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Your 2019MemberHandbookEverything you need to know about your planFor more information, visit Ambetter.IlliniCare.comIf this information is not in your primary language, please call 1-855-745-5507 (TTY/TDD 1-844-517-3431).
Thank you for choosing us as your health insurance plan.We’re excited to help you take charge of your health and tohelp you lead a healthier, more fulfilling life.As our member, you have access to lots of helpful services and resources.This member handbook will help you understand all of them. Inside, you’ll findimportant information about: How your plan worksPreventive care benefitsWhere to go for careHealth management programs Pharmacy benefits Optional adult dentaland vision benefits And much more!YOUR HEALTH IS OUR PRIORITY.If you have questions, we’re always ready to help. And don’t forget to check out ouronline video library at Ambetter.IlliniCare.com. It’s full of useful information.Member Services:1-855-745-5507 (TTY/TDD 1-844-517-3431)Ambetter.IlliniCare.comIf you would like to receive this handbook in Spanish, or if you need help translatingyour health care benefits and services to Spanish, please call Member Services at1-855-745-5507 (TTY/TDD 1-844-517-3431).Ambetter from IlliniCare Health: 1-855-745-5507 (TTY/TDD 1-844-517-3431) Ambetter.IlliniCare.com AMBETTER FROM ILLINICARE HEALTHWelcome to Ambetterfrom IlliniCare Health!
Table of ContentsTable of ContentsHow To Contact Us .3How Your Plan Works .4Membership & Coverage Information .8Covered Services Medical Service Expense Benefits .11Your Primary Care Provider .15Where To Go For Care .19Health & Wellness Programs .22Behavioral Health Services .26Pharmacy Benefits .27Adult Dental and Vision Benefits .29Utilization Management .30Quality Improvement Program .32Member Complaints And Appeals Process .33Member Rights .37Words to Know .39Ambetter from IlliniCare Health: 1-855-745-5507 (TTY/TDD 1-844-517-3431) Ambetter.IlliniCare.com 1AMBETTER FROM ILLINICARE HEALTHMember Handbook Overview .2
Member Handbook OverviewTo request print versions ofall informational materials,you can contact MemberServices at 1-855-745-5507(TTY/TDD 1-844-517-3431)Understanding your health insurance coverage is important. This memberhandbook explains everything you need to know — so take a look! Forinformation about your specific plan’s covered benefits and cost sharing, checkout your Schedule of Benefits and Evidence of Coverage. You can find both inyour online member account.This is your Member Handbook.Your Member Handbook provides you with a high-level overview on how toget the most out of your plan. And it helps you better understand your healthinsurance coverage and services available to you.Find your Member Handbook at Ambetter.IlliniCare.com under “For Members”,“Member Materials and Forms”. Or it is also available to you when you login toyour Member Secure Portal under “Reference Materials”.Login to your Secure Member Portal at Member.AmbetterHealth.comOnce you’re logged in, go to:“My Benefits”Use the drop down arrow to select your current benefit year and click the“Select Year” button.Here you will find your Member Contract information.Your Summary of Benefits and Coverage is an overview of what your plan coversand what it costs.If you want more details about your coverage and costs, you can get thecomplete terms in your Schedule of Benefits and Evidence of Coverage.Schedule of BenefitsYour Schedule of Benefits is a high-level summary of the benefits your plancovers and how much you will have to pay for them.Evidence of CoverageYour Evidence of Coverage is a detailed listing of the benefits your plan covers,as well as any exclusions the plan has.Explanation of Benefits (EOB):An Explanation of Benefits (EOB) is a statement that we send to members toexplain what medical treatments and/or services we paid for on behalf of amember. This shows the amount billed by the provider, the issuer’s payment,and the enrollee’s financial responsibility pursuant to the terms of the policy.We will send an EOB to a member after we receive and adjudicate a claimon your behalf from a provider. If you need assistance interpreting yourExplanation of Benefits, please contact Member Services at 1-855-745-5507(TTY/TDD 1-844-517-3431).Ambetter from IlliniCare Health: 1-855-745-5507 (TTY/TDD 1-844-517-3431) Ambetter.IlliniCare.com 2MEMBER HANDBOOK OVERVIEWThe Resources You Need. Right Here.
How To Contact UsAmbetter from IlliniCare Health999 Oakmont Plaza DriveWestmont, IL 60559If you want to talk, we’re available Monday through Friday,8 a.m. to 8 p.m. CST.Member 4-517-3431Make a Payment1-855-745-5507Behavioral Health Services1-855-745-550724/7 Nurse Advice Line1-844-494-9165Complaints and r.IlliniCare.comWhen you call, have these items ready: Your ID card Your claim number or invoice for billing questionsInterpreter ServicesIf you don’t feel comfortable speaking English, we provide free interpreter services.Call Member Services at 1-855-745-5507 (TTY/TDD 1-844-517-3431) to learn more.Ambetter from IlliniCare Health: 1-855-745-5507 (TTY/TDD 1-844-517-3431) Ambetter.IlliniCare.com 3MEMBER HANDBOOK OVERVIEWHow To Contact Us
How Your Plan WorksHow Your Plan WorksWant more information aboutour service area and in-networkproviders? VisitAmbetter.IlliniCare.comSo You Have Health Insurance —Now What?Having health insurance is exciting. To get the most outof your plan, complete this simple checklist. If you needassistance, call Member Services at 1-855-745-5507(TTY/TDD 1-844-517-3431). We’re available Monday throughFriday, 8 a.m. to 8 p.m. CST.Set up your secure online member account. Do this by visitingthe “For Members” page on Ambetter.IlliniCare.com. Yourmember account stores all of your plan’s benefits and coverageinformation in one place. It gives you access to your Scheduleof Benefits and Evidence of Coverage, claims information, thismember handbook and more.Complete your online Ambetter Wellbeing Survey within thefirst 90 days of your membership. All you have to do is log in toyour online member account. Completing this survey helps usdesign your plan around your specific needs — and it helps youearn 50 inrewards! See page 23 to learn moreabout theprogram.Enroll in automatic bill pay. Call us or log in to your onlinemember account to sign up. Automatic bill pay automaticallywithdraws your monthly premium payment from your bankaccount or charges your credit card, prepaid debit card, orbank debit card. It’s simple, helpful, convenient and secure.Pick your primary care provider (PCP). Just log in to yourmember account and view a list of Ambetter providers in yourarea by using the Provider Directory available on our website.Remember, your PCP, also known as a personal doctor, is themain doctor you will see for most of your medical care. Thisincludes your checkups, sick visits and other basic health needs.Schedule your annual wellness exam with your PCP. After yourfirst checkup, you’ll earn 50 inrewards! Andanytime you need care, call your PCP and make an appointment!Ambetter from IlliniCare Health: 1-855-745-5507 (TTY/TDD 1-844-517-3431) Ambetter.IlliniCare.com 4HOW YOUR PLAN WORKSLearn about how to get themost out of your plan. Set upyour online member accountto get started.
Answers To Your Payment Questions1. Pay online (Our recommendation!)If you have questions aboutpaying your bill, give MemberServices a call at 1-855-745-5507(TTY/TDD 1-844-517-3431).a. Quick Payment: https://centene.softheon.com/Equity/#/search.b. Automatic bill pay: Create your online member account onAmbetter.IlliniCare.com and enroll in automatic bill payment. You canset up automatic bill pay using your credit card, prepaid debit card,bank debit card or bank account.c. You can also pay by credit card, prepaid debit card or bank debit card.Just follow the “pay online” instructions at Ambetter.IlliniCare.com.Sign up for Paperless Billing toreceive your monthly invoicesonline.d. If you have earned My Health PaysTM rewards, you can use your rewardsto help pay your monthly premiums. Log in to your secure memberaccount at Member.AmbetterHealth.com to learn more about the MyHealth PaysTM program and view your card balance.2. Pay by phonea. Pay by Automated Phone. Call us at 1-844-PAY-BETTER (729-2388) and useour Interactive Voice Response (IVR) system. It’s quick and available 24/7!Orb. Call billing services at 1-855-745-5507 (TTY/TDD 1-844-517-3431) between8 a.m. and 8 p.m. CST. You will have the option to pay using theInteractive Voice Response (IVR) system or by speaking to a billingservices representative.3. Pay by maila. Send a check or money order to the address listed on your billing invoicepayment coupon. Be sure to mail your payment at least seven to 10days prior to your premium payment due date. Remember to writeyour member ID number on the check or money order and detach thepayment coupon from the billing invoice and mail with your payment.Mailing to the correct address will ensure your payments are processed in atimely manner.Ambetter from IlliniCare HealthAttn: Billing ServicesPO Box 74008544Chicago, IL 60674-85444. Pay with MoneyGram a. MoneyGram is fast and easy to use when you need to make same-daypremium payments. MoneyGram offers convenient locations, so you canavoid the stress of making a late payment. Plus, Ambetter covers theMoneyGram fee — so you just pay your premium!Ambetter from IlliniCare Health: 1-855-745-5507 (TTY/TDD 1-844-517-3431) Ambetter.IlliniCare.com 5HOW YOUR PLAN WORKSHow Can I Pay My Monthly Premium?
How Can I Pay My Monthly Premium?(Continued)b. To find a MoneyGram location near you, visit MoneyGram.com/BillPayLocations or call 1-800-926-9400. Learn more about usingMoneyGram to make your Ambetter premium payment by visitingMoneyGram.com/BillPayment.What Happens If I Pay Late?Your bill is due before the first day of every month. For example, if you arepaying your premium for June, it will be due May 31.If you don’t pay your premium before its due date, you may enter a grace period.This is the extra time we give you to pay. During a grace period, we may hold —or pend — payment of your claims. During your grace period, you will still havecoverage. However, if you don’t pay before a grace period ends, you run the risk oflosing your coverage. Refer to your Evidence of Coverage for grace period details.Member ServicesHave total or partial hearingloss? Call TTY/TDD 1-844-517-3431or visit Ambetter.IlliniCare.comWe want you to have a great experience with Ambetter. Our Member ServicesDepartment is always here for you. We can help you: Understand how your plan works Learn how to get the care you need Find answers to any questions you have about health insurance See what your plan does and does not cover Pick a PCP that meets your needs Get more information about helpful programs, like Care Management Find other healthcare providers (like in-network pharmacies and labs) Request your member ID card or other member materialsYou must contact the Health Insurance Marketplace to: Update your enrollment information such as your date of birth, address, orwhen reporting an income or life change. End your coverage with Ambetter.Visit HealthCare.gov or call 1-800-318-2596 (TTY: 1-855-889-4325). When you’reconnected, be ready to provide your state and then ask for a representative tohelp you.Ambetter from IlliniCare Health: 1-855-745-5507 (TTY/TDD 1-844-517-3431) Ambetter.IlliniCare.com 6HOW YOUR PLAN WORKSWe Care About Your Health
Deciding whether or not youneed to visit the emergencyroom can be tricky. Call our24/7 nurse advice line at1-844-494-9165 (TTY/TDD1-844-517-3431). They can helpyou decide where to go for care.Our free 24/7 nurse advice line makes it easy to get answers to your health questions.You don’t even have to leave home! Staffed by registered nurses, our 24/7 nurseadvice line runs all day, every day. Call 1-844-494-9165 (TTY/TDD 1-844-517-3431) ifyou have questions about: Your health, medications or a chronic condition Whether you should go to the emergency room (ER) or see your PCP What to do for a sick child How to handle a condition in the middle of the night Accessing our online health information libraryAmbetter from IlliniCare Health: 1-855-745-5507 (TTY/TDD 1-844-517-3431) Ambetter.IlliniCare.com 7HOW YOUR PLAN WORKS24/7 Nurse Advice Line
Membership & Coverage InformationMembership & Coverage InformationImportant Coverage DetailsYour Ambetter coverage is good for as long as you continue to pay yourpremium and meet the eligibility requirements* of the Health InsuranceMarketplace.*In order to maintain Eligibility with a marketplace plan you must: Live in the United States Be a legal, U.S. citizen and Illinois resident within the Ambetter coveragearea (lawfully present) Live within the Ambetter service area Not be incarcerated, institutionalized, or emancipated Not be covered by or eligible for: Medicaid, Medicare, MMP or similar Stateor Federal ProgramsWe do not discriminate against your income, health history, physical or mentalcondition, previous status as a member, pre-existing conditions and/or expectedhealth or genetic status or on the basis of race, color, national origin, sex, religion,sexual orientation, gender identity, age, disability, or housing status.If you need information on Dependent Member Coverage, refer to your Evidence ofCoverage.Finding The Right CareRemember to select an innetwork PCP! Check out ourProvider Directory for a full listof your options and theircontact information. It’s on theFind a Provider page atAmbetter.IlliniCare.com/findadoc.Refer to your Evidence ofCoverage for more informationon your Provider Directory.Every time you receive care,make sure to stay within theAmbetter network.We’re proud to offer you quality care. Our local provider network is the group ofdoctors, hospitals and other healthcare providers who have agreed to provideyou with your healthcare services.To search our online Provider Directory, visit Ambetter.IlliniCare.com/findadoc anduse our Find a Provider tool. This tool will have the most up-to-date informationabout our provider network, including information such as name, address,telephone numbers, hours of operation, professional qualifications, specialty, andboard certification. It can help you find a primary care provider (PCP), pharmacy,lab, hospital or specialist. You can narrow your search by: Provider specialty ZIP code Gender Languages spoken Whether or not he/she is currently accepting new patients. For moreinformation about a provider’s medical school and residency, call MemberServices.A Provider Directory is a listing of providers near you. If you would like a printedcopy of this listing, please call Member Services at 1-855-745-5507(TTY/TDD 1-844-517-3431).Ambetter from IlliniCare Health: 1-855-745-5507 (TTY/TDD 1-844-517-3431) Ambetter.IlliniCare.com 8MEMBERSHIP & COVERAGE INFORMATIONBe aware of important information on keeping your coverage. You canalways access helpful resources and information about your plan. VisitAmbetter.IlliniCare.com and take charge of your health.
Refer to the “Words to Know”section to learn more aboutCopays, Coinsurance andDeductibles.In-Network or Network Provider means a physician or provider who is identifiedin the most current list for the network shown on your identification card.Out-of-Network or Non-Network Provider means a physician or provider whois NOT identified in the most current list for the network shown on your MemberID Card. Services received from an out-of-network provider are not covered,except as specifically stated in your Evidence of Coverage (EOC).Your Ambetter Member Welcome PacketWhen you enroll with Ambetter, you will receive a Member Welcome Packet. YourWelcome Packet includes basic information about the health plan you selected. Youwill receive your Welcome Packet before your Ambetter health coverage begins.Your Ambetter Member ID CardCOPAYSYour member ID card is proof that you have health insurance with us. And it’svery important. Here are some things to keep in mind: Keep this card with you at all timesHMO IN NETWORKONLY: services You will need to present this card anytime you receiveCOVERAGEhealthcare You will receive your MemberEffective Date ofhealthCoverage:Subscriber:ID card(s)[Jane Doe] before your Ambetter[XX/XX/XX]coverage begins. If you Member:don’t get [JohnyourDoe]Member ID Cardbefore yourRXBIN: 004336Policy #:[XXXXXXXXX]coverage begins, call MemberServicesat 1-855-745-5507RXPCN: ADVMember ID #: [XXXXXXXXXXXXX](TTY/TDD OUP: RX5450Plan: We[Ambetter1 (2016) Vision card. Adult Dental: Sinai/IlliniCare Health Network] You will not receive your Welcome Packet and Member ID card(s) untilyour binder payment and firstmonth’sare paidin full.PCP: [ 10coin. afterpremiumded.]Deductible(Med/Rx):Specialist: [ 25 coin. after ded.][ 250/ 500]If you need a temporary ID cardRxor(Generic/Brand):[ 5/ 25if you would likerequesta Replacementafter toRx ded.]Coinsurance(Med/Rx):Urgent Care:[20% coin. after ded.][50%/30%]ID card, log in to your secure memberaccount.ER: 250 copay after ded.]Here is an example of what a member ID card typically looks like:HMO IN NETWORKCOVERAGE ONLY:COPAYSSubscriber:[Jane Doe]Member:[John Doe]Policy #:[XXXXXXXXX]Member ID #: [XXXXXXXXXXXXX]Plan: [Ambetter Balanced Care 1 (2016) Vision Adult Dental: Sinai/IlliniCare Health Network]PCP: [ 10 coin. after ded.]Specialist: [ 25 coin. after ded.]Rx (Generic/Brand):[ 5/ 25 after Rx ded.]Urgent Care: [20% coin. after ded.]ER: 250 copay after ded.]FrontAmbetter.IlliniCare.comMember/Provider Services:1-855-745-5507TTY/TDD: 1-844-517-343124/7 Nurse Line: 1-855-745-5507Effective Date of Coverage:[XX/XX/XX]RXBIN: 004336RXPCN: ADVRXGROUP: RX5450Deductible (Med/Rx):[ 250/ 500]Coinsurance ovider Services:1-855-745-5507TTY/TDD: 1-844-517-343124/7 Nurse Line: 1-855-745-5507Numbers below for providers:Pharmacy Help Desk: 1-844-256-4050EDI Payor ID: 68069EDI Help Desk: Ambetter.IlliniCare.comMedical Claims:IlliniCare HealthAttn: CLAIMSPO Box 5010Farmington, MO63640-5010Ambetter is underwritten by Celtic Insurance Company. Additional information can be found in yourEvidence of Coverage. If you have an Emergency, call 911 or go to the nearest Emergency Room (ER).Emergency services given by a provider not in the plan’s network will be covered without priorauthorization. Receiving non-emergent care through the ER or with a non-participating provider mayresult in a change to member responsibility. For updated coverage information, visitAmbetter.IlliniCare.com.Ambetter from IlliniCare Health is underwritten by Celt
Your 2019 Member Handbook Everything you need to know about your plan For more information, visit . Ambetter.IlliniCare.com. If this information is
