CHP+ Member Benefits Booklet CHP+ State Managed Care Network & CHP+ Prenatal Care Program TABLE OF CONTENTS Welcome! ....................................................................................................................................... 5 Attention State Managed Care Network Members ................................................................... 7 Contact Information ..................................................................................................................... 8 Important Addresses .................................................................................................................... 8 Important Website Addresses...................................................................................................... 8 Important Things to Know About CHP+ ................................................................................... 9 What is Colorado Access?........................................................................................................... 9 Member Identification Card (ID Card) ....................................................................................... 9 Primary Care Providers (PCP) .................................................................................................... 9 In-Network Providers ................................................................................................................ 10 Remember ................................................................................................................................. 10 Frequently Asked Questions for CHP+ Prenatal Care Program Members ............................... 10 Summary of Covered Benefits ................................................................................................... 12 1: Member Rights & Responsibilities ....................................................................................... 14 As a member you have the right to: .......................................................................................... 14 As a member, you have the responsibility to: ........................................................................... 15 Advance Medical Directives ..................................................................................................... 16 2: About Your Health Care Coverage ...................................................................................... 18 Member Identification Card (ID Card) ..................................................................................... 18 Changing Your Information ...................................................................................................... 18 Prenatal Care ............................................................................................................................. 18 Getting Information about your Health Care Providers ............................................................ 18 Primary Care Providers (PCP) .................................................................................................. 18 Other Health Insurance.............................................................................................................. 21 Newborn Child Enrollment ....................................................................................................... 21 3: Managed Care ......................................................................................................................... 23 Pre-authorization ....................................................................................................................... 23 Medically Necessary Health Care Services .............................................................................. 24 1 Have questions? Need help? We are here to help you in the language you speak! Call us at (303) 751-9051, toll free 1-800-414-6198 TTY for the deaf or hard of hearing (720) 744-5126, toll free 1-888-803-4494 Updated February 2014 Appropriate Setting and Pre-Authorization............................................................................... 25 Retrospective Claim Review ..................................................................................................... 27 Ongoing Care Needs ................................................................................................................. 28 Utilization Management ........................................................................................................ 28 Care Management and Disease Education ........................................................................... 28 Transition of Care...................................................................................................................... 29 4: What You Pay For Enrollment & Service ............................................................................ 30 Hold Harmless ........................................................................................................................... 30 When You Can Be Billed For Services ..................................................................................... 30 Services from Out-of-Network Providers ................................................................................. 30 Enrollment Fee .......................................................................................................................... 30 Copayments ............................................................................................................................... 31 Annual Out-of-Pocket Limit ..................................................................................................... 32 5: Membership ............................................................................................................................ 34 Enrollment Process .................................................................................................................... 34 Newborn Child Enrollment ....................................................................................................... 34 Termination Policy .................................................................................................................... 35 When Your CHP+ Coverage Ends ............................................................................................ 35 6: Member Benefits – Covered Services ................................................................................... 37 Member Benefits – Covered Services – Preventive Care Services ........................................... 38 Member Benefits – Covered Services – Family Planning/Reproductive Health ...................... 40 Member Benefits – Covered Services – Maternity and Newborn Child Care .......................... 41 Member Benefits – Covered Services – Provider Office Services ........................................... 43 Member Benefits – Covered Services – Inpatient Facility Services ......................................... 46 Member Benefits – Covered Services – Outpatient Facility Services ...................................... 50 Member Benefits – Covered Services – Emergency and Urgent/After-Hours Care................. 53 Member Benefits – Covered Services – Ambulance Transportation Services ......................... 57 Member Benefits – Covered Services – Outpatient Therapies ................................................. 59 Member Benefits – Covered Services – Home Health Care/Home Infusion Therapy ............. 62 Member Benefits – Covered Services – Hospice Care ............................................................. 64 2 Have questions? Need help? We are here to help you in the language you speak! Call us at (303) 751-9051, toll free 1-800-414-6198 TTY for the deaf or hard of hearing (720) 744-5126, toll free 1-888-803-4494 Updated February 2014 Member Benefits – Covered Services – Human Organ and Tissue Transplant Services ......... 66 Member Benefits – Covered Services – Medical Supplies and Equipment .............................. 71 Member Benefits – Covered Services – Dental-Related Services ............................................ 75 Member Benefits – Covered Services – Food and Nutrition Therapy ...................................... 78 Member Benefits – Covered Services – Mental Health and Substance Abuse Care ................ 81 Member Benefits – Covered Services – Prescription Medications ........................................... 86 Member Benefits – Covered Services – Audiology Services ................................................... 92 Member Benefits – Covered Services – Vision Services .......................................................... 93 7: General Exclusions & Limitations ........................................................................................ 94 8: Administrative Information................................................................................................. 102 Enrollment Fee ........................................................................................................................ 102 Copayments (cost-sharing) ...................................................................................................... 102 CHP+ State Managed Care Network ID Card ........................................................................ 102 Changing Member Information ............................................................................................... 102 Change of Residence ..............................................................................................................