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Member Handbook

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Member Handbook Table of Contents WELCOME ..................................................................................................................... 5 What is the Heritage Health program? ........................................................................ 5 HHA Medically Frail ..................................................................................................... 6 Who is Nebraska Total Care? ..................................................................................... 7 About Your Member Handbook ................................................................................... 7 Other Formats and Languages ................................................................................... 8 Translations and Interpreter Services ......................................................................... 8 IMPORTANT CONTACTS ............................................................................................ 13 Your Personal Contacts ............................................................................................ 13 Contacting Nebraska Total Care ............................................................................... 13 Member Services Can Help ...................................................................................... 14 HOW YOUR HEALTH PLAN WORKS ......................................................................... 15 Your Member ID Card ............................................................................................... 15 24/7 Nurse Advice Line ............................................................................................. 17 Nebraska Total Care Website ................................................................................... 17 Secure Member Portal .............................................................................................. 18 YOUR COVERED BENEFITS ...................................................................................... 19 Excluded Services ..................................................................................................... 23 Native American Access to Care ............................................................................... 23 GETTING CARE ........................................................................................................... 24 Medically Necessary Services ................................................................................... 24 Provider Network ....................................................................................................... 24 Finding New Treatments to Better Care for You ....................................................... 25 Prior Authorization for Services ................................................................................. 26 Prior Authorization for Drugs ..................................................................................... 27 Second Medical Opinion ........................................................................................... 27 Getting Care Out of State .......................................................................................... 27 Urgent Care After Hours ............................................................................................ 28 Emergency Care ....................................................................................................... 29 YOUR PRIMARY CARE PROVIDER ............................................................................ 31 Making Appointments and Getting Care.................................................................... 31 Your Provider Directory ............................................................................................. 31 Choosing a Primary Care Provider (PCP) ................................................................. 32 Visit Your PCP .......................................................................................................... 33 Well-Child CheckUps ................................................................................................ 36 © 2017 Nebraska Total Care, rev. 1/2021 2 Member Services: 1-844-385-2192 NebraskaTotalCare.com Nebraska Relay Service 711 Monday to Friday, 7 a.m. to 8 p.m., Central PHARMACY SERVICES .............................................................................................. 38 Covered Prescriptions ............................................................................................... 38 Non-Covered Prescriptions ....................................................................................... 38 Preferred Drug List (PDL) .......................................................................................... 39 Medicaid Drug Formulary .......................................................................................... 39 Generic Drugs ........................................................................................................... 39 Over-the-Counter (OTC) Drugs ................................................................................. 40 Medication Therapy Management Program .............................................................. 40 Copays ...................................................................................................................... 40 SPECIALTY SERVICES ............................................................................................... 42 Mental Illness and Substance Use ............................................................................ 42 Outpatient Services ................................................................................................... 44 Vision Services .......................................................................................................... 45 Home Health ............................................................................................................. 45 Family Planning Services .......................................................................................... 46 Children with Disabilities ........................................................................................... 46 Transportation ........................................................................................................... 47 ACCESS TO CARE ...................................................................................................... 49 Continuity and Transition for New Members ............................................................. 49 Appointment Waiting Times ...................................................................................... 50 What to Do if You Get a Bill ....................................................................................... 51 HELP FOR YOUR HEALTH ......................................................................................... 52 Health Risk Screening ............................................................................................... 52 Rewards Program ..................................................................................................... 52 Pregnancy and Maternity Services ............................................................................ 54 MyNTC Mobile App ................................................................................................... 56 Community Health Services ...................................................................................... 57 Care Management .................................................................................................... 57 GED Testing Materials .............................................................................................. 60 ConnectionsPLUS® ................................................................................................... 60 Smoking Cessation ................................................................................................... 60 CAP Sessions for Behavioral Health ......................................................................... 61 Sports Physicals ........................................................................................................ 61 Weight Watchers ....................................................................................................... 61 YMCA Memberships ................................................................................................. 62 Boys and Girls Club .................................................................................................. 62 Community Gardens ................................................................................................. 62 ELIGIBILITY INFORMATION ....................................................................................... 63 © 2017 Nebraska Total Care, rev. 1/2021 3 Member Services: 1-844-385-2192 NebraskaTotalCare.com Nebraska Relay Service 711 Monday to Friday, 7 a.m. to 8 p.m., Central General Eligibility ...................................................................................................... 63 Major Life Changes ................................................................................................... 63 Other Insurance ........................................................................................................ 64 Open Enrollment ....................................................................................................... 65 Newborn Enrollment .................................................................................................. 65 Disenrollment ...........................................................................................................
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