Table of Contents Welcome!. 1 ........................................................................ Important things you should know 2 ............................. 1: Your MassHealth Primary Care Clinician (PCC) Plan membership 5 ............................................................ What is MassHealth? What is the PCC Plan? PCC Plan provider network PCC Plan behavioral health provider network Out-of-network services When you travel Keeping your providers up to date Keeping MassHealth up to date Changing your health plan You must qualify for MassHealth to be in the PCC Plan 2: Your MassHealth ID card. 10 ............................................ MassHealth will send you an ID card Lost your MassHealth ID card? 3: Your benefits 11 ................................................................. How to get benefits Transportation Copayments Specialty care and referrals Prior authorization If you get a bill for services 4: Your PCC 18 ....................................................................... What is a PCC? Providers who are PCCs When to call your PCC Your first PCC appointment Call your PCC first when you're sick, unless you think it's an emergency Changing your PCC PCC requests to disenroll a member 5: Your health care 22 ........................................................... Emergencies and urgent care Getting an appointment when you need one Staying healthy Pharmacy coverage For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 i for people who have trouble hearing). The call is free. Table of Contents (continued) 6: Behavioral health (mental health and substance abuse) care 27 .................................................................. Finding behavioral health (mental health and substance abuse) providers Your behavioral health (mental health and substance abuse) coverage 7: Care management services 29 ........................................ 8: Pregnancy and family planning services 31 .................. Pregnancy care Your new baby Family planning 9: Additional services for children 33 ................................. Preventive and well-child care for all children Dental care for children Early intervention services for children 0-3 years old 10: Advance directives. 38 ...................................................... 11: Member rights 39 .............................................................. 12: Appeals and grievances 41 .............................................. Naming a representative for your grievance or appeal What do you do if you do not speak or read English? The grievance process The MBHP internal appeals process The Board of Hearings appeals process 13: Notice of privacy practices. 52 ........................................ Notes. 53 ............................................................................. This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble ii hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. Introduction Welcome! Welcome to the MassHealth Primary Care Clinician Plan (the PCC Plan). We're pleased to have you as a member. This Handbook, along with the Covered Services List, will help you understand your benefits and services as a PCC Plan member. It will also tell you how to call us if you have any questions. Because this Handbook contains important information, please keep it in a place where you can find it when you need it. Note: If you are not enrolled in the PCC Plan, contact the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing) to find out how to get your plan's member handbook. For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 1 for people who have trouble hearing). The call is free. Important things you should know These are important things you should know as a PCC Plan Member: 1. This handbook is about the benefits and services you receive because you are a MassHealth member enrolled in the Primary Care Clinician (PCC) Plan. These services include medical, vision care, behavioral health (mental health and substance abuse), pharmacy, emergency, pregnancy care, and dental services. Please note that you will receive your behavioral health (mental health and substance abuse) services through the Massachusetts Behavioral Health Partnership (MBHP). MBHP is MassHealth's behavioral health services contractor. Read more about covered benefits and services, including behavioral health services, later in this handbook. 2. Call us with your questions or changes Call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing) Monday to Friday, 8:00 A.M. to 5:00 P.M. The call is free. Call us: if you have questions about MassHealth; if you have questions about your PCC Plan coverage or benefits; if you have questions about Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services for children under 21 (see page 28 to read more about EPSDT); if you want to change your PCC; if you want to change your health plan; if you need a new MassHealth ID card; if you move or change your phone number; if your employment status changes; if you're pregnant or have a baby; to ask for help reading any material you get from MassHealth; to ask for Spanish versions of information you get from the PCC Plan; or to speak to someone who speaks Spanish or another language. This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 2 hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. Important things you should know (continued) 3. Call Massachusetts Behavioral Health Partnership (MBHP) with behavioral health (mental health and substance abuse) questions. Call MBHP at 1-800-495-0086 (TTY: 1-617-790-4130 for people who have trouble hearing) 24 hours a day if you have questions about MBHP or behavioral health services. The call is free. Call MBHP: if you have questions about your behavioral health services or benefits if you want more information about how to get these services or find a provider; to ask for help reading any material you get from MBHP; to ask for Spanish versions of information you get from MBHP; or to speak to someone who speaks Spanish or another language. 4. You still have MassHealth when you join us. As a PCC Plan member, you keep all your MassHealth coverage and benefits. 5. You can be enrolled in the PCC Plan for as long as you qualify for MassHealth managed care. As long as you still qualify for MassHealth managed care, you can be covered by the PCC Plan. Call 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing) if you have questions about managed care. 6. You have a PCC. Your PCC will take care of most of your health needs. Your PCC can be either a doctor or a nurse practitioner. You can change your PCC at any time. If you want to change your PCC, call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing). 7. The PCC Plan has providers and hospitals throughout the state. You can find PCC Plan providers (such as medical care providers, medical care specialists, behavioral health providers, and hospitals) all over Massachusetts. For information, call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing). MBHP has behavioral health (mental health and substance abuse) providers throughout the state, too. For information, look at your MBHP Provider Directory or call MBHP at 1-800-495-0086 (TTY: 1-617-790-4130 for people who have trouble hearing). For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 3 for people who have trouble hearing). The call is free. Important things you should know (continued) 8. Present your MassHealth ID card when you need services. You can use your MassHealth ID card to get PCC Plan services, such as health care and prescriptions. This includes the services you get from MBHP. Always carry your MassHealth ID card with you. If you lose your ID card, call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing). 9. Let us know when your phone number or address changes. Call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing) to tell us if you move or change your phone number. 10. You have pharmacy coverage. PCC Plan members can get medicines at pharmacies in Massachusetts that work with MassHealth. Call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing) to find the pharmacy closest to you. Read more about pharmacy coverage later in this handbook. 11. You can receive emergency care for medical and behavioral health (mental health and substance abuse) emergencies. If you have a medical or behavioral health emergency, get care right away! 12. Some services require referrals or prior authorization or both. Some covered services may need a referral or prior authorization (PA) or both. However, many covered services, such as emergency health care, obstetric (pregnancy) services, and family planning services, do not require a referral or prior authorization. Behavioral health services do not require a referral, although some of these services may require PA. Read more about referrals and PA later in this handbook. This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 4 hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. 1 Your MassHealth Primary Care Clinician plan membership What is MassHealth? The Medicaid program in Massachusetts is called the MassHealth program. The Executive Office of Health and Human Services (EOHHS) runs this program. What is the PCC Plan? The Primary Care Clinician (PCC) Plan is a managed care health plan for MassHealth members throughout Massachusetts. Each PCC Plan member must choose a doctor or nurse practitioner to be a primary care clinician (PCC). If you do not choose a PCC, we will choose one for you. It's better if you make the choice! You can see your PCC when you need a checkup or are sick. Your PCC will get to know your health needs, and help you get other health services if you need them. Read more about PCCs later in this handbook. PCC Plan provider network The PCC Plan provider network includes doctors, nurse practitioners, hospitals, community health centers, pharmacies, and other health care providers who are MassHealth providers. Make sure you check to see if a provider accepts MassHealth before going for health care. If you go to a provider who does not accept MassHealth, MassHealth will not pay for the services unless it is an emergency. If you need help finding a MassHealth PCC Plan provider in your area, please call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing). For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 5 for people who have trouble hearing). The call is free. 1 Your MassHealth Primary Care Clinician plan membership PCC Plan behavioral health provider network As a PCC Plan member, you can get behavioral health (mental health and substance abuse) services from the Massachusetts Behavioral Health Partnership (MBHP). MBHP is MassHealth's behavioral health services contractor. MBHP has a large network of mental-health and substance-abuse providers and hospitals throughout the state. Use your MassHealth ID card to get behavioral health services from any MBHP provider. You do not need a referral to see any of MBHP's providers. All you need to do is choose a behavioral health provider from the MBHP Provider Directory. If you did not receive a copy of the Provider Directory or would like an additional copy, please call MBHP at 1-800-495-0086 (TTY: 1-617-790-4130 for people who have trouble hearing). You may also visit the MBHP Web site at www.masspartnership.com to find a provider (click on Find a Provider on the left side of the home page). After you choose a provider from the directory, please call MBHP at 1-800-495-0086 (TTY: 1-617-790-4130 for people who have trouble hearing) to make sure your provider still works with MBHP. This directory is up to date when it's printed, but providers may change from time to time. Although you do not need a referral to see any MBHP provider, some covered services may need PA. For more information about PA, see page 14. Out-of-network services Medical Services The PCC Plan will not pay for services delivered by a provider who is not a MassHealth provider unless it is an emergency. You can get care for emergencies from any provider. For more information about emergencies, see pages 22-23. If you have an emergency, get care right away! This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 6 hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. 1 Your MassHealth PCC plan membership (continued) Behavioral Health Services MBHP will not pay for services provided by a behavioral health provider who is not in the network unless: it is an emergency; or the MBHP network cannot provide those services. You can get care for behavioral health emergencies from any behavioral health provider. For more information about behavioral health emergencies, see pages 22-23. If you have a behavioral health emergency, get care right away! If MBHP's network cannot provide the services, MBHP will cover the out-of-network services until the network can provide them. Call MBHP at 1-800-495-0086 if you have questions about out-of-network behavioral health services. When you travel The PCC Plan will pay for you to see an out-of-state provider for medical care only if: you have an emergency; or your health would be at risk if you had to travel home. Keeping your providers up to date We want to make sure you get the right services at the right time. Tell your providers about: all the health care you are getting; the medicine you are taking (both prescription and over-the-counter medications); and any health problems you may have. Keeping MassHealth up to date It is important to tell MassHealth as soon as possible about changes, such as a new address or phone number, other health insurance, the birth of a baby and other family changes, or a change in your income. For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 7 for people who have trouble hearing). The call is free. 1 Your MassHealth PCC plan membership (continued) Reporting address, phone number, and income changes If MassHealth has your correct address, we can send you information about benefits and services. If we have the wrong address, we can't send you mail and we can't tell you when it's time to renew your MassHealth. You could lose your benefits. To tell MassHealth about your new address and phone number, call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing). Also call this number to report changes in your income. Other health insurance If you have other health insurance, like Medicare, veterans' benefits, or health insurance through your job or a family member's job, or if you have a chance to get other insurance, call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing). MassHealth may help you pay for the other insurance. Birth of a baby If you are expecting a baby, call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing) to find a doctor for your baby before the baby is born. After you have your baby, call the MassHealth Enrollment Center at 1-888-665-9993 (TTY: 1-888-665-9997 for people who have trouble hearing) to tell them that you had your baby. Once your baby is enrolled in MassHealth, call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800- 497-4648 for people who have trouble hearing) to enroll your baby with a doctor of your choice. This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 8 hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. 1 Your MassHealth PCC plan membership (continued) If you receive benefits other than MassHealth You should also report changes if you receive these additional benefits: If you get Transitional Assistance for Dependent Children (TAFDC) or Emergency Aid for Elderly, Disabled or Children (EAEDC), call your local Department of Transitional Assistance (DTA) office at 1-800-445-6604. If you get Supplemental Security Income (SSI) or Social Security Disability Income (SSDI), call your nearest Social Security Administration (SSA) office at 1-800-772-1213. If you get assistance from the Massachusetts Commission for the Blind (MCB), call the MCB at 1-800-392-6450. Changing your health plan Most MassHealth members can change their health plan at any time. To find out about changing, call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing) and say, "I would like to change my health plan." The MassHealth Customer Service Center can: give you information about other health plans in your area; change your health plan while you are on the phone; and tell you when you can start getting health care from your new health plan. In general, you must enroll in a health plan that is offered in the service area where you live. You can call the MassHealth Customer Service Center to find out which health plans are offered in your service area. There are certain cases where you can choose a health plan that is not available in your service area. For more information about these cases, call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 if you have trouble hearing). You must qualify for MassHealth to be in the PCC Plan You cannot continue to be in the PCC Plan if you no longer qualify for MassHealth. For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 9 for people who have trouble hearing). The call is free. 2 Your MassHealth ID card MassHealth will send you a MassHealth ID card MassHealth will send you a MassHealth ID card that looks like the one below. Carry it with you, and use it to get your PCC Plan services, including services from MBHP. This is a sample of the front and back of a MassHealth ID card. Remember to carry your MassHealth ID card and show it, or any other health insurance card you may have, to get health care services or medicine. Please check your MassHealth ID card to make sure the information is correct. If it's not correct, if you did not get a card, or if you lose your card, please call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing). Lost your MassHealth ID card? To get a new MassHealth ID card, call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing). You can get health services even if you don't have your card. Your doctor or other provider can look for your name in the MassHealth system. If your provider cannot find your information in the system, he or she can call the MassHealth Customer Service Center. This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 10 hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. 3 Your benefits How to get benefits As a PCC Plan member, you can get services from your PCC, MBHP providers, and other MassHealth providers. Just show your MassHealth ID card to get your benefits and services. Some covered services may need a referral or PA or both. However, many covered services, such as emergency health care, obstetric (pregnancy) services, and family planning services, do not require a referral or PA. Behavioral health services do not require a referral, although some services require PA. You can look at the Covered Services List in this packet for more information about the services covered by MassHealth and the copayments for those services, and if the services need PCC referral or PA or both. This list and the handbook may change. For the most up-to-date information or if you need help getting benefits or services, you can: talk to your PCC; call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing); or call MBHP at 1-800-495-0086 (TTY: 1-617-790-4130 for people who have trouble hearing). Transportation You may be able to get transportation services when it is medically necessary to take you to get care. Call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing) to find out if you can get these services. For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 11 for people who have trouble hearing). The call is free. 3 Your benefits (continued) Copayments You may need to pay a copayment for some services. A copayment is a small amount of money that you may be charged to get certain services, such as: hospital stays ­ $3 per stay for certain conditions pharmacy ­ See pages 25-26 for more information about your prescription drug coverage and pharmacy copayments Non-pharmacy copayment cap If you have paid $36 in copayments in a calendar year (excluding pharmacy copayments), you have reached the non-pharmacy copayment cap, and you do not need to pay any more non-pharmacy copayments that year. You should get a letter from MassHealth telling you when you reach the copayment cap. If your providers try to charge you any more copayments that year for non-pharmacy services, show them your letter. If you do not receive a letter or if you have any questions, call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing). See page 26 for more information about your pharmacy copayment cap. If you can't pay the copayment The doctor, hospital, pharmacy, or other provider cannot refuse to give you the service or medicine even if you can't pay the copayment. However, the provider can bill you later for the copayment. Please call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing) if a provider will not give you the service or medicine. This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 12 hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. 3 Your benefits (continued) Specialty care and referrals You may need to see a specialist for certain health problems. A specialist is a doctor or other health care provider who has special training, practices a special kind of care, or who provides special treatments. For example, if you have a problem with your heart, you may need to see a cardiologist. As a PCC Plan Member, you can see specialists. However, the PCC Plan requires you to have a referral to see certain types of specialists. A referral is permission to see a specialist. Your PCC will submit a referral to MassHealth if you need to see a specialist. Also, your PCC will work with your specialists to help you get the care you need. It makes good health sense to ask your PCC to help coordinate any specialty care you may need, even if you don't need a referral to see that specialist. If you want to know if you need a referral you can: ask your PCC; check the Covered Services List; or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing). If you go to a specialist that requires a referral and you did not get a referral beforehand, the specialist may refuse to see you. You may need a referral to see a specialist even if you have seen that specialist before. Which services do not need a referral? Some services do not need a referral, such as: emergency services; behavioral health services; obstetric (pregnancy) services; and family planning services. There may be other times when you don't need a referral. Ask your PCC or call 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing). For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 13 for people who have partial or total hearing loss). The call is free. 3 Your benefits (continued) Prior authorization MassHealth or MBHP must approve certain health care and pharmacy services before you get them. This is called prior authorization (PA). During the PA process, MassHealth or MBHP determines if the requested service is medically necessary for you. If you want to know if you need a PA for a service or medication, you can: check the Covered Services List; call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing) for questions about health care services and medications; call MBHP at 1-800-495-0086 (TTY: 1-617-790-4130 for people who have trouble hearing) for questions about behavioral health services; or go to www.mass.gov/druglist to see a list of medications that require PA. If you disagree with a decision made about a request for PA, you can appeal the decision. Read more about appeals later in this handbook. This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 14 hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. 3 Your benefits (continued) PA from MassHealth for medical services, medical equipment, pharmacy, and transportation When your PCC or another medical provider thinks you need a service or medication that needs PA, your provider will ask MassHealth for PA. MassHealth must make a decision on your provider's request within these time frames: If you request this service: MassHealth has this long to decide: Pharmacy (medicine) 24 hours Transportation 7 calendar days (or the number of days needed to avoid serious risk to the health or safety of the member) Private-duty-nursing services 14 calendar days Durable medical equipment 15 calendar days All other services 21 calendar days If MassHealth approves the PA request, we will send a letter to your provider and you can get the services or medication. If MassHealth does not authorize any of the requested services or medication, approves only some of the requested services or medication, or does not approve the full amount, time period, or scope of the services or medication requested, we will send you a letter telling you so. You can talk to your PCC about this and how this may affect your treatment, but you have the right to appeal the decision to the Board of Hearings. If MassHealth does not act on a request for prior authorization within the time frames above, you can file an appeal with the Board of Hearings. Read more about appeals later in this handbook. MassHealth will not pay for a service that needs PA if approval was not given. For more information about requesting PA for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services, see page 35. For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 15 for people who have trouble hearing). The call is free. 3 Your benefits (continued) Preadmission screening by MassHealth for certain hospital stays All medical and surgical elective admissions to an acute hospital must be approved by MassHealth. If you plan to be hospitalized for an elective procedure, your doctor or nurse will submit the necessary paperwork to make a request on your behalf. If MassHealth approves the request, we will notify you and your provider and you can get the requested services. If MassHealth does not approve the hospitalization, we will send you a letter telling you so. You have the right to appeal the decision to the Board of Hearings. PA from MBHP for behavioral health (mental health and substance abuse) services When your behavioral health provider thinks you need a service that needs PA, your provider will ask MBHP for the PA. MBHP must make a decision on your provider's request within 5 calendar days unless you, your provider, or MBHP asks for more time. This can be for up to 5 extra calendar days. MBHP can ask for more time only if it's in your best interest and more information is needed. If your provider or MBHP thinks that taking 5 days to decide the request will put your health at risk, MBHP will make a decision within three working days. This time frame may be extended by an additional 5 calendar days, if you, your provider, or MBHP asks for more time. MBHP can ask for more time only if it is in your best interest and more information is needed. Any time that MBHP asks for more time, MBHP will send you a letter to let you know the reasons. You have the right to file a grievance if you don't agree with MBHP's reasons. Read more about filing a grievance later in this handbook. If MBHP approves the request, MBHP will pay for the service. This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 16 hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. 3 Your benefits (continued) If MBHP does not approve any of the requested services, approves only some of the requested services, or does not approve the full amount, time period, or scope of services requested, MBHP will send you a letter telling you so. You have the right to appeal the decision to MBHP. Also, if MBHP does not act on the request within the time frames above, you can file an appeal with MBHP. Read more about filing an MBHP internal appeal later in this handbook. MBHP will not pay for a service that needs PA if approval was not given. For more information about requesting PA for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services, see page 28. If you get a bill for services You should never get a bill for a covered service (except for a copayment) when you are an eligible PCC Plan member. Providers may not charge you or take money from you (except for copayments) for any services if they can get paid by MassHealth or MBHP. If you get a bill for a MassHealth-covered service, call the doctor's office and say, "I am a PCC Plan member and I got a bill. Here is my MassHealth card number." If you keep getting bills, call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing). We'll help you. If you get a bill for a MassHealth-covered behavioral health (mental health and substance abuse) service given by an MBHP provider, call MBHP at 1-800-495-0086 (TTY: 1-617-790-4130 for people who have trouble hearing). For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 17 for people who have trouble hearing). The call is free. 4 Your PCC What is a PCC? You and each of your family members enrolled in the PCC Plan must choose a primary care clinician (PCC). A PCC is your personal doctor or nurse practitioner. If there are adults and children in the family and everyone wants the same PCC, you can choose a family-practice provider to be the PCC for each family member. Your PCC will do many things for you and your family, such as: give you checkups and help you stay well; treat you for most of your medical problems; refer you to any specialists and work with your specialists to help you get the care you need; admit you to the hospital, if necessary; write prescriptions; and keep your medical records. Providers who are PCCs Here are some providers who can be PCCs: Family-practice doctors treat adults and children. They may also take care of pregnant women. Internal medicine doctors (internists) treat adults and older teenagers. Pediatric doctors (pediatricians) may treat children and young adults up to the age of 21. Independent nurse practitioners work with a MassHealth doctor and may treat patients of many ages. OB/GYN (Obstetrics and gynecology doctor). PCCs practice at different places, such as: single practices; group practices; community health centers; hospital-licensed health centers; and hospital outpatient departments. This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 18 hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. 4 Your PCC (continued) Your first PCC appointment When you become a PCC Plan member, make an appointment to visit your PCC for a checkup if you have not had one with this provider before and if you have not had one recently. The guide below will let you know when checkups are due. Call your PCC's office and tell the office staff that this is your first visit with the PCC. When you see your PCC for the first time, he or she will ask you questions about your health and your family's health. The more your PCC knows about your health history, the better he or she can manage your care. If you have problems getting an appointment, call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing). Here is a guide for how often visits are recommended for adults, pregnant women, and infants and children: Adults Every 1-3 years, depending on your risk factors. Discuss this with your PCC. During Pregnancy Contact your provider to schedule your first appointment as soon as you think you may be pregnant. Women with health or pregnancy problems may need more visits. Stage of Pregnancy Visit Frequency Up to 28 weeks Once a month 28 to 26 weeks Once every two weeks From 36 weeks until delivery (40-42 weeks) Weekly Postpartum visit Usually 4-6 weeks after delivery; may be sooner or more frequent if needed. For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 19 for people who have trouble hearing). The call is free. 4 Your PCC (continued) Infants and Children (under age 21) At 1 to 2 weeks At 12 months At 1 month At 15 months At 2 months At 18 months At 4 months From age 2 through 20 years old, your child At 6 months should see his or her PCC once a year. At 9 months Read more about care for children later on page 33. Call your PCC first when you're sick, unless you think it's an emergency If you think you're having an emergency, call 911 or go to the closest emergency room right away! If it's a behavioral health emergency, you may also contact the Emergency Services Program (ESP) in your area. Contact the MBHP Clinical Access Line at 1-800-496-0086 (TTY: 1-617-790-4130 for people who have trouble hearing), 24 hours a day, to find the name and location of the Emergency Services Program (ESP) in your area. At all other times, call your PCC and ask what to do. You can call your PCC 24 hours a day, seven days a week. If your PCC is not there, another doctor or health care provider will help you. Specialty care and referrals Read more about seeing specialists and getting referrals on page 13. Changing your PCC You can change your PCC whenever you want. To change your PCC, call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing). We'll help you choose a PCC for you and each family member covered by the PCC Plan. This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 20 hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. 4 Your PCC (continued) PCC requests to disenroll a member A PCC may ask to have you removed from his or her list of patients. The PCC can make this request if: the PCC cannot help you with your medical needs; the PCC cannot help you and their other patients with their medical needs if you stay in their list of patients; or your behavior has been noncompliant or disruptive (but not because of any special needs you may have). If the PCC Plan approves the PCC's request, we will send you a letter to tell you that you need to choose a new PCC. You have the right to appeal this decision to the Board of Hearings. Read more about appeals later in this handbook. A PCC cannot ask to have you removed from the list for these reasons: your health condition has gotten much worse; you use a lot of medical services; your mental capacity is reduced; or your behavior has caused problems because you have special needs. For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 21 for people who have trouble hearing). The call is free. 5 Your health care Emergencies and urgent care An emergency is any serious health care problem that you think needs to be treated right away. If you have an emergency, you should get care immediately! If you have a medical emergency, you can: call 911; or go to the closest emergency room right away! If you have a behavioral health emergency, you can: call 911; go to the closest emergency room right away; or contact the MBHP Clinical Access Line at 1-800-496-0086 (TTY: 1-617-790-4130 for people who have trouble hearing), 24 hours a day, to find the name and location of the Emergency Services Program (ESP) in your area. Examples of emergencies Here are some common medical and behavioral health (mental health and substance abuse) emergencies, but there are other kinds of emergencies too. Medical emergencies: broken bones severe pain chest pain severe wounds convulsions shortness of breath fainting or dizzy spells stroke (this includes numbness heart attacks or difficulty with speech) heavy bleeding sudden change of vision loss of consciousness sudden, severe pain or pressure poisoning in or below the chest serious accidents throwing up blood severe burns throwing up a lot severe headaches someone who won't wake up Behavioral health emergencies: wanting to harm yourself hearing voices wanting to harm other people This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 22 hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. 5 Your health care (continued) Other things you should know about emergency care You do not need a referral or PA for emergency care. You can get ambulance transportation for emergencies. After an emergency, call your PCC and make a follow-up appointment. Also call your behavioral health provider after a behavioral health emergency. Urgent care An urgent condition is a health problem that's serious, but you don't think it's an emergency. You can call your PCC to get care. Your PCC must see you within 48 hours of your request. If you have an urgent behavioral health condition, your behavioral health provider must see you within three working days of your request. If you're out of town and have an urgent condition, call your PCC. Your PCC will tell you how to get care. You can call your PCC 24 hours a day, seven days a week. If your PCC is not there, another doctor or health care provider will call you back. For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 23 for people who have trouble hearing). The call is free. 5 Your health care (continued) Getting an appointment when you need one When you don't feel well or when you want to see your health care provider, you don't want to wait too long for an appointment. You should get care within these time frames. Medical care appointments Emergency care: You must get care immediately after you ask for care from any provider of emergency medical services. See pages 22-23 for emergency- care information. Urgent care: If something is wrong, but you do not think it is an emergency, you must get care from your PCC within 48 hours after you ask for an appointment. See page 23 for urgent- care information. Primary care (non urgent, symptomatic care): If you are sick or have other symptoms that are not urgent, you must get care from your PCC within 10 calendar days after you ask for an appointment. Primary care (routine, nonsymptomatic care): If you're not sick and don't have any other symptoms, you must get care from your PCC within 45 calendar days after you ask for an appointment. Children placed in the care or custody of the Department of Children and Families (DCF): If you have responsibility for a child who is placed in the care or custody of DCF, a PCC must: · provide an appointment for the child for a health care screening within seven calendar days after you or the DCF worker asks for it. · provide an appointment for a full medical exam within 30 calendar days after you or the DCF worker asks for it (unless a shorter time frame is required by Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services schedule. See pages 33-34 for EPSDT information. This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 24 hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. 5 Your health care (continued) Behavioral health (mental health and substance abuse) care appointments Emergency care: You must get care immediately after you ask for care from an Emergency Services Program (ESP) or other provider of emergency behavioral health services. See pages 22-23 for emergency-care information. Urgent care: If something is wrong, but you do not think it is an emergency, you must get care from a provider within three working days after you ask for an appointment. See page 23 for urgent-care information. Non-symptomatic or non-urgent care: You must get care from a provider within 10 working days after you ask for an appointment. If you do not get care or an appointment from a behavioral health provider within these time frames, you can file an appeal. Read more about appeals later in this handbook. You should keep appointments, be on time, and call in advance if you are going to be late or have to cancel. Staying healthy Remember, you can prevent some health problems if you get regular health care before you get sick. If you haven't been receiving regular care from a primary care provider, it's a good idea to make an appointment as soon as possible with the PCC you picked. Read more about preventive-care services for children on pages 33 through 38. Pharmacy coverage Your health care provider needs to write or call in a prescription for all medications you need, including those that are sold over the counter. Pharmacy copayments When you pick up your medications, you will need to pay a copayment. The copayment is: $1 for each prescription and refill for each generic drug and over-the-counter drug covered by MassHealth in the following drug classes: antihyperglycemics, antihypertensives, and antihyperlipidemics. The copayment is for first-time prescriptions and each refill. For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 25 for people who have trouble hearing). The call is free. 5 Your health care (continued) $3 for each prescription and refill for all other generic, brand-name, and over-the- counter drugs covered by MassHealth. The copayment is for first-time prescriptions and each refill. You will not have a pharmacy copayment if: you are under age 19; you are enrolled in MassHealth because you were in the care or custody of DCF when you turned 18, and your MassHealth coverage was continued; you are pregnant (you must tell the pharmacist you're pregnant); your pregnancy ended less than 60 days ago; you are receiving family planning supplies; you are in hospice care; you are getting inpatient care in: · an acute hospital; · nursing facility; · chronic-disease hospital; · rehabilitation hospital; or · intermediate-care facility for the mentally retarded; Pharmacy copayment cap If you have paid $200 in pharmacy copayments in a calendar year, you have reached the pharmacy copayment cap, and you do not need to pay any more copayments that year. You should get a letter from MassHealth telling you when you reach the copayment cap. If your providers try to charge you any more pharmacy copayments that year, show them your letter. If you do not receive a letter or if you have any questions, call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing). If you can't pay the copayment The pharmacy must give you your medication even if you can't pay the copayment. However, the pharmacy can bill you later for the copayment. Please call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing) if a pharmacy will not give you your medication. This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 26 hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. 6 Behavioral health (mental health and substance abuse) care Finding behavioral health (mental health and substance abuse) providers Behavioral health (mental health and substance abuse) services are provided to PCC Plan members through the Massachusetts Behavioral Health Partnership (MBHP). MBHP is MassHealth's behavioral health services contractor. If you need behavioral health (mental health or substance abuse) services, MBHP will work with you and your PCC to help you get the care you need. You can reach MBHP at 1-800-495-0086 (TTY: 1-617-790-4130 for people who have trouble hearing). You can look in your Behavioral Health Provider Directory or call MBHP at 1-800-495-0086 (TTY: 1-617-790-4130 for people who have trouble hearing) to find a behavioral health provider in the MBHP network. You do not need a referral from your PCC to see a behavioral health provider. Remember, if you have a behavioral health emergency, you can: call 911; go to the closest emergency room right away; or contact the MBHP Clinical Access Line at 1-800-496-0086 (TTY: 1-617-790-4130 for people who have trouble hearing), 24 hours a day, to find the name and location of the Emergency Services Program (ESP) in your area. Your behavioral health (mental health and substance abuse) coverage You can look at the Covered Services List in this packet for more information about the services covered by MassHealth and the copayments for those services, and if the services need PCC referral or PA or both. Read more about PA earlier in this handbook. This list and the handbook may change. For the most up-to-date information or if you need help getting benefits or services, you can: talk to your PCC; or call MBHP at 1-800-495-0086 (TTY: 1-617-790-4130 for people who have trouble hearing). For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 27 for people who have trouble hearing). The call is free. 6 Behavioral health (mental health and substance abuse) care (continued) Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services for children enrolled in MassHealth Standard or CommonHealth If you or your child is under age 21 and enrolled in MassHealth Standard or CommonHealth, the PCC Plan will pay for all medically necessary services that are needed to treat a medical or behavioral health problem, even if the services are not already provided by MassHealth They are covered if they can be covered under federal Medicaid law. Most of the time, services that you need will be covered under your plan and are listed in the Covered Services List. If the service is not already covered, the clinician or provider who is giving you the service can ask MassHealth for Prior Authorization, MassHealth uses this process to determine if the service is medically necessary. The PCC Plan will pay for the service if PA is given. If PA is denied, you have a right to appeal. See pages 41-51 for more information about the appeals processes. Talk to your child's PCC, behavioral health provider, or other specialist for help in getting these services. This coverage includes health care, diagnostic services, treatment, and other measures needed to correct or improve defects and physical and mental illnesses and conditions. When a PCC (or any other clinician) discovers a health condition, MassHealth will pay for any medically necessary treatment that is covered under Medicaid law if it is delivered by a provider who is qualified and willing to provide the service, and a MassHealth-enrolled physician, nurse practitioner, or nurse midwife supports in writing the medical necessity of the service. You and your PCC can ask MassHealth or MBHP for help to determine what providers may be available in the network to provide these services, and how to use out of network providers, if necessary. This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 28 hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. 7 Care management services Specialized care-management for certain health conditions The PCC Plan offers specialized care-management services for members with specific mental illness and substance abuse problems and those who need help getting health care services. For more information about Specialized Care Management, call the MBHP Assessment Unit at 1-800-495-0086, ext. 5633 (TTY: 1-617-790-4130 for people who have trouble hearing). The PCC Plan provides the following specialized care-management services: Targeted Outreach provides short-term interventions for members who have mental illness or psychosocial issues that may interfere with their ability to access medical care and community-based services. Targeted Outreach aims to remove any barriers to care and connects members with available resources and services, such as temporary transportation to and from the health care provider's office. Care Coordination provides supportive services for members who have both medical and behavioral health issues. Care Coordination reviews the care that members are currently getting to ensure that it is the most appropriate, and coordinates treatment services to support their recovery. Care Coordination also monitors the provision of a member's medical care. This includes ensuring treatment compliance with any chronic conditions and developing a crisis-prevention plan with the member to reduce further hospitalizations. Intensive Clinical Management (ICM) is set up for the most vulnerable members, with the highest risk of hospitalization. ICM coordinates services across all levels of care. Care managers work with the treatment team and the member to create an individualized care plan to develop strategies and goals for integrating behavioral health and medical care, preventing crisis, and ensuring that the member can function in the community. ICM also provides support for pregnant women who have alcohol and/or substance abuse problems. If you have any questions about specialized care management or other behavioral health (mental health or substance abuse) services and how to get them, call the MBHP Clinical Access Line at 1-800-495-0086 (TTY: 1-617-790-4130 for people who have trouble hearing). The Clinical Access Line is available 24 hours a day, seven days a week. For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 29 for people who have trouble hearing). The call is free. 7 Care management services (continued) Community Case Management (CCM) Members who are under age 22 and require continuous skilled nursing services have their MassHealth services coordinated and authorized through the University of Massachusetts Medical School (UMMS) Community Case Management (CCM) team. CCM registered nurses and other clinicians work with you, your health care providers, and other MassHealth providers to help coordinate MassHealth community long term care services for your child. A clinician manager performs an in-person assessment of your child to see what services he or she needs in the community, such as: continuous skilled nursing; durable medical equipment; home health aides; skilled nursing visits; medical supplies; occupational therapy; personal care attendants; physical therapy; and speech therapy. CCM staff can coordinate and authorize these services when your child leaves the hospital or when the child is at home or somewhere else in the community. Call 1-800-863-6068 to get more information about the CCM. This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 30 hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. 8 Pregnancy and family planning services Pregnancy Care The health care you receive before becoming pregnant, while you are pregnant (before your baby is born), and after you have your baby is very important. It's the best way to: learn what you can do to have a healthy baby even before you become pregnant; find out how your pregnancy is going and if there are any problems; and stay healthy after you have your baby. Even if you've given birth before, it's very important for you to get this care. Make an appointment with your PCC, obstetrician/gynecologist (OB/GYN), or nurse midwife When you are planning to get pregnant, you should see your PCC, an obstetrician/gynecologist (OB/GYN) doctor, or a nurse midwife to talk about your health and ways to have a healthy birth. OB/GYNs and nurse midwives are trained to treat pregnant women and deliver babies. As soon you know you are pregnant, make an appointment with an OB/GYN doctor or a nurse midwife. Early and regular prenatal care is very important to help you have a healthy baby and a safe delivery. You should also see your OB/GYN doctor or nurse midwife as often as he or she wants to see you while you are pregnant and after your baby is born. The PCC Plan covers all these visits. If you need help finding an OB/GYN doctor or a nurse midwife, ask your PCC to recommend one or call MassHealth Customer Service. If you are pregnant, you don't need a referral from your PCC to see an OB/GYN doctor or a nurse midwife. You do need a referral if you are not pregnant. You should call to tell your PCC when you are pregnant. It is important to include your PCC because he or she can provide important health information about you to your OB/GYN doctor or nurse midwife. For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 31 for people who have trouble hearing). The call is free. 8 Pregnancy and family planning services (continued) Your new baby Remember to let MassHealth know as soon as your baby is born, so your baby can be enrolled in a health plan. You should also choose a doctor for your baby. You can call the MassHealth Customer Service Center for help in selecting a MassHealth enrolled provider that can see your baby after he or she is born. Family planning You can get family planning services from your PCC or from any MassHealth family planning provider. You do not need a referral. Here are some of the family planning services you can get: family planning medical services; family planning counseling; birth-control advice; pregnancy tests; sterilization services; abortion services; and follow-up health care. If you need help finding a family planning provider, ask your PCC to recommend one. You don't need a referral from your PCC to see a family planning provider. This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 32 hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. 9 Additional services for children Preventive and well-child care for all children Children who are under age 21 should go to their PCC for checkups even when they are well. As part of a well-child checkup, your child's PCC will perform screenings that are needed to find out if there are any health problems. These screenings include health, vision, dental, hearing, behavioral health, developmental, and immunization status screenings. Behavioral health screening can help you and your doctor or nurse to identify behavioral health concerns early. MassHealth requires PCCs to offer to check all children under 21 years old for behavioral health (mental health and substance abuse) problems during each "well-child" visit. PCCs will use a short list of questions or a checklist that you or your child (if he or she is older) fills out and then talks about with the PCC. This list of questions or checklist is called a behavioral health screening tool. You can ask which tool your child's PCC will use and for help in reading the questions. Using the tool will help the PCC better understand your child's strengths and needs. However, you can let your PCC know if you do not want your child's behavioral health to be screened. If you are concerned with the way your child is acting or feeling or your doctor or nurse thinks that your child needs to see a behavioral health provider, your PCC, MassHealth Customer Service, or the MBHP can help you learn how to get these services. For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 33 for people who have trouble hearing). The call is free. 9 Additional services for children (continued) Their phone numbers are as follows. MassHealth Customer Service: 1-800-841-2900, between 8 A.M.. and 5 P.M.. The call is free. TTY: 1-800-497-4648 (for people who have trouble hearing) Massachusetts Behavioral Health Partnership (MBHP): 1-800-495-0086 (Press 4, then 2, to skip prompts.) The call is free. TTY: 617-790-4130 (for people who have trouble hearing) MassHealth pays your child's PCC for these checkups. At well-child checkups, your child's PCC can find and treat small problems before they become big ones. Here are the ages to take a child for full physical exams and screenings: at 1 to 2 weeks at 1 month at 2 months at 4 months at 6 months at 9 months at 12 months at 15 months at 18 months ages 2 through 20 -- children should visit their PCC once a year. Children should also visit their PCC any time there is a concern about their medical, emotional, or behavioral health needs, even if it is not time for a regular checkup. This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 34 hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. 9 Additional services for children (continued) Preventive Pediatric Health-Care Screening and Diagnosis (PPHSD) services for children enrolled in MassHealth Basic, Essential, Prenatal, or Family Assistance If you or your child is under 21 years old and enrolled in MassHealth Basic, Essential, Prenatal, or Family Assistance, the PCC Plan will pay for all medically necessary services covered under your child's coverage type. This means that when a PCC (or any other clinician) discovers a health condition, MassHealth will pay for any medically necessary treatment that is included in your child's coverage type if it is prescribed by a provider who is qualified and willing to provide the service. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services for children enrolled in MassHealth Standard or CommonHealth If you or your child is under age 21 and enrolled in MassHealth Standard or CommonHealth, the PCC Plan will pay for all medically necessary services that are covered by federal Medicaid law, even if the services are not provided by the PCC Plan or MBHP. This coverage includes health care, diagnostic services, treatment, and other measures needed to correct or improve defects and physical and mental illnesses and conditions. When the child's PCC (or any other clinician) discovers a health condition, MassHealth will pay for any medically necessary treatment covered under Medicaid law, if it is delivered by a provider who is qualified and willing to provide the service, and a MassHealth-enrolled physician, nurse practitioner, or nurse midwife supports in writing the medical necessity of the service. You and your PCC can seek assistance from MassHealth or MBHP to determine which providers may be available in the network to provide these services, and how to utilize out­of­network providers, if necessary. For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 35 for people who have trouble hearing). The call is free. 9 Additional services for children (continued) Most of the time, these services are covered by your child's MassHealth coverage type and are included on the Covered Services List. If the service is not already covered or is not on the list, the clinician or provider who will be delivering the service can ask MassHealth for PA. MassHealth uses this process to determine if the service is medically necessary. The PCC Plan will pay for the service if PA is given. If PA is denied, you have a right to appeal. See pages 41-51 for more information about the appeals processes. Talk to your child's PCC, behavioral health provider, or other specialist for help in getting these services. Dental care for children MassHealth pays for dental services, including screenings, cleanings, fluoride application, and many other treatments for children under age 21. Your child's PCC will do a dental exam at each well-child checkup and may also apply a fluoride varnish to your child's teeth to prevent cavities. The PCC will remind you to take your child to a dentist for a full oral examination and cleaning and will provide a fluoride, if needed. Everyone should see a dentist for this full examination every six months. No referral is needed from your child's PCC to see a dentist for these services. If a problem is found with your child's teeth or oral health, treatment may be necessary. Children who are under age 21 and enrolled in MassHealth Standard or CommonHealth can get all medically necessary treatment covered under Medicaid law, including dental treatment, even if the service is not otherwise covered by MassHealth. Children who are under age 21 and enrolled in MassHealth Basic, Essential, Prenatal, or Family Assistance can get all medically necessary services covered under their coverage type. This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 36 hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. 9 Additional services for children (continued) Early intervention services for families of children between birth and three years of age If your child is under three years old, he or she and your family may be eligible for Early Intervention (EI) services if your child: is not developing like other children his or her age; is diagnosed with a physical, emotional, or learning condition that may keep him or her from developing like other children his or her age; may be more likely to have a developmental delay because of certain health conditions. Services are provided by a team, which includes the child's family, his or her doctor, and any other health care providers or teachers who are needed to help your child. A health care provider might include a physical, speech, or occupational therapist, nurse, psychologist, social worker, or other specialists. The EI team will come to your home, a childcare center, or other places in your community. This helps your child to learn and grow with the people that he or she knows the best. Talk to your child's PCC as soon as possible if you think your child has a growth or development problem, or contact your local early intervention program directly to make a referral. Anyone can make a referral by calling 1-800-905-TIES and asking for a listing of certified programs serving your city or town. For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 37 for people who have trouble hearing). The call is free. 10 Advance directives An advance directive is something you write or sign that names the person who you would like to make health care decisions for you and what health care treatment you do or do not want if you get sick or injured and can't talk or write. There are two kinds of advance directives: a health care proxy and a living will. A health care proxy is your written permission for a family member or friend to make health care decisions for you in case you cannot make them yourself. This person is called your "agent" or "proxy." A living will lets you tell what kind of care you want or do not want if you cannot make health care decisions. For example, you may not want to be kept alive using life support. Your living will helps your health care proxy make decisions for you. If you do not have a health care proxy or if your health care proxy is not available, the living will can help your providers care for you. If you choose to sign a health care proxy or living will, you can change your mind at any time and write and sign new ones. You should talk to a lawyer to learn more about advance directives. For more information, you can also call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing) or MBHP at 1-800-495-0086 (TTY: 1-617-790-4130 for people who have trouble hearing). This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 38 hearing) Monday to Friday, 8 a.m. to 5 p.m. The call is free. 11 Member rights As a member of the PCC Plan, you have certain rights. Your rights include the following: Your PCC cannot refuse to give you medically necessary treatment, but your PCC may refer you to a specialist for treatment. The employees of the PCC Plan and your providers must treat you with respect and dignity. The PCC Plan and your providers must keep your health information and records private. They must not give other people information about you unless you give permission or the law says they must (see page 52 for "Notice of Privacy Practices"). Your providers must tell you in advance ­ in a manner you understand ­ about any treatments and alternatives that the providers think should be done. Your providers must make you part of decisions about your health care. You can refuse treatment if you want to (as far as the law allows). You can also know what might happen if you refuse treatment. You can talk about your health care records with your providers, and get copies of all your records. You can also ask for changes to the records as the law allows. If you speak a language other than English, you can ask for an interpreter when you call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing). If you read a language other than English, you can get printed materials about the PCC Plan read aloud to you in your language by calling the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing). If you have trouble seeing or reading, you can get MBHP materials read aloud to you by calling the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing). For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 39 for people who have trouble hearing). The call is free. 11 Member rights (continued) You can choose your own PCC, and you can change your PCC at any time. Some members may be able to leave the PCC Plan and change to another MassHealth plan. To change your PCC or your health plan, call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing). You must get health care within the time frames on pages 24-25. If you do not get behavioral health care when you should, you can file an appeal with MBHP. If you do not get medical care when you should, you can file a grievance with MassHealth. For more information about appeals and grievances see pages 41-51. You can file a grievance with MassHealth Customer Service. You can also appeal to the Board of Hearings and request a fair hearing if you disagree with certain actions or inactions by MassHealth or MBHP. See pages 41-51 for more information about appeals and grievances. The PCC Plan must tell you about all benefits, services, rights, and responsibilities you have under MassHealth. You can ask for a second opinion from another provider if you get behavioral health care from MBHP. You can get emergency care 24 hours a day, seven days a week. See pages 22-23 for more information about emergencies. No one can physically hold you, or keep you away from other people, or do anything to force you to accept treatment. You can do anything on this list without worrying that PCC Plan providers will treat you differently because you did it. This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 40 hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. 12 Appeals and grievances MassHealth expects that you will be treated well when you see a doctor or other provider. However, there may be times when you are not satisfied with the care you get from a MassHealth or MBHP provider. If so, you or your representative can file an appeal or grievance. The appeals process for behavioral health (mental health and substance abuse) services is a little different than the process for other health services and benefits. A behavioral health service is a mental health or substance abuse service provided by a mental health or substance abuse provider in MBHP's Provider Network. All other services will be considered other health services for this section. Naming a representative for your grievance or appeal You can name someone to represent you at a MassHealth grievance, an MBHP grievance, an MBHP internal appeal, or an appeal to the Board of Hearings. Your representative should be someone who knows you (such as a family member or friend) and knows about your problem. Your representative could also be someone who has the legal authority to act for you in making decisions related to health care or payment for health care. For example, a representative may be a: guardian; conservator; executor; administrator; holder of a power of attorney; or health care proxy. This handbook will tell you more about how to name someone to represent you at your appeal or grievance on the following pages. For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 41 for people who have trouble hearing). The call is free. 12 Appeals and grievances (continued) What do you do if you do not speak or read English? If you do not speak or read English, MassHealth will help you for free with interpreter or translation services. If you have any questions about this, please call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing). The grievance process Filing a grievance about behavioral health (mental health and substance abuse) services You have the right to file a formal grievance if: you were not treated with respect by MBHP staff or providers; your rights were not respected by MBHP staff or providers; you are not happy with the service you or a family member received from an MBHP provider; you are not happy with any other action or inaction by MBHP, except if it had to do with authorizing treatment or getting an appointment. In this case, you can file an MBHP internal appeal; you don't agree with MBHP's decision to extend the timelines for deciding your request for PA or for deciding an internal appeal; or you don't agree with MBHP's decision not to review your appeal as an expedited (fast) internal appeal. It may be best to first talk to your provider about your concern. If you don't want to talk to your provider or don't like your provider's answer, you have the right to file a grievance with MBHP. This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 42 hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. 12 Appeals and grievances (continued) How to file a behavioral health grievance Call MBHP at 1-800-495-0086 (TTY: 1-617-790-4130 for people who have trouble hearing). MBHP will help you fill out the form. MBHP will also help you if you need interpreter or TTY services (for people who have trouble hearing). You can also write a letter to MBHP telling them about your grievance. Send it to the following address. Member Grievance Coordinator Massachusetts Behavioral Health Partnership 150 Federal Street, 3rd floor Boston, MA 02110 When you file a grievance with MBHP, you can choose a representative. To choose a representative, you must provide MBHP a signed and dated letter that tells MBHP the name of your representative and that this person can act for you. MBHP will send you a letter to tell you that they received your grievance. MBHP will review your grievance and may call you or your provider to get more information. MBHP will decide within 30 days if you were right. MBHP will send you a letter when they decide. Before MBHP finishes the review, you or your representative can ask for more time (an extension) of up to 14 days. MBHP may also get a 14-day extension if it's in your best interest and they need more information. If MBHP gets more time, they will send you a letter to tell you the reason. For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 43 for people who have trouble hearing). The call is free. 12 Appeals and grievances (continued) Filing a grievance about other MassHealth services You have the right to file a grievance to MassHealth about: your care; your providers; or the services you receive from MassHealth. When you file a grievance with MassHealth, you can choose a representative. To choose a representative, you must provide MassHealth a signed and dated letter that tells MassHealth the name of your representative and that this person can act for you. You may also need to fill out a Permission to Share Information form. This form will give your representative permission to speak for you during the grievance process. You can get a Permission to Share Information form by calling the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing). If possible, you should talk to your provider first about the problem. If you and your provider still do not agree, you can: Call MassHealth at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing) to ask for a grievance form. Fill out the form and send it to Director of Member Services MassHealth 600 Washington Street, 5th floor Boston, MA 02111 or Write a letter about your grievance, and send it to: Director of Member Services MassHealth 600 Washington Street, 5th floor Boston, MA 02111. This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 44 hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. 12 Appeals and grievances (continued) MassHealth will send you a letter to tell you that we received your grievance. MassHealth will review your grievance and may call you or your provider to get more information. MassHealth will contact you within 30 days to let you know the result of your grievance review. The MBHP internal appeals process Filing an MBHP internal appeal for behavioral health (mental health and substance abuse) services You can file an internal appeal with MBHP if you don't agree with one of these actions or inactions by MBHP: MBHP denied your request for a service, approved less service than you asked for, or said that a service you asked for is not covered; MBHP reduced, suspended, or stopped a service MBHP had covered or approved for you in the past; MBHP did not decide your request for PA for a service within the time that we should have (see pages 16-17 for more information on PA); or you cannot get an appointment for behavioral health services within the time that you should be able to (see page 25 for more information on appointments). In most cases, you will get a letter from MBHP about one of these actions. However, you may appeal even if you did not get a letter from MBHP. For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 45 for people who have trouble hearing). The call is free. 12 Appeals and grievances (continued) How to file an MBHP internal appeal If you get a letter from MBHP telling you about any of the actions or inactions above, you or your representative must file your appeal within 30 calendar days after you got that letter. If you did not get a letter from MBHP, you or your representative can appeal within 30 calendar days after you learned that one of the above actions or inactions happened. You can file an appeal by telephone or in writing. Call MBHP at 1-800-495-0086 (TTY: 1-617-790-4130 for people who have trouble hearing). You can also write a letter to MBHP at: Massachusetts Behavioral Health Partnership Attn: Appeals Coordinator 150 Federal Street, 3rd floor Boston, MA 02110. MBHP will also help you if you need an interpreter or TTY services (for people who have trouble hearing). If you have an urgent behavioral health need, you can ask to have your appeal processed more quickly. This is called an expedited appeal. Information you need to file an MBHP internal appeal Please include: your full name; the name of the service that your appeal is about if your appeal involves a decision by MBHP to: · deny your request for a service; · approve less service than you asked for; · not cover a service; or · reduce, suspend, or stop a service MBHP had covered or approved for you in the past; why you feel MBHP should change the decision; and if you would like to keep the service during your appeal. This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 46 hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. 12 Appeals and grievances (continued) If you are appealing because MBHP did not decide your request for PA for a service within the time that we should have, you will receive a letter from MBHP explaining how to appeal this decision. If you are appealing because you could not get an appointment for behavioral-health services within time frames, send a letter to MBHP including the following information: the type of service you were trying to get; the date you asked for the appointment; and the date of the appointment you got. MBHP will send you a letter telling you that we got your appeal. Continuing benefits during your MBHP internal appeal If your internal appeal is about an MBHP decision to change a service you get now by ending it, reducing it, or stopping it, you may want to keep the service while you are appealing. If you keep the service but lose the appeal, you may have to pay back the cost of the service. If you want to keep your services during the appeal, you or your representative must send your appeal request within 10 calendar days from the date of the letter that told you the service would change. You must also ask to keep your service while you are appealing. After you file an MBHP internal appeal You have the right to tell the facts and provide evidence (proof) about your appeal. You can do that in person or in writing. These facts and proofs will be used in the review of your appeal. You may look at your case file, health care records, and other documents and records. If you would like to review these documents, call your provider or MBHP at 1-800-495-0086 (TTY: 1-617-790-4130 for people who have trouble hearing). Getting a decision on your MBHP internal appeal If you do not file an expedited (fast) internal appeal, MBHP will send you a written decision within 20 calendar days. This could be up to five days longer if you, your representative, or MBHP asks for more time. For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 47 for people who have trouble hearing). The call is free. 12 Appeals and grievances (continued) An expedited (fast) MBHP internal appeal If you have an urgent behavioral health need and you think a 20-calendar-day review is too long, you, your representative, or your health care provider can ask MBHP for an expedited appeal (fast review). In most cases, if your provider asks for a fast review, MBHP will approve the request. MBHP will refuse the request by your provider for a fast review only if it's not related to your health. If your provider isn't involved in the request, MBHP can decide if they should do a fast review. If MBHP denies your request for a fast review, they will tell you in writing of this decision. MBHP will process your appeal within the 20-calendar-day time frame. You have the right to file a grievance if you don't agree with this decision (see pages 41-43 for more information). If MBHP approves your request for a fast review, they will review your appeal within three working days. MBHP will send you a letter telling you the decision on your appeal. If you don't agree with MBHP's decision on your appeal, you can file a request for a fair hearing with the MassHealth Board of Hearings (see pages 50-51 for more information). Extending MBHP internal appeal time frames If more time is needed to resolve the appeal, you, your representative, or MBHP can ask for an extra five calendar days. If the appeal is an expedited (fast) appeal, you, your representative, or MBHP can ask for an extra 14 calendar days. MBHP can ask for more time only if: the extension is in your best interest; MBHP needs more information that may lead to approval of your request; and MBHP expects to receive this information within the extra time. If MBHP asks for more time, they will send you a letter. If you don't agree, you or your representative may file a grievance (see pages 41-43 for more information). Approval of your MBHP internal appeal You will get a "Notice of Appeal Resolution" that tells you that your appeal is approved. Your provider can immediately give you the service you asked for. This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 48 hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. 12 Appeals and grievances (continued) Denial of your MBHP internal appeal If MBHP denies your internal appeal, they will send you a notice telling you. If you do not agree with the decision, you can file an appeal directly with the Board of Hearings. Dismissal of your MBHP internal appeal MBHP may dismiss your internal appeal if: someone else files the appeal for you and MBHP does not get your written permission for that person to serve as your representative before the time frame for resolving your appeal ends; or you or your representative filed the appeal more than 30 calendar days after the letter from MBHP telling you that you had a right to appeal (or more than 30 calendar days after you learned about MBHP's actions or inactions if you did not get a letter). If MBHP dismisses your internal appeal, they will send you a notice telling you. If you think that you filed an appeal within 30 calendar days and have proof, you or your representative can disagree with MBHP's decision to dismiss your internal appeal. You or your representative must send MBHP a letter asking for a review of this dismissal within 10 calendar days of the notice telling you that your appeal was dismissed. MBHP will review its decision and notify you if it will continue with your appeal. If MBHP does not resolve your internal appeal within the required time frames You can file your appeal with the Board of Hearings if: MBHP does not resolve your appeal within 20 calendar days (or within five extra calendar days if there is an extension); or MBHP does not resolve your expedited (fast) appeal within three working days (or within 14 extra calendar days if there was extra time). For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 49 for people who have trouble hearing). The call is free. 12 Appeals and grievances (continued) The Board of Hearings appeals process You can ask for an appeal with the MassHealth Board of Hearings if you don't agree with the decision that MBHP made on your internal appeal. You can also appeal certain other actions or inactions by MassHealth about your medical and pharmacy benefits (for example, MassHealth refused to give PA for a service you think you should receive). For questions about these appeals, call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing). Appeals with the Board of Hearings are called fair hearings. You have the right to receive a fair hearing from an impartial hearing officer of the Board of Hearings. Appeals relating to MBHP must first go through MBHP's internal appeals process. If you still don't agree with MBHP's decision, you can ask for a fair hearing. How to file a Board of Hearings appeal You must file your Board of Hearings appeal in writing within 30 calendar days of the decision you want to appeal. To do so, you must fill out the Fair Hearing Request Form that comes with the notice about the decision. If you would like to choose a representative for the purpose of your Board of Hearings appeal, fill out the section on the MassHealth Fair Hearing Request Form. An expedited (fast) fair hearing at the Board of Hearings You can ask for an expedited (fast) fair hearing if: you are appealing a decision to deny an acute hospital admission; you are appealing MBHP's decision on an expedited (fast) internal appeal; or you are appealing a discharge or transfer from a nursing facility. If you want the Board of Hearings to handle your request as a fast fair hearing, you must ask for the fair hearing within 20 calendar days from the day that you got the decision you are appealing. If you file between 21 and 30 calendar days after you got the decision, the Board of Hearings will not make the hearing faster. This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 50 hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. 12 Appeals and grievances (continued) Continuing benefits during your fair hearing at the Board of Hearings If your appeal is about a decision to change a service you get now by ending it, reducing it, or stopping it, you may want to keep the service during the fair hearing process. If you keep the service and lose the fair hearing, you may have to pay back the cost of the service. If you want to keep the service during the appeal, you or your representative must send your fair hearing request within 10 calendar days from the date of the letter from MassHealth that told you the service would change. If you are appealing a decision by MBHP, you must file the appeal within 10 calendar days from the date of the letter telling you MBHP's decision on your internal appeal. You must also ask to keep your service during the appeal process. After you file a Board of Hearings appeal You or your representative may read your case files to prepare for the Board of Hearings appeal process. The Board of Hearings does not have MBHP files, so you must contact MBHP to get your files if you are appealing a decision by MBHP. At the hearing, you may represent yourself or come with an attorney or other representative at your own expense. If you do not understand English or are hearing or sight impaired, tell the Board of Hearings. They will get an interpreter or assistive technology. If you have any questions about the fair-hearing process, please call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble hearing). For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 51 for people who have trouble hearing). The call is free. 13 Notice of privacy practices MassHealth has some information that explains how we may use health information about our members and give it to others. We call this our "Notice of Privacy Practices." You can get a copy of our "Notice of Privacy Practices" by writing to: MassHealth Customer Service Center 55 Summer Street, 8th Floor Boston, MA 02110. You can also get a copy of this notice by going to: www.mass.gov/Eeohhs2/docs/masshealth/privacy/npp-brochure.pdf. To find out about how MBHP uses behavioral health information and shares it with others, you can call MBHP at 1-800-495-0086 (TTY: 1-617-790-4130 if you have trouble hearing) or get a copy of MBHP's Notice of Privacy Practices by visiting MBHP's Web site at: www.masspartnership.com. (Select the "Your Privacy" link under the "For Members" section.) This Member Handbook and Covered Services List summarize the MassHealth benefits and services for PCC Plan members. For more information about benefits, services, rights, and responsibilities required by federal or state regulation, see 42 CFR 430 et seq. and 130 CMR 450 et seq. You can also visit www.mass.gov/masshealth or call the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who have trouble 52 hearing) Monday to Friday, 8 A.M. to 5 P.M. The call is free. Notes For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 53 for people who have trouble hearing). The call is free. Notes For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 54 for people who have trouble hearing). The call is free. Notes For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 55 for people who have trouble hearing). The call is free. Notes For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 56 for people who have trouble hearing). The call is free. Notes For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 57 for people who have trouble hearing). The call is free. Notes For questions about behavioral health (mental health and substance abuse) services, call the Massachusetts Behavioral Health Partnership (MBHP) at 1-800-495-0086 (TTY: 1-617-790-4130 58 for people who have trouble hearing). The call is free. MAXI/PCC/ENG-12/10