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Health Net AccessMember HandbookA helpful guide to getting services(Combined Evidence of Coverage and Disclosure Form)Benefit Year 2015
HELP IN ANOTHER LANGUAGE AND FOR THEDISABLED: HOW CAN I GET HELP?If you need this handbook or other health information in another language or in an alternativeformat such as large font, audio or accessible pdf, please contact Member Services at 1-888-7884408 or TTY/TDD: 1-888-788-4872. Also, if you need interpretive services, please call MemberServices at least five (5) days before your medical appointment to arrange language interpretiveservices in time for your appointments. There is no cost for language interpretation services. Youare not required to use family or friends to interpret for you.Si necesita este manual u otro tipo de información sobre salud traducido a otro idioma o en unformato diferente (como letra grande, audio o PDF accesible), comuníquese con el Departamentode Servicios al Afiliado al 1-888-788-4408 o a la línea TTY/TDD 1-888-788-4872. Además, sinecesita servicios de interpretación, comuníquese con el Departamento de Servicios al Afiliadoal menos cinco (5) días antes de su cita médica para coordinar los servicios de interpretación deidiomas; así podrá disponer de ellos en sus citas médicas. Los servicios de interpretación deidiomas no tienen costo alguno para usted. No es necesario que recurra a un familiar o a unamigo para que cumplan el rol de intérpretes.1
TABLE OF CONTENTSUsing the Health Plan . 5Let’s Get Started: How Do I Get Health Care? . 5Your Primary Care Provider (PCP) . 5How to choose or change a Primary Care Provider (PCP) . 6How can doctor visits help you stay healthy? . 6How to make, change, or cancel an appointment . 6Identification (ID) Cards: How Do I Use Them? . 7Provider Directory . 7Member Services Department . 7Protecting your health information: member verification . 8Cultural Competency . 8Who Gives Me Health Care? . 9Your PCP gives you most of your care . 9Referrals . 9How to get care from a specialist . 9How to get a second opinion. 10Care outside of the Health Net Access network . 10What is Covered: What Kind of Health Care Can I Get from Health Net Access? . 10Approval and Denial process . 10Covered Services . 11More Benefits: What Other Services Can I Get? . 12Hospital Care . 12Case Management . 13Disease Management . 13Tobacco Education And Prevention . 13Orthotics Care . 13Dental Care . 14Behavioral Health Services . 15Medically Necessary Pregnancy Terminations . 16Women’s Health Screening . 16Family Planning . 16Maternity Care . 17Women, Infants And Children (WIC) . 20Well-Child Care / Early Periodic Screening, Diagnostic and Treatment (EPSDT)* . 20Children with special health care needs . 22Who is eligible for Children’s Rehabilitative Services (CRS)?. 22Conditions covered through the CRS program . 22CRS Providers . 22Multispecialty Interdisciplinary Clinics. 23How to make, change or cancel an appointment with a CRS Clinic . 23Early Childhood Services* . 24Head Start. 24Developmental screening tools . 24Community resources . 242
Transportation: How do I get rides to Medical Appointments? . 25Emergency . 25Non-emergency . 25Car seat, wheelchair or stretcher . 25Canceling rides to your appointments. 25Emergency Care: How do I get care in an emergency? . 25Emergency room and urgent care (After-hours care) use . 25How do I use the emergency room appropriately? . 26What to do in case of an emergency . 26Pharmacy Benefits: How do I Get Prescription Drugs? . 27What you need to know about your prescription . 27Refills . 27What should I do if the pharmacy cannot fill my prescription? . 27Important information for AHCCCS members With Medicare Part D Coverage (Dualeligible members). 28Co-payments (AHCCCS Co-payments) . 28People with nominal (optional) Copays . 29People with required (mandatory) Copays . 305% limits on all Copays . 30Children’s Rehabilitative Services (CRS) copayments and deductibles . 30Billing for a covered service . 31Paying for non-covered services . 31Non-Covered Services: What does AHCCCS Not Cover? . 31Services not approved by our plan – Notice of Action . 35Complaints: What Should I Do if I Am Unhappy? . 35What if you have questions, problems or grievances about Health Net Access? . 35Appeal and request for Fair Hearing . 36What if you disagree with a denied service? . 36Who may file an appeal?. 36What can you file an appeal for? . 36What are our timeframes to make decisions about services? . 36What we will do when your appeal is received . 36How do you request a State Fair Hearing? . 37What is an expedited appeal? . 37If you are currently receiving the services requested, can you continue to receive themduring the appeal process? . 37If you are currently receiving the services requested, can you continue to receive themduring the State Fair Hearing process? . 37AHCCCS: How Can I Make Sure I Don’t Lose My Coverage?. 37Renewing AHCCCS Coverage . 37Annual Enrollment Choice (AEC) . 38Health plan changes . 38What to do when your family size changes . 38If you move, you must tell us! . 38Member Rights and Responsibilities. 39Member Rights. 393
Member Responsibilities . 40Important Information: What else do I need to know? . 40Coordination Of Benefits (COB) . 40Special information for our members who have Medicare coverage: . 41Advance Directives . 41Advocacy Information . 41What is Fraud and Abuse? . 424
USING THE HEALTHPLANHealth Net Access is a Managed Care Plan.A Managed Care Plan is a health plan thatprovides health care to its members througha selected group of doctors, hospitals, andpharmacies. You and your doctor play animportant role in your managed care plan.Your doctor helps decide what care youneed, so it is important you see your doctorand talk with him or her about your health.You need to have regular checkups everyyear. Regular screenings help keep youhealthy.Your responsibility as a member is to makesure you always follow these steps whenyou need health care:1) Always carry and show your HealthNet Access Identification (ID) Card.2) Call your doctor’s office forpreventive care or if you have amedical problem.3) Keep your medical appointments orcall the office to reschedule if youare unable to keep an appointment.4) Make sure you have a referral fromyour doctor when you need to see aspecialist.5) Cooperate with your doctor’sinstructions (However, you mayrefuse medical treatment).Contact the Health Net Access MemberServices Department (Member Services)with any questions or concerns about yourhealth benefits or medical services.In this handbook, we use “you” and“your” to mean “the AHCCCS member.”We use “we,” “us,” “our” and “our plan”to mean “Health Net Access.” Only themember can get the benefits talked aboutin this handbook.Contract services are funded in part undercontract with the State of Arizona.LET’S GET STARTED:HOW DO I GETHEALTH CARE?YOUR PRIMARY CARE PROVIDER(PCP)Your Primary Care Provider (PCP) is yourassigned doctor and plays an important rolein your health care. Your PCP will get toknow you, your health needs and medicalhistory. Your PCP will provide routinehealth care and arrange for any specialtycare you may need. You must see yourassigned PCP before you see any otherdoctor, unless you have an emergency orbehavioral health problem. For moreinformation on emergency room use, pleasesee section titled “Emergency Care: HowDo I Get Care in an Emergency?” in thishandbook.Please note: Children under the age of 21 canvisit a dentist without visiting theirPCP first. Women can have a Pap smear ormammogram screening (after age 40and at any age if consideredmedically necessary) once a yearwithout a referral from their PCP.Please contact Member Services formore information on Pap smears andcolonoscopies.*A well-child visit/check is the same as anEarly Periodic Screening, Diagnostic andTreatment (EPSDT) visit.5
HOW TO CHOOSE OR CHANGE APRIMARY CARE PROVIDER (PCP)It is important that you choose a PCP whomakes you feel comfortable. When you havea PCP that you like, your PCP will be ableto better help you with your health care.This relationship is very important inproviding you the care you need. You canfind a list of our doctors on our website atwww.healthnet.com/access or by callingMember Services at 1-888-788-4408(TTY/TDD: 1-888-788-4872). For moreinformation, please see the section titled“Provider Directory” in this handbook.If you wish to change your PCP, please callMember Services for assistance. A PCPchange can be made effective the same dateof the request. However, we encourage younot to change your PCP more than twice ayear.HOW CAN DOCTOR VISITS HELPYOU STAY HEALTHY? Make sure children under the age of21 receive their annual well-examsand immunizations. Adults ages 21 and older shouldreceive their annual well-exams andshould visit their PCP when asymptom or sickness develops or forregular care of a chronic condition. Schedule preventative exams such asPap smear, Mammogram (after age40 and at any age if consideredmedically necessary) and Cancerscreening once a year. Talk to yourdoctor about other importantscreening and preventative tests,such as colonoscopies, prostateexams, diabetes tests, cholesteroltests. Keep your appointment for tests thatyour doctor has ordered for you. Know why it is important for you tohave the test done and what couldhappen if you don’t have it done. Ask your doctor to help you learnhow to take better care of yourself.HOW TO MAKE, CHANGE, ORCANCEL AN APPOINTMENTHow to Make an Appointment: Call your PCP, dentist, or specialistto schedule your appointment Tell the provider’s office: yourname, your AHCCCS Identification(ID) number (this appears on thefront of your Health Net Access IDcard), your doctor’s name, and whyyou need to see this doctor.How to Change an Appointment: Call your doctor’s office at least 24hours ahead of time Tell the doctor’s office: your name,your AHCCCS ID number, the dateof your appointment, and ask to set anew date to see your doctor.How to Cancel your Appointment: Call your doctor’s office 24 hoursahead of time. Tell the doctor’s office that you wantto cancel your appointment andprovide them with: your name, yourAHCCCS ID number, and the dateof your appointment. If already arranged, call MemberServices to cancel transportation orinterpreter services when no longerneeded. If you are unable to contact yourdoctor’s office and need help, pleasecall Member Services.6
IDENTIFICATION (ID)CARDS: HOW DO IUSE THEM?Once you are enrolled in our plan, you willreceive a Health Net Access Identification(ID) card. Do not throw this card away. It isvery important to carry this card with you atall times and show it when you receivemedical services. This card will identify youas our member and lists important phonenumbers and information that your healthcare provider will need.Only you are allowed to use your Health NetAccess ID card for health care services.Never lend, sell, or allow someone to useyour card. This is against the law, and youmight lose your AHCCCS eligibility. Legalaction may also be taken against you.You will need your Health Net Access IDcard to: Make doctor appointments See your doctor Get medicine and supplies Get care from a hospital or othermedical provider Get help and information fromMember ServicesIf you don’t have a Health Net Access IDcard or if you lose your card, call MemberServices at 1-888-788-4408 (TTY/TDD: 1888-788-4872) to get a new one.PROVIDERDIRECTORYA Provider Directory is available online.Visit www.healthnet.com/access to use our“Provider Search” tool or to download acopy of the directory. Included in thedirectory and the online search tool areprimary care physicians, specialists,OB/GYNs, hospitals and more. You mayrequest a copy be mailed to you at nocharge by calling Member Services. Theprovider directory is available in Englishand Spanish.MEMBER SERVICESDEPARTMENTOur Member Services Department (MemberServices) is staffed by representatives whospeak several languages, including Englishand Spanish. Member Services also uses atelephone interpreter service for memberswho speak a language that is not availablewithin the department. You can call MemberServices at 1-888-788-4408 (TTY/TDD: 1888-788-4872), or if you are a TTY user youcan contact the Arizona Relay System at 1800-367-8939. If you speak anotherlanguage other than English or Spanish, callMember Services and we will help get aninterpreter to assist with the phone call.When calling Member Services, pleasehave the following information ready:Your name, your AHCCCS ID number, yourdate of birth, the phone number and addresson file. You will also need a pen and paperto write down important information we willgive you.7
Some of the ways Member Services canhelp you: Answer questions about yourcovered services, benefits, and copays Provide information about doctors,nurse practitioners, and physicianassistants Provide information about programsavailable to members Help you choose or change your PCP Help you schedule a ride to yourdoctor or medical appointments Help you make, change or cancelyour medical appointments Provide you with dentist or specialistinformation Help you if you have a complaint orproblem Help you with your rights as amember Help you schedule a languageinterpreter for your medicalappointments if you cannotcommunicate with your doctor. Thisservice is provided at no cost toyou. Help you change your phone numberand address with AHCCCS. If youare currently being treated forconditions such as diabetes, cancer,asthma, behavioral health,HIV/AIDS, or any disability, callMember Services immediately. Wewill refer you to a Case Manager tomake sure you are getting the careyou need.If your address or phone numberchanges, it is very important that youreport it immediately. Call Member Services with your newaddress and phone number. Call your local Department ofEconomic Security (DES) eligibilityoffice with your new address andphone number. KidsCare members can call 1-877764-5437 or 1-602-417-5437 (TDDfor the hearing impaired: 1-602-4174191).PROTECTING YOUR HEALTHINFORMATION: MEMBERVERIFICATIONWhen you call Member Services, you willbe asked questions to verify your account.We do this for your protection and arerequired to do so by law. This is how wemake sure we do not share your informationwith the wrong person.You will be asked to verify the followinginformation: AHCCCS ID number, birthdate, address, and phone number.To help protect your identity and preventfraud, AHCCCS is adding pictures to itsonline verification tool that providers use toverify your coverage. If you have anArizona driver’s license or state issued ID,AHCCCS will get your picture from theArizona Department of TransportationMotor Vehicle Division (MVD). Whenproviders pull up the AHCCCS eligibilityverification screen, they will see yourpicture (if available) with your coveragedetails.CULTURAL COMPETENCYWe value the many people who live in theareas we serve. We understand that there aremany different ethnic backgrounds of peoplein Maricopa County. We know that yourhealth is affected by your beliefs, culture,and values. We want to help you keep andmaintain good health and good relationshipswith doctors and other providers whounderstand your needs. If you feel that thereis a problem, please contact us. We will helpyou find a provider who will betterunderstand your personal needs. We8
provide language interpretive services atno cost to you. If you cannot communicatewith your provider because of a languagebarrier, please contact Member Services.Sign language interpreters are available atno cost to you. We can schedule aninterpreter to help with your appointment. Ifyou need this or any of our other printedmaterials in another language, please callMember Services. Call us and let us knowif we have overlooked anything that isimportant to you. We will try to help. Wewant you to be comfortable with ourservices.If you would like to share culturalinformation that you feel is important toyour health care, please call MemberServices at 1-888-788-4408 (TTY/TDD: 1888-788-4872).WHO GIVES MEHEALTH CARE?YOUR PCP GIVES YOU MOST OFYOUR CAREYour Primary Care Provider (PCP) is the“gatekeeper” for all services you receive.Your PCP may be providing you medicalservices or your PCP may make plans foryou to get these services from anotherprovider (sometimes called a specialist).You must see your PCP before you seeany other provider or attempt to getoutside services.You do not have to see your PCP for thefollowing: Emergency Services, Behavioral Health services, OB/GYN services, and Dental services for children underthe age of 21.REFERRALSA referral is when your PCP sends you to aspecialist for a specific problem. A referralcan also be to a lab or hospital. We mayneed to review and approve certain referralsand special services before you can get theservices.You do not need a referral for the following: Emergency Services, Behavioral Health services (seeBehavioral Health Services sectionfor more information) OB/GYN services, and Dental services for children underthe age of 21.HOW TO GET CARE FROM ASPECIALISTSome medical services and specialists needour prior approval. If they do, your PCP willarrange for a Prior Authorization for theseservices. We must review these requests.Your PCP’s office will let you know if yourPrior Authorization request is approved.You can also call Member Services to findout the status of your request.If your PCP’s request is denied, we will letyou know by mail. Our letter will also tellyou how to appeal our decision if you arenot happy with it.If you have a question about the denial, youmay call Member Services at 1-888-7884408 (TTY/TDD: 1-888-788-4872). Formore information about filing an appeal fora denied authorization, please see the sectiontitled “Complaints: What Should I Do if IAm Unhappy?” in this handbook.Please note: Women can have a Pap smearor mammogram screening (after age 40 andat any age if considered medicallynecessary) once a year without a referralfrom their PCP. Please contact Member9
Services for more information on Papsmears and colonoscopies.*A well-child visit/check is the same as anEPSDT visit.Your PCP may want you to see a specialistor get special services. Your PCP willarrange for the special services listed below.Some of these special services may requirePrior Authorization.1.2.3.4.5.6.7.8.9.Diet and health coachingHome health visitsOrgan transplantsSkilled nursing home careRehabilitation services like physicaltherapy, occupational therapy, orspeech therapySpecialist careSurgeryCertain x-rays, scans or medical testsDurable Medical Equipment such aswheelchairs or oxygenHOW TO GET A SECOND OPINIONYou have the right to have a second opinionfrom a qualified health care professionalwithin the network. If one is not available inthe network, you have the right to a secondopinion outside the network at no cost toyou. We will help you arrange the secondopinion visit.CARE OUTSIDE OF THE HEALTHNET ACCESS NETWORKIn special cases you may be able to getservices outside of your county and outsideof our network. This includes:1. Emergency and urgent care services2. Specialty care when a specialist isnot available within our network3. When arranged by your doctor andapproved by our plan for MedicallyNecessary carePlease contact Member Services if youwould like more information.WHAT IS COVERED:WHAT KIND OFHEALTH CARE CAN IGET FROM HEALTHNET ACCESS?In order for you to get any health careservice through our plan, the service must beboth: A Covered Benefit with AHCCCS,and Medically NecessaryA “Covered Benefit” means that you can getthis service through AHCCCS and HealthNet Access. “Medically Necessary” meansthat a covered service is provided by aphysician or other licensed practitioner ofthe healing arts within the scope of practiceunder state law to prevent disease, disabilityor other adverse health conditions or theirprogression, or prolong life.APPROVAL AND DENIAL PROCESSSome medical services may need PriorAuthorization. If they do, your provider willarrange for authorization for these services.We must review these authorization requestsbefore you can get the service.Prior Authorization means your doctorhas requested permission for you to get aspecial service. We must approve theserequests before the delivery of services.Prior Authorization is approved based ona review of medical need.Your PCP’s office will let you know whenauthorization is obtained. You can also callMember Services to find out the status of the10
request. We will let you know by mail ifauthorization is denied. In the letter, youwill have instructions on how to file anappeal. The letter will describe the reasonfor the denial. If you have a question aboutthe denial and need help, please callMember Services at 1-888-788-4408(TTY/TDD: 1-888-788-4872). Please seethe section titled “Complaints: What ShouldI Do if I Am Unhappy?” in this handbookfor more information about filing an appealabout a denied authorization.As our member, you may receive thefollowing health care benefits. The listbelow does not include all possible services.Your PCP may be providing you theseservices or your PCP may make plans foryou to get these services from anotherprovider (sometimes called a specialist).You must see your PCP before you seeany other provider or attempt to getoutside services. Care while you are pregnant Case management Checkups for children*, pregnantwomen and Qualified MedicareBeneficiary (QMB) Children’s services includingroutine dental care Chiropractic services for childrenand QMB Emergency medical and surgicalservices related to dental (oral)care Dialysis Disease Management Emergency or Urgent Caremedical treatment Eyeglasses or contacts forRemember: You do not have to see yourPCP for Emergency Services, BehavioralHealth services, OB/GYN services, andDental services for children under the age of21.children, or adults only aftercataracts are removed Family planning / birth control Health care services includingCOVERED SERVICESThe services listed below will be coveredwith us. Call Member Services or talk toyour PCP for more information about theseservices: Ambulance for emergency care Audiology services to evaluatescreenings, diagnosis andmedically necessary treatments Hospice care Hospital care Inpatient rehabilitation services,hearing loss on both outpatientincluding speech, physical andand inpatient basisoccupational therapy. Outpatient Beh
name, your AHCCCS Identification (ID) number (this appears on the front of your Health Net Access ID card), your doctor's name, and why you need to see this doctor. How to Change an Appointment: Call your doctor's office at least 24 hours ahead of time Tell the doctor's office: your name, your AHCCCS ID number, the date
