Need help?

Email membserv@fhp.org
Call Customer Service toll-free:
1-877-347-9363 (KS) or
1-800-347-9363 (MO)
Search the site (top right corner of page)

Important Information for Members of a Federally-Recognized American Indian or Native Alaskan Tribe

Is your child a member of a federally-recognized American Indian or Native Alaska tribe? If so, you will not have to pay a premium for your child's health care coverage. Please contact the HealthWave Clearinghouse at 1-800-792-4884. You can also fax your notice to 1-800-498-1244. They will assist in updating your records.

CMFHP will communicate to Indian Health Service Clinics and CMFHP members who have identified themselves as American Indian/Alaskan Native that you are allowed to receive services from Indian Health Service entities without restrictions.

Kansas Member Home Page

We are glad to have you as a member!

Welcome to Children’s Mercy Family Health Partners (CMFHP)! We are a provider with Kansas HealthWave.

CMFHP provides low-cost or no-cost health insurance to medically vulnerable populations through a partnership with the State of Kansas HealthWave Managed Care Program. CMFHP is the only non-profit health plan owned by a safety-net provider, Children’s Mercy Hospitals and Clinics.

CMFHP members live in areas of Kansas where they get most of your benefits from CMFHP. You either chose or were assigned to CMFHP.

Did You Know ...

All new Kansas CMFHP members must have a KAN Be Healthy/Well Care Exam within the first six months of enrollment. Call Customer Service at 1-877-347-9363 (toll free) for more information. Click here to learn more about preventive care.

Customer Service

We are live and we are local! If you need help or have questions about CMFHP, call Customer Service at 1-877-347-9363 (toll free) or 816-559-9598.

Customer Service is open Monday through Thursday, 7 a.m. to 6 p.m. and Friday from 7 a.m. to 5 p.m. For urgent needs after these hours, please call the Nurse Advice Line at 1-800-347-9369 (toll free).

Customer Service can help you:

Select a Primary Care Provider (PCP) for you or your children.
Make appointments to see the PCP.
Get more information on benefits and limits of your plan.
Help you get transportation to your medical appointments.
Change your PCP or your children’s PCP.
Make a complaint.

ID Cards

CMFHP will send you a plastic member ID card. Each covered member will have their own card.

You should carry this with you at all times. Show it to the provider when you seek medical care.

If you are a HW 19 member, you will also receive a plastic ID card from the state. Take both cards with you when you seek medical care, including the pharmacy.

Your ID card contains important phone numbers. Please check your ID card and make sure your PCP is correct. If it is not correct, please call Customer Service at 1-877-347-9363 (toll free) or 816-559-9598.

Hablamos Espanol!

Si usted no habla Inglés llame 1-877-347-9363 (numero gratis) ó 816-559-9598 para pedir ayuda.

Lo podemos ayudar si usted no habla o entiende Inglés.
Le proporcionare mos un interprete cuando lo necesite.
Puede ser que tengamos este libro en su idioma.
Conseguiremos una copia de los reglamentos de queja o agravio en su idioma.

Translation/Interpreters Available

If you do not speak English, call Customer Service toll-free at 1-877-347-9363 (KS) to ask for help.

We can help if you do not speak or understand English.
We will get you a translator when needed.
We may have this book in your language.
We will get a copy of the grievance and appeal rules in your language.
You can get translated documents in English, Spanish, French, German, Russian, Vietnamese, Arabic, Chinese, Korean and Japanese languages.

We also have the member handbook recorded on a CD and we can send it to you. This can help if you are hearing impaired.

TDD/TTY

We have a special phone number for people with poor hearing. Members who use a Telecommunications Device for the Deaf (TDD) can call 1-877-347-9361 (toll free).

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Benefits

KANSAS BENEFITS Menu- topics include:

Benefits Movie	Behavioral Health
Covered Benefits	Public Health Services
Non-covered Benefits	Pharmacy
Dental	Changes in Your Benefits

Benefits Movie

Benefit from your benefits! Watch this movie about CMFHP benefits.

Covered Services

Listed below are your benefits. Some benefits are different if you are in HW19 or HW 21.

Some benefits are limited and may require prior approval. Call CMFHP at 1-877-347-9363 (toll free) or 816-559-9598 for information about your health benefits.

Services covered by CMFHP:

Allergy testing and treatment
Audiology or hearing services
Durable medical equipment
Emergency ambulance
Emergency room
Family planning services
Home health services
Hospice services
Immunizations (shots)
Inpatient admission

KAN Be Healthy (KBH) exams (newborn up to age 21)
Laboratory services
Lead screening
Newborn services
Non-emergency medical transportation
Office visits
Orthotics and prosthetics
Outpatient surgery
Pregnancy care

Prescription drugs and some over-the-counter medications.
Rehabilitation Services (PT/OT/ST, cardiac and pulmonary)
Vision services and eyeglasses
X-ray services
Wellness exams/sports physicals

Click to go back to BENEFITS MENU

Non-Covered Services

Some services you may receive are not covered at all. You will have to pay for them. Some examples are:

Experimental surgery and procedures
Non-FDA-approved medications
Cosmetic surgery and procedures

Click to go back to BENEFITS MENU

Dental Services

Regular visits to your dentist are important to maintain strong healthy teeth. If you have questions about your benefits, you can call 1-800-766-9012 (toll free).

Behavioral Health and Substance Abuse Services

Your resource for behavioral health and substance abuse benefits is determined by the group number on your ID card.

If your ID card has HW 19 printed next to the words Group Number, you can call for information about participating providers, benefits or if you need a handbook. For behavioral health, call Kansas Health Solutions at 1-888-547-2878 (toll free). For substance abuse call Value Options at 1-866-645-8216 (toll free)
If your ID card has HW 21 printed next to the words Group Number, you may call Cenpatico Behavioral Health for information about your child's behavioral health and substance abuse treatment needs. That number is 1-866-896-7293 (toll free).

You may get these services from CMFHP or a local public health agency:

screening, testing and treatment for sexually transmitted diseases
screening and testing for HIV
screening, testing and treatment for tuberculosis
immunizations (shots) for children
screening, testing and treatment for lead poisoning
WIC (Women, Infant and Children) Program: Provides education and supplemental food to people who meet income, residency, or nutrition guidelines. Children under age five, pregnant or breast-feeding women may be eligible.
family planning, including treatment and education (can be a provider of your choice)

Click to go back to BENEFITS MENU

Pharmacy Services

CMFHP offers prescription coverage. You can look in your Provider Directory for a list of pharmacies you can go to. You can also call us at 1-877-347-9363 (toll free) or 816-559-9598 or visit our online searchable provider directory at www.fhp.org.

Remember to show your CMFHP ID card along with the prescription to the pharmacist. The pharmacist can only give you a 30-day supply at a time. CMFHP has a contract with the state of Kansas to make sure you get quality health care in a cost-effective manner. Prescription drugs are one of the fastest rising costs of medical care. One of the ways to try to best control the costs for this service is to have a preferred drug list. This is a list of generic and brand name drugs that are equal in how they work. Some are more cost-effective than other drugs you may be using now. CMFHP has a Preferred Drug List (PDL) approved by the state.

This is how the Preferred Drug List (PDL) works:

Your doctor must write a prescription for a drug that is on the PDL.
If your prescription is for something else, the pharmacist will have to call the doctor to talk about the preferred drug.
Sometimes doctors write "Dispense as Written" on the prescription form. This means that if the drug is not on our PDL, the pharmacist cannot give you a preferred drug without your doctor's ok. If that drug is not on the PDL, the pharmacist must call your doctor and ask him/her to call CMFHP. The doctor will have to talk to a health plan representative to give a medical reason for using a non-preferred drug.
You can call Customer Service to see if a medication is on the PDL. You can also see a complete list of preferred drugs at www.fhp.org. If you have questions about how this benefit works, please call CMFHP at 1-877-347-9363 (toll free) or 816-559-9598.

Over-the-Counter Medications

CMFHP covers some over-the-counter medicines like cough and cold medicine or fever medicine. The medicine must be written on a prescription pad from your doctor. It must be a generic medication when there is one available.

Brand name over-the-counter (OTC) medicines are covered only when there is no generic available.

Changes in Your Benefits

CMFHP will notify you of changes in your benefits, services or service delivery office/site in writing.

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Copayments - When Will I Have to Pay?

If You Are Billed
CMFHP will pay for all covered HealthWave services. You should not be getting a bill if the medical service you got is a covered CMFHP benefit. If you choose to pay for a service that is not covered, you must agree in writing that you will be responsible for the payment before getting the service.

If you get a bill, do not wait! Call our Customer Service office at 1-877-347-9363 (toll free) or 816-559-9598. CMFHP will look into this for you.

You may have to pay for services you get if:

you go to another health care provider without a referral from your PCP; or
you choose to get medical services that are not covered by CMFHP.

If you get a bill, do not wait! Call our Customer Service office at 1-877-347-9363 or 816-559-9598. CMFHP will look into this for you.

Important Notice: Please read the following information below

We want to make sure that all of our members understand that there are times you may have to pay for services.

When you see a provider, you must make sure they are in our provider network. If you go to a provider out of our network, you may have to pay for that visit.

There are many ways to find a Primary Care Provider (PCP) in our network. You can see all of our in-network PCPs in the provider directory. If you need a specialist, your PCP's office can help you. You can also call Customer Service at 1-877-347-9363. We are here to help you!

When Will I Have to Pay?
When you sign a paper at your provider's office, you may be agreeing to pay for services if it is not covered. Carefully read everything before you sign.

CMFHP will pay most of your medical bills, but there are some services that are not covered or are limited.

You should always ask if the service is covered. Your provider may ask you to sign a statement that you will pay for non-covered services.

If your PCP suggests a service that is not covered, you must pay for that service if you choose to get it.

If you request a service that is not covered, you must pay for that service.

If you are a CMFHP member, your PCP must be an in-network provider. Check with your PCP or call our Customer Service Department.

If you go to the emergency room and it is not an emergency, you may have to pay for the care you get.

Member Handbook

Click here to view the Kansas Member Handbook

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Keeping your coverage

Check your mail! You or your children could lose your HealthWave coverage if you do not respond to state requests for information. Please make sure that you answer all mail from the state.

It is very important you let the HealthWave Clearinghouse at 1-800-792-4884 (toll free) know when your address changes. Important letters and information will be mailed to the address you have given. You or your children could lose your CMFHP coverage if you do not respond to State requests for information. Please make sure that you answer all mail from the State.

Changes You Need To Report

If you move, it is important that you report your new address by calling HealthWave Clearinghouse at 1-800-792-4884 (toll free). Then call CMFHP at 1-877-347-9363 (toll free) or 816-559-9598. Your CMFHP coverage may be affected. If we do not know where you live, you will miss important information about your coverage. Changes you need to report to HealthWave Clearinghouse at 1-800-792-4884 (toll free) include:

family size (including the birth of any babies)
income
address
phone number
availability of insurance, including worker’s compensation, personal injury, medical malpractice or auto accident.

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Privacy, Rights and Responsibilities

topics include: member privacy; member rights and responsibilities; grievances and appeals

Member Privacy (Notice of Health Information Practices)

CMFHP receives protected health information such as your name, address, phone number, and in some cases health information containing your diagnosis, treatment, and a plan for future care or treatment. This information is called your medical record.

It is a:

Plan of your care and treatment;
Way to communicate among the many health professionals caring for you;
Legal document describing the care you received;
Way you or an insurance company verify that services were actually provided;
Tool in educating health professionals;
Source of data for medical research;
Source of information for public health officials charged with improving the health of the nation;
Source of data for facility planning and marketing; and
Tool to help the Hospital assess and continually work to improve the care it delivers.

Understanding what is in your record, and how your health information is used, helps you to:

Ensure its accuracy;
Better understand who, what, when, where, and why others may access your health information; and
Make more informed decisions when giving permission to others to view the information.

Your Health Information Rights
Health plan information collected is the physical property of CMFHP, but the information belongs to you.

You have the right to:

Request limits of certain uses and disclosures of your information;
Obtain a paper copy of Notice of Health Information Practices upon request;
Inspect and copy your health record;
Request amendments to your health record;
Request a record of disclosures of information from your health record;
Request your health information to be communicated by other means or at other locations; and
Revoke any authorization to use or disclose your health information except to the extent that action has already been taken with that information.

Our Responsibilities
CMFHP is required to:

Keep your health information private - this includes protecting oral, written and electronic health information throughout CMFHP;
Provide you with a notice (this document) of the Plan's legal duties and privacy practices with respect to information it collects and maintains about you;
Follow the terms of the notice;
Notify you if the Plan is unable to agree to a limit requested by you on the use or disclosure of your health information; and
Try to meet reasonable requests you may have to communicate health information by others or at other locations.

CMFHP reserves the right to change its practices and to be sure the new practices keep all health information safe. Should the Plan's health information practices change, it will post a revised notice on its web page (www.fhp.org), throughout its facilities, and will have copies available for you to take with you. The Plan will apply any changes to all health information regardless of when created or received. CMFHP will not use or disclose your health information without your permission, except as described in this notice or allowed by law.

For More Information or to Report a Problem
If you have any questions or would like additional information, you may contact the Corporate Compliance Officer at 816-559-9494.

If you believe your privacy rights have been violated, you can file a complaint with the Secretary of the United States Department of Health and Human Services. Contact the Hospital's Privacy Officer at the number above. You will not be penalized for filing a complaint.

Examples of Disclosures for Treatment, Payment, and Health Operations

CMFHP will use your health information for treatment
For example: Information obtained by a nurse, physician, or other member of your healthcare team will be recorded in our record and used to determine the course of treatment that should work best for you. Your physician will document in your record their expectations of the members of your healthcare team. Members of your healthcare team will record the actions they took and their observations. In that way, your physician will know how you are responding to treatment.

CMFHP will also provide our physician or other healthcare provider involved in you care with copies of various reports that will help in treating you once you are discharged.

CMFHP will use your health information for payment.
For example: A bill or other information may be sent to you or the Plan in order for providers to obtain payment. The information on or with the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.

CMFHP will use your health information for regular healthcare business.
For example: Members of the health services staff, Medical Directors, or members of the quality improvement team may use information in your health record to assess the care results to compare it to others with the same condition or receiving the same care. This information will then be used to continually improve the quality and effectiveness of the healthcare and service we provide. HIPAA 3-16-05

Other Uses and Disclosures
Business associates
Additional disclosures of your health information may be made to outside parties known as business associates. There are some services provided to the Plan through contracts with these business associates. Examples include certain laboratory tests and a typing service that types medical reports. The plan may disclose your health information to a business associate so that it can perform the job it has to do. To protect your health information, the Plan requires the business associate to protect your information at all times.

Family notification
CMFHP may use or disclose information to notify or assist in notifying a family member, person representative, or another person responsible for your care and general condition.

Communication with family
Health professionals, using their best judgment, may disclose health information to a family member, other relative, close personal friend, or any other person you identify, about that person's role in your care or payment related to your care.

Research
The Plan may disclose information to researchers when an institutional review board (IRB) has approved their research. The IRB reviews research proposals and follows rules to ensure the privacy of your health information.

Coroners and funeral directors
The Plan may disclose information to coroners and funeral directors as directed by law to carry out their duties.

Organ procurement organizations
If you are an organ donor, the Plan may disclose health information to organ procurement organizations or other organizations engaged in the procurement, banking, or transportation of organs for the purpose of organ and tissue donation and transplant.

Marketing
The Plan does not use your information for marketing.

Food and Drug Administration (FDA)
The Plan may disclose to the FDA health information about adverse events caused by food, supplements, products and product defects, or information to help with product recalls, repairs, or replacement.

Workers' compensation
The Plan may disclose health information as directed by, and as necessary to comply with, laws relating to workers' compensation or other similar programs established by law.

Public health
As required by law, the Plan may disclose your health plan information to public health agencies or authorities charged with preventing or controlling disease, injury, or disability, or to report a suspected case of abuse or neglect.

Correctional institution
Should you be an inmate of a correctional institution, the Plan may disclose to that institution or its agents health information necessary for your health and the health and safety of other individuals.

To avert a serious threat to health and safety
The Plan may use or disclose health information about you when necessary to prevent a serious threat to your health or safety or the health or safety of another person. Any disclosure would only be to someone able to prevent the threat.

Appointment reminders
The Plan may contact you to remind you of your appointments.

Law enforcement The Plan may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

Health oversight agencies
Federal law allows your health information to be released to an appropriate health oversight agency or attorney, provided that a work force member or business associate of the Plan believes in good faith that the Plan engaged in unlawful conduct or has otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers, or the public.

The Department of Health and Human Services (DHHS)
Under privacy standards, the Plan must disclose your health information to DHHS upon request so that DHHS may determine our compliance with those standards.

Lawsuits and disputes
If you are involved in a lawsuit or dispute, the Plan may disclose health plan information about you in response to a subpoena, court order, or administrative order. Information will be disclosed to someone else involved in the dispute only after efforts have been made to tell you about the request or obtain an order protecting the information requested. As required by law, the Plan will disclose health information about you when required to do so by federal, state, or local law.

Military and veterans
If you are a member of the armed forces, the Plan may release health information about you as required by military command authorities. The Plan may also release information about foreign military personnel to appropriate foreign military authorities.

Authorizations
CMFHP may disclose your health information for other reasons that you specifically authorize in writing.

Information rights are provided by 45 CRF 164.522-164.528 of the Health Insurance Portability & Accountability Act of 1996.

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Rights and Responsibilities

You have the right to:

Receive information about CMFHP, its services, its practitioners and providers and member rights and responsibilities;
Be treated with respect and dignity;
Receive needed medical services;
Privacy and confidentiality (including minors) subject to state and federal laws;
Select your own Primary Care Provider (PCP);
Refuse treatment;
Receive information about your health care and treatment options;
Participate in decision-making about your health care, and have a candid discussion of appropriate or medically necessary treatment options for conditions, regardless of cost or benefit coverage;
Voice grievances or appeals about CMFHP or the care we provide;
Make recommendations regarding our member rights and responsibilities policy;
Have access to your medical records and to request changes, if necessary;
Have someone act on your behalf if you are unable to do so;
Get information on our Physician Incentive Plan, if any, by calling 816-559-9598 or toll-free 1-877-347-9363;
Be free of restraint or seclusion from a provider who wants to:

Be free to exercise these rights without retaliation;
Receive one copy of your medical records once a year at no cost to you.

Your Responsibilities as a HealthWave Managed Care Health Plan Member. As a member of CMFHP, you or your children have the following responsibilities:

Use the emergency room only when you have an emergency;
Show your and your child's CMFHP ID card each time you go for medical care;
Keep appointments with providers or call to cancel or reschedule if unable to keep the appointment;
Follow your PCP's advice and treatment plan;
Call your PCP for any medical problems;
Supply information (to the extent possible) that the organization and its practitioners and providers need in order to provide care;
Inform and provide information to CMFHP, your PCP and the state of any other insurance coverage;
Pay for any services received that are not covered benefits if you are told in advance that it is not covered and you agree in writing to pay;
Share medical needs, ask questions and give requested information related to treatment;
Be respectful and cooperative with providers and staff;
Understand your health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible.

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Utilization Review and Discharge Planning Process

When you or your children are in the hospital, the Utilization Management Nurses of CMFHP will work with you and your provider to make sure you receive appropriate services in the most appropriate setting. In addition, the Utilization Management Nurses will work with you and your family to ensure you have all the services you need when you go home from the hospital.

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Grievances and Appeals

See the Member Handbook for more information about reporting problems, grievances and appeals.

This is important information about:

How to file a grievance about CMFHP

How to appeal a decision made by CMFHP

Please read this information carefully. If you have any questions about this information, please call us at 1-877-347-9363

If you are unhappy about something with CMFHP Health Plan there are steps you can take:

Grievance
You may file a grievance if you are dissatisfied about:

The quality of care or services you received
The way you were treated by a provider
A disagreement you may have with a health plan policy
Any aspect of your care

You may file your grievance with us by phone or in writing. Call CMFHP at 1-877-347-9363 (toll free) or 816-559-9598.

Send your written grievance to:
Children's Mercy Family Health Partners
PO Box 411806
Kansas City, MO 64141
Attn: QM Appeals Nurse – DO NOT OPEN IN MAIL ROOM

Your grievance must be filed with us within six (6) months of your concern
We must let you know in writing within 30 days what our decision is

Appeals
You can file an appeal if we send you a "Notice of Action" that says CMFHP:

Denied or gave a limited approval of a requested service
Reduced, suspended, or ended a service already approved
Denied payment for a service
Failed to act within certain time frames

You can file an appeal by phone or in writing.

Unless you need an expedited review, we must resolve your appeal within 30 days. An expedited review is when the regular time frames for resolving your appeal might jeopardize your life or health. A decision will be made within 3 business days for an expedited review.

You must appeal our notice of action within 30 calendar days from the date of the notice of action.
If you need help making your appeal, call us at 1-877-347-9363 (toll free) or 816-559-9598.

Send your written appeal to:
Children's Mercy Family Health Partners
PO Box 411806
Kansas City, MO 64141
Attn: QM Appeals Nurse – DO NOT OPEN IN MAIL ROOM

We will let you know our decision in writing within 30 days

Keep in mind, when you make a grievance or appeal, you have these special rights:

A qualified clinical professional will look at your grievance or appeal if it involves a medical decision.
This is not limited to interpretive services and includes assistance for the hearing impaired. You may ask anyone, such as a family member, your minister, a friend, an attorney, or a Customer Service Representative to help you make a grievance or an appeal.
If your physical or behavioral health is in danger, we will review it within three working days or sooner. This is called an expedited review. Call us if you think you need an expedited review.
We may extend the time for resolution by 14 days if you request the change of time or if we think it is in your interest.
If we change the time for resolution we must tell you in writing the reason for the delay.
If you have been getting medical care and we reduce, suspend, or end the service, you can appeal. You can request that the services continue while the decision is being made as long as you:

We will continue the services as long as:

An authorized provider ordered the service
The authorization period has not expired
You request the extension of benefits

If you do not win your appeal, you may have to pay for the services you got during that period of time.

State Fair Hearing
You can also ask for a State Fair hearing within 30 days from the date of our response to your appeal To do this, write and sign a letter, mail or fax the letter to:

Office of Administrative Hearing
1020 S Kansas
Topeka KS 66612
Or:
Fax to (785) 296-4848

See the Member Handbook for more information about reporting problems, grievances and appeals.