CHIP MEMBER HANDBOOK. Member Services: Travis Service Area:

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1 CHIP MEMBER HANDBOOK Member Services: Travis Service Area: Bastrop, Burnet, Caldwell, Fayette, Hays, Lee, Travis & Williamson Counties CMH-MAR /2014

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3 Page iii Table of Contents Page and CHIP/CHIP Perinate Important Information!...3 Your CHIP ID Card...4 Reading the Sendero CHIP ID Card...4 Using the Sendero CHIP ID Card...4 If you lose your CHIP ID Card or move...4 All about PCPs for CHIP Members and chip Perinate newborn members...5 What do I need to bring to my/my child s doctor s appointment?...5 What is a Primary Care Provider (PCP)?...5 How do I change my child s Primary Care Provider (PCP)?...5 Can a clinic be my/my child s Primary Care Provider (PCP)?...5 How many times can I change my/my child s PCP?...6 When will my PCP change become effective?...6 Are there any reasons why a request to change a PCP may be denied?...6 Can a PCP move me or my child to another PCP for non-compliance?...6 What if I choose to go to another doctor who is not my/my child s PCP?...6 How do I get medical care after my/my child s PCP s office is closed?...7 Physician Incentive Plan Information...7 all about primary care providers for CHIP Perinate Members...7 What do I need to bring to a Perinatal Provider s appointments?...7 Can a clinic be my Perinatal Provider?...7 How do I get medical care after my Perinatal Provider s office is closed?...7 Changing Health Plans for CHIP program Members...8 What if I want to change health plans?...8 Who do I call?...8 How many times can I change health plans?...8 When will my health plan change become effective?...8 Changing Health Plans for CHIP Perinatal Members...8 What if I want to change health plans?...9 Who do I call?...9 When will my health plan change become effective?...9 Can Sendero ask that I get dropped from their health plan for non-compliance, etc?...9 How long is my baby covered? How does renewal work?...10 How do I sign up my newborn baby?...10 What benefits does my baby receive at birth?...10 Benefits Available from Sendero for CHIP Members...11 What are my CHIP benefits? CHIP Member Handbook

4 Page iv How do I get these services for my child?...25 What are copayments and when do I have to pay them?...25 How much are they?...25 What services are not covered? What extra benefits does a member of Sendero get?...27 How can I get these benefits?...28 What health education does offer?...28 BENEFITS AVAILABLE From Sendero FOR CHIP PERINATE MEMBERS What are my unborn child s CHIP Perinate benefits? How can I get these benefits?...42 What services are not covered? CHIP DME/Supplies What health education does offer?...50 What extra benefits does a member of Sendero get?...50 How can I get these benefits?...51 Health Care AND OTHER Services for CHIP members and CHIP Perinate Newborn Members...52 What does medically necessary mean?...52 What is routine medical care and how soon can I expect my child to be seen?...53 What is urgent medical care and how soon can I expect my child to be seen?...53 What is Emergency care, an Emergency Medical Condition, and an Emergency Behavioral Health condition?...54 What is Emergency Services and/or Emergency Care?...54 How do I get my medications?...54 How soon can I expect to be seen/how soon can I expect my child to be seen?...55 Are emergency dental services covered?...55 What do I do if I/or my child need emergency dental care?...55 What is post-stabilization?...55 How do I get medical care after my Primary Care Provider s office is closed?...55 What if I get sick when I am out of town or traveling/ what if my child gets sick when he or she is out of town or traveling?...55 What if I am/my child is out of the state?...56 What if I am/my child is out of the country?...56 What if I need/my child needs to see a special doctor/(specialist)?...56 What is a referral?...56 How soon can I/my child expect to be seen by a special doctor?...56 What services do not need a referral?...56 How can I request a second opinion?...57

5 Page v How do I get help if my child has behavioral (mental) health or alcohol or drug problems?...57 Do I need a referral for this?...57 How do I get my/my child s medications?...57 How do I find a network drug store?...57 What if I go to a drug store not in the network?...57 What do I bring with me to the drug store?...58 What if I need my/my child s medications delivered to me?...58 Who do I call if I have problems getting my/my child s medications?...58 What if I can t get the medication my/my child s doctor ordered approved?...58 What if I lose my/my child s medication?...58 What if I need/my child needs an over-the-counter medication?...58 What if I need/my child needs birth control pills?...58 How do I get eye care services/how do I get eye care services for my child?...58 How do I get dental services for my child?...58 Can someone interpret for me when I talk with my/my child s doctor?...59 How far in advance do I need to call?...59 How can I get a face-to-face interpreter in the provider s office?...59 Se Habla Español...59 Attention Members...59 What if I need/my daughter needs OB/GYN care?...59 Do I have the right to choose an OB/GYN?...59 How do I choose an OB/GYN?...59 If I don t choose an OB/GYN, do I have direct access?...60 Will I need a referral?...60 How soon can I/my daughter be seen after contacting my OB/GYN for an appointment?...60 Can I/my daughter stay with an OB/GYN who is not with Sendero?...60 What if I am pregnant/what if my daughter is pregnant?...60 What other services/activities/education does Sendero offer pregnant women?...60 Who do I call if I have/my child has special health care needs and I need someone to help me?...60 What if I get a bill from my doctor?...61 What do I do if I move/my child moves?...61 Member Rights and Responsibilities...61 Member Rights...61 Member Responsibilities...63 Health Care and other Services for CHIP Perinate Members...64 What does medically necessary mean?...64 What is an Emergency and an Emergency Medical Condition?...64 What is Emergency Services or Emergency Care?...65 CHIP Member Handbook

6 Page vi How do I get medical care after my Primary Care Provider s office is closed?...65 What if I get sick when I am out of town or traveling/ what if my child gets sick when he or she is out of town or traveling?...65 What if I am/my child is out of the country?...66 What if I am out of the state?...66 What is a referral?...66 What services do not need a referral?...66 What if I need services not covered by CHIP Perinatal?...66 How do I get my medications?...66 How do I find a network drug store?...66 What if I go to a drug store not in the network?...67 What do I bring with me to the drug store?...67 What if I need my medications delivered to me?...67 Who do I call if I have problems getting my medications?...67 What if I lose my/my child s medication?...67 What if I need an over-the-counter medication?...67 Can someone interpret for me when I talk to my Perinatal Provider?...67 How far in advance do I need to call?...67 How can I get a face-to-face interpreter in my provider s office?...67 Se Habla Español...67 How do I choose a Perinatal Provider and do I need a referral?...68 What happens if I don t choose an OB/GYN as my Perinatal Provider?...68 How soon can I be seen after contacting a Perinatal Provider for an appointment?...68 Can I stay with my Perinatal Provider if they are not with Sendero?...68 What if I get a bill from my Perinatal Provider and who do I call?...68 What do I have to do if I move?...69 Member Rights and Responsibilities...69 Member Rights...69 Member Responsibilities...70 When does the CHIP Perinatal coverage end?...70 How does renewal work?...71 What benefits does my baby receive at birth?...71 Can I pick a PCP for my baby before the baby is born and who do I call?...71 Complaint Process...71 What should I do if I have a complaint?...71 What are the requirements and time frames for filing a complaint?...71 How long will it take to process my complaint?...71 If I am not satisfied with the outcome, who else can I contact?...72

7 Page vii Can someone from Sendero help me file a complaint?...72 If I am not satisfied with the outcome, who else can I contact?...72 Do I have the right to meet with a Complaints Appeal Panel?...73 What can I do if my doctor asks for a service or medicine for me that is covered but Sendero denies or limits it?...73 How long will it take to process my appeal?...73 Can someone from Sendero help me file an appeal?...73 Expedited appeal...73 What is an expedited appeal?...73 How do I ask for an expedited appeal?...73 What are the time frames for an expedited appeal?...74 What happens if Sendero denies my request for an expedited appeal?...74 independent review organization...74 What is an Independent Review Organization (IRO)?...74 How do I ask for a review by an IRO?...74 What are the time frames for this process?...75 fraud and abuse of the CHIP Program...75 Do you want to report CHIP Waste, Abuse, or Fraud?...75 To report Waste, Abuse, or Fraud, choose one of the following:...75 To report Waste, Abuse, or Fraud, gather as much information as possible...76 CHIP Member Handbook

8 Page 1 SENDERO HEALTH PLANS AND CHIP/CHIP PERINATE CHIP and CHIP Perinate are the health insurance plans in the State of Texas that provide care to families who would not normally have access to care through Medicaid or other private health insurance. These programs are administered by the Texas Health and Human Services Commission (HHSC). By choosing (Sendero), we provide CHIP and CHIP Perinate health services to you and your children. Health care through is available in these central Texas counties: Bastrop Burnet Caldwell Fayette Hays Lee Travis Williamson Sendero is a not-for-profit Health Maintenance Organization (HMO) licensed by the Texas Department of Insurance. By choosing Sendero, you and your child will get all the CHIP and CHIP Perinate health benefits plus more: Your own doctor Friendly and confidential staff Access to many hospitals Free health education Free extra benefits (see pages 27 and 50 of this handbook) Assurance of access to care regardless of nationality, race, religion, origin and gender If you have any questions or concerns about access of care, or feel that you were not allowed access to care because of nationality, race, religion, origin, or gender, please contact Sendero Member Services at as soon as possible. Your concern will be investigated and resolved quickly. The doctor you chose for you and/or your child when you enrolled with Sendero will be you and/or your child s Primary Care Provider (PCP) and will help take care of all you and your child s health care needs.

9 Page 2 First things first. These are a few important things about you and your child s health care: You will receive a Sendero ID Card, if you have not already received one Your PCP s name will be on the Sendero ID Card. Please check the ID Card to make sure the names on it are correct. Get to know you and your child s doctor. Make an appointment with your PCP as soon as possible. Call your PCP for appointments. Tell them you and your child are Sendero CHIP/CHIP Perinate members. Call your PCP whenever you/your child needs health care Follow your PCP s advice Carry your Sendero ID Card(s) with you at all times Use the hospital emergency room for emergencies This Member Handbook answers many questions about Sendero. We hope you read it soon. Keep it in a place where you can find it easily. Please feel free to call or write us if you have any questions. At Sendero we are ready to help you any time during the day or night. We have special services for people who have trouble reading, hearing, seeing, or speak a language other than English or Spanish. If you need this Handbook in a different language, in audio form, larger print, or Braille, let us know and we will get it to you. Just call Sendero Member Services at as soon as possible. Sendero will give these materials to you at no cost. Welcome to Sendero! CHIP Member Handbook

10 Page 3 Important Information! Call Us: Member Services (English or Spanish) (toll-free) For hearing impaired: (TDD) toll-free Interpreter Services also available Write Us: Regular Business Hours: 2028 E. Ben White Blvd., Suite 400 Austin, Texas :00 5:00 CST, Monday through Friday except for state approved holidays Before 8:00am or After 5:00pm: Call and leave a message. We will return your call the next working day. 24 Hour Behavioral Health Hotline: Call (English or Spanish) for information on services. Other interpretive services available. If there is an emergency or crisis, go to the ER or call Hour Nurse Line: If you need medical advice or wish to learn more about a medical condition, you can call this number 24 hours a day, 7 days a week. Vision and Eye Care Number: CHIP Help Line: Dental Care Number: Pharmacy Help Line: Call (toll-free) for questions regarding eye exams and glasses Call (toll-free) Call (toll-free) for questions about dental care Call (toll-free) if you need help getting a prescription filled. Non-Urgent Transportation: Call Member Services toll-free

11 Page 4 YOUR CHIP ID CARD You will get a CHIP Identification (ID) card after you enroll in Sendero. A sample copy of the Sendero ID Card is shown below: Children s Health Insurance Program (CHIP) Member Name: Member ID#: Effective Date: PCP: PCP Phone #: Effective Date of PCP: Co-payment Amounts/Co-pagos: OV: $5 ER: $5 IP: $25 R Brand: $5 R Generic: $0 No Co-payment for CHIP Perinate Newborn No hay Co-pago para los recien Nacidos Perinatal Customer Service Phone Number: FRONT TDI Important Information/Información Importante 24/7 Member Services/Departamento de Servicios para Miembros (gratis) TTY for hearing impaired/tty para personas con problemas del oído /7 Behavioral Health Hotline/Linea de Servicios de Salud Mental Vision Services/Servicios para la vista In case of emergency call 911 or go to the closest emergency room. After treatment, call your PCP within 24 hours. En caso de emergencia, llame al 911 o vaya a la sala de emergencias más cercana. Después de recibir tratamiento, llame al PCP dentro de las 24 horas. NOTICE TO PROVIDER: The member whose name appears on the face of this card is covered by for CHIP services. For provider billing or UM questions, The UM FA number is Submit Claims to:, PO Box 3869, Corpus Christi, T Pharmacist (Only) Call: BIN: PCN: MCD Rx GRP: SND REV 3/14 BACK You and each of your children will have a different card. You will not get a new Sendero CHIP ID Card every month. You will get a new one if you lose your ID Card, or if you call us to change your Primary Care Provider (PCP). Reading the Sendero CHIP ID Card The front of the Sendero CHIP ID card shows important information about you and your child, the PCP s name and PCP s phone number. The back of the card shows important phone numbers for help from Sendero Member Services. If you have an emergency, call 911 or go to the nearest emergency room. Using the Sendero CHIP ID Card Carry your and your child s Sendero CHIP ID Card with you when you and your children get any health care services. You must show your Sendero CHIP ID Card each time you receive health care services. If you lose your Sendero CHIP ID Card or move If you lose the Sendero CHIP ID Card, call us right away at to get a new one. If you move or change phone numbers, call us so we can send you another ID Card. We always need to have your correct address and phone number. PLEASE NOTE: References to you, my or I apply if you are a CHIP member. References to my child apply if you are a CHIP member or CHIP Perinate member. CHIP Member Handbook

12 Page 5 ALL ABOUT PCPS FOR CHIP MEMBERS AND CHIP PERINATE NEWBORN MEMBERS What do I need to bring to my/my child s doctor s appointment? You must take your child s Sendero ID Card with you when you go to the doctor. Don t forget your child s ID Cards and shot records. What is a Primary Care Provider (PCP)? During the enrollment process, you chose a doctor, nurse or clinic from our list to be your child s PCP. This doctor will make sure that your child gets the right care. The PCP will give your child regular checkups, write prescriptions for medicines and supplies when your child is sick, and tell you if your child should see a specialist. To give you the best care possible, your PCP needs to know your child s medical history. Your medical records are private and confidential. Only you, your child s PCP, and other approved providers have a right to see them. If you change doctors for your child, be sure to give the new PCP any information needed about your child s medical history. How do I change my child s Primary Care Provider (PCP)? You may want to change your child to another PCP if: You are not happy with the PCP s care You need a different kind of doctor to take care of your child You move farther away from your child s PCP Your child s PCP is no longer a part of Sendero You/your child do not get along with the PCP You can change your child s PCP by calling toll-free at The Sendero Provider Directory lists all PCPs. You can find it on the Internet at or call us and we will send a copy to you. You will get a new Sendero ID Card that shows the date your new PCP can begin to care for your child. The new card will show the new PCP s name and phone number. Can a clinic be my/my child s Primary Care Provider (PCP)? You may select a clinic as your child s PCP. This can be a Federally Qualified Health Center (FQHC), or a Rural Health Clinic (RHC). If you have questions call Sendero Member Services at

13 Page 6 How many times can I change my/my child s PCP? There is no limit on how many times you can change your child s Primary Care Provider. You can change Primary Care Providers by calling us toll-free at or writing to us at: 2028 E. Ben White Blvd., Suite 400 Austin, T When will the PCP change become effective? You may change your PCP at any time. If you call before the 15 th of the month, the change will become effective immediately. If you call after the 15 th of the month, the PCP will not change until the first of the next month. If your child sees the new PCP before the change, you may have to pay the bill. Are there any reasons why a request to change a PCP may be denied? You may not be able to have the PCP you chose for your child if: The PCP you picked is not seeing new patients, or The PCP you picked is no longer a part of Sendero Can a PCP move me or my child to another PCP for non-compliance? It is important to follow the PCP s advice. Take part in decisions about your child s health care. Your PCP may ask us to assign your child to another PCP if you do not follow his or her advice. It may also happen if you and the PCP do not get along or you miss visits without calling to tell the PCP why you weren t there. The PCP must notify us if this occurs. We will contact you and ask that you select another PCP for your child. What if I choose to go to another doctor who is not my/my child s PCP? You may take your child to any provider who is part of Sendero, if you need 24-hour emergency care from an emergency room. If you need mental health or substance abuse services for your child, you should call the Behavioral Health Hotline at Behavioral Health Services are very private so you do not need the permission from your PCP to get these services. If your child needs a routine vision exam, you do not need permission from the PCP to get these services. But if your child has an eye problem you will need a referral from your PCP. For questions about vision services, call For all other care, your child must only see the PCP listed on his/her Sendero ID Card. If your child sees another PCP, you may have to pay the bill. CHIP Member Handbook

14 Page 7 How do I get medical care after my/my child PCP s office is closed? If your child gets sick at night or on a weekend and cannot wait to get medical care, call your child s PCP for advice, or call our nurse advice line at Your child s PCP is available by phone 24 hours a day, 7 days a week. PHYSICIAN INCENTIVE PLAN INFORMATION A physician incentive plan rewards doctors for treatments that reduce or limit services for people covered by CHIP. Right now, Sendero does not have a physician incentive plan. ALL ABOUT Primary Care Providers FOR CHIP PERINATE MEMBERS What do I need to bring to a Perinatal Provider s appointments? You must take your Sendero ID Card with you when you go to the doctor. If you have not seen them before, you should be prepared to answer any questions the doctor may have about your medical history. Can a clinic be my Perinatal Provider? You may select a clinic as your Perinatal Provider. This can be a Federally Qualified Health Center (FQHC), or a Rural Health Clinic (RHC). If you have questions call Sendero Member Services at How do I get medical care after my Perinatal Provider s office is closed? If you get sick at night or on a weekend and cannot wait to get medical care, call your Perinatal Provider for advice, or call our nurse advice line toll-free at Your Provider or another doctor is available by phone 24 hours a day, 7 days a week.

15 Page 8 CHANGING HEALTH PLANS FOR CHIP Program MEMBERS What if I want to change health plans? You are allowed to make health plan changes: For any reason within 90 days of enrollment in CHIP and once thereafter; For cause at any time; If you move to a different service delivery area; and During the annual CHIP re-enrollment period Who do I call? For more information, call CHIP toll-free at How many times can I change health plans? Families can change plans only once a year. For more information, call CHIP toll free at When will my health 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 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 FOR CHIP PERINATAL 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. 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. CHIP Member Handbook

16 Page 9 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 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 the 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: For any reason within 90 days of enrollment in CHIP Perinatal; If you move into a different service delivery area; and For cause at any time. Who do I call? For more information, call toll-free at When will my health 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 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

17 Page 10 Can Sendero ask that I get dropped from their health plan for non compliance, etc? Yes, Sendero may request that you be dropped from our health plan if: You let someone else use your Sendero ID Card; You do not follow your doctor s advice, for you/your child; You keep going to the emergency room for yourself or your child when you do not have a true emergency; You cause problems at the doctor s office; or You make it difficult for your doctor to help you, your child or other people. How long is my baby covered? How does renewal work? Your baby s coverage is for twelve months. The coverage begins when you enroll the unborn baby when you are pregnant. After the twelve months of coverage ends, you can apply through the state CHIP office to have your baby covered under the CHIP program. How do I sign up my newborn baby? If you are a Sendero Member when you have your baby, your baby is enrolled with Sendero on his/her date of birth. Sendero gets information from the hospital to add your baby as a new Sendero Member. However, it is important that you contact the Texas CHIP program to also report the birth of your baby, so your baby can get all the health care he/she needs. What benefits does my baby receive at birth? If your family is at or below 185% of the Federal Poverty Level (FPL), your newborn will be moved to Medicaid for 12 months of continuous Medicaid coverage beginning on the date of birth. Call to learn more about Medicaid coverage. If your family is above 185% to 200% of the FPL, your child will be eligible to receive the CHIP benefits outlined in this handbook. HHSC will enroll your newborn in your CHIP plan, following standard cut-off rules. CHIP Member Handbook

18 Page 11 BENEFITS AVAILABLE FROM SENDERO FOR CHIP MEMBERS PLEASE NOTE: References to you, my or I apply if you are a CHIP member. References to my child apply if you are a CHIP member or CHIP Perinate member. Sendero gives you every covered service that you are entitled to get through the CHIP and CHIP Perinate Newborn programs. Please see your Evidence of Coverage for covered services and services that are not covered. WHAT ARE MY CHIP BENEFITS? The following explains the CHIP benefits. type of benefit description of benefit limitations copay Inpatient General Acute and Inpatient Rehabilitation Hospital Services Services include: Hospital - given doctor 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 not given free-of-charge to the patient and their administration -rays, imaging and other radiological tests (facility technical component) Requires Notification for nonemergency care and following stabilization of an emergency condition Requires authorization for out-of-network facility and doctors services as well as 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 section Applicable level of inpatient copay applies

19 Page 12 type of benefit description of benefit limitations copay Inpatient General Acute and Inpatient Rehabilitation Hospital Services Laboratory and pathology services (facility technical component) Machine diagnostic tests (EEGs, EKGs, etc.) Oxygen services and inhalation therapy Radiation and chemotherapy Access to DSHS-designated Level III perinatal centers or hospitals meeting equivalent levels of care 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 Hospital, doctor and related medical services, such as anesthesia, associated with dental care 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 provider administered medications; ultrasounds; and histological examination of tissue samples CHIP Member Handbook

20 Page 13 type of benefit description of benefit limitations copay Inpatient General Acute and Inpatient Rehabilitation Hospital Services 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 Inpatient services for 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) 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 Requires authorization and doctor prescription Copays do not apply

21 Page 14 type of benefit description of benefit limitations copay Outpatient Hospital, Comprehensive Outpatient Rehabilitation Hospital, Clinic (Including Health Center) and Ambulatory Health Care Center Services include, but are not limited to, the following services provided in a hospital clinic or emergency room, a clinic or health center, hospital-based emergency department or an ambulatory health care setting: -ray, imaging, and radiological tests (technical component) if performed in an emergency room setting Laboratory and pathology services (technical component) Machine diagnostic tests Ambulatory surgical facility services Drugs, medications and biologicals Casts, splints, dressings Preventive health services Renal dialysis Respiratory services Radiation and chemotherapy Blood or blood products not offered free-of-charge to the patient and the administration of these products Facility and related medical services, such as anesthesia, associated with dental care, when offered 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 nonviable pregnancy include, but are not limited to: dilation and curettage (D&C) procedures; appropriate provider administered medications; ultrasounds; and histological examination of tissue samples May require prior authorization and doctor prescription Applicable level of copay applies to prescription drug services Copays do not apply to preventive services CHIP Member Handbook

22 Page 15 type of benefit description of benefit limitations copay Outpatient Hospital, Comprehensive Outpatient Rehabilitation Hospital, Clinic (Including Health Center) and Ambulatory Health Care Center 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 (excluding pumps and/or devices) 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

23 Page 16 type of benefit description of benefit limitations copay Doctor / Doctor Extender Professional services Services include, but are not limited to the following: American Academy of Pediatrics recommended well-child exams and preventive health services (including but not limited to vision and hearing screening and immunizations) Doctor office visits, inpatient and outpatient services Laboratory, -rays, imaging and pathology services, including technical component and/or professional interpretation Medications, biologicals and materials administered in doctor 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 doctor (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 examination Hospital-based doctor services (including doctorperformed technical and interpretative components) May require authorization for specialty services Applicable level of copay applies to office visits Copays do not apply to preventive visits or to prenatal visits after the first visit CHIP Member Handbook

24 Page 17 type of benefit description of benefit limitations copay Doctor / Doctor Extender Professional services Doctor 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 produce symmetrical appearance; and treatment of physical complications from the mastectomy and treatment of lymphedemas In-network and out-ofnetwork doctor 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 Doctor services medically necessary to support a dentist providing dental services to a CHIP member such as general anesthesia or intravenous (IV) sedation Doctor services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero.) Doctor services associated with miscarriage or nonviable pregnancy include, but are not limited to: dilation and curettage (D&C) procedures; appropriate provider administered medications; ultrasounds; and histological examination of tissue samples

25 Page 18 type of benefit description of benefit limitations copay Doctor / Doctor Extender Professional services 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; 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 type of benefit description of benefit limitations copay Inpatient Mental Health Services Mental health services, including care for serious mental illness, furnished in a free-standing psychiatric hospital, in psychiatric units of general acute care hospitals and in state operated facilities. Does not require prior authorization Does not require Primary Care Provider referral When inpatient 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. Neuropsychological and psychological testing DO require Prior Authorization Applicable level of inpatient copay applies CHIP Member Handbook

26 Page 19 type of benefit description of benefit limitations copay 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 communitybased settings (including school and home-based) or in a stateoperated facility Medication management Rehabilitative day treatments Residential treatment services Sub-acute outpatient services (partial hospitalization or rehabilitative day treatment) Skills training (psychoeducational skill development) Does not require prior authorization for the first 20 visits, then preauthorization is required Does not require Primary Care Provider referral Neuropsychological and psychological testing DO require Prior Authorization 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. A Qualified Mental Health Professional 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 doctor and provides 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 in-home services), patient and family education, and crisis services. Applicable level of copay applies to office visits

27 Page 20 type of benefit description of benefit limitations copay Durable Medical Equipment (DME), Prosthetic Devices and Disposable Medical Supplies 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 help 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 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 Requires prior authorization and doctor 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) Copays do not apply CHIP Member Handbook

28 Page 21 type of benefit description of benefit limitations copay Home and Community 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 Requires prior authorization and doctor 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 Copays do not apply

29 Page 22 type of benefit description of benefit limitations copay 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, crisis stabilization, and 24-hour residential rehabilitation programs. Does not require prior authorization Does not require Primary Care Provider referral Applicable level of inpatient copay applies Outpatient Substance Abuse Treatment Services Outpatient substance abuse treatment services include, but are not limited to: Prevention and intervention services that are offered by doctor and non-doctor providers, such as screening, assessment and referral for chemical dependency disorders Intensive outpatient services Partial hospitalization Intensive outpatient services is defined as an organized nonresidential 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 Does not require prior authorization for the first 20 visits, then preauthorization is required Does not require Primary Care Provider referral Outpatient treatment services up to a maximum of: Intensive outpatient program (up to 12 weeks per 12-month period) Outpatient services (up to sixmonths per 12-month period) Applicable level of copay applies to office visits Rehabilitation Services Habilitation (the act 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 Requires pre-authorization after the 8 th visit and a physician s prescription Copays do not apply CHIP Member Handbook

30 Page 23 type of benefit description of benefit limitations copay Hospice Care Services Services include, but are not limited to: Palliative care, including medical and support services, for children who have six months or less to live, to keep patients comfortable during the last weeks and months before death Treatment services, including treatment related to the terminal illness, are unaffected by electing hospice care services Requires notification only Services apply to the hospice diagnosis Up to a maximum of 120 days with a 6 month life expectancy Patients electing hospice services may cancel this election at anytime Copays do not apply Emergency Services, including Emergency Hospitals, Doctors, and Ambulance Services Health plan cannot require authorization as a condition for payment for emergency conditions or labor and delivery. Covered services include: Emergency services based on prudent layperson definition of emergency health condition Hospital emergency department room and ancillary services and doctor services 24 hours a day, 7 days a week, both by in-network and out-of-network providers Medical screening examination Stabilization services Access to DSHS designated Level I and Level II trauma centers or hospitals meeting equivalent levels of care for emergency services Emergency ground, air or water transportation Emergency dental services, limited to fractured or dislocated jaw, traumatic damage to teeth, and removal of cysts May require authorization for post-stabilization services or equipment Applicable copays apply to non-emergency room visits

31 Page 24 type of benefit description of benefit limitations copay Transplants Covered services include: Using up-to-date Medicare and/or FDA guidelines, all nonexperimental human organ and tissue transplants and all forms of non-experimental corneal, bone marrow and peripheral stem cell transplants, including donor medical expenses Requires notification prior to placing on transplant list Copays do not apply Vision Benefit Covered services include: One examination of the eyes to find the need for and prescription for corrective lenses per 12-month period, without authorization One pair of non-prosthetic eyewear per 12-month period The health plan may reasonably limit the cost of the frames/ lenses Requires preauthorization for protective and polycarbonate lenses when medically necessary as part of a treatment plan for covered diseases of the eye Applicable level of copay applies to office visits billed for refractive exam Chiropractic Services Covered services do not require doctor prescription and are limited to spinal subluxation Requires preauthorization for more than 8 visits Applicable level of copay applies to chiropractic office visits Tobacco Cessation Programs Covered up to $100 for a 12-month period limit for a plan-approved program Does not require prior authorization Health Plan defines planapproved program May be subject to formulary requirements Copays do not apply CHIP Member Handbook

32 Page 25 How do I get these services for my child? Your child s PCP will work with you to make sure your child gets the care needed. You may call Member Services at at any time you have questions. There may be limitations to these services. Call Member Services for information on any limits. What are copayments and when do I have to pay them? Copayment means the amount that a member is required to pay when utilizing certain benefits within the health care plan. The copayment is due at the time of service. Once the copayment is made, further payment is not required by the member. How much are they? The chart below shows the copayments you must make to the provider for certain services for your child covered under CHIP. Members recieving the CHIP Perinatal benefit are exempt from all cost-sharing obligations, including enrollment fees and co-pays. Additionally, CHIP Members are exempt from copays on benefits for well-baby and well-child services, preventative services, or pregnancy-related assistance. federal poverty levels office visits non-emergency er visits inpatient hospitalizations prescription generic drugs prescription brand drugs cost-sharing limits native americans $0 $0 $0 $0 $0 $0 at or below 100% $3 $3 $15 $0 $3 101% 150% $5 $5 $35 $0 $5 151% 185% $20 $75 $75 $10 $35 186% 200% $25 $75 $125 $10 $35 5% of family income per enrollment period 5% of family income per enrollment period 5% of family income per enrollment period 5% of family income per enrollment period

33 What services are not covered? Services not covered for CHIP: Page 26 Inpatient and outpatient infertility treatments or reproductive services other than prenatal care, labor and delivery, and care related to disease, illnesses, or abnormalities related to the reproductive system Personal comfort items including but not limited to personal care kits provided on inpatient admission, telephone, television, newborn infant photographs, meals for guests of patient, and other articles which are not required for the specific treatment of sickness or injury Experimental and/or investigational medical, surgical or other health care procedures or services which are not generally employed or recognized within the medical community Treatment or evaluations required by third parties including, but not limited to, those for schools, employment, flight clearance, camps, insurance or court Private duty nursing services when performed on an inpatient basis or in a skilled nursing facility Mechanical organ replacement devices including, but not limited to artificial heart Hospital services and supplies when confinement is solely for diagnostic testing purposes, unless otherwise pre-authorized by Health Plan Prostate and mammography screening Elective surgery to correct vision Gastric procedures for weight loss Cosmetic surgery/services solely for cosmetic purposes Dental devices solely for cosmetic purposes Out-of-network services not authorized by the Health Plan except for emergency care 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 Services, supplies, meal replacements or supplements provided for weight control or the treatment of obesity, except for the services associated with the treatment for morbid obesity as part of a treatment plan approved by the Health Plan Acupuncture services, naturopathy and hypnotherapy Immunizations solely for foreign travel Routine foot care such as hygienic care Diagnosis and treatment of weak, strained, or flat feet and the cutting or removal of corns, calluses and toenails (this does not apply to the removal of nail roots or surgical treatment of CHIP Member Handbook

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