Member Handbook - Centene...2016/04/13 · para os Servicos ao Associado atraves do numero 1-855-678-6975, TDD/TTY: 1-866-614-1949 para que o(a) possamos ajudar. ROMANIAN: Dacă informaţiile

© 2016 CeltiCare Health Plan of Massachusetts, Inc.™

Member Handbook

CeltiCare Health Plan of Massachusetts, Inc.™ (CeltiCare Health), will accept you into our plan upon referral from the MassHealth regardless of your income, physical or mental condition, age, gender, sexual orientation, religion, physical or mental disability, ethnicity or race, previous status as a Member, pre-existing conditions, and/or expected health or genetic status.

CarePlus

This Member Handbook should be saved with the Summary of Benefi ts to provide you with a complete listing of your covered and excluded services.

Effective Date: August 1, 2015

CeltiCare Health Member Services: 1-855-678-6975; (TDD/TTY) 1-866-614-1949 M – F, 8 a.m. -5 p.m. Cenpatico Behavioral Health: 1-866-896-5053 (TDD/TTY: 1-800-439-2370) M – F, 8 a.m. – 6 p.m.

After hours CeltiCare Health and Cenpatico calls will forward to the 24-hour/7 day NurseWise line www.CeltiCareHealthPlan.com

MassHealth Customer Service: 1-800-841-2900 (TDD/TTY) 1-800-497-4648, M – F 8 a.m.-5 p.m. 1

MEMBER HANDBOOK

OTHER FORMATS AND LANGUAGES

The information in this Member Handbook is about your CeltiCare Health Plan of Massachusetts, Inc. ™ (CeltiCare Health) benefits. If you need information in a different language or provided to you in a different way, please call Member Services so we can help you. The phone number and business hours are at the bottom of each page in this handbook.

Other Languages and Alternative Formats: Call CeltiCare Health’s Member Service department to have a Spanish version of this handbook sent to you. If you need any other language, you can have this document read to you free of charge. CeltiCare Health will also provide information from this handbook in American Sign Language (ASL), braille, large font, or video recorded ASL upon request.

All written materials sent to Members are available in Spanish. English and Spanish versions of this Member Handbook are available on our website: www.CeltiCareHealthPlan.com. Words that are capitalized throughout this Member Handbook are defined in the glossary at the end of the handbook.

ENGLISH: If the enclosed information is not in your primary language, please call 1-855-678-6975 (TDD/TTY only: 1-866-614-1949).

CAMBODIAN:សិនបបើព័ត៌មានដែលភ្ជា ប់បៅទីបនេះមិនដមនជាភ្ជសាបែើមរបស់អ្នកបទ

សូមទូរស័ពទមកបលខ 1-855-678-6975 (សម្រមាប់អ្នកងងឹងឬថ្លង់ TDD/TTY សូមទូរស័ពទមកកាន់បលខ 1-866-614-1949).

CHINESE:如果隨附的資料不屬你的母語，請打電話 1-855-678-6975 (TDD/TYY: 1-866-614-

1949).

FRENCH: Si les pieces jointes ne sont pas dans votre langue maternelle, veuillez appeler le 1-855-678-6975 (Pour sourds et malentendants seulement: 1-866-614-1949).

HAITIAN CREOLE: Enfomasyon ki nan tiliv sa a, se sou avantaj nan CeltiCare Health Plan nan Eta Massachusetts (CeltiCare). Si w bezwen enfomasyon nan yon lot lang, rele Sevis pou Manm yo nan 1-855-678-6975, TDD/TTY: 1-866-614-1949, pou nou kapab ede w.

KOREAN: 동봉한 안내자료가 귀하의 모국어로 준비되어 있지 않으면 1-855-678-6975

(청각장애자/시각장애자용: 1-866-614-1949) 으로 연락하십시오.

PORTUGUESE: A informacao incluida neste folheto diz respeito aos beneficios do seu Plano de Saude CeltiCare de Massachusetts (CeltiCare). Se necessitar de informacoes numa outra lingua, por favor ligue para os Servicos ao Associado atraves do numero 1-855-678-6975, TDD/TTY: 1-866-614-1949 para que o(a) possamos ajudar.

ROMANIAN: Dacă informaţiile alăturate nu sunt in limba dumneavoastră principală, vă rugăm să sunaţi la 1-855-678-6975 (TDD/TTY: 1-866-614-1949).

RUSSIAN: Если прилагаемая информация не на вашем родном языке, позвоните,

пожалуйста, по номеру телефона 1-855-678-6975 (номер телекоммуникационного аппарата

(телетайпа) для лиц с нарушениями слуха: 1-866-614-1949).

http://www.celticarehealthplan.com/



After hours CeltiCare Health and Cenpatico calls forward to the 24-hour/7 day NurseWise line www.CeltiCareHealthPlan.com

MassHealth Customer Service: 1-800-841-2900 (TDD/TTY) 1-800-497-4648, M – F, 8 a.m.-5 p.m. 2

MEMBER HANDBOOK

SPANISH: Si la informacion adjunta no esta en su idioma primario, por favor llame al 1-855-678-6975 (Para TDD/TTY, llame al 1-866-614-1949).

UKRAINIAN: Якщо інформація, що додається, не на вашій рідній мові, зателефонуйте, будь

ласка, за номером 1-855-678-6975 (номер телекомунікаційного апарата (телетайпа) для

осіб з порушеннями слуху: 1-866-614-1949).

VIETNAMESE: Nếu tin tức đính kèm không có ngôn ngữ của quý vị xin gọi 1-855-678-6975 (TDD/TTY: 1-866-614-1949).





MEMBER HANDBOOK

Table of Contents

OTHER FORMATS AND LANGUAGES ....................................................................................... 1 Table of Contents ................................................................................................................... 3 Your Covered Benefits ............................................................................................................ 5 WELCOME TO CELTICARE HEALTH ........................................................................................... 6 INFORMATION SOURCES ........................................................................................................ 6 Your Member Handbook ........................................................................................................ 6 Your Provider Directory .......................................................................................................... 7 CeltiCare Health Website ....................................................................................................... 7 HOW TO CONTACT US ............................................................................................................ 8 INTERPRETER SERVICES .......................................................................................................... 8 YOUR MEMBER ID CARD ........................................................................................................ 9 HOW YOUR PLAN WORKS .................................................................................................... 10 Service Areas Covered .......................................................................................................... 10 Member Services ................................................................................................................. 10 Membership Eligibility ......................................................................................................... 11 Major Life Changes .............................................................................................................. 11 Newborn Enrollment ............................................................................................................ 11 Disenrollment ...................................................................................................................... 11 COVERED SERVICES .............................................................................................................. 12 MEMBER EXTRAS ................................................................................................................. 12 CentAccount® Program. ....................................................................................................... 12 Better-for-You Coupon Saver Program. ................................................................................. 13 myStrength.com. ................................................................................................................. 13 YOU AND YOUR PRIMARY CARE PROVIDER (PCP) .................................................................. 13 Choosing Your PCP from the CeltiCare Health Provider Directory .......................................... 13 Responsibilities of Your PCP ................................................................................................. 14 Coordination of Care ............................................................................................................ 15 Scheduling/Appointment Waiting Times .............................................................................. 15 What to Do if Your Provider Leaves the CeltiCare Health Network ......................................... 16 Continuity and Transition of Care for New Members ............................................................. 17 UTILIZATION MANAGEMENT ................................................................................................ 17 Medically Necessary Services ............................................................................................... 17 Prior Authorization for Services ............................................................................................ 18 Getting a Second Opinion ..................................................................................................... 19 New Technology .................................................................................................................. 19 HEALTHCARE OUTSIDE OF THE CELTICARE HEALTH SERVICE AREA ......................................... 19 OUT-OF-NETWORK CARE ...................................................................................................... 20 SPECIALTY CARE ................................................................................................................... 20 Self-Referrals ....................................................................................................................... 21 AFTER-HOURS CARE ............................................................................................................. 22 NurseWise® .......................................................................................................................... 22 EMERGENCY CARE ............................................................................................................... 22





MEMBER HANDBOOK

POST-STABILIZATION CARE SERVICES .................................................................................... 23 URGENT CARE ...................................................................................................................... 23 BEHAVIORAL HEALTH SERVICES ............................................................................................ 24 Mental Health and Substance Use Disorders ......................................................................... 24 Mental Health Parity ............................................................................................................ 25 PHARMACY PROGRAM ......................................................................................................... 25 Filling a Prescription ............................................................................................................. 26 Prescription Co-payments .................................................................................................... 26 Preferred Drug List (PDL) ...................................................................................................... 26 Emergency Drug Supply........................................................................................................ 26 Over-the-Counter Medications ............................................................................................. 27 Tobacco Cessation Medications ............................................................................................ 27 Pharmacy Prior Authorization Program ................................................................................ 27 Pharmacy Management Programs ........................................................................................ 27 Quantity Limits .................................................................................................................... 27 Step Therapy ....................................................................................................................... 27 New-to-Market Medication .................................................................................................. 28 Age Limits ............................................................................................................................ 28 Specialty Pharmacy Program ................................................................................................ 28 Mandatory Generic Substitution Program............................................................................. 28 Medicare Part D ................................................................................................................... 28 TRANSPORTATION SERVICES ................................................................................................ 29 HEALTH MANAGEMENT ....................................................................................................... 29 Health Needs Assessment .................................................................................................... 29 Staying Healthy .................................................................................................................... 30 Care Management ............................................................................................................... 30 Complex Care Management ................................................................................................. 31 Disease Management ........................................................................................................... 31 Behavioral Health Care Management ................................................................................... 31 Behavioral Health Intensive Clinical Management (ICM) ....................................................... 32 Pregnancy and Maternity ..................................................................................................... 32 Family Planning Services ...................................................................................................... 33 MemberConnections® .......................................................................................................... 33 ConnectionsPLUS® ................................................................................................................ 33 MEMBER SATISFACTION ....................................................................................................... 33 Member Advisory Committee .............................................................................................. 33 Quality Improvement (QI) .................................................................................................... 34 INQUIRIES, GRIEVANCES, AND APPEALS ............................................................................... 34 What is an Inquiry? .............................................................................................................. 35 Authorized Appeal Representative ....................................................................................... 35 What is a Grievance?............................................................................................................ 35 What is an Internal Appeal? ................................................................................................. 37 Behavioral Health Standard Internal Appeals ........................................................................ 38 What is an Expedited (fast) Internal Appeal? ........................................................................ 42 What is a Board of Hearings (BOH) Appeal? .......................................................................... 44





MEMBER HANDBOOK

FRAUD AND ABUSE PROGRAM (FAP) .................................................................................... 45 What to Do if You Get a Bill .................................................................................................. 46 Other Insurance ................................................................................................................... 47 Accidental Injury or Illness (Coordination of Benefits and Subrogation) ................................. 47

Coordination of Benefits ................................................................. 48

Motor Vehicle Accidents and/or Work-related Injury/Illness .......... 48

Subrogation .................................................................................... 48 MEMBER RIGHTS AND RESPONSIBILITIES .............................................................................. 49 ADVANCE DIRECTIVES .......................................................................................................... 50 NOTICE OF PRIVACY PRACTICES ............................................................................................ 52 Authorization to Disclose Health Information ....................................................................... 59 Revocation of Authorization to Disclose Health Information ................................................. 60 GLOSSARY ........................................................................................................................... 61

Your Covered Benefits

A listing of your CeltiCare Health CarePlus Member services (Covered and Excluded/non-covered Services) are contained in the document that accompanies this Member Handbook called the Covered Services List. Keep the Covered Services List together with this Member Handbook to have a complete description of your available and excluded (non-covered) health plan services.





MEMBER HANDBOOK

WELCOME TO CELTICARE HEALTH

This Member Handbook describes your CeltiCare Health CarePlus Plan. It is designed to make it easy for you to make the most of your CeltiCare Health services. As an enrollee in MassHealth’s CarePlus program, we are pleased to have you as a CeltiCare Health Member.

CeltiCare Health is a Managed Care Organization (MCO) overseen by the Massachusetts Executive Office of Health and Human Services (EOHHS). You became a CeltiCare Health Member because you live in Massachusetts. You also became a Member because you are eligible to receive MassHealth benefits in the Massachusetts CarePlus program. CeltiCare Health is a healthcare plan that gives you choices – from choosing your Primary Care Provider (PCP) to a variety of Member services and special programs that help you stay healthy.

If you are a new Member, you will be contacted by CeltiCare Health by phone to welcome you to the Plan and review your benefits. During this call you can ask any questions you may have about your coverage. If we can’t reach you, please call the Member Services department and a representative will be happy to speak with you.

To make sure we can reach you, always call our Member Services department and MassHealth Customer Service if you change your address or phone number. If you don’t keep MassHealth up to date on your contact information, you could lose your MassHealth and CeltiCare Health Eligibility. You can find MassHealth and CeltiCare Health contact information at the bottom of every page of this Member Handbook.

If you also want us to contact you via email, please be sure to provide us with that address either on the phone or by logging into your secure online Member Portal. You can find the portal and get more information on our services by visiting our website: www.CeltiCareHealthPlan.com.

INFORMATION SOURCES

Your Member Handbook

Your Member Handbook is a detailed guide to CeltiCare Health and your healthcare benefits. It is our contract with you. It explains your rights, your benefits, and your responsibilities as a Member of CeltiCare Health’s health plan. Please read this booklet carefully. It tells you how to access CeltiCare Health’s healthcare services. It also provides the following information on CeltiCare Health benefits and services:

Covered/Excluded (non-covered) benefits (found in the Covered Services List that is a separatebooklet you should keep with this Member Handbook).

How to get the medical and Behavioral Health (mental health and substance use disorder) careyou need

How to get your prescriptions filled






MEMBER HANDBOOK

What you may have to pay for your prescriptions

What to do if you are unhappy about your health plan or coverage

Eligibility requirements

CeltiCare Health’s geographic service area

Materials you will receive from CeltiCare Health

You may call Member Services 1-855-678-6975 to receive another copy of the Member Handbook. There is no cost for this. You may also visit our website at www.CeltiCareHealthPlan.com to view the Member Handbook.

Your Provider Directory

A listing of CeltiCare Health Providers is available online at www.CeltiCareHealthPlan.com. You may find any of our Providers, hospitals, and other healthcare practitioners by clicking on Find- a- Provider on the website. There you will be able to search for a Provider by:

Provider specialty

Zip code

Gender

Whether the Provider is accepting new patients

Languages spoken

You will also find information such as address, phone number, office hours, handicap accessibility, languages spoken, and Provider qualifications.

At any time, you can request a printed copy of the Provider Directory. There is no cost. Just call Member Services. The Member Services number is at the bottom of every page in this Member Handbook.

CeltiCare Health Website

CeltiCare Health’s website has resources and features that make it easy for you to get quality care. At: www.CeltiCareHealthPlan.com, you’ll find information on all your CeltiCare Health benefits and services such as:

Finding a Provider

Programs to help you get and stay healthy

Online forms submission

How to reach Member Services and Care Managers

The quarterly newsletter: Better For You

Current events and news

You can also find a copy of the latest Member Handbook in English and Spanish on the website.




http://www.coordinatedcarehealth.com/




MEMBER HANDBOOK

HOW TO CONTACT US

CeltiCare Health 200 West Street, Suite 250 Waltham, MA 02451

Normal Business Hours of Operation 8:00 a.m. to 5:00 p.m. Eastern Standard Time

Member Services ........................................................................................ 1-855-678-6975

TDD/TTY line ............................................................................................... 1-866-614-1949

Member Services Fax ................................................................................. 1-866-614-1953

Cenpatico Behavioral Health (Hours of Operation 8:00 a.m. to 6:00 p.m.)

Mental Health and Substance Use Disorders .................................. 1-866-896-5053

NurseWise®:24/7 availability and after hours coverage

for CeltiCare Health and Cenpatico Behavioral Health ..................... 1-855-678-6975

Pregnancy Notification (for Providers and Members) ................................ 1-855-678-6975

Nurtur® Disease Management 1-855-678-4459

Dental 1-855-678-6975

OptiCare Managed Vision 1-855-650-3794

US Script (Pharmacy) 1-855-688-6591

Acaria Health (Specialty Drugs) 1-800-511-5144

Non-Emergency Transportation (Medically Necessary) ............................. 1-855-678-6975

Emergency Services ............................................................................. Call 911

INTERPRETER SERVICES

You and your healthcare Provider must be able to talk about your medical or Behavioral Health concerns in a way you both can understand. For Members who do not speak English or do not feel comfortable speaking it, CeltiCare Health provides an interpreter service. This is provided at no cost to you. CeltiCare Health also offers services for the Members who are deaf or hard of hearing, and blind or visually impaired. To arrange for interpretation services, call Member Services at 1-855-678-6975 or for TDD/TTY call 1-866-614-1949.





MEMBER HANDBOOK

YOUR MEMBER ID CARD

When you enroll in CeltiCare Health, you will receive a CeltiCare Health Member ID Card within 15 calendar days of Enrollment. This card is proof that you are enrolled with CeltiCare Health. Please keep this card with you at all times. Show it whenever you go for any service under the CeltiCare Health program. If you do not get your CeltiCare Health Member ID card within a few weeks after you join our plan, please call Member Services at 1-855-678-6975.

When you receive your Member ID Card, please check to make sure your name is spelled correctly. Call Member Services if you find any errors on the card.

Always carry your CeltiCare Health Member ID Card to receive healthcare or pharmacy services. You should also always carry your MassHealth ID Card. There are some benefits not covered by CeltiCare Health that you may get directly from MassHealth. Below are two examples of the CeltiCare Health ID card. Both of these card designs can be used: FRONT BACK

FRONT BACK





MEMBER HANDBOOK

This is what your MassHealth ID Card looks like: If you lose your Member ID Card, call Member Services for a replacement. Even if you don’t have your card with you, a healthcare Provider should never deny care to you. If a Provider refuses to treat you, call our Member Services department. We will verify your Eligibility for your Provider on the phone 24 hours a day.

HOW YOUR PLAN WORKS

Service Areas Covered

CeltiCare Health is a health plan available through MassHealth in the Commonwealth of Massachusetts. This means you can get Covered Services as long as you live in our Service Area and use our Network of participating Providers. CeltiCare Health is available in every Region in the state except the islands of Martha’s Vineyard and Nantucket off the coast of Cape Cod. If you have any questions about the Service Areas we cover, call Member Services.

Member Services

Our Member Services department will tell you how CeltiCare Health works and how to get the care you need. The Member Services call center can help you to:

Find a Primary Care Provider (PCP).

Schedule a health care appointment.

Get a new Member ID card.

Get information about CeltiCare Health Covered and Excluded (non-covered) Services as well as additional services provided by MassHealth.

Get a list of health plan Providers.

Report potential Member or Provider Fraud issues.

Request Member printed materials.

Obtain information about Care Management and Behavioral Health services.

For assistance, please call 1-855-678-6975 (TDD/TTY 1-866-614-1949). We are open Monday through Friday from 8:00 a.m. to 5:00 p.m. (EST). If you need to call after business hours, your call will be sent directly to our NurseWise hotline.





MEMBER HANDBOOK

Membership Eligibility

You must be eligible for MassHealth to be eligible for CeltiCare Health’s CarePlus program. Most people have their MassHealth Eligibility re-determined every year. After your initial qualification, you will get an Eligibility Review Verification (ERV) form in the mail one month before your benefits expire. Make sure you immediately fill out the ERV form and return it. If you need another form, call the MassHealth Customer Service center. The number for that and the CeltiCare Health Member Services department are at the bottom of every page in this handbook.

As a Member of CeltiCare Health, you keep all your MassHealth coverage and benefits.

Major Life Changes

Life changes might affect your Eligibility with CeltiCare Health. If you have a major change in your life, please contact MassHealth as soon as you can. You should also contact CeltiCare Health Member Services 1-855-678-6975. If you like, we can inform MassHealth of the change for you.

Some examples of major life changes are:

A change in your name

Move to a different address

A change in your job

Marriage or divorce

You change your phone number

A change in your health status, including disability

Pregnancy

Childbirth

Death in the family

Moving to a new country or out of state

Newborn Enrollment

CeltiCare Health will not be responsible for costs associated with newborns on or after the date of birth. Newborns will be enrolled in MassHealth on their date of birth. Please contact CeltiCare Health as soon as possible after the birth of your child so we can assist you.

Following the birth of your newborn, the doctor or hospital should submit the Notification of Birth (NoB) to the MassHealth Notification of Birth Unit. This form needs to be submitted within 30 calendar days of the newborn’s date of birth.

Disenrollment

You may disenroll from CeltiCare Health, with or without cause. You can do this at any time. Your requests for disenrollment must be directed to MassHealth. You can do this either orally or in writing.





MEMBER HANDBOOK

The MassHealth Customer Service phone numbers are at the bottom of every page of this Member Handbook. There are three kinds of disenrollment: Voluntary, for loss of Eligibility, and for Cause.

Voluntary Disenrollment: You may end your coverage with CeltiCare Health at any time. To disenroll from CeltiCare Health, call MassHealth Customer Service. Your request for Disenrollment will take effect on the last day of the current month. CeltiCare Health will continue to provide coverage for Covered Services through the date of Disenrollment. Coverage includes any custom-ordered equipment approved prior to Disenrollment, even if not delivered until after Disenrollment.

Disenrollment for Loss of Eligibility. If you become ineligible for MassHealth coverage, MassHealth will disenroll you from CeltiCare Health. You will no longer be eligible for coverage by CeltiCare Health as of the date of your MassHealth Disenrollment. You may automatically be re-enrolled in CeltiCare Health if you become eligible again for MassHealth within 6 months, as determined by MassHealth.

Disenrollment for Cause. There may be instances where CeltiCare Health may submit a written request to MassHealth to disenroll you from the health plan. MassHealth will determine when and if CeltiCare Health’s request will be granted. If you are disenrolled from CeltiCare Health, MassHealth will send you a written notification of Disenrollment. You will also be contacted by MassHealth to choose another health plan. Please note that CeltiCare Health may not request your Disenrollment because you have had an adverse change in your health status, you have utilized healthcare services, you have diminished mental capacity, or you have been uncooperative or disruptive because of your special needs.

COVERED SERVICES

CeltiCare Health will not limit or deny services because of a condition you already have or may develop. Please refer to the list of your covered and excluded (non-covered) Member benefits and services (Covered Services List) that is considered part of this CarePlus Member Handbook. In the Covered Services List, you will find information about your medical, Behavioral Health, hospital, Emergency, medical equipment, therapeutic, and other types of coverage. The Covered Services List is in your welcome packet as a separate document. Keep this list with your Member Handbook. Together, the Member Handbook and Covered Services List give you the complete information you need about your insurance coverage.

MEMBER EXTRAS

As a CeltiCare Health Member, you will also be able to take advantage of extra benefits including:

CentAccount® Program. CeltiCare Health has a program to reward you for completing certain

healthy activities … dollar awards! There are no fees or cost to you. Monetary rewards will





MEMBER HANDBOOK

automatically be added to your CentAccount rewards card once the claim for the healthy behavior is received. The CentAccount card is a rewards card that CeltiCare Health issues in your name.

More information on the CentAccount program can be found on our website or feel free to call Member Services.

Better-for-You Coupon Saver Program. CeltiCare Health Members get a mailing with a

newsletter and coupons that can save you money. This comes every three months. We make sure all the nutritional coupons are for healthier options. This helps save you money while making Better-for-You choices. You can also print more coupons from our website, www.CeltiCareHealthPlan.com.

myStrength.com. You may participate in a personalized web-based wellness resource. One in four

Americans will suffer with depression or anxiety sometime in their lifetime. If you are one of them, you can get the help that focuses on your Behavioral Health (mental health and substance use disorder) and spiritual well-being. After completing a brief Wellness Assessment and profile, myStrength will send a personalized home page and weekly action plan that meets your needs. Rediscover your inner peace and mental well-being with:

Powerful eLearning sections that use interactive tools

In-depth resources

Daily motivational inspirations

Weekly activities

YOU AND YOUR PRIMARY CARE PROVIDER (PCP)

When you enroll in CeltiCare Health, you must choose a Primary Care Provider (PCP). Your PCP is a doctor or nurse practitioner you see on a regular basis to take care of your medical needs. You should receive all of your basic healthcare from your PCP. Seeing your PCP for regular check-ups helps you find health problems early. This can help prevent going to the Emergency room. When you become a Member of CeltiCare Health, you should call your PCP and make an appointment for a preventive visit. Be sure to talk to him or her about any health problems you are having.

Choosing Your PCP from the CeltiCare Health Provider Directory

You can choose your PCP from our Network of Primary Care Providers throughout the state. CeltiCare Health’s Provider Directory lists our Network Providers, including:

Primary Care Providers (PCPs)

Community Health Centers

Specialty Providers

Hospitals including Emergency room Locations

Behavioral Health Providers

Behavioral Health Emergency service Providers

Ancillary Service Providers






MEMBER HANDBOOK

Pharmacies Included in the listings is information about how to contact the Provider, where they are located, what languages they speak, their handicap accessibility, hours of operation, and hospital affiliation. The Provider Directory is available online at www.CeltiCareHealthPlan.com by clicking on “Find a Provider.” You can also request a hard copy by calling Member Services. The following types of Providers are Primary Care Providers (PCPs). You can choose among them when selecting a PCP for yourself:

Family Practitioner

General Practitioner

Internal Medicine

Nurse Practitioner

Obstetrician/Gynecologist (OB/GYN) Specialists can also be your PCP for special needs, upon request. If you want to know more about a PCP before you choose, call Member Services at the phone number below. You can also call if you need help choosing a PCP. If you do not choose a PCP within 15 days of your effective date of Enrollment, CeltiCare Health will choose one for you. You can change your PCP at any time without a reason. You can change your PCP by calling Member Services or going online to the Secure Portal of our website.

Responsibilities of Your PCP

Your PCP will:

Make sure that you get all Medically Necessary services in a timely manner

Follow-up on the care you get from other medical Providers

Provide or coordinate all your care except in an Emergency

Refer you to other healthcare Providers and Specialists

Provide any ongoing care you need

Update your medical record, including keeping track of all the care that you get from your PCP and Specialists

Admit you to the hospital and arrange for your hospital care when necessary

Provide Covered Services in the same manner for all patients

Give you regular physical exams.

Provide preventive care

Give you regular immunizations

Make sure you can contact him/her or another doctor at all times

Discuss what Advance Directives are and file the Advance Directives appropriately in your medical record

Write prescriptions

Request Prior Authorization from CeltiCare Health when necessary






MEMBER HANDBOOK

Coordination of Care

It’s important for both your behavioral and physical healthcare Providers to know what kind of care you are getting. Keep your healthcare Providers connected. Do this by completing a health coordination form at your next visit. If your Provider does not supply you with the form, you can get it from www.CeltiCareHealthPlan.com. It is called the “Behavioral Physical Health Coordination Form”. Once you complete the form, give it to your Provider who will then share the form with other healthcare Providers you have named. This will help all your Providers share treatment information. It will also help them share prescribed medication information. Sharing information helps with effective, safe coordination of your care. This is a voluntary form and you have the right to keep all your Behavioral Health, and HIV/AIDS information confidential. Please complete this form only if you are comfortable with your Providers knowing about your Behavioral Health, or HIV/AIDS medical history.

Scheduling/Appointment Waiting Times

Network Providers will be open at reasonable times and always have coverage. You will get an appointment based on your healthcare needs. You should be given an appointment within the following time frames:

Type of Appointment Scheduling Time Frame

Emergency Services including ESP(Behavioral Health Emergency Service Providers)

Immediately upon presentation at the service delivery site, including non-Network and out-of-area facilities, 24 hours/day, 7 days/week

Type of PCP Appointment Scheduling Time Frame

PCP Urgent Visits Within 48 hours of the Member’s request

Non-Urgent Symptomatic Care Within 10 days of the Member’s request

Routine PCP Visits Within 45 calendar days of the Member’s request

Type of Specialist Appointment Scheduling Time Frame

Urgent Care Appointments Within 48 business hours of the Member’s request

Non-Urgent Symptomatic Care Within 30 calendar days of the Member’s request

Routine Specialist Visits Within 60 calendar days of the Member’s request

Type of Behavioral Health Appointment Scheduling Time Frame

Urgent Care Appointments Within 48 hours

All Other Behavioral Health Visits Within 14 calendar days






MEMBER HANDBOOK

Per the Inpatient or 24-hour Diversionary Discharge Plan

Scheduling Time Frame

Non 24-hour Diversionary Services Within 2 calendar days of discharge

Medication Management Within 14 calendar days of discharge

Other Outpatient Services Within 7 calendar days of discharge

Your Provider’s office should be available by telephone 24 hours a day/7 days a week. Your Provider may not be immediately available but there should be instructions on the answering message or service to reach another Provider that is covering during the time you call.

If you have difficulty getting an appointment with or seeing your healthcare Provider, please call Member Services.

IMPORTANT: If you cannot keep an appointment, please call the health care Provider’s office to cancel. Cancel at least 24 hours in advance. If you need to change an appointment, call the health care Provider’s office as soon as possible. They can make a new appointment for you. If you need help getting an appointment, call Member Services.

What to Do if Your Provider Leaves the CeltiCare Health Network

If your PCP is no longer in CeltiCare Health’s Network because they have been disenrolled for reasons not related to quality of care or Fraud, CeltiCare Health will send you a notice at least 30 days before the date this occurs, or as soon as CeltiCare Health is notified. You may need to change your PCP. This can be done through the website secure portal or by calling Member Services. Otherwise, we will automatically reassign you to a new PCP. When you change your PCP, we will send you a PCP Change Notice confirming your new PCP’s name, address, and phone number. You do not need a new Member ID Card.

If you are in active treatment for a chronic or acute medical condition with your health care Provider at the time of his/her termination from the CeltiCare Health Network, CeltiCare Health may approve visits with your health care Provider for up to 30 days after he/she leaves the Network. During this time, we will help you find a new health care Provider. You will receive the same Covered Services. The health care Provider must agree to:

Treat you for your healthcare needs

Accept the same payment rate from CeltiCare Health

Follow CeltiCare Health’s quality assurance standards

Follow CeltiCare Health’s policies about Prior Authorization and following any existing treatmentplan

Provide necessary health information to you related to your care





MEMBER HANDBOOK

CeltiCare Health may be able to also provide continued coverage for you with a disenrolled Provider for other healthcare reasons such as:

You are in your second or third trimester of pregnancy. In this case you may remain under the care of your current OB/GYN through delivery and follow-up within six weeks of the delivery.

You are terminally ill. In this case you may continue to see your health care Provider indefinitely.

Continuity and Transition of Care for New Members

To ensure Continuity of Care, there are some times when CeltiCare Health may be able to provide coverage for health services from a Provider who is not part of our Network.

If you are in your second or third trimester of your pregnancy, you may remain under the care of your current OB/GYN through delivery and follow-up within six weeks of the delivery.

If you are receiving ongoing covered treatment or management of chronic issues, you may continue to get care for a limited period.

If you are terminally ill, you may continue to see your health care Provider indefinitely.

Your health care Provider can arrange for any Prior Authorization, if needed. More information about Prior Authorizations can be found in the following section.

UTILIZATION MANAGEMENT

Medically Necessary Services

Covered Services that you get must be Medically Necessary. This means getting the right care, at the right place, at the right time. CeltiCare Health uses standard guidelines to check Medical Necessity. CeltiCare Health has policies in place to ensure:

Decisions are made based on the appropriateness of the care and service, and that coverage is in place

The organization does not reward its Network Providers or their staff to deny coverage, service, or care

Financial incentives for decision makers do not encourage decisions that result in denying needed treatment





MEMBER HANDBOOK

Prior Authorization for Services

When you need care, always start with a call to your healthcare Provider. Some Covered Services or drugs may need Prior Authorization. Some may need review by CeltiCare Health before services or prescriptions are provided. This includes services or visits to:

an out of Network Provider

some Specialists

home health services

certain surgeries

certain medications

Your healthcare Provider can tell you if a service or prescription needs Prior Authorization before you can get it. For more information visit CeltiCare Health’s website at www.CeltiCareHealthPlan.com. You can also call Member Services at 1-855-678-6975.

Your healthcare Provider will provide CeltiCare Health with the information about why you need the service or medication. We will look to see if the service is covered and that it is appropriate. CeltiCare Health will make the decision as soon as possible, based on your health condition. We will let you and your healthcare Provider know if the service is approved or denied. If you and your healthcare Provider are not happy with the decision, you can request an Internal Appeal. See the “Inquiries, Grievances and Appeals” section in your Member Handbook for more information about Appeals.

Prior Authorization decisions are made by a healthcare professional that has appropriate clinical expertise within the following timeframes:

Standard Authorization decisions: Within 14 calendar days after the request is received.

Expedited (fast) Authorization decisions: Within 3 business days after the request is received. Only a Provider can recommend, or CeltiCare Health can decide, when a Prior Authorization request may be Expedited by determining that following the standard timeframe could seriously jeopardize your life, health, or your ability to get, maintain, or regain maximum function.

These Prior Authorization decision timeframes may be extended up to an additional 14 calendar days if you, your Authorized Appeal Representative, or your Provider requests an extension, or CeltiCare Health has a good reason to believe that:

The extension is in your best interest.

CeltiCare health needs additional information that we think could lead to approval of your request.

Such outstanding information is reasonably expected to be received by the Plan within 14 calendar days.

If CeltiCare Health asks for an extension of the Prior Authorization timeframes; we will send you, and your Authorized Appeal Representative, a written notice. If you or your Authorized Appeal Representative disagrees with this decision, you or your Authorized Appeal Representative may file a


http://www.granitestatehealthplan.com/




MEMBER HANDBOOK

Grievance in writing, over the phone, or in person. CeltiCare Health’s Member Services department can help you with this. If CeltiCare Health did not make a Prior Authorization decision within these timeframes, we will send a written notice to you and your Authorized Appeal Representative. You or your Authorized Appeal Representative has the right to file an Internal Appeal. See the Inquiries, Grievances, and Appeals section of this Member Handbook for more information. CeltiCare Health will send a written notice to you, your Authorized Appeal Representative, and the requesting Provider when any Prior Authorization request is denied, or a service has been authorized in an amount, duration, or scope that is less than requested. You, or your Authorized Appeal Representative, have the right to file an Internal Appeal if you want CeltiCare Health’s decision reviewed.

Getting a Second Opinion

You may ask for a Second Opinion from another CeltiCare Health Provider about any healthcare that your Provider thinks you should have. We may also arrange for you to get a second opinion from a Provider outside of our Network. In both cases CeltiCare Health will pay for your Second Opinion visit.

New Technology

CeltiCare Health evaluates new technology, including medical procedures, drugs and devices, and the new application of existing technology, for coverage determination. The CeltiCare Health medical director and/or medical management staff may periodically identify relevant technological advances for review pertinent to the CarePlus population. The Clinical Policy Committee (CPC) reviews all requests for coverage and makes a determination regarding any benefit changes that are indicated. When a request is received for coverage of new technology that has not been reviewed by the CPC, the CeltiCare Health medical director will review the request and make a one-time determination. This new technology request will then be reviewed at the next regularly scheduled CPC meeting.

HEALTHCARE OUTSIDE OF THE CELTICARE HEALTH SERVICE AREA

When Members are away from home, CeltiCare Health will only cover Emergency, Post-stabilization and Urgent Care within the United States or its territories. To ensure coverage, be sure to take care of your routine healthcare needs before traveling outside of CeltiCare Health’s Service Area. You should still seek needed care in an Emergency when you are outside the United States, but be advised that CeltiCare Health will not cover these services.

If you need Emergency or Urgent Care while you are temporarily outside the CeltiCare Health Service Area call 911 or go to the nearest ER. You do not have to call your Primary Care Provider before seeking Emergency or Urgent Care while outside of the CeltiCare Health Service Area. However; you or a family member should call your Primary Care Provider (or your Behavioral Health Provider in a Behavioral Health Emergency) within 48 hours of receiving this care.





MEMBER HANDBOOK

CeltiCare Health will cover Emergency, Post-Stabilization Care and Urgent Care services delivered outside the Service Area. CeltiCare Health will not cover Emergency Services, Post-Stabilization Care, and Urgent Care services provided outside the United States and its territories.

CeltiCare Health will not cover:

Tests or treatment that your Primary Care Provider asked for before you left the Service Area.

Routine care or follow-up care that can wait until you return to the CeltiCare Health Service Area, such as physical exams, flu shots, and Behavioral Health counseling.

Care that you knew you were going to need before you left the Service Area such as elective surgery.

A Provider may ask you to pay for care received outside of the CeltiCare Health Service Area at the time of service. If you pay for Emergency, Post-Stabilization Care or Urgent Care while outside of CeltiCare Health’s Service Area but within the United States or its territories, you may submit a Claim to CeltiCare Health to be reimbursed. You may call Member Services for help with any bills that you may receive from a Provider. You can find more information about What to Do if You Receive a Bill under that heading in this Member Handbook.

OUT-OF-NETWORK CARE

Providers who do not have a contract with CeltiCare Health are called “out-of-Network Providers”. You are not covered for services provided by an out-of-Network Provider except:

For Emergency, Post-Stabilization, and Urgent Care services.

When your Primary Care Provider has gotten a Prior Authorization from CeltiCare Health for you to go to an out-of-Network Provider.

When you receive Family Planning Services from any MassHealth-contracted Provider of Family Planning Services.

If CeltiCare Health is unable to provide a Medically Necessary service through a CeltiCare Health Network Provider. In this case requests must go through the Prior Authorization process. CeltiCare Health will cover the service in a timely manner with an out-of-Network Provider for as long as the service is determined to be Medically Necessary and not available through a CeltiCare Health Network Provider.

SPECIALTY CARE

There may be times when you may need to see a Specialist. A Specialist is a healthcare Provider trained to provide specific, often more detailed treatments than your PCP. For example, a cardiologist is a doctor who specializes in treating heart problems. Psychiatrists specialize in treating Behavioral Health conditions.





MEMBER HANDBOOK

If you need to see a Specialist, you should first call your PCP. Your PCP can help you identify your specialty care need and refer you to an appropriate Specialist. Your PCP may also help you with any follow-up care that is important for your health and recovery both while being treated by a Specialist and afterward.

Healthcare Providers who have contracts with CeltiCare Health are considered Network Providers. These include Primary Care Providers and Specialists. You must always receive your care from Network Providers except in the case of Emergencies.

Though you do not need a Referral before seeing an in-Network Specialist you may need Prior Authorization for a particular service. Your healthcare Provider can get any Prior Authorization that may be required.

Generally, an Out-of-Network Specialist will not be able to see you without Prior Authorization from CeltiCare Health. If you have questions about getting Prior Authorization, call Member Services.

Some conditions may need ongoing care from a Specialist. CeltiCare Health will continue to authorize care when:

The Specialist in CeltiCare Health’s Network agrees to a treatment plan for you and;

The Specialist provides your PCP with updates on your condition and treatment plan and;

The Specialist’s services to be provided are part of the benefits covered by CeltiCare Health

The treatment is medically necessary.

NOTE: If your Specialist refers you to another Specialist for additional services, an additional Prior Authorization may be needed from CeltiCare Health.

Self-Referrals

You may self-refer for certain Covered Services without Prior Authorization from CeltiCare Health. A complete listing of services that do or do not require Prior Authorization is in your Covered Services List. For example, you may receive benefit coverage for the following Covered Services when the Provider is in the CeltiCare Health Provider Network without any Prior Authorization:

Annual preventive gynecological health examinations

Acute gynecological conditions

Routine outpatient Behavioral Health (mental health and substance use disorder) visits

Family planning services and supplies.

You may receive benefit coverage for the following services even when the doctor is not in the CeltiCare Health Provider Network:

Emergency services

Post-Stabilization Care services





MEMBER HANDBOOK

Urgent Care services

Family Planning Services

AFTER-HOURS CARE

NurseWise®

NurseWise is a free health information phone line staffed by registered nurses. These nurses are ready and eager to answer your health questions. They are there 24 hours a day – every day of the year. NurseWise staff also handle all medical and Behavioral Health calls after regular business hours for CeltiCare Health and Cenpatico Behavioral Health.

By calling NurseWise, you can get free health support and information on symptoms, diagnoses, or treatments to help you stay healthy 24 hours a day, 7 days a week. You can also call NurseWise if you would like help deciding if your illness requires Emergency care. Call any time at 1-855-678-6975 (TTY: 1-866-614-1949). You can get help in many languages. Remember, you can also check with your PCP’s office. NurseWise does not take the place of your PCP but can help when you have questions.

EMERGENCY CARE

Whether you have a medical Emergency or a Behavioral Health Emergency, you should seek immediate care when there is no time to call your healthcare Provider. CeltiCare Health covers Emergency care services 24 hours a day, 7 days a week. Prior Authorization is not required for Emergency care. An Emergency room or other healthcare Provider of Emergency services must give you care immediately 24 hours a day, 7 days a week. CeltiCare Health Members have unrestricted (no limit) access at any qualified Emergency care Provider whether or not the Provider is part of the CeltiCare Health Network. Please note that you are not covered for Emergency care services outside of the United States or its territories. You should still seek Emergency care when you need it when you are outside of the country, but the services you receive will not be covered by CeltiCare Health. Within the United States and its territories, you are covered for ambulance transportation and Post-Stabilization Care services that are related to an Emergency. Post-Stabilization Care services are the services you get after your Emergency condition is stabilized. Note that the Emergency care Provider treating you is responsible for deciding when you are stable enough to be transferred or discharged. In a medical Emergency call 911 immediately or seek care in any hospital Emergency room. For Behavioral Health Emergencies, call 911, go to the nearest hospital Emergency room or immediately call the Emergency Service Program (ESP) Provider in your area. A statewide list of Emergency rooms and ESP Providers can be found in the Find a Provider directory on the CeltiCare Health website or in your CeltiCare Health Provider Directory. Provider Directories can be requested from Member Services. If you are admitted, the facility will contact CeltiCare Health on your behalf within 48 hours. The following list provides some examples of medical and Behavioral Health Emergencies. This list does not cover every type of possible Emergency. Call 911 if you think that you are having an Emergency.





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When to go to the ER

Broken bones

Gun or knife wounds

Bleeding that will not stop

You are pregnant, in labor and/or bleeding

Severe chest pain or heart attack.

Drug overdose

Poisoning

Bad burns

Shock (you may sweat, feel thirsty or dizzy or have pale skin)

Convulsions or seizures

Trouble breathing

Suddenly unable to see, move or speak

Wanting to harm yourself

Wanting to harm other people

When NOT to go to the ER

Flu, colds, sore throats and earaches.

A sprain or strain

A cut or scrape not requiring stitches

To get more medicine or have a prescription refilled

NOTE: Except for Emergency Post Stabilization Care and Urgent Care, you must get all services through CeltiCare Health Network Providers or pre-approved out-of-Network Providers for the service to be covered by CeltiCare Health.

POST-STABILIZATION CARE SERVICES

These are services that are needed to stabilize your condition after an Emergency. They do not require Prior Authorization. It does not matter whether you receive the Emergency care in or outside of the CeltiCare Health Network. We will still cover Post Stabilization Care services to make sure you are stable after an Emergency within the United States and its territories.

URGENT CARE

An Urgent Care condition is a health problem that is serious – but that you do not think is an Emergency. Your PCP must see you within 48 hours after your request for an Urgent Care appointment. Your Behavioral Health Provider must also see you within 48 hours for Urgent Care for Behavioral Health conditions.

If your Urgent Care condition gets worse before you see your PCP or Behavioral Health Provider, you can go to an Emergency room. Even if you are out of town or out of the Service Area, you should call your PCP if an Urgent Care condition occurs.

When you need Urgent Care, follow these steps:





MEMBER HANDBOOK

Call your PCP. The name and phone number are on the Welcome Letter in your Welcome Packet. Your PCP may give you directions over the phone.

If you have changed your PCP since you first got your ID Card, refer to the PCP Change Notification that you were sent upon changing your PCP to find the contact information for your current PCP.

If it is after hours and you cannot reach your PCP, the PCP office voice mail will either have another number for you to call for after-hours coverage or you will reach an answering service and another covering Provider will call you back.

You can always call NurseWise after hours at 1-855-678-6975 (TDD/TTY 1-866-614-1949). You will be connected to a nurse. Have your CeltiCare Health ID card number handy. The nurse may help you over the phone or direct you to other care.

BEHAVIORAL HEALTH SERVICES

Mental Health and Substance Use Disorders

When you feel you need Behavioral Health services, you do not need any Prior Authorization, pre-approval, or Referral to go to a Behavioral Health Provider that is in the CeltiCare Health Network. This is called “self-referral.”

CeltiCare Health provides Behavioral Health services through our partner, Cenpatico Behavioral Health. To find a Cenpatico Behavioral Health Provider you can look in the Find a Provider section of our website, or ask for recommendations from family members, guardians, a community agency, or your general health care Provider (your PCP, or Primary Care Provider).

Certain Behavioral Health services must be authorized in advance for them to be covered. The Covered Services List shows the Behavioral Health services that require Prior Authorization. Your Provider should be able to make arrangements for any needed Prior Authorization for you.

You can always call CeltiCare Health Member Services or Cenpatico Behavioral Health directly. Both numbers are listed at the bottom of this page. Call if you have any questions about finding a Behavioral Health Provider, what services are covered, or how to obtain a Prior Authorization.

Remember, in a Behavioral Health Emergency, call 911, go to the nearest hospital Emergency room, or contact the Emergency Services Program (ESP) Provider in your area. A statewide listing of Emergency Services Program (ESP) Providers is in the CeltiCare Health Provider Directory. The Provider Directory can be found on the website in the Find a Provider section, or you can request a printed copy from Member Services.





MEMBER HANDBOOK

Mental Health Parity

Federal and state laws require that all Managed Care organizations, including CeltiCare Health, provide Behavioral Health services to MassHealth Members in the same way they provide physical health services. This is what is referred to as “parity”. In general, this means that CeltiCare Health must:

Provide the same level of benefits for any mental health and substance use disorder problems you may have as for other physical problems you may have

Have similar Prior Authorization requirements and treatment limitations for mental health and substance use disorder services as it does for physical health services

Provide you or your Provider with the Medical Necessity criteria used by CeltiCare Health for Prior Authorization upon your or your Provider’s request

Provide you within a reasonable time frame the reason for any denial of authorization for mental health or substance use disorder services.

If you think that CeltiCare Health is not providing parity as explained above, you have the right to file a Grievance with CeltiCare Health. For more information about Grievances and how to file them, see the Inquires, Grievances, and Appeals sections of this Member Handbook. You may also file a Grievance with MassHealth by calling the MassHealth Customer Service Center at 1-800-841-2900 ( TTY: 1-800-497-4648) Monday - Friday 8:00 a.m. to 5:00 p.m.

PHARMACY PROGRAM

CeltiCare Health’s Pharmacy Benefit Manager is US Script. US Script is identified on your Member ID Card so your pharmacist knows who to contact when filling your prescriptions. CeltiCare Health and US Script are committed to providing appropriate, high quality and cost effective drug therapy to all Members. You have coverage for prescription medications as well as certain over-the-counter (OTC) drugs when ordered by a CeltiCare Health Provider . CeltiCare Health works with US Script, healthcare Providers, and pharmacists to ensure that CeltiCare Health covers the medicines you may need. Some have limits.

Some require Prior Authorization. See the Prior Authorization section of this Member Handbook for more information.

You should use a generic prescription drug instead of brand-named prescription drug whenever possible. When generic drugs are available, the brand name drug will not be covered without Prior Authorization from CeltiCare Health. If you and your healthcare Provider feel a brand-name drug is Medically Necessary, he or she can ask for Prior Authorization.





MEMBER HANDBOOK

Filling a Prescription

Your CeltiCare Health Provider needs to write a prescription for both prescription medications and over-the-counter medications in order for them to be covered by CeltiCare Health. You can have your prescriptions filled at a Network pharmacy. CeltiCare Health, through US Script, has a large Network of pharmacies throughout the State. You can locate a pharmacy near you by using your CeltiCare Health Provider Directory available on the website under Find a Provider. Be prepared to provide the pharmacist with your prescription and your CeltiCare Health Member ID card. If you have any questions about filling a prescription or finding a pharmacy, call Member Services.

Prescription Co-payments

Certain people do not have to pay Co-payments for prescriptions. These people are listed under Co-Pays in the Covered Services List. Everyone else will need to pay a Co-payment at the pharmacy for their medicines. Check the Covered Services List to find out what your copays are. CeltiCare Health Members pay the same Co-payments for prescription medications as Members of other MassHealth Managed Care plans.

If you are not able to pay the Co-payment, the pharmacy must still fill your prescription. However; the pharmacy can bill you later for the Co-payment. Do not go without your medication if you can’t pay the Co-payment. Please call Member Services if a pharmacy refuses to fill your prescription.

You are not required to pay more than $250 for prescription Co-payments in any calendar year. Once you have reached your annual Co-payment limit (cap) of $250, CeltiCare Health will send you a letter to let you know that you have reached your cap. You can also provide CeltiCare Health with proof that you have reached the Co-payment limit. If you have reached the cap and are still being asked for Co-payments by your pharmacist, call Member Services. CeltiCare Health will confirm that you have reached your cap with your pharmacist for the remainder of the calendar year.

Preferred Drug List (PDL)

CeltiCare Health has a list of covered medications. This is called the Preferred Drug List (PDL) and it is CeltiCare Health’s formulary. For the most current CeltiCare Health PDL, you may call Member Services or visit the CeltiCare Health website www.CeltiCareHealthPlan.com. After selecting “CarePlus” on the website, click “Health Management” and then “Pharmacy”. The PDL also lists the drug categories that may not be covered. If you want a copy of the formulary, call Member Services.

Emergency Drug Supply

The 72-hour Emergency supply policy: State and Federal law require that a pharmacy dispense a 72-hour (3-day) supply of medication to any patient awaiting a Prior Authorization (PA). This Emergency supply lets you continue therapy or start therapy without delay. CeltiCare Health will cover the 72-hour (3-day) supply of medication for any patient awaiting Prior Authorization (PA).






MEMBER HANDBOOK

Over-the-Counter Medications

The CeltiCare Health pharmacy program covers a variety of over-the-counter (OTC) medicines. All covered OTCs appear in the CeltiCare Health PDL. In order for an OTC medicine to be covered by CeltiCare Health, it must be written on a valid prescription by a licensed Provider.

Tobacco Cessation Medications

CeltiCare Health covers certain drugs to help you quit smoking. A prescription written by a licensed Provider is required for these medications. The covered drugs include:

Nicotine replacement products.

Zyban or Wellbutrin.

Chantix.

Pharmacy Prior Authorization Program

Some medications always require Prior Authorization. If your Provider feels that a medication that falls into this group is Medically Necessary for you, he or she can submit a Prior Authorization request. If it is determined that the medication is Medically Necessary, CeltiCare Health will cover the medication. If the Prior Authorization request is denied, you or your Authorized Appeal Representative can appeal the decision.

Pharmacy Management Programs

Celticare Health uses a number of pharmacy programs to promote the safe and correct use of certain prescription medications. Medications that belong to these programs have guidelines that must be met before we cover the medication. You can see which medications belong to a pharmacy program on the drug list (PDL) or formulary on the CeltiCare Health website.

Quantity Limits

Some medications on the CeltiCare Health PDL have quantity limits to make sure the drugs you take are safe. If your healthcare Provider feels you have a medical reason for getting a larger amount, they can ask CeltiCare Health for Prior Authorization.

If CeltiCare Health does not grant Prior Authorization, we will notify you and your healthcare Provider. We will also provide information regarding CeltiCare Health’s Internal Appeal process.

Step Therapy

Some medications listed on the CeltiCare Health PDL may require specific medicines to be used before you can receive the step therapy medicines. If CeltiCare Health has a record that the required medicines





MEMBER HANDBOOK

were tried first, then the step therapy medicines are automatically covered. If CeltiCare Health does not have a record that the required medicines were tried, your healthcare Provider may be required to provide additional information.

If CeltiCare Health does not grant Prior Authorization, we will notify you and your healthcare Provider and provide information regarding CeltiCare Health’s Internal Appeal process.

New-to-Market Medication

CeltiCare Health reviews new medications for safety and efficacy (making sure the medicine works) before we add them to our Preferred Drug List (PDL). If your Provider feels that a new-to-market medication is Medically Necessary, he or she can submit a Prior Authorization request. If approved, CeltiCare Health will cover the medication. If the Prior Authorization request is denied, you or your Authorized Appeal Representative can appeal the decision.

Age Limits

Some medications on the CeltiCare Health PDL may have age limits. These are set for certain drugs, based on the U.S. Food and Drug Administration (FDA) approved labeling for safety concerns and quality standards of care.

Specialty Pharmacy Program

Certain medicines are only covered when they are supplied by CeltiCare Health’s specialty pharmacy program Provider, Acaria Health. These drugs are not available at retail pharmacies. These medications include injectable and intravenous medications that are often used to treat chronic (ongoing) conditions like Hepatitis C or Multiple Sclerosis. These types of health conditions require additional expertise and support. Specialty pharmacies have knowledge in these areas and can provide additional help to Members and Providers.

Mandatory Generic Substitution Program

The federal Food and Drug Administration (FDA) determines that certain generic medications are therapeutically equivalent (“AB rated”) to their brand name alternatives. This means that the “AB rated” generic medication is as effective as the brand name medication. If your Provider determines that the brand name medication is Medically Necessary, he or she may submit a Prior Authorization request. If approved, CeltiCare health will cover the medication. If the Prior Authorization is denied, you or your Authorized Appeal Representative can appeal the decision.

If you have questions about any of the pharmacy services, call Member Services.

Medicare Part D

If you are a CeltiCare Health Member with Medicare coverage, your prescription drug benefit may be covered by a Medicare Prescription Drug Coverage (Part D) plan. Most of your prescription drugs will be covered under your Medicare Part D benefit. You should have a separate ID card for your Medicare





MEMBER HANDBOOK

Prescription Drug Coverage. You will need to show your Medicare Part D ID card when filling a prescription. There are some drugs that CeltiCare Health will continue to cover. For example, CeltiCare Health will continue to cover your over-the-counter (OTC) drugs. CeltiCare Health Co-payment exceptions will still apply for CeltiCare Health covered drugs. For more information, contact CeltiCare Health’s Member Services department. To find out more about your Medicare Prescription Drug Coverage, you may:

Contact Medicare at 1-800-633-4227 (TTY: 1-877-486-2048)

Go to Medicare’s Web site at www.medicare.gov

Go to www.cms.com on the internet. Remember to carry all your ID Cards with you when you go to the pharmacy. When you fill a prescription, please show your CeltiCare Health Member ID Card and your Medicare Prescription ID card.

TRANSPORTATION SERVICES

Please see the Covered Services List that is enclosed in the Welcome Packet with this Member Handbook for CeltiCare Health’s transportation benefits. In addition, as a benefit from MassHealth, some CeltiCare Health CarePlus Members may be eligible for non-Emergency transportation to go to covered healthcare visits. This benefit is administered by MassHealth. However; CeltiCare Health assists Members in obtaining the transportation. In order to be eligible for the benefit:

You do not have a family member or other person who can take you.

You do not have access to public transportation, or there is a medical reason that you cannot use it.

Your appointment must be for a Medically Necessary service.

You must see a MassHealth Provider. For more information, contact CeltiCare Health well in advance of your appointment so that we can assist in processing your request.

HEALTH MANAGEMENT

Health Needs Assessment

CeltiCare Health wants to know how we can better serve you. One way we do this is by asking you to fill out the Health Needs Assessment (HNA) form found in your Welcome Packet. This form gives us information to determine your healthcare needs. Once you fill out the form, please send it back to us right away in the postage-paid envelope we have provided for you. You can also fill out this form on our website www.CeltiCareHealthPlan.com or with a Member Services Representative on the phone. If you have questions about the form, please call us at 1-855-678-6975.


http://www.medicare.gov/

http://www.cms.com/





MEMBER HANDBOOK

Filling out the HNA DOES NOT affect your MassHealth Eligibility or your health benefits in any way. Please know that we will keep your Protected Health Information (PHI) confidential. If you do not fill out your HNA, a CeltiCare Health representative may call you and ask you to give us your HNA information. The answers you give in the HNA help us to help you stay healthy, so please do complete your HNA.

Staying Healthy

Routine preventive care is an important part of staying healthy. CeltiCare Health encourages all Members to visit their Primary Care Providers for preventive care. Examples of preventive care are:

Physical exams every 1 – 3 years.

Blood pressure monitoring at least every 2 years and whenever you have a visit with your PCP.

Cholesterol screening every 5 years.

Pelvic exams and Pap smears (for women) every 1 – 3 years.

Breast cancer screening (mammogram) every year over age 40, or earlier if there is an immediate family history of breast cancer. Breast exams could then be as often as every 6 months.

Colorectal cancer screening every 10 years starting at age 50 (or earlier if there is an immediate family history of colorectal cancer).

Flu shot annually.

Eye exams every 24 months, or more often if there are certain medical conditions that exist.

Dental – some benefits are covered by CeltiCare Health; some are covered by MassHealth. Refer to the Covered Services List booklet for details on dental coverage or call Member Services.

Care Management

CeltiCare Health offers our Members the information and tools needed to build and maintain a healthy lifestyle. Our Care Management program is free for Members. CeltiCare Health Care Managers are registered nurses, social workers, and Behavioral Health professionals. Our Care Management program connects you, your healthcare Providers, and CeltiCare Health together so you can achieve the best possible health. CeltiCare Health Care Managers (or Behavioral Health Care Managers) will be in touch with you to check on your progress and help coordinate care with all needed healthcare Providers. We also help you learn what benefits and community resources are available to you because we recognize that good health is impacted by life situations. If you are eligible, our staff can coordinate services such as transportation to healthcare appointments. We can also assist you in applying for food stamps, housing, Emergency shelter, assistance for utilities, and more. These community resource services are available to all Members, not just those enrolled in a Care Management program, through our Program Specialists on staff. Our Care Management program is free and voluntary. Your participation does not replace the care and services that you receive from your PCP and other healthcare Providers. Entry into the program may happen through completing your Health Needs Assessment (HNA), our claims information, a Referral





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from a hospital Care Manager, one of your Providers, or directly from you by request. If you want more information about CeltiCare Health’s Care Management programs, call Member Services.

Complex Care Management

Complex Care Management is for Members who may be at high risk for problems due to their health condition, complex medical needs, or special healthcare needs. If you are enrolled in Complex Care Management you will get additional care including frequent check-ins from a Care Manager, including in-person visits at home or in the community if needed. You get information and tools along with a team approach to managing your care. The Care Management Team includes registered nurses, pharmacists, and other healthcare Providers who help with your health care and social service needs. They also educate you about what you need to know to manage your condition, arrange for care and coordinate services and medical equipment as needed. The team works together with you to set health related goals and work toward them.

Disease Management

CeltiCare Health has programs to improve the health of our Members that go beyond coordination with your healthcare Provider. We work to help you understand and manage your chronic health conditions by giving you educational materials, tools and resources. The goal of our Disease Management programs is to help you learn and follow new and easy ways to manage specific ongoing challenges such as those on the list below. These programs are free and voluntary. CeltiCare Health works to provide you with personalized Disease Management services to help you control your chronic condition more effectively. This means our Health Coaches can help you understand more about your condition, give you tips on how to integrate the care your Provider has prescribed for your daily life, call you on a regular basis to offer support, education and more. Health coaching provides programs to support the following:

Asthma Back Pain Management Chronic Obstructive Pulmonary Disease

(COPD) Diabetes

High Blood Pressure (Hypertension/Hyperlipidemia)

Heart Failure Tobacco Cessation Weight Management

Note: The Tobacco Cessation Program also includes coverage for counseling sessions and drug therapy. Contact Member Services for details.

For more information on any of the other programs above, please contact CeltiCare Health Member Services.

Behavioral Health Care Management

CeltiCare Health Members can get Care Management support from our partner, Cenpatico Behavioral Health. Care Managers are licensed Behavioral Health clinicians. We can help you find a Behavioral





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Health counselor or explain available treatment options. Some of the conditions supported by Behavioral Health Care Managers are:

Mental health needs such as depression, mood disorders, psychotic disorders, schizophrenia

Substance use disorders such as help needed with alcohol, pain medications, illegal drugs

Call Member Services and ask to speak to a Behavioral Health Care Manager. No Referral is required.

Behavioral Health Intensive Clinical Management (ICM)

CeltiCare Health offers an Intensive Clinical Management Program (ICM) to provide additional support. This is a program for Members who are experiencing complex Behavioral Health or psychosocial conditions, sometimes in addition to medical concerns. ICM is a voluntary, flexible, short-term program designed to meet your individual needs and promote your optimal Behavioral Health. The program is offered by licensed clinicians who provide services by phone and face-to-face meetings with Members and their health care Providers.

ICM Care Managers work with you to advocate for your needs and link you to services. We will work to ensure you receive coordinated care, discharge planning after a Behavioral Health inpatient or 24-hour level of care admission, and resources and support in your community. With your permission, we will coordinate with your PCP and/or other healthcare Providers and Behavioral Health Providers.

To learn more about Behavioral Health Intensive Clinical Management, call Member Services.

Pregnancy and Maternity

If you are pregnant, you will be eligible for insurance coverage through other MassHealth programs. We want to make sure you get the health insurance you need throughout your pregnancy and the birth of your baby. Before we can help, we need to know you are pregnant. Please call Member Services as soon as you learn you are pregnant. We will help you set up the special care that you and your baby need.

Before you get a new MassHealth benefit plan during your pregnancy, CeltiCare Health will cover all Medically Necessary obstetrical and gynecological services through delivery of the child, as well as immediate post-partum care and the follow up appointments within the first six weeks of delivery. Before you transition to another MassHealth benefit plan, CeltiCare Health will offer Care Management for pregnant Members who are at risk for complications of pregnancy and/or poor neonatal outcomes. Care Management will focus on coordinating services and providing integrated care for moderate to high risk pregnant women.

Your newborn child will immediately be enrolled with MassHealth (as the CarePlus program does not cover anyone who is under 21 years of age). Your baby is covered for any medical needs from the moment of birth by MassHealth even if the newborn isn’t enrolled in MassHealth when the baby is born.





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Family Planning Services

CeltiCare Health covers Family Planning Services that include family planning medical services, family planning counseling, birth control advice, pregnancy tests, sterilization services, and follow-up healthcare. You can get Family Planning Services from your PCP. Or, you can get these services from any CeltiCare Health or MassHealth contracted Family Planning Services Provider. These services do not require Prior Authorization. You can self-refer by calling the Family Planning Services Provider directly. Or ask your PCP to refer you to a Family Planning Services Provider. You can find a list of Family Planning Services Providers under “Family Medicine” in the Find a Provider tool on the CeltiCare Health website or you can request a printed directory.

MemberConnections®

MemberConnections is an outreach program that promotes preventive health and connects you to quality healthcare and community social services. MemberConnections representatives are specially trained to work collaboratively with our Care Management staff and provide additional support to our Members. They can help you determine which healthcare Providers are available in your area, find support services, and help arrange for needed services. They can also visit your home to help you with healthcare needs and social services. To learn more, call Member Services .

ConnectionsPLUS®

ConnectionsPLUS is part of the MemberConnections program that provides free cell phones to high-risk Members who do not have safe, reliable access to a telephone. This program allows qualified Members 24-hour instant access to Providers, care managers, CeltiCare Health staff, telehealth services and 911.

To learn more about the program, contact a CeltiCare Healthcare care manager or log onto our website at www.CeltiCareHealthPlan.com.

MEMBER SATISFACTION

Member Advisory Committee

CeltiCare Health has a Member Advisory Committee that gives Members a chance to share their thoughts, ideas, and concerns about the plan. The group meets at least two times a year to talk about the way services are delivered. We may ask Members, Member advocates, and CeltiCare Health staff to join in the meeting. You may ask questions, make suggestions, or share any concerns that you have





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about the delivery of services. Call Member Services, if you would like to attend a Member Advisory Committee meeting in your area.

Quality Improvement (QI)

CeltiCare Health is committed to providing quality healthcare for you. Our primary goal is to improve your health and help you with any illness or disability. Our program follows the National Committee on Quality Assurance (NCQA) standards and helps promote safe, reliable, and quality healthcare. CeltiCare Health adopts and uses evidence-based preventive and clinical practice guidelines for medical and Behavioral Health care which are reviewed and approved on an annual basis or when changes are needed by our Quality Improvement Committee. Our programs include:

Conducting a thorough check on Providers when they become part of the CeltiCare Health

Provider Network. Monitoring the access that CeltiCare Health Members have to all types of healthcare services. Providing programs and educational items about general healthcare and specific diseases. Sending reminders to you for annual tests, such as an adult physical, cervical cancer screening,

and breast cancer screening. Maintaining a Quality Improvement committee that includes participating Providers to help us

develop and monitor our program activities. Reviewing and approving our Quality Improvement program on a yearly basis. Investigating your concerns regarding the healthcare you have received. Using feedback from Members and Providers to design, plan, and implement our quality

activities.

Further information on our Quality Improvement programs and practice guidelines are available upon request.

If you have a concern about the care you received from your Provider or any Covered Service provided by CeltiCare Health, please contact Member Services. CeltiCare Health believes that getting input from Members, can help make the services and quality of our programs better. We conduct a Member survey each year that asks questions about your experience with the healthcare and services you are receiving. If you receive one of our Member surveys, please be sure to fill it out and send it back in the mail.

INQUIRIES, GRIEVANCES, AND APPEALS

CeltiCare Health wants you to contact us if you have any concerns with your care or services. Our Member Services department will help you resolve your concerns. If your concerns extend beyond what Member Services can answer for you, you have the right to make an Inquiry, Grievance, or Internal Appeal.





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You also have the right to voice any concerns to MassHealth at any time. You may call the MassHealth Customer Service center at the number at the bottom of the page.

What is an Inquiry?

An Inquiry is any question or request that you may have about CeltiCare Health’s operations including any interactions you have during medical, Behavioral Health, or any other treatment or service including any questions you have about our Behavioral Health partner, Cenpatico. An inquiry is not about a dissatisfaction you may have with CeltiCare Health. We will resolve your inquiries immediately or within 1 business day of the day we receive your question and notify you by phone, mail, or email. To make an Inquiry, you can call Member Services Department or fax your question to 1-866-614-1953.

Authorized Appeal Representative

An Authorized Appeal Representative is someone you give permission in writing to act on your behalf for a Grievance, an Internal Appeal, or an Office of Medicaid’s Board of Hearings (BOH) Appeal. Your Authorized Appeal Representative can be a family member or any person of your choosing. There is one form to complete for all your care (medical and Behavioral Health). To get the form, call Member Services or download it from the CeltiCare Health website. The form has a place for you to tell us how long your Authorized Appeal Representative has your permission to act on your behalf. You can revoke the permission at any time by writing to us or completing the “Revocation of Authorization to Disclose Health Information” form.

If you are naming an Authorized Appeal Representative during a Grievance or Internal Appeal process, you may have to give us the written authorization naming your Authorized Appeal Representative before our deadline ends. You will be notified about the deadlines. We can help you write an Authorized Appeal Representative letter or you can use the form mentioned above.

What is a Grievance?

A Grievance is any oral or written expression of dissatisfaction with CeltiCare Health including medical or Behavioral Health services.. You or your Authorized Appeal Representative have the right to file a Grievance if you are not satisfied with any aspect of CeltiCare Health’s operations or interactions. You can also file a Grievance if you have a problem with the quality of care or services you receive from a Provider. A Grievance can also be filed when we:

Extend the timeframes to process a Prior Authorization request when you, or your Authorized Appeal Representative, disagree with the decision to extend

Do not approve your request for an Expedited (fast) Internal Appeal and we process it as a standard Internal Appeal

Extend the timeframe to process your Internal Appeal and you, or your Authorized Appeal Representative, disagree with the decision to extend.





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How to File a Grievance

Filing a grievance will not affect your healthcare services. We want to know your concerns so we can improve our services, and address your problems or concerns. We will not hold it against you or treat you differently if you file a Grievance. You can file a Grievance beginning on the date of the situation you are not satisfied with. You, or your Authorized Appeal Representative, can file CeltiCare Health medical or Behavioral Health Grievances by phone by calling Member Services or you can file a Grievance in writing, by faxing it to 1-866-614-1953, or you can file in person or by mail it to the address below.

CeltiCare Health

Grievance and Appeal Coordinator - CarePlus 200 West Street, Suite 250

Waltham, MA 02451 In all cases, be sure to include:

Your first and last name

Your CeltiCare Health or MassHealth CarePlus ID number

Your address and telephone number

What you are unhappy about

What you would like to have happen

After we receive your Grievance, CeltiCare Health will send you a letter within 1 business day of our receipt, letting you know that we have received your Grievance and the expected date of resolution. If someone else is going to file a Grievance for you, we must have your written permission for that person to file your Grievance. You can call Member Services to receive an Authorized Appeal Representative form, or go to www.CeltiCareHealthPlan.com. If you have any proof or information that supports and helps explain your Grievance, send it to us and we will add it to your case. You may also request copies of any documentation that CeltiCare Health used to make the decision about your care. To review your request, we may need additional information. You should include a signed Authorization to Disclose Information form with your Grievance. If you don’t, we will send a form to you for your signature. We need to have a signed authorization from you within 30 calendar days of the request. Without it, CeltiCare Health may issue a decision on the Grievance without being able to review all of your information. You can find the Authorization to Disclose Information form at the back of this handbook.






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Can CeltiCare Health dismiss your Grievance?

Yes. We may dismiss your Grievance if someone else files it on your behalf and we did not receive your written authorization for that person to serve as your Authorized Appeal Representative before our timeframe for resolving your Grievance expired. If this happens, we will send you a Grievance dismissal notification.

How soon will a decision be made on your Grievance?

Once we receive your Grievance, we’ll send you a written letter acknowledging it within 1 business day. We’ll immediately start to work on your Grievance. We’ll send you and your Authorized Appeal Representative a written response within 30 calendar days from the date we received your Grievance.

What do you do if you do not speak English?

If you do not understand English, CeltiCare Health will help you with interpreter or translation services during the Grievance process at no cost to you. If you have any questions about the Grievance process, please call the Member Services department at the numbers below.

What is an Internal Appeal?

There are two types of Internal Appeals; a standard Internal Appeal and an Expedited (fast) Internal Appeal. Either type of Internal Appeal is a request to review an Adverse Action. An Adverse Action is a decision CeltiCare Health made, based on a review of the information provided to deny, reduce, modify, or terminate requested care for you. An Adverse Action can happen when the information provided does not meet the requirements for coverage. The Internal Appeal process gives you an opportunity to ask CeltiCare Health to review this decision. An Adverse Action or inaction occurs if:

We denied or decided to provide limited authorization for a service requested by your healthcare Provider. This can include the decision that the requested service is not a Covered Service.

We reduced, suspended or terminated a Covered Service that was previously appealed.

We denied, in whole or in part, payment for a Covered Service due to service coverage issues.

We did not make a service authorization decision within the allowed timeframes after receiving your request.

We did not notify you of a standard Internal Appeal decision within the allowed timeframes after receiving your request.

You are not able to obtain healthcare services within the specified timeframes described in this Member Handbook

In most cases, you will receive a notice letting you know that one of the actions listed above has occurred. However, you, or your Authorized Appeal Representative, may file an Internal Appeal whenever one of these actions occurs even if you did not receive a notice from CeltiCare Health.





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Who May File an Internal Appeal?

You, the Member

A person named and authorized in writing by you (Authorized Appeal Representative)

Your healthcare Provider You must give written permission if someone else files an Internal Appeal for you. CeltiCare Health will include an Authorized Appeal Representative form in a letter we send back to you about our Adverse Action decision. Contact Member Services if you need help. There are two types of Internal Appeals as described below, a standard Internal Appeal and an Expedited (fast) Internal Appeal.

How Do I File a Standard Internal Appeal?

You, or your Authorized Appeal Representative, can file a standard Internal Appeal for all non-Behavioral Health Internal Appeals by phone, by calling Member Services or you can file a standard Internal Appeal in writing, by faxing it to 1-866-614-1953, or you can mail it to the address below. If you

or your Authorized Appeal Representative wants to submit a standard Internal Appeal in person please visit us at the address listed below.

CeltiCare Health Grievance and Appeal Coordinator - CarePlus

200 West Street, Suite 250 Waltham, MA 02451

We handle oral requests for an Appeal as a standard Internal Appeal in order to give you the earliest possible filing date for the standard Internal Appeal. You may be asked to complete a written signed request. If you don’t send us this written documentation, we may dismiss your standard Internal Appeal.

Behavioral Health Standard Internal Appeals

All Behavioral Health related standard Internal Appeals are delegated to CeltiCare Health’s Behavioral Health partner, Cenpatico Behavioral Health (Cenpatico). Cenpatico is obligated to follow the same standard Internal Appeal process as outlined in these sections of the Member Handbook for CeltiCare Health. For more information please contact Cenpatico directly at 1-866-896-5053.

To file a Behavioral Health standard Internal Appeal in writing please mail or fax the Appeal to the following:

Cenpatico Attn: Appeals Department

12515-8 Research Blvd, Suite 400 Austin, TX 78759

Fax: 1-866-896-5053 Phone: 1-866-896-5053





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When Does a Standard Internal Appeal Have to be Filed?

The Notice of Adverse Action letter CeltiCare Health sends you will tell you that you or your Authorized Appeal Representative have to file a standard Internal Appeal within 30 calendar days from the date of the Notice of Adverse Action, or of learning that an Adverse Action has occurred. There are two levels of standard Internal Appeal – first level and second level.

How Does the Standard Internal Appeal Process Work?

We provide you with two (2) levels of Internal Appeal review, a first level and a second level (reviewed by a clinician not involved with your first level Internal Appeal). You or your Authorized Appeal Representative must file a first level standard Internal Appeal within 30 calendar days from when we gave you notice that an Adverse Action has been decided. If there is a situation where you do not receive a notice from us, you, or your Authorized Appeal Representative may still appeal within 30 calendar days of learning, on your own, that an Adverse Action or inaction was made on your request. Once your first level standard Internal Appeal request is received, we will send you and your Authorized Appeal Representative a written acknowledgement within 1 business day of receiving it. We will immediately begin to work to resolve your standard Internal Appeal. Standard Internal Appeal decisions are made by healthcare professionals who have the appropriate clinical background. We use healthcare professionals who were not involved in the original action that you are appealing. Also, if you request a second level review, a different healthcare professional will review the second level standard Internal Appeal.

What are Your Rights during a Standard Internal Appeal?

We will provide you, or your Authorized Appeal Representative, the time to submit comments, documentation, records, present proof and facts, and other information relevant to your standard Internal Appeal. You can do this in person or in writing. In addition, we will allow you or your Authorized Appeal Representative, to see your files before and during the standard Internal Appeal process. If you do not understand English, we will help you with interpreter or translation services during the Internal Appeal process.

If you or your Authorized Appeal Representative files a standard Internal Appeal, we will not treat you differently or unfairly during or after the process. Legal representatives of a deceased Member’s estate can be included as parties to a standard Internal Appeal.

When will a Standard Internal Appeal Decision be made?

CeltiCare Health will give you an answer and send you and your Authorized Appeal Representative a notice within 20 days from the date CeltiCare Health received your written or oral request for a first level standard Internal Appeal unless:

You or your Authorized Appeal Representative requests to extend the timeframe by up to 5 calendar days, or





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CeltiCare Health requests to extend the timeframe up to 5 calendar days because:

The extension is in your best interest, and;

We need additional information that we believe, if received, will lead to approval of your request, and;

Such information is expected to be received within 5 calendar days.

If you do not agree with CeltiCare Health taking an extension of 5 calendar days, you may file a Grievance as described in the Grievance section above.

What if You Disagree with the First Level Review Decision?

If you disagree with the decision we reach on your first level standard Internal Appeal, you or your Authorized Appeal Representative, can request a second level review of your standard Internal Appeal from either CeltiCare Health (for a medical Appeal) or Cenpatico (for a Behavioral Health Appeal). You can also skip the second level standard Internal Appeal review from CeltiCare Health or Cenpatico, and file an Appeal directly with the Board of Hearings (see “How to File a Board of Hearing Appeal”). If you choose to file with the Board of Hearings after the first level standard Internal Appeal review, you give up (waive) the right to a second level standard Internal Appeal.

If you decide to ask for a second level standard Internal Appeal review, you, or your Authorized Appeal Representative, must file your request with CeltiCare Health within 30 calendar days of receiving the notice of your first level standard Internal Appeal denial.

Once we receive your second level standard Internal Appeal request, we will send you and your Authorized Appeal Representative a written letter acknowledging receipt within 1 business day. We will immediately begin working on the second level review of your standard Internal Appeal. We will resolve your second level review within 20 calendar days unless:

You or your Authorized Appeal Representative requests to extend the timeframe by up to 5 calendar days, or

CeltiCare Health requests to extend the timeframe up to 5 calendar days because:




Please note that CeltiCare Health can only take this extension one time, either during the first level or second level standard Internal Appeal review. If you do not agree with CeltiCare Health taking an extension of 5 calendar days, you may file a Grievance as described in the Grievance section above.





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We will notify you, and your Authorized Appeal Representative, in writing of our second level review decision. If you do not agree with that decision, you, or your Authorized Appeal Representative, can file an Appeal with the Board of Hearings (see “How to File a Board of Hearing Appeal”).

Continuing Services during a Standard Internal Appeal During the first level standard Internal Appeal:

If your first level standard Internal Appeal involves a decision by CeltiCare Health to reduce or stop covering a service that was previously approved, you will automatically continue to receive those services if you or your Authorized Appeal Representative requests a standard Internal Appeal within 10 calendar days from the date you were notified about the Adverse Action. If you do not want to receive these Continuing Services while a standard Internal Appeal is pending, you must specifically tell us that you do not want to receive these services.

During the second level standard Internal Appeal:

In the same way, if your second level standard Internal Appeal involves a decision by CeltiCare Health to reduce or stop covering a service that was previously approved, you will automatically continue to receive those services, if you request a second level standard Internal Appeal within 10 calendar days from receiving your first level standard Internal Appeal resolution notice. If you do not want to receive these Continuing Services while a standard Internal Appeal is pending, you must specifically tell us that you do not want to receive these services.

For both levels of standard Internal Appeal, continued coverage applies only to those services that were approved at the time they began and were not terminated because benefit coverage was exhausted.

When Can CeltiCare Health Dismiss Your Standard Internal Appeal?

We may dismiss your standard Internal Appeal, and send you written notification of this, if:

Someone files a standard Internal Appeal on your behalf and we do not receive your written authorization for that person to serve as your Authorized Appeal Representative before the timeframe for resolving your standard Internal Appeal expires or

You or your Authorized Appeal Representative, do not follow-up on an oral request in writing; or

You, or your Authorized Appeal Representative, file the standard Internal Appeal more than 30 calendar days after our notice telling you that you had a right to a standard Internal Appeal, (or if you did not receive such a notice, more than 30 calendar days after learning on your own about our Adverse Action or inaction that gives you a right to a standard Internal Appeal); or

You, or your Authorized Appeal Representative, file the second level review of your standard Internal Appeal more than 30 calendar days after the notice from us telling you about our decision to uphold your first level standard Internal Appeal.





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Can a Standard Internal Appeal Dismissal be Disputed?

If you or your Authorized Appeal Representative believes that you requested your standard Internal Appeal in time (within 30 calendar days) and have a way to prove that, (supporting evidence) you, or your Authorized Appeal Representative, have the right to dispute our standard Internal Appeal dismissal and request that we continue with your standard Internal Appeal. To do so, you, or your Authorized Appeal Representative, must submit a letter to CeltiCare Health requesting reconsideration of the dismissal within 10 calendar days of the standard Internal Appeal dismissal notice. We will review your request for reconsideration of dismissal and notify you and your Authorized Appeal Representative of our decision.

What is an Expedited (fast) Internal Appeal?

If you or your Authorized Appeal Representative, or your Provider feel that taking the time for a standard Internal Appeal could seriously jeopardize your life, health, or your ability to get, maintain or regain maximum function, an Expedited (fast) Internal Appeal may be requested.

How to request an Expedited (fast) Internal Appeal

Submit the request for the Expedited (fast) Internal Appeal the same way you submit for a standard Internal Appeal. to CeltiCare Health for non-Behavioral Health, Internal Appeals. It can be filed orally bycalling Member Services; or in writing by you, your Authorized Appeal Representative, and/or your Provider. CeltiCare Health will process the Expedited (fast) Internal Appeal when a Provider is serving as your Authorized Appeal Representative even if CeltiCare Health has not received the Authorized Appeal Representative form. CeltiCare Health requires that the Provider submit a signed Authorized Appeal Representative form as documentation that you did authorize the Provider to file the Expedited (fast) Internal Appeal on your behalf; but the Expedited (fast) Internal Appeal will not be delayed while waiting for the form. If being mailed or delivered, send to:

CeltiCare Health Grievance and Appeal Coordinator – CarePlus






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For Behavioral Health Expedited (fast) Internal Appeals, call, mail, or fax to:

Cenpatico Attn: Appeals Department

12515-8 Research Blvd, Suite 400 Austin, TX 78759

Phone: 1-866-896-5053, Fax: 1-866-714-7991

You, your Authorized Appeal Representative, or your healthcare Provider may request an Expedited (fast) Internal Appeal. If your Provider is not involved in your request for an Expedited (fast) Internal Appeal, then we have the right to determine whether or not to process the Internal Appeal as an Expedited (fast) Internal Appeal.

If your request does not qualify for an Expedited (fast) Internal Appeal, we will tell you, your Provider, and your Authorized Appeal Representative, in writing, about the decision. We will then process your Internal Appeal within the standard Internal Appeal 20 calendar-day timeframe. You, or your Authorized Appeal Representative, have the right to file a Grievance if you disagree with this decision not to expedite your Internal Appeal. CeltiCare Health will not take disciplinary action against a Provider who requests an Expedited (fast) Internal Appeal or supports a Member’s Expedited (fast) Internal Appeal request.

How the Expedited (fast) Internal Appeal Process Works

If you meet the qualifications for an Expedited (fast) Internal Appeal, CeltiCare Health will process your Appeal request and notify you of our decision orally and in writing, as quickly as your health requires, but not later than 72 hours from when we received your request. The timeframe can be extended by 14 calendar days as described below. We will notify you, your Authorized Appeal Representative, and your Provider in writing of the decision. We will also try to contact you by telephone to tell you about the decision.

If you are currently receiving Covered Services that are under your Expedited (fast) Internal Appeal, you may continue to receive services through the completion of the Expedited (fast) Internal Appeal process if the Expedited (fast) Internal Appeal was filed within 10 days of receiving CeltiCare Health’s Adverse Action notice, and the services you are appealing were previously authorized by CeltiCare Health

Getting an Expedited (fast) Internal Appeal Extension

If you want to send us additional information that is important to your Expedited (fast) Internal Appeal, you or your Authorized Appeal Representative may request an extension of up to 14 calendar days. We can also request a 14 calendar day extension in writing. If you do not agree with our extension request, you or your Authorized Appeal Representative may file a Grievance as described in the Grievance section above. Please note that CeltiCare Health can only request an extension if:






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What is a Board of Hearings (BOH) Appeal?

If you or your Authorized Appeal Representative is not satisfied with the final standard Internal Appeal or Expedited (fast) Internal Appeal decision, you have a right to request a Fair Hearing through the Massachusetts Executive Office of Health and Human Services (EOHHS), Office of Medicaid’s Board of Hearings (BOH).

When we give you our written decision about your Internal Appeal, we will include the Request for Fair Hearing form and other helpful material that you, or your Authorized Appeal Representative, need to request a Fair Hearing. We can also assist you, or your Authorized Appeal Representative, in completing the BOH (Fair Hearing) Appeal application.

How Do You File a BOH Appeal?

You qualify for a Board of Hearings appeal when you have exhausted CeltiCare Health’s Internal Appeals process. The timeframe to file for a Fair Hearing is different based on the type of hearing you are requesting:

You should file a BOH request within 30 calendar days of CeltiCare Health’s notice of a standard Internal Appeal decision if you, or your Authorized Appeal Representative, do not agree with the decision that we reached on your:

Second level Internal Appeal, or

First level standard Internal Appeal, and you choose not to request a second level standard Internal Appeal through CeltiCare Health; or

Expedited (fast) Internal Appeal, and you no longer are requesting an Expedited (fast) Appeal from the BOH.

You should file a BOH request within 20 calendar days of our notification, if you want an Expedited BOH Appeal. (If you, or your Authorized Appeal Representative, file between 21 and 30 calendar days, the BOH will process your Fair Hearing request within the standard timeframe of 30 calendar days.)

You should file a BOH request within 10 calendar days of receiving our decision on your first level, second level, or Expedited (fast) Internal Appeal if you want to continue receiving the services that are the reason for the BOH Appeal. You may also choose to not continue to receive services during your BOH Appeal. If you lose the BOH Appeal, you may be responsible to pay back the cost of the services that you received while the BOH Appeal was pending.

You, or your Authorized Appeal Representative, should send the BOH Appeal application for a Fair Hearing request to:

Board of Hearings Office of Medicaid

100 Hancock Street, 6th Floor Quincy, MA 02171

Fax: 1-617-847-1204





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Your Rights During the Board of Hearings Appeal Process

CeltiCare Health will submit your documents to the Board of Hearings (BOH) prior to your BOH Appeal. You and your Authorized Appeal Representative will be given access to the same documents that are sent to the BOH about your case. At the hearing, you may represent yourself, or have your Authorized Appeal Representative, an attorney, or your healthcare Provider represent you, acting as your Authorized Appeal Representative. You may also include the legal representative of a deceased Member’s estate if the situation included that deceased Member. If you do not understand English and/or are hearing or sight impaired, the Board of Hearings will make sure that an interpreter and/or assisting device is available for you at the hearing. If you have questions about the Board of Hearings Appeal process, you can call CeltiCare Health’s Member Services Department at: 1-855-678-6975. Our hours of operation are 8:00 a.m. to 5:00 p.m. Monday through Friday.

Board of Hearing Appeal Decision

The BOH will send their decision to you and your Authorized Appeal Representative directly. CeltiCare Health will comply with and implement any BOH Appeal decision made in your favor immediately.

FRAUD AND ABUSE PROGRAM (FAP)

Authority and Responsibility Fraud and Abuse means that a Member, Provider or another person is misusing MassHealth, the CarePlus program, or CeltiCare Health resources.

This could include the following:

Loaning, selling, or giving your CeltiCare Health Member ID card or MassHealth ID card to someone

Misusing CeltiCare Health or MassHealth benefits

Billing CeltiCare Health for “free” services

Wrongful billing to CeltiCare Health by a Provider

Billing CeltiCare Health for services not provided

Any action to defraud CeltiCare Health, MassHealth, or the CarePlus program

CeltiCare Health is serious about finding and reporting Fraud and Abuse. Our staff is available to talk to you about this.





MEMBER HANDBOOK

If you know another CeltiCare Health Member or another person trying to commit healthcare Fraud, please write to the Fraud and Abuse Coordinator in CeltiCare Health’s Compliance Department at:

CeltiCare Health Compliance Department


Or you can call CeltiCare Health’s Fraud and Abuse Program (FAP) Hotline at 1-866-685-8664.

You can also report Fraud and Abuse to the MassHealth Fraud and Abuse Hotline by calling 1-877-437-2830.

Your healthcare benefits are given to you based on your Eligibility for both MassHealth and the CarePlus program. You must not share your benefits with anyone. CeltiCare Health’s Network Providers must report any misuse of benefits to CeltiCareHealth. And CeltiCare Health must report any misuse or wrongful use of benefits to MassHealth. If you misuse your benefits, you could lose them.

If you think a healthcare Provider, doctor, or a hospital is misusing MassHealth or CeltiCare Health resources, tell us right away. We will forward any Provider issues to MassHealth for action. CeltiCare Health will take your call about waste, Fraud and Abuse seriously. Call CeltiCare Health’s FAP Hotline at 1-866-685-8664. You do not need to give your name.

What to Do if You Get a Bill

If you get a bill for a Covered Service, here’s what you should do:

Print the name of the Member who received the care, and his or her CeltiCare Health Member ID Card number on the bill, and

Make a copy for your records. Mail any bills for medical services to:

CeltiCare Health Attn: CLAIMS PO Box 3080

Farmington, MO 63640-3824 Mail any bills for Behavioral Health services to:

Cenpatico Behavioral Health Attn: CLAIMS PO Box 7200

Farmington, MO 63640-3813





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You cannot be charged for:

Emergency, Post Stabilization, or Urgent Care services provided in the United States and its territories.

Services you get from a CeltiCare Health Provider or an out-of-Network Provider if these services were given Prior Authorization by CeltiCare Health.

Services provided by a MassHealth Provider when those services are covered directly by MassHealth

Family Planning Services received from any MassHealth contracted Family Planning Services Provider.

A Provider can charge you for a service if they have received approval from you in advance by explaining that:

The service they want to provide is not a Covered Service, and;

There may be other Covered Services that are available to meet your needs. If the Provider has not explained this to you before providing any service, you cannot be held responsible for payment for that service. Care that is not covered by CeltiCare Health or MassHealth may be your responsibility. We can help you figure out if particular care or a service is a Covered Service. If you have questions, please call Member Services. Do not pay the bill yourself unless you are sure it is your responsibility.

Other Insurance

You must let CeltiCare Health and MassHealth know if you have other insurance coverage with another company. CeltiCare Health can help coordinate your benefits with your other insurance company. CeltiCare Health may contact you to arrange for payments with other insurance if you have another insurance plan. If you have any questions on the Coordination of Benefits process, contact CeltiCare Health Member Services.

Accidental Injury or Illness (Coordination of Benefits and Subrogation)

If a CeltiCare Health Member has to see a healthcare Provider for an injury or illness that was caused by another person or business, you must call Member Services at 1-855-678-6975 (TDD/TTY 1-866-614-1949) to let us know. For example, if you are hurt in a car accident, by a dog bite, or if you fall and are hurt in a store; then another insurance company might have to pay the doctor's bills and/or hospital bills. When you call, we will need the name of the person or business at fault, their insurance company, and the names of any attorneys involved.

You must tell us if you have any other health insurance coverage in addition to MassHealth. You must also let us know whenever there are any changes in your additional insurance coverage. The types of additional insurance you might have include:

Coverage from an employer’s group health insurance for employees or retirees, either for yourself or your spouse

Coverage under workers’ compensation because of a job-related illness or injury





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Coverage for an accident where no-fault insurance or liability insurance is involved

Coverage you have through veteran’s benefits

“Continuation coverage” that you have through COBRA (COBRA is a law that requires employers with 20 or more employees to let employees and their Dependents keep their group health coverage for a time after they leave their group health plan under certain conditions.)

CeltiCare Health is the payer of last resort for payment of medical services involving Coordination of Benefits and third-party-liability or Subrogation. Please see the following sections for more information.

Coordination of Benefits

When you have other health insurance coverage, we work with your other insurance to coordinate your CeltiCare Health benefits. The way we work with the other companies depends on your situation. This process is called Coordination of Benefits. Through this benefit coordination, you will often get your health insurance coverage as usual through us. If you have other health insurance, our coverage will always be secondary when the other plan provides you with healthcare coverage, unless the law states something different. In other situations, such as for benefits that are not covered by CeltiCare Health, you may be able to get your care covered by an insurer other than us. If you have additional health insurance, please call Member Services to find out how payment will be handled.

If you have comprehensive health insurance with another health plan, including Medicare, you may not be eligible for MassHealth benefits from Managed Care organizations, including CeltiCare Health. If you fit this category, you will need to be disenrolled from CeltiCare Health. MassHealth will notify you about this.

Motor Vehicle Accidents and/or Work-related Injury/Illness

If you are in a motor vehicle accident, you must use all of your auto insurance carrier’s medical coverage (including personal injury protection (PIP) and/or medical payment coverage) before we will consider paying for any of your expenses. You must send to us any explanation of payment or denial letters from an auto insurance carrier for us to consider paying a Claim that your Provider sends to us. In the case of a work-related injury or illness, the workers’ compensation carrier will be responsible for those expenses first. You must send to us any explanation of payment or denial letters from an employer insurance carrier for us to consider paying a Claim that your Provider sends to us. Subrogation

If you are injured by the act or omission of another person, your CeltiCare Health benefits will be subrogated. This means that we may use your right to recover money from the person(s) who caused the injury, or from any insurance company, or other party. If another person or party is, or may be, liable to pay for services related to your illness or injury that may have been paid for or provided by us, we will subrogate and succeed to all your rights to recover against such person or party 100 percent of the value of services paid for or provided by us. Claims incurred as a result of any Subrogation case should be submitted before any settlement. Claims for services rendered before a settlement that are not submitted before that settlement is reached may be denied.





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In the event another party reimburses any medical expense we pay for, we will be entitled to recover from you 100 percent of the amount you got for such services from us. The amount you must pay back to us will not be reduced by any attorney’s fees or incurred expenses. To enforce our Subrogation rights under this Member Handbook, we will have the right to take legal action, with or without your consent, against any party to secure recovery of the value of services provided or paid for by us for which that party is, or may be, liable. Nothing in this handbook will be interpreted to limit our right to use any remedy provided by law to enforce CeltiCare Health’s rights to Subrogation under this Member handbook.

We require you to follow all Prior Authorization requirements even when third-party-liability exists. Authorization is not a guarantee of payment.

MEMBER RIGHTS AND RESPONSIBILITIES

Member Rights CeltiCare Health Members have specific rights and Members are entitled to exercise these rights without having their treatment adversely affected by Providers and/or CeltiCare Health. Members have the right to be treated in a manner reflecting respect for their privacy and dignity as a person, without regard to age, gender, race, color, religion, national origin, ancestry, marital status, sexual orientation, income status, physical or mental condition or disability, pre-existing condition, occupation, and/or need for healthcare services.

As a Member, you have the right to:

Be treated with respect and with due consideration for your dignity and privacy.

Receive CeltiCare Health Covered Services and information about CeltiCare Health.

Choose a Primary Care Provider (PCP) within the CeltiCare Health Network and expect the PCP to provide for Covered Services.

Change your PCP.

Be informed of CeltiCare Health’s policies and procedures regarding services, benefits, practitioners and Providers, and Member rights and responsibilities; and be notified of any significant changes in those policies and procedures.

Be made aware of all care and treatment options and alternatives in advance and in a manner appropriate to your condition and your ability to understand those options.

A candid discussion of appropriate or Medically Necessary treatment options for a condition, regardless of cost or benefit coverage.

Receive a Second Opinion on a medical procedure and have CeltiCare Health pay for the Second Opinion visit.

Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation that would adversely affect the way CeltiCare Health and its Providers treat you.





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Participate with practitioners in decisions regarding your healthcare, including the right to refuse treatment to the extent permitted by law, and to be made aware of the potential medical consequences of such action.

Execute an Advance Directive to inform healthcare Providers what to do if you become unable to make decisions about your care.

File a Grievance for an unsatisfactory experience with CeltiCare Health or with any of CeltiCare Health’s contracted Providers and receive a response with the steps taken to address the Grievance.

File an Internal Appeal if you disagree with certain decisions made by CeltiCare Health.

Request and receive a copy of your medical records and request that they be amended or corrected.

Receive privacy during treatment and expect confidentiality of all records and communications.

Have questions and concerns answered completely and courteously.

Make recommendations regarding Member Rights and Responsibilities.

Member Responsibilities

As a CeltiCare Health Member, you have a responsibility to:

Provide CeltiCare Health and Providers with complete and accurate information necessary to care for you, for your medical record and for CeltiCare Health membership records.

Understand and learn about your health problems and any recommended treatment, and participate in developing mutually agreed upon goals, to the degree possible.

Partner with your healthcare Provider and work out treatment plans and goals together.

Follow the plans and instructions for care that you have agreed on with your practitioners.

Schedule and keep appointments and to call to cancel or re-schedule appointments as needed.

Treat all CeltiCare Health staff, Providers and other Members with respect and dignity.

Notify CeltiCare Health of any changes in your personal information, such as address, telephone number, marital status, additions to the family, Eligibility or other health insurance coverage.

Find out if a Provider is an out-of-Network Provider prior to receiving Medically Necessary services. Make sure that your in-Network healthcare Provider has obtained any required Prior Authorization before visiting an out-of-Network Provider.

Understand that you may be responsible for payment of services you receive that are not included in the Covered Services.

ADVANCE DIRECTIVES

All CeltiCare Health Members have a right to make Advance Directives for healthcare decisions as described in state and federal laws. This includes planning treatment before you need it. Advance Directives are forms you can complete to protect your rights for medical care. It can help your PCP and other Providers understand your wishes about your health. Advance Directives will not take away your right to make your own decisions, and will work only when you are unable to speak for yourself.





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Examples of Advance Directives include:

Living Will.

Healthcare Power of Attorney.

“Do Not Resuscitate” Orders.

You should not be discriminated against for not having an Advance Directive. For more information regarding Advance Directives, as well as a form you can use to designate a Healthcare Proxy, call CeltiCare Health Member Services or visit our website





MEMBER HANDBOOK

NOTICE OF PRIVACY PRACTICES

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

Effective January 1, 2014

For help to translate or understand this, please call 1-855-678-6975

Hearing impaired TTY 1-866-614-1949.

Si necesita ayuda para traducir o entender este texto, por favor llame al telefono. 1-855-678-6975.(TTY 1-866-614-1949). Interpreter services are provided free of charge to you.

Covered Entities Duties:

CeltiCare Health is a Covered Entity as defined and regulated under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). CeltiCare Health is required by law to maintain the privacy of your protected health information (PHI), provide you with this Notice of our legal duties and privacy practices related to your PHI, abide by the terms of the Notice that is currently in affect and notify you in the event of a breach of your unsecured PHI.

This Notice describes how we may use and disclose your PHI. It also describes your rights to access, amend and manage your PHI and how to exercise those rights.

CeltiCare Health reserves the right to change this Notice. We reserve the right to make the revised or changed Notice effective for your PHI we already have as well as any of your PHI we receive in the future. CeltiCare Health will promptly revise and distribute this Notice whenever there is a material change to the uses or disclosures, your rights, our legal duties, or other privacy practices stated in the notice. We will make any revised Notices available on www.CeltiCareHealthPlan.com.

Permissible Uses and Disclosures of Your PHI:

The following is a list of how we may use or disclose your PHI without your permission or authorization:

Treatment - We may use or disclose your PHI to a physician or other healthcare Providerproviding treatment to you, to coordinate your treatment among Providers, or to assist us inmaking prior authorization decisions related to your benefits.






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Payment - We may use and disclose your PHI to make benefit payments for the healthcare services provided to you. We may disclose your PHI to another health plan, to a healthcare Provider, or other entity subject to the federal Privacy Rules for their payment purposes. Payment activities may include processing claims, determining Eligibility or coverage for claims, issuing premium billings, reviewing services for Medical Necessity, and performing utilization review of claims.

HealthCare Operations - We may use and disclose your PHI in the performance of our

healthcare operations. These activities may include providing customer services, responding to complaints and Appeals, providing case management and care coordination, conducting medical review of claims and other quality assessment and improvement activities. We may also in our healthcare operations disclose PHI to business associates with whom we have written agreements containing terms to protect the privacy of your PHI. We may disclose your PHI to another entity that is subject to the federal Privacy Rules and that has a relationship with you for its healthcare operations relating to quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, case management and care coordination, or detecting or preventing healthcare fraud and abuse.

Group Health Plan Disclosures – We may disclose your PHI to a sponsor of the group health

plan, such as an employer or other entity that is providing a healthcare program to you. We can disclose your PHI to that entity if they have contracted with us to administer your healthcare program on their behalf.

Appointment Reminders/Treatment Alternatives - We may use and disclose your PHI to

remind you of an appointment for treatment and medical care with us or to provide you with information regarding treatment alternatives or other health-related benefits and services, such as information on how to stop smoking or lose weight.

As Required by Law - If federal, state, and/or local law requires a use or disclosure of your

PHI, we may use or disclose your PHI information to the extent that the use or disclosure complies with such law and is limited to the requirements of such law. If two or more laws or regulations governing the same use or disclosure conflict, we will comply with the more restrictive laws or regulations.

Public Health Activities - We may disclose your PHI to a public health authority for the

purpose of preventing or controlling disease, injury, or disability. We may disclose your PHI to the Food and Drug Administration (FDA) to ensure the quality, safety or effectiveness of products or services under the jurisdiction of the FDA.

Victims of Abuse and Neglect - We may disclose your PHI to a local, state, or federal

government authority, including social services or a protective services agency authorized by law authorized by law to receive such reports if we have a reasonable belief of abuse, neglect or domestic violence.





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Judicial and Administrative Proceedings - We may disclose your PHI in judicial and administrative proceedings, as well as in response to an order of a court, administrative tribunal, or in response to a subpoena, summons, warrant, discovery request, or similar legal request.

Law Enforcement - We may disclose your relevant PHI to law enforcement when required to do so, such as in response to a court order, court-ordered warrant, subpoena or summons issued by a judicial officer, or a grand jury subpoena. We may also disclose your relevant PHI for the purpose of identifying or locating a suspect, fugitive, material witness, or missing person.

Coroners, Medical Examiners and Funeral Directors - We may disclose your PHI to a coroner

or medical examiner. This may be necessary, for example, to determine a cause of death. We may also disclose your PHI to funeral directors, as necessary, to carry out their duties.

Organ, Eye and Tissue Donation - We may disclose your PHI to organ procurement

organizations or entities engaged in the procurement, banking or transplantation of cadaveric organs, eyes or tissues.

Threats to Health and Safety - We may use or disclose your PHI if we believe, in good faith,

that the use or disclosure is necessary to prevent or lessen a serious or imminent threat to the health or safety of a person or the public.

Specialized Government Functions - If you are a Member of U.S. Armed Forces, we may

disclose your PHI as required by military command authorities. We may also disclose your PHI to authorized federal officials for national security and intelligence activities, the Department of State for medical suitability determinations and for protective services of the President or other authorized persons.

Workers’ Compensation - We may disclose your PHI to comply with laws relating to workers’

compensation or other similar programs, established by law, that provide benefits for work- related injuries or illness without regard to fault.

Emergency Situations – We may disclose your PHI in an Emergency situation, or if you are

incapacitated or not present, to a family member, close personal friend, authorized disaster relief agency, or any other person previous identified by you. We will use professional judgment and experience to determine if the disclosure is in your best interests. If the disclosure is in your best interest, we will only disclose the PHI that is directly relevant to the person's involvement in your care.

Inmates - If you are an inmate of a correctional institution or under the custody of a law

enforcement official, we may release your PHI to the correctional institution or law





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enforcement official, where such information is necessary for the institution to provide you with healthcare; to protect your health or safety; or the health or safety of others; or for the safety and security of the correctional institution.

Research - Under certain circumstances, we may disclose your PHI to researchers when

their clinical research study has been approved and where certain safeguards are in place to ensure the privacy and protection of your PHI.

Verbal Agreement to Uses and Disclosure Your PHI

We are permitted to accept your verbal agreement to use and disclose your PHI to family members, close personal friends or any other person you identify. We will give you the opportunity to object to the use or disclosure of your PHI at the time of the request. You can give us your verbal agreement or objection in advance or at the time of the use or disclosure. We will limit the use or disclosure of your PHI in these situations to the information that is directly relevant to that person’s involvement in your healthcare treatment or payment.

We are permitted to accept your verbal agreement or objection to use and disclose your PHI in a disaster situation to an authorized disaster relief entity. We will limit the use or disclosure of your PHI in these situations to the purpose of notifying a family member, personal representative or other person responsible for your care of your location and general condition. You can give us your verbal agreement or objection in advance or at the time of the use or disclose of your PHI.

Uses and Disclosures of Your PHI That Require Your Written Authorization

We are required to obtain your written authorization to use or disclose your PHI, with limited exceptions, for the following reasons:

Sale of PHI – We will request your written authorization before we make any disclosure that is deemed a sale of your PHI, meaning that we are receiving compensation for disclosing the PHI in this manner.

Marketing – We will request your written authorization to use or disclose your PHI for marketing purposed with limited exceptions, such as when we have face-to-face marketing communications with you or when we provide promotional gifts of nominal value.

Psychotherapy Notes – We will request your written authorization to use or disclose any of you psychotherapy notes that we may have on file with limited exception, such as for certain treatment, payment or healthcare operation functions.

All other uses and disclosures of your PHI not described in this Notice will be made only with your written authorization. You may revoke your authorization at any time, the revocation of your authorization must be in writing. The revocation will be effective immediately, except to the





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extent that we have already taken actions in reliance of the authorization and before we received your written revocation.

Individuals Rights

The following are your rights concerning your PHI. If you would like to use any of the following rights, please contact us using the information at the end of this Notice.

Right to Request Restrictions - You have the right to request restrictions on the use and

disclosure of your PHI for treatment, payment or healthcare operations, as well as disclosures to persons involved in your care or payment of your care, such as family members or close friends. Your request should state the restrictions you are requesting and state to whom the restriction applies. We are not required to agree to this request. If we agree, we will comply with your restriction request unless the information is needed to provide you with Emergency treatment. However, we will restrict the use or disclosure of PHI for payment or healthcare operations to a health plan when you have paid for the service or item out of pocket in full.

Right to Request Confidential Communications - You have the right to request that we

communicate with you about your PHI by alternative means or to alternative locations. This right only applies if the information could endanger you if it is not communicated by the alternative means or to the alternative location you want. You do not have to explain the reason for your request, but you must state that the information could endanger you if the communication means or location is not changed. We must accommodate your request if it is reasonable and specifies the alternative means or location where your PHI should be delivered.

Right to Access and Receive Copy of your PHI - You have the right, with limited exceptions,

to look at or get copies of your PHI contained in a designated record set. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your PHI. If we deny your request, we will provide you a written explanation and will tell you if the reasons for the denial can be reviewed and how to ask for such a review or if the denial cannot be reviewed.

Right to Amend your PHI - You have the right to request that we amend, or change, your PHI

if you believe it contains incorrect information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request for certain reasons, for example if we did not create the information you want amended and the creator of the PHI is able to perform the amendment. If we deny your request, we will provide you a written explanation. You may respond with a statement that you disagree with our decision and we will attach your statement to the PHI you request that we amend. If we accept your request to amend the information, we will make reasonable efforts to inform others,





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including people you name, of the amendment and to include the changes in any future disclosures of that information.

Right to Receive an Accounting of Disclosures - You have the right to receive a list of

instances within the last 6-year period in which we or our business associates disclosed your PHI. This does not apply to disclosure for purposes of treatment, payment, healthcare operations, or disclosures you authorized and certain other activities. If you request this accounting more than once in a 12- month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. We will provide you with more information on our fees at the time of your request.

Right to File a Complaint - If you feel your privacy rights have been violated or that we have

violated our own privacy practices, you can file a complaint with us in writing or by phone using the contact information at the end of this Notice. You can also submit a written complaint to the U.S. Department of Health and Human Services (HHS), see the contact information on the HHS website at www.hhs.gov/ocr. If you request, we will provide you with the address to file a written complaint with HHS. WE WILL NOT TAKE ANY ACTION AGAINST YOU FOR FILING A COMPLAINT.

Right to Receive a Copy of this Notice - You may request a copy of our Notice at any time by using the contact information list at the end of the Notice. If you receive this Notice on our web site or by electronic mail (e-mail), you are also entitled to request a paper copy of the Notice.

Contact Information

If you have any questions about this Notice, our privacy practices related to your PHI or how to exercise your rights you can contact us in writing or by phone using the contact information listed below.

CeltiCare Health

Attn: Privacy Official 200 West Street, Suite 250

Waltham, MA 02451

Phone: (855) 678-6975

TDD/TTY (866) 614-1949


http://www.hhs.gov/ocr




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You may also contact the Secretary of the U.S. Department of Health and Human Services

Office for Civil Rights – Region I

U.S. Department of Health & Human Services

Government Center

John F. Kennedy Federal Building

Boston, MA 02203

Voice phone (617)565-1340 FAX (617)565-3809 TDD (617)565-1343


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Authorization to Disclose Health Information

Notice to Member: Completing this form will allow CeltiCare Health Plan to share your health information with the person or

group you identify below.

You do not have to sign this form or give permission to share your health information. Your services and benefits with CeltiCare Health will not change if you do not sign this form.

If you want to cancel the permission you gave someone with this form, fill out the Revocation Form on the next page and mail it to CeltiCare Health.

CeltiCare Health cannot promise that the person or group you allow CeltiCare Health to share your health information with will not share it with someone else.

Keep a copy of all completed forms that you send to us. If you need a copy, CeltiCare Health will send it to you.

Fill in all the information on this form. When finished, mail or fax the form to CeltiCare Health.

Member Information Member Name (Print) Member Date of Birth / / MassHealthcarePlus ID # I give CeltiCare Health Plan permission to share my health information with the person or group named below.

Recipient Information Name (person or group) Mailing Address

City State Zip Phone

CeltiCare Health can share this Health Information: (check boxes that apply)

All of my health information; OR

All of my health information EXCEPT:

Prescription drug/medication information

Acquired Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV) information

Treatment for alcohol and / or substance abuse information

Behavioral health services or psychiatric care information

Other:

Authorization end date: / / (date authorization ends unless cancelled)

Member Signature: Date

Must be signed by Member or Authorized Representative for Member. If signed by personal representative, please note your relationship and provide CeltiCare Health with a copy of your authorization to represent this Member.

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Revocation of Authorization to Disclose Health Information

I want to cancel, or revoke, the permission I gave to CeltiCare Health to share my health information with this person or group:

Recipient Information Name (person or group) Mailing Address

City State Zip Phone

Authorization Signed Date (if known):

Member Information Member Name (Print) Member Date of Birth / / MassHealthcarePlus ID # I understand that my health information may have been shared already because of the permission I gave before. I also understand that this cancellation only applies to the permission I gave to share my health information with this person or group. It does not cancel any other authorization forms I signed for health information to be shared with another person or group.

Member Signature: Date

Must be signed by Member or Authorized Representative for Member. If signed by personal representative, please note your relationship and provide CeltiCare Health with a copy of your authorization to represent this Member.

CeltiCare Health Plan of Massachusetts will stop sharing your health information when we get this form. Use the mailing address below or call Member Services for help.

CeltiCare Health Member Services


Fax Number: 1-866-614-1953




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GLOSSARY

Abuse—The intentional misuse of MassHealth benefits, the CarePlus program or CeltiCare Health resources. An example of Abuse is billing CeltiCare Health for “free” services. Advance Directive – A written statement that tells a Provider what to do if an illness or accident takes away the Member’s ability to make decisions about his or her healthcare.

Adverse Action – The following actions or inactions by CeltiCare Health or Cenpatico: 1. Denying or limiting coverage of a requested healthcare service; 2. Reducing or stopping coverage for a service that was previously approved; 3. Denying payment for a service because it was not Medically Necessary; 4. Not responding to an Authorization request in a timely manner; 5. Not being able to get healthcare within required timeframes; and 6. Not resolving an Appeal request within required timeframes. Appeal: see Internal Appeal Authorization: See Prior Authorization

Authorized Appeal Representative – someone authorized by you in writing to act on your behalf regarding a specific Grievance or Internal Appeal. Behavioral Health – Mental health and substance use disorders. Board of Hearings (BOH) – the Board of Hearings within the Executive Office of Health and Human Ser-vices’ Office of Medicaid.

Board of Hearings (BOH) Appeal – A written request to the BOH, made by a Member or Authorized Appeal Representative to review the correctness of a Final Internal Appeal decision by CeltiCare Health or Cenpatico. Care Management – A program offered by CeltiCare Health and Cenpatico (for Behavioral Health) to our Members who are most in need of assistance with managing multiple situations, services, and/or Providers at one time. The situations may be medical, behavioral, social and/or environmental in nature. The services may be preventive, wellness, disease, treatment or housing related. The Providers may include your or a family Member’s PCP, Specialists, other healthcare Providers – such as home health-care agencies – as well as staff from state agencies. The CeltiCare Health Care Management Program consists of four distinct program categories that provide services for our Members. The four program categories are Care Management Education and Wellness, Care Management Healthcare Coordination, Medical Complex Care Management, and Behavioral Health Intensive Clinical Management (ICM).





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CeltiCare Health (the Plan)–A Managed Care organization providing coverage to MassHealth (Medicaid) CarePlus Members. The Plan contracts with Providers and hospital systems throughout Massachusetts to deliver care to CarePlus Members statewide except for the Islands off the coast of Cape Cod. CeltiCare Health Network Provider – A Provider with which CeltiCare Health has an agreement to provide Covered Services to Members. Cenpatico – A partner of CeltiCare Health that manages and coordinates the Behavioral Health (mental health and substance use disorder) services for Members and manages the Behavioral Health Provider Network. Claim – A bill from a Provider that describes the services that have been provided to a Member. Clinical Practice Guidelines– Standards for care that CeltiCare Health and Cenpatico use with its Provider Network to make sure that Members are getting the best care. Complex Care Management - the implementation of defined and individualized Care Management services to Members with complex health care needs (physical, Behavioral Health and/or social). These Members typically have co-morbidities and psychosocial needs that can significantly diminish their quality of life as well as their ability to adhere to treatment plans designed by their Providers. Members in Complex Care Management programs are typically provided with information individualized to their needs and stage of readiness with a goal of averting the need for more intensive medical services. These services may include home visits if needed.

Continuity of Care – The process that ensures that Members do not have disruptions in their medical or Behavioral Healthcare due to switching health plans or Provider changes. Continuing Services – The process of continuing to receive certain services from CeltiCare Health or Cenpatico during an Internal Appeal. Coordination of Benefits – The process that CeltiCare Health uses to work with any other health insurers Members may have. Co-payment – Payments made by Members at the time of care, for CarePlus there are copays only for Pharmacy prescriptions. Covered Services – The services and supplies covered by CeltiCare Health and MassHealth described in the Covered Services List that accompanied this Member Handbook. Dependent – A person who gets health coverage through another person. Disease Management – CeltiCare Health’s disease or condition specific packages of ongoing services and assistance for specific disease and/or conditions. Services include specific interventions and education/outreach targeted to Members with, or at risk for, these conditions.

Disenrollment – The process by which a Member’s CeltiCare Health coverage ends.





MEMBER HANDBOOK

Effective Date – An Effective Date is the date on which an individual becomes a Member of CeltiCare Health and is eligible for Covered Services. Once a Member is enrolled through MassHealth and MassHealth has sent notification to CeltiCare Health; coverage becomes effective the first day of the following month. Eligibility – MassHealth enrollees qualified to receive MassHealth health coverage. Emergency – A medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that, in the absence of prompt medical attention, could reasonably be expected by a prudent lay person who possesses an average knowledge of health and medicine to result in placing the health of an Enrollee or another person or, in the case of a pregnant woman, the health of the woman or her unborn child, in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any body organ or part; or, with respect to a pregnant woman, as further defined in section 1867(e)(1)(B) of the Social Security Act, 42 U.S.C. § 1395dd(e)(1)(B). Enrollment – The process by which CeltiCare Health registers individuals for Membership. Expedited (fast) Internal Appeal – An Appeal process to provide notification of an Appeal decision as quickly as your health requires, but not later than 72 hours from when CeltiCare Health received the request. Family Planning Services – Services directly related to preventing conception. They include birth control counseling, education about family planning, examination and treatment, laboratory examinations and tests, medically ap-proved methods and procedures, pharmacy supplies and devices, sterilization, including tubal ligation and vasectomy. (Abortion is not a Family Planning Service.) Family Planning Services can be received through any MassHealth Family Planning Services Provider. Final Internal Appeal – The second-level review of an Internal Appeal or, for a Member, or a Member’s Authorized Appeal Representative, who waives the second-level Internal Appeal, the first-level review of an Internal Appeal. Fraud – An intentional deception or misrepresentation made by a person or corporation with the knowledge that the deception could result in some unauthorized benefit under the MassHealth program to himself or herself, the corporation or some other person. An example of Fraud is Members lending their CeltiCare Health Member ID card to others so they can get healthcare or pharmacy services. Grievance – A statement by a Member of dissatisfaction with care or services received. Healthcare Agent or Proxy – The individual responsible for making healthcare decisions for a person in the event that person is unable to make decisions for him/her self. Health Needs Assessment (HNA) – A questionnaire about a Member’s current health situation that helps CeltiCare Health and Cenpatico provide the right care to Members.





MEMBER HANDBOOK

Inpatient – Services requiring at least one overnight stay and generally applies to care in facilities such as hospitals and skilled nursing facilities. Inquiry – Any question a Member has about CeltiCare Health’s or Cenpatico’ operations. Intensive Clinical Management (ICM) – A Behavioral Health Care Management program provided by Cenpatico. ICM care managers, through collaboration with Members and their treatment Providers, work to ensure the coordination and optimization of care; assessment, care planning, discharge planning and mobilization of resources to Members who are dealing with Behavioral Health or psychosocial conditions, sometimes along with medical concerns. Internal Appeal – A request by a MassHealth Member or Authorized Appeal Representative to CeltiCare Health or Cenpatico for review of an Adverse Action or inaction by the Plan. Living Will – A document that lists medical procedures that you do, or do not, want under certain circumstances if you become seriously sick or injured. Managed Care – A system of healthcare delivery that is provided and coordinated by a Primary Care Provider (PCP). The goal is a system that delivers value by providing access to quality, cost effective healthcare. MassHealth – A healthcare program operated by the Massachusetts Executive Office of Health and Human Services (“EOHHS”). In Massachusetts, the national health insurance program called Medicaid is called MassHealth. CeltiCare Health covers MassHealth Members under the MassHealth CarePlus plan. MassHealth Standard – A MassHealth benefit plan that offers a full range of health benefits to certain eligible Members, including families, children under age 18, pregnant women, and disabled individuals under age 65. MassHealth CarePlus – individuals between the ages of 21 and 64 who qualify under MassHealth CarePlus Eligibility criteria. Medically Necessary or Medical Necessity - are those services (1) which are reasonably calculated to prevent, diagnose, prevent the worsening of, alleviate, correct, or cure conditions in the Enrollee that endanger life, cause suffering or pain, cause physical deformity or malfunction, threaten to cause or to aggravate a disability, or result in illness or infirmity; and (2) for which there is no other medical service or site of service, comparable in effect, available, and suitable for the Member requesting the service, that is more conservative or less costly. Medically Necessary services must be of a quality that meets professionally recognized standards of health care, and must be substantiated by records including evidence of such Medical Necessity and quality.

Member – Any person enrolled in CeltiCare Health and MassHealth. Member ID Card – The card that identifies an individual as a Member of CeltiCare Health. The Member ID Card includes the Member’s identification number and information about the Member’s coverage.





MEMBER HANDBOOK

Members will also receive an ID Card from MassHealth. Both ID Cards must be shown to Providers before receiving care. Mental Health Parity – Federal and State Laws that require CeltiCare Health to provide Behavioral Health services to MassHealth Members in the same way we provide physical health services.

Network – The group of Providers contracted by CeltiCare Health to provide healthcare services to Members. Notice of Privacy Practices – A detailed statement about how Member health information can and cannot be used. NurseWise– A 24 hour/7 day a week telephone line that CeltiCare Health Members can call to speak to a trained nurse about health questions. Post Stabilization Care – Care received following an Emergency situation. Primary Care Provider (PCP) – A doctor or nurse practitioner selected by the Member or assigned by CeltiCare Health to provide and coordinate a Member’s healthcare needs. Other healthcare Providers, such as registered nurses, physician’s assistant or nurse midwives, acting on behalf of and in consultation with a PCP, may provide Primary Care Services. Prior Authorization – Approval given by CeltiCare Health or Cenpatico for certain Provider visits or healthcare services in order for these to be covered. This approval must be obtained by your Provider before you go to certain Providers or before you get certain healthcare services. Protected Health Information (PHI) – Information about you that may identify you and that relates to your health condition and/or related healthcare services. Provider – A healthcare professional or facility licensed as required by state law. Providers include doc-tors, hospitals, laboratories, pharmacies, skilled nursing facilities, nurse practitioners, registered nurses, psychiatrists, social workers, licensed mental health counselors, clinical Specialists in psychiatric and mental health nursing, and others. CeltiCare Health will only cover services of a Provider if those services are covered benefits and within the scope of the Provider’s license. Provider Directory – An online search tool or printed booklet containing a list of CeltiCare Health’s affiliated medical facilities and professionals, including Primary Care Providers, Specialists and Behavioral Health Providers. Quality Improvement – A program designed to identify ways to improve the quality of care that Members receive. Referral – A recommendation to receive care from a Provider. Region – MassHealth divides the state into five geographic regions. Your region is the part of the state that you live in and also where you should choose a Primary Care Provider.





MEMBER HANDBOOK

Routine Care – Care that is not Emergency, Post Stabilization Care, or Urgent Care. An examples of Routine Care is a physical exam.

Second Opinion – The process by which a Member seeks an evaluation by another Provider to confirm the diagnosis and treatment plan of their primary Provider.

Service Area – The geographical area approved by MassHealth within which CeltiCare Health has developed a Network of Providers to provide adequate access to Covered Services.

Specialist – A Provider who is trained and certified by the state of Massachusetts to provide specialty services. Examples include cardiologists, obstetricians and dermatologists.

Subrogation – The procedure under which CeltiCare Health can recover the full or partial cost of benefits paid from a third person or entity, such as an insurer.

Urgent Care – Medical care required quickly to prevent a worsening of health due to symptoms that a prudent lay person would believe are not an Emergency but do require medical attention. Urgent Care does not include Routine Care.

Utilization Management – The process by which CeltiCare Health reviews the clinical necessity, appropriateness, or efficiency of covered services, procedures, or settings.

Wellness Initiatives – planned health education activities intended to promote healthy behaviors and lifestyle changes.


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