GA-U Member Benefits Summary

Part 1: About Your Health Plan

• Welcome to Community Health Plan!
• About Community Health Plan
  • About Your Enrollment
  • Getting More Information
  • Your Community Health Plan ID Card
• Frequently Asked Questions

Part 2: Your GA-U Benefits

• Services Covered by Community Health Plan
• Services Covered by DSHS or Other Programs
• Services at Your Local Health Department
• Services Not Covered by Community Health Plan, DSHS, or Other Program
• Payments for Services Not Covered by Community Health Plan, DSHS, or Other Programs
  • 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
  • Getting a Second Opinion
  • Outpatient Mental Health Services
  • Specialty Care
  • 24-Hour Nurse Advice Line
• Hospital Care
  • Pre-Admission Authorization
• Emergency Care
  • What Is an Emergency?
  • What to Do in an Emergency
• Health Coverage When Away from Home

Part 4: Prescription Drug Services

• Formulary
• 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

• Check-Ups When You Are Well
• Adult Immunizations
• Women's Health Care
  • Screening Tests: Breast Cancer
  • Screening Tests: Cervical Cancer
  • If You Are Pregnant or Think You Might Be Pregnant
• Substance Abuse Treatment
• Disabilities

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

• Quality Improvement Program
• 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
  • Member Review and Intervention Program (MRIP)

Part 7: Your Rights and Responsibilities

• Member Rights
• Member Responsibilities
• Advance Directives
  • Community Health Plan Advance Directives Policy.
• Privacy of Your Health Information — Authorizations
  • 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

• Appointing a Personal Representative
• Complaints
• Appeals
• How to File an Appeal or Complaint
• Expedited (Rush) Appeal
• Standard Appeal
• Second Level Appeal
• Independent Review
• Expedited Review by an IRO
• DSHS Hearing

Part 9: Glossary