DC Healthcare Alliance

DC Healthcare Alliance You can call us 24 hours a day, 7 days a week, or stop by our office Monday through Friday from 8:00am 5:30pm. For directions on how to visit us, call (202) 821-1100. Health Plan 1100 New Jersey Ave., SE Ste. 840 Washington, DC 20003 Member Services (202) 821-1100 Toll Free (855) 326-4831

Important Phone Numbers For questions about call: Member Services (202) 821-1100 OR (855) 326-4831 (toll free) 8:00am-5:30pm Monday-Friday If you need care after your doctor s office closes or have a question you need to ask a nurse call: If you need mental health care or have a mental health question call: If you need to see a doctor within 24 hours ( Urgent Care ) call: If you need someone who speaks your language or if you are Hearing Impaired, call: Nurse Helpline (855) 872-1852 (toll free) 24 hours a day, 7 days a week TTY/TDD Your PCP s Office DC Department of Behavioral Health Hotline Your PCP s Office After Hours dial 711 for TTY Assistance (fill in your PCP s information here) 24 hours a day, 7 days a week (888) 793-4357 24 hours a day, 7 days a week (fill in your PCP s information here) Nurse Helpline (855) 872-1852 (toll free) 24 hours a day, 7 days a week Member Services (202) 821-1100 OR 8:00am-5:30pm (855) 326-4831 (toll free) Monday-Friday TTY/TDD 711 24 hours a day, 7 days a week For dental questions: DentaQuest (800) 417-7140 8:00am-5:30pm Monday-Friday FOR AN EMERGENCY, DIAL 911 OR GO TO YOUR NEAREST EMERGENCY ROOM Your Main doctor: Phone: Child s Main doctor: Other Child s Main doctor: Phone: Phone: Welcome to Health Plan Thank you for choosing Health Plan () as your Medicaid Managed Care Organization (MCO). Our commitment is to provide you with access to quality health care with excellent customer service. This Member Handbook contains important information about and how our plan works. We urge you to review it carefully. As a member you will obtain great benefits and services. If changes how it works or learns information about its medical providers that you need to know (such as 2

which doctors are taking new patients and the doctors office hours), you will be informed about the change 30 days before it occurs. New members will receive an invitation in your New Member packet to our New Members Orientation as well as a new member welcome call. The New Member Orientation is our way of providing you with a personal way for you to learn how to best use our health care system and to ask any questions you may have. Quality Corner Did you know that you can get a copy of s Quality Improvement Program summary? The summary includes: QI program activities, goals and outcomes. Just call Member Services @ (202) 821-1100 or visit our website at www.trustedhp.com (member resource section). 3

How this Handbook Works is a managed care plan that is paid by the District of Columbia to help you get health care. In this Handbook we tell you about how works, how to find doctors, how to call us, and what things we pay for. Telling you about these things can be hard to do and hard for everyone to read. Words used in health care and words used by your doctor can sometimes be hard to understand, Sometimes we have to tell you about laws that you need to know about. These also can be hard to understand. To help you, we have underlined some words that might have a different meaning from the one you know. We have explained these words in the back of this book. If you ever have any questions about things you read in this book or other questions about you can call Member Services at (202) 821-1100 or visit www.hp.com we will do our best to help you. How this Member Handbook Can Help You This Member Handbook tells you: How to get health care What Services we will pay for (we call this, what Services are covered by us) What Services we can t pay for How to pick your Primary Care Provider (your PCP) What to do if you get sick What you should do if you have a Complaint (also called a Grievance ) or want to change ( Appeal ) a decision by This Member Handbook gives you basic information about how works and its rules. Please call Member Services if you have any questions 24 hours a day, seven days a week. 4

Table of Contents Important Phone Numbers... 2 Welcome to Health Plan... 2 How this Handbook Works... 4 Your Rights and Responsibilities... 7 Your Member ID Card... 11 Your Primary Care Provider (PCP)... 12 Picking your PCP... 12 How to change your PCP... 13 Routine Care, Urgent Care and Emergency Care... 13 When you are Out of Town:... 14 Providers and Providers who are not part of... 15 Making an Appointment... 16 Making an Appointment with your PCP... 16 Changing or canceling an Appointment... 16 Getting care when your PCP s office is closed... 16 How long it takes to see your doctor... 17 Support Services... 19 Interpretation & Translation Services/Services for the hearing and visually impaired... 19 Interpretation Services... 19 Translation Services... 19 Services for the Hearing and Visually Impaired... 19 Transportation Services... Error! Bookmark not defined. Specialty Care and Referral... 19 How to get specialty care... 19 Self-Referral Services... 20 You DO NOT need a Referral to:... 20 Mental Health Services... 20 Services for alcohol or other drug problems... 20 Birth control and other Family Planning Services... 21 Pharmacy Services and prescription drugs... 22 Disease Management... 22 Services to Keep Adults from Getting Sick... 22 Recommendations for Checkups ( Screenings )... 22 Preventive counseling... 23 Adult Immunizations... 23 Pregnancy... 23 Prenatal and Post-Partum Care... 24 Once you have had your baby, call:... 24 Your Child s Health... 24 Health Check Program for Children (EPSDT)... 24 Immigrant Children... 24 Care for your children s teeth... 25 Children with Special Health Care Needs... 26 The IDEA program... 26 covers the services listed below if your child is in the IDEA program:... 27 5

Immunizations (shots) for children and teens... 28 Your Health Benefits... 28 Health Services covered by... 28 Services We Do Not Pay For... 33 Other Important Information... 34 What to do if you move... 34 What to do if you have a baby... 34 What to do if you adopt a child... 34 What to do if someone in your family dies... 34 How to change your Managed Care Organization... 34 What to do if you get a bill for a covered service... 35 Paying for Non-Covered Services... 35 Advance directives... 35 What to do if you have other insurance... 36 What to do if you are eligible for both Medicaid and Medicare... 36 Physician (doctor) incentive plan disclosure... 36 Complaints/Grievances, Appeals and Fair Hearings... 36 Complaints/Grievances... 36 Appeals and Fair Hearings... 37 Appeals... 37 Expedited (Emergency) Complaints/Grievances and Appeals process... 38 Your rights during the Complaints/Grievances, Appeals and Fair Hearings process... 38 The District s Ombudsman Program... 38 Notice of Privacy Practices... 40 Why Are You Giving This Notice to Me?... 40 What is Health Plan Required to do Under HIPAA?... 40 What is Protected Health Information (PHI)... 40 How Can You Use or Share my PHI?... 40 What are my Rights Under Federal Law with Respect to my PHI?... 42 May I Complain about Your Privacy practices?... 43 How will I know if my rights change?... 43 Medicare Part D Notice to Members... Error! Bookmark not defined. For Members with both Medicare and Medicaid... Error! Bookmark not defined. What Some Words Mean... 45 6

Your Rights and Responsibilities You have a right to: Be treated with respect and dignity. Know that when you talk with your doctors and other providers its private. Have an illness or treatment explained to you in a language you can understand. Participate in decisions about your care. Refuse treatment or care. Be able to see your medical records and to request that they be fixed if they are wrong. Choose an eligible PCP from within s network and to change your PCP. Make a Complaint ( Grievance ) about the care provided to you and receive an answer. Request an Appeal or a Fair Hearing if you believe was wrong in denying, reducing or stopping a service or item. Obtain medical care without unnecessary delay Receive information on advance directives and choose not to have or continue any life-sustaining treatment. Receive a copy of Member Handbook. Continue treatment you are currently receiving until you have a new treatment plan. Receive interpretation and translation services free of charge if you need them. Refuse oral interpretation services. Get an explanation of prior authorization procedures. Obtain summaries of customer satisfaction surveys Receive s Dispense As Written policy for prescription drugs. Receive family planning services and supplies from the provider of your choice. Be free from any form of restrain or seclusion used as coercion, discipline, convenience or retaliation, as specified in other federal regulations on the use of restrains and seclusion. Receive information about benefits available under the District plan, but not covered by. To a candid discussion of appropriate or medically necessary treatment options for your conditions regardless of cost and benefit coverage. Have direct access to a women s health specialist within the network for the covered care necessary to provide women s routine and preventive healthcare services. Also, female enrollees have a right to designate as their PCP a participating provider or an advanced practicing registered nurse who specializes in obstetrics (OB) and gynecology (GYN). Ask for a chaperone to be present when you receive health care. Receive information about Health Plan s financial condition and any special ways we pay our doctors. 7

Your Rights and Responsibilities Continue You have a right to: Received information about Health Plan, our services, our providers and other health care workers, our facilities, and your rights and responsibilities as a member. Receive a second opinion from a qualified health care provider within the network, or arrange for the enrollee to obtain one outside the network, at no cost to you. Be informed about how and where to access any benefits available under the district of Columbia plan but not covered under the contract, including any cost sharing, and how transportation is provided upon enrollment, annually an at least 30 days prior to any change. Not be held liable for the Health Plan s debts in the event of the Health Plan s insolvency. Use any hospital or other setting for emergency care. Be treated no differently by providers or by Health Plan for exercising your rights listed here. 8

You are responsible for: Treating those providing your care with respect and dignity. Following the rules of the D.C. Medicaid Managed Care Program and Health Plan. Following plans and instructions you receive from your doctors and other providers. Going to Appointments you schedule or that schedules for you. Telling your doctor at least 24 hours before the Appointment if you have to cancel. Asking for more explanation if you do not understand your doctor s instructions. To make recommendations regarding Health Plan s Member Rights and Responsibilities policy. Going to the Emergency Room only if you have a medical emergency. Telling and your PCP about medical and personal problems that may affect your health, to help them to provide you care. Reporting to Economic Security Administration (ESA) and if you or a family member have other health insurance. Trying to understand your health problems and participate in developing treatment goals to help and PCP provide your care. Helping your doctor get medical records from providers who have treated you in the past. Telling if you were injured as the result of an accident or at work. 9

COMPLIANCE REPORTING 855 228 1700 The THP Compliance Program offers a confidential and anonymous telephone hotline available 24/7 to voice your concerns about any situation that may conflict with Compliance Program principles. If you want to report concerns or suspicions regarding: Compliance with federal or district law Compliance with THP policies Suspected fraud, waste or abuse Possible ethical or code of conduct violations You may also send a message to our inbox: ReportFraud@HP.com You may also come speak to our Compliance Officer, George Aloth, directly. Your report will remain confidential and your privacy will be respected! No individual who reports Compliance Plan violations or suspected fraud and abuse is retaliated against by anyone who is employed by or contracts with THP. Anyone who believes that he or she has been retaliated against may report this violation to the DHCF Office of Program Integrity and/or the U.S. Office of Inspector General. 10

Your Member ID Card After you sign up for and you have picked a primary care provider (PCP), we will send you a Member ID Card in the mail. This card lets your doctors, hospitals, pharmacies and others know that you are a Member of. Please make sure that the information on your Member Identification Card is correct. If there are any problems, or if you have lost your card, call Member Services (202) 821-1100 or (855) 326-4831 (toll free). Your Member ID Card Looks Like This Each Member has his or her own card. Your children will also have their own cards, you must keep your children s cards so they don t get lost. It is against the law to let anyone else use your Member ID Card or Medicaid card. Please remember to carry your Member ID Card with you all the time. Always show your card before receiving any medical care or getting medicine at a pharmacy. Be sure to keep your Medicaid Card too. 11

Your Primary Care Provider (PCP) When you join, one of our doctors will be your main doctor. This doctor is called your Primary Care Provider or PCP. Your PCP will help you and your family get the health care you need. It is important to call your PCP first when you need care. If you had a doctor before you signed up with please call Member Services at (855) 326-4831. We can help you stay with that doctor if you want to. To find more information about doctors, go to our website or call Member Services at (202) 821-1100. You will find information about the doctors Name, Address and telephone numbers Professional qualifications Specialty Education including the medical school attended Residency Board Certification Status Picking your PCP 1. Pick a PCP at the time you enroll in. This person will be your PCP while you are a member of. If your current PCP is a member of s network, you may stay with that doctor. If you don t have a PCP, you can choose from a list of doctors in our Provider Directory or at www.hp.com Call Member Services at (202) 821-1100 if you need help in picking a doctor. If you do not pick a PCP within the first 10 days of being in our plan, we will choose a doctor for you. If you do not like the PCP we pick for you, you may change your PCP. Call Member Services at (202) 821-1100 to change your PCP. will send you a Member ID Card. Your card will have your PCP s name and phone number on it. 2. Choose a PCP for each family member in our plan, including your children. Your PCP may be one of these kinds of doctors: Family and General Practice Doctor - usually can see the whole family Internal Medicine Doctor - usually sees only adults and children 14 years and older Pediatrician - sees children from newborn up to adult Obstetrician/Gynecologist (OB/GYN) - specializes in women s health and Maternity care If you or your child has Special Health Care Needs, a specialist may be your PCP but you need to call us as and let us know that you would like this. We will try to help you get a specialist to be your PCP, but the specialist would have to agree to it. 12

3. When you pick your PCP, please: Pick a doctor who is close to your home or work. Try to pick a doctor who can send you to the hospital you want. Not all doctors can send patients to all hospitals. Our provider directory lists which hospitals a PCP can send you to. You can also call Member Services for help. Sometimes the PCP you choose won t be able to take new patients. We will let you know if you need to pick a different doctor. How to change your PCP You can change your PCP anytime. Just pick a new PCP from the Provider Directory. Call Member Services at (202) 821-1100 once you have picked a new PCP. If you need help picking a new PCP, Member Services can help you. Routine Care, Urgent Care and Emergency Care There are three kinds of health care you may need: Routine Care, Urgent Care, or Emergency Care. Routine Care is the regular care you get from your PCP. Routine Care is also care you get from other doctors that your PCP sends you to. Routine Care can be Check-Ups, physicals, health Screenings, and care for health problems like diabetes, hypertension, and asthma. If you need Routine Care, call your PCP s office and ask to make an Appointment. Urgent Care is medical care you need within 24 hours, but not right away. Some Urgent Care issues are: A sprain or a strain Throwing Up Lice, scabies or ringworm An earache A cough or cold Refills for medicine Diarrhea A cut or scrape A sore throat Diaper rash Mild Headache If you need Urgent Care, call your PCP s office. If your PCP s office is closed, leave a message with the person who answers the phone when the office is closed. Then call the Nurse Help Line at (855) 872-1852. A nurse will help you decide if you need to go to the doctor right away. The nurse will tell you how to get care. You do not have to go to the Emergency Room or use an ambulance for routine or Urgent Care. Emergency Care is medical care you need right away for a serious, sudden (sometimes life-threatening) injury or illness. Emergency Medical Conditions are: 13

Miscarriage/pregnancy with vaginal bleeding Bleeding that won t stop A broken bone A bad burn You are in labor Drug overdose Shock (you may sweat, feel thirsty or dizzy or have pale skin) Seizures Poisoning Fainting/unconsciousness Gun or knife wounds Suddenly not able to see, move or speak Care When You Are Out-of-Town When you are Out of Town: WHAT TO DO IF YOU HAVE AN EMERGENCY: 1. Call 9-1-1 or go to your nearest emergency room. 2. Show the Emergency Room (ER) your Member I.D. Card. 3. As soon as you can, call your PCP. When you need to see a doctor or get medicine when you are out-of-town, you should: For Routine Care: You must call us and ask if we will pay for you to see a doctor or other provider when you are out of town because doctors who are not in the District of Columbia are not a part of. If does not say it is okay before you get the care, you will have to pay for the care yourself. If you need medicine from a doctor while you are out-of-town, please call our Member Services Department or Nurse Advice Line for help. For Urgent Care: Call your PCP. If your PCP s office is closed, call the Nurse Help Line (855) 872-1852. A nurse will help you decide if you need to go to the doctor right away. The nurse can tell you how to get care. You do not have to go to the Emergency Room or use an ambulance for routine or Urgent Care. For Emergency Care: If you have an emergency, including a mental health or alcohol or other drug emergency, go to the nearest Emergency Room (ER) to get care right away. If you go to the emergency room, you should ask the ER staff to call your PCP. If you go to the emergency room, you should call Member Services as soon as you can. If your child does not live at home and needs to see a doctor, please call Member Services at (202) 821-1100. 14

Providers and Providers who are not part of will pay for the care you get when you go to one of our doctors or other health care providers. We call these doctors and other health care providers our network providers. All these In-Network doctors can be found in your Provider Directory. A doctor or provider who is not one of ours is called an Out-of- Network Provider. If you go to an Out-of-Network doctor, hospital or lab, you may have to pay for the care you get. You will not have to pay if you have asked us first and we have told you, usually in writing, that it is okay. We call this prior written authorization. Prior authorization (or prior approval) means approval for a health service that is not routinely covered by. You must get this approval before you receive the service. To ask about getting a prior authorization call the Utilization Management Department at (202) 821-1145. You may go to a Family Planning provider who is out-of network even if you do not have prior authorization. See page 19 for more information on Family Planning Services. You may go to an Emergency Room which is out-of network even if you do not have prior authorization. Remember: You need to go to a provider in s network. Utilization Management (UM) If you have a question about an approval or denial of medical services or procedures, call the Utilization Management Department at (202) 821-1145 or toll-free at (855) 326-4831, Monday Friday 8:00 5:30. TDD/TTY and language services are available. Decisions about whether covers a service are based on well-known and agreed upon rules on what is best for your health and what is covered by your Medicaid plan (your benefits). does not give bonuses to doctors for saying no to (denying) your request. Money is not used to reward doctors that deny or limit health services you may feel you want or need. 15

Making an Appointment Making an Appointment with your PCP 1. Have your Member ID Card and a pencil and paper close by. 2. Call your PCP s office. Look for your PCP s phone number on the front of your Member ID Card. You can also find it in your Provider Directory or online at www.hp.com 3. Tell the person who answers that you are a Member. Tell them you want to make an Appointment with your PCP. 4. Tell the person why you need an Appointment. For example: a. You or a family member is feeling sick b. You hurt yourself or had an accident c. You need a check- up or follow-up care 5. Write down the time and date of your Appointment. 6. Go to your Appointment on time, and bring your Member ID Card with you. 7. If you need help making an Appointment, please call Member Services at (202) 821-1100. If you are a new Member of, you should make an Appointment for your first health Check-Up as soon as possible. Changing or canceling an Appointment It is very important to go to your Appointment and to be on time. If you need to change or cancel your Appointment, please call the doctor at least 24 hours before your Appointment. For some Appointments, you may have to call more than 24 hours before to cancel. If you do not show up for your Appointment or if you are late, your doctor may decide you cannot be his or her patient. Getting care when your PCP s office is closed If you need to speak to your PCP when the office is closed, call your PCP s office and leave a message with the person who answers the phone when the office is closed. Be sure to give the person who answers your phone number. Someone will call you back as soon as possible. You can also call the Nurse Help Line 24 hours a day at: (855) 872-1852. If you think you have an emergency, call 911 or go to the Emergency Room. 16

How long it takes to see your doctor Your doctor s office must give you an Appointment within a certain number of days after you call. The table below shows how long it will take to get an Appointment. Please call (202) 821-1100 if you cannot get an Appointment during these time periods. Type of visit Your condition You are hurt or sick and need care within 24 hours to avoid getting worse, but you don t need to see a doctor right away How long it takes to see your doctor Urgent Visit Routine Visit Follow-up Visit Adult Wellness Visits Non-urgent Appointments with specialists (by Referral) Child EPSDT checkups -not urgent Some examples of when you need urgent care are: a sprain or strain, diarrhea, throwing up, a cut or scrape, an earache, a sore throat, a cough or cold, diaper rash, refills for medicine, mild headache, lice, scabies, or ringworm. You have a minor illness or injury or you need a regular checkup, but you don t need an urgent Appointment. You need to see your doctor after a treatment you just had to make sure you are healing well. You are having your first Appointment with a new doctor You are due for a regular adult checkup You are due for a prostate exam, a pelvic exam, a PAP smear or a breast exam Your PCP referred you to see a specialist for a non-urgent condition Your child is due for an EPSDT checkup Within 24 hours Within 30 days Within 1-2 weeks depending on the kind of treatment Within 30 days or sooner if necessary Within 30 days Initial checkup: within 60 days Additional checkups: within 30 days of due dates for children under age two; within 60 days of due dates for children age two and older 17

Immigrant Children well-child checkups not urgent IDEA (Early Intervention) assessments Your child is due for a well-child checkup Tests ( assessments ) for children up to age 3 at risk of developmental delay or disability Initial checkup: within 60 days Additional checkups: within 30 days of due dates for children under age two; within 60 days of due dates for children age two and older Within 30 days 18

Support Services Interpretation & Translation Services/Services for the hearing and visually impaired Interpretation and translation Services and Services for the hearing and visually impaired are FREE. Interpretation Services will provide oral interpretation Services if you need them, including at the hospital Please call Member Services at (202) 821-1100 to get Interpretation Services. Please call before your doctor s Appointment if you need interpretation Services. Interpreter Services are usually provided over the telephone. If you need an interpreter to be with you at your doctor s Appointment, you must let us know 2 days or 48 hours before the Appointment. DC uses 6 languages, Spanish, French, Amharic, Chinese, Korean and Vietnamese. Translation Services If you get information from and need it translated into another language, please call the Member Services Department at (202) 821-1100. Services for the Hearing and Visually Impaired If you have trouble hearing, call Member Services at (202) 821-1152 If you have trouble seeing, call Member Services at (202) 821-1100 or (855) 326-4831 (toll free). We can give you information on an audio tape, in Braille or in large print. Specialty Care and Referral How to get specialty care Specialty care is when care is given by a specialist doctor who has extra training and cares for a specific condition or part of the body. For example, a Cardiologist cares for the heart and a Podiatrist cares for the feet. Your PCP will help you know when you need to see a specialist and give you a referral. A referral is a written note given to you by your PCP to see a different doctor. You must get a referral to see a doctor other than your PCP except for well-women visits, family planning, and some mental health services. If you want to see a specialist, but said it wouldn t pay for the visit, you can: 19

Make an Appointment with another doctor in the network and get a second opinion Appeal our decision (see page 36 on Appeals) Ask for a Fair Hearing (see page 36 on Fair Hearings) Self-Referral Services There are certain services you can get without getting prior permission from your PCP. These are called self-referral services and are listed below. You DO NOT need a Referral to: See your PCP Get care when you have an emergency Receive services from your OB/GYN doctor in your network for routine or preventive services (females only) Receive Family Planning Services Receive services for sexually transmitted diseases (STDs) Receive Immunizations (shots) Visit a vision provider in the network Take your child to a dental provider in the network Receive emergency mental health or services for problems with alcohol or other drugs Receive up to 10 mental health sessions (A treatment plan is required after 10 visits.) Mental Health Services Mental health care is for both adults and children. This care helps when you feel depressed or anxious. If you need help, or someone from your family needs help, call The D.C. Department of Behavioral Health Hotline at 1-888-793-4357, 24 hours a day, 7 days a week You can get up to 10 mental health Appointments without a Referral. Services for alcohol or other drug problems Problems with alcohol or other drugs are dangerous to your health and can be dangerous to the health of people around you. It is important to go to the doctor if you need help with these problems. will help you arrange for detoxification services and provide care coordination to help you get other services. To get services for these problems, you can: Call Member Services at (202) 821-1100 or (855) 326-4831 (toll free), 24 hours a day, 7 days a week. Call APRA directly at (202) 727-8473. 20

Birth control and other Family Planning Services You do NOT need a Referral to receive birth control or other Family Planning Services. You can get birth control and other Family Planning Services from any provider you pick. You may choose an out of network provider. You do not need a referral to get these services. If you choose a Family Planning Services doctor other than your PCP, tell your PCP. It will help your PCP take better care of you. Talk to your PCP or call Member Services at (202) 821-1100.for more information on birth control or other Family Planning Services. All birth control and other Family Planning Services are confidential. Family Planning Services include: Pregnancy Testing Counseling for the Woman and the Couple Routine and Emergency Contraception Counseling and Immunizations Screening for all Sexually Transmitted Diseases Treatment for all Sexually Transmitted Diseases Sterilization Procedures (Requires you to sign a form 30 days before the procedure) HIV/AIDS Testing and Counseling Family Planning Services do not include: Routine infertility studies or procedures Hysterectomy for sterilization Reversal of voluntary sterilization HIV/AIDs Treatment Abortion Services HIV/AIDS testing, counseling and treatment You can get HIV/AIDS testing and counseling: When you have Family Planning Services From your PCP From an HIV testing and counseling center For information on where you can get for HIV testing and counseling, call Member Services (202) 821-1100. If you need HIV treatment, your PCP will help you get the care you need. 21

Pharmacy Services and prescription drugs Pharmacies are where you pick up your medicine (drugs). If your doctor gives you a prescription, you must go to a pharmacy in s network. s network includes most pharmacies in the District. You can find the full list of pharmacies in the network online at www.hp.com If you are out of town and you have an emergency or need Urgent Care and need a prescription filled, just contact our Member Services Department or Nurse Help Line (855) 872-1852 (toll free). To get a prescription filled: Pick a pharmacy that is part of the network and is close to your work or home. When you have a prescription, go to the pharmacy and give the pharmacist your prescription and your Member ID Card. If you need help, please call Member Services at (202) 821-1100. Things to remember: You should not be asked to pay for your medicines. Call Member Services if the pharmacy or drug store asks you to pay. Sometimes, your doctor may need to get permission from for a drug. While your doctor is waiting for the permission, you have a right to get the medication: For up to 72 hours OR For one full round of the medicine if you take it less than once a day Case Management and Disease Management If you have a chronic illness or special health care need such as asthma, high blood pressure or mental illness, you may be eligible for our Case Management or Disease Management Program. This means you will have a Care Manager. A Care Manager is someone who works for and who will help you get the services and information you need to manage your illness and be healthier. Your doctor can refer you for this program using the form at http://www.trustedhp.com/referrals.html. You can refer yourself or a family member by calling Member Services at (202) 821-1100. Services to Keep Adults from Getting Sick wants you to take care of your health. We also want you to sign up for health and wellness services we offer to you. Health and wellness services include screenings, counseling and immunizations. Recommendations for Checkups ( Screenings ) Please make an appointment and go see your PCP at least one time every year for a checkup. The list below tells you the type of things to talk with your PCP about during your checkup. Please make an appointment to see your PCP at least once a year for a checkup. 22

Adult Screening Recommendations Screenings for Women Only Screenings for Men Only Blood pressure and cholesterol (lipid disorder) Screening Sexually transmitted diseases Breast cancer Screening (mammogram) Cervical Cancer Prostate cancer Screening Abdominal Aortic Aneurysm HIV/AIDS Screening & testing Diabetes Screening Tobacco Use Alcohol and Other Drug Use Osteoporosis (post-menopausal women) HPV Screening Chlamydia Depression Colorectal Cancer (50 years and older) Obesity Hepatitis C Preventive counseling Preventive counseling is available to help you stay healthy. You can get preventive counseling on: Diet and exercise Alcohol and drug use Smoking cessation HIV/AIDS prevention Obesity Adult Immunizations If you are an adult, you may need some immunizations (shots). Please talk to your PCP about which ones you may need. Pregnancy If you are pregnant or think you are pregnant, it is very important that you go to your OB/GYN doctor right away. You do not need to see your PCP before making this appointment. If you are pregnant, please call: 23

Your ESA Caseworker at 202-727-5355 Member Services at 202-821-1100 or (855) 326-4831 (toll free). Your PCP There are certain things that you need to get checked if you are pregnant. These will help make sure that you have a healthy pregnancy, delivery, and baby. This is called prenatal care. You get prenatal care before your baby is born. Remember, if you are pregnant or think you are pregnant do not drink alcohol, use drugs or smoke. Prenatal and Post-Partum Care When you register with s OB hotline, you get these services: Pregnancy Case Manager Assistance obtaining WIC Prenatal Information & Classes Once you have had your baby, call: Member Services Your OB Case Manager and Your ESACaseworkerYour Child s Health Health Check Program for Children (EPSDT) wants to help your children grow up healthy. If your child is in the D.C. Healthy Families (Medicaid) program, your child will be in the Health Check Program, also called Early and Periodic Screening, Diagnosis and Treatment (EPSDT). This program starts right after your child is born and lasts until your child turns 21. The Health Check Program gives your child a number of important checkups. There is a Health Check (EPSDT) information sheet in this handbook. You can also ask your doctor, call Member Services, or visit our website www.hp.com for a copy of the Health Check (EPSDT) Periodicity Schedule. The schedule tells you when your child needs to go to the doctor. In addition to Health Check/EPSDT services, your child can also get the benefits described in the Member Health Benefits section below. Immigrant Children If your child is in the Immigrant Children s Program, your child will get well-child care. This program starts right after your child is born and lasts until your child turns 21. In addition to well-child care, your child can also get the benefits described in the Member Health Benefits section below. You do not have to pay anything for these Services for your child they are free. If you have any questions or need help with transportation or scheduling an appointment, please call Member Services. 24

Care for your children s teeth All dental health checkups and treatments are free for Members under age 21. Dentists can prevent cavities and teach you and your child how to care for their teeth. From birth up to age 3, your child s PCP may provide dental care during regular check-ups. The PCP may decide to send the child to a dentist. Beginning at age 3, all children should see a dentist in the network for a checkup every year. Look in s Provider Directory or online at www.hp.com to pick a dentist near you. Please call the dentist s office for an appointment. 25

Children with Special Health Care Needs When children have -- or are at risk of having -- physical, developmental, behavioral, or emotional conditions that are permanent or that last a long time, they can have Special Health Care Needs. These children may need health care and other services that are more than or different from what other children need. will check to see if your child has Special Health Care Needs. Please be sure your child has been checked for this. If your child has not been checked to see if they have special healthcare needs, call Member Services at (202) 821-1100. If your child has Special Health Care Needs, your child has the right to have a PCP who is a specialist Be sure your child with a special health care need has a Treatment Plan. Call Member Services to ask for a treatment plan for your child. For more information please contact Member Services at (855) 326-4831 The IDEA program IDEA stands for the Individuals with Disabilities Education Act. IDEA is a federal law. The IDEA program provides special services for your child with developmental delays, disabilities or special needs. Children up to age 3 get early intervention services from. Children age 3 and older get special educational services from the D.C. public school system. 26

Growth Chart: Here are some of the things that you should be looking for as your child grows. Every child develops at his or her own pace. Your child may reach these milestones slightly before or after other children of the same age. Use this as a guide. If you have any concerns, talk to your child s doctor. By the end of 7 months, many children are able to: Turn head when name is called Smile back at another person Respond to sounds with sounds Enjoy social play (such as peek-a-boo) By the end of 1 year (12 months), many children are able to: Use simple gestures (waving bye-bye ) Make sounds such as ma and da Imitate actions in their play (clap when you clap) Respond when told no By the end of 1 ½ years (18 months), many children are able to: Do simple pretend play ( talk on a toy phone) Point to interesting objects Look at object when you point at it and tell them to look Use several single words unprompted By the end of 2 years (24 months), many children are able to: Use 2- to -4 word phrases Follow simple instructions Become more interested in other children Point to an object or picture when named. By the end of 3 years (36 months), many children are able to: Show affection for playmates Use 4- to- 5 word sentences Imitate adults and playmates (run when other children run) Play make-believe with dolls, animals, and people ( feed a teddy bear) By the end of the 4 years (48 months)many children are able to : Use 5- to 6- word sentences Follow 3-step commands ( Get dressed, comb your hair and wash your face ) Cooperate with other children If you think your child is not growing the way he or she should, have your child tested ( IDEA evaluation ). To get an IDEA evaluation, call your PCP. If your child needs IDEA Services, your PCP will refer your child to the D.C. Government s Early Intervention Program. has case managers who can tell you more about IDEA and the other services your child can get. covers the services listed below if your child is in the IDEA program: For children up to age 3, covers all health care services even if the service is in your child s treatment plan. For children aged 3 and older, : Pays for all health care services and services in your child s treatment plan that your child needs when not in school even on evenings, weekends and holidays. Coordinates services that are not provided through the school s treatment plan. For more information on the services your child can get through the IDEA program, contact your child s school. 27

Immunizations (shots) for children and teens Immunizations (shots) are important to keep your child healthy! When your child is very young, your child will need shots every few months. The shots start at birth. These shots protect them from diseases. Your PCP and will schedule appointments for your child s shots. Shots are free. The shot schedule for children is: AGE IMMUNIZATION Birth HepB #1 2 months HepB#2, DTaP#1, RV#1, Hib#1, PCV#@1, IPV#1 4 months DTaP#2, RV#2, Hib#2, PCV#2, IPV#2 6 months HepB#3, Hib#3, DTaP#3, RV#3, PCV#3, IPV#3 12 months HiB#4, MMR#1, Varicella#1, PCV#4, HepA#2 15 months Varicella #2 18 months Hep A#2 4 years-6 years DTAP, MMR, IPV 13 years or older Varicella 11 years-12 years HPV (girls only), MCV4 13 years 18 years Tdap, HPV 18 years or younger MCV4 Every Year Beginning at 6 months, Seasonal Influenza ( flu ) vaccine as recommended each year Your Health Benefits Health Services covered by The list below shows the health care services and benefits for all Members. For some benefits, you have to be a certain age or have a certain need for the service. You may need a Prior Authorization for the service. will not charge you for any of the health care services in this list if you go to a network provider or hospital. You will not have a co-pay, or need to file a claim. If you have a question about whether covers certain health care, call Member Services at (202) 821-1100. 28

BENEFIT Primary Care Services Specialist Services Laboratory & X-ray Services Hospital Services Pharmacy Services (prescription drugs) Emergency Services WHAT YOU GET Preventive, acute, and chronic health care Services generally provided by your PCP Health care Services provided by specially trained doctors or advanced practice nurses. Referrals are usually required Does not include cosmetic Services and surgeries except for surgery required to correct a condition resulting from surgery or disease, created by an accidental injury or a congenital deformity, or is a condition that impairs the normal function of your body Lab tests and X-rays Outpatient Services (preventive, diagnostic, therapeutic, rehabilitative, or palliative Services) Inpatient Services (hospital stay) Prescription drugs included on the drug formulary. You can find the drug formulary at www.hp.com or by calling Member Services. Only includes medications from network pharmacies Includes the following non-prescription (overthe-counter) medicines: - Fever and Pain relievers like Tylenol or Advil - Sinus and Allergy Medicines like Benadryl - Cough and Cold Medicines - Hydrocortisone 1% for Rashes A Screening exam of your health condition and stabilization if you have an Emergency Medical Condition, regardless if the Provider is in or out of the network. Treatment for emergency conditions WHO CAN GET THIS BENEFIT All Members All Members All Members Any Member with a Referral from their PCP or who has an emergency All Members other than dually eligible(medicaid/medicare) Members whose prescriptions are covered under Medicare Part D All Members 29

BENEFIT Family Planning Podiatry WHAT YOU GET Pregnancy Testing: Counseling for the woman Routine and Emergency Contraception Voluntary sterilizations for Members over 21 years of age (requires signature of an approved sterilization form by the Member 30 days prior to the procedure) Screening, Counseling and Immunizations (including for HPV) Screening and preventive treatment for all sexually transmitted diseases Does not include sterilization procedures for Members under age 21 Special care for foot problems Regular foot care when medically needed. WHO CAN GET THIS BENEFIT All Members as appropriate All Members Rehabilitation Services Rehabilitation Services, including physical, speech and occupational therapy All Members Prosthetic devices Replacement, corrective, or supportive devices prescribed by a licensed provider All Members Vision Care Eye exams at least once every year and as needed; and eye glasses (corrective lenses) as needed Members under age 21 Home Health Services In-home health care Services, including: Nursing and home health aide care Home health aide Services provided by a home health agency Physical therapy, occupational therapy, speech pathology and audiology Services All Members 30

BENEFIT Nursing Home Care WHAT YOU GET Full-time skilled nursing care in a nursing home up to 30 consecutive days WHO CAN GET THIS BENEFIT All Members Hospice Care Support Services for people who are dying All Members Adult Wellness Services Immunizations Routine Screening for Sexually Transmitted Diseases HIV/AIDS Screening, testing and counseling Breast cancer Screening (women only) Cervical cancer Screening (women only) Osteoporosis Screening (post-menopausal women) HPV Screening (women only) Prostate cancer Screening (men only) Abdominal aortic aneurysm Screening (men only) Screening for obesity Diabetes Screening Screening for high blood pressure and cholesterol (lipid disorders) Screening for depression Colorectal cancer Screening (Members 50 years and older) Smoking cessation counseling Diet and exercise counseling Mental Health counseling Alcohol and drug Screening Members over age 21 as appropriate 31

BENEFIT Child Wellness Services Dental Benefits Hearing Benefits Alcohol & Drug Abuse Treatment Dialysis WHAT YOU GET Whatever is needed to take care of sick children and to keep healthy children well, including Screening and assessments such as: Health and development history and Screenings Physical and mental health development and Screenings Comprehensive health exam Immunizations Lab tests including of blood lead levels Health education Dental Screening Services Vision Screening Services Hearing Screening Services Alcohol and drug Screening and counseling Mental health Services Does not include any health Services furnished to a child in a school setting General dentistry (including regular and emergency treatment) and orthodontic care for special problems Check-Ups twice a year with a dentist are covered for children ages 3 through 20. A child s PCP can perform dental Screenings for a child up to age 3 Does not include routine orthodontic care Diagnosis and Treatment of conditions related to hearing, including hearing aids and hearing aid batteries Inpatient detoxification Other alcohol/drug abuse services are provided by the Addiction, Prevention and Recovery Administration (APRA) Help with getting care from APRA Inpatient and outpatient substance abuse treatment Other alcohol/drug abuse Services are provided by the Addiction, Prevention and Recovery Administration (APRA) Help with getting care from APRA Hemodialysis Peritoneal Dialysis WHO CAN GET THIS BENEFIT Members under age 21 Members under age 21 (Members 21 years and older can get dental services from Medicaid. Call MCO Dental Help Line at 1-866-758-6807) All Members All Members Members under age 21 All Members 32

BENEFIT Durable Medical Equipment (DME) & Disposable Medical Supplies (DMS) WHAT YOU GET Durable Medical Equipment (DME) Disposable medical supplies (DMS) WHO CAN GET THIS BENEFIT All Members Services We Do Not Pay For Exclusions are benefits and/or services that are not paid for by or DC Medicaid. They include the following: Acupuncture Alcohol and other drug abuse services Chiropractic Services Cosmetic surgery Deliveries (if you are pregnant, contact the Economic Security Administration (ESA) at (202)727-53555 to determine eligibility for Medicaid. Deliveries are covered by Medicaid Experimental or investigational services, surgeries, treatments, and medications Hearing services for members over 21 Services that are part of a clinical trial protocol Abortion, or the voluntary termination of a pregnancy, not required under Federal law Infertility treatment Open heart surgery Organ Transplant Private Duty Nursing Sclerotherapy services and items Sterilizations for persons under the age of 21 Services that are not medically necessary Screening and stabilization services for emergency and medical conditions outside of the network including inside the District. You will be responsible for the charges for the out of network services including emergency services. Treatment for obesity Vision services for members over 21 Any covered services when furnished by providers that are not members of the Network. Services that are NOT medically necessary Non emergency transportation services. After clinical review based on scientific evidence, new technology is evaluated by for inclusion as a covered benefit. Technology assessment decisions are published in the form of medical policies and are posted to our website for your doctor to access and use in their practice. In addition, members may request a copy of a medical policy by contacting our Member Services at (202) 821-1100. All existing medical policies are reviewed at least annually and updated accordingly. 33

Other Important Information What to do if you move Call the District of Columbia (DC) Economic Security Administration (ESA) Change Center at 202-727-5355. Call Member Services at (202) 821-1100. What to do if you have a baby Call DC Economic Security Administration (ESA) Change Center at 202-727-5355. Call Member Services at (202) 821-1100 or (855) 326-4831 (toll free) What to do if you adopt a child Call DC Economic Security Administration (ESA) Change Center at 202-727-5355. What to do if someone in your family dies Call DC Economic Security Administration (ESA) Change Center at 202-727-5355. Call Member Services at (202) 821-1100. Call ESA at 202-727-5355 and Member Services at (202) 821-1100 if: You move You have a baby If you adopt a child Someone in your family dies How to change your Managed Care Organization You can change your MCO once a year, or at any time if you have a good reason. You can change your MCO once a year during the 90 days before your anniversary date the month and date you first joined. D.C. Healthy Families will send you a letter two months before your anniversary date. The letter tells you how to change MCOs. 34