Kansas Member Handbook (approved 11/13/09)

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Customer Service

• 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.

You are a HealthWave member through Family Health Partners. You may have other health insurance too. This may be from a job, an absent parent, union or other source. If you have other health insurance besides HealthWave, that insurance company must pay for most of your health services before Family Health Partners pays. If your other health insurance covers a service not covered by Family Health Partners, you will owe your provider what your insurance does not pay. It is important that you show all your insurance ID cards to your health care provider.

Family Health Partners and your other health insurance policy have rules about getting health care. You must follow the rules for each policy. There are rules about going out-of-network. Some services need prior approval. You may have to pay for the service if you don’t follow the rules. For help, call Family Health Partners at 1-877-347-9363 (toll-free) or 816-559-9598.

If you have health insurance other than Family Health Partners or your insurance changes, details about your insurance are needed. Have your insurance card with you when you call the following numbers.

You must call:

• Family Health Partners at 1-877-347-9363 (toll-free) or 816-559-9598; and
• HealthWave Clearinghouse at 1-800-792-4884 (toll-free).

You must call Family Health Partners at 1-877-347-9363 (toll-free) or 816-559-9598 or HealthWave Clearinghouse at 1-800-792-4884 (toll-free) if:

• you get hurt in a car wreck;
• you get hurt at work;
• you get hurt and have a lawyer; or
• you get money because of an accident.

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

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Important Resource Numbers

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Rights & Responsibilities

Your Rights as a Family Health Partners Member
You have the right to:

• 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;
• 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 toll-free 1­877-347-9363 (toll-free) or 816-559-9598.
• be free of restraint from a provider who wants to:
– make you do something you should not do;
– punish you;
– get back at you;
– make things easier for him or her.

• be free to exercise these rights without retaliation;
• receive copies of your medical records;
• obtain information on the structure and operation of Family Health Partners.

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• Use the emergency room only when you have an emergency. See page 13 for the definition of an emergency.
• Show your and your child’s Family Health Partners ID card each time you go for medical care. Ttile 19 members should also show their state-issued ID card.
• 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.
• Inform and provide information to Family Health Partners, your PCP and HealthWave Clearinghouse at 1-800-792-4884 (toll-free) 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.

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Program Benefits

• 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). See table on page 19
• 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 (go to www.fhp.org or call 1-877-347-9363 (toll-free) or 816-559-9598) See page 9 for more detailed over-the-counter information.
• Rehabilitation (PT/OT/ST, cardiac and pulmonary)
• Vision services and eyeglasses
• X-ray services
• Wellness exams/sports physicals

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

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• 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).

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• 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, or pregnant or breast-feeding women may be eligible.
• family planning, including treatment and education (can be a provider of your choice).

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• The services are obtained in or out of network and are prior approved by a Family Health Partners provider or other Family Health Partners representative;
• The services are in or out of network and are not prior approved within one hour of a request to Family Health Partners for prior approval of more post-stabilization care services;
• Family Health Partners cannot be reached; or
• The Family Health Partners representative and the treating physician cannot agree on your care and a Family Health Partners physician cannot be reached for consultation.

• A Family Health Partners provider at the treating hospital takes over your care;
• A Family Health Partners provider takes over your care by transfer to another hospital or facility;
• A Family Health Partners representative and the treating provider reach an agreement concerning your care; or
• You are moved to an in-network hospital or facility.

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• 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 Family Health Partners. 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 Family Health Partners at 1-877-347-9363 (toll-free) or 816-559-9598.

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Your Provider

• go to www.fhp.org
• click "Find/Change Provider (KS)" in the left menu
• search for a provider
• if the provider has a plus symbol ( + ) in the "Pick PCP" column, you can request that PCP
• click the plus symbol ( + ) for the PCP you want to request
• fill out your member information and click the "request PCP" button
• Customer Service will review and complete your PCP change request and call you if they have any questions

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• Birth control or family planning – you may go to our providers or a HealthWave approved provider. We will pay for this care, even if the provider is not in Family Health Partners.
• Local public health agencies – Members may go to local public health agencies for tests, immunizations (shots) and treatment of sexually transmitted diseases and tuberculosis; HIV/AIDS tests; or for lead poisoning screening, testing and treatment.
• Women’s health service – You may go to any of our GYN providers.

• you go to another health care provider without a referral from your PCP (except for those services listed above); or
• you choose to get medical services that are not covered by Family Health Partners.

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• Cardiac Rehabilitation
• Cochlear Implants
• Durable Medical Equipment fpr purchase in excess of $200
• Formula For Nutrition
• Home Health Services
• Hyperbaric Oxygen Therapy
• Inpatient Admissions
• OB Care
• Orthotic and Prosthetic Devices for purchase in excess of $200
• Out of Network amd Out of Area Provider Referrals
• Outpatient Full or Partial Day Rehabilitation
• Private Duty Nurse
• Respite Care
• Skilled Nursing Admissions
• Speech Therapy (beyond evaluation)
• TMJ (Temporomandibular Joint) Procedures

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Seeing a Provider

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• a fever that won’t go away;
• earaches;
• a rash that won’t go away;
• a pulled or strained muscle; or
• vomiting or diarrhea that doesn’t stop.

If you get urgent care services you may be able to keep the illness from getting worse. You may call your PCP or Nurse Advice at 1-800-347-9369 (toll-free).

For urgent health care appointments, you must be seen within the following time frames:

• for serious illnesses or injuries, appointments will be available at all times;
• for things like a high temperature and vomiting or diarrhea that won’t stop, you must be seen within 24 hours;
• for things like a rash, non-life threatening pain or fever, your provider must see you within two days.

Your PCP will treat you if he or she can. Your PCP will send you to someone else if he or she is not able to see you that soon. It is always important that you take your health insurance cards to your appointments.

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• In an emergency, you do not need to call your PCP first. Go to the nearest emergency room or call 911.
• Call your PCP after an emergency room visit.
• Get your follow up care from your PCP.
• Routine health care services must be received from your PCP when you get back home.
• If you are out of the county, you will be covered for emergency care only. You must remain eligible under HealthWave eligibility guidelines to be covered.

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• chest pain;
• severe pain;
• stroke;
• difficulty breathing;
• bad burns;
• deep cuts/heavy bleeding; or
• gunshot wound.

If you aren’t sure about the medical condition, get help right away or call your PCP’s office for advice. Ask for a number you can call when the office is closed. You can also call Family Health Partners’ Nurse Advice Helpline at 1-800-347-9369 (toll-free).

It’s best to call or go to your provider’s office for things that are not emergencies, like:

• earaches;
• sore throat;
• backaches;
• small cuts; or
• cold/flu.

You should call your PCP to be treated for these things.

Emergency medical services are those health care items and services furnished that are required to evaluate or stabilize a sudden and unforeseen situation or occurrence or a sudden onset of a medical or behavioral health condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the failure to provide immediate medical attention could reasonably be expected by a prudent lay person, possessing average knowledge of health and medicine, to result in:

• placing the patient’s physical or behavioral health (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; or
• serious impairment of bodily functions; or
• serious dysfunction of any bodily organ or part; or
• serious harm to self or others due to an alcohol or drug abuse emergency; or
• injury to self or bodily harm to others; or
• severe pain; or
• with respect to a pregnant woman who is having contractions: (a) there is inadequate time to effect a safe transfer to another hospital before delivery or, (b) transfer may pose a threat to the health or safety of the woman or the unborn.

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• Ambulance services are covered if they are for emergency services.
• The ambulance must go to the nearest hospital that can take care of the emergency.
• If it is decided the ambulance trip was not for an emergency, you may have to pay the bill.
• If you get a bill for ambulance services and you think it was an emergency, contact customer service at 1-877-347-9363 (toll-free) or 816-559-9598.
• For non-emergency medical transportation, call the Non-Emergency Medical Transportation (NEMT) helpline at 1-800-890-6026 (toll-free).

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Your Family’s Health Check List

Each member of your family needs to be seen by your Primary Care Provider (PCP) on a regular basis, even when they aren’t sick. Getting regular care will help keep your family healthy. Use this wellness schedule as a guideline for the exams your family needs.

Children
Well-Child Exams
A well-child exam is recommended at the following ages and is important even if your child is not sick.

Lead Screening and Testing
Children ages 6 months to 6 years will be screened for lead poisoning at every well-child appointment. The blood level should be tested at 12 months and 24 months and as recommended by your PCP.

Vaccines
Take your child’s shot record with you to the well-child exam. If a shot is missed, it will need to be made up at the next appointment.

These exams recommended at the following ages and are important even though you may not be sick.

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Some services may not be included in your benefit package. Please call Customer Service at 1-877-347-9363 (toll-free) or 816-559-9598 for information on your benefit coverage. Screening and treatment for sexually transmitted diseases is confidential. References for wellness schedule available from Customer Service upon request.

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Coverage for Children

HealthWave has a special program for children to provide medically necessary services. The program is called Early Periodic Screening, Diagnosis and Treatment (EPSDT) or KAN Be Healthy. Your Primary Care Provider (PCP) can give your child these services.

Some examples of EPSDT/KAN Be Healthy services include:

• aids to help disabled children talk
• an unclothed physical exam
• blood and/or urine tests
• checking the growth and progress of the child
• child’s medical history
• dental care
• health care management and education
• immunizations (shots)
• personal care to help take care of a sick or disabled child
• psychology/counseling
• screening and testing lead levels in blood
• special therapies such as physical, occupational and speech
• vision, hearing and dental screens

Important tests your child needs are shown on the chart below: Please note these are not all the tests your child may need. Talk with your child’s PCP.

It is very important that children get check-ups regularly from their PCP at the ages listed below.

• Newborn
• By 1 month
• 2 months
• 4 months
• 6 months
• 9 months
• 12 months
• 15 months
• 18 months
• 24 months
• 3 years
• 4 years
• 5 years
• 6 years
• 7 years
• 8 years
• 9 years
• 10 years
• 11 years
• 12 years
• 13 years
• 14 years
• 15 years
• 16 years
• 17 years
• 18 years
• 19 years
• 20 years

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Coverage for Women and Men

Keeping Women Healthy
Annual Well Woman Exam

We want our members to be healthy! Women should have a well woman exam once a year. It is very important to help prevent breast and cervical cancer. This visit includes:

• Breast and pelvic exam
• Pap smear
• Check your blood pressure and body weight
• Mammogram (if appropriate according to your age and risk factors)

• You are covered for one well woman exam every 12 months
• This exam can be performed either by your PCP or by an obstetrician/gynecologist in Family Health Partners’ network.

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• Breast self-exams every month. Ask your PCP for simple instructions. Ask when is the best time to do a manual breast self-exam.
• A manual breast exam will be done by a health care provider as part of your annual well woman exam
• A baseline mammogram between the ages of 35 to 40; every one to two years between the ages of 40 to 50 based on your history; every year at the age of 50 and above

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• At least one (1) visit before 12 weeks of pregnancy;
• At least six (6) more visits after 12 weeks of pregnancy until delivery; and
• At least one (1) post-pregnancy visit.

To sign up for this program or for more information, please call the First Touch Case Managers at 1-888-691-4874 (toll-free).

It is important to see your medical provider and call Family Health Partners as soon as you think you are pregnant. Your baby’s health and your health depend on it.

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Your Baby

Newborn Coverage
If you have a baby you must:

• call HealthWave Clearinghouse at 1-800-792-4884 (toll-free) within 10 days of the baby’s birth or as soon as possible to report the birth of your child. The State will give your baby an identification number, known as a health insurance number;
• also call Family Health Partners at 1-877-347-9363 (toll-free) or 816-559-9598; and
• pick a Primary Care Provider (PCP) for your baby in the Family Health Partner’s network.

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• check your health and your baby;
• talk to you about how things are going;
• answer your questions;
• teach you how to do things such as breast feeding; and
• do lab tests if your PCP orders them.

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Immunizations (Shots) and Testing

Immunizations (Shots) Schedule For Children
Immunizations (shots) help prevent serious illness. This record will help keep track when your child is immunized. If your child did not get their shots at the age shown, they still need to get that shot. Talk to your PCP about your child’s immunizations (shots). Children must have their immunizations (shots) to enter school.

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• you live in or visit a house built before 1978.
• someone in your house works as a:

- plumber;
- battery manufacturer;
- auto mechanic;
- gas station attendant;
- printer;
- steel worker;
- other jobs that contain lead.

There are other ways your child can be poisoned, call 1-877-347-9363 (toll-free) or 816-559-9598 if you have questions about lead poisoning.

High levels of lead can cause brain damage or even death. Lead in children is a common health concern. Children must be tested for lead:

• Children must be tested yearly if the child is between six months and six years and lives in a high-risk area;
• when the child is one year old and again at two years;
• when the child is between six months and six years and might have been exposed to lead; and
• if the child is less than six years old and has never been tested for lead.

A lead screen has two parts. First, the Primary Care Provider (PCP) will ask questions to see if your child may have been exposed to lead. Then the PCP may take some blood from your child to check for lead. This is called a blood lead level test. Children at one year old and again at two years old must have a blood lead level test. Children with high lead levels in their blood must have follow up services for lead poisoning.

High lead levels in a pregnant woman can harm her unborn child. If you are pregnant, talk with your PCP or obstetrician to see if you may have been exposed to lead.

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• Have brothers and sisters or playmates who have (or did have) lead poisoning?
• Live in or regularly visit a house or daycare built before 1950?
• Reside in or visit a house built before 1978 with recent or on going remodeling within the last six months?
• Eat or mouth non-food items? (Do they crave things not fit for food such as dirt, paint chips, clay, ashes, plaster, etc?)
• Play in bare soil or reside in lead smelting area?
• Reside with an individual that works with or has hobbies using lead?
• Receive unusual medicines or folk remedies?
• Have candy, jewelry or pottery from Mexico? If so these items have been found to have high levels of lead.

• Tiredness or hyperactivity
• Reduced attention span
• Irritability
• Difficulty sleeping
• Loss of Appetite
• Constipation
• Weight loss

• Behavior disorders
• Learning disabilities
• Hyperactivity
• Growth failure
• Developmental delay

• Abdominal pain
• Anemia
• Encephalopathy
• Unexplained seizures
• Hearing loss

• Annual blood lead test for all children less than six years of age.
• If a child has no documented blood test, a blood test should be performed immediately.

• Regardless of risk area, your health coverage requires a blood lead test at 12 and 24 months of age.
• If your child has no documented test anytime before 72 months of age, a blood test should be performed immediately.
• Any child spending more than ten (10) hours a week in areas identified as high-risk for lead poisoning shall be blood lead tested annually.

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Other Services

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Health Improvement
Many chronic medical conditions can be treated or prevented and lifestyle choices can be modi­fied to improve your health. Wellness programs are a proven method of encouraging healthier habits and improving health.

CMFHP tries to help you remember the important screenings for your age. We send reminders for the following services in an effort to help you manage your health.

• Well-Child Visit Reminder
• Immunization Reminder
• Lead Screening Reminder
• Mammogram Reminder
• Well-Woman Reminder
• Well-Man Reminder

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• Anxiety Disorders
• Autism Spectrum Disorder
• Cancer
• Cardiac Disease
• Chronic Pain
• Dual diagnoses of behavioral health and substance abuse
• Hepatitis C
• HIV/AIDS
• Pervasive Developmental Disorder
• Sickle Cell Anemia
• Special health care needs

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• Living Will – the patient tells someone in advance what should happen to him/her medi­cally under adverse circumstances.
• Durable Power of Attorney for Health Care – the patient formally picks another adult as the person who will make health care decisions in case the patient is medically unable to do so.

You can find these forms at your local library. Talk about your medical directive with a close rela­tive or trusted friend and your PCP. Someone you trust must know your wishes in case something serious happens. You may also want to speak to an attorney. You do not have to.

For more information, call or write to:
Kansas Bar Association
1200 SW Harrison Street
Topeka, KS 66612-1806
785.234.5696
www.ksbar.org

or

Kansas Department of Aging (www.agingkansas.org/Choices/faq/faq_advance_direct.htm)

We must give this information to all new members. Members who have serious medical or behavioral disorders may not understand. We may have to give it to a family member. When the member’s health improves we will give it to them then. As an insurance company, we do not treat you any differently if you have or do not have Advance Directives.

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Non-Emergency Medical Transportation (NEMT)

• You must be a member of Family Health Partners on the day of your appointment.
• We will only pay for one child and one parent or guardian if your child is under 21 and needs to be away from home overnight or needs someone to be with him/her. We will not pay for other children or adults.

• The appointment is to a health care provider that is in Family Health Partners.
• The appointment is to a service covered by Family Health Partners.
• The appointment is to a health care provider near where you live. If the provider is far away, you may need to say why and get a note from your PCP. There are rules about how far you can travel to a health care appointment and get a ride.
• The NEMT program can take you to a pharmacy or a durable medical equipment (DME) provider only if the pharmacy or DME provider cannot mail or deliver your medicine or equipment to you.

How do I use the NEMT program?
Call 1-800-890-6026 (toll-free). You must call at least 72 hours before the day of the appointment or you may not get NEMT. You may be able to get a ride sooner if your health care provider gives you an urgent care appointment. If you have an emergency, dial 911, or the local emergency phone number.

If you need a ride to a non-medical emergency appointment, call 1-800-890-6026 (toll-free).

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The Grievance Process

Grievance
If you are unhappy about something with Family Health Partners Health Plan there are steps you can take:

You may file a greivance if you are dissatisfied about:

• The quality of care or services you received;
• The way you were treated by a provider; or
• 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 Family Health Partners 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

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• 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 three working days for an expedited review.

• You must appeal our notice of action within 30 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 must let you know in writing within 30 days what our decision is

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:
  — File your appeal within 10 days of the day we mail your Notice of Action, or
  — File your appeal before the action takes place

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.

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Fraud and Abuse

Committing fraud or abuse is against the law.

Fraud is a dishonest act done on purpose.

Examples of member fraud are:

• Letting someone else use your Family Health Partners health insurance card(s) or
• Getting prescriptions with the intent of abusing or selling drugs.

• Billing for services not provided.

• Going to the emergency room for a condition that is not an emergency.

• Prescribing a more expensive item than is necessary.

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Notice of Health Information Practices

• 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 verify that services were actually provided;
• Tool in educating health professions;
• Source of date 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.

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• 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.

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• 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.

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• Keep your health information private;
• 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.

Family Health Partners 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. Family Health Partners will not use or disclose your health information without your permission, except as described in this notice or allowed by law.

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Glossary

Advance Directive.

An advance directive allows you to leave written directions about your medical treatment decisions and/or ask someone to decide your care for you.

Benefits.

Health Care and other services you and other members of your family who are in HealthWave can get as a member of Family Health Partners.

Emergency.

An emergency threatens your life or it can cause serious harm if not cared for right away.

Family Health Partners Approved Provider.

A doctor, nurse, clinic, pharmacy, hospital or other providers enrolled as an approved provider. By contracting with Family Health Partners, the provider agrees to the health plan rules while providing care for you or your child.

EPSDT.

Early Periodic Screening, Diagnosis, and Treatment. See KAN Be Healthy.

Health Care Provider.

An individual or facility (such as a doctor, nurse or nurse practitioner, physician’s assistant, optometrist or psychologist) that is qualified and licensed to provide health care services.

HealthWave.

A way to get your HealthWave coverage from a HealthWave provider in certain counties of the state. You must choose a HealthWave provider or one will be chosen for you. You must also choose a Primary Care Provider (PCP). Use your ID card to get services.

Home Health Care.

Services and care provided in the home following illness, surgery, or injury. Family Health Partners must approve home health care services.

Hospice.

In-home care for a member who is not expected to live more than six months. Family Health Partners must approve hospice services.

ID Card.

A card with important information about your HealthWave benefits. You must show your ID card to the provider’s office when you get care. A provider may refuse to see you if you do not have your card with you. You may have to pay for services if you do not show your ID card.

Immunizations.

Shots that prevent illness or disease. Speak with your or your child’s PCP to find out when you or your child should get their immunizations.

KAN Be Healthy Program (KBH).

An early screening and treatment program for persons under the age of 21. KBH exams help to keep children healthy. (The federal program is called EPSDT.)

Medical Necessity.

Services or supplies which, as determined by the Medical Director or the applicable review committee designated by Family Health Partners, are determined to be:

• reasonable and medically necessary for the prevention, diagnosis or treatment of a physical or behavioral illness or injury; to achieve age appropriate growth and development; to minimize the progression of disability; or to attain, maintain or regain functional capacity; and
• in accordance with accepted standards of practice in the medical community of the area in which the physical or behavioral health services are rendered; and
• service(s) that could not have been omitted without adversely affecting the member’s condition or the quality of medical care rendered; and
• service(s) furnished in the most appropriate setting.

Member.

You are a member in Family Health Partners after you have been approved by the State of Kansas and enrolled in HealthWave.

Non-Covered Benefits.

Services not paid for by Family Health Partners.

Non-Participating Provider.

A provider of medical care that is not a part of the Family Health Partners provider network. Members who see non-participating providers without specific approval from Family Health Partners may have to pay for those services.

Nurse Advice.

A free health information phone line. Nurse Advice is ready to answer your health questions 24 hours a day – seven days a week.

Preventive Care.

Health services you and your family receive that help avoid illness, disease, and serious injury. They may include KAN Be Healthy screenings, routine vaccinations, and regular screening for diseases.

Primary Care Provider (PCP).

This is the doctor you should always see first. Your PCP will manage and coordinate all of your health care needs.

Prior Authorization.

Family Health Partners must review some services to make sure they are covered benefits, and that you are eligible, etc., before we will pay for them. Your PCP will know which services must be reviewed. Your PCP, or the Family Health Partners provider your PCP sends you to, will get these approvals for you.

Provider Directory.

A listing of doctors, hospitals, pharmacies, health departments and other providers contracted to provide services to Family Health Partners members.

Referrals.

A process used by a PCP to let you get health care from another health care provider, usually for specialty treatment.

Second Opinion.

You may have a serious medical condition and disagree with the treatment or diagnosis recommended by your provider. You have the right to see a second provider to get their opinion. Family Health Partners or your PCP will help you get a second opinion. If the first and second opinions are different we will cover a third opinion.

Urgent Care.

Urgent care is when you need medical care quickly but it is not an emergency. Your PCP should schedule urgent care appointments within one to two days depending on your condition.

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revised 11/2009 - approved 11/13/2009