member handbook Form
1022395INMENABS 10/22
AIN MHB ENG 10/22
Serving Hoosier Healthwise,
Healthy Indiana Plan,
and Hoosier Care Connect
Anthem Hoosier Healthwise
MEMBER HANDBOOK Anthem Blue Cross and Blue Shield To get this handbook in other formats, such as Braille, large print or audio CD, call our Member Services at 866-408-6131 (TTY 711) Monday through Friday, 8 a.m. to 8 p.m. Eastern time. You can learn more about Anthem on our website at anthem.com/inmedicaid.
Table of contents
Intro — Quick Guide
6
Part 1 – All about the Hoosier Healthwise Plan
15
HHW benefits
15
Pregnancy care
16
Prenatal and postpartum programs
16
Services Anthem covers
21
Other services
23
Services not covered by Anthem
24
Services from doctors who are not in your plan
24
Self-referral services
25
Dental benefit summary
25
Part 2 – Ways to good health
26
Choose your primary medical provider (PMP)
26
Services from doctors not in the Anthem plan
27
Continuity of care
27
Schedule a health checkup
27
Hoosier HealthWatch
28
Prepare for your doctor visit
29
Think three for your member ID
30
Preapproval
30
Changing your PMP
30
Specialist care
30
Standing referral
31
Getting a second opinion
31
Indiana Right Choices program
31
Behavioral health services
31
Substance use disorder and opioid treatment services
31
Stay well
31
A 24/7 line for your peace of mind
32
Care management
32
Access to complex care management
32
Healthy Families program
32
Educational materials
32
Indiana Quitline
33
Condition Care
33
Healthy Family Lifestyles program
35
Autism Family Supports program
35
Substance use disorder program
36
Human immunodeficiency virus (HIV) rewards program
36
WebMD’s Personal Health Record
36
Sick or hurt? Where do you go?
37
After-hours care
37
Urgent care
37
Emergency care
37
Part 3 – Pharmacy services
38
Filling your prescriptions
38
Pharmacy benefits for HHW members
39
These prescription drugs are not offered
39
Generic drugs
39
Pharmacy copays
39
Preapproval for drugs
40
Other important information
40
Days’ supply of drugs
40
Early refill
40
Emergency safety programs
40
Member medication support
40
Appeal rights
40
Part 4 – Help with special services
42
Help in other languages
42
Help for members with hearing or vision loss
43
Americans with Disabilities Act
43
Special note to our Native American members
43
Part 5 – Know your rights and other helpful information
44
Member rights
44
Member responsibilities
46
New medical treatments
47
Choosing a new health plan
47
If you have other insurance
48
What to do if you get a bill from a provider
48
Privacy policies
48
Your medical records
48
Living will (advance directive)
49
Quality Improvement
49
Reporting fraud and abuse
50
If we can no longer serve you
50
Part 6 – How to resolve a problem with Anthem
53
If you have a question
53
Grievances
54
Expedited (rush) grievance
55
Appeals
55
Expedited (rush) appeal
55
External independent review
56
Expedited (rush) external independent review
57
Medicaid hearing and appeal process
57
HIPAA Notice of Privacy Practices
58
Service Phone number Information Member Services 866-408-6131 (TTY 711) Hours: Monday through Friday, 8 a.m. to 8 p.m. Eastern time. Call for questions about:
} Your Anthem health plan.
} Behavioral health.
} Substance abuse services.
} Pharmacy benefits.
} Utilization management. 24/7 NurseLine — toll-free, 24-hour nurse helpline 866-408-6131 (TTY 711) Talk in private with a nurse 24 hours a day, seven days a week. You may also call this line for an interpreter. Behavioral Health Crisis Hotline 833-874-0016 (TTY 711) Call the Behavioral Health Crisis Line and speak to a licensed behavioral health professional. You can call 24 hours a day, 7 days a week. We are here to help you when you are going through a mental health or substance use crisis. We want to make sure you get the right services as soon as possible. Utilization Management (UM) 866-408-6131 (TTY 711) Hours: Monday through Friday, 8 a.m. to 5 p.m. Eastern time. Call for questions about UM or an approval request. You may ask for an interpreter. If after hours, you can leave a private message. Staff will return your call the next business day or at a different time upon request. Staff will tell you their name, title and organization when making or returning calls. Anthem Transportation Services 844-772-6632 (TTY 888-238-9816) Set up nonemergency rides to the doctor at least two business days before your appointment. Calls for routine reservations are accepted Monday through Friday from 8 a.m. to 8 p.m. Eastern time. Calls for urgent and same day reservations are accepted 24/7. Calls for cancellations, status updates and hospital discharges are accepted 24/7. 6 7 Hoosier Healthwise Quick Guide Welcome to your Anthem Blue Cross and Blue Shield Hoosier Healthwise (HHW) member handbook! Read this quick guide to find out about:
} Your benefits.
} Important phone numbers.
} Choosing a primary medical provider (PMP).
} Pharmacy services.
} Ways to good health. Important phone numbers TTY lines are only for members with hearing or speech loss.
8 9 Service Phone number Information National Poison Control Center (Calls are routed to the closest office.) 800-222-1222 Talk with a nurse or doctor for free poison prevention advice and treatment 24 hours a day, seven days a week. Relay Indiana 800-743-3333 (TTY 711) For members with hearing or speech loss, a trained person will help them speak to someone using a standard phone. Superior Vision 866-866-5641 (TTY 800-428-4833) Find an eye doctor in your plan or learn more about your vision benefits. Women, Infants, and Children (WIC) 800-522-0874 Learn more about this program, which gives healthy food to pregnant members and young mothers. Indiana Family and Social Services Administration (FSSA) 800-403-0864 Call this number to report any information changes like phone, address, and income. FSSA Prior Claims Payment program 800-457-4584 Speak with a program administrator about the prior claims payment program. HHW Enrollment broker 800-889-9949 Can help answer questions in changing plans or update member status. DentaQuest 888-291-3762 Find a dentist or learn more about HHW dental services. Indiana Tobacco Quitline 800-784-8669 Free phone-based service to help smokers quit. Translation or format services 866-408-6131 (TTY 711) We can translate this handbook in other forms such as Braille, large print or audio CD. We can translate information free of charge. TTY lines are only for members with hearing or speech loss. Technology at your service Anthem offers online tools to make it easier for you to access care and services. With our secure member website, you can manage your healthcare with a few clicks. Just go to our website at anthem. com/inmedicaid to set up your secure account. Once you’re registered, you can:
} Choose or change doctors.
} Order a new ID card.
} Look at the status of claims.
} See your care plan.
} Contact Member Services.
} Have messages/communications sent to your account. It’s easy, and you’ll be able to get things done without the wait. Also, check out these Anthem web pages for special programs: Program Web Address Details Healthy Rewards anthem.com/AnthemRewards Offers many rewards for staying healthy Blue Ticket to Health anthem.com/blueticket Partnership with the Indianapolis Colts so you can win prizes for having a wellness checkup Anthem Concierge Unit Managing healthcare can be hard. That’s why we created the Anthem Concierge Unit. This service can help you:
} Complete your Health Needs Screening (HNS).
} Schedule appointments with your primary medical provider (PMP).
} Connect to community services like Women, Infants, and Children (WIC). Call 866-408-6131 (TTY 711) for the Concierge Unit today. You can also write the Anthem Concierge Unit at: Anthem Blue Cross and Blue Shield Mailstop IN0205 C442 220 Virginia Ave. Indianapolis, IN 46209-6227 Has your income, household size, or contact information changed? These changes must be reported within 10 days of when the change occurs:
} Your address or contact information
} Your family income or family size
} You lose your job, change jobs, or get a new job
} You become pregnant, deliver your baby, or when your pregnancy ends
} You become insured under Medicare or another type of insurance
} Any other change that you think may affect your eligibility or benefits for HHW To make these updates:
} Go to FSSABenefits.in.gov.
} Select Sign in or Create account and follow the prompts.
} Call Member Services at 866-408-6131 (TTY 711) if you need assistance. Yes, we have an app for that, too The Sydney Health mobile app puts your healthcare at your fingertips. Downloading the app is free on the App Store® and Google Play™. You can use the app to:
} Find a doctor, hospital or pharmacy in your plan.
} View your claims.
} See your care plan.
} Check your symptoms.
} Talk with a nurse 24/7 about your health.
11 10 A quick look at your HHW benefits With Anthem, you have access to:
} Doctor care
} Chiropractic services
} Hospital care
} Medical supplies
} Therapy services
} Behavioral health
} Smoking cessation
} Skilled nursing facility
} Vision services
} Podiatry services
} Nonemergency transportation Enhanced benefits In addition to your HHW benefits, and many doctors to choose from, Anthem offers you these extras: Enhanced benefits Details Essentials for Expectant Moms
} New parent product toolkit
} Online learning courses on pregnancy, postnatal care, and new baby care
} Essential items to keep baby safe Fresh Fruits and Veggies Program
} One produce box per month for three months delivered to your home
} For pregnant or nursing moms six weeks postpartum Healthy Meals
} 10 frozen healthy family meals delivered to your home Post-discharge meals
} Eligible members receive two customized meals per day for seven days (up to 14 meals) delivered to your home Personal care essentials
} Up to $50 per member per year for personal care or over- the-counter products such as baby care items, first-aid items and feminine care products Boys & Girls Club – Healthy Kids Healthy Choices
} Annual membership to the Boys & Girls Club for members ages 5-18
} Online fitness program and resources Asthma and COPD relief toolkit
} Up to $80 in asthma and allergy relief products School supply assistance
} Up to $50 in school supplies for members ages 5-18 High School Equivalency (HSE) Assistance
} Voucher to cover the cost of HSE tests, practice test, and up to two retests Non-pharmacologic pain management
} Up to $50 for products to help with managing pain Community Resource Link
} Online tool to help you find community-based resources in your area that support health and well-being Enhanced benefits Details Transportation Essentials To assist members in accessing community services and supports, and employment opportunities, eligible HHW members may choose one of the following:
} $50 gas card
} $50 rideshare gift card
} Up to $50 in bus passes Smartphone Member Connect Limited to one per household:
} Free monthly minutes
} 4 GB data and text messaging
} One-time bonus of 200 minutes
} 100 minutes in member’s birthday month Some of these enhanced benefits are limited to certain members and may require completing a health screening, annual dental or wellness visit, registration on our secure member portal, or other qualifications. To find out which benefits you may qualify for, visit the Benefit Reward Hub or call Member Services at 866-408-6131 (TTY 711). Benefits may change or end at any time. For complete benefits, see the Services offered by Anthem section in Part 1. Hoosier Healthwise benefit plans There are two Hoosier Healthwise (HHW) benefit plans Anthem provides access to. For information about premiums, please call 800-457-4584 or visit Indiana Medicaid: Members: HHW Package C / MED Works Premium.
- Package A: children and some pregnant members
Package C: children under 19 who don’t qualify for Package A — requires a small monthly premium based on income Ways to good health Follow these easy steps to begin, manage and maintain good health.
} Choose a doctor — Your primary medical provider (PMP) is the first person you call for your healthcare needs.
} Take the Health Needs Screening — It helps us find the right care for you. You can earn up to $30! See the Healthy Rewards Program section for details.
} Schedule a health checkup — Call your PMP’s office to make an appointment within 60 days of joining Anthem. Get annual checkups even if you do not feel sick. This will help you stay in good health.
} Prepare for your doctor visit — Decide what you want to discuss and write it down. Be ready to talk about your health history.
} Keep your member ID card close — Show it every time you need healthcare services.
13 12 Pharmacy services When you need medicine or certain over-the-counter (OTC) items, your doctor writes you a prescription. You can then go to any Anthem plan pharmacy. To find a pharmacy, call 866-408-6131 (TTY 711). Or go to anthem.com/inmedicaid. Healthy Rewards for staying healthy At Anthem, we want you to be as healthy as you can be. Great health starts with preventive care. Preventive care may include any needed exams, screenings, or vaccinations. It’s the care you get when you’re not sick so your doctor can help you before you get sick. Your health is so important, we want to reward you for it. There are many types of care you can get to earn incentives through our Healthy Rewards program. Talk with your doctor about preventive care that’s right for you. We’ll send you texts and emails to let you know which incentives apply to you. The first reward is for completing the Health Needs Screening (HNS) within 90 days of joining Anthem. You can complete the HNS and earn your rewards in one of two ways:
} Online at anthem.com/HNS.
} Or by calling 866-408-6131 (TTY 711). New Anthem members will receive more details about completing the HNS and other healthy activities. Go to anthem.com/AnthemRewards to find out what other rewards you may be able to earn. Healthy Rewards program rules:
} Medicaid must be your primary insurance.
} You must be an eligible Anthem member at the time the reward is used. If there is a lapse in your coverage after earning the reward, you will not be eligible to use the reward.
} Your Healthy Rewards may only be used at participating retailers like Amazon, DoorDash, Marshall’s, and TJ Maxx in Indiana.
} The purchase of alcohol, tobacco, e-cigarettes, firearms, or prescription drugs is not allowed.
} You must have a valid email. How to start earning Healthy Rewards Register by logging in to the Benefit Reward Hub to redeem your Healthy Rewards and view the rewards you are eligible for. You can also access your Healthy Rewards through the “My Health Dashboard” section of Sydney Health, our mobile app. Or, call the Healthy Rewards customer service line at 888-990-8681 (TTY 711). For more information about these programs, contact your care manager or call Member Services at 866-408-6131 (TTY 711). Blue Ticket to Health Anthem has teamed up with the Indianapolis Colts to help members ages 3 and up stay healthy. To take part, call your doctor to set up a wellness checkup. After you complete your checkup, you’ll be entered for a chance to win prizes, including Colts merchandise. Go to anthem.com/blueticket to learn more. It’s important to see the doctor each year for wellness checkups, even when you’re not sick. It helps the doctor find any health problems early. If you need help setting up a wellness checkup, call Member Services. Community Resource Link We provide you access to online resource tools, like the Community Resource Link, to help you find and apply for community and social services in Indiana. Find these services in your area by visiting anthem.com/inmedicaid. Urgent care or emergency room (ER) When you’re sick or hurt, check the list of symptoms to see where you should go for care. If you need help on which to choose, call our 24/7 NurseLine at 866-408-6131 (TTY 711). Urgent care symptoms:
} Cold, flu, sore throat
Part 1 – All about Hoosier Healthwise Hoosier Healthwise (HHW) is Indiana’s Medicaid plan for pregnant members and children. Anthem provides access to two benefit plans for HHW members, including:
- HHW Package A: for children and pregnant members.
HHW Package C: preventive, primary and acute care services for children under 19 years of age who don’t qualify for Package A. 14 15
} Earache
} Vomiting or diarrhea
} Common sprain
} Minor broken bone
} Minor cuts
} Mild asthma/allergic reactions
} Rash without fever ER symptoms:
} Chest pain, difficulty breathing
} Head and eye injuries
} Uncontrolled bleeding, severe cuts
} Bad broken bone, such as a bone that has broken through skin
} Coughing or vomiting blood
} Bleeding during pregnancy
} Baby under eight weeks with fever
} Rash with fever Your primary medical provider Your primary medical provider (PMP) is the first person you should call for your healthcare needs. Your PMP coordinates things like:
} Checkups and vaccines
} Referrals to specialists
} Referrals for tests and services
} Admission to a hospital Keep your healthcare When you enroll in Hoosier Healthwise (HHW), you may be eligible for up to 12 months. After that, you have to renew your benefits every 12 months. This is called redetermination . The state will send you a letter when it’s time to re-enroll. Here’s what happens:
} About 90 days before the end of your 12-month enrollment period, the state will see if you’re still eligible for HHW.
} If the state doesn’t have enough information, they’ll ask you for more information.
} You must complete and return the requested information to stay enrolled in HHW.
For more information about our prenatal programs, call Member Services at 866-408-6131 (TTY 711). 16 17 Pregnancy care As soon as you know you’re pregnant:
} Call Member Services toll free at 866-408-6131 (TTY 711).
} See your doctor for prenatal care — this is the care you get while you’re pregnant. Our staff will make sure your doctor and hospital are in your plan.
} You will remain in your plan for 12 months after the end of your pregnancy . You must tell the Indiana Family and Social Services Administration your pregnancy has ended. Call 800-403-0864 after your baby is born. During this call, you can also apply for coverage for your baby if you have HHW Package C (CHIP). If you have HHW Package A coverage, your baby will automatically be enrolled in health coverage.
} If you need behavioral healthcare, you can go to any Indiana Health Coverage Programs (IHCP) doctor. Prenatal and postpartum programs New Baby, New LifeSM is the Anthem program for all pregnant individuals. It is very important to see your primary medical provider (PMP) or obstetrician or gynecologist (OB-GYN) for care when you are pregnant. This kind of care is called prenatal care. It can help you to have a healthy baby. Prenatal care is important each time you are pregnant. With our program, members have access to health information and may receive incentives for going to their appointments. Our program also helps pregnant individuals with complicated healthcare needs. Nurse care managers work closely with these members to provide:
} Education.
} Emotional support.
} Help in following their doctor’s care plan.
} Information on services and resources in your community. Our nurses also work with doctors and help with other services members may need. The goal is to promote better health for members and delivery of healthy babies. Quality care for you and your baby At Anthem, we want to give you the very best care during your pregnancy. That’s why you will also be part of My Advocate®, which is part of our New Baby, New LifeSM program. My Advocate gives you the information and support you need to stay healthy during your pregnancy. Get to know My Advocate® My Advocate delivers maternal health education by phone, web, and smartphone app that is helpful and fun. If you choose the phone version, you will get to know MaryBeth, My Advocate’s automated personality. MaryBeth will respond to your changing needs as your baby grows and develops. You can count on:
} Education you can use.
} Communication with your care manager based on My Advocate messaging should questions or issues arise.
} An easy communication schedule.
} No cost to you. With My Advocate, your information is kept secure and private. Each time Mary Beth calls, she’ll ask you for your year of birth. Please don’t hesitate to tell her. She needs the information to be sure she’s talking to the right person. Helping you and your baby stay healthy My Advocate® calls give you answers to your questions, plus medical support if you need it. There will be one important health screening contact followed by ongoing educational outreach. All you need to do is listen, learn, and answer a question or two. If you tell us you have a problem, you’ll get a call back from a care manager. My Advocate topics include:
} Pregnancy care.
} Postpartum care.
} Well-child care. When you become pregnant If you think you are pregnant:
} Call your PMP or OB-GYN doctor right away. You do not need a referral from your PMP to see an OB-GYN doctor.
} Call Member Services at 866-408-6131 (TTY 711) if you need help finding an OB-GYN in the Anthem network. When you find out you are pregnant:
} Call Member Services at 866-408-6131 (TTY 711) to let us know you are pregnant.
} Report your pregnancy to the Indiana Family and Social Services Administration at 800-403-0864. Visit our Pregnancy & Women’s Health page at anthem.com/inmedicaid under Health & Wellness Resources for information and resources on how to keep you and your baby healthy. If you would like to receive pregnancy information by mail, please call Member Services at the number on your member ID card.
18 19 You can access education, including:
} Self-care information about your pregnancy.
} Details on My Advocate that tells you about the program and how to enroll and get health information to your phone by automated voice, web, or smartphone app.
} Healthy Rewards program information on how to redeem your incentives for prenatal, postpartum, and well-baby care.
} Education on having a healthy baby, postpartum depression, and caring for your newborn, with helpful resources. While you are pregnant, you need to take good care of your health. You may be able to get healthy food from the Women, Infants, and Children program (WIC). Member Services can give you the phone number for the WIC program close to you. When you are pregnant, you must go to your PMP or OB-GYN at least:
} Every four weeks for the first six months.
} Every two weeks for the seventh and eighth months.
} Every week during the last month. Your PMP or OB-GYN may want you to visit more than this based on your health needs. When you have a new baby When you deliver your baby, you and your baby may stay in the hospital at least:
} 48 hours after a vaginal delivery.
} 72 hours after a Cesarean section (C-section). You may stay in the hospital less time if your PMP or OB-GYN and the baby’s provider see that you and your baby are doing well. If you and your baby leave the hospital early, your PMP or OB-GYN may ask you to have an office or in-home nurse visit within 48 hours. After you have your baby:
} You must call Member Services at 866-408-6131 (TTY 711) as soon as you can. We will need some information.
} You must call the Indiana Family and Social Services Administration at 800-403-0864 to report the birth. After your baby is born, the My Advocate® program will switch from prenatal education to postpartum and well-child education for up to 12 weeks after your delivery. It’s important to set up a visit with your PMP or OB-GYN after you have your baby for a postpartum checkup. You may feel well and think you are healing, but it takes the body at least six weeks to mend after delivery.
} The visit should be done between 7 to 84 days after you deliver.
} If you delivered by C-section or had complications with your pregnancy or delivery, your PMP or OB-GYN may ask you to come back for a one- or two-week checkup. This is not considered a postpartum checkup. You will still need to go back and see your provider within 7 to 84 days after your delivery for your postpartum checkup. It’s also important to schedule a well-baby visit for baby. Your baby’s PMP can provide the best care by working closely with you. For the first years of life, the American Academy of Pediatricians suggests that your baby have a checkup at birth, 3 to 5 days old, and at 1, 2, 4, 6, 9, 12, 15, 18, 24, and 30 months. At these visits, your baby’s doctor will make sure your baby is getting all the care baby needs including well checks, vaccines, and other care suggested by the Bright Futures EPSDT coverage recommendations. Prenatal rewards If you’re pregnant, you could be rewarded for getting the needed prenatal and postpartum care for you and your baby. To learn more, visit anthem.com/AnthemRewards or call Member Services toll free at 866-408-6131 (TTY 711) to receive information on our prenatal rewards. CenteringPregnancy® CenteringPregnancy is a peer support group, offering individuals a place to share their feelings and concerns during their pregnancy. A group facilitator guides the discussion and introduces new points of view.
20 20 Services Anthem covers From preventive care to vision and pharmacy services, we’re here to help you get and stay healthy. Learn more about your benefits and copays below. Benefits Details Copay Doctor care Includes: preventive care, Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program services, including routine dental, wellness visits and lead screening, physical exams, prenatal care, immunizations, specialty care No copay Chiropractic services Package A: up to five visits per year and 50 therapeutic physical medicine treatments per year Package C: up to five visits per year and 14 therapeutic physical medicine treatments in a rolling 12-month period No copay Hospital care Includes: emergency room, inpatient services, outpatient services and surgeries, lab tests and X-rays, post-stabilization services, ambulance rides for emergencies Package C: $10 for ambulance transport Medical supplies Includes: diabetes supplies, durable medical equipment, hearing aids, orthopedic shoes and leg braces, orthotics, and prosthetic devices No copay Therapy services Physical, speech, occupational and respiratory therapy Package C: maximum of 50 visits for each therapy type, per 12-month period No copay Pharmacy Includes:
} Prescription drugs
} OTC drugs with a prescription
} Diabetic supplies
} Specialty drugs (some high-cost drugs
are paid for by FSSA/OptumRx)
Package C: $3 for generic
drugs, $10 for name
brand drugs
21
Baby shower program
Anthem partners with groups, such as WIC, to host baby showers around the state to educate
pregnant individuals about their babies. There, you can learn about the importance of well-baby
visits, how to select a doctor, schedule appointments and more.
Baby and Me Tobacco Free
This smoking-cessation program aims to lower the tobacco use of pregnant members. Those who
follow these four steps will be eligible for rewards, such as $25 diaper vouchers:
- Enroll in the program
- Take prenatal smoking-cessation classes
- Agree to take a monthly breath test
- Stay smoke-free after their baby is born Go to babyandmetobaccofree.org to find out more. Need a ride? Anthem Transportation Services can help you find out what transportation options are available in your area. You may be able to use public transportation, have a pickup and drop-off service, or be eligible for mileage reimbursement.* You need to call at least two business days before your appointments — but you can call as many as 45 days in advance. Riders must follow state and local laws. This includes wearing seat belts and ensuring minor children are properly secured. Adults are responsible for providing the child’s safety seat. Members under the age of 16 must have an accompanying adult with them to be transported to a medical service. Transportation benefits are different for HHW Package A and Package C members. See below for more information, or call Anthem Transportation Services at 844-772-6632 (TTY 888-238-9816) Monday through Friday, 8 a.m. to 8 p.m. Eastern time.
What is post-stabilization? This is the care you get in the ER or hospital after your condition is stable. Your doctor will examine you to make sure you’re well enough to leave. See the Extra Benefits section in the Quick Guide in front of the handbook to learn more about all the extras Anthem offers. 23 22 Benefits Details Copay Behavioral health Services for mental health and substance abuse No copay Smoking cessation Includes:
} One 12-week course of treatment per calendar year
} Prescription and over-the-counter treatment, such as nicotine patches or gum
} Counseling services No copay Skilled nursing facility Package A: up to 30 days per rolling 12-month period Package C: not offered No copay Vision services Package A:
} Exams for members:
— Under 21: One per year
— 21 years and up: One every two years, unless more frequent care is medically necessary.
} Glasses (including frames and lenses) for members:
— Under 21: One pair per year
— 21 years and older: One pair every five years
} Contact lenses, if medically necessary Package C:
} One exam every 12 months
} One pair of glasses per year (including frames and lenses), except when a specific minimum prescription change makes it medically necessary, or if lenses and/or frames are lost, stolen or broken.
} Contact lenses, if medically necessary No copay Podiatry services Package A: one podiatry visit per year. Package C: routine foot care is not offered. No copay Other services Indiana Health Coverage Programs (IHCP) offers some types of care for HHW members. These are called carve-outs. You may get these services from any IHCP-enrolled doctor. Carve-out services include:
} Medicaid Rehabilitation Option (MRO)
} Individualized Education Plan Services
} Individualized Family Services Plan (First Steps)
} 1915i Waiver wrap-around services Benefits Details Copay Nonemergency transportation
} Package A: unlimited trips to Medicaid providers.
} Package C: only covers ambulance services for nonemergencies between medical facilities, when requested by a participating physician. A trip is defined as door-to-door service, mileage reimbursement for member or driver, or bus passes. Additional transportation benefits are available – see Enhanced Benefits section above. Package A: No copay Package C: $10 copay for nonemergent ambulance transportation
Self-referral services You can receive self-referral services from any IHCP provider, even if they aren’t contracted with Anthem with the exception of certain behavioral health services. Self-referral services include:
} Routine dental services
} Chiropractic care
} Diabetes self-care training
} Emergency services
} Urgent care
} Eye and vision care (except surgical services)
} Family planning
} HIV/AIDS care management
} Podiatry services♦
} Immunizations
} Behavioral health/ psychiatric services† Dental benefit summary Good dental health makes a big difference in your overall health. That’s why it’s important for you to keep your dental appointments and use your recommended dental benefits. HHW offers the routine dental care you need to keep you healthy, including:
} Exams
} Cleanings
} X-rays
} Fillings
} Fluoride treatment (age 20 and under)
} Crowns
} Extractions If you get into an accident and hurt your jaw, mouth, face or teeth, you’ll receive dental work and oral surgery for these services:
} Outpatient
} Doctor’s office
} Emergency care
} Urgent care To find out more about your dental benefits, call DentaQuest at 888-291-3762. Services not covered by Anthem include:
} Services that are not medically necessary
} Nursing home (for more than allowed under plan benefits) or long-term care facility services
} Intermediate Care Facility Services (ICF/MR)
} Services under the Home- and Community- based Services (HCBS) waiver
} Psychiatric state hospital or residential treatment
} Services/care you receive in another country
} Acupuncture
} Experimental or investigational treatments
} Cosmetic surgery (this does not apply to reconstructive surgery)
} Alternative medicine
} Surgery or drugs to help you get pregnant
} Vitamins, supplements, and over-the-counter (OTC) medicines not covered through the pharmacy benefit
} Personal attendant nursing
} For any condition, disease, defect, ailment or injury that takes place while working if you have workers’ compensation
} Hospice — members who need hospice services must disenroll from Anthem HHW and enroll in traditional Medicaid Services from doctors who are not in your plan We contract with doctors to provide the care covered by your plan. Call your PMP or Member Services to find out if you need preapproval before seeing a doctor who isn’t in your plan. You can also call us or visit our portal to find a doctor in your plan. You may be able to see this out-of-plan doctor for a self-referral service. See Self-referral services below for more details. Anthem does not pay for costs from out-of-plan doctors in most cases. We can only give preapproval for those who are part of the Indiana Health Care Programs (IHCP), which means they’re part of the state’s plan. There are a few other situations in addition to self-referral care where we will pay for out-of-plan services. These situations include:
} Services for which you had preapproval from your previous health insurer. We will honor those preapprovals (sometimes called authorizations) for at least 90 days after you join our plan.
} If you are pregnant and join our health plan in your third trimester, we will allow you to continue to see your existing providers regardless of their contract status.
} If your PMP leaves our plan, you may continue to see them while we work with you to find a new PMP within our plan. In the unlikely event where we have not contracted with a provider who offers the services you need within 60 miles of your home, we will work with you to find a provider, even if that provider is out-of-plan. If you get a service from a doctor who is not in our plan or the service is not approved, it’ll be considered an out-of-plan service. This doesn’t apply to some self-referral services. 24 What are some good
daily dental tips?To maintain good oral health,
brush twice a day and floss daily.
♦ This is covered for HHW Package A members only.
† Behavioral health providers who aren’t psychiatrists must be contracted with Anthem.
25
Part 2 – Ways to good health Choose your primary medical provider (PMP) Your PMP is the first person you call for all your healthcare needs. He or she will help you at any time, even after hours, and will respect your cultural and religious beliefs. Your PMP will take care of all your healthcare needs by coordinating:
} Checkups and vaccines.
} Requests to get an OK to give you services if needed.
} Referrals to specialists.
} Referrals for tests and services.
} Admission to a hospital. Your PMP can be a/an:
} Family and general practitioner, a doctor who takes care of babies, children and adults.
} Internist, a doctor who takes care of adults.
} Obstetrician/gynecologist (OB-GYN), a doctor who takes care of women only.
} Doctors at clinics such as health departments, federally qualified health centers and rural health clinics.
} Nurse practitioner.
} Pediatrician, a doctor who takes care of members under age 21. To select a doctor, or PMP, you can:
} Look inside Anthem’s provider directory to find and choose a PMP.
} Go to anthem.com/inmedicaid and select Find a Doctor.
} Call Member Services at 866-408-6131 (TTY 711). How do I find out more about PMPs? Our provider directory tells you all about the doctors in your plan, including:
} Names, addresses, phone numbers and office hours.
} Gender.
} Specialties.
} Languages they speak.
} Hospitals they work in.
} If they take new patients.
} Where they are located (using an online map).
} Medical school and residency completion.
} Professional achievements.
} Board certification status. If you need a provider directory or help choosing a doctor who is right for you, call Member Services at 866-408-6131 (TTY 711). Services from doctors who are not in the Anthem plan Call your PMP or Member Services to find out if you need an OK from a doctor who isn’t in your plan. We can only give an OK for doctors that are part of your plan. If you get a service from a doctor that is not in our plan or the service is not approved, it’ll be considered out-of-plan service. This doesn’t apply to some self-referral services. You may be able to see a doctor who is not in our plan for self-referral. Continuity of care We’re here to help new members get continuing care and coordination of medically necessary services when they join Anthem. This means we will help you if you are transitioning between plans, if you are pregnant, or if you are receiving certain services, including behavioral health. If you want to know if continuity of care is for you, call Member Services at 866-408-6131 (TTY 711). Changing from pediatric care to adult care Did you know you can switch doctors when you get older? If you were an adolescent and reached adulthood, you can switch from your current pediatrician (child doctor) to a provider who cares for adults. We’ll be happy to help you choose a provider for adults. We can also help you transfer your medical records. Please call Member Services if you need assistance. Schedule a health checkup Call your PMP’s office to make an appointment for a checkup within 60 days of joining Anthem. Tell them you’re an Anthem member. When you make an appointment with your PMP to get a checkup, your PMP will:
} Get to know you and discuss your health.
} Get your medical history from you.
} Help you understand your medical needs.
} Teach you ways to help make your health better or help you stay healthy.
} Schedule any needed tests and preventive services. 26 27
28 Hoosier HealthWatch — Early and Periodic Screening, Diagnostic and Treatment (EPSDT) For children up to 21 years of age, we offer EPSDT services. You can help keep your child healthy if:
} You take them to their primary medical provider (PMP) for routine checkups and vaccines (shots).
} You take them to the dentist for routine visits. Anthem follows the guidelines from the American Academy of Pediatrics for well-child visits. These steps will help keep your children healthy and strong. This chart shows when children should visit the doctor for a well-child visit. Protect your family from lead poisoning If a child enrolled in Medicaid is at risk for lead exposure, a blood lead level (BLL) screening should be performed between the ages of 9 and 15 months, or as close as reasonably possible to the member’s appointment. Children should have another blood lead test between the ages of 21 and 27 months, or as close as reasonably possible to the member’s appointment. Any child between the ages of 28 and 72 months that does not have a record of any prior blood lead test must have a blood lead test performed as soon as possible. Do you or your family member:
❑Visit or live in a house built before 1978 (such as the home of a relative or babysitter, a daycare center, or a preschool)?
❑Visit or live in a house built before 1978 that is being or will be remodeled?
❑Have a brother, sister or friend who has had lead poisoning?
❑Visit or live in a house that has chipping, peeling, dusting, or chalking paint?
❑Often visit an adult who works with lead (such as pottery, painting, construction or welding)? See the Preventive Health Guidelines on anthem.com/inmedicaid to learn more about your child’s well visits and shots. Are there other times I should visit my PMP? You should visit your doctor once a year for a checkup — even if you don’t feel sick. To help you remember, schedule your checkup in the same month as your birthday each year. 29 Important child wellness visits Track your child’s growth and development. Don’t forget important vision and hearing tests and shots. Check off each child wellness visit when completed. Baby 1 week 1 month 2 months 4 months 6 months 9 months Early childhood 12 months 15 months 18 months 2 years 30 months 3 years 4 years Lead screening 9-15 months 21-27 months Dental visits By baby’s first tooth appearance and no later than 12 months Middle childhood 5 years 6 years 7 years 8 years 9 years 10 years Teen (Adolescent) 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years 20 years 21 years Prepare for your doctor visit
} Decide what you want to talk about and write down your questions or concerns.
} Be prepared to talk about you and your family’s health history.
} Bring a list of any medications you’re taking or bring them with you.
} Check your current medications and make sure you’re taking them correctly.
30 Standing referral Anthem sometimes lets members get what’s called a standing referral. This means if you need special care or ongoing treatment you can keep seeing the same specialist. Your doctor will make this referral. The treatment given by the specialist must be right for your health issue and needs. To learn more about this, call Member Services at 866-408-6131 (TTY 711). Getting a second opinion If you have questions about care your doctor says you need, you may want a second opinion to make sure the treatment plan is right for you. To get a second opinion, talk to your PMP or call Member Services at 866-408-6131 (TTY 711). Indiana Right Choices program If you’re enrolled in this program, we’ll send you a letter to let you know. A team of experts will help you get the right healthcare at the right time in the right place. Your team will be made up of a PMP, a pharmacy, and a care manager. If you have questions about the Right Choices program, call care management at 866-902-1690. Behavioral health services We offer services for mental health, behavior problems and addiction. You don’t need a referral from your primary medical provider to see someone for these services. Anthem customer service can help you find a doctor in your area. We cover:
} Inpatient services in a hospital.
} Partial hospitalization.
} Intensive outpatient program.
} Individual, family, and group therapy.
} Applied behavior analysis.
} Medication services.
} Psychological testing. Substance use disorder and opioid treatment services Anthem covers substance use treatment to include residential treatment. Some services require prior authorization. We also provide full coverage for Opioid Treatment Program (OTP) services including all levels of care and methadone use and disease testing. Prior authorization is not required for OTP services. We contract with all Division of Mental Health and Addiction (DMHA) certified OTP providers across Indiana. Stay well Each person has special needs at every stage of life. We have programs to help you stay healthy and manage illness. These programs are available to all members at no cost. For women
} Well-woman care includes getting exams such as annual checkups, mammograms and cervical cancer screenings.
} Family planning can teach you about healthy pregnancy, preventing pregnancy or preventing sexually transmitted infections (STIs) such as HIV/AIDS. You can get family planning services from your PMP, a clinic, OB-GYN or a certified nurse-midwife.
} Pregnancy and childbirth classes to help you stay healthy while you’re pregnant.
} 24/7 NurseLine provides support for moms-to-be and new mothers who have questions about breastfeeding. Remember these three things for your member ID
- Keep your member ID card with you at all times. Your ID card is very important. It shows you are an Anthem member and have the right to get healthcare.
- Show this ID card every time you need healthcare services. Only you can get healthcare services with your ID card. Don’t let anyone else use your card.
If you lose your card, ask for a replacement card. Log in at anthem.com/inmedicaid. Or you can call 866-408-6131 (TTY 711). Preapproval (an OK from Anthem) Your PMP will need to get an OK from us for some services to make sure they’re offered. This means that both Anthem and your PMP or specialist agree the services are medically necessary. We may ask your doctor why you need special care. Getting an OK will take no more than seven calendar days or, if urgent, no more than three days. We may not OK payment for a service you or your doctor asks for. If so, we’ll send you and your doctor a letter that explains why. The letter will let you know how to appeal our decision if you disagree with it. See the Appeals section in Part 6. If you have questions, you or your doctor may call Member Services at 866-408-6131 (TTY 711). Or write us at: Anthem Blue Cross and Blue Shield P.O. Box 62509 Virginia Beach, VA 23466 Changing your PMP It’s best to keep the same PMP. He or she knows your health needs. If you choose to see a doctor who is not your PMP and you did not get an OK from us first, you may have to pay for the services. If you want to change your PMP, you can quickly do it online at anthem.com/inmedicaid. Log in to access your secure account and change your PMP. If you don’t have a secure account, you can create one at any time by clicking Register now. You’ll need your member ID number located on your ID card. We can also help you change your PMP over the phone by calling Member Services at 866-408-6131 (TTY 711). Specialist care
} Your PMP may send you to a specialist for special care or treatment.
} They will help choose a specialist to give you the care you need. You may not need an OK from us. Your PMP knows when to ask for an OK.
} Your PMP’s office staff can help you. They can set the day and time for the office visit with a specialist.
} Tell your PMP and the specialist as much as you can about your health.
} Any specialist or other provider not in the Anthem health plan must get an OK from us before they can give you care. You may also need a referral from your PMP. 31
Phone: 866-902-1690 Fax: 855-417-1289 (TTY 711) A care manager will respond to a faxed request within three business days. 32 33 Indiana Quitline When you’re ready to quit, just call the Indiana Tobacco Quitline at 800-Quit-NOW or 800-784-8669 for more information. This service is free for all Indiana residents. Call Member Services at 866-408-6131 (TTY 711) to find out more about signing up for the Quitline. If you’re pregnant, you may be able to earn rewards. Condition Care Our Condition Care program helps guide care for our members with chronic health conditions. The program is voluntary, private, and available at no cost to you from the Condition Care Centralized Care Unit (CCCCU) team. Our team of licensed nurses, called CCCCU care managers, will help you understand your condition and help you meet healthcare goals through education, resources, and referrals to providers for care. You can join the program if you have one of these conditions:
} ADHD
} Asthma
} Autism/Pervasive developmental disorder
} Bipolar disorder
} Coronary artery disease (CAD)
} Chronic kidney disease
} Chronic obstructive pulmonary disease (COPD)
} Congestive heart failure (CHF)
} Diabetes
} HIV/AIDS
} Hypertension
} Major depressive disorder – Adult
} Major depressive disorder – Child and Adolescent
} Pregnancy
} Schizophrenia
} Sickle cell disease
} Substance use disorder For you and your child
} Well-child care includes programs to help you keep your child well. You can learn about healthy habits for your child, the need for regular doctor visits and which vaccines your child needs. You can also earn incentives by taking your child to wellness checkups.
} We offer parenting tips to teach you how to care for your child. A 24/7 line for your peace of mind 24/7 NurseLine lets you talk in private with a registered nurse (RN) about your health. Teens can talk to RNs in private about teen issues. Just call our 24/7 NurseLine at 866-408-6131 (TTY 711). Care management Healthcare can be overwhelming, so we’re here to help you stay on top of it. Your care manager will help you:
} Figure out your care plan.
} Answer questions.
} Get you to the services you need.
} Coordinate with your doctors and support system. If you have experienced a critical event or health issue that is complex, we’ll help you learn more about your illness and develop a plan of care through our complex care management program. Access to complex care management We use data to find out which members qualify for our complex care management program. You can be referred to complex care management through our:
} Medical management program referral.
} Discharge planner referral.
} Member or caregiver referral.
} Practitioner referral.
} 24/7 NurseLine.
If you have one of these health issues or another complex or special health issue and want to learn
more about care management, call care management at 866-902-1690.
Educational materials
You can find Preventive Health Guidelines, an information sheet with helpful ways to stay healthy,
on our website at anthem.com/inmedicaid. We also offer information on specific health-related
topics, the importance of preventive care, and how to navigate the healthcare system on our blog at
anthem.com/inmedicaid Member Materials.
Providers, nurses, social workers and members
or their representatives may refer you to care
management in one of two ways:
35 34 Our care managers can also assist with weight management and smoking cessation services. As a member in the Condition Care program, you’ll benefit from having a care manager who:
} Listens to you and takes the time to understand your specific needs.
} Helps you make a care plan to reach your healthcare goals.
} Gives you the tools, support and community resources that can help you improve your quality of life.
} Provides health information that can help you make better choices.
} Helps you coordinate care with your providers. How to join We’ll send you a letter welcoming you to a Condition Care program, if you qualify. Or, call us toll free at 888-830-4300 (TTY 711) from 8:30 a.m. to 5:30 p.m. Eastern time Monday through Friday. When you call, we’ll:
} Set you up with a care manager to get started.
} Ask you some questions about your health.
} Start working together to create your plan. You can also email us at dmself-referral@anthem.com. Please be aware that emails sent over the internet are usually safe, but there is some risk third parties may access (or get) these emails without you knowing. By sending your information in an email, you acknowledge (or understand) third parties may access these emails without you knowing. You can also visit our website at anthem.com/inmedicaid and select Manage Your Condition under the Health & Wellness Resources tab, or call the CCCCU if you would like a copy of CCCCU information you find online. You are encouraged to follow healthcare advice offered by Anthem and give Anthem information needed to carry out our services. You can choose to opt-out (we’ll take you out of the program) of the program at any time. Please call us toll free at 888-830-4300 (TTY 711) from 8:30 a.m. to 5:30 p.m. Eastern time Monday through Friday to opt out (leave the program) and let your doctor know. You may also call this number to leave a private message for your care manager 24 hours a day. Healthy Families program Healthy Families is a six-month program for ages 7-17, designed to assist families in obtaining a healthier lifestyle. This program provides families with fitness and healthy behavior coaching, written nutrition information, and online and community resources. For additional information or to enroll in the Healthy Families program, call us at 844-421-5661. Autism Family Supports program Anthem and the Indiana Easterseals are proud to offer the Autism Family Supports program for members with moderate-to-severe autism spectrum disorder (ASD). We coordinate care with the member’s PMP, physical and behavioral specialists, as well as schools and social services to fully support the member. The Autism Family Supports program helps members with:
} Care planning.
} Developmental skills.
} Health promotion activities.
} Condition Care programs.
} Transition support 34 35 Autism spectrum disorders program Families touched by autism can speak with counselors from our autism spectrum disorders (ASD) program. We offer a support system to help families understand about the care that’s available. Our goal is to help children with ASD live a healthier life with their families.
37 36 Substance use disorder program Anthem’s substance use disorder (SUD) program helps members with major substance use disorder improve their overall health. Our care managers work with you to identify long-term goals, helping you attain a healthier lifestyle. Human immunodeficiency virus (HIV) rewards program For those with HIV, it’s important to continue taking your medication to help lower levels of the virus in the body. It also allows you to live longer and reduces the spread of the virus. To support our members in this population, we’re offering rewards to those who continue taking their medications and having regular lab tests. You can earn $20 per quarter for up to two quarters per year — a $40 maximum yearly reward. Depending on your condition, you may be enrolled in our HIV management program. If you have HIV and a substance use disorder, you’ll be referred to our substance treatment services. For those with a greater need, we’ll help coordinate care for you. WebMD’s Personal Health Record We’ve partnered with WebMD Health Services to provide WebMD’s Personal Health Record (PHR). WebMD’s PHR will serve as a bank of your health information, using Anthem’s clinical data and health information you add. By giving you the information you need in one place, you’ll be able to make better decisions about your benefits, treatment and doctors in your plan. Urgent or emergency care? Which one do I choose? Go to the Quick Guide and check the Urgent care or emergency room (ER) section for a list of symptoms. 37 36 Sick or hurt? Where do you go? After-hours care An urgent medical condition is not an emergency but needs medical care within 24 hours. It’s not the same as a true emergency. Call your PMP if your condition is urgent, and you need medical help within 24 hours. If you can’t reach your PMP, call 24/7 NurseLine, even on holidays, at 866-408-6131 (TTY 711). Urgent care If you have an injury that could turn into an emergency if not treated within 24 hours, you need urgent care. Call your PMP or 24/7 NurseLine at 866-408-6131 (TTY 711) if you have questions. Emergency care An emergency is a medical condition with such severe symptoms that you reasonably believe not getting medical attention right away may be life threatening or cause serious damage to you or your unborn child. If you have an emergency, call 911 or go to the nearest ER. Call your PMP within 24 hours after you go to the ER or if you’ve checked into the hospital. Your PMP will set up a visit with you for follow-up care. Getting emergency care outside our service area If you need emergency care while you’re traveling outside of our service area, follow these steps to help make sure you get the help you need:
} Call your PMP or have the hospital call your PMP if you need surgery or admission to the hospital, or any other services after you’re stable.
} Show your ID card to the hospital or doctor.
} HHW does not cover services provided outside the U.S.
39 38 Pharmacy benefits for HHW members include:
} Prescription drugs.
} Over-the-counter (OTC) items approved by the Food and Drug Administration (FDA) and listed on the OTC medication list.
} Self-injectable drugs (includes insulin).
} Needles, syringes, blood sugar monitors, test strips, lancets and glucose urine testing strips.
} Drugs to help you quit smoking. These prescription drugs are not offered:
} Over-the-counter (OTC) medicines (unless specified on formulary or PDL list)
} Drugs used to become pregnant
} Experimental or investigational drugs
} Drugs for cosmetic reasons
} Drugs for weight loss
} Drugs for hair growth
} Drugs to treat erectile dysfunction Generic drugs Generic drugs are as good as brand-name drugs. Your pharmacist will give you generic drugs when your doctor has approved them. Here are a few things you need to know:
} Generic drugs must be given when there is one available.
} Brand-name drugs may be given if there is not a generic drug for it.
} The PDL will tell you the exceptions to these rules.
} Generic and preferred drugs must be used for your condition unless your doctor gives a medical reason to use a different drug. Pharmacy copays
} Package C: $3 for generic drugs, $10 for name brand drugs If you have questions, call the Member Services at 866-408-6131, Monday through Friday from 8 a.m. to 8 p.m. Eastern time. Part 3 – Pharmacy services Filling your prescriptions
} Your doctor will write you a prescription for medicine you may need.
} Your doctor will then contact your pharmacy, or you can go there with your prescription. Anthem works with CarelonRx to manage your pharmacy benefits.
} You must use a pharmacy that takes Anthem. This may include mail-order pharmacies. You can find Anthem pharmacies in our provider directory or by calling Member Services at 866-408-6131.
} Your pharmacy benefits have a Preferred Drug List (PDL). The PDL shows some of the drugs offered under the pharmacy benefit. Find the complete PDL list at anthem.com/inmedicaid. 38 39
41 40 41 40 To ask for a review, you must send a letter to the Indiana Family and Social Services Administration within 120 calendar days of receiving our decision about your denial. Send your letter to: Office of Administrative Law Proceedings 402 W. Washington St., Room E034 Indianapolis, IN 46204 A judge will hear your case and send you a letter with the decision within 90 business days after the date that you first asked for the hearing. Preapproval for drugs Some drugs need a preapproval, or an OK, ahead of time. Your doctor must ask for an OK if:
} A drug is listed as nonpreferred on the PDL.
} Certain conditions need to be met before you get the drug.
} You’re getting more of a drug than what is normally expected
} There are other drugs that should be tried first. If a preapproval is needed, your doctor will need to give us details about your health. We will then decide whether Indiana Health Coverage Programs (IHCP) can pay for the drug. This is important because:
} You may need tests or help with a drug.
} You may be able to take a different drug. See your ID card for the phone number for preapproval requests. IHCP or Anthem will decide within 24 hours after getting your request (not including Sundays or some holidays) if your drug request can be approved. Your doctor will be notified. Other things you need to know about your medication
} Days’ supply of drugs You may receive up to a 30-day supply of a drug.
} Early refills Your pharmacist will have to ask for an OK ahead of time if you want to get your prescription refilled early. Do not wait until you’re out of a drug to ask for a refill. Please call your doctor or pharmacy a few days before you run out of your drug.
} Emergency safety programs Through Emergency Safety Communications, we alert you and your doctors about significant safety-related drug recalls or market withdrawals.
} Member medication support To support members who’ve recently visited the emergency room, we send surveys to gather information about your experience and reasons for the visit. If your visit was related to a medication issue, we’ll send a letter about the medications and how to appropriately take them. Appeal rights If your drug request is denied, you or your provider can appeal this decision. If you exhaust your appeals, then you may ask for a Medicaid hearing and appeals review if IHCP or Anthem:
} Denied you a service.
} Reduced a service.
} Ended a service that was approved before.
} Failed to give you timely service.
43 42 Call Member Services at least 72 hours in advance if you need an interpreter or translator at your PMP’s office. Help for members with hearing or vision loss Call our toll-free Member Services line at 866-408-6131 (TTY 711), Monday through Friday from 8 a.m. to 8 p.m., Eastern time. If you need help between 8 p.m. and 8 a.m. or on weekends, call Relay Indiana at 800-743-3333 (TTY 711). Americans with Disabilities Act We meet the terms of the Americans with Disabilities Act (ADA) of 1990. This act protects you from discrimination by us because of a disability. If you believe you have been treated differently because of a disability, please call Member Services toll free at 866-408-6131 (TTY 711). Special note to our Native American members Thank you for choosing Hoosier Healthwise (HHW). You have a choice to receive traditional Medicaid benefits instead of HHW. You can call the Hoosier Healthwise Enrollment Broker at 800-889-9949 for questions about changing your health plan. It won’t cost anything to change, and you may receive more benefits from traditional Medicaid than from HHW. Native American Anthem members can receive services from an Indian healthcare provider if eligible. American Indian healthcare providers include providers operated by:
} Indian Health Service (IHS)
} Tribal Organization
} Urban Indian Organization
} An Indian Tribe Also, if an Indian healthcare provider is in the Anthem plan, you can choose that provider as your PMP. Part 4 – Help with special services Help in another language We offer no-cost services and programs that meet many language and cultural needs and help give you access to quality care. We use an interpreter service that works with more than 200 languages. We offer:
} Health education materials translated into different languages and other formats such as braille, large print, or audio CD.
} Member Services staff able to speak other languages.
} 24-hour access to telephone interpreters.
} Sign language and face-to-face interpreters.
} Doctors who speak other languages.
} Translation or oral interpreter (over the phone or face-to-face) for you while you’re at your primary medical provider’s (PMP’s) office. When did the ADA become law? The Americans with Disabilities Act (ADA) was signed into law on July 26, 1990, by President George H.W. Bush. The 25th anniversary of the ADA was celebrated in 2015. 43 42
45 44 45 44 Part 5 – Know your rights and other helpful information Member rights You and your provider can receive a copy of your Member Rights and Responsibilities by mail, fax or email, or on our website at anthem.com/inmedicaid. As a member of this health plan, you have the right to:
} Receive information about Anthem, the services we provide, doctors and facilities in your plan and your rights and responsibilities. You will also be notified by phone call or mail if benefits, services, or service delivery sites change or end. You can find information about Anthem on our website at anthem.com/inmedicaid. You can also call Member Services at 866-408-6131 (TTY 711).
} Get information about Anthem’s structure and operation.
} Be treated with respect and with due consideration for your dignity and privacy.
} Receive information on available treatment options and alternatives, presented in a way that is right for your condition and that you can understand.
} Know that the date you joined Anthem is the date your benefits begin, and Anthem will not cover services you received before that date.
} Choose a primary medical provider (PMP) who is part of the network and change your PMP without cause or reason.
} Know if your doctor takes part in a physician incentive plan through Anthem. Call us to learn more about this.
} Take part in all decisions about your healthcare. This includes the right to refuse treatment.
} Know which hospitals you should use and have access to them.
} Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation, as specified in federal laws on the use of restraints and seclusions.
} Request and receive a copy of your medical records. And you may request they be amended or corrected, as stated in state and federal healthcare privacy laws.
} Have timely access to covered services and medically necessary care.
} Have honest talks with your doctors about the right treatment for your condition, in spite of the cost.
} Find out how Anthem decides if new technology or treatments should be part of a benefit.
} Have your health plan, doctors and all of your care providers keep your medical records and health insurance information private.
} Have your problems taken care of quickly. This includes things you think are wrong, as well as issues that have to do with your benefits, payment of services or receiving an OK from us.
} Have access to medical advice from your doctor, either in person or by phone, 24 hours a day, seven days a week. This includes emergency or urgent care.
} Obtain interpreter services at no charge if you speak a language other than English or if you have hearing, vision, or speech loss.
} Voice complaints or appeals about Anthem, the Plan, or the care that we provide to you.
} Ask for information and other Anthem materials (letters, newsletters) in other formats. These include Braille, large-size print, or audio CD, at no charge to you. Call Member Services at 866-408-6131 (TTY 711).
} Tell us what you would like to change about your health plan, including the member rights and responsibilities policy.
} Question a decision we make about the care you got from your doctor. You will not be treated differently if you file a complaint.
} Know that Anthem can make changes to your health plan benefits as long as we tell you about them in writing before the changes take effect.
} Know that Anthem does not take the place of workers’ compensation insurance.
} Ask about our quality program and tell us if you would like to see changes made.
} Ask us how we do utilization reviews and give us ideas on how to change them.
} Know you will not be held liable if your health plan becomes insolvent (bankrupt and cannot pay its bills).
} Make an advance directive (also called a “living will”).
} Know that Anthem, your doctors, or your other healthcare providers cannot treat you differently for these reasons:
— Your age
— Your sex or gender identity
— Your sexual orientation
— Your race
— Your national origin
— Your language needs
— The degree of your illness, health condition, or disability
47 46 47 46
} Protect your life.
} Keep you from getting seriously ill or disabled.
} Reduce severe pain through the diagnosis or treatment of disease, illness, or injury. New medical treatments We want you to benefit from new treatments, so we review them on a routine basis. A group of PMPs, specialists and medical directors decide if a treatment:
} Is approved by the government.
} Has shown in a reliable study how it affects patients.
} Will help patients as much as, or more than, treatments we use now.
} Will improve the patient’s health. The review group looks at all of the details. The group decides if the treatment is medically necessary. If your doctor asks us about a treatment the review group has not looked at yet, the reviewers will learn about the treatment. They’ll let your doctor know if the treatment is medically necessary and if we approve it. Choosing a new health plan HHW members may change to a different health plan for any reason during the first 90 days of membership. Native American/Alaska Native members may choose to not use managed care and change to State fee-for-service benefits. If you have questions about changing your health plan, call the Hoosier Healthwise Enrollment Broker at 800-889-9949. You can also change health plans for “just cause” at any time if:
} You have exhausted Anthem’s internal grievance process due to receiving poor quality of care or if there are other instances that are determined to be poor quality of care.
} We can’t provide covered services.
} We fail to comply with certain medical standards and practices.
} There’s a lack of access to providers experienced in dealing with your healthcare needs.
} There are language or cultural barriers.
} You have limited access to primary care clinics or other health services near you.
} Another managed care entity (MCE) has a list of drugs that’s better for your healthcare needs.
} You don’t have access to medically necessary services offered by Anthem.
} A service is not covered by us for moral or religious reasons.
} You need a group of related services at the same time and not all related services are available in our health plan, and your provider says getting the services separately will be a risk to you.
} Your PMP leaves Anthem and re-enrolls with another MCE.
} Other circumstances determined by the Office of Medicaid Policy and Planning or its designee to constitute poor quality of healthcare benefits. If you have a question about changing your health plan or want to get the MCE change form, call the Hoosier Healthwise Enrollment Broker at 800-889-9949. Member responsibilities As a member of this health plan, you have the responsibility to:
} Tell us, your doctor, and your other healthcare providers what they need to know to treat you.
} Understand your health problems, and take part in developing shared treatment goals, to the best degree possible.
} Follow the treatment plans (and instructions for care) you, your doctors and your other healthcare providers agree to.
} Do the things that keep you from getting sick.
} Treat your doctor and other healthcare providers with respect.
} Make appointments with your doctor when needed.
} Keep all scheduled appointments and be on time.
} Call your doctor if you cannot make it to your appointment.
} Always call your PMP first for all of your medical care (unless you have an emergency).
} Show your ID card each time you receive medical care.
} Use the emergency room only for true emergencies.
} Pay any required copays.
} Tell Anthem and the Division of Family Resources (800-403-0864) if:
— You move.
— You change your phone number.
— You have any changes to your insurance.
— Your income changes.
— The number of people in your household changes.
— You become pregnant. Making benefit decisions At Anthem, we care about you and want to help you get the healthcare you need. We do not give incentives for service denials, and we only make decisions based on appropriateness of care and available benefits. Your doctors and other health providers work with you to decide what’s best for you and your health. Your doctor may ask us for our OK to pay for certain healthcare services. We base our decision on two things:
} Whether or not the care is medically necessary.*
} What healthcare benefits you have. We do not pay or reward doctors or other healthcare workers to:
} Deny you care.
} Say you do not have benefits.
} Approve less care than you need. *Medically necessary means Anthem will pay for services needed to:
49 48 49 48 Living will (advance directive) A living will or advance directive is a legal document that describes how you want to be treated if you cannot talk or make decisions for yourself. You can name someone else as the person who will make decisions about your healthcare if you’re unable. You may also want to list the types of care you do or do not want to get. For example, some people do not want to be put on life-support machines if they go into a coma. Your PMP will make sure your living will is in your medical records. You may change or revoke your living will at any time by telling your PMP or other healthcare provider. You may file a complaint with the state survey and certification agency if you believe your doctor is not meeting the terms of your living will. Ask your family, PMP or someone you trust to help you. The forms you need are at office supply stores or a lawyer’s office. Quality improvement You deserve high-quality medical and behavioral healthcare. Anthem’s Quality Improvement program reviews the services you get from Anthem doctors, hospitals, and other healthcare services. This ensures you receive care that is of good quality, helpful and right for you. Your health is important to us, and we believe quality work yields quality results. We make information about our quality improvement program available every year on our website and in writing to members upon request and we work hard to make sure you have access to great care. We do this by:
} Having programs and services to help improve your quality of healthcare.
} Providing learning tools on pregnancy and newborn care for all pregnant members and new moms.
} Finding programs in your community that help you get services if you need them.
} Hosting learning events to answer your questions and concerns and help you make the most of your healthcare.
} Following state and federal guidelines.
} Looking at our quality results to find new ways for better care. Want to know more about our Quality Management program? Would you like to know how it works and how we’re doing? Call Anthem at 866-408-6131 (TTY 711). Ask us to mail you Quality Management program information. We can also tell you more about the ways Anthem makes sure you get quality healthcare services. If you have other insurance Call us at 866-408-6131 (TTY 711) if you or your children have other health benefits. This helps us work with your other insurance company to correctly pay claims. Also call us if you:
} Have a workers’ compensation claim.
} Are waiting for a decision on a personal injury or medical malpractice lawsuit.
} Have a car accident.
} Become eligible for Medicare. In some cases, Anthem may have the right to get back payments they made for you if another insurance company made payments for your healthcare. Let us know right away if you were hurt in an accident or if another company made payments for your healthcare. You’ll need to let us know information about what happened. Call the Subrogation department at 866-891-7397 (TTY 711). What to do if you get a bill from a provider In most cases, you should not get a bill from a provider. But you may have to pay charges if:
} You agreed in writing ahead of time to pay for care that is not offered by Anthem after you asked for an OK from us.
} You agreed ahead of time in writing to pay for care from a provider who does not work with us, and you did not get our OK ahead of time. If you get a bill and you do not think you should have to pay for the charges, call Member Services at 866-408-6131 (TTY 711). Have the bill with you when you call and tell us:
} The date of service.
} The amount being charged.
} Why you’re being billed. Privacy policies Anthem has the right to get information from those who give you care. We use this information so we can pay for and manage your healthcare. We keep this information private between you, your healthcare provider and Anthem, except as the law allows. Refer to the Notice of Privacy Practices at the end of this member handbook to read about your right to privacy. Your medical records Federal and state laws allow you to see your medical records. Ask your PMP for your records first. If you have a problem getting your medical records from your doctor, call Member Services at 866-408-6131 (TTY 711).
51 50 51 You can review the quality and cost of care, as well. This can help you make the best decisions about your care. Visit these sites online to help you find out more:
} The Leapfrog Group — leapfroggroup.org
} Hospital Compare — hospitalcompare.hhs.gov
} Hospital Inpatient Quality Reporting Program — cms.gov/medicare/quality-initiatives-patient- assessment-instruments/hospitalqualityinits/hospitalrhqdapu.html
} Physician Quality Information — Indiana Health Information Exchange, found at ihie.org Your opinion is important to us. You’ll receive a member satisfaction survey each year. If we helped you, please tell us in the survey. Your answers are anonymous. This information is used to improve our services and your care. You can also be part of our Community Health Advisory Network to Gain Equity (CHANGE) Committee by calling Member Services at 866-408-6131 (TTY 711). As part of this group, you can tell us your views and ideas to help us understand what our members need. It will also help us to find out how we can improve the quality and cost of healthcare. Reporting member or provider fraud and abuse First line of defense against fraud We are committed to protecting the integrity of our healthcare program and the effectiveness of our operations by preventing, detecting, and investigating fraud, waste and abuse. Combating fraud, waste and abuse begins with knowledge and awareness.
} Fraud - Any type of intentional deception or misrepresentation made with the knowledge that the deception could result in some unauthorized benefit to the person committing it—or any other person. The attempt itself is fraud, regardless of whether or not it is successful.
} Waste - Includes overusing services, or other practices that, directly or indirectly, result in unnecessary costs. Waste is generally not considered to be driven by intentional actions, but rather occurs when resources are misused.
} Abuse - When healthcare providers or suppliers do not follow good medical practices resulting in unnecessary or excessive costs, incorrect payment, misuse of codes, or services that are not medically necessary. Learn more at fighthealthcarefraud.com. Presentation of a member identification (ID) card does not guarantee eligibility; providers should verify a member’s status by inquiring online or via telephone. Online support is available for provider inquiries on the website, and telephonically. Members should protect their ID cards as they would a credit card, carry their health benefits card at all times, and report any lost or stolen cards to the company as soon as possible. Members should check their explanation of benefits (EOBs) for any errors and then contact member services if something is incorrect. Reporting fraud, waste and abuse If you suspect a provider (e.g., provider group, hospital, doctor, dentist, counselor, medical supply company, etc.) or any member (a person who receives benefits) has committed fraud, waste, or abuse, you have the right to report it. No individual who reports violations or suspected fraud and abuse will 50 be retaliated against for doing so. The name of the person and their information, if supplied, who reports the incident is kept in strict confidence by the Special Investigations Unit (SIU). You can report your concerns by:
} Visiting our fighthealthcarefraud.com education site; at the top of the page, click “Report it” and complete the “Report Waste, Fraud and Abuse” form.
} Calling the SIU fraud hotline at 866-847-8247.
} Calling Member Services at 866-408-6131 (TTY 711).
} Mail a letter to the SIU with your allegation of possible fraud, waste, or abuse to: Special Investigations Unit 740 W. Peachtree St. NW Atlanta, GA 30308 Any incident of fraud, waste or abuse may be reported to us anonymously; however, our ability to investigate an anonymously reported matter may be handicapped without enough information. Hence, we encourage you to give as much information as possible. We appreciate your time in referring suspected fraud, but be advised that we do not routinely update individuals who make referrals as it may potentially compromise an investigation. Examples of provider fraud, waste, and abuse (FWA):
} Altering medical records to misrepresent actual services provided
} Billing for services not provided
} Billing for medically unnecessary tests or procedures
} Billing professional services performed by untrained or unqualified personnel
} Misrepresentation of diagnosis or services
} Overutilization
} Soliciting, offering, or receiving kickbacks or bribes
} Unbundling – when multiple procedure codes are billed individually for a group of procedures which should be covered by a single comprehensive procedure code
} Upcoding – when a provider bills a health insurance payer using a procedure code for a more expensive service than was actually performed When reporting concerns involving a provider (a doctor, dentist, counselor, medical supply company, etc.), include:
} Name, address, and phone number of provider.
} Name and address of the facility (hospital, nursing home, home health agency, etc.).
} Medicaid number of the provider and facility, if you have it.
} Type of provider (doctor, dentist, therapist, pharmacist, etc.).
} Names and phone numbers of other witnesses who can help in the investigation.
} Dates of events.
} Summary of what happened. Examples of member fraud, waste, and abuse:
53 52 53 Part 6 – How to resolve a problem with Anthem We care about the quality of care you get from us and your doctors. If you have a concern, call Member Services at 866-408-6131 (TTY 711), Monday through Friday, 8 a.m. to 8 p.m. Eastern time. Here are some things we can help you with:
} Finding a doctor
} Finding care and treatment
} Issues about how we run the health plan
} Any aspect of your care You will not be treated differently because you call us with a problem or complaint. If you have a question If you’re not happy with the care you get from one of the doctors in your plan, please let us know. You, or someone you choose to act for you, can let us know your problem:
} Use the Chat feature in Sydney Health, our mobile app.
} Log in to your online account through our secure portal at anthem.com/inmedicaid.
} Call us at 866-408-6131 (TTY 711).
} Send us a letter at: Anthem Blue Cross and Blue Shield P.O. Box 62429 Virginia Beach, VA 23466 52 If we can no longer serve you We can’t keep you as a member of the health plan if you:
} Lose your eligibility.
} Are disenrolled from (no longer a member of) the HHW program.
} Move out of Indiana.
} Were signed up in error.
} Become eligible for Medicare. You can leave HHW at any time. If you want to continue with your health benefits, but disenroll from Anthem, there are certain rules. (See section called Choosing a new health plan in Part 5.)
} Forging, altering, or selling prescriptions
} Letting someone else use the member’s ID (identification) card
} Relocating to out-of-service plan area and not notifying us
} Using someone else’s ID card When reporting concerns involving a member, include:
} The member’s name.
} The member’s date of birth, member ID, or case number if you have it.
} The city where the member resides.
} Specific details describing the fraud, waste, or abuse. If a member appears to have committed fraud, waste, or abuse or has failed to correct issues, the member may be involuntarily disenrolled from our healthcare plan, with state approval.
55 54 Our Member Services staff will try to take care of your problem right away. They may have to send the information to the right staff person for a final answer. You may choose not to be named when you tell us, or send us information about, your problem. Grievances A grievance can be filed with us over the phone or in writing. You need to file your grievance within 60 calendar days from the date the problem took place. If you have questions or concerns about your care, try to talk to your doctor first. Then if you still have questions or concerns, call us. If you need help filing your grievance, one of our associates can help you. If you do not speak English, we can get an interpreter for you. You have three ways to file a grievance with us:
- Call Member Services at 866-408-6131 (TTY 711).
- Complete a grievance form found on anthem.com/inmedicaid.
Write us a letter to tell us about the problem. These are the things you need to tell us as clearly as you can:
} Who is involved in the grievance
} What happened
} When did it happen
} Where did it happen
} Why you’re not happy Send your completed form or letter, along with any documents, to: Grievance Coordinator Anthem Blue Cross and Blue Shield P.O. Box 62429 Virginia Beach, VA 23466 54 55 If we can’t make a decision about your grievance within 30 calendar days, we can ask the state agency to give us extra time (up to 14 calendar days). If we do this, we’ll send a letter to tell you why we need more time. Expedited (rush) grievance Members must request an expedited grievance by fax or calling Member Services. Please contact us in one of these ways: Member Services: 866-408-6131 (TTY 711) | Fax: 855-516-1083 If you think waiting 30 calendar days may harm your health, we may be able to give you an answer within 48 hours. This is called an expedited (faster) grievance. In your request, tell us why you think waiting 30 calendar days would harm your health. We’ll make a decision and try to call you within 48 hours from the time we get your grievance. We also will send you a letter within five business days after making our decision. If we don’t think waiting 30 calendar days will harm your health, we’ll send you a letter within two calendar days to let you know we’ll complete your grievance as quickly as we can within 30 calendar days. We’ll also try to call you to tell you what we decide. Appeals If you want to file an appeal about how we solved your problem, an appeal can be requested within 60 calendar days of the date of the grievance resolution letter or service denial letter. Send your appeal to: Appeals Department P.O. Box 62429 Virginia Beach, VA 23466 We’ll send you an acknowledgment letter within three business days after we get your appeal. The letter will tell you we got your appeal request. You can also ask for an appeal by calling Member Services at 866-408-6131 (TTY 711). We’ll make a decision about your appeal within 30 calendar days after we get it. If we cannot decide within 30 calendar days, we can ask the state agency to give us more time (up to 14 calendar days). If we do this, we’ll send you a letter to tell you why we need more time. You may keep your benefits while you’re waiting for your appeal if:
} You asked for the appeal within 10 days of receiving the adverse notice from Anthem;
} Your request involves the termination, suspension, or reduction of a previously authorized course of treatment;
} The services were ordered by an authorized provider;
} The original period covered by the original authorization has not expired;
} And you request an extension of benefits. You may have to pay for the care you get while you wait for an answer about the appeal if the final decision is not what you wanted. What if my problem has to do with a denial of my benefits? You need to file an appeal instead of a grievance. Learn how to file an appeal. The information is located in this section.
57 56 Expedited (rush) external independent review You may ask us to rush your external independent review (EIR) if your health needs it. Members must request an expedited external independent review by fax only. Please fax to 855-516-1083. We’ll take care of your request as fast as we can, but no more than 72 hours from the time we get your appeal. We’ll send you a letter within 24 hours after we make a decision. State Fair Hearing and appeal process If you do not agree with what we decide after completing our appeal process, you can ask for a State Fair Hearing and appeal review. You may ask for this review if we:
} Said no to paying for a service you wanted.
} Said OK to a service, but then we put limits on it.
} Ended payment for a service that we said OK to before.
} Did not give you access to a service fast enough. To ask for a review, you must send a letter to FSSA within 120 calendar days of getting our decision about your appeal. Send your request to: Office of Administrative Law Proceedings 402 W. Washington St., Room E034 Indianapolis, IN 46204 Steps to take if you’re unhappy: A judge will hear your case and send you a letter with the decision within 90 business days of the date that you first asked for a hearing. If you do not agree with the judge’s decision, you can ask for an agency review. You must file for this review within 10 business days after you get your notice of the judge’s decision. You’ll get a written notice of action from the agency review. If the hearing decision was reversed or changed, a letter will give the reasons. If you’re not happy with what the agency decides, you may file for a judicial review. Once your appeal is resolved, we’ll send you a letter to tell you about the decision explaining:
} How to file an external independent review request and/or request a State Fair Hearing.
} Ways to get a faster review.
} Your right to keep your benefits during the review.
} That you may have to pay for care you get while you wait for the decision. Expedited (rush) appeal Members must request an expedited appeal by fax or calling Member Services. Please contact us in one of these ways: Member Services: 866-408-6131 (TTY 711) | Fax: 855-516-1083 You may ask us to rush your appeal if you think waiting 30 calendar days may harm your health. Our Appeals Nurse will let you know we got your appeal within 24 hours from the time we received it. We will send you a letter with our decision within 48 hours. If the Appeals Nurse says no to your request for a rush appeal, we’ll call and send you a letter with the reason for the denial of the expedited request within two calendar days. External independent review If you do not agree with Anthem’s appeal decision, you have the right to request an external independent review (EIR) and/or State Fair Hearing. An EIR does not replace your right to appeal a decision to a State Fair Hearing. This process provides a neutral review of benefit decisions made by Anthem. The EIR is used to resolve appeals if we said no to paying for a service:
} You or your doctor asked for.
} That has to do with your medical needs.
} You asked for that has not been proven to work. A written request must be filed for this process. This must be filed within 120 calendar days for Hoosier Healthwise from the date we told you that your appeal had been denied. Within three business days after we get your request, we’ll send you a letter to say we got it. EIRs are resolved within 15 business days from the date of request. We’ll send you a letter with the answer within 72 hours of Anthem receiving the EIR’s decision. The letter will explain:
} Your right to ask for a State Fair Hearing.
} How to ask for a hearing.
} Your right to keep your benefits until the hearing is over.
} That you may have to pay the costs for services that you’re waiting for if the decision is not what you asked for at the start. 57 56 Appeal Judicial review Agency review State Fair Hearings/ appeals review 57
59 58 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION WITH REGARD TO YOUR HEALTH BENEFITS. PLEASE REVIEW IT CAREFULLY. 59 HIPAA notice of privacy practices The original effective date of this notice was April 14, 2003. This notice was most recently revised in June 2022. Please read this notice carefully. This tells you who can see your protected health information (PHI). It tells you when we have to ask for your OK before we share it. It tells you when we can share it without your OK. It also tells you what rights you have to see and change your information. Information about your health and money is private. The law says we must keep this kind of information, called PHI, safe for our members. That means if you’re a member right now or if you used to be, your information is safe. We get information about you from state agencies for Medicaid and the Children’s Health Insurance Program after you become eligible and sign up for our health plan. We also get it from your doctors, clinics, labs, and hospitals so we can OK and pay for your healthcare. Federal law says we must tell you what the law says we have to do to protect PHI that’s told to us, in writing, or saved on a computer. We also have to tell you how we keep it safe. To protect PHI:
} On paper (called physical), we:
— Lock our offices and files
— Destroy papers with health information so others can’t get it
} Saved on a computer (called technical), we:
— Use passwords so only the right people can get in
— Use special programs to watch our systems
} Used or shared by people who work for us, doctors, or the state, we:
— Make rules for keeping information safe (called policies and procedures)
— Teach people who work for us to follow the rules When is it OK for us to use and share your PHI? We can share your PHI with your family or a person you choose who helps with or pays for your healthcare if you tell us it’s OK. Sometimes, we can use and share it without your OK:
} For your medical care
— To help doctors, hospitals, and others get you the care you need
} For payment, healthcare operations, and treatment
— To share information with the doctors, clinics, and others who bill us for your care
— When we say we’ll pay for healthcare or services before you get them
— To find ways to make our programs better, and to support you and help you get available benefits and services. We may get your PHI from public sources, and we may give your PHI to health information exchanges for payment, healthcare operations, and treatment. If you don’t want this, please visit anthem.com/inmedicaid for more information.
} For healthcare business reasons
— To help with audits, fraud and abuse prevention programs, planning, and everyday work
— To find ways to make our programs better
} For public health reasons
— To help public health officials keep people from getting sick or hurt
} With others who help with or pay for your care
— With your family or a person you choose who helps with or pays for your healthcare, if you tell us it’s OK
— With someone who helps with or pays for your healthcare, if you can’t speak for yourself and it’s best for you We must get your OK in writing before we use or share your PHI for all but your care, payment, everyday business, research, or other things listed below. We have to get your written OK before we share psychotherapy notes from your doctor about you. You may tell us in writing that you want to take back your written OK. We can’t take back what we used or shared when we had your OK. But we will stop using or sharing your PHI in the future. Other ways we can — or the law says we have to — use your PHI:
} To help the police and other people who make sure others follow laws
} To report abuse and neglect
} To help the court when we’re asked
} To answer legal documents
} To give information to health oversight agencies for things like audits or exams
} To help coroners, medical examiners, or funeral directors find out your name and cause of death
} To help when you’ve asked to give your body parts to science
} For research
} To keep you or others from getting sick or badly hurt 58
61 60 What if you have questions? If you have questions about our privacy rules or want to use your rights, please call Member Services toll-free at 866-408-6131 (Hoosier Healthwise, Healthy Indiana Plan); 844-284-1797 (Hoosier Care Connect). If you’re deaf or hard of hearing, call TTY 711. To see more information To read more information about how we collect and use your information, your privacy rights, and details about other state and federal privacy laws, please visit our Privacy webpage at https://www.anthem.com/privacy. What if you have a complaint? We’re here to help. If you feel your PHI hasn’t been kept safe, you may call Member Services or contact the Department of Health and Human Services. Nothing bad will happen to you if you complain. Write to or call the Department of Health and Human Services: Office for Civil Rights U.S. Department of Health and Human Services 233 N. Michigan Ave., Suite 240 Chicago, IL 60601 Phone: 800-368-1019 TDD: 800-537-7697 Fax: 312-886-1807 We reserve the right to change this Health Insurance Portability and Accountability Act (HIPAA) notice and the ways we keep your PHI safe. If that happens, we’ll tell you about the changes in a newsletter. We’ll also post them on the web at anthem.com/inmedicaid. Race, ethnicity, language, sexual orientation, and gender identity We get race, ethnicity, language, sexual orientation, and gender identity information about you from the state Medicaid agency and the Children’s Health Insurance Program. We protect this information as described in this notice. We use this information to:
} Make sure you get the care you need.
} Create programs to improve health outcomes.
} Create and send health education information.
} Let doctors know about your language needs.
} Provide interpretation and translation services. We do not use this information to:
} Issue health insurance.
} Decide how much to charge for services.
} Determine benefits.
} Share with unapproved users. 60
} To help people who work for the government with certain jobs
} To give information to workers’ compensation if you get sick or hurt at work What are your rights?
} You can ask to look at your PHI and get a copy of it. We will have 30 days to send it to you. If we need more time, we have to let you know. We don’t have your whole medical record, though. If you want a copy of your whole medical record, ask your doctor or health clinic.
} You can ask us to change the medical record we have for you if you think something is wrong or missing. We will have 60 days to send it to you. If we need more time, we have to let you know.
} Sometimes, you can ask us not to share your PHI. But we don’t have to agree to your request.
} You can ask us to send PHI to a different address than the one we have for you, or in some other way. We can do this if sending it to the address we have for you may put you in danger.
} You can ask us to tell you all the times over the past six years we’ve shared your PHI with someone else. This won’t list the times we’ve shared it because of healthcare, payment, everyday healthcare business, or some other reasons we didn’t list here. We will have 60 days to send it to you. If we need more time, we have to let you know.
} You can ask for a paper copy of this notice at any time, even if you asked for this one by email.
} If you pay the whole bill for a service, you can ask your doctor not to share the information about that service with us. What do we have to do?
} The law says we must keep your PHI private, except as we’ve said in this notice.
} We must tell you what the law says we have to do about privacy.
} We must do what we say we’ll do in this notice.
} We must send your PHI to some other address, or in a way other than regular mail if you ask for reasons that make sense, like if you’re in danger.
} We must tell you if we have to share your PHI after you’ve asked us not to.
} If state laws say we have to do more than what we’ve said here, we’ll follow those laws.
} We have to let you know if we think your PHI has been breached. Contacting you We, along with our affiliates and/or vendors, may call or text you using an automatic telephone dialing system and/or an artificial voice. We only do this in line with the Telephone Consumer Protection Act (TCPA). The calls may be to let you know about treatment options or other health-related benefits and services. If you do not want to be reached by phone, just let the caller know, and we won’t contact you in this way anymore. Or you may call 844-203-3796 to add your phone number to our Do Not Call list. 61
63 62 62 Your personal information We may ask for, use, and share personal information (PI) as we talked about in this notice. Your PI is not public and tells us who you are. It’s often taken for insurance reasons.
} We may use your PI to make decisions about your:
— Health
— Habits
— Hobbies
} We may get PI about you from other people or groups like:
— Doctors
— Hospitals
— Other insurance companies
} We may share PI with people or groups outside of our company without your OK in some cases.
} We’ll let you know before we do anything where we have to give you a chance to say no.
} We’ll tell you how to let us know if you don’t want us to use or share your PI.
} You have the right to see and change your PI.
} We make sure your PI is kept safe. To get this handbook in other languages or alternate formats, such as Braille, large print or audio CD, call Member Services toll-free at 866-408-6131 (Hoosier Healthwise, Healthy Indiana Plan); 844-284-1797 (Hoosier Care Connect); TTY 711 Monday through Friday from 8 a.m. to 8 p.m. Eastern time. anthem.com/inmedicaid Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc., independent licensee of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
Do you need help with your health care, talking with us or
reading what we send you? We provide our materials in other
languages and formats at no cost to you. Call us toll free at
1-866-408-6131 (Hoosier Healthwise, Healthy Indiana Plan);
1-844-284-1797 (Hoosier Care Connect); TTY 711.
¿Necesita ayuda para con su cuidado de la salud, para hablar con nosotros
o leer lo que le enviamos? Proporcionamos nuestros materiales en otros
idiomas y formatos sin costo alguno para usted. Llámenos a la línea gratuita
al 1-866-408-6131 (Hoosier Healthwise, Healthy Indiana Plan);
1-844-284-1797 (Hoosier Care Connect); TTY 711.
Spanish
ﻫﻞ ﺗﺤﺘﺎج إﻟﻰ ﻣﺴﺎﻋﺪة ﻓﻴﻤﺎ ﻳﺘﻌﻠﻖ ﺑﺮﻋﺎﻳﺘﻚ اﻟﺼﺤﻴﺔ أو ﻓﻲ اﻟﺘﺤﺪث ﻣﻌﻨﺎ أو ﻗﺮاءة ﻣﺎ ﻧﺮﺳﻠﻪ
ﻟﻚ؟ ﻧﻮﻓﺮ اﻟﻤﻮاد اﻟﺨﺎﺻﺔ ﺑﻨﺎ ﺑﻠﻐﺎت وﺗﻨﺴﻴﻘﺎت أﺧﺮى ﻣﺠﺎﻧًﺎ. اﺗﺼﻞ ﺑﻨﺎ ﻋﻠﻰ اﻟﺮﻗﻢ اﻟﻤﺠﺎﻧﻲ
1-866-408-6131
)
Hoosier Healthwise, Healthy Indiana Plan
(؛ 1-844-284-1797
) Hoosier Care Connect (؛ اﻟﻬﺎﺗﻒ اﻟﻨﺼﻲ 711
TTY .
Arabic
သင့္က်န္းမာေရး ေစာင့္ေရွာက္မႈ၊ ကြၽႏ္ုပ္တုိ႔ႏွင့္ ေျပာဆုိမႈ သုိ႔မဟုတ္
ကြၽႏ္ုပ္တုိ႔ သင့္ထံ ေပးပုိ႔သည္ကုိ ဖတ္ရႈမႈအတြက္ အကူအညီ လုိအပ္ပါသလား။
ကြၽႏ္ုပ္တုိ႔၏ စာရြက္စာတမ္းမ်ားိ အျခားဘာသာစကားမ်ားႏွင့္ ပံုစံမ်ားျဖင့္ အခမဲ့
ရရွိႏုိင္ပါသည္။ ဖုန္းေခၚခ အခမဲ့ျဖစ္ေသာ
1-866-408-6131 (Hoosier Healthwise, Healthy Indiana Plan)၊ 1-844-284-1797
(Hoosier Care Connect)၊ TTY 711 သုိ႔ ဖုန္းေခၚဆုိပါ။
Burmese
您在醫療保健方面、與我們交流或閱讀我們寄送的材料時是否需要幫助？
我們免費為您提供用其他語言和格式製作的資料。致電我們的免費電話
1-866-408-6131 (Hoosier Healthwise, Healthy Indiana Plan)；
1-844-284-1797 (Hoosier Care Connect)；聽力障礙電傳 TTY 711。
Chinese
Hebt u hulp nodig bij uw gezondheidszorg, wil u met ons praten of lezen wat
we naar u sturen? We bieden onze literatuur gratis aan u aan in andere talen
en formaten. Bel ons gratis op 1-866-408-6131 (Hoosier Healthwise, Healthy
Indiana Plan); 1-844-284-1797 (Hoosier Care Connect); TTY 711.
Dutch
Avez-vous besoin d'aide pour vos soins de santé, pour parler avec nous ou
pour lire ce que nous vous envoyons? Nous vous offrons notre matériel dans
d'autres langues et formats, sans frais pour vous. Appelez-nous sans frais à
1-866-408-6131 (Hoosier Healthwise, Healthy Indiana Plan); 1-844-284-1797
(Hoosier Care Connect); TTY 711.
French
65
64
Brauchen Sie etwas Hilfestellung mit Ihrer Gesundheitsfürsorge, wenn Sie
mit uns reden oder lesen, was wir Ihnen senden? Wir stellen unsere
Materialien kostenfrei in anderen Sprachen und Formaten bereit. Rufen Sie
uns gebührenfrei unter den folgenden Rufnummern an: 1-866-408-6131
(Hoosier Healthwise, Healthy Indiana Plan); 1-844-284-1797 (Hoosier Care
Connect); TTY 711.
German
—या आपको अपनी €वा€›य देखभाल, हमारे साथ बात करने या हम जो आपको भेजते हÎ उसे पढ़ने
मÓ सहायता कÔ जरत है? हम अÚय भाषाÙ एवं ˜ाप¯ मÓ आपके िलए िब˙कुल मु¸त अपनी
सामि˝य¯ को ˜दान करते हÎ।हमÓ टोल !Ô नंबर 1-866-408-6131 (Hoosier Healthwise,
Healthy Indiana Plan); 1-844-284-1797 (Hoosier Care Connect); TTY 711 पर
फोन करÓ.
Hindi
お客様のヘルスケアについて、お問い合わせの際やお手元に届く資料に関
し、サポートが必要ですか？資料は他言語にて、また読みやすい文字の書式
を無料にて提供しております。詳しくはフリー ダイヤル 、1-866-408-6131
(Hoosier Healthwise、Healthy Indiana Plan); 1-844-284-1797 (Hoosier Care
Connect); TTY 711までお問い合わせください。
Japanese
건강 관리에 도움이 필요하십니까? 아니면 저희와 연락하시거나, 보내드린
자료를 읽는 데 도움이 필요하십니까? 자료를 다른 언어 및 형식으로 무료로
제공해드립니다. 저희에게 1-866-408-6131 (Hoosier Healthwise, Healthy
Indiana Plan); 1-844-284-1797 (Hoosier Care Connect); TTY 711 번으로
연락해 주십시오.
Korean
Brauchscht du Helfe mit dei Health Care, schwetze mit uns odder lese was
mir dir schicke? Mir kenne unsere Materials in annere Schprooche un
Formats mitaus Koscht gewwe. Ruf uns mitaus Koscht uff: 1-866-408-6131
(Hoosier Healthwise, Healthy Indiana Plan); 1-844-284-1797 (Hoosier Care
Connect); TTY 711.
Pennsylvania
Dutch
ﺗﮩﺎﻧﻮں اﭘﻨﯽ ﻧﮕﮩﺪاﺷﺖِ ﺻﺤﺖ، ﺳﺎڈے ﻧﺎل ﮔﻞ ﺑﺎت ﮐﺮن ﯾﺎ ﺟﻮ اﺳﯽ ﺑﮭﯿﺠﻨﮯ آں
اُوﻧﮩﻮں ﭘﮍﮬﻦ وچ ﻣﺪد دی ﻟﻮڑ اے؟ اﺳﯽ ﺗﮩﺎﻧﻮں اﭘﻨﮯ اﻣﻮاد ﮨﻮر زﺑﺎﻧﺎں ﺗﮯ ﻓﺎرﻣﯿﭩﺲ
وچ ﻣُﻔﺖ ﻓﺮاﮨﻢ ﮐﺮدے آں۔ﺳﺎﻧﻮں اﯾﻨﺎں ﭨﺎل ﻓﺮی ﻧﻤﺒﺮاں ﺗﮯ ﻣُﻔﺖ ﮐﺎل ﮐﺮو
1-866-408-6131 (Hoosier Healthwise, Healthy Indiana Plan);
1-844-284-1797 (Hoosier Care Connect); TTY 711.
Punjabi
Вы нуждаетесь в помощи при получении медицинского обслуживания,
во время общения с нами или с прочтением того, что мы вам посылаем?
Мы предоставляем бесплатно наши материалы на других языках и в
иных форматах. Позвоните нам бесплатно по телефону 1-866-408-6131
(программа Hoosier Healthwise, программа Healthy Indiana Plan);
1-844-284-1797 (программа Hoosier Care Connect); TTY 711.
Russian
Kailangan mo ba ng tulong sa iyong pangangalagang pangkalusugan,
pakikipag-usap sa amin o pagbasa sa ipinapadala namin sa iyo? Ibinibigay
ang aming mga materyal sa ibang mga wika at format nang wala kang
babayaran. Tawagan kami nang libre sa 1-866-408-6131 (Hoosier
Healthwise, Healthy Indiana Plan); 1-844-284-1797 (Hoosier Care Connect);
TTY 711.
Tagalog
Quý vị có cần giúp đỡ về dịch vụ chăm sóc sức khỏe của quý vị thông qua
việc trao đổi với chúng tôi hoặc đọc những tài liệu mà chúng tôi gửi cho quý
vị hay không? Chúng tôi cung cấp cho quý vị các tài liệu bằng các ngôn ngữ
và định dạng khác miễn phí. Hãy gọi chúng tôi theo số điện thoại miễn cước
1-866-408-6131 (Hoosier Healthwise, Healthy Indiana Plan);
1-844-284-1797 (Hoosier Care Connect); TTY 711.
Vietnamese
67 66 Notes Anthem Blue Cross and Blue Shield follows federal civil rights laws. We don’t discriminate against people because of their:
} Race
} Color
} National origin
} Age
} Disability
} Sex or gender identity That means we won’t exclude you or treat you differently because of these things. Communicating with you is important For people with disabilities or who speak a language other than English, we offer these services at no cost to you:
} Qualified sign language interpreters
} Written materials in large print, audio, electronic and other formats
} Help from qualified interpreters in the language you speak
} Written materials in the language you speak To get these services, call the Member Services number on your ID card. Or you can call our Grievance Coordinator at 866-408-6131 (TTY 711). Your rights Do you feel you didn’t get these services or we discriminated against you for reasons listed above? If so, you can file a grievance (complaint). File by mail, email, fax or phone: Grievance Coordinator Anthem Blue Cross and Blue Shield P.O. Box 62429, Virginia Beach, VA 23466 Phone: 866-408-6131 (TTY 711) Need help filing? Call our Grievance Coordinator at the number above. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights: On the Web: ocrportal.hhs.gov/ocr/portal/lobby.jsf By mail: U.S. Department of Health and Human Services 200 Independence Ave. SW Room 509F, HHH Building Washington, DC 20201 By phone: 800-368-1019 (TTY/TDD 800-537-7697) For a complaint form, visit hhs.gov/ocr/office/file/index.html. To get this handbook in other languages or alternate formats, such as Braille, large print or audio CD, call Member Services at 866-408-6131 (TTY 711) Monday through Friday, 8 a.m. to 8 p.m. Eastern time. You can learn more on our website at anthem.com/inmedicaid. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc., independent licensee of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
Walk through this policy with us
Review how this policy can be converted into cited criteria, prior authorization checks, and operational automation.