Commonwealth Care Member Guide - BMC HealthNet Plan

Your Plan for
Total Health
COMMONWEALTH CARE MEMBER GUIDE

HOW IS THE MEMBER GUIDE DIFFERENT
FROM THE EOC?
Your Plan for
Total Health
COMMONWEALTH CARE MEMBER GUIDE
MEMBER GUIDE
Quick reference that answers
basic BMC HealthNet Plan
Commonwealth Care health
insurance questions for
new members
Contains helpful tips
and reminders
EOC
Important legal document
that describes the relationship
between you and BMC
HealthNet Plan
Contains details about what
is covered and what is not
covered
Answers your questions
related to membership in our
Commonwealth Care plan
THE MEMBER GUIDE
AND EOC CAN BE FOUND
ONLINE AT BMCHP.ORG.
This document is intended only as a guide and does not contain complete information on your health coverage. Please refer to your
Evidence of Coverage (EOC) for all information on your rights and obligations as a member in the Plan, how the Plan works, covered
services, certain limits and conditions related to covered services, co-payments you must pay when you receive covered services and
other important information related to your membership. The EOC is the legal document that describes the relationship between you
and BMC HealthNet Plan.
1

GENERAL MEMBER INFORMATION
Welcome to Boston Medical Center (BMC) HealthNet Plan.
We are happy to work with you and your primary care provider (PCP) to help
you get the care you need.
This Member Guide is an easy-to-read summary of information for our
members. Your Evidence of Coverage (EOC) has complete member information.
So please read that very important document for all you need to know.
Please note: when you see a word or phrase that’s in italics, then that word is
explained in the “Glossary” at the end.
WHO ARE WE?
BMC HealthNet Plan is a health plan. We work with hospitals, health centers,
clinics and your PCP so you can get the health services you need and take better
care of yourself. We administer and pay for covered services described in
your EOC.
BMC HealthNet Plan Commonwealth Care contracts with
healthcare providers across Massachusetts. This includes
more than 50 hospitals. So you’re near medical care
when you need it.
WHAT IS BMC HEALTHNET PLAN
COMMONWEALTH CARE?
Commonwealth Care is a State health insurance
program established in 2006. BMC HealthNet Plan
is one of the health plans that offer Commonwealth Care.
A LIST OF IMPORTANT
PHONE NUMBERS IS ON
THE BACK COVER.
2

YOUR BMC HEALTHNET PLAN ID CARD
WHAT YOU SHOULD KNOW...
Always carry your BMC
HealthNet Plan ID card with you.
Every BMC HealthNet Plan member receives an
identification (ID) card.
You must be enrolled at the time you receive
health services in order for them to be covered.
Check your ID card to make sure the
information on it is correct. If it’s not correct,
call Member Services.
Never let anyone else use your card. If you
think someone is using your card, call our
tip-line at 1-888-411-4959.
If you lose your ID card…
Order a new one online at bmchp.org
or
Call Member Services and ask them to send
you another one.
3

BMC HEALTHNET PLAN, COMMONWEALTH HEALTH
INSURANCE CONNECTOR AUTHORITY, MASSHEALTH
...AND WHAT THEY MEAN TO YOU
As a resident of Massachusetts, you must have health insurance,
but there are exceptions.
Call the Connector for more information.
MassHealth
Determines if you
are eligible for
Commonwealth Care.
Commonwealth Health
Insurance Connector Authority
Provides information on
all your Commonwealth
Care options.
Re-determines your
eligibility annually.
Updates your records
with changes in
your income
and family
size.
For some members
(plan types II and III):
- Sends you monthly
bills for premium
payments.
- Collects your premium
payments.
BMC HealthNet Plan
Helps you with questions about your health insurance, providers,
and special health programs. We’ll also try to help you contact the
right place if you have other questions.
Large network of healthcare providers, including doctors, hospitals
and pharmacies.
Nurses you can call if you’re sick, hurt, or need healthcare advice.
They’re available 24-hours, every day (Nurse Advice Line).
Special programs for ongoing illnesses like asthma, diabetes and
congestive heart failure.
We can update your phone number and address so you get
important mail from us and the State.
4

HOW YOU BECAME A MEMBER OF BMC HEALTHNET PLAN
You filled out the
Member Benefit Request
(MBR) application and
submitted the required
paperwork.
MassHealth received
your application and
decided you were
eligible for
Commonwealth Care
(plan type I, II, or III).
They sent you a
letter by mail.
You chose, or were
assigned to one of
the health plans.
Congratulations
on choosing BMC
HealthNet Plan!
5

You enrolled with BMC
HealthNet Plan
Commonwealth Care.
You got your member
ID card.
You are a member of
BMC HealthNet Plan
Commonwealth Care
on the 1st of the
You got your newmember
information
month.
packet.
DON’T LOSE YOUR HEALTH INSURANCE. YOU MUST
RENEW YOUR ELIGIBILITY EVERY YEAR. CALL US IF
YOU NEED HELP.
6

WORKING TOGETHER FOR TOTAL HEALTH
7
YOU
You need to help yourself stay healthy.
And you have support from us, your
PCP and other healthcare professionals
you may need.
Always carry your BMC HealthNet
Plan ID card with you. You must
show your ID card to any healthcare
provider before receiving health and
pharmacy services.
Make an appointment with your PCP
right away.
Fill out your Health Risk Assessment
(HRA) right away so we can help you
get the care you need.
Join a fitness club or Weight
Watchers ® to maintain or improve
your health – and get
money back.
In an emergency, go to the nearest
emergency room or call 911 right
away. No referral or prior-authorization
is necessary.
LEARN MORE ABOUT OUR SPECIAL
HEALTH PROGRAMS AT NO COST TO
YOU AT BMCHP.ORG.

YOUR PCP
Your primary care provider (PCP) is
a health professional who delivers or
coordinates the care you need and helps
you stay healthy.
Let us know if you have trouble making an
appointment with your provider.
Your PCP…
Gives you advice to help you get better
and keep you healthy
Writes prescriptions if you need them
Sends you to see a specialist provider if
needed
YOUR HEALTH PLAN
At BMC HealthNet Plan we work with your
medical providers to help you get the
right care and the most out of your health
insurance.
We have people working in our offices
across the state to help you.
Don’t wait until you get sick. Call your PCP
to make an appointment right away.
What happens during your first visit to
your PCP?
Your PCP will most likely…
Give you a physical exam
Ask you questions about you and your
family’s health
Recommend any tests you may need
TO MAKE YOUR FIRST APPOINTMENT WITH
YOUR PCP, CALL HIS OR HER OFFICE.
By using the private, online member selfservice
feature you may…
Order ID cards
Search for a claim
Change your address
Pick or change a PCP
Fill out (online) or print a Health Risk
Assessment (HRA) form
View member benefits specific to your plan
type
BMC HealthNet Plan’s Web site (bmchp.org)
On our main Web site you may…
Search for a network provider near your
home
Read about your benefits (Evidence of
Coverage)
Find out about our special health programs
Access our pharmacy web page
Changing your PCP— online or by phone
You may change your PCP up to three
times a calendar year for any reason.
Examples include:
Your current PCP moves out of the network
You don’t like the way your PCP treats you
during an office visit
You did not select your current PCP
IF YOU NEED HELP PICKING YOUR PCP, CALL
MEMBER SERVICES. AND LET US KNOW IF YOU
HAVE TROUBLE MAKING AN APPOINTMENT.
8

PREMIUMS AND CO-PAYMENTS
Some members may have a premium. A premium is what you must pay to the
Health Connector as part of the cost of your BMC HealthNet Plan coverage.
- You must send your monthly payments to the Health Connector. Call the Health
Connector with any premium questions.
- If you have trouble paying your premium, call the Health Connector. If you stop
paying, you may lose your coverage. Premium and co-payment hardship waivers
are available through the Health Connector for some enrollees. Call the Health
Connector with your premium questions. Their number is 1-877-623-6765.
A co-payment is what you pay directly to a healthcare provider for a health service
when you receive the service. There is an out-of-pocket co-payment maximum. This
means that you will only have to pay a certain total amount of co-payments each
year. Co-payments are usually due at the time of service.
DO NOT SEND MONEY TO
BMC HEALTHNET PLAN.
REFERRALS AND PRIOR-AUTHORIZATIONS
REMEMBER: YOUR PCP DELIVERS OR COORDINATES YOUR CARE.
REFERRALS TO PROVIDERS
- You always need a referral from your PCP to see an out-of-network provider.
Your PCP must call BMC HealthNet Plan to make sure that we approve the
referral. BMC HealthNet Plan may direct you to see a different provider.
- In some cases, you need a referral from your PCP before you see an innetwork
provider.
- You do not need to get a referral for most in-network OB/GYN services.
- If you need a referral in advance and do not get one, you may have to pay for
the services.
PRIOR-AUTHORIZATIONS FOR SERVICES
- Your PCP needs to get approval from us before referring you for certain
health services. This is called a prior-authorization.
9
CALL MEMBER SERVICES AT 1-877-957-5300 IF YOU HAVE ANY QUESTIONS.

WE CARE ABOUT A HEALTHIER YOU
CALL MEMBER SERVICES IF YOU HAVE ANY QUESTIONS
ABOUT YOUR COVERAGE OR THE SERVICES YOU GET.
THE NUMBER IS 1-877-957-5300.
Llámanos 1-877-957-5300.
Hãy goi cho chúng tôi 1-877-957-5300.
Telefone para nós 1-877-957-5300.
Rele nou 1-877-957-5300.
Call our 24-hour Nurse Advice Line to get
medical and other healthcare information
from a highly trained registered nurse. The
number is 1-800-765-7344.
In an emergency, go to the nearest
emergency room or call 911 right away.
You do not need a referral or
prior-authorization before seeking
emergency care.
10

HELPING YOU GET QUALITY CARE
Filling out your Health Risk Assessment (HRA) form helps us meet your
medical needs.
So we can give you help with specific medical conditions, we will ask you
questions like:
- How many medications do you take every day?
- Do you have any heart problems?
The HRA came in the package with your member ID card.
- You can fill out the HRA form using the online member self-service feature
at bmchp.org OR over the phone with one of our representatives.
- You can also send it back to us free of charge in the pre-paid envelope that
came with your HRA.
11

WAYS TO GET INFORMATION
12

MENTAL HEALTH AND SUBSTANCE ABUSE (MH/SA)
AT BMC HEALTHNET PLAN WE COVER A RANGE OF SERVICES AVAILABLE TO HELP
YOU WITH MENTAL HEALTH AND SUBSTANCE ABUSE ISSUES. THEY INCLUDE ANXIETY
OR DEPRESSION OR DEPENDENCY ON DRUGS AND ALCOHOL.
To find out what is covered,
look in your Evidence of Coverage (EOC).
WE CAN HELP YOU FIND A NETWORK
PROVIDER NEAR YOUR HOME.
VISIT OUR WEB SITE AT BMCHP.ORG
OR CALL MEMBER SERVICES.
CALL THE MENTAL HEALTH AND SUBSTANCE ABUSE LINE
IF YOU HAVE ANY QUESTIONS. THE NUMBER IS
1-877-957-5600.
13

HAVING TROUBLE BALANCING YOUR
LIFE AND HEALTH?
SOMETIMES YOU NEED EXTRA HELP. THAT’S WHY WE HAVE MANY
SPECIAL HEALTH PROGRAMS FOR PEOPLE WITH CERTAIN HEALTH
CONDITIONS LISTED BELOW AT NO COST TO YOU:
ASTHMA
CONGESTIVE HEART FAILURE
DIABETES
HIV/AIDS
SUNNY START - PREGNANCY AND POSTPARTUM
STOP SMOKING
CALL MEMBER SERVICES AT
1-877-957-5300
FOR MORE INFORMATION
ABOUT THESE PROGRAMS.
14

PREGNANCY AND FAMILY PLANNING
When you’re pregnant you’ll need special care before you have
your baby. This is called prenatal care.
To start receiving this special care, make an appointment with your
OB/GYN as soon as you become pregnant.
If you have any questions or need help
finding an OB/GYN, call your PCP. Or call
Member Services at 1-877-957-5300.
Call us to enroll in our Sunny Start
program and we will send you information
and special materials to help you with
your pregnancy.
BMC HealthNet Plan also helps you
get family planning services (such as
counseling and birth control advice).
TELL US IF YOU ARE PREGNANT.
YOU MAY NOT NEED TO PAY
A PHARMACY CO-PAYMENT.
15

HEALTHY BEHAVIORS
WANT TO JOIN A FITNESS CLUB?
Get up to $150 back, each year, for joining a fitness club.
WANT TO JOIN WEIGHT WATCHERS®?
Get up to $200 back, each year, for joining Weight Watchers ® .
FOR DETAILS, CALL
MEMBER SERVICES AT 1-877-957-5300
OR GO TO THE COMMONWEALTH CARE MEMBER SECTION OF
OUR WEB SITE: BMCHP.ORG.
16

GETTING A PRESCRIPTION FILLED
YOUR PROVIDER WILL WRITE YOU A PRESCRIPTION IF HE OR
SHE BELIEVES THAT MEDICATION WILL HELP YOU GET BETTER.
PHARMACY PICK-UP
We have 1000 pharmacies
across Massachusetts in our
network where you can get your
prescriptions filled.
Your pharmacy co-payments can
be found on the front of your ID
card and on the Covered Services
List (in the EOC that came with
this packet).
Ask your doctor if your
prescription requires a
prior-authorization.
MAIL-ORDER DELIVERY
Mail-order prescriptions are available
for medications you take on an
ongoing basis. Advantages include:
It’s cheaper (smaller co-payments).
Shipping is FREE.
Your prescription is delivered to
your door.
Your personal information stays
private.
Instructions for mail-order delivery
are on the mail-order form found in
this packet.
17

PREPARING TO SEE YOUR
HEALTHCARE PROVIDER?
MAKE A LIST OF QUESTIONS BEFORE YOU GO.
If you’re not sure what to ask, you can start with
these three questions:*
1WHAT IS MY MAIN PROBLEM?
2
WHAT DO I NEED TO DO?
3
WHY IS IT IMPORTANT
FOR ME TO DO THIS?
*
Before making an appointment with your
PCP, check if he or she is part of the
BMC HealthNet Plan Commonwealth
Care network.
FOR MORE INFORMATION, READ
ABOUT ASK ME 3 AT NPSF.ORG/
ASKME3.
18

GLOSSARY
COMMONWEALTH CARE–A special state-subsidized health insurance program
managed by the Commonwealth Health Insurance Connector Authority. It is
offered through private health plans, including BMC HealthNet Plan.
COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY (HEALTH CONNECTOR)–
A state organization that determines rules for Commonwealth Care.
CO-PAYMENT–What you pay directly to a provider for a covered service.
Co-payments are usually due at the time you receive the service.
COVERED SERVICES–The healthcare services that BMC HealthNet Plan will pay
for if they are necessary for you. Healthcare services that are not in your
benefit package (depending on your plan type--plan type I, II or III) are not
covered services and will not be paid for by BMC HealthNet Plan.
EVIDENCE OF COVERAGE (EOC)–An important legal document that describes
the relationship between you and BMC HealthNet Plan. It tells you
how the health plan works and lists co-payments you must pay when
you receive covered services.
HARDSHIP WAIVER–If you are having a hard time paying premiums or
co-payments, the Connector may grant you an exception so you
don’t have to pay.
HEALTH PLAN–An organization approved by the Health Connector to work
with certain hospitals, clinics and your doctor so you can receive the
health services covered in your EOC.
HEALTH RISK ASSESSMENT (HRA)–A form you fill out that tells BMC HealthNet
Plan about your health needs. The information you provide is kept private.
HEALTH SERVICES (MEDICAL AND MENTAL HEALTH/SUBSTANCE ABUSE)–Services
obtained from a medical or behavioral health provider.
19

MEMBER BENEFIT REQUEST (MBR)–An application you filled out so that MassHealth
can determine your eligibility for state health insurance programs.
NETWORK/IN-NETWORK PROVIDERS–The healthcare professionals who have an
agreement with BMC HealthNet Plan Commonwealth Care to deliver health
services to you.
OUT-OF-POCKET CO-PAYMENT MAXIMUM–The most you will have to pay in copayments
during a year of benefits for covered services. When you have
reached this maximum, BMC HealthNet Plan will send you a letter to take to
your appointments that shows you don’t have to pay any more co-payments.
PLAN TYPE–Benefit packages that are made available from BMC HealthNet
Plan Commonwealth Care. Plan types differ in premium, co-payments and
services that are covered.
PREMIUM–What you must pay the Connector, each month, as part of the cost
of your coverage.
PRESCRIPTION–Needed from your provider to get you the medication you need
for your health condition.
PRIMARY CARE PROVIDER/PRACTITIONER (PCP)–A health professional who delivers
or coordinates the care you need, and helps you stay healthy. A PCP can be
a doctor of internal medicine, family practice, general practice or pediatric
medicine, certified nurse practitioner, or OB/GYN.
PRIOR-AUTHORIZATION (PRE-AUTHORIZATION)–Approval from BMC HealthNet Plan for
specific health services. Your doctor arranges this.
SPECIALIST–A healthcare provider who has received specific medical training
related to a particular health issue or condition. Medical services provided by
a specialist treat a particular disease or part of the body.
20

REMEMBER...
You’re covered for emergencies wherever you are. (Plan type II and III
members pay a co-payment for these services.)
Visit your PCP at least once a year.
Call MassHealth when you change your address, phone number, income or
health status.
Use health services from network providers only, except in emergencies.
Network providers are providers who participate with BMC HealthNet Plan
Commonwealth Care.
Ask your doctor if your prescription requires a prior-authorization. Your
doctor will need to get the prior-authorization from BMC HealthNet Plan
before you can have that prescription filled.
Watch your mail for letters we may send you.
You’re covered for most mental health and substance abuse services, as
long as the provider is in the BMC HealthNet Plan Commonwealth Care
network. Call the Behavioral Health line (1-877-957-5600) if you have
questions.
Call our 24-hour Nurse Advice Line (1-800-765-7344) to get medical and
other healthcare information from a highly trained registered nurse.
21

TO ANSWER ALL YOUR QUESTIONS, OR FIND
OR CHANGE YOUR PCP
BMC HealthNet Plan Member
Services
Hours of operation:
8:00 a.m. – 6:00 p.m.
Phone: 1-877-957-5300
Mental Health/Substance Abuse:
(Beacon Health Strategies)
1-877-957-5600
TTY: 1-866-765-0055
TO CHECK YOUR ELIGIBILITY, SEND IN YOUR
PREMIUMS, OR ASK QUESTIONS ABOUT
PREMIUMS
Commonwealth Health Insurance
Connector Authority (Health
Connector)
Hours of operation:
8:00 a.m. – 5:00 p.m.
Phone: 1-877-623-6765
TTY: 1-877-623-7773
Web site: mahealthconnector.org
Web site: bmchp.org
TO SPEAK TO A NURSE OVER THE PHONE
AND GET ANSWERS TO HEALTH RELATED
QUESTIONS
Nurse Advice Line from
BMC HealthNet Plan
Available 24 hours
Phone: 1-800-973-6273
TO UPDATE YOUR CONTACT INFORMATION DUE
TO A CHANGE IN INCOME AND FAMILY SIZE
Contact MassHealth
Hours of operation:
8:00 a.m. – 5:00 p.m.
Phone: 1-800-841-2900
TTY: 1-800-421-1220
BMCHP.ORG | 1-877-957-5300
15M 06/12