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)