Member Handbook

Your Health. Your Advantage.

If you have any problems in reading or understanding this or any other Paramount Advantage information, please contact our Member Services Department at 419-887-2525 or toll-free 1-800-462-3589,TTY users 419-887-2526 or toll-free 1-888-740-5670, for help at no cost to you. We can help to explain the information or provide the information orally, in English or in your primary language. We may have the information printed in certain other languages or in other ways. If you are visually or hearing-impaired, special help can be provided.

Important information from ODJFS for new members coming from fee-for-service. If you were on Medicaid fee-for-service the month before you became a Paramount Advantage member and have health care services already approved and/or scheduled, it is important that you call Member Services immediately (today or as soon as possible). In certain situations, for a brief time after you enroll, we may allow you to receive care from a provider that is not a Paramount Advantage panel provider. Additionally, we may allow you to continue to receive services that were authorized by Medicaid fee-for-service. However, you must call Paramount Advantage before you receive the care. If you do not call us, you may not be able to receive the care and/or the claim may not be paid. For example, you need to call Member Services if you have the following services already approved and/or scheduled:

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• • • • • • • •

Organ, bone marrow or hematopoietic stem cell transplant Third trimester prenatal (pregnancy) care, including delivery Inpatient/outpatient surgery Appointment with a specialty provider Chemotherapy or radiation treatments Non-routine dental or vision services (for example, braces or surgery) Medical equipment Services you receive at home, including home health, therapies and nursing

After you enroll, your MCP will tell you if any of your current medications require prior authorization that did not require authorization when they were paid by Medicaid fee-forservice. It is very important that you look at the information the MCP provides and contact your MCP’s member services if you have any questions. You can also look on your MCP’s website to find out if your medication(s) require prior authorization. You may need to follow up with the prescriber’s office to submit a prior authorization request to your MCP if it is needed. If your medication(s) requires prior authorization, you cannot get the medication(s) until your provider submits a request to your MCP and it is approved.

Keep These Numbers Handy ISSUANCE DATE: February 1, 2012

To telephone your primary care provider (PCP) Family Member’s Name

His/Her Primary Care Provider

Phone

_________________________

______________________________

_____________________

_________________________

______________________________

_____________________

_________________________

______________________________

_____________________

Family Member’s Name

His/Her Specialists

Phone

_________________________

______________________________

_____________________

_________________________

______________________________

_____________________

_________________________

______________________________

_____________________

To telephone specialists

If you have questions, problems or concerns, call the Member Services Department at 419-887-2525 or toll-free 1-800-462-3589,TTY users 419-887-2526 or toll-free 1-888-740-5670, when: • You have questions about covered benefits. • You have name and address changes. • You have had a baby; to give the name and birth date of the newborn. • You have questions about services not listed in the chapter “What Is Covered?” • You want to change your primary care provider (PCP). • You need transportation assistance (as described on page 31).

Member Services Department: 419-887-2525 or toll-free 1-800-462-3589 TTY users 419-887-2526 or toll-free 1-888-740-5670

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Table of Contents Meanings of Some Words In This Handbook ........................................................................................................5 Welcome to Paramount Advantage™ What is Paramount Advantage? ..............................................................................................................................................................8 Who can join Paramount Advantage?..................................................................................................................................................8 What you must do to receive benefits................................................................................................................................................9

Your Doctor Is Your Health Care Partner Choosing a primary care provider (PCP)........................................................................................................................................10 When should you visit your PCP?........................................................................................................................................................10 Changing your PCP ......................................................................................................................................................................................11 HEALTHCHEK ................................................................................................................................................................................................11 When you need obstetrical or gynecological care ....................................................................................................................13 Qualified family planning provider services ....................................................................................................................................13 Prenatal-postpartum care guidelines ..................................................................................................................................................13 Mental health and substance abuse services..................................................................................................................................15 Seeing a specialist ..........................................................................................................................................................................................15 Making an appointment with a specialist..........................................................................................................................................15

Your Paramount Advantage Identification Card Always keep your ID card(s) with you..............................................................................................................................................16

In Case of Emergency Emergency services ......................................................................................................................................................................................17 If you are out of town ................................................................................................................................................................................17

Urgent Care Centers Using an Urgent Care Center ................................................................................................................................................................18

Going to the Hospital Use a participating hospital ......................................................................................................................................................................18

Filling Prescriptions Use a participating pharmacy..................................................................................................................................................................19 Prescription drugs ..........................................................................................................................................................................................19 You health care provider can order over-the-counter medications ................................................................................19

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Member Services Department: 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

Table of Contents

Phoning Questions to the Member Services Department The Member Services Department will help you right away..............................................................................................20 ProMedica Call Center................................................................................................................................................................................20 How to let Paramount Advantage know if you are unhappy ............................................................................................20 Grievance and appeals (complaint) form ....................................................................................................................................20A State hearings....................................................................................................................................................................................................22

Membership Terminations, Re-Enrolling and Conversion Membership terminations (getting out of Paramount Advantage)..................................................................................23 Choosing a new plan ..................................................................................................................................................................................23 Ending your MCP membership..............................................................................................................................................................23 Just cause membership terminations..................................................................................................................................................24 Optional membership terminations....................................................................................................................................................25 Things to keep in mind if you end your membership..............................................................................................................25 Loss of Medicaid eligibility ........................................................................................................................................................................26 Loss of insurance notice (certificate of creditable coverage) ..............................................................................................26 Automatic renewal of MCP membership........................................................................................................................................26 Case additions ..................................................................................................................................................................................................26 Adding a newborn ........................................................................................................................................................................................26 Can Paramount Advantage end my membership? ....................................................................................................................26 Accidental injury or illness (subrogation) ........................................................................................................................................27 Other health insurance (coordination of benefits - COB)....................................................................................................27

Covered Basic Benefits Restrictions on choice of providers ....................................................................................................................................................28 What is covered?............................................................................................................................................................................................28 Covered services............................................................................................................................................................................................28 Dental benefit ..................................................................................................................................................................................................30 Vision benefit ....................................................................................................................................................................................................30 New technology assessment ..................................................................................................................................................................30 Extra services or programs ......................................................................................................................................................................31 Care management services ......................................................................................................................................................................32

Coordinated Service Program Coordinated Service Program................................................................................................................................................................33

Services Not Covered Services not covered by Paramount Advantage ........................................................................................................................34

Membership Rights and Responsibilities Your membership rights ............................................................................................................................................................................35 Advance directives ........................................................................................................................................................................................36 Members have the responsibility to: ..................................................................................................................................................37 Patient safety ....................................................................................................................................................................................................37

Member Services Department: 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

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Meanings of Some Words In This Handbook Benefits - a list of covered health care services. Care Management - a program where a health coach or a case manager works directly with members with difficult health problems and their PCP to assist in coordinating care to improve health outcomes, increase member’s quality of life, and assist the member with navigating the complex health care system. Case Manager - a registered nurse who works closely with the members, doctors and providers to educate members that have serious health care issues.

HEALTHCHEK - a well-child checkup for children and youth up to the day before they reach 21 years of age that can uncover dental and medical problems before the problems become serious. Health Coach - a medical professional who works closely with members that have chronic disease to promote wellness. Health Maintenance Organization (HMO) see Managed Care Plan. Home Health Agency - a company that provides health care services in your home.

Complaint - see Grievance. Durable Medical Equipment - equipment for medical uses, such as wheelchairs, oxygen tanks, diabetic supplies or aerosol machines. Emergency - an unexpected, serious condition that requires immediate medical assistance when you think your health or the health of your unborn infant is in jeopardy. Generic Drug - a prescription drug approved by the U.S. Food and Drug Administration which has the same active ingredients as a trade-name drug. Grievance - a complaint which members or their authorized representative presents to a managed care plan (MCP) because they are unhappy with something about the MCP or one of their providers.

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Hospital - an institution approved by the State of Ohio that offers a full range of diagnoses and surgeries for treating injured and sick people 24 hours a day. Identification Card - a personalized card for each Paramount Advantage member that must be presented before you can receive services such as checkups, entering the hospital or picking up prescriptions. Inpatient - a service or treatment at a hospital that requires an overnight stay.

Meanings of Some Words In This Handbook

Managed Care Plan (MCP) (formerly known as HMO) - a company that makes arrangements for specific doctors, hospitals and other health care providers to work with MCP members to keep them healthy. Medically Necessary Services - services which are necessary for the diagnosis or treatment of disease, illness or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. Member - a person, sometimes called an enrollee, eligible for benefits through Paramount Advantage. Member Services Department - a department at Paramount Health Care that can be reached by telephone or in person to answer questions and solve complaints promptly. Open Monday - Friday, 7:00 a.m. - 7:00 p.m. (except on holidays). Paramount Advantage is closed on New Year’s Day, Memorial Day, Independence Day (July 4), Labor Day,Thanksgiving Day, day after Thanksgiving and Christmas Day. If the Paramount-recognized holiday occurs on a Saturday, the Member Services Department will be closed on the preceding Friday. If the Paramount-recognized holiday occurs on a Sunday, the Member Services Department will be closed on the following Monday. OB or Gyn - obstetrics or gynecology. ODADAS - Ohio Department of Alcohol and Drug Addiction Services.

ODJFS - Ohio Department of Job and Family Services ODMH - Ohio Department of Mental Health. Outpatient - a service or treatment at a hospital that does not require an overnight stay. Participating Provider - any doctor, hospital, laboratory or other health care provider holding a contract with Paramount Advantage to provide care for members. Prescription Medicine - a drug that can be obtained at the pharmacy if the doctor has written an advance note, sometimes called an order. Primary Care Provider (PCP) - your personal doctor who coordinates your health care and participates with Paramount Advantage. A PCP is usually trained in family practice medicine, internal medicine or pediatrics. Prior Authorization - a process of receiving prior approval from Paramount Advantage before receiving certain services.The review process occurs between Paramount Advantage providers and the Utilization Review Department and is performed by telephone or by telefax. Paramount Advantage will make the decision within two working days. An approval notice will be sent to you within three working days of the decision. If the decision is a denial, the notice will be mailed to you at the same time the decision is made. Decisions are made quicker if your condition is such that you cannot wait two working days for a decision to receive the service. Requests for drugs administered in a provider setting will be decided in 24 hours.

Member Services Department: 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

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Meanings of Some Words In This Handbook

ProMedica Call Center - is a special service available 24 hours a day with general health information plus a staff of nurses to assist you. Please call 419-291-5899 or toll-free 1-800-234-8773,TTY 419-291-5579 or the Ohio Relay Service TTY toll-free at 1-800-750-0750. Referral - the process by which a primary care provider orders treatment for a patient from other Paramount Advantage providers.You do not need a referral authorization from Paramount Advantage to see any Paramount Advantage specialist. Specialist - a doctor who provides covered services to members within his/her area of practice and who has an agreement with Paramount Advantage. Termination - steps to follow to leave Paramount Advantage. Utilization Management (UM) - the evaluation and determination of the appropriateness of patient use of medical care resources and provision of any needed assistance to clinician and/or enrollee, to ensure appropriate use of resources (may include prior authorization, concurrent review, discharge planning and care management).

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Utilization Review (UR) - a review process by which decisions for care are based on whether a service is a Medicaid-covered service and medically necessary. Paramount Advantage follows NCQA standards for utilization review. All determinations for non-urgent care are made within two working days. Determinations for concurrent care (i.e., care in process) are made within one working day. Denials are documented in the form of a letter to members, offering alternatives for care including options that would be covered if applicable.The letter also includes instructions on grievance procedures and appeal and state hearing rights (see pages 20-22).

Welcome to Paramount Advantage™ What is Paramount Advantage?

Who Can join Paramount Advantage?

Welcome to Paramount Advantage, a member of the ProMedica Health System.You are now a member of a health care plan, also known as a managed care plan (MCP), for Covered Families and Children Medicaid consumers, including Healthy Start and Healthy Families. Paramount Advantage is a Toledo-based MCP (formerly known as HMO). In an MCP, you and your primary care provider (PCP) work together to keep you healthy and to care for health problems which may arise. Paramount Advantage may not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, national origin, veteran’s status, ancestry, health status or need for health services in the receipt of health services.

All Covered Families and Children Medicaid consumers, including Healthy Start and Healthy Families, are eligible to select membership.

Paramount Advantage is pleased to provide you with access to quality health care services. Call the Member Services Department any time you have questions about health care services.

It is important to remember that you must receive services covered by Paramount Advantage from facilities and/or providers on Paramount Advantage’s panel. See page(s) 28-30 for information on services covered by Paramount Advantage.The only time you can use providers that are not on Paramount Advantage’s panel is for emergency services, federally qualified health centers/rural health clinics, qualified family planning providers, community mental health centers, Ohio Department of Alcohol and Drug Addiction Services facilities which are Medicaid providers, an out of panel provider that Paramount Advantage has approved you to see.

You can contact Paramount Advantage to get any other information you want, including the structure and operation of Paramount Advantage and how we pay our providers.

Member Services Department: 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

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Welcome to Paramount Advantage™

What you must do to receive benefits Paramount Advantage will pay health care costs if you follow four guidelines: 1. You see your primary care provider (PCP). 2. You get Paramount approval to see out-of-plan providers with the exception of emergency care, federally qualified health centers/rural health clinics and family planning providers listed in your Provider Directory. Health services that are covered are included in the Paramount Advantage benefits outlined on pages 28-32. If you are unsure of coverage, call the Member Services Department before you receive services. 3. You use the emergency room appropriately. (See page 17 for an explanation of emergency care.) 4. You follow the rules outlined in your Member Handbook. If you follow the guidelines above, you should not receive any bills. If you do get bills, call the Member Services Department.

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It is important for any new members that have a health condition that requires ongoing care to call our Member Services Department as soon as possible. For example, if you need surgery, are pregnant, have asthma or diabetes, are receiving speech or physical therapy or have braces, you need to call Member Services.

Your Doctor Is Your Health Care Partner Provider panel When you called the managed care enrollment center (MCEC) to select a managed care plan (MCP), you were asked whether you wanted provider panel information given to you as a printed provider directory or via the internet. If you asked for a printed directory, or did not contact the MCEC to enroll and were assigned to our plan, you should have also received a Provider Directory. The Provider Directory lists all of our panel providers as well as other nonpanel providers you can use to receive services. If you want to use the internet, visit our website at www.paramounthealthcare.com to view up to date provider panel information.

Choosing a primary care provider (PCP) Each member of Paramount Advantage must choose a primary care provider (PCP) from the Paramount Advantage Provider Directory. Your PCP is your personal doctor. Your PCP is an individual physician or physician group practice trained in family medicine (general practice), internal medicine or pediatrics. Your PCP will work with you to direct your health care.Your PCP will do your checkups and shots and treat you for most of your routine health care needs. If needed, your PCP will send you to other doctors (specialists) or admit you to the hospital.

If you need non-emergency care after hours, call your PCP for instructions, or you can call the ProMedica Call Center at 419-291-5899 or tollfree 1-800-234-8773,TTY users 419-291-5579 or the Ohio Relay Service TTY toll-free at 1-800-750-0750.

When should you visit your PCP? You should visit your primary care provider (PCP) for regular HEALTHCHEK exams, adult well exams and when you are ill. Always contact your primary care provider before you see a specialist, have lab tests done or are admitted to the hospital (except in an emergency). The only time you do not need to contact your PCP to see a specialist/consultant are for appointments with obstetricians, gynecologists, certified nurse-midwives, federally qualified health center/rural health clinic providers, family planning providers, certified nurse-practitioners, ODADAS and community mental health Medicaid providers, chiropractors, and vision and dental providers (routine care only). Your PCP is responsible for managing your care, which is a feature of an MCP like Paramount Advantage. If you would like information about how Paramount providers are paid, call the Member Services Department.

You can reach your PCP by calling the PCP’s office.Your PCP’s name and phone number are printed on you Paramount Advantage ID card.

Member Services Department: 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

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Your Doctor Is Your Health Care Partner

Changing your PCP If for any reason you want to change your PCP, you must first call the Member Services Department to ask for the change. Members can change their PCP on a monthly basis. Paramount Advantage will send you a new ID card to let you know that your PCP has been changed and you can begin seeing your new PCP immediately. For the names of the PCP’s in Paramount Advantage, you may look in your Provider Directory, if you requested a printed copy, on our web site at www.paramounthealthcare.com, or you can call the Member Services Department at 419-887-2525 or toll-free 1-800-462-3589,TTY users 419-887-2526 or toll-free -888-740-5670, for help.

HEALTHCHEK Healthchek is Ohio’s early and periodic screening, diagnostic, and treatment (EPSDT) benefit. Healthchek covers medical exams, immunizations (shots), health education, and laboratory tests for everyone on Medicaid from birth to under 21 years of age. These exams are important to make sure that children are healthy and are developing physically and mentally. Mothers should have prenatal exams

and children should have exams at birth, 3-5 days of age and at 1, 2, 4, 6, 9, 12, 15, 18, 24, and 30 months of age. After that, children should have at least one exam per year. Healthchek also covers complete medical, vision, dental, hearing, nutritional, developmental, and mental health exams, in addition to other care to treat physical, mental, or other problems or conditions found by an exam. Healthchek covers tests and treatment services that may not be covered for people over age 20; some of the tests and treatment services may require pre-approval. Healthchek services are available at no cost to members and include: • Preventive check-ups for newborns, infants, children, teens, and young adults under the age of 21. • Healthchek screenings: -

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Complete medical exams (with a review of physical and mental health development) Vision exams Dental exams Hearing exams Nutrition checks Developmental exams Lead testing

• Laboratory tests for certain ages • Immunizations • Medically necessary follow up care to treat

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Your Doctor Is Your Health Care Partner

physical, mental, or other health problems or issues found during a screening. This could include, but is not limited to, services such as: -

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visits with a primary care provider, specialist, dentist, optometrist and other Paramount Advantage providers to diagnose and treat problems or issues in-patient or outpatient hospital care clinic visits prescription drugs laboratory tests

• Health education

If you would like more information on the HEALTHCHEK Program, please contact the Member Services Department at 419-887-2525 or toll-free 1-800-462-3589,TTY users 419-887-2526 or toll-free 1-888-740-5670. Member Services can also provide assistance with and answer questions on how to access care, what services are covered, finding a provider/making an appointment, prior authorizations or transportation assistance. You can call your PCP and dentist to make an appointment for regular check-ups, and ask for a HEALTHCHEK exam when you call.

It is very important to get preventive check ups and screenings so your providers can find any health problems early and treat them, or make a referral to a specialist for treatment, before the problem gets more serious. Some services may require a referral from your PCP or prior authorization by Paramount Advantage. Also, for some EPSDT items or services, your provider may request prior authorization for Paramount Advantage to cover things that have limits or are not covered for members over age 20. Please see page(s) 29-30 to see what services require a referral and/or prior authorization. As a part of Healthchek, care management services are available to all members from birth to under 21 years of age who have special health care needs. Please see page 32 to learn more about the care management services offered by Paramount Advantage.

Member Services Department: 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

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Your Doctor Is Your Health Care Partner

When you need obstetrical or gynecological care

Qualified family planning provider services

For obstetrical or gynecological care only, a female member may see her primary care provider (PCP) or self-refer to a Paramount participating obstetrician or gynecologist (OB or Gyn) or a certified nurse-midwife.

Qualified family planning services are available through your primary care provider (PCP), OB or Gyn, certified nurse-midwife or through a qualified family planning provider, such as Planned Parenthood.You do not need a referral from your PCP to see a participating OB or Gyn, qualified family planning provider or certified nurse-midwife. Simply choose the OB or Gyn, qualified family planning provider or certified nurse-midwife you wish to see from those in the Provider Directory and make an appointment.

The OB or Gyn or certified nurse-midwife may refer you to another specialist if the services are related to an obstetrical or gynecological condition. If your problem is not related to an obstetrical or gynecological condition, you should contact your PCP about seeing a specialist, if needed.

Prenatal-postpartum care guidelines What to expect at a visit with your obstetrician, gynecologist or nurse-midwife The following guidelines for preventive health screening (on the next page) are recommendations to discuss with your OB or Gyn or nurse-midwife.Your OB or Gyn or nurse-midwife may advise fewer services or additional services depending on your specific needs due to individual risk factors.

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Member Services Department: 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

Your Doctor Is Your Health Care Partner

Prenatal-Postpartum Care Guidelines Prenatal-Postpartum Care Guidelines, Paramount Care, Inc. Initial Evaluation Screenings

Lab Studies

Talk with Your Prenatal Provider

Height Weight—current and prepregnancy Blood pressure Physical examination Ultrasound (if indicated)

Hematocrit or hemoglobin levels

Complete history Estimated date of delivery Current medication (prescription and over-the-counter) Tobacco use Substance use Signs and symptoms to report to provider Nutrition Environmental exposure Hot tub warning Exercise Evaluate risk for domestic violence Genetic risk assessment and counseling

Urine for culture and sensitivity Pap test ABO/Rh typing with antibody screening Rubella antibody titer VDRL or RPR, FTA, if reactive Hepatitis B surface antigen HIV antibody testing One-hour glucose tolerance test (at risk) Test for gonorrhea and chlamydia (if indicated) Cystic fibrosis screening (optional) (offered if not done prior to pregnancy) Sickle-cell screening offered to African-Americans

Immunizations Influenza vaccine (if in second or third trimester of pregnancy during flu season)

Follow-Up Visits Screenings

Lab Studies

Talk with Your Prenatal Provider

Weight Blood pressure Uterine height Fetal heart tones Fetal movement (to be recorded each visit during the second and third trimesters) Dipstick urinalysis Presence of contractions Presence of swelling Ultrasound (at risk)

Quadruple screen at 15–20 weeks offered (Alpha-fetoprotein, b-HCG, Unconjugated Estriol, Inhibin A) Antibody screen at 28 weeks (if Rh-negative; prior to giving RhoGAM) Hemoglobin or hematocrit at 28–32 weeks gestation One-hour glucose tolerance test at 28 weeks Group B strep, gonorrhea, chlamydia at 34–35 weeks HIV antibody testing Other lab studies may be ordered based on individual risk factors

Childbirth process Infant feeding Choosing child’s physician WIC/nutrition Birth control Prenatal risk factors RhoGAM (if Rh-negative) Working Air travel during pregnancy Postpartum tubal ligation Circumcision Vaginal birth after cesarean (if indicated) Umbilical cord blood bank Exercise

Follow-up visits are scheduled every four weeks for the first 28 weeks of gestation, every two weeks until 36 weeks of gestation, and weekly thereafter. Other services may be required based on individual needs.

Postpartum Visits Screenings Weight Blood pressure Breasts Abdomen

Talk to Your Prenatal Provider Pelvic exam Episiotomy repair Uterine involution Pap test (if needed)

Interval history How you are adjusting to newborn Breast-feeding

Evaluation of postpartum depression Birth control Return to work

Postpartum visits should be scheduled approximately four to six weeks after delivery. A visit within seven to 14 days of delivery may be advisable after a cesarean delivery, tubal ligation, or complicated pregnancy. Guidelines are recommendations from “Guidelines for Perinatal Care,” sixth edition. These are guidelines for members with an uncomplicated pregnancy. Other services may be required based on an individual members' needs and risk factors.

Paramount offers two postpartum home visits for all Paramount Advantage ™ members.

MAC Approved 2011

ADVANTAGE

Member Services Department: 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

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Your Doctor Is Your Health Care Partner

Mental health and substance abuse services If you need mental health and/or substance abuse services, please call the Member Services Department at 419-887-2525 or toll-free 1-800-462-3589,TTY users 419-887-2526 or toll-free 1-888-740-5670. Paramount Advantage members may receive inpatient and outpatient behavioral health services, subject to the health plan’s prior authorization policies, through any subcontracted provider. Before seeing a subcontracted provider, you should always first contact your PCP. Or you may self-refer directly to a community mental health center or Ohio Department of Alcohol and Drug Addiction Services (ODADAS) facility which is a Medicaid provider. Please see your Provider Directory or call the Member Services Department for the names and telephone numbers of the facilities near you.

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Seeing a Specialist Before seeing a specialist, you should always first contact your PCP. You do not need to contact your PCP to see participating obstetricians, gynecologists, certified nurse midwives, certified nurse practitioners, chiropractors, or vision and dental providers for routine services.You can also see federally qualified health center/rural health clinic providers, qualified family planning providers and providers at community mental health centers or ODADAS facilities that are Medicaid providers.

Making an appointment with a specialist After your PCP recommends a Paramount Advantage specialist, you may then telephone your specialist’s office to make an appointment. If you must cancel your appointment, call the specialist’s office as soon as you can.

Your Paramount Advantage Identification Card You should have received a Paramount Advantage membership ID card. Each member of your family who has joined Paramount Advantage will receive their own card. These cards replace your monthly Medicaid card. Each card is good for as long as the person is a member of Paramount Advantage. You will not receive a new card each month as you did with the Medicaid card.

Always keep your ID card(s) with you You will need your ID card each time you get medical services. This means that you need your Paramount Advantage ID card when you: • • • • • • • •

See your primary care provider (PCP). See a specialist or other provider. Go to an emergency room. Go to an urgent care facility. Go to a hospital for any reason. Get medical supplies. Get a prescription. Have medical tests.

Call the Paramount Advantage Member Services Department as soon as possible at 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670, if: • You have not yet received your card(s) yet. • Any of the information on the card(s) is wrong. • You lose your card(s). • You have a baby.

Member Services Department: 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

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In Case of Emergency Emergency services

Remember, if you need emergency services:

Emergency services are services for a medical problem that you think is so serious that it must be treated right away by a doctor. We cover care for emergencies both in and out of the county where you live.

1. Go to the nearest hospital emergency room or other appropriate setting. Be sure to tell them that you are a member of Paramount Advantage and show them your ID card.

Some examples of when emergency services are needed include: • Broken bones • Convulsions • Difficult breathing • Miscarriage/pregnancy with vaginal bleeding • Poisoning • Severe bleeding • Severe burns • Severe pain in the stomach or chest areas • Shock • Unconsciousness • Vomiting blood You do not have to contact Paramount Advantage for an okay before you get emergency services. If you have an emergency, call 911 or go to the nearest emergency room (ER) or other appropriate setting. If you are not sure whether you need to go to the emergency room, call your primary care provider (PCP) or the ProMedica Call Center at 419-291-5899 or toll-free 1-800-234-8773,TTY users 419-291-5579 or the Ohio Relay Service TTY toll-free at 1-800-750-0750. Your PCP or the ProMedica Call Center can talk to you about your medical problem and give you advice on what you should do.

2. If the provider that is treating you for an emergency takes care of your emergency, but thinks that you need other medical care to treat the problem that caused your emergency, the provider must call Paramount Advantage. 3. Contact your primary care provider (PCP) or call the Member Services Department as soon as possible.Try to call within 48 hours after going to the emergency department. 4. If the hospital has you stay, please make sure that Paramount Advantage is called within 48 hours. 5. Schedule an appointment with your PCP for all follow-up services

If you are out of town If you need non-emergency care when you are out of the county where you live, you are covered. First, try to call your PCP or the 24-hour toll-free ProMedica Call Center at 419-291-5899 or toll-free at 1-800-234-8773,TTY users 419-291-5579, or the Ohio Relay Service TTY toll-free at 1-800-750-0750. If that is not possible, seek treatment at the nearest medical facility or doctor’s office and call the Member Services Department within 48 hours. Schedule an appointment with your PCP for all follow-up services.

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Member Services Department: 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

Urgent Care Centers

Going to the Hospital

Using an Urgent Care Center

Use a participating hospital

If you have a medical problem arise that you don’t think is an emergency, you should call your PCP or visit a participating Urgent Care Center to prevent the injury or illness from getting worse.

You must use participating Paramount Advantage hospitals unless you are traveling out of town or in an emergency. Paramount Advantage offers you a choice of hospitals. Ask your primary care provider (PCP) for names of hospitals where she/he is on staff.

You can also call the ProMedica Call Center for advice and instructions on what to do to help ease the illness or injury.The ProMedica Call Center 24-hour nurse advice line can be reached at 419-291-5899 or toll-free 1-800-234-8773,TTY users 419-291-5579, or the Ohio Relay Service TTY toll-free at 1-800-750-0750. Participating Urgent Care Centers are listed in your provider directory or at: www.paramounthealthcare.com.

Unless it’s an emergency, admission to a hospital requires prior authorization from your doctor and approval by Paramount Advantage. If you are admitted to a hospital out of town, someone must notify your PCP or the Member Services Department within 48 hours or as soon as reasonably possible. You must see your PCP for all follow-up care.

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Filling Prescriptions Using a participating pharmacy

the medication. Reasons why we may priorauthorize a drug include:

Prescriptions from your physician can be filled atany participating pharmacy.There are numerous participating pharmacies. A list of these pharmacies may be found in the Provider Directory that you received in your new member packet. If you have questions, contact the Member Services Department.

• There is a generic or pharmacy-alternative drug available. • The drug can be misused/abused. • There are other drugs that must be tried first.

When you go to the pharmacy, show your Paramount Advantage card to the pharmacist.

Some drugs may also have quantity (amount) limits and some drugs are never covered, such as drugs for weight loss.

Generic drugs, approved by the U.S. Food and Drug Administration, will be used to fill your prescription unless the provider specifies a brand or a trade-name brand which is covered by Medicaid. Generic drugs have the same basic ingredients as trade-name drugs, but may look different. Using the generic drug when it is available helps to keep health care costs down.

If we do not approve a prior authorization request for a medication, we will send you information on how you can appeal our decision and your right to a state hearing.

Prescription drugs

You can call Member Services to request information on our PDL and medications that require prior authorization.You can also look on our web site at www.paramounthealthcare.com. Please note that our PDL and list of medications that require prior authorization can change so it is important for you and/or your provider to check this information when you need to fill/refill a medication.

While Paramount Advantage covers all medically necessary Medicaid-covered medications, we use a preferred drug list (PDL).These are the drugs that we prefer that your provider prescribe. We may also require that your provider submit information to us (a prior authorization request) to explain why a specific medication and/or a certain amount of a medication is needed. We must approve the request before you can get

Your doctor and pharmacist may find the names of the drugs requiring prior authorization or step therapy by going to our website.

Your health care provider can order over-the-counter medications Paramount Advantage will also pay for many over-the-counter medicines, including but not limited to the medicines to treat coughs, colds or fevers, if your health care provider writes a valid prescription. Be sure to fill all prescriptions at a participating pharmacy.

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Member Services Department: 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

Phoning Questions to the Member Services Department The Member Services Department will help you right away

the Ohio Relay Service TTY toll-free at 1-800-750-0750.

Paramount Advantage’s Member Services Department can tell you what services are covered, how to access services, help finding a provider, filing a complaint about the MCP/providers/discrimination, changing your PCP, or accessing language assistance. You should be satisfied with all aspects of the service you receive. If you have questions or recommendations for change, the Member Services Department is thoroughly trained and ready to help you. The Member Services Department can be reached at 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670, Monday - Friday, between 7:00 a.m. - 7:00 p.m. (except on holidays). Paramount Advantage is closed on New Year’s Day, Memorial Day, Independence Day (July 4), Labor Day,Thanksgiving Day, day after Thanksgiving and Christmas Day. If the Paramount-recognized holiday occurs on a Saturday, the Member Services Department will be closed on the preceding Friday. If the Paramount-recognized holiday occurs on a Sunday, the Member Services Department will be closed on the following Monday.

How to let Paramount Advantage know if you are unhappy or do not agree with a decision we made

If you want to tell us about things you think we should change, please call the Member Services Department at 419-887-2525 or toll-free 1-800-462-3589,TTY users 419-887-2526 or toll-free 1-888-740-5670.

ProMedica Call Center If you need medical advice, the ProMedica Call Center is a special service available 24 hours every day with general information plus a staff of nurses to assist you.The ProMedica Call Center telephone number is 419-291-5899 or toll-free 1-800-234-8773,TTY users 419-291-5579 or

If you are unhappy with anything about Paramount Advantage or its providers, you should contact us as soon as possible.This includes if you do not agree with a decision we have made. You, or someone you want to speak for you, can contact us. If you want someone to speak for you, you will need to let us know this. Paramount Advantage wants you to contact us so that we can help you. To contact us you can: • Call the Member Services Department at 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670, or • Fill out the form in your Member Handbook on pages 20 A-B, or • Call the Member Services Department to request they mail you a form, or • Visit our web site at www.paramounthealthcare.com, or • Write a letter telling us what you are unhappy about. Be sure to put your first and last name, the number from the front of your Paramount Advantage member ID card and your address and telephone number in the letter so that we can contact you, if needed. You should also send any information that helps explain your problem. Mail the form or your letter to: Paramount Advantage Member Services Appeals Coordinator P.O. Box 928 Toledo, Ohio 43697-0928

Member Services Department: 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

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Grievance and Appeals (Complaint) Form Name of Member:____________________________________________________________________ Member ID #: ______________________________________________________________________ Name of Subscriber (if different from member): ____________________________________________ Signature: __________________________________________________ Date: _________________ Has this issue been brought to the attention of an employee of Paramount Advantage before? If yes, to whom? ______________________________________________________________________ When? ____________________________________________________________________________

Nature of complaint State all details relating to the incident in question, including names, dates and places. Attach additional sheets if necessary. __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 20A

Member Services Department: 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

Grievance and Appeals (Complaint) Form

__________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Member Services Department: 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

20B

Phoning Questions to the Member Services Department

Paramount Advantage will send you something in writing if we make a decision to: • Deny a request to cover a service for you, • Reduce, suspended or stop services before you receive all of the services that were approved or • Deny payment for a service you received that is not covered by Paramount Advantage. We will also send you something in writing if, by the date we should have, we did not: • Make a decision on whether to okay a request to cover a service for you, or • Give you an answer to something you told us you were unhappy about. If you do not agree with the decision/action listed in the letter, and you contact us within 90 calendar days to ask that we change our decision/action, this is called an appeal.The 90 calendar day period begins on the day after the mailing date on the letter. Unless we tell you a different date, we will give you an answer to your appeal in writing within 15 calendar days from the date you contacted us. If we have made a decision to reduce, suspend or stop services before you receive all of the services that were approved, your letter will tell you how you can keep receiving the services if you choose and when you may have to pay for the services. If you contact us because you are unhappy with something about Paramount Advantage or one of our providers, this is called a grievance.

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Paramount Advantage will give you an answer to your grievance by phone (or by mail if we can’t reach you by phone) within the following time frames: • 2 working days for grievances about not being able to get medical care. • 30 calendar days for all other grievances except grievances that are about getting a bill for care you have received. • 60 calendar days for grievances about getting a bill for care you have received. You also have the right at any time to file a complaint by contacting the: Ohio Department of Job and Family Services Bureau of Policy and Health Plan Services P.O. Box 182709 Columbus, Ohio 43218-2709 1-800-605-3040 or 1-800-324-8680 TTY: 1-800-292-3572 Ohio Department of Insurance 50 W. Town Street 3rd Floor, Suite 300 Columbus, Ohio 43215 1-800-686-1526 If you would like to recommend changes to improve Paramount Advantage care and services, please call the Member Services Department at 419-887-2525 or toll-free 1-800-462-3589,TTY users 419-887-2526 or toll-free 1-888-740-5670.

Member Services Department: 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

Phoning Questions to the Member Services Department

State hearings Paramount Advantage will notify you of your right to request a state hearing when: • A decision is made to deny services. • A decision is made to reduce, suspend, or stop services before all of the approved services are received. • A provider is billing you because Paramount Advantage has denied payment of the service. • A decision is made to propose enrollment or continue enrollment in the Paramount Advantage’s Coordinated Services Program • A decision is made to deny your request to change your Paramount Advantage Coordinated Services Program provider At the time Paramount Advantage makes the decision or is aware that the provider is billing you for payment, we will mail you a state hearing form. If you want a state hearing, you must request a hearing within 90 calendar days.The 90 calendar day period begins on the day after the mailing date on the hearing form. If we have made a decision to reduce, suspend, or stop services before all of the approved services are received and you request the hearing within 15 calendar days from the mailing date on the form, we will not take the action until all approved services are received or until the hearing is decided, whichever date comes first. You may have to pay for services you receive after the proposed date to reduce, suspend, or stop services if the hearing officer agrees with our decision.

To request a hearing, you can sign and return the state hearing form to the address or fax number listed on the form, call the Bureau of State Hearings at 1-866-635-3748 or submit your request via e-mail at [email protected]. A state hearing is a meeting with you, someone from the County Department of Job and Family Services, someone from Paramount Advantage and a hearing officer from ODJFS. Paramount Advantage will explain why we made our decision and you will tell why you think we made the wrong decision.The hearing officer will listen and then decide who is right based upon the information given and whether we followed the rules. If you want information on free legal services but don’t know the number of your local legal aid office, you can call the Ohio State Legal Service Association at 1-800-589-5888 for the local number. State hearing decisions are usually issued no later than 70 calendar days after the request is received. However, if the MCP or Bureau of State Hearings decides that the health condition meets the criteria for an expedited decision, the decision will be issued as quickly as needed but no later than 3 working days after the request is received. Expedited decisions are for situations when making the decision within the standard time frame could seriously jeopardize your life or health or ability to attain, maintain, or regain maximum function.

Member Services Department: 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

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Membership Terminations, Re-Enrolling and Conversion Membership terminations (getting out of Paramount Advantage) As a member of a managed care plan, you have the right to choose to end your membership at certain times during the year. You can choose to end your membership during the first three months of your membership or during the annual open enrollment month for your area. ODJFS will send you something in the mail to let you know when your annual open enrollment month will be. If you live in a mandatory enrollment area, you will have to choose another managed care plan to receive your health care.

Choosing a new plan If you are thinking about ending your membership to change to another health plan, you should learn about your choices. Especially if you want to keep your current doctor(s). Remember, each health plan has its own list of doctors and hospitals that they will allow you to use. Each health plan also has written information which explains the benefits it offers and the rules that it has. If you would like written information about a health plan you are thinking of joining or if you simply would like to ask questions about the health plan, you may either call the plan or call the Managed Care Enrollment Center (MCEC) at 1-800-605-3040,TTY 1-800-292-3572. You can also find information about the health plans in your area by visiting the MCEC web site at www.ohiomcec.com.

Ending your MCP membership If you want to end your membership during the first three months of your membership or open enrollment month for your area you can call the MCEC at 1-800-605-3040,TTY 1-800-292-3572. You can also submit a request on-line to the MCEC web site at www.ohiomcec.com. Most of the time, if you call before the last 10 days of the month, your membership will end the first day of the next month. If you call after this time, your membership will not end until the first day of the following month. If you chose another managed care plan, your new plan will send you information in the mail before your membership start date.

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Membership Terminations, Re-Enrolling and Conversion

Just cause membership terminations Sometimes there may be a special reason that you need to end your health plan membership. This is called a “just cause” membership termination. Before you can ask for a just cause membership termination, you must first call your managed care plan and give them a chance to resolve the issue. If they cannot resolve the issue, you can ask for a just cause termination at any time if you have one of the following reasons:

1. You move and your current MCP is not available where you now live and you must receive non-emergency medical care in your new area before your MCP membership ends. 2. The MCP does not, for moral or religious objections, cover a medical service that you need. 3. Your doctor has said that some of the medical services you need must be received at the same time and all of the services aren’t available on your MCP’s panel. 4. You have concerns that you are not receiving quality care and the services you need are not available from another provider on your MCP’s panel. 5. Lack of access to medically necessary Medicaid-covered services or lack of access to providers who are experienced in dealing with your special health care needs. 6. The PCP you chose is no longer on your MCP’s panel and he/she was the only PCP on your MCP’s panel who spoke your language and was located within a reasonable distance from you. Another health plan has a PCP on its panel who speaks your language and is located in a reasonable distance from you and will accept you as a patient. 7. Other - If you think of staying a member in your current health plan is harmful to you and not in your best interest.

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Membership Terminations, Re-Enrolling and Conversion

You may ask to end your membership for just cause by calling the MCEC at 1-800-605-3040, TTY 1-800-292-3572. ODJFS will review your request to end your membership for just cause and decide if you meet a just cause reason.You will receive a letter in the mail to tell you if ODJFS will end your membership and the date it ends. If you live in a mandatory enrollment area, you will have to choose another managed care plan to receive your health care unless ODJFS tells you differently. If your just cause request is denied, ODJFS will send you information that explains your state hearing right for appealing the decision.

Optional membership terminations Children under nineteen (19) years of age have the option to not be a member of a managed care plan if they are: • Eligible for Supplemental Security Income (SSI) under Title XVI, • Receiving foster care or adoption assistance under Title IV-E, • In foster care or an out-of-home placement, or • Receiving services through the Ohio Department of Health’s Bureau for Children with Medical Handicaps (BCMH). Additionally, if anyone is a member of a federally recognized Indian tribe, regardless of age, they have the option to not be a member of a managed care plan. If you believe that you/your child meet any of the above criteria and do not want to be a member of a managed care plan, you can call the Ohio Department of Job and Family Services (ODJFS) managed care enrollment 25

center at 1-800-605-3040,TTY 1-800-292-3572. If someone meets the above criteria and does not want to be an MCP member, his/her membership will be ended.

Things to keep in mind if you end your membership If you have followed any of the previous steps to end your membership, remember: • Continue to use Paramount Advantage doctors and other providers until the day you are a member of your new health plan or back on regular Medicaid. • If you chose a new health plan and have not received a member ID card before the first day of the month when you are a member of the new plan, call the plan’s member services department. If they are unable to help you, call MCEC at 1-800-605-3040, TTY 1-800-292-3572. • If you were allowed to return to the regular Medicaid card and you have not received a new Medicaid card, call your county case worker. • If you have chosen a new health plan and have any medical visits scheduled, please call your new plan to be sure that these providers are on the new plan’s list of providers and any needed paperwork is done. Some examples of when you should call your new plan include when you have an appointment to see a new doctor, surgery, blood test or X-ray scheduled, and especially if you are pregnant. • If you were allowed to return to regular Medicaid and have any medical visits scheduled, please call the providers to be sure that they will take the regular Medicaid card.

Member Services Department: 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

Membership Terminations, Re-Enrolling and Conversion

Loss of Medicaid eligibility

Adding a newborn

It is important that you keep your appointments with the County Department of Job and Family Services. If you miss a visit or don’t give them the information they ask for, you can lose your Medicaid eligibility. If this would happen, Paramount Advantage would be told to stop your membership as a Medicaid member and you would no longer be covered by Paramount Advantage.

If you are pregnant, you need to call Paramount Advantage when your baby is born so we can send you a new ID card for your baby.

Loss of insurance notice (certificate of creditable coverage) Anytime you lose health insurance, you should receive a notice, known as a certificate of creditable coverage, from your old insurance company that says you no longer have insurance. It is important that you keep a copy of this notice for your records because you might be asked to provide a copy.

Can Paramount Advantage end my membership? Paramount Advantage may ask the Ohio Department of Job and Family Services (ODJFS) to end your membership for certain reasons. The ODJFS must okay the request before your membership can be ended. The reasons that Paramount Advantage can ask to end your membership are: • For fraud or for misuse of your Paramount Advantage ID card. • For disruptive or uncooperative behavior to the extent that it affects the MCP’s ability to provide services to you or other members.

Automatic renewal of MCP membership If you lose your Medicaid eligibility but it is started again within 60 days, you will automatically become a Paramount Advantage member again.

Case additions If someone is added to your assistance group, they will automatically be enrolled in Paramount Advantage.

Paramount Advantage provides services to our members because of a contract that Paramount Advantage has with the ODJFS. If you want to contact ODJFS you can call or write to: Ohio Department of Job and Family Services Bureau of Policy and Health Plan Services P.O. Box 182709 Columbus, Ohio 43218-2709 1-800-605-3040 or 1-800-324-8680 TTY: 1-800-292-3572 You can also visit ODJFS on the web at www.jfs.ohio.gov/ohp.

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Membership Terminations, Re-Enrolling and Conversion

Accidental injury or illness (subrogation)

Other health insurance (coordination of benefits - COB)

If a Paramount Advantage member has to see a doctor for an injury or illness that was caused by another person or business, you must call the Member Services Department to let us know. For example, if you are hurt in a car wreck, by a dog bite or if you fall and are hurt in a store, then another insurance company might have to pay the doctor’s and/or hospital’s bill.

If you or anyone in your family has health insurance with another company, it is very important that you call the Member Services Department and your county case worker about the insurance. For example, if you work and have health insurance, or if your children have health insurance through their other parent, then you need to call the Member Services Department to give us the information. It is also important to call member services and your county caseworker if you have lost health insurance that you had previously reported. Not giving us this information can cause problems with getting care and with bills.

When you call, we will need the name of the person at fault, that person’s insurance company and the name(s) of any attorneys involved.

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Covered Basic Benefits Restrictions on choice of providers

You may self-refer to the following services:

When you join Paramount Advantage it is important to remember that you must receive all medically necessary health care services from Paramount Advantage facilities and/or providers. The only time you can use providers that are not on Paramount Advantage’s panel is for emergency services, federally qualified health centers/rural health clinics, qualified family planning providers, community mental health centers, Ohio Department of Alcohol and Drug Addiction Services facilities which are Medicaid providers, an out of panel provider that Paramount Advantage has approved you to see.

• Primary care provider (PCP) services (see page 10). • Yearly well-adult exams (provided by PCP). • Well-child (HEALTHCHEK) exams for children under the age of 21 (provided by PCP). • Shots (immunizations). • Preventive mammogram (breast) and cervical cancer (Pap smear) exams. • Physical exam required for employment or for participation in job training programs if the exam is not provided free of charge by another source. • Family planning services and supplies (you may self-refer to a qualified family planning provider, certified nurse-midwife, OB, Gyn or PCP). • Obstetrical (maternity care - prenatal and postpartum, including at-risk pregnancy services) and gynecological services. • Certified nurse-midwife services. • Vision (optical) services, including eyeglasses. • Certified nurse-practitioner services. • Federally qualified health center or rural health clinic services. • Emergency services (see page 17). • Chiropractic (back) care.

If you have any questions call the Member Services Department.

What is covered? Paramount Advantage gives you all the benefits you received with your Medicaid health card, with an emphasis on preventive services and personalized care to keep you healthy.

Services Covered by Paramount Advantage Paramount Advantage covers all medicallynecessary Medicaid-covered services. The services covered by Paramount Advantage are covered at no cost to you.

Member Services Department: 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

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Covered Basic Benefits

Some services may require prior authorization from Paramount Advantage prior to obtaining them. When your doctor recommends certain forms of treatment, he/she is responsible for obtaining authorization from Paramount Advantage. Prior Authorization - A process of receiving prior approval from Paramount Advantage before receiving certain services.The review process occurs between Paramount Advantage providers and the Utilization Review Department and is preformed by telephone or by telefax. Paramount Advantage will make the decision within two working days. An approval notice will be sent to you within three working days of the decision. If the decision is a denial, the notice will be mailed to you at the same time the decision is made. Decisions are made quicker if your condition is such that you cannot wait two working days for a decision to receive the service. Requests for drugs administered in a provider setting will be decided in 24 hours.

The following services require a prescription from your doctor or prior authorization:

• Developmental therapy services for children aged birth to six years (Requires a prescription and, for therapy services beyond benefit limits, prior authorization is required.) • Outpatient hospital service (Requires a prescription or some may require prior authorization.) • Inpatient hospital services (Requires prior authorization, except in emergency.) • Prescription drugs, including certain prescribed over-the-counter drugs (some may require prior authorization or step therapy.) See Page 19. • Medical supplies (Requires a prescription.) • Durable medical equipment (DME) (Requires a prescription and some may require prior authorization.) • Ambulance and ambulette transportation (Requires prior authorization, except in an emergency.) • Podiatry (foot) services (Some may require prior authorization.) • Home health services (Requires prior authorization.) • Hospice care (care for terminally ill; e.g., cancer patients) (Requires prior authorization.)

• Diagnostic services (X-ray, lab) (Requires a prescription and some may require prior authorization.) • Speech and hearing services, including hearing aids (Requires a prescription and, for speech therapy services beyond benefit limits, prior authorization is required.) • Physical and occupational therapy (Requires a prescription and, for therapy services beyond benefit limits, prior authorization is required.)

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Member Services Department: 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

Covered Basic Benefits

• Renal dialysis (kidney disease) (If directed by your PCP or kidney specialist to a participating provider, no referral is needed.) • Nursing facility services for a short rehabilitative stay (Requires prior authorization.) • Services for children with medical handicaps (Title V) (Some may require prior authorization.) Additional covered services include the following: • Specialist services (See page 15.) • Dental services (You may self-refer for routine dental; all other dental care requires prior authorization.) • Mental health and substance abuse services (You may self-refer to community mental health and ODADAS facilities. Some services through Paramount Advantage providers may require prior authorization.) This is only a partial list of covered services. If you need additional information, call the Member Services Department at 419-887-2525 or toll-free 1-800-462-3589,TTY users 419-887-2526 or toll-free 1-888-740-5670.

Dental benefit The following is not a complete list of covered services. For additional information, call the Member Services Department. Paramount Advantage members age 20 years or younger are entitled to one initial comprehensive oral examination followed by a routine oral examination every six months (not before six months after the initial comprehensive oral examination).

Paramount Advantage adult members (21 years of age or older) are limited to one routine exam and one cleaning each year. The following services are covered in the initial and routine oral examinations: X-ray, fillings and simple extraction/restorations. Full and partial dentures, orthodontia, general anesthesia, surgical extraction and comprehensive restorations such as root canals, post and core and crowns are covered but require prior authorization.

Vision benefit Paramount Advantage members age 21-59 are entitled to one comprehensive vision examination (and one complete frame and pair of lenses) per 24-month period. Paramount Advantage members age 20 and younger or age 60 and older are entitled to one comprehensive vision examination (and one complete frame and pair of lenses) per 12-month period.

New technology assessment Paramount investigates all requests for coverage of new technology using Hayes Technology Directory as a guideline. If further information is needed, Paramount utilizes additional sources including Medicare and Medicaid policy, Food and Drug Administration (FDA) releases and current medical literature.This information is evaluated by Paramount’s medical director and other physician advisors.

Member Services Department: 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

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Covered Basic Benefits

Extra services or programs Paramount Advantage also offers the following extra services and/or benefits to its members: • Expand selection of eyewear (For information on additional frame and lens selections, contact either the Member Services Department or the vision hardware providers listed in the Provider Directory.) • Member newsletter (mailed quarterly). • Nurses always available to answer questions on the 24-hour hotline (Call the ProMedica Call Center at 419-291-5899 or toll-free 1-800-234-8773,TTY users 419-291-5579 or the Ohio Relay Service TTY toll-free at 1-800-750-0750.) • Health Needs Screening Program (New member health needs are assessed to determine the need for care management services, especially high-risk cases.) • Social Services and High Risk Outreach Programs (Members with social service needs are referred to community agencies and are provided community resource guides; high-risk cases are referred to care management.) • Postpartum Home Health Care Program (Members are eligible for a minimum of two visits by a nurse from a Paramount Advantage home health care provider.) • Local walk-in Member Services Department at 1901 Indian Wood Circle in Maumee, Ohio. • Postcard reminders for immunizations, HEALTHCHEK, mammograms and Pap tests (mailed to members as appropriate). • Community Resource Guide. • NICU Graduate Home Health Care Program (Babies who are discharged from the neonatal intensive care unit are eligible for a minimum of two visits by a nurse from a Paramount Advantage home health care provider.)

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• Prenatal to Cradle Program (Earn up to $100 in gift certificates for obtaining the recommended number of prenatal/ postpartum visits. Contact Paramount Advantage Member Services for additional information.) • Transportation Assistance Program - If you must travel 30 miles or more from your home to receive covered health care services, Paramount Advantage will provide transportation to and from the provider’s office. Paramount Advantage offers additional transportation assistance that includes 30 one-way trips per member per 12-month period to any medical, pharmacy, WIC or CDJFS redetermination appointment. Please contact Paramount Advantage for assistance at 1-866-837-9817,TTY users 1-800-750-0750. Transportation must be scheduled at least two business days before your appointment. In addition to the transportation assistance that Paramount Advantage provides, members can still receive assistance with transportation for certain services through the local county department of job and family services Non-Emergency Transportation (NET) program. Call your county department of job and family services for questions or assistance with NET services. • Paramount Perks (Special service and programs for Paramount Advantage members; i.e., gift card drawings and a personalized call center representative service.) • Important and useful membership and health information at www.paramounthealthcare.com. For more information on how to obtain these Paramount Advantage services or programs, call 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

Covered Basic Benefits

Care management services Paramount Advantage offers care management services that are available to children and adults with special health care needs. Care management includes disease management or case management programs. Disease management is a program where a medical professional (health coach) works with the members that have chronic disease to promote wellness. Case management is a program where RN case managers work with the member, doctors, and providers to coordinate care. Case managers educate the member and help the member understand how to care for him/herself and how to access services that are available through Paramount Advantage participating providers, and also learn about community resources that are available. In addition, we also have outreach coordinators who may assist with talking to the members regarding the benefits of care management services and assist with the initial case management program process. Examples of conditions that may qualify for disease management: • • • • • • • •

Chronic kidney disease COPD CHF Depression Diabetes mellitus Migraines Post cardiac event Asthma

Examples of conditions that my qualify for case management would be: • • • • • • • • • • • •

Difficult pregnancy Uncontrolled diabetes Severe trauma Spinal cord injuries Cancer Organ transplant Major mental health or substance abuse disorder Newborn babies with serious complications such as birth defects or prematurity Members who frequent the ER HIV Asthma Teen pregnancy

Request for care management services may come from the member, a family member, providers or claims information. The case manager, health coach or outreach coordinator will ask the member questions to learn more information about his/her condition(s). If you feel that you could benefit from talking to a case manager, please call Member Services and ask to speak to one.You will be able to talk directly to a case manager at that time or, if one is not readily available, a case manager will return your call as soon as he/she is available. Call Member Services at 419-887-2525 or tollfree 1-800-462-3589,TTY users 419-887-2526 or toll-free at 1-888-740-5670.

Member Services Department: 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

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Coordinated Service Program The State of Ohio permits MCPs to develop and implement programs to assist certain members that have received drugs that are not medically necessary to establish and maintain a relationship with one provider and/or pharmacy to coordinate treatment. Members selected for Paramount Advantage’s program will be provided additional information and notified of their state hearing rights, as applicable. A member may be enrolled in the Coordinated Services Program, or CSP, if a review of his or her utilization demonstrates a pattern of receiving services at a frequency or in an amount that exceeds medical necessity. CSP enrollees must get medications filled at one pharmacy and coordinate medical services through their primary care provider.You can request to change your pharmacy and/or PCP if the assigned pharmacy or provider is no longer accessible. Paramount Advantage will give you approval for you to use a different pharmacy if you have a pharmacy emergency. Selected members enrolled in the CSP will receive additional information and be notified of their right to a state hearing.

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Member Services Department: 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

Services Not Covered Services not covered by Paramount Advantage or Ohio Medicaid Paramount Advantage will not pay for services or supplies received without following the directions in this handbook. Paramount Advantage will not pay for the following services that are not covered by Medicaid: • All services or supplies that are not medically necessary. • Experimental services and procedures, including drugs and equipment, not covered by Medicaid. • Organ transplants that are not covered by Medicaid. • Abortions, except in the case of a reported rape, incest or when medically necessary to save the life of the mother. • Infertility services for males or females, including reversal of voluntary sterilizations. • Voluntary sterilization if under 21 years of age or legally incapable of consenting to the procedure.

• Plastic or cosmetic surgery that is not medically necessary. • Inpatient treatment to stop using drugs and/or alcohol (inpatient detoxification services in a general hospital are covered). • Services for the treatment of obesity unless determined medically necessary. • Inpatient hospital custodial care. • Acupuncture and biofeedback services. • Services to find cause of death (autopsy). • Comfort items in the hospital (e.g.,TV or phone). • Paternity testing. This is not a complete list of the services that are not covered by Medicaid or Paramount Advantage. If you have a question about whether a service is covered, please call the Member Services Department.

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Membership Rights and Responsibilities Your membership rights As a member of Paramount Advantage you have the following rights: • To receive all services that Paramount Advantage must provide. • To be treated with respect and with regard for your dignity and privacy. • To be sure that your medical record information will be kept private. • To be given information about your health. This information may also be available to someone who you have legally okayed to have the information or who you have said should be reached in an emergency when it is not in the best interest of your health to give it to you. • To be able to take part in decisions about your health care unless it is not in your best interest. • To get information on any medical care treatment, given in a way that you can follow. • To be sure that others cannot hear or see you when you are getting medical care. • To be free from any form of restraint or seclusion used as a means of force, discipline, ease or revenge, as specified in federal regulations. • To ask, and get, a copy of your medical records and to be able to ask that the record be changed/corrected if needed. • To be able to say yes or no to having any information about you given out unless Paramount Advantage has to by law. • To be able to say no to treatment or therapy. If you say no, the doctor or MCP must talk to you about what could happen and they must put a note in your medical record about it.

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• To be able to file an appeal, a grievance (compliant) or state hearing. See pages 20-22 of this handbook for information. • To be able to get all MCP written member information from the MCP: • At no cost to you. • In the prevalent non-English languages of members in the MCP’s service area. • In other ways, to help with the special needs of members who may have trouble reading the information for any reason. • To be able to get help free of charge from Paramount Advantage and its providers if you do not speak English or need help in understanding information. • To be able to get help with sign language if you are hearing impaired. • To be told if the health care provider is a student and to be able to refuse his/her care. • To be told of any experimental care and to be able to refuse to be part of the care.

Membership Rights and Responsibilities

• To make advance directives (living will). See the pamphlet in your new member packet, which explains about advanced directives.You can contact the Member Services Department for more information. • To file any complaint about not following your advanced directive with the Ohio Department of Health. • To change your primary care provider (PCP) to another PCP on Paramount Advantage’s panel at least monthly. Paramount Advantage must send you something in writing that says who the new PCP is and the date the change began. • To be free to carry out your rights and know that the MCP, the MCP’s providers or ODJFS will not hold this against you. • To know that the MCP must follow all federal and state laws and other laws about privacy that apply. • To choose the provider that gives you care whenever possible and appropriate. • If you are a female, to be able to go to a women’s health provider on Paramount Advantage’s panel for covered women’s health services. • To be able to get a second opinion from a qualified provider on Paramount Advantage’s panel. If a qualified provider is not able to see you, Paramount Advantage must set up a visit with a provider not on our panel. • To get information about Paramount Advantage from us.

• To contact the United States Department of Health and Human Services Office for Civil Rights and/or the Ohio Department of Job and Family Services Bureau of Civil Rights at the following addresses with any complaint of discrimination based on race, color, religion, sex, sexual orientation, age, disability, national origin, veteran’s status, ancestry, health status or need for health services. Office for Civil Rights United States Department of Health and Human Services 233 N. Michigan Ave., Suite 240 Chicago, Illinois 60601 312-886-2359 TTY 312-353-5693 Bureau of Civil Rights Ohio Department of Job and Family Services 30 E. Broad St., 30th Floor Columbus, Ohio 43215 614-644-2703 or 1-866-227-6353 TTY: 1-866-221-6700 Fax: 614-752-6381

Advanced directives Information on advance directives is located in your new member packet. Paramount Advantage will not discriminate against any individual based on whether or not the individual has executed an advanced directive and will not require advanced directives as a condition of coverage. Paramount Advantage has policies and procedures to ensure that if a member has advance directives their wishes will be honored.

Member Services Department: 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

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Membership Rights and Responsibilities

Members have the responsibility to: • Provide, to the extent possible, information that Paramount Advantage and the participating providers need to care for you. Help your primary care provider (PCP) fill out current medical records by providing current prescriptions and your previous medical records. • Engage in a healthy lifestyle, become involved in your health care and follow the plans and instructions for the care that you have agreed upon with your PCP or specialists. • Treat your PCP with respect and dignity. • Inform your PCP of any symptoms and problems and to ask questions. • Obtain information and consider the information about any treatment or procedure before it is done. Discuss any problems in following the recommended treatment with your PCP. • Respect the privacy of the other patients in the office. • Contact your PCP, or the doctor or facility taking your calls, before seeing a consultant/ specialist.The only times you do not need to contact your PCP to see a consultant/ specialist are for appointments with obstetricians, gynecologists, certified nurse-practitioners, certified nurse-midwives, federally qualified health centers/rural health clinic providers, family planning providers, ODADAS and community mental health Medicaid providers, chiropractors, and vision and dental providers (routine care only). • Continue seeing your previous PCP until the transfer takes effect. • Continue following Paramount Advantage policies and procedures until disenrollment takes effect. • Schedule and keep appointments and be on time. Always call if you need to cancel an appointment or if you will be late. 37

• Learn and follow the policies and procedures as outlined in this handbook. • Indicate to your doctor who you wish to designate to receive information regarding your health. • Obtain medical services from your PCP. • Treat your PCP and his or her staff in a polite and courteous manner. • Carry your ID card at all times and report any lost or stolen cards to Paramount Advantage immediately. Also, contact Paramount Advantage if any information on the card is incorrect or if you have changes in name, address or eligibility. • Inform Paramount Advantage and your case worker of any dependent that is to be added or removed from coverage. • Notify your PCP as soon as possible if you have received emergency treatment within 48 hours. • Call the Member Services Department if you have a problem and need assistance.

Patient safety Paramount is working with other hospitals, doctors and health plans to educate our members about patient safety. Here is what you can do to improve the safety of your medical care: • Provide your doctors with a complete health history. • Be an active member of your health care team.Take part in every decision about your health care. Speak up - ask questions. • Make sure that all of your doctors know about everything that you are taking, including over-the-counter medications and herbal/dietary supplements. • Make sure that your doctors know about any allergies and reactions to medications that you have had.

Member Services Department: 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

Membership Rights and Responsibilities

• Ask for your test results. Don’t assume that no news is good news. • Advise your doctor of any changes in your health. • Follow your doctor’s advice and the instructions for care that you and your doctor have agreed on. • Make sure that you can read the prescriptions you get from your doctor. • Ask your doctor and pharmacist questions about your medications. • What is this medication for? • What are the brand and generic names of the medication? • What does the medication look like? • How should it be taken and for how long? • What should you do if you miss a dose? • How should you store the medication? • Does the medication have side effects? What are they? What should you do if they occur? • When you pick up the medication, ask the pharmacist if this is the medication that was prescribed. • Make sure that you understand the instructions on the label. • Ask the pharmacist about the best device to measure liquid medications. • Read the information that is provided by the pharmacy. It is always important that you play an active role in decisions about your health and your health care.Take responsibility - you can make a difference! If you ever find yourself in the hospital, you’ll likely have many health care workers taking care of you. While they make every effort to provide appropriate care, sometimes errors can happen.

By taking an active role in your care and asking questions, you can help make sure the care you receive is right for you. Should you find yourself needing hospital care, be sure to: • Do your homework. Make sure that the hospital you’re being treated in has experience in treating your condition. If you need help getting this information, ask your doctor or call the Paramount Member Services Department. • See that the health care workers wash their hands before caring for you. This is one way to prevent the spread of germs at home and infections in a hospital. Studies have shown that when patients checked whether health care staff had washed their hands, the workers washed their hands more often and used more soap. • Ask about services or tests. Make sure to ask what test or X-ray is being done to make sure you are getting the right test. In the example of a knee surgery, be sure that the correct knee is prepped for surgery. A tip from the American Academy of Orthopaedic Surgeons urges doctors to sign their initials on the site to be operated on before surgery. • Ask about what to do when you get home. Before leaving the hospital, be sure the doctor talks to you about any medicines you need to take. Make sure you know how often, what dose to take and any side effects to expect from the medicine. Also ask when you can return to your regular activities. See if the doctor has advice or things you can do to help your recovery. If you have any questions or if things just don't seem right after you come home, be sure to call your doctor right away.

Member Services Department: 419-887-2525 or toll-free 1-800-462-3589, TTY users 419-887-2526 or toll-free 1-888-740-5670.

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© 02/01/2012 Paramount Health Care