2018 Member Handbook. A Guide to Your Health Plan

Transcription

1 2018 Member Handbk A Guide t Yur Health Plan

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3 CverKids Member Services call abut yur healthcare FREE Phne Numbers t call fr help TTY/TDD Line: Nurse Help Line DentaQuest call abut dental (teeth) care fr children under age 19 BlueCard call when yu are in an area where BCBST Netwrk Prviders are nt available and yu need emergency healthcare services Fraud Htline call t reprt CverKids fraud r abuse BLUE (2583) Ppulatin Health CverKids Eligibility Services call fr questins abut eligibility

4 Dctrs Names Phne Numbers

5 CverKids SM and yur health plan, BlueCare Tennessee Member Handbk 2018 Necesita un manual de CverKids en españl? Para cnseguir un manual en españl, llame al Yur Right t Privacy There are laws that prtect yur privacy. They say we can t tell thers certain facts abut yu. Read mre abut yur privacy rights in Part 6 f this handbk. Imprtant! Even if yu dn t use yur CverKids, the state still pays fr yu t have it. If yu dn t need yur CverKids anymre, please call CverKids fr free at

6 D yu need free help with this dcument? If yu speak a language ther than English, help in yur language is available fr free. This page tells yu hw t get help in a language ther than English. It als tells yu abut ther help that's available. Spanish: Espanl ATENCION: si tiene a su dispsici6n servicis gratuits de asistencia (TTY: 711: ). Arabic:.( : 711 Chinese:...-JI (TTY 711: ) phf Vietnamese: n6i c6 d!ch ch s (TTY: 711: ). Krean: (TTY: 711: ) : vus des services d'aide linguistique vus snt prpses gratuitement : ). Amhraic: : ). Gujarati: (TTY: 711: Latian: (TTY: German: Deutsch serbisy ng Hindi: Wenn Deutsch sprechen, stehen Rufnummer: (TTY: 711: ). zur sa wika nang Kung ka ng maaari kang gumamit ng mga bayad. Tumawag sa (TTY: 711: ). 711: ) Serb-Cratian: Srpsk-hrvatski Ak gvrite srpsk-hrvatski, jezicke pmci dstupne su vam Nazvite (TTYza sbe sa gvrm iii 711: ). Russian: Persian: nepeeaa. Ecm1 Ha pycckm TO eam 711: ). 711: ) (TTY: 711: ) We bey federal and state civil rights laws. We d nt treat peple in a different way because f their race, clr, birth place, language, age, disability, religin, r sex. D yu think we did nt help yu r yu were treated differently because f yur race, clr, birth place, language, age, disability, religin, r sex? Yu can file a cmplaint by mail, by , r by phne. Here are three places where yu can file a cmplaint: BlueCrss BlueShield f Tennessee Health Care Finance U.S. Department f The Privacy Office and Administratin Health & Human Services Office f Civil Rights Cmpliance Office fr Civil Rights 1 Camern Hill Circle Chattanga, Tennessee Great Circle Rad, Flr 4W 200 Independence Ave SW, Phne: Nashville, Tennessee Rm 509F, HHH Bldg HCFA.Fairtreatment@tn.gv Washingtn, DC Phne: (TRS 711) Phne: Yu can get a cmplaint frm nline (TDD): at: rticle/civil- Yu can get a cmplaint frm n line at: rights-cmpliance Or yu can file a cmplaint nline at: hhs.gv/cr/prtal/lbby.jsf

7 D yu need help talking with us r reading what we send yu? D yu have a disability and need help getting care r taking part in ne f ur prgrams r services? Or d yu have mre questins abut yur health care? Call us fr free at We can cnnect yu with the free help r service yu need. (Fr TTY call: ) BlueCare.' Tennessee BlueCare Tennessee 1 Camern Hill Circle, Suite 73 I Chattanga, TN bl uecare.bcbst.cm BlueCare Tennessee is an Independent Licensee f the BlueCrss BlueShield Assciatin

8 Table f Cntents Welcme t CverKids and yur health plan, BlueCare Tennessee... 1 CverKids... 1 Yur CverKids Health Plan... 1 Part 1: Using yur CverKids Health Plan... 3 CverKids Prviders In Netwrk... 4 Dctr Visits... 5 Behaviral Health Care (Mental Health, Alchl r Drug Abuse Services)... 6 Specialist prviders... 8 Hspital Care... 8 Emergencies Physical Health... 8 Emergencies Mental Health... 9 Part 2: Services that CverKids pays fr Benefit Packages Care with limits Other CverKids Services Yur dctr must fill ut a paper called Certificatin f Medical Necessity fr Abrtin Preventive Care care that keeps yu well Pregnancy After yur baby is brn Preventive Care fr Children: Healthcare fr yur child and teen Dental care fr children (fr teeth) Visin care fr children (fr eyes) Nn-Cvered Services Part 3: Hw the CverKids Prgram wrks fr yu What yu pay fr yur healthcare Cpays Part 4: Help fr prblems with yur CverKids Kinds f prblems and what yu can d Need a new CverKids card? Need t find a dctr r change yur dctr? Need t make a cmplaint abut yur care? Need help getting yur prescriptin medicines?... 29

9 Need help getting yur healthcare services? Are yu getting billed? Did yu have t pay? Ways yur CverKids culd end Part 5: CverKids Appeals Member Grievances Hw t appeal healthcare prblems Administrative Appeals - Getting r keeping CverKids and ther CverKids prblems 35 Part 6: Yur rights and respnsibilities Yur rights and respnsibilities as a CverKids member Yur Right t Appeal Healthcare Prblems in CverKids Yur right t Privacy Yur respnsibility t reprt fraud and abuse Part 7: Healthcare Papers Yu May Need Discriminatin Cmplaint Frm Advance Directives Part 8: Mre infrmatin CverKids Immunizatin Schedule Legal Definitins...56

10 CverKids Welcme t CverKids and yur health plan, BlueCare Tennessee This is yur CverKids member handbk. This handbk tells yu hw t use CverKids t get care. CverKids is managed by the State f Tennessee s Divisin f TennCare. CverKids prvides health insurance t sme children under age 19 and pregnant wmen. Having ther insurance, even Medicare, is nt allwed fr anyne wh has CverKids. Yu may call CverKids Eligibility Services at t request yur CverKids cverage be remved frm CverKids if yu btain ther health insurance. Why is it imprtant t knw abut yur CverKids? Because it helps yu knw abut the kind f healthcare benefits CverKids cvers. It als helps yu knw if yu must pay cpays fr CverKids benefits. We ll tell yu mre abut yur CverKids benefits and cpays later in this handbk. CverKids sent yu a letter t tell yu that yu have CverKids and what day yur CverKids started. If yu have questins r prblems abut yur CverKids dates, yu can call CverKids Eligibility Services fr free at Imprtant! State law says yu must tell CverKids abut any changes that may affect yur cverage. Yu must reprt these changes within 10 days f the change. And, yu must give CverKids the prf they need t make the change. Call CverKids Eligibility Services right away if: Yu mve.** Yu change jbs. The number f peple in yur family changes. Yur incme changes. Yu get grup health insurance. **Anytime yu mve, yu must tell CverKids abut yur new address. Why? CverKids sends yu imprtant infrmatin abut yur CverKids cverage and benefits in the mail. If they dn t have yur current address, yu culd lse yur CverKids. Call CverKids Eligibility Services at t tell them abut yur new address. Yur CverKids Health Plan BlueCare Tennessee is yur CverKids health plan that helps yu get physical r behaviral healthcare (mental health, alchl and drug abuse services). Fr questins abut getting physical r behaviral healthcare, call us at It s a free call. D yu have questins abut yur health? D yu need t knw what kind f dctr yu shuld see? Call ur Nurse Help Line at It s a free call. 1

11 Pharmacy Health Plan Yu have prescriptin cverage thrugh CverKids. CverKids pharmacy plan is called Express Scripts. Yu will nt receive a separate pharmacy card. If yu need a prescriptin filled, yu can g t the pharmacy and use yur CverKids member card. Befre yu g, make sure the pharmacy yu use accepts CverKids. T find ut, g t the Find a Dctr Tl at bluecare.bcbst.cm. Then click n Find a Dctr. This will take yu t Find a Pharmacy. Click Find a Pharmacy. Enter the infrmatin requested t find pharmacies near yu that accept CverKids. Or, yu can call us at D yu need mre help? D yu have questins abut yur card? Call CverKids Member Services at Learn mre abut yur prescriptin cverage in Parts 1 and 2 f this handbk. Dental Health Plan fr children CverKids nly cvers dental care fr children under the age f 19. CverKids dental health plan is DentaQuest. They can help yu if yu have questins abut dental care. T find a DentaQuest dentist, g t Then click Find a Dentist. Or yu can call DentaQuest at Nte! CverKids des nt cver any rutine dental care, including ral surgery, if yu are 19 and lder. 2

12 Part 1: Using yur CverKids Health Plan Every CverKids member has a Member card. This is what yur card lks like: Here are sme f the things that yur card has n it: Member Name is the name f the persn wh can use this card. ID Number is the number that tells us wh yu are. Grup Number is the number that tells us yu are a CverKids member. Prvider Netwrk is the chice f dctrs, hspitals and ther healthcare prviders that take yur CverKids card. Cpays are what yu pay fr each healthcare service. Nt everyne has cpays. Benefit Indicatr is the kind f CverKids benefit package yu have. Yur benefit package is the kind f services r care CverKids cvers fr yu. Carry yur card with yu all f the time. Yu ll need t shw it when yu g t see yur dctr and when yu g t the hspital. This card is nly fr yu. Dn t let anyne else use yur card. If yur card is lst r stlen, r if it has wrng infrmatin n it, call us at fr a new card. It s a free call. If yu have questins abut CverKids, yu can: Call us at r write t us at: CverKids Member Services BlueCare Tennessee 1 Camern Hill Circle Chattanga, TN

13 CverKids Prviders In Netwrk The dctrs and ther peple and places wh wrk with CverKids are called the Prvider Netwrk. All f the CverKids prviders are listed in ur Prvider Directry. Yu can find the Prvider Directry nline at bluecare.bcbst.cm. Or call us at t get a list. Prviders may have signed up r drpped ut after the list was printed. But, the nline Prvider Directry is updated every week. Yu can als call us at t find ut if a prvider is in ur netwrk. Smetimes yur dctr can t prvide the care r treatment yu need because f ethical (mral) r religius reasns. Call us at We can help yu find a dctr wh can prvide the care r treatment yu need. T find dctrs wh speak ther languages, yu can check the CverKids Prvider Directry nline at bluecare.bcbst.cm. Yu must g t dctrs wh take CverKids s CverKids will pay fr yur healthcare. Out f Netwrk A dctr wh is nt in the Prvider Netwrk and desn t take CverKids is called an Out-f- Netwrk prvider. Mst f the time if yu g t a dctr wh is Out-f-Netwrk CverKids will nt pay. But, smetimes, like in emergencies r t see specialists, CverKids will pay fr a dctr wh is Out-f-Netwrk. Unless it s an emergency, yu must have an OK first. The sectins Specialists and Emergencies tell yu mre abut when yu can g t smene wh is Out-f-Netwrk. If yu were already getting care r treatment when yur CverKids started, yu may be able t keep getting the care withut an OK r referral. Call us at t find ut hw. Hw t get free language help at yur healthcare visits If English is nt yur first language, yu can ask fr an interpreter when yu g t get yur care. This is a free service fr yu. Befre yur appintment, call us r yur prvider s yu can get help with language services. Yu can als check in ur Prvider Directry t find dctrs wh speak ther languages nline at bluecare.bcbst.cm. 4

14 Dctr Visits Yur Primary Care Prvider the main persn yu g t fr yur care Yu can have ne main persn fr yur healthcare. He r she can be a dctr, a nurse practitiner, r a physician s assistant. This persn is called yur Primary Care Prvider (PCP). Mst PCPs have regular ffice hurs. But, yu can call yur PCP anytime. If yu call after regular ffice hurs, they will tell yu hw t reach the dctr. If yu can t talk t smene after hurs, call us at Yu shuld select a PCP if yu d nt have ne. Call t get an appintment with yur PCP as sn as yu can. This is even mre imprtant if yu ve been getting care r treatment frm a different dctr. We want t make sure that yu keep getting the care yu need. But even if yu feel OK, yu shuld call t get a check-up with yur PCP. Befre yu g t yur first appintment with yur PCP: 1. Ask yur past dctr t send yur medical recrds t yur PCP. This will nt cst yu anything. These recrds are yurs. They will help yur PCP learn abut yur health. 2. Call yur PCP t schedule yur appintment. 3. Have yur CverKids card ready when yu call. 4. Say yu are a CverKids member and give them yur ID number. 5. Write dwn yur appintment date and time. If yu re a new patient, the prvider may ask yu t cme early. Write dwn the time they ask yu t be there. 6. Make a list f questins yu want t ask yur PCP. List any health prblems yu have. On the day f yur appintment: 1. Take all f yur medicines and list f questins with yu s yur PCP will knw hw t help yu. 2. Be n time fr yur visit. If yu cannt keep yur appintment, call yur PCP t get a new time. 3. Take yur CverKids ID card with yu. Yur PCP may make a cpy f it. If yu have any ther insurance, take that ID card with yu, t. 4. Pay yur cpay if yu have ne. Yu can find ut mre abut cpays in Part 3 f this handbk. Yur PCP will give yu mst f yur healthcare. Yur PCP can find and treat health prblems early. He r she will have yur medical recrds. Yur PCP can see yur whle healthcare picture. Yur PCP keeps track f all f the care yu get. 5

15 Changing yur PCP There are many reasns why yu may need t change yur PCP. Yu may want t see a PCP whse ffice is clser t yu. Or yur PCP may stp wrking with us. If yu d nt find a new PCP, we will help find ne fr yu s that yu can keep getting yur care. T change yur PCP: 1. Find a new PCP in the CverKids netwrk. T find a new PCP, lk in ur Prvider Directry. Or yu can g nline at bluecare.bcbst.cm, r call Then call the new PCP t make sure that he r she is in the CverKids prvider netwrk. Be sure t ask if he r she is taking new patients. Need help finding a new PCP? Call us at We ll wrk with yu t find a new PCP wh is taking new patients. Is yur teenager ready fr an adult health care prvider? We can help yu find a new prvider and ease sme cncerns abut this change. Yu can call Ppulatin Health at fr assistance. Behaviral Health Care (Mental Health, Alchl r Drug Abuse Services) Yu d nt need t see yur PCP befre getting Behaviral Health services. But, yu will need t get yur care frm smene wh is in ur netwrk. If yu re getting care nw, ask yur prvider if they take CverKids. A Cmmunity Mental Health Agency (CMHA) is ne place yu can g fr mental, alchl r drug abuse services. Mst CMHAs take CverKids. Befre yur first visit: 1. Ask yur past dctr t send yur recrds t yur new prvider. They will help yur prvider learn abut yur needs. 2. Have yur CverKids card ready when yu call t schedule yur appintment with yur new prvider. 3. Say yu are a CverKids member and give yur ID number. 4. Write dwn yur appintment date and time. If yu are a new patient, the prvider may ask yu t cme early. Write dwn the time they ask yu t be there. 5. Make a list f questins yu want t ask yur prvider. List any prblems yu have. On the day f yur appintment: 1. Take all f yur medicines and list f questins with yu s yur prvider will knw hw t help yu. 2. Be n time fr yur visit. If yu cannt keep yur appintment, call yur prvider t get a new time. 3. Take yur CverKids ID card with yu. Yur prvider may make a cpy f it. 4. Pay yur cpay if yu have ne. Yu can find ut mre abut cpays in Part 3 f this handbk. If yu need help finding mental health, alchl and drug abuse services, call us at 6

16 Or, if yu have questins abut mental health, alchl and drug abuse services, call us at It s a free call. 7

17 Specialist prviders A specialist is a dctr wh gives care fr a certain illness r part f the bdy. One kind f specialist is a cardilgist, wh is a heart dctr. Anther kind f specialist is an nclgist, wh treats cancer. There are many kinds f specialists. Yur PCP may send yu t a specialist fr care. If the specialist is nt in ur Prvider Netwrk, yur prvider must get an OK frm us first. If yu have cpays, yur cpay is the same even if the specialist is Out-f-Netwrk. Yu d nt have t see yur PCP first t g t a wmen s health dctr fr well-wman checkups. A wmen s health dctr is called an OB/GYN. The wmen s health specialist must still be in ur netwrk. Mre infrmatin abut wmen s healthcare is in Part 2 f this handbk. And remember, yu d nt have t see yur PCP first t see any specialist r a behaviral health prvider fr mental health, alchl r substance abuse services. Hspital Care If yu need hspital care, yur netwrk prvider r behaviral health prvider will set it up fr yu. Yu must have yur netwrk prvider s OK t get hspital care. Unless it is an emergency, we will nly pay fr hspital care if yur netwrk prvider sends yu. Emergencies Physical Health Always carry yur CverKids card with yu. In case f an emergency, dctrs will knw yu have CverKids. Yu can get emergency healthcare any time yu need it. Emergencies are times when there culd be serius danger r damage t yur health if yu dn t get medical care right away. See Part 8 f this handbk fr a full definitin f an emergency. Emergencies might be things like: Shrtness f breath, nt able t talk A bad cut, brken bne, r a burn Bleeding that cannt be stpped Strng chest pain that des nt g away Strng stmach pain that desn t stp Seizures that cause smene t pass ut Nt able t mve yur legs r arms A persn wh will nt wake up Drug verdse These are usually nt emergencies: Sre thrat Cld r flu Lwer back pain Ear ache Stmach ache Small, nt deep, cuts Bruise Arthritis Headache, unless it is very bad and like yu ve never had befre If yu think yu have an emergency, g t the nearest hspital Emergency Rm (ER). In an emergency, yu can g t a hspital that is nt in the Prvider Netwrk. If yu can t get t the ER, call 911 r yur lcal ambulance service. 8

18 If yu are nt sure if it s an emergency, call yur PCP. Yu can call yur PCP anytime. Yur PCP can help yu get emergency care if yu need it. If yu need emergency care, yu dn t have t get an OK frm anyne befre yu get emergency care. After the ER treats yu fr the emergency, yu will als get the care the dctr says yu need t keep stable. This is called pst-stabilizatin care. After yu get emergency care, tell yur PCP r specialist. Yur PCP r specialist needs t knw abut the emergency t help yu with the fllw-up care later. Try t call yur PCP r specialist within 24 hurs f getting emergency care. Emergencies Mental Health Yu can get help fr a behaviral health emergency anytime even if yu are away frm hme. And yu dn t have t get an OK frm anyne befre yu get emergency care. If yu have a behaviral health, alchl r drug abuse emergency, g t the nearest mental health crisis walk in center r ER right away. What if yu dn t knw where yur clsest mental health crisis walk in center is? Call Mental Health Crisis Services at: CRISIS-1 (r ) right away. These calls are free. Or, yu can call yur prvider. Yur prvider can help yu get emergency care if yu need it. CverKids pays fr mental health emergencies even if the dctr r hspital isn t in the Prvider Netwrk. Emergencies are times when there culd be serius danger r damage t yur health r smene else s if yu dn t get help right away. See Part 8 f this handbk fr a full definitin f an emergency. Emergencies might be things like: These are usually NOT emergencies: Planning t hurt yurself Needing a prescriptin refill Thinking abut hurting anther persn If yu have this kind f emergency: G t the nearest mental health crisis walk in center r ER right away r Call 911 r Call Mental Health Crisis Services fr Adults at 855-CRISIS-1 (r ). These calls are free. Children under age 18 If yu are under 18 years ld r yur child is under age 18 and has a behaviral health (mental health, alchl r drug abuse) emergency: G t the nearest ER r Call 911 r Call Mental Health Crisis Services fr Children and Yuth at the fllwing numbers: Memphis Regin at

19 Rural West Tennessee at Rural Middle Tennessee at Nashville Regin at Mental Health C-p (Davidsn Cunty) at Knxville Regin Helen Rss McNabb (Knx, Blunt, Sevier, Ludn and Mnre Cunties) at Sutheast Tennessee at Frntier Health (Hancck, Greene, Hawkins, Washingtn, Unici, Carter, and Jhnsn Cunties) at Yuth Villages, Frntier Health, Helen Rss McNabb, and Mental Health C-Operative ffer statewide crisis services fr children under age 18. If yu g t the ER, smene frm ne f these agencies in yur area may cme help evaluate yur child s need fr care. If yu have prblems reaching smene at the number listed fr yur area, call We will help yu. Yu can als call 911. These calls are free. Always carry yur CverKids card with yu. In case f an emergency, dctrs will knw that yu have CverKids. After the ER treats yu fr the emergency, yu will als get the care that the dctr says yu need t keep stable. This is called pst-stabilizatin care. After yu get emergency care, tell yur prvider. Yur prvider needs t knw abut the emergency t help yu with fllw-up care later. Try t call yur prvider within 24 hurs f getting emergency care. Emergency Care away frm hme Emergency care away frm hme wrks just like yu were at hme. In an emergency, yu can g t a hspital that is Out-f-Netwrk. G t the nearest ER, r call 911. If yu have a behaviral health emergency, yu can call Mental Health Crisis Services fr free at: CRISIS-1 (r ). Try t call yur prvider and CverKids Member Services within 24 hurs f getting the emergency care away frm hme. Shw yur CverKids card when yu get the emergency care. Ask the ER t send the bill t CverKids. If the ER says n, ask if they will send the bill t yu at hme. Or if yu have t pay fr the care, get a receipt. When yu get hme, call us at and tell us yu had t pay fr yur healthcare r that yu have a bill fr it. We will wrk with yu and the prvider t put in a claim fr yur care. 10

20 Part 2: Services that CverKids pays fr Benefit Packages Yu can find a list f CverKids services n the next pages. Sme f the services have limits. This means that CverKids will pay fr nly a certain amunt f that care. The services that are listed as medically necessary mean that yu can have thse services if yur dctr, health plan, and CverKids all agree that yu need them. If yu have questins abut what yur physical health r behaviral health services are, call us at Benefits fr CverKids All CverKids cvered services must be medically necessary, as defined in the CverKids rules. The definitin f medically necessary is in Part 8 f this handbk. Fr mre infrmatin n Services Cvered with limits, please see Care with limits starting n page 13. Behaviral health crisis services (mental health, alchl and drug abuse services) Chirpractic services Cmmunity health clinic services Dental services (nn-rutine) Durable medical equipment (DME) Emergency air and grund ambulance Hme health services Hspice care Immunizatins/Vaccinatins Inpatient and utpatient substance abuse benefits Inpatient hspital services Lab and X-ray services Medical supplies Mental health case management Nn-emergency transprtatin Occupatinal therapy services Organ transplant and dnr prcurement Outpatient hspital services Outpatient behaviral health services (mental health, alchl and drug abuse services) Pharmacy services Physical exams and checkups, diagnstic and treatment services Physical therapy services Cvered Cvered Nt cvered fr pregnant wmen age 19 and lder. Cvered Cvered Cvered with limits Cvered Cvered with limits Cvered Cvered Cvered Cvered Cvered Cvered Cvered Nt Cvered Cvered with limits Cvered Cvered Cvered Cvered Cvered Cvered with limits 11

21 Physician services Private duty nursing Psychiatric inpatient facility services Psychiatric rehabilitatin services Psychiatric residential treatment services Recnstructive breast surgery Renal dialysis services Skilled Nursing Facility Speech therapy services Temprmandibular Jint (TMJ) Nn-surgical treatment Visin services Cvered Nt Cvered Cvered Cvered Cvered Cvered Cvered Cvered with limits Cvered with limits Cvered Cvered with limits Nt cvered fr pregnant wmen age 19 and lder 12

22 Care with limits Benefits are cvered as medically necessary. But sme CverKids benefits have limits. These kinds f care have limits: 1. Durable Medical Equipment 2. Hme Health Services 3. Occupatinal Therapy 4. Physical Therapy 5. Skilled Nursing Facility 6. Speech Therapy 7. Visin Services 1. Durable Medical Equipment Durable Medical Equipment (DME) is any equipment that prvides therapeutic benefits because f certain medical cnditins and/r illness. Sme DME services need prir authrizatin (an OK). There is a limit t the amunt CverKids will pay fr DME. It s called the Maximum Allwable Charge. The limit depends n the kind f Durable Medical Equipment yu need. What if yu rent the same kind f equipment frm multiple DME prviders, and the ttal rental charges are mre than what it wuld cst t buy the equipment? Yu will be respnsible fr the amunt that ges ver what CverKids will pay (the Maximum Allwable Charge). Hearing aids are limited t 1 hearing aid per ear each calendar year up t the age 5; then 1 hearing aid per ear every 2 years thereafter. 2. Hme Health Services There are 2 kinds f Hme Healthcare: Hme Health Nursing and Hme Health Aide Care. Services can be part-time r ff and n during a certain perid f time. Only Hme Health Nursing Services have limits. These services are limited t 125 visits per calendar year fr care given r supervised by a registered nurse. 3. Occupatinal Therapy Occupatinal Therapy includes medically necessary and apprpriate treatment that helps peple wh have physical r behaviral health prblems learn t d the activities f daily life as a result f an illness r injury. Services are limited t 52 visits per calendar year. 4. Physical Therapy Physical Therapy includes medically necessary and apprpriate treatment f a disease r an injury f the muscles r jints. Services are limited t 52 visits per calendar year. 5. Skilled Nursing Facility Skilled Nursing Facility includes medically necessary and apprpriate inpatient care prvided t members requiring medical, rehabilitative r nursing care in a restrative setting. Services are limited t 100 days per calendar year fllwing apprved hspitalizatin. 13

23 Speech Therapy Speech therapy by a licensed speech therapist is cvered fr restratin f speech after a lss r impairment; and t initiate speech due t develpmental delays (as lng as there is cntinued prgress). The lss r impairment must nt be caused by mental, psychneurtic r persnality disrder. Services are limited t 52 visits per calendar year. 6. Visin Services Fr children under age 19, visin services are limited t ne visin exam (including refractive exam and glaucma testing) per calendar year; ne set f lenses (including bifcal, tri-fcal, etc.) per calendar year; and ne set f eyeglass frames every 2 calendar years. Fr pregnant wmen age 19 and lder, visin services are limited t medical evaluatin and management f abnrmal cnditins and disrders f the eye. The first pair f cataract glasses r cntact lens/lenses after cataract surgery are cvered. Have yu used all yur benefits? We can ffer suggestins and ptins fr cntinuing care. Yu can call Ppulatin Health at fr assistance. Other CverKids Services Other cvered services are Ppulatin Health, Hspice Care, Sterilizatin, Abrtin, and Hysterectmy. Mre abut these services can be fund belw. Ppulatin Health If yu are well, Ppulatin Health services prvide yu with infrmatin n hw t stay healthy. If yu have an nging illness r an unhealthy behavir, Ppulatin Health services can help yu d things like: Understand yur illness and hw t feel better Quit smking Manage yur weight Have a healthy pregnancy and healthy baby. Develp a plan f care based n yur child s dctr s advice fr bth medical and behaviral health needs Make chices that help yur child feel better Keep yur child ut f the hspital Help with pharmacy benefit navigatin Help yur child get the right care at the right place at the right time Crdinate care and partner with yur child s health care prvider Help yu understand yur child s health care prviders Help yu explain imprtant infrmatin abut yur child t his r her prviders Help yu t lcate and be assigned a primary care physician/pediatrician fr yur child Ppulatin Health services are prvided whether yu are well, have an nging health prblem r have a terrible health episde. Ppulatin Health services are available t yu depending n yur health risks and need fr the service. 14

24 Ppulatin Health can prvide yu with a care manager. A care manager can help yu get all the care yu need. Yu may be able t have a care manager if yu: G t the ER a lt, r if yu have t g int the hspital a lt, r Need health care befre r after yu have a transplant, r Have a lt f different dctrs fr different health prblems r Have an nging illness that yu dn t knw hw t deal with. Need help with finding resurces and develping a plan f care t help yur child with disabilities r behaviral health needs including Severe and Persistent Mental Illness (SPMI) Need help with resurces t assist with ecnmic and scial cnditins. T see if yu can have a care manager, r if yu want t participate in the Ppulatin Health services, yu (r smene n yur behalf) can call Hspice Care is a kind f medical care fr peple wh are terminally ill. Yu must use a hspice prvider in ur netwrk. Fr help with hspice care, call us at Sterilizatin is the medical treatment r surgery that makes yu nt able t have children. 15

25 T have this treatment, yu must: Be an adult age 21 r lder. Be mentally stable and able t make decisins abut yur health. Nt be in a mental institutin r in prisn. Fill ut a paper that gives yur OK. This is called a Sterilizatin Cnsent Frm. Yu can call us at t get this paper. Yu must fill the paper ut at least 30 days befre yu have the treatment. But in an emergency like premature delivery r abdminal surgery, yu can fill the paper ut at least 72 hurs befre yu have the treatment. Effective June 1, 2016, the sterilizatin service is available t pregnant wmen age 21 and lder. Abrtin is the medical treatment that ends a pregnancy. CverKids pays fr this treatment nly if: Yu are pregnant because f rape r incest, r Yu have a life-endangering physical prblem, injury, r illness that yu culd die frm withut an abrtin. Yur dctr must fill ut a paper called Certificatin f Medical Necessity fr Abrtin. Hysterectmy is medical surgery that remves reprductive rgans. A hysterectmy can be cvered when yu must have it t fix ther medical prblems. After a hysterectmy, yu will nt be able t have children. But, CverKids will nt pay fr this treatment if yu have it just s yu wn t have children. CverKids pays fr this treatment nly if it is medically necessary. Yu have t be tld in wrds and in writing that having a hysterectmy means yu are nt able t have children. Yu have t sign a paper called Statement f Receipt f Infrmatin cncerning Hysterectmy. Effective June 1, 2016, the hysterectmy service is available if medically necessary. Preventive Care care that keeps yu well CverKids cvers preventive care fr children and wmen expecting a baby. Preventive care helps t keep yu well and catches health prblems early s they can be treated. Nte! Yu will nt have cpays fr preventive care. Sme preventive care services are: Checkups fr children Care fr wmen expecting a baby Well baby care Shts and tests Birth cntrl infrmatin 16

26 Pregnancy If yu are pregnant, seeing a dctr can help yu t have a healthier baby. Care befre yur baby is brn is called prenatal care. There are n cpays fr prenatal care. Yu can get this kind f care frm yur PCP, r frm a specialist called an Obstetrician/Gyneclgist. This kind f specialist is smetimes called an OB/GYN dctr. Yu d nt have t see yur PCP first t g t an OB/GYN dctr. But, the OB/GYN dctr must still be in ur Prvider Directry s that CverKids will pay fr the services. If yu are already mre than three mnths pregnant and yu are already seeing an OB/GYN dctr when yu get yur CverKids, yu can still see that dctr t get yur care. But, he r she has t say OK t the amunt that CverKids pays. Call us at t find ut if yu can still see this dctr. We may ask yu t change t an OB/GYN dctr wh is in ur Prvider Directry if it is safe t change. G t all f yur OB/GYN visits, even if yu feel fine. Yur dctr will tell yu hw ften t have checkups while yu are pregnant. After yur first visit, yu may see yur dctr every 4 weeks. Then, after 7 mnths, yu may see yur dctr every 2 r 3 weeks. When it gets clse t when yur baby is due, yu may see yur dctr every week. D what yur dctr says t take gd care f yu and yur baby. Remember t take the vitamins that yur dctr tells yu t. Dn t smke r drink alchl while yu are pregnant. After yur baby is brn, yu shuld have fllw-up care fr yu and yur baby. Care after yur baby is brn is called pstnatal care. Pstnatal care includes circumcisins dne by a dctr and special screenings fr newbrns. Bth yu and yur baby need fllw-up care. Yu shuld see yur dctr 4 t 6 weeks after yu have yur baby. Yur dctr will check t make sure yu are OK. Imprtant! Tell CverKids abut yur baby as sn as pssible s yu can make sure he r she gets cvered. Depending n yur incme, yur baby may qualify fr TennCare instead f CverKids. Here s hw t make sure yur baby gets n CverKids r TennCare: After yur baby is brn, the hspital will give yu papers t get a Scial Security number fr yur baby. Fill ut thse papers and mail them t the Scial Security ffice. Tell CverKids abut yur baby as sn as yu can. Call them at Tell them that yu have filled ut papers fr the baby s Scial Security number. It is imprtant t d these things as sn as yur baby is brn. When yu get yur baby s Scial Security card in the mail, be sure t tell us. If yur baby has TennCare, call If yur baby has CverKids call Give them yur baby s Scial Security number. 17

27 Preventive Care fr Children: Healthcare fr yur child and teen Check In, Check Up, and Check Back! The CverKids prgram strives t keep children healthy. Yur child and teen need regular health checkups, even if they seem healthy. These visits help yur dctr find and treat prblems early. In CverKids, checkups fr children are free. CverKids als pays fr all medically necessary care and medicine t treat prblems fund at the checkup. This includes medical, dental, speech, hearing, visin, and behaviral (mental health, alchl r drug abuse prblems). If yur child hasn t had a checkup lately, call yur child s PCP tday fr an appintment. Ask fr a regular health checkup. Yu can g t yur child s PCP r the Health Department t get checkups. And, if smene else, like yur child s teacher, is wrried abut yur child s health, yu can get a checkup fr yur child. Checkups may include: Health histry Cmplete physical exam Labratry tests (as needed) Immunizatins (shts) Visin/hearing screening Develpmental/behaviral screening (as needed) Advice n hw t keep yur child healthy If yur child s PCP (pediatrician) finds anything wrng, CverKids als gives yur child the medical, dental, speech, hearing, visin, and behaviral (mental health, alchl r drug abuse) treatment that he r she needs. Children shuld g t the dctr fr checkups even if they are nt sick. They shuld have checkups when they are at birth 3-5 days ld 1 mnth 2 mnths 4 mnths 6 mnths 9 mnths 12 mnths 15 mnths 18 mnths 24 mnths 30 mnths 3 years And then every year until age 19 18

28 The vaccinatin shts that children need t get, t keep frm getting sick, are fr: ü Diphtheria ü Tetanus ü Pertussis ü Pli ü Measles ü Mumps ü Rubella (MMR) ü HIB ü Flu (influenza) ü Hepatitis A and B ü Chicken px (varicella) ü Pneumcccal ü Rtavirus ü Human papillmavirus (HPV) ü Meningitis Lk at the schedule f shts listed in Part 8 f this handbk. It is called Children and Teen Immunizatin Schedule. It will help yu knw when yur child shuld get his r her shts. Or, yu can ask yur child s PCP when yur child shuld get his r her sht. 19

29 Dental care fr children (fr teeth) If yu are a child under the age f 19, yu als have a dental plan fr yur teeth called DentaQuest. Their phne number is Yu can call DentaQuest t find a dentist. Or, if yu have questins abut caring fr yur child s teeth, yu can call them. It s a free call. Children s teeth need special care. Children under age 19 shuld have a checkup and cleaning every six mnths. Children need t start seeing a dentist by age 3 r even earlier fr sme children. CverKids will pay fr ther dental care if it is medically necessary. Braces are cvered nly if they are medically necessary. Yu d nt need t see yur PCP befre yu g t a dentist. But, yu will need t g t a DentaQuest dentist. This dental care is nly fr children under age 19. CverKids des nt pay fr any rutine dental care fr pregnant wmen 19 and lder. Visin care fr children (fr eyes) Children s eyes als need special care. Children under 19 years ld can have their eyes checked and get eyeglass lenses and frames as medically necessary. Yur CverKids eye dctr will shw yu which frames yu can chse frm. CverKids will pay fr ther visin care if it is medically necessary. Cntacts are cvered instead f eyeglass lenses. Children d nt have t see their PCP befre seeing their CverKids eye dctr. But, the eye dctr must be in ur Prvider Directry. This visin care is nly fr children under age 19. CverKids des nt pay fr any rutine visin care fr pregnant wmen 19 and lder, Nn-Cvered Services Here is a list f sme services that are nt cvered fr anyne by CverKids. Or, yu can call us at fr a full list. Sme Nn-Cvered Services are: 1. Services that are nt medically necessary. But preventive care (care yu need t stay well) is cvered. 2. Services that are experimental r investigative. 3. Surgery fr yur appearance. But if yu had a mastectmy, recnstructive breast surgery is cvered. 4. Reversal f sterilizatin. 5. Artificial inseminatin, in-vitr fertilizatin r any ther treatment t create a pregnancy. 6. Treatment f imptence. 7. Autpsy r necrpsy. 20

30 8. Physical exams that a new jb says yu need. 9. Any medical r behaviral health (mental health, alchl r drug abuse) treatment if yu are in lcal, state, r federal jail r prisn. 10. Services that are cvered by wrkers cmpensatin insurance. 11. Services that yu gt befre yu had CverKids r after yur CverKids ends. 12. Persnal hygiene, luxury, r cnvenience items. 13. Custdial Care and Sitter Services. 14. Services mainly fr cnvalescent care r rest cures. 15. Ft care fr cmfrt r appearance, like flat feet, crns, calluses, tenails. 16. Transsexual surgery and any treatment cnnected t it. 17. Radial kerattmy r ther surgery t crrect a refractive errr f the eye. 18. Services given t yu by smene in yur family r any persn that lives in yur husehld. 19. Midwife services utside a licensed healthcare facility. 20. Charges in excess f maximum allwable charge. 21. Services r supplies fr rthgnathic surgery. 22. Treatment and therapies fr maintenance purpses. 23. Self-treatment r training. 24. Services r supplies fr methadne maintenance therapy and buprenrphine maintenance therapy. 25. Telephne r cnsultatins r charges t cmplete a claim frm r t prvide medical recrds. Netwrk prviders shuld nt bill yu fr missed appintments nr are the charges fr missed appintments cvered. 26. Any charges fr handling fees. 27. Drugs and supplies available ver-the-cunter that d nt require a prescriptin by Federal r State law. 28. Medicines fr: hair grwth treatment f imptence csmetic purpses treatment f infertility cntrlling yur appetite 29. Medicines that the FDA (Fd and Drug Administratin) says are: DESI this means that research says they are nt effective LTE this means that research says they are less than effective IRS this means that the medicines are identical, related, r similar t LTE medicines. Sme services are cvered fr children under age 19 but nt fr pregnant wmen ver age 19. These services that are nt cvered fr pregnant wmen ver 19 include: 1. Rutine Dental Services. 2. Chirpractic Services. 21

31 3. Eyeglasses, cntact lens r eye exams. But if yu had cataract surgery, yur first pair f cataract glasses r cntact lens/lenses is cvered. 22

32 Part 3: Hw the CverKids Prgram wrks fr yu What yu pay fr yur healthcare Cpays Yur Cpays Preventive care is care that helps yu stay well, like checkups, shts, pregnancy care, and childbirth. This kind f care is always free. Yu d nt have cpays fr preventive care. Mre infrmatin abut preventive care is in Part 2. Fr ther care like hspital stays r sick child visits, yu may have t pay part f the cst. Cpays are what yu pay fr each healthcare service yu get. Nt everyne n CverKids has cpays. Yur CverKids card will tell yu if yu have cpays and what they are. Cpays depend n: the kind f CverKids that yu have, and smetimes n yur family s mnthly incme befre taxes, and hw many peple in yur family live with yu. Yu shuld nly have t pay yur cpay fr yur care. Yu shuld nt be billed fr the rest f the cst f yur care. If yu are billed fr the rest f the cst, yu can appeal. See Part 4 f this handbk t find ut what t d if yu get a bill fr yur care. Nne f the dctrs r healthcare prviders in CverKids can refuse t give yu medically necessary services because yu dn t pay yur cpays. But, CverKids and yur prviders can take steps t cllect any cpays yu we. Yur health plan cards tell yu if yu have cpays. Yur CverKids card tells yu if yu have cpays fr dctrs, specialists, hspital and ER visits. There are three benefit levels fr cpays in CverKids Level 1, 2, r 3. Yur card will tell yu which level yu are in. The fllwing pages tell yu mre abut CverKids cpays and where t call if yu have questins. 23

33 CverKids Cpays D yu pay cpays fr a PCP, Specialist, ER visit, and hspital stay? Nt sure? Check yur CverKids card r call CverKids Member Services at BENEFIT LEVEL Office/Outpatient Services Primary Care Visit Office visit with family practice, general practice, internal medicine, OB/GYN, pediatrics, and walk in clinics Includes nurse practitiners, physician assistants and nurse midwives (licensed healthcare facility nly) wrking under the supervisin f a primary care prvider Specialist Visit and Outpatient Surgery Office visit with any specialty prvider Outpatient surgery including invasive diagnstic services (e.g. clnscpy) - Single cpay per date f service Behaviral Health (Mental Health and Substance Abuse) Services Office visit $15 Cpay $5 Cpay N Cpay $20 Cpay $5 Cpay N Cpay $15 Cpay $5 Cpay N Cpay Outpatient Mental health and substance abuse - Single cpay per date f service Chirpractrs Only cvered fr children under age 19 Rehabilitatin and Therapy Services Including Speech, Physical and Occupatinal Limited t 52 visits per therapy type per Calendar Year $15 Cpay $5 Cpay N Cpay $15 Cpay $5 Cpay N Cpay 24

34 BENEFIT LEVEL Pharmacy - Benefits managed by Express Scripts (ESI) 30 and 90-Day Supply/Specialty $5 generic Pharmacy Drugs $20 preferred brand $40 nnpreferred brand $1 generic $3 preferred brand $5 nnpreferred brand N Cpay Nn-Emergency Care Emergency Rm Visit deemed as NOT a True Medical Emergency Facility (Medical & Behaviral Health (Mental Health and Substance Abuse), including Urgent Care $50 Cpay $10 Cpay N Cpay MUST be an In Netwrk Prvider. If Out f Netwrk prvider, CverKids will NOT pay. Inpatient Stays Inpatient Facility (Medical and Behaviral Health [Mental Health and Substance Abuse]) Cpay waived if readmitted within 48 hurs f initial visit fr same episde f illness r injury $100 Cpay per admissin $5 Cpay per admissin N Cpay Rehabilitatin services Mental Health and Substance Abuse Treatment Visin Services- These Services are nly eligible fr children under age 19. When bth frames and lenses are rdered at the same time, ne cpay is charged Prescriptin Eyeglass Lenses Including bifcal r trifcal Limited t ne per Plan Year $15 Cpay $85 Max Benefit $5 Cpay $85 Max Benefit N Cpay Prescriptin Cntact Lenses in lieu f Eyeglass Lenses Limited t ne per Plan Year $15 Cpay $150 Max Benefit $5 Cpay $150 Max Benefit N Cpay Frames Limited t every 2 Plan Years $15 Cpay $100 Max Benefit $5 Cpay $100 Max Benefit N Cpay 25

35 The fllwing services d NOT require a cpay Preventive Care Office Visits Well-baby, well-child visits Annual physical exam Annual well-wman exam including, but nt limited t, family planning and pap tests Immunizatins Annual hearing and visin screening Screenings including clnscpy, clrectal, labs, nutritinal guidance, Sexually Transmitted Disease (STD), cancer and ther screenings Office/Outpatient Services X-Ray, Lab and Diagnstics Including reading, interpretatin f results, dialysis, radiatin, cbalt, and radiistpe therapy Including MRIs, cat scans and nuclear medicine Allergy Testing and Allergy Injectins Chemtherapy and radiatin therapy Emergency Care Emergency Rm Visit Deemed as an Emergency Medical and Behaviral Health (Mental Health and Substance Abuse) Services Received at an Inpatient Facility Physician Charges (Medical and Behaviral Health [Mental Health and Substance Abuse]) Skilled Nursing Facility Limited t 100 days per Calendar Year fllwing apprved hspitalizatin 26

36 The fllwing services d NOT require a cpay Maternity Services Maternity Related Facility and Prvider Maternity Visits (prenatal and pstpartum care) Hspital admissin fr delivery (N authrizatin required) Other Services Durable Medical Equipment (DME) Including prsthetics/rthtics Hearing aids are limited t 1 hearing aid per ear each Calendar Year up t the age 5; then 1 hearing aid per ear every 2 years thereafter Supplies (31 day supply) Ambulance - Land and Air Emergency t the nearest facility Frm the scene f an accident t the nearest facility Facility t facility when medically apprpriate Hme Health Hme Nursing Care limited t 125 visits per Calendar Year Hme Infusin Therapy Hspice Cpay waived fr all services if member is under hspice care Diabetic Self-Management Training and Educatin Visin Services - These Services are nly eligible fr Children under 19. Annual Visin Exam Including refractive exam and annual glaucma testing Must g t an In-Netwrk prvider 27

37 The CverKids prgram has a limit n the ttal amunt f cpays yu will pay each calendar year. This is called ut f pcket. The cpays yu pay will help yu reach yur ut f pcket limit each calendar year. Yur family s ut f pcket limit every calendar year is based n the incme yu reprt t CverKids. This limit is the mst yu will pay in cpays each calendar year. The mst yu ll pay in cpays each year is 5% f yur family incme. D yu need t knw yur yearly ut f pcket limit? Call CverKids Member Services at If yur incme changes r yur family size changes, yur cpays might change, t. Yu must reprt any changes in family size r incme t CverKids by calling CverKids at within 10 days. D yu have questins abut cpays? We can answer thse questins t. Call CverKids Member Services fr free at

38 Part 4: Help fr prblems with yur CverKids Kinds f prblems and what yu can d Yu can have different kinds f prblems with yur healthcare. Yu can fix sme prblems just by making a phne call. If yu have cmplaints r prblems abut yur healthcare, call us at fr help. Sme prblems may take mre wrk t fix. Here are sme examples f different kinds f prblems and ways that yu can fix them. Need a new CverKids card? If yur card is lst r stlen, r if the infrmatin n yur card is wrng, yu can get a new ne. Fr a new CverKids card, call Yu dn t have t wait fr yur new card t get yur care r medicine. Tell yur dctr r the drug stre that yu have CverKids. Need t find a dctr r change yur dctr? Yu can learn hw t find a new dctr in Part 1 f this handbk. Are yu changing because yu are unhappy with the dctr yu have? Please tell us. Call us at We want t make sure that yu get gd care. Need t make a cmplaint abut yur care? If yu are nt happy with the care that yu are getting, call us at Tell us that yu need t make a cmplaint. N ne can d anything bad t yu if yu make a cmplaint. We want t help yu get gd care. Need help getting yur prescriptin medicines? If yu need help getting yur prescriptin medicine, please call CverKids Member Services at D yu need a dctr t prescribe yur medicine fr yu? What if yu need t find a dctr r yur dctr wn t prescribe the medicine yu need? Call us at

39 D yu need an OK frm CverKids t get yur medicine? It s called a prir authrizatin r PA. If yur medicine needs an OK, call yur dctr. Ask yur dctr t: Call the CverKids Pharmacy Prgram t get CverKids OK fr this medicine. Or, change yur prescriptin t ne that desn t need an OK. What if yur dctr asks fr an OK and CverKids says n? Yu can ask yur dctr t prescribe a different medicine that desn t need an OK. Or, if yu think CverKids made a mistake, yu can appeal. Yu have 30 days after CverKids says n t appeal. Fr mre infrmatin n hw t appeal see Part 5 f this handbk. Need help getting yur healthcare services? Part 2 f this handbk tells yu abut the healthcare services that CverKids pays fr. Fr prblems abut physical and/r behaviral health (mental health, alchl r drug abuse) care, always call us at first. D yu need an OK befre CverKids will pay fr yur healthcare? It s called a prir authrizatin r PA. If yur care needs an OK, call yur dctr. Yur dctr has t ask us fr an OK. Did we say n when yur dctr asked fr an OK fr yur care? Call yur dctr and/r behaviral health (mental health, alchl r drug abuse) prvider and tell him r her that we said n. If yu r yur dctr thinks we made a mistake, yu can appeal. Yu have 30 days after yur health plan says n t appeal. Fr infrmatin n Appeals, g t Part 5 f this handbk. Are yu getting billed? Did yu have t pay? Did yu pay fr healthcare that yu think CverKids shuld pay fr? Or, are yu getting billed fr healthcare that yu think CverKids shuld pay fr? Smetimes yu might get a bill if the dctr desn t knw that yu have CverKids. Every time yu get care, yu must: Tell the dctr r ther place yu get care that yu have CverKids. Shw them yur CverKids card. If yu ve gtten healthcare that yu think CverKids shuld pay fr, call us at If yu re getting bills fr the care, we can help yu find ut why. If yu paid fr the care, we ll see if we can pay yu back. 30

40 Or yu can appeal. If yu re getting bills, yu have 30 days frm when yu get yur first bill t appeal. If yu paid fr the care, yu have 30 days after yu pay t appeal. Fr infrmatin n Appeals, g t Part 5 f this handbk. Ways yur CverKids culd end Yu can ask t end yur CverKids. Yu must call CverKids at Other ways that yur CverKids can end: If smething changes fr yu and yu dn t meet the rules fr CverKids anymre. If yu mve ut f the CverKids area. If yu reach age 19. If yu get ther health insurance. If yu let smene else use yur CverKids card. If yu dn t fllw the rules f CverKids. If yu dn t fill ut redeterminatin papers fr yur CverKids when yu are asked t. CverKids members must renew their CverKids each year. When it s time t see if yu still qualify fr CverKids, CverKids will send yu a letter and redeterminatin pages in the mail. Befre yur CverKids ends, yu will get a letter in the mail. The letter will tell yu why yur CverKids is ending. It als tells yu hw t file an appeal if yu think they ve made a mistake. 31

41 Part 5: CverKids Appeals If yu are having prblems with yur healthcare r CverKids, yu have the right t file an appeal. An appeal is ne way t fix mistakes in CverKids. Yur right t appeal is explained mre in Part 6 f this handbk. There are 2 different kinds f appeals: Administrative Appeals and Medical Appeals. Administrative Appeals are fr prblems like getting r keeping CverKids, disagreeing with the kind f CverKids yu have, r if yu think yur incme r cpay amunts are wrng. Administrative appeals g t CverKids Eligibility Services at Page 35 tells yu mre abut filing an administrative appeal. Medical Appeals/Member Grievances are fr prblems with yur healthcare. Fr prblems with healthcare, always call us at first. If yu still can t get the care yu need, yu can file a medical appeal. Member Grievances Hw t appeal healthcare prblems Yu have 180 days after yu find ut there s a prblem t appeal. Fr care r medicine yu still need, yu have 180 days after CverKids says we wn t pay fr the care. Fr healthcare bills yu think CverKids shuld pay, yu have 180 days after yu get yur first bill. Fr care yu paid fr, yu have 180 days after yu pay fr the care. Hw t file a Member Grievance There are 2 ways t file a Member Grievance: Appeal by phne by calling CverKids Member Services at If yu have a hearing r speech prblem, yu can call us n a TTY/TDD machine. CverKids TTY/TDD number is Call during business hurs. Business hurs are Mnday thrugh Friday frm 8:00 a.m. until 6:00 p.m. Eastern Time. 2. Or, appeal in writing. Yu can write yur appeal n plain paper. If yu write yur appeal n plain paper, be sure yu include the infrmatin n the next page. Or we can mail yu a frm t cmplete and return. If yu want us t send yu ne, call us at

42 Mail yur letter abut yur prblem t: BlueCrss BlueShield f Tennessee Cmmercial Member Grievance 1 Camern Hill Circle Suite 0019 Chattanga, TN Keep a cpy fr yur recrds. Write dwn the date that yu mailed it. Fr all Member Grievances, CverKids needs: Yur name (the name f the persn wh wants t appeal abut their care r medicine) Yur Member number. If yu dn t have the Member number, give yur date f birth. Include the mnth, day and year. The address where yu get yur mail. The name f the persn t call if CverKids has a questin abut yur appeal (this can be yu r smene else). A daytime phne number fr that persn (this can be yur phne number r anther persn s phne number). What else des CverKids need t wrk yur Member Grievance? T get a review abut healthcare prblems, yu must d bth f these things: Yu must give CverKids the facts they need t wrk yur appeal. And, yu must tell CverKids the mistake yu think we made. It must be smething that, if yu re right, means that CverKids will pay fr this care. Depending n the reasn yu are filing a Member Grievance, here are sme ther kinds f infrmatin yu must tell CverKids: Are yu appealing abut care r medicine yu still need? Tell CverKids: The kind f healthcare r medicine yu are appealing abut. And the reasn yu want t appeal. Tell CverKids as much abut the prblem as yu can. Be sure yu say what mistake yu think CverKids made. Send cpies f any papers that yu think may help CverKids understand yur prblem. Are yu appealing fr care yu ve already gtten that yu think CverKids shuld pay fr? Tell CverKids: The date yu gt the care r medicine yu want CverKids t pay fr. The name f the dctr r ther place that gave yu the care r medicine. (If yu have it, include the address and phne number f the dctr r ther place that gave yu the care.) 33

43 If yu paid fr the care r medicine, als give CverKids a cpy f a receipt that prves yu paid. Yur receipt must shw: The kind f care yu gt that yu want CverKids t pay fr And the name f the persn wh gt the care And the name f the dctr r ther place that gave yu the care And the date yu gt the care And the amunt yu paid fr the care If yu re getting a bill fr the care r medicine, give CverKids a cpy f a bill. Yur bill must shw: The kind f care that yu re being billed fr And the name f the persn wh gt the care And the name f the dctr r ther place that gave yu the care And the date yu gt the care And the amunt yu are being billed What des CverKids d when yu appeal abut a healthcare prblem? 1. When CverKids gets yur grievance, they will meet t cnsider yur grievance and any ther infrmatin that yu r thers submitted. 2. If CverKids needs mre facts t wrk yur grievance, they will call yu t ask questins abut what they still need. Yu shuld give CverKids all f the facts that they ask fr, as sn as pssible. If yu dn t, yur grievance may end. 3. CverKids must decide a regular grievance in 30 days. If yu have an emergency appeal, they ll try t decide yur appeal in 72 hurs. If they need mre time t get medical recrds, they can take mre time t finish yur appeal. 4. When CverKids makes a decisin, they will send yu a letter. The letter will infrm yu f the CverKids decisin. It will als tell yu hw t appeal the decisin if yu are nt happy with the utcme. 34

44 Administrative Appeals - Getting r keeping CverKids and ther CverKids prblems An appeal abut CverKids prblems ther than healthcare is called an administrative appeal. An administrative appeal ges t the Eligibility Appeals Unit at the Tennessee Health Cnnectin. Why? CverKids and TennCare are bth managed by the State f Tennessee s Divisin f TennCare. CverKids makes eligibility decisins abut CverKids. An administrative appeal is used fr CverKids prblems like: Yu get a letter that says yur CverKids will end, Or, yur CverKids has ended but yu didn t get a letter because yu mved, Or, yu think yur CverKids cpays are wrng, Or, yu think CverKids gave yu the wrng benefit level. If yu have a prblem like ne f thse listed abve, call Tennessee Health Cnnectin at They will check t see if a mistake has been made. If they decide yu re right, they will fix the prblem. But if they say n, and yu still think a mistake has been made in yur case, yu can appeal. Hw t file an Administrative Appeal There are 2 ways t file an administrative appeal: 1. Appeal by phne by calling Tennessee Health Cnnectin free at Or, appeal in writing. Yu can write yur appeal n plain paper. T file an administrative appeal in writing yu must include: Yur full name (first name, middle initial, last name) Yur Scial Security Number The names f ther peple wh live with yu with the same prblem Yur daytime phne number and the best time t call The specific mistake yu think was made. Tell as much abut the prblem as yu can. Send cpies f any papers that shw why yu think the mistake was made. Then, mail yur letter abut yur prblem t: Tennessee Health Cnnectin Eligibility Appeals Unit P.O. Bx Nashville, TN Keep a cpy f yur appeal. Write dwn the date that yu mailed it t Tennessee Health Cnnectin. 35

45 Part 6: Yur rights and respnsibilities Yur rights and respnsibilities as a CverKids member Yu have the right t: Be treated with respect and in a dignified way. Yu have a right t privacy and t have yur medical and financial infrmatin treated with privacy. Ask fr and get infrmatin abut CverKids, its plicies, its services, its caregivers, and members rights and duties. Ask fr and get infrmatin abut hw CverKids pays its prviders, including any kind f bnus fr care based n cst r quality. Ask fr and get infrmatin abut yur medical recrds as the federal and state laws say. Yu can see yur medical recrds, get cpies f yur medical recrds, and ask t crrect yur medical recrds if they are wrng. Get services withut being treated in a different way because f race, clr, natinal rigin, language, sex, age, religin, disability r ther grups prtected by the civil rights laws. Yu have a right t file a written cmplaint if yu think yu have been treated in a different way because f yur race, clr, natinal rigin, language, sex, age, religin, disability, r any ther grup prtected by the civil rights laws. If yu cmplain r appeal, yu have the right t keep getting care withut fear f bad treatment frm prviders r CverKids. Get care withut fear f physical restraint r seclusin used fr bullying, discipline, cnvenience r revenge. Make appeals r cmplaints abut CverKids r yur care. Part 4 f this handbk tells yu hw. Make suggestins abut yur rights and respnsibilities r hw CverKids wrks. Chse a PCP in the CverKids netwrk. Yu can turn dwn care frm certain prviders. Get medically necessary care that is right fr yu, when yu need it. This includes getting emergency services, 24 hurs a day, 7 days a week. Be tld in an easy-t-understand way abut yur care and all f the different kinds f treatment that culd wrk fr yu, n matter what they cst r even if they aren t cvered. Help t make decisins abut yur healthcare. Make a living will r advance care plan and be tld abut Advance Medical Directives. Ask CverKids t lk again at any mistake yu think they make abut getting n CverKids r keeping yur CverKids r abut getting yur healthcare. End yur CverKids at any time. 36

46 Exercise any f these rights withut changing the way CverKids r its prviders treat yu. Yur rights t stay with CverKids As a CverKids member, yu cannt be mved frm CverKids just because: Yur health gets wrse. Yu already have a medical prblem. This is called a pre-existing cnditin. Yur medical treatment is expensive. Of hw yu use yur services. Yu have a behaviral health (mental health, alchl r drug abuse) cnditin. Yur special needs make yu act in an uncperative r disruptive way. The nly reasns yu can be mved frm CverKids are: If yu reach age 19. If yu get ther health insurance. If yu mve ut f the CverKids area. If yu let smene else use yur ID cards, r if yu use yur CverKids t get medicines t sell. If yu end yur CverKids r yur CverKids ends fr ther reasns. If yu dn t renew yur CverKids when it is time, r if yu dn t give CverKids infrmatin they ask fr when it is time t renew. If yu dn t let CverKids knw that yu mved, and they can t find yu. If yu lie t get r keep yur CverKids. Upn yur death. Yu have the respnsibility t: Understand the infrmatin in yur member handbk and ther papers that we send yu Shw yur CverKids ID card whenever yu get healthcare. G t yur PCP fr all yur medical care unless: Yur PCP sends yu t a specialist fr care. Yu are pregnant r getting well-wman checkups. It is an emergency. 37

47 Use prviders wh are in the prvider netwrk. But, yu can see anyne if it is an emergency. And, yu can see anyne wh has been apprved. Let yur PCP knw when yu have had t g t the Emergency Rm. Yu (r smene fr yu) need t let yur PCP knw by 24 hurs f when yu gt care at the ER. Give infrmatin t CverKids and t yur healthcare prviders s that they can care fr yu. Fllw instructins and rules that are in the handbk abut yur cverage and benefits. Yu must als fllw instructins and rules frm the peple wh are giving yu healthcare. Help t make the decisins abut yur healthcare. Wrk with yur PCP s that yu understand yur health prblems. Yu must als wrk with yur PCP t cme up with a treatment plan that yu bth say will help yu. Treat yur healthcare giver with respect and dignity. Keep healthcare appintments and call the ffice t cancel if yu can t keep yur appintment. Nt let anyne else use yur CverKids ID card and let us knw if it is lst r stlen. Tell CverKids f any changes like: If yu r a family member changes yur name, address, r phne number. If yu have a change in family size. If yu r a family member gets a jb, lse yur jb, r change jbs. If yu r a family member has ther health insurance r can get ther health insurance. Pay any cpays yu need t pay. Let us knw if yu have anther insurance cmpany that shuld pay yur medical care. The ther insurance cmpany culd be insurance like aut, hme, r wrker s cmpensatin. 38

48 Yur Right t Appeal Healthcare Prblems in CverKids In CverKids, yu get yur healthcare thrugh yur CverKids health plan, BlueCare Tennessee. Yu have rights when an actin is taken that keeps yu frm getting healthcare when yu need it. 1. Yu have the right t get an answer frm yur health plan when yu r yur dctr asks fr care. Fr sme kinds f care, yur dctr must get yur health plan s OK befre CverKids will pay fr it. It s called a prir authrizatin r PA. What if yur dctr asks yur health plan t OK care fr yu? Yur health plan must decide in 14 days. If yu can t wait 14 days fr the care yu need, yu can ask them t decide sner. Or, yu can appeal befre the end f the 14 days. If they take mre than 21 days t decide, they must give yu the care yu asked fr unless: The care yu want is a kind f care that CverKids desn t cver. Or, the care yu want is nt safe fr yu. Or, yu dn t have a dctr s rder fr the care yu want. 2. Yu have the right t get a letter frm yur CverKids plan if: Yur CverKids health plan says n when yu r yur dctrs ask fr healthcare. Or, yu have t wait t lng t get healthcare. Or, yur CverKids health plan stps r changes yur healthcare. The letter must say why yu can t get the care and what yu can d abut it. If yur health plan decides t change care yu re getting, yu shuld get a letter at least 10 days befre it happens. If they decide t change yur hspital care, yu shuld get a letter 2 business days befre it happens. What if yur dctr decides t change care yu re getting? Fr these kinds f care, yu shuld get a letter 2 business days befre it happens: Behaviral health (mental health, alchl r drug abuse) treatment fr a pririty member which includes a child with Serius Emtinal Disturbance (SED) r an adult with Severe and Persistent Mental Illness (SPMI) Behaviral health (mental health, alchl r drug abuse) treatment in a hspital r ther place where yu must stay t get the care (inpatient psychiatric r residential services) Care fr a lng-term health prblem when yur health plan can t give yu the next kind f care yu need fr that prblem Hme health services If yur health plan r dctr desn t send yur letter in time, they can t change yur care. 3. Yu have the right t appeal if: CverKids says n when yu r yur dctrs ask fr healthcare. Or, CverKids stps r changes yur healthcare. Or, yu have t wait t lng t get healthcare. 39

49 Or, yu have healthcare bills yu think CverKids shuld have paid fr, but didn t. Yu nly have 30 days t appeal after yu find ut that there is a prblem. Smene wh has the legal right t act fr yu can als file an appeal fr yu. Yur right t Privacy This ntice describes hw medical infrmatin abut yu may be used and disclsed. It als tells yu hw yu can get access t this infrmatin. Please review it carefully. Yur CverKids is nt changing. Yu dn t have t d anything. These papers tell yu hw we keep yur health facts private. The federal gvernment tells us we must give yu these papers. These papers tell yu: 1. the kinds f health infrmatin we have 4. what t d if yu dn t want yur health 2. hw we share it infrmatin shared with certain peple 3. wh we share it with 5. and yur rights abut yur health infrmatin Yur Health Infrmatin is Private We knw yu value the privacy f yur health infrmatin r Prtected Health Infrmatin (PHI). We call this kind f infrmatin yur health facts r PHI. PHI is any infrmatin used t identify yu and t recrd yur health and medical histry. Federal law says we must fllw privacy rules t keep yur PHI private. This law started n April 14, Everyne wh wrks with us and fr us must als fllw these privacy rules. 1. The kinds f PHI we have When yu applied fr CverKids yu tld us certain facts abut yu. Like yur name, where yu live, and hw much mney yu make. We als have health facts like: A list f the health services and treatments yu get Ntes r recrds frm yu dctr, drug stre, hspital, r ther healthcare prviders Lists f the medicine yu take nw r have taken befre Results frm x-rays and lab tests Genetic infrmatin ( genetics are family traits like hair clr r eye clr. It can als be health cnditins that yu have in cmmn with yur bld relatives.) 2. Hw we share yur PHI We can nly share yur PHI as the law lets us. The privacy rules let us share PHI fr yur care, t pay yur health claims, and run ur prgram. We share yur PHI t: Shw yu have CverKids and t help yu get the healthcare yu need. Pay yur health plan and healthcare prviders. 40

50 Check hw CverKids benefits are being used and t check fr insurance fraud. 3. Wh can we share yur PHI with? With yu. We can help yu schedule checkups and send yu news abut health services. Other peple invlved in yur care, like family members r caregivers. Yu can ask us nt t share yur PHI with certain peple. And we can share yur PHI with everyne wh wrks with CverKids like: Health prviders like dctrs, nurses, hspitals, and clinics. Yur health plan r ther cmpanies that have cntracts with CverKids. Peple helping with appeals if yu file a CverKids appeal. Yur appeal may be in persn r ver the phne. Smetimes ther peple may be with yu in yur appeal hearing. Federal, state, r lcal gvernment agencies prviding r checking n healthcare. 4. Wh else can we share yur PHI with? The privacy rules als say we can share PHI with peple like: Crners, funeral hmes, r prviders wh wrk with services like rgan transplants. Medical researchers. They must keep yur PHI private. Public health agencies t update their recrds fr births, deaths, r t track diseases. The curt when the law says we must r when we re rdered t. The plice r fr ther legal reasns. We can reprt abuse r neglect. Other agencies like fr military r veterans activities, natinal security, jails. We can als share yur PHI if we take ut the PHI that tells wh yu are. But, we can t share yur PHI with everyne. And we can t share yur genetic infrmatin t make decisins abut yur eligibility fr CverKids. Smetimes we ll need yur OK in writing befre we can share yur PHI. We ll ask yu t sign a paper giving us yur OK if we need t use r share (disclse) any f the fllwing infrmatin: T use r share ntes a therapist takes during therapy sessins (these are called psychtherapy ntes); T use r share PHI with cmpanies wh will use the infrmatin t try t get ther peple s business (fr marketing purpses); and Sharing (disclsures) PHI with smene else fr mney. Can yu take back yur OK? Yes. Yu can take back yur OK anytime. But yu must tell us in writing. We can t take back the PHI we ve already shared. 1. What if yu dn t want all f yur PHI shared? Yu must ask us in writing nt t share certain facts abut yur health. Yu must tell us the PHI yu dn t want shared and wh yu dn t want us t share yur PHI with. 41

51 There are ther times when we wn t share yur PHI if yu ask us. We ll say OK if we can. But we might nt say OK if yu are a minr child r if we re allwed t share the PHI by law. If we can t say OK, we ll send yu a letter that says why. 2. Yur health infrmatin Rights Yu can take back yur OK anytime but yu must tell us in writing. We can t take back the PHI we ve already shared. Yu can see and get cpies f yur recrds in paper r if we have them in electrnic frm, yu can get them electrnically. Yu must ask in writing t d s. Yu may have t pay mney fr the cst f cpying and mailing yur cpies. If we can t give yu the PHI yu want, we ll send yu a letter that says why. Yu can talk t CverKids abut hw we share yur PHI. And yu have the right t: Ask us in writing nt t share certain facts abut yur health. Ask us t nt shw yur PHI in certain recrds. Ask us t change PHI that s wrng. Yu must ask in writing and tell us why we need t change it. If we can t make the change, we ll send a letter that says why. Ask us in writing t cntact yu in a different way r in a different place. If writing r talking t yu in place puts yu in danger, tell us. Ask us in writing fr a list f wh we ve shared yur PHI with. The list will say wh gt yur health facts fr the six (6) years befre the date f yur request. But, it wn t list the times we ve shared when yu ve given us yur OK. The privacy rules give ther times that wn t be n the list. Like when we use PHI: ü t help yu get healthcare, r ü t help with payment fr yur care, r ü t run ur prgram, r ü t give t law enfrcement if we re required by law t d s. CverKids Respnsibility t yu CverKids safeguards yur PHI t prtect its privacy and security. If yur PHI is nt safeguarded and it gets ut, we have t ntify yu and federal authrities. But we nly have t ntify yu: If the kind f PHI that gt ut wuld identify wh yu are (like yur name, yur Scial Security Number, r yur date f birth) r yur treatment recrds, Depending n wh the persn was that used r saw yur PHI, If anyne actually used r saw yur PHI, What we did t lessen the risk that yur PHI was used. 42

52 Requests ask us in writing Yur requests must be in writing. Be sure yu tell us what yu re asking us t d. Write yur name and CverKids ID number r Scial Security Number n yur letter. Send yur letter t: BlueCrss BlueShield f Tennessee The Privacy Office 1 Camern Hill Circle Chattanga, Tennessee Phne: Fax: privacy_ffice@bcbst.cm Keep a cpy f the letter fr yur recrds. D yu have questins? D yu need help making yur request? Call CverKids Member Services at fr free. Changes in this Ntice CverKids plicies and prcedures abut requests may change withut ntice. We ll use the plicies and prcedures we have in place when yu make yur request. Federal privacy rules and CverKids privacy practices may als change. If imprtant changes are made, we ll send yu the changes in writing. We have the right t apply the changes t all the health facts we have. Or nly t new health facts we get. Questins r Cmplaints We d nt allw different treatment in CverKids. N ne is treated in a different way because f race, language, natinal rigin, disability, religin, sex, clr, age, r ther grups prtected by the civil rights laws. Yu will nt be punished if yu cmplain r ask fr help. D yu have questins? D yu think yur privacy rights have been vilated? D yu think yu have been treated differently? Call CverKids Member Services at fr free. Or yu can write t: BlueCrss BlueShield f Tennessee OR U.S. Department f Health and Human Services The Privacy Office Office fr Civil Rights 1 Camern Hill Circle Atlanta Federal Center, Suite 3 B70 Chattanga, Tennessee Frsyth St. SW Phne: Atlanta, GA Phne:

53 Yur respnsibility t reprt fraud and abuse Mst CverKids members and prviders are hnest. But even a few dishnest peple can hurt the CverKids prgram. Peple wh lie n purpse t get CverKids may be fined r sent t jail. If yu find ut abut a case f fraud and abuse in the CverKids prgram, yu must tell us abut it. But yu dn t have t tell us yur name. Fraud and abuse fr CverKids members can be things like: Lying abut facts t get r keep CverKids. Hiding any facts s that yu can get r keep CverKids. Letting smene else use yur CverKids ID card. Selling r giving yur prescriptin medicines t anyne else. Fraud and abuse fr CverKids prviders can be things like: Billing CverKids fr services that were never given. Billing CverKids twice fr the same service. T tell us abut fraud and abuse, call the BlueCrss BlueShield f Tennessee Cnfidential Cmpliance Htline fr free at Here are sme ther places that yu can call r write t tell us abut fraud and abuse: Agency Phne Address Office f Inspectr General Office f Inspectr General P.O. Bx (OIG) tll-free Nashville, TN Tennessee Bureau f Investigatin (TBI) tll-free TBI Medicaid Fraud Cntrl Unit 901 R.S. Glass Blvd. Nashville, TN Yu can als tell us abut fraud and abuse nline. G t Then click n Reprt TennCare Fraud n the left hand side f the page. 44

54 Part 7: Healthcare Papers Yu May Need Discriminatin Cmplaint Frm Federal and State laws d nt allw TennCare t treat yu differently because f yur race, clr, birthplace, disability, age, sex, religin, r any ther grup prtected by law. D yu think yu have been treated differently fr these reasns? Use these pages t reprt a cmplaint t TennCare. The infrmatin marked with a star (*) must be answered. If yu need mre rm t tell us what happened, use ther sheets f paper and mail them with yur cmplaint. 1.* Write yur name and address. Name: Address: Telephne Hme: ( ) Wrk r Cell: ( ) Address: Name f MCO/Health Plan: Name f TennCare Prgram: Zip: 2.* Are yu reprting this cmplaint fr smene else? Yes N If Yes, wh d yu think was treated differently because f their race, clr, birthplace, disability, age, sex, religin, r any ther grup prtected by law? Name: Address: Telephne Hme: ( ) Wrk r Cell: ( ) Hw are yu cnnected t this persn (spuse, brther, friend)? Zip: Name f this persn s MCO/Health Plan: 3.*Which part f the CverKids prgram d yu think treated yu in a different way: Medical Services Dental Services Pharmacy Services Eligibility Services Appeals Other 4.*Hw d yu think yu were yu treated in a different way? Was it yur: Race Natinal Origin Clr Sex Age Disability Religin Other 45

55 5. What is the best time t talk t yu abut this cmplaint? 6.* When did this happen t yu? D yu knw the date? Date it started Date f the last time it happened 7. Cmplaints must be reprted by 6 mnths frm the date yu think yu were treated in a different way. Yu may have mre than 6 mnths t reprt yur cmplaint if there is a gd reasn (like a death in yur family r an illness) why yu waited. 8.* What happened? Hw and why d yu think it happened? Wh did it? D yu think anyne else was treated in a different way? Yu can write n mre paper and send it in with these pages if yu need mre rm. 9. Did anyne see yu being treated differently r is there anyne wh wuld have mre infrmatin abut what happened? If s, please tell us his/her: Name: Address: Telephne: ( ) 10. D yu have mre infrmatin yu want t tell us abut? 11.* We cannt take a cmplaint that is nt signed. Please write yur name and the date n the line belw. Are yu the Authrized Representative f the persn wh thinks they were treated differently? Please sign yur name belw. As the Authrized Representative, yu must have prf that yu can act fr this persn. If the persn is less than 18 years ld, a parent r guardian shuld sign fr the minr. Declaratin: I agree that the infrmatin in this cmplaint is true and crrect and give my OK fr TennCare t investigate my cmplaint. (Sign yur name here if yu are the persn this cmplaint is fr) (Date) (Sign here if yu are the Authrized Representative) (Date) Are yu reprting this cmplaint fr smene else but yu are nt the persn s Authrized Representative? Please sign yur name belw. The persn yu are reprting this cmplaint fr must sign abve r must tell us r TennCare that it is kay fr them t sign fr him/her. Declaratin: I agree that the infrmatin in this cmplaint is true and crrect and give my OK fr TennCare t cntact me abut this cmplaint. 46

56 (Sign here if yu reprting this fr smene else) (Date) Are yu an assisting persn frm TennCare r smewhere else helping the persn in gd faith with the cmpletin f the cmplaint? If s, please sign belw: (Sign here if yu are an assisting persn) (Date) It is kay t reprt a cmplaint t us r TennCare. Infrmatin in this cmplaint is treated privately. Names r ther infrmatin abut peple used in this cmplaint are shared nly when needed. Please mail a signed Agreement t Release Infrmatin page with yur cmplaint. If yu are filing this cmplaint n behalf f smene else, have that persn sign the Agreement t Release Infrmatin page and mail it with this cmplaint. Keep a cpy f everything yu send. Please mail the cmpleted, signed Cmplaint and the signed Agreement t Release Infrmatin pages t: Office f Civil Rights Cmpliance (OCRC) 310 Great Circle Rad; Flr 3W Nashville, TN r fr free at (TRS 711) HCFA.fairtreatment@tn.gv 47

57 Agreement t Release Infrmatin T investigate yur cmplaint, TennCare r a TennCare Cntractr may need t tell ther persns r agencies imprtant t this cmplaint yur name r ther infrmatin abut yu. T speed up the investigatin f yur cmplaint, read, sign, and mail ne cpy f this Agreement t Release Infrmatin with yur cmplaint. Please keep ne cpy fr yurself. I understand that during the investigatin f my cmplaint TennCare (write name f TennCare Cntractr (like yur health plan) n the line) may need t tell peple my name r ther infrmatin abut me t ther persns r agencies. Fr example, if I reprt that my dctr treated me in a different way because f my clr, my MCO/Health Plan may need t talk t my dctr. Yu d nt have t agree t release yur name r ther infrmatin. It is nt always needed t investigate yur cmplaint. If yu d nt sign the release, we will still try t investigate yur cmplaint. But, if yu dn t agree t let us use yur name r ther details, it may limit r stp the investigatin f yur cmplaint. And, we may have t clse yur case. Hwever, befre we clse yur case if yur cmplaint can n lnger be investigated because yu did nt sign the release, we may cntact yu t find ut if yu want t sign a release s the investigatin can cntinue. If yu are filing this cmplaint fr smene else, we need that persn t sign the Agreement t Release Infrmatin. Are yu signing this as an Authrized Representative? Then yu must als give us a cpy f the dcuments appinting yu as the Authrized Representative. By signing this Agreement t Release Infrmatin, I agree that I have read and understand my rights written abve. I agree t TennCare telling peple my name r ther infrmatin abut me t ther persns r agencies imprtant t this cmplaint during the investigatin and utcme. By signing this Agreement t Release Infrmatin, I agree that I have read and understand my rights written abve. I agree t my MCO/Health Plan r TennCare Cntractr telling peple my name r ther infrmatin abut me t ther persns r agencies imprtant t this cmplaint during the investigatin and utcme. 48

58 This Agreement t Release Infrmatin is in place until the final utcme f yur cmplaint. Yu may cancel yur agreement at any time by calling r writing t TennCare withut canceling yur cmplaint. If yu end the Release Agreement, it nly applies t the future sharing f infrmatin. This will nt change infrmatin that has already been shared abut yu. But we will nt share any mre infrmatin. Signature: Name (Please print): Address: Telephne: ( ) Date: Need help? Please cntact r mail a cmpleted, signed Cmplaint and a signed Agreement t Release Infrmatin frm: TennCare, Office f Civil Rights Cmpliance (OCRC) 310 Great Circle Rad; Flr 3W Nashville, TN r fr free at (TRS 711) HCFA.fairtreatment@tn.gv If yu change yur mind and want t end the Release Agreement cntact OCRC. 49

59 Advance Directives Advance Directives are yur written wishes abut what yu want t happen, if yu get t sick t be able t say. Living Will r Advance Care Plan Machines and medicine can keep peple alive when they therwise might die. Dctrs used t decide hw lng smene shuld be kept alive. Under the Tennessee Right t Natural Death Act, yu can make yur wn chice. Yu can decide if yu want t be kept alive by machines and fr hw lng by filling ut a Living Will. In 2004, Tennessee law changed the Living Will t Advance Care Plan. Either ne is k t use. A Living Will r Advance Care Plan needs t be filled ut while yu can still think fr yurself. These papers tell yur friends and family what yu want t happen t yu, if yu get t sick t be able t say. Yur papers have t be signed, and either witnessed r ntarized. If yur papers are witnessed, yur papers need t be signed in frnt f tw peple wh will be yur witnesses. These peple: Cannt be related t yu by bld r marriage. Cannt receive anything yu wn after yu die. Cannt be yur dctr r any f the staff wh wrk in the place where yu get healthcare. Once they are signed by everyne, it is yur rule. It stays like this unless yu change yur mind. Tennessee Durable Pwer f Attrney fr Healthcare r Appintment f Healthcare Agent The Durable Pwer f Attrney fr Healthcare paper lets yu name anther persn t make medical decisins fr yu. In 2004, Tennessee law changed the Durable Pwer f Attrney fr Healthcare t Appintment f Healthcare Agent. Either ne is k t use. This persn can nly make decisins if yu are t sick t make yur wn. He r she can say yur wishes fr yu if yu can t speak fr yurself. Yur illness can be temprary. These papers have t be signed, and either witnessed r ntarized. Once the papers are signed by everyne, it is yur rule. It stays like this unless yu change yur mind. These papers will nly be used if yu get t sick t be able t say what yu want t happen. As lng as yu can still think fr yurself, yu can decide abut yur healthcare yurself. If yu fill ut these papers, make 3 cpies: Give 1 cpy t yur PCP t put in yur medical file. Give 1 cpy t the persn wh will make a medical decisin fr yu. Keep a cpy with yu t put with yur imprtant papers. Imprtant! Yu d nt have t fill ut these papers. It is yur chice. Yu may want t talk t a lawyer r friend befre yu fill ut these papers. 50

60 ADVANCE DIRECTIVE FOR HEALTH CARE* (Tennessee) Instructins: Parts 1 and 2 may be used tgether r independently. Please mark ut/vid any unused part(s). Part 5, Blck A r Blck B must be cmpleted fr all uses. I, _, hereby give these advance instructins n hw I want t be treated by my dctrs and ther health care prviders when I can n lnger make thse treatment decisins myself. Part I Agent: I want the fllwing persn t make health care decisins fr me. This includes any health care decisin I culd have made fr myself if able, except that my agent must fllw my instructins belw: Name: Relatin: Hme Phne: Wrk Phne: Address: Mbile Phne: Other Phne: Alternate Agent: If the persn named abve is unable r unwilling t make health care decisins fr me, I appint as alternate the fllwing persn t make health care decisins fr me. This includes any health care decisin I culd have made fr myself if able, except that my agent must fllw my instructins belw: Name: Relatin: Hme Phne: Wrk Phne: Address: Mbile Phne: Other Phne: My agent is als my persnal representative fr purpses f federal and state privacy laws, including HIPAA. When Effective (mark ne): I give my agent permissin t make health care decisins fr me at any time, even if I have capacity t make decisins fr myself. I d nt give such permissin (this frm applies nly when I n lnger have capacity). Part 2 Indicate Yur Wishes fr Quality f Life: By marking yes belw, I have indicated cnditins I wuld be willing t live with if given adequate cmfrt care and pain management. By marking n belw, I have indicated cnditins I wuld nt be willing t live with (that t me wuld create an unacceptable quality f life). Yes N Yes N Yes N Yes N Permanent Uncnscius Cnditin: I becme ttally unaware f peple r surrundings with little chance f ever waking up frm the cma. Permanent Cnfusin: I becme unable t remember, understand, r make decisins. I d nt recgnize lved nes r cannt have a clear cnversatin with them. Dependent in all Activities f Daily Living: I am n lnger able t talk r cmmunicate clearly r mve by myself. I depend n thers fr feeding, bathing, dressing, and walking. Rehabilitatin r any ther restrative treatment will nt help. End-Stage Illnesses: I have an illness that has reached its final stages in spite f full treatment. Examples: Widespread cancer that n lnger respnds t treatment; chrnic and/r damaged heart and lungs, where xygen is needed mst f the time and activities are limited due t the feeling f suffcatin. Indicate Yur Wishes fr Treatment: If my quality f life becmes unacceptable t me (as indicated by ne r mre f the cnditins marked n abve) and my cnditin is irreversible (that is, it will nt imprve), I direct that medically apprpriate treatment be prvided as fllws. By marking yes belw, I have indicated treatment I want. By marking n belw, I have indicated treatment I d nt want. Yes N Yes N Yes N CPR (Cardipulmnary Resuscitatin): T make the heart beat again and restre breathing after it has stpped. Usually this invlves electric shck, chest cmpressins, and breathing assistance. Life Supprt / Other Artificial Supprt: Cntinuus use f breathing machine, IV fluids, medicatins, and ther equipment that helps the lungs, heart, kidneys, and ther rgans t cntinue t wrk. Treatment f New Cnditins: Use f surgery, bld transfusins, r antibitics that will deal with a new cnditin but will nt help the main illness. Tube feeding/iv fluids: Use f tubes t deliver fd and water t a patient s stmach r use f IV fluids Yes N int a vein, which wuld include artificially delivered nutritin and hydratin. PLEASE SIGN ON PAGE 2 Page 1 f 2 51

61 Part 3 Other instructins, such as hspice care, burial arrangements, etc.: (Attach additinal pages if necessary) Part 4 Organ dnatin: Upn my death, I wish t make the fllwing anatmical gift fr purpses f transplantatin, research, and/r educatin (mark ne): Any rgan/tissue My entire bdy Only the fllwing rgans/tissues: N rgan/tissue dnatin SIGNATURE Part 5 Yur signature must either be witnessed by tw cmpetent adults ( Blck A ) r by a ntary public ( Blck B ). Signature: (Patient) Date: Blck A Neither witness may be the persn yu appinted as yur agent r alternate, and at least ne f the witnesses must be smene wh is nt related t yu r entitled t any part f yur estate. Witnesses: 1. I am a cmpetent adult wh is nt named as the agent. I witnessed the patient s signature n this frm. Signature f witness number 1 2. I am a cmpetent adult wh is nt named as the agent. I am nt related t the patient by bld, marriage, r adptin and I wuld nt be entitled t any prtin f the patient s estate upn his r her death under any existing will r cdicil r by peratin f law. I witnessed the patient s signature n this frm. Signature f witness number 2 Blck B Blck A. Yu may chse t have yur signature witnessed by a ntary public instead f the witnesses described in STATE OF TENNESSEE COUNTY OF I am a Ntary Public in and fr the State and Cunty named abve. The persn wh signed this instrument is persnally knwn t me (r prved t me n the basis f satisfactry evidence) t be the persn wh signed as the patient. The patient persnally appeared befre me and signed abve r acknwledged the signature abve as his r her wn. I declare under penalty f perjury that the patient appears t be f sund mind and under n duress, fraud, r undue influence. My cmmissin expires: Signature f Ntary Public WHAT TO DO WITH THIS ADVANCE DIRECTIVE: (1) prvide a cpy t yur physician(s); (2) keep a cpy in yur persnal files where it is accessible t thers; (3) tell yur clsest relatives and friends what is in the dcument; (4) prvide a cpy t the persn(s) yu named as yur health care agent. *This frm replaces the ld frms fr durable pwer f attrney fr health care, living will, appintment f agent, and advance care plan, and eliminates the need fr any f thse dcuments. Page 2 f 2 52

62 Part 8: Mre infrmatin CverKids Immunizatin Schedule Under CverKids fr children under 19 we cver: Regular, peridic visits t the dctr t see if the child is develping nrmally and t see if he r she has any physical r behaviral health (mental health, alchl r drug abuse) prblems, dental, r ther cnditins. These visits are called screenings (r screens ) and need t happen accrding t the American Academy f Pediatrics (AAP) Peridicity Schedule. Fr example: Children frm birth thrugh age 30 mnths have the right t get 12 screens; Children frm age 3 thrugh age 11 have the right t get 9 screens Children frm age 12 thrugh age 18 have the right t get 7 screens *In additin, a child has a right t get a screening whenever the child is referred t a dctr by smene such as a teacher wh ntices a change in the child s health r behavir. Screenings include the fllwing: A cmprehensive health and develpment histry; A cmprehensive, unclthed physical exam; Apprpriate immunizatins (shts); Apprpriate visin and hearing tests; Apprpriate labratry tests; Develpmental/behaviral screening (as needed) Health educatin (advice n hw t keep yur child healthy) Yu als get ther services in additin t screening services: Treatment, including rehabilitatin, fr any health prblems (physical, mental r develpmental) r ther cnditins discvered during a screening. Yu can als get scheduling assistance fr services. Regular visits t a dentist fr checkups and treatment thrugh DentaQuest; Regular, peridic tests f the child s hearing and eyesight. Includes treatment f any prblems with hearing and eyesight; Immunizatins (shts) fr diphtheria, tetanus, pertussis, pli, measles, mumps, rubella (MMR), HIB, influenza, Hepatitis A and B vaccines, varicella, Rtavirus, Human papillmavirus (HPV) and Meningitis, pneumcccal; and Rutine lab tests. (Nte a test fr lead in the bld and sickle cell anemia will be dne if the child is in a situatin that might put him r her at risk fr either r bth f these things) 53

63 If yur child has a high level f lead in his r her bld, lead investigatins will be dne. If yu think that yur child has been arund things that have a high lead cntent, such as ld paint, tell yur dctr; and Health educatin; and Other necessary healthcare, diagnstic services, treatment and ther measures necessary t crrect imprve defects r prevent defects frm wrsening; if yur child has physical and mental illnesses and cnditins that are fund in the screening prcess, they are treated. Basic health educatin fr child and parents is part f the preventive services CverKids gives yu. Cpayments are nt required fr preventive services. 54

64 Flgu re 1. Rec mmende d Immun i z at i n s c hedu l e fr per sn s age d 0 thr ugh 18 ye a rs - Un ite d Stat es, (FOR THOSE WHO FALL BEHIND OR START LATE, SEE THE CATCH -UP SCHEDULE [FIGURE 2]). These recmmendatins must be read with the ftntes that fllw. Fr thse wh fall behind r start late, prvide catth-up vaccinatin at the earliest pprtunity as indicated by the green bars in figure I. T determine minimum intervals between dses, see the catch-up schedule (Figure 2 ). Schl entry and adlescent vaccine age grups are shaded. Vaccine Birlh 1 m 2 ms 4 ms 6 ms 9 ms 12 ms 15 ms 18 ms Hepatitis B 1 (HepB) l st dse 2ndds e 3 rd dse ms 2-3 yrs 4-6 yrs 7-10yrs yrs yrs yrs Rtavirus- 2 (RV) RV1 (2-dse series); RVS (3-dse series) 1st dse 2 nd dse See f tn te 2 Diphtheria, tetan, & acellu lar pe rtus sis 3(DTaP; <7 yrs) haemphilus influenzae type b 4 (Hib) Pneumcccal cnjugate 5 (PCV13) Inactivated plivirus 6 (IP V :< yrs) Influenza 7 (IIV;LAIV) Measles, mumps, rubella ^ MMR) 1st dse 2 nd dse 3 rd dse < th dse > 5 th dse 1sr dse 2nd dse See f tn te 4 3rd r 4th d se see f tnte 4 1 dse 2nd dse 3 rd d se 4 th dse 1st dse 2 nd dse 3rd dse Annu al vaccin atin (I IV nly )1 r 2 dses seeft nte 8 4 thd se Annual v ac cina tin (LAIV r IIV ) 1 r 2 dses 1 st d se 2 nd ds e Annual vaccinatin ( L IV r II V) 1 dse nly 55 Varicella (VAR) 1 st d se 2 nd ds e Hepatitis A 10 (HepA) Meningcccal 11 (Hib-MenCY 6 week? Ma-ACWY-O JB ms; MenACWY-CRM 2 ms) Tetanus, diphtheria, & acellular pertussis 2 (Tdape 7 yts) Human papillmavirus 13 (2vHPV: females nly; 4vHPV,9v HPV: males and females) Meningcccal B 17 2-dse series, See F tnte 10 See f nte 11 1st d se ( Tdap ) (3-dse series) See ft nte 1 1 Baste r Pneumcccal plysaccharide 5 (PP5V 23) See f tn te 5 Range f recmme nded ages fr all childr en Range f recmme nde d age s fr ca t ch-up immunizat in I Ran ge ff recmme nded ages I fr certai n high-risk gru ps Range f recmme nde d age s fr nn -high -risk gru ps that may receive vaccine, subje ct t individua l clinical decisin makin g N rec mmenda tin s schedule includes recmmendatins in effect as f January 1,2016. Any dse nt administered at Hie recmmended age shuld be administered at a subsequent visit, when indicated and feasible.the use f a cmbinatin vaccine generally is preferred ver separate injectins f its equivalent cmpnent vaccines. Vaccinatin prviders shuld cnsult the re levan t Advisry Cmmittee n Immu nizatin Practices (ACIP) statement fr detailed recmmendatins, available nline at Clinically significant adverse events that fllw vaccinatin shuld be reprted t the Vaccine Adverse Event Reprting System (VAERS) nline ( r by telephne ( ). Suspected cases f vaccine-preventable diseases shuld be reprted t the state r lcal health department. Additinal infrmatin, including precautins nd cntraindicatins fr vaccinatin, is available frm CDC nline ( v/vaccines/recs/vac-admin/cntraindicaticns.htm) r by telephne ( 800-CDC-INF0[ ]). This schedule is apprved by the Advisry Cmmittee n Immunizatin Practices ( / the American Academy f Pediatrics ( the American Academy f Family Physicians ( and the American Cllege f Obstetricians and Gyneclgists ( NOTE: The abve recmmendatins must be read alng with the ftntes f this schedule.