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My Care FamilyMassHealthMember HandbookIssued and effective January 1, 2019My Care Family offers care and coverage through MassHealth by Greater Lawrence Family Health Center,Lawrence General Hospital, and AllWays Health Partners.
WelcomeWe are pleased to have you as a member. We look forward to working with you and yourPrimary Care Provider (PCP) to keep you healthy.My Care Family is an Accountable Care Organization (ACO) that includes Greater LawrenceFamily Health Center, Lawrence General Hospital, and AllWays Health Partners. You will getyour care at Greater Lawrence Family Health Center and Lawrence General Hospital.AllWays Health Partners provides insurance coverage for the benefits and services that youreceive through your providers. In this handbook, sometimes we will use “My Care Family.”Sometimes we will use “AllWays Health Partners” when talking about your plan, benefits,and services.At My Care Family, a care team works together to make sure you get the care that is rightfor you. Your care team includes you and your PCP, and in some cases it will also includeother providers and your family members. Your care team will include providers fromGreater Lawrence Family Health Center or Lawrence General Hospital. It may also includeother providers in the My Care Family network, or from AllWays Health Partners. The careteam works together to understand what you need and determines the best way for you toget it. You may develop a personalized care plan with your care team and it could includehelp with other things besides medical care, like help finding housing or supports in yourcommunity. Your care plan will be based on your needs and preferences. You can decidehow much or how little you want to participate in your care plan.This handbook has important information to help you understand your benefits and get themost from your coverage. If you have any questions about this book or your plan, contactAllWays Health Partners Customer Service at 1-800-462-5449 (TTY: 711). We are here tohelp you Monday through Friday from 8:00 AM to 6:00 PM, and Thursday from 8:00 AM to8:00 PM.My Care Family MassHealth Member Handbook Issued and Effective January 1, 2019
Getting the most out of your health planFollow these tips to help you understand and access quality healthcare.1. Meet your primary care provider (PCP).A PCP is a doctor, a nurse practitioner, orphysician’s assistant who provides, coordinates,or helps a patient access a range of health careservices. If you are new to My Care Family andhave not met your PCP yet, please make anappointment to meet him or her.4. Always carry your AllWays HealthPartners/My Care Family and MassHealthmember ID cards.Remember to show both ID cards when youget health care. That way, you will getcoverage for the services paid for by MyCare Family or by MassHealth.2. Unless it’s an emergency, when youneed healthcare, call your PCP first.Your PCP will work with you to meet yourhealth care needs. If you need care from anyother provider, hospital, or clinic, your PCPcan assist in coordinating services. ForBehavioral Health (mental health andsubstance use) services, contact anyBehavioral Health provider within the MyCare Family network. Behavioral Health5. Call AllWays Health Partners andMassHealth with any changes thatmight affect your coverage.Call MassHealth if you have a new address, anew phone number, or a new baby. Theseare all changes we need to know about tohelp us serve you.3. If it’s an Emergency, don’t wait.Call 911, your local emergency phone number,or go to the nearest emergency room rightaway. Emergency services are covered in anyemergency department, whether it is in theMy Care Family network or not.For Behavioral Health (mental health andsubstance use) emergencies, call 911, yourlocal emergency phone number, or go to thenearest emergency room.You can also call the Emergency ServicesProgram (ESP) provider in your area. TheStatewide ESP toll-free number is (877) 3821609. They will ask you to enter your zip code.You should enter the zip code for the locationwhere you are at the time. For a list ofemergency rooms in all parts of the state,check your My Care Family Provider Directory.After your emergency has been treated, callyour PCP and your Behavioral Health provider,if you have one, within 48 hours of youremergency. That way, your provider can giveyou any follow-up care you may need.6. When in doubt, call.AllWays Health Partners Customer Service isopen Monday through Friday from 8:00 AM to6:00 PM and Thursday from 8:00 AM to 8:00PM. If you have any questions about yourhealth coverage, call 1- 800-462-5449 (TTY:711).7. Don’t lose your My Care Family orMassHealth coverageMassHealth renews your coverage every year.This is called the Redetermination process.MassHealth will renew you automatically ifthey have enough information. If they do nothave enough information, they will mail youa renewal form (Eligibility ReviewVerification form). Fill out the form andreturn it to MassHealth right away.You can also go to the MassHealth website tofill out your form. The MassHealth website isMAhealthconnector.com. Call MassHealth forhelp with their website.Some members will get a renewal form orletter from MassHealth each year. If youdo not, call MassHealth customer serviceat (800) 841-2900 (TTY (800) 497-4648).
Table of ContentsSection 1Your Member MaterialsMy Care Family Member Handbook . 1Translation and Alternate Formats . 1Contact Information. 1Covered Services List. 1My Care Family Provider Directory . 2Information about My Care Family Providers. 2My Care Family Service Area . 2Section 2MembershipEnrollment . 3About Your Enrollment Options. 3Every Year You Must Renew your MassHealthBenefits/Eligibility . 3Status Changes . 3Voluntary Disenrollment . 3Membership Disenrollment for Loss ofEligibility . 3Membership Disenrollment for Cause . 4Section 3Member CardYour My Care Family Member Card. 5Your MassHealth Card . 5Section 4Referrals and Prior AuthorizationsTypes of authorization and time frames fordecision-making and notification. 6Section 5Member InformationYour PCP . 8How to choose or change a PCP . 8Get to Know Your PCP. 8How to Change Your PCP . 8If Your PCP Leaves My Care Family . 9Emergency Care . 9What to Do in an Emergency . 9If You Are Not Sure it is an Emergency. 9Urgent Care . 9After Hours Care . 9Behavioral Health Providers . 10Behavioral Health Inpatient Care . 10Diversionary Behavioral Health Services . 10Specialty Care . 10How to See a Specialist. 10Out-of-Network Specialty Care . 11Common Questions about Providers andSpecialists . 11Second Opinions . 11Scheduled Hospital Care. 11Care When You Travel Outside the My CareFamily Service Area . 11Family Planning Services . 12Maternity Care . 12Continuity of Care . 12Section 6Utilization Management ProgramAccess and Utilization. 14Section 7My Care Family’s Pharmacy BenefitHow to fill a prescription . 15Pharmacy Reimbursements . 15Over-the-Counter Drugs . 15Pharmacy Copayment (copay) . 16Co-payment Exceptions. 16Safe and Appropriate Use of PrescriptionDrugs . 16Mandatory Generic Policy . 17Prior Authorization . 17Step Therapy . 17Access90 . 17Specialty Pharmacy Program. 18New-to-Market Medication Program. 18Limitations . 18Exceptions . 18Exclusions . 18
Section 8Health-care Access StandardsEmergency Services. 20Urgent Care . 20Primary Care . 20Specialty Medical Care . 20Behavioral Health Care. 20Children in the Care or Custody of theDepartment of Child and Family Services(DCF) . 20Section 9Your My Care Family BenefitsGeneral Coverage Requirements for My CareFamily Benefits . 21What happens if your coverage begins whileyou are in the hospital . 21Your Covered Services List . 21How to Access My Care Family MassHealthBenefits . 22Transportation Assistance . 22How to Access Benefits Not Covered by MyCare Family that are Available Directlythrough MassHealth. 22Excluded Services . 22Section 10Health Care for Your ChildrenPreventive and Well-Child Care for AllChildren . 23Preventive Pediatric Health-care Screeningand Diagnosis (PPHSD) Services for ChildrenEnrolled in MassHealth Family Assistance . 23Early and Periodic Screening, Diagnosis andTreatment (EPSDT) Services for ChildrenEnrolled in MassHealth Standard orCommonHealth . 23Children’s Behavioral Health Initiative (CBHI). 24Dental Care for Children. 26Section 11Additional Services for ChildrenEarly Intervention Services for Children withGrowth or Developmental Problems . 27Section 12Preventive Care for Adults28Section 13Care Management ProgramsNurse Advice Line . 29The Care Management Programs at My CareFamily . 29Complex Care Management . 30Disease Management . 30Section 14Staying HealthyOnline Wellness Tools . 31Telephonic Health Coaching . 31Quit for Life Tobacco Cessation Program . 31Wellness Outreach from My Care Family . 31Section 15Quality Assurance Programs33Section 16When You Have Other CoverageCoordination of Benefits . 34Subrogation . 34AllWays Health Partners’ Right ofReimbursement . 34Section 17Member Rights and ResponsibilitiesYour Rights as an AllWays Health PartnersMember . 35Your Responsibilities as an AllWays HealthPartners Member . 35Mental Health Parity . 36Reporting Health Care Fraud . 36Section 18Communicating with My Care FamilyYour Satisfaction is Important to Us . 37If You Receive a Bill in the Mail or If You Paidfor a Covered Service. 37
Section 19Concerns and InquiriesConcerns . 38Inquiries . 38Section 20Grievance Process andRights for MassHealth MembersQuestions and Answers about the GrievanceProcess . 39Section 21Appeal Process andRights for MassHealth MembersQuestions and Answers about the AppealsProcess . 41Section 22ConfidentialityNotice of Privacy Practices . 47Section 23Advance Directives:Planning for Future Health CareHealth Care Agents and Proxies . 50Living Wills . 50Organ Donation Cards. 50Frequently Asked Questions about AdvanceDirectives . 50Section 24Glossary52
An Important Note about this HandbookMy Care Family is made up of two parts: a health insurance plan and an Accountable Care Organization(ACO), which is a group of providers. AllWays Health Partners is the health insurance part of My Care Family.The other part of My Care Family is the ACO, which is made up of providers mostly from Greater LawrenceFamily Health Center (GLFHC) or Lawrence General Hospital.The providers give you medical and Behavioral Health care and may help you with other things as well, suchas community supports. The health plan AllWays Health Partners mostly handles the non-medical parts ofyour plan, like sending out your ID card. For this reason, you may see references to AllWays Health Partnersor to My Care Family in this handbook.The important thing is that while we may help you in different ways, we are one organization. Bothparts work together to make sure that you have everything you need to get the right care when youneed it. AllWays Health Partners, GLFHC and Lawrence General Hospital are one family – My Care Family.We are glad you are part of our family!
Section 1Your Member MaterialsAs a new member of My Care Family, we will sendyou materials about My Care Family and yourcoverage like: Member Handbook Covered Services listThe My Care Family MassHealth Member Handbookalong with the Covered Services List is an importantdocument that describes your coverage.You can check allwaysmember.org for updates toyour Handbook or Covered Services List. Theupdates may be called an Amendment or Notice.My Care Family Member HandbookThis member handbook explains what you need toknow about your My Care Family coverage. It tellsyou how My Care Family works. It also tells youwhat you can expect from My Care Family.For the rest of this book, the word “you” means“Members of My Care Family.”The handbook may describe services that do notapply to your MassHealth coverage. Please checkthe MassHealth Covered Services List to see whatis covered for you.Please read your My Care Family MemberHandbook and keep it with your Covered Service List.Translation and Alternate FormatsYou can get free copies of all My Care Familymaterials in: Spanish or any other language Braille Large size type American Sign Language video clipsContact InformationAt the bottom of every page of this book, we printimportant contact information.Call AllWays Health Partners about your healthinsurance and benefits.AllWays Health Partnersallwayshealthpartners.orgAllWays Health Partners Customer Service800-462-5449 (TTY: 711)Monday–Friday 8:00 AM to 6:00 PMThursday 8:00 AM to 8:00 PMCall Optum about mental health and substanceuse servicesUnited Behavioral Health(Optum) LWW.com844-451-3519 (TTY: 711)Available 24 hours a day, 7 days a week.Call MassHealth about your Medicaid benefits.MassHealthCustomer Service Center800-841-2900 (TTY: 800-497-4648).Monday–Friday 8:00 AM to 5:00 PMCall AllWays Health Partners if you have a questionand don’t know who to call.Covered Services ListThe Covered Services List includes all the benefitsand services that may be covered by My CareFamily or by MassHealth. The Covered Services Listalso lets you know if you need a Prior Authorizationor Referral before you have a service.Your PCP (PCP) will get referrals and priorauthorizations for you. AllWays Health Partners isresponsible for coordinating all covered benefitslisted in your Covered Services List.The Effective Date for your coverage is the date whenyou become an active My Care Family member.MassHealth Customer Service Center: 1-800-841-2900 (TTY: 1-800-497- 4648) Monday—Friday 8:00 a.m. to 5:00 p.m.My Care Family Customer Service: 1-800-462-5449 (TTY: 711) Monday—Friday 8:00 a.m. to 6:00 p.m., Thursdays 8:00 a.m. to 8:00 p.m.Please visit My Care Family online at www.allwayshealthpartners.org1
My Care Family Provider DirectoryThe My Care Family provider list tells you all theproviders in your network, including: Primary Care offices PCPs Specialists like heart doctors and bonedoctors Behavioral Health providers Pharmacies Labs, imaging centers, and other supportproviders Emergency Service Programs forBehavioral Health emergencies Durable medical equipment suppliersYou must choose a PCP in the My Care Familyprovider network.Our website always has the most current providerlist. Visit the My Care Family website atmycarefamily.org. Call AllWays Health PartnersCustomer Service to ask for a copy of the providerdirectory.Information about My Care FamilyProvidersMassachusetts has a website where you can findmore information about doctors. This website iscalled the Board of Registration in Medicine.The address is https://www.mass.gov/check-aphysician-profile. Click View a Physician Profile tosearch for a doctor.My Care Family Service AreaThe My Care Family Service Area is Lawrence, Lowelland Haverhill and certain towns in the surroundingareas. Here is a full list of towns in the service townNo. owleyLowellSalisburyNorth BillericaW. BoxfordNo. ChelmsfordW. NewburyNutting LakePinehurstTewksburyOther websites also provide information to helpyou make choices about your care.TyngsboroLeapfrogleapfroggroup.orgVisit this site for information about the quality of ahospital.WestfordMassachusetts Health Quality Partnersmhqp.orgVisit this website to learn how different medicalgroups treat the same type of illnessJoint Commission for the Accreditation ofHealthcare Organizations (JCAHO)qualitycheck.orgVisit this website to compare the quality ofdifferent providers.2MA Health Care Quality and Cost Council (HCQCC)mass.gov/myhealthcareoptionsVisit this website to compare the cost and qualityof Massachusetts hospitalsVillage ofNagog WoodsFor more information, call AllWays Health PartnersCustomer Service.You must live in the service area to be a My CareFamily member. You will get most of your care inthe service area at a Greater Lawrence FamilyHealth Center site, at Lawrence General Hospital,or at another primary care site in the My CareFamily network. If you do need care outside theservice area, your PCP will arrange it for you.United Behavioral Health (Optum): 1- 844-451-3519 (TTY: 711) Monday—Friday 8:00 a.m. to 6:00 p.m.EST ;Thursday 8:00 a.m. to 8:00 p.m. EST.Please visit Optum online at www.LWW.com
Section 2MembershipEnrollmentFirst, My Care Family gets your Enrollmentinformation from MassHealth. Then we mail you aMember ID Card within 15 business days. This cardis valid at midnight on the Effective Date of yourMy Care Family Enrollment.As of your Effective Date, My Care Family isresponsible for all the covered benefits listed inyour Covered Services list.When you enroll in My Care Family throughMassHealth, you are accepted regardless of yourrace, color, national origin, age, disability, sex,religion, sexual orientation, gender identity, genderexpression ancestry, marital status, veteran status,occupation, Claims experience, duration ofcoverage, pre-existing conditions, expected healthstatus, or who pays for services.About Your Enrollment OptionsEach year, there will be a period of 90 days whenyou can change your plan for any reason. You willbe enrolled in the health plan that your PCPbelongs to.After the 90 days are up, you cannot change yourplan for the next 9 months unless you have aspecial reason. You will still be able to switch PCPs,but your new PCP must be a part of the same ACO.If you have questions about your health planoptions, call MassHealth Customer Service.Every Year You Must Renew yourMassHealth Benefits/EligibilityMassHealth renews your coverage every year. Thisis called the redetermination process.MassHealth will renew you automatically if theyhave enough information. If they do not haveenough information, they will mail you a renewalform (Eligibility Review Verification form). Fill outthe form and return it to MassHealth right away.You can also go to the MassHealth website to fillout your form. The MassHealth website is:https://www.mass.gov/information-formasshealth- applicants-and-members.Call MassHealth for help with their website.You should get a renewal form or letter fromMassHealth every year. If you do not, callMassHealth. MassHealth, AllWays Health Partners,or your doctor can help you with the renewal form.You will lose your MassHealth coverage if you donot complete your renewal in time.Status ChangesYou must call MassHealth and AllWays HealthPartners if you: Change your address or phone number Have a baby Change your incomeAllWays Health Partners may be able to contactMassHealth for you. When you call us to updateyour information, ask the AllWays Health PartnersCustomer Service Professional if they can send thechanges to MassHealth for you.Voluntary DisenrollmentYou can leave My Care Family during the PlanEnrollment Period. Call the MassHealth CustomerService Center and choose a PCP who is not part ofthe My Care Family Network.Membership Disenrollment for Loss ofEligibilityIf you become ineligible for MassHealth coverage,MassHealth will tell My Care Family. We will stopyour coverage as of the date of your MassHealthDisenrollment. You may automatically be enrolledin My Care Family again if you qualify forMassHealth again within twelve months.MassHealth will decide if you qualify.MassHealth Customer Service Center: 1-800-841-2900 (TTY: 1-800-497- 4648) Monday—Friday 8:00 a.m. to 5:00 p.m.My Care Family Customer Service: 1-800-462-5449 (TTY: 711) Monday—Friday 8:00 a.m. to 6:00 p.m., Thursdays 8:00 a.m. to 8:00 p.m.Please visit My Care Family online at www.allwayshealthpartners.org3
Membership Disenrollment for CauseSometimes My Care Family may ask MassHealth todisenroll a Member. To do this, My Care Familysends MassHealth a written request.We will never drop a member because they are toosick or using too many services. Also, we will notdrop a member because they have special needs orare disruptive because of their special needs.It would be rare for My Care Family to request todrop a member. But, if caring for that membermakes it impossible for us to care for othermembers, we might ask MassHealth to disenrollthat member from My Care Family.MassHealth will decide whether to grant My CareFamily’s Disenrollment request. MassHealth willsend you a letter if you are disenrolled.4United Behavioral Health (Optum): 1- 844-451-3519 (TTY: 711) Monday—Friday 8:00 a.m. to 6:00 p.m.EST ;Thursday 8:00 a.m. to 8:00 p.m. EST.Please visit Optum online at www.LWW.com
Section 3Member CardYour My Care Family Member CardAll the My Care Family members in your family willget an AllWays Health Partners/My Care FamilyMember Identification Card (Member ID Card).Your member ID Card has important informationabout your benefits. It also tells Providers andpharmacists that you are a Member of My CareFamily.Your MassHealth CardAs a MassHealth Member, you will also have aMassHealth card. Always show both cardswhenever you get care or fill a prescription.FirstName MI LastName000000000000Keep your member ID card and your MassHealthcard with you all the time. Show your AllWaysHealth Partners/My Care Family Member ID Cardand your MassHealth card whenever you get careor fill a prescription.Please check your cards to make sure all theinformation is correct. If you have questions or loseyour card, call AllWays Health Partners CustomerService.MassHealth Customer Service Center: 1-800-841-2900 (TTY: 1-800-497- 4648) Monday—Friday 8:00 a.m. to 5:00 p.m.My Care Family Customer Service: 1-800-462-5449 (TTY: 711) Monday—Friday 8:00 a.m. to 6:00 p.m., Thursdays 8:00 a.m. to 8:00 p.m.Please visit My Care Family online at www.allwayshealthpartners.org5
Section 4Referrals and Prior AuthorizationsA referral is a recommendation from a PCP or otherprovider for you to see a specialist or receive aservice. You do not need a referral for: Emergency services1. You, your authorized representative, oryour provider requests an extension. Urgent Care2. AllWays Health Partners believes that: Chiropractic care The added time is in your interest Routine, preventive, or urgent care from aGynecologist or Obstetrician We need more information because: Family planning services provided by anyMassHealth provider Outpatient and diversionary BehavioralHealth services Routine eye examsA prior authorization is approval you get fromAllWays Health Partners or MassHealth before youhave certain services. AllWays Health Partners willnot cover a service if you do not get priorauthorization first for services that need one.Your Covered Services list tells you which servicesneed a prior authorization from AllWays HealthPartners or MassHealth. Here are a few examplesof services that need a prior authorization: Home health care Surgical procedures and elective hospitalstays Routine services from a provider that is notin My Care Family’s networkYour PCP or specialist will help you get priorauthorization if you need it. Make sure you have aprior authorization before you get a service.Types of authorization and time framesfor decision-making and notificationWe make standard authorization decisions as fastas your health condition requires. We will alwaysgive you a decision no more than 14 calendar daysafter we get the request.6It may take AllWays Health Partners 14 morecalendar days to give you a decision if:oThere is a good chance that moreinformation would lead to approval.If we receive more information, itcould result in an approval. In thiscase, the information should bereceived from your provider withinfourteen (14) calendar days.If AllWays Health Partners decides to take moretime, we will send you a letter with the reasons.We will also send you information about your rightto file a grievance if you do not agree with ourdecision to extend the authorization time.oFor all the details on filing a grievance, please seepage 39 or call AllWays Health Partners CustomerService.Expedited (fast) authorizations are made as fast asyour health condition requires. We will make fastdecisions within 3 calendar days after we get therequest.If AllWays Health Partners does not act withinthese times, we will send a letter to tell you whenyou can expect an answer. We will also tell youhow to file an appeal.For information on filing an appeal, please seepage 42 or call AllWays Health Partners CustomerService.Once AllWays Health Partners reviews the request,we will send you and your provider a letter withour decision.United Behavioral Health (Optum): 1- 844-451-3519 (TTY: 711) Monday—Friday 8:00 a.m. to 6:00 p.m.EST ;Thursday 8:00 a.m. to 8:00 p.m. EST.Please visit Optum online at www.LWW.com
We will send a denial letter if AllWays HealthPartners: Does not approve a service Approves only some of the services Does not authorize the full amount,duration or scope of service(s)AllWays Health Partners will not pay for anyservices that are not authorized. AllWays HealthPartners will also send a letter if we decide toreduce, suspend, or terminate previouslyauthorized service(s).If you do not agree with AllWays Health Partners’decisions on the request for a prior authorization,you or can file an appeal.For more information about appeals, see page 41or call AllWays Health Partners Customer Service.Your providers are responsible for getting priorauthorizations from AllWays Health Partners. Butit’s a good idea to check ahead of time to makesure your provider has gotten a prior authorization.You can check on allwaysmember.org or you cancall AllWays Health Partners Customer Service.MassHealth Customer Service Center: 1-800-841-2900 (TTY: 1-800-497- 4648) Monday—Friday 8:00 a.m. to 5:00 p.m.My Care Family Customer Service: 1-800-462-5449 (TTY: 711) Monday—Friday 8:00 a.m. to 6:00 p.m., Thursdays 8:00 a.m. to 8:00 p.m.Please visit My Care Family online at www.allwayshealthpartners.org7
Section 5
Jan 01, 2019 · MassHealth Member Handbook. . Dental Care for Children.26 Section 11 Additional Services for Children Early Intervention Services for Children with . The providers give you medical and Behavioral Health care and may help you with other things as well, such as community supports. The health plan AllWay
