Member handbook. A Provider-Led Arkansas Shared Savings Entity. Member Services: (TTY 711) AR-MHB

Transcription

1 Member handbook A Provider-Led Arkansas Shared Savings Entity AR-MHB Member Services: (TTY 711)

2 Member Handbook Summit Community Care A Provider-Led Arkansas Shared Savings Entity Member Services: (TTY 711) AR-MHB

3 Multi-language Interpreter Services Do you need help with your health care, talking with us or reading what we send you? We provide our materials in other languages and formats at no cost to you. Call us toll free at (TTY 711). English Necesita ayuda con su cuidado de la salud, para hablar con nosotros o leer lo que le enviamos? Ofrecemos nuestros materiales en otros idiomas y formatos sin costo alguno. Llámenos a la línea gratuita (TTY 711). Spanish Quý vị có cần trợ giúp về chăm sóc sức khỏe, nói chuyện với chúng tôi, hoặc đọc nội dung chúng tôi gửi cho quý vị không? Chúng tôi có cung cấp tài liệu ở các ngôn ngữ và định dạng khác, không tính phí với quý vị. Hãy gọi cho chúng tôi theo số miễn phí (TTY 711). Vietnamese Kwoj aikuij ke jiban ikijen ejmour eo am, konono nan kim, ak riiti ta ko kimij jilikin waj nan kwe? Kimij lelok pepa ko ilo elon kain kajin wawin jeje ko ilo ejelok wonen. Jouij m kirtok kim ilo ejelok wonen ilo (TTY 711). Marshallese 您在醫療保健方面 與我們交流或閱讀我們寄送的材料時是否需要幫助? 我們可為您免費提供其 他語言和格式的材料 請撥打我們的免費電話 ( 聽障專線 711) Chinese ທ ານຕ ອງການຄວາມຊ ວຍເຫ ອກ ບການເບ ງແຍງສ ຂະພາບຂອງທ ານ, ຕ ອງການລ ມກ ບພວກເຮ າ ຫລ ານເອກະສານທ ພວກເຮ າສ ງໃຫ ທ ານບ? ພວກເຮ າສະໜອງເອກະສານຂອງພວກເຮ າເປ ນາສາແລະຮ ບແບບອ ນໂດຍທ ານບ ຕ ອງເສ ຍຄ າໃດໆ. ກະລ ນາໂທຟຣ ຫາພວກເຮ າຕາມເບ (TTY 711). Laotian Kailangan mo ba ng tulong sa pangangalagang pangkalusugan, sa pakikipag-usap sa amin, o pagbabasa ng mga ipinapadala namin sa iyo? Nagbibigay kami ng mga materyales sa iba t-ibang mga wika at mga format nang wala kang gagastusin. Tawagan kami ng libre sa telepono bilang (TTY 711). Tagalog AR-MEM

4 هل تحتاج إلى مساعدة بخصوص رعايتك الصحية أو بخصوص التحدث معنا أو قراءة ما نرسله لك فإننا نوفر المواد بلغات وتنسيقات أخرى مجان ا. اتصل بنا على الهاتف المجاني )الهاتف النصي 711(. Arabic Brauchen Sie etwas Hilfestellung mit Ihrer Gesundheitsfürsorge, wenn Sie mit uns reden oder lesen, was wir Ihnen senden? Wir stellen unsere Materialien kostenfrei in anderen Sprachen und Formaten bereit. Sie erreichen uns gebührenfrei unter (TTY 711). German Avez-vous besoin d aide avec vos soins de santé? Souhaitez-vous nous parler ou lire nos communications? Nous pouvons vous fournir gratuitement nos matériels dans d autres langues et en d autres formats. Appelez-nous gratuitement au (TTY 711). French Koj puas xav tau kev pab hais txog kev saib xyuas mob nkeeg rau koj, tham nrog peb lossis pab nyeem daim ntawv peb xa tuaj rau koj? Peb pab txhais cov ntaub ntawv no ua lwm hom ntawv thiab luam tawm ua lwm cov ntawv pub dawb rau koj. Hu rau peb ntawm tus xov tooj hu dawb (TTY 711). Hmong 의료서비스를이용할때, 저희와연락하실때, 또는발송자료를읽고이해하시는데도움이필요하십니까? 저희자료를다른언어및다른형식으로별도의비용없이받으실수있습니다. 수신자부담전화 (TTY 711) 번으로연락해주십시오. Korean Necessita de ajuda com os seus cuidados de saúde, para falar connosco, ou para ler a documentação que lhe enviamos? Fornecemos os nossos materiais noutros idiomas e formatos, sem qualquer custo para si. Ligue-nos gratuitamente para (TTY 711). Portuguese お客様のヘルスケアについて またお電話にてお問い合わせの際やお手元に届く資料に関し サポートが必要ですか? 資料は他言語にて また読みやすい文字の書式を無料にて提供しております 詳しくはフリーダイヤル (TTY 711) までお問い合わせください Japanese क य आपक हम र स व स थ य द खर ख, हमस ब त करन य हमन आपक ज भ ज ह उस पढ न म सह यत क जर रत ह? हम अन य भ ष ओ एव प र र प म आपक ल ए लबल क म फ त अपन स मल य क प रद न करत ह ट फ र न बर (TTY 711) पर हम फ न कर. Hindi શ તમન તમ ર સ વ સ ય સ ભ ળ મ ટ મદદન જર ર છ? અમ ર સ થ વ ત કર અથવ વ ચ જ અમ તમન મ કલ એ છ એ. અમ અમ ર સ મગ ર અન ય ભ ષ ઓ અન ફ મ ટસમ ક ઈ ખચ વગર તમન પહ ચ ડ એ છ એ. અમન ટ લ ફ ર ક લ કર (TTY 711). Gujarati

5 Summit Community Care follows Federal civil rights laws. We don t discriminate against people because of their: Race Color National origin Age That means we won t exclude you or treat you differently because of these things. Disability Sex or gender identity Communicating with you is important For people with disabilities or who speak a language other than English, we offer these services at no cost to you: Qualified sign language interpreters Written materials in large print, audio, electronic, and other formats Help from qualified interpreters in the language you speak Written materials in the language you speak To get these services, call Member Services at (TTY 711). Your rights Do you feel you didn t get these services or we discriminated against you for reasons listed above? If so, you can file a grievance (complaint). File by mail, , fax, or phone: Summit Community Care Member Grievances P.O. Box Virginia Beach, VA Phone: (TTY 711) Fax: Help@summitcommunitycare.com Need help filing? Call our Civil Rights Coordinator at the number above. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights: On the Web: By mail: U.S. Department of Health and Human Services 200 Independence Ave. SW Room 509F, HHH Building Washington, DC By phone: (TTY/TDD ) For a complaint form, visit AR-MEM

6 Contents Welcome to Summit Community Care!... 1 What s in this handbook... 1 What is care coordination?... 1 Your plan of care... 2 If you get CES waiver services... 2 Your rights... 3 What is a PCP?... 3 Choosing and changing your PCP... 4 Grievances... 5 Appeals... 5 What is an advance directive?... 6 Other information... 7 Your resources... 8 Notice of Privacy Practices... 9

7 Welcome to Summit Community Care! At Summit Community Care, we know living a healthy life isn t just about getting care when you re sick. It s about staying independent. Meeting your goals. Having a healthy mind and body. Being part of your community. Summit Community Care is a Provider-Led Arkansas Shared Savings Entity (PASSE). We work with the Arkansas Medicaid program to help you get services and supports you need. From reminding you to get flu shots to helping you find a place to live, we do what we can to help you live healthy. If you re enrolled in Medicaid, you probably will be served by the same provider agency that you know now. If you re new to the program, you can rest assured we understand your needs and take seriously the trust you have placed in us. What s in this handbook This member handbook tells you about the benefits and services you get as a Summit Community Care member. If you have questions about anything in this handbook, call your care coordinator. Member Services is also available 24/7 at (TTY 711). If we update the information in this handbook, we ll send you a letter. The latest handbook will always be on our website at What is care coordination? Our main job is to help you keep track of your care. This is called care coordination. Your Summit Community Care care coordinator is someone with training and experience supporting people with behavioral health issues or developmental disabilities. They may be a case manager, social worker, qualified developmental disabilities professional or other qualified staff. They may be someone you know and work with today. If not, they will get to know you, your caregivers and your doctors. They will help to see that your specialty services are arranged and delivered properly. Once a month, or more often if needed, your care coordinator will meet with you to talk with you about how you re doing. They ll help you: Learn about and manage your health conditions and medicines. Set up any medical, behavioral health and social services you need. Keep all your providers updated about your care and services. Get services and supports you need to live and work in your community. Have questions? We re here 24/7. Visit our website at or call (TTY 711) anytime. AR-MHB

8 Help you move between care settings, like going home after being in a residential facility. Learn about and make healthy choices, like eating healthy foods and exercising. Get quality health care services. Choose and change your primary care provider (PCP), specialists and other providers. You don t have to wait for your monthly meeting if you need immediate help from a care coordinator. You can always contact your care coordinator directly or call Member Services, and we ll connect you to our care coordination team. We re here 24 hours a day, 7 days a week. You can also send us: A fax: An Help@summitcommunitycare.com Your plan of care Your care coordinator is responsible for getting copies of all your treatment and service plans. From there, they will work with you and your care team to create an overall plan of care. Your plan of care says what kinds of services you need, who you get them from, and how often you get them. It might include any of these: Behavioral health treatment plan Person-centered service plan for waiver clients Primary care physician care plan Individualized education program (IEP) Individual treatment plans for developmental clients in day habilitation programs Nutrition plan Housing plan Any existing work plan Justice system-related plan Child welfare plan Medication management plan Your care coordinator will keep track of all the services in your plan of care. They will help you avoid duplicate services, get services right when you need them, and add or change services to meet your needs. They will also look at the results of your Individual Assessment (IA) and use these to update your plan of care. If you get CES waiver services If you participate in the 1915(c) Home and Community Based Services Community and Employment Support (CES) Waiver, your care coordinator will: AR-MHB

9 Set up all your CES waiver services and state plan services. Regularly assess your needs to identify and refer you to medical, social, educational and other publicly funded services you need (no matter who pays for them), as well as community supports you and your family may be eligible for. Track and review the services you receive to promote your health and safety. Help you get immediate care in times of emotional, mental or physical distress. Review your care and services to make sure you re supported in meeting goals in your plan of care. Help you access advocacy services upon your request. Help you with eligibility determinations. Walk you through the reconsideration and appeal process if you get a service denial. Your rights As a Summit Community Care member, you have rights. These include: The right to be treated with respect and with due consideration for your dignity and privacy. The right to get information on available treatment options and alternatives, presented in an appropriate format. The right to participate in decisions about your health care, including the right to say no to treatment. The right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation. The right to ask for and get a copy of your medical records. You can also ask for them to be changed or corrected. The right to exercise your rights without the PASSE treating you badly. The right to be given notice in writing within seven (7) calendar days if your care coordinator changes. The right to receive a member handbook and provider directory within a reasonable amount of time after being assigned to Summit Community Care. What is a PCP? A primary care provider (PCP) is your main doctor. You ll see this doctor for well visits, checkups, immunizations (shots), and when you re sick. Your PCP may also refer you to specialists doctors who focus on one kind of care. Have questions? We re here 24/7. Visit our website at or call (TTY 711) anytime. AR-MHB

10 It s important for you to see your PCP at least once a year for a wellness visit. This way, your PCP can get to know your health needs. It also helps your PCP address health issues that could become more serious over time. Choosing and changing your PCP If you have already chosen a PCP, that doctor is your primary medical contact. If you haven t chosen a PCP, your care coordinator can help you choose a PCP or give you a referral to one. See our provider directory to find PCPs and other providers who work with us. Visit for the latest directory or call Member Services for a hard copy. If your doctor is not on the list, you can find other Medicaid providers at Default.aspx. Then, tell your care coordinator who you want your PCP to be. You can also choose a PCP by: Calling the ConnectCare help line at (TDD ) Going to the DHS office in your county Listing your choices for a PCP on the Medicaid application Make sure the PCP you choose is a Medicaid provider. If you don t see your doctor in our provider directory and you need a list of PCPs who take Medicaid, call ConnectCare, check the DHS website at SearchProviders/tabid/97/Default.aspx or visit your county DHS office. The list tells you: The doctor s name The clinic s address Ages served Languages the doctor or staff speak Phone numbers You can change your PCP by: Calling the ConnectCare help line at (TDD ) OR Visiting the DHS office in your county Here are some things to keep in mind when choosing or changing your PCP. How far away is the doctor? The doctor s office needs to be in the county where you live or in a county right beside yours. If you live in a county that borders another state (Oklahoma, Texas, Louisiana, Mississippi, Missouri or Tennessee), you may choose a doctor in a city on the border in that state. Make sure the doctor takes Arkansas Medicaid. AR-MHB

11 Do you or a family member have a health care need that requires a specialist? Look for a doctor that offers the service you need, or ask your care coordinator for help in finding one. Is there a hospital you like best? Make sure the doctor you choose sends patients to that hospital. (For emergency care, you can use any hospital. Other times, you need a doctor s referral.) Do you or does a family member not speak English? Choose a doctor who speaks your or their language. Grievances If you have a concern or complaint about the services you receive, you can file a grievance at any time. You may file by calling Member Services at (TTY 711). Or you can file a grievance in writing mail a letter to: Summit Community Care Member Grievances P.O. Box Virginia Beach, VA We will look into your grievance and resolve it within 30 days of the date you file. Once we resolve it, we will send you a letter. If you disagree with how we resolve your grievance, you may file a complaint with the state. Our resolution letter will tell you how to file a complaint with the state. Appeals If Arkansas Medicaid will not pay for a service you need, you will get a letter to let you know. If you disagree with the decision, you can: Request an appeal within 30 days from the date on the letter you get from Arkansas Medicaid telling you your services will end. Have a hearing before a DHS hearing officer. Submit your appeal request to: DHS Office of Appeals and Hearings P.O. Box 1437 Slot N401 Have questions? We re here 24/7. Visit our website at or call (TTY 711) anytime. AR-MHB

12 Little Rock, AR Phone: Fax: The Office of Appeals and Hearings must get your request for an appeal hearing within 30 days from the date on the letter you received from Arkansas Medicaid, or your request will be denied. What is an advance directive? An advance directive helps make sure you get the medical care you want if you are ever so sick or injured that you can t speak for yourself. An advance directive also states who you want to make health care decisions for you if that happens. It s important to choose someone you trust. There are two kinds of advance directives: Living will: Tells what kind of treatments you would want and wouldn t want Durable power of attorney: Names a person of your choice to make decisions for you To get an advance directive: Talk to your primary care provider (PCP). Go to caringinfo.org to find your state-specific advance directive. Click the Planning Ahead tab to download and print your state-specific advance directive. Call Member Services we can send you the forms. Once you have the forms: Review your options and rights. Take your time. Think about it. Talk it over with your doctor and loved ones. Fill out and sign your advance directive. Give your signed advance directive to your PCP and other people you trust to have it when needed. You can change your advance directive later if you want. By making your wishes known now, you will be sure to get the kind of care you want or need in the future. AR-MHB

13 Other information Switching to another PASSE If you would like to switch from the PASSE you were assigned to initially, you may: Switch to a new PASSE within the first 90 days at any time. On the 91st day, you can only change your PASSE during the next 12 months for cause. Switch to a new PASSE after the first 90 days for cause. For-cause reasons are: You move out of the state Summit Community Care doesn t, because of moral or religious objections, cover the services you seek Poor quality of care, lack of access to covered services, lack of access to providers experienced in dealing with your health care needs, or if DHS imposes sanctions against Summit Community Care Switch to a new PASSE on your annual anniversary date without cause. If you don t switch on your anniversary, you must stay with your current PASSE for the next 12 months unless you can show cause. To switch to a new PASSE, call or write to: Arkansas Foundation for Medical Care (PASSE CHOICE Counseling) 1020 W. 4th St. Ste. 300 Little Rock, AR Phone: DHS will process your request after they receive your call or letter and let you know their decision. If your request is approved, the start date with your new PASSE will be no later than the first day of the second month following the month DHS receives your request. (For example, if DHS receives your request on March 15th, the start date with your new PASSE will be no later than May 1st.) If your request is not processed timely, it will be approved automatically. If you must provide a for-cause reason with your request but do not properly state the reason, DHS will let you know their decision. If you do not agree, you have the right to appeal. Have questions? We re here 24/7. Visit our website at or call (TTY 711) anytime. AR-MHB

14 Your resources Your care coordinator: Phone #: *Your care coordinator is your first point of contact. Call them first if you have questions or concerns about your benefits, plan of care or how to get services. Member Services: (TTY 711) Arkansas Department of Human Services: (TTY ) All services referenced in this material are funded and provided under an agreement with the Arkansas Department of Human Services. AR-MHB

15 Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION WITH REGARD TO YOUR HEALTH BENEFITS. PLEASE REVIEW IT CAREFULLY. HIPAA Notice of Privacy Practices The effective date of this notice is April 14, The most recent revision date is shown at the end of this notice. Please read this notice carefully. This tells you who can see your protected health information (PHI). It tells you when we have to ask for your OK before we share it. It tells you when we can share it without your OK. It also tells you what rights you have to see and change your information. Information about your health and money is private. The law says we must keep this kind of information, called PHI, safe for our members. That means if you re a member right now or if you used to be, your information is safe. We get information about you from state agencies for Medicaid and the Children s Health Insurance Program after you become eligible and sign up for our health plan. We also get it from your doctors, clinics, labs and hospitals so we can OK and pay for your health care. Federal law says we must tell you what the law says we have to do to protect PHI that s told to us, in writing or saved on a computer. We also have to tell you how we keep it safe. To protect PHI: On paper (called physical), we: Lock our offices and files Destroy paper with health information so others can t get it Saved on a computer (called technical), we: Use passwords so only the right people can get in Use special programs to watch our systems Used or shared by people who work for us, doctors, or the state, we: Make rules for keeping information safe (called policies and procedures) Teach people who work for us to follow the rules Have questions? We re here 24/7. Visit our website at or call (TTY 711) anytime. AR-MHB

16 When is it OK for us to use and share your PHI? We can share your PHI with your family or a person you choose who helps with or pays for your health care if you tell us it s OK. Sometimes, we can use and share it without your OK: For your medical care To help doctors, hospitals and others get you the care you need For health care operations and treatment To find ways to make our programs better, as well as giving your PHI to health information exchanges for health care operations and treatment. If you don t want this, please visit for more information. For health care business reasons To help with audits, fraud and abuse prevention programs, planning and everyday work To find ways to make our programs better For public health reasons To help public health officials keep people from getting sick or hurt With others who help with or pay for your care With your family or a person you choose who helps with or pays for your health care, if you tell us it s OK With someone who helps with or pays for your health care, if you can t speak for yourself and it s best for you We must get your OK in writing before we use or share your PHI for all but your care, payment, everyday business, research or other things listed below. We have to get your written OK before we share psychotherapy notes from your doctor about you. You may tell us in writing that you want to take back your written OK. We can t take back what we used or shared when we had your OK. But we will stop using or sharing your PHI in the future. Other ways we can or the law says we have to use your PHI: To help the police and other people who make sure others follow laws. For example, we may use PHI to report abuse and neglect. To help the court when we re asked. For example, we may use PHI to answer legal documents that are filed with the court like complaints or subpoenas. To give information to health oversight agencies or others who work for the government with certain jobs. For example, we provide information for audits or exams. To help coroners, medical examiners or funeral directors find out your name and cause of death. To help when you ve asked to give your body parts to science or for research. For example, we may share your information if you have agreed to become an organ donor in the event of your death. To keep you or others from getting sick or badly hurt. For example, we may share your PHI to prevent you or others from being harmed in an urgent situation. To give information to workers compensation. For example, we may share your AR-MHB

17 information if you get sick or hurt at work. What are your rights? You can ask to look at your PHI and get a copy of it. We don t have your whole medical record, though. If you want a copy of your whole medical record, ask your doctor or health clinic. You can ask us to change the medical record we have for you if you think something is wrong or missing. Sometimes, you can ask us not to share your PHI. But we don t have to agree to your request. For example, if the PHI is part of clinical notes and by law cannot be released, your request may be denied. You can ask us to send PHI to a different address than the one we have for you or in some other way. We can do this if sending it to the address we have for you may put you in danger. You can ask us to tell you all the times over the past six years we ve shared your PHI with someone else. This won t list the times we ve shared it because of health care, payment, everyday health care business or some other reasons we didn t list here. You can ask for a paper copy of this notice at any time, even if you asked for this one by . If you pay the whole bill for a service, you can ask your doctor not to share the information about that service with us. What do we have to do? The law says we must keep your PHI private except as we ve said in this notice. We must tell you what the law says we have to do about privacy. We must do what we say we ll do in this notice. We must send your PHI to some other address or in a way other than regular mail if you ask and if you re in danger. We must tell you if we have to share your PHI after you ve asked us not to. If state laws say we have to do more than what we ve said here, we ll follow those laws. We have to let you know if we think your PHI has been breached. Contacting you We, along with our affiliates and/or vendors, may call or text you using an automatic telephone dialing system and/or an artificial voice. We only do this in line with the Telephone Consumer Protection Act (TCPA). The calls may be to let you know about treatment options or other health-related benefits and services. If you do not want to be reached by phone, just let the caller know, and we won t contact you in this way anymore. Or you may call to add your phone number to our Do Not Call list. Have questions? We re here 24/7. Visit our website at or call (TTY 711) anytime. AR-MHB

18 What if you have questions? If you have questions about our privacy rules or want to use your rights, please call Member Services at If you re deaf or hard of hearing, call TTY 711. What if you have a complaint? We re here to help. If you feel your PHI hasn t been kept safe, you may call Member Services or contact the Department of Health and Human Services. Write to or call the Department of Health and Human Services: Marisa Smith, Regional Manager Office for Civil Rights U.S. Department of Health and Human Services 1301 Young St., Ste Dallas, TX Phone: TDD: We reserve the right to change this Health Insurance Portability and Accountability Act (HIPAA) notice and the ways we keep your PHI safe. If that happens, we ll tell you about the changes in a newsletter. We ll also post them on the Web at Race, ethnicity and language We receive race, ethnicity and language information about you from the state Medicaid agency and the Children s Health Insurance Program. We protect this information as described in this notice. We use this information to: Make sure you get the care you need Create programs to improve health outcomes Develop and send health education information Let doctors know about your language needs Provide translator services We do not use this information to: Issue health insurance Decide how much to charge for services Determine benefits Disclose to unapproved users AR-MHB

19 Your personal information We must follow state laws if they say we need to do more than the HIPAA Privacy Rule. We may ask for, use and share personal information (PI) as we talked about in this notice. Your PI is not public and tells us who you are. It s often taken for insurance reasons. We may use your PI to make decisions about your: Health Habits Hobbies We may get PI about you from other people or groups like: Doctors Hospitals Other insurance companies We may share PI with people or groups outside of our company without your OK in some cases. For example, we may share PI with claims and billing vendors who we hire to help us run our business. We ll let you know before we do anything where we have to give you a chance to say no. We ll tell you how to let us know if you don t want us to use or share your PI. You have the right to see and change your PI. We make sure your PI is kept safe. Revised February 12, 2018 Have questions? We re here 24/7. Visit our website at or call (TTY 711) anytime. AR-MHB

20 Serving Arkansas counties statewide