asthma Program. The asthma program is offered to members 2 years of age and older. A Care Coordinator will help you manage your asthma. This can help you to better control your asthma so you can do the things that you want to do. Here are a few reminders to help you stay on track: Take your controller medicine every day. This medicine helps to prevent symptoms. It controls swelling and decreases mucus in your airways. Tell your doctor if you need to use your rescue inhaler more than 2 days a week. This may mean that your asthma is out of control. You may need more medicine. Ask your doctor about an asthma action plan. This will help you know what to do when you are sick. Visit your doctor at least 2 times a year. If you need to go to the hospital, make an appointment to see your doctor within 2 weeks of leaving the hospital. Stop smoking and avoid second-hand smoke. Get help to quit smoking by calling the Delaware Quit line at QUIT-NOW ( ) If you would like more information on the Asthma Program, call our Care Management department. CHRONIC OBSTRUCTIVE PULMONARY DISEASE PROGRAM Living with chronic obstructive pulmonary disease (COPD) can be overwhelming. Health Options wants to help! If you are at least 21 years of age and are living with COPD, you may benefit from our COPD program. A Care Coordinator can help you learn how to manage your symptoms so that you can be more active and enjoy life. Here are a few reminders for managing your COPD: Take your breathing medicines as your doctor ordered. Tell your doctor if you have side effects or if you have trouble using your inhaler. Do not stop taking your medicines on your own. This may cause your COPD to flare up. Quit smoking. This is the most important change you can make. You can get help by calling the Delaware Quit line at QUIT-NOW ( ) Get a yearly flu shot. Ask your doctor about a pneumonia shot if you have not had one. Talk to your doctor about an exercise program. Daily exercise can help you to breathe better. Make sure you use your oxygen if it was ordered for you. It can help you to be more active. Avoid going outside when pollution levels are high. Air pollution can make your breathing worse. Pay attention to alerts on the radio and television. If you need to go to the hospital, get all of your medicines filled when you come home. This can help prevent your symptoms from flaring up again. Make an appointment to see your doctor within 2 weeks of leaving the hospital. If you would like more information on the COPD Program call our Care Management department. 23 P age Member Services toll free

25 CARDIAC PROGRAM If you are a member age 21 or older who has congestive heart failure, or had a heart attack, stents, or bypass surgery, you can be part of our Cardiac Program. This program helps you understand how to take care of your heart so you can live a healthy life. The Care Coordinators help you understand what has happened to your heart. They will teach you about a proper diet, exercise and how to take your medicines. They will teach you warning signs to look out for. Here are a few reminders for managing your heart problems: Take your medicine the way your doctor ordered. If you can t, call the office and tell them. Wait to hear from the office before you stop taking your pills. Some heart pills have to be stopped over several days. Do not just stop taking a pill. You can have complications if you do. Follow your doctor s directions for taking your medicine. Make sure you visit your doctor at least twice a year for a checkup. If you are admitted to the hospital make an appointment to see your doctor within 2 weeks of leaving the hospital. Ask your doctor which lab tests you need to control your heart disease. Stop smoking and avoid second-hand smoke. Get help to quit smoking by calling the Delaware Quit line at QUIT-NOW ( ) If you would like more information on the Cardiac Program call our Care Management department. DIABETES PROGRAM If you are a member with diabetes, you can be part of our Diabetes Program. Diabetes can cause problems for your heart, eyes, kidneys and circulation before you even know it. Diabetes can lead to heart failure. It is also the leading cause for amputations. Many people who are getting kidney dialysis are diabetics. We offer a diabetic program that teaches you what symptoms to look for. Care Coordinators teach you about the simple blood and urine tests you should have that warn you of some of the problems BEFORE you even know they are a problem! Here are a few reminders about managing your diabetes: Take your blood sugar readings the way your doctor ordered them. Certain tests will help to show kidney or heart problems. Make sure you get these tests at least every year and more often if the doctor tells you to: HbA1c, LDL-c, urine test, and have your blood pressure taken. Go to your eye doctor and tell them you are a diabetic. You need a dilated retinal eye exam at least every year. Your doctor can tell if diabetes is damaging your eyes during this test. Glasses cannot fix all eye problems caused by diabetes. Ask your doctor which lab tests you need to keep your diabetes under control. Stop smoking and avoid second-hand smoke. Get help to quit smoking by calling the Delaware Quit line at QUIT-NOW ( ). If you would like more information on the Diabetes Program call our Care Management department. 24 P age Member Services toll free

26 EPSDT Members under age 21 are eligible for a special program to find children s health problems early. And, once we find them, we need to keep checking to be sure children stay healthy. We call it the Growing Up Program. This program includes all of the services recommended by the state s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. These services also are called well-visits. These visits are free for enrolled members under 21 years of age. Well visits include screenings needed for your child s PCP to understand any medical needs. During these visits the PCP will complete a physical exam. He will also complete health and developmental history. Vaccines (shots) are part of these visits. Your child s PCP will check on many areas of health during EPSDT exams and screenings. The doctor will check on your child s heart, lungs, eyesight, hearing, and teeth. If your doctor finds areas of concern, he will make a referral to send your child for other tests. He can also send your child to a specialist. The doctor will recommend children age 1 and above go to a dentist as part of their regular EPSDT well child screens. For the EPSDT visit, the doctor could: Give your child shots Ask about your child s nutrition or diet Test your child s urine or blood for medical conditions Ask questions about your child s mental health and speech Ask about social actions and behavior the way your child relates to other kids their age Ask family and relatives to put together a family medical history During your child s EPSDT exam, the PCP will identify if your child is due for a dental appointment based on his or her age. This benefit is offered through your Medicaid ID card. Please remember dental health is very important even with very young children. Talk to your PCP about your child s dental health at each EPSDT visit. It is very important that you keep your EPSDT appointments with the doctor. These physical exams can sometimes be used as the exam your child needs to get into Head Start, or for school, or for a driver s license physical. The doctor may find that your child needs a medically necessary service or a piece of equipment to treat a problem found during a screening visit. If so, the doctor can call Health Options to ask for the service or equipment, and it will be reviewed for approval. If you need more information about the Growing Up program, please call Member Services. Member Services can help you set up an appointment for your child, assist you with dental appointments or help you get a ride for these appointments. COMPLEX CARE COORDINATION 25 P age Member Services toll free

27 Health Options provides a Complex Care Coordination program for eligible members. A Care Coordinator can help you to better understand your health condition and benefits. They can also help to coordinate your health care services by talking with your doctor. A Care Coordinator can tell you about community organizations and resources that may meet your needs. Eligible members may include: Members with multiple medical conditions Members with a complex medical history Members that need assistance to become more self-reliant in managing their health care For further information, please call: Participation in this program is voluntary. Health Options will review the request for enrollment and make the final decision for inclusion in the program. BEHAVIORAL HEALTH CARE COORDINATION Behavioral Health means mental health and drug and alcohol abuse. Health Options provides a Behavioral Health Care Coordination program for eligible members. A Behavioral Health Care Coordinator can help you understand your behavioral health condition and benefits. They can also help to coordinate your behavioral health services by talking with your psychiatrist, your therapist or counselor, or your PROMISE Case Manager if you have one. A Behavioral Health Care Coordinator can tell you more about community organizations and resources that may meet your needs, and can help you develop a way for you to manage your behavioral health needs. For more information please call: TRANSITIONING HOME FROM THE HOSPITAL It can be overwhelming to remember all of the things you need to do when you get home from the hospital. To help make this transition easier for you and your family or caregiver, here are things you and your Care Coordinator can do: Things You Can Do: Keep your discharge instructions Make sure you understand how and when to take your medicines Keep a current list of your medicines See your doctor to ask questions and review your medicines Ask for help from a Care Coordinator or family and friends. They can help with setting up your medicines, having prescriptions filled and reminding you of upcoming appointments. Call your Primary Care Physician (PCP) if you have questions Things the Care Coordinator Can Do: Call you while you are in the hospital to talk about your medicines and follow up appointments 26 P age Member Services toll free

28 Contact you once you get home to review your discharge instructions Contact you after you see the doctor ACCESSIBILITY AND AVAILABILITY STANDARDS This chart shows how long it should take for you to get a doctor s appointment. Member Visits First new member appointment Preventive care appointments Routine primary care (non-urgent) appointments Urgent complaint appointment Emergency appointment First prenatal visit First Trimester First prenatal visit Second Trimester First prenatal visit Third Trimester 24-hour availability Waiting room time Number of patients per hour You should see a healthcare provider in Less than 2 weeks Less than 21 days Less than 21 days Less than 48 hours Immediately Within 21 days of member request Within 7 days of member request Within 3 days of member request 24 hours a day; 7 days a week 1 hour No more than 6 patients per hour This chart shows how long it should take to travel to a doctor s appointment. The amount of time it takes to get to PCPs and specialists you see often Basic hospital services Tertiary services Should be no longer than 30 minutes 45 minutes 60 minutes DIFFERENT TYPES OF CARE There are different types of care that you may receive. These include the following. ROUTINE CARE Routine care is the regular care you get from your PCP, such as checkups to help keep you healthy and office visits when you are sick. You can call your PCP s office to make an appointment for routine care. Your PCP should schedule your appointments within 21 days from when you call the office for an appointment. URGENT CARE A medical condition is urgent if it is not an emergency but should have medical care within 48 hours. Call your PCP if you have an urgent medical condition. If your PCP cannot see you, you for your urgent condition, the list of urgent care centers is at the end of this handbook. 27 P age Member Services toll free

29 If you cannot reach your PCP, call the 24-hour Nurse Help line. The registered nurses (RNs) at the Nurse Help line can answer your health care questions and help you make good health care decisions. If you need emergency health care, call 911 right away. The Nurse Help line is not meant to replace the medical advice of your doctor. Please always ask your doctor for medical advice. AFTER-HOURS CARE You can reach your PCP 24 hours a day at the phone number on your Health Options ID card. After normal business hours, leave your name and phone number with the PCP s answering service. Either your PCP or an on-call doctor will call you back. You also can call the 24-hour Nurse Help line. It is best to work with your PCP for your health care needs. But if you have a medical question and don t know what to do, call our 24-hour Nurse Help line. They can help you decide what to do when you need health care. They can tell you if you should call your PCP, make an appointment or go immediately to the emergency room. The toll-free number for the Nurse Help line is (TTY 711). This number is on the back of your Health Options ID card. OUT-OF-AREA CARE You never know when or where you will get sick or injured. Carry your Health Options ID card with you at all times. If you are outside of Delaware, and your problem is not an emergency or you are not sure if it is, call one of these right away: Your PCP. (Your PCP s phone number is listed on your member ID card.) Member Services. The 24-hour Nurse Help line. If you think you have an emergency, call 911 or go to the nearest emergency room. We cover emergencies anywhere in the United States. You are not covered for services received outside the continental United States. Do not use an emergency room for routine care. We do not cover emergency room visits for routine care, whether the visits are made inside or outside of Delaware. PREGNANCY CARE Care when you are pregnant is called Maternity care. Maternity care includes: Office visits and tests before your baby is born called prenatal care; 28 P age Member Services toll free

30 The hospital stay when you deliver your baby. Office visits and tests after your baby is born called postpartum care. Take good care of yourself and your baby. See your doctor as soon as you know you are pregnant. We have a special program for pregnant women. This program provides education and support to help you have a healthy pregnancy. You should try to remain with us throughout your pregnancy to get the most of this program. Care Coordinators can answer your questions or concerns about your pregnancy. The Care Coordinators can also help with community service referrals. You will also receive information on pregnancy and baby care in the mail. Your first visit with your doctor should be within 14 days of finding out you are pregnant. If you would like more information about the Maternity Program, call our Care Coordination department. Your doctor will notify Health Options about your pregnancy and we will send you information about our MOM Options program and how you can participate. Here are some helpful tips for your pregnancy: Keep all of your prenatal appointments. If you miss an appointment, call your doctor to reschedule. Do not wait until your next visit. Take the prenatal vitamins prescribed by your doctor. Prenatal vitamins are an important part of your prenatal care for both the health of you and your baby. There are many prenatal vitamins available that we pay for. Avoid alcohol, illegal drugs, and smoking. Second-hand smoke can harm you and your unborn child. Get help to quit smoking by calling the Delaware Quit line at QUIT- NOW ( ). Never take any medicines without checking with your doctor first. This includes prescription medications and over the counter medications like aspirin, Tylenol and cough syrup. Eat at least 3 meals a day and choose healthy foods like fruit, meat, milk, vegetables, breads, and cereals. Avoid foods like coffee, soda pop, fast foods, candy, and doughnuts. Drink at least 6 to 8 glasses of water every day. Juice and milk are also healthy choices. Keep your teeth and gums healthy by brushing and flossing daily. Gum infections can increase the risk your baby being born too soon. Wear your seat belt when you are in a car. Make sure the bottom part of the belt goes low under your belly and touching your legs, not across your belly. NURSE MIDWIFE OR CERTIFIED PEDIATRIC/FAMILY NURSE PRACTITIONER You can get health services from certified nurse midwives, certified pediatric nurse practitioners or family nurse practitioners who are part of our provider network. The midwives and nurse practitioners work in doctor offices, hospitals and clinics. Check the Health Options Provider 29 P age Member Services toll free

31 Directory or call Member Services for more information. For your maternity benefit, home birth is not a covered benefit regardless of the provider. SEXUALLY TRANSMITTED DISEASE (STD) CARE If you think you have an STD, please contact your PCP or OB/GYN right away. They can help you get the care you need. You do not need an OK from Health Options before receiving this care. You can also get this care from any Medicaid provider. SPECIALIST CARE Your PCP may send you to a specialist for special care or treatment. Your PCP will work with you to choose the right specialist to give you the care you need. Your PCP s office can help you make the appointment with the specialist. Tell your PCP and the specialist as much as you can about your health, so that all of you can decide what is best. HOSPITAL CARE Your Primary Care Physician (PCP) or specialist will arrange all your admissions to the hospital. You should not be admitted to a hospital without your doctor s orders, unless it is an emergency. If a doctor other than your Health Option s doctor admits you to the hospital, you or your authorized representative should call your PCP within 24 hours of being admitted. Call Member Services if you have any questions. 30 P age Member Services toll free

32 WHAT WE COVER This section talks about the kinds of care you can get through Health Options. Keep in mind that some of these services must be approved by your PCP and/or us first. You may have to pay up to the full amount billed by the providers if you choose to receive services that we do not cover. We only pay for covered care that is medically necessary. HEALTH OPTIONS BENEFITS BENEFITS Bed Liners Behavioral Health Outpatient Mental Health and Substance Abuse Services Behavioral Health Inpatient Mental Health and Substance Abuse Services Blood and Plasma Products Bone Mass Measurement (bone density) Care Management and Coordination Chemotherapy Colorectal and Prostate Screening Exams CT Scans Dental Services ( Under age 21) Call or toll free Dental Services (Adult) Diabetic Education Diabetic Equipment Diabetic Supplies Dialysis COVERAGE for members age 4 and up Under age 18: for 30 visits per year. After 30 visits per year, services are covered by the Department of Services for Children, Youth and Families (DSCYF) Age 18 and older: Under age 18: covered by DSCYF Age 18 and older: The Delaware Medical Assistance Program covers certain dental care for children up to age 21, including the Delaware Healthy Children Program up to age 19. Removal of bony impacted wisdom is covered Not covered except removal of bony impacted wisdom teeth, your physician has to get prior authorization if over $500 Glucose monitors/strips 31 P age Member Services toll free

33 BENEFITS Drugs Prescribed by a Doctor Durable Medical Equipment Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services (for under age 21) Emergency Medical Transportation (Air and ambulance) Emergency Room Care Eye Exam, Medical (for conditions such as eye infections, glaucoma and diabetes) Eye Exam, Routine Eye Glasses and Contact Lenses Family Planning Services Genetic Testing Glaucoma Screening Gynecology Visits Hearing Aids and Batteries Hearing Exams HIV/AIDS Testing Home Health Care and Infusion Therapy Hospice Care Hospitalization Immunizations Lab Tests and X-rays Mammograms Medical Supplies MRI, MRA, PET Scan Nursing Home Obstetrical/Maternity Care COVERAGE, your physician has to get prior authorization if over $500 for All Members if age 20 and younger See additional benefits for adult coverage if age 20 and younger See additional benefits for adult coverage if age 20 and younger, your physician has to get prior authorization if over $500 up to 30 days per year Additional days are considered long term care; an application must be submitted to and approved by the Delaware Medical Assistance Program for long term care. 32 P age Member Services toll free

34 BENEFITS Outpatient Surgery, Same Day Surgery, Ambulatory Surgery Pain Management Services Parenting / Child Birth Education Personal Care / Aide Services (in home) Podiatry Care (routine diabetic care or peripheral vascular disease) Prescription Drugs Primary Care Provider Visits Private Duty Nursing Prosthetics and Orthotics Radiation Rehabilitation (inpatient hospital) Skilled Nursing Facility Care Sleep Apnea Studies Smoking Cessation Counseling Specialty Physician Services Surgical Center Therapy - Outpatient Occupational, Physical, Speech COVERAGE up to 30 days per year ADDITIONAL BENEFITS ADULT EYE EXAMS AND EYE GLASES AND CONTACT LENSES - Regular eye exams are very important. That is why we give this benefit to adults age 21 and over. There is no waiting period to get your vision benefit. You must go to an eye care provider in our network. Be sure to show your Health Options ID card and say that you are a Health Options member. Health Options covers one eye exam every twelve months. Adults may receive up to $150 dollars towards the purchase of eye glasses or contact lenses once every two years. WEIGHT SCALES For members with heart failure, it is very important to manage your health. We help you do that by providing you with a scale to weigh yourself every day. By tracking your weight, you can help your physician make changes to your medications to keep feeling better. 33 P age Member Services toll free

35 PILL BOXES For members that take pills, we provide pill boxes to help you organize and take your medications each day. To learn more, about these Additional Benefits call Member Services of our Care Coordination department. SPECIAL NEEDS If you have a special health care need, we can help. Nurses, social workers, and other healthcare staff help to make sure you get the medical care that you need. We can help you with any problems you have in getting your care. If you would like information about programs in your community such as food banks or HIV programs, call the Care Coordination department at SERVICES NOT COVERED There are some services not covered by us. You may be required to pay for them. Limitations and most exclusions do not apply to members under age 21. Services not covered include: Abortion unless pregnancy is the result of rape or incest, or if the woman suffers a lifeendangering physical condition caused by or arising from the pregnancy itself Autopsies Chiropractic services Cosmetic Surgery (also called plastic surgery), unless medically necessary. Dental services for members 21 years of age or older Christian Science nurse and/or sanitariums Experimental procedures, unless prior approval from us is received. Exercise equipment for the home Care outside of the service area except in an emergency Care outside of the continental US Hippotherapy Infertility treatments Inpatient hospital test that are not ordered by the attending physician or other licensed practitioner, acting within the scope of practice, who is responsible for the diagnosis or treatment of a particular patient s condition Non-emergency services from an out-of-network provider that are not prior approved Personal items or services such as television or a telephone while you are in the hospital. Prescription drugs not listed on the approved drug list, unless an exception is made. Drugs designated as less than effective by the Food and Drug Administration (FDA). These are also known as DESI for the Drug Efficacy Study Implementation drugs. Drugs prescribed for the treatment of erectile dysfunction. Treatment for infertility (when you cannot become pregnant). Work related and travel physicals Services/items that are not medically necessary 34 P age Member Services toll free

36 Respite care Services that are not covered by the Medicaid program Non-medical items or services. Hearing aids for members 21 years of age and older Paternity tests Residential weight loss clinics Single-antigen vaccines and their administration when combined antigen was appropriate Sterilization of a mentally incompetent or institutionalized individual Surgery, medication, or any other medical procedures or services related to sex-change. There may be other services that are not covered by us. If you are not sure if the service you need is covered, call Member Services. Some services, such as transportation and dental care for children, are not covered by us but may be covered by your Delaware Medicaid card. You may have to pay for services that are not covered by us or your Delaware Medicaid card, or for services not provided by a Delaware Medicaid participating provider without an approval. WHEN YOU MAY HAVE TO PAY FOR SERVICES You may have to pay for care you get from a provider who is not part of the Health Options provider network. Call Member Services and they can tell you if a provider is part of the provider network. Sometimes we will pay for your care even if you do not go to a Health Options Medicaid provider: For care in an emergency. When your PCP sends you, and we approve (prior authorize) the care before your visit. For family planning services. You may have to pay for health care if you do not go to a Health Options provider. The only times you would not have to pay are listed above. SERVICES COVERED BY FEE-FOR-SERVICE MEDICAID PROGRAM Medicaid covers some types of care that we do not such as: Dental care for children under age 21 Transportation for things that are not an emergency Some of them may be limited or need an approval from the DMMA ahead of time. To find out more, call your DMMA Customer Services at You also can call our Member Services number if you need help receiving these services. 35 P age Member Services toll free

37 CARE AWAY FROM HOME If you get sick while you are away from home, call your PCP or the 24-Hour Nurse Help line. Your PCP or a nurse can tell you what type of treatment you need and if you should see a doctor. If you need treatment and are too far away to see your PCP within 24 hours, Health Options will help you find a provider or urgent care center nearby. If you have an emergency when you are away from your home, you can still call your PCP or the 24-Hour Nurse Help line. They can help you decide what kind of treatment to get. If you need emergency treatment and you are outside of Delaware, you should go to the nearest urgent care center or hospital. Please let the hospital know that you are a Health Options member and have the hospital call Member Services. If you go to a hospital that is not in the network, we may ask you to move to another hospital in our network when you are well enough to do so. WOMEN, INFANTS, AND CHILDREN (WIC) PROGRAM WIC is a program that provides you with basic, healthy foods assuring that your family is getting the nutrition they need. Foods such as milk, cheese, eggs, juice, peanut butter, cereal, and infant formula are made available for your family. The WIC program also provides many other services free of charge to pregnant women, postpartum women, and children up to the age of five. Services include nutrition education, breastfeeding, prenatal nutrition, medical referrals, counseling, and health screening. You can apply for WIC by calling your local WIC office. If you would like more information about WIC, call our Care Coordination department at MEDICINES AND PRESCRIPTION DRUGS Health Options covers many drugs used for high blood pressure, heart disease, COPD, asthma, diabetes and high cholesterol. We also cover antibiotics, pain medications, eye drops, ear drops, and some over-the-counter drugs. HEALTH OPTIONS COVERED DRUGS ON OUR PDL A Preferred Drug List (PDL) is a list of drugs that we cover when they are medically necessary. The PDL is published by DHSS for Delaware Medicaid members and lists the drugs that are covered. There also are some supplemental drugs that are not on the PDL that Health Options will cover. SOME DRUGS NEED TO BE APPROVED (PRIOR AUTHORIZED) Certain drugs on the PDL need an OK from us ahead of time or have limits based on medical necessity. Your doctor will choose which drug is best for you. If the drug is on our PDL but must be approved before we cover them this is called prior authorization. Your doctor must call Health Options for you if a drug has to be prior authorized. 36 P age Member Services toll free

38 When you get a new prescription, ask your doctor if we need to approve the drug before you can get it. You can also ask your doctor if there is another drug you can use that does not need to be approved. If prior authorization is required, and you are in urgent need of your prescription medicine, your pharmacy may give you a 3-day emergency supply of the medicine. The 3-day emergency supply can be given to you only one time every 60 days. We will send you a letter if we do not approve a prescription drug. The letter will tell you how to file an appeal and how to ask for a State Fair Hearing if needed. If you would like to know if a drug is covered, please call Member Services at , Monday - Friday, 8 am to 8 pm or visit the website at Members with trouble hearing or speaking can call the TTY line at 711 or GENERIC DRUGS INSTEAD OF BRAND-NAME DRUGS Most of the time, only generic prescription drugs are covered. Generic drugs are as good as brandname medicines, so Health Options pays for generic drugs when available. When a drug is available as a generic, the brand-name drug is usually not covered. We must OK payment for drugs that are not on the PDL, including most brand-name drugs. If your doctor thinks you need to take a brand-name drug that is not on the PDL, your doctor will send us a request that tells us why you need the drug. In these cases, your doctor must ask for an OK before you get the drug. In most cases, Health Options will be able to notify you and your doctor if the medication will be covered or not within 24 hours. If the request is sent on a holiday or a weekend or if we need more information from your doctor, it may take longer. If we don t approve the drug, we will tell you in a letter. The letter will tell you how to file an appeal and how to request a State Fair Hearing if needed. OVER-THE-COUNTER (OTC) DRUGS We cover OTC drugs in many categories. The OTC drug needs to be prescribed by your doctor to be covered. The list of the OTCs that are covered was sent to you with your new your new member packet. You can also access the OTC list on our website at If you need help with what OTCs are covered, call a Member Service Representative. HOW DO YOU GET YOUR MEDICINE? Go to a Health Options network drug store and give them your prescription. You will need to show your Health Options ID card and your state Medicaid ID card. The network drug stores are listed in the provider directory available in the online provider search. If you need help finding a network drug store, call a Member Services Representative. Most drugs that are covered by Health Options can be filled for a maximum of a 34-day supply at a time. 37 P age Member Services toll free

39 When you pick up your medication, make sure you understand exactly how to take it. Taking too little or too much of your medicine can make you sick. Make sure to talk to your provider or the pharmacist if you are not sure about when or how to take your medicine. REFILLING YOUR PRESCRIPTIONS Your prescription may be refilled if: Your doctor ordered a refill The refill is permitted by law You have used 83 percent of the drug You do not need to wait until you are out of your drug to get a refill. It is best to get the drug refilled when you have three days left. If you have a problem with your prescription, call Member Services Representative to report it. EMERGENCY SUPPLY OF MEDICATION If you need to start the medication right away, you can ask your pharmacist to give you a 3-day emergency supply of the medication. The 3-day emergency supply benefit will be given to you once per 60 calendar day period for each medication. Your doctor should fax in an exception request. We will let your doctor know if we say OK to your request. If we do not OK your request, we will send you a letter that tells you why and how to appeal the denial. QUANTITY LIMITS Some drugs have limits to the number of doses you may get. This is called a quantity limit. The drug store will not give you more medicine if your doctor does not get an OK from us. The pharmacist will ask your doctor to call us first. WHERE TO GET YOUR PRESCRIPTIONS FILLED Health Options has contracts with a number of pharmacies in your area. These are called innetwork pharmacies. In-network pharmacies include specialty, compounding and 24/7 pharmacies for your convenience. You should always use an in-network pharmacy to get your prescriptions. You can find a list of these pharmacies in our Provider Directory. Or we can help you find a pharmacy in the network near you. Call Member Service at for help. The TTY line is 711 or You may only use an out-of-network pharmacy if you have an emergency. If you have to go to an out-of-network pharmacy in an emergency, ask them to call Health Options at If you are out of state and have an emergency and need prescriptions, the pharmacy can call the pharmacy provider number on the back of your member ID card to make sure your drugs are covered. PHARMACY LOCK-IN 38 P age Member Services toll free

40 Some members may have a medical problem that requires your providers and pharmacy to carefully coordinate your care. If you need this coordinated care, you will be assigned to one pharmacy to fill your prescriptions. This is the lock-in program. If a member is locked into a specific pharmacy, they must use only that pharmacy to get covered medications. Health Options will not cover medications for locked-in members if they use a different pharmacy. If the lockedin pharmacy does not have your medicine, contact Member Services at to be advised how to get that medicine from a different pharmacy. Health Options must verify that your lock-in pharmacy does not have enough of the medication before you can get your medication from a different pharmacy. We will send you a letter if we believe you will benefit from the lock-in program. Health Options will choose your lock-in pharmacy based on the pharmacy where you visit the most often or nearest to your home. If you disagree with our decision to include you in the lock-in program, you have the right to file an appeal. BEHAVIORAL HEALTH DRUGS Health Options is responsible for all your prescriptions, including behavioral health drugs. IMPORTANT THINGS TO KNOW WHEN YOU GET YOUR DRUGS Some drugs may hurt you if you take them at the same time as certain other drugs. To protect your health, we will let your doctor and pharmacist know if we are concerned about the drugs you take. When you get your prescriptions, let the pharmacist know if you have other health insurance. If you are covered by another health plan, that plan will pay first and Health Options will pay second. The total of the two payments cannot be more than the total amount Health Options allows. THE KINDS OF DRUGS HEALTH OPTIONS COVERS We cover: Drugs included on Delaware s Preferred Drug List Prenatal vitamins for women Multivitamins for members Prescriptions for behavioral health conditions Drugs to help you stop smoking. These include: o Nicotine patches, gum, lozenges, and nasal spray o Bupropion Diabetic supplies including: o Blood glucose monitors (continuous blood glucose monitors are covered under your medical benefit) o Tests strips o Lancets o Lancing devices o Urine glucose testing strips Aerochambers 39 P age Member Services toll free

41 Shots that you give yourself, such as insulin, are covered by your pharmacy benefit. Shots that must be given by your doctor in his or her office are covered under your medical benefit, not your pharmacy benefit. Prescriptions to replace lost or stolen drugs, one time per year for each drug - you must make a police report if the stolen medication is a controlled substance. If you lose your drugs, call us toll-free at for help. Members with trouble hearing or speaking can call the TTY line at 711 or We will help you replace the lost drugs. LIMITS ON YOUR PRESCRIPTION DRUG BENEFIT Health Options does not cover all drugs. The items we do not cover: Drugs used for weight loss or gain Drugs used for cosmetic purposes like wrinkles or hair growth Over-the-counter (OTC) drugs, except those listed on the supplemental drug list Over-the-counter (OTC) drugs and supplies when you live in a Long Term Care facility Drugs used in fertility treatments or drugs used for erectile dysfunction Herbal or homeopathic drugs Nutritional supplements Vacation supplies and early refill of drugs Prescriptions for any drugs that are not medically necessary Experimental or investigational drugs DESI drugs Drugs ordered by a physician who has been barred or suspended from participating in the Delaware Medicaid Program Drugs that duplicate a therapy that you are already taking Drugs marketed by a drug company that does not participate in the Federal Medicaid Drug Rebate Program Durable medical equipment (DME) and supplies will still be covered by your medical benefit. PREFERRED DIABETIC SUPPLY LIST (PDSL) EFFECTIVE 1/1/2015 As of January 1, 2015, Health Options will have a Preferred Diabetic Supply List, which includes preferred test strips and preferred meters. The products that are preferred can be found on the website DENTAL SERVICES Dental services for children up to age 21 are covered by the Delaware Medicaid fee-for-service program. Dental services are not covered for adults 21 and over. For children under age 21, extraction of bony-impacted wisdom teeth is covered by Health Options. 40 P age Member Services toll free

42 BEHAVIORAL HEALTH SERVICES Behavioral Health services are provided for mental health and drug and alcohol abuse. Your PCP or behavioral health provider can help you get the behavioral health care you need. If you need further assistance or information a Health Options Behavioral Health Care Coordinator can assist you. Behavioral health care includes inpatient and outpatient services from hospitals, drug and alcohol treatment facilities, psychiatrists, psychologists, counselors, and social workers. NON-EMERGENCY TRANSPORTATION Non-emergency transportation (NET) may be available to get you to and from Medicaid-covered medical appointments that you have made. DMMA contracts for NET services with a transportation broker, LogistiCare, Inc. All fully eligible Medicaid clients are eligible for NET. NET services are not a benefit in the Delaware Healthy Children Program. Transportation arrangements should be made no less than two days in advance of a scheduled appointment. LogistiCare will verify that the recipient is Delaware Medicaid eligible and that transportation is required to a covered service. Once both criteria are confirmed, LogistiCare will arrange for appropriate transportation to the covered medical service by one of their contracted transportation providers. Eligible Delaware Medicaid clients in need of non-emergency transportation should contact LogistiCare at NEW TECHNOLOGY Health Options evaluates new technology to decide if it should be included as a covered benefit. New technology means any skills, equipment, or know-how of doing something better. Health Options looks at new technologies to make sure it is safe and is as good as or better than current medical products or procedures. Health Options has pharmacists and physicians who look at new drugs and new uses for drugs four times a year. New drugs are added to the PDL and/or formulary list on an on-going basis. Drugs may be removed from the PDL and/or formulary four times per year. HOW TO FILE A GRIEVANCE OR APPEAL We want you to be happy with the health care and service you receive. Please let us know if a doctor, hospital, or we do something that you are unhappy about. We will try to fix any problems over the phone. If you don t like something or we can t fix your problem, you can file a grievance or an appeal. This section describes the process. You may call Member Services if you need help or have questions about how to file a grievance or appeal. You cannot be punished for filing a grievance or appeal. You can have someone file an appeal for you or represent you. If you want to have someone file a grievance or appeal or represent you, we will need to have your OK in writing. 41 P age Member Services toll free

43 You or your representative may contact an appeal coordinator at any time for help or any questions about the grievance or appeal process. You may also ask for help with a grievance or appeal by asking for a Member Advocate. You can ask for a Member Advocate by calling Member Services. A Member Advocate can help you: File your grievance or appeal Help you through the grievance or appeal process Answer your questions about the grievance or appeal process Help you get additional information from your doctor to help with your grievance or appeal GRIEVANCES A grievance is a statement of unhappiness, like a complaint, and can either be filed in writing or verbally over the phone. A grievance can be about any service that you received from a doctor or by us. A grievance does not include a denial of benefits for health care service. Those matters are handled as appeals (see Appeals below). Some examples of a grievance are: If a provider or our employee was rude to you If you feel a provider or we did not respect your rights as a member of our plan If you have a problem with the quality of care or services you have received If you have trouble finding or getting services from a provider What should I do if I have a grievance? To file a grievance, you can call Member Services who will help you file your grievance. Your authorized representative or doctor can also file a grievance for you if you give your OK in writing to do so. You or your representative can also file a grievance in writing or by filling out a Member Grievance Form. You can find this form on our website When you file your grievance, here are the things you should include: Your name and member I.D. number (found on your Health Options I.D. card) Your phone number Your address Who is involved in the grievance? What happened? When did it happen? Where did it happen? Why you are not happy with the health care you received? You can send or attach any documents to the Member Grievance Form that will help us look into the problem. You can contact us at: Health Options Member Correspondence 42 P age Member Services toll free

44 PO Box Pittsburgh, PA Phone: When should I file a grievance? You, or your representative, must file your grievance within ninety (90) days of the date the problem happened. What happens after I file a grievance? After you file a grievance, you will get a letter from us within five (5) working days. This letter will tell you that we have received your grievance. It will include information about the grievance process and your rights including: Your right to appoint a representative to act on your behalf Your right to submit additional information Your right to review or request a copy of all documentation regarding the grievance upon request free of charge. Your grievance will be reviewed by one of our staff members who has not been involved with your grievance but knows the most about your issue. A decision will be made within thirty (30) days after we receive your grievance. After a decision is made, a decision letter will be mailed to you. This letter will tell you the reason(s) for the decision. What if I need help during my grievance? If you need help filing a grievance, understanding the grievance process, or need help getting information for us to review, please contact a Member Advocate at APPEALS An appeal is a request for a review of our action. An action is a decision to deny or limit a requested service, including the type or level of service, the reduction, suspension or termination of a service, the denial, in whole or in part or payment for a service; or the failure to provide a service in a timely manner. What should I do if I have an appeal? To file an appeal, you can call Member Services and they will help you file your appeal. You may also have a representative or doctor file an appeal for you if you give your OK in writing to do so. Please note that if your representative or doctor files an appeal for you, you cannot file a separate appeal on your own. If you file your appeal by phone, you must also put your appeal request in writing within ten (10) days of calling Member Services. An appeal review will not take place without your written signature. You, your representative, or doctor can also file an appeal by mail. You can also fill out a Member Appeal Form. You can find this form on our website When you file your appeal, here are the things you should include: 43 P age Member Services toll free

45 Your name and member I.D. name (found on your Health Options I.D. card) Your phone number Your address What are you appealing? Why are you appealing? What do you want as a result of your appeal? You may send or attach any documents that will help us with the review of your appeal. You can contact us at: Health Options Member Correspondence PO Box Pittsburgh, PA Phone: When should I file an appeal? You or your representative must file your appeal within ninety (90) days from the date of the Notice of Action letter. What can I do to continue getting services during the appeal process? If you were previously authorized and getting services that we are now terminating, suspending, or reducing, you may ask to continue getting these services if: You ask to continue receiving services You file an appeal within ten (10) days of the date on the Notice of Action letter You file an appeal on or before the effective date of the proposed action The services were ordered by an doctor The original time period covered by the original authorization has not run out If we continue your services during the appeal process, we will cover these services until: An appeal decision is made You or your representative withdraws the appeal The time period or service limits you were previously authorized for have been met You receive a decision from the State Fair Hearing officer that was not in your favor It is important to know that you may have to pay for the services you received while your appeal was pending if the final decision is not in your favor. What happens after I file an appeal? You will get a letter from us within five (5) working days after your appeal. This letter will tell you that we have received your appeal. It will also include information about the appeal review process. You may choose to have someone to act on your behalf. You or your representative may submit additional information and may ask to look over all documents for the appeal. You may also request a copy of the information used to review your appeal free of charge. In addition, you or your representative have the right to present additional 44 P age Member Services toll free

46 information in-person, telephonically or in writing by sending it to the address or faxed to An Appeal Committee will review your appeal and make a decision. The Appeal Committee members include a representative of the State, a Physician and our Director of Quality or his/her designee. The committee members have not been involved with the issue of your appeal. If your doctor would like to discuss your appeal with one of our doctors, they may call us at to speak with a medical director. You or your representative may extend the timeframe for making the appeal decision for up to fourteen (14) days. We may also extend the timeframe for decision up to fourteen (14) days if additional information is necessary and the delay is in your best interest. If we extend the timeframe, we will send you a written notice with the reason for the delay. A decision letter will be mailed to you within thirty (30) days from the date you filed your appeal or within two (2) business days of the decision, whichever is sooner. This letter will tell you the reason for our decision and further appeal rights including your right to ask for a State Fair Hearing (see What should I do to get a State Fair Hearing below). What if I need help during my appeal? If you need help filing an appeal, understanding the appeal process, or help getting information for us to review, please contact Member services at and ask for a Member Advocate. If you need a translator, we will arrange one for you at no cost. Call Member Service for a translator. What if I don t like Health Options decision about my appeal? If you do not agree with our decision, you or your representative, may ask for a State Fair Hearing (see What should I do to get a State Fair Hearing below). EXPEDITED ( FAST ) APPEALS What should I do if I need a decision faster than 30 days? If you think the normal timeframe to review your appeal could cause you serious health concerns, you or your representative may ask for an expedited ( fast ) appeal. You, your representative, or doctor can request a fast appeal orally or in writing. If we agree that you should get an appeal decision faster, you will receive a decision within three (3) working days from the day you file your request. If we do not agree, we will notify you by phone and by letter within two (2) calendar days of receiving your request that your appeal will follow the standard appeal process. What happens after I file a fast appeal? You may choose someone to act on your behalf. You, your representative, or doctor may submit additional information. Also, you or your representative may look over all documents regarding the appeal upon request free of charge. An Appeal Committee will review your appeal and make a decision. The Appeal Committee members include a representative of the State, a Physician and our Director of Quality or his/her 45 P age Member Services toll free

47 designee. The committee members have not been involved with the issue of your appeal. If your doctor would like to discuss your appeal with one of our doctors, they may call us at to speak with a medical director. You or your representative may extend the timeframe for decision of the appeal up to fourteen (14) days. We may also extend the timeframe for decision of the appeal up to fourteen (14) days if additional information is necessary and the delay is in your best interest. If we extend the timeframe, we will send you a written notice of the reason for the delay. A decision letter will be mailed to you within three (3) working days from the date you filed your fast appeal. This letter will tell you the reason for the decision and further appeal rights including your right to ask for a State Fair Hearing (see What should I do to get a State Fair Hearing below). STATE FAIR HEARING A State Fair Hearing is an appeal process provided by the State of Delaware. You may request a State Fair Hearing instead of or in addition to filing an appeal with us. What should I do to get a State Fair Hearing? You, or your representative, may ask for a State Fair Hearing if: We have denied, suspended, terminated, or reduced a service We have delayed service We have failed to give you timely service You can ask for a State Fair Hearing by calling or writing to the State s Division of Medicaid and Medical Assistance (DMMA) office at: Division of Medicaid & Medical Assistance DMMA Fair Hearing Officer 1901 North DuPont Highway PO Box 906, Lewis Building New Castle, DE or toll free at When should I file a State Fair Hearing? If you or your representative are not happy with the a denial in the Notice of Action or an appeal decision, you may request a State Fair Hearing within ninety (90) days of the date on the Notice of Action or appeal decision letter. What happens after I file a State Fair Hearing? You or your representative will receive a letter from the State Fair Hearing officer that will tell you the date, time, and location of the hearing. The hearing can be held in-person or by telephone. The letter will also tell you what you need to know to get ready for the hearing. You or your representative may review all documentation regarding the State Fair Hearing. Health Options will also have a representative at a State Fair Hearing. 46 P age Member Services toll free

48 The DMMA State Fair Hearing officer will send you a letter with their decision within thirty (30) days from the date of the hearing or for a fast State Fair Hearing, three (3) working days from the date of the hearing. How do I continue getting services during the State Fair Hearing process? If you were previously authorized and getting services that we are now terminating, suspending, or reducing, you may ask to continue getting services if: You ask to continue receiving services You file a State Fair Hearing within ten (10) days of the date on the Notice of Action or appeal decision letter You file for a State Fair Hearing on or before the effective date of the proposed action The services were ordered by an doctor The original time period covered by the original authorization has not run out If we continue your services during the State Fair Hearing process, we will continue to cover these services until: You receive the State Fair Hearing decision You or your representative withdraw the State Fair Hearing The time period or service limits you were previously authorized for has been met It is important to know that you may have to pay for the services you received while your State Fair Hearing was pending if the final decision is not in your favor. If the decision was in your favor, Health Options will arrange for these services right away. What if I do not like the State Fair Hearing decision? If you, or someone you choose, are unhappy with the State Fair Hearing decision, you or your representative can ask for a judicial review in Superior Court. To do this, you must file with the clerk (Prothonotary) of the Superior Court within thirty (30) days of the date of the State Fair Hearing decision. IMPORTANT INFORMATION WHEN WE CAN NO LONGER SERVE YOU You may not be covered by us if: You are disenrolled (removed) from our health plan. You move out of our service area, either out of the state or out of the country. To learn more, please call our Member Services number. Please call our Member Services number if you move out of the state. DISENROLLMENT You may be asked to leave our health plan (disenroll) for these reasons: 47 P age Member Services toll free

49 You no longer are eligible. You move out of our service area, either out of the state, or out of the country. (If you move to a place that is served by other Medicaid plans, you must re-enroll in a new plan right away.) You are placed in an out of state nursing facility, or intermediate care facility for the intellectually disabled for more than 30 calendar days. You are incarcerated (inmate in a public institution) You become deceased You were signed up in error. Your plan ID card was misused. Fraud or misrepresentation happened. CONTACTING OUR MEMBER SERVICES DEPARTMENT Call us toll-free at our Member Services number, Monday - Friday from 8 am to 8 pm. Our staff is trained to help you understand your health plan. They can tell you about: Eligibility Benefits How to get service How to choose or change your PCP The education of your doctor Health plan information Dental and vision care Transportation help Complaints, grievances, and appeals How to get a written copy of policies and procedures about keeping your medical information private ADVANCE DIRECTIVES (LIVING WILLS) An accident or an illness could take away your ability to make your own health care decisions. An advance directive (also called a living will ) is a legal document that tells how you want to be treated if you cannot talk or make decisions for yourself. The law in Delaware gives you the right to make decisions about your health care ahead of time by completing an Advance Directive form. An advance directive lists the types of care you do and do not want to receive. For example, you may want to be put on life-support machines if you are in a coma. Some people do not want to be put on life support machines. An advance directive lists your choices when you cannot make decisions and speak for yourself. An advance directive lists who you want to make decisions when you cannot. You can name a family member or a close friend as the person who will make decisions about your health care if you cannot. 48 P age Member Services toll free

50 Delaware has an advance directive form you can fill out. The form can be downloaded at To make this form legal, you must have two people witness you signing the Advance Directive form. It is recommended but not required that you have a notary public witness you signing the Advance Directive form. When you have an Advance Directive, keep a copy in a safe place and give a copy to your doctor. Make sure your family and caregivers know you have an Advance Directive. Take a copy with you when you go to the hospital. If you make changes to the Advance Directive, make sure your doctor has a copy of the new form and your family and caregiver know you have made changes. REVIEW OF MEMBER RECORDS By joining our health plan and accepting the health care benefits listed in this book, you agree to let us look at your medical records for utilization review, quality assurance and peer review. HOW TO SUGGEST CHANGES IN OUR POLICIES AND SERVICES We use a Community Advisory Committee (CAC) to give members a say about our policies and services. CAC members inform, guide and recommend ideas about educational and operational issues involving our services for their local area. Call our Member Services number if you would like to join the CAC. CHANGES TO THE PLAN If your health care program changes, we will try to tell you 30 calendar days before the start date of the change. Significant changes will be communicated no later than the actual effective date of the change. Health Options services can change without your agreement. Please call our Member Services number if you have questions about program changes. If you have trouble hearing or speaking, you may call 711. TREATMENT OF MINORS Minors are treated as adults when it comes to birth control, pregnancy or family planning (except for sexual sterilization). Our members who are 13 years of age or older may refer themselves to any network or out-of-network OB/GYN for yearly exams and regular health care services (including cervical cancer screenings). They do not need an approval ahead of time from their PCP. Family planning records are kept private. Doctors should keep all family planning records private, even if the patient is a minor, unless the law says it is OK to share your information with others. Your doctor is allowed to share your medical information with other doctors who take care of you, public health officials, or government agencies. YOU HAVE OTHER INSURANCE OR A THIRD PARTY LIABILITY (TPL) You or one of your family members might have other types of insurance. Call Member Services if you or any member of your family is covered by us and another insurance plan. Your caseworker 49 P age Member Services toll free

51 at your local DHSS office also needs to know this information. If you have health, dental or vision insurance through another insurance company, you must use that insurance coverage first as a primary insurance. The other insurance carrier must pay first and we are always the last payer to other insurance coverage you may have. It is important to show your healthcare providers all of your insurance cards. You also need to call us if: You have a workers compensation claim. You are waiting for a decision on a personal injury or medical malpractice lawsuit. You have an auto accident. If you have received care due to an accident or work related injury, Health Options will work with the other insurance companies or associates to make sure your claims are paid correctly. Call Member Service to report any situation where you have received medical care following an accident, work related injury, or any other situation where a different insurance, company, or legal counsel is involved. We can, and should, know about everyone giving you care. We need to know this to pay for your health care. We will not share this information with anyone except your health care provider and others as the law allows. CLAIM WHAT DO I DO WITH A BILL? Delaware Medicaid providers cannot charge you for services that are covered by us. If you get a bill from your doctor or the hospital by mistake, do not pay the bill. Please call Member Services with the billing information and someone will help you. You are not responsible for submitting claims to us, your doctor or the hospital will do that. HELP IN OTHER LANGUAGES We offer services and programs that meet your language and cultural needs and give you access to quality care. We provide a service that has people who can translate in more than 200 languages. We want you to have the right care, so we have: Member Services staff can get you help in your language 24-hour telephone translators Sign language and face-to-face translators Providers who can get you help in your language, if available If you need help in a language other than English during your medical visit, you can ask for a faceto-face or a telephone translator at no cost. HELP FOR MEMBERS WITH HEARING, SPEECH, OR VISION LOSS If you have trouble hearing or speaking, you may call our toll-free TTY line at 711 or from 8 am to 8 pm Monday through Friday. 50 P age Member Services toll free

52 We can provide this handbook and other important plan materials in different ways. This is so people that do not see well can still learn about their plan. Here are the ways we can do this: Large print A CD for listening to plan information Braille Audiotape To get these other formats, or for help reading this Handbook, please call the toll-free Member Services or TTY number (for members with trouble hearing or speaking). AMERICANS WITH DISABILITIES ACT We meet the terms of the Americans with Disabilities Act (ADA) of This act protects you from unfair actions by your health plan because of a disability. If you feel you have not been treated the same as others because of a disability, call our Member Services number. If you have trouble hearing or speaking, you may call our Member Services TTY line. FRAUD & ABUSE Call our Fraud and Abuse Hotline if you think that someone else is using your ID card to get benefits. You can also report if someone is using another member s ID card to get benefits. Your name will be kept private unless we are required to share that information. You can report any doctor or hospital if you suspect fraud or abuse for services provided to anyone with a Medicaid card. CONFIDENTIALITY Protecting your confidential information is a priority to us. We want you to know that Health Options remains vigilant in protecting patient and provider information. Our expectation is that our employees protect all information, in all formats, all the time, this includes protecting information in verbal, paper or electronic format. Additionally, confidential information must be protected to the same extent as protected health information (PHI). Not only do Health Option s employees sign a form annually reminding them about laws and regulations that protect health information, they are also trained on laws protecting privacy such as HIPAA (Health Insurance Portability and Accountability Act), ARRA (American Recovery and Reinvestment Act), and ways to protect system security. INFORMATION ABOUT OUR PLAN If you want to know more about how Health Options operates, contact Member Services. They can provide you with information on the structure of Health Options. 51 P age Member Services toll free

53 If you want to know how we pay your doctors, please contact Member Services. They can provide you with the methods we use. If you want to know more information about our accreditation, call Member Services. They will give you a summary of our report. 52 P age Member Services toll free

54 URGENT CARE LOCATIONS IN DELAWARE Please check for the most recent list of Urgent Care providers. Wilmington Silverside Medical Aid Unit 2700 Silverside Rd Wilmington, DE Got a Doc 1946 Maryland Ave, Suite 100 Wilmington, DE Got a Doc 3001 Philadelphia Pike, Suite 100 Claymont, DE Limestone Medical Aid Unit 1941 Limestone Rd, Suite 114 Wilmington, DE Newark Go Care At Abby 1 Centurian Dr, Suite 106 Newark, DE New Castle MedExpress 129 N DuPont Hwy New Castle, DE Hockessin Premier Urgent Care Lantana Shopping Center 4316 Lantana Drive Hockessin, DE Smyrna Christina Care Health Services Medical Aid Unit 100 S. Main Street Smyrna, DE MedExpress 2722 Concord Pike Wilmington, DE MedExpress 3926 Kirkwood Hwy Wilmington, DE Take Care Health 1710 Faulkland Rd Wilmington, DE Glasgow Medical Center 200 Hygeia Dr, Suite 1300 Newark, DE P age Member Services toll free

55 Please check for the most recent list of Urgent Care providers. Dover Eden Hill Express Care LLC 200 Banning Street, Suite 170 Dover, DE Seaford Ambient Medical Care LLC Sussex Highway #2 Seaford DE Millville Beebe Health Center Walkin at Millville Creekside Plaza, Route 26 Millville, DE Lewes Medical Aid at Longneck 1309 Savannah Road Lewes DE Millsboro Medical Aid at Longneck Plaza Drive, Unit 1 Millsboro, DE MedExpress 15 South DuPont Highway Dover, DE P age Member Services toll free

56 Highmark Blue Cross Blue Shield of Delaware and Health Options are independent licensees of the Blue Cross and Blue Shield Association 55 P age Member Services toll free

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