Member Handbook FAMIS

Transcription

1 Member Handbook FAMIS

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3 Translation Services, Interpreter Services, and Materials for the Visually Impaired This information is important and is available at no charge in Spanish, Chinese (Traditional), Korean, and Vietnamese. If you want someone to read it to you, or if you would like a copy in one of these languages, contact Kaiser Permanente Member Services toll free at , TTY/TDD. You can also get this handbook in large print and/or Braille Interpreter services are offered at no charge. If you need an interpreter during your next doctor visit, inform the appointment clerk when scheduling your appointment. For all other questions, call Member Services at A Member Services representative can provide an interpreter over the phone when you call Members who are deaf, hard of hearing, or speech impaired may call toll free TTY/TDD. Interpreter services are available at Kaiser Permanente facilities. We will provide interpretive services if a non-kaiser Permanente facility cannot provide such services. Esta información es importante y está disponible en español, chino (tradicional), coreano y vietnamita. No tiene ningún costo. Si desea que alguien se la lea, o si desea una copia en uno de estos idiomas, llame a Servicios para Miembros de Kaiser Permanente al número de llamada gratuita (855) , TTY: (866) También puede recibir este manual en letra grande y/o en braille. Ofrecemos servicios de interpretación sin ningún costo. Si necesita un intérprete durante su próxima visita médica, informe al recepcionista a cargo de las citas cuando llame a programar la suya. Para todas las demás preguntas, llame a Servicios para Miembros al (855) Un representante de Servicios para Miembros le asignará un intérprete por teléfono. Los miembros sordos, con dificultades de audición o de lenguaje pueden llamar sin costo al número TTY (866) Nuestros servicios de interpretación se ofrecen en los centros de Kaiser Permanente. Ofrecemos los servicios de interpretación si un centro que no es de Kaiser Permanente no puede ofrecer tales servicios. 1

4 本資訊不僅重要而且有中文 西班牙文 韓文和越南文版本, 免費提供 如果您希望別人讀給您聽, 或者希望獲取一份上述語言的版本, 請撥 Kaiser Permanente 會員服務的免費電話 :(855) 或聾啞 聽力障礙者 TTY/TDD 專線 (866) 您亦可獲取本手冊用大字體及或盲文印刷的版本 我們免費提供口譯服務 如果您在下次看醫生時需要口譯員, 請您在預約時告訴我們的預約員 若有任何其他問題, 請撥會員服務電話 :(855) 會員服務代表會為您提供電話口譯服務 如果會員患有聾啞 聽力或語言障礙症, 您可免費撥打 TTY/TDD 專線 :(866) 我們所有凱薩醫療 (Kaiser Permanente) 機構均提供口譯服務 此外, 在無此等口譯服務的非凱薩醫療機構我們亦將提供口譯服務 이정보는중요하며한국어, 스페인어, 중국어 ( 전통 ) 및베트남어로제공됩니다. 무료입니다. 누가대신읽어주거나다른언어로된사본을원하시면 Kaiser Permanente 회원서비스무료전화인 (855) , (866) TTY/TDD 로연락하십시오. 이핸드북은큰활자및 / 또는점자로도제공됩니다. 저희는통역서비스를무료로제공하고있습니다. 다음번의사방문시통역이필요하시면약속을잡을때약속담당자에게알리십시오. 그밖의다른질문은회원서비스의 (855) 로전화하십시오. 회원서비스담당자가전화통역자를연결해드립니다. 청각상실, 청각장애또는언어장애가있는회원은무료전화인 (866) TTY/TDD 로연락할수있습니다. 저희의통역서비스는 Kaiser Permanente 시설에서제공됩니다. Kaiser Permanente 시설이아닌곳에서통역서비스를제공할수없다면저희가그서비스를제공해드립니다. 2

5 Thông tin này quan trọng và có sẵn bằng tiếng Tây Ban Nha, Hoa, Hàn, và Việt. Thông tin được cung cấp miễn phí. Nếu qu ý vị muốn một người nào đó đọc cho mình, hoặc nếu qu ý vị muốn nhận một bản bằng một trong những thứ tiếng trên, xin gọi Ban Phục vụ Khách hàng của Kaiser Permanente số điện thoại miễn phí (855) , (866) cho máy TTY. Quý vị cũng có thể nhận cuốn cẩm nang này bằng chữ in lớn và/hoặc chữ nổi Braille. Chúng tôi cung cấp dịch vụ thông dịch miễn phí. Nếu qu ý vị cần một thông dịch viên trong chuyến đi bác sĩ kế tiếp, xin nói cho nhân viên phòng mạch lấy hẹn biết. Đối với tất cả các câu hỏi khác, xin gọi Ban Phục vụ Khách hàng tại số (855) Một đại diện của ban này sẽ thu xếp một thông dịch viên qua điện thoại. Khách hàng bị điếc, yếu tai hoặc gặp vấn đề về giọng nói có thể gọi số điện thoại miễn phí (866) cho máy TTY. Dịch vụ thông dịch của chúng tôi có sẵn tại các cơ sở Kaiser Permanente. Chúng tôi sẽ cung cấp dịch vụ thông dịch nếu một cơ sở không phải là Kaiser Permanente không có dịch vụ đó. 3

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7 Welcome Welcome to Kaiser Permanente! Thank you for choosing us. We want to help your child stay healthy. We re also here to serve your child when he or she is sick or injured. This Member Handbook is a guide to Kaiser Permanente benefits and processes. It is written for the parents and guardians of enrolled children, members who are 18 and over, and emancipated minors. We re happy you ve chosen us as your child s partner in good health, and we look forward to helping your child stay well and live well. FAMIS at Kaiser Permanente FAMIS is a program of the Commonwealth of Virginia. Kaiser Permanente is one of the participating managed care organizations. As a managed care organization, Kaiser Permanente provides your child s medical and behavioral health benefits through Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (Health Plan), and the Mid-Atlantic Permanente Medical Group, Inc. (MAPMG). We work together to give your child the medical care he or she needs. What makes Kaiser Permanente special is how we coordinate your child s care. Most Kaiser Permanente members receive care from the doctors of MAPMG. These doctors have their offices in our medical centers, most of which include a pharmacy, lab, and x-ray services all under the same roof. This makes getting care simple and easy. This is called managed care. Our electronic health record system lets you your child s MAPMG doctor, make appointments, read many lab test results, order prescription refills, read about medical conditions, and much more. You can do all this on a computer or smart phone. Each member has a primary care provider (PCP) who checks your child s medical and behavioral health needs and provides/directs the services to meet those needs. Most of the PCPs will be MAPMG doctors who practice in our medical centers. However, we use participating providers and hospitals who must also meet our high standards. At the end of this handbook, we have included a definitions section, which defines terms that may be new to you. If you have questions about any sections of this handbook, contact Member Services at , TTY/TDD. 5

8 Table of Contents Simple Steps to Get Started... 9 Quick Reference Guide Service Area Eligibility, Enrollment, and Disenrollment Member Services Kaiser Permanente s Provider Directory Notifying You of Changes How to Get Medical Care Identification (ID) cards Your child s doctors make care personal Changing your child s PCP or Ob/Gyn Out-of-area services Appointments Specialty care (referrals and self-referrals) Pharmacy services Kaiser Permanente medical centers Medical records My Health Manager hour medical advice Urgent care Emergency care Hospital care Prevention and Disease Management Preventive guidelines Disease management CareConnect Program (Complex case management)

9 What Does the Plan Cover? Prior approval (Service authorization) Copayments Services covered by Kaiser Permanente Services covered by DMAS Services not covered by Kaiser Permanente or DMAS Inquiries, Complaints, and Appeals Inquiries Complaints Expedited reviews of complaints/grievances or appeals Appeals External review process Continuation of services Alternative formats General Information Coordination of benefits Advance directives New medical technologies Quality care at Kaiser Permanente Utilization management Claims How our doctors are paid Your Rights and Responsibilities Privacy information Protecting you from health care fraud and abuse Member rights and responsibilities Definitions

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11 Simple Steps to Get Started Make the most of your child s Kaiser Permanente membership Follow these simple steps to get started to help you build a relationship with your child s doctor and learn ways to make full use of what Kaiser Permanente offers its members. 1. Learn about your child s doctor You can learn about our doctors at kp.org, by reading the provider directory, or by calling Member Services. If you want to change your child s doctor, call Member Services. You may contact them Monday through Friday, 7:30 a.m. to 5:30 p.m., except holidays, at , TTY/TDD. 2. Schedule a health assessment within the first 60 days of enrollment To schedule your child s health assessment with his or her MAPMG PCP, call Monday through Friday, 7 a.m. to 8 p.m., , TTY/TDD. 4. Explore the benefits of kp.org With your child s Kaiser Permanente ID card handy, go to kp.org/register to set up a user ID and password. Once you ve registered, you ll have free, around-the-clock access to the time-saving features of My Health Manager. These services are available from a computer or smart phone. If you get services at Kaiser Permanente medical centers, you can do the following through My Health Manager: your child s doctor s office Schedule routine appointments Order most prescription refills View most lab test results And more 5. Find additional resources You can read about popular health topics, learn about medications, nutrition, and more at kp.org/healthyliving. If your child s doctor does not practice in a Kaiser Permanente medical center, call that doctor s office directly to schedule a health assessment. 3. Tell us about your child s medical history It s important we understand your child s health care needs. For your child s first appointment, please bring: Current medications List of allergies Past medical history Immunization records 9

12 Quick Reference Guide Action Contact What you can do Change your child s doctor Make an appointment 24-hour medical advice Fill a prescription Call Member Services, Monday through Friday, 7:30 a.m. to 5:30 p.m., except holidays, at: TTY/TDD* For MAPMG doctors, call Monday through Friday, 7 a.m. to 8 p.m., at: TTY/TDD* If your child s doctor does not practice in a Kaiser Permanente medical center, call that doctor s office directly to make an appointment. Medical advice is available 24 hours a day, seven days a week at: TTY/TDD* EZ Refill: Call , 24 hours a day, seven days a week. Mail delivery services: Select the EZ Refill mail option to have your child s refillable prescription mailed anywhere in the U.S. Order online: Order your child s prescription refills at kp.org using My Health Manager. MedImpact: Call Change your child s PCP. This doctor will coordinate all of your child s health care needs, including making referrals. Females 13 and older should also choose an obstetrician/gynecologist (Ob/Gyn). You can change your child s PCP or Ob/Gyn at any time, for any reason. We can help you make, cancel, and change appointments with a MAPMG doctor. You can also make, cancel, and change appointments online at kp.org through My Health Manager. If you would like to leave a non-urgent message for a medical advice nurse, you can do so at kp.org if you are registered on My Health Manager. You will receive an answer within one business day. Fill prescriptions at any of our Kaiser Permanente medical center pharmacies after your child s doctor s visit. If your child has a MAPMG doctor, he or she can send the prescription through our electronic medical record system, and your child s prescription can be ready soon after seeing the doctor. To find other participating pharmacies near you, call MedImpact. 10

13 Action Contact What you can do Emergency care Urgent care Behavioral Health Access Line Member Services If you think your child is experiencing a medical emergency, immediately call 911 or go to the nearest emergency facility. If you are unsure about your child s medical problem and want medical advice, call Call our 24-hour medical advice line at: TTY/TDD* Call the Behavioral Health Access Line at: Call Members Services representatives, Monday through Friday, 7:30 a.m. to 5:30 p.m., except holidays, at: TTY/TDD* Report your child s emergency room visit to us as soon as possible by calling Member Services or the medical advice line (on evenings and weekends). If you are not sure your child is experiencing a medical emergency, call our advice nurses. Examples of times when your child might need urgent care are a sudden rash, high fever, severe vomiting, ear infection, or a sprained ankle. You can ask for outpatient treatment for mental illness, emotional disorders, drug abuse, and alcohol abuse from a MAPMG or participating provider without a referral from your child s PCP. Contact Member Services if you need help with your child s health plan. *The Kaiser Permanente TTY/TDD line is available for people who are speech/hearing impaired. 11

14 Service Area Kaiser Permanente serves these cities and counties: Arlington County Alexandria City Fairfax County Fairfax City Falls Church City Loudoun County Manassas City Manassas Park Prince William County Loudoun City of Falls Church City of Manassas City of Fairfax Prince William Fairfax Arlington City of Alexandria City of Manassas Park 12

15 Eligibility, Enrollment, and Disenrollment Eligibility The Virginia Department of Medical Assistance Services (DMAS) decides who can enroll in a managed care organization (MCO) like Kaiser Permanente. They will let us know about your child s eligibility and if there are any changes to that eligibility while your child is enrolled in our plan. The annual enrollment period FAMIS has a period each year when you can choose to stay with Kaiser Permanente or pick a different MCO for your child s coverage. This is called the annual enrollment period. During the annual enrollment period, you may choose an MCO for FAMIS coverage for that year and complete all of the information needed for your child s annual renewal. his/her birth date and two additional months (up to a total of 90 calendar days). After that, the baby will be covered only if DMAS tells us to continue coverage. Please contact DMAS as soon as possible after the baby is born to apply for FAMIS coverage. Coverage start and end DMAS decides when coverage starts and ends. Coverage will start one minute after midnight on the first day of the month after DMAS decides eligibility. If you have any questions about starting dates and coverage, please call the FAMIS Central Processing Unit (CPU) at Losing and regaining FAMIS eligibility Your child may lose eligibility for a number of reasons. The Department of Social Services (DSS) or FAMIS CPU will make the final decision. Your child may be disenrolled and lose coverage with Kaiser Permanente if: Your child moves and you don t tell your local DSS caseworker Your child is no longer eligible for FAMIS Fraud is committed Your child is in police custody, jail, or prison Newborn eligibility Kaiser Permanente will automatically cover a newborn baby under the FAMIS program from Your child is enrolled in other medical programs or facilities such as hospice, foster care, state mental facilities, or inpatient stay to nursing homes for long term care 13

16 You must renew your child s FAMIS benefits at least every 12 months, even if nothing has changed. The enrollment broker will send you a letter telling you the date by which you must renew your child s FAMIS benefits. If you do not renew by the date in the letter, your child will lose his or her benefits. If your child loses FAMIS eligibility, he or she should automatically be re-enrolled in Kaiser Permanente on the first day of the next month after he or she regains eligibility. Please check with the FAMIS CPU at to make sure that your child has been re-enrolled in Kaiser Permanente. Disenrolling your child from Kaiser Permanente We hope you will be pleased with Kaiser Permanente. If you do not like something about us, please call Member Services at , TTY/TDD. We will work with you to address your concerns. You may change health plans for any reason, at any time, during the first 90 calendar days of your child s enrollment. After the first 90 calendar days, you will not be allowed to disenroll from Kaiser Permanente without a good reason for doing so. DMAS will decide if you have a good reason. You can also change plans when your FAMIS coverage renews. If you request a change, it will be effective either on the first day of the next month or the first day of the month after that, depending on when you asked for the change. DMAS pays us a monthly premium for your child s coverage. If your child becomes ineligible for coverage for past months because you did not give truthful information to the FAMIS CPU or failed to tell the FAMIS CPU about changes in your circumstances, you may have to pay DMAS back for these premiums, even if your child did not get medical services through the FAMIS program during these months. 14

17 Member Services Kaiser Permanente Member Services representatives are available Monday through Friday, 7:30 a.m. to 5:30 p.m., except holidays, at TTY/TDD The Member Services staff can answer questions about: How the Kaiser Permanente health plan works Your child s benefits The location of our medical centers The types of services in our centers Providers (PCP, specialist, hospitals, or other providers) Your child s rights and responsibilities Changing your child s PCP Filing a complaint or appeal Changing your address, phone number, or Health education classes Getting a free interpreter, language translation, or information in large print Getting a new Kaiser Permanente ID Card Requesting additional hard copies of member materials, including this handbook and the provider directory 15

18 Kaiser Permanente s Provider Directory The provider directory can be found online at kp.org/medicaid/va. It lists health care providers and hospitals in our network. The directory has the names of doctors, pharmacies, hospitals, labs, radiology, behavioral health, and other health care providers and facilities in your area. If you want help finding a provider for any of our services or would like to request a hard copy of the provider directory, call Member Services at Notifying You of Changes Kaiser Permanente will let you know if there is a change to your child s benefits or services 30 calendar days before that change happens. We will update and send you the member handbook each year. 16

19 How to Get Medical Care Identification (ID) cards Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. FAMIS If you did not receive your child s Kaiser Permanente ID card before your visit, your photo ID will be a temporary ID card. If you do not have a photo ID, we will ask a few questions to check your child s identity. KP Medical RecoRd NuMbeR Please keep your child s Kaiser Permanente and FAMIS ID cards with you at all times. You will need them to make appointments, fill prescriptions, and receive other medical services. You will be asked to show a photo ID when you check-in for any service at a Kaiser Permanente facility. Acceptable photo IDs include: State driver s license Military ID card Medicaid id NuMbeR Sex center dob PRiMaRy care PhySiciaN hospital inpatient/outpatient: Medimpact bin: emergency Room (not admitted): Medimpact PcN & Group: Primary/Specialty care: dental/smiles for children: (888) Pharmacy: this card is for identification only. Possession of this card confers no right to services or benefits unless the holder is a member complying with all provisions of an applicable agreement. Other government issued ID card If you have a medical emergency, call 911 or go to the nearest emergency room. Medical Advice/Appts/Cancel Appt (24 hours a day) TDD Northern Virginia (703) (703) outside Northern Virginia (800) (800) If you are unsure of your condition and require immediate medical advice, call (800) Member Services (M F, 7:30 a.m. 5:30 p.m.) TDD Northern Virginia and toll free (855) (866) Pharmacy helpdesk (800) behavioral health access line (866) Claims for services must be submitted to: Kaiser Foundation health Plan of the Mid-atlantic States, inc. Po box 6233, Rockville, Maryland Providers: For authorizations, contact utilization Management at (800) call Medical advice if you have an emergency hospital admission. If your child s Kaiser Permanente ID card has been lost or stolen, go to My Health Manager at kp.org to request a replacement, or call Member Services at , TTY/TDD. Important Note: A Kaiser Permanente ID card can only be used by the person whose name is on the card. It is illegal for any other person to use the card to get health care services. Your child s doctors make care personal Your child s primary care physician (PCP) It is important for your child to have a PCP, who can be a MAPMG doctor or participating provider. When your child sees a PCP regularly, he or she will get consistent, personalized care. The PCP helps your child stay healthy and treats your child when sick. This doctor is responsible for coordinating your child s health care, including when hospital or specialty care is needed. Your child s obstetrician/gynecologist (Ob/Gyn) If your child is a female age 13 or older, you may choose an Ob/Gyn in addition to a PCP. As with the PCP, your child s Ob/Gyn is a personal doctor, who will coordinate health care needs while communicating with her PCP. You may make appointments directly with an Ob/Gyn without a referral from the PCP. 17

20 Changing your child s PCP or Ob/Gyn You may change your child s PCP or Ob/Gyn at any time for any reason. Simply: Visit kp.org or Call Member Services at We will send you a letter to let you know that we received your change request. We will notify you about doctor changes If your child s PCP leaves Kaiser Permanente or changes office location, we will send you a letter explaining the change, when the change starts, and how to choose a new PCP. Out-of-area services If your child becomes sick or has a medical concern while out of town, you can call our medical advice line for help at Our medical advice line is available 24 hours a day, every day. Registered nurses can help you with your child s health care needs and will work with you and your child s doctor to coordinate services. If you are traveling in the Washington, D.C., or Maryland areas, we have medical centers that are available for urgent care services. Kaiser Permanente does not pay for routine treatments outside of the service area unless we have given approval for that service. We cover emergency care anywhere in the United States at no cost to you. If your child is having an emergency, call 911 or go to the closest emergency room. Make sure you have both your child s Kaiser Permanente and FAMIS ID cards. For more information, see page 37. If your child is admitted to the hospital while away from home, remember to call Kaiser Permanente 18

21 Member Services at as soon as you can so we can help coordinate your child s care. We will not approve continued out-of-area services if your child is able to come home for the needed care. If you are traveling and need medication, please call our pharmacy benefits manager, MedImpact, at to find a participating pharmacy near you. Please see the Prescription drug coverage section of this handbook on page 39. If your child is outside the United States and gets health care services, it will not be covered by Kaiser Permanente or FAMIS. Appointments If your child has a MAPMG doctor, you can make, check, or cancel appointments online and by phone. Appointment wait times Here are some guidelines on how quickly you can expect to have an appointment scheduled. Type of Appointment Routine primary care (excludes health assessments and regularly scheduled visits to monitor chronic conditions) Health assessments, preventive care, initial health assessments for new members Maternity During the first trimester Kaiser Permanente Standard Within 2 weeks of request Within 30 calendar days of request Within 14 calendar days of request Online Register to use My Health Manager on kp.org, where you can make appointments 24 hours a day, seven days a week. By phone Call appointment staff, Monday through Friday, 7 a.m. to 8 p.m., at: Maternity During the second trimester Maternity During the third trimester Maternity If determined as high risk pregnancy Urgent care Within 7 calendar days of request Within 3 business days of request Within 3 business days or immediately if an emergency exists Within 24 hours of the request TTY/TDD If you have a participating provider as your child s doctor, call that doctor s office directly to make an appointment. You need your child s Kaiser Permanente ID number to make an appointment. If your child s doctor is not available on the day and time you need, you can ask for an appointment with another doctor. Emergency services Available immediately upon request Specialty care (referrals and self-referrals) Your child s PCP will need to give a referral, which we will need to approve, to see a specialty doctor for the first time. If you can t reach your child s PCP when a referral is needed, please call us at 19

22 , TTY/TDD. We will help your child get the care that he or she needs. Members with special health care needs will have direct access to see a specialist through a standing referral or for an approved number of visits. If you asked for a referral and it has been denied, you have the right to ask for a review. This is called an appeal. Please see page 44. Here are some other things you should know about specialty care: If your child is seeing a specialist when he or she enrolls in our plan, in almost all cases, your child will be required to switch to a specialist in our network. If your child is seeing a specialist who then leaves the plan, call your child s PCP, who will request approval from us for your child to see another specialist. If your child is in active treatment, he or she may receive approved services from the current specialist for up to 90 calendar days or until we can make arrangements for your child to see a MAPMG specialist or a participating provider. Extension request for prior approval Standard approval decisions For standard approval decisions, we will provide the decision notice as quickly as your health condition requires. We will not take longer than 14 calendar days after getting the request for service. It is possible that you or your child s provider may get another 14 additional calendar days if we receive a request for an extension. Expedited approval decisions We must make an expedited approval decision and provide notice as quickly as your child s health condition requires and no later than 3 business days after getting the request for service. We may extend the 3 business day turnaround time frame by up to 14 calendar days if you request an extension. Out-of-network If Kaiser Permanente is unable to provide a covered service to your child within our network, we may refer your child to a provider that is not part of our participating provider network at no additional cost to you. Self-referrals You do not need to get a referral from your child s PCP for the following services: Routine and Ob/Gyn services (in-network) Emergency services (in- or out-of-network) Outpatient behavioral health services (in-network) Vision care services (in-network; excludes services from an ophthalmologist) Family planning services (from any licensed provider, in- or out-of-network) Pharmacy services Like many healthcare organizations, Kaiser Permanente has a formulary, or a set list of preferred medicines, accessories and supplies, to help your doctor choose the best medicine for your child. A formulary also helps make sure that safe and cost-effective medicines are available. The formulary includes those medicines that have been reviewed and approved by the Pharmacy and Therapeutics Committee for use by Kaiser Permanente doctors and network doctors. The preferred-medicines on our formulary include both brand name and generic medicines approved by the Food and Drug Administration as safe and effective for use (a generic drug contains the same active ingredient as a brand name medicine). 20

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24 When the safety, effectiveness and side-effect profile of two medicines are the same, the cost of the medicine would be considered when adding a medicine to the formulary. For most medicines, a copay will be collected at the pharmacy and the cost may vary depending on the type of product. FAMIS enrollees will be charged the applicable copay of brand or generic for products covered by Medicaid per the FAMIS contract. Medicines not covered under FAMIS include: 1. Sexual dysfunction medicines 2. Fertility medicines 3. Insulin pen cartridge devices 4. Progesterone vaginal suppositories 5. Medicines not approved by the Food and Drug Administration (FDA) If you think your child needs a medicine that is not on the formulary, speak with your child s doctor or call Member Services via telephone or through kp.org to consider the non-formulary exception process. The non-formulary exception process is available so patients and doctors can access medically necessary medicines under the prescription benefit, even if the medicine is not on the formulary. These non-formulary prescriptions are covered by your child s prescription benefit only if your child s doctor requests an exception to the formulary and provides specific information for why no formulary medicines are acceptable. If the criteria for formulary exception are not met, you will be required to pay full price for the nonformulary medicine, not just the prescription copay. Kaiser Permanente can require prior authorization for some medicines in which your doctor will fill out paperwork that will be reviewed and approved by the Pharmacy department before these medicines can be dispensed. The prior authorization process is approved by the Pharmacy and Therapeutics Committee. Examples of medicines that require prior authorization are those used to promote growth (growth hormones) or to help you lose weight (anti-obesity). If you have questions or concerns or wish to appeal the cost of a prescription or the decision on a non-formulary medicine that your child s doctor 22

25 did not consider medically necessary, you must contact Member Services. Member Services can be reached via telephone or through kp.org. To learn which medicines are on the Kaiser Permanente formulary, please go online and visit kp.org or contact Member Services. You can fill prescriptions from any doctor (including dentists) or other prescribers at the pharmacies located in Kaiser Permanente medical centers. There is a pharmacy in almost every Kaiser Permanente medical center. Your child s MAPMG doctor can send most prescriptions by computer from his or her office directly to the medical center pharmacy, where you can pick up the medicine right after your child s visit. When you use any Kaiser Permanente medical center pharmacy, we maintain a record of your child s medications. As prescriptions are entered, your child s personal drug profile is updated. In addition, you may fill prescriptions at participating pharmacies such as Giant, Safeway, Rite Aid, Target, Walmart, and Kmart. You can find a list of all participating pharmacies in the provider directory or by calling Member Services. Be sure to show the pharmacist your child s Kaiser Permanente ID card when filling your child s prescription. If your child is away from home and needs an emergency supply of medication, call our pharmacy benefits manager, MedImpact at MedImpact can help you find a participating pharmacy nearby. If you are in another Kaiser Permanente region, you can go to another Kaiser Permanente pharmacy. If you go to a non-participating pharmacy, call Member Services for help submitting a claim. Prescription refills You can order your refills 24 hours a day, seven days a week using one of the methods below. You can have the medicine mailed to you at no extra cost within 7 to 10 business days, or pick it up at a Kaiser Permanente medical center pharmacy. You ll need your child s Kaiser Permanente ID number and prescription number. Online: If you have an account on My Health Manager at kp.org, you can get refill reminders and request prescription refills. EZ Refill: You can call our EZ Refill line at A Member Services representative can tell you if your child s medication cannot be mailed before using one of these services. If you filled your child s prescription at a participating pharmacy, you should follow their procedures for getting refills. Transferring a prescription If you want to transfer your child s prescription from another pharmacy to a Kaiser Permanente medical center pharmacy, call the Kaiser Permanente pharmacy location of your choice and give them the following information: Your name, your child s name, and your child s Kaiser Permanente member ID number Name and telephone number of the other pharmacy Name of the prescribed medication Prescription number of the prescribed medication Name and phone number of the doctor who prescribed the medication. If you want to transfer your child s prescription from a Kaiser Permanente medical center or mail order pharmacy to another participating pharmacy, you must contact that participating pharmacy. 23

26 Understanding your child s medications Kaiser Permanente pharmacists provide information and advice on prescription and over-the-counter medicines, as well as herbal supplements. You re encouraged to speak to the pharmacist whenever you have a concern about your child s medication. Kaiser Permanente medical centers You ll save time getting your child s care in Kaiser Permanente medical centers where MAPMG doctors practice. Your child will be able to get several needed services at one location. Most of our medical centers offer: Primary care Pediatrics Obstetrics and gynecology Pharmacy services X-ray Lab services Some medical centers also offer: Specialty care Urgent care Behavioral health services Vision care Check the provider directory or kp.org/facilities for services offered at a medical center near you and for hours of operation. Medical records My Health Manager Our electronic health record system stores information about your child s health so MAPMG doctors can see it when they are caring for your child. It will also tell your child s doctors when preventive services are due so we can help keep your child healthy. Prescriptions written for your child by MAPMG doctors are electronically sent to a Kaiser Permanente pharmacy so they will be ready for you to pick up after your child s doctor s visit. This same technology connects you to your child s health care information from a computer or on your smart phone. If you register to use My Health Manager on kp.org, you will be able to: your child s MAPMG doctor s office Read after-visit summaries from your child s MAPMG doctor 24

27 Manage your child s Kaiser Permanente medical center appointments See most lab test results done in Kaiser Permanente labs Order prescription refills from Kaiser Permanente pharmacies Requesting a transfer or copy of your child s medical records For assistance in getting your child s previous medical records, you may go to any Kaiser Permanente Health Information Management Services Department (HIMS/Medical Records) to complete an approval form. The HIMS representative will help you get your child s records within 10 business days of your request. You can also print out an approval form on kp.org. 24-hour medical advice If you have a medical question or an urgent problem, call our advice nurses 24-hours a day, seven days a week at: TTY/TDD Our advice nurses can tell you how to take care of your child at home if he or she does not need to be seen by a doctor. If your child needs a doctor s appointment, an advice nurse can schedule one. When your child has a MAPMG doctor, the advice nurse can see the medical care your child has received from that doctor. This will help them care for your child. Urgent care In addition to our 24 hour medical advice line, we also offer services for urgent care conditions. Urgent care appointments During regular business hours If your child has a MAPMG doctor, you may be given an appointment with him or her to address an urgent condition. If your child has a participating provider, you may call that doctor s office directly. Outside regular business hours During weekends, evenings, and holidays, you may get an urgent care appointment at one of the Kaiser Permanente medical centers in Virginia listed below. You may also go to other Kaiser Permanente urgent care facilities in Maryland and the District of Columbia. For a complete list of urgent care facilities, go to kp.org/facilities or look in your provider directory. Tysons Corner Medical Center 8008 Westpark Drive McLean, VA Hours: 24 Hrs. M Su Reston Medical Center 1890 Metro Center Drive Reston, VA Hours: 5 p.m. 1 a.m. M F 9 a.m. 9 p.m. Sa, Su, Holidays Woodbridge Medical Center Potomac Mills Road Woodbridge, VA Hours: 5:30 p.m. 1 a.m. M F 9 a.m. 9 p.m. Sa, Su, Holidays 25

28 Emergency care Call 911 or go to the nearest emergency room if you feel your child is having an emergency. Do not take time to call us first. Time is precious in an emergency. A medical emergency is sudden and unexpected. It is potentially life-threatening and requires immediate medical attention. You don t need to get our approval first. Some examples of a medical emergency are: Heart attack or stroke symptoms Extreme difficulty breathing Sudden or extended loss of consciousness Uncontrollable bleeding Sudden loss of vision Hospital care Sometimes your child may need to be in the hospital. The doctor will check your child s condition and decide when hospital care is necessary. Your child s doctor arranges hospital care and will send your child to a hospital where MAPMG doctors and participating providers practice. A MAPMG doctor or participating provider will be in charge of care when your child is at the hospital. He or she will be in contact with your child s PCP during the stay. A MAPMG doctor or participating provider will work closely with you to plan your child s discharge from the hospital. Your child s doctor will also decide the best place to get follow-up care. Your child will have a case manager that will help make follow-up appointments. Case managers are nurses or social workers who help your child get the care he or she needs. These are the area hospitals where MAPMG doctors practice. In Virginia: Reston Hospital Center, Reston, VA (labor and delivery services only) Virginia Hospital Center, Arlington, VA In nearby areas: Children s National Medical Center, District of Columbia Sibley Memorial Hospital, District of Columbia (labor and delivery services only) Washington Hospital Center, District of Columbia Greater Baltimore Medical Center, Baltimore, MD Holy Cross Hospital, Silver Spring, MD St. Agnes Hospital, Baltimore, MD Suburban Hospital, Bethesda, MD Behavioral health only: Virginia Hospital Center, Arlington, VA Franklin Square Hospital Center, Baltimore, MD Potomac Ridge at Shady Grove Adventist Hospital, Rockville, MD Washington Adventist Hospital, Takoma Park, MD 26

29 Prevention and Disease Management Preventive guidelines Your child s benefits at Kaiser Permanente include services to help keep him or her healthy and to prevent serious health problems. Children at different ages have different needs. Your child s MAPMG doctor or participating provider will order the tests and exams that are best for your child s age and health history. For a copy of our preventive care clinical guidelines, call Member Services. Regular medical care is very important to keep your child healthy. This care will help keep your child well and prevent illness and the spread of disease. Your child s regular checkups, immunizations (shots), and screening tests are included in our Well Child Care program. 27

30 Immunization Schedule (Birth 6 years) Vaccineq Age u Birth 1 month 2 months 4 months 6 months 9 months 12 months Hepatitis B HepB HepB HepB Rotavirus RV RV RV 15 months 18 months months Diphtheria, tetanus, pertussis DTaP DTaP DTaP DTaP DTaP Haemophilus influenzae type b Hib Hib Hib Hib Pneumococcal PCV PCV PCV PCV PPSV Inactivated poliovirus IPV IPV IPV IPV Influenza Influenza (Yearly) Measles, mumps, rubella MMR MMR Varicella Varicella Varicella Hepatitis A Dose 1 HepA Series Meningococcal MCV4 2 3 years 4 6 years Range of recommended ages for all children Source: cdc.gov Range of recommended ages for certain high-risk groups Range of recommended ages for all children and certain high-risk groups Immunization Schedule (7 18 years) Vaccineq Age u 7 10 years years years Tetanus, diphtheria, pertussis 1 dose (if indicated) 1 dose 1 dose (if indicated) Human papillomavirus 3 doses Complete 3-dose series Meningococcal Dose 1 Booster at 16 years old Influenza Influenza (yearly) Pneumococcal Hepatitis A Complete 2-dose series Hepatitis B Complete 3-dose series Inactivated poliovirus Complete 3-dose series Measles, mumps, rubella Complete 2-dose series Varicella Complete 2-dose series Range of recommended ages for all children Range of recommended ages for catch-up immunization Source: cdc.gov Range of recommended ages for certain high-risk groups 28

31 Your child will be examined periodically to check for any illness. Check-ups are needed more often in the child s first years and less often as they grow older (see check-up and vaccine schedule above). Screening tests, such as blood tests, give the doctor information about your child s health. If any health problems are found, the doctor looks for their cause, makes a diagnosis, and orders treatment. Disease management Kaiser Permanente has disease management programs to help your child live well with a chronic condition. Enrollment in these programs is voluntary, and can be discontinued at any time. For a copy of our disease management clinical guidelines, call Member Services. Some of the disease management services offered address: Asthma Depression Diabetes Coronary artery disease Congestive heart failure Chronic obstructive pulmonary disease If your child has any of these conditions, you can self-refer to our disease management program. Leave a message anytime at with your name and your child s name, your child s medical record number, your address, and the condition for which you are requesting information. Your child is automatically enrolled into a disease management program if he or she is diagnosed with any of the chronic conditions for which we have a program, but you have the right to opt out at any time. CareConnect Program (Complex case management) If your child is experiencing severe health problems or has a newly diagnosed illness that might require extensive services over time, your child s MAPMG doctor or participating provider may suggest that you enroll your child in our CareConnect Program. Complex case managers can provide the following types of help: Initial assessment, including medication review Coordination of care across providers for example, scheduling appointments, telephone consultations, reminders for screening, tests, etc. Care planning based on your needs, priorities, and preferences Coaching and monitoring of your health status Support and education Assistance with access to Kaiser Permanente and community resources If you would like more information or help, you may call the self-referral phone line at (toll free) or call Member Services. 29

32 What Does the Plan Cover? This section explains many of the health care services and benefits that FAMIS members can get through Kaiser Permanente when they need them. Some services are only covered if we approve them first. Our decision has to be made by a qualified health care professional. We will tell you and your child s doctor of our decision. If your child gets services that are not covered benefits, or if your child gets them outside our network, Kaiser Permanente may not cover those services and you may have to pay for those services. If you need more information on what your child s plan does and does not cover, or about prior approval, call Member Services. Prior approval (Service authorization) You may be required to get prior approval from your child s PCP for a covered service. If your child s PCP decides he or she needs a service that requires prior approval, the PCP will send a referral request to us for your child to receive this service. We will review the referral request and notify you of the decision when the review is complete. Talk to your child s PCP if you need a prior approval for any covered service or medical equipment. If you have a question or are not sure if a certain benefit requires prior approval, call Member Services at , TTY/TDD for help. If your child s benefits change, we will notify you 30 calendar days before the change. 30

33 You do not need prior approval for some services including, but not limited to: Care provided at your child s PCP office, including your child s PCP s nurse or doctor s assistant Emergency and urgent care services Family planning services Eye exams from an in-network eye doctor Preventive services Copayments You may be required to pay a copayment for some of the listed services. You are responsible for keeping track of the amount you spend on copayments during the benefit year. If the total of all copays paid by you and other FAMIS enrollees in your family reach the annual copayment maximum, you will no longer be required to pay copayments for the rest of the benefit year. receipts. Submit copayment receipts for yourself and your immediate family members enrolled in the FAMIS program to the FAMIS Central Processing Unit (CPU). Kaiser Permanente is not responsible for managing this process. DMAS will notify us when you have reached your annual copayment maximum. Please mail your healthcare receipts to the FAMIS CPU: FAMIS CPU P.O. Box 1820 Richmond, VA Toll Free: Hours of operation: 8 a.m. 7 p.m. M F 9 a.m. midnight Sa Copayment amounts vary with each service and by the FAMIS tier in which your child belongs. Your child s Kaiser Permanente member ID card indicates the amount you will pay for each service. If your child s copayment is $2 for a routine office visit, you belong in the FAMIS-2 Tier. If your child s copayment amount is $5 for a routine office visit, you belong in the FAMIS-5 Tier. Please pay attention to the copayment requirements for each service within your tier. You may be required to pay a copayment for a service that is not listed on the schedule. Contact Member Services if you have questions regarding copayments. American Indians and Alaska Natives are not required to pay copayments. To make sure you are not overcharged after you have reached your annual copayment maximum, you must keep track of your payments and 31

34 FAMIS copayment schedule Covered Services FAMIS 2 Tier at or below 150% FPL FAMIS 5 Tier above 150% FPL American Indians and Alaska Natives Primary care visits Specialist office visits Outpatient services Family planning services Private duty nursing visits Hearing aids (limited to 2 every 5 years) Preventive care Pregnancy-related care Well baby and well child visits Hospice care Medical supplies Mammograms Immunizations Insulin pumps $2 per visit $5 per visit No copayment No copayment No copayment No copayment Chiropractor services $2 per visit, limited to $500 per calendar year $5 per visit, limited to $500 per calendar year No copayment Durable medical supplies and equipment (including prosthetic and orthotic devices) & diabetic supplies and equipment Supplies: $0 Equipment: $2 per item Supplies: $0 Equipment: $5 per item No copayment Emergency room visits $2 per visit $5 per visit No copayment $10 copayment per visit for nonemergency care $25 copayment per visit for nonemergency care 32

35 FAMIS copayment schedule Covered Services FAMIS 2 Tier at or below 150% FPL FAMIS 5 Tier above 150% FPL American Indians and Alaska Natives Home health services $2 per visit; then covered at 100% up to 90 visits per year $5 per visit; then covered at 100% up to 90 visits per year No copayment Inpatient services, including behavioral health and substance abuse services $15 per admission; no copayment for physician inpatient care $25 per admission; no copayment for physician inpatient care No copayment Skilled nursing facility services $15 per admission; then covered at 100% up to 180 days $25 per admission; then covered at 100% up to 180 days No copayment Prescription drugs $2 per prescription for up to a 34-day supply; $4 per prescription for up to a 90-day supply $5 per prescription for up to a 34-day supply; $10 per prescription for up to a 90-day supply No copayment Vision services $2 per visit $5 per visit No copayment Coverage for one pair of eyeglasses (one pair of frames and one pair of lenses) or contact lenses once every 24 months Coverage for one pair of eyeglasses (one pair of frames and one pair of lenses) or contact lenses once every 24 months $25 eyeglass frames $25 eyeglass frames $35 single vision lenses $35 single vision lenses $50 bifocal lenses $50 bifocal lenses $88.50 trifocal lenses $88.50 trifocal lenses $100 contact lenses $100 contact lenses Annual copayment maximum $180 per family per calendar year $350 per family per calendar year Not applicable 33

36 Services covered by Kaiser Permanente Ambulance We pay for an ambulance in an emergency or when medically necessary. We also pay if we call the ambulance to transfer your child between medical facilities. Behavioral health and substance abuse services Kaiser Permanente covers the following behavioral health services: Inpatient services up to 365 days per admission in a psychiatric unit of a general acute care hospital, including partial day treatment services (prior approval required) Inpatient substance abuse services in a substance abuse treatment facility (prior approval required) Outpatient member, family, and group behavioral health and substance abuse services Electroconvulsive therapy Medication management services Smoking cessation counseling Medications for children, adolescents, and pregnant women Care coordination services Chiropractic services prior approval required We provide chiropractic service coverage up to $500 per calendar year including examination, spinal manipulation, and outpatient chiropractic services to treat an illness or injury when it is medically necessary, appropriate, and approved by the health plan. Clinic services, doctor visits, and outpatient services We cover services which are preventive, diagnostic, therapeutic, rehabilitative, or palliative when it is medically necessary, appropriate, and approved in outpatient hospital settings, clinic facilities, and doctor offices. There are some services we do not cover, including, but not limited to: Alternative medical services, including services of an acupuncturist, naturopath, massage therapist, or Christian Science nurse/sanatoria Disposable supplies for the home including, but not limited to, bandages, gauze, tape, and antiseptics Experimental and investigational procedures, including clinical trials Sexual reassignment Cosmetic surgery prior approval required Cosmetic services are not covered unless performed for medically necessary physiological reasons. Cosmetic services are not covered except to: Correct a deformity resulting from disease, trauma or congenital abnormalities, which cause functional impairment; or Complete a therapeutic treatment as a result of such deformity Court-ordered services We cover court-ordered services when it is both medically necessary and a FAMIS covered service. 34

37 Quantity limits may apply for home blood glucose monitors, lancets, blood glucose strips, insulin syringes and needles. In addition, some insulin delivery devices such as pens or cartridges require prior approval. We do not cover diabetic shoes and inserts. Durable Medical Equipment (DME) and medical supplies prior approval required We cover medical supplies and equipment when it is medically necessary, appropriate, and approved by your child s PCP. Dental services Your child can get routine dental services through the Smiles for Children Program. The toll-free number is Kaiser Permanente provides coverage for some dental-related services when it is medically necessary, appropriate, and approved, including: Anesthesia and hospitalization services for medically necessary dental services Dental services performed by a medical doctor or dentist as a result of a dental accident Preparation of the mouth for radiation therapy Medication for covered dental services Repair of cleft lip or cleft palate or both Diabetic equipment and supplies We provide coverage for the following when medically necessary: U.S. Food and Drug Administration (FDA) approved diabetic equipment Insulin pumps and supplies Home blood glucose monitors, lancets, blood glucose strips and insulin syringes and needles Some of the medically necessary DME we cover include, but is not limited to, the following: Prosthetic services and devices including artificial arms, legs, and their necessary supportive attachments Orthotics including braces, splints, foot orthotics, or when recommended as part of an approved intensive rehabilitation program Ostomy supplies Apnea monitors and CPAP machines Remedial or adaptive devices such as implants or dental devices Wheelchairs Oxygen and oxygen equipment Positioning devices Supplies and equipment necessary to administer enteral nutrition and total parenteral nutrition The following DME or supply items are not covered: Comfort, convenience, or luxury equipment or features Disposable supplies for the home including, but not limited to, bandages, gauze, tape, antiseptics, or medical supplies 35

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39 Exercise or hygiene equipment Non-medical items such as sauna baths or elevators Modifications to your home or car Electronic monitors of the heart or lungs, except infant sleep apnea monitors Medical supplies and prosthetic devices that are not medically needed Diapers for routine use for children under 3 years old who have not been toilet trained Maintenance and necessary repair of medically needed DME will be covered. Equipment that has been damaged due to neglect or abuse will not be repaired or replaced. Emergency, post-stabilization, and urgent care services Emergency, post-stabilization (screenings and follow-up services needed to maintain or improve your condition), and urgent care services are covered without prior approval at no cost to you. Services are covered whether we tell you to go or you decide to go. Family planning services and supplies Family planning services and supplies are covered for your child without prior approval. This includes, but is not limited to: Services/supplies and drugs that delay or prevent pregnancy (including FDA-approved contraceptives) Family planning health education We do not cover the following family planning services and supplies: Drugs, services, and procedures to treat erectile dysfunction Services to treat infertility or promote fertility Surrogacy services Voluntary sterilization such as tubal ligation or vasectomies Hearing screenings and hearing aids Hearing aids are covered when it is medically necessary, appropriate, and approved by your child s PCP. Hearing aids are covered twice every five years. Ear molds and hearing supplies, such as cleaning kits, are covered with each new hearing aid. Newborn infants will be given a hearing screening before going home from the hospital. Home health services prior approval required Home health services when it is medically necessary, appropriate, and approved are covered by the PCP for up to 90 visits per calendar year: Licensed nursing services Personal care services (help with walking, bathing, dressing, giving medicine, teaching self-help skills and/or essential housekeeping tasks Home health aide services Physical therapy Hearing therapy Inhalation therapy Occupational therapy Speech-language therapy We do not cover the following home health services: Community food service delivery arrangements Custodial care that primarily requires patient protective services rather than definitive medical and skilled nursing care services 37

40 Domestic or housekeeping services unrelated to patient care Medical social services Services related to cosmetic surgery Hospice services prior approval required We cover hospice care services for a member diagnosed with a terminal illness with a life expectancy of six months or fewer. Inpatient hospital services prior approval for non-emergency stays required Inpatient hospital stays in general acute care and certified rehabilitation hospitals are covered. Medically necessary stays may be approved for up to 365 days per admission. If your child is admitted to a hospital that is not in the Kaiser Permanente network, we will work with their doctor to transfer them to a hospital in our network. We do not cover the following: A private room unless medically necessary Comfort items including { Television or Radio { Telephone { Visitor meals Laboratory and X-ray services We cover laboratory and X-ray services when it is medically necessary, appropriate, and approved by your child s PCP or licensed practitioner. We only cover lead testing as part of Well Baby Care and Well Child Care visits. Organ transplants prior approval required We cover the following transplants for all members when it is medically necessary, appropriate, and approved by a doctor: Heart Kidney transplants for patients with dialysis dependent kidney failure Liver Single lung transplants Tissues, autologous, allogeneic or syngeneic bone marrow transplants Stem cell transplants for members with lymphoma and myeloma We also provide coverage up to $25,000 for reasonable and necessary procurement/donor related services. Podiatry Reasonable and necessary diagnostic medical or surgical treatment of disease, injury or defects of the foot is covered. The following podiatric services are not covered: Routine foot care Treatment of structural misalignment not requiring surgery Cutting or removal of corns, warts or calluses Trimming of nails Private duty nursing prior approval required Medically necessary private duty nursing is covered under the following conditions: Care is medically necessary and documented by a provider Care is provided by a Registered Nurse (RN) or Licensed Practical Nurse (LPN) The nurse is not a relative of the member s family 38

41 Prescription drug coverage Kaiser Permanente covers drugs on our preferred drug list. The preferred drug list is approved and updated regularly by our doctors, pharmacists, and other health care professionals. This list allows us to choose drugs that are safe and effective. If you would like to check on the coverage of a specific drug, please contact Member Services. You may get a copy of our preferred drug list at kp.org/formulary or by calling Member Services. There may be times when a preferred drug is not the right drug for your child s condition. Your child s MAPMG doctor or participating provider can request coverage of a non-preferred drug for your child if the doctor believes it is medically necessary. If you have questions or disagree with the decision, you can contact Member Services. If you pay out of pocket, and the drug is later determined to be medically necessary, you can request a refund. Prior approval for prescription drugs If your child has prior approval for a prescription drug from another FAMIS or Medicaid health plan, we will cover it. Your child s MAPMG doctor or participating provider can request prior approval for coverage of a medication. Kaiser Permanente will act on such requests within one business day. You and your doctor will be notified in writing when a prescription is denied for coverage. For any questions about the prior approval process for prescription drugs, please call Member Services. Pregnancy related services It is important that if your child becomes pregnant, she sees her PCP or Ob/Gyn for care. We cover prenatal and postpartum care including, but not limited to, the following: Prenatal assessment, education, nutritional assessment, and counseling and postpartum services up to 60 days after the pregnancy has ended HIV testing and counseling/tests for sexually transmitted infections Pap smear Certified nurse midwife services 39

42 Services to treat a medical condition that may complicate pregnancy Smoking cessation counseling and drugs Well Baby Care from birth, including blood lead testing Immunizations After your child delivers her baby, they both may stay in the hospital until the PCP or Ob/Gyn officially discharges them. If the new mom leaves the hospital early, she will be asked to have an office visit or in-home nurse visit within 48 hours of discharge to make sure everyone is well. Second opinions If you are not sure about a medical opinion, you can get a second opinion. Your child s plan covers a visit to another MAPMG doctor or participating provider for a second opinion at no cost to you. Skilled nursing facility care prior approval required We provide coverage for medically necessary services that are provided in a skilled nursing facility for up to 180 days per admission. Telemedicine We cover telemedicine services when it is medically necessary, appropriate, and approved by your child s doctor. Telemedicine is the real time or near real time two-way transfer of medical information between health care professionals using audio/video to diagnose medical conditions. Therapy services prior approval required The following therapy services are covered when it is medically necessary, appropriate, and approved by Kaiser Permanente: 40

43 Audiology Chemotherapy Inhalation therapy Intravenous therapy Occupational therapy Physical therapy Radiation therapy Renal dialysis Speech therapy Transportation We do not provide transportation for routine services to and from providers of covered medical services. Vision Eye screening and refractive exams for eyeglasses and contact lenses, and medically necessary treatment for diseases of or injuries to the eye are covered. We provide vision coverage for all members when prescribed by an optometrist or a doctor skilled in diseases of the eye for the following: Routine eye examinations once every 24 months One pair of eyeglasses (one pair of frames and one pair of lenses) or contact lenses when medically necessary once every 24 months. Infant vision screening Exclusions and limitations There are certain services that we do not cover but instead are covered by DMAS and certain services that are not covered by either Kaiser Permanente or DMAS. This section describes the exclusions and limitations for covered services. Services covered by DMAS The following services are provided by DMAS, not Kaiser Permanente. We will work with you to coordinate these services: Abortions, only if DMAS determines they meet the requirements of the law. Routine dental services through the Smiles for Children Program. Call Smiles for Children at for more information. School health services, which are any service given on school property for special education students that include physical therapy, occupational therapy, speech language pathology, and skilled nursing services. Early intervention services through the Infant and Toddler Connection of Virginia. Your child s PCP must sign an Individualized Family Service Plan to get these services. Contact Infant and Toddler Connection at for more information about these services. Behavioral health services covered by DMAS (no other Community Mental Health Rehabilitative Services other than those listed below are covered by DMAS): { Case management for children at risk of serious emotional disturbance { Community behavioral health rehabilitative services { Inpatient behavioral health services given in a state psychiatric hospital { Intensive-in home services { Behavioral health crisis intervention { Residential Treatment Facility Services (RTF) Level C 41

44 { Temporary detention orders { Therapeutic day treatment { Treatment Foster Care Case Management For information on how to access these services, contact the FAMIS CPU toll free at Services not covered by Kaiser Permanente or DMAS The services below are not covered by Kaiser Permanente or DMAS: Alternative medical services, including services of an acupuncturist, naturopath, massage therapist, or Christian Science Nurse/Sanatoria Assisted living services Certain behavioral health services including, but not limited to, the following: { Substance abuse crisis intervention { Case management for adults with serious mental illness { Mental health day treatment/partial hospitalization services for adults { Psychosocial rehabilitation { Intensive community treatment { Crisis stabilization { Mental health support { Substance abuse day treatment { Opioid treatment { Substance abuse case management { Levels A, B, and C residential treatment for children and adolescents under 21 (group homes) Community food service delivery arrangements Cosmetic dental services, unless performed for medically necessary physiological reasons Domestic or housekeeping services unrelated to patient care Drugs, service, and procedures to treat erectile dysfunction Experimental and investigational procedures, including clinical trials Eye surgery solely for the purpose of correcting refractive defects of the eye, such as myopia, hyperopia, or astigmatism (e.g. LASIK) Infertility services Medical social services Payment of a claim or any other demand or request for payment for a service received from a referral prohibited by law Routine foot care, including treatment of structural misalignment not requiring surgery, cutting or removal of corns, warts, or callus Routine infant formula Services for incarcerated individuals/inmates Sexual reassignment Surrogacy services { Residential substance abuse treatment for pregnant and post partum women 42

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46 Inquiries, Complaints, and Appeals If you need interpreter or translation services, call Member Services at , TTY/TDD. Only you or someone with your written permission can act on behalf of your child. They can be family, friends, or your child s doctor. All we need is a letter from you with the name of that person and that you have given them permission to file an appeal on your child s behalf. Inquiries Action What to do What to expect Feel free to call us anytime with questions or to let us know about changes in your child s life, such as: Giving us your new address or phone number when you move Asking to change your PCP To request a new handbook or provider directory To ask questions about our medical centers or participating providers To clarify benefit coverage or services offered To share a positive experience The above are examples of inquiries and we want to hear from you. Contact us directly. You can call, write, or come to one of our medical centers for assistance. Call us at , TTY/TDD. When you call us, we can tell you which medical center to go to if you want help. Or write us at: Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. Attn: Appeals and Correspondence Unit 2101 East Jefferson Street Rockville, MD Fax: We will make every effort to respond to your inquiry when you first call. If we cannot completely respond to your inquiry on the phone, we will call you back or write you within 30 calendar days of the inquiry. 44

47 Complaints Action What to do What to expect Hearing your complaints/ grievances is important to us. Our Member Service s team is here to help you if: You re concerned about treatment as a member You disagree with a decision made about your care You are having problems with getting doctor s appointments or your medications There are problems with medical bills Sometimes, you may be asked if you want to file a complaint or a grievance. They mean the same thing: a complaint = a grievance. Regardless of which word is used, your concerns will be taken seriously If your problem has to do with a denial of your health care benefits, you will need to file an appeal instead of a complaint. You need to file a complaint/ grievance within 30 calendar days from the date you received a decision from us, which you were unhappy with. You have three ways to file a complaint with us: 1. Call Member Services at , TTY/TDD. 2. Complete a complaint form call us and we can tell you which medical center to go to if you want help. 3. Write a letter about the problem. Send any documentation that will help us look into the complaint. You can write us at: Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. Attn: Appeals and Correspondence Unit 2101 East Jefferson Street Rockville, MD Fax: We will do our best to address your issues or concerns the first time you call. We may ask: Your name What happened Who was involved When it happened How can we help and/or The best way to contact you We will assign someone to your case, who will contact you. We will respond to all complaints within 30 calendar days from the date you first contacted us and after all required documentation has been submitted by you. If you do not agree with the outcome of your complaint, you may file an appeal with Kaiser Permanente. 45

48 Expedited reviews of complaints/grievances or appeals Action What to do What to expect You or your representative can request an Expedited Review if you or your child s doctor believes that taking the regular amount of time would endanger your child s life or health. We will not punish your doctor in any way for asking for an Expedited Review or acting on your behalf to support you with the filing process. Call Member Services at , TTY/TDD. You will receive a call and a letter within 72 hours after we get all of your information and we are able to make a decision. You may ask for an extension up to 14 calendar days. If we do not agree that your review should be expedited, we will inform you right away. We will send you and DMAS a copy of the final decision within 72 hours after receiving your request for review. 46

49 Appeals Action What to do What to expect You, as well as legal representatives of deceased enrollee s estates, your assignee, or someone with your written permission can appeal Kaiser Permanente s decision. If you seek review of the decision before the effective date of the suspension, reduction, or termination of services, you have a right to continuation of coverage. After you get a denial letter/ notice you have 30 calendar days to request an appeal with Kaiser Permanente. To file all appeals or request help with filing an appeal, contact Member Services by calling , TTY/TDD, or send us a letter to the address or fax number below. Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. Attn: Appeals and Correspondence Unit 2101 East Jefferson Street Rockville, MD Fax: When we get your information, we will send a letter within 5 calendar days that we have received and are reviewing your request. You have a right to the following: Review the information being used for the decision and provide additional information Attend the appeal meeting if you wish Have a representative present We will let you know the date, time, and location of the meeting at least 5 days before it is scheduled. We will normally make a decision within 30 calendar days of receipt of the appeal. However, if we need additional information, we may extend that time for 14 calendar days. You may also ask us to extend the review process for up to 14 calendar days if you or your child s provider has more information you would like us to consider. If you do not agree with the outcome of the appeal, you may submit a request for external review in writing to DMAS. This request must be received by DMAS within 30 calendar days after you receive Kaiser Permanente s final decision. 47

50 External review process Action What to do What to expect You can request an External Review only after you have completed Kaiser Permanente s appeal process. For a review from an External Quality Review Organization (EQRO), write to: Department of Medical Assistance Services FAMIS External Review 600 East Broad Street Suite 1300 Richmond, VA Fax: Requests for an external review can t be made until you have fully completed Kaiser Permanente s appeal process. You must submit a letter to DMAS within 30 calendar days after you receive Kaiser Permanente s final appeal decision. A decision will be made within 45 calendar days within receipt of the review unless you request or cause a delay. If the 45 calendar day timeframe could seriously jeopardize your child s health, the EQRO will issue a written decision within 48 hours of your request for an expedited review unless you cause or request a delay and then review may be extended up to 14 calendar days. Kaiser Permanente must comply with the decision of the EQRO. EQRO will investigate your appeal and make a determination as part of the External Review. Kaiser Permanente will give both you and DMAS an appeals summary describing the reason for the denial of services at least 10 calendar days prior to the date of the hearing. The EQRO decision is final and can no longer be appealed. 48

51 You may also address complaints or concerns to the following: State Corporation Commission Bureau of Insurance P. O. Box 1157 Richmond, VA Toll-Free: Local: Virginia Department of Health Professions Office of Licensure and Certification 9960 Mayland Drive, Suite 401 Richmond, Virginia Toll-Free: Local: Fax: Virginia Department of Health Center for Quality Health Care Services and Consumer Protection Complaint Division 3600 West Broad Street Suite 216 Richmond, Virginia Toll-Free: Fax: MCHIP/MCHIP_enrollee_Complaint_Form.doc Continuation of services To continue your benefits during an appeal, you must request a continuation of services. If Kaiser Permanente or the external reviewer does not decide in your favor, you may have to pay for the services that were continued during the appeal. Please contact Member Services at , TTY/TDD, for more detail. Alternative formats This information is important and is available in Spanish, Chinese (Traditional), Korean, and Vietnamese at no charge. If you want someone to read it to you, or if you would like a copy in one of these languages, please call Kaiser Permanente Member Services, toll free, at , TTY/TDD. You can also get this information in large print and/or Braille. 49

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53 General Information Coordination of benefits Coordination of benefits happens when your child has another insurance coverage. Because Kaiser Permanente is always the secondary payor, all claims should be billed to the primary insurance company first. Kaiser Permanente will: Work with the other medical insurance company to cover your child s health care expenses. Process your claims after the primary insurance makes their payment. Make payments up to the allowable amount. Advance directives Emancipated minors and members over 18 years old have rights under advance directive law. An advance directive talks about making a living will. A living will says you may not want medical care if you have a serious illness or injury and may not get better. It is a paper that tells your provider and your family what kinds of care you do not want if you are seriously ill or injured. To make sure you get the kind of care you want if you are too sick to decide for yourself, you can sign a living will. You can change your mind any time after you have signed a living will. You can sign a paper called a durable power of attorney, too. This paper will let you name a person to make decisions for you when you cannot make them yourself. You can ask for a free packet of information about advance directives from Kaiser Permanente Member Services by calling New medical technologies Advances in science bring improved medical care. Kaiser Permanente has a committee made up of doctors, scientists, and other experts chosen from our own staff to study medical advances. They keep track of medical advances and how they fit the benefits that we offer. We do that so we can give you up-to-date, effective, and efficient medical care. Quality care at Kaiser Permanente You can get a copy of our quality report. It s a summary of our quality goals, objectives, and activities. It explains how we improve care and service to our members, providers, and the community. For a complimentary copy of this year s report, please call Member Service at , TTY/TDD. You can also see the report online at kp.org. Utilization management Utilization management describes the different ways to make sure that your child receives the right care at the right time in the right place. Kaiser Permanente s Utilization Management Program uses advice and cooperation from your child s PCP and other caregivers. Utilization management activities happen across all health care settings where Kaiser Permanente provides care. The activities include hospital medical management, complex case management, and renal case management, among others. 51

54 If you want to find out more about our utilization management program, contact a Member Services representative, who can give you: Information about the status of a referral or an approval request A copy of our criteria, guidelines, or protocols used for decision making of coverage or care. No financial incentives exist that encourage decisions that specifically result in denials or create barriers to care and service. In order to maintain and improve the health of our members, all practitioners and health professionals should be especially diligent in identifying any potential underutilization of care or service. Answers to your questions about a denial decision Member Services can also connect you with someone on the utilization management staff. Call Member Services representatives, Monday through Friday, 7:30 a.m. to 5:30 p.m., except holidays, at: TTY/TDD Utilization management affirmation statement Kaiser Permanente administers benefits, ensures compliance with laws and regulations, screens for quality of care, reviews how care and services are used, arranges for your ongoing care, and helps organize the many facets of your care. Decisions made by Kaiser Permanente about which care and services are provided are based on the member s clinical needs, the appropriateness of the care and service, and health plan coverage. Kaiser Permanente does not make decisions regarding hiring, promoting, or terminating its practitioners or other individuals based upon the likelihood or perceived likelihood that the individual will support or tend to support the denial of benefits. Kaiser Permanente does not specifically reward, hire, promote, or terminate practitioners or other individuals for issuing denials Claims Bills for covered services should be sent to: Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. P.O. Box 6233 Rockville, MD How our doctors are paid Doctors who see our members are paid in several ways, including salary, fee-for-service, and case rates. We do not pay doctors to withhold treatment or restrict care. Doctors are not paid any incentives. You can call Member Services for information on how our doctors are paid. 52

55 Your Rights and Responsibilities Privacy information This section describes how patient medical information may be used and disclosed. This also describes how patients can access this information. The privacy of patient information is important to us. That is true whether it is spoken, written, or in electronic format. Patient protected health information (PHI) is information that contains certain personal identifiers such as name, Social Security number, and medical record number. Patient medical records are PHI because they include patient names and other identifiers. New members receive the Kaiser Permanente Notice of Privacy Practices, as required by federal law. This notice describes how PHI may be used and disclosed. This notice is posted in Kaiser Permanente medical centers. It is also on our website, kp.org. The notice gives a full description of rights and protections. Below are highlights of that Notice. Members have the right to receive and request their PHI. They can request it from the medical records office where they are receiving care. Members can ask for information about our disclosures of PHI to third parties, like health departments and DMAS, where we are required by law to share information and can do so without member written permission. Members can also ask us to update PHI if they believe there is a mistake or information is missing. How much PHI is disclosed without member permission can vary. For example, Kaiser Permanente medical center staff needs access to provide member treatment and services. Also, in order to bill or pay for those services, our coders, claims and billing staff need access to PHI. Additionally, because member protection and the quality of our care are very important to us, our quality, licensing and compliance staff has limited access to PHI. Call Member Services if you want a copy of the Kaiser Permanente Notice of Privacy Practices or have questions about the notice. Protecting you from health care fraud and abuse If you suspect a member or a provider has committed fraud, waste, or abuse, you have a responsibility and right to report it. Examples of member fraud, waste or abuse include, but are not limited to: Loaning of insurance ID cards Using more than one provider to get similar treatments and/or medications Frequent emergency room visits for non-emergency conditions Examples of provider fraud, waste, or abuse include, but are not limited to: Billing for services not provided Billing for professional services performed by untrained personnel Altering medical records To report fraud, waste, or abuse, gather as much information as possible. You can report providers or members directly to Kaiser Permanente by writing to: Compliance Department Program Integrity 2101 East Jefferson St. Rockville, MD

56 You may also report fraud directly to the Virginia Medicaid Fraud Control Unit at , or Member rights and responsibilities Member rights Kaiser Permanente members have the following rights: 1. Receive information that empowers member or their representatives to be involved in health care decision making. This includes the right to: a. Actively participate in discussions and decisions regarding health care options. b. Receive and be helped to understand information related to the nature of a health status or condition, including all appropriate treatment and non-treatment options for a condition and the risks involved no matter what the cost is or what benefits are covered. c. Receive relevant information and education that helps promote safety in the course of treatment. d. Receive information about the outcomes of health care received, including unanticipated outcomes. When appropriate, family members or others you have designated will receive such information. e. Refuse treatment, providing you accept the responsibility and consequences of that decision. f. Give someone you trust the legal authority to make decisions for you if you ever become unable to make decisions for yourself by completing and giving us an advance directive, a durable power of attorney for health, living will, or other health care treatment directive. You can rescind or modify these documents at any time. g. Receive information about research projects that may affect health care or treatment. You have the right to choose to participate in research projects. h. Access your medical records and any information that pertains to your child, except as prohibited by law. This includes the right to ask us to make additions or corrections to the medical record. We will review your request based on applicable state and federal law to determine if the requested additions are appropriate. If we approve the request, we will make the correction or addition to protected health information. If we deny your request, we will tell you why and explain your right to file a written statement of disagreement. You or your authorized representative will be asked to provide written permission before records are released, unless otherwise permitted by law. 2. Receive information about Kaiser Permanente and this plan. This includes the right to: a. Receive the information you need to choose or change your child s PCP, including the name, professional level, and credentials of the doctors assisting or treating your child. b. Receive information about Kaiser Permanente, our services, our practitioners and providers, and the rights and responsibilities of members. You also can make recommendations regarding Kaiser Permanente s member rights and responsibility policies. c. Receive information about financial arrangements with doctors that could affect the use of services needed. 54

57 d. Receive emergency services when you, as a prudent layperson, acting reasonably, would have believed that an emergency medical condition existed. e. Receive covered urgently needed services for your child when traveling outside Kaiser Permanente s service area. f. Receive information about what services are covered and what you will have to pay, and an explanation of any bills for services that are not covered. g. File an inquiry, complaint, or appeal about Kaiser Permanente or the care you received without fear of retribution or discrimination, expect problems to be fairly examined, and receive an acknowledgement and a resolution in a timely manner. h. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation, as specified in other federal regulations on the use of restraints and seclusion. 3. Receive professional care and service. This includes a member s right to: a. See plan providers, get covered health care services, and get your prescriptions filled within a reasonable period of time and in an efficient, prompt, caring, and professional manner. b. Have your child s medical care, medical records, and protected health information handled confidentially and in a way that respects privacy. c. Be treated with respect and dignity. d. Request that a staff member be present as a chaperone during medical appointments or tests. e. Receive and exercise your rights and responsibilities without any discrimination based on age, gender, sexual orientation, race, ethnicity, religion, disability, medical condition, national origin, educational background, reading skills, ability to speak or read English, or economic or health status including any mental or physical disability you may have. f. Request interpreter services in your primary language at no charge. g. Receive health care in facilities that are environmentally safe and accessible to all. Member responsibilities As a member of Kaiser Permanente, there is a responsibility to: 1. Promote good health: a. Be active in your child s health care and engage in healthy habits. b. To the best of your ability, give accurate and complete information about your child s health history and health condition to your doctor or other health care professionals treating you. c. Work with us to help you understand your child s health problems and develop mutually agreed upon treatment goals. d. Talk with your child s doctor or health care professional if you have questions or do not understand or agree with any aspect of proposed medical treatment. e. Do your best to improve your child s health by following the treatment plan and instructions your doctor or health care professional recommends. 55

58 f. Schedule your child s health care appointments as recommended by his or her doctor or health care professional recommends. g. Keep scheduled appointments or cancel appointments with as much notice as possible. h. Inform us and your local Department of Social Services caseworker if your address changes or if you no longer live within the plan service area. i. Inform us if your family size changes. 2. Know and understand the plan and benefits: a. Read about the health care benefits and become familiar with them. c. Let us know if you have any questions, concerns, problems or suggestions. d. Inform us if your child has any other health insurance or prescription drug coverage and if there are any changes to that coverage. e. Inform any network or non-participating provider from whom your child receives care that he or she is enrolled in our plan. 3. Promote respect and safety for others: a. Extend the same courtesy and respect to others that you expect when seeking health care services. b. Assure a safe environment for other members, staff, and doctors by not threatening or harming others. b. Bring your payment with your child s visit requires a copayment. 56

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60 Definitions Abuse: Use of health services by members that result in unnecessary costs to the FAMIS program or in payment for services that are not medically necessary. Adverse Action: The denial of authorization for a service; reduction, suspension, or termination of a previously authorized service; denial in whole or in part of a payment for a covered service; or the denial of an enrollee s request to exercise his or her right to obtain services outside of the network. Members may file an appeal of an adverse action. Appeal: A request made by a member (or provider on behalf of a member) to review an adverse action (see definition above) taken by Kaiser Permanente. Review of an adverse action must be conducted by a representative of Kaiser Permanente who has not been directly involved in any prior decision regarding the benefit. Authorized Service: A covered benefit that has been approved by Kaiser Permanente. Business Days: Monday through Friday, 8:30 a.m. to 5:30 p.m. ET, unless otherwise stated. Calendar Days: Any day of the week. Case Management: The timely coordination of services to meet a member s health care and some other needs in a cost-effective manner. Copayment (Copay): Money collected directly from a member for FAMIS services. Covered Services: FAMIS services that Kaiser Permanente is responsible for providing. Department of Medical Assistance Services (DMAS): The organization contracting with Health Plan to provide and/or arrange health care services for FAMIS-eligible people. Department of Social Services (DSS): The Commonwealth of Virginia s agency that determines eligibility for FAMIS. Direct Access: If your child needs to see a specialist frequently because of a chronic, complex, or serious medical condition, the PCP (in consultation with us and the specialist) may develop a treatment plan that allows your child to see the specialist for a certain number of visits without additional referrals. The PCP must contact us and use our guidelines when creating the treatment plan (the doctor will have to get prior approval). Electronic Medical Record: A patient record that is created and securely maintained in an electronic format. Emergency Medical Condition: Illness, injury, or pregnancy-related condition that is sudden and unexpected and which a prudent layperson believes is potentially life threatening and requires immediate medical attention. You don t need to get our approval first. Some examples of a medical emergency are: Heart attack or stroke symptoms Extreme difficulty breathing Sudden or extended loss of consciousness Uncontrollable bleeding Sudden loss of vision Emergency Services: Inpatient and outpatient services by participating or non-participating providers that are necessary to evaluate, treat, or stabilize an emergency medical condition, as defined above. 58

61 External Quality Review Organization (EQRO): The independent contractor assigned by DMAS to handle quality reviews and to conduct final review of Health Plan decisions to FAMIS. Family Access to Medical Insurance Security (FAMIS): An assistance program of DMAS, providing health benefits for Virginia s uninsured children of working Virginia families Family Planning: Those services that delay or prevent pregnancy. Coverage of such services shall not include services to treat infertility or services to promote fertility. FAMIS MOMS: An assistance program for uninsured pregnant females that are not eligible for Medicaid but qualify for coverage based on the FAMIS MOMS eligibility guidelines. These members have Medallion II/Medicaid benefits and do not have cost sharing. Formulary (Preferred Drug List): A list of drugs that Kaiser Permanente has approved. Some drugs need prior approval. Grievance: A complaint by a provider, member, or member representative expressing dissatisfaction with the availability, delivery, or quality of services provided. A grievance is not an appeal. Guardian: An adult who is legally responsible for the care of a minor child or another adult. Health Plan: Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., a non-profit company that operates a managed care organization (MCO). Inquiry: An oral or written request made by or on the behalf of an enrollee that may be: 1) questions regarding the need for additional information about eligibility, benefits, plan requirement or materials received etc., 2) provision of information regarding a change in the enrollee s status such as address, family composition, etc., or; 3) a request for assistance such as selecting or changing a PCP assignment, obtaining translation assistance, obtaining access to care, etc. Inquiries are not expressions of dissatisfaction. Kaiser Foundation Health Plan of the Mid- Atlantic States, Inc. (Health Plan or Kaiser Permanente): Managed Care Organization contracted with DMAS to provide health care services to your child. Kaiser Permanente: Medical care program that is operated by the following entities in the Mid- Atlantic States: Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (Health Plan), Kaiser Foundation Hospitals (KFH), and Mid-Atlantic Permanente Medical Group, P.C. (MAPMG). KP HealthConnect: Kaiser Permanente s electronic medical record system. Managed Care Organization (MCO): An insurance plan that provides primary care doctors, specialists, hospitals and health education services to its members through its own network. Member: A FAMIS eligible enrollee who has been enrolled in Kaiser Permanente by DMAS. Medically Necessary or Medically Needed: Services that your child needs for the treatment of an illness, injury, or pregnancy related condition as determined by your child s doctor. Mid-Atlantic Permanente Medical Group, P.C. (MAPMG): Multi-specialty physician group practice that contracts with Health Plan to provide and arrange for provision of medical services to Kaiser Permanente members. It may also contract with other professional medical services providers to render covered services that it cannot provide through its employees. Non-Participating Provider: Hospitals, skilled nursing facility, pharmacies, doctors and other 59

62 health care providers, who are not contracted with Kaiser Permanente to provide covered services to Members. Participating Provider: Hospitals, skilled nursing facility, pharmacies, doctors and other health care providers, who have contracted with Kaiser Permanente to provide covered services to Members. Physician: A licensed doctor of medicine or osteopathy. Post Stabilization: Covered services ordered by your child s doctor related to an emergency medical condition that are provided after a member s condition is stable so that the condition will remain stable or will improve or resolve. Prior Authorization (prior approval): A step that Kaiser Permanente requires before deciding to pay for medicine or service. Primary Care Physician (PCP): A MAPMG doctor or participating provider, who provides and/or coordinates health care services for your child. Protected Health Information (PHI): Individually identifiable information, including demographics (e.g. age, birth date, sex, address), which relates to a person s health, health care, or payment for health care. Provider Network: The group of health care entity(ies) (e.g. hospitals, pharmacies) and/or health care professional(s) that have contracts to provide covered services to members. Prudent Layperson: A person who is without medical training and who draws on his or her practical experience when making a decision regarding whether emergency medical treatment is needed. A prudent layperson will be considered to have acted reasonably if other similarly situated laypersons would have believed, on the basis of observation of the medical symptoms at hand, that emergency medical treatment was needed. Referrals: Written request by your child s doctor to see a specialist or a non-participating provider. Second Opinion: Review of a diagnosis or proposed course of treatment by a second doctor. Self Refer: Services that a member may schedule directly without a referral. TTY/TDD (Text Telephone/Telecommunications Device for the Deaf): Electronic devices for text communication via a telephone line, used when one or more of the parties has hearing or speech difficulties. Urgent Care Condition: An illness, injury, or pregnancy-related condition that is sudden and unexpected that, if not treated within 24 hours, could lead to serious harm. Utilization Management: The process used to determine the medical necessity of a proposed treatment, including the appropriate level of care. 60

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64 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc East Jefferson Street Rockville, MD _FAMIS_M_br 9/1/13 12/31/13 kp.org/medicaid/va