Utah Children s Health Insurance Plan (CHIP) Member Guide. May Experience you can count on.

Transcription

1 Utah Children s Health Insurance Plan (CHIP) Member Guide May 2016 Experience you can count on.

2

3 What is CHIP? The Children s Health Insurance Program (CHIP) is a state program for uninsured Utah children. Many children who qualify for CHIP come from working families. Uninsured Utah children may qualify if they meet certain requirements on income and family size. Once approved, CHIP covers well-child exams, immunizations, dental care, hearing and eye exams, and more. While enrolled in CHIP, your child will receive dental benefits similar to many commercial plans. DentaQuest will work with you to make sure your child gets needed dental care. DentaQuest will help you find a dentist that takes CHIP and is close to your home. DentaQuest can also help you make an appointment. If you have any questions about the dental program call DentaQuest customer service at Assurance of Non-Discrimination No one is treated in a different way because of race, color, birthplace, language, sex, age, or disability. If you feel you have been treated unfairly or need help, please call Interpretation and Translation Services If you need interpretation/translation services, please call We can provide a translator for you over the phone. If you have a hard time with hearing or speech, please call us at TTY/TDD toll-free How to Use This Handbook This handbook will tell you all about your dental program. It can help you with the following: How to schedule an appointment What is covered by your dental plan What phone numbers you will need for more information 3

4 Table of Contents Enrollment...5 Coverage...5 Making an Appointment...8 At the Dentist Office...8 Emergency Services/Urgent Services...9 Enrollee Rights and Responsibilities...9 Grievance and Appeals...10 Questions...12 Finding a Dentist...12 Find a Dentist on the Go...14 Oral Health Tips...15 You have the right to materials and information, including this handbook in: Audio Braille Larger print Other languages Call DentaQuest Customer Service at Monday - Friday 7:00 am to 4:00 pm for these materials. 4

5 Enrollment Enclosed is a welcome letter and a CHIP identification (ID) card for your child s dental care. It is very important to keep this card in a safe place and not lose it. Take this card with you each time you visit the dentist. If you have questions about your ID card(s), please contact DentaQuest customer service at Monday - Friday 7:00 am to 4:00 pm. It is against the law to let someone else use your CHIP ID card. Coverage DentaQuest uses contracted dentists and eligible benefits are paid at a maximum amount to the dentist. You must pay the co-pay, co-insurance and/or deductible at the time of service and the balance will be paid by DentaQuest. Dentists must consider reimbursement by DentaQuest and your co-pay, co-insurance and/or deductible as payment in full. They cannot balance bill you for additional amounts above the maximum amount for eligible services. The benefit plan your child is enrolled in is determined by the Utah Department of Health and based on family size and income. There are three levels of benefits (plans) below. UTAH CHIP DENTAL BENEFIT CATEGORY PLAN B: MEMBER PORTION PLAN C: MEMBER PORTION AMERICAN INDIAN (NTAM): MEMBER PORTION DIAGNOSTIC AND PREVENTIVE SERVICES Prophylaxis Examinations Space maintainers Fluoride X-rays 0% 0%-NO DEDUCTIBLE 0% BASIC SERVICES Oral Surgery, General Anesthesia or IV Sedation, Endodontics, Periodontics, Palliative, Sealants, Restorative, Denture Repairs 5% 20%-AFTER DEDUCTIBLE 0% MAJOR SERVICES Crowns, Inlays/Onlays, Cast Restorations, Prosthodontics 5% 50%-AFTER DEDUCTIBLE 0% 5

6 ORTHODONTIC SERVICES Lifetime Maximum of $1000, mutually exclusive of the calendar maximum. Percentage paid is based on allowable amounts Only covered if medically necessary and with prior approval. 5% 50%- NO DEDUCTIBLE 0% Annual Deductible None None None Annual Benefit Dollar Limitation Pre-existing Condition Limitation $1000 $1000 $1000 None None None Prior Authorization Requirements Yes, on some Preventive, Basic, and Major Services and Orthodontics Yes, on some Preventive, Basic, and Major Services and Orthodontics Yes, on some Preventive, Basic, and Major Services and Orthodontics Oral examinations and other preventive services including cleaning and fluoride treatments are limited to two (2) per plan year. If necessary, your child age five (5) or younger, may receive eligible services in an outpatient surgical facility. Coverage Exclusions A. Treatment of injuries or illness covered under workers compensation or employers liability laws; services received without cost from any federal, state or local agency, unless this exclusion is prohibited by law. B. Cosmetic surgery or dentistry for purely cosmetic reasons. C. Services for congenital (hereditary) or developmental (following birth) malformations, including but not limited to cleft palate, upper and lower jaw malformations, enamel hypoplasia (lack of development), fluorosis (a type of discoloration of the teeth) and anodontia (congenitally missing teeth), except those services provided to newborn children for cleft lip pr cleft palate. D. Treatment to restore tooth structure lost from wear, erosion or abrasion; treatment to rebuild or maintain chewing surfaces due to teeth out of alignment or occlusion; or treatment to stabilize the teeth. Examples include but are not limited to: equilibration, periodontal splinting or occlusal adjustment. E. Any Single Procedure started prior to the date the Enrollee became 6

7 covered for such services under this program. F. Prescribed drugs, medication, pain killers or experimental procedures. G. Charges by any hospital or other surgical or treatment facility and any additional fees charged by the Dentist for treatment in any such facility. H. Charges for anesthesia, other than general anesthesia and IV sedation in connection with covered oral surgery or selected endodontic and periodontal surgical procedures. I. Extraoral grafts (grafting of tissues from outside the mouth to oral tissues). J. Treatment performed by someone other than a Dentist or a person who by law may work under a Dentist s direct supervision. K. Charges incurred for oral hygiene instruction, a plaque control program, dietary instruction, x-ray duplications, cancer screening or broken appointments. L. Services or supplies covered by any other health plan of the enrollee. M. Treatment rendered by a person who ordinarily resides in your household or who is related to you (or to your spouse) by blood, marriage or legal adoption. N. Except as provided in Section 2.1 D, Services for Orthodontic treatment are excluded. This exclusion includes, but is not limited to: 1) Limited orthodontic and removable appliance therapies. 2) Removable appliances in conjunction with fixed banded treatment. 3) Habit control appliances. 4) Orthodontic services for cosmetic or esthetic reasons. O. Services for any disturbances of the temporomandibular (jaw) joints. Non-Covered Services If you choose to have non-covered services, your dentist must give you a letter that tells you what the services are and how much they will cost you. You will be asked to sign the letter. This letter tells you the service is not covered by CHIP and you are going to pay for it. Non-covered services do not count towards your out-of-pocket maximum. Maximum Out of Pocket Once you have paid five percent (5%) of your family s income in co-pays, co-insurance and/or deductibles, you will no longer have any amount to pay when your child visits the dentist during the current benefit year. The benefit year is 12 months of CHIP coverage, beginning with the month your child became eligible for CHIP. The benefit year and 5% outof-pocket maximum start over at each recertification of eligibility. If you have questions about your maximum out-of-pocket expenses, or have paid out five percent (5%) of your family s income, you will need 7

8 to contact a Health Program Representative (HPR) at the Utah Department of Health by calling After checking the amount you have paid, they will contact DentaQuest and a your child will get a new ID card. The new ID card will not show a co-pay or co-insurance amount due from you. You will need to use this new ID card when your child visits the dentist. Making an Appointment When you call the dentist, you should have these things ready: Pen or pencil and paper Your ID card Your calendar When you call the dentist s office, tell them that you are a CHIP member. Let them know you would like to make an appointment to see the dentist. See which dates and times work best for you. Write down the date and time of the appointment on your calendar. When the date of your appointment comes, just go to the dentist s office. It is that easy. If you are not able to keep the appointment, call the dentist s office as soon as possible to let them know you will not be coming. You should make another appointment as soon as possible. If you have been going to a different dentist, please ask the old dentist to send your child s dental records to your new dentist. At the Dentist s Office When you go to the dentist s office you should bring your child s CHIP ID card. Show your child s ID card when you get there. The dentist can give you some helpful tips on taking care of your teeth and mouth. Helpful Dental Tips Practice good dental health habits. Brush your child s teeth twice a day and floss once a day. Take your child to the dentist for a check-up every six months. Good dental care starts before your child s first birthday and goes throughout your child s life. Never allow your child to fall asleep with a bottle of milk, formula, fruit juice, or sweetened drink. Keep dental appointments. Limit sweets and sodas. 8

9 Good dental health is very important to pregnant women and their unborn children, too. There is a link between the health of a mother s gums and her unborn baby s overall health. Everyone should find a dental home. That means that you have a dentist that you and your family see on a regular basis. The dentist and the office workers know you, welcome you and provide care for your dental needs. Emergency and Urgent Services Emergency services are services for the treatment of any dental issue needing attention right away for the relief of pain, severe bleeding, infection, or serious injury to the teeth, gums, or jaw. Urgent services are services that are not as serious as emergency services, but should not wait until the next appointment. If you have an urgent dental need or dental emergency, please contact your dentist. If you do not have a dentist or your dentist is not available, you can call DentaQuest customer service at or visit to find a dentist. Prior authorization is not required for emergency services. Emergency services may be covered out of area when needed. You can get covered services after an emergency to help maintain or improve your oral health. Statement of Enrollee Rights and Responsibilities The mission of DentaQuest is to increase access to high-quality, compassionate dental services within the available resources. DentaQuest is committed to ensuring that all Enrollees are treated in a manner that respects their rights and acknowledges its expectations of Enrollee s responsibilities. The following is a statement of Enrollee s rights and responsibilities. 1. All Enrollees have a right to receive pertinent written and up-todate information about DentaQuest, the managed care services DentaQuest provides, the Participating Providers and dental offices, as well as Enrollee rights and responsibilities. 2. All Enrollees have a right to privacy and to be treated with respect and recognition of their dignity when receiving dental care. 3. All Enrollees have the right to fully participate with caregivers in the 9

10 decision making process surrounding their health care. 4. All Enrollees have the right to be fully informed about the appropriate or medically necessary treatment options for any condition, regardless of the coverage or cost for the care discussed. 5. All Enrollees have the right to voice a complaint against DentaQuest,or any of its participating dental offices, or any of the care provided by these groups or people, when their performance has not met the Enrollee s expectations. 6. All Enrollees have the right to appeal any decisions related to patient care and treatment. Enrollees may also request an external review or second opinion. 7. All Enrollees have the right to make recommendations regarding DentaQuest s/plan s Enrollees rights and responsibilities policies. 8. All Enrollees have the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation, as specified in other Federal regulations on use of restraints and seclusions. 9. All Enrollees have the right to request and receive a copy of his or her medical records, and to request that they be amended or corrected, as specified in 45 CFR and 45 CFR All Enrollees have the right to be furnished dental care services in accordance with access and quality standards. 11. All Enrollees have the right to be free to exercise all rights and that by exercising those rights, the Enrollee shall not be adversely treated by the Department, DentaQuest, and Participating Providers. Also: 1. All Enrollees have the responsibility to provide, to the best of their abilities, accurate information that DentaQuest and its participating dentists need in order to provide the highest quality of health care services. 2. All Enrollees have a responsibility to closely follow the treatment plans and home care instructions for the care that they have agreed upon with their health care practitioners. 3. All Enrollees, have the responsibility to participate in understanding their health problems and developing mutually agreed upon treatment goals to the degree possible. Grievance Rights Grievances are when you call or send a letter to tell DentaQuest you are not happy with a decision we made, other than a denial of services. Some examples of grievances include: not being able to find a dentist, trouble getting an appointment, the quality of care you got from your dentist, or not being treated fairly by someone who works at your 10

11 dentist s office. If you have a grievance, you can call us at or write to us at: DentaQuest UTAH CHIP Attn: Complaints and Grievances PO Box 2906 Milwaukee, WI Right to Appeal You have the right to appeal if you disagree with a decision DentaQuest made to deny a covered dental service. You have to file your appeal in writing within 30 calendar days after the date you receive a denial notice. You or someone you name to act for you (your authorized representative) may file an appeal. You can name a relative, friend, attorney, or someone else to act for you. Others may already be authorized under state law to act for you. If you want someone to act for you, you and your authorized representative must sign, date and send us a statement naming that person. What do I include with my appeal? You should include: your name, address, member ID number, the reason you disagree with the decision, and any other information you wish to attach. You may send in medical records, doctors letters, or other information that explains why we should cover the service. Call your dentist or doctor if you need this information to help you with your appeal. How do I file an appeal? You or your authorized representative should mail your written appeal to the address below: DentaQuest UTAH CHIP Attention: Appeals Department PO Box 2906 Milwaukee, WI

12 If you do not agree with this decision, you have the right to request a hearing before an administrative law judge with the Department of Health by contacting: Director s Office/Formal Hearings Division of Medicaid and Health Financing P.O. Box Salt Lake City, UT Phone: FAX: Questions about Your Dental Program DentaQuest can answer any questions about the dental program. Please call DentaQuest at if you have questions. If you would like more information on dental health and taking care of your teeth, please visit our website On the website you can read and print information about dental health. Questions about Your Medical Program Call your health plan if you have questions about your medical services, medical provider or a medical claim. Molina Healthcare at or SelectHealth at Find a Dentist DentaQuest will help you find a dentist. There are many dentists available to treat you. You do not need a referral to see a dental specialist. For information on which dentists you can visit please call or visit the website We can help you find the closest dentist that works with the CHIP program. DentaQuest CHIP members may choose any dentist that is participating with DentaQuest CHIP. American Indian CHIP members may see any dentist that takes CHIP including any Indian health care provider. The names of all dentists and dental specialists who take CHIP are available to you on DentaQuest s website at and by calling DentaQuest customer service at

13 When you call DentaQuest, you should have these items ready: Pen or pencil and paper Your ID card When you call DentaQuest, tell them that you are a UTAH CHIP member. Let DentaQuest know why you want to go to the dentist. DentaQuest will give you the names of dentists in your area. Find a Provider on DentaQuest s Website Visit our website at Choose Find a Dentist from the top line. Then follow directions for one of the options below which will give you a list of Utah CHIP dentists within 30 miles of the address you enter, zip code or other options you chose. 1. You may do a quick search by zip code by entering Utah as the state, your zip code and UTAH CHIP as the program in the box labeled Enter Your Geographical Area. 2. Or you may choose to do a detailed search by entering Utah as the state, your zip code and UTAH CHIP as the program in the box labeled Enter Your Geographical Area. You may then choose other options for special needs, handicap accessibility, accepting new patients, provider specialty and office language spoken. 13

14 Find A Dentist on the Go My DentaQuest Mobile application available! DentaQuest now offers a free and fast way to find a dentist on-the-go with the My DentaQuest Mobile application. You can download the free app from your phone s app store. Search for the word DentaQuest, and follow the instructions. You ll have instant access to a list of participating dentists in your area. Finding a dentist on the go Follow these easy steps to find a DentaQuest dentist Log on to the mobile app. Tap Find a Dentist on the main page. Type in your zip code or city and state. Select your search radius. (How close you want your dentist to be from home) Select your program. This information is on your member id card. Select your specialty. It s best to see a general practitioner (general dentist) before seeing a specialist. Your general dentist will let you know if you need to see a specialist. Click on accepting new patients. Once you find a dentist, you can: Automatically call the dental office Add the dentist s name and phone number to your contacts list Link directly to your phone s navigation system to get step-by-step directions Remember: Before you make an appointment, it s important to ask the dental office if it still accepts your plan. 14

15 Oral Health Education DentaQuest wants to help keep your family s teeth and gums healthy. The My DentaQuest Mobile app gives you tips on important oral health topics, such as: What to do in a dental emergency Proper brushing and flossing tips The purpose of sealants How to prevent baby bottle tooth decay, and more! 15

16 11100 W. Liberty Drive Milwaukee, WI (05/16) HB/EN