Read BZI--12 vaetna ina Aetna Better Health® of Loui Notification to Members Important information for members, parents and guardians Each year we like to remind you to review some important information in your Member Handbook. This is the handbook we sent you when you joined Aetna Better Health of Louisiana. You may have also seen the information in your member newsletters or on our website. This information helps you stay active and informed. It can help you when making health care choices for yourself or your child. This notice gives a quick overview of what you need to know. You can find more details in your Member Handbook. If you didn't receive a Member Handbook, you can call Member Services to request one. Or you can read a copy under the “For Members” tab on our website. AetnaBetterHealth.com/Louisiana. Here's how to reach us: * By phone: Just call Member Services 24 hours a day/7 days a week at 1-855-242-0802 (toll-free) * Website: AetnaBetterHealth.com/Louisiana, Click on “Contact us.” + For those who have a hard time seeing, hearing, reading or speaking English— We have services available to help you communicate with us. You can call the Telecommunications Relay Service (TRS) 1-855-242-0802 (TTY: 711) toll free. We can also provide information in other formats. If you need help with language or translation services, call Member Services at 1-855-242-0802. It's available at no cost to you. 1. You have rights and respons 1S We strive to treat you with respect and dignity. We do not discriminate against members based on age, race, sex, religion, national origin, or any other reason that’s against the law. Our providers must also follow the same standards. You have certain rights and responsibilities as well. Knowing them helps you get the covered services you need. You'll find your rights and responsibilities listed in your Member Handbook and on our website, AetnaBetterHealth.com/Louisiana. Click on AetnaBetterHealth.com/Louisiana La2ro7-o1Rea, 2eA-I-IZ Benefits under Member Information. Then click on Rights & Responsibilities. If you have any questions or would like a copy of your rights and responsibilities, call us at 1-855-242-0802. I. Quality improvement at Aetna Better Health of Louisiana That includes: Health management programs that work for you Easy access to quality medical and behavioral health care Help with any complex or chronic conditions or illnesses Support when you need it most High satisfaction with your doctors and with us Our quality improvement activities each year include: Contacting you to remind you to get care (like well-child checkups) Sending you postcards or newsletters about health topics Reviewing the number, quality and kinds of services you receive Reminding your doctors and you about preventive health care Making sure you're continuing to get the care you need * Checking that your calls are answered quickly and that you get the right information * Ensuring your doctor has all the information needed to care for you or your child We have many more quality programs. You can call Member Services at 1-855-242-0802 to learn more about what we do to improve your care. We're also happy to give you a printed copy of our program goals and how we're doing. Or you can read updates on our website at AetnaBetterHealth.com/Louisiana. Ill. Privacy and security of your health care data Protecting your personal health information (PHI) is one of our most important jobs. We train our staff to keep your health care data safe. We set rules to follow when collecting and using PHI. Our rules describe: + How to protect access to PHI, either electronic or paper copies * The right way to treat your health care data no matter what form it is in — written, oral, or electronic * Your right to permit or refuse the release of PHI except for treatment, payment or health care operations reasons * Locking up your records and keeping your health care data in safe areas + Making sure the only staff who have access to your health care data are 2 AetnaBetterHealth.com/Louisiana LA21.07-01Keath ZeAl- Ul -/a those who need it to perform their jobs and care for you We're happy to answer any questions you have about how we protect your health care data. Notice of Privacy Practices: We include a Notice of Privacy Practices in your welcome packet. It tells you how we use your information for health plan benefits. It also tells you how you can see, get a copy of, or change your medical records. Your health information will be kept private and confidential. We will give it out only if the law allows or if you tell us to give it out. For more information or if you have questions, you can call us at 1-855-242-0802, Or you can visit our website at AetnaBetterHealth.com/Louisiana You'll find a link to information on our privacy practices at the bottom of the Home page. IV. Utilization management ‘We want to ensure that our members are getting the services or benefits they need to get or stay healthy. This is called “utilization management” (UM). Our UM staff use clinical criteria, guidelines and written policies to make UM decisions. They check that requested services are «Needed to keep or get youhealthy * Covered by Aetna Better Health of Louisiana You or your provider can get a copy of the guidelines we use to approve or deny services. You can call Member Services at 1-855-242-0802, 24 hours a day/7 days a week with questions about our UM program. Member Services may transfer your call to the UM department for a staff member to help you. We're here to help you with any UM issues * For help if you have vision and/or hearing problems, call the Telecommunications Relay Service (TRS) 1-855-242-0802 (TTY: 711) toll-free * Forhelp with language or translation services, call Member Services at 1-855-242-0802 Our affirmative statement about incentives We want you to feel sure that you're getting the health care and services you need. To that end, we have policies our providers must follow to ensure that you get the right health care. Our policy is to not reward providers or others to deny or give less medically necessary 3 AetnaBetterHealth.com/Louisiana A21-07-01Kaa — soz/21[-12 care toa member of our plan. This is called an “affirmative statement.” We do not reward or pay extra money to health care providers, staff or other people to: + Deny youcare * Give youless care * Deny tests or treatments that are medically necessary Allour members should receive the right health care. If you want more information on this, call us at 1-855-242-0802. V. Benefits and copayments questions You can find a list of covered and non-covered benefits and services in your Member Handbook and on our website. Your Member Handbook also discusses some costs that may be your responsibility Costs you may need to pay As an Aetna Better Health of Louisiana member, you are generally not responsible for paying for covered health care services. There are some exceptions though. For example, if you receive a service and your provider tells you beforehand that it's not a. covered benefit, you may be responsible for paying for it Copays for prescription drugs Aetna Better Health of Louisiana will charge small copays on prescription drugs. Your pharmacy copay depends on the total amount that we would pay the pharmacy for your claim. Member's cost will not exceed 5 percent of your monthly household income. Pharmacy cost Your copay $10.00 or less $0.50 $10.01 to $25.00 $1.00 $25.01 to $50.00 $2.00 $50.01 or more $3.00 a are no copays for the following pharmacy services: Services furnished to pregnant women Emergency services Family planning services * Preventive medicine AetnaBetterHealth.com/Louisiana La-21-07-01Keteed = Be2lal-lz The following members do not have co-pays: «Members under 21 years of age * Members living ina long-term care facility ‘* Members receiving hospice care + Native Americans © Alaskan Eskimos * Home- and Community-Based Waiver recipients * Women whose basis of Medicaid eligibility is breast or cervical cancer If you get a bill from your doctor for a covered health care service, call us. VI. How to get the care youneed Your primary care provider (PCP) is a central part of your health care. Your PCP should be the one you contact first for most health care issues. The provider directory has a list of providers to pick from in your area. You can find your own provider by visiting our website. Click “Find a Provider” at the top of the website. The online provider directory also gives a provider's professional credentials, like board certification. For more information about our providers, you can visit our website at AetnaBetterHealth.com/Louisiana or call Member Services at 1-855-242-0802, You can also visit www-healthgrades.com. This site gives more information about providers such as which medical school they attended and where they did their residency training. Specialty Care Sometimes you or your child may need care from a specialist. Specialists treat special types of conditions, including behavioral health or substance use concerns. Your PCP can recommend a specialist or behavioral health care provider to you. You don't need a formal referral from your PCP as long as the specialist is in our provider network. Female members have direct access to a Aetna Better Health of Louisiana health specialist for preventive care, This includes covered services such as breast exams, Mammograms, pap tests and prenatal care. You don’t need an OK from your PCP. If you have questions, Member Services can help you. Let your PCP know if you visit a specialist, so he or she can support your care. AetnaBetterHealth.com/Louisiana LA21-07-01Repel = 20td4-[1 -/2_ You have the right to get a second opinion from a qualified health care professional at no. cost to you. If an Aetna Better Health of Louisiana provider isn’t available, we'll help you get a second opinion from a non-participating provider. This will still be at no cost to you. Self-referral You can get some specialty services yourself that don’t require your PCP’s approval. We call this self-referral. Some examples are family planning services and behavioral health services. You must go to an Aetna Better Health of Louisiana provider for your service to be covered, except for emergency services. Aetna Better Health of Louisiana members must receive family planning services from an Aetna Better Health of Louisiana provider. How to get after-hours care Call your PCP for after-hours care, except in an emergency. If you or your child gets sick after the PCP’s office is closed - even on weekends - call your PCP. An answering service will make sure the PCP gets your message. Your PCP will call you back to tell you what to do. How to get emergency care Ifyou or your child’s life is in danger, you should always calll 9-1-1 or go to the nearest ‘emergency room (ER). If you need transportation to the hospital, call 9-1-1. The hospital does not have to be in our network for you to get care. If you're not sure it’s an emergency, call your PCP. You should only use an ER for real, life-threatening emergencies. An emergency is the sudden onset of a medical condition with severe symptoms, including severe pain. These symptoms are so serious that not getting immediate medical attention could result in: Loss of life or serious harm to you or another person Apregnant woman becoming very ill and possibly losing her unborn child Some bodily functions ceasing to work Serious harm to any body organ or part Examples of emergencies are: © Sharp chest pain * Choking * Bleeding that won't stop * Passing out Poisoning AetnaBetterHealth.com/Ls La-2-07-01 janaNett 2e2/H_p * Drug overdose * Severe burns * Extreme shortness of breath * Broken bones «Severe spasms or convulsions * Sudden loss of feeling or notbeing able to move Out-of-service care when you're away from home Aetna Better Health of Louisiana's service area is the State of Louisiana. If you're traveling or out of the service area, you're only covered for emergency services. Routine care out of the service areaor out of the country isn’t covered by Medicaid. If you're out of the service area and need health care services, call your PCP. She or he will tell you what to do. (You can also call us to check if you're out of the service area.) If you're not in Louisiana and you think you or your child's life is in danger, go to the closest ER. Show your Aetna Better Health of Louisiana ID card, your Medicaid ID card, and any other insurance ID cards you have to the ER staff. If you or your child get services in the ER and are admitted to the hospital, have staff call us at the number on the back of your ID card. Out-of-network services We have a large network of providers and services. If a provider you want to see is not in our network, your PCP must first get approval from us before you can see that provider. Except for an emergency, only your PCP can make this request. It’s not something you can do yourself. If approved, we will properly and timely cover these services. This is only for as long as you can’t get the service in our network. If you have questions, please call us. Vil. Care Management Help when you need it most Sometimes, managing a chronic condition or multiple conditions can become overwhelming. To offer you support, your doctor, hospital discharge planner or other provider may refer you to Care Management. Or a nurse on our health information line may refer you. However, don't wait for a referral if you need help. You can self-refer by calling us at 1-858-242-0802 and asking for Care Management After you enroll in care management, you'll get a welcome letter that will explain how our services can help you. You'll also get a call from a case manager. iz AetnaBetterHealth.com/Louisiana L&21-07-01Reeve 2oel-Il -/z Our case managers can: * Help you understand your covered benefits * Show you how to get specialty, behavioral health, or hospital services * Talk with your doctors and other agencies to ensure you get needed services « Teach you more about your disease or condition * Help you locate community resources to meet your needs Is your child moving from pediatric to adult care? We have trained professionals on staff to help you in this. We'll work with you to help get the right care for your child's special needs. Your member handbook will give you more information about care management. You can opt in or opt out of the program anytime. We're happy to help you if you have any questions. You can reach us at 1-855-242-0802, vi Pharmacy services If you need medicine, your provider should choose a drug from our Louisiana Medicaid Single Preferred Drug List online at (https://Idh.la.gov/assets/HealthyLa/Pharmacy/PDL.pdf). There are also some drugs not listed on the Louisiana Medicaid Single PDL which may be available for coverage. Most of these drugs do not require an approval. Generic drugs are preferred by the state unless a drug is on the preferred drug list as a Brand Name product. Clinical edits, such as, quantity limits and age restrictions, may apply to some drug categories. You can calll us with any questions at 1-855-242-0802 (TTY: 711). Sometimes your provider will want to give you a drug that is not on our list. If the provider feels that only the drug he wants to prescribe will work for you, they can request approval from us. Your provider knows how to do this. Remember to take your prescriptions to one of the pharmacies listed in our provider directory. Prescription refills, The label on your medicine bottle tells you how many refills your doctor has ordered. You may only get one refill at a time. If the doctor hasn't ordered refills, you must call your doctor or pharmacy at least five (5) days before your medicine runs out. The doctor may want to see you before giving you a refill. AetnaBetterHealth.com/Louisiana LA2+07-01Ktatel = 202-12 Ix. New technology for medical procedures We're always looking at new medical procedures and methods to make sure our members get safe, up-to-date, high-quality medical care. We have a team of doctors who review new health care technologies. They decide if they should become covered services. (We don't cover investigational technologies, methods and treatments still under research.) To decide if a new technology will become a covered service, we will: Study the purpose of each technology Review medical literature Look at the impact and benefits a new technology could have Develop guidelines on how and when to use the technology x. Gi We take member grievances and appeals very seriously We want you to be happy with services you or your child gets from us and our providers. If you're not happy, we want you to let us know. Filing a grievance or appeal will not affect your health care services or Medicaid eligibility. We want to know what is wrong so we can make our services better. vances and appeals We need to know what happened Please give us as much information as you can. For example, include: + The date the incident happened + The names of the people involved * Details about what happened + Yours or your child’s name and member ID number How to file a grievance |f you have a grievance please contact us. If you want a Member Advocate, we'll help. You can file a grievance by: + Calling us toll-free at 1-855-242-0802 + Asking and giving permission for your provider to file a grievance for you © Writing to us at Aetna Better Health of Louisiana Grievance and Appeals PO Box 81139 5801 Postal Road Cleveland, OH 44181 AetnaBetterHealth.com/Louisiana Laer-or-01Kris Zor-I/-|2 How to file an appeal We must approve many services ahead of time in order to pay for them. If we decide not to pay for a service we'll write to you and tell you why. We'll send you a Notice of Adverse Benefit Determination also referred to as a Notice of Action (NOA) letter if we: * Decide not to approve a request for a service * Approve only part of a request for a service The Notice of Adverse Benefit Determination letter will tell you the reasons. If you don't agree with it, you can file an appeal. You must send your appeal to us in writing. You can call us first at 1-855-242-0802, You can write to us at: Aetna Better Health of Louisiana Grievance and Appeals PO Box 81139 5801 Postal Road Cleveland, OH 44181 FAX: 1-844-410-8655 XI. Fraud, Waste and Abuse It's important to report dishonest acts. These dishonest acts are called fraud, waste and abuse. The following acts are the most common types of fraud, waste and abuse: * Members selling or lending their ID card to someone else * Members trying to get drugs or services they do not need * Members forging or altering prescriptions they receive from their providers * Providers billing for services they didn’t give + Providers giving services members do not need Verbal, physical, mental, or sexual abuse by providers Call our Fraud and Abuse Hotline at 1-855-725-0288, 24 hours a day, 7 days a week, to report these types of acts. You can do this without us knowing your name. You can also call the Louisiana Medicaid Fraud & Abuse Hotline Monday-Friday, 8 AM to 5 PM, at 1-800-488-2917. Or you can fill out the Fraud, Waste and Abuse form online at AetnaBetterHealth.com/Loui: 10 AetnaBetterHealth.com/Louisiana a2ror-orKefwed — Ze2/-f/ypa. Aetna Better Health’ of Louisiana Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. This notice takes effect on February 1, 2015. Please review it carefully. What do we mean when we use the words “health information” We use the words “health information” when we mean information that identifies you. Examples include your: * Name * Date of birth * Health care you received * Amounts paid for your care How we use and share your health information To help take care of you: We may use your health information to help with your health care. We also use it to decide what services your benefits cover. We may tell you about services you can get. This could be check-ups or medical tests. We may also remind you of appointments. We may share your health information with other people who give you care. This could be doctors or drug stores. If you are no longer with our plan, with your okay, we will give your health information to your new doctor. Family and friends: We may share your health information with someone who is helping you, if you give us verbal permission. This permission will allow us to talk with ‘someone that may be helping with your care or helping pay for your care, but only for the day that you give us verbal permission. For example, if you have an accident, we may need to talk with one of these people. If you do not want us to give out your health information call us. If you are under eighteen and don’t want us to give your health information to your parents. Call us. We can help in some cases if allowed by state law. * For purposes of this notice, “Aetna” and the pronouns “we,” “us” and “our” refer to all the HMO and licensed insurer subsidiaries of Aetna Inc. These entities have been designated as a single affiliated covered entity for federal privacy purposes. 1 AetnaBetterHealth.com/Louisiana La21-07-01Reid § 2oa-l-/z For payment: We may give your health information to others who pay for your care. Your doctor must give us a claim form that includes your health information. We may also use your health information to look at the care your doctor gives you. We can also check your use of health services. Health care operations: We may use your health information to help us do our job. For example, we may use your health information for: + Health promotion Case management Quality improvement Fraud prevention Disease prevention * Legal matters Acase manager may work with your doctor. They may tell you about programs or places that can help you with your health problem. When you call us with questions we need to look at your health information to give you answers. Sharing with other businesses We may share your health information with other businesses. We do this for the reasons we explained above. For example, you have transportation covered in your plan. We may share your health information with them to help you get to the doctor's office. We will tell them if you are in a motorized wheelchair so they send a van instead of a car to pick you up. Other reasons we might share your health information We also may share your health information for these reasons: * Public safety - To help with things like child abuse. Threats to public health. * Research —To researchers. After care is taken to protect your information. * Business partners ~To people that provide services to us. They promise to keep your information safe. * Industry regulation - To state and federal agencies. They check us to make sure we are doing a good job. * Law enforcement - To federal, state and local enforcement people * Legal actions ~To courts for a lawsuit or legal matter. Reasons that we will need your written okay Except for what we explained above, we will ask for your okay before using or sharing your health information, For example, we will ask for your okay: * For marketing reasons that have nothing to do with your health plan, 12 AetnaBetterHealth.com/Louisiana La-21-07-01Keel = 2U-/ -)/z * Before sharing any psychotherapy notes. * For the sale of your health information. ‘* For other reasons as required by law. You can cancel your okay at any time. To cancel your okay, write to us. We cannot use or share your genetic information when we make the decision to provide you health care insurance. What are your rights? You have the right to look at your health information. * You can ask us for a copy of it. * You can ask for your medical records for free. Call your doctor's office or the place where you were treated. You have the right to ask us to change your health information. You can ask us to change your health information if you think itis not right. + If we don’t agree with the change you asked for, ask us to file a written statement of disagreement. You have the right to get a list of people or groups that we have shared your health information with, You have the right to ask for a private way to be in touch with you. «Ifyou think the way we keep in touch with you is not private enough, call us. * We will do our best to be in touch with you in a way that is more private. You have the right to ask for special care in how we use or share your health information. * We may use or share your health information in the ways we describe in this notice. * You can ask us not to use or share your information in these ways. This includes sharing with people involved in your health care. * We don't have to agree. But, we will think about it carefully. You have the right to know if your health information was shared without your okay. * Weewill tell you if we do this in a letter. Call us toll free at 1-855-242-0802 (TTY: 711) to: * Ask us to do any of the things above. * Ask us for a paper copy of this notice. * Ask us any questions about the notice. 13 AetnaBetterHealth.com/Louisiana La21-07-01Rea = 2ef-le You also have the right to send us a complaint. If you think your rights were violated write to us at: Aetna Better Health of Louisiana Attn: Privacy Officer 2400 Veterans Memorial Blvd., Suite 200 Kenner, LA 70062 You also can file a complaint with regard to your privacy with the U.S. Department of Health and Human Services, Office for Civil Rights. Call us toll free at 1-855-242-0802 (TTY: 711) or go online to "How to File a Complaint" page of the Office for Civil Rights website at www.hhs.gov/ocr/privacy/hipaa/complaints/. Ifyou are unhappy and tell the Office for Civil Rights, you will not lose plan membership or health care services. We will not use your complaint against you. Protecting your information We protect your health information with specific procedures, such as: * Administrative. We have rules that tell us how to use your health information no matter what form it is in - written, oral, or electronic. * Physical. Your health information is locked up and is kept in safe areas. We protect entry to our computers and buildings. This helps us to block unauthorized entry. * Technical. Access to your health information is “role-based.” This allows only those who need to do their job and give care to you to have access. We follow all state and federal laws for the protection of your health information. Will we change this notice? By law, we must keep your health information private. We must follow what we say in this notice. We also have the right to change this notice. If we change this notice, the changes apply to all of your information we have or will get in the future. We will send you @ copy of the new notice, or you can get a copy of the most recent notice on our website at AetnaBetterHealth.com/Loui 14 ActnaBetterHealth.com/Louisiana Lazror-o1Rar BAl- /z Nondiscrimination Notice Aetna complies with applicable federal civil rights laws and does not discriminate based ‘on race, color, national origin, age, disability or sex. Aetna does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Aetna: * Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) * Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card or 1-800-385-4104. If you believe that Aetna has failed to provide these services or discriminated in another way based on race, color, national origin, age, disability or sex, you can file a grievance with our Civil Rights Coordinator at: Address: Attn: Civil Rights Coordinator 4500 East Cotton Center Boulevard Phoenix, AZ 85040 Telephone: 1-888-234-7358 (TTY: 711) Email: MedicaidCRCoordinator@aetna.com You can file a grievance in person or by mail or email. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1- 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, and its affiliates. 15 AetnaBetterHealth.com/Louisiana w2ror-o1