Your 2015/2016 Member Handbook

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If you have any questions or need further assistance, contact UPMC for You Member Services at

1-800-286-4242. Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m. TTY users should call toll-free

1-800-361-2629.

Member Services 1-800-286-4242

TTY Services 1-800-361-2629

www.upmchealthplan.com/foryou

Your 2015/2016

Member Handbook

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Available in large print.

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1-800-361-2629.

Important Telephone Numbers

Important Telephone

Numbers at a Glance

UPMC for You Member Services ... 1-800-286-4242 TTY Line ...1-800-361-2629 PA Enrollment ...1-800-440-3989 HealthChoices TTY Line ... 1-800-618-4225 MA Provider Compliance Hotline

(includes TTY services) ...1-844-347-8477 UPMC Health Plan

Fraud and Abuse Hotline ...1-866-372-8301 UPMC for a New Beginning

Maternity Program ...1-866-463-1462 UPMC for You Special Needs

Department ...1-866-463-1462 UPMC for You Health

Management Programs ... 1-866-778-6073 UPMC for You Dental Benefits ... 1-888-257-0474 UPMC for You Vision Benefits ...1-866-458-2138 Department of Human

Services Hotline ...1-866-542-3015 TTY Line ...1-877-202-3021 UPMC MyHealth Advice Line ...1-866-918-1591 TTY Line ...1-899-918-1593

Important Behavioral

Health Telephone Numbers

at a Glance

Adams County

Community Care Behavioral

Health Organization ...1-866-738-9849 TTY Line ...1-877-877-3580 Allegheny County

Health Organization ... 1-800-553-7499 TTY Line ...1-877-877-3580 Armstrong County

Value Behavioral Health ... 1-877-688-5969 TTY Line ... 1-877-615-8502

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Beaver County

Value Behavioral Health ... 1-877-688-5970 TTY Line ... 1-877-615-8502 Bedford County

PerformCare ...1-866-773-7891 TTY Line ...1-800-654-5984 Berks County

Health Organization ...1-866-292-7886 TTY Line ...1-877-877-3580 Blair County

Health Organization ...1-855-520-9715 TTY Line ...1-877-877-3580 Butler County

Value Behavioral Health ... 1-877-688-5971 TTY Line ... 1-877-615-8502 Cambria County

Value Behavioral Health ...1-866-404-4562 TTY Line ... 1-877-615-8502 Cameron County

Health Organization ... 1-866-878-6046 TTY Line ...1-877-877-3580 Clarion County

Health Organization ... 1-866-878-6046 TTY Line ...1-877-877-3580 Clearfield County ...

Health Organization ... 1-866-878-6046 TTY Line ...1-877-877-3580 Crawford County

Value Behavioral Health ...1-866-404-4561 TTY Line ... 1-877-615-8502 Cumberland County PerformCare ...1-888-722-8646 TTY Line ...1-800-654-5984 Dauphin County PerformCare ...1-888-722-8646 TTY Line ...1-800-654-5984 Elk County

Health Organization ... 1-866-878-6046 TTY Line ...1-877-877-3580 Erie County

Health Organization ...1-855-224-1777 TTY Line ...1-877-877-3580

Fayette County

Value Behavioral Health ...1-877-688-5972 TTY Line ... 1-877-615-8502 Forest County

Health Organization ... 1-866-878-6046 TTY Line ...1-877-877-3580 Franklin County PerformCare ...1-866-773-7917 TTY Line ...1-800-654-5984 Fulton County Perform Care ...1-866-773-7917 TTY Line ...1-800-654-5984 Greene County

Value Behavioral Health ...1-877-688-5973 TTY Line ... 1-877-615-8502 Huntingdon County

Health Organization ... 1-866-878-6046 TTY Line ...1-877-877-3580 Indiana County

Value Behavioral Health ... 1-877-688-5969 TTY Line ... 1-877-615-8502 Jefferson County

Health Organization ... 1-866-878-6046 TTY Line ...1-877-877-3580 Lancaster County PerformCare ...1-888-722-8646 TTY Line ...1-800-654-5984 Lawrence County

Value Behavioral Health ...1-877-688-5975 TTY Line ... 1-877-615-8502 Lebanon County

PerformCare ...1-888-722-8646 TTY Line ...1-800-654-5984 Lehigh County

Magellan Behavioral Health ... 1-866-238-2312 TTY Line ...1-866-238-2313 McKean County

Health Organization ... 1-866-878-6046 TTY Line ...1-877-877-3580 Mercer County

Value Behavioral Health ...1-866-404-4561 TTY Line ... 1-877-615-8502 Northampton County

Magellan Behavioral Health ... 1-866-238-2312 TTY Line ...1-866-238-2313

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1-800-361-2629. Perry County

PerformCare ...1-888-722-8646 TTY Line ...1-800-654-5984 Potter County

Health Organization ... 1-866-878-6046 TTY Line ...1-877-877-3580 Somerset County PerformCare ...1-866-773-7891 TTY Line ...1-800-654-5984 Venango County

Value Behavioral Health ...1-866-404-4561 TTY Line ... 1-877-615-8502 Warren County

Health Organization ... 1-866-878-6046 TTY Line ...1-877-877-3580 Washington County

Value Behavioral Health ...1-877-688-5976 TTY Line ... 1-877-615-8502 Westmoreland County

Value Behavioral Health ...1-877-688-5977 TTY Line ... 1-877-615-8502 York County

Health Organization ...1-866-542-0299 TTY Line ...1-877-877-3580

Emergency Numbers

Ambulance: ... Emergency: 911 or your local emergency services ... Fire: ... PCP: ... Pediatrician: ... Pharmacy: ... Poison Control: ... Police: ... If your address changes, please call your caseworker.

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Section 1. Welcome to UPMC for You ... 1

• Facts about UPMC for You

• What is HealthChoices? • How do I sign up?

• Will I get a UPMC for You ID card? • You can get information 24/7! • How to log in to MyHealth OnLine • How do I contact UPMC for You?

Section 2. Member Services Is Here to

Help You ... 4

• Our Representatives will:

− Provide personal assistance. − Give you information on providers. − Help you select or change your PCP or

schedule an appointment. − Send you an ID card.

− Tell you what is covered or not covered and how to get services.

− Answer questions about your bill. − Help you with other services.

Facts About UPMC

for You

UPMC for You is a Managed Care Organization (MCO) licensed by the Pennsylvania Department of Health and the Pennsylvania Insurance Department. Through contracts with the Department of Human Services (DHS), UPMC for You offers coverage to eligible Medical Assistance recipients throughout 40 Pennsylvania counties.

UPMC for You follows the federal and state laws that affect members, such as the Civil Rights Act of 1964, the Age Discrimination Act of 1975, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and the Americans with Disabilities Act (ADA).

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How do I sign up?

A DHS County Assistance Office caseworker will tell you if you are able to receive Medical Assistance. UPMC for You does not decide if you can receive Medical Assistance. UPMC for You does not decide what benefits will be covered under Medical

Assistance. DHS determines whether you qualify for Medical Assistance, if you will receive coverage under the HealthChoices program, and what benefits you and/or your family members will receive.

If you are eligible, your enrollment will be completed through an independent enrollment broker. The broker can explain which physical health and behavioral health plans you can join, tell you how to choose a primary care practitioner (PCP), and note whether you have any special needs.

If you would like to enroll, call PA Enrollment Services at 1-800-440-3989 or visit http://enrollnow.net. TTY users should call toll-free 1-800-618-4225.

You must continue to sign up through your DHS County Assistance Office every year and be eligible to get Medical Assistance to stay enrolled and be covered by UPMC for You. For assistance in applying for benefits, please visit the PA Compass website at https://www.compass.state.pa.us or contact the Benefit Helpline at 1-800-692-7462.

What is HealthChoices?

HealthChoices is the name of the mandatory Medical Assistance managed care program. It is for most Medical Assistance recipients who live in certain counties. Recipients must enroll in one of the Department of Human Services’ approved physical

health managed care plans.

UPMC for You is a physical health managed care plan and is available to eligible individuals who live in the following counties:

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1-800-361-2629.

Will I get a UPMC

for You

ID card?

Each member of your family who has picked UPMC

for You will get an identification (ID) card. Show this ID card and any other medical insurance cards to UPMC for You participating providers when you get services. You still need to keep your yellow or greenish-blue ACCESS card. Do not throw it away. You may need to use your ACCESS card for other Medical Assistance services.

Your UPMC for You ID card is plastic. When you get it in the mail, remove it from the letter and keep it in your wallet with your ACCESS card. See Section 2 for more information about your card.

You can get information 24 hours a

day/7 days a week!

Staying healthy is a 24/7 task. UPMC for You knows there are plenty of questions when it comes to health resources — questions that can come up at any time of day or any day of the week. Log in to MyHealth OnLine at www.upmchealthplan.com. With online tools like a personal health record, easy to use wellness programs, and detailed ways to search for providers, you are just a click away from great health information. Health resources such as activity trackers, health coaches, WebMD®, and more make MyHealth OnLine an interesting place to visit and explore.

In addition, you can access your benefit information (medical, pharmacy, vision, and dental) for the current and past years, and you can see your claims information for medical and pharmacy. You will have access to documents that explain the Notice of Privacy Practices, your rights and responsibilities as a member, and how to file a Complaint or a Grievance or request a Fair Hearing. You can read member newsletters, print a temporary ID card, or even change your PCP.

How to log in to

My

Health OnLine

Here is how to access MyHealth OnLine:

1. Go to www.upmchealthplan.com. Have your UPMC for You ID card handy.

2. If you already have a MyHealth OnLine account, choose Log In.

3. First time users, please choose “Register” to create an account.

How do I contact UPMC

for You

?

Call 1-800-286-4242 and Member Services will help you with your questions. Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m. TTY users should call toll-free 1-800-361-2629. See Section 3 for more information about Member Services.

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We try hard to be the best at everything we do. And when it comes to Member Services, we truly succeed. Member Services includes our award-winning and dedicated customer service team.* They deliver fast, personal service, and strive to answer your question on the first call.

*UPMC Health Plan’s Health Care Concierge Contact Center was recognized in September 2014 by

J.D. Power for providing “An Outstanding Customer Service Experience” for the Live Phone Channel. For J.D. Power 2014 Contact Certification ProgramSM

information, visit www.jdpower.com.

Our representatives will:

Provide personal assistance.

Member Services will provide personal service when and where you need it, at no cost to you. A representative will provide information to help you make important decisions about your medical, vision, dental, and pharmacy benefits.

Give you information about providers.

Member Services can give you information about participating primary care practitioners (PCP), specialists, hospitals, and other providers. You may request a copy of the most recent provider directory or view the provider directory on the UPMC for You

website at www.upmchealthplan.com.

Help you select or change your PCP or schedule an appointment.

If you are a new member or need a PCP, we can help you select or change your PCP or schedule an appointment. If you decide that the PCP you selected does not meet your needs after you have had an appointment with him or her, call us and we can help you select and schedule an appointment with a new PCP.

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1-800-361-2629. Send you an ID card.

Your UPMC for You ID card does not replace your ACCESS card, so you should carry both cards with you. Your UPMC for You ID card is good as long as you are a UPMC for You member. New members will receive a UPMC for You ID card shortly after their effective date. Remove the ID card from the letter and keep it in your wallet with your yellow or greenish-blue ACCESS card. Be sure that you tell your PCP or other provider’s office staff about all the medical insurance you have whenever you make an appointment, go to your PCP or other provider, or use any UPMC for You medical facilities.

Here is what is printed on your ID card:

• Your name • Your UPMC for You ID number

• Your PCP’s name

• Telephone number of the group in which your PCP practices

• Telephone number for UPMC for You Member Services

If you lose your ID card, visit www.upmchealthplan. com to request or print a temporary card. (See Section 1 for instructions on how to log in.) You can also call Member Services to ask for a new card. If you do not have your card and need services, you can use your ACCESS card and the provider will verify that you are a member of UPMC for You. If you lose your ACCESS card, call your caseworker at your County Assistance Office.

Tell you what is covered or not covered and how to get services.

If you have any questions about what is covered by UPMC for You, call Member Services and a representative can answer your question.

Answer questions about your bill.

A participating Pennsylvania Medical Assistance provider who is in the UPMC for You network cannot charge you for services or balances that are covered by UPMC for You. You are not responsible for a bill if the network provider does not receive payment for your covered services.

There are some exceptions:

Based on your age and benefit category, you may receive a bill if:

• You did not go to a participating provider. • You received services that are not a

covered benefit.

• You have a pharmacy, medical visit, diagnostic test, or other provider copayment due.

• You did not provide your UPMC for You ID card or other insurance information.

• You did not obtain a referral from your PCP or other provider when a referral was needed. • You received non-emergency services in the

emergency room.

• The provider notified you in advance of receiving the service that it was not covered and that you may be responsible.

• Your request for a benefit exception to the limits was denied and the provider notified you in advance of the service that you may be responsible.

• You obtained services while committing identity theft when using someone else’s health

insurance card.

• You did not follow the requirements of your primary insurance, such as using a provider in their network or obtaining a prior authorization if required.

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Remember to show your UPMC for You member ID card as well as any other medical insurance cards you have when you go for your visits. This will help us pay your claim. If you get a bill that you do not think you owe, call Member Services. You will need to have the bill available so that we can help solve your problem. Help you with other services.

Our Member Services representatives can help in other ways, too. They can:

• Help you schedule a visit with your PCP or other provider.

• Explain what you can do and what to expect when filing a Complaint or Grievance.

• Help you arrange the medical care and services you need.

• Help you get copies of utilization review management and clinical practice guidelines. (See Section 11.)

• Explain your pharmacy coverage and how to make the most of your benefits.

• Help you with claims questions and contact the provider, if needed, to help resolve the issue.

How do I contact UPMC

for You

Member Services?

Call Member Services at 1-800-286-4242. TTY users should call toll-free 1-800-361-2629. Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m.

For questions about dental services, call Dental Member Services at 1-888-257-0474 Monday through Friday from 7 a.m. to 8 p.m. TTY users should call toll-free 1-800-201-7165.

For questions about vision services, please call Vision Member Services at 1-866-458-2138 Monday through Friday from 8 a.m. to 7 p.m. TTY users should call toll-free 1-800-361-2629.

How can the UPMC

My

Health Advice

Line help me?

You will have immediate access to health care advice 24 hours a day/7 days a week through the MyHealth Advice Line. Whether you are seeking general health

advice or information regarding a specific medical issue, experienced registered nurses are available around the clock to provide you with prompt and efficient service. Call the UPMC Health Plan MyHealth Advice Line at 1-866-918-1591. TTY users should call toll-free 1-866-918-1593. If it’s an emergency, call 911 or your local ambulance service.

How can

My

Health OnLine help me?

MyHealth OnLine is a secure member website where you can find and store information about your personal health care coverage, send email inquiries to a nurse, and chat live with a Member Services representative.

See Section 1 for instructions on logging in to

MyHealth OnLine.

How do I ask a question through

MyHealth OnLine?

To access the secure Member Message Center and send an email inquiry to a registered nurse, follow these steps:

1. Go to www.upmchealthplan.com and log in as a member.

2. Click on Contact Us in the top right corner of the page.

3. Click on Send a Secure Message. 4. Click Compose.

5. Click Category and select Web Nurse from the drop-down menu.

6. Fill in the subject and your question. 7. Click Submit Message.

A registered nurse will respond within 24 hours of receiving your message. The MyHealth Advice Line and the Member Message Center are not substitutes for medical care. If you need emergency care, go to the nearest emergency room or call 911 or your local ambulance service.

MyHealth OnLine can also be used for claim inquiries, benefit inquiries, eligibility inquiries, PCP changes, and pharmacy and ID card inquiries. Send your message by selecting a category from the drop-down menu.

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1-800-361-2629. Every Medical Assistance member is assigned a

County Assistance Office and a caseworker to help you along the way. You can reach your caseworker by calling the Benefit Helpline at 1-800-692-7462. You can reach UPMC for You Member Services by calling the number listed on the bottom of each right-hand page of this right-handbook.

Call Member Services and your

caseworker when ...

You move, or your phone number changes.

It is very important to keep your address and

telephone number up to date so that you continue to receive information from the Department of Human Services and UPMC for You. If you move or change your phone number, you need to call your DHS County Assistance Office caseworker first. Your caseworker will change your address and/or phone number so you continue to receive important information about Medical Assistance. Then call UPMC for You Member Services and give them your new phone number and/ or address.

If you move out of the county or state in which you currently live or will be out of the service area for more than 30 days, you must notify your caseworker at the County Assistance Office. If you move out of the UPMC for You service area, your PCP will not be able to coordinate your care. Depending on where you move, you may need to disenroll from UPMC for You. Depending on the county you move to, you may need to enroll in another managed care plan. See Section 1 for more information on disenrollment.

You have a new family or household member.

If you have a baby while you are a UPMC for You

member, you need to call your caseworker at the County Assistance Office to have the baby added to your case. Your baby will be covered by UPMC for You

Section 3: When to Contact UPMC

for You

Member Services and Your DHS County

Assistance Office Caseworker

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from the date he or she is born if the mother is a UPMC for You member. Please call Member Services soon after you have your baby so that we can help you select a PCP for your baby. After you select a PCP for your baby, you will receive a UPMC for You ID card for him or her. See Section 1 for enrollment information. Any time you add someone to your family or

household, you need to call your caseworker at the County Assistance Office. Your caseworker

determines Medical Assistance eligibility for your new family or household member and adds him or her to your case. If that person is eligible, he or she can be added as a new member of UPMC for You. See Section 1 for enrollment information.

You want to change your health plan.

Enrollment changes are completed through an independent enrollment broker. If you want or need to make a change, visit www.enrollment.net or call 1-800-440-3989. TTY users should call toll-free 1-800-618-4225. An independent enrollment specialist will help you select a new managed care plan. You will have to disenroll from UPMC for You. You are still a UPMC for You member until the disenrollment is effective. Continue to use your UPMC for You ID card until you are enrolled in your new managed care plan.

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1-800-361-2629.

What is a special need?

A special need is when a UPMC for You member needs some extra help. This may be because you have:

• Physical health problems.

• Trouble getting health care services.

• Special communication needs because you have a vision or hearing impairment or you do not speak English.

• A need for services in your community. • Handicaps or disabilities.

• Behavioral health problems. (UPMC for You does not manage your behavioral health services. Your behavioral health services are managed by a Behavioral Health Managed Care Organization. See Section 8 to find the Behavioral Health Managed Care organization in the county where you live that will handle your needs. The Special Needs staff can help coordinate your physical health and behavioral health care needs.)

What services does the Special Needs

Department provide?

The Special Needs Department helps UPMC for You

members understand how to get covered services. They also help identify services in the community that may help you and your family.

The Special Needs Department can:

• Help you access the benefits you have and the health care services you need as a UPMC for You member.

• Identify UPMC for You participating providers, including specialists.

• Tell you which UPMC for You participating providers speak languages other than English and whether a provider’s office is wheelchair-accessible.

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• Direct you to your behavioral health provider if you need behavioral health services.

• Assist you in getting language interpreter services if needed.

• Help identify community agencies that can provide services that UPMC for You does not cover.

• Help coordinate your health care with UPMC for You participating providers and other community agencies that may be helping you.

• Tell you about UPMC for You programs that may help you, for example, a health management program or the maternity program if you

are pregnant.

• Provide health management for members who have many needs.

• Coordinate services for children who are in the custody of the Office of Children, Youth and Families or a Juvenile Probation Office.

• Assist you in arranging for medical transportation. • Help you file a Complaint or Grievance with

UPMC for You.

• Teach you how to manage your health. • Schedule preventive services.

Is this the department I call if I have a

disability or need my member materials

in a language other than English?

Yes. You should call the Special Needs Department for these needs. Members with hearing and/or vision impairments can obtain information in large print, Braille, or audio format at no cost by calling the Special Needs Department at 1-866-463-1462. TTY users should call toll-free 1-800-361-2629.

For members who do not speak English, the Special Needs Department can use a special translation telephone service. Staff from Special Needs can contact an interpreter who speaks your language. The interpreter will talk with you and the Special Needs staff so you can tell us what we can do to help you. Providers are responsible for arranging an interpreter for members who do not speak English or who communicate through American Sign Language or

other forms of visual/gestural communication. The Special Needs Department can help you and your UPMC for You participating provider find a translator who can communicate for you at your appointments.

Can the Special Needs Department

help me get services that UPMC

for You

does not cover?

UPMC for You understands that you or your family may need services that are not covered by UPMC for You. The Special Needs Department knows about many services provided in your community. Staff will work with you and your family to help identify which community services will meet your needs.

Some services are not covered by UPMC for You, including:

• Support groups.

• Routine transportation to your doctor appointments. (See Section 10 for more information about the Medical Assistance Transportation Program.)

• Homemaker services, except for members with AIDS or symptomatic HIV. (See Section 10.) • Home modifications such as wheelchair ramps or

wider doorways.

The Special Needs Department may not be able to help you get everything that you need, but they will help find you services that may be available in your community.

Who works in the Special

Needs Department?

The Special Needs Department has trained health coaches who can help UPMC for You members who have special needs.

Health coaches are nurses and social workers who can help with care coordination, weight loss, smoking cessation, community resources, exercise advice, and healthy eating tips. UPMC for You also has health coaches in doctors’ offices in the community.

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1-800-361-2629.

Who can call the Special Needs

Department?

Anyone can call the Special Needs Department to ask for help for a UPMC for You member or for information. This includes:

• UPMC for You members • Members’ family or friends

• Hospitals, PCPs, or other providers • Community agencies

• Any other person helping you

If someone else calls for you, the Special Needs Department will contact you to see how they can help. You will be asked to complete a form that will allow us to share information and communicate with others to coordinate your care. The Special Needs Department will keep your information confidential. (See Section 12 for more information about Privacy and Confidentiality.)

How do I contact the Special

Needs Department?

Call 1-866-463-1462. TTY users should call toll-free 1-800-361-2629. The Special Needs staff is available Monday through Friday from 7 a.m. to 8 p.m. and Saturday from 8 a.m. to 3 p.m.

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As a member of UPMC for You, you receive all the health care benefits covered by ACCESS. Your benefits are based on age and benefit category, which are determined by the Department of Human Services. You must be enrolled in UPMC for You on the date that services are received for services to be covered. You do not need to submit claim forms for health care benefits. You may have a small copayment for pharmacy, non-emergent emergency room visits, medical services, or diagnostic testing. Some of your health care benefits may require a prior authorization or have certain limitations. If you or your provider feels that services are not meeting your needs, a benefit or benefit limit exception may be requested. Instructions are provided in this section. If you receive a bill for services or have questions about a bill, call Member Services.

These services are covered

Listed below are some of the services that are covered when determined to be medically necessary:

These services keep you healthy, improve your health, or are necessary to make a diagnosis.

Medical services

• Visits to your PCP

• Visits to a specialist’s office or other provider’s office with a referral from your PCP (a copayment may apply)

• Acute or rehab services while you are in the hospital (a copayment may apply)

• Outpatient hospital services, ambulatory surgical center, or short procedure unit (a copayment may apply)

• Yearly physical exam

• Required general medical exams or office visits for participation in sports and/or camps

• Counseling to stop smoking or using other tobacco products

• Well-child exams, including regular checkups and immunizations/vaccines

• Allergy tests and shots • Laboratory tests

• X-rays, radiation therapy, cardiograms (EKGs), and other diagnostic tests (a copayment may apply)

• Physical, occupational, and speech therapy (a copayment may apply)

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1-800-361-2629. • Cancer treatments

• Nutritional counseling • Kidney dialysis

• Home health care – intermittent skilled nursing visits to perform services such as wound care and dressing changes when ordered by your provider • Home health aide – personal care services

provided for members under the age of 21 when ordered by your provider (requires prior authorization)

• Medical equipment and supplies

• Podiatrist services (a copayment may apply) • Chiropractic services (age restriction and/or a

copayment may apply)

• Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) — medically necessary expanded services for members under the age of 21

• Hearing aids for members under the age of 21 • Private duty nursing-skilled nursing services for

members under the age of 21 when ordered by your provider (requires prior authorization)

Emergency services

• Care in emergency room both in and out of the service area

• Admission to the hospital due to an emergency condition, in and out of the service area

Hospital services

• Hospitalization, including a semiprivate room (a private room is covered if called for by a medical condition), inpatient drugs, and physician services

• Outpatient surgery

• Inpatient and outpatient anesthesia

Skilled nursing services

• Medically necessary services provided in a skilled nursing facility (If you need these services for more than 30 days, the Fee-for-Service (ACCESS) program will pay for these services.)

• Diagnostic tests and therapies

Pharmacy services

If you qualify for Medical Assistance from the Department of Human Services, you will receive:

• Prescription drugs, including birth control pills/ family planning supplies, and medications to help you stop smoking, if needed.

• Some over-the-counter medicines with a provider’s prescription.

• Some over-the-counter vitamins with a provider’s prescription.

To ask about your pharmacy benefit package, contact Member Services.

What services are not covered?

Listed below are some, but not all, of the services not covered by UPMC for You:

• Acupuncture, medically unnecessary surgery, and other procedures that are experimental or are not in accordance with customary standards of medical practice

• Any service found to be medically unnecessary or inappropriate

• Barber, beauty, telephone, and TV service provided during an inpatient stay

• Cosmetic surgery, except when performed in order to improve the functioning of a malformed body part, or as post-mastectomy breast

reconstruction

• Experimental or investigative organ transplants that are not approved by the Department of Human Services

• Fees charged by your provider to complete forms without a medical examination

• Infertility services

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• Non-emergency inpatient and outpatient medical and surgical treatment services provided out of the service area, unless approved by UPMC for You

• Non-emergency routine transportation (see Section 10)

• Prescriptions written by providers who do not participate with UPMC for You, unless approved by UPMC for You

• Reversal of voluntary sterilization

• Services and procedures not covered on the Department of Human Services’ Medical Assistance fee schedule*

• Services and procedures not covered under the EPSDT enhanced benefits program or through waiver programs for which UPMC for You is responsible

• Services by providers who do not participate with UPMC for You, unless approved by UPMC for You

as described in Section 6

• Services obtained when committing identity theft by using someone else’s health insurance cards • Surgical procedures, medical care, and

medication provided in connection with sex-change operations

• Services requiring prior authorization which were not approved or for which prior authorization was not obtained (see Section 11)

• Sunglasses

• Transfer of medical records among PCPs or other providers

*Please note:

• Benefit limitations and most exclusions do not apply to members under the age of 21.

• If you or your provider feels that services are not meeting your needs, have your provider contact the Utilization Management Department to request a benefit exception.

The above list may not include all services that are not covered. If you have any questions about what is covered by UPMC for You, call Member Services. UPMC for You does not manage your behavioral health benefits. These services are managed by a behavioral health managed care organization (see Section 8).

Do some prescription drugs have to be

approved by UPMC

for You

?

Yes. Some prescription drugs have to be approved by UPMC for You. This is called “prior authorization.” Decisions to approve or deny a medication will be made within 24 hours of receiving the request for prior authorization.

If a decision cannot be made, you may receive one of the following:

• A 15-day supply of medication if your prescription qualifies as an ongoing medication

• A 72-hour supply of medication if you have an immediate need for the medication

If your PCP or other provider prescribes a drug for you, you can get it filled at any UPMC for You participating pharmacy. Take the prescription form and your UPMC for You ID card to the pharmacy. If you need help locating the nearest participating pharmacy, finding out whether your prescription requires prior authorization, or obtaining more information on pharmacy benefits, call Member Services and select the number for pharmacy services.

Please see the UPMC for You booklet, “Your

Prescription Drug Program” for more information on your prescription drug program and coverage. The booklet includes a formulary, which is a list of drugs that UPMC for You covers. It also tells you which drugs require prior authorization. If you would like a copy, contact Member Services. You can also find the booklet on our website:

• Go to www.upmchealthplan.com. • Select Shop on the top right side of page. • Select Medical Assistance.

• Select Pharmacy.

• Select UPMC for You Pharmacy Guide.

What pharmacy copayments do I have

as a UPMC

for You

member?

Some drugs have a copayment. A copayment is an amount that you pay to the pharmacist when you receive your prescription or over-the-counter drugs. You cannot be denied a prescription drug if you cannot pay the copayment. Tell your pharmacist if you cannot afford to pay. Your pharmacist can still try to collect the copayment.

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1-800-361-2629. Copayments are as follows:

• Brand-name prescription drugs and brand-name over-the-counter drugs are $3 for each new prescription or refill.

• Generic prescription drugs and generic over-the-counter drugs are $1 for each new prescription or refill.

Many categories of drugs do not have a copayment. These drugs include anti-hypertensives (high blood pressure drugs), anti-neoplastics (cancer drugs), anti-diabetics (diabetes drugs), anti-convulsants (epilepsy drugs), cardiovascular preparations (heart disease drugs), anti-Parkinson’s agents (Parkinson’s disease drugs), AIDS-specific agents, anti-glaucoma agents (glaucoma drugs), antipsychotics (drugs for psychosis), and anti-depressants (drugs for depression). Drugs, including immunization (shots), given by a physician do not have copayments.

Dental Benefits

Dental benefits for adult members include diagnostic, preventive, and restorative services. Please note, limits do exist related to dental benefits for adults, and some services may require prior authorization. Please contact Member Services for more information about benefits.

Members under the age 21 receive dental benefit described in Section 10.

Vision Services

For members age 21 and older:

• Routine vision exams twice a year

• $100 allowance toward eyeglasses (one frame and two lenses) or towards one pair of contact lenses and fitting per year*

• Glasses or contact lenses to treat cataracts or aphakia (medical condition)

• Specialist eye exam with referral from PCP

For members under the age of 21:

• Routine vision exams twice a year, or more often if medically necessary

• $100 allowance towards eyeglasses or toward one pair of contact lenses and fitting*

• Two frames and four lenses per year. (Note: The second pair of glasses are available if medically necessary, for example, your prescription changes.) Exception to limits can be made if medically necessary with written documentation • Replacement of eyeglasses or contact lenses if

they are broken or lost, or if prescription changes, provided written documentation of the necessity of the service is submitted by the provider

• Eyeglasses and all other vision services

deemed medically necessary, provided written documentation of the necessity of the service is submitted by the provider

*If you choose standard eyeglasses or contact lenses that are within the allowance, there is no cost to you. If you exceed the allowance, you will be responsible for any cost over the $100.

What other copayments do I have?

You will also have a copayment for some medical services you get from your provider. Certain services will have a higher copayment than others. At the time of your visit, your provider will tell you what the copayment is and ask you to pay it. You cannot be denied service if you cannot pay the copayment at that time. But you are still responsible for the copayment, and the provider may attempt to collect the copayment by billing you for the overdue amount.

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Adult Medical Assistance Members Ages 18 and Older

Services Copayment

Ambulance (per trip) $0

Dental care $0

Inpatient Hospital (Acute or Rehab)

Per day $3

Maximum with limits $21

Medical Centers

Emergency Department (non-emergent visits) $1 minimum - $3 maximum

Ambulatory Surgical Center $3

Federal Qualified Health Center/Regional Health Center $0

Independent Medical/Surgical Center $2

Convenience Care or Urgent Care Centers $0

Short Procedure Unit $3

Medical Equipment

Purchase $0

Rental $0

Medical Visits

Certified nurse practitioner $0

Chiropractor $1-2

Doctor (PCP, ob-gyn) $0

Optometrist $0

Podiatrist $1-2

Therapy (occupational, physical, speech) $1-2

Outpatient Hospital

Per visit $2

Prescriptions

Generic $1

Brand $3

Diagnostic Services (not performed in a doctor’s office)

Medical diagnostic testing (per service) $1

Radiology diagnostic testing (per service) $1

Nuclear medicine (per service) $1

Radiation therapy (per service) $1

Copayment Schedule

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1-800-361-2629.

Copayment exceptions

Copayments do not apply to:

• Pregnant women, including throughout the postpartum period

• Recipients under the age of 18

• Recipients eligible under the Breast and Cervical Cancer Prevention and Treatment Program • Recipients eligible under Title IV-B and IV-E

Foster Care and Adoption Assistance

• Members who reside in long-term care facilities, including Intermediate Care Facilities for the Intellectually Disabled and Other Related Conditions.

• Copayments also do not apply to the following: emergency services, laboratory services, hospice services, home health agency services, and family planning services and supplies.

If you have questions about copayments, call Member Services.

What are the service limits, or benefit

limits for each benefit year?

Service limits or benefit limits are set for each benefit year and depend on the service type. A benefit year is counted as 1 full year from the time a service is provided.

Limits do not apply to:

• Pregnant women, including throughout the post-partum period

• Recipients under the age of 21 • Nursing facility residents

• Members who reside in an Intermediate Care Facility for the Intellectually Disabled and Other Related Conditions

• Recipients eligible under the Breast and Cervical Cancer Prevention and Treatment Programs • Recipients eligible under Title IV-B and IV-E

Foster Care and Adoption Assistance

Are there exceptions to service or benefit limits?

You or your provider can ask UPMC for You to approve services above these limits. This is called a benefit exception.

A benefit exception to the limit can be granted if: • You have a serious chronic illness or other serious

health condition and without the additional service your life would be in danger; or

• You have a serious chronic illness or other serious health condition and without the additional service your health would get much worse; or • You would need more costly service if the

exception is not granted; or

• You would have to go into a nursing home or institution if the exception is not granted. To ask for a benefit exception:

• You can call Member Services.

• Your provider can call the Provider Prior Authorization Line.

• You or your provider can mail or fax a written request to:

UPMC for You

Attn: Medical Management Department U.S. Steel Tower

600 Grant Street Pittsburgh, PA 15219 Fax: 412-454-2057

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You or your provider must submit the following information to request a benefit exception:

• Your name, address, and telephone number • Your UPMC for You member ID number • A description and supporting clinical

documentation of the service for which you are requesting a benefit exception

• The reason you think the benefit exception is necessary

• Your provider’s name and telephone number A request for a benefit exception may be made before or after you receive the service.

For a benefit exception request made before you receive the service, UPMC for You will make a decision:

• Within 21 days after we receive the request • Within 48 hours after we receive the request,

when the provider indicates an urgent need for a quick response

For benefit exception requests made before you receive the service, if you or your provider is not notified of the decision within 21 days of the date the request is received, the benefit exception will be automatically granted.

For a benefit exception request made after you received the service, UPMC for You will make a decision:

• Within 30 days after we receive the request A benefit exception request made after the service has been delivered must be submitted no later than 60 days from the date UPMC for You rejects the claim. Benefit exception requests made after 60 days from the claim rejection date will be denied. Both you and your provider will receive written notice of the approval or denial of the benefit exception request. If you have exceeded a service limit, your provider may not bill you for services unless both of the following are met:

• The provider requested a benefit exception to the limit and UPMC for You denied the exception. • The provider told you before the service was

provided that you will have to pay for the service if the benefit exception is denied.

What is my right to appeal and

to a Fair Hearing?

You can file a Complaint with UPMC for You and ask for a Fair Hearing from DHS if:

• UPMC for You denies a service and you think you have not reached the limit.

• You or your provider asks for a benefit exception and the exception is denied. See Section 13 for complete details about Complaints, Grievances, and Fair Hearings.

If you have questions about which benefit you are eligible for, call Member Services.

What happens to my benefits if I have

other insurance or Medicare?

IF YOU HAVE MEDICARE, you can get care from any Medicare provider. The provider does not have to participate with UPMC for You. You also do not have to get prior authorization or referrals from your Medicare provider to get specialty care. UPMC for You

will coordinate payment with Medicare. If you need a service that is not covered by Medicare, a UPMC for You participating provider must provide the service and a prior authorization may need to be obtained. (See Section 11.) A participating Pennsylvania Medical Assistance provider who is in the UPMC for You

network cannot charge you for services or balances that are covered by your UPMC for You plan. (See Section 5 for information on covered benefits.) IF YOU HAVE INSURANCE OTHER THAN

MEDICARE, payment for services will be coordinated with your other insurance company. You need to follow the rules of your primary insurance, such as using a provider in their network or seeking a prior authorization if required. If you need a service that is not covered by your other insurance, a UPMC for You

participating provider must provide the service and obtain prior authorization if required. (See Section 11 for a list of services requiring prior authorization.) A participating Pennsylvania Medical Assistance provider who is in the UPMC for You network cannot charge you for services or balances that are covered by UPMC for You. If the service is provided by a provider not in the UPMC for You network, you may

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1-800-361-2629. receive a bill. If the service is not covered by your

other insurance, it may be covered by UPMC for You. Your benefits are based on age and benefit category, which are determined by the Department of Human Services. (See Section 5 for information on covered benefits.) Some services may have copayments or limits that would be your responsibility or may require a prior authorization.

Remember to tell your PCP, other provider offices, and UPMC for You about any medical insurance you have in addition to UPMC for You. If you get a bill that you do not think you owe, call Member Services.

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What is a primary care

practitioner (PCP)?

A primary care practitioner (PCP) is your personal health care provider. Your PCP will help manage all your health care needs. You and your family members who are enrolled in UPMC for You can all have the same PCP unless the PCP only sees specific ages. You can also choose different PCPs.

A PCP may be a family and general practice doctor, a pediatrician, an internal medicine doctor, or a certified registered nurse practitioner (CRNP). Family and general practice doctors treat all family members. Most pediatricians treat children, and most internal medicine doctors treat adults. A CRNP is a registered nurse with advanced training in a specialty area, certified by the boards in that specialty area. A CRNP may diagnose a condition or prescribe medicine under the direction of a doctor.

Some PCP offices have other health care professionals to help them. You may see a health care professional other than your PCP. Examples are CRNPs and physician assistants (PAs). A PA is a health care professional trained to practice medicine with a

doctor’s supervision. A PA may perform physical exams, order and read lab tests, diagnose and treat illness, prescribe medicine, and counsel patients. Your PCP is still responsible for your care.

Here are some of the things your PCP can do to help manage your health care:

• Help you 24 hours a day, seven days a week, including weekends and holidays, either in person or by telephone. Your PCP will make plans for you to be able to contact him or her after hours. • Give you checkups, vaccinations/immunizations

that help prevent diseases, and treat you for most common health problems.

• Order tests and treatments. • Refer you to a specialist.

• Coordinate other services, such as hospital admission, services in your home, or medical equipment.

• Teach you about your health problems and how to take care of yourself.

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1-800-361-2629.

v

Summary of Benefits

How do I choose a PCP?

When you joined UPMC for You, the representative you talked to gave you information on choosing a PCP. If you did not choose a PCP when you signed up, call Member Services. We can give you a list of providers to help you decide the one who is right for you. If you do not contact Member Services, a PCP will automatically be assigned for you.

Some PCPs limit the patients they treat in their office. For example, they may see only children or may no longer take new patients. A UPMC for You Member Services representative can tell you if a PCP has limitations.

How many hours per week will my PCP’s office be open?

PCPs and ob-gyns must have at least 20 office hours per week.

How long will I have to wait in the office to see my PCP?

The expected waiting time is 30 minutes or up to one hour if the provider receives an unexpected urgent visit or is treating someone with a difficult medical need.

Will my PCP’s office be accessible for individuals with disabilities?

All provider offices must meet the Americans with Disabilities Act (ADA) accessibility guidelines.

Will my PCP be on call?

PCPs and ob-gyns must be available 24 hours a day, 7 days a week for urgent and emergency care and to provide appropriate treatment or referrals for treatment. If a provider arranges for coverage by another participating provider, the covering provider must participate with UPMC for You and be available 24 hours a day, 7 days a week, as noted above for PCPs and ob-gyns.

What if my PCP takes an extended leave?

While on an extended leave, a provider must arrange for coverage by another participating provider. If the provider goes on leave for 30 days or longer, the provider must notify UPMC for You.

If your provider leaves our network, UPMC for You

will try to inform you within 15 calendar days of the termination. If you are having difficulty contacting your PCP or a provider in the UPMC for You network, please contact Member Services.

When can I see my new PCP?

Your PCP selection is effective immediately after you call Member Services and tell us the name of your PCP. We will send you a new UPMC for You ID card with the name and phone number of your PCP. Keep your current UPMC for You ID card until you get your new one. Your PCP is always the first person you should call for routine or non-emergency health care needs.

It is important that you get to know your PCP. Call and make an appointment for a visit soon after you become a member. When you make the appointment, tell your PCP if you have any medical insurance in addition to UPMC for You. You should give your PCP as much information as possible about your health. This includes family history, past illnesses, medicines you are taking, and any current health problems or concerns you have.

UPMC for You wants to be sure you are getting health care when you need it. That is why there are standards for appointments at the provider’s office. Your health care needs determine the kinds of visits you need and how soon providers should see you.

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New members

First examination For your first examination, you must be seen by:

Members with HIV/AIDS PCP or specialist no later than seven days after you have become a member of UPMC for You unless you are already being treated by a PCP or specialist.

Members who receive

Supplemental Security Income (SSI)

PCP or specialist no later than 45 days after you have become a member of UPMC for You, unless you are already being treated by a PCP or specialist. Members under the age of 21 PCP for an EPSDT (Early and Periodic Screening, Diagnosis, and Treatment)

screen no later than 45 days after you have become a member of UPMC

for You, unless you are already being treated by a PCP or specialist and are current with screens and immunizations.

All other members PCP visit no later than three weeks after you have become a member of UPMC for You.

PCPs and ob-gyns

Emergency Must be seen immediately or referred to an emergency room.

Urgent medical conditions Must be scheduled within 24 hours of request.

Routine care Must be scheduled within 10 business days of request. Wellness (physical, wellness

exam, well-child exam) Must be scheduled within 3 weeks of request. Well-woman exams Must be scheduled within 3 weeks of request.

Maternity care Initial prenatal care appointments must be scheduled: • First trimester – within 10 business days of request. • Second trimester – within 5 business days of request. • Third trimester – within 4 business days of request.

• High-risk pregnancies – within 24 hours of notifying the provider of the high risk, or immediately, if an emergency exists.

Appointment time frames

Your PCP and ob-gyn must be available to you 24 hours a day, 7 days a week, every day of the year. They may have an answering service or paging system that will contact them after their office has closed. Leave a phone number where the PCP or ob-gyn can call you back.

Your 2015/2016 Member Handbook

Member Services 1-800-286-4242

TTY Services 1-800-361-2629

www.upmchealthplan.com/foryou

Your 2015/2016

Member Handbook

Available in large print.

Important Telephone Numbers

Important Telephone

Numbers at a Glance

Important Behavioral

Health Telephone Numbers

at a Glance

Emergency Numbers

Table of Contents

Facts About UPMC

for You

How do I sign up?

What is HealthChoices?

Will I get a UPMC

for You

ID card?

You can get information 24 hours a

day/7 days a week!

How to log in to

My

Health OnLine

How do I contact UPMC

for You

?

Our representatives will:

How do I contact UPMC

for You

Member Services?

How can the UPMC

My

Health Advice

Line help me?

How can

My

Health OnLine help me?

Call Member Services and your

caseworker when ...

Section 3: When to Contact UPMC

for You

Member Services and Your DHS County

Assistance Office Caseworker

What is a special need?

What services does the Special Needs

Department provide?

Is this the department I call if I have a

disability or need my member materials

in a language other than English?

Can the Special Needs Department

help me get services that UPMC

for You

does not cover?

Who works in the Special

Needs Department?

Who can call the Special Needs

Department?

How do I contact the Special

Needs Department?

These services are covered

Emergency services

Hospital services

Skilled nursing services

Pharmacy services

What services are not covered?

Do some prescription drugs have to be

approved by UPMC

for You

?

What pharmacy copayments do I have

as a UPMC

for You

member?

Dental Benefits

Vision Services

What other copayments do I have?