F a m i l y C a r e. Member Guide. Optima Family Care is underwritten by Optima Health Plan. 11/2016

Transcription

1 F a m i l y C a r e Member Guide 11/2016 Optima Family Care is underwritten by Optima Health Plan.

2 4417 Corporation Lane Virginia Beach, VA Dear Member: Welcome! It is important to read this book. It tells you how to get services. It tells you about the medical services that are covered. It tells you about the medical services that are not covered. It tells you about the rights and responsibilities you have as a Member of the Plan. It tells you about Advance Directives. It tells you about other important information you need about services, your doctor, contacts to people that can help you, and more. You will get your ID card in a separate mailing. Please check your card right away. Call us if your information is not correct. We will send you a new card. All information in this book is general and may change. If you are not sure you have the latest health plan information, you may: Call Member Services at or toll-free Visit our website at optimahealth.com/familycare. Thank you for selecting Optima Family Care. Our goal is to provide you with quality healthcare and excellent customer service. Sincerely, Michael M. Dudley President

3 Table of Contents Your Personal ID Card... 3 Nondiscrimination Notice... 4 Local Departments of Social Services... 5 Access to Care... 7 List of Contracted Hospitals Member Rights and Responsibilities Advance Directives Evidence of Coverage Definitions Summary of Benefits Eligibility Covered Services Exclusions and Limitations Carved Out Services Covered by Medicaid Exclusions from Managed Care Participation Pre-authorization Process Other Health Insurance Claims for Reimbursement Complaints & Appeals Procedures Miscellaneous Privacy Policy Fraud, Waste and Abuse Telephone Number Quick Reference Guide Foreign Language Tagline

4 Your Personal ID Card Member ID Numbers PCP Phone Number Important phone numbers can be found on the back of your Member ID card Medicaid Number Always carry and show your Member ID card and your Medicaid card whenever you get any medical or behavioral healthcare services. Every Member has his or her own Optima Family Care and Medicaid card o Did you lose your ID Card? Call Member Services at or toll-free Ask for a new card. We send new cards right away. IMPORTANT If your name, address, or phone number change, you must contact your Medicaid caseworker at your local Department of Social Services. Also, call Family Care Member Services at or For your convenience, the next few pages contain a telephone list of local area Departments of Social Services. Failure to inform your local Department of Social Services of your change of address may result in loss of Medicaid eligibility and your enrollment in Family Care. Allowing someone else to use your healthcare Member ID card may result in cancellation of your Membership in Family Care. You could face criminal prosecution. 3

5 Notice Informing Individuals About Nondiscrimination and Accessibility Requirements Discrimination is Against the Law Optima Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Optima Health does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Optima Health: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact: Peggy Baker, Civil Rights Coordinator 4417 Corporation Lane, Virginia Beach, VA PABAKER@sentara.com If you believe that Optima Health has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Donna Pillatsch, Director of Compliance and Section 1557 Coordinator 4417 Corporation Lane, Virginia Beach, VA DHPILLAT@sentara.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, Donna Pillatsch (above) is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C Complaint forms are available at 4

6 Local Departments of Social Services Accomack Department of Social Services (757) Alleghany-Covington Department of Social Services (540) Amherst Department of Social Services (434) Bath County Department of Social Services (540) Bland County Department of Social Services (276) Bristol City Department of Social Services (276) Buchanan County Department of Social Services (276) Campbell County Department of Social Services (434) Carroll County Department of Social Services (276) Charlotte County Department of Social Services (434) Chesapeake Department of Social Services (757) Craig County Department of Social Services (540) Danville Division of Social Services (434) Dinwiddie Department of Social Services (804) Floyd County Department of Social Services (540) Franklin City Department of Social Services (757) Galax City Department of Social Services (276) Gloucester Department of Social Services (804) Grayson County Department of Social Services (276) Greensville/Emporia Department of Social Services (434) Hampton Department of Social Services (757) Harrisonburg-Rockingham Dept. of Social Services (540) Henry-Martinsville Department of Social Services (276) Hopewell Department of Social Services (804) James City County Department of Social Services (757) Albemarle County Department of Social Services (434) Amelia Department of Social Services (804) Appomattox Department of Social Services (434) Bedford Department of Social Services (540) Botetourt County Department of Social Services (540) Brunswick County Department of Social Services (434) Buckingham County Department of Social Services (434) Caroline Department of Social Services (804) Charles City Department of Social Services (804) Charlottesville Department of Social Services (434) Chesterfield/Colonial Heights Dept. of Social Services (804) Cumberland County Department of Social Services (804) Dickenson County Department of Social Services (276) Essex Department of Social Services (804) Fluvanna County Department of Social Services (434) Franklin County Department of Social Services (540) Giles County Department of Social Services (540) Goochland Department of Social Services (804) Greene County Department of Social Services (434) Halifax County Department of Social Services (434) Hanover County Department of Social Services (804) Henrico County Department of Social Services (804) Highland County Department of Social Services (540) Isle of Wight Department of Social Services (757) King and Queen Department of Social Services (804)

7 King George Department of Social Services (540) Lancaster County Department of Social Services (804) Louisa County Department of Social Services (540) Lynchburg Department of Human Services (434) Matthews Department of Social Services (804) Middlesex County Department of Social Services (804) Nelson County Department of Social Services (434) Newport News Department of Human Services (757) Northampton County Department of Social Services (757) Norton City Department of Social Services (276) Orange County Department of Social Services (540) Patrick County Department of Social Services (276) Pittsylvania County Department of Social Services (434) Powhatan County Department of Social Services (804) Prince George Department of Social Services (804) Radford City Department of Social Services (540) Richmond County Department of Social Services (804) Roanoke County Department of Social Services (540) Russell County Department of Social Services (276) Shenandoah Valley DSS (Staunton-Augusta Office) (540) Smyth County Department of Social Services (276) Suffolk Department of Social Services (757) Sussex Department of Social Services (434) Virginia Beach Department of Social Services (757) Westmoreland Department of Social Services (804) Wise County Department of Social Services (276) York Poquoson Social Services (757) King William Department of Social Services (804) Lee County Department of Social Services (276) Lunenburg County Department of Social Services (434) Madison County Department of Social Services (540) Mecklenburg County Department of Social Services (434) Montgomery County Department of Social Services (540) New Kent Department of Social Services (804) Norfolk Department of Social Services (757) Northumberland County Department of Social Services (804) Nottoway County Department of Social Services (434) Page County Department of Social Services (540) Petersburg Department of Social Services (804) Portsmouth Department of Social Services (757) Prince Edward County Department of Social Services (434) Pulaski County Department of Social Services (540) Richmond City Department of Social Services (804) Roanoke City Department of Social Services (540) Rockbridge-Buena Vista-Lexington Area Social Services (540) Scott County Department of Social Services (276) Shenandoah Valley DSS (Waynesboro Office) (540) Southampton County Department of Social Services (757) Surry Department of Social Services (757) Tazewell County Department of Social Services (276) Washington County Department of Social Services (276) Williamsburg Human Services (757) Wythe County Department of Social Services (276) Source: 6

8 Access to Care You should receive your healthcare from a participating Family Care doctor, Provider or hospital, unless you have an emergency. Choosing or changing your Primary Care Physician (PCP) is an option for you. You can choose your PCP from a list of participating Plan Providers that includes family practitioners, internists, OB/GYNs, nephrologists and pediatricians. If you would like to choose or change your PCP, call Member Services at or The Plan has some specialists that have agreed to act as a PCP. If you have a disabling condition, chronic illness or special health concern and need a specialist PCP, contact Member Services. If you would like more information about your Provider s education and experience, visit optimahealth.com/familycare or call SENTARA. Making a Doctor s Appointment within the first 30 days on the plan is an important step in your care. Call your PCP at the telephone number on the front of your Member ID card during normal business hours. Your PCP s office can help you set up a routine or urgent office visit or direct medical care to a participating specialist. If you need transportation for the appointment, call From the time you request to see your Provider, you can expect to get an appointment in the following timeframe depending on the reason for your visit: Emergency: Immediately upon request Urgent: 24 hours Illness: 1 week Routine / Well Care: 30 days Behavioral Health Services: Emergency: 6 hours Urgent: 48 hours Routine: 10 days APPOINTMENT TIMEFRAME STANDARDS Initial Pregnancy Care First trimester: 14 days Second trimester: 7 days Third trimester: 3 days High-risk: 3 days or immediately if an emergency Dental Services are covered for Members under age 21, pregnant women and FAMIS MOMS through Smiles for Children. This is a program administered by DentaQuest. Contact Smiles for Children at For more information,, see Dental under the Covered Services section. Call for transportation at least 5 days in advance. Emergency Services are covered. Use the Emergency Room for life-threatening emergencies. Call 911 if it is a life-threatening emergency or go to the nearest emergency room. An emergency is a sudden, unexpected illness or injury that you feel threatens your life, your child s life, the life of your unborn baby, or could hurt your health for a very long time. If you are not sure if you need emergency care, call your PCP or the 24-Hour Nurse Advice Line at or Some examples of emergencies are: Chest pain or breathing trouble Heavy bleeding, throwing up blood or miscarriage Very bad burns Fainting, convulsions, seizures Poisoning or overdose of drugs or medications Feeling that you might harm yourself or others Emergency Services Out of Town are covered. Call 911 if it is a life-threatening emergency or go to the nearest emergency room For minor injuries or immediate medical treatment, go to the nearest walk-in urgent care facility. You may have to pay for the services up front. See Claims for Reimbursement for how to submit your medical bills. 7

9 Access to Care Magellan of Virginia will coordinate non-traditional behavioral health and substance abuse services that are paid for through DMAS. You may call Magellan at or their TDD/TTY interpreter services number at for: General information about services and programs. Help with determining if you or your child needs (behavioral health or substance abuse services). Requesting services. Help with locating an in-network Provider. Reporting concerns or complaints about services. See Carved-Out Services. for a list of services provided by Magellan. Information is also available at MagellanofVirginia.com. Managed Care Helpline is available for Members to call for help or questions regarding eligibility; they can be reached at Member Education is available so you can better understand your benefits and services. You may call to schedule a home visit by a Plan representative. During our visit, we may complete an individual health screening. This will help us address all of your health care needs or concerns. Call the Outreach and Education department at or toll-free to schedule an appointment. Member Services is available from 8:00 a.m. until 6:00 p.m or If you are hearing impaired and have the right equipment, call the hearing impaired number at or or dial 711. If you speak a foreign language, an interpreter is available to help you (in over 140 languages). Assist you if you don t speak English. Si usted habla una lengua extranjera hay interpretes disponibles para ayudalo en mas de 140 idiomas. For visually impaired Members, we offer an oral translation of our Member Orientation material. We can also arrange for an in-home Member education session. Send you large print Member materials. Help you choose or change your PCP. Send you a Provider Directory. Answer questions or concerns about your health plan. Arrange for a sign language interpreter as necessary. Member Services (behavioral health) can answer your questions about behavioral health services from 8:00 a.m. until 6:00 p.m. Call , option 1 or , option 2 or Toll-free TDD relay station: or dial 711. New Medical Treatment or Procedures are reviewed by the Optima Health Medical Director Leadership Committee. The plan evaluates the new treatment through research of current medical literature, regulatory bodies and local standards of practice. Your Provider can contact Family Care to request approval for such a treatment or procedure. Nurse Advice Line can be reached 24 hours per day, including holidays. Call or The nurse can help you: With questions about an injury or illness when your Provider s office is closed. 8

10 Access to Care Obtain medical information and guidance before going to an Emergency Room or an urgent care center. If you are not sure you need emergency care. The emergency room should only be used for a lifethreatening emergency. Behavioral health information and guidance. Nutrition is important. Our staff is here to help you manage your child s nutritional needs THE RIGHT COMBINATION was adapted from the Maine Center for Public Health Keep ME Healthy Project. Practice the following tips every day to keep your child healthy: 5 servings of fruits and vegetables daily, like carrots and apples. 2 hours or less in front of an electronic screen like TV, video games or computers daily because being active means less TV time. 1 hour of walking, cycling, and playing ball is good for their health. 0 sugary drinks. Help your child choose drinks without any added sugar. To create a personal meal plan for your family, visit ChooseMyPlate.gov. Call if you are interested in weight management information. A Member of our staff is available to answer your questions. Partners in Pregnancy is a program to provide guidance, support, and education to our expectant moms. This program is free of charge. The team is available Monday Friday from 8:00 a.m. to 5:00 p.m. Call or at pregnancypartner@optimahealth.com. Prescription Drugs can be filled at any Plan pharmacy or from non-plan pharmacies that agree to accept the Plan s reimbursement rate as payment in full for their services. For more information, see Prescription Drugs under the Covered Services section or visit optimahealth.com/familycare. Quality Improvement Program (QIP) works to improve the quality of your health care.. They monitor all the services provided by the Plan to be sure you receive appropriate care. Follow up on any concerns you may have. If you have any questions or want more information about the QIP, please call or Optima Family Care offers Members a free cell phone. With a cell phone you will be eligible to receive free health text messages for all covered Family Care Members in your household. For additional information, please call Member Services at or Transportation is provided by LogistiCare for all covered medical and behavioral health services. To schedule transportation, call (at least five days in advance) toll free See Transportation Services under the Covered Services section. Vision Services are provided by EyeMed Vision Care. Call EyeMed Vision Care at or visit EyeMed.com to help you find a participating Provider. EyeMed s hours are 9:00 a.m. to 8:30 p.m. Monday through Friday, and Saturdays from 9:00 a.m. to 5:00 p.m. For more information, please see Vision Services under the Covered Services section. If you need transportation for covered vision services call LogistiCare at least 5 days in advance for routine appointments Well-Care Visits for Children. Children should be seen by their doctor more often than adults and should get well-care visits as follows: Newborn 2 months old 6 months old 12 months old 18 months old Before 6 weeks 4 months old 9 months old 15 months old 24 months old 9

11 Access to Care offers Members the opportunity to manage their healthcare online: Find a Doctor or Drug Change Primary Care Physician (PCP) Advance Directives Look and print claims history Member Newsletters and Member Guide Provider Directory 10

12 Contracted Hospitals in Virginia Hospital Name City State Alleghany Regional Hospital Low Moor VA Augusta Medical Center Fishersville VA Bath Community Hospital Hot Springs VA Bedford Memorial Hospital Bedford VA Bon Secours DePaul Medical Center Norfolk VA Bon Secours Mary Immaculate Hospital Newport News VA Bon Secours Maryview Medical Center Portsmouth VA Bon Secours Memorial Regional Medical Center Mechanicsville VA Bon Secours Richmond Community Hospital Richmond VA Bon Secours St. Francis Medical Center Midlothian VA Bon Secours St. Mary's Hospital Richmond VA Buchanan General Hospital Grundy VA Carilion Franklin Memorial Hospital Rocky Mount VA Carilion Giles Memorial Hospital Pearisburg VA Carilion New River Valley Medical Center Radford VA Carilion Roanoke Community Hospital Roanoke VA Carilion Roanoke Memorial Hospital Roanoke VA Carilion Stonewall Jackson Hospital Lexington VA Carilion Tazewell Community Hospital Tazewell VA Centra Lynchburg General Hospital Lynchburg VA Centra Southside Community Hospital Farmville VA Centra Virginia Baptist Hospital Lynchburg VA Chesapeake Regional Medical Center Chesapeake VA Children s Hospital Richmond VA Children s Hospital of The King s Daughters Norfolk VA CJW Medical Center (2 campuses) Richmond VA Clinch Valley Medical Center Richlands VA Danville Regional Medical Center Danville VA Dickenson Community Hospital Clintwood VA Fauquier Hospital Warrenton VA Henrico Doctors Hospital Richmond VA John Randolph Medical Center Hopewell VA Johnston Memorial Hospital Abingdon VA Lewis-Gale Medical Center Salem VA Martha Jefferson Hospital Charlottesville VA Mary Washington Hospital Fredericksburg VA Memorial Hospital Of Martinsville and Henry Co Martinsville VA Montgomery Regional Hospital Blacksburg VA Mountainview Regional Medical Center Norton VA Norton Community Hospital Norton VA Page Memorial Hospital Luray VA Pioneer Community Hospital of Patrick Stuart VA Pulaski Community Hospital Pulaski VA Rappahannock General Hospital Kilmarnock VA Reston Hospital Center Reston VA Riverside Shore Memorial Hospital Nassawadox VA Russell County Medical Center Lebanon VA Sentara Careplex Hospital Hampton VA Sentara Halifax Regional Hospital South Boston VA 11

13 Hospital Name City State Sentara Leigh Hospital Norfolk VA Sentara Norfolk General Hospital Norfolk VA Sentara Northern VA Medical Center Woodbridge VA Sentara Obici Hospital Suffolk VA Sentara Princess Anne Hospital Virginia Beach VA Sentara RMH Medical Center Harrisonburg VA Sentara Virginia Beach Hospital Virginia Beach VA Sentara Williamsburg Regional Medical Center Williamsburg VA Shenandoah Memorial Hospital Woodstock VA Smyth County Community Hospital Marion VA Southampton Memorial Hospital Franklin VA Southern Virginia Regional Medical Center Emporia VA Southside Regional Medical Center Petersburg VA Spotsylvania Regional Medical Center Fredericksburg VA Stafford Hospital Center Stafford VA Twin County Regional Hospital Galax VA University of Virginia Medical Center Charlottesville VA VCU Community Memorial Hospital South Hill VA VCU Medical Center Richmond VA Virginia Hospital Center Arlington VA Warren Memorial Hospital Front Royal VA Wellmont Lonesome Pine Hospital Big Stone Gap VA Winchester Medical Center Winchester VA Wythe County Community Hospital Wytheville VA Contracted Hospitals in Bordering States Hospital Name City State Harlan ARH Hospital Harlan KY Hazard ARH Regional Medical Center Hazard KY Mary Breckenridge ARH Hospital Hyden KY McDowell ARH Hospital McDowell KY Middlesboro ARH Hospital Middlesboro KY Morgan County ARH Hospital West Liberty KY Whitesburg ARH Hospital Whitesburg KY Williamson ARH Hospital South Williamson KY Bristol Regional Medical Center Bristol TN Franklin Woods Community Hospital Johnson City TN Hancock County Hospital Sneedsville TN Hawkins County Medical Center Rogersville TN Holston Valley Medical Center Kingsport TN Indian Path Medical Center Kingsport TN Johnson City Medical Center Johnson City TN Johnson County Community Hospital Mountain City TN Laughlin Memorial Hospital Greeneville TN Sycamore Shoals Hospital Elizabethton TN Unicoi County Memorial Erwin TN Beckley ARH Hospital Beckley WV Bluefield Regional Medical Center Bluefield WV Greenbrier Valley Medical Center Ronceverte WV Princeton Community Hospital Princeton WV Summers County ARH Hospital Hinton WV 12

14 What Are My Rights? Medicaid is a voluntary program. This means that you agree to be part of the Medicaid program and to follow the rules issued by Medicaid and Optima Family Care. Privacy. You have the right to be sure your medical record is kept private and that your records will not be given out without your doctor s permission or your written approval. In the case of a minor, release of information is allowed only by the permission of the legal guardian. be treated with respect, dignity, and privacy. Take part in making decisions about your healthcare. You have the right to pick or change doctors from the list of doctors in the health plan s Provider network. get in touch with your doctor. decide about your healthcare and give permission before the start of any treatment or surgery. refuse treatment to the extent permitted by law. To be told of the possible medical consequences if you do so. ask for a second opinion. discuss your medical record with your doctor. You may receive a copy of that record as required under State law. You may request that the record be amended or corrected. Receive care without restraint. You have the right to be free from being discriminated against due to race, national origin, religion, sex, age, mental or physical disability or the need for healthcare services. be told of appropriate or medically necessary treatment options for your illness regardless of the cost or benefit coverage. Have access to healthcare services. You have the right to get care right away if you have a medical emergency. go to any Medicaid doctor or clinic for birth control or family planning services. Receive all information in a manner that is easily understood. You have the right to be told about your illness or medical condition and the best way to treat in terms you can reasonably be expected to understand. be informed of the Plan s policies and procedures regarding services, benefits, doctors, and other Providers. be told about your rights and responsibilities. To be told of any significant changes in those policies and procedures. ask for a copy of the health Plan s Practice Guidelines. 13

15 What Are My Rights? Get information on emergency and after-hours coverage. You have the right to be told that emergency services do not require pre-authorization. use any hospital or other setting for emergency care. be told what constitutes an emergency medical condition, emergency services and post-stabilization services. Get oral interpretation services. You have the right to receive oral interpretation services free of charge for all non-english languages. be told about these services and how to get them. Exercise your rights without adverse effects. You have the right to be free from being coerced into making decisions about treatment. report any complaint about your doctor or your medical care and receive a response. file an appeal if your medical services are reduced or denied based on medical criteria. have a fair hearing. make recommendations about your rights and responsibilities as a Member. exercise your Member rights and responsibilities without any negative affect by the Plan or its Providers. Receive information on Optima Family Care services. You have the right to: be told at the time of enrollment, and at least once per year, of your right to disenroll from Optima Family Care. get an Member Handbook that tells you about: o Covered benefits o Benefits not covered by Optima Family Care o Carved-out Services o How to get pre-authorization for benefits and services o How to get benefits and services including transportation o How to get emergency care and services o Areas served by Optima Family Care get a Provider Directory that tells you about: o The name, address and phone number of network Providers that include: Primary Care Providers Specialists Hospitals 14

16 What Are My Responsibilities? Medicaid is a voluntary program. This means that you agree to be part of the Medicaid program and to follow the rules issued by Medicaid and Optima Family Care rules. Learn and follow Optima Family Care and Medicaid rules. It is my responsibility to carry your ID cards at all times when getting care and services keep scheduled appointments. To arrive on time. Let your doctor s office know if you must cancel or come late. treat Providers and staff with respect. express your opinions, concerns or complaints in a helpful manner. read and be aware of your health plan s policies and procedures about your services and benefits, and to follow those policies and procedures when receiving care. tell the health plan of any changes that might affect your coverage such as address, marriage, divorce, birth, income or insurance coverage. report any suspected fraud, waste and/or abuse. Tell your Providers about your healthcare needs. It is my responsibility to work with your doctor to establish the proper patient/doctor relationship. work with your doctor or other care coordinators as needed. Make sure that all of our Providers work with each other to give you all the medical and social support you need. tell your doctor or other Provider about any insurance you have. give as many facts as you can to help your doctor or other healthcare Provider take care of you. Take part in making decisions about your health. It is my responsibility to ask any questions and understand the answers about your illness or treatment. get and carefully consider all information necessary to give permission for a procedure or treatment. consider what will happen if you refuse to follow your doctor s instructions or recommendations. follow the plans and instructions for care that you agreed on with your doctor. 15

17 What Is An Advance Care Plan And How Do I Make One? What is an "Advance Care Plan"? An Advance Care Plan, also known as Advance Medical Directive, is a signed and witnessed written document on which you can appoint your Healthcare Agent and state your choices for medical treatment. Virginia Law provides that three sections can be included in your Advance Care Plan. (1) General and end-of-life healthcare instructions: records the medical treatments you DO wish to have, or DO NOT wish to have, should you lose your ability to communicate your wishes. (2) Appointment of a Healthcare Agent to speak for you if you are no longer able to speak for yourself. (3) Appointment of an Agent to assure your wishes for an anatomical gift of your whole body or your organs is done in accordance with your wishes. What is the difference between an Advance Care Plan, Advance Medical Directive, Living Will and a Medical Power of Attorney? An Advance Care Plan or Advance Medical Directive is a document that covers any or all of the three components listed above. Living Wills primarily only cover your healthcare wishes and are usually in a separate document. A Medical Power of Attorney also is usually found in a separate document and usually only covers the appointment of your Healthcare Agent. What are the requirements for making an Advance Care Plan? (1) The declaration must be in writing (2) Signed by the individual named in the document. (3) Signed by two witnesses over the age of 18. Federal Law (Patient Self-Determination Act) requires Optima Health to inform you of your rights regarding decisions about your healthcare. These include: (1) The right to facilitate your own healthcare decisions. (2) The right to accept or refuse medical treatment. (3) The right to make an Advance Care Plan. Virginia State Law (Virginia Code, to -2993) does not require Advance Medical Directives to be notarized, written on any special form, or drafted by an attorney. Advance Medical Directives are voluntary and you may refuse to implement one if you have a conscience objection. Information on Advance Care Plans for the community may be found on the Sentara Healthcare Website at and the Optima Health Website at My Advance Care Planning Guide is available for download at or by calling the Sentara Center for Healthcare Ethics at to request a copy by mail. You may also contact the Virginia Insurance Counseling and Assistance Program (VICAP). Their staff can help answer your questions, give you more information, and offer guidance. VICAP can be reached at TTY users may call The absence of an Advance Care Plan or Advance Medical Directive shall not give rise to any presumption as to your intent to consent to or refuse any particular health care. 16

18 OPTIMA FAMLY CARE EVIDENCE OF C O V E R A G E OPTIMA FAMILY CARE IS UNDERWRITTEN BY OPTIMA HEALTH PLAN 17

19 Definitions For purposes of this document and any enrollment application, questionnaire, form or other document provided or executed in connection with Plan enrollment, the following terms shall have the meanings given them in this Section unless the context requires otherwise: Adverse Action refers to the denial of a service authorization request; or the reduction, suspension, or termination of a previously authorized service; denial in whole or in part of a payment for a covered service; or the denial of an Member s request to exercise his/her right to obtain services outside of the network. Members may file an appeal of an adverse action. Behavioral Health and Substance Abuse Treatment Services are an array of therapeutic and rehabilitation services provided in inpatient and outpatient psychiatric and community mental health settings to diagnose, prevent, correct, or minimize the adverse effect of a psychiatric or substance abuse disorder. Traditional Behavioral Health & Substance Abuse Treatment Services are defined as inpatient and outpatient behavioral health and substance abuse treatment services, including care coordination services covered by the Plan. Non-Traditional Behavioral Health & Substance Abuse Treatment Services are defined as the subset of community mental health and rehabilitation services that are carved out and paid for by DMAS. Behavioral Health Services Administrator (BHSA) is an entity that manages or directs a behavioral health benefits program to include care coordination, Provider management, and reimbursement for such behavioral health services for: (1) the full spectrum of behavioral health services for individuals who are not currently enrolled in managed care; and (2) the subset of community mental health rehabilitation services that are carved out of the Plan s contract with DMAS. Behavioral Therapy Services are Systematic interventions provided by licensed practitioners within the scope of practice as defined under state law or regulation, and covered as remedial care to individuals younger than 21 years of age in the individual s home. Behavioral therapy includes, but is not limited to, applied behavior analysis (ABA). Carved-Out Service is a service that is covered and paid for through the DMAS. Coverage is the right to benefits as defined in this Member Guide which a Member is entitled to receive on the effective date until termination, subject to the Plan s conditions, and limitations and exclusions. Department of Medical Assistance Services/State (DMAS) is the organization contracting with the Plan to provide and/or arrange health care services for Medicaid eligible recipients. Department of Social Services (DSS) is the State organization through which eligibility for Medicaid services is determined. Drug List is a listing of prescription medications which are approved for use by the Plan and which will be dispensed subject to the Plan s established procedure through participating pharmacies to a Member. When designated by the Plan, a generic equivalent shall be dispensed. This list shall be subject to periodic review and modification by the Plan. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is a program of preventive health care and well child examinations with appropriate tests and immunizations for children and teens from birth up to age

20 An unclothed physical examination. Definitions Identifies apparently well children from those who have a disease, condition or abnormality. Looks for those who may need diagnosis, evaluation and/or treatment of their physical or mental problems. Medically necessary services, which are required to correct, improve, or is needed to maintain (ameliorate) defects and physical or mental illnesses that are found during a screening exam are covered as part of EPSDT. Early Intervention (EI) services are developmental supports and services that are performed in natural environments, including home and community based settings in which children with developmental delays participate, to the maximum extent possible. Emergency Custody Order is issued by a magistrate. It requires any person in the magistrate s judicial district who is incapable of volunteering or unwilling to volunteer for treatment, or in the case of a minor, to be taken into custody and transported for an evaluation in order to assess the need for temporary detention order and to assess the need for hospitalization or treatment. FAMIS MOMS Recipients are uninsured pregnant females that are not eligible for Medicaid but qualify for coverage based on the FAMIS MOMS eligibility guidelines. Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires standardization of electronic patient health, administrative and financial data; unique health identifiers for individuals, employers, health plans, and health care Providers; and security standards protecting the confidentiality and integrity of individually identifiable health information past, present or future. Home Health Care Agency is an agency or organization, or subdivision thereof, which: is primarily engaged in providing skilled nursing services and other therapeutic services in the Member s home. is duly licensed, if required, by the appropriate licensing facility. has policies established by a professional group associated with the agency or organization, including at least one physician and one registered nurse (R.N.) to govern the services provided. provides for full-time supervision of such services by a physician or by a registered nurse (R.N.). maintains a complete medical record on each patient. has a full-time administrator. Medically Necessary services and/or supplies are the use of services or supplies as provided by a hospital, skilled nursing facility, physician or other Provider required to identify or treat a Member s illness or injury and which, as determined by the Member s primary care physician and the Plan, are: consistent with the symptoms, diagnosis and treatment of the Member s condition, disease, ailment or injury. in accordance with recognized standards of care for the Member s disease, ailment or injury. appropriate with regard to standards of good medical practice. not solely for the convenience of the Member, his or her primary care physician, participating physician, hospital, or other health care Provider. the most appropriate supply or level of service which can be safely provided to the Member. When specifically applied to an inpatient, it further means that the Member s medical symptoms or condition requires that the diagnosis, treatment or service cannot be safely provided to the Member as an outpatient. 19

21 Definitions Member means the individual who meets the eligibility requirements defined by DMAS and is enrolled in Family Care. Non-Plan Provider is any Provider that is not a contracted Plan Provider. Plan means Optima Family Care or Family Care. Plan Pharmacy is a duly licensed pharmacy which has a contract with the Plan. Plan Provider is a physician, hospital, skilled nursing facility, urgent care center, laboratory or other duly licensed institution or health professional under contract to provide professional and hospital services to Members. A list of Plan Providers and their locations is available to each Member or family upon request or may be obtained at optimahealth.com/familycare. Such list shall be revised from time to time as necessary. A Plan Provider s contract may end, and a Member may be required to utilize another Plan Provider. Pre-authorization is the Plan s process to check the medical necessity of a proposed treatment. The Plan has to make sure the treatment is right for your level of care. The Plan must pre-authorize some goods and services. Protected Health Information (PHI) is individually identifiable information, including demographics, which relates to a person s health, health care, or payment for health care. Service Area shall mean the geographic area within which the Plan has Members: Accomack Buena Vista Emporia Harrisonburg Mathews Pittsylvania Scott Albemarle Campbell Essex Henrico Mecklenburg Poquoson Smyth Alleghany Caroline Floyd Henry Middlesex Portsmouth Southampton Amelia Carroll Fluvanna Highland Montgomery Powhatan Staunton Amherst Charles City Franklin Hopewell Nelson Prince Edward Suffolk Appomattox Charlotte Franklin City Isle of Wight New Kent Prince George Surry Augusta Charlottesville Galax James City Newport News Pulaski Sussex Bath Chesapeake Giles King & Queen Norfolk Radford Tazewell Bedford City Chesterfield Gloucester King William Northampton Richmond City Virginia Beach Bedford Co Colonial Heights Goochland Lancaster Northumberland Richmond Co Washington Bland Craig Grayson Lee Norton Roanoke City Waynesboro Botetourt Covington Greene Lexington Nottoway Roanoke Co Westmoreland Bristol Cumberland Greensville Louisa Orange Rockbridge Williamsburg Brunswick Danville Halifax Lunenburg Page Rockingham Wise Buchanan Dickenson Hampton Madison Patrick Russell Wythe Buckingham Dinwiddie Hanover Martinsville Petersburg Salem York Skilled Nursing Facility is a facility which is licensed by the State and is accredited under one of the programs of the Joint Commission on Accreditation of Healthcare Organizations as a skilled nursing facility or is recognized by Medicare as an extended care facility; and furnishes room and board and 24-hour-a-day skilled nursing care by, or under the supervision of, a registered graduate nurse (RN); and other than incidentally is not a clinic, a rest facility, a home for the aged, a substance abuse facility, rehabilitation facility, or a place for custodial care. Specialist is any Physician who is not a Primary Care Physician. A Plan Specialist shall mean a Specialist who is a Plan Provider. State Fair Hearing is any action or appeal decision rendered by the MCO that may be appealed by the Member to the DMAS Client Appeals Division. 20

22 Definitions Telemedicine is defined as real-time or near real-time two-way transfer of medical data and information using an interactive audio-video connection for the purpose of medical diagnosis and treatment. Services of physicians, nurse practitioners, nurse midwives, clinical nurse specialists-psychiatric, clinical psychologists, clinical social workers, licensed and professional counselors for telemedicine services requires one of these types of Providers at the main hub and satellite spoke sites for a telemedicine service to be reimbursed. Temporary Detention Order (TDO) is an emergency custody order issued following sworn petition to any magistrate that authorized law enforcement to take a person into custody and transport that person to a facility designated on the order to be evaluated, where such person is believed to be mentally ill and in need of hospitalization or treatment. 21

23 S UMMARY OF B ENEFITS Optima Family Care P HYSICIAN S ERVICES Includes Covered Services performed in the Physician s office during the Physician office visit. Pre-Authorization is required for in-office surgery and rehabilitation services. All services from Non-Participating Providers require prior authorization. SERVICES COPAYMENT COMMENTS Primary Care Physician (PCP) Office Visit Covered at 100% Includes covered services performed in the physician s office including outpatient clinic services. Specialist Office Visit Covered at 100% Includes covered services performed in the physician s office including outpatient clinic services. Preventive Care Covered at 100% Includes routine physicals, GYN exam, and pap smears. Maternity Care Pre-authorization is required. Covered at 100% Includes routine prenatal and postnatal care rendered by the OB/GYN. Includes outpatient clinic services. Well Baby and Well Child Care Covered at 100% Includes routine office visits with health assessments and physical exams, routine lab work including blood lead testing and age appropriate immunizations. O UTPATIENT T HERAPY & R EHABILITATION S ERVICES The Plan shall cover therapy services that are medically necessary to treat or promote recovery from illness or injury. Other services include chemotherapy, radiation therapy, IV therapy, Inhalation therapy and dialysis. SERVICES COPAYMENT COMMENTS Outpatient Therapy Services Covered at 100% Includes physical, occupational and speech therapy or visit. Outpatient Rehabilitation Services Pre-authorization is required. Covered at 100% Includes cardiac, pulmonary and vascular rehabilitation treatment or visit. 22

24 SERVICES COPAYMENT COMMENTS Outpatient Chemotherapy, Radiation Therapy, IV Therapy, and Inhalation Therapy Covered at 100% Pre-Authorization is required for IV Therapy with medications and inhalation therapy. Outpatient Dialysis Services Covered at 100% A physician referral is required. O UTPATIENT S URGERY SERVICES COPAYMENT COMMENTS Outpatient Surgery Covered at 100% Pre-authorization is required. O UTPATIENT D IAGNOSTIC P ROCEDURES SERVICES COPAYMENT COMMENTS Diagnostic Procedures Pre-authorization is required. Covered at 100% Includes outpatient lab, x-ray and other diagnostic procedures, including MRI, PET, and CT Scans. I NPATIENT S ERVICES SERVICES COPAYMENT COMMENTS Inpatient Services Pre-authorization is required. Transplants are covered at contracted facilities only. Covered at 100% Physician inpatient care is covered at 100% Includes maternity care, lab, x-ray, surgery and other services. This also includes inpatient rehabilitation services in facilities certified by the Department of Health. E MERGENCY S ERVICES Includes those emergency room facility, Physician, and ancillary services that are rendered during an emergency room visit. Emergency Room Covered at 100% Urgent Care Center Covered at 100% Includes urgent care facility, physician, and ancillary services rendered during an urgent care center visit. Ambulance Covered at 100% Covered for emergency transportation only. 23

25 B EHAVIORAL H EALTH C ARE AND S UBSTANCE A BUSE S ERVICES SERVICES COPAYMENT COMMENTS Inpatient Behavioral Health Services Pre-authorization is required. Inpatient Substance Abuse Services Pre-authorization is required. Outpatient Behavioral Health Care and Substance Abuse Services Pre-authorization is required. Covered at 100% Covered at 100% Covered at 100% Optima Family Care shall cover traditional behavioral health services including inpatient, outpatient (individual, family, and group) therapies, and temporary detention and emergency custody order services; and Magellan of Virginia shall provide coverage for non-traditional, community mental health rehabilitation services. You may call Magellan at or their TDD/TTY interpreter services number at O THER C OVERED S ERVICES SERVICES COPAYMENT COMMENTS Diabetic Supplies and Equipment Includes FDA approved equipment and supplies for the treatment of diabetes and in-person outpatient selfmanagement training and education including medical nutrition therapy. Durable Medical Equipment Pre-authorization is required for items over $750 Pre-authorization is required for all rental items. Early Intervention Services Supplies are covered at 100% if prescribed by your physician. Covered at 100% Covered at 100% for children up to age 3 Please see Diabetic Equipment, Supplies and Services under Covered Services Covered Services include but not limited to durable medical equipment and colostomy, iliostomy, and tracheostomy supplies, and suction and urinary catheters. Carved-out service-covered and paid for by Medicaid Family Planning Services Pre-authorization is NOT required. Covered at 100% Does not include services to treat infertility or to promote fertility. 24