Basic Health Medical Benefits Summary

2011 Basic Health Medical Benefits Summary. Read or download.
Updated information about your plan. Incorporates the Basic Health Benefit Table, which was a separate document in 2010. Content table of contents as outlined below.

2011 Basic Health Medical Benefits Summary Table of Contents

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
  • To Change Your Address
  • WorldDoc 24/7 Health Management

Part 2: Your Basic Health Benefits

Basic Health Benefit Table

Basic Health Services Not Covered

Benefits Terminology

  • Balance billing
  • Copay
  • Deductible
  • Coinsurance
  • Out-of-pocket maximum
  • Explanation of Benefits (EOB)

If You Get a Bill for Covered Services

  • To Submit a Bill
  • 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)

  • To Choose a PCP
  • To Find a Provider, Specialist, or Hospital
  • To Change 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

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

Clinical Criteria

  • Deciding What Care to Use
  • Prior Authorization List
  • Clinical Coverage Criteria
  • Clinical Practice Guidelines
  • Medically Necessary
  • Policy Prohibiting Financial Incentives
  • Contact Utilization Management
  • Case Management
  • Disease Management
  • Behavioral Health (Mental Health)
  • Evaluation of New Technology

Part 7: Your Rights and Responsibilities

Member Rights

Member Responsibilities

Advance Directives

  • Advance Directives Policy and Procedure
  • If You Have Complaints About Advance Directives
  • Additional Information

Community Health Plan Notice of Privacy Practices

  • Privacy and Security of Your Health Information
  • Privacy of Your Health Information — Authorizations
  • How We Use and Share Your Protected Health Information
  • Protections for PHI Sent to Plan Sponsors
  • Your Personal Information and the Web
  • 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?
  • Age of Consent

How Can I Help Stop Health Care Fraud?

Part 8: Grievances and Appeals

How to File a Grievance or an Appeal
Appointing a Personal Representative
Expedited (Rushed) Appeal
Standard Appeal
DSHS Hearing
Independent Review
DSHS Board of Appeals

Part 9: Glossary