CHIP MEMBER HANDBOOK€¦ · health care services in central Texas. When you pick Dell Children’s...

DECEMBER 2016

CHIP MEMBER HANDBOOK Your CHIP Perinatal Unborn Benefits

1-888-596-0268 (TTY 711)

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WELCOME! Thank you for choosing Dell Children’s Health Plan as your CHIP Perinatal health plan. It is our goal – with your help – to make sure you get the best medical care available. You will get your prenatal, delivery, and postpartum care through Dell Children’s Health Plan. This member handbook will tell you how to use Dell Children’s Health Plan to get the health care your unborn child needs.

Dell Children’s Health Plan is an HMO (Health Maintenance Organization) that is a part of the Seton Healthcare Family. The Seton Healthcare Family includes the following:

Seton Family of Hospitals: Seton Medical Center Austin Seton Medical Center Williamson Dell Children’s Medical Center

of Central Texas Seton Northwest Hospital Seton Southwest Hospital Seton Medical Center Hays Seton Highland Lakes Hospital Seton Edgar B. Davis Hospital Seton Shoal Creek Hospital University Medical Center Brackenridge Seton Smithville Regional Hospital

Seton Family Outpatient Centers: Seton Pflugerville Outpatient Center Seton Medical Center Williamson/

Pediatric Therapy Center

Seton Healthcare Network Clinics: Seton McCarthy Clinic Seton Marble Falls Seton Kozmetsky Clinic Seton Lockhart Family Health Center Seton Luling Family Medicine Clinic Seton Topfer Clinic Seton Burnet Healthcare Center

Affiliates of Seton Healthcare Family: Strictly Pediatrics Surgery Center Northwest Surgery Center Hill Country Surgery Center Cedar Park Regional Medical Center Central Texas Rehabilitation Hospital

Dell Children’s Health Plan is part of the Seton Healthcare Family, a leading provider of health care services in central Texas. When you pick Dell Children’s Health Plan as your CHIP Perinatal Health Plan, you can use the entire Seton network.

It is important that you read this member handbook. It will tell you how to get medical help when you need it. It will also tell you about Dell Children’s Health Plan and CHIP Perinatal. You can ask for the member handbook in audio, larger print or in Braille. You can also get it in a language other than English or Spanish.

If you still have questions after you read the handbook, call Member Services at 1-888-596-0268 (TTY 711). Their office hours are 7 a.m. to 6 p.m., Monday through Friday.

Dell Children’s Health Plan Member Services phone number: 1-888-596-0268 (TTY 711) Dell Children’s Health Plan website: dellchildrenshealthplan.com/members

Part of the Seton Healthcare Family, dedicated to providing exceptional care with a human touch.

http://dellchildrenshealthplan.com/members

CHIP Member Handbook Your CHIP Perinatal Unborn benefits

1-888-596-0268 (TTY 711) Dell Children’s Health Plan

December 2016

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Welcome! Thank you for choosing Dell Children’s Health Plan as your CHIP Perinatal health plan. It is our goal – with your help – to make sure you get the best medical care available. You will get your prenatal, delivery, and postpartum care through Dell Children’s Health Plan. This member handbook will tell you how to use Dell Children’s Health Plan to get the health care your unborn child needs.

Dell Children’s Health Plan is an HMO (Health Maintenance Organization) that is a part of the Seton Healthcare Family. The Seton Healthcare Family includes the following:

Seton Family of Hospitals: Seton Medical Center Austin Seton Medical Center Williamson Dell Children’s Medical Center of Central Texas Seton Northwest Hospital Seton Southwest Hospital Seton Medical Center Hays Seton Highland Lakes Hospital Seton Edgar B. Davis Hospital Seton Shoal Creek Hospital University Medical Center Brackenridge Seton Smithville Regional Hospital

Seton Family Outpatient Centers: Seton Pflugerville Outpatient Center Seton Medical Center Williamson/ Pediatric Therapy Center

Seton Healthcare Network Clinics: Seton McCarthy Clinic Seton Marble Falls Seton Kozmetsky Clinic Seton Lockhart Family Health Center Seton Luling Family Medicine Clinic Seton Topfer Clinic Seton Burnet Healthcare Center

Affiliates of Seton Healthcare Family: Strictly Pediatrics Surgery Center Northwest Surgery Center Hill Country Surgery Center Cedar Park Regional Medical Center Central Texas Rehabilitation Hospital

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Dell Children’s Health Plan is part of the Seton Healthcare Family, a leading provider of healthcare services in central Texas. When you pick Dell Children’s Health Plan as your CHIP Perinatal Health Plan, you can use the entire Seton network.

It is important that you read this Member Handbook. It will tell you how to get medical help when you need it. It will also tell you about Dell Children’s Health Plan and CHIP Perinatal. You can ask for the Member Handbook in audio, larger print or in Braille. You can also get it in a language other than English or Spanish.

If you still have questions after you read the Handbook, call Member Services at 1- 888-596-0268 (TTY 711). Their office hours are 7 a.m. to 6 p.m., Monday through Friday.

Seton Health Plan Member Services telephone number: 1-888-596-0268 (TTY 711)

Dell Children’s Health Plan website: dellchildrenshealthplan.com/members

Part of the Seton Healthcare Family, dedicated to providing exceptional care with a human touch.

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dellchildrenshealthplan.com/members

Dear Member:

Welcome to Dell Children’s Health Plan. We are pleased you chose us to arrange for health care for your unborn child.

This member handbook tells you how Dell Children’s Health Plan works and how we can help you have a healthy baby. It tells you how to get prenatal and postpartum care when it is needed, too.

You will get your Dell Children’s Health Plan ID card and more information from us in a few days. Your ID card will tell you when your Dell Children’s Health Plan membership starts. The numbers for our Member Services department and Nurse HelpLine are on there, too.

You can call 1-888-596-0268 (TTY 711) and talk to a Member Services representative about your benefits or visit our website at dellchildrenshealthplan.com/members. You can also talk to a nurse on our 24-hour Nurse HelpLine at 1-888-596-0268 (TTY 711) if you have questions about your health.

Thank you for picking us as your health plan.

Sincerely,

Dell Children’s Health Plan



DELL CHILDREN’S HEALTH PLAN MEMBER HANDBOOK For CHIP Perinate Unborn Members

Dell Children’s Health Plan PO Box 200801

Austin, TX 78759

1-888-596-0268 (TTY 711) dellchildrenshealthplan.com/members

Welcome to Dell Children’s Health Plan Children’s Health Insurance Program (CHIP) Perinatal! You will get your prenatal, delivery, and postpartum care through Dell Children’s Health Plan. This member handbook will tell you how to use Dell Children’s Health Plan to get the health care your unborn child needs.

TABLE OF CONTENTS

WELCOME TO DELL CHILDREN’S HEALTH PLAN ............................................................ 1 INFORMATION ABOUT YOUR NEW HEALTH PLAN.....................................................................................................1 YOUR DELL CHILDREN’S HEALTH PLAN MEMBER HANDBOOK ..................................................................................1

IMPORTANT PHONE NUMBERS.................................................................................... 1 Dell Children’s Health Plan toll-free Member Services line ...............................................................................................1 Dell Children’s Health Plan 24-hour Nurse HelpLine..........................................................................................................2 Other important phone numbers.......................................................................................................................................2

YOUR DELL CHILDREN’S HEALTH PLAN MEMBER ID CARD............................................ 2 What does my Dell Children’s Health Plan ID card look like? ............................................................................................2 Directions for what to do in an emergency........................................................................................................................2 How do I read and use my Dell Children’s Health Plan ID card? ........................................................................................2 How do I replace my Dell Children’s Health Plan ID card if it is lost or stolen? .................................................................3

PROVIDERS FOR CHIP PERINATE MEMBERS ................................................................. 3 WHAT DO I NEED TO BRING TO A PERINATAL PROVIDER APPOINTMENT?...............................................................3 CAN A CLINIC (LOCAL PUBLIC HEALTH CLINIC, RURAL HEALTH CLINIC, FEDERALLY QUALIFIED HEALTH CENTER) BE A PERINATAL PRIMARY CARE PROVIDER? ..............................................................................................3 HOW DO I GET AFTER-HOURS CARE?.........................................................................................................................3

CHANGING HEALTH PLANS .......................................................................................... 3 WHAT IF I WANT TO CHANGE HEALTH PLANS?..........................................................................................................3 HOW MANY TIMES CAN I CHANGE HEALTH PLANS?..................................................................................................4 WHO DO I CALL?.........................................................................................................................................................4 WHEN WILL MY HEALTH PLAN CHANGE BECOME EFFECTIVE?..................................................................................4 CAN DELL CHILDREN’S HEALTH PLAN ASK THAT I GET DROPPED FROM THEIR HEALTH PLAN?................................4

MEDICAID COVERAGE FOR CERTAIN NEWBORNS......................................................... 4

BENEFITS FOR CHIP PERINATE UNBORN MEMBERS ..................................................... 5 WHAT ARE MY UNBORN CHILD’S CHIP PERINATAL BENEFITS?..................................................................................5


How do I get these services?..............................................................................................................................................5 WHAT BENEFITS DOES MY BABY RECEIVE AT BIRTH? ................................................................................................5

What services are not covered?.........................................................................................................................................5 WHAT ARE MY UNBORN CHILD’S PRESCRIPTION DRUG BENEFITS? ..........................................................................5 HOW MUCH DO I HAVE TO PAY FOR MY UNBORN CHILD’S HEALTH CARE UNDER CHIP PERINATAL? .....................5 WILL I HAVE TO PAY FOR SERVICES THAT ARE NOT COVERED BENEFITS?.................................................................5 WHAT EXTRA BENEFITS DOES A MEMBER OF DELL CHILDREN’S HEALTH PLAN GET? HOW CAN I GET THESE BENEFITS FOR MY UNBORN CHILD?...........................................................................................................................6

What health education classes does Dell Children’s Health Plan offer?............................................................................6

HEALTH CARE AND OTHER SERVICES FOR CHIP PERINATE UNBORN MEMBERS ............. 6 HOW IS NEW TECHNOLOGY EVALUATED? .................................................................................................................7 WHAT IS ROUTINE MEDICAL CARE? ...........................................................................................................................7

How soon can I expect to be seen?....................................................................................................................................7 WHAT IS URGENT MEDICAL CARE? ............................................................................................................................7

How soon can I expect to be seen?....................................................................................................................................7 WHAT IS EMERGENCY MEDICAL CARE? .....................................................................................................................7

How soon can I expect to be seen?....................................................................................................................................8 HOW SOON CAN I SEE MY DOCTOR? .........................................................................................................................8 WHAT IS POSTSTABILIZATION? ..................................................................................................................................8 WHAT DOES MEDICALLY NECESSARY MEAN?............................................................................................................8

What if I am out of the state? ............................................................................................................................................9 What if I am/my child is out of the country? .....................................................................................................................9

WHAT IS A REFERRAL?................................................................................................................................................9 What services do not need a referral? ...............................................................................................................................9

WHAT IF I NEED SERVICES THAT ARE NOT COVERED BY CHIP PERINATAL? ........................................................... 10 HOW DO I GET MY MEDICATIONS?......................................................................................................................... 10

How do I find a network drugstore? ................................................................................................................................10 What if I go to a drugstore that is not in the network?....................................................................................................10 What do I bring with me to the drugstore? .....................................................................................................................10 What if I need my medications delivered to me? Who do I call if I have problems getting my medications? ............................10 What if I can’t get the medication my/my child’s doctor ordered approved?.................................................................10 What if I lose my medications? ........................................................................................................................................10 What if I need/my child needs an over-the-counter medication?...................................................................................10 How do I find out what drugs are covered?.....................................................................................................................11 How do I transfer my prescriptions to a network pharmacy?..........................................................................................11 How do I get my medicine if I am traveling?....................................................................................................................11 What if I paid out of pocket for a medicine and want to be reimbursed?.......................................................................11

CAN SOMEONE INTERPRET FOR ME WHEN I TALK WITH MY PERINATAL PROVIDER?........................................... 11 Who do I call for an interpreter?......................................................................................................................................11 How far in advance do I need to call? ..............................................................................................................................11 How can I get a face-to-face interpreter in the provider’s office?...................................................................................11

HOW DO I CHOOSE A PERINATAL PROVIDER AND MAKE AN APPOINTMENT? ...................................................... 11 Will I need a referral?.......................................................................................................................................................11 How soon can I be seen after contacting a perinatal provider for an appointment? ......................................................12 Can I stay with a perinatal provider if the provider is not with Dell Children’s Health Plan? ..........................................12

WHAT IF I GET A BILL FROM A PERINATAL PROVIDER? WHO DO I CALL?............................................................... 12 What information is needed if I get a bill? .......................................................................................................................12

WHAT DO I HAVE TO DO IF I MOVE?....................................................................................................................... 12 WHAT ARE MY RIGHTS AND RESPONSIBILITIES?..................................................................................................... 12 WHEN DOES CHIP PERINATAL COVERAGE END?..................................................................................................... 13 WILL THE STATE SEND ME ANYTHING WHEN CHIP PERINATAL COVERAGE ENDS? ............................................... 13 HOW DOES RENEWAL WORK? ................................................................................................................................ 13

CAN I CHOOSE MY BABY’S PRIMARY CARE PROVIDER BEFORE THE BABY IS BORN?.............................................. 14 Who do I call?...................................................................................................................................................................14 What information do they need?.....................................................................................................................................14

QUALITY MANAGEMENT ............................................................................................14 WHAT DOES QUALITY MANAGEMENT DO FOR MEMBERS?................................................................................... 14 WHAT ARE CLINICAL PRACTICE GUIDELINES? ......................................................................................................... 14

COMPLAINT PROCESS .................................................................................................14 WHAT SHOULD I DO IF I HAVE A COMPLAINT? WHO DO I CALL? ........................................................................... 14

Can someone from Dell Children’s Health Plan help me file a complaint?......................................................................15 How long will it take to process my complaint?...............................................................................................................15 What are the requirements and time frames for filing a complaint? ..............................................................................15 If I am not satisfied with the outcome, who else can I contact?......................................................................................15 Do I have the right to meet with a complaint appeal panel?...........................................................................................15

PROCESS TO APPEAL A CHIP ADVERSE DETERMINATION ............................................16 WHAT CAN I DO IF MY PROVIDER ASKS FOR A SERVICE OR MEDICINE FOR ME THAT IS COVERED, BUT DELL CHILDREN’S HEALTH PLAN DENIES OR LIMITS IT?................................................................................................... 16 HOW WILL I FIND OUT IF SERVICES ARE DENIED?................................................................................................... 16

What are the time frames for the appeal process? .........................................................................................................16 When do I have the right to ask for an appeal? ...............................................................................................................16 Does my request have to be in writing?...........................................................................................................................16 Can someone from Dell Children’s Health Plan help me file an appeal? .........................................................................17

EXPEDITED APPEAL .....................................................................................................17 WHAT IS AN EXPEDITED APPEAL? ........................................................................................................................... 17 HOW DO I ASK FOR AN EXPEDITED APPEAL? .......................................................................................................... 17 DOES MY REQUEST HAVE TO BE IN WRITING?........................................................................................................ 17 WHAT ARE THE TIME FRAMES FOR AN EXPEDITED APPEAL? ................................................................................. 17 WHAT HAPPENS IF DELL CHILDREN’S HEALTH PLAN DENIES THE REQUEST FOR AN EXPEDITED APPEAL?............ 17 WHO CAN HELP ME IN FILING AN EXPEDITED APPEAL?.......................................................................................... 17

INDEPENDENT REVIEW ORGANIZATION PROCESS.......................................................18 WHAT IS AN INDEPENDENT REVIEW ORGANIZATION?........................................................................................... 18 HOW DO I ASK FOR A REVIEW BY AN INDEPENDENT REVIEW ORGANIZATION?.................................................... 18 WHAT ARE THE TIME FRAMES FOR THIS PROCESS? ............................................................................................... 18

FRAUD AND ABUSE INFORMATION.............................................................................18 DO YOU WANT TO REPORT CHIP WASTE, ABUSE, OR FRAUD?............................................................................... 18

ATTACHMENT A..........................................................................................................24

WELCOME TO DELL CHILDREN’S HEALTH PLAN

Information about your new health plan Welcome to Dell Children’s Health Plan. Dell Children’s Health Plan is a health maintenance organization committed to getting you the right care close to home. As a member of the Children’s Health Insurance Program (CHIP) Perinatal, you and your perinatal providers will work together to help you have a healthy baby. Dell Children’s Health Plan helps your unborn child get quality health care. This member handbook will help you understand your health plan. To find out about doctors and hospitals in your area, visit dellchildrenshealthplan.com/members or contact Member Services at 1-888-596-0268 (TTY 711).

Your Dell Children’s Health Plan member handbook This handbook will help you understand your health plan. If you have questions or need help understanding or reading your member handbook, call our Member Services department. Dell Children’s Health Plan also has the member handbook in a large print version, an audio taped version, and a Braille version. The other side of this handbook is in Spanish.

For members who do not speak English, we are able to help in many different languages and dialects, including Spanish. This service is also available for visits with your perinatal provider at no cost to you. Please let us know if you need an interpreter at least 24 hours before your appointment. Call Member Services for more information.

For members who are deaf or hard of hearing, call 711. Dell Children’s Health Plan will set up and pay for you to have a person who knows sign language help you during your provider visits. Please let us know if you need an interpreter at least 24 hours before your appointment.

IMPORTANT PHONE NUMBERS

Dell Children’s Health Plan toll-free Member Services line If you have any questions about your Dell Children’s Health Plan, you can call our Member Services department toll-free at 1-888-596-0268 (TTY 711). You can call us Monday through Friday from 7 a.m. to 6 p.m. Central time, except for state-approved holidays. If you call after 6 p.m. or on a weekend or holiday, you can leave a voice mail message. A Member Services representative will call you back the next business day. These are some of the things Member Services can help you with: • This member handbook • Member ID cards • Your perinatal doctors • Doctor appointments • Health-care benefits • Accessing services • What to do in an emergency and/or crisis • Healthy living • Complaints and medical appeals • Rights and responsibilities

1 TS-MHB-0004-16 12.16 TX CHIP Perinate MHB


Dell Children’s Health Plan 24-hour Nurse HelpLine You can call our 24-hour Nurse HelpLine at 1-888-596-0268 (TTY 711) if you need advice on: • How soon you need care for an illness • What kind of health care is needed • What to do to take care of yourself before you see your provider • How you can get the care that is needed

Other important phone numbers If you have an emergency, you should call 911 or go to the nearest hospital emergency room right away. • If you have questions about eligibility, call CHIP at 2-1-1 or at 1-800-964-2777. • If you need help finding a pharmacy or if you have problems getting prescriptions filled, call Dell Children’s

Health Plan at 1-888-596-0268 (TTY 711) • If you need help with an urgent medical issue or setting up an urgent doctor appointment, call Dell

Children’s Health Plan at 1-888-596-0268 (TTY 711)

YOUR DELL CHILDREN’S HEALTH PLAN MEMBER ID CARD

What does my Dell Children’s Health Plan ID card look like? You will get your Dell Children’s Health Plan ID card in the mail from us. Please carry it with you at all times. Here is what a CHIP Perinatal card looks like:

Directions for what to do in an emergency In case of emergency, call 911 or go to the closest emergency room.

How do I read and use my Dell Children’s Health Plan ID card? Your Dell Children’s Health Plan ID card shows the date you became a Dell Children’s Health Plan member, your subscriber number and what kind of coverage you have. It also lists important phone numbers, like Member Services, the Nurse HelpLine, and Pharmacy. Try to have your ID card with you when you call one of these numbers.

Show your card to any provider or hospital you visit. The card tells providers you are a member of Dell Children’s Health Plan. It also says Dell Children’s Health Plan will pay for the medically needed benefits listed in the


Benefits for CHIP Perinate Unborn Members section. You do not need to show your ID card before you get emergency care.

How do I replace my Dell Children’s Health Plan ID card if it is lost or stolen? If your ID card is lost or stolen, call us right away. We will send you a new one. You may also print a new ID card from our website at dellchildrenshealthplan.com/members. You will need to register and log in to the website to access ID card information.

PROVIDERS FOR CHIP PERINATE MEMBERS

What do I need to bring to a perinatal provider appointment? When you go to a provider’s office, bring your Dell Children’s Health Plan ID card, records, and any medicines you are taking.

Can a clinic (local public health clinic, rural health clinic, federally qualified health center) be a perinatal primary care provider? Yes, clinics listed in the Dell Children’s Health Plan CHIP Perinatal provider directory can be your perinatal provider.

How do I get after-hours care? Except in the case of an emergency (see the section on Emergency care) or care that does not need a referral (see the What services do not need a referral? section), you should always call your provider first before you get medical care. Help from your provider is available 24 hours a day. If you have a medical concern you need to discuss with the provider after the office is closed, call the office phone number. If it is not an emergency, someone should call you back within 30 minutes to tell you what to do. You may also call our Nurse HelpLine at 1-888-596-0268 (TTY 711) 24 hours a day, 7 days a week for help.

If you think you need emergency care (see the section on What is emergency medical care?), call 911 or go to the nearest emergency room right away.

CHANGING HEALTH PLANS Attention: If you meet certain income requirements, your baby will be moved to Medicaid and get 12 months of continuous Medicaid coverage from date of birth.

Your baby will continue to receive services through the CHIP program if you meet the CHIP Perinatal requirements. Your baby will get 12 months of continuous CHIP Perinatal coverage through his or her health plan, beginning with the month of enrollment as an unborn child.

What if I want to change health plans? Once you pick a health plan for your unborn child, the child must stay in this health plan until the child’s CHIP Perinatal coverage ends. The 12-month CHIP Perinatal coverage begins when your unborn child is enrolled in CHIP Perinatal and continues after your child is born.

If you live in an area with more than one CHIP health plan, and you do not pick a plan within 15 days of getting the enrollment packet, HHSC will pick a health plan for your unborn child and send you information about that



health plan. If HHSC picks a health plan for your unborn child, you will have 90 days to pick another health plan if you are not happy with the plan HHSC chooses.

How many times can I change health plans? You can ask to change health plans: • For any reason within 90 days of enrollment in CHIP Perinatal; • If you move to a different service delivery area; and • For cause at any time.

Who do I call? For more information, call toll-free at 1-800-964-2777.

When will my health plan change become effective? Health plan changes become effective the following month if processed prior to the monthly cut-off date. If the change is processed after cut-off, it will become effective the first of the following month.

Can Dell Children’s Health Plan ask that I get dropped from their health plan? There are several reasons you could be disenrolled from Dell Children’s Health Plan without asking to be disenrolled; these are listed below. If you have done something that may lead to disenrollment, we will contact you. We will ask you to tell us what happened.

You could be disenrolled from Dell Children’s Health Plan if: • You are no longer eligible for CHIP • You let someone else use your Dell Children’s Health Plan ID card • You try to hurt a provider, a staff person, or Dell Children’s Health Plan associate • You steal or destroy property of a provider or Dell Children’s Health Plan • You go to the emergency room over and over again when you do not have an emergency • You go to doctors or medical facilities outside the Dell Children’s Health Plan over and over again • You try to hurt other patients or make it hard for other patients to get the care they need • You or your guardian interfere with the care plan that is being provided

If you have any questions about your enrollment, call Member Services.

MEDICAID COVERAGE FOR CERTAIN NEWBORNS

An unborn child who is enrolled in CHIP Perinatal will be moved to Medicaid for 12 months of continuous Medicaid coverage, beginning on the date of birth, if the child lives in a family with an income at or below the Medicaid eligibility threshold.

An unborn child will continue to receive coverage through CHIP Perinatal after birth if the child is in a family with an income above the Medicaid eligibility threshold.


BENEFITS FOR CHIP PERINATE UNBORN MEMBERS

What are my unborn child’s CHIP Perinatal benefits? CHIP Perinatal benefits for your unborn child include: • Up to 20 prenatal visits • Prescription drug coverage • The cost of giving birth* • Two doctor visits for mom after the birth of the baby

*Hospital and other costs related to labor with delivery of the baby. Costs from labor that does not result in a birth and false labor are not covered.

For a complete listing of benefits that are covered, please see the Evidence of Coverage and schedule of benefits and exclusions in Attachment A at the back of this handbook.

You do not have to pay copayments or cost-sharing for covered benefits.

How do I get these services? Your perinatal provider will help you get these types of services.

What benefits does my baby receive at birth? If your baby is eligible as a CHIP Perinate newborn, he or she is eligible for the same coverage as a CHIP member from the date of birth. Your baby will get 12 months of continuous CHIP Perinatal coverage through his or her health plan, beginning with the month of enrollment as an unborn child.

What services are not covered? Some of the services not covered include: • A mother’s hospital visit for services not related to labor with delivery, such as a broken arm or false labor

(you can apply for Emergency Medicaid to cover your hospital visit, but you must meet the income limits) • Specialty treatment for the mother, such as care for asthma, heart conditions, mental health, or substance abuse

For a complete listing of benefits that are not covered, please see the Evidence of Coverage and schedule of benefits and exclusions in Attachment A at the back of this handbook.

What are my unborn child’s prescription drug benefits? Under CHIP, Dell Children’s Health Plan pays for most medicine your doctor says you need for your unborn child. Your doctor will write a prescription, so you can take it to the drugstore or may be able to send the prescription for you. Medication for behavioral health is not covered.

How much do I have to pay for my unborn child’s health care under CHIP Perinatal? You do not have to make any payment for covered benefits for your unborn child’s health care. You do not have to pay any enrollment fees, copays, or cost sharing.

Will I have to pay for services that are not covered benefits? Yes, Dell Children’s Health Plan only pays for covered benefits. If you get services that are not covered, you will be responsible for payment.


What extra benefits does a member of Dell Children’s Health Plan get? How can I get these benefits for my unborn child? Dell Children’s Health Plan covers extra health-care benefits for CHIP Perinate Unborn members. These extra benefits are also called Value-added Benefits (VABs). We give you these benefits to help keep you healthy and to thank you for choosing Dell Children’s Health Plan as your health-care plan. Call Member Services for more information on the extra benefits you can get or visit our website at dellchildrenshealthplan.com/members.

Value-added Benefit How to Get It

Our 24-hour Nurse HelpLine — nurses are available 24 hours a day, 7 days a week for your health-care questions

Call 1-888-596-0268 (TTY 711)

Free cellphone and up to 250 minutes of services each month if you qualify, plus:

• 200 extra one-time bonus minutes when you choose to receive free health text messages from Dell Children’s Health Plan

• Unlimited inbound text messages plus free health and wellness and renewal reminder texts from Dell Children’s Health Plan

• Unlimited minutes when calling our Member Services line

• Minutes include international calling if available

Call 1-888-596-0268 (TTY 711) or go to dellchildrenshealthplan.com/members for more information

Up to $250 for dental checkups, X-rays, cleanings, fillings, and extractions each year for pregnant members age 19 and older

Call 1-888-596-0268 (TTY 711)

$25 gift card upon completion of a maternity class held at a Seton facility

Call 1-888-596-0268 (TTY 711)

What health education classes does Dell Children’s Health Plan offer? Dell Children’s Health Plan works to keep you healthy with our health education programs. We can help you find classes near your home. You can call Member Services to find out where and when these classes are held. Some of the classes include childbirth, infant care, parenting, pregnancy, and protecting yourself from violence.

HEALTH CARE AND OTHER SERVICES FOR CHIP PERINATE UNBORN MEMBERS

Except in the case of an emergency (see section on Emergency Care), you should always call your perinatal provider first before you get medical care. If you have a medical concern you need to discuss with the provider after the office is closed, call the office phone number. If it is not an emergency, someone should call you back within 30 minutes to tell you what to do. You may also call our Nurse HelpLine 24 hours a day, 7 days a week for help.

If you think you need emergency care (see section on What is emergency medical care?), call 911 or go to the nearest emergency room right away.




How is new technology evaluated? The Dell Children’s Health Plan Medical Director and participating providers review and evaluate new medical advances in technology (or the new application of existing technology) in medical procedures, behavioral health procedures, pharmaceuticals, and devices to determine their appropriateness for covered benefits. Scientific literature and government approval are reviewed for determining if the treatment is safe and effective. The new medical advance or treatment (or new application of existing technology) must provide equal or better outcomes than the existing covered benefit treatment or therapy for it to be considered for coverage by Dell Children’s Health Plan.

What is routine medical care? In most cases when you need medical care, you call your perinatal provider to make an appointment. These visits will cover most minor illnesses and injuries that directly relate to your pregnancy, as well as regular prenatal checkups. This type of care is known as routine care.

How soon can I expect to be seen? You should be able to see your perinatal provider within 2 weeks for routine care.

What is urgent medical care? The second type of care is urgent care. There are some injuries and illnesses related to your pregnancy that are not emergencies but can turn into an emergency if they are not treated within 24 hours. Some examples are: • Throwing up • Headaches • Fever over 101 degrees

For urgent care, you should call your perinatal provider. Your perinatal provider will tell you what to do. He or she may tell you to go to his or her office right away, or you may be told to go to some other office to get immediate care. You should follow your perinatal provider’s instructions. In some cases, he or she may tell you to go to the emergency room at a hospital for care. See the next section about emergency care for more information. You can also call our 24-hour Nurse HelpLine at 1-888-596-0268 (TTY 711) for advice about urgent care.

How soon can I expect to be seen? You should be able to see a provider within 24 hours for an urgent-care appointment.

What is emergency medical care? After routine and urgent care, the third type of care is emergency care. If you need help deciding whether to go to the emergency room, call our 24-hour Nurse HelpLine at 1-888-596-0268 (TTY 711). The most important thing is to get medical care as soon as possible.

What is an emergency and an emergency medical condition? A CHIP Perinate member is defined as an unborn child. Emergency care is a covered service if it directly relates to the delivery of the unborn child until birth. Emergency care is provided for the following emergency medical conditions: • Medical screening examination to determine emergency when directly related to the delivery of the covered

unborn child • Stabilization services related to the labor with delivery of the covered unborn child • Emergency ground, air, and water transportation for labor and threatened labor is a covered benefit


• Emergency ground, air, and water transportation for an emergency associated with (a) miscarriage or (b) a nonviable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero) is a covered benefit

Benefit limits: Postdelivery services or complications resulting in the need for emergency services for the mother of the CHIP Perinate member are not a covered benefit.

What are emergency services and/or emergency care? Emergency services and/or emergency care are covered inpatient and outpatient services furnished by a provider that is qualified to furnish such services and that are needed to evaluate or stabilize an emergency medical condition, including post-stabilization care services related to labor and delivery of the unborn child.

How soon can I expect to be seen? You should be able to see a doctor immediately for emergency care.

How soon can I see my doctor? Dell Children’s Health Plan works with the providers in our network to make sure you can see them when you need to. Our providers are required to follow access standards listed below. Standards are measured from the date of presentation or request, whichever occurs first.

Standard Name Dell Children’s Health Plan

Emergency Services As soon as you arrive at the provider for care Urgent Care Within 24 hours of request Routine Primary Care Within 14 days of request Routine Specialty Care Within 3 weeks of request Prenatal Care Within 14 days of request Pregnancy High Risk/3rd trimester Within 5 days of request or immediately, if an emergency

exists After-Hours Care

Refer to the How do I get after hours care? section of this handbook.

What is poststabilization? Poststabilization care services are services covered by CHIP that keep your condition stable following emergency medical care.

What does medically necessary mean? Covered services for CHIP Members, CHIP Perinate Newborn Members, and CHIP Perinate Members must meet the CHIP definition of "Medically Necessary." A CHIP Perinate Member is an unborn child.

Medically Necessary means:

1. Health-care services that are: • Reasonable and necessary to prevent illnesses or medical conditions, or provide early screening,

interventions, or treatments for conditions that cause suffering or pain, cause physical deformity or


limitations in function, threaten to cause or worsen a disability, cause illness or infirmity of a member, or endanger life;

• Provided at appropriate facilities and at the appropriate levels of care for the treatment of a member’s health conditions;

• Consistent with health-care practice guidelines and standards that are endorsed by professionally recognized health-care organizations or governmental agencies;

• Consistent with the member’s diagnoses; • No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and

efficiency; • Not experimental or investigative; and • Not primarily for the convenience of the member or provider; and

2. Behavioral health-care services that: • Are reasonable and necessary for the diagnosis or treatment of a mental health or chemical dependency

disorder, or to improve, maintain, or prevent deterioration of functioning resulting from such a disorder; • Are in accordance with professionally accepted clinical guidelines and standards of practice in behavioral

health care; • Are furnished in the most appropriate and least restrictive setting in which services can be safely provided; • Are the most appropriate level or supply of service that can safely be provided; • Could not be omitted without adversely affecting the member’s mental and/or physical health or the quality

of care rendered; • Are not experimental or investigative; and • Are not primarily for the convenience of the member or provider.

If you have questions regarding an authorization, a request for services, or a utilization management question, you can call Member Services at 1-888-596-0268 (TTY 711).

What if I get sick when I am out of town or traveling/what if my child gets sick when he or she is out of town or traveling? If you/your child need medical care when traveling, call us toll-free at 1-888-596-0268 (TTY 711) and we will help you find a doctor. If you/your child needs emergency services while traveling, go to a nearby hospital, then call us toll-free at 1-888-596-0268 (TTY 711).

What if I am out of the state? If you need emergency care when you are outside of Texas, go to the nearest hospital emergency room or call 911.

What if I am/my child is out of the country? Medical services performed out of the country are not covered by CHIP.

What is a referral? A referral is a request from your perinatal provider for you to get care or treatment from a specialist. If your perinatal provider cannot give you the care you need, he or she will give you a referral to see a specialist. The referral form tells you and the specialist what kind of health care your unborn child needs. Be sure to take the referral form with you when you go to the specialist.

What services do not need a referral? The following services do not require a referral and can be accessed directly: • Emergency care


• Obstetrical/Gynecological care

What if I need services that are not covered by CHIP Perinatal? If you receive a service that is not covered by Dell Children’s Health Plan CHIP Perinatal, you will have to pay for that service.

How do I get my medications? CHIP Perinatal covers most of the medicine your unborn child’s doctor says you need. Your doctor will write a prescription so you can take it to the drug store, or may be able to send the prescription for you.

There are no copayments required for CHIP Perinate members.

How do I find a network drugstore? If you do not know if a drugstore takes Dell Children’s Health Plan, ask the pharmacist. You can also call Member Services for help at 1-888-596-0268 (TTY 711).

What if I go to a drugstore that is not in the network? The pharmacist will explain that they do not accept Dell Children’s Health Plan. You will need to take your prescription to a pharmacy that accepts Dell Children’s Health Plan.

What do I bring with me to the drugstore? When you go to the drugstore, you should bring: • Your prescription(s) or medicine bottle(s) • Your Dell Children’s Health Plan ID card

What if I need my medications delivered to me? Who do I call if I have problems getting my medications? Many pharmacies provide delivery services. Ask your pharmacist if they can deliver to your home. If you have problems getting your medications, please call Dell Children’s Health Plan Member Services at 1-888-596-0268 (TTY 711). We can work with you and your pharmacy to make sure you get the medicine you need.

What if I can’t get the medication my/my child’s doctor ordered approved? If your/your child’s doctor cannot be reached to approve a prescription, your child may be able to get a three-day emergency supply of your/your child’s medication.

Call Dell Children’s Health Plan at 1-888-596-0268 (TTY 711) for help with your medications and refills.

What if I lose my medications? If your medicine is lost or stolen, have your pharmacist contact Dell Children’s Health Plan at 1-888-596-0268 (TTY 711).

What if I need/my child needs an over-the-counter medication? The pharmacy cannot give you an over-the-counter medication as part of your/your child’s CHIP Perinatal benefit. If you need/your child needs an over-the-counter medication, you will have to pay for it.

For any other questions, please call Dell Children’s Health Plan at 1-888-596-0268 (TTY 711).


How do I find out what drugs are covered? Dell Children’s Health Plan uses the state Vendor Drug Program (VDP) list of drugs that your doctor can choose from. It includes all medicines covered by Medicaid and CHIP.

To view the Texas Formulary Drug Search, go to www.txvendordrug.com/formulary/formulary-search.asp.

When there is a generic drug available, it will be covered if it is on the VDP formulary. Generic drugs are equal to brand-name drugs as approved by the Food and Drug Administration (FDA).

How do I transfer my prescriptions to a network pharmacy? If you need to transfer your prescriptions, all you need to do is: • Call the nearest network pharmacy and give the needed information to the pharmacist, or • Bring your prescription container to the new pharmacy and they will handle the rest

How do I get my medicine if I am traveling? If you need a refill while on vacation, call your doctor for a new prescription to take with you.

What if I paid out of pocket for a medicine and want to be reimbursed? If you had to pay for a medicine, you may submit a request for reimbursement. Call Member Services at 1-888-596-0268 (TTY 711) to get information on how to get a reimbursement form and submit a claim.

Can someone interpret for me when I talk with my perinatal provider? Interpreter services are available for visits with your perinatal provider at no cost to you.

Who do I call for an interpreter? Call Member Services for more information.

How far in advance do I need to call? Please call Member Services at least 24 hours before your appointment if you need an interpreter.

How can I get a face-to-face interpreter in the provider’s office? Call Member Services if you need to have an interpreter with you when you talk to your provider.

How do I choose a perinatal provider and make an appointment? You can choose a perinatal provider from the Dell Children’s Health Plan provider directory. It is easy to make an appointment with your perinatal provider. Just call the provider’s office during regular business hours. If you need help making an appointment or choosing a perinatal provider, call Member Services. We will help you. When you call, let the person you talk to know what you need (for example, a checkup or a follow-up visit). Also, tell the provider’s office if you are not feeling well. This will let the provider’s office know how soon you need to be seen. It may also shorten the wait before you see the provider.

Will I need a referral? You won’t need a referral to see your perinatal provider. To learn more about referrals and when you’ll need one, go to the What is a referral? and the What services do not need a referral? sections of this handbook.


http://www.myamerigroup.com/English/Documents/Caremark_Claim_Form.pdf

http://www.txvendordrug.com/formulary/formulary-search.asp

How soon can I be seen after contacting a perinatal provider for an appointment? Once you talk to your perinatal provider and set up an appointment, you will be able to see the provider within 2 weeks.

Can I stay with a perinatal provider if the provider is not with Dell Children’s Health Plan? You may have been seeing a perinatal provider who is not in our network for prenatal care when you joined Dell Children’s Health Plan. In some cases, you may be able to keep seeing this provider for care while you pick a new provider. Please call us to find out more about this. Dell Children’s Health Plan will make a plan with you and your providers so we all know when you need to start seeing your new Dell Children’s Health Plan perinatal provider.

What if I get a bill from a perinatal provider? Who do I call? If you get a bill from a doctor, please call Dell Children’s Health Plan Member Services at 1-888-596-0268 (TTY 711) for help.

Always show your Dell Children’s Health Plan ID card when you see a provider, go to the hospital, or go for tests. Even if your provider told you to go, you must show your Dell Children’s Health Plan ID card to make sure you are not sent a bill for services covered by Dell Children’s Health Plan. You do not have to show your Dell Children’s Health Plan ID card before you get emergency care.

What information is needed if I get a bill? If you do get a bill, send the bill with a letter saying you have been sent a bill to the member advocate in your service area. In the letter, include your name, the telephone number where you can be reached, and your Dell Children’s Health Plan ID number. If you are unable to send a copy of the bill, be sure to include in the letter the name of the provider you got services from, the date of service, the provider’s phone number, the amount charged, and the account number if known. You can call Member Services at 1-888-596-0268 (TTY 711) for help.

What do I have to do if I move? As soon as you have your new address, give it to the local HHSC benefits office and the Dell Children’s Health Plan Member Services Department at 1-888-596-0268 (TTY 711). Before you get CHIP Perinatal services in your new area, you must call Dell Children’s Health Plan, unless you need emergency services. You will continue to get care through Dell Children’s Health Plan until HHSC changes your address.

What are my rights and responsibilities?

Member rights and responsibilities

Member rights: 1. You have a right to get accurate, easy-to-understand information to help you make good choices about your

unborn child’s health plan, doctors, hospitals, and other providers. 2. You have a right to know how the Perinatal providers are paid. Some may get a fixed payment no matter

how often you visit. Others get paid based on the services they provide for your unborn child. You have a right to know about what those payments are and how they work.

3. You have a right to know how the health plan decides whether a Perinatal service is covered or medically necessary. You have the right to know about the people in the health plan who decide those things.

4. You have a right to know the names of the hospitals and other Perinatal providers in the health plan and their addresses.


5. You have a right to pick from a list of health care providers that is large enough so that your unborn child can get the right kind of care when it is needed.

6. You have a right to emergency Perinatal services if you reasonably believe your unborn child’s life is in danger or your unborn child would be seriously hurt without getting treated right away. Coverage of such emergencies is available without first checking with the health plan.

7. You have the right and responsibility to take part in all the choices about your unborn child’s health care. 8. You have the right to speak for your unborn child in all treatment choices. 9. You have the right to be treated fairly by the health plan, doctors, hospitals, and other providers. 10. You have the right to talk to your Perinatal provider in private and to have your medical records kept private.

You have the right to look over and copy your medical records and to ask for changes to those records. 11. You have the right to a fair and quick process for solving problems with the health plan and the plan’s

doctors, hospitals, and others who provide Perinatal services for your unborn child. If the health plan says it will not pay for a covered Perinatal service or benefit that your unborn child’s doctor thinks is medically necessary, you have a right to have another group outside the health plan tell you if they think your doctor or the health plan was right.

12. You have a right to know that doctors, hospitals, and other Perinatal providers can give you information about your or your unborn child’s health status, medical care, or treatment. Your health plan cannot prevent them from giving you this information, even if the care or treatment is not a covered service.

Member responsibilities You and your health plan both have an interest in having your baby born healthy. You can help by assuming these responsibilities: 1. You must try to follow healthy habits. Stay away from tobacco and eat a healthy diet. 2. You must become involved in the decisions about your unborn child’s care. 3. If you have a disagreement with the health plan, you must try first to resolve it using the health plan’s

complaint process. 4. You must learn about what your health plan does and does not cover. Read your CHIP Perinatal Program

Handbook to understand how the rules work. 5. You must try to get to the doctor’s office on time. If you cannot keep the appointment, be sure to call and

cancel it. 6. You must report misuse of CHIP Perinatal services by health care providers, other members, or health plans. 7. You must talk to your provider about your medications that are prescribed.

If you think you have been treated unfairly or discriminated against, call the U.S. Department of Health and Human Services (HHS) toll-free at 1-800-368-1019. You also can view information concerning the HHS Office of Civil Rights online at www.hhs.gov/ocr.

When does CHIP Perinatal coverage end? Coverage ends on the last day of the month your baby is born.

Will the state send me anything when CHIP Perinatal coverage ends? Near the end of CHIP Perinatal, the state will send you information telling you what programs your child may be eligible for. Please be sure to complete and mail back any forms you receive in the mail.

How does renewal work? There is no renewal process for CHIP Perinatal; however, we want your child to keep getting his or her health-care benefits from us if he or she still qualifies.


http://www.hhs.gov/ocr

Can I choose my baby’s primary care provider before the baby is born? You can choose a primary care provider for your baby before he or she is born.

Who do I call? Call Member Services if you need help selecting a primary care provider for your baby.

What information do they need? Have your Dell Children’s Health Plan ID card ready when you call Member Services.

QUALITY MANAGEMENT

What does quality management do for members? The goal of the Dell Children’s Health Plan Quality Management program is to improve the health and well-being of our members. We look at services you have received to be sure you are getting the best preventive health care. If you have a chronic disease, we look to make sure you are getting any needed help with managing your condition.

The Quality Management department develops programs to help improve your knowledge about your health care. We have member outreach teams that may call to encourage you to schedule appointments for needed care. A team member will offer to help you schedule your medical appointments and arrange transportation if you need it. These services are provided free of charge because we want you to enjoy the best possible health.

We work with our contracted providers to give them education and information to help them provide the best care for you. You may receive mailings from us about taking preventive health steps or managing an illness. We encourage members and providers to make suggestions to help us improve quality of care for our members. If you would like more information about Quality Management program goals, our steps to reach those goals, and results, please call Member Services at 1-888-596-0268 (TTY 711).

What are clinical practice guidelines? Dell Children’s Health Plan uses national clinical practice guidelines for the care of members. Clinical practice guidelines are nationally recognized, scientific, and proven standards of care. These guidelines are recommendations for physicians and other health-care providers to diagnose and manage your specific condition. They guide decisions on diagnosis, management, and treatment of patients. If you would like a copy of these guidelines, contact Member Services at 1-888-596-0268 (TTY 711).

COMPLAINT PROCESS

What should I do if I have a complaint? Who do I call? We want to help. If you have a complaint, please call us toll-free at 1-888-596-0268 (TTY 711) to tell us about your problem. You may also send a written complaint to Dell Children’s Health Plan at the office nearest you listed in the front of this handbook. Please address your written request to the member advocate.


Can someone from Dell Children’s Health Plan help me file a complaint? Yes; a Dell Children’s Health Plan Member Advocate can help you file a complaint with Dell Children’s Health Plan or with the appropriate state program. Just call 1-888-596-0268 (TTY 711). Most of the time, we can help you right away or at most within a few days.

How long will it take to process my complaint? We will send you a letter within 30 days of when we get your complaint letter or complaint form. This letter will tell you what we have done to address your complaint. If your complaint is an emergency, we will look into it within 72 hours of getting your call, complaint letter, or complaint form.

What are the requirements and time frames for filing a complaint? Dell Children’s Health Plan will take your complaint over the phone or in writing. Once you make a complaint, we will send you a letter within 5 business days. This means that we have your complaint and have started to look at it. We will include a complaint form with our letter if your complaint was made by telephone. You must fill out this form and mail it back to us. If you need help filling out the complaint form, please call Member Services.

If I am not satisfied with the outcome, who else can I contact? If you are not satisfied with the answer to your complaint, you can also complain to the Texas Department of Insurance by calling toll-free to 1-800-252-3439. If you file or make a complaint, Dell Children’s Health Plan will not and cannot hold it against you. We will still be here to help you get quality health care. If you would like to make your request in writing, send it to:

Texas Department of Insurance Consumer Protection PO Box 149091 Austin, TX 78714-9091

If you can get on the Internet, you can send your complaint in an email at www.tdi.texas.gov/consumer/complfrm.html.

Do I have the right to meet with a complaint appeal panel? If you are not happy with the answer to your complaint, you can ask us to look at it again. This is a second level complaint. You must let us know in writing. When we receive your request, we will send you a letter within 5 business days. This means that we have your request and have started to work on it.

We will have a meeting with Dell Children’s Health Plan staff, network providers, and other Dell Children’s Health Plan members to look at your complaint. We will try to find a day and time for the meeting so you can be there. You can bring someone to the meeting if you want to. You do not have to come to the meeting. We will send you the papers we will look at during this meeting at least 5 business days before the meeting.

We will send you a letter within 30 days of having this meeting to tell you what the group decides about your complaint.


http://www.tdi.texas.gov/consumer/complfrm.html

PROCESS TO APPEAL A CHIP ADVERSE DETERMINATION

What can I do if my provider asks for a service or medicine for me that is covered, but Dell Children’s Health Plan denies or limits it? There may be times when Dell Children’s Health Plan says it will not pay for care that has been recommended by your provider. If we do this, you, the person acting on your behalf or your provider can appeal the decision. An appeal is when you ask Dell Children’s Health Plan to look again at the care your provider asked for and we said we will not pay for. You must file for an appeal within 30 days from the date on our first letter that says we will not pay for a service.

How will I find out if services are denied? You will receive a letter if you have services that are denied.

What are the time frames for the appeal process? When we get your letter or call, we will send you a letter within 5 business days. This letter will let you know we got your appeal. A doctor who has not seen your case before will look at your appeal. He or she will decide how we should handle your appeal.

We will send you a letter with the answer to your appeal. We will do this within 30 calendar days from when we get your appeal. We have a process to answer your appeal quickly if the care your provider says you need is urgent.

If you are not happy with the answer to your first level appeal, you can ask your doctor to ask us to look at the appeal again. This is called a second level appeal/specialty review. Your provider must send us a letter to ask for a second level appeal/specialty review within 10 business days of the date on the first level appeal letter from Dell Children’s Health Plan.

When we get the letter asking for the appeal, we will send you a letter within 5 business days. This letter will let you know we got the letter asking for a second level appeal/specialty review. A doctor who specializes in the type of care your provider says you need will look at the case. We will send you a letter with this doctor’s decision within 15 business days. That letter is our final decision. If you do not agree with our decision, you may ask for an independent review from the state.

When do I have the right to ask for an appeal? You must request an appeal within 30 days from the date on the first letter from Dell Children’s Health Plan that says we will not pay for the service. If you, the person acting on your behalf, or your provider are not happy with the answer to your first level appeal, your provider must send us a letter to ask for a second level appeal/specialty review. This letter must be sent within 10 business days from the date on our letter with the answer to your first level appeal.

If you file a medical appeal, Dell Children’s Health Plan will not hold it against you. We will still be here to help you get quality health care.

Does my request have to be in writing? No. Your request for an appeal can be made orally or in writing.


Can someone from Dell Children’s Health Plan help me file an appeal? You can call Member Services at 1-888-596-0268 (TTY 711) if you need help filing an appeal. If you file a medical appeal, Dell Children’s Health Plan will not hold it against you. We will still be here to help you get quality health care.

EXPEDITED APPEAL

What is an expedited appeal? You, the person you ask to file an appeal for you, or your provider can request an expedited appeal. An expedited appeal is when Dell Children’s Health Plan is required to make a decision quickly based on the condition of your health and taking the time for a standard appeal could jeopardize your or your unborn child’s life or health. You can request an expedited appeal if you or your provider thinks you need the services for an emergency or life-threatening illness.

How do I ask for an expedited appeal? Please call Member Services at 1-888-596-0268 (TTY 711) to start the request as quickly as possible. You can also send us a letter to Dell Children’s Health Plan Appeals, 2505 N. Highway 360, Suite 300, Grand Prairie, TX 75050. Call Member Services if you need help filing an appeal.

If you have a life-threatening condition or we deny prescription drugs or intravenous infusions that are already being received, you or someone acting on your behalf or the provider can ask for an immediate review by an independent review organization. You do not have to go through the Dell Children’s Health Plan internal appeal process first.

Does my request have to be in writing? Your request can be made orally or in writing. You can designate a representative to make the request for you. Call Member Services at 1-888-596-0268 (TTY 711) if you need help filing an appeal.

What are the time frames for an expedited appeal? If we agree that your request for an appeal should be expedited, we will tell you the answer to your appeal within 1 business day of when we get all the information we need to make a decision on your appeal.

What happens if Dell Children’s Health Plan denies the request for an expedited appeal? If we do not agree that your request for an appeal should be expedited, we will call you right away. We will also send you a letter within 3 days to let you know how the decision was made and that your appeal will be reviewed through the standard review process.

Who can help me in filing an expedited appeal? You can ask someone such as a friend, family member, or your child’s doctor to help you file an appeal. You can also contact Member Services at 1-888-596-0268 (TTY 711).


INDEPENDENT REVIEW ORGANIZATION PROCESS

What is an independent review organization? An Independent Review Organization (IRO) is an organization separate from Dell Children’s Health Plan who can review your appeal. If we have said that we will still not pay for the care after the first level appeal or specialty review, you, the person acting on your behalf, or the provider can ask for an independent review. With this review, your appeal will be reviewed by an IRO.

How do I ask for a review by an independent review organization? A request for a review by an IRO form is sent with the first appeal letter that tells you we will not pay for your care. If you need another one of these forms, just call us. You need to sign and complete this form to ask for an independent review. Mail the form back to us at Dell Children’s Health Plan Appeals, 2505 N. Highway 360, Suite 300, Grand Prairie, TX 75050.

We will notify the Texas Department of Insurance (TDI) that you have asked for an independent review once we get your form. The TDI will send you a letter that tells you about the IRO who will look at your case. The IRO will send you a letter to tell you its final decision.

What are the time frames for this process? The IRO will send a letter to you within 20 days of the request for an independent review. In the case of a life-threatening condition, the IRO will contact you with its decision within 4 business days or less of the request and will issue you a written decision within 48 hours after oral notification is made.

FRAUD AND ABUSE INFORMATION

Do you want to report CHIP Waste, Abuse, or Fraud? Let us know if you think a doctor, dentist, pharmacist at a drugstore, other health care provider, or a person getting CHIP benefits is doing something wrong. Doing something wrong could be waste, abuse, or fraud, which is against the law. For example, tell us if you think someone is: • Getting paid for CHIP services that weren’t given or necessary. • Not telling the truth about a medical condition to get medical treatment. • Letting someone else use a CHIP ID. • Using someone else’s CHIP ID. • Not telling the truth about the amount of money or resources he or she has to get benefits.

To report waste, abuse, or fraud, choose one of the following: • Call the OIG Hotline at 1-800-436-6184; • Visit https://oig.hhsc.state.tx.us/ Under the box labeled “I WANT TO”, click “Report Fraud, Waste, or Abuse”

to complete the online form; or • You can report directly to your health plan:

Compliance Officer 823 Congress Ave. Suite 400 Austin, TX 78701 1-800-315-5385


https://oig.hhsc.state.tx.us

Other reporting options include: Call Member Services 1-888-596-0268 (TTY 711).

To report waste, abuse, or fraud, gathers as much information as possible.

When reporting about a provider (e.g., doctor, dentist, counselor, etc.) include: • Name, address, and phone number of provider • Name and address of the facility (hospital, nursing home, home health agency, etc.) • Medicaid number of the provider and facility, if you have it • Type of provider (doctor, dentist, therapist, pharmacist, etc.) • Names and phone numbers of other witnesses who can help in the investigation • Dates of events • Summary of what happened

When reporting about someone who receives benefits, include: • The person’s name • The person’s date of birth, Social Security Number, or case number, if you have it • The city where the person lives • Specific details about the waste, abuse, or fraud

We hope this book has answered most of your questions about Dell Children’s Health Plan. For more information, you can call the Dell Children’s Health Plan Member Services department at 1-888-596-0268 (TTY 711).


THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION WITH REGARD TO YOUR HEALTH BENEFITS. PLEASE REVIEW IT CAREFULLY.

HIPAA Notice of Privacy Practices

The original effective date of this notice was April 14, 2003. The most recent revision date is shown at the end of this notice.

Please read this notice carefully. This tells you who can see your protected health information (PHI). It tells you when we have to ask for your OK before we share it. It tells you when we can share it without your OK. It also tells you what rights you have to see and change your information.

Information about your health and money is private. The law says we must keep this kind of information, called PHI, safe for our members. That means if you’re a member right now or if you used to be, your information is safe.

We get information about you from state agencies for Medicaid and the Children’s Health Insurance Program after you become eligible and sign up for our health plan. We also get it from your doctors, clinics, labs and hospitals so we can OK and pay for your health care.

Federal law says we must tell you what the law says we have to do to protect PHI that’s told to us, in writing or saved on a computer. We also have to tell you how we keep it safe. To protect PHI: • On paper (called physical), we:

– Lock our offices and files – Destroy paper with health information so others can’t get it

• Saved on a computer (called technical), we: – Use passwords so only the right people can get in – Use special programs to watch our systems

• Used or shared by people who work for us, doctors or the state, we: – Make rules for keeping information safe (called policies and procedures) – Teach people who work for us to follow the rules

When is it OK for us to use and share your PHI? We can share your PHI with your family or a person you choose who helps with or pays for your health care if you tell us it’s OK. Sometimes, we can use and share it without your OK: • For your medical care

– To help doctors, hospitals and others get you the care you need • For payment, health care operations and treatment

– To share information with the doctors, clinics and others who bill us for your care – When we say we’ll pay for health care or services before you get them – To find ways to make our programs better, as well as giving your PHI to health information exchanges

for payment, health care operations and treatment. • For health care business reasons

– To help with audits, fraud and abuse prevention programs, planning, and everyday work – To find ways to make our programs better

• For public health reasons – To help public health officials keep people from getting sick or hurt

• With others who help with or pay for your care – With your family or a person you choose who helps with or pays for your health care,

if you tell us it’s OK – With someone who helps with or pays for your health care, if you can’t speak for yourself and it’s best


for you

We must get your OK in writing before we use or share your PHI for all but your care, payment, everyday business, research or other things listed below. We have to get your written OK before we share psychotherapy notes from your doctor about you.

You may tell us in writing that you want to take back your written OK. We can’t take back what we used or shared when we had your OK. But we will stop using or sharing your PHI in the future.

Other ways we can — or the law says we have to — use your PHI: • To help the police and other people who make sure others follow laws • To report abuse and neglect • To help the court when we’re asked • To answer legal documents • To give information to health oversight agencies for things like audits or exams • To help coroners, medical examiners or funeral directors find out your name and cause of death • To help when you’ve asked to give your body parts to science • For research • To keep you or others from getting sick or badly hurt • To help people who work for the government with certain jobs • To give information to workers’ compensation if you get sick or hurt at work

What are your rights? • You can ask to look at your PHI and get a copy of it. We don’t have your whole medical record, though. If

you want a copy of your whole medical record, ask your doctor or health clinic. • You can ask us to change the medical record we have for you if you think something is wrong or missing. • Sometimes, you can ask us not to share your PHI. But we don’t have to agree to your request. • You can ask us to send PHI to a different address than the one we have for you or in some other way. We

can do this if sending it to the address we have for you may put you in danger. • You can ask us to tell you all the times over the past six years we’ve shared your PHI with someone else. This

won’t list the times we’ve shared it because of health care, payment, everyday health care business or some other reasons we didn’t list here.

• You can ask for a paper copy of this notice at any time, even if you asked for this one by email. • If you pay the whole bill for a service, you can ask your doctor not to share the information about that

service with us.

What do we have to do? • The law says we must keep your PHI private except as we’ve said in this notice. • We must tell you what the law says we have to do about privacy. • We must do what we say we’ll do in this notice. • We must send your PHI to some other address or in a way other than regular mail if you ask for reasons that

make sense, like if you’re in danger. • We must tell you if we have to share your PHI after you’ve asked us not to. • If state laws say we have to do more than what we’ve said here, we’ll follow those laws. • We have to let you know if we think your PHI has been breached.

We may contact you You agree that we, along with our affiliates and/or vendors, may call or text any phone numbers you give us, including a wireless phone number, using an automatic telephone dialing system and/or a pre-recorded message. Without limit, these calls or texts may be about treatment options, other health-related benefits and services, enrollment, payment, or billing.


What if you have questions? If you have questions about our privacy rules or want to use your rights, please call Member Services at 1-888-596-0268. If you’re deaf or hard of hearing, call TTY 711.

What if you have a complaint? We’re here to help. If you feel your PHI hasn’t been kept safe, you may call Member Services or contact the Department of Health and Human Services. Nothing bad will happen to you if you complain.

Write to or call the Department of Health and Human Services:

Office for Civil Rights U.S. Department of Health and Human Services 1301 Young St., Suite 1169 Dallas, TX 75202 Phone: 1-800-368-1019 TDD: 1-800-537-7697 Fax: 214-767-0432

We reserve the right to change this Health Insurance Portability and Accountability Act (HIPAA) notice and the ways we keep your PHI safe. If that happens, we’ll tell you about the changes in a newsletter.

Race, ethnicity and language We receive race, ethnicity and language information about you from the state Medicaid agency and the Children’s Health Insurance Program. We protect this information as described in this notice.

We use this information to: • Make sure you get the care you need • Create programs to improve health outcomes • Develop and send health education information • Let doctors know about your language needs • Provide translator services

We do not use this information to: • Issue health insurance • Decide how much to charge for services • Determine benefits • Disclose to unapproved users

Your personal information We may ask for, use and share personal information (PI) as we talked about in this notice. Your PI is not public and tells us who you are. It’s often taken for insurance reasons. • We may use your PI to make decisions about your:

– Health – Habits – Hobbies

• We may get PI about you from other people or groups like: – Doctors – Hospitals – Other insurance companies

• We may share PI with people or groups outside of our company without your OK in some cases. • We’ll let you know before we do anything where we have to give you a chance to say no.


• We’ll tell you how to let us know if you don’t want us to use or share your PI. • You have the right to see and change your PI. • We make sure your PI is kept safe.

Revised January 22, 2016


ATTACHMENT A Evidence of Coverage and Schedule of Benefits and Exclusions

CHILDREN'S HEALTH INSURANCE PROGRAM PERINATAL HEALTH BENEFIT PLAN FOR UNBORN CHILDREN EVIDENCE OF COVERAGE

HEALTH MAINTENANCE ORGANIZATION NONFEDERALLY QUALIFIED PLAN

THIS EVIDENCE OF COVERAGE (CONTRACT) IS ISSUED TO YOU, WHOSE UNBORN CHILD HAS ENROLLED IN DELL CHILDREN’S HEALTH PLAN HEALTH BENEFIT PLAN THROUGH THE CHILDREN'S HEALTH INSURANCE PROGRAM (CHIP) PERINATAL. YOU AGREE TO ADHERE TO THESE PROVISIONS FOR COVERED HEALTH SERVICES BY COMPLETING THE ENROLLMENT FORM AND ACCEPTING THIS EVIDENCE OF COVERAGE. THIS DOCUMENT DESCRIBES YOUR RIGHTS AND RESPONSIBILITIES IN RELATION TO YOUR UNBORN CHILD RECEIVING COVERED HEALTH SERVICES AND BENEFITS FROM DELL CHILDREN’S HEALTH PLAN THROUGH CHIP PERINATAL.

Issued by:

Dell Children’s Health Plan 1-888-596-0268 (TTY 711)

In association with:

Children's Health Insurance Program Perinatal PO Box 149276 Austin, TX 78714-9983 1-800-647-6558


IMPORTANT NOTICE To obtain information or make a complaint: • You may contact your Dell Children’s Health Plan Member Services representative at 1-888-596-0268

(TTY 711) • You may call the Dell Children’s Health Plan toll-free telephone number for information or to make a

complaint at 1-888-596-0268 (TTY 711) • You may also write to Dell Children’s Health Plan at the address at the front of this book

You may contact the Texas Department of Insurance to obtain information on companies, coverage, rights, or complaints at 1-800-252-3439.

You may write the Texas Department of Insurance at:

Texas Department of Insurance PO Box 149104 Austin, TX 78714-9104 Fax #: 512-475-1771 www.tdi.state.tx.us [email protected]

PREMIUM OR CLAIM DISPUTES: Should you have a dispute concerning your fee or about a claim, you should contact the member advocate with Dell Children’s Health Plan first. If the dispute is not resolved, you may contact the Texas Department of Insurance.

ATTACH THIS NOTICE TO YOUR POLICY: This notice is for information only and does not become a part or condition of the attached document.


mailto:[email protected]

http://www.tdi.state.tx.us

TABLE OF CONTENTS

I. Introduction A. Your Unborn Child’s Coverage under Dell Children’s Health Plan B. Your Contract with CHIP Perinatal

II. Definitions

III. When Does an Enrolled Member Become Covered?

IV. Termination of Member’s Coverage A. Disenrollment Due to Loss of CHIP Perinatal Eligibility B. Disenrollment by Dell Children’s Health Plan

V. Your Unborn Child’s Health Coverage A. Selecting Your Unborn Child’s Perinatal Provider B. Changing Your Unborn Child’s Perinatal Provider C. Emergency Services D. Out-of-Network Services E. Continuity of Treatment F. Notice of Claims G. Coordination of Benefits H. Subrogation

VI. How Do I Make a Complaint? A. Complaint Process B. Appeals to the Dell Children’s Health Plan C. Internal Appeal of Adverse Determination D. External Review by Independent Review Organization E. Filing Complaints with the Texas Department of Insurance F. Retaliation Prohibited

VII. General Provisions A. Entire Agreement, Amendments B. Release and Confidentiality of Medical Records C. Clerical Error D. Notice E. Validity F. Conformity with State Law

VIII. Schedule of Benefits, Excluded Services, and Covered Health Services


I. Introduction

A. Your Unborn Child’s Coverage under Dell Children’s Health Plan

Dell Children’s Health Plan provides benefits to your unborn child for covered health services under CHIP Perinatal and determines whether particular health services are covered health services, as described in Section VIII. Schedule of Benefits, Excluded Services, and Covered Health Services below. If properly enrolled, your unborn child is eligible for the benefits described in Section VIII. All services must be provided by participating physicians and providers except for emergency services and for out-of-network services that are authorized by Dell Children’s Health Plan. You have a contract with Dell Children’s Health Plan regarding matters stated in this Section I.A, as more fully described in this contract.

B. Your Contract with CHIP Perinatal

CHIP Perinatal has determined that your unborn child is eligible to receive coverage and under what circumstances the coverage will end. CHIP Perinatal also has determined your unborn child’s eligibility for other benefits under CHIP Perinatal.

II. DEFINITIONS

Administrator: The contractor with the state that administers enrollment functions for CHIP Perinatal is Dell Children’s Health Plan.

Adverse determination: A decision that is made by us or our Utilization Review agent that the health-care services furnished or proposed to be furnished to your unborn child are not medically necessary or not appropriate.

Dell Children’s Health Plan: Dell Children’s Health Plan, otherwise referred to as us, we, or our.

CHIP Perinatal: The Children's Health Insurance Program (CHIP) Perinatal, which provides coverage to each unborn child in accordance with an agreement between Dell Children’s Health Plan and the Health and Human Services Commission of the state of Texas.

Covered Health Services or Covered Services or Coverage: Those medically necessary services that are listed in Section VIII. Schedule of Benefits, Excluded Services, and Covered Health Services of this health benefit plan. Covered services also include any additional services offered by the Dell Children’s Health Plan as Value Added Services (VAS) in Section VIII. Schedule of Benefits, Excluded Services, and Covered Health Services of this health benefit plan.

Disability: A physical or mental impairment that substantially limits one or more of an individual’s major life activities, such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and/or working.

Emergency behavioral health condition: Any condition, without regard to the nature or cause of the condition, which in the opinion of a prudent layperson possessing an average knowledge of health and medicine: 1. Requires immediate intervention and/or medical attention without which the mother of the unborn child

would present an immediate danger to unborn child or others 2. That renders the mother of the unborn child incapable of controlling, knowing, or understanding the

consequences of their actions

Emergency condition: Means an emergency medical condition or an emergency behavioral health condition.


Emergency medical condition: A medical condition manifesting itself by acute symptoms of recent onset and sufficient severity (including severe pain), such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical care could result in: 1. Placing the unborn child’s health in serious jeopardy 2. Serious impairment to bodily functions to the unborn child 3. Serious dysfunction of any bodily organ or part that would affect the unborn child 4. Serious disfigurement to the unborn child, or 5. in the case of a pregnant woman, serious jeopardy to the health of a woman or her unborn child

Emergency services and emergency care: Covered inpatient and outpatient services furnished by a provider who is qualified to furnish such services and that are needed to evaluate or stabilize an emergency medical condition and/or an emergency behavioral health condition, including post-stabilization care services related to labor and delivery of the unborn child.

Experimental and/or investigational: A service or supply is experimental and/or investigational if we determine that one or more of the following is true: 1. The service or supply is under study or in a clinical trial to evaluate its toxicity, safety, or efficacy for a particular

diagnosis or set of indications. Clinical trials include but are not limited to Phase I, II, and III clinical trials. 2. The prevailing opinion within the appropriate specialty of the United States medical profession is that the

service or supply needs further evaluation for the particular diagnosis or set of indications before it is used outside clinical trials or other research settings. We will determine if this (item 2) is true based on: a. Published reports in authoritative medical literature b. Regulations, reports, publications, and evaluations issued by government agencies such as the Agency

for Health Care Policy and Research, the National Institutes of Health, and the FDA. 3. In the case of a drug, a device, or other supply that is subject to FDA approval:

a. It does not have FDA approval. b. It has FDA approval only under its Treatment Investigational New Drug regulation or a similar regulation. c. It has FDA approval, but it is being used for an indication or at a dosage that is not an accepted off-label

use; unlabeled uses of FDA-approved drugs are not considered experimental or investigational if they are determined to be: (i) Included in one or more of the following medical compendia: The American Medical Association

Drug Evaluations, The American Hospital Formulary Service Drug Information, The United States Pharmacopeia Information, and other authoritative compendia as identified from time to time by the Secretary of Health and Human Services

(ii) In addition, the medical appropriateness of unlabeled uses not included in the compendia can be established based on supportive clinical evidence in peer-reviewed medical publications

d. The physician or provider's institutional review board acknowledges that the use of the service or supply is experimental or investigational and subject to that board's approval.

e. Research protocols indicate that the service or supply is experimental or investigational. This item 3 applies for protocols used by the unborn child’s physician or provider, as well as for protocols used by other physicians or providers studying substantially the same service or supply.

Health benefit plan or plan: The coverage provided to the unborn child issued by Dell Children’s Health Plan providing covered health services.

Home health services: Health services provided at a member’s home by health-care personnel, as prescribed by the responsible physician or other authority designated by Dell Children’s Health Plan.


Hospital: A licensed public or private institution as defined by Chapter 241, Texas Health and Safety Code, or in Subtitle C, Title 7, Texas Health and Safety Code.

Illness: A physical or mental sickness or disease.

Independent Review Organization: An entity that is certified by the Commissioner of Insurance under Chapter 4202 to conduct independent review of adverse determinations.

Initial admission: Hospitalization from birth including ICU, transfers from another hospital to a hospital with an NICU, and any readmission that is less than 24 hours post discharge from the initial admission.

Injury or accidental injury: Accidental trauma or damage sustained by the unborn child or the mother of the unborn child to a body part or system that is not the result of a disease, bodily infirmity, or any other cause and could cause harm to the unborn child.

Life-threatening: A disease or condition for which the likelihood of death is probable unless the course of the disease or condition is interrupted.

Medically necessary services: Health services that are: Physical: • Reasonable and necessary to prevent Illness or medical conditions, or provide early screening,

interventions, and/or treatments for conditions that cause suffering or pain, cause physical malformation or limitations in function, threaten to cause or worsen a disability, cause Illness or infirmity of an unborn child, or endanger life of the unborn child

• Provided at appropriate facilities and at the appropriate levels of care for the treatment of an unborn child’s medical conditions

• Consistent with health-care practice guidelines and standards that are issued by professionally recognized health-care organizations or governmental agencies

• Consistent with diagnoses of the conditions • No more intrusive or restrictive than necessary to provide a proper balance of safety,

effectiveness, and efficiency • Not experimental or investigative • Not primarily for the convenience of the mother of the unborn child or health-care provider

Behavioral: • Reasonable and necessary for the diagnosis or treatment of a mental health or chemical

dependency disorder to improve, maintain, or prevent deterioration of function resulting from the disorder

• Provided in accordance with professionally accepted clinical guidelines and standards of practice in behavioral health care

• Not experimental or investigative • Not primarily for the convenience of the mother of the unborn child or health-care provider

Medically necessary services must be furnished in the most appropriate and least restrictive setting in which services can be safely provided and must be provided at the most appropriate level or supply of service which can safely be provided, and which could not be omitted without adversely affecting the unborn child’s physical health and/or or the quality of care provided.

Member: Any covered unborn child who is eligible for benefits and who is enrolled in the Texas CHIP Perinatal.


Out-of-area: Any location outside the Dell Children’s Health Plan CHIP Perinatal service area.

Pediatrician: A physician who is board-eligible/board-certified in pediatrics by the American Board of Pediatrics.

Physician: Anyone licensed to practice medicine in the state of Texas.

Perinatal provider: A physician, physician assistant, advanced practice nurse, or other qualified health-care provider who is contracted with Dell Children’s Health Plan to provide covered health services to an unborn child and who is responsible for providing initial and primary care, maintaining the continuity of care, and initiating referrals for care.

Provider: Any institution, organization, or person, other than a physician, that is licensed to or otherwise authorized to provide a health-care service in this state. The term includes, but is not limited to a hospital, doctor of chiropractic, pharmacist, registered nurse, optometrist, registered optician, pharmacy, clinic, skilled nursing facility, or home health agency.

Service area: CHIP Perinatal provider service area as defined by the Texas Health and Human Services Commission.

Specialist physician: A participating physician, other than a perinatal physician, under contract with Dell Children’s Health Plan to provide covered health services upon referral by the perinatal provider.

Unborn child (CHIP Perinate): Any child from conception to birth whom CHIP Perinatal has determined to be eligible for coverage and who is enrolled under this plan.

Urgent behavioral health care: A behavioral health condition that requires attention and assessment within 24 hours, but does not place the mother of the unborn child in immediate danger to the unborn child or others and the mother of the unborn child is able to cooperate with treatment.

Urgent care: A health condition, including urgent behavioral health care, that is not an emergency but is severe or painful enough to cause a prudent layperson possessing the average knowledge of medicine to believe that her condition as it relates to the unborn child requires medical treatment evaluation or treatment within 24 hours by the perinatal provider or the perinatal provider’s designee to prevent serious deterioration of the unborn child’s condition or health.

Usual and customary charge: The usual charge made by a group, entity, or person who renders or furnishes covered services, treatments, or supplies; provided the charge is not in excess of the general level of charges made by others who render or furnish the same or similar services, treatments, or supplies.

Utilization Review: The system for retrospective, concurrent, or prospective review of the medical necessity and appropriateness of covered health services provided, being provided, or proposed to be provided to an unborn child. The term does not include elective requests for clarification of coverage.

Utilization Review agent: An entity that is certified by the Commissioner of Insurance to conduct Utilization Review.

You and your: Mother of the unborn child.

III. When Does an Enrolled Unborn Child Become Covered?

Coverage of the unborn child begins on the first day of the month in which the unborn child is determined eligible for CHIP Perinatal.


IV. Termination of an Unborn Child’s Coverage

A. Disenrollment Due to Loss of CHIP Perinatal Eligibility

Disenrollment may occur if your unborn child loses CHIP Perinatal eligibility. Your unborn child may lose CHIP Perinatal eligibility for the following reasons: 1. Change in health insurance status, e.g., a parent of an unborn child enrolls in an employer-sponsored health

plan 2. Death of an unborn child 3. Mother of unborn child permanently moves out of the state 4. Unborn child’s parent or authorized representative requests (in writing) the voluntary disenrollment of an

unborn child 5. Mother of unborn child is enrolled in Medicaid or Medicare

B. Disenrollment by Dell Children’s Health Plan

Your unborn child may be disenrolled by us, subject to approval by the Health and Human Services Commission, for the following reasons: 1. Fraud or intentional material misrepresentation made by you after 15 days’ written notice 2. Fraud in the use of services or facilities after 15 days’ written notice 3. Misconduct that is detrimental to safe plan operations and the delivery of services 4. Mother of the unborn child no longer lives or resides in the service area 5. Mother of unborn child is disruptive, unruly, threatening, or uncooperative to the extent that unborn child’s

membership seriously impairs the ability of Dell Children’s Health Plan or the provider to provide services to the unborn child or to obtain a new member, and the mother of the unborn child’s behavior is not caused by a physical or behavioral health condition

6. Mother of the unborn child steadfastly refuses to comply with Dell Children’s Health Plan restrictions (e.g., repeatedly using emergency room in combination with refusing to allow Dell Children’s Health Plan to treat the underlying medical condition)

We will not disenroll an unborn child based on a change in the unborn child‘s health status, diminished mental capacity of the mother of the unborn child, or because of the amount of medically necessary services that are used to treat the unborn child’s condition. We will also not disenroll an unborn child because of uncooperative or disruptive behavior resulting from the mother of the unborn child’s special needs, unless this behavior seriously impairs our ability to furnish services to the unborn child or other enrollees.

V. Your Unborn Child’s Health Coverage

A. Selecting Your Unborn Child’s Perinatal Provider

You shall, at the time of enrollment in the Dell Children’s Health Plan, select your unborn child’s perinatal provider. You may select an obstetrician/gynecologist (OB/GYN) to provide covered health services within the scope of the professional specialty practice of the OB/GYN. The selection shall be made from those physicians and providers listed in the Dell Children’s Health Plan published list of physicians and providers. You have the option to choose a family practice physician with experience in prenatal care or other qualified health-care providers as a perinatal provider.

You shall look to the selected perinatal provider to direct and coordinate your unborn child’s care and recommend procedures and/or treatment.


B. Changing Your Unborn Child’s Perinatal Provider

You may request a change in your unborn child’s perinatal provider. Your request must be made to Dell Children’s Health Plan at least 30 days prior to the requested effective date of the change.

C. Emergency Services When you are taken to a hospital emergency department, freestanding emergency medical facility, or to a comparable emergency facility for care directly related to the labor or delivery of your covered unborn child, the treating physician/provider will perform a medical screening examination to determine whether a medical emergency directly related to the labor with delivery of the covered unborn child exists and will provide the treatment and stabilization of an emergency condition.

If additional care directly related to the labor and delivery of the covered unborn child is required after the unborn child is stabilized, the treating physician/provider must contact Dell Children’s Health Plan. Dell Children’s Health Plan must respond within 1 hour of receiving the call to approve or deny coverage of the additional care requested by the treating physician/provider.

If Dell Children’s Health Plan agrees to the care as proposed by the treating physician/provider or if Dell Children’s Health Plan fails to approve or deny the proposed care within one hour of receiving the call, the treating physician/provider may proceed with the proposed care. Postdelivery services or complications resulting in the need for emergency services for the mother of CHIP Perinatal newborn are not a covered benefit.

You should notify Dell Children’s Health Plan within 24 hours of any out-of-network emergency services or as soon as reasonably possible.

D. Out-of-Network Services

If covered health services are not available to your unborn child through network physicians or providers, Dell Children’s Health Plan, upon the request of a network physician or provider, shall allow referral to an out-of-network physician or provider and shall fully reimburse the out-of-network physician or provider at the usual and customary charge or at an agreed upon rate. Dell Children’s Health Plan further must provide for a review by a specialist of the same or similar specialty as the type of physician or provider to whom a referral is requested before Dell Children’s Health Plan may deny a referral.

E. Continuity of Treatment

The contract between Dell Children’s Health Plan and a physician or provider must provide that reasonable advance notice be given to you of the impending termination from the plan of a physician or provider who is currently treating your unborn child. The contract must also provide that the termination of the physician or provider contract, except for reasons of medical competence or professional behavior, does not release Dell Children’s Health Plan from its obligation to reimburse the physician or provider who is treating your unborn child of special circumstance, such as an unborn child who has a disability, an acute condition, or a life-threatening illness, or is past the 24th week of gestation, for your unborn child’s care in exchange for continuity of ongoing treatment for your unborn child then receiving medically necessary treatment in accordance with the dictates of medical prudence.

Special circumstance means a condition such that the treating physician or provider reasonably believes that discontinuing care by the treating physician or provider could cause harm to your unborn child. Special


circumstance shall be identified by the treating physician or provider who must request that your unborn child be permitted to continue treatment under the physician or provider’s care and agree not to seek payment from you for any amount for which you would not be responsible if the physician or provider were still on the Dell Children’s Health Plan network. Dell Children’s Health Plan shall reimburse the terminated physician or provider for your unborn child’s ongoing treatment. For an unborn child who at the time of termination is past the 24th week of gestation, Dell Children’s Health Plan shall reimburse the terminated physician or provider for treatment extending through delivery, immediate postpartum care, and follow-up checkups within 60 days of delivery.

F. Notice of Claims

You should not have to pay any amount for covered health services. If you receive a bill from a physician or provider, contact Dell Children’s Health Plan.

G. Coordination of Benefits

Your unborn child’s coverage under CHIP Perinatal is secondary when coordinating benefits with any other insurance coverage. This means that the coverage provided under CHIP Perinatal will pay benefits for covered services that remain unpaid after any other insurance coverage has paid.

H. Subrogation

Dell Children’s Health Plan receives all rights of recovery acquired by you or your unborn child against any person or organization for negligence or any willful act resulting in illness or injury covered by Dell Children’s Health Plan, but only to the extent of such benefits. Upon receiving such benefits from Dell Children’s Health Plan, you and your unborn child are considered to have assigned such rights of recovery to Dell Children’s Health Plan, and you agree to give Dell Children’s Health Plan any reasonable help required to secure the recovery.

VI. How Do I Make a Complaint?

A. Complaint Process

Complaint means any dissatisfaction expressed by you orally or in writing to us with any aspect of our operation, including, but not limited to, dissatisfaction with plan administration; procedures related to review or appeal of an adverse determination; the denial, reduction, or termination of a service for reasons not related to medical necessity; the way a service is provided; or disenrollment decisions.

If you notify us orally or in writing of a complaint, we will, no later than the 5th business day after the date of the receipt of the complaint, send to you a letter acknowledging the date we received your complaint. If the complaint was received orally, we will enclose a 1-page complaint form clearly stating that the complaint form must be returned to us for prompt resolution.

After receipt of the written complaint or 1-page complaint form from you, we will investigate and send you a letter with our resolution. The total time for acknowledging, investigating, and resolving your complaint will not exceed 30 calendar days after the date we receive your complaint.

Your complaint concerning an emergency or denial of continued stay for hospitalization will be resolved in 1 business day of receipt of your complaint. The investigation and resolution shall be concluded in accordance with the medical immediacy of the case.


You may use the appeals process to resolve a dispute regarding the resolution of your complaint.

B. Appeals to Dell Children’s Health Plan

1. If the complaint is not resolved to your satisfaction, you have the right either to appear in person before a complaint appeal panel where you normally receive health-care services, unless another site is agreed to by you, or to address a written appeal to the complaint appeal panel. We shall complete the appeals process no later than the 30th calendar day after the date of the receipt of the request for appeal.

2. We shall send an acknowledgment letter to you no later than the 5th day after the date of receipt of the request of the appeal.

3. We shall appoint members to the complaint appeal panel, who shall advise us on the resolution of the dispute. The complaint appeal panel shall be composed of an equal number of our staff, physicians, or other providers, and enrollees. A member of the appeal panel may not have been previously involved in the disputed decision.

4. No later than the 5th business day before the scheduled meeting of the panel, unless you agree otherwise, we shall provide to you or your designated representative: a. Any documentation to be presented to the panel by our staff b. The specialization of any physicians or providers consulted during the investigation c. The name and affiliation of each of our representatives on the panel

5. You or your designated representative, if you are a minor or disabled, are entitled to: a. Appear in person before the complaint appeal panel b. Present alternative expert testimony c. Request the presence of and question any person responsible for making the prior determination that

resulted in the appeal 6. Investigation and resolution of appeals relating to ongoing emergencies or denial of continued stays for

hospitalization shall be concluded in accordance with the medical immediacy of the case but in no event to exceed 1 business day after your request for appeal.

Due to the ongoing emergency or continued hospital stay, and at your request, we shall provide, in lieu of a complaint appeal panel, a review by a physician or provider who has not previously reviewed the case and is of the same or similar specialty as typically manages the medical condition, procedure, or treatment under discussion for review of the appeal.

7. Notice of our final decision on the appeal must include a statement of the specific medical determination, clinical basis, and contractual criteria used to reach the final decision.

C. Internal Appeal of Adverse Determination

An adverse determination is a decision that is made by us or our Utilization Review agent that the health-care services furnished or proposed to be furnished to your unborn child are not medically necessary or appropriate.

If you, your designated representative, or your unborn child’s physician or perinatal provider of record disagrees with the adverse determination, you, your designated representative, or your unborn child’s physician or perinatal provider may appeal the adverse determination orally or in writing.

Within 5 business days after receiving a written appeal of the adverse determination, we or our Utilization Review agent will send you, your designated representative, or your unborn child’s physician or perinatal provider, a letter acknowledging the date of receipt of the appeal. The letter will also include a list of documents that you, your designated representative or your unborn child’s physician or prenatal care provider should send to us or to our Utilization Review agent for the appeal.


If you, your designated representative, or your unborn child’s physician or perinatal provider orally appeal the adverse determination, we or our Utilization Review agent will send you, your designated representative or your unborn child’s physician or perinatal provider a 1-page appeal form. You are not required to return the completed form, but we encourage you to because it will help us resolve your appeal.

Appeals of adverse determinations involving ongoing emergencies or denials of continued stays in a hospital will be resolved no later than 1 business day from the date all information necessary to complete the appeal is received. All other appeals will be resolved no later than 30 calendar days after the date we or our Utilization Review agent receives the appeal.

D. External Review by Independent Review Organization

If the appeal of the adverse determination is denied, you, your designated representative, or your unborn child’s physician or perinatal provider of record have the right to request a review of that decision by an Independent Review Organization (IRO). When we or our Utilization Review agent deny the appeal, you, your designated representative, or you unborn child’s physician or perinatal provider will receive information on how to request an IRO review of the denial and the forms that must be completed and returned to begin the independent review process.

In circumstances involving a life-threatening condition, you are entitled to an immediate review by an IRO without having to comply with the procedures for internal appeals of adverse determinations. In life-threatening situations, you, your designated representative, or your unborn child’s physician or perinatal provider of record may contact us or our Utilization Review agent by telephone to request the review by the IRO; and we or our Utilization Review agent will provide the required information.

When the IRO completes its review and issues its decision, we will abide by the IRO's decision. We will pay for the IRO review.

The appeal procedures described above do not prohibit you, your designated representative, or your unborn child’s perinatal provider from pursuing other appropriate remedies, including injunctive relief, declaratory judgment, or other relief available under law, if you believe that the requirement of completing the appeal and review process places your unborn child’s health in serious jeopardy.

E. Filing Complaints with the Texas Department of Insurance

Any person, including persons who have attempted to resolve complaints through our complaint system process and who are dissatisfied with the resolution, may report an alleged violation to:

Texas Department of Insurance PO Box 149091 Austin, TX 78714-9091

Complaints to the Texas Department of Insurance may also be filed electronically at www.tdi.state.tx.us.

The Commissioner of Insurance shall investigate a complaint against us to determine compliance within 60 days after the Texas Department of Insurance’s receipt of the complaint and all information necessary for the department to determine compliance. The commissioner may extend the time necessary to complete an investigation in the event any of the following circumstances occur: 1. Additional information is needed


http://www.tdi.state.tx.us

2. An onsite review is necessary 3. We, the physician or provider, or you do not provide all documentation necessary to complete the investigation 4. Other circumstances beyond the control of the department occur

F. Retaliation Prohibited

1. We will not take any retaliatory action, including refusal to renew coverage, against an unborn child because the unborn child or person acting on behalf of the unborn child has filed a complaint against us or appealed a decision made by us.

2. We shall not engage in any retaliatory action, including terminating or refusal to renew a contract, against a physician or perinatal provider, because the physician or perinatal provider has, on behalf of an unborn child, reasonably filed a complaint against us or has appealed a decision made by us.

VII. General Provisions

A. Entire Agreement/Amendment

This contract, and any attachments or amendments, are the entire agreement between you and Dell Children’s Health Plan. To be valid, any changes to this contract must be approved by an officer of Dell Children’s Health Plan and attached to this contract.

B. Release and Confidentiality of Medical Records

Dell Children’s Health Plan agrees to maintain and preserve the confidentiality of any and all your medical records. However, by enrolling in Dell Children’s Health Plan, you authorize the release of information, as permitted by law, and access to any and all of your medical records for purposes reasonably related to the provision of services under this contract, to Dell Children’s Health Plan, its agents and employees, your unborn child’s perinatal provider, participating providers, outside providers of Utilization Review Committee, CHIP Perinatal, and appropriate governmental agencies. The Dell Children’s Health Plan privacy protections are described in more detail in its Notice of Privacy Practices. The Notice of Privacy Practices is available at dellchildrenshealthplan.com/members or you may request a copy by calling 1-888-596-0268 (TTY 711).

C. Clerical Error

Clerical error or delays in keeping your records for you and your unborn child’s Evidence of Coverage with CHIP Perinatal: 1. Will not deny coverage that otherwise would have been granted 2. Will not continue coverage that otherwise would have terminated

If any important facts given to CHIP Perinatal about you or your unborn child are not accurate and they affect coverage: 1. The true facts will be used by CHIP Perinatal to decide whether coverage is in force 2. Any necessary adjustments and/or recoupments will be made

D. Notice

Benefits under Workers' Compensation are not affected.

E. Validity



The unenforceability or invalidity of any provision of this Evidence of Coverage shall not affect the enforceability or validity of the rest of this contract.

F. Conformity with State Law

Any provision of this contract that is not in conformity with the Texas HMO Act, and state or federal laws or regulations governing CHIP, or other applicable laws or regulations shall not be rendered invalid but shall be construed and applied as if it were in full compliance with the Texas HMO Act, and state or federal laws or regulations governing CHIP, and other applicable laws or regulations.

VIII. Schedule of Benefits, Excluded Services, and Covered Health Services

These health services, when medically necessary, must be furnished in the most appropriate and least restrictive setting in which services can be safely provided and must be provided at the most appropriate level or supply of service can safely be provided and that could not be omitted without adversely affecting the member’s physical health or the quality of life.

Emergency care is a covered CHIP Perinatal service limited to those emergency services that directly relate to the delivery of the covered unborn child until birth and must be provided in accordance with Section V.C. Emergency services. Please refer to Section II. Definitions for the definition of "emergency and emergency condition" and the definition of "emergency services and emergency care" to determine if an emergency condition exists.

Covered benefit Limitations Copayments Inpatient general acute

Services include: Covered medically necessary hospital-provided services: • Operating, recovery, and other

treatment rooms • Anesthesia and administration (facility

technical component) • Medically necessary surgical services

are limited to services that directly relate to the delivery of the unborn child and services related to miscarriage or nonviable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero)

• Inpatient services associated with: − Miscarriage, or − A nonviable pregnancy (molar

pregnancy, ectopic pregnancy, or a fetus that expired in utero)

• Inpatient services associated with miscarriage or nonviable pregnancy include, but are not limited to:

For CHIP Perinates in families with incomes at or below 185 percent of the Federal Poverty Level (FPL), the facility charges are not a covered benefit; however, professional service charges associated with labor with delivery are a covered benefit.

For CHIP Perinates in families with incomes above 185 percent, up to and including 200 percent of the FPL, benefits are limited to professional service charges and facility charges associated with labor with delivery until birth.

Surgical services are limited to services that directly relate to the delivery of the unborn child.

Hospital-provided services are limited to labor with delivery until birth.

None


Covered benefit Limitations Copayments − Dilation and curettage

procedures − Appropriate provider-

administered medication − Ultrasound − Histological examination of tissue

samples

Comprehensive outpatient hospital, clinic May require prior authorization and None (including Health Center), and physician prescription. ambulatory health-care center

Services include the following services Laboratory and radiological services are provided in a hospital clinic or emergency limited to services that directly relate to room, a clinic or health center, hospital- antepartum care and/or the delivery of the based emergency department, or an covered CHIP Perinate until birth. ambulatory health-care setting: • X-ray, imaging, and radiological tests Ultrasound of the pregnant uterus is a

(technical component) covered benefit of CHIP Perinatal when • Laboratory and pathology services medically indicated. Ultrasound may be

(technical component) indicated for suspected genetic defects, • Machine diagnostic tests high-risk pregnancy, fetal growth • Drugs, medications, and biologicals retardation, gestational age conformation,

that are medically necessary or miscarriage or nonviable pregnancy. prescription and injection drugs

• Outpatient services associated with: Amniocentesis, cordocentesis, Fetal − Miscarriage, or Intrauterine Transfusion (FIUT), and − A nonviable pregnancy (molar ultrasonic guidance for cordocentesis, FIUT

pregnancy, ectopic pregnancy, or are covered benefits of CHIP Perinatal with a fetus that expired in utero) an appropriate diagnosis.

• Outpatient services associated with miscarriage or nonviable pregnancy Laboratory tests for CHIP Perinatal are include, but are not limited to: limited to: nonstress testing, contraction

− Dilation and curettage procedures stress testing, hemoglobin or hematocrit

− Appropriate provider-administered medications

− Ultrasounds − Histological examination of tissue

repeated 1 per trimester and at 32 to 36 weeks of pregnancy; or complete blood count, urinalysis for protein and glucose every visit, blood type and Rh antibody screen; repeat antibody screen for Rh

samples negative women at 28 weeks followed by RHO immune globulin administration if indicated; rubella antibody titer, serology for syphilis, hepatitis B surface antigen, cervical cytology, pregnancy test, gonorrhea test, urine culture, sickle cell test, tuberculosis (TB) test, human immunodeficiency virus (HIV) antibody screen, chlamydia test, other laboratory tests not specified but deemed medically


Covered benefit Limitations Copayments necessary, and multiple marker screens for neural tube defects (if the client initiates care between 16 and 20 weeks); screen for gestational diabetes at 24 to 28 weeks of pregnancy; and other lab tests as indicated by medical condition of client.

Surgical services associated with: • Miscarriage or • A nonviable pregnancy (molar

pregnancy, ectopic pregnancy, or a fetus that expired in utero) are a covered benefit

Physician/physician extender professional services

Services include, but are not limited to the following: • Medically necessary physician services

are limited to prenatal and postpartum care and/or the delivery of the covered unborn child until birth

• Physician office visits, inpatient and outpatient services

• Laboratory, X-rays, imaging and pathology services, including technical component and/or professional interpretation

• Medically necessary medications, biologicals, and materials administered in physician’s office

• Professional component (in/outpatient) of surgical services, including: − Surgeons and assistant surgeons

for surgical procedures directly related to the labor with delivery of the covered unborn child until birth

− Administration of anesthesia by Physician (other than surgeon) or CRNA

− Invasive diagnostic procedures directly related to the labor with delivery of the unborn child

− Surgical services associated with miscarriage or a nonviable pregnancy (molar pregnancy,

Does not require authorization for specialty services for use of contracted providers. Requires authorization for use of out-of-network providers.

Professional component of the ultrasound of the pregnant uterus when medically indicated for suspected genetic defects, high-risk pregnancy, fetal growth retardation, or gestational age conformation.

Professional component of amniocentesis, cordocentesis, Fetal Intrauterine Transfusion (FIUT); and ultrasonic guidance for amniocentesis, cordocentesis, and FIUT.

None


Covered benefit Limitations Copayments ectopic pregnancy, or a fetus that expired in utero)

• Hospital-based physician services (including physician-performed technical and interpretive components)

• Professional component associated with: − Miscarriage or − A nonviable pregnancy (molar


• Professional services associated with miscarriage or nonviable pregnancy include, but are not limited to: − Dilation and curettage procedures − Appropriate provider-

administered medications − Ultrasounds − Histological examination of tissue

samples Prenatal care and prepregnancy family services and supplies

Covered services are limited to an initial visit and subsequent prenatal (antepartum) care visits that include: • 1 visit every 4 weeks for the first 28

weeks of pregnancy; 1 visit every 2 to 3 weeks from 28 to 36 weeks of pregnancy; and 1 visit per week from 36 weeks to delivery; more frequent visits are allowed as medically necessary

Does not require authorization for specialty services for use of contracted providers. Requires authorization for use of out-of-network providers.

Professional component of the ultrasound of the pregnant uterus when medically indicated for suspected genetic defects, high-risk pregnancy, fetal growth retardation, or gestational age conformation.

Professional component of amniocentesis, cordocentesis, Fetal Intrauterine Transfusion (FIUT); and ultrasonic guidance for amniocentesis, cordocentesis, and FIUT.

None

Emergency services, including emergency hospitals, physicians, and ambulance services

Health plan cannot require authorization as a condition for payment for emergency conditions related to labor and delivery.

Covered services are limited to those emergency services that are directly related to the delivery of the covered

Postdelivery services or complications resulting in the need for emergency services for the mother of the CHIP Perinate are not a covered benefit.


Covered benefit Limitations Copayments unborn child until birth. • Emergency services based on prudent

layperson definition of emergency health condition

• Medical screening examination to determine emergency when directly related to the delivery of the covered unborn child

• Stabilization services related to the labor and delivery of the covered unborn child

• Emergency ground, air, and water transportation for labor and threatened labor is a covered benefit

• Emergency services associated with: − Miscarriage or − A nonviable pregnancy (molar


Case management services

Case management services are a covered benefit for the unborn child.

These covered services include outreach informing, case management, care coordination, and community referral.

None

Care coordination services

Care coordination services are a covered benefit for the unborn child.

None

Value-added services See Extra Benefits None

CHIP Perinatal Exclusions from Covered Services for CHIP Perinates • For CHIP Perinates in families with incomes at or below 185 percent of the federal poverty level, inpatient

facility charges are not a covered benefit if associated with the initial perinatal newborn admission: “initial perinatal newborn admission” means the hospitalization associated with the birth

• Inpatient and outpatient treatments other than prenatal care, labor with delivery, and postpartum care related to the covered unborn child until birth; services related to preterm, false, or other labor not resulting in delivery are excluded services

• Inpatient mental health services • Outpatient mental health services • Durable medical equipment or other medically related remedial devices • Disposable medical supplies • Home and community-based health-care services • Nursing care services • Dental services • Inpatient substance abuse treatment services and residential substance abuse treatment services • Outpatient substance abuse treatment services • Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders • Hospice care


• Skilled nursing facility and rehabilitation hospital services • Emergency services other than those directly related to the delivery of the covered unborn child • Transplant services • Tobacco cessation programs • Chiropractic services • Medical transportation not directly related to the labor or threatened labor and/or delivery of the covered

unborn child • Personal comfort items, including, but not limited to, personal care kits provided on inpatient admission,

telephone, television, newborn infant photographs, meals for guests of patient, and other articles that are not required for the specific treatment related to labor and delivery or postpartum care

• Experimental and/or investigational medical, surgical, or other health-care procedures or services that are not generally employed or recognized within the medical community

• Treatment or evaluations required by third parties, including but not limited to those for schools, employment, flight clearance, camps, insurance, or court

• Private duty nursing services when performed on an inpatient basis or in a skilled nursing facility • Mechanical organ replacement devices, including but not limited to an artificial heart • Hospital services and supplies when confinement is solely for diagnostic testing purposes and not a part of

labor and delivery • Prostate and mammography screening • Elective surgery to correct vision • Gastric procedures for weight loss • Cosmetic surgery/services solely for cosmetic purposes • Dental devices solely for cosmetic purposes • Out-of-network services not authorized by the health plan except for emergency care related to the labor

and delivery of the covered unborn child • Services, supplies, meal replacements, or supplements provided for weight control or the treatment of obesity • Acupuncture services, naturopathy, and hypnotherapy • Immunizations solely for foreign travel • Routine foot care such as hygienic care (routine foot care does not include treatment of injury or

complications of diabetes) • Diagnosis and treatment of weak, strained, or flat feet; and the cutting or removal of corns, calluses, and

toenails (this does not apply to the removal of nail roots or surgical treatment of conditions underlying corns, calluses, or ingrown toenails)

• Corrective orthopedic shoes • Convenience items • Orthotics primarily used for athletic or recreational purposes • Custodial care (care that assists with the activities of daily living, such as assistance in walking, getting in and

out of bed, bathing, dressing, feeding, toileting, special diet preparation, and medication supervision that is usually self-administered or provided by a caregiver; this care does not require the continuing attention of trained medical or paramedical personnel)

• Housekeeping • Public facility services and care for conditions that federal, state, or local law requires be provided in a public

facility or care provided while in the custody of legal authorities • Services or supplies received from a nurse that do not require the skill and training of a nurse • Vision training, vision therapy, or vision services • Reimbursement for school-based physical therapy, occupational therapy, or speech therapy services • Donor nonmedical expenses • Charges incurred as a donor of an organ • Coverage while traveling outside of the United States and U.S. territories (including Puerto Rico, U.S. Virgin

Islands, Commonwealth of Northern Mariana Islands, Guam, and American Samoa)


Dell Children’s Health Plan follows Federal civil rights laws. We don’t discriminate against people because of their:

• Race • National origin • Disability • Color • Age • Sex or gender identity

That means we won’t exclude you or treat you differently because of these things.

Communicating with you is important For people with disabilities or who speak a language other than English, we offer these services at no cost to you: • Qualified sign language interpreters • Written materials in large print, audio, electronic, and other formats • Help from qualified interpreters in the language you speak • Written materials in the language you speak

To get these services, call the Member Services number on your ID card. Or you can call our Member Advocate at 1-888-596-0268 (TTY 711).

Your rights Do you feel you didn’t get these services or we discriminated against you for reasons listed above? If so, you can file a grievance (complaint). File by mail, email, fax, or phone:

Member Advocate – Dell Children’s Health Plan Phone: 1-888-596-0268 (TTY 711) 823 Congress Ave., Suite 400 Fax: 512-382-4965 Austin, TX 78701 Email: [email protected]

Need help filing? Call our Member Advocate at the number above. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights:

• On the Web: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf • By mail: U.S. Department of Health and Human Services

200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

• By phone: 1-800-368-1019 (TTY/TDD 1-800-537-7697)

For a complaint form, visit www.hhs.gov/ocr/office/file/index.html.

TS-MEM-0156-16

http://www.hhs.gov/ocr/office/file/index.html

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

mailto:[email protected]

We can translate this at no cost. Call the customer service number on your member ID card.

Podemos traducir esto gratuitamente. Llame al número de Spanish servicio de atención al cliente que aparece en su tarjeta de identificación (ID Card).

ىعلن ودمالف تاهالم قرم داختسأب، ءاضعالات امدخبصل تا.اناجمد واماله ذهة مجترع يطتسن .كديلءاضالعاةقاطب

Arabic

Մենք կարող ենք անվճար թարգմանել սա: Զանգահարեք Armenian հաճախորդների սպասարկման բաժին ձեր անդամաքարտում (ID card) նշված հեռախոսահամարով:

Burmese

我們可以免費為您提供翻譯版本。請撥打您 ID 卡上所列的電話號碼洽詢客戶服務中心。

Chinese

تشپه کا من يعجارمت ادمخه راشمه ب .مينکه مجرتن اتيابرن ايگراه ب ران يام ينواتی ما م Farsi ID(ان تی ياساشنت راک

Nous pouvons traduire ceci gratuitement. Appelez le numéro du French service après-vente sur votre carte d’identification.

.دزنين بفلت، هدشج رد )

Nou ka tradwi sa la pou okenn pri. Pélé nimero sèvis kliyentèl la Fr. Creole sou tô kat didantité.

Wir können das gerne kostenlos übersetzen. Bitte wenden Sie German sich an die Kundenservice-Hotline auf Ihrer ID-Karte.

Mπορούμε να σας μεταφράσουμε το παρακάτω χωρίς χρέωση. Greek Καλέστε τον αριθμό του Τμήματος Εξυπηρέτησης Πελατών που θα βρείτε στην κάρτα ταυτοποίησής σας.

અમ આ ભાષાતર કોઈપણ ખચર લીધા િવના કર શક એ છ એ. તમારા ID કાડર પર આપલ

ગારક સવા નબર પર ફોન કરો.

Gujarati

Hebrewהלקוחות הנמצא על גבי כרטיס הזיהוי שלך.

Hindi

Peb txhais tau qhov ntawm no dawb. Hu rau lub chaw haujlwm Hmong pab cov neeg siv peb cov kev pab tus xovtooj uas nyob ntawm koj daim npav ID rau tus tswv cuab.

MEMCOMM-0489-16

אנחנו יכולים לתרגם את זה ללא עלות. התקשר למספר של שירות

हम इसका अनवाद �नशल कर सकत ह�। अपनक काडर पर �दए गए ग ID

सवा नबर पर फोन कर�। ाहक

Possiamo effettuare la traduzione gratuitamente. Contatti il Italiannumero dell’assistenza clienti riportato sulla Sua tessera identificativa.

私たちは、この文章を無料で翻訳することができます。ご自身の IDカードにあ Japanese るカスタマーサービス番号へお電話ください。

េយើង ចបកែបជនេ យឥតអស រសពេ ែផកេស ៃថអេទ ។ សមទ អតថជន មេលខ នេ េលើបណ ID អក ។ របស

Khmer

저희는 이것을 무료로 번역해 드릴 수 있습니다 . 가입자 ID 카드에 Korean 있는 고객 서비스부 번호로 연락하십시오 .

ພວກເຮາສາມາດແປອນນ ໃຫ ານໄດຟຣ. Laotian ໃຫໂທຫາຝາຍບລການລ ກຄາທມເບ ໃນບດປະຈາຕວຂອງທານ. ຢ ທ

Możemy to przetłumaczyć bez żadnych kosztów. Zadzwoń pod Polish numer obsługi klienta za pomocą karty ID.

Podemos traduzir isto gratuitamente. Ligue para o serviço de Portuguese atendimento ao cliente que consta no seu cartão de identificação.

Мы можем это бесплатно перевести. Позвоните в отдел Russian обслуживания по телефону, приведенному на вашей идентификационной карточке участника плана.

Možemo to prevesti besplatno. Pozovite na broj korisničkog Serbian servisa s Vaše identifikacione kartice (ID).

Maaari namin ito isalin-wika nang walang bayad. Mangyaring Tagalog tawagan ang numero ng customer service sa inyong ID card na pang miyembro.

เราสามารถแปลไดโดยไมมคาใชจายใดๆ Thai ตดตอหมายเลขโทรศพทของฝายบรการลกคาบนบตรประจาตวของคณ

ربمنے کس ورسر مڻسکے ئگے يدر پڈ راک IDےنپا۔ ںيہے تکسر کت ف مہ مجرتا کس ام ہ۔ ںيرکل اکر پ

Urdu

Chúng tôi có thể phiên dịch tài liệu này miễn phí. Xin gọi dịch vụ Vietnamese khách hàng qua số điện thoại ghi trên thẻ ID hội viên của quý vị.

סװירסער עמטוסקאם דעט ופר .לצאפאן פוײ רפן צזערעבאיס דאן נעקער מי Yiddish .לטרקאט טעטינעדאיר ײעאף ױאר מענו

MEMCOMM-0489-16

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