WASHINGTON APPLE HEALTH In Clark and Skamania Counties YOUR MEDICAL AND BEHAVIORAL HEALTH BENEFIT BOOK 2018

Transcription

1 WASHINGTON APPLE HEALTH In Clark and Skamania Counties YOUR MEDICAL AND BEHAVIORAL HEALTH BENEFIT BOOK 2018 CHPW_MA_001_12_2017_SW_Handbook_FIMC_2018 Updated 12/2017

2 Table of Contents Welcome to Community Health Plan of Washington and Washington Apple Health Integrated Managed Care....4 Important contact information...4 How to use this book...4 The plan, our providers, and you...5 You will need two cards to access services...6 Community Health Plan of Washington ID card...7 Services Card...7 Changing health plans...8 Using private health insurance and your Community Health Plan of Washington coverage...8 How to get health care...8 How to choose your primary care provider (PCP)...9 How to get specialty care and referrals...9 Services you can get WITHOUT a referral Payment for health care services You have no copays However you might have to pay if: Getting care in an emergency or when you are away from home Behavioral Health Organization (BHO) Behavioral health organization contacts Getting care after hours Expectations for when a health plan provider will see you You must go to a Community Health Plan of Washington doctor, pharmacy, behavioral health provider or hospital Behavioral health services Health care services for children Benefits covered by Community Health Plan of Washington Additional services from Community Health Plan of Washington Plans may insert any additional benefits or value-added options here. Error! Bookmark not defined. Services covered by Apple Health Fee-For-Service: Services NOT covered by Community Health Plan of Washington or Apple Health Fee-For-Service: 26 If you want to file a complaint or grievance: Important information about appeals and administrative hearings Your rights Your responsibilities Patient Review and Coordination Advance directive Mental health advance directive P age

3 We protect your privacy Please be advised that this handbook does not create any legal rights or entitlements. You should not rely on this handbook as your only source of information about Apple Health (Medicaid). The handbook is intended to just provide a summary of information about your physical and behavioral health benefits. You can get detailed information about the Apple Health programs by looking at the Health Care Authority laws and rules page on the Internet 3 P age

4 Welcome to Community Health Plan of Washington and Washington Apple Health Integrated Managed Care. We want to be sure you get off to a good start as a new enrollee. To get to know you better, we will get in touch with you in the next few weeks. You can ask us any questions you have, or get help making appointments. If you need to speak with us before we contact you, our phone lines are open 8 a.m. to 5 p.m. (PST), Monday through Friday. You will receive both physical and behavioral health benefits (mental health and drug and alcohol treatment services) from Community Health Plan of Washington. Important contact information Community Health Plan of Washington Customer Service Hours 8 a.m. to 5 p.m. (PST), Monday through Friday Customer Service Phone Numbers TTY Website Address Beacon Health Options Crisis line is available 24 hours a day, 7 days a week NCWA number SWWA number Health Care Authority (HCA) Apple Health Customer Service Washington Health Benefit Exchange Monday Friday 7 a.m. to 5 p.m. Monday-Friday 8 a.m. to 6 p.m TRS or TTY TRS or TTY How to use this book This handbook is your guide to physical and behavioral health services. When you have a question, check the list below to see who can help. If you have any questions about Changing or disenrolling from Apple Health Eligibility for health care services How to get Apple Health covered services not included through the plan ProviderOne Services card Contact HCA at: ProviderOne Client Portal is available at: Call toll-free P age

5 Or: Choosing or changing a provider Covered services or medications Making a complaint Appealing a decision that affects your benefits Your medical care Referrals to specialists Your behavioral health services: mental health and drug and alcohol treatment services Changes to your account such as address change, income change, marital status, pregnancy, and births or adoptions Community Health Plan of Washington at (TTY 7-1-1) or go online to Your primary care provider. (If you need help to select a primary care provider, call Community Health Plan of Washington at TTY 7-1-1) or go online to The Nurse Hotline can be reached at (TTY 7-1-1) Washington Health Benefit Exchange at WAFINDER ( ) or go online to The plan, our providers, and you When you join Community Health Plan of Washington, one of our providers will take care of you. Most of the time that person will be your primary care provider (PCP). If you need to have a test, see a specialist, access behavioral health services, or go into the hospital, your PCP may coordinate your care. In some cases, you can go to certain providers without your PCP coordinating it first. This applies only to certain services. See page 10 for details. If you do not speak English, we can help. We want you to know how to use your physical and behavioral health benefits. If you need any information in another language, just call us. We will find a way to talk to you in your own language. We can help you find a provider who can speak your language. To ask for information in another language, please call us at (TTY 7-1-1), Call us if you need information in other formats or help to understand this handbook. If you have a disability, are blind or have limited vision, are deaf or hard of hearing or do not understand this book or other materials, call us. We can help you get the help you need. We can provide you materials in another format, like Braille. We can tell you if a provider s office is wheelchair accessible or has special communications devices or other special equipment. Also, we have services like: TTY line (Our TTY phone number is 7-1-1). Information in large print. Help in making or getting to appointments. Names and addresses of providers who specialize in specific care needs. At Community Health Plan of Washington, our Quality improvement Program has three goals: Better Health, Better Care, and Lower Costs. Better Health focuses on activities to improve the health of our members in all stages of life. Better Care enhances the health services our providers deliver to our 5 P age

6 members. Lower Costs ensure that care is appropriate and valuable resources are used effectively. We achieve these goals by measuring performance and intervening to improve results. If you have questions or want more information about the Quality Improvement Program, please call our Customer Service at (TTY 7-1-1) or us at You will need two cards to access services 6 P age

7 Community Health Plan of Washington ID card Your ID card should arrive within 30 days of your enrollment date. If any information is incorrect on your ID card, call (TTY 7-1-1) right away. Your ID card will have your Community Health Plan of Washington member ID number. Carry your ID card at all times and show it each time you go for care. If you are eligible and need care before the card comes, you can call Member Services at (TTY 7-1-1). Services Card You will also receive an Apple Health Services Card in the mail. About two weeks after you enroll in Washington Apple Health through you will receive a blue Services Card (also called a ProviderOne card) like the one pictured here. Keep this card. Your Services Card is active and shows you are enrolled in Apple Health. ProviderOne The number on the card is your ProviderOne client number (nine-digits ending in WA). You can look online to check that your enrollment has started or switch your health plan through the ProviderOne Client Portal at Health care providers can also use ProviderOne to see whether their patients are enrolled in Apple Health. Each member of your household who is eligible for Apple Health will receive his or her own Services Card. Each person has a different ProviderOne client number that stays with him or her for life. If you had Apple Health coverage in the past (or had Medicaid before it was known as Apple Health), HCA will not mail you a new card. Your old card and client number is still valid, even if there is a gap in coverage. 7 P age

8 If you don t receive the card, the information is incorrect, or you lose your card: Use the ProviderOne client portal at Request a change online at o Select the topic Services Card. Call the HCA Customer Service Center at There is no charge for a new card. It takes seven to 10 days to get the new card in the mail. Your old card will stop working when you ask for a new one. Changing health plans You have the right to request to change your health plan at any time while on Apple Health. Depending on when you request to change plans, your new plan may start as soon as the first of the next month. It s important to make sure you are officially enrolled in the newly requested plan prior to seeing providers in another plan s network. Changing health plans must be done through the Health Care Authority. There are several ways to switch your plan: Go to the Washington Healthplanfinder website. Visit the ProviderOne Client Portal website Request a change online at Select the topic Enroll/Change Health Plans. Call the HCA Customer Service Center at NOTE: If you are enrolled in the Patient Review and Coordination program, you must stay with the same health plan for one year. If you move, please contact us. Using private health insurance and your Community Health Plan of Washington coverage We may pay co-pays, deductibles and services your private health insurance does not cover. You can avoid out-of-pocket costs if you make sure your health care providers are either a member of Community Health Plan of Washington s provider network or willing to bill Community Health Plan of Washington for any co-pays, deductibles, or balances that remain after your primary coverage pays your health care bill. When you go to your doctor or other medical provider(s), show all of your cards including the private health insurance card, your Apple Health services card and Community Health Plan of Washington card. If your private health insurance ends or changes or you have any other questions regarding your private health insurance, contact Community Health Plan of Washington. How to get health care Services you can access include regular check-ups, immunizations (shots), and other treatments. Your Primary Care Provider (PCP) will take care of most of your health care needs, but you must have an appointment to see your PCP. As soon as you choose a PCP, call to make an appointment. Even if you have no immediate health care needs, you need to establish yourself as a patient with your chosen PCP. Being an established patient will help you get care faster once you do need it. 8 P age

9 If you can, it s important to prepare for your first appointment. Your PCP will need to know as much about your medical and behavioral health history as you can tell him or her. Write down your health history, and make a list of any medical concerns or conditions you have now, the prescriptions you have, and the questions you want to ask your PCP. If you cannot keep an appointment, call to let your PCP know. How to choose your primary care provider (PCP) You may have already picked your PCP, but if you have not, you should do so right away. Each family member can have a different PCP, or you can choose one PCP to take care of all family members who have Apple Health Managed Care coverage. If you do not choose a PCP, Community Health Plan of Washington will choose one for you. If you want to change your PCP, Community Health Plan of Washington can help you choose a new one. In addition, one of our behavioral health providers will take care of your mental health and drug and alcohol treatment needs. If you need counseling, testing or need to see a behavioral health specialist, Community Health Plan of Washington will coordinate your behavioral health care needs. How to get specialty care and referrals If you need care that your PCP cannot give, he or she will refer you to a medical or behavioral health specialist who can. Talk with your PCP to be sure you know how referrals work. If you think a specialist does not meet your needs, talk to your PCP. Your PCP can help you if you need to see a different specialist. There are some treatments and services that your PCP must ask Community Health Plan of Washington to approve before you can get them. That is called a pre-approval or pre-authorization. Your PCP will be able to tell you what services require this approval, or you can call us to ask. If we do not have a medical or behavioral health specialist in the Community Health Plan of Washington network who can give you the care you need, we will get you the care you need from a specialist outside the Community Health Plan of Washington network using the pre-approval process. In order to start the request for specialty care, please schedule an appointment with your PCP. Community Health Plan of Washington processes prior authorization requests according to the following timeline: Prior authorization requests for routine care are processed within 5 business days of receiving the request from the provider. Prior authorization requests for urgent care are processed within 24 hours of receiving the request from the provider. Both routine and urgent request may be delayed if your PCP does not provide the necessary information. Prior authorization decision letters are faxed directly to the provider that made the request and are mailed to the member. Call Customer Service at (TTY 7-1-1) for more information about the prior authorization process. Prior authorization decision letters are faxed directly to the provider that made the request and are mailed to the member. 9 P age

10 Call Customer Service at (TTY 7-1-1) for more information about the prior authorization process. Appeal Process If Community Health Plan of Washington denies the prior authorization request you can ask for an appeal. Below are the steps in the appeal process: STEP 1: Community Health Plan of Washington Appeal STEP 2: Independent Review STEP 3: State Hearing STEP 4: Health Care Authority (HCA) Board of Appeals Review Judge Continuation of services during the Appeal Process If you want to keep getting previously approved services while we review your appeal, you must tell us within 10 calendar days of the date on your denial letter. If the final decision in the appeal process agrees with our action, you may need to pay for services you received during the appeal process. STEP 1-Community Health Plan of Washington Appeal: We can help you file your appeal. If you need help filing an appeal, call Customer Service at (TTY 7-1-1). Within 72 hours, we will let you know in writing that we got your appeal. You may choose someone, including an attorney or provider, to represent you and act on your behalf. You must sign a consent form allowing this person to represent you. Community Health Plan of Washington does not cover any fees or payments to your representatives. This is your responsibility. You have 60 calendar days after the date of Community Health Plan of Washington s denial letter to ask for an appeal. You or your representative may submit information about your case in person or in writing. If you want copies of the guidelines we used to make our decision, we can give them to you. Before or during the appeal, you or your representative may look at your file, medical records, or other documents considered in the appeal. We will send you our decision in writing within 14 calendar days, unless we tell you we need more time. Our review will not take longer than 28 calendar days, unless you give us written consent. STEP 2-Independent Review: If you do not agree with the decision from the State Hearing, you can ask for an independent review within 21 calendar days of the Hearing decision or you may go directly to Step 4. Call Community Health Plan of Washington at (TTY 7-1-1) for help. Any extra information you want us to look at must be given to us within five days of asking for the independent review. If you ask for this review, your case will 10 P age

11 be sent to an Independent Review Organization (IRO) within three working days. You do not have to pay for this review. Community Health Plan of Washington will let you know the outcome within 15 calendar days. STEP 3-State Hearing: If you disagree with Community Health Plan of Washington s appeal decision, you can ask for a State Hearing. You must complete the Plan s appeal process before you can have a hearing. You must ask for a hearing within 120 calendar days of the date on the appeal decision letter. When you ask for a hearing, you need to say what service was denied, when it was denied, and the reason it was denied. Your provider may not ask for a hearing on your behalf. To ask for a State Hearing: Contact the Office of Administrative Hearing directly at , or write to them at P.O. Box 42489, Olympia, Washington, You may consult with a lawyer or have another person represent you at the hearing. If you need help finding a lawyer, check with the nearest Legal Services Office. You can also call the NW Justice CLEAR line at or visit their website at STEP 4-Health Care Authority (HCA) Review Judge Decision: If you do not agree with the IRO decision, you can ask for a final review of your case by the HCA Review Judge. You must ask for this within 21 calendar days after the IRO decision is mailed. The decision of the HCA Review Judge is final. To ask for this review contact: HCA Board of Appeals Phone: (360) P.O. Box Toll-free: (844) Olympia, WA Fax: (360) Expedited (faster) Decisions If you or your provider thinks waiting for a decision would put your health at risk, you may ask for an expedited (faster) appeal, state hearing, or IRO. Information that you think we need to look at must be given to us quickly. We will review your request and make a decision within 3 calendar days. If we decide your health is not at risk, we will let you know and we will follow the regular timeframe to make our decision. 11 P age

12 Second Opinion: You can get a second opinion about your health care or condition. Call (TTY 7-1-1) to find out how to get a second opinion. Washington State Health Insurance Consumer Assistance Program The Consumer Protection Division in the Washington State Office of the Insurance Commissioner can help you with questions and complaints. For help, contact: Consumer Protection Division P.O. Box Olympia, WA Phone: Insurance Consumer Hotline If your PCP or Community Health Plan of Washingont refers you to a provider outside our network and you receive appropriate approval, you are not responsible for any of the costs. Community Health Plan of Washington will pay for these services. Certain benefits are available to you that are not covered through Community Health Plan of Washington. Other community-based services and programs provide these benefits. These are called fee-for-service benefits. Fee-for-service benefits include dental care, vision hardware for children, and long-term care. These are the benefits that you will need your ProviderOne card to access. Your PCP or Community Health Plan of Washington will help you find these benefits and coordinate your care. See page 24 for more details on covered benefits. Services you can get WITHOUT a referral You do not need a referral from your PCP to see another one of our in-network providers if you: Are pregnant. Want to see a midwife. Need women s health services. Need family planning services. Need to have a breast or pelvic exam. Need HIV or AIDS testing. Need immunizations. Need sexually transmitted disease treatment and follow-up care. Need tuberculosis screening and follow-up care. Payment for health care services You have no copays. However you might have to pay if: 12 P age

13 You get a service that is not covered, such as chiropractic care or cosmetic surgery. You get a service that is not medically necessary. You don t know the name of your health plan, and a service provider you see does not know who to bill. This is why you must take your Services Card and health plan card with you every time you need services. You get care from a service provider who is not in your health plan s network, unless it s an emergency or has been pre-approved by your health plan. You don t follow your health plan s rules for getting care from a specialist. You have other insurance that pays first but you didn t share the information with the provider. If you get a bill, please call us at (TTY 7-1-1) Getting care in an emergency or when you are away from home Medical Emergencies: You are always covered for emergent care anywhere in the United States. Some examples of an emergency are: A heart attack or severe chest pain. Bleeding that won t stop or a bad burn. Broken bones. Trouble breathing, convulsions, or loss of consciousness. When you feel you might hurt yourself or others. If you are pregnant and have signs like pain, bleeding, fever, or vomiting. If you think you have an emergency, call 911 or go to the nearest hospital location where emergency providers can help you. Emergencies are covered anywhere in the United States. As soon as possible, call your PCP, behavioral health provider, or Community Health Plan of Washington to arrange for follow-up care after the emergency is over. Medical care away from home: If you need medical care that is not an emergency or urgent, or need to get prescriptions filled while you are away from home, call your PCP or us for advice. We will help you get the care you need. Routine or preventive care, like a scheduled provider visit or well-exam, is not covered when you are outside of your service area (county). Behavioral Health Crisis: If you or someone you know is experiencing a crisis: Threatens to or talks about hurting or Increases alcohol or drug use killing themselves Feels hopeless Withdraws from friends and family Feels rage or uncontrolled anger Feels anxious, agitated, or unable to sleep Feels trapped, like there is no way out Encounters dramatic mood changes Engages in reckless behaviors Sees no reason for living Call: Beacon Health Options Phone Number: Beacon Health Options (Beacon) operates a crisis phone line 24 hours a day, 7 days a week to provide phone assistance for crisis calls from children and adults. Professional counselors will answer your call. 13 P age

14 North Central Washington (Chelan, Douglas, and Grant County) number Southwest Washington (Clark and Skamania County) number Beacon can dispatch mobile crisis teams, conduct disaster outreach, and perform suicide intervention. Designated Mental Health Professionals (DMHPs) may also initiate 72 hour involuntary holds on those persons evaluated to be of high risk to harm themselves or others, or who cannot provide for their own safety and welfare as a result of being gravely disabled. Behavioral health care away from home: If you need behavioral health care that is not an emergency or urgent, or need to get prescriptions filled while you are away from home, call Community Health Plan of Washington for advice. We will help you get the care you need. Routine or follow-up behavioral health care is not covered when you are outside of your service area (county). Behavioral Health Organization (BHO) In April 2016, Behavioral Health Organizations replaced the Regional Support Networks (RSN). BHOs integrate mental health and drug and alcohol services in each region, transforming two service delivery systems into one region-wide system. The Department of Social and Health Services (DSHS) manages the contracts for mental health and substance use disorder (SUD) services for 9 of the Regional Service Areas (RSA) in the state, excluding the Southwest Washington (SW WA) and North Central (NC WA) regions, where these services have been transferred to IMC and BHSO plans. 14 P age

15 Behavioral health organization contacts Organization Counties served Phone number Website Greater Columbia BHO Asotin, Benton, Columbia, Franklin, Garfield, Kittitas, Klickitat, Walla Walla, Whitman, Yakima or Great Rivers BHO Cowlitz, Grays Harbor, Lewis, Pacific, Wahkiakum King County BHO King North Sound BHO Island, San Juan, Skagit, Snohomish, Whatcom or community-humanservices/mental-healthsubstance-abuse.aspx OptumHealth Pierce County BHO Pierce or Salish BHO Clallam, Jefferson, Kitsap or sbhomain.htm Spokane County Regional BHO Adams, Ferry, Lincoln, Okanogan, Pend Oreille, Spokane, Stevens or mentalhealth Thurston- Mason BHO Mason, Thurston or Washington Recovery Help Line ( Getting care after hours Getting care after hours: The toll-free phone number to call for medical advice from a nurse 24 hours a day, seven days a week, is (TTY 7-1-1). Call your PCP s office or the Nurse Advice Line for advice on how to reach a provider after hours. Urgent care: Urgent care is when you have a physical or behavioral health problem that needs care right away, but your life is not in danger. This could be a child with an earache who wakes up in the middle of the night, a sprained ankle, or a reaction or side effect to a medication you are taking. Urgent care is covered anywhere in the United States. If you think you need to be seen quickly, 15 P age

16 contact us. You can also call your PCP s office or our 24-hour Nurse Advice Line, 7 days a week, at (TTY 7-1-1). Expectations for when a health plan provider will see you How soon you get in to see your provider depends on the care you need. You should expect to see one of our providers within the following timelines: Emergency care: Available 24 hours a day, seven days a week. Urgent care: Office visits with your PCP or other provider within 24 hours. Routine care: Office visits with your PCP or other provider within ten days. Routine care is planned and includes regular provider visits for medical problems that are not urgent or an emergency. Preventive care: Office visits with your PCP or other provider within 30 days. Examples of preventive care are annual physicals (also called checkups), well-child care visits, annual women s health care, and immunizations (shots). You must go to a Community Health Plan of Washington doctor, pharmacy, behavioral health provider or hospital You must use doctors and other medical and behavioral health providers who work with Community Health Plan of Washington. We also have certain hospitals and pharmacies you must use. Call our member service line at (TTY 7-1-1) or visit our website to get a provider directory or get more information about our providers, hospitals, and pharmacies. The directory of providers, pharmacies, and hospitals includes: The service provider s name, location, and phone number. The specialty and medical degree. The languages spoken by those providers. Any limits on the kind of patients (adults, children, etc.) the provider sees. Identifying which PCPs are accepting new patients. NOTE: If you are enrolled in the Patient Review and Coordination program, you must stay with the same health plan for one year. Call us if you move. Behavioral health services If you need mental health or drug and alcohol treatment services, your PCP and Community Health Plan of Washington can help coordinate your behavioral health care. We cover assessments for mental health services you might need such as, counseling, evaluations and medications for addressing mental health symptoms. We also cover drug and alcohol assessments, treatments such as counseling, and medication. You will have a choice of treatment providers within our network of behavioral health providers. If you want to use your mental health or drug and alcohol treatment benefits, talk with your PCP or call our member service line at (TTY 7-1-1). 16 P age

17 For more information about mental health benefits, please visit: Prescriptions We use a list of approved drugs. This is called a formulary or a preferred drug list. Your prescribing provider should prescribe medications to you from this list. You can call us and ask for: A copy of the formulary or preferred drug list. Information about the group of providers and pharmacists who created the formulary. A copy of the policy on how we decide what drugs are covered and how to ask for authorization of a drug that is not on the formulary or preferred drug list. To make sure your drugs will be paid for, you must get your medications at a pharmacy that we contract with. Call us and we will help you find a pharmacy near you. Medical equipment and medical supplies You can get medical equipment and supplies when they are medically necessary and prescribed by your health care provider. We must pre-approve most equipment and supplies. For more information, call us. Special health care needs or long-term illness If you have special health care needs, you may be eligible for additional benefits through our disease management program, Health Home program, or case management. You may also get direct access to specialists. In some cases, you may be able to use your specialist as your PCP. Call us for more information. Long-term care services Aging and Long-Term Support Administration (ALTSA) Home and Community Services (HCS) If you need long-term care services, including an in-home caregiver, these services are provided through ALTSA, not by your health plan. To get more information about long-term care services, call your local Home and Community Services (HCS) office. Long-Term Care Services and Supports ALTSA Home and Community Services must approve these services. Call your local HCS office for more information: REGION 1 Adams, Asotin, Benton, Chelan, Columbia, Douglas, Ferry, Franklin, Garfield, Grant, Kittitas, Klickitat, Lincoln, Okanogan, Pend Oreille, Spokane, Stevens, Walla Walla, Whitman, Yakima or REGION 2N Island, San Juan, Skagit, Snohomish, and Whatcom ; Nursing Facility Intake 17 P age

18 REGION 2S King: REGION 3 Clallam, Clark, Cowlitz, Grays Harbor, Jefferson, Kitsap, Lewis, Mason, Pacific, Pierce, Thurston, Skamania, Wahkiakum Services for People with Developmental Disabilities The Developmental Disabilities Administration (DDA) must approve these services. If you need information or services please contact your DDA local office: Region 1: Chelan, Douglas, Ferry, Grant, Lincoln, Okanogan, Pend Oreille, Spokane, Stevens or R1ServiceRequestA@dshs.wa.gov Region 1: Adams, Asotin, Benton, Columbia, Franklin, Garfield, Grant, Kittitas, Klickitat, Walla Walla, Whitman, Yakima or R1ServiceRequestB@dshs.wa.gov Region 2: Island, San Juan, Skagit, Snohomish, Whatcom or R2ServiceRequestA@dshs.wa.gov Region 2: King or R2ServiceRequestB@dshs.wa.gov Region 3: Kitsap, Pierce or R3ServiceRequestA@dshs.wa.gov Region 3: Clallam, Clark, Cowlitz, Grays Harbor, Jefferson, Lewis, Mason, Pacific, Skamania, Thurston, Wahkiakum or R3ServiceRequestB@dshs.wa.gov Health care services for children Children and youth under age 21 have a health care benefit called Early and Periodic Screening, Diagnosis, and Treatment (EPSDT). EPSDT includes a full range of screening, diagnostic, and treatment services. Screenings can help identify potential physical, behavioral health or developmental health care needs which may require additional diagnostics and/or treatment. This benefit includes any diagnostic testing and medically necessary treatment needed to correct or improve a physical and behavioral health condition, as well as additional services needed to support a child who has developmental delay. These services can be aimed at keeping conditions from getting worse or slowing the pace of the effects of a child s health care problem. EPSDT encourages early and continuing access to health care for children and youth. An EPSDT screening is sometimes referred to as a well-child or well-adolescent checkup. A well-child checkup or EPSDT screening should include all of the following: Complete health and developmental history. A full physical examination, including lead screening as appropriate. Health education and counseling based on age and health history. 18 P age

19 Vision testing. Hearing testing. Laboratory tests. Blood lead screening. Eating or sleeping problems. Oral health screening. Immunizations (shots). Behavioral health and substance use disorder screening. When a health care condition is diagnosed by a child s medical provider, the child s provider(s) will: Treat the child if it is within the provider s scope of practice; or Refer the child to an appropriate provider for treatment, which may include additional testing or specialty evaluations, such as: developmental assessment, comprehensive mental health, substance use disorder evaluation, or nutritional counseling. Treating providers communicate the results of their services to the referring EPSDT screening provider(s). Some covered health care services may require pre-approval. All non-covered services require preapproval either from us or from the State, if the service is offered by the State as fee-for-service care. Benefits covered by Community Health Plan of Washington Some of the benefits we cover are listed below. Check with your provider or contact us if a service you need is not listed. For some services, you may need a referral from your PCP and/or preapproval from us. Some services are limited by number of visits or supply/equipment items. If you need additional services, your provider may request a Limitation Extension (LE). We also review Exception to Rule (ETR) requests for non-covered services. Remember to call us before you get medical services or ask your PCP to help you. Medical Benefit Comments Antigen (allergy serum) Applied Behavioral Analysis (ABA) Audiology Tests Autism Screening Bariatric Surgery Biofeedback Therapy Birth Control Allergy shots. Assist children (under age 21) with autism spectrum disorders and other developmental disabilities in improving the communication, social and behavioral skills. Hearing tests. Available for all children 18 months and 24 months. Pre-approval required for bariatric surgery. Only available in HCA-approved Centers of Excellence. Limited to plan requirements. See Family Planning Services. 19 P age

20 Blood Products Breast Pumps Chemotherapy Chiropractic Care Cochlear Implant Devices and Bone Anchored Hearing Aid (BAHA) Devices Contraceptives Cosmetic Surgery Developmental Screening Diabetic Supplies Dialysis Drug and Alcohol Treatment Services also referred to as Substance Use Disorder Services Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Emergency Services Includes blood, blood components, human blood products, and their administration. Some types may require pre-approval. Some services may require pre-approval. Benefit is for children under age 21 with referral from PCP after being seen for an EPSDT (well-child care) screening. Benefit is for children under age 21. See Family Planning Services. Only when the surgery and related services and supplies are provided to correct physiological defects from birth, illness, physical trauma, or for mastectomy reconstruction for post-cancer treatment. One screening available for all children at 9 months, 18 months, and between 24 and 30 months. Limited supplies available without pre-approval, additional supplies available with pre-approval. Pre-approval may be required. Drug and alcohol treatment services may include: Assessment Brief intervention and referral to treatment Withdrawal management (detoxification) Outpatient treatment Intensive outpatient treatment Inpatient residential treatment Opiate substitution treatment services Case management EPSDT includes a full range of prevention, diagnostic, and treatment services to make sure children under age 21 get all the care they need to identify and treat health problems at an early stage. Any health treatment that is medically necessary, even if the treatment is not listed as a covered service. See Health care services for children section. Available 24 hours per day, 7 days per week anywhere in the United States. Enteral Nutrition (products and equipment) Evaluation and treatment/community Hospitalization Parenteral nutritional supplements and supplies for all enrollees. Enteral nutrition products and supplies for all ages for tube-fed enrollees. Oral enteral nutrition products for enrollees under age 21. Medically necessary inpatient behavioral health crisis care. 20 P age

21 Eye Exams You must use our provider network. Call us for benefit information. For children under age 21, eyeglasses, contact lenses, and hardware fittings are covered separately under the fee-for-service program using your ProviderOne Services Card. The Eyewear Supplier list at Family Planning Services Habilitative Services Health Education and Counseling Hearing Exams and Hearing Aids HIV/AIDS Screening Home Health Care Hospital, Inpatient and Outpatient Services Hospital Inpatient Rehabilitation (physical medicine) Immunizations/ Vaccinations Lab and X-ray Services Mammograms Maternity and Prenatal Care Medical Equipment Medical Supplies Medically Intensive Children s Program Medication Assisted Therapy (MAT) You can use our network of providers, or go to your local health department or family planning clinic. Call us to see if you are eligible. Examples: Health education for conditions such as diabetes and heart disease. Covered for enrollees under age 21. You have a choice of going to a family planning clinic, the local health department, or your PCP for the screening. A health home provides additional help coordinating your care. Contact Community Health Plan of Washington to see if you are eligible for the health home program Must be pre-approved by Community Health Plan of Washington. Must be pre-approved by Community Health Plan of Washington for all non-emergency care. Must be approved by Community Health Plan of Washington. Our members are eligible for immunizations from their primary care provider, pharmacy or their local health department. Check with your provider or contact member services for more information on the scheduling of your immunization series. Some services may require pre-approval. See Women s Health Care. See Women s Health Care. Most equipment must have pre-approval from Community Health Plan of Washington. Call Community Health Plan of Washington at (TTY 7-1-1) for specific details. Most supplies must have pre-approval from Community Health Plan of Washington. Call us at (TTY 7-1-1) for specific details Covered for children under age 18 only. Medications associated with drug and alcohol treatment services are covered by Community Health Plan of Washington. 21 P age

22 Mental Health Treatment Mental health services may include: Intake Evaluation Individual treatment services Medication management Medication monitoring Group treatment services Peer support Brief intervention and treatment Family treatment High intensity treatment Therapeutic Psychoeducation Day support Stabilization services Rehabilitation case management Mental health services provided in a residential setting Special population evaluation Psychological assessment Crisis Services Freestanding Evaluation and Treatment Nutritional Therapy Covered for enrollees under age 21 when medically necessary and referred by the provider after an EPSDT screening. Organ Transplants Call Community Health Plan of Washington at (TTY 7-1-1) for specific details. Osteopathic Manipulative Therapy Outpatient Rehabilitation (Occupational, Physical, and Speech Therapies) Limited benefit: Ten osteopathic manipulations per calendar year are covered by the health plan, only when performed by a plan doctor of osteopathy (D.O.). Limited benefit. Call Community Health Plan of Washington at (TTY 7-1-1) for specific details. Limit applies whether performed in any of the following: Outpatient clinic Outpatient hospital The home by a Medicare-certified home health agency Apple Health may cover services through the fee-forservice program for children when provided in an approved neurodevelopmental center. See: Oxygen and Respiratory Services Pharmacy Services Podiatry Some services may require pre-approval. Must use participating pharmacies. We have our own drug formulary (list). Contact Community Health Plan of Washington at (TTY 7-1-1) for a list of pharmacies. Limited benefit: Call Community Health Plan of Washington at 1/ (TTY 7-1-1) for specific information. 22 P age

23 Radiology and Medical Imaging Services Skilled Nursing Facility (SNF) Smoking Cessation Some services may require pre-approval. Covered for short-term (less than 30 days) services. Additional services may be available. Contact Community Health Plan of Washington at (TTY 7-1-1). Covered for all enrollees with or without a PCP referral or preapproval. Call us. Transgender Health Services Tuberculosis (TB) Screening and Follow-up Treatment Women s Health Care Hormone and mental health therapy for all ages, and puberty blocking treatment for adolescents. You have a choice of going to your PCP or the local health department. Routine and preventive health care services, such as maternity care, reproductive health, general examination, contraceptive services, testing and treatment for sexually transmitted diseases, and breast-feeding. Additional services from Community Health Plan of Washington We encourage our members to get regular and preventive care. Our wellness programs make sure members know how to access free services so they can stay well and manage their health. We conduct outreach over the phone and through the mail to share important information about preventive screenings, tests and other health care services that can help every member feel their best. Not feeling well? Call our free Nurse Advice Line 24 hours a day, 7 days a week. Toll free: , TTY Relay: Care and tips for a healthy pregnancy. Pregnant mothers can find support and resources throughout their pregnancy with our New Arrivals Program. These free programs help pregnant members maintain a healthy pregnancy. Learn more at Receive extended pregnancy care through First Steps (Maternity Support Services).This program, provided through Washington Health Care Authority, supplies access to prenatal, medical, and dental care during prenatal, delivery, and after delivery. For more information and details of full benefits visit Receive rewards for keeping yourself and your kids healthy with Children First. Pregnant Mothers and Kids receive rewards for staying up-to-date on immunizations and well child and prenatal checkups. Visit for application forms and more information. You can quit. We can help. Achieve your goal and quit smoking with the help of a coach, aids, and web support with the Quit for Life program. Learn more at Check out our member center. You can log onto and print your ID card, download your member handbook, change your PCP, update your address, and more. Health information at your fingertips with Health and Wellness A to Z. Take an active role in your care. Get information for staying healthy, learn about health conditions, access information on when to get care, and more. You can find this information at 23 P age

24 under the For Members menu. Then select Health and Wellness option, and navigate to the Health and Wellness A to Z section. Get Community Health Plan of Washington information at your fingertips. The My CHPW app allows you to search the provider directory, and access the 24/7 Nurse Advice Line on-thego. Learn how the Health Homes program can make managing your care easier. Eligible members can receive assistance with transitional care, care coordination, health education, care management, and much more. You can get more information at Manage your mental health. The Mental Health Integration Program gives you easier access to mental health providers in your primary care clinic, for no additional fee. Care coordinators can consult with specialists and make mental health referral for you, if needed. Speak to a Community Health Plan of Washington representative to learn more. Youth Behavior Health Services Support. CHPW has home, school and community-based services to help children with behavioral needs. When a child s behavior disrupts family life, school or peers, they can benefit from behavioral health support. The support includes: intensive care coordination, intensive mental health services provided in the home and ongoing help to stabilize the youth and family to prevent more restrictive or institutional placement. Services covered by Apple Health Fee-For-Service: We and your PCP can help coordinate your care with other community-based services and programs. To access these services you need to use your ProviderOne card. If you have a question about a benefit or service not listed here, call us at (TTY 7-1-1). 24 P age

25 Service Ambulance Services (Air and Ground) Comments All ambulance transportation services provided to Washington Apple Health clients, including those enrolled in a managed care organization (MCO), is covered by the Health Care Authority. For emergencies or when transporting between facilities, such as, from the hospital to a rehabilitation center. Non-emergency ambulance transportation is covered for clients who are dependent and/or require mechanical transfers, a stretcher to be moved when needed for medical appointments for covered services. Examples include: a person who is ventilator dependent, quadriplegic, etc. Dental Services Early Support for Infants and Toddlers (ESIT) from Birth to Age 3 Eyeglasses and Fitting Services Long-Term Care Services and Services (LTSS) for People with Developmental Disabilities You need to see a dental provider who has agreed to be an Apple Health fee-for-service provider. A list of dental providers and more information on dental benefits is available at or you can call HCA directly for more information at Please call for information. Covered for clients under age 21. You will need to see an Apple Health fee-for-service provider. The Aging and Long Term Support Administration (ALTSA) must approve these services. Call (Aging and Disability Services). Maternity Support Services Part of the First Steps Program. Call Non-Emergency Medical Transportation (NEMT) for Medical and Behavioral Health Appointments Pregnancy Terminations, Voluntary Apple Health pays for transportation services to and from necessary non-emergency physical and behavioral health care appointments. If you have a current ProviderOne Services Card, you may be eligible for transportation. Call the transportation provider (broker) in your area to learn about services and limitations. Your regional broker will arrange the most appropriate, least costly transportation for you. A list of brokers can be found at Click on Transportation Broker Directory. Includes termination and follow-up care for any complications. 25 P age

26 Sterilizations, under age 21 Transgender Health Services Must complete sterilization form 30 days prior or meet waiver requirements. Reversals not covered. Surgical procedures and postoperative complications. Services NOT covered by Community Health Plan of Washington or Apple Health Fee-For-Service: If you get any of these services, you may have to pay the bill. If you have any questions, call Community Health Plan of Washington at (TTY 7-1-1). Service Alternative Medicines Comments Acupuncture, Christian Science practice, faith healing, herbal therapy, homeopathy, massage, or massage therapy. Chiropractic Care for Adults Cosmetic or Plastic Surgery Diagnosis and Treatment of Infertility, Impotence, and Sexual Dysfunction Marriage Counseling and Sex Therapy Nonmedical Equipment Personal Comfort Items Physical Exams Needed for Employment, Insurance, or Licensing Including tattoo removal, face lifts, ear or body piercing, or hair transplants. Such as ramps or other home modifications. Services Not Allowed by Federal or State Law Weight Reduction and Control Services Weight-loss drugs, products, gym memberships, or equipment for the purpose of weight reduction. If you want to file a complaint or grievance: You or your authorized representative have the right to file a complaint. This is called a grievance. We will help you file and resolve your grievance. Grievances or complaints can be about: A problem with your doctor s office or behavioral health provider. Getting a bill from your provider. Being sent to collections due to an unpaid medical bill. The quality of your care or how you were treated. Any other problems you may have getting health care. 26 P age