Advantage 2012 Member Handbook - Medicare Advantage
Advantage 2012 Member Handbook - Medicare Advantage
Advantage 2012 Member Handbook - Medicare Advantage
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<strong>2012</strong> <strong>Member</strong> <strong>Handbook</strong><br />
A Coordinated Care plan with a <strong>Medicare</strong> <strong>Advantage</strong> contract and a contract with the<br />
Ohio Medicaid program<br />
H0908_MEM012_003 CMS Approved 08/25/2011
<strong>Member</strong> <strong>Handbook</strong><br />
Welcome to Buckeye<br />
Welcome to <strong>Advantage</strong> by Buckeye Community Health Plan (HMO SNP) (Buckeye), a<br />
subsidiary of Centene Corporation. Buckeye is a <strong>Medicare</strong> <strong>Advantage</strong> Special Needs<br />
Plan offering <strong>Medicare</strong> <strong>Advantage</strong> Part D, and is not a “Medigap” <strong>Medicare</strong> Supplement<br />
Insurance policy.<br />
It is important for any new members with a health condition that requires<br />
ongoing care to call our <strong>Member</strong> Services department as soon as possible.<br />
For example, if you need surgery, have asthma, diabetes, congestive heart<br />
failure, are receiving physical therapy, or treatment for behavioral health<br />
conditions, you need to call <strong>Member</strong> Services. Also, new members<br />
currently taking any medication(s) need to confirm as soon as possible<br />
whether or not their medication(s) must be prior approved. If a medication<br />
needs prior approval, you cannot obtain the medication until your doctor<br />
submits a request and it is approved. You can check by contacting our <strong>Member</strong><br />
Services department, or you can look on our website at www.bchpohio.com.<br />
It is important to remember that you must receive all medically-necessary covered<br />
healthcare services from Buckeye facilities and/or providers. You should have received<br />
a Provider Directory that lists all of our panel providers, as well as other providers you<br />
can see. The only time you can use providers not on Buckeye’s panel is for emergency<br />
or urgently needed care, or for services that <strong>Medicare</strong> requires our plan to cover but we<br />
are unable to provide in network.<br />
If you need to receive the information in this <strong>Member</strong> <strong>Handbook</strong> in a different format<br />
(such as in Spanish or another language, large print, or audio CD), please call us so we<br />
can send you a copy.<br />
As you review the information in this <strong>Member</strong> <strong>Handbook</strong>, remember we are here to<br />
answer any questions you have and assist you in any way that we can. If you have<br />
questions or concerns, please call us at (toll-free) 1-866-389-7690 or (TTY) 1-800-750-<br />
0750 8 a.m. to 8 p.m. seven days a week.<br />
We look forward to working with you to safeguard your health!<br />
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<strong>Member</strong> <strong>Handbook</strong><br />
Table of Contents<br />
Introduction……………………………………………………………………………………3<br />
Identification Cards……………...……………………………………………………………5<br />
Family Doctor or Primary Care Provider…………………………………………………6<br />
Out-of-Area, After Hours, and Emergency Care…………………………………...……7<br />
Covered Services……………………………..………………………………………………9<br />
More Services and Programs………………..……………………………………………10<br />
Coordination of Benefits Between <strong>Medicare</strong> and Medicaid…………………10<br />
Additional Value Added Services..………………………………………………10<br />
Additional Programs..………………………………………………………………10<br />
Nursewise..……………………………………………...……………………10<br />
<strong>Member</strong>Connections..……………………………………...………………11<br />
Case Management..…………………………………………………………11<br />
Prescription Medications..…………………………………...……………………………13<br />
Asked to Pay – Just Say No..…………………………………………………..…………14<br />
<strong>Member</strong> Rights and Responsibilities..………………………..…………………………15<br />
Complaints and Appeals..…………………………………………………………………16<br />
Definitions..……………………………………………………………..……………………17<br />
Important Phone Numbers..………………………………….……………………………19<br />
2
<strong>Member</strong> <strong>Handbook</strong><br />
Introduction<br />
Thank you for your interest in Buckeye!<br />
We are hoping to serve you by providing <strong>Medicare</strong> services and benefits in a way that<br />
enables you to get the most out of life.<br />
About Buckeye<br />
Buckeye is a <strong>Medicare</strong> <strong>Advantage</strong> Plan, contracted with the Centers for <strong>Medicare</strong> and<br />
Medicaid Services (CMS). Buckeye offers:<br />
• All Original <strong>Medicare</strong> benefits (Parts A and B)<br />
o Hospital care<br />
o Home health care<br />
o Preventive care<br />
o Durable medical equipment<br />
• Prescription drug coverage (Part D)<br />
To be a member of our Plan, you must live in our service area, be entitled to <strong>Medicare</strong><br />
Part A, be enrolled in <strong>Medicare</strong> Part B, and be eligible for Medicaid in Ohio.<br />
Consumers eligible for full Medicaid can enroll or disenroll in our plan at any time during<br />
the year.<br />
Today, Buckeye’s service area spans 30 counties in Ohio.<br />
What’s so “special” about Buckeye?<br />
Buckeye is also known as a Special Needs Plan because we only enroll <strong>Medicare</strong> and<br />
Medicaid eligible consumers, known as “dual eligible” consumers. Our <strong>Advantage</strong><br />
plan was created to help dual eligible consumers get the most out of the benefits and<br />
services available through <strong>Medicare</strong> and Medicaid. We provide access to personal,<br />
local care needed to help people stay healthy and independent.<br />
<strong>Advantage</strong> by Buckeye Community Health Plan helps <strong>Medicare</strong> and Medicaid<br />
consumers get quality healthcare and live independently. See the page ten for many<br />
of the benefits you can get in addition to your healthcare services. It is your choice!<br />
For Help Understanding These Materials<br />
If you have any problems in reading or understanding this information, please contact<br />
Buckeye <strong>Member</strong> Services for help. We can help to explain the information or provide<br />
the information in other formats. If you are visually or hearing-impaired, special help<br />
can also be provided.<br />
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<strong>Member</strong> <strong>Handbook</strong><br />
Counties of Operation<br />
4
<strong>Member</strong> <strong>Handbook</strong><br />
Identification Cards<br />
Identification Cards<br />
You should have received your Buckeye membership identification (ID) card. This card<br />
replaces your red, white and blue <strong>Medicare</strong> card and is good for as long as you are a<br />
member of Buckeye. Store your red, white, and blue <strong>Medicare</strong> card in a safe place<br />
in case you need it later. You won’t need to show this card again unless you come off<br />
of our plan or need hospice services.<br />
Please carry your Buckeye <strong>Advantage</strong> membership card that we gave you at all times.<br />
You will need your Buckeye <strong>Advantage</strong> ID card each time you get medical services –<br />
you should take all of your medical cards (Buckeye <strong>Advantage</strong> ID, Medicaid, AARP), to<br />
any healthcare appointment.<br />
This means that you will need your Buckeye ID card when you:<br />
• See your primary care provider (PCP)<br />
• See a specialist or other providers<br />
• Go to an emergency room<br />
• Go to an urgent care facility<br />
• Go to a hospital for any reason<br />
• Get medical supplies<br />
• Have medical tests<br />
Here is a sample card to show you what it looks like:<br />
If your ID card is lost, stolen, or arrives with incorrect information on it (for example, it is<br />
missing your PCP name, has an incorrect PCP listed) or your name is spelled incorrectly,<br />
call <strong>Member</strong> Services right away.<br />
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<strong>Member</strong> <strong>Handbook</strong><br />
Primary Care Provider<br />
Choosing a Family Doctor or Primary Care Provider (PCP)<br />
Each member must choose a family doctor or primary care provider<br />
(PCP) from Buckeye’s provider directory. Your PCP is an individual<br />
physician, physician group practice, advance practice nurse or advance<br />
practice nurse group practice trained in family medicine (general practice)<br />
or internal medicine.<br />
Your PCP will work with you to direct your healthcare. Your PCP will treat<br />
you for most of your routine healthcare needs. If needed, your PCP will<br />
send you to other doctors (specialists) or admit you to the hospital.<br />
Sometimes, there may be a reason that a specialist may need to be your PCP. If you<br />
and/or your specialist believe that they should be your PCP, you should call the <strong>Member</strong><br />
Services department to discuss.<br />
You can reach your PCP by calling the PCP’s office. Your PCP’s name and telephone<br />
number are printed on your Buckeye ID card.<br />
Changing Your PCP<br />
If for any reason you want to change your PCP, you must first call the <strong>Member</strong> Services<br />
department. When you call, be sure to tell <strong>Member</strong> Services if you are seeing a<br />
specialist or getting other covered services that needed you PCP’s approval (such as<br />
home health services and durable medical equipment). <strong>Member</strong> Services will help you<br />
make sure that you can continue with the specialty care and other services you have<br />
been getting when you change your PCP. They will check to be sure the PCP you want<br />
to switch to is accepting new patients. <strong>Member</strong> Services will change your membership<br />
record to indicate your new PCP and will tell you when the change to your new PCP will<br />
take effect. They will also send you a new ID card that shows the name and phone<br />
number of your new PCP.<br />
For the names of contracted PCPs, you may look in your provider directory, on our<br />
website at www.bchpohio.com, or you can the <strong>Member</strong> Services Department for help.<br />
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<strong>Member</strong> <strong>Handbook</strong><br />
Out-of-Area, After Hours and<br />
Emergency Care<br />
Out-Of-Area And After Hours Care<br />
If your PCPs office is closed or you are away from home and you have a problem that is<br />
not an emergency, call your PCP at the phone number listed on your ID card. You can<br />
also call NurseWise 24 hours a day, seven days a week toll-free at 1-866-389-7690,<br />
option 7, (TTY 1-800-750-0750). A nurse will answer and help you determine what to<br />
do.<br />
Medical care is available through Buckeye physicians 24 hours a day, seven days a<br />
week. After hours, your PCP’s phone will be answered by either answering service or<br />
and answering machine with specific instructions. Be sure to follow the machine’s<br />
instructions. The answering service will have your PCP or the doctor who is covering<br />
for the PCP call you back. Tell them you are a Buckeye member and explain your<br />
problem. They will tell you what to do. You can also visit a contracted Urgent Care<br />
Center listed in our provider directory or on our website at www.bchpohio.com, or your<br />
can call NurseWise.<br />
Emergency Services<br />
Emergency services are services for a medical problem that you think is so serious that<br />
it must be treated right away by a doctor.<br />
Some examples of when emergency services are needed include:<br />
-A fracture (broken bone) -Severe bleeding<br />
-Chest pain or other severe pain<br />
-Severe shortness of breath<br />
-Poisoning<br />
-A bad burn<br />
-Fainting/unconsciousness<br />
-Seizures<br />
-Suddenly not able to see, move or speak<br />
-Shock (you may sweat, feel thirsty or dizzy, or have pale skin)<br />
You do not have to call Buckeye for an okay before you get emergency services.<br />
If you have an emergency, call 911 or go to the NEAREST emergency room (ER),<br />
call your PCP or the Buckeye NurseWise 24-hour nurse hotline, at 1-866-389-7690,<br />
option 7 (TTY 1-800-750-0750) (24 hours a day). Your PCP or the Buckeye<br />
NurseWise hotline can talk to you about your medical problem and give you advice on<br />
what you should do.<br />
Please note that you may self-refer to a Buckeye plan Urgent Care Center after hours if<br />
that facility is open at the time.<br />
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<strong>Member</strong> <strong>Handbook</strong><br />
Emergency Care<br />
Remember, if you need emergency services:<br />
• Go to the NEAREST hospital emergency room or other appropriate setting. Be<br />
sure to tell them that you are a Buckeye member and show them you ID card.<br />
• If the provider that is treating you for an emergency takes care of your<br />
emergency but thinks that you need other<br />
medical care to treat the problem that caused<br />
your emergency, the provider must call Buckeye.<br />
• Call your PCP (or ask the hospital to call your<br />
PCP) as soon as possible. This lets your PCP<br />
know that care you received. Your PCP can<br />
then take over coordination of your care. You<br />
must contact your PCP within 24 hour to arrange<br />
follow-up care within the service area with<br />
participating providers.<br />
• If the hospital has you stay, please make sure<br />
that Buckeye is called within 24 hours.<br />
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<strong>Member</strong> <strong>Handbook</strong><br />
Covered Services<br />
Buckeye covers the following medically necessary <strong>Medicare</strong>-covered services:<br />
Ambulance transportation<br />
• Chiropractic (back) services<br />
• Diabetes self-monitoring, training and supplies<br />
• Dialysis (kidney)<br />
• Durable medical equipment and related supplies<br />
• Emergency services<br />
• Home health services<br />
• Hospice care (care for terminally ill, e.g., cancer patients)<br />
• Inpatient hospital services<br />
• Inpatient mental healthcare<br />
• Medical nutrition therapy<br />
• Outpatient diagnostic tests (x-ray, lab) and therapeutic services and supplies<br />
• Outpatient mental healthcare<br />
• Outpatient rehabilitation services (physical/occupational/speech therapy)<br />
• Outpatient substance abuse services<br />
• Outpatient surgery (including ambulatory surgical center services)<br />
• Physician services, including doctor office visits<br />
• Podiatry (foot) services<br />
• Prescription drugs<br />
• Preventive care<br />
•<br />
•<br />
•<br />
•<br />
o<br />
o<br />
o<br />
o<br />
o<br />
o<br />
o<br />
Bone-mass measurements<br />
Cardiovascular disease testing<br />
Colorectal screening<br />
Immunizations<br />
Mammography screening<br />
Pap tests, pelvic exams, and clinical breast exams<br />
Physical exams (initial exam as well as additional checkups needed for<br />
the diagnosis or treatment of an illness or injury or to improve the<br />
functioning of a malformed body member)<br />
Prostrate cancer screening exams<br />
o<br />
Prosthetic devices and related supplies<br />
Skilled nursing facility care<br />
Urgently needed care<br />
Vision services (limited)<br />
*For a list of services not routinely covered by Buckeye, or more information<br />
about the above benefits, refer to your Evidence of Coverage booklet or contact<br />
<strong>Member</strong> Services.<br />
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<strong>Member</strong> <strong>Handbook</strong><br />
More Services & Programs<br />
Coordination of Benefits Between <strong>Medicare</strong> and Medicaid<br />
Most of the covered benefits are also covered by Medicaid. <strong>Advantage</strong>s of this are:<br />
Medicaid is usually the payer of last resort – this means you must access<br />
benefits that are covered by both programs through <strong>Medicare</strong> (Buckeye) first and<br />
Medicaid last.<br />
Once you have reached your limit for a service in the <strong>Medicare</strong> program, you<br />
might be able to continue getting the benefit through the Medicaid program.<br />
In some cases, Medicaid will pay for services or costs that <strong>Medicare</strong> does not<br />
(such as routine dental and vision care, and hearing aids).<br />
If you have questions about how your benefits are coordinated between programs,<br />
contact (see contact phone numbers on last page) -<br />
• <strong>Medicare</strong>-Buckeye <strong>Member</strong> Services<br />
• Medicaid-ODJFS Consumer Hotline<br />
Additional Value-Added Services<br />
Buckeye also offers the following additional benefits for our members:<br />
• Emergency medical response system<br />
• Non-emergency transportation – up to 30 round trips per year<br />
• Over-the-counter (OTC) supplies – up to $25 per month for certain OTC items<br />
shipped free to your home from our mail order pharmacy<br />
• Health club membership – up to $250 annual reimbursement for health club<br />
membership and fitness classes<br />
• Dental services – up to 1 oral exam and cleaning every year with additional<br />
comprehensive services<br />
• Vision services – up to $300 every year for one routine eye exam and eyewear<br />
including lenses, frames, contacts, and upgrades<br />
• Hearing services – up to $750 every year for routine hearing test and hearing<br />
aid, including warranty, fitting, and evaluation<br />
• NurseWise – free access to our 24 hour health information line staffed by<br />
nurses.<br />
The services below are available by contacting NurseWise, Buckeye’s 24-hour<br />
nurse hotline, at 1-866-246-4358, option 7 (TTY 1-800-750-0750):<br />
o Medical advice line<br />
o Health information library<br />
o Help in determining where to go for care<br />
o Answers to questions about your health or medicines<br />
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<strong>Member</strong> <strong>Handbook</strong><br />
More Services & Programs<br />
Buckeye also offers several additional programs for our members, including but not<br />
limited to:<br />
<strong>Member</strong>Connections<br />
We have a special program called <strong>Member</strong>Connections.<br />
Our <strong>Member</strong>Connections outreach representatives will talk<br />
to you on the phone, send you information in the mail, and/or<br />
visit your home if you prefer. They will be glad to talk to you about:<br />
•<br />
•<br />
•<br />
•<br />
•<br />
How to choose or change doctors<br />
Covered healthcare services and how to use services<br />
How to get medical advice when you can't get your doctor<br />
How to live a healthy life<br />
Any other healthcare service problem you may have<br />
<strong>Member</strong>Connections outreach representatives can also help connect you to<br />
community social services if you need food, housing, clothing, utility services, etc. To<br />
reach <strong>Member</strong>Connections, call <strong>Member</strong> Services.<br />
Care Management<br />
Buckeye is pleased to inform you that we have a case management program to help<br />
members learn more about their health concerns. Our care management program is<br />
designed to let us work with members to help them maintain good health and assist<br />
them and their doctor to arrange services that they may need to manage their health.<br />
The goal of our program is to learn what information or services members need<br />
to meet their healthcare needs in order to become more independent.<br />
<strong>Member</strong>s who have serious conditions may be referred to the care management<br />
program. Examples of these conditions include:<br />
• Asthma<br />
• Diabetes<br />
• Congestive heart failure (CHF)<br />
• Coronary artery disease (CAD)<br />
• Non-mild hypertension (high blood pressure)<br />
• Chronic obstructive pulmonary disease (COPD)<br />
• Severe mental illness<br />
• Severe cognitive and/or developmental limitation<br />
• High-risk or high-cost substance abuse disorder<br />
• Frequent admissions or ED room visits<br />
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<strong>Member</strong> <strong>Handbook</strong><br />
More Services & Programs<br />
Please call Buckeye’s <strong>Member</strong> Services if you would like more information about our<br />
care management services.<br />
When you are a patient in the hospital, if you are feeling well enough to<br />
have visitors, our nurses or social workers may come to your hospital<br />
room to visit you to discuss your discharge planning needs, answer any<br />
questions you may have about our benefits and services offered, and<br />
provide information to you about our case management program. Our<br />
staff will always check with the hospital staff first before entering your<br />
room to be sure that the timing is right for us to visit you.<br />
Other ways care managers work with our members include:<br />
• Care managers will work with your healthcare providers behind the scenes to<br />
manage any transitions from one hospital to another, from a hospital to a nursing<br />
facility, or from your home to a nursing facility. Our goal is to handle the<br />
coordination of these events so that you can focus on what’s important – your<br />
health.<br />
• Buckeye staff, including nurses, care managers, and outreach workers may<br />
contact you if a doctor has requested a phone call, if you request the phone call,<br />
or if Buckeye feels that care management services would be helpful to you.<br />
• Buckeye staff may ask you questions to learn more information about your<br />
conditions(s).<br />
• Buckeye staff will provide information to help you understand how to care for<br />
yourself and how to access services (including local resources).<br />
• Buckeye staff will talk to your family doctor or PCP and any other healthcare<br />
providers to coordinate care.<br />
Who do you contact if you have questions?<br />
You should call Buckeye’s <strong>Member</strong> Services if you have any questions about care<br />
management services or if you feel you would benefit from care management services.<br />
What to do if you want out of the program?<br />
Although Buckeye provides care management services for our members, we are aware<br />
that some members would prefer to not participate. For specifically identified members,<br />
Buckeye provides an "opt-out of care management" process. If you choose to not<br />
participate in our care management program, you can decline participation at any time<br />
by notifying your care manager (call <strong>Member</strong> Services and ask for your care manager).<br />
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<strong>Member</strong> <strong>Handbook</strong><br />
Prescription Medications<br />
While Buckeye covers all medically necessary <strong>Medicare</strong>-covered medications, we use a<br />
formulary. These are drugs that we prefer that your physician prescribe. We may also<br />
require that your provider submit information to us (a prior authorization request) to<br />
explain why a specific medication and/or a certain amount of the medication is needed.<br />
We must approve the request before you can get the medication. Reasons why we<br />
have prior authorization requirements on certain drugs include:<br />
•<br />
•<br />
•<br />
There is a generic or pharmacy alternative drug available<br />
The drug can be misused/abused<br />
There are other drugs that must be tried first<br />
Some drugs may also have quantity (amount) limits and<br />
some drugs are never covered, such as drugs for weight loss<br />
How do I get my medications?<br />
You must get all prescriptions filled at a pharmacy in our provider network. When you<br />
go to the pharmacy, make sure to take ALL of your medical cards (for example, your<br />
Buckeye <strong>Advantage</strong>, Medicaid, and any other medical or prescription plan ID cards<br />
such as AARP ID cards). Your pharmacist will know which medications are covered by<br />
which program.<br />
What will my drugs cost?<br />
Most Buckeye members have a $0 co-payment for generic medications (including brand<br />
drugs treated as generic) and a $0, $3.30, or $6.50 co-payment for other medications.<br />
Ask your provider to prescribe generic medications if possible so that you will have no<br />
co-payment.<br />
Where can I get more information about the pharmacy benefit?<br />
You can obtain additional information on your pharmacy benefits from:<br />
•<br />
•<br />
•<br />
Your Evidence of Coverage (Chapters 5 and 6)<br />
Your formulary online at www.bchpohio.com<br />
Buckeye <strong>Medicare</strong> <strong>Member</strong> Services – please contact us immediately if you<br />
are having any trouble getting your medications or are being asked to pay<br />
something other than $0, $3.30, or $6.50 for a medication.<br />
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<strong>Member</strong> <strong>Handbook</strong><br />
Asked to Pay–Just Say No<br />
Because our <strong>Medicare</strong> members are dual eligible (also on Medicaid), the only costs<br />
you should ever have to pay for <strong>Medicare</strong> covered and authorized services from a<br />
network (plan) provider are co-payments for non-generic medications. This section<br />
explains how this is possible and what to do if something goes wrong.<br />
As a Buckeye <strong>Medicare</strong> Plan <strong>Member</strong>, Your Costs For <strong>Medicare</strong> Services Are:<br />
Part A and B Services - $0<br />
Part D Services - $0 for generic medications and $3.30 or $6.50 for brand name<br />
medications. If you are in an institution, you will have no co-payments. Your costs may<br />
be more if you lose full Medicaid and eligibility for <strong>Medicare</strong> low-income subsidy.<br />
Your Evidence of Coverage has costs listed for all of these services (such as<br />
premiums, co-pays, and other charges). All costs, except for the Part D co-payments<br />
will be paid for by Medicaid or <strong>Medicare</strong>.<br />
As an ODJFS Medicaid <strong>Member</strong>, Your Costs For Medicaid Services Are:<br />
•<br />
•<br />
•<br />
•<br />
•<br />
Visits to the emergency room that are not an emergency - $3<br />
Dental visits - $3<br />
Vision visits - $2 & eyeglasses - $1<br />
Brand name, non-generic drugs - $2<br />
Drugs that require prior authorization - $3 (Medicaid drugs not covered by<br />
<strong>Medicare</strong>)<br />
Why is maintaining your Medicaid eligibility so important?<br />
You can only be on our plan if you have eligibility for Medicaid. If you lose Medicaid<br />
eligibility, your membership in this plan will end after 6 months. During this time, your<br />
costs for <strong>Medicare</strong> services will increase because Medicaid will no longer cover all of<br />
your out-of-pocket <strong>Medicare</strong> costs.<br />
How do you maintain your Medicaid eligibility?<br />
Your CDJFS office will notify you when your case is due for review, a process known as<br />
redetermination. Cases are reviewed to make sure your circumstances have not<br />
changed (for example, you still require the level of assistance you are receiving). This<br />
may require you to return completed paperwork by mail, or visit your local CDJFS office<br />
within a certain time period. You have to successfully complete this process to<br />
maintain your Medicaid eligibility – so watch for those notices from Medicaid!<br />
If you have any questions about your program eligibility, contact:<br />
• <strong>Medicare</strong>-Buckeye <strong>Member</strong> Services<br />
• Medicaid-ODJFS Consumer Hotline<br />
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<strong>Member</strong> <strong>Handbook</strong><br />
<strong>Member</strong> Rights & Responsibilities<br />
As a member of Buckeye, you have the following rights:<br />
•<br />
•<br />
•<br />
•<br />
•<br />
•<br />
•<br />
•<br />
•<br />
•<br />
To be treated with dignity and respect<br />
To have your personal and health information kept private<br />
To file complaints (sometimes called grievances), including complaints about the<br />
quality of your care<br />
To appeal (get a review of) certain decisions about health care coverage<br />
To receive emergency care when and where you need it<br />
To receive information in a way you understand<br />
To learn about all of your treatment choices and participate in treatment decision<br />
To have your questions about Buckeye answered<br />
To receive access to doctors, specialists, and hospitals<br />
To be protected from discrimination<br />
As a member of Buckeye, you also have several responsibilities.<br />
They are to learn and understand each right you have under our plan.<br />
That includes the responsibility to:<br />
•<br />
•<br />
•<br />
•<br />
•<br />
•<br />
•<br />
•<br />
•<br />
•<br />
•<br />
Ask questions if you don’t understand your rights<br />
Keep your scheduled appointments<br />
Cancel appointments in advance when you can’t keep them<br />
Only go to the emergency room when it is an emergency<br />
Keep your Buckeye <strong>Advantage</strong> ID card with you at all times<br />
Notify your PCP of emergency room treatment<br />
Always contact your PCP for your non-emergency<br />
medical needs<br />
Be sure you have approval from your PCP before going to a<br />
specialist (except for providers that you can self-refer to such as women’s health<br />
specialists, federally qualified health centers/rural health clinics, community<br />
mental health centers)<br />
Tell your PCP about your health<br />
Talk to your providers about your healthcare needs and ask questions about the<br />
different ways your healthcare problems can be treated.<br />
Treat providers and staff with respect<br />
15
<strong>Member</strong> <strong>Handbook</strong><br />
Complaints & Appeals<br />
You have the right to appeal any decision made by Buckeye concerning your treatment<br />
or payment for services. If you wish to file a grievance/appeal, please contact <strong>Member</strong><br />
Services. If you do not have access to a phone, you can complete this form or write a<br />
letter that includes the information requested below. The complete form or your letter<br />
should be mailed to:<br />
<strong>Advantage</strong> by Buckeye Community Health Plan<br />
Attention: Grievance & Appeals<br />
175 South 3 rd Street, Suite 1200<br />
Columbus, Ohio 43215<br />
Fax 1-866-786-1036<br />
Date: ________________<br />
<strong>Member</strong>: _____________________________________________________________<br />
Address of <strong>Member</strong>: _____________________________________________________<br />
Phone number of <strong>Member</strong>: ________________________________________________<br />
<strong>Member</strong> ID Number Listed on Buckeye ID Card: _______________________________<br />
Has this issue been brought to the attention of a Buckeye employee before? _________<br />
If yes, when? __________________________ To whom? _______________________<br />
Nature of Complaint: (Please state all details relating to the incident in question,<br />
including names, dates, places, etc. Please attach additional sheets of supporting<br />
documentation about your grievance/appeal if necessary.)<br />
______________________________________________________________________<br />
______________________________________________________________________<br />
______________________________________________________________________<br />
______________________________________________________________________<br />
*If you wish to end your membership in our plan, contact <strong>Member</strong> Services. Until your<br />
membership ends, you must keep getting your <strong>Medicare</strong> services and/or prescription<br />
drug coverage through our Plan.<br />
*If you have a complaint about the Medicaid program or want to find out how to appeal<br />
a decision about your Medicaid benefits, contact the ODJFS Medicaid Consumer<br />
Hotline.<br />
16
<strong>Member</strong> <strong>Handbook</strong><br />
Definitions<br />
Appeal: An appeal is a special kind of complaint you make if you disagree with a decision to<br />
deny a request for health care services or payment for services you already received.<br />
Copayment: An amount you may be required to pay as your share of the cost for a<br />
medical service or supply, like a doctor’s visit or a prescription. A copayment is usually<br />
a set amount, rather than a percentage. For example, you might pay $10 or $20 for a<br />
doctor’s visit or prescription.<br />
Covered Services: The general term we use in this booklet to mean all of the healthcare<br />
services and supplies that are covered by our Plan.<br />
Dual Eligible or Dually Eligible Consumers: Individuals who are entitled to <strong>Medicare</strong><br />
Part A and/or Supplemental Medical Insurance and are eligible for Medicaid to pay<br />
some form of <strong>Medicare</strong> cost sharing (such as premiums, copays, etc.). To maintain<br />
your dual eligible status, you MUST maintain your full Medicaid eligibility.<br />
Emergency Care: Emergency services are services for a medical problem you think is so<br />
serious that it must be treated right away by a doctor.<br />
Extra Help: A <strong>Medicare</strong> Program to help people with limited income and resources pay<br />
<strong>Medicare</strong> prescription drug program costs, such as premiums, deductibles, and<br />
coinsurance.<br />
Identification Card (ID Card): A card for each member that is needed by your doctor’s office<br />
before you can receive care.<br />
Medically Necessary: Services or supplies that: are proper and needed for the diagnosis or<br />
treatment of your medical condition.<br />
<strong>Medicare</strong>: Created by Congress in 1965, <strong>Medicare</strong> (also know as Original or fee-forservice<br />
<strong>Medicare</strong>) is the federal government’s national health insurance program for:<br />
• People age 65 or older<br />
• People under age 65 with disabilities who have been receiving Social Security<br />
disability benefits for a set amount of time (24 months in most cases)<br />
• People of any age with end-stage renal disease (ESRD) (permanent kidney<br />
failure that requires dialysis or a transplant)<br />
17
<strong>Member</strong> <strong>Handbook</strong><br />
Definitions<br />
<strong>Medicare</strong> benefits are divided into two categories: Part A and Part B. <strong>Medicare</strong> Part A<br />
is hospital insurance that provides basic coverage for hospital stays, nursing home<br />
facilities, hospice care, and home health care. <strong>Medicare</strong> Part B is medical insurance<br />
that covers many of the fees associated with doctor visits, laboratory testing, and<br />
outpatient services and supplies.<br />
<strong>Medicare</strong> <strong>Advantage</strong> Plan: <strong>Medicare</strong> <strong>Advantage</strong> Plans (also known as <strong>Medicare</strong> Part<br />
C) are types of health plans that are approved by <strong>Medicare</strong> and run by private insurance<br />
companies like Buckeye. These plans are paid a set amount of money by the federal<br />
government to provide basic <strong>Medicare</strong> benefits (Parts A and B) and the resulting<br />
savings are passed along to you in the form of additional benefits such as lower costs<br />
and additional benefits. <strong>Medicare</strong> Prescription Drug Plans are a type of <strong>Medicare</strong><br />
<strong>Advantage</strong> Plan that offer prescription drug coverage (Part D).<br />
<strong>Member</strong> Services: A department within our Plan responsible for answering your<br />
questions about your membership, benefits, grievances, and appeals.<br />
Premium: The periodic payment to <strong>Medicare</strong>, or Buckeye, for health care coverage.<br />
Primary Care Provider (PCP): Your family doctor (who must be contracted with the<br />
insurance company) is trained in family medicine (general practice) or internal medicine.<br />
Your PCP will work with you to direct your healthcare. Your PCP will do your check-ups<br />
and treat you for most of your healthcare needs. If needed, your PCP will send you to<br />
other doctors (specialists) or admit you to the hospital.<br />
Prior Authorization – Approval in advance to get services AND/OR certain drugs that<br />
may or may not be on our formulary. In Buckeye, some in-network services are<br />
covered only if your doctor or other network provider gets “prior authorization” from<br />
Buckeye. Some drugs are covered only if your doctor or other network provider gets<br />
“prior authorization” from us. Covered drugs that need prior authorization are marked in<br />
the formulary.<br />
Special Needs Plan: A type of <strong>Medicare</strong> <strong>Advantage</strong> Plan that focuses on individuals<br />
with special needs such as institutionalized beneficiaries, dually eligible (eligible for<br />
Medicaid and <strong>Medicare</strong>), and/or beneficiaries with severe or disabling chronic<br />
conditions.<br />
18
<strong>Member</strong> <strong>Handbook</strong><br />
Important Phone Numbers<br />
<strong>Member</strong> Services<br />
<strong>Advantage</strong> by Buckeye Community Health Plan<br />
1-866-389-7690<br />
1-800-750-0750 (TTY)<br />
1-866-719-5435 (Fax)<br />
175 S. 3 rd Street, Suite 1200 Columbus, OH 43215<br />
www.bchpohio.com<br />
8 a.m. - 8 p.m., 7 days a week<br />
NurseWise: 1-866-389-7690 option 7<br />
Your Buckeye Care Manager/Phone:__________________________<br />
Transportation: 866-973-2522<br />
Medicaid<br />
Ohio Department of Job and Family Services<br />
Ohio Medicaid Consumer Hotline<br />
1-800-324-8680<br />
1-800-292-3572 (TTY)<br />
http://jfs.ohio.gov<br />
Monday – Friday 7 a.m. – 8 p.m. and Saturday 8 a.m. – 5 p.m.<br />
County You Live In:_______________________________________<br />
Case Number:___________________________________________<br />
Case Worker/Phone/Address:_______________________________<br />
Primary Care Provider<br />
Your Primary Care Provider/Phone:________________________________<br />
Your Pharmacy/Phone:__________________________________________<br />
Notes:________________________________________________________<br />
_____________________________________________________________<br />
Emergency: 911 or local emergency number<br />
19
175 South 3rd Street, Suite 1200, Columbus, Ohio 43215<br />
1-866-389-7690<br />
TDD/TTY: 1-800-750-0750<br />
Hours of Operation:<br />
8 a.m. - 8 p.m., 7 days a week<br />
www.bchpohio.com<br />
© <strong>2012</strong> Buckeye Community Health Plan HMO SNP. All rights reserved.