Guide to
Washington Health Program
with Community Health Plan of Washington
Including:
About Your Enrollment:
•
Your ID card
•
World Doc 24/7 FREE Health Management Tools
•
Health Information Portal (HIP) FREE Claims and Account Tools
Getting Care:
•
Choosing a PCP
•
Specialists, second opinions, hospital care
•
Getting care after clinic hours
•
FREE Nurse Advice Line
•
Emergency care
•
Urgent Care Center visits
•
When you get care outside your service area
Your Benefits:
•
Your medical benefits, including cost sharing
•
Your pharmacy benefits, including formulary and finding a pharmacy
•
Services not covered
Advance Directives
Your Privacy
Appeal and Grievance Process for Washington Health Members
Contact Information
Washington Health Program
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 [email protected]
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 website (www.chpw.org), click the Our Providers tab.
• Contact the Community Health Plan customer service team.
FREE HEALTH INFORMATION PORTAL (HIP)
For information about eligibility, benefits, authorizations, and claims or to enroll in a disease management program:
https://hip.chpw.org/login.asp?FT=N
FREE 24-HOUR NURSE ADVICE LINE
Voice 1-866-418-1002 toll free
TTY 1-866-418-1006 toll free
FREE 24/7 WORLDDOC HEALTH MANAGEMENT TOOLS
To enroll in the free web-based personal health management system, use this direct link: https://www.worlddoc.com/chpw
Contacts Outside Community
Health Plan
WASHINGTON STATE HEALTH CARE AUTHORITY
Web www.washingtonhealth.hca.wa.gov/
Phone:
• Voice 1-800-660-9840
• 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
Table of Contents
About Your Enrollment ... 5
How to Stay Enrolled or Disenroll ... 5
Your Community Health Plan ID Card ... 5
How to Change Your Address ... 6
How to Change Your Annual Maximum Benefit ... 6
FREE Health Information Portal (HIP) helps you manage your benefits ... 6
FREE WorldDoc Personal Health Management System health information and tools ... 7
Getting Care: Start by Choosing a Primary Care Provider (PCP) ... 7
Specialists or Behavioral Health Services ... 8
Getting a Second Opinion ... 8
Hospital Care ... 8
Making an Appointment ... 10
Appointment Standards ... 10
To Get Care After Clinic Hours ... 11
24-Hour Nurse Advice Line ... 11
Urgent Care Center Visits ... 11
When You Get Out-of-Area Care ... 12
How to Submit a Claim if You Get a Bill ... 12
Explanation of Benefits (EOB) ... 13
Balance Billing When You Get Care Outside Washington State ... 13
Washington Health Program Cost Sharing ... 14
Maternity Delivery Services Window Deductible ... 15
Washington Health Program Benefits ... 15
Washington Health Program Benefit Table ... 16
Washington Health Program Services Not Covered ... 26
Prescription Drug Services ... 28
To Find Participating Pharmacies ... 28
Pharmacy Cost Sharing ... 28
Your Right to Safe and Effective Pharmacy Services ... 29
Frequently Asked Questions About Pharmacy ... 30
Quality Improvement Program ... 32
How We Manage Your Care: Utilization Management ... 33
Evaluation of New Technology ... 33
Advance Directives ... 33
Member Rights and Responsibilities ... 35
Member Rights... 35
Your right to get information about the organization, its services, its practitioners and providers and member rights and responsibilities. ... 35
Your right to be treated with respect and recognition of your dignity and right to privacy. ... 36
Your right to a candid discussion of appropriate or medically necessary treatment options for your or your child's conditions, regardless of cost or benefit coverage. ... 36
Your right to voice complaints or appeals about the organization or the care it provides. ... 37 Your right to make recommendations regarding the organization's member rights and
Your right to choose your providers and your health plan. ... 37
Member Responsibilities ... 38
Your responsibility to supply information (to the extent possible) that the organization and its practitioners and providers need in order to provide care. ... 38
Your responsibility to understand your health problems and participate in developing mutually agreed upon treatment goals, to the degree possible. ... 38
Your responsibility to follow plans and instructions for care that you have agreed to with your practitioners... 38
Your responsibility to treat your providers and staff with respect. ... 38
Your responsibility to work with Community Health Plan of Washington. ... 39
Community Health Plan Notice of Privacy Practices ... 40
Privacy and Security of Your Health Information ... 40
Privacy of Your Health Information - Authorizations ... 41
Your Personal Information and the Web ... 43
Your Rights About Your Protected Health Information ... 44
How Do I Use My Rights? ... 46
Age of Consent ... 47
Grievance and Appeal Process for Washington Health Program Members ... 50
First Level Appeal ... 51
Expedited (Rush) Appeal ... 51
Second Level Appeal ... 51
Independent Review ... 52
Expedited Review by an IRO ... 52
Appointing an Authorized Representative ... 52
About Your Enrollment
At Community Health Plan of Washington, our goal is to provide you and your family access to affordable, high-quality medical care services. We serve all ages, from babies to seniors, with providers who have deep community roots and include some of the best doctors, nurses, and specialists in the state.
You can enroll in Washington Health Program at any time. There is no open enrollment period. You can disenroll at any time.
How to Stay Enrolled or Disenroll
You can lose your enrollment if you fail to supply information when you are asked to provide it to Washington Health or if you fail to pay your premiums on time. This may result in a
temporary suspension or permanent disenrollment and you might have to reapply. For information about recertification, see the
To avoid a suspension or disenrollment:
• Pay your premiums on time.
• Supply information promptly when Washington Health Program or Community Health Plan asks for it.
• Keep us informed of changes in your family. (See How to Change Your Address.) You may disenroll from Washington Health Program at any time.
To learn more about changes that affect your eligibility, about how to disenroll, and about changing between Health 75 and Health 100 maximum benefit limits:
• See Chapter Two, "Making Changes and Maintaining Eligibility," in the
• Visit the Washington Health Program website, www.washingtonhealth.hca.wa.gov/.
• Call Washington Health Program customer service at 1-800-660-9840. TTY users, please call the Washington Relay Service by dialing 7-1-1.
• Write to Washington Health Program, P.O. Box 42714, Olympia, WA 98504-2714.
Your Community Health Plan ID Card
We send you an ID card when you enroll in Community Health Plan of Washington. Each person in your family who signs up with Community Health Plan will have his or her own ID card. You will need to show your ID card each time you get medical care. This includes medical visits, specialist visits, hospital visits, and pharmacy prescriptions.
How to Change Your Address
Changes to your family—such as adding or deleting a family member or moving to a new address—can affect your Washington Health Program eligibility and coverage.
If you move, you must inform both Community Health Plan of Washington and the Washington State Health Care Authority (HCA).
To change your address or other family information with Community Health Plan, please 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 e impaired, please call TTY Relay: Dial 7-1-1.
To change your address or other information with the Health Care Authority, you can:
• Use the Change Form included with your bill.
• Call Washington Health Program customer service at 1-800-660-9840. TTY users, please call the Washington Relay Service by dialing 7-1-1.
• Write to Washington Health at P.O. Box 42714, Olympia, WA 98504-2714.
• Download a form from the HCA web site:
www.washingtonhealth.hca.wa.gov/materials.html
How to Change Your Annual Maximum Benefit
When you enroll in Washington Health Program, you choose whether you want to be in Health 75 (with a $75,000 annual maximum benefit per member per year) or Health 100 (with a
$100,000 annual maximum benefit per member per calendar year). After you reach your annual maximum benefit per calendar year, you are responsible for 100% of your health care costs, including pharmacy for the remainder of the calendar year.
You can change between the two annual benefit limits at any time. However, when you change you will have to complete a new application and Standard Health Questionnaire (SHQ) and
submit them to the HCA for approval. Also, your yearly deductibles and your out-of-pocket
maximum start over when you enroll in the new benefit plan.
FREE Health Information Portal (HIP) helps you manage your
benefits
Washington Health Program members are invited to use the Health Information Portal (HIP). This online service enables you to get up-to-date information about your Community Health Plan eligibility, benefits, authorizations for service, and claims and to enroll in a disease management program.
To sign up to access the Community Health Plan Health Information Portal, https://hip.chpw.org/login.asp?FT=N.
FREE WorldDoc Personal Health Management System health
information and tools
Washington Health Program members get free access to health risk assessment tools and rich health information through the WorldDoc 24/7 Personal Health Management System.
If you are a Washington Health Program member, you are welcome to log on and use these resources such as:
• A Personal Evaluation System (PES) that provides you with access to thousands of the most common medical conditions and treatments.
• A Health Risk Assessment (HRA) that identifies areas to discuss with your doctor.
• Access to an extensive set of health educational materials.
• And so much more!
To log in or get more information about WorldDoc, go to: https://www.worlddoc.com/login.aspx
Getting Care: Start by Choosing a Primary Care Provider
(PCP)
As a member of Community Health Plan of Washington, you must choose a primary care provider (PCP). If you do not choose a PCP, we will choose one for you. Every covered member in your family can choose his or her own PCP.
If you are pregnant, it is best to choose a PCP in our network for your baby before the birth. If you do not choose one by the time your baby is born, we will choose one for you. You can change your baby’s PCP later if you wish. The new PCP will become effective no later than the beginning of the month after your request.
To find participating and preferred providers, including the provider’s location, qualifications, languages spoken, and availability:
• Visit the Community Health Plan of Washington website at www.chpw.org. Click the Our 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.
• 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 [email protected]. If you are hearing or speech impaired, please call TTY Relay: Dial 7-1-1.
These sources can also tell you about a provider's professional qualifications—including medical school attended, residency completed, and board status.
Specialists or Behavioral Health Services
If you and your PCP agree that you need to see a specialist or get behavioral health services, your PCP will write you a referral. You can see any specialist who is in the Community Health Plan network of doctors, but ask your PCP for a referral before getting specialist services unless it is an emergency.
In some cases, we also need to okay your specialist care before you get it. This is called a prior authorization.
To see the most current list of services, drugs, and equipment requiring prior authorization:
• Visit the Community Health Plan website, www.chpw.org. Click the Member Services tab, and then select Patient Safety. Click the link to the Prior Authorization List. You can also download a PDF of the list to print and read.
• If you want a printed Prior Authorization List sent to you, please 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 [email protected]. If you are hearing or speech impaired, please call TTY Relay: Dial 7-1-1.
Getting a Second Opinion
As a member of Community Health Plan, you have a right to a second opinion. For the second opinion to be paid for by us, the provider must be part of our network (providers who work with Community Health Plan). Your primary care provider must also okay it (give you a referral). To get a second opinion, ask your PCP for the name of another qualified Community Health Plan provider. For a list of participating providers and specialists, including their location, languages spoken, and availability:
• Visit the Community Health Plan of Washington website at www.chpw.org. Click the Our Providers tab, and then select the type of search you want.
• To get a printed report or have someone search for you, 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 [email protected]. If you are hearing or speech impaired, please call TTY Relay: Dial 7-1-1.
Hospital Care
If you need to go to the hospital for nonemergency care, you must first get an authorization from Community Health Plan of Washington. For more information about getting an authorization for nonemergency hospital care, please see
For a list of participating hospitals:
• Visit the
• 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 e hearing or speech impaired, please call TTY Relay: Dial 7-1-1.
You do not need an authorization to visit a hospital in an emergency. In an emergency, call 911 or go to the hospital nearest you. For more information, see
Give the hospital your PCP's name so the hospital can tell your PCP about your emergency treatment.
Remember: You can call your PCP 24 hours a day to get help and advice. For more information
about contacting getting medical advice after clinic hours, see
Covered Hospital Services
The following hospital services are covered:
• Semi-private room and board, including meals; private room and special diets; and general nursing services.
• Hospital services, including use of operating room and related facilities, intensive care unit and services, labor, and delivery room, anesthesia, radiology, laboratory, and other
diagnostic services.
• Normal newborn baby care following birth while in a contracting facility. Covered services include, but are not limited to, nursery and laboratory services.
• Drugs and medications administered while an inpatient.
• Special duty nursing.
• Dressings, casts, equipment, oxygen services, and radiation and inhalation therapy.
If a member is hospitalized in a facility outside our network, Community Health Plan has the right to require transfer of the member to a health plan facility in our network at the health plan’s expense, when the member's condition is sufficiently stable to enable safe transfer.
If the member refuses to transfer to a contracting facility, all further costs incurred during the hospitalization are the responsibility of the member.
If a member transfers to a contracting facility without a prior authorization from the Plan, the member pays for the transportation.
Pre-Admission Authorization
All planned inpatient hospital care must have an approval (prior authorization) from Community Health Plan, except hospital care for psychiatric illness and substance abuse. Even though you do not need prior authorization for hospital care for psychiatric illness and substance abuse, we still need to be told if you get admitted. For more information about prior authorizations, see In advance of the admission or procedure, your provider faxes Community Health Plan (206-624-7769) for an approval. After its review, Community Health Plan tells you and your provider of its decision.
Please make sure that your provider gets this approval from Community Health Plan before you are admitted to the hospital.
The pre-admission authorization does not apply to emergency hospitalizations.
Nurses and doctors at Community Health Plan will watch your progress while you are in the hospital. We help doctors arrange for care for you after you go home if you need it.
Making an Appointment
To make an appointment, call your primary care provider's office. When you call to make an appointment:
• Please tell your PCP's office if you are a new member.
• Be sure to ask for an interpreter if you need one.
Appointment Standards
Generally, you should expect to be able to see a provider in the following timelines:
• Preventive Care: Office visit with your PCP or other provider within 30 calendar days.
Examples of preventive care are physical exams, annual women’s health care, and immunizations (shots).
• Routine Care: Office visit with your PCP or other provider within 10 calendar days. Routine
care is for medical problems that are not urgent or an emergency.
• Urgent: Office visit with your PCP or other provider within 48 hours. Urgent care is for
medical problems that need care right away, but are not an emergency.
• Emergency: Available 24 hours per day, seven days per week at the nearest hospital. An
To Get Care After Clinic Hours
1. Call your primary care clinic. Most PCPs offer after-hours medical advice by phone.
2. If the clinic or your PCP is not available, call the Nurse Advice Line toll free 1-866-418-1002 (voice) or 1-866-418-1006 (TTY for speech or hearing impaired). The nurses can help you when you have questions about health concerns or need health information.
3. If your symptoms are severe or if your PCP cannot see you right away, ask your PCP if you can go to an urgent care center, where they can treat you that same day. Urgent care is covered only if you get an authorization from your PCP. (For more information about prior authorizations, see the website, www.chpw.org, or contact our customer service team.) 4. If you cannot reach your PCP and you think you are too sick to wait, go to the nearest
emergency room. (For more information, see "Emergency Care.")
24-Hour Nurse Advice Line
You can call the free Nurse Advice Line to get health care information 24 hours a day, 7 days a week. The nurses can help you when you have questions about health concerns or need health information. To speak to a nurse, call toll free 1-866-418-1002 (voice) or 1-866-418-1006 (TTY for speech or hearing impaired).
• Emergency Care
If you cannot reach your PCP, and you think you are too sick or your child is too sick to wait, call 911 or your police department or go to the nearest emergency room.
For information about how Washington Health Program defines an emergency, see Chapter 7, "Covered Services and Member Costs," in the Washington Health Program Member Handbook (Certificate of Coverage) available at www.washingtonhealth.hca.wa.gov/materials.html. You or someone you know should tell your PCP about your emergency room visit by the next business day or as soon as your health allows.
Urgent Care Center Visits
If symptoms are severe or if your PCP cannot see you right away, ask your PCP if you can go to an urgent care center, where they can treat you that same day.
Important note about urgent care centers: Emergency room visits do not require a referral or
okay from your doctor or from Community Health Plan of Washington. However, if you go to an urgent care center, get a referral from your primary care provider before you go if you can. If you cannot get the referral from your PCP before you go, call your PCP the next day and get the referral then.
When You Get Out-of-Area Care
While you are traveling or are out of our service area, Community Health Plan pays for medically necessary emergency care, urgent care, and follow-up care that cannot wait until you get home. Community Health Plan authorizes care at other facilities when the use of participating facilities is not practical. We also pay for medicines needed for emergency treatment.
If you have an emergency while traveling or you are not in our service area, call 911 or go to the nearest emergency room. You must notify your PCP within 24 hours after your emergency room or urgent care center visit or as soon as your health allows.
We will pay for your follow-up care while you are traveling or are out of our service area only if it is first approved by your PCP and by Community Health Plan.
If you need a 30-day supply of a prescription before you go on vacation, please ask your PCP before you leave. If you need more than a 30-day supply, please 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 [email protected]. If you are hearing or speech impaired, please call TTY Relay: Dial 7-1-1.
How to Submit a Claim if You Get a Bill
You will get a bill from a provider who has provided services to you that require a deductible and coinsurance.
If you get care from a provider who contracts with Community Health Plan of Washington, the provider usually bills the Plan directly.
If you get a bill for services that you think are covered by Washington Health Program, send the bill directly to Community Health Plan at:
CHP Claims PO Box 269002
Plano, Texas 75026-9002
In most cases, Community Health Plan will first send you an Explanation of Benefits (EOB) that explains what service you got, what the allowed amount is for that service, what Community Health Plan has paid, and what you must pay. The EOB will also give you information about how much you have paid toward your deductible and out-of-pocket maximum.
The provider or facility where you got services will then send you a bill. You must pay the provider or facility directly. You may also get a bill for the balance of charges when the provider charges more than the allowed amount for that service.
If you get an EOB or if you have questions about your bill, contact the provider’s office or 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 e impaired, please call TTY Relay: Dial 7-1-1.
In some cases, you may get a bill from a provider or a facility that did not know about your
Washington Health Program coverage. When you fill out information for your provider, be sure to list Community Health Plan as the health plan that provides your coverage. Do not list the
Washington Health Program.
Benefits and services may be denied if Community Health Plan gets the bill more than 12 months after the date you got services.
Explanation of Benefits (EOB)
If you owe any payment when you get medical services, Community Health Plan of Washington sends you a detailed Explanation of Benefits. The EOB explains:
• Which procedures and services you received
• The allowed amount for each service
• How much Community Health Plan pays
• How much you must pay
Your Explanation of Benefits will also track each covered family member's annual deductible and out-of-pocket maximum.
Balance Billing When You Get Care Outside Washington State
Balance billing is when you receive a bill for a covered service from a medical provider for the part of the costs that were not paid by your insurance company. A law that went into effect in August 2011 forbids balance billing for covered services by providers in Washington State. The amended state law only applies to providers in Washington State. You may be responsible to pay some balance billed costs if you see a provider outside of Washington State who is not in our network and if Community Health Plan cannot work with the provider to reduce theWashington Health Program Cost Sharing
Covered Benefit
Participating Provider Nonparticipating Provider
Description
Annual benefit maximum
Health 75: $75,000
Health 100: $100,000 Health 75: $75,000 Health 100: $100,000 Total maximum amount (including prescriptions) the Plan will pay per person in any calendar year. Annual deductible $500/member $1,500 family $1,000/member $3,000 family
Amount you pay every year before the Plan pays for covered services. Annual out-of-pocket maximum $3,000/member $9,000 family $5,000/member $15,000 family
Set limit after which the Plan pays 100% of allowable
charges. Deductible, copay, and pharmacy do not count toward the annual maximum.
Coinsurance 30% 50% Percentage of allowed charges you pay after you meet the deductible.
Office visit copay
$10 for preferred providers*; 30% for affiliate providers
50%
• Visit the Community Health Plan of Washington website at www.chpw.org. Click the Our Providers tab and select the type of search you want.
* To find a preferred provider:
• To get a printed report or have someone search for you, call the Community Health Plan customer service team at 1-800-440-1561, Monday–Friday, 8:00 am – 5:00 pm, or email [email protected]. If you are hearing or speech impaired, please call TTY Relay: Dial 7-1-1.
Note: Pharmacy cost sharing is handled differently; however, pharmacy costs do count toward
your annual benefit maximum. For more information about pharmacy cost sharing, see "Pharmacy Cost Sharing."
Maternity Delivery Services Window Deductible
The six-month maternity delivery services window, or waiting period for coverage, applies if your baby is born within six months of your enrollment or re-enrollment in Washington Health Program. If you deliver your baby within the maternity window, your delivery care is subject to a $5,000 deductible and to coinsurance.
The $5,000 maternity delivery services window deductible applies only to deliveries during the six months after your initial enrollment or re-enrollment. If you deliver your baby after the six-month maternity window (waiting period), you pay regular coinsurance and deductible without the $5,000 maternity window deductible.
Regardless of when you deliver, the $5,000 maternity window deductible does not apply to
other maternity-related services, such as full prenatal care, postpartum care, care for
pregnancy complications, well-child newborn care, and termination of pregnancy.
Washington Health Program Benefits
It is important to read the pages about benefits carefully to understand what Community Health Plan covers and what you pay.
For more information about what is covered, what you pay for services, and whether the deductible applies for a specific service:
• See the
• SDrug Services."
• See the HCA Washington Health Program website, www.washingtonhealth.hca.wa.gov
• 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 ema speech impaired, please call TTY Relay: Dial 7-1-1.
Washington Health Program Benefit Table
• For updated information, check with your provider or Community Health Plan of Washington customer service.
• If you do not find a service listed in this table, check "Washington Health Program Services Not Covered."
• Services you get from a nonparticipating provider may require a prior authorization. The headings in the table mean:
• Benefit: A description of the benefit.
• Copay, deductible, coinsurance: If this service requires a copay or coinsurance or affects your deductible, you will find that
information here.
• Details: More information about the benefit itself, including whether it requires an approval, such as prior authorization.
Benefit Copay, deductible,
coinsurance*
Details
Acupuncture After deductible,
coinsurance is: 30% participating, 50% nonparticipating.
Prior authorization required for more than 6 visits.
Allergy treatment: Treatment including testing, serum, injections
After deductible, coinsurance is: 30% participating, 50% nonparticipating.
Does not require prior authorization.
Allergy treatment: Allergy office visit $10 copay for preferred. For nonpreferred, after deductible, coinsurance is 30% participating, 50% nonparticipating.
Prior authorization required for more than 12 specialty provider visits per year.
Ambulance services (Includes approved transfers from one facility to another)
After deductible, coinsurance is 30%.
Benefit Copay, deductible, coinsurance*
Details
Anesthesia and anesthesia-related oxygen services After deductible, coinsurance is: 30% participating, 50% nonparticipating.
Oxygen therapy not related to anesthesia covered in full.
Biofeedback therapy Prior authorization required for more than 6 visits. Blood, blood components, fractions (such as
plasma, platelets, packed cells, albumin), and their administration
After deductible, coinsurance is: 30% participating, 50% nonparticipating.
Does not require prior authorization.
Chemical dependency: residential and outpatient treatment, methadone treatment
After deductible, coinsurance is: 30% participating, 50% nonparticipating.
Includes services such as diagnostic evaluation and education, organized individual and group
counseling. Does not require prior authorization. $5,000 maximum benefit in 24 calendar months, $10,000 lifetime maximum.
Court-ordered treatment covered only when the Plan determines it is medically necessary.
Chiropractic, occupational, physical therapy inpatient or outpatient services
After deductible, coinsurance is: 30% participating, 50% nonparticipating.
Requires prior authorization.
Up to a combined maximum 12 visits per calendar year. Of those, no more than 6 can be for
chiropractic care. Visits qualify only when used as post-operative treatment after reconstructive joint surgery. Visits must be within 1 year after surgery. Diagnostic or other imaging to determine therapy is not covered.
Benefit Copay, deductible, coinsurance*
Details
Emergency Room care $100 copay per visit. (No copay if admitted.) Subject to deductible and coinsurance.
For more information, see "Emergency Care."
• Does not require prior authorization, physician order, or plan-approved referral.
• 24 hours a day, 7 days a week.
• Includes ambulance and pharmacy medications; subject to copay, coinsurance.
• Includes acute detox to 72 hours.
• Must transfer to contracted facility if required by the Plan.
Equipment and supplies After deductible, coinsurance is: 30% participating, 50% nonparticipating.
Durable medical equipment (DME), prosthetics, orthotics, related supplies. Does not apply oxygen equipment, oxygen contents, and supplies for the delivery of oxygen.
Limited coverage; check with your provider or Community Health Plan about specific supplies and equipment.
Family planning services, including: IUDs, diaphragms, cervical caps, long-acting
progestational agents; and elective sterilization
After deductible, coinsurance is: 30% participating, 50% nonparticipating.
Does not require prior authorization.
Family planning services, including: regular contraception, such as birth control pills, and emergency contraception; and
medroxyprogesterone injection
$10 office visit copay in network; pharmacy copay.
Benefit Copay, deductible, coinsurance*
Details
Health and wellness education about diabetes, including nutrition, exercise, prevention of acute or chronic complications, monitoring, medication
After deductible, coinsurance is: 30% participating, 50% nonparticipating.
Does not require prior authorization. Up to 10 hours per calendar year.
Home health After deductible,
coinsurance is: 30% participating, 50% nonparticipating. Hospice services After deductible,
coinsurance is: 30% participating, 50% nonparticipating.
Requires prior authorization.
Hospital inpatient and outpatient care:
• Semiprivate room and board, including meals; private room and special diets; general and special duty nursing services
• Hospital services, such as operating room, intensive care unit, anesthesia, radiology, laboratory, labor & delivery room
• Drugs and medications while inpatient
• Dressings, casts, equipment, oxygen services, radiation and inhalation therapy
• Normal newborn baby care following birth
After deductible, coinsurance is: 30% participating, 50% nonparticipating.
Benefit Copay, deductible, coinsurance*
Details
Injections including but not limited to:
• Abatacept (Orencia)
• Botulinim (Botox) (not cosmetic) • Infliximab (Remicade)
• Hyaluronic acid derivatives (Synvisc or Hyalgan)
• Natalizumab (Tysabri)
• Omalizumab (Xolair)
• Palivizumab (Synagis)/RespiGam (up to 5 injections between November 15 and April 15)
After deductible, coinsurance is: 30% participating, 50% nonparticipating.
Some injections require prior authorization. Check with your provider or contact the Community Health Plan customer service team.
Laboratory and pathology tests and interpretations After deductible, coinsurance is: 30% participating, 50% nonparticipating.
Does not require prior authorization.
Mammogram No coinsurance for
participating. 50% coinsurance after deductible for nonparticipating.
For annual breast cancer screening only, includes radiology and interpretation of results once every 12 months. For information about diagnostic mammography, see Radiology in this table. Maternity care After deductible,
coinsurance is: 30% participating, 50% nonparticipating. $5,000 deductible for delivery within 6 months of enrollment.
Does not require prior authorization. Member may self-refer to women's health care specialist.
For more information, see "Maternity Delivery Services Window Deductible."
Benefit Copay, deductible, coinsurance*
Details
Mental health After deductible, coinsurance is: 30% participating, 50% nonparticipating.
Inpatient covered in full for 10 days per calendar year. Outpatient covered to 12 visits per year. Outpatient visits require physician order for provider in network or Plan-approved referral to provider outside network.
Office visits to manage medication do not count toward the 12-visit maximum.
No authorization is required for involuntary admissions.
Newborn baby care: normal care following birth while in participating facility, laboratory services, routine newborn exams
After deductible, coinsurance is: 30% participating, 50% nonparticipating.
Maternity and newborn services. For more information about maternity benefits, see
"Maternity Delivery Services Window Deductible." Nutritional counseling for diagnoses other than
obesity
After deductible, coinsurance is: 30% participating, 50% nonparticipating.
Up to 12 visits per year. Does not require prior authorization for up to 12 visits a year.
Benefit Copay, deductible, coinsurance*
Details
Office visits: evaluation and management, including urgent care
$10 copay for preferred provider.
30% coinsurance after deductible for
participating nonpreferred.
50% coinsurance after deductible for
nonparticipating.
Includes exam, consult, evaluation, treatment plan. Does not require prior authorization.
Organ transplants, including professional and facility fees for inpatient; diagnostic tests and exams; surgery and follow-up care. Includes:
• Bone marrow including peripheral stem cell rescue
• Cornea (does not require prior authorization)
• Heart
• Heart-lung
• Liver
• Kidney
• Kidney-pancreas
After deductible, coinsurance is: 30% participating, 50% nonparticipating.
Coinsurance and annual maximum apply.
Limitations:
• After 12-consecutive-month waiting period
• When medically necessary Waiting period exceptions:
• Newborns
• Conditions that are not pre-existing
• Children younger than 19
Organ transplants—For organ transplant donor:
• Initial medical expenses of harvesting • Costs of treating complications
After deductible, coinsurance is: 30% participating, 50% nonparticipating.
To be covered, donor must be Washington Health member. Requires prior authorization and referral from Community Health Plan case manager.
Benefit Copay, deductible, coinsurance*
Details
Oxygen, including:
• Rental of oxygen equipment • Oxygen contents
• Supplies for delivery of oxygen
No copay or coinsurance.
• Requires prior authorization.
• Exempt from pre-existing condition waiting
period.
• Backup-only portable oxygen not covered.
Pharmacy For Tier 1, copay is $10
participating, $20 nonparticipating. For Tier 2, copay is 50%. After you reach the annual benefit maximum, you pay 100% for Tier 1 & Tier 2.
30-day supply. Requires prescription.
To find out if a specific drug is covered in your pharmacy benefit, you can search online or refer to the Community Health Plan Formulary booklet. For more information or to get the booklet, see
"Prescription Drug Services." Plastic and reconstructive services only:
• To correct physical functional disorder resulting from congenital disease or abnormality.
• To correct physical functional disorder following
an injury or incidental to covered surgery.
• In connection with mastectomy. • For equipment and supplies to treat
lymphedema in limited circumstances.
• Cosmetic plastic and reconstructive services are not covered.
After deductible, copay is: 30% participating, 50% nonparticipating.
For mastectomy or post-mastectomy breast reconstruction, does not require prior authorization.
Post-mastectomy reconstruction may include:
• Reconstruction of breast on which mastectomy
performed
• Surgery and reconstruction of other breast to
produce symmetrical appearance
• Internal or external prostheses
• Physical complications of all stages of mastectomy
Benefit Copay, deductible, coinsurance*
Details
Preventive care Covered in full for participating. 50% coinsurance after deductible for nonparticipating.
Immunizations, medical exams, sports physicals, women's health care, well baby exams. In this table, see also: Well child exams, Women's health care.
Preventive screenings Covered in full for participating. 50% coinsurance after deductible for nonparticipating.
Including PAP smear, PSA testing, colorectal cancer screening, cholesterol screening, diabetes
screening, bone density testing, mammogram screening.
Do not require prior authorization.
Not all colonoscopies are covered. Check with your provider to make sure you have the proper
approvals before you get the services. Radiation therapy and injectable or infused
chemotherapy
After deductible, coinsurance is: 30% participating, 50% nonparticipating.
Requires prior authorization for more than 12 specialty provider visits per year. Some
chemotherapy agents require prior authorization. These therapies are covered under your medical, not pharmacy benefit.
Radiation therapy: Radiology, nuclear medicine, ultrasound, laboratory, other diagnostic services
After deductible, coinsurance is: 30% participating, 50% nonparticipating.
Includes diagnostic imaging, including diagnostic mammograms.
Radiation therapy: PET scan, all MRI imaging, CT-head, CT angiography
After deductible, coinsurance is: 30% participating, 50%
Benefit Copay, deductible, coinsurance*
Details
Radiation therapy: X-ray, ultrasound, echoes, nuclear medicine
After deductible, coinsurance is: 30% participating, 50% nonparticipating.
Does not require prior authorization.
Skilled nursing facility: Room and board, ancillaries, professional fees.
After deductible, coinsurance is: 30% participating, 50% nonparticipating.
Prior authorization required.
Smoking cessation: Nicotine gum and patches For Tier 1, copay is $10 participating, $20 nonparticipating. For Tier 2, copay is 50%.
Covered if filled as prescription from your provider.
Surgical services After deductible, coinsurance is: 30% participating, 50% nonparticipating.
Always check with your provider to make sure you have the proper approvals before you get the services.
Urgent care (see Office visits)
Well child exams Covered in full for participating. 50% coinsurance after deductible for nonparticipating. Women's health care Covered in full for
participating. 50% coinsurance after deductible for nonparticipating.
Washington Health Program Services Not Covered
This is a brief summary of services that Community Health Plan of Washington will not pay for. For details:
• See Appendix A: Schedule of Benefits, Section IV. Limitations and Exclusion, B. Exclusions in the Washington Health Program Member Handbook (Certificate of Coverage).
• 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 [email protected]. If you are hearing or speech impaired, please call TTY Relay: Dial 7-1-1.
General Exclusions
Any service or supply not specifically listed as a covered service unless it is medically necessary, prescribed by a contracting provider, and authorized in advance by Community Health Plan, including:
• Services that do not meet the definition of medical necessity.
For more information about what "medically necessary" means, see the detailed definition of medical necessity in Appendix A: Schedule of Benefits, Section I. Medically necessary services, supplies, or interventions in the Washington Health Program Member Handbook (Certificate of Coverage).
• Services you got before your effective date of coverage with Community Health Plan.
Specific Exclusions
Note: For a complete list of exclusions, see Appendix A: Schedule of Benefits, Section B:
Exclusions, in the Washington Health Program Member Handbook(Certificate of Coverage).
• Birthing classes.
• Charges for missed appointments or failure to provide timely notice for cancellation of appointments; charges for completing or copying records or forms.
• Chiropractic, occupational, or physical therapy, diagnostic or imaging procedures for determination of therapy services only.
• Conditions resulting from acts of war (declared or not).
• Cosmetic surgery, including treatment for complications of cosmetic surgery, except as specified in the Washington Health Program Member Handbook (Certificate of Coverage).
• Custodial or domiciliary care or rest cures. For additional information, see the Washington Health Program Member Handbook(Certificate of Coverage).
• Dental services, including orthodontic appliances, and services for temporomandibular joint (TMJ) problems, except for repair necessitated by accidental injury to sound natural teeth or jaw. The repair must begin within 90 days of the accidental injury or as soon thereafter as is medically feasible, provided the member is eligible for covered services at the time that services are provided.
• Direct complications arising from excluded services.
• Doula services.
• Routine eye exams, including eye refraction, except when provided as part of a routine preventive care exam.
• Eyeglasses or contact lenses, except the first intraocular lens following cataract surgery.
• Hearing aids.
• Homeopathy.
• Hospital charges for personal comfort items such as telephones, televisions, and guest trays; or a private room unless authorized by Community Health Plan.
• HPV immunization (Gardasil) for members 26 or older.
• Immunizations except as covered for preventive care. Immunizations for the purpose of travel, for employment, or because of where you live are not covered.
• Implants, except:
• Artificial joints.
• Cardiac devices.
• Implants as defined in the Plastic and Reconstructive Surgery benefit in the Washington Health Program Member Handbook (Certificate of Coverage).
• Intraocular lenses, except the first intraocular lens following cataract surgery.
• Infertility treatments, such as investigation of or treatment for infertility or impotence; reversal of sterilization; artificial insemination; in-vitro fertilization.
• Interpreter services for office visits; ask your provider if you need an interpreter.
(Community Health Plan covers interpreter services for administrative issues such as grievance hearings.)
• Lasik eye surgery.
• Medical services you got from or were paid for by the Veterans Administration or by state
or local government, except when in conflict with Washington State or federal law or regulation. For more information, see the Washington Health Program Member Handbook
(Certificate of Coverage).
• Medical services, drugs, supplies, or surgery directly related to the treatment of obesity including morbid obesity (such as, but not limited to, gastroplasty, gastric stapling, or intestinal bypass). Obesity (bariatric) surgeries.
• Neurodevelopmental therapy for children age 6 or younger.
• Portable oxygen, if only a backup to stationary oxygen system.
• Recreation therapy.
• Replacement for lost or stolen medications.
• Routine foot care.
• Sex reassignment surgery.
• Shingles vaccination (Zostavax or varicella).
• Sleep studies, except initial sleep study authorized by the Plan. Only one sleep study per member per calendar year is covered.
• Speech therapy.
• Transportation except as specified under Organ Transplant and Emergency Care in the
Washington Health Program Member Handbook (Certificate of Coverage).
Prescription Drug Services
Community Health Plan's network of participating pharmacies includes pharmacy chains and neighborhood drug stores. If you get your prescription filled at a participating pharmacy in the Community Health Plan network, the share of allowed charges that you pay for Tier 1 drugs is less than if you get them at a pharmacy that is not in this network.
To Find Participating Pharmacies
To find participating pharmacies, you can:
• Visit the Community Health Plan of Washington website at www.chpw.org. Click the Providers tab and select the type of search you want.
• Get a printed report or have someone search for you by calling the Community Health Plan of Washington customer service team at 1-800-440-1561, Monday through Friday from 8:00 am to 5:00 pm, or emailing [email protected]. If you are hearing or speech impaired, please call TTY Relay: Dial 7-1-1.
Pharmacy Cost Sharing
Note: To read about cost sharing in general, see "Washington Health Program Cost Sharing."
Participating Pharmacy
• Generic drugs contained in the health plan’s formulary.
Tier 1 – Copayment: $10
• All oral contraceptives in the health plan’s formulary.
• Diabetic supplies, including syringes and needles, diabetic test strips, lancets, and insulin.
• Inhaled short-acting beta-agonists.
• Inhaled steroids.
• Inhaled anticholinergic bronchodilators.
• Beta-blockers for severe heart failure.
• Anti-platelet clotting inhibitors for patients after intra-arterial stent placement.
Brand-name drugs in the Plan's formulary and nonformulary drugs approved by the Plan.
Tier 2 – Copayment 50%
Nonparticipating Pharmacy
• Generic drugs contained in the health plan’s formulary.
Tier 1 – Copayment: $20
• All oral contraceptives in the health plan’s formulary.
• Diabetic supplies, including syringes and needles, diabetic test strips, lancets, and insulin.
• Inhaled short-acting beta-agonists.
• Inhaled steroids.
• Inhaled anticholinergic bronchodilators. Beta-blockers for severe heart failure.
Brand-name drugs in the Plan's formulary and nonformulary drugs approved by the Plan.
Tier 2 – Coinsurance 50%
Retail and Mail Order Pharmacy
Retail Pharmacy Benefit. You can get up to a 30-day supply of prescribed drugs at a
participating retail pharmacy. Your out-of-pocket expense can be found in "Pharmacy Cost Sharing."
Mail Order Pharmacy Benefit.
Using a Nonparticipating Pharmacy
Community Health Plan does not have a mail order pharmacy benefit.
You can get up to a 30-day supply of prescribed drugs at a nonparticipating pharmacy.
If you fill prescriptions at a nonparticipating pharmacy, you must first pay for the prescriptions and submit to Community Health Plan for reimbursement. Ask for a reimbursement form by calling 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 [email protected]. If you are hearing or speech impaired, please call TTY Relay: Dial 7-1-1.
For information about prescriptions you fill when you are outside your service area, see question 7 in the "Frequently Asked Questions About Pharmacy."
Fill out the form and send it with your receipt(s) that include the following information: pharmacy name and address, fill date, drug name, drug strength, drug NDC number, quantity, days supply, prescription number, and your cost to:
Express Scripts, Inc. Attn: Claims Dept. P.O. Box 390873
Bloomington, MN 55439-0873
All drugs filled at a nonparticipating pharmacy are subject to the same restrictions as drugs filled at a participating pharmacy. Once all requirements are met, your out-of-pocket expense can be found in "Pharmacy Cost Sharing."
Your Right to Safe and Effective Pharmacy Services
State and federal laws set rules for safe and effective pharmacy services. These laws give you the right to know what pharmacy services are paid for by your plan.
If you would like more information about what pharmacy services are paid for by Community Health Plan of Washington, please call the Community Health Plan customer service team at 1-800-440-1561, Monday – Friday from 8:00 am to 5:00 pm, or e
Frequently Asked Questions About Pharmacy
1. Does this plan limit or exclude certain drugs my health care provider might prescribe?
The Community Health Plan of Washington drug formulary is formed by an independent Pharmacy and Therapeutics (P&T) Committee. This P&T Committee is made up of Washington State providers and pharmacists from various medical specialties. The P&T Committee
members review medications based on safety, effectiveness, and cost, selecting the products that show the most value in each class.
Community Health Plan's formulary is a mandatory generic formulary. This means that the brand-name product will not be paid for without first trying the formulary generic product.
2. When can my plan change its drug formulary list? If a change occurs, will I have to pay more to use a drug I had been using?
The Community Health Plan P&T Committee reviews the formulary several times each year to make sure Community Health Plan covers needed drugs. When the formulary is updated, changes are posted online. In most cases, you will get written notice 60 days before Community Health Plan removes your drug from the formulary. In some cases when a drug is removed from the formulary you will need to pay more for the drug.
3. What should I do if I want a change from limitations or exclusions for drugs specified in this plan?
Your PCP should call Community Health Plan's pharmacy benefit manager, Express Script, Inc. (ESI), at 1-888-256 6132, 24 hours a day, seven days a week, to ask for formulary exceptions such as quantity limit changes and nonformulary drugs. A decision might be made during the call for both normal circumstances and emergency medical conditions. The decision may take up to 3 business days.
4. What should I do to ask for a drug excluded by my medical plan?
If your drug won't be paid for when you try to fill the prescription at the pharmacy, you have the right to appeal.
If you want to appeal, please 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 [email protected]. If you are hearing or speech impaired, please call TTY Relay: Dial 7-1-1.
5. How much do I have to pay to get a prescription filled for a formulary drug at a participating pharmacy?
In general, for Tier 1 formulary generic drugs you pay a $10 copay if you get the prescription from a participating pharmacy, and a $20 copay if you get it elsewhere. If the prescription costs less than the copay, you pay the cost of the drug only.
For Tier 2 brand-name drugs or drugs not on the Plan formulary, after Plan approval (prior authorization) you pay 50% of the prescription cost regardless of where you get it.
For more detailed information about prescription costs, see "Pharmacy Cost Sharing."
6. Do I have to use certain pharmacies?
No. However, your share of the approved cost for your prescription will be higher if you get it from a nonparticipating pharmacy.
Community Health Plan works with more than 1,000 participating pharmacies in Washington State. To learn which pharmacies work with Community Health Plan:
• To find a provider, pharmacy, clinic, or hospital, visit the Community Health Plan of
Washington website at www.chpw.org. Click the Our Providers tab and then select the type of search you want.
• To get a printed report or have someone search for you, call the Community Health Plan of Washington customer service team at 1-800-440-1561, Monday through Friday from 8:00 am to 5:00 pm, or email [email protected]. If you are hearing or speech impaired, please call TTY Relay: Dial 7-1-1.
7. How many days’ supply of most medications can I get? What if I’m traveling?
You can get up to a 30-day supply of prescribed drugs.
If you need a 30-day supply of a prescription before you leave on a planned trip away from our service area, please ask your PCP before you leave. If you need more than a 30-day supply, please call the Community Health Plan customer service team at the number below.
For more information, please 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 [email protected]. If you are hearing or speech impaired, please call TTY Relay: Dial 7-1-1.
8. What other pharmacy services does my health plan pay for?
The pharmacy services only pay for formulary medications, unless the Plan agrees to pay for the nonformulary drug.
To find out more about your rights under the law, call the Washington State Office of the Insurance Commissioner at 1-800-562-6900. If you have a problem or concern about the
pharmacist or pharmacy serving you, please call the Washington State Department of Health at 1-800-525-0127.
Quality Improvement Program
The Community Health Plan Quality Improvement Program makes sure our service meets clinical and customer service standards. We set some standards ourselves and we comply with those set by government and national organizations that measure quality.
We have programs in place to assess and improve patient safety, clinical quality, and the quality of behavioral health services. We understand that knowledge is one of the greatest tools in preventing chronic disease and getting appropriate preventive care. Our efforts to help you manage your health risk include programs to manage diabetes and asthma. We help you assess your risk of diseases such as diabetes, encourage you to get proper treatment and care, and inspire you to take charge of your chronic conditions for a lifetime.
We use HEDIS (Healthcare Effectiveness Data and Information Set) as one set of standards to measure our performance. HEDIS is a list of rates of health care measures reported by health plans each year. Community Health Plan of Washington reports its HEDIS rates to Quality Compass published by the National Committee for Quality Assurance (NCQA).
For more information about the Quality Improvement Program:
• Visit the Community Health Plan website at www.chpw.org. Click the Member Services tab and select Patient Safety, then click the link to the Quality Improvement Program.
• 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 [email protected]. If you are hearing or speech impaired, call TTY Relay: Dial 7-1-1. The customer service team can send you information in writing.
How We Manage Your Care: Utilization Management
An appropriate peer reviewer (medical director, pharmacist, or associate clinical director) is available to discuss any Utilization Management process, authorization, or denial by calling Customer Service at 1-800-440-1561. Relevant policies and clinical criteria are available upon request.
Prior authorization review is the process that Community Health Plan of Washington uses to review certain medical, surgical, and behavioral health services. Services must meet the criteria of medical necessity and appropriateness of care before services are rendered.
To see the list of services that require a prior authorization, you can:
• Visit the Community Health Plan website at www.chpw.org. Click the Member Services tab and select Patient Safety, then click the link to the prior authorization list.
• 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 [email protected]. If you are hearing or speech impaired, call TTY Relay: Dial 7-1-1. The customer service team can send you information in writing.
Evaluation of New Technology
Community Health Plan of Washington is committed to keeping up with news and research about new tests, drugs, treatments, and devices and new ways to use current procedures, drugs, and devices.
A provider or member can ask the Plan to cover a new technology. A Community Health Plan doctor leads the review of the new technology and may ask an outside reviewer to give an opinion, too.
For more information about how the Community Health Plan uses research and outside experts to decide, see "Care Managmen
New technologies are approved based on standards that protect patient safety. To learn more about the decision process or the specific standards, please call our Utilization Management team. See "Contact Utilization Management."
Advance Directives
An advance directive gives written instructions about your future medical care in case
something happens to you and you are unable to tell someone your medical wishes. For the state of Washington, this written instruction takes the form of two documents: a Health Care Directive (also known as a Living Will) and a Durable Power of Attorney for Health Care.
You have certain rights about advance directives:
• The right to make your own decisions about your medical care.
• The right to accept or refuse surgical or medical treatment.
• The right to have an advance directive.
• The right to cancel an advance directive at any time.
Advance Directives Policy and Procedure
Anyone who asks for a copy of the Community Health Plan advance directives policy and procedures will be given a copy. You do not have to be a member to see the policy and procedure.
Community Health Plan puts its policy and procedure about advance directives online at www.chpw.org. You can also ask for the advance directives policy and procedure by calling 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 [email protected]. If you are hearing or speech impaired, please call TTY Relay: Dial 7-1-1.
If You Have Complaints About Advance Directives
If you think that Community Health Plan or its providers, contractors, vendors, or business associates are not following the rules for advance directives, you may file a grievance. For information about filing a grievance, see "Grievances and Appeals."
Additional Information
More information, resources, and forms about your advance directive rights are on the Washington State Medical Association Advance Directives Q & A web page:
Member Rights and Responsibilities
Note: Your provider’s office offers additional rights and responsibilities, which are posted in
your health center or clinic.
For the full list of Washington Health Program rights and responsibilities, see Chapter 4, Rights,
Responsibilities, and Privacy, in the
Member Rights
Your right to get information about the organization, its services, its practitioners and providers and member rights and responsibilities.
• You have a right to ask for information in writing about your rights and responsibilities.
• You have a right to have information about your health care plan and its services explained to you in a way you will understand, and in a different language if necessary.
• You have a right to interpreters when you contact Community Health Plan, either by phone
or in writing.
• You have a right to know the name, title, and qualifications of the practitioners, providers, and staff who care for you.
• You have a right to get information in writing about what you must do to see a provider other than your PCP.
• You have a right to ask for information in writing about what you must do when you need
our okay for health care services.
• You have a right to get information in writing about Community Health Plan’s structure and operations.
• You have a right to get information in writing about how we pay doctors and hospitals. You may also get an explanation of how referrals to specialists affect our payment to providers.
• You have a right to get information in writing about if we pay providers extra for certain care (physician incentive programs).
• You have a right to ask for information in writing about which medical service you use and showing how we paid for a service. This is known as an explanation of benefits (EOB).
• You have a right to request copies of your medical record and ask for changes when necessary.
• You have a right to know that the government has set standards for safe and effective pharmacy services.
• You have a right to know what drugs are covered by your insurance. For more information, ask for a copy of the Community Health Plan Drug Formulary by calling 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 [email protected]. If you are hearing or speech impaired, please call TTY Relay: Dial 7-1-1.
• You have a right to get information in writing about how we report how well we do with your care. We measure our performance using the Healthcare Effectiveness Data
Information Set, or HEDIS. You may ask to see the HEDIS data and have someone explain what the information means.
If you want any of the information listed above, please 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 [email protected]. If you are hearing or speech impaired, please call TTY Relay: Dial 7-1-1.
Your right to be treated with respect and recognition of your dignity and right to privacy.
• You have a right to be given care and service that go along with your values and beliefs.
• You have a right to get services without being discriminated against.
• You have a right to have your or your child's medical record and information or conversations regarding your health care treated confidentially.
• You have a right to expect that Community Health Plan and your providers will protect your privacy. (See the "Community Health Plan Notice of Privacy Practices.")
• You have a right to have your wishes for your future medical care made known to others if
you are too sick to let them know. This includes the right to choose a person to make medical decisions for you if you are unable to do so. You can do this with a living will, a durable power of attorney for health care, or both. For more information, see "Advance Directives."
• Your right to participate with practitioners in making decisions about your or your child's
health care:
• You have a right to provide your written okay to have the medical care.
• You have a right to be told how to make your wishes known about future care. That
includes the right to choose a person to make medical decisions for you if you are unable to do so. For more information, see "Advance Directives."
• You have a right to refuse treatment and be told what might happen with your health.
• You have a right to refuse to take part in experimental research.
Your right to a candid discussion of appropriate or medically necessary treatment options for your or your child's conditions, regardless of cost or benefit coverage.
• You have a right to get information about what health care services you or your child can get.
• You have a right to get information about other health care options available from Community Health Plan.
• You have a right to get information about what you must do when you need an okay for health care services.
