Member Handbook - Community Care Alliance of Illinois

Member
Handbook
Health Services for Independent Living
Welcome to CCAI
Community Care Alliance of Illinois (CCAI) is a not-for-profit health plan
sponsored by safety-net hospitals.
CCAI exists to help seniors and adults with disabilities. CCAI provides
you with all the same services covered by the State’s Primary Care Case
Management Program (PCCM) and more, including coordinated care and
bonus benefits.
Our goal is to help you feel and function better. We do this by creating a care
plan that is just for you. We also focus on prevention, health and wellness. Our
providers will help you get the right health care at the right time.
CCAI Contact Information:
Member Services:
322 South Green Street • Chicago, IL 60607
866-871-2305 • 312-932-8181
TTY for the Hearing Impaired: 888-461-2378
Website: www.ccaillinois.com
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Table of Contents
CCAI Service Area ........................................................................... 4
Member Service Commitment......................................................... 4
Member ID Cards............................................................................ 4
Your Primary Care Provider and Primary Care Team..................... 5-7
Selecting a PCP......................................................................... 5
Anchor Health Homes............................................................... 5
Anchor Health Homes Map....................................................... 6
Changing Your PCP.................................................................... 6
Contacting Your Doctors (PCP or WHCP).................................. 6
Making an Appointment with your PCP..................................... 7
Your Primary Care Team............................................................ 7
Care Management and Disease Management............................ 7
Preventative Services and Health Education.................................... 8
Covered Medical Services................................................................ 8
Preventive Services.................................................................... 9
Health Education....................................................................... 9
Referral Services.............................................................................. 9
Second Opinion........................................................................ 9
Emergency Care............................................................................. 10
Urgent Care............................................................................. 10
Emergency Care...................................................................... 10
Hospitalization........................................................................ 10
Behavioral Health................................................................... 11
Transportation................................................................................ 11
Prescription Drugs ........................................................................ 11
Bonus Benefits............................................................................... 12
Member Rights............................................................................... 13
Disenrollment Procedure............................................................... 14
Advance Directives (Living Will).................................................... 14
Complaint & Grievance Procedures.......................................... 14-15
Medical Care Appeal............................................................... 15
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CCAI Service Area
CCAI serves people living in the following counties in Rockford: Boone,
McHenry and Winnebago.
Member Service Commitment
We have an experienced Member Services Staff. They are disability-competent.
This means that they are specially trained to answer your questions and help
you get the care you need.
Call 866-871-2305 to speak with a member of our staff. This is a free call.
Hours are 8:30 a.m. to 5 p.m. Monday through Friday.
We can take calls in any language. Information is also available in different
formats. These include large font, TTY and more.
Our Staff will:
• give you a welcome call
• explain how to get services
• answer your questions
• send you a CCAI member ID card
Member ID Cards
Your Member ID card
Every CCAI member receives an ID card.
Always carry it with you. The card has:
• your name
• your doctor’s information
• member services phone number
• behavioral health services
phone number
• pharmacy information
• nurse hotline phone number
It also has our web address and other
important phone numbers that you can
call to get help any time, day or night.
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• help you contact your Long-Term
Services and Supports or Nurse
Care Coordinator
• schedule medical transportation
Your Primary Care Provider and Care Team
When you join CCAI you will be asked to choose a primary care provider (PCP).
Your PCP is your main doctor or nurse practitioner. They know about the issues
that you face. Your PCP will keep your health records and arrange for all of your
medical care. This includes preventive care and referring you to a specialist.
Your PCP may be a:
• Family Practice Doctor who cares for people of all ages
• Internal Medicine Doctor who focuses on adults
• Nurse Practitioner who has received training to provide primary care
• Women’s Health Care Provider (WHCP) who focuses on women’s health
• Specialist who knows about special health care needs (only for those
who qualify)
Selecting a PCP
You can choose a PCP on our website. You can also call Member Services at
866-871-2305 and we can help you find a PCP who is right for you.
If you have a PCP that you like, but they are not in our network, you can ask to
keep seeing your doctor for up to 90 days. During this time we’ll ask your PCP
to join CCAI. If your doctor doesn’t agree, then you’ll be asked to choose a
different one.
Anchor Health Homes
If you don’t have a PCP, you might want to select one at a CCAI Anchor Health
Home. (But you can chose any PCP in the CCAI network.) Anchor Health
Homes are sites of care that have committed to offering a range of services to
CCAI members. They are fully disability accessible. Allowing for total access
from the parking lot to the exam room. They also offer a wide range of services
on-site.
CCAI’s Anchor Health Homes include:
• Crusader Clinic
• Rockford Health System
To learn more about Anchor Health Homes, call Member Services
at 866-871-2305.
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Anchor Health Homes Map
Changing your PCP
You may change your PCP or WHCP at any time. To do so, call Member
Services or visit our website. The phone number to call is 866-871-2305.
You can go to your new doctor the first day of the next month.
Contacting Your Doctors (PCP or WHCP)
You can call your doctor 24 hours a day. If your doctor is not available, he will
have a “doctor on call” who will care for you. The telephone number for your
doctor is printed on the front of you Member ID Card. Remember to carry your
Member ID Card with you at all times.
If you have a question about your health, a symptom or your medications, you
can also call our free nurse hotline at 888-346-4968. It is available to you 24
hours, 7 days a week.
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Making an Appointment with your PCP
You should make an appointment to see your PCP as soon as possible after you
join CCAI. This is even more important if you have never seen them before.
Most doctors and nurse practitioners work by appointment.
• If you need an appointment, call the PCP office at the phone number on
your ID card.
• If you are going to be late for your appointment, call the PCP’s office to
let them know. They may ask you to set up another appointment time.
• If you need to cancel your appointment, call your PCP’s office.
Your Primary Care Team
In addition to a PCP, you will have a Nurse Care Coordinator. Other members
of your care team may also include:
• Physician Specialist
• Social Worker who can connect you to social and community services
• Registered Nurse who is fully trained in care management
• Physical, Occupational and Speech Therapists
• Peer Support Counselor who has a similar condition to yours or experience
Care Management and Disease Management
A Nurse Care Coordinator will coordinate your care. They will help your care
team develop your Care Plan. You will have the chance to approve your Care
Plan.
A Nurse Practitioner may visit you in your home. They can assess your health
and well-being.
Your Nurse Care Coordinator will work with you to help you reach your health
goals. They will:
• get to know you and help you set and reach goals
• help you get services and supplies you need
• coordinate your services
• offer guidance and support
• serve as a key resource
• consult with your care team
• ensure consistency of services
• act as an advocate for you
You can reach your Nurse Care Coordinator during regular business hours at
866-871-2305.
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Preventive Services and Health Education
All new members are asked to complete a Health Risk Survey. This form asks
about your needs for services including:
• Medical
• Social
• Functional
• Psychiatric
• Environmental
• Financial
Your answers will be used to develop your care plan. Your Primary
Care Team will meet with you every week, month or year depending
on your needs.
Covered Medical Services
Here’s a list of some of the medical services we cover. For a complete listing,
look in your Certificate of Coverage. This can also be found on our website
www.ccaillinois.com.
• Medical visits
• Laboratory and x-ray services
• Emergency care
• Behavioral health
• Home health care
• Preventive services
• Hospital inpatient services
• Health and wellness programs
• Physical therapy
• Hospice
• Optical services
• Prescription drugs
• Preventative Dental services
• Family planning
• Speech and language therapy
Transportation to all appointments is available if needed. To schedule a ride,
call Member Services at 866-871-2305.
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Preventive Services
We want to keep you healthy. You may get your shots, medical checkups and
care through CCAI.
You also will get reminders about preventive services. Below are some
preventive services we offer:
• Free Weight Watchers membership
• Diabetic care program
• Mammogram program
• AfterCare program
• Free health and wellness classes
Health Education
Health information can be found on our website www.ccaillinois.com. Health
topics are also discussed in the Member Newsletter.
CCAI Anchor Health Homes and hospitals will have special events that you can
attend. These include special programs and health education classes.
Referral Services
When you need care that your PCP can’t provide, you may be given a referral.
A referral is needed to see a doctor other than your PCP. It is also required
for specialty care services. Your Nurse Care Coordinator will help you get
a referral.
You don’t need a referral for:
• Regular tests or screenings
• Urgent care
• Emergency services
• Behavioral health and substance
abuse services
You do need a referral for:
• Specialty care
• Scheduled surgery
• MRI and CT Scans
• Scheduled hospitalization
Second Opinion
Your doctor may want you to have surgery. Or diagnose you with a disease.
You may want to talk to another doctor.
If you do, you have the right to ask for a second opinion. To arrange for one,
call Member Services at 866-871-2305.
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Emergency Care
Urgent Care
Urgent Care means you need health care soon, but it is not an emergency.
Call your PCP. Do not wait for your next appointment. The name and number of
your PCP are on the front of your member ID card. Your PCP will listen to you,
evaluate your condition and see you within 24 hours, if needed.
Examples of urgent care are:
• Ear aches
• Skin infections
• Minor burns or cuts
• Blistered sunburn
• Bad cold or sore throat
Emergency Care
An emergency is any medical problem that would cause death or long term
injury if not treated right away. CCAI will cover Emergency Medical care. It
does not matter where you are or when you need it.
In an emergency you should:
• Go to the nearest emergency room
• Call 911
• Call an ambulance if there is no 911 service in the area
Examples of an Emergency Medical condition include:
• Heavy bleeding
• Shock
• Extreme pain
• Poison
• Chest pain
• Convulsions or extreme bodily
shaking
• Severe burns
•
Broken bones
• Passing out
• Throwing up blood
• Difficulty breathing
Hospitalization
If you need to go to a hospital, your PCP tell you where to go. They will send
you to a hospital that is in the CCAI network. Your PCP will work with CCAI to
get approval for your in-patient care.
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If you are hospitalized after an emergency, you should have someone contact
CCAI within 24 hours or as soon as reasonably possible. The phone number to
call is 866-871-2305.
When you are stable, you may be moved to a CCAI network hospital. After an
Emergency Medical condition, you must get all your follow-up care through
your PCP.
Behavioral Health
You can get mental health services and help with drug or alcohol abuse
from CCAI. You do not need a referral from your PCP.
We work with PsychHealth, Ltd., and have more than 650 professionals who
can help you. To speak with someone at PsychHealth, call 800-753-5456.
No one will know that you called.
Transportation
If you need a ride to the doctor, call Member Services. The number is
866-871-2305. You must call more than one business day before your
appointment to get a ride.
Rides are for the member with the appointment. A family member or
caregiver may go too. After the appointment, the driver will stop at a
pharmacy so you may get prescritions filled on the way home.
Prescription Drugs
CCAI has chosen CVS Caremark to provide
your prescription benefits. You can go to
any CVS in the network. Most other local
pharmacies are in-network too.
You should take your CCAI ID card with you to the pharmacy. This will help you
avoid filling out claims.
• For up to a 30-day supply, go to a participating pharmacy.
• For up to a 90-day supply, mail order prescriptions to your home.
To find an in-network pharmacy, call Member Services at 866-871-2305
or visit our website www.ccaillinois.com.
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Bonus Benefits
CCAI offers our members extra free services. They include:
Co-Pays: Members do not pay co-pays: Jewel/Osco Coupons: Members can
ask for and get up to five $1 Equaline
• To go to the
Room
coupons per month. Equaline is the
doctor
• F or hospital
Jewel-Osco generic brand.
• To go to the
services
Emergency
• F or prescriptions Mammogram Program: Female
members over 40 years old can get a
Adaptive Tai Chi: Information about
$25 Payless gift card. They must have
Tai Chi is on the CCAI website at
their annual breast check.
www.ccaillinois.com. Members can
go to classes for free if told to.
Medical AfterCare Incentive Program:
Members can get Target gift cards. They
must see their doctor within 15 days after:
• An Emergency Room visit ($10)
• A hospital stay ($20)
Chronic Disease Self-Management
Programs: Members who have a longlasting disease can go to classes. CCAI
will pay for these classes. Members will
get a $25 Target gift card just for going.
Nurse Line: CCAI’s Nurse Line is available
24 hours/day 7 days/week. Nurses
will answer your health questions. The
number to call is 888-346-4968.
Prepaid Cell Phone: Some members
can get prepaid cell phones. The phones
can be used to call only 911 or their:
• Doctor
• Care Coordinator
Preventive Dental Visits: Members can get
their teeth cleaned two times each year.
Diabetic Care Program: Members
who have diabetes can get a $30
Target gift card. They must be in
Care Management. Also, they must
complete:
• A PCP visit
screening
• Blood test
• E ye exam
• Cholesterol
•U
rine screening
Psych AfterCare Rewards Program:
Members who see their doctor after going
to the hospital for mental health get JewelOsco coupons. Members can get a:
• $20 coupon if they see their doctor
within 7 days
• $10 coupon if they see their doctor
within 30 days
Extra Pharmacy Benefits: Members can
order their medicine. It will be sent to
them in the mail. They can get up to a 90day supply this way. The phone number
to call is on the Member ID card.
Vision Rebate: Members can get $20
back for glasses or contacts. Members
can get the money back once a year.
Extra Transportation Benefits: Members
can get a free ride to the drug store
after going to the doctor.
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Weight Watchers Membership:
Members can go to Weight Watchers
for free. Weight Watchers helps people
lose weight.
For more information, call Member
Services at 866-871-2305 or email
us at [email protected].
Member Rights
CCAI members have the right to:
• Be treated with dignity and respect
•Privacy
• Receive quality health care
• Receive an explanation of
their illness
• Receive an explanation of their
treatment options
• Share in deciding the type of care
they will receive. Persons under
18 who are married, pregnant, or
have a child also have this right.
• Refuse health care (to the extent
of the Law) and understand what
may happen if they do
• Ask for a summary of their records
• Request that their medical records
be changed
• Be free from any form of restraint
or seclusion used as a means of
coercion, discipline, convenience
or retaliation
• To be free to exercise these rights
and the exercise of these rights
does not adversely affect the way
CCAI treats members
• Make a Living Will
CCAI members have the responsibility to:
• Treat members of their Care Team
• Become involved in their health
with dignity and respect
care
• Make and keep appointments and
• Consider the outcome of refusing
be on time. Call if they need to
treatment
cancel an appointment or if they
• Learn and follow the CCAI policies
will be late.
in their Member Handbook
• Get referrals from their CCAI doctor
• Carry their CCAI member ID card
• Notify CCAI as soon as possible
with them at all times
after receiving emergency room
• Report any lost or stolen cards to
services
CCAI Member Services
• Explain their health problem and
• Call Member Services if they
symptoms to the doctor and to ask
need help
questions
• Respect the privacy of other
• Follow their doctor’s treatment plan
people waiting for health care
• Discuss with their doctor anything
services
that could keep them from
following his or her instructions
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Disenrollment Procedures
You can stop being a CCAI member at any time. To disenroll, call Member
Services at 866-871-2305. You can also call the State Client Enrollment Services
at 877-912-8880 to change medical plans.
If you have been disenrolled from CCAI due to loss of eligibility, call the
Client Enrollment Services at 877-912-8880 to re-enroll.
Advance Directives (Living Will)
This is how you can express your wishes (if something were to happen to
you). It is a legal paper to write down what medical care you want. If you
have questions, call Member Services at 866-871-2305.
Complaint and Grievance Procedures
If you have a problem with CCAI, call Member Services. We will try to help you.
You, or someone you want to speak for you, can contact us. If you want someone
else to speak for you, you’ll need to let us know this. To contact us you can:
• Call Member Services at 866-871-2305
TTY for the Hearing Impaired 888-461-2378
• Write us a letter or email telling us why you are unhappy. Be sure to include
you Name and CCAI ID Number. Put your phone number in the letter too.
Mail the letter to:
Community Care Alliance of Illinois
Member Services Department
322 South Green Street, Suite 400
Chicago, IL 60607
Or email us privately at: [email protected]
CCAI will follow up within 3 business days. If we cannot reach you we will
send you a letter.
If you do not agree with us, you may submit a formal grievance in writing at the
address or email address above. We will work to resolve your formal grievance
within 90 business days. We may ask for an extension of 14 days. If we need
more time, we will notify you by letter within 3 business days. When your
formal grievance is resolved, we will notify you within 10 days in writing.
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You may request a fair hearing to HFS if you still do not agree with us. Your
request must be made to HFS between 20 and 90 days from the date of our
letter. Send the request to
Illinois Department of Healthcare and Family Services
Fair Hearing System
401 South Clinton
Chicago, IL 60607-3800
Medical Care Appeal
If we deny you medical care, you can ask us to change our decision. This
process is called an Appeal. You must contact us within 90 days. We will notify
you in writing of the Appeal decision.
We may deny the Appeal because we believe the medical care is not
appropriate or necessary. If you disagree, you may request an external
independent review in writing. Your request must be written in 30 days. CCAI
will notify you of the process. The external independent reviewer will make a
decision within 5 days. You will be notified in writing.
If you do not agree with the results, you may request a hearing through the HFS
Fair Hearing Process. You must do so between 20 and 90 days from the date of
the external independent review result letter.
If your Appeal remains denied, you can submit a request for a fair hearing to:
Illinois Department of Healthcare and Family Services
Fair Hearing System
401 South Clinton
Chicago, IL 60607-3800
The decision by HFS is final.
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322 S. Green Street, Suite 400
Chicago Illinois 60607