Summertime is for fun and checkupsAs our children grow, they need checkups. Sometimes they need a well-child checkup. They need these when they are babies and when they are teenagers. If your child has not had one recently, check with your primary care physician (PCP) to see if it is time.

Sometimes we notice things our children are doing or not doing and wonder about them. This includes changes in moods and behaviors. Maybe you wonder, “What’s going on with my child, they never used to do this.” Your primary care physician can help with this as well. They can do some quick assessments in the office to determine if your child

might be at risk for things like ADD, depression or even substance use. If they cannot provide the assessment or think more help is needed, they can give you advice. Or you can call us. Our member services representatives and case managers can help with this as well.

Sometimes these things you wonder about can be an early sign of something that could lead to problems later. Please talk to your

primary care provider about these things during a regular check-up. Make a list of questions before you go so you remember everything. Early to mid-summer is a great time to do this before “back-to-school” time.

Presorted StandardU.S. Postage

PAIDDallas, TX

Permit No. 178

Aetna Better HealthP.O. Box 569150Dallas, TX 75356-9150

AM

TX-16-04-04

Summer 2016

AETNA BETTER HEALTH®

Welcome to Aetna Better Health of TexasChoosing the right health plan for yourself and your family is important. We’re very glad you chose Aetna Better Health as your managed care health plan.

With Aetna Better Health, you’ll get all the Medicaid or CHIP benefits you have now—plus more.

You’ll be able to:• Choose a doctor or health care provider close to where

you live• Get rides to your scheduled medical appointments at

no cost to you• Talk to a nurse 24 hours a day, 7 days a week• Call member services for more services and benefits

Keeping you healthy is our No. 1 goal. That means connecting you with the care and resources you need, when you need them.

Give us a call—we’re here to help! You can call us with questions toll-free at: • 1-800-306-8612 (Medicaid Tarrant)• 1-800-248-7767 (Medicaid Bexar)

1 2 Birth month months

HepB

RV

HepB

DTaP

Hib

PCV

IPV

Shaded boxes indicate the vaccine can be given during shown age range.

4 6 months months

HepB

RV RV

DTaP DTaP

Hib Hib

PCV PCV

IPV IPV

DTaP

PCV

Hib

Influenza (Yearly)*

HepA§

MMR Varicella

12 15 18 19–23 2–3 months months months months years

4–6 years

DTaP

IPV

MMR

Varicella

See back page for more information on vaccine­

preventable diseases and the vaccines that prevent them.

2016 Recommended Immunizations for Children from Birth Through 6 Years Old

Is your family growing? To protect your new baby and yourself against whooping cough, get a Tdap vaccine in the third trimester of each pregnancy. Talk to your doctor for more details.

For more information, call toll free 1-800-CDC-INFO (1-800-232-4636)

or visit http://www.cdc.gov/vaccines

FOOTNOTES: * Two doses given at least four weeks apart are recommended for children aged 6 months through 8 years of age who are getting an influenza (flu) vaccine for the first time and for some other children in this age group.

§ Two doses of HepA vaccine are needed for lasting protection. The first dose of HepA vaccine should be given between 12 months and 23 months of age. The second dose should be given 6 to 18 months later. HepA vaccination may be given to any child 12 months and older to protect against HepA. Children and adolescents who did not receive the HepA vaccine and are at high-risk, should be vaccinated against HepA.

If your child has any medical conditions that put him at risk for infection or is traveling outside the United States, talk to your child’s doctor about additional vaccines that he may need.

NOTE: If your child misses a shot, you don’t need to start over, just go back to your child’s doctor for the next shot. Talk with your child’s doctor if you have questions about vaccines.

2

2016 activity calendarFind this year’s activity calendar on our website under the Health and Wellness tab. You can print this out and follow the activities each day to keep your family active.

Quality cornerWell-child visits for babies, children and teens bring great rewardsAll children grow and change at their own rate. Regular yearly checkups help make sure your child stays healthy and is developing well. During these visits, your child’s doctor checks your child from head to toe. If the doctor finds any problems, he or she can treat them quickly.

Your child can also get the shots he or she needs. You’ll find a schedule on page 2 from the Centers for Disease Control and Prevention (CDC).

When you take your child to the doctor, it’s a good idea to make a list of any questions you have and take them with you. This way you can get all the information you need to give your child the best care. Remember, you won’t be charged for this visit.

Happiness is a well-child visit completedYour children can get gifts when they complete their checkups.• Children ages 3 to 6 that complete yearly well-child visits get a bicycle

helmet at no cost. • Teens ages 12 to 18 that complete yearly teen well-visits get a

$10 gift card.

Call us today to learn more:• 1-800-306-8612 (Medicaid Tarrant)• 1-800-248-7767 (Medicaid Bexar)

You can find the CDC’s vaccine schedules for 0 to 6 years and 7 to 18 years on our website at: www.aetnabetterhealth.com/texas/wellness/child/shots.

Quality Improvement Program Aetna Better Health Plans work to give our members better care and services. Each year we report how well we are providing health care services. Many of the things we report on are major public health issues.

These are our 2016 goals:• Increase the number of well-visits for

children ages 3 to 6 years old• Increase childhood vaccinations• Raise the number of doctor visits for

pregnant women before and after birth• Improve overall member satisfaction

with the delivery of health care services

We want to hear from you. Our plan conducts member surveys each year. Our 2015 survey showed that members are happy with our customer service and how well doctors communicate. Our goal is to continue to improve the quality of service and care you receive.

We’ll share these results with you in our member newsletters and on the website throughout the year. You can visit us at www.aetnabetterhealth.com/texas or call member services: • 1-800-306-8612 (Medicaid Tarrant)• 1-800-248-7767 (Medicaid Bexar)

3

Keeping your appointment with your doctorMaking an appointment means the doctor’s office is aware you are coming and has made time to see you.

No matter how hard we try, sometimes life gets in the way of our plans. It may be a last-minute phone call, an unexpected visitor at the door, or you are stuck driving in traffic. The result is you may be late or miss your appointment.

What should you do? It’s important to call the doctor’s office and tell them you will be late or need to cancel the appointment.

If you’re going to be late, the office may not be able to get you in with the doctor as soon as you arrive. Or the office may suggest you reschedule your appointment for another day or time. If you have to cancel your appointment, they can usually set up a new appointment with you during the same call.

As it is with any other schedule—work, school or social plans—when you are late, you can miss something important. And you leave others waiting. No one likes to be left waiting.

It’s the same with your doctor. Most doctors’ daily schedules are full with patients needing to be seen. If one person is late, it can make the rest of

the day run behind. This can mean longer wait times for patients (like you) that arrive afterward and on time for their appointment.

Again, no one likes to be kept waiting, especially when they have an appointment. Remember the appointment you made is just as important to your doctor as it is to you. Both the doctor and you set aside time for your medical needs.

If you have ever had to wait past your appointment time, chances are, someone else was late for their appointment earlier that day.

4

Member rights and responsibilitiesJust a reminder: You can find Aetna Better Health plan member rights and responsibilities in the member handbook. The member handbook is located at www.aetnabetterhealth.com/texas/member/

medicaid/handbook. Member rights and responsibilities are distributed to new members upon enrollment and annually in the member newsletter.

Why did my doctor send me a bill?It is never fun to get bills in the mail. Doctor bills can be costly and scary. We have some tips for you to keep them out of your mailbox.

1. Always use a provider in the Aetna Better Health Network. • Not all providers have

contracts with Medicaid. You may have to pay for bills from providers who do not have contracts with Aetna Better Health.

2. Carry the paper Aetna Better Health Card with you everywhere.• An illness or accident can

happen anywhere, any time.

3. Be sure to show the doctor or hospital your Aetna Better Health Card when you arrive or before you leave.• Members are responsible for

showing proof of coverage at the time of service.

4. Make sure the name on the card matches what your doctor has on your file.• Check with the provider to

make sure the spelling of your name matches your

Aetna Better Health Card. A wrong spelling can cause the doctor’s bill to be rejected.

5. Be sure to contact the Texas Health and Human Services Commission when you move.• You can make changes to your

address and phone number by calling or going to the Your Texas Benefits website: www.yourtexasbenefits.com. Just follow these steps:- Log in to your account.- Go to the “View My Case”

section of the website.- Click on the “Case Facts” tab

near the top of the page.- Find the case number for the

record you need to change. Click on the “Report a Change” button next to that case number.

• To make changes by phone, you can call this number toll-free: 1-855-827-3748. Then select English or Spanish.

• If you were in foster care and are age 18 or older, you can call 2-1-1.

If you still get a bill from your doctor, do not ignore it. Send it to Aetna Better Health so we can find out why.

5

Prescription drugsHow to get the medicines you need Check that your pharmacy is in our network It’s easy to get your medicine when you need it. All you need to do is to take your prescription to a network drug store. Show your Aetna Better Health of Texas ID card. If you have Medicare or other coverage, you need to show that ID card also.

To get a list of network drug stores, call member services:• 1-800-306-8612 (Medicaid

Tarrant)• 1-800-248-7767 (Medicaid Bexar)

Our lines are open Monday through Friday, 8 a.m. to 5 p.m., Central Standard Time. You can also find information on our website at www .aetnabetterhealth.com/texas.

Make sure your medicines are on the Vendor Drug Program Aetna Better Health of Texas usually covers only medicines on the HHSC/VDP drug formulary that include all drugs that are Federal Drug Administration (FDA) approved for Medicaid coverage. We cover these drugs when they are medically necessary. You can find this list in your welcome packet. These are drugs that the FDA has approved.

To get a list of network drug stores you can call member services at the number on your Aetna Better Health ID card. Or you can visit our website at www.aetnabetterhealth.com/texas.

Prior authorization: Some medicines need to be approved. We must approve some medicines on our drug list before we can cover them. We do this through “prior authorization” or “Step Therapy.” Prior authorization is an approval that we require for certain services and medications.

Step Therapy: Some drugs are not approved unless another drug has been tried first. With Step Therapy (ST), we’ll ask you to try another drug first before we will cover the drug you request.

When you get a new prescription, ask your provider if you need approval for the medicine before you can get it. If so, ask if there is another medicine you can use that doesn’t need approval. If we need to approve your medicine, your provider must call us on your behalf. We’ll then review the request. If the pharmacist cannot reach us to make sure it is approved, he or she can give you a three-day temporary supply of the new drug. We’ll tell you in writing if we don’t approve the request. You have the right to appeal. We’ll tell you how to start the appeal/complaint process if you want to do that.

Quantity limits: Some drugs have limits on the number of doses you may get. This is called a quantity limit. The FDA decides safe dose limits. The pharmacist will fill your prescription according to FDA safe dosing limits. He or she will do this even if your provider wrote the prescription for more. The pharmacist will not give you more

medicine if your provider doesn’t get it approved. The pharmacist will ask your provider to call us first.

Medical exceptions: If your medicine is not on the HHSC/VDP drug formulary, ask your provider if there is one on the drug list you can use. If not, your provider must ask us for a medical exception. We will decide after review and, if necessary, after talking with your provider. We’ll need to know why the drug on our drug list won’t work for your medical condition. If your provider doesn’t ask for the exception, we may not pay for it. We will try to review the medical exception request within 24 hours. If we can’t meet this deadline, the pharmacist can give you a three-day supply of the drug. If we don’t approve your medical exception, we’ll tell you in writing. We’ll also tell you how to start the appeal process.

Brand-name drugs instead of generic alternatives: Generic drugs work just as well as brand-name medicines. Aetna Better Health of Texas pays for generic drugs when available and allowed by the vendor drug program (VDP) drug formulary. If your provider wants you to have a brand-name drug and it’s not on the VDP drug formulary, he or she must ask us for a medical exception. We will review the request. If we don’t approve the request for a brand-name drug, we’ll tell you in writing. We’ll also tell you how to start the appeal/complaint process.

6

Texas Medicaid Vendor Drug Formulary changesPreferred drug additions and deletions 2016These are changes that the Texas Vendor Drug Program (VDP) made to the 2016 VDP drug formulary. The table below lists those changes.

Recent changes to Texas Medicaid Vendor Drug Formulary 2015 to 2016

Abilify MaintenaBactrobanBydureonCleocin OvulesClortrimazole/

betamethasoneDelzicolEntrestoFelodipineFluocinolone oil

FluticasoneInvega TrinzaMometasone solutionOmeprazoleNaproxen suspensionOlanzapine ODTOrapred ODTPazeoPCE

Drugs added to Vendor Drug Formulary

Drugs moved to Vendor Drug Formulary

Moved to Non-Preferred Vendor Drug Formulary

GuanfacineMemantine

Intuniv Namenda

Total changes: 22

7

Does my child have ADHD?Attention deficit hyperactivity disorder (ADHD) can affect a child’s success in school and in peer relationships. Symptoms vary and are sometimes hard to recognize. To diagnose ADHD, a doctor will use special criteria. A child with ADHD may:• Interrupt when others are

talking or have trouble waiting their turn when playing games

• Have outbursts of anger when it seems inappropriate

• Be unable to sit still (they fidget and run around rather than sitting)

• Have trouble finishing homework, chores or projects

• Have trouble paying attention (They say they heard you but cannot tell you what you said)

• Make careless mistakes even though they know the answer

• Space out and not seem to know what is going on around them—this can be another side of ADHD, rather than being loud and overly busy

All kids have some of these behaviors some of the time. If your child has behavior that is affecting school success or leading to problems with their peers, take the next step.

Find someone to test your child for ADHD. You can ask your doctor to help you. If your child is diagnosed as having ADHD, medicine and counseling will help.

If your child begins taking medicine, take him or her back to the doctor in two to three weeks. Make sure it’s the same doctor who prescribed the medicine. Then every three or four months take your child back to the same doctor. This helps the doctor track

your child’s progress. You want to make sure the medicine is doing all it can to help your child be successful in school and with peers.

Questions? Call case management Monday through Friday, 8 a.m. to 5 p.m., at:• 1-800-306-8612

(Medicaid Tarrant)• 1-800-248-7767

(Medicaid Bexar)

Transitioning from pediatric to adult providersIf you or someone in your family is 18 years or older and is identified as “medically fragile” by your medical providers, we can help you get the right care. Just call one of our case managers.

Our case manager can help you move from pediatric providers to adult providers. You can continue to see your pediatric providers while looking to see which adult providers work best for you.

Our goal is to ease the stress of transitioning to an adult medical provider. Call member services at: • 1-800-306-8612 (Medicaid Tarrant)• 1-800-248-7767 (Medicaid Bexar)

8

Access and availabilityGet the care you need when you need itAetna Better Health of Texas is helping provide the best health care possible for our members. When our members and health care providers work together, they can achieve the best outcome. This starts with our members knowing where, when and how they can get care.

All members have the right to be seen by a provider within certain time frames. This is called appointment and access availability. That generally means how soon you can expect to get care. You should know the appointment and access availability standards so you can get the care you need when you need it. The amount of time it takes often depends upon the type of care you need and how urgent it is.

Access and availability standards for Aetna Better Health members

Provider type                                      Time frame in days

Primary care provider (PCP)

Emergency  24 hours a day, 7 days a week

Urgent care                                         24 hours a day

Routine  Within 14 days of request

Specialist

Routine behavioral health      Within 14 days of request

Pregnancy care

First trimester                                     Within 14 days of request

High-risk pregnancy or new members in the third trimester            

Within 5 days of request

Our providers want to meet these standards to give the best service possible. If you have a problem getting an appointment or cannot be seen as noted above, let us know. Just call the member services phone number located on the back of your member ID card.

Integrated Care ManagementWe have an Integrated Care Management program that supports people with special health care needs. This program can help you to get the care you need. This includes: • Needs when you are pregnant• Behavioral health needs, such as for

depression or anxiety• Long-term illness, such as diabetes• Other health care needs

We are here to help as much or as little as you would like.

If you are enrolled in the program, your team may include the following people: • A care manager• A care management associate

Your team members are here to help you. They will work with you and your providers. They will help you meet the health goals that are important to you. They will provide information about the program that includes:• How to use the services• How to be eligible to participate• How to opt in or opt out

They will also:• Provide you with resources• Provide educational handouts• Help with access to other services

If you are our member and you would like to participate in this program, then you can. Providers, family members or caregivers can also refer a member for care management. Call member services at the number below and ask for care management: • 1-800-306-8612 (Medicaid Tarrant)• 1-800-248-7767 (Medicaid Bexar)

Health care for children of seasonal farmworkersDo you travel from place to place to work on farms or ranches?

Aetna Better Health wants you to get the health care services your child might need. We can help you plan for checkups and shots

with your child’s doctor that may be due when you are working out of the area. Call 1-800-327-0016 for more information.

9

Notice of privacy practices We are required by law to keep your health information private. The notice of privacy practices explains how we use health information about you. It also lets you know when we can share that information with others. It tells you about your rights to your health information and how you can protect those rights.

We use the words health information when we mean information about your health that identifies you. Examples may include:• Name• Date of birth• Health care you received• Amounts paid for your care

We may need your written OK before sharing some informationIn some cases we must ask you for your written OK before using or sharing your health information. Some examples are:• Before sharing your psychotherapy notes• For other reasons as required by law

You can cancel your OK at any time. To cancel your OK, let us know in writing.

Also, we cannot use or share your genetic information when we provide you with health care insurance.

You have the right to know if we shared your health information without your OK. If this happens, we will send you a letter.

Your right to a second opinionAs a member of Aetna Better Health, you have the right to get a second opinion from a qualified health care professional. This is at no cost to you.

You may want to confirm you’re getting the right treatment for an illness. Or you may want to ask about surgery your provider says you need.

To ask about getting a second opinion, just call

member services at:• 1-800-306-8612

(Medicaid Tarrant)• 1-800-248-7767

(Medicaid Bexar)

There’s no extra cost to you for a second opinion from a provider in our network. For a second opinion from an

out-of-network provider, you’ll need approval from us. If there isn’t a network provider available, we’ll help you get a second opinion from an out-of-network provider. This is still at no cost to you.

You can get a copy of the updated privacy notice online at www.aetnabetterhealth.com/texas/members/privacy or by calling us toll-free: • 1-800-306-8612 (Medicaid Tarrant)• 1-800-248-7767 (Medicaid Bexar)

You can also write to us at:

Aetna Better Health P.O. Box 569150 Dallas, Texas, 75356-9150

10

Access to women’s health servicesFemale members have direct access to a women’s health care specialist without an OK from their doctor or from the plan for Aetna Better Health for covered services such as:• Prenatal care• Breast exams• Mammograms• Pap tests

Aetna Better Health also covers these services for women:• Well-women visits, including

routine prenatal care• Family planning methods

and counseling• Human papillomavirus

(HPV) testing• Counseling for sexually-

transmitted infections• Counseling and screening for

human immunodeficiency virus (HIV)

• Screening and counseling for interpersonal and domestic violence

• Screening for diabetes, if you are pregnant

• Support, supplies and counseling for breastfeeding

Questions about your benefits? Call member services at:• 1-800-306-8612 (Medicaid

Tarrant)• 1-800-248-7767 (Medicaid Bexar)

Utilization Management Making sure you get the right careWe designed our Utilization Management program to assist members like you in getting the right care at the right time. Our Utilization Management (UM) staff can help you and your doctors make decisions about your health. Your care and satisfaction are at the center of what we do.

How we make decisions• We base UM decisions

on the appropriateness

of the care and services you need.

• We don’t base our decisions on past coverage.

• We don’t reward doctors. We don’t reward other people for denying coverage or care services.

• Our decisions are not based on financial incentives. That could result in fewer services that our members need.

If you ever need to contact someone from UM, just call member services at: • 1-800-306-8612

(Medicaid Tarrant)• 1-800-248-7767

(Medicaid Bexar)

The UM department has a toll-free voicemail and phone line available 24 hours a day, 7 days a week. The UM department conducts outgoing communications with practitioners and providers regarding authorizations during the hours of 8 a.m. and 5 p.m. CST. Communications received after normal business

hours are returned on the next business day. Communications received after midnight Monday through Friday are responded to on the same business day. Member services can also provide callers with TDD/TTY. We have language assistance services for providers and members who need them. UM staff self-identify by name, title and organization name when initiating and returning calls regarding UM issues.

11

Safely access your health information online We protect your privacy Our secure online web portal offers you a fast, convenient way to access services, ask questions and get any information you need. You can access the web portal on our website. It’s easy. All you need to do is register and create a log-in.

You can register for the portal today on a computer or on your mobile smart phone. You’ll need your health plan member ID number and a valid email address to complete the process. Just go to www.aetnabetterhealth.com/texas. Once on the site, go to the “Member Log In” link, and then “Log In to the Web Portal.” Then click the “Register Now as Member” button to get started. After you log in, look at the bottom of the screen for a link to our privacy policy.

Below are some of the great benefits you can get by accessing this portal:• Health and wellness: You can complete

a health survey and track your health progress online.

• Access to educational resources and programs: You’ll find self-help tools for topics like breaking the smoking habit and weight management.

• View the status of claims: You can view your claims from start to finish.

• Access to pharmacy benefit services: You can:

-Get information on drug costs. -Request an exception for a drug your plan doesn’t cover. -Locate a pharmacy. -Ask a pharmacist about medications.

• Access personalized information on health plan services: You can:

-Request an ID card. -Change your primary care provider. -Get information on referrals and authorizations.

• Access special services: You can: -Complete a personal health record online. -Complete a screening to see if you’re eligible for disease management or wellness programs.

• Access a health information line: You can send a question to a nurse about a health issue and receive a response within 24 hours.

For more information, just visit our website. You can also register by calling member services at: • 1-800-306-8612 (Medicaid Tarrant)• 1-800-248-7767 (Medicaid Bexar)

Healthy Living is published for the members of Aetna Better Health, P.O. Box 569150, Dallas, TX 75356-9150.

This is general health information and should not replace the advice or care you get from your provider. Always ask your provider about your own health care needs.

Models may be used in photos and illustrations.

Tarrant Medicaid 1-800-306-8612

Bexar Medicaid 1-800-248-7767

Medical transportation 1-855-687-3255

Seasonal Farmworker Hotline 1-800-327-0016

Texas HHSC 1-800-252-8263 or 2-1-1

(Call to find the nearest HHSC office and for customer service.)

2016 © Coffey Communications, Inc. All rights reserved.

AM

www.aetnabetterhealth.com/texas12