Medi-Cal Health Plan. Anthem Blue Cross Partnership Plan Member Services Guide Evidence of Coverage. Effective July

Transcription

1 Medi-Cal Health Plan Anthem Blue Cross Partnership Plan Member Services Guide Evidence of Coverage Effective July ACA-MHB

2 Medi-Cal Health Plan Anthem Blue Cross Partnership Plan Member Services Guide Evidence of Coverage Effective July ACA-MHB

3 Welcome Welcome! You now are a member of Anthem Blue Cross Partnership Plan (Anthem Blue Cross). We work with the state of California to bring you the Medi-Cal Program. Now that you are a member of this health plan family, we want to make sure you get what you need from your health plan. This book explains your new health plan. Here is what you will find inside: How this health plan works The importance of completing your Health Assessment Which services are covered and which are not How to get help if you do not understand something How to get help if you have a problem with this health plan How to get help if you have a problem with a health care provider Your member rights and responsibilities How we keep your information private A 24-hour phone line to call if you need to talk to a registered nurse or want access to hundreds of audio health topics. (The 24/7 NurseLine phone numbers are listed at the bottom of each right-hand page.) Our toll-free Customer Care Center phone numbers listed at the bottom of each right-hand page. Free health programs to help you be well This symbol lets you know when you need an OK from Anthem Blue Cross or your doctor before you get care Definitions for some terms that may be new to you Check for your Anthem Blue Cross member ID card Your Anthem Blue Cross member ID card was sent to you separate from this book. Did you get it? If not, call us toll-free at If you have hearing or speech loss, you may call the TTY line at Your ID card lists your main doctor. We call this person a primary care physician, or PCP. To change your PCP, look through the Provider Directory and choose a new one. Then, fill out the PCP Selection Form sent with this book and mail it back to us. The form already has our address on it. No stamp is needed. How we may contact you During the year we may contact you about important health issues. For example, we may ask you to complete a private health assessment. Or we may let you know when important exams are due or remind you if you forget to refill a prescription. Please open our letters and answer our calls. They are for you and your health. 1

4 Welcome Tell us if you move If you move, Anthem Blue Cross could still be your health plan. When you move, please write or call to give us your new address. Our phone number is If you have hearing or speech loss, you may call our TTY line at And here s our address: Anthem Blue Cross Partnership Plan P.O. Box 9054 Oxnard, CA Anthem Blue Cross could still be your health plan if you live in: Alameda, Alpine, Amador, Butte, Calaveras, Colusa, Contra Costa, El Dorado, Fresno, Glenn, Inyo, Kings, Madera, Mariposa, Mono, Nevada, Placer, Plumas, Sacramento, San Benito, San Francisco, Santa Clara, Sierra, Sutter, Tehama, Tulare, Tuolumne or Yuba. Call us to get a Provider Directory that lists the names of doctors near your new home. You also can find a list of providers on our website at anthem.com/ca/medi-cal. If you need to change your PCP, choose one from the Provider Directory. Then, fill out the PCP Selection Form and mail it back to us. Questions? Comments? Monday through Friday from 7 a.m. to 7 p.m. If you have hearing or speech loss, you may call our TTY line at You also may call the 24/7 NurseLine, the 24-hour nurse help line, toll free 24 hours a day, seven days a week. That phone number is The 24/7 NurseLine TTY line is If you have hearing or speech loss, you also may call the California Relay Line at 711 at any time. This combined Evidence of Coverage and Disclosure Form is a summary only. The contract itself should be read to decide what rules apply. Podemos traducir esto gratuitamente. Llame al número de servicio de atención al cliente que aparece en su tarjeta de identificación (ID card). 2

5 Table of Contents Table of Contents Welcome!... 1 Check for your Anthem Blue Cross member ID card... 1 How we may contact you... 1 Tell us if you move... 2 Questions? Comments?... 2 Part 1 Important things to do... 7 Part 2 Important phone numbers... 9 Part 3 Benefit quick reference guide...10 Part 4 How to use your health plan...17 Your Anthem Blue Cross member ID card...17 Choosing a PCP...18 Appointment Accessibility Standards...19 Provider Directory...20 Physician incentive plans...21 Initial health assessment (IHA)...21 Making an appointment with your PCP...21 What to do when your PCP s office is closed...22 Changing your PCP...22 Specialist care and prior authorization (an OK from Anthem Blue Cross)...23 Standing referrals...24 Getting a second medical opinion...24 Utilization Management (UM)...25 Out-of-area care...25 Out-of-network care...26 How to get answers from Anthem after business hours...26 Important Note...26 For women...27 For you and your child...28 For managing illnesses...28 Disease Management...28 Part 5 What Anthem Blue Cross covers

6 Table of Contents Ambulance services...29 Dental care...29 Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services...30 *Behavioral health treatment (BHT)...30 Emergency and post-stabilization services...31 Family planning services...31 Limits...32 Long-Term Services and Supports (LTSS)...34 Mental health and substance use services...36 Pregnancy and maternity care...37 Vision services...41 Part 6 Sensitive and private care...42 Adolescent sensitive services (minor consent services)...42 Adult sensitive services...42 Sensitive and private care abortion services for adults and adolescents...42 Part 7 What Anthem Blue Cross does not cover...43 Dental care...43 Medical equipment...43 Mental health/substance abuse (inpatient care)...43 Mental health/substance abuse (outpatient care)...44 Pregnancy and maternity care...44 Professional services...44 Other services...45 California Children s Services (CCS)...46 Part 8 How to get prescription drugs...48 What can my doctor prescribe?...48 Compound Drugs...48 Where can I get my prescriptions filled?...49 Medicare Part B and D prescription coverage...49 Part 9 Emergency and urgent care services...50 What is an emergency?...50 What to do in an emergency...50 What to do when you need urgent care...51 Not sure if it s an emergency?

7 Table of Contents How to get emergency transportation...51 Post-stabilization care after an emergency...52 Part 10 Programs to help keep you well...53 For healthy living...53 For women...53 For you and your child...54 For managing illnesses...54 Disease Management DMCCU...54 Care Management...55 For your peace of mind...55 How to use these programs...55 Extra programs from your state...55 Part 11 Help with special services...57 Help for members who do not speak English...57 Help for members with hearing or vision loss...57 The Americans with Disabilities Act of Part 12 How to resolve a problem with Anthem Blue Cross...59 If you have a problem (complaint)...59 State fair hearing...60 To file an appeal...61 To disenroll (leave this health plan)...61 Expedited (quick) disenrollment...61 Department of Managed Health Care...62 Other help...62 Part 13 If we no longer can serve you...63 Other reasons we can t keep you on our plan...63 Waiver programs...64 Part 14 Other things you may need to know...65 Advance directives (living wills)...65 Approval of new medical treatments...65 Cancer clinical trials...66 Clinical trials...66 Deductibles and copays...68 How we pay providers

8 Table of Contents How to send us a claim...68 Information you can get annually (each year)...69 Keeping your information private...69 Organ donation...70 Plan changes...70 Public participation...70 Quality Improvement...70 Third-party liability...71 Transitional Medi-Cal (TMC)...71 What to do if you get a bill...71 Reporting client or provider waste, abuse and fraud...71 Part 15 Your health care rights and responsibilities...73 Your Health Care Rights and Responsibilities...73 Get the information you need to make sure you get the most from your health plan and share your feedback. This inc ludes information on:...73 What are your responsibilities as a health care consumer?...74 Part 16 Definitions

9 Part 1 Important things to do Part 1 Important things to do Keep your Anthem Blue Cross ID card with you at all times. Show it each time you need health care service. Do not let anyone else use your ID card. Check that the PCP on your ID card is the one you want. If you want a new PCP, let us know right away. Set up an appointment for an initial health assessment (first health visit) with your PCP right away. During the first visit, your PCP learns about your health care needs to help you stay healthy. If you are an adult, this visit needs to be within 120 days after joining Anthem Blue Cross. For children under 18 months of age, this visit needs to be within 60 calendar days after joining Anthem Blue Cross. Call your PCP before you get medical care, unless you have an emergency. Your doctor s office staff will help you set up a health visit for care. If you need a ride to and from your doctor visit, call our toll-free Customer Care Center at You can get interpreter service by calling our toll-free Customer Care Center number. If you have hearing or speech loss, you may call our TTY line at If you need a face-to-face interpreter, please call us 72 hours in advance. If you need to cancel, we require 24-hour notice. Obtain early prenatal care for your pregnancy. Early care with an OB is important you can make an appointment with an OB without making a PCP appointment first. Go to Part 5 to find out more. Call the toll-free 24/7 NurseLine at (TTY line ) if you are not sure what to do. You can access registered nurses (RNs) at this line 24 hours a day, seven days a week, to help you with your health questions. Have your ID card ready when you call. The nurse will ask for your ID card number. Call 911, if you have a medical EMERGENCY. Get help right away. Call 911 or go to the nearest emergency room (ER) for medical care. You will be covered for emergency care even if the provider is not part of the Anthem Blue Cross network. Health Assessment. You are the one who knows the most about your health. As a part of your health plan, you will be asked to complete a personal and private health assessment. The assessment is a ten-minute survey. The assessment is voluntary. This information is private. We use what you tell us in the health survey to ensure you get the most out of your health plan. For example, if you tell us you have not had a health exam in over a year, we will help you schedule your free yearly exam. Or if you forget to refill a prescription, we will send you a gentle reminder. Finally, we may use your information to direct you to certain services like New Baby, New Life if you are pregnant. Your health is important to you. You will get a letter about your personal health assessment. The letter will let you know what number to call for more information. You can call any time, day or night. Your private health assessment is very important to you, so be sure to answer all the questions as best as you can. 7

10 Part 1 Important things to do You are important to us. We want to help you get the health care you need. Thank you for being part of the Anthem Blue Cross health plan family. 8

11 Part 2 Important phone numbers Part 2 Important phone numbers Anthem Blue Cross Customer Care Center TTY /7 NurseLine (24-Hour Nurse Help Line) TTY Anthem Care Management Department of Managed Health Care TTY Denti-Cal TTY Vision Service Plan TTY Department of Health Care Services Office of Family Planning Department of Social Services Public Inquiry and Response Unit TTY Department of Health Care Services Medi-Cal Managed Care Ombudsman Health Care Options Indian Health Services Express Scripts, Inc. (ESI) California Relay Line TTY lines are only for members with hearing or speech loss. 9

12 Part 3 Benefit quick reference guide Part 3 Benefit quick reference guide We want to help you get the care you need. The charts below tell you about the benefits covered by your health plan. This chart is a summary only. Please refer to Part 5 What Anthem Blue Cross covers for a full list of your plan s benefits. You may need an OK ahead of time from your PCP and/or Anthem Blue Cross for some of these services. Anthem Blue Cross will pay only for covered services that are medically necessary. If you are out of town and need help to get an OK for medical care, call us at our toll-free Customer Care Center or CCC TTY number (for members with hearing or speech loss). Benefit Coverage Limits Services from a licensed ambulance company or air ambulance for an emergency health issue only Ambulance services Dental care We cover: Treatment when your natural teeth are damaged or broken by an accident (when care is given within six months of the damage) General anesthesia for dental work given in a hospital or surgical center to members: Who are younger than 7 years of age. Have a developmental (growth) issue and are under 21 years of age. Who need it when medically necessary. Diagnostic X-ray and lab services CT, MRI, MRA, PET and SPECT tests need an OK from us. Early and Periodic Screening, Diagnosis, and Treatment We cover: Blood tests X-rays Lab tests Pap tests Human papillomavirus (HPV) tests Preventive health care services, including: Health screenings Physical exams Hearing screenings You must use a lab in the network. Services are for members under 21 years of age only 10

13 Part 3 Benefit quick reference guide Benefit Coverage Limits (EPSDT) services Dental screenings Vaccines Lab tests, including checking blood lead level Behavioral health Teaching you about health topics treatments (BHT) Behavioral health treatment to children and benefits need OK adolescents 0-21 years of age diagnosed with from us. Autism Spectrum Disorder (ASD) Emergency and post-stabilization services Family planning services Home health care Hospice Out-of-network hospice providers and in-patient hospice care only. Hospital services All emergency services you get in the U.S. are covered. You do not need an OK from us for any of these services. We cover: Medical visits for birth control Teaching you about family planning Counseling Birth control Pregnancy tests and other lab tests Tests for sexually transmitted infections (STI) Sterilization We cover: Visits or supplies from a licensed home health agency or nurse group Care from a health aide who works under a registered nurse or a therapist Physical, occupational (work-related) or speech therapy We cover: Medical care Physical needs Social needs Spiritual comfort We cover: A hospital room with two or more beds Care in special units We do not cover: Surgery to reverse sterilization Hysterectomy for sterilization reasons Fertility treatments such as artificial insemination and in vitro fertilization We do not cover: Comfort items, including but not 11

14 Part 3 Benefit quick reference guide Benefit Coverage Limits You do not need an OK from us if you are having a baby or an emergency. Operating, delivery or special treatment rooms Dialysis treatment Drugs, including oxygen, the hospital gives you during your stay Physical, occupational (work-related) or speech therapy Giving you someone else s blood Chemotherapy Radiation therapy Breast cancer surgery (mastectomy or lymph node dissection): You and your doctor decide how long you will need to stay in the hospital after breast cancer surgery. We will cover care for any problems that come from the surgery, including lymphedema. Long-Term Services and Supports (LTSS) Some LTSS benefits are covered by us for all members who qualify to receive these services. Multi-Purpose Senior Services Program (MSSP) You may qualify for MSSP services if you are 65 years or older with disabilities and are eligible for nursing facility placement but wish to remain at home. MSSP services allow you to remain safely at home as an Services provided by MSSP may include: - Adult day care/support center - Housing assistance - Chore and personal care assistance - Protective supervision - Care management - Respite - Transportation - Meal services - Social services - Communication services. IHSS benefits may include the following services: - Meal preparation and cleanup - Laundry - Personal care services (such as limited to: Telephones Television Guest meals A private room will be covered when medically necessary. 12

15 Part 3 Benefit quick reference guide Benefit Coverage Limits alternative to nursing facility placement. In-Home Supportive Services (IHSS) If you are disabled, or blind, or are over 65 years of age and are unable to live at home without help, you may qualify for IHSS benefits. IHSS allows you to remain safely in your own home. You do not qualify if you live in a nursing or community care facility. Medical supplies and equipment Medical supplies and equipment need an OK from your PCP and us. All custom-made durable medical equipment needs an OK from us. bowel and bladder care, bathing, grooming and paramedical services) - Grocery shopping and errands - Transportation to medical appointments - Household and yard cleaning - Accompaniment to medical appointments - Protective supervision We cover: Man-made body parts to replace missing body parts A prosthesis to replace a breast (after mastectomy) and make it look the same as the real breast Supplies needed for an ostomy Equipment and supplies needed for diabetes: Blood sugar monitors Blood and urine testing strips Insulin pumps and all supplies needed for the pump We do not cover: Items used only for comfort or hygiene Items used only for exercise Items used only for making a room or home more comfortable, such as: Air conditioning Air filters Air purifiers Spas Swimming pools Pregnancy and maternity care We cover: Doctor care while you are pregnant and after You have the right to stay in the hospital at least 48 hours after a 13

16 Part 3 Benefit quick reference guide Benefit Coverage Limits you give birth Nurse-midwife services (a person other than a doctor or nurse who helps deliver your baby) Tests (while you are pregnant) to see if the baby is healthy or sick (when you have a high vaginal delivery. You have the right to stay in the hospital for at least 96 hours after a cesarean section (C-section). risk of having a sick baby) Hospital care Vaginal childbirth and C-section Newborn baby exam Alpha-fetoprotein (AFP) screening Abortions (a procedure to end pregnancy) Mental health and Substance use disorder services include We do not cover substance use Screening, Brief Intervention, and Referral to services for conditions services Treatment (SBIRT). identified as relational (Outpatient) problems such as Mental health benefits include: Individual and group mental health evaluation and treatment (psychotherapy) Psychological testing when clinically indicated to evaluate a mental health condition Outpatient services for the purposes of monitoring drug therapy Outpatient laboratory, drugs, supplies and supplements Psychiatric consultation couples counseling and family counseling. Professional services Some professional services need an OK from your PCP and us. We cover: Routine doctor visits for health problems, first-time visits and vaccines Specialist office visits Well-baby and well-child care Well-woman care Care by a foot doctor for foot and ankle problems Child Health and Disability Prevention (CHDP) services Putting fluoride varnish on the teeth of children younger than 6 years of age Family planning services You may see any licensed family planning provider without an OK from your PCP or us Foot doctor services are for children and young adults under 21 years of age. Hearing exams are covered for children and young adults under 21 years of age. Speech therapy is covered for children and young adults under 21 years of age. If you are diagnosed with a developmental 14

17 Part 3 Benefit quick reference guide Benefit Coverage Limits Hearing aids for hearing problems. To find the right hearing aid for you, you must: Have your hearing loss measured. Have a full ear, nose and throat exam. Allergy tests Physical, occupational (work-related) or speech therapy disability, you will be referred to a Regional Center. The Regional Center will evaluate your condition and provide access to nonmedical services provided through the Regional Center. Skilled nursing facilities Telehealth We cover: Skilled nursing care on a 24-hour-per-day basis. Bed and board (daily meals). Case management X-ray and laboratory procedures. Physical, Speech and Occupational Therapy. See also Physical and Occupational Therapy and Speech Therapy. Prescribed drugs and medications. Medical supplies, appliances and equipment ordinarily furnished by the SNF. Telehealth allows your doctor and you to meet with specialists who can see and talk to you and your doctor at the same time using computers and other special equipment. We cover care that includes long-term care for the month you enter the facility and the month after that. Transportation (when it is not an emergency) We cover: Your nonemergency transfer from a hospital to another hospital, facility or your home Vision (eyesight) services For children and young adults under 21 years of age, we cover: One eye exam and one pair of glasses every two years For adults over 21 years of age, we cover: One eye exam every two years A yearly eye exam if you have diabetes Medically necessary contact lenses and eyesight aids We do not cover: Eyeglasses or contact lenses used for reasons other than to fix your eyesight (such as for your looks or your job). Eye surgery to fix 15

18 Part 3 Benefit quick reference guide Benefit Coverage Limits eyesight (such as near-sightedness). 16

19 Part 4 How to use your health plan Part 4 How to use your health plan If you have any questions, please call our toll-free Customer Care Center or TTY phone number. If you are pregnant, call us. We can help you get the care you need and help you choose a doctor for your baby. Your Anthem Blue Cross member ID card Always carry your ID card with you. Show your ID card to your PCP, hospital or other provider each time you go for health care services. You are the only one who can get health care services with your ID card. If you let someone else use your ID card, we may not be able to keep you on this health plan. Your effective date of coverage is on your card. You can begin getting health care benefits through us on this date. Also, look on your card for these phone numbers: Your PCP s office The toll-free Anthem Blue Cross Customer Care Center phone line The 24/7 NurseLine (24-hour nurse help line) 17

20 Part 4 How to use your health plan Here is a sample of what your ID card could look like: Choosing a PCP New members must choose a PCP (main doctor) within 30 days from the time they enroll. If you do not choose a PCP within 30 days, we will assign one to you. If you need help choosing a doctor who is right for you, call our toll-free Customer Care Center or TTY phone number. Your ID card will have the name, phone number and address of the PCP you chose or the PCP assigned to you if you did not choose one. If you want a new PCP, look in the Provider Directory to find a list of PCPs who work with us. It s best to choose a PCP close to your home. We may ask you to change your PCP if: The PCP s office is more than 10 miles from your home. (You may stay with a PCP who is more than 10 miles from your home. But we may want to talk to you about it.) The PCP is not taking new patients. The PCP is no longer in the Anthem Blue Cross network. The doctor s specialty does not give care to patients your age. 18

21 Part 4 How to use your health plan You may choose a nurse-midwife, a physician s assistant or a nurse practitioner as your PCP. These providers are called mid-level practitioners. Your ID card will list only the name of the doctor who employs this person, but you can still get care from the mid-level practitioner you chose. Female members may see a women s health specialist in the Anthem Blue Cross network without a referral from their PCP. The women s health specialist may be a nurse-midwife, physician s assistant or a nurse practitioner. Call us if you need help finding a women s health specialist. Appointment Accessibility Standards All providers must offer members appointments that fit the standards below. Referring and treating providers may extend the wait time for an appointment, including preventive care services. The provider must decide and note in their records that a longer wait time will not have a negative impact on the member s health. Rescheduling an appointment should be done in a manner that is appropriate for the member s health care needs and makes sure continuity of care is consistent. General appointment scheduling Emergency examination Urgent (sick) examination Nonurgent (sick) examination Routine primary care examination (nonurgent) Nonurgent consults/specialty referrals Nonurgent care with nonphysician mental health providers (where applicable) Nonurgent ancillary Mental health appointment, nonphysician Immediate access, 24 hours/7 days a week Within 24 hours of request Within hours of request or as clinically indicated Within 10 business days of request Within 15 business days of request Within 10 business days of request Within 15 business days of request Within 10 business days of request Initial health assessments Children under the age of 18 months Children age 19 months to 20 years of age Preventive care visits Services for members under the age of 21 Within 60 days of enrollment (or within American Academy of Pediatrics (AAP) guidelines, whichever is less) Within 120 days of enrollment Within 14 days of request Services for members 21 years of age and older Initial health assessments Within 120 days of enrollment Preventive care visits Within 14 days of request Routine physicals Within 30 days of request 19

22 Part 4 How to use your health plan 1st and 2nd trimester 3rd trimester High-risk pregnancy Postpartum Prenatal and postpartum visits Within 7 days of request Within 3 days of request Within 3 days of identification Between 21 and 56 days after delivery Provider Directory Our Provider Directory lists providers that work with Anthem Blue Cross such as: PCPs Obstetricians Gynecologists Certified nurse-midwives Nurse practitioners Optometrists Psychologists Pharmacies Hospitals Skilled nursing facilities Urgent care centers Federally Qualified Health Clinics Indian Health Centers (To learn more about Indian Health Centers, call , or visit The directory lists provider addresses, phone numbers, business hours and the languages spoken by the provider s office staff. You also can check the directory to find out if a provider can take new patients. To find out more about a PCP or other provider, such as the doctor s specialty, medical school, training or board credentials, visit these websites: American Medical Association ( AIM DocFinder ( The level of physical accessibility information of provider offices is listed in our Provider Directories for: Basic access Limited access We also use the following Accessibility Indicator symbols in our Provider Directories to further show the areas of accessibility at a provider office: P = Parking 20

23 Part 4 How to use your health plan EB = Exterior building IB = Interior building W = Waiting room R = Restroom E = Exam room T = Exam table S = Wheelchair weight scale If you need a Provider Directory, call our toll-free Customer Care Center or TTY phone number. Physician incentive plans You have the right to know if your PCP is part of a physician incentive plan through Anthem Blue Cross. To learn more about this, call us at If you have hearing or speech loss, you may call the TTY line at Initial health assessment (IHA) As well as completing your personal health assessment, we ask all new members to see their PCP soon after joining this health plan. The first meeting with your PCP is important because the doctor gets to know your health needs. To do so, the PCP will do an initial health assessment. During the IHA, the doctor will: Get to know you and talk about your health. Learn your medical history. Give you a physical exam. Give you health information you need. Help you to know your health needs. Teach you ways to help make your health better or to help you stay healthy. Provide you with the results of the IHA. Adults need to see their PCP for an IHA within 120 days of joining Anthem Blue Cross. Children under 18 months of age need to see their PCP for an IHA within 120 calendar days of joining Anthem Blue Cross. We want to help you and your family stay healthy. Routine visits to the doctor are important. You can get a copy of the guidelines that tell you about exams, screenings and vaccines that are helpful for infants, children, young adults and adults on the Web. Just go to anthem.com. Please note that your plan may not cover everything listed in these guidelines. To find out more about these guidelines, please call the toll-free CCC or TTY number. Making an appointment with your PCP Call your PCP s office to set up a health visit. Tell the person who answers the phone that you are an 21

24 Part 4 How to use your health plan Anthem Blue Cross member. Have your ID card with you when you call. You may be asked for your member ID number. Make sure to bring your ID card with you for your health visit with your PCP. Be on time for your health visits. Call your PCP s office as soon as you can if: You will be late. You cannot keep your appointment. This will help shorten everyone s time in the waiting room. Your PCP may not be able to see you if you are late. If you cancel your health visit, someone at your PCP s office can help you set up a new one. Call your PCP before you get any medical care, unless you have an emergency. You may get OB/GYN care in the Anthem Blue Cross network without calling your PCP. What to do when your PCP s office is closed If you call your PCP after office hours, you can leave your name and phone number with the answering service. Either your PCP or an on-call doctor will call you back. If this is to set up a routine checkup, it is better to call the office during business hours. If you have a health concern you feel you must speak to someone about right away, please call the 24/7 NurseLine at If you have hearing or speech loss, please call the TTY line at The 24/7 NurseLine nurse can tell you about access to services. If you have an emergency, call 911 or go to the nearest emergency room. Changing your PCP Most of the time, it is best to keep the same PCP. Then he or she can get to know your health needs and history and provide continuity in your health care. We want you to be happy with your PCP. So, if you want to change your PCP, you can, one time per month. You may change your PCP at any time during the month, but only once. Your request will go into effect on the first day of the next month. To change your PCP, call our toll-free Customer Care Center or TTY phone number. If you choose to change your PCP, please take note: When choosing a new PCP, you must choose a doctor who will see new patients. A request to change your PCP may be denied if the PCP you want is not taking new patients. We will let you know when you can start seeing your new PCP. When you change your PCP often, your health care may not be as good as it could be. Each time you pick a new PCP, he or she needs to review your medical history, medicines and any 22

25 Part 4 How to use your health plan ongoing treatment. This type of review takes a lot of time that your PCP could spend on your current concern. Anthem Blue Cross, or your PCP, may ask you to change PCPs if: Your PCP is no longer part of the Anthem Blue Cross network. You are not able to get along with or agree with your PCP. You keep making appointments and don t show up for them. You are often late for your health visits. We will tell you in writing if we need to change your PCP. Specialist care and prior authorization (an OK from Anthem Blue Cross) Your PCP may send you to a specialist for some types of care or treatment. This includes care for HIV or AIDS. Please note: Your PCP will work with you to choose a specialist to give you the care you need. Your PCP s office can help you set up a time to see the specialist. Your PCP will give you an Authorization for Referral Services form. The specialist will fill out the form and send it back to your PCP. You need to tell your PCP and the specialist as much as you can about your health. That way, all of you can decide what is best. A specialist may treat you for as long as he or she thinks you need it. Your PCP or specialist will need to get a prior authorization (an OK) from us for some types of care to make sure they are covered. This is called prior authorization. This means that both Anthem Blue Cross and your PCP (or specialist) agree that the type of care asked for is medically necessary. Medically necessary refers to reasonable and necessary services needed to protect life, to keep the patient from getting seriously ill or disabled, or to reduce severe pain through the diagnosis or treatment of disease, illness or injury. These services need an OK ahead of time: Inpatient and outpatient hospital care, except in the case of an emergency. (You do not need an OK ahead of time for a medical emergency.) Specialist care given by a provider outside of your network will need an OK ahead of time. CT, MRI, MRA, PET and SPECT scans The use of some medical equipment Transport that is not for an emergency Applied Behavioral Analysis Once we get your PCP s or specialist s request for a prior authorization for a service, we will decide within: Five business days for a routine service. 72 hours for an urgent service. 23

26 Part 4 How to use your health plan We care about you and want to help you get the health care you need. Your PCP works with you to decide what s best for your health. Your PCP and other providers base their decisions on two things: Whether or not the care is right for your health issue What health care benefits you have Your doctor may ask us to approve payment for certain types of health care services. We base our decision on two things: Whether or not the care is medically necessary. See Part 16 Definitions to learn more about medically necessary. What health care benefits you have You should know that we do not reward providers or other persons that do utilization review to deny coverage or services. Emergency or out-of-area urgent care does not need an OK from your PCP or us. See Part 9 Emergency and urgent care services to learn more about this. Standing referrals A standing referral lets you see the same specialist without getting an OK for each visit. You may need a standing referral if: You have a health problem that needs special medical care over a long time. Your health problem puts your life at risk, gets worse over time, or keeps you from doing all the things that healthy people can do and you need your care managed by your specialist. If you see a specialist or get specialty care from a provider inside or outside of your network before you get an OK from us, you will have to pay for the cost of the treatment. If we deny a request for specialty services, we will send you a letter telling you why the request was denied. And we ll tell you how to appeal if you do not agree with the denial. If you have trouble getting a standing referral, call us toll free at Member Services. Those with speech or hearing loss can use the TTY number. If, after you call, you still believe that your needs have not been met, please see Part 12 How to resolve a problem with Anthem Blue Cross. This is a summary of Anthem Blue Cross specialist referral policy. You can get a full copy of our policy. Call our toll-free Member Services number. Those with speech or hearing loss can call the TTY number. Getting a second medical opinion You might have questions about care that your doctor says you need. You may want a second opinion from another doctor. This is helpful if: 24

27 Part 4 How to use your health plan You have questions about a surgery your doctor suggests. You have questions about what health issue your doctor finds or the treatment he or she suggests for a chronic health issue. You have questions about a health issue that could cause loss of life, limb or major body function. Your doctor s advice is not clear (you don t know what he or she is trying to tell you). The diagnosis given does not match the test results. Your doctor cannot figure out what is wrong with you. Treatment is not making you feel better. You are concerned about your doctor s treatment plan. To get a second opinion, you should talk to your doctor or call us. We will pay for a second medical opinion at no cost to you if you or your network provider asks for it. The second medical opinion must be given by a qualified health care provider in our network. Your doctor will work with you to choose a provider to give the second opinion. You do not need an OK from us for a second opinion given by a network provider. If no provider within the network is qualified to give your second opinion, you can a visit a provider outside our network to give the second opinion. And we will pay for it. When choosing the second doctor, we will take into account how far you are able to travel. When you ask for a second opinion, we will tell you within five business days if the second opinion is approved. If you have a chronic illness or could lose your life, limb or major body function, we will decide within 72 hours. To learn more about second opinions, call us at our toll-free Customer Care Center or TTY phone number. You may appeal if you are denied a second opinion. To learn more, see Part 12 How to resolve a problem with Anthem Blue Cross. Utilization Management (UM) Anthem Blue Cross makes sure that UM staff works at least 8 hours a day on normal business days. Just call the toll-free CCC or TTY number between 7 a.m. and 5 p.m. to talk to someone. Health plan staff can make and receive calls during and after normal business hours. We will tell you how to learn more about a request. We also will tell you how to send a fax or leave a voice mail message with your contact information so someone can call you back the next business day. Out-of-area care If you are outside of this health plan s service area and need care that is not an emergency, call one of these right away: Your PCP 25

28 Part 4 How to use your health plan 24/7 NurseLine Anthem Blue Cross Customer Care Center Anthem Blue Cross covers emergencies in the United States. The only health care services that are covered outside the United States are emergencies in Mexico or Canada that require you to stay in the hospital. An emergency condition is a medical or psychiatric condition with such severe symptoms (such as active labor or severe pain) that a prudent layperson who has an average knowledge of health and medicine, could reasonably believe the lack of immediate medical care could: Place your health or the health of your unborn baby in serious jeopardy (at risk) Cause harm to a body function Cause serious dysfunction of a body part or organ (meaning, cause a body part or organ to not work right). Active labor means labor at a time when one of these occurs: You cannot be safely transferred in time to another hospital before delivery. A transfer may harm your health and safety or the health and safety of your unborn child. The emergency room (ER) is the best place for a person to be if he or she has these types of situations. The ER should not be used for routine care. ERs don t have access to your medical history and records. Your PCP, who knows you best, will not be in the ER to care for you. Out-of-network care In most cases, you must use a provider within the Anthem Blue Cross network. To learn more, call our toll-free Customer Care Center or TTY phone number. We can help you get the care you need. How to get answers from Anthem after business hours Our Customer Care Center is open Monday through Friday, 7 a.m. to 7 p.m. You can leave a message from 7 p.m. to 7 a.m. Monday through Friday and on weekends. We will call you back the next business day. You can call us if you have questions about this health plan or to find out if: You need an OK from your PCP or specialist for a type of service to be covered by us. We have approved the service you want. You also can call the 24/7 NurseLine. A registered nurse (RN) is ready to help you over the phone with any health concern. The nurse can tell you about access to services. A nurse also can help if you need an interpreter after hours. The RN who answers the 24/7 NurseLine also can help you with getting an OK for services or care when needed. Important Note Some hospitals and providers have a moral objection to perform some services. Some hospitals and other providers do not provide one or more of the following services that may be 26

29 Part 4 How to use your health plan covered under your plan contract and that you or your family member might wish to receive: Family planning Contraceptive services (includes emergency contraception) Sterilization (includes tubal ligation at the time of labor and delivery) Infertility treatments Abortion (choosing to end a pregnancy) You can find out more before you enroll. Besides calling us, you can call the doctor or clinic you plan to use. For women Expecting? Start Smart with New Baby, New Life If you are expecting a baby, it is an exciting time. Doing what s best for your baby means learning all you can. As an expectant mother, you are automatically enrolled in a special program called New Baby, New Life that offers support for women who are going to have a baby or just had a baby. There is no cost to you for this program. As part of New Baby, New Life you will receive: A Prenatal Packet that includes a booklet and brochures to help you learn about pregnancy and childbirth A questionnaire will be completed to find out if there are risks to you or your baby while you are pregnant A Postpartum Packet that includes a booklet on infant care, postpartum depression and reminders on seeing your doctor for a checkup after giving birth as well as a reminder for your baby s checkup. New Baby, New Life helps pregnant members with complex health needs. Nurse case managers work closely with these members to give: Education Emotional support Help in following their doctor s care plan If you have any questions or concerns about your health, you can call the 24/7 NurseLine at (TTY ). Day or night, our nurses can assist you. If you are expecting a baby and need assistance or help in finding a doctor, call us at (Members with hearing or speech loss may call the TTY line at ). Well-woman care can help you stay healthy with breast exams, breast X-rays and cervical cancer screenings. Family planning programs can help teach you: How to be as healthy as you can before you get pregnant. How to prevent pregnancy. How to prevent STIs such as HIV/AIDS. 27

30 Part 4 How to use your health plan For you and your child Well-child visits are for children younger than 21 years of age. During these visits, the doctor checks the child s hearing, vision and teeth. Vaccines are given during these visits. Ask your doctor when you should bring your child in for the next checkup. These visits follow the American Academy of Pediatrics and Child Health and Disability Prevention program. This health plan suggests doctors set up well-child visits within 14 calendar days of the request. Our childhood obesity program is called Get Up and Get Moving! The Get Up and Get Moving! program is intended to help prevent childhood obesity. The program helps teach parents and children the need for exercise and good eating habits. It is not a weight loss program. We offer parenting tips to help teach you how to care for your child. The 24/7 NurseLine is a toll-free, 24-hour nurse help line. Teens also may call this line to talk in private with an RN about their health issues. For managing illnesses Disease Management If you have a chronic medical condition, you don t have to go it alone. Our Disease Management Centralized Care Unit (DMCCU) program can help you get more out of life. The program is voluntary and private and you can join at no cost to you. You re eligible for the program if you have one of these conditions: - Lung conditions like asthma or chronic obstructive pulmonary disease (COPD) - Diabetes - Behavioral health conditions like major depressive disorder, bipolar disorder, schizophrenia and substance use disorder - HIV/AIDS - Heart conditions like coronary artery disease (CAD), congestive heart failure (CHF) and hypertension As part of our DMCCU programs, you can speak to a nurse case manager to help you develop a care plan specific to your needs. We ll work closely with you by phone to support all of your health care needs and coordinate care with your health care providers. To take part in the DMCCU program, just call (Members with hearing or speech loss may call the TTY line at 711). Calling can be your first step on the road to better health. Information for Native American members If you are a Native American, you do not have to enroll in a Medi-Cal managed care health plan. You can get health care at an Indian Health Service site in your area. If you have been enrolled in Anthem Blue Cross, you can disenroll at any time. 28

31 Part 5 What Anthem Blue Cross covers Part 5 What Anthem Blue Cross covers Here are the kinds of care you can get under this health plan. We offer these types of service at no cost to you. But some of the services shown below must be approved by your PCP or your health plan first. Emergency or out-of-area urgent care does not need an OK. To learn more about covered services or getting an OK, call us at our toll-free Customer Care Center or TTY phone number. Ambulance services These services need to come from a licensed ambulance company or air ambulance for an emergency health issue only. We cover these: Base charge and mileage Supplies that are not used again Monitoring (keeping an eye on a health concern) EKGs Cardiac defibrillation (a method of changing the heartbeat) CPR Oxygen IV solutions Dental care Only these types of members will receive dental services: Pregnant women who get the service as part of their care that has to do with pregnancy or for treatment of a condition that may cause problems in pregnancy. Children or young adults who are 21 years old and younger and get full scope Medi-Cal. Members who live in a licensed nursing home or subacute facility. Members needing dental treatment that could have been provided by a doctor. If you have questions or want to learn more about dental services, please call Denti-Cal at Members with hearing or speech loss may call the Denti-Cal TTY line at You also may visit the Denti-Cal website at: We cover these: Treatment when your natural teeth are injured or broken by an accident (when care is given within six months of the injury) General anesthesia for dental work given in a hospital or surgical center to members: Who are younger than 7 years of age. With a developmental issue (under 21 years of age). Who need it when medically necessary. 29

32 Part 5 What Anthem Blue Cross covers Anesthesia is covered under your medical benefits. Diagnostic X-ray and laboratory services All high-cost radiology work such as CT, MRI, MRA, PET and SPECT needs an OK from your PCP and us. We cover blood tests, X-rays, lab work and radiation therapy to test, diagnose, treat and follow up on your care. You must use a lab in the network. This benefit also includes, but is not limited to: Tests to check your heart, brain and breasts for problems. The tests most often used to find cancer. Lab tests used to manage diabetes. (The tests are for cholesterol, triglycerides, microalbuminuria, HDL/LDL, hemoglobin A1c glycohemoglobin and creatinine) Yearly cervical cancer screenings approved by the FDA. (Screenings include the Pap test and the human papillomavirus, HPV, test.) Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services These services are also called well-child visits. These visits include health screens as well as diagnosis, treatment and shots for children through the month of their 21st birthday. We also cover EPSDT supplemental services needed to treat a medical problem found as part of an EPSDT visit. We cover: Health and development background (how your child grows and develops) Physical exam Hearing screenings Dental screenings Vaccines Lab tests including blood lead level Teaching about health topics Applied Behavioral Analysis for Autism Spectrum Disorders* EPSDT supplemental services include, but are not limited to: Case management Supplemental nursing care Pediatric day health care *Behavioral health treatment (BHT) BHT for autism spectrum disorder (ASD). This treatment includes applied behavior analysis and other evidence-based services. This means the services have been reviewed and have been shown to work. The services should develop or restore, as much as possible, the daily functioning of a member with ASD. 30