PASC-SEIU Homecare Workers

PASC-SEIU Homecare Workers

Health Care Plan for In-Home Supportive Services Workers

2018

A Helpful Guide to Your Health Care Benefits

Gu?a ?til para sus beneficios de atenci?n m?dica

A Helpful Guide to Your Health Care Benefts

Thank you for your membership with L.A. Care Health Plan. When you join, you will get this package of important information in the mail. It is about your health coverage. We need you to read and understand it.

Tis Member Handbook you are reading contains the Evidence of Coverage and Disclosure Form (EOC). It has the terms and conditions of your health care benefts, summarizes the L.A. Care Health Plan (L.A. Care) policies and rules, and tells you how to get health care. Te Member Handbook is broken down into the following sections:

? Combined Evidence of Coverage and Disclosure Form......................................................... 3 ? How to Get Your Prescription Drugs........................................................................................55 ? Stay Healthy ? Preventive Health Guidelines for Adults......................................................57 ? Notice of Privacy Practices ........................................................................................................61 ? Nurse Advice Line ? List of Audio Health Topics ...................................................................65

Te information listed below can be found in this Member Handbook:

Basic Information ? What benefts and services are covered ? What benefts and services are not covered ? How your health plan makes decisions about when new treatments will become benefits ? What care you can and cannot get when you are out of Los Angeles County or the L.A. Care network ? How to access care when you are out of Los Angeles County ? How to change or get care from your primary care physician (PCP) ? How to get information about doctors ? How to get a referral for special care or to go to the hospital ? What to do when you need care right away or when the ofce is closed ? What to do if you have an emergency ? How to get prescriptions flled, other pharmacy program information and updates ? Co-payments and other charges ? What to do if you get a bill ? How to keep you and your family healthy guide

L.A. Care has the following Special Programs: ? Quality Improvement Programs to tell us how we can improve quality of care, safety and services for our members. Tese Programs tell us how to measure our progress so that we can meet our goals and provide quality services and decide what we may need to change ? Case Management Programs for members who have difcult medical problems ? Programs to better manage diseases, like diabetes and/or asthma

How Decisions Are Made About Your Care ? How our doctors and staf make decisions about your care based only on need and benefits. We do not encourage doctors to provide less care than you need and doctors are not paid to deny care. ? How to reach us if you want to know more about how decisions are made about your care ? How to appeal a decision about your care ? L.A. Care has a list of covered drugs called a Formulary ? Te formulary is updated and posted monthly, and you can fnd the formulary and updates on our website at . ? Certain covered drugs have restrictions such as Step Terapy (ST), Quantity Limits (QL), and or require a Prior Authorization (PA).

LA0718 02/18

? FDA approved generic drugs will be used in most situations, even when a brand-name drug is available.

? If your drug is non-Formulary, or has a restriction, your doctor will need to submit a request to L.A. Care. Te request can be approved if there is a documented medical need.

? To see a full list and explanation of the pharmaceutical management procedures and restrictions, visit L.A. Care's website at .

Member Issues ? Your rights and responsibilities as a health plan member ? How to complain when you are unhappy ? What to do if you are disenrolled from your plan ? How L.A. Care protects and uses your personal health information

You may view this Member Handbook before enrollment in a program. Be sure to see our website , or call us at 1.844.854.7272 if you would like paper copies.

2018 PASC-SEIU Member Handbook

PASC-SEIU Homecare Workers Health Care Plan for In-Home Supportive Services Workers

Combined Evidence of Coverage and Disclosure Form (Member Handbook)

2018

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Table of Contents

Customer Service

6

Welcome! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Health Information Privacy . . . . . . . . . . . . . . . . . . . . 6 Identifcation Card (ID Card) . . . . . . . . . . . . . . . . . . . 6 The Provider Directory . . . . . . . . . . . . . . . . . . . . . . . . 7 Language and Interpreting Services . . . . . . . . . . . 7 Hearing Impaired Services. . . . . . . . . . . . . . . . . . . . . .7 Vision Impaired Services. . . . . . . . . . . . . . . . . . . . . . . 7 Health Care Access for Patients with Disabilities. . 7 Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Timely Access of Care . . . . . . . . . . . . . . . . . . . . . . . . . .8 Helpful information at on the Internet . . 8

Member Bill of Rights

9

Grievance & Appeals

17

L.A. Care Grievance Process. . . . . . . . . . . . . . . . . . . 17

How to File a Grievance . . . . . . . . . . . . . . . . . . . . . . 17

How to File a Grievance for Urgent Cases. . . . . . 18

Independent Medical Review . . . . . . . . . . . . . . . . . 18

Review by the Department of Managed Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Eligibility and Enrollment . . . . . . . . . . . . . . . . . . . . . 19

Payment Responsibilities

21

Monthly Premium. . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Annual Co-payment Maximum . . . . . . . . . . . . . . . 21

Member Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

How to Get Care

11

Primary Care Physician (PCP). . . . . . . . . . . . . . . . . . 11

Scheduling Appointments . . . . . . . . . . . . . . . . . . . 11

Referrals and Prior Authorizations. . . . . . . . . . . . . 12

Referrals to Specialty Physicians . . . . . . . . . . . . . . 12

Standing Referrals. . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Second Opinions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Behavioral Health Services. . . . . . . . . . . . . . . . . . . . 13

How to Find a Pharmacy . . . . . . . . . . . . . . . . . . . . . 13

Emergency and Urgent Care Services . . . . . . . . . 15

Non-Qualifed Services . . . . . . . . . . . . . . . . . . . . . . . 16

Continuity of Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Summary of Benefts

22

Plan Benefts

29

Asthma Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Blood and Blood Products. . . . . . . . . . . . . . . . . . . . 29 Behavioral Health Services. . . . . . . . . . . . . . . . . . . . 29 Cancer Clinical Trials. . . . . . . . . . . . . . . . . . . . . . . . . . 30 Cataract Spectacles and Lenses . . . . . . . . . . . . . . . 30 Confdential HIV and STD Testing . . . . . . . . . . . . . 30 Dental Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Diabetic Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Diagnostic X-Ray and Laboratory Services . . . . . 30 Durable Medical Equipment (DME) . . . . . . . . . . . 31

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