1 2 WELCOME TO CHIP, BROUGHT TO YOU BY HIGHMARK BLUE SHIELD Thank you for choosing CHIP, brought to you by Highmark Blue Shield. Please take a few minutes to review the information in this handbook. It can help you take full advantage of the valuable health care benefits PLEASE PAY YOUR PREMIUM ON you have selected for your child. TIME Our CHIP Enrollment and Eligibility Unit The state of Pennsylvania requires that, if you fail to pay Administers your child’s CHIP coverage. Please your premium for Low-Cost or Full-Cost CHIP as required by applicable insurance laws, your child will lose CHIP call the toll-free Member Service number, coverage. 1-800-345-3806, Monday through Friday, If you have any questions about this requirement, from 8:30 a.m. to 4:30 p.m., if you please call 1-800-345-3806. have questions about your child’s coverage or want information on how to access the program’s benefits. Hearing-impaired members may call toll-free TTY 1-877-323-8480. 3 TABLE OF CONTENTS OSTEOPOROSIS SCREENING (Bone Mineral WELCOME TO CHIP, BROUGHT TO YOU BY Density Testing, or BMDT) .............................. 36 HIGHMARK BLUE SHIELD ........................ 3 HABILITATIVE SERVICES ............................... 37 TABLE OF CONTENTS ........................... 4 HOME HEALTH CARE SERVICES ................ 37 UNDERSTANDING HEALTH COVERAGE PRESCRIPTION DRUG BENEFITS ................. 37 DIABETICS: FREE BLOOD GLUCOSE TERMS ........................................................ 7 MONITORS ......................................................... 39 YOUR CHILD’S CHIP HEALTH CARE CARING PROGRAM ........................................... 40 COVERAGE ............................................. 10 CLINICAL TRIALS ........................................... 40 THE IDENTIFICATION CARD ................ 15 LEAD AWARENESS AND YOUR CHILD . 42 YOUR CHILD’S ACCESS TO CARE ..............15 HOW LEAD AFFECTS YOUR CHILD’S CHOOSING PROVIDERS ......................... 16 HEALTH .............................................................. 42 HIGHMARK BLUE SHIELD PREMIER UNDERSTANDING CHIP GUIDELINES ... 45 BLUE SHIELD AND HIGHMARK BLUE APPLYING FOR NEW COVERAGE ............... 45 SHIELD FOR COVERED SERVICES ........16 ELIGIBILITY REQUIREMENTS ....................... 45 NETWORK CARE ..............................................16 PRE-EXISTING CONDITIONS ........................ 45 OUT-OF-NETWORK CARE ................................18 RENEWING COVERAGE ................................... 45 OUT-OF-AREA CARE .........................................19 CHANGES IN ELIGIBILITY............................ 46 INTER-PLAN ARRANGEMENTS ......................20 TRANSFERS ........................................................ 46 CHOOSING A PRIMARY CARE CHANGES IN YOUR ADDRESS .................... 46 PROVIDER .........................................................22 IMPARTIAL REVIEWS OF ELIGIBILITY HOW TO OBTAIN INFORMATION DETERMINATIONS .......................................... 46 REGARDING YOUR PCP .................................23 ENDING CHIP COVERAGE ............................ 47 NETWORK FOR PRESCRIPTION DRUG PAYING FOR CHIP COVERAGE ............. 48 COVERAGE ........................................................23 UNITED CONCORDIA COMPANIES, INC. PAYMENT DUE DATES ................................... 48 PAYMENT OPTIONS ........................................ 48 (UCCI) FOR DENTAL CARE* ..........................24 LATE PAYMENTS ............................................. 48 DAVIS VISION, INC. FOR VISION CARE** ....24 PREMIUM INCREASES ...................................... 48 SUMMARY OF BENEFITS ..................... 25 RECEIVING A BILL FOR SERVICES ........... 49 PREVENTIVE CARE ...........................................31 TO OBTAIN A CLAIM FORM ......................... 49 RETAIL CLINICS ..............................................31 IF YOUR CHILD HAS OTHER HEALTH TELEMEDICINE ................................................31 INSURANCE ....................................................... 49 SPECIALIST CARE ...........................................32 IF YOU SUSPECT FRAUD OR PROVIDER SPECIALIST VIRTUAL VISITS ......................32 ABUSE ................................................................. 50 HEARING CARE SERVICES ..............................32 YOUR RIGHTS AND RESPONSIBILITIES FOR URGENT CARE ..................................................32 YOUR CHILD’S CARE ............................. 51 HOSPITAL CARE ..............................................33 YOUR RIGHTS ................................................... 51 WOMEN’S CARE ................................................33 YOUR RESPONSIBILITIES ............................. 52 MATERNITY CARE ..........................................34 HOW TO SUBMIT A COMPLAINT ................ 53 NEWBORN CARE ..............................................35 EMERGENCY CARE .........................................35 ENSURING YOUR CHILD RECEIVES MENTAL HEALTH/SUBSTANCE ABUSE QUALITY CARE ...................................... 54 SERVICES ............................................................36 THE CARE/UTILIZATION PROCESS ........... 54 CASE MANAGEMENT SERVICES ................ 55 4 RESOLVING PROBLEMS ................................56 DENTAL BENEFITS ............................... 132 IF YOU NEED ADDITIONAL Who can my child see for dental care? ................ 132 INFORMATION ..................................................56 Can my child receive services from a non- HOW WE DECIDE IF A TECHNOLOGY OR participating dental provider ................................ 132 DRUG IS EXPERIMENTAL .............................57 How much does dental care cost ......................... 133 EVALUATING NEW DRUGS ..........................57 What dental services are not covered by CHIP ... 133 HOW WE PROTECT YOUR RIGHT TO What dental services are covered by CHIP? ... 133 CONFIDENTIALITY .........................................58 DENTAL SPECIFIC LIMITATIONS ................ 136 IMPORTANT DENTAL PHONE NUMBERS TAKE CHARGE OF YOUR ....................... 59 AND ADDRESSES ............................................. 136 CHILD’S HEALTH ..................................... 59 CHIP VISION BENEFITS ........................ 137 MEMBER NEWSLETTER ...................................59 HOW DOES MY CHILD RECEIVE OUR WEBSITE ....................................................59 SERVICES FOR VISION CARE?.................. 139 WEBSITE VERIFICATION .................................60 CAN MY CHILD RECEIVE SERVICES FROM MYCARE NAVIGATOR .....................................60 A NON-PARTICIPATING VISION CALL BLUES ON CALL .....................................60 PROVIDER? ...................................................... 139 HELP YOUR CHILD TO QUIT TOBACCO .......61 IMPORTANT VISION PHONE NUMBERS AND ENJOY MEMBER DISCOUNTS .........................61 ADDRESSES ...................................................... 139 BABY BLUEPRINTS ...........................................62 CHIP Notice of Privacy Practices.......... 140 DESCRIPTION OF BENEFITS ............... 63 HIGHMARK BLUE SHIELD INC. NOTICE OF EXCLUSIONS ........................................... 86 PRIVACY PRACTICES ........................... 143 Healthcare Management.......................... 91 General Information ............................... 100 How to File a Claim ................................ 104 DEFINITIONS .......................................... 116 * Dental coverage is provided by United Concordia Companies, Inc. United Concordia Companies, Inc. is a separate company that administers Highmark Blue Shield dental services. ** Vision coverage is provided by Davis Vision, Inc. Davis Vision, Inc. is a separate company that administers Highmark Blue Shield vision benefits. 5 This Booklet is not a Contract This booklet does not constitute a contract of benefits and provisions. The complete set of terms of coverage are set forth in the Group Contract issued by Highmark Blue Shield, an Independent Licensee of the Blue Cross and Blue Shield Association. This booklet is merely a description of the principal features of your child's CHIP benefits, brought to you by Highmark Blue Shield's PPOPlus program. Highmark Blue Shield does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations. This managed care plan may not cover all of your health care expenses. Read this booklet carefully to determine which health care services are covered. If you have any questions, please contact your Member Service Representative toll-free at 1-800-345-3806. Please keep in mind that you could be financially responsible for total payment to the provider for any services received that are not covered by this program. 6 UNDERSTANDING HEALTH COVERAGE TERMS This handy reference section explains commonly used health coverage terms. You might find it useful to refer back to this section as you read your handbook. Authorization – Process through which certain services are determined by Highmark Blue Shield to be medically necessary and appropriate. Benefit Period – The benefit period is the specified period of time during which charges for covered services must be incurred in order to be eligible for payment by Highmark Blue Shield. A charge shall be considered incurred on the date you receive the service or supply for which the charge is made. Your child's benefit period is a calendar