M E M B E R H A N D B O O K. Health Care Benefits. Guía del Miembro

Transcription

1 M E M B E R H A N D B O O K Health Care Benefits Guía del Miembro

2 Title Table Of Contents MEMBER HANDBOOK Page Interpreter Services Alternate Format If You Need Services Now Where To Call When Do I Call OHMS When Do I Call My Caseworker Two Benefit Packages Member Plan Id Card OMAP Medical Care Identification Your Primary Care Provider Changing Primary Care Providers Getting Medical Care Same-day Appointments After Hours Care Emergency Care What To Do If You Have An Emergency Emergency Care When You Are Away From Home Routine Care Away From Home Hospitalization Specialist Care Pregnancy Care Newborn Enrollment Exceptional Needs Care Coordination (ENCC) Alcohol And Drug Treatment Services Help To Stop Smoking Mental Health Services And Providers Dual Eligibles (Medicaid/medicare) Exclusions (Non-covered Services) Physician Reimbursement Other Benefits Vision Care Hearing Aid Services Skilled Nursing Facility Care Pharmacy Durable Medical Equipment (DME) Health Promotion For Children And Adults Complaints And Appeals Disenrollment If You Move Out Of The County Advanced Directives Oregon Health Management Services Providers

3 WELCOME TO (OHMS) Si usted necesita asistencia para traducir esta informacion a espanol, por favor de llamar a o This handbook gives important information about your benefits. Please take time to read it and keep this copy to answer questions. INTERPRETER SERVICES If you need an interpreter for doctor visits or to assist you with the questions contact or TTY Interpreters can be available either by telephone or in person. ALTERNATE FORMAT If you need this Oregon Health Plan Member handbook or other informational materials in another form, such as: Other language Large print Computer disc Braille Audio tape Oral presentation Call our Member Services Department at or TTY to request the format you need. You will not be penalized in any way for asking for this information. IF YOU NEED SERVICES NOW Call OHMS Member Services if you are unable to see your Primary Care Provider (PCP) the first month you are on our plan and if you need: Prescription Supplies Other necessary items Services MEMBER HANDBOOK PAGE 1

4 WHERE TO CALL: If you need help reading this booklet, you can call or visit the Oregon Health Management Services office and speak with Member Services. Member Services can also help if you have questions about what you have read. The Oregon Health Management Services office location and contact numbers are: 128 SW I Street, Suite A Grants Pass, Oregon Telephone: (541) and Facsimile: (541) TTY: Business hours are 8 am to 5 pm, Monday through Friday, except for legal holidays. An answering service is available when the office is closed. WHEN DO I CALL? Oregon Health Management Services (OHMS) is happy to help you with your questions. We want to be sure that you understand your benefits under your Health Plan. Please call us if you have questions about: Services that are covered by the Health Plan; How to choose a Primary Care Provider (PCP) for yourself and each covered member of your family; To arrange for help with complex medical and/or special needs through our Exceptional Needs Coordinator (ENCC); If you need an interpreter for a medical appointment; If you need transportation to a medical appointment; If you have a complaint about our health plan or providers WHEN DO I CALL MY CASEWORKER? For help with these questions or problems, call your caseworker: If you have recently moved or had a name change; You loose your OMAP Medical Care ID; You learn you are pregnant; You have a new baby; You have questions about assistance or programs other than your health plan. MEMBER HANDBOOK PAGE

5 TWO BENEFIT PACKAGES: Under the Oregon Health Plan there are two different benefit packages: STANDARD AND PLUS. Your benefit package will be listed on your OMAP Medical ID card and is determined by the State of Oregon when you apply for the Oregon Health Plan. Oregon Health Management Services does not determine your eligibility for a benefit package. We will be happy to help you understand the services offered under your personal benefit package. You and other members of your family may have different benefit packages. The OHP Standard Benefit Package is a leaner benefit package than OHP Plus. Please be sure to note the differences identified in this handbook. The following services have limited coverage for the OHP Standard benefit package: Selected dental (emergency dental benefits); Selected durable medical equipment and medical supplies; Selected home enteral/parenteral services; Selected hospital services; The following services are NOT covered under the Standard Benefit Package: Hearing aids and related services (i.e., exams for the sole purpose of determining the need for or the type of hearing aid); Home health services except when related to limited specific infusion services; Non-emergency medical transportation; Occupational therapy services; Physical therapy services; Speech and language therapy services; Visual Services such as frames, lenses, contacts corrective devices and eye exams for the purpose of prescribing glasses or contacts. If you have questions about a service or treatment, please call our Member Services Department. They will be happy to help you in finding out if it is covered for you. MEMBER PLAN ID CARD Each member of Oregon Health Management Services will receive an OHMS medical ID card. This card is very important because it identifies you and has other important information for you and your provider. It tells you who your PCP is, their telephone number, and what to do in an emergency. You should present this card whenever you need medical services. MEMBER HANDBOOK PAGE

6 OMAP MEDICAL CARE IDENTIFICATION The Office of Medical Assistance Programs (OMAP) will issue a Medical Care Identification form for each month. This form is a full sheet of paper printed on both sides. You MUST KEEP THIS FORM WITH YOU AND SHOW IT TO YOUR DOCTOR, THE PHARMACY, HOSPITAL AND ALL MEDICAL PROVIDERS. (If you lose your OMAP Medical Care Identification, contact your Department of Human Services (DHS) worker. YOUR PRIMARY CARE PROVIDER: As an Oregon Health Management Services (OHMS), Oregon Health Plan (OHP) member, you must select a primary care doctor/nurse practitioner. If you do not choose a Primary Care Provider (PCP), one will be chosen for you. When you come on our plan every attempt will be made to maintain your relationship with your current provider (if he/she is on our provider panel). Current providers in Josephine County are listed on the last page of this handbook. If you do not choose a primary care provider within 30 days of coming on our plan, OHMS will assign you to a Primary Care Provider. We will send you a notice telling you to which PCP you have been assigned. To help establish an ideal relationship with your PCP: 1. Please schedule your appointments with your assigned Primary Care Provider (PCP). Your PCP is responsible for all treatment you receive, including referrals to specialists. 2. If you are a new patient to OHMS, call soon and schedule a health maintenance exam with your Primary Care Provider (PCP). That way, your PCP is able to become familiar with you and help meet your special health care needs. Be aware however, that health maintenance exams are routine care and it may take several weeks to be seen. If you need urgent care in the meantime, feel free to schedule another appointment. 3. If possible, before your first visit, contact your former medical office and arrange for the transfer of your medical records to your new PCP. These records help to provide a complete picture of your health history and help your new PCP continue your medical care. MEMBER HANDBOOK PAGE 4

7 Remember you are an important partner in your own health care CHANGING PRIMARY CARE PROVIDERS: If you want to change your PCP, call the Oregon Heath Management Services office. A Member Services representative will help you. You can change your Primary Care Provider (PCP) twice in a year if there is another provider within our provider panel accepting new patients. It may take up to 30 days for a change in PCP to happen. All changes will become effective the first day of the next month. GETTING MEDICAL CARE: Please call in advance for routine, non-emergency appointments, and several weeks in advance for annual exams. IMPORTANT: If you must cancel an appointment, call your Primary Care Provider (PCP) as far in advance as possible, preferably twenty-four (24) hours before the scheduled appointment. If you miss too many appointments, you could be requested to leave the Health Plan. Missed appointments take away time from other patients who also need to be seen. SAME-DAY APPOINTMENTS: If you have a sudden illness or injury requiring same-day attention, call your Primary Care Provider (PCP) and explain your need to be seen. Your PCP will either: Schedule an appointment for you, Give you medical advice over the phone, or Send you to an Urgent Care Facility or a hospital. MEMBER HANDBOOK PAGE 5

8 AFTER HOURS CARE: Your PCP is available to serve your health care needs 24 hours a day, 7 days a week. If you are sick and need to talk with your PCP after the office is closed, call your PCP s number. Your PCP or an on-call provider will call you back and let you know what care you need. You may be referred to a facility if he or she thinks you need immediate care. EMERGENCY CARE: Take care of problems before they become serious. Call your PCP when you are sick. Please do not wait until after office hours to get care for you or your family. Emergency care is covered twenty-four (24) hours a day, seven (7) days a week. Oregon Health Management Services is responsible for payment of emergency services when it is a true emergency, otherwise, OHMS will only pay for the evaluation. WHAT TO DO IF YOU HAVE AN EMERGENCY: If you believe you have an emergency medical condition, call 911 or go to the emergency room. An emergency medical condition means you have symptoms that are severe (including severe pain). You believe your health will be in serious danger if you don t get help right away. This includes your unborn child s health if your are pregnant. Some examples of emergencies are: Trouble breathing Chest pain Severe cuts or burns Loss of consciousness/blackout Vomiting blood Bleeding that does not stop Broken bones Tell the emergency personnel the name of your Primary Care Provider. Follow-up care is NOT an emergency. You should call your PCP s office and make arrangements for follow-up care if needed. DO NOT go to the emergency room for care that should take place in your PCP s office. Routine care for sore throats, colds, flu, back pain, and tension headaches is not considered an emergency. If you are not sure your condition is an emergency, call your PCP. Your PCP or another doctor in his/her call group is always available to give you advice 24 hours a day, 7 days a week. Tell the on-call doctor what is wrong with you even if he/she is not your usual doctor or nurse practitioner. MEMBER HANDBOOK PAGE 6

9 EMERGENCY CARE WHEN YOU ARE AWAY FROM HOME: If you are traveling and have an emergency, go to the nearest emergency room or call 911. Emergency services are only authorized as long as the emergency exists. Please call our office to arrange for further care if it is needed while you are gone. You may reach our office from outside the local area by calling , or TTY ROUTINE CARE AWAY FROM HOME: Routine or follow-up care away from home is not covered unless you have prior approval from your Primary Care Provider. If you do not have the approval, you may have to pay for the medical service you received. HOSPITALIZATION: Hospital care for the OHP Standard Benefit Package is limited. Call our Member Services for more information. When hospital care is required your Primary Care Provider will make the necessary arrangement. Hospital care for OHMS members is provided at: Three Rivers Community Hospital 500 SW Ramsey Avenue Grants Pass, OR (541) Rogue Valley Medical Center 2825 East Barnett Road Medford, OR Providence Medford Medical Center 1111 Crater Lake Avenue Medford, OR (541) If you require a specialized service that is not provided at the local hospital you will be referred to a different hospital. The length of your hospital admission is determined by your Primary Care Provider (PCP) or the admitting doctor. MEMBER HANDBOOK PAGE

10 SPECIALIST CARE: If it is necessary for you to receive specialty care, you MUST BE REFERRED BY YOUR PRIMARY CARE PROVIDER. See your PCP first. Your Primary Care Provider may need to contact Oregon Health Management Services for approval for that referral. You do not need a referral for mental health, chemical dependency or family planning services. PREGNANCY CARE: If you are pregnant, or think that you may be, you should see your Primary Care Provider right away. Regular checkups are important for having a healthy baby. By keeping your regularly scheduled appointments, you can keep yourself and your baby healthy. OHMS has specialists for your pregnancy care. Members should not go out-of-town thirty (30) days prior to birth. Please talk to your OB specialist if you must travel near your expected delivery date. If you must leave OHMS service area, your Plan is only responsible for emergency care outside OHMS service area. OHMS would cover the delivery and the baby s newborn checkup but not prenatal care. Follow-up care for Mother and Baby are also not covered while you are out of the plan s service area. NEWBORN ENROLLMENT: Your newborn child will be covered by Oregon Health Management Services. However, your baby should be enrolled in Oregon Health Management Services as soon as possible (preferably within two (2) weeks). Contact your Department of Human Services (DHS) caseworker to enroll him or her. Health Plan benefits for newborns include well-baby care and immunizations. Routine check-ups during a child s first 5 years of life help your doctor spot problems early, when treatment is more effective. EXCEPTIONAL NEEDS CARE COORDINATION (ENCC): Exceptional Needs Care Coordination (ENCC) assists Plan members who have complex medical and/or special needs. The ENCC helps persons who have disabilities or difficulties with the coordination of their health care. Persons who have special medical supply, equipment needs, or who will require more support services may request ENCC services. Call the Member Services Department and ask to talk to the ENCC representative. OHMS wants to make sure your special needs are considered! ALCOHOL AND DRUG TREATMENT SERVICES: Outpatient treatment of alcohol and drug (chemical) dependency services are part of the basic benefit package for OHMS Health Plan members. These services include education, outpatient, intensive outpatient, detoxification, or methadone services. You do not need a referral to seek chemical dependency treatment. Family members also may receive counseling in dealing with alcohol and chemical dependency issues. MEMBER HANDBOOK PAGE

11 Oregon Health Management Services provides outpatient counseling through: Choices Counseling Center 109 NE Manzanita Avenue Grants Pass, OR (541) When you call CHOICES, their trained counselors will make an appointment with you to talk about your condition and work out a treatment plan for you. You may visit CHOICES on your own. You do not need a referral. Your Primary Care Provider may also suggest you visit CHOICES for an evaluation. HELP TO STOP SMOKING: Oregon Health Management Services will pay for services to help you quit smoking. This benefit includes pharmacy products (such as nicotine patches and other prescribed drugs). Talk to your Primary Care Provider for more information or contact our office. MENTAL HEALTH SERVICES AND PROVIDERS: The OHP Standard Benefit Package covers outpatient only for mental health services. Mental health services include assessment to find out what is wrong with you. OHP members may also receive consultations, case management, therapy, medication management, urgent and emergency care, and inpatient psychiatric care. Mental health services will identify and treat such conditions as anxiety, depression, schizophrenia, post-traumatic stress and eating disorders. Mental Health Services include a diagnosis to find out what is wrong with you. Your Primary Care Provider (PCP) can assist you with a referral to a Mental Health Provider, or you may contact Mental Health yourself. You do not need a referral to seek mental health services. Mental health services are provided by: Jefferson Behavioral Health Josephine County: (541) Jackson County: (541) Douglas County: (541) All counties (toll free): TTY, all counties: MEMBER HANDBOOK PAGE

12 DUAL ELIGIBLES (MEDICAID/MEDICARE): Some people are eligible for both OHP and Medicare health benefits. They are called Dual Eligibles. If you are a Dual Eligible, Oregon Health Management Services will take care of the Medicare covered services as well as the OHP covered services. If you receive a Medicare Explanation of Benefits (EOB) denying any of your Medicare covered services, don t be alarmed. Send your EOB to Oregon Health Management Services. You are not responsible for paying the coinsurance and deductible unless you sought care from non-oregon Health Management Services providers for services that were not an emergency or were not referred by an Oregon Health Management Services provider. EXCLUSIONS (NON-COVERED SERVICES): Not all medical treatments are covered. When you think you need medical treatment, contact your Primary Care Provider. If you have questions about covered or non-covered services, contact our Member Services Department or look at your Oregon Health Plan Client Handbook. PHYSICIAN REIMBURSEMENT: You are entitled to ask if the Plan has special financial arrangements with our physicians that can affect the use of referrals and other services. To get this information, call our Member Services Department and request information about our physician payment arrangements. OTHER BENEFITS: Oregon Health Management Services can provide foreign language interpreters or sign language interpreters and hearing services if a member needs such services. Please contact the Plan forty-eight (48) hours in advance to allow us to obtain the needed interpreter service. Your Primary Care Provider office has a variety of education materials concerning health and prevention. These include videos, brochures, audio tapes, and nurse counseling. The local hospitals also offer free health education classes on a regular basis. Call either Three Rivers Medical Center or the Member Services representative at Oregon Health Management Services for current class information. MEMBER HANDBOOK PAGE 10

13 VISION CARE: Oregon Health Management Services is responsible for providing visual services including routine vision screenings and glasses. Contact your PCP for other problems, such as injury or infection. Your PCP will refer you to specialty care, if needed. How often you may receive routine vision care depends on your age: Adults (21 years or older) may receive an eye exam and glasses (if needed) once every two years. Children (20 years or younger) may receive and eye exam and glasses once a year. Routine eye examinations, frames, lenses, contacts, vision aids, and vision therapy are NOT covered under the OHP Standard Benefit Package. Treatment for eye disease is covered under the OHP Standard Benefit Package. HEARING AID SERVICES: Oregon Health Management Services is responsible for providing hearing aids and batteries. If you are in need of hearing services, ask your PCP for a referral. If you are already receiving hearing services, please call our office so we can arrange for continuation of your care. Hearing services are NOT covered for clients who have the OHP Standard Benefit Package. SKILLED NURSING FACILITY CARE: Skilled Nursing Facility (SNF) care is covered for up to twenty (20) days following hospitalization when medically necessary. Addition SNF care may be covered by Medicaid, or if you have Medicare. Please call the OHMS Member Services Department if you need help in arranging care. PHARMACY: You may use any pharmacy of your choice that will accept your OMAP Medical Care Identification and Plan Medical ID card. Oregon Health Management Services has arrangements with all the pharmacies in the Josephine County area. If you are out of the area and need a prescription filled, go to the nearest chain pharmacy, for example: Albertsons (Sav-on), Bi-Mart, Rite-Aid, Safeway, Walgreens or WalMart. The pharmacist may need special authorization to fill some medications. To manage an on-going health condition you will receive a 30-day supply of a drug you take regularly. This is the routine amount for such a prescription. Prescriptions are filled with generic drugs whenever possible. MEMBER HANDBOOK PAGE 11

14 This information is for any member of your household who has Medicare and Medicaid (Oregon Health Plan) coverage. On January 1, 2006, OHP will stop paying for your prescription drugs. Instead, a new federal program called the Medicare Prescription Drug program will pay for your drugs. This drug benefit will be Part D of your Medicare coverage starting January 1. Medicare requires co-payments for Part D drug coverage. Most of the plans that provide a drug benefit will charge a co-payment from $1 to $5. Oregon Health Plan (OHP) Oregon Health Management Services (OHMS) will continue to pay for all other covered health services. Not all medications are covered under the OHMS drug coverage plan. Contact your PCP to discuss alternatives. Services and supplies not-covered include: Impotence medications Fertility medications Medications prescribed for cosmetic purposes Medications with no proven therapeutic indication Experimental or investigational medications Medications prescribed for weight loss or the treatment of obesity (including, but not limited to amphetamines) Stolen, lost, spilled or destroyed prescription medications DURABLE MEDICAL EQUIPMENT (DME): Many pharmacies and suppliers provide medical equipment for OHMS. If you need items, such as diabetes testing supplies, incontinent supplies or ostomy equipment, ask your pharmacy if they are able to provide the equipment for you. You may also contact any of the DME suppliers (Apria, Lincare, Byrum, or Home Health Express) directly. Not all supplies are covered under the OHP Standard Benefit Package. If you have questions, feel free to contact OHMS and our Member Services Staff will be happy to help you. HEALTH PROMOTION FOR CHILDREN AND ADULTS: Preventive care is a very important part of the care you receive from your Primary Care Provider (PCP). Preventive care includes such things as: Maternity, newborn care Well-child exams, immunizations (shots) Routine physical exams for children and adults Please discuss the recommended schedule for health check-ups with your provider. MEMBER HANDBOOK PAGE 12

15 Medical examinations to tell what is wrong with you and laboratory, x-ray and other appropriate testing is also covered. Family planning services and supplies, including sterilization, birth control pills, and intrauterine device (IUD) are available through OHMS providers. COMPLAINTS AND APPEALS Oregon Health Management Services and our providers want to give you the best medical care possible. If you have a complaint or grievance with any part of your treatment, please contact your Primary Care Provider or our Member Services Department. You may contact them in person, by phone or in writing. We will start our investigation when you first contact us, but we will ask that verbal requests be followed by a written request. You will need to give our Member Services staff your consent to investigate your complaint. Without this consent, Member Services may not be able to help you. Our staff will look into both medical and non-medical problems. We will get back to you within five (5) working days. OHMS has up to thirty (30) days to give you a decision. If you wish to appeal a decision by Oregon Health Management Services to deny a healthcare service, you may request an appeal by contacting us as described above. You have 45 days from the date on the Notice of Action to file an appeal. If you believe your medical problem cannot wait for a regular review of your appeal, call our Member Services Department. Ask if your situation qualifies for an immediate review. You must complete OHMS appeal process before you can request a hearing from OMAP. You have 45 days from the date shown on the Notice of Appeal Resolution to request an Administrative Hearing. You can get the Administrative Hearing form from your DHS worker or Oregon Health Management Services. DISENROLLMENT: You may be disenrolled (taken off) from a Health Plan for various reasons: If you move outside of the service area of the Health Plan. (Please inform OHMS and your DHS worker if you move.) Your personal situation may change and you are no longer eligible for the OHP. You may decide to change Health Plans. You could also be requested to leave a Health Plan because you missed too many appointments. You committed fraudulent or illegal acts. You were abusive to staff or property. MEMBER HANDBOOK PAGE 13

16 IF YOU MOVE OUT OF THE COUNTY: If you move out of the County in which you signed up for the Oregon Health Plan, be sure to tell your Department of Human Services (DHS) worker immediately. They will help you change your address so that you will continue to receive your benefit information. They will also help you change to another plan in the area where you now live, if necessary. If you don t tell your DHS worker, you may have difficulty getting medical care for you and your family. Routine health care must be provided by your Primary Care Provider (PCP) until you have changed to a new plan. ADVANCED DIRECTIVES: If you are an adult, you have the right to know about any medical treatment your doctor recommends for you and to refuse it if you choose. However, a serious illness or sudden injury could leave you unable to make decisions or express your wishes. In such a situation, your relatives would have to decide what you would want. Oregon has a law that allows you to say in writing, ahead of time, how you would want to be treated if you were seriously ill or injured. The legal documents for this are called Advance Directives. The Advance Directive lets you name a person to direct your health care when you cannot do so. This person is called your health care representative. Your health care representative does not need to be a lawyer or health care professional. Your representative should be someone with whom you have discussed your wishes in detail. Your health care representative must agree in writing to represent you. The Advance Directive also allows you to give instructions for health-care providers to follow if you become unable to direct your care. The Advance Directive lets you tell your doctor to stop life-sustaining help if you are near death. This tells your doctor that you do not want your life prolonged if you have an injury or illness or disease that two doctors agree you will not recover from. You will get care for pain and to make you comfortable no matter what choices you make. The Advance Directive is only valid if you voluntarily sign it when you are of sound mind. Unless you limit the duration of your Advance Directive, it will not expire. You also may revoke your Advance Directive at any time. You have the right to decide your own health care as long as you are able to, even if you have completed the Advance Directive. Completing the Advance Directive is your choice. If you choose not to fill out and sign the Advance Directive form, it will not affect your health plan coverage or your access to care. Oregon Advance Directive forms are available at no cost from Oregon Health Management Services, or by contacting your local hospital. For more information about Advance Directives, call: Oregon Health Management Services, or Oregon Health Decisions (in Portland) at or (503) MEMBER HANDBOOK PAGE 14

17 PROVIDERS Please call Oregon Health Management Services for a list of providers. (541) or (800) , or TTY CLEAR CREEK FAMILY PRACTICE Redwood Hwy. Selma, Oregon GRANTS PASS CLINIC 495 SW Ramsey Avenue Grants Pass, OR DR. EDSWORTH JOHN Physicians Medical Group 1619 NW Hawthorne Ave #201 Grants Pass, OR LA CLINICA 3617 South Pacific Highway Medford, OR PEDIATRIC OFFICES 1465 B NE 7 th Street Grants Pass, OR SISKIYOU COMMUNITY HEALTH CENTER Grants Pass 125 NE Manzanita Avenue Grants Pass, OR SISKIYOU COMMUNITY HEALTH CENTER Illinois Valley 318 Cave Highway Cave Junction, OR MEMBER HANDBOOK PAGE 15

18 NOTES MEMBER HANDBOOK PAGE 16

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20 128 SW I Street, Suite A Grants Pass, OR Administration (541) Referrals (541) Toll-free (800)