2010 Basic Health Medical Benefits Summary

Part 1: About Your Health Plan

• Welcome to Community Health Plan!
• About Community Health Plan
  • Health Coverage Tax Credit (HCTC)
  • About Your Enrollment
  • Getting More Information
  • Your Community Health Plan ID Card

Part 2: Your Basic Health Benefits

• Benefits and Services Not Subject to Deductible and Coinsurance
• Benefits and Services Subject to Deductible and Coinsurance
• Exclusions
• Benefits Terminology
  • Copay
  • Deductible
  • Coinsurance
  • Out-of-pocket maximum
  • Explanation of Benefits (EOB)
• If You Get a Bill for Covered Services
  • Third-Party Liability
  • Coordination of Benefits (COB) and Third-Party Liability (Subrogation)
• About Prior Authorizations and Referrals
  • What Is a Referral?
  • When Do I Need to Get a Referral?
  • What Is a Prior Authorization?
  • When Do I Need to Get a Prior Authorization?
  • Prior Authorization List
    • Care that requires a prior authorization includes

Part 3: Your Medical Care

• Your Primary Care Provider (PCP)
  • Choosing a PCP
  • Changing Your PCP
• Making an Appointment
  • Appointment Standards
• When You Need Medical Care
• When You Are Sick or Your Child Is Sick
  • Getting a Second Opinion
  • Specialty Care
  • Children First Rewards Community Health Plan Members for Getting the Care They Need
• 24-Hour Nurse Advice Line
• Hospital Care
  • Covered Hospital Services
  • Pre-Admission Authorization
• Emergency Care
  • What Is an Emergency?
  • What to Do in an Emergency
  • Health Coverage When You Travel

Part 4: Prescription Drug Services

• Formulary
• Copayments for Drugs
• Retail Pharmacy Benefit
• Mail Order Pharmacy Benefit
• Nonformulary and Prior Authorization Requests
• Health Coverage When You Travel
• Using an Out-of-Network Pharmacy in an Emergency
• Your Right to Safe and Effective Pharmacy Services
• Frequently Asked Questions About Pharmacy

Part 5: Staying Healthy: Preventive Care

• Adult Health
  • Adult Immunizations
  • Women’s Health Care
    • Screening Tests: Breast Cancer
    • Screening Tests: Cervical Cancer
• When You Are Pregnant
  • New Arrivals
  • First Steps
  • How to Get a Car Seat for Your New Baby
  • After You Give Birth
• Infant, Child, and Teen Health
  • Routine Well Child Physical Exam Schedule
  • Well Child Visits
• Immunizations
  • Children First Rewards for Members Who Get Immunized
  • Immunization Schedule for Children

Part 6: How We Make Sure You Get the Best Health Care

• Quality Improvement
• Care Management
  • Utilization Management: Working to Get You Covered and Necessary Care
  • Behavioral Health
  • Clinical Criteria
  • ‘Medically Necessary’
  • Evaluation of New Technology
  • Policy Prohibiting Financial Incentives
  • Contact Utilization Management
  • Case Management
  • Disease Management

Part 7: Your Rights and Responsibilities

• Member Rights
• Member Responsibilities
• Advance Directives
  • Community Health Plan Advance Directives Policy
• Privacy of Your Health Information — Authorizations
  • Age of Consent
  • Your Personal Information and the Web
  • Community Health Plan Notice of Privacy Practices
    • How We Use and Share Your Protected Health Information
    • Your Rights About Your Protected Health Information
    • How Do I Use My Rights?
    • Can I "Opt Out" of Certain Disclosures?
    • What if We Change Our Privacy Practices?
    • How Do I Ask Questions?
    • How Do I Report a Problem?
• How Can I Help Stop Health Care Fraud?

Part 8: Grievances and Appeals

• Time Limits for Filing an Appeal
• First Level Appeal
• Expedited (Rush) Appeal
• Second Level Appeal
• Independent Review
• Expedited (Rush) Review by an IRO
• Appointing an Authorized Representative

Part 9: Glossary