Your Member Handbook Important information about your health plan

Transcription

1 Your Member Handbook Important information about your health plan Understand Your Health Benefits Meet Your Care Team We re Here for You 24/7

2 Table of Contents SECTION ONE: NAVIGATING NEXTLEVEL TABLE OF CONTENTS 1 NEXTLEVEL HEALTH: YOUR PARTNER IN CARE 3 GET THE INFORMATION YOU NEED IN OTHER LANGUAGES OR FORMATS 4 WORDS TO KNOW 4 NEXTLEVEL HEALTH: HERE FOR YOU 24/7 6 IMPORTANT CONTACT INFORMATION 7 INFORMATION TO REMEMBER 8 YOUR NEXTLEVEL MEMBER ID CARD 9 NEXTLEVEL: YOUR MEDICAL HOME 9 WHO WE SERVE 10 SERVICE AREA: WE RE IN YOUR COMMUNITY 11 YOUR BENEFITS 12 NEXTLEVEL EXTRA BENEFITS 23 MEMBER SERVICES 24 PRESCRIPTIONS 24 CHOOSING YOUR PCP 25 GETTING CARE 26 NEXTLEVEL S PROVIDER PARTNERS 27 ACCESS TO YOUR DOCTOR 27 YOUR CARE TEAM 28 YOUR CARE PLAN 29 CARE MANAGEMENT & DISEASE MANAGEMENT 29 YOUR MEMBER PROFILE 30 Facebook.com/NextLevelIL 1

3 GOING TO THE EMERGENCY ROOM 30 TRANSPORTATION 32 DENTAL CARE 32 TAKING THE STEPS TO BETTER HEALTH 33 FREQUENTLY ASKED QUESTIONS 34 WE WANT TO HEAR FROM YOU 35 CHANGES IN YOUR HEALTH PLAN 35 YOUR RIGHTS AND RESPONSIBILITIES 36 GRIEVANCES AND APPEALS 37 ABUSE, NEGLECT AND EXPLOITATION 45 2 (312) Toll Free: TTY: Illinois Relay at 711

4 NextLevel Health: Your Partner in Care Thank you for choosing NextLevel Health! We are a Managed Care Community Network (MCCN) that works with the community, providers and most importantly, you and your support system to help you take the steps toward better health. NextLevel Health is a Medicaid health plan. We work with you to take your health to the NextLevel. You have a care team that knows you and your community. Together with your Primary Care Provider (PCP), NextLevel ensures all of your needs are met. You can choose your health plan and you can switch health plans during the annual open enrollment period which occurs near your enrollment anniversary date. To learn more about your Health Plan choices, contact Illinois Client Enrollment Services at or visit We are happy you decided to join NextLevel Health. If you have any questions, contact us anytime. How to reach us: By Phone: (312) Toll Free: For deaf and hearing impaired: Illinois Relay 711 By Mail: 3019 W. Harrison Street Chicago, IL Online: NextLevelHealthIL.com info@nlhpartners.com In Person: 3019 W. Harrison Street Chicago, IL We look forward to working with you to take your health to the NextLevel. Cheryl Whitaker, MD, MPH, FACP President & Chief Executive Officer NextLevel Health 3 Facebook.com/NextLevelIL

5 Get the information you need in other languages or formats NextLevel wants to make it easy for you to understand and access your health care and benefits. That s why we make information available in other languages and formats. You can receive written information about NextLevel in Spanish. If you speak another language, NextLevel offers oral interpretation, too. Call us and we will connect you with interpreters available that speak over 200 languages. We can also arrange an interpreter to go with you to your medical visits. And let us know if you need information in a different format such as Braille, large print, or audio CDs. Just contact us as directed on p.3 and at the bottom of every page. We can be reached at (312) , toll free at , or for the hearing impaired, by calling Illinois Relay at 711. NextLevel desea que usted entienda el cuidado de su salud y sus beneficios médicos. Es por esta razón que hacemos que esta información esté disponible en otros idiomas y otros formatos. Usted puede recibir información sobre NextLevel en español. Si habla otro idioma, comuníquese con nosotros y podemos ayudar a interpretar esta información para asegurar que usted la entiende. O, si usted necesita la información en un formato diferente, por ejemplo, la letra Braille, la letra de tamaño grande, o los discos compactos de audio. Comuníquese con nosotros para pedir información en español o la asistencia con otros idiomas o para recibir información en otros formatos. Se puede hablar con nosotros llamando al (312) , al número sin cargos, al , o para las personas con impedimentos auditivos, llamando a la Retransmisión de Illinois, al 711. NextLevel quiere que se disponga de la interpretación oral cuando usted la necesite. Cuando usted nos llama, tenemos intérpretes que hablan más de 200 idiomas a nuestra disposición. También podemos hacer arreglos para que un intérprete vaya con usted, acompañándolo a sus consultas médicas. Words to Know Health care can be confusing. NextLevel is here to help. Below are words that are used throughout this Member Handbook, and their definitions. If you ever have trouble understanding your Member Handbook or your benefits, contact us. Appeal: When you disagree with a decision about your health care, you can request that the decision be reversed. 4 (312) Toll Free: TTY: Illinois Relay at 711

6 Behavioral Health Specialist: The member of your Care Team who focuses on mental health and behavioral health needs. This includes depression, anxiety and other mental health conditions, as well as alcohol, drug or other substance use issues. A Behavioral Health Specialist can also offer you support with finding services for housing, financial assistance or help reapplying for Medicaid. Community Engagement Specialist: A member of your Care Team who focuses on your overall well-being and will contact you to complete your Health Risk Screening. The Community Engagement Specialist can also link you to social services. Care Management: A service offered by NextLevel to help you get the care you need, and set up services and appointments you need to stay healthy. Care Coordinator/Care Manager: The member of your Care Team who focuses on your overall needs and takes care of making appointments, arranging for transportation and other assistance you may need to get medical care. Emergency Medical Condition: When you have a health symptom or condition that puts you in serious jeopardy and in need of immediate medical attention. This can be the result of an accident, a chronic medical condition, or anything that causes serious impairment to your bodily functions, or results in your body not working correctly. Emergency Services: These are medical services that are provided to you in a hospital or emergency room to address serious and immediate health threats you are experiencing. Grievance: A complaint that you can submit if you are unhappy with services you receive from NextLevel, your Care Team or your doctor. HFS (Illinois Department of Healthcare and Family Services): This is the state agency that is in charge of Medicaid in Illinois. Home and Community-Based Service Waivers: A type of program offered by the State of Illinois that provides additional services to people who are elderly, have a disability or qualify for care in their homes or communities so they can continue to live independently. Medical Home: The place where all of your health care needs are met. NextLevel, together with your Primary Care Provider, make up your Medical Home. Post Stabilization Services: This service is related to an emergency medical condition and is provided after you are in the hospital to ensure your condition remains stable or continues to improve. Facebook.com/NextLevelIL 5

7 Prescription: This is medicine your doctor will tell you to take. Usually, your doctor will call the pharmacy to order the medication. Or, your doctor will give you a written order that you can take to the pharmacy. The pharmacy will then give you the medication you need. Preventive care: Health care that helps you stay healthy and avoid serious illness. This includes things like get well visits with your doctor or flu shots. Primary Care Provider (PCP): Your family doctor. The doctor that you choose to help you stay healthy. Prior Authorization: You may be required to get approval from your doctor before you can receive certain medical services. Your doctor or your Care Manager will help you get the approvals you need. Referral: Your Primary Care Provider will inform you of other doctors you may need to see who are specialists or experts in areas related to your health needs. Specialist: A doctor who is an expert in a certain area of medicine. You may need to see this type of doctor for particular types of health conditions. NextLevel Health: Here for You 24/7 NextLevel is here for you when you need us. Our Care Teams are available 24 hours a day, seven days a week, and 365 days a year. We also have a crisis line available to you. You can use this if you are experiencing a mental health crisis. Whatever your needs, we want to assist in any way we can. If you aren t sure if we can help, ask us anyway. We are available to help find resources you need to get support. Your health is about more than seeing your Primary Care Provider. We are here to make sure every part of your life from housing and finances to family health and personal goals are in good health. All of these things can impact your health, and NextLevel is here to support you as you take the steps to better health. 6 (312) Toll Free: TTY: Illinois Relay at 711

8 Important Contact Information Contact: Contact to: Contact Info: NextLevel Member Services NextLevel 24/7 Nurse Line Reach your Care Team Get answers to questions about your benefits Change your Primary Care Provider (PCP) Get a replacement ID card Help with setting up health services such as a doctor s visit or mental health appointment Set up transportation to your doctor s appointment Link to services such as housing, nutrition or financial assistance Get assistance with your Medicaid recertification Submit a grievance or appeal Get answers to any health question Ask if you should visit the emergency room because of a health condition (312) Toll Free: TTY: Illinois Relay (312) Toll Free: TTY: Illinois Relay NextLevel Crisis Line Get help because of a mental health crisis (312) Toll Free: TTY: Illinois Relay Client Enrollment Services Enroll in a health plan Learn about Health Plan choices TTY: Enrollhfs.illinois.gov Facebook.com/NextLevelIL 7

9 Information to Remember There is information that you will need when you go to your doctor, or contact NextLevel. Use the areas below to write in this information. If you re not sure of some of the fields below, contact us. We can help find the information you need. My NextLevel Member ID Number My PCP My PCP s Phone Number My Care Team My Care Team s Phone Number Your Member to Do List As a NextLevel Health Member, there are certain items you need to do to ensure you re healthy. Contact your Care Team. Complete your Health Risk Screening with your Care Team. Create your Care Plan with your Care Team. Review your Member Handbook. Make an appointment to see your Primary Care Provider. 8 (312) Toll Free: TTY: Illinois Relay at 711

10 Your NextLevel Member ID Card With your Member Welcome Packet, you will receive a NextLevel Member ID Card. This ID card includes your name, date of birth, your NextLevel Member ID number, the date you were effective with NextLevel, as well as your Primary Care Physician s name and phone number. It is important to have this card with you, and to take it to your doctor s appointments. Your doctor will need to see your ID card each time you receive care. If you need a new ID card, contact NextLevel s Member Services department. Below is an example of the NextLevel ID Card: NextLevel: Your Medical Home A medical home is where you go to receive health care services. This includes physical, mental and social health. Your Primary Care Provider (PCP), along with your NextLevel Care Team will serve as your medical home. We will all work together to help you take the steps to better health. NextLevel works with you to coordinate your care. This means that we help you understand what benefits you receive and work with your doctors to get you the care you need to stay healthy. NextLevel may contact you to: Check to make sure you are receiving the care you need. Ask you general questions about your health care needs and services. Work with you to create your Care Plan, which includes your health goals. Help you arrange care, non-emergency transportation or other services to meet your physical, emotional, mental or social needs. Remind you of an upcoming doctor s visit or test. Invite you to an event to learn more about your health. Help you pick a Primary Care Provider (PCP). Facebook.com/NextLevelIL 9

11 Ask you to respond to a survey. Ask you to participate in a Member Advisory Committee. Who We Serve NextLevel Health is dedicated to helping our Members receive the best health care. The Members we service include: People with disabilities, including those who are on Home and Community Based Services (HCBS) waivers as part of the Home Services Program and Community Care Program. Adults 19 to 64 without dependent children who recently became eligible for Medicaid as a result of the Affordable Care Act and Medicaid expansion, also known as ACA Adults. Families, which include parents from the ages of 19 to 64 and their dependent children. This includes participants in All Kids, Family Care and Moms & Babies programs. Below is a chart that shows the eligibility requirements for each NextLevel Member. Seniors and People with Disabilities 19 years or older for disabled; 65 years and older for seniors Eligible for Medicaid, but not Medicare Live within NextLevel s service area Medicaid ACA Adults Between the ages of 19 to 64, without dependent children Medicaid eligible Live within NextLevel s service area Family Health Plan Between the ages of 19 to 64, includes dependent children Medicaid eligible Live within NextLevel s service area 10 (312) Toll Free: TTY: Illinois Relay at 711

12 Service Area: We re in Your Community NextLevel Health serves Medicaid Members in Chicago and throughout Cook County. 11 Facebook.com/NextLevelIL

13 Your Benefits NextLevel Health Members receive the same benefits you had under the standard Medicaid program, plus added benefits. Below is a list of the benefits you receive as a NextLevel Health Member. There may be benefit limitations or some services may require a prior authorization. Main Types of Care, Benefit Limits and Copays for NextLevel Health Members Type of Care Description Benefit Limit Copay Medical Services Doctor s Visit Any appointment to see your None. doctor. This can be an annual visit or to address a medical problem. For children, any Early, Periodic Screening, Diagnosis and Treatment Services (also known as EPSDT or well-child visits) are covered. Specialty Care If it is determined by the None. Primary Care Provider that a specialist physician is needed, the Primary Care Provider will make the referral on behalf of the patient and notify NextLevel. Care received from a community clinic Emergency Room Visit Community clinics (also known as a Federally Qualified Health Centers or FQHCs) are just like visiting your Primary Care Provider. You can get your annual check-up or get care for a certain health problem. If visit is due to a health emergency. Includes poststabilization services. These services include care you need to maintain a stable condition after an emergency. A doctor will let you know if you need a prior authorization for any service received at a community clinic. None. Prior authorization is not required. 12 (312) Toll Free: TTY: Illinois Relay at 711

14 Type of Care Description Benefit Limit Copay Hospital Inpatient If you are admitted to the A doctor will let you know if hospital. you need to be admitted to Hospital Outpatient Ambulatory Surgical Treatment Center Services Nursing Facility Services Advanced Practice Nurse Services Brand Prescriptions Generic Prescriptions Over-the-counter Prescriptions If you receive care at a hospital or similar facility, but do not need to be admitted. A center that focuses on outpatient surgical procedures and services. If you need to be admitted to a nursing facility for a short or long term stay. Services provided by nurses who are experts in certain medical specialties. Medication and Prescription Services This type of medication uses a brand name. Your doctor will know which medication is right for you. This type of medication is the same as the brand, but usually has a different name. Your doctor will know which medication is right for you. You can receive certain overthe-counter prescriptions for free, if you get a prescription from your doctor. Contact your Care Coordinator for more information. the hospital. Your doctor will tell you if you need this service. A prior authorization may be required. Your doctor will tell you if you need this service. A prior authorization may be required. Your doctor will tell you if you need this service. A prior authorization may be required. Your doctor will tell you if you need this service. A prior authorization may be required. Prior authorization for certain medications may be required. Please check the NextLevel preferred drug list, located on the website at NextLevelHealthIL.com. Prior authorization for certain medications may be required. Please check the NextLevel preferred drug list, located on the website at NextLevelHealthIL.com. You need to get a prescription from your doctor for NextLevel to cover over-the-counter medications. Behavioral Health and Mental Health Services Facebook.com/NextLevelIL 13

15 Type of Care Description Benefit Limit Copay 24-hour Behavioral A service 24 hours a day to None. Health Crisis hotline connect you immediately to a Behavioral Health Specialist if you are experiencing a crisis. Therapy/Counseling Talk to a health care professional about your emotional and mental health None. Behavioral Health inpatient and outpatient services Mental Health Assessment and/or Psychological Evaluation Mental Health Inpatient Services Mental Health Outpatient Services Behavioral Health Day Treatment Substance Abuse Treatment (drugs and alcohol) Crisis Intervention and Screening needs and goals. Services for behavioral health conditions provided in the hospital, or done with a provider in the community. An evaluation by a mental health practitioner to understand any mental health or psychological needs you may have. If you are admitted to the hospital because of a mental health condition. This can include substance abuse treatment. If you receive mental health services at the hospital. Receiving services for a day for mental health or behavioral health conditions. Treatment for a substance problem such as alcohol abuse or drug abuse. Assistance from a mental health professional if you are having a mental health crisis. Referral required. None. Referral required. A doctor will let you know if you need to be admitted to the hospital. Referral required. Your doctor will tell you if you need this service. Referral required. Your doctor will tell you if you need this service. Services included but not limited to: Residential treatment, outpatient, inpatient, day treatment, detoxification and psychiatric evaluation services. None. 14 (312) Toll Free: TTY: Illinois Relay at 711

16 Type of Care Description Benefit Limit Copay Community-based services Includes community treatment and support in a one-on-one, family or group setting. Also includes intensive outpatient programs. None. Long term residential care Early Periodic Screening, Diagnosis and Treatment Services (EPSDT or well-child visits) Cervical cancer screening Mammogram Prostate cancer screening Flu Shot A long term inpatient program to treat behavioral health and mental health conditions. Preventive Care Doctor s visits for those under age 21 years which includes ongoing assessment of growth and needed vaccinations (shots) and other treatments. Test to screen for cancer in the cervix. The cervix is part of a woman s reproductive system. Image of the breast to screen for possible cancer. Exam to screen for prostate cancer in men. The prostate is a gland that is part of a man s reproductive system. This is a shot during flu season that will help you stay healthy. Prior Authorization required. Your doctor will tell you if you need this service. None. None. None. Covered for men 40 years or older who are at risk; covered for all men 50 or older. None. Maternity Care Family Planning Services This includes care for women Your doctor will tell you if during pregnancy. Women you need this service. need check-ups before and after babies are born. Be sure to tell your Care Coordinator if you are pregnant. 15 Facebook.com/NextLevelIL

17 Type of Care Description Benefit Limit Copay Family Planning Family planning includes services relating to: Contraception to prevent pregnancy HPV vaccination Pap test and any followups for abnormal Pap tests HIV testing Other procedures to permanently prevent pregnancy. This includes a vasectomy and tying tubes. Your doctor will help you decide if these services are needed. Dental Members under 21 years old Dental Members age 21 and older Care for Your Teeth, Eyes and Ears Care for your teeth. It is None. important for overall health to be sure your teeth are healthy. Two (2) cleanings and exams per year (Every six months) Additional exams as requested by your dentist Emergency dental services Services for relief of pain or infection Services for restoration of teeth Services to maintain oral health Instruction on self-care oral hygiene This is care for your teeth. It is important for overall health to be sure your teeth are healthy. Two (2) cleanings and exams per year (Every six months) One set of preventive x- rays per year Emergency dental services Prior authorization required. 16 (312) Toll Free: TTY: Illinois Relay at 711

18 Type of Care Description Benefit Limit Copay Dental Practice Visits Certain Members with Prior authorization required. disabilities and/or a mental health condition may need a practice visit to feel comfortable at the dentist. This can be arranged if needed. Orthodontia If braces or other dental Prior authorization required. equipment is needed. Covered for individuals under age 21 years old if medically necessary. Root canals and Dental services to fix your Prior authorization required. crowns teeth, if medically necessary for those 21 years and younger. Eye Exams Get an eye exam to see if you One eye exam per year. need glasses. Eye glasses One pair of eyeglasses every 2 years $50 allowance for glasses from a licensed provider. Prior authorization required. Hearing Exam Exam to test your hearing. None Hearing Aid or cochlear implant A device to assist your hearing. Prior authorization required. Transportation Services Ambulance or emergency transportation Transportation by a medical ambulance or other type of emergency vehicle that is None. Non- emergency Transportation medically necessary. If you aren t able to arrange a ride to your doctor, your Care Manager can assist you. Waiver Services Transportation authorized by your Care Manager through an in-network provider. Includes transportation to the Pharmacy to get medications. 48 hours advance notice required. Facebook.com/NextLevelIL 17

19 Type of Care Description Benefit Limit Copay This waiver includes additional You need to meet certain services you may qualify for to qualifications to receive help you live in the these types of services. Your community. This includes: Care Team will help you Adult Day Service apply for these services if Adult Day Service you qualify. Transportation Homemaker Services Personal Emergency Response System Elderly Waiver Also known as: Aging Waiver or Community Care Program Persons with Disabilities Waiver Also known as: Physical Disabilities Waiver or Home Services Program (HSP) This waiver includes additional services you may qualify for to help you live in the community. This includes: Adult Day Service Adult Day Service Transportation Environmental Accessibility Adaptions for the Home Home Delivered Meals Home Health Aide Homemaker Services Nursing skilled Nursing intermittent Personal Assistant Personal Emergency Response System Physical, Occupational and Speech Therapy Respite Specialized Medical Equipment and supplies You need to meet certain qualifications to receive these types of services. Your Care Team will help you apply for these services if you qualify. 18 (312) Toll Free: TTY: Illinois Relay at 711

20 Type of Care Description Benefit Limit Copay Persons with Brain This waiver includes additional You need to meet certain Injury Waiver services you may qualify for to qualifications to receive Also known as: Brain help you live in the these types of services. Your Injury Waiver, community. This includes: Care Team will help you Traumatic Brain Injury Adult Day Service apply for these services if Waiver, or Home Adult Day Service you qualify. Services Program Transportation (HSP) Behavioral Services Day Habilitation Environmental Accessibility Adaptions for the Home Home Delivered Meals Home Health Aide Homemaker Services Nursing skilled Nursing intermittent Personal Assistant Personal Emergency Response System Physical, Occupational and Speech Therapy Prevocational Services Respite Specialized Medical Equipment and supplies Supported Employment Facebook.com/NextLevelIL 19

21 Type of Care Description Benefit Limit Copay People with HIV or This waiver includes additional You need to meet certain AIDS Waiver services you may qualify for to qualifications to receive Also known as: AIDS help you live in the these types of services. Your Waiver or Home community. This includes: Care Team will help you Services Program Adult Day Service apply for these services if (HSP) Adult Day Service you qualify. Transportation Environmental Accessibility Adaptions for the Home Home Delivered Meals Home Health Aide Homemaker Services Nursing skilled Nursing intermittent Personal Assistant Personal Emergency Response System Physical, Occupational and Speech Therapy Respite Specialized Medical Equipment and supplies 20 (312) Toll Free: TTY: Illinois Relay at 711

22 Type of Care Description Benefit Limit Copay Supportive Living SLFs includes the following You need to meet certain Program Waiver (SLP) covered Services: qualifications to receive Also known as: Nursing Services these types of services. Your Supportive Living Personal Care Care Team will help you Facility Waiver (SLF) Medication apply for these services if administration, oversight you qualify. and assistance in selfadministration Laundry Housekeeping Maintenance Social and recreational programming Ancillary Services 24 Hour Response/Security staff Health Promotion and Exercise Emergency Call System Daily Checks Quality Assurance Plan Management of Resident Funds, if applicable Blood, blood components and related services Chiropractic Services Dialysis Home Health Care Hospice Care Other Medical Services You may need blood as a result of a medical condition. Services for the back and spine. Covered for members under the age of 21. Treatment for kidney disease. Dialysis performs some of the functions of a healthy kidney. Help in your home. This could be a nurse, or someone who provides physical therapy. End of life care. This is care that is needed if you have a serious illness. Your doctor will tell you if you need this service. Prior authorization required. Covered for those who have kidney disease. Your doctor will tell you if you need this service. Prior authorization required. Facebook.com/NextLevelIL 21

23 Type of Care Description Benefit Limit Copay Hysterectomy When a women s uterus is removed. This is a surgical procedure. Only covered if your doctor believes it is necessary. Radiology Laboratory Services Medical Equipment and Supplies Occupational Therapy Observation Physical Therapy Podiatry Speech Therapy Sterilization Procedures Ultrasound Images taken of your body. For example, an x-ray to see if you have a broken bone. This covers a range of tests your doctor may request, such as a blood test. This includes items you may need for your health, such as a wheelchair or oxygen. Helps you perform your daily activities. If your health condition needs to be monitored in the hospital, but you do not need to be admitted. Help with movement. For example, this service would help you after an injury. Foot care. Covered for Members under the age of 21 and for diabetic members age 21 and over. Diabetic members receive routine foot care and orthopedic shoes every two years. Help with speaking and language skills. Procedure that prevents pregnancy. This can be for both men and women. This type of procedure is permanent. Type of image used by doctors to see what s happening inside the body. Typically used for women during pregnancy. Your doctor will tell you if you need this service. Your doctor will tell you if you need this service. Prior authorization required. Prior authorization is required. Your doctor will tell you if you need this service. Prior authorization is required. Your doctor will tell you if you need this service. Prior authorization is required. Your doctor will tell you if you need this service. Prior authorization required. Prior authorization is required. Your doctor will tell you if you need this service. Your doctor will have you complete forms. These forms make sure you understand the procedure and give your consent. Only covered if your doctor believes it is necessary. 22 (312) Toll Free: TTY: Illinois Relay at 711

24 Services Not Covered There are certain services that Medicaid doesn t cover. Services that are not covered include: Experimental procedures: Treatment that are not the usual course of treatment. Research procedure: Procedure or treatment that is not the usual course of treatment. This type of treatment is still being studied by researchers. Medical examinations required for entrance into adult educational or vocational program: Certain programs need a medical exam to qualify. These types of exams and tests are not covered. Autopsy: This is a service that is performed after a person dies. It takes a look at the causes for a person s death. Artificial insemination: This is when semen is put into a woman s body to get her pregnant. Medical or surgical procedures performed for cosmetic purposes: This is a procedure that does not improve your health or is not required to remedy an injury or health condition. For example, plastic surgery. Medical or surgical transsexual treatment services: This is treatment for individuals that want to change gender. Acupuncture: This is a treatment that involves needles being placed in certain parts of the body. Elective Surgery: Surgery that is not necessary for your health is elective. Please note: This is not a full list of non-covered services. If you have a question about whether a service is covered, contact us. NextLevel Extra Benefits In addition to the regular Medicaid benefits, NextLevel will provide you with extra benefits to help make sure you can get the care you need and keep you healthy. Below is a chart of these benefits. Once NextLevel sees that you have completed the activity (as a result of a claim submitted by your doctor), we will mail you your reward. For certain rewards, your Care Team may visit you to give you the reward in person. If you have questions about the rewards you are able to receive, contact us. Activity Pregnancy and New Mom Orthopedic Shoes Transportation Reward Get a new car seat, with instructions on how to properly install by your Care Manager upon discharge from hospital or birthing center. Gift card for completing scheduled prenatal visits Members with diabetes over the age of 21 orthopedic shoes ordered by doctor. Transportation to pharmacy to pick up medicines 23 Facebook.com/NextLevelIL

25 Member Services NextLevel is here to serve you and answer your questions. Our Member Services department is available 8:30 am 5 pm Central Time to answer your questions and concerns. They can help you with: Questions about your benefits. Help finding a Primary Care Provider (PCP) or Women s Health Care Provider (WHCP). Referrals to specialists. Getting you a replacement Member ID Card. Information about social services. Getting you in contact with your Care Team. Any additional questions or concerns you have. Prescriptions Your doctor may prescribe medication to treat your health condition. You will get your prescriptions filled at a pharmacy. You must use a pharmacy in NextLevel s network. If you need help finding a pharmacy close to your home, contact us. It s important to follow the instructions from your doctor and pharmacist about the medications you are prescribed. If you have trouble understanding how to take your medications, contact us. Your Care Team can assist you. You do not have a copay for your medications. NextLevel has a preferred drug list, which includes all the medications that are covered. You may need a prior authorization for certain medications. The preferred drug list can be found on NextLevel s website at Contact us to request a copy of NextLevel s preferred drug list. Your doctor will prescribe a brand name medication or a generic medication. Brand name medications usually cost more. Generic medications are similar to brand name medications. They usually have the same ingredients. You can always ask your doctor if a generic option is available. But your doctor will know what medication is best for you. You can also receive certain over-the-counter medications at a lower cost. You need a prescription from your doctor for over-the-counter medication. It is important to discuss with your doctor all the medications you take. If you take medicine for both a physical and a mental health condition, let your doctor and Care Coordinator know. It is 24 (312) Toll Free: TTY: Illinois Relay at 711

26 important for your Care Team to know all the medications you are taking to ensure you are receiving the best care. If you take a certain prescription regularly, you may be able to receive that medicine in the mail. Talk to your Care Team if you d like to receive your medication in the mail. He or she can assist you in setting up this service. Choosing Your PCP NextLevel has partnered with providers in your community, so you can receive the health care services you need. It is important for every Member to choose a Primary Care Provider (PCP). Your PCP is responsible for your overall care and well-being. They are the lead of your Care Team. You will receive all of your care through your PCP. Your PCP must be in the NextLevel Health network. You can see a listing of NextLevel PCPs in the provider directory that came with your Member Handbook. This provider directory is also posted on our website at NextLevelHealthIL.com. Member Services can also assist you in choosing a PCP. Many different types of doctors can serve as your PCP. Your PCP, along with you and your Care Team, work together to meet your health goals. Your PCP can be a family practice doctor, a general practice doctor, or for women, an OB/GYN. If choosing an OB/GYN, this is known as a Women s Health Care Provider (WHCP). If you have certain needs, you may even want a specialist to be your PCP. A specialist can be a PCP by working with NextLevel. The specialist needs to agree to look over your entire care, not just specific needs. Picking the right PCP It is important for you to pick a PCP that is right for you. Your PCP should understand your health conditions. You want good, open communication with your PCP. When picking a PCP, it s important to remember: You do not have to pick your current doctor as your PCP. You can change your PCP once a month, if you choose. Think about where you receive care now. Do you want to continue to get care at that clinic or doctor s office? Or is there another clinic or doctor s office that you prefer? Do you need your doctor to speak another language? Does your doctor understand your cultural needs and preferences? Do you feel comfortable with your doctor? You can change your PCP or WHCP once a month. To change your PCP, you must contact NextLevel Member Services. Your PCP/WHCP change will be active within 30 days. Facebook.com/NextLevelIL 25

27 You can change your PCP at any time for cause. Reasons to change your PCP may include having a bad experience or not being able to access the doctor s office. If this is the case, contact NextLevel right away, and we will help change your PCP. It is important to make an appointment with your PCP when you want to see your doctor. Call the doctor s office to set up an appointment. If you are unable to make an appointment, it is important to let your doctor know. If you are unable to make an appointment because you don t have a ride, contact NextLevel so we can set up transportation for you. Your PCP will have normal business hours and will be available by phone during those hours. After business hours, you will have access to a service that can help you contact your doctor when you have an urgent medical problem. If you are unable to contact your PCP, you can contact NextLevel s Nurse Advice Line. If you are looking for a different type of provider, such as a mental health, behavioral health, specialist, dentist, optometrist or any other provider outside of your PCP, you choose one of the providers in the NextLevel network. For specialist care, including behavioral health and mental health, ask for a referral from your PCP. You will also need to find out whether that provider is in NextLevel s network and whether they are accepting new patients. If you are unsure about a provider you want to see, contact us. Your Care Team can help you decide. Getting Care When you need to go to a doctor s office, mental health appointment, pharmacy emergency room, or anywhere else to get health care services, you ll need to present your NextLevel ID Card. This card will let doctors know that you are covered. For certain care, you may need a specialist. Specialists are doctors that focus on a specific part of the body or disease. If you need to see a specialist for any reason, you will need a referral from your Primary Care Provider. You can see any specialist in the NextLevel network. If you need help finding a specialist, contact your NextLevel Care Team. Your Care Team can help you find the doctor you need, and help you set up an appointment. For certain types of care, you may need a prior authorization. This is approval for certain services. Your doctor will know what types of care need prior authorization and will work with NextLevel to coordinate approval for any services you may need. Family Planning Services NextLevel covers all family planning services for Members, which includes: Care for women during pregnancy 26 (312) Toll Free: TTY: Illinois Relay at 711

28 Contraception to prevent pregnancy HPV vaccination Pap test and any follow-ups for abnormal Pap tests HIV testing It is important if you are sexually active to get regular checkups to ensure you are healthy. If you are pregnant, you need checkups before and after the baby is born. Be sure to tell your Care Team if you are pregnant. With NextLevel, you are also eligible to receive rewards for going to certain appointments related to your pregnancy. This includes: A visit during the first three months of your pregnancy (also known as the first trimester) Six visits during your pregnancy One doctor s visit after your pregnancy (called a postpartum visit) When completing all these necessary screenings, NextLevel will give you a $50 gift card toward health-related items. NextLevel s Provider Partners NextLevel Health has teamed up with local providers in your community to give you better access to health care services. Our provider partners include PCPs, health clinics, hospitals, urgent care clinics, school-based health centers, specialists, behavioral health providers, substance abuse providers, dentists and others. Our Provider Directory was included in the packet with your Member handbook and is also available to view or download on our website at NextLevelHealthIL.com. The Directory has the most up-to-date listing of the providers in our network. This includes the names, locations, telephone numbers and languages spoken by providers. It also includes information about access if you have a disability, or if the provider has any age restrictions. If you are unable to see our directory online, give us a call. We can assist you in finding the provider you need, or we ll send you the directory in the format you request. This includes hard copy or an alternate format such as large print. Access to Your Doctor NextLevel makes sure that your PCP is available when you need medical attention and that you can make appointments and see your doctor within a reasonable amount of time. Below is a summary of these guidelines that all in-network PCPs must follow. If you ever have trouble getting an appointment with your PCP, please contact us. Your Care Team can assist you. Facebook.com/NextLevelIL 27

29 Appointment Type Routine, preventive care for infants under 6 months old Routine, preventive care Urgent care, but not requiring a visit to the emergency room Problem or complaint that is not serious or urgent Follow-up appointment after visit to the emergency room Prenatal visit during the 1st trimester Prenatal visit during the 2nd trimester Prenatal visit during the 3rd trimester PCP Availability Appointment can be made within 2 weeks of request Appointment can be made within 5 weeks of request Within 1 business day Appointment made available within 3 weeks of request Appointment available within 7 days Appointment available within 2 weeks Appointment available within 1 week Appointment available within 3 days NextLevel works with your PCP to ensure they meet certain access standards for individuals with disabilities. This includes having accessible entrances, walkways and bathrooms. If you ever have trouble receiving care because of accessibility, please let us know. We ll work with you and your PCP to ensure it doesn t happen again. If you need to contact your PCP after hours, your doctor should have 24-hour answering services. If necessary, you can always contact NextLevel s Nurse Advice Line and our staff of nurses can answer your health questions or concerns. Your Care Team NextLevel ensures that you receive the best health care. We do this by providing you with a health Care Team that assists you in meeting all of your health care goals. Your Primary Care Provider leads your Care Team. Other members of your Care Team include: Care Coordinator/Care Manager: This member of your team will help you with any medical needs and goals you may have. For example, they can help you make appointments with your doctor and set up transportation. Care Coordinators / Managers are available to answer questions. They may visit you at home. If you are ever in the emergency room, they will come see you, and find out how you are doing. Behavioral Health Specialist: The Behavioral Health Specialist is the member of your Care Team who assists with your emotional and mental health. If you have a mental health condition, such as depression, they ll help connect you with counselors and doctors who can meet your needs. If you need certain social supports, such as financial help and housing, this member of your Care Team can assist you in finding those resources. 28 (312) Toll Free: TTY: Illinois Relay at 711

30 Community Engagement Specialist: This member of your Care Team will reach out to you on a regular basis with health information. They will help you receive preventive care, such as cancer screenings, flu shots and other needed services. They can help you with any issue that may come up with your care. They may visit you at home or at your doctor s office. They can link you to community programs in your neighborhood. Your Care Team works with you to ensure you can access all the health benefits and community resources you need to stay healthy. The Care Team understands that the most important member of the team is YOU. To find out who your Care Team is, contact NextLevel Health. Your Care Plan Your Care Manager, together with your PCP and your entire Care Team will work with you to create a Care Plan. Your Care Plan includes your goals for becoming healthier. It is important that you have input on your care plan. If you receive any Home and Community Based Services as part of a waiver, your Service Plan will be included in your Care Plan. A waiver includes the Home Services Program (HSP) and the Community Care Program (CCP). NextLevel will work with you and your providers to assist in coordinating services. We ensure all your services work together to help you achieve your best health and independence. Care Management & Disease Management As a result of your condition, you may need more support from NextLevel. This is called Care Management. Care Management is provided to those individuals who have a significant health event and need ongoing help. This also includes those that receive services under a Home and Community Based Services Waiver. If you believe you need Care Management services, please contact us. We will work with you to get the services you need. Care Management includes: Assessing your current condition Addressing your risks and needs Assisting in managing your medications Ongoing education about your health condition Care Managers work with you to help you set goals. Each goal is focused on a certain activity, which will help you manage your condition. For more information about NextLevel s Care Management program, please contact us. Facebook.com/NextLevelIL 29

31 If your condition is ongoing, you may be referred to NextLevel s Disease Management program. This program focuses on education regarding your condition and provides you with tools to self-manage your condition. If you believe you would benefit from Disease Management, let your Care Team know. He or she can provide you with more information on NextLevel s Disease Management Programs. Your Member Profile NextLevel Health has an online portal just for our Members. This portal allows you to see valuable information about your health care. This includes: Basic information about you like your name, address, phone number and age. Your chosen Primary Care Provider. Results of your Health Risk Screening and Health Risk Assessment. The members of your Care Team and how to contact them. Your Care Plan, which includes your health goals. Educational information including videos. Information about upcoming NextLevel Health events. Secure communications with your Care Team or PCP through messaging or video chat. Your next doctor s visit or next visit with your Care Coordinator. To access the Member portal and your profile, visit our website at NextLevelHealthIL.com, and select Login. You ll need to enter your personal information to register. Once you sign up, you ll be able to access all your health information in one central location. Your Care Team doesn t just include your Care Coordinators. It includes your family members, your caregivers and the other people in your life who provide support. If you wish, you can allow others to have access to your Member Profile. To do this, have the other person visit us at NextLevelHealthIL.com, click register and then set up their own profile. Once they re in the system, you can give them permission to see you profile. Going to the Emergency Room Part of taking care of your health is understanding what to do in an emergency. For certain health conditions, it will be important to call 911 or go to the emergency room. If there is no 911 service in your area, you should call an ambulance. You do not need prior approval or a referral to go to the emergency room. You can go to any hospital or other provider when you need emergency care. You can get emergency care at any hospital. It does not matter if that hospital is in NextLevel s network. It is important for you to receive care immediately. Poststabilization services are covered. These services are to ensure your condition is stable after an 30 (312) Toll Free: TTY: Illinois Relay at 711

32 emergency. It is important to contact NextLevel immediately if you are getting emergency care. You Care Team can help support your needs when you are experiencing an emergency. You can find information on facilities providing emergency services and post stabilization services in NextLevel s provider directory. A directory was provided with your Member Handbook. You can also find the directory on NextLevel s website at or by contacting Member Services. When you call 911 If you are having an emergency, dial on your telephone. Someone will immediately answer, and ask you, What is your emergency? By telling the person on the phone what is happening, they can best assist you and they can send help. When you don t need care right away, it is best to make an appointment with your PCP. If your condition is still urgent, but is not an emergency, you can visit an urgent care center. This could be when if you or someone in your family is experiencing a bad cold or flu or has a minor injury and you need care now. An urgent care center is typically open longer than normal business hours. Some are even open 24 hours a day. Urgent care centers that are in NextLevel s network are listed in the Provider Directory found on the NextLevel website. Below are examples of when to go to the emergency room and when to visit an urgent care center, clinic or make an appointment with your PCP: Emergency Care Trouble breathing Broken bones Neck or back injuries Choking Sudden loss of speech, vision or mobility Unconsciousness Severe burns Sexual assault Overdose Chest pains or heart attack Fear that you may hurt yourself or someone else Non-emergent Care: Visit an urgent care center, clinic, or your PCP Cold or runny nose Flu Sore throat Back strain Small injuries such as a twisted ankle Routine care If you re not sure if you should be going to the emergency room, contact NextLevel s Nurse Advice Line. Our staff of nurses can answer your questions. We can let you know if you should go to the emergency room, or if there is an urgent care center that may serve your needs better. Our Nurse Advice Line is a crisis line, too. If you are experiencing a mental health crisis, contact us. We can direct you to the best place to get help. 31 Facebook.com/NextLevelIL

33 Transportation NextLevel provides transportation for you to travel to covered medical visits. This includes when you need a ride to the Pharmacy to pick up medication. It also includes any transportation that is medically necessary, such as an ambulance to the Emergency Room. If you need an ambulance, call To set up a ride to a covered medical service, contact Member Services 48 hours before your appointment. Dental Care NextLevel covers dental services. There is no copay and you do not need a referral from your PCP. This includes visits to the dentist for dental exams, teeth cleaning, cavity filling, root canals and tooth pulling (extractions). Certain services may require you to get prior approval before you can receive the service. Benefits for Members Over 21 For those Members over 21 years old, dental services include: One cleaning and exam per year Additional exams as requested by your dentist Emergency dental services Services for pain relief or treating infection Services to restore of teeth Services to maintain oral health Instruction on self-care oral hygiene Benefits for Members Under 21 For those Members that are 21 years and older, dental services include: Two cleanings and exams per year (Every 6 months) One set of preventive x-rays per year Emergency dental services Under the dental benefit, we encourage you to go to a dentist for an oral exam. At the exam, your dentist will develop a treatment plan for you. If the treatment plan includes a covered dental service that requires prior approval, the dentist will request the approval. If approved, the dentist can perform the service. For Members who have a developmental disability or serious mental illness, it may be frightening to go to the dentist. NextLevel offers practice exams for these Members, so they 32 (312) Toll Free: TTY: Illinois Relay at 711

34 can become familiar with what happens at the dentist s office, which may help make the visit easier. To arrange for this type of service, contact NextLevel s Member Services department. If you have any questions about finding a dentist or what is covered under your dental benefit, call NextLevel. You can also call Dental Services at If you use a TTY, call Taking the Steps to Better Health Take care of yourself by knowing what preventive exams you need. These are different based on your age and gender or if you have certain health conditions. Below is a chart of some of the steps you should take for your health. Be sure to talk to your PCP about any tests or exams that you may need. Your PCP is the expert and will work with you to figure out what is best for your health. About You Type of Care Recommended: Under 21 years Early and Periodic Screening, Diagnosis and Treatment Services (also known as EPSDT or well-child visits) Medical checkups Physical exam Assessment of your child s growth, development and nutrition Assessment of your child s mental and behavioral health Lab tests, including tests for lead, and lead education Vaccines (shots) when due Vision and hearing screening Referrals for other medically necessary services 21 years or older Doctor s visit with your PCP each year Flu shot each year Body mass index assessment (BMI) Women 19 years or older Pap test to screen for cervical cancer every one to three years for women who are sexually active A test for HPV Women 40 years or older Mammogram each year to screen for breast cancer Cholesterol screening Men 40 years or older Prostate exams to screen for prostate Facebook.com/NextLevelIL 33

35 About You Type of Care Recommended: cancer. Your PCP will help you decide how often to receive this exam based on your medical history. Cholesterol screening Have diabetes HbA1c test each year Cholesterol test each year Frequently Asked Questions We know health care can be confusing. NextLevel is here to help. Below are some frequently asked questions about NextLevel. If you have a question, and the answer isn t listed, let us know. What is NextLevel Health? NextLevel Health is a Medicaid Health Plan. We are contracted with the Illinois Department of Healthcare and Family Services to provide health care services to people who are enrolled in Medicaid. We also help our Members understand and navigate the health care system. We are a group of committed professionals who are dedicated to working with the community. Do I have to pick a Primary Care Provider (PCP)? Yes, it is important for you to select a PCP that is in our network. Your PCP will lead your Care Team to ensure you are meeting your health care goals. Visit our website at to see our provider directory and find an in-network provider that can assist you in meeting your health goals. You can always give us a call, and we can assist you in choosing a PCP. How can I change my PCP? It s easy to change your PCP. Call and we can help you pick a new in-network PCP. If you already have a doctor in mind, verify that they re in our network by checking our provider directory and then contact us. We will make sure that your PCP information is updated. I have a question about my benefits. Who can I contact? Call NextLevel and we can answer any questions you have, as well as help you set up services. Call us at (312) , toll free at or if you re hearing impaired, at Illinois Relay at 711. I need to see a mental health or behavioral health provider. Do I need a referral? You will need a referral from your PCP to see specialists. This includes a mental health or behavioral health provider. You can check our Provider Directory on our website to find a 34 (312) Toll Free: TTY: Illinois Relay at 711

36 provider close to your home or contact your Care Team by calling NextLevel. We can assist you in finding a provider and setting up an appointment. We Want to Hear from You Our Members are important to us. We want to make sure NextLevel is the health plan you need. We are always looking for your feedback and input. That s why NextLevel has many ways for you to let us know how we re doing and give us suggestions on how we can improve. We have a Member Advisory Committee, which meets regularly to give us feedback. This is directly shared with our leadership team, so we can make changes based on Member input. If you d like to join our Member Advisory Committee, please contact us. NextLevel will send out surveys to Members to find out how you think we re doing. These surveys will be sent to you in the mail and you can fill them out or complete them on the Member Portal. These surveys will allow you to tell us about your Care Team and whether we re meeting your health, social and cultural needs. When you receive this survey, please fill it out. It is important for us to hear your thoughts and comments so we can improve our service. In addition to our Member Advisory Committee and Member Surveys, we welcome your feedback at any time. You can contact us by phone, fax, and or through the Member portal. Once you send us your comments, they will be given to our Quality Improvement Committee. This committee is responsible for always looking for ways NextLevel can be better. Changes in Your Health Plan You get to choose your health plan. We re glad you chose NextLevel. But, if you believe a different health plan will serve you better, you can switch. When you first become a NextLevel Member, you have the option to switch health plans within ninety (90) days. After this time, you ll be locked-in to a health plan for a year. Open Enrollment Every year, Members have the option to switch health plans during the open enrollment period. This happens on your anniversary data, the date you were first enrolled in the program. Illinois Client Enrollment Services (CES) will send you a letter before open enrollment starts. The letter will include information about the different plans you can choose. If you want to stay with your current health plan, you don t have to do anything. However, if you want to switch, you ll need to contact CES. Facebook.com/NextLevelIL 35

37 Phone: Call Monday through Friday 8 am to 7 pm Central Time. On Saturdays from 9 am to 3 pm Central Time. The call is free. If you are hearing impaired, you can call TTY Online: Visit Enrollhfs.illinois.gov to sign up online. You ll be able to choose a health plan, pick a Primary Care Provider (PCP) and review your information. You ll need your name, date of birth, recipient ID number (RIN) and the last 4 digits of your social security number. Mail: Fill out the enrollment form you received in the mail. Send it to Client Enrollment Services in the envelope provided. The address is: Illinois Client Enrollment Services PO Box 1337 Chicago, IL Disenrolling from NextLevel During the Year You may want or need to disenroll from NextLevel. You can disenroll for the following reasons: You re moving out of NextLevel s service area. You received poor quality of care. NextLevel is not covering the services you need. NextLevel doesn t have a Provider in our network that meets your needs. To disenroll from the Health Plan, contact NextLevel s Member Services department. Your Rights and Responsibilities As a NextLevel Member, you have certain rights and responsibilities. You have the right to: Be treated with respect, dignity and privacy. Receive information on your treatment choices in a way that you understand. Have your PCP explain your treatment in a way that makes sense to you. Ask questions and have them answered by your PCP. Make decisions about the care you get. This includes saying no to care you don t want. Get a copy of your medical records from your PCP and have the records corrected if needed. Change your PCP as often as once a month. Pick the same PCP for you and your family, or pick different PCPs for each member of your family. 36 (312) Toll Free: TTY: Illinois Relay at 711

38 Call your PCP to get help. Complain about your PCP. Exercise your rights freely without negative consequences such as discrimination or retaliation. Exercising your rights will not adversely affect the way you are treated. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation. Request information from NextLevel, including information about the structure and operations of the health plan, physician incentive plans and quality performance indicators, including Member satisfaction. You have the responsibility to: Learn your rights as a NextLevel Health Member. Keep your appointments and cancel in advance the ones you cannot keep. Treat your PCP with respect. Tell your PCP about your health care needs and about any other health care services you are getting. Keep up-to-date on immunizations (shots). Contact your PCP first for care that is not an emergency. Get a referral from your PCP before getting care that needs a referral. Tell your PCP about other services you get that do not need a referral. Let your Care Team know about important changes, such as changes in your name, address, phone number, income or family size. Share important information that is needed by your Providers. Follow the instructions and guidelines given by your PCP. Grievances and Appeals We want you to be happy with services you get from NextLevel Health and our providers. If you are not happy, you can file a grievance or appeal. Grievances A grievance is a complaint about any matter other than a denied, reduced or terminated service or item. NextLevel Health takes Member grievances very seriously. We want to know what is wrong so we can make our services better. If you have a grievance about a provider or about the quality of care or services you have received, you should let us know right away. NextLevel Health has special procedures in place to help members who file grievances. We will do our best to answer your questions or help to resolve your concern. Filing a grievance will not affect your health care services or your benefits coverage. Facebook.com/NextLevelIL 37

39 These are examples of when you might want to file a grievance. Your provider or a NextLevel Health staff member did not respect your rights. You had trouble getting an appointment with your provider in an appropriate amount of time. You were unhappy with the quality of care or treatment you received. Your provider or a NextLevel Health staff member was rude to you. Your provider or a NextLevel Health staff member was insensitive to your cultural needs or other special needs you may have. You can file your grievance on the phone by calling Member Services. You can also file your grievance in writing and then mail or fax to: NextLevel Health Attn: Grievance and Appeals Dept W. Harrison St Chicago, IL Fax: (312) In the grievance letter, give us as much information as you can. For example, include the date and place the incident happened, the names of the people involved and details about what happened. Be sure to include your name and your member ID number. You can ask us to help you file your grievance by calling Member Services. If you do not speak English, we can provide an interpreter at no cost to you. Please include this request when you file your grievance. At any time during the grievance process, you can have someone you know represent you or act on your behalf. This person will be your representative. If you decide to have someone represent you or act for you, inform NextLevel Health in writing the name of your representative and his or her contact information. We will try to resolve your grievance right away. If we cannot, we may contact you for more information. Appeals You may not agree with a decision or an action made by NextLevel Health about your services or an item you requested. An appeal is a way for you to ask for a review of our actions. You may appeal within sixty (60) calendar days of the date on our Notice of Action form. If you want your services to stay the same while you appeal, you must say so when you appeal, and you must file your appeal no later than ten (10) calendar days from the date on our Notice of Action form. The list below includes examples of when you might want to file an appeal. Not approving or paying for a service or item your provider asks for 38 (312) Toll Free: TTY: Illinois Relay at 711

40 Stopping a service that was approved before Not giving you the service or items in a timely manner Not advising you of your right to freedom of choice of providers Not approving a service for you because it was not in our network If we decide that a requested service or item cannot be approved, or if a service is reduced or stopped, you will get a Notice of Action letter from us. This letter will tell you the following: What action was taken and the reason for it Your right to file an appeal and how to do it Your right to ask for a State Fair Hearing and how to do it Your right in some circumstances to ask for an expedited appeal and how to do it Your right to ask to have benefits continue during your appeal, how to do it and when you may have to pay for the services Here are two ways to file an appeal. 1) Call Member Services at (312) or toll free at If you file an appeal over the phone, you must follow it with a written signed appeal request. 2) Mail or fax your written appeal request to: NextLevel Health 3019 W. Harrison St Chicago, IL Fax: (312) If you do not speak English, we can provide an interpreter at no cost to you. Please include this request when you file your appeal. If you are hearing impaired, call the Illinois Relay at 711. Can someone help you with the appeal process? You have several options for assistance. You may: Ask someone you know to assist in representing you. This could be your Primary Care Physician or a family member, for example. Choose to be represented by a lawyer or legal professional. If you have a waiver for Disabilities, Traumatic Brain Injury or HIV/AIDS, you may also contact CAP (Client Assistance Program) at or (TTY). To appoint someone to represent you, you have the option to: 1) Send us a letter informing us that you want someone else to represent you and include his or her contact information in the letter or, 2) Fill out the Authorized Representative Appeals form. You may find this form on our website at: Facebook.com/NextLevelIL 39

41 Appeal Process We will send you an acknowledgement letter within three (3) business days saying we received your appeal. We will tell you if we need more information and how to give us such information in person or in writing. A provider with the same or similar specialty as your treating provider will review your appeal. It will not be the same provider who made the original decision to deny, reduce or stop the medical service. NextLevel Health will send our decision in writing to you within fifteen (15) business days of the date we received your appeal request. NextLevel Health may request an extension up to fourteen (14) more calendar days to make a decision on your case if we need to get more information before we make a decision. You can also ask us for an extension, if you need more time to obtain additional documents to support your appeal. We will call you to tell you our decision and send you and your authorized representative the Decision Notice. The Decision Notice will tell you what we will do and why. If NextLevel Health s decision agrees with the Notice of Action, you may have to pay for the cost of the services you got during the appeal review. If NextLevel Health s decision does not agree with the Notice of Action, we will approve the services to start right away. Things to keep in mind during the appeal process: At any time, you can provide us with more information about your appeal, if needed. You have the option to see your appeal file. You have the option to be there when NextLevel Health reviews your appeal. How can you speed up your Appeal? If you or your provider believes our standard timeframe of fifteen (15) business days to make a decision on your appeal will seriously jeopardize your life or health, you can ask for an expedited appeal by writing or calling us. If you write to us, please include your name, member ID number, the date of your Notice of Action letter, information about your case and why you are asking for the expedited appeal. We will let you know within twenty-four (24) hours if we need more information. Once all information is provided, we will call you within twenty-four (24) hours to inform you of our decision and will also send you and your authorized representative the Decision Notice. How can you withdraw an Appeal? You have the right to withdraw your appeal for any reason, at any time, during the appeal process. However, you or your authorized representative must do so in writing, using the same address as used for filing your appeal. Withdrawing your appeal will end the appeal process and no decision will be made by us on your appeal request. 40 (312) Toll Free: TTY: Illinois Relay at 711

42 NextLevel Health will acknowledge the withdrawal of your appeal by sending a notice to you or your authorized representative. If you need further information about withdrawing your appeal, call NextLevel Health Member Services. What happens next? After you receive the NextLevel Health appeal Decision Notice in writing, you do not have to take any action and your appeal file will be closed. However, if you disagree with the decision made on your appeal, you can take action by asking for a State Fair Hearing Appeal and/or asking for an External Review of your appeal within thirty (30) calendar days of the date on the Decision Notice. You can choose to ask for both a State Fair Hearing Appeal and an External Review or you may choose to ask for only one of them. State Fair Hearing If you choose, you may ask for a State Fair Hearing Appeal within thirty (30) calendar days of the date on the Decision Notice, but if you want to continue your services, you must ask for a State Fair Hearing Appeal within ten (10) calendar days of the date on the Decision Notice. If you do not win this appeal, you may be responsible for paying for these services provided to you during the appeal process. At the State Fair Hearing, just like during the NextLevel Health Appeals process, you may ask someone to represent you, such as a lawyer or have a relative or friend speak for you. To appoint someone to represent you, send us a letter informing us that you want someone else to represent you and include his or her contact information in the letter. You can ask for a State Fair Hearing in one of the following ways: Your local Family Community Resource Center can give you an appeal form to request a State Fair Hearing and will help you fill it out if you request assistance. If you want to file a State Fair Hearing Appeal related to your medical services or items, or Elderly Waiver (Community Care Program - CCP) services, send your request in writing to: Illinois Department of Healthcare and Family Services Bureau of Administrative Hearings 69 W. Washington Street, 4th Floor Chicago, IL Fax: (312) HFS.FairHearings@illinois.gov Or you may call (855) , TTY: (800) If you want to file a State Fair Hearing Appeal related to mental health or substance abuse services, Persons with Disabilities Waiver services, Traumatic Brain Injury Waiver Facebook.com/NextLevelIL 41

43 services, HIV/AIDS Waiver services, or any Home Services Program (HSP) service, send your request in writing to: Illinois Department of Human Services Bureau of Hearings 69 W. Washington Street, 4th Floor Chicago, IL Fax: (312) Or you may call (800) , TTY: (877) State Fair Hearing Process The hearing will be conducted by an Impartial Hearing Officer authorized to conduct State Fair Hearings. You will receive a letter from the appropriate office informing you of the date, time and place of the hearing. This letter will also provide information about the hearing. It is important that you read this letter carefully. At least three (3) business days before the hearing, you will receive information from NextLevel Health. This will include all evidence we will present at the hearing. This will also be sent to the Impartial Hearing Officer. You must provide all the evidence you will present at the hearing to NextLevel Health and the Impartial Hearing Officer at least three (3) business days before the hearing. This includes a list of any witnesses who will appear on your behalf, as well as all documents you will use to support your appeal. You will need to notify the appropriate Hearings Office of any accommodation you may need. Your hearing may be conducted over the phone. Please be sure to provide the best phone number to reach you during business hours in your request for a State Fair Hearing. The hearing may be recorded. Continuance or Postponement You may request a continuance during the hearing or a postponement prior to the hearing; either of which may be granted if good cause exists. If the Impartial Hearing Officer agrees, you and all parties to the appeal will be notified in writing of a new date, time and place. The time limit for the appeal process to be completed will be extended by the length of the continuation or postponement. Failure to Appear at the Hearing Your appeal will be dismissed if you, or your authorized representative, do not appear at the hearing at the time, date and place on the notice and you have not requested postponement in writing. If your hearing is conducted via telephone, your appeal will be dismissed if you do not answer your telephone at the scheduled appeal time. A Dismissal Notice will be sent to all parties to the appeal. 42 (312) Toll Free: TTY: Illinois Relay at 711

44 Your hearing may be rescheduled, if you let us know within ten (10) calendar days from the date you received the Dismissal Notice, if the reason for your failure to appear was: A death in the family Personal injury or illness which reasonably would prohibit your appearance A sudden and unexpected emergency If the appeal hearing is rescheduled, the Hearings Office will send you or your authorized representative a letter rescheduling the hearing with copies to all parties to the appeal. If we deny your request to reset your hearing, you will receive a letter in the mail informing you of our denial. The State Fair Hearing Decision A Final Administrative Decision will be sent to you and all interested parties in writing by the appropriate Hearings Office. This Final Administrative Decision is reviewable only through the Circuit Courts of the State of Illinois. The time the Circuit Court will allow for filing of such review may be as short as thirty-five (35) days from the date of this letter. If you have questions, please call the Hearing Office. External Review (for medical services only) Within thirty (30) calendar days after the date on the NextLevel Health appeal Decision Notice, you may choose to ask for a review by someone outside of NextLevel Health. This is called an external review. The outside reviewer must meet the following requirements: Board-certified provider with the same or like specialty as your treating provider Currently practicing Have no financial interest in the decision Not know you and will not know your identity during the review External Review is not available for appeals related to services received through the Elderly Waiver, Persons with Disabilities Waiver, Traumatic Brain Injury Waiver, HIV/Aids Waiver, or the Home Services Program. Your letter must ask for an external review of that action and should be sent to: NextLevel Health 3019 W Harrison St Chicago, IL Fax: (312) What Happens Next? We will review your request to see if it meets the qualifications for external review. We Facebook.com/NextLevelIL 43

45 have five (5) business days to do this. We will send you a letter letting you know if your request meets these requirements. If your request meets the requirements, the letter will have the name of the external reviewer. You have five (5) business days from the letter we send you to send any additional information about your request to the external reviewer. The external reviewer will send you and/or your representative and NextLevel Health a letter with their decision within five (5) calendar days of receiving all the information they need to complete their review. Fast External Review If the normal time frame for an external review could jeopardize your life or your health, you or your representative can ask for an expedited external review. You can do this over the phone or in writing. To ask for an expedited external review over the phone, call NextLevel Member Services. To ask in writing, send us a letter at the address below. You can only ask once for an external review about a specific action. Your letter must ask for an external review of that action. NextLevel Health 3019 W. Harrison St Chicago, IL Fax: (312) What happens next? Once we receive the phone call or letter asking for an expedited external review, we will immediately review your request to see if it qualifies for an expedited external review. If it does, we will contact you or your representative to give you the name of the reviewer. We will also send the necessary information to the external reviewer so they can begin their review. As quickly as your health condition requires, but no more than two (2) business days after receiving all information needed, the external reviewer will make a decision about your request. They will let you and/or your representative and NextLevel Health know what their decision is verbally. They will also follow up with a letter to you and/or your representative and NextLevel Health with the decision within forty-eight (48) hours. 44 (312) Toll Free: TTY: Illinois Relay at 711

46 Abuse, Neglect and Exploitation There may be times when someone you rely on takes advantage of you. This could be your caregiver, a family member or even your doctor. It s important to understand and recognize the signs of abuse, neglect and exploitation. What is Abuse? Abuse is when someone harms you. This can be done to you physically or sexually. It also includes emotional abuse. Below are examples of each of these types of abuse. Physical Abuse: If a person hits, punches, kicks you. Or if someone threatens you with a weapon such as a gun or knife. Sexual Abuse: If someone touches you in an intimate way that you did not allow. This includes inappropriate touching of the genital area, breasts or buttocks. Emotional Abuse: This includes someone using demeaning, harmful or threatening words. This includes controlling behavior, isolation or embarrassment. What is Neglect? Neglect is when someone withholds the necessities of life from you. This includes if someone who cares for you withholds or doesn t provide you with food, clothing, shelter or medical care. What is Exploitation? Exploitation is when someone takes advantage of you. This could include a caregiver or personal assistant taking money or assets from you for their own personal gain. If you experience Abuse, Neglect or Exploitation, report it. Your information will be kept private. To report an instance of Abuse, Neglect or Exploitation: Call your NextLevel Care Team. By notifying your Care Team, we can assist you in reporting to the proper authorities, and if your current situation is unsafe, they can help ensure your safety. Contact your Care Team at (312) , toll free at , or if you re hearing impaired, Illinois Relay at 711. For Members 18 years and older, report to the Illinois Department on Aging via the Adult Protective Services (APS) hotline at or (TTY). For people residing in nursing facilities, report to the Illinois Department of Public Health s Nursing Home Complaint Hotline at For people living in Supportive Living Facilities (SLF) report to the Illinois Department of Healthcare and Family Services SLF Complaint Hotline at Facebook.com/NextLevelIL 45