Member Handbook Medallion 3.0 Medicaid Managed Care
AVA-MHB-0019-17
www.anthem.com/vamedicaid
Medallion 3.0 Medicaid
Managed Care
Member Handbook
www.anthem.com/vamedicaid AVA-MHB-0019-17
HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association.
ANTHEM is a registered trademark of Anthem Insurance Companies, Inc..
Anthem HealthKeepers Plus Member Services 1-800-901-0020 (TTY 711)
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HealthKeepers, Inc. follows Federal civil rights laws. We don’t discriminate against people because of their: Race Color
National origin Age
Disability
Sex or gender identity
That means we won’t exclude you or treat you differently because of these things. Communicating with you is important For people with disabilities or who speak a language other than English, we offer these services at no cost to you: Qualified sign language interpreters Written materials in large print, audio, electronic, and other formats Help from qualified interpreters in the language you speak Written materials in the language you speak To get these services, call the Member Services number on your ID card at 1-800-901-0020 (Medallion Medicaid, FAMIS) or 1-855-323-4687 (CCC Plus); TTY 711. Your rights Do you feel you didn’t get these services or we discriminated against you for reasons listed above? If so, you can file a grievance (complaint). File by mail, email, fax, or phone: HealthKeepers, Inc. for Anthem HealthKeepers Plus Attention: Civil Rights Coordinator for Discrimination Complaints P.O. Box 62429 Virginia Beach, VA 23464 Phone: 1-800-901-0020 (Medallion Medicaid, FAMIS) or 1-855-323-4687 (CCC Plus); TTY 711. Fax: 1-855-832-7294 Email:
[email protected] Need help filing? Call our Civil Rights Coordinator at the number above. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights:
On the Web: By mail:
By phone:
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf U.S. Department of Health and Human Services 200 Independence Ave., SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019 (TTY/TDD 1-800-537-7697)
For a complaint form, visit www.hhs.gov/ocr/office/file/index.html.
AVA-MEM-0479-17
We can translate this at no cost. Call the customer service number on your member ID card. Podemos traducir esto gratuitamente. Llame al número de servicio de atención al cliente que aparece en su tarjeta de identificación (ID Card). بأستخدام رقم الهاتف المدون على، اتصل بخدمات االعضاء.ًنستطيع ترجمة هذه المواد مجانا .بطاقة االعضاء لديك Մենք կարող ենք անվճար թարգմանել սա: Զանգահարեք հաճախորդների սպասարկման բաժին ձեր անդամաքարտում (ID card) նշված հեռախոսահամարով:
Spanish
Arabic Armenian
Burmese 我們可以免費為您提供翻譯版本。請撥打您 ID 卡上所列的電話號碼 洽詢客戶服務中心。 به شماره خدمات مراجعين ما که پشت.ما می توانيم اين را به رايگان برايتان ترجمه کنيم . تلفن بزنيد،) درج شدهID( کارت شناسايی تان
Chinese Farsi
Nous pouvons traduire ceci gratuitement. Appelez le numéro du service après-vente sur votre carte d’identification.
French
Nou ka tradwi sa la pou okenn pri. Pélé nimero sèvis kliyentèl la sou tô kat didantité.
Fr. Creole
Wir können das gerne kostenlos übersetzen. Bitte wenden Sie sich an die Kundenservice-Hotline auf Ihrer ID-Karte. Mπορούμε να σας μεταφράσουμε το παρακάτω χωρίς χρέωση. Καλέστε τον αριθμό του Τμήματος Εξυπηρέτησης Πελατών που θα βρείτε στην κάρτα ταυτοποίησής σας. અમે આન ું ભાષાુંતર કોઈપણ ખર્ચ લીધા વિના કરી શકીએ છીએ. તમારા ID કાર્ચ પર આપેલ
German Greek
Gujarati
ગ્રાહક સેિા નુંબર પર ફોન કરો.
התקשר למספר של שירות הלקוחות.אנחנו יכולים לתרגם את זה ללא עלות .הנמצא על גבי כרטיס הזיהוי שלך हम इसका अनव ु ाद ननशल् ु क कर सकते हैं। अपने ID कार्ड पर ददए गए ग्राहक
Hebrew Hindi
सेवा नंबर पर फोन करें ।
Peb txhais tau qhov ntawm no dawb. Hu rau lub chaw haujlwm pab cov neeg siv peb cov kev pab tus xovtooj uas nyob ntawm koj daim npav ID rau tus tswv cuab. MEMCOMM-0489-16
Hmong
Possiamo effettuare la traduzione gratuitamente. Contatti il numero dell’assistenza clienti riportato sulla Sua tessera identificativa. 私たちは、この文章を無料で翻訳することができます。ご自身のIDカードにあ るカスタマーサービス番号へお電話ください。
Italian
Japanese
យ ង ើ អាចបកប្របជូ នយោ ឥតអស់ថ្លៃ អវយី េ ។ សូ មេូ រស័ព្ទយៅប្នែ កយសវា អតិលិជន តាមយេខមានយៅយេើប័ណ្ណ ID របស់អែក ។
Khmer
저희는 이것을 무료로 번역해 드릴 수 있습니다. 가입자 ID 카드에 있는 고객 서비스부 번호로 연락하십시오.
Korean
ພວກເຮ ີ້ ທ ່ ານໄດ ີ້ ຟຣ ີ ີ້ ໃຫ ີ . ົ າສາມາດແປອັນນ ່ີ ມ ໃຫ ູ ກຄ ີ້ ໂທຫາຝ ່ າຍບ ໍ ິ ລການລ ີ້ າທ ູ່ ໃນບັດປະຈ ໍ າຕ ່ ານ. ີ ເບ ີ ຢ ົ ວຂອງທ
Laotian
Możemy to przetłumaczyć bez żadnych kosztów. Zadzwoń pod numer obsługi klienta za pomocą karty ID. Podemos traduzir isto gratuitamente. Ligue para o serviço de atendimento ao cliente que consta no seu cartão de identificação.
Polish Portuguese
Мы можем это бесплатно перевести. Позвоните в отдел обслуживания по телефону, приведенному на вашей идентификационной карточке участника плана.
Russian
Možemo to prevesti besplatno. Pozovite na broj korisničkog servisa s Vaše identifikacione kartice (ID).
Serbian
Maaari namin ito isalin-wika nang walang bayad. Mangyaring tawagan ang numero ng customer service sa inyong ID card na pang miyembro.
Tagalog
เราสามารถแปลไดโดยไม มี ้ ่ คาใช ่ ้จายใดๆ ่ ติดตอหมายเลขโทรศั พทของฝ ตรประจาตัวของคุณ ่ ์ ่ ายบริการลูกคาบนบั ้
Thai
کارڈ پر دیے گئے کسٹمر سروس کے نمبرID ہم اس کا ترجمہ ُمفت کر سکتے ہیں۔ اپنے پر کال کریں۔
Urdu
Chúng tôi có thể phiên dịch tài liệu này miễn phí. Xin gọi dịch vụ khách hàng qua số điện thoại ghi trên thẻ ID hội viên của quý vị. רופט דעם קאסטומער סערװיס.מיר קענען דאס איבערזעצן פרײ פון אפצאל .נומער אױף אײער אידענטיטעט קארטל
MEMCOMM-0489-16
Vietnamese Yiddish
CONTENTS
Help in other languages or alternate formats ................................................................................6
Medicaid Managed Care Plan .......................................................................................................8
Welcome to the Anthem HealthKeepers Plus plan offered by HealthKeepers, Inc. ....................8
How to use this handbook.............................................................................................................8
Your welcome packet .................................................................................................................11
Member ID card ..........................................................................................................................11
Provider and Pharmacy Directories ............................................................................................11
What is the Anthem HealthKeepers Plus service area? ..............................................................12
List of covered drugs ..................................................................................................................13
List of Covered and Non-Covered Services ...............................................................................13
Your cost-sharing responsibilities...............................................................................................13
Information about Eligibility ......................................................................................................13
Getting help right away...............................................................................................................14
Anthem HealthKeepers Plus Member Services ..........................................................................14
How to contact Anthem HealthKeepers Plus Member Services ................................................14
How Anthem HealthKeepers Plus Member Services representatives can help you...................14
Case management services .........................................................................................................14
Behavioral Health Crisis Line.....................................................................................................15
Medical advice line available 24 hours a day, 7 days a week.....................................................15
Other resources ...........................................................................................................................16
How Managed Care Works..........................................................................................................16
What makes you eligible to be a member? .................................................................................17
What makes you unqualified to be a managed care member?....................................................17
Enrollment...................................................................................................................................17
Health plan assignment ...............................................................................................................17
Changing your health plan ..........................................................................................................18
Automatic re-enrollment.............................................................................................................18
Enrollment for newborns ............................................................................................................18
What are the advantages of choosing the Anthem HealthKeepers Plus plan? ...........................19
What is a Health Risk Assessment?............................................................................................19
Continuity of care period ............................................................................................................20
What if I have other coverage? ...................................................................................................20
How to Get Regular Care and Services ......................................................................................20
How to get care from a primary care provider (PCP).................................................................20
Provider directory .......................................................................................................................21
Choosing your PCP.....................................................................................................................21
If your current PCP is not in the Anthem HealthKeepers Plus network.....................................21
Changing your PCP.....................................................................................................................21
Getting an appointment with your PCP ......................................................................................22
Appointment standards ...............................................................................................................22
How to get care from other network providers ...........................................................................22
Travel time and distance standards .............................................................................................23
Anthem HealthKeepers Plus Member Services 1-800-901-0020 (TTY 711)
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Accessibility................................................................................................................................23
What if a provider leaves the Anthem HealthKeepers Plus network?........................................23
What types of people and places are network providers?...........................................................24
What are network pharmacies? ...................................................................................................24
Services you can get without a referral or prior authorization....................................................24
How to Get Specialty Care and Services.....................................................................................24
What are specialists?...................................................................................................................24
How do I access a network specialist?........................................................................................25
How to get care from out-of-network providers .........................................................................25
How to get care from out-of-state providers...............................................................................25
How to Get Emergency Care and Services.................................................................................26
What is an emergency? ...............................................................................................................26
What do you do in an emergency?..............................................................................................26
What is a medical emergency? ...................................................................................................26
What is a behavioral health emergency? ....................................................................................26
Examples of nonemergencies .....................................................................................................26
If you have an emergency when you are away from home ........................................................26
What is covered if you have an emergency? ..............................................................................27
Notifying the Anthem HealthKeepers Plus plan about your emergency....................................27
After an emergency.....................................................................................................................27
If you are hospitalized.................................................................................................................27
What if it wasn’t a medical emergency after all? .......................................................................27
How to Get Urgently Needed Care..............................................................................................28
What is urgently needed care? ....................................................................................................28
How to Get Prescription Drugs ...................................................................................................28
Rules for the Anthem HealthKeepers Plus plan’s outpatient drug coverage..............................28
Getting your prescriptions filled .................................................................................................28
List of Covered Drugs.................................................................................................................29
Limits for coverage of some drugs .............................................................................................29
Getting approval in advance .......................................................................................................30
Trying a different drug first ........................................................................................................30
Quantity limits ............................................................................................................................30
Emergency supply.......................................................................................................................30
Noncovered Drugs ......................................................................................................................30
Changing pharmacies..................................................................................................................31
What if you need a specialized pharmacy?.................................................................................31
Can you use mail-order services to get your prescriptions? .......................................................31
Can you get a long-term supply of drugs? ..................................................................................31
Can you use a pharmacy that is not in our network? ..................................................................31
What is the Patient Utilization Management and Safety (PUMS) program? .............................31
Benefits...........................................................................................................................................32
General coverage rules................................................................................................................32
Benefits covered through the Anthem HealthKeepers Plus plan................................................33
Extra benefits included in the Anthem HealthKeepers Plus plan ...............................................35
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What is Early and Periodic Screening, Diagnostic and Treatment services (EPSDT)? .............35
How to access EPSDT service coverage ....................................................................................35
How to access early intervention service coverage ....................................................................35
How to access Behavioral Health services .................................................................................36
How to access Addiction and Recovery Treatment Services (ARTS) .......................................36
How to access nonemergency transportation services................................................................37
Transportation services covered by the Anthem HealthKeepers Plus plan ................................37
Services Not Covered....................................................................................................................37
If you receive noncovered services.............................................................................................38
Services Covered Through Medicaid Fee-For-Service..............................................................38
Carved out services .....................................................................................................................38
Services that will end your enrollment .......................................................................................39
Service Authorization Procedure ................................................................................................40
Service authorizations explained ................................................................................................40
Service authorizations and continuity of care .............................................................................41
How to submit a service authorization request ...........................................................................41
What happens after submitting a service authorization request?................................................41
Time Frames for Service Authorization Review ........................................................................41
Benefit determination..................................................................................................................42
Care notification..........................................................................................................................42
Post payment review ...................................................................................................................42
Appeals, State Fair Hearings, and Complaints (Grievances) ...................................................42
Your right to appeal ....................................................................................................................42
Authorized representative ...........................................................................................................43
Adverse benefit determination....................................................................................................43
How to submit your appeal .........................................................................................................43
Continuation of benefits..............................................................................................................44
What happens after we get your appeal ......................................................................................44
Time frames for appeals..............................................................................................................44
Standard appeals .........................................................................................................................44
Expedited appeals .......................................................................................................................44
If we need more information.......................................................................................................45
Written notice of appeal decision ...............................................................................................45
Your right to a State Fair Hearing...............................................................................................45
Standard or expedited review requests .......................................................................................46
Authorized representative ...........................................................................................................46
Where to send the State Fair Hearing request.............................................................................46
After you file your State Fair Hearing appeal.............................................................................46
State Fair Hearing time frames ...................................................................................................46
Expedited appeal.........................................................................................................................46
Standard appeal...........................................................................................................................47
Continuation of benefits..............................................................................................................47
If the State Fair Hearing reverses the denial ...............................................................................47
If services were not continued while the State Fair Hearing was pending .................................47
If services were provided while the State Fair Hearing was pending.........................................47
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If you disagree with the State Fair Hearing decision ..................................................................47
Your right to file a complaint......................................................................................................47
What kinds of problems should be complaints ...........................................................................47
Complaints about quality ............................................................................................................48
Complaints about privacy ...........................................................................................................48
Complaints about poor customer service ....................................................................................48
Complaints about accessibility ...................................................................................................48
Complaints about communication access ...................................................................................48
Complaints about waiting times..................................................................................................48
Complaints about cleanliness......................................................................................................48
Complaints about communications from us ...............................................................................48
There are different types of complaints ......................................................................................48
Internal complaints......................................................................................................................49
External complaints ....................................................................................................................49
You can file a complaint with the Managed Care Helpline........................................................49
You can file a complaint with the Office for Civil Rights..........................................................49
Member Rights..............................................................................................................................50
Your rights ..................................................................................................................................50
Your right to be safe ...................................................................................................................51
Your right to confidentiality .......................................................................................................51
Your right to privacy...................................................................................................................51
How to join the Member Advisory Committee ..........................................................................55
We follow non-discrimination policies.......................................................................................55
Member Responsibilities ..............................................................................................................55
Your responsibilities ...................................................................................................................55
Advance Directives .....................................................................................................................56
Where to get the Advance Directives form.................................................................................56
Completing the Advance Directives form ..................................................................................56
Share the information with people you want to know about it ...................................................56
We can help you get or understand Advance Directives documents..........................................57
Other resources ...........................................................................................................................57
If your Advance Directives are not followed..............................................................................57
Fraud, Waste, and Abuse .............................................................................................................58
What is Fraud, waste and abuse? ................................................................................................58
How do I report fraud, waste or abuse? ......................................................................................58
Maternal and Child Health Resources........................................................................................60
Special care for pregnant members.............................................................................................60
When you become pregnant........................................................................................................60
Your pregnancy education package ............................................................................................60
During your pregnancy ...............................................................................................................61
When you have a new baby ........................................................................................................61
After you have your baby ...........................................................................................................61
FAMIS Covered Services .............................................................................................................62
External appeals for FAMIS members .......................................................................................79
Anthem HealthKeepers Plus Member Services 1-800-901-0020 (TTY 711)
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Key Words and Definitions Used in this Handbook ..................................................................80
Member Services ........................................................................................................................84
Appendix A.................................................................................................................................84
Help in other languages or alternate formats
This handbook is available for free in other languages and formats including online, large print, braille or audio CD. To request this handbook in an alternate format and/or language, call Member Services at 1-800-901-0020, and it will be provided within five business days. If you are having difficulty understanding this information, please contact our Member Services staff at 1-800-901-0020 (TTY 711) for help at no cost to you. Additionally, members with alternative hearing or speech communication needs can dial 711 to reach a Telecommunications Relay Services (TRS) operator who will help you reach Anthem HealthKeepers Plus Member Services staff. Voice and TRS users can make a 711 call from any telephone anywhere in the United States free of charge. If you do not speak English, call us at 1-800-901-0020 (TTY 711). We have access to interpreter services and can help answer your questions in your language. We can also help you find a health care provider who can communicate with you in your language. Spanish: Si no habla inglés, llámenos a 1-800-901-0020 (TTY 711). Tenemos acceso a servicios de intérprete y podemos ayudar a responder sus preguntas en su idioma de forma gratuita. También podemos ayudarle a encontrar un proveedor de atención médica que pueda comunicarse con usted en su idioma. Korean: 영어로 말할 수 없다면1-800-901-0020 (TTY 711). 로 전화하십시오. 저희는 통역 서비스를 이용할 수 있으며 귀하의 언어로 된 질문에 무료로 답변 할 수 있습니다. 우리는 또한 귀하의 언어로 의사 소통 할 수있는 의료 서비스 제공자를 찾도록 도울 수 있습니다.
Anthem HealthKeepers Plus Member Services 1-800-901-0020 (TTY 711)
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Vietnamese: Nếu bạn không nói được tiếng Anh, hãy gọi cho chúng tôi tại 1-800-901-0020 (TTY 711). Chúng tôi có quyền truy cập vào các dịch vụ phiên dịch và có thể giúp trả lời câu hỏi của bạn trong ngôn ngữ của bạn miễn phí. Chúng tôi cũng có thể giúp bạn tìm thấy một nhà cung cấp chăm sóc sức khỏe người có thể giao tiếp với bạn bằng ngôn ngữ của bạn. Chinese: 如果您不会说英语，请致电1-800-901-0020 (TTY 711)。我们可以使用翻译服务 ，并可以用您的语言免费回答您的问题。 我们还可以帮助您找到一个能用您的语言与您 沟通的医疗保健提供者。 Arabic: نت إغا٪ الϦٌ لو٫ جϴ ، ةϴ ل يز٫ Ϩ اإلϟ ع ل َ ب نا اث ض1-Ϧٌ Λ ث بلϠا-Ϧٌ Λ ث بلϠ ا1-800-901-0020 (TTY 711)Ϟٌ ح ضϠ ه جرج ن خ عهات ع ل َ ا،ϲٌ ش قϧ٫ وϴً Ϧ ث شاعع أϳ ع ل َ ب ةاإلج ا ف٩ ل غة أ س ئ ل جϠب ا دا صةϠ ا٩ ب. ن نا٫ وϴ ضاϴ أ٩ غ ثٌؼ ه شاععثϠ ة هٌف ر ع ل َ اϴ رعاϠ ض ح ية اϠ اϧ ϴ ػϠ اϧ٫ وϴ ϟ جٌا صϠ ا٩ه غ ل غةϠ دا صة ب اϠ ا٩ ب. Tagalog: kung ikaw ay hindi nagsasalita ng ingles , mo sa amin 1-800-901-0020 (TTY 711). kami ay ng interpreter paglilingkod at makakatulong ang sagot sa tanong na ang wika ng katungkulan . at kami ay tulungan ka ng ng pangangalaga sa kalusugan nagkakaloob na ang pamamahagi sa inyo sa inyong mga wika. Farsi: نا1-800-901-0020 (TTY 711) έیذ دήاس ب̴یϤΗ با ناΖ̴لیش̶ صحةϧ ή̳ کϤذ ڪϧوΗ ̶ا نϤ شϥباί ΕالوΌجم شفاه̶ و سήΘ نΕ خذناϫس̶ بήΘدس ϫ ڪΖس ̶Θش ها̵ بهذΖقةή نϪذϨ دهϫέ کϤیذ ڪϧوΗ ̶ نϦیϨچϤ نا ه.ذϨڪ .یذϨ ڪ پیذέ خودϥباί اϤةاط با شΗέ ذϧوΗ ̶ن Amharic: እንግሊዝኛ መናገር የማይችሉ ከሆነ, 1-800-901-0020 (TTY 711) ይደውሉልን. እኛ የአስተርጓሚ አገልግሎቶች መዳረሻ ያላቸው እና ከክፍያ ነጻ በራስዎ ቋንቋ ውስጥ የእርስዎን ጥያቄዎች መልስ ለማግኘት ይችላሉ. እኛ ደግሞ እንደ እናንተ የእርስዎን ቋንቋ ከአንተ ጋር መገናኘት የሚችል የጤና እንክብካቤ አቅራቢ እንዲያገኙ ሊረዱዎት ይችላሉ. Urdu: ή آپ اگή ی ںى ہ ی زڱاى ڰ، ج و ب ون حے1-800-901-0020 (TTY 711) ή پϢ ګ ال ی ںہή ی ںګ. Ϣ ہ Ϣ جή سائ ج ڪ خ ذمات ڱک م حέ ہ ے حا صم ڱέُ اϡج ګ ے ف ثέب اه ڱاپ و اى چاί ϡګ ا سواال ت ګ ے آپ ی ں ی يےد جوابϡ مذد ی ںή س ڬ حے ګ. Ϣ ب اه ڱک آپ جو آپ ڱب َ ى ے ہί ϡ ی ثچ ب ات ساج َ ګ ے آپ ی ںή ګ ب َال ی ڬ َد ڱک ص خث ی ڪا س ڬ حےϢ اہή ج بلش ڱک فϡ مذد ی ںή ی ں ً س ڬ حے ګ. French: Si vous ne parlez pas anglais, appelez-nous à 1-800-901-0020 (TTY 711). Nous avons accès à des services d'interprètes et pouvons vous aider à répondre à vos questions dans votre langue gratuitement. Nous pouvons également vous aider à trouver un fournisseur de soins de santé qui peut communiquer avec vous dans votre langue. Russian: Если вы не говорите по-английски, позвоните нам по телефону 1-800-901-0020 (TTY 711). Мы имеем доступ к услугам переводчика и может помочь ответить на ваши вопросы на вашем языке бесплатно. Мы также можем помочь вам найти поставщика медицинских услуг, которые могут общаться с вами на вашем языке.
Anthem HealthKeepers Plus Member Services 1-800-901-0020 (TTY 711)
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Hindi: आप अग्रtं जm नहीं बोलतt हैं, तो 1-800-901-0020 (TTY 711) पर कvल करें । हम दभाििया सtवाओ ं कt िलए उपयोग िकया n हu और िन: शल्क n अपनm भािा में आपकt सवालों कt जवाब कर सकतt ह।ैं हम यह भm मदद कर सकता हu आप एक स्वास्थय् दtखभाल प्रदाता जो आपकी भािा में आप कt साथ संवाद कर सकतt ह।ैं German: Wenn Sie kein Englisch sprechen, rufen Sie uns unter 1-800-901-0020 (TTY 711) an. Wir haben Zugang zu Dolmetscherdiensten und können Ihnen helfen, Ihre Fragen in Ihrer Sprache kostenlos zu beantworten. Wir können Ihnen auch helfen, einen Arzt zu finden, der mit Ihnen in Ihrer Sprache kommunizieren kann. Bengali: আĚ ইংরđĚজ ৌĒরą ęĚđ ę, ąęĖরĒ 1-800-901-0020 (711 TTY) আďęরেđ ĕরে যĐęগęরĐęগ করু. আďđę যেę্ęĔěđ ĚđরĔৌęগুĚĒরą অ্যęরেĕ আরছ এৌং Ěখđচę আęđ ্ęĔęয় আęđ প্ররেđ উত্তđ ĕęĖęĐয কđরą ęরđ. আďđę ĕęĖęĐয কđরą ęরđ একটি স্বęরযযđ Đত্ন প্রেęকęđě Đęđę আęđ ্ęĔęয় আęđ ĕęরĆ যĐęগęরĐęগ কđরą ęরđ. Portuguese: Se você não fala inglês, ligue para 1-800-901-0020 (TTY 711). Temos acesso a serviços de intérprete e podemos ajudar a responder às suas perguntas no seu idioma gratuitamente. Também podemos ajudá-lo a encontrar um profissional de saúde que possa se comunicar com você em seu idioma.
Medicaid Managed Care Plan Welcome to the Anthem HealthKeepers Plus plan offered by HealthKeepers, Inc. Thank you for choosing us as your preferred Medicaid Managed Care plan. If you are a new member, we will get in touch with you in the next few weeks to go over some very important information with you. You can ask us any questions you may have or get help making appointments. If you need to speak with us right away or before we contact you, call Anthem HealthKeepers Plus Member Services at 1-800-901-0020 (TTY 711), visit our website at www.anthem.com/vamedicaid, or call Virginia Medicaid Managed Care Helpline at 1-800-643-2273 (TTY 1-800-817-6608) Monday – Friday, 8:30 a.m. – 6:00 p.m. for help. This handbook is also available on the Anthem HealthKeepers Plus website located at www.anthem.com/vamedicaid. How to use this handbook This handbook will help you understand your benefits and how you can get help from us. This handbook is a health care and Anthem HealthKeepers Plus member guide that explains health care services, behavioral health coverage, prescription drug coverage, and other services and supports covered under the program. This guide will help you take the best steps to make our health plan work for you. Feel free to share this handbook with a family member or someone who knows your health care needs. When you have a question or need guidance, please check this handbook, call Anthem HealthKeepers Plus Member Services at 1-800-901-0020 (TTY 711), visit our website at www.anthem.com/vamedicaid, or call Virginia Medicaid Managed Care Helpline free of charge at 1-800-643-2273 (TTY 1-800-817-6608) Monday-Friday, 8:30 a.m.-6 p.m.
Anthem HealthKeepers Plus Member Services 1-800-901-0020 (TTY 711)
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Your welcome packet Member ID card You should have received a welcome packet that included your Anthem HealthKeepers Plus member ID card. Your member ID card is used to access Medicaid managed care program health care services and supports at doctor visits and when you pick up prescriptions. You must show this card to get services or prescriptions. Below is a sample card to show you what yours will look like:
For FAMIS members, yours will look like:
If you haven’t received your card, or if your card is damaged, lost or stolen, call the Member Services number located at the bottom of this page right away, and we will send you a new card. Keep your Commonwealth of Virginia Medicaid ID card to access services that are covered through the State, under the Medicaid fee-for-service program. These services are described in Services Covered through Medicaid Fee-For-Service, in Section 10 of this handbook. Provider and Pharmacy Directories You should have received information about the Anthem HealthKeepers Plus Provider and Pharmacy Directories. These directories list the providers and pharmacies that participate in the Anthem HealthKeepers Plus network. While you are a member of our plan, and in most cases, you must use one of our network providers (doctors and pharmacies in our plan) to get covered services.
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You may ask for a paper copy of the Provider and Pharmacy Directory by calling Member Services at the number at the bottom of the page. You can also see or download the Provider and Pharmacy Directory at www.anthem.com/vamedicaid. Use your provider directory to find: A primary care provider (PCP) Specialists Doctors in your area Doctors who speak your language Contact information for doctors you want to see Pharmacies in the Anthem HealthKeepers Plus plan You can also search for doctors and other providers near you with our Find a Doctor tool online and on our Anthem Medicaid mobile app. Search by location, provider type or specialty to find the provider you’re looking for. Visit our website at www.anthem.com/vamedicaid or download the Anthem Medicaid mobile app. What is the Anthem HealthKeepers Plus service area? We serve members anywhere in the Commonwealth of Virginia. Our service area includes the cities and counties listed below. Central region: Accomack, Amelia, Brunswick, Caroline, Charles City, Chesterfield, Colonial Heights, Cumberland, Dinwiddie, Emporia, Essex, Franklin City, Fredericksburg, Goochland, Greensville, Hanover, Henrico, Hopewell, King and Queen, King George, King William, Lancaster, Lunenburg, Mathews, Mecklenburg, Middlesex, New Kent, Northampton, Northumberland, Nottoway, Petersburg, Powhatan, Prince Edward, Prince George, Richmond City, Richmond County, Southampton, Stafford, Surry, Sussex, Westmoreland Tidewater region: Chesapeake, Gloucester, Hampton, Isle of Wight, James City County, Newport News, Norfolk, Poquoson, Portsmouth, Suffolk, Virginia Beach, Williamsburg, York Northern and Winchester region: Alexandria, Arlington, Clarke, Culpeper, Fairfax City, Fairfax County, Falls Church, Fauquier, Frederick, Loudoun, Manassas City, Manassas Park, Page, Prince William, Rappahannock, Shenandoah, Warren, Winchester Charlottesville Western region: Albemarle, Amherst, Appomattox, Augusta, Buckingham, Campbell, Charlotte, Charlottesville, Danville, Fluvanna, Greene, Halifax, Harrisonburg, Louisa, Lynchburg, Madison, Nelson, Orange, Pittsylvania, Rockingham, Staunton, Waynesboro Roanoke/Alleghany region: Alleghany, Bath, Bedford City, Bedford County, Botetourt, Buena Vista, Covington, Craig, Floyd, Franklin County, Giles, Henry, Highland, Lexington, Martinsville, Montgomery, Patrick, Pulaski, Radford, Roanoke City, Roanoke County, Rockbridge, Salem, Wythe Southwest region: Bland, Bristol, Buchanan, Carroll, Dickenson, Galax, Grayson, Lee, Norton, Russell, Scott, Smyth, Tazewell, Washington, Wise
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Only people who live in our service area can enroll with us. If you move outside of our service area, you cannot stay in this plan. If this happens, you will receive a letter from Department of Medical Assistance Services (DMAS) asking you to choose a new plan. You can also call the Managed Care Helpline if you have any questions about your health plan enrollment. Contact the Managed Care Helpline at 1-800-643-2273 or visit the website at virginiamanagedcare.com. List of covered drugs The Provider and Pharmacy Directory will tell you about doctors, specialists and pharmacies in our plan. You must use a pharmacy in our plan to fill your prescriptions. The directory will help you pick a PCP and a pharmacy that you prefer. You can access or download the Provider and Pharmacy Directory at www.anthem.com/vamedicaid or receive a printed copy by calling 1-800-901-0020 (TTY 711) Monday through Friday from 8 a.m. to 6 p.m. Eastern time. For a list of drugs we cover, first look at our Preferred Drug List (PDL). The PDL is a list of preferred drugs that we pay for. Doctors must prescribe drugs on our PDL whenever possible. If you do not see your medication in our PDL, you can look to see if it is in our formulary. Our formulary is a comprehensive list of all the drugs we pay for. All of the drugs on our PDL are in our formulary, but not all of the drugs in our formulary are preferred. If your medication is in our formulary but not on our PDL, we will still pay for it — but you may need to get prior authorization (preapproval) in order for us to do so. You can access or download our PDL and formulary anytime at www.anthem.com/vamedicaid. You can also request a printed copy by calling Member Services at 1-800-901-0020 (TTY 711). List of Covered and Non-Covered Services See section 8 of this handbook or you can access or download Anthem HealthKeepers Plus Covered Services at www.anthem.com/vamedicaid or receive a printed copy by calling 1-800-901-0020 (TTY 711). See Continuity of Care Period in Section 2 of this handbook. Your cost-sharing responsibilities Medallion Medicaid members don’t have any cost-sharing responsibilities (copays) for benefits or services covered by the Anthem HealthKeepers Plus plan. FAMIS members may have some costsharing responsibilities based on their coverage. For more information about covered benefits for FAMIS members, see Section 17 of this handbook. Information about Eligibility If you have questions about your Medicaid eligibility, contact your case worker at the Department of Social Services in the city or county where you live. If you have questions about the services you get under your Anthem HealthKeepers Plus plan, please call the Member Services number listed at the bottom of this page. You may also visit Cover Virginia at www.coverva.org, or call 1-855-242-8282 or TDD: 1-888-221-1590. These calls are free.
Anthem HealthKeepers Plus Member Services 1-800-901-0020 (TTY 711)
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Getting help right away Anthem HealthKeepers Plus Member Services Our Member Services Staff are available to help you if you have any questions about your benefits, services, or procedures or have a concern about the Anthem HealthKeepers Plus plan. How to contact Anthem HealthKeepers Plus Member Services CALL
1-800-901-0020 This call is free. Monday-Friday from 8 a.m. to 6 p.m. Eastern time We have free interpreter services for people who do not speak English.
TTY
711 This call is free. Monday-Friday from 8 a.m. to 6 p.m. Eastern time
FAX WRITE
1-800-964-3627 Member Services Anthem HealthKeepers Plus P.O. Box 27401 Mail Drop VA2002-N500 Richmond, VA 23279 www.anthem.com/vamedicaid
WEBSITE
How Anthem HealthKeepers Plus Member Services representatives can help you Our Member Services representatives can help you: Answer questions about the Anthem HealthKeepers Plus plan Answer questions about claims, billing or Member ID Cards Assistance finding or checking to see if a doctor is in the Anthem HealthKeepers Plus network Assistance with changing your Primary Care Provider (PCP) Help you understand your benefits and covered services including the amount that we will pay so that you can make the best decisions about your health care. Appeals about your health care services (including drugs). An appeal is a formal way of asking us to review a decision we made about your coverage and asking us to change it if you think we made a mistake. Complaints about your health care services (including prescriptions). You can make a complaint about us or any provider (including a non-network or network provider). A network provider is a provider who works with the health plan. You can also make a complaint about the quality of the care you received to us or to the Managed Care Helpline at 1-800-643-2273. Case management services If you have complex health issues, we’ll connect you with a case manager. Case managers help make sure you receive the attention and quality of care your health issues demand. They’ll work with your PCP to design a care plan that reflects your specific needs and can help you find resources in your community for other services you might need.
Anthem HealthKeepers Plus Member Services 1-800-901-0020 (TTY 711)
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Case management doesn’t cost you anything. You can ask for case management services and opt out of them at any time. If you think case management services could help you, you or your provider can call our Member Services team at 1-800-901-0020 (TTY 711) Monday through Friday from 8 a.m. to 6 p.m. Eastern time and ask to be transferred to the Case Management department. Once you are assigned a case manager, he or she will reach out to you with his or her contact information. Member Services can also connect you with the case management team if you have questions or concerns or if you want to change your case manager. CALL
1-800-901-0020 This call is free. Monday through Friday from 8 a.m. to 6 p.m. Eastern time We have free interpreter services for people who do not speak English.
TTY
TTY 711 This call is free. This number is for people who have hearing or speaking problems. You must have special telephone equipment to call it. Monday through Friday from 8 a.m. to 6 p.m. Eastern time
FAX
1-866-920-4097
WRITE
Member Services Anthem HealthKeepers Plus P.O. Box 27401 Mail Drop VA2002-N500 Richmond, VA 23279 www.anthem.com/vamedicaid
WEBSITE
Behavioral Health Crisis Line Contact us if you do not know how to get services during a crisis. We will help find a crisis provider for you. Call 1-800-901-0020 (TTY 711). If your symptoms include thoughts about harming yourself or someone else, you should: Get help right away by calling 911. Go to the closest hospital for emergency care. CALL
TTY
1-800-901-0020 This call is free. Available 24 hours a day, 7 days a week We have free interpreter services for people who do not speak English. TTY 711 This call is free. This number is for people who have hearing or speaking problems. You must have special telephone equipment to call it.
Medical advice line available 24 hours a day, 7 days a week You can reach a nurse or behavioral health professional 24 hours a day, 7 days a week to answer your questions toll-free at 1-800-901-0020 (TTY 711). Choose the prompt for our 24/7 NurseLine to get help with health questions, options for care and advice on where to go when you need care.
Anthem HealthKeepers Plus Member Services 1-800-901-0020 (TTY 711)
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CALL
1-800-901-0020 This call is free. Available 24 hours a day, 7 days a week We have free interpreter services for people who do not speak English.
TTY
TTY 711 This call is free. This number is for people who have hearing or speaking problems. You must have special telephone equipment to call it.
Other resources Smiles for Children through DentaQuest, DMAS Dental Benefits Administrator
For questions or to find a dentist in your area, call Smiles For Children at 1-888-912-3456. Information is also available on the DMAS website at: http://www.dmas.virginia.gov/. Just go to “Other Maternal and Child Health Programs” on the “Maternal and Child Health” tab. Or visit the DentaQuest website at: http://www.dentaquestgov.com/.
Transportation
1-877-892-3988 (TTY 711)
DMAS Transportation Contractor for transportation to and from DD Waiver Services
1-866-386-8331 TTY 1-866-288-3133 Or dial 711 to reach a relay operator
Magellan of Virginia; DMAS Behavioral Health Services Administrator
Toll-free:1-800-424-4046 TDD: 1-800-424-4048 Or dial 711 to reach a relay operator http://www.magellanofvirginia.com/
Department of Health and Human Services’ Office for Civil Rights
1-800-368-1019 or visit the website at www.hhs.gov/ocrwww.hhs.gov/ocr
Maximus
1-800-643-2273
How Managed Care Works The program is a mandatory managed care program for members of Virginia Medicaid (12VAC30 120-370). The Department of Medical Assistance Services (DMAS) contracts with managed care organizations (MCOs) to provide most Medicaid covered services across the state. The Anthem HealthKeepers Plus plan is approved by DMAS to provide person-centered care coordination and health care services. Through this person-centered program, our goal is to help you improve your quality of care and quality of life.
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What makes you eligible to be a member? When you apply for Medical Assistance, you are screened for all possible programs based on your age, income, and other information. To be eligible for a Medical Assistance Program, you must meet the financial and non-financial eligibility conditions for that program. Please visit the Virginia Department of Social Services’ (VDSS) Medicaid Program page for eligibility details and/or VDSS Medicaid Forms and Applications page for application and other Medicaid form details. You are eligible for when you have full Medicaid benefits, and meet one of the following categories: Children under age 21 Foster Care and Adoption Assistance Child under age 26 Pregnant women including two months post delivery Parent Care-Takers Medicaid eligible persons who do not meet certain exclusion criteria must participate in the program. Enrollment is not a guarantee of continuing eligibility for services and benefits under the Virginia Medical Assistance Services Program. For more information about exclusionary criteria and participation, please refer to 12VAC30-120-370. What makes you unqualified to be a managed care member? You would not be able to participate if any of the following apply to you: You lose Medicaid eligibility. You do not meet one of the eligible categories above You meet exclusionary criteria 12VAC30-120-370 see appendix A. You are hospitalized at the time of enrollment You are enrolled in a Home and Community Based (HCBS) waiver You are admitted to a free standing psychiatric hospital You are receiving care in a Psychiatric Residential Treatment Level C Facility (children under 21) You meet the criteria for another Virginia Medicaid program Hospice Third Party Liability Enrollment Enrollment in the program is required for eligible individuals. DMAS and the Managed Care Helpline manage the enrollment for the program. To participate in, you must be eligible for Medicaid. The program allows for a process which speeds up member access to care coordination, disease management, 24-hour nurse call lines, and access to specialty care. This is especially important for members with chronic care needs, pregnant women, and foster care children who quickly need access to care. Health plan assignment You received a notice from DMAS that included your initial health plan assignment. With that notice DMAS included a comparison chart of health plans in your area. The assignment notice provided you with instructions on how to make your health plan selection.
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You may have chosen us to be your health plan. If not, DMAS may have assigned you to our health plan based upon your history with us as your managed care plan. For instance, you may have been enrolled previously through Medicaid and we were your managed care organization. You may also have been assigned to us if certain providers you see are in our network. Changing your health plan Assistance through the Managed Care Helpline can help you choose the health plan that is best for you. For assistance, call the Managed Care Helpline at 1-800-643-2273 or visit the website at virginiamanagedcare.com. The Managed Care Helpline is available Monday through Friday (except on State Holidays) from 8:30 a.m. to 6 p.m. Operators can help you understand your health plan choices and/or answer questions about which doctors and other providers participate with each health plan, among many helpful items. The helpline services are free and are not connected to any health plan. You can change your health plan during the first 90 days of your enrollment for any reason. You can also change your health plan once a year during open enrollment for any reason. You will get a letter from DMAS during open enrollment with more information. You may also ask to change your health plan for “good cause” at any time. The Helpline handles good cause requests and can answer any questions you have. Contact the Helpline at 1-800-643-2273 or visit the website at virginiamanagedcare.com. Automatic re-enrollment If your enrollment ends with us and you regain eligibility for the program within 60 days or less, you will automatically be reenrolled with us. You will be sent a re-enrollment letter from the Department of Medical Assistance Services. Enrollment for newborns If you have a baby, you will need to report the birth of your child as quickly as possible to enroll you baby for Medicaid. You can do this by: Calling the Cover Virginia Call Center at 1 (855) 242-8282 to report the birth of your child over the phone, or Contacting your local Department of Social Services to report the birth of your child. You will be asked to provide your information and your infant’s: Name Date of Birth Race Sex The infant’s mother’s name and Medicaid ID number We will provide benefits for your newborn for the entire birth month plus two additional consecutive months regardless of whether the newborn receives a Medicaid ID number. If you change the newborn’s enrollment during the “birth month plus two” period, then the new MCO will provide coverage for your newborn. In such cases, the former MCO is not responsible once the newborn is enrolled into another MCO.
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Coverage for your newborn for the “birth month plus two” period is not contingent on the mother’s continued enrollment with us. We will cover the newborn even if the mother does not remain enrolled after the newborn’s date of birth. What are the advantages of choosing the Anthem HealthKeepers Plus plan ? Some of the advantages of include: You will have access to Anthem HealthKeepers Plus Care Managers. Your care manager works with you and with your providers to make sure you get the care you need. You will be able to take control over your care with help from our care team and care managers. The care team and Care Managers are available to work with you to come up with a care plan specifically designed to meet your health needs. An on-call nurse or other licensed staff is available 24 hours per day, 7 days per week to answer your questions. We are here to help you. You can reach us by calling 1-800-901-0020 (TTY 711) at any time. When you choose us, you get more than just a health plan. You get: A team who has served Virginians with Medicaid for more than two decades. All your health care benefits, no matter where you live. We offer Medallion Medicaid and FAMIS benefits statewide. Over 25,000 plan doctors, hospitals and specialists to choose from. Plus, we offer no-cost extras like: Smartphone with monthly minutes, data, texts and unlimited calls to Member Services Mobile app – easily find health plan details on the go, plus search for nearby plan doctors, call the 24/7 NurseLine and more right from the app Sports physicals for kids New Baby, New LifeSM program – get rewards for keeping up with checkups and tips and tools to help you and your baby stay healthy Coupons with special discounts to local retailers Boys & Girls Club memberships for kids in the Southwest region What is a Health Risk Assessment? Within the first few weeks after you enroll with us, Case Management may reach out to you to ask questions about your needs and choices. They will talk with you about any medical, behavioral, physical, and social service needs that you may have. This meeting may be in-person or by phone and is known as a health risk assessment (HRA). An HRA is a complete assessment of your medical, psychosocial, cognitive, and functional status. The HRA is generally completed within the first 60 to 90 days of your enrollment with the Anthem HealthKeepers Plus plan depending upon the type of services that you require. This health risk assessment will enable Case Management to help you get the care that you need.
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Continuity of care period If the Anthem HealthKeepers Plus plan is new for you, you can keep previously authorized and/or scheduled doctor’s appointments and prescriptions for the first 30 days. If your provider is not currently in the Anthem HealthKeepers Plus network, then you may be asked to select a new provider that is in our provider network. If your doctor leaves our network, we will notify you within 15 days so that you have time to select another provider. What if I have other coverage? Medicaid is the payer of last resort. This means that if you have other insurance such as Tricare, Medicare, or private insurance, that insurance will have to pay first. We have the right and responsibility to collect for covered Medicaid services when Medicaid is not the first payer. Let Member Services know if you have other insurance so that we can best coordinate your benefits. Our Case Managers will also work with you and your other health plan to coordinate your services.
How to Get Regular Care and Services “Regular care” means routine care such as exams, well care check-ups, shots or other treatments to keep you well, getting medical advice when you need it, and refer you to the hospital or specialists when needed. Be sure to call your PCP whenever you have a medical question or concern. If you call after hours on weekends, leave a message and where or how you can be reached. Your PCP will call you back as quickly as possible. Remember, your PCP knows you and knows how the health plan works. Your care must be medically necessary. The services you get must be needed: – To prevent, or diagnose and correct what could cause more suffering, or – To deal with a danger to your life, or – To deal with a problem that could cause illness, or – To deal with something that could limit your normal activities. How to get care from a primary care provider (PCP) A PCP is a doctor selected by you who meets state requirements and is trained to give you basic medical care. You will usually see your PCP for most of your routine health care needs. Your PCP will work with you to coordinate most of the services you get as a Member of our plan. Coordinating your services or supplies includes checking or consulting with other plan providers about your care. If you need to see a doctor other than your PCP you may need a referral (authorization) from your PCP. You may also need to get approval in advance from your PCP before receiving certain types of covered services or supplies. In some cases, your PCP will need to get authorization (prior approval) from us. Since your PCP will provide and coordinate your medical care, you should have all of your past medical records sent to your PCP’s office. Contact Member Services with any questions about referrals or prior authorizations.
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Provider directory The provider directory includes a list of all of the doctors, specialty physicians, hospitals, clinics, pharmacies, laboratories, affiliations, accommodations for persons with physical disabilities, behavioral health providers, provider addresses, phone numbers, web site URLs, and new patient acceptance who work with the Anthem HealthKeepers Plus plan. We will also provide you with a paper copy of the provider directory upon request. You can also call Anthem HealthKeepers Plus Member Services at the number on the bottom of this page for assistance. Choosing your PCP If you do not have a PCP, we can help you find a highly qualified PCP in in your community. For help
locating a provider you can use our online provider directory at www.anthem.com/vamedicaid.
You may want to find a doctor:
Who knows you and understands your health condition,
Who is taking new patients,
Who can speak your language, or
Who has accommodations that you require
If you have a disabling condition or chronic illnesses you can ask us if your specialist can be your
PCP. We also contract with Federally Qualified Health Centers (FQHC). FQHCs provide primary and
specialty care. Another clinic can also act as your PCP if the clinic is a network provider.
Women can also choose an OB/GYN for women’s health issues. These include routine check-ups,
follow-up care if there is a problem, and regular care during a pregnancy. Women do not need a PCP
referral to see an OB/GYN provider in our network.
If you do not select a PCP by the 25th of the month before the effective date of your coverage, the
Anthem HealthKeepers Plus plan will auto-enroll you with a PCP. We will notify you in writing of the
assigned PCP. You will need to call the member services number at the bottom of the page to select a
new PCP.
If you need help finding a PCP, use our Find a Doctor tool online to search for PCPs near you at
www.anthem.com/vamedicaid. You can search by ZIP code, specialty and more. If you need more
help, call our Member Services team at the number below. We are here to help Monday through Friday
from 8 a.m. to 6 p.m. Eastern time.
If your current PCP is not in the Anthem HealthKeepers Plus network You can continue to see your current PCP for up to 90 days even if they are not in the Anthem HealthKeepers Plus network. During the first 90 days of your enrollment with the Anthem HealthKeepers Plus plan, your care manager can help you find a PCP in plan name’s network. At the end of the 90 day period, if you do not choose a PCP in the our network, we will assign a PCP to you. Changing your PCP You may call Member Services or go to our website to change your PCP at any time to another PCP in our plan. Please understand that it is possible your PCP will leave our plan. We will tell you within 15 days of the provider’s intent to leave our network. We will also transition you to a new PCP at least 30 calendar days before the effective date of your doctor’s disenrollment.
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We are happy help you find a new PCP. The web address for our Member Services program is www.anthem.com/vamedicaid. You can also call the number at the bottom of this page. It’s easy to change your PCP online. Our web tool is fast, convenient and available 24/7. To change your PCP online: Go to www.anthem.com/vamedicaid and log in to your secure account. Haven’t set up an account yet? Follow the instructions on the login page — all you need is your Anthem HealthKeepers Plus member ID number. Use our Find a Doctor tool to search for a PCP. Follow the instructions to change your PCP right from your secure account. If you need more help finding or changing your PCP, call Member Services at the number below. If you choose to change your PCP, we’ll send you a new member ID card with your PCP’s name on it. Getting an appointment with your PCP Your PCP will take care of most of your health care needs. Call your PCP to make an appointment. If you need care before your first appointment, call your PCP’s office to ask for an earlier appointment. If you need help making an appointment, call Member Services at the number below. Appointment standards You should be able to get an appointment with your PCP within the same amount of time as any other
patient seen by the PCP. Expect the following times to see a provider:
For an emergency - immediately.
For urgent care office visits with symptoms –24 hours of request.
For routine primary care visit – within 30 calendar days.
If you are pregnant, you should be able to make an appointment to see an OB/GYN as follows:
First trimester (first 3 months) - Within fourteen (14) calendar days of request.
Second trimester (3 to 6 months) - Within seven (7) calendar days of request.
Third trimester (6 to 9 months) - Within five (5) business days of request.
High Risk Pregnancy - Within three (3) business days or immediately if an emergency exists.
If you are unable to receive an appointment within the times listed above, call Member Services at
the number below and they will help you get the appointment. How to get care from other network providers Our provider network includes access to care 24 hours a day 7 days per week and includes hospitals, doctors, specialists, urgent care facilities, home and community based service providers, early intervention providers, rehabilitative therapy providers, addiction and recovery treatment services providers, home health, durable medical equipment providers, and other types of providers. The Anthem HealthKeepers Plus plan provides you with a choice of providers and they are located so that you do not have to travel very far to see them. There may be special circumstances where longer travel time is required; however, that should be only on rare occasions.
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Travel time and distance standards We will provide you with the services you need within the travel time and distance standards described in the table below. These standards apply for services that you travel to receive from network providers. These standards do not apply to providers who provide services to you at home. If you live in an urban area, you should not have to travel more than 30 miles or 45 minutes to receive services. If you live in a rural area you should not have to travel more than 60 miles or 75 minutes to receive services. Member Travel Time & Distance Standards Standard
Distance
Time
Urban • PCP • Specialists • Obstetrician
15 Miles 30 Miles NA
30 Minutes NA 45 Minutes
Rural • PCP, • Specialists • Obstetrician
30 Miles 60 Miles NA
60 Minutes NA 45 Minutes
Accessibility We want to make sure that all providers and services are as accessible (including physical and geographic access) to individuals with disabilities as they are to individuals without disabilities. If you have difficulty getting an appointment to a provider, or accessing services because of a disability, contact Member Services at the telephone numbers below for assistance. What if a provider leaves the Anthem HealthKeepers Plus network? A network provider you are using might leave our plan. If one of your providers does leave our plan,
you have certain rights and protections that are summarized below:
Even though our network of providers may change during the year, we must give you
uninterrupted access to qualified providers. When possible, we will give you at least 15 days’ notice so that you have time to select a new provider. We will help you select a new qualified provider to continue managing your Health care needs. If you are undergoing medical treatment, you have the right to ask, and we will work with you to ensure, that the medically necessary treatment you are getting is not interrupted. If you believe we have not replaced your previous provider with a qualified provider or that your care is not being appropriately managed, you have the right to file a complaint. If you find out one of your providers is leaving our plan, please contact your Case Manager so we can assist you in finding a new provider and managing your care.
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What types of people and places are network providers? Our network providers include:
Doctors, nurses, and other health care professionals that you can go to as a Member of our plan;
Clinics, hospitals, nursing facilities, and other places that provide health services in our plan;
Providers for children with special health care needs,
Behavioral Health and Substance Abuse practitioners, therapists, and counselors
You can use any doctor or specialist as long as they are in the Anthem HealthKeepers Plus plan — regardless of where you live. What are network pharmacies? Network pharmacies are pharmacies (drug stores) that have agreed to fill prescriptions for our Members. Use the Provider and Pharmacy Directory to find the network pharmacy you want to use. Except during an emergency, you must fill your prescriptions at one of our network pharmacies if you want our plan to help you pay for them. Call Member Services at the number at the bottom of the page for more information. Both Member Services and our website can give you the most up-to-date information about changes in our network pharmacies and providers Services you can get without a referral or prior authorization In most cases, you will need an approval from your PCP before seeing other providers. This approval is called a referral. You can get services like the ones listed below without first getting approval from your PCP: Any services from network providers Emergency services from network providers or out-of-network providers. Urgent care from network providers. Family Planning Services and Supplies Routine women’s health care services. This includes breast exams, screening mammograms (x rays of the breast), Pap tests, and pelvic exams as long as you get them from a network provider Additionally, if you are eligible to get services from Indian health providers, you may see these providers without a referral.
How to Get Specialty Care and Services What are specialists? If you need care that your PCP cannot provide, your PCP may refer you to a specialist. Most of the
specialists are in the Anthem HealthKeepers Plus network. A specialist is a doctor who provides health
care for a specific disease or part of the body. There are many kinds of specialists. Here are a few
examples:
Oncologists care for patients with cancer.
Cardiologists care for patients with heart problems.
Orthopedists care for patients with bone, joint, or muscle problems.
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If you need to see a specialist for ongoing care, your PCP may be able to refer you for a specified number of visits or length of time (known as a standing referral). If you have a standing referral, you will not need a new referral each time you need care. If you have a disabling condition or chronic illnesses you can ask us if your specialist can be your PCP. How do I access a network specialist? No referrals or authorizations (approval from us before getting a service or medication) are required to see a network specialist (specialist in our plan). Please see Section 8 (Benefits) for information about which services require authorization. How to get care from out-of-network providers All visits to out-of-network doctors and specialists require an authorization from us. We authorize
visits to out-of-network providers when there’s an emergency, or when we don’t have a doctor in the
plan who can give you the service or procedure you need.
If we do not have a specialist in the Anthem HealthKeepers Plus network to provide the care you need,
we will get you the care you need from a specialist outside of our network. We will also get you care
outside of our network in any of the following circumstances:
When the Anthem HealthKeepers Plus plan has approved a doctor out of its established network;
When emergency and family planning services are rendered to you by an out of network provider
or facility; When you receive emergency treatment by providers not in the network; When the needed medical services are not available in our network; When we cannot provide the needed specialist within the distance standard of more than 30 miles in urban areas or more than 60 miles in rural areas; When the type of provider needed and available in our network does not, because of moral or religious objections, furnish the service you need (the Anthem HealthKeepers Plus plan does not have moral or religious restrictions on coverage for counseling or referral services, but certain innetwork providers may have restrictions); Within the first ninety (90) calendar days of your enrollment, where your provider is not part of our network but he has treated you in the past; and, If you are in a nursing home when you enroll with us, and the nursing home is not in our network. If your PCP or Anthem HealthKeepers Plus plan refer you to a provider outside of our network, you are not responsible for any of the costs. See Section 14 of this handbook for information about what a patient pay is and how to know if you have one. How to get care from out-of-state providers The Anthem HealthKeepers Plus plan is not responsible for services you obtain outside Virginia
except under the following circumstances:
Necessary emergency or post-stabilization services;
Where it is a general practice for those living in your locality to use medical resources in another
State; and,
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The required services are medically necessary and not available in-network and within the Commonwealth.
How to Get Emergency Care and Services What is an emergency? You’re always covered for emergencies. An emergency is a sudden or unexpected illness, severe pain, accident or injury that could cause serious injury or death if it is not treated immediately. What do you do in an emergency? Call 911 at once! You do not need to call us first. Go to the closest hospital. Calling 911 will help you get to a hospital. You can use any hospital for emergency care, even if you are in another city or state. If you are helping someone else, please remain calm. Tell the hospital that you are an Anthem HealthKeepers Plus member. Ask them to call us at the number on the back of your Insurance Card. What is a medical emergency? This is when a person thinks he or she must act quickly to prevent serious health problems. It includes symptoms such as severe pain or serious injury. The condition is so serious that, if it doesn’t get immediate medical attention, you believe that it could cause: serious risk to your health; or serious harm to bodily functions; or serious dysfunction of any bodily organ or part; or in the case of a pregnant woman in active labor, meaning labor at a time when either of the following would occur: – There is not enough time to safely transfer you to another hospital before delivery. – The transfer may pose a threat to your health or safety or to that of your unborn child. What is a behavioral health emergency? A behavioral health emergency is when a person thinks about or fears they might hurt themselves or someone else. Examples of nonemergencies Examples of nonemergencies are: colds, sore throat, upset stomach, minor cuts and bruises, or sprained muscles. If you are not sure, call your PCP or the Anthem HealthKeepers Plus 24/7 Nurse HelpLine at: 1-800-901-0020 (TTY 711). If you have an emergency when you are away from home You or a family Member may have a medical or a behavioral health emergency away from home. You may be visiting someone outside Virginia. While traveling, your symptoms may suddenly get worse. If this happens, go to the closest hospital emergency room. You can use any hospital for emergency care. Show them your member ID card. Tell them you are in the Anthem HealthKeepers Plus program.
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What is covered if you have an emergency? You may get covered emergency care whenever you need it, anywhere in the United States or its territories. If you need an ambulance to get to the emergency room, our plan covers that. If you have an emergency, we will talk with the doctors who give you emergency care. Those doctors will tell us when your medical emergency is complete. Notifying the Anthem HealthKeepers Plus plan about your emergency Notify your doctor and the Anthem HealthKeepers Plus plan as soon as possible about the emergency within 48 hours if you can. However, you will not have to pay for emergency services because of a delay in telling us. We need to follow up on your emergency care. Your Care Coordinator will assist you in getting the correct services in place before you are discharged to ensure that you get the best care possible. Please call our Member Services team at 1-800-901-0020 (TTY 711) Monday through Friday from 8 a.m. to 6 p.m. Eastern time. This number is also listed on the back of your Member ID card. After an emergency We will provide necessary follow-up care, including to out of network providers, until your physician says that your condition is stable enough for you to transfer to an in-network provider, or for you to be discharged. If you get your emergency care from out-of-network providers, we will try to get network providers to take over your care as soon as possible after your physician says you are stable. You may also need follow-up care to be sure you get better. Your follow-up care will be covered by our plan. If you are hospitalized If you are hospitalized, a family Member or a friend should contact the Anthem HealthKeepers Plus plan as soon as possible. By keeping us informed, your Care Coordinator can work with the hospital team to organize the right care and services for you before you are discharged. Your Care Coordinator will also keep your medical team including your home care services providers informed of your hospital and discharge plans. What if it wasn’t a medical emergency after all? Sometimes it can be hard to know if you have a medical emergency. You might go in for emergency care, and the doctor may say it wasn’t really a medical emergency. As long as you reasonably thought your health was in serious danger, we will cover your care. However, after the doctor says it was not an emergency, we will cover your additional care only if: You go to a network provider, or The additional care you get is considered “urgent care” and you follow the rules for getting urgently needed care this care. (See Urgently Needed Care in Section 6 of this handbook.)
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How to Get Urgently Needed Care What is urgently needed care? Urgently needed care is care you get for a sudden illness, injury, or condition that isn’t an emergency but needs care right away. For example, you might have an existing condition that worsens and you need to have it treated right away. In most situations, we will cover urgently needed care only if you get this care from a network provider. However, if you can’t get to a doctor in the plan, we will cover urgently needed care you get from an out-of-network provider. You can find a list of urgent care centers we work with in our Provider and Pharmacy Directory, available on our website at www.anthem.com/vamedicaid. When you are outside the service area, you might not be able to get care from a network provider. In that case, our plan will cover urgently needed care you get from any provider.
How to Get Prescription Drugs This Section explains rules for getting your outpatient prescription drugs. These are drugs that your provider orders for you that you get from a pharmacy or drug store. Rules for the Anthem HealthKeepers Plus plan’s outpatient drug coverage We will usually cover your drugs as long as you follow the rules in this Section. 1. You must have a doctor or other provider write your prescription. This person often is your primary care provider (PCP). It could also be another provider if your primary care provider has referred you for care. 2. You must use a network pharmacy to fill your prescription. 3. Your prescribed drug must be on our List of Covered Drugs. If it is not on the Drug List, we may be able to cover it by giving you an authorization. Usually, your provider will request an authorization if they think you need a drug that is not on our List of Covered Drugs. If you wish to request an authorization yourself, call Member Services at the number listed at the bottom of the page. 4. Your drug must be used for a medically accepted indication. This means that the use of the drug is either approved by the Food and Drug Administration or supported by certain reference books. Getting your prescriptions filled In most cases, we will pay for prescriptions only if they are filled at Anthem HealthKeepers Plus network pharmacies. A network pharmacy is a drug store that has agreed to fill prescriptions for our Members. You may go to any of our network pharmacies. To find a network pharmacy, you can look in the Provider and Pharmacy Directory, visit our website, or contact Member Services at the number at the bottom of the page. To fill your prescription, show your Member ID Card at your network pharmacy. The network pharmacy will bill us for the cost of your covered prescription drug. If you do not have your Member ID Card with you when you fill your prescription, ask the pharmacy to call us to get the necessary information.
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If you need help getting a prescription filled, you can contact Member Services at the number at the bottom of the page. List of Covered Drugs The Anthem HealthKeepers Plus plan has a List of Covered Drugs that we select with the help of a team of doctors and pharmacists. Our List of Covered Drugs also includes all of the drugs on the DMAS Preferred Drug List (PDL), but the DMAS PDL may vary from our Anthem HealthKeepers Plus PDL. The List of Covered Drugs can be found at www.anthem.com/vamedcaid. The List of Covered Drugs tells you which drugs are covered by us and tells you if there are any rules or restrictions on any drugs, such as a limit on the amount you can get. You can call Member Services to find out if your drugs are on the List of Covered Drugs or check online at www.anthem.com/vamedicaid or we can mail you a paper copy of the List of Covered Drugs. The List of Covered Drugs may change during the year. To get the most up-to-date List of Covered Drugs, visit www.anthem.com/vamedicaid or call our Member Services team at 1-800-901-0020 (TTY 711) Monday through Friday from 8 a.m. to 6 p.m. Eastern time. They’ll also send you a paper copy, free of charge, if you need one. We update the online drug list whenever there are changes. We’ll also notify you in writing about any changes to the List of Covered Drugs which will require you to switch to a different drug, especially if the drug comes off the Preferred Drug List. We’ll generally cover a drug on our PDL as long as you follow the rules explained in this section. You can also get drugs that are not on the PDL when medically necessary, but your doctor may need to get an authorization (preapproval) from us. Limits for coverage of some drugs For certain prescription drugs, special rules limit how and when we cover them. In general, our rules encourage you to get a drug that works for your medical condition and that is safe and effective, and cost effective. If there is a special rule for your drug, it usually means that you or your provider will have to take extra steps for us to cover the drug. For example, your provider may need to request a service authorization for you to receive the drug. We may or may not agree to approve the request without taking extra steps. Refer to Service Authorization and Benefit Determination and Service Authorizations and Continuity of Care in Section 11 of this Handbook. If we are new for you, you can keep getting your authorized drugs for the duration of the authorization or for 90 days after you first enroll, whichever is sooner. Refer to Continuity of Care Period in Section 11 of this handbook. If we deny or limit coverage for a drug, and you disagree with our decision, you have the right to appeal our decision. Refer to Your Right to Appeal in Section 12 of this handbook. If you have any concerns, contact your Care Coordinator. Your Care Coordinator will work with you and your PCP to make sure that you receive the drugs that work best for you.
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Getting approval in advance For some drugs, you or your doctor must get a service authorization approval from the Anthem HealthKeepers Plus plan before you fill your prescription. If you don’t get approval, we may not cover the drug. Trying a different drug first We may require that you first try one (usually less-expensive) drug before we will cover another (usually more-expensive) drug for the same medical condition. For example, if Drug A and Drug B treat the same medical condition, the plan may require you to try Drug A first. If Drug A does not work for you, then we will cover Drug B. This is called step therapy. Quantity limits For some drugs, we may limit the amount of the drug you can have. This is called a quantity limit. For example, the plan might limit how much of a drug you can get each time you fill your prescription. To find out if any of the rules above apply to a drug your physician has prescribed, check the List of Covered Drugs. For the most up-to-date information, call Member Services or visit our website at www.anthem.com/vamedicaid. Emergency supply There may be an instance where your medication requires a service authorization, and your prescribing physician cannot readily provide authorization information to us, for example over the weekend or on a holiday. If your pharmacist believes that your health would be compromised without the benefit of the drug, we may authorize a 72-hour emergency supply of the prescribed medication. This process provides you with a short-term supply of the medications you need and gives time for your physician to submit a service authorization request for the prescribed medication. Noncovered Drugs By law the types of drugs listed below are not covered by Medicare or Medicaid:
Drugs used to promote fertility;
Drugs used for cosmetic purposes or to promote hair growth;
Drugs used for the treatment of sexual or erectile dysfunction, such as Viagra®, Cialis®, Levitra®,
and Caverject®, unless such agents are used to treat a condition other than sexual or erectile dysfunction, for which the agents have been approved by the FDA; Drugs used for treatment of anorexia, weight loss, or weight gain; All DESI (Drug Efficacy Study Implementation) drugs as defined by the FDA to be less than effective, including prescriptions that include a DESI drug; Drugs that have been recalled; Experimental drugs or non-FDA-approved drugs; and, Any drugs marketed by a manufacturer who does not participate in the Virginia Medicaid Drug Rebate program.
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Changing pharmacies If you need to change pharmacies and need a refill of a prescription, you can ask your pharmacy to transfer the prescription to the new pharmacy. If you need help changing your network pharmacy, you can contact Member Services at the number at the bottom of the page or your Care Coordinator. If the pharmacy you use leaves the Anthem HealthKeepers Plus network, you will have to find a new network pharmacy. To find a new network pharmacy, you can look in the Provider and Pharmacy Directory, visit our website, or contact Member Services at the number at the bottom of the page or your Care Coordinator. Member Services can tell you if there is a network pharmacy nearby. What if you need a specialized pharmacy? Sometimes prescriptions must be filled at a specialized pharmacy. These prescriptions are called specialty drugs. They often need you to have special care while taking them. Specialty drugs are often used to treat chronic illnesses, and they usually require special handling, administration or monitoring. We have a specialty pharmacy network for our members in case you need specialty drugs. These specialty pharmacies provide the special care needed when a specialty drug is dispensed. If you need specialty drugs, you must use a specialty pharmacy in our plan. The specialty pharmacies in our plan are Accredo and Acaria Health. If you have questions regarding your specialty pharmacy or your specialty drugs, call: Accredo at 1-877-241-3489 Acaria Health at 1-800-511-5144 Or you can call us at 1-800-901-0020 (TTY 711) if you have any difficulty obtaining your specialty medicines. We’re here to help. Call us to find out if a drug is considered a specialty drug or to get a copy of the specialty drug list. You and your doctor can work together to decide which drug is best for you. Can you use mail-order services to get your prescriptions? You cannot use mail-order services to get your prescriptions. Can you get a long-term supply of drugs? You can get up to a 31-day supply of your drugs. Can you use a pharmacy that is not in our network? In general, we will not pay for medicines you get at pharmacies that aren’t in our plan. What is the Patient Utilization Management and Safety (PUMS) program? Some members who require additional monitoring may be enrolled in the Patient Utilization Management and Safety (PUMS) program. The PUMS program is required by DMAS and helps make sure your drugs and health services work together in a way that won’t harm your health. As part of this program, we may check the Prescription Monitoring Program (PMP) tool that the Virginia Department of Health Professions maintains to review your drugs. This tool uses an electronic system to monitor the dispensing of controlled substance prescription drugs.
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If you are chosen for PUMS, you may be restricted to or locked into only using one pharmacy or only going to one provider to get certain types of medicines. We will send you a letter to let you know how PUMS works. The inclusion period is for 12 months. At the end of the lock in period, we’ll check in with you to see if you should continue the program. If you are placed in PUMS and don’t think you should be in the program, you can appeal. You must appeal to us within 60 days of when you get the letter saying that you have been put into PUMS. You can also request a State Fair Hearing. Refer to Appeals, State Fair Hearings, and Complaints in Section 12 of this handbook. If you’re in the PUMS program, you can get prescriptions after hours if your selected pharmacy doesn’t have 24-hour access. You’ll also be able to pick a PCP, pharmacy or other provider where you want to be locked in. If you don’t select providers for lock in within 15 days, we’ll choose them for you.
Members who are enrolled in PUMS will receive a letter from the Anthem HealthKeepers Plus plan
that provides additional information on PUMS including all of the following information:
A brief explanation of the PUMS program;
A statement explaining the reason for placement in the PUMS program;
Information on how to appeal to us if placed in the PUMS program;
information regarding how request a State Fair Hearing after first exhausting the our
appeals process; Information on any special rules to follow for obtaining services, including for emergency or after hours services; and Information on how to choose a PUMS provider. Contact Member Services at the number below or your Care Coordinator if you have any questions on PUMS.
Benefits General coverage rules To receive coverage for services you must meet the general coverage requirements described below. 1. Your services (including medical care, services, supplies, equipment, and drugs) must be medically necessary. Medically necessary generally means you need the services to prevent, diagnose, or treat a medical condition or prevent a condition from getting worse. 2. In most cases, you must get your care from a network provider. A network provider is a provider who works with the Anthem HealthKeepers Plus plan. In most cases, we will not pay for care you get from an out- of-network provider unless the service is authorized by us. Section 3 has information about Services You Can Get Without First Getting Approval From Your PCP. Section 4 has more information about using network and out-of-network providers. 3. Some of your benefits are covered only if your doctor or other network provider gets approval from us first. This is called service authorization. Section 11 includes more information about service authorizations 4. If the Anthem HealthKeepers Plus plan is new for you, you can keep seeing the doctors you go to now for the first 30 days. You can also keep getting your authorized services for the duration of the authorization or for 30 days after you first enroll, whichever is sooner. Also see Continuity of Care Period in Section 11.
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Benefits covered through the Anthem HealthKeepers Plus plan We cover all of the following services for you when they are medically necessary. Regular medical care, including office visits with your PCP, referrals to specialists, exams, etc. See Section 3 of this handbook for more information about PCP services. Preventive care, including regular check-ups, well baby/child care. See Section 3 of this handbook for more information about PCP services. Addiction, recovery, and treatment services (ARTS), including inpatient, outpatient, community based, medication assisted treatment, peer services, and case management. Services may require authorization. Additional information about ARTS services is provided later in this Section of the handbook. Behavioral health services, including inpatient and outpatient psychotherapy individual, family, and group are covered. (Except community mental health rehabilitation services are covered through Magellan, the DMAS Behavioral Health Services Administrator; see Section 8 of this handbook.) Clinic services. Colorectal cancer screening. Court ordered services. Durable medical equipment and supplies (DME). Early and periodic screening diagnostic and treatment services (EPSDT) for children under age 21. Additional information about EPSDT services is provided later in this Section of the handbook. Early intervention services for children from birth to age 3. Additional information about early intervention services is provided later in this Section of the handbook. Electroconvulsive therapy (ECT). Emergency custody orders (ECO). Emergency services including emergency transportation services (ambulance, etc.). Emergency and post stabilization services. Additional information about emergency and post stabilization services is provided in Section 5 and 6 of this handbook. End stage renal disease services. Eye examinations. Family planning services, including services, devices, drugs (including long acting reversible contraception) and supplies for the delay or prevention of pregnancy. You are free to choose your method for family planning including through providers who are in/out of the Anthem HealthKeepers Plus network. We do not require you to obtain service authorization or PCP referrals on family planning services. Glucose test strips. Hearing (audiology) services. Home health services. Hospital care – inpatient/outpatient. Human Immunodeficiency Virus (HIV) testing and treatment counseling. Immunizations. Inpatient psychiatric hospital services. Laboratory, Radiology and Anesthesia Services. Lead investigations
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Mammograms. Maternity care- includes: pregnancy care, doctors/certified nurse-midwife services. Additional information about maternity care is provided in Section 6 of this handbook. Nurse Midwife Services through a Certified Nurse Midwife provider. Organ transplants. Orthotics, including braces, splints and supports - for children under 21, or adults through an intensive rehabilitation program. Outpatient hospital services. Pap smears. Physician’s services or provider services, including doctor’s office visits. Physical, occupational, and speech therapies. Podiatry services (foot care). Prenatal and maternal services. Prescription drugs. See Section 7 of this handbook for more information on pharmacy services. Private duty nursing services (through EPSDT) Under Age 21 Prostate specific antigen (PSA) and digital rectal exams. Prosthetic devices including arms, legs and their supportive attachments, breasts, and eye prostheses). Psychiatric or psychological services. Radiology services. Reconstructive breast surgery. Renal (kidney) dialysis services. Rehabilitation services – inpatient and outpatient (including physical therapy, occupational therapy, speech pathology and audiology services). Scheduled immunizations Second opinion services from a qualified health care provider within the network or we will arrange for you to obtain one at no cost outside the network. The doctor providing the second opinion must not be in the same practice as the first doctor. Out of network referrals may be approved when no participating provider is accessible or when no participating provider can meet your individual needs. Surgery services when medically necessary and approved by the Anthem HealthKeepers Plus plan. Telemedicine services. Temporary detention orders (TDO). Tobacco Cessation Services. Transportation services, including emergency and non-emergency (air travel, ground ambulance, stretcher vans, wheelchair vans, public bus, Volunteer/ registered drivers, taxi cabs. We will also provide transportation to/from most carvedout services. Additional information about transportation services is provided later in this Section of the handbook. Vision services. Well Visits. Abortion services- coverage is only available in cases where there would be a substantial danger to life of the mother.
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Extra benefits included in the Anthem HealthKeepers Plus plan As a member of the Anthem HealthKeepers Plus plan you have access to services that are not generally covered through Medicaid fee-for-service. These are known as “enhanced benefits.” We provide the following enhanced benefits: Smartphone with monthly minutes, data, texts and unlimited calls to Member Services Mobile app — easily find health plan details on the go, plus search for nearby plan doctors, call the 24/7 NurseLine and more right from the app Sports physicals for kids New Baby, New LifeSM program — get rewards for keeping up with checkups and tips and tools to help you and your baby stay healthy Coupons with special discounts to local retailers Boys & Girls Club memberships for kids in the Southwest region * If you have any questions about these benefits, please call our Member Services Department at the number on the bottom of this page. What is Early and Periodic Screening, Diagnostic and Tr eatment services (EPSDT)? The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program is a federally mandated Medicaid benefit that provides comprehensive and preventive health care services for children under age 21. If you have a child that is under age 21, EPSDT provides appropriate preventive, dental, behavioral health, developmental, and specialty services. It includes coverage for immunizations, well child visits, lead investigations, private duty nursing, personal care, and other services and therapies that treat or make a condition better. It will also cover services that keep your child’s condition from getting worse. EPSDT can provide coverage for medically necessary services even if these are not normally covered by Medicaid. How to access EPSDT service coverage The Anthem HealthKeepers Plus plan provides most of the Medicaid EPSDT covered services. However, some EPSDT services, like pediatric dental care, are not covered by us. For any services not covered by us, you can get these through the Medicaid fee-for-service program. Additional information is provided in Section 11 of this handbook. There are no authorization requirements for getting EPSDT services, unless the provider is not in our network. How to access early intervention service coverage If you have a baby under the age of three, and you believe that he or she is not learning or developing like other babies and toddlers, your child may qualify for early intervention services. Early intervention includes services such as speech therapy, physical therapy, occupational therapy, service coordination, and developmental services to help families support their child’s learning and development during everyday activities and routines. Services are generally provided in your home.
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The first step is meeting with the local Infant and Toddler Connection program in your community to see if your child is eligible. Children from birth to age three are eligible if he or she has (i) a 25% developmental delay in one or more areas of development; (ii) atypical development; or, (iii) a diagnosed physical or mental condition that has a high probability of resulting in a developmental delay. For more information call your Care Coordinator. Your Care Coordinator can help. If your child is enrolled in the Anthem HealthKeepers Plus plan, we provide coverage for early intervention services. Your Care Coordinator will work closely with you and the Infant and Toddler Connection program to help you access these services and any other services that your child may need. Information is also available at www.infantva.org or by calling 1-800-234-1448. How to access Behavioral Health services Behavioral health services offer a wide range of treatment options for individuals with a mental health or substance use disorder. Many individuals struggle with mental health conditions such as depression, anxiety, or other mental health issues as well as using substances at some time in their lives. These behavioral health services aim to help individuals live in the community and maintain the most independent and satisfying lifestyle possible. Services range from outpatient counseling to hospital care, including day treatment and crisis services. These services can be provided in your home or in the community, for a short or long timeframe, and all are performed by qualified individuals and organizations. Some Behavioral Health services are covered for you through Magellan, the DMAS Behavioral Health Services Administrator (BHSA). Our Member Services can help coordinate the services you need, including those that are provided through the BHSA. If you need Behavioral Health services, call our Member Services team at the number at the bottom of the page. We’re here to help you get the services and providers you need. Some services may require a prior authorization (preapproval), including: Inpatient Behavioral Health services Any psychological testing that takes more than four hours. All neuropsychopathic testing How to access Addiction and Recovery Treatment Services (ARTS) The Anthem HealthKeepers Plus plan offers a variety of services that help individuals who are struggling with using substances, including drugs and alcohol. Addiction is a medical illness, just like diabetes, that many people deal with and can benefit from treatment no matter how bad the problem may seem.
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If you need treatment for addiction, we provide coverage for services that can help you. These services
include settings in inpatient, outpatient, residential, and community-based treatment. Medication
assisted treatment options are also available if you are dealing with using prescription or non prescription drugs. Other options that are helpful include peer services (someone who has experienced
similar issues and in recovery), as well as case management services. Talk to your PCP or call your
Care Coordinator to determine the best option for you and how to get help in addiction and recovery
treatment services. To find an ARTS provider, you can look in the Provider and Pharmacy Directory,
visit our website, call your Care Coordinator, or contact Member Services at one of the
numbers below.
To get ARTS services, talk with your provider directly, or give us a call at the Member Services
number at the bottom of this page. Certain ARTS program services require a
preapproval, including:
Substance abuse Intensive Outpatient Programs (IOPs)
Substance abuse peer support services
Substance abuse inpatient detox services
Suboxone and other substance abuse pharmacy-related services except for Gold Card providers
How to access nonemergency transportation services Transportation services covered by the Anthem HealthKeepers Plus plan Non-Emergency transportation services are covered by us for covered services, carved out services, and enhanced benefits. Transportation may be provided if you have no other means of transportation and need to go to a physician or a health care facility for a covered service. For urgent or non-emergency medical appointments, or if you are having problems getting transportation to your appointments, call Southeastrans at 1-877-892-3988 (TTY 711). In case of a life-threatening emergency, call 911. Refer to How to Get Care for Emergencies in Chapter 5 of this handbook.
Services Not Covered The following services are not covered by Medicaid or the Anthem HealthKeepers Plus plan. If you receive any of the following non-covered services you will be responsible for the cost of these services. Acupuncture Administrative expenses, such as completion of forms and copying records Artificial insemination, in-vitro fertilization, or other services to promote fertility Assisted suicide Certain drugs not proven effective Certain experimental surgical and diagnostic procedures Chiropractic services Christian Science nurses
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Cosmetic treatment or surgery Daycare, including sitter services for the elderly (except in some home- and community-based service waivers) Dentures for Members age 21 and over Drugs prescribed to treat hair loss or to bleach skin Elective Abortions Erectile Dysfunction Drugs Experimental or Investigational Procedures Eyeglasses or their repair for Members age 21 or older Immunizations if you are age 21 or older (except for flu and pneumonia for those at risk and as authorized by us) Medical care other than emergency services, urgent services, or family planning services, received from providers outside of the network unless authorized by us Routine dental care if you are age 21 or older Services rendered while incarcerated Care outside of the United States
If you receive noncovered services We cover your services when you are enrolled with our plan and: Services are medically necessary, and Services are listed as Benefits Covered Through the Anthem HealthKeepers Plus plan in Section 8 of this handbook, and You receive services by following plan rules. If you get services that aren’t covered by our plan or covered through DMAS, you must pay the full cost yourself. If you are not sure and want to know if we will pay for any medical service or care, you have the right to ask us. You can call Member services or your Care Coordinator to find out more about services and how to obtain them. You also have the right to ask for this in writing. If we say we will not pay for your services, you have the right to appeal our decision. Section 12 provides instructions for how to appeal our coverage decisions. You may also call Member Services to learn more about your appeal rights or to obtain assistance in filing an appeal.
Services Covered Through Medicaid Fee-For-Service DMAS will provide you with coverage for any of the services listed below. These services are known as “carved-out services.” You stay in the Anthem HealthKeepers Plus plan when receiving these services. Your provider bills fee-for-service Medicaid (or its Contractor) for these services. Carved out services Community Mental Health Rehabilitation Services (CMHRS) are provided through Magellan, the DMAS Behavioral Health Services Administrator. CMHRS are listed below. Detailed information about CMHRS is available on the Magellan website at: http://www.magellanofvirginia.com or by calling: 1-800-424-4046 TDD: 1-800-424-4048 or TTY 711. – Mental Health Case Management
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– – – – – – – – – – –
Therapeutic Day Treatment (TDT) for Children Under Age 21 Crisis Intervention and Stabilization Intensive Community Treatment Mental Health Skill-building Services (MHSS) Intensive In-Home Psychosocial Rehab Level A and B Group Home for Children Under Age 21 Treatment Foster Care Case Management Behavioral Therapy Mental Health Peer Supports Dental Services provided through the Smiles For Children program
The state has contracted with DentaQuest to coordinate the delivery of all Medicaid dental services.
The name of the program is Smiles For Children. Smiles For Children provides coverage for the
following populations and services:
For children under age 21: diagnostic, preventive, restorative/surgical procedures, as well as
orthodontia services. For pregnant women: x-rays and examinations, cleanings, fillings, root canals, gum related treatment, crowns, bridges, partials, and dentures, tooth extractions and other oral surgeries, and other appropriate general services. Orthodontic treatment is not included. The dental coverage ends 60 days after the baby is born. For adults age 21 and over, coverage is only available for limited medically necessary oral surgery services. Routine dental services are not covered for adults other than as described above for pregnant women. If you have any questions about your dental coverage through Smiles For Children, you can reach DentaQuest Member Services at 1-888-912-3456, Monday through Friday, 8:00 a.m. - 6:00 p.m. EST. The TTY/TDD number is 1-800-466- 7566. Additional Smiles For Children program information is provided at: https://www.coverva.org/programs_smiles.cfm. The Anthem HealthKeepers Plus plan provides coverage for non-emergency transportation for any dental services covered through Smiles for Children, as described above. Contact Member Services at the number below if you need assistance. School health services including certain medical, mental health, hearing, or rehabilitation therapy services that are arranged by your child’s school. The law requires schools to provide students with disabilities a free and appropriate public education, including special education and related services according to each student’s Individualized Education Program (IEP). While schools are financially responsible for educational services, in the case of a Medicaid-eligible student, part of the costs of the services identified in the student's IEP may be covered by Medicaid. When covered by Medicaid, school health services are paid by DMAS. Contact your child’s school administrator if you have questions about school health services. Services that will end your enrollment If you receive any of the services below, your enrollment with the Anthem HealthKeepers Plus plan will close and you will be served by the Medicaid Fee-For-Service program so long as you remain eligible for Medicaid.
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You are receiving care in an Intermediate Care Facility for Individuals with Intellectual Disabilities. You are receiving care in a Psychiatric Residential Treatment Level C Facility (children under 21). You are receiving care in a Nursing Facility. You are receiving care in a long-term care facility.
Service Authorization Procedure Service authorizations explained There are some treatments, services, and drugs that you need to get approval for before you receive them or in order to be able to continue receiving them. This is called a service authorization. Your doctor makes requests for service authorizations. A service authorization helps to determine if certain services or procedures are medically needed and covered by the plan. Decisions are based on what is right for each member and on the type of care and services that are needed. We look at standards of care based on: Medical policies National clinical guidelines Medicaid guidelines Your health benefits We do not reward employees, consultants, or other providers to: Deny care or services that you need Support decisions that approve less than what you need Say you don’t have coverage Service authorizations are not required for early intervention services, emergency care, family planning services (including long acting reversible contraceptives), preventive services, and basic prenatal care. The following treatments and services must be authorized before you get them: Outpatient services Behavioral Health services Transplants Out-of-network services Inpatient services You can also check to see what services might require a service authorization by calling Member Services at the number listed at the bottom of this page. To find out more about how to request approval for these treatments or services you can contact Member Services at the number below or call your Care Coordinator.
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Service authorizations and continuity of care If you are new to the Anthem HealthKeepers Plus plan, we will honor any service authorization approvals made by the Department of Medical Assistance Services or issued by another plan for up to 30 days (or until the authorization ends if that is sooner than 30 days). How to submit a service authorization request Usually, your provider will submit a service authorization request, but if you wish to submit a service authorization request yourself, just call Member Services at 1-800-901-0020 (TTY 711). We’re happy to help. What happens after submitting a service authorization request? We have a review team to be sure you receive medically necessary services. Doctors and nurses are on the review team. Their job is to be sure the treatment or service you asked for is medically needed and right for you. They do this by checking your treatment plan against medically acceptable standards. The standards we use to determine what is medically necessary are not allowed to be more restrictive than those that are used by DMAS. Any decision to deny a service authorization request or to approve it for an amount that is less than requested is called an adverse benefit determination (decision). These decisions will be made by a qualified health care professional. If we decide that the requested service is not medically necessary, the decision will be made by a medical or behavioral health professional, who may be a doctor or other health care professional who typically provides the care you requested. You can request the specific medical standards, called clinical review criteria, used to make the decision for actions related to medical necessity. After we get your request, we will review it under a standard or expedited (fast) review process. You or your doctor can ask for an expedited review if you believe that a delay will cause serious harm to your health. If your request for an expedited review is denied, we will tell you and your case will be handled under the standard review process. Time Frames for Service Authorization Review In all cases, we will review your request as quickly as your medical condition requires us to do so but no later than 14 calendar days after we get your request for service for standard service authorizations. If we need more information, or if you or your provider requests, this time frame can be extended by an additional 14 calendar days. In some cases, if your provider indicates that this standard time frame for review could seriously harm your life, physical health or mental health, we will make an expedited authorization decision and provide notice as quickly as your health condition requires and no later than 72 hours after we get your request for service. This 72-hour turnaround time frame can be extended by up to 14 calendar days if you request an extension or if we need more information. If we need more information to make either a standard or expedited decision about your service request we will: Write and tell you and your provider what information is needed. If your request is in an expedited review, we will call you or your provider right away and send a written notice later.
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Tell you why the delay is in your best interest.
Make a decision no later than 14 days from the day we asked for more information.
You, your provider, or someone you trust may also ask us to take more time to make a decision. This
may be because you have more information to give the Anthem HealthKeepers Plus plan to help
decide your case. This can be done by calling Member Services Monday through Friday from
8 a.m. to 6 p.m. Eastern time. You can also fax in your information to 1-800-964-3627.
You or someone you trust can file a complaint with the Anthem HealthKeepers Plus plan if you don’t
agree with our decision to take more time to review your request. You or someone you trust can also
file a complaint about the way we handled your service authorization request to the State through the
Managed Care Helpline at 1-800-643-2273. Also see Your Right to File a Complaint, in Section 12 of
this handbook.
Benefit determination We will notify you with our decision by the date our time for review has expired. But if for some reason you do not hear from us by that date, it is the same as if we denied your service authorization request. If you disagree with our decision, you have the right to file an appeal with us. Also see Your Right to Appeal, in Section 12 in this handbook. We will tell you and your provider in writing if your request is denied. A denial includes when the request is approved for an amount that is less than the amount requested. We will also tell you the reason for the decision and the contact name, address, and telephone number of the person responsible for making the adverse determination. We will explain what options for appeals you have if you do not agree with our decision. Also see Your Right to Appeal, in Section 12 of this Handbook. Care notification In most cases, if we make a benefit determination to reduce, suspend, or end a service we have already approved and that you are now getting, we must tell you at least 10 days before we make any changes to the service. Post payment review If we are checking on care or services that you received in the past, we perform a provider post payment review. If we deny payment to a provider for a service, we will send a notice to you and your provider the day the payment is denied. You will not have to pay for any care you received that was covered by the Anthem HealthKeepers Plus plan even if we later deny payment to the provider.
Appeals, State Fair Hearings, and Complaints (Grievances) Your right to appeal You have the right to appeal any adverse benefit determination (decision) by the Anthem HealthKeepers Plus plan that you disagree with that relates to coverage or payment of services. For example, you can appeal if we deny:
A request for a health care service, supply, item or drug that you think you should be able to get, or
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A request for payment of a health care service, supply, item, or drug that the Anthem HealthKeepers Plus plan denied. You can also appeal if we stop providing or paying for all or a part of a service or drug you receive through that you think you still need.
Authorized representative You may wish to authorize someone you trust to appeal on your behalf. This person is known as your authorized representative. You must inform the Anthem HealthKeepers Plus plan of the name of your authorized representative. You can do this by calling our Member Services Department at one of the phone numbers below. We will provide you with a form that you can fill out and sign stating who your representative will be. Adverse benefit determination There are some treatments and services that you need to get approval for before you receive them or in order to be able to continue receiving them. Asking for approval of a treatment or service is called a service authorization request. This process is described earlier in this handbook. Any decision we make to deny a service authorization request or to approve it for an amount that is less than requested is called an adverse benefit determination. Refer to Service Authorization and Benefit Determinations in Section 11 of this handbook. How to submit your appeal If you are not satisfied with a decision we made about your service authorization request, you have 60 calendar days after hearing from us to file an appeal. You can do this yourself or ask someone you trust to file the appeal for you. You can call Member Services at one of the numbers below if you need help filing an appeal or if you need assistance in another language or require an alternate format. We will not treat you unfairly because you file an appeal. You can file your appeal by phone or in writing. You can send the appeal as a standard appeal or an expedited (fast) appeal request. You or your doctor can ask to have your appeal reviewed under the expedited process if you believe your health condition or your need for the service requires an expedited review. Your doctor will have to explain how a delay will cause harm to your physical or behavioral health. If your request for an expedited appeal is denied we will tell you and your appeal will be reviewed under the standard process. Send your Appeal request to: Grievance and Appeals Department HealthKeepers, Inc. P.O. Box 62429 Virginia Beach, VA 23464 You can also call or fax us. Call the Appeals and Grievances Department at 1-800-901-0020 (TTY 711). You can also fax it to us at 1-866-920-4097. If you send your standard appeal by phone, it must be followed up in writing. Expedited process appeals submitted by phone do not require you to submit a written request.
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Continuation of benefits In some cases you may be able to continue receiving services that were denied by us while you wait for your appeal to be decided. You may be able to continue the services that are scheduled to end or be reduced if you ask for an appeal: Within ten days from being told that your request is denied or care is changing; or By the date the change in services is scheduled to occur. If your appeal results in another denial you may have to pay for the cost of any continued benefits that you received if the services were provided solely because of the requirements described in this Section. What happens after we get your appeal Within five days, we will send you a letter to let you know we have received and are working on your appeal. Appeals of clinical matters will be decided by qualified health care professionals who did not make the first decision and who have appropriate clinical expertise in treatment of your condition or disease. Before and during the appeal, you or your authorized representative can see your case file, including medical records and any other documents and records being used to make a decision on your case. This information is available at no cost to you. You can also provide information that you want to be used in making the appeal decision in person or in writing. Send any appeals-related information that may aid us in making a determination to: Grievance and Appeals Department HealthKeepers, Inc. P.O. Box 62429 Virginia Beach, VA 23464 You can also call Member Services at one of the numbers below if you are not sure what information to give us. Time frames for appeals Standard appeals If we have all the information we need we will tell you our decision within 30 days of when we receive your appeal request. We will tell you within 2 calendar days after receiving your appeal if we need more information. A written notice of our decision will be sent within 2 calendar days from when we make the decision. Expedited appeals If we have all the information we need, expedited appeal decisions will be made within 3 calendar days of receipt of your appeal. We will tell you our decision by phone and send a written notice within 2 calendar days from when we make the decision.
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If we need more information If we can’t make the decision within the needed timeframes because we need more information we will:
Write you and tell you what information is needed. If your request is in an expedited review, we
will call you right away and send a written notice later; Tell you why the delay is in your best interest; and Make a decision no later than 14 additional days from the timeframes described above. You, your provider, or someone you trust may also ask us to take more time to make a decision. This may be because you have more information to give the Anthem HealthKeepers Plus plan to help decide your case. This can be done by writing to: Grievance and Appeals Department HealthKeepers, Inc. P.O. Box 62429 Virginia Beach, VA 23464 You can also give us a call. Just call the Member Services number listed at the bottom of this page. We’re here to help Monday through Friday from 8 a.m. to 6 p.m. You or someone you trust can file a complaint with us if you do not agree with our decision to take more time to review your appeal. You or someone you trust can also file a complaint about the way we handled your appeal to the State through the Help Line at 1-800-643-2273. Written notice of appeal decision If we do not tell you our decision about your appeal on time, you have the right to appeal to the State through the State Fair Hearing process. An untimely response by us is considered a valid reason for you to appeal further through the State Fair Hearing process. We will tell you and your provider in writing if your request is denied or approved in an amount less than requested. We will also tell you the reason for the decision and the contact name, address, and telephone number of the person responsible for making the adverse determination. We will explain your right to appeal through the State Fair Hearing Process if you do not agree with our decision. Your right to a State Fair Hearing If you disagree with our decision on your appeal request, you can appeal directly to DMAS. This process is known as a State Fair Hearing. You may also submit a request for a State Fair Hearing if we deny payment for covered services or if we do not respond to an appeal request for services within the times described in this handbook. The State requires that you first exhaust (complete) the Anthem HealthKeepers Plus appeals process before you can file an appeal request through the State Fair Hearing process. If we do not respond to your appeal request timely, DMAS will count this as an exhausted appeal.
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Standard or expedited review requests For appeals that will be heard by DMAS you will have an answer generally within 90 days from the date you filed your appeal with DMAS. The 90 day timeframe does not include the number of days between our decision on your appeal and the date you sent your State fair hearing request to DMAS. If you want your State Fair Hearing to be handled quickly, you must write “EXPEDITED REQUEST” on your appeal request. You must also ask your doctor to send a letter to DMAS that explains why you need an expedited appeal. DMAS will tell you if you qualify for an expedited appeal within 72 hours of receiving the letter from your doctor. Authorized representative You can give someone like your PCP, provider, friend or family member written permission to help you with your State Fair Hearing request. This person is known as your authorized representative. Where to send the State Fair Hearing request You or your representative must send your standard or expedited appeal request to DMAS by internet, mail, fax, email, telephone, in person, or through other commonly available electronic means. Send State Fair Hearing requests to DMAS within no more than 120 calendar days from the date of our final decision. You may be able to appeal after the 120 day deadline in special circumstances with permission from DMAS. You may write a letter or complete a Virginia Medicaid Appeal Request Form. The form is available at your local Department of Social Services or on the internet at http://www.dmas.virginia.gov/Content_atchs/forms/dmas-200.pdf. You should also send DMAS a copy of the letter we sent to you in response to your Appeal. You must sign the appeal request and send it to: Appeals Division Department of Medical Assistance Services 600 E. Broad Street Richmond, Virginia 23219 Fax: (804) 452-5454 Standard and Expedited Appeals may also be made by calling (804) 371-8488. After you file your State Fair Hearing appeal DMAS will notify you of the date, time, and location of the scheduled hearing. Most hearings can be done by telephone. State Fair Hearing time frames Expedited appeal If you qualify for an expedited appeal, DMAS will give you an answer to your appeal within 72 hours of receiving the letter from your doctor. If DMAS decides right away that you win your appeal, they will send you their decision within 72 hours of receiving the letter from your doctor. If DMAS does not decide right away, you will have an opportunity to participate in a hearing to present your position. Hearings for expedited decisions are usually held within one or two days of DMAS receiving the letter from your doctor. DMAS still has to give you an answer within 72 hours of receiving your doctor’s letter.
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Standard appeal If your request is not an expedited appeal, or if DMAS decides that you do not qualify for an expedited appeal, DMAS will give you an answer within 90 days from the date you filed your appeal with DMAS. The 90-day time frame does not include the number of days between our decision on your appeal and the date you sent your State fair hearing request to DMAS. You will have an opportunity to participate in a hearing to present your position before a decision is made. Continuation of benefits In some cases you may be able to continue receiving services that were denied by us while you wait for
your State Fair Hearing appeal to be decided. You may be able to continue the services that are
scheduled to end or be reduced if you ask for an appeal:
Within ten days from being told that your request is denied or care is changing;
By the date the change in services is scheduled to occur.
Your services will continue until you withdraw the appeal, the original authorization period for your
service ends, or the State Fair Hearing Officer issues a decision that is not in your favor. You may,
however, have to repay the Anthem HealthKeepers Plus plan for any services you receive during the
continued coverage period if Plan’s adverse benefit determination is upheld and the services were
provided solely because of the requirements described in this Section.
If the State Fair Hearing reverses the denial If services were not continued while the State Fair Hearing was pending If the State Fair Hearing decision is to reverse the denial, the Anthem HealthKeepers Plus plan must authorize or provide the services under appeal as quickly as your condition requires and no later than 72 hours from the date we receives notice from the State reversing the denial. If services were provided while the State Fair Hearing was pending If the State Fair hearing decision is to reverse the denial and services were provided while the appeal is pending, the Anthem HealthKeepers Plus plan must pay for those services, in accordance with State policy and regulations. If you disagree with the State Fair Hearing decision The State Fair Hearing decision is the final administrative decision rendered by the Department of Medical Assistance Services. If you disagree with the Hearing Officer’s decision, you may appeal it to your local circuit court. Your right to file a complaint We will try our best to deal with your concerns as quickly as possible to your satisfaction. Depending on what type of concern you have, it will be handled as a complaint or as an appeal. What kinds of problems should be complaints The complaint process is used for concerns related to quality of care, waiting times, and customer service. Here are examples of the kinds of problems handled by our complaint process.
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Complaints about quality You are unhappy with the quality of care, such as the care you got in the hospital. Complaints about privacy You think that someone did not respect your right to privacy or shared information about you that is confidential or private. Complaints about poor customer service
A health care provider or staff was rude or disrespectful to you.
Anthem HealthKeepers Plus staff treated you poorly.
Anthem HealthKeepers Plus is not responding to your questions.
You are not happy with the assistance you are getting from your Care Coordinator.
Complaints about accessibility You cannot physically access the health care services and facilities in a doctor or provider’s office. You were not provided requested reasonable accommodations that you needed in order to participate meaningfully in your care. Complaints about communication access Your doctor or provider does not provide you with a qualified interpreter for the deaf or hard of hearing or an interpreter for another language during your appointment. Complaints about waiting times
You are having trouble getting an appointment, or waiting too long to get it. You have been kept waiting too long by doctors, pharmacists, or other health professionals or by Member Services or other Anthem HealthKeepers Plus staff.
Complaints about cleanliness You think the clinic, hospital or doctor’s office is not clean. Complaints about communications from us
You think we failed to give you a notice or letter that you should have received. You think the written information we sent you is too difficult to understand. You asked for help in understanding information and did not receive it.
There are different types of complaints You can make an internal complaint and/or an external complaint. An internal complaint is filed with and reviewed by the Anthem HealthKeepers Plus plan. An external complaint is filed with and reviewed by an organization that is not affiliated with us.
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Internal complaints To make an internal complaint, call Member Services at the number below. You can also write your complaint and send it to us. If you put your complaint in writing, we will respond to your complaint in writing. You can file a complaint in writing, by mailing it to us at: Member Services Anthem HealthKeepers Plus P.O. Box 27401 Mail Drop VA2002-N500 Richmond, VA 23279 You can also fax us at 1-800-964-3627 or call Member Services if you have any questions. So that we can best help you, include details on who or what the complaint is about and any information about your complaint. The Anthem HealthKeepers Plus plan will review your complaint and request any additional information. You can call Member Services at the number below if you need help filing a complaint or if you need assistance in another language or format. We will notify you of the outcome of your complaint within a reasonable time, but no later than 30 calendar days after we receive your complaint. If your complaint is related to your request for an expedited appeal, we will respond within 24 hours after the receipt of the complaint. External complaints You can file a complaint with the Managed Care Helpline You can make a complaint about the Anthem HealthKeepers Plus plan to the Managed Care Helpline at 1-800-643-2273 (TTY 1-800-817-6608) Monday – Friday, 8:30 a.m. – 6:00 p.m. You can file a complaint with the Office for Civil Rights You can make a complaint to the Department of Health and Human Services’ Office for Civil Rights if you think you have not been treated fairly. For example, you can make a complaint about disability access or language assistance. You can also visit http://www.hhs.gov/ocr for more information. Office of Civil Rights - Region III Department of Health and Human Services 150 S. Independence Mall West, Suite 372 Public Ledger Building Philadelphia, PA 19106 Phone: 1-800-368-1019 Fax: 215-861-4431 TDD: 1-800-537-7697
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Member Rights Your rights It is the policy of the Anthem HealthKeepers Plus plan to treat you with respect. We also care about keeping a high level of confidentiality with respect for your dignity and privacy. As a Member you have certain rights. You have the right to: Receive timely access to care and services; Take part in decisions about your health care, including your right to choose your providers from our network providers and your right to refuse treatment; Confidentiality and privacy about your medical records and when you get treatment; Receive information and to discuss available treatment options and alternatives presented in a manner and language you understand; Get information in a language you understand — you can get oral translation services free of charge; Receive reasonable accommodations to ensure you can effectively access and communicate with providers, including auxiliary aids, interpreters, flexible scheduling, and physically accessible buildings and services; Receive information necessary for you to give informed consent before the start of treatment; Be treated with respect and dignity; Get a copy of your medical records and ask that the records be amended or corrected; Be free from restraint or seclusion unless ordered by a physician when there is an imminent risk of bodily harm to you or others or when there is a specific medical necessity. Seclusion and restraint will never be used a s a means of coercion, discipline, retaliation, or convenience; Get care without regard to disability, gender, race, health status, color, age, national origin, sexual orientation, marital status or religion; Be informed of where, when and how to obtain the services you need from the Anthem HealthKeepers Plus plan, including how you can receive benefits from out-of-network providers if the services are not available in Plan name’s network. Complain about us to the State. You can call the Helpline at 1-800-643-2273 to make a complaint about us. Appoint someone to speak for you about your care and treatment and to represent you in an Appeal; Make advance directives and plans about your care in the instance that you are not able to make your own health care decisions. See Section 14 of this handbook for information about Advance Directives. Change your health plan once a year for any reason during open enrollment or change your MCO after open enrollment for an approved reason. Reference Section 2 of this handbook or call the Managed Care Helpline at 1-800-643-2273 (TTY 1-800-817-6608) or visit the website at virginiamanagedcare.com for more information. Appeal any adverse benefit determination (decision) by the Anthem HealthKeepers Plus plan that you disagree with that relates to coverage or payment of services. See Your Right to Appeal in this Section 15 of the handbook.
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File a complaint about any concerns you have with our customer service, the services you have received, or the care and treatment you have received from one of our network providers. See Your Right to File a Complaint in Section 15 of this handbook. To receive information from us about our plan, your covered services, providers in our network, and about your rights and responsibilities. To make recommendations regarding our member rights and responsibility policy, for example by joining our Member Advisory Committee (as described later in this Section of the handbook.)
Your right to be safe Everyone has the right to live a safe life in the home or setting of their choice. Each year, many older adults and younger adults who are disabled are victims of mistreatment by family members, by caregivers and by others responsible for their well-being. If you, or someone you know, is being abused, physically, is being neglected, or is being taken advantage of financially by a family member or someone else, you should call your local department of social services or the Virginia Department of Social Services' 24-hour, toll-free hotline at: 1-888 832-3858. You can make this call anonymously; you do not have to provide your name. The call is free. They can also provide a trained local worker who can assist you and help you get the types of services you need to assure that you are safe. Your right to confidentiality The Anthem HealthKeepers Plus plan will only release information if it is specifically permitted by state and federal law or if it is required for use by programs that review medical records to monitor quality of care or to combat fraud or abuse. Our staff will ask questions to confirm your identity before we discuss or provide any information regarding your health information. We will request your written authorization to coordinate treatment for related to substance use disorder and addiction, recovery and treatment services. Your right to privacy Information about your health and money is private. The law says we must keep this kind of information, called PHI, safe for our members. That means if you’re a member right now or if you used to be, your information is safe. We get information about you from state agencies for Medicaid and the Children’s Health Insurance Program after you become eligible and sign up for our health plan. We also get it from your doctors, clinics, labs, and hospitals so we can OK and pay for your health care. Federal law says we must tell you what the law says we have to do to protect PHI that’s told to us, in writing or saved on a computer. We also have to tell you how we keep it safe. To protect PHI: On paper (called physical), we: – Lock our offices and files – Destroy paper with health information so others can’t get it Saved on a computer (called technical), we:
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– Use passwords so only the right people can get in – Use special programs to watch our systems Used or shared by people who work for us, doctors or the state, we: – Make rules for keeping information safe (called policies and procedures) – Teach people who work for us to follow the rules
When is it OK for us to use and share your PHI? We can share your PHI with your family or a person you choose who helps with or pays for your health care if you tell us it’s OK. Sometimes, we can use and share it without your OK: For your medical care – To help doctors, hospitals and others get you the care you need For payment, health care operations and treatment – To share information with the doctors, clinics and others who bill us for your care – When we say we’ll pay for health care or services before you get them – To find ways to make our programs better, as well as giving your PHI to health information exchanges for payment, health care operations and treatment. If you don’t want this, please visit www.anthem.com/vamedicaid for more information. For health care business reasons – To help with audits, fraud and abuse prevention programs, planning, and everyday work – To find ways to make our programs better For public health reasons – To help public health officials keep people from getting sick or hurt With others who help with or pay for your care – With your family or a person you choose who helps with or pays for your health care, if you tell us it’s OK – With someone who helps with or pays for your health care, if you can’t speak for yourself and it’s best for you We must get your OK in writing before we use or share your PHI for all but your care, payment, everyday business, research or other things listed below. We have to get your written OK before we share psychotherapy notes from your doctor about you. You may tell us in writing that you want to take back your written OK. We can’t take back what we used or shared when we had your OK. But we will stop using or sharing your PHI in the future. Other ways we can — or the law says we have to — use your PHI: To help the police and other people who make sure others follow laws To report abuse and neglect To help the court when we’re asked To answer legal documents To give information to health oversight agencies for things like audits or exams To help coroners, medical examiners or funeral directors find out your name and cause of death To help when you’ve asked to give your body parts to science For research To keep you or others from getting sick or badly hurt To help people who work for the government with certain jobs
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To give information to workers’ compensation if you get sick or hurt at work What are your rights? You can ask to look at your PHI and get a copy of it. We don’t have your whole medical record, though. If you want a copy of your whole medical record, ask your doctor or health clinic. You can ask us to change the medical record we have for you if you think something is wrong or missing. Sometimes, you can ask us not to share your PHI. But we don’t have to agree to your request. You can ask us to send PHI to a different address than the one we have for you or in some other way. We can do this if sending it to the address we have for you may put you in danger. You can ask us to tell you all the times over the past six years we’ve shared your PHI with someone else. This won’t list the times we’ve shared it because of health care, payment, everyday health care business or some other reasons we didn’t list here. You can ask for a paper copy of this notice at any time, even if you asked for this one by email. If you pay the whole bill for a service, you can ask your doctor not to share the information about that service with us. What do we have to do? The law says we must keep your PHI private except as we’ve said in this notice.
We must tell you what the law says we have to do about privacy.
We must do what we say we’ll do in this notice.
We must send your PHI to some other address or in a way other than regular mail if you ask for
reasons that make sense, like if you’re in danger. We must tell you if we have to share your PHI after you’ve asked us not to. If state laws say we have to do more than what we’ve said here, we’ll follow those laws. We have to let you know if we think your PHI has been breached. We may contact you You agree that we, along with our affiliates and/or vendors, may call or text any phone numbers you give us, including a wireless phone number, using an automatic telephone dialing system and/or a pre recorded message. Without limit, these calls or texts may be about treatment options, other healthrelated benefits and services, enrollment, payment, or billing. What if you have questions? If you have questions about our privacy rules or want to use your rights, please call 1-800-901-0020 (Medallion Medicaid, FAMIS) or 1-855-323-4687 (CCC Plus); TTY 711. What if you have a complaint? We’re here to help. If you feel your PHI hasn’t been kept safe, you may call Member Services or contact the Department of Health and Human Services. Nothing bad will happen to you if you complain.
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Write to or call the Department of Health and Human Services: Office for Civil Rights U.S. Department of Health and Human Services 150 S. Independence Mall West Suite 372, Public Ledger Building Philadelphia, PA 19106-9111 Phone: 1-800-368-1019 TDD: 1-800-537-7697 Fax: 1-215-861-4431 We reserve the right to change this Health Insurance Portability and Accountability Act (HIPAA) notice and the ways we keep your PHI safe. If that happens, we’ll tell you about the changes in a newsletter. We’ll also post them on the web at www.anthem.com/vamedicaid. Race, ethnicity and language We receive race, ethnicity and language information about you from the state Medicaid agency and the Children’s Health Insurance Program. We protect this information as described in this notice. We use this information to: Make sure you get the care you need Create programs to improve health outcomes Develop and send health education information Let doctors know about your language needs Provide translator services We do not use this information to: Issue health insurance Decide how much to charge for services Determine benefits Disclose to unapproved users Your personal information We may ask for, use and share personal information (PI) as we talked about in this notice. Your PI is not public and tells us who you are. It’s often taken for insurance reasons. We may use your PI to make decisions about your: – Health – Habits – Hobbies We may get PI about you from other people or groups like: – Doctors – Hospitals – Other insurance companies We may share PI with people or groups outside of our company without your OK in some cases. We’ll let you know before we do anything where we have to give you a chance to say no. We’ll tell you how to let us know if you don’t want us to use or share your PI. You have the right to see and change your PI.
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We make sure your PI is kept safe. How to join the Member Advisory Committee We would like you to help us improve our health plan. We invite you to join our Member Advisory Committee. On the committee, you can let us know how we can better serve you. Going to these meetings will give you and your caregiver or family Member the chance to help plan meetings and meet other Members in the community. These educational meetings are held once every three months. If you would like to attend or would like more information, please contact Anthem HealthKeepers Plus Member Services using one of the numbers below. We follow non-discrimination policies You cannot be treated differently because of your race, color, national origin, disability, age, religion, gender, marital status, pregnancy, childbirth, sexual orientation, or medical conditions. If you think that you have not been treated fairly for any of these reasons, call the Department of Health and Human Services, Office for Civil Rights at 1-800-368-1019. TTY users should call 1-800-537-7697. You can also visit http://www.hhs.gov/ocr for more information. The Anthem HealthKeepers Plus plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation or gender identity.
Member Responsibilities Your responsibilities As a Member, you also have some responsibilities. These include: Present your Anthem HealthKeepers Plus Membership card whenever you seek medical care. Provide complete and accurate information to the best of your ability on your health and medical history. Participate in your care team meetings, develop an understanding of your health condition, and provide input in developing mutually agreed upon treatment goals to the best of your ability. Keep your appointments. If you must cancel, call as soon as you can. Receive all of your covered services from the Anthem HealthKeepers plan’s network. Obtain authorization from us prior to receiving services that require a service authorization review (see Section 14). Call us whenever you have a question regarding your Membership or if you need assistance tollfree at one of the numbers below. Tell us when you plan to be out of town so we can help you arrange your services. Use the emergency room only for real emergencies. Call your PCP when you need medical care, even if it is after hours. Tell us when you believe there is a need to change your plan of care. Tell us if you have problems with any health care staff. Call Member Services at one of the numbers below. Call Member Services at one of the phone numbers below about any of the following:
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– If you have any changes to your name, your address, or your phone number. Report these also – – – – – –
to your case worker at your local Department of Social Services. If you have any changes in any other health insurance coverage, such as from your employer, your spouse’s employer, or workers’ compensation. If you have any liability claims, such as claims from an automobile accident. If you are admitted to a nursing facility or hospital. If you get care in an out-of-area or out-of-network hospital or emergency room. If your caregiver or anyone responsible for you changes. If you are part of a clinical research study.
Advance Directives You have the right to say what you want to happen if you are unable to make health care decisions for yourself. There may be a time when you are unable to make health care decisions for yourself. Before that happens to you, you can: Fill out a written form to give someone the right to make health care decisions for you if you become unable to make decisions for yourself. Give your doctors written instructions about how you want them to handle your health care if you become unable to make decisions for yourself. The legal document that you can use to give your directions is called an Advance Directive. An advance directive goes into effect only if you are unable to make health care decisions for yourself. Any person age 18 or over can complete an advance directive. There are different types of advance directives and different names for them. Examples are a living will, a durable power of attorney for health care, and advance care directive for health care decisions. You do not have to use an advance directive, but you can if you want to. Here is what to do: Where to get the Advance Directives form You can get the Virginia Advance Directives form at: http://www.vdh.virginia.gov/OLC/documents/2011/pdfs/2011-VA-AMD-Simple.pdf. You can also get the form from your doctor, a lawyer, a legal services agency, or a social worker. Organizations that give people information about Medicaid may also have advance directive forms. You can contact the Virginia State Bar for more information. Visit them on the web at http://www.virginiaadvancedirectives.org. You can also contact Member Services to ask for the forms. Completing the Advance Directives form Fill it out and sign the form. The form is a legal document. You may want to consider having a lawyer help you prepare it. There may be free legal resources available to assist you. Share the information with people you want to know about it Give copies to people who need to know about it. You should give a copy of the Living Will, Advance Care Directive, or Power of Attorney form to your doctor. You should also give a copy to the person you name as the one to make decisions for you. You may also want to give copies to close friends or family members. Be sure to keep a copy at home.
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If you are going to be hospitalized and you have signed an advance directive, take a copy of it to the hospital. The hospital will ask you whether you have signed an advance directive form and whether you have it with you. If you have not signed an advance directive form, the hospital has forms available and will ask if you want to sign one. We can help you get or understand Advance Directives documents Your Care Coordinator can help you understand or get these documents. They do not change your right to quality health care benefits. The only purpose is to let others know what you want if you can’t speak for yourself. Remember, it is your choice to fill out an advance directive or not. You can revoke or change your advance care directive or power of attorney if your wishes about your health care decisions or authorized representative change. Other resources You may also find information about advance directives in Virginia at: www.virginiaadvancedirectives.org. You can store your advance directive at the Virginia Department of Health Advance Healthcare Directive Registry: www.virginiaregistry.org/. If your Advance Directives are not followed If you have signed an advance directive, and you believe that a doctor or hospital did not follow the instructions in it, you may file a complaint with the following organizations. For complaints about doctors and other providers, contact the Enforcement Division at the Virginia Department of Health Professions: CALL
Virginia Department of Health Professions: Toll-Free Phone: 1-800-533-1560 Local Phone: 804-367-4691
WRITE
Virginia Department of Health Professions Enforcement Division 9960 Mayland Drive, Suite 300 Henrico, Virginia 23233-1463
FAX
804-527-4424
EMAIL
[email protected]
WEBSITE
http://www.dhp.virginia.gov/Enforcement/complaints.htm
For complaints about nursing facilities, inpatient and outpatient hospitals, abortion facilities, home care organizations, hospice programs, dialysis facilities, clinical laboratories, and health plans (also known as managed care organizations), contact the Office of Licensure and Certification at the Virginia Department of Health:
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CALL
Toll-Free Phone: 1-800-955-1819 Local Phone: 804-367-2106
WRITE
Virginia Department of Health Office of Licensure and Certification 9960 Mayland Drive, Suite 401 Henrico, Virginia 23233-1463
FAX
804-527-4503
EMAIL
[email protected]
WEBSITE
http://www.vdh.state.va.us/olc/complaint/
Fraud, Waste, and Abuse What is Fraud, waste and abuse? Fraud is an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him/herself or some other person. It includes any act that constitutes fraud under applicable Federal or State law. Waste includes overutilization, underutilization, or misuse of resources. Waste typically is not an intentional act, but does result in spending that should not have occurred. As a result, waste should be reported so that improper payments can be identified and corrected Abuse includes practices that are inconsistent with sound fiscal, business, or medical practice, and result in unnecessary cost to the Medicaid program, payment for services that are not medically necessary, or fail to meet professionally recognized health care standards. Common types of health care fraud, waste, and abuse include: Medical identity theft Billing for unnecessary items or services Billing for items or services not provided Billing a code for a more expensive service or procedure than was performed (known as up-coding) Charging for services separately that are generally grouped into one rate (Unbundling) Items or services not covered When one doctor receives a form of payment in return for referring a patient to another doctor. These payments are called “kickbacks.” How do I report fraud, waste or abuse? If you suspect a client (a person who receives benefits) or a provider (such as a doctor or dentist) has
committed waste, abuse or fraud, you have a responsibility and a right to report it.
Examples of client waste, abuse or fraud include but are not limited to:
Loaning insurance ID cards.
Using more than one provider to obtain similar treatments and/or medications.
Frequent emergency room visits for nonemergency conditions.
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Examples of provider waste, abuse or fraud include but are not limited to:
Billing for services not provided.
Billing professional services performed by untrained personnel.
Altering medical records.
To report waste, abuse or fraud, gather as much information as possible.
You can report providers or clients directly to your health plan at:
Government Business Division Special Investigations Unit
Anthem HealthKeepers Plus
P.O. Box 66407 Virginia Beach, VA 23462 Telephone: 1-800-368-3580
When reporting a person who receives benefits, provide this information:
The person’s name
The person’s date of birth, Social Security number or case number, if possible The city where the person resides
Specific details about the waste, abuse or fraud
When reporting a provider (doctor, dentist or counselor), provide this information:
Name, address and telephone number of the provider
Name and address of the facility (hospital, nursing home or home health agency)
The Medicaid number of the provider or facility (if you know it)
The type of provider (doctor, pharmacist or physical therapist)
Names and phone numbers of other witnesses who can help in the investigation
Dates of events
Summary of what happened
If you would prefer to refer your fraud, waste, or abuse concerns directly to the State, you can report to
the contacts listed below.
Department of Medical Assistance Services Fraud Hotline
Recipient Fraud: 1-800-371-0824 or (804) 786-1066
Provider Fraud: 1-800-371-0824 or (804) 786-2071
Virginia Medicaid Fraud Control Unit (Office of the Attorney General)
Email:
[email protected]
Fax: 804-786-3509
Office of the Attorney General
Medicaid Fraud Control Unit
202 North Ninth Street
Richmond, VA 23219
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Virginia Office of the State Inspector General Fraud, Waste, and Abuse HotlinePhone: 1-800-723-1615 Fax: 804-371-0165 Email:
[email protected] State FWA Hotline 101 N. 14th Street The James Monroe Building 7th Floor Richmond, VA 23219
Maternal and Child Health Resources Special care for pregnant members New Baby, New LifeSM is a program for pregnant members. It is very important to see your primary care provider (PCP) or obstetrician or gynecologist (OB/GYN) for care when you are pregnant. This kind of care is called prenatal care. It can help you to have a healthy baby. Prenatal care is always important even if you have already had a baby. Our program helps pregnant members with complicated health care needs. A nurse care manager work closely with pregnant members to provide: Education Emotional support Help in following their doctor’s care plan Information on services and resources in your community, such as transportation, the Women, Infants, and Children program (WIC), breastfeeding and counseling Your case manager will also work with your doctors and help with other services you may need. The goal is to promote better health for members and delivery of healthy babies. When you become pregnant If you think you are pregnant: Call your PCP or OB/GYN doctor right away. You do not need a referral from your PCP to see an OB/GYN doctor. Call Member Services if you need help finding an OB/GYN in the Anthem HealthKeepers Plus network When you find out you are pregnant, you must also call Member Services. Your pregnancy education package We will send you a pregnancy education package. It will include: A congratulations letter A self-care book with information about your pregnancy; you can also use this book to write down things that happen during your pregnancy Having a Healthy Baby brochure with helpful resources
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During your pregnancy While you are pregnant, you need to take good care of your health. You may be able to get healthy food from WIC. Member Services can give you the phone number for the WIC program close to you. When you are pregnant, you must go to your PCP or OB/GYN at least: Every four weeks for the first six months Every two weeks for the seventh and eighth months Every week during the last month Your PCP or OB/GYN may want you to visit more than this based on your health needs. When you have a new baby When you deliver your baby, you and your baby may stay in the hospital at least:
48 hours after a vaginal delivery
72 hours after a Cesarean section (C-section)
You may stay in the hospital less time if you PCP or OB/GYN and the baby’s provider sees that you and your baby are doing well. If you and your baby leave the hospital early, your PCP or OB/GYN may ask you to have an office or in-home nurse visit within 48 hours. After you have your baby After you have your baby, you must: Call Member Services as soon as you can to let your case manager know you had your baby. We will need details about your baby. Call and apply for Medicaid for your baby. We will send you postpartum education package after you have your baby. It will include: A congratulations letter A self-care book with information on caring for your newborn Postpartum depression brochure Making a Family Life Plan brochure It’s important to set up a visit with your PCP or OB/GYN after you have your baby for a postpartum checkup. You may feel well and think you are healing, but it takes the body at least six weeks to mend after delivery. The visit should be done between 21 and 56 days after you deliver If you delivered by C-section, your PCP or OB/GYN may ask you to come back for a one or two week post-surgery checkup. This is not considered a postpartum checkup. You will still need to go back and see your provider within 21 to 56 days after your delivery for your postpartum checkup.
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FAMIS Covered Services If you have a child who is a FAMIS member, his or her covered services differ from covered services for Medallion members. There is no cost sharing for members who are American Indians or Alaskan Natives. Here is a list of FAMIS covered services: Service
FAMIS Covered
Network Cost Sharing & Benefit Limits 150% 150%
Inpatient Hospital Services
Yes
$15 per confinement
$25 per confinement
Outpatient Hospital Services
Yes
$2 per visit (waived if admitted)
$5 per visit (waived if admitted)
$2 (limited to $500 per calendar year)
$5 (limited to $500 per calendar year)
Chiropractic Services
Yes
Notes and Day Limitations The MCO is required to cover inpatient stays in general acute care and rehabilitation hospitals for all members up to 365 days per confinement in a semi-private room or intensive care unit for the care of illness, injury, or pregnancy (includes medically necessary ancillary services). The Contractor shall cover alternative treatment plan for a patient who would otherwise require more expensive services, including, but not limited to, long-term inpatient care. The Contractor must approve in advance the alternative treatment plan. The MCO shall cover outpatient hospital services which are preventive, diagnostic, therapeutic, rehabilitative or palliative in nature that are furnished to outpatients, and are furnished by an institution that is licensed or formally approved as a hospital by an officially designated authority for State standard-setting. Observation bed services shall be covered when they are reasonable and necessary to evaluate a medical condition to determine appropriate level of treatment or non-routine observation for underlying medical complications. Outpatient services include emergency services, surgical services, diagnostic, and professional provider services. Facility charges are also covered.
The MCO shall provide $500.00 per calendar year coverage of medically necessary spinal manipulation and outpatient chiropractic services rendered for the treatment of an illness or injury.
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Service
Clinic Services Outpatient physician visit in the office or hospital Primary care Specialty care Maternity services
Court Ordered Services
Dental Services
FAMIS Covered Yes
Network Cost Sharing & Benefit Limits 150% 150% $2 $5
$0
No
No except in certain circumstances
$0
Notes and Day Limitations
The MCO shall cover clinic services that are defined as preventive, diagnostic, therapeutic, rehabilitative, or palliative services that are provided to outpatients and are provided by a facility that is not part of a hospital but is organized and operated to provide medical care to outpatients. With the exception of nurse-midwife services, clinic services are furnished under the direction of a physician or a dentist. Renal dialysis clinic visits are also covered. There are no copayments for maternity services. The MCO is not required to cover this service unless the service is both medically necessary and is a FAMIS covered service. The Contractor is required to cover CPT codes billed by an MD as a result of an accident. The Contractor is required to cover medically necessary anesthesia and hospitalization services for certain individuals when determined such services are required to provide dental care. Pediatric dental services (for eligible children up to age 21) are covered through the Smiles for Children Program through the Department’s Dental Benefit Administrator (DBA). For more information regarding SFC benefits, call 1-888-912-3456.
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Service
Early Intervention Services
Early, Periodic, Screening, Diagnosis and Treatment (EPSDT)
FAMIS Covered
No* (These are covered by DMAS)
No
Network Cost Sharing & Benefit Limits 150% 150%
Notes and Day Limitations The Contractor is not required to provide coverage for Early Intervention services as defined by 12 VAC 30-50-131. EI services for children who are enrolled in a contracted MCO are covered by the Department within the Department’s coverage criteria and guidelines. Early intervention billing codes and coverage criteria are described in the Department’s Early Intervention Program Manual, on the DMAS website at http://websrvr.dmas.virginia.gov/ProviderManuals/Default.aspx. The Contractor shall cover other medically necessary rehabilitative and developmental therapies, when medically necessary, including for EI enrolled children where appropriate.
The MCO is not required to cover this service. The MCO is required to cover well-baby and well child care services.
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Service
FAMIS Covered
Emergency Services using Prudent Layperson Standards for Access Hospital emergency room Yes Physician care
Non-emergency use of the Emergency Room
Post Stabilization Care Following Emergency Services
Yes
Experimental and Investigational Procedures
No
Network Cost Sharing & Benefit Limits 150% 150%
$2 per visit
$5 per visit
$2 per visit (waived if part of ER visit for true emergency)
$5 per visit (waived if part of ER visit for true emergency)
$10 per visit
$25 per visit
Notes and Day Limitations
The MCO shall provide for the reasonable reimbursement of services needed to ascertain whether an emergency exists in instances in which the clinical circumstances that existed at the time of the beneficiary’s presentation to the emergency room indicate that an emergency may exist. The MCO shall ensure that all covered emergency services are available twenty-four (24) hours a day and seven (7) days a week. The MCO shall cover all emergency services provided by out-of-network providers. The MCO may not require prior authorization for emergency services. This applies to out-of-network as well as to in-network services that a member seeks in an emergency. Members who present to the emergency room shall pay the emergency room co-payment. If it is determined that the visit was a non-emergency, the hospital may bill the member only for the difference between the emergency room and non-emergency co-payments, i.e. $8.00 for 150% and $20.00 for 150%. The hospital may not bill for additional charges. The MCO must cover post-stabilization services subsequent to an emergency that a treating physician views as medically necessary AFTER an emergency medical condition has been stabilized. The MCO must cover the following services without requiring authorization, and regardless of whether the member obtains the services within or outside the MCO’s network. The MCO is not required to cover this service.
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Service
FAMIS Covered
Network Cost Sharing & Benefit Limits 150% 150%
Notes and Day Limitations The MCO shall cover all family planning services, which includes services and drugs and devices for individuals of childbearing age which delay or prevent pregnancy, but does not include services to treat infertility or to promote fertility. FAMIS covered services include drugs, and devices provided under the supervision of a physician. The MCO may not restrict a member’s choice of provider for family planning services or drugs and devices, and the MCO is required to cover all family planning services and supplies provided to its members by network providers.
Family Planning Services
Yes
Hearing Aids
Yes
Home Health Services
Yes
$2 per visit
$5 per visit
$2
$5
The MCO shall cover hearing aids as outlined under Durable Medical Equipment. Hearing aids shall be covered twice every five years.
$5 per visit
The MCO shall cover home health services, including nursing and personal care services, home health aide services, PT, OT, speech, hearing and inhalation therapy up to 90 visits per calendar year. Personal care means assistance with walking, taking a bath, dressing; giving medicine; teaching self-help skills; and performing a few essential housekeeping tasks. The MCO is not required to cover the following home health services: medical social services, services that would not be paid for by FAMIS if provided to an inpatient of a hospital, community food service delivery arrangements, domestic or housekeeping services which are unrelated to patient care, custodial care which is patient care that primarily requires protective services rather than definitive medical and skilled nursing care services, and services related to cosmetic surgery.
$2 per visit
Code of Virginia § 54.1-2969 (D), as amended, states that minors are deemed adults for the purpose of consenting to medical services required in case of birth control, pregnancy or family planning, except for purposes of sexual sterilization.
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Service
Hospice Services
Immunizations
FAMIS Covered
Yes
Yes
Network Cost Sharing & Benefit Limits 150% 150%
$0
$0
$0
$0
Notes and Day Limitations The MCO shall cover hospice care services to include a program of home and inpatient care provided directly by or under the direction of a licensed hospice. Hospice care programs include palliative and supportive physician, psychological, psychosocial, and other health services to individuals utilizing a medically directed interdisciplinary team. Hospice care services must be prescribed by a Provider licensed to do so; furnished and billed by a licensed hospice; and medically necessary. Hospice care services are available if the member is diagnosed with a terminal illness with a life expectancy of six months or fewer. Hospice care is available concurrently with care related to the treatment of the child’s condition with respect to which a diagnosis of terminal illness has been made. The MCO is required to cover immunizations. The MCO shall ensure that providers render immunizations, in accordance with the most current Advisory Committee on Immunization Practices (ACIP). The MCO is required to work with the Department to achieve its goal related to increased immunization rates. The MCO is responsible for educating providers, parents and guardians of members about immunization services, and coordinating information regarding member immunizations. FAMIS eligible members shall not qualify for the Free Vaccines for Children Program.
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Service
Inpatient Mental Health Services
FAMIS Covered
Network Cost Sharing & Benefit Limits 150% 150%
Yes
$15 per confinement
$25 per confinement
Yes
$15 per confinement
$25 per confinement
Yes
$15 per confinement
$25 per confinement
Laboratory and X-ray Services
Yes
$2 per visit
$5 per visit
Lead Testing
Yes
$0
$0
Mammograms
Yes
$0
$0
Inpatient Rehabilitation Hospitals Inpatient Substance Abuse Services
Notes and Day Limitations Inpatient mental health services are covered for 365 days per confinement, including partial day treatment services. Inpatient hospital services may include room, meals, general-nursing services, prescribed drugs, and emergency room services leading directly to admission. The MCO is not required to cover any services rendered in free-standing psychiatric hospitals to members up to nineteen (19) years of age. Medically necessary inpatient psychiatric services rendered in a psychiatric unit of a general acute care hospital shall be covered for all FAMIS members. All inpatient mental health admission for individuals of any age to general acute care hospitals shall be approved by the MCO using its own prior authorization criteria. The MCO may cover services rendered in free- standing psychiatric hospitals as an enhanced benefit. Psychiatric residential treatment (level C) is not a covered service under FAMIS. The MCO shall cover inpatient rehabilitation services in facilities certified as rehabilitation hospitals and which have been certified by the Department of Health. The Mental Health Parity and Addiction Act of 2008 mandate coverage for mental health and substance abuse treatment services. Inpatient substance abuse services in a substance abuse treatment facility are covered. The MCO is required to cover all laboratory and x-ray services ordered, prescribed and directed or performed within the scope of the license of a practitioner in appropriate settings, including physician office, hospital, independent and clinical reference labs. No co-pay shall be charged for laboratory or x-ray services that are performed as part of an encounter with a physician. The MCO is required to cover blood lead testing as part of well baby, well childcare. MCO is required to cover low-dose screening mammograms for determining presence of occult breast cancer
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Service
FAMIS Covered
Network Cost Sharing & Benefit Limits 150%
Medical Supplies Yes
$0 for supplies $2 per item for equipment
Medical Equipment
150%
$0 for supplies $5 per item for equipment
Equipment
Medical Transportation
Yes
$2
Notes and Day Limitations
$5
The Contractor is responsible for payment of any specially manufactured DME equipment that was prior authorized by the Contractor. Professional ambulance services when medically necessary are covered when used locally or from a covered facility or provider office. This includes ambulance services for transportation between local hospitals when medically necessary; if prearranged by the Primary Care Physician and authorized by the MCO if, because of the member's medical condition, the member cannot ride safely in a car when going to the provider's office or to the outpatient department of the hospital. Ambulance services will be covered if the member's condition suddenly becomes worse and must go to a local hospital's emergency room. For coverage of ambulance services, the trip to the facility or office must be to the nearest one recognized by the MCO as having services adequate to treat the member's condition; the services received in that facility or provider’s office must be covered services; and if the MCO or the Department requests it, the attending provider must explain why the member could not have been transported in a private car or by any other less expensive means. Transportation services are not provided for routine access to and from providers of covered medical services.
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Service
Organ Transplantation
Outpatient Mental Health and Substance Abuse Services
FAMIS Covered
Yes
Yes
Network Cost Sharing & Benefit Limits 150% 150% $25 per $15 per confinement confinement and and $2 per outpatient visit (Services to identify donor limited to $25,000 per member)
$2 per visit
$5 per outpatient visit (Services to identify donor limited to $25,000 per member)
$5 per visit
Notes and Day Limitations
The MCO shall cover organ transplantation services as medically necessary and per industry treatment standards for all eligible individuals, including but not limited to transplants of tissues, autologous, allogeneic or synegenic bone marrow transplants or other forms of stem cell rescue for children with lymphoma and myeloma. The MCO shall cover kidney transplants for patients with dialysis dependent kidney failure, heart, liver, pancreas, and single lung transplants. The Contractor shall cover necessary procurement/donor related services. The MCO is not required to cover transplant procedures determined to be experimental or investigational.
The Mental Health Parity and Addiction Act of 2008 mandates coverage for mental health and substance abuse treatment services. Accordingly, the Contractor is responsible for covering medically necessary outpatient individual, family, and group mental health and substance abuse treatment services. The Contractor shall provide coverage to members, for mental health and substance abuse treatment services. Emergency counseling services, intensive outpatient services, day treatment, and substance abuse case management services are carved-out of this contact and shall be covered by the Department.
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Service
FAMIS Covered
Community Mental Health Rehabilitative Services (CMHRS)–
Yes
Pap Smears
Yes
Physical Therapy, Occupational Therapy, Speech Pathology and Audiology Services
Yes
Network Cost Sharing & Benefit Limits 150% 150%
Notes and Day Limitations The Contractor is not required to cover community mental health Rehabilitation services (CMHRS). Different than under Medicaid, for FAMIS MCO members, not all CMHRS services are covered by the Department as carved-out services. CMHRS services that are covered by the Department include: Intensive in-home services, therapeutic day treatment, mental health and substance abuse crisis intervention, and case management for children at risk of (or with) serious emotional disturbance. The remaining CMHRS are not covered by either fee-for-service or managed care for FAMIS MCO members. For a complete list of CMHRS services, see the Department's Community Mental Health Rehabilitation Services Manual available on the DMAS website at http://websrvr.dmas.virginia.gov/ProviderManuals/ManualChapters/CMH S/Chapter4_cmhrs.pdf.
$0
$2 per visit
$0
$5 per visit
The MCO is required to cover annual pap smears
The MCO shall cover therapy services that are medically necessary to treat or promote recovery from an illness or injury, to include physical therapy, speech therapy, occupational therapy, inhalation therapy, and intravenous therapy. The MCO shall not be required to cover those services rendered by a school health clinic.
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Service
FAMIS Covered
Physician Services Inpatient physician care Outpatient physician visit in the office or hospital
Network Cost Sharing & Benefit Limits 150% 150%
$0
$0
Yes $2 per visit
$5 per visit
Primary Care
$2 per visit
$5 per visit
Specialty care Maternity services
$0 per visit
$0 per visit
PregnancyRelated Services
Yes
$0
Notes and Day Limitations
$0
The MCO shall cover all symptomatic visits provided by physicians or physician extenders within the scope of their licenses. Cosmetic services are not covered unless performed for medically necessary physiological reasons. Physician services include services while admitted in the hospital, outpatient hospital departments, in a clinic setting, or in a physician’s office.
The MCO shall cover services to pregnant women, including prenatal services for FAMIS and FAMIS MOMS. There is no co-pay for pregnancy related services. No cost sharing at all will be charged to members enrolled in FAMIS MOMS.
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Service
FAMIS Covered
Network Cost Sharing & Benefit Limits 150% 150%
Prescription Drugs
Retail up to 34day supply Retail 35-90day supply
$2 per prescription $4 per prescription
$5 per prescription $10 per prescription
$4 per prescription
$10 per prescription
Yes
Mail service up to 90-day supply
Notes and Day Limitations The MCO shall be responsible for covering all medically necessary drugs for its members that by Federal or State law requires a prescription. The MCO shall cover all FAMIS covered prescription drugs prescribed by providers licensed and/or certified as having authority to prescribe the drug. The MCO is required to cover prescription drugs prescribed by the outpatient mental health provider. The MCO is not required to cover Drug Efficacy Study Implementation (DESI) drugs or over the counter prescriptions. The MCO may establish a formulary, may require prior authorization on certain medications, and may implement a mandatory generic substitution program. However, the MCO shall have in place special authorization procedures to allow providers to access drugs outside of this formulary, if medically necessary. The MCO shall establish policies and procedures to allow providers to request a brand name drug for a member if it is medically necessary. The MCO shall cover atypical antipsychotic medications developed for the treatment of schizophrenia. The MCO shall ensure appropriate access to the most effective means to treat, except where indicated for the safety of the patient. The Contractor shall not cover prescriptions for erectile dysfunction medication for members identified as having been convicted of felony sexual offenses. (If a generic is available, member pays the copayment plus 100% of the difference between the allowable charge of the generic drug and the brand drug.)
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Service
FAMIS Covered
Network Cost Sharing & Benefit Limits 150% 150%
Private Duty Nursing Services
Yes
$2 per visit
$5 per visit
Prosthetics/ Orthotics
Yes
$2 per item
$5 per item
Psychiatric Residential Treatment Services
No
School Health Services
Yes*
Notes and Day Limitations The MCO shall cover private duty nursing services only if the services are provided by a Registered Nurse (RN) or a Licensed Practical Nurse (LPN); must be medically necessary; the nurse may not be a relative or member of the member's family; the member's provider must explain why the services are required; and the member's provider must describe the medically skilled service provided. Private duty nursing services must be pre- authorized. The MCO shall cover prosthetic services and devices (at minimum, artificial arms, legs and their necessary supportive attachments) for all members. At a minimum, the MCO shall cover medically necessary orthotics (i.e., braces, splints, ankle, foot orthoses, etc. add items listed in Handbook) for members. The MCO shall cover medically necessary orthotics for members when recommended as part of an approved intensive rehabilitation program. This service is non-covered under FAMIS. *The MCO is not required to cover school-based services provided by a local education agency or public school system. The MCO shall not deny medically necessary outpatient or home setting therapies based on the fact that the child is also receiving therapies at school. School health services that meet the Department’s criteria will continue to be covered as a carveout service. The MCO shall not be required to cover these services rendered by a school health clinic.
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Service
FAMIS Covered
Network Cost Sharing & Benefit Limits 150% 150%
Second Opinions
Yes
$2 per visit
$5 per visit
Skilled Nursing Facility Care
Yes
$15 per confinement
$25 per confinement
Telemedicine Services
Yes
Temporary Detention Orders
No $15 per confinement if inpatient
$25 per confinement if inpatient
$2 per visit outpatient
$5 per visit outpatient
Therapy Services
Yes
Notes and Day Limitations The MCO shall provide coverage for second opinions when requested by the member for the purpose of diagnosing an illness and/or confirming a treatment pattern of care. The MCO must provide for second opinions from a qualified health care professional within the network, or arrange for the member to obtain one outside the network, at no cost to the member. The MCO may require an authorization to receive specialty care for an appropriate provider; however, cannot deny a second opinion request as a non-covered service. The MCO shall cover medically necessary services that are provided in a skilled nursing facility for up to 180 days per confinement. The MCO shall provide coverage for medically necessary telemedicine services. Telemedicine is defined as the real time or near real time twoway transfer of medical data and information using an interactive audio/video connection for the purposes of medical diagnosis and treatment. Currently the Department recognizes only physicians and nurse practitioners for medical telemedicine services and requires one of these types of providers at the main (hub) satellite (spoke) sites for a telemedicine service to be reimbursed. Additionally, the Department currently recognizes three telemedicine projects. The MCO is not required to cover this service. Coverage may be available through the State TDO program.
The MCO shall cover the costs of renal dialysis, chemotherapy and radiation therapy, and intravenous and inhalation therapy.
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Service
FAMIS Covered
Network Cost Sharing & Benefit Limits 150% 150%
Tobacco Dependence Treatment (i.e., Tobacco or Yes Smoking Cessation) for Pregnant Women Transportation No
Notes and Day Limitations
The MCO shall provide coverage for tobacco dependence treatment for pregnant women without cost sharing. Treatment includes counseling and pharmacotherapy.
Transportation services are not provided for routine access to and from providers of covered medical services. The Contractor shall cover all routine well baby and well childcare recommended by the American Academy of Pediatrics Advisory Committee, including routine office visits with health assessments and physical exams, as well as routine lab work and age appropriate immunizations.
Well Baby and Well Child Care
Yes
$0
$0
The following services rendered for the routine care of a well child: Laboratory services: blood lead testing, HGB, HCT or FEP (maximum of 2, any combination); Tuberculin test (maximum of 3 covered); Urinalysis (maximum of 2 covered); Pure tone audiogram for age 3-5 (maximum of 1); Machine vision test (maximum of 1 covered). Well child visits rendered at home, office and other outpatient provider locations are covered at birth and months, according to the American Academy of Pediatrics recommended periodicity schedule. Hearing Services: All newborn infants will be given a hearing screening before discharge from the hospital after birth.
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FAMIS Covered
Service
Network Cost Sharing & Benefit Limits 150% 150%
Vision Services Once every 24 months:
Routine eye exam
Yes
Eyeglass frames (one pair)
$2 Member Payment
$5 Member Payment
$25 Reimbursed by Plan
$25 Reimbursed by Plan
Notes and Day Limitations The MCO shall cover vision services that are defined as diagnostic examination and optometric treatment procedures and services by ophthalmologists, optometrists, and opticians. Routine refractions shall be allowed at least once in twenty-four (24) months. Routine eye examinations, for all members, shall be allowed at least once every two- (2) years. The MCO shall cover eyeglasses (one pair of frames and one pair of lenses) or contact lenses prescribed as medically necessary by a physician skilled in diseases of the eye or by an optometrist for members.
Eyeglass lenses (one pair) single vision
$35 Reimbursed by Plan
bifocal
$50 Reimbursed by Plan $88.50 Reimbursed by Plan $100 Reimbursed by Plan
trifocal
contacts
Inpatient Mental Health Services Rendered in a Freestanding Psychiatric Hospital
No
$35 Reimbursed by Plan $50 Reimbursed by Plan $88.50 Reimbursed by Plan $100 Reimbursed by Plan
The MCO is not required to cover this service. However, the MCO may cover services rendered in free-standing psychiatric hospitals to members up to nineteen (19) years of age as an enhanced benefit offered by the MCO. Medically necessary inpatient psychiatric services rendered in a psychiatric unit of a general acute care hospital shall be covered for all FAMIS members.
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Service
Abortions Cost Sharing: Annual CoPayment Limit FAMIS MOMS
FAMIS Covered
Network Cost Sharing & Benefit Limits
Notes and Day Limitations
150% 150%
No
The MCO is not required to cover services for abortion. Calendar year Calendar limit: $180 per family
year limit: $350 per family
Plan pays 100% of allowable charge once limit is met for covered services. No cost sharing will be charged to American Indians and Alaska Natives. Benefits are the same as those available under Medallion 3.0.
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External appeals for FAMIS members If you have a problem with what we decide after completing our appeal process, you can ask for an external review. This process is different for FAMIS members than it is for Medallion Medicaid members. If you don’t agree with a coverage or appeal decision, you or your child’s authorized representative may send an appeal request to KEPRO. You may ask for an external review if we: ● Said “no” to paying for a service you wanted for your child ● Said “OK” to a service, but then we put limits on it ● Ended payment for a service that we said “OK” to before ● Did not give your child access to a service fast enough To ask for an external review, this request must be sent in writing and be signed within 30 days of receipt of our Appeal Notice of Action resolution letter and sent to: FAMIS External Review Request c/o KEPRO 2810 N. Parham Road, Suite 305 Henrico, VA 23294 www.dmas.kepro.com This right is only available to you when you have completed our appeal process. If you have concerns about the appeal that you feel have not been addressed, you have the right to register the complaint with the Virginia Department of Health Professions at 1-800-533-1560. You may also register complaints with the Managed Care Helpline at 1-800-643-2273. You may also write them at: Office of Licensure and Certification Virginia Department of Health 9960 Mayland Drive, Suite 401 Richmond, VA 23233 Hotline: 1-800-955-1819 Richmond Metropolitan Area: 1-804-367-2106 or 1-804-367-2102 Fax: 1-804-527-4502 Email:
[email protected] Web page: www.vdh.virginia.gov You may also call Cover Virginia at 1-855-242-8282 to register your complaints.
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Key Words and Definitions Used in this Handbook Adverse benefit determination: Any decision to deny a service authorization request or to approve it for an amount that is less than requested. Appeal: A way for you to challenge an adverse benefit determination (such as a denial or reduction of benefits) made by the Anthem HealthKeepers Plus plan if you think we made a mistake. You can ask us to change a coverage decision by filing an appeal. Activities of daily living: The things people do on a normal day, such as eating, using the toilet, getting dressed, bathing, or brushing the teeth. Balance billing: A situation when a provider (such as a doctor or hospital) bills a person more than the Anthem HealthKeepers Plus plan’s cost-sharing amount for services. We do not allow providers to “balance bill” you. Call Member Services if you get any bills that you do not understand. Brand name drug: A prescription drug that is made and sold by the company that originally made the drug. Brand name drugs have the same ingredients as the generic versions of the drugs. Generic drugs are made and sold by other drug companies. Care Coordinator: One main person from the Anthem HealthKeepers Plus plan who works with you and with your care providers to make sure you get the care you need. Care coordination: A person-centered individualized process that assists you in gaining access to needed services. The Care Coordinator will work with you, your family Members, if appropriate, your providers and anyone else involved in your care to help you get the services and supports that you need. Care plan: A plan for what health and support services you will get and how you will get them. Care team: A care team may include doctors, nurses, counselors, or other health professionals who are there to help you get the care you need. Your care team will also help you make a care plan.
Helpline: an Enrollment Broker that DMAS contracts with to perform choice counseling and enrollment activities.
Centers for Medicare & Medicaid Services (CMS): The federal agency in charge of Medicare and Medicaid programs. Complaint: A written or spoken statement saying that you have a problem or concern about your covered services or care. This includes any concerns about the quality of your care, our network providers, or our network pharmacies. The formal name for “making a complaint” is “filing a grievance.” Coverage decision: A decision about what benefits we cover. This includes decisions about covered drugs and services or the amount we will pay for your health services. Cost Sharing – member pays a portion of the co-pay and/or medical bill. The Medallion managed Care Program does not have cost sharing. Covered drugs: The term we use to mean all of the prescription drugs covered by the Anthem HealthKeepers Plus plan.
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Covered services: The general term we use to mean all of the health care, services and supports, supplies, prescription and over-the-counter drugs, equipment, and other services covered by us. Durable medical equipment: Certain items your doctor orders you to use at home. Examples are walkers, wheelchairs, or hospital beds. Emergency medical condition: An emergency means your life could be threatened or you could be hurt permanently (disabled) if you don’t get care quickly. If you are pregnant, it could mean harm to the health of you or your unborn baby. Emergency medical transportation: Your condition is such that you are unable to go to the hospital by any other means but by calling 911 for an ambulance. Emergency room care: A hospital room staffed and equipped for the treatment of people that require immediate medical care and/or services. Excluded services: Services that are not covered under the Medicaid benefit. Fair hearing: See State Fair Hearing. The process where you appeal to the State on a decision made by us that you believe is wrong. Fee-for-service: The general term used to describe Medicaid services covered by the Department of Medical Assistance Services (DMAS). Generic drug: A prescription drug that is approved by the federal government to use in place of a brand name drug. A generic drug has the same ingredients as a brand name drug. It is usually cheaper and works just as well as the brand name drug. Grievance: A complaint you make about us or one of our network providers or pharmacies. This includes a complaint about the quality of your care. Habilitation services and devices: Services and devices that help you keep, learn, or improve skills and functioning for daily living. Health insurance: Type of insurance coverage that pays for health, medical and surgical expenses incurred by you. Health plan: An organization made up of doctors, hospitals, pharmacies, providers of long-term services, and other providers. It also has Care Coordinators to help you manage all your providers and services. They all work together to provide the care you need. Health risk assessment: A review of a patient’s medical history and current condition. It is used to figure out the patient’s health and how it might change in the future. Home health aide: A person who provides services that do not need the skills of a licensed nurse or therapist, such as help with personal care (like bathing, using the toilet, dressing, or carrying out the prescribed exercises). Home health aides do not have a nursing license or provide therapy. Home health care: Health care services a person receives in the home including nursing care, home health aide services and other services. Hospice Services: A full set of services coordinated by a variety of health care professionals to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as described in a specific patient plan of care. Hospitalization: The act of placing a person in a hospital as a patient. Hospital outpatient care: Care or treatment that does not require an overnight stay in a hospital.
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List of Covered Drugs (Drug List): A list of prescription drugs covered by the Anthem HealthKeepers Plus plan. We choose the drugs on this list with the help of doctors and pharmacists. The Drug List tells you if there are any rules you need to follow to get your drugs. The Drug List is sometimes called a “formulary.” Medically Necessary: This describes the needed services to prevent, diagnose, or treat your medical condition or to maintain your current health status. This includes care that keeps you from going into a hospital or nursing facility. It also means the services, supplies, or drugs meet accepted standards of medical practice or as necessary under current Virginia Medicaid coverage rules. Medicaid (or Medical Assistance): A program run by the federal and the state government that helps people with limited incomes and resources pay for long-term services and supports and medical costs. Member Services: A department within the Anthem HealthKeepers Plus plan responsible for answering your questions about your Membership, benefits, grievances, and appeals. Model of care: A way of providing high-quality care. The model of care includes care coordination and a team of qualified providers working together with you to improve your health and quality of life. Network: “Provider” is the general term we use for doctors, nurses, and other people who give you services and care. The term also includes hospitals, home health agencies, clinics, and other places that provide your health care services, and medical equipment. They are licensed or certified by Medicaid and by the state to provide health care services. We call them “network providers” when they agree to work with us and accept our payment and not charge our Members an extra amount. While you are a Member of the Anthem HealthKeepers Plus plan, you must use network providers to get covered services. Network providers are also called “plan providers.” Network pharmacy: A pharmacy (drug store) that has agreed to fill prescriptions for Anthem HealthKeepers Plus Members. We call them “network pharmacies” because they have agreed to work with us. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies. Non-participating provider: A provider or facility that is not employed, owned, or operated by the Anthem HealthKeepers Plus plan and is not under contract to provide covered services to our members. Nursing facility: A medical care facility that provides care for people who cannot get their care at home but who do not need to be in the hospital. Specific criteria must be met to live in a nursing facility. Out-of-network provider or Out-of-network facility: A provider or facility that is not employed, owned, or operated by the Anthem HealthKeepers Plus plan and is not under contract to provide covered services to Members of the Anthem HealthKeepers Plus plan. Participating provider: Providers, hospitals, clinics, and other places that provide your health care services, medical equipment, and services that are contracted with the Anthem HealthKeepers Plus plan. Participating providers are also “in-network providers” or “plan providers.”
Anthem HealthKeepers Plus Member Services 1-800-901-0020 (TTY 711)
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Physician services: Care provided to you by an individual licensed under state law to practice medicine, surgery, or behavioral health. Health Plan: An organization made up of doctors, hospitals, pharmacies, and other providers. It also has Care Coordinators to help you manage all your providers and services. They all work together to provide the care you need. Prescription drug coverage: Prescription drugs or medications covered (paid) by us. Some over-the -counter medications are covered. Prescription drugs: A drug or medication that, by law, can be obtained only by means of a physician's prescription. Primary Care Physician (PCP): Your primary care physician is the doctor who takes care of all of your health needs. They are responsible to provide, arrange, and coordinate all aspects of your health care. Often they are the first person you should contact if you need health care. Your PCP is typically a family practitioner, internist, or pediatrician. Having a PCP helps make sure the right medical care is available when you need it. Prosthetics and Orthotics: These are medical devices ordered by your doctor or other health care provider. Covered items include, but are not limited to, arm, back, and neck braces; artificial limbs; artificial eyes; and devices needed to replace an internal body part or function. Provider: A person who is authorized to provide your health care or services. Many kinds of providers participate with the Anthem HealthKeepers Plus plan, including doctors, nurses, behavioral health providers and specialists. Referral: In most cases you PCP must give you approval before you can use other providers in our network. This is called a referral. Rehabilitation services and devices: Treatment you get to help you recover from an illness, accident, injury, or major operation. Service area: A geographic area where the Anthem HealthKeepers Plus plan is allowed to operate. It is also generally the area where you can get routine (non-emergency) services. Service authorization: Approval needed before you can get certain services or drugs. Some network medical services are covered only if your doctor or other network provider gets an authorization from the Anthem HealthKeepers Plus plan. Skilled Nursing Care: Services from licensed nurses or other health care professionals, such as physical therapists who provide services in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing homeSpecialist: A doctor who provides health care for a specific disease, disability, or part of the body. Urgently needed care: Care you get for a non-life threatening sudden illness, injury, or condition that is not an emergency but needs care right away. You can get urgently needed care from out-of network providers when network providers are unavailable or you cannot get to them.
Anthem HealthKeepers Plus Member Services 1-800-901-0020 (TTY 711)
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Member Services 1-800-901-0020 CALL
Calls to this number are free. Monday-Friday from 8 a.m. to 6 p.m. Eastern time Member Services also has free language interpreter services available for non-English speakers. 711
TTY
Insert if plan uses a direct TTY number: This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. Insert days and hours of operation.
FAX
1-800-964-3627
WRITE
Member Services Anthem HealthKeepers Plus P.O. Box 27401 Mail Drop VA2002-N500 Richmond, VA 23279
WEB SITE
www.anthem.com/vamedicaid
Appendix A. The following individuals shall be excluded (as defined in 12VAC30-120-360) from participating in mandatory managed care as defined in the § 1915(b) managed care waiver. Individuals excluded from mandatory managed care shall include the following: 1. Individuals who are inpatients in state mental hospitals; 2. Individuals who are approved by DMAS as inpatients in long-stay hospitals, nursing facilities, or intermediate care facilities for individuals with intellectual disabilities; 3. Individuals who are placed on spend-down; 4. Individuals who are participating in the family planning waiver, or in federal waiver programs for home-based and community-based Medicaid coverage prior to managed care enrollment (except eligible EDCD members); 5. Individuals under age 21 who are approved for DMAS residential facility Level C programs as defined in 12VAC30-130-860;
Anthem HealthKeepers Plus Member Services 1-800-901-0020 (TTY 711)
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6. Newly eligible individuals who are in the third trimester of pregnancy and who request exclusion within a department-specified timeframe of the effective date of their MCO enrollment. Exclusion may be granted only if the member's obstetrical provider (i.e., physician, hospital, or midwife) does not participate with the member's assigned MCO. Exclusion requests made during the third trimester may be made by the member, MCO, or provider. DMAS shall determine if the request meets the criteria for exclusion. Following the end of the pregnancy, these individuals shall be required to enroll to the extent they remain eligible for Medicaid; 7. Individuals, other than students, who permanently live outside their area of residence for greater than 60 consecutive days except those individuals placed there for medically necessary services funded by the MCO; 8. Individuals who receive hospice services in accordance with DMAS criteria; 9. Individuals with other comprehensive group or individual health insurance coverage, including Medicare, insurance provided to military dependents, and any other insurance purchased through the Health Insurance Premium Payment Program (HIPP); 10. Individuals requesting exclusion who are inpatients in hospitals, other than those listed in subdivisions 1 and 2 of this subsection, at the scheduled time of MCO enrollment or who are scheduled for inpatient hospital stay or surgery within 30 calendar days of the MCO enrollment effective date. The exclusion shall remain effective until the first day of the month following discharge. This exclusion reason shall not apply to members admitted to the hospital while already enrolled in a department-contracted MCO; 11. Individuals who request exclusion during assignment to an MCO or within a time set by DMAS from the effective date of their MCO enrollment, who have been diagnosed with a terminal condition and who have a life expectancy of six months or less. The individual's physician must certify the life expectancy; 12. Certain individuals between birth and age three certified by the Department of Behavioral Health and Developmental Services as eligible for services pursuant to Part C of the Individuals with Disabilities Education Act (20 USC § 1471 et seq.) who are granted an exception by DMAS to the mandatory managed care enrollment; 13. Individuals who have an eligibility period that is less than three months; 14. Individuals who are enrolled in the Commonwealth's Title XXI SCHIP program; 15. Individuals who have an eligibility period that is only retroactive; and 16. Children enrolled in the Virginia Birth-Related Neurological Injury Compensation Program established pursuant to Chapter 50 (§ 38.2-5000 et seq.) of Title 38.2 of the Code of Virginia.
Anthem HealthKeepers Plus Member Services 1-800-901-0020 (TTY 711)
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Member Services 1-800-901-0020 TTY 711
HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.
