AETNA BETTER HEALTH SM PREMIER PLAN 2017 Evidece of Coverage Aeta Better Health SM Premier Pla (Medicare-Medicaid Pla) is a health pla that cotracts with Medicare ad Illiois Medicaid to provide beefits of both programs to erollees. www.aetabetterhealth.com/illiois H2506_17_002_MBR HNDBK ACCEPTED
Helpful iformatio Member Services 1-866-600-2139 (TTY: 711) Represetatives available 24 hours a day, 7 days a week Address Aeta Better Health Premier Pla 333 West Wacker Drive, Suite 2100 Chicago, IL 60606 Erollmet ad Applicatio Services Illiois Cliet Erollmet Broker (ICEB) 1-877-912-8880 TTY: 1-866-565-8576 Trasportatio Services Medical Trasportatio Maagemet, Ic. No-Emergecy Trasportatio 1-888-513-1612 Detal Services DetaQuest 1-800-416-9185 Behavioral Health Services 1-866-600-2139 (T T Y: 711) Laguage Iterpretatio Services Icludig Sig Laguage Iterpretatio ad CART Reportig 1-866-600-2139 (T T Y: 711) Represetatives available 24 hours a day, 7 days a week Appeals ad Grievaces Aeta Better Health Premier Pla Att: Appeals ad Grievaces Maager 333 West Wacker Drive, Suite 2100 Chicago, IL 60606 1-866-600-2139 (T T Y: 711) To make a request for a fair hearig: Illiois Departmet of Healthcare ad Family Services Bureau of Assistace Hearigs 401 South Clito, Sixth Floor Chicago, IL 60607 1-800-435-0774 T TY: 1-877-734-7429 Fraud ad Abuse Hotlie 1-877-436-8154 Visio Services March Visio 1-888-493-4070 Pharmacy Services 1-866-600-2139 (T T Y: 711) www.aetabetterhealth.com/illiois
Aeta Better Health Premier Pla MEMBER HANDBOOK Aeta Better Health SM Premier Pla Member Hadbook Jauary 1, 2017 December 31, 2017 Your Health ad Drug Coverage uder the Aeta Better Health Premier Pla Medicare-Medicaid Pla This hadbook tells you about your coverage for the time you are erolled with Aeta Better Health Premier Pla through December 31, 2017. It explais health care services, behavioral health coverage, prescriptio drug coverage, ad log-term services ad supports. Log-term services ad supports iclude log-term care ad home ad commuity based waivers (HCBS). HCBS waivers ca offer services that will help you stay i your home ad commuity. This is a importat legal documet. Please keep it i a safe place. Aeta Better Health Premier Pla pla is offered by Aeta Better Health of Illiois. Whe this Member Hadbook says we, us, or our, it meas Aeta Better Health of Illiois. Whe it says the pla or our pla, it meas Aeta Better Health Premier Pla. You ca get this hadbook for free i Spaish or speak with someoe about this iformatio i other laguages for free. Call 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. Usted puede obteer este maual e español, o habler co alguie acerca de esta iformacióe otros idioma de forma gratuita. Llame 1-866-600-2139, (TTY: 711), 24 horas al día, 7 días de la semaa. La llama es gratis. You ca get this hadbook for free i other formats, such as large prit, braille, or audio. Call 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. If you wish to make a stadig request to receive all materials i a laguage other tha Eglish, or i a alterate format, you ca call Aeta Better Health Premier Pla Member Services at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 1
Aeta Better Health Premier Pla MEMBER HANDBOOK Disclaimers Aeta Better Health Premier Pla is a health pla that cotracts with both Medicare ad Illiois Medicaid to provide beefits of both programs to erollees. Limitatios ad restrictios may apply. For more iformatio, call Aeta Better Health Premier Pla Member Services or read the Aeta Better Health Premier Pla Member Hadbook. This meas that you may have to pay for some services ad that you eed to follow certai rules to have Aeta Better Health Premier Pla pay for your services. The List of Covered Drugs ad/or pharmacy ad provider etworks may chage throughout the year. We will sed you a otice before we make a chage that affects you. Beefits may chage o Jauary 1 of each year. If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 2
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 1: Gettig started as a member Chapter 1: Gettig started as a member Table of Cotets A. Welcome to Aeta Better Health Premier Pla... 4 B. What are Medicare ad Medicaid?... 4 Medicare... 4 Medicaid... 4 C. What are the advatages of this pla?... 5 D. What is Aeta Better Health Premier Pla s service area?... 6 E. What makes you eligible to be a pla member?... 6 F. What to expect whe you first joi a health pla... 7 G. What is a care pla?... 8 H. Does Aeta Better Health Premier Pla have a mothly pla premium?... 8 I. About the Member Hadbook... 8 J. What other iformatio will you get from us?... 8 Your Aeta Better Health Premier Pla Member ID Card... 9 Provider ad Pharmacy Directory... 9 List of Covered Drugs... 10 The Explaatio of Beefits... 10 K. How ca you keep your Erollee Profile up to date?... 11 Do we keep your persoal health iformatio private?... 11 If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 3
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 1: Gettig started as a member A. Welcome to Aeta Better Health Premier Pla Aeta Better Health Premier Pla is a Medicare-Medicaid Pla. A Medicare-Medicaid pla is a orgaizatio made up of doctors, hospitals, pharmacies, providers of log-term services ad supports, ad other providers. It also has case maagers ad care teams to help you maage all your providers ad services. They all work together to provide the care you eed. Aeta Better Health Premier Pla was approved by the State ad the Ceters for Medicare & Medicaid Services (CMS) to provide you services as part of the Medicare-Medicaid Aligmet Iitiative. The Medicare-Medicaid Aligmet Iitiative is a demostratio program joitly ru by Illiois ad the federal govermet to provide better health care for people who have both Medicare ad Medicaid. Uder this demostratio, the state ad federal govermet wat to test ew ways to improve how you get your Medicare ad Medicaid health care services. B. What are Medicare ad Medicaid? Medicare Medicare is the federal health isurace program for: people 65 years of age or older, some people uder age 65 with certai disabilities, ad people with ed-stage real disease (kidey failure). Medicaid Medicaid is a program ru by the federal govermet ad the state that helps people with limited icomes ad resources pay for log-term services ad supports ad medical costs. It covers extra services ad drugs ot covered by Medicare. Each state decides what couts as icome ad resources ad who qualifies. They also decide what services are covered ad the cost for services. States ca decide how to ru their programs, as log as they follow the federal rules. Medicare ad Illiois must approve Aeta Better Health Premier Pla each year. You ca get Medicare ad Medicaid services through our pla as log as: we choose to offer the pla, ad Medicare ad the State approve the pla. Eve if our pla stops operatig i the future, your eligibility for Medicare ad Medicaid services will ot be affected. If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 4
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 1: Gettig started as a member C. What are the advatages of this pla? You will ow get all your covered Medicare ad Medicaid services from Aeta Better Health Premier Pla, icludig prescriptio drugs. You do ot pay extra to joi this health pla. Aeta Better Health Premier Pla will help make your Medicare ad Medicaid beefits work better together ad work better for you. Some of the advatages iclude: You will have a care team that you helped put together. Your care team may iclude doctors, urses, couselors, or other health professioals who are there to help you get the care you eed. You will have a case maager. This is a perso who works with you, with Aeta Better Health Premier Pla, ad with your care providers to make sure you get the care you eed. You will be able to direct your ow care with help from your care team ad case maager. The care team ad case maager will work with you to come up with a care pla specifically desiged to meet your health eeds. The care team will be i charge of coordiatig the services you eed. This meas, for example:»» Your care team will make sure your doctors kow about all medicies you take so they ca reduce ay side effects. Your care team will make sure your test results are shared with all your doctors ad other providers. If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 5
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 1: Gettig started as a member D. What is Aeta Better Health Premier Pla s service area? Our service area icludes these couties i Illiois: Cook DuPage Kae Kakakee Will Oly people who live i our service area ca get Aeta Better Health Premier Pla. If you move outside of our service area, you caot stay i this pla. E. What makes you eligible to be a pla member? You are eligible for our pla as log as: you live i our service area, ad you have both Medicare Part A ad Medicare Part B, ad you are eligible for Medicaid, ad you are a Uited States citize or are lawfully preset i the Uited States, ad you are age 21 ad older at the time of erollmet, ad you are erolled i the Medicaid Aid to the Aged, Blid ad Disabled category of assistace, ad if you meet all other Demostratio criteria ad are i oe of the followig Medicaid 1915(c) waivers: o o o o o Persos who are Elderly; Persos with Disabilities; Persos with HIV/AIDS; Persos with Brai Ijury; or Persos residig i Supportive Livig Facilities. If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 6
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 1: Gettig started as a member F. What to expect whe you first joi a health pla Whe you first joi the pla, you will get a health risk assessmet withi the first 90 days. A member of our care maagemet team will cotact you to talk about your health ad service eeds before your services start or withi the first 30 days of erollig with Aeta Better Health Premier Pla. He or she will ask you a few questios to idetify your immediate ad log-term eeds. He or she will work with you, your providers, your family ad whomever you chose to develop a pla to coordiate all of your care ad services eeds to help you move through the health care system more smoothly. The care maagemet team will help you lear more about your health care eeds. They ca help your family ad/or caregivers also, if you would like. They will support you i workig with your providers ad caregivers (if applicable) to meet the health care goals that are importat to you. If this is your first time i a Medicare-Medicaid Pla, you ca keep seeig the doctors you go to ow for 180 days. If you chaged to Aeta Better Health Premier Pla from a differet Medicare-Medicaid Pla, you ca keep seeig the doctors you go to ow for 90 days. There are special circumstaces whe you may see your doctors loger. Call your assiged case maager or the Member Services Departmet at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week for more iformatio. After the care maagemet team cotacts you, they ca assist you i coordiatig all your care ad services. You will eed to see doctors ad other providers i the Aeta Better Health Premier Pla etwork. A etwork provider is a provider who works with the health pla. See Chapter 3 for more iformatio o gettig care. If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 7
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 1: Gettig started as a member G. What is a care pla? A care pla is the pla for what medical, behavioral, log-term supports, social ad fuctioal services you will get ad how you will get them. After your health risk assessmet, your care team will meet with you to talk about what services you eed ad wat. Together, you ad your care team will make a care pla. Every year, your care team will work with you to update your care pla whe the services you eed ad wat chage. If you are gettig Home ad Commuity Based Waiver services, you will also have a service pla. The service pla lists the services you will get ad how ofte you will get them. This service pla will become part of your overall care pla. H. Does Aeta Better Health Premier Pla have a mothly pla premium? No. I. About the Member Hadbook This Member Hadbook is part of our cotract with you. This meas that we must follow all of the rules i this documet. If you thik we have doe somethig that goes agaist these rules, you may be able to appeal, or challege, our actio. For iformatio about how to appeal, see Chapter 9, or call 1-800-MEDICARE (1-800-633-4227). The cotract is i effect for the moths you are erolled i Aeta Better Health Premier Pla betwee Jauary 1, 2017 ad December 31, 2017. J. What other iformatio will you get from us? You should have already gotte a Aeta Better Health Premier Pla Member ID Card, iformatio about how to access a Provider ad Pharmacy Directory, ad a List of Covered Drugs. If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 8
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 1: Gettig started as a member Your Aeta Better Health Premier Pla Member ID Card Uder our pla, you will have oe card for your Medicare ad Medicaid services, icludig log-term services ad supports ad prescriptios. You must show this card whe you get ay services or prescriptios. Here s a sample card to show you what yours will look like: AETNA BETTER HEALTH SM PREMIER PLAN Member Name: Last Name, First Name Member ID: 000000000-00 Health Pla (80840): ifo to come Medicaid ID: 00000000 PCP Name: Last Name, First Name PCP Phoe: 000-000-0000 CMS - H2506 001 RxBIN 610591 RxPCN MEDDADV RxGRP RX8815 I case of emergecy, call 911 or go to the earest emergecy room. Member Services: 1-866-600-2139 (TTY 711) Behavioral Health: 1-866-600-2139, optio 9 Pharmacy Help Desk: 1-866-600-2139 Detal Services: 1-800-416-9185 Trasportatio Services: 1-866-600-2139 Visio Services: 1-888-493-4070 24-Hour Nurse Advice: 1-866-600-2139 Website: www.aetabetterhealth.com/illiois Sed Claims To: Aeta Better Health PO Box 66545 Phoeix, AZ 85082-6545 Payer ID: 26337 If your card is damaged, lost, or stole, call Member Services right away ad we will sed you a ew card. As log as you are a member of our pla, you do ot eed to use your red, white, ad blue Medicare card or your Medicaid card to get services. Keep those cards i a safe place, i case you eed them later. Provider ad Pharmacy Directory The Provider ad Pharmacy Directory lists the providers ad pharmacies i the Aeta Better Health Premier Pla etwork. While you are a member of our pla, you must use etwork providers to get covered services. There are some exceptios whe you first joi our pla (see page 7). You ca ask for a aual Provider ad Pharmacy Directory by callig Member Services at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. You ca also see the Provider ad Pharmacy Directory at www.aetabetterhealth.com/illiois or dowload it from this website. The Provider & Pharmacy Directory gives you iformatio o how to obtai care ad lists health care professioals (such as doctors, urse practitioers, ad psychologists), facilities (such as hospitals or cliics), ad support providers (such as Adult Day Health ad Home Health providers) that you may see as a Aeta Better Health Premier Pla member. It also lists the pharmacies that you may use to get your prescriptio drugs. What are etwork providers? Aeta Better Health Premier Pla s etwork providers iclude: o Doctors, urses, ad other health care professioals that you ca go to as a member of our pla; o Cliics, hospitals, ursig facilities, ad other places that provide health services i our pla; ad o Home health agecies, durable medical equipmet suppliers, ad others who provide goods ad services that you get through Medicare or Medicaid. Network providers have agreed to accept paymet from our pla for covered services as paymet i full. If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 9
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 1: Gettig started as a member What are etwork pharmacies? Network pharmacies are pharmacies (drug stores) that have agreed to fill prescriptios for our pla members. Use the Provider ad Pharmacy Directory to fid the etwork pharmacy you wat to use. Except durig a emergecy, you must fill your prescriptios at oe of our etwork pharmacies if you wat our pla to help you pay for them. Call Member Services at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week for more iformatio. The call is free. You ca also see the Provider ad Pharmacy Directory at www.aetabetterhealth.com/illiois or dowload it from this website. Both Member Services ad Aeta Better Health Premier Pla s website ca give you the most up-to-date iformatio about chages i our etwork pharmacies ad providers. List of Covered Drugs The pla has a List of Covered Drugs. We call it the Drug List for short. It tells which prescriptio drugs are covered by Aeta Better Health Premier Pla. The Drug List also tells you if there are ay rules or restrictios o ay drugs, such as a limit o the amout you ca get. See Chapter 5 for more iformatio o these rules ad restrictios. Each year, we will sed you a copy of the Drug List, but some chages may occur durig the year. To get the most up-to-date iformatio about which drugs are covered, visit www.aetabetterhealth.com/illiois or call Member Services at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. The Explaatio of Beefits Whe you use your Part D prescriptio drug beefits, we will sed you a summary report to help you uderstad ad keep track of paymets for your Part D prescriptio drugs. This summary report is called the Explaatio of Beefits (or EOB). The Explaatio of Beefits tells you the total amout you or others o your behalf have spet o your Part D prescriptio drugs ad the total amout we have paid for each of your Part D prescriptio drugs durig the moth. Chapter 6 gives more iformatio about the Explaatio of Beefits ad how it ca help you keep track of your drug coverage. A Explaatio of Beefits is also available whe you ask for oe. To get a copy, please cotact Member Services. If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 10
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 1: Gettig started as a member K. How ca you keep your Erollee Profile up to date? You ca keep your erollee profile up to date by lettig us kow whe your iformatio chages. The pla s etwork providers ad pharmacies eed to have the right iformatio about you. They use your erollee profile to kow what services ad drugs you get ad how much it will cost you. Because of this, it is very importat that you help us keep your iformatio up-to-date. Let us kow the followig: If you have ay chages to your ame, your address, or your phoe umber If you have ay chages i ay other health isurace coverage, such as from your employer, your spouse s employer, or workers compesatio If you have ay liability claims, such as claims from a automobile accidet If you are admitted to a ursig home or hospital If you get care i a out-of-area or out-of-etwork hospital or emergecy room If your caregiver or ayoe resposible for you chages If you are part of a cliical research study If ay iformatio chages, please let us kow by callig Member Services at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. Do we keep your persoal health iformatio private? Yes. Laws require that we keep your medical records ad persoal health iformatio private. We make sure that your health iformatio is protected. For more iformatio about how we protect your persoal health iformatio, see Chapter 11. If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 11
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources Chapter 2: Importat phoe umbers ad resources Table of Cotets A. How to cotact Aeta Better Health Premier Pla Member Services... 14 Cotact Member Services about:... 14 Questios about the pla... 14 Questios about claims, billig or Member ID Cards... 14 Coverage decisios about your health care... 14 Appeals about your health care... 14 Complaits about your health care... 14 Coverage decisios about your drugs... 15 Appeals about your drugs... 15 Complaits about your drugs... 15 Paymet for health care or drugs you already paid for... 15 B. How to cotact your Case Maager... 16 Cotact your case maager about:... 16 Questios about your health care... 16 Questios about gettig behavioral health services, trasportatio, ad log-term services ad supports (LTSS)... 16 C. How to cotact the Nurse Advice Call Lie... 18 Cotact the Nurse Advice Call Lie about:... 18 Questios about your health care... 18 D. How to cotact the Behavioral Health Crisis Lie... 19 Cotact the Behavioral Health Crisis Lie about:... 19 If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 12
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources E. How to cotact the Seior Health Isurace Program (SHIP)... 20 Cotact SHIP about:... 20 Questios about your Medicare health isurace... 20 F. How to cotact the Quality Improvemet Orgaizatio (QIO)... 21 Cotact KEPRO about:... 21 Questios about your health care... 21 G. How to cotact Medicare... 22 H. How to cotact Medicaid... 23 I. How to cotact the Illiois Health Beefits Hotlie... 23 J. How to cotact the Illiois Log Term Care Ombudsma Program... 24 K. Other resources... 24 If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 13
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources A. How to cotact Aeta Better Health Premier Pla Member Services CALL TTY 1-866-600-2139 This call is free. 24 hours a day, 7 days a week We have free iterpreter services for people who do ot speak Eglish. 711 This call is free. 24 hours a day, 7 days a week FAX 1-855-802-4291 WRITE EMAIL WEBSITE Aeta Better Health Premier Pla 333 West Wacker, Suite 2100, MC F646 Chicago, IL 60606 aetabetterhealthilliois@aeta.com www.aetabetterhealth.com/illiois Cotact Member Services about: Questios about the pla Questios about claims, billig or Aeta Better Health Premier Pla Member ID Cards Coverage decisios about your health care A coverage decisio about your health care is a decisio about:» your beefits ad covered services, or» the amout we will pay for your health services. Call us if you have questios about a coverage decisio about health care. To lear more about coverage decisios, see Chapter 9. Appeals about your health care A appeal is a formal way of askig us to review a decisio we made about your coverage ad askig us to chage it if you thik we made a mistake. To lear more about makig a appeal, see Chapter 9. Complaits about your health care You ca make a complait about us or ay provider icludig a o-etwork or etwork provider. A etwork provider is a provider who works with the health pla. You ca also make a complait about the quality of the care you got to us or to the Quality Improvemet Orgaizatio (see Sectio F below). If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 14
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources If your complait is about a coverage decisio about your health care, you ca make a appeal. (See the sectio above.) You ca sed a complait about Aeta Better Health Premier Pla right to Medicare. You ca use a olie form at https://www.medicare.gov/medicarecomplaitform/home.aspx. Or you ca call 1-800-MEDICARE (1-800-633-4227) to ask for help. To lear more about makig a complait about your health care, see Chapter 9. Coverage decisios about your drugs A coverage decisio about your drugs is a decisio about:» your beefits ad covered drugs, or» the amout we will pay for your drugs. This applies to your Part D drugs, Medicaid prescriptio drugs, ad Medicaid over-the-couter drugs. For more o coverage decisios about your prescriptio drugs, see Chapter 9. Appeals about your drugs A appeal is a way to ask us to chage a coverage decisio. You, your doctor or your prescriber ca sed your appeal request to us i writig or you may call us at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. For more o makig a appeal about your prescriptio drugs, see Chapter 9. Complaits about your drugs You ca make a complait about us or a pharmacy. This icludes a complait about your prescriptio drugs. If your complait is about a coverage decisio about your prescriptio drugs, you ca make a appeal. (See the sectio above.) You ca sed a complait about Aeta Better Health Premier Pla right to Medicare. You ca use a olie form at https://www.medicare.gov/medicarecomplaitform/home.aspx. Or you ca call 1-800-MEDICARE (1-800-633-4227) to ask for help. For more o makig a complait about your prescriptio drugs, see Chapter 9. Paymet for health care or drugs you already paid for For more o how to ask us to pay you back, or to pay a bill you got, see Chapter 7. If you ask us to pay a bill ad we dey ay part of your request, you ca appeal our decisio. See Chapter 9 for more o appeals. If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 15
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources B. How to cotact your Case Maager As a Aeta Better Health Premier Pla member, you will be assiged a case maager whe you eroll. Your case maager is assiged based o where you live. This perso works with you ad your care providers to make sure you get the care ad services you eed. Your case maager will give you his or her phoe umber ad email address so you ca cotact him or her. You ca also cotact your case maager by callig our Care Maagemet Lie at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. It is importat that you have a good relatioship with your case maager. If you wat to chage your case maager, please call the Care Maagemet Lie. CALL TTY 1-866-600-2139 This call is free. 24 hours a day, 7 days a week We have free iterpreter services for people who do ot speak Eglish. 711 This call is free. 24 hours a day, 7 days a week. FAX 1-855-802-4291 WRITE EMAIL WEBSITE Aeta Better Health Premier Pla 333 West Wacker, Suite 2100, MC F646 Chicago, IL 60606 aetabetterhealthilliois@aeta.com www.aetabetterhealth.com/illiois Cotact your case maager about: Questios about your health care Questios about gettig behavioral health services, trasportatio, ad log-term services ad supports (LTSS) If your provider or Case Maager thiks you may be eligible for Log Term Care or additioal supports ad services to keep you i your home, they will refer you to a agecy that will decide if you are eligible for those services. If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 16
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources Sometimes you ca get help with your daily health care ad livig eeds. You might be able to get these services:» Skilled ursig care» Persoal Assistat» Homemaker» Adult Day Care» Emergecy Home Respose System» Physical therapy» Occupatioal therapy» Speech therapy» Home health care If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 17
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources C. How to cotact the Nurse Advice Call Lie Aeta Better Health Premier Pla has a Nurse Advice Lie available to help aswer your medical questios, give advice o treatmet optios ad cofirm erollmet. The Nurse Advice Lie does ot take the place of your primary care provider but is available as aother resource for you. This umber is available 24 hours a day, 7 days a week. It is staffed by medical professioals. CALL TTY 1-866-600-2139 This call is free. 24 hours a day, 7 days a week. We have free iterpreter services for people who do ot speak Eglish. 711 This call is free. 24 hours a day, 7 days a week. Cotact the Nurse Advice Call Lie about: Questios about your health care We kow that health care issues do t limit themselves to a 9 to 5 work schedule. Aeta Better Health Premier Pla is dedicated to providig iformatio to help you make iformed choices about your health care whatever time of day you have questios. We offer a toll-free Nurse Advice Call Lie that you ca call 24 hours a day, 7 days a week, 365 days a year to get health questios aswered for you ad your family. The Nurse Advice Call Lie is staffed with registered urses experieced i providig iformatio o a wide variety of health topics. This valuable service helps you lear about health coditios ad medical procedures. It also helps you commuicate with your PCP. For example, our Nurse Advice Call Lie urses ca provide tips o how to describe health symptoms more clearly ad ask the right questios durig offce visits. If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 18
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources D. How to cotact the Behavioral Health Crisis Lie CALL TTY 1-866-600-2139, Optio 9. This call is free. 24 hours a day, 7 days a week. We have free iterpreter services for people who do ot speak Eglish. 711 This call is free. 24 hours a day, 7 days a week. Cotact the Behavioral Health Crisis Lie about: Ay behavioral health crisis you experiece. Call the toll-free behavioral health crisis lie at 1-866-600-2139, Optio 9 (TTY: 711), 24 hours a day, 7 days a week. Some symptoms of a behavioral health crisis are: o o o o o o o Hopelessess, feelig like there s o way out Axiety, agitatio, sleeplessess or mood Feelig like there is o reaso to live Rage or ager Egagig i risky activities without thikig Icreasig alcohol or drug abuse Withdrawig from family or frieds If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 19
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources E. How to cotact the Seior Health Isurace Program (SHIP) The Seior Health Isurace Program (SHIP) gives free health isurace couselig to people with Medicare. SHIP is ot coected with ay isurace compay or health pla. CALL TTY WRITE EMAIL WEBSITE 1-800-548-9034 Moday-Friday 8:30 a.m. - 5 p.m. The call is free. 1-866-323-5321 Moday-Friday 8:30 a.m. - 5 p.m. The call is free. Seior Health Isurace Program Illiois Departmet o Agig Oe Natural Resources Way, Suite 100 Sprigfield, IL 62702-1271 AGING.SHIP@illiois.gov http://www.state.il.us/agig/ship/ Cotact SHIP about: Questios about your Medicare health isurace SHIP couselors ca:» help you uderstad your rights,» help you uderstad your pla choices,» aswer your questios about chagig to a ew pla,» help you make complaits about your health care or treatmet, ad» help you straighte out problems with your bills. If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 20
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources F. How to cotact the Quality Improvemet Orgaizatio (QIO) Our state has a orgaizatio called a KEPRO. This is a group of doctors ad other health care professioals who help improve the quality of care for people with Medicare. KEPRO is ot coected with our pla. CALL 1-855-408-8557 TTY 1-855-843-4776 This umber is for people who have hearig or speakig problems. You must have special telephoe equipmet to call it. WRITE WEBSITE KEPRO 5201 West Keedy Boulevard, Suite 900 Tampa, FL 33609 www.keproqio.com Cotact KEPRO about: Questios about your health care You ca make a complait about the care you got if:» You have a problem with the quality of care,» You thik your hospital stay is edig too soo, or» You thik your home health care, skilled ursig facility care, or comprehesive outpatiet rehabilitatio facility (CORF) services are edig too soo. If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 21
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources G. How to cotact Medicare Medicare is the federal health isurace program for people 65 years of age or older, some people uder age 65 with disabilities, ad people with ed-stage real disease (permaet kidey failure requirig dialysis or a kidey trasplat). The federal agecy i charge of Medicare is the Ceters for Medicare & Medicaid Services, or CMS. CALL 1-800-MEDICARE (1-800-633-4227) Calls to this umber are free, 24 hours a day, 7 days a week. TTY WEBSITE 1-877-486-2048 This call is free. This umber is for people who have hearig or speakig problems. You must have special telephoe equipmet to call it. http://www.medicare.gov This is the offcial website for Medicare. It gives you up-to-date iformatio about Medicare. It also has iformatio about hospitals, ursig homes, physicias, home health agecies, ad dialysis facilities. It icludes booklets you ca prit right from your computer. You ca also fid Medicare cotacts i your state by selectig Forms, Help & Resources ad the clickig o Phoe umbers & websites. The Medicare website has the followig tool to help you fid plas i your area: Medicare Pla Fider: Provides persoalized iformatio about Medicare prescriptio drug plas, Medicare health plas, ad Medigap (Medicare Supplemet Isurace) policies i your area. Select Fid health & drug plas. If you do t have a computer, your local library or seior ceter may be able to help you visit this website usig its computer. Or, you ca call Medicare at the umber above ad tell them what iformatio you are lookig for. They will fid the iformatio o the website, prit it out, ad sed it to you. If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 22
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources H. How to cotact Medicaid Medicaid helps with medical ad log-term services ad supports costs for people with limited icomes ad resources. You are erolled i Medicare ad i Medicaid. If you have questios about your Medicaid eligibility, call the Illiois Departmet of Huma Services Customer Help Lie. CALL TTY EMAIL WEBSITE 1-800-843-6154 Moday-Friday 8 a.m. 5 p.m. The call is free. 1-800-447-6404 Moday-Friday 8 a.m. 5 p.m. The call is free. DHS.WebBits@illiois.gov http://www.dhs.state.il.us I. How to cotact the Illiois Health Beefits Hotlie The Illiois Departmet of Healthcare ad Family Services Health Beefits Helplie helps people erolled i Medicaid with service or billig problems. They ca help you file a complait or a appeal with our pla. CALL TTY WEBSITE 1-866-468-7543 Moday-Friday 8 a.m. - 4:45 p.m. The call is free. 1-877-204-1012 Moday-Friday 8 a.m. - 4:45 p.m. The call is free. http://www.hfs.illiois.gov This is the offcial website for Medicaid. It gives you up-to-date iformatio about Medicaid. If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 23
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources J. How to cotact the Illiois Log Term Care Ombudsma Program The Illiois Log Term Care Ombudsma Program helps protect ad promote the rights of people who live i ursig homes ad other log-term care settigs. It also helps solve problems betwee these settigs ad residets or their families. CALL TTY WRITE EMAIL WEBSITE 1-800-252-8966 Moday-Friday 8:30 a.m. 5 p.m. The call is free. 1-888-206-1327 Moday-Friday 8:30 a.m. 5 p.m. The call is free. Log Term Care Ombudsma Program Illiois Departmet o Agig Oe Natural Resources Way, Suite 100 Sprigfield, IL 62702-1271 agig.ilseior@illiois.gov http://www.illiois.gov/agig/protectioadvocacy/ltcombudsma/pages/ default.aspx K. Other resources Illiois Cliet Erollmet Services is available to assist you with pla comparisos, fid a provider ad eroll i a health pla. CALL 1-877-912-8880 Moday to Friday 8 a.m. to 7 p.m. TTY 1-866-565-8576 EMAIL WEBSITE hfs.webmaster@illiois.gov www.illioisceb.com If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 24
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources Northeaster Illiois Agecy o Agig The Agecy o Agig serves as a lik betwee local, state ad atioal agig programs ad services. It ca help coect a vast etwork of seior providers to those who eed them. It works to give at-risk elders the opportuity to stay i their ow homes with digity ad safety. The agecy advocates ad collaborates with commuities to prepare seiors ad families for agig. CALL 1-800-582-2000 WRITE EMAIL WEBSITE Northeaster Illiois Agecy o Agig P.O. Box 809 Kakakee, IL 60901 ifo@ageguide.org www.ageguide.org Age Optios Age Optios is a oprofit orgaizatio coectig older adults ad those who care for them with resources ad service optios so they ca live their lives to the fullest. CALL 1-800-699-9043 TTY 1-708-524-1653 WRITE EMAIL WEBSITE Age Optios 1048 Lake Street, Suite 300 Oak Park, IL 60301-1102 iformatio@ageoptios.org www.ageoptios.org If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 25
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 2: Importat phoe umbers ad resources Access Livig Access Livig is a chage aget committed to fosterig a iclusive society that eables Chicagoas with disabilities to live fully-egaged ad self-directed lives. Staff ad voluteers combie kowledge ad persoal experiece to deliver programs ad services that equip people with disabilities to advocate for themselves. CALL 1-312-640-2100 TTY 1-312-640-2102 WRITE WEBSITE Access Livig 115 West Chicago Aveue Chicago, IL 60654 www.accesslivig.org You will fid more resources at the Aeta Better Health Premier Pla website: www.aetabetterhealth.com/illiois. If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 26
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services Chapter 3: Usig the pla s coverage for your health care ad other covered services Table of Cotets A. About services, covered services, providers, ad etwork providers... 28 B. Rules for gettig your health care, behavioral health, ad log-term services ad supports covered by the pla... 28 C. Your case maager... 29 D. Gettig care from primary care providers, specialists, other etwork providers, ad out-of-etwork providers... 30 E. How to get log-term services ad supports (LTSS)... 33 F. How to get behavioral health services... 33 G. How to get trasportatio services... 34 H. How to get covered services whe you have a medical emergecy or urget eed for care, or durig a disaster... 34 I. What if you are billed directly for the full cost of services covered by our pla?... 37 J. How are your health care services covered whe you are i a cliical research study?... 38 K. How are your health care services covered whe you are i a religious o-medical health care istitutio?... 39 L. Rules for owig durable medical equipmet... 40 If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 27
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services A. About services, covered services, providers, ad etwork providers Services are health care, log-term services ad supports, supplies, behavioral health, prescriptio ad over-the-couter drugs, equipmet ad other services. Covered services are ay of these services that our pla pays for. Covered health care ad log-term services ad supports are listed i the Beefits Chart i Chapter 4. Providers are doctors, urses, specialists ad other people who give you services ad care. The term providers also icludes hospitals, home health agecies, cliics, ad other places that give you health care services, medical equipmet, ad log-term services ad supports. Network providers are providers who work with the health pla. These providers have agreed to accept our paymet as full paymet. Network providers bill us directly for care they give you. Whe you see a etwork provider, you usually pay othig for covered services. B. Rules for gettig your health care, behavioral health, ad log-term services ad supports covered by the pla Aeta Better Health Premier Pla covers all services covered by Medicare ad Medicaid. This icludes medical, behavioral health, log term services ad supports, ad prescriptio drugs. Aeta Better Health Premier Pla will geerally pay for the health care ad services you get if you follow the pla rules. To be covered: The care you get must be a pla beefit. This meas that it must be icluded i the pla s Beefits Chart. (The chart is i Chapter 4 of this hadbook). The care must be medically ecessary. Medically ecessary meas you eed services to prevet, diagose, or treat your medical coditio or to maitai your curret health status. This icludes care that keeps you from goig ito a hospital or ursig home. It also meas the services, supplies, or drugs meet accepted stadards of medical practice or are otherwise ecessary uder curret Medicare or Illiois Medicaid coverage rules. You must have a etwork primary care provider (PCP) who has ordered the care or has told you to see aother doctor. As a pla member, you must choose a etwork provider to be your PCP.»» I most cases, your etwork PCP must give you approval before you ca use other providers i the pla s etwork. This is called a referral. To lear more about referrals, see page 31. You do ot eed a referral from your PCP for emergecy care or urgetly eeded care or to see a woma s health provider. You ca get other kids of care without havig a referral from your PCP. To lear more about this, see page 31. If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 28
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services»»»»» To lear more about choosig a PCP, see page 31. Please ote: If this is your first time i a Medicare-Medicaid Pla, you may cotiue to see your curret providers for the first 180 days with our pla, at o cost, if they are ot a part of our etwork. If you chaged to Aeta Better Health Premier Pla from a differet Medicare-Medicaid Pla, you may cotiue to see your curret providers for the first 90 days with our pla, at o cost, if they are ot a part of our etwork. Durig the trasitio time, our care coordiator will cotact you to help you fid providers i our etwork. After that time, we will o loger cover your care if you cotiue to see out-of-etwork providers. You must get your care from etwork providers. Usually, the pla will ot cover care from a provider who does ot work with the health pla. Here are some cases whe this rule does ot apply: The pla covers emergecy or urgetly eeded care from a out-of-etwork provider. To lear more ad to see what emergecy or urgetly eeded care meas, see page 34. If you eed care that our pla covers ad our etwork providers caot give it to you, you ca get the care from a out-of-etwork provider. I this situatio, we will cover the care at o cost to you. To lear about gettig approval to see a out-of-etwork provider, see page 32. The pla covers kidey dialysis services whe you are outside the pla s service area for a short time. You ca get these services at a Medicare-certified dialysis facility. Whe you first joi the pla, you ca cotiue seeig the providers you see ow for 180 days from eligibility durig your cotiuity of care period. This gives members the ability to see existig providers for acute ad chroic health coditios so care is ot disrupted. Please cotact your case maager if additioal cosideratio is required. C. Your case maager What is a case maager? A Aeta Better Health Premier Pla case maager is a urse, a social worker or other health care professioal. The case maager works with the member to coordiate care ad help get covered services ad other special services he or she eeds. For example, if a member has a disability, the case maager ca help provide the member access to the equipmet he or she may eed, such as a wheelchair, walker or oxyge tak. The case maager ca also help by coordiatig special services, such as medical deliveries or home attedat care. How ca you cotact your case maager? Aeta Better Health Premier Pla members ca cotact their case maager by callig 1-866-600-2139 (TTY: 711) 24 hours a day, 7 days a week. If you wat to chage your case maager, please call the Care Maagemet Lie. If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 29
Aeta Better Health Premier Pla MEMBER HANDBOOK Chapter 3: Usig the pla s coverage for your health care ad other covered services D. Gettig care from primary care providers, specialists, other etwork providers, ad out-of-etwork providers Gettig care from a primary care provider You must choose a primary care provider (PCP) to provide ad maage your care. What is a PCP, ad what does the PCP do for you? What is a PCP? A primary care provider (PCP) is a doctor, urse or cliic i the Aeta Better Health Pla etwork that provides your primary health care. What types of providers may act as a PCP? The followig types of providers ca act as PCPs for Aeta Better Health Premier Pla members: Geeral practitioers Iterists Family practitioers Wome s health care providers Federally Qualified Health Ceters (FQHC) Nurse practitioers workig with doctors Specialists, i some cases You may be able to choose a specialist PCP if you are pregat, have chroic health coditios, disabilities, or special health care eeds. You or your providers ca request a specialist to be your PCP at ay time. If you make a request, you will be cotacted to see if you eed a specialist as a PCP. Aeta Better Health Premier Pla s Medical Director will approve or dey requests after determiig whether you meet the criteria ad whether the specialist you have requested is willig to act as a PCP for you. The role of a PCP Your primary care provider (PCP) is oe of your parters for your health who focuses o your overall health. Your PCP makes sure you get recommeded screeigs ad risk assessmets. What is the role of the PCP i coordiatig covered services? There may be a time whe you have a health problem that ca t be treated by your PCP aloe. Sometimes you may eed specialty care or to see a specialist. Your PCP will work with you ad your care team to help you get special services or see a specialist. If ecessary, your care team or PCP will request prior authorizatio before the service is redered. If you have questios, please call Aeta Better Health Premier Pla at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more iformatio, visit www.aetabetterhealth.com/illiois. 30