2014 PLUS Member Handbook. Your guide to benefits and services

Transcription

1 2014 PLUS Member Handbook Your guide to benefits and services

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3 Important instructions If you become sick: Call your Primary Care Provider. If you become sick after normal office hours: Call your Primary Care Provider. The answering service will give you the phone number of the doctor on call that day. OR Call the FREE Nurse Help Line at If you believe you have an emergency medical condition: Go to the nearest hospital emergency room. OR Call If you have questions about AllCare Health Plan coverage: Please call Member Services between 8 a.m. and 5 p.m. Monday through Friday at , or toll free If you are hearing impaired, dial TTY number Important records Family members on AllCare Health Plan: Name ID Number Your family s Primary Care Providers (doctor or nurse practitioner): Name Phone Number Member Services Toll-Free TTY/TDD

4 July 16, 2013 Dear Member, Welcome to AllCare Health Plan. Our goal is to help you and your family get quality health care as easily and quickly as possible. Please read this Handbook carefully because it will answer many of your questions about our services and how to get them. The information is current as of July 16, The Handbook is updated yearly and within 90 days of changes in state and federal laws. AllCare Health Plan is a Coordinated Care Organization or a CCO. A CCO is set up so that anyone who provides your care, such as doctors, counselors, nurses and dentists will be able to focus on prevention and improving care. Instead of just treating you when you get sick, we can work with you to keep you healthy and better manage existing health conditions. AllCare Health Plan is owned by Mid Rogue Independent Physician Association (IPA), which is located in Josephine County. AllCare has a contract with the state to serve the Oregon Health Plan members in Josephine, Jackson and Curry counties, and parts of Douglas County. Thank you for choosing AllCare Health Plan for your health care needs. If you would like more information about our company please call the Member Service Department at the number listed below. Getting the Handbook in another format This handbook is available in English and Spanish, also online at com. Please call our Member Service Department if you need the Handbook in another language, in large print, on a computer disk, on an audiotape, in person or in Braille. Member Services Department at , toll-free at , or TTY Si no habla Inglés Si no habla Inglés, o no oye bien, o tiene algún impedimento al hablar, usted puede conseguir servicos gratis de interpretatión. Favor de contactar , , TTY Document approved by Carol Simila, DMAP, 07/16/ AllCare Health Plan PLUS Member Handbook Rev. 7/19/2013

5 Table of Contents Your Member Rights Your Member Responsibilities What is the Oregon Health Plan (OHP) Getting Help with our Health Plan Disenrollment What your member ID card does for you Change of address About Your CCO Changing Your CCO What OHP Plus covers What OHP Plus does NOT cover Choosing your Primary Care Provider Changing your Primary Care Provider If you have Medicare or other insurance Meeting your Primary Care Provider If you need an Interpreter Transportation: When you need a ride to a medical appointment Ambulances When you are sick Nurse Help Line If your illness is urgent What to do in an emergency Hospital care Case and Disease Management Services ICM: When you have special medical needs Take Charge of your Health Seeing a specialist Preventive health care: Keeping you healthy Prescriptions Women s health care and family planning Pregnancy and pre-natal care Newborn care Health services for older children and teens Dental Medical equipment Vision and hearing care Quitting tobacco Mental health services Alcohol and drug treatment End-of-Life decisions How to make a Complaint or a Grievance Appeals and Hearings Confidentiality Physician reimbursement Important Words Glossary PLUS Member Handbook AllCare Member Services Toll-Free TTY/TDD

6 Your Member Rights u To be treated with dignity and respect. u To be treated the same as other people seeking health care. u To select or change your Primary Care Provider, within the guidelines. u To get mental health, alcohol and drug treatment, and family planning services. u To have a friend, family member or advocate present during appointments and at other times as needed, within clinical guidelines. u To participate in decisions about your health care and receive treatment. u To refuse treatment (except for court-ordered treatment), and be told what might happen by refusing treatment. u To be given information about your condition and covered and non-covered services to allow an informed decision about proposed treatment(s). u To be free from any form of restraint and seclusion. u To receive written materials describing rights, responsibilities, available benefits, how to access medical services, and what to do in an emergency. u To have written materials explained in a way you will understand. u To receive necessary and reasonable services to diagnose the presenting condition. u To receive covered services under the Oregon Health Plan that are medically appropriate and used by most providers. u To get Preventive Services, such as immunization shots and a women s annual exam. u To get urgent or emergency care 24 hours a day, 7 days a week, along with follow-up care to help you remain stable. u To receive a referral to specialty providers for medically appropriate covered services including second opinions. u To have a clinical record maintained that documents conditions, services received, and referrals made. u To look at your own medical records unless your provider feels it is not safe for you. u To transfer a copy of your clinical record to another provider. u To have someone plan your medical care if you cannot speak for yourself. u To receive written notices before your treatment, medications or medical services are stopped or reduced. u To know how to make a complaint to us and receive a response. u To ask for an administrative hearing with the Department of Human Services (DHS). u To receive interpreter services. u To be told ahead of time if your health care provider needs to change your appointment. 6 AllCare Health Plan PLUS Member Handbook Rev. 7/19/2013

7 Your Member Responsibilities u To choose your primary care provider (PCP) or clinic. u To treat all health care providers and staff with respect. u To be on time for appointments or call ahead if you need to cancel, are unable to keep the appointment, or if you are going to be late. u To get health exams and preventive health services from your PCP or clinic when you should. u To go to your PCP or clinic for all your health care services, except in an emergency. u To get a referral to a specialist from your PCP before going to a specialist, unless self-referral to the specialist is allowed. u To use urgent and emergency care appropriately and to call your PCP or our Member Services Department within three days of the emergency. u To give correct information for your clinical record. u To help your PCP or clinic get your records from other health care providers. This may include signing a release of information form. u To ask questions about condition and treatment options until you get answers that you understand. u To use information to make decisions about treatment before it is given. u To help your provider make a treatment for you. u To follow your treatment plan. u To tell your provider that your health care is covered under the Oregon Health Plan before you get medical services. u To tell the Department of Human Services (DHS) worker of a change of address or phone number. u To show your OHP Medical ID Card every time you get medical services. u To tell the Department of Human Services worker if someone in the family becomes pregnant and to notify the DHS worker of the birth of a child. u To tell the Department of Human Services worker if your address or phone number changes. u To tell the DHS worker if any family members move in or out of the household. u To tell the DHS worker if there is any other insurance available. u To pay for non-covered services. u To pay the monthly OHP premium (if required) on time. u To let the Plan know if you have been hurt or injured in an accident and received money. You may have to pay us back for any treatment we paid for. u To let us know if you have a complaint. AllCare Member Services Toll-Free TTY/TDD

8 AllCare is right here in Southern Oregon, serving your friends, neighbors and coworkers.

9 What is the Oregon Health Plan (OHP) The Oregon Health Plan (OHP) is a program that pays for low-income Oregonians health care. The State of Oregon and the US Government s Medicaid program pay for it. It covers different groups of services, called benefit packages: OHP Standard is for Oregon residents who are older than 18. It covers doctor visits, prescriptions, emergencies, mental health services, urgent or immediate treatment and help with addiction to cigarettes, alcohol and drugs. Some people who have OHP Standard pay a monthly charge, called a premium, for it. OHP Plus is for pregnant women, children 18 years old and under, and people with disabilities of any age. It covers doctor visits, prescriptions, hospital stays, dental care, mental health services, and help with addiction to cigarettes, alcohol and drugs. OHP Plus can provide glasses, hearing aids, medical equipment, home health care, and transportation to health care appointments. Managed Care and Fee For Service CCOs (Coordinated Care Organizations) are a type of managed care. Another type is Dental Care Organizations (DCOs). The Oregon Health Authority (OHA) wants OHP members to have their health care managed by organizations set up to do just that. OHA pays managed care companies a set amount each month to provide their members the health care services they need. In some parts of Oregon, most OHP members must receive managed medical and dental care. Health services for OHP members not in managed care are paid by OHA, called fee-for-service (FFS). OHP members who have a good reason to receive FFS medical care can ask to leave managed care. Talk to your case worker about the best way to receive your medical care. There are other benefit packages. An OHA or DHS case worker can tell you which benefits you have. OHP does not cover everything. A list of the 498 diseases and conditions that are covered, called the Prioritized List of Health Services, is on the web at The diseases and conditions below line 498 usually are not covered by OHP. Something that is below the line could be covered if the patient has an above-the-line condition that could get better if their below-theline condition gets treated. Native American Rights Tribal members can receive their care from a tribal clinic or wellness center. This is true whether you are in a managed care plan or not. Please talk to your case worker about the best place to receive your health care. AllCare Member Services Toll-Free TTY/TDD

10 Getting Help with our Health Plan The Member Services Department is happy to help you with your questions about what services All- Care Health Plan covers. Please call us if you have questions about: Services that are covered by the Plan How to make an appointment with a PCP How to see a specialist When you call us When calling Member Services, please have in front of you your: AllCare Health Plan Identification Card Oregon Health Identification Card Division of Medical Assistance Programs (DMAP) coverage letter. Any information that might help us answer your questions How to select a Primary Care Provider (PCP) How to use preventive health care services Complaints, concerns or suggestions. Having this information handy allows us to look up your file quickly and answer your questions promptly. Telephone: , Toll free: Hearing impaired (TTY): Office hours: Monday-Friday 8 a.m. to 5 p.m. Our offices are wheelchair accessible. Location/mailing address: AllCare Health Plan AllCare Health Plan 740 SE 7th Street 1390 Biddle Road, Suite 105 Grants Pass, OR Medford, OR If you need health care services right away Please call our Member Services Department at , toll free at , or TTY , if you are unable to get an appointment with your Primary Care Provider the first month of enrollment and need prescriptions, medical supplies, other medical items, or other medical services. Disenrollment Disenrollment from AllCare Health Plan may occur if you: Have other health insurance. Move out of AllCare Health Plan service area (Josephine, Jackson and Curry counties, and parts of Douglas County). Commit fraudulent or illegal acts. Are abusive to your provider, your provider s staff, Plan staff or property. 10 AllCare Health Plan PLUS Member Handbook Rev. 7/19/2013

11 What your member ID card does for you To get medical care and prescriptions, you must show your Oregon Health ID Card and AllCare Health Plan Identification Card every time you visit your PCP or pharmacy. It is best to keep these cards with you at all times. An AllCare Health Plan Identification Card is included in your New Member Packet. The card is important because it: Shows you are a member of AllCare Health Plan Lists your PCP and his or her telephone number Explains what to do in an emergency Includes important pharmacy information If you lose your AllCare Health Plan identification card, call Member Services as soon as possible. Member Services will send you a new card so you can continue to visit your PCP and get prescriptions filled. Change of address If you change your address and/or phone number, you need to call: Your Department of Human Services (DHS) caseworker, or the Oregon Health Plan (OHP) branch office, , TTY AllCare Health Plan Member Services Department ( , toll free at , or TTY ) Your PCP s office. Call your DHS caseworker immediately if your move out of the AllCare Health Plan service area (Josephine, Jackson and Curry counties, and parts of Douglas County). Your DHS caseworker will help you change to another plan so you can continue to receive health coverage. About Your CCO AllCare Health Plan is a Coordinated Care Organization (CCO). We are a group of all types of health care providers who work together for people on OHP in our community, such as Options, Jackson County Mental Health and Curry County Mental Health for Mental Health needs and On track for Alcohol and Drug treatment. We also partner with many Community Organizations to help you with other health care services such as Living Well with Chronic Conditions, AllCare Obesity Project and Better Breathers Club just to mention a few. For a complete list of the Community Organizations which AllCare partners with call the AllCare Member Service Department at; Toll free: Hearing impaired (TTY): AllCare Member Services Toll-Free TTY/TDD

12 Our CCO brings together all types of care under one group. We are also set up to make sure that anyone who provides you care, such as doctors, counselors, and nurses are better able to focus on prevention and Improving care overall. This means your providers won t only treat you when you get sick they will also help you find ways to stay healthy and manage existing conditions. AllCare CCO plan will: Give you the tools and support your need to stay healthy Provide care and give advice that is easy to understand and follow Work with local resources to improve health and health care Focus on prevention and avoid unnecessary trips to the hospital or emergency room Work so that all Oregon Health Plan clients are treated fairly Involvement in Plan Activities AllCare is forming a Community Advisory Council. We invite you to apply to serve on the Council. Most of the Council will be Oregon Health Plan members. Other members will be people from government agencies and groups that provide OHP services. If you are interested in being a member of the Community Advisory Council, please call Member Service for an application. AllCare has several healthy living programs and activities that you can participate in. For more information about services available in your area, please call the Member Service Department at , toll free at , or TTY Changing Your CCO If you would like to change your CCO (Coordinated Care Organization) contact your caseworker or the DHS office for the procedure in agreement with OAR There are several chances for you to change as long as another plan is open for enrollment: If you or a family member did not want the CCO you ve been assigned to, you can change plans during the first 30 days after you enroll. Everyone in your family who is on OHP must change to the same plan. If you are new to OHP, you can change plans during the first 90 days after you enroll. If you move to a place that your CCO doesn t serve, you can change plans as soon as you tell your caseworker about the move. You can change plans each time your caseworker finds that you meet the requirements for OHP. This is called recertification and usually happens about the same time once each year. If you are also on Medicare, you can change plans anytime. 12 AllCare Health Plan PLUS Member Handbook Rev. 7/19/2013

13 What OHP Plus covers Preventive care, such as annual physical exams, well-child care and immunizations (shots) Medical examinations in your PCP s office and treatment, if needed Medical and surgical treatments for conditions that are expected to get better with treatment Nursing home care for covered conditions, up to 20 days Vision services for children 1-20 years old, and pregnant women Family planning services Prescription drugs Hospital and emergency care Doctor visits while you are in the hospital X-ray, laboratory and other testing services Home health care Hospice care Physical, occupational and speech therapy Emergency transportation Outpatient alcohol and drug treatment Exceptional Needs Care Coordination (ENCC) for persons with disabilities or aged 65 years and older Note: Some prescriptions, procedures and medical equipment may need prior approval from AllCare Health Plan. Examples of medical problems you might receive treatment for include, but are not limited to: Appendicitis Cancer Eye diseases Kidney stones Asthma Diabetes Head injuries Pneumonia Broken bones Ear infections Heart disease Rheumatic fever Burns Epilepsy Infections Stomach or leg ulcers Treatment until your condition is stable What OHP Plus does NOT cover Colds, diaper rash, sunburns and other things that get better without going to a doctor Diseases or conditions for which there is no useful treatment Cosmetic treatment Services to help you get pregnant Call your PCP or clinic when you think you need medical treatment. Your PCP will advise you what to do. If you have questions about covered or non-covered services, please call our Member Services Department. Copayments or Bills As an AllCare member you do not have to pay co-pays or bills for medications, to see a provider or any other covered services. If you are asked to pay for a service that AllCare covers please call the Member Service Department at , toll free at , or TTY AllCare Member Services Toll-Free TTY/TDD

14 Our team of contracted providers is dedicated to your health care.

15 Choosing your Primary Care Provider To receive medical services, you must choose a doctor or nurse practitioner as your Primary Care Provider (PCP) from the AllCare Provider Directory that we send you or you may get this from the AllCare website at Family Medicine for children and adults Internal Medicine only for adults Pediatrician only for children * You can also find the directory on line at Your PCP (doctor or nurse practitioner) will: Get to know you and your medical history Provide all your medical care Keep your medical records up-to-date and in one place Send you to a specialist, if needed Admit you to a hospital, if needed If you already have a doctor or nurse practitioner, make sure he or she is listed in AllCare Health Plan Provider & Pharmacy Directory. If your PCP is not listed, you must choose a PCP who is listed in this directory. It is a good idea to choose a PCP close to where you live. Once you chose a PCP: Fill out the green Primary Care Provider Selection Form in the new member packet. Fold and mail the pre-stamped form. A new AllCare Health Plan identification card, with your new doctor or nurse practitioner s name and phone number, will be sent to you. OHP requires you to select a PCP within 30 days. If you have not returned your selection form within two weeks, we will assign a PCP for you. *Please note: AllCare Health Plan does not require our Providers to collect co pays from our members for covered services. If you have any questions about co pays please call AllCare Health Plan Member Service Department at ; toll free ; TTY Changing your Primary Care Provider If you want a new PCP, please call our Member Services Department. A representative will help you make the change. Be sure to contact Member Services as soon as you decide to change, as you cannot see your new PCP until the change becomes effective. The Member Services representative will tell you when the change will become effective and send you a new identification card with your new PCP s name and phone number. You may change your PCP twice in 12 months. Additional PCP changes must be approved by our Member Services Manager. AllCare Member Services Toll-Free TTY/TDD

16 Patient-Centered Primary Care Home We want you to get the best care possible. One way we try to do that is ask our providers to be recognized by the Oregon Health Authority as a Patient-Centered Primary Care Home (PCPCH). That means they can receive extra funds to follow their patients closely, and make sure all their medical and mental health needs are met. You can ask at your clinic or provider s office if it is a PCPCH. If you have Medicare or other insurance If you also have Medicare, AllCare Health Plan will coordinate your Medicaid benefits with your Medicare benefits. If you have other insurance coverage and are on AllCare Health Plan, call your DHS caseworker or AllCare Health Plan Member Service Department. Indian Health Services If you are a Native American or Alaska native, you can get your health care from a tribal clinic. If your provider is not in our network, they must follow the same rules as network providers. Only covered benefits will be paid for. If a service requires AllCare s pre-approval, the provider must request it before providing the service. Meeting your Primary Care Provider After you get your AllCare Health Plan identification card, please have a physical exam with your new doctor or nurse practitioner within 90 days. This first visit helps your doctor or nurse practitioner get to know you and your medical needs before you get sick. If the doctor you already see is an AllCare Health Plan provider, a first visit is not necessary unless you have not seen your doctor within the last 12 months. If you have not had a doctor s appointment in the last year, please schedule a physical exam within 90 days (three months) of enrollment. If you need an Interpreter When you make your first appointment with your PCP, tell the receptionist that you need an interpreter. If your PCP does not already have an interpreter, Member Services can help your PCP get an interpreter for your appointment by phone or in person. If you cannot keep an appointment If you make an appointment with your PCP and cannot keep it, be sure to call your PCP s office at least one day before the appointment. The receptionist will help you schedule another appointment. If you miss an appointment without canceling or rescheduling, your PCP may not want to see you again. 16 AllCare Health Plan PLUS Member Handbook Rev. 7/19/2013

17 Transportation: When you need a ride to a medical appointment Your OHP Plus benefits include a free ride to health care appointments. Rides are provided by Trans- Link. When you call TransLink, have your Oregon Health ID Card, the name and address of the provider, and appointment date and time in front of you. Call TransLink between 7 a.m. and 7p.m. weekdays, and two to three days before your appointment. You may leave a message after hours. The phone numbers are: , or toll-free TTY *Please call the AllCare Member Service , Toll free , TTY if you have any problems arranging transportation to your physical or mental health appointment. Ambulances AllCare Health Plan will pay for an ambulance in an emergency or when it is medically necessary. Do not call an ambulance unless you think you have a medical emergency. You may be asked to pay the bill. When you are sick Please call your Primary Care Provider (PCP) when you become sick. Tell the receptionist or nurse what is wrong so they can determine whether or not you need a same-day appointment. Take your AllCare Health Plan identification card and your Oregon Health identification card to your appointment. If you become sick at night, on weekends or holidays, call your PCP. Your PCP provides medical care 24 hours a day, 7 days a week. If your PCP is not working that day, the answering service will refer you to another doctor on call to answer your PCP s calls. Nurse Help Line This phone number is for non-emergency health question. If you have a non-emergency question about you health or the medicines your are taking, you may call our free Nurse Help Line 24 hours a day, 7 days a week. The Nurse Help Line is staffed by specially trained nurses who will ask about your symptoms and give you advice. All calls are confidential. The toll-free phone number is: ; TTY: AllCare Member Services Toll-Free TTY/TDD

18 AllCare is right here to help you understand your benefits. Stop in or call us between 8 a.m. and 5 p.m. and let us know how we can help.

19 If your illness is urgent An urgent medical problem is one that needs attention soon to prevent harm to your health, but is not an emergency. If you are sick, call your PCP. Your PCP, or the doctor on call, will either: schedule an appointment with you give you medical advice over the phone, or send you to an Urgent Care facility or a hospital. Do not go to an Urgent Care facility or hospital for care that can be provided by your PCP. What to do in an emergency If you believe you have an emergency medical condition, call or go directly to the emergency room. You will receive necessary treatment until your condition is stable. An emergency medical condition means you have severe symptoms and believe your health will be in serious danger if you don t get help right away. Examples of emergencies include, but are not limited to: bleeding that won t stop chest pain or suspected heart attack, poisoning seizures or convulsions your unborn child s health if you are pregnant sever stomach pain serious injuries or burns unconsciousness (when a person cannot wake up) difficulty breathing If you are not sure your condition is an emergency, call your Primary Care Provider (PCP), or the on call doctor. They will instruct you what to do. Do not go to a hospital emergency room for care that should take place in your PCP s office. Care for sore throats, colds, flu, back pain, tension headaches or other routine illnesses are not considered an emergency. Hospital care AllCare Health Plan Plus covers emergency care, 24 hours a day, 7 days a week, and hospitalization if needed. If you have an emergency condition you do not need preapproval, go to the hospital nearest to you. Hospitals in AllCare Health Plan service area are: Three Rivers Community Hospital * Rogue Valley Medical Center * 500 SW Ramsey Ave East Barnett Road Grants Pass, OR Medford, OR TTY (hearing impaired): Toll free: TTY (hearing impaired): TTY toll free: , ext AllCare Member Services Toll-Free TTY/TDD

20 Providence Medical Center * Sutter Coast Hospital * 1111 Crater Lake Highway 800 E. Washington Blvd. Medford, OR Crescent City, CA Toll free: TTY (hearing impaired): TTY toll free: Ashland Community Hospital * Curry General Hospital * 280 Maple Street th Street Ashland, OR Gold Beach, OR TDD (hearing impaired): Toll free: * Spanish-speaking staff and interpreter services available After you leave the hospital If your doctor says you need additional nursing care after you leave the hospital, care at a skilled nursing facility such as a nursing home is covered for up to 20 days. Additional skilled care may be covered by Medicaid or Medicare if you have Medicare benefits. Please call AllCare Health Plan Member Services Department if you need help arranging additional care. Case and Disease Management Services Our nurses and other case management staff have special training in many chronic health conditions such as diabetes, heart failure, asthma, depression or high blood pressure. If you have been in the hospital or nursing home, our staff knows how scary it can be with the many things you or your family may need to remember. We can help you understand your provider s treatment plan and will work closely with your providers to make sure you have the help you need. We know our members come from many different backgrounds and cultures and speak many different languages and we are here to help with your medical services based on your language, religion, gender or any other concerns you might have. If you have any questions please call our Member Service Department at or TTY for more information. AllCare Health Plan wants you to reach your health goals and stay as healthy as possible. Please call the Member Service or TTY for more information. Primary Care Team Specialists AllCare knows there are times when you may need help in finding the best care that is right for you. Your Primary Care team may have people specially trained to do this. These people are called Com- 20 AllCare Health Plan PLUS Member Handbook Rev. 7/19/2013

21 munity Health Workers, Peer Wellness Specialists, and Personal Health Navigators. Contact our Member Service or , TTY for more information. ICM: When you have special medical needs Intensive Care Managers (ICM) help members who have special medical needs. For example, a coordinator helps people with disabilities, who are 65 years and older, have special supply and equipment needs, or who need community support services. If you have special needs, an ICM can help you: Understand your Oregon Health Plan and Medicare benefits Choose doctors and other health care providers who know about your special needs Get medical equipment that has been prescribed by your PCP Connect with community agencies that may be able to help you Make sure all of your health care providers are working on the same plan of care for you Make sure that you receive quality health care that is right for you Make sure your special needs are considered You may request ICM services by calling our Member Services Department. Take Charge of your Health AllCare has a team ready to help you and your family have a healthier life. Our team can help you manage your illness if you have one. However, only you can take charge of your health. You can do this by making healthy food choices, being as active as you can, and visiting your provider regularly to prevent small health problems from becoming big ones. Remember, it is important for you to make good choices for your children so that they will grow and develop as healthy as possible. Seeing a specialist A specialist is a doctor with extra training in treating a part of the body, a disease, or a type of injury. Specialists provide treatment your PCP cannot. Most specialty services need a referral from your PCP, so you should see your PCP first. Your PCP may need to ask AllCare Health Plan for approval of the referral. The approved referral is sent directly to the specialist. The specialist s office will call you to set up a visit. Services that require a referral include: Visits with a specialist (podiatrist, neurologist, endocrinologist or orthopedist) Physical therapy Speech therapy AllCare Member Services Toll-Free TTY/TDD

22 AllCare wants to make sure you and your baby have the best care, from the very beginning.

23 Services that do not require a referral include: Routine vision exams for pregnant women and children 0-20 years old who are on the Plus Plan Prenatal care (with a PCP or OB) Mental health treatment Drug and/or alcohol treatment Women s annual exam Family planning Preventive health care: Keeping you healthy In addition to treating you when you are sick, your PCP can help you to stay healthy. Physical exams are an important part of keeping you and your family healthy. When your PCP sees you regularly, it is easier to spot health problems before they become difficult to treat. Your PCP also can tell you how to stay healthy. Be wise immunize An important, effective way to stay healthy is with shots that help your body become immune to certain diseases. Infants and children need many shots as they grow. Adults should get a shot for tetanus (a very serious infection) every 10 years. Shots for the flu and pneumonia are a good idea for people who are over 65, or who have a chronic illness. If you think you need other immunizations, please talk to your PCP. AllCare Health Plan covers preventive health care including: Regular physical exams for children and adults Immunization shots Medical tests such as x-rays and blood tests Most other preventive screening tests ordered by your PCP Prescriptions If you need to have a prescription filled, you may go to any pharmacy listed in AllCare Health Plan Provider & Pharmacy Directory. You will need to take your: Prescription Oregon Health ID card AllCare Health Plan identification card The pharmacist cannot fill your prescription without all three pieces of paperwork. The pharmacist needs special approval to fill some medications. Not all medications are covered under AllCare Health Plan drug coverage plan. Contact your PCP to discuss other options. AllCare Member Services Toll-Free TTY/TDD

24 Most Mental Health Medications are not paid by AllCare Health Plan; they are paid by the Division of Medical Assistance Program (DMAP). If you get a mental health medication from your PCP or Mental Health provider, let the pharmacy know that it needs to be billed as fee-for-service. Diplomat Pharmacy must be used for all specialty medications. If you have questions about a prescription(s) that need to be filled at Diplomat Pharmacy please call to speak with one of Customer Service Representatives or call our Member Service Department at , toll-free , TTY Women s health care and family planning AllCare Health Plan covers many services for women s special health care needs, including a yearly physical exam that includes: Pap smear Breast exam General health assessment Mammograms (breast X-rays) also are covered when they are needed or recommended. Talk with your PCP about how often you need a mammogram. You may go to your PCP for your annual exam, or you may go to a gynecologist. However, if your gynecologist wants to see you for a follow-up to your annual exam you will need a referral from your PCP. If you want to see the gynecologist for other women s health care problems, you will need a referral from your PCP. Family planning AllCare Health Plan covers both family planning services and birth control supplies. You do not need a referral from your PCP for family planning services. You may visit any AllCare Health Plan provider or your County Health Department. You also may go to any family planning clinic, doctor or nurse practitioner who will take your DMAP Medical Care Card. Covered services and supplies include: Sterilization (a consent form must be filled out 30 days before this procedure) Depo-Provera Norplant implants Birth control pills Condoms Talk with your PCP to see if other supplies are covered. These services and supplies are available through any provider who will accept your Oregon Health ID. Abortions are a fee-for-service benefit covered by DMAP, not AllCare Health Plan. 24 AllCare Health Plan PLUS Member Handbook Rev. 7/19/2013

25 Pregnancy and pre-natal care If you are pregnant, or think you might be, call your PCP right away. It is very important that you begin pre-natal care early. By starting your pre-natal care early and getting regular pre-natal checkups, you can keep yourself and your baby healthy. AllCare Health Plan pregnancy benefits include: Pre-natal visits Labor and delivery (child birth) services Post-partum (after the delivery) care AllCare Health Plan does not cover home births. You may see your PCP or an obstetrician (OB a doctor who specializes in pregnancy care) for your pre-natal care. However, your OB doctor does not provide treatment of everyday illnesses and injuries. You should call your PCP for these illnesses and injuries. During your pregnancy, our Member Services representatives can help you find: An OB doctor Pre-natal nutritional counseling Birthing classes (we pay for classes taken from contracted instructors) Parenting classes You must choose your OB from our provider panel. For more information about starting pregnancy care, please call your PCP or Member Services. You also need to contact your DHS caseworker as soon as you know you are pregnant. If you miscarry or have an abortion, you should notify your DHS caseworker and AllCare Health Plan. Delivery of babies when you are traveling Try to stay within AllCare Health Plan service area during the last 30 days of your pregnancy. However, if you must leave the service area, AllCare Health Plan covers only emergency care for you and your baby. AllCare Health Plan will cover your baby s delivery and newborn check-up while in the hospital, but not the pre-natal care. AllCare Health Plan also will pay for any other emergency care involving you or your baby. After the baby is born Call your DHS caseworker as soon as possible after your baby has been born. DHS will notify All- Care Health Plan. The sooner you notify DHS, the sooner we will have your baby in our system which will make it easier for you to get health care for your baby. AllCare Health Plan will cover your baby for the first 30 days of life. Your baby might be eligible for OHP for one year, even if you are no longer covered. Circumcision for infants between 1 week and 4 weeks of age is a covered benefit on our plan if mother was on our plan at the time of birth. AllCare Member Services Toll-Free TTY/TDD

26 Newborn care AllCare Health Plan benefits for newborns include well-baby care, which is a series of regular checkups during a child s first five years of life. These check-ups help your doctor see problems early, when treatment is more effective. We also cover immunizations shots. Circumcision for infants between one to four weeks of age is a covered benefit on our plan if the mother was on our plan at the time of birth. This procedure must be done in an office setting unless a prior authorization for a different setting was approved. Immunizations (shots) Immunization shots protect our bodies against diseases, such as chickenpox and measles. These shots are very effective and important for children. Your child will need many shots during his/her first 15 months of life. More shots are needed when entering kindergarten and middle school. If you do not know if your child has received all of his/her shots, or if you have a question about immunizations shots, talk to your child s PCP. Health services for older children and teens Children between the ages of five years and 18 years are eligible for a well-child check-up once every two years. You also may take your child to his/her PCP if you have concerns about your child s physical, mental or emotional progress, such as bed wetting, inability to pay attention in school, behavior problems, and mood changes. Dental If you need dental services, contact the dental care organization listed on your DHS Medical Care identification card. AllCare is your Medical and Mental Health Plan; It does not cover you dental services. Medical equipment If you think you need medical equipment, such as diabetic supplies, walkers or incontinent supplies, talk to your PCP. Your doctor is best able to decide what you need. Vision and hearing care AllCare Health Plan provides limited vision services, as listed below: Pregnant women may receive an eye exam and glasses. Children may receive an eye exam and glasses once every year. 26 AllCare Health Plan PLUS Member Handbook Rev. 7/19/2013

27 Children years old must also be on the Plus plan. Diabetics may receive a diabetic eye exam once every year. AllCare Health Plan has eye doctors (optometrists and ophthalmologists) available for your vision care. Please call Member Services if you need help finding an eye doctor. Eye problems If your vision suddenly worsens, or if your eyes become infected or injured, see your Primary Care Provider. Your PCP will refer you to a specialist if needed. Hearing If you think you need a hearing exam, call your PCP for a referral to a specialist. If you were receiving hearing services before enrolling in our plan, please call Member services about continuing those services. AllCare will pay for some hearing aids and batteries. Please call Member Services about hearing aid benefits. Quitting tobacco If you need help quitting smoking or chewing tobacco, call , TTY or call your PCP; no referral is needed. He/she will prescribe a treatment plan for you. AllCare Health Plan coverage includes nicotine gum, patches, Zyban and Chantix. We also provide individual support and counseling to help you quit. Mental health services Your PCP may refer you for a mental health evaluation, or you may get an evaluation on your own. During your evaluation, a counselor will diagnose your mental health concerns (such as anxiety or depression). Your counselor then will create a treatment plan with you. Covered services include: Mental health evaluation Case management Therapy Medication management Urgent care Emergency care Inpatient psychiatric care Important: You do not need a referral to get mental health services from a network provider. AllCare Member Services Toll-Free TTY/TDD

28 Declaration of Mental Health Services Oregon has a form for stating your wishes for mental health care if you were in a mental health crisis or if something prevents you from making decisions about your mental health treatment. The form is called the Declaration for Mental Health Treatment. You can complete it when you can understand and make decisions about mental health care. The Declaration for Mental Health treatment says how you want care to be provided during times when you are unable to make such wishes known. Only a court or two doctors can decide if you are not able to make decisions about your mental health care. This form allows you to make choices about the kinds of care you want and do not want. It can be used to name an adult to make decisions about your care. This person named must agree to represent you and must follow your wishes. If your wishes are unknown, this person will decide what you would want. A declaration form is only good for three (3) years. You may become unable to decide during those three (3) years. If so, your declaration will remain good until you can make decisions again. You may change or cancel your declaration when you can understand and make choices about your care. You must give your new form to your Primary Care Physician and the person you name to make decisions. For more information on the Declaration for Mental Health Treatment go to the State of Oregon s website at: If you have a disability and need this document in an alternate format, please call the State of Oregon s Department of Human Services at: (503) (voice) or (503) (TDD). OHP mental health providers in the AllCare Health Plan service area are: Josephine County Douglas County Options for Southern Oregon Douglas County Health & Social Services Toll free Toll free TTY TTY Crisis Line Crisis Line (800) Jackson County Curry County Jackson County Mental Health Curry County Mental Health Toll free Toll free TTY TTY Crisis Line Crisis Line (877) AllCare Health Plan PLUS Member Handbook Rev. 7/19/2013

29 Alcohol and drug treatment AllCare Health Plan covers treatment to help you stop using alcohol and drugs. You do not need a referral you may visit an alcohol and drug dependency provider on your own. Alcohol and drug treatment services include: Outpatient treatment Intensive outpatient treatment Detoxification Acupuncture Medication assisted treatment including Methadone maintenance Individual and group counseling for you and your family members Case Management Confidentiality: Federal and state laws protect the privacy of all OHP members. No one may release information to anyone outside AllCare Health Plan about a member s chemical dependency without the member s written permission. AllCare Health Plan and its providers may not release or disclose any information about an OHP member for any purpose except as directed by the OHP member. AllCare Health Plan and its providers may not give information, except for purposes directly related to the administration of the Oregon Health Plan. When you call an alcohol and drug dependency provider, a counselor will schedule an appointment with you to discuss your condition and develop a treatment plan. AllCare Health Plan alcohol and drug dependency providers are: 24-hour Help Line: Josephine County Curry County OnTrack Curry County Human Services 806 NW 6th St Colvin St. Grants Pass, OR Gold Beach, OR OnTrack Family Coalition Center Cave Junction, OR Jackson County OnTrack 221 W. Main St. Medford, OR AllCare Member Services Toll-Free TTY/TDD

30 End-of-Life decisions 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. A serious illness or sudden injury could leave you unable to make decisions or express your wishes. If that happens, your relatives would have to decide on for you. 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 document for this is called an Advance Directive. 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, 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 cancel 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 not 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. Advance Directive forms are available from AllCare Health Plan, online at SHIBA/docs/advance_directive_form.pdf, or by contacting your local hospital. If you would like to send a complaint about your provider not following your wishes in your Advance Directive, you may send that to the State Survey and Certification office at 800 NE Oregon St., Ste 305, Portland, OR Or by calling or by fax: For more information about an Advance Directive, call: AllCare Health Plan, or Oregon Health Decisions (in Portland) at or & TTY call 711. How to make a Complaint or a Grievance If you are very unhappy with AllCare Health Plan for your health care services, your provider or provider staff, you can complain or file a grievance. We will try to make things better. Just call the Member Service Department at , toll free at , or TTY , or send us a letter to 740 SE 7th Street, Grants Pass, OR We will call or write back in a week 30 AllCare Health Plan PLUS Member Handbook Rev. 7/19/2013

31 to let you know that we are working on it. We will send you a letter within 30 calendar days from the date the complaint was received explaining how we will address your complaint. We will not tell anyone about your complaint unless you ask us to. Appeals and Hearings If we deny, stop or reduce a medical service your provider has ordered, we will mail you a Notice of Action letter explaining why we denied the service. The letter will have instructions on how to ask us to change our decision. You have a right to ask us to change it through an appeal, a hearing, or both. You must ask no more than 45 calendar days from the date on the Notice of Action letter. How to Appeal a Denial In an appeal, a new health care professional at AllCare Health Plan will review your case. Ask us for an appeal by: Calling the Member Service Department at , toll free at , or TTY or writing us a letter. If you want help with this, call and we can fill out an appeal form for you to sign. You can also ask your caseworker for help. You will get a Notice of Appeal Resolution from us in 16 calendar days letting you know if the reviewer agrees or disagrees with the denial. You can keep on getting a service that already started before we denied it. If you continue the service and the reviewer agrees with the original denial, you may have to repay the cost of the services that you received after getting the denial letter. How to get a Fast Decision on an Appeal or Denial If your provider believes that you have an urgent medical problem that cannot wait for a regular appeal, tell us that you want a fast (expedited) review. Include a statement from your provider or ask them to call us and explain why it is urgent. We will call you with a decision no later than 3 working days from the date we received the appeal. Provider Appeals You, your representative or a subcontractor/provider, with your approval, who disagrees with a notice of action (notice) has the right to file an appeal with AllCare for you when their services are denied by the plan. How to get an Administrative Hearing You may request a hearing without first filing an appeal with AllCare. You must file a hearing request with the State of Oregon no later than 45 calendar days from the date of AllCare s notice of action or AllCare Member Services Toll-Free TTY/TDD

32 notice of appeal resolution. If you file the hearing request with the Department of Human Services/ State of Oregon or AllCare no later 45 calendar days from the date of the notice, the State of Oregon shall consider the request timely. Your Notice of Action denial letter will have a Hearing Request form that you can send in. You can also ask us to send you a Hearing Request form, or call OHP Client Services at , TTY 711, to ask for a form. At the hearing, which will be held over the phone, you can tell the judge why you do not agree with our denial and why the services should be covered. You do not need a lawyer, but you can have one or someone else, like your doctor, with you. If you hire a lawyer you must pay their fees. You can ask the Public Benefits Hotline (a program of Legal Aid Services of Oregon and the Oregon Law Center) at , TTY 711, for advice and possible representation. Information on free Legal Aid can also be found at Expedited Hearing If your provider believes that you have an urgent medical problem that cannot wait for a regular hearing process, write on the form that you want a fast (expedited) hearing. Include a statement from your doctor explaining why it is urgent. You should get a decision in 3 workdays. Hearing Request forms may be sent to: Division of Medical Assistance Programs Attention: Hearings Unit 500 Summer St. NE, E49 Salem, OR Confidentiality The medical care you and your family receive through AllCare Health Plan and your Primary Care Provider is kept private. So are your medical records. If you want your medical records sent to another provider, your PCP will ask you to sign a release that authorizes their office to send the records. If you have a complaint or file a grievance, that information also is confidential. AllCare Health Plan will send you a complete copy of our Notice of Privacy Practices for you to read. Once you have read and understood this information we ask that you sign the attached form and return to us so that we can keep it on file. If at any time you would like another copy please let us know by calling the Member Services Department. We are also very serious about federal privacy laws and that is why when you call our Member Services Department we may ask for identifying information before we speak to you about any health care or eligibility questions. How to get a copy of your medical record Your PCP will have your most complete medical records. To get a copy, talk to your PCP. Your PCP is allowed to charge you a reasonable fee for copying your medical records. 32 AllCare Health Plan PLUS Member Handbook Rev. 7/19/2013

33 Your AllCare Health Plan medical record contains information about your medical care and billing. To get a copy, call Member Services or write to: AllCare Health Plan Attention: Member Services 740 SE 7th Street Grants Pass, OR We may need up to 30 days to provide you with your medical record. If your medical record is more than 50 pages, you will be charged $0.25 per page to cover the cost of supplies, labor and postage. If there are 50 or fewer pages, there is no charge. Physician reimbursement You have the right to ask if AllCare Health Plan has special financial arrangements with its physicians that can affect the number of referrals and other services they use. To get this information, call AllCare Health Plan and ask for information about physician payment arrangements. Important Words Glossary Administrative Hearing A hearing is done by an administrative law judge of the state Office of Administrative Hearings. You can ask for this after you receive a Notice of Action to deny, reduce or stop benefits. Advance Directive A legal document that explains the type of medical treatment you want if you should become unable to communicate your wishes with your health care providers. AllCare Health Plan A branch of the Mid Rogue Independent Physician Association that has contracted with the state to administer the Oregon Health Plan in Josephine, Jackson and Curry counties, and in parts of Douglas County. AllCare Health Plan A branch of the Mid Rogue Independent Physician Association that has contracted with the state to provide the Oregon Health Plan in Josephine, Jackson and Curry counties, and in parts of Douglas County. Appeal A request for review of a denial of health care service, or review of a denial of payment for services or prescription drugs you have received. You may also appeal a decision to stop services or drugs that you are receiving. CCO Coordinated Care Organization group. A plan that brings together all kinds of care under one Complaint A telephone call or letter to us complaining about your health care or about one of our network providers. A complaint does not involve coverage or payment disputes (see Appeals). Community Health Workers needed. A specially trained person to help you get the best health services AllCare Member Services Toll-Free TTY/TDD

34 Declaration for Mental Health Treatment A legal document for appointing a mental health care representative and giving instructions for mental health care providers to follow, before you become unable to direct your own mental health care. DHS DMAP Plan. Department of Human Services. Division of Medical Assistance Programs. The state agency that oversees the Oregon Health Emergency An emergency medical condition means you have severe symptoms and believe your health will be in serious danger if you don t get help right away. This includes your unborn baby if you are pregnant. If you believe you have an emergency medical condition, call or go directly to the hospital emergency room. Examples of emergencies include, but are not limited to, bleeding that won t stop, bad stomach or chest pain, suspected heart attack or stroke, serious injuries or burns, poisoning, unconsciousness (when a person cannot be awakened), seizures, and difficulty breathing. ICM Intensive Care Manager. An AllCare Health Plan employee who helps members with difficult or special medical needs receive proper health care and other assistance from community agencies. Grievance A complaint about your health care or one of our network providers. This type of complaint does not involve coverage or payment disputes (see Appeals). Immunizations Also called vaccines (shots). Medicines that are injected into the body to prevent a person from getting a disease that may cause serious health problems. Member Services An AllCare Health Plan department that assists you with your questions and problems with health care services. Notice of Action OHP OHP Plus Our written response to you about any request for service or payment for service. Oregon Health Plan, also known as Medicaid. OHP Standard a benefit package with expanded benefits. Peer Wellness Specialists Personal Health Navigators needed. a benefit package with limited benefits. A specially trained person to help you get the best health services needed. A specially trained person to help you get the best health services Post Stabilization Care to keep you stable after an emergency is over and there is no chance of another emergency.. PCP or Primary Care Provider The doctor or nurse practitioner you have chosen to be the main provider of your health care services. Specialist of injury. A doctor who has extra training in treating a specific part of the body, a disease, or a type 34 AllCare Health Plan PLUS Member Handbook Rev. 7/19/2013

35 Urgent care Medical treatment of a problem that needs immediate attention but is not a medical emergency (life threatening). Well-child care A series of regular medical exams where a doctor or nurse practitioner looks for problems with a child s physical and mental development to ensure early and more effective medical treatment.

36 PlusNOD February 7, 2014 GRANTS PASS 740 SE 7th Street Grants Pass, OR Tel MEDFORD 1390 Biddle Road, Ste. 105 Medford, OR Tel MEMBER SERVICES TOLL-FREE TTY/ TDD