Path2Health Member Services Guide. Benefit Year anthem.com/ca

Transcription

1 Path2Health Member Services Guide Benefit Year 2012 anthem.com/ca

2 Important Phone Numbers Anthem Blue Cross Customer Care Center (CCC) TTY /7 NurseLine (24-Hour Nurse Help Line) TTY Anthem Care Management Vision Service Plan (Vision) TTY DentaQuest (Dental) TTY MedImpact Healthcare Systems, Inc. Prescription Drug Services* (Pharmacy) TTY (Relay) TTY lines are only for members with hearing or speech loss CAMENABC 12/11

3

4 Welcome! You now are a member of Path2Heath offered by Anthem Blue Cross Life and Health Insurance Company (Anthem Blue Cross). We work with the County Medical Services Program (CMSP) Governing Board to bring you the Path2Health Program. CMSP has contracted with Anthem Blue Cross to offer the medical, dental and vision benefits of the Path2Health Program that are described below. This book explains your new health coverage program. Here is what you will find inside: How Path2Health works Which services are covered and which are not How to get help if you do not understand something How to get help if you have a problem with a health care provider Your member rights How we keep your information private A 24-hour phone line to call if you need to talk to a registered nurse or want access to hundreds of audio health topics (The 24/7 NurseLine phone numbers are listed at the bottom of each right-hand page.) Our toll-free Customer Care Center (CCC) phone numbers listed at the bottom of each right-hand page. Free health programs to help you be well This symbol lets you know when you need an approval from Anthem Blue Cross before you get care Definitions for some terms that may be new to you Check for your Path2Health member ID card Your Anthem Blue Cross Life and Health Insurance Company (Anthem Blue Cross) Path2Health identification (ID) card was sent to you separate from this book. Did you get it? If not, call us toll-free at If you have hearing or speech loss, you may call the CCC TTY line at Your ID card lists your main doctor. We call this person a primary care physician, or PCP. If you want to change your PCP, you can visit our Provider Finder online at wellpoint.com/epf/finderrouter?company=bcc. If you need help finding a provider, you also may call the CCC or CCC TTY line. Tell us if you move When you move, please write or call to give us your new address. Our phone number is If you have hearing or speech loss, you may call our CCC TTY line at And here s our address: ANTHEM BLUE CROSS PO BOX Los Angeles, CA Questions? Comments? If you have any questions or want to learn more, please call us at , Monday through Friday, from 7 a.m. to 7 p.m. If you have hearing or speech loss, you may call our CCC TTY line at You also may call the 24/7 NurseLine, the 24-hour nurse help line, toll free, 24 hours a day, seven days a week. That phone number is The 24/7 NurseLine TTY line is If you need help at any time, you may call the California Relay Line at 711. This combined Member Services Guide and Disclosure Form is a summary only. The contract itself should be read to decide what rules apply. Podemos traducir esto gratuitamente. Llame al número de servicio de atención al cliente que aparece en su tarjeta de identificación (ID card).

5

6 Table of Contents Part 1 Important things to do...1 Part 2 How to use your health coverage program...2 Part 3 What Path2Health covers...7 Part 4 How to get prescription drugs Part 5 What Path2Health does not cover...14 Part 6 Emergency and urgent care services Part 7 Programs to help keep you well Part 8 Help with special services Part 9 How to resolve a problem with Anthem Blue Cross Part 10 If we no longer can serve you Part 11 Other things you may need to know Part 12 Your health care rights and responsibilities Part 13 Definitions Customer Care Center (CCC): TTY: /7 NurseLine: /7 NurseLine TTY: TTY lines are only for members with hearing or speech loss.

7

8 Part 1 Important things to do Keep your Anthem Blue Cross Path2Health ID card with you at all times. Show it each time you need health care service. Do not let anyone else use your ID card. Check that the PCP on your ID card is the one you want. If you want a new PCP, let us know right away. Set up an appointment for an initial health assessment (first health visit) with your PCP right away. During the first visit, your PCP learns about your health care needs to help you stay healthy. If you are an adult, this visit needs to be within 120 days after joining Anthem Blue Cross. Call your PCP before you get medical care, unless you have an emergency. Your doctor s office staff will help you set up a health visit for care. You can get interpreter service by calling our toll-free CCC line. If you have hearing or speech loss, you may call our CCC TTY line at If you need a face-to-face interpreter, please call us 72 hours in advance. If you need to cancel, we require 24-hour notice. Call the toll-free 24/7 NurseLine at (TTY line ) if you are not sure what to do. You can talk to a registered nurse (RN) about your health questions 24 hours a day, seven days a week. Have your ID card ready when you call. The nurse will ask for your ID card number. Call 911 if you have a medical EMERGENCY. Get help right away. Call 911 or go to the nearest emergency room (ER) for medical care. You will be covered for emergency care within the United States (U.S) and U.S. territories even if the provider is not part of the Anthem Blue Cross network. You are important to us. We want to help you get the health care you need. Thank you for being part of Path2Health. 1

9 Part 2 How to use your health coverage program If you have any questions please call our toll-free CCC or CCC TTY line. Your Anthem Blue Cross Path2Health member ID card Always carry your ID card with you. Show your ID card to your PCP, hospital or other provider each time you go for health care services. You are the only one who can get health care services with your ID card. If you let someone else use your ID card, we may not be able to keep you on this health coverage program. Also, look on your card for these phone numbers: Your PCP s office The toll-free Anthem Blue Cross CCC phone line The 24/7 NurseLine (24-hour nurse help line) Here is a sample of what your ID card could look like: (front) Choosing a PCP New members must choose a PCP (main doctor) within 30 days from the time they enroll. If you do not choose a PCP within 30 days, we will assign one to you. If you need help choosing a doctor who is right for you, call our toll-free CCC or CCC TTY line. Your ID card will have the name, phone number and address of the PCP you chose or the PCP assigned to you if you did not choose one. You can find a new PCP online at wellpoint.com/epf/finderrouter?company=bcc. It s best to choose a PCP close to your home. We may ask you to change your PCP if: The PCP is not taking new patients. The PCP is no longer in the Anthem Blue Cross network. You may choose a physician s assistant or a nurse practitioner as your PCP. These providers are called mid-level practitioners. Your ID card will list only the name of the doctor who employs this person, but you can still get care from the mid-level practitioner you chose. Female members may see a women s health specialist in the Anthem Blue Cross network for covered care including women s routine and preventive health care services. The women s health specialist may be a doctor, physician s assistant, or a nurse practitioner. Call us if you need help finding a women s health specialist. Provider Finder Our online Provider Finder lists providers that work with Anthem Blue Cross such as: PCPs Nurse practitioners Optometrists Psychologists (back) 2

10 Part 2 How to use your health coverage program Pharmacies Hospitals Urgent care centers Federally Qualified Health Clinics The Provider Finder lists provider addresses, phone numbers, business hours and the languages spoken by the provider s office staff. You also can check the directory to find out if a provider can take new patients. To find out more about a PCP or other provider, such as the doctor s specialty, medical school, training, or board credentials, visit these websites: American Medical Association (ama-assn.org) AIM DocFinder (docboard.org/docfinder.html) Initial health assessment (IHA) We ask all new members to see their PCP soon after joining this health coverage program. The first meeting with your PCP is important because the doctor gets to know your health needs. To do so, the PCP will do an IHA. During the IHA, the doctor will: Get to know you and talk about your health. Learn your medical history. Give you a physical exam. Give you health information you need. Help you to know your health needs. Teach you ways to help make your health better or to help you stay healthy. Provide you with the results of the IHA. Members should see their PCP for an IHA within 120 days after joining Path2Health. Making an appointment with your PCP Call your PCP s office to set up a health visit. Tell the person who answers the phone that you are a Path2Health member. Have your ID card with you when you call. You may be asked for your member ID number. Make sure to bring your ID card with you for your health visit with your PCP. Be on time for your health visits. Call your PCP s office as soon as you can if: You will be late. You cannot keep your appointment. This will help shorten everyone s time in the waiting room. Your PCP may not be able to see you if you are late. If you cancel your health visit, someone at your PCP s office can help you set up a new one. Call your PCP before you get any medical care, unless you have an emergency. What to do when your PCP s office is closed If you call your PCP after office hours, you can leave your name and phone number with the answering service. Either your PCP or an on-call doctor will call you back. If this is to set up a routine checkup, it is better to call the office during business hours. If you have a health concern you feel you must speak to someone about right away, please call the 24/7 NurseLine at If you have hearing or speech loss, please call the TTY line at The 24/7 Nurseline nurse can tell you how to access services. If you have an emergency, call 911 or go to the nearest emergency room. Changing your PCP Most of the time, it is best to keep the same PCP. Then he or she can get to know your health needs and history and give you continuity in your health care. We want you to be happy with your PCP. So, if you want to change your PCP, you can 3

11 Part 2 How to use your health coverage program do so at any time. You may change your PCP at any time during the month. Your request will go into effect on the first day of the next month. To change your PCP, call our toll-free CCC or CCC TTY line. If you choose to change your PCP, please note: When choosing a new PCP, you must choose a doctor who will see new patients. A request to change your PCP may be denied if the PCP you want is not taking new patients. We will let you know when you can start seeing your new PCP. When you change your PCP often, your health care may not be as good as it could be. Each time you choose a new PCP, he or she needs to review your medical history, medicines, and any ongoing treatment. This type of review takes a lot of time that your PCP could spend on your current concern. Anthem Blue Cross, or your PCP, may ask you to change PCPs if: Your PCP is no longer part of the Anthem Blue Cross network. You are not able to get along with, or agree with, your PCP. You keep making appointments and don t show up for them. You are often late for your health visits. You are rude or abusive to your PCP or your PCP s staff. You disrupt the PCP s office. We will tell you in writing if we need to change your PCP. Specialist care and prior authorization (an OK from Anthem Blue Cross) Your PCP may send you to a specialist for some types of care or treatment. This includes care for HIV or AIDS. Please note: Your PCP will work with you to choose a specialist to give you the care you need. Your PCP s office can help you set up a time to see the specialist. You need to tell your PCP and the specialist as much as you can about your health. That way all of you can decide what is best. A specialist may treat you for as long as he or she thinks you need it. Your PCP or specialist may need to get an OK from us for some types of care to make sure they are covered. This is called prior authorization. This means that both Anthem Blue Cross and your PCP or specialist agree that the type of care asked for is medically necessary. Medically necessary is care that is reasonable and needed to: Protect life Keep the patient from getting seriously ill or disabled Reduce severe pain by finding out what is wrong or treating a disease, illness or injury These services need an OK ahead of time: Inpatient and outpatient hospital care, except in the case of an emergency. (You do not need an OK ahead of time for a medical emergency.) Specialist care given by a provider outside of your network. CT, MRI, MRA, PET and SPECT scans The use of some medical equipment 4

12 Part 2 How to use your health coverage program Transport that is not for an emergency Mental health and substance abuse counseling Once we get your provider s request for an OK for a service, we will decide within: Five business days for a routine service. 72 hours for a needed service that is urgent based on your health problem. We care about you and want to help you get the health care you need. Your PCP works with you to decide what s best for your health. Your PCP and other providers base their decisions on two things: Whether or not the care is right for your health issue What health care benefits you have Your doctor may ask us to approve payment for certain types of health care services. We base our decision on two things: Whether or not the care is medically necessary. To learn more about medically necessary, see Part 14 Definitions. What health care benefits you have You should know that we do not reward providers or other persons to deny coverage or services. Out-of-area emergency care does not need an OK from Anthem Blue Cross. To learn more about this, see Part 6, Emergency and Urgent Care Services. To view online, or ask for a copy of Anthem Blue Cross s clinical practice guidelines, go to anthem.com/ca/provider/f3/s1/t0/pw_ a pdf?refer=culdesac&name=ssb. You also may call our toll-free CCC or CCC TTY line listed on your member ID card. Utilization Management (UM) Anthem Blue Cross makes sure that UM staff works at least eight hours a day on normal business days. To talk to someone, just call the toll-free CCC or CCC TTY line between 7 a.m. and 5 p.m. Anthem Blue Cross staff can make and get calls during and after normal business hours. When a staff member calls you back about an OK for services, you will be told who is calling, his or her title, and for whom he or she works. You will be told how to learn more about a request. You also will be told how to send a fax or leave a voice mail message with your contact information so someone can call you back the next business day. Out-of-area care If you are outside of Path2Health s service area and need care that is not an emergency, call one of these right away: Your PCP 24/7 NurseLine Anthem Blue Cross CCC Path2Health covers emergencies in the United States and U.S. territories only. There is no coverage outside the United States and U.S. territories. If an emergency takes place while you are out of the service area, you may get emergency care at the nearest ER. The provider must tell Anthem Blue Cross within 24 hours after you are seen in the ER. An emergency is a medical or psychiatric condition with such severe symptoms (such as active labor or severe pain) that you reasonably believe the lack of getting medical care right away could: Place your health at risk (in jeopardy) Cause impairment to a body function Cause the dysfunction of a body part or organ 5

13 Part 2 How to use your health coverage program The emergency room (ER) is the best place for a person to be if he or she has these types of situations. The ER should not be used for routine care. ERs don t have access to your medical history and records. Your PCP, who knows you best, will not be in the ER to care for you. Poststabilization Care After an Emergency Once your emergency medical condition has been treated at a hospital it is no longer an emergency because your condition is stabilized. The doctor who is treating you may want you to stay in the hospital for a while longer before it may be safe for you to leave. These services are called poststabilization services. The doctor must ask for an OK from us and we will pay for these services when needed for medical reasons. How to get answers from Anthem after business hours Our CCC is open Monday through Friday, 8 a.m. to 5 p.m. From 5 p.m. to 8 a.m., Monday through Friday and on weekends, you can leave a message. We will call you back the next business day. You can call us if you have questions about Path2Health or to find out if: You need an OK from your PCP or specialist for a type of service to be covered by us. We have approved the service you want. You also can call the 24/7 NurseLine. A registered nurse (RN) is ready to help you over the phone with any health concern. The nurse can tell you how to access services. A nurse also can help if you need an interpreter after hours. The RN who answers the 24/7 NurseLine also can help you with getting an OK for services or care when needed. Out-of-network care In most cases, you must use a provider within the Path2Health network to get covered services. To learn more, call our toll-free CCC or CCC TTY line. We can help you get the care you need. 6

14 Part 3 What Path2Health covers Here are the kinds of care you can get under this health coverage program. We offer these types of service at no cost to you. But some of the services shown below must be approved by Anthem Blue Cross first. Emergency care does not need an OK. To learn more about covered services or getting an OK, call us at our toll-free CCC or CCC TTY line. Ambulance services These services need to come from a licensed ambulance company or air ambulance for an emergency health issue only. We cover these: Base charge and mileage Supplies that are not used again Monitoring (keeping an eye on a health concern) EKGs Cardiac defibrillation (a method of changing the heartbeat) CPR Oxygen IV solutions Dental care You have full comprehensive dental coverage through DentaQuest, the dental benefit manager for Path2Health. Some dental services need an OK from DentaQuest. You can get dental services from a dentist, endodontist or oral surgeon. Dental services include: Care to prevent and find out what is wrong A limit of two oral exams each year A limit of two teeth cleanings each year Periapical X-rays medically necessary to find out what is wrong Basic healing care Silver or resin fillings Emergency treatment for relief of pain General anesthesia or I.V. sedation (needs an OK from DentaQuest) Major healing services Special healing procedures to restore lost tooth structure Crowns - when placement of a filling cannot be done (needs an OK from DentaQuest). Limit of one per 60 months Endodontics Root canal therapy on permanent teeth (needs an OK from DentaQuest). Limit of one tooth per lifetime. Prosthetics Repair and adjustment on removable and fixed bridges Standard partial dentures Full dentures to replace permanent teeth that have been pulled out (needs an OK from DentaQuest). Limit of one per 60 months. Oral or maxillofacial surgery Taking out a tooth by surgical and nonsurgical means, including pre- and post-operative care (some services need an OK from DentaQuest). Limit of one tooth per lifetime. Getting an OK from DentaQuest Your dentist can ask for an OK for services from DentaQuest before treatment begins by sending papers that show the course of treatment is needed. Services that need an OK from DentaQuest should not be started before it is approved or denied by us. Your request will be denied if the papers we need are not sent with the request. The dental office runs the risk of not 7

15 Part 3 What Path2Health covers being paid if treatment that is not an emergency is started before DentaQuest makes a coverage decision. DentaQuest knows that you may not be able to get an OK before you get emergency treatment. If that is the case, your dentist may ask for review after treatment. Before you get emergency care, you need the same papers as an OK. Your dentist should know that claims sent without the needed papers will be denied. Your dentist can find a list of all covered services, benefit limits and what is needed for an OK in the DentaQuest Dental Office Reference Manual (ORM) which can be found online at dentaquestgov.com. Need help finding a provider? We will pay for covered services if you use a dentist in the network. For help finding a provider go to click on Find a Dentist at the top of the screen and follow the prompts to find an in-network dentist or specialist closest to you. Anthem Blue Cross offers dental benefits through DentaQuest. DentaQuest is not part of Anthem Blue Cross (an independent company). To learn more about your dental benefits, to find a dental provider or to resolve your dental benefit issues, you may call DentaQuest at If you have hearing or speech loss, you may call the DentaQuest TTY line at Diagnostic X-ray and lab services All special radiology work such as CT, MRI, MRA, PET and SPECT needs an OK from Anthem Blue Cross. We cover blood tests, X-rays, lab work and radiation therapy to test, find out what is wrong, treat and follow up on your care. You must use a lab in the network. This benefit also includes: Tests to check your heart, brain and breasts for problems. The tests most often used to find cancer. Lab tests used to manage diabetes. The tests are for cholesterol, triglycerides, microalbuminuria, HDL/LDL, hemoglobin A1C glycohemoglobin and creatinine Yearly cervical cancer screenings approved by the FDA. Screenings include the Pap test and the human papilloma virus (HPV) test. Home health care Needs an OK from Anthem Blue Cross. We cover the care given by health care staff in the home such as: Visits or supplies from a licensed home health agency or nurse group. Physical, occupational or speech therapy. Care from a health aide who works under a registered nurse or a therapist. Your provider must ask for home health care for you and get an OK from us before you get care. 8

16 Part 3 What Path2Health covers Hospital services Needs an OK from Anthem Blue Cross. You do not need an OK if it is an emergency. We cover these: A hospital room with two or more beds Care in special units Operating and special treatment rooms Breast cancer surgery (mastectomy or lymph node dissection): You and your doctor decide how long you will need to stay in the hospital after this surgery. We will pay for this stay. We will pay for care that is needed and any problems that come from this surgery. Testing the blood, heart and urine Taking X-rays Supplies Physical, occupational and radiation therapy Chemotherapy Hemodialysis treatment Medical supplies, equipment and other services Needs an OK from Anthem Blue Cross. All custom-made durable medical equipment (DME) needs an OK from Anthem Blue Cross. Path2Health covers these: Manmade body parts to replace missing body parts as well as the supplies needed for the surgery and the care of these parts Parts needed to replace a breast and make it look the same as the real breast Supplies needed for a colostomy Medical equipment and supplies that last a long time (Your PCP must order them. Only the person who needs the supplies can use them for a health problem. Call us to find out if you should rent or buy.) Insulin pumps and all supplies needed for the pump if you have diabetes problems (needs an OK from us ahead of time) Tools used to treat your feet if you have diabetes problems Drugs, including oxygen, the hospital gives you during your stay Giving you someone else s blood Emergency room (ER) use Services to keep your condition stable after you have been treated for an emergency 9

17 Part 3 What Path2Health covers Mental health and substance abuse services Some of these services need an OK from Anthem Blue Cross. Inpatient mental health stays need an OK from your county mental health plan. These stays are limited to 10 days per fiscal year (July to June) and up to six days per episode. Outpatient mental health services need an OK from Anthem Blue Cross and may be covered for a mental health or substance abuse diagnosis. Outpatient mental health services are limited to the below services per calendar year (January to December). For a mental health issue we cover these: One initial evaluation 10 therapy sessions for one person or in a group (or any mix of these that equals 10 sessions) For a substance abuse issue we cover these: One initial evaluation Two counseling sessions for one person 20 group therapy sessions Pre-enrollment medical care For enrolled Path2Health members, Path2Health will pay for medical services that are caused by a qualifying medical event that took place during the 10 calendar day right before the member s first month of Path2Health coverage. A qualifying medical event is any emergency health issue that caused the Path2Health member to get emergency medical care. This pre-enrollment coverage is not the same as retroactive eligibility for Path2Health. To learn more, call your county eligibility worker. Professional services Some of these services need an OK from Anthem Blue Cross. We cover these: Office visits for health problems or injuries Routine doctor visits, first-time visits and vaccines Well-woman care: Checkups and tests adult women can have every year Chlamydia screening Giving you someone else s blood Care by a foot doctor for foot and ankle problems that make it hard to walk Breast exams and X-rays of your breasts Cancer screening tests Doctor visits for these tests: Human papillomavirus (HPV) Pap smear Cervical cancer Prostate cancer Outpatient X-ray, lab and radioisotope tests to find out what is wrong One visit from your doctor each day you are in the hospital (Your doctor may be able to visit more often. This depends on your health problem.) Radiation therapy Chemotherapy Learning how to manage diabetes Hearing aids for hearing problems. To find the right hearing aid for you: You must first have your hearing loss measured. You also must have a full ear, nose and throat exam. 10

18 Part 3 What Path2Health covers Allergy tests and treatment Breathing treatments Physical, occupational and speech therapy Visits to a specialist Surgery and surgical help (such as reconstructive surgery to give you back the use of a body part, to correct a deformity caused by an injury, or to make your breasts look the same after a breast is removed.) Anesthesia (when you have surgery) Telemedicine Telemedicine helps you get care from a specialist, even though you and the doctor are not in the same place. The program uses computers, special equipment and phone lines to connect you. With telemedicine: It may be easier or faster for you to get care from a specialist without going far from your home. Your doctor can choose from the Anthem Blue Cross network of specialists, no matter where you live. The specialist uses computers and other special equipment to see and talk to you and your doctor at the same time. Your doctor can send your medical data and pictures of your health problem to a specialist for review. Your doctor still takes care of you. Some of your network doctors use telemedicine, and may suggest using it to treat you when you need a specialist. Transportation (when it is not an emergency) We only cover your nonemergency transfer from a hospital to another hospital, facility or your home when: You have a medical necessity. (See what this means in Part 14, Definitions. ) A provider in your network asks for the service. We give our OK before you get the service. We do not cover public transport, such as airplane, car or taxi rides. Vision services We offer vision benefits to all Anthem Blue Cross Path2Health members through Vision Service Plan (VSP). VSP is not part of Anthem Blue Cross (an independent company). You can find VSP providers on our website at anthem.com/ca. You do not need an OK from your PCP or us for vision care. We cover: One eye exam every two years Within two years, a second eye exam if you have had a major change in your sight that shows the need for this exam. Contact lenses and vision aids that are medically necessary. A sum of $80 for materials (lenses and frames) every two years. We do not cover: Eyeglasses used for reasons other than to correct your vision (such as for your looks or your job) Contact lenses that are not medically necessary Eye surgery to correct vision (such as if you are near-sighted) If you have questions about your vision benefits, you may call VSP at If you have hearing or speech loss, you may call the VSP TTY line at

19 Part 4 How to get prescription drugs You do not have a copay, deductible or other share of cost for these drugs. Path2Health will cover your drugs if they are: Ordered by a doctor. For the care and treatment of an injury or an illness. On the Path2Health/CMSP Drug Formulary (drug list). Approved by MedImpact staff (after a Medication Request Form is used to approve a drug because it is not on the list). What can my doctor order? MedImpact, the pharmacy benefit manager for Path2Health and CMSP, has a Path2Health/CMSP drug list, from which your doctor can order drugs for you. Drugs on the list are approved by the federal Food and Drug Administration (FDA), These drugs are safe and known to treat the health issue for which your doctor orders them. To find out if a drug is on the Path2Health drug list, go to mypath2health.org or call If you have hearing or speech loss, you may call MedImpact at to be connected to the TTY relay service. When you get your prescription filled, you will not get more than a 30-day supply. Your doctor may write that you can get refills. Your local pharmacy staff can call your doctor to check if you can get refills. Some important things to know about your Path2Health prescription drug benefit: Some drugs need an OK from MedImpact ahead of time (prior authorization) or they may have limits based on medical need. MedImpact will review and decide on these requests within 2 business days. Some drugs are not on the drug list. If your doctor thinks you need to take a drug that is not on the list, he or she will need to send us a Medication Request Form to ask for an OK before you get the drug. This form can be found at mypath2health.org. A hospital emergency room (ER) doctor may give you a prescription. Path2Health will cover this drug and MedImpact will pay for it. If MedImpact says no to a request for an OK: You and your doctor will get a letter from MedImpact that lets you know why. You may appeal MedImpact s decision. To learn more, go to mypath2health.org or call If you have hearing or speech loss, you may call MedImpact at to be connected to the TTY relay service. Or, you may fax the appeal to To learn more about second-level appeals and state fair hearings, please see Part 10 How to resolve a problem with Path2Health. 12

20 Part 4 How to get prescription drugs Where can I get my prescription filled? A wide range of pharmacies take part in the MedImpact pharmacy network for Path2Health. You must go to one of these pharmacies for your drugs. Path2Health will not pay for drugs you get from a pharmacy that is not in the MedImpact pharmacy network. To learn more about pharmacies in the network, go to mypath2health,org or call MedImpact at If you have hearing or speech loss, you may call MedImpact at to be connected to the TTY relay service. If you have an emergency and you are outside of California, Path2Health will pay for drugs you get when you go to a pharmacy that takes part in MedImpact s national pharmacy network. An emergency is defined as release from the hospital, the emergency room or an urgent care facility. You will be asked to give proof at the pharmacy before your prescription is approved by MedImpact for payment. To learn more about pharmacies that take part in the national network, go to mypath2health.org or call MedImpact at If you have hearing or speech loss, you may call MedImpact at to be connected to the TTY relay service. Path2Health does not give coverage for emergencies of any kind outside of the United States and U.S. Territories. 13

21 Part 5 What Path2Health does not cover Here are the kinds of care Path2Health does not cover. To learn more, call our toll-free CCC or CCC TTY line. We can answer your questions about what we don t cover. We want to help you get the care you need. Dental care Dental care is given through DentaQuest. Path2Health does not cover any cosmetic dental services like teeth bleaching, dental veneers, or braces to straighten teeth. Medical equipment We do not cover these: Items used only for your comfort or hygiene Items used for exercise Items used only for making a room or home comfortable, such as: Air conditioning Spas Air filters Swimming pools Air purifiers Elevators Supplies for hygiene or look Mental health or substance abuse (outpatient and residential care) We do not cover these: Methadone maintenance services Residential treatment facilities Pregnancy and maternity care We do not cover these: Prenatal care and delivery services Surgery to reverse sterilization Fertility treatments (such as artificial insemination and in vitro fertilization) If you become pregnant while enrolled in the Path2Heatlh program, tell your eligibility worker at your county social services department right away as you may be eligible for the Medi-Cal program. If you are seeking treatment that has to do with infertility, please call the Family Planning, Access, Care and Treatment Program (F-PACT) at to learn more about signing up for their program and finding an F-PACT provider. Professional services We do not cover these: Routine physical exams asked for by a job, school, camp or sports program Weight loss services, programs or supplies Eye exercises or other services for eye care (except for eye exams) Foot care, such as nail trimming (except for members with diabetes or for medical necessity) Acupuncture services that have to do with the care of the feet Cosmetic surgery done just to look good Reconstructive surgery when the surgery would make only a small change for the better Healing by prayer or spiritual means Chiropractic services Acupuncture services Sex change services 14

22 Part 5 What Path2Health does not cover Other services We do not cover these: Any care that needs an OK ahead of time but has not been approved by Anthem Blue Cross Any care or service outside of the United States or U.S. Territories Any service or supply that is not medically necessary Services that are still being researched or are new Services that have not been proven to work Long-term care at a skilled nursing facility (call your county social services department right away if you need long-term care) Any service that is not listed somewhere else in this guide as being covered by Anthem Blue Cross Services you are supposed to pay for by law Services given to you at no cost to you Care for problems that have to do with work and can be paid for by: Workers compensation Your employer Disease law that has to do with your job Health issues caused by nuclear energy when the government can pay for treatment Services or care that can be paid for by other health care coverage Private duty nursing Custodial care Syringes and needles that are not approved by your doctor Any illness, injury or disease for which someone else must pay by law 15

23 Part 6 Emergency and urgent care services What is an emergency? An emergency is a medical or mental health issue with such severe signs (such as severe pain) that you reasonably believe the lack of medical care right away could: Place your health at risk. Cause loss of a body function. Cause a body part or organ to not work as it should. The emergency room (ER) is the right place for a person to be if he or she has these types of cases. The ER should not be used for routine care. ERs don t have access to your medical history and records. Your PCP, who knows you best, will not be in the ER to care for you. Call 911 or go to the nearest ER for emergency care. Emergency care is covered within the United States and U.S. Territories only. If an emergency takes place while you are out of the service area, you may get emergency care at the nearest ER. The provider must tell Anthem Blue Cross within 24 hours after you are seen in the ER. What to do in an emergency? In an emergency, get help right away. Call 911 or go to the nearest ER for medical care. You will be covered for emergency care even if the provider is not part of the Anthem Blue Cross network. The provider must call Anthem Blue Cross within 24 hours after you are seen in the ER. This should be done for any emergency (near your home or while you are away). For emergency transport, call 911. You do not need an OK from us when you have an emergency. Poststabilization care after an emergency Once your medical condition has been treated at a hospital and it no longer is an emergency because your condition is stabilized. The doctor who is treating you may want you to stay in the hospital for a while longer before it may be safe for you to leave. These services are called poststabilization services. The doctor must ask for an OK from us and we will pay for these services when needed for medical reasons. What to do when you need urgent care An urgent medical condition is NOT an emergency, but needs medical care within 24 hours. Call your PCP if you do not have an emergency, but you need medical help within 24 hours. Urgent care can be used for health problems such as: Earaches Fever Stomach pain Vomiting Minor burns Sprains If you cannot reach your PCP, call our toll-free CCC or CCC TTY line. Or, call the 24/7 NurseLine. Not sure if it s an emergency? If you are not sure your health issue is an emergency, call your PCP or the 24/7 NurseLine. Your PCP or the 24/7 NurseLine can tell you about access to services. Both phone numbers are on your ID card. The 24/7 NurseLine is free and nurses can help you any hour of the day or night. Do not use the ER for routine care. 16

24 Part 6 Emergency and urgent care services How to get emergency transport Call 911 if you believe you need an ambulance. If you are not sure, call your PCP and follow your PCP s advice. You do not need an OK from Anthem Blue Cross for emergency transport. Do not call 911 for a health issue that is not an emergency. We may refuse to pay if you use an ambulance when you don t have an emergency such as these health issues: Earaches Colds Flu Sore throats 17

25 Part 7 Programs to help keep you well Each person has special needs at every stage of life. Whether you are a man or a woman, we have programs to help you stay healthy and manage illness. Anthem Blue Cross members do not have to pay to join these programs or find out about them. They are all at no cost to you and can help you stay well. To find out more about these programs, you can call our toll-free CCC or CCC TTY line. We offer programs or health education that can help you: Make good food choices and exercise. Manage and control your weight. Manage and control your asthma. Manage and control your diabetes. Keep your heart healthy. Control high blood pressure and cholesterol. Quit smoking. Prevent sexually transmitted infections (STIs) such as HIV/AIDS. Prevent pregnancy that is not planned. Keep from being dependent on drugs and alcohol. For healthy living We can show you how to help manage your weight, eat better and stay on an exercise program. Our heart-health brochures help you learn how to control your blood pressure, cholesterol and weight. Our stop smoking program can help you kick the habit. Brochures on drugs and alcohol dependence show you how to stop problems before they start. We can give or send you details about STIs such as HIV/AIDS in private. For managing illnesses The Healthy Habits Count with Diabetes Program can connect you with someone who can: Help teach you about healthy eating. Remind you about screenings. Set up referrals to specialists to help you manage and control your diabetes. You may sign up for our diabetes program by calling If you have hearing or speech loss, you may call our TTY line at Once enrolled, you will get details to help you manage your diabetes. You also get a yearly diabetes calendar that includes a list of the different diabetes screenings. The Cardiovascular (Heart) Health Program can connect you with someone who can: Help teach you about healthy eating. Set up referrals to specialists to help you manage and control your heart disease. But you do not have to join. Your benefits will not change if you do not join. Care Management Care Management is no-cost service offered by this health program to help you manage your health care needs. If you have a concern about a new finding or change in your health, please call our toll-free Care Management line at Ask to speak with an RN or social worker case manager. 18

26 Part 7 Programs to help keep you well For your peace of mind The 24/7 NurseLine lets you talk in private with an RN about your health. The toll-free number is If you have hearing or speech loss, you may call the TTY line at The line is open 24 hours a day, 7 days a week. You also may call the 24/7 NurseLine and listen to tapes on hundreds of health topics such as these: Preventive health care guidelines to help you see the doctor at the right times High blood pressure Diabetes HIV/AIDS Extra programs from your state Based on where you live, you could get more programs for your health such as: Stop Smoking Programs You can choose from several programs to help you quit smoking. The Breast and Cervical Cancer Treatment Program (BCCTP) This program gives full-scope, no-cost Medi-Cal coverage for as long as cancer is getting treated. You must be eligible for the program. Please call to learn more about how to sign up for the BCCTP or to find a provider in the network. How to use these programs We want to offer these programs in a way that will work best to help you learn. Here are some of the ways you can get these health programs: Books and brochures that we can send you. You can keep them at home as you learn. Classes you can take where a health expert will show you how to take care of yourself. One-on-one learning where a health expert talks to you in-person or by phone. To learn more, call our toll-free CCC or CCC TTY line or your PCP. 19

27 Part 8 Help with special services The Anthem Blue Cross network providers have ramps, restrooms, parking spaces and elevators for disabled members so they can get the health care they need. Help for members who do not speak English If you do not speak English and need help during your doctor visit, you can get help in your language 24 hours a day. Just call our toll-free CCC number or CCC TTY line and ask for a face-to-face or phone interpreter at no cost. We will get someone who can speak your language. If you need someone to translate for you while you are at your PCP s office, ask your PCP to call us 72 hours in advance. We will be glad to help. We suggest that you use an interpreter who speaks your language so you do not have to use a family member or a friend to translate for you. You can choose to have your family or friend translate if that is what you want. You can call the 24/7 NurseLine if you need someone to interpret for you after regular office hours. We offer this guide and other Path2Health materials in languages other than English. To learn more, call our toll-free CCC or CCC TTY line. Help for members with hearing or vision loss We have a toll-free number for members with hearing or speech loss (a TTY line). That number is The TTY line is open from 7 a.m. to 7 p.m. Monday through Friday. To get the help you need between 7 p.m. and 7 a.m., and on weekends, leave a message. We will call you back the next business day. You also may call the 24/7 NurseLine. That phone number is If you have hearing or speech loss, you may call the 24/7 NurseLine TTY line. That phone number is Members with vision loss can get this guide, letters and other Path2Health materials in other formats such as: Large print Computer disk format Braille Audio CD To get these other formats or for help reading this guide, letters and other Path2Health materials, call our toll-free CCC or CCC TTY line. Interpreter services are offered in sign language and in a member s own language. If services are not given to you in the language you ask for, you may file a complaint with Anthem Blue Cross. If you do not get written information in the language you ask for, you also may file a complaint. To learn more, see Part 10, How to resolve a problem with Anthem Blue Cross. 20

28 Part 8 Help with special services The Americans with Disabilities Act of 1990 Anthem Blue Cross follows the Americans with Disabilities Act (ADA) of This federal law protects you from being treated in a different way by your health coverage program because you are disabled. Section 504 of the Rehabilitation Act of 1973 states that no person shall, because of a disability, be kept from taking part in, be denied the benefits of, or not be treated the same as others under any program or activity that gets or benefits from federal funds. If you believe Anthem Blue Cross or a provider in the Anthem Blue Cross network has not met your disability access needs, you may file a complaint with us. Just call our toll-free CCC or CCC TTY line. If you believe you have not been treated the same as others because of your disability, please call us. Programs or activities that get money from the state of California must follow California Government Code Section 11135, which does not allow you to be treated in a different way for any of these reasons: Ethnic background Religion Age Sex Color Disability 21

29 Part 9 How to resolve a problem with Anthem Blue Cross If you have a problem (Complaint) If you have a complaint about the care you get from us or a provider in the Anthem Blue Cross network, you can file a complaint by phone or in writing within 180 days from when the problem started. We can help you with your problem. Most problems can be solved quickly. To file your complaint in writing, call us and we will mail you a form. When you fill out the form, make sure you: Write in your member ID number from your ID card. Tell us what happened or how we can help you. After you fill out the form, mail it to: GRIEVANCE COORDINATOR ANTHEM BLUE CROSS PO BOX 9054 OXNARD CA Our grievance coordinator will process your form and resolve your complaint. You can ask us to cover approved care while your complaint is being resolved. Call our toll-free CC or CCC TTY line to speak to a grievance coordinator. Call us to help you translate your complaint as well. We will send you a letter: Within five days of getting your form to let you know we are looking into your grievance. Within 30 days after getting your form to let you know how we resolved the problem. We will respond within three days after getting your form if your case has to do with a serious or direct threat to your health that may cause: To file an appeal If you do not agree with what we decide and you get a Notice of Action (NOA) letter from us, you may file an appeal. Your provider may ask for the appeal on your behalf. You or your provider must ask for the appeal within 60 days of the mail date on the NOA letter. We will send you a letter within five days of getting your appeal request to let you know we are looking into your appeal. Within 30 days after getting your appeal to let you know how we resolved your case. You can keep your benefits while the appeal is being reviewed. You or your provider must ask to continue your benefits within 10 days of the mail date on the NOA letter. You can call us at the toll-free CCC or CCC TTY line to file your appeal. You also can write to us at: GRIEVANCE COORDINATOR ANTHEM BLUE CROSS PO BOX Los Angeles, CA To file a second-level appeal If you are not happy with what Anthem Blue Cross decides after they review your appeal that has to do with a denial, delay or change of a service, you can file a second-level appeal to the County Medical Services Program (CMSP) Governing Board. You can take your case to the Board only after Anthem has reviewed and taken an action on your appeal. You have the right to ask for a second-level appeal within 60 days after you get Anthem Blue Cross s response to your appeal. Severe pain Death The loss of a limb or a major body function 22

30 Part 9 How to resolve a problem with Anthem Blue Cross To ask for a second-level appeal call, the CMSP Governing Board at , ext. 10. Or go to the Path2Health website at mypath2health.org to get a second-level appeal request form. Or write to: SECOND-LEVEL APPEALS COUNTY MEDICAL SERVICES PROGRAM (CMSP) GOVERNING BOARD 1451 RIVER PARK DRIVE SUITE 222 SACRAMENTO CA CMSP will send you a letter: Within five days of getting your second-level appeal request to let you know they are looking into your second-level appeal. Within 30 days after getting your second-level appeal to let you know how CMSP resolved your case). You can keep your benefits while the appeal is being reviewed. You or your provider must ask to continue your benefits within 10 days of the mail date on the NOA letter. To file a State fair hearing A state fair hearing is the final way you can file a complaint if Path2Health denies, delays or changes a service. You can take your case to the state of California only after you have gone through the appeal and second-level appeals processes explained in this guide. You have the right to ask for a state fair hearing any time within 90 days after you get CMSP s final response to your second-level appeal request. To ask for a state fair hearing call, the California Department of Social Services (DSS) Public Inquiry and Response Unit at Or write to: CALIFORNIA DEPARTMENT OF SOCIAL SERVICES STATE HEARING DIVISION PO BOX MS SACRAMENTO CA We can help you ask for a state fair hearing as well. If you need help in a language other than English, we will get someone who speaks your language. Call our toll-free CCC or CCC TTY line Monday through Friday from 7 a.m. to 7 p.m. You may leave a message from 7 p.m. to 7 a.m., and on the weekends. We will call you back the next business day. Your provider can ask for a state fair hearing for you. He or she must get an OK from the state to act on your behalf. If you would like your provider to ask for a state fair hearing, call DSS at the phone number above. DSS will send you a letter that tells you our side no later than two business days before the hearing. Both of us will have a chance to give both sides of the case at the hearing. If the judge rules in your favor, we must follow what the judge decides. You can write a letter to ask for a second hearing no later than 30 days after the decision is made if you do not agree with what the judge decides. If the time needed for a state fair hearing would put your life, health or ability to fully function in danger, then you or your PCP can ask for a quick (expedited) state fair hearing. The state must decide no later than three working days after it gets the request. You can ask for a quick state fair hearing by writing to: EXPEDITED HEARING UNIT STATE HEARINGS DIVISION 744 P ST MS SACRAMENTO CA FAX: To disenroll (leave Path2Health) You may choose to leave Path2Health at any time for any reason. To do so, call your eligibility worker at your county social services department. It may take 15 to 45 days to process your request to leave Path2Health. 23