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Driscoll Children’s Health Plan w w w. d c h p K i d s . c o m an affiliate of Driscoll Health System h i da lg o s e rv i c e a r e a Cameron, Duval, Hidalgo, Jim Hogg, Maverick, McMullen, Starr, Webb, Willacy, and Zapata Counties STAR MEMBER HANDBOOK March 2012 Member services TOLL-FREE: 1-855-425-3247 DCHP49 w w w. d c h p K i d s . c o m Your STAR benefits include: Doctor visits Prescription drugs Hospital care at local hospitals Shots (immunizations) Eye exams and glasses (under age 21) Hearing and dental exams (under age 21) Interpretation services Free transportation to your doctor Prenatal care Mental health benefits Advice on how to manage asthma and diabetes Driscoll Children’s Health Plan offers you these value added services: Transportation Services. Help with transportation services to medical appointments or prenatal health education classes Eyeglasses. $100 for glasses every 24 months (age 2 and over) Sports Physical. Free sports/school physicals Cell Phone. Loaner cell phone for pregnant members or members with special health-care needs who need one Pregnancy and Birthing Classes. Prenatal classes and nutritional counseling for pregnant women, including free community baby showers (currently available in Hidalgo, Cameron, Starr, and Willacy counties) Asthma Services. Services for members with asthma, including allergyfree pillow cover and bed cover Membership at Boys and Girls ClubS. Family membership to Boys and Girls Clubs where available or a $25 allowance each year toward participation in a local sports team Page 1 Driscoll Children’s Health Plan Call us: Se Habla Español Write us: Regular Business Hours: Before 8 a.m. or after 5 p.m. 24 Hour Behavioral Health Services Hotline Vision and Eye Care Number Dental Care Number – for questions or dentist facts STAR Help Line Medicaid Managed Care Helpline Pharmacist Help Line Non-Urgent Transportation Driscoll Children’s Health Plan Form Number: DCHP49 Member Services 1-855-425-3247 (toll-free) Access to covered services and emergency information For those with hearing loss: 1-800-855-2880 (TTY) toll-free Interpreter Services also exists Driscoll Children's Health Plan 615 N Upper Broadway, Suite 1621 Corpus Christi, TX 78401-0764 8 a.m. to 5 p.m. CST, Monday through Friday except for state approved holidays Call and leave a message. We will return your call the next working day. 1-888-423-0264 (English or Spanish) with facts on services and will assist with obtaining services. Also have other interpretive services. If there is an emergency or crisis, go to the ER or call 9-1-1. 1-877-615-7729 for questions about eye exams and glasses Delta Dental Insurance Company – 1-877-5765899 DentaQuest – 1-800-516-0165 MCNA Dental – 1-800-494-6262 1-800-964-2777 Call 1-866-566-8989 for help to get services. This is a state wide helpline. Those with hearing loss call the TDD#: 1-866-222-4306 Call 1-855-425-3247 (toll-free) if you need help getting a prescription filled. The state has medical transportation services for you, if you need a ride to the doctor’s office. Call 1-877-633-8747, Monday through Friday, 8 a.m. to 5 p.m. (CST). Call early to arrange for a ride. Medicaid/STAR Member Handbook Page 2 Welcome! Welcome to Driscoll Children's Health Plan By choosing the Driscoll Children’s Health Plan (DCHP), you/your child will get all the STAR/Medicaid health benefits – plus more. Your own doctor Friendly and confidential staff The use of Driscoll Children’s Hospital and many other hospitals Free health education for children of any age The right to get care regardless of nationality, race, religion, origin and gender If you have any questions or concerns about getting care, and feel that you were not allowed to get care because of nationality, race, religion, origin, or gender, please call DCHP Member Services at 1-855-425-3247 as soon as possible. Your concern will be investigated and fixed quickly. The doctor you picked when you joined DCHP will be you/your child's Primary Care Provider and will help take care of all you/your child’s health care needs. First things first. These are a few important things about you/your child's health care. You will receive a DCHP ID card, if you have not already received one. Your Primary Care Provider’s name will be on the DCHP ID card. Please check the ID card to make sure the names on it are correct. Get to know you/your child’s doctor. Make an appointment with your Primary Care Provider as soon as possible. Call you/your child’s Primary Care Provider for appointments. Tell them you/your child is a DCHP STAR member. Call your Primary Care Provider whenever you/your child needs health care. Follow your Primary Care Provider’s advice. Carry you/your child's DCHP ID card with you at all times. Use the hospital emergency room only for emergencies. This Member Handbook answers many questions about DCHP. We hope you read it soon. Keep it in a place where you can find it easily. Please feel free to call or write us if you have any questions. At DCHP we are ready to help you any time during the day or night. We have special services for people who have trouble reading, hearing, seeing, or speak a language other than English or Spanish. If member materials, including this handbook, are needed in a different way such as audio, larger print, Braille, other language, etc., call Member Services at 1-855-425-3247 as soon as possible. DCHP will give these materials to you at no cost. Again, Welcome! Driscoll Children's Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 3 Table of Contents Page Driscoll Children's Health Plan and Important Phone Numbers Welcome to Driscoll Children's Health Plan Your STAR ID Card DCHP Identification Card (ID Card) Reading the DCHP ID Card Using the DCHP ID Card If you lose your ID Card or move Your Texas Benefits Medicaid Card Proof of Medicaid (Temporary Form) All About Primary Care Providers What do I need to bring with me to the doctor’s visits? You and Your Child’s Primary Care Provider How do I change my Primary Care Provider? When will my Primary Care Provider change become effective? Can a Clinic be a Primary Care Provider? (RHC/FQHC) How many times can I change my Primary Care Provider? Are there any reasons why my request to change Primary Care Provider might not be approved? Can my Primary Care Provider move me to another Primary Care Provider for non-compliance? What if I choose to go to another doctor who is not my Primary Care Provider? What is the Medicaid Limited Program? Physician Incentive Plan Facts Changing health plans What if I want to change health plans? Who do I call? How many times can I change health plans? When will my health plan change become effective? Can DCHP ask that I get dropped from their health plan (for non-compliance, etc.)? Benefits For DCHP STAR What are my health care benefits? How do I get these services? Are there any limits to any covered services? What number do I call to find out about these services? What services are not covered? What Extra Benefits do I get as a member of DCHP? How do I get these benefits? What are my prescription drug benefits? Behavioral (Mental) Health and Substance Abuse Services How do I get help if I have mental or drug problems? Do I need a referral for this? Attention Female Members What if I need OB/GYN care? Driscoll Children’s Health Plan Form Number: DCHP49 1 2 7 7 7 7 8 9 9 9 9 9 9 10 10 10 10 10 11 11 11 11 11 11 12 12 12 13 13 13 13 14 14 14 14 Medicaid/STAR Member Handbook Page 4 Table of Contents Page Do I have a right to pick an OB/GYN? How do I pick an OB/GYN? If I do not pick an OB/GYN, do I have direct access? Will I need a referral? Can I stay with my OB/GYN if they are not with DCHP? What if I am pregnant? Who do I need to call? What other services/activities/education does the health plan offer pregnant women? Where can I find a list of birthing centers? How soon can I be seen after contacting my OB/GYN for an appointment? Can I pick a Primary Care Provider for my baby before the baby is born? How and when can I switch my baby’s Primary Care Provider? Can I switch my baby’s health plan? How do I sign up my newborn baby? How and when do I tell my health plan? How do I get family planning services? Do I need a referral for this? What is Case Management for Children and Pregnant Women? What type of services would my child or I get? Family Planning Providers Where do I find a family planning services provider? Texas Health Steps What is Texas Health Steps? What services are offered by Texas Health Steps? How and when do I get Texas Health Steps medical and dental checkups for my child? Does my doctor have to be a part of the DCHP network? Do I have to have a referral? What if I need to cancel an appointment? What if I am out of town and my child is due for a Texas Health Steps checkup? What if I am a Migrant Farm Worker? Other Coverage and Services What Health Education classes does DCHP offer? What other services can DCHP help me get? (non-capitated services) How do I get eye care services? How do I get dental care services for my child? Interpreter Can someone interpret for me when I talk with my doctor? Who do I call for an interpreter? How far in advance do I need to call? How can I get a face-to-face interpreter in the doctor’s office? Prescription Coverage How do I get my medications? How do I find a network drug store? Driscoll Children’s Health Plan Form Number: DCHP49 14 14 14 15 15 15 15 15 15 15 15 16 16 16 16 16 16 16 16 17 17 17 17 18 18 18 18 18 18 18 19 19 19 19 19 19 20 20 Medicaid/STAR Member Handbook Page 5 Table of Contents Page What if I go to a drug store that is not in network? What do I bring with me to the drug store? What if I need my medications delivered to me? Who do I call if I have problems getting my medications? What if I can’t get the medication my doctor ordered approved? What if I lose my medications? Health Care and Other Services What does Medically Necessary mean? (Both Acute Care and Behavioral Health) What is routine medical care and how do I get it? What is urgent medical care and how do I get it? Emergency Care Emergency Medical Care Are Emergency Dental Services Covered? What do I do if I need Emergency Dental Care? How soon can I expect to be seen? What is post stabilization? How do I get medical care after my Primary Care Provider’s office is closed? What if I get sick when I am out of town or traveling? What if I am out of the state? What if I am out of the country? Transportation If I do not have a car, how can I get a ride to the doctor’s office? Who do I call for a ride to a medical appointment? How far in advance do I need to call? Can someone I know give me a ride to my appointment and get money for mileage? Who do I call if I have a complaint about the service or staff? What are the hours of operation and limits for transportation services? Referrals to Specialists What if I need to see a special doctor (specialist)? What is a referral? How soon can I expect to be seen by a specialist? Who do I call if I have special health care needs and need someone to help me? What services do not need a referral? How can I ask for a second opinion? Advance Directives What if I am too sick to make a decision about my medical care? What are advance directives? How do I get an advance directive? Other Facts What happens if I lose my Medicaid coverage? What if I get a bill from my doctor? Who do I call? Driscoll Children’s Health Plan Form Number: DCHP49 20 20 20 20 20 20 20 21 21 22 23 23 23 23 23 24 24 24 24 24 24 24 25 25 25 25 25 25 25 25 26 26 26 26 26 26 Medicaid/STAR Member Handbook Page 6 Table of Contents Page What facts will they need? What do I do if I move? What if I have other health insurance in addition to Medicaid? How do my medical bills get paid if I have other insurance? What if I have an accident and DCHP pays the bill? Services That Require Prior Authorization What can I do if my doctor asks for a service for me that’s covered but the health plan denies it or limits it? How will I find out if services are denied? How to Appeal a Denied Service Can I appeal when DCHP has not paid a claim? Can someone from DCHP help me file an appeal? Can I file an appeal with the State? What is an Expedited Appeal? How can I ask for an Expedited Appeal? What happens if the health plan denies the request for an expedited appeal? Who can help me file an Expedited Appeal? State Fair Hearing Can I ask for a State Fair Hearing? Complaints What should I do if I have a complaint? Who do I call? How long will it take to process my complaint? Information on how to file a complaint with HHSC once I have gone through the DCHP Complaint process Fraud and Abuse of the STAR Program Do you want to report Waste, Abuse or Fraud? Reporting Waste, Abuse or Fraud Information that must be available on a once a year basis Member Rights and Responsibilities What are my rights and responsibilities? Driscoll Children’s Health Plan Form Number: DCHP49 26 26 26 27 27 28 28 28 29 29 29 29 29 29 29 30 30 30 31 31 31 32 32 32 Medicaid/STAR Member Handbook Page 7 Driscoll Children’s Health Plan and STAR Driscoll Children’s Health Plan provides services for the Medicaid program, called STAR. This provides care to families who would not normally be able to get care. By choosing the Driscoll Children’s Health Plan (DCHP), we can provide STAR health services to you and your children. Health care through DCHP STAR is in these South Texas counties: Cameron Duval Hidalgo Jim Hogg McMullen Maverick Starr Webb Willacy Zapata DCHP is a not-for-profit Health Maintenance Organization (HMO) licensed by the Texas Department of Insurance. Your STAR ID Card You will get a STAR Identification (ID) card after you join DCHP. A copy of the DCHP ID card is shown below. Facts about you or your child Primary Care Provider name and phone number Each of you and your children will have a different card. You will not get a new DCHP STAR card every month. You will get a new one if you lose your ID, or if you call us to change your Primary Care Provider. Reading the DCHP STAR ID Card The front of the DCHP STAR ID card shows important facts about you/your child, the Primary Care Provider’s name and Primary Care Provider’s phone number. The back of the card shows important phone numbers for emergencies or other help from DCHP Member Services. Using the DCHP ID Card Carry your and your child’s DCHP STAR ID Card with you when you/your child get any health care services. You must show your STAR ID Card each time for any health service. If you lose an ID Card or Move If you lose the DCHP STAR ID Card, call us right away at 1-855-425-3247 to get a new one. Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 8 Your Texas Benefits Medicaid Card When you are approved for Medicaid, you will get a Your Texas Benefits Medicaid Card. This plastic card will be your everyday Medicaid ID card. You should carry and protect it just like your driver’s license or a credit card. The card has a magnetic stripe that holds your Medicaid ID number. Your doctor can use the card to find out if you have Medicaid benefits when you go for a visit. You will get a new Your Texas Benefits Medicaid card every time you change your health plan. If you are not sure if you are covered by Medicaid, you can find out by calling toll-free at 1-800-252-8263. You can also call 2-1-1. First pick a language and then pick option 2. Your health history is a list of medical services and drugs that you have gotten through Medicaid. We share it with Medicaid doctors to help them decide what health care you need. If you don’t want your doctors to see your health history through the secure online network, call toll-free at 1-800-252-8263. The Your Texas Benefits Medicaid card has these facts printed on the front: Your name and Medicaid ID number. The name of the Medicaid program you’re in if you get your Medicaid services through a health plan. This would be STAR, STAR Health, or STAR+PLUS. The date HHSC made the card for you. Facts your drug store will need to bill Medicaid. The name of the health plan you’re in and the plan’s phone number. The name of your doctor and drug store if you’re in the Medicaid Limited program. Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 9 Proof of Medicaid (Temporary Form) If you lose Your Texas Benefits Medicaid Card you can get a temporary Medicaid form. The temporary form is Form 1027-A. You can use this form until you get Your Texas Benefits Medicaid Card. Your temporary form will work just like the Your Texas Benefits Medicaid Card. Contact the STAR Help Line at 1-800-964-2777 to learn more on how to get a temporary form. All About Primary Care Providers What do I need to bring with me to my doctor’s appointment? You must take your/your child’s DCHP ID card, and Your Texas Benefits Medicaid Card with you when you go to the doctor. If your child is going to the doctor, don’t forget your child’s shot records. You and your child’s Primary Care Provider During the process when you joined DCHP, you chose a doctor from our list to be your/your child’s Primary Care Provider. This doctor will make sure that you/your child gets the right care. The Primary Care Provider will give you/your child regular checkups, write prescriptions for medicines and supplies when you/your child is sick, and tell you if you/your child should see a specialist. To give you the best care possible, your Primary Care Provider needs to know your and your child’s medical history. Your medical records are private and confidential. Only you, your Primary Care Provider, and other approved providers have a right to see them. If you change doctors, be sure to give your new Primary Care Provider any facts needed about your medical history. How can I change my Primary Care Provider? You might want to change to another Primary Care Provider if: You are not happy with your Primary Care Provider’s care. You need a different doctor to take care of your child. You move farther away from your Primary Care Provider. Your Primary Care Provider is no longer a part of DCHP’s network. You do not get along with the Primary Care Provider. You can change your/your child’s Primary Care Provider by calling toll-free at 1-855-425-3247. The DCHP Provider Directory lists all Primary Care Providers. You will get a new ID card that shows the date the new Primary Care Provider can begin to care for you or your child. The new card will show the new Primary Care Provider’s name and phone number. When will my Primary Care Provider change become effective? th You can change the Primary Primary Care Care Provider Provider at at anytime. anytime. If you call BEFORE BEFORE the ofthe themonth, month, the the change the the 5th 15 of th change will become become effective effectiveimmediately. immediately. IfIf you you call call AFTER AFTER the ofthe themonth, month, the the Primary Primary Care Care change will the 5th 15 of Provider willnot notchange changeuntil until first of the month. Provider will thethe first of the nextnext month. Can a Clinic be my Primary Care Provider? (RHC/FQHC) You/your child can pick a clinic as your Primary Care Provider. This can be a Federally Qualified Health Center (FQHC), or a Rural Health Clinic (RHC). If you have questions call Member Services at 1-855425-3247. Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 10 How many times can I change my Primary Care Provider? There is no limit on how many times you can change you or your child’s primary care provider. You can change primary care providers by calling us toll-free at 1-855-425-3247 or writing to: Driscoll Children’s Health Plan ATT: Request to change PCP 615 N Upper Broadway, Suite 1621 Corpus Christi, TX 78401-0764 Are there reasons why my request to change my Primary Care Provider might not be approved? You might not be able to have the Primary Care Provider you chose if: The Primary Care Provider you picked is not seeing new patients. The Primary Care Provider you picked is no longer a part of DCHP. You have already changed Primary Care Providers more than four (4) times in one year. Can my Primary Care Provider move me to another Primary Care Provider for non-compliance? It is important to follow the Primary Care Provider’s advice. Take part in decisions about your/your child’s health care. Your Primary Care Provider might ask us to assign you/your child to another Primary Care Provider if you do not follow his or her advice. It might also happen if you and the Primary Care Provider do not get along or you miss visits without calling to tell the Primary Care Provider why you weren’t there. The Primary Care Provider must tell us if he or she wants you to change your/your child’s Primary Care Provider. We will contact you and ask that you pick another Primary Care Provider. What if I choose to go to another doctor who is not my Primary Care Provider? If you choose to see another doctor who is not your/your child’s Primary Care Provider, the services must be authorized. For questions, contact Member Services at 1-855-425-3247. You can go to any provider who is part of DCHP, if you need: 24-hour emergency care from an emergency room. Family Planning services and supplies. If you need mental health or substance abuse services you should call the Behavioral Health Hotline at 1888-244-4142. Behavioral Health Services are very private so you do not need for your Primary Care Provider to agree for you to get these services. If you need a routine vision exam, you do not need your Primary Care Provider to agree for you to get these services. But if you have an eye problem you will need a referral from your Primary Care Provider. For questions about vision services, call 1-866-838-7614. For all other care, you must only see the Primary Care Provider listed on your ID Card. What is the Medicaid Limited Program? You may be put in the Limited Program if you do not follow Medicaid rules. It checks how you use Medicaid pharmacy services. Your Medicaid benefits remain the same. If you are put in the Medicaid Limited Program: Pick one drug store at one location to use all the time. Be sure your main doctor, main dentist, or the specialists they refer you are the only doctors that give you prescriptions. Do not get the same type of medicine from different doctors. To learn more call 1-800-463-6184 Option 4. Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 11 Physician Incentive Plans A physician incentive plan rewards doctors for treatments that reduce or limit services for people covered by Medicaid. Right now, Driscoll Children’s Health Plan does not have a physician incentive plan. Changing Health Plans What if I want to change health plans? You can change your health plan by calling the Texas STAR Program Helpline at 1-800-964-2777. During the first 90 days after you are enrolled in a health plan, you can change to another plan for any reason. After 90 days with a health plan, you can change to another plan once for any reason. An example of good cause is that you can’t get the care you need through the health plan. If you are in the hospital, a residential Substance Use Disorder (SUD) treatment facility, or residential detoxification facility for SUD, you will not be able to change health plans until you have been discharged. If you call to change your health plan on or before the 15th of the month, the change will take place on the first day of the next month. If you call after the 15th of the month, the change will take place the first day of the second month after that. For example: If you call on or before April 15, your change will take place on May 1. If you call after April 15, your change will take place on June 1. Who do I call? Call the Texas STAR Program Helpline at 1-800-964-2777 to change health plans. How many times can I change health plans? You can change health plans as many times as you want, but not more than once a month. When will my Health Plan change become effective? th If you call to change your/your child’s health plan on or before the 15 of the month, the change will take th place on the first day of the next month. If you call after the 15 of the month, the change will take place the first day of the second month after that. For example: If you call on or before April 15, your change will take place on May 1. If you call after April 15, your change will take place on June 1. Can Driscoll Children's Health Plan ask that I get dropped from their plan (for non-compliance, etc.)? Yes, Driscoll Children's Health Plan might ask that you be removed from our health plan. DCHP might ask for your removal if: You let someone else use your DCHP ID Card. You let someone else use Your Texas Benefits Medicaid Card You do not follow your doctor’s advice, for you or your child. Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 12 You keep going to the emergency room for yourself or your child when you do not have a true emergency. You cause problems at the doctor’s office. You make it difficult for your doctor to help you or other people. If there are changes in your health plan, you will be sent a letter. Benefits For DCHP STAR What are my health care benefits? Driscoll Children's Health Plan covers all the benefits Medicaid covers, including: Care to help you/your child stay well. Needed medical care for adults and children. Vaccines for children under 21 years old. Specialty doctor services Chiropractic (Back doctor) Services. Podiatry (Foot doctor) Services. Laboratory Services. X-ray Services. Surgery without staying in the hospital overnight. Hospital care. 24-hour emergency care from an emergency room. Unlimited Prescription Drugs (through the Vendor Drug Program). Eye exams and glasses. Ear doctor visits and hearing aids. Home health Services (health care at home). Ambulance Services, if you need it. Dialysis (help from a machine) for kidney problems. Durable medical equipment and supplies (wheelchair) Transplantation of organs and tissues (such as heart or kidney) Family planning services and supplies (such as birth control). Prenatal care Birthing center services Behavioral (mental) health services. Help with substance abuse (such as alcohol or drugs). A checkup every year for adult members. A Texas Health Steps checkup for members under the age of 21 years No 30 day spell of illness limit And many other benefits (call Member Services at 1-855-425-3247 for more facts) How do I get these services? Your or your child’s Primary Care Provider will work with you to make sure your child gets the care needed. Are there any limits to any covered services? There might be limits to these services. Call Member Services to learn more. Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 13 What number do I call to find out about these services? You can call Member Services at 1-855-425-3247 at any time you have questions. What services are not covered? The following services, which might not be all services, are not covered by STAR: Acupuncture (healing using needles and pins) Hypnosis Cosmetic surgery (such as a face-lift) Artificial insemination Ear piercing Hospital bereavement Hair transplant Infertility treatment In-vitro fertilization Experimental medicines or procedures Marital counseling Medical testimony and reports Non-authorized services Penile implant Radial keratotomy Respite care Reversal of sterilization Any services that you don’t have to have (is not medically necessary) Any service that your/your child’s Primary Care Provider does not say is “OK” Any service you get outside of the United States What Extra Benefits do I get as a Member of Driscoll Children's Health Plan? All Driscoll Children's Health Plan members are able to receive Value Added services. The following are extra benefits that you or your child may have: Asthma environmental review with free pillow and bed covers $100 for eye glasses every 24 months (age 2 and over) Extra transportation benefit for doctor appointments for members who qualify Sports/school physicals Temporary cell phones for members who are pregnant or members with special health care needs, who need a telephone Prenatal education and nutritional counseling for pregnant women Access to Boys and Girls Clubs where available. Sports Scholarships of $25 per member per year are also available. For facts about all the extra benefits call Member Services at 1-855-425-3247. How can I get these Benefits? For eyeglasses, contact our vision vendor at 1-866-838-7614. For question on how to get any of the other value added services, contact Member Services at 1-855425-3247. Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 14 What are my prescription drug benefits? Driscoll Children’s Health Plan covers most drugs your doctor orders. Services at 1-855-425-3247. To learn more call Member Behavioral (Mental) Health and Substance Abuse Services How do I get help if I have mental health, alcohol, or drug problems? You can get help for behavioral (mental) health problems and/or substance (drug) abuse. The provider you pick must be a provider with Driscoll Children's Health Plan’s Behavioral Health network. Call the Behavioral Health Hotline on your ID card for help. The phone number is 1-888-244-4142. You can call anytime 24 hours a day, seven (7) days a week. Behavioral health services are very private so you do not need your/your child’s Primary Care Provider to agree for you/your child to get these services. If you/your child has an emergency related to mental health problems or drug or alcohol abuse, go to the nearest hospital emergency room or call 911 for an ambulance. Do I need a referral for this? You can go to a DCHP mental health provider without a referral from your/your child’s Primary Care Provider. Attention Female Members What if I need OB/GYN care? Driscoll Children's Health Plan allows you to pick an OB/GYN (doctor for women’s health) but this doctor must be in the same network as your Primary Care Provider. Do I have a right to pick an OB/GYN? You have the right to pick an OB/GYN without a referral from your Primary Care Provider. An OB/GYN can give you: One well-woman checkup each year. Care related to pregnancy. Care for any female medical condition. Referral to special doctor within the network. How do I pick an OB/GYN? You can only go to OB/GYNs who are part of the Driscoll Children's Health Plan. You do not need a referral from your Primary Care Provider. To pick an OB/GYN, call Member Services at 1-855-425-3247. You can also have your OB/GYN doctor be your Primary Care Provider. If you want to have your OB/GYN doctor be your Primary Care Provider, call Member Services at 1-855-425-3247. If I do not pick an OB/GYN, do I have direct access? You are not required to pick an OB/GYN doctor. But, if you are pregnant you should pick an OB/GYN doctor to take care of you. You can have direct access to an OB/GYN doctor. Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 15 Will I need a referral? No, you will not need a referral from your Primary Care Provider to see an OB/GYN doctor. Can I stay with my OB/GYN if they are not with Driscoll Children's Health Plan? If you are six (6) months pregnant or more you can stay with the OB/GYN doctor you are seeing, even if he/she is not with Driscoll Children's Health Plan. To learn more call Member Services at 1-855-4253247. What if I am pregnant? It is very important that you call Driscoll Children's Health Plan to tell us you are pregnant and what doctors you are seeing. Who do I need to call? Call Member Services at 1-855-425-3247 if you are pregnant. It is very important to start your prenatal care immediately. What other services/activities/education does the health plan offer pregnant women? Pregnant women will receive case management and health education. A nurse case manager will: Contact you by phone. Contact you by mail. Provide education about your pregnancy. Help you find an OB/GYN doctor. Evaluate your healthcare and education needs. Help you coordinate special needs visits and transportation. Report on your progress to your Primary Care Provider and/or OB/GYN doctor. Give you a temporary cell phone for use while you are pregnant, if you do not have a phone. Help you select a Baby Doctor for your baby. There are other extra benefits for pregnant women that include: Limited dental benefit for members 21 years of age or older Home visits for new mothers Prenatal education and nutritional counseling Intensive outpatient treatment/day treatment for chemical dependency/abuse for members 21 years of age or older Residential treatment for chemical dependency/abuse for members 21 years of age or older Where can I find a list of birthing centers? If you need to know where there is a birthing center, call member services at 1-855-425-3247. They can help you. How soon can I be seen after contacting my OB/GYN for an appointment? You should be able to get an appointment within two weeks of your request. Can I pick a Primary Care Provider for my baby before the baby is born? Yes. Call Member Services at 1-855-425-3247 and pick a Primary Care Provider for your baby. Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 16 How and when can I switch my baby’s Primary Care Provider? If you do not pick a Primary Care Provider for your baby, one will be picked for you. If you are unhappy with the one picked for you, you can call Member Services and change the Primary Care Provider. Can I switch my baby’s health plan? For at least 90 days from the date of birth, your baby will be covered by the same health plan you joined. You can ask for a health plan change before the 90 days is up if both your current health plan and your new health plan agree with transfer. You cannot change health plans while your baby is in the hospital. How do I sign up my newborn baby? When your baby is born, call your Health and Human Services Commission – Office of Eligibility Services caseworker right away so your baby can get Medicaid. How and when do I tell my health plan? It is also important that you call Member Services or your Case Manager to let us know that your baby is born as soon as possible. You will receive a Medicaid ID (Tour Texas Benefits Medicaid Card) that says “Newborn Call Plan”. This means the baby is in the mother’s health plan for at least 90 days from the date of birth. How do I get family planning services? Family planning services (such as birth control and counseling) are very private. You can have a once a year visit, counseling and tests. You can also have drugs and supplies that prevent pregnancy. Ask your Primary Care Provider if he/she offers family planning services such as birth control. If you do not feel comfortable talking with your Primary Care Provider, call Member Services at 1-855-425-3247. You can go to any family planning clinic that will take your Medicaid form. Do I need a referral for this? You do not need to ask your Primary Care Provider for a referral to get family planning services or supplies. What is Case Management for Children and Pregnant Women? Case Management for Children and Pregnant Women provides services to children with a health condition/health risk, birth through twenty (20) years of age and to high-risk pregnant women of all ages. This program helps with any medical, social educational and any other medically necessary service that you might need. For facts call 1-877-847-8377 (1-877-THSTEPS). What type of services would my child or I get? The CPW program helps with facts on nutrition, physical and mental health care, well-child care, and financial assistance programs. To learn more, visit the Case Management for Children and Pregnant Women website at http://www.dshs.state.tx.us/caseman/default.shtm. Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 17 Family Planning Providers Where do I find a family planning services provider? You can find the locations of family planning providers near you online at http://www.dshs.state.tx.us/famplan/locator.shtm , or you can call Driscoll Children’s Health Plan at 1-855425-3247 for help in finding a family planning provider. Texas Health Steps What is Texas Health Steps? Texas Health Steps is for children birth through 20 years old who have Medicaid. Texas Health Steps gives your child free medical and dental checkups. These checkups are important and should be set up within 45 days of becoming a Driscoll Children's Health Plan member. Even if a child looks and feels well, he or she might still need a checkup. What services are offered by Texas Health Steps? Texas Health Steps can help in many ways. Some of the things done in a Texas Health Steps medical checkup are: Physical exam, measuring height and weight. Hearing and eye check. Checking for a good diet. Vaccines (when needed). Blood tests (when needed). TB test. Dental checkups start at 6 months of age. This care includes: Teeth cleaning every six (6) months Fillings Getting teeth pulled Crowns Root canals, and Getting wisdom teeth pulled. If you are 21 years old or older, Medicaid/STAR will cover dental care only if it is an emergency that puts your life in danger. How and when do I get Texas Health Steps medical and dental checkups for my child? All of the Driscoll Children's Health Plan Primary Care Providers who work with children are also able to offer Texas Health Steps services. You might want to talk to your child’s Primary Care Provider first. Don’t forget to show your Driscoll Children's Health Plan ID card and Your Texas Medicaid Benefits Card to your Primary Care Provider. Dental checkups can be received every 6 months beginning at 6 months of age. If the dentist finds a problem, he/she can also treat the problem in a follow-up visit. If the dentist has to do needed dental treatment at the hospital or some place other than his/her office, you will need to contact Driscoll Children's Health Plan before the service is done. Call Texas Health Steps for facts about dental treatment at 1-877-847-8377 (1-877-THSTEPS) Monday to Friday from 8 a.m. to 8 p.m., Central Time. Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 18 Does my doctor have to be part of the Driscoll Children's Health Plan network? All of Driscoll Children's Health Plan Primary Care Provider’s are Texas Health Steps providers. You need to take your child to their Primary Care Provider for a Texas Health Steps medical checkup. Do I have to have a referral? Your child’s Primary Care Provider is who will provide the Texas Health Steps medical checkup. No referral is needed to see the Primary Care Provider. What if I need to cancel an appointment? Call and make an appointment for each family member who needs to be seen. Call if you cannot make your appointment. Some Primary Care Providers ask patients to call at least 24 hours before their appointment so that another patient can use that time slot. What if I am out of town and my child is due for a Texas Health Steps exam? If you have moved or are out of town when your child’s Texas Health Steps medical checkup exam is due, call Member Services for help at 1-855-425-3247. What if I am a Migrant Farm Worker? You can get your checkup sooner if you are leaving the area. Other Coverage and Services What Health Education classes does Driscoll Children's Health Plan offer? DCHP has education for members on many different health subjects. There is no charge for DCHP’s health education. Health education might include facts on: Immunizations Special diets for diabetes Asthma care Wellness programs and health fairs If you need health education materials in another language, or in another format, call Member Services at 1-855-425-3247. What other services can DCHP help me get (non-capitated services)? Medicaid/STAR program offers services that are not offered by DCHP. DCHP can help you get these services. Call Member Services at 1-855-425-3247 to find out how. Examples of these programs are: Texas Health Steps dental (including orthodontia) Early Childhood Intervention (ECI) case management and service coordination. Department of State and Health Services for targeted case management. Department of State and Health Services for mental health rehabilitation. Department of State and Health Services for case management for Children and Pregnant Women. Texas School Health and Related Services (SHARS). Department of Assistive and Rehabilitative Services Blind Children’s Vocational Discovery and Development Program. Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 19 Tuberculosis services provided by the Department of State and Health Services-approved providers Vendor Drug Program (for drugs not given to you in the doctor’s office) Health and Human Services Commission’s Medical Transportation DADS hospice services. Audiology services and hearing aids for children under age 21. Personal care services for children under age 21. For facts about any of these or other health services, contact Member Services at 1-855-425-3247. How do I get eye care services? You/your child can get an eye exam and prescription glasses. You can have an exam one time every 12 months. Children might be able to have additional eye examinations and prescription glasses as part of the Texas Health Steps. You do not need a referral from your Primary Care Provider to see an eye doctor or therapeutic optometrist. For facts about eye care and where you can find an eye doctor or therapeutic optometrist, call 1-888-268-2664.If you are over the age of 21, you can get an eye exam and prescription glasses one time every 24 months. How do I get dental services for my child? Your child’s Medicaid dental plan provides dental services including services that help prevent tooth decay and services that fix dental problems. Call your child’s Medicaid dental plan to learn more about the dental services they offer. Driscoll Children’s Health Plan covers emergency dental services your child gets in a hospital or ambulatory surgical center. This includes services the doctor provides and other services your child might need like anesthesia. Interpreter Can someone interpret for me when I talk with my doctor? Yes. We will arrange for an interpreter to help you during your visit. Who do I call for an interpreter? Call Member Services at 1-855-425-3247. How far in advance do I need to call? You will need to call at least 48 hours in advance of your appointment. How can I get a face-to-face interpreter in the provider’s office? The interpreter we arrange for you can be someone that comes to the office. This interpreter will be in the doctor’s office with you. Let us know if this is what you want. Se Habla Espanol – DCHP has people to help you who speak both Spanish and English. We also have member brochures in Spanish. Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 20 Prescription Coverage How do I get my medications? Medicaid pays for most medicine your doctor says you need. Your doctor will write a prescription so you can take it to the drug store, or may be able to send the prescription for you. How do I find a network drug store? A network pharmacy can be found on the pharmacy network list at www.dchpkids.com or contact member services at 1-877-220-6376 for help finding a network drug store. What if I go to a drug store not in the network? The drug store can call the pharmacy help line on the back of your member ID card. They will assist in obtaining a fill for you. What do I bring with me to the drug store? You will need to bring Your Texas Benefits Medicaid ID card and/or your Driscoll Children’s Health Plan ID card. What if I need my medications delivered to me? Please visit www.dchpkids.com for a complete pharmacy network list at or call member services at 1-877220-6376 for pharmacies that offer free delivery. Who do I call if I have problems getting my medications? Please contact member services at 1-877-220-6376 if you have problems getting your medication. What if I can’t get the medication my doctor ordered approved? If your doctor cannot be reached to approve a prescription, you may be able to get a three-day emergency supply of your medication. Call Driscoll Children’s Health Plan at [insert toll-free number] for help with your medications and refills. What if I lose my medication(s)? Lost or stolen medications are not a covered benefit. You may call your pharmacy and request an early refill on and pay the cost of the medication. Health Care and Other Services What does Medically Necessary mean? Medically Necessary means: (1) For Members birth through age 20, the following Texas Health Steps services: (a) screening, vision, and hearing services; and (b) other Health Care Services, including Behavioral Health Services, that are necessary to correct or ameliorate a defect or physical or mental illness or condition. A determination of whether a service is necessary to correct or ameliorate a defect or physical or mental illness or condition: Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 21 (i) must comply with the requirements of the Alberto N., et al. v. Suehs, et al. partial settlement agreements; and (ii) may include consideration of other relevant factors, such as the criteria described in parts (2)(b-g) (2)(a-g) and and (3)(a-b) (3)(b-g)ofofthis thisdefinition. definition. (2) For Members over age 20, non-behavioral health related healthcare services that are: (a) reasonable and necessary to prevent illnesses or medical conditions, or provide early screening, interventions, and/or treatments for conditions that cause suffering or pain, cause physical deformity or limitations in function, threaten to cause or worsen a handicap, cause illness or infirmity of a member, or endanger life; (b) provided at appropriate facilities and at the appropriate levels of care for the treatment of a member’s health conditions; (c) consistent with health care practice guidelines and standards that are endorsed by professionally recognized health care organizations or governmental agencies; (d) consistent with the diagnoses of the conditions; (e) no more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency; (f) are not experimental or investigative; and (g) are not primarily for the convenience of the member or provider; and (3) For Members over age 20, behavioral health services that are: (a) are reasonable and necessary for the diagnosis or treatment of a mental health or chemical dependency disorder, or to improve, maintain, or prevent deterioration of functioning resulting from such a disorder; (b) are in accordance with professionally accepted clinical guidelines and standards of practice in behavioral health care; What is routine medical care and how do I get it? The Primary Care Provider you chose will help you or your child with all your health care. Your or your child’s Primary Care Provider will get to know you and arrange regular checkups. He or she will treat you when you or your child is sick. Your Primary Care Provider will give you prescriptions for medicine. He or she will send you or your child to a special doctor (specialist) if you need one. It is important that you do what your or your child’s Primary Care Provider says. You should take part in decisions made about your or your child’s health care. If you cannot make a decision about your or your child’s health care, you can pick someone else to do it for you. Call your Primary Care Provider at the number on your or your child’s Driscoll Children's Health Plan ID card when you need to see him/her. Someone in the Primary Care Provider’s office will set a time for you. It is very important that you keep your appointment. Call early to set up visits. Call back if you have to cancel. You need a new appointment for each person if more than one person needs to see the doctor. You should be able to get an appointment for routine care within two (2) weeks. What is urgent medical care and how do I get it? Urgent medical care is when you/your child are sick or hurt and need treatment as soon as possible to keep you/your child from getting worse. These are situations when you need to call your Primary Care Provider first: Earache Toothache or baby teething Rash Colds, cough, sore throat, flu or sinus problems Minor sun burn Minor cooking burn Chronic back pain Minor headache Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 22 Broken cast Stitches needing to be removed Medication refills Your or your child’s Primary Care Provider is there for you, directly or through other doctors helping to cover the office, 24 hours a day, 7 days a week. You can expect to be seen for urgent medical care within 24 hours. Emergency Care Emergency Medical Care Emergency medical care is provided for Emergency Medical Conditions and Emergency Behavioral Health Conditions. Emergency Medical Condition means: A medical condition manifesting itself by acute symptoms of recent onset and sufficient severity (including severe pain), such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical care could result in: (1) placing the patient’s health in serious jeopardy; (2) serious impairment to bodily functions; (3) serious dysfunction of any bodily organ or part; (4) serious disfigurement; or (5) in the case of a pregnant women, serious jeopardy to the health of a woman or her unborn child. Emergency Behavioral Health Condition means: Any condition, without regard to the nature or cause of the condition, which in the opinion of a prudent layperson, possessing average knowledge of medicine and health: 1. requires immediate intervention and/or medical attention without which the Member would present an immediate danger to themselves or others; or 2. which renders the Member incapable of controlling, knowing or understanding the consequences of their actions. Emergency Services and Emergency Care means: Covered inpatient and outpatient services furnished by a provider that is qualified to furnish such services and that are needed to evaluate or stabilize an Emergency Medical Condition and/or Emergency Behavioral Health Condition, including post-stabilization care services. You or your child has an EMERGENCY medical need if: You think your or your child’s condition is life threatening. You or your child has serious pain. Serious harm could come to you or your child without immediate medical attention. If you or your child has an emergency, go to the closest Emergency Room right away or call 9-1-1. Examples of when to go to the emergency room are: Someone might die without immediate medical attention. Someone has bad chest pains. Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 23 Someone cannot breathe or is choking. Someone has passed out or is having a seizure. Someone is sick from poison or a drug overdose. Someone has a broken bone. Someone is bleeding a lot. Someone has been attacked (raped, stabbed, shot, beaten). Someone is about to deliver a baby. Someone has a serious injury to the arm, leg, hand, foot, or head. Someone has a severe burn. Someone has a severe allergic reaction or has an animal bite. Someone has trouble controlling behavior and without treatment is dangerous to self or others. Go to the nearest hospital if you think you or your child has any of these problems. You can call 911 for help in getting to the hospital emergency room. If you go to the ER, be sure to call you/your Primary Care Provider within 24 hours, or as soon as you/your child is medically stable. Are Emergency Dental Services Covered? Driscoll Children’s Health Plan covers limited emergency dental services for the following: Dislocated jaw Traumatic damage to teeth and supporting structures Removal of cysts Treatment of oral abscess of tooth or gum origin Treatment and devices for craniofacial anomalies Drugs for any of the above conditions Driscoll Children’s Health Plan also covers dental services your child gets in a hospital. This includes services the doctor provides and other services your child might need, like anesthesia. What do I do if I need Emergency Dental Care? During normal business hours, call your child’s Main Dentist to find out how to get emergency services. If your child needs emergency dental services after the Main Dentist’s office has closed, call us toll-free at 1-855-425-3247 or call 911. How soon can I expect to be seen? Emergency care is there for you 24 hours a day, 7 days a week. What is post stabilization? Post-stabilization care services are services covered by Medicaid that keep your/your child’s condition stable following emergency medical care. How do I get medical care after my Primary Care Provider’s office is closed? If you/your child gets sick at night or on a weekend and cannot wait to get medical care, call your Primary Care Provider for advice. Your Primary Care Provider or another doctor is there for you by phone 24 hours a day, 7 days a week. If you/your child has a fever or a sore throat and you are not sure what to do, call your Primary Care Provider’s office. The office will have an answering service or Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 24 message on how to contact the Primary Care Provider. The Primary Care Provider should return your call within thirty (30) minutes. What if I get sick when I am out of town or traveling? If you/your child gets sick while you are out of town or out of state, call your Primary Care Provider at the phone number listed on the front of your DCHP STAR ID card. You can also call Member Services at the number on the back of your ID card. If you/your child has an emergency while you are out of town or out of state, go to the nearest ER. Contact your or your child’s Primary Care Provider to schedule appointments or get prescriptions if you/your child are going to be temporarily away from home. Make sure you have enough medicine for the all the time you/your child is away. You/your child will still be under the care of your Primary Care Provider if you/your child gets sick while out of town. If you/your child sees an out-of-town doctor, you might have to pay except in an emergency. Call Member Services at 1-855-425-3247 for more facts. Keep your/your child’s DCHP ID card with you at all times If you need medical care when traveling, call us toll-free at 1-855-425-3247 and we will help you find a doctor. If you need emergency services while traveling, go to a nearby hospital, then call us toll-free at 1-855425-3247.. What if I am out of the state? If you/your child has an emergency while you are out of the state, go to the nearest ER. What if I am out of the country? Driscoll Children's Health Plan does not cover any care outside of the United States. Transportation If I do not have a car, how can I get a ride to a doctor’s office? If you need a ride to a doctor’s office, you can get help with medical transportation services. Call medical transportation as soon as you know you will need a ride. Who do I call for a ride to a medical appointment? If you need to know more or need a ride to the doctor, call this number: 1-877-633-8747 How far in advance do I need to call? You must call at least two days before you need a service. For example, If you need a ride on Monday, call medical transportation by Thursday the week before. Can someone I know give me a ride to my appointment and get paid for mileage? The state has medical transportation services that can also help pay for mileage for someone who to drive you to an appointment. This driver can be you, a family members, neighbor, or volunteer. Please call 1-877-633-8747 to learn more. Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 25 Who do I call if I have a complaint about the service or staff? If you have a complaint about the service or staff, call the medical transportation services at 1-877-6338747, or call Member Services at 1-855-425-3247. What are the hours of operation and limits for transportation services? To schedule a ride, you can call medical transportation between 8 a.m. to 5 p.m., Monday – Friday except for federal holidays. Call medical transportation for any limitations on transportation services. Referrals to Specialists What if I need to see a special doctor (specialist)? Your Primary Care Provider will tell you if you/your child needs to see a specialist. Your Primary Care Provider will make sure that you/your child gets the special care needed. In general, you cannot go to another doctor or get a special service if your Primary Care Provider does not agree to make a referral. What is a referral? A referral is when your Primary Care Provider sends you to another doctor or service for care. How soon can I expect to be seen by a specialist? You should expect the specialist to give you an appointment within 30 days for non-urgent care or within 24 hours for urgent care. Who do I call if I have special health care needs and need someone to help me? You/your child might need more health and other services because of complex or chronic conditions. There might be times when DCHP might allow a special doctor (Specialist) to be your/your child’s Primary Care Provider. Call Member Services at 1-855-425-3247 to learn more on special services that DCHP has for you or your child. A Case Manager will call you back to talk about these special needs. What services do not need a referral? You can get some services without going to your Primary Care Provider first. These include: Emergency care Routine vision care OB/GYN Care Behavioral Health Services It is good to let your Primary Care Provider know when you receive other care, but you are not required to. This lets your Primary Care Provider know all of your/your child’s needs. How can I ask for a second opinion? Driscoll Children's Health Plan will pay for a second opinion. Call Member Services at 1-855-425-3247 to arrange for a second opinion. The Case Management Department will be glad to help you with this. You will need to call us for authorization before you get a second opinion. Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 26 Advance Directives What if I am too sick to make a decision about my medical care? Sometimes people are too sick to make decisions about their health care. If this happens, how will a doctor know what you want? You can make an Advance Directive. What are advance directives? An advance directive is a letter that tells people what you want to happen if you get very sick. One kind of Advance Directive is a Living Will, which tells your doctor what to do if you are too sick to tell him or her. The other kind is a Durable Power of Attorney, which lets a friend or family member (who you pick) make decisions for you. Any Advance Directive you make starts when you get very sick and will last until you change or cancel it. How do I get an advance directive? If you would like more facts about Advance Directives, call Member Services at 1-855-425-3247. Other Facts What happens if I lose my Medicaid coverage? If you lose Medicaid coverage but get it back again within six (6) months you will get your Medicaid services from the same health plan you had before losing your Medicaid coverage. You will also have the same Primary Care Provider you had before. What if I get a bill from my doctor? You should never get a bill from your/your child’s Primary Care Provider or any DCHP doctor. Who do I call? If you get a bill from your/your child’s Primary Care Provider or other Doctor, call DCHP Member Services at 1-855-425-3247, and someone will call the provider’s office. We will help explain the benefits. What facts will they need? When you call us, please have your/your child’s ID card and the provider’s bill ready. DCHP Member Services will need these to help you. What do I do if I move? As soon as you have your new address, give it to the local HHSC benefits office and DCHP Member Services Department at 1-855-425-3247. Before you get Medicaid services in your new area, you must call DCHP unless you need emergency services. You will keep getting care through DCHP until HHSC changes your address. What if I have other health insurance in addition to Medicaid? You are required to tell Medicaid staff about any private health insurance you have. You should call the Medicaid Third Party Resources hotline and update your Medicaid case file if: Your private health insurance is canceled. Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 27 You get new insurance coverage. You have general questions about third party insurance. You can call the hotline toll-free at 1-800-846-7307. If you have other insurance you might still qualify for Medicaid. When you tell Medicaid staff about your other health insurance, you help make sure Medicaid only pays for what your other health insurance does not cover. IMPORTANT: Medicaid providers cannot turn you down for services because you have private health insurance as well as Medicaid. If providers accept you as a Medicaid patient, they must also file with your private health insurance company. How do my medical bills get paid if I have other insurance? Your other insurance will pay for your medical bills first. Any remaining bill will be paid by Driscoll Children's Health Plan. What if I have an accident and Driscoll Children's Health Plan pays the bill? In an accident your accident insurance must pay the bill. Accident insurance can be car or home insurance. We will try to get back any money paid by Driscoll Children's Health Plan for a medical bill. We might try to get back money from the person responsible for the accident if this was not you. Driscoll Children's Health Plan has a contract with a company to help us get back any money we might have paid. If you are contacted by this company we ask that you help us get back the money we have paid. You will not have to pay the bill. If you are injured in an accident and the Health Plan provides you medical benefits, you must: Completely pay back the Health Plan first from any money you received related to the accident. Completely pay back the Health Plan first from payments made to you by the person that caused the accident. Completely pay back the Health Plan first from payments made to you by any insurance company or organization. Give the Health Plan all of the information you have about the accident. Sign a medical release allowing the Health Plan to investigate the accident. If you have been in an accident and choose not to make a claim, the Health Plan can make a claim in your name. If you are in an accident and the health plan provides medical benefits for your injuries, you must give the plan the part of your claim related to these medical benefits. The Health Plan will not pay for your attorney’s fees. Services That Require Prior Authorization There are some services that will require your/your child’s Primary Care Provider or other provider to contact DCHP and get approval for you/your child to receive the service. Some of these services are: All admissions to a hospital (except in an emergency situation, where telling DCHP within 24 hours of admission is required) Admission to a rehabilitation center Outpatient surgery Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 28 Rehabilitation therapy (physical therapy, speech therapy and occupational therapy) Home health services, including home intravenous therapy Referral to a Specialist doctor other than an OB/GYN or Mental Health doctor Durable Medical Equipment services that cost over $300 Use of ambulance for medical transportation (not emergency transport) Asking for services by a provider who does not have a contract with DCHP Other forms of medical treatment (such as hypnosis, massage therapy) To call for authorization, you or your doctor can call the Member Services number 1-855-425-3247, Monday through Friday, 8 a.m. until 5 p.m., CST. If there is no authorization for the service, you might have to pay for it. You have a right to know the cost of any service before you/your child receives that service. If you agree to get services that DCHP does not cover or authorize, you might have to pay for them. Your/your child’s hospital stay is reviewed everyday. Services might be reviewed after they are delivered or paid. What can I do if my doctor asks for a service for me that’s covered but the health plan denies it or limits it? There might be times when the Driscoll Children's Health Plan Medical Director denies these services. When this happens, you can appeal this decision. To appeal these medical decisions, call Member Services at 1-855-425-3247. How will I find out if services are denied? You will be sent a letter telling you of the denial of services. If you do not agree with this denial you may appeal this decision. The form to appeal this decision is included with your denial letter. To make sure you have continuity of current authorized services, you need to appeal this denial within ten (10) days from the date on the denial letter or within ten (10) days of the date the denial will take place. How to Appeal a Denied Service You have thirty (30) days from the date you receive the denial letter to send us an appeal If we are denying services that you currently receiving, you must file an appeal within ten (10) days of the denial letter or within ten (10) days of the date the denial will take place. If a request for an appeal is received verbally, you/your provider will need to put the appeal in writing. If your provider sends us the appeal, you or your representative will need to sign that request unless you need an expedited appeal. For facts about how to file this appeal using the form that was sent to you, call Member Services at 1-855-4253247. We will send you a letter within five (5) days of receiving your appeal, to let you know that we did receive it. We will complete the appeal review within thirty (30) days. If we need more time to review the appeal, we will send you a letter telling you why we need more time. You can also ask for more time to resolve the appeal. Your appeal can be extended up to fourteen (14) more days. Can I appeal when DCHP has not paid a claim? Yes, you can submit an appeal in writing. If the claim was not paid you can appeal this. Call Member Services at 1-855-425-3247. Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 29 Can someone from Driscoll Children's Health Plan help me file an appeal? Yes. Contact Member Services at 1-855-425-3247. Can I file an appeal with the State? You have the right to appeal to the state at any time during or after the plan’s appeal process. If you do not agree with our decision, you can ask for a State Fair Hearing. You must make the request in writing for a Fair Hearing within ninety (90) days of the date on the notice of action. If you do not ask a hearing within 90 days, you lose your right to a hearing. See facts below about how to ask for a State Fair Hearing. What is an Expedited Appeal? An expedited appeal is when the health plan has to make a decision quickly based on the condition of your health, and taking the time for a standard appeal could jeopardize your life or health. How can I ask for an Expedited Appeal? Call the DCHP Health Services Department to ask for an expedited appeal. The number is 1-877-4551053. You can ask for an expedited appeal verbally, or in writing. If you need help in filing this appeal, contact Member Services at 1-855-425-3247 and they will arrange for a Member Representative to help you. We will review your case and get back to you within three business days after we receive your request. If the request is an emergency or for when you are in the hospital we will get back with you within one business day. What happens if the health plan denies the request for an expedited appeal? If DCHP denies your request for an expedited appeal, we will refer your appeal to the regular appeal process, and call you to inform you of the denial right away. We will then follow up with a letter within 2 calendar days. Who can help me file an Expedited Appeal? A Member Representative will help you file an expedited appeal. If you need help, call Member Services at 1-855-425-3247. State Fair Hearing Can I ask for a State Fair Hearing? If you, as a member of the health plan, disagree with the health plan’s decision, you have the right to ask for a fair hearing. You may name someone to represent you by writing a letter to the health plan telling them the name of the person you want to represent you. A doctor or other medical provider may be your representative. If you want to challenge a decision made by your health plan, you or your representative must ask for the fair hearing within 90 days of the date on the health plan’s letter with the decision. If you do not ask for the fair hearing within 90 days, you may lose your right to a fair hearing. To ask for a fair hearing, you or your representative should either send a letter to the health plan at: Driscoll Children's Health Plan 615 N Upper Broadway, Suite 1621 Corpus Christi, Texas 78401-0764 Or call 1-855-425-3247 Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 30 You have the right to keep getting any service the health plan denied or reduced at least until the final hearing decision is made if you ask for a fair hearing by the later of: (1) 10 days from the date you get the health plan’s decision letter or (2) the day the health plan’s letter says you service will be reduced or end. If you do not ask for a fair hearing by this date, the service the health plan denied will be stopped. If you ask for a fair hearing, you will get a packet of information letting you know the date, time and location of the hearing. Most fair hearings are held by telephone. At that time, you or your representative can tell why you need the service the health plan denied. HHSC will give you a final decision within 90 days from the date you asked for the hearing. Complaints What should I do if I have a complaint? We want to help. If you have a complaint you can call us. Your doctor can file a complaint for you. We will not punish you or your doctor for filing a complaint. You can file a complaint either in writing or by calling us. Who do I call? If you have a complaint, please call us at 361-653-7689 or toll-free at 1-855-425-3247 to tell us about your problem. Can someone from Driscoll Children’s Health Plan help me file a Complaint? A Driscoll Children's Health Plan Member Services Advocate can help you file a complaint. Just call 1855-425-3247. Most of the time, we can help you right away or at the most within a few days. How long will it take to process my complaint? We will send you a letter to let you know we received the complaint. This letter will be sent within five (5) days of receiving your complaint. We will send you a form to complete and mail to us. This form will give us more detail about your complaint but is not required. At the most, we will respond with an answer to your complaint within thirty (30) days of receipt. If you are not happy with the way we help you, you can call us and appeal. You are not required to file an appeal in writing. Driscoll Children’s Health Plan wants to help you get the best healthcare for your family. If you have questions about how to file a complaint, an appeal, or need additional help, call us toll-free at 1-855-4253247. We will be glad to help. Call us: Driscoll Children’s Health Plan DCHP Member Services 1-855-425-3247 Write to us: Driscoll Children’s Health Plan ATT: Complaints Coordinator 615 N Upper Broadway, Suite 1621 Corpus Christi, TX 78401-0764 All complaints are reviewed and reported to the Quality Improvement Committee. They are also reviewed to make sure that timely answers are given. Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 31 Information on how to file a Complaint with HHSC once I have gone through the DCHP Complaint Process Once you have gone through the Driscoll Children's Health Plan complaint process, you can complain to the Health and Human Services Commission (HHSC) by calling toll-free at 1-866-566-8989. If you would like to make your complaint in writing, please send it to the following address: Texas Health and Human Services Commission Health Plan Operations-H-320 PO Box 85200 Austin, Texas 78708-5200 ATTN: Resolution Services Fraud and Abuse of the STAR Program Do you want to report Waste, Abuse, or Fraud? Let us know if you think a doctor, dentist, pharmacist at a drug store, other health care providers, or a person getting benefits is doing something wrong. Doing something wrong could be waste, abuse or fraud, which is against the law. For example, tell us if you think someone is: Getting paid for services that weren’t given or necessary. Not telling the truth about a medical condition to get medical treatment. Letting someone else use their Medicaid ID. Using someone else’s Medicaid ID. Not telling the truth about the amount of money or resources he or she has to get benefits. To report waste, abuse, or fraud, choose one of the following: Call the OIG Hotline at 1-800-436-6184; Visit https://oig.hhsc.state.tx.us/ and pick “Click Here to Report Waste, Abuse and Fraud” to complete the online form; or You can report directly to your health plan: Driscoll Children's Health Plan ATT: Compliance Officer 615 N Upper Broadway, Suite 1621 Corpus Christi, Texas 78401-0764 Phone Number: 1-855-425-3247 To report waste, abuse or fraud, gather as much information as possible. o When reporting a provider (a doctor, dentist, counselor, etc.) include: Name, address, and phone number of provider Name and address of the facility (hospital, nursing home, home health agency, etc.) Medicaid number of the provider and facility, if you have it Type of provider (doctor, dentist, therapist, pharmacist, etc.) Names and phone numbers of other witnesses who can help in the investigation Dates of events Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 32 o Summary of what happened When reporting someone who receives benefits, include: The person’s name The person’s date of birth, Social Security Number, or case number if you have it The city where the person lives Specific details about the waste, abuse or fraud Information That Must Be Available On A Once a Year Basis As a member of Driscoll Children's Health Plan you can ask for and get the following information each year: Information about network providers- at a minimum Primary Care Providers, specialists, and hospitals in our service area. This information will include names, addresses, telephone numbers, and languages spoken (other than English) for each network provider, plus identification of providers that are not accepting new patients. Any limits on your freedom of choice among network providers. Your rights and responsibilities. Information on complaint, appeal and fair hearing procedures. Information about benefits available under the Medicaid program, including amount, duration and scope of benefits. This is designed to make sure you understand the benefits to which you are entitled. How you get benefits including authorization requirements. How you get benefits, including family planning services, from out-of-network providers and/or limits to those benefits. How you get after hours and emergency coverage and/or limits to those kinds of benefits, including: o What makes up emergency medical conditions, emergency services and post-stabilization services. o The fact that you do not need prior authorization from your Primary Care Provider for emergency care services. o How to get emergency services, including instructions on how to use the 911 telephone system or its local equivalent. o The addresses of any places where providers and hospitals furnish emergency services covered by Medicaid. o A statement saying you have a right to use any hospital or other settings for emergency care. o Post-stabilization rules. Policy on referrals for specialty care and for other benefits you cannot get through your Primary Care Provider. Driscoll Children’s Health Plan practice guidelines. Member Rights and Responsibilities What are my rights and responsibilities? As a member of DCHP Medicaid/STAR, you have rights and responsibilities. If you have any questions or concerns, please call us. We are here to help. You can call us toll-free at 1-855-425-3247. MEMBER RIGHTS: 1. You have the right to respect, dignity, privacy, confidentiality and nondiscrimination. That includes the right to: Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 33 a. Be treated fairly and with respect. b. Know that your medical records and discussions with your providers will be kept private and confidential. 2. You have the right to a reasonable opportunity to choose a health care plan and primary care provider. This is the doctor or health care provider you will see most of the time and who will coordinate your care. You have the right to change to another plan or provider in a reasonably easy manner. That includes the right to: a. Be told how to choose and change your health plan and your primary care provider. b. Choose any health plan you want that is available in your area and choose your primary care provider from that plan. c. Change your primary care provider. d. Change your health plan without penalty. e. Be told how to change your health plan or your primary care provider. 3. You have the right to ask questions and get answers about anything you do not understand. That includes the right to: a. Have your provider explain your health care needs to you and talk to you about the different ways your health care problems can be treated. b. Be told why care or services were denied and not given. 4. You have the right to agree to or refuse treatment and actively participate in treatment decisions. That includes the right to: a. Work as part of a team with your provider in deciding what health care is best for you. b. Say yes or no to the care recommended by your provider. 5. You have the right to use each complaint and appeal process available through the managed care organization and through Medicaid, and get a timely response to complaints, appeals, and fair hearings. That includes the right to: a. Make a complaint to your health plan or to the state Medicaid program about your health care, your provider or your health plan. b. Get a timely answer to your complaint. c. Use the plan’s appeal process and be told how to use it. d. Ask for a fair hearing from the state Medicaid program and get information about how the process works. 6. You have the right to timely access to care that does not have any communication or physical access barriers. That includes the right to: a. Have telephone access to a medical professional 24 hours a day, 7 days a week to get any emergency or urgent care you need. b. Get medical care in a timely manner. c. Be able to get in and out of a health care provider’s office. This includes barrier free access for people with disabilities or other conditions that limit mobility, in accordance with the Americans with Disabilities Act. d. Have interpreters, if needed, during appointments with your providers and when talking to your health plan. Interpreters include people who can speak in your native language, help someone with a disability, or help you understand the information. e. Be given information you can understand about your health plan rules, including the health care services you can get and how to get them. 7. You have the right to not be restrained or secluded when it is for someone else’s convenience, or is meant to force you to do something you do not want to do, or is to punish you. 8. You have a right to know that doctors, hospitals, and others who care for you can advise you about your health status, medical care, and treatment. Your health plan cannot prevent them from giving you this information, even if the care or treatment is not a covered service. 9. You have a right to know that you are not responsible for paying for covered services. Doctors, hospitals, and others cannot require you to pay copayments or any other amounts for covered services. Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Page 34 MEMBER RESPONSIBILITIES: 1. You must learn and understand each right you have under the Medicaid program. That includes the responsibility to: a. Learn and understand your rights under the Medicaid program. b. Ask questions if you do not understand your rights. c. Learn what choices of health plans are in your area. 2. You must abide by the health plan’s and Medicaid’s policies and procedures. That includes the responsibility to: a. Learn and follow your health plan’s rules and Medicaid rules. b. Choose your health plan and a primary care provider quickly. c. Make any changes in your health plan and primary care provider in the ways established by Medicaid and by the health plan. d. Keep your scheduled appointments. e. Cancel appointments in advance when you cannot keep them. f. Always contact your primary care provider first for your non-emergency medical needs. g. Be sure you have approval from your primary care provider before going to a specialist. h. Understand when you should and should not go to the emergency room. 3. You must share information about your health with your primary care provider and learn about service and treatment options. That includes the responsibility to: a. Tell your primary care provider about your health. b. Talk to your providers about your health care needs and ask questions about the different ways your health care problems can be treated. c. Help your providers get your medical records. 4. You must be involved in decisions about service and treatment options, make personal choices, and take action to keep yourself healthy. That includes the responsibility to: a. Work as a team with your provider in deciding what health care is best for you. b. Understand how the things you do can affect your health. c. Do the best you can to stay healthy. d. Treat providers and staff with respect. e. Talk to your provider about all of your medications. If you think you have been treated unfairly or discriminated against, call the U.S. Department of Health and Human Services (HHS) toll-free at 1-800-368-1019. You also can view information concerning the HHS Office of Civil Rights online at www.hhs.gov/ocr. Driscoll Children’s Health Plan Form Number: DCHP49 Medicaid/STAR Member Handbook Notes
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