DC Healthy Family. Trusted Health Plan 1100 New Jersey Ave., SE Ste. 840 Washington, DC Member Services (202) Toll Free (855)

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1 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) Trusted Health Plan 1100 New Jersey Ave., SE Ste. 840 Washington, DC DC Healthy Family Member Services (202) Toll Free (855)

2 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: If you need someone who speaks your language or if you are Hearing Impaired, call: If you need a ride to an Appointment, 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 Member Services (202) OR 8:00am-5:30pm (855) (toll free) Monday-Friday TTY/TDD Member Services (202) :00am-5:30pm Monday-Friday MTM (855) (toll free) 8:00am-6:00pm M-F 9:00am-3:00pm Sat. After Hours for Emergencies 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: Child s Main doctor: Other Child s Main doctor: Phone: Phone: 2 Trusted Member Services (202)

3 Welcome to Trusted Health Plan Thank you for choosing Trusted Health Plan (Trusted) as your Medicaid 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)

4 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 24 hours a day, seven days a week. 4 Trusted Member Services (202)

5 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 When you are Out of Town: 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 Transportation Services Specialty Care and Referral How to get specialty care Self-Referral Services You DO NOT need a Referral to: Mental Health Services 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 Child s Health Health Check Program for Children (EPSDT) Immigrant Children Care for your children s teeth Children with Special Health Care Needs The IDEA program Trusted covers the services listed below if your child is in the IDEA program: Trusted Member Services (202)

6 Immunizations (shots) for children and teens 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 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 What to do if you are eligible for both Medicaid and Medicare 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? Medicare Part D Notice to Members For Members with both Medicare and Medicaid What Some Words Mean Trusted Member Services (202)

7 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)

8 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)

9 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 Medicaid Card too. 9 Trusted Member Services (202)

10 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)

11 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 11 Trusted Member Services (202)

12 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 emergency room. 2. Show the Emergency Room (ER) your Trusted Member I.D. Card. 3. As soon as you can, call your PCP. When you are Out of Town: When you need to see a doctor or get medicine when you are out-of-town, you should: For Routine Care: You must call us and ask if we will pay for you to see a doctor or other provider when you are out of town because doctors who are not in the District of Columbia are not a part of Trusted. If Trusted does not say it is okay before you get the care, you will have to pay for the care yourself. If you need medicine from a doctor while you are out-of-town, please call our Member Services Department or Nurse Advice Line for help. For Urgent Care: Call your PCP. If your PCP s office is closed, call the Nurse Help Line (855) A nurse will help you decide if you need to go to the doctor right away. The nurse can 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. For Emergency Care: If you have an emergency, including a mental health or alcohol or other drug emergency, go to the nearest Emergency Room (ER) to get care right away. If you go to the emergency room, you should ask the ER staff to call your PCP. If you go to the emergency room, you should call Member Services as soon as you can. If your child does not live at home and needs to see a doctor, please call Member Services at (202) Trusted Member Services (202)

13 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-of- Network 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)

14 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)

15 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 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 How long it takes to see your doctor Urgent Visit Routine Visit Follow-up Visit Adult Wellness Visits Non-urgent Appointments with specialists (by Referral) 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. You have a minor illness or injury or you need a regular checkup, but you don t need an urgent Appointment. You need to see your doctor after a treatment you just had to make sure you are healing well. 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 24 hours Within 30 days Within 1-2 weeks depending on the kind of treatment Within 30 days or sooner if necessary Within 30 days 15 Trusted Member Services (202)

16 Child EPSDT checkups -not urgent Immigrant Children well-child checkups not urgent IDEA (Early Intervention) assessments Your child is due for an EPSDT checkup Your child is due for a well-child checkup Tests ( assessments ) for children up to age 3 at risk of developmental delay or disability Initial checkup: within 60 days Additional checkups: within 30 days of due dates for children under age two; within 60 days of due dates for children age two and older Initial checkup: within 60 days Additional checkups: within 30 days of due dates for children under age two; within 60 days of due dates for children age two and older Within 30 days 16 Trusted Member Services (202)

17 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. Transportation Services Trusted will provide transportation to doctor s appointments for you if you need it. Call MTM Transportation at (855) to tell them what time and what day you need to be picked up. You must call at least two (2) business days (not including Saturday and Sunday) before your Appointment to get transportation. If you need transportation to EPSDT visits or urgent visits, you can call the day before the Appointment to ask for transportation. The types of transportation are bus, Metro, tickets to pay for a taxi, wheel chair vans, and ambulances. The type of transportation you get depends on your medical needs. 17 Trusted Member Services (202)

18 Give MTM Transportation your Member ID, phone number and address where you can be picked up. Also tell them the name, address, and phone number of the medical/dental facility or doctor s office you are going to. 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. 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 Take your child to a dental provider in the network Receive emergency mental health or services for problems with alcohol or other drugs Receive up to 10 mental health sessions (A treatment plan is required after 10 visits.) 18 Trusted Member Services (202)

19 Mental Health Services Mental health care is for both adults and children. This care helps when you feel depressed or anxious. If you need help, or someone from your family needs help, call The crisis hotline at Beacon Behavioral Health (855) The D.C. Department of Mental Health Hotline at , 24 hours a day, 7 days a week You can get up to 10 mental health Appointments without a Referral. 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. 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 19 Trusted Member Services (202)

20 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 Trusted s network. Trusted s network includes most pharmacies in the District. You can find the full list of pharmacies in the Trusted 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 Trusted 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 Trusted Member ID Card. If you need help, please call Member Services 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. 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 20 Trusted Member Services (202)

21 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 Screenings for Women Only Screenings for Men Only Blood pressure and cholesterol (lipid disorder) Screening Sexually transmitted diseases Breast cancer Screening (mammogram) Cervical Cancer Prostate cancer Screening Abdominal Aortic Aneurysm HIV/AIDS Screening & testing Diabetes Screening Tobacco Use Alcohol and Other Drug Use Osteoporosis (post-menopausal women) HPV Screening Chlamydia Depression Colorectal Cancer (50 years and older) Obesity Hepatitis C 21 Trusted Member Services (202)

22 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: Your ESA Caseworker 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 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 IMA Caseworker 22 Trusted Member Services (202)

23 Your Child s Health Health Check Program for Children (EPSDT) Trusted wants to help your children grow up healthy. If your child is in the D.C. Healthy Families (Medicaid) program, your child will be in the Health Check Program, also called Early and Periodic Screening, Diagnosis and Treatment (EPSDT). This program starts right after your child is born and lasts until your child turns 21. The Health Check Program gives your child a number of important checkups. There is a Health Check (EPSDT) information sheet in this handbook. You can also ask your doctor, call Member Services, or visit our website for a copy of the Health Check (EPSDT) Periodicity Schedule. The schedule tells you when your child needs to go to the doctor. In addition to Health Check/EPSDT services, your child can also get the benefits described in the Member Health Benefits section below. Immigrant Children If your child is in the Immigrant Children s Program, your child will get well-child care. This program starts right after your child is born and lasts until your child turns 21. In addition to well-child care, your child can also get the benefits described in the Member Health Benefits section below. You do not have to pay anything for these Services for your child they are free. If you have any questions or need help with transportation or scheduling an appointment, please call Member Services. Care for your children s teeth All dental health checkups and treatments are free for Trusted Members under age 21. Dentists can prevent cavities and teach you and your child how to care for their teeth. From birth up to age 3, your child s PCP may provide dental care during regular check-ups. The PCP may decide to send the child to a dentist. Beginning at age 3, all children should see a dentist in the Trusted network for a checkup every year. Look in Trusted s Provider Directory or online at to pick a dentist near you. Please call the dentist s office for an appointment. 23 Trusted Member Services (202)

24 Children with Special Health Care Needs When children have -- or are at risk of having -- physical, developmental, behavioral, or emotional conditions that are permanent or that last a long time, they can have Special Health Care Needs. These children may need health care and other services that are more than or different from what other children need. Trusted will check to see if your child has Special Health Care Needs. Please be sure your child has been checked for this. If your child has not been checked to see if they have special healthcare needs, call Member Services at (202) If your child has Special Health Care Needs, your child has the right to have a PCP who is a specialist Be sure your child with a special health care need has a Treatment Plan. Call Trusted Member Services to ask for a treatment plan for your child. For more information please contact Member Services at (855) The IDEA program IDEA stands for the Individuals with Disabilities Education Act. IDEA is a federal law. The IDEA program provides special services for your child with developmental delays, disabilities or special needs. Children up to age 3 get early intervention services from Trusted. Children age 3 and older get special educational services from the D.C. public school system. 24 Trusted Member Services (202)

25 Growth Chart: Here are some of the things that you should be looking for as your child grows. Every child develops at his or her own pace. Your child may reach these milestones slightly before or after other children of the same age. Use this as a guide. If you have any concerns, talk to your child s doctor. By the end of 7 months, many children are able to: Turn head when name is called Smile back at another person Respond to sounds with sounds Enjoy social play (such as peek-a-boo) By the end of 1 year (12 months), many children are able to: Use simple gestures (waving bye-bye ) Make sounds such as ma and da Imitate actions in their play (clap when you clap) Respond when told no By the end of 1 ½ years (18 months), many children are able to: Do simple pretend play ( talk on a toy phone) Point to interesting objects Look at object when you point at it and tell them to look Use several single words unprompted By the end of 2 years (24 months), many children are able to: Use 2- to -4 word phrases Follow simple instructions Become more interested in other children Point to an object or picture when named. By the end of 3 years (36 months), many children are able to: Show affection for playmates Use 4- to- 5 word sentences Imitate adults and playmates (run when other children run) Play make-believe with dolls, animals, and people ( feed a teddy bear) By the end of the 4 years (48 months)many children are able to : Use 5- to 6- word sentences Follow 3-step commands ( Get dressed, comb your hair and wash your face ) Cooperate with other children If you think your child is not growing the way he or she should, have your child tested ( IDEA evaluation ). To get an IDEA evaluation, call your PCP. If your child needs IDEA Services, your PCP will refer your child to the D.C. Government s Early Intervention Program. Trusted has case managers who can tell you more about IDEA and the other services your child can get. Trusted covers the services listed below if your child is in the IDEA program: For children up to age 3, Trusted covers all health care services even if the service is in your child s treatment plan. For children aged 3 and older, Trusted: Pays for all health care services and services in your child s treatment plan that your child needs when not in school even on evenings, weekends and holidays. Coordinates services that are not provided through the school s treatment plan. For more information on the services your child can get through the IDEA program, contact your child s school. 25 Trusted Member Services (202)

26 Immunizations (shots) for children and teens Immunizations (shots) are important to keep your child healthy! When your child is very young, your child will need shots every few months. The shots start at birth. These shots protect them from diseases. Your PCP and Trusted will schedule appointments for your child s shots. Shots are free. The shot schedule for children is: AGE IMMUNIZATION Birth HepB #1 2 months HepB#2, DTaP#1, RV#1, Hib#1, PCV#@1, IPV#1 4 months DTaP#2, RV#2, Hib#2, PCV#2, IPV#2 6 months HepB#3, Hib#3, DTaP#3, RV#3, PCV#3, IPV#3 12 months HiB#4, MMR#1, Varicella#1, PCV#4, HepA#2 15 months Varicella #2 18 months Hep A#2 4 years-6 years DTaP, MMR, IPV 13 years or older Varicella 11 years-12 years HPV (girls only), MCV4 13 years 18 years Tdap, HPV 18 years or younger MCV4 Every Year Beginning at 6 months, Seasonal Influenza ( flu ) vaccine as recommended each year 26 Trusted Member Services (202)

27 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 Laboratory & X-ray Services Hospital Services Pharmacy Services (prescription drugs) 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 Lab tests and X-rays Outpatient Services (preventive, diagnostic, therapeutic, rehabilitative, or palliative Services) Inpatient Services (hospital stay) Prescription drugs included on the Trusted drug formulary. You can find the drug formulary at or by calling Member Services. Only includes medications from network pharmacies Includes the following non-prescription (overthe-counter) medicines: - Fever and Pain relievers like Tylenol or Advil - Sinus and Allergy Medicines like Benadryl - Cough and Cold Medicines - Hydrocortisone 1% for Rashes WHO CAN GET THIS BENEFIT All Members All Members All Members Any Member with a Referral from their PCP or who has an emergency All Members other than dually eligible(medicaid/medicare) Members whose prescriptions are covered under Medicare Part D 27 Trusted Member Services (202)

28 BENEFIT Emergency Services Family Planning Podiatry WHAT YOU GET A Screening exam of your health condition and stabilization if you have an Emergency Medical Condition, regardless if the Provider is in or out of the Trusted network. Treatment for emergency conditions Pregnancy Testing: Counseling for the woman Routine and Emergency Contraception Voluntary sterilizations for Members over 21 years of age (requires signature of an approved sterilization form by the Member 30 days prior to the procedure) Screening, Counseling and Immunizations (including for HPV) Screening and preventive treatment for all sexually transmitted diseases Does not include sterilization procedures for Members under age 21 Special care for foot problems Regular foot care when medically needed. WHO CAN GET THIS BENEFIT All Members All Members as appropriate All Members Rehabilitation Services Rehabilitation Services, including physical, speech and occupational therapy All Members Prosthetic devices Replacement, corrective, or supportive devices prescribed by a licensed provider All Members Vision Care Eye exams at least once every year and as needed; and eye glasses (corrective lenses) as needed One pair of eyeglasses every two years except when the Member has lost his or her eyeglasses or when the prescription has changed by more than 0.5 diopter Members under age 21 Members age 21 and older 28 Trusted Member Services (202)

29 BENEFIT Home Health Services WHAT YOU GET In-home health care Services, including: Nursing and home health aide care Home health aide Services provided by a home health agency Physical therapy, occupational therapy, speech pathology and audiology Services WHO CAN GET THIS BENEFIT All Members Personal care Services Services provided to a Member by an individual qualified to provide such Services who is not a member of the individual s family, usually in the home, and authorized by a physician as a part of the Member s treatment plan. All Members Is not available to Members in a hospital or nursing home Nursing Home Care Full-time skilled nursing care in a nursing home up to 30 consecutive days All Members Hospice Care Support Services for people who are dying All Members Transportation Services Transportation to and from medical Appointments All Members 29 Trusted Member Services (202)

30 BENEFIT Adult Wellness Services Child Wellness Services WHAT YOU GET Immunizations Routine Screening for Sexually Transmitted Diseases HIV/AIDS Screening, testing and counseling Breast cancer Screening (women only) Cervical cancer Screening (women only) Osteoporosis Screening (post-menopausal women) HPV Screening (women only) Prostate cancer Screening (men only) Abdominal aortic aneurysm Screening (men only) Screening for obesity Diabetes Screening Screening for high blood pressure and cholesterol (lipid disorders) Screening for depression Colorectal cancer Screening (Members 50 years and older) Smoking cessation counseling Diet and exercise counseling Mental Health counseling Alcohol and drug Screening Whatever is needed to take care of sick children and to keep healthy children well, including Screening and assessments such as: Health and development history and Screenings Physical and mental health development and Screenings Comprehensive health exam Immunizations Lab tests including of blood lead levels Health education Dental Screening Services Vision Screening Services Hearing Screening Services Alcohol and drug Screening and counseling Mental health Services Does not include any health Services furnished to a child in a school setting WHO CAN GET THIS BENEFIT Members over age 21 as appropriate Members under age Trusted Member Services (202)

31 BENEFIT Dental Benefits Hearing Benefits Mental Health Services WHAT YOU GET General dentistry (including regular and emergency treatment) and orthodontic care for special problems Check-Ups twice a year with a dentist are covered for children ages 3 through 20. A child s PCP can perform dental Screenings for a child up to age 3 Does not include routine orthodontic care Diagnosis and Treatment of conditions related to hearing, including hearing aids and hearing aid batteries Services provided by mental health providers, including: Diagnostic and assessment services Physician and mid-level visits, including: o Individual counseling o Group counseling o Family counseling o FQHC Services Medication/Somatic treatment Crisis Services Inpatient Hospitalization and Emergency Department Services Day Services Intensive Day Treatment Case management Services Services for individuals 65 years and older in an institution for mental disease Treatment for any mental condition that could complicate pregnancy Patient Psychiatric Residential Treatment Facility Services (PTRF) for Members under 22 years of age for thirty (30) consecutive days Mental health Services for children that are included in an IEP or IFSP during holidays, school vacations, or sick days when the child is not in school Care coordination for Members receiving the following Services from DMH: Community based interventions Multi-systemic therapy (MST) Assertive Community Treatment (ACT) Community Support WHO CAN GET THIS BENEFIT Members under age 21 (Members 21 years and older can get dental services from Medicaid. Call MCO Dental Help Line at ) All Members All Members 31 Trusted Member Services (202)

32 BENEFIT Alcohol & Drug Abuse Treatment Durable Medical Equipment (DME) & Disposable Medical Supplies (DMS) WHAT YOU GET Inpatient detoxification Other alcohol/drug abuse services are provided by the Addiction, Prevention and Recovery Administration (APRA) Help with getting care from APRA Inpatient and outpatient substance abuse treatment Other alcohol/drug abuse Services are provided by the Addiction, Prevention and Recovery Administration (APRA) Help with getting care from APRA Durable Medical Equipment (DME) Disposable medical supplies (DMS) WHO CAN GET THIS BENEFIT All Members Members under age 21 All Members Services We Do Not Pay For Exclusions are benefits and/or services that are not paid for by Trusted or DC Medicaid. They include the following: Cosmetic surgery Experimental or investigational services, surgeries, treatments, and medications Services that are part of a clinical trial protocol Abortion, or the voluntary termination of a pregnancy, not required under Federal law Infertility treatment Sterilizations for persons under the age of 21 Services that are not medically necessary 32 Trusted Member Services (202)

33 Other Important Information What to do if you move Call the District of Columbia (DC) Economic Security Administration (ESA) Change Center at Call Trusted Member Services at (202) What to do if you have a baby Call DC Economic Security Administration (ESA) Change Center at Call Trusted Member Services at (202) or (855) (toll free) What to do if you adopt a child Call DC Economic Security Administration (ESA) Change Center at What to do if someone in your family dies Call DC Economic Security Administration (ESA) Change Center at Call Trusted Member Services at (202) Call ESA at Member AND Member Services at (202) if: You move You have a baby Someone in your family dies How to change your Managed Care Organization You can change you MCO once a year, or at any time if you have a good reason. You can change your MCO once a year during the 90 days before your anniversary date the month and date you first joined Trusted. D.C. Healthy Families will send you a letter two months before your anniversary date. The letter tells you how to change MCOs. 33 Trusted Member Services (202)

34 Changing Your MCO If You Have a Good Reason You have the right to change your MCO at any time after the first 90 days if you have a good reason. Examples of good reasons are poor quality of care and you can t see the providers you need. Call DC Healthy Families at if you would like more information on how to change MCOs. You will not be allowed to get health care from Trusted anymore if you: Lose your Medicaid eligibility Establish Social Security Income (SSI) eligibility A child will be removed from Trusted if the child: Becomes a ward of the District The D.C. government may remove you from Trusted if you: Let someone else use your Member ID Card; The District finds you committed Medicaid fraud; or You do not follow your Member responsibilities. What to do if you get a bill for a covered service If you get a bill for a covered service that is in the list above, call Member Services at (202) Paying for Non-Covered Services If you decide you want a service that we do not pay for and you do not have written permission from Trusted you will have to pay for the service yourself. If you decide to get a service that we do not pay for, you must sign a statement that you agree to pay for the service yourself. Remember to always show your Member ID Card and tell doctors that you are a Member of Trusted before you get services. Advance directives An advance directive is a legal document you sign that lets others know your health care choices. It is used when you are not able to speak for yourself. Sometimes this is called a living will or a durable power of attorney. 34 Trusted Member Services (202)

35 An advance directive can let you pick a person to make choices about your medical care for you. An advance directive also lets you say what kind of medical treatment you want to receive if you become too ill to tell others what your wishes are. It is important to talk about an advance directive with your family, your PCP, or others who might help you with these things. If you want to fill out and sign an advance directive, ask your PCP for help during your next appointment, or call Member Services at (202) and they will help you. What to do if you have other insurance If you are a Member of Trusted and eligible for Medicaid, you must tell us right away if you have any other health insurance. Please call Member Services at (202) and tell us right away. What to do if you are eligible for both Medicaid and Medicare If you have Medicare and Medicaid, please tell Trusted so you can pick Medicare providers. If you have Medicare, you will have to sign up for Medicare Part D for your prescription drugs. Medicaid will pay your co-pays. See page 44 of this handbook for more information. Physician (doctor) incentive plan disclosure You have the right to find out if Trusted has special financial arrangements with Trusted s doctors. Please call Trusted Member Services at (202) for this information. Complaints/Grievances, Appeals and Fair Hearings Trusted and the D.C. government both have ways that you can complain about the care you get or the Services Trusted provides to you. You may choose how you would like to complain as described below. Complaints/Grievances If you are unhappy with something that happened to you, you can file a Complaint/Grievance. Examples of why you might file a Complaint/Grievance include: You feel you were not treated with respect You are not satisfied with the health care you got It took too long to get an Appointment To file a Complaint/Grievance, you should call Member Services at (202) or (855) (toll free). Your doctor can also file a Complaint/Grievance for you. You should file a Complaint/Grievance as soon as possible and no later than 90 days after the thing you are unhappy about. Trusted will usually give you a decision within 30 days but may ask for extra time (but not more than 44 days total) to give a decision. 35 Trusted Member Services (202)

36 Appeals and Fair Hearings If you believe your benefits were unfairly denied, reduced, delayed or stopped, you have a right to file an Appeal with Trusted and request a Fair Hearing with the D.C. s Office of Administrative Hearings. To file an Appeal with Trusted call Member Services at (202) To file a request for a Fair Hearing, call or write the District government at: Deadlines District of Columbia Office of Administrative Hearings Clerk of the Court 441 4th Street, NW N450 Washington, DC Telephone Number: You must file an Appeal or request a Fair Hearing within 90 days of getting Trusted s notice of action. If you want to continue receiving the benefit during your Fair Hearing or Appeal, you must request the Fair Hearing or Appeal within the later of the following: Within 15 days from Trusted postmark of the Notice of Action or The intended effective date of Trusted s proposed action (or, in other words, when the benefit is to stop). Your provider may file an Appeal or request for a Fair Hearing on your behalf. Appeals If you call and give your Appeal over the phone, Trusted will summarize your Appeal in a letter and send you the letter for you to sign. Be sure to read the letter carefully. You must sign the letter and return it to the Trusted in order to have an Appeal. Your Appeal will be decided by Trusted within 14 calendar days from the date your Appeal was received. If Trusted needs more time to get information and the District decides this would be best for you, or if you or your Advocate requests more time, Trusted may increase this time period for the decision by 14 calendar days. Trusted must give you written notice of the extension. You will receive written notice of Trusted s decision about your Appeal in the mail. If you are not happy with Trusted s decision about your Appeal you may request a Fair Hearing. Expedited (Emergency) Complaints/Grievances and Appeals process If your Appeal is determined to be an emergency, Trusted will give you a decision within 3 calendar days. An Appeal is considered an emergency if it would be harmful or painful to you if you had to wait for the standard time frame of the Appeal procedure. 36 Trusted Member Services (202)

37 All Appeals filed by Members with HIV/AIDS, mental illness or any other condition that requires attention right away, will be resolved and communicated back to the Member within 24 hours of filing the Appeal. Your rights during the Complaints/Grievances, Appeals and Fair Hearings process You have the right to a Fair Hearing. You may request a Fair Hearing from the Office of Administrative Hearings at any time before, during or after you have filed an Appeal with Trusted, but no more than ninety (90) days from the date Notice of Action is mailed. You have a right to keep receiving the benefit we denied while your Appeal or Fair Hearing is being reviewed. To keep your benefit during a Fair Hearing, you must request the Fair Hearing within a certain number of days - This could be as short as 10 days. You have the right to have someone from Trusted help you through the Grievance and Appeals process. You have a right to represent yourself or be represented by your family caregiver, lawyer, or other representative. You have a right to have accommodations made for any special health care need you have. You have a right to adequate TTY/TTD capabilities, and Services for the visually impaired. You have a right to adequate translation Services and an interpreter. You have a right to see all documents related to the Complaint/Grievance, Appeal or Fair Hearing. If you have any questions about the Complaints/Grievances and Appeals/Fair Hearings process, please call Member Services at (202) The District s Ombudsman Program The Ombudsman Program is a District of Columbia government program that provides assistance and advice to you in receiving health care from your MCO. The Ombudsman can: Explain the health care you have a right to receive; Respond to your questions and concerns about your health care; Help you understand your rights and responsibilities as an Enrollee in an MCO; Provide assistance in getting you the health care you are supposed to have; Answer questions and concerns you may have about the quality of your health care; Help you resolve problems with your doctor or other health care provider; and Provide assistance in resolving complaints and problems with Trusted; and 37 Trusted Member Services (202)

38 Assist with the appeal process. To reach the Ombudsman Program, call or (Toll Free). The Ombudsman Program does not make decisions in grievances/complaints, appeals or fair hearings. The Office of Health Care Ombudsman & Bill of Rights is located at: 899 North Capitol Street, N.E. 6 th Floor Washington, D.C (202) (OFFICE) (202) (FAX) 1 (877) (TOLL FREE) healthcareombudsman@dc.gov ( ) (WEBSITE) 38 Trusted Member Services (202)

39 Notice of Privacy Practices This Notice describes how medical information about you may be used and disclosed, and how you can get this information. Please read it carefully. Why Are You Giving This Notice to Me? Trusted Health Plan knows that information about you and your health is personal, and we are required by the federal Health Insurance Portability and Accessibility act (HIPAA) to tell you what your responsibilities are and what rights you have under the law. What is Trusted Health Plan Required to do Under HIPAA? Make sure that your protected health information is kept private; Give you this notice to tell you about our legal duties and privacy practices with respect to your PHI; and Follow the terms of this notice. What is Protected Health Information (PHI) Protected Health Information (PHI) is defined as any oral, written or electronic information that: Identifies you or can be used to identify you. Either comes from you or has been created or received by a health care provider, a health plan, or a healthcare clearinghouse. Has to do with your physical and/or mental health or condition, providing health care to you, or paying for providing health care to you. In this notice, protected health information will be written as PHI. How Can You Use or Share my PHI? There are laws that allow or require us to use or disclose your PHI for many reasons. This Notice tells you how we may use and disclose your PHI. While not every use or disclosure is listed, the ways we may use to share your PHI falls within one of the descriptions below. For Treatment: We may use and share your PHI for treatment. For example, we may use or share your PHI to enroll you in a disease management program, or to share it with your case manager. For Payment to Caregivers: We may use and share your PHI in order to pay for health care you receive. For example, a bill that we may receive from your doctor may have information on it that identifies you, the nature of your illness, the treatment or tests given to you and the supplies that might have been used. 39 Trusted Member Services (202)

40 For Health Care Operations: We may use and share your PHI to run our business. We protect your PHI by limiting access to it within our Plan. Only our employees directly involved in our business activities that require access to your PHI are authorized to see or discuss your PHI. For example, we may use your PHI to review and improve the quality of healthcare services you receive. In addition, Trusted shares your PHI with our business partners; however, they are under the same obligations to protect your PHI as Trusted is. For Another Covered Entity s Needs: We may share your PHI with another covered entity, such as a doctor or health plan, for their treatment or payment use. For example, we may share your PHI with a health plan to help them pay for your care. We may also share your PHI with them so that they can do certain business tasks if you have or have had a relationship with them. To remind you of appointments and health-related benefits or services: We may use your PHI to send you appointment reminders. We may use PHI to tell you about other health care treatment, services, or benefits. To comply with the law: We will share your PHI when we are required by law to do so. We will share PHI when we are required to in a court or other legal proceeding. For example, we will disclose PHI if a law says that we must report PHI about people who have been abused. To report public health activities: We will share PHI with government officials in charge of collecting certain PHI. For example, we may share PHI about births, deaths, and some diseases. For health oversight activities: We may share PHI if a government agency conducting activities approved or required by law, such as audits, investigations, licensure or disciplinary actions. Oversight agencies include government agencies that look after the health care system, benefit programs, including Medicaid, SCHIP, or Healthy Kids, and government regulation programs. For purposes of disposition of your remains: We may share your PHI with coroners, medical examiners, and funeral directors. If permitted by law, we may also share PHI with organizations that help find organs, eyes, and tissue to be donated or transplanted. To avoid harm: In order to avoid a serious threat to the health or safety of a person or the public, we may provide PHI to law enforcement or others who may be able to stop or lessen the harm. 40 Trusted Member Services (202)

41 For certain government functions: We may share PHI for national security reasons. For example, we may share PHI to protect the President of the United States. For Workers Compensation: We may share PHI to obey workers compensation laws. Lawsuits and disputes: If you are involved in a lawsuit or a dispute, we may share PHI about you in response to a court or administrative order or other lawful process. For research: We may share your PHI with researchers when an institutional review board or privacy board as followed the HIPAA information requirements. Other Uses and Sharing of Your Health Information: We will ask for your written permission, called as an authorization, before we make any use or disclosure of your PHI not described in this notice. If you give us your written permission, you may still decide later that you no longer want us to use or disclose your PHI in that way. If you change your mind, you must tell us in writing. We will then stop using your PHI in that way. Will You Give my PHI to my Family, Friends, or Others? We may share PHI about you with a friend or family member who is involved with your care or who helps pay for your care when you are present. For example, if one of our case managers visits you in the hospital and our mother is with you, we may discuss your PHI with you in front of her. We will not discuss your PHI with others if you tell us not to. There may be times when you are not present or are unable to make healthcare decisions. If this should happen, we may share your PHI if we think it is best for you. For example, we may share PHI with someone who is with you when you are unconscious so that you can receive care. What are my Rights Under Federal Law with Respect to my PHI? The law gives you the following rights regarding your PHI. To receive these rights, please call Member Services. 1. You can see or get copies of some of your PHI Sometimes your right to see or get copies of your PHI may be limited. You must ask us in writing. We may charge a fee for copying and mailing the PHI. 2. You may ask us to limit our uses and disclosures for purposes of treatment, payment or healthcare operations. We are not required to agree to the request. You may also ask us to limit 41 Trusted Member Services (202)

42 disclosures to someone who is involved in our care or payment for your care, like a family member or friend. 3. You may ask us to send your PHI to another address if it is necessary to protect you from danger. You may ask us to communicate with you in a certain way if it is necessary to protect you from danger. For example, you may ask us to send PHI to you at work instead of at home. You may ask us to send your PHI by rather than regular mail. You must tell us in writing what you want. You must tell us that you could be in danger if we do not agree to your request. 4. You can get a list of certain disclosures we have made of your PHI. The list will only include disclosures made after April 14, The list will not include certain types of disclosures. We will give you one list free during any 12 month period. You will need to pay for any additional lists during that time. 5. You may ask us to correct your PHI if you think there is a mistake. You must ask us in writing and tell us why you want us to correct the information. 6. You may get a paper copy of this notice at any time. To obtain a paper copy of this notice, please call Member Services. May I Complain about Your Privacy practices? Yes! YOU WILL NOT BE PUNISHED FOR FILING A COMPLAINT. If you think we violated your privacy rights you may file a complaint. You must send your written complaint to: Trusted Health Plan 1100 New Jersey Ave., SE Ste. 840 Washington, DC You may send a written complaint to the Secretary of the Department of Health and Human Services (DHHS) at: Office for Civil Rights 200 Independence Avenue, SW Washington, DC You may also call DHHS at (877) How will I know if my rights change? We may change this notice and our privacy policies at any time. Then the new notice will apply to all of your PHI. We will make the new notice available to you at all times. The new notice will contain the new effective date. If you have any questions about this notice, please contact Member Services at (202) Trusted Member Services (202)

43 Medicare Part D Notice to Members For Members with both Medicare and Medicaid If you get Medicare and Medicaid at the same time, beginning on January 1, 2006, you will get your medicines from the Medicare Part D program. Trusted will only cover your medicines for Certain over -the -counter drugs Barbiturates Benzodiazepines If you have any questions about your medicines please call Trusted s Member Services. If you have questions about Medicare Part D you can also call Medicare at MEDICARE ( ) or visit the website. 43 Trusted Member Services (202)

44 What Some Words Mean Advance Directive A written, legal paper that you sign that lets others know what health care you want, or do not want, if you are very sick or hurt and cannot speak for yourself Advocate Appeal Appointment Care Manager Check-Up Complaint Contraception Covered Services Detoxification Development Disease Management Program Durable Medical Equipment A person who helps you get the health care and other Services you need An appeal is a special kind of complaint you make if you disagree with a decision Trusted makes to deny a request for health care services or payment for services you already received. You may also make this kind of complaint if you disagree with a decision to stop services that you are receiving A certain time and day you and your doctor set aside to meet about your health care needs Someone who works for Trusted and will help those people in the Disease Management Program get the care and information they need to stay healthy See Screening See Grievance Birth control Health care Services that Trusted will pay for Getting rid of harmful substances from the body such as drugs and alcohol The way in which your child grows A program to help people with chronic illnesses or Special Health Care Needs such as asthma, high blood pressure or mental illness get the care and Services they need Special medical equipment that your doctor may ask or tell you to use in your home 44 Trusted Member Services (202)

45 Emergency Care EPSDT Fair Hearing Family Planning Family and General Practice Doctor Grievance Handbook Health Check Program Hearing Impaired IDEA Immunization Internal Medicine Doctor Interpretation/Translation Services Managed Care Organization (MCO) Managed Care Plan Maternity Care you need right away for a serious, sudden, sometimes life-threatening condition Early, Periodic Screening, Diagnosis and Treatment Program (also called Health Check Program) that gives health care to members under 21 years old If you file a Grievance/Complaint you can ask for a hearing with D.C.'s Office of Administrative Hearings Services such as pregnancy tests, birth control, testing and treatment for sexually transmitted diseases, and HIV/AIDs testing and counseling A doctor that can treat the whole family If you are unhappy with the care you get or the health care services Trusted gives you, you can call Member Services to file a Grievance/Complaint This book that gives you information about Trusted and our services See EPSDT If you cannot hear well, or if you are deaf Individuals with Disabilities Education Act; a federal law that gives services to children with developmental delays and special health care needs Shot, vaccine Doctor for adults and children over 14 years old Help from Trusted when you need to talk to someone who speaks your language, or you need help talking with your doctor or hospital A company that is paid by the District of Columbia to give you health care and health services A plan that gives you a list of Providers that you can see The time when a woman is pregnant 45 Trusted Member Services (202)

46 Member Member Identification Card Mental Health Network Providers Non-Covered Services OB/GYN Out-of-Network Providers Pediatrician Pharmacy Physician Incentive Plan Post Partum Care Prenatal Care Prescription Preventive Counseling Primary Care Provider (PCP) Prior Authorization Provider Directory Providers Referral The person who gets health care from Trusted The card that lets your doctors, hospitals, drug stores, and others know that you are a member of Trusted How a person thinks, feels and acts in different situations Doctors, nurses, dentists, and other people who take care of your health who are a part of Trusted Health care that Trusted does not pay for Obstetrician/Gynecologist; a doctor who is trained to take care of a woman s health, including when she is pregnant Doctors, nurses, dentists, and other people who take care of your health who are not a part of Trusted A children's doctor The store where you pick up your medicine Tells you if your doctor has any special arrangements with Trusted Health care for a woman after she has her baby Care that is given to a pregnant woman the whole time she is pregnant Medicine that your doctor orders for you; you must take the it to the pharmacy/drugstore to pick up the medicine When you want to talk to someone about ways to help you stay healthy or keep you from getting sick or hurt The doctor that takes care of you most of the time Written permission from Trusted to get health care or treatment that is not usually paid for by Trusted A list of all providers who are part of the Trusted Doctors, nurses, dentists, and other people who take care of your health When your main doctor gives you a written note that sends you to see a different doctor 46 Trusted Member Services (202)

47 Routine Care Screening Self-Referral Services Services Special Health Care Needs Specialist Specialty Care Sterilization Procedures Transportation Services Treatment Urgent Care Visually Impaired The regular care you get from your primary care provider or a doctor that your primary care provider sends you to. Routine Care can be a Check- Up, physical, health screen, and regular care for health problems like diabetes, asthma and hypertension A test that your doctor or other health care provider may do to see if you are healthy. This could be a hearing test, vision test, or a test to see if your child is developing normally Certain services you can get without getting a written note or Referral from your main doctor The care you get from your doctor or other health care Provider Children and adults who need health care and other services that are more than or different from what other children and adults need A doctor who is trained to give a special kind of care like an ear, nose and throat doctor or a foot doctor Health care provided by doctors or nurses trained to give a specific kind of health care A surgery you can have if you do not want children in the future Help from Trusted to get to your appointment, which can include bus or metro tickets, tickets to pay for a taxi, wheel chair vans, or ambulances. The type of transportation you get depends on your medical needs The care you get from your doctor Care you need within 24 hours, but not right away If you cannot see well or you are blind 47 Trusted Member Services (202)

48 Trusted Member Services (202)

49 Nos puede llamar las 24 horas del día, los 7 días de la semana, o visitar nuestra oficina de lunes a viernes de 8:00 a.m. a 5:30 p.m. Para obtener instrucciones sobre cómo visitarnos, llame al (202) Trusted Health Plan 1100 New Jersey Ave., SE Ste. 840 Washington, DC DC Healthy Family Servicio para Afiliados (202) Llamada gratuita: (855)

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51 Números Telefónicos Importantes (Arranque esta página y manténgala cerca de su teléfono) Si tiene preguntas sobre Trusted, llame a: Servicios para Afiliados (202) O (855) De Lunes a Viernes de 8:00 a.m. a 5:30 p.m. Si necesita atención fuera del horario de atención del consultorio de su médico o si tiene alguna pregunta para hacerle a una enfermera, llame a: Si necesita atención de salud mental o tiene una pregunta sobre la salud mental, llame a: Si necesita visitar un médico dentro de un período de 24 horas ( Atención de Urgencia ) llame a: Si necesita alguien que hable su idioma o si tiene Problemas Auditivos, llame al: Si usted necesita transporte para asistir a una Cita, llame a: Servicios TTY/TDD para Afiliados (202) De Lunes a Viernes de 8:00 a.m. a 5:30 p.m. Línea de Asistencia Telefónica de Enfermería Línea de Asistencia Telefónica de Enfermería con Servicio TTY/TDD El Consultorio de su PCP Línea de Asistencia Telefónica de Enfermería Línea Directa de Asistencia Telefónica del Departamento de Salud Mental de DC El Consultorio de Su PCP Línea de Asistencia Telefónica de Enfermería (855) las 24 horas del día, los 7 días a la semana (855) las 24 horas del día, los 7 días a la semana (Complete la información de su PCP aquí) las 24 horas del día, los 7 días a la semana 1-(888) las 24 horas del día, los 7 días a la semana (Complete la información de su PCP aquí) (855) las 24 horas del día, los 7 días a la semana Servicios para Afiliados (202) O (855) De Lunes a Viernes de 8:00 a.m. a 5:30 p.m. Servicios TTY/TDD para Afiliados (202) De Lunes a Viernes de 8:00 a.m. a 5:30 p.m. MTM :00am-6:00pm M-F (gratuitamente) 9:00am - 3:00pm (Sáb. Horario Extraordinario para Emergencias DentaQuest (855) De Lunes a Viernes de 8:00 Si tiene preguntas sobre Odontología: a.m. a 5:30 p.m. Si tiene preguntas sobre EyeQuest (855) De Lunes a Viernes de 8:00 Oftalmología: a.m. a 5:30 p.m. EN CASO DE EMERGENCIA, LLAME AL 911 O ACUDA A LA SALA DE EMERGENCIAS MÁS CERCANA Su médico Principal: Teléfono: Médico Principal de su niño: Médico Principal del otro niño: Teléfono: Teléfono: 2 Servicios para Afiliados de Trusted (202)

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53 Bienvenido a Trusted Health Plan Gracias por elegir a Trusted Health Plan, Inc., (Trusted), como su Organización de Asistencia Médica Administrada (MCO, por sus siglas en inglés) de Medicaid. Nuestro compromiso es proporcionarle una atención sanitaria de calidad y brindarle un excelente servicio de atención al cliente. Este Manual del Afiliado contiene información importante sobre Trusted y sobre cómo funciona nuestro plan. Le solicitamos revisarlo cuidadosamente. Como afiliado de Trusted obtendrá grandes beneficios y servicios. Si Trusted modifica la forma en la que funciona o si se recibe información sobre sus proveedores de servicios médicos que usted necesita saber, (como por ejemplo, quiénes son los médicos que estén aceptando nuevos pacientes y el horario de atención de los consultorios médicos), se le informará sobre el cambio 30 días antes de que suceda. Los nuevos afiliados recibirán una invitación para asistir a nuestra Orientación para Nuevos Afiliados, en su paquete para Nuevos Afiliados, así como también, una llamada de bienvenida. La Orientación para Nuevos Afiliados es una forma de proporcionarle personalmente la información sobre cómo puede aprovechar al máximo el sistema de atención sanitaria y de responderle las preguntas que pueda tener. 3 Servicios para Afiliados de Trusted (202)

54 Cómo Funciona este Manual Trusted es un plan de servicio médico administrado pagado por el Distrito de Columbia para ayudarle a obtener atención sanitaria. En este Manual le informamos cómo funciona Trusted, cómo buscar los médicos, cómo llamarnos y cuáles gastos médicos son los que se cubren. Informarle sobre estos temas puede ser algo difícil de hacer; y difícil de leer para cualquier persona. Las palabras que se utilizan en la atención sanitaria y aquellas que son utilizadas por su médico a veces pueden ser difíciles de comprender. A veces debemos informarle sobre las leyes que necesita conocer. Estas también pueden ser difíciles de entender. Para brindarle ayuda, hemos subrayado algunas palabras que pueden tener un significado diferente del que usted conoce. Hemos explicado el significado de estas palabras en el dorso de este libro. Si alguna vez tiene preguntas sobre los temas que lee en este libro o si tiene otras preguntas sobre Trusted, puede comunicarse con el Servicio para Afiliados de Trusted llamando al (202) o visitando nuestro sitio y haremos todo lo posible para ayudarle. Cómo este Manual de Afiliados puede ayudarle Este Manual de Afiliados le dice: Cómo obtener atención médica Qué Servicios pagaremos (a esto le llamamos, qué Servicios están "cubiertos" por nosotros) Qué Servicios no podemos pagar Cómo elegir a su Proveedor de atención primaria (su PCP) Qué hacer si usted se enferma Lo que usted debe hacer si usted tiene una Queja (también llamado un Reclamo ) o desea cambiar ( Apelar ) una decisión por Trusted Este Manual del Afiliado le brinda información básica sobre cómo funciona Trusted y sus reglas. Por favor llame al Servicio para Afiliados de Trusted si tiene preguntas las 24 horas del día, los 7 días de la semana. 4 Servicios para Afiliados de Trusted (202)

55 Índice Números Telefónicos Importantes... 2 Bienvenido a Trusted Health Plan... 3 Cómo Funciona este Manual... 4 Sus Derechos y Responsabilidades... 7 Su Tarjeta de ID de Afiliado... 9 Su Proveedor de Atención Primaria (PCP) Elección de su PCP Cómo cambiar su PCP Atención de Rutina, Atención de Urgencia y Atención de Emergencia QUÉ HACER SI TIENE UNA EMERGENCIA: Cuando se encuentre fuera de la ciudad: Proveedores de Trusted y Proveedores que no forman parte de Trusted Concertar una Cita Concierte una Cita con su PCP Para cambiar o cancelar una Cita Para recibir atención médica cuando el consultorio de su PCP está cerrado Cuánto tiempo lleva ver a su médico Servicios de Apoyo Servicios de Interpretación y Traducción/Servicios para personas con problemas auditivos y de visión Servicios de Interpretación Servicios de Traducción Servicios para personas con Problemas Auditivos y de Visión Servicios de Transporte Atención Especializada y Derivaciones Cómo obtener atención médica especializada Servicios de Auto-Derivación NO necesita una Derivación para: Servicios de Salud Mental Servicios para problemas con el alcohol u otras drogas Servicios para Afiliados de Trusted (202)

56 Control de la natalidad y otros Servicios de Planificación Familiar Servicios de farmacia y medicamentos recetados Administración de Enfermedades Servicios de Prevención de Enfermedades para Adultos Recomendaciones para los Exámenes de Control ( Exámenes de Detección ) Asesoría preventiva Inmunizaciones para Adultos Embarazo Atención Prenatal y de Posparto Una vez haya tenido su bebé, llame a: La Salud de su Niño Programa de Control de Salud para Niños (EPSDT) Servicios para Afiliados de Trusted (202)

57 Sus Derechos y Responsabilidades Usted tiene derecho a: Ser tratado con respeto y dignidad Mantener la privacidad de sus conversaciones con sus médicos y con otros proveedores Recibir una explicación sobre una enfermedad o tratamiento en un idioma que pueda comprender Participar en las decisiones sobre su atención médica Recibir una explicación detallada, clara y comprensible sobre las opciones de tratamiento y los riesgos de cada opción para que pueda tomar una decisión fundamentada Rehusar el tratamiento o atención médica Permanecer libre de restricciones físicas y químicas Poder ver su historial clínico y solicitar que se corrija si está incorrecto Elegir un PCP que cumpla con los requisitos dentro de la red de Trusted y cambiar su PCP Presentar un Reclamo ( Denuncia ) sobre la atención médica que se le proporcionó y recibir una respuesta al respecto Solicitar una Apelación o una Audiencia Imparcial si cree que Trusted se equivocó al negar, reducir o suspender un servicio o elemento Recibir Servicios de Planificación Familiar y suministros del proveedor de su elección Obtener atención médica sin retraso innecesario Recibir información sobre directivas anticipadas y elegir no recibir o continuar cualquier tratamiento que prolongue su vida Recibir una copia de este Manual del Afiliado de Trusted Continuar el tratamiento que está recibiendo en la actualidad hasta que reciba un nuevo plan de tratamiento Recibir los Servicio de interpretación y traducción sin cargo si lo necesita Rechazar los Servicios de interpretación Obtener una explicación sobre los procedimientos de autorización previa Recibir información sobre la situación financiera de Trusted y sobre cualquier método especial que utilicemos para pagarle a nuestros médicos Obtener resúmenes de encuestas de satisfacción del cliente Recibir la política de Trusted Preparar según lo escrito para los medicamentos de prescripción 7 Servicios para Afiliados de Trusted (202)

58 Usted tiene la responsabilidad de: Tratar a los que le presten atención médica con respeto y dignidad Respetar las reglas de DC Programa de Servicios Médicos Administrados de Medicaid y Trusted Seguir las instrucciones que reciba de sus médicos y demás proveedores Asistir a las Citas que programó o que Trusted programó para usted Avisar a su médico al menos con 24 horas de anticipación si necesita cancelar su Cita Solicitar una mayor explicación si no comprende las instrucciones de su médico Ir a la Sala de Emergencias sólo si tiene una emergencia médica Comunicar a su PCP sobre los problemas médicos y personales que pueden afectar a su salud Informar a la Administración de Mantenimiento de Ingresos (ESA, en inglés) y a Trusted si usted o un miembro de su familia tiene otro seguro de salud Tratar de entender sus problemas de salud y participar en el desarrollo de los objetivos de su tratamiento Ayudar a su médico a obtener su historial clínico de los proveedores que le han prestado sus servicios en el pasado Informar a Trusted si se lesionó como consecuencia de un accidente o en su trabajo 8 Servicios para Afiliados de Trusted (202)

59 Su Tarjeta de ID de Afiliado Después que se haya inscrito en Trusted y haya elegido un proveedor de atención primaria (PCP), le enviaremos una Tarjeta de ID de Afiliado por correo. Esta tarjeta hará saber a sus médicos, hospitales, farmacias y demás proveedores que usted es un Afiliado de Trusted. Por favor, asegúrese de que la información que aparece en su Tarjeta de Identificación de Afiliado esté correcta. Si hay algún problema, o si ha perdido su tarjeta, llame al Servicio para Afiliados al (202) o al (855) (llamada gratuita). Su Tarjeta de ID de Afiliado Luce Así Cada Afiliado de Trusted tiene su propia tarjeta. Sus niños también deberán tener sus propias tarjetas, usted deberá guardar las tarjetas de sus hijos para que no se pierdan. Es contra la ley permitir que alguna otra persona utilice su Tarjeta de ID de Afiliado o su Tarjeta de Medicaid. Recuerde llevar consigo su Tarjeta de ID de Afiliado todo el tiempo. Siempre muestre su tarjeta antes de recibir cualquier atención médica u obtener medicamentos en una farmacia. También asegúrese de guardar su Tarjeta de Medicaid. 9 Servicios para Afiliados de Trusted (202)