Buckeye Health Plan. Member Handbook. West and Northeast Regions TDD/TTY: BuckeyeHealthPlan.com

Transcription

1 Buckeye Health Plan Member Handbk West and Nrtheast Regins TDD/TTY: BuckeyeHealthPlan.cm

2 Table f Cntents NOTICE If yu have any prblems in reading r understanding this infrmatin r any ther Buckeye Health Plan (Buckeye) infrmatin, please cntact ur Member Services at (TTY ) fr help at n cst t yu. We can help t explain this infrmatin r prvide the infrmatin rally, in English r in yur primary language. We may have this infrmatin printed in sme certain ther languages r in ther ways. If yu are visually r hearing-impaired, special help can be prvided. Yu can als access Buckeye infrmatin n ur website at All members can cmmunicate with Buckeye thrugh the use f the website. Each inquiry will receive a respnse within ne business day f receipt f the message thrugh ur website. This includes, but is nt limited t, requests fr member infrmatin such as ID cards, member handbks, and prvider directries. Other services ffered n the website include: News and events Prvider search fr dctrs, specialists, and facilities Prgram infrmatin This Member Handbk is effective January 1, 2017.

3 Imprtant Phne Numbers Emergency: 911 r lcal emergency number Buckeye Member Services: Hur Nurse Advice Line: Transprtatin Services: Ohi Relay Service: TTY nly: Member Services hurs are Mnday - Friday, 7:00 a.m. t 7:00 p.m., excluding hlidays. Buckeye is clsed n these hlidays: New Year's Day Memrial Day Labr Day Christmas Day Martin Luther King Jr.'s Birthday Independence Day Thanksgiving Day Buckeye will als be clsed an additinal tw days thrughut the year. We will ntify ur members abut thse ffice clsings at least 30 days in advance f the clsing. A hliday that falls n a Saturday is bserved n the Friday befre it. One that falls n a Sunday is bserved n the Mnday after it. PCP's Name: Ohi Cnsumer Htline: TTY: PCP's Phne #: PCP s After-Hurs #: Yur Child's PCP's Name: Yur Child's PCP's Phne #: Yur Child's PCP's After-Hurs Phne #: Yur Pharmacy: Pharmacy s Phne #: Yur Dentist: Dentist s Phne #: 2

4 Table f Cntents MEANING OF WORDS THAT YOU WILL FIND IN THIS HANDBOOK... 4 WELCOME... 5 YOUR MEMBER IDENTIFICATION (ID) CARD... 6 NEW MEMBER INFORMATION... 7 SERVICES AND BENEFITS... 8 Cvered Services... 8 Healthchek... 9 Self-Referral Services Out-f-Netwrk Services New Technlgy Mental Health/Substance Abuse Services Additinal Services and Benefits Available Start Smart fr Yur Baby Be Well! Incentive Prgram Yur CentAccunt Card Transprtatin Visin services Dental Services Respite Hur Nurse Advice Line Asthma Prgram MemberCnnectins TEXT4BABY Healthcare Reminders Member Newsletters Care Management Services Nt Cvered by Buckeye YOUR PRIMARY CARE PROVIDER (PCP) Chsing and Changing Yur PCP AFTER HOURS, OUT-OF-COUNTY AND EMERGENCY CARE PRESCRIPTION DRUGS GRIEVANCES (COMPLAINTS) State Hearings Grievance/Appeals Frm MEMBERSHIP TERMINATION Lss f Medicaid Eligibility Lss f Insurance Ntice (Certificatin f Creditable Cverage) Autmatic Renewal f MCP Membership Ending Yur MCP Membership Chsing a New Plan Just Cause Membership Terminatins Things t Keep in Mind if Yu End Yur Membership Optinal Membership Terminatins Can Buckeye End My Membership? YOUR MEMBERSHIP RIGHTS YOUR MEMBERSHIP RESPONSIBILITIES OTHER INFORMATION Accidental Injury r Illness (Subrgatin) Other Health Insurance (Crdinatin f Benefits - COB) PRIVACY NOTICE ADVANCE DIRECTIVES LANGUAGE ASSISTANCE STATEMENT OF NON-DISCRIMINATION

5 Welcme MEANINGS OF WORDS THAT YOU WILL FIND IN THIS HANDBOOK Benefits: Emergency: Grievance: Healthchek: Identificatin Card (ID card): MHA: Participating Prvider: Primary Care Prvider (PCP): Prir Authrizatin: Referral: Specialist: Healthcare services that are cvered by Buckeye Health Plan. Emergency services are services fr a medical prblem that yu think is s serius that it must be treated right away by a dctr. A cmplaint abut Buckeye r ne f ur prviders. A prgram f cmprehensive preventive health services available t Medicaid cnsumers frm birth until the day befre age 21. The prgram is designed t maintain health by prviding early interventin t discver and treat health prblems. A card fr each Buckeye member that is needed by yur dctr s ffice befre yu can receive care. Ohi Department f Mental Health and Addictin Services. A dctr, hspital, r ther licensed healthcare prvider that has a signed cntract with Buckeye t prvide care fr ur members. Yur persnal healthcare prvider (wh must be participating with Buckeye). Yur PCP is an individual physician, physician grup practice, advanced practice nurse r advanced practice nurse grup practice trained in family medicine (general practice), internal medicine, r pediatrics. The prcess f getting prir apprval frm Buckeye as t the apprpriateness f a service r medicatin. Prir authrizatin des nt guarantee cverage. Yur dctr will submit a prir authrizatin request t Buckeye t get certain services apprved fr them t be cvered. If Buckeye des nt apprve the request, we will ntify yu and give yu infrmatin abut the Buckeye grievance and appeal prcess and yur right t a State Hearing. Additinally, inpatient services may receive cncurrent review t mnitr prgress and medical necessity f the inpatient care. The prcess f yur PCP recmmending r requesting services fr yu befre yu can get them. Yur PCP will call and arrange these services fr yu; give yu written apprval t take with yu when yu get the referred services; r just tell yu what t d. In sme cases, Buckeye may authrize a specialist t make referrals fr yu. A dctr wh prvides services fr a particular kind f health service such as a pdiatrist (ft dctr) r cardilgist (heart dctr). 4

6 Welcme WELCOME TO BUCKEYE HEALTH PLAN Welcme t Buckeye Health Plan (Buckeye), a subsidiary f Centene Crpratin. Yu are nw a member f a healthcare plan, als knwn as a managed care plan (MCP). Buckeye Health Plan prvides health care services t Ohi residents eligible fr Aged, Blind r Disabled, Cvered Families and Children (including Healthy Start and Healthy Families), and adult extensin Ohi Medicaid cnsumers wh receive their health care services thrugh MCPs. Buckeye may nt discriminate n the basis f race, clr, religin, sex, sexual rientatin, age, disability, natinal rigin, veteran s status, ancestry, health status, r need fr health services in the receipt f health services. It is imprtant t remember that yu must receive services cvered by Buckeye frm facilities and/r prviders n Buckeye s netwrk. See pages 8-19 fr infrmatin n services cvered by Buckeye. The nly time yu can use prviders that are nt n Buckeye s panel is fr: Emergency services Federally qualified health centers/rural health clinics Certified nurse midwives r certified nurse practitiners Qualified family planning prviders Ohi Department f Mental Health and Addictin Services (MHAS) certified Cmmunity Mental Health Centers and treatment centers r Ohi Department f Alchl and Drug Addictin Services certified treatment centers. An ut-f-panel prvider that Buckeye has apprved yu t see If yu called the Medicaid Htline t select a managed care plan (MCP), yu were asked whether yu wanted ur netwrk f prviders infrmatin given t yu as a printed prvider directry r via the internet. If yu asked fr a printed directry yu shuld have als received a Prvider Directry. The Prvider Directry lists all f ur panel prviders as well as ther nn-netwrk prviders yu can use t receive services. If yu did nt call the Medicaid Htline and were assigned t ur plan, yu can request a printed prvider directry by calling the member services department r by returning the pst card yu received with yur member identificatin card. If yu want t use the internet, visit ur website at t view up t date prvider panel infrmatin. 5

7 ID Cards IDENTIFICATION (ID) CARDS Yu shuld have received a Buckeye membership ID card. Each member f yur family wh has jined Buckeye will receive their wn card. These cards replace yur mnthly Medicaid card. Each card is gd fr as lng as the persn is a member f Buckeye. Yu will nt receive a new card each mnth as yu did with the Medicaid card. If yu are pregnant, yu need t let Buckeye knw and als call when yur baby is brn s we can send yu a new ID card fr yur baby. SAMPLE SAMPLE (ID Card Frnt) (ID Card Back) ALWAYS KEEP YOUR ID CARD(S) WITH YOU Yu will need yur ID card each time yu get medical services. This means that yu need yur Buckeye ID card when yu: See yur primary care prvider (PCP). See a specialist r ther prvider. G t an emergency rm. G t an urgent care facility. G t a hspital fr any reasn. Get medical supplies. Get a prescriptin. Have medical tests. Call yur Buckeye Member Services as sn as pssible at (TTY ) if: Yu have nt received yur card(s) yet. Any f the infrmatin n the card(s) is wrng. Yu lse yur card(s). Yu have a baby. 6

8 Member Infrmatin NEW MEMBER INFORMATION If yu were n Medicaid fee-fr-service the mnth befre yu became a Buckeye member and have healthcare services already apprved and/r scheduled, it is imprtant that yu call member services immediately (tday r as sn as pssible). In certain situatins, fr a brief time after yu enrll, we may allw yu t receive care frm a prvider that is nt in Buckeye's prvider netwrk. Additinally, we may allw yu t cntinue t receive services that were authrized by Medicaid fee-frservice. Hwever, yu must call Buckeye befre yu receive the care. If yu d nt call us, yu may nt be able t receive the care and/r the claim may nt be paid. Fr example, yu need t call member services if yu have the fllwing services already apprved and/r scheduled: Organ, bne marrw, r hematpietic stem cell transplant Third trimester prenatal (pregnancy) care, including delivery Inpatient/utpatient surgery Appintment with a primary care r speciality prvider Appintment with a primary care prvider Chemtherapy r radiatin treatments Treatment fllwing discharge frm the hspital in the last 30 days Nn-rutine dental r visin services (fr example braces r surgery) Medical equipment Services yu receive at hme, including hme health, therapies, and nursing After yu enrll, yur MCP will tell yu if any f yur current medicatins require prir authrizatin that did nt require authrizatin when they were paid by Medicaid fee-frservice. It is very imprtant that yu lk at the infrmatin the MCP prvides and cntact yur MCP s member services if yu have any questins. Yu can als lk n yur MCP s website t find ut if yur medicatin(s) require prir authrizatin. Yu may need t fllw up with the prescriber s ffice t submit a prir authrizatin request t yur MCP if it is needed. If yur medicatin(s) requires prir authrizatin, yu cannt get the medicatin(s) until yur prvider submits a request t yur MCP and it is apprved. 7

9 Services & Benefits SERVICES COVERED BY BUCKEYE As a Buckeye Health Plan member yu will cntinue t receive all medically necessary Medicaid-cvered services at n cst t yu. Hwever, hw yu receive the services may be different than hw yu received the services in the past. It is imprtant t read the fllwing infrmatin that explains hw t receive services as a Buckeye member. If yu have questins, please cntact Buckeye Member Services. Buckeye cvers all medically-necessary Medicaid-cvered services. Ambulance and ambulette transprtatin Certified nurse midwife services Certified nurse practitiner services Chirpractic (back) services Dental services (includes tw child and adult peridic ral exams and cleanings per year, mre than what is available with fee-fr-service Medicaid) Develpmental therapy services fr children aged birth t six years Diagnstic services (x-ray, lab) Durable medical equipment Emergency services Family planning services and supplies Federally Qualified Health Center r Rural Health Clinic services Free Standing Birth Center services at a free-standing birth center (call member services fr qualified centers) Hme health services Hspice care (care fr terminally ill, e.g., cancer patients) Inpatient hspital services Medical supplies Mental health and substance abuse services Nursing facility services fr a shrt term rehabilitative stay (call member services fr available prviders; ODM may determine return t fee fr service Medicaid) Obstetrical (maternity care - prenatal and pstpartum including at risk pregnancy services) and gyneclgical services Outpatient hspital services Physical and ccupatinal therapy Physical exam required fr emplyment r fr participatin in jb training prgrams if the exam is nt prvided free f charge by anther surce Pdiatry (ft) services Prescriptin drugs, including certain prescribed ver-the-cunter drugs Preventive mammgram (breast) and cervical cancer (pap smear) exams Primary care prvider services Renal dialysis (kidney disease) Respite Services (fr Supplemental Scial Security Incme -SSI members under 21 years f age) Screening and cunseling fr Obesity Services fr children with medical handicaps (Title V) Shts (immunizatins) Specialist services Speech and hearing services, including hearing aids Visin (ptical) services, including expanded selectin f eyeglasses and cntact lenses (mre than what is available with fee-fr-service Medicaid) Well-child (Healthchek) exams fr children under the age f 21 Yearly well-adult exams 8

10 Services & Benefits If yu must travel 30 miles r mre frm yur hme t receive cvered healthcare services, Buckeye will prvide transprtatin t and frm the prvider s ffice. Please cntact Member Services at least 48 hurs (tw business days) in advance fr assistance. In additin t the transprtatin assistance that Buckeye prvides, members can still receive assistance with transprtatin fr certain services thrugh the lcal cunty department f jb and family services Nn-Emergency Transprtatin (NET) prgram. Call yur cunty department f jb and family services fr questins r assistance with NET services. Buckeye cvers all medically necessary Medicaid-cvered services, including the fllwing: Primary care prvider services. Members can see any cvered PCP fr primary cvered services: 1) Yearly well-adult exams. 2) Shts/immunizatins 3) Physical exam required fr emplyment r fr participatin in jb training prgrams if the exam is nt prvided free f charge by anther surce. 4) HEALTHCHEK Healthchek is Ohi s early and peridic screening, diagnstic, and treatment (EPSDT) benefit. Healthchek cvers medical exams, immunizatins (shts), health educatin, and labratry tests fr everyne eligible fr Medicaid under the age f 21 years. These exams are imprtant t make sure that children are healthy and are develping physically and mentally. Mthers shuld have prenatal exams and children shuld have exams at birth, 3-5 days f age, and at 1, 2, 4, 6, 9, 12, 15, 18, 24, and 30 mnths f age. After that, children shuld have at least ne exam per year. Healthchek als cvers cmplete medical, visin, dental, hearing, nutritinal, develpmental, and mental health exams, in additin t ther care t treat physical, mental, r ther prblems r cnditins fund by an exam. Healthchek cvers tests and treatment services that may nt be cvered fr peple ver age 20; sme f the tests and treatment services may require prir authrizatin. Healthchek services are available at n cst t members and include: Preventive check-ups fr newbrns, infants, children, teens, and yung adults under the age f 21. Healthchek screenings: Cmplete medical exams (with a review f physical and mental health develpment) Visin exams Dental exams Hearing exams Nutritin checks 9

11 Services & Benefits Develpmental exams Lead testing Labratry tests fr certain ages Immunizatins Medically necessary fllw up care t treat physical, mental, r ther health prblems r issues fund during a screening. This culd include, but is nt limited t, services such as: visits with a primary care prvider, specialist, dentist, ptmetrist and ther Buckeye prviders t diagnse and treat prblems r issues in-patient r utpatient hspital care clinic visits prescriptin drugs labratry tests Health educatin It is very imprtant t get preventive check ups and screenings s yur prviders can find any health prblems early and treat them, r make a referral t a specialist fr treatment, befre the prblem gets mre serius. Sme services may require a referral frm yur PCP r prir authrizatin by Buckeye. Als, fr sme EPSDT items r services, yur prvider may request prir authrizatin fr Buckeye t cver things that have limits r are nt cvered fr members ver age 20. Please see pages t see what services require a referral and/r prir authrizatin. As a part f Healthchek, care management services are available t all members under the age f 21 years wh have special health care needs. Please see page 17 t learn mre abut the care management services ffered by Buckeye. Yu can btain Healthchek services by calling yur PCP s r dentist s ffice and scheduling an appintment. Make sure yu tell them it is fr Healthchek. If yu wuld like mre infrmatin abut the Healthchek prgram, r if yu need assistance with accessing care fr cvered services, making an appintment with a prvider, getting transprtatin, r prir authrizatin, please cntact Buckeye s Member Services department at (TTY ). Please see the frm in this member packet yu will need t fill ut and send back t Buckeye Health Plan (paid pstage included). We will use the infrmatin t prvide services t help yur family stay healthy. 10

12 Services & Benefits Self-referred services are services that yu may access withut permissin frm yur Primary Care Prvider r frm Buckeye. Yu may self-refer t a Buckeye prvider fr the fllwing services: Obstetrical (OB) and/r gyneclgical services, including: Maternity care fr prenatal and pstpartum, including at-risk pregnancy services Preventive mammgram (breast) and cervical cancer (pap tests) exams Chirpractr Pdiatry (Ft) Care Certified Nurse Midwife Rutine Dental Care Rutine Visin (Optical) Services, including eyeglasses Certified Nurse Practitiner Urgent Care Centers Specialist services Regular X-rays and lab (participating specialists may als send yu fr diagnstic tests) Outpatient hspital services (sme surgical prcedures may require prir authrizatin) Clinic services Health educatin Services fr children with medical handicaps (Title V) Renal dialysis (kidney disease) Nn-emergency wheelchair van transprtatin Yu may self-refer t any prvider fr the fllwing: Emergency services, including ambulance transprtatin (see page 21). Family planning services and supplies frm a Qualified Family Planning Prvider (listed in the Prvider Directry). Care at Federally Qualified Health Center r Rural Health Clinic (listed in the Prvider Directry). The fllwing are services that require a PCP referral and prir authrizatin frm Buckeye: MRIs MRAs Bariatric surgery Pain Management PET Scans CAT Scans Cardiac Nuclear Scans Nursing facility services fr a shrt-term rehabilitative stay 11

13 Services & Benefits Hme healthcare Hspice care (care fr terminally ill, fr example, cancer patients) In-patient hspital services (emergency admissins d nt require a referral r prir authrizatin) Medical supplies (sme diabetic supplies fr insulin and bld glucse mnitring d nt require authrizatin) Durable Medical Equipment Speech and hearing services, including hearing aids Physical, Occupatinal and Speech Therapy AFTER the first 30 visits Nn-rutine dental care (fr example, surgery) Nn-rutine visin (ptical) services (fr example, surgery) Nn-emergency ambulance and ambulette transprtatin Plastic and recnstructive surgens Develpmental therapy services fr children aged birth t six years OB Ultrasunds (abve 2 per pregnancy) Genetic Testing (prenatal, cancer screening, testing fr children with develpmental delays) OUT - OF - NETWORK SERVICES Cverage fr ut-f-netwrk services are available when Buckeye Health Plan is unable t prvide a necessary cvered service in an adequate and timely manner. NEW TECHNOLOGY Buckeye wants t make sure yu have access t the mst up-t-date medical care. We have a team that watches fr advances in medicine. This may include new medicine,tests,surgeries r ther treatment ptins. The team checks t make sure the new treatments are safe. We will tell yu and yur dctr abut new services cvered under yur benefits. MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES If yu need mental health and/r substance abuse services, please call (TTY ) fr assistance frm a Buckeye Member Services Representative. Or yu may self-refer directly t a Ohi Department f Mental Health and Addictin Services (MHAS) (ODMH) certified Cmmunity Mental Health Center r Ohi Department f Mental Health and Addictin Services (MHAS) certified cmmunity mental health center r Ohi Department f Alchl and Drug Addictin Services (ODADAS) certified treatment centers. Please see yur prvider directry r call ur member services department fr the names and telephne numbers f the facilities near yu. Buckeye s cntracted mental health prviders are listed in ur Prvider Directry, and can be fund n ur website at 12

14 Services & Benefits BUCKEYE S ADDITIONAL SERVICES AND BENEFITS AVAILABLE TO ALL MEMBERS Unless therwise nted, t get the services listed belw cntact Buckeye's Member Services at (TTY ). Member Services hurs are Mnday thrugh Friday, 7 a.m. t 7 p.m. excluding hlidays listed n page 2. Yu can als call Member Services fr assistance with Grievances and Appeals; if yu receive a bill fr services frm a prvider; need help finding a prvider r changing yur Primary Care Prvider; need language assistance; r need help accessing cvered services. We are here t answer all f yur questins and address any cncerns yu might have. Buckeye ffers the fllwing extra services and benefits t members. Start Smart Fr Yur Baby Start Smart fr Yur Baby is ur special prgram fr wmen wh are pregnant. This prgram will help yu take gd care f yurself and yur baby befre the baby is brn. Start Smart fr Yur Baby prvides yu with infrmatin abut pregnancy. It als helps yu find slutins fr any prblems that cme up while yu are pregnant. We knw having a baby can be hard n yu and yur family. We want t help. We care abut the health f yu and yur baby and want t make sure yu bth grw healthy and stay healthy. It is very imprtant that yu start seeing yur dctr as sn as yu find ut that yu are pregnant. It is als imprtant that yu take yur baby t the dctr after he/she is brn fr needed immunizatins and health screenings. In this prgram, members can earn up t $225 n a CentAccunt pre-paid Mastercard fr ging t pre-natal, pst-partum, and well-baby visits fr the first 15 mnths f life. During the pregnancy, it s als imprtant fr members t fllw dctr s rders fr a healthy pregnancy. T be eligible, a pregnant wman must enrll by submitting a Ntificatin f Pregnancy frm at least 6 weeks prir t her due date. Pregnancy - $25 (Fr the 3 rd, 6 th, and 9 th prenatal visit NOP required) Pstpartum - $50 (Visit must be days after delivery) Infant Well Visit - $100 (Must cmplete 6 visits in the first 15 mnths f life) We have many ways t help yu have a healthy pregnancy. But befre we can help, we need t knw yu are pregnant. Please call us at (TTY ) as sn as yu learn yu are pregnant. We will set up the special care yu and yur baby need. Be Well! Incentive Prgram Buckeye Health Plan members can take part in a special member-nly prgram called Be Well! This prgram will help yu stay healthy. It als rewards yu fr being active in yur healthcare. In this prgram, yu can earn up t $185 plus $50 fr each adlescent child yu have enrlled n a pre-paid CentAccunt card fr seeing 13

15 Services & Benefits yur dctr fr these annual wellness services in each calendar year that yu are a Buckeye member. Flu Sht (During flu seasn, September April fr ages 6 mnths - 5 years and 50 and lder) - $25 Physician Exam with yur PCP (Age 21 and lder with assigned PCP) - $35 Diabetic Management (Age 18 and lder - all 4 diabetic tests must be dne in the same calendar year: LDL-C, HbA1c, Eye and Nephrlgy) - $100 Mammgram - $25 (Wmen ages 40-69) Adlescent Well Care (Fr each child ages per year) - $50 Call Buckeye s Member Services Department at (TTY ). We ll give yu mre infrmatin abut ur services and the Be Well! Prgram fr members. YOUR CENTACCOUNT CARD Yur CentAccunt card can be used at mst grcery stres, pharmacies, retail stres/chains that accept debit cards. This card can nt be used at fast fd chains, liqur stres, r tbacc shps. Please nte that membership terminatin will result in the clsing f yur CentAccunt card. If yu reenrll in the plan after 60 days, yu will be sent a new card. Als, it may take 4 6 weeks fr benefits t appear n the card. 14

16 Services & Benefits TRANSPORTATION Buckeye prvides rund trip cverage fr cvered services 30+ miles away. In additin, Buckeye ffers up t 30 rund-trip visits (60 ne-way trips) per member per 12-mnth perid t cvered healthcare/dental appintments, WIC appintments, and redeterminatin appintments with yur Ohi Dept f Jb and Family Services (ODJFS) casewrker. Members can call Member Services directly 48 hurs (tw business days) in advance at t schedule transprtatin. If transprtatin is needed fr an urgent medical appintment, we will arrange fr a direct pick-up, withut waiting 48 hurs (if verified with yur dctr). Yu can get a ride at n cst t yu t all medical appintments including: Dental visits Prenatal care appintments Primary care ffice visits Childhd immunizatins Specialist appintments Urgent care centers WIC appintments Redeterminatin (face-t-face) visits with casewrkers/cdjfs Pharmacies - after a dctr's visit Buckeye des nt prvide transprtatin fr emergency services. If yu have an emergency, call 911 r g t the nearest emergency rm right away. If yu are nt sure whether yu need t g t the emergency rm, call yur PCP r ur 24 Hur Nurse Advice Line, Buckeye's Health Infrmatin Line at (TTY at ). If healthcare/dental appintments are needed beynd 15 rund-trip (30 ne-way) per member per 12-mnth perid, yu may cntact the ODJFS abut assistance. 15

17 Services & Benefits v VISION BENEFITS T keep yur eyes healthy, Buckeye ffers these benefits fr yu and yur family: Buckeye ffers annual eye exams fr children and adults. Eyewear (new glasses) are prvided annually fr children under the age f 21 and adults age 60 and ver. Eyewear fr members age 21 thrugh 59 is prvided every tw years. Buckeye will prvide $50 per year tward the purchase f cntact lenses fr children up t age 21 and adults 60 and lder. $50 every tw years fr members years f age. Buckeye ffers $50 per year tward the cntact lens fitting fee fr children up t age 21 and adults age 60 and lder. This is available every tw years fr adults age Fee-fr-service Medicaid des nt cver cntacts. Bth cntacts and glasses may nt be btained in the same year (r in the same tw years fr adults age 21-59). v DENTAL BENEFITS Buckeye ffers these advantages fr yur dental care: Tw peridic ral exams and cleanings per year. Extractins and fillings. Braces cvered under the age f 21. Partials, dentures, crwns (prir authrizatin is required). N cpayments fr dental services. RESPITE Respite services are services that prvide shrt-term, temprary relief t an infrmal unpaid caregiver f a member under the age f 21 and thse eligible f Supplemental Security Incme (SSI) t supprt and preserve the primary caregiving relatinship. Caregivers shuld cntact the member s Buckeye care manager t arrange this benefit. 16

18 Services & Benefits v 24 Hur Nurse Advice Line Buckeye's 24 Hur Nurse Advice Line is staffed with Registered Nurses 24-hurs-a-day, every day f the year and is yur surce fr health infrmatin. Buckeye Nurses have spent lts f time caring fr peple. Nw they are ready and eager t help yu. The services listed belw are available by cntacting ur Nurse Advice Line at (TTY ): Medical advice line Health infrmatin library Help in determining where t g fr care Answers t questins abut yur health Advice abut a sick child Infrmatin abut pregnancy Advice n hw much medicine t give yur child Nt sure if yu need t g t the Emergency Rm r Urgent Care Center? Smetimes yu may nt be sure if yu need t g t the Emergency Rm r Urgent Care Center. Call the Nurse Advice Line. A nurse can assist yu in knwing if it is an emergency r if it can wait. Emergency services are services fr a medical prblem that is s serius that it must be treated right away by a dctr. ASTHMA PROGRAM If yu have a child with asthma, we have an Asthma Management Prgram that can help yu manage yur child's asthma better. Asthma is a disease that makes it hard t breathe. Peple with asthma: Are ften shrt f breath Make a whistling sund when they breathe Cugh a lt, especially at night While asthma cannt be cured, it can be cntrlled. If yur child has asthma, ur prgram will help yu: Identify things that cause an asthma attack Knw when an asthma attack is ccurring sn enugh t prevent serius cmplicatins Get the right medicine and devices t prevent an attack See yur child's dctr fr treatment Please call ur Asthma Care Manager at (TTY ) if yur child has asthma. Be sure t call if yur child: Has been in the hspital fr asthma during the past year Has been in the Emergency Rm tw r mre times in the past six mnths fr asthma Has been in the dctr's ffice three r mre times in the past six mnths fr asthma Takes ral sterids fr asthma 17

19 Services & Benefits MemberCnnectins We have a special prgram t cnnect yu t quality healthcare and scial services. It's called MemberCnnectins. Our MemberCnnectins utreach representatives will talk t yu n the phne when yu call (TTY ), send yu infrmatin in the mail, and visit yur hme if yu wuld like fr them t cme. They will be glad t talk t yu abut: Hw t chse a dctr Hw t change dctrs Cvered healthcare services Hw t use yur healthcare services Hw t get medical advice when yu can't get yur dctr Explain the difference in emergency and nn-emergent care Hw t live a healthy life Hw t get immunizatins and health screenings Any ther healthcare service prblem yu may have MemberCnnectins utreach representatives can als help cnnect yu t cmmunity scial services if yu need fd, husing, clthing, utility services, etc. T reach MemberCnnectins, call (TTY ). v TEXT4BABY If yu are pregnant r have a baby under ne year ld, Buckeye encurages yu t take part in, a FREE service that helps yu prepare fr mtherhd. will send yu appintment reminders, persnalized infrmatin n prenatal care, baby's develpment,signs f labr,breastfeeding,nutritin and mre right t yur cell phne. It's easy t sign up and messages are free. T sign up visit : Yu may stp the service by texting STOP (ALTO fr Spanish) t T learn mre please visit 11.text4baby.rg. * Nrmal data charges may apply if yu access any links included in free messages. Cntent may nt be available n all carriers. Fr help text the wrd HELP t r inf@text4babyrg v HEALTHCARE REMINDERS Buckeye peridically sends pstcards and text messages t members reminding them t schedule imprtant healthcare appintments fr things such as immunizatins (shts), dental visits, and mammgraphy and lead screenings. MEMBER NEWSLETTERS Buckeye mails tw issues f its quarterly newsletter, Healthy Mves, t its members and psts all fur issues n the Buckeye web site. These newsletters include infrmatin abut prgram benefits, as well as articles abut health and wellness tpics. 18

20 Services & Benefits CARE MANAGEMENT Buckeye ffers care management services that are available t children and adults with special health care needs. Our care management prgram helps members learn mre abut their health cncerns such as: Asthma Diabetes Cngestive heart failure (CHF) Crnary artery disease (CAD) Nn-mild hypertensin (high bld pressure) Chrnic bstructive pulmnary disease (COPD) HIV/AIDS Severe mental illness Severe cgnitive and/r develpmental limitatin Transplants High-risk r high-cst substance abuse disrder Frequent admissins r ED rm visits High risk pregnancies Premature babies Children with special health care needs Mental and Behaviral Health Individual, grup and family cunseling sessins frmental, behaviral health and substance use disrders. Psychlgical and develpmental testing. Medicatin Management. Electrcnvulsive therapy (ECT). The prgram is designed fr members t have assistance frm care managers t help them imprve r maintain gd health, and assist in arranging services they may need t manage their health. The gal f ur prgram is t wrk tgether in develping a plan f care t help ur members becme mre independent in meeting their healthcare needs. Please call Buckeye s Member Services department at (TTY ) if yu wuld like mre infrmatin abut BuckeyeCare, ur care management prgram. Althugh Buckeye prvides care management services fr ur members, we are aware that sme members wuld prefer t nt participate. Fr specifically identified members, Buckeye prvides an "pt-ut f care management" prcess. If yu chse t nt participate in ur care management prgram, yu can decline participatin at any time by ntifying yur care manager. When yu are a patient in the hspital, if yu are feeling well enugh t have visitrs, ur nurses r scial wrkers may cme t yur hspital rm t visit yu t discuss yur discharge planning needs, answer any questins yu may have abut ur benefits and services ffered, and prvide infrmatin t yu abut ur care management prgram. Our staff will always check with the hspital staff first befre entering yur rm t be sure that the timing is right fr us t visit yu. 19

21 Services & Benefits Additinally: Buckeye staff, including nurses, care managers, and utreach wrkers may cntact the member if a dctr has requested a phne call, if the member requests the phne call, r if Buckeye feels that care management services wuld be helpful t the member. Buckeye staff may ask the member questins t learn mre infrmatin abut his/her cnditins(s). Buckeye staff will prvide infrmatin t help a member understand hw t care fr his/her self and hw t access services (including lcal resurces). Buckeye staff will talk t the member s PCP and ther service prviders t crdinate care. Members shuld call Buckeye s Member Services department at (TTY ) if they have any questins abut care management services r if they feel they wuld benefit frm care management services. SERVICES NOT COVERED BY BUCKEYE OR OHIO MEDICAID Buckeye will nt pay fr services r supplies received withut fllwing the directins in this handbk. Buckeye will nt pay fr the fllwing services that are nt cvered by Medicaid: Abrtins except in the case f a reprted rape, incest r when medically necessary t save the life f the mther Bifeedback services All services r supplies that are nt medically necessary Assisted suicide services, defined as services fr the purpse f causing, r assisting t cause, the death f an individual Cmfrt items in the hspital (e.g., TV r phne) Experimental services and prcedures, including drugs and equipment, nt cvered by Medicaid and nt in accrdance with custmary standards f practice Infertility services fr males r females, including reversal f vluntary sterilizatins Inpatient hspital custdial care Inpatient treatment t stp using drugs and/r alchl (in-patient detxificatin services in a general hspital are cvered) Paternity testing Plastic r csmetic surgery that is nt medically necessary Services fr the treatment f besity unless determined medically necessary Services t find cause f death (autpsy) Vluntary sterilizatin if under 21 years f age r legally incapable f cnsenting t the prcedure This is nt a cmplete list f the services that are nt cvered by Medicaid r Buckeye. If yu have a questin abut whether a service is cvered, please call the Member Services department. 20

22 Primary Care Prvider CHOOSING A PRIMARY CARE PROVIDER (PCP) Each member f Buckeye must chse a primary care prvider (PCP) frm Buckeye s prvider directry. Yur PCP is an individual physician, physician grup practice, advance practice nurse r advance practice nurse grup practice trained in family medicine (general practice), internal medicine, r pediatrics. Yur PCP will wrk with yu t direct yur healthcare. Yur PCP will d yur check-ups and shts and treat yu fr mst f yur rutine healthcare needs. If needed, yur PCP will send yu t ther dctrs (specialists) r admit yu t the hspital. Yu can reach yur PCP by calling the PCP's ffice. Yur PCP's name and telephne number are printed n yur Buckeye ID card. CHANGING YOUR PCP If fr any reasn yu want t change yur PCP, yu must first call the Member Services department t ask fr the change. A member can change their PCP mnthly. Please nte, any changes t the selected PCP within the first mnth f membership will be effective the date f the request fr the PCP change. If yu request a PCP change after yur first mnth f membership, the change will be effective n the first day f the next mnth. Buckeye will send yu a letter and new ID card t let yu knw that yur PCP has been changed and the date yu can start seeing the new PCP. Fr the names f the PCPs in Buckeye, yu may lk in yur prvider directry, n ur website at r yu can call the Buckeye Member Services department at (TTY ) fr help. 21

23 Emergency Care OUT-OF-AREA, AFTER HOURS, AND EMERGENCY CARE OUT-OF-AREA AND AFTER HOURS CARE If yur PCPs ffice is clsed r yu are away frm hme anywhere in the United States, and yu have a prblem that is nt an emergency, call yur Buckeye PCP at the phne number listed n yur ID card. Yu can als call 24 Hur Nurse Advice Line, 24 hurs a day, seven days a week tll-free at , (TTY ). A nurse will answer and help yu determine what t d. Medical care is available thrugh Buckeye prviders 24-Hur a day, seven days a week. After hurs, yur PCP's phne will be answered by either an answering service r an answering machine with specific instructins. Be sure t fllw the machine's instructins. The answering service will have yur PCP r the dctr wh is cvering fr the PCP call yu back. Tell them yu are a Buckeye member and explain yur prblem. They will tell yu what t d. Yu can als visit a cntracted Urgent Care Center listed in ur Prvider Directry r n ur website at r yu can call the Nurse Advice Line tll-free at , (TTY ). EMERGENCY SERVICES Emergency services are thse treatments that are required fr an injury r illness that must have immediate treatment by a dctr. We cver care fr emergencies bth in and ut f the cunty where yu live, anywhere in the United States. Sme examples f when emergency services are needed include: - Chest pain - Pisning - Brken arm r leg - Severe bleeding - Severe burns - Sudden shrtness f breath r difficulty breathing - Miscarriage/pregnancy with vaginal bleeding Yu d nt have t cntact Buckeye fr an kay befre yu get emergency services. If yu have an emergency, call 911 r g t the NEAREST emergency rm (ER) r ther apprpriate setting. If yu are nt sure whether yu need t g t the emergency rm, call yur primary care prvider r the Buckeye Nurse Advice Line, at , (TTY ). Yur PCP r the Buckeye Nurse Advice Line can talk t yu abut yur medical prblem and give yu advice n what yu shuld d. Please nte that yu may self-refer t a Buckeye Urgent Care Center after hurs if that facility is pen at the time. 22

24 Emergency Care Remember, if yu need emergency services: G t the nearest hspital emergency rm r ther apprpriate setting. Be sure t tell them that yu are a member f Buckeye and shw them yur ID card. If the prvider that is treating yu fr an emergency takes care f yur emergency but thinks that yu need ther medical care t treat the prblem that caused yur emergency, the prvider must call Buckeye. Call yur Buckeye PCP (r ask the hspital t call yur PCP) as sn as pssible. This lets yur PCP knw the care yu received. Yur PCP can then take ver crdinatin f yur care. Yu must cntact yur PCP within 24 hurs t arrange fllw-up care within the service area with participating prviders. If the hspital has yu stay, please make sure that Buckeye is called within 24 hurs. 23

25 Prescriptin Drugs While Buckeye cvers all medically necessary Medicaid-cvered medicatins, we use a preferred drug list (PDL). These are the drugs that we prefer that yur prvider prescribe. We may als require that yur prvider submit infrmatin t us (a prir authrizatin request) t explain why a specific medicatin and/r a certain amunt f a medicatin is needed. We must apprve the request befre yu can get the medicatin. Reasns why we may prir authrize a drug include: There is a generic r pharmacy alternative drug available. The drug can be misused/abused. There are ther drugs that must be tried first and that have fewer risks. Sme drugs may als have quantity (amunt limits and sme drugs are never cvered, such as drugs fr weight lss. If we d nt apprve a prir authrizatin request fr a medicatin, we will send yu infrmatin n hw yu can appeal ur decisin and yur right t a state hearing. Yu can call member services t request infrmatin n ur PDL and medicatins that require prir authrizatin. Yu can als lk n ur website at Please nte that ur PDL and list f medicatins that require prir authrizatin can change s it is imprtant fr yu and/r yur prvider t check this infrmatin when yu need t fill/refill a medicatin. If yu can't lcate a Buckeye-qualified pharmacy near yur hme there are ther ptins t get yur medicatins. Buckeye wrks with a netwrk f pharmacies that als have mail delivery service available. We ffer a three mnth supply f maintenance medicatins (drugs used t treat lng term cnditins r illnesses) by mail. Fr a cmplete list f cvered medicatins fr this service and t learn mre abut cvered drugs and thse that need prir authrizatin visit The State f Ohi permits MCPs t develp and implement prgrams t assist certain members receiving medicatins that are nt medically necessary t establish and maintain a relatinship with their prvider and/r pharmacy t crdinate treatment. Members selected fr Buckeye s prgram will be prvided additinal infrmatin and ntified f their state hearing rights, as applicable. Members wh are enrlled int the Cntrlled Substances and Member Management (CSMM) prgram will have restrictins upn the physicians and pharmacies they may use fr cntrlled substances, except fr emergency situatins. Members will als have the ability t change designated prviders accrding t the plicy. 24

26 Grievances GRIEVANCES (COMPLAINTS) Hw t Let Buckeye Knw If Yu Are Unhappy r D Nt Agree With A Decisin We Made If yu are unhappy with anything abut Buckeye r its prviders yu shuld cntact us as sn as pssible. This includes if yu d nt agree with a decisin we have made. Yu, r smene yu want t speak fr yu can cntact us. If yu want smene t speak fr yu, yu will need t let us knw this. Buckeye wants yu t cntact us s that we can help yu. T cntact us yu can: Call the Member Services department at (TTY ), r Fill ut the frm in yur member handbk, r Call the Member Services department t request they mail yu a frm, r Visit ur website at r Write a letter telling us what yu are unhappy abut. Be sure t put yur first and last name, the number frm the frnt f yur Buckeye member ID card, and yur address and telephne number in the letter s that we can cntact yu, if needed. Yu shuld als send any infrmatin that helps explain yur prblem, such as the date and where the prblem ccurred. Buckeye Health Plan Appeals/Grievance Crdinatr 4349 Eastn Way, Suite 400 Clumbus, OH Buckeye will send yu a letter if we make a decisin t: deny a request t cver a service fr yu; reduce, suspend r stp services befre yu receive all f the services that were apprved; r deny payment fr a service yu received that is nt cvered by Buckeye We will als send yu a letter if we failed t make a decisin in a timely manner. Fr example... make a decisin n whether t kay a request t cver a service fr yu, r give yu an answer t smething yu tld us yu were unhappy abut If yu d nt agree with the decisin/actin listed in the letter, and yu cntact us within 90 calendar days t ask that we change ur decisin/actin, this is called an appeal. The 90 calendar day perid begins n the day after the mailing date n the letter. Unless we tell yu a different date, we will give yu an answer t yur appeal in writing within 15 calendar days frm the date yu cntacted us. 25

27 Grievances If we have made a decisin t reduce, suspend r stp services befre yu receive all f the services that were apprved, yur letter will tell yu hw yu can keep receiving the services if yu chse and when yu may have t pay fr the services. Grievances If yu cntact us because yu are unhappy with smething abut Buckeye r ne f ur prviders, this is called a grievance. Buckeye will give yu an answer t yur grievance by phne (r by mail if we can t reach yu by phne) within the fllwing time frames: 2 wrking days fr grievances abut nt being able t get medical care 30 calendar days fr all ther grievances except grievances that are abut getting a bill fr care yu have received 60 calendar days fr grievances abut getting a bill fr care yu have received Yu als have the right at anytime t file a cmplaint by cntacting the: Ohi Department f Medicaid Ohi Department f Insurance Bureau f Managed Care 50 W. Twn Street, 3 rd Flr, Suite 300 P.O. Bx Clumbus, Ohi Clumbus, Ohi r TTY: State Hearings Buckeye will ntify yu f yur right t request a state hearing when: a decisin is made t deny services a decisin is made t reduce, suspend, r stp services befre all f the apprved services are received a prvider is billing yu because Buckeye has denied payment f the service a decisin is made t prpse enrllment r cntinue enrllment in the Buckeye Cntrlled Substances and Member Management (CSMM) prgram a decisin is made t deny yur request t change yur Buckeye Cntrlled Substances and Member Management (CSMM) prvider At the time Buckeye makes the decisin, r is aware that the prvider is billing yu fr payment, we will mail yu a state hearing frm. If yu want a state hearing, yu must request a hearing within 90 calendar days. The 90 calendar day perid begins n the day after the mailing date n the hearing frm. If we have made a decisin t reduce, suspend, r stp services befre all f the apprved services are received and yu request the hearing within 15 calendar days frm the mailing date n the frm, we will nt take the actin until all apprved services are received r until the hearing is decided, whichever date cmes first. Yu may have t pay fr services yu receive after the 26

28 Grievances prpsed date t reduce, suspend, r stp services if the hearing fficer agrees with ur decisin. State hearing decisins are usually issued n later than 70 calendar days after the request is received. Hwever, if the MCP r Bureau f State Hearings decides that the health cnditin meets the criteria fr an expedited decisin, the decisin will be issued as quickly as needed, but n later than 3 wrking days after the request is received. Expedited decisins are fr situatins when making the decisin within the standard time frame culd seriusly jepardize yur life r health r ability t attain, maintain, r regain maximum functin. T request a hearing yu can sign and return the state hearing frm t the address r fax number listed n the frm, call the Bureau f State Hearings at , r submit yur request via at bsh@jfs.hi.gv. A state hearing is a meeting with yu, smene frm the Cunty Department f Jb and Family Services, smene frm Buckeye and a hearing fficer frm the Ohi Department f Jb and Family Services. Buckeye will explain why we made ur decisin and yu will tell why yu think we made the wrng decisin. The hearing fficer will listen and then decide wh is right based upn the infrmatin given and whether we fllwed the rules. If yu want infrmatin n free legal services but dn t knw the number f yur lcal legal aid ffice, yu can call the Ohi State Legal Services Assciatin at , fr the lcal number. 27

29 Grievances GRIEVANCES/APPEALS FORM Date If yu wish t file a grievance/appeal, please cntact Member Services at (TTY ). If yu d nt have access t a phne, yu can cmplete this frm r write a letter that includes the infrmatin requested belw. The cmpleted frm r yur letter shuld be mailed t: Buckeye Health Plan Appeals/Grievance Crdinatr 4349 Eastn Way, Suite 400 Clumbus, OH Or fax t fllwing the incident causing the cmplaint. Please nte: Yu must prvide cmplete and accurate cntact infrmatin belw s Buckeye can cntact yu t wrk with yu n reslving yur issue. Name f Member: Address f Member: Phne number f Member: Member MMIS Number: Legal Guardian/Custdial Parent: Has this issue been brught t the attentin f a Buckeye emplyee befre? If yes, when? T whm? Nature f Cmplaint: (Please state all details relating t the incident in questin, including names, dates, places, etc. Please attach additinal sheets f supprting dcumentatin abut yur grievance/appeal, if necessary.) The sectin belw will be cmpleted by Buckeye. Reslutin: Representative: Date: 28

30 Membership Terminatin MEMBERSHIP TERMINATION Lss f Medicaid Eligibility It is imprtant that yu keep yur appintments with the Cunty Department f Jb and Family Services. If yu miss a visit r dn t give them the infrmatin they ask fr, yu can lse yur Medicaid eligibility. If this wuld happen, Buckeye wuld be tld t stp yur membership as a Medicaid member and yu wuld n lnger be cvered by Buckeye. Lss f Insurance Ntice (Certificatin f Creditable Cverage) Anytime yu lse health insurance, yu shuld receive a ntice, knwn as a certificate f creditable cverage, frm yur ld insurance cmpany that says yu n lnger have insurance. It is imprtant that yu keep a cpy f this ntice fr yur recrds because yu might be asked t prvide a cpy. Autmatic Renewal f MCP Membership If yu lse yur Medicaid eligibility but it is started again within 60 days, yu will autmatically becme a Buckeye member again. Ending Yur MCP Membership As a member f a managed care plan, yu have the right t chse t end yur membership at certain times during the year. Yu can chse t end yur membership during the first three mnths f yur membership r during the annual pen enrllment mnth fr yur area. The Ohi Department f Medicaid will send yu smething in the mail t let yu knw when yur annual pen enrllment mnth will be. If yu live in a mandatry enrllment area, yu will have t chse anther managed care plan t receive yur healthcare. If yu want t end yur membership during the first three mnths f yur membership r pen enrllment mnth fr yur area yu can call the Medicaid Htline at (TTY ). Yu can als submit a request n-line t the Medicaid Htline website at Mst f the time, if yu call befre the last 10 days f the mnth, yur membership will end the first day f the next mnth. If yu call after this time, yur membership will nt end until the first day f the fllwing mnth. If yu chse anther managed care plan, yur new plan will send yu infrmatin in the mail befre yur membership start date. Chsing a New Plan If yu are thinking abut ending yur membership t change t anther health plan, yu shuld learn abut yur chices. Especially if yu want t keep yur current dctr(s). 29

31 Membership Terminatin Remember, each health plan has its wn list f dctrs and hspitals that they will allw yu t use. Each health plan als has written infrmatin that explains the benefits it ffers and the rules that it has. If yu wuld like written infrmatin abut a health plan yu are thinking f jining r if yu simply wuld like t ask questins abut the health plan, yu may either call the plan r call the Medicaid Htline at (TTY ). Yu can als find infrmatin abut the health plans in yur area by visiting the Medicaid Htline website at Just Cause Membership Terminatins Smetimes there may be a special reasn that yu need t end yur health plan membership. This is called a "Just Cause" membership terminatin. Befre yu can ask fr a just cause membership terminatin yu must first call yur managed care plan and give them a chance t reslve the issue. If they cannt reslve the issue, yu can ask fr a just cause terminatin at any time if yu have ne f the fllwing reasns: 1. Yu mve and yur current MCP is nt available where yu nw live and yu must receive nn-emergency medical care in yur new area befre yur MCP membership ends. 2. The MCP des nt, fr mral r religius bjectins, cver a medical service that yu need. 3. Yur dctr has said that sme f the medical services yu need must be received at the same time and all f the services aren t available n yur MCP s panel. 4. Yu have cncerns that yu are nt receiving quality care and the services yu need are nt available frm anther prvider n yur MCP s panel. 5. Lack f access t medically necessary Medicaid-cvered services r lack f access t prviders that are experienced in dealing with yur special healthcare needs. 6. The PCP that yu chse is n lnger n yur MCP s panel and he/she was the nly PCP n yur MCP s panel that spke yur language and was lcated within a reasnable distance frm yu. Anther health plan has a PCP n their panel that speaks yur language that is lcated within a reasnable distance frm yu and will accept yu as a patient. 7. Other If yu think staying as a member in yur current health plan is harmful t yu and nt in yur best interest. Yu may ask t end yur membership fr Just Cause by calling the Medicaid Htline at ; TTY The Ohi Department f Medicaid will review yur request t end yur membership fr just cause and decide if yu meet a just cause reasn. Yu will receive a letter in the mail t tell yu if the Ohi Department f Medicaid will end yur membership and the date it ends. If yu live in a mandatry enrllment area, yu will have t chse anther managed care plan t receive yur healthcare unless the Ohi Department f Medicaid tells yu differently. If yur just cause request is 30

32 Membership Terminatin denied, the Ohi Department f Medicaid will send yu infrmatin that explains yur state hearing right fr appealing the decisin. Things t Keep in Mind If Yu End Yur Membership If yu have fllwed any f the abve steps t end yur membership, remember: Cntinue t use Buckeye dctrs and ther prviders until the day yu are a member f yur new health plan r back n regular Medicaid. If yu chse a new health plan and have nt received a member ID card befre the first day f the mnth when yu are a member f the new plan, call the plan s Member Services department. If they are unable t help yu, call the Medicaid Htline at ; TTY If yu were allwed t return t the regular Medicaid card and yu have nt received a new Medicaid card, call yur cunty casewrker. If yu have chsen a new health plan and have any medical visits scheduled, please call yur new plan t be sure that these prviders are n the new plan s list f prviders and any needed paperwrk is dne. Sme examples f when yu shuld call yur new plan include: when yu have an appintment t see a new dctr, a surgery, bld test r x-ray scheduled and especially if yu are pregnant. If yu were allwed t return t regular Medicaid and have any medical visits scheduled, please call the prviders t be sure that they will take the regular Medicaid card. Optinal Membership Terminatins Children under nineteen (19) years f age have the ptin nt t be a member f a managed care plan if they are: Eligible fr Supplemental Security Incme (SSI) under Title XVI; Receiving fster care r adptin assistance under Title IV-E; In fster care r an ut f hme placement; r Receiving services thrugh the Ohi Department f Health s Bureau fr Children with Medical Handicaps (BCMH). Additinally, if anyne is a member f a federally recgnized Indian tribe, regardless f age, they have the ptin t nt be a member f a managed care plan. If yu believe that yu/yur child meet any f the abve criteria and d nt want t be a member f a managed care plan, yu can call the Medicaid Htline at (TTY ). If smene meets the abve criteria and des nt want t be an MCP member, their membership will be ended. 31

33 Membership Terminatin Excluded frm MCP Membership The fllwing individuals are nt permitted t jin a managed care plan. Dually eligible under bth the Medicaid and Medicare prgrams. Institutinalized ( in a nursing hme and are nt eligible under the Adult Extensin categry, lng-term care facility, ICF-IID, r sme ther kind f institutin). Receiving Medicaid Waiver services and are nt eligible under the Adult Extensin categry. If yu believe that yu meet any f the abve criteria and shuld nt be a member f a managed care plan, yu must call the Medicaid Htline at (TTY ). If yu meet the abve criteria, yur MCP membership will be ended. Can Buckeye End My Membership? Buckeye may ask the Ohi Department f Medicaid t end yur membership fr certain reasns. The Ohi Department f Medicaid must kay the request befre yur membership can be ended. The reasns that Buckeye can ask t end yur membership are: Fr fraud r fr misuse f yur Buckeye ID card. Fr disruptive r uncperative behavir t the extent that it affects Buckeye's ability t prvide services t yu r ther members. 32

34 Membership Rights YOUR MEMBERSHIP RIGHTS As a member f Buckeye, yu have the fllwing rights: T receive all services that Buckeye must prvide. T be treated with respect and with regard fr yur dignity and privacy. T be sure that yur medical recrd infrmatin will be kept private. T be given infrmatin abut yur health. This infrmatin may als be available t smene wh yu have legally kayed t have the infrmatin r wh yu have said shuld be reached in an emergency when it is nt in the best interest f yur health t give it t yu. T be able t take part in decisins abut yur healthcare unless it is nt in yur best interest. T get infrmatin n any medical care treatment, given in a way that yu can fllw. T be sure that thers cannt hear r see yu when yu are getting medical care. T be free frm any frm f restraint r seclusin used as a means f frce, discipline, ease, r revenge as specified in Federal regulatins. T ask, and get, a cpy f yur medical recrds, and t be able t ask that the recrd be changed/crrected if needed. T be able t say yes r n t having any infrmatin abut yu given ut unless Buckeye has t by law. T be able t say n t treatment r therapy. If yu say n, the dctr r Buckeye must talk t yu abut what culd happen and they must put a nte in yur medical recrd abut it. T be able t file an appeal, a grievance (cmplaint) r state hearing. See pages f this handbk fr infrmatin. T be able t get all Buckeye written member infrmatin frm Buckeye: at n cst t yu; in the prevalent nn-english languages f members in Buckeye s service area; in ther ways, t help with the special needs f members wh may have truble reading the infrmatin fr any reasn. T be able t get help free f charge frm Buckeye and its prviders if yu d nt speak English r need help in understanding infrmatin. T be able t get help with sign language if yu are hearing impaired. T be tld if the healthcare prvider is a student and t be able t refuse his/her care. 33