f Benefits H0281_SummaryBenefits15_Accepted_11192014
H0281_SummaryBenefits15_Accepted_11192014 Summary f Benefits This is a summary f health services cvered by IlliniCare Health fr January 1, 2015. This is nly a summary. Please read the Member Handbk fr the full list f benefits. IlliniCare Health is a health plan that cntracts with bth Medicare and Illinis Medicaid t prvide benefits f bth prgrams t enrllees. It is fr peple with bth Medicare and Medicaid. Under IlliniCare Health yu can get yur Medicare and Medicaid services in ne health plan. An IlliniCare Health care crdinatr will help manage yur health care needs. This is nt a cmplete list. The benefit infrmatin is a brief summary, nt a cmplete descriptin f benefits. Fr mre infrmatin cntact the plan r read the Member Handbk. Limitatins, cpays, and restrictins may apply. Fr mre infrmatin, call IlliniCare Health Member Services r read the IlliniCare Health Member Handbk. Benefits, List f Cvered Drugs, and pharmacy and prvider netwrks, and/r cpayments may change frm time t time thrughut the year and n January 1 f each year. Cpays fr prescriptin drugs may vary based n the level f Extra Help yu receive. Please cntact the plan fr mre details. Yu can ask fr this infrmatin in ther frmats (such as large print). Call 1-877-941-0482. The call is free. Yu can get this dcument in Spanish, r speak with smene abut this infrmatin in ther languages fr free. Call 1-877-941 0482. The call is free. Usted puede btener este dcument en españl, hablar cn alguien acerca de esta infrmación en trs idimas de frma gratuita. Llame al 1-877-941-0482. La llamada es gratuita. If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 1
The fllwing chart lists frequently asked questins. Frequently Asked Questins (FAQ) What is a Medicare-Medicaid Plan What is a care crdinatr What are lng-term services and supprts Will yu get the same Medicare and Medicaid benefits in IlliniCare Health that yu get nw Answers A Medicare-Medicaid Plan is an rganizatin made up f dctrs, hspitals, pharmacies, prviders f lng-term services, and ther prviders. It als has care crdinatrs t help yu manage all yur prviders and services. They all wrk tgether t prvide the care yu need. A care crdinatr is ne main persn fr yu t cntact. This persn helps manage all yur prviders and services and makes sure yu get what yu need. Lng-term services and supprts are services prvided thrugh a Lng Term Care Facility r thrugh a Hme and Cmmunity Based Waiver. Enrllees have the ptin t receive lng-term services and supprts (LTSS) in the least restrictive setting when apprpriate, with a preference fr the hme and the cmmunity, and in accrdance with the Enrllee s wishes and Care Plan. Yu will get yur cvered Medicare and Medicaid benefits directly frm IlliniCare Health. Yu will wrk with a team f prviders wh will help determine what services will best meet yur needs. This means that sme f the services yu get nw may change. When yu enrll in IlliniCare Health, yu and yur care team will wrk tgether t develp an Individualized Care Plan t address yur health and supprt needs. During this time, yu can keep seeing yur dctrs and getting yur current services fr 90 days, r until yur care plan is cmplete. When yu jin ur plan, if yu are taking any Medicare Part D prescriptin drugs that IlliniCare Health des nt nrmally cver, yu can get a temprary supply. We will help yu get anther drug r get an exceptin fr IlliniCare Health t cver yur drug, if medically necessary. If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 2
Frequently Asked Questins (FAQ) Can yu g t the same dctrs yu see nw Answers Often that is the case. If yur prviders (including dctrs, therapists, and pharmacies) wrk with IlliniCare Health and have a cntract with us, yu can keep ging t them. Prviders with an agreement with us are in-netwrk. Yu must use the prviders in IlliniCare Health s netwrk. If yu need urgent r emergency care r ut-f-area dialysis services, yu can use prviders utside f IlliniCare Health's plan. All services prvided by an ut-f-netwrk prvider require prir authrizatin. If yu receive emergency care at an ut-f-netwrk hspital and need inpatient care after yur emergency cnditin is stabilized, yu must return t a netwrk hspital in rder fr yur care t cntinue t be cvered. T find ut if yur dctrs are in the plan s netwrk, call Member Services r read IlliniCare Health s Prvider and Pharmacy Directry. If IlliniCare Health is new fr yu, yu can cntinue seeing the dctrs yu g t nw fr 180 days, r until yur care plan is cmplete. If yu are transferring frm anther Demnstratin Plan t IlliniCare Health, yu can cntinue t see yur existing prvider fr 90 days. What happens if yu need a service but n ne in IlliniCare Health s netwrk can prvide it Where is IlliniCare Health available Mst services will be prvided by ur netwrk prviders. If yu need a service that cannt be prvided within ur netwrk, IlliniCare Health will pay fr the cst f an ut-f-netwrk prvider. The service area fr this plan includes: Ck, DuPage, Kane, Kankakee, Lake, Will cunties in Illinis. Yu must live in ne f these areas t jin the plan. D yu pay a mnthly amunt (als called a premium) under IlliniCare Health Yu will nt pay any mnthly premiums t IlliniCare Health fr yur health cverage. If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 3
Frequently Asked Questins (FAQ) What is prir authrizatin What is a referral What is Extra Help Answers A referral means that yur primary care Prvider must give yu apprval t see smene that is nt yur primary care prvider. If yu dn t get apprval, IlliniCare Healthmay nt cver the services. There are certain specialists in which yu d nt need a referral, such as wmen health specialists. Fr mre infrmatin n when a referral is necessary, see the Member Handbk. A referral means that yur primary care prvider must give yu apprval t see smene that is nt yur primary care prvider. If yu dn t get apprval, IlliniCare Health may nt cver the services. There are certain specialists fr which yu d nt need a referral, such as wmen health specialists. Fr mre infrmatin n when a referral is necessary, see the Member Handbk. Extra Help is a Medicare prgram that helps reduce yur prescriptin drug prgram csts such as cpays. Yur prescriptin drug cpays under IlliniCare Health already include the amunt f Extra Help yu qualify fr. Fr mre infrmatin abut this extra help, cntact yur lcal Scial Security Office, r call Scial Security at 1-800-772-1213. TTY users may call 1-800-325-0778. If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 4
Frequently Asked Questins (FAQ) Answers Wh shuld yu cntact if yu have questins r need help If yu have general questins r questins abut ur plan, services, billing, r member cards, please call IlliniCare Health Member Services: CALL 1-877-941-0482 Calls t this number are free. Frm Octber 1 t February 14, yu can call us 7 days a week frm 8 a.m. t 8 p.m. Frm February 15 t September 30, yu can call us Mnday thrugh Friday frm 8 a.m. t 8 p.m. Member Service als has free telephnic and in-persn language interpreter services available fr peple wh d nt speak English. TTY 711 (Illinis State Relay) This number is fr peple wh have hearing r speaking prblems. Yu must have special telephne equipment t call it. Calls t this number are free. Frm Octber 1 t February 14, yu can call us 7 days a week frm 8 a.m. t 8 p.m. Frm February 15 t September 30, yu can call us Mnday thrugh Friday frm 8 a.m. t 8 p.m. If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 5
Frequently Asked Questins (FAQ) Wh shuld yu cntact if yu have questins r need help (cntinued) Answers If yu have questins abut yur health, please call the Nurse Advice Call line: CALL 1-877-941-0482 TTY Calls t this number are free. Seven days a week, 24 hurs a day. Member Service als has free telephnic and in-persn language interpreter services available fr peple wh d nt speak English. 711 (Illinis State Relay) This number is fr peple wh have hearing r speaking prblems. Yu must have special telephne equipment t call it. Calls t this number are free. Seven days a week, 24 hurs a day. If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 6
The fllwing chart is a quick verview f what services yu may need, yur csts and rules abut the benefits. Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu want t see a dctr Visits t treat an injury r illness $0 Services that d nt require a referral r prir authrizatin are: PCP visits Emergency Care Urgently-Needed-Care visits Pdiatry visits Chirpractic visits Wellness visits, such as a physical $0 N authrizatin required Transprtatin t a dctr s ffice $0 Authrizatin required Cntact plan fr details. Specialist care $0 N referral r authrizatin required Care t keep yu frm getting sick, such as flu shts Welcme t Medicare preventive visit (ne time nly) $0 N referral r authrizatin required $0 N prir authrizatin required. The visit includes a review f yur health, as well as educatin and cunseling abut the preventive services yu need including certain screenings and shts. Yu may need a referral fr ther services if needed. If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 7
Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need medical tests Lab tests, such as bld wrk $0 Prir authrizatin may be required X-rays r ther pictures, such as CAT scans Screening tests, such as tests t check fr cancer $0 Prir authrizatin required fr utpatient diagnstic prcedures, tests, X-rays, and therapeutic services $0 Medicare apprved Preventive Screenings d nt require a referral r prir authrizatin. Hwever, it is best t ntify ur plan when Diagnstic tests are scheduled t ensure n authrizatin is required. If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 8
Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need drugs t treat yur illness r cnditin Generic drugs (n brand name) $0 fr a 30-day supply. $0 fr a 90-day supply There may be limitatins n the types f drugs cvered. Please see IlliniCare Health s List f Cvered Drugs (Drug List) fr mre infrmatin. Prir authrizatin may be required Fr sme drugs, yu can get a lng-term supply (als called an extended supply ) when yu fill yur prescriptin. A lng-term supply is up t a 90-day supply. It csts yu the same as a ne-mnth supply. If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 9
Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Fr generic drugs* (including brand drugs treated as generic), either: Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Brand name drugs $0 cpay; r $1.20 cpay; r $2.65 cpay Fr all ther drugs: $0 cpay; r $3.60 cpay; r $6.60 cpay There may be limitatins n the types f drugs cvered. Please see IlliniCare Health s List f Cvered Drugs (Drug List) fr mre infrmatin. Prir authrizatin may be required Please refer t ur List f Drugs t view thse drugs available fr an extended day supply. Fr sme drugs, yu can get a lng-term supply (als called an extended supply ) when yu fill yur prescriptin. A lng-term supply is up t a 90-day supply. It csts yu the same as a ne-mnth supply. *depending n the level f LIS cverage. If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 10
Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Over-the-cunter drugs $0 There may be limitatins n the types f drugs cvered. Please see IlliniCare Health s List f Cvered Drugs (Drug List) fr mre infrmatin. Our plan prvides $70 per calendar quarter fr cvered Over-the-Cunter (OTC) items. OTC items cvered by the benefit are limited t items that are cnsistent with current CMS guidance. Unused amunts may nt be carried ver frm ne calendar quarter t the next calendar quarter. OTC items are available thrugh mail rder. Please cntact the plan fr a list f cvered OTC items and fr instructins n hw t rder OTC items. Medicare Part B prescriptin drugs $0 Part B drugs include drugs given by yur dctr in his r her ffice, sme ral cancer drugs, and sme drugs used with certain medical equipment. Read the Member Handbk fr mre infrmatin n these drugs. Prir authrizatin required. Yu need therapy after a strke r accident Occupatinal, physical, r speech therapy $0 Prir authrizatin required. If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 11
Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need emergency care Emergency rm services $0 Emergency rm services d nt require a referral r prir authrizatin and can be prvided at an in-r ut-f-netwrk facility. Nt cvered utside the U.S. and its territries except under limited circumstances. Ambulance services $0 Emergent ambulance services d nt require a referral r prir authrizatin and can be prvided by an in-r ut-f-netwrk prvider. Prir authrizatin is required fr medically necessary nn-emergent ambulance services. Urgent care $0 Urgent Care Services d nt require a referral r prir authrizatin. Urgently needed care may be furnished by in-netwrk prviders r ut-f-netwrk prviders when netwrk prviders are temprarily unavailable r inaccessible. Yu need hspital care Hspital stay $0 Prir authrizatin required. Except in an emergency, yur dctr must tell the plan yu are ging t be admitted t the hspital. Dctr r surgen care $0 During a hspital stay, Dctr and surgen care are cvered and des nt require prir authrizatin. If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 12
Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need help getting better r have special health needs Rehabilitatin services $0 Prir authrizatin required Medical equipment fr hme care $0 Prir authrizatin required Skilled nursing care $0 Prir authrizatin required Yu need eye care Eye exams $0 Exams t diagnse and treat diseases and cnditins f the eye. One rutine eye exam is cvered nce every year. Glasses r cntact lenses $0 One pair f Medicare-cvered eyeglasses (lenses and frames) r cntact lenses after cataract surgery. Our plan will cver 1 pair f eyeglasses (lenses and frames) every tw years. Yu need dental care The plan cvers the fllwing dental services: Diagnstic services Restratin services Extractins Additinal dental services fr pregnant wman prir t the delivery f their children: Oral Exams Cleaning $0 Prir authrizatin may be required. Limitatins may apply fr specific services. $0 N prir authrizatin required. If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 13
Health need r prblem Yu need hearing/auditry services Yu have a chrnic cnditin, such as diabetes r heart disease Yu have a mental health cnditin Yu have a substance abuse prblem Yu need lng-term mental health services Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Hearing screenings $0 N prir authrizatin required fr: - Diagnstic and rutine hearing exams - Hearing aid evaluatin Hearing aids $0 One hearing aid every three years. Services t help manage yur disease $0 N prir authrizatin required fr Diabetes nutritin management training. Care Management Prgrams are available fr the fllwing: Asthma, Heart Disease, Chrnic Obstructive Pulmnary Disease, and Heart Failure. Diabetes supplies and services $0 Therapeutic shes r inserts are cvered when medically necessary. Diabetes supplies and services may be limited t specific manufacturers, prducts, and/r brands. Cntact plan fr list f cvered supplies. Mental r behaviral health services $0 Prir authrizatin required Substance abuse services $0 Prir authrizatin required Inpatient care fr peple wh need mental health care $0 Prir authrizatin required If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 14
Health need r prblem Yu need durable medical equipment (DME) Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Wheelchairs $0 Prir authrizatin required May be limited t specific manufacturers, prducts, and/r brands. Cntact plan fr list f cvered supplies. Canes $0 N authrizatin required Crutches $0 N authrizatin required Walkers $0 N authrizatin required Oxygen $0 Prir authrizatin required fr medically necessary services. If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 15
Health need r prblem Yu need help living at hme Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Meals brught t yur hme $0 Yu must be fund eligible t receive waiver services by the Divisin f Rehabilitatin Services. Once eligibility fr services has been determined, prir authrizatin will be required t receive services within the specific waiver. Hme services, such as cleaning r husekeeping Changes t yur hme, such as ramps and wheelchair access Persnal care assistant (Yu may be able t emply yur wn assistant. Call Member Services fr mre infrmatin.) $0 Yu must be fund eligible t receive waiver services by the Divisin f Rehabilitatin Services r the Illinis Department n Aging. Once eligibility fr services has been determined, prir authrizatin will be required t receive services within the specific waiver. $0 Yu must be fund eligible t receive waiver services by the Divisin f Rehabilitatin Services r the Illinis Department n Aging. Once eligibility fr services has been determined, prir authrizatin will be required t receive services within the specific waiver. $0 Yu must be fund eligible t receive waiver services by the Divisin f Rehabilitatin Services. Once eligibility fr services has been determined, prir authrizatin will be required t receive services within the specific waiver. If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 16
Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Hme health care services $0 Yu must be fund eligible t receive waiver services by the Divisin f Rehabilitatin Services r the Illinis Department n Aging. Once eligibility fr services has been determined, prir authrizatin will be required t receive services within the specific waiver. Services t help yu live n yur wn $0 Yu must be fund eligible t receive waiver services by the Divisin f Rehabilitatin Services r the Illinis Department n Aging. Once eligibility fr services has been determined, prir authrizatin will be required t receive services within the specific waiver. Adult day services r ther supprt services $0 Yu must be fund eligible t receive waiver services by the Divisin f Rehabilitatin Services r the Illinis Department n Aging. Once eligibility fr services has been determined, prir authrizatin will be required t receive services within the specific waiver. If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 17
Health need r prblem Yu need a place t live with peple available t help yu Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Assisted living r ther husing services $0 Yu must be fund eligible t receive waiver services by the Divisin f Rehabilitatin Services r the Illinis Department n Aging. Once eligibility fr services has been determined, prir authrizatin will be required t receive services within the specific waiver. Nursing hme care $0 Yu must be fund eligible t receive waiver services by the Divisin f Rehabilitatin Services r the Illinis Department n Aging. Once eligibility fr services has been determined, prir authrizatin will be required t receive services within the specific waiver. Respite care $0 Yu must be fund eligible t receive waiver services by the Divisin f Rehabilitatin Services. Once eligibility fr services has been determined, prir authrizatin will be required t receive services within the specific waiver. If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 18
Other services that IlliniCare Health cvers: Other services IlliniCare Health cvers (This is nt a cmplete list. Call Member Services r read the Member Handbk t find ut abut ther cvered services.) Transprtatin Tbacc Cessatin Cunseling fr Pregnant Wmen Family Planning Services 24/7 Nurse Advice Line $0 cpay Behavir Health Services Services in an Intermediate Care Facility fr the Mentally Retarded Hspice Care Telehealth Nutritin Cunseling Prir authrizatin required. Cntact the plan fr details. $0 cpay per trip - Services Transprtatin t medical appintments - Other services Prir authrizatin required $0 cpay Prgram designed t help pregnant wmen quit smking Prir authrizatin required $0 cpay Prir authrizatin required $0 cpay Prir authrizatin required $0 cpay Prir authrizatin required $0 cpay A Medicare-cvered hspice prvider must prvide care. $0 cpay. Cntact plan fr mre details. $0 cpay Fr peple with renal (kidney) disease but nt n dialysis. We cver 3 hurs f ne-n-ne cunseling services during yur first year that yu receive medical nutritin therapy services under Medicare and 2 hurs each year after that. If yur cnditin, treatment, r diagnsis changes, yu may be able t receive mre hurs f treatment with a physician s rdered. If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 19
Services that IlliniCare Health des nt cver: Services IlliniCare Health des nt cver (This is nt a cmplete list. Call Member Services t find ut abut ther excluded services.) Experimental medical and surgical prcedures, equipment and medicatins, unless cvered by Original Medicare r under Medicare-apprved clinical research study r by ur plan. These are items and prcedures determined by ur plan, Original Medicare and the state Medicaid Agency t nt be generally accepted by the medical cmmunity. Surgical treatment fr mrbid besity, except when it is cnsidered medically necessary and cvered under Original Medicare. Private rm in a hspital, except when it is cnsidered medically necessary. Fees charged by yur immediate relatives r members f yur husehld. Persnal items in yur rm at a hspital r a skilled nursing facility, such as a telephne r a televisin. Elective r vluntary enhancement prcedures r services (including weight lss, hair grwth, sexual perfrmance, athletic perfrmance, csmetic purpses, anti-aging and mental perfrmance), except when medically necessary. Csmetic surgery r prcedures, unless because f an accidental injury r t imprve a malfrmed part f the bdy. Hwever, all stages f recnstructin are cvered fr a breast after a mastectmy, as well as fr the unaffected breast t prduce a symmetrical appearance. Reversal f sterilizatin prcedures, sex change peratins, and nn-prescriptin cntraceptive supplies. Acupuncture. Naturpath services (uses natural r alternative treatments). Services prvided t veterans in Veterans Affairs (VA) facilities. Hwever, when emergency services are received at VA hspital and the VA cst sharing is mre than the cst sharing under ur plan, we will reimburse veterans fr the difference. Members are still respnsible fr ur cstsharing amunts. LASIK surgery Services that yu get frm nn-plan prviders, except fr care a medical emergency and urgently needed care, renal (kidney) dialysis services that yu get when yu are temprarily utside the IlliniCare Health service area. Emergency facility services fr nn-authrized, rutine cnditins that are nt a medical emergency. If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 20
Services received withut an authrizatin, when an authrizatin is required fr getting that service. Yur rights as a member f the plan As a member f IlliniCare Health, yu have certain rights. Yu can exercise these rights withut being punished. Yu can als use these rights withut lsing yur health care services. We will tell yu abut yur rights at least nce a year. Fr mre infrmatin n yur rights, please read the Member Handbk. Yur rights include, but are nt limited t, the fllwing: Yu have a right t respect, fairness and dignity. This includes: The right t get cvered services withut cncern abut race, ethnicity, natinal rigin, religin, gender, age, mental r physical disability, sexual rientatin, genetic infrmatin, ability t pay, r ability t speak English The right t request infrmatin in ther frmats (e.g., audi CD ROM, large print, cassette, Braille) The right t be free frm any frm f restraint r seclusin The right nt t be billed by prviders Yu have the right t get infrmatin abut yur health care. This includes infrmatin n treatment and yur treatment ptins. This infrmatin shuld be in a frmat yu can understand. These rights include getting infrmatin n: Descriptin f the services we cver Hw t get services If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 21 Hw much services will cst yu Names f health care prviders and care managers Yu have the right t make decisins abut yur care, including refusing treatment. This includes the right: T chse a Primary Care Prvider (PCP) and yu can change yur PCP at any time T see a wmen s health care prvider withut a referral T get yur cvered services and drugs quickly T knw abut all treatment ptins, n matter what they cst r whether they are cvered T refuse treatment, even if yur dctr advises against it T stp taking medicine T ask fr a secnd pinin. IlliniCare Health will pay fr the cst f yur secnd pinin visit. Yu have the right t timely access t care that des nt have any cmmunicatin r physical access barriers. This includes the right t: Get medical care timely
Get in and ut f a health care prvider s ffice. This means barrier free access fr peple with disabilities, in accrdance with the Americans with Disabilities Act Have interpreters t help with cmmunicatin with yur dctrs and yur health plan. Yu have the right t seek emergency and urgent care when yu need it. This means: Yu have the right t get emergency services withut prir apprval in an emergency Yu have the right t see an ut f netwrk urgent r emergency care prvider, when necessary The right t ask fr and get a cpy f yur medical recrds in a way that yu can understand and t ask fr yur recrds t be changed r crrected. The right t have yur persnal health infrmatin kept private. Yu have the right t make cmplaints abut yur cvered services r care. This includes the right t: File a cmplaint r grievance against us r ur prviders Ask fr a state fair hearing Get a detailed reasn fr why services were denied Yu have a right t cnfidentiality and privacy. This includes: Fr mre infrmatin abut yur rights, yu can read the IlliniCare Health Member Handbk. If yu have questins, yu can als call IlliniCare Health Member Services. If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 22
If yu have a cmplaint r think we shuld cver smething we denied If yu have a cmplaint r think IlliniCare Health shuld cver smething we denied, call IlliniCare Health at 1-877-941-0482. Yu may be able t appeal ur decisin. Fr questins abut cmplaints and appeals, yu can read Chapter 9 f the IlliniCare Health Member Handbk. Yu can als call IlliniCare Health Member Services. T file a cmplaint, grievance, r appeal with ur plan, please cntact Member Services at 1-877-941-0482 r yu can write t ur plan at the fllwing address: IlliniCare Health 999 Oakmnt Plaza Dr., Suite 400 Westmnt, IL 60559 If yu suspect fraud Mst health care prfessinals and rganizatins that prvide services are hnest. Unfrtunately, there may be sme wh are dishnest. If yu think a dctr, hspital r ther pharmacy is ding smething wrng, please cntact us. Call us at IlliniCare Health Member Services. Phne numbers are n the cver f this summary. Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users shuld call 1-877-486-2048. Yu can call these numbers fr free, 24 hurs a day, 7 days a week. Yu may als cntact the Illinis State Plice at 1-888-557-9503 r yu can write t the Illinis State Plice at the fllwing address: Illinis State Plice Medicaid Fraud Cntrl Unit 801 Suth Seventh Street, Suite 500-19 Springfield, IL 62703 If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 23
Multi-Language Insert English: We have free interpreter services t answer any questins yu may have abut ur health r drug plan. T get an interpreter, just call us at 1-877-941-0482. Smene wh speaks English/Language can help yu. This is a free service. Spanish: Tenems servicis de intérprete sin cst algun para respnder cualquier pregunta que pueda tener sbre nuestr plan de salud medicaments. Para hablar cn un intérprete, pr favr llame al 1-877-941-0482. Alguien que hable españl le pdrá ayudar. Este es un servici gratuit. Chinese Mandarin: 我 们 提 供 免 费 的 翻 译 服 务, 帮 助 您 解 答 关 于 健 康 或 药 物 保 险 的 任 何 疑 问 如 果 您 需 要 此 翻 译 服 务, 请 致 电 1-877-941 0482 我 们 的 中 文 工 作 人 员 很 乐 意 帮 助 您 这 是 一 项 免 费 服 务 Chinese Cantnese: 您 對 我 們 的 健 康 或 藥 物 保 險 可 能 存 有 疑 問, 為 此 我 們 提 供 免 費 的 翻 譯 服 務 如 需 翻 譯 服 務, 請 致 電 1-877-941 0482 我 們 講 中 文 的 人 員 將 樂 意 為 您 提 供 幫 助 這 是 一 項 免 費 服 務 Tagalg: Mayrn kaming libreng serbisy sa pagsasaling-wika upang masagt ang anumang mga katanungan niny hinggil sa aming planng pangkalusugan panggamt. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa 1-877-941-0482. Maaari kayng tulungan ng isang nakakapagsalita ng Tagalg. It ay libreng serbisy. French: Nus prpsns des services gratuits d'interprétatin pur répndre à tutes vs questins relatives à ntre régime de santé u d'assurance-médicaments. Pur accéder au service d'interprétatin, il vus suffit de nus appeler au 1-877-941-0482. Un interlcuteur parlant Français purra vus aider. Ce service est gratuit. Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1-877-941-0482 sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí. H0281_MultiLangInsert15_Accepted 09022014 If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 24
German: Unser kstenlser Dlmetscherservice beantwrtet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dlmetscher erreichen Sie unter 1-877-941-0482. Man wird Ihnen drt auf Deutsch weiterhelfen. Dieser Service ist kstenls. Krean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다. 통역 서비스를 이용하려면 전화 1-877-941-0482 번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다. Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону 1-877-941-0482. Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная. إننا نقدم خدمات المترجم الفوري المجانیة للا جابة عن أي أسي لة تتعلق بالصحة أو جدول الا دویة لدینا. للحصول على مترجم فوري لیس علیك سوى الاتصال بنا على 941-877-1 Arabic:.بمساعدت ك. ھذه خدمة مجانیة 0482. سیقوم شخص ما یتحدث العربیة Italian: È dispnibile un servizi di interpretariat gratuit per rispndere a eventuali dmande sul nstr pian sanitari e farmaceutic. Per un interprete, cntattare il numer 1-877-941-0482. Un nstr incaricat che parla Italianvi frnirà l'assistenza necessaria. È un servizi gratuit. Prtugués: Dispms de serviçs de interpretaçã gratuits para respnder a qualquer questã que tenha acerca d nss plan de saúde u de medicaçã. Para bter um intérprete, cntacte-ns através d númer 1-877-941-0482. Irá encntrar alguém que fale idima Prtuguês para ajudar. Este serviç é gratuit. French Crele: Nu genyen sèvis entèprèt gratis pu repnn tut kesyn u ta genyen knsènan plan medikal swa dwòg nu an. Pu jwenn yn entèprèt, jis rele nu nan 1-877-941-0482. Yn mun ki pale Kreyòl kapab ede w. Sa a se yn sèvis ki gratis. Plish: Umżliwiamy bezpłatne skrzystanie z usług tłumacza ustneg, który pmże w uzyskaniu dpwiedzi na temat planu zdrwtneg lub dawkwania leków. Aby skrzystać z pmcy tłumacza znająceg język plski, należy zadzwnić pd numer 1-877-941-0482. Ta usługa jest bezpłatna. If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 25
Summary f Benefits Hindi: हम र स व स थ य य दव क य जन क ब र म आपक कस भ प श न क जव ब द न क लए हम र प स मफ त दभ षय स व ए उपलब ध ह. एक दभ षय प प त करन क लए, बस हम 1-877-941-0482 पर फ न कर. क ई व य क त ज हन द ब लत ह आपक मदद कर सकत ह. यह एक मफ त स व ह. Japanese: 当 社 の 健 康 健 康 保 険 と 薬 品 処 方 薬 プランに 関 するご 質 問 にお 答 えするために 無 料 の 通 訳 サービスがありますございます 通 訳 をご 用 命 になるには 1-877- 941-0482にお 電 話 ください 日 本 語 を 話 す 人 者 が 支 援 いたします これは 無 料 のサービスです If yu have questins, please call IlliniCare Health at 1-877-941-0482. Frm Octber 1 t February 14, yu can call us 7 days a week frm 26
999 Oakmnt Plaza Drive Westmnt, IL 60559 Phne: 877-941-0482 TTY: 711 http://mmp.illinicare.cm