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Email membserv@fhp.org
Call Customer Service toll-free:
     1-800-347-9363 (MO)
     1-877-347-9363 (KS) or
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Introduction to CMFHP

• Eligibility - Do I Qualify?
• Customer Service and ID Cards
• Interpreter Services, TDD/TYY
• FAQs
• Informacion en Espanol (coming soon)

Benefits - covered and non-covered

• Benefits eBook and Benefits Movie
• Member Handbook and Audio Handbook
• When Will I Have to Pay?
• Important Phone Numbers

Providers and Getting Medical Care

• Find or Change a Provider
• Need a Ride? - 1-800-890-6026
• 24-Hr Nurse Advice Line - 1-800-347-9369
• Appointments with Your PCP
• When Will I Have to Pay?
• Emergency Care, Urgent Care, Preventive Care
• Care Away from Home or After-Hours Care

Keeping Coverage and Changing Plans

Programs to Help You

• Disease Management Programs: Asthma, Diabetes, Depression (MO)
• Complex Health Care Needs
• Healthy Lifestyles (HeLP)
•   First Touch for Pregnant Women
•   Immunizations (shots)
• Information on Dental Care
• Special Health Care Needs
• Lead Poisoning Prevention
•   Help to Quit Tobacco Use
• Patient Safety and Decision-Making
• Community Programs and Resources

Newsletters, Brochures, and Podcasts/Audio Programs

Privacy, Your Rights, Utilization Management

• Privacy and Rights and Responsibilities
• Utilization Management (UM)
• Grievances and Appeals

CMFHP Quality and Service Standards

• Quality Improvement
• New Technology

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 Alaskan tribe? If so, you will not have to pay a premium for your child's health care coverage.

To stop owing a premium, send a copy of the proof of your child's tribal membership to the Premium Collections Unit by mail, fax, or email. Be sure to include your child's name and MO HealthNet identification number with your proof.

• MAIL:
MO HealthNet Division
Premium Collections Unit
P.O. Box 6500
Jefferson City, MO 65102-6500

• FAX: (573) 526-2471
• EMAIL: Scan your records and email to AskMHD@dss.mo.gov. Type the words Premium Collections Unit in the subject line of your email.

Proof of membership can be a copy of a tribal membership card or letter issued by a tribe that is recognized by the United States Department of the Interior, Bureau of Indian Affairs

MO approved 10/29/09

Eligibility: "Do I Qualify?" - Information for Missouri

Children’s Mercy Family Health Partners (CMFHP) is a not-for-profit safety net health plan. We offer low- or no-cost health insurance for eligible children and families through MO HealthNet Managed Care.

You must apply for MO HealthNet to see if you or your family is eligible. The State of Missouri has eligibility guidelines for MO HealthNet. You must meet these guidelines to be eligible.

Benefit Information

Benefits Movie

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

Covered Benefits

The following services are covered benefits for MO HealthNet Managed Care members of CMFHP. Please keep in mind that services and benefits change from time to time.

This list is for your general information only. Some services are excluded from coverage by the State of Missouri MO HealthNet program. Some benefits are limited to children and pregnant women. Some services require prior authorization. You can call CMFHP Customer Service for more information about specific services and benefits at 1-800-347-9363 (toll free).

Your Health Benefits in MO HealthNet Managed Care.   Some benefits are limited based on your eligibility group or age. The benefits that may be limited have a "*" next to them. Some services need prior approval before getting them. Call CMFHP Customer Service at 1-800-347-9363 or 816-559-9599 for information about your health benefits.

You may get these services from your MO HealthNet Managed Care health plan 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

The following services are covered for pregnant women and children:

The following health care services are available.

  They are not covered by CMFHP. These services are covered by MO HealthNet Fee-for-Service using MO HealthNet approved providers.

The following are additional benefits covered by CMFHP.

  These additional benefits are not part of the regular benefit package, but have been approved for payment for CMFHP members.

Non Covered Benefits.

The services listed below are examples of services CMFHP does not cover. This may not include all items. It is meant to be a general list. If you have any questions, please call Customer Service toll-free at 1-800-347-9363. CMFHP will not pay for any services when they are not covered by MO HealthNet and not approved by your PCP or CMFHP.

Pharmacy

The following health care services are available. They are not covered by CMFHP. These services are covered by MO HealthNet Fee-for-Service using MO HealthNet approved providers.

Pharmacy (including prescriptions and some over the counter medications). Some copayments apply. Call MO HealthNet at 1-800-392-2161 or 1-573-751-6527 for more details on how to obtain your prescriptions.

Pharmacy Dispensing Fees

Children under 19 do not have to pay a pharmacy dispensing fee. Members nineteen (19) and older pay a pharmacy dispensing fee for each drug they get. This fee is $0.50 up to $2.00 for each drug. The amount of this fee is based on the cost of the drug. You should never pay a fee of more than $2.00 for each drug. Remember, if you get more than one drug at the same time, you will pay these fees for each drug you get.

You will not pay a dispensing fee when the medicine is for an emergency, family planning, a foster child, EPSDT/HCY services, or a pregnancy related reason.

To ask what you have to pay, call MO HealthNet Division Participant Service at 1-800-392-2161. You will be able to get your prescription even if you cannot pay. You will still owe the fee and must pay it like your other bills.

Changes in Your Benefits

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

Have other questions? We can help! Call CMFHP Customer Service toll-free at 1-800-347-9363.

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CMFHP Provider Network

Finding a Primary Care Provider (PCP)

You can learn about in-network providers and hospitals at our online searchable provider directory. You can also get provider certification and education info by phone or mail. Just call Customer Service at 1-800-347-9363. They can help you find a provider or hospital. Once you choose a PCP, your PCP can help you get specialist, behavioral health or other hospital services.

Steps For Changing Your PCP

To change your PCP, call us at 1-800-347-9363 or 816-559-9599. You can also change your PCP by going to our Online Provider Directory and following these instructions:

• 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

Choosing and Changing Your PCP

You must choose a PCP. If you do not, we will need to choose one for you. Your PCP will manage your health care. The PCP knows the CMFHP network and can guide you to specialists if you need one. You may ask for a specialist as your PCP if you have a chronic illness or disabling condition. We will work out a plan to make sure you get the care you need.

You have a right to change PCPs in our MO HealthNet Managed Care health plan at least twice a year. Children in state custody may change PCPs as often as needed. To do this, call us at 1-800-347-9363 or 816-559-9599, or go to our Online Provider Directory. We will make the change effective immediately when you call or go online.

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CMFHP Utilization Management (UM) policies

When you or your children are in the hospital, the Utilization Management Nurses and Medical Directors of CMFHP will work with your Primary Care Provider (PCP) or the provider caring for you in the hospital in determining how long you need to be in the hospital. CMFHP may decide you can be better cared for either at home or in another health care setting.

If you or your provider do not agree with the decision of CMFHP, you may appeal the utilization review decision. To appeal the utilization review decision you should follow the appeal process outlined on page 35 of your Member Handbook.

Medical Review Process
Medical review is done to confirm the medical necessity of treatments or services provided, as well as the appropriateness of the care setting. Medical review requires review of specific clinical information onsite, over the telephone, or via written communication. Medical Review Nurses gather all pertinent clinical information gathered from the treating providers, review against the medical necessity decision criteria and consider individual member needs, as well as the local healthcare delivery system. Once the review is complete, the Medical Review Nurse confirms medical necessity, the appropriateness of the care setting, and authorizes the requested service. When the Medical Review Nurse is not able to confirm the medical necessity and appropriateness of care setting, the case is referred to a Board Certified physician who has an active medical license in Missouri for review. Any denial decisions are done by a Board Certified provider.

Providers and members have the right to a copy of the criteria used in making decisions about requests. If you would like a copy of the criteria, please contact the Prior Authorization Department at 1-888-691-4872 or fax your request to 1-877-347-9366. CMFHP will mail or fax you a written copy of the criteria within three (3) business days of your request.

Utilization staff members are available for questions related to prior authorization and coverage: Monday – Friday; 8:00am – 5:00pm. They can be reached by toll free phone at 1-888-691-4872 or toll free fax at 1-877-347-9366. The same toll free phone number and toll free fax number are available 24/7 for communication of utilization management issues. Information left after normal business hours should include; caller's name, caller's contact number, member name, and member ID number. The request will be responded to the next business day.

CMFHP makes all UM decisions based only on the appropriateness of care and service, the existence of coverage for the member, and his or her unique health necessities. CMFHP never rewards or provides financial incentives to its employees, practitioners, providers, or any other individual to deny services or to make decisions that result in underutilization. This information is also available on our website, www.fhp.org.

If your provider would like to discuss a decision with a CMFHP Medical Director, your provider may call the Prior Authorization Department at 1-888-691-4872 and ask to speak with the Medical Director.

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CMFHP Privacy Policies

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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CMFHP Pharmaceutical Management Procedures

Pharmacy services (including prescriptions and some over the counter medications) are not covered by CMFHP, but you can still get these services.

Pharmacy services are covered by MO HealthNet Fee-for-Service using MO HealthNet approved providers.

Some copayments apply. MO HealthNet decides which medications are covered and may set limits on the amount of medication and how often you can receive it. To get more information about pharmacy benefits, please check with MO HealthNet Divison Participant Services by calling 1-800-392-2161. You can also access the MO HealthNet Division Participant Services website.

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Questions?

Have other questions? We can help! Call CMFHP Customer Service toll-free at 1-800-347-9363.

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Eligibility ... Enrollment ... What's the difference?

Eligibility for MO HealthNet comes first. After you are eligible, then you can enroll in a health plan.

The state decides who is eligible, or qualified, for MO HealthNet.

If you live in an area of the state covered by MO HealthNet Managed Care, and the state says you are eligible, you can enroll in a MO HealthNet Managed Care health plan.

Once the state says you are eligible for MO HealthNet, you can choose to enroll in a MO HealthNet Managed Care plan. There are several plans to choose from. CMFHP is one of the plans you can choose and is the #1 choice of health plans in the Western region.

To see if you or your children are eligible for MO HealthNet, you must apply. You can download and print an application from the MO HealthNet Managed Care website. You can also get one at your local Family Support Division office.

If you have other questions about eligibility, how to apply , or how to qualify for MO HealthNet, please visit the MO HealthNet Managed Care website or call MO HealthNet at 1-573-751-3425.

Once you or your family becomes eligible for MO HealthNet, you will get an enrollment packet. The enrollment packet will help you choose a managed care health plan. CMFHP is one of the plans you can choose.

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Why should I choose CMFHP?

Because we want to serve you and your family! We're pleased to say that more people choose Children's Mercy Family Health Partners than any other health plan in the regions we serve. Here are some of the things we offer:
A large provider network – we want to work with you and your health care provider! You have lots of options when it comes to choosing a provider. Live and local customer service to help you! Transportation at no cost for approved medical appointments, including the pharmacy. We can even reimburse you for gas if you have a car or someone takes you. A Nurse Advice Line available 24 hours a day, 7 days a week to help you with health care concerns. We can help you if you do not speak or understand English. We have access to interpreters who speak over 100 languages. ¡Hablamos Espanol! Nosotros empleamos a personas que pueden contestar sus preguntas en Español. Para información en Español, llame a 1-800-347-9363.		Download our brochure for more information!	¡Descargue nuestro folleto para más información!

Still have questions about Children’s Mercy Family Health Partners? We want to serve you and your family. Let us put the pieces together for you!

Call Children’s Mercy Family Health Partners Customer Service toll-free at 1-800-347-9363.

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membserv@fhp.org
Kansas: 1-877-347-9363 toll-free      Missouri: 1-800-347-9363 toll-free
Hablamos Espanol! Llame a Servicio al Cliente para mas informacion.

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