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IMPORTANT information for you
We are here to help! Call 1-800-964-2247 | cookchp.org
CHIP Perinatal Member Handbook
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CHIP Perinatal Member HandbookIMPORTANT information for you
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INTRODUCTION
Welcome to the Cook Children’s Health Plan (CCHP) CHIP Perinatal family. We know that picking a health plan that delivers quality care and services is important to you. Our commitment is to you and your family. We look forward to serving you. We have a long history of caring for North Texans in Denton, Hood, Johnson, Parker, Tarrant, and Wise counties. Working closely with a wide range of providers, we want to be sure that you get the best care when you need it.
To make sure that you get the most out of your CHIP Perinatal benefits, you need to know how your health plan works. Keep this handbook close by. It will tell you how CHIP Perinatal medical plan works and what services are covered. This will help you get the best care possible.
We have staff members who speak English and Spanish. We can also help you if you need help understanding or reading this handbook because you: • Need this handbook in larger print, Braille, or audio • Speak a language other than English or Spanish
You can call our Member Services Department to get help at 1-800-964-2247. If you are hearing impaired and need to contact Cook Children’s Health Plan, please call 682-885-2138 or toll-free at 1-844-644-4137.
The Member Services Representatives can answer your questions and help you: • Change your address or phone number; • Understand what services are covered; • Listen to your complaints and concerns; or • Schedule an interpreter.
Emergency CareConditions that need immediate attention and without it you think will cause serious harm or jeopardy to your health are considered emergency care. If you have a life threatening condition or behavioral health crisis, go to the nearest emergency department or call 9-1-1. You do not need a referral for emergency care.
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IMPORTANT PHONE NUMBERS
YOUR CHIP ID NUMBER ––––––––––––––––––––––––––––––––––––––––––––
YOUR PRIMARY CARE PROVIDER NAME ––––––––––––––––––––––––––––––––––––––––––––
YOUR PRIMARY CARE PROVIDER ADDRESS –––––––––––––––––––––––––––––––––––––––––––– YOUR PRIMARY CARE PROVIDER PHONE NUMBER ––––––––––––––––––––––––––––––––––––––––––––
Cook Children’s Health Plan: 8 a.m. to 5 p.m. Monday-Friday except for State holidays
(toll-free) 1-800-964-2247 (local) 682-885-2247TTY/TDD for hearing impaired Members (toll-free) 1-844-644-4137 (local) 682-885-2138
Our representatives speak English and Spanish to help you. We have an interpreter service that can help with other languages.
For Emergencies and/or behavioral health crisis after hours/weekends, please call 9-1-1 or go to the nearest emergency department. If your call is not an emergency, you can leave a message and your call will be returned the next business day
Pharmacy Assistance: 8 a.m. to 5 p.m. Monday-Friday except for State holidays
If you have questions about your pharmacy benefits call Cook Children’s Health Plan at:(toll-free) 1-800-964-2247 (local) 682-885-2247
Care Management and Baby Steps program: 8 a.m. to 5 p.m. Monday-Friday except for State holidays
(toll-free) 1-800-964-2247 (local) 682-885-2247TTY/TDD for hearing impaired Members (toll-free) 1-844-644-4137 (local) 682-885-2138
We have Case Managers ready to help you with your healthcare needs.
Nurse Advice Line 24/7: 1-866-971-2665
Cook Children’s Health Plan has a nurse advice line that is available 24 hours if you need to speak to a nurse. The nurses that take your call know about the CHIP Perinatal Program, covered services and have access to the Cook Children’s Health Plan provider network. Nurses are available in English and Spanish.TDD/TTY: Toll-Free 1-844-514-3772
CHIP PERINATAL DENTAL
Cook Children’s Health Plan offers $250 of basic dental services to pregnant women on CHIP Perinatal Liberty Dental: 1-888-902-0349TTY/TDD: 1-800-735-2929
Texas CHIP Program Helpline: 2-1-1 option 2 or toll free at: 1-877-541-7905
For any questions about the CHIP Program.
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TABLE OF CONTENTS
Introduction 1
Important Phone Numbers 2
Table of Contents 3
Your Cook Children’s Health Plan ID Card 4
Accessing Care – Appointments 5
Accessing Care – Primary Care Providers 5
Accessing Care – Specialty Care 6
Accessing Care – Women’s Health 7
Accessing Care – Out of the Area 7
Accessing Care – CHIP Perinatal Moms 8
Changing Health Plans (CHIP Perinatal) 9
Interpreter Services 10
Care Defined 10
Benefits and Services 12
Prescriptions 31
CHIP Special Services 32
Extra Benefits 32
Health Education and Other Resources 33
Costs/Money 34
Complaints and Appeals 35
Independent Review Organization 36
Member Rights and Responsibilities 37
Fraud and Abuse 38
Subrogation 38
Privacy Notice 39
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YOUR COOK CHILDREN’S HEALTH PLAN ID CARD
When and where do I use my Cook Children’s Health Plan ID card? Everyone who becomes a member of our health plan gets an ID card. This ID card has important phone numbers that you may need. The ID card gives the doctor and office staff important information. If you get an ID card that has wrong information listed, call Member Services. They will help you get a new ID card.
How to use your/your child’s ID card Take your Cook Children’s Health Plan ID card with you at all times and show it to the provider, clinic or hospital to get the care you need. They will need the details on the card to know that you are a Cook Children’s Health Plan member. Do not let anyone else use your ID card. You will not get a new ID card every month. We will send you a new ID card if you request one.
How to read your/your child’s Cook Children’s Health Plan ID card Your ID card will say CHIP Perinatal and identify you as a Cook Children’s Health Plan member. Your ID card is in English and Spanish, and has this information on it: • Member’s name. • Member’s ID number. • Member’s category. • Member Services phone number. • Toll-free 24/7 Nurse Advice Line
How to replace a lost or stolen ID card? If you lose your ID card or if it is stolen, call Member Services. They will send you a new ID card.
Here is what a Cook Children’s Health Plan ID card looks like:
ID Card Sample
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Send claims for: Send claims for:
For member pharmacy information: 1-800-964-2247Para Información sobre Farmacias para Miembros
In case of emergency, call 911 or go to the closest emergency room.
For pharmacies and prescribers only: 1-877-908-6023
24-hour nurse advice line: 1-866-971-2665Línea de Consejería de Enfermeras disponibles 24 horas al día
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Member: Plan eff. date:
ID no:
Member’s category:
Category A: 0% to 186% Federal Poverty Level (FPL)
Category B: 186% to 201% Federal Poverty Level (FPL)
In case of emergency, call 911 or go to the closest emergency room. 24-hour nurse advice line: 1-866-971-2665Member Services (8 a.m. to 5 p.m.) or to leave a message(24 hours/7 days a week): 1-800-964-2247Provider Services (8 a.m. to 5 p.m.) or to leave a message(24 hours/7 days a week): 1-888-243-3312
Send claims for: Hospital Facility Billing for members that are 0% to 186% of FPL (Category A) to:TMHPP.O. Box 200555Austin, TX 78720-0555
Note: This card does not guarantee coverage. Call 1-800-964-2247 to confirm member eligibility.
NAVITUSBIN: 610602PCN: MCDRX Group: CCH
Send claims for: Hospital Facility Billing for members that are above 186% to 201% of FPL or Professional/other services for all members regardless of FPL percentage to:Cook Children’s Health PlanP.O. Box 961295Fort Worth, TX 76161
Member Identification CardTDI
For pharmacies and prescribers only:1-877-908-6023
For member pharmacy information: 1-800-964-2247
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ACCESSING CARE – APPOINTMENTS
ACCESSING CARE – PROVIDERS
What do I need to bring to a perinatal provider’s appointment?
You should take this with you when you go to your doctor’s appointment: • Cook Children’s Health Plan member ID card. • List of all medications you are taking. • Paper to take notes on information you get from the doctor.
Can a clinic be a Perinatal Provider? (Rural Health Clinic/Federally Qualified Health Center) Yes.
How do I get after hours care? Your Primary Care Provider or another doctor is ready to help by phone 24 hours a day, 7 days a week. You can also call our 24/7 Nurse Advice Line.
References to “you,” “my,” or “I” apply if you are a CHIP member. References to “my child” apply if your child is a CHIP
member or a CHIP Perinate member.
What is a physician incentive plan? CCHP cannot make payments under a physician incentive plan if the payments are designed to induce providers to reduce or limit Medically Necessary Covered services to Members. Right now, Cook Children’s Health Plan does not have a physician incentive plan.
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ACCESSING CARE – SPECIALTY CARE
What if I need to see a special doctor (specialist)? Your Primary Care Provider is the only doctor you need for most health care services. If you have a special health problem, they might ask you to see another doctor or have special tests done. This is called a referral.
What is a referral? Your primary care provider or attending specialist may request or arrange for you to see a new specialist. This is called a “referral”. If you have a specialist who already takes care of you, then a referral is not needed. If your specialist is contracted with Cook Children’s Health Plan, then no authorization is needed for specialist visits. An authorization is needed for out of network specialists to help with claims payment. Your Case Manager can also help you with access to specialists.
How soon can I expect to be seen by a specialist? You can expect to see a specialist within: • 30 days for routine care. • 24 hours for urgent care.
Please be on time for your visit. If you need to cancel a visit, please call the office as soon as you can. Remember, the participating specialist is only allowed to give services if: • Your Primary Care Provider asked for it on the referral request. • It is a CHIP-covered benefit.
What services do not need a referral? You do not need a referral for: • Emergency • Obstetrics and gynecology (OB/GYN) • Behavioral health • Routine eye care
How can I ask for a second opinion? You have the right to a second opinion from a Cook Children’s Health Plan (CCHP) provider if you are not satisfied with the plan of care offered by the specialist. Your primary care doctor 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 CCHP provider, that visit will have to be approved. If you need help getting a second opinion, call Member Services.
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ACCESSING CARE – WOMEN’S HEALTH
ACCESSING CARE – OUT OF THE AREA
What if I need/my daughter needs OB/GYN care? 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.
Cook 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.
You may get care for female health care needs from an OB/GYN or your Primary Care Provider. If you have any questions about this benefit or need help in choosing an OB/GYN, please call Member Services at 1-800-964-2247.
Do I have the right to choose an OB/GYN? Yes.
How do I choose a Perinatal Provider? Will I need a referral? You can pick any OB/GYN listed in our Provider Directory. If you do not see your OB/GYN in the directory, call Member Services. He or she may have recently joined our network. You do not need a referral to see an OB/GYN.
If I don’t choose an OB/GYN, do I have direct access? Yes.
What if I get sick when I am out of town or traveling? If you need medical care when traveling, call us toll-free at 1-800-964-2247 and we will help you find a doctor. If you need emergency services while traveling, go to a nearby hospital, then call us toll-free at 1-800-964-2247.
What if I am out of the state? If you/your child gets sick when you/your child are out of the state and you/your child have an emergency care need, go to an emergency room. If you/your child has an urgent care need, you should call your/your child’s Primary Care Provider’s office. Ask them to give you direction on getting care. You can also call our Nurse Advice Line and let them know about your problem.
What if I am out of the country? Medical services performed out of the country are not covered by CHIP.
How soon can I be seen after contacting a perinatal provider for an appointment?You can see your OB/GYN within: • Four weeks for well-woman checkups. • Two weeks for prenatal care. • Sooner if medically necessary.
Can I stay with a perinatal provider if they are not with Cook Children’s Health Plan? If you/your daughter are past the 24th week of pregnancy when you/she joins, you/she will be able to stay under the care of your/her current OB/GYN. If you/she chooses, you/she can pick an OB/GYN who is in our network as long as the doctor agrees to treat you/her. We can help you change doctors. Please call our Baby Steps program at 1-800-862-2247.
What if I am pregnant/what if my daughter is preg-nant? Who do I need to call? Call Care Management as soon as you know you or your daughter is pregnant. They will help you get the medical care that is needed during pregnancy. You/she needs to apply right away for Medicaid services.
What other services/activities/education does Cook Children’s Health Plan offer pregnant women? We offer pregnant women our “Baby Steps” program. Our case managers help pregnant members get the services that they need. We mail a prenatal packet to all pregnant members. It has information about how to stay healthy, a list of childbirth classes, and much more.
What do I have to do if I move? As soon as you have your new address, give it to HHSC by calling 2-1-1 or updating your account on YourTexasBenefits.com and call the Cook Children’s Health Plan (CCHP) Member Services department at 1-800-964-2247. Before you get CHIP services in your new area, you must call CCHP, unless you need emergency services. You will continue to get care through CCHP until HHSC changes your address.
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ACCESSING CARE – CHIP PERINATAL MOMS
How do I choose a perinatal provider? Will I need a referral? If you need help choosing a perinatal provider, please call Member Services. You do not need a referral.
What is routine medical care? In most cases when you need medical care, you call your CHIP Perinatal Provider to make an appointment. These visits will cover most minor illnesses and injuries that directly relate to your pregnancy, as well as regular prenatal checkups. This type of care is known as routine care.
How soon can I be seen after contacting a Cook Children’s Health Plan perinatal provider for an appointment? You should be able to see your Perinatal Provider within 2 weeks for routine care.
How do I get after-hours care? Your doctor will have someone to help you when the office is closed. Only call after hours if you need urgent care. If it is an emergency, go to the nearest emergency room or call 9-1-1. You can also call our Nurse Advice Line and let them know about your problem.
What if I choose to go to another doctor who is not my Cook Children’s Health Plan CHIP Perinatal Provider? If you go to a doctor who is not your CHIP Perinatal Provider, you might have to pay the bill.
Can I stay with a CHIP Perinatal Provider if they are not with Cook Children’s Health Plan? You can see a doctor who is not in our network: • If you are/your daughter is pregnant when you/your daughter start your coverage with us. • If you are in the last three months of your pregnancy. • If you have a health problem that would make changing to a new doctor unsafe.
What services are not covered? Are there any limits to any covered services? Please turn to page 12 of this handbook for a full list of covered, non-covered services, and services that have limits.
What if I need services that are not covered by CHIP Perinatal? If you need services that are not covered by CHIP Perinatal, we will try to help you find services that are not covered. Call Baby Steps at 1-800-862-2247.
Can I choose my baby’s Primary Care Provider before the baby is born? Who do I call? What information do they need? Yes. Call Member Services. We will help you find a Primary Care Provider for your baby. We will need your name and your member ID number.
When does CHIP Perinatal coverage end? You will be covered until you deliver your baby. Once you have your baby, you will no longer be covered.
Will the state send me anything when my CHIP Perinatal coverage ends? HHSC will send you a letter telling you that you no longer have benefits.
How does renewal work for CHIP Perinatal? Your CHIP Perinatal coverage is for twelve months. This starts when you enroll the unborn baby when you are pregnant, and continues for the baby only, after the baby is born for a total of twelve months. In the tenth month of coverage you will receive a CHIP renewal form. You must fill it out and send it to the state. The state will decide if your child is eligible for Medicaid or CHIP.
Concurrent enrollment of family members in CHIP and CHIP Perinatal, and Medicaid Coverage for certain newborns Children enrolled in CHIP will remain in the CHIP Program, but will be moved to a medical health plan that is providing CHIP Perinatal coverage. Copayments, cost sharing and enrollment fees will still apply for those children that are enrolled in the CHIP Program.
• If an unborn child enrolled in CHIP Perinatal lives in a family with an income at or below 186% of the Federal Poverty Level, they will be moved to Medicaid for 12 months of continuous Medicaid coverage, beginning on the date of birth.
• If an unborn child enrolled in CHIP Perinatal lives in a family with an income above 186% to 201% of the Federal Poverty Level, they will continue to receive coverage through the CHIP program as a “CHIP Perinate Newborn” beginning on the date of birth.
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CHANGING HEALTH PLANS (CHIP PERINATAL)
Attention: • If you meet certain income requirements, your baby will be moved to Medicaid and get 12 months of continuous Medicaid coverage from date of birth. • Your baby will continue to receive services through the CHIP program if you meet the CHIP Perinatal requirements. Your baby will get 12 months of continuous CHIP Perinatal coverage through his or her health plan, beginning with the month of enrollment as an unborn child.
What if I want to change health plans? • Once you pick a health plan for your unborn child, the child must stay in this health plan until the child’s CHIP Perinatal coverage ends. The 12-month CHIP Perinatal coverage begins when your unborn child is enrolled in CHIP Perinatal and continues after your child is born.
• If you do not pick a plan within 15 days of getting the enrollment packet, HHSC will pick a health plan for your unborn child and send you information about that health plan.
• If HHSC picks a health plan for your unborn child, you will have 90 days from your effective date of coverage to pick another health plan if you are not happy with the plan HHSC chooses.
• The children must remain with the same health plan until the end of the CHIP Perinatal member’s enrollment period, or the end of the other children’s enrollment period, whichever happens last. At that point, you can pick a different health plan for the children.
You can ask to change health plans: • For any reason within 90 days of enrollment in CHIP Perinatal. • If you move into a different service delivery area; and • For cause at any time.
Who do I call? For more information, call toll-free at 1-800-964-2777.
How many times can I change health plans? When will my change become effective? You can change health plans once each year. If you call to change your health plan on or before the 15th of the month, the change will take place on the first day of the next month. If you call after the 15th of the month, the change will take place the first day of the second month after that. For example: • If you call between April 1 and April 15, your change will take place on May 1. • If you call between April 16 and April 30, your change will take place on June.
Can Cook Children’s Health Plan ask that I leave their plan for non-compliance, etc.? Yes. We might ask that a member be taken out of the plan for “good cause.” “Good cause” could be, but is not limited to: • Threats or physical acts leading to harming of staff or providers. • You lend your ID card to another person so that they can obtain services. • You make false statements. • You are dishonest in the use of services or facilities. • You continue to disregard your Primary Care Provider’s advice. • You keep going to the emergency room when you do not have an emergency. • Refusal to go by policies and procedures, such as: » You miss visits over and over again. » You are rude or act out against a provider or a staff person. » You keep using a doctor that is not a Cook Children’s Health Plan provider.
We will not ask you to leave the program without trying to work with you. If you have any questions about this process call Member Services. The Texas Health and Human Services Commission will decide if a member can be told to leave the program.
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INTERPRETER SERVICES
CARE DEFINED
Can someone interpret for me when I talk to my perinatal provider? Who do I call for an interpreter? If the provider does not have someone to interpret for you, call Member Services. We will help find an interpreter.
How far ahead of time do I need to call? Call us as soon as you make a doctor’s appointment. We need at least a two-day notice.
What is routine medical care? How soon can I expect to be seen/how soon can I expect my child to be seen? If you need a physical checkup, then the visit is routine. Your doctor should see you within 14 days. It is best to see your doctor before you get sick so that you can build your relationship with him or her. It is much easier to call your doctor with your medical problems if they know who you are.
What is urgent medical care and how soon can I ex-pect to be seen? If you need medical care for things such as minor cuts, burns, infections, nausea or vomiting, then your visit is urgent. Call your Primary Care Provider. He/she can usually see you within one day. Your Primary Care Provider should see you within 24 hours after you ask for urgent care. Call Member Services if you need help finding urgent care.
How soon can I expect to be seen? The emergency room staff will decide based on your condition.
How do I get medical care after my Primary Care Pro-vider’s office is closed? Your Primary Care Provider (PCP) or another doctor is available by phone 24 hours a day, 7 days a week. If you get sick at night or on the weekend you can call your PCP’s office number for help. The office will have an answering service or message on how to contact the PCP. The PCP should return your call within 30 minutes.
FOR CHIP MEMBERS AND CHIP PERINATAL MEMBERS Covered services for CHIP Members, CHIP Perinate Newborn Members and CHIP Perinatal members must meet the CHIP definition of “Medically Necessary.” A CHIP Perinate Member is an unborn child.
How can I get a face-to-face interpreter in the provider’s office? When you call to set up your visit, tell the person you are talking to you need an interpreter with you during the visit. If they cannot help, call Member Services.
What is 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 disability, cause illness or infirmity of a member, or endanger life. b. Provided at appropriate facilities and at the appropriate levels of care for the treatment of a member’s health conditions. c. Consistent with health care practice guidelines and standards that are endorsed by professionally recognized health care organizations or governmental agencies. d. Consistent with the 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 investigative: and g. Not primarily for the convenience of the member or provider. 2. Behavioral Health Services that: a. Are reasonable and necessary for the diagnosis or treatment of a mental health or chemical dependency disorder, or to improve, maintain, or prevent deterioration of functioning resulting from such a disorder. b. Are in accordance with professionally accepted clinical guidelines and standards of practice in behavioral health care. c. Are furnished in the most appropriate and least restrictive setting in which services can be safely provided.
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CARE DEFINED
d. Are the most appropriate level or supply of service that can safely be provided? e. Could not be omitted without adversely affecting the member’s mental and/or physical health or the quality of care rendered. f. Are not experimental or investigative; and g. Are not primarily for the convenience of the member or provider.
What is an Emergency and an Emergency Medical Condition? A CHIP Perinate Member is defined as an unborn child. Emergency care is a covered service if it directly relates to the delivery of the unborn child until birth. Emergency care is provided for the following Emergency Medical Conditions:
• Medical screening examination to determine emergency when directly related to the delivery of the covered unborn child. • Stabilization services related to the labor with delivery of the covered unborn child. • Emergency ground, air and water transportation for labor and threatened labor is a covered benefit. • Emergency ground, air and water transportation for an emergency associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero) is a covered benefit.
Benefit limits: Post-delivery services or complications resulting in the need for emergency services for the mother of the CHIP Perinate are not a covered benefit.
What is Emergency Services or Emergency Care? Emergency Services or Emergency Care are covered inpatient and outpatient services furnished by a provider that is qualified to furnish such services and that are needed to evaluate or stabilize an Emergency Medical Condition, including post-stabilization care services related to labor and delivery of the unborn child.
What is post-stabilization? Post-stabilization care services are services covered by CHIP that keep the Member’s condition stable following emergency medical care.
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BENEFITS & SERVICESWhat are my unborn child’s CHIP Perinatal benefits? How do I get these services?CHIP Perinatal members can get most services by calling their CHIP Perinate Provider.
Services include but are not limited to the following:• Hospital-provided physician 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 that are not provided 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 DSHS-designated Level III perinatal centers or hospitals meeting equivalent levels of care. • In-network or out-of-network 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 following an uncomplicated delivery by cesarean section. • Hospital, physician and related medical services, such as anesthesia, associated with dental care. • Inpatient services associated with (a) miscarriage or (b) a non-viable 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. » Histological examination of tissue samples. • Surgical implants. • Other artificial aids including surgical implants.• Inpatient services for a mastectomy and breast reconstruction include: » All stages of reconstruction on the affected breast. » External breast prosthesis for the breast(s) on which medically necessary mastectomy procedure(s) have been performed. » Surgery and reconstruction on the other breast to produce symmetrical appearance.
CHIP PERINATAL SCHEDULE OF BENEFITS
INPATIENT GENERAL ACUTE AND INPATIENT REHABILITATION HOSPITAL SERVICES
Schedules of Benefits
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BENEFITS & SERVICES
» Treatment of physical complications from the mastectomy and treatment of lymphedemas. • Implantable devices are covered under Inpatient and Outpatient services and do not count toward the DME 12-month period limit. • Pre-surgical or post-surgical 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.
Limitations
• May require authorization for non-emergency care and care following stabilization of an emergency condition. • Requires authorization for in-network or out-of-network facility and physician 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 cesarean section.
SKILLED NURSING FACILITIES (INCLUDES REHABILITATION HOSPITALS)
Benefit
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.
Limitations
• Requires authorization and physician prescription. • 60 days per 12-month period limit.
OUTPATIENT HOSPITAL, COMPREHENSIVE OUTPATIENT REHABILITATION HOSPITAL, CLINIC (INCLUDING HEALTH CENTER) AND AMBULATORY HEALTH CARE CENTER
Benefit
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 biologicals. • Casts, splints, dressings. • Preventive health services. • Physical, occupational and speech therapy.
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BENEFITS & SERVICES
• Renal dialysis. • Respiratory services. • Radiation and chemotherapy. • Blood or blood products that are not provided free-of-charge to the patient and the administration of these products. • Outpatient services associated with (a) miscarriage or (b) a non-viable 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. • Facility and related medical services, such as anesthesia, associated with dental care, when provided in a licensed ambulatory surgical facility. • 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. » External breast prosthesis for the breast(s) on which medically necessary mastectomy procedure(s) have been performed. » Surgery and reconstruction on the other breast to produce symmetrical appearance. » 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. • Pre-surgical or post-surgical 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. » Severe traumatic skeletal and/or congenital craniofacial deviations; or » Severe facial asymmetry secondary to skeletal defects, congenital syndrome conditions and/or tumor growth or its treatment.
Limitations
• May require prior authorization and physician prescription.
PHYSICIAN/PHYSICIAN EXTENDER PROFESSIONAL SERVICES
Benefit
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). • Physician 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 physician’s office. • Allergy testing, serum, and injections.
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BENEFITS & SERVICES
• Professional component (in/out-patient) of surgical services including: » Surgeons and assistant surgeons for surgical procedures including appropriate follow-up care. » Administration of anesthesia by physician (other than surgeon) or CRNA. » Second surgical opinions. » Same-day surgery performed in a hospital without an overnight stay. • Invasive diagnostic procedures such as endoscopic examinations. • Hospital-based physician services (including physician performed technical and interpretive components). • Physician and professional services for a mastectomy and breast reconstruction include: » All stages of reconstruction on the affected breast. » External breast prosthesis for the breast(s) on which medically necessary mastectomy procedure(s) have been performed. » Surgery and reconstruction on the other breast to produce symmetrical appearance. » Treatment of physical complications from the mastectomy and treatment of lymphedemas. • In-network and out-of-network Physician 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 cesarean section. • Physician services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero). Physician services associated with miscarriage or non-viable pregnancy include, but are not limited to: » Dilation and curettage (D and C) procedures. » Appropriate provider-administered medications. » Ultrasounds. » Histological examination of tissue samples.
• Physician services medically necessary to support a dentist providing dental services to a CHIP member such as general anesthesia or intravenous (IV) sedation. • Pre-surgical or post-surgical 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. » Severe traumatic skeletal and/or congenital craniofacial deviations. » Severe facial asymmetry secondary to skeletal defects, congenital syndrome conditions and/or tumor growth or its treatment.
Limitations
• May require authorization for specialty services.
PRENATAL CARE AND PRE-PREGNANCY FAMILY SERVICES AND SUPPLIES
Benefit
Covered, unlimited prenatal care and medically necessary care related to diseases, illness, or abnormalities related to the reproductive system.
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BENEFITS & SERVICES
Limitations
• Limitations and exclusions to these services are described under inpatient, outpatient and physician services. • Primary and preventive health benefits do not include pre-pregnancy family reproductive services and supplies, or prescription medications prescribed only for the purpose of primary and preventive reproductive health care.
BIRTHING CENTER SERVICES
Benefit
Covers birthing services provided by a licensed birthing center.
Limitations
• Limited to facility services (e.g., labor and delivery). • Applies only to CHIP members.
SERVICES RENDERED BY A CERTIFIED NURSE MIDWIFE OR PHYSICIAN IN A LICENSED BIRTHING CENTER
Benefit
CHIP Members: covers prenatal services and birthing services rendered in a licensed birthing center. CHIP Perinate Newborn Members: Covers services rendered to a newborn immediately following delivery.
Limitations
• No limitations.
DURABLE MEDICAL EQUIPMENT (DME), PROSTHETIC DEVICES AND DISPOSABLE MEDICAL SUPPLIES
Benefit
$20,000 in a 12-month period limit for DME, prosthetic, devices and disposable medical supplies (diabetic supplies and equipment are not counted against this cap). Services include DME (equipment which 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 assist the treatment of a medical condition, including:• 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. • Hearing aids. • Diagnosis-specific disposable medical supplies, including diagnosis-specific prescribed specialty formula and dietary supplements.
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BENEFITS & SERVICES
Limitations
• May require prior authorization and physician prescription. • $20,000 in a 12-month period limit for durable medical equipment (DME), prosthetics, devices and disposable medical supplies (implantable devices, diabetic supplies and equipment are not counted against this cap).
HOME AND COMMUNITY HEALTH SERVICES
Benefit
Services that are provided in the home and community, including but not limited to: • Home infusion. • Respiratory therapy. • Visits for private duty nursing (RN, LVN). • Skilled nursing visits as defined for home health purposes (may include RN or LVN). • 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.
Limitations
• Requires prior authorization and physician prescription. • 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 are not intended to provide 24-hour skilled nursing services. • Services are not intended to replace 24-hour inpatient or skilled nursing facility services.
INPATIENT MENTAL HEALTH SERVICES
Benefit
Mental health services, including for serious mental illness, furnished in a free-standing psychiatric hospital, psychiatric units of general acute care hospitals and state-operated facilities including but not limited to: • Neuropsychological and psychological testing. • 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 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.
Limitations
• May require prior authorization for non-emergency services. • Does not require primary care provider referral.
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BENEFITS & SERVICES
OUTPATIENT MENTAL HEALTH SERVICES
Benefit
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 (psycho-educational skill development).
Limitations
• May require 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 Provider- Community Services (QMHP-CS), is defined by the Texas Department of State Health Services (DSHS) in Title 25 T.A.C., Part I, Chapter 412, Subchapter G, Division I, §§412.303 (48), QMHP-CSs shall be providers working through a DSHS-contacted Local Mental Health Authority or a separate DSHS-contracted entity. QMHP-CSs shall be supervised by a licensed mental health professional or physician and provide services in accordance with DSHS standards. Those services include individual and groups skills training (which can be components of interventions such as day treatment and in-home services), patient and family education, and crisis services.
INPATIENT SUBSTANCE ABUSE TREATMENT SERVICES
Benefit
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.
Limitations
• May require prior authorization for non-emergency services. • Does not require primary care provider referral.
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OUTPATIENT SUBSTANCE ABUSE TREATMENT SERVICES
Benefit
Services include, but are not limited to, the following: • Prevention and intervention services that are provided by physician and non-physician providers, such as screening, assessment and referral for chemical dependency disorders. • Partial hospitalization. • Intensive outpatient services. • Intensive outpatient services is defined as an organized non-residential service providing structured group and individual therapy, educational services, and life skills training which consists of at least 10 hours per week for 4 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.
Limitations
• May require prior authorization. • Does not require primary care provider referral.
REHABILITATION SERVICES
Benefit
Services include, but are not limited to, the following: • Habilitation (the process of supplying a child with the means to reach age-appropriate developmental milestones through therapy or treatment) and rehabilitation services include, but are not limited to the following: » Physical, occupational and speech therapy. » Developmental assessment.
Limitations
May require prior authorization and physician prescription.
HOSPICE CARE SERVICES
Benefit
Services include, but are not limited to, the following: • Palliative care, including medical and support services, for those children who have 6 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.
BENEFITS & SERVICES
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BENEFITS & SERVICES
Limitations
• Requires authorization and physician prescription. • 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 any time.
EMERGENCY SERVICES, INCLUDING EMERGENCY HOSPITALS, PHYSICIAN AND AMBULANCE SERVICES
Benefit
CCHP cannot require authorization as a condition for payment for Emergency Conditions or labor and delivery. Covered services include, but are not limited to the following: • Emergency services based on prudent lay-person definition of emergency health condition. • Hospital emergency department room and ancillary services and physician services 24 hours a day, seven (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 and water transportation. • Emergency dental services, limited to fractured or dislocated jaw, traumatic damage to teeth, and removal of cysts and treatment related to oral abscess of tooth or gum origin.
Limitations
• May require authorization for post-stabilization services.
TRANSPLANTS
Benefit
Services include, but are not limited to, the following: • Using up-to-date FDA guidelines, all non-experimental human organ and tissue transplants and all forms of non-experimental corneal, bone marrow and peripheral stem cell transplants, including donor medical expenses.
Limitations
• Requires authorization.
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BENEFITS & SERVICES
VISION SERVICES
Benefit
Covered services include: • One (1) examination of the eyes to determine the need for and prescription for corrective lenses per 12-month period, without authorization. • One pair of non-prosthetic eyewear per 12-month period.
Limitations
• The health plan may reasonably limit the cost of the frames/lenses. • Requires authorization for protective and polycarbonate lenses when medically necessary as part of a treatment plan for covered diseases of the eye.
CHIROPRACTIC SERVICES
Benefit
Covered services do not require physician prescription and are limited to spinal subluxation.
Limitations
• May require authorization for twelve visits per 12-month period limit (regardless of number of services or modalities provided in one visit). • Requires authorization for additional visits.
CASE MANAGEMENT AND CARE COORDINATION SERVICES
Benefit
These services include outreach informing, case management, care coordination and community referral.
Limitations
• No limitations.
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BENEFITS & SERVICES
DRUG BENEFITS
Benefit
Services include, but are not limited to, the following: • Outpatient drugs and biologicals, including pharmacy-dispensed and provider-administered outpatient drugs and biologicals. • Drugs and biologicals provided in an inpatient setting.
Limitations
• No limitations.
EXCLUSIONS
What benefits are not covered?
The following benefits are not covered under the CHIP program: • 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). • 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 articles which 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. • Treatment or evaluations required by third parties including, but not limited to, those for schools, employment, flight clearance, camps, insurance or court. • 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. • Dental devices solely for cosmetic purposes. • Out-of-network services not authorized by health plan except for emergency care and physician services for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following and uncomplicated delivery by cesarean section. • Services, supplies, meal replacements, or supplements provided 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 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.
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• 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 con firmed 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 assists a child with the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, toileting, special diet preparation, and medication supervision that is usually self-administered or provided by a parent. This care does not require the continuing attention of trained medical or paramedical personnel.) This exclusion does not apply to hospice services. • Housekeeping. • Public facility services and care for conditions that federal, state or local law requires be provided in a public facility or care provided while in 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 therapy, occupational therapy, or speech therapy services are not covered except when ordered by a Physician/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
What are my unborn child’s CHIP Perinatal benefits? How do I get these services? CHIP Perinatal members can get most services by calling their CHIP Perinate Provider.
CHIP PERINATAL SCHEDULE OF BENEFITS
INPATIENT GENERAL ACUTE AND INPATIENT REHABILITATION HOSPITAL SERVICES
Benefit
Services include: • Operating, recovery and other treatment rooms. • Anesthesia and administration (facility technical component). • Inpatient services associated with (a) miscarriage or (b) a non-viable 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. » Histological examination of tissue samples.
BENEFITS & SERVICES
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BENEFITS & SERVICES
Limitations
• Medically necessary surgical services are limited to services that directly relate to the delivery of the unborn child, and services related to miscarriage or non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero). • For CHIP Perinates in families with incomes at or below 186% of the Federal Poverty Level, the facility charges are not a covered benefit; however, professional services charges associated with labor with delivery are a covered benefit.• For CHIP Perinates in families with incomes above 186% to 201% of the Federal Poverty Level, benefits are limited to professional service charges and facility charges associated with labor with delivery until birth, and services related to miscarriage or a non-viable pregnancy.
OUTPATIENT HOSPITAL, COMPREHENSIVE OUTPATIENT REHABILITATION HOSPITAL, CLINIC (INCLUDING HEALTH CENTER) AND AMBULATORY HEALTH CARE CENTER
Benefit
Services include, the following 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. • Drugs, medications and biologicals that are medically necessary prescription and injection drugs. • Outpatient services associated with (a) miscarriage or (b) a non-viable pregnancy include (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. » Histological examination of tissue samples. • Amniocentesis, cordocentesis, fetal intrauterine transfusion (FIUT) and ultrasonic guidance for the cordocentesis, FIUT are covered benefits with an appropriate diagnosis. • Surgical services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero).
Limitations
• May require prior authorization and physician prescription. • Laboratory and radiological services are limited to services that directly relate to ante partum care and/or the delivery of the covered CHIP Perinate until birth. • Ultrasound of the pregnant uterus is a covered benefit when medically indicated. Ultrasound may be indicated for suspected genetic defects, high-risk pregnancy, fetal growth retardation, or gestational age confirmation or miscarriage or non-viable pregnancy. • Laboratory tests are limited to: » Non-stress testing. » Contraction. » Stress testing.
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BENEFITS & SERVICES
» Hemoglobin or hematocrit repeated once a trimester and at 32-36 weeks of pregnancy; or complete blood count (CBC). » Urinalysis for protein and glucose every visit. » Blood type and RH antibody screen. » Repeat antibody screen for Rh negative women at 28 weeks followed by RHO immune globulin administration if indicated. » Rubella antibody titer. » Serology for syphilis. » Hepatitis B surface antigen. » Cervical cytology. » Pregnancy test. » Gonorrhea test. » Urine culture. » Sickle cell test. » Tuberculosis (TB) test. » Human immunodeficiency virus (HIV) antibody screen. » Chlamydia test. » Other laboratory tests not specified but deemed medically necessary. » Multiple marker screens for neural tube defects (if the client initiates care between 16 and 20 weeks). » Screen for gestational diabetes at 24-28 weeks of pregnancy. » Other lab tests as indicated by medical condition of client.
PHYSICIAN/PHYSICIAN EXTENDER PROFESSIONAL SERVICES
Benefit
Services include, but are not limited to, the following: • Medically necessary physician services are limited to prenatal and postpartum care and/or the delivery of the covered unborn child until birth. • Physician office visits, in-patient and out-patient services. • Laboratory, x-rays, imaging and pathology services including technical component and/or professional interpretation. • Medically necessary medications, biologicals and materials administered in physician’s office. • Professional component (in/outpatient) of surgical services, including: » Surgeons and assistant surgeons for surgical procedures directly related to the labor with delivery of the covered unborn child until birth. » Administration of anesthesia by physician (other than surgeon) or CRNA. » Invasive diagnostic procedures directly related to the labor with delivery of the unborn child. » Surgical services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero). • Hospital-based physician services (including physician-performed technical and interpretive components). • Professional component of the ultrasound of the pregnant uterus when medically indicated for suspected genetic defects, high-risk pregnancy, fetal growth retardation or gestational age confirmation. • Professional component of amniocentesis, cordocentesis, fetal intrauterine transfusions (FIUT) and ultrasonic guidance for amniocentesis, cordocentesis, and FIUT. • Professional component associated with (a) miscarriage or (b) non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero).
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BENEFITS & SERVICES
• Professional services associated with miscarriage or non-viable pregnancy include, but are not limited to: » Dilation and curettage (D and C) procedures. » Appropriate provider-administered medications. » Ultrasounds. » Histological examination of tissue samples.
Limitations
• May require prior authorization and physician prescription.
PRENATAL CARE AND PRE-PREGNANCY FAMILY SERVICES AND SUPPLIES
Benefit
Covered services are limited to an initial visit and subsequent prenatal (ante partum) care visits that include: • One (1) visit every four (4) weeks for the first 28 weeks of pregnancy. • One (1) visit every two (2) to three (3) weeks from 28 to 36 weeks of pregnancy. • One (1) visit per week from 36 weeks to delivery. More frequent visits are allowed as medically necessary.
Limitations
Limit of 20 prenatal visits and two (2) postpartum visits (maximum within 60 days) without documentation of a complication of pregnancy. • More frequent visits may be necessary for high-risk pregnancies. High-risk prenatal visits are not limited to 20 visits per pregnancy. Documentation supporting medical necessity must be maintained in the physician’s files and is subject to retrospective review.
Visits after the initial visit must include: • Interim history (problems, marital status, fetal status). • Physical examination (weight, blood pressure, fundal height, fetal position and size, fetal heart rate, extremities). • Laboratory tests (urinalysis for protein and glucose every visit; hematocrit or hemoglobin repeated once a trimester and at 32-36 weeks of pregnancy; multiple marker screen for fetal abnormalities offered at 16-20 weeks of pregnancy; repeat antibody screen for Rh negative women at 28 weeks followed by Rho immune globulin administration if indicated; screen for gestational diabetes at 24-28 weeks of pregnancy; and other lab tests as indicated by medical condition of client).
BIRTHING CENTER SERVICES
Benefit
Covers birthing services provided by a licensed birthing center.
Limitations
• Limited to facility services related to labor with delivery.
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BENEFITS & SERVICES
• Applies only to CHIP Perinate Members (unborn child) with incomes at 186% FPL to 201% FPL.
SERVICES RENDERED BY A CERTIFIED NURSE MIDWIFE OR PHYSICIAN IN A LICENSED BIRTHING CENTER
Benefit
Covers prenatal services and birthing services rendered in a licensed birthing center.
Limitations
Prenatal services subject to the following limitations: Services are limited to an initial visit and subsequent prenatal (ante partum) care visits that include: • One (1) visit every four (4) weeks for the first 28 weeks of pregnancy. • One (1) visit every two (2) to three (3) weeks from 28 to 36 weeks of pregnancy. • One (1) visit per week from 36 weeks to delivery.
More frequent visits are allowed as medically necessary. Benefits are limited to: • Limit of 20 prenatal visits and two (2) postpartum visits (maximum within 60 days) without documentation of a complication of pregnancy. • More frequent visits may be necessary for high-risk pregnancies. High-risk prenatal visits are not limited to 20 visits per pregnancy. Documentation supporting medical necessity must be maintained in the physician’s files and is subject to retrospective review.
Visits after the initial visit must include: • Interim history (problems, marital status, fetal status). • Physical examination (weight, blood pressure, fundal height, fetal position and size, fetal heart rate, extremities). • Laboratory tests (urinalysis for protein and glucose every visit; hematocrit or hemoglobin repeated once a trimester and at 32-36 weeks of pregnancy; multiple marker screen for fetal abnormalities offered at 16-20 weeks of pregnancy; repeat antibody screen for Rh negative women at 28 weeks followed by Rho immune globulin administration if indicated; screen for gestational diabetes at 24-28 weeks of pregnancy; and other lab tests as indicated by medical condition of client).
EMERGENCY SERVICES, INCLUDING EMERGENCY HOSPITALS, PHYSICIAN AND AMBULANCE SERVICES
Benefit
CCHP cannot require authorization as a condition for payment for emergency conditions related to labor with delivery. Covered services are limited to those emergency services that are directly related to the delivery of the unborn child until birth. • Emergency services based on prudent layperson definition of emergency health condition. • Medical screening examination to determine emergency when directly related to the delivery of the covered unborn child. • Stabilization services related to the labor with delivery of the covered unborn child. • Emergency ground, air and water transportation for labor and threatened labor is a covered benefit.
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BENEFITS & SERVICES
• Emergency ground, air and water transportation for an emergency associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero) is a covered benefit.
Limitations
• Post-delivery services or complications resulting in the need for emergency services for the mother of the CHIP Perinate are not a covered benefit.
CASE MANAGEMENT AND CARE COORDINATION SERVICES
Benefit
These services include outreach informing, case management, care coordination and community referral.
Limitations
• No limitations.
DRUG BENEFITS
Benefit
Services include, but are not limited to, the following: • Outpatient drugs and biological, including pharmacy-dispensed and provider-administered outpatient drugs and biologicals. • Drugs and biologicals provided in an inpatient setting.
Limitations
• Services must be medically necessary for the unborn child.
Exclusions
What benefits are not covered? • For CHIP Perinates in families with incomes at or below 186% of the Federal Poverty Level, inpatient facility charges are not a covered benefit if associated with the initial Perinatal Newborn admission. “Initial Perinatal Newborn admission” means the hospitalization associated with the birth. • Contraceptive medications prescribed only for the purpose of primary and preventive reproductive health care (i.e., cannot be prescribed for family planning). • Inpatient and outpatient treatments other than prenatal care, labor with delivery, services related to (a) miscarriage and (b) a non-viable pregnancy, and postpartum care related to the covered unborn child until birth. • Inpatient mental health services. • Outpatient mental health services. • Durable medical equipment or other medically related remedial devices. • Disposable medical supplies with the exception of a limited set of disposable medical supplies published at txvendor drug.com/formulary/limited-hhs.shtml when they are obtained from an authorized pharmacy provider. • Home and community-based health care services.
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BENEFITS & SERVICES
• Nursing care services. • Dental services. • Inpatient substance abuse treatment services and residential substance abuse treatment services.• Outpatient substance abuse treatment services. • Physical therapy, occupational therapy, and services for individuals with speech, hearing and language disorders. • Hospice care. • Skilled nursing facility and rehabilitation hospital services. • Emergency services other than those directly related to the labor with delivery of the covered unborn child. • Transplant services. • Tobacco cessation programs. • Chiropractic services. • Medical transportation not directly related to the labor or threatened labor, miscarriage or non-viable pregnancy and/ or delivery of the covered unborn child. • 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 articles which are not required for the specific treatment related to labor with delivery or post-partum care. • Experimental and/or investigational medical, surgical or other health care procedures or services which are not generally employed or recognized within the medical community. • Treatment or evaluations required by third parties including, but not limited to, those for schools, employment, flight clearance, camps, insurance or court. • Private duty nursing services when performed on an inpatient basis or in a skilled nursing facility. • 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). • Mechanical organ replacement devices including, but not limited to, an artificial heart. • Hospital services and supplies when confinement is solely for diagnostic testing purposes and not a part of labor with delivery. • 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 related to the labor with delivery of the covered unborn child. • Services, supplies, meal replacements or supplements provided for weight control or the treatment of obesity. • Medications prescribed for weight loss or gain. • Acupuncture services, naturopathy, and hypnotherapy. • Immunizations solely for foreign travel. • Routine foot care such as hygienic care. • 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). • Corrective orthopedic shoes. • Convenience items. • Over-the-counter medications. • Orthotics primarily used for athletic or recreational purposes.• Custodial care (care that assists with the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, toileting, special diet preparation, and medication supervision that is usually self-administered or provided by a caregiver. This care does not require the continuing attention of trained medical or
31
BENEFITS & SERVICES
paramedical personnel). • Housekeeping. • Public facility services and care for conditions that federal, state or local law requires be provided in a public facility or care provided while in the custody of legal authorities. • Services or supplies received from a nurse, which do not require the skill and training of a nurse. • Vision training, vision therapy or vision services. • Reimbursement for school-based physical therapy, occupational therapy or speech therapy services are not covered. • Donor non-medical expenses. • Charges incurred as a donor of an organ.
BENEFITS & SERVICES – CHIP PERINATAL MOMS How do I get these services for my unborn child? Your doctor will work with you to make sure you and your unborn child get the services needed.
How much do I have to pay for my unborn child’s health care under CHIP Perinatal? There are no co-payments or cost-sharing limits for you as a CHIP Perinatal member. This means that you do not have to pay when you see a perinatal doctor.
Will I have to pay for services that are not covered by CHIP Perinatal? You may have to pay for services that are not covered by the program. We will also try to help you find services that are not covered by the program.
What benefits does my baby receive at birth? Your baby will receive the same benefits as all other the CHIP members, except there are no co-pays while on CHIP Perinatal.
What services are not covered? Services that are not covered are listed in the benefits and services section above.
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PRESCRIPTIONS
How do I get my medications? CHIP Perinatal covers most of the medicine your doctor says you need for your pregnancy. Your doctor will write a prescription so you can take it to the drug store, or may be able to send the prescription to the drug store for you.There are no co-payments required for CHIP Perinate Members.
How do I find a network drug store? To find an in-network drug store, you can: • Call Member Services. • Go to the Cook Children’s Health Plan website at cookchp.org. • Refer to your Cook Children’s Health Plan Provider Directory.
What if I go to a drug store not in the network? Ask that pharmacy to call the Pharmacist Help Line number on the back of your/your child’s Cook Children’s Health Plan ID card. They can help you get your prescription.
What do I bring with me to the drug store? You must take your Cook Children’s Health Plan ID card with you.
What if I need my medications delivered to me? For a list of pharmacies that deliver, you can: • Call Member Services. • Look in the Cook Children’s Health Plan Provider Directory.
What if I can’t get my medication approved? If your doctor cannot be reached to approve a prescription, you may be able to get a three-day emergency supply of your medication. Call Cook Children’s Health Plan Member Services at 1-800-964-2247 for help with your medications and refills. Who do I call if I have problems getting my/my child’s medications? Call Member Services.
What if I need an over-the-counter medication? The pharmacy cannot give you an over-the-counter medication as part of your CHIP benefit. If you need 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 questions, please call Member Services at 1-800-964-2247.
What if I lose my/my child’s medication? Medications that are lost or stolen are not a covered benefit. You can call your pharmacy for a refill and pay for it.
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.
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Extra benefit What can I get Limits How to get it Nurse Advice Line Access to CCHP’s 24-hour No limits. Call 1-866-971-2665 nurse advice line. Prenatal Class • Classes may be online or in-person. Call Care Management
CHIP SPECIAL SERVICES
SPECIAL HEALTH CARE NEEDS
Who do I call if I have/my child has special health care needs and I need someone to help me? Our Case Managers are here to help with services for members with special health care needs.
What extra benefits does a Cook Children’s Health Plan offer? What health education classes does CCHP offer? How can I get these benefits for my unborn child? Cook Children’s Health Plan members get the following value-added services and extra benefits.
EXTRA BENEFITS
A structured dental program for pregnant women enrolled as CHIP Perinate members that includes up to $250 of basic and major dental services.
Baby Basics book for all pregnant members enrolled in the CCHP Baby Steps Program.
• $50 Incentive per pregnancy for Members who complete a prenatal visit with an approved provider during the first trimester of pregnancy or within 42 days of enrollment in CCHP.
• $50 Incentive per pregnancy for postnatal members who complete a post-partum visit with an approved provider 21-56 days after delivery.
Prenatal Dental (CHIP Perinatal members only)
Baby Basics Book
Gift Programs
• $250 limit. • Does not include orthodontia or cosmetic services. • Must be enrolled in the CCHP Baby Steps Program.
• One book per pregnant member. • Must be enrolled in the CCHP Baby Steps Program.
• Visit must be with an approved provider during the first trimester of pregnancy or within 42 days of enrollment in CCHP.
• Visit must be with an approved provider during the 21-56 days after delivery.
Call Liberty Dental at 1-888-902-0349
Call Care Management
Call Member Services
Up to $100 for prepared childbirth or breastfeeding classes per pregnancy with contracted health/childbirth educators, community agencies, and OB provider offices.
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HEALTH EDUCATION & OTHER RESOURCES
COSTS/MONEY
What is Women, Infants, and Children (WIC)? WIC is a program for pregnant women, new moms and children age 5 and under. The WIC program helps teach pregnant women and new moms how to eat well and stay healthy.
How do I apply for WIC? Call 1-800-942-3678.
Who can get WIC services? • Pregnant women. • Women who are breastfeeding a baby who is 1 year old or younger. • Women who have had a baby in the last six months. • Children 5 years or younger who meet the income requirements. • Parents (including single women and men), stepparents, guardians and foster parents of infants and children.
How much do I have to pay for my health care? You might have to pay a copayment when you or your child gets certain covered services. Your ID card will list your copayment amount.
What are copayments? How much are they and when do I have to pay them? The table below lists the CHIP copayment by the amount your family makes. Copayments are paid to the doctor or drug store at the time of service.Your ID card lists the copayments that you must pay. Remember to show your ID card when you have an office visit, go to the hospital or have a prescription filled.
Are services free? Yes. Services are free to those who qualify.
What does WIC provide? • Education on eating food that is good for you. • Healthy food. • Breastfeeding help.
Copayments do not apply to CHIP Perinate newborn, CHIP Perinate, and CHIP members that are Native Americans or Alaskan Natives. There are no copayments for well-baby and well-child care services, preventative services or pregnancy-related assistance.
CHIP Perinate members do not have to pay the enrollment fee.
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COSTS/MONEY
Federal Poverty Level
Native AmericansAt or below 151%151% to 186%186% to 201%
Office Visits
$0$5$20$25
ER Visit
$0$5$75$75
Inpatient Stay
$0$35$75$125
Generic Drugs
$0$0$10$10
Brand Drugs
$0$5$35$35
Enrollment Fees
$0$0$35$50
Cost-sharing Cap (per 12-month term of coverage)
5% of family’s income
CCHP is not responsible for payment of unauthorized non-emergency services provided to a CHIP member by an out-of-network provider. In such circumstances, the CHIP member will be responsible for all costs.
Will I have to pay for services that are not covered? If the service is not a covered benefit, then you will have to pay for the service. If you have any questions, please call Member Services.
What if I get a bill from my doctor? Who do I call? What information will they need? Your doctor should not bill you for a covered service. If you do get a bill from a doctor, call the doctor’s office and make sure they have your CHIP information. All of the information your doctor needs to bill Cook Children’s Health Plan for the service is on your/child’s ID card.
If you feel that you should not have received a bill or you need help to understand the bill, call Member Services. We will help explain the bill to you. We can talk to the doctor’s office for you to explain your/your child’s benefits. When you call us, please have your/your child’s ID card and the doctor’s bill with you. We will need that information so we can help you.
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COMPLAINTS & APPEALS
COMPLAINTS What should I do if I have a complaint? Who do I call? We want to help. If you have a complaint, please call us toll-free at 1-800-964-2247 to tell us about your problem. A Cook Children’s Health Plan Member Services advocate can help you file a complaint. Just call 1-800-964-2247. Most of the time, we can help you right away or at most within a few days. Cook Children’s Health Plan cannot take any action against you as a result of your filing a complaint.
Where can I mail a complaint? For written complaints, please send your letter to Cook Children’s Health Plan. Your letter must state your name, your member ID number, your phone number and address, and the reason for your complaint. Please send your letter to:
Cook Children’s Health Plan Attention: Complaints and Appeals P.O. Box 2488 Fort Worth, TX 76113-2488
What are the requirements and timeframes for filing a complaint? There is no time limit on filing a complaint with Cook Children’s Health Plan. We will send you a response letter telling you what we did about your complaint.
How long will it take to process my complaint? Most of the time we can help you right away or within a few days. You will get a response letter within 30 days from when your complaint was received by Cook Children’s Health Plan.
Can someone from Cook Children’s Health Plan help me file a complaint? Yes, Member Services can help you file a complaint.
Do I have the right to meet with a Complaint Appeal Panel (CAP)? Yes. You have the right to appear in person before the CAP or send a written appeal to the CAP.
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, TX 78714-9091
If you can get on the Internet, you can send your complaint in an email to http://tdi.texas.gov/consumer/complfrm.html.
APPEALSWhat can I do if my doctor asks for a service or medi-cine for me that’s covered, but Cook Children’s Health Plan (CCHP) denies or limits it? You may ask CCHP for another review of this decision. This is called an “appeal.” You can call Member Services and ask for an appeal.
How will I find out if services are denied? If services are denied, we will send your provider a letter telling them why the service was denied. A copy of the letter will also be sent to you.
What are the timeframes for the appeal process? We will send you a letter within five working days to let you know: • That we received your request for appeal. • If we need any more information in order to process the appeal. • If you called us to request an appeal, we will send you a one-page appeal form. You must complete the appeal form and send it back to Cook Children’s Health Plan.
We will complete the appeal no later than 30 calendar days from the date you asked for the appeal.
When do I have the right to request an appeal? You may request an appeal whenever you do not agree with our decision to deny services or care for you.
Does my request have to be in writing? Yes. An appeal form will be included in each letter you receive when Cook Children’s Health Plan denies a service to you. This form must be signed and sent back. You can request an appeal by phone and an appeal form will be sent to you, which must be signed and returned.
Can someone from Cook Children’s Health Plan help me file an appeal? Yes, Member Services can help you file an appeal. They will send you an appeal request form and ask that you send it back before your appeal request is taken.
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 can ask for this type of appeal in writing or by phone. Make sure you write “I want a quick decision or an expedited appeal,” or “I feel my/my child’s health could be hurt by waiting for a standard decision.” To request a quick decision by phone, call Member Services.
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COMPLAINTS & APPEALS
INDEPENDENT REVIEW ORGANIZATION
Does my request for an expedited appeal have to be in writing? We can accept your request orally or in writing. Mail written requests to:
Cook Children’s Health Plan Attn: Appeals PO Box 2488 Fort Worth, TX 76113-2488
What happens if Cook Children’s Health Plan denies the request for an expedited appeal? If we deny an expedited appeal, it will be resolved within 30 days. You will get a letter telling you why and what other choices you may have.
What is an Independent Review Organization (IRO)? An Independent Review Organization (IRO) is an outside organization that the Texas Department of Insurance (TDI) picks to review your health plan’s denial of a service you and your doctor feel is medically necessary. The IRO is not related to your doctor or your health plan. You can ask for a review by an IRO after you complete the appeal process with us, or if we have denied a service that you think is life-threatening. There is no cost to you for this.
How do I ask for a review by an Independent Review Organization (IRO)? Call Care Management. We will send you a letter if we deny a service because it is not medically necessary. The letter will include a form you can fill out to ask for an IRO.
What are the timeframes for an expedited appeal? We have one working day from the time we get the information and appeal request.
Who can help me in filing an expedited appeal? Member Services will help you. Call Member services at 1-800-964-2247.
What are the timeframes for this process? If it is not a life-threatening condition, no later than the earlier of the:
• 15th day after the date the IRO gets all the information they need to make their decision; or • 20th day after the date the IRO gets the request for a review.
If it is a life-threatening condition, no later than the earlier of the:
• 5th day after the date the IRO gets all the information they need to make their decision; or • 8th day after the date the IRO gets the request for a review.
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MEMBER RIGHTS & RESPONSIBILITIES
CHIP PERINATE What are my responsibilities? Member rights: 1. You have a right to get accurate, easy-to-understand information to help you make good choices about your unborn child’s health plan, doctors, hospitals and other providers. 2. You have a right to know how the perinatal providers are paid. Some may get a fixed payment no matter how often you visit. Others get paid based on the services they provide for your unborn child. You have a right to know about what those payments are and how they work. 3. You have a right to know how the health plan decides whether a perinatal service is covered or medically necessary. You have the right to know about the people in the health plan who decide those things. 4. You have a right to know the names of the hospitals and other Perinatal providers in the health plan and their addresses. 5. You have a right to pick from a list of health care providers that is large enough so that your unborn child can get the right kind of care when it is needed. 6. You have a right to emergency perinatal services if you reasonably believe your unborn child’s life is in danger, or that your unborn child would be seriously hurt without getting treated right away. Coverage of such emergencies is available without first checking with the health plan. 7. You have the right and responsibility to take part in all the choices about your unborn child’s health care. 8. You have the right to speak for your unborn child in all treatment choices. 9. You have the right to be treated fairly by the health plan, doctors, hospitals, and other providers.10. You have the right to talk to your perinatal provider in private, and to have your medical records kept private. You have the right to look over and copy your medical records and to ask for changes to those records. 11. You have the right to a fair and quick process for solving problems with the health plan and the plan’s doctors, hospitals and others who provide perinatal services for your unborn child. If the health plan says it will not pay for a covered perinatal service or benefit that your unborn 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.
12. You have a right to know that doctors, hospitals and other perinatal providers can give you information about your or your unborn child’s health status, medical care or 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 having your baby born healthy. You can help by assuming these responsibilities. 1. You must try to follow healthy habits. Stay away from tobacco and eat a healthy diet. 2. You must become involved in the decisions about your unborn child’s care. 3. If you have a disagreement with the health plan, you must try first to resolve it using the health plan’s complaint process. 4. You must learn about what your health plan does and does not cover. Read your CHIP Perinatal Program Handbook to understand how the rules work. 5. 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. 6. You must report misuse of CHIP Perinatal services by health care providers, other members, or health plans. 7. 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.
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FRAUD & ABUSE
SUBROGATION
How do I report someone who is misusing/abusing the program or services?
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 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.texas.gov/report-fraud and click the red “Report Fraud” box to complete the online form; or • You can report directly to your health plan:
Cook Children’s Health Plan Attention: Regulatory Compliance Manager P.O. Box 2488 Fort Worth, TX 76113-2488 1-800-964-2247
To report waste, abuse or fraud, gather as much infor-mation as possible: When reporting about a provider (a doctor, dentist, counselor, etc.) include: • Name, address and phone number of provider. • Name and address of the facility (hospital, nursing home, home health agency, etc.). • Medicaid number of the provider and facility, if you have it. • Type of provider (doctor, dentist, therapist, pharmacist, etc.). • Names and phone numbers of other witnesses who can help in the investigation. • Dates of events. • Summary of what happened.
When reporting about someone who gets benefits, include: • The person’s name. • The person’s date of birth, Social Security number, or case number if you have it. • The city where the person lives. • Specific details about the waste, abuse or fraud.
What is subrogation? We might ask for payment for medical expenses to treat an injury or illness that was caused by someone else. This is a “right of subrogation.” We reserve the right to get back the cost of medical benefits paid when another party is (or might be responsible) for causing the illness or injury to you. We can ask to get back the cost of medical expenses from you if you get expenses from the other party.
We may use and share your information as we:
• Help manage the health care treatment you receive• Run our organization• Pay for your health services• Administer your health plan• Help with public health and safety issues• Do research• Comply with the law• Respond to organ and tissue donation requests and
work with a medical examiner or funeral director• Address workers’ compensation, law enforcement,
and other government requests• Respond to lawsuits and legal actions
➤ See pages 3 and 4 for more information on these uses and disclosures
You have the right to: • Get a copy of your health and claims records• Correct your health and claims records• Request confidential communication• Ask us to limit the information we share• Get a list of those with whom we’ve shared
your information• Get a copy of this privacy notice• Choose someone to act for you• File a complaint if you believe your privacy
rights have been violated
➤ See page 2 for more information on these rights and how to exercise them
Our Uses and
Disclosures
Your Rights
➤ See page 3 for more information on these choices and how to exercise them
You have some choices in the way that we use and share information as we:
• Answer coverage questions from your family and friends• Provide disaster relief• Market our services and sell your information
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Your Information. Your Rights.Our Responsibilities.
Your Choices
Notice of Privacy Practices • Page 1
Cook Children's Health PlanP.O. Box 2488, Fort Worth, Texas76113-2488
Privacy Official: Kathleen RomanPhone: 682-885-2866Email: [email protected]: www.cookchp.org
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Notice of Privacy Practices • Page 2
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Your Rights
Get a copy of your health and claims records
• You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct health and claims records
• You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not.
Ask us to limit what we use or share
• You can ask us not to use or share certain health information for treatment, payment, or our operations.
• We are not required to agree to your request, and we may say “no” if it would affect your care.
Get a list of those with whom we’ve shared information
• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
• You can complain if you feel we have violated your rights by contacting us using the information on page 1.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.
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Notice of Privacy Practices • Page 3
In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in payment for your care
• Share information in a disaster relief situation
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
• Marketing purposes
• Sale of your information
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
Your Choices
Help manage the health care treatment you receive
• We can use your health information and share it with professionals who are treating you.
Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.
Run our organization
• We can use and disclose your information to run our organization and contact you when necessary.
• We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.
Example: We use health information about you to develop better services for you.
Pay for your health services
• We can use and disclose your health information as we pay for your health services.
Example: We share information about you with your dental plan to coordinate payment for your dental work.
Administer your plan
• We may disclose your health information to your health plan sponsor for plan administration.
Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge.
How do we typically use or share your health information? We typically use or share your health information in the following ways.
Our Uses and
Disclosures
continued on next page
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Notice of Privacy Practices • Page 4
Help with public health and safety issues
• We can share health information about you for certain situations such as: • Preventing disease• Helping with product recalls• Reporting adverse reactions to medications• Reporting suspected abuse, neglect, or domestic violence• Preventing or reducing a serious threat to anyone’s health or safety
Do research • We can use or share your information for health research.
Comply with the law • We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests and work with a medical examiner or funeral director
• We can share health information about you with organ procurement organizations.
• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests
• We can use or share health information about you:• For workers’ compensation claims• For law enforcement purposes or with a law enforcement official• With health oversight agencies for activities authorized by law • For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
• We can share health information about you in response to a court or administrative order, or in response to a subpoena.
How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Cook Children's Health Plan never markets or sells personal information.
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Notice of Privacy Practices • Page 5
Our Responsibilities
• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this NoticeWe can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you.
This Notice of Privacy Practices applies to the following organizations.
Effective: 09/07/2013
Cook Children's Health Plan
Privacy Official: Kathleen Roman; 682-885-2866; [email protected]
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