Keeping our commitment to you!...Call your perinatal provider’s office first if you need urgent care. The doctor must have his or her phone answered 24 hours a day, seven days a

A peak flow meter and OptiChamber are yours free

as your first line of defense for asthma.

A free cell phone with 500* free monthly minutes are yours to be a first line of defense for

medical emergencies.

We keep you prepared for the game with one free sports

physical.

CHIP Member Handbook

JANUARY 2019

Covering Atascosa, Bandera, Bexar, Comal, Guadalupe, Kendall, Medina and Wilson counties.

Keeping our commitment to you!

12238 Silicon Drive, Ste. 100 San Antonio, TX 78249Member Services: 1-800-434-2347

*For qualifying members SPBD | 12.00185 Rev. 4 01/19

www.cfhp.com Click here to return to the Table of Contents2

For Emergency Services dial 9-1-1 or go to the nearest emergency room!• Regular business phone hours: 8 a.m. - 5 p.m., Central Time• Monday to Friday, except state-approved holidays. • After hours and on weekends, nurses answer the phone to help you.

PHONE NUMBERS

Member Services:Local ..........................................................................(210) 358-6300 Outside Bexar County (toll-free) .............................1-800-434-2347

• Learn how to get access to benefits• English & Spanish• Language Interpreter Services• 24-Hour Nurse Advice Line• If you have an emergency, dial 9-1-1

Local TTY (for hearing impaired) .............................(210) 358-6080

Outside Bexar County TTY (toll-free) ......................1-800-390-1175

Behavioral Health & Substance Abuse Services Crisis Hotline: Toll-free ....................................................................1--877-221-2226

• 24-hours a day, 7 days a week• English & Spanish• Interpreter services available• If you have an emergency, dial 9-1-1

Other Helpful Numbers:CHIP Help Line ..........................................................1-800-647-6558 Eye Care ....................................................................(210) 358-6300

Dental providers:DentaQuest ..............................................................1-800-508-6775 MCNA ........................................................................1-800-494-6262

Addresses:Community First Health Plans has two offices where we can help you:

Main Office at The Oaks - Community First Health Plans 12238 Silicon Drive, Suite 100

San Antonio, TX 78249

Community Office at Avenida Guadalupe - Community First Health Plans 1410 Guadalupe Street, Suite 222


Office HoursOffice hours are 8:30 a.m. to 5 p.m. Monday to Friday, except state-approved holidays.

Visit our website at: www.cfhp.com.

How To Reach U

s


This handbook is for CHIP and CHIP Perinatal Program members. Please read this handbook. It explains the benefits you may receive. It also answers questions about how to get those benefits.

Community First Health Plans (CFHP) is a locally owned and non-profit health plan. Our doctors, hospitals and providers will make sure you get the health care you need.

What if I need help understanding or reading the member handbook? Call Member Services for help. If you need the handbook in audio, larger print, Braille or in another language, just call! A paper copy of this handbook can be mailed to you within 5 business days, free of charge. Call us. Our number is at the bottom of every page.

Member Services Our Member Services Representatives can help you in many ways:

• Help you in English or Spanish, or find an interpreter who speaks your language.• Answer your questions about benefits or where to go for health care.• Help you find services you can get without a referral from your Primary Care Provider, like vision,

behavioral health, gynecology and dental.• Help you change your Primary Care Provider.• Send you a new member ID card if it is lost or stolen.• Solve problems or complaints you may have.• Help you get into health education classes, such as CPR.

ConfidentialityWe are committed to ensuring that your personal health information is secure and confidential. Our doctors and other providers must do the same. Community First’s use of PHI will only be used to administer your health plan and fulfilling state and federal requirements. Your personal health information will not be shared with anyone else. We will not do this without your express written approval. You have the right to access your medical records. You have the right to consent in writing for specific individuals to have access to your PHI. Authorizations that are granted by you will be shared with those individuals specifically noted in your written approval.

Community First has physical, electronic, and procedural safeguards in place to protect your information. Oral, written or electronic information is protected. Community First policies and procedures state all Community First employees must protect the confidentiality of your protected health information (PHI). An employee may only access PHI when they have an appropriate reason to do so. Each employee must sign a statement that he or she understands Community First’s privacy policy. On a yearly basis, Community First will send a notice to employees to remind them of this policy. Any employee who does not follow Community First’s privacy policies is subject to discipline. This can include up to and including dismissal.

For a copy of our Notice of Privacy Practices, please visit our website at www.cfhp.com.

THESE SYMBOLS REPRESENT MEMBER INFORMATION FOR:

CHIP & CHIP Perinatal NewbornCHIP Perinatal NewbornCHIP Perinate (Mom)

Wel

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Com

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How To Reach Us ��2Welcome to Community First Health Plans! ��3

What if I need help understanding or reading the member handbook? ....................................................3Member Services ..........................................................................................................................................3Confidentiality ...............................................................................................................................................3

Table of Contents �� 4CFHP Member ID Card �� 8

What if my ID card is lost or stolen? ............................................................................................................ 8Changing Health Plans For CHIP Members �� 10

What if I want to change health plans? ...................................................................................................... 10Who do I call? ............................................................................................................................................... 10

Changing Health Plans For CHIP Perinatal Members �� 10What If I want to change health plans? ...................................................................................................... 10Who do I call? ............................................................................................................................................... 10How many times can I change health plans? ............................................................................................. 10When will my health plan change become effective? ................................................................................11Can CFHP ask that I get dropped from their health plan (for non-compliance, etc.)?..............................11

Concurrent Enrollment of Family Members in the CHIP and CHIP Perinatal Programs, and Medicaid Coverage for Certain Newborns ��11Primary Care Providers for CHIP Members & CHIP Perinatal Newborn Members �� 12

What is a Primary Care Provider? ............................................................................................................... 12What do I need to bring to my/my child’s doctor’s appointment? ........................................................... 12Can a clinic be my/my child’s Primary Care Provider? ............................................................................... 12How can I change my/my child’s Primary Care Provider? ......................................................................... 12How many times can I change my/my child’s Primary Care Provider? ...................................................... 12When will a Primary Care Provider change become effective? ................................................................. 13Are there any reasons why my request to change a Primary Care Provider may be denied? ................. 13What if I choose to go to another doctor who is not my/my child’s Primary Care Provider? ................. 13Can my Primary Care Provider move me or my child to another Primary Care Provider?. ...................... 13How do I get medical care after my/my child’s Primary Care Provider’s office is closed? ....................... 13What about Physician Incentive Plans? ...................................................................................................... 13

Benefits for CHIP Members and CHIP Perinate Newborn Members �� 14What are the CHIP program benefits? Are there any limits to any covered services? ............................. 14What services are not covered? ................................................................................................................. 26Durable Medical Equipment (DME)/Supplies ............................................................................................27

Benefits for CHIP Perinate Newborn Members ��32What are the CHIP Perinate Newborn benefits? .......................................................................................32What services are not covered? ..................................................................................................................42Durable Medical Equipment (DME)/SUPPLIES ......................................................................................... 43How do I get these services/how do I get these services for my child? .................................................. 48What benefits does my baby receive at birth?.......................................................................................... 48What extra benefits does a member of CFHP get? .................................................................................. 48How can I get these benefits/how can I get these benefits for my child? ............................................... 48What are co-payments? How much are they and when do I have to pay for them? .............................. 48

Health Care and Other Services for CHIP Members and CHIP Perinate Newborn Members ��50What is routine medical care? ................................................................................................................... 50How soon can I expect to be seen/how soon can I expect my child to be seen? ................................... 50What is urgent medical care? ..................................................................................................................... 50How soon can I expect to be seen/how soon can I expect my child to be seen? .................................. 50What is an Emergency, an Emergency Medical Condition, and an Emergency Behavioral Health Condition?............................................................................................. 50What is Emergency Services or Emergency Care? ..................................................................................... 51

Table of Contents


How soon can I expect to be seen? ............................................................................................................51Are Emergency Dental Services Covered? .................................................................................................51What do I do if I need/my child needs Emergency Dental Care? ...............................................................51What is post-stabilization? ..........................................................................................................................51

Health Care and Other Services for CHIP Members and CHIP Perinatal Members �� 52What does Medically Necessary mean? .................................................................................................... 52What if I get sick when I am out of town or traveling/what if my child gets sick when he or she is out of town or traveling? .................................................................................................. 52What if I am/my child is out of the state? ................................................................................................. 52What if I am/my child is out of the country? ............................................................................................. 53What is a referral? ...................................................................................................................................... 53What services do not need a referral? ....................................................................................................... 53What if I need/my child needs to see a special doctor (specialist)? ........................................................ 53How soon can I expect to be seen by a specialist/how soon can I expect my child to be seen by a specialist? ..................................................................................................................... 53Can I get a second opinion? ....................................................................................................................... 53How do I get help if I have/my child has behavioral (mental) health or drug problems? Do I need a referral for this? .................................................................................................................. 53What are my prescription drug benefits? .................................................................................................. 54How do I get my/my child’s medications? ................................................................................................. 54How do I find a network drug store? ......................................................................................................... 54What if I go to a drug store not in the network? ...................................................................................... 54What do I bring with me to the drug store? ............................................................................................. 54What if I need my medications delivered to me? ...................................................................................... 54Who do I call if I have problems getting my medications? ....................................................................... 54What if I can’t get the medication my/my child’s doctor ordered approved? ........................................ 55What if I lose my medication(s)? ............................................................................................................... 55How Do I Find Out What Drugs Are Covered? .......................................................................................... 55How Do I transfer My Prescriptions to a Network Pharmacy? ................................................................ 55Will I Have a Copay? .................................................................................................................................... 55How Do I Get My Medicine If I Am Traveling? ........................................................................................... 55What If I Paid Out of Pocket For a Medicine and Want To Be Reimbursed? ........................................... 56What If I Need Durable Medical Equipment or Other Products Normally Found in a Pharmacy? ............................................................................................................ 56What if I need/my child needs an over the counter medication?............................................................. 56

For CHIP Members and CHIP Perinate Newborn Members �� 56What if I need/my child needs birth control pills? ..................................................................................... 56How do I get eye care services/how do I get eye care services for my child? ......................................... 56How do I get dental services for my child? .............................................................................................. 56Can someone interpret for me when I talk with my/my child’s doctor? ................................................. 56Who do I call for an interpreter? How can I get a face-to-face interpreter in the provider’s office? ......................................................................................................................... 56How far in advance do I need to call? ........................................................................................................ 56What if I need/my daughter needs OB/GYN care? Do I have the right to choose an OB/GYN? .............. 57How do I choose an OB/GYN? .................................................................................................................... 57If I don’t choose an OB/GYN, do I have direct access? ............................................................................. 57Will I need a referral? .................................................................................................................................. 57How soon can I/my daughter be seen after contacting an OB/GYN for an appointment? ..................... 57Can I/my daughter stay with an OB/GYN who is not with CFHP? ............................................................. 57What if I am pregnant/what if my daughter is pregnant (FOR CHIP MEMBERS)? ................................. 57Who do I need to call? ................................................................................................................................ 57What other services/activities/education does CFHP offer pregnant women? ....................................... 57

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Who do I call if I have/my child has special health care needs and I need someone to help me? .......... 57What if I get a bill from my doctor? ........................................................................................................... 58Who do I call? What information will they need? ..................................................................................... 58What do I have to do if I move? ................................................................................................................ 58

Member Rights and Responsibilities for CHIP Members and CHIP Perinate Newborn Members �� 58Member Rights ........................................................................................................................................... 58Member Responsibilities ........................................................................................................................... 59

Providers for CHIP Perinate Members ��60What do I need to bring to a Perinatal Provider’s appointment? ............................................................60Can a clinic be a Perinatal Provider? ..........................................................................................................60How do I get after hours care? ..................................................................................................................60

Benefits for CHIP Perinate Members ��61What are my unborn child’s CHIP Perinatal benefits? ...............................................................................61How do I get these services? .....................................................................................................................69What services are not covered? .................................................................................................................69What are my unborn child’s prescription drug benefits? ..........................................................................71How much do I have to pay for my health care under CHIP Perinatal? ....................................................71Will I have to pay extra for services that are not covered benefits? ........................................................71What extra benefits does CFHP offer? .......................................................................................................71How can I get these benefits? ....................................................................................................................71

Health Care and Other Services for CHIP Perinate Members �� 71What is routine medical care? ....................................................................................................................71How soon can I expect to be seen? ............................................................................................................71What is urgent medical care? ..................................................................................................................... 72How soon can I expect to be seen? .......................................................................................................... 72What is an Emergency and an Emergency Medical Condition? ............................................................... 72What is Emergency Services and/or Emergency Care? ............................................................................. 72How soon can I expect to be seen? ........................................................................................................... 72How do I get medical care after my Primary Care Provider’s office is closed? ........................................ 72What if I get sick when I am out of town or traveling? ............................................................................ 72What if I am out of the state? ................................................................................................................... 73What if I am out of the country? ................................................................................................................ 73What is a referral? ...................................................................................................................................... 73What services within the network do not need a referral? ...................................................................... 73What if I need services that are not covered by CHIP Perinatal? ............................................................. 73How do I get my medications? .................................................................................................................. 73How do I find a network drug store? ......................................................................................................... 73What if I go to a drug store not in the network? ...................................................................................... 73What do I bring with me to the drug store? ............................................................................................. 74What if I need my medications delivered to me? ...................................................................................... 74Who do I call if I have problems getting my medications? ....................................................................... 74What if I lose my medication(s)? ............................................................................................................... 74Can someone interpret for me when I talk with my perinatal provider? ................................................ 74Who do I call for an interpreter? How can I get a face-to-face interpreter in the provider’s office? ..... 74How far in advance do I need to call? ........................................................................................................ 74How do I choose a perinatal provider? Will I need a referral? .................................................................. 74How soon can I be seen after contacting a perinatal provider for an appointment? ............................. 74Can I stay with a perinatal provider if they are not with CFHP? ............................................................... 74What other services/activities/education does CFHP offer? .................................................................... 74What if I get a bill from a perinatal provider? ........................................................................................... 74Who do I call? What information will they need? ..................................................................................... 74What do I have to do if I move? ................................................................................................................ 75

Table of Contents


Member Rights and Responsibilities for CHIP Perinate Members �� 75Member Rights ........................................................................................................................................... 75Member Responsibilities ........................................................................................................................... 76When does CHIP Perinatal coverage end? ................................................................................................ 76Will the state send me anything when CHIP Perinatal coverage ends? .................................................. 76How does renewal work? .......................................................................................................................... 76What benefits does my baby receive at birth?.......................................................................................... 76Can I choose my baby’s Primary Care Provider before the baby is born? ............................................... 76Who do I call? What information do they need? ....................................................................................... 77

Health Education Classes �� 77What health education classes does CFHP offer? ..................................................................................... 77Get moving for better health: ................................................................................................................... 77Have an exercise routine: ......................................................................................................................... 77Healthy eating: .......................................................................................................................................... 78Social/mental health: ................................................................................................................................. 78

Utilization Management Process �� 78How to Obtain Information About the UM Process and Authorization of Care �� 78

What should I do if I have a complaint? Who do I call? Can someone from CFHP help me file a complaint? ....................................................................................................................... 78If I am not satisfied with the outcome, who else can I contact? ............................................................. 79How long will it take to process my complaint? ....................................................................................... 79What are the requirements and timeframes for filing a complaint? ....................................................... 79What if I am not satisfied with the outcome, who else can I contact? .................................................... 79Do I have the right to meet with the complaint appeal panel? ...............................................................80

Process to Appeal a CHIP Adverse Determination ��80What can I do if my doctor asks for a service or medicine for me that’s covered but CFHP denies or limits it? .........................................................................................................................80How will I find out if services are denied? .................................................................................................80When do I have the right to ask for an appeal? Does my request have to be in writing? Can someone from CFHP help me file an appeal? ................................................................................80What are the timeframes for the appeal process? ...................................................................................80What if the services I need are for an emergency or I am in the hospital? .............................................80What is an expedited appeal? ....................................................................................................................80What are the timeframes for an expedited appeal? .................................................................................80How do I ask for an expedited appeal? Who can help me in filing an appeal? Does my request have to be in writing? ................................................................................................80What happens if CFHP denies the request for an expedited appeal? ......................................................81

Independent Review Organization Process��81What is an Independent Review Organization? .........................................................................................81How do I ask for a review by an Independent Review Organization? ......................................................81What are the timeframes for this process? ................................................................................................81What if I am not happy with the final decision? .........................................................................................81

New Medical Technology �� 82Fraud and Abuse: Report CHIP Waste, Abuse, or Fraud �� 83

Do you want to report CHIP Waste, Abuse, or Fraud? How do I report someone who is misusing/abusing the Program or services? .............................................................................. 83

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You will get a CFHP ID card for each person enrolled in the plan. If you do not get a card, call Member Services. We will send you a card. Your card will list:

• Your name or your child’s name• Member ID number• Your effective date• Your Primary Care Provider’s name, address, and phone number• Your copayments (for CHIP members only. CHIP Perinatal members do

not have a copayment)• What to do in an emergency• How to reach Member Services• How to get help in Spanish

Carry this card with you at all times. Show the ID card to your doctor so they know you are covered by the CHIP Program.

What if my ID card is lost or stolen?Call CFHP Member Services and a member advocate will send you a new one. You also can request a new Member ID card through our secure member portal on the CFHP website, www.cfhp.com.

CFHP Mem

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CFHP

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www.cfhp.com | (210) 358-63009

CFHP Mem

ber ID CardDirections for what to do in an emergency� In case of an emergency call 911 or go to the closest emergency room. After treatment, call your child’s PCP within 24 hours or as soon as possible.Instrucciones en caso de emergencia� En caso de emergencia, llame al 911 o vaya a la sala de emergencias más cercana. Después del tratamiento, llame al PCP de su hijo dentro de 24 horas o tan pronto como sea posible.Member Services Department (24 hours/7 days a week) inside Bexar County (210) 358-6300TDD (210) 358-6080, Toll-Free 1-800-434-2347, TDD 1-800-390-1175

Departamento de Servicios para Miembros (las 24 horas del dia/7 dias a la semana) Dentro del condado de Bexar (210) 358-6300, Linea TDD (210) 358-6080, Gratis 1-800-434-2347, Linea TDD 1-800-390-1175

Behavioral Health | Servicios de Salud Mental Crisis Hotline (Toll-Free), Linea en caso de crisis (gratis): 1-877-221-2226, 24 hours/7 days a week, 24 horas al dia/7 dias a la semanaNotice to Hospitals and Other Providers: All inpatient admissions require pre-authorization, except in the case of emergency. Please call CFHP within 24 hours at (210) 358-6050 or fax to (210) 358-6040.

RX Group: CFG Pharmacy Help Desk: 1-877-908-6023

BIN#: 610602 PCN: MCD

Submit professional/other claims to:Community First Health Plans - Claims12238 Silicon Drive, Suite 100, San Antonio, Texas 78249 For electronic claims submit to Availity: Payer ID = COMMF

H E A L T H P L A N S

CHIP

TDI Navitus Health Solutions BIN:610602

Name:

Member No: Group No. <Effective Date>

Primary Care Physician:

<PCP Ph. #:>

Co-Payments: There are no co-payments or cost sharing. | Copagos: No hay copagos ni paticipación en los gastos.

Perinatal NewbornH E A L T H P L A N S

CHIP


Name:

Member No: <Effective Date>

Division No:

Primary Care Physician:

<PCP Ph. #:>


Directions for what to do in an emergency� In case of an emergency call 911 or go to the closest emergency room. After treatment, call your child’s PCP within 24 hours or as soon as possible.Instrucciones en caso de emergencia� En caso de emergencia, llame al 911 o vaya a la sala de emergencias más cercana. Después del tratamiento, llame al PCP de su hijo dentro de 24 horas o tan pronto como sea posible.Member Services Department (24 hours/7 days a week) inside Bexar County (210) 358-6300TDD (210) 358-6080, Toll-Free 1-800-434-2347, TDD 1-800-390-1175



RX Group#: CFG Pharmacy Information: 1-877-908-6023









Perinatal 306 MomH E A L T H P L A N S

CHIP


Name:


Division No:







Submit professional/other claims to:Community First Health Plans - Claims12238 Silicon Drive, Suite 100, San Antonio, Texas 78249

Submit hospital claims to:Texas Medicaid & Healthcare Partnership Claims

PO Box 200555, Austin, Texas 78720-0555For electronic claims submit to Availity: Payer ID = COMMF

H E A L T H P L A N S

Perinatal 305 MomH E A L T H P L A N S

CHIP


Name:


Division No:



FOR CHIP MEMBERS

What if I want to change health plans?You are allowed to make health plan changes:

• For any reason within 90 days of enrollment in CHIP and once thereafter;• for cause at any time;• if you move to a different service delivery area; and• during the annual CHIP re-enrollment period.

Who do I call?For more information, call CHIP toll-free at 1-800-647-6558.

FOR CHIP PERINATAL MEMBERS

• Attention: If you meet certain Income requirements, your baby will be moved to Medicaid and get 12 months of continuous Medicaid coverage from date of birth.

• Your baby will continue to receive services through the CHIP program if you meet the CHIP Perinatal requirements. Your baby will get 12 months of continuous CHIP Perinatal Program coverage through his or her health plan, beginning with the month of enrollment as an unborn child.

What If I want to change health plans?• Once you pick a health plan for your unborn child, the child must stay in this health plan until the

child’s CHIP Perinatal Program coverage ends. The 12 month CHIP Perinatal coverage begins when your unborn child is enrolled in CHIP Perinatal Program and continues after your child is born.

• If you live in an area with more than one CHIP Perinatal Program health plan, and you do not pick a plan within 15 days of getting the enrollment packet, HHSC will pick a health plan for your unborn child and send you information about that health plan. If HHSC picks a health plan for your unborn child, you will have 90 days to pick another health plan if you are not happy with the plan HHSC chooses.

• If you have children covered by CHIP, their health plans might change once you are approved for CHIP Perinatal coverage. When a member of the family is approved for CHIP Perinatal coverage and picks a perinatal health plan, all children in the family that are enrolled in CHIP must join the health plan providing the CHIP Perinatal services. The children must remain with the same health plan until the end of the CHIP Perinatal member’s enrollment period, or the end of the other children’s enrollment period, whichever happens last. At that point, you can pick a different health plan for the children.

• You can ask to change health plans: ¡ for any reason within 90 days of enrollment in CHIP Perinatal; ¡ if you move to a different service delivery area; and ¡ for cause at any time.

Who do I call?For more information, call toll-free at 1-800-647-6558.

How many times can I change health plans?You are allowed to make health plan changes for any reason within 90 days of enrollment in CHIP, for cause at any time, or during the annual re-enrollment period.

Changing Health Plans


When will my health plan change become effective?If you call to change your health plan on or before the 15th of the month, the change will take place on the first day of the next month. If you call after the 15th of the month, the change will take place the first day of the second month after that. For example:

• If you call on or before April 15, your change will take place on May 1.• If you call after April 15, your change will take place on June 1.

Can CFHP ask that I get dropped from their health plan (for non-compliance, etc�)?We can ask to drop you if you do any of these things:

• Move out of our service area.• You are not able to get Medicaid.• Enter a hospice or long-term care facility.• You do not follow CFHP policies and procedures.• Let someone else use your CFHP Member ID card.• You are rude, abusive or you do not work with CFHP staff, primary care providers, other providers, or

their staff.

CONCURRENT ENROLLMENT OF FAMILY MEMBERS IN THE CHIP AND CHIP PERINATAL PROGRAMS, AND MEDICAID COVERAGE FOR CERTAIN NEWBORNS

If you are a CHIP Perinatal member and have children covered by CHIP, they will continue to receive CHIP benefits, but will be moved to the same health plan that is providing the CHIP Perinatal coverage. Co-payments, cost-sharing, and enrollment fees still apply for those children enrolled in the CHIP Program.

Families at or below 185% of the Federal Poverty Level:If you are pregnant and in the CHIP Perinatal Program, your baby will be moved to Medicaid for 12 months of continuous Medicaid coverage when he or she is born.

Families above 185% to 200% of the Federal Poverty Level:If you are pregnant and in the CHIP Perinatal Program, your baby will continue to get coverage through the CHIP Program as a “CHIP Perinate Newborn” when he or she is born.

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PRIMARY CARE PROVIDERS FOR CHIP MEMBERS AND CHIP PERINATE NEWBORN MEMBERS

References to “you,” “my,” or “I” apply if you are a CHIP member. References to “my child” apply if your child is a CHIP member or a CHIP Perinate Newborn Member.

What is a Primary Care Provider? The Primary Care Provider is your/your child’s own doctor or clinic. The Primary Care Provider will take care of your/your child’s medical needs. If a specialist or tests are needed, the Primary Care Provider will ask for them. Your/your child’s Primary Care Provider must be available, in person or by phone, 24 hours a day, seven days a week. Or they must have another doctor on call. If you/your child has a serious medical condition, you may ask for a specialist to be the Primary Care Provider. This has to be approved by CFHP. The specialist also must be willing to be your/your child’s Primary Care Provider.

What do I need to bring to my/my child’s doctor’s appointment?Bring your/your child’s CHIP ID card. Also bring any other information about your/his/her health care needs. This includes any prescriptions for you/your child.

Can a clinic be my/my child’s Primary Care Provider? Yes. Choose one of the Rural Health Clinics or Federally Qualified Health Centers from our CHIP Provider Directory.

How can I change my/my child’s Primary Care Provider? For a list of physicians and providers in the CFHP network, visit our website at www.cfhp.com. This list is updated every two weeks. You can also call Member Services if you have questions about a physician’s professional qualifications or for the most current information about the provider network. Call us at (210) 358-6300 or toll-free at 1-800-434-2347. An Advocate can help you pick a new primary care provider. You can also ask to change your primary care provider through our secure member portal on CFHP’s website at www.cfhp.com. Click on “Member Portal Login.” Click on “Contact Us,” then on “Send a secure request to Member Services.” Fill out the “Member Contact Us” form and hit “submit.”

How many times can I change my/my child’s Primary Care Provider?There is no limit on how many times you can change your or your child’s primary care provider. You can change primary care providers by calling us toll-free at 1-800-434-2347 or writing to:

Community First Health Plans Attention: Member Services 12238 Silicon Drive, Suite 100


You may also request a change on our website through our secure member portal at www.cfhp.com.

When will a Primary Care Provider change become effective?• If you ask to change by the 15th of any month, you can start seeing the new Primary Care Provider the

first day of the next month.• If you ask to change after the 15th of the month, you will have to wait until the first day of the second

month.• Until then, your old Primary Care Provider must approve any hospital or special

care for you.

Prim

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bers & CHIP Perinate N

ewborn M

embers


Here is an example:• If you change your Primary Care Provider on or before August 15, you can start seeing the new

Primary Care Provider on September 1.• If you ask to change after August 15, you must wait until October 1 to see your new Primary Care

Provider.

Are there any reasons why my request to change a Primary Care Provider may be denied?CFHP may deny your Primary Care Provider request if:

• The Primary Care Provider you picked does not provide in the care you need. • The Primary Care Provider you picked is no longer accepting new patients.• You are in the hospital at the time you make the request.

What if I choose to go to another doctor who is not my/my child’s Primary Care Provider? If you choose to go to another doctor, you may be asked to pay the bill. Or, you also may be asked to sign a form that says you will pay the bill. It will be much better for you to go to your/your child’s Primary Care Provider.

Can my Primary Care Provider move me or my child to another Primary Care Provider?Yes, for these reasons:

• You miss three appointments in a row and don’t call ahead of time.• You do not follow the doctor’s advice.• You are rude or do not work with your child’s doctor or the office staff.

The Primary Care Provider, however, must refer to the health plan. You have the right to appeal.

How do I get medical care after my/my child’s Primary Care Provider’s office is closed?Call your Primary Care Provider’s office first if your child has an urgent problem. The doctor must have his or her phone answered 24 hours a day, seven days a week. You also may call CFHP’s after-hours nurse advice line at (210) 358-6300. You may also call toll-free at 1-800-434-2347. A nurse will talk to you. The nurse can send you to urgent care. In an emergency, go to the nearest ER!

What about Physician Incentive Plans?A physician incentive plan rewards doctors for treatments that reduce or limit services for people covered by CHIP. Right now, CFHP does not have a physician incentive plan.

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BENEFITS FOR CHIP MEMBERS AND CHIP PERINATE NEWBORN MEMBERS

References to “you,” “my,” or “I” apply if you are a CHIP Member. References to “my child” apply if your child is a CHIP Member or a CHIP Perinate Newborn Member.

What are the CHIP Program benefits? Are there any limits to any covered services?The following benefits are for CHIP members. For more information about the health plan, continue on page 26.

Covered Benefits Limitations Co-paymentsInpatient General Acute and Inpatient Rehabilitation Hospital Services

Services include:• Hospital-provided Physician or

Provider services• Semi-private room and board (or private if medically

necessary as certified by attending)• General nursing care• Special duty nursing when

medically necessary• ICU and services• Patient meals and special diets• Operating, recovery and other

treatment rooms• Anesthesia and administration (facility technical

component)• Surgical dressings, trays, casts, splints• Drugs, medications and biologicals• Blood or blood products that are not provided free-

of-charge to the patient and their administration• X-rays, imaging and other radiological tests (facility

technical component)• Laboratory and pathology services (facility technical

component)• Machine diagnostic tests (EEGs, EKGs, etc.)• Oxygen services and inhalation therapy• Radiation and chemotherapy• Access to DSHS-designated Level III perinatal centers

or Hospitals meeting equivalent levels of care• In-network or out-of-network facility and Physician

services for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated delivery by caesarian section.

• Hospital, physician and related medical services, such as anesthesia, associated with dental care.

• Requires authorization for non-Emergency Care and care following stabilization of an Emergency Condition.

• Requires authorization for in-network or out-of-network facility and Physician services for a mother and her newborn(s) after 48 hours following an uncomplicated vaginal delivery and after 96 hours following an uncomplicated delivery by caesarian section.

Applicable level of inpatient co-payment per admission.

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Covered Benefits Limitations Co-payments• Inpatient services associated with (a) miscarriage

or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero.) Inpatient services associated with miscarriage or non-viable pregnancy include, but are not limited to:

¡ dilation and curettage (D&C) procedures; ¡ appropriate provider-administered medications; ¡ ultrasounds; and ¡ histological examination of tissue samples.

• Pre-surgical or post-surgical orthodontic services for medically necessary treatment of craniofacial anomalies requiring surgical intervention and delivered as part of a proposed and clearly outlined treatment plan to treat:

¡ cleft lip and/or palate; or ¡ severe traumatic, skeletal and/or congenital craniofacial deviations; or

¡ severe facial asymmetry secondary to skeletal defects, congenital syndromal conditions and/or tumor growth or its treatment.

• Surgical implants• Other artificial aids including surgical implants• Inpatient services for a mastectomy and breast

reconstruction include: ¡ all stages of reconstruction on the affected breast; ¡ surgery and reconstruction on the other breast to produce symmetrical appearance; and

¡ treatment of physical complications from the mastectomy and treatment of lymphedemas.

• Implantable devices are covered under Inpatient and Outpatient services and do not count towards the DME 12 month period limit.

Skilled Nursing Facilities (Includes Rehabilitation Hospitals)

Services include, but are not limited to, the following:• Semi-private room and board• Regular nursing services• Rehabilitation services• Medical supplies and use of appliances and

equipment furnished by the facility

• Requires authorization and physician prescription.

• 60 days per 12-month period limit.

None

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Covered Benefits Limitations Co-paymentsOutpatient Hospital, Comprehensive Outpatient Rehabilitation Hospital, Clinic (Including Health Center) and Ambulatory Health Care Center

Services include, but are not limited to, the following services provided in a hospital clinic or emergency room, a clinic or health center, hospital-based emergency department or an ambulatory health care setting:• X-ray, imaging, and radiological tests (technical

component)• Laboratory and pathology services (technical

component)• Machine diagnostic tests• Ambulatory surgical facility services• Drugs, medications and biologicals• Casts, splints, dressings• Preventive health services• Physical, occupational and speech therapy• Renal dialysis• Respiratory services• Radiation and chemotherapy• Blood or blood products that are not provided free-

of-charge to the patient and the administration of these products

• Facility and related medical services, such as anesthesia, associated with dental care, when provided in a licensed ambulatory surgical facility.

• Outpatient services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero). Outpatient services associated with miscarriage or non-viable pregnancy include, but are not limited to:


• May require prior authorization and physician prescription.

Applicable level of co-payment for generic drugs and for brand drugs.

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Covered Benefits Limitations Co-payments• Pre-surgical or post-surgical orthodontic services

for medically necessary treatment of craniofacial anomalies requiring surgical intervention and delivered as part of a proposed and clearly outlined treatment plan to treat:



• Surgical implants• Other artificial aids including surgical implants• Outpatient services provided at an outpatient

hospital and ambulatory health care center for a mastectomy and breast reconstruction as clinically appropriate, include:

¡ all stages of reconstruction on the affected breast;

¡ surgery and reconstruction on the other breast to produce symmetrical appearance; and


• Implantable devices are covered under Inpatient and Outpatient services and do not count towards the DME 12 month period limit

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Covered Benefits Limitations Co-paymentsPhysician/Physician Extender Professional Services

Services include, but are not limited to the following:• American Academy of Pediatrics recommended well-

child exams and preventive health services (including but not limited to vision and hearing screening and immunizations)

• Physician office visits, in-patient and outpatient services

• Laboratory, x-rays, imaging and pathology services, including technical component and/or professional interpretation

• Medications, biologicals and materials administered in Physician’s office

• Allergy testing, serum and injections• Professional component (in/outpatient) of surgical

services, including: ¡ Surgeons and assistant surgeons for surgical procedures including appropriate follow-up care

¡ Administration of anesthesia by Physician (other than surgeon) or CRNA

¡ Second surgical opinions ¡ Same-day surgery performed in a Hospital without an over-night stay

¡ Invasive diagnostic procedures such as endoscopic examinations

• Hospital-based Physician services (including Physician-performed technical and interpretive components)

• Physician and professional services for a mastectomy and breast reconstruction include:

¡ all stages of reconstruction on the affected breast; ¡ surgery and reconstruction on the other breast to produce symmetrical appearance; and


• May require authorization for specialty services.

Applicable level of co-payment for office visits.

• In-network and out-of-network Physician services for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated delivery by caesarian section.

• Physician services medically necessary to support a dentist providing dental services to a CHIP member such as general anesthesia or intravenous (IV) sedation.

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Covered Benefits Limitations Co-payments• Physician services associated with (a) miscarriage

or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero). Physician services associated with miscarriage or non-viable pregnancy include, but are not limited to:





Birthing Center Services • Covers birthing services provided by a licensed birthing center. Limited to facility services (e.g., labor and delivery)

None

Services rendered by a Certified Nurse Midwife or physician in a licensed birthing center�

• Covers prenatal, birthing, and postpartum services rendered in a licensed birthing center.

None

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Covered Benefits Limitations Co-paymentsDurable Medical Equipment (DME), Prosthetic Devices and Disposable Medical Supplies

Covered services include DME (equipment that can withstand repeated use and is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of Illness, Injury, or Disability, and is appropriate for use in the home), including devices and supplies that are medically necessary and necessary for one or more activities of daily living and appropriate to assist in the treatment of a medical condition, including but not limited to:• Orthotic braces and orthotics• Dental Devices• Prosthetic devices such as artificial eyes, limbs,

braces, and external breast prostheses• Prosthetic eyeglasses and contact lenses for the

management of severe ophthalmologic disease• Other artificial aids including surgical implants • Hearing aids• Implantable devices are covered under Inpatient

and Outpatient services and do not count towards the DME 12-month period limit.

• Diagnosis-specific disposable medical supplies, including diagnosis-specific prescribed specialty formula and dietary supplements.


• $20,000 per 12-month period limit for DME, prosthetics, devices and disposable medical supplies (implantable devices, diabetic supplies and equipment are not counted against this cap).

None

Home and Community Health Services

Services that are provided in the home and community, including, but not limited to:• Home infusion• Respiratory therapy• Visits for private duty nursing (R.N., L.V.N.)• Skilled nursing visits as defined for home health

purposes (may include R.N. or L.V.N.). • Home health aide when included as part of a plan

of care during a period that skilled visits have been approved.

• Speech, physical and occupational therapies.

• Requires prior authorization and physician prescription.

• Services are not intended to replace the CHILD’S caretaker or to provide relief for the caretaker.

• Skilled nursing visits are provided on intermittent level and not intended to provide 24-hour skilled nursing services.

• Services are not intended to replace 24-hour inpatient or skilled nursing facility services.

None

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Covered Benefits Limitations Co-payments

Inpatient Mental Health Services

Mental health services, including for serious mental illness, furnished in a free-standing psychiatric hospital, psychiatric units of general acute care hospitals and state operated facilities, including but not limited to: • Neuropsychological and psychological testing.

• Requires prior authorization for non-emergency services.

• Does not require PCP referral.

• When inpatient psychiatric services are ordered by a court of competent jurisdiction under the provisions of Chapters 573 and 574 of the Texas Health and Safety Code, relating to court ordered commitments to psychiatric facilities, the court order serves as binding determination of medical necessity. Any modification or termination of services must be presented to the court with jurisdiction over the matter for determination.

Applicable level of inpatient co-payment.

Outpatient Mental Health Services

Mental health services, including for serious mental illness, provided on an outpatient basis, including, but not limited to: • The visits can be furnished in a variety of

community-based settings (including school and home-based) or in a state-operated facility.

• Neuropsychological and psychological testing• Medication management• Rehabilitative day treatments• Residential treatment services• Sub-acute outpatient services (partial

hospitalization or rehabilitative day treatment)

• Skills training (psycho-educational skill development)

• May require prior authorization.


• When outpatient psychiatric services are ordered by a court of competent jurisdiction under the provisions of Chapters 573 and 574 of the Texas Health and Safety Code, relating to court ordered commitments to psychiatric facilities, the court order serves as binding determination of medical necessity. Any modification or termination of services must be presented to the court with jurisdiction over the matter for determination.


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Covered Benefits Limitations Co-payments• A Qualified Mental

Health Provider – Community Services (QMHP-CS), is defined by the Texas Department of State Health Services (DSHS) in Title 25 T.A.C., Part I, Chapter 412, Subchapter G, Division 1), §412.303(48). QMHP-CSs shall be providers working through a DSHS-contracted Local Mental Health Authority or a separate DSHS-contracted entity. QMHP-CSs shall be supervised by a licensed mental health professional or physician and provide services in accordance with DSHS standards. Those services include individual and group skills training (that can be components of interventions such as day treatment and in-home services), patient and family education, and crisis services.

Inpatient Substance Abuse Treatment Services

Inpatient substance abuse treatment services include, but are not limited to:• Inpatient and residential substance abuse

treatment services including detoxification and crisis stabilization, and 24-hour residential rehabilitation programs�




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Covered Benefits Limitations Co-paymentsOutpatient Substance Abuse Treatment Services

Outpatient substance abuse treatment services include, but are not limited to, the following:• Prevention and intervention services that are

provided by physician and non-physician providers, such as screening, assessment and referral for chemical dependency disorders.

• Intensive outpatient services• Partial hospitalization• Intensive outpatient services is defined as an

organized non-residential service providing structured group and individual therapy, educational services, and life skills training that consists of at least 10 hours per week for four to 12 weeks, but less than 24 hours per day.

• Outpatient treatment service is defined as consisting of at least one to two hours per week providing structured group and individual therapy, educational services, and life skills training.



Applicable level of co-payment for office visit

Rehabilitation Services

Habilitation (the process of supplying a child with the means to reach age-appropriate developmental milestones through therapy or treatment) and rehabilitation services include, but are not limited to the following:• Physical, occupational and speech therapy• Developmental assessment


None

Hospice Care Services

Services include, but are not limited to:• Palliative care, including medical and support

services, for those children who have six months or less to live, to keep patients comfortable during the last weeks and months before death

• Treatment services, including treatment related to the terminal illness, are unaffected by electing hospice care services.


• Services apply to the hospice diagnosis.

• Up to a maximum of 120 days with a 6 month life expectancy.

• Patients electing hospice services may cancel this election at anytime.

None

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Covered Benefits Limitations Co-paymentsEmergency Services, including Emergency Hospitals, Physicians, and Ambulance Services

Health Plan cannot require authorization as a condition for payment for Emergency Conditions or labor and delivery.

Covered services include:• Emergency services based on prudent lay person

definition of emergency health condition• Hospital emergency department room and ancillary

services and physician services 24 hours a day, 7 days a week, both by in-network and out-of-network providers

• Medical screening examination • Stabilization services• Access to DSHS designated Level 1 and Level II

trauma centers or hospitals meeting equivalent levels of care for emergency services

• Emergency ground, air and water transportation• Emergency dental services, limited to fractured or

dislocated jaw, traumatic damage to teeth, and removal of cysts

• Requires authorization for post-stabilization services.

Applicable level of co-payment for non-emergency ER.

Transplants

Covered services include:• Using up-to-date FDA guidelines, all non-

experimental human organ and tissue transplants and all forms of non-experimental corneal, bone marrow and peripheral stem cell transplants, including donor medical expenses.

• Requires authorization. None

Vision Benefit

Covered services include:• One examination of the eyes to determine the

need for and prescription for corrective lenses per 12-month period, without authorization

• One pair of non-prosthetic eyewear per 12-month period

• The health plan may reasonably limit the cost of the frames/lenses.

• Does not require authorization for protective and polycarbonate lenses when medically necessary as part of a treatment plan for covered diseases of the eye.

Applicable level of co-payment for office visit.

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Covered Benefits Limitations Co-paymentsChiropractic Services

Covered services do not require physician prescription and are limited to spinal subluxation

• Does not require authorization for twelve visits per 12-month period limit (regardless of number of services or modalities provided in one visit).

• Requires authorization for additional visits.

Applicable level of co-payment for office visit.

Tobacco Cessation Program

Covered up to $100 for a 12-month period limit for a plan approved program

• Does not require authorization.

• Health Plan defines plan-approved program.

• May be subject to formulary requirements.

None

Value-added Services

• Extra vision benefits.• A prescription discount card your whole family can use.• Free sports and school physicals.• 24-hour Nurse Advice Line.• Bus tokens for doctor visits or health classes.• Weight management program.• Member gift card programs.• Healthy Expectations Prenatal program.• Smoking cessation program.• Asthma kit.• Emergency advice kit.• Diabetes program incentive.• Adult lifestyle classes.• Newborn & postpartum classes for new fathers.• MP3 player with health podcast.• Expectant mommy baby shower.• New mommy mingle & advice meetings.• Low-cost dental referrals.• Temporary phone help.• Post-discharge incentives.• Free toddler booster seats.

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• Bike safety & repair class.• Zumba classes.• Notary services.• Personal counseling from registered nurse for asthma, diabetes, pregnancy, and behavioral health. • 10$ gift card upon enrollment into Community First’s AsthmaMatters Program• $10 gift card upon completion of asthma education sessions• Free gift for attending classes for new fathers• Free birthing classes• Home visits for high-risk pregnant women• Online member focused mental health resources

Covered Benefits (cont.)

What services are not covered?• Inpatient and outpatient infertility treatments or reproductive services other than prenatal care,

labor and delivery, and care related to disease, illnesses, or abnormalities related to the reproductive system.

• Contraceptive medications prescribed only for the purpose of primary and preventive reproductive health care (i.e. cannot be prescribed for family planning).

• Personal comfort items including but not limited to personal care kits provided on inpatient admission, telephone, television, newborn infant photographs, meals for guests of patient, and other articles that are not required for the specific treatment of sickness or injury.

• Experimental and/or investigational medical, surgical or other health care procedures or services that are not generally employed or recognized within the medical community. This exclusion is an adverse determination and is eligible for review by an Independent Review Organization (as described in D, “External Review by Independent Review Organization”).

• Treatment or evaluations required by third parties including, but not limited to, those for schools, employment, flight clearance, camps, insurance or court.

• Dental devices solely for cosmetic purposes.• Private duty nursing services when performed on an inpatient basis or in a skilled nursing facility.• Mechanical organ replacement devices including, but not limited to artificial heart• Hospital services and supplies when confinement is solely for diagnostic testing purposes, unless

otherwise pre-authorized by Health Plan.• Prostate and mammography screening.• Elective surgery to correct vision.• Gastric procedures for weight loss.• Cosmetic surgery/services solely for cosmetic purposes.• Out-of-network services not authorized by the Health Plan except for emergency care and physician


• Services, supplies, meal replacements or supplements provided for weight control or the treatment of obesity, except for the services associated with the treatment for morbid obesity as part of a treatment plan approved by the Health Plan.

• Medications prescribed for weight loss or gain.• Acupuncture services, naturopathy and hypnotherapy.• Immunizations solely for foreign travel.• Routine foot care such as hygienic care (routine foot care does not include treatment injury or

complications of diabetes).

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• Diagnosis and treatment of weak, strained, or flat feet and the cutting or removal of corns, calluses and toenails (this does not apply to the removal of nail roots or surgical treatment of conditions underlying corns, calluses or ingrown toenails).

• Replacement or repair of prosthetic devices and durable medical equipment due to misuse, abuse or loss when confirmed by the Member or the vendor.

• Corrective orthopedic shoes.• Convenience items.• Over-the-counter medications.• Orthotics primarily used for athletic or recreational purposes.• Custodial care (care that assists a child with the activities of daily living, such as assistance in

walking, getting in and out of bed, bathing, dressing, feeding, toileting, special diet preparation, and medication supervision that is usually self-administered or provided by a parent. This care does not require the continuing attention of trained medical or paramedical personnel.) This exclusion does not apply to hospice services.

• Housekeeping.• Public facility services and care for conditions that federal, state, or local law requires be provided in a

public facility or care provided while in the custody of legal authorities.

• Services or supplies received from a nurse, that do not require the skill and training of a nurse • Vision training and vision therapy.• Reimbursement for school-based physical therapy, occupational therapy, or speech therapy services

are not covered except when ordered by a Physician/PCP.• Donor non-medical expenses.• Charges incurred as a donor of an organ when the recipient is not covered under this health plan.• Coverage while traveling outside of the United States and U.S. Territories (including Puerto Rico, U.S.

Virgin Islands, Commonwealth of Northern Mariana Islands, Guam, and American Samoa).

DURABLE MEDICAL EQUIPMENT (DME)/SUPPLIES

SUPPLIES COVERED EXCLUDED COMMENTS/MEMBER CONTRACT PROVISIONSAce Bandages

X Exception: If provided by and billed through the clinic or home care agency it is covered as an incidental supply.

Alcohol, rubbing

X Over-the-counter supply.

Alcohol, swabs (diabetic)

X Over-the-counter supply not covered, unless RX provided at time of dispensing.

Alcohol, swabs

X Covered only when received with IV therapy or central line kits/supplies.

Ana Kit X A self-injection kit used by patients highly allergic to bee stings.Arm Sling X Dispensed as part of office visit.Attends (Diapers)

X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan.

Bandages XBasal X Over-the-counter supply.

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SUPPLIES COVERED EXCLUDED COMMENTS/MEMBER CONTRACT PROVISIONSBatteries – initial

X For covered DME items.

Batteries – X For covered DME when replacement is necessary due to normal use.

Betadine X See IV therapy supplies.Books XClinitest X For monitoring of diabetes.Colostomy Bags

See Ostomy Supplies.

XX Over-the-counter supply. Contraceptives are not covered

under the plan.Cranial Head Mold

X

Dental Devices

X Coverage limited to dental devices used for the treatment of craniofacial anomalies, requiring surgical intervention.

Diabetic Supplies

X Monitor calibrating solution, insulin syringes, needles, lancets, lancet device, and glucose strips.

Diapers/ X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan.

Diaphragm X Contraceptives are not covered under the plan.Diastix X For monitoring diabetes.Diet, Special

X

Distilled Water

X

Dressing Supplies/Central Line

X Syringes, needles, Tegaderm, alcohol swabs, Betadine swabs or ointment, tape. Many times these items are dispensed in a kit when includes all necessary items for one dressing site change.

Dressing Supplies/Decubitus

X Eligible for coverage only if receiving covered home care for wound care.

Dressing Supplies/Peripheral IV Therapy

X Eligible for coverage only if receiving home IV therapy.

Dressing Supplies/Other

X

Dust Mask X

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SUPPLIES COVERED EXCLUDED COMMENTS/MEMBER CONTRACT PROVISIONSEar Molds X Custom made, post inner or middle ear surgery.Electrodes X Eligible for coverage when used with a covered DME.Enema Supplies


Enteral Nutrition Supplies

X Necessary supplies (e.g., bags, tubing, connectors, catheters, etc.) are eligible for coverage. Enteral nutrition products are not covered except for those prescribed for hereditary metabolic disorders, a non-function or disease of the structures that normally permit food to reach the small bowel, or malabsorption due to disease.

Eye Patches

X Covered for patients with amblyopia.

Formula X Exception: Eligible for coverage only for chronic hereditary metabolic disorders a non-function or disease of the structures that normally permit food to reach the small bowel; or malabsorption due to disease (expected to last longer than 60 days when prescribed by the physician and authorized by plan.) Physician documentation to justify prescription of formula must include:• Identification of a metabolic disorder, dysphagia that

results in a medical need for a liquid diet, presence of a gastrostomy, or disease resulting in malabsorption that requires a medically necessary nutritional product.

Does not include formula:• For members who could be sustained on an age-appropriate

diet.• Traditionally used for infant feeding.• In pudding form (except for clients with documented

oropharyngeal motor dysfunction who receive greater than 50 percent of their daily caloric intake from this product).

• For the primary diagnosis of failure to thrive, failure to gain weight, or lack of growth or for infants less than twelve months of age unless medical necessity is documented and other criteria, listed above, are met.

Food thickeners, baby food, or other regular grocery products that can be blenderized and used with an enteral system that are not medically necessary, are not covered, regardless of whether these regular food products are taken orally or parenterally.

Gloves X Exception: Central line dressings or wound care provided by home care agency.

Hydrogen Peroxide


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SUPPLIES COVERED EXCLUDED COMMENTS/MEMBER CONTRACT PROVISIONSHygiene Items

X


Insulin Pump (External) Supplies

X Supplies (e.g., infusion sets, syringe reservoir and dressing, etc.) are eligible for coverage if the pump is a covered item.

Irrigation Sets, Wound Care

X Eligible for coverage when used during covered home care for wound care.

Irrigation Sets, Urinary

X Eligible for coverage for individual with an indwelling urinary catheter.

IV Therapy Supplies

X Tubing, filter, cassettes, IV pole, alcohol swabs, needles, syringes and any other related supplies necessary for home IV therapy.

K-Y Jelly X Over-the-counter supply.Lancet Device

X Limited to one device only.

Lancets X Eligible for individuals with diabetes.Med Ejector

X

Needles and Syringes/Diabetic

See Diabetic Supplies.

Needles and Syringes/IV and Central Line

See IV Therapy and Dressing Supplies/Central Line.

Needles and Syringes/Other

X Eligible for coverage if a covered IM or SubQ medication is being administered at home.

Normal Saline

See Saline, Normal.

Novopen X

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SUPPLIES COVERED EXCLUDED COMMENTS/MEMBER CONTRACT PROVISIONSOstomy Supplies

X Items eligible for coverage include: belt, pouch, bags, wafer, face plate, insert, barrier, filter, gasket, plug, irrigation kit/sleeve, tape, skin prep, adhesives, drain sets, adhesive remover, and pouch deodorant. Items not eligible for coverage include: scissors, room deodorants, cleaners, rubber gloves, gauze, pouch covers, soaps, and lotions.

Parenteral Nutrition/Supplies

X Necessary supplies (e.g., tubing, filters, connectors, etc.) are eligible for coverage when the Health Plan has authorized the parenteral nutrition.

Saline, Normal

X Eligible for coverage:a) when used to dilute medications for nebulizer treatments;b) as part of covered home care for wound care;c) for indwelling urinary catheter irrigation.

Stump Sleeve

X

Stump Socks

X

Suction Catheters

X

Syringes See Needles/Syringes.Tape See Dressing Supplies, Ostomy Supplies, IV Therapy Supplies.

X Cannulas, Tubes, Ties, Holders, Cleaning Kits, etc. are eligible for coverage.

Under Pads See Diapers/Incontinent Briefs/Chux.Unna Boot X Eligible for coverage when part of wound care in the home

setting. Incidental charge when applied during office visit.Urinary, External Catheter & Supplies

X Exception: Covered when used by incontinent male where injury to the urethra prohibits use of an indwelling catheter ordered by the PCP and approved by the plan.

Urinary, Indwelling Catheter & Supplies

X Cover catheter, drainage bag with tubing, insertion tray, irrigation set and normal saline if needed.

Urinary, X Cover supplies needed for intermittent or straight catherization.

Urine Test Kit

X When determined to be medically necessary.

Urostomy supplies


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What are the CHIP Perinate Newborn benefits?The following benefits are for CHIP Perinate newborn members. For more information about the health plan, continue on page 42.

Covered Benefits Limitations Co-payments*Inpatient General Acute and Inpatient Rehabilitation Hospital Services

Services include:• Hospital-provided Physician or Provider services• Semi-private room and board (or private if

medically necessary as certified by attending)• General nursing care• Special duty nursing when medically necessary• ICU and services• Patient meals and special diets• Operating, recovery and other treatment rooms• Anesthesia and administration (facility technical

component)• Surgical dressings, trays, casts, splints• Drugs, medications and biologicals• Blood or blood products that are not provided free-

of-charge to the patient and their administration• X-rays, imaging and other radiological tests (facility

technical component)• Laboratory and pathology services (facility technical

component)• Machine diagnostic tests (EEGs, EKGs, etc.)• Oxygen services and inhalation therapy• Radiation and chemotherapy• Access to DSHS-designated Level III perinatal

centers or Hospitals meeting equivalent levels of care

• In-network or out-of-network facility and Physician services for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated delivery by caesarian section.

• Hospital, physician and related medical services, such as anesthesia, associated with dental care.

• Surgical implants. • Other artificial aids including surgical implants

• Requires authorization for non-Emergency Care and care following stabilization of an Emergency Condition.

• Requires authorization for in-network or out-of-network facility and Physician services for a mother and her newborn(s) after 48 hours following an uncomplicated vaginal delivery and after 96 hours following an uncomplicated delivery by caesarian section.

None

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Covered Benefits Limitations Co-payments*• Inpatient services for a mastectomy and breast

reconstruction include: ¡ all stages of reconstruction on the affected breast; ¡ surgery and reconstruction on the other breast to produce symmetrical appearance; and


• Implantable devices are covered under Inpatient and Outpatient services and do not count towards the DME 12-month period limit.




Skilled Nursing Facilities (Includes Rehabilitation Hospitals)

Services include, but are not limited to, the following:• Semi-private room and board• Regular nursing services• Rehabilitation services• Medical supplies and use of appliances and

equipment furnished by the facility


• 60 days per 12-month period limit.

None

Outpatient Hospital, Comprehensive Outpatient Rehabilitation Hospital, Clinic (Including Health Center) and Ambulatory Health Care Center

Services include but are not limited to the following services provided in a hospital clinic or emergency room, a clinic or health center, hospital-based emergency department or an ambulatory health care setting:• X-ray, imaging, and radiological tests (technical


component)• Machine diagnostic tests• Ambulatory surgical facility services

• May require authorization and physician prescription.

None

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Covered Benefits Limitations Co-payments*• Drugs, medications and biologicals• Casts, splints, dressings• Preventive health services• Physical, occupational and speech therapy• Renal dialysis• Respiratory services• Radiation and chemotherapy• Blood or blood products that are not provided free-

of-charge to the patient and the administration of these products

• Facility and related medical services, such as anesthesia, associated with dental care, when provided in a licensed ambulatory surgical facility,

• Surgical implants. • Other artificial aids including surgical implants • Outpatient services provided at an outpatient

hospital and ambulatory health care center for a mastectomy and breast reconstruction as clinically appropriate, include:

¡ all stages of reconstruction on the affected breast;

¡ surgery and reconstruction on the other breast to produce symmetrical appearance; and


• Implantable devices are covered under Inpatient and Outpatient services and do not count towards the DME 12-month period limit.





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Covered Benefits Limitations Co-payments*Physician/Physician Extender Professional Services

Services include, but are not limited to the following:• American Academy of Pediatrics recommended well-child

exams and preventive health services (including but not limited to vision and hearing screening and immunizations)

• Physician office visits, in-patient and out-patient services• Laboratory, x-rays, imaging and pathology services,

including technical component and/or professional interpretation

• Medications, biologicals and materials administered in Physician’s office

• Allergy testing, serum and injections• Professional component (in/outpatient) of surgical services,

including: ¡ Surgeons and assistant surgeons for surgical procedures including appropriate follow-up care


¡ Second surgical opinions ¡ Same-day surgery performed in a Hospital without an over-night stay

¡ Invasive diagnostic procedures such as endoscopic examinations


• Physician and professional services for a mastectomy and breast reconstruction include:

¡ all stages of reconstruction on the affected breast; ¡ surgery and reconstruction on the other breast to produce symmetrical appearance; and


• In-network and out-of-network Physician services for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated delivery by caesarian section.

• Physician services medically necessary to support a dentist providing dental services to a CHIP member such as general anesthesia or intravenous (IV) sedation.


None

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Covered Benefits Limitations Co-payments*• Pre-surgical or post-surgical orthodontic services

for medically necessary treatment of craniofacial anomalies requiring surgical intervention and delivered as part of a proposed and clearly outlined treatment plan to treat:



Services rendered by a Certified Nurse Midwife or physician in a licensed birthing center�

• Covers services rendered to a newborn immediately following delivery.

None

Durable Medical Equipment (DME), Prosthetic Devices and Disposable Medical Supplies

Covered services include DME (equipment that can withstand repeated use and is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of Illness, Injury, or Disability, and is appropriate for use in the home), including devices and supplies that are medically necessary and necessary for one or more activities of daily living and appropriate to assist in the treatment of a medical condition, including but not limited to:• Orthotic braces and orthotics• Dental devices• Prosthetic devices such as artificial eyes, limbs,

braces, and external breast prostheses • Prosthetic eyeglasses and contact lenses for the

management of severe ophthalmologic disease• Hearing aids• Diagnosis-specific disposable medical supplies,

including diagnosis-specific prescribed specialty formula and dietary supplements. (See Attachment A)


• $20,000 12-month period limit for DME, prosthetics, devices and disposable medical supplies (diabetic supplies and equipment are not counted against this cap).

None


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Covered Benefits Limitations Co-payments*Home and Community Health Services

Services that are provided in the home and community, including, but not limited to:• Home infusion• Respiratory therapy• Visits for private duty nursing (R.N., L.V.N.)• Skilled nursing visits as defined for home health

purposes (may include R.N. or L.V.N.). • Home health aide when included as part of a plan of

whatcare during a period that skilled visits have been approved.

• Speech, physical and occupational therapies.


• Services are not intended to replace the CHILD’S caretaker or to provide relief for the caretaker.

• Skilled nursing visits are provided on intermittent level and not intended to provide 24- hour skilled nursing services.

• Services are not intended to replace 24-hour inpatient or skilled nursing facility services.

None

Inpatient Mental Health Services

Mental health services, including for serious mental illness, furnished in a free-standing psychiatric hospital, psychiatric units of general acute care hospitals and state-operated facilities, including, but not limited to:• Neuropsychological and psychological testing.



• When inpatient psychiatric services are ordered by a court of competent jurisdiction under the provisions of Chapters 573 and 574 of the Texas Health and Safety Code, relating to court ordered commitments to psychiatric facilities, the court order serves as binding determination of medical necessity. Any modification or termination of services must be presented to the court with jurisdiction over the matter for determination.

None

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Covered Benefits Limitations Co-payments*Outpatient Mental Health Services

Mental health services, including for serious mental illness, provided on an outpatient basis, including, but are not limited to:• The visits can be furnished in a

variety of community-based settings (including school and home-based) or in a state-operated facility.

• Neuropsychological and psychological testing

• Medication management• Rehabilitative day treatments• Residential treatment services• Sub-acute outpatient services (partial

hospitalization or rehabilitative day treatment)

• Skills training (psycho-educational skill development

• May require prior authorization.• Does not require PCP referral.• When outpatient psychiatric services

are ordered by a court of competent jurisdiction under the provisions of Chapters 573 and 574 of the Texas Health and Safety Code, relating to court ordered commitments to psychiatric facilities, the court order serves as binding determination of medical necessity. Any modification or termination of services must be presented to the court with jurisdiction over the matter for determination.

• A Qualified Mental Health Provider – Community Services (QMHP-CS), is defined by the Texas Department of State Health Services (DSHS) in Title 25 T.A.C., Part I, Chapter 412 Subchapter G, Division 1, §412.303(31). QMHP-CSs shall be providers working through a DSHS-contracted Local Mental Health Authority or a separate DSHS-contracted entity. QMHP-CSs shall be supervised by a licensed mental health professional or physician and provide services in accordance with DSHS standards. Those services include individual and group skills training that can be components of interventions such as day treatment and in-home services), patient and family education, and crisis services.

None


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Covered Benefits Limitations Co-payments*Inpatient Substance Abuse Treatment Services

Inpatient substance abuse treatment services include, but are not limited to:• Inpatient and residential substance abuse treatment

services including detoxification and crisis stabilization, and 24-hour residential rehabilitation programs.



None

Outpatient Substance Abuse Treatment Services

Outpatient substance abuse treatment services include, but are not limited to the following:• Prevention and intervention services that are

provided by physician and non-physician providers, such as screening, assessment and referral for chemical dependency disorders.

• Intensive outpatient services• Partial hospitalization• Intensive outpatient services is defined as an

organized non-residential service providing structured group and individual therapy, educational services, and life skills training that consists of at least 10 hours per week for four to 12 weeks, but less than 24 hours per day.

• Outpatient treatment service is defined as consisting of at least one to two hours per week providing structured group and individual therapy, educational services, and life skills training.



None

Rehabilitation Services

Services include, but are not limited to, the following:• Habilitation (the process of supplying a child with

the means to reach age-appropriate developmental milestones through therapy or treatment) and rehabilitation services include, but are not limited to the following:

• Physical, occupational and speech therapy• Developmental assessment


None

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Covered Benefits Limitations Co-payments*Hospice Care Services

Services include, but are not limited to:• Palliative care, including medical and support

services, for those children who have six months or less to live, to keep patients comfortable during the last weeks and months before death

• Treatment services, including treatment related to the terminal illness, are unaffected by electing hospice care services.


• Services apply to the hospice diagnosis.

• Up to a maximum of 120 days with a 6-month life expectancy.

• Patients electing hospice services may cancel this election at anytime.

None

Emergency Services, Including Emergency Hospitals, Physicians, and Ambulance Services

Health Plan cannot require authorization as a condition for payment for Emergency Conditions or labor and delivery.

Covered services include but are not limited to the following:• Emergency services based on prudent lay person

definition of emergency health condition• Hospital emergency department room and ancillary

services and physician services 24 hours a day, 7 days a week, both by in-network and out-of-network providers

• Medical screening examination • Stabilization services• Access to DSHS designated Level 1 and Level II

trauma centers or hospitals meeting equivalent levels of care for emergency services

• Emergency ground, air and water transportation• Emergency dental services, limited to fractured or

dislocated jaw, traumatic damage to teeth, and removal of cysts.

• Requires authorization for post-stabilization services.

None

Transplants

Services include but are not limited to the following:• Using up-to-date FDA guidelines, all non-

experimental human organ and tissue transplants and all forms of non-experimental corneal, bone marrow and peripheral stem cell transplants, including donor medical expenses.

• Requires authorization. None


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Covered Benefits Limitations Co-payments*Vision Benefit

Services include:• One examination of the eyes to determine

the need for and prescription for corrective lenses per 12-month period, without authorization

• One pair of non-prosthetic eyewear per 12-month period

• The health plan may reasonably limit the cost of the frames/lenses.

• Does not require authorization for protective and polycarbonate lenses when medically necessary as part of a treatment plan for covered diseases of the eye.

None

Chiropractic Services

Covered services do not require physician prescription and are limited to spinal subluxation

• Does not require authorization for twelve visits per 12-month period limit (regardless of number of services or modalities provided in one visit).

• Requires authorization for additional visits.

None

Tobacco Cessation Program

Covered up to $100 for a 12- month period limit for a plan approved program

• Does not require authorization.• Health Plan defines plan-

approved program.• May be subject to formulary

requirements.

None

Case Management and Care Coordination Services

• These services include outreach, informing, case management, care coordination and community referral.

None

[Value-added services]

• A prescription discount card your whole family can use.

• 24-hour Nurse Advice Line.• Bus tokens for doctor visits or health classes.• Free flu shots for CHIP Perinatal members.• Healthy Expectations Prenatal program.• Newborn & postpartum classes for new

fathers.• MP3 player with health podcast.• Expectant mommy baby shower.• New mommy mingle & advice meetings.• Temporary phone help.• Post-discharge incentives.• Free toddler booster seats.• Notary services.

None

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WHAT SERVICES ARE NOT COVERED?

All of the following exclusions match those found in the CHIP program�• Inpatient and outpatient infertility treatments or reproductive services other than prenatal care,

labor and delivery, and care related to disease, illnesses, or abnormalities related to the reproductive system.

• Contraceptive medications prescribed only for the purpose of primary and preventive reproductive health care (i.e. cannot be prescribed for family planning).

• Personal comfort items including but not limited to personal care kits provided on inpatient admission, telephone, television, newborn infant photographs, meals for guests of patient, and other articles that are not required for the specific treatment of sickness or injury.



• Private duty nursing services when performed on an inpatient basis or in a skilled nursing facility.• Mechanical organ replacement devices including, but not limited to artificial heart.• Hospital services and supplies when confinement is solely for diagnostic testing purposes, unless

otherwise pre-authorized by Health Plan.• Prostate and mammography screening.• Elective surgery to correct vision.• Gastric procedures for weight loss.• Cosmetic surgery/services solely for cosmetic purposes.• Dental devices solely for cosmetic purposes.• Out-of-network services not authorized by the Health Plan except for emergency care and physician


• Services, supplies, meal replacements or supplements provided for weight control or the treatment of obesity, except for the services associated with the treatment for morbid obesity as part of a treatment plan approved by the Health Plan.

• Medications prescribed for weight loss or gain.• Acupuncture services, naturopathy and hypnotherapy.• Immunizations solely for foreign travel.• Routine foot care such as hygienic care (routine foot care does not include treatment injury or

complications of diabetes).• Diagnosis and treatment of weak, strained, or flat feet and the cutting or removal of corns, calluses

and toenails (this does not apply to the removal of nail roots or surgical treatment of conditions underlying corns, calluses or ingrown toenails).

• Replacement or repair of prosthetic devices and durable medical equipment due to misuse, abuse or loss when confirmed by the Member or the vendor.

• Corrective orthopedic shoes.• Convenience items.• Over-the-counter medications.• Orthotics primarily used for athletic or recreational purposes.


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• Custodial care (care that assists a child with the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, toileting, special diet preparation, and medication supervision that is usually self-administered or provided by a parent. This care does not require the continuing attention of trained medical or paramedical personnel.) This exclusion does not apply to hospice.


public facility or care provided while in the custody of legal authorities.• Services or supplies received from a nurse, do not require the skill and training of a nurse. • Vision training and vision therapy.• Reimbursement for school-based physical therapy, occupational therapy, or speech therapy services

are not covered except when ordered by a Physician/PCP.• Donor non-medical expenses.• Charges incurred as a donor of an organ when the recipient is not covered under this health plan.• Coverage while traveling outside of the United States and U.S. Territories (including Puerto Rico, U.S.


DURABLE MEDICAL EQUIPMENT (DME)/SUPPLIES

Note: DME/SUPPLIES are not a covered benefit for CHIP Perinate Members but are a benefit for CHIP Perinate Newborns�

SUPPLIES COVERED EXCLUDED COMMENTS/MEMBER CONTRACT PROVISIONS

Ace Bandages X Exception: If provided by and billed through the clinic or home care agency it is covered as an incidental supply.

Alcohol, rubbing X Over-the-counter supply.Alcohol, swabs (diabetic)

X Over-the-counter supply not covered, unless RX provided at time of dispensing.

Alcohol, swabs X Covered only when received with IV therapy or central line kits/supplies.

Ana Kit Epinephrine

X A self-injection kit used by patients highly allergic to bee stings.

Arm Sling X Dispensed as part of office visit.Attends (Diapers)


Bandages XBasal Thermometer


Batteries – initial X For covered DME items.Batteries – replacement

X For covered DME when replacement is necessary due to normal use.

Betadine X See IV therapy supplies.

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Books XClinitest X For monitoring of diabetes.Colostomy Bags See Ostomy Supplies.Communication Devices

X

Contraceptive Jelly

X Over-the-counter supply. Contraceptives are not covered under the plan.

Cranial Head Mold

X

Dental Devices X Coverage limited to dental devices used for treatment of craniofacial anomalies requiring surgical intervention.

Diabetic Supplies X Monitor calibrating solution, insulin syringes, needles, lancets, lancet device, and glucose strips.

Diapers/Incontinent Briefs/Chux


Diaphragm X Contraceptives are not covered under the plan.Diastix X For monitoring diabetes.Diet, Special XDistilled Water XDressing Supplies/Central Line

X Syringes, needles, Tegaderm, alcohol swabs, Betadine swabs or ointment, tape. Many times these items are dispensed in a kit when includes all necessary items for one dressing site change.

Dressing Supplies/Decubitus

X Eligible for coverage only if receiving covered home care for wound care.

Dressing Supplies/Peripheral IV Therapy

X Eligible for coverage only if receiving home IV therapy.

Dressing Supplies/Other

X

Dust Mask XEar Molds X Custom made, post inner or middle ear surgery.Electrodes X Eligible for coverage when used with a covered DME.Enema Supplies X Over-the-counter supply.


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Enteral Nutrition Supplies

X Necessary supplies (e.g., bags, tubing, connectors, catheters, etc.) are eligible for coverage. Enteral nutrition products are not covered except for those prescribed for hereditary metabolic disorders, a non-function or disease of the structures that normally permit food to reach the small bowel, or malabsorption due to disease.

Eye Patches X Covered for patients with amblyopia.Formula X Exception: Eligible for coverage only for chronic

hereditary metabolic disorders a non-function or disease of the structures that normally permit food to reach the small bowel; or malabsorption due to disease (expected to last longer than 60 days when prescribed by the physician and authorized by plan.) Physician documentation to justify prescription of formula must include:• Identification of a metabolic disorder, dysphagia

that results in a medical need for a liquid diet, presence of a gastrostomy, or disease resulting in malabsorption that requires a medically necessary nutritional product

Does not include formula:• For members who could be sustained on an age-

appropriate diet.• Traditionally used for infant feeding• In pudding form (except for clients with

documented oropharyngeal motor dysfunction who receive greater than 50 percent of their daily caloric intake from this product)

• For the primary diagnosis of failure to thrive, failure to gain weight, or lack of growth or for infants less than twelve months of age unless medical necessity is documented and other criteria, listed above, are met.

Food thickeners, baby food, or other regular grocery products that can be blenderized and used with an enteral system that are not medically necessary, are not covered, regardless of whether these regular food products are taken orally or parenterally.

Gloves X Exception: Central line dressings or wound care provided by home care agency.

Hydrogen Peroxide


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Hygiene Items XIncontinent Pads X Coverage limited to children age 4 or over only when

prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan.

Insulin Pump (External) Supplies

X Supplies (e.g., infusion sets, syringe reservoir and dressing, etc.) are eligible for coverage if the pump is a covered item.

Irrigation Sets, Wound Care

X Eligible for coverage when used during covered home care for wound care.

Irrigation Sets, Urinary

X Eligible for coverage for individual with an indwelling urinary catheter.

IV Therapy Supplies

X Tubing, filter, cassettes, IV pole, alcohol swabs, needles, syringes and any other related supplies necessary for home IV therapy.

K-Y Jelly X Over-the-counter supply.Lancet Device X Limited to one device only.Lancets X Eligible for individuals with diabetes.Med Ejector XNeedles and Syringes/Diabetic

See Diabetic Supplies.

Needles and Syringes/IV and Central Line

See IV Therapy and Dressing Supplies/Central Line.

Needles and Syringes/Other

X Eligible for coverage if a covered IM or SubQ medication is being administered at home.

Normal Saline See Saline, Normal.Novopen XOstomy Supplies X Items eligible for coverage include: belt, pouch,

bags, wafer, face plate, insert, barrier, filter, gasket, plug, irrigation kit/sleeve, tape, skin prep, adhesives, drain sets, adhesive remover, and pouch deodorant. Items not eligible for coverage include: scissors, room deodorants, cleaners, rubber gloves, gauze, pouch covers, soaps, and lotions.

Parenteral Nutrition/Supplies

X Necessary supplies (e.g., tubing, filters, connectors, etc.) are eligible for coverage when the Health Plan has authorized the parenteral nutrition.


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Saline, Normal X Eligible for coverage:a) when used to dilute medications for nebulizer

treatments;b) as part of covered home care for wound care;c) for indwelling urinary catheter irrigation.

Stump Sleeve XStump Socks XSuction Catheters

X

Syringes See Needles/Syringes.Tape See Dressing Supplies, Ostomy Supplies, IV Therapy

Supplies.Tracheostomy Supplies

X Cannulas, Tubes, Ties, Holders, Cleaning Kits, etc. are eligible for coverage.

Under Pads See Diapers/Incontinent Briefs/Chux.Unna Boot X Eligible for coverage when part of wound care in

the home setting. Incidental charge when applied during office visit.

Urinary, External Catheter & Supplies

X Exception: Covered when used by incontinent male where injury to the urethra prohibits use of an indwelling catheter ordered by the PCP and approved by the plan.

Urinary, Indwelling Catheter & Supplies

X Cover catheter, drainage bag with tubing, insertion tray, irrigation set and normal saline if needed.

Urinary, Intermittent

X Cover supplies needed for intermittent or straight catherization.

Urine Test Kit X When determined to be medically necessary.Urostomy supplies


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How do I get these services/how do I get these services for my child?Call Member Services. We’ll be happy to explain how you or your child can obtain these services.

What benefits does my baby receive at birth?Your baby will receive benefits under the CHIP Program as outlined in this member handbook.

What extra benefits does a member of CFHP get? • Extra vision benefits (CHIP members)• A prescription discount card your whole family can use (CHIP and CHIP Perinatal members)• Free sports physicals (CHIP members)• 24-hour Nurse Advice Line (CHIP and CHIP Perinatal members)• Bus tokens for doctor visits or health classes (CHIP and CHIP Perinatal members)• Weight management program (CHIP members)• Member gift card programs (CHIP members)• Free flu shots for CHIP Perinatal members• Healthy Expectations Prenatal program (CHIP and CHIP Perinatal members)• Smoking cessation program (CHIP members)• Asthma kit (CHIP members)• Asthma pillow cover (CHIP members)• Emergency advice kit (CHIP members)• Diabetes program incentive (CHIP members)• Adult lifestyle classes (CHIP members)• Newborn & postpartum classes for new fathers (CHIP and CHIP Perinatal members)• MP3 player with health podcast (CHIP and CHIP Perinatal members)• Expectant mommy baby shower (CHIP Perinatal members)• New mommy mingle & advice meetings (CHIP Perinatal members)• Low-cost dental referrals (CHIP members)• Temporary phone help (CHIP and CHIP Perinatal members)• Post-discharge incentives (CHIP and CHIP Perinatal members)• Free toddler booster seats (CHIP and CHIP Perinatal members)• Bike safety & repair class (CHIP members)• Zumba classes (CHIP members)• Notary services (CHIP and CHIP Perinatal members)• $10 gift card upon enrollment into Community First’s AsthmaMatters Program• $10 gift card upon completion of asthma education sessions

How can I get these benefits/how can I get these benefits for my child?Call Member Services. We’ll be happy to explain how you or your child can obtain these services.

What are co-payments? How much are they and when do I have to pay for them?Co-payments for medical services or prescription drugs are paid at the time your child receives services. Some services have no co-payments. Your child’s CHIP ID card lists his or her co-payments. Be sure to present the ID card when you seek services for your child. There are some limits to how much your family pays for co-payments. See the following chart.


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CHIP COST-SHARINGEnrollment Fees (for 12-month enrollment period): Charge:At or below 150% of FPL* $0Above 150% up to and including 185% of FPL $35Above 185% up to and including 200% of FPL $50

Co-Pays (per visit): Charge:At or below 100% of FPLOffice Visit $3Non-Emergency ER $3Generic Drug $0Brand Drug $3Facility Co-Pay, Inpatient $15Cost-sharing Cap 5% (of family's income)***Above 100% up to and including 150% FPLOffice Visit $5Non-Emergency ER $5Generic Drug $0Brand Drug $5Facility Co-Pay, Inpatient (per admission) $35Cost-sharing Cap 5% (of family's income)***Above 150% up to and including 185% FPLOffice Visit $20Non-Emergency ER $75Generic Drug $10Brand Drug $35Facility Co-Pay, Inpatient (per admission) $75Cost-sharing Cap 5% (of family's income)***Above 185% up to and including 200% FPLOffice Visit $25Non-Emergency ER $75Generic Drug $10Brand Drug $35Facility Co-Pay, Inpatient (per admission) $125Cost-sharing Cap 5% (of family's income)***

*The federal poverty level (FPL) refers to income guidelines established annually by the federal govern-ment. ** Effective March 1, 2012, CHIP members will be required to pay an office visit co-payment for each non-preventive dental visit. *** Per 12-month term of coverage.

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Co-payments and enrollment fees do not apply for the following groups:• CHIP Perinate members• CHIP Perinate newborn members• CHIP Native American members• CHIP Alaskan Native members

Also, there is no cost-sharing for all CHIP members the following services:• Well-baby• Well-child• Preventive care• Pregnancy-related care

HEALTH CARE AND OTHER SERVICES FOR CHIP MEMBERS AND CHIP PERINATE NEWBORN MEMBERS References to “you,” “my,” or “I” apply if you are a CHIP member. References to “my child” or “my daughter” apply if your child is a CHIP member or a CHIP Perinate Newborn Member.

What is routine medical care? Routine care is when you or your child goes to the doctor for a checkup. It also means going when you or your child is sick. Immunizations are part of routine care.

How soon can I expect to be seen/how soon can I expect my child to be seen?You can expect your or your child’s Primary Care Provider will see you, him or her within two weeks after you call for a routine appointment.

What is urgent medical care?An urgent medical problem is when you or your child is sick or hurt and needs treatment as soon as possible. Call your/your child’s Primary Care Provider first, any time night or day. You may be referred to an urgent care center.

How soon can I expect to be seen/how soon can I expect my child to be seen? You can expect to be seen for urgent care within 24 hours.

FOR CHIP MEMBERS AND CHIP PERINATE NEWBORN MEMBERS

What is an Emergency, an Emergency Medical Condition, and an Emergency Behavioral Health Condition?Emergency care is a covered service. Emergency care is provided for Emergency Medical Conditions and Emergency Behavioral Health Conditions. “Emergency Medical Condition” is a medical condition characterized by sudden acute symptoms, severe enough (including severe pain), that would lead an individual with average knowledge of health and medicine, to expect that the absence of immediate medical care could result in:

• placing the member’s health in serious jeopardy;• serious impairment to bodily functions;• serious dysfunction of any bodily organ or part;• serious disfigurement; or• in the case of a pregnant CHIP member, serious jeopardy to the health of the CHIP member or her

unborn child.

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“Emergency Behavioral Health Condition” means any condition, without regard to the nature or cause of the condition, which in the opinion of an individual, possessing an average knowledge of health and medicine:

• requires immediate intervention or medical attention without which the member would present an immediate danger to himself/herself or others; or

• renders the member incapable of controlling, knowing or understanding the consequences of his/her actions.

What is Emergency Services or Emergency Care?“Emergency Services” and “emergency care” means health care services provided in an in-network or out-of-network hospital emergency department, free-standing emergency medical facility, or other comparable facility by in-network or out-of-network physicians, providers, or facility staff to evaluate and stabilize Emergency Medical Conditions and/or Emergency Behavioral Health Conditions. Emergency services also include any medical screening examination or other evaluation required by state or federal law that is necessary to determine whether an Emergency Medical Condition and/or an Emergency Behavioral Health Condition exists.

How soon can I expect to be seen?You can expect to be seen as soon as is appropriate for your medical condition. For example, life-threatening injuries require immediate attention.


Are Emergency Dental Services Covered?CFHP will pay for some emergency dental services provided in a hospital, urgent care center, or ambulatory surgical center setting, such as services for:

• Treatment of a dislocated jaw.• Treatment of traumatic damage to teeth and supporting structures.• Removal of cysts.• Treatment of oral abscess of tooth or gum origin.• Treatment for craniofacial anomalies.• Drugs for any of the above conditions.

CFHP also covers other dental services your child gets in a hospital, urgent care center, or ambulatory surgical center setting. This includes services from the doctor and other services your child might need, like anesthesia.


What do I do if I need/my child needs Emergency Dental Care?During normal business hours, call your child’s Main Dentist to find out how to get emergency services. If your child needs emergency dental services after the Main Dentist’s office has closed, call us toll-free at 1-800-434-2347.

What is post-stabilization?Post-stabilization care services are services covered by CHIP that keep your condition stable following emergency medical care.

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FOR CHIP MEMBERS AND CHIP PERINATAL MEMBERS

What does Medically Necessary mean?Covered services for CHIP Members, CHIP Perinate Newborn Members, and CHIP Perinate Members must meet the CHIP definition of “Medically Necessary.” A CHIP Perinate member is an unborn child.

Medically Necessary means:1. Health Care Services that are:

a. reasonable and necessary to prevent illnesses or medical conditions, or provide early screening, interventions, and/or treatments for conditions that cause suffering or pain, cause physical deformity or limitations in function, threaten to cause or worsen a disability, cause illness or infirmity of a Member, or endanger life;

b. provided at appropriate facilities and at the appropriate levels of care for the treatment of a Member’s health conditions;

c. consistent with health care practice guidelines and standards that are endorsed by professionally recognized health care organizations or governmental agencies;

d. consistent with the member’s diagnoses; e. no more intrusive or restrictive than necessary to provide a proper balance of safety,

effectiveness, and efficiency;f. are not experimental or investigative; andg. are not primarily for the convenience of the Member or Provider; and

2. Behavioral Health Services that:a. are reasonable and necessary for the diagnosis or treatment of a mental health or chemical

dependency disorder, or to improve, maintain or prevent deterioration of functioning resulting from such a disorder;

b. are in accordance with professionally accepted clinical guidelines and standards of practice in behavioral health care;

c. are furnished in the most appropriate and least restrictive setting in which services can be safely provided;

d. are the most appropriate level or supply of service that can safely be provided;e. could not be omitted without adversely affecting the member’s mental and/or physical health or

the quality of care rendered;f. are not experimental or investigative; andg. are not primarily for the convenience of the Member or Provider.

What if I get sick when I am out of town or traveling/what if my child gets sick when he or she is out of town or traveling? If you/your child needs medical care when traveling, call us toll-free at 1-800-434-2347 and we will help you find a doctor.

If you/your child needs emergency services while traveling, go to a nearby hospital, then call us toll-free at 1-800-434-2347.

What if I am/my child is out of the state? CFHP pays for emergencies anywhere in the United States. If you have an emergency, you don’t have to call your Primary Care Provider first. Just go to the ER. Call your Primary Care Provider within 24 hours of the emergency. If you can’t, call as soon as possible.

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If you are away and have an urgent problem, you must call your Primary Care Provider. You may also call CFHP. We have a Nurse Advice Line available 24 hours a day, 7 days a week. You must call first before getting care. If you need follow-up care, your Primary Care Provider will arrange it. Please return to the CFHP service area if you need follow-up care. If you are too sick to travel back, call 1-800-434-2347 to let CFHP know.

What if I am/my child is out of the country?Medical services performed out of the country are not covered by CHIP.

What is a referral? A referral is when your Primary Care Provider thinks you should see a specialist. It can also be when you need special treatment. Your Primary Care Provider will arrange the services for you. It is important to wait until all the paperwork is complete. It must be done before you go to an appointment for the referral.

Your Primary Care Provider’s office will usually make the appointments for you. If you have any questions about referrals, please call Member Services.

What services do not need a referral?• Behavioral Health Services• OB/GYN Services• Vision exams from an optometrist• Family planning services

Call CFHP if you need assistance finding a provider or to help you schedule an appointment.

What if I need/my child needs to see a special doctor (specialist)? If you need to see a special doctor, your Primary Care Provider will send you. Your Primary Care Provider will send you to someone in the CFHP network.

How soon can I expect to be seen by a specialist/how soon can I expect my child to be seen by a specialist?You should be seen within two weeks when you or your doctor call for an appointment. If you have an urgent problem, you should be seen within 48 hours. Community First doctors must follow certain time frames. Call Member Services for help if you do not get an appointment in this time frame.

Can I get a second opinion?You can get a second opinion. The second doctor must be in our network. Call Member Services for help finding another doctor.

How do I get help if I have/my child has behavioral (mental) health or drug problems? Do I need a referral for this?Call (210) 358-6300 if you child needs to be seen for a mental problem. You can call toll-free at 1-800-434-2347. You can also call if your child has a problem with drugs. You can take your child for behavioral health services. You do not need a referral from your child’s Primary Care Provider.

What are my prescription drug benefits?Most prescription medicines your doctor says you need are covered. Your prescription must be filled by a drug store that takes CHIP. If you have problems getting your prescriptions filled, call us at 1-800-434-2347. A Member Services Advocate will help you.

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How do I get my/my child’s medications?CHIP covers most of the medicine your/your child’s doctor says you need. Your/your child’s doctor will write a prescription so you can take it to the drug store, or may be able to send the prescription for you.

Exclusions include: contraceptive medications prescribed only for the purpose to prevent pregnancy and medications for weight loss or gain.

You may have to pay a co-payment for each prescription filled depending on your income. There are no co-payments required for CHIP Perinate Newborn Members.

Adults as well as children can get as many prescriptions as are medically necessary. CFHP members are not limited to 3 prescriptions per month. For prescription drugs covered by CFHP, you may go to any pharmacy that takes CFHP to have your prescription filled.

It is good to use the same pharmacy each time you need medicine. This way your pharmacist will know about problems that may happen when you take more than one prescription. If you use another pharmacy, you should tell the pharmacist about any other medicines you are taking.

How do I find a network drug store?You can call Member Services at (210) 358-6300 or toll-free at 1-800-434-2347 for help to find a network drug store. You can also find a list of drug stores in the CFHP network on our website. Visit our website at www.cfhp.com.

What if I go to a drug store not in the network?If you go to a drug store that is not in the network, your prescription may not be covered. You may be responsible for the charges of the prescription medication. You will need to take your prescription to a pharmacy that accepts CFHP.

What do I bring with me to the drug store?You should bring your prescription(s) or medicine bottle(s), and your CFHP ID card. Show the card to the drug store.

What if I need my medications delivered to me?You may be able to have your medications brought to you through mail order. CFHP’s partner for pharmacy benefits is Navitus. Their mail order partner is Wellpartner. You may also be able to have your medications delivered to you at home. This can be done by some pharmacies. Please call Member Services to learn more.

Who do I call if I have problems getting my medications?Call Member Services at (210) 358-6300 or toll-free at 1-800-434-2347. We can work with you and your pharmacy to make sure you get the medicine you need.


What if I can’t get the medication my/my child’s doctor ordered approved?If your/your child’s doctor cannot be reached to approve a prescription, your child may be able to get a three-day emergency supply of your/your child’s medication.

Call CFHP at 1-800-434-2347 for help with your medications and refills.

What if I lose my/my child’s medication(s)?Call Member Services for help at (210) 358-6300 or toll-free at 1-800-434-2347.

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How Do I Find Out What Drugs Are Covered?CFHP uses the state Vendor Drug Program (VDP) list of drugs that your doctor can choose from. It includes all medicines covered by Medicaid and CHIP.

To view the Texas Formulary Drug Search, go to: www.txvendordrug.com/formulary/formulary-search.asp.

When there is a generic drug available, it will be covered if it is on the VDP formulary. Generic drugs are equal to brand-name drugs as approved by the Food and Drug Administration (FDA).

Some prescriptions require prior approval. A prior approval drug requires your provider to submit clinical data to support the need for the drug. The pharmacist will notify you if a drug your doctor prescribed requires prior approval. If this happens, contact your provider and ask him/her to submit the request for the medication and the clinical data to CFHP.

Some drugs require step edits. A step edit requires the trial and failure of another drug (s) prior to approving the requested drug. If the pharmacist notifies you that your drug requires step edits, contact your provider and ask if about trying the other medications first.

Your prescription will be filled with a 30-day supply.

How Do I transfer My Prescriptions to a Network Pharmacy?If you need to transfer your prescriptions, all you need to do is:

• Call the nearest network pharmacy and give the needed information to the pharmacist or• Bring your prescription container to the new pharmacy, and they will handle the rest.

Will I Have a Copay?You may have to pay a co-payment for each prescription filled depending on your income.

How Do I Get My Medicine If I Am Traveling?CFHP has network pharmacies in all 50 states. If you need a refill while on vacation, call your doctor for a new prescription to take with you.

What If I Paid Out of Pocket For a Medicine and Want To Be Reimbursed?If you had to pay for a medicine, please contact CFHP at 210-358-6300 or 1-800-434-2347 for assistance with reimbursement.

What If I Need Durable Medical Equipment or Other Products Normally Found in a Pharmacy?Some durable medical equipment and products normally found in a pharmacy are covered. For all members, CFHP pays for nebulizers, ostomy supplies, and other covered supplies and equipment if they are medicalIy necessary. For children (birth through age 20), CFHP pavs for medically necessary prescribed over-the-counter drugs, diapers, formula, and some vitamins and minerals.

Call 210-358-6300 or 1-800-434-2347 for more information about these benefits


What if I need/my child needs an over the counter medication?The pharmacy cannot give you an over the counter medication as part of your/your child’s CHIP benefit. If you need/your child needs an over the counter medication, you will have to pay for it.

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What if I need/my child needs birth control pills?The pharmacy cannot give you/your child birth control pills to prevent pregnancy. You/your child can only get birth control pills if they are needed to treat a medical condition.

How do I get eye care services/how do I get eye care services for my child?Eye care services are covered. Glasses are covered if they are medically necessary. Your child can get one eye exam every year. Call Member Services if you have any questions.

How do I get dental services for my child? Community First Health Plans will pay for some emergency dental services in a hospital or ambulatory surgical center. Community First Health Plans will pay for the following:

• Treatment of a dislocated jaw.• Treatment of traumatic damage to teeth and supporting structures.• Removal of cysts.• Treatment of oral abscess of tooth or gum origin.• Treatment and devices for craniofacial anomalies.

Community First Health Plans covers hospital, physician and related medical services for the above conditions. This includes services from the doctor and other services your child might need, like anesthesia or other drugs.

The CHIP medical benefit provides limited emergency dental coverage for dislocated jaw, traumatic damage to teeth, and removal of cysts; treatment of oral abscess of tooth or gum origin; treatment and devices for craniofacial anomalies; and drugs.

Your child’s CHIP dental plan provides all other dental services, including services that help prevent tooth decay and services that fix dental problems. Call your child’s CHIP dental plan to learn more about the dental services they offer.

Can someone interpret for me when I talk with my/my child’s doctor?Yes.

Who do I call for an interpreter? How can I get a face-to-face interpreter in the provider’s office?Call Member Services and we will arrange for an interpreter to help you during your visit.

How far in advance do I need to call? How can I get a face-to-face interpreter in the providers’ office?Member Services will help you set up the doctor’s visit. They will get someone to go to the visit with you. Please call at least two business days (48 hours) before your/your child’s visit.

What is Early Childhood Intervention?Early Childhood Intervention (ECI) is a program in Texas for families with children, up to three years old, who have disabilities or problems with development. ECI services are offered at no cost to Community First members. Services include: • Evaluation and assessment • Development of an Individual Family Service Plan (IFSP) • Care Management • Translation and interpreter services

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What are some examples of ECI services? • Audiology and vision services • Nursing and nutrition services • Physical therapy • Occupational therapy • Speech-language therapy • Specialized skills training

Do I need a referral for this? Where do I find an ECI provider?Yes, you need a referral to request an evaluation of your child. To find an ECI provider, call Community First at 1-800- 434-2347.


What if I need/my daughter needs OB/GYN care? Do I have the right to choose an OB/GYN?ATTENTION MEMBERS: You have the right to pick an OB/GYN for yourself/your daughter without a referral from your/your daughter’s Primary Care Provider. An OB/GYN can give you:

• One well-woman checkup each year.• Care related to pregnancy.• Care for any female medical condition.• Referral to special doctor (specialist) within the network.

CFHP allows you/your daughter to pick any OB/GYN, whether that doctor is in the same network as your/your daughter’s Primary Care Provider or not.

How do I choose an OB/GYN?You can find a list of available OB/GYN doctors from the CHIP provider directory. Or you can view our website at www.cfhp.com. You can also call us so we can help you choose a doctor.

If I don’t choose an OB/GYN, do I have direct access?Yes, you still have direct access if you don’t choose an OB/GYN.

Will I need a referral?You do not need a referral from your Primary Care Provider. You do not need to check first with CFHP.

How soon can I/my daughter be seen after contacting an OB/GYN for an appointment?You/she should be able to get an appointment within two weeks of the request.

Can I/my daughter stay with an OB/GYN who is not with CFHP?If you or your daughter is not pregnant, you will need to choose another OB/GYN from CFHP. Call us so we can help you choose a doctor.

What if I am pregnant/what if my daughter is pregnant (FOR CHIP MEMBERS)? You/your daughter can see a CFHP OB/GYN. You/your daughter does not need a referral from your/her Primary Care Provider. You/she does not need to check first with CFHP.

Who do I need to call?Call Member Services so we can help you choose a doctor.

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What other services/activities/education does CFHP offer pregnant women?CFHP has a special prenatal program. There are gifts for women who complete education classes. Call Member Services for more information. Home visits for high-risk pregnant women.

Who do I call if I have/my child has special health care needs and I need someone to help me? CFHP offers services to members with special health care needs. Call Member Services and we will help you find a case manager to help you.

What if I get a bill from my doctor?You should not get a bill for any services covered under CHIP.

• You might also get a bill if you go to a doctor who is not with CFHP. • You might also get a bill if you go to an emergency room when it is not an emergency.

If you pay for covered services, call us right away. You must ask CFHP to pay you back no later than 90 days after you paid for the services.

Who do I call? What information will they need?Member Services can help you figure out what to do. Be sure to have a copy of the bill in front of you when you call.

What do I have to do if I move? As soon as you have your new address, give it to the local HHSC benefits office and Community First Health Plans’ Member Services Department at 1-800-434-2347. Before you get CHIP services in your new area, you must call Community First Health Plans, unless you need emergency services. You will continue to get care through Community First Health Plans until HHSC changes your address.

MEMBER RIGHTS AND RESPONSIBILITIES FOR CHIP MEMBERS AND CHIP PERINATE NEWBORN MEMBERS

MEMBER RIGHTS:1. You have a right to get information about Community First, its services, its providers, and member

rights and responsibilities. 2. You have the right to get accurate, easy-to-understand information to help you make good choices

about your child’s health plan, doctors, hospitals and other providers.3. Your health plan must tell you if they use a “limited provider network.” This is a group of doctors

and other providers who only refer patients to other doctors who are in the same group. “Limited provider network” means you cannot see all the doctors who are in your health plan. If your health plan uses “limited networks,” you should check to see that your child’s primary care provider and any specialist doctor you might like to see are part of the same “limited network.”

4. You have a right to know how your doctors are paid. Some get a fixed payment no matter how often you visit. Others get paid based on the services they give to your child. You have a right to know about what those payments are and how they work.

5. You have a right to know how the health plan decides whether a service is covered and/or medically necessary. You have the right to know about the people in the health plan who decide those things.

6. You have a right to know the names of the hospitals and other providers in your health plan and their addresses.

7. You have a right to pick from a list of health care providers that is large enough so that your child can get the right kind of care when your child needs it.

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8. If a doctor says your child has special health care needs or a disability, you may be able to use a specialist as your child’s primary care provider. Ask your health plan about this.

9. Children who are diagnosed with special health care needs or a disability have the right to special care.

10. If your child has special medical problems, and the doctor your child is seeing leaves your health plan, your child may be able to continue seeing that doctor for three months, and the health plan must continue paying for those services. Ask your plan about how this works.

11. Your daughter has the right to see a participating obstetrician/gynecologist (OB/GYN) without a referral from her primary care provider and without first checking with your health plan. Ask your plan how this works. Some plans may make you pick an OB/GYN before seeing that doctor without a referral.

12. Your child has the right to emergency services if you reasonably believe your child’s life is in danger, or that your child would be seriously hurt without getting treated right away. Coverage of emergencies is available without first checking with your health plan. You may have to pay a co-payment depending on your income. Copayments do not apply to CHIP Perinatal Members.

13. You have the right and responsibility to take part in all the choices about your child’s health care.14. You have the right to speak for your child in all treatment choices.15. You have the right to get a second opinion from another doctor in your health plan about what kind

of treatment your child needs.16. You have the right to be treated fairly by your health plan, doctors, hospitals and other providers.17. You have the right to talk to your child’s doctors and other providers in private, and to have your

child’s medical records kept private. You have the right to look over and copy your child’s medical records and to ask for changes to those records.

18. You have the right to a fair and quick process for solving problems with your health plan and the plan’s doctors, hospitals and others who provide services to your child. If your health plan says it will not pay for a covered service or benefit that your child’s doctor thinks is medically necessary, you have a right to have another group, outside the health plan, tell you if they think your doctor or the health plan was right.

19. You have the right to know that doctors, hospitals, and others who care for your child can advise you about your child’s health status, medical care, and treatment. Your health plan cannot prevent them from giving you this information, even if the care or treatment is not a covered service.

20. You have a right to know that you are only responsible for paying allowable copayments for covered services. Doctors, hospitals, and others cannot require you to pay any other amounts for covered services.

21. You have a right to make recommendations regarding Community First’s member rights and responsibilities policy.

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MEMBER RESPONSIBILITIES:

You and your health plan both have an interest in seeing your child’s health improve. You can help by assuming these responsibilities.

1. You must try to follow healthy habits. Encourage your child to stay away from tobacco and to eat a healthy diet.

2. You must become involved in the doctor’s decisions about your child’s treatments.3. You must work together with your health plan’s doctors and other providers to pick treatments for

your child that you have all agreed upon.4. If you have a disagreement with your health plan, you must try first to resolve it using the health

plan’s complaint process.5. You must learn about what your health plan does and does not cover. Read your Member

Handbook to understand how the rules work.6. If you make an appointment for your child, you must try to get to the doctor’s office on time. If you

cannot keep the appointment, be sure to call and cancel it.7. If your child has CHIP, you are responsible for paying your doctor and other provider’s co-payments

that you owe them. If your child is getting CHIP Perinatal services, you will not have any co-payments for that child.

8. You must report misuse of CHIP or CHIP Perinatal services by health care providers, other members, or health plans.

9. You must talk to your provider about your medications that are prescribed.10. You have a responsibility to provide information to Community First or its providers (to the extent

possible) that is needed to provide care.

If you think you have been treated unfairly or discriminated against, call the U.S. Department of Health and Human Services toll-free at 1-800-368-1019. You can also view information concerning the HHS Office of Civil Rights online at www.hhs.gov/ocr.

PROVIDERS FOR CHIP PERINATE MEMBERS

What do I need to bring to a Perinatal Provider’s appointment?You should bring your CFHP member ID card with you.

Can a clinic be a Perinatal Provider?Yes, you can choose any from our CHIP Provider directory:

• Local Public Health Clinics• Rural Health Clinics• Federally Qualified Health Centers

How do I get after hours care?Call your perinatal provider’s office first if you need urgent care. The doctor must have his or her phone answered 24 hours a day, seven days a week. You also may call CFHP’s after-hours nurse advice line at (210) 358-6300. You may also call toll-free at 1-800-434-2347. A nurse will talk to you. The nurse can send you to urgent care. If you have an emergency, go to the ER!

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BENEFITS FOR CHIP PERINATE MEMBERS

What are my unborn child’s CHIP Perinatal benefits?The following benefits are for CHIP Perinatal members. For more information about the health plan, continue on page 69.

Covered Benefits Limitations Co-payments*Inpatient General Acute

Services include:• Covered medically necessary Hospital-provided

services • Operating, recovery and other treatment rooms• Anesthesia and administration (facility technical

component)• Medically necessary surgical services are limited to

services that directly relate to the delivery of the unborn child and services related to miscarriage or non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero).

• Inpatient services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero.) Inpatient services associated with miscarriage or non-viable pregnancy include, but are not limited to: dilation and curettage (D&C) procedures, appropriate provider-administered medications, ultrasounds, and histological examination of tissue samples.

• For CHIP Perinates in families with incomes at or below 185% of the Federal Poverty Level, the facility charges are not a covered benefit; however professional services charges associated with labor with delivery are a covered benefit.

• For CHIP Perinates in families with incomes above 185% up to and including 200% of the Federal Poverty Level, benefits are limited to professional service charges and facility charges associated with labor with delivery until birth.

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Birthing Center Services • Covers birthing services provided by a licensed birthing center. Limited to facility services (e.g., labor and delivery).

• Applies only to CHIP Perinate Members (unborn child) with incomes at 186% FPL to 200 % FPL.

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Covered Benefits Limitations Co-payments*Comprehensive Outpatient Hospital, Clinic (Including Health Center) and Ambulatory Health Care Center

Services include the following services provided in a hospital clinic or emergency room, a clinic or health center, hospital-based emergency department or an ambulatory health care setting:• X-ray, imaging, and radiological tests (technical


component)• Machine diagnostic tests• Drugs, medications and biologicals that are

medically necessary prescription and injection drugs

• Outpatient services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero.) Outpatient services associated with miscarriage or non-viable pregnancy include, but are not limited to: dilation and curettage (D&C) procedures, appropriate provider-administered medications, ultrasounds, and histological examination of tissue samples.


• Laboratory and radiological services are limited to services that directly relate to ante partum care and/or the delivery of the covered CHIP Perinate until birth.

• Ultrasound of the pregnant uterus is a covered benefit of the CHIP Perinatal Program when medically indicated. Ultrasound may be indicated for suspected genetic defects, high-risk pregnancy, fetal growth retardation, or gestational age conformation, or miscarriage or non-viable pregnancy.

• Amniocentesis, Cordocentesis, Fetal Intrauterine Transfusion (FIUT) and Ultrasonic Guidance for Cordocentesis, FIUT are covered benefits of the CHIP Perinatal Program with an appropriate diagnosis.

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Covered Benefits Limitations Co-payments*• Laboratory tests for the CHIP Perinatal

Program are limited to: nonstress testing, contraction stress testing, hemoglobin or hematocrit repeated one a trimester and at 32-36 weeks of pregnancy; or complete blood count (CBC), urinanalysis for protein and glucose every visit, blood type and RH antibody screen; repeat antibody screen for Rh negative women at 28 weeks followed by RHO immune globulin administration if indicated; rubella antibody titer, serology for syphilis, hepatitis B surface antigen, cervical cytology, pregnancy test, gonorrhea test, urine culture, sickle cell test, tuberculosis (TB) test, human immunodeficiency virus (HIV) antibody screen, Chlamydia test, other laboratory tests not specified but deemed medically necessary, and multiple marker screens for neural tube defects (if the client initiates care between 16 and 20 weeks); screen for gestational diabetes at 24-28 weeks of pregnancy; other lab tests as indicated by medical condition of client.

• Surgical services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy or a fetus that expired in utero) are a covered benefit.

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Covered Benefits Limitations Co-payments*Physician/Physician Extender Professional Services

Services include, but are not limited to the following:• Medically necessary physician services are limited

to prenatal and postpartum care and/or the delivery of the covered unborn child until birth.

• Physician office visits, in-patient and out-patient services

• Laboratory, x-rays, imaging and pathology services, including technical component and/or professional interpretation

• Medically necessary medications, biologicals and materials administered in Physician’s office

• Professional component (in/outpatient) of surgical services, including:

¡ Surgeons and assistant surgeons for surgical procedures directly related to the labor with delivery of the covered unborn child until birth.


¡ Invasive diagnostic procedures directly related to the labor with delivery of the unborn child.

¡ Surgical services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero).


• Professional component associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero.) Professional services associated with miscarriage or non-viable pregnancy include, but are not limited to: dilation and curettage (D&C) procedures, appropriate provider-administered medications, ultrasounds, and histological examination of tissue samples.


• Professional component of the ultrasound of the pregnant uterus when medically indicated for suspected genetic defects, high-risk pregnancy, fetal growth retardation, or gestational age conformation.

• Professional component of Amniocentesis, Cordocentesis, Fetal Intrauterine Transfusion (FIUT) and Ultrasonic Guidance for Amniocentesis, Cordocentrsis, and FIUT.

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Covered Benefits Limitations Co-payments*Services rendered by a Certified Nurse Midwife or physician in a licensed birthing center�

Covers prenatal, birthing, and postpartum services rendered in a licensed birthing center. Prenatal services subject to the following limitations: Services are limited to an initial visit and subsequent prenatal (ante partum) care visits that include:• (1) One (1) visit every four (4)

weeks for the first 28 weeks or pregnancy; (2) one (1) visit every two (2) to three (3) weeks from 28 to 36 weeks of pregnancy; and (3) one (1) visit per week from 36 weeks to delivery.

• More frequent visits are allowed as Medically Necessary. Benefits are limited to:

• Limit of 20 prenatal visits and two (2) postpartum visits (maximum within 60 days) without documentation of a complication of pregnancy. More frequent visits may be necessary for high-risk pregnancies. High-risk prenatal visits are not limited to 20 visits per pregnancy. Documentation supporting medical necessity must be maintained and is subject to retrospective review.

• Visits after the initial visit must include:

¡ interim history (problems, marital status, fetal status);

¡ physical examination (weight, blood pressure, fundalheight, fetal position and size, fetal heart rate, extremities) and

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Covered Benefits Limitations Co-payments*laboratory tests (urinanalysis for protein and glucose every visit; hematocrit or hemoglobin repeated once a trimester and at 32-36 weeks of pregnancy; multiple marker screen for fetal abnormalities offered at 16-20 weeks of pregnancy; repeat antibody screen for Rh negative women at 28 weeks followed by Rho immune globulin administration if indicated; screen forgestational diabetes at 24-28 weeks of pregnancy; and other lab tests as indicated by medical condition of client).

Prenatal care and prepregnancy family services and supplies

Covered services are limited to an initial visit and subsequent prenatal (ante partum) care visits that include:• One visit every four weeks for the first 28 weeks

or pregnancy; one visit every two to three weeks from 28 to 36 weeks of pregnancy; and one visit per week from 36 weeks to delivery. More frequent visits are allowed as medically necessary.

• Does not require prior authorization.

• Limit of 20 prenatal visits and 2 postpartum visits (maximum within 60 days) without documentation of a complication of pregnancy. More frequent visits may be necessary for high-risk pregnancies. High-risk prenatal visits are not limited to 20 visits per pregnancy. Documentation supporting medical necessity must be maintained in the physician’s files and is subject to retrospective review.

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Covered Benefits Limitations Co-payments*• Visits after the initial visit

must include: interim history (problems, maternal status, fetal status), physical examination (weight, blood pressure, fundal height, fetal position and size, fetal heart rate, extremities) and laboratory tests (urinanalysis for protein and glucose every visit; hematocrit or hemoglobin repeated once a trimester and at 32-36 weeks of pregnancy; multiple marker screen for fetal abnormalities offered at 16-20 weeks of pregnancy; repeat antibody screen for Rh negative women at 28 weeks followed by Rho immune globulin administration if indicated; screen for gestational diabetes at 24-28 weeks of pregnancy; and other lab tests as indicated by medical condition of client).

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Covered Benefits Limitations Co-payments*Emergency Services, including Emergency Hospitals, Physicians, and Ambulance Services

Health Plan cannot require authorization as a condition for payment for emergency conditions related to labor and delivery.

Covered services are limited to those emergency services that are directly related to the delivery of the covered unborn child until birth.• Emergency services based on prudent lay person

definition of emergency health condition.• Medical screening examination to determine

emergency when directly related to the delivery of the covered unborn child.

• Stabilization services related to the labor and delivery of the covered unborn child.

• Emergency ground, air and water transportation for labor and threatened labor is a covered benefit.

• Emergency services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero.)

• Post-delivery services or complications resulting in the need for emergency services for the mother of the CHIP Perinate are not a covered benefit.

None

Case Management Services

Case management services are a covered benefit for the Unborn Child.

• These covered services include outreach informing, case management, care coordination and community referral.

None

Care Coordination Services

Care coordination services are a covered benefit for the Unborn Child.

None

Drug Benefits

Services include, but are not limited to the following:•Outpatient drugs and biologicals; including pharmacy-dispensed and provider-administered outpatient drugs and biologicals; and•Drugs and biologicals provided in an inpatient setting.

• Services must be medically necessary for the unborn child.

None


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Covered Benefits Limitations Co-payments*Value-added services• A prescription discount card your whole family can

use.• 24-hour Nurse Advice Line.• Bus tokens for doctor visits or health classes.• Free flu shots for CHIP Perinatal members.• Healthy Expectations Prenatal program• Newborn & postpartum classes for new fathers.• MP3 player with health podcast.• Expectant mommy baby shower.• New mommy mingle & advice meetings.• Temporary phone help.• Post-discharge incentives.• Free toddler booster seats.• Notary services.• Personal counseling from registered nurse for

asthma, diabetes, pregnancy, and behavioral health.• Free gift for attending classes for new fathers• Free birthing classes• Home visits for high-risk prenant women

None

How do I get these services?Call Member Services. We’ll be happy to explain how you can get these services.

What services are not covered?• For CHIP Perinates in families with incomes at or below 185% of the Federal Poverty Level, inpatient

facility charges are not a covered benefit if associated with the initial Perinatal Newborn admission. “Initial Perinatal Newborn admission” means the hospitalization associated with the birth.

• Inpatient and outpatient treatments other than prenatal care, labor with delivery, and postpartum care related to the covered unborn child until birth. Services related to preterm, false or other labor not resulting in delivery are excluded services.

• Inpatient mental health services.• Outpatient mental health services.• Durable medical equipment or other medically related remedial devices.• Disposable medical supplies.• Home and community-based health care services.• Nursing care services.• Dental services.• Inpatient substance abuse treatment services and residential substance abuse treatment services.• Outpatient substance abuse treatment services.• Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language

disorders.• Hospice care.• Skilled nursing facility and rehabilitation hospital services.• Emergency services other than those directly related to the delivery of the covered unborn child.

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• Transplant services.• Tobacco Cessation Programs.• Chiropractic Services.• Medical transportation not directly related to the labor or threatened labor and/or delivery of the

covered unborn child.• Personal comfort items including but not limited to personal care kits provided on inpatient admission,

telephone, television, newborn infant photographs, meals for guests of patient, and other articles that are not required for the specific treatment related to labor and delivery or post partum care.



• Private duty nursing services when performed on an inpatient basis or in a skilled nursing facility.• Mechanical organ replacement devices including, but not limited to artificial heart.• Hospital services and supplies when confinement is solely for diagnostic testing purposes and not a part

of labor and delivery.• Prostate and mammography screening.• Elective surgery to correct vision.• Gastric procedures for weight loss.• Cosmetic surgery/services solely for cosmetic purposes.• Dental devices solely for cosmetic purposes.• Out-of-network services not authorized by the Health Plan except for emergency care related to the

labor and delivery of the covered unborn child.• Services, supplies, meal replacements or supplements provided for weight control or the treatment of

obesity.• Medications prescribed for weight loss or gain.• Acupuncture services, naturopathy and hypnotherapy.• Immunizations solely for foreign travel.• Routine foot care such as hygienic care (routine foot care does not include treatment of injury or

complications of diabetes).• Diagnosis and treatment of weak, strained, or flat feet and the cutting or removal of corns, calluses and

toenails (this does not apply to the removal of nail roots or surgical treatment of conditions underlying corns, calluses or ingrown toenails).

• Corrective orthopedic shoes.• Convenience items.• Over-the-counter medications.• Orthotics primarily used for athletic or recreational purposes.• Custodial care (care that assists with the activities of daily living, such as assistance in walking, getting

in and out of bed, bathing, dressing, feeding, toileting, special diet preparation, and medication supervision that is usually self-administered or provided by a caregiver. This care does not require the continuing attention of trained medical or paramedical personnel).


public facility or care provided while in the custody of legal authorities.• Services or supplies received from a nurse that do not require the skill and training of a nurse.


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• Vision training, vision therapy, or vision services.• Reimbursement for school-based physical therapy, occupational therapy, or speech therapy services are

not covered. • Donor non-medical expenses.• Charges incurred as a donor of an organ. • Coverage while traveling outside of the United States and U.S. Territories (including Puerto Rico, U.S.


What are my unborn child’s prescription drug benefits?Most prescription medicines your doctor says you need are covered. Your prescription must be filled by a drug store that takes CHIP. If you have problems getting your prescriptions filled, call us at 1-800-434-2347. A Member Services Advocate will help you.

How much do I have to pay for my health care under CHIP Perinatal?Under CHIP Perinatal, there are no co-payments and no cost-sharing.

Will I have to pay extra for services that are not covered benefits?Yes, you will have to pay for any services you get if they are not covered under CHIP Perinatal.

What extra benefits does CFHP offer?• A prescription discount card your whole family can use.• 24-hour Nurse Advice Line.• Bus tokens for doctor visits or health classes.• Free flu shots for CHIP Perinatal members.• Healthy Expectations Prenatal program.• Newborn & postpartum classes for new fathers.• MP3 player with health podcast.• Expectant mommy baby shower.• New mommy mingle & advice meetings.• Temporary phone help.• Post-discharge incentives.• Free toddler booster seats.• Notary services.

How can I get these benefits?Call Member Services. We’ll be happy to explain how you can obtain these services.

HEALTH CARE AND OTHER SERVICES FOR CHIP PERINATE MEMBERS

What is routine medical care? Routine care is when you go to the doctor for a checkup. It also means going when you are sick. Immunizations are part of routine care.

How soon can I expect to be seen?

You can expect to be seen by your Perinatal Provider within two weeks after you call for a routine appointment.

What is urgent medical care?An urgent medical problem is when you are sick or hurt and need treatment as soon as possible. Call your Perinatal Provider first, any time night or day. You may be referred to an urgent care center.

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How soon can I expect to be seen? You can expect to be seen for urgent care within 24 hours.

FOR CHIP PERINATE MEMBERS

What is an Emergency, an Emergency Medical Condition, and an Emergency Behavioral Health Condition?Emergency care is a covered service. Emergency care is provided for Emergency Medical Conditions and Emergency Behavioral Health Conditions. “Emergency Medical Condition” is a medical condition characterized by sudden acute symptoms, severe enough (including severe pain), that would lead an individual with average knowledge of health and medicine, to expect that the absence of immediate medical care could result in:

• placing the member’s health in serious jeopardy;• serious impairment to bodily functions;• serious dysfunction of any bodily organ or part;• serious disfigurement; or• in the case of a pregnant CHIP member, serious jeopardy to the health of the CHIP member or her unborn child.

“Emergency Behavioral Health Condition” means any condition, without regard to the nature or cause of the condition, which in the opinion of an individual, possessing an average knowledge of health and medicine:

• requires immediate intervention or medical attention without which the member would present an immediate danger to himself/herself or others; or• renders the member incapable of controlling, knowing or understanding the consequences of his/her actions.

What is Emergency Services or Emergency Care?“Emergency Services” and “emergency care” means health care services provided in an in-networkor out-of-network hospital emergency department, free-standing emergency medical facility, orother comparable facility by in-network or out-of-network physicians, providers, or facility staff toevaluate and stabilize Emergency Medical Conditions and/or Emergency Behavioral Health Conditions.Emergency services also include any medical screening examination or other evaluation required bystate or federal law that is necessary to determine

How soon can I expect to be seen?You can expect to be seen as soon as is appropriate for your medical condition. For example, life-threatening injuries require immediate attention.

How do I get medical care after my Primary Care Provider’s office is closed?Call your Primary Care Provider’s office first if you have an urgent problem. The doctor must have his or her phone answered 24 hours a day, seven days a week. You also may call CFHP’s after-hours nurse advice line at (210) 358-6300. You may also call toll-free at 1-800-434-2347. A nurse will talk to you. The nurse can send you to urgent care. In an emergency, go to the nearest ER!

What if I get sick when I am out of town or traveling?If you need medical care when traveling, call us toll-free at 1-800-434-2347 and we will help you find a doctor.

If you need emergency services while traveling, go to a nearby hospital, then call us toll-free at 1-800-434-2347.

What if I am out of the state? CFHP pays for emergencies anywhere in the United States. If you have an emergency, you don’t have


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to call your Perinatal Provider first. Just get help. Call your Perinatal Provider within 24 hours of the emergency. If you can’t, call as soon as possible.

If you are away and have an urgent problem, you must call your Perinatal Provider. You may also call the CFHP after-hours Nurse Advice Line. You must call first before getting care. If you need follow-up care, your Perinatal Provider will arrange it. Please return to the CFHP service area if you can to get follow-up care. If you are too sick to travel back, call 1-800-434-2347 to let CFHP know.

What if I am out of the country?Medical services performed out of the country are not covered by CHIP.

What is a referral? A referral is when your Perinatal Provider thinks you should see a specialist. It can also be when you need special treatment. Your Perinatal Provider will arrange the services for you. It is important to wait until all the paperwork is complete. It must be done before you go to an appointment for the referral.

Your Perinatal Provider’s office will usually make the appointments for you. If you have any questions about referrals, please call Member Services.

What services within the network do not need a referral?• Behavioral Health Services• OB/GYN Services• Vision exams from an optometrist• Family planning services

Call CFHP if you need assistance finding a provider or to help you schedule an appointment.

What if I need services that are not covered by CHIP Perinatal?We can give you information about community services that are available. Call Member Services for more information.

How do I get my medications?CHIP Perinatal covers most of the medicine your unborn child’s doctor says you need. Your doctor will write a prescription so you can take it to the drug store, or may be able to send the prescription for you.

There are no co-payments required for CHIP Perinate Members.

How do I find a network drug store?You can call Member Services for help to find a network drug store. You can also find a list of drug stores in the CFHP network on our website. Visit our website at www.cfhp.com

What if I go to a drug store not in the network?If you go to a drug store that is not in the network, your prescription may not be covered. You may be responsible for the charges of the prescription medication.

What do I bring with me to the drug store?You should bring your CFHP ID card and Your Texas Benefits Medicaid Card. Show both cards to the drug store.

What if I need my medications delivered to me?You may be able to get your medication delivered to you if the medicine qualifies for mail order. CFHP’s partner for pharmacy benefits is Navitus. Their mail order program partner is Wellpartner. You can find out more about how to get your medications delivered to you by calling Member Services. You can also find out more information on our website at www.cfhp.com.

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Who do I call if I have problems getting my medications?Call Member Services. We’re here to help.

What if I lose my medication(s)?Call Member Services for help.

Can someone interpret for me when I talk with my perinatal provider?Yes.

Who do I call for an interpreter? How can I get a face-to-face interpreter in the provider’s office?Call Member Services and we will arrange for an interpreter to help you during your visit.

How far in advance do I need to call?You need to call us at least 24 hours before your appointment.

How do I choose a perinatal provider? Will I need a referral?You can find a list of available perinatal providers from CHIP provider directory. Or you can view our website at www.cfhp.com. You can also call us so we can help you choose a doctor. You do not need a referral.

How soon can I be seen after contacting a perinatal provider for an appointment?You should be able to get an appointment within two weeks of the request.

Can I stay with a perinatal provider if they are not with CFHP?You will need to choose a perinatal provider from CFHP. Call us so we can help you choose a doctor.

What other services/activities/education does CFHP offer?CFHP has a special prenatal program. There are gifts for women who complete a prenatal survey or education classes. Call Member Services for more information.

What if I get a bill from a perinatal provider?You should not get a bill for services covered under CHIP Perinatal. You might get a bill if you go to a doctor who is not with CFHP. You might also get a bill if you receive treatment in an emergency room if it is not an emergency.

Who do I call? What information will they need?Member Services can help you figure out what to do. Be sure to have a copy of the bill in front of you when you call.

What do I have to do if I move? As soon as you have your new address, give it to HHSC by calling 2-1-1 or updating your account on YourTexasBenefits.com and calling Community First Health Plans’ Member Services Department at 1-800-434-2347. Before you get CHIP services in your new area, you must call Community First Health Plans, unless you need emergency services. You will continue to get care through Community First Health Plans until HHSC changes your address.

What if I can’t get the medication my/my child’s doctor ordered approved?If your/your child’s doctor cannot be reached to approve a prescription, you/your child may be able to get a three-day emergency supply of your/your child’s medication.

Call Community First at 1800-227-2347 for help with your/your child’s medications and refills.


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What if I need/my child needs an over-the-counter medication?The pharmacy cannot give you an over-the-counter medication as part of your/your child’s CHIP benefit. If you need/your child needs an over-the-counter medication, you will have to pay for it.

MEMBER RIGHTS AND RESPONSIBILITIES FOR CHIP PERINATE MEMBERS

MEMBER RIGHTS:1. You have a right to get information about Community First, its services, its providers, and member

rights and responsibilities. 2. You have a right to get accurate, easy-to-understand information to help you make good choices

about your unborn child’s health plan, doctors, hospitals, and other providers.3. You have a right to know how the Perinatal providers are paid. Some may get a fixed payment no

matter how often you visit. Others get paid based on the services they provide for your unborn child. You have a right to know about what those payments are and how they work.

4. You have a right to know how the health plan decides whether a Perinatal service is covered and/or medically necessary. You have the right to know about the people in the health plan who decide those things.

5. You have a right to know the names of the hospitals and other Perinatal providers In the health plan and their addresses.

6. You have a right to pick from a list of health care providers that is large enough so that your unborn child can get the right kind of care when it is needed.

7. You have the right to emergency Perinatal services if you reasonably believe your unborn child’s life is in danger, or that your unborn child would be seriously hurt without getting treated right away. Coverage of such emergencies is available without first checking with the health plan.

8. You have the right and responsibility to take part in all the choices about your unborn child’s health care.

9. You have the right to speak for your unborn child in all treatment choices.10. You have the right to be treated fairly by the health plan, doctors, hospitals and other providers.11. You have the right to talk to your Perinatal provider In private, and to have your medical records kept

private. You have the right to look over and copy your medical records and to ask for changes to those records.

12. You have the right to a fair and quick process for solving problems with the Health plan and the plan’s doctors, hospitals and others who provide Perinatal services for your unborn child. If the health plan says it will not pay for a covered Perinatal service or benefit that your unborn child’s doctor thinks is medically necessary, you have a right to have another group, outside the health plan, tell you If they think your doctor of the health plan was right.

13. You have a right to know that doctors, hospitals, and other Perinatal providers can give you information about your or your unborn child’s health status, medical care, or treatment. Your health plan cannot prevent them from giving you this information, even if the care or treatment is not a covered service.

14. You have a right to make recommendations regarding Community First’s member rights and responsibilities policy.

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MEMBER RESPONSIBILITIES:

You and your health plan both have an interest In having your baby born healthy. You can help by assuming these responsibilities.

1. You must understand your health problems and work with your provider to develop agreed-upon goals (to the degree possible).

2. You must try to follow healthy habits. Stay away from tobacco and eat a healthy diet.3. You must become involved in the decisions about your unborn child’s care.4. If you have a disagreement with the health plan, you must try first try to resolve it using the health

plan’s complaint process.5. You must learn about what your health plan does and does not cover. Read your CHIP Perinatal

Program Handbook to understand how the rules work.6. You must try to get to the doctor’s office on time. If you cannot keep the appointment, be sure to call

and cancel it.7. You must report misuse of CHIP Perinatal services by health care providers, other members, or health

plans.8. You must talk to your provider about your medications that are prescribed.9. You have a responsibility to provide information to Community First or its providers (to the degree

possible) that is needed to provide care.

If you think you have been treated unfairly or discriminated against, call the U.S. Department of Health and Human Services (HHS) toll-free at 1-800-368-1019. You can also view information concerning the HHS Office of Civil Rights online at www.hhs.gov/ocr.

When does CHIP Perinatal coverage end?You and your baby have 12 months of benefits. Benefits will start with the month you enroll yourself in CHIP Perinatal. Your newborn baby’s benefits will end 12 months from when you first enrolled.

Will the state send me anything when CHIP Perinatal coverage ends?Yes. In month 10, you will receive a CHIP renewal packet.

How does renewal work?You will need to complete the renewal application. Then you will mail it to the enrollment address. If your baby qualifies, he or she will become a traditional CHIP member.

What benefits does my baby receive at birth?If your family is at or below 185% of the Federal Poverty Level (FPL), your newborn will be moved to Medicaid for 12 months of continuous Medicaid coverage beginning on the date of birth. If your family is above the 185% to 200% of the FPL, your child will be eligible to receive the CHIP benefits outlined in this handbook.

Can I choose my baby’s Primary Care Provider before the baby is born?Yes. It is best to pick your baby’s Primary Care Provider before he or she is born.

Who do I call? What information do they need?Call CFHP’s Member Services Department. They can help you choose a Primary Care Provider for your baby. Tell them either your due date or the baby’s date of birth. If you do not choose a Primary Care Provider, we will choose one for your baby.


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FOR CHIP, CHIP PERINATE NEWBORN, AND CHIP PERINATAL (MOM) MEMBERS:

What health education classes does CFHP offer?Personal wellness means doing things in your life that will have a good effect on your health, every day. It means working to stay as healthy as possible, to help you live the best possible life. There are three parts to feeling well. They are your body health, your social health and your mental health. When these three are balanced, you can live a healthier life. Wellness is a choice. You have to take the time to know about good health and you have to make good choices. A healthy life can help cut down or stop those things that place us at risk for sickness and disease.

CFHP refers members to community-based health education classes and provides many types of written information. These are a few of the topics available:

• CPR• Asthma education• Diabetes education:

¡ What is diabetes? ¡ Eating right with diabetes ¡ How to take care of your feet ¡ Nutrition

• Dangers of smoking• Risks of second-hand smoke to children• Children and alcohol abuse• Inhalants, stimulants and other drugs • Injury Prevention• Safe proofing your home• Passenger safety• Bicycle safety• Gun safety

Get moving for better health: Exercise helps your heart and body get into shape. It helps your weight by cutting down the fat stored in your body. It also helps give you strong bones, gets your energy level up and helps your muscles tone up. People who exercise feel better about themselves. They do not get stressed or depressed as much as people who do not exercise. They also sleep better.

Have an exercise routine: You will stick with it if you make it a normal part of your day. Keep it simple, 20 to 30 minutes a day, 3 to 5 days each week. See your health care provider before you start. Be sure you are okay to exercise. Try walking, riding a bike, swimming, dancing or aerobics. For building your muscles, try lawn work, like pulling weeds, mowing the lawn, and raking leaves. Park your car at the far end of the parking lot at the store and mall. Encourage your child to do sports, at school or in a community program. Housework like mopping, sweeping, vacuuming, dusting and washing windows is good exercise. Drink lots of water before and after you exercise.

Healthy eating: Healthy eating helps you cut down your risk of heart disease, diabetes and many types of cancer. It helps you get and keep a healthy body weight. Foods you eat can affect your energy level. The best diet is one that includes fruits, vegetables, meats and breads. Eat breakfast. Breakfast is the most important meal of

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the day. Eat smaller amounts and limit your second helping. Limit high-fat foods. Eat wheat breads and cereals, without added fat and sugar. Limit desserts, sweets and processed foods. Try fresh and frozen fruits and vegetables. Instead of a candy bar or chips and soda for a snack, try a piece of fruit, a bagel, pretzels, yogurt, carrot sticks, crackers or low-fat microwave popcorn. Use salt in moderation. Limit soft drinks and alcoholic beverages. Do not try fast weight-loss diets. Change your eating habits and work to lose only one-half to a pound a week.

Social/mental health: Your social and mental well-being is an important part of your health. People who feel mentally healthy feel good about themselves and are better able to deal with the challenges of our sometimes-hectic lifestyles. Make time to relax and enjoy things that make you feel good. Go to a movie. Watch a softball game. Exercise. Go for a walk. Sit in your favorite chair and read a good book. Pray. Daydream. Buy a tape and listen to it in a quiet, dark room. Start a hobby. Make it simple. Know when you need help and ask for it.

Utilization Management ProcessUtilization Management decision-making is based only on appropriateness of care and service and existence of coverage. Community First Health Plans does not award providers or other individuals for issuing denials of coverage. Utilization Management decision makers are not awarded financially to make decisions that result in underutilization.

To make UM decisions, Community First Health Plans uses the requesting practitioner’s recommendation and nationally recognized criteria and guidelines, and applies the criteria in a fair, impartial, and consistent manner that serves the best interest of our Members. To ensure that Members receive the most appropriate healthcare, Community First Health Plans reviews your care before, during, and after you receive it to ensure it is covered. Pre-service review occurs before you receive care and post-service review occurs before the claim is paid when you receive care that was not authorized in advance. Generally, the member’s practitioner requests prior authorization from Community First Health Plans before you receive care; however, it is the member’s responsibility to make sure that they are following Community First Health Plans rules for accessing care. If you are obtaining care from a non-network provider, call (210) 358-6070 or toll-free at 1-800-434-2347 to request Community First’s review of your care. Out-of-network care that is not approved in advance by Community First is not covered. We also review your care while you are in the hospital and work with the hospital staff to help ensure you have a smooth transition to home or your next care setting. Our experienced clinical staff reviews all requests. Member needs that fall outside of standard criteria are reviewed by our physician staff for plan coverage and medical necessity. Community First Health Plans approves or denies services based upon whether or not the service is medically needed and a covered benefit.

How to Obtain Information About the UM Process and Authorization of Care:Utilization management staff are available to assist you with any questions or concerns you may have regarding the UM process and the authorization of care. You may speak with a UM staff member by calling (210) 358-6060 or toll-free at 1-800-434-2347 during normal business hours, Monday through Friday, 8:30 a.m. to 5 p.m. On-call UM staff can be reached for urgent issues after hours, weekends, and holidays by calling the same phone numbers and advising the answering service of your need to speak with a UM staff member.

What should I do if I have a complaint? Who do I call? Can someone from CFHP help me file a complaint?We want to help. If you have a complaint, please call us toll-free at 1-800-434-2347 to tell us about your problem. A Community First Health Plans Member Services Advocate can help you file a complaint. Just call 1-800-434-2347. Most of the time, we can help you right away or at the most within a few days.

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Community First Health Plans cannot take any action against you as a result of your filing a complaint.

If I am not satisfied with the outcome, who else can I contact?If you are not satisfied with the answer to your complaint, you can also complain to the Texas Department of Insurance by calling toll-free to 1-800-252-3439. If you would like to make your request in writing, send it to:

Texas Department of InsuranceConsumer Protection

P.O Box 149091Austin, TX 78714-9091

If you can get on the Internet, you can send your complaint in an email to http://www.tdi.texas.gov/consumer/complfrm.html.

How long will it take to process my complaint?If you call to file a complaint, we will mail you a letter within 5 calendar days from the date you call to tell you we received your complaint. We will also send you a complaint form.

What are the requirements and timeframes for filing a complaint?After you return the complaint form, we will mail you a letter within 5 calendar days from the date we received your form to tell you we received it. We will mail you our decision within 30 calendar days.

Send your complaint to:Member Services

Community First Health Plans12238 Silicon Drive, Suite 100


What if I am not satisfied with the outcome, whom else can I contact?If you are not happy with our answer, you can file a complaint appeal in writing. Call our Member Services Advocates.

If you file a complaint appeal, we will mail you a letter within 5 calendar days from the date we received your form to tell you we received it. We will schedule an Appeal Panel hearing.

Do I have the right to meet with the complaint appeal panel?Five calendar days before the hearing, you will receive a letter with important information about your appeal rights. You may appear before the Appeal Panel.

After the Appeal Panel hearing, we will send you our answer. We will mail the letter within 30 calendar days from when we received your written appeal.

You can file a complaint with TDI at any time.

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PROCESS TO APPEAL A CHIP ADVERSE DETERMINATION

What can I do if my doctor asks for a service or medicine for me that’s covered but CFHP denies or limits it?CFHP may deny a health care service or medicine, if it is not medically necessary. A medicine can also be denied:

• If the medicine does not work better than other medicines on the CFHP Preferred Drug List.• If there is another medicine that is similar that you must try first that you have not used before.

If you disagree with the denial, you can ask for an appeal.

How will I find out if services are denied?You will receive a letter telling you about the decision, with an appeal form.

When do I have the right to ask for an appeal? Does my request have to be in writing? Can someone from CFHP help me file an appeal?If you are not happy with the decision, you can appeal by phone or by mail. Send in the appeal form, or call us. A Member Services Advocate can help you file an appeal. Just call (210) 358-6300 or toll free at 1-800-434-2347.

What are the timeframes for the appeal process?You must request an appeal within 180 days from the date on your notification of the denial, reduction or suspension of previously authorized services, or by the effective date of the action. You may provide appeal information by phone, in writing or in person. We will send you a letter within 5 calendar days to tell you we received your appeal. We will mail you our decision within 30 calendar days.

What if the services I need are for an emergency or I am in the hospital?For emergencies or hospital admissions, or to continue current prescriptions and intravenous medications, or for denial of step therapy medication protocol exception, you can request an Expedited Appeal.

What is an expedited appeal?An Expedited Appeal is when the health plan has to make a decision quickly based on the condition of your health, and taking the time for a standard appeal could jeopardize your life or health.

What are the timeframes for an expedited appeal?If we have all the information we need, we will have an answer within one to three days after we recieve your appeal.

How do I ask for an expedited appeal? Who can help me in filing an appeal? Does my request have to be in writing?Call us. Our Member Service Advocates can help you. Your request does not have to be in writing.

What happens if CFHP denies the request for an expedited appeal?We will notify you. Your request will be moved to the regular appeal process and we will notify you of the change by mail within 2 calendar days.

What if I am not happy with the answer to my appeal? Can I request an External Review? You can ask for an External Review if you are not satisfied with the CFHP decision on your appeal. You are not required to pay for the cost of the External Review. If CFHP does not answer your standard or expedited appeal within the timelines given, you may request an External Review without waiting for the answer to your appeal. Call MAXIMUS Federal Services at the address and phone numbers below.

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HHS Federal External Review Request MAXIMUS Federal Services 3750 Monroe Avenue, Suite 705 Pittsford, NY 14534 Fax Number: 1-888-866-6190 Telephone Number: 1-888-866-6205

What are the timeframes for an External Review? An External Review must be requested within four months from the receipt of the CFHP appeal decision letter. You must complete the request form and submit it to MAXIMUS Federal Services or call MAXIMUS. CFHP will provide all the documents and information related to the denial to the External Reviewer. You may submit any additional information you want the External Reviewer to consider. The External Reviewer will mail you and CFHP the decision within 45 days after the date the examiner receives the request for External Review.

For life-threatening conditions, urgent care situations and for current prescriptions and intravenous medications, you can call MAXIMUS to request an expedited External Review before or after exhausting the CFHP appeal process. The reviewer will send a decision as soon as possible, but no later than 3 days after the examiner receives the request for an expedited External Review.

INDEPENDENT REVIEW ORGANIZATION PROCESS

What is an Independent Review Organization?This is a group of doctors, who are not employees of CFHP. A specialist will review your appeal and make a final decision.

How do I ask for a review by an Independent Review Organization?Call us to request a review by an Independent Review Organization. You can also request it in writing.

What are the timeframes for this process?We will mail you the final decision within 15 calendar days from when we received your request for an Independent Review Organization.

What if I am not happy with the final decision?If you are still not happy, you can contact the Texas Department of Insurance (TDI). You can contact TDI at:

Texas Department of InsuranceP.O. Box 149104

Austin, TX 78714-9104 1-800-252-3439

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NEW MEDICAL TECHNOLOGY

The Community First Medical Director and participating providers review and evaluate new medical advances in technology (or the new application of existing technology). This is done for medical procedures, behavioral health procedures, pharmacy management, and devices on an individual basis to determine if they are appropriate for covered benefits. Scientific literature and government approval are reviewed for determining if the treatment is safe and effective. The new medical advance or treatment (or new application of existing technology) must provide equal or better outcomes than the existing covered benefit or therapy for it to be considered for coverage.

For more information about how Community First reviews new medical technology, please call us. We can be reached at (210) 358-6300 or toll-free at 1-800-434-2347.

HealthEducationClasses


FRAUD AND ABUSE: REPORT CHIP WASTE, ABUSE OR FRAUD

Do you want to report CHIP Waste, Abuse, or Fraud? How do I report someone who is misusing/abusing the Program or services?Let us know if you think a doctor, dentist, pharmacist at a drug store, or other health-care provider, or a person getting CHIP benefits is doing something wrong. Doing something wrong could be waste, abuse or fraud, which is against the law. For example, tell us if you think someone is:

• Getting paid for CHIP services that weren’t given or necessary.• Not telling the truth about a medical condition to get medical treatment.• Letting someone else use a CHIP ID.• Using someone else’s CHIP ID.• Not telling the truth about the amount of money or resources he or she has to get benefits.

To report waste, abuse, or fraud, choose one of the following:• Call the OIG Hotline at 1-800-436-6184;• Visit https://oig.hhsc.state.tx.us/ Under the box labeled “I WANT TO,” click “Report Fraud, Waste, or

Abuse” to complete the online form; or• You can report directly to your health plan:

Community First Health Plans12238 Silicon Drive, Suite 100

San Antonio, TX 782491-800-434-2347

To report waste, abuse or fraud, gather as much information as possible�• When reporting about a provider (a doctor, dentist, counselor, etc.) include:

¡ Name, address, and phone number of provider ¡ Name and address of the facility (hospital, nursing home, home health agency, etc.) ¡ Medicaid number of the provider and facility, if you have it ¡ Type of provider (doctor, dentist, therapist, pharmacist, etc.) ¡ Names and phone numbers of other witnesses who can help in the investigation ¡ Dates of events ¡ Summary of what happened

• When reporting about someone who gets benefits, include: ¡ The person’s name ¡ The person’s date of birth, Social Security Number, or case number if you have it ¡ The city where the person lives ¡ Specific details about the waste, abuse or fraud

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Community First Health Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, gender identity, or sexual orientation. Community First Health Plans does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, gender identity or sexual orientation.

Community First Health Plans provides free auxiliary aids and services to people with disabilities to communicate effectively with our organization, such as:

• Qualified sign language interpreters

• Written information in other formats (large print, audio, accessible electronic formats, and other written formats)

Community First Health Plans also provides free language services to people whose primary language is not English, such as:

• Qualified interpreters

• Information written in other languages

If you need these auxiliary services, please contact Community First Member Services at 1-800-434-2347. TTY (for hearing impaired) at 210-358-6080 or toll free 1-800-390-1175.

If you wish to file a complaint regarding, claims, eligibility, or authorization, please contact Community First Member Services at 1-800-434-2347.

If you feel that Community First Health Plans failed to provide free language services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, gender identity, or sexual orientation, you can contact the director of Compliance by phone, fax or email at:

(210) 510-2482 TTY number: 1-800-390-1175 Fax: (210) 358-6014 E-mail: [email protected]

You may 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. You may also file a complaint 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 Phone: 1-800-368-1019 1-800-537-7697 (TDD)

Complaint forms are available at: http://www.hhs.gov/ocr/office/file/index.html.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asisten-cia lingüística. Llame al 1-800-434-2347 (TTY: 1-800-390-1175).

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-434-2347 (TTY: 1-800-390-1175).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-434-2347 (TTY：1-800-390-1175）。

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-434-2347 (TTY: 1-800-390-1175)번으로 전화해 주십시오.

.ناجملابلصتا رب مق 2347-434-800-1 مقر نإف تامدخ اسملا ةدع وغللا ةی وتت ف كل-800-1 :ةظوحلم اذإ تنك ثدحتت ركذا،ةغللاتاھ مصلا لاو: 390-1175

یک تامدخ تفم ںیم بایتسد ںیہ ۔ لاک ود وب ےتل،ںیہ وت پآ وک نابز یک ددم :TTY) 2347-434-800-1 ربخ :راد رگا پآ راک (1-800-390-1175

PAUNAWA: Kung nagsasalita ka ng Ta-galog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-434-2347 (TTY: 1-800-390-1175).

ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-800-434-2347 (ATS : 1-800-390-1175)

ध्यान द: यद आप हदी बोलते ह तो आपके िलए मुफ्त म भाषा सहायता सेवाए ंउपलब्ध ह। 1-800-434-2347 (TTY: 1-800-390-1175) पर कॉल कर। یم وگتفگ یسراف نابز هب رگا :هجوت ناگیار تروصب ینابز تالیهست ،دینک-434-800-1 .دیریگب سامت امش یارب2347 (TTY: 1-800-390-1175)

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfs-dienstleistungen zur Verfügung. Ruf-nummer: 1-800-434-2347 (TTY: 1-800-390-1175).

ध्यान दें: यदि आप हिंदी बोलते हैं तो आपके लिए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-800-434-2347 (TTY: 1-800-390-1175) पर कॉल करें।ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-434-2347 (телетайп: 1-800-390-1175).

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-434-2347 (TTY:1-800-390-1175）まで、お電話にてご連絡ください。

ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ້າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາ, ໂດຍບໍ່ເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-800-434-2347 (TTY: 1-800-390-1175).

12238 Silicon Drive, Ste. 100 • San Antonio, TX 78249

www.cfhp.comMember Services: 1-800-434-2347

Documents

Keeping our commitment to you!...Call your perinatal provider’s office first if you need urgent care. The doctor must have his or her phone answered 24 hours a day, seven days a