The Healthy Families Program Exclusive Provider Organization (EPO) Member Services Guide Evidence of Coverage

Transcription

1 The Healthy Families Program Exclusive Provider Organization (EPO) Member Services Guide Evidence of Coverage Effective October 1, 2012 to September 30, 2013 Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Healthy Families is a service mark of the Managed Risk Medical Insurance Board. Express Scripts, Inc is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members CA /12

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3 Welcome to Anthem Blue Cross Healthy Families Program Thank you for choosing our plan. You now are a member of Anthem Blue Cross. We work with the state of California to bring you the Healthy Families Program health insurance. Now that you are part of this health plan family, we want to make sure you get the best from us and your membership. This book is called a Member Services Guide/ Evidence of Coverage. It tells you how to use your new health plan. Here is what you will find inside: How your health plan works Which services are covered and which are not How to get help if you don t understand part of your plan How to get help if you have a problem with us or a health care provider Your member rights Your member responsibilities How we keep your information private Free health programs to help keep you well A 24-hour phone line to call if you need to talk to a registered nurse or want access to more than 300 audio health topics (24/7 NurseLine phone numbers are listed at the bottom of each right-hand page of this book.) Our Member Services phone numbers listed at the bottom of each right-hand page } } A special symbol that looks like this to show you when you need an OK from Anthem Blue Cross or your doctor before you get care. Member Services /7 NurseLine: TTY lines are for members with hearing or speech loss only. anthem.com/ca

4 Check for your Anthem Blue Cross member ID card Your Anthem Blue Cross member ID card was sent to you separately. Did you get it? If not, call us toll-free at If you have hearing or speech loss, you may call our TTY line at One-on-One Help Close to Your Home We have staff members who live in your community to help you. They are called community resource coordinators. To learn more about our community resource coordinators, call us toll-free at If you have hearing or speech loss, you may call our TTY line at Tell us if you move If you move, we could still be your health plan. When you move, please remember to call or write to us and give us your new address. Our phone number is If you have hearing or speech loss, you may call our TTY line at And here s our address: Anthem Blue Cross PO Box 9054 Oxnard CA Questions? Comments? If you have any questions, please call us toll-free at Monday through Friday from 7 a.m. to 7 p.m. If you have hearing or speech loss, you may call our TTY line at You also may call 24/7 NurseLine, the 24-hour nurse help line, toll-free 24 hours a day, seven days a week. That phone number is The 24/7 NurseLine TTY line for members with hearing or speech loss is

5 The Healthy Families Program Combined Evidence of Coverage and Disclosure Form This Combined Evidence of Coverage and Disclosure Form constitutes only a summary of the Health Plan s policies and coverage under the Healthy Families Program (HFP). The Health Plan contract and the HFP regulations (California Code of Regulations, Title 10, Chapter 5.8) issued by the California Managed Risk Medical Insurance Board (MRMIB), should be consulted to determine the exact terms and conditions of coverage. These regulations may be viewed on the Internet at mrmib.ca.gov. Additionally, the HFP regulations require the Health Plan to comply with all requirements of the Knox-Keene Health Care Service Plan Act of 1975, as amended (California Health and Safety Code, section 1340, et seq.), and the Act s regulations (California Code of Regulations, Title 28). Any provision required to be a benefit of the program by either the Act or the Act s regulations shall be binding on the Health Plan, even if it is not included in the Evidence of Coverage booklet or the Health Plan contract. Terms in this book In this book, you, your, and member refers to the child or children enrolled in the Healthy Families Program. We, us, and our refers to Anthem Blue Cross. Provider, plan provider, or participating provider refers to a licensed doctor, hospital, medical group, pharmacy or other health care provider that gives you health care services. Member Services /7 NurseLine: TTY lines are for members with hearing or speech loss only. anthem.com/ca

6 Eligibility and enrollment Information about eligibility, enrollment, disenrollment, the starting date of coverage, transfers to another health plan, annual requalification, premium payments and the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) is included in the Healthy Families Program Handbook that was mailed to you by the Healthy Families Program. If you have questions on these topics or would like another copy of the Handbook, please contact the Healthy Families Program at the following address or toll-free telephone number: The Healthy Families Program PO Box Sacramento CA If you have hearing or speech loss, you may call the California Relay Service at 711 (TTY). To learn more about the Healthy Families Program, visit the MRMIB website at mrmib.ca.gov.

7 Prior OK Table of contents Part 1 Introduction...3 This symbol tells you when you need an OK ahead of time by Anthem Blue Cross, or your doctor, for these services to be covered by Anthem Blue Cross. Part 2 Definitions...5 Part 3 Your health care rights and responsibilities...11 Part 4 Accessing care...13 Part 5 How to use your health plan...15 Part 6 How to get prescription drugs...25 Part 7 Emergency and urgent care services...29 Part 8 What Anthem Blue Cross covers...33 Part 9 Benefit descriptions...43 Part 10 Programs to help keep you well...63 Part 11 Coordination of services...67 Part 12 Part 13 What Anthem Blue Cross does not cover...71 How to resolve a problem with Anthem Blue Cross...73 Part 14 General information...79 Part 15 Other things you may need to know...83 Part 16 Important phone numbers...85 Part 17 Map of the plan s service area...87 Member Services /7 NurseLine: TTY lines are for members with hearing or speech loss only. anthem.com/ca 1

8 Important things to do Keep your Anthem Blue Cross ID card with you at all times. Show it every time you need health care services. Do not let anyone else use your card. Set up an initial health assessment with your doctor right away. During the first exam, the doctor can learn about the patient s health care needs and help him or her stay healthy. Call your doctor before you get medical care, unless it is an emergency. The staff in your doctor s office will help you make an appointment for care. If it is an emergency, get help right away. Call 911 or go to the nearest emergency room for medical care. You do not need an OK from us or your doctor for emergency care. It does not matter if you are inside or outside of our service area. You will be covered for emergency services in the U.S. even if the provider is not part of your network. If you are not sure what to do, you can call 24/7 NurseLine, the 24-hour nurse help line. The toll-free phone number is The 24/7 NurseLine TTY line for members with hearing or speech loss is Have your Anthem Blue Cross ID card ready when you call. The nurse will ask for your member ID number. You are important to us. We want to help you get the health care you need. Thank you for choosing Anthem Blue Cross. 2

9 INSERT PHOTO Part 1 Introduction 24/7 NurseLine 24-hour nurse help line Help in other languages Your Anthem Blue Cross member ID card

10 Part 1 Introduction Welcome to Anthem Blue Cross and the Healthy Families Program. We are glad you are part of the Anthem Blue Cross family. If you have any questions about your health plan please call our toll-free Member Services line at the bottom of the page. If you have hearing or speech loss, you may call our toll-free TTY line. 24/7 NurseLine 24-hour nurse help line If you have a health concern, you can call 24/7 NurseLine, the 24-hour, toll-free nurse help line. This service has registered nurses who can help you: With health care decisions. Decide when to visit your doctor. Teens can discuss their special health care concerns with a registered nurse. The call is private and free. When you call the 24/7 NurseLine number, you also can access audiotapes on more than 300 health topics. If you have hearing or speech loss, you may call the toll-free 24/7 NurseLine TTY number. Help in other languages If you, or someone you choose to represent you, would prefer to speak in a language other than English, call us at our toll-free Member Services or TTY number (for those with hearing or speech loss). We can help you find a doctor who speaks your language or who has an interpreter on staff. You do not have to use family members or friends as interpreters. If you cannot find a doctor who meets your language needs, we can provide an interpreter for you at no charge. You also may get this book and other health plan materials, in English, Spanish, Korean, Chinese or Vietnamese. Please call our toll-free Member Services or TTY number (for those with hearing or speech loss). Your Anthem Blue Cross member ID card You have received an Anthem Blue Cross ID card for each child who is enrolled. Show this card to the staff in the doctor s office, hospital or pharmacy when you go for health care services. Look on your ID card for the important phone numbers you need: Your doctor 24/7 NurseLine the 24-hour nurse help line The Anthem Blue Cross toll-free Member Services (and TTY) numbers The prescription drug services number The Anthem Blue Cross Behavioral Health Program number Always carry your Anthem Blue Cross ID card with you in case of an emergency. The member listed on the card is the only person who can get health care services with that Anthem Blue Cross member ID card. Do not let anyone else use your Anthem Blue Cross ID card. If someone other than the member uses the card, then that person will be billed for the services he or she gets. Also, if you let someone else use your ID card, we may not be able to keep you in this health plan. If you did not get your card yet, or if you lost your card, please call our toll-free Member Services or TTY number (for those with hearing or speech loss). 4

11 INSERT PHOTO Part 2 Definitions 5

12 Part 2 Definitions Here are some of the terms used in this book: Active labor means there is not enough time to safely transfer the member to another hospital before the baby is born, or when transferring the member may pose a threat to the health and safety of the member or the unborn child. Acute condition means a medical issue where signs come on quickly due to an illness, injury or other medical problem. This issue needs prompt medical attention and does not last for a long time. Appropriately qualified health care professional means a doctor or specialist who has the clinical background, training and expertise to help people with a certain illness, disease or medical issue. Authorization means that certain services must be OK d by Anthem Blue Cross and your doctor before you get them for the services to be covered. Prior authorization means the services must be authorized before you get them. Benefits (covered services) are those services, supplies and drugs that a member can get with this health plan. A service is not a benefit (even if it is listed as a covered service or benefit in this book) if it is not medically necessary or if it is not given by a network provider with an OK by Anthem Blue Cross when needed. Benefit year means the 12-month period starting October 1 of each year at 12:01 a.m. Complaint is also called a grievance or an appeal. Examples of a complaint can be when: You can t get a service, treatment, or medicine you need. Your plan denies a service and says it is not medically necessary. You have to wait too long for an appointment. You got poor care or were treated rudely. Your plan does not pay you back for emergency or urgent care that you had to pay for. You get a bill that you believe you should not have to pay. Copay is a fee, which a provider may collect from a member, for a covered benefit at the time the service is given. Emergency care is a medical or psychiatric condition with such severe symptoms (including active labor or severe pain) that a prudent layperson, who has an average knowledge of health and medicine, could reasonably believe the lack of immediate medical attention could: Place your health (or the health of your unborn child) in jeopardy Cause impairment to a body function Cause dysfunction of a body organ or part Evidence of Coverage and Disclosure Form (EOC) is the name of this book, which describes your coverage and benefits. Exclusion means any medical, surgical, hospital or other treatment that Anthem Blue Cross does not cover. Experimental or investigational service is any treatment, therapy, procedure, supplies, drugs or their use, facilities or their use, equipment or its use, devices or their use, that does not follow generally accepted professional medical standards, or it has not been decided if it is safe and efficient for treating a certain illness, injury or medical issue. Federal Poverty Income Guideline means the federal poverty income guideline set each year by the U.S. Department of Health and Human Services. The guidelines are used to determine eligibility for certain programs such as HFP or Medi-Cal. The poverty guidelines are sometimes referred to as the federal poverty level (FPL). 6

13 Definitions Grievance is a written or oral notice of a problem with Anthem Blue Cross, or a provider and includes quality of care concerns. This can be a complaint, dispute, request for reconsideration or an appeal made by you, or someone you choose to represent you. When we are not sure if the notice is a grievance or a question, it will be seen as a grievance. Healthy Families Program is the state program run by the Managed Risk Medical Insurance Board (MRMIB). This program gives medical, dental and vision coverage to children who meet the eligibility and income requirements. Families make a monthly payment to be on the program. Hospital is a health care facility licensed by the state of California, and accredited by the Joint Commission on Accreditation of Health Care Organizations, as either: An acute care hospital. A psychiatric hospital. A hospital operated mainly for the treatment of alcoholism and/or substance abuse. This does not include a facility that is mainly a rest home, a nursing home or a home for the aged. Nor does it include the skilled nursing facility part of a hospital. Income Category A, B or C means how much you pay for the monthly premium and copayments as determined by your income category. The income categories are determined based on the current Federal Poverty Income Guidelines as follows: Income Category A = 100%-150% of the Federal Poverty Income Guideline Income Category B = 151%-200% of the Federal Poverty Income Guideline Income Category C = 201%-250% of the Federal Poverty Income Guideline Inpatient care means you have to stay in a hospital or other facility overnight for the medical care you need. Managed Risk Medical Insurance Board (MRMIB) is the state agency that runs the Healthy Families Program. Part 2 Member Services /7 NurseLine: TTY lines are for members with hearing or speech loss only. anthem.com/ca 7

14 Part 2 Definitions Medically necessary means health care services or products that are: Given in line with professionally recognized standards of practice. Chosen by the treating doctor to be useful for the medical issue. Given at the right type, supply and level of service, while considering the risks, benefits and other options. Member is a person who joins Anthem Blue Cross for his or her health care. In this book, a member also is referred to as you. Member ID card is the ID card given to members by Anthem Blue Cross. This card has: The member ID number. The provider contact information. Important phone numbers. Mental health care services means psychotherapy, counseling, medical management, or other services most commonly given by a psychiatrist, psychologist, licensed clinical social worker, or marriage and family therapist, to diagnose or treat mental or emotional disorders or the mental or emotional problems that have to do with an illness, injury or any other condition. Nonparticipating provider is a provider who does not have a contract with Anthem Blue Cross to provide services to members. Nonpreferred drug is a prescription drug or supply, which is not listed on the PDL. To be covered, these need an OK from us. Orthotic device is a support or brace made to support a joint or muscle that is weak or does not work the way it should, or to improve the function of movable body parts. Outpatient care means you do not have to stay overnight in a hospital or other facility for the medical care you need. Out-of-area services are emergency or urgent care services given outside of the Anthem Blue Cross service area. These services could not be delayed until the member returned to the service area. Participating provider or plan provider is a doctor or facility that has a contract with us at the time you get covered services. Plan is the Anthem Blue Cross EPO plan described in this book and run by us for the state of California. Plan doctor is a doctor of medicine or osteopathy who: Gives a service covered under this Evidence of Coverage. Is licensed in the state where he or she practices. Practices within the scope of his or her license. Has a contract with Anthem Blue Cross to give covered services to members as stated in this agreement. Preferred drug list (PDL) is a list of brand-name and generic prescription drugs and supplies that Anthem Blue Cross prefers as the first line of drug therapy. Even though a drug or supply is on the PDL, your doctor may not order it for your health issue. Prosthetic device is a man-made device used to replace a body part. Provider is any of these: Doctor Hospital Skilled nursing facility Other licensed health professional Other licensed health facility Other licensed home health agency 8

15 Definitions Provider Directory is the book that lists the providers that have a contract with Anthem Blue Cross to give covered services. Psychiatric Emergency Medical Condition means a mental disorder with acute signs severe enough to cause either a harm to yourself or others, or you are not able to provide for or use, food, shelter or clothing due to the mental disorder. Serious chronic condition means a medical issue that is caused by a disease, illness or other medical problem or disorder that: Is serious and does not go away. Gets worse over time. Needs ongoing treatment to control signs or keep it from getting worse. Serious Emotional Disturbance (SED) means a diagnosed mental condition in a child that is not a substance abuse disorder or developmental disorder. A child with SED also behaves in a way that is not appropriate for the child s age. A county mental health department decides if a child has SED based on California Law (Welfare and Institutions Code Section (a)(2)). In making that decision, the county will consider whether a child has certain problems. These could include trouble taking care of himself or herself, problems at school or problems with family relationships. The child also might have other problems such as being at risk of suicide or violence. Or, the child might meet the state s Special Education requirements. The county also may look at whether the child is at risk of being removed from the home and how long the condition is expected to last. Service area means the parts of California where you can get Anthem Blue Cross. Your service area is within 30 minutes travel time or 15 miles of where you live or work. Severe Mental Illnesses (SMI) means: Schizophrenia Schizoaffective disorder Bipolar disorder (manic-depressive illness) Major depressive disorders Panic disorder Part 2 Member Services /7 NurseLine: TTY lines are for members with hearing or speech loss only. anthem.com/ca 9

16 Part 2 Definitions Obsessive-compulsive disorder Pervasive developmental disorder or autism Anorexia nervosa Bulimia nervosa Skilled nursing facility is a place that gives you 24-hour-a-day nursing services that only trained health professionals may give. Specialist is a plan doctor who gives you services within his or her area of practice. You do not need a referral for some specialty services. Terminal illness means a medical condition that cannot be reversed or cured and most likely will cause death within one year or less if the disease follows its natural course. Triage or Screening means to assess a member s health by a doctor or nurse who is trained to screen to decide if the member s need for care is urgent. Triage or Screening Waiting Time means the time waiting to speak by phone with a doctor or nurse who is trained to screen a member who may need care. Urgent care is given to you right away to keep your health from getting worse because of an illness or injury you did not expect and for which treatment cannot be delayed. 10

17 INSERT PHOTO Part 3 Your health care rights and responsibilities As an Anthem Blue Cross member, you have the right to: As an Anthem Blue Cross member, your responsibilities are to:

18 Part 3 Your health care rights and responsibilities As an Anthem Blue Cross member, you have the right to: Be treated with respect, dignity and the right to privacy all the time. Choose your provider from our Provider Directory. Get medical care in a timely manner. Be part of honest talks about your health care needs and treatment options, no matter the cost and whether your benefits cover them. Be part of decisions that are made by your doctors and other providers about your health care needs. Talk to your doctor about things that are private. Have your medical records kept private unless you tell us in writing that it is OK to share them or it is allowed by law. Tell us your concerns about Anthem Blue Cross and the health care services you get. Learn about us, our services, doctors and other health care providers. Learn about your rights and responsibilities. Tell us what you think about your rights and responsibilities and suggest changes. See your medical records as allowed by law. Get services from providers outside of your network in an emergency. Ask for an interpreter at no charge to you. Use interpreters who are not your family members or friends. File a complaint or an appeal about Anthem Blue Cross, any care you get or if your language needs are not met. As an Anthem Blue Cross member, your responsibilities are to: Tell us, your doctors and other health care providers what they need to know to treat you. Learn as much as you can about your health issues and work with your doctor to set up treatment goals you agree on. Ask questions about any medical issue and make sure you understand what your doctor tells you. Follow the care plan and instructions that you have agreed on with your doctors or other health care professionals. Always show your member ID card when you get health care services. Use the emergency room only in cases of an emergency or as your doctor tells you. Make and keep medical appointments and tell your doctor at least 24 hours in advance when you cannot make it. Tell us when you change your address, family status or other health care coverage. Tell us right away if you get a bill that you should not have gotten or if you have a complaint. Treat all Anthem Blue Cross staff and doctors with respect and courtesy. 12

19 Part 4 Accessing care Physical access Access for members with hearing or speech loss Access for members with vision loss The Americans with Disabilities Act of Disability access complaint

20 Part 4 Accessing care Physical access We have made every effort to ensure that the disabled have easy access to our offices and the offices and facilities of Anthem Blue Cross providers. If you are not able to find a provider with easy access, please call us toll-free at and we will help you find a provider with better access. The Member Services phone number and the TTY line (for those with hearing or speech loss) are listed at the bottom of each right-hand page. Access for members with hearing or speech loss If you have hearing or speech loss, you may call us on our TTY line at , Monday through Friday, from 7 a.m. to 7 p.m. To get the help you need between 7 p.m. and 7 a.m. and on weekends, please call the California Relay Service TTY at 711. You also may call the 24/7 NurseLine TTY line at Access for members with vision loss This Evidence of Coverage (EOC) and other important plan materials will be offered in alternative formats for members with vision loss. Members with vision loss can get this EOC, letters and other plan materials in other formats such as: Large print Computer disk format Braille Audiotape To get these other formats, or for help in reading this EOC and other plan materials, please call our toll-free Member Services or TTY number (for those with hearing or speech loss). Interpreter services are given in sign language, legal, tactile and intermediary. The Americans with Disabilities Act of 1990 Anthem Blue Cross follows the Americans with Disabilities Act (ADA) of This federal law protects you from being treated differently by us because you are disabled. Section 504 of the Rehabilitation Act of 1973 states that no qualified disabled person shall because of a disability be kept from taking part in, be denied the benefits of, or not be treated the same as others under any program or activity that gets or benefits from federal funds. Programs or activities that get money from the state of California must follow California Government Code Section 11135, which does not allow you to be treated different for any of these reasons: Race or ethnic group Religion Age Sex Color Disability Disability access complaint If you believe Anthem Blue Cross, or a provider in your network, has not met your disability access needs, you may file a complaint with us by calling our toll-free Member Services or TTY number (for those with hearing or speech loss). If your disability access complaint remains unresolved, you may contact: ADA Coordinator Managed Risk Medical Insurance Board PO Box 2769 Sacramento CA If you have hearing or speech loss, you may call the California Relay Service TTY at

21 Part 5 How to use your health plan Your Anthem Blue Cross member ID card Choosing a doctor Voluntary Medical Home Initial health assessment (IHA) Making an appointment with your doctor Continuity of care for new members Continuity of care for termination of provider Choosing a specialist Prior Authorization (an OK from Anthem Blue Cross) Getting a second medical opinion Utilization management (UM) Copayments (Copays)...22 Member liabilities

22 Part 5 How to use your health plan Your Anthem Blue Cross member ID card You have received an Anthem Blue Cross ID card for each child who is enrolled. Show this card to the staff in the doctor s office, hospital or pharmacy when you go for health care services. Look on your ID card for the important phone numbers you need: Your doctor 24/7 NurseLine the 24-hour nurse help line The Anthem Blue Cross toll-free Member Services (and TTY) number The prescription drug services number The Anthem Blue Cross Behavioral Health Program number Always carry your Anthem Blue Cross ID card with you in case of an emergency. The member listed on the card is the only person who can get health care services with that Anthem Blue Cross member ID card number. Do not let anyone else use your Anthem Blue Cross ID card. If someone other than the member uses the card, then that person will be billed for the services he or she gets. And, if you let someone else use your ID card, Anthem Blue Cross may not be able to keep you in this health plan. If you did not get your card yet, or if you lost your card, please call our toll-free Member Services or TTY number (for those with hearing or speech loss) at the bottom of the page. Choosing a doctor Voluntary Medical Home As a Healthy Families Program EPO member, you have the chance to choose a provider to serve as a Voluntary Medical Home (VMH). This is a brand new program that Anthem Blue Cross now offers. It is your choice to be part of this program. The VMH program is offered in most service areas in California, but because it is new, a VMH provider may not be offered in all areas. Through this new VMH program, you get to choose a provider (often a pediatrician or a family practice doctor) who not only gives you care when you are sick but also works with you to be healthy and to prevent disease. The VMH provider you choose will help you get access to special services you may need such as care for childhood obesity, asthma, diabetes, heart disease or pregnancy. If you decide to choose a VMH provider to work with you to be healthy and to use special services, you still have access to all doctors in the network. Choosing a VMH provider does not limit your choices in any way. In fact, your VMH provider also can help manage all of your care. For instance, your VMH provider decides if your health care needs may be covered by the California Children s Service (CCS) program. (To learn more about CCS, please see Part 11, Coordination of services.) You also can change your VMH provider or leave the program if it does not meet your needs. This will not change your membership in Anthem Blue Cross. Please call our toll-free Member Services number if you would like to know more about choosing a VMH. Members with speech or hearing loss may call our toll-free TTY line. If you do not choose a VMH, your Anthem Blue Cross Healthy Families EPO plan is a selfreferral program. This means that you can choose to see any doctor who works with Anthem Blue Cross. Look in the Provider Directory that came with your ID card for a list of doctors who work with Anthem Blue Cross. We have doctors in every California county. The Provider Directory also lists specialists, hospitals and mental health providers who work with Anthem Blue Cross. If you do not see a doctor listed in this directory, Anthem Blue Cross will not pay for those services. If you need help choosing a doctor who is right for you, give us a call and we can help. 16

23 How to use your health plan Part 5 Initial health assessment (IHA) All new members are urged to see their doctor for an initial health exam within 60 days of joining the Healthy Families Program. The first meeting with your new doctor is important. It s a time to get to know each other and review your health status. Your doctor will help you know your medical needs and tell you how to stay healthy. During the IHA, your doctor will: Get to know you and talk about your health. Learn your medical history. Give you health information you need. Teach you ways to help make your health better or to stay healthy. Give you the results of your IHA. Call your doctor s office for an appointment today. Making an appointment with your doctor Call your doctor s office for an appointment and tell the staff that you are an Anthem Blue Cross Healthy Families Program member. Have your Anthem Blue Cross ID card with you when you call. You may be asked for the numbers on the card. Call your doctor before you get any medical care, unless it is an emergency. You can reach your doctor 24 hours a day. If you call after office hours, leave your name and phone number with the answering service. Either your doctor, or the on-call doctor, will call you back. Be on time for appointments. Call your doctor s office as soon as you can if: You are going to be late. You can t keep your appointment. This helps shorten everyone s time in the waiting room. If you cancel an appointment, someone at your doctor s office can help you set up a new one. Anthem Blue Cross providers have ramps, restrooms, parking spaces and elevators for disabled members so they can get the health care they need. Member Services /7 NurseLine: TTY lines are for members with hearing or speech loss only. anthem.com/ca 17

24 Part 5 How to use your health plan Continuity of care for new members We sometimes allow new members to get health care from a doctor or hospital that is not in your network. This may be done if we believe there are medical reasons for you to stay with a provider that is not in your network. If you are a new member, you may ask for an OK for medical care from a provider who is not in your network if you were getting the care before you signed up with Anthem Blue Cross AND: You have an acute condition. (We will cover the care you get until the short-term health problem goes away.) You have a serious chronic condition. (We will cover the care you get until you complete a course of treatment and arrange for a safe transfer to another doctor. We will talk to you and your doctor about this decision. The care you get from the doctor you have now will not last for more than 12 months from the time you signed up with Anthem Blue Cross.) You are pregnant or you have just had a baby and you are still getting postpartum care (care after the baby is born). (We will cover the care you get until the end of your pregnancy.) You have a terminal illness. (We will cover the care you get for the full term of the illness. The care you get from the doctor you have now will not last for more than 12 months from the time you signed up with Anthem Blue Cross.) You have a newborn child 36 months of age or younger who is getting care. (The care given from the doctor you have now will not last for more than 12 months from the time you signed up with Anthem Blue Cross.) You have a surgery or other procedure planned that: The health plan you had before said was OK. Is being done to help treat your health problem. Your doctor, in a written statement, has said that you need. Will take place within 180 days from the date you signed up with Anthem Blue Cross. Please call us if you want to stay with the doctor you have now or if you want a copy of this policy. You may call our toll-free Member Services or TTY number (for those with hearing or speech loss). We will decide if you can get care from the doctor you have now based on your health problem. If your request is approved, you will have to pay only the copays for this plan. We will ask your doctor to agree to follow the same rules that doctors who are in your network giving the same care must follow. The rules include how your doctor gets paid. If your doctor does not agree to follow these rules, then we do not have to let you keep seeing that doctor for care. We do not have to let a new member stay with a doctor who is not in your network if: The member was covered by a different health plan. The member was getting this care when the Healthy Families Program coverage went into effect. We only cover benefits for continued care as stated here. We will call you, or call or fax your doctor, to tell you if we approve your request to keep seeing the doctor you are seeing now. If we deny your request and you do not agree with us, you can appeal. See Part 13, How to resolve a problem with Anthem Blue Cross. 18

25 How to use your health plan Part 5 If you want to know more about continuing care, you may call the Department of Managed Health Care (DMHC), which protects EPO members. The DMHC toll-free phone number is (1-888-HMO-2219). The DMHC toll-free TTY number (for those with hearing or speech loss) is You also may visit the DMHC website at hmohelp.ca.gov. Continuity of care for termination of provider If your provider or other health care provider stops working with Anthem Blue Cross, we will send you a letter 60 days before his or her contract ends. We will let you keep seeing a provider whose contract has ended if you were getting care from this provider before the contract ended AND: You have an acute condition. (We will cover the care you get until the short-term health problem goes away.) You have a serious chronic condition. (We will cover the care you get until you complete a course of treatment and arrange for a safe transfer to another doctor. We will talk to you and your doctor about this decision. The care you get from the doctor you have now will not last for more than 12 months from the time you signed up with Anthem Blue Cross.) You are pregnant or you have just had a baby and you still are getting postpartum care (care after the baby is born). (We will cover the care you get until the end of your pregnancy.) You have a terminal illness. (We will cover care you get for the full term of the illness. The care you get from the doctor you have now will not last for more than 12 months from the time you signed up with Anthem Blue Cross.) You have a newborn child who is 36 months of age or younger who is getting care. (The care given from the doctor you have now will not last for more than 12 months from the time you signed up with Anthem Blue Cross.) You have a surgery or other procedure planned that: The health plan you had before said was OK. Is being done to help treat your health problem. Your doctor, in a written statement, has said that you need. Will take place within 180 days of the time you signed up with Anthem Blue Cross. Member Services /7 NurseLine: TTY lines are for members with hearing or speech loss only. anthem.com/ca 19

26 Part 5 How to use your health plan You have a health issue that keeps getting worse or makes it harder to function (degenerative or disabling condition). If we let you stay with a doctor whose contract is ending, that doctor must agree in writing to still follow the terms of the contract while giving you care. The terms include how the doctor is paid. If the doctor does not agree with these terms, we do not have to let you stay with the doctor after the contract ends. In all cases, you will not be able to keep seeing a provider whose contract ended for these reasons: Medical disciplinary cause or reason Fraud Doing something else that was against the law Please call us if you want to stay with the doctor you have now or if you want a copy of this policy. You may call our toll-free Member Services or TTY number (for those with hearing or speech loss). We will decide if you can get care from the doctor you have now based on your health issue. If your request is approved, you will have to pay only the copays for this plan. We will call you, or call or fax your doctor, to tell you if we approve your request to keep seeing the doctor whose contract is ending. If we deny your request and you do not agree with us, you can appeal. See Part 13, How to resolve a problem with Anthem Blue Cross. If you want to know more about continuing care, you may call the Department of Managed Health Care (DMHC), which protects HMO members. The DMHC toll-free phone number is (1-888-HMO-2219). The DMHC toll-free TTY number (for those with hearing or speech loss) is You also may visit the DMHC website at hmohelp.ca.gov. Choosing a specialist When you need special care, you only may choose a doctor from the Anthem Blue Cross Provider Directory. If you have questions about a doctor in the Provider Directory, call our toll-free Member Services or TTY number (for those with hearing or speech loss). Prior Authorization (an OK from Anthem Blue Cross) Your doctor will manage your health care needs and may send you to a different provider if you need special care. Your doctor will talk with you about the best way for you to get the care you need. Your doctor may need to get an OK from us for some services for us to pay for them. Prior authorization is when both Anthem Blue Cross and your doctor agree that the service or care you get is medically necessary. These services include, but are not limited to: Inpatient and outpatient hospital care Surgery including outpatient ambulatory surgical care All infusion therapies Some drugs, including some preferred drug list drugs Speech therapy CT, MRI, MRA, PET and SPECT Organ transplants Hospice High-cost and custom-made durable medical equipment Cataract glasses and lenses, including surgery to remove a cataract and insert a lens Hearing aids and services that have to do with hearing aids Home health care 20

27 How to use your health plan Part 5 Your doctor may need to get an OK from us for other services as needed. Mental health services also need an OK from us. Before you ask for nonemergency mental health services, either you or your doctor must call the Anthem Blue Cross Behavioral Health Program at We may ask the doctor why you need special care. You may call us to find out how we make our decisions. You do not need an OK from us for these: Emergency or urgent care In-network OB/GYN services Family planning services Treatment for a sexually transmitted disease (STD) If you are not sure if you need an OK from us, talk with your doctor. You also may call our toll-free Member Services or TTY number (for members with hearing or speech loss). If there is no provider in your network to give you the care you need, your doctor will get an OK from us and refer you to a provider outside your network. If you see a specialist or get specialty care inside or outside your network before you get an OK from us, you will have to pay for the cost of the treatment. If we deny a request for specialty services, we will send you a letter telling you why the request was denied and how you can appeal if you do not agree with the denial. Getting a second medical opinion You might have questions about your illness or the care your doctor says you need. You may want to get a second opinion from another doctor. You should speak to your doctor if you want a second opinion. You or your doctor also may ask us for help. You must get services from a doctor within your network. If there is no qualified doctor in your network to give you the care you need, We will OK a second opinion from a doctor outside of your network. In this case, you will have to pay all of the copays for the second opinion. Getting a second opinion is helpful if: You have questions about a surgery your doctor says you need. You have questions about a diagnosis or treatment for a chronic condition or a health issue that could cause death or greatly weaken or cause loss of a limb or body function. Member Services /7 NurseLine: TTY lines are for members with hearing or speech loss only. anthem.com/ca 21

28 Part 5 How to use your health plan Your doctor s advice is not clear, or is hard for you to understand. Your doctor is unable to diagnose your condition or the diagnosis is in doubt due to test results that conflict with each other. The treatment you are getting has not improved your medical condition within the timeframe it should. You have tried to follow the treatment plan or talked with your doctor because you are concerned about the diagnosis or treatment plan. If we deny your request to get a second opinion and you do not agree with us, you can appeal. See Part 13, How to resolve a problem with Anthem Blue Cross. You also can get a copy of our policy by calling our toll-free Member Services or TTY number (for those with hearing or speech loss). Utilization management (UM) Your PCP or doctor works with your to decide what care is best. We always want you to have the care you need. For some health care services, your doctor may have to ask us for our OK so that the service will be paid or covered by us. This process is called Utilization Management, or UM for short. You should know that: We make coverage decisions based on care and services you need and the benefits you have. We base our decisions on whether or not the care is right for your health issues and is medically necessary. (See Part 2, Definitions to learn more about medically necessary. ) We do not reward doctors or other UM decision-makers for issuing denials. We do not offer financial incentives to UM decision-makers to encourage decisions that result in less care given. We make sure that UM staff work at least eight (8) hours day on normal business days. To find out more about our review process, please call our toll-free Member Services or TTY number (for those with hearing or speech loss). Copayments (Copays) You will be required to pay a small amount of money for some services. This is called a copay. The maximum amount of money you are required to pay in one benefit year is $250 for all children in your household. All copays paid for Healthy families members in your household count toward the $250 maximum. Make sure you keep all receipts from your doctors visits and prescription drugs for all family members enrolled in the Healthy Families Program. As soon as you have paid $250 in a benefit year, send copies of these receipts to Anthem Blue Cross at the address on your Anthem Blue Cross ID card. No Healthy Families members in your household will have to pay copays for the rest of the benefit year when Anthem Blue Cross receives your receipts. You will still need to pay copays until Anthem Blue Cross receives proof that you have paid a total of $250 in copays. If you can show that you paid more than $250 in copays between October 1, 2011 and September 30, 2012, the plan will reimburse you for the amount over $250. You have no copay for: Routine exams and care to help keep you from getting sick. Members 24 months of age and younger for well-baby care, health exams and some other office visits. Members who are American Indians or Alaskan Natives do not have a copay. The Healthy Families Program rules define who fits into these groups. To 22

29 How to use your health plan Part 5 learn more about this, look in the Healthy Families Program Handbook. You also may call the Healthy Families Program at Member liabilities Most of the time, the only amount a member pays for covered services is the copay. You may have to pay for services you get that are NOT covered services, such as: Nonemergency services received in the emergency room Nonemergency or nonurgent services received outside of the Anthem Blue Cross service area if you did not get an OK from us before you got those services Specialty services you got if you did not get a required referral or OK from us before getting those services. (See Prior Authorization (an OK from Anthem Blue Cross) in Part 5, How to use your health plan); Services from a nonparticipating provider, unless the services are for situations allowed in this Evidence of Coverage booklet (for example, emergency service, urgent services outside the Anthem Blue Cross service area, or specialty services approved by Anthem Blue Cross). See Prior Authorization (an OK from Anthem Blue Cross) in Part 5, How to use your health plan Services you got that are greater than the limits described in this book unless approved by us. Anthem Blue Cross is responsible to pay for all covered services including emergency services. You are not responsible to pay a provider for any amount owed by the health plan for any covered service. If we do not pay a provider that is not in your network for covered services, you do not have to pay that provider for the cost of the covered services. Covered services are those services that are given per this book. The provider who is not in your network must bill us, not you, for any covered service. But keep in mind, services from a provider who is not in your network are not covered services unless they are listed as covered in this book. If you get a bill for a covered service from any provider, whether in or outside of the Anthem Blue Cross network, call us at If you have speech or hearing loss, you may call our TTY line at Member Services /7 NurseLine: TTY lines are for members with hearing or speech loss only. anthem.com/ca 23

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31 Part 6 How to get prescription drugs What your provider can order...26 What to do if Anthem Blue Cross denies your drug request Continuing a drug therapy Where to get your prescriptions filled

32 Part 6 How to get prescription drugs What your provider can order We use a chosen list of drugs called a preferred drug list (PDL) to help your doctor choose which drugs to order. Certain drugs on the list need an OK ahead of time or have limits based on medical necessity. A group of doctors and pharmacists updates this list of drugs every three months. Updating this list helps ensure that the drugs on it are safe and useful. Although a drug may be on the list, your doctor may choose not to order it for you for your health issue. If your doctor thinks you need to take a drug that is not on this list, your doctor needs to ask for an OK from Anthem Blue Cross before giving it to you. We may ask your doctor to try other drugs first. If you would like to know if a drug is on the PDL or if you want a copy of the Anthem Blue Cross Healthy Families Program PDL, please call us at Only your doctor knows which drug is best for you. We will cover a prescription drug for a use other than what the U.S. Food and Drug Administration (FDA) says it can be used for if: The drug is medically necessary to treat a covered medical condition. The drug is known to treat that health issue in medical text that is reviewed by peers. Some drugs may need an OK from us based on medical necessity. This is called prior authorization of benefits. To learn more about this process, call us at If you have hearing or speech loss, you may call our TTY line at You also may visit us on the web at anthem.com/statesponsored. Your network pharmacies will give you generic drugs. If your doctor wants you to have a brandname drug that has an equal generic version, your doctor must first send a written request to us for an OK. We will review and decide on all drug requests, brand-name or generic within one business day. The pharmacist may give you a 72-hour emergency supply of the medicine if he or she thinks it is needed. You will pay the copay for the supply, but we will pay the rest. What to do if Anthem Blue Cross denies your drug request If we deny your drug request, we will send you a letter telling you why. The letter also will tell you about any other drugs or treatments that you could use. If you have a problem with Anthem Blue Cross services, call our toll-free Member Services or TTY number (for those with hearing or speech loss). If, after you call us, you still believe that your needs have not been met, please see Part 13, How to resolve a problem with Anthem Blue Cross. Continuing a drug therapy Certain drugs should not be replaced once they have been started. These are called Narrow Therapeutic Index (NTI) drugs. We cover NTI drugs even if they are not on the PDL or do not have an equal generic version. NTI drugs are covered under the prescription drug benefit without your doctor writing on the prescription, do not substitute or dispense as written. To get a list of NTI drugs, call us at For your health and safety, we check the drugs you are using. If we see that you are using too many drugs, we will tell your doctor and the pharmacy. Some drugs can be harmful if taken together. 26

33 How to get prescription drugs Part 6 Where to get your prescriptions filled In your Provider Directory, you will find a list of pharmacies near you that work with Anthem Blue Cross. You must go to one of these pharmacies for your prescription drugs. We will not cover your drugs if you go to a pharmacy that is not in your network. If you have an emergency and cannot go to a pharmacy in your network, go to the nearest pharmacy and have them call us at If the pharmacy is not willing to call us, you may have to pay for the emergency supply of drugs. When you send the receipt to us, we will pay you back. You may get emergency birth control from a pharmacy in your network. We also cover emergency birth control from a pharmacy that is not in your network if your network pharmacy is closed. Have the pharmacy call us at If the pharmacy is not willing to call us, you may have to pay for the emergency supply of drugs. When you send the receipt to us, we will pay you back. We can help you find a pharmacy in your network near you and answer any questions you might have about your pharmacy benefits. Call us at our toll-free Member Services or TTY number (for those with hearing or speech loss). Member Services /7 NurseLine: TTY lines are for members with hearing or speech loss only. anthem.com/ca 27

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35 Part 7 Emergency and urgent care services What is an emergency?...30 What is urgent care? Not sure if it s an emergency? Services that are not covered Post-stabilization and follow-up care after an emergency

36 Part 7 Emergency and urgent care services What is an emergency? An emergency is a medical or mental condition with such severe signs (including active labor or severe pain) that you believe not getting medical care right away could: Place your health or the health of your unborn child at risk Impair a body function Cause dysfunction of a body organ or part You should go, or have someone take you to the ER when you have: Broken bones Chest pain Severe burns Fainted A drug overdose Paralysis Severe cuts that won t stop bleeding Mental health emergency conditions Call 911 or go to the nearest emergency room for emergency care. Emergency services are covered inside and outside of the Anthem Blue Cross service area. Outside of your service area, treatment for emergencies includes urgently needed services to keep your health from getting much worse due to an illness or injury that you did not expect for which treatment cannot be delayed until you return to your service area. You can go to any hospital for an emergency. It does not matter if that hospital is inside or outside your network. Once you are stable, you may be moved to a hospital in your network for further care. If you are admitted to a hospital for an emergency, you or your doctor must call us within 48 hours, or as soon as you can. If you or your doctor does not call us within 48 hours, you may have to pay some of the charges. What is urgent care? Urgent care means services to keep your health from getting much worse due to an illness or injury that you did not expect, prolonged pain or a problem from a health issue that you have now (including pregnancy) for which treatment cannot be delayed. If you need urgent care at a time when your doctor s office is open, call your doctor to set up a visit as soon as you can. If you need urgent care at night or on the weekend and you are inside the Anthem Blue Cross service area, call your doctor. Leave your name and phone number with the answering service. Your doctor, or an on-call doctor, will call you back soon. You also may call 24/7 NurseLine, the toll-free, 24-hour nurse help line, or the 24/7 NurseLine TTY (for those with hearing or speech loss). A nurse can help you find an urgent care provider. If you need urgent care when you are outside the Anthem Blue Cross service area, call 24/7 NurseLine, the 24-hour nurse help line. A nurse can help you find an urgent care provider. You should go to the closest urgent care provider. You do not need an OK from us to get urgent care services when you are outside of the Anthem Blue Cross service area. To be covered, urgent care services must be needed because the illness or injury will become much more serious if you wait for a routine doctor s visit. On your first visit with your doctor, talk about what he or she wants you to do when the office is closed and you believe you need urgent care. 30

37 Emergency and urgent care services Part 7 Not sure if it s an emergency? If you are not sure if a health issue is an emergency, call your doctor or 24/7 NurseLine, the toll-free, 24-hour nurse help line, to access triage or screening services. If it is after your doctor s normal office hours, leave your name and phone number with the answering service and your doctor, or an on-call doctor, will call you back soon. You also may call 24/7 NurseLine at or the TTY line at (for those with hearing or speech loss) and a nurse can help you. Services that are not covered We do not cover medical services that are given in an emergency or urgent care setting for health issues that are not emergencies or not urgent, if you should have known that the issue was not an emergency or urgent. You will have to pay for all charges that have to do with these services. Post-stabilization and follow-up care after an emergency Once your emergency medical condition has been treated at a hospital and an emergency no longer exists because your condition is stabilized, the doctor who is treating you may want you to stay in the hospital for a while longer before you can safely leave the hospital. The services you get after an emergency condition is stabilized are called poststabilization services. If the hospital where you got emergency services is not part of the Anthem Blue Cross network (noncontracted hospital), the hospital will call us to get an OK for you to stay in that hospital. If we approve your continued stay in the hospital that is not in your network, you will not have to pay for services except for any required copays. If we tell the hospital that you can safely be moved to a hospital in your network, we will arrange and pay for you to be moved from the hospital that is not in your network to a hospital that is in your network. If we decide that you can be safely transferred to a hospital in your network and you or your parent or legal guardian do not agree to you being transferred, the hospital that is not in your network must give you or your parent or legal guardian a written notice stating that you will have to pay for all of the cost for post stabilization services given to you at the hospital that is not in your network after your emergency condition is stabilized. Member Services /7 NurseLine: TTY lines are for members with hearing or speech loss only. anthem.com/ca 31

38 Part 7 Emergency and urgent care services You also may have to pay for services if the hospital that is not in your network cannot find out what your name is and cannot get contact information at the plan to ask for approval to give services once you are stable. If you feel that you were not billed correctly for post stabilization care that you got from a hospital that is not in your network, please call Member Services at Monday through Friday from 7 a.m. to 7 p.m. If you have hearing or speech loss, you may call our TTY line at

39 Part 8 What Anthem Blue Cross covers 33

40 Part 8 What Anthem Blue Cross covers We want to help you get the care you need. This chart can help you compare benefits and is a summary only. Please see the benefit descriptions for a detailed description of covered benefits and limits. This symbol means that prior authorization (an OK from Anthem Blue Cross) is needed for us to cover these services. All services must be medically necessary and received from a provider in your network. We charge no deductibles for covered services. There also are no yearly or lifetime benefit limits for any of these covered services. Benefit* Services Cost to Member (Copay) Income Category A Acupuncture Services must be given by a health plan provider in your network. A limit of 20 visits per benefit year Alcohol/Drug abuse treatment (Inpatient) Alcohol/Drug abuse treatment (Outpatient) Ambulance (Medical transportation services)** Nonemergency transport needs an OK from Anthem Blue Cross Biofeedback Blood and blood products** Processing Storing Giving Cataract glasses and lenses ** The surgery to remove a cataract and insert a lens needs an OK from Anthem Blue Cross Staying overnight in the hospital to remove toxic substances from the system Crisis intervention and treatment of alcoholism or drug abuse. Emergency ambulance transport Nonemergency transport to transfer a member from: one hospital to another a hospital to another facility a hospital or other facility to home Services must be given by a health plan provider Cataract glasses and lenses Cataract contact lenses Lenses that go in the eye to replace the natural lens of the eye after cataract surgery $5 per visit $10 per visit No copay Cost to Member (Copay) Income Categories B&C No copay $5 per visit $10 per visit No copay No copay $5 per visit $10 per visit No copay No copay No copay No copay 34

41 What Anthem Blue Cross covers Part 8 Benefit* Services Cost to Member (Copay) Income Category A California Children s Service (CCS) Chiropractic Clinical Cancer Trials Diabetic care** Some diabetic test strips need an OK from Anthem Blue Cross Diagnostic, X-Ray and lab services** CT, MRI, MRA, PET and SPECT need an OK from Anthem Blue Cross CCS is a state program that treats children who have certain physical handicaps and who need special medical care. Services provided through the CCS program are managed by the county CCS office. If the CCS program decides that the member s condition is eligible for CCS services, and CCS is treating the eligible condition, the member stays in the Healthy Families Program and still gets medical care from their network providers for services that do not have to do with the CCS-eligible condition. The member will get treatment for the CCS-eligible condition through the special network of CCS providers and/ or CCS-approved specialty centers. Services must be given by a provider in your network A limit of 20 visits per benefit year Coverage for a member taking part in a cancer clinical trial, phase I through IV, when the member s doctor suggests it, and the member meets certain rules. Equipment and supplies to manage and treat insulin-dependent diabetes, noninsulin-dependent diabetes and gestational diabetes (as medically necessary, evenif you can get these items without a prescription) Blood tests, lab work and radiological services (as medically necessary) to: Test Diagnose Treat Follow up on care given No copay $5 per visit $10 per visit $5 per office visit Copay for prescriptions as described in the Prescription Drug Program section $5 per office visit Copay for prescriptions as described in the Prescription Drug Program section No copay Cost to Member (Copay) Income Categories B&C No copay $10 per office visit Copay for prescriptions as described in the Prescription Drug Program section $10 per office visit Copay for prescriptions as described in the Prescription Drug Program section No copay 35

42 Part 8 What Anthem Blue Cross covers Benefit* Services Cost to Member (Copay) Income Category A Durable Medical Equipment (DME)** Custom-made DME needs an OK from Anthem Blue Cross Other DME, such as insulin pumps, wheelchairs and oxygen equipment, also may need an OK from Anthem Blue Cross Emergency health care services** Family planning services Health education Hearing aids and services Home health care services Hospice Hospital services (Inpatient) Hospital services (Outpatient) Maternity care Medical equipment used in the home if it meets these rules: Mainly used for medical reasons Will be used many times Is used only by a person who is sick or injured Emergency services are covered 24 hours a day (you can go to any provider either inside or outside of the Anthem Blue Cross service area) All family planning services when you choose to use them. Classes on healthy habits and how to best use the health care services Tests for hearing loss Hearing aids to correct hearing loss Services given at the home by health care staff For members who are diagnosed with a terminal illness and who choose hospice care instead of traditional health care services Room and board Nursing care All other medically necessary ancillary services Services to diagnose or treat an illness and do surgery at a hospital or outpatient facility. Professional and hospital services That have to do with maternity care No copay $5 per visit You do not have to pay the copay if you are admitted to the hospital No copay No copay No copay No copay No copay No copay No copay, except: $5 per visit for physical, occupational or speech therapy No copay No copay No copay, except: $5 per visit for physical, occupational or speech therapy $5 per visit for emergency health care services (you do not have to pay the copay if you are hospitalized) No copay Cost to Member (Copay) Income Categories B&C No copay $15 per visit You do not have to pay the copay if you are admitted to the hospital No copay, except: $10 per visit for physical, occupational or speech therapy No copay No copay No copay, except: $10 per visit for physical, occupational or speech therapy $15 per visit for emergency health care services (you do not have to pay the copay if you are hospitalized) No copay 36

43 What Anthem Blue Cross covers Part 8 Benefit* Services Cost to Member (Copay) Income Category A Mental health care services (Inpatient) Mental health care in a hospital in your network when ordered and done by a mental health provider in your network for the treatment of a mental health condition. Mental Health Care Diagnosis and treatment of a mental health condition Inpatient mental health care services for the treatment of Severe Mental Illnesses (SMI): Schizophrenia Schizoaffective disorder Bipolar disorder (manic-depressive illness) Panic disorder Obsessive-compulsive disorder Pervasive developmental disorder or autism Anorexia nervosa Bulimia nervosa Serious Emotional Disturbance (SED) Services Inpatient mental health care services for the treatment of a member who the county decides has a SED condition Anthem Blue Cross shall give all medically necessary covered services until the county mental health department shows eligibility for a child with SED and the county mental health department gives the medically necessary services to treat the SED. Anthem Blue Cross and the county mental health department will manage services to ensure that all medically necessary services and treatment are given to a member with SED. The member will stay enrolled in the Healthy Families Program and will keep getting primary care, specialty care and all other services from Anthem Blue Cross for medical conditions that do not have to do with the SED No copay No copay No copay Cost to Member (Copay) Income Categories B&C No copay 37

44 Part 8 What Anthem Blue Cross covers Benefit* Services Cost to Member (Copay) Income Category A Mental health care services (Outpatient) Mental health care when ordered and done by a mental health provider who is in your network Mental Health Care This includes, but is not limited to the treatment of children who have had family dysfunction or trauma, such as child abuse and neglect, domestic violence, substance abuse in the family, or divorce and bereavement Family members may be taking part in the treatment when medically necessary for the health and return to better health of the child Outpatient mental health care services for the treatment of Severe Mental Illnesses (SMI): Schizophrenia Schizoaffective disorder Bipolar disorder (manic-depressive illness) Panic disorder Obsessive-compulsive disorder Pervasive developmental disorder or autism Anorexia nervosa Bulimia nervosa $5 per visit $10 per visit $5 per visit $10 per visit Cost to Member (Copay) Income Categories B&C 38

45 What Anthem Blue Cross covers Part 8 Benefit* Services Cost to Member (Copay) Income Category A Serious Emotional Disturbance (SED) Nutritional counseling Organ transplants** Orthotics and prosthetics** Outpatient mental health care services for the treatment of a member who the county decides has a SED condition Anthem Blue Cross may refer the member to the county mental health department for treatment of SED. Anthem Blue Cross shall give all medically necessary covered services until the county mental health department shows eligibility for a child with SED and the county mental health department gives the medically necessary services to treat the SED. Anthem Blue Cross and the county mental health department will manage services to ensure that all medically necessary services and treatment are given to a member with SED. The member will stay enrolled in the Healthy Families Program and will keep getting primary care, specialty care, and all other services for medical conditions from Anthem Blue Cross that do not have to do with the SED. Up to five hours of nutritional counseling with a registered dietitian (RD). The RD will: Assess your current nutritional and physical activity status Help you set goals for your nutritional and physical activity status Give you suggestions to help you meet your goals Organ and bone marrow transplants that are medically necessary and not experimental or investigational Original and replacement devices that are ordered by a licensed provider and given by a provider in your network No copay No copay No copay No copay Cost to Member (Copay) Income Categories B&C No copay No copay No copay No copay 39

46 Part 8 What Anthem Blue Cross covers Benefit* Services Cost to Member (Copay) Income Category A Cost to Member (Copay) Income Categories B&C Phenylketonuria (PKU)** Testing and treatment of PKU No copay No copay Medically necessary therapy given in: $5 per visit when done in the home or $10 per visit when done in the home or Physical, occupational, and speech therapy** A doctor s office other outpatient setting other outpatient setting (Only speech therapy needs an OK from Anthem Blue Cross) Prescription drug program** Some medications need an OK from Anthem Blue Cross A hospital A skilled nursing facility Another outpatient setting Drugs ordered by a licensed doctor No copay for inpatient therapy $5 copay per prescription for up to a 30-day supply of brand name or generic drugs from a retail pharmacy $5 per prescription for up to a 90-day supply of maintenance drugs from mail-order program No copay for prescription drugs given in a hospital No copay for drugs given in a doctor s office or in an outpatient setting while at the facility No copay for FDA-approved birth control drugs and devices No copay for inpatient therapy $10 copay per prescription for up to a 30 day supply for generic drugs from a retail pharmacy $15 copay per prescription for up to a 30 day supply for brand name drugs unless there is not an equal generic version $10 copay if the use of a brand name drug is medically necessary $10 copay per prescription for up to a 90 day supply for maintenance generic drugs purchased either through a pharmacy that is in your network or through the plan s mail order program $15 copay per prescription for up to a 90-day supply for maintenance brand name drugs purchased either through a pharmacy that is in your network or through the plan s mail order program unless there is no generic equivalent $10 copay if the use of a brand name drug is medically necessary. No copay for drugs given in a hospital No copay for drugs given in a doctor s office or in an outpatient setting while at the facility No copay for FDA-approved birth control drugs and devices 40

47 What Anthem Blue Cross covers Part 8 Benefit* Services Cost to Member (Copay) Income Category A Preventive health service Routine health exams and services Professional services Reconstructive surgery and surgery** Deductibles Lifetime Limits Skilled nursing care Well-baby care Routine tests to find out what is wrong Lab tests and services Vaccines Services to find diseases that show no signs Services and consults by a doctor or other licensed health care provider Performed on abnormal structures of the body caused by congenital defects, developmental anomalies, trauma, infection, tumors or disease and are performed to improve function or create a normal appearance Services provided in a licensed skilled nursing facility No copay $5 per office or home visit, except: No copay for doctor visits while in the hospital No copay for surgery, anesthesia or radiation, chemotherapy or dialysis treatments No copay for members 24 months of age or younger No copay for vision or hearing tests or for hearing aids No copay No copay Benefit is limited to a maximum of 100 days per benefit year No deductibles will be charged for covered benefits No lifetime limits on benefits apply under this plan Cost to Member (Copay) Income Categories B&C No copay $10 per office or home visit, except: No copay for doctor visits while in the hospital No copay for surgery, anesthesia or radiation, chemotherapy or dialysis treatments No copay for members 24 months of age or younger No copay for vision or hearing tests or for hearing aids No copay No copay Benefit limited to a maximum of 100 days per benefit year *Benefits are provided only for services that are medically necessary. **These services may be covered and paid for by the California Children s Services (CCS) program if the member is found to be eligible for CCS services. 41

48

49 Part 9 Benefit descriptions Acupuncture Substance abuse treatment Alcohol/Drug abuse treatment services (Inpatient)...44 Alcohol/Drug abuse treatment services (Outpatient).. 44 Ambulance (Medical transport services) Biofeedback Blood and blood products...45 Cataract glasses and lenses...45 Chiropractic services Clinical Cancer Trials (Tests to see if a drug works) Diabetic care...46 Diagnostic X-ray and lab services Durable Medical Equipment (DME) Emergency health care services Family planning services...48 Health education Hearing aids and services Home health care services...50 Hospice Hospital services (Inpatient) Hospital services (Outpatient) Maternity care Mental health care services (Inpatient)...53 Mental health care services (Outpatient)...54 Nutritional counseling...55 Organ transplants...55 Orthotics and prosthetics (Manmade body parts) Phenylketonuria (PKU)...56 Physical, occupational and speech therapy Prescription drug program Mail service prescription drug program...58 Maintenance drugs Preventive health services Professional services...60 Reconstructive surgery Skilled nursing care

50 Part 9 Benefit descriptions NOTE: Members in Income Category A shall pay no more than $5 copay for covered services that apply as described in this part of this book. Here are the kinds of benefits you can get through Anthem Blue Cross when medically necessary. Keep in mind that some of these services must be OK d by your doctor and/or us first. There are no yearly or lifetime benefit limits for any of these covered services. All services must be medically necessary and given by a provider in your network. Please see Part 8, What Anthem Blue Cross covers, for an easy-to-use chart of your benefits. If you have questions about what is covered, call our toll-free Member Services or TTY number (for those with hearing or speech loss). Acupuncture Cost to member: $5-$10 per visit We cover acupuncture services from a provider in your network. Limits We cover 20 visits per benefit year. Substance abuse treatment Diagnosis and treatment of a substance abuse condition. If you think your child may have a substance abuse condition Anthem Blue Cross will give you information on how to get services for your child. Call Anthem Blue Cross Member Services to get information on how to get services for your child. Alcohol/Drug abuse treatment services (Inpatient) Needs an OK from Anthem Blue Cross Cost to member: No copay Staying in the hospital for alcoholism or drug abuse as medically necessary to remove toxic substances from the system. Alcohol/Drug abuse treatment services (Outpatient) Needs an OK from Anthem Blue Cross Cost to member: $5-$10 per visit Crisis intervention and treatment of alcoholism or drug abuse as an outpatient as medically necessary. Ambulance (Medical transport services) Needs an OK from Anthem Blue Cross Cost to member: No copay We cover emergency ambulance transport to the first hospital that will take you for emergency care. This service includes ambulance service given through the 911 emergency response system. The service includes moving you from one hospital to another or to some other facility, as long as the transport is: Medically necessary. Requested by a doctor in your network. OK d ahead of time by Anthem Blue Cross. Limits We do not cover public transport such as an airplane, car or taxi. Biofeedback Needs an OK from Anthem Blue Cross Cost to member: $5-$10 per visit We cover biofeedback services from a provider in your network. Limits We do not cover biofeedback for SMI and SED conditions. 44

51 Benefit descriptions Part 9 Blood and blood products Cost to member: No copay We cover processing, storing and giving out blood and blood products. You get this benefit whether you are in the hospital or not. This service also includes taking and saving your blood when medically necessary. Cataract glasses and lenses Needs an OK from Anthem Blue Cross Cost to member: No copay We cover cataract glasses and lenses, contact lenses or lenses that go in the eye and take the place of the natural lens of the eye after cataract surgery. This benefit also includes one pair of standard eyeglasses or contact lenses, if needed, after cataract surgery when a lens is placed in the eye. The surgery to remove the cataract and insert a lens in the eye needs an OK from Anthem Blue Cross. Chiropractic services Cost to member: $5-$10 per visit We cover services from a provider in your network. Limits We cover 20 visits per benefit year. Clinical Cancer Trials (Tests to see if a drug works) Needs an OK from Anthem Blue Cross Cost to member: $5-$10 copay per office visit (See the Prescription Drug Program section at the end of this chapter for prescription copays.) We cover your part in a cancer clinical trial for phases I through IV when your doctor suggests it and you meet these rules: You must be diagnosed with cancer. You must be accepted into a phase I, phase II, phase III or phase IV clinical trial for cancer. Your doctor, who is giving covered services, must suggest you take part in the trial after he or she decides that it may help you. Member Services /7 NurseLine: TTY lines are for members with hearing or speech loss only. anthem.com/ca 45

52 Part 9 Benefit descriptions The trial must meet these rules: The drugs must be made to fight the cancer. The treating doctor must have in writing that he or she wants you in the trial. The treatment given must be OK d by one of these agencies (unless it involves a drug that does not need to follow the federal rules for a brand new drug): The National Institutes of Health The U.S. Food and Drug Administration (FDA) The U.S. Department of Defense The U.S. Department of Veterans Affairs We cover payment of the costs for routine patient care. This includes drugs, items, devices and services that would be covered if they were not part of an OK d clinical trial program. Routine patient costs for cancer clinical trials include: Health care services needed to test the drug, item, device or service Health care services needed to see if the drug, item, device or service works Health care services given to prevent problems that arise from the drug, item, device or service Health care services needed for the care of any side effects that may take place from the drug, item, device or service (This includes finding out how the side effects came about and treating them.) Limits We do not cover the use of drugs or devices that are not OK d by the FDA. We do not cover services other than health care services, such as travel, housing and other expenses that do not have to do with the treatment that a member may have because he or she took part in the trial. We do not cover items or services that are used just to gather facts about the trial and are not used in the treatment itself. We do not cover health care services that are otherwise not a benefit (except those excluded because they are investigational or experimental). We do not cover health care services that are given free of charge by the trial research sponsors to people in the trial. We may cover only clinical cancer trials done by doctors and hospitals in your network, unless the testing for the trial is not done in California. Diabetic care Needs an OK from Anthem Blue Cross Cost to member: $5-$10 copay per office visit (See the Prescription Drug Program section at the end of this chapter for prescription copays.) We cover equipment and supplies to manage and treat insulin-dependent diabetes, noninsulindependent diabetes and gestational diabetes as medically necessary, even if you can get these items without a prescription. This benefit includes: Blood glucose monitors and testing strips Some diabetic test strips need an OK from Anthem Blue Cross. Blood glucose monitors made to help those with vision loss Insulin pumps and all supplies needed for the pump Ketone urine testing strips Lancets and lancet puncture tools Alcohol pads Pen delivery systems made for giving insulin 46

53 Benefit descriptions Part 9 Care given by a foot doctor to prevent or treat problems caused by diabetes Insulin syringes Visual aids (but not eyewear) to help those with vision loss get the right dose of insulin Insulin Prescription drugs used to treat diabetes Glucagon We also cover training on how to help manage your diabetes on your own, sessions on how to eat right and classes you can take to help you use the diabetes tools ordered by your Anthem Blue Cross doctor. Diagnostic X-ray and lab services All high-cost radiology such as CT, MRI, MRA, PET and SPECT need an OK from Anthem Blue Cross. Cost to member: No copay We cover blood tests, X-rays, lab work and radiation therapy to test, diagnose, treat and follow up on the care of members. You must use a lab in your network. This benefit also includes, but is not limited to: Tests to check your heart, brain and breasts for any problems The tests most often used to find cancer Lab tests used to manage diabetes (This includes at least cholesterol, triglycerides, microalbuminuria, HDL/LDL and Hemoglobin A1C Glycohemoglobin.) Yearly cervical cancer screenings OK d by the FDA (This includes the Pap test and the human papilloma virus test, HPV. If your doctor does not do these tests, he or she must refer you to a doctor who does.) Durable Medical Equipment (DME) Custom-made durable medical equipment needs an OK from Anthem Blue Cross. Other DME, such as insulin pumps, wheelchairs and oxygen equipment, also may need an OK from Anthem Blue Cross Cost to member: No copay Member Services /7 NurseLine: TTY lines are for members with hearing or speech loss only. anthem.com/ca 47

54 Part 9 Benefit descriptions We cover DME that is made for use in the home if it meets these rules: It is medically necessary. It will be used many times. It is used only by a person who is sick or hurt. We may decide whether to rent or buy standard DME. We cover costs to repair or replace DME unless it was misused or lost. DME includes, but is not limited to: Oxygen and oxygen equipment Standard blood glucose monitors as medically necessary for members who have insulin-dependent, noninsulin dependent or gestational diabetes Blood glucose monitors for those with vision loss as medically necessary for members who have insulin-dependent, noninsulin-dependent or gestational diabetes Insulin pumps and all supplies needed for the pump Visual aids (but not eyewear) for those with vision loss so they can give the right dose of insulin Sleep apnea monitors Tools for the feet used to prevent or treat the side effects of diabetes Child and adult asthma supplies such as nebulizer machines, face masks, tubing, related supplies and peak flow meters Ostomy bags and urinary catheters and supplies Limits We do not cover items that are for your comfort or convenience. We do not cover supplies that you throw away, except ostomy bags, urinary catheters and supplies that meet Medicare coverage rules. We do not cover exercise equipment. We do not cover hygiene equipment. We do not cover experimental or research equipment. We do not cover tools that are not used for medical reasons, such as sauna baths, elevators or changes to a home or car. We do not cover deluxe equipment. We do not cover more than one machine that does the same thing. Emergency health care services Cost to member $5-$15 per visit. (You do not have to pay the copay if you are admitted to the hospital.) An emergency is a medical or mental condition with such severe symptoms (including active labor or severe pain) such that a prudent layperson, who has an average knowledge of health and medicine, could reasonably believe the lack of immediate medical attention could: Place your health or the health of your unborn child at risk Impair a body function Cause dysfunction of a body organ or part We cover you for emergency service 24 hours a day. You may go to a provider either inside or outside of the Anthem Blue Cross service area for emergency care. Family planning services Cost to member: No copay We cover family planning services when you choose to use them. This includes: Counseling and surgery to keep women from getting pregnant as allowed by state or federal law Diaphragms 48

55 Benefit descriptions Part 9 All forms of birth control that are OK d by the FDA (This is covered under the prescription drug benefit. See the Prescription Drug Program section at the end of this chapter to learn more.) Choosing to end a pregnancy Sexually transmitted disease (STD) testing and treatment Some hospitals and other doctors do not give all of the family planning services that you or your family may need. You should find out before you go see a provider for this type of care. Call the provider or call us at our toll-free Member Services or TTY number (for those with hearing or speech loss). Health education Cost to member: No copay We cover classes on healthy habits and how best to use the health care services from Anthem Blue Cross and the other health care groups that work with us. We also cover one cycle or course of treatment (per benefit year) to help you stop smoking. You must attend a stopsmoking class or program to get this benefit. We also have a childhood obesity program called Get Up & Get Moving! A parent toolkit tells you how to help your child eat well and get plenty of exercise. To get a free copy of this kit, call our toll-free Member Services number. Those with hearing or speech loss can call the TTY line. Hearing aids and services Needs an OK from Anthem Blue Cross Cost to member: No copay We cover a hearing test to see how much hearing has been lost and which hearing aid would be best. This benefit includes: Hearing aids and ear molds Hearing aid tools The first battery Cords and other tools used with the hearing aid } } Visits to check the fit of the hearing aid, talk with the doctor about how the hearing aid is working or to adjust or repair the hearing aid (We cover these visits for the first year you have the hearing aid.) Member Services /7 NurseLine: TTY lines are for members with hearing or speech loss only. anthem.com/ca 49

56 Part 9 Benefit descriptions Home health care services Needs an OK from Anthem Blue Cross Cost to member: No copay, except for $5-$10 per visit for physical, occupational and speech therapy done in the home We cover health services given at home by health care staff. This benefit includes: Visits by RNs, LVNs and home health aides Physical, occupational and speech therapy Breathing therapy when ordered by a licensed doctor who is part of your network Limits Home health care services are limited to those services given or ordered by your doctor or someone chosen by us. If a basic health care service can be given in more than one place, your doctor or someone chosen by us, will choose where the care will take place. We will do what it thinks is best for the member when it comes to the care and place it chooses for the member. We do not cover care given to you in your home by someone other than a nurse. Hospice Needs an OK from Anthem Blue Cross Cost to member: No copay We cover hospice care for members who are found to have a terminal illness and 12 months or less to live and choose this type of care. The hospice care must be given by a licensed nurse or caregiver or a licensed home health agency with federal Medicare certification (under the California Hospice Licensure Act of 1990). But the hospice may choose to make plans for a licensed person or group to give care. The hospice benefit includes: Nursing care Medical social services Home health aide services Doctor services, drugs, medical supplies and machines Counseling and bereavement services Physical, occupational and speech therapy Short-term care in a hospital Pain control and help managing other signs from the illness Services to help you care for your home Services from people who do not get paid Short-term care in the hospital when you need to rest The decision to enter hospice can be changed at any time. Limits Members who choose hospice care may not use any other benefits under the plan for the terminal illness while the hospice care is being used. Hospital services (Inpatient) Needs an OK from Anthem Blue Cross Cost to member: No copay We cover hospital services received in a room with two or more beds, common furniture, common tools, routine nursing care and meals (including special diets when medically necessary). This benefit includes all other medically necessary services, including, but is not limited to: The use of an operating room and the place where the room is Intensive care units and services 50

57 Benefit descriptions Part 9 Drugs and biological products used in drugs Anesthesia Oxygen Medical tests X-ray services Special duty nursing Physical, occupational and speech therapy Breathing therapy Giving of blood and blood products Other rehab services Other services to find out what is wrong with you Planning for your care when you get out of the hospital This benefit also includes general anesthesia and facility costs for dental work if: You have to stay in the hospital because you have another health issue when you have the dental work. The dental work you need is severe. This dental benefit is only allowed for: Members under age 7. Members (of any age) with developmental issues. Members (of any age) with another health issue and for whom general anesthesia is medically necessary. We will work with your dental plan to set up the dental services listed above. If you have surgery for breast cancer (mastectomy or lymph node dissection), you and your doctor decide how long you will need to stay in the hospital after the surgery. We cover this stay. We also cover care you need after the surgery and all problems that may take place from the surgery. Limits We do not cover personal items, comfort items or a private room in a hospital (unless they are medically necessary). We do not cover services of dentists or oral surgeons for dental work. Member Services /7 NurseLine: TTY lines are for members with hearing or speech loss only. anthem.com/ca 51

58 Part 9 Benefit descriptions Hospital services (Outpatient) Needs an OK from Anthem Blue Cross Cost to member: No copay, except for $5-$10 per visit for physical, occupational and speech therapy done when you do not have to stay in the hospital and $5-$15 per visit for emergency health care services. (You do not have to pay this copay if you are admitted to the hospital.) We cover services to diagnose or treat an illness and to do surgery at a hospital or an outpatient facility. This includes, but is not limited to: Physical, speech and occupational therapy Hospital services that can be given without staying in the hospital Related outpatient services and supplies, such as: An operating room A treatment room Other services Drugs that are given to you by the hospital or facility staff for use during your stay Outpatient observation needs an OK from Anthem Blue Cross. This benefit also includes general anesthesia and facility costs for dental work if: You have to stay in the hospital or surgery center because you have another health issue when you have the dental work. The dental work you need is severe. This dental benefit is only allowed for: Members under age 7. Members (of any age) with developmental issues. Members (of any age) with another health issue and for whom general anesthesia is medically necessary. We will work with your dental plan to set up the dental services listed above. Limits We do not cover the services of dentists or oral surgeons for dental work. Maternity care Cost to member: No copay We cover maternity care given by a hospital or doctor that is medically necessary, including: Care given to the mother before and after the baby is born (This includes problems with the pregnancy. A third, and any ultrasound exams that follow, need an OK from us.) Newborn exams and nursery care while the mother is in the hospital (This includes newborn hospital visits and phenylketonuria (PKU) testing and treatment. The newborn is covered while the mother is in the hospital. Once the mother leaves the hospital, the newborn is no longer under the mother s ID number. The mother needs to get health insurance for the newborn. Taking part in the statewide prenatal testing program (This program is given by the State Department of Health Services and is called the Expanded Alpha Feto Protein Program.) Testing to see if the baby is healthy or sick if you have a high-risk pregnancy Sessions to talk to someone about how to eat right, what to feed the baby, how to take care of your health, and how to take care of the baby s health, as well as what social support you might need Labor and delivery care (This includes the services of a midwife.) 52

59 Benefit descriptions Part 9 This benefit covers care in the hospital for 48 hours after a normal vaginal birth and 96 hours after a cesarean section. If you stay longer, you need to get an OK from us. If your doctor talks to you and decides to discharge you from the hospital before the 48 or 96 hours, then we will cover a follow-up visit with your doctor if it is within 48 hours after you leave the hospital. During this visit the doctor will talk to you about what to do as a parent, how to breastfeed or bottle-feed and physical exams for you and the baby. You and your doctor will decide if you want this visit to be in your home, in the hospital or at the doctor s office. Mental health care services (Inpatient) Needs an OK from Anthem Blue Cross Cost to member: No copay Before you seek any nonemergency mental health services, you must call Anthem Blue Cross Behavioral Health Programs at Mental health care in a hospital that is in your network when ordered and done by a mental health provider that is in your network. Mental health care Diagnosis and treatment of a mental health condition. If you think your child may have a mental health condition Anthem Blue Cross will give you information on how to get services for your child. Call Anthem Blue Cross Member Services to get information on how to get services for your child. Inpatient mental health care services for the treatment of Severe Mental Illnesses (SMI): Schizophrenia Schizoaffective disorder Bipolar disorder (manic-depressive illness) Major depressive disorders Panic disorder Obsessive-compulsive disorder Pervasive developmental disorder or autism Anorexia nervosa Bulimia nervosa Member Services /7 NurseLine: TTY lines are for members with hearing or speech loss only. anthem.com/ca 53

60 Part 9 Benefit descriptions Serious Emotional Disturbances (SED) Inpatient mental health care services for the treatment of a member that the county decides has a SED condition We will give all medically necessary covered services until the county mental health department shows eligibility for a child with SED and the county mental health department gives the medically necessary services to treat the SED. Anthem Blue Cross and the county mental health department will manage services to ensure that medically necessary services and treatment are given to a member with SED. The member will stay enrolled in the Healthy Families Program and will keep getting primary and specialty care and all other services from us for medical conditions that do not have to do with the SED. To learn more about SED diagnosis and treatment benefits, see Part 11, Coordination of Services. Mental health care services (Outpatient) Needs an OK from Anthem Blue Cross Cost to member $5-$10 per visit (does not apply to SED) Before you get any nonemergency mental health services, you must call Anthem Blue Cross Behavioral Health Programs at Mental health care services when ordered and done as an outpatient by an Anthem Blue Cross mental health provider in your network. Mental health care Includes treatment for members who have had family dysfunction or trauma, such as child abuse and neglect, domestic violence, substance abuse in the family, divorce or bereavement. Family members take part in the treatment to the extent the provider decides it is right for the health and return to better health of the member. Outpatient mental health care services for the treatment of Severe Mental Illnesses (SMI): Schizophrenia Schizoaffective disorder Bipolar disorder (manic-depressive illness) Major depressive disorders Panic disorder Obsessive-compulsive disorder Pervasive developmental disorder or autism Anorexia nervosa Bulimia nervosa Serious Emotional Disturbance (SED) Outpatient mental health care visits for the treatment of a member that the county decides has a SED condition. For members with a Serious Emotional Disturbance (SED), outpatient and related professional services that have to do with the SED may be given by the county mental health department. We may refer the member to the county mental health department for treatment of SED. We will give all medically necessary covered services until the county mental health department shows eligibility for a child with SED and the county mental health department gives the medically necessary services to treat the SED. Anthem Blue Cross and the county mental health department will manage services to ensure that medically necessary services and treatment are given to a member with SED. 54

61 Benefit descriptions Part 9 The member will stay enrolled in the Healthy Families Program and will keep getting primary and specialty care and all other covered services for medical conditions that do not have to do with the SED from Anthem Blue Cross. To learn more about SED diagnosis and treatment benefits, see Part 11, Coordination of services. Nutritional counseling Needs an OK from Anthem Blue Cross Cost to member: No copay This is a new benefit offered to members between 2 and 18 years of age and who have either of these: A Body mass Index (BMI) equal to or greater than the 85th percentile for a member age 2 through their 19th birthday A BMI equal to or greater than 25 for a member age 18 If you are eligible for this benefit, you will get up to five hours of nutritional counseling with a registered dietitian (RD). The RD may meet with you one-on-one, in a group counseling session or over the phone. The RD will: Assess your current nutritional and physical activity status Help you set goals for your nutritional and physical activity status Give you tips to help you meet your goals Organ transplants Needs an OK from Anthem Blue Cross Cost to member: No copay We cover organ and bone marrow transplants that are medically necessary and not experimental or investigational. This benefit includes payment for these: Medical and hospital costs of a donor or a person who may be a donor, if these costs have to do with the transplant for a member Testing a member s relatives for matching bone marrow Searching for, and testing, bone marrow donors (not related to the member) through a known donor registry Costs that have to do with getting donor organs from a known donor transplant bank, as long as the costs have to do with the transplant of the member Member Services /7 NurseLine: TTY lines are for members with hearing or speech loss only. anthem.com/ca 55

62 Part 9 Benefit descriptions The California Children s Services (CCS) program may cover these services instead of Anthem Blue Cross, if the member is found to be eligible for CCS. We will work with CCS to handle these benefits for the member. To learn more about CCS, see Part 11, Coordination of services. If we deny your transplant request because the service is experimental or investigational, you may ask for an independent medical review (IMR). To learn more about the IMR process, please see Part 13, How to resolve a problem with Anthem Blue Cross. Orthotics and prosthetics (Manmade body parts) Needs an OK from Anthem Blue Cross Cost to member: No copay We cover new and replacement orthotics (a brace or splint used to help or treat a muscle, joint or bone that is not working right) and prosthetics (manmade body parts). This benefit includes, but is not limited to: Medically necessary replacement prosthetics or orthotics when they are ordered by a licensed doctor Parts needed to install a voice box when one had to be removed Special shoes and inserts for diabetics Prosthetics needed to replace a breast and make it look the same as the real breast after a breast is removed We cover these items when they are ordered by a doctor, OK d by us and given by a doctor in your network. We also cover repairs if the items were not misused or lost. Limits We do not cover all special shoes, shoe inserts or arch supports. We do not cover dental parts. We do not cover electronic machines that speak for you when you can t. We do not cover more than one device for the same part of the body. We do not cover eyeglasses (except for eyeglasses or contact lenses needed after cataract surgery). We do not cover: Elastic knee supports Corsets Elastic stockings Garter belts Phenylketonuria (PKU) Cost to member: No copay We cover testing and treatment of PKU. This includes formulas and special food that are: Part of a diet ordered by a licensed doctor who consults with a doctor who specializes in the treatment of metabolic diseases and who is in your network or OK d by Anthem Blue Cross. Medically necessary to control physical or mental problems caused by this disease. Medically necessary to help the member return to normal after this disease. Physical, occupational and speech therapy Only speech therapy needs an OK from Anthem Blue Cross Cost to member: No copay for therapy you get in the hospital (This benefit includes services you get in a skilled nursing facility.) $5-$10 per visit when therapy is done in the home or other outpatient setting 56

63 Benefit descriptions Part 9 We cover therapy that is medically necessary. The therapy may be given in: A doctor s office. A hospital. A skilled nursing facility. Another outpatient setting. During your treatment, Anthem Blue Cross may check to see if the therapy is helping you. Prescription drug program Certain drugs need an OK from Anthem Blue Cross. Cost to member No copay for drugs given in a hospital No copay for drugs given in a doctor s office or in an outpatient setting while you stay at the facility No copay for drugs or devices to keep you from getting pregnant that are approved by the FDA $5 or $10 per prescription for up to a 30-day supply of generic drugs (including drugs to stop smoking) at a retail pharmacy $5 or $15 per prescription for up to a 30-day supply of brand name drugs (including drugs to stop smoking) at a retail pharmacy unless there is no equal generic version or if the use of a brand name drug is medically necessary then the $10 copay applies. $5 or $10 per prescription for up to 90-day supply of maintenance generic drugs if you get them through our mail-order program (maintenance drugs are drugs that you take for 60 days or more and are often ordered for a health issue that lasts a long time). $5 or $15 per prescription for up to a 90-day supply of maintenance brand name drugs if you get them through Anthem Blue Cross mail order program, unless there is no generic equivalent or if the use of a brand name drug is medically necessary, then the $5 or $10 copayment applies (maintenance drugs are drugs you take for 60 days or more and are often ordered for a health issue that lasts a long time). Member Services /7 NurseLine: TTY lines are for members with hearing or speech loss only. anthem.com/ca 57

64 Part 9 Benefit descriptions We cover medically necessary drugs and supplies when ordered by a licensed doctor acting within the scope of his or her license, including, but is not limited to: Injectable drugs and needles needed to give those drugs (you may get some self-injectable drugs from your doctor) Insulin, glucagon, needles and pen delivery systems for giving the insulin Blood glucose testing strips, urine ketone testing strips, lancets and lancet puncture tools used to check and treat diabetes Items you use to give covered drugs and throw away after one use, such as: Spacers and inhalers for drugs you breathe into your lungs Syringes that come with the drugs inside, so you can give them to yourself at home Vitamins that your doctor orders for you while you are pregnant Fluoride by itself or fluoride added to vitamins that your doctor orders for you Drugs you get while in a rest home, nursing home, convalescent hospital or similar facility when ordered for a covered service by a doctor in your network (You must get these drugs from a pharmacy in your network.) One cycle or course of treatment per benefit year to help you quit smoking. (You need a written OK from your doctor to get the product and you must go to a stop-smoking class or program while you are using the product.) All forms of birth control that are OK d by the FDA To learn more about our prescription drug coverage, please see Part 6, How to get prescription drugs. Limits We do not cover drugs ordered only to make you look better. We do not cover patent or over-the-counter drugs ordered by your doctor. This includes items used for birth control, such as these: Jellies Ointments Foams Condoms We do not cover drugs that do not need to be ordered in writing by your doctor (except insulin and stop-smoking drugs as listed above). We do not cover dietary supplements (except for formulas or special food products to treat phenylketonuria (PKU), appetite suppressants or any other diet drugs or medications unless medically necessary for the treatment of morbid obesity. We do not cover experimental or investigational drugs. If we deny your request for a drug because it is experimental or investigational, you may ask for an independent medical review (IMR). To learn more about the IMR process, please see Part 13, How to resolve a problem with Anthem Blue Cross. Mail service prescription drug program You will get your mail service prescription drugs through Express Scripts, Inc. (ESI), which contracts with Anthem Blue Cross. (We do not give out drugs or fill prescriptions.) When you get your prescriptions filled at a retail pharmacy, you will be given no more than a 30-day supply. You may get 30-day refills if your doctor wrote your prescription with refills. When you get your prescription filled through the Mail Service Prescription Drug Program at ESI, you will get a 90-day supply. 58

65 Benefit descriptions Part 9 Maintenance drugs Maintenance drugs are drugs you take for a long time for an ongoing health issue. This includes these kinds of health issues: Arthritis Heart disease Diabetes High blood pressure You may get maintenance drugs through the Mail Service Prescription Drug Program. There is a $5 or $10 - $15 copay for each prescription. The prescription must have the dosage, your name, your address and your doctor s signature. The first time you use the mail-in prescription program, you must include a completed patient profile form. You will get this form when you enroll in the program. After the first time you use the program, your mail-in order only needs to have the prescription and copay. Not all drugs are offered through the Mail Service Prescription Drug Program. This includes: Drugs not on the PDL Drugs to treat impotence or sexual dysfunction Injectables drugs, except for insulin Antibiotics Please check with the Mail Service Prescription Drug Program to find out if the drug you need is offered by mail. Call the program toll-free at Or, write to the program at: Anthem Blue Cross Mail Service Prescription Drug Program PO Box Cincinnati OH If you have a retail pharmacy question, call ESI at Or, write to: Anthem Blue Cross PO Box 4165 Woodland Hills CA Member Services /7 NurseLine: TTY lines are for members with hearing or speech loss only. anthem.com/ca 59

66 Part 9 Benefit descriptions Preventive health services Cost to member: No copay Routine health exams, including all routine diagnostic testing and lab services that are right for such exam if they follow the most current Recommendations for Preventive Pediatric Health Care used by the American Academy of Pediatrics The right vaccines for a certain age, including vaccines that are needed for travel, if they follow the most current version of the Recommended Childhood Immunization Schedule/United States used by the Advisory Committee on Immunization Practices. Preventive services also include services to find diseases without signs, including, but is not limited to: Well-baby care during the first two years of a child s life, including newborn hospital visits, health exams and other office visits. A range of family planning services that you choose. Birth control services Prenatal care Vision and hearing testing Sexually Transmitted Disease (STD) testing Human Immunodeficiency Virus (HIV) testing Routine cytology exams Yearly exams (pelvic exam, Pap smear, and breast exam) and any other gynecological services from your doctor or an OB/GYN provider in your network (You do not need an OK from your doctor for these tests.) Medically accepted cancer screening tests, including but is not limited to breast, prostate and cervical cancer screenings, and including Human Papillomavirus (HPV) screening. Health education services, including education regarding personal health behavior and health care, oral health care, including taking your child to a dentist before the first tooth comes through (before age 2) and recommendations how to get the most out of your health coverage. Limits The number of routine health exams will not be increased for reasons that do not have to do with the member s medical needs such as: The member s desire for extra physical exams Reports or other services that have to do with getting or keeping a job, licenses or a school sports clearance. Professional services Most services need an OK from Anthem Blue Cross Cost to member: $5-$10 per office or home visit, except: No copay for doctor visits while you are in the hospital. No copay for surgery, anesthesia, radiation, chemotherapy or dialysis treatments. No copay for members 24 months of age or younger. No copay for vision testing. No copay for hearing testing or hearing aids. We cover medically necessary services and consults with a doctor or other licensed health care provider including: Surgeon, assistant surgeon, and anesthesia (inpatient or outpatient) Inpatient hospital and skilled nursing facility visits 60

67 Benefit descriptions Part 9 Office visits including visits for allergy tests and treatments, radiation therapy, chemotherapy and dialysis treatment Home visits Dilated retinal eye exams Eye exams to find out if you need glasses Hearing tests, hearing aids and other services including: Tests to see how much hearing you have lost Tests to find out which hearing aid is best for you Ear molds The first battery for your hearing aid Cords for the hearing aid Other equipment used with the hearing aid For the first year you have your hearing aid, there is no charge for visits to make the hearing aid fit right, to talk with you about wearing a hearing aid, to adjust the hearing aid or to repair the hearing aid. Limits We do not cover batteries or other equipment you use with the hearing aid, except those items you get with the first hearing aid you buy. We do not cover costs for a hearing aid that is stronger than the one your doctor says you need. We do not cover replacement parts for a hearing aid or the repair of a hearing aid after the first year. We do not cover replacement of a hearing aid more than once in three years. We do not cover surgery to implant a hearing aid. Reconstructive surgery Needs an OK from Anthem Blue Cross Cost to member: No copay We cover medically necessary surgery on body parts that are not normal due to: Defects that you have at birth A problem with your development Member Services /7 NurseLine: TTY lines are for members with hearing or speech loss only. anthem.com/ca 61

68 Part 9 Benefit descriptions Trauma Infection Tumors Disease This surgery must be done to help you function better or to make you look normal. This benefit includes surgery to make your breasts look the same after a breast is removed. This includes medically necessary dental or orthodontic services that are an integral part of reconstructive surgery for cleft palate procedures or services. Cleft palate treatment may be given by the California Children s Services (CCS) program upon referral by Anthem Blue Cross and managed with the local CCS program. But, in the end, we must provide services if the child is not eligible for CCS or if CCS services are not approved or given by the CCS program. To learn more about the CCS program, please read Part 11, Coordination of services in this book. Medical supplies Common tools and equipment given to you in the facility Limits We cover up to 100 days per benefit year. We do not cover custodial care. Skilled nursing care Needs an OK from Anthem Blue Cross Cost to member: No copay We cover medically necessary services ordered by a licensed doctor in your network that are given in a licensed skilled nursing facility. This benefit includes: Skilled nursing care given 24 hours a day Bed and board X-rays Lab tests Breathing therapy Physical, speech and occupational therapy Medical social services Drugs ordered by a doctor 62

69 Part 10 Programs to help keep you well For healthy living...64 For you and your child...64 For managing your health...64 For your peace of mind Call to learn more

70 Part 10 Programs to help keep you well Each person has special needs at every stage of life. Whether you are a man or a woman, a child or an adult, we have programs to help you stay healthy and manage illness. Members of our health plan do not have to pay to join these programs or to learn more about them. They are all free. We hope you use them because we want you to be well and to stay that way. For healthy living We offer health education tips to help you learn how to: Stay healthy when you are pregnant. Keep your children safe and healthy. Maintain good nutrition and exercise. Manage and control your weight. Manage and control your asthma. Manage and control your diabetes. Keep your heart healthy. Control high blood pressure and cholesterol. Quit smoking. Prevent sexually transmitted diseases and HIV/AIDS. Prevent unplanned pregnancy. Use new parenting skills. Prevent dependence on drugs and alcohol. For you and your child Well-child visits are for children up to their 19th birthday. During these visits, the doctor checks the child s hearing, vision and teeth. Vaccines are given during these visits as needed. Ask your doctor when you should bring your child in for the next appointment. These services follow the most current U.S. Recommended Childhood Immunization Schedule, as adopted by the Advisory Committee on Immunization Practices. Our childhood obesity program teaches parents about exercise and good eating habits for children. We have parenting tips to teach you how to care for your child. For managing your health ConditionCare can help you manage your asthma drugs and take better care of you. You may enroll in our asthma program by calling If you have hearing or speech loss, you may call our TTY line at Nurse Coaches and Health educators are available Monday through Friday, 6:30 a.m. to 7 p.m. PST and Saturday 7 a.m. to 5:30 p.m. PST. Pregnancy tips help you have a healthy pregnancy. Call us about free childbirth classes. Prenatal services offer educational materials to help you have a healthy pregnancy. You also get a gift when you see your doctor after your baby is born. 64

71 Programs to help keep you well Part 10 For your peace of mind 24/7 NurseLine, the 24-hour nurse help line, lets you talk in private with a nurse about your health. Specially trained nurses can talk to teens about their health issues. This toll-free phone line is open 24 hours a day, seven days a week. The 24/7 NurseLine also has a TTY line for members with hearing or speech loss. You also can call 24/7 NurseLine and access audiotapes on more than 300 health topics such as: Infant and child health Pregnancy Allergies Sexually transmitted diseases such as HIV or AIDS Call to learn more Call us at If you have hearing or speech loss, you may call the TTY line at You also may call your doctor to find out more about these programs. Member Services /7 NurseLine: TTY lines are for members with hearing or speech loss only. anthem.com/ca 65

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73 Part 11 Coordination of services California Children s Services (CCS) County mental health benefits for Serious Emotional Disturbance (SED) children What is Serious Emotional Disturbance (SED)?

74 Part 11 Coordination of services California Children s Services (CCS) As part of the services provided through the HFP, members needing specialized medical care may be eligible for services through the CCS program. CCS is a California medical program that treats children who have certain physically handicapping conditions and who need specialized medical care. This program is available to all children in California whose families meet certain medical, financial and residential eligibility requirements. All children enrolled in the Healthy Families Program are deemed to have met the financial eligibility requirements of the CCS program. Services provided through the CCS program are coordinated by the county CCS office. If a member s primary care provider suspects or identifies a possible CCS-eligible condition, he or she must refer the member to the local CCS program. Anthem Blue Cross can assist with this referral. Anthem Blue Cross also will make a referral to CCS when the Plan identifies a possible CCS-eligible condition. The CCS program will determine whether the member s condition is eligible for CCS services. If the CCS program determines that the condition is a CCS-eligible condition, and CCS is treating the eligible condition, the member will remain enrolled in the Healthy Families Program. He or she will be referred to the specialized network of CCS providers and/or CCS-approved specialty centers. These CCS providers and specialty centers are highly trained to treat CCS-eligible conditions. Anthem Blue Cross will continue to provide primary care, prevention services and any other services that are not related to the CCS-eligible condition, as described in this booklet. Anthem Blue Cross also will work with the CCS program and providers to coordinate care provided by both the CCS program and Anthem Blue Cross. If a condition is determined not to be eligible for CCS program services, the member will continue to receive all medically necessary services from Anthem Blue Cross. In addition, Anthem Blue Cross is responsible for all covered services if CCS does not authorize or does not actually provide those specific services. If CCS authorizes services for a CCS condition, but the services are not or cannot be provided in a timely manner or within the geographic area, Anthem Blue Cross will provide the services in the health plan s network to the extent that they are covered services. Although all children enrolled in the HFP are determined to be financially eligible for the CCS program, the CCS office must verify residential status for each child in the CCS program. If a member is referred to the CCS program, the member s parents or legal guardian will be asked to complete a short application to verify residential status and ensure coordination of the member s care after the referral has been made. Additional information about the CCS program can be obtained by calling Anthem Blue Cross Member Services at Members with hearing or speech loss may call the TTY line at If you would like to talk to your local county CCS program, call us to get the phone number. County mental health benefits for Serious Emotional Disturbance (SED) children If the member shows the behaviors listed below, the member may be able to access mental health services through Anthem Blue Cross: Serious problem eating or sleeping. Often crying or sad Says things that worry you 68

75 Coordination of services Part 11 Behaving in ways that cause serious family and school problems Ongoing or frequent problems with playmates and friends Purposefully hurting him/herself and others As part of the services given through the Healthy Families Program, members needing specialized mental health services for a Serious Emotional Disturbance (SED) will be referred for a SED assessment to their local county mental health department. The referral may be made by the member s primary care provider or by Anthem Blue Cross. Parents also may refer the member directly to the county mental health department if the parents suspect the member suffers from any of the conditions listed below. The county mental health clinician will have the final determination of whether the member meets SED criteria. What is Serious Emotional Disturbance (SED)? SED refers to any diagnosable mental disorder (in a child under age 19) that severely disrupts social, academic and emotional functioning. A child is considered to have SED only if his or her inappropriate behavior does not result from drug or alcohol substance abuse or a developmental disorder. To determine if a child has an SED condition, the child must have a mental disorder as identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, other than a primary substance use disorder or developmental disorder, which results in behavior inappropriate to the child s age according to expected developmental norms. In addition, he or she must meet one or more of the following criteria: Has substantial difficulties in at least two of the following areas: self-care, school functioning, family relationships, or the ability to function in the community, and either of the following occurs: The child is at risk of removal from the home or already has been removed. The mental health condition has been present for more than six months or is likely to continue for more than one year if not treated. Shows signs of psychotic behavior, risk of suicide or risk of violence, which are related to a mental disorder Meets special education eligibility requirements not related to developmental disorders Member Services /7 NurseLine: TTY lines are for members with hearing or speech loss only. anthem.com/ca 69

76 Part 11 Coordination of services If a member is determined to have a SED, care for the SED will be provided by the county mental health department. The plan may refer the member to the county mental health department for treatment of SED. The plan shall provide all medically necessary covered services until the county mental health department establishes eligibility for a member child with SED and the county mental health department provides the medically necessary services to treat the SED. The plan and the county mental health department will coordinate services to ensure that medically necessary services and treatment are provided to a member with a SED condition. The member will remain enrolled in the Healthy Families Program and will continue to receive primary care, specialty care and all other services for medical conditions not related to the SED from Anthem Blue Cross. If a member does not meet the SED criteria, or services are not covered, authorized or provided by the county mental health department, the member will continue to receive all medically necessary covered health and mental health care services subject to applicable limitations, from Anthem Blue Cross. If county mental health authorizes services for SED, but the services are not or cannot be provided in a timely manner or within the geographic area, Anthem Blue Cross will provide the services in the health plan s network to the extent that they are covered services. Services provided by the county for the SED condition are provided by the county to members at no cost and may include, but are not limited to: Outpatient visits for treatment of SED Inpatient mental health care for the treatment of SED Day treatment programs Individual or family therapy All medications prescribed to treat the SED condition Counseling assistance with medication management related to the SED condition Additional information about services for children with a SED can be obtained by contacting the county s mental health department. The phone number of your county mental health department can be found in the government listing section of the phone book under the heading County Government. 70

77 Part 12 What Anthem Blue Cross does not cover 71

78 Part 12 What Anthem Blue Cross does not cover These health benefits are not covered by Anthem Blue Cross: Any service or item that is not listed in Part 9, Benefits description Any service or item that is not listed as being covered may not be a benefit Any benefit that is more than the limits listed in Part 9, Benefits description Services, supplies, items, procedures or equipment that is not medically necessary (Unless they are listed in Part 9, Benefits description.) Services you got outside the United States Any care you got before you had coverage with us (This does not apply to covered services to treat problems that came from care you got before you had coverage with us.) Any care you get after your coverage with Anthem Blue Cross ends Experimental or investigational care that does not follow generally accepted professional medical standards or it has not been decided if it is safe and efficient for treating a certain illness, injury or medical issue for any: Treatment Therapy Procedure Supplies Drugs or their use Facilities or their use Equipment or its use Devices or their use If we deny a request for any of items listed above, you may ask for an independent medical review (IMR). To learn more about the IMR process, see Part 13, How to resolve a problem with Anthem Blue Cross. Medical services that you get in an emergency care setting for health issues that are not emergencies (This is the case if you should have known that you did not need emergency care.) Glasses (unless glasses or contact lenses are needed after cataract surgery) The diagnosis and treatment of infertility is not covered unless it is given along with covered gynecological services (Treatments for health issues that have to do with the reproductive system are covered.) Long-term care benefits are not covered except when we say they are OK (This section does not exclude short-term skilled nursing care or hospice benefits.) Treatment for an injury or sickness you got while working, which will be paid by workers compensation (We will give you the care you need when you need it, but you or your legal guardian must make sure that we are paid for that care.) Care that can be paid for by insurance or covered under any other insurance or health care service plan (We will give you the care you need when you need it. You or your legal guardian must make sure that we are paid for that care.) Services for a health issue that can be covered by the California Children s Services (CCS) program (The state pays for CCS services. If your child is referred to CCS and you refuse their services and get treatment on your own, you will have to pay for the treatment, even if it was given by your network providers.) Cosmetic surgery that is done only to change or reshape part of the body to make the person look better. 72

79 Part 13 How to resolve a problem with Anthem Blue Cross If you have a problem Cultural and linguistic complaints To file an appeal Independent Medical Reviews (IMRs)...75 Review by the Department of Managed Health Care (DMHC) Binding arbitration

80 Part 13 How to resolve a problem with Anthem Blue Cross If you are thinking about leaving Anthem Blue Cross, we would like to talk with you. Please call us at our toll-free Member Services or TTY number (for those with hearing or speech loss). We would like to help you with any problem you are having. If you have a problem If you have a complaint about the care you get from us or a provider in the Anthem Blue Cross network, you can file a complaint by phone or in writing within 180 days from when the problem started. We can help you with your problem. Most problems can be solved quickly. If you have a problem with your doctor, we suggest that you talk to your doctor first. If you still have concerns, you can file a complaint with us at any time. To begin this process you can write, call or fax us at: Anthem Blue Cross The Healthy Families Program PO Box 9054 Oxnard CA Phone number: Fax number: To learn more about the grievance process, you also may visit our website at anthem.com/ca (click Members) Our grievance coordinator will process and resolve your complaint. You may call us to help you translate your complaint as well. We will send you a letter: Within five days of getting your request to let you know we are looking into your grievance. Within 30 days after getting your request to let you know how we resolved the problem. If your case has to do with a serious or immediate threat to your health that may cause severe pain, death or loss of a limb or major body function, we will respond within three days after getting your request. Cultural and linguistic complaints If you think that we did not meet your cultural and linguistic needs, please call us at our toll-free Member Services or TTY number (for those with hearing or speech loss. You have the right to get free interpreter services from us. To file an appeal If we deny, delay or change your medical care request and you do not agree with what we decide, you can file an appeal. Your provider may ask for an appeal on your behalf. You or your provider must ask for an appeal within 180 days of the health plan s mail date on the notice of action letter. We will send you a letter: Within five days of getting your appeal request, telling you we are looking into your appeal. Within 30 days after getting your appeal, telling you how we resolved your case. You may call us at our toll-free Member Services or TTY phone number to file your appeal. You also may write us at: Anthem Blue Cross The Healthy Families Program PO Box 9054 Oxnard CA Phone number: TTY Line:

81 How to resolve a problem with Anthem Blue Cross Part 13 Independent Medical Reviews (IMRs) If we or a plan provider denies, delays or modifies your medical care request, you may be eligible for an IMR. During an IMR, the DMHC gives details about your case to a medical specialist who reviews it and decides about your case. You will get a copy of the decision. If the IMR specialist says so, we will cover the health care services. You can ask for an IMR if you meet all three of these rules: 1. Your doctor says a health care service is medically necessary. You got urgent or emergency care that your doctor said was medically necessary. You have been seen by a doctor in your network to diagnose or treat the medical issue for which you seek the IMR 2. The health care service you want reviewed was denied, changed or delayed by us or one of its doctors in your network because it was not medically necessary. 3. You have filed an appeal with us and one of these happens: The decision you did not agree with was upheld. The appeal has not been resolved after 30 calendar days. If your appeal is approved for faster review, you do not have to file an appeal with us before you ask for an IMR. Also, the DMHC may decide that you do not have to follow the Anthem Blue Cross appeal process in some cases. For cases that are not urgent, the IMR group chosen by the DMHC will decide within 30 days from the time they get your form and the papers that support your request for an IMR. The IMR group will decide within three business days if waiting 30 days could cause an immediate serious threat to your health. This includes, but is not limited to: Severe pain Losing your life, a limb, or a major body function The experts can ask to extend that deadline up to three more days if they do not get all of the papers they need for the review. If you choose not to ask for an IMR, you may give up your right to pursue legal action against us about the care that you wanted. You do not have to pay for an IMR. Member Services /7 NurseLine: TTY lines are for members with hearing or speech loss only. anthem.com/ca 75

82 Part 13 How to resolve a problem with Anthem Blue Cross To learn more about the IMR process or to request an IMR form, please call our toll-free Member Services or TTY number (for those with hearing or speech loss). Review by the Department of Managed Health Care (DMHC) The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at and use your health plan s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You also may be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. You can call, write or use the website to contact the DMHC Health Care Help Center. You can write to the Help Center at: California Department of Managed Health Care Health Care Help Center 980 9th Street, Suite 500 Sacramento CA The department also has a toll-free telephone number, HMO-2219, and a TDD line, , for members with hearing or speech loss. The department s Internet website hmohelp.ca.gov has complaint forms, IMR applications forms, and instructions online. You also can contact the department at helpline@dmhc.ca.gov. Binding arbitration This Binding Arbitration provision does not apply to class actions. ALL DISPUTES INCLUDING BUT NOT LIMITED TO DISPUTES RELATING TO THE DELIVERY OF SERVICE UNDER THE PLAN OR ANY OTHER ISSUES RELATED TO THE PLAN AND CLAIMS OF MEDICAL MALPRACTICE MUST BE RESOLVED BY BINDING ARBITRATION, IF THE AMOUNT IN DISPUTE EXCEEDS THE JURISDICTIONAL LIMIT OF SMALL CLAIMS COURT. California Health and Safety Code Section and Insurance Code Section require specified disclosures in this regard, including the following notice: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. YOU AND ANTHEM BLUE CROSS AGREE TO BE BOUND BY 76

83 How to resolve a problem with Anthem Blue Cross Part 13 THIS ARBITRATION PROVISION AND ACKNOWLEDGE THAT THE RIGHT TO A JURY TRIAL IS WAIVED FOR BOTH DISPUTES RELATING TO THE DELIVERY OF SERVICE UNDER THE PLAN OR ANY OTHER ISSUES RELATED TO THE PLAN AND MEDICAL MALPRACTICE CLAIMS. The Federal Arbitration Act shall govern the interpretation and enforcement of all proceedings under this Binding Arbitration provision. To the extent that the Federal Arbitration Act is inapplicable, or is held not to require arbitration of a particular claim, state law governing agreements to arbitrate shall apply. The arbitration findings will be final and binding except to the extent that state or federal law provides for the judicial review of arbitration proceedings. The arbitration is initiated by the member making a written demand on Anthem Blue Cross. The arbitration will be conducted by Judicial Arbitration and Mediation Services ( JAMS ), according to its applicable Rules and Procedures. If for any reason JAMS is unavailable to conduct the arbitration, the arbitration will be conducted by another neutral arbitration entity, by agreement of the member and Anthem Blue Cross, or by order of the court, if the member and Anthem Blue Cross cannot agree. The costs of the arbitration will be allocated per the JAMS Policy on Consumer Arbitrations. If the arbitration is not conducted by JAMS, the costs will be shared equally by the parties, except in cases of extreme financial hardship, upon application to the neutral arbitration entity to whom the parties have agreed, in which cases, Anthem Blue Cross will assume all or a portion of the costs of the arbitration. Please send all Binding Arbitration demands in writing to: Anthem Blue Cross PO Box 9086 Oxnard CA Member Services /7 NurseLine: TTY lines are for members with hearing or speech loss only. anthem.com/ca 77

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85 Part 14 General information If you have other health insurance...80 How third-party recovery works and what you need to do...80 Workers compensation...80 Coordination of benefits Explanation of Benefits (EOB) Limits of other coverage How we pay our providers What to do if you get a bill...82 Public participation...82 Program changes...82 Organ and tissue donation

86 Part 14 General information If you have other health insurance It is best for you to tell your network doctor if you have more health care coverage than just this plan. Most health plans work with each other to not pay for care more than once, but they still allow you to make use of both programs. Your Anthem Blue Cross coverage is secondary to all other coverage, except Medi-Cal. We pay for your care after any other health plan you have has paid. Be sure to tell your doctor about all of the health care coverage you have. That way you will get all of the benefits you should. We pay benefits under this program after benefits are paid by a member s enrollment in any other health care program. Be sure to tell your provider about all the programs under which you have coverage so that you will get all of the benefits you should get. To learn more or if you have questions about your health insurance, call our toll-free Member Services or TTY number (for those with hearing or speech loss). How third-party recovery works and what you need to do If you get sick or hurt because of the wrongful act or omission of another person or a third party, and you get paid for the care and you are made healthy again before we are to be paid, then you must follow these rules: Pay us for the reasonable cost of services paid by us (as allowed by California Civil Code section 3040) as soon as you collect the money, whether by action or law, settlement or otherwise. Work with us when we try to collect the reasonable value of services given by us (as allowed by California Civil Code section 3040). We may file a lien with the person whose act caused the injury, his or her agent, or the court. We have the right to be paid or paid back when you get paid by a third party. You must protect our rights. This includes letting us know when you get money back from a third party. If you get money from a third party without a final court verdict, the rule that you must be made whole before we get paid back does not refer to noneconomic damages such as pain and suffering. Workers compensation Under workers compensation, employer s liability law or other laws like these, if a third party has to pay all or part of the cost of medical services given by us, we will give the benefits as listed in this book at the time of need. The member will agree to give us a lien for the reasonable value (the cost for medical care where you live) of the services given by us. The lien may be filed with the third party, his or her agent, or the court. By taking the coverage as listed in this book, members agree to help us by giving us any papers needed to protect our rights. Coordination of benefits When you enroll in Anthem Blue Cross, you agree to fill out and give us any papers needed so we can be paid and manage coverage with other health plans or insurance policies. We will pay less when you have other coverage, even if a claim is not filed with the other plan. The benefits that are to be paid will be reduced when you have benefits under such other plan or policy, whether or not the claim is made for the same. You still must pay copays even if you have more than one Anthem Blue Cross plan. 80

87 General information Part 14 Explanation of Benefits (EOB) We want to be sure you get the medical care you need. We do this through your Explanation of Benefits (EOB). After you receive medical care, you will get your EOB in the mail. Your EOB is not a bill. It is a summary of the coverage you receive. Your EOB shows: Total amounts charged for services/supplies received. The amount of the charges your plan covers. The amount which you are responsible for (if any). General information about your appeals rights. If you have questions about your EOB, or need help to understand it, please call Member Services at The TTY line for members with hearing or speech loss is Limits of other coverage This health plan coverage is not made to copy any benefits that you can get under government programs. This includes CHAMPUS/ TRICARE, Medi-Cal, or workers compensation. By filling out a form to enroll, you agree to fill out and give to us any papers needed so these programs can get paid. How we pay our providers We pay the doctors in your network this way. We pay some of our doctors and health care providers a fee-for-service. This means the doctors give health care services to their patients, then they send a bill to us for each of the services they give you. Anthem Blue Cross and these health care providers agree on how much is paid for each service. Your doctor may get a financial bonus from us if they meet our rules for giving quality care. You may ask Anthem Blue Cross, your doctor, or your doctor s medical group for a written report of this bonus. Hospitals and other health care facilities are paid by us in two ways: They get a fixed amount of money for the service that Anthem Blue Cross and the hospital or facility, agree upon in advance. They get a lower amount of money for the service that Anthem Blue Cross and the hospital or facility, agree upon in advance. You would not have to pay the difference. Member Services /7 NurseLine: TTY lines are for members with hearing or speech loss only. anthem.com/ca 81

88 Part 14 General information You do not have to pay if we do not pay your provider for covered benefits. What to do if you get a bill If you do not tell your doctor or other health care provider that you are a member of the Healthy Families Program, you may have to pay for your health care. If you get a bill while you have coverage, take care of it right away. If you do not take care of it, the doctor may send the bill to a collection agency. If you get a bill, follow these steps: Call us at our toll-free Member Services or TTY number (for those with hearing or speech loss) and ask for a member claim form. Get a detailed bill from your doctor or other health care provider. Mail the detailed bill with a filled in member claim form to: Anthem Blue Cross The Healthy Families Program PO Box 9054 Oxnard CA If you would like to be considered for membership on the Consumer Relations/Public Policy Committee, please call our toll-free Member Services or TTY number (for those with hearing or speech loss). Program changes During the year, we may send you updates about changes to your health plan. We may send you a Provider Directory, a Member Kit and an Evidence of Coverage. If you want to know more about the changes, you may call our toll-free Member Services or TTY number (for those with hearing or speech loss). Organ and tissue donation You can help save lives and give people a chance to live a normal life by becoming an organ donor. If you think you might want to donate your organs, please speak with your doctor. To learn more about being an organ and tissue donor, visit the Department of Health and Human Services website at organdonor.gov. Public participation We have a Consumer Relations/Public Policy Committee to help our board of directors. This group is made up of members of our health plan, providers in your network and a member of our board of directors. This group makes sure the comfort and dignity of our members is considered. It makes sure our services are easy to access for our members. The committee gives input on the Cultural and Linguistics Needs Assessment. The committee may look at the way we use our funding. They also may review complaints we get from our members. The Consumer Relations/Public Policy Committee reports to our board of directors. 82

89 Part 15 Other things you may need to know 83

90 Part 15 Other things you may need to know You may have questions that have not been answered yet in this book. Look through this section for the answers. You may be able to get help from your county s Women, Infants and Children (WIC) Program. The WIC Program gives out food vouchers and can tell you about other programs in your area. To get the WIC phone number in your area, call us at our toll-free Member Services or TTY number (for those with hearing or speech loss). You can have access to your medical records as allowed by law. You can file a form ahead of time to tell your doctor or other health care provider what to do, or not to do, if you are in danger of dying. This form is called an advance directive. At least once a year, we will send a form to some of our members to find out if they are happy with their health care. So that we can pay for your health care, we have the right to get information from anyone giving that care. We keep this information between you, the health care provider and us. The services covered by us can be changed without your agreement. We will let you know of any changes by mail. Your benefits depend on what is covered on the date you get the service. If we need to tell you about any changes in the plan, we will do so at least 30 days before the change. We will contact you at the address we have in our records. If your address changes, please call the Healthy Families Program at Anthem Blue Cross does not replace workers compensation insurance. 84

91 Part 16 Important phone numbers 85

92 Part 16 Important phone numbers Member Services (Anthem Blue Cross) TTY Line /7 NurseLine (24-hour nurse help line) TTY Line Prescription Drug Services Anthem Blue Cross Behavioral Health Program The Healthy Families Program Department of Managed Health Care HMO-2219 TTY Line California Relay Service (for members with speech or hearing loss)

93 Part 17 Map of the plan s service area 87

94 Part 17 Map of the plan s service area 88