Member Handbook. Salud

Transcription

1 Member Handbook Salud

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3 A Quick Guide to your Presbyterian Salud health plan Welcome to Presbyterian Salud, we re proud to be your health plan. Our purpose is to improve your health. You ve taken an important step to make sure that your family has health coverage. Please read the simple steps below. We want to make sure you are ready to receive care when you need it. Take these three steps 1. Choose your primary care provider (PCP). This is the healthcare practitioner who will take care of most of your needs. This includes referring you to another practitioner if needed. Read more about the importance of a PCP on page 7 of this handbook. To find a PCP: Look in the Presbyterian Salud Provider Directory that came with this member handbook. You can look by city to find a PCP close to you. Look on our website, and click on Find a Doctor for the most up-to-date list of PCPs. Call the Presbyterian Customer Service Center ( Customer Service ) for help. See the phone numbers and hours at the bottom of each page of this handbook. 2. Call Customer Service if you are receiving medical services that you need to continue. These services include: Case management. Home health services. Medical equipment. Pregnancy care. Surgery that has already been scheduled. Other ongoing care such as radiation, chemotherapy, dialysis, ventilator care, diabetes care or pain control. 3. Put your Presbyterian Salud member Identification (ID) card in a safe place. Make sure to take it with you when you receive medical services or fill prescriptions. Healthcare practitioners will ask for it when you have an appointment. Your health coverage Your Presbyterian Salud plan covers the services listed below. Make sure to read more about these services in Section 2 Covered and Non-Covered Services. Some of these services may need to be approved before you have them. For your service to be covered, it must be medically necessary. Your PCP should provide the service or refer you to another provider in the Presbyterian Salud network for the service. You should only go to healthcare practitioners, hospitals, pharmacies and other providers that are in-network. In-network means that Presbyterian Salud has a contract with them to provide services to Presbyterian Salud members. In-network providers are listed in the Presbyterian Salud Provider Directory. Here are some of the services covered by this plan: Preventive services like immunizations (shots), well child checks, mammograms and Pap tests. Lab tests. Hospital care. Urgent care and emergency care. Prescription drugs. Behavioral healthcare (provided by OptumHealth New Mexico). Dental services. Vision services. Transportation. 1

4 Presbyterian Customer Service Center If you have any questions about Presbyterian Salud, Customer Service can help you. You may send an to them at Or, call them at one of the numbers below, Monday through Friday from 7 a.m. to 6 p.m.: In Albuquerque (English and Spanish): (505) Outside Albuquerque (English and Spanish): Navajo/Diné in Albuquerque: (505) Navajo/Diné outside Albuquerque: TTY phone line for hearing impaired: If you call after hours, your call will be answered by our automated phone system. You can use this system to: Leave a message for us to call you back in the morning. Leave a message saying that you have a complaint or appeal. Get transportation help right away. Talk to a nurse at NurseAdvice New Mexico right away if you have a health question. Choose a healthy life Presbyterian Salud works with many of the finest hospitals and doctors in New Mexico. We have a large network of independent healthcare professionals to help you get the healthcare you need. With contracted doctors and other practitioners throughout New Mexico, we re always close by to help you. We want you to choose to have a healthy life. This means taking charge of your own healthcare. The first step is to take good care of yourself and to let your PCP know if you have any health problems. The next step is to read this handbook carefully. It will help you to understand Presbyterian Salud and your benefits. Section 5 of this handbook includes Preventive Healthcare Guidelines. For 24-hour service, log onto My Pres Online. You can go to our website, and register on the home page. We look forward to working with you to improve your health! Behavioral Health OptumHealth New Mexico , TTY: All Behavioral Health benefits are provided by OptumHealth New Mexico. Presbyterian manages all of your physical healthcare benefits. If you have questions about your Behavioral Health benefits, please contact OptumHealth New Mexico. You can call them 24 hours a day, 7 days a week. This Presbyterian Salud Member Handbook was revised November Services are funded in part under contract with the State of New Mexico. MPC

5 TABLE OF CONTENTS Section 1 How Presbyterian Salud works...5 Presbyterian Customer Service Center... 5 Continuing your medical care... 5 Individuals with Special Healthcare Needs... 6 Presbyterian Salud is a Managed Care Organization (MCO)... 7 Your Primary Care Provider... 7 How to schedule an appointment... 9 How to cancel or change an appointment... 9 Referrals and specialists... 9 Copays for services Second Opinions Member Eligibility Use your benefits the right way Other insurance and Medicare Claims for services you receive Translation services Consumer Advisory Board Utilization Management Quality Improvement Presbyterian Healthy Solutions Section 2 Covered and non-covered services...15 Covered services Services that require Prior Authorization Behavioral Health Dental services Emergency care Family planning Services NurseAdvice New Mexico Pharmacy (prescription drugs) Pregnancy services Transportation benefits Vision services New medical treatments Women s Health and Cancer Rights Act of Value-Added Benefit for Native Americans

6 Non-covered services Experimental treatments Section 3 Your Rights and Responsibilities...32 Grievances and appeals How to switch to another Managed Care Organization How to disenroll from Salud! managed care Member rights and responsibilities Fraud and abuse Section 4 Other Important Information...39 Protecting your privacy Advance Directives Guidelines for enrollment Section 5 Health Information and Screenings...44 Preventive Healthcare Guidelines

7 Section 1 How Presbyterian Salud Works Presbyterian Customer Service Center The Presbyterian Customer Service Center is available to help you Monday through Friday from 7 a.m. to 6 p.m. Customer Service is closed on weekends and holidays. See the bottom of each page in this handbook for the list of phone numbers and times. Customer Service can: Help you pick a Primary Care Provider (PCP) or a Primary Care Obstetrician (PCO) if you are pregnant. Help you with a medical problem or complaint. Tell you about your benefits (what is covered and what is not covered). Help with transportation needs. Let you know about community resources that are available. Take your feedback, concerns and ideas for improving our services. You can also reach us by mail and on the Internet: Presbyterian Customer Service Center P.O. Box Albuquerque, NM Send an to Customer Service at info@phs.org. You can use our website, to access Pres Online and look at your plan information at any time. With Pres Online, our secure online site for members, you can: Look up your benefit plan information. Check your eligibility. Change your PCP. View your claims. Request replacement identification (ID) cards. Check the status of Prior Authorization requests. Send a question to Customer Service. To log in to Pres Online, register on the home page of our website, Continuing your medical care Now that you have chosen Presbyterian Salud, we want to make sure that you can continue your needed treatments or other services. Contact Customer Service and please let us know if you need to continue services like: Case management. Home health services. Medical equipment. Pregnancy care. 5

8 Surgery that has already been scheduled. Other ongoing care such as radiation, chemotherapy, dialysis, ventilator care, diabetes care or pain control. Also let us know if you: Have other insurance coverage. Use or have used Indian Health Services. Are pregnant and when your baby is due. If you are a Presbyterian Salud member and your Primary Care Provider leaves or is no longer in our network, you can continue your care with that practitioner for at least 30 days depending on your medical needs. This also applies to pregnant women in their second trimester. Pregnant women in their third trimester can continue seeing the same practitioner for the rest of their pregnancy. Individuals with Special Healthcare Needs Some Presbyterian Salud members need extra help with their healthcare. Presbyterian Salud helps members with special healthcare needs. Individuals with special healthcare needs usually have long-term health problems: They usually need more healthcare services or more complex healthcare services than most members need. They usually have medical or behavioral health problems that limit their ability to function. Adults who need healthcare and related services that are different from the services needed by most individuals. This includes the need to see their Primary Care Provider more often, take many different medicines, see many specialists or use therapies more often. Adults who need extra help with things like walking, bathing, dressing and eating. Children (under age 21) with Special Healthcare Needs include: Children who have or are at increased risk for an ongoing physical, developmental or behavioral health condition. Children who need healthcare and related services that are different from the services needed by most children. Children who are eligible for Social Security Insurance (SSI) as disabled under Title XVI. Children identified in the Department of Health Title V Children s Medical Services Program. Children in Home and Community-based Waiver Programs. Children receiving foster care or adoption assistance support through Title IV-E. Other children in foster care or out-of-home placement. Children who are eligible for services through the Individuals with Disabilities Education Act. Children whose clinical assessment shows that they have special healthcare needs. Adults with Special Healthcare Needs include: Adults who have ongoing physical, mental, neurobiological (such as autism or bipolar disorders) emotional and/or behavioral health conditions. How to get help for special healthcare needs If you think that you or your child has special healthcare needs, please call our Intake Coordinator in Albuquerque toll-free at , from 8 a.m. to 5 p.m. You can leave a message if you call 6

9 after office hours. We also have a handbook with more information to help you take care of special healthcare needs. This handbook will tell you more about all of the special services that we have. When you call, ask for the Handbook for Individuals with Special Healthcare Needs. Presbyterian Salud is a Managed Care Organization (MCO) Presbyterian Salud is a Managed Care Organization (MCO). Sometimes MCOs are also called HMOs. HMO stands for Health Maintenance Organization. Being an MCO means that we are a health insurance company whose most important job is to keep you well. As an MCO, we have contracts with many providers all over New Mexico. As a member of Presbyterian Salud, you can choose to see only those providers who are contracted with Presbyterian Salud. There are some exceptions: If you have an emergency (see page 18), please go to the nearest emergency facility. If the providers in our network cannot give you medically necessary care, we will help you find an out-of-network provider at no cost to you, except for any copayments that may apply. Native American members may self-refer to an Indian Health Service or tribal healthcare facility for services. For more information about Presbyterian, or to find out about our physician incentive plans, please call Customer Service. Or go to our website, and select About Us. Your Primary Care Provider (PCP) Your Primary Care Provider (PCP) is the person who will help you with all your healthcare needs. When you are sick or need a checkup, call your PCP s office. Your PCP may be a doctor, physician assistant or nurse practitioner. You and your PCP should work as a team to take care of your health. You should feel comfortable talking to your PCP about all of your healthcare needs. Choose your PCP You will need to choose a PCP who is in the Presbyterian network. Then call Customer Service and tell us the name of the PCP you have chosen. PCPs who are in the network are listed in the Presbyterian Salud Provider Directory. You can ask your friends and relatives if they have a PCP they like. Then check if the PCP is on the list. If the practitioner you want is on the list and is taking new patients, you can choose him or her to be your PCP. If you are pregnant, you may choose to have an Obstetrician as your PCP. If you need more information before choosing a PCP, call Customer Service. They can tell you: Where a practitioner went to medical school. What specialty the practitioner practices. The practitioner s board certification status. What languages the practitioner speaks. If you need a copy of the Presbyterian Salud Provider Directory, you may: Call Customer Service to request a copy. your request to info@phs.org. Visit our website at to view the provider directory online. 7

10 The provider directory is a list of all of the Primary Care Providers and Self-referral Service Providers you can choose to see if you are a Presbyterian Salud member. The types of providers are: PCPs OB/GYN Pharmacy Emergency Room/Urgent Care Routine Dental, Routine Vision and Transportation The provider directory includes the names, locations and phone numbers of the providers in our network. It also has information about the languages they speak and if they are accepting new patients. Call OptumHealth New Mexico for a list of Behavioral Health providers. You can contact OptumHealth New Mexico 24-hours a day at We are always adding new practitioners. If you want to see a practitioner who is not on the list, please contact Customer Service. They will tell you if the practitioner has been added to the list since the provider directory was printed. Specialist as a PCP You can choose a specialist to be your PCP if both Presbyterian and the specialist agree to this. Specialists who agree to be a member s PCP usually do so because the member has special healthcare needs (see page 6) and it is in the best interest of the member s health. A PCP close to home Presbyterian Salud wants to be sure that you have the medical services you need close to where you live. We have contracts with PCPs all over New Mexico. In fact, we have enough PCPs so that most of our members are within 40 miles of a PCP anywhere in New Mexico. Presbyterian Salud requires that you choose a PCP who is a reasonable distance from your home. If you live in Bernalillo, Doña Ana, Los Alamos and Santa Fe counties, your PCP should be within 30 miles. If you live in Chaves, Curry, Eddy, Grant, Lea, Luna, McKinley, Otero, Roosevelt, Sandoval, San Juan, Taos and Valencia counties, your PCP should be within 45 miles. If you live in Catron, Cibola, Colfax, DeBaca, Guadalupe, Harding, Hidalgo, Lincoln, Mora, Quay, Rio Arriba, San Miguel, Sierra, Socorro, Torrance and Union counties, your PCP should be within 60 miles. Please call Customer Service if you have questions or need help choosing a PCP. Contacting your PCP after hours Call your PCP s office even if the office is closed. Your PCP will have an answering service that can take a message or help you get care. Or the office may have a phone message that tells you how to get help. You can also call NurseAdvice New Mexico toll-free at to help you decide how to get care. NurseAdvice New Mexico will also give you medical advice. How to change your PCP Your Primary Care Provider (PCP) is an important part of your medical care team. If you have any questions about your care, just ask your PCP. We want you and your PCP to be able to work together. If you want to change PCPs for any reason, please call or write 8

11 Customer Service. Parents or legal guardians may also make a PCP change for a member who is a minor or an incapacitated adult. If you request to change your PCP on or before the 20th of the month, you may begin to see your new PCP any time after the first of the following month. For example, if you call on June 5 to change PCPs, your change will be effective on July 1. If you request to change your PCP after the 20th of the month, the change will be effective the first of the month following the next month. For example, if you call on June 21, your change will be effective on August 1. If you have any concerns about the care you are getting, please call Customer Service. day. The nurse can help you decide if you need to see your PCP or go to an Urgent Care or emergency facility. If you have a life-threatening medical emergency, call 911 or the emergency number in your area. (It is very important that you read the Emergency care section on page 18 of this handbook.) These symptoms are often emergencies: Chest pains. Bleeding that will not stop. Loss of consciousness. Poisoning. Severe burns. Shortness of breath. Uncontrollable feelings of wanting to hurt yourself or others. How to schedule an appointment You need to call your PCP s office to make an appointment before you can be seen. This will give your PCP a chance to spend as much time with you as needed. If you show up without an appointment, your PCP may not be able to see you. For routine care, you can schedule most appointments within three weeks of your call. PCP offices open at different times because they set their own hours. When you call, always tell the office staff that you are a Presbyterian Salud member and the reason why you need an appointment. If you need urgent care, your PCP may want to see you within 24 hours. Your PCP may send you to an Urgent Care Center if he or she can t see you that day. If you are sick and not sure if you need to see your PCP, call NurseAdvice New Mexico toll-free at You can call 24 hours a day, every How to cancel or change an appointment Call your PCP s office if you need to cancel or change your appointment. Call at least 24 hours before the scheduled time. This will give your PCP more time to see other patients. If you do not know your PCP s telephone number, call Customer Service. We can cancel the appointment for you. Referrals and specialists Your PCP is in charge of providing or arranging for most of the healthcare needs that are covered by Presbyterian Salud. Your PCP will refer you to other doctors when you need specialty care. Your PCP s office will schedule the specialist appointment for you or ask you to make the appointment yourself. If you know a specialist or hospital you want to go to when your PCP is referring you for care, ask if your PCP has a relationship with that specialist or 9

12 hospital. Your PCP will give you a referral if he or she does have a relationship. You will need a referral almost every time you see a specialist. Specialists that are in our network are listed in the provider directory. If you need specialist information or have questions about referrals, call Customer Service or your question to info@phs.org. You do not need a referral for these services: Behavioral Health. Emergency care. Family planning. Routine dental care. Routine vision care. Routine visits to a gynecologist. Visits to an obstetrician. You may use any family planning provider near you, even if the provider is not in the Presbyterian Salud network. Presbyterian recommends that you tell your PCP about using the services listed above. This will help him or her do a better job to improve your health. However, it is your right not to tell your PCP about receiving services that do not require a referral. If your PCP is not an OB/GYN and you need to see an OB/GYN for routine care, you do not have to see your PCP first. You can just make an appointment with the OB/GYN. Here is a list of the routine care you can get from your OB/GYN: Contraception. Family planning. Pap Test. Pregnancy. Sexually transmitted disease (STD) prevention and treatment. Treatment of vaginal infection. If you are pregnant on the date you become a Presbyterian Salud member, please contact Customer Service and let us know. If you are in your first or second trimester, in most cases you will be allowed to continue your care with that practitioner for at least 30 days. If you are in your third trimester of pregnancy, you can continue seeing your practitioner for the rest of your pregnancy. Copays for services If your member ID card says Copay applies, you will need to pay for the services listed below. Working Disabled (WDI) $5 Prescriptions $7 Dentist visit $7 Doctor visit, urgent care visit, or vision visit $7 Outpatient therapy $20 Emergency Room services $30 Inpatient hospital admission Children s Health Insurance Program (CHIP) $2 Prescriptions $5 Doctor visit, urgent care visit, or vision visit $5 Outpatient therapy $5 Dentist visit $15 Emergency Room services $25 Inpatient hospital admission 10

13 Keep track of your copays Every time you make a copay, keep your receipts. You are responsible for collecting and adding up your receipts and submitting the total to the Medical Assistance Division Client Services Bureau to show when your copayment maximum has been met. Presbyterian may send you a notice if you owe money to the provider. This includes payments for other services that are not covered by Medicaid. Note: If you are a Native American member, you do not have to pay any copays. Divorce. Guardianship. Marriage. If you have a change in family size: Tell the local Income Support Division office that signed you up for Medicaid about the change in family size.to add a family member or newborn, call the New Mexico Medicaid Managed Care Information Line toll-free at Call the Presbyterian Customer Service Center to choose a PCP for a new family member. Second Opinions You have a right to receive a second opinion for surgery or your treatment plan. Presbyterian will help you find a qualified practitioner to give you a second opinion. In most cases, the practitioner will be in the Presbyterian Salud network. If there is no qualified practitioner in the network, then we will help you find a qualified practitioner outside of the network. You do not have to pay for a second opinion from an innetwork practitioner. To avoid paying for services, Presbyterian must approve out-of-network services. To request a second opinion, please contact Customer Service by at info@phs.org or by phone. Member eligibility If your family size changes, your Medicaid eligibility and your Presbyterian Salud enrollment status might change. Some changes that may affect your eligibility and enrollment are: Adoption. Birth. Death. Let us know if you move If you move, you must give your new address to the Income Support Division office that signed you up for Medicaid. Please also call Presbyterian s Customer Service Center if you move. We need to be able to keep in touch with you and mail you important information. Please make sure we have your current address and phone number. Presbyterian Salud will let you know when there are changes to your health plan. We will either mail a letter to your home or we will send you a new version of this handbook. We may also inform you through a newsletter. The newsletter is usually mailed to you every three or four months. Use your benefits the right way Your Presbyterian Salud member ID card is for your use only. It is an important document to help you get the healthcare services you need. You are responsible for protecting your ID card. Protect it the same way you protect your driver s license, checkbook or other personal information. Misusing your ID card or ID 11

14 number, like giving, loaning or selling the card or the information on it, could result in losing your benefits. Presbyterian also could take legal action if you commit fraud. Keep your ID card in a safe place. You may notice other things that are not right. For example, a practitioner billing Presbyterian for services you did not receive or people receiving Medicaid benefits when they should not. Or you notice someone using someone else s ID card. If you notice anything like this happening, please call or write Customer Service. See the information about Fraud and Abuse on page 38 of this handbook. Other insurance and Medicare If you or your family has other medical insurance or Medicare, tell Customer Service and any persons who provide you with care. This helps Presbyterian and your practitioner identify who is responsible for your medical bills. We are required to get this information. This information will not change the services that are available to you. If you lose your Medicaid coverage, you might be able to get Presbyterian Health Plan insurance from an employer. Please call Customer Service or them at info@phs.org. Customer Service will contact our health plan sales department. The sales department will call you to discuss different insurance plan choices to help take care of your healthcare needs. Claims for services you receive If you receive a bill or a claim for covered services that you received, please do not pay it. We will pay the covered amount. Send the bill or claim to us at the address below. Note: You can be financially responsible for charges if you voluntarily received nonemergency or non-urgent services from a provider or practitioner who is not in the Presbyterian provider network. Please send your bill or claim to us at the following address: Presbyterian Customer Service Center P.O. Box Albuquerque, NM Translation services Presbyterian offers translation services for more than 140 languages. Some of these languages are Spanish, Vietnamese, Portuguese, Russian, and American Sign. Our Customer Service Representatives speak English, Spanish and Navajo/Diné. When you call Customer Service, ask to be helped in the language you need. Presbyterian Salud also makes written materials available in languages and formats other than written English. We provide these translations when we learn that there are large groups of Presbyterian Salud members who can use a language or format other than English. To request written materials in Spanish or in another language or format, please call Customer Service or send an to info@phs.org. Consumer Advisory Board We know you have important things to say and we want to make sure your voice is heard. Join the Presbyterian Salud Consumer Advisory Board and you can share your ideas about Presbyterian Salud. Board members get to: 12

15 Talk about current issues. Make suggestions to fix service issues or concerns. Provide input to member communications. Celebrate our successes. The benefits of being a board member include: Everyone at the meeting receives payment for their time and travel. We serve lunch at our board meetings. If you need a ride, we will have someone pick you up and drop you off. You can make a difference. Prior Authorization Some healthcare services require Prior Authorization from Presbyterian Salud. During Prior Authorization, Presbyterian Salud checks to make sure that the services are both necessary and timely. If you would like a copy of the Prior Authorization Guide, contact Customer Service. Concurrent Review Nurses work with discharge planners from hospitals or other medical facilities to make sure that you can stay in the facility for as long as you need care. We listen to our Consumer Advisory Board and you can help Presbyterian Salud become even better. Our board meets four times a year. If you have an idea on how we can serve you better, this is your chance to share ideas. Please call Customer Service or them at info@phs.org if you are interested in joining. Utilization Management Presbyterian Salud uses a process called Utilization Management to take the best care of you in the best place and at the right time. This process is made up of other processes that are explained below. If you have questions about these processes, please contact Customer Service. Retrospective Review Nurses review your insurance claims to make sure you received the necessary healthcare that was right for you. Care Coordination This is the process Presbyterian uses to help coordinate your medical needs whether you are in the hospital or at home. If you are in a hospital, a Presbyterian Nurse Case Manager will work with the hospital staff to help make the discharge process successful. When you are at home, a Nurse Case Manager will help you get services specific to your medical needs and will help find services in your area. Care Coordination works with you, your family and your practitioners to be sure you go to the hospital or the emergency center only when it is necessary. Utilization Management decision-making is based only on the appropriateness of care and service and your coverage. Presbyterian Salud does not reward practitioners or others for denying coverage or service. Money rewards are not given to utilization management decision-makers that might result in under-use of care. Case Management This is a process for managing the services for members with long-term or complex health problems. We work with practitioners, members and their families to be sure that members go to the hospital and emergency facility only when needed. We also make sure that members are using the right medicine. Our Case Managers use medical, social and community resources to help our members manage their own health. 13

16 Quality Improvement Presbyterian Salud s Quality Improvement Program is designed to improve the quality of care and services that members receive. We work to improve breast and cervical cancer screening, immunizations and the care of our members with asthma, diabetes and depression. Presbyterian Salud is finding new ways to improve our Customer Service and the benefit information we send to you. If you have any questions about our Quality Improvement Program, please call Customer Service. Presbyterian Healthy Solutions Presbyterian Healthy Solutions is a program for Presbyterian members who need help when they have a chronic medical condition. A chronic condition can be like diabetes, high blood pressure or coronary artery disease. We can help you: Learn more about your medical condition and how to treat it. Make the lifestyle changes that will improve your health. Find the best way to work with your healthcare practitioners. Have more energy to do the things that are important to you. Presbyterian Healthy Solutions provides: Support from health coaches, pharmacists and Case Managers. Easy to understand materials. Lifestyle and motivational tools. For more information call Healthy Solutions at (505) or toll-free at You can call Monday through Thursday from 12 noon to 8:00 p.m. and Friday from 10:00 a.m. to 6:00 p.m. 14

17 Section 2 Covered and Non-Covered Services Covered services The following list includes the services available to you as a Presbyterian Salud member. Some of these services may require Prior Authorization. Some may be limited by the Medicaid program guidelines. The New Mexico Medical Assistance Division reserves the right to add or delete benefits. Any covered service you get must be medically necessary. The type and amount of services you need are based on your medical condition. For example, you may need a certain number of physical therapy visits for a broken leg and a different number of therapy visits for a stroke. The length of time you would need to have these services may also be different. If you have a question about the number, type and length of time you or your family member might need a service, please contact Customer Service. Covered services include: Practitioner office visits. Children s preventive health services and Tot-to- Teen Check-ups. Hospital services, inpatient and outpatient. Medically necessary surgeries including preoperative and post-operative care. Pregnancy-related services. (See the Pregnancy services section on page 23.) Emergency medical services including Emergency facility visits. (See the Emergency care section on page 18.) Post-stabilization care (follow-up care you receive after a medical emergency). Laboratory, X-ray, and medical imaging services. Pharmacy services (includes prescriptions written by physical health practitioners, but does not include prescriptions written by behavioral health practitioners). (See the Pharmacy services section on page 21). Medical supplies, some medical equipment and some prosthetic devices. Dental services for children and adults (see Dental services section on page 17). Emergency dental care and medically necessary extractions. Vision services including glasses for children and adults. (See Vision Services section on page 29.) Family planning services. Reproductive services. Assistance with emergency and medically necessary transportation. (See the Transportation section on page 25.) 15

18 Physician services, hospitalization, prescription drugs, or other medical services related to nonexperimental organ transplants. Organ transplants. Podiatry (foot and ankle) services. Special rehabilitation services such as physical, occupational, and speech. Home healthcare. Hospice services. Pregnancy terminations. Dialysis treatments. Nutritional services. Telehealth services. Hearing services. Case management and care coordination services. Personal care services for children. Private-duty nursing for children. Second opinions by Presbyterian practitioners other than your PCP (see the Second Opinion section on page 11). Mastectomy-related services such as reconstructive surgery (surgery to make your breasts look the same) and artificial breasts. Procedures to fix complications from your mastectomy, such as lymphedema. Services provided in schools and school-based clinics. Services provided to Native Americans by traditional healers (see the Traditional healer benefit section on page 30). Services that require Prior Authorization Some services will need Prior Authorization to be covered by Presbyterian Salud. All services must be medically necessary. Your PCP or specialist will request Prior Authorization on your behalf. Services that require Prior Authorization from Presbyterian Salud include, but are not limited to, the following: Behavioral health: For questions about Prior Authorization for behavioral health services, call OptumHealth New Mexico at , 24 hours a day. Durable Medical Equipment (DME): These are items that can be used many times and are for medical purposes only. They are used to help with physical limitations and disabilities. The items can be used in the member s home under a physician s supervision. Some examples include: Wheelchairs CPAPs (for breathing) Orthotics: These items are used to improve the function of a moveable part of the body. Foot orthotics such as shoe inserts for members with diabetes may be covered. Specially made foot orthotics when attached to a leg brace may be covered. Prosthetics: These items are substitutes for a missing body part. Drugs/Pharmacy: Discuss with your Primary Care Provider. Dental services: some dental services require Prior Authorization before services are performed. Home healthcare services: Prior Authorization is required for non-presbyterian home healthcare. Prior Authorization is not necessary for Presbyterian Home Healthcare. Hospice. Inpatient admissions at non-presbyterian facilities. Surgical/Diagnostic Procedures Breast repair and reconstruction (male and female). Cosmetic surgeries. (These are usually not covered. Talk with your PCP.) Some back surgeries and back procedures. 16

19 Vision services: Some vision services require Prior Authorization before services are performed. Other: Transplant services (all transplants). Experimental services. Clinical cancer trials. New technology. Investigational technology. PET scan (positron emission tomography). Magnetic Resonance Imaging (MRI). Morbid obesity all office visits, services, special equipment, and surgeries. Out-of-network office visits, surgeries, treatments, and hospital stays. Behavioral Health In addition to medical concerns, there may be times when you need help with mental or emotional health, or alcohol- or drug-related problems. We call these services Behavioral Healthcare. OptumHealth New Mexico provides your Behavioral Health benefits. To access these services, call OptumHealth New Mexico. Their phone numbers are listed at the bottom of every page in this member handbook. There are four ways you can get Behavioral Healthcare: 1. Call OptumHealth New Mexico 24 hours a day. 2. Call your Behavioral Health practitioner. 3. Call your PCP. He or she will help you get the care you need. 4. If you need transportation to a Behavioral Health appointment, call Customer Service at (505) or toll-free at , to arrange for a ride. No referral needed You do not need a referral from your PCP to get Behavioral Healthcare. You can go directly to a Behavioral Health provider for help. Presbyterian Salud encourages you to tell your PCP if you are using these services. However, one of your rights is that you do not have to tell your PCP that you are using these services. Please call OptumHealth New Mexico with any questions about a Behavioral Health referral. Behavioral Health emergencies If you are having an emergency (for example, if you feel like hurting yourself or others or if you are not able to take care of yourself), you should do one of these things: Call 911. Call OptumHealth New Mexico 24 hours a day. Go to the nearest Emergency facility. How your Behavioral Health benefits work When you call OptumHealth New Mexico, they will help you get the care you need. The customer service representative will ask for your name and birthdate. The representative can help you find a practitioner. Continuing Behavioral Healthcare You may need to select a new provider for your Behavioral Healthcare. OptumHealth New Mexico can help you select a provider for your Behavioral Healthcare. Please contact OptumHealth New Mexico with any questions. Dental services Presbyterian Salud helps you take care of your teeth. Make your appointments today for routine dental exams. Starting routine dental exams now will mean 17

20 better lifelong dental health for you and your children. You do not need a referral from your PCP for dental services. We cover dental services for members of all ages. You must choose a dentist from the Dental Care Providers section of the Presbyterian Salud Provider Directory. Call your dentist to make an appointment and to find out if the services will be covered by Medicaid. Some exams and services are limited. Preventive dental services Coverage for dental services is limited. See below for some of the limitations. Your dental care provider will be able to tell you if services will be covered by Presbyterian Salud. Preventive services include: Dental cleaning: Limitations: One cleaning every 6 months for children under age 21 and for members 21 years and older who have developmental disabilities. One cleaning every 12 months for members 21 years and older. Fluoride treatments: Limitations: One treatment per member every 6 months for children under age 21. For members 21 years and older, this service must be medically necessary to be covered. Molar sealants: Limitations: Service is covered only for children under age 21. Only one treatment per tooth every five years. Other covered dental services (with limitations) The services are also covered but have limitations. Your Presbyterian Salud dental care provider will be able to tell you if services will be covered by Presbyterian Salud. Covered services include: Diagnostic services such as exams, including in an emergency. X-rays. Emergency services. Replacing teeth. Treating the nerves and blood vessels inside the tooth, such as a root canal. Oral surgery. Extractions. Using braces or other procedures to correct and straighten teeth (if you meet the guidelines). Emergency care If you are very sick or have an injury that you believe must be treated as an emergency, call 911 (or the emergency number in your area) or go to the emergency room. If you have an emergency, you may go to any hospital or facility that provides emergency care. You do not need Prior Authorization. You do not need a referral from your PCP. The provider directory shows the locations within the Presbyterian Salud network where providers and hospitals provide emergency services and poststabilization services. The list below shows some of the reasons to call for emergency help: Very bad chest pain or other pain. Hard time breathing. Uncontrolled bleeding. Loss of consciousness. Poisoning. Severe burns. Broken bone. Cut-off arm or leg. 18

21 Injured eye. Uncontrollable feelings of wanting to hurt yourself or others. The Emergency facility doctors and nurses take care of people who are so sick that they could get worse or die if they don t get care right away. It s important you go to an emergency facility only for true emergencies. If you have other symptoms that are not severe, and you are not sure if you need to go to the emergency room, follow the Count guidelines below. What is an emergency? If you: Are using reasonably good judgment, and Have a severe medical or behavioral health condition (including severe pain), and Believe that your health can be seriously harmed unless you get healthcare right away, or Believe that a body function, body part, or organ can be damaged unless you get healthcare right away, then this is an emergency. An emergency can also mean the health of a family member or an unborn child is at risk. Count Call your PCP s office. They will let you know where you should get care. 2. Call NurseAdvice New Mexico at You can speak to a nurse 24 hours a day, 7 days a week. The nurse will ask questions and tell you who to call or where to go for care. If your PCP s office is closed, the nurse can also help you decide what you should do. 3. Go to an urgent care center. Urgent care is when you need medical attention right away for an unexpected illness or injury, and it is not reasonable to get medical care from your PCP. The list below shows symptoms that probably don t need treatment in an emergency facility: Earache. Flu. Runny nose or cold. Rash. Sore throat. Stomach ache. If you believe that you have an emergency, you will not be billed for a visit to an Emergency facility. Presbyterian Salud will not deny a claim for emergency services even if the Emergency facility workers decide that your health problem is not an emergency. However, if you know that your illness is not serious or life-threatening and you go to the Emergency facility, you may be billed. You may also have to wait a long time to be seen. Follow-up care after an emergency After a visit to an Emergency facility, you may need follow-up care. The follow-up healthcare you receive will either keep your health steady or improve or resolve your health problem. This is called poststabilization care. You may receive post-stabilization care in a hospital or other facility. Presbyterian Salud covers this care. For other follow-up care, such as medicine refills or having a cast removed, go to your PCP s office. 19

22 Emergency care out-of-area If you are outside New Mexico (but not outside the United States), or you see a practitioner who is not on our list of Presbyterian Salud practitioners, you are out of Presbyterian Salud s service area. We call this being out-of-area. When you are out-of-area, we cover you for emergency services only. If you are out-of-area and have a life-threatening emergency, go to the nearest emergency service provider and show them your Presbyterian Salud member ID card. If you are out-of-area and the care you need is not life-threatening, call NurseAdvice New Mexico at Note: Healthcare services received outside of the United States are not covered. Behavioral Health benefits are covered by OptumHealth New Mexico. Please contact OptumHealth New Mexico about their out-of-area policy. Family planning services Presbyterian Salud offers family planning services and reproductive health services to all of its members, including adolescents. You have the right to receive these services when you need them and in private. You can visit your PCP or go to any family planning center or family planning practitioner for these services. You do not need a referral. Family planning or birth control helps you decide when you are ready to have a baby. To get help with your decision, you can see a qualified family planning practitioner (including an obstetrician) or a representative of Planned Parenthood. You do not need a referral from your PCP. Presbyterian Salud covers the following family planning services: Health education and counseling so that you will know which birth control method is best for you. Lab tests if you need them to help you decide which birth control you should use. Follow-up care for trouble you may have from using a birth control method that a family planning provider gave you. Family planning counseling. Birth control pills and devices including IUDs and condoms. Pregnancy testing and counseling. Tubal ligation. Vasectomies. Morning-after medication and pregnancy termination. Women have the right to self-refer to a women s healthcare specialist for routine and preventive services. Women may also have a PCP who is not a women s healthcare specialist. NurseAdvice New Mexico One important way you can take charge of your own healthcare is by using NurseAdvice New Mexico. Nurses are available 24 hours a day, 7 days a week to answer your healthcare questions. They can also help you decide if you need to get care from your PCP or if you can treat yourself at home. 20

23 The nurses do not take the place of your PCP. But, if it s late at night or you cannot reach your PCP, the nurses can help you decide what to do. The nurses can help you feel better and stay healthy. Pharmacy (prescription drugs) When your PCP or other healthcare practitioner gives you a prescription for medicine, you will need to get that medicine at one of the pharmacies listed in the Presbyterian Salud Provider Directory. Usually, these are the only pharmacies where you can get your medicine. You can use an out-of-network pharmacy only if Presbyterian Salud approves a request from your practitioner. To find a pharmacy near you, check the Presbyterian Salud Provider Directory. You can also call Customer Service or ask your PCP. Remember to show your Presbyterian Salud member ID card when you fill your prescription. If you have a problem getting your prescription filled, please call your PCP or Customer Service. For all new prescriptions: Presbyterian Salud will give you up to a 30-day supply of your medicine depending on how your practitioner writes the prescription. If your new prescription works for you, then your next two refills will be for 30 days each time. You can get a 30-day supply at a time or you can use our mail-order program that will give you a 90-day supply. You can also get a 90-day supply at most local pharmacies. To use the 90-day supply program, call Customer Service and they will help you fill out a mail-order form so you will get your prescription in the mail. Customer Service can also tell you what local pharmacies will give you a 90-day supply. At some pharmacies in certain communities in New Mexico, a 90-day supply may not be available to you. Please call Customer Service for details or with any questions. Behavioral Health prescriptions If your Behavioral Health practitioner writes you a prescription for medicine, OptumHealth New Mexico, not Presbyterian Salud, will cover that prescription. Please tell the pharmacist if you are filling a prescription written by a Behavioral Health practitioner. Presbyterian Salud covers all of your prescriptions that are written by non-behavioral Health practitioners. Prescription drugs and your safety Presbyterian Salud wants your healthcare to be as safe as possible. You can do some simple things that will increase your safety. We recommend that you: Start by being involved in your healthcare. If your illness makes this difficult, get help from someone you trust. Studies show that being involved creates the best results. Always carry a list of all the drugs that you are taking. This includes prescription drugs, over-the-counter drugs, and any supplements. Review this list with your practitioner at every visit. When your practitioner writes a prescription, make sure the writing is readable. When you go to the pharmacy, make sure you get the right drug and the right dose. If you have to measure your own medicine, ask your pharmacist to show you how to do so. If you have any other questions about your medicine, ask. Don t guess. 21

24 Presbyterian Salud s formulary A formulary is a list of approved prescription drugs. Our formulary is called a selectively closed formulary. This means that Presbyterian Salud will usually cover only the drugs on the list. Most of the drugs on the Presbyterian Salud formulary are generic drugs. Presbyterian Salud covers the first-line generic drug in each therapeutic class (type) of drug. Some formulary drugs require Prior Authorization. This means that your practitioner will have to request permission before prescribing the medicine. The formulary is available for you to review. Please call Customer Service to learn more about the drugs on the formulary. Your practitioners and pharmacy also have a copy of the formulary. Generic and brand-name drugs When a company creates and patents a prescription drug, the drug is called a brand-name drug. When another company makes the same drug, it is called a generic drug. Generic drugs usually cost less to buy than brand-name drugs, but they are made the same way. Each therapeutic class of drugs may have more than one brand-name and generic drug. Presbyterian Salud selects a first-line generic drug in most classes of drugs. Reviewing the formulary Presbyterian Salud uses a pharmaceutical management process to make sure that your prescription drugs are safe and effective. A team of pharmacists and physicians meets every two months. Some of these team members are Presbyterian Salud employees and others are from the community. The team is called the Pharmacy and Therapeutics Committee. The team looks at new drugs. They also look at new uses for existing drugs. If the drug is proven to be safe and effective, then they add it to the list of drugs available to members. The team may say that the drug can only be used to treat certain health problems. These restrictions are noted on the list. Experimental drugs are never added to the list. The team also looks at drugs already on the list. Sometimes, a new drug is a better treatment for a health problem than an older drug. In this case, the team may remove the older drug from the list. Also, if two drugs are equally safe and effective, the more costly drug may be removed from the list. If your medicine is not on the formulary Presbyterian Salud wants you to have the right prescriptions to improve your health, even if these prescriptions are not on the formulary. You may need a drug that is not on the formulary or that is not approved to treat your condition. In these cases, your practitioner can send a request to Presbyterian Salud for an exception. We will look at your practitioner s request and give authorization if we find the nonformulary drug is medically necessary. Approval is usually given for two reasons: A similar drug that is on the formulary is determined to be not as effective in improving your health. A similar drug that is on the formulary is determined to be harmful to your health. To make sure you do not have any problems filling your prescriptions, always ask your practitioner to check the formulary. If he or she prescribes a drug that is not on the formulary, the practitioner must have approval from Presbyterian Salud before you can get that medicine. 22

25 Without Presbyterian Salud s approval, the pharmacy will not be able to fill your prescription. We understand that you may need a non-formulary drug quickly. In an emergency, Presbyterian Salud will respond to your practitioner s request within 24 hours. You may use the appeals process (see page 32) if your request is denied. Paying for prescriptions Presbyterian Salud covers both formulary and approved non-formulary drugs. You do not have to pay a copay or fee, unless a copay is listed on your Presbyterian Salud member ID card. You may be responsible for the cost of a nonformulary drug if you get the drug without an approval from Presbyterian Salud. Pregnancy services Caring for pregnant women is important to us! We offer special services for pregnant women. If you are pregnant or think you may be, call Customer Service right away. When you call, we will: Help you choose a Primary Care Obstetrician (PCO) or Certified Nurse Midwife for your pregnancy care (also called prenatal care). Tell you about special programs for pregnant members. Help you choose a pediatrician for your baby and a Primary Care Provider for you after your six-week checkup following the birth of your baby, if eligible. Prenatal care (care during pregnancy) Early and regular prenatal care is very important for you and your baby s health. Your practitioner will: Give you information about childbirth classes. Let you know about good nutrition and exercise. Help you in the future with family planning services (including Norplant, birth control pills, condoms, and tubal ligation). At your prenatal care visits, be sure to tell your doctor the name of the pediatrician you want as your baby s Primary Care Provider. Within 30 days after your baby is born, tell your Income Support Division (ISD) Medicaid case-worker so your baby can be covered by Medicaid. The sooner you tell the case-worker about your baby s birth, the sooner your baby will have Medicaid coverage. This will let you schedule medical services for your baby. If you are no longer pregnant (because of miscarriage or abortion), and do not need the services of a Primary Care Obstetrician or Certified Nurse Midwife, call Customer Service. Medicaid benefits for pregnant women in Category of Eligibility 035 are limited to pregnancy-related services, family planning services and dental screening services only. See page 24 for information about when you should see your PCP or Primary Care Obstetrician when you are pregnant. Birthing options You can choose to have your pregnancy-related services provided at home or in a birthing center by a licensed certified nurse-midwife (CNM) or a licensed direct-entry midwife (DEM). These services will be covered only if they are provided by healthcare practitioners who have an approved Provider 23

26 Agreement with the Human Services Department/ Medical Assistance Division (HSD/MAD). If you are interested in having a midwife, call Presbyterian and request a midwife packet. Call Presbyterian Salud s Birthing Options Program at , 8 a.m. to 5 p.m. or leave a message. Follow the instructions in the packet when you receive them. If you choose a midwife for out-of-hospital birthing services, it is your right and your responsibility to: Ask the midwife you have chosen if he or she has malpractice insurance. Receive an informed consent or informed choice agreement from the midwife you have chosen about anticipated or unanticipated complications. If the midwife does not have malpractice insurance, you are assuming all risks of damage and injury. For more information about these services, contact Presbyterian Salud s Birthing Options Program intake nurse at You may also call Presbyterian s PRESious Beginnings program at Health guidelines for pregnant women Visit a healthcare practitioner as soon as you think you might be pregnant. Your practitioner will tell you how often you need to visit after your first visit. Usually you will visit your practitioner every four weeks until your last trimester. Then you will visit your practitioner every two weeks until your last month. Then you will visit every week during the last month. You will need to visit your practitioner again four to six weeks after you deliver your baby. Follow the guidelines below in addition to those listed for your age in the Preventive Healthcare Guidelines on pages Screenings You can expect to have the following screenings during your pregnancy: Education and Counseling Your practitioner should discuss these topics with you during your pregnancy. Immunizations (shots) Blood, urine, and other tests that will check the health of you and your baby. Tobacco cessation/effects of passive smoking Alcohol/other drug use Nutrition, including adequate calcium intake Multivitamin with folic acid Breastfeeding for child s health Lap/shoulder belts Infant safety car seats Sexually transmitted infection (STI) prevention Importance of postpartum visit (follow-up visit after baby is born) Birth control (at postpartum visit) Flu shot (ask your PCP) Rubella after delivery, if needed 24

27 Transportation benefits Presbyterian Salud provides transportation to medical and behavioral health appointments if you do not have transportation. Presbyterian s transportation provider has different types of transportation available. The type you qualify for is based on your pick-up location and where you are going. You may only qualify for one type of transportation solution. The types of transportation solutions include: Public, fixed-route bus (for example, ABQ Ride, RoadRUNNER Transit, CATS, etc.) Fixed-route rail (Amtrak, Rail Runner Express) Regional, fixed route (Greyhound) Regional shuttle services (offered by the community) Commercial air Door-to-door shared-ride vehicle The transportation provider will ask you questions to determine the type of transportation for which you qualify. They will also ask questions about the practitioner appointment to be sure that they know the location of the office. Based on the type of transportation, you may need to change the times of your appointments. Emergency transportation If you need emergency transportation for a lifethreatening situation, call 911 or the emergency telephone number in your area. We cover emergency transportation by ambulance, air ambulance, or specially equipped van. You should carry your Presbyterian Salud member ID card with you at all times. Same-day transportation Same-day transportation is available only if you need urgent healthcare services and don t have transportation. Same-day transportation is NOT available if you forgot to call for a ride for a scheduled appointment. If you are sick and feel like you need to see your PCP that same day, call your PCP. Your PCP will help you decide if you should come in that day. He or she may send you to an urgent care center instead. Urgent care is when your PCP feels you should be seen by a healthcare practitioner that same day. How to get transportation help If you need a ride to your appointment, call Customer Service. After hours, you can use our automated menu to get transportation help right away. You may also call the transportation provider directly at Call Monday through Friday from 5:00 a.m. to 8:00 p.m. and weekends from 6:00 a.m. to 4:00 p.m. You can call at any time to cancel or check a reservation or for discharge-related requests. Please note: The transportation provider is located in Arizona, a state that does not observe Daylight Savings Time (when we turn our clocks back one hour). From March through November each year, the hours for the transportation provider are: 6 a.m. to 7 p.m. weekdays and 5 a.m. to 3 p.m. on weekends. You must be an eligible Presbyterian Salud member to receive covered transportation services. Transportation to a pharmacy is not a Medicaidcovered benefit. You need to call Customer Service or the transportation provider before your appointment to schedule a ride. Here are rules for how soon you need to call. 25

28 If you live within 65 miles of your provider/ practitioner, call for a ride 48 hours before the appointment. If you live more than 65 miles from your provider/ practitioner, call 72 hours before the scheduled appointment. If you are not sure if you live within 65 miles of your provider/practitioner, please call Customer Service. Advance notice is required for transportation so that the most appropriate service can be arranged/ provided. Information you need before calling to reserve a ride You will need the following information when you schedule a ride: Your full name. Your New Mexico Medicaid ID number. This number is on your Presbyterian Salud member ID card. The time of the appointment. Physical address of the practitioner or facility. Name and phone number of the practitioner or facility. Return time. Special needs (medical equipment, oxygen, wheelchair, walker, medical attendant, etc.). Reason for the appointment. For example, medical appointment, dental appointment, or vision appointment. The Transportation provider will call to verify all appointments with your provider before your transport. Qualified attendants If you are an adult Presbyterian Salud member and need assistance, you may ask to have an attendant go with you to your appointment. We will provide transportation services for one approved attendant over the age of 18, that is needed to assist you. We may require a letter from your Primary Care Provider saying that it is medically necessary for you to have an attendant for your appointment. The attendant must be over age 18. He or she must be able to help in your medical needs. He or she cannot also require help. For example, your attendant cannot be on oxygen, need help getting in or out of the vehicle or need a wheelchair. Presbyterian Salud s Medical Director must approve transportation for your attendant before the transportation. Transportation for a companion (a child under age 18 or other family member or friend who is not an attendant ) is not covered. A person age 18 or younger is considered a companion and not a qualified attendant. Transportation to another city for healthcare Your healthcare practitioner may want you to see a provider in another city. We look at these requests on a case-by-case basis. Customer Service can help you find the closest appropriate provider/practitioner. If we approve the travel to another city: Presbyterian Salud will provide transportation in New Mexico or within 100 miles of the border (excluding Mexico). Presbyterian Salud will arrange for approved, out-ofstate transportation that is more than 100 miles from the New Mexico border. Transportation may be by bus, train, air or ambulance. 26

29 We do not provide transportation outside of your city if you refer yourself for services. For transportation out of your community, we may require a letter from your Primary Care Provider telling us why this is medically necessary. We will need the letter before the trip takes place. The letter must confirm that the facility you are being referred to is the closest provider for the needed treatment. Note: You may choose any available provider within the Presbyterian network, but transportation is covered only to the closest qualified provider. Door-to-door transportation If you qualify for door-to-door transportation, the transportation provider will give you a 30-minute range when they will pick you up. Please be ready at the beginning of the 30-minute range. The driver may arrive at any time during this 30-minute range. For example, you may be told that your driver will pick you up between 2:00 p.m. and 2:30 p.m. You must be ready to be picked up starting at 2:00 p.m., as the driver will come at any time between 2:00 p.m. and 2:30 p.m. If you are not ready, you could miss your ride. Drivers will wait up to 10 minutes within your 30-minute range. The driver will wait 10 minutes. Drivers cannot wait longer because they have other people to transport. If you miss your return time because your appointment is running late, you will be placed into a will call status. Once the transportation provider is told that you are ready, it can take up to 90 minutes to be transported. The transportation provider will verify with your provider what time your appointment was finished. Canceled or changed appointments You are required to call the transportation provider as soon as your appointment has been changed or canceled, or at least two hours before your scheduled pick-up time. Missed transportation appointments If you miss two or more transportation appointments in a row, a Customer Service representative will call you. The call will remind you of your responsibility to cancel transportation reservations at least two hours before your pick-up time or as soon as you know you will not be going to the appointment. If you continue to not cancel your transportation appointment when you don t need it, you may no longer qualify for the doorto-door option. Instead, the transportation provider may offer you a different option of transportation to your doctor appointments. When the driver arrives, you will need to sign a form that says you are eligible to receive Medicaid services. The driver will also make sure you have a scheduled medical or behavioral health appointment for that day. You may also have to write your Medicaid ID number on the form. This number is on your Presbyterian Salud member ID card. Individuals with Special Healthcare Needs Our transportation provider can transport you or your child if you have special healthcare needs. When you schedule your ride please let Customer Service know that you or your child has a special healthcare need. Transporting children No child under 10 years of age will be transported without a parent or legal guardian. A minor (ages 10 27

30 years to 17 years) may be provided safe transportation if a parent or legal guardian is not present or cannot make the trip with them. The parent or guardian of these children must provide: A signed Parental Release form. Emergency Contact Information sheet. provider when you make your reservation. They will tell you at that time. If you have door-to-door transportation, you must bring the food or drink in sealed containers. You may not eat in the vehicle. Presbyterian Salud will work with the transportation provider to make sure that the child is transported safely and to take care of any special needs on the Emergency Contact Sheet. The transportation provider keeps this sheet. The transportation provider may also call Customer Service for help with contacting a parent or legal guardian in an emergency. Other transportation solutions Presbyterian Salud may reimburse friends, nonhousehold relatives or volunteers to give you a ride to your appointment. You must request and be approved for mileage reimbursement before your trip. If it is approved, you will be given a form and instructions on how to submit it. To get the authorization, call the transportation provider at You will need to have the name and address of the office where you have your appointment. Submit the reimbursement form within 60 days from the day of your appointment. Reimbursement for the transportation is not always approved. The transportation provider decides when to use this option. Food and drink The rules for eating and drinking are based on the type of transportation. If it is medically necessary to bring food or drink, you must tell the transportation Meals and lodging Presbyterian Salud will pay for lodging for members who must travel more than four (4) hours one way for medical services. Unless you have an emergency, Presbyterian Salud must approve your request for lodging reimbursement before the trip. Presbyterian Salud will pay for meals for members who must leave their home community for eight hours or more for medical services. Unless you have an emergency, Presbyterian Salud must approve the request for meals reimbursement before the trip. Presbyterian Salud covers transportation, meals, and lodging for one attendant if the member receiving medical services is younger than 18 years of age. The attendant for a member younger than 18 years of age should be the parent or legal guardian. If the member is 18 years of age or older, the member s medical practitioner must put it in writing that there is a medical necessity for an attendant. Presbyterian Salud will not cover transportation, meals, or lodging for attendants under 18 years of age. Unless you have an emergency, Presbyterian Salud must approve your request to cover an attendant s meals and lodging before the trip. 28

31 You must send original receipts to the Presbyterian Customer Service Center. You must also send a cover letter with: 1. Member s name. 2. Member s Medicaid number. 3. Attendant s name and relationship to patient. 4. Date(s) of medical services. 5. Practitioner(s) name, address, and phone number. The maximum amount we pay for lodging is the set New Mexico Medicaid rate. Call Customer Service to ask for a Reimbursement Form. Send the Reimbursement Form and original receipts to: Presbyterian Health Plan Presbyterian Customer Service Center P.O. Box Albuquerque, NM The items we do not pay, include but are not limited to: In-room movies, telephone charges, room service, laundry, and other convenience items. Out-of-state transportation, meals, and lodging Presbyterian Salud must pre-approve all out-of-state transportation, meals and lodging. We will approve out-of-state transportation only for approved out-ofstate medical services. Air/Ground Ambulance In state and out-of-state If you have a medical or health emergency, dial 911 or the emergency number in your area. The transportation provider does not coordinate with air or ground ambulance transportation. Presbyterian coordinates all non-emergent ambulance services. You, your provider s office or a Nurse Care Coordinator should call Customer Service. Vision services Presbyterian Salud helps you take care of your eyes. It s important to have your eyes checked regularly. A routine eye exam can find serious health problems. Plus, eye exams for kids can find problems that can affect the way they learn and develop. Presbyterian Salud covers specific vision care services needed to diagnose and treat eye diseases and to correct vision. Medicaid has specific guidelines for when eyeglasses and contact lenses are covered. Routine eye exams Routine eye exams are covered by Presbyterian Salud. Children are limited to one routine eye exam in a 12- month period or when care is medically necessary. Adults are limited to one routine eye exam in a 36-month period. You must choose an eye care provider in the Presbyterian Salud provider network. These eye care providers are listed in the Vision Care Practitioners section of your Presbyterian Salud Provider Directory. You do not need a referral. Eyeglasses Medicaid has specific guidelines for when eyeglasses are covered. Your eye care provider will be able to tell you after your exam if a set of eyeglasses will be covered by Presbyterian Salud. Even if the eye care provider says you need eyeglasses, the glasses may not be covered unless you meet the specific guidelines from Medicaid. 29

32 For example: Let s say that you have worn eyeglasses for two years. When you have an eye exam to check your vision, your vision has not changed at all or has not changed enough to meet Medicaid s guidelines. In this case, Presbyterian Salud may not pay for a new set of eyeglasses. Coverage for children is limited to one set of corrective lenses and eyeglass frames in a 12-month period (if the child meets the Medicaid guidelines) or when medically necessary. Coverage for adults is limited to one set of corrective lenses and eyeglass frames in a 36-month period (if you meet the Medicaid guidelines). Bifocals, tinted lenses and balance lenses are covered in some cases. Minor repairs to eyeglasses are covered. Contact lenses Medicaid has specific guidelines for when contact lenses are covered. You must also have prior authorization to receive contact lenses. Even if Presbyterian Salud would cover a set of eyeglasses, it may not cover contact lenses. Your eye care provider will be able to tell you after your exam if contacts will be covered by Presbyterian Salud. Coverage for children is limited to one pair of contact lenses in a 12-month period instead of glasses (if the child meets the Medicaid guidelines) or when medically necessary. Coverage for adults is limited to one pair of contact lenses in a 36-month period instead of glasses (if you meet the Medicaid guidelines). Eye prosthesis Presbyterian Salud covers eye prostheses (artificial eyes) when medically necessary. New medical treatments New technologies and procedures are evaluated by a committee of medical practitioners and management staff. The New Mexico Medical Assistance Division of the New Mexico Human Services Department reserves the right to add or remove benefits. Women s Health and Cancer Rights Act of 1998 Presbyterian Salud provides benefits for mastectomyrelated services including: Reconstruction and surgery to achieve symmetry between the breasts. Prostheses. Treatment of complications resulting from a mastectomy (including lymphedema). This is required by the Women s Health and Cancer Rights Act of If you have any questions, please contact Customer Service. Value-Added Benefit for Native Americans Traditional healer benefit This benefit covers the healer s (provider s) services for counseling and healing rituals. The benefit covers a maximum of $200 in a 12-month period. This benefit requires Prior Authorization. Medications must be prescribed by an in-network healthcare practitioner. Medications must be on the Presbyterian Salud drug formulary to be covered. Coverage does not include transportation, herbs or tobacco product. 30

33 Non-covered services The services listed below are examples of services that are not covered: Acupuncture. Chiropractic services. Services performed or prescribed under the direction of a person who is not a healthcare practitioner. Prescriptions written by Behavioral Health practitioners (these prescriptions will be covered by OptumHealth New Mexico). Sex-change operations. Reversal of voluntary sterilization. Services or items needed only for cosmetic reasons including plastic surgery. Laser vision correction, unless it is medically necessary. Services that Medicaid determines to be experimental or done mainly for research purposes. Personal care items, like toothbrushes and television sets in hospital rooms. Services received outside the United States. Medical services provided to a person who is an inmate of a public institution. Fertility drugs, in-vitro fertilization and other prepregnancy fertility services. Some adult dental services. Most over-the-counter drugs. Some Durable Medical Equipment (contact Customer Service for a list of what is not covered.) Transportation to pharmacy providers. Note for Category of Eligibility 029 members: Family Planning services are covered by fee-for-service Medicaid but are not covered by the Medicaid Salud plan. Experimental treatments Presbyterian Salud will cover only the costs of medical treatments and medicines that have been shown to work. We do not cover the costs of treatments that Medicaid determines to be experimental. We also do not cover the costs of services performed or prescribed under the direction of a person who is not a healthcare practitioner. Behavioral Health benefits are covered by OptumHealth New Mexico. Please contact OptumHealth New Mexico about their experimental treatment policy. See the phone numbers at the bottom of the page. 31

34 Section 3 Your Rights and Responsibilities Grievances and appeals If you are not satisfied with your physical healthcare, you should discuss the problem with your Primary Care Provider (PCP). If you still have concerns after talking with your PCP, call Customer Service. Customer Service can help you if you have a specific complaint about your physical healthcare. If you have a complaint about your behavioral healthcare, please contact OptumHealth New Mexico. See the phone numbers on the bottom of each page in this handbook. The grievance process You may also file a grievance about your physical healthcare. A grievance is an official notice of your dissatisfaction with your physical healthcare. If you decide to file a grievance, you must do so within 90 calendar days of the date that you had the problem with your healthcare. You may file a grievance orally or in writing. If you need help filing a grievance, please call Customer Service. Customer Service can also help you translate the grievance into English. You can send your grievance in writing to: Presbyterian Salud Grievance Coordinator P.O. Box Albuquerque, NM You may also send your grievance in an to info@phs.org. Presbyterian will send you a letter saying that we received your grievance. The letter will be sent within five business days. We will resolve your grievance within 30 calendar days. If we cannot resolve your grievance within the 30-day period, we may request an extra 14 calendar days. Also, you have the right to request a 14-day extension. The New Mexico Human Services Department (HSD) must approve any 14-day extension. If we ask for the extension, we will send you a letter that explains why we asked for the extension. We will send you the letter within two business days. When we resolve your grievance, we will send you a letter. The letter will explain what information we used to resolve your grievance. It will explain how we 32

35 resolved your grievance. The letter will also state that we have finished working on the grievance. Unless they are involved in your grievance, we will not tell anyone about your grievance without your permission or unless we are required to by law. We will still give you the physical healthcare that you need, even if you file a grievance. You will not be punished for filing a grievance with Presbyterian Salud. Presbyterian keeps copies of all filed grievances. You may ask to see copies of your grievances at any time. Please use the contact information on page 32 to see your grievances. If you have a complaint or grievance about your behavioral healthcare, the Medical Assistance Division has a special number to call. Call the Behavioral Health Ombudsman at Please call between 8:00 a.m. and 5:00 p.m. Monday through Friday. Or, write to: Behavioral Health Ombudsman Medical Assistance Division 2025 South Pacheco Street Santa Fe, NM The appeals process Presbyterian Salud wants you to have the physical healthcare you need. Our employees are very careful to make sure that the physical healthcare you receive is the right kind and right amount of care. You have the right to disagree with any of Presbyterian Salud s decisions or actions that affect your physical healthcare. For example, you can disagree with us if: A physical healthcare service that you or your provider requests is limited or denied. A physical healthcare service that you have already been authorized to receive is limited or denied. Presbyterian Salud decides not to pay for all or part of a physical healthcare service. Presbyterian Salud does not give you good service or does not respond to your complaints. Presbyterian Salud does not complete a Prior Authorization for routine care within 14 days, or for urgent care within 72 hours. If you disagree with a decision or action that affects your physical healthcare, you may file an appeal with Presbyterian Salud. An appeal is an official notice of your disagreement and a request for review of our decision or action. If you decide to file an appeal, you must do so within 90 calendar days of the date that you received notice of the decision. You may file an appeal orally or in writing. If you need help filing an appeal, please call Customer Service. Customer Service can also help you translate the appeal into English. You can call or write to Presbyterian Salud. Call toll-free or (505) in Albuquerque and ask to file an appeal. Or, write to: Presbyterian Salud Appeals Coordinator P.O. Box Albuquerque, NM You may also send your appeal in an to info@phs.org. Presbyterian keeps copies of all filed appeals. You may ask to see these copies at any time. Contact the Appeals Coordinator to ask to see your appeal. 33

36 If you or your provider files an appeal within 13 calendar days of receiving notice of our decision, and you request an extension of the benefit, we will continue the physical healthcare service until: The appeal is withdrawn. 13 days have passed after mailing a resolution of the appeal letter and there is no further disagreement. The time period or limits of the authorized healthcare service have expired. You will be able to look at your medical records and files. If you want, someone else involved in your physical healthcare can speak for you. Both Level I and Level II appeals are heard by Presbyterian employees, including physicians. However, you will have a new group of employees hearing a Level II appeal. You may have to pay for services received if the appeal is resolved in favor of Presbyterian Salud. After receiving your appeal, we will send you a letter within five business days. The letter will state that we received your appeal. It will also state when we expect to resolve your appeal. We will resolve your appeal within 30 calendar days. Our appeals process allows members to ask for a Level I appeal and a Level II appeal. A Level I appeal is a first appeal. If a Level I appeal is resolved in favor of Presbyterian Salud, you can ask for a Level II appeal. We will resolve both appeals within a total of 30 calendar days. We can ask HSD to approve a 14-day extension if we need more time to resolve your appeal. Also, you can ask for a 14-day extension. If we ask for an extension, we will send you a letter that explains why we asked for the extension. We will send you the letter within two business days. During the appeals process, you will be able to explain why you disagree with Presbyterian Salud. You will be able to show evidence to us. At the end of the 30-day period, we will send a letter to you and to your practitioner. The letter will state our decision and the date of the resolution. If the decision is not in your favor, the letter will also tell you how to continue your disagreement by asking for a fair hearing through HSD. Quick decisions on appeals If you feel that your physical health may be seriously harmed by waiting for the regular appeals process, you may ask for a quick decision on your appeal. Most of the time we will process an appeal within 30 calendar days, but if it is an emergency, we will handle it right away. If you need a quick decision on your appeal, please tell us. Be sure to say that it is because you feel that your physical health may be seriously harmed if you have to wait for the regular appeals process. We will work to resolve a quick appeal as soon as possible. Please note that HSD allows up to three (3) working days to resolve a quick appeal. Fair Hearing process You may ask for a fair hearing through HSD before, during, or after filing and resolving an appeal with Presbyterian Salud. If you decide to ask for a fair hearing, you must do so within 90 calendar days 34

37 of receiving notice of the decision with which you disagree. To request a fair hearing, write to: Fair Hearing Section New Mexico Human Services Department 37 Plaza La Prensa P. O. Box 2348 Santa Fe, NM Or call: (505) or toll-free and then press 6. If you request a fair hearing within 13 calendar days of our decision to deny or limit a physical healthcare service, and you request an extension of the benefit, Presbyterian will continue the service and wait for the outcome of the fair hearing. You may have to pay for services received if the fair hearing is resolved in favor of Presbyterian Salud. How to switch to another Managed Care Organization (MCO) If you are not satisfied with Presbyterian Salud and want to switch to a different MCO, you have 90 days from the date that you become a member to ask for a different MCO. If you leave and then return to Presbyterian Salud, you will need to stay with Presbyterian Salud for 12 months. This lock-in period of 12 months is part of the Medicaid Program Guidelines. Members may request to break a lock-in for a good reason, such as: Maintaining continuity of care. Allowing family members to all belong to the same MCO. Correcting a clerical error that caused the member to be enrolled with the wrong MCO. Traveling a reasonable distance for primary healthcare. You can speak for yourself at the hearing. You may have a friend, relative, spokesperson, or attorney speak for you. You can also ask the Hearings Bureau to show you your file. We will not tell anyone about your appeal or fair hearing without your permission or unless we are required to by law. We will still give you the physical healthcare that you need, even if you disagree, file an appeal or ask for a fair hearing. You will not be punished for disagreeing with Presbyterian Salud, for filing an appeal or for requesting a fair hearing. You will need to send a written request to the New Mexico Human Services Department (HSD) to switch to another MCO during the lock-in period. If you need help with your request, please call Customer Service. HSD will approve or deny the request. They will notify you and Presbyterian Salud of their decision. Send your written request to: HSD Client Services Bureau P.O. Box 2348 Santa Fe, NM If HSD approves your request to switch to a different MCO, Presbyterian Salud will help you transfer your care to the new MCO. We will work to make this transfer as smooth as possible. 35

38 At the end of the 12-month lock-in period, you will be notified by mail that you may choose to stay with Presbyterian Salud or switch to a different MCO. Also, if you lose Medicaid eligibility for two months or less, you will automatically be re-enrolled with Presbyterian Salud. If the end of the 12-month lock-in period occurs during the time that you are not in Medicaid, you can ask to switch to another MCO anytime after you return to Presbyterian Salud. How to disenroll from Salud! managed care You have the right to disenroll from Salud!, even during a lock-in period, if you have a good reason to do so, such as: You move out of the Salud! service area (Salud s service area is the state of New Mexico and 100 miles from the border). Salud! will not cover a healthcare service for moral or religious reasons. You need related healthcare services to be done at the same time and: there is no network provider who can do this another provider has determined that you would be at risk if you received the services separately. Other reasons such as: receiving poor quality of care problems getting covered services problems finding a provider who has experience dealing with your health needs. The New Mexico Human Services Department (HSD) must review and approve any request to disenroll. For help with the disenrollment process, call Customer Service. A written request for disenrollment must be sent to HSD for review. HSD will approve or deny the request. HSD must approve or deny the request no later than the first day of the second month following the month during which the request was sent. For example, if a request is sent on June 14, then HSD must approve or deny the request no later than August 1. If HSD does not respond in time, then the request is approved. Send your written request to: HSD Client Services Bureau P.O. Box 2348 Santa Fe, NM If your disenrollment request is denied, then you may request a fair hearing. See page 34. Member rights and responsibilities As a member of Presbyterian Salud, you have specific rights and responsibilities. This section lists them for you. You can also find this information on our website, Presbyterian Salud respects your rights. Our partnership with you will be best when we ensure your rights and you meet your responsibilities. We follow the Americans with Disabilities Act, federal, and state laws as required. You have the right to: Get information about Presbyterian Salud, services, how to access them, your rights and responsibilities and the practitioners available for your care. Be treated with respect and recognition of your dignity and right to privacy. Participate with your practitioner in all decisions about your healthcare, including your treatment plan 36

39 and the right to refuse treatment. Family members and/or legal guardians or decision-makers also have this right, as appropriate. Talk about appropriate or medically necessary treatment options for your health conditions, regardless of cost or benefit coverage. File a grievance or appeal about Presbyterian Salud or the care that you received. Grievances can be filed with Presbyterian Salud and New Mexico Human Services Department without fear of retaliation. Make recommendations about Presbyterian Salud s Member Rights and Responsibilities policy. Receive healthcare that is free from discrimination. Choose a practitioner or provider from the Presbyterian Salud network (a referral or authorization may be necessary to see some practitioners). Receive a second opinion from another Presbyterian Salud practitioner or Presbyterian Salud shall arrange for you to obtain a second opinion outside the network at no cost to you. Have an interpreter when you do not speak or understand the language that is being spoken. Know the name and professional background of anyone involved in your treatment and the name of the person primarily responsible for your care. Discuss healthcare concerns with the person responsible for providing your healthcare or with the Customer Service department. Receive healthcare that is free from any form of restraint or seclusion that is used to coerce, discipline or punish you or that is used merely for the convenience of a healthcare provider. Decide on Advance Directives for your healthcare as allowed by law. Please see Advance Directives and decisions about your healthcare on page 43 for more information. Inspect and get a copy of your Protected Health Information as allowed by law. Receive confidential communications of your Protected Health Information from Presbyterian Salud. Request an amendment, or addition to, your Protected Health Information if, for example, you feel the information is incomplete or wrong. Request that the Use or Disclosure of your Protected Health Information is restricted (see page 40). Receive an accounting of Protected Health Information Disclosures. Get a paper copy of the official Privacy Notice from Presbyterian Salud upon request (even if you have already agreed to receive electronic Privacy Notices). Disenroll from Presbyterian Salud with approval from HSD. Select a Managed Care Organization and switch from one MCO to another without threats or harassment. Receive any information in a different format in compliance with the Americans with Disabilities Act (ADA). Give informed consent for medical services. Choose a surrogate decision-maker to be involved as appropriate, to assist with care decisions. Be free from harassment by Presbyterian Salud or its network providers in regard to contractual disputes between Presbyterian and providers. 37

40 You have a responsibility to: Give complete health information to help your practitioner or provider give you the care you need. This includes providing childhood immunization records for members up to age 21. Follow your treatment plans and instructions for medications, diet, and exercise as agreed upon by you and your practitioner. Do your best to understand your health problems and take part in developing treatment goals agreed upon by you and your practitioner. Make appointments ahead of time for practitioner visits, well-child checkups, prenatal care, and transportation services. Keep your appointment, or call your practitioner to reschedule or cancel no later than 24 hours before your appointment. Tell your practitioners if you do not understand explanations about your healthcare. Treat your practitioners and other healthcare employees with respect and courtesy. Show your ID card to each practitioner before getting medical services (or you may be billed for the service). Know the name of your PCP. Get a referral from your PCP before seeking treatment that requires a referral. Call your PCP or NurseAdvice New Mexico before going to an Emergency Room, except in situations that you believe are life-threatening or that could permanently damage your health. Tell the New Mexico Human Services Department and Presbyterian Salud when your phone number, address or family status changes. Tell Presbyterian Salud if you have other health insurance, including Medicare. Give a copy of your Living Will and Advance Directives to your PCP for inclusion in your medical records. Read and follow this handbook. Fraud and abuse Fraud and abuse increase the cost of healthcare for everyone. Presbyterian Salud cooperates with government, regulatory, and law enforcement agencies to report suspicious activity. This includes both provider and member activity. Presbyterian Salud has a hot line to report suspicious activity. The telephone numbers are (505) (Albuquerque area) and (toll-free). The following are examples of suspicious provider activity that you should report: Charging for services that you did not receive. Billing more than one time for the same service. Billing for one type of service but giving you another type. The following are examples of suspicious member activity that you should report: Forging or selling prescriptions. Falsifying enrollment information. Allowing someone else to use your ID card. By preventing fraud and abuse, Presbyterian Salud can focus on improving the health of individuals, families and communities. 38

41 Section 4 Other Important Information Protecting your privacy Presbyterian Salud is serious about protecting your privacy. We know that you trust us to use your personal information to improve your health. We do not share your private information with anyone, unless we have your permission or if we are allowed to or required to by law. Protected Health Information Protected Health Information is any health information about you that we send, receive, or keep as part of our daily work to improve your health. This includes information sent, received, and kept by electronic, written and oral means. If we have health information that clearly identifies you, or that could be used to identify you and your health needs, we call this Protected Health Information. Medical records and claims are two examples of Protected Health Information. Use and Disclosure Use occurs when Protected Health Information is shared among Presbyterian Salud employees. Disclosure occurs when Protected Health Information is shared by two or more organizations. For example, your Primary Care Provider discloses Protected Health Information to Presbyterian Salud. Your privacy rights As a Presbyterian Salud member, you have the right to: Inspect and get a copy of your Protected Health Information. Request restrictions on certain uses and disclosures of Protected Health Information. Receive confidential communications about your Protected Health Information from Presbyterian Salud. Request an amendment or addition to incorrect or incomplete Protected Health Information. Receive an accounting of Protected Health Information Disclosures. Get a paper copy of the official Privacy Notice from Presbyterian Salud upon request (even if you already agreed to receive electronic Privacy Notices). For more information about your rights, please see the next page. 39

42 Inspecting and getting a copy of your Protected Health Information You have the right to request access to inspect and get a copy of your Protected Health Information. There are a few exceptions. You do not have the right to access Protected Health Information that contains: Psychotherapy notes. Information gathered in reasonable expectation of, or for use in, a civil, criminal, or administrative action or proceeding, such as information that is protected by attorney-client privilege. Protected Health Information maintained by Presbyterian Salud that is subject to the Clinical Laboratory Improvement Amendments of 1988 (CLIA) 42 U.S.C. 263a, to the extent the provision of access to the member would be prohibited by law; or exempt from the Clinical Laboratory Improvements Amendments of 1988 (CLIA), pursuant to 42 CFR 493.3(a)(2). To request access to inspect and get a copy of your Protected Health Information, you must send a request in writing to: Presbyterian Salud Attn.: Director, Customer Service P.O. Box Albuquerque, NM Presbyterian Salud will act on this request no later than thirty (30) days after receiving it. If we cannot complete your request within thirty (30) days, we may take up to thirty (30) more days. However, we must give you a written reason for any delay. And, we must tell you by what date we will act on your request. Requesting restrictions of Use and Disclosure Presbyterian Salud uses and discloses information only to deliver healthcare products and services to our members per our contracts or to meet legal requirements. A list of specific purposes includes, but is not limited to: Claims payment. Fraud and abuse prevention. Data collection. Performance measurements. Meeting state and federal requirements. Utilization management. Research for accreditation. Preventive health services. Early detection and disease management programs. Treatment. Coordination of care. Quality assessment and measurement, including member surveys. Research of complaints and grievances. Billing. Responding to member requests for information, products or services. You have the right to request that Use or Disclosure of your Protected Health Information is restricted to: Presbyterian Salud s treatment, payment, and healthcare operations; and persons involved in your care (e.g., family member, other relative, close personal friend, or any other person you name); notification of your location, general condition, or death; a public or private entity assisting in disaster relief. By law, Presbyterian Salud may deny any requests to restrict its use of Protected Health Information. If we 40

43 do agree to a restriction on the use of your Protected Health Information, Presbyterian Salud will still be obligated to disclose that information as required by law or may exercise the right to use that information as otherwise permitted by law. You may make your request in writing or we will document your verbal request. Requesting an Amendment (addition to) Protected Health Information You have the right to request an amendment, or addition to, your Protected Health Information if, for example, you feel it is incomplete or inaccurate. This right lasts for as long as we keep the information. You do not have the right to delete Protected Health Information. Send your written request to Customer Service. The request must include a supporting reason to make an amendment. By law, Presbyterian Salud may deny your request. We must approve or deny your request no later than 60 days after receipt of your request. We must send you written notice of our decision. Requesting an account of Protected Health Information Disclosures You have the right to request an account of Protected Health Information Disclosures. For each Disclosure, the account must include: The date of the Disclosure. The name and address (if known) of the entity or person who received the Protected Health Information. A brief description of the Disclosed Protected Health Information. A brief statement that explains why the information was Disclosed or a copy of the written Disclosure request. 41 To make a request, please contact Customer Service. Use of consents and authorizations Written authorization is required for Disclosure of Protected Health Information except as otherwise permitted or required by law. A member s legal guardian, custodial parent or legal representative may also sign an authorization as allowed by law. All participating providers, practitioners, and facilities must follow federal and state laws and keep patient information confidential. This includes a patient s HIV/AIDS status, mental health, sexually transmitted diseases or alcohol/drug abuse. Presbyterian Salud will not disclose your Protected Health Information without your authorization, except as permitted or required by law. Please note that you give limited consent or authorization when you sign your enrollment form. You allow Presbyterian Salud and its authorized agents, regulatory agencies, and affiliates to access your Protected Health Information. To request an Authorization Form, please call Customer Service or visit us at Authorization forms will be kept in your medical record or enrollment file. Members who are unable to give consent or authorization Sometimes, courts or doctors decide that certain members do not understand enough to make their own healthcare decisions. These members cannot legally give consent or authorization. For these members, a legal guardian or other legal representative must sign the form.

44 Keeping information private and safe Presbyterian Salud follows strict confidentiality policies. All Protected Health Information is kept in a physically secure location. Only Presbyterian Salud employees and other authorized persons have access to Protected Health Information. In addition, all employees must: Use Protected Health Information only if it is essential to job-related tasks. Not discuss Protected Health Information unless it is essential to job-related tasks. Keep reports and other Protected Health Information from the view of other patients, members, and employees who do not need the information for a job-related task. Obtain signed confidentiality statements from volunteers and signed confidentiality agreements from organizations in a business relationship with Presbyterian Salud to ensure the proper handling of Protected Health Information. Sign a confidentiality agreement. Violation of these rules by an employee may result in immediate dismissal. Information collected by our website, Presbyterian enforces security measures to protect personal health information that is maintained on the website, network, software, and applications. We collect two types of information from visitors to our website: 1. We monitor our website traffic statistics, including: Where visitor traffic comes from. How traffic flows within the website. What browser type people use. Traffic statistics help us improve the website and find out what visitors find interesting and useful. 2. If you fill out a form on the Presbyterian website, you might provide us with personal information such as your name, address, billing information, and health plan member status. Presbyterian uses your personal information to reply to your concerns. We save this information as needed to keep responsible records and handle inquiries. We do not sell, trade, or rent our visitors personal information to other companies or partners. Ask Customer Service about Pres Online. Disclosure to government agencies and other organizations Presbyterian does not disclose Protected Health Information to anyone unless we have your permission or if we are allowed to or required to by law. In some cases, it is legal for us to disclose Protected Health Information to certain government agencies or accrediting organizations. These agencies and organizations make sure we comply with applicable laws and standards. Use of measurement data Presbyterian sometimes uses member health data to learn more about the illnesses that affect our membership. The data help to improve the overall care that Presbyterian Salud practitioners give to members. This is not the same as Protected Health Information. No names are given in the data. The data cannot be used to identify you or your health needs. 42

45 Questions about our privacy practices If you have any questions about our privacy practices, please call Customer Service. You may also refer to our website, for helpful information such as the provider directory, claims status, eligibility status. The website also includes information such as member rights and responsibilities and our official Joint Notice of Privacy Practices. Advance directives and decisions about your healthcare Advance directives make your wishes known if you are sick or hurt and can t speak for yourself. Presbyterian has a handbook called Making Healthcare Decisions. This handbook has information about advance directives. Call Customer Service to ask for a copy of the handbook. You can also find information and forms on our website: patients/info/advdirective/index.htm. Types of advance directives include: Living will. This lets you detail the treatments you want and don t want if you can t speak for yourself. A living will can tell a caregiver if you want to be fed or given fluids through tubes. It also tells the healthcare practitioners if you want them to make special efforts to save your life. To avoid problems with state and federal laws about practitioner care, make sure you clearly say what you want and don t want. Durable power of attorney for healthcare. This lets you choose a friend or relative to make medical decisions for you if you can t do that yourself. Do-not-resuscitate order. This lets caregivers know you don t want to receive CPR if your heart stops beating. Make sure to give copies of your Power of Attorney statement or Living Will to your provider, practitioner and to the hospital, if you are admitted. Always keep a copy for yourself. You may change these directions. If you make changes, make sure everyone has a new copy. If you cannot express your healthcare wishes, a court may appoint someone (called a guardian) to make decisions for you. However, the best way to have your healthcare wishes carried out is to write very clear directions about the kind of healthcare you want. Presbyterian cannot help you prepare written directions. Customer Service can give you the contact information for agencies that can help you write directions about your healthcare decisions. Guidelines for enrollment The following people cannot enroll in the Salud plan: Individuals in long-term care facilities. People eligible for both Medicare and Medicaid (known as dual eligibles ). Native Americans, except those who voluntarily enroll in Salud. Out-of-state foster care placements. Individuals receiving premium assistance. The following people are subject to mandatory enrollment in the Salud plan: Salud-eligible individuals (all other population groups not listed above). The following people are free to enroll in the program: Native Americans who choose to enroll in Salud. 43

46 Section 5 Health Information and Screenings Preventive Healthcare Guidelines Keeping kids healthy! Children are special to Presbyterian Salud. We have a program called EPSDT (Early and Periodic Screening, Diagnostic and Treatment) which includes Tot-To- Teen Checkups (well-child checkups). Tot-to-Teen checkups cover immunizations and other preventive healthcare for children and young people up to age 21. Preventive healthcare and well-child checkups may help prevent serious illness. Your Primary Care Provider (PCP) will provide these services. We will send you a reminder when it s time for your children to have a health check. You can then call your child s PCP to make an appointment. Schedule a well-child visit for your child within six months of enrolling in Presbyterian Salud. Immunizations (shots) for your kids An Immunization Schedule will help you to know the shots your child needs and at what age they should get them. Also, be sure to talk to your child s PCP to make sure that your child s shots are up-todate. Bring your child s shot records to each visit. For more information on immunizations or to build a personalized shot schedule for your child, visit a special page on our website, Keeping yourself healthy Our Preventive Healthcare Guidelines list the exams and screenings you should have and at what age you should have them. These are general guidelines for healthy children and adults. Your child s PCP may want you and your child to get these services more or less often. Talk to your PCP about what is right for you and your child. Schedule a visit within six months of enrolling in Presbyterian Salud. Talk to your Primary Care Provider for tips on how to stay healthy, such as eating right and exercising regularly. Take charge of your healthcare! 44