Child Health Plan Plus Benefits Booklet. Plan underwritten by Rocky Mountain HMO

Transcription

1 Child Health Plan Plus Benefits Booklet Plan underwritten by Rocky Mountain HMO CHP+-BENEFITS BOOKLET MS

2 Welcome to Rocky Mountain Health Plans (RMHP) and Our Partnership in Good Health! We believe keeping quality health care accessible and affordable requires the active participation and commitment of our Members, physicians, other health care providers, and us. RMHP is dedicated to providing quality medical care; friendly, helpful service; and a range of awareness programs and benefits designed to help our Members achieve and maintain good health. We want Members to get the most from health plan coverage and avoid unnecessary costs, so please take a few minutes to read this booklet. We also encourage you to call one of our Customer Service Representatives for a brief orientation to plan benefits and procedures. If You Have a Question or Concern If you have any questions about your coverage, call or RMHP Customer Service. Address: Hours: Phone Number: TDD/TTY Number: Address: Rocky Mountain Health Plans 2775 Crossroads Blvd. PO Box Grand Junction, CO :00 a.m. 5:00 p.m. Monday Friday or (Para asistencia en español llame al or ) 711 (for the hearing impaired only). Special equipment is required. customer_service@rmhp.org For callers who speak languages other than English or Spanish, RMHP uses Certified Language International (CLI) Language Interpreters. If you are hearing impaired and use TTY equipment, dial 711 for Relay Colorado. This service is available 24 hours a day 365 days a year. To communicate with non-tty users, a hard-of-hearing person uses a special statesponsored service known as a relay center. Operators at these relay centers accept calls from TTY users on their own TTY devices, then verbally relay the information to a hearing person using a standard telephone connection. When the hearing person replies, the relay operator types the response into their TTY phone and sends the response to the TTY user at the other end. In cases where a hearing person needs to initiate a call to a TTY user, this process is performed in reverse (instead of the TTY user calling the relay center, the hearing person initiates the conversation and the relay center operator dials the hard-of-hearing person's TTY device). 1 Customer Service: or

3 Rocky Mountain Health Plans is a partner with CHP+ in making sure you receive quality health care. Use the table below to decide when to contact CHP+ and when to contact RMHP. Change of Address Add a Child to Your Coverage Change Primary Care Physician Change of Health Insurance Stop Coverage Pay Premium Request a New Member ID Card Questions About Coverage Information About Care From a Specialist Preauthorization For Services Reimbursement for Covered Medical Services or Prescription Drugs You Paid for Yourself You Have a Complaint Call RMHP Customer Service Call CHP+ Customer Service Call RMHP Customer Service Call CHP+ Customer Service Call CHP+ Customer Service Send to CHP+ Call or RMHP Customer Service Call or RMHP Customer Service Ask Your Primary Care Physician Ask Your Primary Care Physician Call or RMHP Customer Service Complete Complaint Form and Send it to RMHP Call CHP+ at: Address: Hours: Child Health Plan Plus PO Box Glendale, CO :00 a.m. 6:00 p.m. Monday Friday Phone Number: Member Satisfaction We are always interested in your experiences with RMHP. One way we receive information from our Members is through surveys. Your answers to these surveys help us do a better job of helping you use your health care benefits. We appreciate your time and interest in answering these surveys, if you receive one. If you experience a problem or have a concern with our service, please let us know by filling out the complaint form toward the back of this booklet. We have a complaint process to review your concerns. When we receive your complaint, our Customer Service Department will initiate a thorough investigation. Our Customer Service representatives can tell you more about this process. RMHP Participates in the Colorado Children s Immunization Registry In January 2004, RMHP began participating in the Colorado Immunization Information System (CIIS). The CIIS is a computer system operated by the University of Colorado for the Colorado Department of Public Health and Environment under the Colorado Immunization Act. RMHP sends the CIIS immunization data obtained from immunization claims. The immunization registry keeps track of a child s immunizations (shots) so all of the information is stored in one place. Keeping a complete record of your child s immunizations is important so that your child gets all the 2 Customer Service: or

4 recommended immunizations. Your health care provider can also use the registry to look up your child s immunization record to find out what shots are needed. Information in the CIIS can only be released to the entities identified in the Colorado Immunization Act. Parents can choose at any time to have their child s shot record excluded from the Colorado Immunization Registry. A form can be obtained from the CIIS. For more information, contact CIIS at or Disclosure Notice Women s Health and Cancer Rights Act of 1998 Notice is required under the Women s Health and Cancer Rights Act of 1998 to all RMHP group and individual plan participants concerning specified benefits under this act. The act requires the following coverage be provided for group and individual Members receiving benefits in connection with a mastectomy and electing breast reconstruction. Reconstruction of the breast on which the mastectomy has been performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; and Prostheses and physical complications in all stages of mastectomy, including lymphedemas, in a manner determined in consultation with the attending physician and the patient. Such coverage will be subject to deductibles, coinsurance, copayment, and other provisions of the Member s applicable plan. Important Personal Health Care Decisions RMHP believes in preventive health care benefits such as routine physicals, immunizations and well-child care to help you and your family maintain good health. Your quarterly Member newsletter, Focus on Health, is designed to provide you with health care information and news about your coverage. We encourage you to read each issue. How can I learn about Rocky Mountain s Privacy Practices? RMHP respects the privacy of your protected health information. Our Notice of Privacy Practices describes your rights and how medical information about you may be used or disclosed. View it on our website at rmhp.org, click on Privacy and Disclosures at the bottom of the page. Or, if you would like a paper copy, call Customer Service at to request one, or write us at Rocky Mountain Health Plans, Privacy Notice, PO Box 10600, Grand Junction CO Equal Opportunity Policy It is the policy of RMHP to provide equal opportunity and to prevent discrimination based on race, color, national origin, age, or disability in admission or access to, or treatment or employment in, RMHP programs, health care plans, and activities to the extent required by applicable law. If you have any questions concerning this policy, please contact the Member Concerns Coordinator at Additional Information You can get more information about how RMHP works. You can get information on how RMHP is arranged. You can also get information on our physician incentive plans. Call RMHP Customer Service at Throughout this booklet, the words you and your refer to the Member (you and/or your child). 3 Customer Service: or

5 Table of Contents Section How the CHP+ Plan Works... 7 Contract Year... 7 Call Within 48 Hours... 7 Referrals Are Not Required... 7 Member Identification Card... 7 Change Form... 7 Copayments and Premiums... 7 Out-of-Pocket Limit... 8 Your Primary Care Physician (PCP) is Very Important to Your Health... 8 Every Time You Need Health Care Services, Work With Your PCP... 9 In Case of Emergency Care Management and Quality Improvement Programs Section Covered Services and Benefits Alcohol and drug abuse treatment Allergy Testing and Treatment Ambulance Services Chemo and Radiation therapy Dental care (for children only) Dietary Counseling and Nutritional Services Emergency and Urgent Care Services Health Education Hearing care Home Health Care Hospice Care Inpatient Hospital Medical/Surgical Services Kidney Dialysis Laboratory, X-rays and other imaging services Maternity and Newborn Care Medical equipment and supplies Mental health care Office visits/pcp and other doctor visits Outpatient/Surgical Services Prescription Drugs and Supplies Preventive, Routine, and Reproductive Health Services Reconstructive Surgery Rehabilitation/Therapy Skilled Nursing Facility Services Surgical Services TMJ Services Transplants Vision Services Section General Exclusions How Experimental Services Are Determined Examples of Experimental Services Section Coordination of Benefits and Subrogation Coordination of Benefits (COB) Third-Party Liability Subrogation Automobile Insurance Customer Service: or

6 Settlement of Automobile Insurance Coverage Diligent Pursuit of Coverage Section Claims Payment Acceptable Claims Where to Send Your Claim Overpayments Section Appeal and Grievance Processes Section A. Appeal an Action Section B. File a Grievance Section C. State Fair Hearing Jurisdiction and Venue Time is of the Essence HIPAA Privacy Complaints Quality of Care Concerns Release of Records Changes to the Dispute Resolution Procedures RMHP Member Complaint Form Section Enrollment and Termination Information Who Is Eligible Who Is Not Eligible When Coverage Begins Application for Coverage Adding a Child Fraud Terminating Coverage When Coverage Ends Membership Records Section General Provisions Sending Notices Availability of Provider Service Changes to the Benefits Booklet Delivery of Documents Execution of Papers Fraudulent Health Plan Acts Reporting Fraud Independent Contractors Pilot Programs Release of Information Utilization Review and Quality Management Refusal to Follow Recommended Treatment Catastrophic Events Research Fees Member s Legal Expense Obligations Section Member Rights and Responsibilities Evaluation of New Technologies Section Your Right to Make Health Care Decisions Customer Service: or

7 Introduction to Advance Directives RMHP Advance Directives Policy Advance Directives Cardio Pulmonary Resuscitation (CPR) Directive Substitute Decision Makers (Medical Proxies) Guardians Medical Durable Power Of Attorney Medical Durable Power of Attorney for Heath Care Decisions Living Wills Advance Directives Coalition Section Glossary Customer Service: or

8 Section 1 How the CHP+ Plan Works This benefits booklet describes the CHP+ Plan benefits, limits and exclusions of the Rocky Mountain Health Plans (RMHP) CHP+ Plan. This benefits booklet also describes how you can obtain benefits and other rules of the CHP+ Plan. By enrolling in the CHP+ Plan, you agree to the rules of this benefits booklet. This benefits booklet and the CHP+ Plan are subject at all times to RMHP s contract with the Colorado Department of Health Care Policy and Financing to provide covered services under the CHP+ Plan. Contract Year Your contract benefit year is January 1 through December 31. This means all your benefits are measured on a calendar year. This includes such things as your maximum annual copayment and treatments limited to a certain number of sessions per year. Call Within 48 Hours After you receive emergency care out of the RMHP service area, you must contact RMHP within 48 hours. Referrals Are Not Required You do not need a referral to see a participating provider for covered health care services. However, it is still important that you select a PCP. Your PCP will provide your routine and preventive care and can help you decide when you should see a specialist. You should always let your PCP know when you have received care from any other provider, so that your PCP can monitor your overall health. Member Identification Card Your Member identification (ID) card shows that you are a Member of RMHP s CHP+ Plan, a program administered as a partnership between state government and private business. Anytime you go to the doctor or hospital or get a prescription, show this card. The Member ID card itself does not give you any rights apart from this benefits booklet. The Member ID card does not give you the right to receive benefits under this benefits booklet if your eligibility ends or your coverage under the CHP+ Plan is terminated. Change Form If you change your membership in any way, such as changing your address, you must fill out and submit a change form to CHP+. This form can be obtained by calling CHP+ Customer Service at , Monday Friday, 8:00 a.m. to 6:00 p.m. You must also inform RMHP of any change by calling RMHP Customer Service at or Copayments and Premiums Copayments may be required for some health care services and prescription drugs. These copayments are listed on a separate document included with this booklet and on your Member ID card. The amount of your copayments is 7 Customer Service: or

9 determined based on your family size and income level. You pay your copayments directly to the provider at the time you receive a service or prescription drug. Premiums are required for you to be enrolled in CHP+. Your annual premiums will be determined at the time of your enrollment or renewal and will be based on your income and family size. You are responsible for making the premium payments directly to CHP+. If premiums are not paid, you may be disenrolled. (See Section 7: Enrollment and Termination Information). The contracts between RMHP and its providers include a hold harmless clause. This clause states that your provider cannot expect you to pay for covered services for which RMHP has agreed to pay. Services from nonparticipating providers are covered only under limited circumstances; nonemergency services from nonparticipating providers are not covered unless specifically preauthorized by RMHP. You are always liable for a provider s full billed charge for any non-covered services. Out-of-Pocket Limit Your CHP+ acceptance letter will report to you the maximum amount of money your family can expect to spend for CHP+ health care services each year. The out-of-pocket annual maximum is designed to protect Members families from catastrophic health care expenses. The annual out-of-pocket limit is 5 percent of your adjusted gross income. Once the copayments you have paid for covered medical services during a calendar year reaches the annual out of pocket limit, you do not pay a copayment for the rest of that calendar year. It is your responsibility to keep track of all the limits. Follow these instructions to keep track: Save your copayment receipts from covered medical care and covered prescription drugs. When you have reached your annual out-of-pocket limit, call CHP+ Eligibility and Enrollment at CHP+ Eligibility and Enrollment will ask for proof that you have reached your annual out-of-pocket limit. Send them copies of your receipts as proof. Your Primary Care Physician (PCP) is Very Important to Your Health At the time of enrollment, you must select a PCP. This doctor is very important. He or she provides or arranges for most of the care you will need. RMHP wants to be sure you are working with a primary care doctor. Follow these steps: 1. Pick a doctor or clinic from the Primary Care Physicians section of our Provider Directory. Each family member can have a different PCP. You must let us know who the PCP is for each member of your family that belongs to RMHP. You may already have a doctor you see when you are sick. If that doctor is with RMHP and is in the PCP section, you can pick him or her as your PCP. If your doctor is not on the list or you don t have a doctor, pick a doctor whose office is close to your home. 2. If you pick a doctor you have not seen before, you must call the doctor s office first. Ask the office if they will take you as a new patient. If they will take you as a patient, tell them you are picking the doctor as your new PCP. 8 Customer Service: or

10 We are here to help. Call RMHP Customer Service if you need help finding a PCP or if you need a Provider Directory. You may go to your PCP: for checkups and shots. for care when you are sick or hurt. to ask questions about your health. for help finding a specialist if you need one. for help getting the care ordered by specialty doctors; for example, surgery or home health care. hospital admission, if need be. How to change your PCP If you want to change your PCP, follow the steps above for picking a PCP. If you are changing doctors because you moved, remember to give us your new address. You must tell us who your new doctor is before you see that new doctor. If you have prescriptions or you are getting care from a specialist, talk to your new PCP about it. Your new PCP needs to know everything about your health to be sure you get the care you need. The date you call RMHP to request the PCP change will be the day your new PCP is effective. To have medical records transferred from one physician to another, contact your former PCP. You are responsible for any charges related to transferring your medical records. Every Time You Need Health Care Services, Work With Your PCP Making doctor appointments Call your PCP s office and tell them you are an RMHP CHP+ Member. Give them your CHP+ ID number if they ask for it. For non-urgent care, you will get an appointment within two weeks of the day you call. If you are too sick to wait two weeks, you can be seen within 48 hours. For adult physical exams, you should be able to get an appointment within four months of the day you call. If you can t get in to see your PCP as fast as you think you should, call RMHP Customer Service at Canceling doctor appointments If you can t make it to your doctor s appointment, you must call the doctor s office and tell them as soon as possible. You should call at least 24 hours before your appointment to tell them you can t make it. The doctor may charge you for missing the appointment if you don t cancel it. RMHP will not pay that charge. You will have to pay for it. Specialty care Sometimes when you see your PCP, he or she will want you to get specialty care. You do not need a referral to a specialist that works with RMHP. The specialty care you receive must be on the list of covered services in the Covered Services and Benefits section in this booklet. Call and make an appointment with the specialist. Be sure to show your Member ID card when you go for your appointment. Doctors that do not work with RMHP In general, care from doctors that do not work with RMHP is not covered. This does not apply to emergency care and urgent care. Call RMHP Customer Service if you need care that you cannot get from a doctor that works with 9 Customer Service: or

11 RMHP. You must have permission before going to a doctor that does not work with RMHP. If we give you written permission to see a doctor that does not work with RMHP, you will not have to pay extra for the care you get. For continuity of care, you may also be approved to see a doctor that does not work with RMHP who is already treating you if: you have been seen by the doctor at least 3 times prior to your enrollment in RMHP; at least 3 visits occurred within 6 months prior to the request for approval; and such visits are part of the same treatment plan. RMHP will decide on a case-by-case basis, at its sole discretion, whether to approve visits to a doctor that does not work with RMHP for continuity of care. Access You should be able to get most of your health care from doctors within 30 miles or a 30-minute drive from your home. If you live out of town or in a small town, there may not be a doctor close by. In this case, you will be able to see the nearest available doctor who works with us. If you cannot find a doctor close to you, call Customer Service for help. RMHP has a plan for making sure our Members can get to a doctor when they need one. This is called our access plan. Call RMHP Customer Service if you would like a copy of this plan. Preauthorization RMHP must approve some types of care before you receive it. This helps make sure the care you get will work for you. This helps to make sure you are getting care that is medically necessary. If you were supposed to get approval before getting care but you didn t, you will have to pay for the care yourself. The best thing to do is to be sure all your care is arranged by your PCP. In general, you must go to doctors, hospitals, and pharmacies listed in our Provider Directory. If you have questions about which doctors you can see, call RMHP Customer Service at or Learn about the health care providers that work with RMHP You can find health care providers that work with RMHP in the Directory of Participating Providers. The Directory of Participating Providers is available on our website at rmhp.org. You can get a printed copy of the Directory of Participating Providers by calling Customer Service. Customer Service can also help you find out about a health care provider s professional qualifications such as their schooling and certifications. In Case of Emergency You can get urgent and emergency care anywhere in the United States. You can get care 24 hours a day. You can get care every day of the year. You do not need an okay from RMHP to go to the emergency room for a true emergency. If you are not able to call us and let us know about your emergency room visit or urgent care visit, your care will still be covered. Emergency room services are expensive. Many doctors will take care of you in their offices after hours or on weekends. Some hospitals even have convenience rooms where you can get care. There may also be an urgent care center near you. These cost less than going to the emergency room. You may have to pay the cost yourself if you go to the emergency room when you don t have a true emergency. 10 Customer Service: or

12 You should use an emergency room ONLY when: Your condition is so serious you can t call your PCP. You call your PCP and he or she tells you to go to an emergency room. You have a life-or limb-threatening emergency. A life- or limb-threatening emergency means you feel your life or a limb is in danger. It means you feel you need medical care to avoid death or to avoid negatively affecting your health. You think your condition may endanger the life of your unborn child. You are in severe pain. You have lost consciousness for any period of time. Here s what to do if you have a life- or limb-threatening emergency: Go to the closest emergency room, call 911, or call the local emergency phone number. Tell the emergency room staff you are an RMHP Member. Call your PCP as soon as you can. Call RMHP within 72 hours if you re admitted to the hospital. Show your CHP+ ID card at the hospital. Here s what to do if you have a non-life-threatening emergency: Call your PCP, if you can, and tell them about your illness or injury. Follow what your doctor tells you about whether to go to the hospital or to the doctor s office. If you can t reach your doctor, go to the nearest emergency room. Call RMHP within 72 hours if you re admitted to the hospital. Show your CHP+ ID card at the hospital. Here s what to do if you get sick or injured but it s not an emergency: Call your PCP. The office telephone message may give you a number to call for a doctor who can take care of you. This may happen if your doctor is not there. This may also happen when the office is closed. There will always be someone to answer your call. You can always get help. Tell the doctor you re an RMHP Member and tell them about your illness or injury. Follow the doctor s instructions about whether to go to the hospital or to the doctor s office. Call RMHP Customer Service if: you need help understanding your benefits; or you are admitted to the hospital. Urgent care Urgent care is not the same as emergency care. Urgent care is for a sickness or injury that needs medical care quickly but is not life- or limb-threatening. If you need urgent care, call your PCP s office and follow what they tell you to do. If you need urgent medical care after normal business hours, you still have to call your PCP s office. This includes weekends and holidays. Your care will still be covered even if you are not able to call us and let us know about your urgent care visit. There is always a doctor who will return your call and give you instructions. Doctors who care for RMHP patients are on call day and night, every day, for emergencies. If you need urgent care, you can call your PCP s office any 11 Customer Service: or

13 time of the day or night and leave a message. Even if your PCP is not there, a doctor will call you back to tell you how to get care. For urgent care, you will get an appointment with a doctor within 48 hours of the time you call your PCP s office. Care Management and Quality Improvement Programs How can a Case Manager help you? They know about health care. They know about community services so they can help you get the care you need. They work with you and your doctors to help you reach your health goals. They can explain covered services. They can help you learn to care for yourself. Learning to live with a health problem can be frightening and difficult, but RMHP is here to help you. We want you to follow your doctor s treatment plan and learn about your disease. Our nurses and Case Managers will work with you one-on-one. How to Contact Care Management Staff We have nurses that can help you with any of your needs or answer questions about your care. Examples: you have a surgery scheduled and want to discuss options with someone we have approved or denied a service for you you need to see a specialist and you want assistance finding the right doctor you have a disease and you have questions You can call us Monday through Friday 8 A.M. to 5 P.M. by calling Customer Service at , Toll free and asking for the Care Management. You can also call us collect during normal business hours. After business hours you can leave a message and we will call you back the next business day. You may send a fax to us at or toll free If you need language assistance you can call us. This is free of charge. If you are hearing impaired and use TDD or TTY call 711. This is free of charge. If your covered service ends, and you still need care, we can tell you about available options. If you have questions about our programs or your claims, call Customer Service at We can also send you information if you want more information. We base our care management decisions only on the appropriateness of care and services. Rocky Mountain does not pay our participating providers to deny care and services. We do not offer incentives to our employees or others that encourage denying care. RMHP also has a Quality Improvement plan that lets us see the quality of RMHP. This includes health care and member services. We always want to improve our quality. You can request a copy of this plan at no cost to you. If you feel you did not get the right care, you can complain. If your care was not given by the right person, at the right place, or at the right time, you can complain. There is a form at the back of this handbook that you can fill out or you can call Customer Service at Your complaints help us see what works and what we need to fix. 12 Customer Service: or

14 If you are pregnant, RMHP can help you have a healthy baby. We can talk to you to see if you are at risk of having your baby early. Our nurses can also help you with special issues: Twins Breast-feeding Premature labor Diabetes Bed rest Stop-smoking program Learning to live with a health problem can be frightening and difficult, but RMHP is here to help you. We want you to follow your doctor s treatment plan and learn about your disease. Our nurses and Case Managers will work with you one-on-one. 13 Customer Service: or

15 Section 2 Covered Services and Benefits Health services are covered for you when they are medically necessary. Medically necessary means the services you receive from a doctor or clinic are the right services for your problem. They are the services other people with the same medical problem would receive. Just because your doctor requests a service does not make it medically necessary. If you don t know if a service is covered or not, call RMHP Customer Service and ask. In most cases, you must use doctors, hospitals, and drug stores listed in our Provider Directory. RMHP pays for services marked with this symbol: Services that aren t covered are marked with this symbol: Alcohol and drug abuse treatment Inpatient and outpatient drug and alcohol rehab, testing and monitoring is covered. Outpatient aftercare following the initial treatment period for alcohol and drug abuse rehab. Detox for drug and alcohol use is covered when medically necessary. This can be in the hospital or out of the hospital. Detox is limited to getting rid of the drug or alcohol from your body. The following are not covered: court ordered treatment that would otherwise not be covered; the cost of any damages to a treatment facility caused by you; long-term care (when you require long-term care or other therapeutic resources, RMHP can refer you to the appropriate community resource, but RMHP will not be responsible for the cost); and services provided or billed for by a school, halfway house. All alcohol and drug abuse treatment services must be preauthorized by your PCP. If you do not complete the entire treatment program, you will be responsible for paying billed charges for all services related to the treatment, regardless of when you received such services. Allergy Testing and Treatment Direct skin (percutaneous and intradermal), patch allergy tests and RAST (radioallergosorbent testing), allergy medications administered by injection in a provider s office and charges for allergy serum are covered. Ambulance Services RMHP covers ambulance services for a medical emergency. If you take the ambulance and it is not an emergency, you may have to pay for the care yourself. In an emergency situation (for example, an accident or sudden severe illness), the plan covers participating and nonparticipating ambulance services. 14 Customer Service: or

16 The following services are not covered: commercial transport, private aviation or automobile, private automobile, or air taxi services; if an ambulance has been called for you and you choose to not get the transport, you are responsible for any charges; ambulance transport from the emergency facility back to your home; ambulance services required only because there was no other transportation available or was inconvenient. Chemo and Radiation therapy Treatment of cancer by standard chemotherapy and/or radiation therapy is covered when you receive treatment in at a participating hospital, freestanding treatment facility or clinic, provider s office, or your home. Dental care (for children only) If you have an accident, services to repair a sound and natural tooth or related body tissue is covered. Sound and natural means teeth that are whole, without impairment or periodontal disease and did not need treatment for any other reason than the accident. Dental services related to the accidental injury must be initiated within 72 hours and completed within six months of the accident. Coverage is available for inpatient hospital room expenses and ancillary services associated with dental services only if you have a non-dental physical condition, such as hemophilia or heart disease that makes hospitalization medically necessary. This plan does not cover any costs associated with the dental service itself (for example, services of a dental surgeon are not covered). You can get fluoride varnish services from an in-network Primary Care Provider (PCP). Services provided by an in-network PCP do not require pre-authorization. The fluoride varnish must be received at an in-network PCP office. The PCP must also perform a risk assessment at the time of the Fluoride Varnish treatment and must have received the appropriate training for the Fluoride Varnish treatment. Coverage is available for the following: Up to 2 Fluoride Varnish treatments in a calendar year. Children ages 0 through age 4. The following services are not covered: Dental injuries cause by chewing, biting or crooked teeth (malocclusion). 15 Customer Service: or

17 Dietary Counseling and Nutritional Services Dietary counseling is covered following a new diagnosis of a diabetic condition or a diagnosis for a clinical problem that makes a special diet medically necessary.. Enteral Nutrition and nursing visits to assist with enteral nutrition are covered. These services are usually provided by a home health agency. Medically necessary TPN received in the home is a covered for the first 21 days following a hospital discharge. If medically necessary, additional days may be allowed up to a maximum of 42 days per calendar year as determined to be medically necessary and when pre-authorized by RMHP. Medical Foods and Theraputic formulas are covered for home use of inherited enzymatic disorders involved in the metabolism of amino, organic and fatty acids. Such disorders include phenylketonuria, maternal phenylketonuria, maple syrup urine disease, tyrosinemia, homocystinuria, histidinemia, urea cycle disorders, hyperlysinemia, glutaric acidemias, methylmalonic acidemia and propionic acidemia The following services are not covered: formulas for any medical condition that does not meet the above requirements; and over-the-counter infant formulas. Emergency and Urgent Care Services In case of emergency, call 911 or go to the nearest hospital or medical facility. Emergency room services are covered for true emergencies only. You can go to a hospital that works with RMHP or to the nearest hospital. The doctors will evaluate and stabilize your condition. They will provide services and supplies necessary to maintain a stabilized condition or to improve your condition. You must get follow-up care from your PCP. Your doctor decides when you are stable enough for transfer or release. If you go to the emergency room and it is not an emergency, you may have to pay for the care yourself. If you have an emergency outside our service area, we will cover your visit. We will cover follow-up care only until you are able to safely return to the service area. RMHP covers post-stabilization care. This means care you get after you have been seen in the Emergency Room/Urgent Care for an illness or injury. If you are traveling outside the country you are covered for an emergency. You will have to pay for the service and will then be reimbursed by RMHP. To get reimbursed, RMHP requires proof of payment, like a receipt, and all information to be translated into English and converted into U.S. dollars. Urgent and after hours care received within the RMHP service area is covered only when it is provided by your PCP, another participating provider, or an urgent care center. Urgent care received by you within the United States is covered only when you are traveling or temporarily absent from the RMHP service area. 16 Customer Service: or

18 Coverage for urgent care outside the RMHP service area is limited to the lesser of the actual charge or the usual and customary charge for similar services in the region where you received urgent care. Charges in excess of that amount are your responsibility. The following services are not covered: use of the emergency room for non-emergency service. services received outside of the service area if you knew you needed the care before you left the service area; and follow-up care from a nonparticipating hospital or health care provider as a result of an emergency, if you could have returned to the service area to receive care without medically harmful results. When you receive an itemized bill from a nonparticipating hospital for emergency care or urgent care, send it to RMHP within 60 days of the date you received services. RMHP requires proof of payment, such as a receipt, to reimburse you directly. If you do not submit claims for emergency care and urgent care you received out of the RMHP service area within such 60-day period, RMHP has no obligation to pay for such care. Health Education Health education provided by your PCP is covered. This may include information on achieving and maintaining physical and mental health and preventing illness and injury. If you have been diagnosed as diabetic, you may receive coverage for diabetic education classes attended within the first six months after diagnosis. Your doctor may ask a series of age-appropriate questions during your health maintenance visit. This will help the PCP decide on topics to talk about during your health education discussion. These questions will follow the recommendations made by the American Academy of Pediatrics. Hearing care Age-appropriate hearing screenings for preventive care, newborn hearing screening and follow-up for a failed screening is covered. Hearing aids needed because of congenital and traumatic injuries are covered once every five years. New hearing aids can be provided more often when changes to the existing hearing aid cannot meet your needs. Services and supplies including the initial assessment, fitting, adjustments, and auditory training are provided. Home Health Care Home health services are covered when services are provided by a PCP, specialist or facility that works with RMHP. This includes skilled nursing care, home health aide services, physician home visits, therapies, supplies and medications. Services must be ordered and directed by your PCP or another provider that works with RMHP. The following services are not covered: custodial care; care that is provided by a nurse who ordinarily lives in your home or is a member of your immediate family; food or meal services other than dietary counseling; 17 Customer Service: or

19 Hospice Care pastoral/religious or spiritual counseling; care related to non-covered services or surgical procedures; and personal comfort or convenience items or services, including homemaker services. Hospice care is special care for patients who are expected to live for less than six months. RMHP must preauthorize inpatient and home hospice care if you are terminally ill before you receive care. Hospice services must be received through a participating hospice program. Hospice services include skilled nursing care, physician visits, medical supplies and equipment, therapies, nutritional guidance and support and medications. Respite care is also covered. Respite care provides a brief break for the family providing total care to the terminally ill. You may be placed in respite care for a period not to exceed five continuous days for every 60 days of hospice care. You may not be placed in respite care for more than two respite care stays during a hospice benefit period If you require an extension of the hospice benefit period, the hospice agency must provide a new treatment plan. The hospice benefit period begins on the date the PCP or attending physician certifies that you are terminally ill and have a life expectancy of six months or less. Also, your participating physician must write a letter to RMHP to request a longer hospice benefit period. No more than one additional hospice benefit period will be approved. The following services are not covered: food services and meals, other than nutritional counseling; services or supplies for personal comfort or convenience, including homemaker and housekeeping services; private duty nursing; pastoral and spiritual counseling; and supportive services provided to the family of a terminally ill person when the person is not a Member of this plan. Inpatient Hospital Medical/Surgical Services When you stay in the hospital for one day or more it is called inpatient care. Your services include a semiprivate room, operating room, and related services. Some of these related services are food, drugs, oxygen, surgery, and tests to find out what is wrong. Unless you have a true emergency, RMHP must approve your hospital stay before you go. You must go to a hospital that works with us. The following services are not covered: private room expenses, unless your medical condition requires isolation to protect him/her from exposure to dangerous bacteria and diseases (conditions that require isolation include but are not limited to severe burns and conditions that require isolation according to public health laws); admissions, visits, or consultations related to non-covered services or procedures; inpatient physician services received on a day for which facility charges were denied; telephone consultations; and 18 Customer Service: or

20 Kidney Dialysis extended care facility admissions or admissions to similar institutions. Renal dialysis, hemodialysis, peritoneal dialysis and the cost of equipment rentals and supplies for use in home dialysis is covered. You may receive dialysis services in your home if the services are preauthorized by RMHP before you receive the care Therapeutic dialysis services are covered only when: you are not eligible for Medicare; you are covered by Medicare but do not have a Medicare supplemental insurance policy; and services are performed by a participating dialysis provider. Laboratory, X-rays and other imaging services Diagnostic services like x-rays, radiology services, labs, and diagnostic tests to find out what is wrong are covered. They need to be ordered by your PCP or a participating provider. Covered services include: radiology, ultrasound, and nuclear medicine tests; laboratory and pathology tests; genetic testing to diagnose a disease; EKG, EEG, and other electronic diagnostic medical procedures; and hearing and vision tests required for diagnosis and/or treatment of an accidental illness or injury. The following services are not covered: Diagnostic services related to a non-covered service. Maternity and Newborn Care Care women need while pregnant is covered. Services in the hospital when having a baby are covered. You can get care from your PCP or any OB/GYN doctor that works with RMHP. The hospital stay must be approved by RMHP before you go to the hospital. Coverage for maternity services includes: hospital charges for semiprivate room expenses and ancillary services, including the use of labor, delivery, or recovery rooms; prenatal medical care and prenatal case management services; maternity-related diagnostic tests; routine or complicated delivery, Cesarean section 19 Customer Service: or

21 postnatal medical care (including at-home follow-up care visits if performed within 72 hours following your or your child s discharge); necessary anesthesia services by a provider qualified to perform such services; spontaneous (unintentional) termination of pregnancy prior to full term; and abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. Coverage for routine newborn care services include: hospital nursery services for a newborn; physician care of a newborn in the hospital after delivery; pediatrician standby at a Cesarean section; and services related to circumcision of a male newborn. If the mother is covered by CHP+, her baby is eligible for one full year of coverage by the CHP+ plan if the baby is not eligible for Medicaid. This coverage will begin at birth. However, the health plan and/or the state must be notified of the birth in order for the coverage to become effective. The following services are not covered: care for deliveries outside of the service area within five weeks of the anticipated delivery date; adoption or surrogate expenses; paternity testing; storage costs for umbilical blood; testing for inherited disorders; elective abortion; and prenatal and maternity services provided by a nonparticipating provider. Medical equipment and supplies Equipment like crutches, wheelchairs, and oxygen are covered. Supplies like insulin needles and colostomy bags are covered. You must have a doctor s prescription for medical equipment. The equipment must be approved by RMHP. Some equipment is limited up to a maximum of $2,000 per calendar year payable by RMHP. The below equipment is subject to that maximum: oxygen and oxygen equipment; orthopedic appliances (this does not include orthotics, whether functional or otherwise); crutches; glucometers; the rental or, if preapproved by RMHP, purchase of durable medical equipment, including repairs, when prescribed by a participating physician or other participating provider and required for therapeutic use (for example, wheelchairs and walkers); and 20 Customer Service: or

22 prostheses and orthopedic appliances or devices (for example, neck brace); their fitting, adjustment, repairs, or replacement because of wear or a change in your condition that necessitates a new appliance. For member with diabetes, orthotic shoe inserts and orthopedic shoes not attached to a brace. If the $2,000 per calendar year limit is exceeded, you can be referred to the appropriate community resource. RMHP will not pay for any cost after the $2,000 limit has been reached. The following medically necessary items will not be subject to the durable medical equipment payment limit of $2,000 per calendar year: durable medical equipment owned by the facility and medical supplies used during a covered admission or during a covered outpatient visit; medical supplies (including casts, dressings, and splints used in lieu of casts) used during covered outpatient visits; and surgically implanted prosthetics or devices preauthorized by RMHP before you receive the device. Coverage is not available for items such as but not limited to: air conditioners, biofeedback equipment, exercise equipment, humidifiers, purifiers, self-help devices, and whirlpools; deluxe equipment, such as motor-driven wheelchairs, chair-lifts or beds, when standard equipment is available and adequate; comfort items such as bed boards, waterbeds, hospital beds, flotation mattresses, bathtub lifts, over-bed tables, adjustable beds, and telephone arms; cost of repairs that exceed the rental price of another unit for the estimated period of need or that exceeds the purchase price of a new unit; medical equipment such as sphygmomanometers and stethoscopes; supplies not authorized by your PCP or participating provider, including items used for comfort, convenience, or personal hygiene; some contraceptive devices (for coverage, see Preventive, Routine, and Family Planning Services or Prescription Drugs); and medical supplies and orthopedic appliances that can be purchased over-the-counter, including but not limited to colostomy bags, catheters, dressings for bed sores and burns, gauze, and bandages. orthotic shoe inserts (except for members with diabetes). orthopedic shoes not attached to a brace (except for members with diabetes). Mental health care Inpatient and outpatient care for mental illness including, Neurobiologically based mental illness and Mental Disorders, are covered when medically necessary. There are no limits to the number of days and/or visits per year. Benefits for residential treatment services are covered in a licensed residential treatment facility that can provide day services and 24-hour supervision. Residential treatment services must be preauthorized by RHMP before you receive services. 21 Customer Service: or

23 Home based services are also so covered for specialized mental health care in your home when traditional mental health services have not been effective. Services must be preauthorized by RMHP before you receive services. If you are admitted for an inpatient medical/surgical admission and need be transferred to an inpatient psychiatric unit, or vice versa, each stay is considered a separate admission. The following services are not covered: residential treatment services for Anorexia Nervosa or Bulimia; services related to sexual dysfunction; court- or police-ordered treatment that would not otherwise be covered; psychoanalysis or psychotherapy that a Member may use as credit toward earning a degree or furthering his/her education; the cost of any damages to a treatment facility caused by you; services not preauthorized by RMHP; services provided or billed for by a school or halfway house; biofeedback; and hypnotherapy. Office visits/pcp and other doctor visits Visits to your PCP or another doctor that works with RMHP are covered. This includes care received in your provider s office, in an urgent care center, in your home, in a hospital emergency room, consultations, second opinions, medications administered by injection and vision and hearing examinations (non-routine). After hours care to get advice or treatment after your doctor s normal hours are covered. Outpatient/Surgical Services Outpatient services received in the outpatient department of a hospital, emergency room, birthing center, ambulatory surgical facility, freestanding kidney dialysis facility, or other covered outpatient treatment facilities are covered. Prescription Drugs and Supplies Prescription drugs, self-administered injectables and medical supplies listed on the Good Health Formulary are covered. Prescription drugs and supplies are covered only when prescribed by a participating provider and dispensed by a participating pharmacy. Some drugs and supplies are not covered and some have quantity limits. Some drugs and supplies must be approved by RMHP before you can pick them up. You can get a 31- day supply of prescription drugs at a retail pharmacy or a 90-day supply through mail order. You can call RMHP Customer Service or go on-line at rmhp.org for a copy of the Good Health Formulary. For each prescription purchased at a participating pharmacy, you pay the copayment amount specified on your Member ID card. (If the retail price of a prescription drug is less than the copayment, your copayment will be the lower actual retail price.) 22 Customer Service: or