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North Dakota Medicaid Expansion Program Member Handbook Welcome

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North Dakota Medicaid Expansion Program Member Handbook Welcome North Dakota Medicaid Expansion Program Member Handbook Welcome This is your guide to your health insurance benefits, please read it carefully. This book includes important information about covered services, finding a provider, when and how to get pre-approvals for care, how to access care, resources, tips and much more. Help understanding this document is free. If you would like it in a different format (for example, in a larger font size or using a screen reader), please call us at (855) 305-5060 (toll-free) | TTY/TDD: (877) 652-1844 (toll-free). Help in a language other than English is also free. Please call (800) 892-0675 (toll-free) to connect with us using free translation services. 2 What’s included in this member handbook Section 1: How do I Contact Sanford Health Plan? ....................................................................... 5 Section 2: Special Communication Needs .................................................................................... 6 Services for the deaf and hearing impaired ............................................................................ 6 Services for visually impaired ................................................................................................. 6 Section 3: Is There Help if I Speak Another Language? .............................................................. 7 Section 4: What are My Benefits? .............................................................................................. 10 What your plan covers and your costs ...................................................................................10 How can I get a ride? ..............................................................................................................14 Do I always have a copay? ......................................................................................................14 Section 5: Are There Times When Sanford Health Plan Will Not Pay for Care? ......................... 15 What is not paid for by this plan? ............................................................................................15 Section 6: What if I Have Other Health Insurance Coverage? ..................................................... 16 Section 7: How Do I Get Care? .................................................................................................... 17 What is a primary care provider (PCP)? .................................................................................17 What providers are in the Sanford Health Plan Medicaid Expansion Network? ...................17 What if my provider leaves the network? ...............................................................................18 What if I need to see a specialist? ..........................................................................................18 Do I always need a referral for Out-of-Network care? ..........................................................18 How can I get treatment for a mental health and/or substance use disorder? ....................19 Can I go to other health systems (Mayo Clinic, University of Minnesota)? ............................20 What if I see an out-of-network provider? .............................................................................20 What if I travel outside the Sanford Health Plan service area? .............................................20 How can I get more information about my provider? ............................................................20 Section 8: When do I Need to get Prior Approval for Care? ....................................................... 21 How much time does it take to get prior approval? ...............................................................22 Section 9: What do I do if I am Unhappy With a Decision or Service? ......................................... 23 Complaint process ................................................................................................................. 23 Internal appeal process ..........................................................................................................24 External appeal process .........................................................................................................25 Section 10: Nondiscrimination Policy ........................................................................................ 26 Section 11: What Does my ID Card Look Like? ........................................................................... 27 3 Section 12: How do I Read my Explanation of Benefits (EOB)? ................................................... 28 Section 13: How do I get Care After Hours? ............................................................................... 29 What if I need care right away? ............................................................................................. 29 What do I do in an emergency? ............................................................................................. 29 What if I am hospitalized? .......................................................................................................30 Section 14: What Drugs are Covered on the Plan? ..................................................................... 30 Section 15: How does Sanford Health Plan Help Take Care of me? ............................................ 31 Can I get extra help when I am sick? .....................................................................................31 What if I have a chronic health condition? ..............................................................................31 What if I want to talk to a nurse? ............................................................................................31 I’d like to quit smoking. Can you help? ...................................................................................32 What if I’m pregnant?..............................................................................................................32 Benefits for members ages 19 and 20 ...................................................................................32 Let your wishes be known: Complete a Health Care Advance Directive .............................. 33 What is a Durable Power of Attorney for Health Care? ........................................................ 33 What is a Living Will? ............................................................................................................. 33 Conscientious objections ....................................................................................................... 34 Quality Improvement Program .............................................................................................. 34 HEDIS®/CAHPS® .....................................................................................................................35 New technology ......................................................................................................................35 Section 16: Member Rights and Responsibilities ....................................................................... 36 You have the right to ...............................................................................................................36 You have the responsibility to .................................................................................................37 Section 17: If You Misuse Your Benefits ..................................................................................... 39 Fraud .....................................................................................................................................39 Coordinated Services Program (CSP) ....................................................................................39 Section 18: Confidentiality and Disclosure of Personal Health Information .............................. 41 Notice of privacy practices .....................................................................................................41 Protection of oral, written and electronic information across the organization .................. 44 Privacy complaints ................................................................................................................ 45 4 Section 1: How do I Contact Sanford Health Plan? Customer Service is available whenever you have a question or concerns about benefits or services. Business hours are Monday through Friday from 8 a.m. to 5 p.m., Central Time. If you need free help in a language other than English, call (800) 892-0675. Department Questions about… Phone number Benefits, claims, how to find a Customer Toll-free: (855) 305-5060 provider, file a complaint or order Service TTY/TDD: (877) 652-1844 another ID card Medical Getting approval from the Plan Toll-free: (855) 276-7214 Management for health care services TTY/TDD: (877) 652-1844 Care/Case Case management services and help Toll-free: (888) 315-0884 Management with care coordination TTY/TDD: (877) 652-1844 Rides to You must call us at least 2 Toll-free: (800) 236-4907 Doctor Visits days before you need a ride TTY/TDD: (877) 652-1844 (Transportation) Translation Free help in a language Toll-free: (800) 892-0675 Services other than English Appeals and Filing an appeal, find out about Toll-free: (877) 652-8544 Denial your appeal or complaint status TTY/TDD: (877) 652-1844 Website sanfordhealthplan.com Member Portal sanfordhealthplan.com/memberlogin Create your account today: Step 1 Step 4 Agree to the terms and conditions Go paperless! Elect to receive Step 2 your Explanation of Benefits (EOBs)
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