Member Handbook. Your Personal Guide to Better Health

Transcription

1 Member Handbook Your Personal Guide to Better Health Revised July 2015

2 Member Handbook Your Personal Guide to Better Health List of Helpful Numbers My Arbor Health Plan ID number (fill in your number) Other family members Arbor Health Plan ID numbers My primary care provider PCP/medical home My child s PCP/medical home My dentist My child s dentist My Arbor Health Plan care manager Medicaid Enrollment Center In the Lincoln area: Arbor Health Plan 24-hour Nurse Call Line Non-emergency transportation Intelliride TTY Vision and eye care: Avesis Eye Care Behavioral health and substance abuse services: Magellan Health Services Arbor Health Plan Member Services TTY You can write to Member Services at:...arbor Health Plan P.O. Box 7336 London, KY ACCESSNebraska Nebraska Medicaid Eligibility Line Get information from the Internet. Arbor Health Plan also communicates to members through our website at Our Member Handbook is available in Spanish.

3 Your Personal Guide to Better Health Member Handbook Questions? Call Member Services at Need translations? Call Care Management/Complex Care Management 8:00 a.m. 6:30 p.m. (CST) call Utilization Management 8:00 a.m. 6:00 p.m. (CST) call

4 Table of Contents Welcome to Arbor Health Plan...2 About us... 2 Our mission... 2 How we can help you... 2 How you can help us... 3 Getting Information...4 On the Web... 4 In other languages and formats... 4 Getting Started...5 Enrolling... 5 Your ID cards... 5 Things to know about your ID cards... 6 Arbor Health Plan Benefits and Services...7 Getting care, staying well... 7 Getting in touch with your primary care provider (PCP)... 9 Getting care from specialists...10 Specialist office visits...11 Out-of-network providers...11 Chiropractic services...12 Nurse Call Line...12 Urgent care...13 Emergencies...14 Hospital care...15 Federally qualified health centers (FQHCs) and rural health centers (RHCs)...15 Home health care...15 Durable medical equipment (DME) and medical supplies...15 Nursing facility services...16 Eye care...16 Eye care benefits for children (age 20 and younger)...16 Eye care benefits for adults (age 21 and older)...16 Access to women s health specialists...16 Family planning services...16 Care Management...16 Getting care for your family...17 If you are pregnant...17 Bright Start program for pregnant members...18 Lamaze classes...18 Bright Start diaper program...19 Postpartum care...19 Care for your children...20 Arbor Health Plan s Special Programs...21 Disease Management Programs...22 Breast cancer screening...22 Quit using tobacco...22 Getting Care When You Are Away from Home...23 We pay attention to your care...23 Dedication to Quality Care...24 Medically Necessary Services and Benefits...25 Prior Authorization...26 Prior authorization process...26 Services needing preapproval (prior authorization)...26 Services needing preapproval from the Nebraska Department of Health and Human Services...27 Getting Other Benefits and Services...28 Transportation...28 Behavioral health treatment...28 Dental services...28 Pharmacy services...28 Benefit Limits...29 If You Have Other Health Insurance...30 If You Get a Bill or Statement...31 Loss of Benefits (Disenrollment)...32 Member Rights and Responsibilities...33 Member rights...33 Member responsibilities...34 Summary Notice of Privacy Practices...35 Advance Directive...36 Living will...36 Durable Power of Attorney for health care...36 Notice of action...37 Member Grievances, Appeals and State Fair Hearings...38 Grievance system...38 Grievances...38 Appeals...39 Expedited appeals...39 State fair hearing...40 Continuing benefits during an appeal and/or state fair hearing...40 Fraud and Abuse...41 Special Situations...42 Continuing care...42 Changing your primary care provider (PCP)...44 If your PCP is leaving the Arbor Health Plan network...44 My Personal Medical Diary...45 Notes...47 Arbor Health Plan may not cover all of your expenses. Read your Member Handbook carefully so you will know which health care services are covered. You have the right to ask for, and get, the information in this Member Handbook each year. Arbor Health Plan 1

5 Welcome to Arbor Health Plan About us Arbor Health Plan is a managed care organization that arranges the health care services you and covered members of your family need. We help you and your family members stay healthy. We want to make sure you and your family are treated with respect and that your health care services are provided in a way that is private and confidential. Arbor Health Plan is dedicated to quality health care in your community. It is important to understand all you can about how your new health plan works. Please keep reading this handbook. Our mission Our mission at Arbor Health Plan is to help people: Get care. Stay well. Build healthy communities. How we can help you Do you need help? Member Services can help you with these questions: How do I get medical care? How do I choose my primary care provider (PCP) and find a medical home? How do I get my medical records? How do I get a list of Arbor Health Plan providers? What services and benefits are covered? How do I find out about special-needs services? What do I do if I get a bill? How do I file a grievance or an appeal? Call to talk to a Member Services representative 24 hours a day, 7 days a week. Or go to 2 Arbor Health Plan

6 Welcome to Arbor Health Plan How you can help us We need you to help us. It is important to remember to: Let ACCESSNebraska, Arbor Health Plan and your health care providers know of any changes that may affect your membership, health care needs or benefits. Some examples include, but are not limited to, the following: You are pregnant. You have a new baby. Your address or phone number changes. You or one of your children has other health insurance. You have a special medical condition. Your family size changes. You move out of the county or state. Keep your benefits up to date with ACCESSNebraska. Find out when your benefits will end. Make sure all your information is up to date so you can keep your benefits. REMEMBER: You must always call ACCESSNebraska at to let them know of your changes. You can also make changes online at and go to Report Changes. Work with Arbor Health Plan and our health care providers. This means following the guidelines given to you about Arbor Health Plan and following your health care provider s instructions about your care. This includes: Making appointments with your health care provider. Canceling appointments when you cannot make your appointment. Calling Arbor Health Plan when you have questions. Treat your health care providers and their staff with respect and dignity. Talk with your health care provider to agree on goals for your treatment, to the degree you are able to do so. Talk with your health care provider so you can understand your health problems, to the degree you are able to do so. If you have any questions about your responsibilities or for more information, please call Member Services at Arbor Health Plan 3

7 Getting Information On the Web We have made it easy for you to find what you are looking for on our website. Go to for the following information: Help finding a provider. Benefits and services. Preventive health guidelines and screening recommendations. HIPAA notice of privacy practices. Our Member Handbook is available in English and Spanish. To request other formats, call Member Services at Member rights and responsibilities. Grievance, appeals and fair hearings. Community services. Contact information. If you do not have access to the Internet, most of the information above is included in this handbook. If you have questions, please call Member Services at In other languages and formats Arbor Health Plan can provide written member materials in languages other than English and in other formats for the visually impaired. These materials do not cost you any money. Please call Arbor Health Plan Member Services at to ask for member materials in another language or other formats. If you do not speak English, we can help you. Our Language Line Service has representatives who speak languages other than English. If your PCP or specialist cannot provide an interpreter for your appointments, Arbor Health Plan will provide an interpreter to help you. Interpreter services do not cost you any money. If you are deaf or hard of hearing, our TTY number is Or you can call the Nebraska Relay service at Arbor Health Plan

8 Getting Started It is easy to get care with Arbor Health Plan. Let us tell you how. Enrolling When you are eligible for the Medicaid program, you need to choose a health plan. Medicaid choice counselors help you make this decision. Medicaid choice counselors can: Help you and your family enroll in a health plan. Answer questions about your choice of health plans. Help you if you decide to change health plans. You can talk to a Medicaid choice counselor by calling the Medicaid Enrollment Center at In the Lincoln area, call Once you are enrolled in Arbor Health Plan, you will get a welcome kit. The information in this kit tells you about all of your benefits and services. When you choose a health plan, you are enrolled for 12 months. You are allowed to change your health plan 1 time during that 12 months. To change more often than that, you must show a Medicaid choice counselor that you have a reason (cause). Please see page 32 for more information on cause and disenrollment. Your ID cards Arbor Health Plan ID card After you are enrolled in Arbor Health Plan, you will get an Arbor Health Plan ID card. If you have not received your card, or if you have lost it, please call Member Services for a new card. Your Arbor Health Plan ID card is very important; keep it with you at all times. Nebraska Medicaid card You will also get a Medicaid ID card from the Department of Health and Human Services. If you lose your Medicaid ID card, call ACCESSNebraska at If you need help or if you have questions about your cards, call Member Services at Arbor Health Plan 5

9 Getting Started Things to know about your ID cards You may need to show your medical insurance cards at every doctor and pharmacy visit. You may need to show your: Arbor Health Plan ID card. It is important to carry all of your medical insurance cards with you at all times. Medicaid ID card. Any other health insurance card(s) you have. You will also need your Medicaid ID card for: Transportation. See page 28 for more information. Behavioral health treatment (mental health/drug and alcohol substance abuse services). See page 28 for more information. 09/30/2013 M P R To Last Name, First Name MEMBER ID SEX DOB xx/xx/xxxx STATE MEDICAID ID EFFECTIVE xx/xx/xxxx PRIMARY DOCTOR Name Practice Street Address Town, State Zip Phone A G E m n O w M r A This is your permanent Medicaid ID card. Keep this card. To verify your current eligibility for Medicaid, call toll-free at ( in Lincoln or in Omaha). If you are enrolled in Managed Care, you can verify your information by calling (in Lincoln, ). If your card is lost or stolen, call your caseworker. Last Name, First Name MEMBER ID SEX Eligibility must be verified. To verify eligibility and obtain information regarding DOB xx/xx/xxxx Street Address claims submission, call NMES at (in Lincoln, ; log-on to STATE MEDICAID ID or call the Town, Medicaid State Inquiry Zip Line at (in Lincoln, ). Phone EFFECTIVE xx/xx/xxxx PRIMARY DOCTOR Name Practice This card is non-transferable and is for identification only and is not a guarantee of benefits or eligibility. Any Fraudulent or unauthorized use of this card is strictly prohibited and punishable by law. Member Services & Filing Grievances Provider Services & Prior Authorization Report Medicaid Fraud To Speak with a Nurse Anytime Always carry your Arbor Health Plan card. You ll need it to get your benefits. Go to your Arbor Health Plan Primary Care Physician (PCP) for medical care. Emergency Room: Go to an Emergency Room near you when you believe your medical condition may be an emergency. If you get emergency care, please notify your PCP. Out-of-Area Care: Report out-of-area care to Arbor Health Plan and your PCP within 48 hours. Mental Health, Drug & Alcohol Services: Call the toll free number for your region. If you don t know the number, call Member Services at Arbor Health Plan 6 Arbor Health Plan

10 Arbor Health Plan Benefits and Services The Nebraska Medicaid program determines the covered benefits and services people get on Medicaid. You must use an Arbor Health Plan network provider to get these benefits and services, unless: The services are emergency services. The services are family planning services. You get prior authorization (preapproval) to use a provider who is not in Arbor Health Plan s network. Getting care, staying well When you join Arbor Health Plan, you choose a primary care provider (PCP). Think of this as your medical home. Your PCP is the doctor, nurse practitioner or physician assistant you regularly see. Your PCP s office is your medical home. Your medical home will provide medical services and give you advice on health matters. Your PCP will also keep other providers you see informed of your medical record, and advise whenever the records are needed. If you did not pick a PCP when you enrolled, you will have 10 days from the date you enrolled to pick a PCP. If you do not pick a PCP within 10 days, Arbor Health Plan will assign a PCP for you and your family. You can choose the same PCP for your whole family or you can have a different PCP for each family member. There are different kinds of practitioners who can be PCPs, including: Family practice and general practice doctors, who treat adults and children. Internal medicine doctors or internists, who treat members older than the age of 18. Pediatricians, who treat children from birth to age 21. Physician assistants. Nurse practitioners. Some doctors have trained health care assistants whom you may see during an appointment, such as: Medical residents. Nurse midwives. Arbor Health Plan 7

11 Arbor Health Plan Benefits and Services For questions about changing your PCP, see the section Changing your PCP on page 44 of this handbook. You can change your PCP at any time and for any reason. In some cases, if you have health needs that require specialized care, you may be able to choose a specialist as your PCP. For more information, please call Member Services at All Indian Health Services (IHS) facilities are in our provider network. You may access covered services at these facilities if you are eligible to be seen there. This includes choosing your primary care physicians at IHS. As your medical home, your PCP will help you stay healthy. By having regular visits with your PCP, he or she will be able to: Learn your health history and keep your records up to date. Answer questions about your health. Give you information about healthy eating and diet. Give you the shots and screenings you need. Help you get care from other providers, if needed. Find problems before they become serious. Provide Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services for members 20 years old and younger. See the Care for your children section on page 20 for more information. Provide preventive treatment for conditions like diabetes, high blood pressure, asthma and allergies. New member? Remember to: Make an appointment with your PCP right away your PCP s phone number is on your Arbor Health Plan ID card. Have your medical records sent from your old PCP to your new PCP, if you have picked a new PCP. Get regular checkups. 8 Arbor Health Plan

12 Arbor Health Plan Benefits and Services Getting in touch with your primary care provider (PCP) You can call your PCP for medical problems 24 hours a day, 7 days a week. There is no limit to how many times you can visit your PCP. It is important to be on time for your appointment. If you are going to be late or need to cancel your appointment, call the PCP s office ahead of time and let the office know. If you need to change your appointment, try to let the PCP s office know at least 24 hours before the appointment. It may be time for a checkup if: You should: Your child is under 13 years old. See your child s PCP regularly for shots and screenings. You (or your child) are 11 to 20 years old. See your (or your child s) PCP once every year. You are a woman 18 years or older, or are sexually active. You have learned you are pregnant. See your GYN (gynecologist) for a Pap test every year, or as directed by your doctor. See your OB (obstetrician)/gyn right away and make regular appointments. See page 17 for more information. You are a woman 40 years old or older. Get your mammogram once every year or as directed by your doctor. You are a man 50 years old or older. Talk to your doctor about screenings for prostate cancer. You are 50 years old or older. Talk to your doctor about screenings for colon and rectal cancer. The Nurse Call Line is there for you 24 hours a day, 7 days a week. Call Please remember that the Nurse Call Line does not take the place of your doctor. Always follow up with your doctor if you have questions about your health care. Arbor Health Plan 9

13 Arbor Health Plan Benefits and Services Getting care from specialists If you have health needs that require specialized care, your PCP might send you to a specialist. A specialist is a doctor trained to treat certain health problems. Specialists can include: Heart doctors (cardiologists). Skin doctors (dermatologists). Doctors for women s issues (gynecologists). Doctors for pregnant women (obstetricians). Foot doctors (podiatrists). Eye doctors (ophthalmologists). Cancer doctors (oncologists). Surgeons. Doctors for blood problems (hematologists). 10 Arbor Health Plan

14 Arbor Health Plan Benefits and Services Your PCP can help you choose a specialist and make an appointment. You can get a list of Arbor Health Plan specialists by going to and clicking on Find a Provider, or by calling Member Services at Specialist office visits Arbor Health Plan covers your visits to specialists in our network. There is no limit to how many times you may see the specialist. If the specialist thinks you need surgery or other special treatment, you can ask to see another specialist. This is called a second opinion. If you want a second opinion, ask your PCP for a specialist in a different practice within the Arbor Health Plan network. Out-of-network providers Visits to providers who are not in the Arbor Health Plan network will need to have prior approval from Arbor Health Plan. Your doctor will help you get approval. Please see the Prior Authorization section on page 26 for more information. If Arbor Health Plan does not have a provider who can treat your health problem, you have the right to ask to see a provider who is not in the Arbor Health Plan network. You can talk to your PCP about this. If you have questions about out-of-network providers, please call Member Services at Arbor Health Plan 11

15 Arbor Health Plan Benefits and Services Chiropractic services Arbor Health Plan covers chiropractic care. Members 20 years of age and younger need prior approval. Please see the Benefit Limits section on page 29 for more information about the number of visits and treatments you can get. Nurse Call Line Our Nurse Call Line is a confidential service that you can call 24 hours a day, 7 days a week. Trained nurses can answer questions about your health and give you information when your doctor is not available. They can help you decide which kind of care you need. When you call the toll-free Nurse Call Line, the nurse will: Ask you questions about your health. Give you information on how to care for yourself at home, when appropriate. Give you information to help you decide what other care you need. The Nurse Call Line has an audio library where you can listen to information about health topics. The Nurse Call Line is there for you 24 hours a day, 7 days a week. Call Please remember that the Nurse Call Line does not take the place of your doctor. Always follow up with your doctor if you have questions about your health care. 12 Arbor Health Plan

16 Arbor Health Plan Benefits and Services Urgent care Urgent care is for conditions that are serious, but are not emergencies. This is when you need immediate attention from a doctor, but not in the emergency room (ER). If you need urgent care, but you are not sure if it is an emergency, call your PCP first. If you cannot reach your PCP, call the Arbor Health Plan Nurse Call Line. Your PCP or the nurse will help you decide if you need to go to the ER, the PCP s office or to an urgent-care center near you. If you go to an urgent-care center or the ER, be sure to call your PCP the next day to make an appointment. Your PCP must schedule an appointment for you within 2 calendar days of your request for an urgent-care appointment. Examples of urgentcare conditions: Coughing. Colds. Vomiting. Pink eye. Diarrhea. Stomachache. Earache. Rashes. Sore throat. Lacerations. Toothache. Arbor Health Plan 13

17 Arbor Health Plan Benefits and Services Emergencies An emergency is a serious or life-threatening condition that: Requires immediate medical care. Places the health of the person at risk. Causes serious harm to the body and its functions. If you have an emergency, call 911 for an ambulance or go directly to the nearest hospital emergency room (ER). If you need care, but are not sure if it is an emergency, call your PCP first. If you cannot reach your PCP, call the Arbor Health Plan Nurse Call Line at Your PCP or the nurse will help you find the best care available for you at that time. You do not need approval from Arbor Health Plan to receive care in an emergency. You have the right to get the care you need. You also have the right to say no to treatment and to ask for, or say no to, a transfer to another hospital. The care you get during and after an emergency is aimed to improve your medical issue or to make it go away. After an emergency, you may need care to help your medical issue get better or go away. The hospital will call Arbor Health Plan to get approval for these services and care. Arbor Health Plan will cover these services when appropriate. You don t have to pay for emergency care even if you go to a facility that s not in the Arbor Health Plan network. If an Arbor staff member tells you to get emergency care, you still don t have to pay. Call your PCP to make an appointment for care after your emergency. Do not go back to the ER where you were treated unless your PCP tells you to. Examples of emergencies: Chest pain. Choking. Poisoning. Severe wound or heavy bleeding. R R Being unable to breathe properly. Severe spasms/ convulsions. Loss of speech. RBroken R bones. Severe burns. Drug overdose. Sudden loss of feeling or not being able to move. Severe dizzy spells, fainting or blackout. 14 Arbor Health Plan

18 Arbor Health Plan Benefits and Services Hospital care Arbor Health Plan covers medically necessary hospital services, including outpatient services like X-rays and laboratory tests, when they are medically necessary. Your PCP or specialist can help you get hospital services that are in the Arbor Health Plan network. Go to or call Member Services to find out if a particular hospital is in the Arbor Health Plan network. Federally qualified health centers (FQHCs) and rural health centers (RHCs) Arbor Health Plan covers care at FQHCs and RHCs that are in the Arbor Health Plan network. Please see our online provider directory at or call member services to find a center near you. Home health care If your PCP or specialist thinks you need care at home, he or she may ask for a home health nurse or aide for you. Private duty nursing in the home might also be covered. Home health care and private duty nursing both need preapproval (prior authorization). Your PCP or specialist will ask Arbor Health Plan for this approval before you get the service. Durable medical equipment (DME) and medical supplies Medical supplies are generally: Disposable. Required for care of a medical condition. Used at home. This does not include: Personal-care items (such as deodorant, talcum powder, bath powder, soap, toothpaste, eye wash or contact solution). Oral or injectable over-the-counter drugs and medicines. Durable medical equipment (DME) is generally an item and/or device that: Can be used again and again. Is primarily used for a medical purpose. Is used in the home. Arbor Health Plan 15

19 Arbor Health Plan Benefits and Services Some examples of DME are oxygen tanks, special medical beds, walkers and wheelchairs. Examples of supplies are diapers, catheters and diabetes testing supplies. Some DME will need preapproval. Your PCP or specialist will ask Arbor Health Plan for this approval before you get the DME. Please see the Prior Authorization section on page 26 of this handbook for more information. Nursing facility services Arbor Health Plan covers short-term skilled care in a nursing facility, when the plan is for the member to return home. This type of care needs prior authorization by Arbor Health Plan. Your PCP or specialist will ask for approval for you before you go to the nursing facility. Eye care Regular eye exams are important. Call your eye doctor to schedule a routine eye exam. Eye care benefits for children (age 20 and younger) Members age 20 and younger are eligible for 1 eye exam every year. They are also eligible for 1 pair of eye glasses every year, or more often if approved. Contact lenses are covered when medically necessary, when standard lenses do not correct vision. Eye care benefits for adults (age 21 and older) Members age 21 and older are eligible for 1 eye exam every 24 months. These members are also eligible for 1 pair of eye glasses once every 24 months. Contact lenses are covered if medically necessary, when standard lenses do not correct vision. Access to women s health specialists Female members can access care from any women s health provider within the Arbor Health Plan network for: Routine GYN (female) care, such as physical, breast and pelvic exams, Pap smears, and education. Preventive health services. GYN problems for diagnosis, evaluation, treatment and follow-up care. Maternity care, including all visits. Family planning services You can go to any Arbor Health Plan or Medicaid doctor or clinic you choose for family planning services. You can choose doctors and clinics not in the Arbor Health Plan network. You do not need a referral from your PCP for routine family planning services. Please call Member Services, , with any questions. Care Management Care management is a service for members with special needs. Examples of special needs are long-term illnesses, injuries and pregnancies. Our goal is to help you use your benefits and get the care you need. If you have questions, call our Care Management department at Arbor Health Plan

20 Getting Care for Your Family If you are pregnant If you think you are pregnant, call your PCP to make an appointment. You do not need a referral from your PCP for these services. It is important to see your doctor regularly while you are pregnant and to keep all your appointments. This will help you and your baby stay healthy. Your doctor must schedule an appointment for you within a certain number of days from when he or she learns you are pregnant. Your appointment must be made within: 14 working days When you are in your first 3 months of pregnancy (first trimester). 7 working days When you are in your second 3 months of pregnancy (second trimester). 3 working days When you have a high-risk pregnancy. If you are pregnant, remember to: Call ACCESSNebraska at to update your information. You can also make changes online at and go to Report Changes. Make an appointment with your doctor and be sure to keep all your appointments while you are pregnant. Make an appointment with your dentist. Quit smoking if you smoke. Choose a doctor for your baby before your baby is born. Join Arbor Health Plan s Bright Start program by calling Arbor Health Plan 17

21 Getting Care for Your Family Bright Start program for pregnant members The Bright Start program helps you stay healthy when you are pregnant and also helps you have a healthy baby. The Bright Start program gives you information about the importance of: Eating right. Taking your prenatal vitamins. Receiving medical care in a timely manner. Staying away from drugs, alcohol and smoking. Visiting your dentist so you can keep your gums healthy. Arbor Health Plan will work with your doctors to make sure you get the care you need. Arbor Health Plan also has information to help with other services, like: Food and clothes. Transportation. The WIC (Women, Infants and Children) program. Breast-feeding. Home care. Helping you understand your emotions. Domestic abuse. Call Bright Start for more information toll free at Care managers are available to answer questions, provide educational materials and work with you during your pregnancy. You can access health and wellness advice from a nurse 24 hours a day, 7 days a week. Lamaze Classes Lamaze is a way of breathing that is used during labor. Arbor Health Plan offers free Lamaze classes to all pregnant members. There are no limits to the number of classes you can go to. Please call Bright Start at for more information and to find a class near you. 18 Arbor Health Plan

22 Getting Care for Your Family Bright Start diaper program The Bright Start diaper program offers free diapers to pregnant members who meet certain goals during their pregnancy. To get the diapers, you, as a pregnant member, must get your care from an Arbor Health Plan OB/GYN (obstetrician/gynecologist) provider or PCP. You must have your postpartum visit to your OB/GYN within days after your baby is born. You will get a letter from Bright Start when you have met your goals. The diapers will be shipped to your home. If you have questions about the Bright Start diaper program, please call Bright Start at Postpartum care Postpartum is the time just after you have had your baby. During this time, you want to make sure you: Call your OB doctor or PCP to make an appointment for your postpartum checkup. Try to get an appointment for 4 to 6 weeks after your baby is born, unless your doctor wants to see you sooner. Call ACCESSNebraska at Tell them about your new baby. This is very important. They will make sure you get the benefits and services your baby needs. Call the baby s doctor to make an appointment for your baby. Your baby should see the doctor at 2 4 weeks of age, unless the doctor wants to see your baby sooner. Do you have the Baby Blues? Sometimes women feel down or sad after having a baby. This is normal. Please ask yourself these 2 questions: During the past month, have I often felt down, depressed or hopeless? During the past month, have I often had little interest or pleasure in doing things? If you answer yes to one or both of these questions, please call our Bright Start department at our toll-free number, We want to make sure you get the help you need. Arbor Health Plan 19

23 Getting Care for Your Family Care for your children Arbor Health Plan cares for members younger than age 21 through a special program called Health Check, or Early and Periodic Screening, Diagnosis and Treatment (EPSDT). This program helps Arbor Health Plan make sure your children get the medical care they need to help prevent and/or find out about childhood diseases and illnesses early. Your child can see a pediatrician, a family practice doctor, a nurse practitioner or a physician assistant. The provider you choose for your child will be your child s primary care provider (PCP). To keep your children healthy, you need to make regular appointments with your child s PCP. These are called well-child visits and they are important at every age. They are different from visits to the PCP when your child is sick. At a well-child visit, the PCP will examine your child. What the PCP does during the exam depends on the age of your child. The PCP will ask questions, order tests and check your child s growth based on the age of your child. If you have questions or want to find out more about this program, call Member Services and ask for a Health Check/EPSDT care manager. My To Do list: Make an appointment for my baby s first doctor visit. Have my child see the PCP for his or her shots and screenings. Make sure my teenager sees the PCP every year for a checkup. Make appointments for the whole family to see the dentist every 6 months. Have my child s eyes checked. Get my checkup so I can stay healthy for my children! 20 Arbor Health Plan

24 Arbor Health Plan s Special Programs Disease management programs Arbor Health Plan offers disease management programs for members. You can get help managing asthma, diabetes, chronic obstructive pulmonary disease (COPD), heart disease, high blood pressure and obesity. Arbor Health Plan s disease management programs can help you make a plan to improve your health. You will learn how to: Self-manage your condition. Take your medications. Eat well. Exercise. Stay healthy. For more information, call Arbor Health Plan has special programs to help you stay healthy. You do not need a referral from your PCP to be in any of these programs. If you have one of the health care conditions listed below, you could become a part of one of our special programs. Asthma. Chronic obstructive pulmonary disease (COPD). Diabetes. Heart disease, including high blood pressure. Obesity. These programs can help you better understand your condition. A care manager helps coordinate your health care and then sends information to you about your condition. If you have extra needs, your care manager will work with you and your PCP. You will set and work on personal goals to improve your health and quality of life. If you have any questions about our special programs, or you do not want to be a part of these programs, call the Care Coordination program at or write to: Care Coordination Program Arbor Health Plan 2120 S. 72nd Street, Suite 1000 Omaha, NE Arbor Health Plan 21

25 Arbor Health Plan s Special Programs Breast cancer screening Arbor Health Plan encourages women to do a breast self-exam every month. We also want you to get a mammogram every year after the age of 40. Your doctor may want you to get a mammogram earlier. You do not need a referral from your doctor to get a mammogram, but you do need a prescription from your doctor. Talk to your doctor. A mammogram is an X-ray of your breasts. A mammogram and monthly self-exams can find breast cancer early. A mammogram can show a lump before you or your doctor can feel it. Cancer that is found early is easier to treat, and this can save your life. Make sure you: Talk to your doctor about when to get your mammogram. Talk to your doctor or call Member Services at about where to get your mammogram. Get a prescription from your doctor to have your mammogram. You do not need a referral from your doctor or prior authorization to get a mammogram. Quit using tobacco Arbor Health Plan wants you to quit smoking cigarettes and using any other tobacco products, like cigars, pipes and chewing tobacco. If you smoke or if you are affected by someone who smokes, we can help support you. Call Rapid Response at to obtain information about the Nebraska Medicaid Tobacco Cessation Program. Another resource is the Quitline at QUITNOW ( ). You may also be eligible for tobacco cessation products through the Nebraska Medicaid pharmacy benefit. Please call the Nebraska Medicaid Inquiry Line at for more information. 22 Arbor Health Plan

26 Getting Care When You Are Away from Home There are times when you will need care while you are away from home. If you are sick or need urgent or emergency care in the United States while you are away from home, here is what you should do: If you think you have an emergency, call 911 or go to the nearest hospital emergency room (ER). If you are sick and you are not sure if it is urgent or an emergency, call your PCP. Your PCP can help you decide if you need to go to the nearest ER or urgent-care center. If you get care in the ER and you are admitted to the hospital while you are away from home, have the hospital call Arbor Health Plan. The phone number is listed on the back of your ID card. Remember, Member Services is here to help you 24 hours a day, 7 days a week. We pay attention to your care Arbor Health Plan s licensed doctors and nurses monitor the services given to all members. They also make decisions about medically necessary care and services. They make these decisions using: Nationally accepted guidelines. Medical information including your Medicaid benefits and your personal medical needs. Arbor Health Plan does not reward health care providers for denying, limiting or delaying benefits or health care services. We also do not give incentives to our staff for making decisions about medically necessary services or benefits that result in more or less health care coverage and services. When you are away from home and cannot reach your doctor, call the Nurse Call Line! The Nurse Call Line is there for you toll-free 24 hours a day, 7 days a week, at When you call the toll-free Nurse Call Line, the nurse will: Ask you questions about your health. Give you information on how to care for yourself at home. Give you information to help you decide what other care you need. Please remember the Nurse Call Line does not take the place of your doctor. Always follow up with your doctor if you have questions about your health care. Arbor Health Plan 23

27 Dedication to Quality Care Arbor Health Plan expects all network providers to give quality care to you and your family. We monitor if the health care and services are being used in the right way, and if they are appropriate and necessary. We conduct member satisfaction surveys each year and give member education on health-related issues. If you believe you or your family got care that was not appropriate, please call Member Services. Arbor Health Plan will review the issue. If you would like more information about our quality improvement goals, activities or outcomes, call Member Services at Arbor Health Plan

28 Medically Necessary Services and Benefits Care and services provided to our members must be medically necessary. This means they are the right care, at the right time, provided in the right place and by the right provider. All services requiring the use of new technology are reviewed by the Nebraska Department of Health and Human Services (DHHS). Coverage for the use of new technology is determined by DHHS. If you need help understanding any of this information, please call Member Services at Arbor Health Plan 25

29 Prior Authorization Some services need to be approved as medically necessary by Arbor Health Plan before your PCP or other health care provider can help you get these services. This process is called prior authorization. Prior authorization process 1. Your provider gives Arbor Health Plan information to show us the service is medically necessary. 2. Arbor Health Plan nurses and doctors review the information. They use rules approved by the Department of Health and Human Services to see if the service is medically necessary. 3. If the request is approved, we will let you and your health care provider know it was approved. 4. If the request is not approved, a letter will be sent to you and your health care provider telling you the reason for the decision. You can appeal any decision Arbor Health Plan makes. If you receive a denial and would like to appeal it, talk to your provider. He or she will work with Arbor Health Plan to determine if there were any problems with the information that was submitted. You may also file a grievance or apply for a state hearing at any time. For more information, see page 38. Services needing preapproval (prior authorization) Some of the services that need preapproval are: All services you get out of the network (except for emergency care, post-stabilization and some family planning services). Air ambulance for non-emergency needs. Cardiac rehabilitation. Chiropractic care for pediatric members up to the age of 3. Cosmetic surgery. Diapers/Pull-Up diapers (over age 3) of more than 186 per month. DME all rentals. DME purchases $500 and over. Inpatient hospital care. Home health care (after 6 visits). Hyperbaric oxygen. MRI, MRA, MRS, CT scan, nuclear cardiac imaging, PET scan and SPECT scan. Therapy and related services after 60 visits per calendar year for members 21 and older. This is not a complete list, just some examples. If you have questions, please call Member Services at , or talk to your doctor. As an Arbor Health Plan member, you are not responsible to pay for medically necessary, covered services provided by Nebraska Medicaid providers. 26 Arbor Health Plan

30 Prior Authorization You may have to pay when the service provided is not covered by Arbor Health Plan. Your provider will ask you to sign an agreement to pay for the noncovered service. Services needing preapproval from the Nebraska Department of Health and Human Services: Abortions. Transplants (except corneal). Arbor Health Plan 27

31 Getting Other Benefits and Services The following benefits and services are available to Arbor Health Plan members. Arbor Health Plan does not provide these services, but can help you get them. If you have questions or need help, please call Member Services at Transportation If you have an emergency, please call 911 right away. For non-emergency medical transportation, Nebraska Medicaid has a program for Medicaid-eligible members. To find out if you qualify, call AMR Access2Care at TTY users can call Please remember: You must call at least 3 business days before your appointment to schedule your ride. You can schedule as early as 30 days before your appointment. You will need to know the street address, city and ZIP code for the location of your appointment. You must have your Medicaid ID number when you call to schedule your ride. Behavioral health treatment Behavioral health treatment (care for mental health and drug and/or alcohol abuse) is not covered by Arbor Health Plan. These services are covered for you under Nebraska Medicaid. If you need these services, please call Magellan Health Services at They will help you get the behavioral health services you need. Dental services Dental services are not covered by Arbor Health Plan. These services are covered for you under Nebraska Medicaid. If you need these services, please call the Nebraska Medicaid Inquiry Line at Pharmacy services Pharmacy services are not covered by Arbor Health Plan. These services are covered for eligible members under Nebraska Medicaid. If you have questions about eligibility or need to get these services, please call the Nebraska Medicaid Inquiry Line at Arbor Health Plan

32 Benefit Limits Some of the benefit limits for Arbor Health Plan members are: Benefit Limit Cardiac rehabilitation Limit of 12 weeks or 36 sessions. Chiropractic care Care is limited to treatment of the spine by manual manipulation and X-rays for treatment of spinal subluxations. Adults age 21 and older are limited to 12 treatments per calendar year. Children age 12 and younger require prior approval for all services and are limited to 18 treatments in the first 5 months after the first treatment. No more than 1 treatment a day will be covered. Durable medical equipment (DME) DME is reusable and may be rented or purchased. DME may require prior approval. A 3-month supply is the most a member can get at one time for disposable supplies. Eye care Adults age 21 and older are limited to 1 routine eye exam every 24 months. Adults age 21 and older are limited to 1 pair of eye glasses every 24 months. Contact lenses for adults age 21 and older are covered only if vision cannot be corrected with regular glasses. Children age 20 and younger are limited to 1 routine eye exam and 1 pair of eye glasses each year. Home health care for physical, occupational and speech therapy Adults age 21 and older are limited to a combined total of 60 sessions per fiscal year. There are no limits for children age 20 and younger. Observation Limited to 48 hours (does not apply to maternity patients). This is not a complete list of benefit limits. If you have questions, please call Member Services at Arbor Health Plan 29

33 If You Have Other Health Insurance If you have other medical insurance, give that information to your health care providers. ACCESSNebraska at also needs your other medical insurance information. Medicaid is the payer of last resort. This means that if you have other medical insurance, your other medical insurance must be billed first. You are required to show all of your medical cards at each doctor s office and/or pharmacy visit. This helps make sure your health care bills get paid. 30 Arbor Health Plan

34 If You Get a Bill or Statement As an Arbor Health Plan member, you are not responsible to pay for medically necessary covered services supplied by a Nebraska Medicaid provider. If you receive a bill or statement, notify Arbor Health Plan Member Services at right away. Remember to ask your health care provider: Are you an Arbor Health Plan provider? Does this service need prior authorization? Asking these 2 questions could save you from getting a bill. Arbor Health Plan 31

35 Loss of Benefits (Disenrollment) You will lose your Arbor Health Plan benefits (be disenrolled from Arbor Health Plan) if: You are no longer eligible for Medicaid. You move out of the covered area and are no longer eligible for Arbor Health Plan. Your condition or illness could be better cared for by another plan. There is evidence you have engaged in fraud, forgery or unauthorized use or abuse of medical services. You have reached the effective date of your requested disenrollment (see below for when you can ask to disenroll). *Notice of the request for the member s disenrollment from Arbor Health plan is sent to a member at the same time it is sent to the Nebraska Department of Health and Human Services. You will not lose your Arbor Health Plan benefits if: You have changes to the state of your health. You are using more medical services. You are uncooperative or disruptive because of your special needs or condition, except when your continued enrollment in the plan seriously impairs its ability to furnish services to you or other members. You can ask to be disenrolled from Arbor Health Plan: For cause, at any time. A cause includes, but is not limited to: You move out of the Arbor Health Plan service area. You receive poor-quality care. You are not able to access covered services or providers. You request service that Arbor Health Plan does not cover because of moral or religious objections. Without cause, once every 12 months and within 90 days of your enrollment, or on the date the state sends you notice of the enrollment, whichever is later. You also have 90 days to disenroll after being re-enrolled after a temporary loss of Medicaid. You cannot disenroll from Arbor Health Plan without cause if you don t request disenrollment from the plan at 12 months. You are unable to get all related services you are requesting at one time, within the Arbor Health Plan network, to avoid unnecessary risk to you. You can disenroll without cause at any time if the state sanctions the plan resulting in temporary management or the plan is required to pay a financial penalty. Disenrollment from Arbor Health Plan is effective on the first day of the following month or no later than the first day of the second month. Please contact the Medicaid Enrollment Center with questions at Arbor Health Plan

36 Member Rights and Responsibilities Arbor Health Plan is committed to treating members with respect and dignity. Arbor Health Plan, and its network of doctors and other providers of services, does not discriminate against members based on race, sex, religion, national origin, disability, age, sexual orientation or any other basis prohibited by law. As a member, you have rights and responsibilities. Member rights As a member of Arbor Health Plan, you have certain rights, including the right to: Get information about Arbor Health Plan and its health care providers, as well as information about member rights and responsibilities. Get information about your benefits and services. Talk to your health care provider about treatment options for your care, regardless of the cost or benefit provided. Talk with your health care provider about your condition and treatment plans. Be part of the decisions about your health care, including the right to refuse treatment. Choose your PCP from the Arbor Health Plan network. Change your PCP at any time. Share ideas that relate to the Arbor Health Plan member rights and responsibilities policy. Voice concerns or complaints, or appeal decisions about Arbor Health Plan or the care you receive. Have your medical care, private health information and records kept private. Approve or deny release of protected health information except when required by law. Receive medical care in a timely manner. Be treated by Arbor Health Plan and its providers with respect and with consideration for your dignity and privacy. Receive proper medical care 24 hours a day, 7 days a week. Get materials and/or help in other languages and formats, if needed. Get a second opinion at no cost to you. Request and receive special provider incentive program information. Choose any person to obtain information, make decisions or request an appeal on your behalf. If you would like more information, have questions or want to make suggestions, please call Member Services at Arbor Health Plan 33

37 Member Rights and Responsibilities Member responsibilities Please remember that you have a responsibility to: Let Arbor Health Plan and your health care providers know of any changes that may affect your membership, health care needs or benefits. Some examples include, but are not limited to, the following: You are pregnant. Your address or phone number changes. You or one of your children has other health insurance. You have a special medical condition. Remember: You must also call ACCESSNebraska at to let them know of your changes. You can also make changes online at by going to Report Changes. Choose a health plan and PCP within 10 days of enrolling with Arbor Health Plan. Take your Arbor Health Plan ID card and your Medicaid ID card with you to all your doctor appointments. Understand your benefits and services with Arbor Health Plan and call Arbor Health Plan when you have questions. Treat your health care providers and their staff with respect and dignity. Talk with your health care provider about your health problems and agree on goals for your treatment. Follow your health care providers instructions. Follow the guidelines described in the Arbor Health Plan Member Handbook. If you have any questions about your responsibilities or need more information, please call Member Services at Arbor Health Plan

38 Summary Notice of Privacy Practices This summary describes how medical information about you may be used and shared with others. It explains how you can receive your medical information. It also explains how we protect your personal information about your health. Please review this information carefully. Arbor Health Plan is required by law to protect the privacy of your health information. Arbor Health Plan would like to inform you of the policies regarding your protected health information (PHI), which can be oral, written or electronic. Health care providers use your medical information during treatment, as well as during payment processing. Arbor Health Plan has to use and disclose your PHI to arrange for your health care services and to pay our providers. Many steps are taken to make sure this information is protected. Arbor Health Plan is not allowed to use or share your medical information without your agreement. Here are 3 examples: Patient treatment. For example, health care providers talking to each other about a patient s treatment. Making a payment. For instance, our claims processing department using medical information to pay providers. Health care operations. For example, identifying members with certain chronic illnesses so we can send treatment information to them or their providers. Some other examples of how Arbor Health Plan may use or share your PHI without your agreement include: Legal requirements. Public health activities. Reporting abuse. Research. Providing information to you. Avoiding a serious threat to the member or the public. Law enforcement. Sometimes we are required to get your authorization so we can use or share your PHI. Your authorization to let us use or share your PHI may be cancelled at any time unless the information has already been shared. You can get a copy of your PHI that we have in our records. You may also receive a description of some ways we use your PHI. We are required by law to keep this information confidential by maintaining the privacy and security of your protected health information. For example, all Arbor Health Plan associates must sign and follow the company s confidentiality policy. Also, all company computers are password-protected and equipped with security protection devices. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your protected health information. For a copy of the full Notice of Privacy Practices and/or for any questions or comments regarding PHI, please call Member Services at You can also go to our website at Arbor Health Plan 35

39 Advance Directive The Patient Self-Determination Act is a federal law. It says that you have the right to choose medical care and treatment you may or may not want. You have the right to make these wishes known to your doctor or other health care provider through an Advance Directive. An Advance Directive is a decision you make ahead of time about the medical care you do or do not want if you are unable to make a decision about medical care at the time it is needed. Advance Directives are used only if you are unable to speak or make decisions for yourself. Your Advance Directive would be used if you were determined by a doctor to be in a terminal or vegetative state. Arbor Health Plan will honor your Advance Directive to the fullest extent allowed by law. There are two kinds of documents that can serve as an Advance Directive in Nebraska: Living will A living will is a written record of how you wish your medical care to be handled if you are no longer able to decide and speak for yourself. This document should say what type of medical treatments you would or would not want to have. Durable Power of Attorney for health care This is a legal document that gives the name of the person you want to make medical treatment decisions for you in case you cannot make them for yourself. This person does not have to be a lawyer. To make sure your wishes are met if you cannot speak or make a decision about your care, you should write an Advance Directive and give a copy to your PCP, as well as to family members. If you have any questions about Advance Directives, please call Member Services at Arbor Health Plan

40 Notice of Action A notice of action is provided to the member and provider in writing at least 10 days before the termination, suspension or reduction of previously authorized services. The notice of action is shortened to 5 days if probable member fraud is verified. Arbor Health Plan will give this notice for the following situations: Death of a member. A signed statement from you requesting that Arbor Health Plan end your services. You provide information requiring termination or reduction of services and know the result of your action. You are admitted to a health care facility that makes you ineligible for authorized service. Your address is unknown and returned mail has no forwarding address. Your provider orders a change in your level of care. An unfavorable decision was made for admission to a nursing facility. Other reasons for notice are: Your health or safety would be endangered. Your health improves allowing for transfer. You are discharged due to more urgent needs. You have not been a resident in a nursing facility for 30 days (applies to nursing facility transfer unfavorable actions). Arbor Health Plan 37

41 Member Grievances, Appeals and State Fair Hearings We hope that you are satisfied with Arbor Health Plan and our health care providers. If you have questions or concerns about your Arbor Health Plan benefits or services, please call Member Services. We can help you with most questions and concerns. If we cannot immediately resolve your questions or concerns, we will investigate the issue and respond to you within 30 days. If you are still not satisfied, you have the right to file a grievance, appeal or request a fair hearing with the state of Nebraska. Grievance system Arbor Health Plan s grievance system includes: A grievance process where you can submit a grievance or complaint. An appeal process where you can appeal a decision Arbor Health Plan has made to deny or limit services. A fair hearing process, where you can submit your grievance or appeal before the state in a fair hearing. Each of these processes is explained in this section. Grievances What is a grievance? A grievance is a way for you to tell Arbor Health Plan that you are not happy with the way your care has been handled. If you are not happy with a decision Arbor Health Plan has made about your medical care, you would file an appeal and not a grievance. Why file a grievance? You were not happy with the quality of care you got from Arbor Health Plan or an Arbor provider. Someone from Arbor Health Plan or from your provider s office was rude or disrespectful. You believe your rights as a member were not upheld by Arbor Health Plan or an Arbor provider. How do you file a grievance? You can file a grievance in writing or by phone. To file a grievance by phone, you can call Member Services at TTY users may call You can call 24 hours a day, 7 days a week. To file a written grievance, send to: Complaints and Grievances Department P.O. Box 7335 London, KY ATTN: Complaints and Grievances Your grievance can be filed by your provider for you, but you must give written consent. A grievance can be filed with Arbor Health Plan or with the Medicaid Enrollment Center. 38 Arbor Health Plan

42 Member Grievances, Appeals and State Fair Hearings Appeals What is an appeal? An appeal is a request for Arbor Health Plan to review an action taken by Arbor Health Plan. You may file an appeal if you are not satisfied with any of the following decisions: A denial of services that your doctor requested. A reduction or limitation of health care services you are getting. A suspension of or end to a health care service you are getting. If Arbor Health Plan denies, reduces, limits, suspends or ends health care services, a written notice of action will be sent to you about this decision. If you receive a notice of action and do not agree with the Arbor Health Plan decisions, you may file an appeal. You can file the appeal by telephone or in writing. If you file your appeal by telephone, you will also need to send a letter afterward. If you would like your doctor to submit an appeal for you and he or she agrees to do so, you must give your written consent. You may also choose someone else besides your doctor to represent you and make a request for an appeal. However, if the appeal is expedited, you do not need to take this step. The appeal must be filed within 90 days after the date on the notice of action. To file an appeal, you can call Member Services at TTY users may call You can call 24 hours a day, 7 days a week. To file your appeal in writing, you or your authorized representative can send the letter to: Arbor Health Plan P.O. Box 7335 London, KY ATTN: Member Appeals Arbor Health Plan will start to review your appeal request the day we get it. A decision will be made within 30 calendar days, unless additional information is needed. Arbor Health Plan will send you or your authorized representative a letter with the decision about the appeal. The letter will explain how the decision was made. Expedited appeals Appeals are expedited when a decision needs to be made in less than 30 days. Arbor Health Plan will expedite an appeal when your life or health is at risk. Expedited appeals are for health care services, not for denied claims. How to file an expedited appeal To file an expedited appeal by phone or get more information about the appeal process, please call Member Services at TTY users may call Arbor Health Plan 39

43 Member Grievances, Appeals and State Fair Hearings Arbor Health Plan will start to review your appeal request the day it is received. We will make a decision within 72 hours of receiving your request. You will be notified by phone and by mail within 3 calendar days of this decision. Arbor Health Plan may extend the 72-hour time period by up to 14 calendar days if you request an extension, or if Arbor Health Plan shows a need for additional information and how the delay is in your interest. If you ask for an appeal to be expedited and Arbor Health Plan does not believe the appeal needs a faster decision, the appeal will be reviewed within the standard appeal time frame. You will be informed in writing and by phone within 2 calendar days if the time frame for your appeal has changed. Arbor Health Plan members or their representatives will be allowed to present facts and evidence to support their expedited appeals. Limited time is available for doing so. This information can be presented in person or in writing. The members or their representatives will be informed how long they have to submit information for an expedited review. State fair hearing You can request a state fair hearing about a notice of action any time within 90 days from the date on the notice. This would include receiving Arbor Health Plan s appeal determination. How do you request a state fair hearing? Please send your request in writing to: Department of Health and Human Services Legal Services-Hearing Section P.O. Box Lincoln, NE Continuing benefits during an appeal and/or state fair hearing You can keep getting covered services while you wait for Arbor Health Plan to decide on an appeal or while a state fair hearing is pending, if all of the following apply: The appeal is filed on or before the later of: 10 days from the date Arbor Health Plan mailed the notice of action. The date that the notice of action is scheduled to take effect. The appeal is related to reduced or suspended services or to services that were previously authorized for you. The services were ordered by an authorized provider. The authorization period for the services has not ended. You asked that the services continue. If Arbor Health Plan continues your benefits while deciding an appeal or while a state fair hearing is pending, the services must be continued until one of the following happens: You decide not to continue the appeal. You do not request a state fair hearing within 10 days from the date that Arbor Health Plan mails the notice of action. The authorization for services expires or authorization service limits are met. 40 Arbor Health Plan

44 Fraud and Abuse Payment will not be provided for the continued services if the final decision from the appeal or the state fair hearing is against you. If Arbor Health Plan agrees with you on the appeal or the state fair hearing officer agrees with you, Arbor Health Plan will pay for the services you got while you waited for the decision. Unfortunately, there may be times when you see fraud or abuse relating to Medicaid services. Some examples of fraud and abuse by a health care provider are: Billing or charging you for services that Arbor Health Plan covers. Offering you gifts or money to get treatment or services that you do not need. Offering you free services, equipment or supplies in exchange for using your Arbor Health Plan member number. Giving you treatment or services that you do not need. Physical, mental or sexual abuse by medical staff. Some examples of fraud and abuse by a member are: Members selling their ID cards to other people. Members lending their ID cards to other people. Members abusing their benefits by seeking drugs or services that are not medically necessary. You can report fraud and abuse by calling the Arbor Health Plan Hotline number at You can also report fraud and abuse to the Department of Health and Human Services. To report provider fraud and abuse call or toll-free at To report member fraud and abuse in Lincoln and greater Nebraska, call In Omaha, call To report member or provider fraud and abuse, go to the website at You do not have to give your name, but if you do, the provider or member will not be told it was you who made the report. Arbor Health Plan 41

45 Special Situations Continuing care If you are getting ongoing treatment from a provider who is not in the Arbor Health Plan network, you may be able to continue that treatment. Treatment or services are ongoing if you were treated during the past 12 months for a condition where you need to get follow-up care or additional treatment. Services are also considered to be ongoing if they have been preapproved. You are allowed to continue ongoing treatment with a health care provider who is not in the Arbor Health Plan network when any of the following happens: You are a new Arbor Health Plan member and you are getting ongoing treatment from a health care provider who is not in the Arbor Health Plan network. You are a current Arbor Health Plan member and you are getting ongoing treatment from a health care provider whose contract has ended with Arbor Health Plan for reasons that are not-for-cause. Not-for-cause reasons means that the provider s contract did not end because of the quality of the provider s care or because the provider did not meet other contract or regulatory requirements. If you are... Arbor Health Plan will allow you to... A new Arbor Health Plan member Keep getting treatment from a health care provider who is not in the Arbor Health Plan network. You can continue treatment for up to 60 days from the date you were enrolled in Arbor Health Plan. A new Arbor Health Plan member and you are pregnant as of the date you enroll in Arbor Health Plan Keep getting treatment from an obstetrician (OB) or midwife who is not in the Arbor Health Plan network until the end of your postpartum care related to your delivery. A current Arbor Health Plan member and your health care provider (doctor, midwife or CRNP) stops participating with Arbor Health Plan and you need to keep getting health care Continue going to the provider for treatment for up to 90 days from the date Arbor Health Plan tells you that the health care provider stops participating in the Arbor Health Plan network, or for up to 60 days from the date the provider s contract with Arbor Health Plan ends whichever is longer. 42 Arbor Health Plan

46 Special Situations If you are... Arbor Health Plan will allow you to... A current Arbor Health Plan member and your health care provider (doctor, midwife or CRNP) stops participating with Arbor Health Plan and you need to keep getting health care Continue going to the provider for treatment for up to 90 days from the date Arbor Health Plan tells you that the health care provider stops participating in the Arbor Health Plan network, or for up to 60 days from the date the provider s contract with Arbor Health Plan ends whichever is longer. A current Arbor Health Plan member, and your health care provider other than a doctor, midwife or CRNP (like a health care facility or health care agency) stops participating with Arbor Health Plan, and you need to keep receiving care Continue going to the provider for treatment for up to 60 days from the date Arbor Health Plan tells you that the health care provider will not be in the Arbor Health Plan network, or for up to 60 days from the date the provider stops participating with Arbor Health Plan whichever is longer. A current Arbor Health Plan member in your second or third trimester of pregnancy and the OB or midwife whom you see stops participating with Arbor Health Plan Continue going to the provider for treatment from that OB or midwife until you deliver your baby and receive postpartum care related to the delivery. Requests for ongoing treatment or services are reviewed case-by-case. If you want to keep getting treatment or services with a health care provider who is not in the Arbor Health Plan network, you must either: Call Member Services for help with continuing care. Ask your health care provider to call Arbor Health Plan s Utilization Management department at Once we have the request to continue care, we will review your case. We will notify you and your health care provider by telephone if continued services have been authorized. If for some reason we do not approve continued care, you and your health care provider will get a telephone call and a letter that includes our decision and information about your right to appeal the decision. You must get approval from Arbor Health Plan to continue care. Arbor Health Plan will not cover continuing care when: The provider s contract has ended because of quality-of-care issues. The provider is not a Nebraska Medicaid provider. The provider did not comply with regulations or other contract requirements. The services are not ongoing. Arbor Health Plan 43

47 Special Situations Changing your primary care provider (PCP) If you move or want to change your PCP for any reason, we will help you choose another PCP in your area. You can change your PCP at any time and for any reason. How to change your PCP If you have access to the Internet: Go to and click on Find a Provider to choose a provider in your area. If you do not have access to the Internet: We can send a Provider Directory to you. Once you change your PCP: We will ask why you want to change your PCP. This will help us learn about any possible problems with the services given by PCPs in our network. You will get a new Arbor Health Plan ID card. When your new card arrives, destroy your old card at once. Call your old PCP and ask to have your medical records sent to your new PCP. Call your new PCP to make an appointment. If your PCP is leaving the Arbor Health Plan network There are times when a PCP will leave Arbor Health Plan. If your PCP leaves the plan, we will let you know within 15 days after we receive a termination notice so you can choose a new PCP. If you do not choose a new PCP by the date we give you, we will choose a PCP for you. We will send a letter to you with the name of your new PCP. You will also get a new ID card in a separate mailing. When your new card arrives, destroy your old card. If you do not want the PCP we have chosen for you, you can change your PCP at any time by calling Member Services at Arbor Health Plan

48 My Personal Medical Diary Appointment is with Appointment date and time Questions for my appointment Arbor Health Plan 45

49 My Personal Medical Diary Name of medicine Date filled Questions for my appointment 46 Arbor Health Plan

50 Notes Arbor Health Plan 47

51 Our mission We help people get care, stay well and build healthy communities. We have a special concern for those who are poor. Our values Advocacy. Care of the poor. Compassion. Competence. Dignity. Diversity. Hospitality. Stewardship. 3700ARB