Empowering Your Health Care 2021 Medallion Member Handbook VirginiaPremier.com Virginia Premier | Call Member Services at 1-800-727-7536 (TTY/TDD: 711), weekdays 8 am to 8 pm Page | 1 Medicaid Managed Care Member Handbook Effective July 1, 2021 Commonwealth of Virginia Department of Medical Assistance Services Virginia Premier | Call Member Services at 1-800-727-7536 (TTY/TDD: 711),DMAS_1019 weekdays-MHB 8 am-500030 to 8 pm Approved Page | 2 Table of Contents Help in Other Languages or Alternate Formats in Other ........................................................ 9 1. Medicaid Managed Care Plan .......................................................................................... 11 Welcome to Virginia Premier ............................................................................................................................................ 11 How to Use This Handbook ............................................................................................................................................... 11 Your Welcome Packet and Member ID Card .................................................................................................................... 12 Virginia Premier Elite Individual .................................................................................................................................... 12 Virginia Premier Elite Family (FAMIS) ........................................................................................................................... 12 Virginia Premier Elite Individual (Medicaid Expansion) ................................................................................................ 12 Provider and Pharmacy Directory ..................................................................................................................................... 13 What Is Virginia Premier’s Service Area? .......................................................................................................................... 13 List of Covered Drugs ........................................................................................................................................................ 15 List of Covered and Non-Covered Services ....................................................................................................................... 15 Information About Eligibility ............................................................................................................................................. 16 Getting Help Right Away ................................................................................................................................................... 16 Virginia Premier’s Member Services ............................................................................................................................. 16 How to Contact Virginia Premier Member Services ..................................................................................................... 16 How Virginia Premier’s Member Services Representatives Can Help You: ...................................................................... 17 How to Contact a Virginia Premier Care Manager ............................................................................................................ 17 Care Management Services .......................................................................................................................................... 17 Who can participate in care management? .................................................................................................................. 17 What does the program include? ................................................................................................................................. 17 How do I get more information? .................................................................................................................................. 18 Medical Advice Line Available 24 Hours A Day, 7 Days A Week ....................................................................................... 18 Behavioral Health Crisis Line ............................................................................................................................................. 19 2. How Managed Care Works .............................................................................................. 20 What Makes You Eligible to be a Member? ...................................................................................................................... 20 What Makes You NOT Eligible To Be A Member? ............................................................................................................ 20 Third Party Liability ........................................................................................................................................................... 21 Comprehensive Health Coverage.................................................................................................................................. 21 Enrollment......................................................................................................................................................................... 21 Health Plan Assignment .................................................................................................................................................... 22 Changing Your Health Plan ................................................................................................................................................ 22 Automatic Re-Enrollment ................................................................................................................................................. 22 Virginia Premier | Call Member Services at 1-800-727-7536 (TTY/TDD: 711), weekdays 8 am to 8 pm Page | 3 What Are the Advantages of Choosing Virginia Premier? ............................................................................................ 22 What is a Health Risk Assessment? ................................................................................................................................... 23 Transition of Care Period .................................................................................................................................................. 23 What If I Have Other Coverage? ....................................................................................................................................... 23 3. How to Get Regular Care and Services ............................................................................. 23 How to Get Care From A Primary Care Provider (PCP) ..................................................................................................... 24 Provider and Pharmacy Directory ..................................................................................................................................... 24 Choosing Your PCP ............................................................................................................................................................ 24 You can choose to see an Indian Health Care Provider if: ................................................................................................ 24 If Your Current PCP Is Not in Virginia Premier’s Network ................................................................................................. 25 How to Get Care From Other Network Providers ............................................................................................................. 25 Changing Your PCP ............................................................................................................................................................ 25 Getting an Appointment with Your PCP ........................................................................................................................... 25 Appointment Standards .................................................................................................................................................... 25 Travel Time and Distance Standards ................................................................................................................................. 26 Member Travel Time & Distance Standards ................................................................................................................. 26 Accessibility ....................................................................................................................................................................... 26 What If A Provider Leaves Virginia Premier’s Network?................................................................................................... 27 What Types of People and Places Are Network Providers? ............................................................................................. 28 What Are Network Pharmacies? ....................................................................................................................................... 28 4. How to Get Specialty Care and Services ........................................................................... 28 What are Specialists? ........................................................................................................................................................ 28 How Do I Access A Network Specialist? ...........................................................................................................................