Your Medical Care Services Medical Benefits with Community Health Plan of Washington

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Your Medical Care Services

Medical Benefits

ith Community Health Plan of Washington

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Including:

Your Benefits:

•

• Services covered by Community Health Plan

• Services covered by Health Care Authority or other programs

Services covered at your local health department

• Services not covered by Community H

ealth Plan, HCA, or other

programs

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Payments for services not cove

ow to Get More Information

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UPDATED December 9, 2011

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Contact

Information

Medical Care Services with Community Health Plan of Washington

Community Health Plan Contacts

CUSTOMER SERVICE

Hours Monday‐Friday 8:00 am – 5:00 pm Voice 1‐800‐440‐1561 toll free

TTY TTY Relay: Dial 7‐1‐1 Email customercare@chpw.org

OFFICE PHONE 206‐521‐8830 voice

WEB www.chpw.org

MAILING ADDRESS

Community Health Plan of Washington

720 Olive Way, Suite 300

Seattle, WA 98101‐1830

FIND PROVIDERS

• Visit the Provider Directory Search

online: On the Community Health Plan

web site (www.chpw.org), click the

Providers tab.

• Contact the Community Health Plan

customer service team.

FREE 24‐HOUR NURSE ADVICE LINE

Voice 1‐866‐418‐1002 toll free TTY 1‐866‐418‐1006 toll free

Contacts Outside Community

Health Plan

Medical Care Services (Medicaid)

Web hrsa.dshs.wa.gov/mcs/index.shtml

Medicaid customer service phone

• Voice 1‐800‐562‐3022 • TTY TTY Relay: Dial 7‐1‐1.

WASHINGTON STATE

To learn about your rights under the law,

call the Washington State Office of the

Insurance Commissioner: 1‐800‐562‐6900.

If you have a problem or concern, call the Washington State Department of Health

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T

able

of

Services

Covered

by

Community

Health

Plan

of

Washington

This is a summary of services and treatments covered by Community Health Plan of Washington

("Community Health Plan" or "the Plan") and the Washington State Health Care Authority (HCA)

for Medical Care Services. Some health care services are not covered.

Services and treatments are covered only if medically necessary.

You will need a referral from your PCP and often an authorization from Community Health Plan

before you get a service or treatment. If you get a service before you get an authorization or

referral, you might have to pay for it yourself. (See "About Prior Authorizations and Referrals."

Community Health Plan covers professional services. HCA covers facility services.

For information about services covered by Community Health Plan:

• "Medical Care Services Benefit Table" lists benefits covered by the Plan when they are

medically necessary. (See "Medically Necessary.") The Details column tells more about the

benefit, including whether it requires a referral or prior authorization.

• "Services Covered by HCA or Other Programs" lists services offered by HCA or other

agencies and programs when they are medically necessary.

• "Services at Your Local Health Department" lists services offered by your local Washington

State Department of Health office when they are medically necessary. You must show your

ProviderOne ID card to get these services. For information, call 1‐800‐562‐3022.

• "Services Not Covered by Community Health Plan, HCA, or Other Program" lists services and

treatments that are not covered on your Medical Care Services program.

• "Payments for Services Not Covered" explains when services are not covered and how third

parties may pay for services.

For more information about which services are covered by the Plan: • Contact your provider or other clinic staff.

• Phone the Community Health Plan customer service team at 1‐800‐440‐1561, Monday

through Friday from 8:00 am to 5:00 pm or email customercare@chpw.org. If you are

hearing or speech impaired, call TTY Relay: Dial 7‐1‐1.

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Medical Care Services Benefit Table

Note: If you do not find a service listed in this table, please check the lists that follow it:

• "Services Covered by HCA or Other Programs"

• "Services at Your Local Health Department"

• "Services Not Covered by Community Health Plan, HCA, or Other Program"

Benefit Details

Ambulance transportation for emergency medical conditions For non‐emergency conditions, appropriate

transportation, including ambulance if needed, is covered if any of the following is true:

• You need to move to another location to get a service.

• You need to be carried on a stretcher.

• You need medical attention en route.

Anesthesia

Antiretroviral agents HCA covers protease inhibitors. (See "Services Covered

by HCA or Other Programs.")

Blood and blood products

Cardiac rehabilitation Requires prior authorization.

Chemotherapy, oral and injectable or infused Some agents require prior authorization. Check before

getting the treatment.

Circumcision only to treat underlying medical condition

Diagnostic procedures and tests, including laboratory Covered by Community Health Plan, depending on the

specific procedure or test.

Durable medical equipment Not a covered benefit. However, in very limited cases

your provider may work with Community Health Plan to get a prior authorization.

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Emergency services, including post‐emergency follow‐up in a clinic or hospital.

Emergency service is covered when:

• You need immediate medical attention that won't wait for you to see your doctor.

• Somebody from your clinic or the Nurse Advice Line tells you to seek emergency care.

Eye exams An eye exam is covered once in a 24‐month period. Eye

care services for medical conditions are not limited. Frames are paid for by HCA.

Growth hormone therapy injections Requires prior authorization:

• Prescription and prior authorization if you self administer.

• Plan prior authorization if provider administers.

Health education for asthma, diabetes, and heart disease Up to 6 visits per calendar year. Requires prior

authorization.

Home health services through state‐licensed agencies Requires prior authorization.

Home infusion therapy Requires prior authorization.

Hospital care: some outpatient surgery, including emergency room and outpatient services

Outpatient surgery requires prior authorization

HPV test

Immunizations, including but not limited to:

• Flu (For more information, see Adult Immunizations.)

• Menactra (meningococcal vaccine)

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Injections including but not limited to:

• Botox (not for cosmetic)

• Enbrel

• Euflexxa

• Orencia

• Orthovisc

• Remicade infusion

• Synagis or RespiGam

• Synvisc or Hyalgan

• Tysabri (natalizumab)

• Xolair

• If self administered, requires prescription and a prior authorization from Express Scripts, Inc. (ESI), the Community Health Plan pharmacy benefit manager.

• If the patient cannot self administer, requires Community Health Plan prior authorization.

IV therapy, home or outpatient Requires prior authorization.

Laboratory diagnostic tests Covered by Community Health Plan, depending on the

specific test.

Lymphedema treatment Requires prior authorization for more than 12 visits per

year. Covered by HCA or by Community Health Plan.

Mammogram When done in a free‐standing imaging center.

Mental health services, including:

• Brief mental health services from a care coordinator at the primary care clinic

• Six months of mental health services from a Community Mental Health Agency (by referral from a care coordinator)

• Unlimited management of medications provided by PCP or in conjunction with mental health treatment

Requires a referral from your primary care provider to the care coordinator at the primary care clinic.

Neuropsychological testing Requires prior authorization for more than 12 visits per

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Office visits with providers such as physicians, physician assistants, registered nurses (RNs), advanced registered nurse practitioners (ARNPs), podiatrists, audiologists, and certified dietitians

• Referrals to network providers. The Plan requires use of in‐network providers whenever possible. If a request is received from the member's PCP, Plan authorization is required after the first 12 visits.

• Referrals to out‐of‐network providers. In

circumstances that require a referral to an out‐of‐ network specialist, authorization from the Plan is required from the first visit.

Orthoptic (eye training) care for eye conditions

Osteopathic manipulation Requires prior authorization for more than 10 visits per

year. Pain treatment, including office visits, outpatient rehabilitation,

treatment (nerve block, epidural, steroid injection)

Requires prior authorization for more than 12 visits per year.

Pharmacy and prescriptions (outpatient) Only drugs on the Community Health Plan Formulary

are covered.

Physical, occupational, and speech therapy Requires prior authorization for more than 12 visits per

year.

Podiatry, including diabetic foot care

Preventive care, such as immunizations, screening colonoscopies, mammograms, bone density testing

Radiation treatment Some agents require prior authorization. Check before

getting the treatment. Radiology (including PET scans, some MRI and MRA, CT‐head, and CT

angiography), nuclear medicine, ultrasound, laboratory, other diagnostic services, including x‐rays and echos

All imaging below requires a prior authorization:

• CT angiography

• PET scan

• MRI/MRA

Rehabilitation, inpatient and outpatient.

May include physical therapy, occupational therapy, speech therapy.

• Inpatient requires a referral from your PCP.

• Outpatient requires prior authorization for more than 12 visits per year.

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Skilled nursing facility Requires referral from your PCP.

Sleep study for obstructive sleep apnea and narcolepsy diagnosis only

Smoking cessation: Prescribed drugs and some nicotine replacement

Specialty care, when referred by your PCP

Surgeries including, but not limited to:

• Adenoidectomy

• Ambulatory or same day outpatient surgery

• Arthroscopy (knee)

• Bladder neck suspension

• Blepharoplasty

• Breast reduction

• Bunionectomy

• Hip, knee, or shoulder replacement

• Hysterectomy

• Lasik eye surgery to correct medical condition such as glaucoma, retinal detachment, cataracts

• Mastectomy

• Rhinoplasty

• Sclerotherapy, leg vein

• Septoplasty

• Spontaneous miscarriage

• Strabismus

• Tonsillectomy

• UPPP (uvulopalatopharyngoplasty)

All inpatient surgeries and some outpatient surgeries require prior authorization. Check before getting the treatment.

Mastectomy does not require prior authorization for treatment related to breast cancer.

Urgent care, including post‐emergency follow‐up. Visits to urgent care centers require a referral from

your PCP.

Wound care, home health agency Requires prior authorization.

Wound care, outpatient Requires prior authorization for more than 12 visits per

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Services

Covered

by

Health

Care

Authority

or

Other

Programs

The services listed in this section are paid for by HCA or other programs. You must use

providers who will take your ProviderOne ID card. Your provider will know how to bill for

payment. These services are paid by HCA or another program, but they will be coordinated by

your PCP and Community Health Plan of Washington ("Community Health Plan" or "the Plan").

• Chemical dependency detoxification, inpatient treatment, outpatient counseling • Convalescent or custodial care

• Limited dental care (not routine care) • Eyeglass frames, lenses, and fitting services • Hearing aid

• Interpreter services for medical visits

• Maternity care & delivery, services, or maternity support/infant case management.

(Medical Care Services members who become pregnant receive their care through HCA.) • Mental health services, including:

• 24‐hour crisis intervention

• Emergency mental health services • Inpatient psychiatric care

• Methadone treatment for addiction

• Nursing facilities through Aging and Disability Services

• Protease inhibitors. (Some antiretrovirals are covered by Medical Care Services.) • Sterilizations when younger than 21 years old

• Substance abuse treatment covered by Division of Behavioral Health and Recovery • Vocational rehabilitation

• Voluntary pregnancy termination

Services

at

Your

Local

Health

Department

As a member of Community Health Plan of Washington, you can get the services listed in this

section from Community Health Plan providers or you can go directly to a local health

department or family planning clinic. You must use providers who will take your ProviderOne ID

card and who will bill HCA for payment.

Services you can get at your local health department: • Family planning services and birth control

• HIV and AIDS testing

• Immunizations (For more information, see "Adult Immunizations.") • Sexually transmitted disease treatment and follow‐up care

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Services

Not

Covered

by

Community

Health

Plan,

HCA,

or

Other

Programs

• Acupuncture • Adult day health • Biofeedback therapy • Childbirth classes

• Chiropractic care for adults • Cosmetic surgery and services • Court‐ordered services

• Doula services

• Experimental and investigational treatment or services.

Community Health Plan believes these health care services are not generally as effective, or

have not been scientifically proven to be effective, for a particular disease or condition.

They are not covered until good research shows they are more helpful than harmful.

Community Health Plan looks at requests for experimental or investigational procedures on

a case‐by‐case basis.

• Gender dysphoria or sex reassignment surgery

• Homeopathy

• Hospice care

• Hypnotherapy

• Immunizations for international travel • Lasik eye surgery to correct vision • Massage therapy

• Medical exams for Social Security Disability benefits

• Medical services while in jail, beginning when a law enforcement officer takes the member

into custody • Naturopathy

• Out‐of‐country (outside of the United States) care and care outside of Washington state and

border cities

• Personal comfort items while in the hospital, such as telephone charges and TV • Pharmacy: mail order prescriptions, take home drugs prescribed by hospital • Physical exams needed for employment, immigration, insurance, or licensing • Plastic surgery for cosmetic reasons

• Reversal of voluntary surgical sterilizations • Services not allowed by federal or state law

• Sexual dysfunction treatment, including impotence treatment; penile prosthesis; diagnosis

and treatment of infertility, impotence, and sexual dysfunction • Sports physicals

• TMJ treatment, including medical and surgical treatment and appliances • Zostavax (shingles) immunization

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For

Information

About

Prescription

Services

• See "Prescription Drug Services" online or request a printed copy.

• Visit the Community Health Plan website (www.chpw.org). Click the Plans tab, and then

select Medical Care Services.

• Contact the Community Health Plan customer service team at 1‐800‐440‐1561, Monday

through Friday from 8:00 am to 5:00 pm, or email customercare@chpw.org. If you are

hearing or speech impaired, please call TTY Relay: Dial 7‐1‐1.

Payments

for

Services

Not

Covered

You do not have to pay for covered services. However, you might have to pay if you:

• Get treatment or services not covered by Community Health Plan of Washington, Health Care Authority, or other programs.

• Decide to get care outside of the Community Health Plan of Washington network of providers without prior, written Community Health Plan permission.

• Get non‐emergency services outside Washington State.

ThirdParty Liability

Community Health Plan will decide whether or how to pay for accident‐related medical bills. If it appears that another insurance company should pay, we will get payment from that company for any payments we made. If you get a settlement, you may need to refund Community Health Plan for any bills we have paid related to the accident.

If you were hurt while at work, your medical bills will be paid by workers' compensation. You must tell your primary care provider and Community Health Plan about your injury right away.

Your workers' compensation will cover all your injury‐related bills. If the injury is not work related, Community Health Plan will pay all related covered expenses after we get a denial letter from your workers' compensation plan.

Subrogation is when there is another company that pays for health care services you get because of an injury or illness. For example, your auto insurance may pay if you are injured in a car accident, or workers' compensation may pay if you are hurt on the job. Subrogation is different than coordination of benefits because the third party will only pay for the services that are related to that injury or illness.

Coordination of benefits happens when you are covered by more than one health insurance plan at the same time.

If you have two insurance plans or if another company should pay for your medical bills, call the Community Health Plan customer service team at 1‐800‐440‐1561, Monday through Friday from 8:00 am to 5:00 pm, or email customercare@chpw.org. If you are hearing or speech impaired, call TTY Relay: Dial 7‐1‐1.

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You should also call the Medical Assistance customer service center at 1‐800‐562‐3022 to tell them you have other insurance. The other insurance plan must pay first for all the medical care it covers. Community Health Plan will then pay for the remaining covered charges.

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HOW

TO

GET

MORE

INFORMATION

You can learn more about Medical Care Services, about Community Health Plan of Washington,

and about how to use your plan.

We send you information:

We send you printed information when you become a member, annually during the time you

are a member, and at other times to make sure you get the most out of your health care.

You can request printed information:

This packet includes a postcard to order printed information about specific topics or a booklet

that includes all of your member information. You can get this information anytime you want it.

You can request information in another language or another format:

You can also ask us to translate the information into the language you prefer to read. If your

vision is impaired or you have difficulty reading, we can read the information to you.

To get more information about your plan:

• The How to Find Important Information sheet enclosed in this package lists information

available to you and tells you how to find the information or get a printed copy sent to you. • To find a provider, pharmacy, clinic, or hospital, visit the Community Health Plan of

Washington website at www.chpw.org. Click the Providers tab and select the type of search

you want. To get a printed report or have someone search for you, contact our customer

service team. (Contact information below.)

• You can also search our formulary (approved drug list) to find out if your prescription is

covered. Visit our website, www.chpw.org. Click the Providers tab and select Formulary

Search. To get a printed report or have someone search for you, please contact our

customer service team. (Contact information below.)

• Contact the Community Health Plan customer service team at 1‐800‐440‐1561, Monday

through Friday from 8:00 am to 5:00 pm, or email customercare@chpw.org. If you are

hearing or speech impaired, please call TTY Relay: Dial 7‐1‐1.

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Your Medical Care Services Medical Benefits with Community Health Plan of Washington