A R I Z O N A. UnitedHealthcare Medicaid Member Handbook /11

Transcription

1 A R I Z O N A UnitedHealthcare Medicaid Member Handbook /11

2 Important Information Emergency Member Services: Toll-Free TDD (for the hearing impaired) or 711 Websites Your Health Providers Your health plan website: Visit this website to learn about what is happening around the State of Arizona. You will find information about health resources and prevention. This website allows AHCCCS members to view their own active healthcare and health plan enrollment for several services. Be sure to fill in the blanks so you will have these numbers ready. My Member ID: My Doctor: My Doctor s Phone Number: My Doctor s Address: My Dentist: Pharmacy: 3141 North 3rd Avenue Phoenix, AZ October 1, 2010 Services funded in part by the State of Arizona Medicaid Member Handbook

3 Table of Contents Welcome to Language and Cultural Services Your ID Card Member Rights and Responsibilities Fraud and Abuse : A Managed Care Program Your Primary Care Physician (PCP) Health Care Services Benefit Redesign Children s Care Immunizations (Shots) Adult Care Dental Care Family Planning Services Pregnancy Services Copayments Behavioral Health Services Emergency and Urgent Care Transportation Changes in Information Member Complaints Decisions About Your Health Care (Advance Directives) Privacy and Your Health Care Changing Health Plans Other Insurance and Medicare Glossary Health Plan Notices of Privacy Practices Financial Information Privacy Notice Arizona 1

4 Welcome to UnitedHealthcare Arizona Physicians IPA Making a Difference, One Member at a Time Quality is what we stand for at UnitedHealthcare Arizona Physicians IPA. We are committed to giving you the best care possible. We want you to get the services that you need for a happy and healthy life. You can help us do this by taking care of yourself and your family. is an AHCCCS managed care plan. We work with health care providers to provide all AHCCCS covered services. We will help you take charge of your own health care. Your UnitedHealthcare Arizona Physicians IPA Member Handbook Please read this handbook. It will tell you: Your rights and responsibilities as a member How to get health care services What services are covered and not covered How to use your benefits correctly Where to go for help Information about UnitedHealthcare Arizona Physicians IPA Member Services Member Services is here to help you! Member Services can: Answer questions about your health care benefits Help solve a problem or concern you might have with your doctor or any part of the health plan Help you find a doctor Tell you about our doctors, their backgrounds, and the care facilities in our network Help you if you get a medical bill Tell you about community resources available to you Help you if you speak another language, are visually impaired, need oral interpretation services, or sign language services Member Services Available 24 hours a day, 7 days a week TDD (for the hearing impaired): or 711 When You Call Us We ask questions to check your identity. We do this to protect your privacy. This is federal and state law. Gather the following information before you call: Member ID number Current address and phone number on file with AHCCCS Date of birth DDD/ALTCS Members: Look for this box throughout the member handbook. It will tell you details about your unique benefits and services. 2 Medicaid Member Handbook

5 Language and Cultural Services Clear communication is important to get the health care you need. UnitedHealthcare Arizona Physicians IPA provides member materials to you in a language or format that may be easier for you to understand. We also have interpreters for you to use if your doctor does not speak your language. If your doctor does not understand your cultural needs, we can help. We will work with your doctor or help you pick a new doctor. Call UnitedHealthcare Arizona Physicians IPA Member Services at for translation services, to find a doctor who understands your cultural needs, or for materials in another language or format. These services are provided at no cost to you Arizona 3

6 Language and Cultural Services (cont.) Medicaid Member Handbook

7 Your ID Card When you join UnitedHealthcare Arizona Physicians IPA, you will receive a ID card. Your UnitedHealthcare Arizona Physicians IPA ID card is your key to getting health care services. It has your Medicaid ID number, your name and other important information. Your AHCCCS ID card identifies you as a UnitedHealthcare Arizona Physicians IPA member. When you get your card, check it carefully. Call Member Services right away if any of the information on your card or your child s card is wrong. DDD/ALTCS Members: Members enrolled with the Division of Developmental Disabilities (DDD) will get an ID card from UnitedHealthcare Arizona Physicians IPA. DDD members must use this card for all services. Contact Member Services if you need a replacement card. Be sure your address with us is correct. If your address has changed you will need to notify your DDD support coordinator right away. Quick Tips Your ID card is for your use only. Don t let others use it Carry your ID card at all times and keep it in a safe place Do not lose your card or throw it away You will need your card when you get medical care or when you pick up medicine at the pharmacy Misusing your medical ID number, like loaning or selling the card or the information on it, is against the law Misusing your card or medical ID number may result in legal actions and you could lose your AHCCCS eligibility, benefits and health care services If you notice others getting AHCCCS/ DDD benefits they are not eligible for or someone misusing the medical ID card, please tell us right away. You can call or write AHCCCS or UnitedHealthcare Arizona Physicians IPA Member Services. AHCCCS also has a Member Fraud Hotline you can call at ITS NOT OK ( ) or You may also call AHCCCS or to report any provider you believe may be giving services to members that are not needed or should not be given Arizona 5

8 Member Rights and Responsibilities We want to have a good relationship with you. For this to happen, you need to know your rights and responsibilities. You have the right to: Respect and Dignity Be treated with respect and dignity by staff and health care providers Receive covered benefits and services regardless of race, color, gender, religion, age, national origin, ability to speak English, handicap, ability to pay, marital status, sexual preference, genetic information or physical or mental handicap Have services given in a way that respects your culture, language, background and abilities Know the languages spoken by each contracted UnitedHealthcare Arizona Physicians IPA doctor Receive interpreter services free of charge Get this information in a language or format that you understand, including sign language or Braille Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation Confidentiality and Privacy Privacy during medical visits, appointments and treatments Privacy and protection of your health information Access to your medical records or child s medical records as allowed by law this request may be denied if the information is psychotherapy notes; collected for a civil, criminal or administrative action; protected health information subject to the Federal Clinical Laboratory Improvements Amendments of 1988, or exempt pursuant to 42 CFR 493.3(a)(2) Request a copy of your medical records, at no cost to you, be told how long it will take UnitedHealthcare Arizona Physicians IPA to get the record to you, and/or what to do if your record request is denied by Correct your medical record as allowed by law Change your doctor that is contracted with UnitedHealthcare Arizona Physicians IPA up to 3 times per year Refuse care or refuse care from certain doctors Know the professional background of any person involved in your care Know the name of your doctor Treatment Decisions Talk to your doctor about your health care and how to get covered services. Call Member Services if you have questions that your doctor did not answer Get information on available treatments and treatment options and the right to refuse treatment, appropriate to your condition in language that you understand Be involved in decisions about your health care, or have a representative facilitate care or help make decisions if you are not able to do so Request a second opinion from a qualified health care professional within 6 Medicaid Member Handbook

9 Member Rights and Responsibilities (cont.) UnitedHealthcare Arizona Physicians IPA s network at no cost to you. A second opinion may be received from an out-of-network provider, at no cost to you, if there is no in-network coverage Get information on how to get mental health care, substance abuse services, or a referral for specialty services not provided by your PCP Know how UnitedHealthcare Arizona Physicians IPA evaluates new technology and decides to cover new treatments Other Receive emergency care without approval from your doctor or UnitedHealthcare Arizona Physicians IPA Know if you need insurance for very large claims (stop-loss insurance) Request information on whether or not has physician incentive plans that affect the use of referral services Know how UnitedHealthcare Arizona Physicians IPA compensates doctors Receive a summary of member survey results Request information about grievances, appeals and requests for hearings Request information about getting services outside UnitedHealthcare Arizona Physicians IPA s contracted service area You have the responsibility to: Respect Read and follow this handbook Treat all UnitedHealthcare Arizona Physicians IPA staff and health care providers with respect and dignity Protect your ID card and show it before you get services. Do not throw your card away Follow Instructions Know the name of your Primary Care Physician (PCP). Your PCP is your doctor that coordinates your health care needs See your PCP for your health care needs Use the emergency room for life threatening care only. Go to your PCP or urgent care centers for all other care Follow your doctor s instructions and treatment plan, and tell your doctor if their explanations are not clear Bring your child s immunization records with you to appointments until the child is 18 years old Appointments Make an appointment before you visit your PCP or any other UnitedHealthcare Arizona Physicians IPA health care provider Schedule appointments during office hours instead of using urgent care or emergency rooms If you need a ride, call at least 3 days before your appointment Arrive on time for appointments Please call the office at least one day in advance if you must cancel an appointment If you cancel your appointments, be sure to cancel your transportation at Arizona 7

10 Member Rights and Responsibilities (cont.) Share Information Be honest and direct with your PCP. Give them health history on you or your child Call AHCCCS if you have changes in address, family size or questions about eligibility Tell your doctor, AHCCCS, and UnitedHealthcare Arizona Physicians IPA if you have other insurance, such as Medicare Give a copy of your Living Will to your PCP DDD/ALTCS Members: With the help of your DES/DDD Support Coordinator, your responsibilities include: Keep your ALTCS eligibility predetermination appointments Select a PCP within 10 days of notification of plan enrollment Coordinate all necessary covered medical services through your PCP Notify the DES/DDD support coordinator of changes in your address or phone number or if your private insurance has changed Arrive on time for your appointments or call ahead if you can t make it Provide all the information to your PCP that is requested by the PCP Notify your DDD support coordinator and UnitedHealthcare Arizona Physicians IPA with all the information, including changes in private and public insurance, third party liability, financial assistance, or other benefits received by you Pursue eligibility with Children s Rehabilitative Services (CRS) when referred by DES/DDD or Direct any complaints or problems to DES/DDD, Health Care Services, Member Services or your DD Liaison as soon as possible Participate in family-centered consultations at the request of, your Support Coordinator or other personnel 8 Medicaid Member Handbook

11 Fraud and Abuse Fraud provides services to people who are in need and qualify for AHCCCS. It is important to make sure that our members and providers follow the rules for getting and billing for covered services. If the rules aren t followed, a member or provider might be committing fraud. Report anything you see that doesn t look right. This includes: Using someone else s ID card or allowing someone to use yours Giving a wrong address in order to qualify for AHCCCS A doctor or facility billing you for covered services Abuse wants you to feel safe when you go to the doctor or a UnitedHealthcare Arizona Physicians IPA facility. If you are ever touched or talked to in a way that is uncomfortable, this is called abuse. It is important to tell someone about it. Reporting Fraud & Abuse You can report fraud or abuse by calling Member Services at You can also call AHCCCS at or You do not have to give your name. You will not get in trouble for reporting fraud or abuse. Arizona 9

12 UnitedHealthcare Arizona Physicians IPA: A Managed Care Program is a managed care program. This means that all of the medical care and service you receive must be requested and provided by a doctor or health care provider that is in the UnitedHealthcare Arizona Physicians IPA network. UnitedHealthcare Arizona Physicians IPA understands that current members have relationships with their doctors and health care providers. To maintain these relationships, UnitedHealthcare Arizona Physicians IPA may allow a nonparticipating doctor or health care provider to treat a recipient if approval is provided by UnitedHealthcare Arizona Physicians IPA. This is called a prior authorization. will work with your health care providers to make sure you receive the care you need. 10 Medicaid Member Handbook

13 Your Primary Care Physician (PCP) Your health care is important to us. We carefully screen and pick our doctors so you receive the best care. When you enroll, you will be assigned a Primary Care Physician (PCP). Your PCP is your personal care doctor. Your PCP will provide or arrange the covered services you need. Make sure you talk to your PCP about any health problems you have. That way, your PCP gets to know you and your medical history. Always follow your PCP s instructions and get approval before you get any medical services. If you are pregnant you may choose your Primary Care Obstetrician (PCO) as your primary care physician. Part of good health care is seeing your PCP for checkups, even if you don t feel sick. may send you a reminder to help you know when to go for a check-up. When you don t feel well, your PCP will help you. Be sure to call your PCP right away. Your PCP may refer you to a doctor who is a specialist. Changing Your PCP Your PCP is an important part of your medical care team. You and your PCP need to work together. If for any reason you want to change your PCP, call UnitedHealthcare Arizona Physicians IPA Member Services. If you change your PCP, you must choose another PCP from the UnitedHealthcare Arizona Physicians IPA Provider Directory. We can help you choose a new PCP or tell you more about the PCPs in our network. Member Services can send you a list of our providers at no cost to you. If your PCP does not speak your language, call Member Services. UnitedHealthcare Arizona Physicians IPA will provide you with an interpreter at no cost to you. Arizona 11

14 Your Primary Care Physician (PCP) (cont.) Making Appointments It is important for you to set up an appointment before you arrive at your PCP s office. When you call the PCP s office, tell them you are a UnitedHealthcare Arizona Physicians IPA member and why you need an appointment. If you don t make an appointment and just show up, your PCP may not be able to see you. Routine appointments can be scheduled with your PCP within three weeks. Once you get to the office, your doctor will try to see you within 45 minutes. You may have to wait longer if there is an emergency. If you need urgent care, your PCP should see you within 48 hours. If you need emergency care, your PCP should see you that day. Canceling or Changing Appointments If you need to cancel or change your appointment, tell the PCP s office at least one day before the appointment. This lets the doctor see other patients. If you cancel an appointment, be sure to make another appointment for a different time. Seeing a Specialist Your PCP is in charge of ALL your covered health care needs. If you need specialty care, your PCP may refer you to a specialist or another doctor. There are four exceptions to this: Members with special health care needs may be able to see specialists on a regular basis. Women can make an appointment with an in-network Obstetrician/Gynecologist (OB/GYN) for preventive or routine services without a referral from their PCP. (Please see the UnitedHealthcare Arizona Physicians IPA Provider Directory for a list of doctors.) All members can self-refer for behavioral health services through their local RBHA. See page 29 for more information Members under 21 years of age can self-refer for dental and vision screenings. Contact Member Services to obtain a copy of the UnitedHealthcare Arizona Physicians IPA Provider Directory at no cost to you. 12 Medicaid Member Handbook

15 Health Care Services These are many of the AHCCCS covered services you can receive if they are medically necessary. Your PCP will help you decide if you need them. If you receive services that are not covered by AHCCCS, you may be required to pay for them. Section 1 All Members AHCCCS-approved organ and tissue transplants and related prescriptions Behavioral health services (see page 29) Doctor office and specialist visits Durable medical equipment and supplies Emergency care and services Emergency dental services, including emergency tooth or teeth removal, medically necessary dentures, and relief from pain and/or infection. AHCCCS will not cover dental services (including emergency dental services) unless the care needed is a medical or surgical service related to dental (oral) care. Covered dental services for members 21 years of age and older must be related to the treatment of a medical condition such as acute pain, infection, or fracture of the jaw. Covered dental services include examining the mouth, x-rays, care of fractures of the jaw or mouth, giving anesthesia, and pain medication and / or antibiotics. Certain pre-transplant services and prophylactic extraction of teeth in preparation for radiation treatment of cancer of the jaw, neck or head is also covered. Emergency eye care. Cataract removal and follow up services, only if approved by UnitedHealthcare Arizona Physicians IPA. End of life services Family planning services HIV/AIDS Therapy Home and Community Based Services Home health services (such as nursing and home health aid) Hospital care Immunizations (shots) Incontinence briefs (For ages 3-20 when specific medical criteria is met.) Inpatient rehabilitation services, including occupational, speech and physical therapy Kidney dialysis Laboratory visits and x-rays Maternity care (prenatal, labor and delivery, postpartum) Medical foods (Total Parenteral Nutrition) Medically necessary foot care* Medically necessary surgical services* Medically necessary transportation* Nursing home up to 90 days a year Nutritional assessments Prescriptions on UnitedHealthcare Arizona Physicians IPA s list of covered medicines and prescribed by your doctor Respiratory therapy * Medical Necessity: Health care or products that a prudent, or wise, doctor would give to a patient to prevent, diagnose, or treat an illness, injury, disease or its symptoms in a way that follows generally accepted standards for medicine and is not just for the convenience of the patient, physician or other health care provider. Arizona 13

16 Health Care Services (cont.) Section 2 Additional Services for Children Under 21 Chiropractic services Conscious sedation (medicine to relieve pain during a medical procedure while the patient is awake) Cochlear implants and maintenance Hearing aids Hospital care health risk assessments and screening (including EPSDT services) Outpatient and inpatient speech, occupational, and physical therapy Routine physical exams (well visits) Routine preventive and therapeutic dental services Vision services, including exams, prescriptive lenses and cataract removal and follow-up services if authorized by Section 3 Additional Services for Qualified Medicare Beneficiaries (QMB) Any services covered by Medicare but not by AHCCCS (see your Medicare handbook) Chiropractic services Outpatient occupational therapy (Therapy used to regain the ability to return to work or care for one s self) Respite services (Temporary services to give a primary caregiver a break) Section 4 Additional Services for DDD/ALTCS Members Adaptive aids Certain specialized durable medical equipment approved by UnitedHealthcare Arizona Physicians IPA Specific prescriptions and some over-the-counter medicines to meet special needs Non-Covered Services for All Members Abortions and abortion counseling unless the pregnancy is the result of rape or incest, a physician decides that it is medically necessary because the pregnancy will cause a serious physical or mental health problem for the pregnant member, or continuing the pregnancy is lifethreatening. Cosmetic services or items Experimental organ transplants, unless approved by AHCCCS Hearing aids for members age 21 or older Medical services for those in an institution for TB (tuberculosis) treatment Over-the-counter medicines and medical supplies (except under certain conditions) Personal care items such as combs, razors, soap, etc. Prescriptions not on our list of covered medications, unless approved by Reversal of voluntary sterilization 14 Medicaid Member Handbook

17 Health Care Services (cont.) Routine circumcisions Services from a provider who is not contracted with UnitedHealthcare Arizona Physicians IPA (unless prior approved by the Health Plan). If you have other insurance, you can see a noncontracted provider. If you are unsure, call Member Services. Services that are determined to be experimental by the health plan medical director Sex change operations Treatment to straighten teeth, unless medically necessary and approved by Other Non-Covered Services for Adults (Age 21 and Over) See excluded benefit If you have any questions if a service is covered or not, talk to your PCP or call Member Services. How will I know if a service has been approved or denied? reviews the service request from you, your PCP, or your specialist. Your doctor will tell you if the service is approved. If the service has been denied, UnitedHealthcare Arizona Physicians IPA will send you a letter, called a Notice of Action. Normal authorization decisions will be made within 14 calendar days from the date the request is received. Extensions of up to 14 calendar days can be received if it is in your best interest. For example, we may be waiting to receive your medical records from your doctor. Instead of making a decision without those records, we may ask you if it s okay to get more time to receive the records. That way, the decision can be made with the best information. We will send you a letter asking for the extension. If we have not made a decision for a request by day 14 (or day 28 if there is an extension), the request will be denied and we will send you a notice by mail. Expedited (Rush) decisions in urgent, lifethreatening situations should be made in 3 working days. See page 35 for more information on Notice of Actions letters and actions you can take. The criteria that were used to make decisions about your care are available to you upon request. Call Member Services at for more information about filing an appeal or see page 35 Arizona 15

18 Benefit Redesign Due to Arizona s huge budget problems and more people being added to the Medicaid Program, after 10/1/2010, United Healthcare Arizona Physicians IPA under the direction of the AHCCCS Administration, will no longer pay for certain medical care for anyone who is 21 years old or older. If you are a Qualified Medicare Beneficiary, we will continue to pay your Medicare deductible and coinsurance for these services. The medical services that will no longer be covered are: AHCCCS EXCLUDED BENEFITS TABLE (SERVICES WHICH ARE NOT PAID FOR) FOR ADULTS 21 YEARS AND OLDER EFFECTIVE 10/1/2010 Benefit/Service Insulin Pumps Percussive Vests Bone-Anchored Hearing Aid Cochlear Implant Lower limb Microprocessor controlled joint/ Prosthetic Orthotics Service Description Service Excluded From Payment A machine that is worn to give insulin through the day to a person as needed This vest is placed on a person s chest and shakes to loosen mucous. A hearing aid that is put on a person s bone near the ear by surgery. This is to carry sound. A small device that is put in a person s ear by surgery to help you hear better. A device that replaces a missing part of the body and uses a computer to help with the moving of the joint. A support or brace for weak joints or muscles. An orthotic can also support a deformed part of the body. AHCCCS will not pay for insulin pumps. Supplies, equipment maintenance (care of the pump) and repair of pump parts will be paid for. AHCCCS will not pay for percussive vests. Supplies, equipment maintenance (care of the vest) and repair of the vest will be paid for. AHCCCS will not pay for Bone-Anchored Hearing AID (BAHA). Supplies, equipment maintenance (care if the hearing aid) and repair of any parts will be paid for. AHCCCS will not pay for cochlear implants. Supplies, equipment maintenance (care of the implant) and repair of any parts will be paid for. AHCCCS will not pay for a lower limb (leg, knee or foot) prosthetic that includes a microprocessor (computer chip) that controls the joint. AHCCCS will no longer pay for orthotics. Supplies, equipment maintenance and repair of component parts will be paid for. Orthotics means items like leg braces, wrist splints and neck braces. Maintenance (care of existing orthotics) and repair of parts will still be paid for. 16 Medicaid Member Handbook

19 Benefit Redesign (cont.) Benefit/Service Emergency Dental Service Services by Podiatrist Well Exams Service Description Service Excluded From Payment Emergency services are when you have a need for care immediately like a bad infection in your mouth or pain in your teeth or jaw. Any service that is done by a doctor who treats feet and ankle problems. Well exams are when a person visits the doctor for a check up when they are not sick. AHCCCS will not cover dental services (including emergency dental services) unless the care needed is a medical or surgical service related to dental (oral) care. Covered dental services for members 21 years of age and older must be related to the treatment of a medical condition such as acute pain, infection, or fracture of the jaw. Covered dental services include examining the mouth, x-rays, care of fractures of the jaw or mouth, giving anesthesia, and pain medication and / or antibiotics. Certain pre-transplant services and prophylactic extraction of teeth in preparation for radiation treatment of cancer of the jaw, neck or head is also covered. AHCCCS will not pay for services provided by a podiatrist or podiatric surgeon for adults. Contact your health plan for other contracted providers who can perform medically necessary foot and ankle procedures, including reconstructive surgeries. Well visits are not paid for. Well visits are when a person goes to the doctor s office for a routine check up instead of going for a cold or some other sickness or problem. However, pap smears, mammograms, and colonoscopies will still continue to be covered. Arizona 17

20 Benefit Redesign (cont.) Benefit/Service Transplants Service Description Service Excluded From Payment A transplant is when an organ or blood cells are moved from one person to another. The following non-experimental transplants will not be paid for, even for members on a waiting list, on or after 10/1/2010 with the exception that if the member is in the prep and transplant phase or follow up care, then the transplant and all subsequent care is covered. That means that you would need to be in the hospital being prepared for surgery with your donor organ or bone marrow having arrived by 10/1/2010. The following transplant types will not be paid for if a new request is received after 9/30/10 or a transplant has not been started by 10/1/10: Pancreas only transplants (total, partial or islet cell) Pancreas after kidney transplants Lung transplants Allogeneic unrelated hematopoietic cell (bone marrow) transplants Liver transplants for members with a diagnosis of Hepatitis C Heart transplants for nonischemic cardiomyopathies -Non-ischemic cardiomyopathy is defined as a condition in which the underlying cardiac abnormality has not resulted in irreversible permanent damage to the heart muscle. Members with non-ischemic cardiomyopathy have sufficient cardiac function to circulate adequate volumes of blood and oxygen to the heart muscle and other body organs Any other transplant not listed by AHCCCS as covered. You can speak with your health plan for a list of transplants that would be paid for. Approval is based on the medical need and if the transplant is on the covered list. Only transplants listed by AHCCCS as covered will be paid for. 18 Medicaid Member Handbook

21 Benefit Redesign (cont.) Benefit/Service Physical Therapy Service Description Service Excluded From Payment Exercises taught or provided by a Physical Therapist to make you stronger or help improve movement. Outpatient physical therapy visits are limited to 15 visits per contract year (10/1--9/30). The member who has Medicare should talk to the health plan for help in determining how the visits will be counted. Arizona 19

22 Children s Care participates in the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program. Early Periodic Screening, Diagnostic and Treatment (EPSDT) is a comprehensive child health program of prevention and treatment, correction, and improvement (amelioration) of physical and mental health problems for AHCCCS members under the age of 21. The purpose of EPSDT is to ensure the availability and accessibility of health care resources, as well as to assist Medicaid recipients in effectively utilizing these resources. EPSDT services provide comprehensive health care through primary prevention, early intervention, diagnosis, medically necessary treatment, and follow-up care of physical and behavioral health problems for AHCCCS members less than 21 years of age. EPSDT services include screening services, vision services, dental services, hearing services and all other medically necessary mandatory and optional services listed in federal law 42 USC 1396d(a) to correct or ameliorate defects and physical and mental illnesses and conditions identified in an EPSDT screening whether or not the services are covered under the AHCCCS state plan. Limitations and exclusions, other than the requirement for medical necessity and cost effectiveness do not apply to EPSDT services. A well child visit is synonymous with an EPSDT visit and includes all screenings and services described in the AHCCCS EPSDT and dental periodicity schedules. Amount, Duration and Scope: The Medicaid Act defines EPSDT services to include screening services, vision services, dental services, hearing services and such other necessary health care, diagnostic services, treatment and other measures described in federal law subsection 42 USC 1396d(a) to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the (AHCCCS) state plan. This means that EPSDT covered services include services that correct or ameliorate physical and mental defects, conditions, and illnesses discovered by the screening process when those services fall within one of the 28 optional and mandatory categories of medical assistance as defined in the Medicaid Act. Services covered under EPSDT include all 28 categories of services in the federal law even when they are not listed as covered services in the AHCCCS state plan, AHCCCS statutes, rules, or policies as long as the services are medically necessary and cost effective. EPSDT includes, but is not limited to, coverage of: inpatient and outpatient hospital services, laboratory and x-ray services, physician services, nurse practitioner services, medications, dental services, therapy services, behavioral health services, medical supplies, prosthetic devices, eyeglasses, transportation, and family planning services. EPSDT also includes diagnostic, screening, preventive and rehabilitative services. However, EPSDT services do not include services that are solely for cosmetic purposes, or that are not cost effective when compared to other interventions. 20 Medicaid Member Handbook

23 Children s Care (cont.) Children from birth to 12 months old should have 8 EPSDT visits. Below is a schedule for children from birth to 12 months of age: 1st visit: 2nd visit: 3rd visit: 4th visit: 5th visit: 6th visit: 7th visit: 8th visit: Birth to 2 days old 2 to 4 days old 1 to 4 weeks old 4 to 8 weeks old 2 to 4 months old 4 to 6 months old 6 to 9 months old 9 to 12 months old After your child is 12 months old, follow the guidelines below: Children from 12 to 24 months should have 3 EPSDT visits Children from 2 to 20 years old should have 1 EPSDT visit every year Check-ups may include: Comprehensive history Comprehensive unclothed physical exam Developmental history and behavioral health screening Oral health and dental screening Nutritional assessment Lead testing Immunizations (shots) Tuberculosis test Speech, hearing and eye exams Lab work (including blood lead testing) Health education and guidance about your child s health care and development Talking about your child s behavior Children s Rehabilitative Services (CRS) CRS provides medical services for children and youth who have certain medical, disabling or potentially disabling conditions. Children or youth who have medical conditions that qualify for CRS must receive their care through a CRS provider unless the medical condition is a covered benefit through private insurance. Arizona Women, Infants, and Children (WIC) WIC is a federally funded program providing residents with nutritious foods, nutrition education, and referrals. WIC serves women, infants and children under age five who meet eligibility guidelines. Contact WIC at Head Start Head Start provides comprehensive education, health, nutrition, and parent involvement services to low-income children and their families. Contact the Arizona Head Start Association at or visit them on the web at Arizona Early Intervention Program (AzEIP) The Arizona Early Intervention Program is a statewide system of supports and services for families of children from birth to 3 years old with disabilities or developmental delays. Contact or (outside Maricopa County) for more information. Arizona 21

24 Immunizations (Shots) Immunizations (shots) can keep you and your child from getting sick in the future. Talk with your child s primary care physician about the immunizations that are needed when they are needed. You should use an immunization schedule and have the schedule when you visit your child s doctor. An EPSDT schedule can be found on the AHCCCS web site in Chapter 400 of the AMPM, Exhibit at You can also use this link to see a schedule of immunizations for your child. Centers for Disease Control and Prevention (CDC), Immunization Schedules, gov/vaccines/recs/schedules/default.htm 22 Medicaid Member Handbook

25 Adult Care Getting care early may help your doctor find and treat health problems and keep you healthy. Follow the schedule below for your wellness care. Your PCP will also give you tips to stay healthy, like eating right and exercising regularly. Adult Care Schedule Types of Service Years Old 65 Years Old and Over Physical exam Every year Every year (unclothed) Blood pressure check Every year (additional tests based on your health history) Every year (additional tests based on your health history) Cholesterol check Every 5 years Every year Breast exam Every year Every year Mammogram Once at age 35; Every year Every year for age 40 and over Pap smear Annually from age 16 or See your PCP or GYN sooner if needed Colorectal cancer Every year from age 50 Every year Testicular exam Every 2 years from age Not required Flu vaccine Ask your PCP if you are at risk Every year TD (tetanus diphtheria) Every 10 years Every 10 years Health education Every doctor visit Every doctor visit Pneumonia vaccine Ask your doctor if you are at risk Ask your doctor if you are at risk Prostate screening Every year after age 50 Every year (additional tests based on your health history) HIV screening Ask your doctor if you are at risk Ask your doctor if you are at risk Immunizations (shots) Ask your doctor if you are at risk Ask your doctor if you are at risk Sexually transmitted disease screening Ask your doctor if you are at risk Ask your doctor if you are at risk Tuberculosis screening Once (additional tests based on Ask your doctor if you are at risk your health history) These are general guidelines. Your PCP may want you to get these services more or less often. Arizona 23

26 Dental Care wants to keep all of our members smiling. Dental care is covered for members under age 21. To keep your children s smile healthy and strong, teach them to brush their teeth at least two times a day and floss at least once a day. Make sure they visit a dentist twice a year. The American Association of Pediatric Dentistry recommends that dental visits begin by age 1. Children age 1 through 20 should visit a dentist twice a year for an exam, cleaning and fluoride treatment. Children do not need a referral from their PCP to see a dentist. You can call any dentist in UnitedHealthcare Arizona Physicians IPA s Provider Directory to make an appointment. The following routine dental services are only covered for members under the age of 21: Dental exams Fillings for cavities Dental cleanings X-rays to screen for dental problems Application of topical fluoride Dental sealants Members under age 21 can also receive emergency dental services. If your dentist does not speak your language, call Member Services. UnitedHealthcare Arizona Physicians IPA will provide you with an interpreter at no cost to you. DDD/ALTCS Members: UnitedHealthcare Arizona Physicians IPA has dentists that can take care of your special needs. Contact the DDD Liaisons at or to find a dentist. 24 Medicaid Member Handbook

27 Family Planning Services Family planning services help you protect yourself from having unwanted pregnancy and/or contracting a sexually transmitted disease. Both men and women are eligible to receive family planning services. Family planning services are available from your primary care doctor or from any Planned Parenthood ( ) office statewide. Women may also see an OB/GYN to receive these services without a referral from their PCP. The OB/GYN must be contracted with UnitedHealthcare Arizona Physicians IPA. These services are offered at no cost to you. Family planning includes the following services: Birth control pills: Pills taken every day Condoms (Rubbers) Depo Provera: Shot given every 3 months for women Diaphragm: Vaginal removable barrier worn by women Emergency contraceptive pill (ECP): Pill taken after unplanned sex to prevent pregnancy Family planning counseling services Family planning lab services IUD: Device placed in the uterus Natural family planning Spermicidal jelly, cream or foam: Vaginal medication Subcutaneous (under the skin) implantable contraceptives Tubal ligation: Surgical procedure for women 21 and older Vascetomy: Surgical procedure for men 21 and older The following services are not covered family planning or family planning extension services: Infertility services including diagnostic testing, treatment services or reversal of surgical infertility Abortion counseling Abortions Hysterectomies Hysteroscopic tubal sterilization If you are a SOBRA member, you may still get services after your baby s birth. You will be automatically enrolled in the Family Planning Services Extension Program (FPS) for up to 24 months. Eligibility is redetermined every 12 months. If you lose eligibility for Family Planning Services, UnitedHealthcare Arizona Physicians IPA can help you find low-cost or no-cost family planning services. We can also help you find low-cost or no-cost primary care services while you are an FPS member or if you lose eligibility altogether. If you need help finding these services, call Member Services at Arizona 25

28 Pregnancy Services knows that healthy moms have healthy babies. That is why we take special care of all our moms-to-be. If you think you may be pregnant or as soon as you know you are pregnant, call UnitedHealthcare Arizona Physicians IPA Member Services and your PCP. UnitedHealthcare Arizona Physicians IPA has a program called Healthy First Steps. It helps expectant mothers get the health care services if they need it, as well as medications and medical supplies. UnitedHealthcare Arizona Physicians IPA will help you: Choose a Primary Care Obstetrician (PCO), nurse practitioner, physician assistant or certified nurse-midwife (CNM) for pregnancy care Get information about special programs for UnitedHealthcare Arizona Physicians IPA pregnant members Schedule appointments and exams Choose a pediatrician (child s doctor) for your new baby and a PCP for you after the birth Choose a PCP for you after the birth or return to the PCP you had before your pregnancy. Call member services at after your delivery Get information on community programs such as WIC (Women, Infants, and Children). You can call WIC at Your doctor will give you: Care before and after your baby is born (no co-payments) Information about having a healthy pregnancy, such as good nutrition, quitting smoking, and exercise Information about childbirth options and childbirth classes Help with family planning choices and services after your baby s birth (including birth control pills, condoms and tubal ligation) Prenatal care appointment time frames: First Trimester Within 14 days of request for appointment Second Trimester Within 7 days of request for appointment Third Trimester Within 3 days of request for appointment High-Risk Pregnancy Within 3 days or immediately if it is an emergency Your appointments are very important to your health and the health of your baby. You should see your doctor during pregnancy even if you feel good. If you need to change your appointment, contact your doctor before your appointment. You should also see your doctor within 60 days after your baby s birth (postpartum care). If you are pregnant, you can have an HIV test. If your test is positive, you can get specialty treatment and medical counseling. Talk to your primary care physician or contact your local department of public health for testing. If you find out you are no longer pregnant, call Member Services. They will help you arrange any health care services or changes you may need. Quitting Smoking One of the most important ways you can improve your own health care is to stop smoking. If you need help quitting, talk to your doctor. The Arizona Smoker s Helpline (ASHLine) can also help with quitting. ASHLine offers help with information and referrals to programs or services. You can call ASHLine at Medicaid Member Handbook

29 Copayments Co-payments for AHCCCS members will change starting on October 1, Inside the Member handbook you can read about the changes for AHCCCS members who are NOT eligible for MED or AHCCCS Care. Because there is a lawsuit about co-payments for members in MED and AHCCCS Care, co-payments for these members may be different, and they can change during the next year. You can find out what co-payments you have by calling your health plan member services representative at or by going to myahcccs.com. You can also ask your provider to look up your eligibility to tell you what co-payments you have. The health plan website at also has information about co-payments. This stuffer tells you about the co-payments for members in the MED and AHCCCS Care programs. If you are in MED or AHCCCS Care, these co-payments start November 1, Members in the MED Program are people with high medical expenses who are not eligible for any other AHCCCS Program because of their income. Members in AHCCCS Care are adults who: Do not have an eligible deprived child living with them (see Arizona Administrative Code R ), are not pregnant, are not aged 65 or over, or are not disabled. Members in MED and AHCCCS Care are asked to pay higher co-payments for some of the AHCCCS medical services they receive. Members in MED and AHCCCS Care are required to pay the co-pays. This means that members need to pay these co-payments in order to get services. Pharmacists and medical providers can refuse services if the co-pay is not paid. There are some MED and AHCCCS Care members who are never asked for copayments. There are also some services that never have co-payments. The following persons in MED and AHCCCS Care are never asked to pay co-payments: Children under age 19 People determined to be Seriously Mentally Ill (SMI) by the Arizona Department of Health Services Individuals up through age 20 eligible to receive services from the Children s Rehabilitative Services program People who are in nursing homes, residential facilities such as an Assisted Living Home or who receive Home and Community Based Services such as attendant care or a visiting nurse People who receive hospice care Also, co-payments are never charged for the following services: Hospitalizations Emergency services Family Planning services and supplies Pregnancy related health care including tobacco cessation treatment for pregnant women Services paid on a fee-for-service basis Arizona 27

30 Co-payments (cont.) Beginning November , members in MED and AHCCCS Care have the following required co-payments: Service Copayment Generic Prescriptions and Brand Name Prescriptions when there is no generic $4.00 Brand Name Prescriptions when there is a generic that can be used $10.00 Non-emergency use of an emergency room $30.00 Doctor office visits $5.00 Pharmacists and Medical Providers CAN REFUSE services if the copayments are not made. If you don t think you belong in the MED or AHCCCS Care program or if your circumstances have changed, contact your eligibility office to ask them to review your eligibility. IMPORTANT: Remember that the copays for people in the MED and AHCCCS Care programs may change because of a lawsuit. The co-pays that are listed above start November 1, If the co-pays change, we will tell you so. 28 Medicaid Member Handbook

31 Behavioral Health Services We are concerned about how you feel. Behavioral health services can help you with personal problems that may affect you and/ or your family. These problems may be stress, depression, anxiety or using drugs or alcohol. Your AHCCCS card may have the phone number of the provider (Regional Behavioral Health Authority or RBHA) that will give you behavioral health or substance abuse services. You are assigned to a provider (RBHA) based on where you live. The provider (RBHA) will pay for most behavioral health services including most prescriptions for behavioral health conditons. If you card does not list the provider (RBHA) you are assigned to, please refer to the listing on page 30 or call Member Services for assistance. For behavioral health emergencies, please contact the crisis phone number for your local RBHA. DDD/ALTCS Members: You are eligible for behavioral health services through your local RBHA. If you need help getting these services, call your UnitedHealthcare Arizona Physicians IPA DDD Liaisons at or Behavioral health services you may be eligible for through the RBHA include: Behavioral health case management services Behavioral health medicines, monitoring, and adjustment Behavioral management Doctor services Emergency and medically necessary transportation Emergency or crisis services Individual, group and family therapy and counseling Inpatient hospital services Lab and radiology services Nursing services Other support services Partial care, basic and intensive Rehabilitation services Respite care Screening, evaluation, and diagnosis Substance abuse (drug & alcohol) counseling Each county has a RBHA. They will help you find out what type of services you are eligible for and where you can get them. All members are covered for behavioral health services in a crisis or emergency situation. If you have any questions about what is covered, call your local RBHA. A list of RBHA contact information is found on the next page. What If I Have a Behavioral Health Emergency? If you have a behavioral health emergency, it is important to get help right away. Please call the crisis phone number for your local RBHA. These phone numbers are on page 30. Remember, you should only call 911 if you are having a life-threatening medical emergency or if you are going to hurt yourself or someone else. Arizona 29