Your Rights Under Healthy Options
by: Northwest Health Law Advocates
What are Healthy Options and Basic Health Plus?
Healthy Options is the name of the Medicaid and SCHIP "managed care" program offered by the Department of Social and Health Services. Under Healthy Options you are enrolled in a health plan, such as Group Health, Regence Blue Shield, Molina, Columbia United Providers, or Community Health Plan of Washington. Health plans work in the following way:
-
Generally you have to go to clinics, providers' offices, and pharmacies that have contracts with your plan. (There are some exceptions.)
-
You have to choose a primary care provider (PCP) who gives you care for routine health needs. The PCP can be a doctor or nurse practitioner. If you need care from a specialist (such as a neurologist, cardiologist, or orthopedist), you must get a referral from the PCP.
-
Often your doctor or pharmacist must get approval from the health plan for the care or medications they think you should receive.
Most, but not all, Medicaid-covered services are available through your health plan (see the chart on page 4). For children, Healthy Options is available not just through DSHS, but also through Basic Health, where it is called "BH Plus" or "Basic Health Plus."
Who Must Enroll in Healthy Options?
Unless you receive SSI, Medicare, GA-U or GA-X or you qualify for an "exemption" from Healthy Options (see page 2), you must generally enroll if you are:
- a parent or relative caring for a child or children, or
- a child under age 19, not in foster care, or
- pregnant.
Some immigrants are also not enrolled in Healthy Options.
In addition to Healthy Options, DSHS has a mandatory managed care program for GA-U clients. It also offers optional managed care programs that include long-term care and other components for individuals with disabilities or age 65 and above. These managed care programs are different from Healthy Options and only operate in certain counties.
How Do I Choose a Plan and PCP?
DSHS should provide you with an Enrollment Packet at least two months before it's time to choose. DSHS will choose a plan for you if you don't choose one in time. HOWEVER, it's best to check with Medical Assistance Customer Service Center, 1-800-562-3022, if you haven't gotten a Packet.
Here are things to consider in choosing a plan and PCP:
My Family Doctor:
In what plan or plans are my family's providers? Usually DSHS requires your family to choose a single plan for all family members in Healthy Options. To be absolutely sure your provider is still in a plan and is still taking Healthy Options patients, call his or her office. The DSHS web site has a list of providers by county at http://fortress.wa.gov/dshs/maa/ipndweb/.
My Specialist and Pharmacy:
Will the PCP I choose be able to refer me to the specialist I want to see? Call the
PCP's office, before you enroll, to make sure they will refer you to the specialist of your choice. Call the Plan for a list of pharmacies you may use.
Location:
Where is the PCP's office? Is it convenient?
Quality of Care:
What have you heard from others about the plan and the PCP? Try to talk with friends, family members or others and ask the following questions: How does the PCP deals with Medicaid clients? Is it hard to get hold of their doctor or the on-call after hours? Have you heard complaints that people can't get appointments or the referrals they need?
Who is Exempt from Healthy Options?
An exemption from Healthy Options will allow you to get medical care from your choice of providers who take medical coupons, without being limited to a single plan or PCP.
You May Qualify for an exemption if:
-
you are homeless or in temporary housing for 120 days or less;
-
you have been getting treatment that will be interrupted by enrollment in the plan and the interruption will jeopardize your life, health or ability to attain, maintain, or regain maximum function;
-
you are a child identified by DSHS as a child with special health care needs;
-
your current provider speaks your language and is not in a plan and you cannot find a provider in the plan who does, and an interpreter is not available;
-
you are Native American or Alaska Native, in which case you are automatically exempt and are only enrolled in Healthy Options if you request;
-
you have managed care coverage through medical insurance other than Medicaid.
You may request an exemption by calling 1-800-794-4360, or by contacting your DSHS caseworker. It is best to submit a written request with supporting medical or other evidence. DO IT SOON to avoid delay in getting out of a plan. If DSHS denies the exemption, they must send you a notice explaining the reasons and your right to a fair hearing. (See "What if I Disagree with My Health Plan?")
If I Am in Healthy Options, but I Didn't Choose My Plan, How Do I Know Which Plan I Am Enrolled in?
If you are in Healthy Options but do not choose a plan, DSHS will assign you to one. Your health plan should send you a card. Also, a code for your health plan and the health plan telephone number appear on your medical coupon (Medical Assistance ID). The code is below the letters "HMO" on the medical coupon. The codes for the health plans are:
- ANH = Asuris Northwest Health Plan
- CHPW or CHPP = Community Health Plan of Washington
- CUP or CUPP = Columbia United Providers
- GHC or GHP = Group Health Cooperative
- KHPP = Kaiser Health Plan
- MHC or MHCP = Molina Health Care
- RBS = Regence Blue Shield
The health plan has a toll-free telephone number. This number appears on the medical coupon. You can call this number if you have any questions about health care services or medications, want to change primary care providers, or want to file a complaint or appeal.
Special Note for Victims of Abuse
Some clients may need to change PCPs due to potential spouse abuse. Children in foster care may need to change PCPs if there is a threat of abuse by their parents. DSHS has requested that all health plans develop written procedures to ensure that they will maintain confidentiality. If you think this applies to you, contact your plan's consumer representative and ask if they have these procedures in place. Or call the Medical Assistance Customer Service at 1-800-562-3022.
What if I Want to See another Provider for My Women's Health Care Services Who Is Different from My PCP?
May I see a nurse practitioner, obstetrician-gynecologist, nurse, midwife or other women's health care doctor for my women's health services even though I have a different PCP? The answer is yes! Washington State law requires all health plans, including Healthy Options, to allow you to go to the provider of your choice, without referral from a PCP, to get women's health services. These include prenatal and maternity care, birth control, gynecological exams, PAP smears, etc. You may go to different types of providers to receive this care, such as a doctor, physician's assistant, nurse practitioner or nurse midwife. Remember, the provider must be a member of your health plan.
Which Services Are Covered by My Plan?
There are some services that you can get in your plan. There are other services that you can get outside of your plan without a referral from the provider or permission from the plan. Patients are not charged for any covered services. Some services, such as immunizations, are covered both by the Plan and outside it. Below is basic information on covered services. More information is available at http://fortress.wa.gov/dshs/maa/HealthyOptions/pdffiles/2007/BENEFIT%20Matrix%20Update%202006.doc (current as of 2007).
|
COVERED BY THE HEALTHY OPTIONS PLAN |
OUTSIDE THE HEALTHY OPTIONS PLAN, COVERED BY MEDICAID |
|
Office visits - physician, physician assistant, nurse practitioner, nurse midwife, nurses, dieticians |
Immunizations** |
|
Immunizations, well-child exams (EPSDT)* |
Sexually Transmitted Diseases** |
|
Hospital inpatient care, nursing facility, hospice |
Tuberculosis and HIV/AIDS Screens** |
|
Hospital outpatient |
Family Planning** |
|
Lab, radiology, medical imaging, diagnostic testing |
Eyeglasses, hearing aids |
|
Emergency services, including ambulance |
Dental |
|
Home health care |
Maternity support services and maternity case management |
|
Surgical services |
Substance abuse services |
|
Physical therapy, speech therapy, occupational therapy, audiology, rehabilitation services, chemotherapy |
School medical services |
|
Women's health services (discussed above) and Maternity care |
Voluntary termination of pregnancy |
|
Medical equipment and supplies |
Certain surgical procedures |
|
Psychological evaluation/testing;
Mental health services up to 12 hours per year plus medication management (if client does not meet Regional Support Network's Access to Care Standards) |
Mental health services when client meets Regional Support Network's Access to Care Standards |
*EPSDT is a screening/diagnosis/treatment program for kids up to age 19 for medical and mental health.
**Available at many county Public Health Clinics. May also be available through your plan.
What If I Disagree with My Health Plan? What Are My Rights?
If you disagree with something you are being told by someone in your health plan, you're not sure it's right, you want to stay with a doctor who's dropping out of your plan, you feel you've been treated unfairly, or you think you might get better care elsewhere, here are some things you can do:
Request a second opinion:
Plans are required to give you a second opinion from another provider in the plan when you ask for it. Call your health plan. In addition, second opinions outside the plan can be authorized by a fair hearing judge. You must first request a DSHS hearing (see below).
Contact your plan's consumer representative:
Every plan has a consumer advocate or representative. The phone number should be on the back of your Plan Card. Sometimes this person can help resolve the problem. Generally the health plan must treat your call as a grievance or appeal and follow the appropriate procedures.
File a grievance or an appeal:
Health plans have policies and procedures for reviewing their decisions. Every plan must give you a copy of its grievance and appeal process. We recommend filing a grievance or appeal in writing, though the plan must accept them orally too. Contact your plan to do this. An appeal is a request that the health plan change an action it has made. You can appeal if:
- The health plan has said that it will deny, end, or change a service;
- The health plan has denied payment for a service;
- The health plan has not provided services in a timely manner;
- The health plan is not responding to a grievance or request that you have made;
If you appeal because the plan has said it will stop or change a service, you have the right to continue getting the service during the appeal process. You must request that it be continued within ten days of being notified that it may be stopped or changed. If you are unsuccessful with your appeal, you may have to pay the health plan for the service. Make sure to explain the reason for your appeal, such as denial of a specialty referral.
A grievance is any expression of dissatisfaction about anything that is not considered an appeal. You can file a grievance any time you are dissatisfied with the services you are receiving or not receiving from a health plan or a doctor, pharmacy, or other provider with your health plan.
Request a fair hearing and pursue independent review:
If you do not agree with the final outcome of your appeal, you can request a fair hearing. In a fair hearing, a neutral judge makes the decision. The judge is not with DSHS or your health plan. You may request a hearing at your local DSHS office or by calling your local DSHS office. You can also request a fair hearing by writing to:
Office of Administrative Hearings
P.O. Box 42489
Olympia, WA 98504
1-800-583-8270
If you disagree with the decision in the fair hearing, you have a right to independent review. This is review by an Independent Review Organization, a committee outside your health plan. To request an independent review, contact your health plan in writing and send a copy of the request to the Office of Administrative Hearings. If the Independent Review does not resolve the issue, you have the right to appeal the fair hearing decision through the Board of Appeals. Because the timeframe and procedure for the fair hearing appeal is a little unclear in the law, you may want to contact CLEAR (888-201-1014) to receive assistance with the process.
Board of Appeals
P.O. Box 45803
Olympia, Wa 98504-5803
1-877-351-0002
Change Plans:
You may change plans as often as you like. The change will take effect the next month, as long as you request it at least 7 working days prior to the end of the month. However, try to get your change in by the 15th of the month. Call 1-800-562-3022.
Children may switch to Basic Health Plus by calling 1-800-826-2444. Basic Health Plus has some different plans and providers. The medical coverage for kids is the same as Healthy Options.
Change primary care providers:
You may change your PCP for any reason. The change will become effective at the beginning of the next month. Call your health plan to switch.
Contact the Healthy Options Hotline or the Healthy Options Client Advocate:
They may be able to help resolve your complaint and are interested in hearing about problems with plans. Phone numbers are at the end of this publication.
Contact Legal Services:
Your local legal services office may be able to advise or represent you. If not, they can provide information to help you represent yourself in a fair hearing.
What are My Other Rights?
What if I do not speak English well or I am deaf or hearing impaired?
Plan providers must arrange for interpreter services for medical visits at no cost to you. If they refuse or there are difficulties, contact Medical Assistance Customer Service (phone number below).
Do I have to pay for Healthy Options?
There is no charge for any Healthy Options service, or any other Medicaid service. If a service is not covered by Medicaid, you may only be billed for it if you first sign an agreement to pay for it. If you do receive a bill, call Medical Assistance Customer Service at 1-800-562-3022. If the bill is sent to a collection agency, if you are sued, or if your wages are being garnished as a result of a medical bill, contact your local legal services office.
What if I have no way to get to any PCP or other health visits?
Call your county transportation provider. They will ask you about your provider and your medical care. Have your Healthy Options card with you. You can get the transportation provider's number from your health plan or DSHS worker. They must pick you up and bring you back at no charge.
Is there a limit on when I can receive care?
You have the right to receive proper medical care without discrimination of any kind, 24 hours a day, 7 days a week.
After Healthy Options ...How is My Health Care Covered?
Kids stay on Healthy Options or Basic Health Plus as long as family income stays below a certain level (look for our brochure about Medical programs for kids).
If you've begun working - Healthy Options will cover parents and caretaker relatives for a year or more after your income exceeds Medicaid levels, up to a certain income. (You may be required to pay monthly premiums in the second half-year.) After that, if your employer doesn't provide full insurance coverage, consider applying for Basic Health plan (BH), a state-run insurance program where your premium depends on your income. DSHS must review children's eligibility. Call Basic Health to find out about coverage, copayments, pre-existing conditions, and to get a premium quote (phone number below) and waiting time to enroll.
If you go off Medicaid because of income other than from working? Your children may stay on Healthy Options depending on family income (see above). Adults who are disabled, blind, or over 65 may still be eligible for Medicaid. Consider applying for Basic Health, a state-run insurance program where your premium depends on your income. Call Basic Health to find out about coverage, copayments, preexisting conditions, waiting time to enroll, and to get a premium quote (phone number below).
Key Phone Numbers
Medical Assistance Customer Service Healthy Options Fax Number
1-800-562-3022 1-360-664-0408
TTY/TTD 1-800-848-5429
Healthy Options Exemptions, Basic Health Information
Disenrollments and Complaints 1-800-660-9840
1-800-794-4360
Northwest Health Law Advocates
This publication provides general information concerning your rights and responsibilities. It is not intended as a substitute for specific legal advice.
This information is current as of the date of its printing, October 2007.
|
