DC Healthcare Alliance

Transcripción

1 Trusted Health Plans 1100 New Jersey Ave., SE Ste. 840 Washington, DC Member Services (202) Toll Free (855) DC Healthcare Alliance You can call us 24 hours a day, 7 days a week, or stop by our office Monday through Friday from 8:00am 5:30pm. For directions on how to visit us, call (202)

2

3 Important Phone Numbers (Tear this page out and put it near your phone) For questions about Trusted call: Member Services (202) OR (855) (toll free) 8:00am-5:30pm Monday-Friday If you need care after your doctor s office closes or have a question you need to ask a nurse call: If you need mental health care or have a mental health question call: If you need to see a doctor within 24 hours ( Urgent Care ) call: TTY/TDD Member Services (202) :00am-5:30pm Monday-Friday Nurse Helpline (855) (toll free) 24 hours a day, 7 days a week TTY/TDD Nurse Helpline (202) After Hours dial 711 for TTY Assistance calling (855) hours a day, 7 days a week Your PCP s Office (fill in your PCP s information here) Nurse Helpline (855) (toll free) 24 hours a day, 7 days a week DC Department of Mental Health Hotline (888) hours a day, 7 days a week Your PCP s Office (fill in your PCP s information here) Nurse Helpline (855) (toll free) 24 hours a day, 7 days a week If you need someone who speaks your Member Services (202) OR (855) (toll free) 8:00am-5:30pm Monday-Friday language or if you are Hearing Impaired, call: TTY/TDD Member Services (202) :00am-5:30pm Monday-Friday If you need a ride to an Appointment, call: Member Services (202) OR (855) (toll free) 24 hours a day, 7 days a week For dental questions: DentaQuest (855) :00am-5:30pm Monday-Friday For vision questions: EyeQuest (855) :00am-5:30pm Monday-Friday FOR AN EMERGENCY, DIAL 911 OR GO TO YOUR NEAREST EMERGENCY ROOM Your Main doctor: Phone: Other Provider: Pharmacy: Phone: Phone: 2 Trusted Member Services (202)

4

5 Welcome to Trusted Health Plan Thank you for choosing Trusted Health Plan (Trusted) as your Managed Care Organization (MCO). Our commitment is to provide you with access to quality health care with excellent customer service. This Member Handbook contains important information about Trusted and how our plan works. We urge you to review it carefully. As a Trusted member you will obtain great benefits and services. If Trusted changes how it works or learns information about its medical providers that you need to know (such as which doctors are taking new patients and the doctors office hours), you will be informed about the change 30 days before it occurs. New members will receive an invitation in your New Member packet to our New Members Orientation as well as a new member welcome call. The New Member Orientation is our way of providing you with a personal way for you to learn how to best use our health care system and to ask any questions you may have. 3 Trusted Member Services (202)

6 How this Handbook Works Trusted is a managed care plan that is paid by the District of Columbia to help you get health care. In this Handbook we tell you about how Trusted works, how to find doctors, how to call us, and what things we pay for. Telling you about these things can be hard to do and hard for everyone to read. Words used in health care and words used by your doctor can sometimes be hard to understand, Sometimes we have to tell you about laws that you need to know about. These also can be hard to understand. To help you, we have underlined some words that might have a different meaning from the one you know. We have explained these words in the back of this book. If you ever have any questions about things you read in this book or other questions about Trusted you can call Trusted Member Services at (202) or visit we will do our best to help you. How this Member Handbook Can Help You This Member Handbook tells you: How to get health care What Services we will pay for (we call this, what Services are covered by us) What Services we can t pay for How to pick your Primary Care Provider (your PCP) What to do if you get sick What you should do if you have a Complaint (also called a Grievance ) or want to change ( Appeal ) a decision by Trusted This Member Handbook gives you basic information about how Trusted works and its rules. Please call Trusted Member Services if you have any questions. 4 Trusted Member Services (202)

7 Table of Contents Important Phone Numbers... 2 Welcome to Trusted Health Plan... 3 How this Handbook Works... 4 Your Rights and Responsibilities... 7 Your Member ID Card... 9 Your Primary Care Provider (PCP) Picking your PCP How to change your PCP Routine Care, Urgent Care and Emergency Care Routine Care Urgent Care Emergency Care WHAT TO DO IF YOU HAVE AN EMERGENCY: Trusted Providers and Providers who are not part of Trusted Making an Appointment Making an Appointment with your PCP Changing or canceling an Appointment Getting care when your PCP s office is closed How long it takes to see your doctor Support Services Interpretation & Translation Services/Services for the hearing and visually impaired Interpretation Services Translation Services Services for the Hearing and Visually Impaired Specialty Care and Referral How to get specialty care Self-Referral Services You DO NOT need a Referral to: Services for alcohol or other drug problems Birth control and other Family Planning Services Pharmacy Services and prescription drugs Disease Management Services to Keep Adults from Getting Sick Recommendations for Checkups ( Screenings ) Preventive counseling Adult Immunizations Pregnancy Prenatal and Post-Partum Care Once you have had your baby, call: Your Health Benefits Health Services covered by Trusted Services We Do Not Pay For Other Important Information What to do if you move What to do if you have a baby Trusted Member Services (202)

8 What to do if you adopt a child What to do if someone in your family dies How to change your Managed Care Organization What to do if you get a bill for a covered service Paying for Non-Covered Services Advance directives What to do if you have other insurance Physician (doctor) incentive plan disclosure Complaints/Grievances, Appeals and Fair Hearings Complaints/Grievances Appeals and Fair Hearings Appeals Expedited (Emergency) Complaints/Grievances and Appeals process Your rights during the Complaints/Grievances, Appeals and Fair Hearings process The District s Ombudsman Program Notice of Privacy Practices Why Are You Giving This Notice to Me? What is Trusted Health Plan Required to do Under HIPAA? What is Protected Health Information (PHI) How Can You Use or Share my PHI? What are my Rights Under Federal Law with Respect to my PHI? May I Complain about Your Privacy practices? How will I know if my rights change? What Some Words Mean Trusted Member Services (202)

9 Your Rights and Responsibilities You have a right to: Be treated with respect and dignity Know that when you talk with your doctors and other providers its private Have an illness or treatment explained to you in a language you can understand Participate in decisions about your care Receive a full, clear and understandable explanation of treatment options and risks of each option so you can make an informed decision Refuse treatment or care Be free of physical and chemical restraints Be able to see your medical records and to request that they be fixed if they are wrong Choose an eligible PCP from within Trusted s network and to change your PCP Make a Complaint ( Grievance ) about the care provided to you and receive an answer Request an Appeal or a Fair Hearing if you believe Trusted was wrong in denying, reducing or stopping a service or item Receive Family Planning Services and supplies from the provider of your choice Obtain medical care without unnecessary delay Receive information on advance directives and choose not to have or continue any life-sustaining treatment Receive a copy of this Trusted Member Handbook Continue treatment you are currently receiving until you have a new treatment plan Receive interpretation and translation Services free of charge if you need them Refuse oral interpretation Services Get an explanation of prior authorization procedures Receive information about Trusted s financial condition and any special ways we pay our doctors Obtain summaries of customer satisfaction surveys Receive Trusted s Dispense As Written policy for prescription drugs 7 Trusted Member Services (202)

10 You are responsible for: Treating those providing your care with respect and dignity Following the rules of the D.C. Medicaid Managed Care Program and Trusted Following instructions you receive from your doctors and other providers Going to Appointments you schedule or that Trusted schedules for you Telling your doctor at least 24 hours before the Appointment if you have to cancel Asking for more explanation if you do not understand your doctor s instructions Going to the Emergency Room only if you have a medical emergency Telling your PCP about medical and personal problems that may affect your health Reporting to Economic Security Administration (ESA) and Trusted if you or a family member have other health insurance Trying to understand your health problems and participate in developing treatment goals Helping your doctor in getting medical records from providers who have treated you in the past Telling Trusted if you were injured as the result of an accident or at work 8 Trusted Member Services (202)

11 Your Member ID Card After you sign up for Trusted and you have picked a primary care provider (PCP), we will send you a Member ID Card in the mail. This card lets your doctors, hospitals, drug stores and others know that you are a Member of Trusted. Please make sure that the information on your Member Identification Card is correct. If there are any problems, or if you have lost your card, call Member Services (202) or (855) (toll free). Your Member ID Card Looks Like This Each Trusted Member has his or her own card. Your children will also have their own cards, you must keep your children s cards so they don t get lost. It is against the law to let anyone else use your Member ID Card or Medicaid card. Please remember to carry your Member ID Card with you all the time. Always show your card before receiving any medical care or getting medicine at a pharmacy. Be sure to keep your Alliance ID Card too. 9 Trusted Member Services (202)

12 Your Primary Care Provider (PCP) When you join Trusted, one of our doctors will be your main doctor. This doctor is called your Primary Care Provider or PCP. Your PCP will help you and your family get the health care you need. It is important to call your PCP first when you need care. If you had a doctor before you signed up with Trusted please call Member Services at (855) We can help you stay with that doctor if you want to. Picking your PCP 1. Pick a PCP at the time you enroll in Trusted. This person will be your PCP while you are a member of Trusted. If your current PCP is a member of Trusted s network, you may stay with that doctor. If you don t have a PCP, you can choose from a list of doctors in our Provider Directory or at Call Member Services at (202) if you need help in picking a doctor. If you do not pick a PCP within the first 10 days of being in our plan, we will choose a doctor for you. If you do not like the PCP we pick for you, you may change your PCP. Call Member Services at (202) to change your PCP. Trusted will send you a Member ID Card. Your card will have your PCP s name and phone number on it. 2. Choose a PCP for each family member in our plan, including your children. Your PCP may be one of these kinds of doctors: Family and General Practice Doctor - usually can see the whole family Internal Medicine Doctor - usually sees only adults and children 14 years and older Pediatrician - sees children from newborn up to adult Obstetrician/Gynecologist (OB/GYN) - specializes in women s health and Maternity care If you or your child has Special Health Care Needs, a specialist may be your PCP but you need to call us as and let us know that you would like this. We will try to help you get a specialist to be your PCP, but the specialist would have to agree to it. 3. When you pick your PCP, please: Pick a doctor who is close to your home or work. Try to pick a doctor who can send you to the hospital you want. Not all doctors can send patients to all hospitals. Our provider directory lists which hospitals a PCP can send you to. You can also call Member Services for help. Sometimes the PCP you choose won t be able to take new patients. We will let you know if you need to pick a different doctor. 10 Trusted Member Services (202)

13 How to change your PCP You can change your PCP anytime. Just pick a new PCP from the Provider Directory. Call Member Services at (202) once you have picked a new PCP. If you need help picking a new PCP, Member Services can help you. Routine Care, Urgent Care and Emergency Care There are three kinds of health care you may need: Routine Care, Urgent Care, or Emergency Care. Routine Care is the regular care you get from your PCP. Routine Care is also care you get from other doctors that your PCP sends you to. Routine Care can be Check-Ups, physicals, health Screenings, and care for health problems like diabetes, hypertension, and asthma. If you need Routine Care, call your PCP s office and ask to make an Appointment. Urgent Care is medical care you need within 24 hours, but not right away. Some Urgent Care issues are: A sprain or a strain Throwing Up Lice, scabies or ringworm An earache A cough or cold Refills for medicine Diarrhea A cut or scrape A sore throat Diaper rash Mild Headache If you need Urgent Care, call your PCP s office. If your PCP s office is closed, leave a message with the person who answers the phone when the office is closed. Then call the Nurse Help Line at (855) A nurse will help you decide if you need to go to the doctor right away. The nurse will tell you how to get care. You do not have to go to the Emergency Room or use an ambulance for routine or Urgent Care. Emergency Care is medical care you need right away for a serious, sudden (sometimes life-threatening) injury or illness. Miscarriage/pregnancy with vaginal bleeding Bleeding that won t stop A broken bone A bad burn You are in labor Drug overdose Shock (you may sweat, feel thirsty or dizzy or have pale skin) Seizures Poisoning Trusted 11 Member Services (202)

14 Fainting/unconsciousness Gun or knife wounds Suddenly not able to see, move or speak Care When You Are Out-of-Town WHAT TO DO IF YOU HAVE AN EMERGENCY: 1. Call or go to your nearest in-network emergency room. 2. Show the Emergency Room (ER) your Trusted Alliance Member I.D. Card. 3. As soon as you can, call your PCP. 12 Trusted Member Services (202)

15 Trusted Providers and Providers who are not part of Trusted Trusted will pay for the care you get when you go to one of our doctors or other health care providers. We call these doctors and other health care providers our network providers. All these In-Network doctors can be found in your Provider Directory. A doctor or provider who is not one of ours is called an Out-ofNetwork Provider. If you go to an Out-of-Network doctor, hospital or lab, you may have to pay for the care you get. You will not have to pay if you have asked us first and we have told you, usually in writing, that it is okay. We call this prior written authorization. Prior authorization (or prior approval) means approval for a health service that is not routinely covered by Trusted. You must get this approval before you receive the service. Call Member Services at (202) to ask about getting a prior authorization. You may go to a Family Planning provider who is out-of network even if you do not have prior authorization. See page 19 for more information on Family Planning Services. Remember: You need to go to a provider in Trusted s network. 13 Trusted Member Services (202)

16 Making an Appointment Making an Appointment with your PCP 1. Have your Member ID Card and a pencil and paper close by. 2. Call your PCP s office. Look for your PCP s phone number on the front of your Member ID Card. You can also find it in your Provider Directory or online at 3. Tell the person who answers that you are a Trusted Member. Tell them you want to make an Appointment with your PCP. 4. Tell the person why you need an Appointment. For example: a. You or a family member is feeling sick b. You hurt yourself or had an accident c. You need a check- up or follow-up care 5. Write down the time and date of your Appointment. 6. Come to your Appointment on time, and bring your Member ID Card with you. 7. If you need help making an Appointment, please call Member Services at (202) If you are a new Member of Trusted, you should make an Appointment for your first health Check-Up as soon as possible. Changing or canceling an Appointment It is very important to come to your Appointment and to be on time. If you need to change or cancel your Appointment, please call the doctor at least 24 hours before your Appointment. For some Appointments, you may have to call more than 24 hours before to cancel. If you do not show up for your Appointment or if you are late, your doctor may decide you cannot be his or her patient. Getting care when your PCP s office is closed If you need to speak to your PCP when the office is closed, call your PCP s office and leave a message with the person who answers the phone when the office is closed. Be sure to give the person who answers your phone number. Someone will call you back as soon as possible. You can also call the Nurse Help Line 24 hours a day at: (855) If you think you have an emergency, call 911 or go to the Emergency Room. 14 Trusted Member Services (202)

17 How long it takes to see your doctor Your doctor s office must give you an Appointment within a certain number of days after you call. The table below shows how long it will take to get an Appointment. Please call (202) if you cannot get an Appointment during these time periods. Type of visit Your condition How long it takes to see your doctor You are hurt or sick and need care within 24 hours to avoid getting worse, but you don t need to see a doctor right away Urgent Visit Some examples of when you need urgent care are: a sprain or strain, diarrhea, throwing up, a cut or scrape, an earache, a sore throat, a cough or cold, diaper rash, refills for medicine, mild headache, lice, scabies, or ringworm. Within 24 hours Routine Visit You have a minor illness or injury or you need a regular checkup, but you don t need an urgent Appointment. Within 30 days Follow-up Visit You need to see your doctor after a treatment you just had to make sure you are healing well. Within 1-2 weeks depending on the kind of treatment Adult Wellness Visits Non-urgent Appointments with specialists (by Referral) You are having your first Appointment with a new doctor You are due for a regular adult checkup You are due for a prostate exam, a pelvic exam, a PAP smear or a breast exam Your PCP referred you to see a specialist for a non-urgent condition Within 30 days or sooner if necessary Within 30 days 15 Trusted Member Services (202)

18 Support Services Interpretation & Translation Services/Services for the hearing and visually impaired Interpretation and translation Services and Services for the hearing and visually impaired are FREE. Interpretation Services Trusted will provide oral interpretation Services if you need them, including at the hospital. Please call Member Services at (202) to get Interpretation Services. Please call us before your doctor s Appointment if you need interpretation Services. Interpreter Services are usually provided over the telephone. If you need an interpreter to be with you at your doctor s Appointment, you must let us know 2 days or 48 hours before the Appointment. Translation Services If you get information from Trusted and need it translated into another language, please call Member Services at (202) Services for the Hearing and Visually Impaired If you have trouble hearing, call Member Services at (202) If you have trouble seeing, call Member Services at (202) or (855) (toll free). We can give you information on an audio tape, in Braille or in large print. Specialty Care and Referral How to get specialty care Specialty care is when care is given by a specialist doctor who has extra training and cares for a specific condition or part of the body. For example, a Cardiologist cares for the heart and a Podiatrist cares for the feet. Your PCP will help you know when you need to see a specialist and give you a referral. A referral is a written note given to you by your PCP to see a different doctor. You must get a referral to see a doctor other than your PCP except for well-women visits, family planning, and some mental health services. 16 Trusted Member Services (202)

19 If you want to see a specialist, but Trusted said it wouldn t pay for the visit, you can: Make an Appointment with another doctor in the Trusted network and get a second opinion Appeal our decision (see page 36 on Appeals) Ask for a Fair Hearing (see page 36 on Fair Hearings) Self-Referral Services There are certain services you can get without getting prior permission from your PCP. These are called self-referral services and are listed below. You DO NOT need a Referral to: See your PCP Get care when you have an emergency Receive services from your OB/GYN doctor in your network for routine or preventive services (females only) Receive Family Planning Services Receive services for sexually transmitted diseases (STDs) Receive Immunizations (shots) Visit a vision provider in the network (only provided to Alliance Members under 21 years old) Receive emergency mental health or services for conditions that are life-threatening and related to withdrawal of alcohol or narcotics Services for alcohol or other drug problems Problems with alcohol or other drugs are dangerous to your health and can be dangerous to the health of people around you. It is important to go to the doctor if you need help with these problems. Trusted will help you arrange for detoxification services and provide care coordination to help you get other services. To get services for these problems, you can: Call Member Services at (202) or (855) (toll free), 24 hours a day, 7 days a week. Call APRA directly at (202) Birth control and other Family Planning Services You do NOT need a Referral to receive birth control or other Family Planning Services. You can get birth control and other Family Planning Services from any provider you pick. You do not need a referral to get these services. If you choose a Family Planning Services doctor other than your PCP, tell your PCP. It will help your PCP take better care of you. Talk to your PCP or call Trusted Member Services at (202) for more information on birth control or other Family Planning Services. 17 Trusted Member Services (202)

20 All birth control and other Family Planning Services are confidential. Family Planning Services include: Pregnancy Testing Counseling for the Woman and the Couple Routine and Emergency Contraception Counseling and Immunizations Screening for all Sexually Transmitted Diseases Treatment for all Sexually Transmitted Diseases Sterilization Procedures (Requires you to sign a form 30 days before the procedure) HIV/AIDS Testing and Counseling Family Planning Services do not include: Routine infertility studies or procedures Hysterectomy for sterilization Reversal of voluntary sterilization HIV/AIDs Treatment Abortion Services HIV/AIDS testing, counseling and treatment You can get HIV/AIDS testing and counseling: When you have Family Planning Services From your PCP From an HIV testing and counseling center For information on where you can get for HIV testing and counseling, call Member Services (202) If you need HIV treatment, your PCP will help you get the care you need. Pharmacy Services and prescription drugs Pharmacies are where you pick up your medicine (drugs). If your doctor gives you a prescription, you must go to a pharmacy in the Alliance pharmacy network. You can find the full list of pharmacies in the Alliance Pharmacy network online at If you are out of town and you have an emergency or need Urgent Care and need a prescription filled, just contact our Member Services Department or Nurse Help Line (855) (toll free). To get a prescription filled: Pick a pharmacy that is part of the Alliance Pharmacy network and is close to your work or home. When you have a prescription, go to the pharmacy and give the pharmacist your prescription and your Alliance Member ID Card. If you need help, please call Member Services 18 Trusted Member Services (202)

21 Things to remember: You should not be asked to pay for your medicines. Call Trusted Member Services if the pharmacy or drug store asks you to pay. In the event the Alliance pharmacy is closed, and you need to fill your prescription, contact Trusted for permission to obtain your medication at an alternate pharmacy. Sometimes, your doctor may need to get permission from Trusted for a drug. While your doctor is waiting for the permission, you have a right to get the medication: For up to 72 hours OR For one full round of the medicine if you take it less than once a day If you are out of town and you have an emergency or need urgent care, you will need to contact Trusted at and we will help you find a pharmacy where you can get urgently needed medications. Disease Management If you have a chronic illness or special health care need such as asthma, high blood pressure or mental illness, we may put you in our Disease Management Program. This means you will have a Care Manager. A Care Manager is someone who works for Trusted and who will help you get the services and information you need to manage your illness and be healthier. Services to Keep Adults from Getting Sick Trusted wants you to take care of your health. We also want you to sign up for health and wellness services we offer to you. Health and wellness services include screenings, counseling and immunizations. Recommendations for Checkups ( Screenings ) Please make an appointment and go see your PCP at least one time every year for a checkup. The list below tells you the type of things to talk with your PCP about during your checkup. Please make an appointment to see your PCP at least once a year for a checkup. Adult Screening Recommendations Blood pressure and cholesterol (lipid disorder) Screening Sexually transmitted diseases 19 Trusted Member Services (202)

22 HIV/AIDS Screening & testing Diabetes Screening Screenings for Women Only Screenings for Men Only Breast cancer Screening Prostate cancer Screening Tobacco Use (mammogram) Alcohol and Other Drug Use Cervical Cancer Depression Osteoporosis Abdominal Aortic Aneurysm Colorectal Cancer (50 years and older) (post-menopausal women) HPV Screening Obesity Chlamydia Hepatitis C Preventive counseling Preventive counseling is available to help you stay healthy. You can get preventive counseling on: Diet and exercise Alcohol and drug use Smoking cessation HIV/AIDS prevention Obesity Adult Immunizations If you are an adult, you may need some immunizations (shots). Please talk to your PCP about which ones you may need. Pregnancy If you are pregnant or think you are pregnant, it is very important that you go to your OB/GYN doctor right away. You do not need to see your PCP before making this appointment. If you are pregnant, please call: Economic Security Administration (ESA) at Member Services at or (855) (toll free). Your PCP There are certain things that you need to get checked if you are pregnant. These will help make sure that 20 Trusted Member Services (202)

23 you have a healthy pregnancy, delivery, and baby. This is called prenatal care. You get prenatal care before your baby is born. Remember, if you are pregnant or think you are pregnant do not drink alcohol, use drugs or smoke. Prenatal and Post-Partum Care When you register with Trusted s OB hotline, you get these services: Pregnancy Case Manager Assistance obtaining WIC Prenatal Information & Classes Once you have had your baby, call: Member Services Your Trusted OB Case Manager and Your ESA Caseworker Your Health Benefits Health Services covered by Trusted The list below shows the health care services and benefits for all Trusted Members. For some benefits, you have to be a certain age or have a certain need for the service. Trusted will not charge you for any of the health care services in this list if you go to a network provider or hospital. If you have a question about whether Trusted covers certain health care, call Trusted Member Services at (202) BENEFIT Primary Care Services Specialist Services WHAT YOU GET Preventive, acute, and chronic health care Services generally provided by your PCP Health care Services provided by specially trained doctors or advanced practice nurses. Referrals are usually required Does not include cosmetic Services and surgeries except for surgery required to correct a condition resulting from surgery or disease, created by an accidental injury or a congenital deformity, or is a condition that impairs the normal function of your body WHO CAN GET THIS BENEFIT All Members All Members 21 Trusted Member Services (202)