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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 N U E C E S ser v ice area Aransas, Bee, Brooks, Calhoun, Goliad, Jim Wells, Karnes, Kenedy, Kleberg, Live Oak, Nueces, Refugio, San Patricio and Victoria Counties CHIP MEMBER HANDBOOK March 2012 Member services TOLL-FREE: 1-877-451-5598 DCHP7 w w w. d c h p K i d s . c o m Your CHIP benefits include: Doctor visits Prescription drugs Hospital care at local hospitals Shots (immunizations) Eye exams and glasses Hearing and dental exams Interpretation services Free transportation to your doctor 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 Bee, Jim Wells, Kleberg, Nueces, San Patricio and Victoria counties) Asthma Services. Services for members with asthma, including allergyfree pillow cover and bed cover Membership at YMCA or Boys and Girls ClubS. Family membership to YMCA or Boys and Girls Clubs where available or a $25 allowance each year toward participation in a local sports team SMOKING CESSATION BENEFITS. Additional benefits available for overthe-counter smoking cessation products Page 1 Introduction Introduction to Driscoll Children's Health Plan By picking the Driscoll Children’s Health Plan (DCHP), your child will get all the CHIP benefits – plus more. • • • • • Your own doctor Friendly and confidential staff Use of Driscoll Children’s Hospital and many other hospitals Free health education for children of any age Getting 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 contact DCHP Member Services at 1-877-451-5598 as soon as possible. Your concern will be investigated and fixed quickly. The doctor you picked when you joined DCHP CHIP will be your child's Primary Care Provider and will help take care of all your child’s health care needs. First things first. These are a few important things about 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 your child’s doctor. Make an appointment with your Primary Care Provider as soon as possible. Call your Primary Care Provider for appointments. Tell them your child is a DCHP CHIP member. Call your Primary Care Provider whenever your child needs health care. Follow your Primary Care Provider’s advice. Carry 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. References to “you,” “my,” or “I” apply if you are a CHIP Member. References to “my child” or “my daughter” apply if your child is a CHIP or CHIP Perinate Newborn Member. 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 you need this handbook on tape (audio), in larger print, in Braille, or another language than Spanish, tell Member Services at 1-877-451-5598 as soon as possible. DCHP will give these materials to you at no cost. Again, Welcome! Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook Page 2 Driscoll Children’s Health Plan Important Phone Numbers Call us: Se Habla Español Write us: Regular Business Hours: Before 8 a.m. or after 5 p.m. 24 Hour/7 Days A Week Behavioral Health Hotline Vision and Eye Care Number Dental Care Number Pharmacist Help Line CHIP Help Line Driscoll Children’s Health Plan Form Number: DCHP7 Member Services 1-877-451-5598 (toll-free) (English or Spanish) If there is an emergency or crisis, go to the ER or call 9-1-1. 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, Suite1621 Corpus Christi, TX 78477 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. 1-877-330-3312 (English or Spanish) with facts on services. Other interpretive services exist. If there is an emergency or crisis, go to the ER or call 9-1-1. 1-888-268-2334 for questions regarding eye exams and glasses Delta Dental – 1-866-561-5891 DentaQuest – 1-800-508-6775 MCNA Dental – 1-800-494-6262 Call 1-877-451-5598 (toll-free) if you need help getting a prescription filled. 1-800-647-6558 CHIP Member Handbook Page 3 Table of Contents Page Introduction ………………………………………………….…………………………………………………….. Important Phone Numbers …………………………………………………………………………..………….. Table of Contents …………………………………………………………………………..…………………….. Driscoll Children’s Health Plan and CHIP ……………………………………………………………………. Your CHIP ID Card ………………………………………………………………………………………………... DCHP CHIP Identification Card (ID Card) …………………………………………………………………… Reading the DCHP CHIP ID Card ……………………………………………………………………………. Using the DCHP CHIP ID Card ………………………………………………………………………………. If you lose your ID Card or move …………………………………………………………………………….. All About Primary Care Providers ………………………………………………………………………..…… What do I need to bring to my / my child’s Doctor’s appointment? ………………………………………. What is a Primary Care Provider? …………………………………………………………………………… Can I have a Specialist doctor be my child’s Primary Care Provider? ………………………………….. Can a Clinic be my / my child’s Primary Care Provider? …………………………………………………. How can I change my / my child’s Primary Care Provider? ………………………………………………. How many times can I change my / my child’s Primary Care Provider? ………………………………… When will a Primary Care Provider change become effective? ………………………………………….. Are there any reasons why my request to change my Primary Care Provider may be denied? ……… Can a Primary Care Provider move me / my child to another Primary Care Provider for non-compliance? What if my Primary Care Provider leaves the health plan? ……………………………………………….. What if I choose to go to another doctor who is not my / my child’s Primary Care Provider? …………. How do I get medical care after my / my child’s Primary Care Provider office is closed? ……………… Physician Incentive Plan ………………………………………………………………………………………. 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.? …………………….. Health Care and Other Services …………………………………………………………………………………. What is routine medical care? …………………………………………………………………………………. What is urgent medical care? ………………………………………………………………………………….. What is a limited provider network? …………………………………………………………………………… Emergency Care …………………………………………………………………………………………………… What is Emergency, an Emergency Medical Condition and an Emergency Behavioral Health Condition? What is Emergency Services and/or Emergency Care? ……………………………………………………. Are Emergency Dental Services Covered? …………………………………………………………………… What do I do if I need Emergency Dental Care? ……………………………………………………………… How soon can I expect to be seen / how soon can I expect my child to be seen? ……………………….. Getting care at night or on weekends ………………………………………………………………………….. What is post stabilization? ………………………………………………………………………………………. What if I get sick when I am out of town or traveling / what if my child gets sick when he or she is out of town or traveling? What if I am / my child is out of the state? ………………………………………… What if I am / my child is out of the country? ………………………………………………………………….. ATTENTION FEMALE MEMBERS …………………………………………...…………………………………… What if I need / my daughter needs OB/GYN care? ……………………..…………………………………… Do I have the right to choose an OB/GYN? …………………………………………………………………… How do I choose an OB/GYN? ……………………………………………….………………………………… If I don’t choose an OB/GYN, do I have direct access? ……………………………………………………… Will I need a referral? ……………………………………………………………………………………………. How soon can I / can my daughter be seen after contacting the OB/GYN for an appointment? ……….. Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook 1 2 3 6 6 6 6 6 7 7 7 7 7 7 7 8 8 8 8 8 8 9 9 9 9 9 9 9 9 10 10 10 10 11 11 11 11 11 12 12 12 12 13 13 13 13 13 13 13 13 Page 4 Can I / my daughter stay with an OB/GYN who is not with Driscoll Children’s Health Plan? ……………. What if I am pregnant / my daughter is pregnant? Who do I call? ………………………………………….. What other services / activities / education does Driscoll Children’s Health Plan offer pregnant women?. CHIP Benefits ………………………………………………………………………………………………………… What are my CHIP Benefits? ……………………………………………………………………………………. How do I get these services / how do I get these services for my child? …………………………………… What services are not covered? …………………………………………………………………………………. Medicaid Versus CHIP Coverage for CHIP Perinatal Program Newborns ………………………………….. What are the CHIP Perinatal benefits? …………………………………………………………………………. Concurrent Enrollment of Family Members in CHIP and CHIP Perinatal …………………………………… What are my prescription drug benefits? ……………………………………………………………………….. Behavioral (Mental) Health Services ……………………………………………………………………………… How do I get help if I have/my child has behavioral (mental) health or drug problems? ………………….. Do I need a referral for this? …………………………………………………………………………………….. Prescription coverage …………………………………………………………………………………………...…. How do I get my / my child’s medications? ……………………………………………………………………. How do I find a network drug store? ……………………………………………………………………………. What if I go to a drug store not in network? ……………………………………………………………………. What do I bring with me to the drug store? …………………………………………………………………….. What if I need my / my child’s medications delivered to me? ………………………………………………… Who do I call if I have problems getting my / my child’s medications? …………………………………….. What if I can’t get the medication my / my child’s doctor ordered approved? ……………………………… What if I lose my / my child’s medication? ……………………………………………………………………… What if I need / my child needs an over the counter medication for CHIP? ………………………………… What if I need / my child needs more than 34 days of a prescribed medication? …………………………. What if I need / my child needs birth control pills? ……………………………………………………………. Other Health Coverage and Services ……………………………………………………………………………. What health education classes does DCHP offer? ……………………………………………………………. How do I get eye care services / how do I get eye care services for my child? ……………………………. How do I get dental services / how do I get dental services for my child? ………………………………….. Interpreter ……………………………………………………………………………………………………………… Can someone interpret for me when I talk with my / my child’s 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 provider’s office? …………………………………………….. Costs of Your DCHP CHIP Insurance ............................................................................................................ What are Co-payments? How much are they and when do I have to pay them? ………………………….. What Extra Benefits does a member of Driscoll Children's Health Plan get? ………………………………. How can I get these benefits / how can I get these benefits for my child? ………………………………….. CHIP Cost-Sharing Caps …………………………………………………………………………………………. What If I get a bill from my Doctor? ……………………………………………………………………………… Who do I call? ……………………………………………………………………………………………………… What information will they need? ……………………………………………………………………………….. What do I have to do if I move? …………………………………………………………………………………. What if I have an accident and Driscoll Children’s Health Plan pays the bill? ……………………………… Other costs for CHIP Members . ………………………………………………………………………………… Referrals to Specialists …………………………………………………………………………………………….. What is a referral? ………………………………………………………………………………………………… What services do not need a referral? ………………………………………………………………………….. What if I / my child needs to see a special doctor (specialist)? ………………………………………………. How soon can I expect to be seen by a specialist / how soon can I expect my child to be seen by a specialist? …………………………………………………………………………………………………… Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook 14 14 14 14 14 14 14 14 14 15 15 15 15 15 15 15 16 16 16 16 16 16 16 16 16 16 17 17 17 17 17 17 17 17 17 18 18 18 18 19 19 19 19 19 19 20 20 20 20 20 20 Page 5 Who do I call if I have / my child has special health care needs and I need someone to help me? …….. 20 How can I ask for a second opinion? …………………………………………………………………………… 20 Services that require prior authorization ……………………………………………………………………….. 21 How to Appeal a Denied Service …………………………………………………………………………………. 21 What can I do if my doctor asks for a service for me that’s covered but Driscoll Children's Health Plan denies or limits it? ………………………………………………………………………………………….. 21 How will I find out if services are denied? ……………………………………………………………………… 22 What are the timeframes for the appeal process? ……………………………………………………………. 22 When do I have the right to ask for an appeal? ………………………………………………………………. 22 Does my request have to be in writing? ……………………………………………………………………….. 22 Can someone from DCHP help me file an appeal? ………………………………………………………….. 22 Expedited Appeal …………………………………………………………………………………………………… 22 What is an Expedited Appeal? …………………………………………………………………………………. 22 How do I ask for an Expedited Appeal? ……………………………………………………………………….. 22 Does my request have to be in writing? ……………………………………………………………………….. 22 What are the timeframes for an expedited appeal? …………………………………………………………... 22 What happens if DCHP denies your request for an Expedited Appeal? ……………………………………. 22 Who can help me in filing an appeal? ………………………………………………………………………….. 22 Independent Review Organization (IRO) Process …………………………………………………………….. 23 What is an Independent Review Organization? ………………………………………………………………. 23 How do I ask for a review by an Independent Review Organization? ………………………………………. 23 What are the timeframes for this process? …………………………………………………………………….. 23 What if I need an appeal decision quickly? ……………………………………………………………………. 23 Complaints ……………………………………………………………………………………………………………. 23 What should I do if I have a complaint? ………………………………………………………………………… 23 Who do I call? ……………………………………………………………………………………………………… 24 Can someone from DCHP help me file a complaint? …………………………………………………………. 24 How long will it take to process my complaint? ………………………………………………………………… 24 What are the requirements and timeframes for filing a complaint? ………………………………………….. 24 If I am not satisfied with the outcome, who else can I contact? ……………………………………………… 24 Do I have the right to meet with a Complaint Appeal Panel? ………………………………………………… 25 Fraud and Abuse of the CHIP Program ………………………………………………………………………….. 25 Do you want to report CHIP Waste, Abuse or Fraud? ………………………………………………………… 25 Reporting Waste, Abuse or Fraud in CHIP by a Provider or Client ………………………………………….. 25 Member Rights and Responsibilities …………………………………………………………………………….. 26 Members Have a Right To ………………………………………………………………………………………… 26 Member Responsibilities …………………………………………………………………………………………... 27 DCHP CHIP Scope of Benefits ……………………………………………………………………………………… 28 What does Medically Necessary mean? ………………………………………………………………………… 28 Description of Benefits …………………………………………………………………………………………….. 29 Value Added Services ……………………………………………………………………………………………… 43 Exclusions …………………………………………………………………………………………………………… 43 DME/Supplies ……………………………………………………………………………………………………….. 45 Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook Page 6 Driscoll Children’s Health Plan and CHIP Laws passed by the U.S. Congress and the Texas Legislature started the Children’s Health Insurance Program (CHIP) in Texas. CHIP helps children of families that have incomes too high to qualify for Medicaid but too low to easily afford private family coverage. By picking the Driscoll Children’s Health Plan (DCHP), we can give CHIP benefits to your children from birth through age 18. Health care through DCHP CHIP exists in these south Texas counties: • • • • • Aransas Bee Brooks Calhoun Goliad • • • • • Jim Wells Karnes Kenedy Kleberg Live Oak • • • • Nueces Refugio San Patricio Victoria DCHP is a not-for-profit Health Maintenance Organization (HMO) licensed by the Texas Department of Insurance. Your CHIP ID Card You will get a CHIP Identification (ID) card after you join DCHP. A copy of the DCHP ID card is shown below. Facts about your child Primary Care Provider name and phone number Each of your children will have a different card. You will not get a new DCHP CHIP 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 CHIP ID Card The front of the DCHP CHIP ID card shows important facts about your child, the Primary Care Provider’s name and Primary Care Provider’s phone number. It also shows the amounts (co-payments) you might have to pay for your doctor visits or for prescriptions. The back of the card shows important phone numbers for emergencies or other help from DCHP Member Services. Using the DCHP CHIP ID Card Carry your child’s DCHP CHIP ID Card with you when your child gets any health care services. You must show your CHIP ID Card each time for any health service. Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook Page 7 If you lose an ID Card or Move If you lose the DCHP CHIP ID Card, call us right away at 1-877-451-5598 to get a new one. If you move or change phone numbers, call us so we can send you another ID card. We always need to have your correct address and phone number. All About Primary Care Providers What do I need to bring to my / my child’s Doctor’s appointments? Always take your / your child’s DCHP ID card with you when you go to the doctor. If your child is going to get vaccines, don’t forget your child’s vaccine records. What is a Primary Care Provider? The Primary Care Provider you chose is considered your child’s “medical home”. He or she will help you with all medical care. Your Primary Care Provider will get to know you and your child. He or she will do regular checkups and treat your children when they are sick. Your Primary Care Provider will prescribe medicines and medical supplies for your children and send them to a specialist if needed. It is important to follow the Primary Care Provider’s advice. Take part in decisions about your child’s health care. Your Primary Care Provider might ask us to assign you 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. The Primary Care Provider must tell us if this happens. We will contact you and ask that you pick another Primary Care Provider. Call your Primary Care Provider during office hours when you can. If possible, do not wait until evening to call to take care of a medical problem. Most illnesses tend to get worse as the day goes on. Call early. You must only see the Primary Care Provider listed on your ID Card. If you see another Primary Care Provider, you will have to pay the bill. Can I have a Specialist doctor be my child’s Primary Care Provider? There might be times when DCHP might allow a Specialist to be your child’s Primary Care Provider. This is for Children with Special Health Care Needs (CSHCN). You must sign the Agreement for Specialist to function as a Primary Care Provider form. The Specialist must also sign the form agreeing to be the Primary Care Provider. Our Medical Director will review and will make a decision about approval within thirty (30) days of receiving the request. You will receive this decision in a letter that we will send to you. If your request is denied, you do have the right to appeal the decision. (See page 21 about how to file a complaint and appeal.) The effective date of this change will be the first of the month when the request was made. Call DCHP Member Services at 1-877-451-5598 to learn more. Can a Clinic be my / my child’s Primary Care Provider? You can pick a clinic as the Primary Care Provider for your child. This can be a Federally Qualified Health Center (FQHC), or a Rural Health Clinic (RHC). If you have questions call Member Services at 1877-451-5598. How can I change my / my child’s 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 kind of 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. Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook Page 8 You can change your Primary Care Provider by calling toll-free at 1-877-451-5598. The DCHP Provider Directory lists all Primary Care Providers. You will get a new ID card that shows the date your new Primary Care Provider can begin to care for your child. The new card will show the new Primary Care Provider’s name and phone number. Changing your Primary Care Provider will not stop you from getting care. If you need care before the date your new Primary Care Provider can start caring for your child, call the Primary Care Provider on your current card. To give you the best care possible, your Primary Care Provider needs to know 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 many times can I change my / my child’s Primary Care Provider? There is no limit on how many times you can change your or your child’s primary care provider. You can change primary care providers by calling us toll free at 1-877-451-5598 or writing to Driscoll Children’s Health Plan, 615 N Upper Broadway Suite 1621, Corpus Christi, Texas. 78401-0764. When will a Primary Care Provider change become effective? You can change your Primary Care Provider at anytime. If you call BEFORE the 5th of the month, the change will become effective immediately. If you call AFTER the 5th of the month, the Primary Care Provider will not change until the first of the next month. If you see the new Primary Care Provider before the change, you will have to pay the bill. Are there any reasons why my request to change my Primary Care Provider may be denied? 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. Can a Primary Care Provider move me or my child to another Primary Care Provider for noncompliance? It is important to follow the Primary Care Provider’s advice. Take part in decisions about your child’s health care. Your Primary Care Provider might ask us to assign 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 this happens. We will contact you and ask that you pick another Primary Care Provider. What if my Primary Care Provider leaves the health plan? If your Primary Care Provider decides to no longer be a provider for DCHP and your child has special needs, we will continue to pay for services to this Primary care Provider up to 90 days after the effective date when the provider left. Your Primary Care Provider will need to send us a request to continue to provide service and to explain the special needs of your child. If we terminate your Primary Care Provider, except for medical competence or professional behavior, we will notify you right away. We will continue to pay for services if your child is special needs up to 90 days after the effective termination date. If we terminate your Primary Care Provider for medical competence or professional behavior, we will notify you right away. You will need to pick right away another Primary Care Provider that is a network provider for DCHP. What if I choose to go to another doctor who is not my / my child’s Primary Care Provider? You can go to any provider, if you need 24-hour emergency care from an emergency room. Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook Page 9 You can go to any DCHP OB/GYN provider. You do not need a referral from your Primary Care Provider. If you need mental health or substance abuse services you should call the Behavioral Health Hotline at 1877-330-3312. Behavioral Health Services are very private so your Primary Care Provider does not need to agree for you to get these services. If you need a routine vision exam, your Primary Care Provider does not need 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 1-888-268-2334. For all other care, you must only see the Primary Care Provider listed on your ID Card. If you see another Primary Care Provider, you might have to pay the bill. How do I get medical care after my / my child’s Primary Care Provider’s office is closed? Except in an emergency, if 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 exists by phone 24 hours a day, 7 days a week. If your child has a fever or a sore throat and you are not sure what to do, call your Primary Care Provider’s office. Physician Incentive Plan A physician incentive plan rewards doctors for treatments that reduce or limit services for people covered by CHIP. 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 are allowed to make health plan changes: • For any reason within 90 days of enrollment in CHIP; • For cause at any time; • During the annual CHIP re-enrollment period. Who do I call? For more information, call CHIP toll-free at 1-800-647-6558. How many times can I change health plans? A CHIP member may change health plan at anytime for these reasons: • For any reason within 90 days of enrollment in CHIP; • For cause at any time; • During the annual CHIP re-enrollment period. When will my health plan change become effective? The health plan change will become effective the following month after you requested the change. Can DCHP ask that I get dropped from their health plan for non-compliance, etc.? DCHP may request that you be taken out of our health plan for “good cause”. Good Cause could be: 1. Fraud or abuse by a member 2. Threats of physical acts leading to harming of DCHP staff or providers 3. Theft 4. Refusal to go by DCHP policies and procedures, like: Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook Page 10 a. b. c. d. Let someone use your CHIP ID card Miss appointments to your provider over and over Rude or act out against a provider or a DCHP staff member Keep using a doctor that is not a DCHP provider DCHP will not ask you to leave the health plan without trying to work with you. If you have questions about this process, call Member Services at 1-877-451-5598. The Texas Health and Human Services Commission will decide if a Member can be told to leave the program. Health Care and Other Services What is routine medical care? Routine medical care might be when your child is seeing the Primary Care Provider for a well-child visit. Routine medical care might also be your first visit with the Primary Care Provider. o How soon can I expect to be seen / how soon can I expect my child to be seen? You should expect the Primary Care Provider to give you an appointment within 14 days for your first visit or for any other routine care. If your Primary Care Provider refers your child to a Specialist, you should be seen within three (3) weeks. What is urgent medical care? Urgent medical care is when your child is sick or hurt and needs treatment as soon as possible to keep your child from getting worse. These are situations when you need to call your child’s 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 Broken cast Stitches needing to be removed Medication refills o How soon can I expect to be seen / how soon can I expect my child to be seen? You can expect to be seen for urgent medical care within 24 hours. What is a limited provider network? A limited provider network is a list of providers who only refer members to other providers within our network. DCHP does not have any limited provider networks. A list of all our providers can be found on our website at www.dchpkids.com Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook Page 11 Emergency Care What is an Emergency, an Emergency Medical Condition and an Emergency Behavioral Health Condition? Emergency care is a covered service. Emergency care is provided for Emergency Medical Conditions and Emergency Behavioral Health Conditions. “Emergency Medical Condition” means a medical condition of recent onset and severity, including, but not limited to, severe pain that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that the child’s condition, sickness, or injury is of such a nature that failure to get immediate care could result in: • • • • • placing the child’s health in serious jeopardy; serious impairment to bodily functions; serious dysfunction of any bodily organ or part; serious disfigurement; or in the case of a pregnant child, serious jeopardy to the health of the fetus. “Emergency Behavioral Health Condition” means any condition, without regard to the nature or cause of the condition, that in the opinion of a prudent layperson, possessing average knowledge of medicine and health: • • requires immediate intervention and/or medical attention without which the child would present an immediate danger to himself or others; or that renders the child incapable of controlling, knowing or understanding the consequences of his actions. What is Emergency Services and/or Emergency Care? “Emergency services” and/or “emergency care” means health care services provided in an in-network or out-of-network hospital emergency department, free-standing emergency medical facility, or other comparable facility by in-network or out-of-network physicians, providers, or facility staff to evaluate and stabilize Emergency Medical Conditions and/or Emergency Behavioral Health Conditions. Emergency services also include, but are not limited to, any medical screening examination or other evaluation required by state or federal law that is necessary to determine whether an Emergency Medical Condition and/or an Emergency Behavioral Health Condition exists. Are Emergency Dental Services Covered? Your child’s CHIP medical plan will pay for some emergency dental services, such as: • 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 The CHIP medical plan also covers dental services your child gets in a hospital. This includes services from the doctor 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 1-877-451-5598. Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook Page 12 If 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. Someone has bad chest pains. 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 have any of these problems. You can call 9-1-1 for help in getting to the hospital emergency room. A cold, cough, rash, small cuts, minor burns or bruises are not good reasons to go to the Emergency Room. How soon can I expect to be seen / how soon can I expect my child to be seen? Emergency medical care is ready through the closest hospital 24 hours a day, 7 days a week. If you go to the ER, be sure to call your Primary Care Provider within 24 hours, or as soon as your child is medically stable. Getting care at night or on weekends If your child gets sick at night or on a weekend and cannot wait to get medical care, call your child’s Primary Care Provider for advice. The Primary Care Provider or another doctor is ready by phone 24 hours a day, 7 days a week. If your child has a fever or a sore throat and you are not sure what to do, call the Primary Care Provider’s office. What is post stabilization? Post-stabilization care services are services covered by CHIP that keep your condition stable following emergency medical care. What if I get sick when I am out of town or traveling / what if my child gets sick when he or she is out of town or traveling? What if I am / my child is out of the state? If you/your child needs medical care when traveling, call us toll-free at 1-877-451-5598 and we will help you find a doctor. If you/your child needs emergency services while traveling, go to a nearby hospital, then call us toll free at 1-877-451-5598. Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook Page 13 Keep your / your child’s DCHP ID card with you at all times. When you / your child will be temporarily away from home, you should contact your Primary Care Provider ahead of time to schedule appointments or obtain prescriptions to last for the duration of your child’s stay. If your child gets sick while he or she is out of town—and it is not an emergency—he or she will still remain under the care of your Primary Care Provider. With the exception of emergency care, if you / your child sees an out-of-town doctor you might have to pay. What if I am / my child is out of the country? . Medical services performed out of the country are not covered by CHIP. ATTENTION FEMALE MEMBERS What if I need / my daughter needs OB/GYN care? If you need help picking an OB/GYN doctor you can call Member Services at 1-877-451-5598. If you or your child is pregnant you should choose an OB/GYN for care. ATTENTION MEMBERS You have the right to pick an OB/GYN for yourself / your daughter without a referral from your / your daughter’s 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 (specialist) within the network. Driscoll Children’s Health Plan allows you / your daughter to pick any OB/GYN, whether that doctor is in the same network as your / your daughter’s Primary Care Provider or not. If you have questions about OB/GYN services, call DCHP Member Services at 1-877-451-5598. Do I have the right to choose an OB/GYN? You do have the right to choose any provider who provides OB/GYN services. How do I choose an OB/GYN? Pick an OB/GYN provider from your DCHP Provider Directory. If you pick an OB/GYN who is not on the DCHP Provider Directory list, you might have to pay. If I don’t choose an OB/GYN, do I have direct access? Yes, you may go directly to an OB/GYN Provider. Will I need a referral? No, you will not need a referral from your Primary Care Provider. How soon can I / can my daughter be seen after contacting the OB/GYN for an appointment? You / your daughter should be able to get an appointment within 2 weeks of calling for an appointment. If you / your daughter are 7 months pregnant or more and a new member, you / your daughter should be able to get an appointment within 5 days, or immediately if there is an emergency. Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook Page 14 Can I / my daughter stay with an OB/GYN who is not with Driscoll Children's Health Plan? If you / your daughter is close to the end of the pregnancy, you may stay with the OB/GYN doctor you or your daughter has been seeing. Otherwise, you need to contact DCHP Member Services at 1-877-451-5598. Ask for a Case Manager who can help you with finding an OB/GYN doctor who is with Driscoll Children's Health Plan. What if I am pregnant / what if my daughter is pregnant? Who do I need to call? It is very important that you call Driscoll Children's Health Plan to tell us you / your daughter is pregnant and what doctors you or she is seeing. Call Member Services at 1-877-451-5598. It is very important for you / her to start prenatal care immediately. You also need to call the CHIP hotline at 1-800-647-6558 so that you or your daughter may be moved to the CHIP Perinatal Program. What other services / activities / education does Driscoll Children's 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. Tell you about your / your daughter’s pregnancy. Help you find an OB/GYN doctor for you / your daughter. There are other value added services that you can have if you / your daughter are pregnant. See page 46 for the list of value added services. CHIP Benefits What are my CHIP Benefits? For a full list of benefits see pages 29-43. How do I get these services / how do I get these services for my child? Call Member Services at 1-877-451-5598. We will be happy to explain how you or your child can get these benefits. What services are not covered? A list of services not covered by CHIP are on page 43 of this Member Handbook. Medicaid Versus CHIP Coverage for CHIP Perinatal Program Newborns At birth, the CHIP Perinate Newborn will be moved to Medicaid for twelve (12) months continuous coverage, if the newborn lives in a family with an income at or below 185% of the Federal Poverty Level (FPL). If the family income is 186% to 200% FPL, the CHIP Perinate Newborn will continue to be in the CHIP Program. What are the CHIP Perinatal benefits? For the CHIP Perinatal Newborn, the benefits are the same as for CHIP members. For the mother of the CHIP Perinatal Newborn, see the CHIP Perinate Program Member Handbook. Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook Page 15 o How do I get these services for my child? The CHIP Perinatal Newborn will begin CHIP services at birth o What benefits does my baby receive at birth? The benefits for the newborn baby, that qualifies as a CHIP member, are the same as for CHIP members. Concurrent Enrollment of Family Members in CHIP and CHIP Perinatal For members in the CHIP Perinatal Program, the health plan that is chosen will also be the health plan for other CHIP Members in the family. So if another health plan is chosen by the CHIP Perinatal member, the children on CHIP will be moved to the same health plan. Co-payments are still applicable for the CHIP Members. CHIP Perinatal Program Members have no copayments. What are my prescription drug benefits? Driscoll Children’s Health Plan covers most drugs your doctor orders. Services at 1-877-451-5598. To learn more call Member Behavioral (Mental) Health Services How do I get help if I have / my child has behavioral (mental) health or drug problems? You can get help for behavioral (mental) health problems and/or substance (drug) abuse. You can go to a mental health provider without a referral from your Primary Care Provider. 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 1-877-330-3312. You can call anytime 24 hours a day, seven (7) days a week. If 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. Do I need a referral for this? Behavioral health services are very private so your Primary Care Provider does not have to agree for you to get these services. You do not need a referral from your Primary Care Provider. Prescription Coverage How Do I Get My / My Child’s Medications? CHIP covers most of the medicine your/your child’s doctor says you need. Your/your child’s doctor will write a prescription so you can take it to the drug store, or may be able to send the prescription for you. Exclusions include: contraceptive medications prescribed only for the purpose to prevent pregnancy and medications for weight loss or gain. You might have to pay a co-payment for the prescription filled depending on your income. Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook Page 16 How do I find a network drug store? Call Member Services at 1-877-451-5598. They will be able to help you find a drug store. You may also visit the DCHP website to find a drug store. The website is www.dchpkids.com What if I go to a drug store not in network? The pharmacy can call the Pharmacy Help Desk number on the back of your ID card. They will help in obtaining a medication for you. What do I bring with me to the drug store? You will need to bring your CHIP ID card with you to the drug store. What if I need my / my child’s medications delivered to me? Call Member Services at 1-877-451-5598 and they will help you find a drug store that delivers medications. Who do I call if I have problems getting my / my child’s medications? Call Member Services at 1-877-451-5598. What if I can’t get the medication my / my child’s doctor ordered approved? If your / your child’s doctor cannot be reached to approve a prescription, your child may be able to get a three-day emergency supply of your/your child’s medication. Call Driscoll Children’s Health Plan at 1-877-451-5598 for help with your medications and refills. What if I lose my/my child’s medication? Lost medication is not a covered benefit. You may contact your pharmacy for an early refill and pay the cost of the medication. What if I need/my child needs an over the counter medication for CHIP? The pharmacy cannot give you an over the counter medication as part of your/your child’s CHIP benefit. If you need/your child needs an over the counter medication, you will have to pay for it. What if I need/my child needs more than 34 days of a prescribed medication? The pharmacy can only give you an amount of a medication that you need/your child needs for the next 34 days. For any other questions, please call Driscoll Children’s Health Plan at 1-877-451-5598. What if I need/my child needs birth control pills? The pharmacy cannot give you/your child birth control pills to prevent pregnancy. You/your child can only get birth control pills if they are needed to treat a medical condition. Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook Page 17 Other Health Coverage and Services What health education classes does DCHP 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 1-877-451-5598. How do I get eye care services / how do I get eye care services for my child? Eye care services include one examination by an eye doctor per year. You or your child may get one pair of eyeglasses each year. To learn more about eye exams or glasses, call our eye care vendor at 1-888-268-2334. How do I get dental services/how do I get dental services for my child? Your child’s CHIP dental plan provides dental services including services that help prevent tooth decay and services that fix dental problems. Call your child’s CHIP dental plan to learn more about the dental services they offer. The CHIP dental plan phone numbers are Delta Dental – 1-866-561-5891; DentaQuest – 1-800-508-6775; or MCNA Dental – 1-800-494-6262. Driscoll Children’s Health Plan covers emergency dental services your child gets in a hospital. 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 / my child’s doctor? Yes. This can be Spanish, or other language. You or your doctor may call to arrange for an interpreter. Who do I call for an interpreter? Call Member Services at 1-877-451-5598. We will arrange for an interpreter to help you during your visit. 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: DCHP7 CHIP Member Handbook Page 18 Costs of Your DCHP CHIP Insurance What are co-payments? How much are they and when do I have to pay them? Co-payments are part of the doctor’s bill or prescription costs that you will have to pay. The following table lists the CHIP co-payment schedule according to family income. Co-payments for medical services or prescription drugs are paid to the doctor’s office or drug store at the time of service. No co-payments are paid for preventive care such as well-child or well-baby visits or immunizations. Your child’s health plan ID card lists the co-payments that apply to your family. Present your ID card when you receive office visit or emergency room services or have a prescription filled. Co-payments do not apply to CHIP Perinate Newborn. Office Visits NonEmergency Room Visits Inpatient Hospitalizations Prescription Generic Drugs Prescription Brand Drugs Once a Year Reporting Caps $0 $0 $0 $0 $0 $0 $3 $3 $15 $0 $3 101%-150% $5 $5 $35 $0 $5 151%-185% $20 $75 $75 $10 $35 186%-200% $25 $75 $125 $10 $35 Federal Poverty Levels Native Americans At or Below 100% 5% cap of family yearly income 5% cap of family yearly income 5% cap of family yearly net income 5% cap of family yearly net income What extra benefits does a Member of Driscoll Children's Health Plan get? All Driscoll Children's Health Plan members might be able to receive the following Extra Benefits (Value Added services): • • Eyeglasses with a retail value up to $100 every 24 months. Transportation services for members who have special health care needs, and do not have transportation to their doctor or health education classes. • Temporary Cell Phones for members who meet medical criteria. • Sport/school physicals. • Smoking cessation benefits. • Environment review for members with asthma, and free pillow and bed covers once the review is done. • Prenatal education and nutritional counseling for pregnant women who live in Nueces, Jim Wells, Bee, Victoria, Kleberg or San Patricio Counties. • Access to Boys and Girls Clubs where available or membership at YMCA in Corpus Christi or Victoria. Sports Scholarships of $25 per member per year are also available. How can I get these benefits / how can I get these benefits for my child? For eyeglasses, contact our vision vendor at 1-888-268-2334. If you need transportation services to your doctor, call Member Services at 1-877-451-5598 to arrange these services. You will need to call 48 hours in advance of your doctor’s appointment to arrange these services. Services might exist in the evenings or on weekends. Extra time might be needed to arrange for these services. Operation hours are 8 a.m. to 5 p.m. Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook Page 19 For temporary cell phones or questions about any of the extra benefits, contact Member Services at 1-877-451-5598. For prenatal education or nutritional counseling contact Member Services at 1-877-451-5598. CHIP Cost-Sharing Caps When you joined CHIP you received a form that you should use to track your CHIP expenses. To ensure that you do not exceed your cost-sharing limit, please keep track of your CHIP-related expenses on this form. The CHIP welcome letter tells you exactly what your cost-sharing cap is based on your family’s income. If you have lost this letter, please call CHIP hotline at 1-800-647-6558 and they will tell you what your yearly limit is. When you reach your yearly cap, please send the form to the HHSC Administrative Services Contractor. This contractor will notify us that you have reached your yearly cap. Once we are notified we will issue a new member ID card within five (5) days from the day we were notified. This new card will indicate that no co-payments are due when your child receives services. If you must go to the doctor or emergency room before you get your new ID card, have the doctor or emergency room contact us to verify co-pay amounts. We will inform them that there is no co-pay required. Call member services at 1-877-451-5598. What if I get a bill from my Doctor? Except for co-payments, you / your child should never get a bill from your Primary Care Provider or DCHP doctor. The co-payments and costs are shown on the front of your / your child’s ID Card. Co-payments usually have to be paid before you / your child receives health care or gets a prescription. Who do I call? If you get a bill from your Primary Care Provider or other doctor, call DCHP Member Services at 1-877451-5598, and someone will call the provider’s office. We will help explain your benefits and copayments. What information 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 have to do if I move? As soon as you have your new address, give it to the local HHSC benefits office and Driscoll Children’s Health Plan Member Services Department at 1-877-451-5598. Before you get CHIP services in your new area, you must call Driscoll Children’s Health Plan, unless you need emergency services. You will continue to get care through Driscoll Children’s Health Plan until HHSC changes your address. 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 might 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. Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook Page 20 Other costs for CHIP members CHIP membership is for 12 months. When you reenroll your children in the CHIP program there will be an enrollment fee that must be paid. You will be told how much that costs when you reenroll. Referrals to Specialists What is a referral? A referral is when your Primary Care Provider sends you / your child to another doctor for service or care. What services do not need a referral? You can get some services without going to your / your child’s Primary Care Provider first. These include: • Emergency care • OB/GYN Care • Behavioral Health and Substance Abuse Services • Routine eye exams It is good to let your / your child’s Primary Care Provider know when you / your child receive other care, but you are not required to. This lets your / your child’s Primary Care Provider know all of your / your child’s needs. What if I / my child needs to see a special doctor (specialist)? Your / your child’s Primary Care Provider will tell you if you / your child needs to see a specialist. Your / your child’s 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 / your child’s Primary Care Provider does not agree to make a referral. How soon can I expect to be seen by a specialist / how soon can I expect my child to be seen by a specialist? You should expect the specialist to give you a routine appointment within thirty (30) days of the request. For an urgent request, you should expect to have an appointment within 24 hours of the request. Who do I call if I have / my child has special health care needs and I need someone to help me? You / Your child might need more health and other services because of a disability or chronic or complex medical or behavioral health condition. There might be times when DCHP might allow a special doctor (Specialist) to be your child’s Primary Care Provider. Call Member Services at 1-877-451-5598 to learn more on special services that DCHP has for you or your child with special health care needs. How can I ask for a second opinion? You have the right to a second opinion from a Driscoll Children’s Health Plan Provider if you are not satisfied with the plan of care offered by the Specialist. Your Primary Care Provider should be able to give you a referral for a second opinion visit. If your doctor wants you to see a Specialist that is not a Driscoll Children’s Health Plan Provider, that visit will have to be approved before you can see the Provider. Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook Page 21 Services That Require Prior Authorization The following services require that your Primary Care Provider or other provider contact DCHP for approval for the service before given: • • • • • • • • • • • • • • • • • • • • • • • • • All admissions to a hospital (except in an emergency situation, where telling DCHP within 24 hours of admission is required) Admissions required before the day of surgery Admission to an observation program for 48 hours Admission to a rehabilitation center Outpatient ambulatory / surgical procedure Surgical assistants for outpatient / ambulatory surgical procedure Non-emergency request for a surgeon to help with a surgery 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 doctor Allergy testing for children less than five (5) years of age Chronic pain medications / pain clinic treatments Sleep studies / sleep labs Pneumogram Radiological procedures which require admission for observation Special Radiological procedures, like MRI, CT Scan, or PET Scan 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 Out of area / out of network services Bio-feedback treatment Injectable drugs that cost over $300 Temporal Mandibular Joint (TMJ) treatment Organ transplant evaluation Other forms of medical treatment (such as hypnosis, massage therapy) To call for authorization, you or your doctor might call the Member Services number 1-877-451-5598, Monday through Friday, 8 a.m. to 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. You / your child’s hospital stay is reviewed every day. delivered or paid. Services might be reviewed after they are How to Appeal a Denied Service What can I do if my doctor asks for a service for me that’s covered but Driscoll Children's Health Plan denies or limits it? When this happens, you can appeal this decision. To appeal these medical decisions, call Member Services at 1-877-451-5598. Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook Page 22 How will I find out if services are denied? There might be times when the DCHP Medical Director does not approve these services. You will be sent a letter telling you the services were not approved. If the DCHP Medical Director denies a service, you may appeal this decision. What are the timeframes for the appeal process? You have thirty (30) days from the date on the denial letter to appeal. 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. When do I have the right to ask for an appeal? You may request an appeal anytime a service is limited or denied. If you wish to appeal a denial of a service that is not a covered benefit, then you will need to file a complaint. See page 20 to see how to file a complaint. Does my request have to be in writing? You or your provider can appeal verbally or in writing. If a request for an appeal is received verbally, you or your provider will need to put the appeal in writing. Can someone from DCHP help me file an appeal? Yes. If you need help in filing an appeal, call Member Services at 1-877-451-5598 Expedited Appeal 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 do I ask for an Expedited Appeal? You need to call Member Services at 1-877-451-5598 to ask for an expedited appeal. Does my request have to be in writing? Your request does not have to be in writing. You or your doctor can ask for this type of appeal. What are the timeframes for an expedited appeal? Your request will be reviewed and a response given to you and your doctor within one day of asking for the appeal. What happens if DCHP denies your request for an expedited appeal? You can discuss your request for an expedited appeal with the Medical Director if there are questions. Requests for expedited appeal are very serious. We want to make sure your child receives the care that is medically necessary. Who can help me in filing an appeal? If you need help with filing this appeal, call Member Services at 1-877-451-5598. Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook Page 23 Independent Review Organization (IRO) Process What is an Independent Review Organization? An Independent Review Organization is an organization that the Texas Department of Insurance (TDI) picks to review appeals for health plans. When a member or doctor is not happy with the health plan appeal response, this organization will make a decision in the appeal. This organization reviews adverse determinations (denials) that were made by DCHP, and the denial was upheld when you sent us an appeal. An adverse determination is a determination (decision) by a utilization review agent (like DCHP) that health care services provided or proposed to be provided to a patient (or member) are not medically necessary or are experimental or investigational. Utilization review means a process for review that includes prospective (in the future), concurrent (what is happening right now) or retrospective review (what has happened in the past) of the medical necessity and appropriateness of health care services. This also includes a review prospective, concurrent, or retrospective review to determine the experimental or investigational nature of health care services. This Independent Review Organization may review an appeal for experimental and investigational service request that has been denied by DCHP. How do I ask for a review by an Independent Review Organization? We will send you forms with our appeal response. These forms are to request that an Independent Review Organization review your appeal. This is done if you are not happy with the results of the DCHP appeal. To ask for a review by an Independent Review Organization, call DCHP at 1-877-451-5598. You will need to complete the IRO form that DCHP sent to you and fax it to us at 361-882-4520. You can also mail it to us at: Driscoll Children's Health Plan ATT: Appeals Coordinator 615 N Upper Broadway, Suite 1621 Corpus Christi, Texas 78401-0764 We will send your request to TDI right away. What are the timeframes for this process? TDI will arrange for an Independent Review Organization (IRO) to review your appeal within one (1) business day after they receive the request. The IRO will review your case. They will make a decision about the service within fifteen (15) days, but no longer than twenty (20) days after they receive the request. DCHP will follow the IRO decision. We will pay for the IRO process. We will also pay for the service if the IRO decision is to offer the service. What if I need an appeal decision quickly? If your child is in the hospital or needs an appeal decision quickly due to his/her condition, contact DCHP right away. You do not need to go through the regular appeal process. We will send your request to TDI right away. The IRO will make a decision about your child’s care within five (5) days, but no longer than eight (8) days after they receive the request. DCHP will follow the IRO decision. We will pay for the IRO process. Complaints What should I do if I have a complaint? We want to help. If you have a complaint, please call us toll-free at 1-877-451-5598 to tell us about your problem. A Driscoll Children’s Health Plan Member Services Advocate can help you file a complaint. Just call 1-877-451-5598. Most of the time, we can help you right away or at the most, within a few days. Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook Page 24 Who do I call? Please call our Member Services Department at 361-904-0955 or toll free at 1-877-451-5598. Can someone from DCHP help me file a complaint? A Member Services Advocate can help you with filing a complaint. Call us: Driscoll Children’s Health Plan DCHP Member Services 1-877-451-5598 Write to us: Driscoll Children’s Health Plan ATT: Complaints Coordinator 615 N Upper Broadway, Suite 1621 Corpus Christi, TX 78401-0764 The Member Services Representative will help you file the complaint and will explain the complaint process. If you call us with a complaint, we will send you a one page complaint form for you to complete. You must send this form back to us right away. This will help us resolve your complaint quickly. If you need help with the form, the Member Services Representative can help. How long will it take to process my complaint? Most of the time, we can help you right away or at the most within a few days. We will send you a letter within five (5) working days telling you we have received your complaint. Within thirty (30) days of receiving your written complaint, we will mail you a letter with the outcome of the complaint. This outcome letter will include our resolution, the specific medical or contractual reason, the doctor or other provider consulted, the type of doctor consulted, and the appeals process with deadlines, if you do not like our response. What are the requirements and timeframes for filing a complaint? You may file a complaint at any time. The timeframe to file a complaint when we have denied a service because it is not a covered benefit is different. For a complaint about denying a service, you must notify us within thirty (30) days of the denial letter. 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 one page form to complete and mail to us. We will not punish you for filing a complaint. All complaints are reviewed to make sure that there is follow-up. They are also reviewed to make sure that timely answers are given. If I am not satisfied with the outcome, who else can I contact? If you are not satisfied with the answer to your complaint, you can also complain to the Texas Department of Insurance by calling toll-free to 1-800-252-3439. If you would like to make your request in writing send it to: Texas Department of Insurance Consumer Protection P.O. Box 149091 Austin, Texas 78714-9091 Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook Page 25 Do I have the right to meet with a Complaint Appeal Panel? You also have the right to appear before a Complaints Appeal Panel. This panel is made up of DCHP employees, doctors, and other CHIP members. The doctors on this panel were not involved with the original complaint response. The doctors will have experience in the care that is being reviewed. You may also submit a written appeal to the Complaints Appeal Panel. DCHP will complete the appeals process by the 30th day after the date the written request for appeal was received. If your appeal is for an ongoing emergency or continued stay in the hospital, we will review this appeal quickly depending on the immediacy of the case. We will respond no later than one business day after the request for appeal is received. Because of this urgent review, your appeal will be reviewed by a doctor or provider of similar specialty as the condition, procedure or treatment for your child, and the doctor or provider will not have been involved with your child’s care before. Fraud and Abuse of the CHIP program REPORT CHIP WASTE, ABUSE OR FRAUD Do you want to report CHIP Waste, Abuse or Fraud? Let us know if you think a doctor, dentist, pharmacist at a drug store, other health-care provider, or a person getting CHIP 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 CHIP services that weren’t given or necessary. Not telling the truth about a medical condition to get medical treatment. Letting someone else use a CHIP ID. Using someone else’s CHIP ID. Not telling the truth about the amount of money or resources he or she has to get the 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: o Driscoll Children’s Health Plan ATT: Compliance Officer 615 N Upper Broadway, Suite 1621 Corpus Christi, Texas 78401-0764 Phone – 1-877-324-7543 To report waste, abuse or fraud, gather as much information as possible. • When reporting about a provider (a doctor, dentist, counselor, etc.) include: o Name, address, and phone number of provider o Name and address of the facility (hospital, nursing home, home health agency, etc.) o Medicaid number of the provider and facility, if you have it o Type of provider (doctor, dentist, therapist, pharmacist, etc.) o Names and the phone numbers of other witnesses who can help in the investigation o Dates of events o Summary of what happened • When reporting about someone who receives benefits, include: o The person’s name Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook Page 26 o o o 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. Member Rights and Responsibilities FOR CHIP MEMBERS AND CHIP PERINATE NEWBORN MEMBERS If you have any questions or concerns, please call us. We are here to help. You can call us toll-free at 1877-451-5598. MEMBERS HAVE THE RIGHT TO: 1. You have the right to get accurate, easy-to-understand information to help you make good choices about your child’s health plan, doctors, hospitals and other providers. 2. Your health plan must tell you if they use a “limited provider network.” This is a group of doctors and other providers who only refer patients to other doctors who are in the same group. “Limited provider network” means you cannot see all the doctors who are in your health plan. If your health plan uses “limited networks,” you should check to see that your child’s primary care provider and any specialist doctor you might like to see are part of the same “limited network”. 3. You have a right to know how your doctors are paid. Some get a fixed payment no matter how often you visit. Others get paid based on the services they give to your child. You have a right to know what those payments are and how they work. 4. You have a right to know how the health plan decides whether a service is covered and/or medically necessary. You have the right to know about the people in the health plan who decide those things. 5. You have a right to know the names of the hospitals and other providers in your health plan and their addresses. 6. You have a right to pick from a list of health care providers that is large enough so that your child can get the right kind of care when your child needs it. 7. If a doctor says your child has special health care needs or a disability, you may be able to use a specialist as your child’s primary care provider. Ask your health plan about this. 8. Children who are diagnosed with special health care needs or a disability have the right to special care. 9. If your child has special medical problems, and the doctor your child is seeing leaves your health plan, your child may be able to continue seeing that doctor for three months, and the health plan must continue paying for those services. Ask your plan about how this works. 10. Your daughter has the right to see a participating obstetrician/gynecologist (OB/GYN) without a referral from her primary care provider and without first checking with your health plan. Ask your plan how this works. Some plans may make you pick an OB/GYN before seeing that doctor without a referral. 11. Your child has the right to emergency services if you reasonably believe your child’s life is in danger, or that your child would be seriously hurt without getting treated right away. Coverage of emergencies is available without first checking with your health plan. You may have to pay a copayment depending on your income. Co-payments do not apply to the CHIP Perinatal Program. 12. You have the right and responsibility to take part in all the choices about your child’s health care. Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook Page 27 13. You have the right to speak for your child in all treatment choices. 14. You have the right to get a second opinion from another doctor in your health plan about what kind of treatment your child needs. 15. You have the right to be treated fairly by your health plan, doctors, hospitals and other providers. 16. You have the right to talk to your child’s doctors and other providers in private, and to have your child’s medical records kept private. You have the right to look over and copy your child’s medical records and to ask for changes to those records. 17. You have the right to a fair and quick process for solving problems with your health plan and the plan’s doctors, hospitals and others who provide services to your child. If your health plan says it will not pay for a covered service or benefit that your child’s doctor thinks is medically necessary, you have a right to have another group, outside the health plan, tell you if they think your doctor or the health plan was right. 18. You have a right to know that doctors, hospitals, and others who care for your child can advise you about your child’s 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. MEMBER RESPONSIBILITIES: You and your health plan both have an interest in seeing your child’s health improve. You can help by assuming these responsibilities. 1. You must try to follow healthy habits. Encourage your child to stay away from tobacco, and to eat a healthy diet. 2. You must become involved in the doctor’s decisions about your child’s treatments. 3. You must work together with your health plan’s doctors and other providers to pick treatments for your child that you have all agreed upon. 4. If you have a disagreement with your health plan, you must try to first resolve it using the health plan’s complaint process. 5. You must learn about what your health plan does and does not cover. Read your Member Handbook to understand how the rules work. 6. If you make an appointment for your child, you must try to get to the doctor’s office on time. If you cannot keep the appointment, be sure to call and cancel it. 7. If your child has CHIP, you are responsible for paying your doctor and other providers copayments that you owe them. If your child is getting CHIP Perinatal Program services, you will not have any co-payments for that child. 8. You must report misuse of CHIP or CHIP Perinatal Program services by health care providers, other members or health plans. 9. You must talk to your provider about your medications that are prescribed. 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: DCHP7 CHIP Member Handbook Page 28 DCHP CHIP Scope of Benefits What does medically necessary mean? Covered services for CHIP and CHIP Perinate Newborn Members must meet the CHIP definition of "Medically Necessary." Medically Necessary means: 1. Health Care 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 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 member’s diagnoses; e. no more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency; f. not experimental or investigational; and g. not primarily for the convenience of the member or provider; and 2. Behavioral Health Services that are: a. 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. provided in accordance with professionally accepted clinical guidelines and standards of practice in behavioral health care; c. not experimental or investigative; and d. not primarily for the convenience of the Member or Provider. Medically Necessary Services must be furnished in the most appropriate and least restrictive setting in which services can be safely provided and must be provided at the most appropriate level or supply of service that can safely be provided and that could not be omitted without adversely affecting the child’s physical health and/or the quality of care provided. Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook Page 29 Type of Benefit Description of Benefit Inpatient General Acute and Inpatient Rehabilitation Hospital Services Services include: Hospital-given doctor or provider services Semi-private room and board (or private if medically necessary as certified by attending) General nursing care Special duty nursing when medically necessary ICU and services Patient meals and special diets Operating, recovery and other treatment rooms Anesthesia and administration(facility technical component) Surgical dressings, trays, casts, splints Drugs, medications and biologicals blood or blood products not given free-of-charge to the patient and their administration X-rays, imaging and other radiological tests (facility technical component) Laboratory and pathology services (facility technical component) Machine diagnostic tests (EEGs, EKGs, etc) Oxygen services and inhalation therapy Radiation and chemotherapy Access to DSHSdesignated Level III perinatal centers or hospitals meeting equivalent levels of care In-network or out-ofnetwork facility and Physician services for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours Driscoll Children’s Health Plan Form Number: DCHP7 Co-Pay Limitations Requires prior authorization for nonemergency care and following stabilization of an emergency condition Requires authorization for in-network or out-ofnetwork facility and doctors services for a mother and her newborn(s) after 48 hours following an uncomplicated vaginal delivery and after 96 hours following an uncomplicated delivery by caesarian section Applicable level of inpatient copay applies CHIP Member Handbook Page 30 Type of Benefit Description of Benefit Driscoll Children’s Health Plan Form Number: DCHP7 Limitations Co-Pay following an uncomplicated delivery by caesarian section. Hospital, doctor and related medical services, such as anesthesia, associated with dental care Inpatient services associated with (a) miscarriage or (b) a nonviable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero.) Inpatient services associated with miscarriage or non-viable pregnancy include, but are not limited to: - dilation and curettage (D&C) procedures; - appropriate provider administered medications; - ultrasounds; and - histological examination of tissue samples. Pre-surgical or postsurgical orthodontic services for medically necessary treatment of craniofacial anomalies requiring surgical intervention and delivered as part of a proposed and clearly outlined treatment plan to treat: - cleft lip and/or palate; or - severe traumatic skeletal and/or congenital craniofacial deviations; or - severe facial asymmetry secondary to skeletal defects, congenital syndromal conditions and/or tumor growth or its treatment. Surgical implants CHIP Member Handbook Page 31 Type of Benefit Description of Benefit Other artificial aids including surgical implants Inpatient services for mastectomy and breast reconstruction include: - all stages of reconstruction on the affected breast; - surgery and reconstruction on the other breast to produce symmetrical appearance; and - treatment of physical complications from the mastectomy and treatment of lymphedemas. Implantable devices are covered under Inpatient and Outpatient services and do not count towards the DME 12-month period limit. Services include, but are not limited to, the following: Semi-private room and board Regular nursing services Rehabilitation services Medical supplies and use of appliances and equipment furnished by the facility Services include, but are not limited to, the following services provided in a hospital clinic or emergency room, a clinic or health center, hospital-based emergency department or an ambulatory health care setting: X-ray, imaging, and radiological tests (technical component) Laboratory and pathology services (technical component) Machine diagnostic tests Ambulatory surgical facility services Drugs, medications and Co-Pay Limitations Skilled Nursing Facilities (Includes Rehabilitation Hospitals) Outpatient Hospital, Comprehensive Outpatient Rehabilitation Hospital, Clinic (Including Health Center) and Ambulatory Health Care Center Driscoll Children’s Health Plan Form Number: DCHP7 • Requires authorization and doctor prescription 60 days per 12-month period limit May require prior authorization and doctor prescription Co-pays do not apply Applicable level of co-pay applies to prescription drug services Co-pays do not apply to preventive services CHIP Member Handbook Page 32 Type of Benefit Description of Benefit Driscoll Children’s Health Plan Form Number: DCHP7 Limitations Co-Pay biologicals Casts, splints, dressings Preventive health services Physical, occupational and speech therapy Renal dialysis Respiratory Services Radiation and chemotherapy Blood or blood products not offered free-of-charge to the patient and the administration of these products Facility and related medical services, such as anesthesia, associated with dental care, when offered in a licensed ambulatory surgical facility. Outpatient services associated with (a) miscarriage or (b) a nonviable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero.) Outpatient services associated with miscarriage or non-viable pregnancy include, but are not limited to: - dilation and curettage (D&C) procedures; - appropriate provider administered medications; - ultrasounds; and - histological examination of tissue samples. Pre-surgical or postsurgical orthodontic services for medically necessary treatment of craniofacial anomalies requiring surgical intervention and delivered as part of a proposed and clearly outlined treatment plan to treat: - cleft lip and/or palate; CHIP Member Handbook Page 33 Type of Benefit Description of Benefit or severe traumatic skeletal and/or congenital craniofacial deviations; or - severe facial asymmetry secondary to skeletal defects, congenital syndromal conditions and/or tumor growth or its treatment. Surgical implants Other artificial aids including surgical implants Outpatient services provided at an outpatient hospital and ambulatory health care center for a mastectomy and breast reconstruction as clinically appropriate, include: - all stages of reconstruction on the affected breast; - surgery and reconstruction on the other breast to produce symmetrical appearance; and - treatment of physical complications from the mastectomy and treatment of lymphedemas. Implantable devices are covered under Inpatient and Outpatient services and do not count towards the DME 12-month period limit Services include, but are not limited to the following: American Academy of Pediatrics recommended well-child exams and preventive health services (including but not limited to vision and hearing screening and immunizations) Co-Pay Limitations - Doctor / Doctor Extender Professional Services Driscoll Children’s Health Plan Form Number: DCHP7 May require authorization for specialty services Applicable level of co-pay applies to office visits Co-pays do not apply to preventive visits or to prenatal visits after the CHIP Member Handbook Page 34 Type of Benefit Description of Benefit Driscoll Children’s Health Plan Form Number: DCHP7 Doctor office visits, inpatient and outpatient services Laboratory, x-rays, imaging and pathology services, including technical component and/or professional interpretation Medications, biologicals and materials administered in doctor’s office Allergy testing, serum and injections Professional component (in/outpatient) of surgical services, including: • Surgeons and assistant surgeons for surgical procedures including appropriate follow-up care • Administration of anesthesia by doctor (other than surgeon) or CRNA • Second surgical opinions • Same-day surgery performed in a hospital without an over-night stay • Invasive diagnostic procedures such as endoscopic examination Hospital-based doctor services (including doctor-performed technical and interpretative components) Doctor and professional services for a mastectomy and breast reconstruction include: - all stages of reconstruction on the affected breast; - surgery and reconstruction on the other breast to Limitations Co-Pay first visit CHIP Member Handbook Page 35 Type of Benefit Description of Benefit Driscoll Children’s Health Plan Form Number: DCHP7 Limitations Co-Pay produce symmetrical appearance; and - treatment of physical complications from the mastectomy and treatment of lymphedemas. In-network and out-ofnetwork doctor services for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated delivery by caesarian section Doctor services medically necessary to support a dentist providing dental services to a CHIP member such as general anesthesia or intravenous (IV) sedation. Doctor services associated with (a) miscarriage or (b) a nonviable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero.) Doctor services associated with miscarriage or non-viable pregnancy include, but are not limited to: - dilation and curettage (D&C) procedures; - appropriate provider administered medications; - ultrasounds; and - histological examination of tissue samples. Pre-surgical or postsurgical orthodontic services for medically necessary treatment of craniofacial anomalies requiring surgical intervention and delivered as part of a proposed and clearly outlined treatment CHIP Member Handbook Page 36 Type of Benefit Durable Medical Equipment (DME), Prosthetic Devices and Disposable Medical Supplies Description of Benefit plan to treat: - cleft lip and/or palate; - severe traumatic skeletal and/or congenital craniofacial deviations; or - severe facial asymmetry secondary to skeletal defects, congenital syndromal conditions and/or tumor growth or its treatment. Covered services include DME (equipment that can withstand repeated use, and is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of illness, injury or disability, and is appropriate for use in the home), including devices and supplies that are medically necessary and necessary for one or more activities of daily living, and appropriate to help in the treatment of a medical condition, including, but not limited to: Orthotic braces and Orthotics Dental devices Prosthetic devices such as artificial eyes, limbs braces, and external breast prostheses Prosthetic eyeglasses and contact lenses for the management of severe ophthalmologic disease Other artificial aids including surgical implants Hearing aids Implantable devices are covered under Inpatient and Outpatient services and do not count towards the DME 12-month period limit. Diagnosis-specific Driscoll Children’s Health Plan Form Number: DCHP7 Co-Pay Limitations Requires prior authorization and doctor prescription $20,000 per 12-month period limit for DME, prosthetics, devices and disposable medical supplies (implantable devices, diabetic supplies and equipment are not counted against this cap) Co-pays do not apply CHIP Member Handbook Page 37 Type of Benefit Birthing Center Services Services rendered by a Certified Nurse Midwife or Physician in a licensed birthing center Home and Community Health Services Inpatient Mental Health Services Description of Benefit disposable medical supplies, including diagnosis-specific prescribed specialty formula and dietary supplements Covers birthing services provided by a licensed birthing center. Covers prenatal, birthing and postpartum services rendered in a licensed birthing center. Services that are provided in the home and community, including, but not limited to: Home infusion Respiratory therapy Visits for private duty nursing (R.N., L.V.N.) Skilled nursing visits as defined for home health purposes (may include R.N. or L.V.N.). Home health aide when included as part of a plan of care during a period that skilled visits have been approved Speech, physical and occupational therapies. Mental health services, including for serious mental illness, furnished in a freestanding psychiatric hospital, psychiatric units of general acute care hospitals and state operated facilities, including but not limited to: Driscoll Children’s Health Plan Form Number: DCHP7 Neuropsychological and psychological testing. Co-Pay Limitations Limited to facility services (e.g. labor and delivery) Limited to a licensed birthing center Co-pays do not apply Requires prior authorization and doctor prescription Co-pays do not apply Services are not intended to replace the child's caretaker or to provide relief for the caretaker Skilled nursing visits are provided on intermittent level and not intended to provide 24-hour skilled nursing services Services are not intended to replace 24hour inpatient or skilled nursing facility services Requires prior authorization for nonemergency services Does not require Primary Care Provider referral. When inpatient psychiatric services, are ordered by a court of competent jurisdiction under the provisions of Chapters 573 and 574 of the Texas Health and Safety Code, relating to court ordered Co-pays do not apply Applicable level of inpatient copay applies CHIP Member Handbook Page 38 Type of Benefit Description of Benefit Co-Pay Limitations commitments to psychiatric facilities The court order serves as binding determination of medical necessity. Any modification or termination of services must be presented to the court with jurisdiction over the matter for determination. Outpatient Mental Health Services Mental health services, including for serious mental illness, provided on an outpatient basis, including but not limited to: The visits can be furnished in a variety of community-based settings (including school and home-based) or in a state-operated facility. Neuropsychological and psychological testing. Medication management Rehabilitative day treatments Residential treatment services Sub-acute outpatient services (partial hospitalization or rehabilitative day treatment) Skills training (psychoeducational skill development) Driscoll Children’s Health Plan Form Number: DCHP7 Requires prior authorization. Does not require Primary Care Provider referral. When outpatient psychiatric services are ordered by a court of competent jurisdiction under the provisions of Chapters 573 and 574 of the Texas Health and Safety Code, relating to court ordered commitments to psychiatric facilities, the court order serves as binding determination of medical necessity. Any modification or termination of services must be presented to the court with jurisdiction over the matter for determination. A Qualified Mental Health Professional – Community Services (QMHP-CS), is defined by the Texas Department of State Health Services (DSHS) in Title 25 Applicable level of co-pay applies to office visits. CHIP Member Handbook Page 39 Type of Benefit Inpatient Substance Abuse Treatment Services Outpatient Substance Abuse Treatment Services Description of Benefit Inpatient substance abuse treatment services include, but are not limited to: inpatient and residential substance abuse treatment services including detoxification and crisis stabilization, and 24-hour residential rehabilitation programs. Outpatient substance abuse treatment services include, but are not limited to: Prevention and intervention services that are offered by doctor and non-doctor providers, such as screening, assessment and referral for chemical dependency disorders. Intensive outpatient services Partial hospitalization Intensive outpatient services is defined as an organized non-residential service providing Driscoll Children’s Health Plan Form Number: DCHP7 Co-Pay Limitations T.A.C., Part I, Chapter 412, Subchapter G, Division 1), §412.303(48). QMHPCSs shall be providers working through a DSHS-contracted Local Mental Health Authority or a separate DSHScontracted entity. QMHP-CSs shall be supervised by a licensed mental health professional or doctor and provides services in accordance with DSHS standards. Those services include individual and group skills training (that can be components of interventions such as day treatment and inhome services), patient and family education, and crisis services. Requires prior authorization for nonemergency services Applicable level of inpatient copay applies Does not require Primary Care Provider referral. Requires prior authorization. Does not require Primary Care Provider referral. Outpatient treatment services up to a maximum of: Intensive outpatient program (up to 12 weeks per 12-month period). Outpatient services (up to six-months per 12- Applicable level of co-pay applies to office visits. CHIP Member Handbook Page 40 Type of Benefit Rehabilitation Services Hospice Care Services Description of Benefit structured group and individual therapy, educational services, and life skills training that consists of at least 10 hours per week for four to 12 weeks, but less than 24 hours per day. Outpatient treatment service is defined as consisting of at least one to two hours per week providing structured group and individual therapy, educational services, and life skills training. Habilitation (the process of supplying a child with the means to reach ageappropriate developmental milestones through therapy or treatment) and rehabilitation services include, but are not limited to, the following: Physical, occupational and speech therapy Developmental assessment Services include, but are not limited to: Palliative care, including medical and support services, for those children who have six months or less to live, to keep patients comfortable during the last weeks and months before death Treatment services, including treatment related to the terminal illness, are unaffected by electing hospice care services. Driscoll Children’s Health Plan Form Number: DCHP7 Co-Pay Limitations month period) Requires prior authorization and doctor prescription Co-pays do not apply Requires authorization and doctor prescription Co-pays do not apply Services apply to the hospice diagnosis Up to a maximum of 120 days with a 6 month life expectancy Patients electing hospice services may cancel this election at anytime CHIP Member Handbook Page 41 Type of Benefit Emergency Services, including Emergency Hospitals, Doctors, and Ambulance Services Description of Benefit Health plan cannot require authorization as a condition for payment for Emergency Conditions or labor and delivery. Covered services include: Emergency services based on prudent lay person definition of emergency health condition Hospital emergency department room and ancillary services and doctor services 24 hours a day, 7 days a week, both by in-network and out-of-network providers Medical screening examination Stabilization services Access to DSHS designated Level I and Level II trauma centers or hospitals meeting equivalent levels of care for emergency services Emergency ground, air or water transportation Emergency dental services, limited to fractured or dislocated jaw, traumatic damage to teeth, and removal of cysts. Driscoll Children’s Health Plan Form Number: DCHP7 Co-Pay Limitations May require authorization for poststabilization services Applicable copays apply to non-emergency room visits. CHIP Member Handbook Page 42 Type of Benefit Transplants Vision Benefit Chiropractic Services Description of Benefit Covered services include: Using up-to-date FDA guidelines, all nonexperimental human organ and tissue transplants and all forms of non-experimental corneal, bone marrow and peripheral stem cell transplants, including donor medical expenses Covered services include: o One examination of the eyes to find the need for and prescription for corrective lenses per 12month period, without authorization o One pair of nonprosthetic eyewear per 12-month period Requires authorization Co-pays do not apply The health plan may reasonably limit the cost of the frames/lenses. Covered services do not require doctor prescription and are limited to spinal subluxation • Requires authorization for protective and polycarbonate lenses when medically necessary as part of a treatment plan for covered diseases of the eye. Requires authorization for twelve visits per 12month period limit (regardless of number of services or modalities offered in one visit) Applicable level of co-pay applies to office visits billed for refractive exam • Tobacco Cessation Programs Co-Pay Limitations Covered up to $100 for a 12month period limit for a planapproved program Driscoll Children’s Health Plan Form Number: DCHP7 Requires authorization for additional visits. Requires authorization Health Plan defines plan-approved program. May be subject to formulary requirements. • Applicable level of co-pay applies to chiropractic office visits Co-pays do not apply CHIP Member Handbook Page 43 Type of Benefit Description of Benefit Limitations Additional Services for Asthmatics Home assessment regarding asthma triggers. Members participating will receive hypoallergenic pillow and bed covers Additional Vision Services $100 for eyewear every 24 months. Sports/School Physicals Sports/school physicals are an extra covered benefit • Requires prior authorization • Members must be previously identified through case management as having persistent asthma • Limited to members who need glasses • Services are for members 2 years of age and older • Does not require prior authorization Temporary Phone Assistance Temporary cell telephones available for members who meet medical criteria Prenatal Education and Nutritional Counseling for Pregnant Women Offered as baby showers at various locations, at multiple times every month Additional Transportation Services Transportation for medical appointments and health education classes for members needing transportation • Access to Boys and Girls Clubs (where available) • YMCA Membership • $25/year/member for sports scholarship Access to Physical Fitness Opportunities Additional Smoking Cessation Benefits Value Added Services Additional $50 benefit available to members Co-Pay • Co-pays do not apply • Co-pays do not apply for eyewear. • • Requires authorization • Member must be pregnant or have special needs, with no telephone services • Limited to members who reside in Nueces, Jim Wells, Bee, Victoria, Kleberg and San Patricio Counties, only • Requires authorization • • YMCA memberships are limited to Corpus Christi and Victoria • Members will be responsible for a portion of the YMCA membership fee • Does not require prior authorization • Restricted to one time reimbursement per member Applicable level of co-pay for office visit. Co-pays do not apply • Co-pays do not apply • Co-pays do not apply • Co-pays do not apply • Co-pays do not apply EXCLUSIONS Inpatient and outpatient infertility treatments or reproductive services other than prenatal care, labor and delivery, and care related to disease, illnesses, or abnormalities related to the reproductive system. Contraceptive medications prescribed only for the purpose of primary and preventive reproductive health care (i.e. cannot be prescribed for family planning). Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook Page 44 Personal comfort items including but not limited to personal care kits provided on inpatient admission, telephone, television, newborn infant photographs, meals for guests of patient, and other article that are not required for the specific treatment of sickness or injury Experimental and/or investigational medical, surgical or other health care procedures or services that are not generally employed or recognized within the medical community. This exclusion is an adverse determination and is eligible for review by an Independent Review Organization as described on page 23 of this handbook. Treatment or evaluations required by third parties including, but not limited to, those for schools, employment, flight clearance, camps, insurance or court Dental devices solely for cosmetic purposes Private duty nursing services when performed on an inpatient basis or in a skilled nursing facility. Mechanical organ replacement devices including, but not limited to artificial heart Hospital services and supplies when confinement is solely for diagnostic testing purposes, unless otherwise pre-authorized by Health Plan Prostate and mammography screening Elective surgery to correct vision Gastric procedures for weight loss Cosmetic surgery/services solely for cosmetic purposes Out-of-network services not authorized by the Health Plan except for emergency care and doctor services for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated delivery by caesarian section Services, supplies, meal replacements or supplements offered for weight control or the treatment of obesity, except for the services associated with the treatment for morbid obesity as part of a treatment plan approved by the Health Plan Medications prescribed for weight loss or gain. Acupuncture services, naturopathy and hypnotherapy Immunizations solely for foreign travel Routine foot care such as hygienic care (routine foot care does not include treatment injury or complications of diabetes) Diagnosis and treatment of weak, strained, or flat feet and the cutting or removal of corns, calluses and toenails (this does not apply to the removal of nail roots or surgical treatment of conditions underlying corns, calluses or ingrown toenails) Replacement or repair of prosthetic devices and durable medical equipment due to misuse, abuse or loss when confirmed by the Member or the vendor Corrective orthopedic shoes Convenience items Over-the-counter medications Orthotics primarily used for athletic or recreational purposes Custodial care (care that helps a child with the activities of daily living, such as help in walking, getting in and out of bed, bathing, dressing, feeding, toileting, special diet preparation, and medication supervision that is usually self-administered or given by a parent. This care does not require the continuing attention of trained medical or paramedical personnel.) This exclusion does not apply to hospice. Housekeeping Public facility services and care for conditions that federal, state, or local law requires be given in a public facility or care given while in the custody of legal authorities Services or supplies received from a nurse, that do not require the skill and training of a nurse Vision training and vision therapy Reimbursement for school-based physical therapy, occupational therapy, or speech therapy services are not covered except when ordered by a Doctor/ Primary Care Provider Donor non-medical expenses Charges incurred as a donor of an organ when the recipient is not covered under this health plan Coverage while traveling outside of the United States and U.S. Territories (including Puerto Rico, U.S. Virgin Islands, Commonwealth of Northern Mariana Islands, Guam, and American Samoa). Driscoll Children’s Health Plan Form Number: DCHP7 CHIP Member Handbook Page 45 DME/SUPPLIES SUPPLIES COVERED Ace Bandages X Alcohol, rubbing Alcohol, swabs (diabetic) Alcohol, swabs X Ana Kit Epinephrine X Arm Sling Attends (Diapers) X X Bandages Basal Thermometer Batteries – first Batteries – replacement Betadine Books Clinitest Colostomy Bags Communication Devices Contraceptive Jelly X X X X Diabetic Supplies X Diapers/Incontinent Briefs/Chux X Driscoll Children’s Health Plan Form Number: DCHP7 X X . X X X X Dressing Supplies/Decubitus Dressing Supplies/Peripheral IV Therapy Dressing Supplies/Other Dust Mask Ear Molds X X Cranial Head Mold Dental Devices Diaphragm Diastix Diet, Special Distilled Water Dressing Supplies/Central Line EXCLUDED X X X X X X X X COMMENTS/MEMBER CONTRACT PROVISIONS Exception: If given by and billed through the clinic or home care agency it is covered as an incidental supply. Over-the-counter supply. Over-the-counter supply not covered, unless RX given at time of dispensing. Covered only when received with IV therapy or central line kits/supplies. A self-injection kit used by patients highly allergic to bee stings. Dispensed as part of office visit. Coverage limited to children age 4 or over only when prescribed by a doctor and used to give care for a covered diagnosis as outlined in a treatment care plan Over-the-counter supply. For covered DME items For covered DME when replacement is necessary due to normal use. See IV therapy supplies. For monitoring of diabetes. See Ostomy Supplies. Over-the-counter supply. Contraceptives are not covered under the plan. Coverage limited to dental devices used for the treatment of craniofacial anomalies, requiring surgical intervention. Monitor calibrating solution, insulin syringes, needles, lancets, lancet device, and glucose strips. Coverage limited to children age 4 or over only when prescribed by a doctor and used to give care for a covered diagnosis as outlined in a treatment care plan Contraceptives are not covered under the plan. For monitoring diabetes. Syringes, needles, Tegaderm, alcohol swabs, Betadine swabs or ointment, tape. Many times these items are dispensed in a kit when includes all necessary items for one dressing site change. Able to get coverage only if receiving covered home care for wound care. Able to get coverage only if receiving home IV therapy. X X X Custom made, post inner or middle ear surgery CHIP Member Handbook Page 46 SUPPLIES COVERED Electrodes Enema Supplies Enteral Nutrition Supplies X Eye Patches Formula X X EXCLUDED X X Gloves X Hydrogen Peroxide Hygiene Items Incontinent Pads X X X Insulin Pump (External) Supplies X Irrigation Sets, Wound Care Irrigation Sets, Urinary IV Therapy Supplies X K-Y Jelly Lancet Device Driscoll Children’s Health Plan Form Number: DCHP7 X X X X COMMENTS/MEMBER CONTRACT PROVISIONS Able to get coverage when used with a covered DME. Over-the-counter supply. Necessary supplies (e.g., bags, tubing, connectors, catheters, etc.) are eligible for coverage. Enteral nutrition products are not covered except for those prescribed for hereditary metabolic disorders, a non-function or disease of the structures that normally permit food to reach the small bowel, or malabsorption due to disease Covered for patients with amblyopia. Exception: Able to get coverage only for chronic hereditary metabolic disorders a non-function or disease of the structures that normally permit food to reach the small bowel; or malabsorption due to disease (expected to last longer than 60 days when prescribed by the doctor and authorized by plan.) Doctor documentation to justify prescription of formula must include: •Identification of a metabolic disorder , dysphagia that results in a medical need for a liquid diet, presence of a gastrostomy, or disease resulting in malabsorption that requires a medically necessary nutritional product Does not include formula: •For members who could be sustained on an ageappropriate diet. •Traditionally used for infant feeding •In pudding form (except for people with documented oropharyngeal motor dysfunction who receive greater than 50 percent of their daily caloric intake from this product) •For the primary diagnosis of failure to thrive, failure to gain weight, or lack of growth or for infants less than twelve months of age unless medical necessity is documented and other criteria, listed above, are met. Food thickeners, baby food, or other regular grocery products that can be blenderized and used with an enteral system that are not medically necessary, are not covered, regardless of whether these regular food products are taken orally or parenterally. Exception: Central line dressings or wound care given by home care agency. Over-the-counter supply. Coverage limited to children age 4 or over only when prescribed by a doctor and used to give care for a covered diagnosis as outlined in a treatment care plan Supplies (e.g., infusion sets, syringe reservoir and dressing, etc.) are eligible for coverage if the pump is a covered item. Able to get coverage when used during covered home care for wound care. Able to get coverage for person with an indwelling urinary catheter. Tubing, filter, cassettes, IV pole, alcohol swabs, needles, syringes and any other related supplies necessary for home IV therapy. Over-the-counter supply. Limited to one device only. CHIP Member Handbook Page 47 SUPPLIES COVERED Lancets Med Ejector Needles and Syringes/Diabetic Needles and Syringes/IV and Central Line Needles and Syringes/Other Normal Saline Novopen Ostomy Supplies X X COMMENTS/MEMBER CONTRACT PROVISIONS Able to get coverage for person with diabetes. See Diabetic Supplies See IV Therapy and Dressing Supplies/Central Line. X Able to get coverage if a covered IM or SubQ medication is being administered at home. See Saline, Normal X X Parenteral Nutrition/Supplies X Saline, Normal X Stump Sleeve Stump Socks Suction Catheters Syringes Tape X X X Tracheostomy Supplies Under Pads Unna Boot X Items eligible for coverage include: belt, pouch, bags, wafer, face plate, insert, barrier, filter, gasket, plug, irrigation kit/sleeve, tape, skin prep, adhesives, drain sets, adhesive remover, and pouch deodorant. Items not eligible for coverage include: scissors, room deodorants, cleaners, rubber gloves, gauze, pouch covers, soaps, and lotions. Necessary supplies (e.g., tubing, filters, connectors, etc.) are eligible for coverage when the Health Plan has authorized the parenteral nutrition. Eligible for coverage: a) when used to dilute medications for nebulizer treatments; b) as part of covered home care for wound care; c) for indwelling urinary catheter irrigation. X Urinary, External Catheter & Supplies X Urinary, Indwelling Catheter & Supplies Urinary, Intermittent X Urine Test Kit Urostomy supplies X Driscoll Children’s Health Plan Form Number: DCHP7 EXCLUDED X See Needles/Syringes. See Dressing Supplies, Ostomy Supplies, IV Therapy Supplies. Cannulas, Tubes, Ties, Holders, Cleaning Kits, etc. are eligible for coverage. See Diapers/Incontinent Briefs/Chux. Eligible for coverage when part of wound care in the home setting. Incidental charge when applied during office visit. Exception: Covered when used by incontinent male where injury to the urethra prohibits use of an indwelling catheter ordered by the Primary Care Provider and approved by the plan Cover catheter, drainage bag with tubing, insertion tray, irrigation set and normal saline if needed. Cover supplies needed for intermittent or straight catherization. When decided to be medically necessary. See Ostomy Supplies. CHIP Member Handbook NOTES NOTES
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