CHIP MEMBER HANDBOOK

Transcription

1 DECEMBER 2016 CHIP MEMBER HANDBOOK Your Child s CHIP Benefits (TTY 711) TS-MHB

2 WELCOME! Thank you for choosing Dell Children s Health Plan as your CHIP health plan. It is our goal with your help to make sure the children in our health plan get the best medical care available. As a Dell Children s Health Plan CHIP member, you can pick your own doctor or clinic. The doctor or clinic you pick will be the primary care provider for your child. You can pick a primary care provider that you have used before, one that is close to your home, or one that someone you know has used. If you wish, Dell Children s Health Plan will help you pick a primary care provider. Dell Children s Health Plan is an HMO (Health Maintenance Organization) that is a part of the Seton Healthcare Family. The Seton Healthcare Family includes the following: Seton Family of Hospitals: Seton Medical Center Austin Seton Medical Center Williamson Dell Children s Medical Center of Central Texas Seton Northwest Hospital Seton Southwest Hospital Seton Medical Center Hays Seton Highland Lakes Hospital Seton Edgar B. Davis Hospital Seton Shoal Creek Hospital University Medical Center Brackenridge Seton Smithville Regional Hospital Seton Family Outpatient Centers: Seton Pflugerville Outpatient Center Seton Medical Center Williamson/ Pediatric Therapy Center Seton Healthcare Network Clinics: Seton McCarthy Clinic Seton Marble Falls Seton Kozmetsky Clinic Seton Lockhart Family Health Center Seton Luling Family Medicine Clinic Seton Topfer Clinic Seton Burnet Healthcare Center Affliates of Seton Healthcare Family: Strictly Pediatrics Surgery Center Northwest Surgery Center Hill Country Surgery Center Cedar Park Regional Medical Center Central Texas Rehabilitation Hospital Dell Children s Health Plan is part of the Seton Healthcare Family, a leading provider of health care services in central Texas. When you pick Dell Children s Health Plan as your CHIP Health Plan, you can use the entire Seton network. It is important that you read this member handbook. It will tell you how to get medical help when you need it. It will also tell you about Dell Children s Health Plan and CHIP. You can ask for the member handbook in audio, larger print or in Braille. You can also get it in a language other than English or Spanish. If you still have questions after you read the handbook, call Member Services at (TTY 711). Their offce hours are 7 a.m. to 6 p.m., Monday through Friday. Dell Children s Health Plan Member Services phone number: (TTY 711) Dell Children s Health Plan website: dellchildrenshealthplan.com/members Part of the Seton Healthcare Family, dedicated to providing exceptional care with a human touch.

3 CHIP Member Handbook Your child s CHIP benefits (TTY 711) Dell Children s Health Plan December 2016 TS-MHB

4 Welcome! Thank you for choosing Dell Children s Health Plan as your CHIP health plan. It is our goal with your help to make sure the children in our health plan get the best medical care available. As a Dell Children s Health Plan CHIP member, you can pick your own doctor or clinic. The doctor or clinic you pick will be the primary care provider for your child. You can pick a primary care provider that you have used before, one that is close to your home, or one that someone you know has used. If you wish, Dell Children s Health Plan will help you pick a primary care provider. Dell Children s Health Plan is an HMO (Health Maintenance Organization) that is a part of the Seton Healthcare Family. The Seton Healthcare Family includes the following: Seton Family of Hospitals: Seton Medical Center Austin Seton Medical Center Williamson Dell Children s Medical Center of Central Texas Seton Northwest Hospital Seton Southwest Hospital Seton Medical Center Hays Seton Highland Lakes Hospital Seton Edgar B. Davis Hospital Seton Shoal Creek Hospital University Medical Center Brackenridge Seton Smithville Regional Hospital Seton Family Outpatient Centers: Seton Pflugerville Outpatient Center Seton Medical Center Williamson/ Pediatric Therapy Center Seton Healthcare Network Clinics: Seton McCarthy Clinic Seton Marble Falls Seton Kozmetsky Clinic Seton Lockhart Family Health Center Seton Luling Family Medicine Clinic Seton Topfer Clinic Seton Burnet Healthcare Center Affiliates of Seton Healthcare Family: Strictly Pediatrics Surgery Center Northwest Surgery Center TS-MHB

5 Hill Country Surgery Center Cedar Park Regional Medical Center Central Texas Rehabilitation Hospital Dell Children s Health Plan is part of the Seton Healthcare Family, a leading provider of healthcare services in Central Texas. When you pick Dell Children s Health Plan as your CHIP Health Plan, you can use the entire Seton network. It is important that you read this Member Handbook. It will tell you how to get medical help when you need it. It will also tell you about Dell Children s Health Plan and CHIP. You can ask for the Member Handbook in audio, larger print or in Braille. You can also get it in a language other than English or Spanish. If you still have questions after you read the Handbook, call Member Services at (TTY 711). Their office hours are 7 a.m. to 6 p.m., Monday through Friday. Dell Children s Health Plan Member Services telephone number: (TTY 711) Dell Children s Health Plan website: dellchildrenshealthplan.com/members Part of the Seton Healthcare Family, dedicated to providing exceptional care with a human touch. TS-MHB

6 dellchildrenshealthplan.com/members Dear Parent/Guardian: Welcome to Dell Children s Health Plan, a Children s Health Insurance Program (CHIP) Health Maintenance Organization (HMO). We are pleased that you chose us to arrange for health-care benefits for your child. The member handbook tells you how Dell Children s Health Plan works and how to help keep your child healthy. It tells you how to get health care when it is needed, too. There is also information included about a free membership for your child to the Boys & Girls Club or YWCA. The clubs provide many fun and educational activities for children. They are a great place to go after school. There is something for everyone! You will get your child s Dell Children s Health Plan ID card and more information from us in a few days. Your ID card will tell you when your child s Dell Children s Health Plan membership starts. The name of your child s doctor is on the card too. Please check the doctor s name shown on your child s ID card. If it is not right, please call us. You can talk to a Member Services representative at (TTY 711) about your child s benefits. You can also talk to a nurse on our 24-hour Nurse HelpLine by calling (TTY 711) if your child is sick or if you need nurse advice about a medical condition. Thank you for picking us as your child s health plan. Sincerely, Dell Children s Health Plan

7 Health Tips That Make Health Happen Your child needs to go to the doctor now! When is it time for a well-child checkup? Your child needs to have regular checkups. This way, your child s primary care provider can see if there is a problem before it becomes a bad problem. When your child becomes a Dell Children s Health Plan member, call his or her primary care provider and make the first appointment before the end of 90 days. Well-child checkups for children Children need more well-care checkups than adults. Your child should get checkups at the times listed below. Birth Well-child Checkup Schedule for Your Child 9 months old 3-5 days 12 months old By 1 month old 15 months old 2 months old 18 months old 4 months old 24 months old 6 months old 30 months old After age 2 1/2, your child should visit the doctor every year. Dell Children s Health Plan encourages and covers annual checkups for members ages Be sure to make these appointments and take your child to his or her doctor when scheduled. Find health problems before they get worse and harder to treat. Prevent health problems that make it hard for your child to learn and grow. If your child s doctor finds a health problem during a checkup, your child can get the care he or she needs such as eye exams and glasses, hearing tests and hearing aids, or dental care. What if my daughter becomes pregnant? If you think your daughter is pregnant, call her doctor or OB/GYN right away. This can help her have a healthy baby. If you have any questions or need help making an appointment with your child s doctor or OB/GYN, please call Dell Children s Health Plan Member Services at (TTY 711). ALERT! DO NOT LOSE YOUR CHILD S HEALTH-CARE BENEFITS RENEW ELIGIBILITY FOR CHIP BENEFITS ON TIME!

8 Dell Children s Health Plan Member Handbook For CHIP and CHIP Perinate Newborn Members Dell Children s Health Plan PO Box Austin, TX Table of Contents (TTY 711) dellchildrenshealthplan.com/members WELCOME TO DELL CHILDREN S HEALTH PLAN... 1 INFORMATION ABOUT YOUR CHILD S NEW HEALTH PLAN...1 YOUR DELL CHILDREN S HEALTH PLAN MEMBER HANDBOOK...1 IMPORTANT PHONE NUMBERS... 1 DELL CHILDREN S HEALTH PLAN TOLL-FREE MEMBER SERVICES LINE...1 DELL CHILDREN S HEALTH PLAN 24-HOUR NURSE HELPLINE...2 BEHAVIORAL HEALTH AND SUBSTANCE ABUSE SERVICES...2 OTHER IMPORTANT PHONE NUMBERS...2 YOUR DELL CHILDREN S HEALTH PLAN ID CARD... 2 WHAT DOES MY CHILD S DELL CHILDREN S HEALTH PLAN ID CARD LOOK LIKE?...2 HOW DO I READ AND USE MY CHILD S DELL CHILDREN S HEALTH PLAN ID CARD?...3 HOW DO I REPLACE MY CHILD S DELL CHILDREN S HEALTH PLAN ID CARD IF IT IS LOST OR STOLEN?...3 PRIMARY CARE PROVIDERS FOR CHIP MEMBERS AND CHIP PERINATE NEWBORN MEMBERS... 3 WHAT IS A PRIMARY CARE PROVIDER?...3 WHAT DO I NEED TO BRING TO MY CHILD S DOCTOR S APPOINTMENT?...4 CAN A CLINIC (LOCAL PUBLIC HEALTH CLINIC, RURAL HEALTH CLINIC, FEDERALLY QUALIFIED HEALTH CENTER) BE MY CHILD S PRIMARY CARE PROVIDER?...4 HOW CAN I CHANGE MY CHILD S PRIMARY CARE PROVIDER?...4 HOW MANY TIMES CAN I CHANGE MY CHILD S PRIMARY CARE PROVIDER?...4 WHEN WILL MY CHILD S PRIMARY CARE PROVIDER CHANGE BECOME EFFECTIVE?...4 ARE THERE ANY REASONS WHY MY REQUEST TO CHANGE MY CHILD S PRIMARY CARE PROVIDER MAY BE DENIED?...4 CAN A PRIMARY CARE PROVIDER MOVE MY CHILD TO ANOTHER PRIMARY CARE PROVIDER FOR NONCOMPLIANCE?...4 WHAT IF I CHOOSE TO GO TO ANOTHER DOCTOR WHO IS NOT MY CHILD S PRIMARY CARE PROVIDER?...5 HOW DO I GET MEDICAL CARE AFTER MY CHILD S PRIMARY CARE PROVIDER S OFFICE IS CLOSED?...5 PHYSICIAN INCENTIVE PLANS... 5 CHANGING HEALTH PLANS... 5

9 WHAT IF I WANT TO CHANGE HEALTH PLANS?...5 WHO DO I CALL?...5 HOW MANY TIMES CAN I CHANGE HEALTH PLANS?...5 WHEN WILL MY HEALTH PLAN CHANGE BECOME EFFECTIVE?...5 CAN DELL CHILDREN S HEALTH PLAN ASK THAT I GET DROPPED FROM THEIR HEALTH PLAN?...6 COVERAGE FOR NEWBORNS... 6 BENEFITS FOR CHIP AND CHIP PERINATE NEWBORN MEMBERS... 6 WHAT ARE MY CHILD S CHIP AND CHIP PERINATE NEWBORN PROGRAM BENEFITS?...6 How do I get these services for my child?...7 Are there any limits to any covered services?...7 What are the CHIP Perinate Newborn benefits? What benefits does my baby receive at birth?...7 What benefits are not covered?...7 What are my prescription drug benefits?...7 WHAT ARE COPAYMENTS?...7 How much are they and when do I have to pay them?...7 WHAT ARE CHIP COST-SHARING CAPS?...8 WHEN WILL I GET AN EXPLANATION OF BENEFITS?...8 WHAT EXTRA BENEFITS DOES A MEMBER OF DELL CHILDREN S HEALTH PLAN GET? HOW CAN I GET THESE BENEFITS FOR MY CHILD?...8 WHAT HEALTH EDUCATION CLASSES DOES DELL CHILDREN S HEALTH PLAN OFFER? HEALTH CARE AND OTHER SERVICES FOR CHIP MEMBERS AND CHIP PERINATE NEWBORN MEMBERS...10 WHAT DOES MEDICALLY NECESSARY MEAN? HOW IS NEW TECHNOLOGY EVALUATED? WHAT IS ROUTINE MEDICAL CARE? How soon can I expect my child to be seen?...11 WHAT IS URGENT MEDICAL CARE? How soon can I expect my child to be seen?...12 WHAT IS EMERGENCY MEDICAL CARE? What is an Emergency, an Emergency Medical Condition, and an Emergency Behavioral Health Condition?...12 What are Emergency Services and/or Emergency Care?...12 How Soon Can I Expect My Child to Be Seen?...12 ARE EMERGENCY DENTAL SERVICES COVERED? WHAT DO I DO IF I NEED/MY CHILD NEEDS EMERGENCY DENTAL CARE? HOW SOON CAN I SEE MY DOCTOR? WHAT IS POST-STABILIZATION? DISEASE MANAGEMENT CENTRALIZED CARE UNIT (DMCCU) PROGRAM WHAT IS COMPLEX CASE MANAGEMENT? WHAT IS A MEMBER WITH SPECIAL HEALTH CARE NEEDS (MSHCN)? WHAT IS EARLY CHILDHOOD INTERVENTION (ECI)? Do I need a referral for this?...16 Where do I find an ECI provider?...16 HOW DO I GET MEDICAL CARE AFTER MY PRIMARY CARE PROVIDER S OFFICE IS CLOSED? WHAT IF I GET SICK WHEN I AM OUT OF TOWN OR TRAVELING/WHAT IF MY CHILD GETS SICK WHEN HE OR SHE IS OUT OF TOWN OR TRAVELING? What if my child is out of the state?...16

10 What if I am/my child is out of the country?...16 WHAT IF MY CHILD NEEDS TO SEE A SPECIAL DOCTOR (SPECIALIST)? WHAT IS A REFERRAL? What services do not need a referral?...17 How soon can I expect my child to be seen by a specialist?...17 HOW CAN I ASK FOR A SECOND OPINION? HOW DO I GET HELP IF MY CHILD HAS BEHAVIORAL (MENTAL) HEALTH OR DRUG PROBLEMS? Do I need a referral for this?...17 HOW DO I GET MY/MY CHILD S MEDICATIONS? How do I find a network drugstore?...18 What if I go to a drugstore not in the network?...18 What do I bring with me to the drugstore?...18 What if I need my child s medications delivered to me?...18 Who do I call if I have problems getting my medications?...18 What if I can t get the medication my/my child s doctor ordered approved?...18 What if I lose my child s medications?...18 WHAT IF I NEED/MY CHILD NEEDS AN OVER-THE-COUNTER MEDICATION? How do I find out what drugs are covered?...18 How do I transfer my prescriptions to a network pharmacy?...19 What if a copay is required and I am unable to pay it?...19 How do I get my medicine if I am traveling?...19 What if I paid out-of-pocket for a medicine and want to be reimbursed?...19 WHAT IF I NEED/MY CHILD NEEDS BIRTH CONTROL PILLS? HOW DO I GET EYE CARE SERVICES FOR MY CHILD? HOW DO I GET DENTAL CARE SERVICES FOR MY CHILD? CAN SOMEONE INTERPRET FOR ME WHEN I TALK WITH MY CHILD S DOCTOR? Who do I call for an interpreter?...19 How far in advance do I need to call?...19 How can I get a face-to-face interpreter in the provider s office?...19 WHAT IF MY DAUGHTER NEEDS OB/GYN CARE? DOES SHE HAVE THE RIGHT TO CHOOSE AN OB/GYN? How do I choose an OB/GYN?...20 If I don t choose an OB/GYN, do I have direct access?...20 Will I need a referral?...20 How soon can my daughter be seen after contacting an OB/GYN for an appointment?...20 Can my daughter stay with an OB/GYN who is not with Dell Children s Health Plan?...20 WHAT IF MY DAUGHTER IS PREGNANT? Who do I call?...20 What other services/activities/education does Dell Children s Health Plan offer pregnant women?...21 WHO DO I CALL IF MY CHILD HAS SPECIAL HEALTH-CARE NEEDS AND I NEED SOMEONE TO ASSIST ME? WHAT IF MY CHILD CAN T USE STANDARD TRANSPORTATION TO GET TO MEDICAL APPOINTMENTS? WHAT IF I GET A BILL FROM MY CHILD S DOCTOR? WHO DO I CALL? What information will they need?...22 WHAT DO I HAVE TO DO IF MY CHILD MOVES? RECERTIFY YOUR CHILD S CHIP BENEFITS ON TIME WHAT ARE MY RIGHTS AND RESPONSIBILITIES? QUALITY MANAGEMENT...24 WHAT DOES QUALITY MANAGEMENT DO FOR YOU? WHAT ARE CLINICAL PRACTICE GUIDELINES? COMPLAINT PROCESS...24

11 WHAT SHOULD I DO IF I HAVE A COMPLAINT? WHO DO I CALL? CAN SOMEONE FROM DELL CHILDREN S HEALTH PLAN HELP ME FILE A COMPLAINT? HOW LONG WILL IT TAKE TO PROCESS MY COMPLAINT? WHAT ARE THE REQUIREMENTS AND TIME FRAMES FOR FILING A COMPLAINT? IF I AM NOT SATISFIED WITH THE OUTCOME, WHO ELSE CAN I CONTACT? DO I HAVE THE RIGHT TO MEET WITH A COMPLAINT APPEAL PANEL? PROCESS TO APPEAL A CHIP ADVERSE DETERMINATION...26 WHAT CAN I DO IF MY CHILD S PROVIDER ASKS FOR A SERVICE FOR MY CHILD THAT IS COVERED BUT DELL CHILDREN S HEALTH PLAN DENIES OR LIMITS IT? HOW WILL I FIND OUT IF SERVICES ARE DENIED? WHAT ARE THE TIME FRAMES FOR THE APPEAL PROCESS? WHEN DO I HAVE THE RIGHT TO ASK FOR AN APPEAL? DOES MY REQUEST HAVE TO BE IN WRITING? CAN SOMEONE FROM DELL CHILDREN S HEALTH PLAN HELP ME FILE AN APPEAL? EXPEDITED APPEALS...27 WHAT IS AN EXPEDITED APPEAL? HOW DO I ASK FOR AN EXPEDITED APPEAL? DOES MY REQUEST HAVE TO BE IN WRITING? WHAT ARE THE TIME FRAMES FOR AN EXPEDITED APPEAL? WHAT HAPPENS IF DELL CHILDREN S HEALTH PLAN DENIES THE REQUEST FOR AN EXPEDITED APPEAL? WHO CAN HELP ME IN FILING AN EXPEDITED APPEAL? INDEPENDENT REVIEW ORGANIZATION PROCESS...28 WHAT IS AN INDEPENDENT REVIEW ORGANIZATION? HOW DO I ASK FOR A REVIEW BY AN INDEPENDENT REVIEW ORGANIZATION? WHAT ARE THE TIME FRAMES FOR THIS PROCESS? FRAUD AND ABUSE INFORMATION...28 DO YOU WANT TO REPORT CHIP WASTE, ABUSE, OR FRAUD? ATTACHMENT A - EVIDENCE OF COVERAGE AND SCHEDULE OF BENEFITS AND EXCLUSIONS...34

12 WELCOME TO DELL CHILDREN S HEALTH PLAN Information about your child s new health plan Welcome to Dell Children s Health Plan. Dell Children s Health Plan is a health maintenance organization (HMO) committed to getting your child the right care close to home. As a Children s Health Insurance Program (CHIP) or CHIP Perinate Newborn member, you and your child s providers will work together to help keep your child healthy. Dell Children s Health Plan helps your child get quality health care. This member handbook will help you understand your child s health plan with Dell Children s Health Plan. To find out about doctors and hospitals in your area, visit dellchildrenshealthplan.com/members or contact Member Services at (TTY 711). Your Dell Children s Health Plan member handbook This member handbook is for CHIP members and CHIP Perinate Newborn members. When there are differences in the way things work between CHIP and CHIP Perinate Newborn members (like in the section on copayments), we will explain those differences. This handbook will help you understand your child s health plan. References to you, my, or I apply if you are a CHIP member. References to my child apply if your child is a CHIP member or a CHIP Perinate Newborn member. If you have questions or need help understanding or reading this member handbook, call our Member Services department. Dell Children s Health Plan also has the member handbook in a large print version, an audio taped version, and a Braille version. The other side of this handbook is in Spanish. IMPORTANT PHONE NUMBERS Dell Children s Health Plan toll-free Member Services line If you have any questions about your child s health plan with Dell Children s Health Plan, you can call our Member Services department toll-free at (TTY 711). You can call us Monday through Friday from 7 a.m. to 6 p.m. Central time, except for state-approved holidays. If you call after 6 p.m. or on a weekend or holiday, you can leave a voice mail message. A Member Services representative will call you back the next business day. These are some of the things Member Services can help you with: This member handbook Member ID cards Your child s doctors Doctor appointments Transportation Health-care benefits Accessing services What to do in an emergency and/or crisis Cost-sharing information Well care Special kinds of health care Healthy living Complaints and medical appeals Rights and responsibilities 1

13 For members who do not speak English, we are able to help in many different languages and dialects, including Spanish. This service is also available for visits with your child s doctor at no cost to you. Please let us know if you need an interpreter at least 24 hours before your appointment. Call Member Services for more information. For members who are deaf or hard of hearing, call 711. Dell Children s Health Plan will set up and pay for you to have a person who knows sign language help you during your doctor visits. Please let us know if you need an interpreter at least 24 hours before your appointment. Dell Children s Health Plan 24-hour Nurse HelpLine You can call our 24-hour Nurse HelpLine at (TTY 711) if you need advice on: How soon your child needs care for an illness What kind of health care is needed What to do to take care of your child before you see the provider How you can get the care that is needed Behavioral Health and Substance Abuse Services The Behavioral Health and Substance Abuse Services line is available to members 24 hours a day, 7 days a week at (TTY 711). It is a free service which you can hear in English or Spanish. For other languages, interpreter services are available. You can call the Behavioral Health and Substance Abuse Services line for help in getting services. If your child has an emergency, you should call 911 or go to the nearest hospital emergency room right away. Other important phone numbers If you have an emergency, you should call 911 or go to the nearest hospital emergency room right away. If you have questions regarding eligibility, call CHIP at If you need help finding a pharmacy or if you have problems getting prescriptions filled, call Dell Children s Health Plan at (TTY 711) If you need help with vision care, call Superior Vision of Texas at If you have dental questions, call your child s CHIP dental plan, DentaQuest at or MCNA Dental at If you have questions about your child s development, call the Texas Early Childhood Intervention Program at YOUR DELL CHILDREN S HEALTH PLAN ID CARD What does my child s Dell Children s Health Plan ID card look like? You will get your child s Dell Children s Health Plan ID card in the mail from us. Please carry it with you at all times. Show it to any provider or hospital you visit. You do not need to show your child s ID card before getting emergency care. Here is what your child s Dell Children s Health Plan ID card looks like: 2

14 How do I read and use my child s Dell Children s Health Plan ID card? The card tells providers and hospitals your child is a member of Dell Children s Health Plan. It also says that Dell Children s Health Plan will pay for the medically needed benefits listed in the Benefits for CHIP and CHIP Perinate Newborns section of this handbook. Your copayments are listed, too. In case of emergency, call 911 or go to the closest emergency room. After treatment, call your child s PCP within 24 hours or as soon as possible. Your child s Dell Children s Health Plan ID card lists many of the important phone numbers you need to know, like our Member Services department and 24-hour Nurse HelpLine. You can also call Member Services and ask for and ID card in Spanish. How do I replace my child s Dell Children s Health Plan ID card if it is lost or stolen? If your child s ID card is lost or stolen, call us toll-free at (TTY 711) right away. We will send you a new one. You may also print a new ID card from our website at dellchildrenshealthplan.com/members. You will need to register and log in to the website to access ID card information. PRIMARY CARE PROVIDERS FOR CHIP MEMBERS AND CHIP PERINATE NEWBORN MEMBERS What is a primary care provider? Dell Children s Health Plan members must have a family doctor, also called a primary care provider. Your child s doctor must be in the Dell Children s Health Plan network. Your child s doctor will give your child a medical home. That means that the doctor will get to know your child and your child s health history and be able to help your child get the best possible care. Your child s doctor will give your child all of the basic health services needed. Your child s doctor will also send your child to other doctors or hospitals when he or she needs special care. When you enrolled your child in Dell Children s Health Plan, you should have picked a doctor. If you did 3

15 not, we assigned one. We picked one who should be close to you. This doctor's name and phone number are on your child s Dell Children s Health Plan ID card. What do I need to bring to my child s doctor s appointment? When you go to the doctor's office for your child s appointment, bring your child's ID card, shot records, and any medicines he or she is taking. Can a clinic (local public health clinic, rural health clinic, federally qualified health center) be my child s primary care provider? Yes, clinics listed in the Dell Children s Health Plan provider directory can be your child s primary care provider. How can I change my child s primary care provider? If you need to change your child s primary care provider, you can visit our website at dellchildrenshealthplan.com/members. You can also call Member Services at (TTY 711) to request a provider directory or let us help you pick a new doctor. How many times can I change my child s primary care provider? There is no limit on how many times you can change your child s primary care provider. You can change primary care providers by calling us toll-free at (TTY 711) or writing to us at the address in the front of this book. When will my child s primary care provider change become effective? We can change your child s primary care provider on the same day you ask for the change. The change will be effective immediately. Call the doctor s office if you want to make an appointment. If you need help, call Member Services. We will help you make the appointment. Are there any reasons why my request to change my child s primary care provider may be denied? You will not be able to change your child s doctor if: The doctor you have picked cannot take new patients The new doctor is not a part of the Dell Children s Health Plan network Can a primary care provider move my child to another primary care provider for noncompliance? Yes, your child s doctor may ask for your child to be changed to another doctor. He or she may do this if: You do not follow his or her medical advice over and over again Your child s doctor agrees that a change is best for your child Your child s doctor does not have the right experience to treat your child The assignment to your child s doctor was made in error 4

16 What if I choose to go to another doctor who is not my child s primary care provider? If you want your child to go to a doctor who is not his or her primary care provider, please talk to your child s doctor first. In most cases, your child s doctor needs to give you a referral so your child can see another doctor. This is done when your child s doctor cannot give him or her the care needed. Please read the What if my child needs to see a special doctor (specialist)? section of this handbook to learn more about referrals. If you go to a doctor that your child s doctor has not referred you to, the care your child receives may not be covered by Dell Children s Health Plan. Also read the Services that do not need a referral section for more information. How do I get medical care after my child s primary care provider s office is closed? If you have a medical concern that you need to discuss with your child s provider after the office is closed, call the number on your child s ID card. If it is not an emergency, someone should call you back within 30 minutes to tell you what to do. You may also call our Nurse HelpLine 24 hours a day, 7 days a week for help. If you think your child needs emergency care (see the What is emergency medical care? section), call 911 or go to the nearest emergency room right away. PHYSICIAN INCENTIVE PLANS Dell Children s Health Plan rewards doctors for treatments that reduce or limit services for people covered by CHIP. This is called a physician incentive plan. You have the right to know if your child s primary care provider (main doctor) is part of this physician incentive plan. You also have a right to know how the plan works. You can call (TTY 711) to learn more about this. CHANGING HEALTH PLANS What if I want to change health plans? You are allowed to make health plan changes: For any reason within 90 days of enrollment in CHIP and once thereafter; For cause at any time; If you move to a different service delivery area; and During the annual CHIP re-enrollment period. Who do I call? For more information, call CHIP toll-free at How many times can I change health plans? Generally you can only change health plans once a year during annual CHIP re-enrollment. However, you are also allowed to change health plans for any reason within 90 days of enrollment in CHIP and for cause at any time. You can also change health plans if you move to a different service delivery area. When will my health plan change become effective? Health plan changes become effective the following month if processed prior to the monthly cut-off date. If the change is processed after cut-off, it will become effective the first of the following month. 5

17 Can Dell Children s Health Plan ask that I get dropped from their health plan? There are several reasons your child could be disenrolled from Dell Children s Health Plan without asking to be disenrolled. These are listed below. If you have done something that may lead to disenrollment, we will contact you. We will ask you to tell us what happened. Your child could be disenrolled from Dell Children s Health Plan if: Your child is no longer eligible for CHIP You let someone else use your child s Dell Children s Health Plan ID card You try to hurt a provider, a staff person, or Dell Children s Health Plan associate You steal or destroy property of a provider or Dell Children s Health Plan You go to the emergency room over and over again when you do not have an emergency You go to doctors or medical facilities outside the Dell Children s Health Plan over and over again You try to hurt other patients or make it hard for other patients to get the care they need You interfere with the care plan that is being provided If you have any questions about your enrollment, call Member Services. COVERAGE FOR NEWBORNS An unborn child who is enrolled in the CHIP Perinate program will be moved to Medicaid for 12 months of continuous Medicaid coverage, beginning on the date of birth, if the child lives in a family with an income at or below the Medicaid eligibility threshold. An unborn child will continue to receive coverage through the CHIP Perinate Newborn program after birth if the child is born to a family with an income above the Medicaid eligibility threshold. A CHIP Perinate Newborn is eligible for 12 months of continuous enrollment, beginning with the month of enrollment as a CHIP Perinate unborn child. Once a CHIP Perinate Newborn member s coverage expires, the child will be added to any active CHIP program case for siblings. If there is not an active case for siblings, the family will receive a CHIP renewal form in the 10th month of the child s CHIP Perinate Newborn coverage. The renewal form must be completed and submitted to continue benefits. BENEFITS FOR CHIP AND CHIP PERINATE NEWBORN MEMBERS What are my child s CHIP and CHIP Perinate newborn program benefits? The following list shows some of the health-care benefits covered. For a complete listing of covered benefits, please see the Evidence of Coverage and Schedule of Benefits and Exclusions in Attachment A at the back of this handbook. Regular checkups and office visits Prescription drugs and vaccines Access to medical specialists and mental health care Hospital care and services Medical supplies, X-rays, and lab tests Treatment of special health needs Treatment of pre-existing conditions 6

18 Coverage for CHIP and CHIP Perinate Newborn members is the same. How do I get these services for my child? Your child s primary care provider will give your child the care needed or refer you to a doctor that can give the care needed. If you have a question or are not sure whether we offer a certain benefit, you can call Member Services for help. Are there any limits to any covered services? Yes. Covered services must be medically necessary and in certain cases must be authorized. See the Evidence of Coverage and Schedule of Benefits and Exclusions in Attachment A at the back of this handbook for limits to covered services. What are the CHIP Perinate Newborn benefits? What benefits does my baby receive at birth? If your baby is eligible as a CHIP Perinatal Newborn, he or she is eligible for the same coverage as a CHIP member from the date of birth. Your baby will get 12 months of continuous CHIP Perinatal program coverage through his or her health plan, beginning with the month of enrollment as an unborn child. What benefits are not covered? For a complete listing of benefits that are not covered, please see the Evidence of Coverage and Schedule of Benefits and Exclusions in Attachment A at the back of this handbook. For questions about services not covered by Dell Children s Health Plan, please call Member Services. What are my prescription drug benefits? Under CHIP, Dell Children s Health Plan pays for most medicine your doctor says you need. Your doctor will write a prescription so you can take it to the drugstore or may be able to send the prescription for you. What are copayments? Copayments are the amounts that a member is required to pay when getting certain CHIP covered services. You must pay the copayment at the time a health-care service is received. These can be different based on family income and the kind of service. Some services do not have copayments like well-child or well-baby visits or immunizations (shots). No copayments are paid for preventive care and pregnancy-related services. Your child s Dell Children s Health Plan ID card lists the copayments that apply to your family situation. Present your child s ID card when you get office visit services or have a prescription filled. You do not have to show your child s ID card before he or she gets emergency care. If the cost of a covered service is less than the member s copayment, the member will be required to pay no more than the cost of the covered service. How much are they and when do I have to pay them? The following table shows the CHIP copayment schedule according to family income. Enrollment fees and copayments do not apply for CHIP Perinate Newborn members and CHIP members who are Native Americans or Alaskan Natives. 7

19 Federal Poverty Levels At or Below 100% Above 100% up to and including 150% Above 150% up to and including 185% Above 185% up to and including 200% Office Visits Nonemergency Room Visits Hospital Stays (per admission) Prescription Generic Drugs Prescription Brand Drugs $3 $3 $15 $0 $3 $5 $5 $35 $0 $5 $20 $75 $75 $10 $35 $25 $75 $125 $10 $35 Annual Cost Sharing Caps 5% cap of family annual gross income 5% cap of family annual gross income 5% cap of family annual gross income 5% cap of family annual gross income What are CHIP cost-sharing caps? The member guide you received from CHIP when you enrolled includes a tear out form that you should use to track your CHIP expenses. To make sure that you do not exceed your cost-sharing limit, please keep track of your CHIP-related expenses on this form. The enrollment packet welcome letter tells you exactly how much you must spend before you are eligible to mail the form back to CHIP. If you have misplaced your welcome letter, please call CHIP at 2-1-1, and they will tell you what your annual cost-sharing limit is. When you reach your annual cap, please send the form to CHIP, and they will notify Dell Children s Health Plan. We will send you a new member ID card. This new card will show that no copayments are due when your child gets services. When will I get an explanation of benefits? There may be times when you will need to pay a provider for all or part of the cost for a service your child gets. You may also have to pay part of the cost for a prescription. This will happen if you owe a copayment or if you must meet a deductible. You must also pay a provider for services your child gets that are not covered under CHIP. We will send you an Explanation of Benefits (EOB) only if you must pay the provider a payment to meet your deductible or if the service is not covered. The EOB will tell you how much you owe the provider. It will explain why you owe the provider a payment. We will also let the provider know how much you owe. You will need to make a payment directly to the provider. You will not get an EOB if you only have to pay a copayment. This is because a copayment should be paid at the time that you see the provider or get the prescription. What extra benefits does a member of Dell Children s Health Plan get? How can I get these benefits for my child? Dell Children s Health Plan covers extra health-care benefits for CHIP and CHIP Perinate Newborn members. These extra benefits are also called Value-added Benefits (VABs). We give you these benefits to help keep you healthy and to thank you for choosing Dell Children s Health Plan as your health-care plan. Call Member Services 8

20 for more information on the extra benefits you can get or visit our website at dellchildrenshealthplan.com/members. Value-added Benefit Our 24-hour Nurse HelpLine nurses are available 24 hours a day, 7 days a week for your health-care questions How to Get It Call (TTY 711) Vision Hardware and Contact Lenses: You can get up to $100 off the price of upgraded eyeglass lenses and frames every 2 years. Members ages can get up to $100 for contact lenses instead of glasses every 2 years. Call Superior Vision of Texas at Help getting a ride to doctor visits for members with chronic illnesses Call (TTY 711) One free sports or school physical every year for members age 6-18 Free basic Boys & Girls Club membership where available for members in Bastrop, Hays, Travis and Williamson counties YMCA membership for Greater Williamson County for families on Dell Children s Health Plan. YMCA Youth Sport Session: You can get one YMCA youth sports session, such as flag football, soccer, volleyball, basketball, baseball, kickball, or t-ball, each year for members ages 5-14 in Hays, Travis, and Williamson counties. Free cellphone and up to 250 minutes of services each month if you qualify, plus: 200 extra one-time bonus minutes when you choose to receive free health text messages from Dell Children s Health Plan See your primary care provider Go to your local Boys & Girls Club or call (TTY 711) for assistance. Call (TTY 711) Call (TTY 711) or go to healthplan.com for more information Unlimited inbound text messages plus free health and wellness and renewal reminder texts from Dell Children s Health Plan Unlimited minutes when calling our Member Services line Minutes include international calling if available Allergy-free pillow cover: 1 allergy-free pillow cover each year for certain members with asthma ages 0-20 in our disease management program. Dell Children s Health Plan recognizes the importance of education for pregnant women. Call (TTY 711). Ask to speak with Case Management Call (TTY 711) Dell Children s Health Plan will provide a $25 gift card upon completion of a maternity class held at a Dell Children s Health Plan facility. $25 gift card for pregnant members for getting a prenatal checkup 9

21 Value-added Benefit How to Get It within 42 days of enrollment or in the first trimester and a $25 gift card for completing a post-partum visit within 21 to 56 days after delivery. Smoking/tobacco cessation help Counseling and nicotine replacement therapy products are available for members who are age 18 after all CHIP benefits are used. Members receive a $20 gift card each year for receiving their timely annual well-child exam ages 3 through 18 years in accordance with the state schedule. Child booster seat Car booster seat for members age 4 to 12 who get an Initial Health Assessment or an annual Well Child Checkup within 90 days of enrollment to the plan. Safety helmet Safety helmet for members age 3 to 18 who get an Initial Health Assessment or an annual Well Child Checkup within 90 days of enrollment to the plan. Behavioral Health Bonus: Free behavioral health assessment and navigation by trained resource navigators. Call (TTY 711) Call Member Services at (TTY 711) Call Member Services at (TTY 711) Call Member Services at (TTY 711) Call Member Services at (TTY 711) What health education classes does Dell Children s Health Plan offer? Dell Children s Health Plan works to keep your child healthy with our health education programs. We can help you find classes near your home. You can call Member Services to find out where and when these classes are held. Some of the classes include childbirth, infant care, parenting, pregnancy, and protecting yourself from violence. HEALTH CARE AND OTHER SERVICES FOR CHIP MEMBERS AND CHIP PERINATE NEWBORN MEMBERS What does medically necessary mean? Covered services for CHIP Members, CHIP Perinate Newborn Members, and CHIP Perinate Members must meet the CHIP definition of "Medically Necessary." A CHIP Perinate Member is an unborn child. Medically Necessary means: 1. Health-care services that are: Reasonable and necessary to prevent illnesses or medical conditions, or provide early screening, interventions, or treatments for conditions that cause suffering or pain, cause physical deformity or limitations in function, threaten to cause or worsen a disability, cause illness or infirmity of a member, or endanger life; Provided at appropriate facilities and at the appropriate levels of care for the treatment of a member s health conditions; 10

22 Consistent with health-care practice guidelines and standards that are endorsed by professionally recognized health-care organizations or governmental agencies; Consistent with the member s diagnoses; No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency; Not experimental or investigative; and Not primarily for the convenience of the member or provider; and 2. Behavioral health-care services that: Are reasonable and necessary for the diagnosis or treatment of a mental health or chemical dependency disorder, or to improve, maintain, or prevent deterioration of functioning resulting from such a disorder; Are in accordance with professionally accepted clinical guidelines and standards of practice in behavioral health care; Are furnished in the most appropriate and least restrictive setting in which services can be safely provided; Are the most appropriate level or supply of service that can safely be provided; Could not be omitted without adversely affecting the member s mental and/or physical health or the quality of care rendered; Are not experimental or investigative; and Are not primarily for the convenience of the member or provider. If you have questions regarding an authorization, a request for services, or a utilization management question, you can call Member Services at (TTY 711). How is new technology evaluated? The Dell Children s Health Plan Medical Director and participating providers review and evaluate new medical advances in technology (or the new application of existing technology) in medical procedures, behavioral health procedures, pharmaceuticals, and devices to determine their appropriateness for covered benefits. Scientific literature and government approval are reviewed for determining if the treatment is safe and effective. The new medical advance or treatment (or new application of existing technology) must provide equal or better outcomes than the existing covered benefit treatment or therapy for it to be considered for coverage by Dell Children s Health Plan. What is routine medical care? In most cases when your child needs medical care, you call your child s primary care provider to make an appointment. These visits will cover most preventive care, minor illnesses, and injuries. This type of care is known as routine care. How soon can I expect my child to be seen? Your child should be able to see his or her doctor within 2 weeks for routine care. What is urgent medical care? The second type of care is urgent medical care. There are some injuries and illnesses that are not emergencies but can turn into emergencies if they are not treated within 24 hours. Some examples are: Throwing up Minor burns or cuts Earaches Headaches 11

23 Sore throat Fever over 101 degrees Muscle sprains/strains For urgent care, you should call your child s doctor. Your child s doctor will tell you what to do. The doctor may tell you to go to his or her office right away, or you may be told to go to some other office to get immediate care. You should follow the doctor's instructions. In some cases, the doctor may tell you to go to the emergency room at a hospital for care. See the next section about emergency care for more information. You can also call our 24-hour Nurse HelpLine at (TTY 711) for advice about urgent care. How soon can I expect my child to be seen? Your child should be able to see a provider within 24 hours for an urgent care appointment. What is emergency medical care? After routine and urgent care, the third type of care is emergency care. If you need help deciding whether to go to the emergency room, call our 24-hour Nurse HelpLine. The most important thing is to get medical care as soon as possible. What is an Emergency, an Emergency Medical Condition, and an Emergency Behavioral Health Condition? Emergency care is a covered service. Emergency care is provided for Emergency Medical Conditions and Emergency Behavioral Health Conditions. Emergency Medical Condition is a medical condition characterized by sudden acute symptoms, severe enough (including severe pain), that would lead an individual with average knowledge of health and medicine, to expect that the absence of immediate medical care could result in: Placing the member s health in serious jeopardy; Serious impairment to bodily functions; Serious dysfunction of any bodily organ or part; Serious disfigurement; or In the case of a pregnant CHIP member, serious jeopardy to the health of the CHIP member or her unborn child. Emergency Behavioral Health Condition means any condition, without regard to the nature or cause of the condition, which in the opinion of an individual, possessing average knowledge of health and medicine: Requires immediate intervention or medical attention without which the member would present an immediate danger to himself/herself or others; or Renders the member incapable of controlling, knowing, or understanding the consequences of his/her actions. What are Emergency Services and/or Emergency Care? Emergency Services and Emergency Care means health care services provided in an in-network or out-ofnetwork hospital emergency department, free-standing emergency medical facility, or other comparable facility by in-network or out-of-network physicians, providers, or facility staff to evaluate and stabilize Emergency Medical Conditions or Emergency Behavioral Health Conditions. Emergency services also include any medical screening examination or other evaluation required by state or federal law that is necessary to determine whether an Emergency Medical Condition and/or an Emergency Behavioral Health Condition exists. How Soon Can I Expect My Child to Be Seen? Your child should be able to see a doctor immediately for emergency care. 12

24 Are Emergency Dental Services Covered? Dell Children s Health Plan will pay for some emergency dental services provided in a hospital, urgent care center, or ambulatory surgical center setting such as services for: Treatment of a dislocated jaw. Treatment of traumatic damage to teeth and supporting structures. Removal of cysts. Treatment of oral abscess of tooth or gum origin. Treatment for craniofacial anomalies. Drugs for any of the above conditions. Dell Children s Health Plan also covers other dental services your child gets in a hospital, urgent care center, or ambulatory surgical center setting. This includes services from the doctor and other services your child might need like anesthesia. What do I do if I need/my child needs Emergency Dental Care? During normal business hours, call your child s Main Dentist to find out how to get emergency services. If your child needs emergency dental services after the Main Dentist s office has closed, call us toll-free at (TTY 711). How soon can I see my doctor? Dell Children s Health Plan works with the providers in our network to make sure you can see them when you need to. Our providers are required to follow access standards listed below. Standard Name Dell Children s Health Plan Emergency Services Urgent Care Routine Primary Care Routine Specialty Care Preventive Health: Child Preventive Health: Newborn Prenatal Care Pregnancy High Risk/3rd trimester Behavioral Health Non-life-threatening Emergency Behavioral Health Urgent Care Behavioral Health-Routine Care After-Hours Care As soon as you arrive at the provider for care Within 24 hours of request Within 14 days of request Within 3 weeks of request Within 60 days of request Within 14 days of request Within 14 days of request Within 5 days of request or immediately, if an emergency exists Within 6 hours of request Within 24 hours of request The earlier of 10 business days or 14 calendar days from request Primary care providers are available 24/7 directly or through an answering service. Refer to the How do I get medical care after my primary care provider s office is closed? section of this handbook. What is post-stabilization? Post-stabilization care services are services covered by CHIP that keep your child s condition stable following emergency medical care. 13