CHIP. CHIP Member Handbook. CHIP Manual para Miembros. CHIlDrEN S HEAlTH INSUrANCE PrOGrAM

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1 CHIP Member Handbook CHIlDrEN S HEAlTH INSUrANCE PrOGrAM CHIP Manual para Miembros CHIP Including CHIP CHIP Perinate and and Perinate Newborn For For more more information, please please call call Para Para más más información, por por favor, favor, llame llame al al A product A product of of Parkland Community Health Health Plan, Plan, Inc. Inc. Dallas Dallas Service Service Area October Área Área de servicio de servicio de de Dallas Octubre de 2013 de 2013 TXP ENG/SPA

2 This book belongs to: My Child s Primary Care Provider (PCP) is: My Child s PRIMARY CARE PROVIDER s address is: My Child s PRIMARY CARE PROVIDER s telephone number is: Member Handbook for Parkland KIDSfirst and Parkland CHIP Perinate Newborn Parkland KIDSfirst/CHIP Perinate Newborn uses the services of Aetna Life Insurance Company (Aetna). Aetna is not the insurer or sponsor of Parkland KIDSfirst/CHIP Perinate Newborn. i 009MS-MH Member Services / TTY

3 Important Phone Numbers and Addresses Call us: Write us: Parkland KIDSfirst Member Services (toll-free), 8:00 AM to 5:00 PM, Monday through Friday (except for State-approved holidays) English/Spanish and Language Line Interpreter Services available Phones answered by Nurse Line or leave voic after hours Parkland Community Health Plan, Inc. Attention: Parkland KIDSfirst and Parkland CHIP Perinate Newborn Member Services P.O. Box Dallas, TX Behavioral Health Services CHIP: Call Beacon at (includes mental health and For emergencies, call or go to the nearest Emergency substance abuse, English/ Room, or call toll-free for help. Spanish interpreter available CHIP Perinate Newborn: Call Member Services hours/ day, 7 days/week) For emergencies, call or the Parkland Nurse Line tollfree at for help. CHIP Help Line: CHIP Dental Plans: Emergencies: Parkland 24-hour Nurse Line: DentaQuest MCNA Dental Plans Call or go to the nearest hospital emergency room or (bilingual and Language Line offered) Prescription Drugs: Call Member Services toll-free TD/TTY: For persons who are deaf or hard of hearing, please call the Relay Texas TDD/TTY line at and ask them to call our Member Services Line at Vision Services CHIP: Call Block Vision at CHIP Perinate Newborn: Call Website: ii 009MS-MH Member Services / TTY

4 WELCOME TO OUR PARKLAND KIDSfirst and Parkland CHIP Perinate Newborn Members!!! Dear Parkland KIDSfirst and Parkland CHIP Perinate Newborn Members: Thank you for choosing Parkland KIDSfirst and Parkland CHIP Perinate Newborn! Parkland KIDSfirst and Parkland CHIP Perinate Newborn are offered by Parkland Community Health Plan, Inc. (PCHP), a licensed Health Maintenance Organization (HMO) in the State of Texas that makes it easier for you to get good medical care for your child. Through Parkland KIDSfirst and Parkland CHIP Perinate Newborn, we are pleased to offer your child all the benefits offered in the State of Texas s Children s Health Insurance Program (or CHIP ) plus expanded and value-added benefits. Information on eligibility and benefits are included in this Member Handbook. You picked your child s doctor or clinic when you joined Parkland KIDSfirst. If your baby is a Parkland CHIP Perinate Newborn member, you will need to pick your baby s doctor or clinic. This doctor or clinic you picked is your child s Primary Care Provider and will be your child s medical home. Here are a few important things you need to do to help us give your children the best care: Check the ID card to make sure we have the right information. Your child s Primary Care Provider s name will be on your child s Parkland KIDSfirst or Parkland CHIP Perinate Newborn ID Card. Make any necessary appointments and get to know your child s Primary Care Provider Call your child s Primary Care Provider for appointments and tell them your child is a Parkland KIDSfirst or Parkland CHIP Perinate Newborn member. Call your child s Primary Care Provider when your child needs care. Follow your child s Primary Care Provider s advice. Carry your child s Parkland KIDSfirst or Parkland CHIP Perinate Newborn ID card with you at all times. Use the hospital Emergency Room (ER) only for emergencies. We have nurses and other staff who can speak English and Spanish and are ready to help your child at any time day or night. We have special services for people who have trouble reading, hearing, seeing, or speaking a language other than English or Spanish. You can ask for the Member Handbook in audio, other languages, Braille or larger print. If you need an audiocassette or CD, we will mail it to you. To get help, just call Member Services toll-free at You may also visit our website at We wrote this Member Handbook to answer most of your questions about Parkland KIDSfirst and Parkland CHIP Perinate Newborn. We hope you read it right away and keep it handy. Please feel free to call or write us if you have any questions or would like to make suggestions. iii 009MS-MH Member Services / TTY

5 DO YOU HAVE QUESTIONS? TABLE OF CONTENTS WE HAVE ANSWERS!... ON PAGE Important Numbers ii Member ID Card What if I need help understanding or reading the Member Handbook? 1 Information about the Parkland KIDSfirst and Parkland CHIP Perinate Newborn Identification Card (ID Card) 1 How to read your child s Parkland KIDSfirst and Parkland CHIP Perinate Newborn ID Card 2 How to use your child s Parkland KIDSfirst and Parkland CHIP Perinate Newborn ID Card 2 What if my child s Parkland KIDSfirst or Parkland CHIP Perinate Newborn ID Card gets lost? 2 Primary Care Providers for CHIP and CHIP Perinate Newborn Members What do I need to bring to my/my child's doctor's appointment? 3 What is a Primary Care Provider? 3 How do I choose my/ my child s Primary Care Provider? Can a clinic be my/my child s Primary Care Provider? 3 What about a PCP for a Child with Special Health Care Needs (CSHCN)? 4 How can I change my/my child s Primary Care Provider? How many times can I change my/ my child s Primary Care Provider? 4 When will a Primary Care Provider change become effective? 4 Are there any reasons why my request to change a Primary Care Provider may be denied? 5 Can a Primary Care Provider request that I/my child be changed to another Primary Care Provider for non-compliance? 5 What if I choose to go to another doctor who is not my/ my child s Primary Care Provider? 5 Physician Incentive Plans 6 Changing Health Plans/Concurrent Enrollment in CHIP and CHIP Perinatal Programs What if I want to change health plans? When will the change be effective? Who do I call? 6 How do I renew my/my child s CHIP coverage? 7 Can Parkland Community Health Plan ask that I/my child get dropped from their health plan? 8 Benefits for CHIP and CHIP Perinate Newborn Members What are the CHIP and CHIP Perinatal Benefits? What is Medically Necessary? 8 How do I get these services for me or my child? 22 What benefits does my baby get at birth? 23 What benefits are not covered? 23 What are Co-Payments? How much are they and how do they apply? 28 What about other services or programs? 29 What extra benefits does a member of Parkland KIDSfirst or Parkland CHIP Perinate Newborn get? 29 What health education classes does Parkland Community Health Plan offer? 30 How can I get these extra benefits for myself or my child? 30 Health Care & Other Services for CHIP and CHIP Perinate Newborn Members How do I/my child get routine care? What is routine medical care? How soon can I/my child expect to be seen? 31 What if I/my child needs urgent care? What is urgent medical care? How soon can I/my child expect to be seen? 31 iv 009MS-MH Member Services / TTY

6 What if I/my child has an emergency? What is emergency medical care? How soon can I/my child expect to be seen? 32 Are emergency dental services offered? 33 What is post-stabilization?) 33 What if I/my child needs care at night or on a weekend? (How do I get medical care after my/my child s Primary Care Provider s office is closed? 33 What if I/my child gets sick while we are out of town or traveling out of state? What if I/ my child is out of the country? 34 What if I/my child needs to see a special doctor (specialist)? How soon can I/my child expect to be seen by a specialist? 34 What is a referral and what services do not need a referral? 34 How can I ask for a second opinion? 35 How do I get my/my child s medications? 35 How do I/my child get eye care services? 36 How do I/my child get dental services? 36 Want to quit using tobacco? 37 How do I get help if I have/my child has behavioral (mental) health or drug problems? Is a referral necessary? 37 Can someone interpret for me when I talk with my/my child s doctor? 37 What if I/my daughter needs OB/GYN care? 38 What if I/my daughter is pregnant? Who do I need to call? 39 What other services/activities/education does the plan offer pregnant women? 39 Who do I call if I have/my child has special health care needs and I need someone to help me? 39 What do I do if I have to move/my child moves? 40 What if I get a bill from my/my child s doctor? 40 What is the most I will have to pay for my child s health care services? 40 What are my rights and responsibilities? 41 Complaints and Appeal Process What if I have a problem or I am not happy with Parkland KIDSfirst or Parkland CHIP Perinate Newborn or my child s health care? 43 What if I am not satisfied with the outcome, what more can I do? How do I file an appeal? 43 What can I do if Parkland KIDSfirst or Parkland CHIP Perinate Newborn denies or limits my doctor s request for a covered service? 44 What is an expedited appeal? 45 What is an Independent Review Organization? 47 Fraud Information How do I report someone who is misusing the CHIP Program? 47 Privacy Notice 49 v 009MS-MH Member Services / TTY

7 What if I Need Help Understanding or Reading the Member Handbook? We have special services for people who have trouble reading, hearing, seeing, or speak a language other than English or Spanish. You can ask for the Member Handbook in audio or other languages. You can also ask for the Member handbook in Braille or larger print. If we learn that you might need the audiocassette or compact disc (CD), we will mail it to you. To get help, call Parkland KIDSfirst and Parkland CHIP Perinate Newborn Member Services toll-free at , or mail to Parkland Community Health Plan, Attention: Member Services, P. O. Box , Dallas, TX References to you, my, or I apply if you are a CHIP Member. References to my child apply if your child is a CHIP Member or a CHIP Perinate Newborn Member. Information about the Parkland KIDSfirst and Parkland CHIP Perinate Newborn Identification Cards (ID Cards) You will get a Parkland KIDSfirst Identification (ID) card from us when your child is enrolled in Parkland KIDSfirst. An example of the Parkland KIDSfirst ID card is shown below. The Member ID is the same as your child's CHIP ID number and with the numbers 0, 1, 2, 3, 4, 5, or 6. Each member will have a different card. Your Directions for What to Do In An Emergency In case of emergency call or go to the closest emergency room. After treatment, call your child s Primary Care Provider (PCP) within 24 hours or as soon as possible. For additional information regarding emergency services, please refer to your Member Handbook. Mail claims to this address: Claims Processing Center P.O. Box Phoenix, AZ Payor ID: In case of an emergency, please call Instrucciones en caso de emergencia. En caso de emergencia, llama al o vaya a la sala de emergencia más cercana. Después de recibir tratamiento, llame al proveedor principal (PCP) de su hijo dentro de 24 horas o tan pronto como sea posible. Para más información sobre servicios de emergencia, favor de referirse al Manual para Miembros. Envie reclamaciones a este dirección. Claims Processing Center P.O. Box Phoenix, AZ Payor ID: En caso de una emergencia, por favor llama al child will get a new ID card if it gets lost, if you call us to change your child s Primary Care Provider, or if your child s co-pays change. Parkland CHIP Perinate Newborn ID Card You will get a Parkland CHIP Perinate Newborn Identification (ID) card from us when your baby joins Parkland CHIP Perinate Newborn. Please call Member Services at to let us know the baby was born. You should also call the CHIP Help Line at to let them know. An example of the Parkland CHIP Perinate Newborn ID card is shown next MS-MH Member Services / TTY

8 The Member ID is the same as your child's CHIP ID number and If you have more than one baby, each baby will have a separate ID card. Directions for What to Do In An Emergency In case of emergency call or go to the closest emergency room. After treatment, call your PCP within 24 hours or as soon as possible. For additional information regarding emergency services, please refer to your Member Handbook. In case of an emergency, please call Instrucciones en caso de emergencia. En caso de emergencia, llama al o vaya a la sala de emergencia más cercana. Después de recibir tratamiento, llame al proveedor principal (PCP) de su hijo dentro de 24 horas o tan pronto como sea posible. Para más información sobre servicios de emergencia, favor de referirse al Manual para Miembros. En caso de una emergencia, por favor llama al Mail claims to this address: Claims Processing Center P.O. Box Phoenix, AZ Payor ID: Envie reclamaciones a este dirección. Claims Processing Center P.O. Box Phoenix, AZ Payor ID: How to Read Your Child s Parkland KIDSfirst and Parkland CHIP Perinate Newborn ID Card The front of the Parkland KIDSfirst and Parkland CHIP Perinate Newborn ID cards has important information about your child. It also has the name and phone number of your child s Primary Care Provider. The Parkland KIDSfirst ID card will have co-payment information, if applicable. Copayments are not required for Parkland CHIP Perinate or Parkland CHIP Perinate Newborn. The Parkland CHIP Perinate Newborn ID card will show no co-payment information. The back of the card has more information and important phone numbers for you to call if you need help. How to Use Your Child s Parkland KIDSfirst and Parkland CHIP Perinate Newborn ID Card You must take your child s Parkland KIDSfirst or Parkland CHIP Perinate Newborn ID Card with you when your child is taken to get any health care services. You will need to show your child s Parkland KIDSfirst or Parkland CHIP Perinate Newborn ID Card each time your child needs services. What if the Parkland KIDSfirst or Parkland CHIP Perinate Newborn ID Card Gets Lost? If your child s Parkland KIDSfirst or Parkland CHIP Perinate Newborn ID Card gets lost, please call Member Services toll-free right away at to get a new one. If your child s address or 2 009MS-MH Member Services / TTY

9 phone number changes, please call us so we can send a new Parkland KIDSfirst or Parkland CHIP Perinate Newborn ID card with the correct information and update our records. What Do I Need to Bring to My/My Child's Doctor's Appointment? When you go to your doctor's appointment, you should take these with you: Parkland KIDSfirst or Parkland CHIP Perinate Newborn ID card Vaccination (shot) records A list of all prescription and over-the-counter medications you or your child takes Pen and paper to take notes (Sometimes you might get a lot of information, and it helps to write things down.) What Is a Primary Care Provider? Your child's Primary Care Provider may be a doctor, clinic, OB-GYN, physician s assistant, or a nurse practitioner that you can go to for medical care. Your child's Primary Care Provider will manage any medical care your child needs. Your child's doctor can take care of routine medical problems. Sometimes your child may have a problem that needs to be handled by a specialist. The Primary Care Provider will know who can best handle the problem and can arrange to have you see the right specialist. The Primary Care Provider will authorize your child to see the specialist with a Referral Form and tell you how to schedule an appointment. If your child needs to be admitted to a hospital, your Primary Care Provider can help with the hospital admission. Think of your child's Primary Care Provider as a partner who helps manage your child's medical care and well-being. How Do I Choose My/My Child's Primary Care Provider? Can a Clinic Be My/My Child s Primary Care Provider? You picked your child s Primary Care Provider from our list of Parkland KIDSfirst and Parkland CHIP Perinate Newborn providers. Your child s Primary Care Provider is considered to be his or her medical home. If your child sees the same doctor or clinic all the time, that doctor can get to know your child and his/ her medical history. When that doctor knows your child, the doctor can give better care. You may have chosen one Primary Care Provider for each child or you may have picked the same Primary Care Provider for all your children. Primary Care Providers can be: Family Doctors (with experience treating children) Pediatricians (only see children) Obstetricians/Gynecologists (OB/GYNs) (a women s doctor) General Practitioners (GPs) Advanced Nurse Practitioners (ANPs) Federally Qualified Health Clinics (FQHCs) 3 009MS-MH Member Services / TTY

10 Rural Health Clinics (RHCs) Remember: the Primary Care Provider will be the one you call when your child needs care. Look in your Parkland KIDSfirst and Parkland CHIP Perinate Newborn Provider Directory for the names, addresses and telephone numbers of Parkland KIDSfirst and Parkland CHIP Perinate Newborn Primary Care Providers, or call Member Services toll-free at for help. You can also see or print a copy of the Provider Directory at What about a Primary Care Provider for a Child with Special Health Care Needs (CSHCN)? There may be times when Parkland KIDSfirst and Parkland CHIP Perinate Newborn may allow a special doctor (Specialist) to be your child s Primary Care Provider (for Children with Chronic and Complex Special Health Care Needs CCSHCN). Call Member Services toll-free at for more information. How Can I Change My/ My Child s Primary Care Provider? How Many Times Can I Change My/My Child s Primary Care Provider? There is no limit on how many times you can change your or your child s Primary Care Provider. You can change Primary Care Providers by calling us toll-free at or writing to: Parkland KIDSfirst PO Box Dallas, TX When Will a Primary Care Provider Change Become Effective? The change will become effective on the day you call us to make the change. You/your child will get a new ID card that shows the date your/your child s new Primary Care Provider will be effective. The new card will also show the new Primary Care Provider s name, address and phone number on it. Changing your child s Primary Care Provider will not stop your child from getting care. If you need care before the new Primary Care Provider is effective, call the doctor on your/your child s current ID card. Here are some reasons why you may want to change your/your child s Primary Care Provider: You are not happy with the current Primary Care Provider s care You/your child is in the hospital at the time you make the request You need a different kind of doctor to take care of you/your child You/your child s Primary Care Provider is no longer near you because you have moved The Primary Care Provider is no longer a part of Parkland KIDSfirst or Parkland CHIP Perinate Newborn 4 009MS-MH Member Services / TTY

11 Are There Any Reasons Why My Request to Change a Primary Care Provider May Be Denied? Here are some reasons why your child may not be able to have the Primary Care Provider you chose: The Primary Care Provider you picked cannot see new patients The Primary Care Provider you picked is no longer a part of Parkland KIDSfirst or Parkland CHIP Perinate Newborn Can a Primary Care Provider Request That I/My Child Be Changed to Another Primary Care Provider for Non-Compliance? Here are some reasons why your/your child s Primary Care Provider may ask that you pick a new doctor: You/your child frequently misses appointments and you did not call to let the Primary Care Provider know You are not following your/your child s Primary Care Provider s advice You will get a letter in the mail if you need to pick a new Primary Care Provider for your child. You will need to pick a new Primary Care Provider right away. If you do not pick a new Primary Care Provider, we will pick one for you/your child. We will pick one near your home and send you a new ID card with the new Primary Care Provider s name, address and telephone number on it. To give your child the best care possible, the Primary Care Provider needs to know your child s medical history. Your child s medical records are private and confidential. Only you, your child s doctor, and other approved providers have a right to see them. If you change doctors, be sure to give your child s new Primary Care Provider any information needed about his or her medical history. What if I Choose to Go to Another Doctor Who Is Not My/My Child s Primary Care Provider? Most of the time, you need to go to your child s Primary Care Provider first. If you choose to go to another doctor, you may have to pay. However, there are some benefits that do not require that you go to your child s Primary Care Provider first. They include: Emergency Care (Parkland KIDSfirst and Parkland CHIP Perinate Newborns) OB/GYN Care (Parkland KIDSfirst members only) Call Member Services toll-free at for more information MS-MH Member Services / TTY

12 Physician Incentive Plans A physician incentive plan rewards doctors for treatments that reduce or limit services for people covered by CHIP. Right now, Parkland Community Health Plan does not have a physician incentive plan. What If I Want to Change Health Plans? Who Do I Call? Parkland KIDSfirst Members You are allowed to make health plan changes: For any reason within 90 days of enrollment in CHIP; For cause at any time During the annual CHIP re-enrollment period. Parkland CHIP Perinate Newborn Members Attention: If you meet certain income requirements, your baby will be moved to Medicaid and get 12 months of continuous Medicaid coverage from date of birth. This applies to members whose family income is at or below 185% of the Federal Poverty Level. Your baby will continue to receive services through the CHIP Program if you meet the CHIP Perinatal requirements. Your baby will get 12 months of continuous CHIP Perinatal coverage through his or her health plan, beginning with the month of enrollment as an unborn child. This applies to members whose family income is 186% to 200% of the Federal Poverty Level. What if I want to change health plans? Once you pick a health plan for your unborn child, the child must stay in this health plan until the child s CHIP perinatal coverage ends. The 12 month CHIP Perinatal coverage begins when your unborn child is enrolled in CHIP Perinatal and continues after your child is born. If you live in an area with more than one CHIP health plan, and you do not pick a plan within 15 days of getting the enrollment packet, HHSC will pick a health plan for your unborn child and send you information about that health plan. If HHSC picks a health plan for your unborn child, you will have 90 days to pick another health plan if you are not happy with the plan HHSC chooses. If you have children covered by CHIP, their health plans might change once you are approved for CHIP Perinatal coverage. When a member of the family is approved for CHIP Perinatal coverage and picks a perinatal health plan, all children in the family that are enrolled in CHIP must join the health plan providing the CHIP Perinatal services. The children must remain with the same health plan until the end of the CHIP Perinatal member s enrollment period, or the end of other children s enrollment period, whichever happens last. At that point, you can pick a different health plan for the children. You can ask to change health plans once per enrollment year or: for any reason within 90 days of enrollment in CHIP Perinatal; if you move to a different service delivery area; and for cause at any time MS-MH Member Services / TTY

13 When does the plan change become effective? If you call to change your health plan on or before the 15 th of the month, the change will take place on the first day of the next month. If you call after the 15 th of the month, the change will take place on the first day of the second month after that. For example: If you call on or before April 15, your change will take place on May 1. If you call after April 15, your change will take place on June 1. Who do I call? For more information, call the CHIP Help Line toll-free at Note: If you are a CHIP Perinate member and you have children who are covered by CHIP, the copayments, cost-sharing and enrollment fees still apply for those children enrolled in CHIP. How Do I Renew My/My Child s CHIP Coverage? Parkland KIDSfirst Members You should get a renewal packet in the mail from the State during your/your child s 9 th month of coverage. This packet will include a renewal application, a letter asking for current income and deduction information, and a postage paid envelope. You should: Look over the information on the renewal application Update any information as needed Attach your current income and deduction verifications Sign and date the application Look over your health plan choice Return the application and other documents by the due date. The renewal application is due by the 1 st day of the 10 th month of coverage. It is important that you pay your child s enrollment fee on time so there is no gap in coverage. For more information, please call the CHIP Help Line at Parkland CHIP Perinate Newborn Members You should get a renewal packet in the mail from the State during your child s 9 th month of coverage. This packet will include a renewal application, a letter asking for current income and deduction information, and a postage paid envelope. You should: Look over the information on the renewal application Update any information as needed Attach your current income and deduction verifications Sign and date the application Look over your health plan choice Return the application and other documents by the due date MS-MH Member Services / TTY

14 The renewal application is due by the 1 st day of the 10 th month of coverage. It is important that you pay your child s enrollment fee on time so there is no gap in coverage. For more information, please call the CHIP Help Line at Can Parkland Community Health Plan Ask That I/My Child Get Dropped from Their Health Plan? Yes. Parkland Community Health Plan might ask that a Member be taken out of the health plan for several reasons: You/your child turns nineteen. You fail to re-enroll your child at the end of the 12-month eligibility period. There is a change in health insurance status, such as your child enrolling in another CHIP health plan. Your child dies Your child permanently moves out of the state. You/your child frequently does not follow the doctor s advice. You keep taking your child to another doctor or clinic without first getting approval from your child s Primary Care Provider. You or your child shows a pattern of disruptive or abusive behavior not related to a medical condition. You/your child misses many appointments without letting the doctor know in advance. Fraud or abuse by a Member Theft What Is Medically Necessary? What Are the CHIP and CHIP Perinate Newborn Benefits? References to you, my, or I apply if you are a CHIP Member. References to my child apply if your child is a CHIP Member or a CHIP Perinate Newborn Member. Covered services for CHIP Members and CHIP Perinate Newborn Members must meet the CHIP definition of "medically necessary." A CHIP Perinate Member is an unborn child. Medically Necessary means: 1. Health care services that are: a. reasonable and necessary to prevent illnesses or medical conditions, or provide early screening, interventions, and/or treatments for conditions that cause suffering or pain, cause physical deformity or limitations in function, threaten to cause or worsen a disability, cause illness or infirmity of a member, or endanger life; b. provided at appropriate facilities and at the appropriate levels of care for the treatment of a member s health conditions; c. consistent with health care practice guidelines and standards that are endorsed by professionally recognized health care organizations or governmental agencies; 8 009MS-MH Member Services / TTY

15 d. consistent with the member s diagnoses; e. no more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency; f. not experimental or investigative; and g. not primarily for the convenience of the member or provider; and 2. Behavioral Health Services that are: a. are reasonable and necessary for the diagnosis or treatment of a mental health or chemical dependency disorder, or to improve, maintain, or prevent deterioration of functioning resulting from such a disorder; b. in accordance with professionally accepted clinical guidelines and standards of practice in behavioral health care; c. are furnished in the most appropriate and least restrictive setting in which services can be safely provided; d. are the most appropriate level or supply of service that can safely be provided; e. could not be omitted without adversely affecting the member s mental and/or physical health or the quality of care rendered; f. not experimental or investigative; and g. not primarily for the convenience of the member or provider. There is no lifetime maximum on benefits; however, 12-month period or lifetime limitations do apply to certain services, as specified in the following chart. Co-pays apply until a family reaches its specific cost-sharing maximum. Co-pays do not apply to the Parkland CHIP Perinate Newborn members. Type of Benefit Description of Benefit Limitations Co-Pay Inpatient General Applicable level Acute and of inpatient copay applies for Inpatient Rehabilitation CHIP Members Hospital Services Services include: Hospital-provided Physician or Provider services Semi-private room and board (or private if medically necessary as certified by attending) General nursing care Special duty nursing when medically necessary ICU and services Patient meals and special diets Operating, recovery and other treatment rooms Anesthesia and administration (facility technical component) Surgical dressings, trays, casts, splints Drugs, medications and biologicals Blood or blood products that are not provided free-ofcharge to the patient and their administration For Parkland CHIP Perinate Newborns in families with incomes at or below 185% of the Federal Poverty Level (FPL) the facility charges are not a covered benefit for the initial Perinate Newborn admission. Facility charges are a covered benefit after the initial Perinate Newborn admission. For Parkland CHIP Perinate Newborns in families with incomes at or below 185% of the Federal Poverty Level, professional service charges are a covered benefit for No co-pays required for CHIP Perinate Newborn Members 9 009MS-MH Member Services / TTY

16 Type of Benefit Description of Benefit Limitations Co-Pay X-rays, imaging and other radiological tests (facility technical component) the initial Perinate Newborn admission and subsequent Laboratory and pathology admissions. services (facility technical component) May require authorization for non- Machine diagnostic tests (EEGs, EKGs, etc.) Emergency Care and care following Oxygen services and inhalation therapy stabilization of an Emergency Condition. Radiation and chemotherapy Access to DSHS-designated Level III perinatal centers or Hospitals meeting equivalent levels of care May require authorization for innetwork or out-ofnetwork facility and In-network or out-of-network facility and Physician services for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated delivery by caesarian section. Physician services for a mother and her newborn(s) after 48 hours following an uncomplicated vaginal delivery and after 96 hours following an uncomplicated delivery by caesarian Hospital, physician and related medical services, such as anesthesia, associated with dental care. section. Inpatient services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero.) Inpatient services associated with miscarriage or non-viable pregnancy include, but are not limited to: - dilation and curettage (D&C) procedures; - appropriate provideradministered medications; - ultrasounds; and - histological examination of tissue samples. Pre-surgical or post-surgical orthodontic services for medically necessary treatment MS-MH Member Services / TTY

17 Type of Benefit Description of Benefit Limitations Co-Pay of craniofacial anomalies requiring surgical intervention and delivered as part of a proposed and clearly outlined treatment plan to treat: - cleft lip and/or palate; or - severe traumatic, skeletal and/or congenital craniofacial deviations; or - severe facial asymmetry secondary to skeletal defects, congenital syndromal conditions and/or tumor growth or its treatment. Surgical implants Other artificial aids including surgical implants Inpatient services for a mastectomy and breast reconstruction include: - all stages of reconstruction on the affected breast; - surgery and reconstruction on the other breast to produce symmetrical appearance; and - treatment of physical complications from the mastectomy and treatment of lymphedemas. Implantable devices are covered under Inpatient and Outpatient services and do not count towards the DME 12 month period limit Skilled Nursing Facilities (Includes Rehabilitation Hospitals) Outpatient Hospital, Services include, but are not limited to, the following: Semi-private room and board Regular nursing services Rehabilitation services Medical supplies and use of appliances and equipment furnished by the facility Services include, but are not limited to, the following services Requires authorization and physician prescription. 60 days per 12-month period limit. May require prior authorization and No Co-pays for CHIP or CHIP Perinate Newborn Members Applicable MS-MH Member Services / TTY

18 Type of Benefit Description of Benefit Limitations Co-Pay Comprehensive Outpatient Rehabilitation Hospital, Clinic (Including Health Center) and Ambulatory Health Care Center physician prescription. provided in a hospital clinic or emergency room, a clinic or health center, hospital-based emergency department or an ambulatory health care setting: X-ray, imaging, and radiological tests (technical component) Laboratory and pathology services (technical component) Machine diagnostic tests Ambulatory surgical facility services Drugs, medications and biologicals Casts, splints, dressings Preventive health services Physical, occupational and speech therapy Renal dialysis Respiratory services Radiation and chemotherapy Blood or blood products that are not provided free-ofcharge to the patient and the administration of these products Facility and related medical services, such as anesthesia, associated with dental care, when provided in a licensed ambulatory surgical facility. Outpatient services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero). Outpatient services associated with miscarriage or non-viable pregnancy include, but are not limited to: - dilation and curettage (D&C) procedures; - appropriate provideradministered medications; - ultrasounds; and level of copay applies to prescription drug services for CHIP Members No co-pays required for CHIP Perinate Newborn Members MS-MH Member Services / TTY

19 Type of Benefit Description of Benefit Limitations Co-Pay - histological examination of tissue samples. Pre-surgical or post-surgical orthodontic services for medically necessary treatment of craniofacial anomalies requiring surgical intervention and delivered as part of a proposed and clearly outlined treatment plan to treat: - cleft lip and/or palate; or - severe traumatic, skeletal and/or congenital craniofacial deviations; or - severe facial asymmetry secondary to skeletal defects, congenital syndromal conditions and/or tumor growth or its treatment. Surgical implants Other artificial aids including surgical implants Outpatient services provided at an outpatient hospital and ambulatory health care center for a mastectomy and breast reconstruction as clinically appropriate, include: - all stages of reconstruction on the affected breast; - surgery and reconstruction on the other breast to produce symmetrical appearance; and - treatment of physical complications from the mastectomy and treatment of lymphedemas. Implantable devices are covered under Inpatient and Outpatient services and do not count towards the DME 12 month period limit Physician/ Physician Extender Services include, but are not limited to the following: American Academy of May require authorization for specialty services. Applicable level of copay applies MS-MH Member Services / TTY

20 Type of Benefit Description of Benefit Limitations Co-Pay Professional for CHIP Services Members Pediatrics recommended wellchild exams and preventive health services (including but not limited to vision and hearing screening and immunizations) Physician office visits, inpatient and outpatient services Laboratory, x-rays, imaging and pathology services, including technical component and/or professional interpretation Medications, biologicals and materials administered in Physician s office Allergy testing, serum and injections Professional component (in/outpatient) of surgical services, including: - Surgeons and assistant surgeons for surgical procedures including appropriate follow-up care - Administration of anesthesia by Physician (other than surgeon) or CRNA - Second surgical opinions - Same-day surgery performed in a Hospital without an over-night stay - Invasive diagnostic procedures such as endoscopic examinations Hospital-based Physician services (including Physicianperformed technical and interpretive components) Physician and professional services for a mastectomy and breast reconstruction include: - all stages of reconstruction on the affected breast; - surgery and reconstruction on the other breast to No co-pays required for CHIP Perinate Newborn Members MS-MH Member Services / TTY

21 Type of Benefit Description of Benefit Limitations Co-Pay produce symmetrical appearance; and - treatment of physical complications from the mastectomy and treatment of lymphedemas. In-network and out-ofnetwork Physician services for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated delivery by caesarian section. Physician services medically necessary to support a dentist providing dental services to a CHIP member such as general anesthesia or intravenous (IV) sedation. Physician services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero). Physician services associated with miscarriage or non-viable pregnancy include, but are not limited to: - dilation and curettage (D&C) procedures; - appropriate provideradministered medications; - ultrasounds; and - histological examination of tissue samples. Pre-surgical or post-surgical orthodontic services for medically necessary treatment of craniofacial anomalies requiring surgical intervention and delivered as part of a proposed and clearly outlined treatment plan to treat: - cleft lip and/or palate; or MS-MH Member Services / TTY

22 Type of Benefit Description of Benefit Limitations Co-Pay - severe traumatic, skeletal and/or congenital craniofacial deviations; or - severe facial asymmetry secondary to skeletal defects, congenital syndromal conditions and/or tumor growth or its treatment. Birthing Center Services Services rendered by a Certified Nurse Midwife or physician in a licensed birthing center. Durable Medical Equipment (DME), Prosthetic Devices and Disposable Medical Supplies Covers birthing services provided by a licensed birthing center. Limited to facility services (e.g., labor and delivery) Covers prenatal, birthing and postpartum services in a licensed birthing center. Covered services include DME (equipment that can withstand repeated use and is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of Illness, Injury, or Disability, and is appropriate for use in the home), including devices and supplies that are medically necessary and necessary for one or more activities of daily living and appropriate to assist in the treatment of a medical condition, including but not limited to: Orthotic braces and orthotics Dental Devices Prosthetic devices such as artificial eyes, limbs, braces, and external breast prostheses Prosthetic eyeglasses and contact lenses for the management of severe ophthalmologic disease Other artificial aids including surgical implants Hearing aids May require prior authorization and physician prescription. $20,000 per 12-month period limit for DME, prosthetics, devices and disposable medical supplies (implantable devices, diabetic supplies and equipment are not counted against this cap). No Co-pays for CHIP or CHIP Perinate Newborn Members No Co-pays for CHIP or CHIP Perinate Newborn Members No Co-pays required for CHIP or CHIP Perinate Newborn Members MS-MH Member Services / TTY

23 Type of Benefit Description of Benefit Limitations Co-Pay Implantable devices are covered under Inpatient and Outpatient services and do not count towards the DME 12- month period limit. Diagnosis-specific disposable medical supplies, including diagnosis-specific prescribed specialty formula and dietary supplements. Home and Community Health Services Inpatient Mental Health Services Services that are provided in the home and community, including, but not limited to: Home infusion Respiratory therapy Visits for private duty nursing (R.N., L.V.N.) Skilled nursing visits as defined for home health purposes (may include R.N. or L.V.N.). Home health aide when included as part of a plan of care during a period that skilled visits have been approved. Speech, physical and occupational therapies. Mental health services, including for serious mental illness, furnished in a freestanding psychiatric hospital, psychiatric units of general acute care hospitals and state operated facilities, including but not limited to: Neuropsychological and psychological testing. Requires prior authorization and physician prescription. Services are not intended to replace the CHILD'S caretaker or to provide relief for the caretaker. Skilled nursing visits are provided on intermittent level and not intended to provide 24-hour skilled nursing services. Services are not intended to replace 24- hour inpatient or skilled nursing facility services Requires prior authorization for nonemergency services. Does not require PCP referral. When inpatient psychiatric services are ordered by a court of competent jurisdiction under the provisions of Chapters No Co-pays required for CHIP or CHIP Perinate Newborn Members Applicable level of inpatient copay applies for CHIP Members No co-pays required for CHIP Perinate Newborn Members MS-MH Member Services / TTY

24 Type of Benefit Description of Benefit Limitations Co-Pay 573 and 574 of the Texas Health and Safety Code, relating to court ordered commitments to psychiatric facilities, the court order serves as binding determination of medical necessity. Any modification or termination of services must be presented to the court with jurisdiction over the matter for determination. Outpatient Mental Health Services Mental health services, including for serious mental illness, provided on an outpatient basis, including, but not limited to: The visits can be furnished in a variety of community-based settings (including school and home-based) or in a stateoperated facility Neuropsychological and psychological testing. Medication management Rehabilitative day treatments Residential treatment services Sub-acute outpatient services (partial hospitalization or rehabilitative day treatment) Skills training (psychoeducational skill development) May require prior authorization. Does not require PCP referral. When outpatient psychiatric services are ordered by a court of competent jurisdiction under the provisions of Chapters 573 and 574 of the Texas Health and Safety Code, relating to court ordered commitments to psychiatric facilities, the court order serves as binding determination of medical necessity. Any modification or termination of services must be presented to the court with jurisdiction over the matter for determination. Applicable level of copay applies for CHIP Members. No co-pays required for CHIP Perinate Newborn Members MS-MH Member Services / TTY

25 Type of Benefit Description of Benefit Limitations Co-Pay Inpatient Substance Abuse Treatment Services Inpatient substance abuse treatment services include, but are not limited to: Inpatient and residential substance abuse treatment services including detoxification and crisis stabilization, and 24-hour residential rehabilitation programs. A Qualified Mental Health Provider Community Services (QMHP-CS), is defined by the Texas Department of State Health Services (DSHS) in Title 25 T.A.C., Part I, Chapter 412, Subchapter G, Division 1), (48). QMHP- CSs shall be providers working through a DSHS-contracted Local Mental Health Authority or a separate DSHS-contracted entity. QMHP-CSs shall be supervised by a licensed mental health professional or physician and provide services in accordance with DSHS standards. Those services include individual and group skills training (that can be components of interventions such as day treatment and inhome services), patient and family education, and crisis services. May require prior authorization for nonemergency services. Does not require PCP referral Applicable level of inpatient copay applies to CHIP Members No co-pays required for CHIP Perinate MS-MH Member Services / TTY

26 Type of Benefit Description of Benefit Limitations Co-Pay Newborn Members Outpatient Substance Abuse Treatment Services Rehabilitation Services Hospice Care Services Outpatient substance abuse treatment services include, but are not limited to, the following: Prevention and intervention services that are provided by physician and non-physician providers, such as screening, assessment and referral for chemical dependency disorders. Intensive outpatient services Partial hospitalization Intensive outpatient services is defined as an organized non-residential service providing structured group and individual therapy, educational services, and life skills training that consists of at least 10 hours per week for four to 12 weeks, but less than 24 hours per day. Outpatient treatment service is defined as consisting of at least one to two hours per week providing structured group and individual therapy, educational services, and life skills training. Habilitation (the process of supplying a child with the means to reach age-appropriate developmental milestones through therapy or treatment) and rehabilitation services include, but are not limited to the following: Physical, occupational and speech therapy Developmental assessment Services include, but are not limited to: Palliative care, including medical and support services, for those children who have six months or less to live, to May require prior authorization. Does not require PCP referral. Requires prior authorization and physician prescription. Requires authorization and physician prescription. Services apply to the hospice diagnosis. Applicable level of copay applies to office visits for CHIP Members. No co-pays required for CHIP Perinate Newborns. No Co-pays required for CHIP or CHIP Perinate Newborn Members. No Co-pays required for CHIP or CHIP Perinate Newborn MS-MH Member Services / TTY