Get the Most from Your Coverage
You Deserve Quality Healthcare. And you also deserve to have the information you need to get the most from your coverage. Goals for quality are set and reviewed by your health plan to make sure you get the care you need.
This information is part of a Quality Program designed to improve the services and care you receive. It provides details about your coverage and services available to you.
Contact Participant Services to learn more about the Quality Program.
Know Your Rights
Being a participant means there are things you should expect from your health plan. These are some of your rights:
- You should have access to all the services available to participants
- You should be treated with courtesy and respect
- You should be able to get a copy of your medical record
- You should know your medical data will be kept private. There are policies in place to guard your health records and protected health information.
It’s also important to know what you can do to get the most from your coverage:
- Ask questions if you don’t understand your rights
- Be sure to keep your scheduled appointments
- Keep your Participant ID Card with you so you have it at appointments
- Tell your doctor if you have gotten care in an emergency room.
The full list of rights and responsibilities is in your Participant Handbook.
Getting the Care You Need
Your PCP is the doctor you’ll see for routine checkups and care. Your PCP will help find other types of healthcare providers if you need one. You can also search Find-a-Provider on your health plan website.
As children get older, they should change from seeing a pediatrician to seeing an adult doctor. Teens don’t need checkups as often as young kids do, but they should see their PCP at least once a year. Regular visits will help them stay up to date on vaccines. If teens have a condition such as diabetes or asthma, it’s very important that they keep seeing their doctors and not miss a visit. Call your health plan if you need help finding an adult provider.
You should be able to schedule an appointment with your PCP and get medical care when you need it. You may have to wait a little longer to get in to see certain other types of providers, like specialists. Call your health plan if you can’t get an appointment in a timely manner.
You should get high quality medications and the right treatment for your conditions. But not all drugs are covered. And some may need to be approved before they’re covered. The Preferred Drug List (PDL) is located on your health plan website. It is updated regularly and lists drugs that are covered by insurance. Talk to your doctor or pharmacist to review the PDL and answer questions about your medications.
The Utilization Management (UM) Department looks at your health records and may also talk with your doctor to decide if a service you need is covered. These decisions are not based on financial reasons. And doctors and staff are not rewarded for saying no to care. All UM decisions are based on:
- If the service is medically necessary
- If the service works well
- If the service is right for you
New medicines, tests and procedures come out every year. A team of doctors and other experts decide if new medical care will be covered by your health plan. Your plan covers care that is medically necessary. Not every new medical service is covered for all members.
If a service is denied, you have the right to appeal that decision. You will be sent a letter explaining how to make an appeal. All appeal requests are decided according to your request, condition and benefits.
Care Management is for members who may need extra help taking care of their health. Some people have several health conditions and see more than one doctor. Others need help arranging the services their doctors may have ordered. Working with a care manager lets you understand major health problems, work well with your doctors and get the care you need.
Get More Information
Your Participant Handbook is a great source for information about your coverage and benefits. It also lists important phone numbers.
Call: You can also contact Participant Services for additional help at 1-844-626-6813. Translation services are available if you need them.
Member Services to get:
- A paper copy of your Participant Handbook, Privacy Notice or anything on your health plan website
- Help finding a doctor and making an appointment
- Help speaking with a care manager
- Help with an appeal for a service that’s been denied
- Help with a ride to your appointment
Your health plan website also has a lot of helpful information. Visit it to find the Participant Handbook, Find-a-Provider tool, and the Preferred Drug List. You can also use it to help you manage your health.
Creating an online participant account is free and easy. With it, you can:
- Find or change your PCP
- Request a new Participant ID Card or print a temporary ID Card
- View and update your personal information
You can also send a message directly to your health plan from your participant account.