Welcome to Molina Healthcare.

Transcription

1 Welcome to Molina Healthcare. Your Extended Family. MolinaHealthcare.com New Mexico Member Handbook Centennial Care 2017

2

3 Molina Healthcare of New Mexico (Molina) complies with all Federal civil rights laws that relate to healthcare services. Molina offers healthcare services to all members without regard to race, color, national origin, age, disability, or sex. Molina does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. This includes gender identity, pregnancy and sex stereotyping. To help you talk with us, Molina provides services free of charge: Aids and services to people with disabilities o Skilled sign language interpreters o Written material in other formats (large print, audio, accessible electronic formats, Braille) Language services to people who speak another language or have limited English skills o Skilled interpreters o Written material translated in your language o Material that is simply written in plain language If you need these services, contact Molina Member Services at (800) If you think that Molina failed to provide these services or treated you differently based on your race, color, national origin, age, disability, or sex, you can file a complaint. You can file a complaint in person, by mail, fax, or . If you need help writing your complaint, we will help you. Call our Civil Rights Coordinator at (866) , or TTY, 711. Mail your complaint to: Civil Rights Coordinator 200 Oceangate Long Beach, CA 90802

4 You can also your complaint to Or, fax your complaint to (505) You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. Complaint forms are available at You can mail it to: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C You can also send it to a website through the Office for Civil Rights Complaint Portal, available at If you need help, call ; TTY

5 ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti go Diné Bizaad, saad bee 1k1 1n7da 1wo d66, t 11 jiik eh, 47 n1 h0l=, koj8 h0d77lnih (TTY: 711.) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY:711) ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم: 711(. 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: 711) まで お電話にてご連絡ください ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (TTY : 711).

6 ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). ध य न द : यदद आप ह द ब लत ह त आपक ललए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY: 711) पर क ल कर توجه: اگر به زبان فارسی گفتگو می کنید تسهیالت زبانی بصورت رايگان برای شما فراهم می باشد. با ) (TTY: تماس بگیريد. เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: 711).

7 Thank you for choosing Molina Healthcare! Ever since our founder, Dr. C. David Molina, opened his first clinic in 1980, it has been our mission to provide quality health care to everyone. We are here for you. And today, as always, we treat our Members like family. The most current version of the handbook is available at MolinaHealthcare.com

8 In this handbook you will find helpful information about: Your Membership (pg 06) Your Provider (pg 10) ID Card Quick Reference Phone Numbers Find your Provider Schedule your First Visit Interpreter Services 02 (800)

9 Your Benefits (pg 14) Your Extras (pg 18) Your Policy (pg 22) Molina Network Vision and Dental No-Cost Cell Phone Covered Drugs Health Education Health Programs Community Resources Coverage Billing Rights and Responsibilities NOTE: If you have any problem reading or understanding this or any Molina Healthcare information, call Member Services at (800) (TTY: 711). We can explain in English or in your primary language. We may have it printed in other languages. You may ask for it in braille, large print, or audio. If you are hearing or sight impaired, special help can be provided. MyMolina.com 03

10 Health care is a journey and you are on the right path: 1. Review your Welcome Kit You should have received your Molina Healthcare ID card. There is one for you and one for every Member of your family. Please keep it with you at all times. If you haven t received your ID card yet, visit MyMolina.com or call Member Services. 2. Register for MyMolina Signing up is easy. Visit MyMolina.com to change your Primary Care Practitioner (PCP), view service history, request a new ID card and more. Connect from any device, anytime! 04 (800)

11 3. Talk about your health We ll call you for a short interview about your health. It will help us identify how to give you the best possible care. Please let us know if your contact info has changed. 4. Get to know your PCP PCP stands for Primary Care Practitioner. He or she will be your personal provider. To choose or change your provider, go to MyMolina.com or call Member Services. Call your provider within the next ninety (90) days to schedule your first visit. 5. Get to know your benefits With Molina you have health coverage and extra at no cost. We offer transportation to medical appointments, health education and people dedicated to your care. MyMolina.com 05

12 Your Membership Your Membership 06 (800)

13 ID Card There is one ID for each Member. Your name Your Provider Your Provider s phone number The date you started with Molina You need your ID card to: See your provider, specialist ER Go to an emergency room Go to urgent care H Go to a hospital PCMH Get medical supplies and/or prescriptions Have medical tests MyMolina.com 07

14 Your Membership Quick Reference Need Emergency Online Access - Find or change your provider - Update your contact information - Request an ID card - Get health care reminders - Track office visits Getting Care - Urgent Care - Minor illnesses - Minor injuries - Physicals and checkups - Preventive care - Immunizations (shots) Call 911 Go to MyMolina.com and sign up Call Your Provider: Name and Phone Action 08 (800) Find a provider at: MolinaHealthcare.com/ProviderSearch 24-Hour Nurse Advice Line (888) (English) (866) (Spanish) TTY: 711 A nurse is available twenty-four (24) hours a day, seven (7) days a week. Virtual Care MolinaHealthcare.com/Telehealth Urgent Care Centers Find a provider or urgent care center MolinaHealthcare.com/ProviderSearch

15 Your Membership Your Plan Details - Questions about your plan - Questions about programs or services - ID card issues - Interpreter services - Transportation - Help with your visits - Prenatal care - Well infant visits with PCP or OB/GYN Changes/Life Events - Coverage - Contact Info - Marriage - Divorce Member Services (800) Monday through Friday, 8:00 a.m. 5:00 p.m. To schedule a ride to an appointment (888) Covered Drugs You can find a list of preferred drugs at MyMolina.com. You an also call Member Services to help you. Children, Youth and Families Department (855) Social Security Administration (800) Income Support Division (ISD) (800) New Mexico Relay Services (800) MyMolina.com 09

16 Your Provider Your Provider 10 (800)

17 Your Provider Find Your Provider Your Primary Care Practitioner (PCP) takes care of all your medical needs. Your PCP s office is your Health Home. It s important to have a provider who makes you feel comfortable. It s easy to choose one with our Provider Directory, a list of providers. You can pick one for you and another for others in your family, or one who sees all of you. After you ve picked your PCP, you can fill out the PCP Selection Form in your Member packet. Mail it in the envelope provided. You will not need a stamp. Schedule your first visit to get to know your provider. Call Molina Healthcare at (800) if you need help making an appointment or finding a provider. If you do not choose a provider, Molina will do it for you. Molina will choose a provider based on your address, preferred language and providers your family has seen in the past. MyMolina.com 11

18 Your Provider Schedule Your First Visit Visit your provider within ninety (90) days of signing up. Learn more about your health and let your provider know more about you. Your provider will: Treat you for most of your routine health care needs; Review your tests and results; Prescribe medications; Refer you to other providers specialists; and Admit you to the hospital if needed. Interpreter Services If you need to speak in your own language, we can assist you. An interpreter can help you talk to your provider, pharmacist, or other medical service providers. We offer this service at no cost to you. An interpreter can help you: Make an appointment Talk with your provider File a complaint, grievance or appeal Learn about the benefits of your health plan If you need an interpreter, call the Member Services Department. The number is on the back of your Member ID card. You can also ask your provider s staff to call the Member Services Department for you. They will help you get an interpreter to assist you during your appointment. 12 (800)

19 Your Provider You must see a provider who is part of Molina. If for any reason you want to change your provider, go to MyMolina.com. You can also call Member Services. If you change your provider, Molina Healthcare will send you a new ID card. The new ID card will show the date you can start seeing the new provider. Remember, you can call the Nurse Advice Line at any time. Our nurses can help you locate an urgent care. MyMolina.com 13

20 Your Benefits Your Benefits 14 (800)

21 Your Benefits Molina Network We have a growing family of providers and hospitals. And they are ready to serve you. Visit providers who are part of Molina. You can find a list of these providers at MolinaHealthcare.com/ProviderSearch. Call Member Services if you need a printed copy of this list. The online directory contains provider information such as names, telephone numbers, addresses, specialties and professional qualifications. Every provider on the list offers handicapped access to Members. For a full list of covered services, and to see which services require prior approval, please refer to pages MyMolina.com 15

22 Your Benefits Vision and Dental We are here to take care of the whole you, including your teeth, gums and eyes. Molina covers: For ages 20 and under: One (1) exam and one (1) pair of glasses every year For ages 21 and older: One (1) exam and one (1) pair of glasses every three (3) years. Limits apply for Alternative Benefit Plan Members. Also, Molina covers regular dentist visits, checkups and cleanings. Please contact Member Services Department with any questions regarding your dental benefits at (800) Please check our Provider Directory to find optometrists or providers who can provide you with these services at MyMolina.com. No-cost Cell Phone Get a phone to use 24/7. Talk up to 350 minutes every month. As a Molina Member, you also get unlimited texts. You can even get provider visit reminders and health tips sent to you. Calls to Molina s Member Services Department will not count toward your 350 minutes. 16 (800)

23 Covered Drugs Molina Healthcare covers all your medically necessary medications. Your Benefits We use a preferred drug list (PDL). These are the drugs we prefer your provider to prescribe. Most generic drugs are included in the list. You can find a list of the preferred drugs at MyMolina.com. There are also drugs that are not covered. For example, drugs for erectile dysfunction, weight loss, cosmetic purposes and infertility are not covered. We are on your side. We will work with your provider to decide which drugs are the best for you. Transportation If you do not have your own transportation, we will provide transportation so you don t have to miss your next visit. Molina provides round-trip visits - for covered, medically necessary non-emergent services. Members may use this benefit to visit any Molina Healthcare-contracted provider. Medical visits include trips to a provider, clinic, therapy or behavioral health appointment. Trips to the pharmacy or to pick up durable medical equipment are not covered. For more information, please see page 32. MyMolina.com 17

24 Your Extras Your Extras 18 (800)

25 Your Extras MyMolina.com: Manage your health plan online Connect to our secure portal from any device, wherever you are. Change your provider, update your contact info, request a new ID card and much more. To sign up, visit MyMolina.com. Health Education and Incentives Programs Live well and stay healthy! Our programs help you control your weight, stop smoking or get help with chronic diseases. You can get learning materials, care tips and more. We also have programs for expectant mothers. If you have asthma, diabetes, heart problems or any other chronic illness, one of our nurses or Care Coordinators will contact you. You can also sign up on MyMolina.com, our secure Member portal, or call the Health Management Department at (800) , ext (TTY/TDD: 711). Pregnancy Rewards Are you going to have a baby? Molina Healthcare wants you to have a healthy pregnancy and baby. You could earn gift rewards with our program, Pregnancy Rewards! It is easy. Sign up at MyMolina.com, our secure portal, or call (800) ext (TTY/TDD: 711). Molina will send you a packet in the mail. MyMolina.com 19

26 Your Extras Care Coordination We have a team of nurses and social workers called Care Coordinators that are ready to serve you. They are very helpful and will give you extra attention if you have: Asthma Behavioral health disorders Chronic Obstructive Pulmonary Disease (COPD) Diabetes High blood pressure High-risk pregnancy For more information, please reference the Policy section on page 23 or call Care Coordination at (855) (800)

27 Your Extras Centennial Rewards Program Every Centennial Care Member is enrolled in the Centennial Rewards Program. There s no sign-up required. With the program, you earn reward points by taking healthy steps like getting tests your provider recommends, taking prescribed medicine and going to the dentist. You ll get a Centennial Rewards catalog when you earn your first reward points. Use them to order catalog items at CentennialRewards.com or by calling toll-free (877) Shipping costs will not apply. Go to CentennialRewards.com for complete details. Community Resources We are part of your community. And we work hard to make it healthier. Local resources, health events and community organizations are available to you. They provide great programs and convenient services. Best of all, most of them are at no cost or at low cost to you. Call 211. This is a free and confidential service that will help you find local resources. Available 24/7 New Mexico Department of Health (505) Women, Infant, Children (WIC) (866) Income Support Division (ISD) (800) New Mexico Human Services Department (HSD) (888) MyMolina.com 21

28 Your Policy 22 (800)

29 Appointment Guidelines Your provider s office should give you an appointment for the listed visits in this time frame: Appointment Type Urgent Care Routine or non-urgent care Well-child preventive care Adult preventive care Specialist When you should get the appointment Within 24 hours No more than 14 calendar days Within 30 days Within 30 days Within 21 days Care Coordination We want to make sure you are getting the right kind of medical care. Under Centennial Care, each Member enrolled in Molina Healthcare will have access to Care Coordination services. You may reach the Care Coordination Unit toll free at (855) Monday - Friday between 8:00 a.m. and 5:00 p.m. A Care Coordinator will help you: Understand your benefits under Centennial Care; Identify community resources for services, which are not part of Centennial Care; Become an advocate for your health care; and much more. Care Coordinators will conduct Health Risk Assessments (HRA), Comprehensive Needs Assessments (CNA) and Reassessments for Members assigned to them. Your Care Coordinator will determine your physical health, behavioral and long-term care needs from these assessments. Care Coordinators ensure that Molina staff for medical, behavioral and long-term care are aware of all of your needs and treatments when reviewing requests for services. Your Care Coordinator can also provide you with resources for food, shelter, clothing, community centers, support groups and other community resources. Preventive Health Guidelines/Well-Child Health Check The well-child health check, Early and Periodic Screening, Diagnostic and Treatment it is a special program that provides comprehensive and preventive health care services for Centennial Care Members. It is available from birth through 20 years of age. The program gives your child regular well-child check ups, immunizations and medical care to keep them healthy. Well-child check ups are important because they help prevent illness and help find health-related problems early. Please see the Preventive Health Guideline chart on page 24. If your child needs assistance with activities of daily living because of qualifying medical conditions, special services like Community Benefits are available. MyMolina.com 23

30 Preventative Health Guidelines Child under age 1 1 month, 2 months, 4 months, 6 months, 9 months Child over age 1 to 30 months Child over age 3 to 20 years 12 months, 15 months, 18 months, 24 months, 30 months Each year Pregnancy and Newborn Care Medicaid Birthing Options Program If you are pregnant and eligible for Medicaid, you have a choice of who will provide care for you. You can also choose where your baby will be born. Women in New Mexico have choices about where to give birth: A birth center A hospital Your own home Many health care practitioners/providers offer pregnancyrelated services. Many times they work together to provide care for you and your baby: Certified Nurse-Midwives* Family Practice Physicians Licensed Midwives* Nurse Practitioners Obstetricians Physician Assistants Services for pregnant women may include: Prenatal care Care Coordination Childbirth education Birthing services for labor and delivery Postpartum care Breastfeeding counseling Reproductive health Family planning If you would like to select out-of-hospital services provided by a midwife*, please send the following information by mail: Your name Your address Your telephone number Name of midwife Telephone number for the midwife you have chosen Mail this information to the following address: Pregnancy-Related Services Benefits Bureau HSD-MAD P.O. Box 2348 Santa Fe, NM Or call the Medical Assistance Division toll free at (888) (800)

31 *These services are only covered if they are provided by healthcare providers who have an approved Provider Agreement with the Human Services Department/Medical Assistance Division. What If I Have a Baby? Medicaid covers your newborn baby for the birth month and the month after that. You must enroll your new baby in Molina Healthcare for continued coverage. To sign your new baby up for Molina Healthcare, call your Human Services Department (HSD) caseworker as soon as possible after you give birth. Questions? Call Member Services. Covered Services for Centennial Care Members Approval Process Prior Approval (PA) is a request for service from your provider. You do not need it for most medical services. But some services do require it. Molina Healthcare s medical staff and your provider review the need for this care before services are given. They make sure it s right for your condition. For a list of covered services that require a PA and those that don t, see the Covered Services chart. You can also visit MolinaHealthcare.com or call Member Services. Covered Services Ambulance transportation by ground for an emergency Behavioral Health: Accredited Residential Treatment Center and Non-Accredited Residential Treatment Centers, Group Homes and Treatment Foster Care I and II Behavioral Health: Applied Behavior Analysis (Autism) Behavioral Health: Mental Health; Inpatient facility; Psychiatric Unit of a general hospital or a free standing psychiatric hospital Behavioral Health: Outpatient; mental health, alcohol and chemical dependency services Cardiology (Heart station procedures: Dobutamine Stress Echocardiogram test) PA is not required. PA is required. PA is required for Stage 3 only. PA is required. PA is not required. PA required. Your Policy MyMolina.com 25

32 Covered Services - Continued Covered Services - Continued Certified nurse midwife services PA is not required. Family planning services and supplies PA is not required. Certified nurse practitioner services PA is not required. Dental services Routine services do not require PA. Dental services other than routine care require PA. Federally Qualified Health Center or Rural Health Clinic services PA is not required. Developmental therapy services for children aged birth to six years PA is required for all developmental therapy services after the initial evaluation is completed. 30 dates of service per 12-month period for any combination of services are covered. Free-standing birth center services at a free-standing birth center PA is not required. Members should call Member Services to see if there are any qualified centers in New Mexico. Diagnostic services (x-ray, lab) Durable medical equipment Selected diagnostic services (including CT scans, interventional radiology, MRIs, MRAs, and SPECT) require PA. Some durable medical equipment items require PA. Home health services Hospice care (care for terminally ill, e.g., cancer patients) PA required after initial evaluation plus 6 visits. PA is not required, notification only. Limits apply. Emergency services PA is not required. 26 (800)

33 Covered Services - Continued Covered Services - Continued Inpatient hospital services Inpatient rehabilitation services Inpatient hospital services (except for emergency admissions) and elective admissions, including pregnancy delivery services, and all inpatient surgeries, require PA. Notification to Molina Healthcare is required within 24 hours of admission or by the next business day for emergency admissions. PA required. Nursing facility services for a short-term rehabilitative stay Obstetrical (maternity care: prenatal and postpartum including at-risk pregnancy services) and gynecological services Nursing facility services require PA. Nursing facility stays are covered for Members, unless the New Mexico Human Services Department s Medical Assistance Division (MAD) determines that the Member will return to fee for service. Members in need of nursing services should call Member Services for information on available Providers. PA is not required. Medical supplies Some medical supplies require PA. Oral and reconstructive surgery PA required. Neuropsychological Test PA is not required. Outpatient hospital services Some outpatient services require PA. MyMolina.com 27

34 Covered Services - Continued Covered Services - Continued Pain management services Physical and occupational therapy Physical exam required for employment or for participation in job training programs if the exam is not provided free of charge by another source Podiatry (foot) services Prescription drugs, including certain prescribed over-the-counter drugs PA required. PA is required for all occupational and physical therapy services. Limits apply PA is not required. Office visits for examination and plan of care do not require PA. In-office podiatry procedures and interventions require PA. Selected drugs, including injectables and some overthe-counter drugs, require PA. Primary Care Practitioner services Renal dialysis (kidney disease) Respite services Screening and counseling for obesity Services for children with medical handicaps (Title V) PA is not required. PA is not required. Respite services require PA. Respite services offer short-term, temporary relief to the informal, primary caregiver of a Supplemental Security Income (SSI) Member under the age of 21 in order to support and preserve the primary care giving relationship. PA is not required. Screening and counseling for obesity requires a referral by a provider. PA is not required. Preventive mammogram (breast) and cervical cancer (pap smear) exams PA is not required. Shots (immunizations) Sleep studies PA is not required. PA required. 28 (800)

35 Covered Services - Continued Specialist services Speech and hearing services, including hearing aids Transportation (nonemergency medical) for out-of-town transportation, meals and lodging farther than four hours away from your home Vision (optical) services, including eyeglasses Well-child exams for children under the age of 21 Office visits to see a specialist do not require PA. Some specialist services do require PA. PA is required for all speech therapy and hearing services (language, pathology and audiology) after the completion of six (6) visits. PA required. PA is not required. PA is not required. The following sections apply to all Centennial Care and Alternative Benefit Plan (ABP) Members. Services Not Covered Molina Healthcare will not pay for services or supplies received without following the directions in this handbook. Some examples of non-covered services include: Acupuncture Plastic or cosmetic surgery that is not medically necessary Surrogacy This is not a complete list. If you have a question about if a service is covered, call Member Services at (800) Failure to pay for non-covered Services will not result in a loss of Medicaid benefits. Services for Native American Members If you are a Native American Member, you can self-refer to Indian Health Services (IHS) or 638 Tribal Healthcare facilities. This can be done for any service. You do not need to ask your PCP for permission. You can also selfrefer to any provider in the Molina Healthcare network. If you are a Member that is registered as Native American Member with the Income Support Division (ISD), you do not have co-payments for any services. Yearly well-adult exams PA is not required. MyMolina.com 29

36 Native American Members can access a traditional healing benefit once a year as part of their health care funding permitted. For more information, call the Care Coordination unit toll free at (855) Second Opinions A second opinion is when you ask to see another Molina Healthcare provider about your medical condition. You can get a second opinion from another provider. You have the right to a get second opinion. If a qualified provider is not available in the network, you may get the second opinion from an outside of network provider at no cost to you. If you think you need a second opinion, call Member Services. You might want a second opinion if: You are not sure you need the care You are not sure of the provider s findings You have a difficult problem Your provider is not sure of a right diagnosis You have not improved You are not satisfied with your provider We can help you make your appointment. If we can t find a provider that is part of the Molina network, we will find a provider for you. How to Get Specialty Care and Referrals If you need care that your PCP cannot give, he or she will refer you to a specialist who can. Talk with your PCP to be sure you know how referrals work. If you think a specialist does not meet your needs, talk to your PCP. Your PCP can help you if you need to see a different specialist. There are some treatments and services that your PCP must ask Molina Healthcare to approve before you can get them. That is called a Prior Authorization. Your PCP will be able to tell you what services require this approval. If we do not have a specialist in Molina Healthcare who can give you the care you need, we will get you the care you need from a specialist outside Molina Healthcare. Getting a referral from your PCP ensures your health care is coordinated and all your providers know your health care goals and plans. This request for Prior Authorization must be done before any treatments or tests take place. If a request for specialty care is denied by Molina Healthcare, we will contact you and your PCP within one (1) to seven (7) days. You or your PCP can appeal our decision. See pages Choosing a Specialist as a PCP If you have a serious illness and are seeing a specialist, your specialist may be able to act as your PCP. The specialist must agree to meet the minimum requirements of Molina Healthcare s PCP care. Call Member Services to ask about this. Members may be approved to have a specialist act as their PCP. These decisions are based on continuity of care. They must be approved by Molina Healthcare s Medical Director. The Member must get a written note from the specialist 30 (800)

37 whom they want as a PCP. The specialist must agree to act as a PCP for that Member. The note must include the reason for using the specialist as a PCP. The specialist must send the note to Molina s Healthcare Services department at: Molina Healthcare of New Mexico, Inc. ATTN: Healthcare Services P.O. Box 3887 Albuquerque, NM The specialist can fax the note toll free to (888) The request will be denied if the specialist does not want to be your PCP. The request will be denied if the note does not show why the specialist must be your PCP. You and the specialist will be notified of the denial by telephone. This call will happen within twenty-four (24) hours of the denial decision. You and the specialist will also be notified in writing. You will get this notice within two (2) business days after the denial decision. You will also be told of your appeal rights. You will be told of your right to select a different PCP. If You Need to See a Provider Who is Not Part of Molina If your PCP leaves the Molina Healthcare network, we will send you a letter telling you about this right away. We will pick a new PCP for you and we will send you a new ID card. You can keep this PCP. You can also call Member Services to pick a PCP of your choice from the Molina Healthcare network. If a Molina Healthcare provider is unable to provide you with necessary and covered services, Molina Healthcare must cover the needed services through an out-of-network provider. The cost to you should be no greater than it would be if the provider were in Molina Healthcare s network. This must be done in a timely manner for as long as Molina s provider network is unable to provide the service. What is an Emergency? An emergency needs to be taken care of right away. You don t need approval for an emergency. If you are outside the state of New Mexico, emergency services will be covered. Call 911 or go to an Emergency Room (ER) near you. You can go to any ER that is not part of Molina Healthcare. You can get care twenty-four (24) hours a day, seven (7) days a week. Here are some examples of emergencies: Broken bones Bleeding that does not stop Heart attacks Major burns Drug overdoses If you don t have an emergency, don t go to the ER. Call your PCP. If you need non-emergent care after normal business hours, you can also visit an Urgent Care Center. You can find Urgent Care Centers in the provider directory. If you need help finding one, you can call Member Services. You may also visit our website at MolinaHealthcare.com/ProviderSearch. MyMolina.com 31

38 If you go to the ER, tell them you are covered by Molina Healthcare and show them your Molina Healthcare ID card. If the ER doctor says that you don t have to stay but you still do, you may have to pay. You might need care after you leave the ER. Do not go to the ER for follow up care. Call your PCP within forty-eight (48) hours and tell him/her what kind of care you received. Molina Healthcare has a 24-Hour Nurse Advice Line which can also help you understand and get the medical care you need. Call (888) for English or (866) for Spanish. What is Post-Stabilization? These are services you get after ER care. These services keep your condition stable. You do not need approval for these services. After your visit to the ER, you should call your provider as soon as you can. Your provider will help you get any follow-up care you need. You can also call Member Services for help. What to do if you have an emergency need for Durable Medical Equipment? If you have an emergency need for durable medical equipment (DME), call your DME provider. Call 911 if you are in immediate danger. Call Member Services if you cannot get the help you need from your DME provider. Transportation for Non-Emergencies The transportation service is available twenty-four (24) hours a day, seven (7) days a week at (888) This number is also on your ID card. If you think you have an emergency, please call 911. Do not call the transportation service if you have an emergency. We provide round-trip rides for appointments to providers for medically necessary services if you do not have your own transportation. Not all services qualify for this benefit. The appropriate type of transportation will be used. It may be car, van, bus, or train. Eligible Members will be picked up and dropped off at the home address that is in Molina s system. You must call before your appointment depending on the type of transportation you need: - Schedule your non-urgent ride at least three (3) business days before your visit or your request may be denied. - If you need to travel by plane, please request the travel four (4) weeks before your visit. - If you need to see a provider on a regular basis, you may schedule ninety (90) days in advance. We will provide transportation only if you are still an eligible Member. Transportation to a pharmacy or to pick up durable medical equipment is not a benefit. 32 (800)

39 To decide what type of vehicle will be used for your ride, you may be asked: Are you on oxygen? Do you use a wheelchair or walker? Do you require someone to go with you? Are you going with your child? What are your or your child s special health care needs? Please be ready when the driver comes to pick you up. Here are some important reminders: You will be given a thirty (30) minute range of time for your pick up. - Once the driver arrives, the driver will wait up to ten (10) minutes. If you miss three (3) or more scheduled pick-ups, a Transportation or Member Services Representative will call you. If you keep missing transportation appointments, you may no longer qualify for door-to-door rides. The transportation provider may provide you with a different transportation option to your medical visits. If your appointment is canceled and/or you cannot make your appointment, please call and cancel your ride at least four (4) hours before you are going to be picked up. Care Aide: A parent may go with a child who is 18 years of age and younger. Unless a letter of medical necessity has been approved, a child/or children may not accompany their parents when their parent is the patient. If you need another person to go with you, a medical provider must provide proof of medical necessity in writing prior to scheduling the transport. Minor children: A parent or legal guardian must ride with a child who is under 12 years of age. For a child 12 to 18 years to ride alone, the parent or legal guardian must sign a release form. Keeping Track of Your Trip The Transportation Representative will make note of the information about the trip and send you a form. If a family member or companion takes the Member to a provider visit, the Member must be in the vehicle for mileage to be paid. Molina will not pay for a relative s (or friend s) mileage from their house to the Member s house. It will only pay for mileage when the Member is in the car. If a contracted provider is in a Member s city, Molina will not pay for mileage to go to another city to see a provider or if you self-refer to a provider out of the Molina network, unless the Member has a referral. MyMolina.com 33

40 You may not be paid if the form is not received back within thirty (30) days or if the trip was not approved in advance. While the transportation team is talking to you and if the case sounds like an emergency, we will tell you to hang up the telephone and call 911. We will take care of paying for the ambulance later. Do not call us first if you think a problem is a true emergency. Please call 911. Meals and Lodging for out-of-town trips: The transportation benefit may pay for meals and lodging if you go out of town for a covered service that is more than four (4) hours (one-way by ground transportation from your home). Your Care Coordinator or the Transportation Representative will let you know if your meals and lodging will be covered. All transportation, meals, out-of-town lodging, or out-of-state travel requests require approval prior to travel. Please call (888) to arrange lodging. You must get this approval before the trip or your expenses may not be paid. This approval is in addition to prior authorizations (PA) or approval you might have received for the provider visit. Covered Drugs To be sure you are getting the care you need, we may require that your provider submit a PA request to us. Your provider will need to explain why you need a certain drug or a certain amount of a drug. We must approve the PA request before you can get the medication. Reasons why we may require PA of a drug include: There is a generic or another alternative drug available; The drug can be misused or abused; The drug is listed in the formulary but not found on the Preferred Drug List (PDL); and/or There are other drugs that must be tried first Prescriptions for short-term use to a 30-day supply. Many prescriptions for long-term use may be filled for up to 90- day supply. All specialty drugs are limited to a 30-day supply and must be filled by the preferred specialty pharmacy. The pharmacy cannot refill your medication more than five (5) days before the refill date. If we do not approve a PA request for a drug, we will send you a letter. The letter will explain how to appeal our decision. It will also detail your rights to a State Fair Hearing. Some drugs may also have quantity (amount) limits and some drugs are never covered. Some drugs that are never covered are: Drugs for weight loss Drugs for erectile dysfunction Drugs for infertility We require the use of generic drugs when available. If your provider believes you need a brand name drug, the provider may submit a PA request. Molina Healthcare will determine whether to approve the brand name drug. Remember to fill your prescriptions before you travel out of state. 34 (800)

41 The PDL can change. It is important for you and your provider to check the PDL when you need to fill or refill a medication. You can find a list of the preferred drugs at MyMolina.com. Refer to our provider directory to find an in-network pharmacy. You can find an in-network pharmacy by visiting our website at MolinaHealthcare.com. You can also call Member Services to find a network pharmacy near you. Access to Behavioral Health Molina can help you get the behavioral health services you and your family need. You must use a provider that is part of our behavioral health network, unless it s an emergency. Your benefits cover: inpatient and outpatient services, and provider visits. You don t need a referral to see a provider. Care Coordinators can help you get the services you need and provide a list of covered services. What to do if you are having a problem You might be having any of these feelings: Sadness that does not get better; Feeling hopeless and/or helpless; Guilt; Worthlessness; Difficulty sleeping; Poor appetite or weight loss; and Loss of interest If so, call Member Services at (800) Contacting a Peer Support Specialist for Behavioral Health Needs Molina Healthcare supports the use of Peer Support Specialists to assist Members in their recovery from mental health or substance abuse issues. Please call your Care Coordinator at Molina for referral to a program which provides peer support specialists or for referral to a wellness center. You may also call your Core Service Agency in your community for support in connecting to a Peer Support Specialist or local wellness center. Emergency Behavioral Health Services A behavioral health emergency is a mental health condition that may cause extreme harm to the body or cause death. Some examples of these emergencies are: Attempted suicide; Danger to self or others; So much functional harm that the person is not able to carry out actions of daily life; and Functional harm that will likely cause death or serious harm to the body. If you have an emergency, go to the closest hospital ER. You can go to any other emergency place right away. You can call 911. If you go to the ER, let your provider know as soon as you can. If you have a behavioral health emergency and can t get to an approved provider, do the following: Go to the closest hospital or facility MyMolina.com 35

42 Call the number on your ID card Call the New Mexico Crisis and Access line at (855) NMCRISIS Mental Health and/or Substance Abuse Services If you need mental health and/or substance abuse services, call Member Services for information at (800) , or you may self-refer directly to a Community Mental Health Center or a Behavioral Health Services Division (BHSD) facility, which are Medicaid practitioners. You can also look at the provider directory online at MolinaHealthcare.com, visit the Member portal at MyMolina.com or call our Member Services for the names and telephone numbers of the facilities near you. Long Term Support Services for Centennial Care Members Long Term Support Services (LTSS) benefit people with chronic physical and/or behavioral health conditions. When you complete a Health Risk Assessment (HRA), the results of the HRA could show that you may benefit from LTSS. If it is determined that you may benefit from LTSS, a Care Coordinator will need to schedule and complete an In-Home Comprehensive Needs Assessment (CNA) with you. If you do not require twenty-four (24) hour care, you may be eligible for Community Benefits, which allow you to remain in your home and supplement the care you receive from natural supports. There are two types of Community Benefits: Agency Based Community Benefits and Self- Directed Community Benefits. Your Care Coordinator can tell you more about Community Benefits. Hospice Care Hospice is a service to care for a patient with a terminal illness. The patient usually has a life expectancy of six (6) months or less. Licensed hospice programs in the state of New Mexico give support and comfort to the patient and the family during the final months of life. If you have questions about hospice care, please call Member Services. How to Access Hospital Services Inpatient Hospital Services You must have a Prior Authorization (PA) to get hospital services except in the case of an emergency or urgent care services. However, if you get services in a hospital or you are admitted to the hospital for an emergency or out-of-area urgent care services, your hospital stay will be covered. This happens even if you do not have a PA. Medical/Surgical Services We cover the following inpatient services in a participating provider hospital or rehabilitation facility, when the services are generally and customarily provided by acute care general hospitals or rehabilitation facilities inside our service area: 36 (800)

43 Room and board, including a private room if medically necessary Specialized care and critical care units General and special nursing care Operating and recover rooms Services of participating provider physicians, including consultation and treatment by specialists Anesthesia Drugs prescribed in accord with our Drug Formulary guidelines (for discharge drugs prescribed when you are released from the hospital, please refer to Prescription Drugs and Medications ) Radioactive materials used for therapeutic purposes DME and medical supplies Imaging, laboratory, and special procedures, including MRI, CT, and PET scans, and ultrasound imaging Mastectomies (removal of breast) and lymph node dissections Blood, blood products and their administration, blood storage (including the services and supplies of a blood bank) Physical, occupational, and speech therapy (including treatment in an organized, multidisciplinary rehabilitation program) Respiratory therapy Medical social services and discharge planning It is the provider s job to file a claim when you get services. They must do this when Molina Healthcare is the primary insurance. They must send the claim within ninety (90) days from the date you get the service. You must pay your co-payment if one applies. You do not have to pay for the services if you get a referral when needed. You do not have to pay for the services if your provider gets a PA when needed. You do not need to file a claim to Molina Healthcare. This is the provider s job. How Does Molina Pay Providers for Your Care? Molina Healthcare contracts with providers in many ways. Some providers are paid each time they see you and for each procedure they perform. Other providers receive a flat amount for each month a Member is assigned to their care, whether or not they see the Member. Some providers may be offered rewards for excellent preventive care and monitoring the use of hospital services. Molina Healthcare does not reward providers or employees for denying medical coverage or services. Molina Healthcare also does not give bonuses to providers to give you less care. For more information about how providers are paid, please call Member Services. Molina Healthcare cannot provide confidential provider information through Member Services or any other department. MyMolina.com 37

44 Payment and Bills If you get a bill from a plan provider for approved and covered services, call Member Services. Do not pay the bill until you have talked to us. You may have to pay for services that are not covered. You may also have to pay for services from providers who are not part of our network. If the services were an emergency, you don t have to pay. If you need help, call Member Services. Preventive Care Services for Centennial Care and Alternative Benefit Plan Members The following preventive services are recommended for Centennial Care and ABP Members by the United States Preventive Services Task Force (USPSTF). Some limits do apply, so please call Member Services for more information. Abdominal aortic aneurysm screening: men Alcohol misuse: screening and counseling Anemia screening: pregnant women Aspirin to prevent cardiovascular disease: men and women Bacteriuria screening: pregnant women Blood pressure screening in adults Breast Cancer Susceptibility Gene (BRCA) screening Breast cancer preventive medication Breast cancer screening Breastfeeding counseling Cervical cancer screening Chlamydial infection screening: pregnant and non-pregnant women Cholesterol abnormalities screening: men and women Colorectal cancer screening Depression screening: adults Diabetes screening Falls prevention in older adults: exercise, physical therapy and vitamin D Folic acid supplementation Gonorrhea screening: women Healthy diet counseling Hepatitis B screening: pregnant women Hepatitis C virus infection screening: adults HIV screening: non-pregnant adolescents and adults HIV screening: pregnant women Intimate partner violence screening: women of childbearing age Obesity screening and counseling: adults Osteoporosis screening: women Rh incompatibility screening: first pregnancy visit Rh incompatibility screening: weeks gestation Sexually transmitted infections counseling 38 (800)

45 Skin cancer behavioral counseling Syphilis screening: non-pregnant and pregnant women Tobacco use counseling and interventions: nonpregnant adults; and tobacco use counseling: pregnant women Centennial Care Alternative Benefit Plan Supplement The Alternative Benefit Plan (ABP) is a part of the New Mexico Medicaid program known as Centennial Care. The ABP is designed to provide medical insurance coverage to adults who earn up to 133% of the Federal Poverty Level (FPL). The benefits, in some cases, are not the same as Centennial Care. Be sure to read more below to know what benefits are covered under the ABP. ABP recipients will have their medical condition evaluated by Molina Healthcare. If it is determined that you meet the qualifying conditions, you may choose to become an ABP Exempt recipient. If you choose to become ABP Exempt, your coverage will change from the ABP benefit package to the full Medicaid (Centennial Care) benefit package. Please call Member Services for full details regarding ABP Exempt qualifications. Covered Services Adult diapers and other incontinence products (non- Medicare covered) PA is required Bariatric Surgery PA is required. Limits apply MyMolina.com 39