Illinois Partnership
for Health
Member Handbook
iph-newmbrhandbk-0714
TABLE OF CONTENTS
Welcome to the Illinois Partnership for Health (IPH). . . . . . . . . . . . . . . . . . . 3
How to Get this Handbook in Another Language . . .. . .. . .. . .. . .. . .. . .. . 3
Get to Know Your Health Plan . . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . 3
What are some basic terms?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
What is a medical home?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Why is it good to have a medical home? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
What is a Primary Care Provider (PCP)?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Why can’t I just go to the emergency room for all of my care? . . . . . . . . . . 6
Can a specialist be a PCP? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
How do I pick a different PCP if I need a new one?. . .. . .. . .. . .. . .. . .. . . 7
What if the doctor I see can’t be my PCP? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Can I change my PCP? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
What if my PCP asks me to change to another doctor? . . .. . .. . .. . .. . .. . . 8
Things to Remember. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . 8
Can I change out of IPH and pick a new plan?. . .. . .. . .. . .. . .. . .. . .. . .. . 8
Know How to Use Your Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Using Your IPH Member Card. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . 8
Visiting Your PCP. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . 9
Making an Appointment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
At Your Visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Emergency Care. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . . 9
Urgent Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Routine Care and Care for Non-Urgent Sickness or Injury . . . . . . . . . . . . . . 11
Referrals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Benefit Details. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Copayments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Adult Benefits and Copayments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Specialist Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Family Planning Services . . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . . 14
Maternity Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Dental Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Vision Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Non-Emergency Transportation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Services Not Covered by Medicaid . . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . . 17
Rights and Responsibilities. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . .. . . 18
Grievances and Appeals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Grievances. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Appeals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Privacy and Confidentiality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Reasons IPH May Contact You. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2
Welcome to the Illinois Partnership for Health (IPH)
Illinois Partnership for Health (IPH) is a group of community health systems
working with the Illinois Department of Healthcare and Family Services (HFS)
and the Centers for Medicare & Medicaid Services (CMS) to provide and
coordinate the delivery of health care for those on Medicaid.
We share one goal—to build a stronger you. We give you healthy ground to start
building on, and all the tools and resources you need to keep you and your family
well.
Please feel free to contact us with any questions at 1-877-633-2531. TTY users
call 1-800-526-0844 or 711 or via mail or email with the information below:
Illinois Partnership for Health
301 S. Vine St.
Urbana, Illinois 61801
Fax Number: 1-217-337-3425
Email: IPHmemberservices@healthalliance.org
How to Get this Handbook in Another Language
You can ask for this handbook in another language by calling us at
1-877-633-2531. TTY users call 1-800-526-0844 or 711.
Get to Know Your Health Plan
As an IPH member, you have access to a hospital and all its parts that help care
for people and a “medical home” where you will have a Primary Care Provider
(PCP) who gets to know you and makes sure you get the help you need. The
medical home team will work with your PCP to get you and your family the
health services and community services you need. Your state determines your
eligibility for a plan with IPH.
What are some basic terms?
You’ll be able to learn about your plan if you understand some common terms.
Here are a few. This list is also available at ILpartnershipforhealth.org.
3
Term
4
What It Means
Benefits
Benefits are the medical services and treatments currently
provided by Medicaid that you will continue to receive with IPH.
These are also called “covered services” and are described below.
Care
Coordination
Illinois Partnership for Health gives you a health care team, led by
the doctor you choose to be your main doctor. That doctor is your
Primary Care Physician or PCP. Your health care team—including
your care coordinator—works with you, your doctor and IPH to
help you get the care and services you need, when and where you
need them. To reach your care coordinator, call us at
1-877-633-2531. TTY users call 1-800-526-0844 or 711.
Copayment
(or Copay)
A small fee you may have to pay for some services, like
prescription drugs. Your copay depends on the Medicaid program
you are in and what health care service you need.
Covered
Services
The services (also called “benefits”) you get through Medicaid
and your IPH Member Card. To find out if a service is covered
check this handbook or call us at 1-877-633-2531. TTY users call
1-800-526-0844 or 711.
Disease
Management
A program to improve the health of people with long-term health
conditions, such as diabetes or asthma. In a Disease Management
Program, you receive special services and education about your
disease or health condition to make sure you know how to stay
as healthy as possible. It also means all of your health care team
members know of your condition and are watching your progress.
HFS (The
Illinois
Department
of Healthcare
and Family
Services)
This state agency runs the Medicaid program and is partnering
with IPH to help you get more coordinated care through a medical
home.
Medical
Home
A medical home is the system of health care providers responsible
for your medical care, centered on your Primary Care Provider
(PCP). Start with your PCP and your medical home for all your
health care needs. From checkups to when you’re sick and need
medicine, your medical home is your “first stop.”
Prenatal Care
Care a pregnant woman gets the whole time she is pregnant. This
care is important for the mom’s and baby’s health.
Primary Care
Provider
(PCP)
Your family doctor, nurse, or other healthcare provider at your
medical home who takes care of you and your family. See page 6
for more info.
Referral
Your PCP may send (or refer) you to a specialist for care. The
specialist will still be a part of your medical home, but he or she
may be an expert in a particular area of care. See “Specialist”
below for more info.
Specialist
A doctor who practices a special kind of medicine, like an ear,
nose and throat doctor or a foot doctor.
What is a medical home?
A medical home is where you go for health care. Think of it as your “first stop.”
Your medical home is where your Primary Care Provider (PCP) practices. It’s
where your medical records are kept on file, and the system that keeps your
PCP up to date. And if you need to see a specialist or connect to a community
resource, your medical home can help.
These are the health systems in our Illinois Partnership for Health plan. You can
choose a PCP at one of these health systems and it will become your medical
home.
Medical Home
Counties Served
Blessing Health System
Adams, Brown, Hancock, Pike, Schuyler
Cadence Health
DuPage, Kane
Carle Foundation
Champaign, Clark, Coles, Crawford, Cumberland,
Douglas, Edgar, Effingham, Ford, Iroquois, Jasper,
Moultrie, Piatt, Richland, Vermilion
Decatur Memorial
Christian, Dewitt, Macon, Moultrie, Piatt, Shelby
KishHealth System
DeKalb, Kendall, LaSalle, Ogle
Memorial Health
System
Cass, Christian, Logan, Macoupin, Mason, Menard,
Montgomery, Morgan, Sangamon
OSF HealthCare
Boone, Dewitt, Fulton, Henderson, Henry, Knox,
LaSalle, Livingston, Marshall, McHenry, McLean, Ogle,
Peoria, Putnam, Stark, Tazewell, Warren, Winnebago,
Woodford
Riverside HealthCare
Rockford Health
System
Ford, Grundy, Iroquois, Kankakee, Livingston, Will
Boone, DeKalb, LaSalle, Lee, McHenry, Ogle,
Stephenson, Whiteside, Winnebago
Other counties served include Mercer and Rock County.
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Why is it good to have a medical home?
Healthy or sick—everyone needs places and people they trust. Your medical
home is just that. Your PCP (one of the most important parts of your medical
home) gets to know you and your needs, and can help you spot problems and
find answers to questions about your health.
What is a Primary Care Provider (PCP)?
Your PCP is the doctor you choose to provide and coordinate all of your health
care—one of the most important people at your medical home. Your PCP will be
from one of these categories: internal medicine, family medicine, or pediatrics
(for children). He or she should always be the first person you call about your
health (unless it’s an emergency). Because your PCP is always your “first stop”
for care, he or she gets to know you and your health needs.
Here are a few things your PCP will do. This isn’t a complete list.
• Take care of you when you are sick.
• Give your children regular checkups and immunizations (shots) to help them stay well.
• Help you manage a disease and other conditions, like diabetes, high blood pressure and asthma.
• Refer you to specialists or another health care provider when needed. • Answer questions you have about your health.
• Give you the information and resources you need to stay healthy.
Why can’t I just go to the emergency room for all of my care?
The emergency room is great at taking care of people…in an emergency. But
it’s not good at taking care of people who don’t have an emergency. It’s a very
expensive place to get other care because of all of the equipment and special
staff they have to keep at the ready. Plus, they don’t know the “big picture” of
your health. They help with emergencies like, severe burns, poisoning, a serious
accident, broken bones, seizures and chest pain—but when it comes to your
overall (or big picture) health, you need your PCP. You and your PCP get to
know each other so he or she can help you figure out what to do when you’re
sick or when something just doesn’t feel right.
Can a specialist be a PCP?
In some cases, a specialist can be a PCP but only if that specialist is registered as
a PCP with Medicaid. That means the specialist has to agree to provide primary
6
care services and meet other requirements of PCPs. If you think you need to see
a specialist, talk to your PCP who can help you find a specialist when that type
of care is needed.
How do I pick a different PCP if I need a new one?
Great question. Think about where you and your family get your care now.
Ask yourself:
• Do you like the care you get? • Do you want to stay with that doctor or clinic?
• Do you know another doctor or clinic that you like? Or a relative or friend likes?
To see if this doctor is a part of the IPH family and can be your PCP:
• Visit ILpartnershipforhealth.org and click “Find a Doctor.” Type the doctor’s name and press “Search.” Make sure you spell the doctor’s name right, or your search will return no results.
• Call us toll-free at 1-877-633-2531 (TTY users call 1-800-526-0844
or 711), and we can check for you.
Once you know if the doctor can be your PCP, call Illinois Health Connect
toll-free at 1-877-912-1999 (TTY: 1-866-565-8577). Once you change your PCP,
we will send you a new IPH Member Card with your new doctor’s name and
phone number.
What if the doctor I see can’t be my PCP?
We’ll help you find one in our IPH family. We have many to choose from—all
giving you and your family top-notch care and attention. Call us toll-free at
1-877-633-2531 (TTY users call 1-800-526-0844 or 711).
Can I change my PCP?
If you have a problem with your PCP, talk to your PCP to try to work it out first.
If you’re not able to work things out, call us toll-free at 1-877-633-2531
(TTY users call 1-800-526-0844 or 711), and we’ll help you find a different PCP.
You cannot change your PCP more than one time per month. Once you find
a new PCP, you will need to call Illinois Health Connect to let them know you
want to change. Call Illinois Health Connect toll free at 1-877-912-1999
(TTY: 1-866-565-8577).
7
What if my PCP asks me to change to another doctor?
If you don’t agree to follow your PCP’s treatment plan, or if your PCP feels
another doctor could take better care of you, he or she may ask you to choose a
different doctor. If this happens, IPH will contact both you and your PCP to talk
about it.
Before your PCP can stop treating you, IPH will send you a letter with your
PCP’s reason for asking for the change. If you don’t agree with his or her reason,
you can file a complaint (see page 19). You will not have to change your PCP
until the complaint process is complete.
Things to Remember
•
•
•
•
You can pick the same PCP for everyone in your family, or you can pick different PCPs for each member of your family.
Whenever you have a health need, call your PCP. Your PCP will either find a time for you to come in or get answers to you by phone.
If your PCP’s office is closed, call his or her number anyway. All IPH PCPs have either call answering services or instructions on where to call for help after hours and on weekends.
Your PCP’s name and phone number will be listed on your IPH Member Card. If you lose your IPH Member Card, call us toll-free at 1-877-633-2531 (TTY users call 1-800-526-0844 or 711), and we’ll send you a replacement.
Can I change out of IPH and pick a new plan?
Yes. You have the right to cancel your IPH membership within the first 90 days
of your effective date. You can only change plans once during this 90-day period.
After 90 days, you will not be allowed to change plans until 12 months from
your effective date.
To learn more about your health plan choices, including how to change plans,
call Illinois Client Enrollment Services at 1-877-912-8880
(TTY: 1-866-565-8576) or visit http://enrollhfs.illinois.gov.
Know How to Use Your Benefits
Using Your IPH Member Card
With IPH, you will have two ID cards—one for IPH and your HFS Medical
Card. You must show the cards when you get any services or prescriptions. Your
PCP name and number will be on your IPH Member Card.
8
If your card is damaged, lost or stolen, call us right away toll-free at
1-877-633-2531 (TTY users call 1-800-526-0844 or 711), and we will send you
a new card.
Visiting Your PCP
If you have a new PCP, it’s important to see your new PCP as soon as possible
(even though you might not be sick right now). That way, when you do get sick
or have a question about your health, your PCP already knows you and your
health care needs.
Making an Appointment
To make an appointment, call your PCP’s office at the number listed on your IPH
Member Card.
If you’re going to be late for your appointment or can’t make it, call your PCP’s
office right away. You can set up another time.
At Your Visit
Here are a few things your PCP might do at your first visit.
• Check your blood pressure
• Check your blood sugar (for diabetes)
• Check your height and weight
• Do a breast exam and PAP smear (for women)
• Give you information on family planning and sexually
transmitted infections
• Talk with you about substance abuse and your mental health
• Do screenings, such as rectal exams for older adults
• Help schedule a mammogram
• Talk to you about quitting smoking, healthy eating and other habits important to your health
Emergency Care
An emergency is a life-threatening health problem. It will seriously affect your
health if it’s not treated right away. Only go to the emergency room or call 911 if
the problem is serious.
You do not need a referral from your PCP to go to the emergency room, but you
should call your PCP first if you’re not sure whether to go to the emergency
room or not.
9
Here are some ways to help you decide if you should call your PCP first (to
make an appointment) or go to the emergency room right away.
Call Your PCP
First
•
•
•
•
•
•
•
Fever
Cough
Runny nose
Ear ache
Rash
Pain medicine
Refill of a
medicine
Go to the Emergency Room
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Severe pain
Poisoning
A serious accident
Bleeding that won’t stop
Serious burns
Damage to your eyes
Broken bones
Throwing up blood
High fever
Seizures
Sudden loss of feeling in your limbs or not being
able to move
Severe stomach pain
Passing out
Choking or severe shortness of breath
Miscarriages
Strong feeling that you might hurt yourself or
another person
If your PCP’s office is closed, call his or her number anyway. All PCPs have
either call answering services or instructions on where to call for help after hours
and on weekends. This ensures that you have 24 hour access to someone who can
help you.
Urgent Care
During business hours, you should call your PCP for advice on where to go for
care or go to an urgent care walk-in clinic connected with your medical home
system.
After business hours, call your PCP’s office. All PCPs and medical home systems
have either call answering services or instructions on where to call for help after
hours and on weekends.
10
Routine Care and Care for Non-Urgent Sickness or Injury
During business hours, call your PCP’s office or use other online tools your
doctor may have available to schedule an appointment or for advice on where to
go for care.
Referrals
You NEED A REFERRAL from your PCP for:
•
Services provided by another PCP not in your plan’s network. Without the referral, Medicaid will not pay for the visit.
You DO NOT NEED A REFERRAL for services such as:
•
•
•
•
•
•
•
Family Planning OB/GYN Services
Services provided to newborns up to 91 days after birth
Emergency Room Services
Emergency and Non-Emergency Transportation
Prescriptions
Dental Services
Eye Exams and Services
Services provided by:
•
•
•
•
School-Based/Linked clinics for children under age 21
Local Health Departments
Mobile vans
Community Health Clinic Homeless Sites and Migrant Health Centers
Benefit Details
The table that starts on page 11 lists the types of care you may need to seek, a
quick description of the type of care, whether there is a limit on how you may
access the care and the copay amount for the visit. This is NOT a complete list
of services and is specific to services for adults. Services for children may be
different. In addition, for some children, there are no copays for any service or
prescription drug and for others there are higher copays. This depends on the All
Kids program the child is in.
11
Copayments
For some medical services, you will have to pay a small amount, also called a
copayment. Doctors and hospitals cannot:
• Bill you for any services covered by your HFS Medical Card. • Bill you for more than the copayment.
If you get a bill for a service you think is covered, call us toll-free at
1-877-633-2531 (TTY users call 1-800-526-0844 or 711).
Adult Benefits and Copayments
Type of
Care
Description
Benefit
Limit
Copay
Medical Services
Doctor’s Visit
Any appointment to see your doctor. This
can be for an annual visit or for a certain
problem.
None
$3.90/
visit
Emergency
Room Visit
If visit is because of a health emergency.
None
$0
If visit is not an emergency, a copay
applies.
None
$3.90/
visit
Hospital
Inpatient
If you are admitted to the hospital.
A doctor
will let
you know
if you
need to be
admitted
to the
hospital.
$3.90/
day
Hospital
Outpatient
This is if you receive care at the hospital,
but do not need to be admitted.
Your
doctor
will tell
you if you
need this
service.
$0
None
$3.90/
visit
Mental Health Services
Behavioral
Health
12
This includes counseling for mental
health conditions.
Mental Health If you are admitted to the hospital because A doctor
Inpatient
of a mental health condition. This can
will let
Services
include substance abuse treatment.
you know
if you
need to be
admitted
to the
hospital.
$3.90/
day
Mental Health If you receive mental health services at
the hospital.
Outpatient
Services
Your
doctor
will tell
you if you
need this
service.
$0
None
$0
Substance
Abuse
Treatment
(drugs and
alcohol)
This is treatment for a substance problem
such as alcohol abuse or drug abuse.
Preventive Care
Cervical
Cancer
Screening
Test to screen for cancer in the cervix.
The cervix is part of a woman’s
reproductive system.
None
$0
Mammogram
Image of the breast to screen for possible
cancer.
None
$0
Prostate
Cancer
Screening
Exam to screen for prostate cancer in
Covered
$0
men. The prostate is a gland that is part of for men
a man’s reproductive system.
40 years
or older
who are at
risk. Or,
covered for
all men 50
or older.
Flu Shot
This is a shot during flu season that will
help you stay healthy.
None
Hearing Care
Exam to test your hearing. Can also cover
hearing aids, if needed.
One
$0
hearing aid
every three
years.
$0
13
Transportation Services
Ambulance
Transportation by a medical ambulance or None
or emergency other type of emergency vehicle.
transportation
$0
Specialist Care
If your PCP says you need to see a specialist, this visit is covered when:
• The specialist who gives you care works with IPH, and
• Your PCP refers you to the specialist.
To be sure the specialist is a part of the IPH family, ask your PCP or call us tollfree at 1-877-633-2531 (TTY users call 1-800-526-0844 or 711), and we can
check for you.
Family Planning Services
Family planning includes services relating to:
• Contraception to prevent pregnancy
• HPV vaccination
• Pap test and any follow-ups for abnormal Pap tests
• HIV testing
• Other procedures to permanently prevent pregnancy. This includes a vasectomy and “tying tubes.”
Your doctor will help you decide if these services are needed.
Pregnancy Test
If you think you’re pregnant and need a pregnancy test, make an appointment
with your PCP.
Maternity Care
This includes care for women during pregnancy. Women need check-ups before
and after the baby is born. Be sure to tell your Care Coordinator if you are
pregnant. Your doctor will tell you if you need this service. You do not need a
referral to see an OB/GYN to get care for your pregnancy, but your PCP can help
you find a provider for your maternity care.
Care During Pregnancy
Pregnant women need special care during their pregnancy called “prenatal care.”
This special care helps pregnant women stay healthy and helps their babies stay
14
healthy, too. Even if a woman has been pregnant before, prenatal care is still
very important. This care should start as soon as possible after a woman learns
she is pregnant.
Even if you’re just thinking about having a baby, you should talk to your PCP
about what you can do before getting pregnant that will make your pregnancy
and your baby healthier.
If you’re already pregnant, call or visit your PCP, who will help you find a
prenatal care provider. Your PCP may also have information about your health
that your prenatal care provider will ask for at your first visit.
It is best to get regular prenatal care during your whole pregnancy and use the
same doctor for all your prenatal care. You should also see your PCP or
OB/GYN after your baby is born.
If you need help finding a doctor or making an appointment, call us toll-free at
1-877-633-2531 (TTY users call 1-800-526-0844 or 711).
Dental Services
You DO NOT NEED A REFERRAL from your PCP for dental services.
Medicaid covers dental services for children and adults. These services include
visits to prevent disease, detect problems and restore your teeth—such as exams,
teeth cleaning, cavity filling, root canals and extractions. In some cases, there
may be a copay for services, but there are no copays for exams. There may also
be limitations on how often you can get a service.
Under the dental benefit, we encourage you to go to a dentist for an oral exam.
At the exam, your dentist will develop a treatment plan for you. If the treatment
plan includes a covered dental service that requires prior approval, the dentist
will request the approval. If approved, the dentist can perform the service.
Children should visit the dentist for a checkup every six months starting no later
than age 2.
If you have any questions about finding a dentist or what is covered under your
dental benefit, call IPH at 1-877-633-2531 (TTY users call 1-800-526-0844 or
711). The call is free.
For more information, visit DentaQuest’s member documents’ page at
http://www.dentaquest.com/state-plans/regions/illinois/member-page/memberdocuments/.
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Vision Services
You DO NOT NEED A REFERRAL from your Primary Care Provider (PCP)
for Medicaid covered vision services.
Medicaid covered vision services include eye exams, eyeglasses and specialty
services if needed. Adults are limited to one pair of eyeglasses in a two year
period. Children are covered for eyeglasses as needed.
Vision services must be provided by a Medicaid-enrolled vision care provider.
There may be copays for a vision exam and other services. Check with your
vision care provider. Some vision services and materials, such as contact lenses
and low vision devices, require prior approval before you can get them. Your
vision care provider will request prior approval if necessary.
Eye Specialists and Services
An eye specialist is called an ophthalmologist. To see an ophthalmologist
because of eye disease or eye injury, you DO need a referral from your PCP.
To find out what vision services are covered for you or if you need help finding
a vision care provider or ophthalmologist, please call IPH at 1-877-633-2531
(TTY users call 1-800-526-0844 or 711). The call is free.
Prescription Drugs
Medicaid provides coverage for prescription drugs. To get your medication, you
will need a prescription from your medical provider. Adults (19 – 64) are allowed
four prescriptions per month. A provider can prescribe more drugs if first getting
prior approval. In Illinois, most if not all pharmacies accept Medicaid. If you
want to be sure, call the pharmacy first.
There are copays for most medications. The amount of the copay depends on the
type of drug as listed in the chart: brand name, generic or over-the-counter. For
children in All Kids, the amount of co-pay will depend on their specific All Kids
program. If you have questions about whether Medicaid will cover a prescription
or if there will be a copay, contact HFS Health Benefits Hotline at
1-866-468-7543 (TTY users call 1-877-204-1012).
Most, if not all pharmacies in Illinois accept Medicaid but if you need help
finding a pharmacy, call 1-877-633-2531 (TTY users call 1-800-526-0844
or 711).
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Type
Copay
Amount
Brand name prescription
$3.90
Generic prescription
$2.00
Over-the-counter medication with prescription from your doctor *
$2.00
* Over-the-counter prescriptions are not covered for children in All Kids
Premium level 2. Children in All Kids Assist do not have any copays.
Non-Emergency Transportation
You DO NOT NEED A REFERRAL from your PCP for non-emergency
transportation services. If it is hard for you to get to your medical appointments
either because you do not have a car to use or because you cannot afford the gas,
IPH will help you get a ride to your PCP or clinic. This is not for ambulance
services.
Medicaid covers non-emergency transportation to the nearest possible provider
only.
To see if you qualify for non-emergency transportation services, please call us at
1-877-633-2531 (TTY users call 1-800-526-0844 or 711). You can call between
8 a.m. and 5 p.m. Monday through Friday. The call is free.
You must call and ask for help to get a ride at least two business days (not
counting weekends or holidays) before the trip. When you call for approval for a
ride, you must give:
•
•
•
•
•
The name, address and phone number of the person who needs
the ride
The recipient identification number (this is the number on the person’s HFS or All Kids medical card)
The name and address of the doctor or clinic the person will be seeing
The date, time and reason for the appointment
The name of the transportation provider, if known
Services Not Covered by Medicaid
There are certain services that Medicaid does not cover. These services include:
•
•
Experimental procedures: This is treatment that isn’t typical.
Research procedure: This is a procedure or treatment that is not typical.
This type of treatment is still under research.
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•
•
•
•
•
•
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Medical examinations required for entrance into an adult educational or vocational program: Certain programs need a medical exam
to qualify.
These types of exams and tests are not covered.
Adult Acupuncture: This is a treatment that involves needles being placed in certain parts of the body. Acupuncture is a covered benefit
for children.
Autopsy: This is a service that is performed after a person dies. It takes a look at the causes for a person’s death.
Artificial insemination
Chiropractic services for adults.
Medical or surgical procedures performed for cosmetic purposes: This is a procedure that does not improve your health. For example,
plastic surgery.
Medical or surgical transsexual treatment services: This is treatment for individuals that want to change gender.
Please note, this is not a full list of non-covered services. If you have a question
if a service is covered, contact us. We can be reached at 1-877-633-2531
(TTY users call 1-800-526-0844 or 711).
Rights and Responsibilities
Every year, we will remind you of your rights and responsibilities as an IPH
member.
You have the right to:
• Be treated with respect, dignity and privacy.
• Have your PCP explain your treatment in a way that makes sense
to you.
• Ask questions and have them answered by your PCP.
• Make decisions about the care you get. This includes saying “no” to care you don’t want.
• Get a copy of your medical records from your PCP. If your records are wrong, you can tell your PCP to correct them.
• Change your PCP (as often as once a month).
• Pick the same PCP for you and your family, or pick different PCPs for each member of your family.
• Call your PCP and get help.
• Complain about your PCP.
• Be free from any discrimination or retaliation.
You have the responsibility to:
• Learn your rights as a member.
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•
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•
•
•
•
•
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Keep your appointments and cancel any you can’t make.
Treat your PCP with respect.
Tell your PCP about your health care needs and about any other health care services you are getting.
Keep up to date on immunizations (shots).
Call your PCP first for care that is not an emergency.
Get a referral from your PCP before getting care that needs a referral.
Tell your PCP about other services you get that do not need a referral.
Tell HFS about changes to your name, address, phone number, income or family size.
Share important information needed by your providers.
Follow what your PCP says.
Grievances and Appeals
If you have a problem or complaint, Illinois Partnership for Health wants you to
get the best possible service. When something goes wrong or you are not treated
well, we want to know.
Grievances
A grievance is a complaint to Illinois Partnership for Health about any matter
involving IPH other than a denied, reduced or terminated service or medical
item.
Illinois Partnership for Health takes member grievances very seriously. We want
to know what is wrong so we can make our services better. Illinois Partnership
for Health has special procedures in place to help members who file grievances.
We will do our best to answer your questions or help to resolve your problem
or concern. Filing a grievance will not affect your health care services or your
benefits coverage.
These are examples of when you might want to file a grievance with IPH:
•
•
•
•
•
Your medical provider or an Illinois Partnership for Health staff member did not respect your rights.
You had trouble getting an appointment with your provider or Care Coordinator, or talking with your provider or Care Coordinator, in an appropriate amount of time.
You were unhappy with the quality of care or treatment you received.
Your provider or an Illinois Partnership for Health staff member was rude to you.
Your provider or an Illinois Partnership for Health staff member was insensitive to your cultural needs or other special needs you may have.
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Step 1: How to file a grievance.
If you have a grievance about your Primary Care Provider, Illinois Partnership
for Health, or the service you have received:
1. You can call the Illinois Partnership for Health Helpline at
1-877-633-2531 Toll Free; or 1-800-526-0844 or 711 for Voice/TTY to report it.
2. You can put your grievance in writing and mail, email or fax it to:
Illinois Partnership for Health
301 S. Vine St.
Urbana, Illinois 61801
Fax Number: 1-217-337-3425
Email: IPHmemberservices@healthalliance.org
3. You can also register your grievance on the IPH website, ILpartnershipforhealth.org.
When you file your grievance, give us as much information as you can. For
example, include the date and place the incident happened, the names of the
people involved and details about what happened. Be sure to include your name
and your Illinois Partnership for Health member ID number.
You can designate another person to help you file a grievance with us. You will
need to fill out the Authorized Representative Designation form. This form is on
the IPH website, ILpartnership-forhealth.org. You can also obtain this form by
calling Illinois Partnership for Health Helpline at 1-877-633-2531 (TTY users
call 1-800-526-0844 or 711).
Step 2: Reviewing your grievance
We will make a record of your grievance. We will have someone not involved
with the matter you are complaining about review your grievance and try to find
a solution. Your satisfaction is important to us.
Step 3: Taking action on your grievance
We take action on all grievances within 30 days of receiving it. We will let you
know what we decide.
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Step 4: If you are not satisfied with the action we take on your grievance, you
may write to:
Illinois Department of Healthcare and Family Services
Bureau of Managed Care
Attn: ACE Grievances
401 South Clinton Street, 6th Floor
Chicago, IL 60607
Someone from HFS will review the matter and follow up with you as quickly as
possible.
Appeals
You may not agree with a decision or an action made by the Illinois Department
of Healthcare and Family Services (HFS) or the Illinois Department of
Human Services (DHS). An appeal is a way for you to ask for a review of the
Department’s (HFS or DHS) actions and decisions. For example, you may not
agree with a decision made or an action by the Department about your services
or a medical item you requested.
You may appeal within sixty (60) calendar days of the date on the letter from
the Department informing you of its denial or action. If you want your services
to stay the same while you appeal, you must file your appeal no later than ten
(10) calendar days from the date on the Department’s letter informing you of
its denial or action. You can designate another person to help you file an appeal
with us. We will need something in writing that authorizes that person to speak
on your behalf. When you appeal, you are asking for a hearing to review the
Department’s action or decision that you disagree with. The person reviewing the
Department’s action or decision will be a hearing officer.
The list below includes examples of when you might want to file an appeal. You
may want to appeal if the Department:
•
•
•
•
Does not approve or pay for a service or item that you or your
provider asks for
Stops your benefits (coverage)
Says that you will start to get fewer benefits
Changes your co-payments
You can also appeal if you think the Department made a mistake about any
action or decision. You may not get a hearing on your appeal if the Department’s
action or decision was because of a change in the law.
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How to Make an Appeal
When you file your appeal, tell the Department what action or decision you
disagree with and want them to review. Be sure to include your name, address,
phone number, email and your HFS Medical Card Identification Number (the
“ID#” next to your name on the Medical Card).
An appeal is filed either with HFS or DHS, depending on the agency that made
the decision you are contesting. Generally, an appeal is filed with the agency that
made the decision and sent you the letter informing you of its denial or action.
•
If you want to file an appeal related to your medical services or items, Developmental Disability(DD), or Elderly Waiver (Community Care Program (CCP)) services, send your request in writing via mail, fax or email to:
Illinois Department of Healthcare and Family Services
Attn: Fair Hearings Section
401 South Clinton, 6th Floor
Chicago, IL 60607
Fax #: 1-312-793-2005
Email: HFS.FairHearings@illinois.gov
Or you may call HFS at 1-855-418-4421. If you use a TTY, call HFS at
1-877-734-7429. The call is free.
•
If you want to file an appeal related to your Medicaid application
eligibility, food stamps, TANF, Persons with Disabilities Waiver services, Traumatic Brain Injury Waiver services, HIV/AIDS Waiver services or any Home Service Program (HSP) services, send your request in writing via mail, fax or email to:
Illinois Department of Human Services
Attn: Bureau of Hearings
401 South Clinton, 6th Floor
Chicago, IL 60607
Fax #: 1-312-793-3387
Email: DHS.BAHNewAppeal@illinois.gov
Or you may call DHS at 1-800-435-0774. If you use a TTY, call DHS at
1-877-734-7429. The call is free.
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Privacy and Confidentiality
We keep your “protected health information” private. A few examples of
protected health information are:
• Your name (and the names of your children or other people living in your house)
• Your telephone number
• Your address
• Your ID number
• Your date of birth
• Your Social Security number
• Your admission/discharge date
• Your medical procedure and diagnosis
We may need to share your protected health information with other people
important to your care. Some examples of when we can share information are:
• To help you get medical care
• To arrange payment for your care and services
• If we are required by law
Reasons IPH May Contact You
We want you and your family to get the health care needed to stay well. One way
we do this is by staying in touch with you. We may contact you by phone or mail
to:
• Help you pick a new PCP—Sometimes PCPs are no longer able to be a PCP in IPH for some reason, such as moving offices or retiring. When this happens, you will be contacted to pick a new PCP.
• Remind you about your regular checkups or preventive care you may need—We will mail you a letter and/or call you to remind you to make an appointment.
• Ask you to participate in a survey to tell us how we’re doing—They
help us see what’s working and what can be done better. You may not get one every year, because a group of survey participants is randomly selected each year.
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