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MEMBER HANDBOOK - BMC HealthNet Plan

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					                                         BMC HEALTHNET PLAN

               MEMBER HANDBOOK
                                 A list of your member benefits and services (Covered Services List)
                                       is included as a separate document. Make sure you keep this
                                         Member Handbook and the Covered Services List together.




BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
                                                       INTRODuCTION
              Welcome to BMC HealthNet Plan (the Plan)! This Member handbook will help you understand
              the benefits and Covered Services you get as a Plan Member. It will also explain how to contact
              us if you have any questions.

              You can call BMC HealthNet Plan’s Member services department to have a Spanish ver-
              sion of this Member handbook sent to you. Or, call to have this Member handbook read
              to you in any language. All written materials sent to Members are available in Spanish.
              They can also be read to you in any language. Call the Member services department at
              the number at the bottom of each page:

              •   For copies of materials in Spanish
              •   For oral (spoken) translations into other languages
              •   To have written materials read to you
              •   To receive a copy of this Member handbook in braille, large font or to request
                  American Sign Language video clips.

              All translation services for Members are free of charge.

              English and Spanish versions of this Member handbook are also available on our Web site,
              bmchp.org.

              Some words in this Member handbook have special meaning. These words are capital-
              ized throughout the handbook. You can look up the meaning of these words in the glos-
              sary in section 15 of the Member handbook.




BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
                                             TABLE OF CONTENTS
               For a list of your Member benefits and Covered Services, see
               the Covered Services list included with this Member handbook.


               Section 1. Overview of BMC HealthNet Plan Membership ..................................................1
                 What is BMC HealthNet Plan? .............................................................................................1
                 New Member orientation ..................................................................................................... 1
                 Doctors and other healthcare Providers near you ...............................................................1
                 Provider Directory ................................................................................................................1
                 Provider information .............................................................................................................1
                 Your MassHealth coverage ..................................................................................................1
                 About your Enrollment options ............................................................................................1
                 Special help if you have certain medical conditions ........................................................... 1
                 Get More ............................................................................................................................ 2


               Section 2. Your BMC HealthNet Plan ID card ....................................................................... 2
                 A Member ID Card will be mailed to you ............................................................................. 2
                 Lost your Member ID Card? ................................................................................................ 2


               Section 3. Contacting your Providers, contacting us .......................................................... 2
                 Your healthcare Providers ................................................................................................... 2
                 BMC HealthNet Plan .......................................................................................................... 2
                 Benefits, Eligibility and healthcare questions ..................................................................... 3
                 Care when you travel outside our Service Area ................................................................. 3


               Section 4. Your Benefits ......................................................................................................... 4
                 How to obtain your benefits ............................................................................................... 4
                 Specialty care ..................................................................................................................... 4
                 Receiving care from Providers within the BMC HealthNet Plan Network .......................... 4
                 When Prior Authorization is needed for visits to Specialists .............................................. 4




BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
                                     TABLE OF CONTENTS
                  When Prior Authorization is needed for other services................................................... 6
                  Timeframes for Prior Authorization Decisions ................................................................ 6
                  Receiving care from Providers outside of the BMC HealthNet Plan Network ................ 6
                  Coverage if you change plans .........................................................................................7
                  If you get a bill for Covered Services .............................................................................. 7
                  Extras “free” for our Members ........................................................................................8
                  Process to evaluate new technology .............................................................................. 8
           Section 5. Your Primary Care Provider (PCP) ............................................................ 8
                  Primary Care Provider (PCP) ...........................................................................................8
                  Picking a PCP ................................................................................................................. 8
                  Providers who are PCPs ................................................................................................. 8
                  Call your PCP for an appointment .................................................................................. 9
                  Call your PCP first when you’re sick – unless you think it’s an Emergency ....................9
                  Changing your PCP ........................................................................................................ 9
                  Getting a Second Opinion ...............................................................................................9
           Section 6. Your Health Care ..................................................................................... 9
                  Emergencies and Urgent Care ........................................................................................9
                  Behavioral Health care .................................................................................................. 10
                  Health Risk Assessment ................................................................................................11
                  How long it should take to get care ..............................................................................11
                  Children in the care or custody of the
                  Department of Children and Families (DCF)...................................................................12
                  Utilization Management .................................................................................................12
                  Quality Improvement Program........................................................................................12
                  Clinical Practice Guidelines ...........................................................................................12
                  Transportation assistance .............................................................................................. 2    1
                  Staying healthy ..............................................................................................................13
                  Prescription medication coverage .................................................................................13
                  If you can’t pay the Co-payment ...................................................................................14
                  Mail order pharmacy program .......................................................................................14
                  Pharmacy programs ......................................................................................................14
                  Medicare part D .............................................................................................................15


BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
                                                 TABLE OF CONTENTS
               Section 7. Pregnancy, Family Planning, Preventive Care and Well-Child Care,
               EPSDT, Children’s Behavioral Health Initiative and Early Intervention ........................... 15
                 Pregnancy (prenatal) care ................................................................................................. 15
                 Make an appointment with an obstetrician/gynecologist (OB/GYN) ............................... 15
                 Your OB/GYN doctor ........................................................................................................ 16
                 Family Planning Services .................................................................................................. 16
                 Preventive and well child care for all children ................................................................. 16
                 Preventive Pediatric Health Care Screening and Diagnosis (PPHSD) services ................ 16
                 Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services .................... 17
                 Children’s Behavioral Health Initiative (CBHI).................................................................... 17
                 Dental care for children .................................................................................................... 17
                 Additional services for children ........................................................................................ 18


               Section 8. Care Management .............................................................................................. 18
                 Care Management Education and Wellness .................................................................... 19
                 Care Management Health Care Coordination .................................................................. 19
                 Care Management Select ................................................................................................ 19
                 Behavioral Health Care Management .............................................................................. 19
                 Intensive Clinical Management ........................................................................................ 19


               Section 9. Rights and Responsibilities .............................................................................. 20
               Section 10. Inquiries, Grievances and Appeals ................................................................. 22
               Section 11. Notice of Privacy Practices ............................................................................. 27
               Section 12. Advance Directives .......................................................................................... 31
               Section 13. Disenrollment ................................................................................................... 31
               Section 14. Coordination of Benefits/Subrogation .......................................................... 32
               Section 15. Glossary ............................................................................................................ 33
               Section 16. Index .................................................................................................................. 38




BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
    SECTION 1                                                          Providers throughout most of
                                                                       Massachusetts. Our Service Area
                                                                                                                                  printed Provider Directory, call our
                                                                                                                                  Member services department
                                                                       includes the following regions of
    Overview of Your                                                   Massachusetts: Western, Central,
                                                                                                                                  Provider information
                                                                                                                                  If you want more Provider infor-
    BMC HealthNet Plan                                                 Southeastern, Northern and Greater
                                                                                                                                  mation -- such as any malprac-
                                                                       Boston. We work with doctors,
    Membership                                                         hospitals, and other Providers to
                                                                                                                                  tice, medical school or residency
                                                                                                                                  information -- contact the Mas-
    What is BMC HealthNet Plan?                                        offer healthcare services within our
                                                                                                                                  sachusetts Board of Registra-
    BMC HealthNet Plan is a Managed                                    Service Area. This means that you
                                                                                                                                  tion of Medicine. The number is
    Care plan. Being part of a Man-                                    don’t need to travel a long way to
                                                                                                                                  1-800-377-0550; or go to www.
    aged Care plan means that you                                      get your health care.
                                                                                                                                  massmedboard.org and click on
    will choose a Primary Care Pro-
                                                                                                                                  “Physician Profiles.”
    vider (PCP) who will manage your                                   You can find out more information
    health care and coordinate your                                    about our Service Area and how                             Your MassHealth coverage
    care with Specialists, if necessary.                               BMC HealthNet Plan contracts                               As a Member of BMC HealthNet
    You can choose your PCP from                                       with healthcare Providers by call-                         Plan, you keep all your MassHealth
    BMC HealthNet Plan’s Provider                                      ing our Member services depart-                            coverage and benefits; therefore,
    Network. See section 5 of this                                     ment.                                                      you must be MassHealth eligible
    Member handbook for more infor-                                                                                               in order to be covered by BMC
                                                                       Provider Directory
    mation about PCPs.                                                                                                            HealthNet Plan. Most people have
                                                                       Our Provider Directory shows
                                                                                                                                  to have their MassHealth eligibility
    New Member orientation                                             BMC HealthNet Plan’s Network
                                                                                                                                  re-determined every year. So make
    BMC HealthNet Plan will contact                                    Providers, including:
                                                                                                                                  sure you immediately fill out and
    you to welcome you to the Plan                                     •    Primary Care Sites                                    return your Eligibility Review Veri-
    and go over all your benefits so                                   •    Primary Care Providers (PCPs)                         fication (ERV) form to MassHealth
    you understand how to use them.                                    •    Hospitals                                             when you get it in the mail. If you
    This is also a good time for you                                   •    Specialty Providers                                   need another form or help filling
    to ask any questions you may                                       •    Behavioral Health Providers                           out the form, call BMC HealthNet
    have about your coverage. If we
                                                                                                                                  Plan’s Member services depart-
    can’t reach you, please call the                                   You are free to choose among our                           ment, or call the MassHealth cus-
    Member services department and                                     Network of Primary Care Providers                          tomer service center. The numbers
    a representative will be happy to                                  in our Service Area. The Provider                          are at the bottom of every page of
    speak with you. To make sure we                                    Directory also has a complete list                         this handbook.
    can reach you, always call our                                     of our Network pharmacies, facility
    Member services department and                                     and ancillary Providers, hospital                          About your Enrollment options
    MassHealth customer service                                        Emergency services, Emergency                              If you have questions about your
    if you change your address or                                      Services Program (ESP) Providers                           health plan enrollment options
    phone number. If you don’t keep                                    for Behavioral Health, and durable                         with MassHealth – including BMC
    MassHealth up to date on your                                      medical equipment suppliers.                               HealthNet Plan – please call the
    contact information, you could                                                                                                MassHealth customer service cen-
    lose your MassHealth and BMC                                       In the Provider Directory, you can                         ter. The number is at the bottom
    HealthNet Plan eligibility. You                                    also find information about Provid-                        of the page. You may change your
    can find contact information at                                    ers, including contact information,                        Managed Care plan at any time
    the bottom of every page in this                                   languages spoken, handicap ac-
    handbook.                                                                                                                     Special help if you have
                                                                       cessibility, hours of operation and,
                                                                                                                                  certain health conditions
    Doctors and other healthcare                                       when applicable, hospital affilia-
                                                                                                                                  BMC HealthNet Plan offers special
    Providers near you                                                 tion.
                                                                                                                                  health programs to Members with
    We contract with doctors,                                                                                                     certain health conditions. For
    hospitals, pharmacies, Behavioral                                  To access our Provider Directory,
                                                                                                                                  example, we have programs for
    Health and other healthcare                                        go to bmchp.org. For a copy of a
                                                                                                                                  Members with:

    BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
    8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
    (en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
    1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
    Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
    Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
1
  •	     asthma                                                        correct. If it’s not correct, or if you                    Member, call our Member services
  •	     cancer                                                        did not get an ID Card, please call                        department. The number is at the
  •	     congestive heart failure                                      the Member services department                             bottom of this page. We will verify
  •	     depression                                                    promptly. (Remember: If you                                your Eligibility for the Provider.
  •	     diabetes                                                      change your address and phone

                                                                                                                                  SECTION 3
  •	     high blood pressure                                           number, you need to call the
  •	     HIV/AIDS                                                      Member services department and
  •	     obesity                                                       you need to call the MassHealth
  •	     or who are pregnant                                           customer service center to update                          Contacting your
                                                                       your information.)
  See Section 8 for more                                                                                                          Providers, contacting us
  information on our Care Manage-                                                                                                 Your healthcare Providers
  ment programs. If you have a
  chronic or long-term condition that                                                                                             •	 You should write down your
  is not listed here, BMC HealthNet                                                                                                  PCP’s phone number and put
  Plan will work with you and your                                                                                                   it somewhere where you can
  health care Provider to manage                                                                                                     find it quickly. Call your PCP
  your care.                                                                                                                         first for health-related ques-
                                                                                                                                     tions or problems, except in
  Get more!                                                                                                                          an Emergency. In case of an
  Members of BMC HealthNet                                                                                                           Emergency, you should call
  Plan get all the benefits that                                                                                                     911 or go to the nearest hos-
  MassHealth provides. See your                                                                                                      pital Emergency room. See
                                                                       Your ID Card has important phone
  Covered Services list in this                                                                                                      our online Provider Direc-
                                                                       numbers for contacting us. And it
  handbook for a list of your BMC                                                                                                    tory at bmchp.org for a list of
                                                                       says what to do when you need
  HealthNet Plan benefits. Plus                                                                                                      statewide hospital Emergency
                                                                       Emergency or urgent Care. (See
  BMC HealthNet Plan Members get:                                                                                                    rooms.
                                                                       Section 6 for more information
  •	 Free health care information                                      about Emergency or urgent Care.)                           •	 If you have a Behavioral Health
     from highly trained registered                                                                                                  Emergency, call 911 or go to
     nurses through our 24-hour                                        Always carry your BMC HealthNet                               the nearest hospital Emergency
     Nurse Advice Line                                                 Plan ID Card to receive healthcare                            room. You can also contact the
  •	 Free infant/toddler car seats                                     or pharmacy services. You should                              Emergency Services Program
  •	 Free bicycle helmets for kids                                     also always carry your MassHealth                             (ESP) Provider in your area. See
  •	 Free manual breast pumps for                                      ID Card.                                                      our online Provider Directory at
     nursing mothers                                                                                                                 bmchp.org for a list of statewide
                                                                       Lost your BMC HealthNet                                       ESPs.

  SECTION 2
                                                                       Plan Member ID Card?
                                                                       To replace your BMC HealthNet                              BMC HealthNet Plan
                                                                       Plan ID Card, call the Member                              •	 Call our Member services
  Your BMC HealthNet                                                   services department. You can also
                                                                       order a new ID Card from our Web
                                                                                                                                     department if you have ben-
                                                                                                                                     efit questions. You will find the
  Plan ID Card                                                         site, bmchp.org. Call MassHealth                              phone number at the bottom of
                                                                       to order a new Mass Health card.                              this page.
  A BMC HealthNet Plan Member                                          The number is below. Even if
  ID Card will be mailed to you                                                                                                   •	 Our Web site, bmchp.org, con-
                                                                       you don’t have your ID Card, a                                tains a lot of important informa-
  Every BMC HealthNet Plan
                                                                       healthcare Provider should never                              tion, such as:
  Member receives a BMC
                                                                       deny care to you or your BMC
  HealthNet Plan identification (ID)
                                                                       HealthNet Plan covered family                                         o       Find out about
  Card (ID Card) like the one shown
                                                                       Members. If a Provider refuses                                                your coverage
  below. Please check your ID Card
                                                                       to treat you or a covered family                                      o       Search for a
  to make sure the information is

BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
                                                                                                                                                                                              2
                       healthcare Provider                                           Member services depart-                      You can also call the Nurse Advice
              o        Find a provider’s hospi-                                      ment. The number is at the                   Line from BMC HealthNet Plan.
                       tal affiliation                                               bottom of the page.                          The number is 1-800-973-6273.
              o        Find health information                                o      If you have questions about                  You can get healthcare information
              o        Read our Member                                               your MassHealth benefits,                    from a highly trained registered
                       newsletter                                                    you may call us or call                      nurse, 24 hours a day, seven days
              o        Find a pharmacy                                               MassHealth at one of the                     a week. Some examples of health
                       near you                                                      following numbers: BMC                       problems or questions include:
                                                                                     HealthNet Plan at 1-888-
    You may also send an e-mail to us                                                566-0010 (TTY/TDD 1-866-                     •	     feeling sick
    from our Web site, bmchp.org.                                                    765-0055) or MassHealth                      •	     dizziness
                                                                                     at 1-888-841-2900 (TTY/                      •	     back pain
    If you don’t have a computer at                                                                                               •	     coughing
    home, you can go to your local                                                   TDD 1-800-497-4648).
                                                                                                                                  •	     baby is crying and feels hot
    library for free internet access.                                                                                             •	     colds
                                                                       •      Health-related questions
    Benefits, Eligibility and                                                 o      If you think you’re having a                 Remember: The Nurse Advice Line
    healthcare questions                                                             health (medical or Behav-                    can help you, but it should not
    We want to make sure it’s easy                                                   ioral Health) Emergency*,                    take the place of your healthcare
    for you to get the information                                                   call 911 or go to the nearest                Provider.
    you want. Here is some helpful                                                   hospital Emergency room.
    information.                                                                     (See Section 6 for more                      Care When You Travel Outside
                                                                                     information on Emergency                     our Service Area
    •	 MassHealth Eligibility ques-
                                                                                     care.) Remember to call                      When Members are away from
         tions
                                                                                     your PCP about your Emer-                    home, BMC HealthNet Plan will
    If you have questions about your
                                                                                     gency as soon                                cover only Emergency, Post-
    MassHealth Eligibility, you may call
                                                                                     as possible.                                 stabilization and urgent Care
    us or call MassHealth at one of the
                                                                              o      If you are having a Behav-                   services*. To ensure coverage, be
    following numbers:
                                                                                     ioral Health Emergency*,                     sure to take care of your routine
                                                                                     you can also call your                       health care needs before traveling
    BMC HealthNet Plan at 1-888-
                                                                                     local Emergency Services                     outside of BMC HealthNet Plan’s
    566-0010 (TTY/TDD 1-866-765-
                                                                                     Program (ESP) Provider.                      Service Area.
    0055) or
                                                                                     Often ESPs can be a bet-                     *Only Emergency, Post-
    MassHealth at 1-888-841-2900
                                                                                     ter choice than a hospital                   stabilization and Urgent Care
    (TTY/TDD 1-800-497-4648).
                                                                                     Emergency room. Remem-                       health services provided in the
                                                                                     ber to call your PCP, and                    United States or its territories
    • Benefits questions
                                                                                     your Behavioral Health                       are covered. You should still
       o Refer to your Covered Ser-
                                                                                     Provider, if you have one,                   seek care in an Emergency
          vices list in this handbook
                                                                                     about your Emergency as                      when you are outside the United
          for more information about
                                                                                     soon as possible.                            States, but be advised that BMC
          your benefits. Your Covered
                                                                              o      If you are not having a                      HealthNet Plan will not cover
          Services list will also show
                                                                                     medical or Behavioral                        these services.
          you which benefits are
                                                                                     Health Emergency, always
          covered by BMC HealthNet                                                                                                If you need Emergency or urgent
                                                                                     call your healthcare Pro-
          Plan and which are covered                                                                                              Care while you are temporarily
                                                                                     vider first if you have ques-
          by MassHealth. When you                                                                                                 outside the BMC HealthNet Plan
                                                                                     tions about your health or
          want to speak with some-                                                                                                Service Area, go to the nearest
                                                                                     if you need urgent Care or
          one about the benefits and                                                                                              doctor or hospital Emergency
                                                                                     Routine Care.
          Covered Services you get                                                                                                room. You do not have to call
          as a BMC HealthNet Plan                                                                                                 your Primary Care Provider before
          Member, please call our                                                                                                 seeking Emergency or urgent Care


    BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
    8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
    (en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
    1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
    Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
    Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
3
  while outside the BMC HealthNet
  Plan Service Area. You or a family                                   SECTION 4                                                  certain disorders with bones and
                                                                                                                                  joints. Pulmonologists treat asth-
  member should call your Primary                                                                                                 ma and other breathing problems.
  Care Site (or your Behavioral                                        Your Benefits                                              Psychiatrists specialize in treating
  Health provider in a Behavioral                                      How to obtain your benefits                                mental health conditions.
  Health Emergency) within 48 hours                                    The Covered Services list in this
  of receiving out-of-area care.                                       Member handbook shows that                                 If you think you need to see a
                                                                       BMC HealthNet Plan covers most                             Specialist, you should first call
  BMC HealthNet Plan will cover all                                    of your benefits. But MassHealth                           your PCP. Your PCP can help you
  Medically Necessary Emergency,                                       also directly covers some benefits                         identify your specialty care needs
  Post-stabilization and urgent Care                                   even though BMC HealthNet Plan                             and refer you to an appropriate
  Services delivered outside the Ser-                                  may coordinate them. That’s why                            Specialist. Your PCP may also help
  vice Area. BMC HealthNet Plan will                                   you should always carry both                               you with any follow-up care that is
  not cover:                                                           your BMC HealthNet Plan and                                important for your health and re-
  •	 Emergency services provided                                       MassHealth ID Cards.                                       covery, both while being treated by
     outside the united States or its                                                                                             a Specialist and afterward. There-
     territories.                                                      Always check your Covered Ser-                             fore, it is important that you talk
                                                                       vices list to see what services are                        with your PCP about your special-
  •	 Tests or treatment that your                                                                                                 ty care needs and treatment even
                                                                       covered and what services are not
     Primary Care Provider asked for                                                                                              after you are feeling better and no
                                                                       covered. And, always show your
     before you left the Service Area.                                                                                            longer need those services.
                                                                       BMC HealthNet Plan ID Card to
  •	 Routine Care or follow-up care                                    receive your Plan Covered Servic-
     that can wait until your return                                                                                              Receiving care from
                                                                       es and benefits. If you need help
     to the Service Area, such as                                                                                                 Providers within the BMC
                                                                       getting any benefits or Covered                            HealthNet Plan Network
     physical exams, flu shots, stitch                                 Services, please call our Member
     removal, mental health counsel-                                                                                              Healthcare Providers who have
                                                                       services department. Your Primary                          contracts with BMC HealthNet
     ing.                                                              Care Provider is the best person                           Plan are considered Network
  •	 Care that you knew you were                                       to tell you if you need any of these                       Providers. These include both
     going to get before you left the                                  services.                                                  Primary Care Providers and
     Service Area such as elective                                                                                                Specialists. You must always
     surgery.                                                          If you need a ride to a health care                        receive your care from Network
                                                                       appointment, and if you’re eligible                        Providers, except as described
  A Provider may ask you to pay
                                                                       for non-emergency transportation                           in “Receiving care from Providers
  for care received outside of BMC
                                                                       services, we can help arrange for                          outside of the BMC HealthNet
  HealthNet Plan’s Service Area
                                                                       it. Just call our Member services                          Plan Network” later in this section
  at the time of service. If you pay
                                                                       department and a representative
  for Emergency Care, Post-stabi-
                                                                       can assist you. (See Section 6 for                         When Prior Authorization is
  lization Care or urgent Care that
                                                                       more information on transportation                         needed for visits to Network
  you receive while outside of BMC
                                                                       assistance.)                                               Specialists
  HealthNet Plan’s Service Area
  but within the united States or                                      Specialty care                                             •     Your PCP coordinates all your
  its territories, you may submit a                                    There may be times when you may                                  care, including specialty care.
  Claim to BMC HealthNet Plan to                                       need to see a Specialist.                                        Your PCP or Specialist does not
  be reimbursed. See the section on                                                                                                     need to get a Prior Authoriza-
                                                                       A Specialist is a healthcare Provid-
  “If You Receive a Bill” to find out                                                                                                   tion from BMC HealthNet Plan
                                                                       er who is trained to provide specif-
  how to submit a Claim. You may                                                                                                        before you visit most Special-
                                                                       ic, often more detailed, treatments
  also call the Plan’s Member ser-                                                                                                      ists in BMC HealthNet Plan’s
                                                                       than your PCP. For example, a
  vices department for help with any                                                                                                    Provider Network. For example,
                                                                       cardiologist is a doctor who spe-
  bills that you may receive from a                                                                                                     your PCP or Specialist does not
                                                                       cializes in treating heart problems.
  Provider.                                                                                                                             need a Prior Authorization for
                                                                       Orthopedists specialize in treating


BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
                                                                                                                                                                                              4
         you to visit a Specialist within                                                                                                  exam, including any follow-up
         the Network if your PCP and                                   Prior authorization is NOT required                                 obstetric or gynecological ser-
         the Specialist are both affili-                               in the following cases:                                             vices determined to be medi-
         ated with the same hospital or                                                                                                    cally necessary as a result of
                                                                       •      In an Emergency                                              such exam
         if the Specialist is affiliated with                          •      To see a BMC HealthNet Plan                           •      Medically necessary evalua-
         Boston Medical Center.                                               Network Specialist affiliated                                tions and related health care
    However, there are some situa-                                            with Boston Medical Center                                   services for acute or Emergen-
    tions, described below,                                            •      To see a BMC HealthNet Plan                                  cy gynecological conditions
    where your PCP or Specialist                                              Network Specialist affiliated                         •      To get a mammogram
    does need to get Prior Authoriza-                                         with the same hospital as your                        •      To get Family Planning Ser-
    tion from BMC HealthNet Plan                                              PCP                                                          vices from any BMC HealthNet
    before you see a Specialist within                                 •      To see a BMC HealthNet Plan                                  Plan Network Family Plan-
    BMC HealthNet Plan’s Provider                                             Network Specialist affiliated                                ning Services Provider or
    Network.                                                                  with any BMC HealthNet Plan                                  MassHealth-contracted Family
                                                                              contracted hospital not listed                               Planning Services Provider
    Your PCP or Specialist must get                                           above                                                 •      For the first 12 visits to a Be-
    Prior Authorization before you see                                 •      To go to any BMC HealthNet                                   havioral Health Provider
    a Specialist who is affiliated with                                       Plan Network obstetrician,
    any of the following hospitals, un-                                       gynecologist, certified nurse                         Before you visit a Specialist, you
    less your PCP and the Specialist                                          midwife or family practitioner                        should always check with your
    are both affiliated with the same                                         who is affiliated with any Net-                       PCP or the Specialist to find out if
    hospital:                                                                 work hospital for the following                       he or she has gotten Prior Authori-
                                                                              types of care:
    •    Beth Israel Deaconess Medical                                 •      Maternity care
         Center (all locations)
                                                                       •      Routine annual gynecologic
    •    Carney Hospital
    •    Children’s Hospital                                            If you would like to go                       Does my PCP or Net-                   Will BMC HealthNet Plan
         (all locations)                                                to a Network Specialist                       work Specialist have to               approve a Prior Authori-
    •    Mount Auburn Hospital                                          affliated with:                               get Prior Authorization                  zation for my visit?
                                                                                                                      from BMC HealthNet
    •    St. Elizabeth’s Medical Center                                                                               Plan before I visit this
    •    Tufts Medical Center                                                                                         network Specialist?
    •    Women and Infants Hospital of                                  Boston Medical Center                                     NO                             NOT APPLICABLE
         Rhode Island
                                                                        the same hospital as my                                   NO                             NOT APPLICABLE
                                                                        PCP
    When prior authorization is re-
                                                                        any network hospital -                                    NO                             NOT APPLICABLE
    quired, it will be granted                                          except those hospitals
    for specialty care with specialists                                 listed in the box below
    affiliated with the above hospitals                                 •      Beth Israel                                       YES*                       BMC HealthNet Plan will
    when the specialty care is not avail-                                      Deaconess Medical                                                              approve your visit only
    able from:                                                                 Center-(all locations)                   (* unless the network                if the specialty care you
                                                                        •      Carney Hospital                           specialist is affiliated               need is not available
                                                                        •      Children’s Hospital-                     with the same hospital              from a network Special-
    •    a specialist affiliated with Bos-                                     (all locations)                               as your PCP.)                  ist affiliated with Boston
         ton Medical Center; or                                         •      Mount Auburn Hos-                                                            Medical Center or a BMC
    •    a BMC HealthNet Plan Net-                                             pital                                                                        HealthNet Plan Network
                                                                        •      St. Elizabeth’s Medi-                                                         Specialist affiliated with
         work Specialist affiliated with                                       cal Center                                                                   the same hospital as the
         the same hospital as the Mem-                                  •      Tufts Medical Center                                                               Member’s PCP
         ber’s PCP                                                      •       Women and Infants
                                                                               Hospital of Rhode
    Here is a chart to further explain                                         island
    how this works:


    BMC HealthNet Plan Member Services Department                                                                                  MassHealth Customer Service
    8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012              8:00 a.m. – 5:00 p.m., Monday-Friday
    (en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •          1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
    1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
    Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
    Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
5
  zation from BMC HealthNet Plan, if                                          when an Authorization request                       the Plan does not make the Autho-
  necessary.                                                                  may be expedited (processed                         rization decisions within the above
                                                                              fast) by determining that fol-                      timeframes. (For more information
  You can look up hospital affilia-                                           lowing the standard timeframe                       on how to file a Grievance or an
  tions for PCPs and specialists on                                           could seriously jeopardize your                     Internal Appeal, please see Sec-
  our website. You can also call our                                          life or health, or your ability to                  tion 10 “Inquiries, Grievances and
  Member services department for                                              get, maintain or regain maxi-                       Appeals.”)
  help with this.                                                             mum function.
                                                                                                                                  We will send a written notice to
  When Prior Authorization is                                          These Authorization decision time-                         you, and your Authorized Rep-
  needed for other services                                            frames may be extended to up to                            resentative, and the requesting
  In addition to Prior Authorization                                   an additional 14 calendar days if                          Provider of any decision to deny
  needed to see certain Network                                        you or your Provider requests an                           an Authorization request, or to
  Specialists, there are other                                         extension, or the Plan has a good                          authorize a service in an amount,
  services that must be authorized                                     reason to believe that:                                    duration, or scope that is less than
  in advance by BMC HealthNet                                                                                                     requested. You, or your Authorized
  Plan, MassHealth or Beacon                                           •      The extension is in your best                       Representative, have the right to
  Health Strategies in order for these                                        interest.                                           file an Internal Appeal if the Plan
  services to be covered. (Beacon                                      •      The Plan needs additional                           denies an Authorization request or
  Health Strategies is responsible                                            information that we think, if we                    authorizes a service amount, dura-
  for authorizing Behavioral Health                                           receive it, will lead to approval                   tion or scope that is less than what
  - mental health and substance                                               of your request.                                    was requested. (For more infor-
  abuse - services for Members).                                       •      Such outstanding information                        mation on how to file a Grievance
                                                                              is reasonably expected to be                        or an Internal Appeal, please see
  The Covered Services list in                                                received by the Plan within 14                      Section 10 “Inquiries, Grievances
  this Member handbook shows                                                  calendar days.                                      and Appeals.”)
  the services that require Prior
  Authorization. When a service                                                                                                   Receiving care from
                                                                       If BMC HealthNet Plan asks for                             Providers outside of the BMC
  requires Prior Authorization, your                                   an extension of the Authorization
  Provider must submit a request for                                                                                              HealthNet Plan Network
                                                                       timeframes, we will send you, and                          Providers who do not have
  those services to BMC HealthNet                                      your Authorized Representative, a
  Plan, Beacon Health Strategies                                                                                                  contracts with BMC HealthNet
                                                                       written notice. If you or your Au-                         Plan are considered “out-of-
  (for Behavioral Health services) or                                  thorized Representative disagree
  MassHealth.                                                                                                                     Network Providers.” You are not
                                                                       with this decision, you or your                            covered for services provided
                                                                       Authorized Representative may                              by an out-of-Network Provider,
  Timeframes for Prior
                                                                       file a Grievance in writing, over the                      except in any of the following
  Authorization Decisions
                                                                       phone or in person. Our Member                             cases:
  Prior Authorization decisions are
                                                                       services department representa-
  made by a healthcare professional
                                                                       tives can help you with this. (For                         •     An Emergency
  that has appropriate clinical
                                                                       more information on how to file a                          •     Your Network Primary Care
  expertise within the following
                                                                       Grievance or an Internal Appeal,                                 Provider (PCP) has gotten
  timeframes:
                                                                       please see Section 10 “Inquiries,                                Prior Authorization from BMC
                                                                       Grievances and Appeals.”)                                        HealthNet Plan
  •      Standard Authorization deci-
                                                                                                                                  •     Family Planning Services with
         sions: Within 14 calendar days
                                                                       We will send a written notice to                                 any MassHealth-contracted
         after the request is received.
                                                                       you, and your Authorized Repre-                                  provider of Family Planning
  •      Expedited (fast) Authorization
                                                                       sentative, if we did not meet these                              services
         decisions: Within 72 hours
                                                                       timeframes. You, or your Autho-                            •     If BMC HealthNet Plan is
         after the request is received.
                                                                       rized Representative, have the                                   unable to provide a specific
         Only a Provider can recom-
                                                                       right to file an Internal Appeal if                              covered service through a
         mend, or the Plan can decide,

BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
                                                                                                                                                                                              6
         BMC HealthNet Plan Network                                   sure that you have Authorization                                   Mail any bills for medical
         Provider. Requests must go                                   before you see a Provider that is                                  services to:
         through the Prior Authorization                              not part of the Plan’s Network.
         process described above. If                                  You may ask your PCP to arrange                                    Member Services Department
         BMC HealthNet Plan deter-                                    this or call the the Plan’s Member                                 BMC HealthNet Plan
         mines that the specific covered                              services department.                                               Two Copley Place, Suite 600
         service is medically necessary                               When your Provider is no longer                                    Boston, MA 02116
         and not available through a                                  in BMC HealthNet Plan’s Network
         BMC HealthNet Plan Network                                   because they have been disen-                                      Mail any bills for Behavioral
         provider, BMC HealthNet Plan                                 rolled from the Plan’s Network                                     Health services to:
         will adequately cover the ser-                               for reasons not related to quality                                 Beacon Health Strategies, LLC
         vice in a timely manner with an                              of care or Fraud, BMC HealthNet                                    500 Unicorn Park Drive,
         out-of-Network Provider for as                               Plan may be able to provide cover-                                 Suite 401
         long as the service is medically                             age for:                                                           Woburn, MA 01801
         necessary and not available
         through a BMC HealthNet Plan                                 •     up to 30 calendar days if the                         •      You cannot be charged for:
         Network Provider.                                                  Provider is your PCP or up to                                Emergency or Post Stabiliza-
                                                                            90 calendar days if the Provid-                              tion Care services provided
    Coverage if you                                                         er, including a PCP, is provid-                              in the united States and its
    changed plans                                                           ing you with active treatment                                territories. Post Stabilization
    To ensure continuity of care,                                           for a chronic or acute medical                               Care services are the services
    there are some times when BMC                                           condition or until that active                               you get after your Emergency
    HealthNet Plan may be able                                              treatment is completed, which-                               condition is brought under
    to provide coverage for health                                          ever comes first.                                            control so that your condi-
    services from a Provider who                                      •     If you are in your second or                                 tion can then stay stable. For
    is not part of our Network. For                                         third trimester of your preg-                                example, if you’re treated for a
    new Members who were already                                            nancy, you may remain under                                  Behavioral Health Emergency
    receiving care from a Provider                                          the care of your current OB/                                 by an Emergency Services
    who is not part of BMC HealthNet                                        GYN (even if out of Network)                                 Program (ESP) Provider, you
    Plan’s Network when they join the                                       through delivery and follow-up                               may also be covered for the
    Plan:                                                                   within the first six weeks of                                follow-up services such as
                                                                            delivery. Your second trimester                              community crisis stabilization
    •    If you are in your second or                                       is the start of your 4th month                               services once your Emergency
         third trimester of your preg-                                      of pregnancy based on the                                    has been dealt with.
         nancy, you may remain under                                        expected delivery date.                               •      Services you get from a BMC
         the care of your current OB/                                 •     With respect to a terminal ill-                              HealthNet Plan Provider or
         GYN (even if Out-of-Network)                                       ness, coverage shall apply to                                an out-of-Network Provider
         through delivery and follow-up                                     services rendered until death.                               if these services were prior
         check-up within the first six                                                                                                   authorized by the Plan. It is the
         weeks of delivery. Your second                               If you get a bill for services                                     responsibility of the Provider to
         trimester is the start of your 4th                           If you get a bill for a Covered                                    obtain prior authorization from
         month of pregnancy based on                                  Service, here’s what you should                                    BMC HealthNet Plan when
         the expected delivery date.                                  do:                                                                needed.
    •    For a limited period, if you are                                                                                         •      Services provided by a
                                                                      •     Print the name of the Member
         receiving ongoing covered                                                                                                       MassHealth Provider when
                                                                            who received the care, and his
         treatment or management of                                                                                                      those services are covered
                                                                            or her BMC HealthNet Plan
         chronic issues, including previ-                                                                                                directly by MassHealth.
                                                                            Member ID Card number on
         ously authorized services for                                                                                            •      Family Planning Services
                                                                            the bill.
         Covered Services.                                                                                                               received from any MassHealth
                                                                      •     Make a copy of the bill for your
                                                                                                                                         contracted Family Planning-
                                                                            records.
    It is still your responsibility to make                                                                                              Services Provider.

    BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
    8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
    (en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
    1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
    Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
    Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
7
  However, care that is not cov-                                       coverage. (Efficacy means that                             •	 Keep your medical records
  ered by BMC HealthNet Plan or                                        the technology works.) Such                                •	 Write prescriptions
  MassHealth may be your respon-                                       technologies include medical                               •	 Request Prior Authorizations
  sibility to pay. We can help you                                     and Behavioral Health therapies,                              from BMC HealthNet Plan,
  figure this out.                                                     devices, surgical and diagnostic                              when necessary
  If you have questions, please call                                   procedures and medications.                                •	 Respond to your phone calls
  our Member services department.                                                                                                    about your medical needs or
  We’ll help you resolve the problem.                                  The review process by the Plan’s                              problems, even after business
                                                                       medical staff includes consulting                             hours.
  Extras, “free” for our                                               with medical experts who have
                                                                                                                                  Picking a PCP
  Members                                                              expertise in the new technology;
                                                                                                                                  Call us if you need help choosing
   • Infant/toddler safety car seats                                   research and review of published
                                                                                                                                  a PCP. And if you already have
     – If you’re having a baby, call                                   peer-reviewed medical literature
                                                                                                                                  a PCP when you call, we want
     the Member services depart-                                       and reports from appropriate gov-
                                                                                                                                  to make sure that we have the
     ment to find out how to get                                       ernmental agencies (such as the
                                                                                                                                  correct information for our records.
     your free convertible car seat.                                   federal Food and Drug Administra-
                                                                                                                                  If you haven’t picked a PCP yet,
     You can get the seat up to                                        tion), and policies and standards
                                                                                                                                  we have a long list of PCPs and
     45 days before your due                                           of nationally recognized medical
                                                                                                                                  we’ll help you choose one for
     date.                                                             associations and specialty so-
                                                                                                                                  you and for each BMC HealthNet
  • Bicycle helmets for kids – Kids                                    cieties. The information is then
                                                                                                                                  Plan-enrolled family Member. Even
     who are Members of BMC                                            presented to the Plan’s internal
                                                                                                                                  though you can pick a PCP from
     HealthNet Plan can get a free                                     committees who are responsible
                                                                                                                                  anywhere in our Network, it makes
     bike helmet. Call our Member                                      for making final decisions con-
                                                                                                                                  sense that you pick one who
     services department to find out                                   cerning coverage of the medical
                                                                                                                                  is near you. You should call us
     how to get the helmet.                                            technology.
                                                                                                                                  immediately to pick a PCP if you
  • Manual breast pumps – A

                                                                       SECTION 5
                                                                                                                                  haven’t already done so. Or check
     nursing mother needs a pre-
                                                                                                                                  out our online Provider Directory
     scription from her healthcare
                                                                                                                                  at bmchp.org. You can also have
     Provider for a manual breast
     pump. Call the Member ser-                                        Your Primary Care                                          a printed Provider Directory sent
                                                                                                                                  to you by calling our Member
     vices department to find out                                      Provider (PCP)                                             Services department. BMC
     how to get the manual breast
                                                                       Primary Care Provider (PCP)                                HealthNet Plan will assign a PCP
     pump.
                                                                       Every BMC HealthNet Plan                                   to any Member who does not pick
  • The Nurse Advice Line from
                                                                       Member needs to have a Primary                             one within 15 days of Effective
     BMC HealthNet Plan can help
                                                                       Care Provider (PCP). He or she                             Date of enrollment in the Plan. You
     you answer your health ques-
                                                                       is your personal doctor or nurse                           can change your PCP at any time
     tions 24-hours a day, seven
     days a week. The number is                                        practitioner. Your PCP will do                             Providers who are PCPs
     1-800-973-6273. Remember:                                         many things for you and your                               There are a few different kinds of
     the Nurse Advice Line can help                                    BMC HealthNet Plan enrolled                                healthcare Providers who may act
     you, but it should not take the                                   family Members:                                            as PCPs:
     place of your Primary Care                                        •	 Provide or coordinate all your                          •	 Family practice Providers treat
     Provider.                                                            care, except in an Emergency                               adults and children. They can
                                                                       •	 Treat you for your basic health                            also provide women’s health
  Process to evaluate new                                                 needs and problems                                         services for pregnant women.
  technology                                                           •	 Refer you to other healthcare                           •	 General practice Providers
  BMC HealthNet Plan reviews                                              Providers and Specialists                                  treat adults and children.
  new medical technologies and                                         •	 Admit you to the hospital and                           •	 Internal medicine Providers
  new uses for existing medical                                           arrange for your hospital care,                            treat adults over the age of 17
  technologies for safety and                                             if necessary                                               years. (A medical doctor who
  efficacy before we determine

BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
                                                                                                                                                                                              8
       practices internal medicine is                                 you and your family’s health his-                           have. We can also arrange for you
       called an “internist.”)                                        tory, the better he or she can man-                         to get a second opinion from a
    •	 Pediatric Providers treat chil-                                age your care. Adults should visit                          provider outside of our network. In
       dren and young adults up to                                    their PCPs at least once a year for                         both cases, BMC HealthNet Plan will
       age 21 years.                                                  a comprehensive annual exam.                                pay for your Second Opinion visit.
    •	 Nurse practitioners – registered                               Infants, children and pregnant
       nurses with advanced training                                  women should see their PCPs
       in the treatment of many health
       issues.
                                                                      more often. Please see Section
                                                                      7 for information on how often to                            SECTION 6
    •	 Obstetricians/Gynecolo-                                        see your healthcare Provider.
       gists treat women’s health
                                                                                                                                  Your Health Care
       and reproductive issues. (they        Call your PCP first when                                                             Emergencies and Urgent Care
       must also be contracted with          you’re sick – unless you think                                                       Emergencies*
       BMC HealthNet Plan as a PCP.          it’s an Emergency                                                                    Whether you have a medical
       Check your online Provider            Your PCP will provide and coor-                                                      Emergency or a Behavioral Health
       Directory at bmchp.org to             dinate all your care, except in an                                                   Emergency, you should seek im-
       see if they are listed as a PCP.)     Emergency. If you think you are                                                      mediate care when there’s no time
                                             having an Emergency, call 911 or                                                     to call your health care Provider.
    Each family Member enrolled in BMC go to the nearest hospital Emer-
    HealthNet Plan must have a PCP If   .    gency room listed in our online                                                      You do not need approval from
    everyone in your family wants the        Provider Directory at bmchp.org.                                                     your health care Provider to seek
                ,
    same PCP you can choose a family If it’s a Behavioral Health Emer-
                                                                                                                                  Emergency care. And you’re cov-
    practice or general practice Provider gency, call 911, go to the near-
                                                                                                                                  ered for Emergency care 24 hours
    to be the PCP for each BMC Health- est hospital Emergency room, or
                                                                                                                                  a day, seven days a week, even
    Net Plan family Member.                  contact the nearest Emergency                                                        if you’re outside BMC HealthNet
    Call your PCP for an                     Services Program (ESP) Provider                                                      Plan’s Service Area or need to
    appointment                              listed in both our online and print                                                  see an out-of-Network Provider*.
    When you become a BMC Health- Provider Directories. If you need a                                                             You’re also covered if a BMC
    Net Plan Member, you should              printed directory, call Member Ser-                                                  HealthNet Plan representative tells
    make an appointment to see your vices and they will send you one.                                                             you to seek Emergency care. Note:
    PCP for a checkup. Your PCP’s            At all other times, you should call                                                  You cannot be denied Emergency
    name is on your BMC HealthNet            your PCP’s office. There’s always a                                                  care based on your diagnosis
    Plan ID Card. Make sure you write healthcare Provider on call for you,                                                        (your illness or condition).
    down your PCP’s phone number             24 hours a day, seven days a week
    and put it where you can find it         to help you.                                                                         *However, you are not covered
    quickly.                                 Changing your PCP                                                                    for Emergency care outside of
                                             We want you to be happy with                                                         the United States or its territo-
    Call your PCP’s office. Tell the of- your PCP. It is important to have                                                        ries. You should still seek Emer-
    fice staff this will be your first visit an ongoing relationship with your                                                    gency care when you’re outside
    with this PCP, or that this is your      PCP for continuity of your health-                                                   the country, but be aware that
    first visit with the PCP using your      care and wellness. However, if you                                                   the services you receive will not
    BMC HealthNet Plan insurance. If feel the need to change your PCP,                                                            be covered by BMC HealthNet
    you have any problems making an you can pick a new PCP at any                                                                 Plan.
    appointment, call our Member ser- time by calling our Member ser-                                                             The Emergency care doctor or
    vices department. If it’s your first     vices department.                                                                    Provider treating you is responsible
    visit with your PCP, most likely you Getting a Second Opinion                                                                 for deciding when you are stable
    will get a physical exam. Your PCP You may ask for a Second Opinion                                                           enough to be transferred or dis-
    will ask you questions about your from another BMC HealthNet Plan                                                             charged. The Provider’s decision
    health and your family’s health.                                                                                              is binding on those responsible for
                                             Provider about any health care that
    The more your PCP knows about                                                                                                 coverage and payment. This means
                                             your Provider thinks you should


    BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
    8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
    (en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
    1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
    Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
    Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
9
  that BMC HealthNet Plan and                                          cies. This list does not include all                       if you’re out of town or out of the
  anyone responsible for covering or                                   the health Emergencies that you                            Service Area, you should call your
  paying for your care must follow                                     might have. Call 911 if you think                          PCP if an urgent Care condition
  the direction the Provider decides.                                  you are having an Emergency.                               occurs. You can call your PCP 24
                                                                                                                                  hours a day, seven days a week. If
  You are also covered for ambu-                                       Examples of medical                                        your PCP is not available, a cov-
  lance transportation and Post                                        Emergencies                                                ering doctor or other healthcare
  Stabilization Care services that                                                                                                Provider will call you back.
  are related to an Emergency. Post                                    •	 Broken bones
  Stabilization Care services are the                                  •	 Throwing up continuously                                Behavioral Health care
  services you get after your Emer-                                    •	 Throwing up blood                                       Choosing Behavioral Health ser-
  gency condition is stabilized so that                                •	 Convulsions                                             vices
  your condition can then stay stable.                                 •	 Chest pain                                              BMC HealthNet Plan has part-
  For example, if you’re treated for                                   •	 Fainting or dizzy spells                                nered with Beacon Health Strat-
  a Behavioral Health Emergency at                                     •	 Heart attacks                                           egies (Beacon) to manage and
  an Emergency Services Program                                        •	 Loss of consciousness                                   coordinate the Behavioral Health
  (ESP) provider, you are also cov-                                    •	 Poisoning                                               (mental health and substance
  ered for the follow-up services you                                  •	 Serious accidents                                       abuse) services for Members and
  will need once your Emergency has                                    •	 Severe burns                                            manage the Behavioral Health Pro-
  been dealt with. This follow-up care                                 •	 Severe pain                                             vider network. Beacon is a Mas-
  might include outpatient visits or                                   •	 Severe headaches                                        sachusetts based company with
  treatment at another facility.                                       •	 Severe wounds                                           an excellent reputation for coor-
                                                                       •	 Heavy bleeding                                          dinating quality Behavioral Health
  In a medical Emergency: Call                                         •	 Shortness of breath                                     services.
  911 or immediately seek care in                                      •	 Stroke (this includes numb-
  any hospital Emergency room. A                                          ness or difficulty with speech)                         You can find a list of Behavioral
  statewide list of Emergency rooms                                    •	 Sudden change of vision                                 Health Providers in our online
  is in your BMC HealthNet Plan                                        •	 Sudden, severe pain or pres-                            Provider Directory at bmchp.org. If
  Provider Directory in the “Statewide                                    sure in or below the chest                              you need a printed Provider Direc-
  Emergency Care by Hospitals” and                                                                                                tory, call our Member Services
  in our online Provider Directory at                                  Examples of Behavioral Health                              department.
  bmchp.org                                                            Emergencies

                                                                       •	 Wanting to harm yourself                                Behaviroal Health services are
  In a Behavioral Health Emer-                                         •	 Wanting to harm other people                            available by “self-Referral”. This
  gency: Call 911, go to the nearest                                                                                              means that you can go to a BMC
  hospital Emergency room or im-                                       Urgent Care                                                HealthNet Plan Behavioral Health
  mediately contact the Emergency                                      An urgent Care condition is a                              Provider when you want to. You
  Services Program (ESP) Provider                                      health problem that’s serious – but                        can find the listing of these Provid-
  in your area. A statewide list of                                    that you do not think is an Emer-                          ers in our online Provider Directory
  ESPs is in your Provider Directory                                   gency. Your PCP must see you                               or you can ask family members,
  in the “Statewide Behavioral Health                                  within 48 hours after you request                          guardians, a community agency, or
  Emergency Services Programs”                                         for an urgent Care appointment.                            your Provider (including your PCP)
                                                                       Your Behavioral Health Provider                            to recommend a BMC HealthNet
  and in our online Provider Directory                                 must also see you within 48 hours                          Plan Behavioral Health Provider.
  at bmchp.org.                                                        for urgent Care for Behavioral                             No Prior Authorization is needed
                                                                       Health conditions. If your urgent                          for up to the first 12 visits to a
  Below are some examples of medi-                                     Care condition gets worse before                           Behavioral Health Provider in our
  cal and Behavioral Health Emer-                                      you are seen by your PCP or Be-                            Network. Your Behavioral Health
  gencies. Please note that these are                                  havioral Health Provider, you can                          Provider will arrange for any need-
  only the most common Emergen-                                        go to an Emergency room. Even                              ed Prior Authorizations beyond the


BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
                                                                                                                                                                                              10
     first 12 visits. Certain Behavioral                               It is very important that you fill                          a week. Members have unrestrict-
     Health services, like diversionary                                out the HRA and return it to us in                          ed (no limit) access at any qualified
     and inpatient, must be authorized                                 the postage-paid envelope that’s                            Emergency care Provider whether
     in advance for them to be cov-                                    provided. You can also complete                             or not the Providers are part of
     ered. The Covered Services List                                   your HRA online via the Member                              BMC HealthNet Plan’s Network.
     in this Member handbook shows                                     self service section at bmchp.org.
     the Behavioral Health services that                               Filling out your HRA DOES NOT                               Urgent Care
     require Prior Authorization. Your                                 affect your MassHealth Eligibility                          A healthcare Provider must give
     Provider should be able to make                                   or your health benefits in any way.                         you urgent Care within 48 hours of
     arrangements for Prior Authori-                                   Please know that we will keep your                          your request for an appointment.
     zation. You can always call the                                   Protected Health Information (PHI)
     Behavioral Health Member line                                     confidential.                                               Primary care
     (see the phone number listed at                                                                                               Non-urgent, symptomatic care (if
     the bottom of this page) if you      If you do not fill out your HRA, a                                                       you are sick or have other symp-
     have any questions about Prior       representative from BMC Health-                                                          toms that are not urgent): A health-
     Authorization for Behavioral Health  Net Plan may call you and ask                                                            care Provider must give you care
     Covered Services.                    you to give us your Health Risk                                                          within 10 calendar-days of your
                                          Assessment information. (See                                                             request for an appointment.
     Remember, in a Behavioral Health Section 11 for information about
     Emergency you should call 911, go your PHI and your rights to keep it                                                         Routine, non-symptomatic care (if
     to the nearest hospital Emergency private.) The answers you give in                                                           you’re not sick and don’t have any
     room, or contact the Emergency       the Health Risk Assessment help                                                          other symptoms):
     Services Programs (ESP) Provider us to help you stay healthy, so                                                              A healthcare Provider must give
     in your area. A statewide list of    please complete your HRA.                                                                you care within 45 calendar days
     Emergency Services Program                                                                                                    of your request for an appoint-
     (ESP) Providers is in your printed   How long it should take                                                                  ment. That is unless you or your
     and online Provider Directory at     to get care                                                                              child needs an appointment as
     bmchp.org.                           When you don’t feel well or when                                                         part of the EPSDT (Early and
                                          you really want to see your health-                                                      Periodic Screening, Diagnosis and
     Note that you are not covered        care Provider, you don’t want                                                            Treatment) Periodicity Schedule
     for Emergency care outside of        to wait too long for an appoint-                                                         Your child’s health care Provider
     the United States or its territo-    ment. That’s why we require all                                                          can give you more information
     ries. You should still seek Emer- of our Providers to comply with                                                             about EPSDT schedules. (For
     gency care when you’re outside the guidelines that follow. You                                                                more information on EPSDT, see
     the country, but be aware that       shouldn’t need to wait any longer                                                        Section 7.)
     the services you receive will not than what is listed. If you think that
     be covered by BMC HealthNet          any of these timeframes have not                                                         Routine, first prenatal and first
     Plan.                                been met, then you, or your Au-                                                          family-planning visit
                                          thorized Representative, have the                                                        Within 10 working days of request-
     Health Risk Assessment               right to file an Internal Appeal. (For                                                   ing an appointment.
     Your new-Member materials            Appeals information, see Section
     include a special form called a      10, “Inquiries, Grievances and Ap-                                                       Specialty care
     Health Risk Assessment (HRA).        peals.”)                                                                                 Non-urgent, symptomatic care (if
     The HRA will help us to better                                                                                                you’re sick or have other symp-
     understand your health needs – so Getting medical care                                                                        toms that aren’t urgent): A health-
     that we can make sure that we ad- Emergency care                                                                              care Provider must give you care
     dress your health care needs and     An Emergency room or other                                                               within 30 calendar-days of your
     that you’re getting any special care healthcare Provider of Emergency                                                         request for an appointment.
     you may need.                        services must give you care imme-
                                          diately, 24 hours a day, seven days                                                      Routine, non-symptomatic care


     BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
     8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
     (en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
     1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
     Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
     Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
11
  (if you’re not sick and don’t have                                   or custody of DCF, a healthcare                            to improve the quality of care and
  symptoms): A healthcare Pro-                                         provider must:                                             services that our Members re-
  vider must give you care within 60                                                                                              ceive. For example, in the past the
  calendar-days of your request for                                    •	 Give your child a healthcare                            Plan focused on improving care
  an appointment.                                                         screening within seven calen-                           for Members with diabetes and
                                                                          dar days after you or the DCF                           asthma as well as on improving
  Getting Behavioral Health care                                          worker asks for it.                                     overall coordination of care and
  Emergency Behavioral Health care                                     •	 Give your child a full medical                          Member satisfaction with the Plan.
  A hospital Emergency room, an                                           exam within 30 calendar days                            At the end of each year we will
  Emergency Services Program                                              after you or the DCF worker                             evaluate our progress, identify
  (ESP) Provider or other healthcare                                      asks for it, unless a shorter                           opportunities for improvement and
  Provider of Emergency services                                          time frame is required by Early                         establish the following year’s goals
  must give you care immediately,                                         and Periodic Screening, Diag-                           and Quality Improvement program
  24 hours a day, seven days a                                            nosis and Treatment (EPSDT)
  week.                                                                   services schedule. (See Sec-                            Clinical Practice Guidelines
                                                                          tion 7 for EPSDT information.)                          BMC HealthNet Plan adopts,
  Urgent Behavioral Health Care                                                                                                   develops and implements Clinical
  A healthcare Provider must give                                      Utilization Management                                     Practice Guidelines (CPGs) rele-
  you urgent Care within 48 hours of                                   utilization Management is a                                vant to its membership for provid-
  your request for an appointment.                                     process used by qualified BMC                              ing appropriate, effective care to
  Other Behavioral Health services                                     HealthNet Plan staff to make sure                          all our Members and includes pre-
  A healthcare Provider must give                                      you’re getting the right health care                       ventive and non-preventive acute
  you care within 14 calendar days                                     when you need it. The utilization                          and long-term clinical services for
  of your request for an appoint-                                      Management decision making                                 medical and Behavioral Health
  ment.                                                                process at BMC HealthNet Plan                              conditions. CPGs help us estab-
  For services described in an                                         follows certain guidelines to en-                          lish standards of care throughout
  Inpatient or 24-hour diversionary                                    courage the right use of services                          our Provider Network. The Plan
  services discharge plan, you must                                    to help ensure positive outcomes                           adopts Clinical Practice Guidelines
  get care within these time frames:                                   for our Members. For example, the                          from national sources or develops
                                                                       Plan bases all utilization Manage-                         guidelines in collaboration with
  •	 For non-24-hour diversionary                                      ment decisions only on the Medi-                           specialty organizations and/or
     services: within two calendar                                     cal Necessity and appropriateness                          regional collaborative groups. You
     days of discharge                                                 of care and services, as well as on                        may request a copy of the Plan’s
  •	 For medication management:                                        the existence of coverage. BMC                             current CPGs by contacting the
     within 14 calendar days of                                        HealthNet Plan does not reward                             Member services department.
     discharge                                                         decision makers for issuing deni-
  •	 For other outpatient services:                                    als nor does it offer them financial                       Transportation assistance
     within seven calendar days of                                     incentives that encourage under-                           As a benefit from MassHealth,
     discharge                                                         utilization of services.                                   some BMC HealthNet Plan Mem-
  •	 For Intensive Care Coordina-                                                                                                 bers may be eligible to have
     tion services: within twenty-                                     BMC HealthNet Plan Members can                             non-Emergency transportation
     four (24) hours of Referral,                                      call 1-888-566-0010 to find out the                        arranged for them to go to health
     including self-Referral, offering a                               status or outcome of utilization re-                       care visits. This is a service that
     face-to-face interview with the                                   view decisions involving their care.                       BMC HealthNet Plan administers
     family.                                                                                                                      for MassHealth. In order to be
                                                                       Quality Improvement program                                eligible for this benefit:
  Children in the care or cus-                                         BMC HealthNet Plan’s Quality                               1. You do not have a family
  tody of the Department of                                            Improvement committee approves                                member or other person who
  Children and Families (DCF):                                         a Quality Improvement program                                 can take you.
  If you have children in the care                                     (QIP) annually. This program looks                         2. You do not have access to


BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
                                                                                                                                                                                              12
        public transportation, or there is     lier if sexually active)                                                            ing a pharmacy, call our Member
        a medical reason that you          •	 Breast cancer screening (mam-                                                        services department.
        cannot use it.                         mogram) every year over age                                                         Paying at the pharmacy
     3. Your appointment must be for a         40 (or earlier if there is an im-                                                   unless you fall into one of the cat-
        Medically Necessary Service.           mediate family history of breast                                                    egories below, you will need to pay
     4. You must see a MassHealth              cancer. Breast exams could                                                          a Co-payment at the pharmacy
        Provider.                              then be as often as every six                                                       for your prescription drugs. Please
                                               months.)                                                                            refer to your Covered Services list
     For more information, contact our •	 Colorectal cancer screen-                                                                for information on Co-pays.
     Member services department. You           ing every 10 years starting at
     should contact the Plan well in           age 50 (or earlier if there is                                                      Please note that BMC Health-
     advance of your appointment so            an immediate family history                                                         Net Plan Members pay the same
     we can process your request.              of colorectal cancer. In that                                                       Co-payments for prescription
                                               case, exams could be more                                                           medications as Members of other
     Staying healthy                           frequent.)                                                                          MassHealth Managed Care plans.
     The best health care happens          •	 Flu shot annually
     before you get sick. It’s called      •	 Eye exams once every 24                                                              Some Members don’t have a
     preventive care. To help you stay         months (or more often if there                                                      pharmacy Co-payment
     healthy, we’ve put together a chart       are certain medical conditions                                                      You do not have a pharmacy
     to show you all the tests and shots       that exist.)                                                                        Co-payment if:
     you and your children should          •	 Dental. (Both adults and chil-
     have, depending on age. If you’d          dren are eligible for dental ben-                                                   •      You are under age 19.
     like a copy of the chart to be sent       efits. Some of these benefits                                                       •      You are enrolled in MassHealth
     to you, please call the Member            are covered by BMC Health-                                                                 because you were in the care
     services department. You can also         Net Plan. Some are covered                                                                 and custody of the Department
     find the chart on our Web site at         by MassHealth. Refer to your                                                               Children and Families (DCF)
     bmchp.org.                                Covered Services list in this                                                              when you turned 18, and your
     Preventive care for adults                Member Handbook for details                                                                MassHealth coverage was
     Routine preventive care is an             on dental coverage or call the                                                             continued.
     important part of staying healthy.        Member Services department.)                                                        •	     You are pregnant. (You must
     BMC HealthNet Plan encourages                                                                                                        tell the pharmacist you’re preg-
     all Members to visit their Primary    Prescription medication
                                           coverage                                                                                       nant.)
     Care Providers for preventive care.                                                                                           •	     It’s within 60 days following the
                                           Getting your prescriptions filled
     Examples of covered preventive                                                                                                       month your pregnancy ended.
                                           Your BMC HealthNet Plan health-
     care benefits for Members ages 21                                                                                             •	     You are receiving family-plan-
                                           care Provider needs to write a
     and older include:                                                                                                                   ning supplies.
                                           prescription for both prescription
                                           medications and over-the-counter                                                        •	     You are in hospice care.
     •	 Physical exams every one to                                                                                                •	     You are receiving Inpatient care
                                           medications if you need them.
         three years                                                                                                                      in an acute hospital, nursing
                                           BMC HealthNet Plan has more
     •	 Blood pressure monitoring                                                                                                         facility, chronic disease hos-
                                           than 1,000 pharmacies in our
         at least every two years and                                                                                                     pital, rehabilitation hospital, or
                                           Network across Massachusetts –
         whenever you have a visit with                                                                                                   intermediate-care facility for
                                           including all the major chain stores
         your PCP                                                                                                                         the developmentally delayed.
                                           – where you can pick up your
     •	 Cholesterol screening every                                                                                                •	     You have met the Co-payment
                                           medications.
         five years beginning at age 18                                                                                                   cap for the calendar year (Janu-
         or as recommended by your                                                                                                        ary through December) of $200.
                                           Our online Provider Directory lets
         healthcare Provider                                                                                                              We’ll send you a letter to let
                                           you search for a pharmacy in your
     •	 Pelvic exams and Pap smears                                                                                                       you know that you’ve reached
                                           area where you can get your medi-
         (women) every one to three                                                                                                       your cap. If you have reached
                                           cines. If you have problems find-
         years (starting at age 21 or ear-                                                                                                the $200 cap and are still being


     BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
     8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
     (en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
     1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
     Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
     Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
13
         asked for Co-payments, you                                    medications in the mail. Once you                          want more information about the
         should send your receipts to                                  sign up, you can refill prescriptions                      pharmacy programs, visit our Web
         BMC HealthNet Plan. (The cap                                  by mail, phone, or online.                                 site at bmchp.org. Or you can call
         is the total amount of the Co-                                                                                           our Member services department
         payments you’ve been charged,                                 You can find more information                              and ask for the pharmacy depart-
         whether or not you actually paid                              about the mail-order pharmacy                              ment.
         the Co-payments.) If you don’t                                program in the special insert that                         Prior Authorization program – Some
         have receipts for all the Co-                                 came as part of this packet. You                           medications always require Prior
         payments you were charged,                                    can also call informedMail™ at                             Authorization. If your Provider feels
         you can request a prescription                                1-800-881-1966.                                            that a medication that falls into this
         Co-payment record from your                                                                                              group is Medically Necessary for
                                                                       Pharmacy programs
         pharmacist. When you’re ready                                                                                            you, he or she can submit a Prior
                                                                       While most medications simply
         to send in your receipts, call                                                                                           authorization request. That request
                                                                       require a prescription from
         BMC HealthNet Plan’s Mem-                                                                                                will be reviewed by a clinician. If
                                                                       your healthcare Provider, BMC
         ber services department. Ask                                                                                             the medication is Medically Nec-
                                                                       HealthNet Plan uses a number of
         them to send you a copy of a                                                                                             essary, BMC HealthNet Plan will
                                                                       pharmacy programs to promote
         form you’ll need to fill out and                                                                                         cover the medication. If the Prior
                                                                       the safe and correct use of
         include with your receipts when                                                                                          Authorization request is denied,
                                                                       certain prescription medications.
         you send them to us. You can                                                                                             you or your Authorized Represen-
                                                                       Medications that belong to these
         also get a copy of the form at                                                                                           tative can appeal the decision.
                                                                       programs have Clinical Practice
         our Web site, bmchp.org. (You                                                                                            (See Section 10 for Grievances
                                                                       Guidelines that must be met
         will need to download the form                                                                                           and Appeals information.)
                                                                       before we cover the medication.
         to a printer.) The instructions for
                                                                       You can see which medications                              Step therapy program – Some
         where to send your receipts are
                                                                       belong to a pharmacy program on                            types of medications have many
         on that form.
                                                                       the drug list or formulary on the                          options. Step therapy requires that
  If you can’t pay the                                                 BMC HealthNet Plan Web site,                               a Member tries certain first-level
  Co-payment                                                           bmchp.org. The formulary also                              medications before BMC Health-
  The pharmacy still must fill your                                    lists the drugs that may not be                            Net Plan will cover another medi-
  prescription even if you can’t pay                                   covered. If you want a copy of the                         cation of that type. If you and your
  the Co-payment. However, the                                         formulary, please call our Member                          Provider feel that a certain first-
  pharmacy can bill you later for the                                  services department and ask for                            level medication is not appropriate
  Co-payment. Don’t go without                                         the pharmacy department.                                   to treat a medical condition, your
  your medication if you can’t pay                                                                                                Provider can submit a Prior Autho-
  the Co-payment. Please call our                                      If your BMC HealthNet Plan                                 rization request. That request will
  Member services department if a                                      healthcare Provider thinks it is                           be reviewed by a clinician. If the
  pharmacy refuses to give you your                                    Medically Necessary for you to                             medication is Medically Necessary,
  prescription.                                                        take a medication that’s only                              BMC HealthNet Plan will cover the
                                                                       covered in one of our pharmacy                             medication. If the Prior Authoriza-
  Mail-order pharmacy program                                          programs, he or she can submit                             tion request is denied, you or your
  BMC HealthNet Plan Members can                                       a Prior Authorization request to                           Authorized Representative can
  have maintenance medications                                         BMC HealthNet Plan. This request                           appeal the decision. (See Section
  sent to their homes instead of                                       will be reviewed by a clinician. If                        10 for Grievances and Appeals
  filling prescriptions at a local                                     the medication is Medically Nec-                           information.)
  retail pharmacy. Maintenance                                         essary, BMC HealthNet Plan will
  medications are those medications                                                                                               New-to-market medication program
                                                                       cover the medication. If the Prior
  that are refilled regularly for                                                                                                 – BMC HealthNet Plan reviews
                                                                       Authorization request is denied,
  conditions like diabetes, asthma                                                                                                new medications for safety and
                                                                       you or your Authorized Represen-
  and high blood pressure. You                                                                                                    efficacy before we add them to our
                                                                       tative can appeal the decision.
  can enroll with informedMail™                                                                                                   list of medications or formulary.
                                                                       (See Section 10 for Grievances
  order pharmacy to start getting                                                                                                 (Efficacy means that the medica-
                                                                       and Appeals information.) If you

BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
                                                                                                                                                                                              14
     tion works.) If your Provider feels  Administration (FDA) determines                                                          1-877-486-2048); (2) go to Medi-
     that a new-to-market medication      that certain generic medications                                                         care’s Web site at
     is Medically Necessary, he or she    are therapeutically equivalent (“AB                                                      www.medicare.gov; (3) refer to the
     can submit a Prior Authorization     rated”) to their brand name alter-                                                       Medicare and You Handbook; (4)
     request. That request will be re-    natives. This means that the “AB                                                         go to www.cms.com on the inter-
     viewed by a clinician. If approved,  rated” generic medication is as                                                          net. Remember to carry all your ID
     BMC HealthNet Plan will cover the    effective as the brand name medi-                                                        Cards with you when you go to the
     medication. If the Prior Authoriza-  cation. If your Provider determines                                                      pharmacy. When you file a pre-
     tion request is denied, you or your  that the brand name medication                                                           scription, please show your BMC
     Authorized Representative can        is Medically Necessary, he or she                                                        HealthNet Plan Member ID Card
     appeal the decision. (See Section    may submit a Prior Authorization                                                         and your Medicare Prescription ID
     10 for Grievances and Appeals        request. That request will be re-                                                        card.
     information.)                        viewed by a clinician. If approved,
     Quantity limitation program – This   BMC HealthNet Plan will cover the
     program ensures the safe and ap- medication. If the Prior Authoriza-
                                                                                                                                   SECTION 7
     propriate use of some medications tion request is denied, you or your                                                         Pregnancy, Family
     by covering a specific amount        Authorized Representative can
     that can be dispensed (given by      appeal the decision. (See Section                                                        Planning, Preventive
     the pharmacist) at one time. If      10 for Grievances and Appeals                                                            Care and Well Child
     your Provider feels that a quantity information.)
     greater than the specified amount
                                                                                                                                   Care, EPSDT,
     is Medically Necessary, he or she
                                          Medicare Part D
                                          If you are a BMC HealthNet Plan
                                                                                                                                   Children’s Behavioral
     can submit a Prior Authorization
                                          Member with Medicare coverage,                                                           Health Initative, and
     request. That request will be re-
     viewed by a clinician. If approved,
                                          your prescription drug benefit                                                           Early Intervention
                                          may be covered by a Medicare
     BMC HealthNet Plan will cover the
                                          Prescription Drug Coverage (Part                                                         Pregnancy (prenatal) care
     medication. If the Prior Authoriza-
                                          D) plan. Most of your prescription
     tion request is denied, you or your                                                                                           The health care you get while
                                          drugs will be covered under your
     Authorized Representative can                                                                                                 you’re pregnant (before your baby
                                          Medicare Part D benefit. You
     appeal the decision. (See Section                                                                                             is born) is called “prenatal care.”
                                          should have a separate ID card for
     10 for Grievances and Appeals                                                                                                 This type of care is very important.
                                          your Medicare Prescription Drug
     information.)                                                                                                                 It’s the best way to see how your
                                          Coverage. You will need to show
     Specialty pharmacy program –                                                                                                  pregnancy is going, if you and your
                                          your Medicare Part D ID card when
     This program requires that some                                                                                               unborn baby are getting adequate
                                          filling a prescription. There are
     medications be supplied by a                                                                                                  nutrition, and to make sure your
                                          some drugs that BMC HealthNet
     specialty pharmacy. These medi-                                                                                               baby is developing properly. Your
                                          Plan will continue to cover. For
     cations include injectable and                                                                                                health care Provider will monitor
                                          example, BMC HealthNet Plan
     intravenous medications that are                                                                                              you throughout your pregnancy to
                                          will continue to cover your over-
     often used to treat chronic (ongo- the-counter (OTC) drugs. BMC                                                               make sure your baby is developing
     ing) conditions like Hepatitis C or                                                                                           properly. Even if you’ve given birth
                                          HealthNet Plan Co-payment
     Multiple Sclerosis. These types of exceptions will still apply for BMC                                                        before, it’s very important for you
     health conditions require additional HealthNet Plan covered drugs. For                                                        to get prenatal care throughout
     expertise and support. Specialty                                                                                              your current pregnancy.
                                          more information, contact BMC
     pharmacies have knowledge            HealthNet Plan’s Member services                                                         Make an appointment with
     in these areas and can provide       department. To find out more                                                             an obstetrician/gynecologist
     additional help to Members and       about your Medicare Prescription                                                         (OB/GYN)
     Providers.                           Drug Coverage, you may:                                                                  You need to see an obstetrician
     Mandatory generic substitution pro- (1) contact Medicare at                                                                   (OB) as soon as you can after you
     gram – The federal Food and Drug 1-800-633-4227 (TTY:                                                                         become pregnant. An obstetrician


     BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
     8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
     (en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
     1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
     Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
     Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
15
  is a doctor who’s trained to treat                                   up health care.                                            Or it can be another screening tool
  pregnant women and deliver                                           You can get Family Planning                                chosen by your PCP. You can ask
  babies. This type of doctor is                                       Services from your PCP. Or,                                your PCP which tool he or she will
  usually also a gynecologist (GYN).                                   you can get these services from                            use when screening your child for
  That means that he or she is                                         any BMC HealthNet Plan or                                  Behavioral Health concerns.
  trained to know all about diseases                                   MassHealth contracted Family
  of the female reproductive system.                                   Planning Services Provider.                                Your Provider will discuss the
  The short name for this combined                                                                                                completed screening with you. The
  specialty is OB/GYN.                                                 These services do not require Prior                        screening will help you and your
  If you think you’re pregnant, you                                    Authorization. You can self-refer                          doctor or nurse decide if your child
  should either:                                                       by calling the Family Planning                             needs further assessment by a Be-
                                                                       Services Provider directly. Or ask                         havioral Health Provider or another
                                                                       your PCP to refer you to a Family                          medical professional. Information
  •	 Ask your PCP to recommend                                                                                                    and assistance will be available if
     an OB/GYN doctor (you do not                                      Planning Services Provider. For a
                                                                       listing of these providers, see our                        you or your doctor or nurse thinks
     need a Prior Authorization).                                                                                                 that your child needs to see a Be-
  OR                                                                   online or printed Provider Direc-
                                                                       tory.                                                      havioral Health Provider. For more
  • Call a BMC HealthNet Plan                                                                                                     information on how to access
     OB/GYN doctor and make an                                                                                                    Behavioral Health Covered Servic-
                                                                       Preventive and well-child
     appointment. You don’t need                                       care for all children                                      es, or to pick a Behavioral Health
     a Prior Authorization to see a                                    Children who are under age 21                              Provider, talk to your PCP or call
     BMC HealthNet Plan OB/GYN                                         should go to their PCP for check-                          our Behavioral Health Member line
     doctor. But your PCP can pro-                                     ups even when they are well. As                            listed at the bottom of the page.
     vide important health informa-                                    part of a well-child checkup, your                          BMC HealthNet Plan pays your
     tion about you to the OB/GYN                                      child’s PCP will offer screenings                          child’s PCP for these checkups.
     doctor so that you and your                                       to find out if there are any health                        At well-child checkups, the PCP
     unborn baby remain in good                                        problems. These screenings in-                             can find and treat small problems
     health. That’s why you need                                       clude health, vision, dental, hear-                        before they become big ones. Here
     to tell your PCP that you’re                                      ing, Behavioral Health, develop-                           are the ages to take a child for full
     pregnant.                                                         mental, and immunization status                            physical exams and screenings:
                                                                       screenings.
  Your OB/GYN doctor                                                                                                              •	    at 1 to 2 weeks
  Early and regular prenatal care is                                   Behavioral Health screenings can                           •	    at 1 month
  very important to help you have a                                    help you and your doctor or nurse                          •	    at 2 months
  healthy baby and a safe delivery.                                    to identify Behavioral Health con-                         •	    at 4 months
  We recommend that you see your                                       cerns early. MassHealth requires                           •	    at 6 months
  OB/GYN as soon as you think                                          that Primary Care Providers and                            •	    at 9 months
  you’re pregnant. You should also                                     nurses use standardized screening                          •	    at 12 months
  see your OB/GYN as often as the                                      tools to check a child’s Behav-                            •	    at 15 months
  OB/GYN wants to see you. BMC                                         ioral Health during their well-child                       •	    at 18 months
  HealthNet Plan covers all these                                      visits. The screening tools are ap-                        •	    At ages 2-20 – children should
  visits.                                                              proved by MassHealth. Screening                                  visit their PCP once a year.
                                                                       tools are short questionnaires or
  Family Planning Services                                             checklists that the parent or child                        Children should also visit their
  BMC HealthNet Plan covers Family                                     (depending on the child’s age) fill                        PCP any time there is a concern
  Planning Services that include                                       out and discuss with the doctor or                         about their medical, emotional or
  family planning medical services,                                    nurse. The screening tool might be                         Behavioral Health needs, even if it
  family planning counseling, birth                                    the Pediatric Symptom Checklist                            is not time for a regular checkup.
  control advice, pregnancy tests,                                     (PSC) or the Parents’ Evaluation
  sterilization services, and follow-                                  of Developmental Status (PEDS).


BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
                                                                                                                                                                                              16
     Preventive Pediatric               of the service. You and your                                                               services including individual, group
     Healthcare Screening and           PCP can seek help from BMC                                                                 or family therapy, “diversionary”
     Diagnosis (PPHSD) services         HealthNet Plan to determine what                                                           services such as partial hospi-
     for children enrolled in           Providers may be available in the                                                          talization and Inpatient care. As
     MassHealth Basic, Essential        Plan’s Network to provide these                                                            part of the Children’s Behavioral
     or Family Assistance
                                        services and how to use out-of-                                                            Health Initiative, Behavioral Health
     If you or your child is under
                                        Network Providers, if necessary.                                                           services for certain children and
     21 years old and enrolled in
                                        Most of the time these services                                                            youth under the age of 21 have
     MassHealth Basic, Essential or
                                        are covered by your child’s                                                                been expanded to include, when
     Family Assistance BMC HealthNet
                                        coverage type and are included                                                             Medically Necessary, home- and
     Plan will pay for all Medically
                                        on your Covered Services list. If                                                          community-based services in-
     Necessary Services covered under
                                        the service is not already covered                                                         cluding mobile crisis intervention,
     your child’s coverage type. This
                                        or is not on the list, the clinician                                                       in-home therapy, in-home behav-
     means that, when a PCP (or any
                                        or Provider who will deliver the                                                           ioral services, family support and
     other clinician) discovers a health
                                        service can ask BMC HealthNet                                                              training, therapeutic mentoring
     condition, BMC HealthNet Plan will
                                        Plan for Prior Authorization. BMC                                                          and intensive care coordination.
     pay for any Medically Necessary
                                        HealthNet Plan uses this process                                                           A statewide list of Community Ser-
     Services included in your child’s
                                        to determine if the service is                                                             vice Agencies can be found in your
     coverage type.
                                        Medically Necessary. The Plan                                                              printed and online Provider Direc-
     Early and Periodic Screening, will pay for the service if Prior                                                               tory. For more information, call
     Diagnosis and Treatment            Authorization is given. If Prior                                                           our Behavioral Health Member line
     (EPSDT) services for children Authorization is denied, you, or                                                                listed at the bottom of the page.
     enrolled in MassHealth             your Authorized Representative,
     Standard or CommonHealth           have a right to appeal. (See Sec-                                                          Dental care for children
     If you or your child is under age  tion 10 for more information about                                                         MassHealth pays for preventive
     21 and enrolled in MassHealth      the Appeal processes.) Talk to your                                                        and basic services for the
     Standard or CommonHealth,          child’s PCP, Behavioral Health Pro-                                                        prevention and control of dental
     BMC HealthNet Plan will pay for    vider or other Specialist for help in                                                      diseases and the maintenance of
     all Medically Necessary Services   getting these services.                                                                    oral health for children.
     that are covered by federal
     Medicaid law (even if the services Children’s Behavioral Health                                                               Your child’s PCP will give a dental
     are not specifically mentioned in  Initiative (CBHI)                                                                          exam at each well-child checkup.
     your Covered Service list). This   The Children’s Behavioral Health                                                           When your child is three years old
     coverage includes health care,     Initiative is an inter-agency                                                              (or earlier if there are problems) his
     diagnostic services, treatment and initiative of the Commonwealth’s                                                           or her PCP will suggest that you
     other measures needed to correct Executive Office of Health and                                                               take your child to the dentist at
     or improve deficits and physical   Human Services whose mission                                                               least twice a year.
     and Behavioral Health illnesses    is to strengthen, expand and
     and conditions. When a PCP or      integrate Massachusetts state                                                              When your child goes for routine
     any other clinician discovers a    services into a comprehensive,                                                             exams, the dentist will give a full
     health condition, BMC HealthNet    community-based system of care,                                                            dental exam, teeth cleaning and
     Plan will pay for any Medically    to ensure that families and their                                                          fluoride treatment. It’s important
     Necessary Services covered         children with significant behavioral,                                                      that your child gets the following
     under Medicaid law. The treatment emotional and mental health needs                                                           dental care:
     must be delivered by a Provider    obtain the services necessary
     who is qualified and willing to    for success in home, school and                                                            •	 A dental checkup every six
     provide the service. In addition   community.                                                                                    months starting no later than
     a physician, nurse practitioner,                                                                                                 age three.
     or nurse midwife must support                                     BMC HealthNet Plan provides a                               •	 Other dental treatments need-
     in writing the Medical Necessity                                  full range of Behavioral Health                                ed, even before age three,


     BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
     8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
     (en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
     1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
     Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
     Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
17
         if your child’s PCP or den-                                   vices under federal law.                                   Our Care Management program
         tist finds problems with your                                                                                            includes you, your health care
         child’s teeth or oral health.                                 Early intervention services                                Providers, and us, working together
                                                                       for children with growth or                                for you to be healthy. BMC Health-
  Your child’s dental health may                                       developmental problems                                     Net Plan care managers (or Bea-
  be improved by having fluoride                                       Some children need extra help for                          con care managers, if Behavioral
  varnish applied to his or her teeth.                                 healthy growth and development.                            Health) will be in touch with you to
  This can be done by a dentist or                                     Providers who are early                                    check on your progress and help
  other healthcare Provider. Fluo-                                     intervention Specialists can help                          coordinate care with all necessary
  ride varnish is mostly for children                                  them. Some of these Providers are:                         health care Providers.
  up to age 3. But it is allowed for                                                                                              We also help you learn what ben-
  Members up to age 21 if they                                         •	 Social workers
                                                                       •	 Nurses                                                  efits and community resources
  don’t have access to a dentist. It’s                                                                                            are available because we want
  best to have the varnish applied                                     •	 Physical, occupational and
                                                                          speech therapists                                       to help you with more than just
  when the child is very young. That                                                                                              health care. Our experienced staff
  means as soon as the front teeth                                                                                                can link you with services such as
  begin to show at around age six                                      All of these Providers work with
                                                                       children under three years old –                           transportation to health care ap-
  months.                                                                                                                         pointments, food stamps, housing
                                                                       and their families – to make sure
                                                                       a child gets any extra support                             and emergency shelter, assistance
  Children who are under age 21                                                                                                   with utilities, and support groups.
  and enrolled in MassHealth Stan-                                     necessary. Some of the services
                                                                       are given at home. And some are                            These community resource ser-
  dard or CommonHealth can get                                                                                                    vices are available to all Members,
  all Medically Necessary Services                                     at early intervention centers.
                                                                       Talk to your child’s PCP as soon                           not just those enrolled in Care
  covered under Medicaid law. This                                                                                                Management.
  includes dental treatment even if                                    as possible if you think your child
  the service is not otherwise cov-                                    has growth or development prob-                            Medical Care Management, in-
  ered by MassHealth.                                                  lems. Or contact your local early                          cluding disease management,
                                                                       intervention program directly.                             consists of three program levels to
  Children who are under age 21                                                                                                   make sure you receive the neces-

                                                                       SECTION 8
  and enrolled in MassHealth Basic,                                                                                               sary level of Care Management.
  Essential or Family Assistance can                                                                                              The three levels are:
  get all Medically Necessary Ser-
  vices covered under their cover-                                     Care Management                                            •	 Care Management Education
  age type. This includes dental                                                                                                     and Wellness
  treatment.                                                           BMC HealthNet Plan is committed                            •	 Care Management Health Care
                                                                       to giving you, our Members, the                               Coordination
  Talk to your child’s PCP or dentist                                  information and tools you need                             •	 Care Management Select
  for help in getting these services.                                  to build and maintain a healthy                            In addition to our medical Care
                                                                       lifestyle. Our Care Management                             Management program, Beacon
  Please note:                                                         program is free for Members                                Health Strategies (Beacon) offers
  •	 Children do not need Pri-                                         (adults and children) and is just a                        BMC HealthNet Plan Members Be-
     or Authorization to see a                                         phone call away.                                           havioral Health Care Management
     MassHealth dentist.                                               Our experienced staff includes                             and Intensive Clinical Manage-
  •	 Children can visit a dentist                                      registered nurses, licensed social                         ment (ICM) services. For Members
     before age three.                                                 workers, and trained Care Man-                             with both medical and Behavioral
                                                                       agement Specialists. Our staff                             Health care needs, BMC Health-
  Additional services for                                              works with you to help you under-                          Net Plan’s and Beacon’s Care
  children                                                             stand and get the right services                           Management teams will work
  Children under age 21 years are                                      and information so you can man-                            together to ensure full coordination
  entitled to certain additional ser-                                  age your condition and be healthy.                         of care.


BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
                                                                                                                                                                                              18
     Care Management Education          Care Management Select                                                                     with certain Behavioral Health
     and Wellness                       Care Management Select manages                                                             conditions. Our care managers
     This level of Care Management      Members with complex medical                                                               are licensed Behavioral Health
     offers educational materials, tools,
                                        conditions. If you are at high risk                                                        clinicians that are trained to help
     and resources for wellness and     for problems because of your                                                               you with your Behavioral Health
     prevention. The goal is to help youhealth condition or have complex                                                           care needs. Beacon can help
     learn and follow new and easy      medical needs or special health                                                            with you with finding a Behavioral
     ways to manage specific illnesses  care needs, you may be enrolled                                                            Health counselor near you or
     such as diabetes, asthma, and      in Care Management Select. This                                                            explaining available treatment
     cancer. You can access these       level gives you all the information                                                        options. Some of the conditions
     resources by logging on to         and tools you need to manage                                                               followed in this program are:
     bmchp.org and clicking on Care     your condition, but includes more
     Management under the Member        frequent check-ins from a care                                                             •	 Depression
     pages. BMC HealthNet Plan’s        manager, including in-person                                                               •	 Emotional distress significantly
     online Wellness Center also has    visits at home or in the community                                                            impacting your relationships,
     helpful information for Members    as needed. A Care Management                                                                  school, work, job performance,
     on how to stay healthy.            team, including registered nurses,                                                            difficulty with sleep or eating
                                        pharmacists, and other health care                                                            patterns
     Care Management Health             Providers help with your medical                                                           •	 Mental health needs such as
     Care Coordination                  and social needs. They also                                                                   bipolar disorder, mood dis-
     The Health Care Coordination level educate you about what you need                                                               orders, psychotic disorders,
     offers Members a more involved     to know about managing your                                                                   schizophrenia
     approach. Care managers work       condition, arranging for care, and                                                         •	 Substance use or misuse such
     with you and a team of health      coordinating services and medical                                                             as alcohol, pain medications,
     care Providers to help you be as   equipment. The team works                                                                     illegal drugs
     healthy as possible. This involves together with you to set health
     an assessment of your condition,   related goals and work towards                                                             To learn more:
     coordination of care, and review   them.
     of available benefits. Your care                                                                                              •	 Call 1-888-217-3501 for Be-
     manager can help you set up        Our Care Management program                                                                   havioral Health Care Manage-
     services such as family support    is free and voluntary. Your par-                                                              ment
     and community resources.           ticipation in the program does not
                                                                       replace the care and services that                          Intensive Clinical
     Our care managers help you come                                   you receive from your PCP and                               Management
     up with your individual care plan.                                other health care Providers. En-                            Beacon also offers an Intensive
     By following this care plan, you                                  try into the program may happen                             Clinical Management program
     will learn more about your condi-                                 through completing your Health                              (ICM) to provide additional sup-
     tion while building skills to lead                                Risk Assessment, our claims in-                             port. This is a Care Management
     a healthy lifestyle. Some of the                                  formation, a referral from a hospi-                         program provided by Beacon for
     conditions followed in this pro-                                  tal Care Manager or one of your                             BMC HealthNet Plan Members
     gram are:                                                         providers, or self- referral.                               who are experiencing complex
     •	   Asthma                                                                                                                   Behavioral Health or psychosocial
     •	   Diabetes                                                     To learn more:                                              conditions, sometimes in addi-
     •	   Congestive heart failure                                     • Call 1-866-853-5241 for medi-                             tion to medical concerns. ICM is
     •	   HIV/AIDS                                                         cal Care Management.                                    a voluntary, flexible, short-term
     •	   Obesity                                                                                                                  program to meet the individual
     •	   Pregnancy                                                    Behavioral Health Care                                      needs and promote your optimal
     •	   Hypertension                                                 Management                                                  Behavioral Health. Both adults and
     •	   Breast cancer                                                Beacon offers support to BMC                                children can receive ICM services.
                                                                       HealthNet Plan Members                                      The program is offered by licensed


     BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
     8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
     (en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
     1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
     Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
     Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
19
  Behavioral Health clinicians who                                     Specialist for treatment that your                             or visit BMC HealthNet Plan
  provide services by phone and                                        PCP cannot provide.                                            or Beacon Health Strategies
  during face to face meetings with                                                                                                   (for Behavioral Health). Call
                                                                       Your Rights
  Members and their health care                                                                                                       the Member services depart-
                                                                       1. You have the right to be treated
  Providers.                                                                                                                          ment if you need help with this
                                                                          with respect and with recogni-
  ICM care managers work with you                                                                                                     service.
                                                                          tion of your dignity and right to
  to advocate for your needs and                                                                                                  9. You have the right to choose
                                                                          privacy. (See Section 11 “No-
  link you to services. We will work                                                                                                  your own Primary Care Provid-
                                                                          tice of Privacy Practices”.)
  to ensure you receive coordinated                                                                                                   er (PCP) and you can change
                                                                       2. You have the right to be told
  care, discharge planning after a                                                                                                    your PCP at any time. You
                                                                          about and understand any ill-
  Behavioral Health care admission,                                                                                                   must call the Member services
                                                                          ness you have.
  and resources and support in your                                                                                                   department if you want to
                                                                       3. You have the right to be told in
  community. With your permission,                                                                                                    change your PCP.
                                                                          advance – in a manner you un-
  we will collaborate with your PCP                                                                                               10. You have the right to receive
                                                                          derstand – of any treatment(s)
  and/or other health care Provid-                                                                                                    health care within the time-
                                                                          and alternatives that a Provider
  ers and family members in order                                                                                                     frames described in the “How
                                                                          feels should be done.
  to assist you. Our ICM care plans                                                                                                   Long It Should Take To Get an
                                                                       4. You have the right to take part
  are individually developed with you                                                                                                 Appointment” part of Section
                                                                          in decisions regarding your
  and your Behavioral Health care                                                                                                     6, and to file an Internal Appeal
                                                                          health care, including the right
  Providers and establish goals and                                                                                                   if you do not receive your care
                                                                          to refuse treatment as far as
  the resources you need to achieve                                                                                                   within those timeframes.
                                                                          the law allows, and to know
  the goals.                                                                                                                      11. You have the right to voice a
                                                                          what the outcome may be.
  For more information about Be-                                                                                                      complaint and file a Grievance
                                                                       5. You have the right to have an
  havioral Health Care Management                                                                                                     with the BMC HealthNet Plan
                                                                          open and honest discussion
  or ICM:                                                                                                                             Member services department,
                                                                          of appropriate or Medically
                                                                                                                                      Beacon Health Strategies, and/
                                                                          Necessary treatment options
  •	 Call our behavioral                                                                                                              or MassHealth customer ser-
                                                                          for your health conditions,
     health member line at                                                                                                            vice center about services you
                                                                          regardless of cost or benefit
     1-888-217-3501 (24 hours a                                                                                                       received from the Plan or from
                                                                          coverage. You may be respon-
     day/7 days a week)                                                                                                               a health care Provider. You also
                                                                          sible for payment of services
  •	 Or visit our Web site:                                                                                                           have the right to Appeal cer-
                                                                          not included in the Covered
     www.bmchp.org                                                                                                                    tain decisions made by BMC
                                                                          Services list for your coverage
                                                                                                                                      HealthNet Plan or Beacon
                                                                          type.
                                                                                                                                      Health Strategies (for Behav-

  SECTION 9                                                            6. You have the right to expect
                                                                          your healthcare Providers to
                                                                          keep your records private, as
                                                                                                                                      ioral Health). The reasons for
                                                                                                                                      Grievances and Internal Ap-
                                                                                                                                      peals are described in Section
  Rights and                                                              well as anything you discuss
                                                                                                                                      10, “Inquiries, Grievances and
  Responsibilities                                                        with them. No information will
                                                                          be released to anyone without
                                                                                                                                      Appeals.”
                                                                                                                                  12. You have the right to talk about
  As a Member of BMC HealthNet                                            your consent, unless required
                                                                                                                                      your health records with your
  Plan, you have certain rights con-                                      by law.
                                                                                                                                      Provider and obtain a complete
  cerning your health care. You also                                   7. You have the right to request
                                                                                                                                      copy of those records. You
  have certain responsibilities to the                                    an interpreter when you re-
                                                                                                                                      also have the right to request a
  Providers who are taking care of                                        ceive health care. Call the
                                                                                                                                      change to your health records.
  you.                                                                    Member services department if
                                                                                                                                  13. You have the right to know and
  Regardless of your health con-                                          you need help with this ser-
                                                                                                                                      receive all of the benefits, services,
  dition, you cannot be refused                                           vice.
                                                                                                                                      rights and responsibilities you have
  Medically Necessary treatment.                                       8. You have the right to request
                                                                                                                                      under BMC HealthNet Plan and
  But your PCP may refer you to a                                         an interpreter when you call
                                                                                                                                      MassHealth.


BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
                                                                                                                                                                                              20
     14. You have the right to have your                                   from BMC HealthNet Plan and                                 remember that refusing treat-
         Member Handbook and any                                           change to another MassHealth                                ment recommended by your
         printed materials from BMC                                        health plan by calling the                                  healthcare Provider might harm
         HealthNet Plan translated into                                    MassHealth customer service                                 your health.
         your primary language, and/                                       center.                                                 9. You should authorize your PCP
         or to have these materials                                    21. You have the right to receive                               to get copies of all your health
         read aloud to you if you have                                     information about BMC Health-                               records.
         trouble seeing or reading. Oral                                   Net Plan, our services, and                             10. You must receive all your
         interpretation services will be                                   Providers, and your rights and                              health care from BMC Health-
         made available upon request                                       responsibilities.                                           Net Plan Providers, except
         and free of charge.                                           22. You have the right to make                                  in cases of Emergency or
     15. You have the right to ask for                                     recommendations about our                                   Family Planning Services or
         a Second Opinion about any                                        Rights and Responsibilities                                 unless BMC HealthNet Plan
         health care that your PCP                                         statement.                                                  provides a prior authorization
         advises you to have. BMC                                                                                                      for out-of-Network care. For
         HealthNet Plan will pay for the                               Your Responsibilities                                           services not covered by BMC
         cost of your Second Opinion                                   1. You should tell your healthcare                              HealthNet Plan that you get
         visit.                                                           Provider your health com-                                    using your MassHealth Card,
     16. You have the right to receive                                    plaints clearly and provide as                               you may receive care from any
         Emergency care, 24 hours                                         much information as possible.                                MassHealth contracted Pro-
         a day, seven days a week.                                     2. You should tell your healthcare                              vider.
         Please see the “Emergencies”                                     Provider about yourself and                              11. You must not allow anyone
         section for complete informa-                                    your health history.                                         else to use your BMC Health-
         tion.                                                         3. You should talk to your PCP                                  Net Plan or MassHealth ID
     17. You have the right to be free                                    about seeking the services of                                cards to obtain healthcare
         from any form of physical re-                                    a Specialist before you go to                                services. See the “Reporting
         straint or seclusion that would                                  a hospital (except in cases of                               Health Care Fraud” section
         be used as a means of coer-                                      Emergencies or when you refer                                that follows.
         cion, force, discipline, conve-                                  yourself for certain Covered                             12. You must notify BMC Health-
         nience or retaliation.                                           Services).                                                   Net Plan’s Member ser-
     18. You have the right to freely                                  4. You should treat your health-                                vices department and the
         exercise these rights without                                    care Provider with dignity and                               MassHealth customer service
         adversely affecting the way                                      respect.                                                     center when you believe that
         BMC HealthNet Plan and its                                    5. You should keep appoint-                                     someone has purposely mis-
         Providers treat you.                                             ments, be on time, and call in                               used BMC HealthNet Plan or
     19. You have the right to receive                                    advance if you’re going to be                                MassHealth benefits or ser-
         health treatment from BMC                                        late or have to cancel.                                      vices.
         HealthNet Plan Providers                                      6. You should learn about your                              13. You must notify BMC Health-
         without regard to race, age,                                     health problems and any                                      Net Plan’s Member ser-
         gender, sexual preference,                                       recommended treatment, and                                   vices department and the
         national origin, religion, health                                consider the treatment before                                MassHealth customer service
         status, economic status, or                                      it’s performed.                                              center if you change your ad-
         physical disabilities. And no                                 7. You should partner with your                                 dress or phone number.
         Provider should engage in any                                    healthcare Provider and work
                                                                                                                                   You are responsible for payment of
         practice, with respect to any                                    out treatment plans and goals
                                                                                                                                   services not included in the Cov-
         BMC HealthNet Plan Member,                                       together.
                                                                                                                                   ered Services list for your cover-
         that constitutes unlawful dis-                                8. You should follow the in-
                                                                                                                                   age type.
         crimination under any state or                                   structions and plans for care
         federal law or regulation.                                       that you and your healthcare                             Reporting healthcare Fraud
     20. You have the right to disenroll                                  Provider have agreed to, and                             If you know of anyone trying to


     BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
     8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
     (en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
     1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
     Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
     Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
21
  commit healthcare Fraud, please                                      immediately or, at the latest, within                      Representative (see description
  call our confidential compliance                                     one business day of the day we                             above) have the right to file
  hotline at 1-888-411-4959. You                                       receive your Inquiry. We will let                          a Grievance if you are not
  do not need to identify yourself.                                    you know about the outcome/                                satisfied with any aspect of BMC
  Examples of healthcare Fraud                                         resolution on the day your Inquiry                         HealthNet Plan’s or Beacon
  include:                                                             is resolved. To make an Inquiry,                           Health Strategies’ operations or
                                                                       call the Plan’s Member services                            interactions, or with the quality of
  •	 Receiving bills for healthcare                                    department or Beacon Health                                care or services you receive from a
     services you never received                                       Strategies (for Behavioral Health).                        Provider. A Grievance can also be
  •	 People loaning their health                                       The phone numbers are at the                               filed when we:
     insurance ID cards to others                                      bottom of the page
     for the purpose of receiving                                                                                                 •     Extend the timeframes to pro-
     healthcare services or pre-                                       Authorized Representative                                        cess a Prior Authorization re-
     scription medications                                             for Grievances and Internal                                      quest and you, or your Autho-
  •	 Being asked to provide false or                                   Appeals, and Board of                                            rized Representative, disagree
                                                                       Hearings
     misleading healthcare informa-                                                                                                     with those decisions.
                                                                       An Authorized Representative is
     tion                                                                                                                         •     Do not approve your request
                                                                       someone you have authorized, in
                                                                                                                                        for an Expedited (fast) Internal
                                                                       writing, to act on your behalf with

  SECTION 10
                                                                                                                                        Appeal and processes it as a
                                                                       respect to a Grievance, Internal
                                                                                                                                        standard Internal Appeal, and/
                                                                       Appeal, or Office of Medicaid’s
                                                                                                                                        or
                                                                       Board of Hearings (BOH) Appeal.
  Inquiries, Grievances                                                If your Authorized Representative
                                                                                                                                  •     Extend the timeframes to pro-
                                                                                                                                        cess your Internal Appeal and
  and Appeals                                                          is your family member, you can
                                                                                                                                        you, or your Authorized Repre-
                                                                       have him or her represent you
  We want you to contact us if you                                                                                                      sentative, disagree with those
                                                                       in multiple Grievance or Internal
  have any concerns with your care                                                                                                      decisions.
                                                                       Appeal cases. The family member
  or services. Our Member services                                     can have a standing Authorization
  department will help you resolve                                                                                                For an explanation of these time-
                                                                       until you send the Plan a letter
  your concerns. The phone num-                                                                                                   frames, see the sections “How
                                                                       informing us that the Authorization
  bers are at the bottom of the page.                                                                                             Long Should It Take to Get an Ap-
                                                                       has been revoked. If you pick an
                                                                                                                                  pointment”, “Services that Require
                                                                       Authorized Representative who
  You also have the right to voice                                                                                                Prior-Authorization” and “How
                                                                       is not a family member, you must
  any concerns to MassHealth at                                                                                                   Quickly Will You Receive a Deci-
                                                                       get a new Authorization each
  any time. You may call a cus-                                                                                                   sion on Your Internal Appeal”
                                                                       time. We must receive this written
  tomer service representative at                                      Authorization before our deadline                          When can the Plan or Beacon
  the MassHealth customer service                                      for resolving your Grievance                               Health Strategies dismiss
  center at one of the numbers at                                      or Standard Internal Appeal                                your Grievance?
  the bottom of the page.                                              expires. We can help you write an                          We may dismiss your Grievance
                                                                       Authorized Representative letter,                          if someone else files it on your
  Inquiries
                                                                       or we can mail you an Authorized                           behalf and we did not receive
  An Inquiry is any question or
                                                                       Representative form for you to                             your written Authorization for that
  request that you may have about
                                                                       complete. For a copy of the form,                          person to serve as your Authorized
  BMC HealthNet Plan’s or Beacon
                                                                       call the Plan’s Member services                            Representative before our time-
  Health Strategies’ (Behavioral
                                                                       department or Beacon Health                                frame for resolving your Grievance
  Health manager) operations. An
                                                                       Strategies (for Behavioral Health).                        expires. If this happens, we will
  Inquiry does not address your
                                                                       The phone numbers are at the                               send you a Grievance dismissal
  dissatisfaction with the Plan or
                                                                       bottom of the page.                                        notification.
  Beacon Health Strategies (see
  “What is a Grievance?” below).                                       What is a Grievance?
  We will resolve your Inquiries                                       You or your Authorized

BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
                                                                                                                                                                                              22
     How to file a Grievance                                                                                                              a service requested by your
     You, or your Authorized Appeal                                               BMC HealthNet Plan                                      healthcare Provider, including
     Representative, may file a                                                 1350 Main St., 13th floor                                 the determination that the re-
     Grievance in writing, over the                                              Springfield, MA 01107                                    quested service is not a Cov-
     telephone, or in person. If you                                                                                                      ered Service.
     want to submit a Grievance over                                               BMC HealthNet Plan                              •	     We reduced, suspended or
     the telephone, you may call:                                                 66 West St., Suite 205                                  terminated a Covered Service
                                                                                   Pittsfield, MA 01201                                   that was previously authorized.
     •	 BMC HealthNet Plan’s Mem-                                                                                                  •	     We denied, in whole or in part,
        ber services department at the                                 How quickly will the Plan or                                       payment for a Covered Service
        number listed at the bottom of                                 Beacon make a decision on                                          due to service coverage is-
        the page                                                       your Grievance?                                                    sues.
     •	 For Grievances related to                                      Once we receive your Grievance,                             •	     We did not make a service Au-
        Behavioral Health services, call                               we’ll send you a written acknowl-                                  thorization decision within the
        our Behavioral Health Member                                   edgement of receipt within one                                     timeframe described in Section
        line listed at the bottom of the                               business day. We’ll immediately                                    4.
        page.                                                          begin to work on resolving your                             •	     We did not notify you of an
                                                                       Grievance. We’ll send you and                                      Internal Appeal decision within
     If you, or your Authorized Repre-                                 your Authorized Representa-                                        the timeframe described in
     sentative, want to submit a Griev-                                tive a written response within 30                                  Section 10.
     ance in writing, please mail it to:                               calendar days from the date we                              •	     You’re unable to obtain health-
                                                                       received your Grievance.                                           care services within the time-
           BMC HealthNet Plan --                                                                                                          frames described in Section 6
                                        What do you do if you do not
                MassHealth              speak English?                                                                                    “Your Health Care”.
        Two Copley Place, Suite 600     If you do not understand English,
             Boston, MA 02116           the Plan or Beacon Health                                                                  In most instances, you will receive
       Attention: Member Grievances     Strategies (for Behavioral Health)                                                         a notice letting you know that one
             Fax: 617-897-0805          will help you with interpreter or                                                          of the actions listed above has
                                        translation services during the                                                            occurred. However, you, or your
     Grievances regarding behavioral    Grievance process at no cost to                                                            Authorized Representative, may
     health services can be mailed or   you. If you have any questions                                                             file an Internal Appeal whenever
     filed in person at:                about the Grievance process,                                                               one of these actions occurs, even
                                        please call the BMC HealthNet                                                              if you did not receive a notice from
     Quality Department – Ombudsman Plan Member services department                                                                BMC HealthNet Plan or Beacon
        Beacon Health Strategies, LLC   or Beacon Health Strategies (for                                                           Health Strategies. Parties involved
      500 unicorn Park Drive, Suite 401 Behavioral Health) at the numbers                                                          in the Internal Appeal can also
               Woburn, MA 01801         below.                                                                                     include the legal representative of
               Fax: 781-994-7636                                                                                                   a deceased Member’s estate.
      If you want to submit a Grievance What is an Internal Appeal?                                                                Internal Appeal decisions are
      to BMC HealthNet Plan in person, You, or your Authorized Appeal                                                              made by healthcare professionals
                we are located at:      Representative, has the right to                                                           who have the appropriate clinical
                                        file an Internal Appeal with BMC                                                           expertise and were not involved
              BMC HealthNet Plan        HealthNet Plan or Beacon Health                                                            in the original action that is being
         Two Copley Place, Suite 600    Strategies (for Behavioral Health                                                          appealed or, if the Internal Appeal
               Boston, MA 02116         concerns) if you disagree with one                                                         has multiple levels, were not in-
                                        of the following Adverse Actions or                                                        volved in any of the previous levels
              BMC HealthNet Plan        inactions:                                                                                 of review.
            Bourne Counting House
                                        •	 We denied or decided to pro-                                                            When and how to file a
               One Merrills Wharf                                                                                                  standard Internal Appeal
           New Bedford, MA 02740             vide limited Authorization for


     BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
     8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
     (en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
     1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
     Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
     Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
23
  with the Plan or Beacon                                                    Attention: Member Appeals                            Strategies requests to extend the
  We provide Members two levels of                                               Fax: 617-897-0805                                timeframe by up to five calendar
  Internal Appeal review, a first level                                                                                           days as described below. We will
  and a second level (reviewed by                                      If you want to submit an Internal                          notify you, or your Authorized
  a clinician not involved with your                                   Appeal pertaining to Behavioral                            Representative, in writing of our
  first level Internal Appeal). You, or                                Health services, please mail it to:                        decision.
  your Authorized Representative,
  may file a first level Internal Appeal                                     Appeals Coordinator                                  What do you do if you
  within 30 calendar days of our                                        Beacon Health Strategies, LLC                             disagree with the decision
  notice to you telling you that one                                   500 Unicorn Park Drive, Suite 401                          the Plan or Beacon reached
                                                                                                                                  on your first level
  of the Adverse Actions described                                            Woburn, MA 01801
                                                                                                                                  Internal Appeal?
  above has occurred. However,                                                Fax: 781-994-7636
                                                                                                                                  If you disagree with the decision
  if you did not receive a notice
                                                                                                                                  we reach on your first level Internal
  from the BMC HealthNet Plan or                                       If you, or your Authorized Repre-
                                                                                                                                  Appeal, you, or your Authorized
  Beacon Health Strategies, you, or                                    sentative, want to submit an Inter-
                                                                                                                                  Representative, can either request
  your Authorized Representative,                                      nal Appeal in person, please visit
                                                                                                                                  a second level review of your
  may appeal within 30 calendar                                        us at the applicable office location
                                                                                                                                  Internal Appeal through us, or you
  days of learning on your own                                         above.
                                                                                                                                  can skip the second level Internal
  that one of the Adverse Actions
                                                                                                                                  Appeal review and file an Appeal
  described above occurred.                                            Oral requests to appeal an action
                                                                                                                                  directly with the Board of Hearings
                                                                       are treated as Appeals (to estab-
                                                                                                                                  (see “How to File a Board of
  You, or your Authorized Represen-                                    lish the earliest possible filing date
                                                                                                                                  Hearing Appeal”). If you choose
  tative, may file a first level Internal                              for the Appeal). We will confirm
                                                                                                                                  to file with the Board of Hearings,
  Appeal in writing, over the tele-                                    your oral Inquiry in writing, unless
                                                                                                                                  you waive the right to a second
  phone, or in person. If you, or your                                 you, your Authorized Representa-
                                                                                                                                  level Internal Appeal review.
  Authorized Representative, want                                      tive, or your Provider requests an
  to submit a first level Internal Ap-                                 expedited (fast) resolution (deci-
                                                                                                                                  If you decide to request a second
  peal over the telephone, you may                                     sion).
                                                                                                                                  level Internal Appeal review, you,
  call:
                                                                                                                                  or your Authorized Representative,
                                                                       Once your first level Internal Ap-
                                                                                                                                  must file your request with BMC
  •	 BMC HealthNet Plan’s Member                                       peal is received, an Appeals &
                                                                                                                                  HealthNet Plan or Beacon Health
     services department at one                                        Grievances specialist will send you
                                                                                                                                  Strategies (for Behavioral Health
     of the toll-free numbers at the                                   and your Authorized Representa-
                                                                                                                                  concerns) within 30 calendar days
     bottom of the page.                                               tive a written acknowledgement of
                                                                                                                                  of receiving the notice of your
  •	 Or you may call the Appeals                                       receipt within one business day,
                                                                                                                                  first level Internal Appeal denial.
     department at (617) 748-6338.                                     and will immediately begin to work
                                                                                                                                  Once we receive your second
  •	 For Appeals related to Behav-                                     on resolving your Appeal.
                                                                                                                                  level Internal Appeal request, we
     ioral Health services, call our
                                                                       How quickly will you receive                               will send you and your Authorized
     Behavioral Health Member
                                                                       a decision on your first level                             Representative a written acknowl-
     line listed at the bottom of the
                                                                       Internal Appeal?                                           edgement of receipt within one
     page.
                                                                       unless you, or your Authorized                             business day. We will immediately
  If you, or your Authorized Repre-                                    Representative, file an Expedited                          begin to work on the second level
  sentative, want to submit a first                                    (fast) Internal Appeal, we will                            review of your Internal Appeal
  level Internal Appeal in writing,                                    resolve your first level Internal                          and will resolve your second level
  please mail it to:                                                   Appeal within a total of 20                                review within a total of 20 calendar
                                                                       calendar days from the day                                 days unless you, your Authorized
         BMC HealthNet Plan --                                         we receive it unless you, your                             Representative, or BMC HealthNet
              MassHealth                                               Authorized Representative, BMC                             Plan or Beacon Health Strategies
       Two Copley Place, Suite 600                                     HealthNet Plan or Beacon Health                            requests to extend the timeframe
           Boston, MA 02116                                                                                                       by up to five calendar days as

BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
                                                                                                                                                                                              24
     described below. (BMC HealthNet                                   is totally unrelated to your health                         possible to request a second level
     Plan and Beacon Health Strate-                                    condition. If your Provider is not                          Internal Appeal review through
     gies cannot request an extension if                               involved in your request for an Ex-                         BMC HealthNet Plan or Beacon
     we requested an extension during                                  pedited (fast) Internal Appeal, then                        Health Strategies for Expedited
     your first level Internal Appeal.) We                             we have the right to determine                              (fast) Internal Appeals.
     will notify you, and your Authorized                              whether or not to process the Ap-
     Representative, in writing of our                                 peal as an Expedited (fast) Internal                        Can Internal Appeal
     decision. If you disagree with the                                Appeal.                                                     timeframes be extended?
     decision, you, or your Authorized                                                                                             You, or your Authorized
     Representative, can file an Appeal   If your request does not qualify for                                                     Representative, may request
     with the Board of Hearings (see      an Expedited (fast) Internal Appeal,                                                     to extend the timeframes for
     “How to File a Board of Hearing      we will notify you and your Autho-                                                       resolving standard Internal
     Appeal”).                            rized Representative, in writing,                                                        Appeals by up to five calendar
                                          of this decision and process your                                                        days for each level of Internal
     What is an Expedited (fast)          Internal Appeal within the standard                                                      Appeal. We may request to
     Internal Appeal?                     20 calendar-day timeframe. You,                                                          extend the timeframes for
     BMC HealthNet Plan and Beacon or your Authorized Representa-                                                                  resolving either your first level
     Health Strategies (for Behavioral    tive, have the right to file a Griev-                                                    or second level Internal Appeal
     Health concerns) provide Members ance following the procedures                                                                by five calendar days. You, your
     with one level of Expedited (fast)   described above if you disagree                                                          Authorized Representative, BMC
     Internal Appeal review. You, your    with this decision not to treat your                                                     HealthNet Plan or Beacon Health
     Authorized Representative, or your Internal Appeal as an Expedited                                                            Strategies may request to extend
     healthcare Provider can request      (fast) Internal Appeal (see “How to                                                      the timeframes for resolving
     that your Internal Appeal be         File a Grievance”).                                                                      Expedited (fast) Internal Appeals
     expedited (processed fast) if you                                                                                             by up to 14 calendar days.
     or your healthcare Provider feel     Neither BMC HealthNet Plan nor                                                           Whenever we choose to extend a
     that taking the 20 calendar-day      Beacon Health Strategies will take                                                       timeframe, we will send you, and
     timeframe for a standard Internal    disciplinary action against a Pro-                                                       your Authorized Representative,
     Appeal resolution could seriously    vider who requests an Expedited                                                          a notice of this decision. If you
     jeopardize your life, health or your (fast) Internal Appeal or supports a                                                     disagree with the decision, you, or
     ability to get, maintain or regain   Member’s Expedited (fast) Internal                                                       your Authorized Representative,
     maximum function.                    Appeal request.                                                                          may file a Grievance following the
                                                                                                                                   procedures described above (see
     You, or your Authorized Repre-                                    If your Appeal is expedited (fast), it                      “How to File a Grievance”).
     sentative, may request an Expe-                                   is decided within 72 hours unless
     dited (fast) Internal Appeal from                                 the timeframes are extended as
     BMC HealthNet Plan or Beacon                                      described below. We will notify                             Please note that we can only re-
     Health Strategies (for Behavioral                                 you, and your Authorized Repre-                             quest an extension if:
     Health concerns). If your Pro-                                    sentative in writing of the decision.
     vider is acting as your Authorized                                We will also try to contact you be                          •	 The extension is in your best
     Representative, or if your Provider                               telephone to tell you about the                                interest.
     supports the request filed by you                                 decision.                                                   •	 We need additional information
     or your Authorized Representative,                                                                                               that we believe, if received, will
     in most cases we will honor the                                   If you, or your Authorized Repre-                              lead to approval of your request.
     request that your Internal Appeal                                 sentative, disagree with the deci-                          •	 Such outstanding information
     be treated as an Expedited (fast)                                 sion that we reach with your Ex-                               is reasonably expected to be
     Internal Appeal. We may refuse                                    pedited (fast) Internal Appeal, you                            received within the five or 14
     your Provider’s request to expedite                               can file an Appeal with the Board                              calendar-days extension time-
     (process fast) your Expedited (fast)                              of Hearings (see “How to File a                                frame.
     Internal Appeal request only if it                                Board of Hearing Appeal”). It is not


     BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
     8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
     (en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
     1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
     Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
     Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
25
  When can the Plan or Beacon                                          you, or your Authorized                                    •	 Indicate in your request that
  dismiss your Internal Appeal?                                        Representative, have the right to                             you want to continue to get
  We may dismiss your Internal                                         dispute our Appeal dismissal and                              these services.
  Appeal if:                                                           request that we continue with your
                                                                       Appeal. To do so, you, or your                             Your rights during the
  •	 Someone else files an Internal                                    Authorized Representative, must                            Internal Appeal process
     Appeal on your behalf and we                                      submit a letter to BMC HealthNet                           We will provide you, or your
     do not receive your written                                       Plan or Beacon Health Strategies                           Authorized Representative, a
     Authorization for that person                                     (for Behavioral Health concerns)                           reasonable opportunity to present
     to serve as your Authorized                                       requesting reconsideration of the                          evidence and allegations of fact
     Representative before the                                         dismissal within 10 calendar days                          or law, in person and in writing,
     timeframe for resolving your In-                                  of the Internal Appeal dismissal                           as well as allow you, or your
     ternal Appeal expires. A written                                  notice.                                                    Authorized Representative, to
     Authorization is not required                                     We will review your request for                            access your files before as well as
     for Expedited Appeals; OR                                         reconsideration of dismissal and                           during the Internal Appeal process.
  •	 You, or your Authorized Rep-                                      notify you and your Authorized
     resentative, filed the Standard                                   Representative of our decision.                            If you do not understand English,
     or Expedited (fast) Internal                                                                                                 we will help you with interpreter
     Appeal more than 30 calendar                                      Continuing Services during                                 or translation services during the
     days after the notice from BMC                                    your Internal Appeal                                       Internal Appeal process at no cost
     HealthNet Plan or Beacon                                          If your Internal Appeal involves a                         to you.
     Health Strategies telling you                                     decision by us to modify a previ-
     that you had a right to Ap-                                       ously authorized service, including                        What if we do not resolve
     peal (or, if you did not receive                                  a decision to reduce, suspend,                             your Standard/Expedited
                                                                       or terminate a service, you can                            Internal Appeal within the
     such a notice, more than 30
                                                                       choose to continue receiving the                           required timeframes?
     calendar days after learning on
                                                                       requested services from BMC                                If we do not resolve your (first or
     your own about our actions or
                                                                       HealthNet Plan or Beacon Health                            second level) standard Internal
     inactions that give you a right
                                                                       Strategies during the Internal                             Appeal within 20 calendar days
     to Appeal); OR
                                                                       Appeal process. But if you lose                            (or within five additional calendar
  •	 You, or your Authorized Rep-
                                                                       the Appeal, you may have to pay                            days if we take an extension), you,
     resentative, filed the second
                                                                       back the cost of these services.                           or your Authorized Representative,
     level review of your Internal
                                                                       If you want to receive Continuing                          can file your Appeal with the Board
     Appeal more than 30 calendar
                                                                       Services, you or your Authorized                           of Hearings (see “How to File a
     days after the notice from BMC
                                                                       Representative must:                                       Board of Hearings Appeal” below).
     HealthNet Plan or Beacon
     Health Strategies telling you                                                                                                How to file a Board of
     about our decision to uphold                                      •	 Submit your (Standard first                             Hearings Appeal
     your first level Internal Appeal.                                    level or Expedited (fast)) Inter-                       You, or your Authorized
                                                                          nal Appeal request within 10                            Representative, have the right to
  We will send you and your Autho-                                        calendar days from the date of                          request a hearing before a hearing
  rized Representative an Internal                                        our notice that it has decided                          officer at the Executive Office
  Appeal dismissal notification.                                          to modify a previously autho-                           of Health and Human Services,
                                                                          rized service or submit your                            Office of Medicaid’s, Board of
  Can an Internal Appeal                                                  second level standard Inter-                            Hearings. You may file a hearing
  dismissal be disputed?                                                  nal Appeal request within 10                            request within 30 calendar days of
  If you, or your Authorized                                              calendar days from the date of                          the Plan’s or Beacon’s notification
  Representative, believe that you                                        our notice that it decided your                         of a standard or Expedited (fast)
  indeed requested your Internal                                          first level Internal Appeal; and                        Internal Appeal decision if you, or
  Appeal within 30 calendar days                                       •	                                                         your Authorized Representative,
  and have supporting evidence,                                        •	                                                         disagree with the decision that we


BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
                                                                                                                                                                                              26
     reach when we resolve your:           decision to reduce, suspend,                                                            the Board of Hearings Appeal
                                           or terminate a service, you can                                                         process, please call the BMC
     •	 first level standard Internal      choose to continue receiving the                                                        HealthNet Plan or Beacon Health
          Appeal and you choose to skip requested services during the                                                              Strategies (for Behavioral Health
          our second level Internal Ap-    Board of Hearings Appeal process.                                                       concerns) Member services de-
          peal;                            But if you lose the Appeal, you                                                         partment at the numbers listed at
     •	 second level standard Internal may have to pay back the cost                                                               the bottom of the page.
          Appeal; OR                       of these services. If you want                                                          You also have the right to voice
     •	 Expedited (Fast) Internal Ap-      to receive Continuing Services                                                          any concerns to MassHealth at
          peal.                            during the Board of Hearings                                                            any time. You may call a cus-
                                           process, you, or your Authorized                                                        tomer service representative at
     We will include the request for fair Representative, must submit your                                                         the MassHealth customer service
     hearing form and other instructive Board of Hearings Appeal request                                                           center at the number at the bot-
     material that you, or your Autho-     within ten (10) calendar days from                                                      tom of the page.
     rized Representative, need to         the date of the decision resolving
     request a fair hearing in the written your Internal Appeal. If you do not
     decision resolving your Internal      want to keep getting the requested
     Appeal. We will also assist you, or services during your Board of                                                             SECTION 11
     your Authorized Representative, in Hearing Appeal, you must check
     completing the application.           Box A in Section III of the fair
                                                                                                                                   Notice of Privacy
                                           hearing form.                                                                           Practices
     How do you get an Expedited
     (fast) fair hearing at the            What rights do you have                                                                 This Notice describes how health
     Board of Hearings?                    during the Board of Hearings                                                            information about you may be
     If you, or your Authorized            Appeal process?                                                                         used and communicated, and how
     Representative, are appealing a       BMC HealthNet Plan and Beacon                                                           you can get this information.
     decision resolving an Expedited       Health Strategies (for Behavioral
     (fast) Internal Appeal and you, or    Health concerns) will allow you, or                                                     Please review this Notice of Pri-
     your Authorized Representative,       your Authorized Representative, to                                                      vacy Practices carefully. If you
     also want the Board of Hearings       access your files during the Board                                                      have any questions, please call
     to handle your request as an          of Hearings Appeal process.                                                             the BMC HealthNet Plan Member
     Expedited (fast) fair hearing, you,                                                                                           services department.
                                           At the hearing, you may represent
     or your Authorized Representative,    yourself or be accompanied by                                                           This Notice of Privacy Practices,
     must submit the fair hearing request an Authorized Representative or                                                          which was effective April 14,
     within 20 calendar days from the      an attorney, acting as your Autho-                                                      2003, describes how we may use
     date of the decision. If you, or your rized Representative, at your own                                                       and communicate your Protected
     Authorized Representative, file       expense. Parties may also include                                                       Health Information (PHI) to carry
     between days 21 and 30 calendar       the legal representative of a de-                                                       out treatment, payment or health-
     days, the Board of Hearings will      ceased Member’s estate.                                                                 care administration, and for other
     process your Appeal within the                                                                                                purposes that are permitted or
     standard Board of Hearings Appeal We will implement the Board of                                                              required by law. It also describes
     timeframe.                            Hearings Appeal decision immedi-                                                        your rights to access and control
                                           ately.                                                                                  your Protected Health Informa-
     Continuing Services during            If you do not understand English                                                        tion. Protected Health Information
     your fair hearing at the Board and/or are hearing or sight im-                                                                or PHI is information about you,
     of Hearings                           paired, the Board of Hearings will                                                      including demographic informa-
     If your Board of Hearings Appeal      make sure that an interpreter and/                                                      tion, that may identify you and that
     involves a decision by BMC            or assisting device is available for                                                    relates to your health condition
     HealthNet Plan or Beacon Health       you at the hearing.                                                                     and/or related healthcare services.
     Strategies to modify a previously
     authorized service, including a       If you have any questions about
                                                                                                                                   By law, we are required to:

     BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
     8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
     (en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
     1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
     Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
     Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
27
                                                                       We will also record the actions                            ment, payment and operations.
  •	 Maintain the privacy and con-                                     they took and their observations.                          Required By Law: We will com-
     fidentiality of your Protected                                    That way, the healthcare team                              municate PHI about you when we
     Health Information                                                will know how you responded to                             are required to do so by federal,
  •	 Give you this Notice of Privacy                                   treatment.                                                 state or local law. This includes
     Practices                                                         For Payment: We may use and                                workers’ compensation laws. We
  •	 Follow the practices in this                                      communicate PHI about you so                               may release PHI about you for
     Notice                                                            that others may bill and receive                           workers’ compensation or similar
                                                                       payment for the treatment and                              programs. These programs pro-
  We use physical, electronic and                                      services that you received.                                vide benefits for work-related
  procedural safeguards to protect                                                                                                injuries or illness.
  your privacy. Even when disclo-                                      For Health Care Administration:
  sure of PHI is allowed, we only use                                  We may use and communicate                                 Public Health and Safety: We
  and disclose PHI to the minimum                                      PHI about you to support our nor-                          may communicate your PHI for
  amount necessary for the permit-                                     mal business activities. For exam-                         public health reasons, for example
  ted purpose.                                                         ple, we may use your information                           to prevent or control disease and
                                                                       to review and improve the services                         to report births and deaths.
  Other than the situations men-                                       you receive, communicate infor-
  tioned in this Notice of Privacy                                                                                                Abuse or Neglect: We may com-
                                                                       mation to personnel for review                             municate your PHI to a govern-
  Practices, we cannot use or share                                    and learning purposes, and com-
  your Protected Health Information                                                                                               ment authority if we reasonably
                                                                       municate your Protected Health                             believe you are a victim of abuse
  without your written permission,                                     Information to other organizations
  and you may cancel your permis-                                                                                                 or neglect. We will only communi-
                                                                       that help us with our business                             cate this type of information to the
  sion any time by sending us a                                        activities.
  written notice.                                                                                                                 extent required by law, if you agree
                                                                       For Personal Communications:                               to the disclosure, or if the dis-
  We reserve the right to change this                                  We may contact you to provide                              closure is allowed by law and we
  Notice of Privacy Practices and to                                   appointment or refill reminders, or                        believe it is necessary to prevent
  make the revised notice effective                                    information about possible treat-                          serious harm to you or someone
  for any of your current or future                                    ment options or alternatives and                           else.
  Protected Health Information. You                                    other health-related benefits, or
  are entitled to a copy of the Notice                                                                                            Health Oversight Activities: We
                                                                       services that may be of interest to                        may communicate PHI to a health
  of Privacy Practices currently in                                    you.
  effect.                                                                                                                         oversight agency for activities au-
                                                                       Fundraising Activities: We may                             thorized by law, including audits,
  We May Use and                                                       use PHI about you in an effort to                          investigations, inspections, and li-
  Communicate Protected                                                raise money. If you do not want                            censing purposes. We may have to
  Health Information (PHI)                                             us to contact you for fundraising                          do this for certain state and federal
  about You                                                            efforts, you may opt out by no-                            agencies to monitor the healthcare
  For Treatment: We may                                                tifying us, in writing, with a letter                      system, government programs and
  communicate PHI about you to                                         addressed to the BMC HealthNet                             compliance with civil rights laws.
  doctors, nurses, technicians,                                        Plan Privacy Officer.                                      Lawsuits and Disputes: If you
  office staff or other personnel
                                                                                                                                  are involved in a lawsuit or dis-
  who are involved in taking care of                                   Privacy Officer                                            pute, we may communicate PHI
  you and need the information to                                      BMC HealthNet Plan                                         about you in response to a court
  provide you with health care. For                                    Two Copley Place, Suite 600                                or administrative order. We may
  example, if you are being treated                                    Boston, MA 02116                                           also communicate PHI about you
  for a back injury, we may share
                                                                                                                                  because of a subpoena or other
  information with your Primary Care                                   In some limited situations, the law                        lawful process, subject to all ap-
  Provider, the back Specialist and                                    allows or requires us to use or                            plicable legal requirements.
  the physical therapist so they can                                   communicate your health informa-
  determine the proper care for you.                                   tion for purposes beyond treat-                            Law Enforcement: We may


BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
                                                                                                                                                                                              28
     release your PHI upon request         approval process. This process                                                          Food and Drug Administration
     by a law enforcement official in      requires an evaluation of the pro-                                                      (FDA): We may communicate to
     response to a valid court order,      posed research project and its use                                                      the FDA, or persons under the
     subpoena or similar process.          of PHI, and balances the research                                                       jurisdiction of the FDA, your PHI
                                           needs with our Members’ need for                                                        as it relates to adverse events with
     Military, Veterans, National
                                           privacy. Before we use or disclose                                                      medications, foods, supplements
     Security and Intelligence: If If
                                           PHI for research, the project will                                                      and other products and market-
     you are a member of the armed
                                           have been approved through this                                                         ing information to support product
     forces, we may release your PHI
                                           special approval process. How-                                                          recalls, repairs or replacement.
     as required by military command
     authorities. We may be required by ever, this special approval process
     other government authorities to re- is not required when we allow                                                             Your rights regarding
     lease your PHI for national security researchers who are preparing a                                                          Protected Health Information
     activities.                           research project to look at infor-                                                      about you
                                           mation about patients with specific                                                     Right to Access and Copy: You
     Family and Friends: We may            medical needs, so long as the PHI                                                       have the right to inspect and
     communicate PHI to a member           they review does not leave BMC                                                          receive a copy of PHI that may
     of your family, a relative, a close   HealthNet Plan                                                                          be used to make decisions about
     friend, or any other person you
                                                                                                                                   your care. usually, this includes
     identify who is directly involved in Coroners, Medical Examiners and
                                                                                                                                   medical and billing records.
     your health care or payment relat- Funeral Directors: We may com-
                                           municate PHI to coroners, medical                                                       Psychotherapy notes may not be
     ed to your care. For example, we
                                                                                                                                   inspected or copied. To inspect
     may communicate PHI to a friend examiners and funeral directors
                                                                                                                                   or receive a copy of your records,
     who brings you into an Emergency for identification purposes and as
                                           needed to help them carry out their                                                     you must submit a written request
     room.
                                           duties consistent with applicable                                                       to the BMC HealthNet Plan Privacy
     Serious Threat to Health or           law.                                                                                    Officer.
     Safety: We may use and commu-
                                                                                                                                   Privacy Officer
     nicate PHI about you when neces- Organ and Tissue Donation: If
                                           you are an organ donor, we may                                                          BMC HealthNet Plan
     sary to prevent a serious threat
                                           communicate your PHI to organi-                                                         Two Copley Place, Suite 600
     to your health and safety or the
                                           zations that handle organ procure-                                                      Boston, MA 02116
     health and safety of the public or
     another person.                       ment, banking or transplantation                                                        We may deny your request to
                                           for purposes of tissue donation                                                         inspect or receive a copy in cer-
     Disaster Relief: We may com-          and transplant.                                                                         tain very limited circumstances. If
     municate PHI to an authorized
                                                                                                                                   you are denied access to PHI, we
     public or private entity for disaster Correctional Facilities: If you are or
                                           become an inmate in a correctional                                                      will notify you in writing, and you
     relief purposes. For example, we
                                           facility, we may communicate your                                                       may request that the denial be
     might communicate your PHI to
                                                                                                                                   reviewed. If you request a review,
     help notify family members of your PHI to the correctional facility or its
                                           agents, as necessary, for your health                                                   a BMC HealthNet Plan attorney
     location or general condition.
                                           and the health and safety of other                                                      or other qualified BMC Health-
     Research: under certain circum-       individuals.                                                                            Net Plan employee who was not
     stances, we may use and disclose                                                                                              involved in the original decision
     your PHI for research purposes.       Business Associates: Some of our
                                                                                                                                   to deny your request to inspect
     For example, a research project       services and products are provided
                                                                                                                                   or receive a copy of your records
     may involve comparing the health through contracts with business as-                                                          will re-evaluate your request, and
     and recovery of all Members           sociates, and we may communicate
                                                                                                                                   respond to you in writing.
     who received a particular type of     your PHI to our business associates
                                           so that they may perform the job we                                                     Right to Amend: If you believe
     Care Management to those who
                                           have asked them to do. To protect                                                       that PHI we have about you is
     received another for the same
                                                                                                                                   incorrect or incomplete, you may
     condition. Most research projects, your PHI, however, we require the
                                           business associates to properly                                                         ask us to amend the information.
     however, are subject to a special
                                           safeguard your PHI.                                                                     You have the right to request an


     BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
     8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
     (en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
     1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
     Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
     Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
29
  amendment for as long as the                                         your request, you must tell us: (1)                        Authorizations for Other Uses
  information is kept by or for BMC                                    what information you want to limit;                        and Disclosures of PHI
  HealthNet Plan. You must request                                     (2) whether you want to limit the                          uses or disclosures of your PHI
  an amendment, in writing, to the                                     Plan’s use and/or disclosure of the                        for other purposes or activities
  BMC HealthNet Plan Privacy Of-                                       information; (3) to whom you want                          not listed above will be made only
  ficer and include a reason that                                      the limits to apply (for example,                          with your written authorization
  supports your request. In certain                                    disclosures to your spouse); and                           (permission). If you provide us
  cases, we may deny your request                                      (4) your contact address.                                  with written authorization to use
  for amendment.                                                                                                                  or disclose your PHI, you may
                                                                       Right to Request Confidential
                                                                                                                                  revoke your authorization in
  Right to an Accounting of Dis-                                       Communication: You have the
                                                                                                                                  writing at any time. If you revoke
  closures: You have the right to                                      right to request that we com-
                                                                                                                                  your authorization, we will no
  request an “accounting of disclo-                                    municate with you about medical
                                                                                                                                  longer use or disclose your PHI
  sures.” This is a list of the entities                               matters in a certain way or at a
                                                                                                                                  for the reasons covered by your
  or persons (other than yourself) to                                  certain location. For example, you
                                                                                                                                  written authorization. However,
  whom the Plan has disclosed your                                     can ask that we only contact you
                                                                                                                                  we are unable to take back any
  health information without your                                      by telephone at work or that we
                                                                                                                                  disclosures that have already been
  written authorization. The account-                                  only contact you by mail at home.
                                                                                                                                  made with your authorization.
  ing would not include disclosures                                    Your request must specify how or
  for treatment, payment, health                                       where you wish to be contacted.                            Compliance with laws
  care operations, and certain other                                   We will accommodate all reason-                            If more than one law applies to this
  disclosures exempted by law. To                                      able requests. To request confi-                           Notice of Privacy Practices, we will
  obtain an accounting, you must                                       dential communication, you must                            follow the more stringent law.
  submit your request, in writing, to                                  complete and submit a Request
  the BMC HealthNet Plan Privacy                                       for Confidential Communication                             Complaints
  Officer. It must state a time period,                                Form to the BMC HealthNet Plan                             If you believe your privacy rights
  which may not be longer than six                                     Privacy Officer. You can get a form                        have been violated, you may file a
  years and may not include dates                                      by calling our Member services                             complaint with our office or with
  before April 14, 2003.                                               department.                                                the Secretary of the Department of
  Right to Request Restrictions:                                       Right to Obtain a Paper Copy                               Health and Human Services.
  You have the right to request a                                      or Electronic Version of This                              To file a complaint with our office,
  restriction or limitation on the PHI                                 Notice: You have the right to a                            contact:
  we use or disclose about you for                                     paper copy of this Notice of Pri-
  treatment, payment or health care                                    vacy Practices. You may ask us to                          Privacy Officer
  operations. You also have the right                                  give you a copy of this Notice of                          BMC HealthNet Plan
  to request a limit on the PHI we                                     Privacy Practices at any time by                           Two Copley Place, Suite 600
  disclose about you to someone                                        contacting the Member Services                             Boston, MA 02116
  who is involved in your care or the                                  Department. You may also obtain
  payment for your care, such as a                                     an electronic version of this Notice                       You will not be penalized for filing
  family member or friend. We are                                      of Privacy Practices on our Web                            a complaint.
  not required to agree with your re-                                  site, bmchp.org.
  quest. If we do agree, we will com-                                  Assistance in Preparing Written                            You may file a complaint under the
  ply with your request unless the                                     Documents: BMC HealthNet Plan                              HIPAA Privacy Rule with the Office
  information is needed to provide                                     will provide you with assistance                           of Civil Rights (OCR). Complaints
  you with emergency treatment.                                        in preparing any of the requests                           must be filed in writing within 180
  BMC HealthNet Plan will notify you                                   explained in this Notice of Privacy                        days of an alleged violation, unless
  in writing whether we agree or not                                   Practices that must be submitted                           OCR extends this time require-
  with your request. Please submit                                     in writing. There will be no cost to                       ment for good cause. You can
  your request in writing to the BMC                                   you for this.                                              find additional information at the
  HealthNet Plan Privacy Officer. In                                                                                              following Web site: http:www.hhs.


BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
                                                                                                                                                                                              30
     gov/ocr/hipaa, including the Health                               Health Care Proxy                                           If you become ineligible for
     Information Privacy Complaint                                     A Health Care Proxy is a document                           MassHealth coverage, MassHealth
     Form. You can file HIPAA Privacy                                  that lets you name someone                                  will disenroll you from BMC
     complaints via email to OCRCom-                                   to make decisions about your                                HealthNet Plan. You will no longer
     plaint@hhs.gov or by mail to the                                  medical care – including decisions                          be eligible for coverage by BMC
     following OCR                                                     about life support – if you can no                          HealthNet Plan as of the date of
                                                                       longer speak for yourself. This                             your MassHealth Disenrollment.
     Regional Office:                                                  person would carry out the wishes                           You may automatically be re-
     Office for Civil Rights U.S. De-                                  you described in your “living will.”                        enrolled in BMC HealthNet Plan
     partment of Health & Human                                        This person becomes known                                   if you become eligible again for
     Services JFK Federal Building                                     as your Health Care “Agent” or                              MassHealth within 6 months, as
     Room 1875                                                         “Proxy.”                                                    determined by MassHealth.
     Boston, MA 02203                                                  Once you set up your Advance
                                                                       Directives, you can change your                             Disenrollment for cause
     If you need help filing a complaint                               mind at any time.                                           BMC HealthNet Plan will not
     you can call OCR’s toll free num-                                                                                             request to disenroll a Member
     ber 1-800-368-1019.                                               To get the Health Care Proxy and                            due to an adverse change in
                                                                       Living Will forms, you can visit                            a Member’s health status or
                                                                       BMC HealthNet Plan’s Web site at

     SECTION 12
                                                                                                                                   because of a Member’s utilization
                                                                       bmchp.org. BMC HealthNet Plan                               of medical services, diminished
                                                                       can also mail the forms to you.                             mental capacity or uncooperative
                                                                       Call the Plan’s Member services
     Advance Directives                                                department.
                                                                                                                                   or disruptive behavior resulting
                                                                                                                                   from his or her special needs.
     Advance Directives are legal docu-
     ments that allow you to share your

                                                                       SECTION 13
                                                                                                                                   There may be instances where
     decisions about end-of-life care
                                                                                                                                   BMC HealthNet Plan may submit
     ahead of time. Advance Directives
                                                                                                                                   a written request to MassHealth
     provide a way for you to communi-
     cate your wishes to family, friends                               Disenrollment                                               to disenroll a Member from the
                                                                                                                                   Plan. MassHealth will determine
     and health care professionals, and
                                                                       Voluntary Disenrollment                                     when and if BMC HealthNet Plan’s
     to avoid confusion. An Advance
                                                                       You may end your coverage with                              request will be granted. If you are
     Directive allows you to legally
                                                                       BMC HealthNet Plan at any time.                             disenrolled from BMC HealthNet
     express in writing your health care
                                                                       To disenroll from BMC HealthNet                             Plan, MassHealth will send you
     wishes in case you can’t do so if
                                                                       Plan, call MassHealth customer                              written notification of Disenroll-
     you are seriously sick or injured.
                                                                       service. Voluntary Disenrollments                           ment. You also will be contacted
     There are two kinds of Advance
                                                                       are usually effective one business                          by MassHealth to choose another
     Directives: a Living Will and a
                                                                       day after BMC HealthNet Plan                                health plan.
     Health Care Proxy.
                                                                       gets the request from MassHealth.
                                                                       BMC HealthNet Plan will continue

                                                                                                                                   SECTION 14
     Living Will
     The Living Will lists medical                                     to provide coverage for:
     procedures/types of health care
                                                                       •	 Covered Services through the
     that you do, or do not want under
                                                                          date of Disenrollment
                                                                                                                                   Coordination of
     certain circumstances if you
     become seriously sick or injured.                                 •	 Any custom-ordered equip-                                Benefits/Subrogation
     An example would be if you                                           ment approved prior to Disen-
                                                                          rollment, even if not delivered                          You must tell us if you have any
     decided that you don’t want to be
                                                                          until after Disenrollment.                               other health insurance coverage in
     kept alive using life support if you
                                                                                                                                   addition to MassHealth. You must
     became very ill.
                                                                       Disenrollment for loss of                                   also let us know whenever there
                                                                       Eligibility                                                 are any changes in your additional


     BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
     8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
     (en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
     1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
     Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
     Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
31
  insurance coverage. The types of                                     provides you with health care                              be subrogated. This means that
  additional insurance you might                                       coverage, unless the law states                            we may use your right to recover
  have include:                                                        something different. In other                              money from the person(s) who
                                                                       situations, such as for benefits                           caused the injury or from any
  •	 Coverage from an employer’s                                       that are not covered by BMC                                insurance company or other party.
     group health insurance for em-                                    HealthNet Plan, you may be able                            If another person or party is, or may
     ployees or retirees, either for                                   to get your care covered by an                             be, liable to pay for services related
     yourself or your spouse                                           insurer other than us. If you have                         to your illness or injury that may
  •	 Coverage under workers’ com-                                      additional health insurance, please                        have been paid for or provided by
     pensation because of a job-                                       call us at 888-257-1985 to find out                        us, we will subrogate and succeed
     related illness or injury                                         how payment will be handled.                               to all your rights to recover against
  •	 Coverage for an accident                                          If you have comprehensive health                           such person or party 100 percent
     where no-fault insurance or li-                                   insurance with another health                              of the value of services paid for or
     ability insurance is involved                                     plan,                                                      provided by us.
  •	 Coverage you have through
     veteran’s benefits                                                including Medicare, you are not                            Claims incurred as a result of
  •	 “Continuation coverage” that                                      eligible for MassHealth benefits                           any Subrogation case should be
     you have through COBRA                                            from Managed Care organizations,                           submitted before any settlement.
     (COBRA is a law that requires                                     including BMC HealthNet Plan.                              Claims for services rendered
     employers with 20 or more                                         If you fit this category, you will                         before a settlement that are not
     employees to let employees                                        need to be disenrolled from BMC                            submitted before that settlement is
     and their Dependents keep                                         HealthNet Plan. MassHealth will                            reached may be denied.
     their group health coverage                                       notify you about this.
     for a time after they leave their                                                                                            In the event another party reimburses
                                                                       Motor vehicle accidents and/
     group health plan under certain                                   or work-related injury/illness                             any medical expense we pay for,
     conditions.)                                                      If you are in a motor vehicle                              we will be entitled to recover from
                                                                       accident, you must use all of your                         you 100 percent of the amount you
  BMC HealthNet Plan is the payer                                      auto insurance carrier’s medical                           got for such services from us. The
  of last resort for payment of medi-                                  coverage (including personal injury                        amount you must pay back to us
  cal services involving Coordination                                  protection (PIP) and/or medical                            will not be reduced by any attorney’s
  of Benefits and third-party-liability                                payment coverage) before we will                           fees or incurred expenses.
  or Subrogation. Please see the                                       consider paying for any of your
  following sections for more                                          expenses. You must send to us any                          To enforce our Subrogation rights
  information.                                                         explanation of payment or denial                           under this Member handbook, we
                                                                       letters from an auto insurance                             will have the right to take legal
  Coordination of Benefits                                                                                                        action, with or without your
  When you have other health                                           carrier for us to consider paying a
                                                                       Claim that your Provider sends to us.                      consent, against any party to
  insurance coverage, we work with                                                                                                secure recovery of the value of
  your other insurance to coordinate                                   In the case of a work-related injury
                                                                       or illness, the workers’ compensation                      services provided or paid for by us
  your BMC HealthNet Plan benefits.                                                                                               for which that party is, or may be,
  The way we work with the other                                       carrier will be responsible for those
                                                                       expenses first. You must send to                           liable. Nothing in this handbook
  companies depends on your                                                                                                       will be interpreted to limit our right
  situation. This process is called                                    us any explanation of payment or
                                                                       denial letters from an auto insurance                      to use any remedy provided by law
  Coordination of Benefits. Through                                                                                               to enforce its rights to Subrogation
  this benefit coordination, you will                                  carrier for us to consider paying a
                                                                       Claim that your Provider sends to us.                      under this Member handbook.
  often get your health insurance
  coverage as usual through us. If                                                                                                We require you to follow all Prior
                                                                       Subrogation                                                Authorization requirements even
  you have other health insurance,
                                                                       If you are injured by the act or                           when third-party-liability exists.
  our coverage will always be
                                                                       omission of another person, your                           Authorization is not a guarantee of
  secondary when the other plan
                                                                       BMC HealthNet Plan benefits will                           payment.

BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
                                                                                                                                                                                              32
     Member cooperation
     As a Member of BMC HealthNet
     Plan, you agree to cooperate
                                                                       SECTION 15                                                  Beacon Health Strategies – A
                                                                                                                                   partner of BMC HealthNet Plan
                                                                                                                                   that manages and coordinates the
     with us in exercising our rights to                               Glossary                                                    Behavioral Health (mental health
     Subrogation and Coordination of                                                                                               and substance abuse) services for
     Benefits. This means you must                                     Advance Directive – A written                               Members and manages the Be-
     complete and sign all necessary                                   statement that tells a Provider                             havioral Health Provider network.
     documents to help us exercise our                                 what to do if an illness or accident
     rights. This also means that you                                  takes away the Member’s ability                             Behavioral Health – Mental health
     must give us notice before settling                               to make decisions about his or her                          and substance abuse services
     any Claim arising out of injuries                                 health care.
     you sustained by any liable party(s)                                                                                          BMC HealthNet Plan (the Plan)–
     for which we have                                                 Adverse Action – The follow-
                                                                                                                                   A managed care organization
     provided coverage. You must not                                   ing actions or inactions by BMC
                                                                                                                                   providing coverage to MassHealth
     do anything that might limit our                                  HealthNet Plan or Beacon Health
                                                                                                                                   (Medicaid) and Commonwealth
     right to full reimbursement. These                                Strategies:
                                                                                                                                   Care members. The Plan contracts
     Subrogation and recovery provisions                               1. Denying or limiting coverage of
                                                                                                                                   with Providers and hospital sys-
     apply, whether or not the Member                                     a requested healthcare service;
                                                                                                                                   tems throughout Massachusetts
     recovering money is a minor.                                      2. Reducing or stopping coverage
                                                                                                                                   to deliver care to Members state-
     We ask that you:                                                     for a service that was previously
                                                                                                                                   wide.
                                                                          approved;
                                                                       3. Denying payment for a service                            BMC HealthNet Plan Network
     •	 Give us all information and
                                                                          because it was not Medically                             Provider – A Provider with which
        documents we request
                                                                          Necessary;                                               BMC HealthNet Plan has an agree-
     •	 Sign any documents we think
                                                                       4. Not responding to an                                     ment to offer Covered Services to
        are necessary to protect our
                                                                          Authorization request in a timely                        Members.
        rights
     •	 Promptly assign us any money                                      manner;                                                  Board of Hearings – the Board
        gotten for services for which                                  5. Not being able to get health                             of Hearings within the Executive
        we’ve provided or paid                                            care within required timeframes;                         Office of Health and Human Ser-
     •	 Promptly notify us of any pos-                                    and                                                      vices’ Office of Medicaid.
        sible Subrogation or benefit                                   6. Not resolving an Appeal request                          Board of Hearings (BOH) Appeal
        coordination potential                                            within required timeframes.                              – A written request to the BOH,
                                                                       Appeal – A request by a MassHealth                          made by a Member or Authorized
     You also must agree to do nothing                                 Member/Authorized Representative                            Representative to review the cor-
     to prejudice or interfere with our                                to BMC HealthNet Plan or Beacon                             rectness of a Final Internal Appeal
     rights to Subrogation or benefit                                  Health Strategies or the Office of                          decision by BMC HealthNet Plan
     coordination. If you are not willing                              Medicaid’s Board of Hearings for                            or Beacon Health Strategies.
     to help us, you will be liable to us                              review of an action or inaction by the
                                                                       Plan.                                                       Care Management – A program
     for any expenses we may incur,
                                                                                                                                   offered by BMC HealthNet Plan
     including reasonable attorneys’
                                                                       Authorization – A special approval                          and Beacon Health Strategies (for
     fees, in enforcing our rights under
                                                                       by BMC HealthNet Plan or Beacon                             Behavioral Health) to our Mem-
     this plan. Nothing in this Member
                                                                       Health Strategies for payment of                            bers who are most in need of
     handbook may be interpreted to
                                                                       certain Covered Services that is done                       assistance with managing multiple
     limit our right to use any means
                                                                       prior to receiving the services.                            situations, services, and/or Provid-
     provided by law to enforce our
                                                                                                                                   ers at one time. The situations may
     rights to Subrogation or benefit
                                                                       Authorized Representative – some-                           be medical, behavioral, social and/
     coordination under this plan.
                                                                       one authorized by you in writing to                         or environmental in nature. The
                                                                       act on your behalf regarding a spe-                         services may be preventive, well-
                                                                       cific Grievance or Appeal.                                  ness, disease, treatment or hous-
                                                                                                                                   ing related. The Providers may


     BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
     8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
     (en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
     1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
     Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
     Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
33
  include your or a family member’s                                    Clinical Practice Guidelines–                              individual becomes a Member
  PCP, Specialists, other health care                                  Standards for care that BMC                                of BMC HealthNet Plan and is
  Providers – such as home health                                      HealthNet Plan and Beacon Health                           eligible for Covered Services.
  care agencies – as well as staff                                     Strategies use with its Provider                           Generally one business day
  from state agencies.                                                 Network to make sure that Mem-                             after BMC HealthNet Plan re-
  The BMC HealthNet Plan Care                                          bers are getting the best care.                            ceives notification of Enrollment
                                                                                                                                  from Mass Health.
  Management Program consists of
  four distinct program categories                                     Community Service Agency                                   Eligibility – MassHealth enrollees
  that provide services for our Mem-                                   (CSA) – There are 32 CSA’s across                          qualified to receive MassHealth
  bers. The four program categories                                    the state offering care coordina-                          health coverage.
  are Care Management Education                                        tion services to MassHealth eli-                           Emergency – A medical condi-
  and Wellness, Care Management                                        gible youth with serious emotional                         tion, whether physical or mental,
  Health Care Coordination, Care                                       disturbance (SED) and their fami-                          manifesting itself by symptoms
  Management Select, and Intensive                                     lies/caregivers.                                           of sufficient severity, including
  Clinical Management (ICM).                                                                                                      severe pain, that, in the absence
                                                                       Continuity of Care – The process                           of prompt medical attention,
  Child Adolescent Needs and                                           that ensures that Members do not                           could reasonably be expected by
  Strengths (CANS) Tool – A tool                                       have disruptions in their medical                          a prudent lay person who pos-
  that provides a standardized way                                     or Behavioral Health care due to                           sesses an average knowledge of
  for Behavioral Health Providers to                                   switching health plans or Provider                         health and medicine to result in
                                                                                                                                  placing the health of an Enrollee or
  organize information gathered dur-                                   changes.                                                   another person or, in the case of
  ing Behavioral Health clinical as-                                                                                              a pregnant woman, the health of
  sessments for Members under the                                      Continuing Services – The pro-                             the woman or her unborn child, in
  age 21 and during the discharge                                      cess of continuing to receive cer-                         serious jeopardy, serious impair-
  planning process from inpatient                                      tain services from BMC HealthNet                           ment to bodily function, or serious
  psychiatric hospitalizations and                                     Plan or Beacon Health Strategies                           dysfunction of any body organ or
  community based acute treatment                                      during an Appeal.                                          part; or, with respect to a pregnant
  services.                                                                                                                       woman, as further defined in sec-
                                                                       Coordination of Benefits – The                             tion 1867(e)(1)(B) of the Social Se-
                                                                       process that BMC HealthNet Plan                            curity Act, 42 u.S.C. § 1395dd(e)
  Children’s Behavioral Health                                         uses to work with any other health                         (1)(B).
  Initiative (CBHI) – The Children’s                                   insurers Members may have.                                 Enrollment – The process by
  Behavioral Health Initiative is an                                                                                              which BMC HealthNet Plan regis-
  inter-agency initiative of the Com-                                  Co-payment – Payments made by                              ters individuals for membership.
  monwealth of Massachusetts’                                          Members at the time of care.
  Executive Office of Health and Hu-                                                                                              EPSDT (Early and Periodic
  man Services whose mission is to                                     Covered Services – The services                            Screening, Diagnostic and Treat-
  strengthen, expand and integrate                                     and supplies covered by BMC                                ment) Services – Preventive care
  Massachusetts state services into                                    HealthNet Plan and MassHealth                              and treatment services provided
  a comprehensive, community-                                          described in the Covered Services                          by a Primary Care Provider on a
                                                                       list in this Member handbook.                              periodic schedule. The schedule is
  based system of care, to ensure
                                                                                                                                  determined by the age when each
  that families and their children with                                Dependent – A person who gets                              procedure is to be provided and
  significant behavioral, emotional                                    health coverage through another                            includes a complete assessment
  and mental health needs obtain the                                   person, such as a spouse, parent,                          (e.g. health screens), service coor-
  services necessary for success in                                    or grandparent.                                            dination, crisis intervention and in
  home, school and community.                                                                                                     home services.
                                                                       Disenrollment – The process by
  Claim – A bill from a Provider that                                  which a Member’s BMC HealthNet                             Expedited (fast) Internal Appeal
  describes the services that have                                     Plan coverage ends.                                        – A 72-hour Appeal process.
  been provided to a Member.
                                                                       Effective Date – An Effective                              Family Planning Services –
                                                                       Date is the date on which an                               Services directly related to pre-

BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
                                                                                                                                                                                              34
     venting conception. They include                                                                                              (1) persons who have been identi-
     birth control counseling, education   Intensive Clinical Management                                                           fied by the Department of Mental
     about family planning, examination    (ICM) – A Care Management pro-                                                          Health (DMH) as getting services
     and treatment, laboratory exami-      gram provided by Beacon Health                                                          or as being on a waiting list to
     nations and tests, medically ap-      Strategies. ICM care managers                                                           get services from the DMH, are
     proved methods and procedures,        through collaboration with Mem-                                                         “long-term unemployed,” and
     pharmacy supplies and devices,
                                           bers and their treatment Providers,
     sterilization, including tubal ligation                                                                                       have income at or below 100%
     and vasectomy. (Abortion is not a     work to ensure the coordination                                                         of the federal poverty level; or (2)
     Family Planning Service.)             and optimization of care; assess-                                                       persons who are getting Emer-
                                           ment, care planning, discharge                                                          gency Aid to the Elderly, Disabled
     Final Internal Appeal – The           planning and mobilization of                                                            and Children (EAEDC) through the
     second-level review of an Inter-      resources to Members who are                                                            Department of Transitional Assis-
     nal Appeal or, for a Member, or a     dealing with Behavioral Health or                                                       tance; or (3) persons who are re-
     Member’s Appeal Representative, psychosocial conditions, some-                                                                ceiving MassHealth Basic pending
     who waives the second-level Inter- times along with in addition to                                                            an appeal to the Board of Hearings
     nal Appeal, the first-level review of medical concerns.                                                                       of EOHHS’s decision that they are
     an Internal Appeal.                                                                                                           no longer eligible for MassHealth.
                                           Internal Appeal – A verbal or writ-
     Fraud – An intentional decep-         ten request for BMC HealthNet                                                           MassHealth CommonHealth – A
     tion or misrepresentation made        Plan or Beacon Health Strategies                                                        MassHealth benefit plan that offers
     by a person or corporation with       to review an Adverse Action.                                                            health benefits to certain disabled
     the knowledge that the deception                                                                                              children under age 18, and certain
     could result in some unauthor-        Living Will – A document that lists                                                     working or non-working disabled
     ized benefit under the MassHealth medical procedures that you do, or                                                          adults between the ages of 18 and 64.
     program to himself or herself, the    do not, want under certain circum-
     corporation or some other person. stances if you become seriously                                                             MassHealth Essential – A
     An example of Fraud is Members        sick or injured.                                                                        MassHealth benefit plan that offers
     lending their BMC HealthNet Plan                                                                                              health benefits to certain individu-
     ID card to others so they can get     Managed Care – A system of                                                              als or Members of a couple over
     health care or pharmacy services. health care delivery that is provid-                                                        the age of 18 and under the age of
     Grievance – A statement by a          ed and coordinated by a Primary                                                         65 who are long-term unemployed
     Member of dissatisfaction with        Care Provider (PCP). The goal is                                                        and who do not meet the eligibility
     care or services received.            a system that delivers value by                                                         criteria for MassHealth Basic.
     Health Care Agent or Proxy – The providing access to quality, cost
     individual responsible for making     effective health care.                                                                  MassHealth Family Assistance
     healthcare decisions for a person                                                                                             – A MassHealth benefit plan that
     in the event that person is unable    MassHealth – A health care pro-                                                         offers health benefits to certain eli-
     to make decisions for him/her self. gram operated by the Massachu-                                                            gible Members, including families
                                           setts Executive Office of Health                                                        and children under the age of 18.
     Health Risk Assessment – A            and Human Services. The national
     questionnaire about a Member’s        health insurance program called                                                         MassHealth Standard – A
     current health situation that helps Medicaid is called MassHealth in                                                          MassHealth benefit plan that offers
     BMC HealthNet Plan and Beacon Massachusetts. BMC HealthNet                                                                    a full range of health benefits to
     Health Strategies provide the right Plan covers MassHealth Members                                                            certain eligible Members, includ-
     care to Members.                      under the Standard, Common-                                                             ing families, children under age
                                           Health, Basic, Family Assistance                                                        18, pregnant women, and disabled
     Inpatient – Services requiring        and Essential Plans.                                                                    individuals under age 65.
     at least one overnight stay and
     generally applies to care in facili-  MassHealth Basic – A                                                                    Medicare Part D – As a BMC
     ties such as hospitals and skilled    MassHealth benefit plan that                                                            HealthNet Plan MassHealth Mem-
     nursing facilities.                   offers health benefits to certain                                                       ber with Medicare coverage, your
                                           individuals over the age of 18 and                                                      prescription drug benefit may be
     Inquiry – Any question a Member under the age of 65 who qualify                                                               covered by a Medicare Prescrip-
     has about BMC HealthNet Plan’s        under EOHHS’s MassHealth Basic                                                          tion Drug Coverage (Part D) plan.
     or Beacon Health Strategies’ op-      eligibility criteria which includes                                                     Most of your prescription drugs
     erations.

     BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
     8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
     (en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
     1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
     Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
     Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
35
  will be covered under your Medi-                                     received following an Emergency                            Provider if those services are cov-
  care Part D benefit.                                                 situation.                                                 ered benefits and within the scope
                                                                                                                                  of the Provider’s license.
  Medically Necessary Services                                         PPHSD – Preventive Pediatric
  – those services 1) which are                                        Healthcare Screening and Di-                               Provider Directory – An online
  reasonably calculated to prevent,                                    agnosis. These are preventive                              search tool or printed booklet
  diagnose, prevent the worsening                                      care and treatment services that                           containing a list of BMC HealthNet
  of, alleviate, correct or cure condi-                                BMC HealthNet Plan covers for                              Plan’s affiliated medical facilities
  tions in the Member that endanger                                    MassHealth Members under the                               and professionals, including Pri-
  life, cause suffering or pain, cause                                 age of 21 who are part of the Ba-                          mary Care Providers, Specialists
  physical deformity or malfunction,                                   sic, Family Assistance or Essential                        and Behavioral Health Providers.
  threaten to cause or to aggravate                                    plans.
  a disability, or result in illness or                                                                                           Quality Improvement – A pro-
  infirmity; and 2) for which there is                                 Primary Care Provider (PCP) – A                            gram designed to identify ways
  no comparable medical service or                                     doctor or nurse practitioner se-                           to improve the quality of care that
  site of service available or suitable                                lected by the Member or assigned                           Members receive.
  for the Member requesting the                                        by BMC HealthNet Plan to pro-
  service that is more conservative                                    vide and coordinate a Member’s                             Referral – A recommendation to
  or less costly; and 3) are of a qual-                                healthcare needs. Other health-                            receive care from a Provider.
  ity that meets generally accepted                                    care Providers, such as registered
  standards of medical care.                                           nurses, physician’s assistant or                           Region – MassHealth divides the
                                                                       nurse midwives, acting on behalf                           state into five geographic regions.
  Member – Any person enrolled                                         of and in consultation with a PCP,                         Your region is the part of the state
  in BMC HealthNet Plan and                                            may provide Primary Care Ser-                              that you live in and also where
  MassHealth.                                                          vices.                                                     you should choose a Primary Care
                                                                                                                                  Provider.
                                                                       Prior Authorization – Approval
  Member ID Card – The card                                            given by BMC HealthNet Plan or
  that identifies an individual as a                                   Beacon Health Strategies for cer-
  Member of BMC HealthNet Plan.                                                                                                   Routine Care – Care that is not
                                                                       tain Provider visits or health care                        Emergency or urgent Care. Exam-
  The Member ID Card includes                                          services in order for these to be
  the Member’s identification num-                                                                                                ples of Routine Care are physical
                                                                       covered. This approval must be                             exams and well-child care visits.
  ber and information about the                                        obtained by your Provider before
  Member’s coverage. Members                                           you go to certain Providers or
  will also receive an ID Card from                                                                                               Second Opinion – The process by
                                                                       before you get certain healthcare                          which a Member seeks an evalua-
  MassHealth.                                                          services.
  Both ID Cards must be shown to                                                                                                  tion by another Provider to confirm
  Providers before receiving care.                                                                                                the diagnosis and treatment plan
                                                                       Protected Health Information                               of their primary Provider.
                                                                       (PHI) – Information about you that
  Network – The group of Provid-                                       may identify you and that relates
  ers contracted by BMC HealthNet                                                                                                 Service Area – The geographi-
                                                                       to your health condition and/or                            cal area approved by MassHealth
  Plan to provide health care ser-                                     related healthcare services.
  vices to Members.                                                                                                               within which BMC HealthNet Plan
                                                                                                                                  has developed a Network of Pro-
                                                                       Provider – A healthcare profes-                            viders to provide adequate access
  Notice of Privacy Practices –
                                                                       sional or facility licensed as re-                         to Covered Services.
  A detailed statement about how
  Member health information can                                        quired by state law. Providers
  and cannot be used.                                                  include doctors, hospitals, labora-                        Specialist – A Provider who is
                                                                       tories, pharmacies, skilled nursing                        trained and certified by the state of
  Nurse Advice Line – A 24 hour/7                                      facilities, nurse practitioners, regis-                    Massachusetts to provide spe-
  day a week telephone line that                                       tered nurses, psychiatrists, social                        cialty services. Examples include
  BMC HealthNet Plan Members                                           workers, licensed mental health                            cardiologists, obstetricians and
  can call to speak to a trained                                                                                                  dermatologists.
                                                                       counselors, clinical Specialists in
  nurse about health questions.                                        psychiatric and mental health nurs-                        Subrogation – The procedure
                                                                       ing, and others. BMC HealthNet                             under which BMC HealthNet Plan
  Post Stabilization care – Care
                                                                       Plan will only cover services of a                         can recover the full or partial cost

BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
                                                                                                                                                                                              36
     of benefits paid from a third per-
     son or entity, such as an insurer.

     Urgent Care – Medical care re-
     quired quickly to prevent a wors-
     ening of health due to symptoms
     that a prudent lay person would
     believe are not an Emergency but
     do require medical attention. ur-
     gent Care does not include Rou-
     tine Care.

     Utilization Management – The
     process by which BMC HealthNet
     Plan reviews the clinical necessity,
     appropriateness, or efficiency of
     covered services, procedures, or
     settings.




     BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
     8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
     (en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
     1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
     Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
     Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
37
  SECTION 16
  INDEX
  Advance Directives ................................................ 31                                   Eligibility Review Verification (ERV) .....................................1
  Appeal representative ........................................... 23                                     Emergencies .........................................................................9
  Appeals ...................................................................23                            Emergency room ................................................................. 9
  Asthma ..................................................................... 2                           Extras .................................................................................... 2
  Becoming a Member .............................................. 1                                       Family Planning Services .................................................... 7
  Behavioral Health .................................................... 6                                 Family practice doctors ...................................................... 8
  (mental health and substance abuse)                                                                      Fraud (reporting) ................................................................. 22
  Benefits .......................... see Covered Services List                                            Free for our Members ......................................................... 8
  Bicycle helmets ....................................................... 2                                General practice doctors .................................................... 8
  Bills ............................................................................ 7                     Generic medications ......................................................... 15
  Board of Hearing Appeal ...................................... 27                                        Grievances ..........................................................................22
  Breast pumps .......................................................... 2                                Growth problems (children) ............................................... 18
  BMC HealthNet Plan ............................................... 1                                     Gynecologist ........................................................................ 9
  Car seats .................................................................. 2                           Health care ........................................................................... 1
  Care Management ................................................ 18                                      Health Risk Assessment ....................................................11
  Changing your PCP ................................................ 9                                     High blood pressure ............................................................ 2
  Chronic disease management ............................. 19                                              ID Card ................................................................................. 2
  Congestive heart failure .......................................... 2                                    Internal Appeals ................................................................. 23
  Contact information .............. See bottom of pages                                                   Internal medicine doctors ................................................... 8
  Copayment cap (pharmacy) ................................. 14                                            Inquiries .............................................................................. 22
  Copayments (pharmacy) ...................................... 13                                          Manual breast pumps ......................................................... 2
  Covered benefits............. see Covered Services list                                                  MassHealth .......................................................................... 1
  Dental care for children ........................................ 17                                     Member Services Department ........................................... 1
  Department of Children & Family (DCF) .............. 12                                                  Membership ........................................................................ 1
  Development problems (children) ....................... 18                                               Mental health services ........................................................ 10
  Diabetes ................................................................. 19                            New Member orientation ................................................... 1
  Disenrollment ......................................................... 31                               Not covered ......................................................................... 4
  Doctor ....................................................................... 1                         Nurse Advice Line from BMC HealthNet Plan .................. 2
  Early and Periodic Screening ............................... 17                                          Obstetrician .......................................................................... 9
  Diagnostic and Treatment (EPSDT)
                                                                                                           OB/GYN ............................................................................. 16
  Early intervention services .................................... 18


BMC HealthNet Plan Member Services Department                                                                                        MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012                    8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •                1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
                                                                                                                                                                                                           38
     Over-the-counter medications ................................... 13
     Pediatric doctors .......................................................... 9
     Pharmacy ...................................................................... 2
     Post-stabilization .......................................................... 4
     Pregnancy ................................................................... 15
     Prenatal care ............................................................... 15
     Prescription medication coverage ............................ 13
     Preventive care ........................................................... 13
     Preventive Pediatric Healthcare ................................ 16
     Screening and Diagnosis (PPHSD)
     Primary Care Provider (PCP) ....................................... 1
     Prior-Authorization ...................................................... 22
     Privacy practices ........................................................ 27
     Privacy complaint ....................................................... 30
     Protected Health Information (PHI) ........................... 11
     Provider Directory ......................................................... 1
     Questions ...................................................................... 1
     Referrals ........................................................................ 4
     Responsibilities ........................................................... 21
     Rights ........................................................................... 20
     Services .............. (covered) see Covered Services list
     Services not covered ...........see Covered Services list
     Special healthcare needs ............................................ 1
     Specialty care ............................................................... 4
     Substance abuse services (including detoxification).. 10
     Transportation assistance .......................................... 12
     urgent Care .................................................................. 10
     Web site ....................................... See bottom of pages
     Well-child care ............................................................ 16




     BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
     8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
     (en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
     1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
     Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
     Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
39
                                                                      Details about Your Membership Card




           Your Name                                                                                                                                   Information that
                                                                                                                                                       enables you to have
           Your personal                                                                                                                               prescriptions filled
           BMC HealthNet Plan                                                                                                                          at any participating
           Identification Number                                                                                                                        pharmacy

           Your personal
           doctor’s name




          BMC HealthNet
          Plan’s toll-free
          Member Services
          Department number




BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
                                                                                                                                                                                              40
     BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
     8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
     (en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
     1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
     Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
     Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
41
BMC HealthNet Plan Member Services Department                                                                                MassHealth Customer Service
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)
                                                                                                                                                                                              42
                                                                                                                                                                                              MH - HB 02/11 20M




BMC HealthNet Plan Member Services Department
                                                                      Member Services Call Center                            MassHealth Customer Service
                                                                        BMC HealthNet Plan
8:00 a.m. – 6:00 p.m., (Eastern Time) Monday-Friday 1.888.566.0010 (English and other languages) • 1.888.566.0012            8:00 a.m. – 5:00 p.m., Monday-Friday
(en Español) • 1.866.765.0055 (TTY/TDD for hearing impaired) • 1.800.421.1220 (relay operator for hearing impaired) •        1.800.841.2900 • 1.800.497.4648 (TTY/TDD for hearing impaired)
                                                                      Two Copley Place, Suite 600
1.888.217.3501 (Behavioral Health: mental health and substance abuse questions 24 hours a day/7 days a week managed by
Beacon Health Strategies) • 1.888.727.9441 (Behavioral Health TTY/TDD for hearing impaired) • 1.800.973.6273 (Nurse Advice
                                                                          Boston, MA 02116
Line) • Web Site www.bmchp.org • www.beaconhealthstrategies.org (Behavioral health)

				
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